The HNP PRSP Sourcebook Abdo S. Yazbeck Agnes L.B. Soucat Adam Wagstaff Charles C. Griffin Mariam Claeson Milla McLachlan Timothy A. Johnston
The HNP PRSP SourcebookAbdo S. YazbeckAgnes L.B. SoucatAdam WagstaffCharles C. GriffinMariam ClaesonMilla McLachlanTimothy A. Johnston
Overview of the Presentation• What is the HNP PRSP sourcebook?• Where we end up• Conceptual framework & stages of PRSP• Assessing outcomes of the poor• Understanding outcomes of the poor• Endpoint—policy design, implementation,
and M&E
What’s the HNP PRSP sourcebook?
• A framework—not a blueprint—for puttingtogether a poverty-focused health policy
• Diagnostic tools & resources—not solutions• Pointers for policy-making—covering the
What questions, as well as the How questions• An owner’s manual and a service
manual—text plus annexes• A tool for public expenditure analysts, system
reformers, and service managers
HNP & the PRSP• Adverse HNP outcomes are:
– an important cause of income poverty– a dimension of multidimensional poverty
• Objectives of PRSP:– to assess HNP outcomes, especially amongst
income poor;– to understand causes of low HNP outcomes
amongst the poor, and– to design policies (a) to improve HNP outcomes
amongst the poor and (b) to reduce theimpoverishing effect of adverse HNP outcomes
Where we end up …
ProblemArea
Issues Actions
PublicExpenditure
• Reallocations to improvetargeting and efficiency ofexpenditure
• 3-5 year plan for expenditurechanges, taking into accountreallocations and newresources
Making theHealthSystemFunctionBetter
• Increasing effectiveness,quality, and outputs throughimproved systemperformance.Improving receptiveness ofthe system to poor andexcluded populations
• Systemic reforms inincentives, contracting,ownership, insurancecoverage, and coordinationamong partners
• Pilot testing• Knowledge dissemination;
training and communicationabout changes
TargetedInterventions that Work
• Implementable, business-like, focused interventionsfor the poor
• Measurable and evaluatedoutcomes
• Projects and pilots in systemcontext: targeted maternaland child health, nutrition,public health programs
A conceptual framework…• Poverty occurs at household and community
levels. To find out why the system fails toreach the poor, need to look first at thehousehold and community. Listen to voices ofthe poor, but some bottlenecks are systemicand require changes in ways of doing businessregardless of the poverty performance.
• Prioritization is needed. Resources andcapacity limited. No laundry lists.
Why?
Households/CommunitiesGovernment
policies & actionsHealth system &related sectors
Healthoutcomes
Health &nutritionalstatus;mortality
Community factors
environment,culture, values,social capital,ecology, geography,etc.
Householdbehaviors &risk factors
Use of public &private healthservices, dietaryand sanitarypractices,lifestyle, care &stimulation ofchildren, etc.
Health serviceprovision
Availability,accessibility, qualityof health services;Input markets
Householdresources
Income,assets, land,education, etc.
Determinants of Health Outcomes
Supply in relatedsectors
Availability,accessibility, prices& quality of food,energy, roads, water& sanitation, etc.
Overall health sectorstrategy, priority-setting and resourceallocation in publicsector, monitoring &evaluation, advocacy,regulation
Other govt. policies,e.g. infrastructure,transport, energy,agriculture, water &sanitation, etc.
Healthoutcomes
Health financingRevenue collection,pooling anddisbursement/purchasing
Diagnostics →→→→ ←←←← Monitoring & Evaluation
Households/CommunitiesGovernment
policies & actionsHealth system &related sectors
Healthoutcomes
Health &nutritionalstatus;mortality
Community factors
environment,culture, values,social capital,ecology, geography,etc.
Householdbehaviors &risk factors
Use of public &private healthservices, dietaryand sanitarypractices,lifestyle, care &stimulation ofchildren, etc.
Health serviceprovision
Availability,accessibility, qualityof health services;Input markets
Householdresources
Income,assets, land,education, etc.
Determinants of Health Outcomes
Supply in relatedsectors
Availability,accessibility, prices& quality of food,energy, roads, water& sanitation, etc.
Overall health sectorstrategy, priority-setting and resourceallocation in publicsector, monitoring &evaluation, advocacy,regulation
Other govt. policies,e.g. infrastructure,transport, energy,agriculture, water &sanitation, etc.
Healthoutcomes
Health financingRevenue collection,pooling anddisbursement/purchasing
PRSP stages1 Assessing health outcomes amongst the poor2 Understanding outcomes amongst the poor
– Assessing risk factors, health care use of the poor– Explaining risk factors, health service use of the poor
• Household/community influences (income, knowledge,social capital, etc.)
• Health system influences– Health service provision: What are the levels of
availability, quality, etc., for the poor? Why?– Health financing: How do they influence affordability, and
hence use of services and disposable income?
3 Designing policy for the poor– Overall health sector strategy, priority-setting and resource
allocation in public sector, monitoring & evaluation,advocacy, regulation
Focus on outcomes, amongst the poor
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
180.0
Bolivia 1998 India 1992/93 Kenya 1998
Und
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rths
Poorest fifth2nd poorest fifthMiddle fifth2nd richest fifthRichest fifth
HNP lifecycle & outcomes
7days
28 days
1 year
Birth
5 years
10 years
20 years
Early neonatal period
Perinatal period
Neonatal periodPregnancy
Adulthood
Infancy
Adolescence
Childhood
Main stages in the life-cycle
Reproductive period
Ageing
Death
"Pre-school years
"School-age"
Risks vary at different stages.
Each has correspondingoutcome indicator.
Annexes outlining risksand outcome indicators,
data availability.
HNP Poverty TGInformation sheets. Data
broken down across wealthquintiles—for 48 countries on key MCH
outcomes, and risk factors, use ofhealth services, etc.
Risks vary at different stages
Neonatal periodInfectionPoor breastfeedingNeonatal death
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InfancyPoor nutritionPoor growth and developmentFrequent illnessInfant death
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✉✉✉✉✉✉✉✉
Pregnancy (mother)AnaemiaEclampsiaUnsafe abortionEctopic pregnancyMaternal deathPregnancy (child)AnaemiaIUGRMalformationsFoetal death
✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉
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Early neonatalperiod (child)SepsisAsphyxiaFailure to initiate breastfeedingHypothermiaPost-partum (maternal)SepsisHaemorrhageMaternal death
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Birth (mother)Delivery complicationsHaemorrhageMaternal deathBirth (child)Low birth weightStillbirthPreterm birthBirth trauma or deathCongenital syphilis
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Main risks of pregnancy and early life
Outcome measures vary too
Perinatal periodPerinatal mortality rate
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Neonatal periodNeonatal mortality rate
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InfancyAnthropometryDisease incidence ratesInfant mortality rate
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Pregnancy and birthUnsafe abortion rateUnwanted pregnancy rateMaternal mortality rate
Birth weightStillbirth rate
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Main outcome measures of pregnancy and early life
7days
28 days
1 year
Birth
Households/CommunitiesGovernment
policies & actionsHealth system &related sectors
Healthoutcomes
Health &nutritionalstatus;mortality
Community factors
environment,culture, values,social capital,ecology, geography,etc.
Householdbehaviors &risk factors
Use of public &private healthservices, dietaryand sanitarypractices,lifestyle, care &stimulation ofchildren, etc.
Health serviceprovision
Availability,accessibility, qualityof health services;Input markets
Householdresources
Income,assets, land,education, etc.
Determinants of Health Outcomes
Supply in relatedsectors
Availability,accessibility, prices& quality of food,energy, roads, water& sanitation, etc.
Overall health sectorstrategy, priority-setting and resourceallocation in publicsector, monitoring &evaluation, advocacy,regulation
Other govt. policies,e.g. infrastructure,transport, energy,agriculture, water &sanitation, etc.
Healthoutcomes
Health financingRevenue collection,pooling anddisbursement/purchasing
HNP lifecycle: risk factors, interventions
7days
28 days
1 year
Birth
5 years
10 years
20 years
Early neonatal period
Perinatal period
Neonatal periodPregnancy
Adulthood
Infancy
Adolescence
Childhood
Main stages in the life-cycle
Reproductive period
Ageing
Death
"Pre-school years
"School-age"
Annexes summarize what’s known about health interventions,
risk factors & behaviorsfor key risks.
Annexes outline what’s known about training & resource
requirements for delivering services, how to do good BCC,
intersectoral issues, etc.
Annexes point to data allowing the poor’s use
of health services, risk factors, etc. to be assessed.
Household & community factors
Area Issues Diagnostic tools Policy angle
Household Income, wealth,education,knowledge, genderbias
Householdsurveys; variousstatistical methods
Health finance;social protection;BCC and healtheducation;advocacy forgender equality
Community Physical factors,values & culture,social capital
Communitysurveys,consultationexercises
Transport & infra-structure;advocacy forchanges inattitudes harmfulto HNP outcomes;foster socialcapital
Health provision: diagnostic toolsDeterminants ofSector’s performance
Examples of problem Diagnostic tools
Accessibility Low access to PHC, to communitybased activities
Consultation exercises; household surveys
Availability Shortages of drugs vaccines,trained staff
Facility surveys
Organizational quality Inconvenient opening hours, lack ofprivacy
Consultation exercises
Service Production Price, perceived quality
Continuity Weak linkages with communitystructures. Poor supervision
Consultation exercises
Technical Quality Inefficacious services because ofnon respect of standards
Facility surveys
Social Accountability No voice of the poor in delivery ofservices
Consultation exercises
Allocative efficiency Low funding to cost-effective PHC Cost-effectiveness analysis
Expenditures equity Low level of resources channeledto the poor
Benefit incidence analysis
Health provision: solutionsDeterminants ofSector’s performance
Examples of problem Structural problems to explore
Accessibility Low access to PHC, to communitybased activities
“Mix”. Core Packages and areas ofresponsibility. Human Resources
Availability Shortages of drugs vaccines,trained staff
Pharmaceuticals. Human Resources
Organizational quality Inconvenient opening hours, lack ofprivacy
Human Resources. Community/civil societyParticipation
Service Production Price, perceived quality “Mix”
Continuity Weak linkages with communitystructures. Poor supervision
Community participation. Contracting
Technical Quality Inefficacious services because ofnon respect of standards
Contracting. Pharmaceuticals. HumanResources. Stewardship
Social Accountability No voice of the poor in delivery ofservices
Community and civil participation
Allocative efficiency Low funding to cost-effective PHC Purchasing
Expenditures equity Low level of resources channeledto the poor
Purchasing. Stewardship
Health financing issues
Area Issues Diagnostic tools Policy angle
Collectingrevenues
Sustainability;balance betweenuser fees andprepayment; feewaivers for thepoor; makingprepaymentsprogressive
Overall revenue levels;financing mix; surveyanalysis of fee waivers;progressivity andpoverty-impact analyses
Make financingsustainable; reduceemphasis on userfees and try feewaivers for poor; linkprepayments toincome via tax orsocial insurance
Fund pooling Size, wealth &diversity of riskpools; coveringthe poor for majorrisks
Analyses of pools—whois covered in each andfor what; gaps incoverage
Merging pools—esp.groups with differentrisks and resources
Purchasing Using revenues tobuy services forthe poor
Benefit incidence Needs-basedgeographicalresource allocationmechanisms
The layers of policy problems
ProblemArea
Issues Actions
PublicExpenditure
• Reallocations to improvetargeting and efficiency ofexpenditure
• 3-5 year plan for expenditurechanges, taking into accountreallocations and newresources
Making theHealthSystemFunctionBetter
• Increasing effectiveness,quality, and outputs throughimproved systemperformance.Improving receptiveness ofthe system to poor andexcluded populations
• Systemic reforms inincentives, contracting,ownership, insurancecoverage, and coordinationamong partners
• Pilot testing• Knowledge dissemination;
training and communicationabout changes
TargetedInterventions that Work
• Implementable, business-like, focused interventionsfor the poor
• Measurable and evaluatedoutcomes
• Projects and pilots in systemcontext: targeted maternaland child health, nutrition,public health programs
HNP lifecycle: risk factors,interventions
7days
28 days
1 year
Birth
5 years
10 years
20 years
Early neonatal period
Perinatal period
Neonatal periodPregnancy
Adulthood
Infancy
Adolescence
Childhood
Main stages in the life-cycle
Reproductive period
Ageing
Death
"Pre-school years
"School-age"
Health interventions are cumulative.
Prioritize interventions at several points to get
sustained, high-impact health improvements.
Interventions in one generation brings benefits to successive generations.
Identify key risks for families and associated gaps
in the health system, where interventions can break
the cycle of poverty and ill health.
Resources for stages 1&2• Life cycle annexes. One for each stage. Each to cover: key
risks; corresponding outcome indicators, definition,measurement, and data availability; key medicalinterventions/proximate determinants/household behaviors/riskfactors associated with each risk/outcome, and where data canbe got on each; and the key policy issues specific to the area inquestion.
• HNP Poverty Information Sheets. Data—broken down acrosswealth quintiles—for 48 countries on key MCH outcomes, andrisk factors, use of health services, etc.
• Annexes on surveys.
HNP indicators by povertystatusHNP Poverty TG Information Sheets
(48 Countries)• Infant & under-five mortality rate• % of children stunted &
underweight• % of children with diarrhea and ARI• % of mothers with low Body Mass
Index• Total & Adolescent Fertility Rates
Interventions vary overlifecycle
Neonatal periodEssential newborn careBreastfeeding counsellingImmunizationManagement of illness
✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉✉
Pregnancy, birth andperinatal period Antenatal careEssential obstetric careEssential family planningNutritional interventionsCommunity mobilization for safer home births
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Main interventions in pregnancy and early life
7days
28 days
1 year
BirthInfancyBreastfeeding counsellingNutrition interventionsManagement of illnessCare for developmentImmunizationOther preventive measures
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Key behaviors vary overlifecycle
Good practice for child health• Health & nutrition services
– immunization, bed nets, infection treatment
• Dietary & feeding practice– breastfeeding, complementary feeding >6 months
• Sanitary practices– hand washing, disposal of feces
• Care & stimulation of child– activities, interactions
• Maternal factors
HNP behaviors by povertystatus
HNP Poverty TG Information Sheets(48 Countries)
• Immunization rates amongst children aged 12-23for measles, DPT and polio
• % of children with diarrhea receiving ORH• % of children with ARI taken to medical facility• % of births for which women received at least
one antenatal consultation• % of births attended by medically trained person• % of married women using contraception
Determinants of behaviors forchild health• Household resources
– income, education, intra-household inequalities, …
• Community factors– environment & geography, culture and values, ...
• Prices, quality & availability of public andnongovernmental health services
• Prices, quality and availability of othergoods & services– food, energy, water & sanitation services, transport
Establishing key determinants
• Focus groups & one-to-oneinterviews—e.g. El Salvador
• Simple tabulations from householdsurveys—e.g. India
• Regression analyses—e.g. Cebu
Governments• Health & related services
– Delivery• access & availability, quality, efficiency, stewardship,
including making services more pro-poor– Financing
• user fees, insurance—improving access for the poorand improving the distribution of the burden offinancing insurance
• Beyond health services– Household resources, income and education,
water & sanitation, food & agriculture,infrastructure—key is to enhance impact on HNPoutcomes
Households/CommunitiesGovernment
policies & actionsPublic sector &
markets
Childhealthoutcomes:
Health andnutritionalstatus;mortality
Communityfactors:
environment,culture, values,ecology,geography, etc.
Householdbehavior:
Use of public &private healthservices, dietaryand sanitarypractices,maternalfactors, care &stimulation ofchild, etc.
Availability, prices& quality of public& non-govt healthservices
Householdresources:
Income,assets, land,education, etc.
Determinants of Child Health Outcomes
Availability,prices & quality offood, energy,roads, water &sanitation,education
HNP policies: e.g.financing andexpenditure,provision,stewardship, inter-sectoral, evaluation &monitoring.
Other govt. policies,e.g. infrastructure,transport, energy,agriculture, water &sanitation, etc.
Public Policy: Problems andAvailable Instruments
Problem Area Instruments
Public Expenditures –What Can You Do with$3-$5 Per Capita?
PRSP Expenditure Review
Making the HealthSystem Function Better
Sector Reforms, ChangeInitiatives
Targeted Interventionsthat Work
Govt. Coordination of ExistingInitiatives (internal & externallyfinanced), M&E, Projects
Problems, Issues, ActionsProblemArea
Issues Actions
PublicExpenditure
Reallocations to GainEfficiency and Targeting
• 3-5 Year Plan forExpenditure Changes
Making theHealthSystemFunctionBetter
Incentives, Contracting,Ownership, InsuranceCoverage, Coordination
• System Change/ReformPlanning
• Pilot Testing• Conferences, KM,
TrainingTargetedInterventionsthat Work
Business-like, focusedinterventions for thepoor, with measurableand evaluated outcomes
• Projects and Pilots inSystem Context:Targeted MCH,Nutrition, Public HealthPrograms
Government policies & the determinantsof HNP behaviors
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Availability & accessibility of HNP servicesQuality of HNP services
Price of HNP servicesHousehold incomeGeneral education
Health-specific knowledgeGender inequality
Price, availability, accessibility & quality offood
Price, availability, accessibility & quality ofwater & sanitation
Community & social capital
Determinants ofHNP behaviors &outcomes
Governmentpolicies
Example for Expenditures•Availability and accessibility of HNP services: Set clear priorities within budgetconstraints: (1) Public Health and Preventive Services; (2) Basic Clinic Services forMothers and Children; Improving Risk Protection for the Poor. This entails, in practice,balancing spending on (a) specific public health/preventive interventions; (b) primary vs.other levels of care. ; and (c) improving access of poor to high cost services when in need.•Quality of HNP services: Quality is determined by quantity and quality of labor, capital,equipment, and consumables. It is thus partially dependent on balanced expendituredecisions on (a) labor v. equipment and consumables, (b) capital v. recurrent expenditures,and (e) maintenance.•Price of HNP services: Public expenditure decisions are joint with revenue decisions inthe HNP system. User fees are a response to inadequate public funding. Provision must bemade for full financing of services to be delivered without charge to consumers, whichrequires (a) priorities for public funding and (b) pricing of services to close expenditure gaps.•Household income: Expenditures should include formula to provide additional subsidiesfor poorer areas and for poorer households for priority HNP services•Health-specific knowledge: Core public health function of government requiring adequatefinancing•Gender inequality in control over resources: Almost all basic health services involvemothers and children; women should be carefully consulted in the budgeting process.
Criticisms
• Shop or Service Manual– Conceptual, excess sophistication,
especially on data– Short on practical assistance to
produce an HNP chapter– Too Long
• Missing– Supply constraints– Various disease threats, especially for
adults
Needed
• Owner’s Manual– Simple presentation of main issues– How to go about collecting and
organizing the information– How to make the case simply for HNP
• As always, authors must juggle– More coverage needed– But make it simpler