Ministerial Leadership in Health - Harvard University · PDF fileMinisterial Leadership in...

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Ministerial Leadership in Health

Health Sector Strengthening

Planning and Strategy Development Workshop

Pretoria, South Africa

25 – 30 January, 2015

EVALUATION REPORT produced by

Helene Perold and Dr Marinda Weideman With the support of

The Children’s Investment Fund Foundation (UK) and The Bill and Melinda Gates Foundation

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Contents

1 Introduction ......................................................................................................................... 3

2 Summary of evaluation findings ............................................................................................ 3

3 Evaluation methodology ....................................................................................................... 4

Objectives ........................................................................................................................................... 5

Evaluation instruments ....................................................................................................................... 5

Indicators ............................................................................................................................................ 6

4 Overall assessment ............................................................................................................... 8

Competence assessment .................................................................................................................... 8

Daily assessments of learning ........................................................................................................... 12

Day Two feedback ......................................................................................................................... 13

Day Three feedback ...................................................................................................................... 14

Day Four feedback ........................................................................................................................ 16

Day Five feedback ......................................................................................................................... 18

5 Profiles of country feedback ............................................................................................... 20

Cape Verde ....................................................................................................................................... 21

Comparison of health and finance participant learning gains ...................................................... 21

How are these results likely to impact on the team? ................................................................... 24

The Gambia ....................................................................................................................................... 25



Tanzania ............................................................................................................................................ 30



Uganda .............................................................................................................................................. 36

Comparison of health and finance representative learning gains ................................................ 37


6 Conclusions ........................................................................................................................ 41

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1 Introduction The Ministerial Leadership in Health Program (MLIH), under the auspices of the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School, in January 2015 facilitated a six day health sector strengthening planning and strategy development workshop as part of the MLIH Program’s in-country follow up. The follow-up phase of the MLIH Program aims to institutionalize closer collaboration between health and finance ministries in the effort to increase effective allocation and efficient utilization of the national health budget with the goal of improving standards of first line care.

Held in Pretoria, South Africa, the workshop was attended by 29 senior officials from the health and finance ministries in four African countries: Cape Verde, The Gambia, Tanzania and Uganda. The distribution of health and finance ministry representatives from each country was as follows:

Country Number of Health Ministry participants

Number of Finance Ministry participants Other Total

Cape Verde 3 3 6 The Gambia 2 3 5 Tanzania 5 4 9 Uganda 5 3 Facilitator 9 TOTAL 15 13 1 29

The purpose of the workshop was to facilitate planning by the country teams of an intervention strategy focusing on the primary upstream causes of downstream inefficiencies in health care delivery. The following graphic illustrates the “pathway to impact” which structured the country-specific analysis by the teams.

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2 Summary of evaluation findings At the start of the workshop all 29 participants indicated that they felt ‘somewhat equipped’ to carry out the 14 actions listed in the competence assessment for health sector strengthening. Specific areas of concern related to analysing inefficiencies in health budget utilization, using root cause analysis, analysing the health care delivery chain, prioritising interventions for a knock-on effect on larger institutional improvements, establishing delivery targets, developing data systems and identifying risks to implementation.

By the end of the workshop the group’s overall score was close on ‘very well equipped’ to undertake the 14 actions.

The highest levels of knowledge and confidence were developed among the health ministry representatives from Cape Verde, The Gambia and Tanzania. In the Uganda team the highest levels of growth occurred among the finance ministry representatives. The Tanzania finance ministry participants scored the lowest ratings for knowledge and confidence improvement.

Going forward, teams may need support in the following areas:

• Identify health budget utilization inefficiencies (Uganda) • Develop a comprehensive implementation strategy (Tanzania and Uganda) • Strengthen data systems for implementation monitoring and building a culture of evidence-

based decision-making (Cape Verde, Tanzania, Uganda) • Manage risks to the implementation strategy (Cape Verde, Tanzania and Uganda) • Build a guiding coalition to support the implementation of the plan (The Gambia and

Tanzania) • Prioritize focused interventions to create a knock-on effect to achieve larger institutional

improvements (The Gambia, Tanzania and Uganda) • Achieve targets in procurement, supply management and health worker productivity

(Tanzania and Uganda)

Participants mostly found the workshop content very relevant to their professional development. Some had the opportunity to engage with new ideas and approaches for the first time. Others said that the topics were not new to them, but that the workshop had provided new insights and skills that would enable them to implement their planned strategy more effectively. The workshop also helped motivate participants to pursue results-driven change.

The workshop design succeeded in developing productive inter-ministerial working relationships between health and finance ministry representatives in the country teams. Health representatives gained a better understanding of financial issues, budget reallocation and how to derive value for money in the face of constrained resources. Finance representatives gained insight into the role of public health (particularly primary health care) in national economic development and learnt about the challenges facing their public health systems in terms of procurement, supply management and health worker productivity. Both health and finance representatives found the root cause analysis very valuable as a starting point for strategy development, and were persuaded of the importance of making efficiency gains in order to derive greater benefit from the available financial resource base. A number of finance representatives noted the importance of reallocating resources so as to increase health budgets, but are clearly aware of the pressures this will create in other sectors.

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3 Evaluation An evaluation process was designed to track the learning experienced by participants throughout the course of the week. The process followed the workshop curriculum, which focused on:

• examining whether the health budget is used effectively and efficiently • identifying points of intervention in procurement, supply management and health worker

productivity • designing levers for change in respect of

o facility maintenance, equipment and supplies o adequate ‘on time’ drug supply distribution o health worker attitudes, responsiveness, absenteeism and patient waiting time

• assessing impact with regard to improved standards of care and increased patient satisfaction.

The workshop was designed to maximise engagement between team members from each country around the concepts and skills required to increase the effective and efficient use of financial and human resources in health care delivery. A key objective of the process was to enable representatives from the health and finance ministries in each country to develop a common understanding and agreement on a concerted plan and implementation strategy to achieve more effective health budget allocation and target key inefficiencies in health budget utilization impacting on the quality of health care delivery. (See workshop program in Annexure 1).

The evaluation process thus comprised daily assessments, which were conducted to provide the Harvard team with real-time participant feedback and to gauge the extent to which participants felt they had gained useful knowledge and skills. The feedback will inform future workshops of this nature and can be used to guide the provision of additional in-country capacity building and technical support as needed. The implementation of the planned strategy will be monitored by the Program over a period of 18 months.

Objectives The objectives of the evaluation were to:

a. Assess the impact of the workshop on participants’ knowledge, skill and confidence levels b. Gather feedback from participants on:

• the value of the different sessions in the workshop program • whether they learnt anything new • how they would implement what they had learnt once back home and • the likelihood of the health and finance representatives working together to deploy

resources more effectively for improved health systems outcomes.

Evaluation instruments The evaluation instruments were designed to gather quantitative and qualitative data from all 29 participants on a daily basis. The following measures were used:

1 A baseline and end-line competence assessment, administered at the start and the end of the workshop program. Using a five-point scale, participants rated themselves on how well-equipped they felt to carry out 14 actions (see below) associated with strengthening service delivery in their public health systems.

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2 Daily feedback instruments were administered at the end of Days Two, Three, Four and

Five. Using a five-point rating scale, participants indicated the extent to which they felt they had gained the knowledge and skill required to use their health budgets more effectively and efficiently, and to implement the changes to improve procurement, supply management and health worker productivity in their countries. Participants also had the opportunity to explain their ratings and to indicate what additional information they needed.

3 At the end of Day Four the evaluator held short discussions (20-30 minutes) with each country team to gain greater insight into the feedback provided by team members over the course of the week, and to assess their overall impressions of the value of the workshop.

Indicators Core indicators were developed for the competence assessment in relation to the overall content of the workshop. Indicators for each day reflect the topics covered on the day and repeated some of the core indicators to check levels of improvement in the course of the week.

In the baseline and final Competence Assessments, participants were asked to indicate how well equipped they felt to undertake each of the tasks or activities outlined in the 14 statements below, using a scale of 1 (not at all equipped) to 5 (very well equipped):

1 Analyze and set priorities for more effective health budget allocation 2 Identify areas in your health care budget that could provide resource gains (fiscal space)

for addressing priority challenges in health care service delivery 3 Identify and analyze health budget utilization inefficiencies in key health care delivery

functions: procurement, supply management, health worker productivity 4 Develop a plan of focused interventions to achieve greater efficiency in resource

utilization and improve standards of service delivery 5 Develop a comprehensive strategy for implementing the intervention plan 6 Understand how to work effectively as part of a team 7 Build processes to ensure productive collaboration between colleagues from health and

finance 8 Use root cause analysis to identify and resolve budgetary challenges 9 Analyze the health care delivery chain to identify weak links 10 Prioritize focused interventions to create a knock-on effect to achieve larger institutional

improvements 11 Establish delivery targets to help measure progress 12 Identify, communicate with and engage key stakeholders to help implement the

intervention plan 13 Develop data systems for effective implementation monitoring 14 Identify risks to implementation and develop effective risk mitigation strategies.

Day Two focused on analysing the root causes of problems in the health system, setting priorities and using budgets effectively and efficiently. At the end of the day participants were asked to rate themselves on a scale from 1 to 5 on the following actions, where 1 is equivalent to very little knowledge and confidence, and 5 is equivalent to being fully knowledgeable and confident:

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1 Analyze and set priorities for more effective health budget allocation 2 Use root cause analysis to identify immediate challenges in health worker productivity,

procurement and supply distribution/management 3 Identify and analyze inefficiencies in the utilization of the health care budget in

procurement, supply management, health worker productivity 4 Identify areas in your budget that provide fiscal space for health care delivery functions 5 Identify and prioritise opportunities for increasing the effectiveness of budgetary allocation 6 Analyze the health care delivery chain to identify weak links 7 Identify opportunities for improving the efficiency of budgetary spend to improve service

delivery.

Day Three focused on designing interventions and developing an intervention strategy. Associated with this, participants discussed why and how to establish data systems, set targets, and build teams. Once again at the end of the day participants were asked to rate their knowledge and confidence from 1 to 5 in relation to the following actions:

1 Prioritise focused interventions to create a knock-on effect to achieve larger improvements 2 Develop a plan of focused, practical interventions to achieve greater efficiency in resource

utilisation and improve standards of service delivery 3 Develop a comprehensive strategy for implementing the intervention plan 4 Set measurable and time-bound targets for each priority 5 Know what data is needed to track implementation 6 Know how to strengthen data systems for effective implementation monitoring 7 Practice evidence-based decision-making 8 Understand how to work effectively as part of a team 9 Develop processes for more effective collaboration between health and finance.

Day Four focused on organising for implementation and the sessions covered topics such as the science of delivery, developing the foundations for delivery and tools for planning delivery. At the end of the day participants again used the five-point rating scale to indicate their knowledge and confidence to carry out the following nine actions:

1 Establish the systems and processes for implementing the reforms successfully 2 Establish a guiding coalition to support the implementation of the intervention plan 3 Strengthen the links between key actors in the delivery chain 4 Likelihood of achieving the targets for increasing health worker productivity 5 Likelihood of achieving the targets for improved procurement processes 6 Likelihood of achieving the targets for improved supply chain and distribution management 7 Set clear performance goals for individuals and teams 8 Put in place systems and procedures for individual and collective accountability 9 Identify risks to effective implementation and develop effective risk mitigation strategies.

Day Five focused on mobilising and communicating for implementation as well as monitoring, routines and dashboards and at the end of the day participants rated their knowledge and confidence on eight actions using the five-point scale:

1 Identify, communicate with and engage key stakeholders to help implement the intervention plan

2 Develop a strategy for mobilising and communicating with key stakeholders

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3 Develop a core message to communicate the implementation plan and how it will be achieved

4 Able to communicate bad news to stakeholders 5 Develop the routines needed to monitor performance, and diagnose and address problems 6 Explain the value of monitoring routines 7 Ensure that monitoring routines are respected and implemented as planned 8 Use data to correct course when necessary.

4 Overall assessment

Competence assessment The average score across the 14 statements for all participants at the beginning of the workshop was 3.3, indicating that participants felt somewhat equipped to carry out these actions. This increased to a score of 4.7 (close to ‘very well equipped’) by the end of the workshop, showing an improvement in levels of confidence and knowledge across all the areas covered in the programme. Figure 1 shows that scores for the baseline assessment ranged between 2.7 and 4.1 out of 5; this improved to between 4 and 4.7 out of 5 in the final assessment.

Figure 1 Overall competence assessment, baseline and endline: How well-equipped do you feel to …

The baseline scores show that from the outset all participants felt that they had a basic knowledge of the workshop focus areas. Although some averaged scores on the baseline were lower than 2.5, these were in the minority and many respondents reported existing levels of knowledge at 4, signalling that they felt well equipped to undertake those tasks. It is interesting that, overall, participants indicated relatively high levels of confidence even in relation to complex issues such as their ability to identify areas in the health budget that could provide resource gains for priority challenges (a rating of 3.6 for the group as a whole), and their ability to analyze and set priorities for more effective health budget allocation (a rating of 3.5). Nevertheless, by the end of the workshop the group scores increased in each case to 4.6, which suggests that the workshop added value to participants’ existing knowledge and experience.

4 4.1

4.6 4.5

4.2 4.5 4.6

4.5 4.7

4.3 4.5

4.4 4.6 4.6

2.7 3

3.5 3.2

3 3.1 3.2

3.5 4.1

3.4 3.3

2.9 3.6

3.5

0 1 2 3 4 5

14. Identify risks to implementation13. Develop data systems for effective…

12. Identify, communicate and engage with…11.Establish delivery targets

10. Prioritize focused interventions9.Analyse the health care delivery chain

8. Use root cause analysis7. Build processes to ensure productive…

6. Understand how to work as a team5. Develop a comprehensive implementation…

4. Develop a plan of focused interventions3. Identify health budget utilisation inefficiencies

2. Identify areas in health budget that could…1. Analyze and set priorities for health budget

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At the start of the workshop, Cape Verde participants recorded high levels of confidence across the 14 indicators; the Gambia and Tanzania were in the middle, while Uganda’s scores were lower than the others. It may be that at this stage the Uganda team had a more realistic assessment of the challenges faced than the participants from the other countries, as evidenced by the major improvement in their scores on the final competence assessment.

Given that the ratings are self-reported and are thus subjective indications of how individuals perceive their abilities, it is useful to look at participants’ qualitative comments on their baseline competence assessments. These showed they felt they needed most guidance in respect of:

• Identify and analyse health budget utilization inefficiencies in procurement, supply management and health worker productivity – especially for some members of the Uganda team. Their ratings increased from 3 to 4.7.

• Use root cause analysis. This was a concern for some participants from The Gambia, which increased its ratings from 2 to 4.5, and Uganda, which increased its ratings from 3.3 to 5.

• Analyse the health care delivery chain – this was challenging for some people from The Gambia, which improved from 2.5 to 4.5, for some members of the Tanzania team, which improved from 3.2 to 4.6, and for some participants from Uganda, which went from 2.7 to 5.

• Prioritise interventions to create a knock-on effect – this was also a challenge for some from The Gambia, which showed a large improvement from 1.5 to 4.5, Tanzania, which improved from 3.4 to 4.6, and Uganda which went from 3 to 4.

• Establish delivery targets: At the start of the workshop some Uganda delegates were worried about the availability of good data to do this, but by the end of the workshop the team’s rating for this indicator improved from 1.3 to 5.

• Developing data systems was a concern for some participants who said they needed guidance: The Gambia team’s score improved from 3.5 to 5; Tanzania went from 3.4 to 4.6; and Uganda went from 2.5 to 5.

• Identifying risks was indicated as a weak area in the teams from The Gambia, Tanzania and Uganda, but scores improved in The Gambia team from 2.5 to 5, in the Tanzania team from 2.6 to 4.6 and in the Uganda team from 3.3 to 4.3.

Figure 2 shows the extent of improvement overall per indicator. It shows that in the course of the week participants at the lowest end of the scale increased their knowledge and confidence by up to 1.5 points while participants at the highest end of the scale increased their knowledge and confidence by 0.6 points. On average, there was a 1.1 point improvement per indicator.

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Figure 2 Overall competence assessment, baseline and endline: Overall improvement per indicator

On the final competence assessment the biggest improvements were reported for:

• Identify and analyse health budget utilisation inefficiencies in key health care delivery functions: procurement, supply management, health worker productivity

• Use root cause analysis to identify and resolve budgetary challenges • Analyse the health care delivery chain to identify weak links

In the final analysis, participants felt most equipped to:

• Understand how to work effectively as part of a team • Analyse and set priorities for more effective health budget allocation • Identify areas in your health care budget that could provide resource gains (fiscal space) for

addressing priority challenges in health care service delivery • Use root cause analysis to identify and resolve budgetary challenges • Identify, communicate with and engage key stakeholders to help implement the

intervention plan

Participants felt least equipped to:

• Identify risks to implementation and develop effective risk mitigation strategies • Develop data systems for effective implementation monitoring • Prioritize focused interventions to create a knock-on effect to achieve larger institutional

improvements.

1.3 1.1 1.1

1.3 1.2

1.4 1.4

1 0.6

0.9 1.2

1.5 1

1.1

0 0.5 1 1.5 2 2.5 3 3.5 4








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How much of this workshop was new? The group discussions with the evaluator confirmed that the workshop gave many of the participants the opportunity to engage with new ideas and approaches, and develop new skills:

Learning to work in the ‘fiscal space’ was a source of new and important knowledge. (Tanzania finance representative)

I found the concepts pertaining to effectiveness and efficiencies covered during the workshop very useful. Before, the meaning and the application of the terms got mixed up for me. Now it is clear in terms of meaning, application and impact. (Tanzania health representative)

I learnt something new – productivity is about using resources effectively. (Tanzania health representative)

Learning root cause analysis – that was new. (The Gambia finance representative)

The lab – getting stakeholder input and doing a situation analysis. Then monitoring. (Uganda health representative)

Identifying systemic inefficiencies – benchmarking, unit pricing in the context of health. (Uganda finance representative)

A number of participants said that much of the workshop content was not new to them. However, they mentioned important new insights and skills gained in the course of the daily sessions:

We already had planning and M&E, but with this training we have acquired better tools so that we can apply the practices that we have already put in place. (Cape Verde representative)

None of the workshop content was new, but I now have additional techniques and knowledge and skills on the various subjects. (Tanzania finance representative)

We use the BRN* system in Tanzania so that the idea of taking small steps towards big results is not new to us. … We will use what we have learned in the workshop to complement the BRN system. (Tanzania finance representative)

Monitoring progress through routines and dashboards – this was not new, but very relevant. (The Gambia finance representative)

A participant from the Cape Verde finance ministry added that attendance at the workshop had improved the leadership skills of all attendees. This, he said, was particularly important, because good leadership is a necessary condition for the effective functioning of an organisation. He argued that in the absence of good leadership, even the best methodologies would not succeed.

*Big Results Now (BRN) is an approach adopted by the Tanzania Ministry of Health and Social Welfare to increase working efficiency and effectiveness by prioritizing some things that can make big changes. BRN has four thematic areas namely performance management, human resources for health redistribution, health commodities, and maternal, new-born and child health. These initiatives have been prioritized for implementation in order to produce Big Results in a short period of time. The initiatives are not replacing other existing initiatives. (Clarification provided by a senior member of the Tanzania country team.)

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Daily assessments of learning Following the baseline competence self- assessment, workshop participants were asked to self-assess the progress in their knowledge and confidence on a daily basis. Indicators relevant to the content of daily workshops were developed and used for this purpose (see section 3.3 above).

The assessment instruments were administered at the end of each day and participants were asked to rate themselves using a five-point scale on which 1 was equivalent to very little knowledge and confidence acquired, and 5 was equivalent to having acquired full knowledge and confidence. A rating of 3 would suggest a neutral assessment. More specifically; 1= not at all equipped, 2=poorly equipped, 3=somewhat equipped, 4=well equipped, and 5=very well equipped.

As noted previously, the ratings are not an objective measure of knowledge and confidence acquired. Self-assessments are relative to own experience and personality, and the data does not indicate that certain groups of respondents acquired more knowledge than others. Comparing the scores does show, however, that some teams felt they acquired sufficient knowledge to carry out the required tasks while others felt that they could have learned more.

Comparisons between the baseline competence data and the daily reports show that respondents reported increased knowledge and confidence on a daily basis (with the exception of Day Four). The analysis shows that most additional support is needed for topics covered on Day Four, which focused on organising for implementation; the least additional support is required for subjects covered on Day Five, which focused on mobilizing and communicating for implementation as well as monitoring, routines and dashboards.

Table 1 shows the overall daily self-reported score for the acquisition of knowledge and confidence ranges from 3.9 to 4.5, suggesting that respondents felt knowledgeable and confident about the material covered during the workshop.

The value of case studies A number of participants commented on the value of the practical experience shared through the case studies from different countries.

One participant from Tanzania described how the case studies helped her understand the practical application of the skills she acquired on target setting and using data to track the achievement of targets. A participant from The Gambia said that the practical examples of team work provided her with new insights. A Uganda participant put it this way:

The faculty from different institutions provided us with new experiences e.g. Malaysia on a performance delivery unit team, the UK emphasis on measuring performance, how to get deliverables through a fast track process, how to think big, develop the programme and then find the resources. (Uganda health representative)

One participant from Cape Verde said that although he was familiar with, and had previously used, the methodologies presented, the practical case studies were “extremely important” in providing information . He said it was “very positive” to see that in practice these methodologies have resulted in gains for the countries using them, and added that “it gave us confidence in what we are doing. We are now very excited about implementing our plans”.

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Table 1 Overall feedback ranges per day

Day Range: from Range: To Two: Root cause analysis, setting priorities & using budgets efficiently and effectively

3.6 4.3

Three: Designing interventions and an intervention strategy

4.1 4.5

Four: Organising for implementation 3.7 4.3 Five: Communication & monitoring 4.3 4.8 Overall feedback range (Days 2-5) 3.9 4.5

High-level analysis per day and per country is presented below.

Day Two feedback

Day Two focused on analysing the root causes of problems in the health system, setting priorities and using budgets effectively and efficiently.

Figure 3 Day Two feedback: Overall group

The average feedback for Day Two (including responses from all participants from all four countries) ranged from between 3.6 (somewhat confident and knowledgeable) to 4.3 (confident and knowledgeable), indicating that respondents generally felt confident and knowledgeable about the content covered during the second day of the workshop. Respondents felt most knowledgeable and confident to ‘use root cause analysis to identify immediate challenges in health worker productivity, procurement and supply distribution/management’ (4.3), but only somewhat confident with regard to three other indicators:

• Analyse the health care delivery chain to identify weak links (3.6)

1

2

3

4

5

1. Analyse and setpriorities for more

effective health budget

2. Use root causeanalysis to identify

challenges in healthworker productivity

3. Identify and analyseinefficiencies in the

utilisation of the healthcare budget

4. Identify areas incountry budgets that

provide fiscal space forhealth care delivery

functions

5. Identify andprioritize opportunities

for increasing theeffectiveness of

budgetary allocation

6. Analyse the healthcare delivery chain to

identify weak links

7. Identifyopportunities for

improving theefficiency of budgetary

spend to improve…

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• Identify and prioritize opportunities for increasing the effectiveness of budgetary allocation (3.9). This was reflected in the qualitative comments as well.

• Identify opportunities for improving the efficiency of budgetary spend to improve service delivery (3.9)

The presentation of the data per country below, suggests some important variations (for detail see the country profiles in Section 5). Participants from Cape Verde felt confident and knowledgeable, and scored 4 on all indicators presented. Participants from the Gambia and Tanzania felt confident to very confident and knowledgeable as indicated by their scoring range of 4 to 5. The range reported by Ugandan participants is lower, with a minimum score of 3 and a maximum score of 4. As Table 2 indicates, the Uganda scores brought down the self-assessment scores of the overall group on Day Two.

Table 2 Day Two self-assessment range comparison by country

Country teams Range: from Range: To Cape Verde 4 4 The Gambia 4 5 Tanzania 4 5 Uganda 3 4 Overall 3.6 4.3

Looking at the high and low scoring indicators across the country teams, the following received ratings of 5:

• Analyze and set priorities for more effective health budget allocation (Tanzania) • Use root cause analysis to identify immediate challenges in health worker productivity,

procurement and supply distribution/management (Gambia & Tanzania) • Identify and analyze inefficiencies in the utilisation of the health care budget in

procurement, supply management, and health worker productivity (Tanzania) • Identify areas in country budgets that provide fiscal space for health care delivery functions

(Tanzania) • Identify and prioritize opportunities for increasing the effectiveness of budgetary allocation

(Gambia)

The following indicator received the lowest rating (a score of 3): • Identify opportunities for improving the efficiency of budgetary spend to improve service

delivery (Uganda)

Day Three feedback

Day Three focused on designing interventions and developing an intervention strategy. Associated with this, participants discussed why and how to establish data systems, set targets, and build teams. The average feedback for Day Three (based on responses from all participants from all four countries) ranged from between 4.1 and 4.5 indicating that respondents generally felt confident and knowledgeable about the content covered during the third day of the workshop. Respondents felt most knowledgeable and confident to set measurable and time-bound targets for each priority (4.5).

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Figure 4 Day Three feedback: Overall group

The presentation of the data per country in Table 3 suggests some important variations in the team assessments for the day (for detail see the country profiles in Section 5). Participants from Cape Verde felt somewhat confident to confident and knowledgeable and scored between 3.8 and 4.5. Participants from The Gambia felt confident and knowledgeable to very confident and knowledgeable as indicated by the 4.2 to 4.8 response range. Tanzanian respondents had a similar assessment, with a score ranging from 4 to 4.6. The range for Uganda was 3.6 to 4.5, the lowest among the four teams.

Table 3 Day Three self-assessment range comparison by country

Unit Range: from Range: To Cape Verde 3.8 4.5 The Gambia 4.2 4.8 Tanzania 4 4.6 Uganda 3.6 4.5 Overall 3.6 4.3

As Table 3 indicates, on Day Three none of the indicators received a rating of 5, but the following ones drew the highest ratings:

• Setting measurable and time-bound targets for each priority (4.8 from the Gambia, and 4.6 from Tanzania)

• Developing a plan of focused, practical interventions to achieve greater efficiency in resource utilisation and improved standards of service delivery (4.6 from Tanzania)

Qualitative responses indicated that respondents placed a high and positive value on the component of the workshop focusing on developing an understanding of how to work effectively as part of a team.

1

2

3

4

5

1.Prioritise focusedinterventions

2. Develop a plan ofinterventions

3. Develop acomprehensive strategy

4. Set measurable targets

5. Know what data isneeded

6. Know how tostrengthen data systems

7. Practice evidence-based decision-making

8. Understand how towork as a team

9. Develop processes forcollaboration

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The following indicators received the lowest ratings for the day, suggesting areas in which the learning experience of respondents could be expanded:

• Developing a comprehensive strategy for implementing intervention plans (3.6 from Uganda)

• Knowing how to strengthen data systems for effective implementation monitoring (3.8 from Cape Verde), and

• Practising evidence-based decision-making (3.8 from Uganda).

Day Four feedback Day Four focused on organising for implementation, and the sessions covered topics such as the science of delivery, developing the foundations for delivery, and tools for planning delivery. The average feedback for Day Four (including responses from all participants from all four countries) ranged from 3.7 to 4.3 indicating that respondents generally felt somewhat confident and knowledgeable about the content covered during the fourth day of the workshop.

Figure 5 Day Four feedback: Overall group

The responses suggest that more support could be beneficial for some participants in following areas:

• Strengthening the links between key actors in the delivery chain (3.9) • Likelihood of achieving the targets for improved procurement processes (3.9) • Likelihood of achieving the targets for improved supply chain and distribution management

(3.9) • Identifying risks to effective implementation and the development of effective risk

mitigation strategies (3.7).

1

2

3

4

5

1. Establish systems andprocesses

2. Establish a guidingcoalition

3. Strengthen the linksbetween key actors

4. Achieving the targetsfor health worker…

5. Achieving the targetsfor improved…

6. Achieving the targetsfor improved supply…

7. Set clear performancegoals

8. Put in place systems foraccountability

9. Identify risks toimplementation

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On Day Four the comparatively low rates of confidence and knowledge expressed (in relation to Day Three, for example) were influenced by low scores reported by representatives from the Tanzanian finance ministry (see below).

Respondents felt most knowledgeable and confident to establish a guiding coalition to support the implementation of intervention plans, and to set clear performance goals for individuals and teams. Qualitative responses also emphasized the value of inter-departmental cooperation, teamwork and related opportunities for cross-learning.

The presentation of the data per country below suggests some important variations, not only between countries, but between the financial and health sector representatives within particular countries (a pattern that is also somewhat evident from the overall baseline and end-line comparative analysis).

Respondents from Cape Verde felt confident and knowledgeable about the Day Four content and their self-assessment scores ranged from 4 to 4.3. However, when compared to the baseline self-assessment the Cape Verde team reported no increase in their knowledge with regard to strengthening the links between key actors in the delivery chain, suggesting a need for more support.

Representatives from the Gambia were consistently confident and knowledgeable, to very confident and knowledgeable, with a self-assessment score range of 4.2 to 4.6. Uganda, again, had a lower minimum assessment score, ranging from (somewhat) 3.7 to (confident and knowledgeable) 4.6.

In this instance, however, it is the Tanzania scores (and in particular the scores from representatives of the Tanzania financial representatives) that lowered the average score. With the exception of their ability to set clear performance goals for individuals and teams, representatives from the Tanzania finance ministry were only somewhat confident and knowledgeable in all other areas covered on Day Four. This suggests that considerable support is required by this group. In the qualitative responses, concerns were also raised by representatives of the Tanzania finance ministry about overlap between the workshop’s ‘small steps towards big results’ approach and the ‘Big Results Now’ system in operation in the country.

Table 4 Day Four self-assessment range comparison by country

Unit Range: from Range: To Cape Verde 4 4.3 The Gambia 4.2 4.6 Tanzania (overall) 3.5 4.5 Tanzania finance) 3 4.3 Tanzania (health) 4 4.8 Uganda 3.7 4.6 Overall 3.6 4.3

While some indicators drew high ratings and others low ratings, the following were problematic for some respondents:

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• Establish the systems and processes for implementing the reforms successfully (3.8 from Tanzania finance participants)

• Establish a guiding coalition to support the implementation of the intervention plan (4.6 from the Gambia, 3.5 from Tanzania finance, 4.8 from Tanzania health, Uganda 4.6)

• Strengthen the links between key actors in the delivery chain (3.5 from Tanzania finance, Cape Verde repeated zero knowledge gain)

• Likelihood of achieving the targets for increasing health worker productivity (3.8 from Tanzania overall, 3.8 from Tanzania finance)

• Likelihood of achieving the targets for improved procurement processes (3.5 from Tanzania overall, 3 from Tanzania finance)

• Likelihood of achieving the targets for improved supply chain and distribution management (3.6 from Tanzania overall, 3.5 from Tanzania financial, 3.8 from Uganda)

• Set clear performance goals for individuals and teams (4.8 from Tanzania health) • Put in place systems and procedures for individual and collective accountability (4.6 from

The Gambia, 3.8 from Tanzania finance) • Identify risks to effective implementation and develop effective risk mitigation strategies

(3.6 from Tanzania overall, 3.5 from Tanzania finance, 3.7 from Uganda).

Day Five feedback Day Five focused on mobilizing and communicating for implementation as well as monitoring, routines and dashboards. The highest levels of satisfaction or reported learnings for the week are associated with the Day Five content. The average feedback for Day Five (including responses from all participants from all four countries) ranged from 4.3 to 4.8 indicating that respondents generally felt very confident and knowledgeable about the content covered during the fifth day of the workshop.

19

Figure 6 Day Five feedback: Overall group

The highest scores were given to the following indicators, suggesting that respondents felt most knowledgeable and confident to:

• Identify, communicate with and engage key stakeholders to help implement the intervention plan (4.8 overall, 4.6 from Cape Verde, 4.6 from The Gambia, 4.6 from Tanzania, 5 from Uganda)

• Develop a strategy for mobilising and communicating with key stakeholders (4.6 overall, 4.6 from Cape Verde, 4.6 from Tanzania, 4.7 from Uganda)

• Develop a core message to communicate the implementation plan and how it will be achieved (4.7 from Tanzania)

• Develop the routines needed to monitor performance, and diagnose and address problems (4.6 from Cape Verde, 4.6 from Tanzania)

• Ensure that monitoring routines are respected and implemented as planned (4.6 from Cape Verde, 4.6 from Tanzania)

• Use data to correct course when necessary (4.6 from The Gambia)

The presentation of the data per country in Table 5 below, suggests fewer variations per country assessment for Day Five. Participants from Cape Verde felt very confident and knowledgeable with a score range of 4.3 to 4.6. Respondents from the Gambia (4.2 to 4.6) and Tanzania (4.1 to 4.7) were similarly very confident and knowledgeable. In this instance, representatives from Uganda were responsible for the highest single score (see above) and had a self-assessment range of 4.2 to 5, also indicating very high levels of confidence and knowledge.

1

2

3

4

5

1. Identify, engage andcommunicate with

stakeholders

2. Develop a strategy formobilising and

communicating with keystakeholders

3. Develop a coremessage to communicatethe implementation plan

4. Able to communicatebad news

5. Develop the routinesneeded to monitor

performance

6. Explain the value ofmonitoring routines

7. Ensure that monitoringroutines are respected

and implemented

8. Use data to correctcourse when necessary

20

Table 5 Day Five self-assessment range comparison by country

Unit Range: from Range: To Cape Verde 4.3 4.6 The Gambia 4.2 4.6 Tanzania 4.1 4.7 Uganda 4.2 5 Overall 3.6 4.3

The data suggests a very high level of knowledge and confidence acquisition on Day Five, particularly with regard to identifying, communicating with and engaging with key stakeholders around the implementation of intervention plans.

5 Profiles of country feedback A key feature of this workshop was the involvement of representatives from the ministries of health as well as the ministries of finance from each of the participating countries. In the country profiles below we document the overall self-reported learning of each team, and also report separately on the feedback from the health and finance representatives to see if there are similarities and differences in their responses to the workshop content.

21

Cape Verde The baseline scores of the Cape Verde country team (see Figure 7) show that team members felt relatively well equipped to carry out the actions referred to in the competence indicators. Nevertheless the team members’ final ratings at the end of the workshop show that they felt they had acquired knowledge and confidence, particularly about four indicators, allocating a rating of 4.7 to each one:

1 Analyze and set priorities for more effective health budget allocation 2 Identify areas in your health care budget that could provide resource gains (fiscal space) for

addressing priority challenges in health care service delivery 3 Understand how to work effectively as part of a team 4 Identify, communicate with and engage key stakeholders to help implement the

intervention plan.

Figure 7 Cape Verde: Team baseline and final competence barometer results

The indicators show that the team benefited from the focus on prioritization and budget allocation, found value in the combination of the health and finance mix in the team members, and improved their stakeholder management skills.

The team showed the biggest improvements (in descending order) in the following areas:

• Establish delivery targets to help measure progress (3 → 4.5) • Identify and analyze health budget utilization inefficiencies in key health care delivery

functions: procurement, supply management, health worker productivity (3 → 4.3) • Identify risks to implementation and develop effective risk mitigation strategies (3 → 4.3) • Use root cause analysis to identify and resolve budgetary challenges (3 → 4.3) • Develop data systems for effective implementation monitoring (3 → 4.2).

Comparison of health and finance participant learning gains

The team from Cape Verde comprised three health ministry participants and three from the finance ministry.

4.3 4.2

4.7 4.5

4.3 4.5

4.3 4.3

4.7 4.3 4.3 4.3

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3 3

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22

Health ministry participant results

Respondents from the health ministry felt very equipped at the end of the workshop, giving full scores (5 out of 5) to seven areas of the training (see Figure 8) and high scores to all others.

Figure 8 Cape Verde health representatives’ competence assessment, baseline and endline

Even in areas in which participants felt comfortable at the start of the workshop, important shifts were reported (see Figure 9).

Figure 9 Cape Verde health representatives’ improvement per indicator

There were four areas in which the health representatives reported the most growth with a 2 point increase in one case and an increase of 1.7 points in the others:

• Identify risks to implementation and develop effective risk mitigation strategies (2 point change)

5 4.7

5 5

4.7 5

4.7 4.3

5 4.7 4.7 4.7

5 5

3 3

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4 3.7

0 1 2 3 4 5

14. Identify risks to implementation13. Develop data systems for…

12. Identify, communicate and…11.Establish delivery targets


8. Use root cause analysis7. Build processes to ensure…

6. Understand how to work as a team5. Develop a comprehensive…4. Develop a plan of focused…

3. Identify health budget utilisation…2. Identify areas in health budget that…1. Analyze and set priorities for health…

Baseline

Final

2 1.7 1.7 1.7

0.7 1.3

1.4 1 1

0.7 0.4

1 1

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23

• Establish delivery targets to help measure progress (1.7 points) • Identify, communicate with and engage key stakeholders to help implement the

intervention plan (1.7 points) • Develop data systems for effective implementation monitoring (1.7 points) • Identify risks to implementation and develop effective risk mitigation strategies (1.7 points).

Finance ministry participant results The finance ministry participants demonstrated less growth in knowledge and confidence than their health counterparts. There were two areas in particular in which the finance representatives reportedly still lacked knowledge:

• Develop data systems for effective implementation monitoring (3.7) • Identify risks to implementation and develop effective risk mitigation strategies (3.7)

Figure 10 Cape Verde finance representatives’ competence assessment, baseline and endline

Figure 11 illustrates the (point based) knowledge shifts made by this group, with the largest improvements occurring in identifying and analysing health budget utilization inefficiencies (1.3 point change), using root cause analysis (1 point change) and engaging with stakeholders (1 point change). There was no change over the baseline in respect of analysing and setting priorities for more effective health budget allocation.

3.7 3.7

4.3 4 4 4 4

4.3 4.3

4 4 4

4.3 4.3

3 3.3

4 3.3

4 3.7

3 4 4

3.5 3.5

2.7 3.7

4.3

0 1 2 3 4 5






4. Develop a plan of focused interventions3. Identify health budget utilisation…


Baseline

Final

24

Figure 11 Cape Verde finance representatives’ competence assessment, improvement per indicator

Although the results show that the health ministry representatives experienced more growth during the workshop than their finance counterparts, ultimately both health and finance ministry representatives indicated that they all need more support in respect of developing data systems for effective implementation monitoring, and identify the risks to implementation and effective risk mitigation strategies to keep implementation on track.

How are these results likely to impact on the team? In discussion with the evaluator the team members commented that all aspects of the workshop were very relevant to their professional development. In addition, the workshop motivated them and helped develop their leadership capacity:

We feel like leaders now. We also feel that there be a willingness from others to learn from us and that we will be able to guide them.

When asked how their work will be different from before, the participants pointed to three factors:

• The value of having a plan • Building a coalition to carry out the plan • The importance of training others to use the skills gained during the workshop

What we have now is a plan. We have a short-term plan for an entire year. This includes quick wins that we can achieve in the short term. But we also have defined what we intend to achieve in the long term for the project. So we are going to implement and we now have better tools to do so. We are also going to do the monitoring and assessment of our activities and we have identified points of improvement in all areas – human resources, procurement and the drug distribution chain.

We want to build a coalition and we have the required support from our ministers to do so. We will also work as a core team for the delivery of this program. We have a mandate. We

0.7

0.3

1

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0

0.3

1

0.3

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1.3

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0

0 0.5 1 1.5 2 2.5 3 3.5 4

14. Identify risks to implementation

13. Develop data systems for effective…

12. Identify, communicate and engage with…

11.Establish delivery targets

10. Prioritize focused interventions

9.Analyse the health care delivery chain

8. Use root cause analysis

7. Build processes to ensure productive collaboration

6. Understand how to work as a team

5. Develop a comprehensive implementation strategy

4. Develop a plan of focused interventions

3. Identify health budget utilisation inefficiencies

2. Identify areas in health budget that could provide…

1. Analyze and set priorities for health budget

25

will engage with our stakeholders. We will build a huge alliance to bring about these reforms and to have more efficient and sustainable health service delivery to the country.

The leadership and personnel training will also contribute to improved human resource management, which turn will have a “scale down/trickle down” effect. In other words, the training received at the workshop that focused on evaluation, monitoring and coaching is the lever or small act that will result in the biggest impact in all three areas [procurement, supply management and health worker productivity].

When asked about the prospects for health and finance ministry representatives working together, participants responded that they had worked together before, but in an ad hoc manner, and that the workshop process facilitated coherent cooperation on which they can build and continue in the longer term.

We already work together. For example, we [referring to three team members] work in the Ministry of Finance, but our work focuses specifically on the health sector. I do so in budgets, my colleague does so in accounts, my other colleague in planning. We report to both ministers, so the linkage is very strong. We were working together before, but not as effectively as we worked together here. Now we have better motivation to work together effectively because our ministers want us to work together. They mandated us to come here and work together.

Team members indicated that they would like further support from the MLIH Program to help them train colleagues at the intermediate level:

We want this training in other levels, for intermediate leaders, to build this coalition of leadership.

We want to be coached so that we can train others.

The idea is not that they [the MLIH Program] come and do everything – they just have to do the coaching so that this team is trained to train and coach their inferiors. We want to ensure that there is continuity in this process, so they will do the work at the base, so as a guarantee that we are going on the right route.

The Gambia Despite starting the workshop with several low and mid-range scores, the country team from The Gambia showed strong improvements in the following areas (shown here with final scores in descending order):

• Use root cause analysis to identify and resolve budgetary challenges (2.8 → 4.8) • Analyze the health care delivery chain to identify weak links (2.6 → 4.4) • Identify risks to implementation and develop effective risk mitigation strategies (2.8 → 4.4) • Identify, communicate with and engage key stakeholders to help implement the

intervention plan (3.8 → 4.4) • Prioritize focused interventions to create a knock-on effect to achieve larger institutional

improvements (2.4 → 4.2).

26

Figure 12 The Gambia: Team baseline and final competence barometer results

Comparison of health and finance participant learning gains


The results were disaggregated by health and finance ministry participants (two health and three finance ministry representatives) and are represented in figures 13-16 below.

Figure 13 shows that the health ministry representatives felt very confident and knowledgeable at the conclusion of the workshop. They gave six areas the maximum rating of 5, and rated the other eight areas at 4.5.

Figure 13 The Gambia health representatives’ competence assessment, baseline and endline

4.4 4.4

4.8 5

4.2 4.4

4.8 4.6 4.6 4.6

4.4 4.4

4.8 4.4

2.8 3.4 3.4 3.5

2.4 2.6

2.8 3.4

4 3.8

3.2 3.5

3.8 3.6

0 1 2 3 4 5








5

5

4.5

5

4.5

4.5

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5

5

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4.5

5

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4

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2

3

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7. Build processes to ensure productive…


5. Develop a comprehensive implementation…


3. Identify health budget utilisation…

2. Identify areas in health budget that could…


Baseline

Final

27

These results show exceptionally high reported improvements in their knowledge and competence levels, compared to the other sub-groups of attendees analysed. As is shown in Figure 14, there was a three point increase in the team’s ability to prioritise focused interventions to create a knock-on effect to achieve larger institutional improvements (1.5 → 4.5) and a 2.5 point increase in the following indicators:

• Use root cause analysis to identify and resolve budgetary challenges (2 → 4.5) • Identify risks to implementation and develop effective risk mitigation strategies (2.5 → 5).

Figure 14 The Gambia health representatives’ improvement per indicator

Finance ministry participant results Finance representatives from The Gambia also reported high degrees of knowledge and confidence, although not as high as their counterparts from the health ministry. Figure 15 shows that the finance respondents felt most equipped to:

• Use root cause analysis to identify and resolve budgetary challenges (3.3 → 5) • Establish delivery targets to help measure progress (3.3 → 5) • Identify, communicate with and engage key stakeholders to help implement the

intervention plan (3.3 → 5).

Figure 16 shows that these results represent increases of 1.7 points in each case, with a 1.6 point increase reported for knowledge and confidence in analysing the health care delivery chain.

2.5

1.5

1

1

3

2

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2

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7. Build processes to ensure productive collaboration


5. Develop a comprehensive implementation strategy


3. Identify health budget utilisation inefficiencies

2. Identify areas in health budget that could provide…


28

Figure 15 The Gambia finance representatives’ competence assessment, baseline and endline

Figure 16 The Gambia finance representatives’ competence assessment, improvement per indicator

As was the case with Cape Verde, the analysis shows that the health ministry representatives experienced more growth during the workshop than their finance counterparts. Given their higher confidence levels, it is likely that they will be able to support their colleagues in finance in the areas in which the latter scored lowest by the end of the workshop:

• developing data systems for effective implementation monitoring • identifying the risks to implementation and effective risk mitigation strategies to keep

implementation on track • prioritizing focused interventions to create a knock-on effect to achieve larger institutional

improvements.

4 4

5 5

4 4.3

5 4.7

4.3 4.3 4.3 4.3

4.7 4.3

3 3.3 3.3 3.3

3 2.7

3.3 3.7 3.7 3.7 3.7 3.7 3.7

3.3

0 1 2 3 4 5

14. Identify risks to implementation13. Develop data systems for effective…12. Identify, communicate and engage…

11.Establish delivery targets10. Prioritize focused interventions

9.Analyse the health care delivery chain8. Use root cause analysis

7. Build processes to ensure productive…6. Understand how to work as a team

5. Develop a comprehensive…4. Develop a plan of focused interventions

3. Identify health budget utilisation…2. Identify areas in health budget that…1. Analyze and set priorities for health…

Baseline

Final

1 0.7

1.7 1.7

1 1.6

1.7 1

0.6 0.6 0.6 0.6

1 1

0 0.5 1 1.5 2 2.5 3 3.5 4




8. Use root cause analysis7. Build processes to ensure productive collaboration

6. Understand how to work as a team5. Develop a comprehensive implementation strategy


2. Identify areas in health budget that could provide…1. Analyze and set priorities for health budget

29

How are these results likely to impact on the team? Like their co-participants from Cape Verde, The Gambia team said that all aspects of the workshop were very relevant to their professional development. One member of the finance ministry commented that learning how to use the health budget to drive improvements in the health system was particularly relevant, while one of the health ministry participants singled out the value of how to make the health system more efficient by focusing on how resources are used and by focusing on results.

Finance ministry participants commented on the relevance of using targets and data to measure progress, saying:

It is necessary for informed decision-making

It is efficient and the professional use of data is necessary. We are engaging with GBoS1 to develop better data.

It needs to be noted, however, that developing data systems for effective implementation monitoring drew one of the three lowest scores on the finance ministry participants’ endline competence assessment.

When asked how their work will be different from before, the participants mentioned the following benefits that they gained from the workshop:

I will apply new skills and have new responsibilities.

I will have more energy.

I will focus on result-based financing of primary health care.

With finance interacting with health, I will look harder at how to use existing resources more intensively.

I learnt skills to use in parts of my job

We need to deliver for our Ministers. The Permanent Secretaries will monitor internally.

When the finance participants were asked specifically how the approaches and tools advocated by the workshop would influence their actions, they responded as follows:

The Minister of Finance is responsible for national development planning and a health population produces economic gains. As a citizen I want to see change happen. In 2014, X was allocated for health and they spent more than 100%. So we need to create a realistic budget and reduce budget allocations to other sectors to cover crises/shortfalls.

The participants affirmed the value of the health-finance team work approach used in the workshop and described its impact in this way:

The combination of finance and health ministry participants injected new blood into the organisation.

When asked how they would continue the interaction between the team members, one participant said: The Gambia is very small – our offices are in walking distance from each other. Challenged by the evaluator on how they would make time for this interaction, another participant said: Time may

1 The Gambia Bureau of Statistics

30

be a problem, but we could meet at close of business or even during the weekend – it needs strong commitment. This holds the risk that the collaboration between health and finance may be side-lined during the working day.

The team will look to their ministers for support in implementing the plan and strategy developed during the workshop:

We need moral support and continual consultation with our Ministers to get the necessary leverage to make the changes. We also need help to assess progress and adjust where necessary.

Tanzania At the start of the workshop the Tanzania team started the workshop by indicating that it felt least equipped to deal with budget utilization issues, the health care delivery chain and risk analysis (see Figure 17). The scores show that at the outset it felt most equipped to work as a team and build collaborative processes. This spread suggests that the team was more experienced in the ‘softer’ aspects of planning and strategy development and less equipped to tackle the more technical and financial aspects.

By the end of the workshop the team’s highest score was given to identifying areas in the health budget that could provide fiscal space for addressing priority challenges in health care service delivery. The next highest ratings were for team work and building productive collaboration processes, suggesting that these remain areas of comfort in comparison with the strategic resource demands of the job.

Figure 17 Tanzania: Team baseline and final competence barometer results

The Tanzania country team showed the biggest improvements (in descending order) in the following areas:

• Identify areas in the health care budget that could provide resource gains (fiscal space) for addressing priority challenges in health care service delivery (3.3 → 4.8)

• Analyze and set priorities for more effective health budget allocation (3.3 → 4.3) • Analyze the health care delivery chain to identify weak links (2.3 → 4.9)

3.5 4

4.3 4.5

4.2 4.3

4.5 4.7 4.7

4.2 4.5

4.3 4.8

4.5

2.6 3.3 3.4

3.2 3.1

2.9 3.6

3.9 4.1

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3 3.3

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31

• Identify and analyze health budget utilization inefficiencies in key health care delivery functions: procurement, supply management, health worker productivity (3 → 4.3)

• Establish delivery targets to help measure progress (3.2 → 4.5). As is shown below, improved knowledge and confidence varied widely between the health and finance members of the team.

Comparison of health and finance participant learning gains The Tanzania team comprised five health ministry representatives and four from the finance ministry.


In line with the overall group ratings, the health ministry participants indicated at the start of the workshop that they felt most equipped to work as a team (4.4), build processes for productive collaboration (3.8) and engage with stakeholders (3.8) – see Figure 18.

Figure 18 Tanzania health representatives’ competence assessment, baseline and endline

At the end of the workshop the health representatives felt well equipped to carry out most of their tasks as indicated by the fact that their lowest average rating was a very confident 4.4. The group felt most equipped (at 4.8) to do the following;

• Identify areas in your health care budget that could provide resource gains (fiscal space) for addressing priority challenges in health care service delivery

• Develop a plan of focussed interventions to achieve greater efficiency in resource utilisation and improve standards of service delivery

• Understand how to work effectively as part of a team • Use root cause analysis to identify and resolve budgetary challenges.

These areas of improvement show a stronger emphasis on the technical and financial issues covered at the workshop.

4.6 4.6 4.6

4.4 4.6 4.6

4.8 4.6

4.8 4.6

4.8 4.6

4.8 4.6

2.6 3.4

3.8 2.8

3.4 3.2

3.4 3.8

4.4 3.6

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Baseline

Final

32

The health representatives on the team also reported important improvements in a number of areas (see Figure 19), notably:

• A 2.4 point improvement in feeling equipped to establish delivery targets to help measure progress, and

• An improvement of 2 points in their ability to identify risks to implementation and develop effective risk mitigation strategies.

Figure 19 Tanzania health representatives’ improvement per indicator

Finance ministry participant results At the start of the workshop the Tanzania finance representatives indicated that they felt poorly equipped to undertake activities that require knowledge of the health sector. These include analysing the health care delivery chain (rated 2.5) or identifying inefficiencies in health care delivery functions (procurement, supply management and health worker productivity) (3) or identifying interventions that would have a knock-on effect on the health system (2.8). On each of these indicators the finance respondents scored their competence at 3 or less (see Figure 20).

2 1.2

0.8 2.4

1.2 1.4 1.4

0.8 0.4

1 1.4

1.6 1.6 1.6

0 0.5 1 1.5 2 2.5 3 3.5 4








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Figure 20 Tanzania finance representatives’ competence assessment, baseline and endline

By contrast, they felt more equipped to:

• Analyze and set priorities for more effective health budget allocation (3.3) • Identify areas in the health care budget that could provide resource gains (fiscal space) for

addressing priority challenges in health care service delivery (3.5) • Develop a plan of focused interventions to achieve greater efficiency in resource utilization

and improve standards of service delivery (3.5) • Understand how to work effectively as part of a team (3.8) • Use root cause analysis to identify and resolve budgetary challenges (3.8) • Establish delivery targets to help measure progress (3.8) • Build processes to ensure productive collaboration between colleagues from health and

finance (4)

Despite this, by the end of the workshop these participants expressed some of the lowest post-workshop knowledge and confidence levels. Furthermore the ratings of increased knowledge and skills acquisition for this group are comparatively low and come off a low base, which is perhaps cause for concern. For example, in regard to their ability to develop data systems for effective implementation and monitoring the group reported zero knowledge and confidence acquisition. Low rates of improvement were also reported for their ability to identify risks to implementation and develop effective risk mitigation strategies (see Figure 21).

2.8 3.3

4 4.3

3.8 4

4.3 4.5 4.5

3.8 4.3 4.3

4.5 4.5

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3 3.8

2.8 2.5

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3.8 3.3

3.5 3

3.5 3.3

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Baseline

Final

34

Figure 21 Tanzania finance representatives’ competence assessment, improvement per indicator

How are these results likely to impact on the team? The Tanzania team members had mixed responses to the relevance of the workshop to their professional development. The limited time available meant that only one or two individuals could comment on each of the six areas covered during the workshop, so these responses are cannot be regarded as representative of the whole team.

The focus areas mentioned as being ‘very relevant’ to their professional development were:

• Using the health budget to drive improvements in the health system • Using targets and data to measure progress • Working as part of a joint health-finance ministry team.

Because the health ministry is a big ministry, so any results in this sector will be big, and big results in this sector will impact on all other sectors. We come from finance and we define objectives and targets for different ministries. Now I feel more responsible for health issues, after interacting with health people. I have learned from them, especially that we need to allocate more resources at primary level.

A representative from the health ministry said that she acquired new target setting skills, as well as skills to use data to track the achievement of targets. The workshop also gave her “the skills to strengthen our data systems”. Although she knew much of the material before attending the workshop, she now has the ability to use/implement her knowledge, primarily as a result of the case studies on practical application that were presented.

‘Relevant’ focus areas were mentioned as being:

• Organising for implementation • Monitoring progress through routines and dashboards.

0.3 0

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1 1.5

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0.8 1.3

1 1.2

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35

A health ministry participant commented on the value of organising for implementation as follows:

This was relevant to me, because the presentations from the other countries showed us that the most important thing is planning, so that when you start implementing you know exactly how to implement the plan. Because resources are always scarce, so we always have to prioritise. So if you have a good plan, and you commit to implementation, you can succeed despite not having enough resources. That was an area of personal growth for me.

One finance participant said that issues associated with making the health system more efficient were ‘somewhat relevant’:

When I look at the budget for the Ministry of Health, I see that the budget is very small and that there is too little budget at the primary level. We have to use the same small amount of money [but] when you try to solve a problem at some level, you create a problem elsewhere. It is somewhat relevant, because one will still need extra resources.

When asked how their work will be different from before, a health ministry participant explained that the team had prepared a briefing for both the health and finance ministers as well as the top management from the two ministries “so that all the key people will know what we are discussing and will arrive at the same understanding. We much depend on the support of these ministers and permanent secretaries. The first thing to do when we get home is to get these people to the same understanding as us.”

Another health participant described her first steps as being:

I need to give feedback to my boss. If I keep my boss on track of what is happening on my job, for example, what we have agreed here. I can’t go straight to the minister. I first have to spend time to make sure that my boss understands what I have learnt here. Then in a month, as a team, we try to make sure that the task that we have done here, reaches the minister.

Team members clearly appreciated the value of the health and finance ministry representatives working together. As is clear from the comments cited above, finance participants learnt a great deal about public health and the importance of investing in primary health care. Health participants clearly benefited from their interaction with their colleagues from the finance ministry:

We did not work together effectively before. As health we did not know that much about financial issues. We have learnt a lot from the ministry of finance team. We have learned about fiscal space, reallocation, how to find a new source of funds, we were forced to think in different ways. We know we have to prioritise issues, and reallocate budgets, instead of getting additional budgets. It was very relevant to me personally, because I have never been in a group like this.

Through this workshop I was able to recognise that the budget we have for health is not a lot of money, but if we use it efficiently we can improve health care delivery. We can prioritise. Now we have commitment from two key stakeholders to use the budget more effectively and efficiently, which means that we can do more than we do now.

When asked what additional support the team would require to implement the planned strategy, one person mentioned the importance of circulars being issued, particularly on the issue of fiscal space. However, most of the respondents talked about the need for additional funds “to improve sustainability” and for other reasons:

36

We need the Harvard team to support us. Of course reallocation is the best approach in some cases, but if you already have an acute deficit, the reallocation from A to B just leaves a hole elsewhere. Both ministers must be involved. We appreciate reallocation and efficient resources use, but we can’t deny that we need more resources and we need other sources of funds. We expect Harvard to produce additional funding. We really need the financial support – to help us to use what we have learned and to help us strengthening our health system. We need additional funds to improve sustainability. We need people like USAID to give us this financial support. We are looking for other funders to build up the system.

Uganda At the start of the workshop the Uganda team’s baseline ratings indicated that participants felt somewhat equipped or poorly equipped to undertake the actions required to develop plans and strategies to strengthen their health system. The team’s average baseline score was 2.9, compared with average baseline scores for Cape Verde (3.6), The Gambia (3.3) and Tanzania (3.3).

However, by the end of the workshop, Uganda’s average final competence score went up to 4.5, compared with 4.4 for Cape Verde, 4.5 for The Gambia and 4.4 for Tanzania. Figure 22 shows the results from the Uganda team’s final competence assessment in comparison with the results from the baseline assessment.

Figure 22 Uganda: Team baseline and final competence barometer results

The baseline scores for all 14 indicators ranged between 2 and 3.7 while in the final assessment they ranged from 3.8 to 4.8. Figure 23 shows that by the end of the workshop the team members felt confident and better equipped in respect of all 14 indicators, despite initially being the most cautious of the four teams.

At the highest end of the scale in the final assessment, Uganda participants felt most equipped to:

• Use root cause analysis to identify and resolve budgetary challenges (4.8) • Analyse the health care delivery chain to identify weak links (4.8)

The indicators for which the biggest changes were reported include (in rank order of change):

3.8 4.2

4.5 4.3

4.2 4.8 4.8

4.7 5

4.2 4.7

4.2 4.3

4.7

2.5 2

3.2 2.5

2.7 2.8

2.5 3.5

3.3 2.8

3 2

3.7 3.5

0 1 2 3 4 5








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• Use root cause analysis to identify and resolve budgetary challenges (2.5 → 4.8) • Develop data systems for effective implementation monitoring (2 → 4.8) • Identify and analyse health budget utilisation inefficiencies in key health care delivery

functions: procurement, supply management, health worker productivity (2 → 4.2) • Analyse the health care delivery chain to identify weak links (2.8 → 4.8)

The indicators for which the smallest changes were reported include (from least to most):

• Identify areas in your health care budget that could provide resource gains (fiscal space) for addressing priority challenges in health care service delivery (3.4 → 4.3)

• Analyse and set priorities for more effective health budget allocation (3.5 → 4.7) • Build processes to ensure productive collaboration between colleagues from health and

finance (3.5 → 4.7) • Identify, communicate with and engage key stakeholders to help implement the

intervention plan (3.2 → 4.5).

Comparison of health and finance representative learning gains The Uganda team comprised five health ministry representatives, three finance ministry representatives and one facilitator.


Figure 22 presents the reported changes in confidence levels among the Uganda health ministry participants. While the final ratings are high overall, the changes are less dramatic than those reported by finance ministry participants and suggest comparatively lower levels of confidence and possibly satisfaction.

Figure 22 Uganda health representatives’ competence assessment, baseline and endline

These ratings show that the confidence levels of these health participants grew most in the following areas:

• Understand how to work effectively as part of a team (3.2 → 4.8) • Use root cause analysis to identify and resolve budgetary challenges (3.2 → 4.6)

3.8 3.6

4.4 4.2

4 4.6 4.6 4.6

4.8 3.8

4.4 3.8

4.6 4.6

2.6 2.8

3.4 3

3.6 3.8

3.2 3.8

3.2 3.2

3.8 2.8

4 3.6

0 1 2 3 4 5








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• Establish delivery targets to help measure progress (3 → 4.2) • Identify risks to implementation and develop effective risk mitigation strategies (2.6 → 3.8)

As is shown in Figure 23, however, very small changes – less than 1 point – were reported for seven indicators (shown here from least to most change):

• Develop a comprehensive strategy for implementing the intervention plan (3.2 → 3.8) • Prioritize focused interventions to create a knock-on effect to achieve larger institutional

improvements (3.6 → 4) • Identify areas in your health care budget that could provide resource gains (fiscal space) for

addressing priority challenges in health care service delivery (4 → 4.6) • Develop a plan of focussed interventions to achieve greater efficiency in resource utilisation

and improve standards of service delivery (3.8 → 4.4) • Build processes to ensure productive collaboration between colleagues from health and

finance (3.8 → 4.6) • Analyse the health care delivery chain to identify weak links (3.8 → 4.6) • Develop data systems for effective implementation monitoring (2.8 → 3.6).

Figure 23 Uganda health representatives’ improvement per indicator

Finance ministry participant results

Figure 24 shows the changes for the Uganda finance ministry participants. The results suggest a dramatic growth in confidence levels between the baseline and final assessments, and are particularly striking in comparison with the changes reported by the health ministry participants. The high number of ‘5’ ratings given by finance participants also suggest a high degree of satisfaction with the workshop and learnings among this group.

1.2 0.8

1 1.2

0.4 0.8

1.4 0.8

1.6 0.4

0.6 1

0.6 1

0 0.5 1 1.5 2 2.5 3 3.5 4








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Figure 24 Uganda finance representatives’ competence assessment, baseline and endline

.

The ratings show that the confidence levels of these participants grew most in the following areas:

• Establish delivery targets to help measure progress (1.3 → 5) • Develop data systems for effective implementation monitoring (2.3 → 5) • Develop a plan of focused interventions to achieve greater efficiency in resource utilisation

and improve standards of service delivery (2.3 → 5) • Analyse the health care delivery chain to identify weak links (2.7 → 5).

Finance representatives reported the smallest shifts in knowledge and confidence for understanding how to work more effectively as a team (4.3 → 5) and building processes to ensure productive collaboration (3.7 → 4.3).

4.3 5 5 5

4 5 5

4.3 5 5 5

4.7 4.3

5

3.3 2.3

3.7 1.3

3 2.7

3.3 3.7

4.3 3.7

2.3 3

3.3 4

0 1 2 3 4 5








40

Figure 25 Uganda finance representatives’ competence assessment, improvement per indicator

How are these results likely to impact on the team?

In discussion with the evaluator, team members identified root cause analysis and communication with stakeholders as two of the most valuable aspects of the workshop. They also found all six focus areas very relevant to their professional development.

For example, one health ministry participant said that the information about using the health budget to drive improvements in the health system could help him improve his regional hospital, especially in relation to fiscal space. Other health ministry participants mentioned the value of organising for implementation, and monitoring progress through routines and dashboards. While these areas were not new to them, the workshop gave them greater appreciation of the approaches and motivated them to drive for results:

This was not new, but I got more encouragement to act and implement programmes for results. The workshop invigorated us.

One finance ministry participant described the value of the sections on making the health system more efficient:

This was very relevant because of the return on public investment. Also, understanding the health system as an input/output production system.

Another saw it this way:

The national stated objective is improved service delivery in health and education. This workshop showed us how to get more mileage through increased efficiencies.

Asked about the value of working as a joint health-finance ministry team, a health ministry participant said that:

Functional literacy on both sides improved in relation to understanding the building blocks of the health system and its challenges, and what the health system aims to achieve with existing resources. There were useful insights about the role of the private sector.

1 2.7

1.3 3.7

1 2.3

1.7 0.6

0.7 1.3

2.7 1.7

1 1

0 0.5 1 1.5 2 2.5 3 3.5 4








41

Participants pointed out that although they already had a working relationship (such as a desk officer for health in the Finance Ministry), the workshop helped them identify common issues that they can solve together:

The common denominator is improved service delivery.

We have consensus around performance-based financing and the input/output relationship.

We need to build a good foundation – this has helped.

The participants identified three steps that are likely to produce big changes in the health system: identifying the root causes of inefficiencies, demonstrating quick wins and stakeholder identification analysis:

The interventions seem small, but we’re confident they will produce changes. E.g. staff absenteeism: one needs effective supervision to improve work productivity.

The demonstration effective of quick wins to win over sceptics and generate systemic momentum.

When asked how their work will be different from before, the participants indicated that the workshop helped them developed a new perspective on their work:

We’ve been challenged to accomplish what we’ve planned. This needs energy and burning the midnight oil. We knew the issues, but glossed over them. The interface with the presenters and the finance people showed that we can sort things out.

I’ll continue with my tasks, but will continue the spirit and direction of what we’ve planned – through the meetings and briefings we have planned.

I will communicate upwards. In a bureaucracy you take orders from above, but I’ve been exposed to how you communicate upwards and how one can leverage the decision-making powers of one’s seniors for a better return.

In order to implement the plan and strategy developed at the workshop, team members said they need the following support:

We have identified risks. Now we need a supportive environment – support from the top technical and political leadership – they are the ones who initiated this. This will help us achieve more than we have planned.

We need facilitation to meet the stakeholders we need to work with. We may also need financial resources to action the plan.

We need visits from the MLIH Program team.

6 Conclusions At the start of the workshop all 29 participants indicated that they felt ‘somewhat equipped’ to carry out the 14 actions listed in the competence assessment for health sector strengthening. Specific areas of concern related to analysing inefficiencies in health budget utilization, using root cause

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analysis, analyzing the health care delivery chain, prioritizing interventions for a knock-on effect, establishing delivery targets, developing data systems and identifying risks to implementation.

By the end of the workshop the group’s overall score was close on ‘very well equipped’ to undertake the 14 actions.

The data show that the highest levels of knowledge and confidence were developed among the health ministry representatives from Cape Verde, The Gambia and Tanzania. The Uganda team showed converse results: here the highest levels of growth occurred among the finance ministry representatives. The Tanzania finance ministry participants scored the lowest ratings for knowledge and confidence improvement.

The data from Day 4 shows that participants, especially the Tanzania finance representatives, found the topic of organising for implementation to be particularly challenging. It was not possible to determine whether this was a function of the presentations or a lack of program implementation experience on the part of participants. Future workshops could consider using the daily feedback to identify the teams or individuals who require additional support.

Overall the results show that going forward, country teams may need support in the following areas:

• Identify health budget utilisation in efficiencies (Uganda) • Develop a comprehensive implementation strategy (Tanzania and Uganda) • Strengthen data systems for implementation monitoring and building a culture of evidence-

based decision-making (Cape Verde, Tanzania, Uganda) • Manage risks to the implementation strategy (Cape Verde, Tanzania and Uganda) • Build a guiding coalition to support the implementation of the plan (The Gambia and

Tanzania) • Prioritize focused interventions to create a knock-on effect to achieve larger institutional

improvements (The Gambia, Tanzania and Uganda) • Achieve targets in procurement, supply management and health worker productivity

(Tanzania and Uganda)

Participants mostly found the workshop content very relevant to their professional development. Some had the opportunity to engage with new ideas and approaches for the first time. Others said that the topics were not new to them, but that the workshop had provided new insights and skills that would enable them to implement their planned strategy more effectively. The workshop also helped motivate participants to pursue results-driven change.

The workshop design succeeded in developing productive inter-ministerial working relationships between health and finance ministry representatives in the country teams. Health representatives gained a better understanding of financial issues, budget reallocation and how to derive value for money in the face of constrained resources. Finance representatives gained insight into the role of public health (particularly primary health care) in national economic development and learnt about the challenges facing their public health systems in terms of procurement, supply management and health worker productivity. Both health and finance representatives found the root cause analysis very valuable as a starting point for strategy development, and were persuaded of the importance of making efficiency gains in order to derive greater benefit from the available financial resource base. A number of finance representatives noted the importance of reallocating resources so as to increase health budgets, but are clearly aware of the pressures this will create in other sectors.

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These findings demonstrate that there is value in combining the health and finance ministry representatives in planning the strategic interventions. They also show, however, that there may be key differences between the health and finance participants, which the content and the workshop design may need to take account of in future.

Leadership from the ministers of health and finance provided the teams with clear lines of accountability and motivated participants to think hard about how they are going to take the next steps to implement their planned strategies. Although some individuals said they were unlikely to be able to make changes in their jobs in the weeks following the workshop, it was clear that they expect their respective ministers to hold them to account for tangible outcomes. It remains to be seen (in the follow-up survey six months hence and in-country interviews in 12 months’ time) whether the teams manage to keep their planned implementation program on track. Risk management proved to be a difficult area for all the teams, as is the process of developing reliable data systems for monitoring targets.

Finally, the limitations of self-assessed competence measures need to be noted. It would be useful to consider an actual skills/competency test pre- and post-workshop to see how this aligns with the self-assessments, and to produce more empirical data in support of knowledge and confidence acquisition for health systems strengthening.

o o o 0 o o o

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Annexure 1

Health Sector Strengthening Planning and Strategy Development Workshop

Irene Country Lodge, Pretoria, South Africa January 25-30, 2015

“Rules of Engagement” • All participants must attend all sessions and fully participate in all team work. • All sessions will begin punctually. • Cell phones, other mobiles devices and laptops must be kept turned-off during all sessions to

avoid distraction and disruption.

Sunday, January 25

All day Teams arrive

4:00pm Welcome and Discussion of Workshop Objectives and Expected Outcomes

(St. Andrews Room) Michael Sinclair

4:30 – 6:00pm Teams Present: Who, How, Why: Team Vision, Organization and Procedures? Michael Sinclair

6:00 – 8:00pm Working Dinner

Teams Present: High Level Analysis of Plans and Targets

Saad Rizvi

Monday, January 26

7:30 – 9:30am Working Breakfast: Presentation and Discussion

(St. Andrews Room) Health Delivery Gains from Effectiveness and Efficiency

Rifat Atun

9:30 – 10:30am Root Cause Analysis and Priority Setting: Getting to the Heart of the Problem

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Rifat Atun, Saad Rizvi

10:30 – 10:50am Refreshment Break

10:50 – 12:00pm Budget Effectiveness: Finding the Fiscal Space


12:00 – 2:30pm Working Lunch:

Teams Work on Health Budget Effectiveness Analysis (Finding Fiscal Space)

2:30 – 3:30pm Budget Efficiency: Identifying Weak Links in Service Delivery Chain


3:30 – 5:30pm Teams Work on:

(a) Identifying Apparent Inefficiency in Key Service Delivery Functions; (b) Re-examine Budget Effectiveness Analysis and Potential Resource

Gains; (c) Prioritizing Potential Efficiency/Service Delivery Benefits;

(d) Root Cause Analysis

5:30 – 6.30pm Teams Report Back: Review of Proposed Efficiency Gains

(Gazebo)

6:30 – 8:30pm Dinner conversation:

(Gazebo) Getting to 300 Feet: Lessons from the Malaysian Experience”

Idris Jala

Tuesday, January 27


(St. Andrews Room) Shaping Interventions: Think Big, Do Something

Richard Page Jones, Len le Roux, Michael Sinclair

9:30 – 10:30am Shaping Interventions: Thinking About Practical Solutions

Richard Page Jones, Rifat Atun

10:30 – 1:00pm Teams Work on Outlining Intervention Strategy: Discussion and Review

1:00 – 2:00pm Lunch

2:00 – 3:00pm Data Systems: Why and How Saad Rizvi 3:00 – 3:20pm Refreshment Break 3:20 – 5:30pm Target Setting: Best Practices and Team Exercise Rifat Atun, Saad Rizvi

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5:30 – 8:00pm Working Dinner:

(Gazebo) Why Teams Matter and Team Building Exercise Michael Sinclair, Len le Roux

Wednesday, January 28


(Gazebo) The Science of Delivery: An Introduction

Richard Page Jones

9:00 – 11:00am Organizing for Implementation: Lessons from Malaysia

Chris Tan and Fabian Bigar

11:00 – 11.20am Refreshment Break

11:20 – 1:00pm Organizing for Implementation: Developing the Foundations for Delivery

Richard Page Jones, Saad Rizvi

1:00 – 2:00pm Lunch

2:00 – 3:30pm Planning for Implementation: Tools for Planning Delivery

Richard Page Jones

3:30 – 6:00pm Teams Work on Organization and Planning

6:00 – 8:00pm Working Dinner (barbecue): (Gazebo) Lesson on Approaches to Implementation from Ghana, Namibia and

Malaysia Len le Roux, Frank Nyonator, Chris Tan

Thursday, January 29

7:30 – 9:00am Working Breakfast:

(St Andrews Room) Mobilizing and Communicating for Implementation

Saad Rizvi, Richard Page Jones

9:00 – 11:00am Teams Map Strategy for Mobilizing and Communicating (Report Back and Review)

11:00 – 11:20am Refreshment Break

11:20 – 1:00pm Driving Delivery: Monitoring, Routines and Dashboards

Saad Rizvi, Fabian Bigar

1:00 – 2:00pm Lunch

2:00 – 4:00pm Teams Develop Routines and Progress Trackers (Report Back and Review)

4:00 – 4:45pm Finalizing Plans and Implementation Strategy

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Saad Rizvi, Richard Page Jones

4:45 – as needed Teams Work on Refining and Finalizing Plans and Implementation Strategy

6:00pm Working Dinner: Team Work Continues Friday, January 30

7:30 – 11:00am Working Breakfast: (St. Andrews) Presentation and Review of Plans and Implementation Strategy 11:00 – Onwards Lunch and Leisure Opportunity

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MLIH In-Country Follow-up Regional Workshop: Faculty and Expert Biographies

Rifat Atun

Professor of Global Health Systems, Harvard School of Public Health

Dr. Atun is formerly professor of International Health Management at Imperial College and head of their Health Management Group. He is also an honorary professor at the London School of Hygiene and Tropical Medicine. He is the joint lead for the innovation work streams at the National Centre for Infection Prevention and Management (UK). From 2008-12 he was a member of the Executive Management Team of The Global Fund to Fight AIDS, Tuberculosis and Malaria as the Director of Strategy, Performance and Evaluation Cluster. He chairs Eastern Healthcare Partners, a start-up focused on combating non-communicable diseases.

Fabian Bigar

Associate Director, Performance Management and Delivery Unit (PEMANDU), Malaysia Mr. Bigar has been with PEMANDU since January, 2010 and has been with the healthcare team since August 2010. His primary responsibilities include monitoring the progress of the Healthcare Entry Point Projects (EPP) under the Economic Transformation Programme (ETP), facilitation and intervention where necessary and designing and running problem solving labs. Before ETP, his work in PEMANDU covered the Ministerial Key Results Area under the Government Transformation Programme as well as involvement in the Subsidy Rationalisation Lab. Between August and December 2014, Mr. Bigar was in Tanzania as the lead coordinator for the Tanzania BRN Healthcare NKEA lab. Prior to joining PEMANDU, Fabian spent 15 years with the Ministry of Health of Malaysia, since January 1995. While in Health Ministry, Fabian served in various capacities including; health budget management; public policy; international relations; as well as dealing with trade related issues in health. He was part of the WHO Intergovernmental Working Group on Public Health, Innovation and Intellectual Property from 2006 to 2008 and was involved in various trade in health related forums organized by both WHO and WTO. Fabian received his BSc. from Case Western Reserve University, Cleveland, Ohio and his Masters in Public Policy from the National Graduate Institute for Policy Studies, Tokyo.

Idris Jala Minister in the Office of the Prime Minister and Chief Executive Officer of the Performance Management and Delivery Unit (PEMANDU), Malaysia YB Senator Dato’ Sri Idris Jala was appointed Minister in Prime Minister’s Office and CEO of PEMANDU in 2009. In this role, he leads the development of the Government Transformation Programme targeting seven National Key Results Areas; reducing crime, fighting, corruption, improving student outcomes, raising living standards of low-income households, improving rural basic infrastructure, improving urban public transport and lowering cost of living. He has enlisted the participation of both the public and private sectors to help implement reforms set to transform the Malaysian economy and become a high-income country by 2020. Currently, Minister Jala also sits as a Member of the World

49

Economic Forum’s Global Agenda Council on New Growth Models and the World Bank’s panel of Advisory Experts for Competitive Industries practices division. Prior to his appointment with PEMANDU, he was the Managing Director and CEO of Malaysian Airlines from 2005 to 2009, helping to turn the company around to achieving record profits following a period of major financial losses. He previously worked for Royal Dutch Shell in several capacities: Managing director of Shell MDS in Malaysia (2002–05), Vice president for retail marketing for Shell International (2000–02), and Managing director for Shell Sri Lanka (1998–2000). He holds a Bachelor’s degree from Universiti Sains Malaysia and a Masters degree from Warwick University, UK. Len le Roux Senior Director, Synergos Institute, Namibia Mr. le Roux is a Senior Director and Senior Fellow at the Synergos Institute, where he leads the African Public Health Leadership and Systems Innovation Initiative. The Initiative applies a high-performance, business-consulting approach called the Innovation Lab, and seeks to create a replicable model for improving public health leadership and systems performance, beginning in Namibia. Mr. le Roux was previously Director of the Rössing Foundation, a non-governmental organization established in 1978 as part of Rössing Uranium's Corporate Social Investment Programme to empower Namibians to improve their quality of life. He holds a Bachelor's Degree in Social Science and has attended numerous management training workshops. Mr. le Roux is an expert in the area of financial sustainability of grantmaking foundations and has conducted training exercises and consultancies both in Namibia and internationally. He has been instrumental in the formation of a number of Namibian foundations, is a founding member of the Namibian NGO Forum and sits on the Boards of a number of local foundations. He has a personal interest in leadership and transformation.

Frank Nyonator

Project Director, Ghana Evaluate for Health and former Ministerial Advisor, Ministry of Health, Ghana

Dr. Nyonator has served in many capacities in Ghana’s Ministry of Health, including Acting Director General and Director of Policy Planning, Monitoring and Evaluation Division of the Ghana Health Service. Dr. Nyonator was the former Volta Regional Director of Health Administration and was also Health Systems Advisor for the WHO Country Office in Abuja, Nigeria from 2008-2009. He served as a member of the Technical Steering Committee of the Child and Adolescent Health (CAH) Department, WHO Headquarters, Geneva from 2005-2007. He has been serving as a member of the GAVI Alliance Independent Review Committees as health Systems expert since 2006. From 2007-2008, Dr. Nyonator served as the Vice Chair of the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases Joint Coordinating Board. He was the Chairman of the Programs Sub-Committee for the Sixtieth WHO African Regional Meeting held in Malabo, 2010. Dr. Nyonator is a Member of Health Systems Action Network, a member of the Global Health Council, American Public Health Association, Population Association of America, Ghana College of Physicians and Surgeons and Ghana Medical Association. Dr. Nyonator has authored and co-authored a number of publications on health system issues including community-based health planning and services initiative in Ghana, caring for the poor, and migration by graduates of the University of Ghana Medical School. He has a

50

certificate in Financing Health Care in Developing Countries from Boston University, USA, and a certificate in Health Sector Reform for Primary Health Care from the University of Sussex, Brighton, UK, an MPH from Leeds University, UK, and MB ChB degree from the University of Ghana Medical School, Legon. Dr. Nyonator’s research interests and experience are in health systems and health service provision especially using new technologies.

Richard Page Jones

Partner, Delivery Associates, United Kingdom

Mr. Jones brings a wealth of national and international experience and an outstanding track record of delivery at the heart of Government. He has facilitated high profile national and international events involving Ministers and senior stakeholders. Richard was previously a Director in the Prime Minister’s Delivery Unit in the United Kingdom where he was responsible for overseeing the delivery of targets in both Health and Education. He also developed the influential priority review tool – a methodology for action focused reviews of the implementation of key policies across Government and led a number of these reviews of the delivery of Health targets in England.

Saad Rizvi

Partner, Delivery Associates, United Kingdom

Mr. Rizvi advised systems in Asia, Europe, Africa and North America on delivery, reform and systemic innovation. Saad also led Sir Michael Barber’s delivery team in Pakistan for the Pakistan Education Task Force. As Pearson’s executive director of efficacy, he ensured delivery of learning outcomes and performance across all the company’s products, services, investments and acquisitions. Saad is the co-author of ‘Oceans of Innovation’ and ‘An Avalanche is Coming’ and serves as a non-executive director at a number of companies in the technology space.

Michael Sinclair

Director of Global Programs in the Division of Policy Translation and Leadership Development, Harvard School of Public Health; and Executive Director of the Ministerial Leadership in Health Program

Prior to joining the Harvard faculty, Dr. Sinclair was Senior Vice President at the Henry J. Kaiser Family Foundation for more than 20 years. In that position, he was responsible for the Foundation’s extensive programming in South Africa working closely with the post-apartheid government to establish an equitable health system and develop the leadership needed to build a sustainable democracy. Dr. Sinclair also has extensive experience of working at the ministerial level in Africa generally, as well as Latin America and Asia to facilitate sharing of global health reform experience and to increase leadership effectiveness. He is an expert in health systems planning and management contributing to national scale initiatives decentralizing health authority, promoting primary health care and implementing innovative approaches to maternal and child health, and HIV prevention, and has worked with many international and bi-lateral agencies including the World Bank, the African Development Bank and key U.N. agencies, as well as multi-national corporations, private foundations and

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other non-government organizations. Dr. Sinclair was educated in South Africa and the United Kingdom and holds a PhD in Political Science from the University of Leicester (UK).

Chris Tan

Director, Performance Management and Delivery Unit (PEMANDU), Malaysia

*In association with the Children’s Investment Fund Foundation (UK), the Bill & Melinda Gates Foundation, Bloomberg Philanthropies, The Norwegian Agency for Development Cooperation, the GE Foundation, and the Rockefeller Foundation

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