Application of the EHTP Methodology to plan Primary Health Care Services in Mozambique

Transcription

1 Application of the EHTP Methodology to plan Primary Health Care Services in Mozambique Enrico Nunziata iii,, Peter Heimann ii,iii and Humberto Cossa iv i Consultant WHO and MoH Mozambique, ii WHO- OSD Department and ii Medical Research Council of South Africa, iv Director, Directorate of Planning and Cooperation, MoH Mozambique I. INTRODUCTION/PROLOGUE Services Delivery Planning whether promotive, preventive or curative is a fundamental Healthcare System (HS) activity to better allocated limited resources. Planning exercise is even more important when activities are spread over several concurrent vertical projects that may sub-utilize available resources. In general, Healthcare Technology (HT) planning exercise is done adjusting previously developed Standards Lists. These techniques, besides causing ill adaptation of experiences matured in another environment, may create inappropriate builds-up and biases with the consequence of under or over resources utilization. The World Health Organization (WHO) jointly with the Medical Research Centre (MRC) of South Africa developed a methodology and a Tool for HT planning based on Intervention Oriented Resources Planning Approach. The methodology and the tool are called EHTP (Essential Healthcare Technology Planning) [1]. The Ministry of Health of Mozambique decided to test this methodology at PHC to evaluate its effectiveness and its possible impact in improving the present planning methodology. The exercise was carried out in a Health Centre (HC) close to the capital city of Maputo since, from the one side, it offered easy access and, from the other side, it provided a good representation of a typical PHC facility around the country The results received the appreciation from both the planner at central level and those at more operative level: Directorate of Health of Maputo City, Director of General Hospital José Macamo and Managers of the Bagamoio Health Center. II. OBJECTIVE The objective of the test was the application of the EHTP methodology and package to plan and project the resource need during the activities of the newly introduced and created Voluntary Counselling and Testing (VCT) Cabinets at Primary Health Care Level in Mozambique. III. METHODOLOGY The process used was the typical recommended by the EHTP Implementation Guidelines written by WHO [2], i.e.: Design i the CPG of the interventions along with the procedures utilized and the resources used from the people working in the field; Validate the CPG with the Program Responsible at National Level; Create a Target Disease Profile (Patient Load) and Ideal Situation; Obtain the Disease Profile (Actual Patient Load) from real data (Available Information System); Simulate the Ideal situation and the Observed one comparing and contrasting the results. An interview session with the counsellor responsible for one VCT Cabinet recently built in an Urban Health Centre in the Maputo City periphery was carried out, the information from the interview were translated into the EHTP package format producing the CPG, (Figure 7 shows the first visit/interventions carried out at VCT in Mozambique). For each Procedure the techniques and the technology, identified during the interview, were introduced in the database. Once everything was set, the information was printed out and then an interview with the National coordinator allowed to check and validate the collected data. Both the counsellor and the National coordinator said that the patient load (Disease Profile in EHTP nomenclature) target for the VCT Cabinet was initially identified at 250 individual/month (see Figure 1). Once this task was completed, an interview with the responsible of the PSI Foundation (a NGO that helped in setting up the first VCT Cabinet in Mozambique) helped in collecting actual data on cost and on Patient workload based on the expenses they incurred and their Information System. In Figure 2 the actual data are plotted showing the patient load for the first VCT (1 de Maio) established in Mozambique in There are no data for the first two months since the VCT started to operate in March Once all these data were collected, a series of Simulation were run. The first simulation run (Simulation No. 1) that was performed was on the i The authors prepared within the project implementation a set of form for data collection.

2 First Visit CPG with the target and the actual patient load with all the resources at 100% efficiency (Figure 3). Then to see what the Simulation Tool could provide for decision makers, a second simulation (Simulation no. 2) was run for the same patient load but considering a reduced efficiency for the personnel, from 100% to 75% (Figure 4). A third simulation (Simulation No. 3) was run only for the actual patient load (the one in Figure 2) but supposing the Counsellor are available only from 9:00 to 12:00, referred as half time in the document (Figure 5), and not for the all opening period, referred as full time, of the VCT Cabinet (8:00 15:30). Before proceeding to the results/discussion, some methodological considerations and assumptions must be explained. In particular: as a part of an initial CPG that is posted in every VCT Cabinet. The delay represent the worst case scenario, i.e., when a new individual comes in the VCT Cabinet and found the cabinet occupied with a previous person that has just started the process. Strictly speaking the delays should not be part of a CPG but they must be inserted at this stage for the Simulation tool to take them in consideration. HR Efficiency (simulation no. 2 no. 3) An efficiency of 75% means that the HR is available for clinical work only for 75% of his/her time while the other 25% would be either spent in administrative tasks (like filling reports) or other activities that are not clinical related. Therefore, expressing the efficiency in this term allows for real life situation modelling where personnel actually does takes breaks, drink coffee, writes reports and, then, is not available for clinical work. Patient Load (Target and Actual) The Target Patient Load (TPL, Figure 1) is the one projected by the planner when the first VCT Cabinet was installed. The Actual Patient Load (APL, Figure 2) is the one obtained from the Information System after the first year or running the VCT Cabinet. Figure 1: Target Patient Load for the first year of operation for the First Visit for the VCT Cabinet in Mozambique (source MoH Mozambique-GATV Program and PSI Foundation) Other Resources This document mainly focus on the HR needs for the VCT Cabinet but the simulation actually included the all set of technologies needed. The result of the dynamic Essential Technology List simulation is reported in Table 3 along with the cost implication (to be discussed below). Figure 2: Actual Patient Load for the First Visit during the first year of VCT Cabinet Operation in one Health Centre in Mozambique (source PSI Foundation) Figure 3: Result of the first Simulation (see text) as provided by the EHTP Simulation Tool CPG and the time delays (Figure 7) The CPGs in the figures show delay boxes. These delay boxes were introduced based on the result of the interview and the experience developed by the Counsellor in their daily activity. Nevertheless, these delays were already considered during the setting up of the VCT Cabinet and were introduced

3 IV. RESULTS AND DISCUSSSION A summary of the results are reported in Table 1,2 & 3. Figure 4: Result of the Second Simulation (see text) as provided by the EHTP Simulation Tool Figure 5: Result of the first Simulation (see text) as provided by the EHTP Simulation Tool Human Resources Implication The Average patient load is calculated based on the total patient seen in an year and for the targeted area is 250 since it was supposed 250 patient/month while the other one is calculated based on the real data and provide a value of patient/month. The minimum quantity is the number necessary in case the efficiency of the resource (in this case the counsellor) is 100% and the actual need (Effective Quantity) in the situation where the constraints held. As the constraint increase from 100% to 75% and from full time to half time, the effective quantity increase as well from 1.2 to 2.9 for the Actual Patient Load. The results suggested that the VCT Cabinet was actually already understaffed at the starting of the operations, since only one Counsellor was employed and one cabinet built. De facto, the planners, based on the experiences of the first year VCT activities, decided that the new cabinets should be installed with 2 Counsellors from the beginning. Patient Load HR Efficiency (%) HR Availability Average Patient Load Minimum Quantity (@100% eff.) Effective Quantity Target Patient Load 100 full Actual Patient Load 100 full Target Patient Load 75 full Actual Patient Load 75 full Actual Patient Load 75 full Actual Patient Load 75 half Table 1: Summary of the results of the Simulation Patient Load HR Efficiency (%) HR Availability Average Patient Load Minimum Quantity (@100% eff.) Effective Quantity Actual Patient Load 75 full Projected Patient Load 76 full Table 2: Summary of the results of the Simulation - comparison between present status and projected load Nevertheless, looking at the APL of Figure 2, it could be already implied that the APL could go as high as 600 patient/day. Based on this observation, we performed another Simulation (Simulation No. 4) taking a new patient load, Projected Patient Load (PPL) of 600 patients/month. The results of this simulation are reported in Table 2. The results suggest that actually adding a second counsellor is not enough the real need would be 4 counsellors (3.1 calculated by the Simulation) and as a consequence the VCT should be built with 4 cabinets from the starting, at least for the Maputo City District.

4 long period of time. Due to this situation a lot of considerations on the opportunity costs could be done but at the moment are beyond the scope of this brief document; A marginal cost was estimated for taking an extra patient. It has been calculated to be 7.99 usd ( ); Figure 6: Projected Patient Load for the First Visit during the first year of VCT Cabinet Operation in one Health Centre in Mozambique Other Resources and Costs Table 3 reports the results of Simulation No. 3 (302.9 average patient per month based on the APL of Figure 2) for the dynamic list of Essential Technology List and related costs. The only result left that is not showed would be the one referring to the Infrastructure since there are no drugs involved in these interventions. From the analysis of the data in the table a series of considerations could be made: To set the clinic in Mozambique, excluding the cost for the infrastructure, the cost is 2,471 dollars and some cents. There are some other investment cost that were not included in this simulation like a coffee machine and other house ware that are not critical for carrying out the service. The investment was calculated running up the effective quantity of goods need to the nearest higher number, i.e.. if the simulation calculate an effective quantity of 0.6 chairs then the minimum number of chairs to be bought is 1. To run the clinic for a year, for an average patient load of 302 patients/months the cost implication for consumable is 28,764 usd. This calculation was made excluding cleaning material, overheads costs (water, electricity, etc..) and management costs; Therefore the consumable costs are those that have the major impact on the running of the clinic; The financial cost implication of the initial investment is minimum considering the goods have an average life cycle of 12.5 years (as defined in the simulation. Indeed, the usage of the goods is very low leaving them idling for a IV. CONCLUSIONS The test carried out and the results obtained shown the impact that the methodology and the tool could have on the planning and management of Health System. Indeed not only it could have predicted, mathematically, the actual needs in term of number of HR necessary for the VCT based on the initial Target Patient Load and used CPGs, but also it could have indicated to the planners that based on the initial data collection on actual Patient Load, that moving from one to two counsellor was not enough and that actually it would be necessary to employ immediately 4 counsellor and therefore build 4 cabinets. It also demonstrated that a initial calculation of the cost implication based on the actual cost for purchasing the goods in a given country could be estimated and therefore used either for funding seeking and for future planning. Naturally this is one of the first field application of the methodology and more testing exercises are needed to fully proof and demonstrate its validly, repeatability and effectiveness. Moreover, sensitivity analysis would be necessary to validate the test the robustness of the Simulation system. Testing are also necessary in more complex environments where more intervention are done simultaneously (for example in the MCH area of a Health Center or a District hospital) but the present test carried out in such a close environment allowed to prove the initial validity of the methodology comparing the simulated results with the data obtained from the information system expost. V. REFERENCES 1. Essential Healthcare Technology package: Concept and Methodology, P. Heimann, WHO Internal Document, EHTP Implementation Guidelines, P. Heimann and H. Kader, WHO Internal Document, 2002

5 Description Disposable / Reusable Effective Quantity / yr Unit Purchase Price Total Investment Total Medical Device Usage Cost/yr Marginal Cost / patient Alcohol D 8, n/a Cotton Balls D 8, n/a Disinfectant, Hibitane in Alcohol D 8, n/a 1, Gloves, Unsterile D 8, n/a Lancets, Blood D 4, n/a Paper, Body Cleansing D 90, n/a Rapid Tests, HIV, Determine D 6, n/a 11, Rapid Tests, HIV, Uni- Gold D 2, n/a 11, Tags, VCT Tests D 1, n/a Tubes, Capillary D 8, n/a 1, Sub-Total 28, Cabinets, Filing R Chairs R Chairs, Office R Chairs, Waiting R Clocks, Wall R Containers, Cotton R Containers, Glass R Desk R Desk, Front, Reception Area R Pen, Ballpoint R Player, Radio/CD R Player/Recorder, VCR R Refrigerators R Stools, Fixed R Tables, Center R Television Sets, Hospital R Trolley, Tests R Waste Receptacles, Paper R Sub-Total 2, Table 3: Full Technology List for First Visit at VCT Cabinet in Mozambique with costs

6 Figure 7: CPG for First Visit (walk-in) at VCT Cabinet in Mozambique