Highlights of the 5YPOW (2007 -2011)

1. Highlights of the 5YPOW (2007 -2011) By Dr Eddie Addai Director PPME, MOH

2. Outline of Presentation • Part 1: • Overview of the 5YPOW focusing on the strategic thrust and programmes • Part 2: • Capital Investment Plan • Part 3 • Financing the 5YPOW III

3. The Long Road to the 5YPOWIII • Health Forum with the health forum in November 2005 • Development of a New Health Policy • Five Year Programme of Work • Presented at last Summit • Stakeholder retreats in January and March • Comments and suggestions from partners have been incorporated • 2007 was a transitional year

4. Highlights of 5YPOW III

5. The 5YPOW III • A framework and not a plan • Summary of goals, strategic objectives, priorities, programmes and priority activities • Placed within cost and financial projections • Creates a bridge between the Government’s long term vision, GPRS and Health Policy on one hand and the operational details in annual POW and MTEF • Builds on lessons from 5YPOW I&II • But different in a number of respects • Mission, Goals and strategic objectives have been refined • Adopts through the 4 strategic objectives a comprehensive and more balanced approach to addressing the challenges of the health sector • Establishes clearer link between objectives, costs and financing within a medium term framework

6. 5YPOW III • Features • Derives from the principles of primary health care • Places health at the centre of development and emphasizes inter-sectoral action • A framework for harmonizing and alignment of investments and actions of partners • Emphasizes regenerative health and nutrition as a core strategy • Recognizes the role of clinical care and rehabilitation • Lays the foundation for scaling towards health related MDGs • It is intended to be a living document • To be updated as new knowledge becomes available • This will be done through the SWAP processes and annual POWs

7. Strategic Issues and Innovations • Strategic Interventions • Reappraisal of the role of public sector in health delivery • Strengthening and expanding partnerships • Careful allocation of resources between priorities • Fundamental changes in the way health professional are managed • Deployment of combination of taxes, subsidies and provision of public goods and services to improve health • Strategic Innovations • Creating wealth through health and promoting regenerative health and nutrition • Making sure that National health Insurance Works well • Limiting health inequalities • A new focus on priorities

8. Overview of Strategic Objectives and Guiding Principles

9. Guiding Principles • The health sector is more than health services; it includes all activities, institutions and resources whose primary purpose is to promote, protect, restore and maintain health • Health is multi-dimensional in nature and requires partnerships. • Programme design and development will: • be people centred focusing on individuals, families and households in their community settings, • recognise the inter-generational benefits of health • reinforce the continuum of care approach to health development • be prioritized to ensure maximum health gains for the limited resources • Planning, resource allocation and implementation will be results-oriented paying attention to equity, efficiency and sustainability

10. Strategies • Promoting an individual lifestyle and behavioral model for improving health and vitality • Strengthening multi-sectoral advocacy and actions for enhancing environmental health and safety • Rapid scaling up of high impact health, reproduction and nutrition interventions and services targeting the poor, disadvantaged and vulnerable groups and bridging the gap between gap between interventions that are known to be effective and the current relatively low level of effective population coverage • Investing in strengthening health system capacity to manage and expand access to quality health services and sustain high coverage • Promoting governance, partnerships and sustainable financing

11. Strategic Objectives • Healthy Lifestyle and Healthy Environment • Addressing risk factors • Health Reproduction and Nutrition Services • Enhancing coverage and quality of health services • General Health System Strengthening • Strengthening capacity for service delivery and governance • Governance, partnerships and Sustainable Financing • Achieving results

12. Medium Term Priorities • Ensuring healthier mothers and children through scaling up implementation of high impact and rapid delivery health interventions • Promoting good nutrition across the life span, food security and food safety • Combating communicable diseases such as HIV/AIDS, Malaria, Tuberculosis, epidemic prone diseases and diseases that almost exclusively affect the poor such as Bururli Ulcer, Guinea worm, Leishmaniasis, Lymphatic Filariasis, schistosiamiasis, etc. • Effectively collaborating with relevant MDAs and stakeholders to improve housing, personal hygiene, environmental sanitation and access to potable water

13. Medium Term Priorities • Reducing risk factors associated with non communicable diseases such as tobacco and alcohol use, lack of exercise, poor eating habits, unsafe driving and stress • Strengthening clinical management of diseases as well as prevention and management of blindness and promotion of mental health • Strengthening surveillance and response to epidemics and emergencies • Strengthening the regulatory framework within the health sector • Forging stronger, integrated, effective, equitable and accountable health systems including strengthening financing, human resources management, information management and private sector.

14. Healthy Lifestyle and Healthy Environment • Programme Components (3) • Health promotion and Regenerative health and nutrition • Inter-sectoral Advocacy, Action and Collaboration aimed at improving environment health and safety • Food safety

15. Health, Reproduction and Nutrition Services • Programme Components (9) • Communicable Disease Control • Non Communicable Disease Control • Reproductive and Sexual Health • Child Health • Nutrition • Emergency preparedness and epidemic response • Clinical Care • Traditional and Alternative Medicine • Rehabilitation

16. Integration of Horizontal approaches Malaria CDC NCD RSH Diarrhea CH Nut HIV TB Pneumonia etc. community based services Outreach services clinical services

17. General Health System Strengthening • Programme Components (7) • Human resource development • Infrastructure Development • Information Management • Health Industries • Equipment • Transport • Medicines and Essential Logistics

18. Governance and Financing • Programme Components (7) • Organizational reforms and institutional development • Policy development and management functions • Health Financing and National Health Insurance • Partnerships, coordination and collaboration • Performance management and accountability • Regulation • Efficiency and Equity

19. Capital Investment Plan

20. CIP III Linkage to POW 3 • Strategic Objective 3: Strengthening health system capacity to expand, manage and sustain a high coverage of quality health interventions and services for promoting health, preventing diseases, treating the sick and rehabilitating the disabled

21. Key Result Areas • Increased geographical access to health services with emphasis on deprived and peri-urban areas; • Improved availability of appropriate equipment and Transport; and • Improved health information system and deployment of ICT

22. Objectives of CIP III • To keep existing health facilities/institutions functional/operational; • To increase scope of services consistent with the needs of the sector; • To increase access to health services.

23. Components of the Capital Investment Plan • Civil works infrastructure; • Biomedical Equipment; • Transport; and • Information and Communication Technology

24. Programmed Objectives of CIP Components • Infrastructure: To focus on increasing geographical access, well maintained health facilities and health enhancing infrastructure; • Equipment: Toprovide health facilities with functional equipment; • Transport: To increase vehicle availability for service delivery and supervision; • ICT: To generate and use evidence for decision making, programme development, resource allocation and management, through research, statistics, information management and deployment of ICT

25. Investment Plan Scenarios • Scenario 1: Sustaining current levels of health delivery and expansion of training institutions • Scenario 2: Limited expansion of Health facilities and Services • Scenario 3: • Full service expansion of Health facilities and Services

26. Scenario 1(Sustaining current level of health delivery and expansion of training institutions) • Completion of all ongoing projects; • Rehabilitation and PPM of existing health infrastructure; • Expansion of training institutions; • PPM and replacement of over aged and broken down biomedical equipment and vehicles; • Equip facilities established without equipment and transport input; • Implementation of a strategic plan for National Health Management Information System

27. Scenario 1Infrastructure Facilities currently under Construction • CHIPS Compounds 107 • Health Centres 43 • Polyclinics 5 • District Hospitals 25 • Psychiatric Hospital projects 5 • Regional Hospital projects 5 • Staff Accommodation 18 • Offices/RHMT/DHMT 8 • Training Institutions 30 • Teaching Hospital Projects 12 • Statutory Bodies 9

28. Scenario 2(Limited expansion of health facilities and services in addition to Scenarios 1) • Construction of additional 255 CHPS compounds; • Construction of additional 25 Health Centres; • Upgrading of 20 Health Centres to district hospitals; • Construction of additional 20 District Hospitals; • Reactivation and completion of abandoned projects; • Expand and construct new and existing training institutions; • Upgrade obsolete equipment with modern technology to reduce risk of service delivery (e.g. medical gas delivery, laundry, sterilisation, patient lifting etc.) • Provide additional equipment and transport to fill the gap in stock required for standard of service delivery;

29. Scenario 3(Full expansion of health facilities and services in addition to Scenarios 1 & 2) • Construction of additional CHPS compounds, health centres and hospitals especially in hard-to-reach/deprived and peri-urban areas and the newly created districts. • Initiate new projects to introduce new services or expand the services within an existing health institution • Rehabilitation of selected projects in Psychiatric, Regional and Teaching Hospitals • Construction of nationwide staff accommodation • Initiate projects to introduce new services or expand the services within existing health institutions including the teaching hospitals; • Provide additional equipment and transport to enhance service delivery;

30. Estimated Cost of CIP III by Scenarios

31. Financing 5YPOW III

32. Issues • What results do we want to achieve? • How much will it cost to achieve the results? • How much resources can be mobilized? • What is achievable with the available resources? • How do we deal with the resource gap?

33. Developing a the Sector Medium Term Financing Framework – Methodological Issues • Focusing on achieving MDGs • but not dogmatic about limiting activities to MDGs • Health system bottleneck analysis and reduction • Scenario planning • Pragmatism and realism • Recognizing fiscal and budgetary constraints including existing commitments, sunk costs and fixed cost • Using MTFF to improve allocative and technical efficiency

34. Costing Scenarios – Assumptions • Item 1 cost is likely to increase • More health workers will be needed to meet • Existing HR gaps • Expansions of health services including CHPS implementation • Ambulance Service • New cadre of herbal medicine practitioners • Index linking health sector wages to inflation but no real growth over the next 5 years • Redistribution of staff

35. Item 1 Scenarios • Scenario 1: Modest increase in staff cost • 5% increase in numbers • No real increase in wage bill but index linked to inflation • 5% wage bill invested in staff redistribution and retention • Scenario 2: More substantial increase in staff cost • 10% increase in numbers • No real increase in wage bill but index linked to inflation • 10% wage bill invested in staff redistribution and retention • Scenario 3: Same as scenario 2

36. Administration budget (Item 2) • Control of administrative cost but the starting point is rather low in 2006 • One off increase • 20% increase in item 2 budget in 2007 compared to 2006 • Efficiency saving measures on running costs • Then no real growth but index linked to inflation

37. Service Budget (Item 3) • Address bottle necks related to sustaining and scaling up service delivery with focus on: • Community based activity • Availability of commodities and inputs for public health and other free services • Protecting the poor and vulnerable groups by financing free and pro-poor services including premium for health insurance • Providing operational funds for services delivery • Supervision and quality of care initiatives

38. Item 3 Scenarios • Scenario 1 – 5% increase in 2007 • Scenario 2 – 10% increase in 2007 • Scenario 3: Same as scenario 2

39. Investment budget (Item 4) • Scenario 1: Sustaining current services • Scenario 2: Limited expansion • Scenario 3: Full service expansion

40. Costing Estimates USD per capita per year

41. FINANCING

42. Financing (Assumptions and Scenarios) • Assumption: Increases in health spending is driven by growth and will be indexed to inflation and population growth • Scenario 2: Preferred – 29.4 USD per capita • Growth will remain at 6.5% per annum; • Government revenue will stay in the region of 22% of GDP • Proportion of total spending will not exceed 15% • MDBS will remain at around its current level - 10% of total government expenditure • Inflation will be around 10% per annum

43. Financing (Assumptions and Scenarios) • IGF will be linked to growth, but will lose 10% of its value per annum to the NHIS scheme • NHIF will be driven by growth • The Health Fund and earmarked funds will grow with inflation, but will remain stable in real value; • HIPC and other debt relief allocations to health will remain at around the same level as at present (2% of budget for 2007)

44. Scenario 3 : High Case – 37.23 USD per capita • The proportion of government allocation to health increases to 18% from 2008, • the proportion of government revenue rises to 24% of GDP • The discretionary debt relief rises to 5% of total health expenditure • All other assumptions are the same as in scenario 2

45. Scenario 1: Pessimistic 27.55 USD per capita. • Retains the assumptions of scenario 2, • Government revenue is reduced to 20% of GDP

47. MDGs Impact

48. MDGs Impact

49. The Resource Gap Challenge if we want to achieve MDGs • An annual and medium term Challenge • Strategies • Resource Mobilization • Further prioritization and sequencing of priorities • Efficiency Savings and reallocation within the budget constraint

50. Financing the gap (1): additional resource mobilisation • GoG – reaching Abuja targets and responding to shift to MDBS • Donors – resources to finance MDG push including vertical funds • Loans – to finance capital investments • Loans – to finance recurrent cost????? • Pubic Private Financing Initiatives?????