DHPI Key principles Facilitators’ Workshop on District Health Performance Improvement Lilongwe, 25 th – 27 th March 2015

The logic of the approach Use a solid analytical framework and a practical operational approach to improve district performance and reduce inequities (DO THE RIGHT THING AND TO IT RIGHT) Use few interventions to identify issues in the delivery of services and promotion of behaviors that affect many interventions (EFFICIENCY) Address such issues to increase coverage and quality of services and promotion provided (GOAL IN MIND) Monitor reduction of issues/bottlenecks and increased coverage of the few interventions selects, knowing that other interventions are also benefitting of the work done Act immediately if implementation is poor or not happening

Analytical framework

Six coverage determinants, from supply to demand side, analyze where health system bottlenecks exist. A bottleneck is a loss of system efficiency Adapted from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2) Availability – essential health commodities Adequate coverage – continuity/completion Initial utilization – first contact of multi-contact services Accessibility – physical access of services Effective coverage – quality/impact Target Population Availability – human resources

Commodities Human resources Geographic Access Utilization Initial Continuous Quality (meeting minimum standards) = effective coverage (Result of interface between health system and communities) Supply side (More health system controlled) Demand side (Barriers to utilization) Quality (More health system controlled) 3 main categories of coverage determinants + +

Six determinants of coverage Determinants from supply Determinants from demand Determinants from quality

Common bottlenecks and their causes

Tracer interventions

Six common ACSD packages in three delivery modes: Antenatal care plus Skilled birth delivery Postnatal care Immunization plus Key family practices Integrated case management of diarrhoea, malaria, pneumonia Three delivery platforms F

Coverage of RMNCH interventions organized by service delivery platform across the continuum of care

Tracer interventions: useful to analyze service delivery platforms AND packages Coverage of RMNCH interventions organized by service delivery platform across the continuum of care

Coverage of YCSD interventions organized by service delivery platform across the continuum of care Different programs will look at a different selection of interventions

Coverage of YCSD interventions organized by service delivery platform across the continuum of care Different programs will look at a different selection of interventions

Practical operational approach

Increase ANC 4 coverage from 60% to 90% Increase geogr access from 70% to 100% Organise weekly integrated ANC-EPI-ITN outreach Organise a community mobilization campaign Identify outreach sites in all communities >5 km of CHC Indicators Only 60% of pregnant women attend ANC 4 Only 70% of the pop reside <5 km of CHC Introduce ANC through outreach activities How the analysis informs planning DIVA - DIAGNOSEDIVA - INTERVENE

The process

Steps Diagnose Select interventions Define indicators Identify information sources and collect data Identify the bottlenecks Identify areas lagging behind Analyse the root causes of bottlenecks Intervene Prioritize solutions with all stakeholders Define an implementation and monitoring plan Support implementation Verify Monitor frequently using existing opportunities Adjust Take corrective actions to ensure impact

Time line Diagnose Select interventions Define indicators Identify information sources and collect data Identify the bottlenecks Identify areas lagging behind Analyse the root causes of bottlenecks Intervene Prioritize solutions with all stakeholders Define an implementation and monitoring plan Support implementation Verify Monitor frequently using existing opportunities Adjust Take corrective actions to ensure impact 1 month variable 1 week 12 months