UPDATE OF ACTIVITIES FOR THE INVESTMENT CASES IN INDIA, INDONESIA, NEPAL, PHILIPPINES, PNG AND INDONESIA

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1 UPDATE OF ACTIVITIES FOR THE INVESTMENT CASES IN INDIA, INDONESIA, NEPAL, PHILIPPINES, PNG AND INDONESIA Eliana Jimenez Soto (University of Queensland)

2 FOCUS Policy-driven: Impact on plans and budgets One size-does-not-fit-all: Different approach/scope in each country Equity: Target vulnerable women and children Sub-national Decentralization Heterogeneity: Different constraints to scale-up, different strategies

3 TWO PHASES Mapping and consultation (October 2009) Implementation (End of 2010) Equity Analysis Scaling-Up Analysis

4 Mapping and consultation Mapping data, reports, studies available in each country What level/type of data are available for the analysis Avoid unnecessary duplication Build on existing work

5 Mapping and consultation Identify how the IC adds value to the on-going agenda in each country Encourage open and honest discussions with policymakers Establish the scope of the IC: Policy questions that can & cannot be addressed by the IC Identify the key policy/planning/budgeting milestones that the IC should fit into How best the IC supports the scale-up of MNCH priority interventions Facilitate the performance-based budgeting for priority interventions Develop a standardized & rigorous -but pragmatic & flexiblemethodological framework that builds on existing approaches

6 Steps in the Investment Case Estimate current burden of MNCH mortality Determine coverage levels of key interventions Review equitable progress towards MDGs 4 and 5 Identify the vulnerable women and children to be targeted by the scaling-up Identify health system constraints and bottlenecks hampering the scaling-up of key interventions targeting vulnerable Women and Children Identify alternative strategies to overcome those constraints and bottlenecks Describe alternative scenarios of required investment and impact

7 STANDARDIZED METHODOLOGICAL FRAMEWORK Equity analysis identifies the vulnerable women and children to be targeted by the scaling-up of key priority interventions Scaling-up analysis builds on existing methodologies Sub-national analyses used to build a National IC with equity focus

8 STANDARDIZED METHODOLOGICAL FRAMEWORK IC informed by Systematic review of the literature on strategies to scale-up & target vulnerable women and children Global and country specific

9 STANDARDIZED METHODOLOGICAL FRAMEWORK Systematic and documented methodology for problemsolving workshops with policymakers Benchmarking: Use of best-performance cases to draw lessons and as a reality check Use of standardized business problem-solving techniques Performance-focused Design-oriented Solutions are based on best-available evidence and pragmatic

10 Equity Analysis Maternal, neonatal and child mortality: Levels Trends Distribution by equity markers Prediction to 2015 to establish the counterfactual of business as usual Who are the most vulnerable mothers and children? Causes of death What are the key interventions that will address the most common causes of mortality? What are the key equity markers to focus on? Geography, SES, caste, ethnicity

11 Scaling-Up Analysis What are the constraints to increase coverage of key interventions addressing the major causes of mortality of vulnerable groups? What strategies could be implemented to scale-up those key interventions targeting the most vulnerable population? Is the scale-up of those strategies affordable? What is the likely impact of those strategies? Which are the key monitoring indicators that should be in place to evaluate the implementation of those strategies? Typologies of Districts and Provinces

12 EQUITY, SUB-NATIONAL AND NATIONAL INVESTMENT CASES

13 EQUITY, SUB-NATIONAL AND NATIONAL ANALYSES For the IC to provide the evidence required by countries to make equitable progress towards MDGs 4 & 5: The equitable distribution of MNCH health to be analyzed from A NATIONAL perspective: Identify the vulnerable population in the country Distribution of MNCH between provinces/districts The service-delivery constraints and the associated strategies should be analyzed from a SUB- NATIONAL perspective Account for decentralization and diversity in the country

14 EQUITY, SUB-NATIONAL AND NATIONAL ANALYSES Both supply and demand factors constrain the scale-up of priority interventions: Supply of health services: Target LOCATIONS Demand of health services: Target POPULATIONS In some cases groups are vulnerable due to geographical access; or those vulnerable groups can be geographically isolated Example: Mountain districts in Nepal; tribal populations in Orissa & Jharkhand

15 Orissa: District level indicators Source DHLS 3

16 EQUITY, SUB-NATIONAL AND NATIONAL ANALYSES In other cases, the vulnerable populations are dispersed across the country, for example the poor

17 Delivery at Health Facility by Wealth Quintile in Nepal Source: NDHS 1996, 2001 and 2006 Data tape

18 EQUITY, SUB-NATIONAL AND NATIONAL ANALYSES We propose the use of typologies to identify the number of sub-national IC that would be required Typologies that reflect different constraints and different strategies across locations Different criteria in each country/state discussed with policymakers Nepal: Ecological regions & choose worst performing in each region Indonesia: High/Low MNCH indicators; fiscal capacity; island non-island Orissa & Jharkhand: Tribal; rural Intuitive and appealing to policymakers to facilitate implementation Target vulnerable populations within each typology

19 Choice of sub national units in Nepal Mountain Most districts included in the scaling-up analysis Eastern-most districts to draw lessons from best-performing cases Hill Selected Mid and Far Western districts with worst MNCH indicators for scaling-up analysis Western hills to draw lessons from best-performing cases Terai Selected Central terai districts with worst MNCH indicators for scaling-up analysis Eastern terai as comparison

20 Example: Choice of sub national units in Nepal Selected districts: Highest mortality rates and lowest intervention coverage Cover 25% of the population, but 45% of the lowest SES quintile Use results from these sub-national IC to inform the IC targeting the vulnerable populations (55% of the lowest SES quintile) in the excluded districts

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22 EQUITY, SUB-NATIONAL AND NATIONAL ANALYSES How to use the sub-national IC to build a National IC? Group ALL the sub-national units within each typology and use the aggregate for the scaling-up analysis Provides total estimate of costings & impact for the country Local policymakers might deny the aggregated data. It is them, not me! Useful to provide overall guidance to central/state government & advocacy Central/state government interested in using the results to support planning/budget at local government level India

23 EQUITY, SUB-NATIONAL AND NATIONAL ANALYSES Choose a few sub-national units within each typology for discussions with policymakers and use these results to inform the modeling of the IC for the excluded districts/provinces Data still close to policymakers, but less transparent analytical process Useful to provide overall guidance to both national and subnational levels & advocacy Support planning and budgeting at the level of LGU Nepal

24 EQUITY, SUB-NATIONAL AND NATIONAL ANALYSES Undertake the IC for ONE selected district/province in each typology Addresses one of the key constraints to scale-up: supporting local governments in linking priorities/plans/budgets Very few units will NOT build a national IC Multiplier effect if strong government commitment to roll-out the IC Explore the potential of the IC to provide a template that can be used by other districts/provinces in country WITHOUT massive data-entry Use the process to draw the lessons for planning & budgeting that can be used in the rest of the country Indonesia and Philippines

25 UPDATE OF COUNTRY ACTIVITIES

26 INDIA Orissa, UP, MP, Chhattisgarh, Jharkhand, National Partners: PHFI (scaling-up) & Indicus Analytics (Equity) Engagement of key stakeholders: Delays in discussions with the government due to elections Central Ministry of Health and Family Welfare Positive feedback on approach (participatory and starting with structured discussion on problems!) Government officials from the State of Orissa Positive feedback. Added value in structured documentation of problems and potential solutions Equity focus: tribal and poor in rural areas

27 INDIA Visits to Governments in UP and MP (August), Chhattisgarh & Jharkhand (Early next year) Preliminary discussions with DPs in New Delhi Activities & Plan Mapping of datasets and reports for the five states Preliminary analysis to identify vulnerable populations to be targeted in each state and typologies First workshops with policymakers in Orissa due in September Preliminary IC results: Orissa (early 2010); UP & MP (mid-2010); Chhattisgarh & Jharkhand (late 2010)

28 INDONESIA National Partners: Gadjah Mada University (UGM) and National Institute of Health Research and Development (NIHRD) Engagement of key stakeholders: UNICEF facilitated a National Inception Meeting for this IC, held on 2 nd June Chaired by the government s National Planning Board (Bappenas) Representation from several government ministries and departments & development partners Strong government ownership Technical Working Group & Steering Committee Led by the government With participation from development partners To ensure IC aligned with and driven by government priorities

29 INDONESIA Activities & Plan Mapping of datasets and reports Preliminary analysis to identify vulnerable groups and typologies for sub-national analysis discussed in the TWG In late August, Steering Committee to discuss the choice of typologies, districts/provinces, and number of sub-national IC to be undertaken in Indonesia Will set the scope of the IC in Indonesia

30 NEPAL National Research Partner: New Era Government engagement: Positive feedback on the IC and its focus on equity The objective: IC to inform the national planning processes for the NHSP-IP II (five year program) currently underway. A change of Government in June has led to some delays in the NHSP planning processes Provides us with more realistic timelines for preliminary results of the IC in Nepal Preliminary recommendations should be provided by the end of this year

31 NEPAL UNICEF facilitated 3-day workshop with government officials and development partners Three basic typologies of districts identified (Mountain, Terai & Hills), so three sub-national IC will be undertaken Discussions on the number of districts to be included in each sub-national IC A sample of 29 districts in each typology has been identified Results from the IC in the sample of districts will be used to model the results of the IC in the excluded districts

32 PHILIPPINES National Research Partner: UPEcon Engagement of Key Stakeholders: Unicef has led the process of government buy-in Strong government support at national and provincial level Active participation of development partners in IC discussions The government requested the IC to directly assist selected provinces/ and or independent cities to develop MDGs 4 and 5 related investment plans and proposals Through the Province/City-wide Investment for Health (PIPH/CIPH)

33 PHILIPPINES Activities & Plan Mapping of datasets and reports Workshops on the IC facilitated by Unicef with broad support from government Discussions with government on the scope of the IC The IC will be undertaken in two provinces (East Samar and North Samar) and one city (Pasay City) Preliminary results for at least two IC will be required by the end of 2009 Results from these three IC will be used to inform the modelling of the IC for the vulnerable populations in the country as a whole

34 PAPUA NEW GUINEA National Research Partner: UPNG Engagement of key stakeholders: As in the other countries, the IC proposal was discussed with government officials and DPs prior to commencing activities. General agreement amongst government officials and DPs was: Added value of the equity analysis, which could be used to inform 20 year National Health Plan No added value of the scaling-up analysis in the current environment

35 PAPUA NEW GUINEA Activities and Plan: Mapping of datasets and reports Equity analysis: Preliminary estimates to be discussed with representatives from the Department of Health and the Statistics Office in late August Final results ready by December to inform the National Health Plan