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Proposals in 2016


In 2016, six programmes submitted proposals about their implementation experiences for documentation and publication in the German Health Practice Collection. As in previous years, all GIZ- and KfW health and social protection experts, and their counterparts, were invited to have their say in the selection of those which should be documented and shared with an international audience.

In November 2016 the BMZ division ‘Health and Population Policy’ decided that learnings generated by the IDPoor programme in Cambodia and by the population dynamics project in Togo should be documented as GHPC case studies. In addition, they requested that the GHPC should produce an Evidence Brief on possible role that local pharmaceutical production could play in health system strengthening and specifically for pandemic preparedness. The Evidence Brief is meant to feed into the respective discussions at the G20 summit in Hamburg in June 2017.

Improving Access to Medicines in the East African Community through strengthening local pharmaceutical manufacturing

1. Working title for the proposed case study

“Improving Access to Medicines in the East African Community through strengthening local pharmaceutical manufacturing”

2. Applicants

German programme: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) - Global Project “Access to Medicines”, Sector Project “Development-oriented Trade Policy and Trade and Investment Promotion”, Regional Project “Support to the East African Community Integration Process”.

Partner: The East African Community Secretariat

3. Development challenge

Access to medicines is a key element of a functioning and effective health system. Access can be understood four-dimensionally: (1) medicines must be available in the sufficient quantity; (2) they must be physically and financially accessible to all population groups; (3) medicines must be medically and culturally acceptable; and (4) of good quality. However, the World Health Organisation states that about two billion people worldwide cannot access the medicines they need. For example, the United Nations estimates that 1.2 million people died as a result of AIDS in 2014, and many million more are affected by other communicable diseases. These lives could have potentially been saved or extended with access to appropriate treatment. The causes for shortcomings in medicines supply are diverse; medicines are not affordable, they are not available where the patient lives and/or are of sub-standard quality. Furthermore, for some diseases, especially those tropical diseases that most often affect lower-income countries, effective treatments do not exist yet due to lack of research. The United Nations has taken up the issue of access to medicines in the 2030 Agenda included in Target 8 of Sustainable Development Goal 3 on healthy lives which states, “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”.

In the East African Community, made up of the Member States of Burundi, Kenya, Rwanda, Tanzania and Uganda, access to medicines remains an ongoing challenge. While improvements have been made in the access to treatment for some widespread infectious diseases such as malaria or HIV/AIDS, overall prevalence levels are still high and vary strongly in between countries. Table 1 provides the example of access to anti-retroviral drugs:

Proportion (%) of population with advanced HIV infection with access to antiretroviral drugs
Country 2009 2011
Burundi 35,3 53,5
Kenya 50,8 72,3
Rwanda 76,9 81,7
Tanzania 32,1 53,9
Uganda 41,0 53,9

Table 1 (Source: EAC RPMPOA Poverty Impact Assessment)

Additionally, other communicable and especially non-communicable diseases like cancer or diabetes are on the rise in East Africa. Currently, treatment is unaffordable to most low-income patients if available at all. Moreover, maintaining quality of medicines in the market is often impaired by poor storage facilities and weak capacities of medical professionals to manage drugs.

4. Intervention / implementation 

Addressing the shortage of medicines in developing countries and East Africa in particular has been on the development agenda for some time now. The main tool of the international community has been to directly provide low-cost medicines to affected countries via channels such as the Global Fund. While this method has shown some success, it cannot sustainably solve the underlying structural problems in the global pharmaceutical market. The industry is dominated by large research-based, profit-driven pharmaceutical companies from mostly industrialized economies. Patent protection allows companies to charge high prices to recover research costs, but in turn makes drugs often unaffordable for low-income patients. Moreover, the market for medicines against tropical diseases is small and offers little economic incentives for developing better treatment options. The situation was somewhat alleviated by the rise of generic medicines producers in Asia that brought down the prices of essential drugs. However, many developing countries still remain completely dependent on international companies and the donor community to ensure uninterrupted access to essential medicines.

Thus, strengthening local pharmaceutical manufacturing can be an important step towards sustainable access to medicines through establishing self-sufficiency of developing countries in their medicines production. Additionally, there is evidence that local manufacturing has several extra advantages; it can improve product affordability, cater better to local health needs, and create distribution networks that especially target the needs of poor consumers in rural areas. Moreover, the existence of pharmaceutical production is associated with advanced technological, industrial, intellectual, organizational, and research-related capabilities that are paramount to tackling developing countries’ healthcare needs.

The strength of the pharmaceutical sector differs greatly from one EAC country to the next. Kenya is the main pharmaceutical hub with 42 listed companies and 30% of demand produced locally. In contrast, Tanzania’s local production share has been decreasing and the three landlocked EAC countries are even more dependent on imports, including imports from Kenya. The German development cooperation has noted great potential within the region, as the EAC has selected pharmaceutical production as one of its strategic industries for regional policy support.

Since 2012, the regional GIZ-EAC cooperation programme has supported local pharmaceutical manufacturing. In order to integrate the interventions in a sustainable strategic framework, the GIZ project assisted the development and governance of the EAC Regional Pharmaceutical Manufacturing Plan of Action (RPMPoA) by the EAC Secretariat and relevant stakeholders. Moreover, next to building the policy and governance structure, the project made sure to increase the coordination capacity of the private sector itself by strengthening the Federation of East African Pharmaceutical Manufacturers (FEAPM). During this process it became clear that an effective strategy has to coherently address six topics that together form the pillars of the RPMPoA:

  1. Promotion of pharmaceutical production
  2. Investment in pharmaceutical production
  3. Medicines regulation capacity
  4. Skills and knowledge on pharmaceutical production
  5. Utilization of TRIPS flexibilities
  6. Pharmaceutical innovation, research and development

Over the years, both the Global Project “Access to Medicines” and the Sector Project “Development-oriented Trade Policy and Trade and Investment Promotion” have since joined to support individual activities within this RPMPoA framework.

The sector project has been especially active in the pillar on advising EAC countries on how to use the flexibilities of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). The exemption of least-developed countries (LDCs) from having to provide protection of pharmaceutical patents, which has recently been extended until 2033, creates a powerful incentive for investors to invest in the generics industry in LDCs and thereby build their technological capabilities. Subsequently, the Sector Project has concentrated on capacity building for implementation of TRIPS in a way that secures other objectives like access to medicines. Participants were members of government institutions, parliamentary structures, patent offices, representatives of the judiciary, as well as civil society organisations. The joint training with partners such as UNCTAD, South Centre or UNIDO, were in many cases accompanied by policy advice on how to build a legal framework that encourages innovation, technology transfer and access to medicines without violating intellectual property rights. Alumni of capacity building measures can today network and discuss policy and legal approaches to access to medicines and the promotion of innovation on the Global Academy for Innovation and Access platform (www.gafia.com)

In addition to supporting the RPMPoA’s steering structure and providing advice on policy coherence for access to medicines in the EAC, the Global Project implemented several more specific interventions, such as bringing universities and local producers closer together by establishing an internship programme. Furthermore, GIZ has conducted an analysis of the local medicines market to allow producers to better position themselves. The Global Project also engages in the strengthening of regulatory capacities through training, for instance teaching Kenyan regulatory bodies on issues like WHO inspection standards.

To conclude, the chosen approach is quite complex in its geographical reach across the five EAC countries and the diverse partner landscape. However, this reflects the complexity of the requirements of the pharmaceutical sector.

5. Implementation challenges, adaptation and learning

Overall, the GIZ projects have been quite successful in putting local pharmaceutical manufacturing high on the agenda of the EAC’s policy on access to medicines. The knowledge and engagement of many different stakeholders on the topic is remarkable. However, the process of implementing the RPMPoA has only begun and faces several bottlenecks.

To begin with, it was a challenge to move from establishing the regional plan of action to its implementation on a national level. Ultimately, the governance structure had to be expanded to include national steering groups and focal points. With the additional support of the Global Project, which has more possibilities to work bilaterally on a national level, this could be realized.
Yet, the national focus also has its downsides: For instance, the liberalization of cross-country public procurement would help to create a real common market for pharmaceuticals, but is currently not making advances. Since this is an issue that requires a solution on a regional level, the GIZ projects realized that it is important to keep the balance between supporting national implementation and not forgetting about the regional aspect. Thus, delegates from the national steering groups still meet on a regional level. Likewise, the projects continue to work with the private sector on lobbying for regional support policies like finalizing the liberalization of regional public procurement.

Another interesting governance issue is the question of who shall lead the policy process. The regional EAC project started off working closely with the EAC Secretariat’s department responsible for health, but the Secretariat slowly shifted the responsibility towards their industrialization department. The GIZ projects reacted by making sure to always integrate both the health and the industry aspect of supporting local pharmaceutical manufacturing. In the national steering groups, this has translated into the participation of multiple line ministries. Interestingly, depending on the country, the responsibility of chairing the national steering groups was either taken up by the Ministry of Industry, Ministry of Health, or even a respective private sector association. Through the regional coordination and the overarching RPMPoA, the GIZ projects can make sure that the implementation processes are moving into the same direction. The Global Project’s activities on policy coherence should help to further align the efforts of different line ministries and other stakeholders towards the goal of improving access to medicines.

The activities concentrating on improved utilization of TRIPS flexibilities have been successful in creating awareness for the topic among policy makers and knowledge gained is reflected in the EAC Regional Intellectual Property Policy. Yet, many local producers still find it difficult to use the TRIPS flexibilities to their benefit and produce patent-protected generics. In many cases, this is connected to the technological complexities. A stronger technology and knowledge transfer from industrialized countries could improve the use of the flexibilities. Yet, local production facilities also need to upgrade to be able to produce more advanced pharmaceuticals. With the Global Project’s activities on supporting the upgrading to the WHO Good Manufacturing Practices in Kenya, GIZ recently started to put more emphasis on this issue. Yet, in the context of the German Health Care Practice Collection, it would be interesting to explore the limited use of the TRIPS flexibilities incentive for local production in greater detail.

Finally, in order for local pharmaceutical manufacturing to be successful in the long-term, producers need to be able to access new markets. Currently, important markets remain closed for locally produced medicines. This counts especially for the large international tenders of donor funds and international agencies that rarely source in East Africa, but generally prefer to import drugs from Asia. While these are often cheaper due to economies of scale, some East African companies would be able to competitively supply a smaller share of the demand. Moreover, in the long-term, a more developed local production in East Africa would make the countries less dependent on this donor support in the first place. This trade-off between the future-oriented sustainable approach and the approach of procuring as efficiently as possible in the present leads to incoherencies in the German and international development cooperation with the EAC. The GIZ projects have started to discuss these issues with agencies like the Global Fund and they seem to be interested to begin procuring locally to a limited degree, but this process will still take a while.

6. Results

So far, the major outcome has appeared at the policy and systems levels: The development of the EAC RPMPoA and the frequent meetings of its regional and national steering groups are promising, as are the TRIPS activities contributed to the Regional Intellectual Property Policy. Moreover, the capacity of the private sector to get involved in policy discussions has been strengthened; FEAPM has now more than 30 member companies and is frequently meeting with the public sector.

It is harder to connect activities to outcomes reflecting a stronger local pharmaceutical industry. Yet, certain output indicators show how the projects have directly strengthened producers. For instance, the Global Project has supported gap analyses in 34 Kenyan companies on what must be improved for them to meet the WHO Good Manufacturing Practices standards. Based on this analysis, several of the largest Kenyan companies can now plan their next investments.

7. Insights

The German development cooperation’s approach of using local manufacturing to sustainably improve access to medicines is quite unique. Its application in the EAC is the longest-running and most encompassing project of its kind. This case study can shed more light on the effectiveness of this approach, which can be especially relevant in the context of the UN High Level Panel on Access to Medicines, which seeks to identify innovative approaches to the old problem of balancing access and inventor rights.

Moreover, local production can be discussed as part of the Agenda 2030. It can be one way to reach SDG 3.8 [“achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”] in a more sustainable manner than the delivery of donated drugs to developing countries.

Ensuring the safety of medicines: Monitoring adverse drug events and occurrence of falsified medicines in Malawi

1. Working title

Ensuring the safety of medicines: Monitoring adverse drug events and occurrence of falsified medicines in Malawi

2. Applicants

Names of German programme(s) and partner institution(s) submitting this proposal:
Partner: Pharmacy Department, College of Medicine, University of Malawi
German programme: Malawi German Health Programme, GIZ Malawi

3. Development challenge 

Many causes of disease can be prevented or treated with effective essential medicines. However, any medicine may have adverse effects, and in developing countries these adverse effects can be different from those in developed countries due to different co-morbidities and co-medications, different nutritional status and different genetic predisposition of the patients. It is therefore recommended by the World Health Organization (WHO) that all countries introduce Pharmacovigilance Centres to detect, assess, and prevent adverse drug effects1. In 2010, 134 countries had introduced a PV programme. As one of the world’s least developed countries, Malawi was not part of this group of countries, still in 2015, and remained without a PV Centre and/or respective assessment expertise. In addition, the topic was not included in the curriculum of the Pharmacy Department of the College of Medicine, the medical faculty of the University of Malawi (UNIMA).

Another serious medicine-related risk results from the occurrence of falsified and substandard medicines which are found especially in countries where the infrastructure for pharmaceutical analysis is weak. Substandard and falsified medicines pose a serious threat to public health:

  • They lack therapeutic efficacy which results in prolonged illness and even death of patients. 
  • They may cause direct harm to patients by toxic effects. 
  • Their purchase, distribution and application leads to a waste of scarce resource in the health care sector. 
  • They create a loss of credibility of the health care system, especially at community level.
  • Health workers lose trust in medications and treatment schedules, undermining adherence to treatment guidelines.
  • Insufficient amounts (or insufficient release) of anti-infective ingredients contribute to the emergence of antibiotic resistance pathogens. 

Alarming reports have been published on the scale of this problem. A review of surveys from 21 countries of sub-Saharan Africa concluded that 20 % of medicines were falsified, and 35 % failed chemical analysis. It has been estimated that more than 120.000 deaths of under-five children annually may be associated with the consumption of poor-quality antimalarial medicines.

Especially least developed countries like Malawi need to be empowered to (1) determine the scale of adverse effects of genuine medicines in their respective country context, as well as (2) to assess the prevalence of falsified and substandard medicine in their country, in order to inform politics on the scale and severity of the problem, and in order to allow the planning and execution of appropriate countermeasures. This is often prevented by the exorbitant costs of equipment for drug quality analysis. Where such equipment is available, its technical sensitivity leads to high maintenance requirements and costs. In the absence of expertise in and budgets for technical maintenance, this consequently limits the effectiveness of expensive high-tech equipment in low-resource countries, as the equipment very soon becomes dysfunctional. Therefore, innovative, low-cost solutions are required, especially for de-centralized, continuous surveillance programs for medicine quality.

[1] Pharmacovigilance (PV) is defined as “the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other drug-related problem”

4. Intervention / implementation

The two development challenges outlined above (adverse drug reactions caused by genuine, good-quality medicines, and public health risks presented by falsified / sub-standard medicines) require an integrated approach, based on human resource capacity building and support with the institutionalisation of required national medicine control structures. A sustainable solution requires the long-term commitment of national stakeholders, including academic research institutions, regulatory bodies, and health care providers, as well as the formation of long-lasting partnerships with international reference centres and laboratories. As funding is scarce, innovative, low-cost solutions need to be identified to assure sustainable, independent practice upon termination of donor support. With these conditions in mind, the following approach was chosen. The implementation concerns the time frame of 01/2014 – 12/2016. The results of the implementation benefit the entire population of Malawi, insofar as Malawians are in need of medication purchased / prescribed locally.

The approach chosen by the Malawi German Healt Programme (MGHP) rested on several pillars. Firstly, an integrated expert was placed in the Pharmacy Department of College of Medicine (CoM) to provide technical and organisational support to the Department. Together with the department’s leadership, he assessed the ability of the Pharmacy Department of CoM to respond to priority areas within the mandate of the department. Upon identifying the interest of the Department to address the area “Safety of Medicines”, he furthermore assisted the Department in identifying the institutional and structural challenges and the requirement for additional expertise. Through these joint efforts of Department leadership and integrated expert, it became clear that the Department as well as other stakeholders, such as the national drug regulatory agency, the “Pharmacy, Medicines and Poisons Board of Malawi”, were eager to address the challenges at hand, but human and financial resource shortages prevented Malawi in moving the issue forward.

Having verified both the need for support in the area of Quality of Medicine, as well as the willingness of national stakeholders to institutionalize the topic of quality control of medicines as a priority intervention area, the MGHP, through the Integrated Expert at CoM, engaged in the development of a strategy which would transform the Pharmacy Deparment from a stakeholder with an interest, but very limited capacity in the field of Safety of Medicines, to the country’s most active agent in Safety of Medicines in a time span of just over one year. This was achieved through the following milestones:

Firstly, the Pharmacy Department at College of Medicine identified its human resource needs required to transform the Department into a leading provider of Safety of Medicine education. Upon consolidation of this list, financial commitment was sought from the College’s management to assure the long-term employment of the respective personnel as College staff, financed by the University of Malawi. Only when the long-term funding requirements were secured, the Department, with support of the GIZ Integrated Expert, approached the Malawi German Health Programme for additional support, which was realised as follows:

Firstly, with financial assistance from the GIZ-implemented EU/BMZ co-funded programme “Strengthening Specialised Medical Care in Malawi” (SSMCM), a highly qualified and experienced female Malawian pharmacist was repatriated from the UK. The expert consequently joined the Pharmacy Department of CoM under a UNIMA-funded full-time contract. This partner commitment is seen as critical to the success of this measure.

The repatriated expert and another senior department member were consequently capacitated through the SSMCM project to attend training courses in Pharmacovigilance at the WHO Collaborating Centre for Pharmacovigilance in Accra, Ghana, and the WHO Collaborating Centre for International Drug Monitoring in Uppsala, Sweden, respectively.

Next, a pharmacovigilance expert from the University of Cardiff, UK, was brought to Malawi to assist the Pharmacy Department to develop a teaching curriculum for Pharmacovigilance, with assistance of the SSMCM Project. This subject has since been integrated into the overall Pharmacy curriculum and assures the continued qualification of PV experts in the country through the above-mentioned.

In addition to the introduction of Pharmacovigilance as a field of academic teaching, the Department of Medicine, with support from the Integrated Expert, the MGHP, and other partners (U.S. Centre for Disease Control; WHO), managed to establish, furnish, and equip a Pharmacovigilance Centre. This was realized on the grounds of the College of Medicine’s main campus in Blantyre, through provision of office space by CoM, and financial support for the equipment of the centre from various partners, including funds from the MGHP. A pilot study on the utilization of mobile phones for the reporting of adverse drug events was initiated.

With regards to the identification of sub-standard and falsified medicines, another lecturer of the Pharmacy Department was enabled by the SSMCM Project to attend laboratory trainings in drug quality analysis at a WHO-prequalified laboratory in Nairobi, Kenya, and at the Pharmaceutical Institute of the University of Würzburg, Germany. Through the MGHP, he was further supported in attending an international course on “Quality of Medicine & Public Health” at the London School of Hygiene & Tropical Medicine in London, U.K. With financial support from the MGHP, this lecturer subsequently carried out a study on the occurrence of falsified and substandard antimalarial and antibiotic medicines in Malawi. For this study, he used the innovative, low-cost “Minilab” technology of the Global Pharma Health Fund, which was developed in Germany for pharmaceutical analysis in resource-limited settings (https://www.gphf.org/en/minilab/index.htm).

Both, for the pharmacovigilance program and for the drug quality study, written agreements secured the smooth collaboration with the national drug regulatory agency, i.e. the Pharmacy, Medicines and Poisons Board of Malawi.

5. Implementation challenges, adaptation and learning

Pharmacovigilance: An important challenge was the collaboration between the involved national agencies. The College of Medicine, University of Malawi, has competent staff, basic expertise, suitable rooms and a strong motivation to assist in the establishment of a national pharmacovigilance programme. However, it is the national drug regulatory agency (in this case: the Pharmacy, Medicines and Poisons Board [PMPB] of Malawi) which is ultimately responsible for pharmacovigilance in the country. However, PMBP is understaffed and underfunded, and has limited capacity to take up new responsibilities. The good personal and working relationships between the Pharmacy Department, University of Malawi, and PMPB were crucial for the success of the programme.

Drug quality: Malawi is a least developed country, and the possibilities for chemical analysis of drug quality are extremely limited. The utilization of a simple and inexpensive technology for drug quality analysis, i.e. the “Minilab” developed by the German organization Global Pharma Health Fund (www.gphf.org), proved essential for the feasibility of this part of the programme. Still, a certain number of confirmatory analyses using state-of-the-art analytical methods were indispensable. These could be implemented, at affordable cost, by the establishment of south-south collaboration with the WHO-prequalified laboratory for drug quality analysis at the Mission for Essential Drugs and Supplies in Nairobi, Kenya. However, execution of these analyses abroad caused delays in the execution of the study. The establishment of a sufficiently equipped laboratory at the Pharmacy Department, University of Malawi, would substantially improve the feasibility of drug quality studies in Malawi.

6. Results

The capacity for Pharmacovigilance (PV) was firmly established at CoM. In addition to the integration of PV into the overall Pharmacy curriculum, a PV Centre was established on CoM’s main Blantyre campus. The centre has since been visited by experts of the WHO African Collaborating Centre for Pharmacovigilance, Ghana, who encouraged CoM / UNIMA to join the WHO Programme for International Drug Monitoring.

The study carried out by the Pharmacy Department of the University of Malawi on the presence of falsified and substandard medicines confirmed that approximately 95 % of the medicines available in the public and church health facilities (including remote rural facilities) were of good quality. However, a small number of medicines showed minor or major quality problems. In contrast, a higher portion of the medicines collected in private pharmacies and drug stores, and especially from informal markets, showed quality problems. Most importantly, one medicine was identified which was sold by an illegal street vendor and which did not contain the declared antimalarial ingredients, but completely different pharmaceutically active compounds. This type of counterfeiting represents a serious risk to public health. The Minilab proved to be a powerful, affordable and simple appropriate technology for drug analysis in resource-limited settings. The national drug regulatory agency was informed of the outcomes of the study, and a first scientific publication from this study has appeared, a second one is in preparation.

7. Insights

1) The availability of a moderate but quite flexible fund for short-term training courses of national personnel abroad, and for local teaching assignments of international experts, was extremely useful for capacity-building at the local partner institution. In the current project, this fund was provided through the EU/BMZ co-funded programme “Strengthening Specialized Medical Care in Malawi”. However, such training funds can only act as catalysts. Another, and equally important, success factor was the willingness of the partner institution (here: College of Medicine, University of Malawi) to commit to further developing its own expertise through its own resources (Full-time personnel contracts; Provision of office space for PV lab), and the commitment by the Pharmacy Department to develop “Safety of Medicines” as a strategic capacity area. 

2) A central success factor needs to be seen in the placement of an integrated expert within the structure of the partner institution. This assured continuous engagement with the partner institution, from the identification stage through to the development and implementation of solutions. This case study shows that Integrated Experts have a strategic role to play, rather than simply adding to the work force of often understaffed partner organisations. Where this strategic role is realized, Integrated Experts can add substantial value to Technical Co-operation measures. Often, this is not realized, due to the insufficient integration of Integrated Experts into the seconding TC programme and reporting lines of Integrated Experts solely focussed on partner institutions. 

3) Trust of the population in the public health care system is vital for effective health care, yet it is undermined everywhere in Africa by growing suspicions of many medicines being falsified or of substandard quality. The low-cost assessment of the quality of medicines in Malawi has shown that in fact most medicines in the public health care facilities in Malawi were of good quality, and a critical review of the existing literature suggests that similar studies in other African countries may yield similar results, helping to restore trust in public health care. However, this does not mean that quality control should be discontinued and/or discounted. It remains highly important to assure continued improvement in the quality of medicines. Especially in least developed settings, low-cost technologies, such as the “Minilab” technology developed by the Global Pharma Health Fund (www.gphf.org) constitute good practices with potential for replication in other countries.

Improving Maternal and Newborn Care in Tanzania

1. Working title for the proposed case study

Improving Maternal and Newborn Care in Tanzania

2. Applicants

Partner: Regional Health Management Team Lindi and Mtwara Region, Tanzania
German programme: Tanzanian German Programme to Support Health of GIZ, Tanzania

3. Development challenge

Newborn and maternal mortality in Tanzania are unacceptably high with 25 per 1,000 (DHS 2016) and 398/100,000 (WHO 2015). Thus, Millennium Development Goal 4 and 5 of 19/1,000 and 193/100,000 were not met. A National Road Map to Accelerate Decrease in Maternal and Newborn Mortality exists with regional implementation plans but effects of efforts remain to be seen.

Evidence-based interventions known to decrease mortality are identified since long, and are advocated by international organizations, for example Emergency Obstetric and Newborn Care (EmONC), Skilled Birth Attendance (SBA) and competency-based training for EmONC. It is noted internationally that a positive impact of EmONC and SBA can only be seen if an enabling environment for the provision of these services is in place. The challenge is how to successfully implement these interventions in a setting with multiple health system challenges which lead to a lack of enabling environment. (e.g. human resource crisis with lack of clinical staff and of managerial and leadership competencies at health facility level and overwhelmed staff at regional and district level, lack of preventive maintenance management for technical equipment, weak medical supply system and a weak referral system).

On avarage 4.4 nurses/nurse midwives were available in Tanzania between 2007 and 2014 (WHO 2015) and 0.03 physicians were available for 1,000 inhabitants in 2012 (WHO Regional Office for Africa, 2014). 37.8% of selected generic medecines were on average available in 2007 - 2015 (WHO 2015).

During the last Tanzania Demographic and Health Survey of 2015 it was found that only 60 % of women delivered at a health facility with potential quick access to EmONC services, and of these only 64% delivered with a skilled provider (DHS 2016). The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) only last year piloted a competency-based training on EmONC and Clinical Mentoring in one region of the country.

A know-do-gap between research evidence on best practices to achieve an enabling environment and implementation exists, partly due to the fact that many programme managers lack the capacity and vision to document processes and outcome of their implementation activities using solid research design and to publish their results in scientific journals.

4. Intervention / implementation

Overall Approach

The intervention was conceived after a pilot intervention jointly implemented with the Regional Health Management Team (RHMT) Lindi and Voluntary Services Overseas (VSO) in 2012 and 2013, focussed on the establishment of a specialized newborn care unit at the regional referral hospital and two other district hospitals and training in basic newborn care for referring health facilities, which led to a significant decrease in newborn mortality. In a participatory way priority areas for interventions were identified with RHMTs and Council Health Management Teams (CHMTs). Dysfunctional health system building blocks that needed strengthening to overcome barriers to implementation of activities within those priority areas were identified. Literature reviews on priority areas were conducted and results of international discussions and communication with other stakeholders in country were used to compare approaches, identify best practice, for example the use of competency-based emergency obstetric care training courses, use existing synergies and learn from other public or international programmes. Together with the partner institutions an operational plan and respective activities were jointly developed. To facilitate implementation within a human resource deprived context, regional teams of midwives and clinical officers support regional health management teams in planning and conducting activities. An elaborated M&E framework was developed jointly including implementation research to deliver more contextual information in support of routine M&E and to build up local research capacity. Great care was taken to identify and consult all relevant local stakeholders in the programme regions to avoid duplication and create synergies.

Implementation focuses on five priority areas, which support an enabling environment for EmONC, with supportive supervision and mentoring using scenario-based skills drills and on-the-job training:

1. Capacity building and human resource management support
  • Skills-based Emergency Obstetric Care & Training in Clinical Mentoring.
  • Basic and specialized newborn care training.
  • Training of health facility staff on basic maintenance and repair of medical equipment.
  • Support to district authorities to recruit biomedical engineers for all districts.
2. Quality improvement of service delivery
  • Establishment of special Newborn Care Units in all hospitals and development of standard operational procedures and a triage checklist to identify sick newborns (NTC).
  • Leadership orientation for enabling environment to support EmONC for facility managers.
  • Orientation on data management and data use for quality improvement to all facility managers.
  • Support to roll out and follow up on Maternal and Perinatal Death Surveillance and Response (MPDSR).
  • Strengthening of existing Ward Improvement Teams for Maternity and Newborn Care with a focus on patient flow and management issues.
3. Improvement of referral communication
  • Clustering of referring facilities into referral networks.
  • Development of cluster referral action plans and follow up through supervision.
4. Procurement of medical equipment and maintenance management support
  • Development of a preventive maintenance management system to document equipment models, schedule preventive maintenance and organize repair of broken equipment.
  • Support to clinical services through procurement of medical equipment together with other partners.
5. Monitoring and evaluation, implementation research
  • Participatory development of an M&E framework beyond programme indicators to identify challenges and document lessons learnt.
  • Midterm evaluation with major involvement of local partner organizations in development of ToRs and methodology and implementation.
  • Implementation research together with Berlin School of Public Health, Germany, University of Applied Sciences, Windesheim Honours College, Netherlands,Georgetown University, USA and local partner organizations to increase research capacity also on a peripheral level and to foster a culture of integrated programme evaluation which will generate robust evidence from future programmes that can be shared with the international community. Research topics are burnout in health workers from maternity and newborn care services, availability of skilled birth attendants in health centres, service availability and readiness for CEmOC services in health centres and the evaluation of a newborn triage checklist designed for low resource settings.

Set-up of the intervention, stakeholders/partners, coverage and duration of the implementation.

The Improved Maternal and Newborn Care Project (IMCH), as part of the Tanzanian German Programme to Support Health, is implemented in two rural, remote regions in the Southeast of Tanzania, in Lindi and Mtwara Region in 213 health facilities, with a projected population of 2,239,866 for 2016. The projected number of deliveries for both regions is 69,436 for the same year. The programme started implementation in September 2015 and will continue up to April 2017. Direct partners are the Ministry of Health, Community Development, Gender, Elderly and Children and the RHMTs of Lindi and Mtwara Region. Other partners are the CHMTs and Hospital Management Teams of involved districts and facilities, international organizations active in the field of maternal and newborn care in the two regions, such as VSO, Safe the Children, EGPAF and Ifakara Health Institute.

5. Implementation challenges, adaptation and learning
Challenges

With only two years, the implementation period for this project is very short and it will be very difficult to document impact on some of the indicators. This timeframe is also challenging for the planned participatory approach. On the other hand, maternal and newborn health issues are currently high on the political agenda internationally and nationally and there is pressure on the partner institutions to implement the regional road maps together with different up-coming new developments such as the upgrading of basic emergency obstetric care facilities (BEmOC) to comprehensive ones (CEmOC).

Due to changing availability of funds from central level, budget and operational plan had to be adjusted twice.

1. Dysfunctionality of health system blocks

All health system blocks were identified as dysfunctional and many were beyond the control of the regional partner organizations or the project but necessary to create an enabling environment, such as availability of drugs for EmOC or human resources and unavailable or delapidated infrastructure.

It became clear during stakeholder discussions and implementation that to improve the referral system health centres needed strengthening to offer CEmOC services. Although the government favours a coverage of 80% it was obvious that this could not be achieved given the available financial and human resources.

The referral system in both regions is challenges by remoteness of facilities, lack of transportation and sustainable funding. After a meeting of all health facility managers it became clear, that physical meetings are not cost effective and leave out the other staff these facilities. With limited funding no capital investments such as ambulances or repair of infrastructure could be made.

2. Cooperation and coordination

Several international organizations are active in maternal and newborn care in both regions. Coordination of different actors is crucial to avoid duplication and to make best use of available resources, but difficult given the need for action and scarce resources in the regions on one side and funding procedures and pre-conditions for international organizations on the other side. Voluntary Services Overseas for example, came to both regions with the plan to implement similar activities in the regions, financed by a different organization.

3. Capacity of National Personnel

Remoteness of the facilities makes supervision difficult and time-consuming. In addition clinical personnel often lacks supervisory and mentoring capacity and vice versa, supervisors often lack clinical knowledge to mentor HCWs concerning their daily tasks.

Adaptations

1. Health System Strengthening

CEmOC support to HCs was taken up at a later stage of the project through implementation research on service availability and readiness (SARA) and capacity building for health care workers on surgical and anaesthesiology skills. The SARA assessment is designed to support RHMTs in their decision making how to distribute their limited resources most cost-effectively to introduce CEmOC services. Existing health care workers from selected facilities are included in the above trainings to receive capacity building on surgical and anaesthetic skills related to obstetric surgery. Based on the data from baseline assessments and SARA tool health centres with CEmOC services will receive an extended set of equipment related to emergency obstetric care.

To enhance communication and create a sustainable means of communication mobile technology will be used through the development of a master list of available mobile devices and social media use in all participating health facilities. Based on this list individual referral clusters are advised which type of mobile technology or social media to use for communication.

The same network will be used for e-buddying, a cascade mentoring system, where specialists from secondary or tertiary referral institutions and professional orgnaisations will mentor medical doctors at district hospitals and CEmOC HCs, who in turn will e-mentor maternity and newborn care workers at lower health facilities.

2. Cooperation and Coordination

Great care was taken from the beginning of the project to identify all relevant actors in the field. These organizations were all visited and areas of synergies were identified. In the case of VSO, the RMOs and their teams were empowered to execute a coordinator function concerning implementation of activities in maternal and newborn care through a Memorandum of Understanding between both RHMTs, TGPSH and VSO. Involvement of VSO volunteers in activities of the programme and frequent meetings at programme management level help to decrease duplication. In the case of the establishment of Newborn Care Units for example, the project provided the capacity development and equipment for the new units whereas VSO, supported the facilities through renovation measures.

A close partnership with KfW will include the procurement of equipment related to EmOC services at lower health facility level.

Other thematic areas of TGPSH were included in the stakeholder mapping and areas of synergy and mutual support were identified. A close link to the thematic area of quality improvement with a standardized approach and regular meetings is established.

3. Capacity Building of National Personnel

A team of five Tanzanian Midwives, six Clinical Officers and two Assistant Medical officers with experience in mentoring was recruited to support the regional partner organizations, especially on supervision and mentoring. This team received on-the-job training and mentoring in special newborn care and the use of obstetric and newborn models to conduct fire drills and to conduct implementation research.

A facilitator/supervisor pool is now developed from RHMT, CHMT and hospital staff with an elaborated system of quality control, feedback and mentoring forthese visits.

After the end of this project, National personnel capacitated in this way can add a different set of experiences to the partner institutions or other work places after they are re-integrated into National structures.

6. Results
  • 384 out of 700 health workers are trained in Emergency obstetric care and 500 out of 700 HCW are trained on basic newborn care. 
  • Managers of 213 health facilities are trained on data management and its use in quality improvement and are sensitized on the importance of an enabling environment for good quality obstetric care and maternal and perinatal survival support through quarterly supervision and mentoring.
  • 10 biomedical technicians (out of 28 newly trained technicians for the whole country) are assigned for Lindi and Mtwara Regions through normal government channels.
  • All 13 hospitals in the regions have established special Newborn Care Units and joint Ward Improvement Teams for Maternity and Newborn Care Unit with monthly mentoring visits. 
  • A data base on available mobile technology for all health facilities was developed to create inter-professional networks and remote mentorship as well as a communication system to facilitate pre-referral information and communication using social networks.
  • Procurement of medical equipment related to MNH by several stakeholders (VSO, KFW, GIZ), based on a baseline assessment in each facility is coordinated to avoid duplication and achieve synchronicity in terms of models and brands. Biomedical Technicians already in place and RHMTs are involved in this process to ensure alignment to national standards and needs.
  • Three joint research projects are ongoing together with RHMTs. One study conducted, one in data collection stage, one in proposal writing stage. A midterm evaluation is planned with major methodological input of the ministry of health and the technical working group on Reproductive, Maternal, Newborn, Child and Adolescent Health, RMNCAH.
7. Insights

Support to health system strengthening is complex but crucial for quality maternal and newborn care. Thus, concerted efforts from several partners will be needed to create an enabling environment for quality of care. This can be reached through a thorough stakeholder analysis and early communication with potential partners to negotiate areas of implementation. This step is crucial but difficult due to different agendas and obligations towards funding organisations.

Local partner institutions should be empowered to coordinate these efforts and should start to do so as early as in the proposal writing stadium.

The know-do gap between health researchers and implementers can be decreased through capacity building within partner institutions. This can also foster empowerment of partner institutions to take over the coordination process and influence the design of interventions.

Capacity building interventions should be embedded in an M&E framework beyond requirements of BMZ to document improvement in a volatile environment with frequent adaptations to bottle necks. Implementation research can support the design of realistic M&E models to document and share best practice and innovation.

Cross-sectoral approach: Accounting for population dynamics in national sector planning in Togo

1. Working title for the proposed case study

Cross-sectoral approach: Accounting for population dynamics in national sector planning in Togo

2. Applicants

Partner: Directorate for Population Studies at the Ministry of Development Planning, National Institute for Statistics and Economic and Demographic Studies (INSEED)

German programme(s): [GIZ Togo] Promoting Good Governance and Decentralization (ProDeG), Rural Development and Agriculture (ProDRA), Employment Promotion and Vocational Training (ProFoPEJ), [GIZ HQ] SI Population Dynamics, Sexual and Reproductive Health and Rights

3. Development challenge

(a) Development challenges in Togo:

i. Togo encounters two key demographic challenges: First, an increasing internal migration, mostly to urban centres (annual average growth: 1.3%). Second, a growing youth bulge. The population under the age of 15 still accounts for 42.2%. However, the dependency rate is dropping steadily, while Togo’s population growth is slowing down and the share of young working-age adults aged 15 to 24 is growing (almost up to 20%). Thus, a demographic dividend is in sight. Togolese sector policy planning did neither account sufficiently for the needs of a growing urban population, nor did it adapt to the changes in age structure. It was in urgent need of taking into account its population dynamics for medium- and long-term planning to turn the demographic challenges into development opportunities.

ii. At the same time, civil registration offices were weak in capacity and not sufficiently equipped and capacitated to provide routine and standardised data. The national system of statistics struggled to guarantee the availability of timely and disaggregated data. A new national population policy was adopted in 1998, but a strategic orientation had not yet been elaborated. Only by 2011, a new statistics law came into force. Also a new National Statistics Development Strategy (NSDS) for 2015-2019 was adopted. The collection and analysis of timely and disaggregated demographic data has, however, not yet been improved. Even more, using population data in national policy planning was still far from being realistic. Togo’s development challenges with regard to institutions and capacity for the purpose of collecting, analysing, and disseminating population data did not enable the country to address its demographic challenges. For that matter, Togo had to build up strong data routine systems, adequate statistical and analytical capacity, and means to integrate population trends into sector policy planning.

(b) Relevance of the development challenges on the international development agenda:

Demographic trends, which vary in scope in each country, have a huge impact on the development of each country and will also be felt globally. The 2030 Agenda monitors progress in sustainable development. In order to do so reliable and disaggregated data must be collected, used and made available. The broad and universal SDG Agenda contains an extensive need of demographic data. Currently, more than 40% of all SDG indicators are based on population data. For countries to meet the monitoring requirements, much support is needed to strengthen their institutional and human capacities concerned with population data, statistics and population policy.

4. Intervention / implementation

The Approach and Set-up of the Intervention:

i. To support Togo in taking on its demographic development challenges, the intervention pursued the objective to better align Togo’s sector planning with medium- and long-term population development. It specifically targeted the national sector planning via GDC programmes on the national level, with a specific focus on the regions around the three mid-sized cities of Tsévié, Kpalimé and Sokodé.

ii. A multi-sectoral approach was chosen to advance the multi-sectoral field of population dynamics. The intervention built upon existing efforts of GDC programmes and worked effectively at their interface. All GIZ programmes operating in the three priority areas of GDC in Togo, namely good governance and decentralisation, agriculture and rural development, and vocational training and youth employment, found common ground when faced with demographic data shortage, especially with regard to socio-demographic data on young-aged migratory flows to cities. As a first step, the three programmes jointly decided to support the idea of setting up an inventory and of identifying ways to integrate demographic trends into their activities.

iii. The three GDC programmes originally agreed to pursuing the following steps: (1) elaboration of an inventory that sets out to explore Togo’s socio-demographic data collection, analysis and use; (2) analysis of the available data that lays out Togo’s medium- to long-term demographic trajectories, especially in the three focus regions of German GDC programmes, and (3) on the basis of the analysis, providing advisory support on how to account for population dynamics in national sector strategies and GDC programmes. In the course of the intervention, the envisaged analysis (step two) was exchanged for three prospective demographic studies carried out by the newly- constituted unit at the Ministry of Development Planning.

iv. Direct partner to the measure was the Togolese Ministry for Development Planning and therein the Directorate for Population Studies. The latter was newly constituted in 2015, replacing the Directorate for Population Planning and operating directly under the General Directorate of the Ministry. Its 15 staff members were entrusted with the analysis of demographic trends; with informing the government about them; as well as with the elaboration and implementation of measures related to population dynamics. Like the Directorate for Population Studies, the National Institute for Statistics and Economic and Demographic Studies (INSEED) and its National Statistics Council (CNS)are also operating under the Ministry for Development Planning.

v. In the light of a demographic dividend and the multi-sectoral national growth and employment strategy SCAPE (Stratégie de la Croissance Accélérée et de Promotion d’Emploi) that aims at fostering a sustainable development, the thematic focus area for all GDC programmes was employment promotion of young people, especially in rural areas, against the background of their health and social development.

vi. The intervention was set up as an individual measure financed through the Study and Expert Fund (SEF). This approach was carefully chosen as the adequate mode of intervention to show and further explore possibilities of supporting GDC partner countries in accounting for their population dynamics. While usually the SEF supports measures of a duration of 12 months, the population dynamics measure was extended to 15 months (12/2014 – 03/2016) and had total funding volume of 150.000 EUR. In addition, the SEF measure was supported technically and financially by the Headquarters’ Sector Initiative ‘Population Dynamics, Sexual and Reproductive Health and Rights’ with an additional funding volume of about 20.000 EUR.

5. Implementation challenges, adaptation and learning

Main delivery/ implementation challenges/ bottlenecks:

i. The cross-sectoral approach required a long preparation phase to get all actors involved on board. Lengthy consultations with all partners prior to setting up the proposal for the measure were necessary to get started and everyone on the same page. It was assumed that once implementation had started, the need for coordination would decline. However, even if implementation went smoothly, the cross-sectoral approach continued to require a lot of communication among the programmes and back-stopping support to the partners.

ii. The intervention started with a stocktaking exercise (inventory) that put the availability and qualitative robustness of demographic data and its sources in Togo to the test. This initial inventory mirrored that the country had considerable demographic data gaps, especially when it comes to disaggregated data from regional and local levels, and a weak statistical system with a tiny pool of skilled people. Especially data on internal migration was unavailable, which was anticipated from the start. Other than anticipated the intervention was unable to find a way to support the improvement of migration data availability in Togo.

iii. While setting up the intervention, the institutional set-up had just been changing in the Ministry of Development Planning. The newly-established units there had their own drive and proactively developed ideas, such as elaborating prospective demographic studies and a handbook for the integration of population dynamics in national policy planning. This proactive engagement of the unit required an adaptation of the originally planned activities, led to more output and more time-intensive accompaniment.

iv. In order to deal with this cross-cutting theme, a local and multi-disciplinary team of consultants, e.g. for the prospective demographic studies, must be put together to pool all expertise necessary.

v. After the intervention had ended, its aim [accounting for Togolese population dynamics in national sector politics] is now partially carried on by the GDC decentralisation programme. The programme continues dealing with an important sub-set of population dynamics only (incl. birth and death registration). A new GDC Health Programme will possibly take up work in Togo shortly. As planning advances, it could become likely that it incorporated another sub-set of the cross-cutting theme population dynamics. All other involved programmes in situ remain interested in the topic, specifically the Employment Programme in the wake of enlarging their repertoire and amount of people they reach with support measures. The challenge remains the same: coordinating a cross-cutting issue among sectors.

Adaptations:

i. The proactive engagement of the newly-constituted units in the Togolese Ministry of Development Planning required the SEF measure to adapt and provide additional support e.g. to the elaboration of the manual on the integration of population dynamics into policy planning.
ii. The originally envisaged elaboration of an analysis to lay out Togo’s medium- to long-term demographic trajectories, required adaptation and was switched for three prospective demographic studies, one on the subject of each GDC priority area.

Lessons learned:

iii. This small-scale measure together with the change in the institutional set-up at the national policy level resulted in a very promising catalyst to support the country in integrating population trends for better policy strategies. Nonetheless, an intervention like this must be complemented by further structural developments and further coordination efforts, e.g. among civil registration offices, national resorts, etc. to build the basis for continuous successful planning. In addition, capacity building must further be fostered on a long-term basis in order to support an in-depth understanding of the complex implications of population dynamics. Only in this way, cohesion in policy-making and sustainable policy planning can be guaranteed.

iv. Demographic data gaps exist everywhere, varying in extend. Policy advice of the integration, analysis, dissemination and use of population data will be increasingly in demand as well as the need for adapted development responses.

v. The measures of the intervention were not suitable to support the improvement of the availability of migration data gaps.

6. Results

i. Envisaged Outputs: inventory on demographic data collection, analysis and use and its actors, analysis in the form of three prospective demographic studies on (i.) employment and vocational training, (ii.) agriculture, and (iii.) decentralisation, and advisory support to the Ministry of Development Planning and other resort ministries. While the inventory revealed data gaps and gave an overview of the involved actors, the three prospective studies provided first assessments on how national policy planning should go about urban professional education and agricultural development planning while assimilating demographic considerations.

ii. Additional Output: Development co-operation in the field of population dynamics was incorporated into the protocol of the intergovernmental negotiations between Togo and Germany in March 2016. Capacity building in the form of training modules; support on the elaboration of a manual on the integration of population dynamics into national sector policy planning developed by the Ministry; support to the public communication and promotion of the measure (official launch); study trip of Togolese partners to Germany for a mutual learning experience on demography and statistics with German institutions and to strengthen networks and partnerships between ministries in charge of demographic development, statistic offices and consulting bodies in the field of population policies; consultative action with other relevant stakeholders at an international conference in South Africa (Africities 2015) on the subject of urbanisation; organisation of an official event (final workshop) for a large number of official representatives from all over Togo to present the results of the measure and further sensitise decision-makers for population dynamics. Additional outputs such as the study trip, yielded spill-over effects, for instance, on the support of Togo’s central unit for statistics (INSEED) with regard to the next census’ operational planning and technical set-up, as well as for its technical advisory function to other resort ministries.

iii. Outcomes: With the inventory and the three prospective demographic studies, the measure revealed further insights on Togo’s demographic profile (disaggregated for gender, age and place) and its prospective impact on the sectors in question. The manual has been applied for the first time in the case of the new national agricultural strategy (PNIASA II). By supporting public communication and promotion of the measure, it has drawn attention to the German-Togolese Cooperation in the field and the national public of the importance of population dynamics for national and regional development strategies. Advisory support and capacity building measures have strengthened the newly-constituted Directorate of the Ministry of Development Planning in fulfilling its tasks and sectoral ministries in how to integrate PD into their policies and planning. The unit has produced the first prospective demographic studies and integrated a demographic perspective into revised national strategies.

After the measure had ended, the Directorate for Population Studies has furthermore trained 8 ministries (namely agriculture, environment, social actions, grass-roots development, education, health, labour, decentralisation and the public policy department of Ministry for Development Planning) to utilize the manual on the integration of population dynamics into national sector policy planning during a three day workshop sponsored by UNFPA.

iv. Expected Future Outcomes: The manual is envisaged to be employed when designing the new national decentralisation strategy (Plan National de Développement Durable – PNDD), constituting the successor of the national growth and employment strategy (Stratégie de Croissance Accélérée et de Promotion de l’Emploi – SCAPE). Furthermore, the manual is envisaged to serve as a basis for the development of a capacity development concept in the field of population dynamics with regard to its integration into policy planning for Francophone Africa. As such, also South-South cooperation can be fostered. Those who were trained on the manual will from part of a monitoring unit which aims to validate the integration of population variables into development policies, programmes and projects.

v. Impact: The integration of population dynamics into national strategies such as PNIASA or PNDD is expected to have a positive long-term effect on the development of the Togolese agriculture and employment sector and national growth strategies, e.g. to harness the demographic dividend. As such, the amount of young people that enter professional education can better be matched with the needs of the labour market, specifically considering the field of agriculture, in different regions of Togo, specifically in urban areas.

7. Insights

New insights on international discussions on development challenges:

i. Population dynamics poses a challenge to various sectors. Sustainable development can be fostered when policy planning:

  • takes into account demographic trends, 
  • is based on a robust evidence base with regard to population data, and 
  • can rely on qualified people to interpret them und put them to use.

As such, demographic challenges can be converted into opportunities.

ii. Similarly, the same seems to be true for programmes of development cooperation. A short-term and small-scale individual measure resulted to being the perfect fit that engaged all programmes operating in the three priority areas of GDC to join forces. The notion of a shared demographic data shortage – a gap needed to fill for future successful programming – created common ground, which is why the measure set out with the idea to support GDC programmes in recognising the data gaps and discussing with national partners how they can be filled and how the usage of existing demographic data can be improved and coordinated better by national institutions. Thereby, it acknowledged and simultaneously served the joint need for disaggregated and reliable population data of development programmes and its partners.

iii. As a cross-cutting issue, population dynamics required a multi-sectoral approach. The measure embraced this approach and thereby gained systemic relevance. The demographic dividend as an overall topic is important to different sectors for different reasons that the measure could account for. 

iv. As a small-scale individual measure, the Togolese case involved a great number of partners and sectors with comparatively little financial and technical contributions. The number of outputs was astonishingly high and knowledge of the measure was gained unexpectedly and unintendedly nationwide. While the former was due to the proactive engagement of the ministerial unit, the latter can be attributed to the useful impression gained by the involved regions that helped spreading the word.

v. Given the strong political commitment in Togo, the time was right to set an intervention in motion. Political support and legislation was backing the intervention so that capacities and newly-constituted institutional structures could be strengthened. 

vi. Development on the side-lines: Parallel to the intervention, the EU started evaluating the modernisation of civil registration and vital statistics in Togo with an amount of 14 Mio. EUR, specifically targeting the governance of civil registries and local finance. It can be considered a positive development that other lead development actors such as the EU acknowledge demographic data gaps to be an important issue in Togo which is in need of support.

Improvement in the management and use of health technology by Uzbek hospital personnel through targeted training measures by combining technical and clinical knowledge.

1. Working title for the proposed case study

Improvement in the management and use of health technology by Uzbek hospital personnel through targeted training measures by combining technical and clinical knowledge.

2. Applicants

Partner: Ministry of Health of Uzbekistan

German programme: Advanced training for medical and technical professionals to work with modern high technology equipment in Uzbekistan.

3. Development challenge

The project is co-financed between Ministry of Health of Uzbekistan and the German Federal Government (BMZ). The project is executed by the German International Technical Cooperation (GIZ), the aim being to improve health service quality where project contributes to fulfil the gap related to insufficient use of expensive high-technology medical equipment in the country because of lack of knowledge and skills of the respective hospital staff.

The demise of the Soviet Union era has brought several challenges to the Uzbek national health system. During the past 10 years challenges of limited resources and a dramatic increase in NCD’s, i.e. morbidity rate of 63% for CVD[1]. Furthermore, rising trends in infectious diseases (particularly respiratory), diabetes, cancer, and traumatology cases are evident. This poses major challenges to the public health system highlighting the significant importance of investments in diagnostic and therapeutic technologies to address such demands.

For the last 15 years the majority of the investments has been included constructing and repairing of the main facilities and investing about 60 million euro for the new equipment at the secondary and tertiary levels of health care: CT-Scanners, MRT’s and Angiography were a major part of these investments. There were purchased medical equipment due to the programs financed by donors including high tech facilities, medical imaging, laboratory diagnostics, ICU, minimal- invasive and endoscopic surgery. Nowadays such facilities are placed in hospitals both at secondary and at tertiary levels in the regions.

At the same time, there is a deficit of skilled staff in the country for effective and rational usage of this equipment, in the maintenance, logistics. As the result, the quality of the medical services based on the modern ways of treatment and diagnostics is insufficient.

Rising trends of morbidity in particular predominates over CVD, neoplasm and traumatology and the demand in diagnostic and treating facilities increases annually. Usage of modern high tech equipment means the lack of medical staff and special training for operating with such complicated technologies. Due to such demands, the project promotes the capacity building in addition to the strengthening of the maintenance of the existing equipment.

[1] United Nations priorities in Uzbekistan in 2013, 
WHO Regional Office report for Europe and the European Commission on preventing injuries and promoting safety in Europe, 2011

4. Intervention / implementation

The Project supports ongoing training, organises technical support by involvement of international and regional experts, and promotes international partnerships with specialised clinics and international teaching hospitals, supports participation at scientific meetings (workshops, congress, in the frame of trade fairs i.e.) and acts as a broker to meet leading medical equipment manufacturers (PPP). GIZ involvement boosts the number of skilled staff, improves the quality assurance and improves the management of procurement, logistics and maintenance.

Within the project four training centres on imaging technologies and laparoscopy methods were equipped according to world standards and have been refurbished through own Uzbek MoH and/or hospital funds. The necessary equipment has been provided by the German side.

Implementation is ongoing since 2012. After starting the cooperation with the Republican Research Centre of Emergency Medicine (RRCEM) comprising 13 regional branches and 172 sub-branches, the project actually scales-up the work with KfW financed pilot sites including National Scientific Center for Paediatrics and 13 oblast multi-profile paediatric hospitals and with the republican perinatal clinic including regional branches. Thus, the activities of the project covers all institutions of mother and child health in the secondary and tertiary levels of public health.

5. Implementation challenges, adaptation and learning

After the introduction and continuous use of modern technologies in public facilities, patients and health care staff observed early diagnosis, early case management, fast recovery, and reduced complications. Practical exercises during training reflected the actual work settings and are now switched to modern methods for diagnosis and surgery. Patients are aware and informed about the early diagnosis, minimally invasive surgery, and the demand for such care is are rising. Additional surgeons, radiographers and nurses are being trained to address this demand, but still the gap is not reduced, and higher workload among staffs were recorded.

The patients and hospital staff perceived increase in quality of care in public hospitals when compared before the training and implementing its use. However, some participants sensed a need of refresher training and supervision during work to reduce any risk in the use of the new technologies.

Beside all positive aspects some participants also expressed dissatisfaction towards management during training, which includes a surgeon who shared the frustration on management of the training, especially in the later phase, and said: “… we used to have four units, now we have only two… when a group is big we feel competition … a struggle to touch equipment and practice... The ratio of the number of equipment units and trainees should be better.”

The hindrances participants listed while working in their work station includes, over-utilization of single equipment, old and semi/non-functioning equipment due to lack of maintenance services, lack of consumables, shortage of spare parts, spare and insufficient instruments and stitching materials in priority facilities. Overall, these issues are reducing the performance of the facility.
Recommendations and support requested from the participants mainly included regular refresher trainings, trainings from international experts and trainings abroad, use of the local language for training (especially for nurses) , provision of up-to-date training materials, regular preventive maintenance of the equipment, provision of additional laparoscopic units both at training centre and work stations, adequate supply of the spares and consumables, establishment of a knowledge and skills sharing platform, and future training topics as per participants interest.

6. Results

Study tours were organized for TIAME’s educational staff to cooperating partners of international clinics, information visits to medical manufacturers in countries such as Austria, Belarus, Germany and Russia (Khodjibaev, Anvawrov et al. 2014). Moreover, international experts and professors have come to TIAME from abroad (mainly St. Petersburg and Belarus) to teach and train TIAME’s educational staff (Hanser 2015). 

As many as 600 professionals (surgeons, radiographers and nurses) are trained under the project framework. The trained professionals are implementing their learnings at all levels.
Kirkpatrick's training evaluation model evaluates training in four dimensions which includes reaction (measures reaction to the training, experience), learning (measures increase in knowledge, skills, confidence as a result of the training), behaviour (measures application of the information), and results (analyses the outcome of training).

All levels have already been measured by the project which showed a positive result with a reduction in average length of stay (ALOS), early diagnosis of diseases like brain tumors, trauma, ischemic stroke and haemorrhagic stroke (GIZ 2014). There is also an increased proportion of diagnosis and surgeries in selected health facilities (GIZ 2014). 

According to the project baseline study report by Hanser A.C, the project expected that the doctors trained in laparoscopy accomplish 90% of gynaecological standard interventions by minimal-invasive interventions. The first three dimensions have been evaluated by involvement of master degree student of Heidelberg Public Health University (GIZ 2016). This study aimed to explore reaction, learning and behavior of training participants from their perception, under broad categories of training influence on their knowledge, improved skills, personal competency, satisfaction and accountability towards their job.

The survey results showed participants appreciating training as they are realizing the contribution of training in their daily work on handling emergency and complicated cases with higher confidence and proficiency, thus saving more lives. One FGD explored that surgeons and nurses are able to synchronize during surgeries as nurses were able to understand the need of instruments before surgeons request them, observing in the monitor and anticipating. Priority hospitals are now implementing improved diagnosis and surgeries, compared to before. Besides training, the availability of new equipment in the hospitals seems to be a success factor.

The training has helped some participants to rise as trainers to train others, replicating the training methods. For instance, regional facilities in Andijon and Navoiy are now organizing trainings for other radiographers in the district. Some of the trainers expressed their thoughts about being the trainer as: “This training helped me to build the trainer inside me.”. Another trainer shared how he is following the similar training delivery approach: “…training rooms with individual computers to show images, questionnaires to assess knowledge before and after training and give certificates at the end.”

7. Results

The demise of the Soviet Union era has brought several challenges to the Uzbekistan national health system. The project approach demonstrates how best to cope with major problems in the public health system of former soviet countries thereby providing insights in health systems in transition and reshape.

“Leaving no one behind: Enabling poverty targeting through participatory identification of poor households in Cambodia”

1. Working title for the proposed case study

“Leaving no one behind: Enabling poverty targeting through participatory identification of poor households in Cambodia”

2. Applicants

Partner: Ministry of Planning, Royal Kingdom of Cambodia

German programme: Identification of Poor Households Programme, GIZ

3. Development challenge

The fight against poverty remains one of Cambodia’s greatest challenges. Although the poverty rate has dropped in recent years to around 14% nationwide by estimates of the Ministry of Planning (MoP), Cambodia still ranks in the lower third of the Human Development Index and exhibits some of the worst inequalities in the region. Multi-dimensional poverty still affects 46 % of the population. Therefore, poverty reduction is the overarching goal of the Cambodian development strategy and the core of its emerging social protection system. In the mid-term, the government aims to provide a wide range of social services to selected beneficiaries and target groups. For poverty reduction programs to work efficiently and effectively, national policy-makers as well as planners of donor-funded programmes need to know which are the households in greatest need of support. 

Targeting social services to the poor in order to achieve a maximum impact with scarce resources is a concern for many developing countries and one of the most challenging aspects in the implementation of social programmes. There is a wide range of mechanisms for identifying individuals or household’s eligibility, from geographical or categorical approaches to (proxy) means-testing or self-targeting, each coming with its advantages and limitations. None of these methods is 100% accurate and usually there are trade-offs between targeting accuracy (inclusion and exclusion errors) and cost.

Prior to IDPoor, no nation-wide data on poor households was available in Cambodia. As a consequence, different organisations used different methodologies to identify beneficiaries for their pro-poor social services. This was not only costly and a burden on communities, but also meant that data was not comparable and that support could not be targeted in a unified, transparent and equitable way.

4. Intervention / implementation

In 2005, the MoP, with support from GIZ and other development partners such as the Australian Department of Foreign Affairs and Trade (DFAT), started to develop a procedure to identify poor households in order to address the above-mentioned challenges. Since the beginning, active involvement of other development partners helped to build a consensus on the national guidelines and contributed to the fact that IDPoor is now widely appreciated. The so-called Identification of Poor Households (IDPoor) Programme provides regularly updated data on poor households across the entire country and is used by policy decision-makers, government institutions and non-governmental organisations to plan poverty reduction programmes. As they are most affected by poverty, IDPoor has so far focused on the coverage of rural areas. An adjusted procedure for the identification of poor households in urban areas is currently in the piloting phase and will be implemented nationwide from 2017 onwards. Since the very beginning of IDPoor, GIZ advisory staff has been working hand-in-hand with the MoP to develop, implement and improve the IDPoor process. The following provides an overview of the most important approaches and interventions taken throughout the programme.

Using a standardised procedure to identify poor households: After studying different identification mechanism, IDPoor together with relevant stakeholders decided to use a proxy-means test with participatory elements as the basis for its identification questionnaire. The questionnaire consists of a set of easily observable and verifiable household characteristics which are believed to be correlated with poverty and therefore used as proxy indicators. Besides standard identifiers such as the household’s assets (i.e. house conditions, access to sanitation, electricity, durable equipment) and income, special circumstances are also taken into account in the assessment.

Involving communities in the identification process: In addition to ministerial staff, the process relies on villagers who facilitate the assessment of who in their community is living in poverty. Thus, in each round of IDPoor an estimated number of 35,000 persons are actively involved. Villagers select representatives, who are then trained, conduct the household interviews and present draft lists of poor households to the community for feedback and validation. IDPoor’s community-based identification mechanism has the advantage of relying on local knowledge, which makes it easier to verify whether respondents are accurately reporting their situation. The participatory and consultative process of IDPoor is aimed at promoting transparency and accuracy. Although community-based targeting still has the risk of elite capture i.e. of the process being dominated by powerful local individuals or groups, an independent assessment found that elite capture remains relatively limited within IDPoor.

Improving access to social services: Households identified as eligible through the IDPoor process are classified as poor (poor category 2) or very poor (poor category 1). They receive so-called Equity Cards, which can be used to access a range of services provided by governmental and non-governmental organisations.

Ensuring sustainability through recurrent (partner-led) capacity development: At the national level, GIZ has supported the MoP with trainings on every step of the process – from planning to budgeting, management, engaging and coordinating different stakeholders, monitoring, and policy advocacy. IDPoor relies on a cascading training process at the sub-national level. Instead of hiring external research agencies, the identification process is in each village carried out by a Village Representative Group, with the support and supervision of a Planning and Budgeting Committee Representative Group, the Commune Council, and Provincial and District Coordination Teams. Throughout the process, MoP provides training at the provincial level, monitors the implementation and gives ongoing technical support.

Using Information Technology: With the introduction of a modern database technology the foundations for improved access to and exchange of data have been laid. Users, such as government institutions, non-governmental organisations or other institutions who use IDPoor data for targeting purposes, can register online via the IDPoor Information System (IIS, available here) to retrieve targeting data. Poverty maps on the website show the poverty levels in different areas which enables geographical targeting. Moreover, the system allows social service providers to verify the validity of Equity Cards online.

The IIS has recently been extended by a function to register national identity card numbers of poor households in its database. This is the basis for future compatibility with other population registers. Moreover, as part of the Urban IDPoor pilot, a mobile application is used to collect biometric data. This will be made available to improve beneficiary verification and authentication via fingerprint. This video provides a detailed overview of IDPoor and its IT infrastructure.

5. Implementation challenges, adaptation and learning

Adapting the approach to existing local capacities: One of the most important success factor for efficient identification and targeting are the implementation capacities of all involved actors. Especially at the sub-national level, the IDPoor programme was faced with weak administrative capacities of implementing bodies. In order to deal with this challenge, rather than relying on complex approaches, the programme was adapted such as to create simple processes that would allow effective implementation even at local level. For example, after field testing and piloting, the questionnaire was simplified. Continuous capacity development through trainings at national and sub-national levels at the beginning of each implementation round every year strengthens administrative and other procedural capacities.

Nonetheless, there is a certain extent to which local capacity limits are insurmountable. In the early years of IDPoor, there have been attempts to conduct digitisation and entry of IDPoor questionnaires at the provincial level. This led to significant data errors and hence compromised the quality of IDPoor’s database and it was decided to hire a professional data entry company at central level. Although this improved the quality of the data, this solution turned out to be too costly to be sustainable. As result, IDPoor is developing an IT solution which simplifies the data entry and to – again - decentralise the data entry via the use of webforms. As, in general, the IDPoor’s IT infrastructure, such as the database and report generation system, was constructed such that it could be easily maintained and administered by non-specialised government staff, and as general ICT capacities have improved in recent years, the hope is for the decentralised data entry to be more successful now.

Ensuring financial sustainability and ownership in an environment of limited resources: Ensuring the financial sustainability of IDPoor and its continuation beyond the GIZ project term was one of the main concerns from the beginning. There has been an agreement by which the Royal Government of Cambodia would gradually increase its financial share of the programme. The MOP now fully funds the implementation of IDPoor in rural areas and shows a high degree of ownership of the IDPoor mechanism. However, the timely disbursement of the required annual government budget tranches for the IDPoor rounds by the Ministry of Economy and Finance (MEF) has presented itself as a further challenge. The late disbursement of the annual budget has led to a delayed start of upcoming IDPoor rounds. In this context, the lack of reform in public sector remuneration should be regarded as a risk. Low salaries combined with little incentive for individual performance mean that dedication and motivation to overcome challenges are quickly exhausted. This is a remaining challenge which can currently only be responded to by adapting the IDPoor implementation time plan. A sustainable solution is dependent on the before-mentioned public sector reforms that would increase the financial autonomy and flexibility of the MOP. GIZ supports the MOP in advocating for such reforms.

Improving IDPoor data dissemination and outreach: During the first years, the focus of the IDPoor programme was to ensure that the data collection process was implemented properly. Data publication and dissemination were not considered the mandate of the programme. As a consequence, many providers of social services and poverty reduction measures were not adequately informed about IDPoor and continued to collect their own data or re-edited the data provided by IDPoor. Hence, it was necessary to improve the user-friendliness of the system, as well as potential users’ awareness to enhance its outreach. Staff of the MOP are trained to better analyse and respond to IDPoor user requests and organise user forums to collect feedback. GIZ is currently supporting the MOP in developing software which is aimed at allowing disaggregated data extracts to be downloaded according to user-specified database queries. This will reduce the workload for the MOP significantly and will ensure that data tailored to users’ needs is more easily available.

Ensuring availability of up-to-date targeting data: The identification of poor households requires substantial human, financial and time resources in its implementation. Given the limited resources, one province can only be covered every three years. There have been concerns about un-identified potential beneficiaries who might have fallen into poverty in between two rounds, or have been absent during the time of IDPoor interviews.

In order to deal with this challenge, the Health Equity Funds (HEF) financed by the Ministry of Health and supported by the GIZ health programme have introduced a post-ID verification. HEFs can now identify beneficiaries using the IDPoor questionnaire and criteria and issue a temporary equity card which entitles for free health care services. The data is then sent to MOP to ensure that the households will be included in the next regular IDPoor implementation round. While the post-ID process has allowed addressing the challenge of ensuring up-to-date data, it has also raised further challenges as it potentially undermines IDPoor’s principles, such as community involvement. Therefore, ongoing efforts are aimed at rationalizing post-ID arrangements without undermining IDPoor’s core processes.

Improving the accuracy of the IDPoor targeting mechanism: An independent assessment of IDPoor showed that the acceptance of IDPoor among villagers is good. 1 Inclusion leakages to the rich are considered as low, and coverage levels of the poor as relatively high. The study concludes that the accuracy of the IDPoor mechanism can be considered as satisfactory, but further efforts should be made specially to ensure the inclusion of vulnerable groups. Poor households from ethnic minorities seem to face a higher likelihood of being excluded from the IDPoor process. The currently tested urban IDPoor procedures will therefore include new targeting criteria for indicators addressing major vulnerabilities such as disabilities, chronical illness, debt and education and there are plans to subsequently extend the modifications to rural IDPoor. Moreover, the urban IDPoor process also foresees the implementation of a complaint mechanism to allow potential beneficiaries as well as other involved stakeholder to inform IDPoor about irregularities in the identification process, which should further improve the accuracy.

6. Results

Today IDPoor covers 100% of all rural villages in Cambodia and identifies around 250 000 poor households in each of the yearly rounds. One round is implemented in a third of the country’s provinces, thereby achieving a three-year update cycle of the data on poor households of any given rural area.. A study commissioned by GIZ in late 2015 found that 150 projects and programmes are using IDpoor data for targeting poverty alleviation interventions. Among others, this includes programmes funded by the German Development Cooperation, such as the regional economic development programme in the northeast of the country and free health care services under the HEFs. Further services for the beneficiaries include school feeding and scholarships programmes (by the Ministry of Education, Youth and Sport and the World Food Programme), social transfers (World Bank and UNICEF), disaster relief (Cambodian Red Cross), low interest loans, social land concessions by the government, agricultural training and provision of utilities (mosquito nets, wells and latrines, water supply and electricity), legal service support and a variety of other services from numerous NGOs. IDPoor data is also used for research studies and as planning aid for other actors’ interventions.

Around 3 million poor persons have benefitted from IDPoor by getting access to a number of social services with their household’s equity card. As an example, free health care services equivalent to 45,735,085.95 USD have been provided to poor equity card holders by health equity funds between 2010 and 2015 (source: University Research Cambodia Ltd).

As a result of the programme’s success, the IDPoor procedure was confirmed as the government’s standard tool for targeting pro-poor measures by the adoption and promulgation of Sub-decree 291 and is also an important element in the National Social Protection Strategy for the Poor and Vulnerable and other strategies. Thereby, IDPoor is a key enabler for an active and needs-driven policy of poverty reduction and plays a crucial role in steering and monitoring the progress towards the first Sustainable Development Goal “End poverty in all its forms everywhere”.

7. Insights

A main insight that comes with IDPoor is that, contrary to what is often mentioned in the literature, the successful implementation of a proxy means test targeting methodology is possible despite limited administrative capacity. IDPoor achieves satisfactory accuracy without increasing the complexity of identification too much. We believe that these learnings i.e. how to successfully implement a complex proxy means test, how to strengthen limited local capacities and how to successfully involve the donor community while ensuring that the programme continues to have a strong local ownership is exceptional in the context of identification and targeting mechanisms and can prove useful for other programmes internationally.  

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