Content

Proposals in 2011

These are the proposals that German-supported health and social protection programmes submitted for publication in 2011. 


In April 2011, German Development Cooperation (GDC) staff working in health and social protection programmes were invited to help assess proposals submitted to the GHPC.

Three good practice approaches have been selected from all 2011 proposals and have been documented in the following publications:

Maternal Health Services in Kenya – How to improve access for the poor

Why should this approach be documented in the German Health Practice Collection?

  • Introduction

MDG 5 shows indeed the least progress of all the MDGs with globally more than 500,000 pregnancy-related deaths per annum and remains a very problematic goal in Sub-Saharan Africa and South Asia.

Among the major reasons for low success rates for MDG 5 in Kenya was insufficient access to qualified maternal health services. However, reliable and sustainable access to maternal health services require integrated health systems. Although vertical programmes may have improved distinct health indicators for a certain period they fell short in improving MDG 5.

It is against this background, that the need for sustainable solutions is more urgent than ever. We believe that the results of the GDC Health Programme Kenya provide considerable knowledge and evidence on how to impact on this especially challenging global goal. This publication captures innovative aspects of the diverse contribution of Kenyan-German Development cooperation to equitable access to good quality Sexual and Reproductive Health care.

  • Approach

GDC provides substantial inputs through voucher schemes, social franchising networks and policy advice activities that are embodied by

- improving access and empowerment of the vulnerable and the poor,
- enhancing accountability and service qualtiy of the service providers,
- strengthening partnerships between the public and private sector,
- improving efficiency of health financing.

  • Innovation

Various factors make this contribution “best practice”:

- The strategic objective of the GDC approach is to integrate reproductive health services into the health financing strategy. Through the implemention of innovative RH programmes as pilots of health financing strategy GDC ensures sustainable financing of RH services. At the same time these projects provide innovative models for the reforms of health financing and health systems strengthening in Kenya.

- OBA-Voucher-Programme for RH as a practical example of a “fast-track” strategy to improve MMR and support the development of long term financing strategies. Demand Side Financing (OBA) is now a National Flagship Programme. GDC has supported the development of budget lines and Government funding mechanisms for contraceptives and for demand side financing in Kenya.

- GDC is contributing to improve information systems and evidence based decision making in SRH, particularly in the provision of human – and gender – relevant information as well as costing data and projections on SRH cost and MDG 4, 5 and 6 fiscal implications.

- Complementarity of the GDC instruments.– GDC support SRH development through a balanced, longer-term and well integrated mix of investments, capacity development, development of policies strategies, standards and best practices models for high quality services delivery

- Private Sector Involvement:

  • OBA and Social Franchising have been spearheading the participation of the private sector in SRH delivery, demonstrating the potential of the private sector to provide health services to the poor at sustainable cost. Private financial management firms and private insurance company are partners in this process.
  • Working with the private sector has been complemented by the development of national policies that provide a legal and public financial management framework for the transfer of funds between Government and private sector.

What evidence on outputs (e,g., products or services, numbers of people covered) and outcomes (i.e., impacts on the health conditions and populations addressed) results and impact of this approach is available to show that it is effective?

  • Financial Cooperation

1) The approach intends to contribute to the reduction of maternal mortality as well as under 5 mortality (MDG 5 and 4). This is achieved through increasing the rate of institutional deliveries, ANC uptake and postnatal care, as well as improving quality of care in contracted and accredited facilities.

2) On a more systemic level, the approach intends to develop and introduce important elements of a long-term health financing system based on demand side financing (such as a national/social health insurance scheme) to policymakers, service providers and, importantly, the target group. This includes elements of contracting, accreditation, claims processing, quality monitoring and assurance, (risk-independent) pre-payment, subsidisation of the poor (solidarity).

The first set of objectives can be measured quantitatively, and there is substantial evidence on the effectiveness both in Kenya and elsewhere: For the first phase alone, 79,231 vouchers were sold for safe deliveries of which 60,581 were utilised (76%) and 25,746 for family planning, of which 11,296 were utilised (44%). For safe deliveries this rate is higher than in some other programmes (in comparison to Uganda, and the non-utilisation is mainly attributable to distance to the facility as well as difficulties in finding transport (e.g. at night) to the facility). Utilisation of safe motherhood services (incl. antenatal and postnatal care as well as facility deliveries) have increased substantially in all regions and facilities, which are part of the programme, but differ between districts. This is evident from facility records. Findings of a recent study (submitted for publication, as part of the larger independent evaluation, which is continuing) confirm this finding and show that residents in the slum areas of Nairobi where the voucher had been introduced were significantly more likely to have an institutional delivery following the introduction of OBA (Bellows et al submitted). Project documentation and, indeed, external research also found that the rate of the poor accessing these services have increased.

Overall, the results from Kenya confirm that uptake of vouchers lead to a higher rate of deliveries in facilities - a major factor in reducing maternal mortality in target areas. It also confirms findings of other voucher programmes for maternal health (e.g. Bangladesh and Cambodia), which demonstrated a higher rate of facility deliveries following the introduction of vouchers (Hatt et al 2010, Ir et al 2010).

Similarly, the results confirm findings of similar programmes where vouchers have been used for other services, such as STD diagnosis and treatment in Uganda. The GDC financed pilot in Uganda showed an increase in utilisation of STI services and a significant reduction of syphilis prevalence in the voucher group compared to the control group (B. Bellows).

For the second set of objectives, results appear more in a qualitative manner, primarily in influencing and developing the long-term health financing policy debate. Effectivneness here is evident from policy discussion, documentation and we expect that the tools development as part of the voucher approach will substantially influence and support the introduction of insurance (incl. the informal and poor). On the level of providers, the effect is more immediate and the improvement of quality of services in the contracted providers is evident and well documented in the quality monitoring, which will be detailed in the manuscript. The increasing uptake of vouchers among the target group also demonstrates the shift of mindset among users who quickly gained an understanding that risk-independent pre-payment provides access to quality services. Documentation of the targetting process and also the independet evaluation have shown that access to services have improved for the poor, although differences among the group of the poor are continuing to be researched at present.

  • Technical cooperation

Impact of GIZ Health Sector Programme Kenya Interventions in Reproductive Health

In the current Sector Strategy Paper one of the areas of intervention in Sexual Reproductive Health is; improving the capacities and quality of services provided by public and private sector health providers in selected districts and facilities in the field of sexual and reproductive health, in cooperation with the private sector. This is in line with the National Health Sector Strategy Plan II (NHSSP II). This was acknowledged in the Project Progress Review (May 2010) that stated:

“The contribution of GTZ-HSP is in line with Kenya’s overall development goals and priorities in the health and social sectors and is fully integrated in the objectives of health and gender-related MDGs, Vision 2030, the National Health Sector Strategy Paper II (NHSSP II), the Joint Programme of Work and Funding (JPWF), and the Ministerial Strategic Plans (2008 to 2012). All support activities are integrated in the respective annual operational plans (AOPs). Germany is a signatory of the SWAp and the Kenyan Health Sector CoC.” (Programme Progress Review, 2010)

In the course of the NHSSP II, significant changes have been made in reproductive health, for example with an increase in access to family planning services:

  • Trends achieved among the WRA receiving FP commodities AOP1 – AOP5

(Health Sector Performance Report: July 2008 to June 2009)


  • Trends in Deliveries conducted by skilled health attendants in health facilities

(Source: Presentation on AOP 5 Service Delivery-Joint Review Mission)

The programme’s overall objective is to improve access to equitable good quality affordable healthcare of the poor, particularly in the area of reproductive health. The national data when disaggregated by wealth quintiles and other indices such as urbanization and gender shows an improvement in reproductive health outcomes.

  • Data disaggregated by Urbanization Level

(Health Sector Performance Report: July 2008 to June 2009, 2010)

  • Data disaggregated by Gender

(Health Sector Performance Report: July 2008 to June 2009)

  • Data Disaggregated by Poverty Index

(Health Sector Performance Report: July 2008 to June 2009)

The contribution of the GIZ Health Sector Programme is therefore validated by this data as the indicators in the above tables are the same indicators for the programme. GIZ-HSP works in rural districts with high poverty levels and high fertility rates.

These positive changes are the result of sustained effort over time as reflected by trend analysis of the Kenya Demographic Health Survey results (1989 to 2008). The GIZ Health Sector Programme has provided support to the Kenyan government in reproductive health over this period. The tables below show improvements in attendance of antenatal clinic, skilled attendance as well as contraceptive prevalence rates. This has resulted in lowering of total fertility rates though maternal mortality rate is not declining in a similar manner.

  • Trends in ANC Coverage (at least one visit) & skilled birth attendance, Kenya, surveys 1989-2008 

(Kenya Health Policy Framework 1994 – 2010: Analysis of Performance, Analytical Review of Health Progress, and Systems Performance , 2010)

  • Trends in overall contraceptive use rate among married women (%women on any method)

(Kenya Health Policy Framework 1994 – 2010: Analysis of Performance, Analytical Review of Health Progress, and Systems Performance , 2010)

In addition to the above service level impact areas, the GIZ Health Sector Programme represents the GDC as lead partner in reproductive health within the SWAp framework. GIZ-HSP is involved in various government led coordination mechanisms such as the Inter-Agency Coordination Committee on Reproductive Health. GIZ-HSP in conjunction with DFID recently also supported a joint mission on harmonization of support to reproductive health among key donors and government. The impact of this has been better coordination of input and interventions in this sub-sector.

Bibliography

Heidelberg, e. G. (2010). Programme Progress Review.

Ministry of Public Health and Sanitation & Ministry of Medical Services: Kenya. (2010). Health Sector Performance Report: July 2008 to June 2009. Technical Planning and Monitoring Department.

Ministry of Public Health and Sanitation. (2010). Kenya Health Policy Framework 1994 – 2010: Analysis of Performance, Analytical Review of Health Progress, and Systems Performance . Nairobi.

What documentation (studies, reports, photos, films (or other documentation) on the approach is available and can be used in describing it?

National Documents (Policy, strategy, reviews etc.)
Feasibility and other Studies and Evaluation Reports
Internal: Regular GTZ / KFW/ DED reporting, SSPs, Programme Proposals etc.
A detailed list will be provided later.

Which didactic or operational materials (manuals, IEC material, protocols) or similar can be made available for downloading from the GHPC online toolbox?

Multitude of IEC materials; can be accessed through the GTZ Document Management System
GTZ Weblog articles.

Applicants

GIZ

Klaus J. Hornetz, Sector Coordinator, Kenyan-German Development Cooperation in Health Care
Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH
PO Box 41607 00100 Nairobi. Kenya
T + 254 20 2725684
M 0726 610 126, 0736 507 523
F + 254 20 2719217
E klaus.hornetz@giz.de

KfW

Piet Kleffmann, Director KfW/DEG Office Nairobi
T +254 20 4228-200
M +254 722 203 603
P.O. Box 52074-00200
Nairobi, Kenya
Riverside Westlane off Riverside Drive
piet.kleffmann@kfw.de

Ministry of Public Health and Sanitation

Dr. S.K. Sharif, Director Public Health
Ministry of Public Health and Sanitation
P.O. Box 30016 – 00100 Nairobi
sksharif@africaonline.co.ke

Partnering with civil society (BACKUP)

Why should this approach be documented in the German Health Practice Collection?

  • Setting the scene

- Civil society (CS) plays an important role in an effective HIV response in order to achieve universal access to prevention, care, treatment and support for vulnerable populations. Civil society often knows the needs and expectations of different target populations and could foster transparency and accountability. A rights based approach and the fight against stigma and discrimination is – in many instances – well, vigorously and credibly dealt with by civil society.

- But civil society is not the magic bullet donors like to imagine. It is therefore not always ready to immediately and fully play the role envisaged for it, e.g. in policy dialogue, development of technical guidance or grant implementation. Institutional limitations that cause civil society organizations to suffer from almost the same weaknesses as governments, as well as the power bias towards government need to be taken into account. Fair and balanced representativeness of civil society is, in many settings, another huge challenge.

- Many of the eight MDGs can only be reached if CS has more voice and influence in responding to public health threats such as HIV. This implies that far more funding and investments in capacity development and in professional business approaches for civil society partners will be needed.

- Working with civil society is one of the key strategic objectives that guide German development cooperation.

- The approach of the Global Fund fully reflects the importance of CS, e.g. in its governance model, CCM guidelines, policies like dual-track financing and community systems strengthening. Participation of civil society is one of the fundamental principles of the Global Fund - and Germany as member of the Board has constantly been reinforcing this approach since 2002. In its framework document, the Global Fund states that it “will support programs that stimulate partnerships involving government and civil society.” With the objective to support financing for community action for better health outcomes the Global Fund Board recommends for proposals to routinely include measures for strengthening of community systems.

- However:

  • Capacity and information of CSO with regard to Global Fund guidelines is often weak and so is their role in national coordinating mechanisms;
  • National governments tend to see CS as a competitor or watchdog and tend not to work as closely as necessary with CS, despite evidence of the sector’s comparative advantage and Global Fund guidelines.

  • How BACKUP partners with CS to increase Global Fund grant efficiency and effectiveness

- The German BACKUP Initiative is one of two bilateral providers of technical assistance (TA) focussing on Global Fund related processes and strengthening civil society. Thus BACKUP is stepping in an important niche – increasing the visibility of German Development Cooperation internationally. (GHPC selection criteria: innovation)

- BACKUP’s support is demand-driven, flexible and fast which serves the particular needs of many CSOs. The TA incorporates three cross-cutting areas: health system strengthening, community systems strengthening and gender. (GHPC selection criteria: gender awareness)

- BACKUP procedures accentuate ownership of partner organizations by giving them the lead in designing and planning the TA. By raising relevant issues (see cross-cutting areas mentioned above) and discussing the preparation of the TA with the partner, BACKUP also aims to strengthen the partners’ organisational capacity. (GHPC selection criteria: participatory and empowering approach)

- In order to assure alignment with national policies and strategies, BACKUP requests partners to coordinate with national coordinating mechanisms, such as the CCMs, and also to seek the endorsement of the local GIZ Country Offices.

- Internal and external quality checks (i.e. CCM endorsement, GIZ Country Office endorsement, expert review and continued technical feedback in the proposal process through BACKUP staff) ensure compliance and quality of each proposal. In addition, BACKUP follows up on the implementation and quality of selected projects during its regular monitoring visits to partner countries. (GHPC selection criteria: quality of M&E)

- The current demand-driven BACKUP approach substantially supports the effective implementation of Global Fund Board decisions at operational level and thus reinforces the policy reform process of the Global Fund Board which is strongly encouraged by Germany (BMZ) as a Board member. Key reform processes encompass participation of civil society, gender equality, health system strengthening and rights-based approaches.

- BACKUP partners with important international CSOs such as ICASO/CSAT, IPPF and International HIV/AIDS Alliance. BACKUP also cooperates with multilateral organisations such as UNAIDS, WHO and the Global Fund Secretariat to help updating policies, technical guidelines and training documents re the pivotal role of civil society for comprehensive national responses to HIV, e.g. for most at-risk populations (MARP) such as sex workers, drug users or men having sex with men.

- BACKUP’s support for the Civil Society Action Team (CSAT) allows this civil society-led global initiative to coordinate, broker and advocate for technical support to CSOs implementing or seeking grants from the Global Fund. Hosted globally by ICASO, with seven regional hubs worldwide, CSAT delivers its mandate by identifying opportunities for CSOs to access Global Fund grants, provides information on technical support and guidance to CSOs and, through its community action activities, mobilizes advocacy and action on emerging issues in Global Fund grant processes.

- Its support, good working relations and regular exchange allow BACKUP to be well informed on current international developments and to provide feedback from country level experiences. On the other hand, BACKUP provides topical information from international discussions to its partner organizations at country level.

- By linking bilateral support at country level with multilateral cooperation, BACKUP can also feed back country level information as well as international discussions to the BMZ.

- The BACKUP approach in managing funds and providing fast and adequate technical assistance upon request has proven to be transferable to other sectors and development topics, , e.g. the GIZ sector programme on Pandemic Preparedness or the BACKUP Education Programme for Africa. (GHPC selection criteria: transferability)

 

What evidence on outputs (e.g., products or services, numbers of people covered) and outcomes (i.e., impacts on the health conditions and populations addressed) results and impact of this approach is available to show that it is effective?

  • Technical support mechanisms for Global Fund processes. A qualitative study. GTZ BACKUP Initiative; Katzan, Julia; 2008
  • BACKUP Programme Progress Review Report 2008
  • BACKUP Annual Progress Reports
  • Progress/final reports of international/multilateral partnerships (WHO, UNAIDS, CSAT, IPPF)
  • Selected project reports of supported activities
  • Reports of BACKUP monitoring visits to selected partner countries (Ghana, Burkina Faso, Nepal)
  • CSAT publications (e.g. on role of civil society in CCMs)
  • Analysis of performance of Global Fund CS Principal Recipients, 2011 (Global Fund, internal working document)
  • Global Fund Results Reports (annually published)

The BACKUP Initiative and the Global Fund have been created in 2002.
CSAT has been started by ICASO in 2007.

What documentation (studies, reports, photos, films (or other documentation) on the approach is available and can be used in describing it?

  • See documents mentioned above
  • Rolle und Bedeutung der Zivilgesellschaft am Beispiel der Deutschen BACKUP Initiative (GTZ, Abteilung 43, HH Rudolph und P Weis, Dez 2010).
  • Summary of technical support provided by the German BACKUP Initiative for the development of proposals to the Global Fund (Round 7 - Round 9). German BACKUP Initiative, Vezertzi, Marianthi; 2010
  • Health, Education and Social Protection. German BACKUP Initiative. A programme for supporting partner countries in handling global financing in the health sector. Factsheet, 2009
  • Millennium Development Goals in der Praxis. Projektbeispiele aus der GTZ-Arbeit weltweit, ‚Global Fund to fight AIDS, Tuberculosis and Malaria - Deutsche BACKUP Initiative‘. GTZ, Juni 2010
  • BACKUP Webpage at www.gtz.de/backup
  • BACKUP module in GIZ methodological product
  • German HIV Practice Collection. Regions of expertise. How Knowledge Hubs are boosting HIV prevention, treatment and care across whole regions; Bozicevic, I.; Schonning, S.; Jurkevich, I.; Kloss, K.; Laukamm-Josten, U.; Petitgirard, A.; 2010
  • Radiating knowledge. How a core of experts based in Croatia is boosting HIV surveillance across Eastern Europe, Central Asia and beyond. WHO Collaborating Centre Knowledge Hub for Capacity Development in HIV Surveillance. German BACKUP Initiative; Bozicevic, I.; Garcia Calleja, J. M.; Lesko, D.; Zigrovic, L.; Oreskovic, S.; 2009
  • Getting sensitive. Helping civil society groups gain funding for gender-sensitive HIV programmes. An Exploratory Project in Malawi and Uganda. German BACKUP Initiative; Papy, Juliette; Vezertzi, Marianthi; 2009
  • Deutsche BACKUP Initiative, Strukturprinzipien & Operationalisierung, 09/2010 (GIZ, internal document)

 

Which didactic or operational materials (manuals, IEC material, protocols) or similar can be made available for downloading from the GHPC online toolbox?

  • Guidelines for application. The BACKUP Initiative, July 2010
  • FAQ on the application and review process. Answers to recurring questions. The BACKUP Initiative, July 2010
    The German BACKUP Initiative’s Approach to Supporting Gender-Responsive HIV Programming. The BACKUP Initiative, March 2010
  • What makes HIV programmes gender-responsive? A guideline document produced by the German BACKUP Initiative. The BACKUP Initiative, March 2010
  • What makes health systems gender responsive? How to integrate gender-specific issues in health systems strengthening activities? Guidance for partner organisations applying for technical support from the German BACKUP Initiative, February 2011
  • Health, Education and Social Protection. German BACKUP Initiative. A programme for supporting partner countries in handling global financing in the health sector. Factsheet, 2009
  • Accelerating action. A technical support guide to develop capacity and to benefit from global health financing. The BACKUP Initiative, 2007
  • BACKUP application and report forms
  • Factsheet: Civil Society Action Team: Supporting civil society engagements in Global Fund grants, April 2009
  • CSS challenges for UNAIDS in providing TA, UNAIDS, July 2009
  • SUPPORTING COMMUNITY BASED RESPONSES TO AIDS: A guidance tool for including Community Systems Strengthening in Global Fund proposals, UNAIDS, January 2009
  • A framework for analysing and organising data regarding community system strengthening in Round 8, International HIV/AIDS Alliance, Global Fund Grant Support Team
  • Global Fund Community Systems Strengthening Framework, 2010
  • Global Fund, Round 10 Information Sheet: Community Systems Strengthening, 2010
  • Global Fund, Round 10 Information Sheet: Dual-Track Financing, 2010
  • Global Fund, CCM Guidelines
  • Report on Community Systems Strengthening (CSS) - Training Session, December 2008
  • Several CSAT guidelines, handbooks, publications on engagement of civil society in Global Fund work.
  • Aidspan guides at http://www.aidspan.org/index.php?page=guides

What itinerary and schedule would you recommend for the writer, when visiting your country to collect material for this GHPC report?

Give an indication of the places the writer charged with the documentation of this approach should visit, interviews to be done, the persons who should be interviewed and sites/events/activities that should be visited/witnessed and documented.

Country visits to:
- CSAT Hub: Thailand, Asia-Pacific Network of People Living with HIV/AIDS (APN+)/7Sisters, Vince Crisostomo, Regional Coordinator

- Partner organization on country level, e.g. in CARITAS (DRC), WAPCAS (Ghana), BURCASO (Burkina Faso), RENIP+ (Niger)

- Telephone or video conference with:

  • Robert Carr and Kieran Daly (ICASO),
  • Nadia Rafif, Kibibi M. Thomas Mbwavi, Titus Twesige, Vince Crisostomo (representatives of CSAT regional hubs),
  • Michael O’Connor, Sandii Lwin, and Fund Portfolio Managers, (Global Fund)),
  • Joy Backory (UNAIDS),
  • GIZ AV, e.g. Holger Till (Ghana), Klaus Hornetz (Kenya), Anselm Schneider (DRC), Markus Behrend (Nepal)
  • International HIV/AIDS Alliance (Renato Pinto and Lee Abdelfadil - Brighton, Javier Hourcade Beloq - LAC)

When, where and in which language (in addition to English) would you like to distribute the resulting publication?

Name upcoming conferences and routine events and information channels through which you hope to distribute the publication: ICASA African AIDS Conference in December 2011 (Addis Ababa, Ethiopia), International AIDS Conference 2012 (Washington), GIZ Sector Network Meeting Asia and Africa, GIZ healthnet mailing list, download from BACKUP website, ICASO and CSAT website, Knowledge Hub networks.

Give estimates of the number of printed copies that you would need per language version

Short version English: 1000
Short version 2nd language
Long version English:
400
Long version 2nd language

Please note that we will contact you one year after the publication date to find out whether you were able to distribute the report as planned.

Applicants

GIZ

Peter Weis
Head of Programme
peter.weis@giz.de
Tel. +49-6196-79-1080

International Council of AIDS Service Organizations (ICSAO) / Civil Society Action Team (CSAT)

Robert Carr
Director, Policy and Advocacy
robertc@icaso.org
Tel. +1-416-921-0018 ext 17

The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria

Michael O’Connor
Team Leader
Private Sector and Civil Society Team
Michael.OConnor@theglobalfund.org

Quality needs people (SQI network)

Why should this approach be documented in the German Health Practice Collection?

Describe in what ways this approach is innovative or representative of the ‘state of the art’ in its field; explain how it contributes to raising the profile of German Development Cooperation in its field (refer to policy briefs, sector strategy papers and the GDC profile in health or HIV, respectively).

Why does quality matter? What seems like a ridiculous questions becomes more complicate if we wonder why available resources are not always translated into a system which produces quality results, in health but of course also in other sectors. A common misunderstanding of decision makers is that inputs like money, staff, or infrastructure automatically lead to the desired results and that inputs simply need to be increased if the results are not satisfying. The SQI approach looks at the processes between inputs and results and offers answers how to use inputs more efficiently and achieve better quality with the systems’ resources.

SQI is a generic approach which was developed in the health sector, but can be used in various sectors and adapted to different contexts.

A large number of organisations at different levels in a multilevel system (policy, management and implementation) define standards and goals in an ongoing and participative way which can be used to measure their achievements, compare themselves with others competitively, learn from the results and initiate changes.

SQI was started in Guinea and was then adapted to other countries like Morocco, Cameroon, and Yemen. SQI is being also introduced to improve services for the victims of gender based violence in the Democratic Republic of Congo.

SQI brought a culture of self assessment and continuous improvement to hundreds of health care facilities within a short time period of one to two years. The high number of health facilities created a critical mass for improvement, “pulling” other facilities with them.

The participative and systemic approach supports the management of sectoral reforms and enables a more systematic and efficient resource allocation. As a result, SQI links TC and FC partners and improves the health system as a whole. At the same time, dormant forces in the system are mobilised by the competition, awareness for quality and personal responsibility is strengthened, and incentives are created for personnel working at the implementation level. A decisive factor for sector-wide effect is that all institutions in the health care system are included in the quality management – both those responsible for health care administration and those responsible for health care delivery.

SQI as methodological product (DMS 177) is included in the GIZ strategic orientation for scaling up .

A pool of experts from countries that had experienced the approach was created to safeguard the specificity and innovative character of SQI, while keeping in focus the diversity of the different settings.

Morocco:

The prototype for this systemic quality improvement approach is based on the “Concours Qualité” implemented by the Ministry of health in Morocco with the support of GIZ. It focuses on achieving process quality through positive, voluntary competition, for the dual purpose of promoting institutional development and improving the performance of the health care system as a whole by strengthening the implementation of corresponding reforms.

Three editions were so far implemented with steady increasing numbers of participants. The third edition, held in 2010, was entered by all the country’s provincial health departments, all the Ministry of Health hospitals and all the maternity hospitals. For health centres, the “Concours Qualité” was organised on a decentralised basis.

The specific incentives for participation were the visibility and rating of the work of the individual structures in the sector, plus financial “rewards” by linking state subsidies and investment to the action plans. Significant results were so far produced: implementation of quality culture and leadership, better self esteem of health workers, better application of standards and guidelines, closer relations between the different health care system levels and more visibility of quality improvement interventions. The main achievement is that the “Concours Qualité” has provided new momentum and drive in Morocco’s health care system.

A major success factor was the strong political support and the strong involvement of the ministry of health in conception and implementation.

The sustainability of the approach after the closure of the GIZ project is reinforced by the European Union health sector program that had included SQI as a condition for program implementation.

Yemen:

The Yemeni Quality Improvement (QIP) approach has an overwhelming acceptance amongst the leadership of the Ministry of Public Health and Population (MoPHP), managers and primary health care staff. It has proven a strong and sustained mobilizing effect on first-line health facility staff, encouraging them to engage in a self-determined quality improvement process. It also has shown an outstanding effect on user satisfaction and user rates in the enrolled facilities. Even in a little conducive environment with very low public health budget, a stagnating civil service reform and an incomplete decentralization process most of the QIP participants continue on their own after a year of programme support; some even spread the QI process to technical areas not supported by the YGRHP, and convince local councils and other development partners of supporting them.

QIP gives an example how a participatory, culturally adapted process can lead to the successful implementation of a rather innovative program even in a difficult environment.

What evidence on outputs (e,g., products or services, numbers of people covered) and outcomes (i.e., impacts on the health conditions and populations addressed) results and impact of this approach is available to show that it is effective?

Please list all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach. Also, please explain how long this approach has been implemented to date

Documents Morocco:

Three sessions of “Concours Qualité” (2007, 2008/09 and 2010) have been so far implemented nationally with a constantly increased number of participants from several types of health facilities at decentralized level.

Documents Yemen:

Guidebook: “Quality improvement for health care providers: With friendly guidance and support”.

Health Management Research & Training Institute: Assessing the effects of the Yemeni German Quality Improvement Programme (YG-QIP) on utilisation of services, user and staff satisfaction. Final Report May 2010.

QIP is implemented since 2006 with gradual but steady expansion.

What documentation (studies, reports, photos, films (or other documentation) on the approach is available and can be used in describing it?

Morocco :

  • Film 2010 English version
  • Flyers Concours Qualité ( Arabic, French, English), maternities (Arabic, French and English), flyers CDTMR (Arabic and French)
  • Operational guide (French and English)

Yemen:

  • Factsheet QIP
  • Success stories of the Yemeni-German Reproductive Health Programme: The spirit of change.

Which didactic or operational materials (manuals, IEC material, protocols) or similar can be made available for downloading from the GHPC online toolbox?

Generic product:

SQI advisors guide

Morocco:

Guides d’auto évaluation et de score en PdF de 5 types de structures, Module de formation des auditeurs analystes, différentes présentations ppp
Le Concours Qualite du systeme de santé du Maroc - Guide operationnel, Juin 2010

Yemen:

Guidebook: “Quality improvement for health care providers: With friendly guidance and support”

Comprehensive HIV & TB Programme for Hospitality Industry and High Risk Groups (Ghana)

Why should this approach be documented in the German Health Practice Collection?

This project focuses on using the hospitality industry to reach High Risk Groups such as sex workers and their clients. It contributes to GIZ’s profile through the raising of awareness on HIV/TB within the most at risk population (MARP).

Unique with this project is the partnerships that have been formed to afford the implementation of this project. Through a co-financing mechanism between GIZ-Support for the Private Sector in the AIDS Fight in Africa (SPAA), the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) Round 8 project. The GIZ-Regional Coordination Unit for HIV & Tuberculosis, based in Ghana, with its extensive experience in the area of sustainable HIV & TB workplace programmes, is acting as sub-recipient to the GAC and supporting the Ghana Tourist Board in implementing a HIV & TB workplace programme for Hospitality Industries in Ghana with a focus on high risk groups and high risk behaviour.

Also innovative is the comprehensive approach to HIV testing. In order to increase uptake for HIV testing in a setting which cuts down on stigma, an approach of testing at the same time for other preventable diseases such as hypertension, and diabetes is employed.

What evidence on outputs (e.g., products or services, numbers of people covered) and outcomes (i.e., impacts on the health conditions and populations addressed) results and impact of this approach is available to show that it is effective?

The approach started in May 2010. Therefore the external evaluations are still in progress. Evidence can however be provided through the following:

  • Quarterly narrative and financial reports
  • M&E reports
  • M&E Workshop report
  • Hospitality baseline survey
  • Needs assessment survey

In addition to being innovative and effective, approaches documented in the GHPC should be: transferable to other contexts; participatory and empowering; gender-sensitive; cost-effective and sustainable. In what way is your approach meeting these criteria?

The approach is transferable to other industries as well as to other countries. The Regional Coordination Unit for HIV & TB (ReCHT) already has extensive experience with HIV-Workplace Programmes and Employee Wellbeing Programmes embracing health, social protection and financial wellness. The programmes are planned and implemented in partnership with private organisations from several sectors, such as mining, automobile industries, banking or beverages, and public partners in the areas of revenue, health, transportation and water. The joint financing of such programmes generally leads to commitment and the use of synergies. The co-financing mechanism with the GFATM is different in the sense that the partner, the Ghana Aids Commission, is fully providing the financial resources through the GFATM. However, being the principal recipient their involvement is high and therefore ownership is high.

The approach is also highly participatory as the hospitality industries and the Ghana Tourist Board (GTB) are taking ownership by appointing focal persons to actively engage in the planning and implementation process. The Ghana Tourist Board in collaboration with the hospitality industry have been empowered to take up the whole programme once the GFATM financing mechanism has phased out, which also makes the programme sustainable. The joint use of resources, such as bringing all focal persons under one umbrella regionally and developing only one joint Workplace Policy for the entire industry makes the programme cost-effective.

Which existing documentation materials (studies, reports, photos, films (or other documentation) could be used as background for the proposed publication?

The reports under point five (5) can fully be made available. Additionally, pictures are taken of each activity and/or programme. On 5th May 2011 there will be the policy launch of the programme which will be pictured and most likely filmed.

Which didactic or operational materials (manuals, IEC material, protocols) or similar can be made available for downloading from the GHPC online toolbox?

  • A comprehensive Workplace Policy.
  • Different information materials, such as two (2) different posters on safe sex, one (1) poster on condom use, two (2) brochures on condom use. More materials are currently being developed, an education video on various diseases such as Malaria, HIV/AIDS, or Hepatitis B.
  • All studies can be shared.

What itinerary and schedule would you recommend for the writer, when visiting your country to collect material for this GHPC report?

The following sites should be visited by the writer:

  • Ghana Aids Commission(GAC)
  • Country Coordinating Mechanism (CCM)
  • GIZ-ReCHT
  • Ghana Tourist Board (GTB)
  • Novotel Hotel

The following persons are potential interviewees:

  • Dr. Angela El-Adas (GAC)
  • Dr. Derrick Aryeh (CCM)
  • Dr. Holger Till (GIZ)
  • Adeline Boateng (GTB)
  • Bertha Appeynarh (GTB, Regional)
  • Mr. Amon Kotei (Novotel Hotel)

When, where and in which language (in addition to English) would you like to distribute the resulting publication?

Conference on Cooperation with Private Sector Health Africa in Tanzania, Regional EWP Structure, ReCHT’s private and public partners, Sector Network for Health and Social Protection

Applicants

GIZ Regional Coordination Unit for HIV & TB (GIZ-ReCHT)

Dr. Holger Till, Team Leader, GIZ-ReCHT
Phone +233-24-4335516
Email: holger.till@giz.de

Ghana AIDS Commission

Angelea El-Adas, Director General
aeladas@ghanaids.gov.gh
+233-302-762492

Strengthening the Indonesian National Health Information System as catalyst to strengthen the health system

Why should this approach be documented in the German Health Practice Collection?

Since 2000, the German government through GIZ supported the health sector in Indonesia with the implementation of 5 projects in 3 provinces. In 4 of these projects, improving health information systems featured strongly as identified solution towards health systems strengthening. Among initiatives introduced were management information systems for hospitals, primary healthcare centres and human resources at provincial and district health offices. During the process of implementation, it became clear that various shortcomings at the national policy level are obstacles for sustainable success.

As the German Development Cooperation in the health sector comes to an end in Indonesia by 31 Dec 2011, the final phase of the Consolidation Program / Policy Analysis and Formulation (PAF) included strengthening of the Health Information System (HIS) on the policy level in its programme. This was a strategic decision to address the chronic needs for improvement of the management of the Indonesian (HIS). Problem areas within the HIS include:

  • Fragmentation in the system resulting in various programs, departments, donor agencies and academician having their own information system for the collection of health data and indicators. This resulted in duplication and waste of resources, inaccuracy of data and a high burden for field health workers.
  • In the year 2001, Indonesia switched from a strong centralized authoritarian regime to a decentralized democratic system with changes in roles and responsibilities for central and local level. Decentralization brought about unintended side effects whereby provinces embarked on individual initiatives in the absence of clear guidelines and governance from the central level. Decentralization and lack of governance from the central level resulting in various different types of HIS, often not interoperable, being adopted at the local level.
  • Weak management capacity of the staff of the Health Data and Information Centre (Ministry of Health-MoH) and at the local levels.

Consequences of this situation is that  some provincial health offices produce over 300 reports  (ranging from surveillance to annual reports) and use up to eight different health related information systems (software). This problem occurs frequently in other countries as well and is not addressed due to a lack of resources and capacity.

The strategy adopted by PAF is to assist the MoH in producing a comprehensive HIS strategic plan together with the introduction of a new HIS model, capitalizing on Information and Communication Technology (ICT) solutions. A HIS framework is also being drafted to serve as a guideline on minimum standards and interoperability. The technical expertise provided by GIZ is drawn from the HIS experiences in 3 different provinces in a decentralized environment. The experiences confirm that strong governance and standardization is required to avoid systems fragmentation.

As the activities in the strategic plan are being concretized and are going through the process of national review and approval, the most crucial activities are being funded and implemented through the support from PAF. These are

  1. Capacity building of the Centre for Data and Information (CDI), MoH
  2. Development of a generic HIS software
  3. Short training programs for HIS managers in the field

Recognizing the need for further financial and technical support towards the successful implementation and continuation of the activities within the strategic plan, PAF identified “application to round 10 of the Global Fund to fight AIDS, TB and Malaria” for funding under its health system strengthening component as the solution. Through the financial support from the German BACKUP Initiative, the CDI MoH as the primary recipient has been granted USD 12 million over the next 5 years for implementation of HIS strengthening activities.

The main argument on why this should be documented by GHPC is the unusual and innovative approach; A common and serious but often insufficiently addressed problem of weak HIS governance is tackled by assuring that the MoH obtains sufficient funding through a global health initiative. To bridge the time period of receiving the funding and to be fully prepared to implement the activities appropriately, PAF is offering the MoH technical expertise and advice in building up the national policies and to guarantee sustainability. The outputs and experiences from the previous 3 German supported projects in the area of HIS are capitalized and consolidated at the national level with the current PAF project. The previous projects provided PAF with the thorough understanding of the Indonesian HIS challenges and built up the expertise and competences to provide the MoH with the support provided currently by PAF.

 

What evidence on outputs (e,g., products or services, numbers of people covered) and outcomes (i.e., impacts on the health conditions and populations addressed) results and impact of this approach is available to show that it is effective?

Please list all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach. Also, please explain how long this approach has been implemented to date;

Input:

The tools, results, experiences and lessons learned in the area of HIS from the 3 former German supported projects (Aceh, HRD, SISKES) in the provinces of Aceh, NTT and NTB are now used in the support provided by the PAF project to the MoH. This results in the PAF team being able to provide advice and assistance which accommodates the realities of the decentralized areas.

Output:

The following are the outputs of this initiative:

  1. HIS strengthening 5 year national strategic plan
  2. HIS framework document
  3. Curriculum on HIS manager training (short course)
  4. Generic HIS application software (for primary health care centres, and district/provincial health authorities)
  5. PAF supports the capacity building of staffs within the CDI MoH to ensure the momentum for HIS strengthening can continue post GDC support

Use of Output:

  1. The strategic plan guides improvement initiatives and budgeting planning for HIS strengthening by CDI MoH.
  2. HIS framework document is used as a national guideline to promote standardization and integration of systems (interoperable).
  3. Due to the high cost of procuring application software for computerized HIS, the MoH will issue a generic HIS software (developed by PAF, free and open sourced) to be used by provinces which does not have funds prior to procure such applications. This software will encompass functions of all the currently used health software to ensure that users only need to use 1 platform for their work.

Impact:

Strengthened governance of the HIS allows for improvement in the provision of timely, accurate health data to better support decision making in the health sector

 

In addition to being innovative and effective, approaches documented in the GHPC should be: transferable to other contexts; participatory and empowering; gender-sensitive; cost-effective and sustainable. In what way is your approach meeting these criteria?

 

Transferable

All solutions identified can be used to address similar situations in other environments. Precisely why publication of the approach and solutions is so crucial.

Participatory

The solutions identified for HIS strengthening are collectively derived through focus group discussions between GIZ PAF technical advisors and the counterpart. Experience shows that the counterpart knows and understands the problems and solutions but that they were unable to plan and implement strategically.

Gender sensitive

The HIS provides accurate sex disaggregated data enabling gender sensitive decision and policy making.

Cost effective

Improved governance of the HIS results in the harmonization of various systems. This reduces duplication in efforts to record and report health data and in turn makes the health system more efficient and hence more cost effective.

Sustainable

Capacity building of technical staffs within the CDI MoH in strategic thinking and in understanding the common HIS issues; advocacy to the top management within MoH ; and ensuring sufficient funding resources will help to ensure efforts are sustained.


Which existing documentation materials (studies, reports, photos, films (or other documentation) could be used as background for the proposed publication?

GIZ PAF HIS Factsheet
GIZ PAF HIS policy development experience in Indonesia (presentation)

 

Which didactic or operational materials (manuals, IEC material, protocols) or similar can be made available for downloading from the GHPC online toolbox?

Indonesian HIS Strategic Plan (expected completion June 2011)
Indonesian HIS Framework (expected completion Oct 2011)
Sample curriculum for HIS short course (expected completion June 2011)

Applicants

Consolidation Programme Health / Policy Analysis & Formulation in the Health Sector (PAF) Indonesia

Paul Rueckert, Principal Advisor, GIZ
paul.rueckert@giz.de
+62 (811) 889108

Ministry of Health, Indonesia

Jane Soepardi, Head of Department, Centre for Data and Information
janesoepardi@yahoo.com
+62 (81) 1966169

BMZ glossary

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