The challenge

Delivering COVID-19 vaccines has posed unprecedented challenges in terms of delivery volume, reaching new target populations, diversity of delivery strategies, and sometimes complex product profiles—elements which must all be managed rapidly in order to achieve effective coverage.

Countries have had to adapt delivery strategies due to the gaps in vaccine supply and reach different priority target populations. In order to plan and budget for future phases of vaccine delivery for COVID-19 or a potential future pandemic vaccine, an accurate understanding of the costs and operational considerations associated with the vaccination program so far is urgently needed.

The approach

ThinkWell is conducting costing studies of COVID-19 vaccine delivery in Bangladesh, Côte d’Ivoire, DRC, Mozambique, the Philippines, Uganda, and Vietnam to generate economic evidence to the support the sustainable rollout of COVID-19 vaccines and help governments plan for future vaccine delivery.

In each country, bottom-up ingredients-based costing studies are being conducted in collaboration with local research institutions to estimate the cost of delivering COVID-19 vaccines through various delivery strategies, reaching different target populations, and using products with varying cold chain requirements. The studies are also mapping out the service delivery process and funding flows, and capturing the source and use of different types of paid and volunteer health workers mobilized to deliver COVID-19 vaccines. Semi-structured interviews are being conducted with stakeholders to assess the rollout and its challenges.

ThinkWell has developed a general research protocol for the country studies to describe the generalized approach, scope, methods, and expected outputs. While recognizing that the diverse range of vaccine rollout modalities will require tailored research approaches in each of the countries, this general research protocol is aimed at ensuring comparability across countries and facilitating cross-country learnings. Preliminary results were presented at the IHEA 2023 Immunization Economics Pre-Congress in July 2023, and you can see below for more information and findings from each country when available.

Côte d’Ivoire

In Côte d’Ivoire, Genesis Analytics and ThinkWell implemented the costing study, with a team from Université Felix Houphouet Boigny collecting data on the cost of delivering COVID-19 vaccines from March to May 2022. The study found a relatively low financial cost for delivering vaccines in 2022 (US$0.67 per dose delivered) which likely reflected a lack of funding rather than low financial requirements to support vaccination. The higher economic cost (US$3.16 per dose delivered) highlights the important role of both existing paid staff as well as volunteers. Read the full study report here and see the poster presented at the IHEA 2023 Immunization Economics Pre-Congress.

Vietnam

ThinkWell worked with the Hanoi University of Public Health in Vietnam to estimate the cost of delivering COVID-19 vaccines in 2021. The financial cost was found to be low at US$0.59 per dose delivered, though this masked shortages in staffing and other resources that the vaccination program had to work around. Limited investments to expand capacity for the rollout meant that a significant burden was placed on the existing health system resources. Read the full study report here and see the poster presented at the IHEA 2023 Immunization Economics Pre-Congress.

Overview

ThinkWell is launching a new project to generate high-quality economic evidence on the delivery of immunization and other essential health services to zero-dose children and missed communities. This project will bring together global and country level institutions to close these evidence gaps, and strengthen capacity at local research institutes to produce actionable economic evidence to inform policy making and program management.

Background

The global community has set ambitious goals to look beyond national immunization coverage outcomes and prioritize communities that have been left behind from the advances made over the last decades. Reaching so-called zero-dose children, those that have missed out on all routine vaccines¹, is a central pillar of both WHO’s Immunization Agenda 2030 and Gavi’s 5.0 strategy, however, economic evidence to support decisionmakers in this is lacking.

Estimating the costs and benefits of reaching zero-dose children will require a new way of thinking, including novel research design, methods, and metrics. Economic evidence for immunization programs is usually focused on estimating the average costs and benefits of reaching a broad population group, but reaching zero-dose children likely comes with increasing marginal costs.

Implementation

ThinkWell will work with research institutions in three countries to generate critical economic evidence on reaching zero-dose children. In each of the countries, these local research institutes will facilitate the development of the scope of the study and work with the ministry of health to frame the research question. The researchers will lead the study design, implementation, and analysis, with coaching and mentoring support from ThinkWell, from global level methodological experts, and from each other.

¹As measured by the proxy indicator: number of children that lack the first dose of diphtheria-tetanus-pertussis containing vaccine (DTP1)

Summary

Under the USAID-funded Efficiencies for Clinical HIV Outcomes (ECHO) project and as a sub-partner to Abt Associates, ThinkWell provides the Mozambican government with data, measured findings, and recommendations to make service delivery decisions that help achieve HIV epidemic control. Specifically, we analyze data at the provincial, district, and facility levels to conduct rapid cycle evaluations to support HIV service delivery decisions. In addition, we solve persistent health system bottlenecks and study potential best practices for scale-up. Finally, we ensure that Mozambique uses the latest evidence for rapid scale-up of effective HIV interventions.

Breaking New Ground

ThinkWell supports ECHO to identify and prototype approaches to assist the Mozambican government to institutionalize efficient practices for reaching and maintaining high quality standards for HIV service delivery.

Challenges

Due to reduced funding for HIV epidemic control efforts, there’s a need to identify more efficient solutions to health system challenges at the health facility, district, provincial, and central levels. Mozambique also needs feasible approaches to strengthen the government and local counterparts’ capacity. Finally, there’s a need to institutionalize best practices that will sustain progress towards the UNAIDS 95-95-95 targets.

Approach

ThinkWell’s approach to data for decision making is guided by evidence and based on the use of local data and global best practices. Using a rapid, transparent, cyclical, and collaborative approach to monitoring, evaluation, and learning (MEL), ThinkWell aims to shorten the learning loop and accelerate progress towards achieving ECHO’s goals. ThinkWell is also designing new solutions to program implementation gaps.

Results

To date, ThinkWell has developed tools to conduct a cycle of rapid evaluation. We’ve also created criteria to deploy rapid response units. Finally, we’ve identified innovative approaches to classify health facilities, monitor their evolution, and compare their performance to prioritize and target interventions more efficiently.

Summary

Under USAID’s Health Policy Plus (HP+) program, we provided support to the Mozambique’s Ministry of Health (MISAU) to develop an investment case for the Global Financing Facility (GFF) to improve reproductive, maternal, neonatal, child, and adolescent health (RMNCAH). We currently provide technical assistance to operationalize the investment case at the provincial level while strengthening policy and coordination among partners at the central level.

Through embedded technical assistance, we support MISAU to strengthen public financial management functions across the ministry and improve monitoring and evaluation planning processes. We conduct capacity building activities at the central and provincial levels and develop tools to improve the efficiency of public financial management activities. Finally, we support MISAU to consolidate the planning and budget functions in e-SISTAFE via a planning and budgeting module, in collaboration with the Ministry of Finance. This module implements the planning and budgeting system to increase effectiveness in governance and achieve a more responsive, participatory, transparent, and accountable financing system for the health sector.

Breaking New Ground

Co-ordination among health partners and within MISAU departments is crucial for the investment case’s successful implementation. ThinkWell leads informative sessions to health partners on the investment case to foster transparency of information among stakeholders. Additionally, ThinkWell revitalized technical working groups on maternal and child health and ensure continuous technical support on the investment case’s implementation.

Challenges

In Mozambique, weaknesses in resource flow and management often limit the amount of funds that reach the point of service. This impacts improvements in health outcomes. Strong public financial management capacity is more important than ever. With decentralization underway, provinces and districts will have greater autonomy, which must be accompanied by more accountability. As one of the largest sectors, the health sector must be able to manage public finances, efficiently use systems—such as the planning and budgeting system—and implement other reforms undertaken by the Ministry of Finance. When donors have confidence in public financial management systems, they are more open to direct on-budget funding—which can be executed by the state—to further enhance the health system.

Approach

Our goal is to increase health governance effectiveness to achieve a more responsive, participatory, transparent, and accountable health system. ThinkWell’s approach strengthens public financial management, monitoring and evaluation, and planning and budgeting through embedded technical assistance in MISAU. We also create tools and procedures, with a capacity transfer plan that is mindful of the specific limitations of the MoH’s structure. Additionally, ThinkWell strategically supports MISAU to ensure its technical ownership on the investment case’s implementation.

Results

Through HP+, ThinkWell improved adherence to finance procedures manual requirements both at the central and provincial levels where HP+ continued its efforts to decentralize public financial management procedures. ThinkWell assembled national guidelines on public financial management and rolled out a training package on public financial management nation-wide. To strengthen the government’s public financial management capacity, we conducted an evaluation of public financial management training from 2014 to 2018. We summarized the evaluation’s findings in a document that offers a series of evidence-based recommendations to make future public financial management trainings to MISAU’s staff more effective. This document can be found here.

In the public financial management domain, we developed a dashboard to allow MISAU to analyze financial data around health delivery and resources to support decision-making processes. We also created user manuals to ensure proper documentation is available for the dashboard’s future use. We assessed the health sector audits from 2013 to 2017. Financial audits are an important tool to enforce compliance and accountability as well as to identify gaps in people’s understanding and practices. This audit assessment provided an overview of MISAU’s audit findings as well as recommendations for corrective actions. The document can be found here.

Summary

With support from the Bill & Melinda Gates Foundation, ThinkWell implements the Covid-19 Essential Health Services & Response Coordination project in Mozambique. We provide technical assistance to the Ministry of Health’s (MoH) Directorate for Planning and Coordination (DPC) to strengthen the MoH’s management of its Covid-19 response and the continuity of essential services during the pandemic. The DPC’s role is central to coordinating all health sector actors (public, private, donors, and implementing partners) to implement the National Strategic Health Plan (PESS) and the investment case of the Global Financing Facility (GFF). During this 12-month grant (October 2020-October 2021), ThinkWell will strengthen key functions of DPC in four areas:

1. Sector leadership, including the alignment of donors’ health sector and production of sector strategies, plans, and monitoring documents
2. Active data analysis to orient and facilitate the MoH’s use of data for planning and decision-making
3. Streamlined management of Covid-19, including financial management
4. Efficient management of essential service provision

Challenges

Mozambique has a high burden of disease, including an estimated 9 million cases of malaria, 2.2 million people living with HIV, and a TB incidence rate of 73/100,000. Given that, there is risk that, if not carefully monitored and managed, the strategy to contain and manage coronavirus may have the unintended consequence of increasing mortality from other causes. Prior to the pandemic, economic volatility, typhoons, and social unrest had already burdened the health sector. Donor coordination and pooled funding mechanisms has declined, even though international assistance contributes 50% of the country’s health financing. Stagnant public sector salaries limited the MoH’s ability to recruit and retain staff. Health sector actors are coalescing around the pandemic and the GFF investment case. This presents an opportunity to reinvigorate coordination, planning, delivery, and monitoring of essential health services.

Approach

The project’s approach to technical assistance is a progressive, multi-stage process to support the MoH towards transformational change. ThinkWell is moving away from embedding project staff in the MoH, since embedded staff often get pulled into completing daily tasks. Instead, we seek to transfer capacity to the MoH for their staff to lead and perform effectively.

Breaking New Ground

This grant is one of three country pilots for investment case implementation support that are part of a new partnership model for the Global Financing Facility and the Bill & Melinda Gates Foundation. One conclusion from the GFF strategy refresh was that countries need strong national leadership, including planning units, to lead multi-stakeholder engagement and implementation of the investment case. The strategy is to identify technical assistance gaps and build long-term institutional capacity. Mozambique and the other pilot countries will generate lessons for the other 36 GFF countries.

Results

The expected results include:

• DPC will more actively lead coordination of health sector donors and adoption of a collective results framework (Quadro Unico)
• DPC will lead the development and refinement of tools and platforms for planning and monitoring of the implementation of the National Strategic Health Plan (PESS) and the Global Financing Facility investment case
• DPC will increase the MoH directorates’ ability for medical services, public health programs, and provinces to use data for monitoring and planning, and ultimately to improve access to quality services

Summary

With funding from the U.S. Department of Health & Human Services (HRSA) and as a sub-partner to International Training and Education Center for Health (I-TECH) at the University of Washington, ThinkWell supports the project “A Comprehensive Approach to Improve Performance of Human Resources for Health in Mozambique.” The project aims to improve the performance and productivity of health facility professionals. Leveraging ThinkWell’s human resources for health (HRH) and health systems expertise, we support the Ministry of Health (MoH) to improve health workers’ performance by (i) testing new approaches and models for health worker allocation, (ii) contributing to the design of a strategy to improve performance, motivation, and management through a performance based financing mechanism appropriate to the national context and MoH objectives, and (iii) through a comprehensive site management approach, strengthen primary health care facility management to more efficiently and effectively meet changing service demands.

Breaking New Ground

In a three-pronged approach, the project:

1. Developed and assisted the MoH to integrate a tool that calculates health facility HRH needs, based on service provision history and current staffing levels, into the annual district planning process
2. Advocated for and supports the MoH to develop a strategy to improve performance through a MoH-led national performance-based financing mechanism
3. Assists the MoH to develop a management and administrative procedures manual, develop staffing structure for high-volume primary care facilities in order to maximize efficiency, and enable them to more effectively meet changing demands

Challenges

In Mozambique, severe resource constraints in the health sector are exacerbated by misallocation of resources, poor management, and poor health worker motivation. Health worker production and allocation in Mozambique has historically been guided by health worker to population ratios at national, provincial, and district-levels and by standard health-team structures. Since similar sized populations may have different healthcare demands and health facilities may attend vastly different numbers of patients, this has led to staff allocations that don’t correspond to needs.

In addition, a combination of insufficient resources, remuneration, management structures that do not reward performance, highly centralized decision making, and poor HR management have resulted in highly demotivated and disempowered frontline health providers.

Finally, the health care demands placed on primary care facilities have dramatically increased and changed over the last 30 years due to the HIV pandemic and an ongoing decentralization process. Yet management structures, systems, and procedures have not kept pace. This has resulted in inefficiencies, poor quality of care, and long waiting times.

Approach

ThinkWell developed a human resource allocation tool that allows planners at all levels to manage the allocation of key health professionals at primary care facilities based on historical service provision and current staffing data. To ensure institutionalization and empower district-level decisionmakers, the project trained district human resource managers and chief medical officers from all provincial directorates and districts.

With the National Institute of Health, we convened a workshop for implementing partners to discuss and compare their approaches improve primary healthcare facility management. We are currently conducting a deep dive assessment of high-volume primary care facilities that will inform a management and administration procedures manual for primary healthcare facilities.

Results

The National Directorate of Human Resources (DRH) of the Ministry of Health adopted the HRH allocation tool and integrated it into the annual planning process (PESS) at the district-level to allow district health directorates to better recruit, allocate, reallocate, and plan HRH priorities. The MoH requested ThinkWell to provide technical support for the tool’s implementation. District-level staff who normally only input data for national health and human resource information systems now use data from these systems to make staff allocation decisions.

Summary

Under the initiative of the Wellcome Trust and Alliance for Health Policy and System Research (AHPSR), ThinkWell conducted a case study as part of a nine-country research initiative. The case study aimed to identify key competencies and strategies that can strengthen institutional capacity for demand generation and use of health system research to inform health policy. We designedthe case study’s conceptual framework to capture the development of capacities for health policy and health system research as well as the improved capacities’ expected outcomes.

Breaking New Ground

The case study captured reflections from a wide range of participants in three categories: Ministry of Health (MoH) staff, donors, and academy and research representatives. We obtained a clear picture of the patterns of progress, challenges, constraints, and failures of the health system and captured the dynamics of their interactions. Finally, our case study shed a light on the existing power dynamics among crucial health system actors.

Challenges

Mozambique’s public health administration faces a combination of features common to other low-income countries: a set of “young” institutions, a predominantly rural population scattered over an extended territory, and a weak economy. Mozambique’s unique sociopolitical and economic context includes its post-conflict setting, its centralized administration, and its external aid-dependent health sector. In addition, Mozambique faces a scarcity of qualified professionals in various social sectors. It also ranks among the lowest countries in the Human Development Index (HDI) and has one of the highest HIV prevalence rates in the world.

Approach

In our research, we used a case-study methodology to allow for a reflection on the study participants’ nuanced perceptions. Through their perceptions, we had the chance to obtain a clear picture of the health system’s progress, challenges, constraints, and failures. We triangulated these perceptions with reporting on health sector developments. Stakeholders’ perceptions also helped to capture the dynamics of their interactions. Finally, the case study shed a light on the existing power dynamics among crucial health system actors. During the research protocol’s preparation, we conducted a literature review of articles on health system strengthening in developing countries as well as articles on health system evidence, health policy, and health system research.

Results

Although the use of evidence in policymaking is standard in national documents, such as strategic plans, senior officers and program heads have often resisted accepting evidence outside of established mechanisms. The shortage of dedicated staff with the capacity to synthetize and interpret evidence for uptake into policy is a major constraint. Scarcity of financial and human resources creates a stronger dependency on development partners. It also creates power imbalances between the Ministry of Health and the donor community. There is a variety of influential actors in the donor community with conflicting agendas. This further hinders the MoH’s capacity to make independent decisions and it contributes to the fragmentation of the time and attention of the MoH decision-makers. Senior staff in the MoH have expressed a hierarchization of evidence, with a preference for results that present solutions versus ones that present problem diagnoses. The National Health Research Agenda’s approval is an important step towards mechanisms and capacities that stimulate needs assessment and evidence uptake into policies.

Summary

In Mozambique, the Vale a Pena project (“it’s worth it” in Portuguese) aims to transform how rural Mozambican girls aged 10-19 perceive and access modern contraception. Vale a Pena’s objective is to create an enabling environment that increases demand for modern contraceptives and results in additional family planning (FP) users in rural areas. The project is divided into a six month inception phase and a 24-month implementation phase. During the inception phase, PSI and N’weti, in partnership with the design firm ThinkPlace, employed a human-centered design-inspired approach to identify project solutions that are rooted in the needs and aspiration of adolescent girls. During the implementation phase, project solutions were piloted, refined, and scaled up. Throughout the inception phase, ThinkWell conducted operational research to inform implementation.

Breaking New Ground

The project used human-centered design (HCD) to achieve a deeper understanding of the barriers and behavior drivers of rural adolescents girls. The project also designed user-centered, catalytic interventions to increase adolescents’ use of family planning. ThinkWell conducted operational research to continually inform the design and the implementation of project solutions.

Challenges

With 67% of the population under the age of 24, Mozambique faces several challenges in increasing demand for youth-friendly FP. Most adolescents and young women in Mozambique are aware of contraceptives. Despite this high level of awareness, myths about the side effects are prevalent. Many girls receive information from their friends or siblings, and even those that visit a health facility may receive misinformation from providers that perpetuates the myths. Especially in rural areas, where marriage and fertility are culturally very important, adolescent girls don’t seek out contraceptives because of the perceived future risk.

Approach

Vale a Pena produced evidence to inform project implementation, scalability, and sustainability. In the inception phase, our operational research employed an emergent design to conceptualize the research sub-questions, as well as in data collection and analysis. This approach allowed for unanticipated information arising within the research process to feed back into the research design.

Results

During the inception period, the following questions were identified to guide operational research:

1. To what extent did the project achieve the desired results for the inception phase?
2. What are the added value and challenges related to the key features of the inception phase?
3. To what extent is the project adaptive during the inception phase?

Results from the first assessment enabled the project team to gain a deeper understanding of rural adolescent’s barriers to FP.