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News Table 1: Number of benchmarks per Health System (HS) function (horizontal) for the three levels of implementation (vertical) and total HS functions National District Community Total A. Governance 44 40 36 120 1. Information/Assessment 4 4 3 11 Capacity 2. Policy Formulation and 16 15 11 42 Planning 3. Social Participation and 10 9 10 29 System Responsiveness 4. Accountability 10 9 9 28 5. Regulation 4 3 3 10 B. Financing 13 16 14 43 6. Pooling and Allocation 7 10 7 24 of Financial Resources 7. Joint financing 5 5 6 16 8. Purchasing and Provider 1 1 1 3 Payments C. HR 33 35 33 101 9. Planning 5 6 4 15 10. Policies 5 5 4 14 11. Performance 4 4 5 13 Management 12. Training and education 11 12 12 35 13. In-service training or 6 6 6 18 IMSAM/MNCH* integrated training 14. Pre-service training 2 2 2 6 IMSAM /MNCH integrated D. Supply 18 17 9 44 15. Pharmaceutical Policy, 12 13 5 30 Laws, and Regulations 16. Joint supply 3 3 3 9 management** 17. Selection of 3 1 1 5 Pharmaceuticals E. Service delivery 23 31 29 83 18. Availability and 2 2 3 7 continuity of care 19. Access and coverage of 3 3 4 10 IMSAM services 20. Utilisation 6 6 5 17 21. Organisation: Integrated 3 4 4 11 package 22. Quality assurance 7 13 9 29 23. Community Participation 2 3 4 11 in Service Delivery F. HIS 13 16 7 36 24. IMSAM integrated in HIS 10 13 6 29 25. M&E 3 3 1 7 TOTAL 144 155 128 427 *Maternal, newborn and child health ** RUTF supply falls under this catergory intends to further guide the identification and coverage of gaps in sustained integration of CMAM. Components of framework The framework is composed of three parts: • benchmark matrix to facilitate assessment • a tool (visual) to help summarise main assessment findings • a planning, monitoring and evaluation tool to facilitate yearly and multiyear planning, monitoring and evaluation. The benchmarks matrix suggests for each of the six HS components, a series of conditions, referred to as benchmarks 8 , that should be in place in order to help attain a sustainable level of IMSAM into the health system (see Table 1 for an overview). Programme staff must take these into account when planning, implementing, monitoring, and evaluating IMSAM. The benchmarks matrix has three levels as planning, implementing, monitoring, and evaluating are approached differently at national, sub-national/district or community level. The benchmark matrix can be used vertically by one of the three implementation levels (national, sub-national/ district, and community) or horizontally by HS function, expressed under the six building blocks (governance, financing, human resources, supply, service delivery and health information system). The way the benchmark matrix is used depends on national or local priorities, identified by all relevant stakeholders, especially by government services responsible and/or closely involved in CMAM. This flexible use should support CMAM programme managers in defining IMSAM technical and financial inputs in health sector audits, programmatic and financial reviews and sectoral reforms. For example, if stakeholders agree that the objective is to assess human resources (HR) for IMSAM, because investment in HRs for the health sector is planned, the assessors can single out the benchmarks for the HR component (see Figure 1 for an example). Meanwhile the community component can be looked at, for example, in preparation for community health policy development discussions or just for regular yearly, or multi-year, planning or evaluation purposes. Framework in practice At this stage of development of the approach, the benchmarks are grouped per level and per HS function on excel sheets (as reflected in Figure 1). Each level of planning and implement ation (national, sub-national/district, community) corresponds to one excel sheet. On each sheet, the first column corresponds to a HS function and its sub-division (see Figure 2). The second column gives the benchmarks/conditions list followed by a column on guidance, if any. Different assessors can assess each benchmark/condition separately according to a range of provided possible scenarios (expressed in columns: highly adequate, adequate, present but not adequate, not adequate at all). This allows for objective and quantitative rating compared to the benchmark/ condition for integration. A column for comments is included, so assessors can add qualitative comments in addition to the rating, explaining why/how/when. The next column will capture the data sources, followed by the score from interviewees and their names. The last column will indicate the average score, reflected in the visual tool (see Figure 3). As obvious from this description, the final results depend entirely on the opinion of assessors. It is therefore essential to include all relevant stakeholders. Ideally, these are HS 8 Also called golden standards by the WHO/Health matrix Figure 1: district benchmark assessment work sheet for planning part of Human Resources (HR) HS function Functions Benchmarks Guidance Highly Adequate Present but not Not adequate adequate adequate at all HR 9. Planning 9.1 Health care professionals distribution in urban and rural areas balanced YES, highly adequate 9.2 Human resources data system set up YES, the system exists and is used regularly 9.3 Comprehensive human-resource strategy for MNCHN initiated 9.4 Facilities have adequate numbers of staff and it exists scale up and down of staff according to the season and livelihood zones including a HR planning system At least 90% of staff are in place YES, the strategy exists, it's comprehensive and implemented YES, Staff is in place and scale up & down exists 9.5 Special budget dedicated to HR YES, it exists with adequate resources 9.6 Job classification system created YES, the system exists and is functional Rationale/ Comments: NA or If not adequate, why? Data source Response from interviewees 3 2 1 0 Name 1 Name 2 Name 3 YES, adequate YES, the system exists but is seldom used YES, the strategy exists and implemented but not comprehensive YES, staff are in place but scale up & down are rare YES, it exists but without adequate resources YES, the system exists and is functional but partially YES, partially adequate YES the system exists but it is never used YES, the strategy exists, it's comprehensive but not implemented YES, the position exist but is not filled YES, it exists but not used YES, the system exists but is not functional NO, not adequate NO, no system NO, no HR strategy NO, no adequate staff NO, no special budget NO, no system Average 59
News specialists, CMAM programme managers, M&E specialists, technical and financial partners, etc. Given the importance of including the right people in the assessment, a mapping of actors prior to the assessment is advised (see below). This will limit the risk of biased results. Using results of the assessment, the feasibility of addressing the identified gaps can be analysed using the planning tool. This planning tool can be used to facilitate comparison of the target result, also present in the benchmarks matrix as the benchmark or condition, with the existing situation, or identified gap (See Figure 4 for an example). Weaknesses, barriers to change and opportunities are identified, interventions proposed and budget and timelines defined. Once this analysis is completed, proposed actions, timeline, cost, etc. can be put together in a yearly or multiyear action plan. Progress on implementation of the action plan can then be monitored on a regular basis. Suggested process for use of the framework At this stage of development of the tool, four steps are suggested. They are composed of: Step 1: Pre-assessment As indicated, the framework needs to fit context specific needs. During the pre-assessment step, all country specific details will be agreed. These include: a) identification/ mapping of all relevant stakeholders to be invited to support assessment (government services, donors, CMAM partners, etc.), b) agreement of the scope, time frame, budget and dates of the assessment, c) identification of IMSAM and health systems data sources and documents, listing of identified gaps as well as health system strengthening interventions, etc. Step 2: Assessment using benchmark matrix This step starts with a literature review of all relevant documents. These can be HR policies, M&E tools used, data collected from facilities, facility registers, quality supervision reports, administrative and budget documents, supply registration lists, review of training curricula, client exit interviews reports, etc. The benchmark matrix is then filled out by different stakeholders or assessors. It is important to note that this is a self-assessment (important for stakeholders, especially MoH, ownership) undertaken by a group of experts. It is advised to organise group work in a way that the assessors only assess the benchmarks, or conditions, they are expert on. This also helps keep duration of assessment to a minimum, as different groups can work simultaneously. After the group work, the different results will be brought together and discussed as explained in Step 3. When available information is insufficient, key informant interviews, e.g. health system users, can be organised in order to complete the assessment. In addition, site visits are highly UNICEF/NYHQ2009-0204/Ysenburg, Somalia, 2009 A woman feeds a child a ready-to-use food as part of a UNICEF-supported nutrition programme in Jowhar Camp, Somalia Figure 3: Example of visualisation tool with summary of results: IMSAM Human Resources – District level assessment results Results Rating Level Adequacy achieved IMSAM Human Resources – District A HR- mean* 1.4 46% HR – mean HR planning 1.2 40% 3.0 HR policy 3 100% 2.0 In-services HR planning Performance management 2.3 76% 1.0 Training & education 1.3 43% 0.0 In-services 0.7 23% Training & education Performance management *Average for all HR section results HR policy recommended as they allow direct observation of most of the service delivery components (e.g. facility registers, daily availability of services, stock-out, reports….) and therefore reduce the bias in the scoring. Step 3: Analysis and validation During the consensus building meeting, the average rating for each condition is given, visualised and results are reviewed. The presentations and final assessment report should include rating and summary of comments, as rating alone cannot capture all aspects of the conditions. For example, the condition could be present but supported 100% by NGOs and therefore not sustainable. Steps 1 to 3 are closely linked and implemented during the same exercise, while Step 4 can be organised at a different moment after analysis of assessment results. Step 4: Development of multi-year and yearly action plan Starting from the identified gaps (conditions that are not fulfilled, benchmarks not reached), the stakeholders will analyse which Legend Rating Level Adequacy achieved Highly adequate 2.25 - 3 75 -100% Adequate 1.50 – 2.24 50 – 74% Present, but not adequate 0.75 – 1.49 25 – 49% Not adequate at all 0 – 0.74 0 – 24% gaps they want to address, how these gaps will be addressed and within which time frame using the planning tool (shared earlier in Figure 4). This will be captured in the corresponding action plan. From this exercise, yearly and multi-year action plans can be defined, including a corresponding monitoring and evaluation approach. Stakeholders can decide to repeat all steps or parts on a yearly or multi-year basis as part of monitoring, evaluation and planning of national CMAM programmes. Expected results The process is expected to facilitate national ownership, commitment and sustained adequate investment in the management of acute severe malnutrition and to provide a standardised approach for identification of bottlenecks in scaling up of IMSAM across countries. Even, if the approach is meant to be standardised, countries should adapt the framework to their context. This approach will allow for development of yearly and multi-year costed actions plans Figure 4: Example of Planning tool: HR function at community level Level HS function Target Result (benchmark) Community HR Clear written ToR for CHW Weakness current result Oral ToR Threat/ Barriers to changing result Staff turnover Lack of literate staff Opportunities for change/ enabling factors National guideline exist Objective /expected results 100% of CHWs have signed a JD Proposed intervention to address change - CHW supervisor to write ToR - DMO to standardise ToR according to national guideline Impact on other MNCH programme & HS Performance - Standardisation among CHWs - Integration with iCCM HR performance Feasibility Timeline/ implementation speed Human Resources needed yes Year 1 - 90% CHWs position staffed Cost Budget: xx USD TOR: Terms of reference CHW: Community Health Workers JD: Job description DMO: District Medical Officer iCCM: Intergrated Community Case Management 60
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July 2012 Issue 43 ISSN 1743-5080 (
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The overall aim of the Addis Ababa
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Editorial Éditorial A note on term
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Editorial Éditorial Haile Gebrsela
Page 9 and 10: Editorial Éditorial governance). S
Page 11 and 12: Editorial Éditorial incorporated b
Page 13 and 14: Editorial Éditorial the MoH and in
Page 15 and 16: Editorial Éditorial Filling RUTF j
Page 17 and 18: Field Article percentage points per
Page 19 and 20: Field Article sion for relevant sta
Page 21 and 22: Field Article anisms, especially fo
Page 23 and 24: Field Article Health and nutrition
Page 25 and 26: Field article Table 2: Number of he
Page 27 and 28: Field article MOH, Ghana MUAC measu
Page 29 and 30: Field article Box 1: Outline of the
Page 31 and 32: Field article Nutrition outcomes ar
Page 33 and 34: Field article feeding (IYCF) practi
Page 35 and 36: Field article other cluster activit
Page 37 and 38: Linear programming to design low co
Page 39 and 40: Research reporting rate sometimes r
Page 41 and 42: Field article Through twice yearly
Page 43 and 44: Field article Table 2: Chronology o
Page 45 and 46: Field article The following assessm
Page 47 and 48: Field article Brief history and bac
Page 49 and 50: Field article France and UNICEF sup
Page 51 and 52: Field article Table 3: Facility-bas
Page 53 and 54: Field article Article de terrain Ba
Page 55 and 56: Field article Article de terrain th
Page 57 and 58: Field article Article de terrain Fi
Page 59: News UNICEF/NYHQ2008-1649/Pirozzi,
Page 63 and 64: News Integration of the management
Page 65 and 66: Conference on Government experience
Page 67 and 68: News Update on Minimum Reporting Pa
Page 69 and 70: Field Article Table 1: Nutrition si
Page 71 and 72: Field Article Table 5: Experience f
Page 73 and 74: Field Article six mobile teams were
Page 75 and 76: Field Article different programmes,
Page 77 and 78: Field Article (IYCF) issues, Target
Page 79 and 80: Field Article term sustainability.
Page 81 and 82: Field Article from UNICEF, using th
Page 83 and 84: Field Article spearheaded by UNICEF
Page 85 and 86: Evaluation absence of pre-service t
Page 87 and 88: Field Article (58% of the global to
Page 89 and 90: Table 4: Proportion (%) severely un
Page 91 and 92: Field Article ACF, Yobe State, Nige
Page 93 and 94: Field Article team, comprised of (O
Page 95 and 96: is also to create a more meaningful
Page 97 and 98: Field Article District training in
Page 99 and 100: Professional profile Dr Nadera Haya
Page 101 and 102: People in aid CMAM Conference, Addi
Page 103 and 104: Invite to submit material to Field
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