NATURALEZA DE LA ELECTRICIDAD (II)

Table 23. Baseline and targets in Planning, Budgeting, and Monitoring

EXPECTED OUTPUTS / OUTCOMES HSSP III BASELINE 2011 TARGETS 2015 TARGETS 2018

# Administrative Sectors without a health center

20 10 0

5.1.1 The planning process and annual plans

In terms of priorities, indicators, and the overall planning process, HSSP III is fully aligned with the upcoming EDPRS II. However, as HSSP III starts in July 2012 (and lasts until June 2018), it starts one year ahead of EDPRS, which is expected to start in July 2013 and will last until June 2018. The main advantage of this schedule is that HSSP III will be a fully integrated part of EDPRS II. All districts will develop their comprehensive district plans for the next EDPRS planning cycle and in this way align themselves to the overall EDPRS II. At the same time, all DHUs are charged to develop their five-year health sector–specific plans in collaboration with the management of the district hospitals and the responsible staff in the health centers.

Once the overall five-year health sector plans for all the districts have been finalized and endorsed by the District Councils, the DHUs will initiate the elaboration of the more detailed annual plans with specific interventions and targets. In this process, the DHUs will ensure not only that DH management and HC staff are involved, but also that donors, NGOs, CSOs, FBOs, and the private sector operating in that district are fully part of the planning and monitoring process. It is of utmost importance that all available resources for the district interventions are known and shared, and that all activities are coordinated among the various stakeholders.

Figure 3. The Rwandan planning process by level and time frame

5.1.2 Budgeting and budgeting cycle

As is already current practice at the national level, the planning and budgeting process will be supported by MTEF (with resource ceilings provided by MINECOFIN) and by an elaborate Resource Tracking Tool (RTT). There is a clear commitment to bring the various expenditure tracking instruments—RTT, National Health Accounts (NHA), and Public Expenditure and Financial Accountability (PEFA)—into one system through the Resource Tracking Tool. However, according to the MTR, the potential of the tracking tool, the joint annual work plan and the district health systems tools have not yet been effectively utilized to inform the planning and budgeting process at national and district levels. Results from the RTT are not available to inform the planning and resource allocation process. The Planning Department will coordinate with other relevant departments and units (Health Financing Unit [HFU], M&E, QA, Single Project Implementation Unit [SPIU]) regarding development of guidelines that will bring all the information and resources into one harmonized planning, budgeting, and monitoring tool, preferably in the first year of the HSSP III.

5.1.3 Monitoring

The MTR found that the Ministry of Health’s strategic plans are well aligned with the EDPRS. The administrative districts have overall strategic plans between 2007 and 2012 in which the sector plans are included. The health facilities (districts hospitals and health centers) are implementing annual operational plans that are aligned to the HSSP II strategic objectives, showing resource commitments from different sources. There are forward and backward looking reviews with stakeholders to reach consensus on targets, budgets, and CPAF indicators for the coming year and to review performance of the previous year.

5.1.4 Main challenges to planning, budgeting, and monitoring

In summary, the main challenges identified in the planning, budgeting, and monitoring process are:  Insufficient capacity of planning and M&E function in the Ministry of Health: While the sector has

strong M&E capacity within many of the operational units (RBC, MCH/clinical units, and districts), there is limited staffing and inadequate coordination and harmonization of M&E activities in the central MOH.

Strategic priorities and major targets

Strategic priorities and targets, and resource frameworks Targets, activities and budgets

CENTRAL LEVEL

DISTRICT LEVEL

HEALTH FACILITY LEVEL (DHs and HCs

5 YEARS NATIONAL

JUNE 2013 to July 2017 SECTOR STRATEGIC PLAN

ANNUAL HEALTH OPERAITONAL PLANS

EDPRS II HSSP III NATIONAL CONSOLIDATED OPERAITONAL PLAN

District Development Plan District HEALTH STRATEGIC PLAN

DISTRICT CONSOLIDATED OPERATIONAL PLAN

FACILITY STRATEGIC PLAN FACILITY OPERAIOTNAL PLAN

COMMUNITY OPERATIOTNAL PLAN

 Decentralization: A decentralization strategic plan has been drafted, however the roles of the administrative DHU and the district hospitals (DH) with respect to public health planning, monitoring, and evaluation remain unclear.

 Inadequate coordination mechanisms of health stakeholders at district level: the newly formed District Health Unit (DHU) is understaffed and there are insufficient capacities of health staff at district level (planning, M&E, financial management and communication).

 Board of directors, health committees, and DHU personnel not prepared: These key actors are unprepared to effectively carry out their responsibilities for the management and monitoring of health activities in their respective institutions.

 Absence of standardized tools for planning and M&E according to decentralization policies and

strategies: Considerable data are generated from many levels of the health system to monitor the

sector’s performance. The recent efforts to define a minimum list of indicators for the health sector and streamline the HMIS should reduce the burden of routine data collection on health workers and improve quality of data collection and use.

 Insufficient technical supervision and mentoring of DHs: Integrated supervision was introduced over the past fiscal year as a mechanism to monitor the quality of service delivery. However, it has yet to be harmonized fully with other important quality assurance mechanisms, such as PBF evaluations and health facility accreditation. Regular supervision of health facilities by DHUs is limited due to lack of means of transport.

 Inadequate research and strategic plan development capacity: A Health Sector Research Policy and Strategic Plan was prepared in 2011, but steps have not yet been taken to develop capacity in this area or to establish mechanisms to promote research activities that are aligned with the health sector’s priorities and can help to ensure that strategies implemented have the desired impact.

5.1.5 Planning, budgeting, and monitoring strategic priorities and key interventions

Based on these challenges, HSSP III identifies the following strategies and interventions in planning, budgeting and M&E:

1. Strengthen MOH Planning Unit:

 Recruit additional staff to undertake the challenges of HSSP III in terms of planning and M&E function;

 Continue capacity-building of existing staff;

 Adapt the capacity-building process at national and district levels to MINECOFIN guidelines (in particular on the financial and fiduciary guidelines to be used by the DHU);

 Quarterly meetings between the MOH, MINECOFIN, and the development partners to assess progress on the basis of HSSP III indicators. The principles of mutual accountability will remain the leading feature of the new strategic plan.

2. Harmonize planning and M&E systems and procedures across institutions and levels:  Review existing M&E frameworks and tools to identify good models to expand;

 Provide support to health institutions in order to implement harmonized M&E frameworks linked to their strategic plans;

 Standardize planning and budgeting tools.

3. Strengthen capacity in planning and M&E of health workers and program managers:

 Include M&E and planning in pre- and in-service training for health workers and program managers—with an increasing focus on decentralized institutions such as DHU and district health facilities;

 The Planning Department will develop a capacity-building plan (curriculum) that will allow the DHUs to draft their annual plans, taking the new guidelines on decentralization, M&E, and financial management (including fiduciary issues) into account.

4. Increase DHU–DHMT / district participation in M&E and planning:

 Coordinate with the Health Financing Unit and the M&E Unit that the district plans include a credible budget and provide the relevant baseline and target information through the HMIS;

 Strengthen the elaboration of Joint Annual Work Plans (JAWP), the Imihigo target setting, and the monitoring process with enhanced M&E system (equity focused, evidence-based, results-based, and addressing national development priorities). These interventions should be linked with those in HMIS and e-Health to enhance use of data within the health sector;  Initiate quarterly performance reviews of plans and budget execution.

5. Link results and outputs with inputs and budget:

 The health sector will build local capacity in operations research and implement studies to monitor the cost effectiveness of key interventions;

 Planning and monitoring follow the calendar year, while the resources follow the budget year, thus making it difficult to link results to funding. It is thus important to harmonize planning and budgeting cycles as well as costs (unit), templates, and other tools and guidelines for central level institutions, districts and health facilities (e.g., JAWP).

6. Increase the number of experts in health economics, planning, and health metrics:  Create a master level training in health economics, planning, and metrics. 7. Improve the measurement of quality of services and data dissemination:

 Develop quality indicators and conduct regular assessment—including customer satisfaction indicators;

 Systematize use of data for planning, integrating data available from different databases;  Reinforce data publication of the health sector.

8. Reinforce and streamline integrated supervision:

 Continue integrated supervision with better harmonization of existing quality assurance tools (supervision, PBF quality assessment and accreditation) and explore targeted supervision to make the process more cost effective.

9. Continue to improve data quality:

 The capacity of M&E officers will be built, M&E tools and procedures will be standardized, and data quality assessment will be institutionalized.

10. Assess performance and impact of the programs on the health of the population:

 Program impact and outcome evaluation are undertaken and key performance indicators have been set (defined in program M&E plans)