This piece was written by Kate Gooding, Gabrielle Appleford, Nicola Wiafe
The success of national policies and plans for universal health coverage depends on implementation. Much of this implementation takes place at the local level, where health services are managed and delivered. This means district health management teams (DHMTs) play a crucial role in promoting health service coverage, quality and public health. In many countries, decentralisation has increased the role of DHMTs, and they often have key responsibilities for designing annual plans and budgets, overseeing facilities, managing staff, monitoring and reporting.
These responsibilities need to be performed well, as effective planning and management underpin progress in other areas of the health system. Sound planning is particularly important because district health budgets are often small: district managers need to identify and prioritise activities that can make the most of limited resources and bring the greatest benefit. However, district health planning is often rushed, and sometimes based on previous activities or donor interests rather than systematic thinking about district needs.
An evidence-based approach to planning
More use of district health service data can support effective planning by helping DHMTs to identify key gaps in health service coverage and their causes – for example, whether problems relate to lack of medicines, health worker skills, or community uptake of interventions. Techniques such as the ‘5 whys’ approach or problem tree analysis can then be used to understand underlying causes, and stakeholder discussions and prioritisation criteria can help to select activities that are most likely to be feasible and effective.
UNICEF has been supporting DHMTs in East and Southern Africa to use these more evidence-based approaches, using a method called bottleneck analysis, and we are working with UNICEF to evaluate progress and identify lessons that can strengthen support for DHMT planning and management.
Our findings highlight a range of issues that can help or hinder DHMTs’ use of evidence, their approach to planning, and implementation of annual plans. Important issues include accurate health systems data that can indicate bottlenecks; planning guidelines that support DHMTs in identifying local priorities; help and collaboration from political decision makers, NGOs and other development agencies; predictable and adequate resources to implement plans; and capacity to adapt plans and budgets around unexpected shocks such as COVID-19. Several of these issues have been highlighted by others, including limited DHMT decision space due to lack of funds and associated reliance on donors, and the influence of power relations with political structures, but here are some other, perhaps more overlooked issues that we’ve found so far.
Do district managers see planning as a useful investment of their time?
One area evident in many districts was the importance of DHMT motivation and interest in detailed planning. In the past, district plans have often not been implemented – sometimes because of insufficient budgets, or because plans were not regularly reviewed and followed. Many DHMT members appreciate the use of evidence incorporated in the bottleneck analysis approach, but this approach also requires more effort. DHMT members may not immediately see value in investing time for this given their high workloads and past experience of plans not being used.
Even if we have a beautiful plan those activities will still not be implemented, because funds are never enough. … The plans are not serving any purpose. (district planning committee member, Malawi)
DHMTs’ interest in planning is also affected by budgeting systems: if the system that determines allocation of national funds to DHMTs is not linked to the annual plans, DHMTs may focus on the system that brings the resources and see less value in planning.
Planning is hard work and district managers are busy
Another important issue highlighted by several DHMT members relates to the complexity of the planning processes and time requirements: DHMT staff are busy, planning and budgeting deadlines are tight, and planning processes can be lengthy – in some cases requiring completion of numerous online forms and tables. This can mean planning is rushed, particularly at the crucial later stages of selecting priorities and budgeting. Workshops for planning can provide dedicated time for DHMTs to focus, but funding for workshops may not be sustained once donor support ends, and it can be hard to complete all stages of planning within the workshops – and to retain enough concentration for later steps.
Planning takes a very long time – there are times when we stay in the office until 22:00 hours to meet the deadlines. (district health management team member, Tanzania)
Building the value of planning
These issues are not easy to overcome: they involve stakeholders and systems at national and district level; links between ministries and departments; activities and interests among a range of development partners; engrained approaches; wider health system capacity; and tricky balances around providing support while ensuring sustainable systems. While fully embedding evidence-based planning requires action on multiple fronts, steps to ensure planning has value for DHMTs, and leads to action may help to sustain more systematic approaches. This might include, for example, encouraging DHMTs to identify activities that can be developed within existing resources so that plans are affordable, supporting regular review of plans during the year to promote attention to their implementation, and working with national and sub-national stakeholders to align budgeting and planning systems
UNICEF is continuing with DHSSi and taking steps to further enhance the value of planning for DHMTs. We are now starting round 2 of the evaluation, and will continue working with UNICEF to see how these activities progress and to identify lessons that can inform district management capacity interventions.