Ensuring links between Health Systems Strengthening and Outcomes: Results Chain for HNP

1. Africa Flagship Workshop on Health Systems Strengthening: Financing for Results Ensuring links between Health Systems Strengthening and Outcomes:Results Chain for HNP Gayle H. Martin PhD Senior Economist (Health)

2. Results Agenda in HNP • Globally more pressure to deliver on results • Stronger accountability for results • MDGs • Global Fund Evaluation • World Bank’s HNP Evaluation • Increasing prominence of Health Systems Strengthening agenda: • Unique window of opportunity • Need to show results in performance of the health system: health outcomes and financial protection

3. Results Agenda in HNP • Part of the problem is the absence of a results logic that links Inputs and Outputswith Outcomes and Impacts • Particularly important in a complex sector • Health systems strengthening investments pose an even bigger challenge: • Link between HHS and health outcomes is not guaranteed • Africa region’s strategic vision: • Health Systems FOROutcomes

4. HNP Results Chain • What is new? • If you think of it as a database of indicators … nothing is new • But … if you think of it as an organizing framework that in practical and tangible ways provides a results logic linking inputs to impacts and makes explicit the links between health systems inputs and health outcomes • How was it developed? • Indicators from global consultative processes that have produced targets and measures by which results in specific areas will be judged (e.g., MDGs, UNGASS, RBM, Stop TB, WHO HSS initiative, etc.)

5. Development of the Results Chain • Desk review: • of established multi-agency consultative process that yielded indicators and results chains (e.g., MDGs, UNGASS, WHO consultations on HSS etc.) • Applied to Results Frameworks in PADs of active projects (malaria, HIV/AIDS, nutrition, population, HSS and health reform projects) • Integrate previously “stand-alone” results score cards of vertical diseases to ensure holistic approach to results management • Make explicit the health system underpinnings of many of the HNP operations

6. Structure IMPACTS OUTCOMES Intermediate OUTCOMES OUTPUTS ACTIVITIES INPUTS

7. Structure IMPACTS OUTCOMES Intermediate OUTCOMES OUTPUTS ACTIVITIES INPUTS Modified behavior, conditions, situation for population, communities, businesses, or organizations resulting from project outputs • Products and services delivered by project • -Health facilities constructed • Drugs procured • Health personnel trained • Tasks undertaken to produce outputs • Construct health facilities • Procure drugs • Train health personnel • Resources • Money • Staff • Facilities meet minimum service standards • Facilities have no drug stock-outs • Health workers diagnose and treat malaria correctly • Increased access to basic health service package • Children immunized • Pregnant women receiving antenatal care • Improved health outcomes • Increased economic growth

8. Structure • Two dimensions: • Levels and Categories

9. Levels IMPACTS OUTCOMES Intermediate OUTCOMES OUTPUTS ACTIVITIES INPUTS Modified behavior, conditions, situation for population, communities, businesses, or organizations resulting from investments • Products and services delivered by investments • -Health facilities constructed • Drugs procured • Health personnel trained • Tasks undertaken to produce outputs • Construct health facilities • Procure drugs • Train health personnel • Resources • Money • Staff • Facilities meet minimum service standards • Facilities have no drug stock-outs • Health workers diagnose and treat malaria correctly • Increased access to basic health service package • Children immunized • Pregnant women receiving antenatal care • Improved health outcomes • Increased economic growth LEVEL IV LEVEL III & II LEVEL I LEVEL 0

10. IMPACTS OUTCOMES Intermediate OUTCOMES OUTPUTS ACTIVITIES INPUTS • Level 0 (highest level) • - Refers to health and development outcomes (expressed as impact indicators) • - Examples: IMR, U5MR, MMR, HIV prevalence, Households impoverished annually by out of pocket payments (%) LEVEL IV LEVEL III & II LEVEL I LEVEL 0

11. IMPACTS OUTCOMES Intermediate OUTCOMES OUTPUTS ACTIVITIES INPUTS • Level IV (lowest level) • - Refers to outputs that arise from inputs and activities • - Examples: health centers constructed, drugs procured, staff hired etc. LEVEL IV LEVEL III & II LEVEL I LEVEL 0

12. Challenges • The challenge is how to ensure that outputs (health centers constructed, drugs procured, staff hired etc.) results in improved health outcomes (IMR, U5MR, MMR, HIV prevalence etc.)

13. IMPACTS OUTCOMES Intermediate OUTCOMES OUTPUTS ACTIVITIES INPUTS • Level III and II: • - Intermediate outcome indicators • - Measured as service capacity (level III) and functioning of services (level II) LEVEL IV LEVEL III & II LEVEL I LEVEL 0

14. IMPACTS OUTCOMES Intermediate OUTCOMES OUTPUTS ACTIVITIES INPUTS • Level I: • - Outcome indicators • - Measures access to services or coverage LEVEL IV LEVEL III & II LEVEL I LEVEL 0

15. Contribution to income protection Contribution to health outcomes Outcome indicators • Maternal Health • Maternal mortality ratio (per 100,000). [MDG] - Households impoverished annually by out of pocket payments (%). Intermediate Outcome indicators Output indicators Impact indicators Service delivery Capacity Coverage

16. Improved coverage of high impact interventions, and utilization of essential health services Outcome indicators • Maternal Health • - Deliveries attended by skilled personnel (%). [IDA/RMS] [MDG] • - Deliveries in a health facility (%). • Pregnant women attending at least 1 ANC visit (%). [MDG] • Pregnant women that received a tetanus vaccine (%). Intermediate Outcome indicators Output indicators Impact indicators Service delivery Capacity Coverage

17. Outcome indicators Intermediate Outcome indicators Output indicators Impact indicators Service delivery Capacity Coverage • Production function for Health & Risk Protection* • Infrastructure and equipment • Drugs, supplies and commodities • Human resources • Accountability and institutional capacity • Behavior change • Financing and Risk Pooling Categories

18. Outcome indicators INFRASTRUCTURE Intermediate Outcome indicators Constructing/Rehabilitating Health Facility Buildings Improved Availability of Infrastructure Effective Access to Health Services PHARMACEUTICALS Service delivery Improved Supply of Quality Drugs, Consumables and Supplies Outputs Capacity Effective Access to Quality Drugs, Consumables and Supplies Procuring Drugs, Consumables, and Supplies HUMAN RESOURCES Training and Retaining Health Workers Improved Availability of Skilled Human Resources Effective Human Resources ACCOUNTABILITY AND INSTITUTIONAL CAPACITY Accountability Instruments Improved Accountability Improved Quality and Efficiency Developing Institutional Capacity Improved Management and Institutional Capacity BEHAVIOR CHANGE FINANCING AND FINANCIAL PROTECTION Develop risk pooling mechanisms Removing Financial Barriers to Access Improved Risk Pooling Ensure sufficient Financial Resources for Health

19. Outcome indicators Intermediate Outcome indicators Improved Supply of Drugs, Consumables, Supplies Effective Drug Availability Procuring Drug;s, Consumables, Supplies Service delivery Outputs Capacity • Population mentioning lack of drugs as a reason for not using health services (%) • Drugs per prescription (number). • - Share of drugs prescribed from the country's essential medicines list (%). • - Share of pharmacies surveyed with more than 10% of their inventory in non-registered drugs (%). • Share of health facilities with all tracer medicines and commodities in stock on day of visit (%). [WHO-HSS] • - Health facilities with no reported stock outs of top 10 essential drugs continuously for one week during the last 3 months (%). • - Pharmaceuticals and medical equipment procured (US$, LCU). [IDA-15] • - Contraceptives procured (US$, LCU). [IDA-15] • Consumables procured (US$, LCU).

20. Outcome indicators DevelopRisk Pooling Mechanisms Improved coverage and functional of risk pooling mechanisms Intermediate Outcome indicators - Health financing policy including provider payment mechanisms in place (prepared, adopted and disseminated). - Regulatory framework for health insurance in place (prepared, adopted and disseminated). - Health insurance agency functional. - Health services pricing policy in place (prepared, adopted and disseminated). DevelopRisk Pooling Mechanisms - Population enrolled in health insurance or other risk pool mechanism (%, % by income quintile). • - Population benefitting from waivers and exemptions (%). • - Health Insurance claims that are not paid within statutory time period (%). • - Share of the poorest 20% households who benefited from health insurance coverage through targeted subsidies (%). • -  Share of poor and vulnerable groups exempted to pay copayments in health facilities (%). • - Share of formal sector employees who are covered through health insurance plans supported by their employer (%). Service delivery - Health financing policy including provider payment mechanisms in place (prepared, adopted and disseminated). - Regulatory framework for health insurance in place (prepared, adopted and disseminated). - Health insurance agency functional. - Health services pricing policy in place (prepared, adopted and disseminated). Outputs Capacity

21. Refer to hand-outs

22. Challenges • The challenge is how to link inputs (health centers constructed, drugs procured, staff hired etc.) with health outcomes (IMR, U5MR, MMR, HIV prevalence etc.) • Non-health sector determinants of health outcomes • If there are non-health sector determinants of health outcomes should we hold ourselves accountable for health outcomes (impact indicators) or lower level of results instead? • What can health sector be held accountable for? • Level I: COVERAGE: Improved coverage of high impact interventions, and utilization of essential health services

23. Outcome indicators Intermediate Outcome indicators Output indicators Impact indicators Improved coverage of high impact interventions, and utilization of essential health services Service delivery Capacity Coverage • Health service utilization - People with access to a basic package of health, nutrition, or population services (percent increase). [IDA-15] • - People who reported an illness in the past 3 weeks who used health services (%). Child Health - Children immunized (number). [IDA-15] -Children aged 1years immunized against measles (%). [MDG] - Children under 5 years vaccinated with DPT3 (%). - Children under 5 years fully vaccinated (%). • Maternal Health - Pregnant women receiving antenatal care during a visit to a health provider (number). [IDA-15] • - Pregnant women attending at least 3 ANC visits (%). • - Pregnant women attending at least 1 ANC visit (%). [MDG] • - Pregnant women screened for syphilis during ANC vist (%). • - Pregnant women that received a tetanus vaccine (%). • - Births (deliveries) attended by skilled health personnel (%).[MDG] • - Births delivered in a health facility(%). [UNICEF]

24. Outcome indicators Intermediate Outcome indicators Output indicators Impact indicators Improved coverage of high impact interventions, and utilization of essential health services Service delivery Capacity Coverage • Maternal Health - Pregnant women receiving antenatal care during a visit to a health provider (number). [IDA-15] • - Pregnant women attending at least 3 ANC visits (%). • - Pregnant women attending at least 1 ANC visit (%). [MDG] • - Pregnant women screened for syphilis during ANC vist (%). • - Pregnant women that received a tetanus vaccine (%). • - Births (deliveries) attended by skilled health personnel (%).[MDG] • - Births delivered in a health facility(%). [UNICEF]