Part IV: The Role of the RBM Partnership
5. In-Country Planning
Successful malaria control requires strong planning at the country, regional and district level. Planning is needed to determine the overall strategy, the required actions, the necessary resources and how the implementation should be monitored. As outlined in the OECD Paris Declaration on Aid Effectiveness,[8]Paris Declaration on Aid Effectiveness: Ownership, harmonization, alignment, results and mutual accountability. Paris, OECD, 2005.
Click for source all partners within a country need to be aligned behind a single strategy and actions need to be harmonized and complementary to increase effectiveness. These planning objectives, however, are often not met. In recent years, increased interest from different donors and aid organizations has led to a proliferation of plans and the time spent on planning. There is a need to harmonize and streamline planning activities within each country. The Harmonization Working Group (HWG) and the Sub-Regional Networks (SRNs) are the main coordinating bodies within the RBM Partnership for in-country planning.
Planning for malaria control programs should always be closely integrated with the general public health planning for all diseases. Such integration ensures that the activities are aligned and that synergies, for example in building health systems or delivery of interventions, can have a maximum effect. Although integrated public health planning is more likely to occur during the rapid scale-up of interventions to achieve the 2010 targets, it is equally important for a sustained planning effort when the burden from malaria is lower.
This chapter describes the challenges of planning, the priorities of the RBM Partnership in response to these challenges, and Partnership recommendations for in-country planning processes. The chapter concludes by sharing recommendations for good planning practices compiled after work with countries.
Key Challenges
There are a number of challenges regarding the planning within countries. While harmonization of donor requirements needs planning coordination at the international level, other planning efforts should be addressed within countries.
International Planning Process. Lack of harmonization of donor requirements can lead to burdensome financing and reporting processes imposed by the international community. The funding and monitoring and evaluation processes of different donors are often quite demanding (perhaps appropriately so), leading to heavy workloads for in-country government staff members. Many country officials indicate that they spend a significant portion of their time complying with financing and reporting requirements made by donors and other international partners. Harmonizing donor requirements for proposals and indicators to track performance would remove a high capacity burden on countries.
Country Planning Process.
- Narrow involvement in planning process. Often, the planning exercise undertaken in countries does not involve all partners and stakeholders, making it difficult to coordinate and align activities. In some cases, planning does not reach outside the malaria community, which impedes integration with other health programs.
- Poor coordination between national and district plans. Another challenge is the limited dialogue among the national, regional and district-levels. This leads to poor coordination and differences in planning targets and approaches.
- Little prioritization in a resource-limited environment. There may be a gap between activities described in plans and what is effectively implemented on the ground. This gap occurs when plans set objectives and activities to achieve them with limited consideration of whether resources are available. Prioritization processes in a limited resources environment are often not part of the planning process and therefore cannot be controlled. Although country business plans need to be based on country needs and not on the available resources, the annual implementation plans have to take the budget and funding into account.
- Lack of capacity. In many malarious countries, the lack of program managers or planning skills within malaria departments impedes the ability to develop strong plans without the help of consultants or support of partner organizations such as WHO and UNICEF or Partnership mechanisms such as Harmonization Working Group (HWG) and Sub-Regional Networks (SRNs). There is a strong need to build capacity at the country level for the planning process.
- Lack of regular review. Country plans are often revised only at the end of their lives and are not subjected to regular revisions. Good monitoring and evaluation systems are needed to track progress against targets and make necessary changes.
- Lack of medium-term planning for financing. Tools or frameworks for medium-term financial planning at the national level, such as Medium Term Expenditure Frameworks (MTEFs), enable countries to coordinate planning and budgeting with a medium-term horizon (~3 years) across several sectors. It is essential for malaria activities to be included in these analyses, in order to be prioritized at the national level and to clarify medium term budget requirements. There are synergies between this effort and the elaboration of country business plans with medium-term perspective.
Priorities
Planning priorities vary according to the stage of malaria control.
Priorities for scaling up.
A) Support the development of needs assessments and country business plans focused on rapid scale-up by 2010. HWG will continue to provide support for overall malaria control planning by providing countries with a needs assessment template and tools. HWG and SRNs will also coordinate assistance to countries as they complete needs assessments, and will assist in writing country business plans based on the needs assessments.[9]de Savigny D et al. Fixing Health Systems, 2nd Edition, International Development Research Center, 2008.
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While the above planning process is essential to achieve the 2010 targets, there is also a need to strengthen district planning capabilities. The Tanzania Essential Health Interventions Program Team (TEHIP) experience and learning, discussed in more detail later in this chapter, provides a framework for enhancing district level planning.
B) Tools for planning. Working together with members of HWG, the RBM Secretariat will share available tools and best practices for planning on their website, which is available for those involved in country planning activities.
C) Advocate for the harmonization of partners and donors. Strong country business plans can be the basis for donor support to countries. Coordination and harmonization between donors at the country level will ensure that they are aligned around the strategy and business plans. Harmonization of donors at the international level in terms of requirements for fund proposals and performance tracking indicators is also a key component to lower the burden of planning processes which often impede country implementation capability.
D) Support strengthening of country planning process. HWG and SRNs will support the NMCP in establishing strong structures within the ministry of health to lead the program. This support would include guidance based on the experience of individual partners and continuous improving of the planning process. Support might also include the provision of direct technical assistance to high-burden countries in the form of a full-time employee placed within the NMCP to support planning and financing.
E) Advocate for a government-led planning process. HWG will encourage strong commitment and support from heads of state and the ministries of finance and health. Such commitment is essential to foster broader support across the country, especially helping to remove the bottlenecks that can impede rapid scale-up.
F) Support translation of needs assessments and business plans into funding proposals and support to dialogue with major donors. A high approval rate of proposals in the Global Fund’s Round 8 and other upcoming funding applications such as the World Bank and the U.S. President’s Malaria Initiative (PMI) will ensure that countries have the necessary funds to undertake the rapid scale-up of activities planned for 2008, 2009 and 2010. HWG and SRNs will provide support for the writing and submission of funding proposals by setting-up workshops and holding mock technical review panels. This support is designed to build country capabilities and to assist country teams directly with the writing of funding proposals to maximize approval chances. Negotiations and dialogue with international donors also need to be supported.
Priorities for sustained control and elimination.
G) Support development of plans aimed at sustaining control and strengthening health systems. HWG will provide support for overall planning at the country level with a strong emphasis on strengthening health systems and integrating malaria with other existing health services. This support for needs assessment and country business plans will include developing template tools tailored for sustained control, holding workshops involving health systems experts and organizing best practice sharing.
H) Support planning for scale-up of new commodities, especially rolling-out of malaria vaccine. There will need to be consideration of how a malaria vaccine will be distributed and supplied within countries, e.g. integrated within the Expanded Program for Immunization (EPI). Furthermore, a malaria vaccine would need adequate procurement and supply chain management (PSM) structures including strong cold chains and increased refrigeration capacity. A group from HWG will be designated to work in coordination with the PSM WG in order to support planning and provide technical assistance on the implementation of new tools, including vaccines.
I) Encourage the development of multi-country regional plans. HWG and SRNs will support the development of multi-country regional plans and funding proposals in order to foster coordination between neighboring countries.
Organizational Implications
Within the RBM Partnership, partners working with the Harmonization Working Group as well as the RBM Sub-Regional Networks are strongly supporting countries with their planning efforts. HWG is focusing on a number of high-burden countries in sub-Saharan Africa. There needs to be an increase in resources to support more countries with the planning process, both for MAWG but also at a more regional level within the SRNs, who also play a very strong role in planning activities. In all regions, WHO regional and country offices, as well as other local partner organizations, play a critical role in supporting country planning activities.
Table IV.5: Summary of Planning activities
| Reference to priority | Major actions | Completed by | Coordinator (bold) / Sub-coordinatorsa |
| A, B | Create tools for needs assessments and templates for country business plans | Q3 2008 | HWG |
| A | Assist countries in rolling out needs assessments and business plan tools with help of consultants | Q4 2008 | HWG, SRNs, Regional RBM partnersb |
| C | Advocate for the harmonization of donors requirements at the international and national level | 2010 | HWG, SRNs |
| D, E | Advocate for strong country planning process and leadership from national authorities | 2010 | HWG, SRNs, Regional RBM partnersb |
| F | Support the development of funding proposals for major donors (GFATM R8 and R9, WB, PMI) to ensure enough funds for scale-up | 2010 | HWG, SRNs, Regional RBM partnersb |
| G,H,I | Assist countries in updating their plans to adapt them to Sustained Control | 2011 | HWG, SRNs, Regional RBM partnersb |
| G,H,I | Support the development of funding proposals for major donors (GFATM, WB, PMI) to ensure enough funds for sustained control | 2015 | HWG, SRNs, Regional RBM partnersb |
a Main coordinating group / body in the RBM partnership indicated in bold. Closely linked contributors within the RBM partnership are also listed. RBM partners are not listed explicitly as their involvement occurs through the Working Group.
b Regional RBM partners are country/regional offices of the WHO, UNICEF, World Bank, NGOs and other organizations
Partnership Recommendations
As described by MACEPA[10]Planning: Coordinating and Aligning efforts. MACEPA Learning Community. Available on the MACEPA website.
Click for source the strongest plans are:
- Led by governments
- Inclusive of all partners’ contributions to malaria control
- Informed by data gathered through monitoring and evaluation
- Complementary at all levels
Government leadership. High-level country officials (head of state, ministries of health and finance) should announce a commitment to support efforts against malaria. Following these commitments, the planning effort should be led by the National Malaria Control Program.
Inclusive of all partners. The planning process should involve all partners within the country. Depending on the country, this could include members of the National Malaria Control Program, representatives of the public and private health sectors, representatives of NGOs and faith-based organizations active in the country, representatives of donor institutions, and members of the local research community, including operational research. The planning process should also include experts from outside the malaria field for guidance on specific topics, especially representatives of other sectors such as finance, agriculture or education, as well as health experts from other programs such as child and maternal health. The planning activities for the fight against malaria must be coordinated with those for other diseases to obtain synergies, for example, multiple diseases might be able to utilize shared delivery methods.
Informed by data. To prioritize activities in a resource-constrained situation, planning must be supported by data gathered through monitoring and evaluation. An example of how data can be used to inform country business plans is the comprehensive needs assessments currently supported by the RBM Harmonization Working Group. The results of the needs assessments are being used to prepare strong country business plans based on the actual needs of countries.
Complementary at all levels. In-country planning requires complementary efforts at the national, regional and district levels. At the national level, the planning effort often includes a number of components – each with a different purpose and focus – which complement each other to form the overall national plan. A recommended structure for this plan has three core components with complementary purposes and different time horizons (see Figure IV.1):
- The Strategic Plan: defines the country’s vision and high-level strategy for fighting malaria, as well as the program’s main goals. The time-frame for this plan may be around 5 years, but in some cases may also be longer, for example covering a timeframe of 10 years.
- The Business Plan:[11]May also be referred to by other names such as Implementation Plan. gets partners aligned by detailing the main activities that need to happen to achieve the goals, with clear milestones, responsible parties, and budgets. The business plan builds on the work of the strategic plan and then uses a needs assessment process (human, financial, interventions) to achieve the targets laid out in the strategic plan. The time-frame for the business plan should be shorter than the strategic plan and is often around 3 years.
- The Workplan:[12]May also be referred to by other names such as Action Plan. is a detailed operational document that sets forth step-by-step all activities that should happen within a planning cycle including timelines, and identifies parties responsible for implementing them. Progress should be monitored throughout the year at regular intervals (quarterly for instance). The time-frame for the workplan typically covers one year, but may also be shorter if required for rapid action.
Figure IV.1: Three types of country plans with different focus and timeframe
It is important that the national strategy and business plan is translated into regional and local plans. Initially this may be led from the national level, but to strengthen the country planning process, the district level should be strongly involved and accountable for their planning process.
An example of the positive impact of more decentralized ownership of planning was demonstrated by the Tanzania Essential Health Interventions Program Team (TEHIP).[13]de Savigny D et al. Fixing Health Systems, 2nd Edition, International Development Research Center, 2008.
Click for source In this case, a decentralized planning and funding process using evidence-based planning tools resulted in improved efficiency and effective coverage for key primary health care services and large health gains. These improvements enabled the district health planners to target their budgets toward local health priorities. To enable such programs, funding support should be provided to the district budgets as well as good tools for planning and management, such as the tools developed for TEHIP.
Owned by implementers. Ownership of the plan by those who will implement it is a key to success. Ownership by implementers can be increased through decentralization of planning: e.g. national authorities provide detailed guidelines and the planning effort is conducted at the local level. Decentralization is a dynamic accompanying the move from scale-up to sustained control and elimination which redefines roles: the national malaria control program evolves from being an implementer to providing overall guidance and consolidating certain activities that may be more rationally managed at the national level.
Elements of a Good Planning Process
One objective of the plans developed by countries is to organize and coordinate efforts from all local partners in all regions of the country behind common objectives and a common strategy. Therefore, the plans should be oriented towards concrete and measurable actions with clear milestones and identification of roles. Table IV.6 presents an indicative list of topics which could be covered in business plans and workplans.
Table IV.6: Key elements of country plans
| Business plan (timeframe ~3 years) |
Workplan (timeframe ~1 year) |
|
|
Include human resources plan. All plans should take into account and plan for the human resources required to carry-out the activities, so that these needs are also budgeted and funded accordingly. Human resources issues are a key element of health systems strengthening, currently supported by several global initiatives. Malaria planners at the country level need to participate in these initiatives and ensure that the needs of the national control program are taken into account.
Regular review and updates. In every planning process, there should be a regular review and analysis of strengths and weaknesses of the malaria control program. This requires that health metrics be defined and that monitoring and evaluation be conducted to track the ongoing activities and the impact. Regular review is essential to identify bottlenecks, such as whether commodities were reaching end users, and, if not, why not; to determine whether there were any stock-outs; to assess the impact of behavior change communication programs; and to determine if there are sufficient human resources to support the activities and make any adjustments to the plans. Every activity of the plan should be monitored through specific metrics and indicators as part of the ongoing country M&E system, and regular analysis of the program should take place at least quarterly and could entail revisions of the plans (See Part IV - Chapter 7: Monitoring and Evaluation). Updates of plans need to be made regularly, especially to align medium and long-term plans with local annual workplans.
Plans tailored to the stage: scale-up, sustained control, elimination.
Scale-up stage: For countries engaged in rapid scale-up, plans should focus on rapid nationwide roll-out of interventions to achieve the 2010 targets. The Harmonization Working Group and WHO through its regional and country offices has been supporting countries with this planning process by providing tools and technical assistance to carry out comprehensive needs assessments. These are then translated into a detailed 3-year business plan with quarterly timelines for the roll-out and delivery of malaria interventions. These plans are based on the needs identified—for example, the number of interventions and activities needed to achieve the 2010 targets—and incorporate all timing considerations that have to be integrated—for example, rainy seasons, procurement and delivery times, and funding cycles.
Sustained control stage: When countries have achieved their scale-up targets, it will be important that their plans also include how to maintain coverage with malaria interventions through numerous distribution channels, health systems strengthening and maintenance of in-country communication to ensure correct use of interventions. Advocacy will also be needed to ensure there is continued support for the malaria efforts. During sustained control, the process for increasing integration of malaria interventions into the broader health systems should be translated into the plans.
Elimination stage: Plans for the elimination stage would need to be targeted around active case detection, foci and outbreak identification, and achieving and maintaining high levels of surveillance, monitoring and evaluation with strong health management information systems (HMIS) and reporting systems.
Planning in a resource-limited environment. Country business plans based on the needs in the country should ideally provide the basis for proposals submitted to external donors and to ministries of finance for funding. In order to avoid discrepancies between targets and implemented activities, country business plans need to explain clearly the principles and criteria that will be used for prioritization (geographically and in terms of activities implemented) in the event that the funding does not cover the full budget requirements.
The 'W' principle, which has been adapted from an industry best practice example, can be applied to malaria for the two levels of planning and prioritization that need to occur: 1) the national level planning and prioritization based on the allocation of grants, and 2) the district level planning and prioritization based on the budgets set for different districts:
Figure IV.2: Recommended malaria program planning process
Figure IV.2 shows the planning process for country level planning. National strategic and business plans incorporate international guidelines and are based on country needs. The business plans or proposals are then submitted for funding to both the national ministry of finance and international donors. After grant allocation, there may need to be a subsequent prioritization of activities if the requested budget is not fully funded and the activities are detailed in the workplans. Finally, the tracking of the activities and progress has to occur.
At the national level, the prioritization will need to consider district budget allocation as well as the highest priority activities. Budget allocation across districts can, for example, take into account population at risk, transmission levels or levels of poverty, whereas criteria for budgeting for different activities could take into account the estimated impact on burden per dollar spent or the estimated feasibility. Annual workplans developed can then take these criteria into account and base planned activities for the coming year on the available or pledged funding.
At the district level, the 'W' principle should be applied and prioritization has to occur. Districts should prepare their business plans based on the national strategy, policies and guidelines. The budget requests are then submitted to the national government for funding. Based on the actual budget allocations across districts, the districts may then have to prioritize within their borders how they should best spend the available resources.
National Malaria Control Program structure. For a strong national control program and the associated planning efforts, there needs to be a good NMCP structure. An example for how an NMCP may be organized is provided in Figure IV.3, from work by MACEPA.[14]Paul Libiszowski, MACEPA, personal communication, June 2008. The example demonstrates the importance of operational relationships within the ministry of health, both vertically and laterally. However, it is important to emphasize that each country may have or need to develop its own variation based on factors including partner roles, degree of decentralization, public / private compositions and management styles. The number of people required can be determined with a rapid assessment of the strategic / organizational needs.
Figure IV.3: Illustrative malaria program organizational structure
