1. The Responsibility and Authority Mapping Process (RAMP) Developed by Management Sciences for Health, Inc. 2006

2. Presentation outline  Why develop the RAMP?  What does the RAMP consist of?  Objectives of a RAMP exercise  Methodology of application  Results of field trial  Next steps

3. Why develop the RAMP?  Health sector and other reforms are changing how health services are delivered  These changes have considerable management implications  Clear definition of responsibility and authority is lacking  Confusion of roles is common

4. A simple tool is needed to assess health managers’ understanding of where new management responsibilities reside.

5. What does the RAMP consist of?  RAMP is a process with three phases –Prepare for field application –Collect, analyze, and present data –Use findings to make management decisions  RAMP instrument facilitates data collection and analysis  RAMP data collection worksheet is an easily adaptable matrix –Nine functional areas –1-12 functions per functional area –1-7 determining questions per function Questions are closed to reduce confusion Clarifying comments can also be recorded

6. Nine functional areas  Health service delivery  Public health surveillance and response  Financial resources  Personnel  Drugs, vaccines, and supplies  Equipment and transport  Capital construction and maintenance  Health and management information  Health communication

7. Excerpt from the RAMP data collection matrix

8. Objectives of RAMP exercise Practical way to:  Assess whether all respondents have the same understanding about who has responsibility or authority  Compare perceptions among respondent groups about distribution of responsibilities among different power holders  Compare respondents’ understanding at different points in time

9. Methodology  Interviews: –Guided interviews with groups of respondents, or respondents filling in the data collection form individually –All key respondent groups represented  Analysis and report: –Degree of consensus among respondent groups –Extent of agreement regarding which power holder(s) has responsibility or authority to carry out the functions

10. A quick tour through the RAMP instrument

11. Sample completed response sheet

12. Sample chart showing level of consensus among all respondents

13. Sample bar chart showing different groups’ responses to a determining question

14. Analysis of findings in our situation

15. All functional areas  136 determining questions  82 total respondents across all respondent groups

17. Health service delivery: summary charts  Number of determining questions: 11

18. Health service delivery: key points  Very low level of consensus –No high or moderate consensus on any questions –No consensus on 36% of questions  Many functions at National level –23% of answers were “National only;” another 38% were “Shared national and sub-national”

19. Public health surveillance and response: summary charts  Number of determining questions: 15

20. Public health surveillance and response: key points  High consensus among responses to 1/3 of questions –Some of this due to high percentage of respondents who said that functions did not exist (35% of answers)  Also the second-highest level of “No consensus”—27% of questions, second only to Health Service Delivery functional area

21. Financial resources: summary charts  Number of determining questions: 26

22. Financial resources: key points  Moderate level of consensus for 35% of questions, but low consensus for another 61% of questions  Across all functional areas, the smallest percentage of “No consensus” (4%)  One of the more centralized functional areas: 31% of answers were “National only,” with another 26% “Shared national and sub-national”  Relatively high level of facility involvement, compared to other functional areas –In 13% of answers, perception was that facility alone had the responsibility or authority

23. Personnel: summary charts  Number of determining questions: 33

24. Personnel: key points  High or moderate consensus for 61% of questions  Across all functional areas, the second- highest percentage of “None/ Does not exist” answers (22%)  In 17% of questions, function was perceived to be carried out at District level only, higher than any other functional area

25. Drugs, vaccines, and supplies: summary charts  Number of determining questions: 15

26. Drugs, vaccines, and supplies: key points  Third highest percentage of questions with “No consensus” (19%)  About 50% of responses indicated some level of National involvement, either “National only” or “Shared national and sub-national”

27. Equipment and transport: summary charts  Number of determining questions: 13

29. Equipment and transport: key points  No questions with high consensus  Second-highest percentage of “Low consensus” questions  By far the highest percentage of responses indicating that function takes place at Provincial level only (17%)  Greatest percentage of respondents perceived that these functions are carried out jointly at sub- national levels (without needing to consult the National level)—18%

30. Capital construction and maintenance: summary charts  Number of determining questions: 7

31. Capital construction and maintenance: key points  Highest percentage of “Moderate consensus” across all respondents  Approximately 57% of responses showed either High or Moderate consensus—second highest across all the functional areas  High degree of responsibility and authority at National level –63% of answers were either “National only” or “Shared national and sub-national”

32. Health and management information: summary charts  Number of determining questions: 11

33. Health and management information: key points  No “High consensus” for any of the questions in this functional area  Responsibility perceived as concentrated at National level: highest combined percentage of “National only” and “Shared national and sub-national” (64%)  Second highest percentage of responses indicating the perception that functions are carried out jointly at the sub-national level (17%)

34. Health communication: summary charts  Number of determining questions: 4

36. Health communication: key points  Very low level of consensus overall –Low consensus on 75% of questions –No consensus on remaining 25% of questions  Despite lack of consensus, nearly half (48%) of responses agreed that responsibility was shared among national and sub-national levels

37. Next steps  Corrective steps to address key issues –**Fill this out, based on your own findings  Suggestions for further analysis –**Fill this out, based on your own findings