Planning And Evaluation In Public Health

PROGRAM PLA NN ING and EV ALUATI ON in PUB LIC HEAL TH Lecturer: Rosa Marie N. Flores, M.D. M.P.H. FPAFP,DFM

OBJECTIVE

Content

Activities EvaStudent Teacher luati on

At the end of session, the student should be able to :plan and evaluate a program or a project :define program planning,project planning

Knowledge ♦ Why plan ♦ Definition of planning a project ♦ Priority setting among health project ♦ Identification of areas for project dev’t ♦ Steps in project formulation or planning , implementation, monitoring and evaluation

♦Actively ♦Discuss Listens ♦Lectures ♦Com Municates ♦ SGD

Exam : Short & Long

Why plan? ♦ It focuses and directs your efforts - how much you have achieved your plan - how to achieve your plan ♦ It organizes people - it will be your duty to delineate tasks/outline ♦ It’s a good method of communication (e.g. when you go to the mayor, you plan ) - if you are working with the C.E.O. the first part could be the summary - but since you are planning ,your letter would start

♦ Allows improvement of system --- you will know where the system is strong or weak

What is Planning? ♦ It is a process of making current decisions in the light of their future effect ♦ It is the process of ordering priorities, diagnosing causes of problems and allocating resources to achieve predetermined objectives ♦ It is an exhaustive, comprehensive review of all alternatives (methods) towards making a decision for future actions to allow attainment or achieve goals (implementation) and bring about desired changes (objectives) in the client community.

What is planning (cont’d): ♦ Planning answers the following questions: ♥ Where are we going ? ♥ Why are we going or where do we want go? there? ( GOALS/OBJECTIVE SETTING) ♥ Where are we now? (SITUATIONAL ANALYSIS) -- included under plan formulation

♥ What resources are at our disposal?

♥ How do we get we get there? ♥ What do we need to get (STRATEGY/ACTIVITY SETTING) there? ♥ How do we know we are there? (EVALUATION)

PRO GRA M PLANN ING   3. 4. 5. 6. 7. 8. 9.

Objectives: At the end of the session, the student must be able to: Define program planning Give the characteristics of health programs Enumerate and give examples of types of programs Explain the key elements of a program Explain the clinical nature of the planning process Demonstrate how to write program objectives and set targets Differentiate regular activities from developmental activities

De fin itio ns  Program planning— is the formulation of strategies for the achievement of a given health policy objective  Health programs--- are results of health policies , therefore no health program means no health policy.  Note: There can be several Health Programmes for a given Health Policy or a given Health Policy or several Health Policies for a given Program.

♦ ELEMENTS OF PLANNING ( describes the essential nature of planning ):

♣ CONTRIBUTION OF PLANNING TO OBJECTIVES ♣ PRIMACY OF PLANNING – first of the managerial functions to be performed

♣ PERVASIVENESS OF PLANNING – found at all managerial levels

♣ COORDINATION OF PLANNING – coordinating the what, who, when, how, where and why of planning

♣ SELECTION OF PLANNING ALTERNATIVES - concerned with planning alternatives ♣ EFFICIENCY AND ECONOMY OF PLANNING - considers potential values received from planning versus costs incurred

♣ FLEXIBILITY OF PLANNING - ability to adjust to changing conditions ♣ CONTROL OF PLANNING - provides a feedback mechanism to change plan when necessary

STEPS IN THE PLANNING PROCESS: 1. COMMUNITY ANALYSIS : SITUATIONAL ANALYSIS and PROBLEM IDENTIFICATION A. Needs assessment : Identification of the Problem. B. Involves collection of detailed information concerning the community under study General overview obtained, then specific aspects of community are analyzed including community health status  Information derived from a variety of sources 

♣ PURPOSE OF THIS STEP: is to identify within each of the four technical areas the problems and their underlying causes

♣1.COMMUNITY ANALYSIS has three ( 3 ) components: 1.1 DESCRIPTION OF THE PRESENT SITUATION (DEMOGRAPHY) 1.1.1 POPULATION :Total number of people : Geographic distribution (including accessibility information) : age-sex composition : vital statistical rates crude birth rate,  crude death rate,  IMR, MMR

natural growth rate  the presence of , and types

1.1.2. HEALTH STATUS : leading causes of morbidity : leading causes of mortality : leading causes of IMR : leading causes of MMR : leading causes of hospital admission / utilization : leading causes of consultation

1.1.3 HEALTH RESOURCES 1.1.3.1 Health Facilities : (1.) type (unsuitable design) : (2.)number (lack) : (3.)geographical distribution (maldistribution w/ concentration in the rural areas, not optimally situated, illequipped) : (4.)state of repair and utilization (not properly supplied and maintained)

1.1.3.1 HEALTH FACILITIES (cont’d)  Explanations are sought in the following:  Lack of recognition of the problem by the high decision-maker  Lack of planning  Use of wrong criteria for distribution (including political, personal, and technical administrative)  Defective policies in matters of personnel, supply, and finance and defective procedures1

1.1.3.2 MANPOWER : by type : number (inadequacy in number) and distribution (maldistribution) : the expenditures : the population coverage of specific programs (achievements) & : analysis of current and recently concluded heath resources

The problems usually identified regarding manpower are : 1) inadequacy in number, 2) maldistribution, 3) inefficient utilization, 4) low quality and 5) motivation. Explanations are sought in the field of higher policies in education , migration, and distribution, training, attitudes, managerial competence, technical and administrative policies and procedures.

1.1.3.3 Intersectoral and intrasectoral relationships: Th e r easo ns for t he abse nce o f good wo rkin g rela tionsh ips are so ught.

1.1 DESCRIPTION OF THE PRESENT SITUATION: DEMOGRAPHY (cont’d) 1.1.4 HEALTH RELATED SOCIO-ECONOMIC FACTORS/ RESOURCES : economic activities : nutrition : waste disposal : water supply : transportation : communication : education : housing

: agriculture : industries

Three (3) Components of the Community Analysis (cont’d) Situational Analysis / Problem Identification (Cont’d)

1:2 PROJECTION: a must in long term planning. The ones projected are: A. Population B. The different Rates of specific disease/conditions (based on observed trends and possible impacts of programmes and trends observed in the health-related socioeconomic factors)

1:3 PROBLEM IDENTIFICATION and EXPLANATION: The last part of the situational analysis consists of: - identification of the problems = w/o it , planning cannot proceed in the right - explanation of the causes - indication of areas of change (constraint/obstacles analysis) - accurate statements of problems lead to clear objective setting - the product of this analysis would result to tables, detailed descriptions, projections and some conclusions  identify within each of the four technical area of the problems and their underlying causes  the 0utputs --- are a list of problems and constraints and proposals for changes in areas where required

STEPS IN THE PLANNING PROCESS (Cont’d): 2. DEFINING AND VERIFYING THE PROBLEM: COMMUNITY DIAGNOSIS -the final step in COMMUNITY ANALYSIS -involves synthesizing all collected data and determining gaps between health problems and services the gaps –indications of need within the community and any subpopulation within the community that may be particularly affected by health problems the group --becomes the target population

 Establishing program goals - first important process - once needs are verified can be translated into program goals - all subsequent activities should focus on designing program that will address an identified need in particular population  Defining and assessing behavior: - must define behaviors related to the problem - “the essence of health education is planned behavior change” planned changes in behaviors that are related to maintenance and improvement of health.

3.PLAN FORMULATION / DEVELOPING A PROGRAM PLAN 3.1 Objective Setting and Strategy Formulation 3.1.1 Setting of objectives/ formulation of objectives - The following steps are followed: A. Setting the overall health policy w/c includes the following: (1.) Main objectives….w/c should be SMART S pecific (what) M easurable ( by how much) A ttainable R ealistic T ime Bound (when) (2) priority setting (3) general (basic) strategy

- Planning group must select educational methods (chosen alternative of proven merit and Review of Literature is important here)

PLANNING OF PROGRAMS (HEALTH PROGRAMS) =Refer to the courses of actions and necessary resources for the improvement of a given health problem = is a timed series of service activities and development efforts requiring physical, human, and financial resources for the implementation of one or more course of action to achieve a given health policy objective

Examples of Health Programs: MCH  ENVIRONMENTAL HEALTH  EPI  COMMUNICABLE DISEASE CONTROL  NONCOMMUNICABLE DISEASE CONTROL

-The distinction between a strategy and a program is a matter of specificity and feasibility. -Both contain service and developmental activities. = However where these are implicit not distinguishable from strategy, and not tested for feasibility they should be quite explicit and feasible by the time a programme is formulated

Selection of Programs in the Health Plan -1st step is to review the existing ones, how they performed in the past, and their relevance to the priority health problems. -Experience has shown that there is very little option in selecting programs since most of the existing ones , de-emphasizing some activities or introducing changes in direction - The main determinant in the choice of program is the relevance to the main health problem and having established a list an assignment of an order of importance -The programs included in the list will be needed.

PROGRAMS: 1. Programs for direction, coordination, and management - formulation of policy - direction, coordination, and control of program activities - provision of informal and administrative support, including personnel, finance, logistic and legal services 2. Health System Infrastructure -planning and development of basic health facility network - health manpower policies and training - health education and public information

3. Technology Programs =MCH including Family Planning and Nutrition = Environmental Health = Communicable Disease Control = Non-Communicable Disease Control = Psycho-social health to include mental health, alcohol and drug abuse = Oral Health = Worker’s Health = Rehabilitation = Laboratory and Biological products = Health of the Elderly = Research and Protocol Dev’t

THE KEY ELEMENTS OF A HEALTH PROGRAM

KEY ELEMENTS OF A HEALTH PROGRAM: 1. NAME = w/c identifies it as close as possible with a healthy policy objective (s) or disease condition (s) it intends to solve/ improve 2. A BRIEF STATEMENT OF THE PRIORITY DISEASE/CONDITIONS IT INTENDS TO SOLVE/IMPROVE - to include the magnitude and - extent of the problem, and a - comment on why it is important - the statement should also include the status of status of the program (should there be an existing one) and the important constraints which hamper the program 3. AN OBJECTIVE (S) – which indicates quantified changes from existing levels of occurrence with specifications of time frames

4. BUDGET- only certain specific resource. 5.Disease condition targets, which indicates quantified charges from existing levels of occurrence with specification of time frames 6.SERVICE TARGETS– which include percentages of the coverage of a given eligible population. Health service target refers to the health activities applied directly to the individual in the community or environment in order to improve the health status.

7. APPROACH—which describes the ACTION to be pursued such as MANNER OF IMPLEMENTATION (vertical or integrated with basic health units) - program tactics, clinic attendance, house to house campaign, etc. - the field units responsible for the delivery of services and the role of the other units - the principal constraints or obstacles to the program’s implementation noted in the past and what needs to be done to overcome them. = the latter refers to the development of activities that should be applied to the staff, facility, organization, procedures, etc. in order to overcome the principal constraints and raise

8. LINKAGES – this should include the following : = the participation of the other government facilities outside the health ministry. = the responsibilities if any of the private sector = the possible involvement of other related sectors. = it is important that specific sectors be identified, approached and be made active participants in formulating an intersectoral plan of action.

9. PROGRAMME REQUIREMENTS need to be calculated such as - the key personnel for program direction and - doses of vaccine in EPI if a program will be implemented through the existing health service network. = for vertical programs the whole budget need to be estimated. 10. NEED FOR TECHNICAL COOPERATION FROM EXTERNAL AGENCIES - specify nature of needed cooperation 11. EVALUATION INDICATOR(S) = this is decided upon considering the health policy objectives, the health status targets and the service targets

PROGRAMME OBJECTIVES / TARGET OBJECTIVES: ♦ Program Objectives: - Essentially the same as the health policy objective - the most important consideration is that whatever objective formulation, should state what is to be done by the program with regards to a priority health problem identified at the stage of situational analysis .

♦ Target Objectives: ♠ are quantified objectives with a time factor ♠ e.g. may be expressed as: ♥ reduction of maternal mortality to a specific level, ♥ reduction of cholera or TB levels to zero cases, etc. ♠ define quantity and quality of activities to be accomplished by disease reduction targets or health status targets / health impact objectives.

2 types: 1. Service Targets / input targets - act directly to reduce the disease / condition level 2. Developmental activities / resource targets : - aim to remove the obstacles to the appropriate delivery of service targets or strengthen the capability to such delivery

EXAMPLES OF TARGETS: Health status – reduction to zero levels of tetanus neonatorum Service – full immunization of all pregnant women with tetanus toxoid within three yrs. DEVELOPMENTAL ACTIVITIES Staff = assignment of a complete rural health

Facilities

unit for each municipality within 3 years = construction of 50 health centers in 3

yrs Expenditures = jt js necessary to determine how much can be done to reduce the problems within a specified period of time

Targets cont’d: = target statements are guided by removability of corresponding constraints = target statements must be very clear free from double interpretation = plans are periodically reviewed and adjusted and careful projection should take care Service Targets = are discussed 1st before the disease/ condition reduction targets because the latter depends on the degree of achievement of the former. = However in the writing of programmes disease/condition targets are presented first. = Balancing act between what is epidemiologically desirable and what is administratively feasible

 Operational standards to be observed for activities: 1. Duration of activity (e.g. length of hospitalization) 2. Frequency of application of activity per case/ person/ establishment number of times OPT will be given per child 3. Staff performance ( e g : consultation per hour, per vaccination ) 4. Facility performance (e.g. bed occupancy rate)

 Activities will be carried out by trained staff provided with appropriate equipments and medical supplies and with adequate supervision.  Productivity and efficiency are assumed.

HEALTH SERVICE DESIGN:- what are the systems involved IDENTIFICATION OF NEEDS FOR PROJECTS BUDGET ESTIMATES

3. Establishing Program Goals - first step is = to identify goals for health education =identify the resources and constraints

FORMATIVE EVALUATION: = RELEVANCE and ADEQUACY of a plan /program is decided; = It is done during the stage of program formulation

4. PLANNING FOR IMPLEMENTATION: Two (2) activities included here are: 1. The planning of preparation and 2. Developmental activities: = allocation of resources = securing legal authorization to start implementation = promotional activities planning = preparation for the institution of minor changes = refer to the institution of major changes including the introduction of new developmental activities

5. EVALUATION: SUMMATIVE EVALUATION = Evaluation of effectiveness and impact = done at the end of implementation

5. DESIGNING PROGRAM EVALUATION = must be included in the planning process = must have evaluation criteria or standards by which the program achievements can be assessed = are assessed in terms of their accomplishment = ease in drafting this depends on the way the health plan has been formulated = a good plan should have evaluation guides = the overriding concern of evaluation is to determine the impact on the health condition of the country. : endpoint of plan but also the start of another plan : checks if the plan is successful or not : do monitoring first, revise, and evaluate

EVALUATION: Summative Evaluation= evaluation of effectiveness and impact; done at the end of implementation. DESIGNING PROGRAM EVALUATION:  must be included in the planning process  must have evaluation criteria or standards by which the program achievements can be assessed  process or outcome evaluation = determine the extent to which the program achievements can be assessed

PROCESS OR OUTCOME EVALUATION: = determines the extent to which the objectives contained in policies, programs and projects have been achieved

STEPS IN THE PLANNING PROCESS: (cont’d) 2. Defining and Verifying the Problem (cont’d)  Establishing program goals - First important process - Once needs are verified can be translated into program goals. All subsequent activities should focus on designing program that will address and identified need in particular population  Defining and assessing behavior -must define behaviors related to the problem. “ The essence of health education is planned behavior change, “ planned changes in behaviors that are related to maintenance and improvement of health.

3. PLAN FORMULATION / DEVELOPING A PROGRAM PLAN: Objective Setting and Strategy Formulation Planning For Implementation Establishing Program Goals  the first step is to identify goals for health education  identify resources and constraints  SETTING THE OBJECTIVES/ FORMULATION OF OBJECTIVES The following steps are followed: ( 1.)setting the overall health policy which

(2.) Includes the ff: a. main objectives b. priority setting c. general (or basic) strategy (3.) planning of programmes (4.) health service design (5.) identification of needs for projects (6.) budget estimates

 planning group must select educational methods (chosen alternative of proven merit and review of literature is imp’t. Formative evaluation= relevance and adequacy of a plan/program is decided; it is done during the stage of program formulation.

Planning for Implementation: Two Activities 1. The planning for preparation and developmental activities  Preparatory activities: ♥ allocation of resources ♥ securing legal authorization to start implementation ♥ promotional activities planning preparation for the institution of minor changes  Developmental activities ♥ refer to the institution of major changes including the introduction of new developmental activities 2. Actual delivery of health services

 Are assessed in terms of their accomplishment  Ease in drafting this depends on the way the health plan has been formulated  A good plan should have evaluation guides  The overriding concern of evaluation is to determine the plan impact on the health condition of the country ♥ endpoint of plan but also start of another plan ♥ checks if the plan is successful or not ♥ do monitoring first, revise and evaluate  Involves synthesizing all collected data and determine gaps between health problems and services. ♥ the gaps– indications of need within the community that may be particularly affected by health problems ♥ the group– becomes the target population

Ch ara cterist ic s of He alth Pr ograms  Relevant: must be based on priority health problems.  Effective: Must answer the problems they were intended for  Efficient: outcomes are attained with the least amount of resources

Typ es of Pr ogramme s  Programs for Direction, Coordination and Management  Formulation of Policy, Programmes and Projects  Provision of Informational or administrative support  Health System Infrastructure  Planning and development of basic health facility network

       

Health manpower policies and training Health education and public information Technology programmes MCH, Family planning and nutrition Environmental health Communicable disease control Non communicable disease control Mental and Community Mental Health

Ke y Ele ments o f a He alth Pr ogram           

1. Name of program 2. Basis of a program 3. Health policy objectives 4. Disease condition targets 5. Strategies / service targets / activities 6. Approach 7. Linkages 8. Program budget 9. Linkages 10. Need for technical cooperation 11. Evaluation indicators

 Nature of Program Planning Process: --Cyclical Identification of areas of concern Assessment Formulation of alternatives Decision Inclusion into the Program Plan

PROJECT PLANNING: What is a PROJECT: ♦ The most concrete means of translating policies and programs into specific courses of action. ♦ A temporary management activity that breaks up upon completion of the designed output. ♦ It is a time-limited undertaking involving a series of interrelated activities. Its ultimate purpose is to incorporate such desired changes/developments into the health care system as will enable the health programme or facility to develop or enhance its capability for delivering a specified health service.

Identification of areas for planning development:  In program planning, obstacles to programme delivery has been listed in the situational analysis, and measures to solve them have been proposed in designing the program approach.  A review is made of these proposals of each program to determine the degree of their interrelationships with each other. The review should lead to the classification of lesser numbers of but larger project efforts. If the latter is not feasible, then the changes/developments may be dealt with through several smaller efforts.  Prevailing policies, the existing administrative expertise for carrying out the proposed changes and the extent of their interrelationship with each other will influence the choice.

3 Groupings: 1-Through programs and services Ex. =Strengthening of basic health services = integration of maternal and child health and family planning = development of a national government pharmaceutical store 2-Through major activities Ex: = training = construction/infrastructure = design of administrative subsystem 3- A combination of the 2

♦ NATURE OF PLANNING ♥ IMPORTANT ELEMENTS THAT DESCRIBES THE ESSENTIAL NATURE OF PLANNING : ♣ CONTRIBUTION OF PLANNING TO OBJECTIVES ♣ PRIMACY OF PLANNING – first of the managerial functions to be performed ♣ PERVASIVENESS OF PLANNING – found at all managerial levels ♣ COORDINATION OF PLANNING – coordinating the what, who, when, how, where and why of planning

♣ SELECTION OF PLANNING ALTERNATIVES - concerned with potential values received from planning versus costs incurred ♣ EFFICIENCY AND ECONOMY OF PLANNING -considers potential values received from planning versus costs incurred ♣ FLEXIBILITY OF PLANNING - ability to adjust to changing conditions ♣ CONTROL OF PLANNING - provides a feedback mechanism to change plan when necessary

APPROACH TO PLANNING: ♦ Flow may be TOP-DOWN or BOTTOM- UP or ♥ “Top- Down approach ” ♥ “ Bottom- Up Approach ” ♥ “ Combined Approach “

 Then the listed projects are classified into HIGH and LOW PRIORITY GROUPINGS accdg to some criteria.  The following will receive high priority: 1. Projects which relate to urgent problems and which have significant political implications 2. Projects which relate to urgent problems and which have significant political implications. 3 Projects which will give improve effectiveness and efficiency in the utilization of resources (and hence the maximization of their impacts).

 Then the time-span or life of each project is roughly calculated and indication is given as to when it will be started.  Resource requirements in monetary terms are calculated and incorporated into the plan budget.

Approved list of projects w/indication of priority Prepare specific objectives of each project Determine activities and formulate a plan of work for each project Prepare monitoring scheme for each project Prepare requirements for the administration of each project

Write the project document for each project

Secure authorization to implement projects FLOWCHART ON PROJECT PLANNING

ANALYSIS OF THE HEALTH SECTOR Objectives: 1.Review and evaluate the available resources for the delivery of health care 2. Identify deficiencies and weaknesses within the health care delivery system 3. Evaluate the relevance of present policies/strategies in improving health Subtypes: 1.comonents of the health sector 2. study of intersectoral relationship 3. analysis of intrasectoral relationship 4. Analysis of health facilities 5. Analysis of health manpower

PROJECT DEVELOPMENT 2. Problem identification Problem explanation (CONSTRAINTS, OBSTACLES, ANALYSIS) 2. Problem preparation- assessing the viability of the project from the technical, economic, financial, and operational point of view. 3. Project appraisal and financing 4. Project implementation 5. Project operation 6. Project reappraisal

PROBLEM ANALYSIS (PROBLEM TREE) EXAMPLE : LOSS OF CONFIDENCE IN BUS COMPANY Passengers hurt or killed

People are late

Frequent bus accidents Drivers not Careful

Bad conditions of vehicles Enough

Vehicles

Bad road conditions

Maintenance

OBSTACLES MATRI X = basi s of proj ect pl anni ng Obstacles Technology

Staff

Procedure

♦ SCOPE OF THE PLAN: ♥ COMPREHENSIVE or ♥ PARTIAL 6. Comprehensive Planning: a plan that includes all sectors of the economy (public and private) 2. Partial planning a plan that includes some aspects or even just one aspect of the economy ♦ SUBSTANTIALITY OF THE PLAN : • if the plan covers the more dominant part or the majority, the plan is considered substantial 2. if it covers only a small part the plan must be changed into a comprehensive one for it to be more significant

♦ TIME-SPAN ♥ Long-term Planning

- At least eight ( 8 ) years ♥ Medium- term Planning -Four ( 4 ) to Seven ( 7 ) years ♥ Short-term Planning-----One (1) to two ( 2 ) years

♦ AUTHORITATIVENESS Either: ♥ INDICATIVE or ♥ PRESCRIPTIVE ♥ Indicative Planning: ♣ used merely as a guide or terms of reference ♣” indicating “ what the sector may do ♣ not binding ♥ Prescriptive Planning ♣ command or control planning ♣ has to be accepted and implemented

♦ Three ( 3 )Levels of Administration and

Operation ♣ Top or decision –making level ♣ Middle level ♣ First level ♦ Natural Expected Outputs of National Health Planning: ♣ National Health Policies ♣ Health Programmes ♣ Health Projects

♦ PRIORITIZATION ♥ Criteria: 3. Which problems has greater impact in terms of death, days lost from work, rehabilitation cost, family disorganization 4. Are subpopulations at special risk? 5. Which problem is susceptible to intervention ? 6. Which of the social problems is more neglected by other agencies? 7. Which of the problem when correctly addressed has the highest potential for attractive yield ? 8. Is it ranked as a national priority?

♦ HANLON’S PRIORITY METHOD 2. Size of the Problem (0-2) ) = % of population affected -------------------------------------------------- a 3. Seriousness of the Problem ( 0- 20 ) ------------- b a. Urgency—Public concern? Public health concern? b. Severity---Mortality, Morbidity, Disability c. Medical Costs to individuals directly affected d. Future Needs (trends in health care needs, forecast of potential number of persons to be affected) 3. Effectiveness of the solution (0-10)-------------------c How well it can be solved. Defined as improvement of the service program.

Hanlon’s Priority Method ( Cont’d ) 4. HANLON’S PRIORITY CRITERIA: P-E-A-R-L ----d P riority --------------------0-1 E conomic Feasibity----0-1 A cceptability -------------0-1 R esources-----------------0-1 L egality -------------------0-1 ♥ FORMULA

= (a + b) c / d

STEPS IN THE PLANNING PROCESS: 1. COMMUNITY ANALYSIS : SITUATIONAL ANALYSIS and PROBLEM IDENTIFICATION A. Needs assessment : Identification of the Problem. B. Involves collection of detailed information concerning the community under study General overview obtained, then specific aspects of community are analyzed including community health status  Information derived from a variety of sources 

♣ PURPOSE OF THIS STEP: is to identify within each of the four technical areas the problems and their underlying causes

♣1.COMMUNITY ANALYSIS has three ( 3 ) components: 1.1 DESCRIPTION OF THE PRESENT SITUATION (DEMOGRAPHY) 1.1.1 POPULATION :Total number of people : Geographic distribution (including accessibility information) : age-sex composition : vital statistical rates (crude birth rate, crude death rate, IMR, MMR, natural growth rate, the presence of , and types and number of

1.1.2. HEALTH STATUS : leading causes of morbidity : leading causes of mortality : leading causes of IMR : leading causes of MMR : leading causes of hospital admission / utilization : leading causes of consultation

1.1.3 HEALTH RESOURCES 1.1.3.1 HEALTH FACILITIES : type (unsuitable design) : number (lack) : geographical distribution ( maldistribution w/ concentration in the rural areas, not optimally situated, ill-equipped) : state of repair and utilization (not properly supplied and maintained)

1.1.3.1 HEALTH FACILITIES (cont’d)  Explanations are sought in the following:  Lack of recognition of the problem by the high decision-maker  Lack of planning  Use of wrong criteria for distribution (including political, personal, and technical administrative)  Defective policies in matters of personnel, supply, and finance and defective procedures1

1.1.3.2 MANPOWER : by type : number (inadequacy in number) and distribution (maldistribution) : the expenditures : the population coverage of specific programs (achievements) & : analysis of current and recently concluded heath resources

The problems usually identified regarding manpower are : 1) inadequacy in number, 2) maldistribution, 3) inefficient utilization, 4) low quality and 5) motivation. Explanations are sought in the field of higher policies in education , migration, and distribution, training, attitudes, managerial competence, technical and administrative policies and procedures.

1.1 .3.3 Interse ctoral and in trase ctoral relatio nships: Th e r easo ns for t he abse nce o f good wo rkin g rela tionsh ips are so ught.

Pr epara tio ns o f th e List of Co nst rain ts/ Pr oble m Tre e

 It is to be noted that health status problems are explainable on the basis of problems identified under health resources and socio-economic factors.  Likewise population characteristics contribute remarkably towards health service utilization and health practice and by itself determine the incidence of certain illnesses.

1.1 DESCRIPTION OF THE PRESENT SITUATION: DEMOGRAPHY (cont’d) 1.1.4 HEALTH RELATED SOCIO-ECONOMIC FACTORS/ RESOURCES : economic activities : nutrition : waste disposal : water supply : transportation : communication : education : housing

: agriculture : industries

Three (3) Components of the Community Analysis: Situational Analysis / Problem Identification (Cont’d)

1:2 PROJECTION: a must in long term planning. The ones projected are: A. Population B. The different Rates of specific disease/conditions (based on observed trends and possible impacts of programmes and trends observed in the health-related socioeconomic factors)

1:3 PROBLEM IDENTIFICATION and EXPLANATION: The last part of the situational analysis consists of: - identification of the problems = w/o it , planning cannot proceed in the right - explanation of the causes - indication of areas of change (constraint/obstacles analysis) - accurate statements of problems lead to clear objective setting - the product of this analysis would result to tables, detailed descriptions, projections and some conclusions  identify within each of the four technical area of the problems and their underlying causes  the 0utputs --- are a list of problems and constraints and proposals for changes in areas where required

STEPS IN THE PLANNING PROCESS (Cont’d): 2. DEFINING AND VERIFYING THE PROBLEM: COMMUNITY DIAGNOSIS -the final step in COMMUNITY ANALYSIS -involves synthesizing all collected data and determining gaps between health problems and services the gaps –indications of need within the community and any subpopulation within the community that may be particularly affected by health problems the group --becomes the target population

 Establishing program goals - first important process - once needs are verified can be translated into program goals - all subsequent activities should focus on designing program that will address an identified need in particular population  Defining and assessing behavior: - must define behaviors related to the problem - “the essence of health education is planned behavior change” planned changes in behaviors that are related to maintenance and improvement of health.

3.PLAN FORMULATION / DEVELOPING A PROGRAM PLAN 3.1 Objective Setting and Strategy Formulation 3.1.1 Setting of objectives/ formulation of objectives - The following steps are followed: A. Setting the overall health policy w/c includes the following: (1.) Main objectives….w/c should be SMART S pecific (what) M easurable ( by how much) A ttainable R ealistic T ime Bound (when) (2) priority setting (3) general (basic) strategy

- Planning group must select educational methods (chosen alternative of proven merit and Review of Literature is important here)

PLANNING OF PROGRAMS (HEALTH PROGRAMS) =Refer to the courses of actions and necessary resources for the improvement of a given health problem = is a timed series of service activities and development efforts requiring physical, human, and financial resources for the implementation of one or more course of action to achieve a given health policy objective

Examples of Health Programs: MCH  ENVIRONMENTAL HEALTH  EPI  COMMUNICABLE DISEASE CONTROL  NONCOMMUNICABLE DISEASE CONTROL

-The distinction between a strategy and a program is a matter of specificity and feasibility. -Both contain service and developmental activities. = However where these are implicit not distinguishable from strategy, and not tested for feasibility they should be quite explicit and feasible by the time a programme is formulated

Selection of Programs in the Health Plan -1st step is to review the existing ones, how they performed in the past, and their relevance to the priority health problems. -Experience has shown that there is very little option in selecting programs since most of the existing ones , de-emphasizing some activities or introducing changes in direction - The main determinant in the choice of program is the relevance to the main health problem and having established a list an assignment of an order of importance -The programs included in the list will be needed.

TYPES OF PROGRAMS: -Field Operation or Health Impact Programs and Supporting Programs - Direct Service Programmes and Functional Support Programs - Direct Coordination and Management Health System Infrastructure and - Technology Programs

PROGRAMS: 1. Programs for direction, coordination, and management - formulation of policy - direction, coordination, and control of program activities - provision of informal and administrative support, including personnel, finance, logistic and legal services 2. Health System Infrastructure -planning and development of basic health facility network - health manpower policies and training - health education and public information

3. Technology Programs =MCH including Family Planning and Nutrition = Environmental Health = Communicable Disease Control = Non-Communicable Disease Control = Psycho-social health to include mental health, alcohol and drug abuse = Oral Health = Worker’s Health = Rehabilitation = Laboratory and Biological products = Health of the Elderly = Research and Protocol Dev’t

KEY ELEMENTS OF A HEALTH PROGRAM: 1. NAME = w/c identifies it as close as possible with a healthy policy objective (s) or disease condition (s) it intends to solve/ improve 2. A BRIEF STATEMENT OF THE PRIORITY DISEASE/CONDITIONS IT INTENDS TO SOLVE/IMPROVE - to include the magnitude and - extent of the problem, and a - comment on why it is important - the statement should also include the status of status of the program (should there be an existing one) and the important constraints which hamper the program 3. AN OBJECTIVE (S) – which indicates quantified changes from existing levels of occurrence with specifications of time frames

4. BUDGET- only certain specific resource. Disease condition targets, which indicates quantified charges from existing levels of occurrence with specification of time frames 5.SERVICE TARGETS– which include percentages of the coverage of a given eligible population. Health service target refers to the health activities applied directly to the individual in the community or environment in order to improve the health status

6. APPROACH—which describes the ACTION to be pursued such as MANNER OF IMPLEMENTATION (vertical or integrated with basic health units) - program tactics, clinic attendance, house to house campaign, etc. - the field units responsible for the delivery of services and the role of the other units - the principal constraints or obstacles to the program’s implementation noted in the past and what needs to be done to overcome them. = the latter refers to the development of activities that should be applied to the staff, facility, organization, procedures, etc. in order to overcome the principal constraints and raise

7. LINKAGES – this should include the following : = the participation of the other government facilities outside the health ministry. = the responsibilities if any of the private sector = the possible involvement of other related sectors. = it is important that specific sectors be identified, approached and be made active participants in formulating an intersectoral plan of action.

8. PROGRAMME REQUIREMENTS need to be calculated such as - the key personnel for program direction and - doses of vaccine in EPI if a program will be implemented through the existing health service network. = for vertical programs the whole budget need to be estimated. 9. NEED FOR TECHNICAL COOPERATION FROM EXTERNAL AGENCIES - specify nature of needed cooperation 10. EVALUATION INDICATOR(S) = this is decided upon considering the health policy objectives, the health status targets and the service targets

PROGRAMME OBJECTIVES / TARGET OBJECTIVES: = Program Objective: - Essentially the same as the health policy objective - the most important consideration is that whatever objective formulation should state : what is to be done by the program with regards to a priority health problem identified at the stage of situational analysis .

= Target: - quantified objectives with a time factor - may be expressed as reduction of maternal mortality to a specific level, reduction of cholera or TB levels to zero cases, etc. - define quantity and quality of activities to be accomplished by disease reduction targets or health status targets / health impact objectives.

2 types: 1. Service Targets / input targets - act directly to reduce the disease / condition level 2. Developmental activities / resource targets : - aim to remove the obstacles to the appropriate delivery of service targets or strengthen the capability to such delivery

EXAMPLES OF TARGETS: Health status – reduction to zero levels of tetanus neonatorum Service – full immunization of all pregnant women with tetanus toxoid within three yrs. DEVELOPMENTAL ACTIVITIES Staff = assignment of a complete rural health

Facilities

unit for each municipality within 3 years = construction of 50 health centers in 3

yrs Expenditures = jt js necessary to determine how much can be done to reduce the problems within a specified period of time

Targets cont’d: = target statements are guided by removability of corresponding constraints = target statements must be very clear free from double interpretation = plans are periodically reviewed and adjusted and careful projection should take care Service Targets = are discussed 1st before the disease/ condition reduction targets because the latter depends on the degree of achievement of the former. = However in the writing of programmes ‘ disease/condition targets are presented first. = Balancing act between what is epidemiologically desirable and what is administratively feasible

 Operational standards to be observed for activities: 1. Duration of activity (e.g. length of hospitalization) 2. Frequency of application of activity per case/ person/ establishment number of times OPT will be given per child 3. Staff performance ( e g : consultation per hour, per vaccination ) 4. Facility performance (e.g. bed occupancy rate)

 Activities will be carried out by trained staff provided with appropriate equipments and medical supplies and with adequate supervision.  Productivity and efficiency are assumed.

HEALTH SERVICE DESIGN:- what are the systems involved IDENTIFICATION OF NEEDS FOR PROJECTS BUDGET ESTIMATES

3. Establishing Program Goals - first step is = to identify goals for health education =identify the resources and constraints

FORMATIVE EVALUATION: = RELEVANCE and ADEQUACY of a plan /program is decided; = It is done during the stage of program formulation

4. PLANNING FOR IMPLEMENTATION: Two (2) activities included here are: 1. The planning of preparation and 2. Developmental activities: = allocation of resources = securing legal authorization to start implementation = promotional activities planning = preparation for the institution of minor changes = refer to the institution of major changes including the introduction of new developmental activities

EVALUATION: SUMMATIVE EVALUATION = Evaluation of effectiveness and impact = done at the end of implementation

5. DESIGNING PROGRAM EVALUATION = must be included in the planning process = must have evaluation criteria or standards by which the program achievements can be assessed = are assessed in terms of their accomplishment = ease in drafting this depends on the way the health plan has been formulated = a good plan should have evaluation guides = the overriding concern of evaluation is to determine the impact on the health condition of the country. : endpoint of plan but also the start of another plan : checks if the plan is successful or not : do monitoring first, revise, and evaluate

PROCESS OR OUTCOME EVALUATION: = determines the extent to which the objectives contained in policies, programs and projects have been achieved

STEPS IN THE PLANNING PROCESS: (cont’d) 2. Defining and Verifying the Problem (cont’d)  Establishing program goals - First important process - Once needs are verified can be translated into program goals. All subsequent activities should focus on designing program that will address and identified need in particular population  Defining and assessing behavior -must define behaviors related to the problem. “ The essence of health education is planned behavior change, “ planned changes in behaviors that are related to maintenance and improvement of health.

3. PLAN FORMULATION / DEVELOPING A PROGRAM PLAN: Objective Setting and Strategy Formulation Planning For Implementation Establishing Program Goals  the first step is to identify goals for health education  identify resources and constraints  SETTING THE OBJECTIVES/ FORMULATION OF OBJECTIVES The following steps are followed: ( 1.)setting the overall health policy which

(2.) Includes the ff: a. main objectives b. priority setting c. general (or basic) strategy (3.) planning of programmes (4.) health service design (5.) identification of needs for projects (6.) budget estimates

 planning group must select educational methods (chosen alternative of proven merit and review of literature is imp’t. Formative evaluation= relevance and adequacy of a plan/program is decided; it is done during the stage of program formulation.

Planning for Implementation: Two Activities 1. The planning for preparation and developmental activities  Preparatory activities: ♥ allocation of resources ♥ securing legal authorization to start implementation ♥ promotional activities planning preparation for the institution of minor changes  Developmental activities ♥ refer to the institution of major changes including the introduction of new developmental activities 2. Actual delivery of health services

EVALUATION: Summative Evaluation= evaluation of effectiveness and impact; done at the end of implementation. DESIGNING PROGRAM EVALUATION:  must be included in the planning process  must have evaluation criteria or standards by which the program achievements can be assessed  process or outcome evaluation = determine the extent to which the program achievements can be assessed

 Are assessed in terms of their accomplishment  Ease in drafting this depends on the way the health plan has been formulated  A good plan should have evaluation guides  The overriding concern of evaluation is to determine the plan impact on the health condition of the country ♥ endpoint of plan but also start of another plan ♥ checks if the plan is successful or not ♥ do monitoring first, revise and evaluate  Involves synthesizing all collected data and determine gaps between health problems and services. ♥ the gaps– indications of need within the community that may be particularly affected by health problems ♥ the group– becomes the target population

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