Health Planning and

Resource Mobilization
By
Dereck Chitama, MBA
(Finance), MPH (Health
Economics)

Health Planning

What is planning?

Is a systematic method of trying to attain explicit

objective for the future through the efficient and
appropriate use of resources available now and in
the future?

What is health? (Ambiguous because it has different interpretations

and sometime inaccurately interchanged with health care)

Health- state of either an individual or community

influenced by a number of factors. e.g health care,
poverty, education levels etc

Health definition cont.

Narrowest concept- See it as state of the
physical bodily organs (Unhealthy if there is
malfunctioning of a part of a body eg lung or
kidney)
Broader but related: See health as not only
the mechanics of the different bodily organs
but in the ability of the body as a whole to
function.

WHO definition of HEALTH (Widely

applied)
More holistic view It shift away from
the organic and functionally based
definitions.
It
consider not only physical and
mental states but also social and
economic relationship.
The state of physical, mental and social
well being and not merely the absence
of disease or illness.

TYPES OF PLANNING
Activity planning
Relate to setting of monitorable
timetables and schedules for the
implementation of pre-set activities
Example: Flow chart or Gant charts,
Critical path analysis etc

Allocative planning
The making of the decision on how
resources should be spent-Which this
topic is primarily concern

Important questions in planning

process
Where are we going? (Objectives)
With what? (Resources)
How? (Efficient and Appropriate
implementation)
When? (Future)
Degree of formalization (Explicitness,
systematic)

Basis for planning

Scarcity and choices
Based on recognition that resources are
limited.
At individual level: not difficult to
recognize as most of us have wants
outstripping our income, hence we have
to make choices between different wants.
At organization level: Choices are needed
eg. Need to decide whether to grow,
contrast or consolidate.

Basis for planning

Economist would say resources are
scarce in comparison to the use to which a
society /organization wishes to put them.
Within the health sector, resources
available are insufficient to meet all the
health care needs or demands that society
would like satisfied.
Note: Planning is not confined to the public
sector alone: even private hospital/sector
need to plan.

Basis for planning cont..

It is increasingly recognized that no
health care system can meet all the
health care needs of its people
There is a need to successfully
channel resources away from low
priority use to high priority ones.
That means choices have to be made

Example of Choices to be
made

Approaches to planning
Comprehensive rationalism
The approach suggest a chronologically ordered
cycle of events, each leading to unavoidable next
event. Such events are often depicted in a form of
a continuous cycle.
The first event analyses the current position or
the problem to be solves( Situation analysis)
Next, the aim are decided (where we want to be)
List all the possible alternatives course of action
Assess their feasibility and capability of achieving
them
Implementation

Comprehensive rationalism

Approaches to planning
Mixed scanning
The
difficulties
of
operating
comprehensive system are recognized
by proponent of mixed scanning
Hence decision taken to narrow down
the comprehensive rationalism by
focusing planning attention on selected
area of interest.

Mixed scanning
It involve determining the priority areas of
planning and it is within this the
examination of options occurs.
It called mixed scanning because it involve
a broad sweep or scan of the whole health
sector which form the basis for the more
detailed examination of selected areas.
Criteria need to be set as
to what
constitute the problem ,priority and
therefore deserve special attention.

Mixed scanning

Approaches to planning
Incrementalism
Recognizes the political nature of
planning than in the previous approaches.
The term political nature is used here in a
wide sense to refer to effects of various
interest groups and not party politics.
It is a series of disjointed steps moving in
an incremental manner toward the set
goals, the degree of movement at any
time being determined by the political
context.

Incrementalism
It recognizes that a planning that deals with social
issues affecting groups of people, there can be no
objectivity or shared assumptions.
Hence a plan that can be viewed sensible by
decision maker may be viewed with suspicious, if
not opposition by some groups.
Consequently planning can rarely proceed in a
straight line toward set goals.
The degree to which can proceed smoothly in a
straight line toward desired goals without
deviation depends largely on the degree to which
plan has sufficient direct political support to
overcome countervailing forces

Incrementalism

Realistic rational health

planning
What is happening in reality?
No health planning conform to any of the above
models in its pure form
A successful planning must combine strong
technical skill with recognition of the political
process.

It perhaps more accurate to describe

planning as a cyclical set of activities
(planning spiral), with the end point of each
cycle forming the start of the next cycle but
in a higher plane

Planning cycle

Planning cycle
Situational analysis - This involve
assessment of the present situation.
Examine current and projected characteristics
of the population.
Examine physical and social-economic
characteristics of the population
Available infrastructure
Analyse policy and political environment
including existing health policies.
Analysis of health needs of the population
Services provided

Planning cycle
Priority setting -determining the hierarchy
of goals, objectives and targets of the
organization
It will be influenced by situational
analysis, especially the health needs and
broad policy objectives
Priorities need to be feasible and set
within the context of social and political
climate , available resources
Clear criteria for selection of priorities are
needed

Planning cycle
Options appraisal -Generation and
assessment of various options for achieving
the set objectives or targets.
Each option is assessed in terms of
Its impact on health target (when and how much)
Resource implications e.g cost effectiveness,
affordability given the resource constraints
Feasibility of each option- examine if there are
other barriers to its success (such as technical
and political constraints).

Planning cycle
Programming and Budgeting
This translate the result of option
appraisal into series of programmes,
each with budget.
This process is carried for each priority
area and its associated targets.
The result of this stage is a plan
document

Implementation and
monitoring This involve implementation of the
plan.
Transforming the broad programmes
into more specific and budgeted set of
tasks and activities.
Involve the drawing up of operational
plan or work plan

Planning cycle
Evaluation: Analysis if success or failure
in attaining the objectives, its impact etc.
It provide basis for the next situational
analysis and hence fresh lead into the
planning spiral.

Planning as a political
process
is important to bear in mind that planning is a

It
political process.
It is highly influenced by the context and actor
with a stake in the policy outcome.
It is concerned about changes therefore brings
supporters and opponents.
Many plan have failed because of over attention
into bureaucratic formalities and ignore the its
political process.
The relationship between planers, donners policy
makers, service-managers, communities, NGOs,
CSOs and other stakeholders is important to the
success of a plan.

Case study

Examine the following case (do it in groups and present findings to

each other)
In a country heavily dominated by curative hospital based care, the
health plan calls for a switch in resources from such activities to
community based health promotive activities. In particular the plan
calls for
A slow down of hospital building programme
The creation of community health workers cadre, supervised by nurse from
nearby clinic
A training programme for nurses in diagnostic skills
The development of community health committee
A variety of health promoting activities, including a ban on smoking in public
places

Discussion questions
Which groups are likely to support/oppose the plan and why?
How could analysis of this help in ensuring the implementation of the plans?

Private and Public sector

planning
Is there any difference??

Different aims of the two sector

Public sector aim at Improvement of the health status of
the community by meeting their health needs WHILE
have the objective of making profit by responding to
individual health demand
Different roles
- Private sector operate within the context and
environment controlled by regulatory functions of public
sector/state. Hence public sector have influence on the
activities of private sector.

Private and Public sector

planning
Comparison of planning in private and
public sector reveal strong similarities
(though terminology employed may differ)
They both require similar combination of
technical skills and political analysis
The differences reflect the deferent
organizational culture of the two providers.

Private and Public sector

planning
Private sector planning

Public sector planning

Determination of mission statement

Setting of goals

SWOT analysis incl. Marketing

Situational analysis. Incl. need

assessment

Determination of strategy

Optional appraisal and monitoring

Operational plans

Operational plans

Implementation

Implementation

Feedback

Evaluation and Monitoring

Levels of planning
Within the public, private for profit and NGOs there
are likely to be different levels of planning.
At each level, planning may occur and may be
different as well.
However, principles and broad process may be the
similar,
As one move down the plan will be more specific
with central plan providing broad strategic
directions
Each level need to take account of plan being
developed both in other organizations working in
the same horizontal level and higher level in the
system (vertical dimension)

Levels of planning
Health Ministry
National Strategic plan

Regional health organization

Regional plan

Private health
organization
Business plans
sector org
Business plan

Primary health care

Service plans

NGOs
Organizational
Plans

District health
organization
District plans

Primary health care

Service plans

Resource mobilization in health

sector
Definition
Refers to the way in which a country FINANCES its
HEALTH CARE SERVICES or Collection of funds from
various sources to finance health care and using
them to purchase services from public and private
providers of health care

Goals of health care financing

on the supply side by ensuring that essential
services are adequately financed and delivered;
on the demand side by reducing financial barriers
to access and by making sure that funds are raised
and services delivered in ways which are
affordable to all.

Introduction cont
In a typical low income country revenues
are raised from

Taxes

General tax
Ear marked taxes/sin tax

Insurances

-Social insurance

-Private insurance
-Community based insurance
User fees
Overseas development assistance (ODA

Resources mobilization in
Tanzania
( NHA, 2001).

Tax revenue
Often the main source of funding
Low income countries- 15% of GDP as per Abuja
declaration
High income countries 31% of GDP
Possible to increase but depends on political will and
competition from other sectors.
Can be used to provide services directly through state
institutions or contracting services with private
providers.
Create moral hazards for consumers and providers
No adverse selection- All citizen are covered

Tax revenue cont

Constraints of tax funding
it is difficult to increase tax revenue in African
countries (in order to cover the ongoing increase in
health expenses) due to the limited tax base and it is
often not feasible or advisable to increase tax rates
any further.
The high level of external debt experienced in many
countries consume a considerable share of
government revenue from taxes to go cover these
debts. Vastly improved debt relief, and indeed debt
cancellation (as has begun to happen), should be
advocated for, which would enable governments to
devote more of their limited tax funding to the
provision of health and other social services

Discussions on issues
around tax revenue
Why we have failed to reach
the Abuja declaration target?
Spending 15% of GDP
What are the advantages and
disadvantages

Insurance
Private insurance Private health insurance simply means that
individuals purchase policies from private (either
for-profit, not-for-profit) insurers. Or employers
to offer health cost cover to its employees
In many countries the private sector plays an
important role in providing health insurance e.g
South Africa
There is a clear link between payment of a
premium and entitlement of services (actuarially
based)

Private insurance cont

Actuarially based- Pricing premiums
according to the individual risk of a person
seeking insurance.
The voluntary nature of commercial health
insurance makes it especially liable to
problems of adverse selection and, to a
lesser extent, moral hazard
In order to combat the former, insurers will
tend to refuse to cover pre-existing
conditions (cream skimming)
To combat moral hazard- Co-payment is
normally used.

Moral Hazard
Behaviour that increase the probability
of the event to occur (patient moral
hazard- Lead to over utilization of
service.
Doctor moral hazard??? Leads to .
Measures to prevent
Co-payment
Capitation
Limit of benefit
Treatment guidelines

Adverse Selection (AS)

Is a result of information asymmetry.
-Individuals are able to buy insurance at a
rate that are not actuarially fair because
of information asymmetry.
-Those who are ill most of the time go for
the scheme
-Big family in size (number) go for the
scheme

Discussion

The concept of market for health

insurance in Tanzania , is it new?

Social health Insurance

(SHI)
German classical example of SHI:
One of the first country to institute SHI
nationally(1883).
Started as small sickness funds for
defined employment groups i.e guild
funds, regional funds; national structure
gradually phased in (Incremental
approach i.e regional to national,
optional to compulsory, gradual inclusion
of population groups, gradual expansion
of benefit package).

SHI cont
SHI Key features
Mandatory membership of formal
employees
Supported by legislative and
institutional frameworks
Standard payroll deduction from
employees
Contributions are not risk based but on
ability to pay.
Insured have access to benefit package

Aims of SHI
To improve access to health careUltimate goal is universal coverage.
To reduce the financial barriers to
care.

Community based insurance

(CBI)
Any not for profit insurance scheme that is aimed
primarily at the informal sector and formed on the
basis of a collective pooling of health risks and
members participate in its management
(Atim,1998)
Referred by a range of names: micro-insurance,
community financing, mutual funds etc.
Variety of design and administrative organizations
and procedures within and across countries and
regions.
In Tanzania: CHF,UMASITA,VIBINDO etc

CBI characteristics
Objective: Improve financial protection and
access.
Member pay premium at the beginning (cash
or In-kind to insurer)
Community participation in design and
management
Prone to adverse selection and moral hazard
Low coverage- low revenue if not well
designed
Sustainability???

Out of pocket expenditure/User

fee
Direct payment by user to health service provider
Often single largest source of financing health care
Wide spread in developing countries
60% of low middle countries

There is policy concern about user fees/OOP

as it may lead to catastrophic health
spending and impoverish people (estimate
that up
to 178million people suffer from financial catastrophe
and 104million are forced into poverty.)-Medical poverty
trap???

Deters access to health care service especially for

poor /vulnerable
Self treatment and irrational prescription and usage

On the other side easy to collect, generate

resources for non-salary portion

Donor Funding
Are funds donated in kindness
Are usually for specifically designed
health projects/programmes
Have a variety of contributions I.e
both monetary and technical
assistance
Provides almost the same proportion
of funds for health as the
Government

Donor funding cont

Constraints of donor funding
Donor funding could potentially undermine the
role of the Ministry of Health in crucial areas of
health policy, particularly in relation to health
care financing. That the ministry of health would
be more responsive to donor demands, and it is
possible that donors could attempt to impose
their health sector priorities than our priorities.
There are also concerns about the unreliability of
this particular source of financing and a growing
awareness of the need to find sustainable
domestic financing alternatives.

Sector wide approach (SWAP)

New approach to development aid. Health sector
partners pool their funds contributed for health

Increase role of donor in national sectoral

strategy
Replace project specific funding with pooled
funding for the entire sector.
Include reforms to health management systems
and priority setting
Emphasis on national ownership of of reforms and
the role of government
Wide range of stakeholder are involved eg NGOs,
Private sector, Civil society etc

END
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