Planning health policy Health/finance dialogue (1) 6 April 2011 Nairobi

Overview Value for money, planning and prioritisation Types of planning and tools Planning for health reforms Corporate and policy planning Why planning fails and what to do about it Information for planning Planning approaches Priority setting Country examples

Value for money, planning & prioritisation

VFM = optimal use of resources to achieve the intended outcomes Typical VFM questions What are the goals of the health system? What resources are required to meet the objectives and outcomes? Are we using resources well to produce services? Are we using services well to produce better health Planning: “process of setting goals, developing strategies, and outlining tasks and schedules to accomplish the goals” “open, rational and systematic means of producing decisions about the allocation of resources” prioritisation a key part of planning Answers many of the VFM questions - integral part of searching for VFM

Planning for health reforms Key macro issues in (policy) planning for health Role of state: regulator, financier or provider? Decentralisation Rationale Issues

Corporate and policy planning Policy planning: Broader focus o putting in place right systems to achieve goals Corporate planning: strategic and operational Key components of planning:

Why planning fails …. Even where following ideal cycles, plans not always implemented successfully: Senior management commitment & understanding; lack of acceptance by operational personnel Stakeholders ignored and confusion (and lack of linkages) between different types of planning (strategic and operational) Overly complex plans Skills and competencies of planners Not robustly focused on scaling up evidence-based/outcome-orientated programmes Lack of multi-sectoral approach Limited attention to country-specific bottlenecks Poor costing – normative and disease-focused Link between plans, budgets and results/lack of accountability mechanisms Planning processes require data and information for analysis of the current situation, identification of gaps and setting of priorities Population: growth, composition, needs Health service information Budget and costing data Information on impact

… and what to do about it Integrating health planning processes Quality of the planning process Capacity-building Focusing on results Monitoring, review, transparency and accountability Managing aid

Some planning approaches Results-based management framework Logical framework approach Performance-based budgeting and linking plans and budgets SWAPs and sector-wide approaches

Priority setting A priority when: Political leaders express sustained concern Government enacts policies offering strategies to address Government allocates and releases commensurate public budgets (Shiffman 2007) Priority setting refers to decisions on how to allocate limited resources: key part of policy development and planning Large number of trade-offs and choices: Health with other sectors (education, environment and environmental heath services Health promotion versus curative services, primary care versus secondary care (and the also alternative ways of delivering certain services) Decisions between different disease groups (communincable, non-communicable, injury) and diseases (HIV/Aids, malaria TB)

Priority setting Key considerations are efficiency and equity How are priorities typically set? “implicit& historic” or “incremental and implicit” – without explicit evidence relative burdens and impact “historical” or political” (Mitton&Donaldson 2004) Some refer to “ad hoc” (Younkoung et al 2009) Been growing demand for evidence-based decisions and development of tools for supporting prioritisation Incorporating epidemiological evidence (burden of disease) Taking account of cost Factoring in impact

Quantitative evidence for priority setting Costing and costing tools Rapid development in context of increased pressure and funding of Aids “technical review” of 13 costing tools for MDGs Generally start with population estimates (demand), choice of interventions (options), costing of interventions Burden of disease Cost-benefit analysis Ranking alternatives on basis of net benefits (benefit-costs) Practical difficulties (impossibilities) – deciding which benefits to include & how to value in monetary terms Cost-effectiveness analysis Compares effectiveness (impact on health) to cost Ranks interventions on basis of “ratio of eventual outcomes to cost” (Smith 2009)

Some examples of tools WHO CHOICE Marginal Budgeting for Bottlenecks Costing and costing tools Multi-criteria decision analysis (see table) Program budgeting and marginal analysis Accountability for reasonableness

Prioritisation - Tool development Many complexities: lack of dependable information; multiple players, few systematic processes for decision-making Economic and epidemiological considerations not the only ones: Equity Values Political factors Broader consultation of stakeholders and use of expert groups Sometimes technically simpler options taken but still rigour (Zanzibar malaria case study)

Country examples Kenya NHSSP II – Uganda HSSP III Zambia Priority-setting