HEALTH MASTER PLAN SRI LANKA HEALTH & SHINING ISLAND IN THE 21 ST CENTURY PROJECT PROFILES. Other Units FEBRUARY 2009 MINISTRY OF HEALTH & NUTRITION
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1 HEALTH MASTER PLAN SRI LANKA HEALTH & SHINING ISLAND IN THE 21 ST CENTURY PROJECT PROFILES Other Units FEBRUARY 2009 MINISTRY OF HEALTH & NUTRITION
2 Reporting Directors DDG/BES Project No Programme or Project Title 98. DDG/BES Medical Equipment Management Improvement DDG/DS 99. DDG/DS e Oral Health Services Management Improvement Project PDHS 100 PDHS Strengthening & Reorganising the Financial System & Capacity of the PDHS Office and Other Current & Future Autonomous Programmes & Institutions Priority (as identified by DDGs)
3 1 HEALTH SERVICES DELIVERY 1.2 PROGRAMME FOR ORGANIZATIONAL DEVELOPMENT Medical Equipment management improvement(as of March 2008) A Focal Point DDG(BES), Provincial Directors of Health Services. B Implementing Agencies DDG(BES), Central BES, PDHS, Provincial BES, Respective Hospitals C Target Areas & Beneficiaries Beneficiaries are all patients and the health care workers of the entire country Project Summary Ministry of Health is committed to ensure the availability of good quality, safe and effective essential drugs to the people. The aim is to make sure efficient supply with continuous availability of life saving, essential drugs vaccines in all health institutions. This project covers supply and distribution of all essential drugs and all other medical supplies except medical equipments to all government and semi government health institutions. Also it is responsible to the supply of narcotic drugs to both public and privet sector. Prime problems at present the Medical Supplies Division is facing are incompatibility of physical drug estimates with the financial allocations. Increased receipt of poor quality drugs, delay of supply as per agreed schedules leading to extra expenditure on local purchases and absence of good guidelines for re-imbursement for quality failed drugs. The "First in First out" principle is hardly practiced due to failure in quick identification of batch numbers and expiry dates on outer packages because of labels containing small illegible letters & figures. As a result ledger entries cannot be made as per batch amounts and no cross sectional age analysis of stocks can be made. Reliable most recent information should be collected regularly on drugs & use of drugs from planers and consumers to improve the rational use of drugs to make the project efficient & effective. Planning for future developments should take into consideration the adequate additional requirements of medical supplies in estimates in advance to avoid delays and problem of exceeding allocations. 1. Justification: Medical equipment management in the country is still performed centrally by the Division of Biomedical Engineering Service, and this division is responsible for all the procurement, maintenance and management activities related to medical equipment, in most of the government hospitals in the country. Provincial councils also procure equipment but their maintenance capabilities are not in par with the required level. 1
4 The total assets maintained by the central BES is estimated to be Rs. 12,000 million. These assets are distributed among several levels of government hospitals scattered all over the country. Due to ever increasing sophistication and the ever-increasing quantities of equipment, this central equipment management system has become no more effective and sustainable. Therefore in order to increase the efficiency and cost-effectiveness, decentralised units need to be established at provincial level and at teaching hospital level. It is also required to strengthen the central BES as medical equipment technology is stedily growing in sophistication at a rapid pace. At present one technician is responsible for 750 hospital beds, and there is no mechanism/budget to upgrade their knowledge and skills resulting most of them are not in par with the current technological advancements. It is also observed that more emphasis is given to procure sophisticated capital equipment and establishing new units, neglecting the maintenance of commonly used equipment. The present maintenance system has further deteriorated due to inadequate maintenance budget, skilled manpower, lack of a maintenance policy and lack of basic facilities required for the successful functioning etc. The available resources are hardly sufficient to implement periodic inspection and preventive maintenance system, though it is essential for safe and reliable operation of medical equipment. It is noteworthy that providing more budget on maintenance can definitely reduce the budget on new procurement and the net result would be a big saving to the health sector. At present, approximately 50% of the medical equipment at government hospitals in the country is not in proper working condition due to lack of maintenance and non-availability of consumables, trained operators etc. Especially at provincial level, there are large number of sub-standard equipment and there is no uniformity in availability of equipment at similar institutions due to non-availability of standard equipment list and generic specifications. Still enough attention is not given for the decommissioning obsolete equipment out of the system. Lack of information required for decision-making and lack of coordination between BES and hospitals has also contributed adversely to this situation. Therefore it is paramount to have a computerised medical equipment information system including equipment inventories, equipment related policies, maintenance records, equipment planning methodologies and cost involved etc. Non-availability of this information has affected to the system by making it difficult to arrive at informed and evidence based decisions on medical equipment management. In addition, there shall be a methodology to monitor and evaluate the performances of equipment, to make decisions more precisely in the future. In order to ensure good management and engineering practices, it is mandatory to train engineers at central BES and provincial BES on healthcare technology management and clinical engineering. There shall be a mechanism and a budget line for continues training of technical personnel, end-users, supporting staff, and decision-makers in both public and private sector. The central BES facility could be utilised to train technical staff from developing countries. There had been some successful programmes conducted by central BES for Biomedical Engineers/Technicians from developing countries in collaboration with Japan International Cooperation Agency (JICA). 2
5 2. Important Assumptions/Risks/Conditions: Risks: Government policies may be changed. Sufficient budget may not be allocated. Sufficient human resources and facilities may not be provided. Equipment policy may be changed time to time. Medical equipment has not been a correct priority as being an important component in functioning of health sector. Difficulty in coordinating with other agencies who are responsible for the project implementation. Delays in implementing related projects. Accepting used/discarded equipment as donations which could not be serviced in Sri Lanka. 3. Project Objective: Objective Indicators Means of Verification To increase efficiency and Equipment up time Equipment maintenance cost-effectiveness of medical Mean time before records equipment in utilisation and equipment failure (MTBF) Surveys management in the public health Response time to Equipment records and sector attend repairs staff records Number of functional Training records maintenance units at Inspection and preventive provincial level maintenance records Number of functional maintenance units at teaching hospital level Number of hospital beds per technician Number of training courses conducted for end-users, technical and other staff Number of hospitals covered by the medical equipment information system Number of IPM programmes conducted 3
6 4. Project Output/Product: Outputs Indicators Means of Verification An efficient and effective medical Availability of efficient Project report equipment maintenance system established in public health sector and effective medical equipment maintenance system An evidence based equipment procurement planning system established A medical equipment management system established A training centre established for continuous training on health care technologies and clinical engineering Public private partnership maximized Availability of evidence based equipment procurement planning system Availability of medical equipment management system Availability of a training centre Number of private organizations working in partnership with the state Project report Project report Project report Reports 5. Related Projects: Project No. Project Title Facility Development According to the Rationalized Health Services Delivery Plan 1.14 Strengthening of Laboratory and Diagnostic Services Technology Assessment Medical Supplies (including drugs) 6. Relevant Agencies to be Coordinated: MoH, Provincial Governments, Central BES, Respective hospitals. 7. Monitoring & Evaluation: 1. Who? Central MoH, Central BES, Respective hospitals, Provincial Health authorities, Provincial BES. 2. When? Annual report, Annual survey, Periodic survey, Ad-hoc survey 3. What actions to be taken based on results of monitoring & evaluation? Revision of procedures, Identification of performance gap and find solutions in order to fill the gap. 4
7 8. Activities: Activities Expected Results Process Indicators Establish provincial maintenance units Establishment hospital based maintenance units at District Base / District General/Teaching Hospitals Strengthen the capacity at central BES Formulate a equipment purchasing, maintenance and replacement policy Establish a system for an equipment audit Establishment of standard list of equipment for each category of Health Institutions Formulation of generic specification for all equipment and issue guidelines to provincial set up Establishment of evidence based spare parts procurement plan Establish a mechanism for better coordination between hospitals & MSD to assist procurement of reagents, consumables etc. 10 Establishment of a computer based medical equipment information system (data base) at centre/district general/teaching hospitals, including equipment inventory, maintenance information, stores management etc. 11 Organize post graduate opportunities in medical equipment management /clinical engineering for BES engineers and provincial engineers 12 Develop equipment utilization monitoring criteria Provincial maintenance units in place Hospital based maintenance units established Capacity at central BES improved Equipment policy developed Equipment audit system developed Institution specific standard developed Generic specifications identified Spare parts procurement plan developed Coordination between hospitals & MSD to assist procurement of reagents, consumables etc. improved A computer based medical equipment information system developed Post graduate opportunities in medical equipment management /clinical engineering developed Equipment utilization monitoring criteria developed Develop proposals Purchase equipment Train HRs Develop proposals Purchase equipment Train HRs Develop proposals Train HRs Nominate consultative team Develop policy Develop the system Pilot the system Nominate consultative team Develop list Nominate consultative team Develop guidelines Nominate consultative team Develop plan Appoint a working group Design the mechanism Identity the data field Design the system Pilot the system Identity training needs Appoint a working group Develop the criteria 5
8 13 Establish a training programme and centre to provide CE for BES staff, end users, provincial BES staff, private sector personnel and others 14 Establish a mechanism to assist private sector in their capacity building and in maintenance of equipment 15 Develop a system to assist private sector in calibration /testing their equipment Staff trained A mechanism established to assist private sector in their capacity building and in maintenance of equipment A system developed to assist private sector in calibration /testing their equipment Identity training needs Design training programmes Appoint a working group Develop the mechanism Appoint a working group Develop the criteria 6
9 1 HEALTH SERVICES DELIVERY 1.4 DISEASE CONTROL PROGRAMME e Non-Communicable Diseases control: Oral Health services management improvement project(as of March 2008) A Focal Point B Implementing Agencies C Target Areas & Beneficiaries D.D.G./MS D.D.G. (D.S) Respective Regional Dental Surgeons Pre school children and school children Ante natal mothers Hospital Dental Service and population in general. Young adults in high Fluoride area Adults at age of 35 years or more Project Summary: The Oral Health Services Management Improvement Project aims to improve efficiency of the oral health care delivery system through the provision of promotive, preventive, curative and rehabilitative services of high quality, so that the entire population will achieve high level of oral health. The following activities are implemented by Central Ministry of Health and Provincial Ministries of Health with the assistance of local and international agencies:- Oral health promotion of pre natal and post natal mothers, parents of pre-school children targeting the child population Screening of children at 1 ½ years and 3 years to identify those with high risk of dental caries and start early interventions Promotive and Preventive programmes directed towards improvement of Oral Health of the school-going population. Provision of latest developments in Dentistry in the field of Restorative Dentistry to people who cannot afford its high cost in the private sector. Improvement of curative dental services in the country by updating equipment and technologies in hospitals and expanding Dental Specialist Services up to Base Hospitals. Dental Services made accessible to remote areas in the country. Alleviate sufferings of youth affected by dental fluorosis in high fluoride areas. Reduce the disease burden caused by oral cancer. 1. Justification: The demand for health care is high, while budgets are limited. Therefore emerging strategies and programmes of health care provision need to be pro-poor, efficient and equitable. At present oral health care provision should be viewed in such a scenario. The state sector oral health care system has the responsibility in ensuring good oral health care of the population. Promotion of oral health, reducing the disease burden by preventing oral diseases and provision 7
10 of comprehensive oral health care to people is primary goal of oral health care system. However its failure needs sophisticated dental treatment such as composite fillings, root canal treatment, crowns ad bridges and dental implants which could be catastrophically costly. Hence, the attempts should be made to reduce the disease load to a level which can be managed by the treatment programme. Interventions for dental caries and periodontal disease have to start from the formative years of teeth and childhood as early as 1 ½ years. Local literature reveals that maximum movement of early childhood caries to be seen in the first 3 years of age. School children up to the age of 13 years are being taken care of mainly by the School Dental Therapists. There are only a few Adolescent School Dental Clinics in the country manned by Dental Surgeons to care for the Adolescent children. Hence the urgent need is to establish more Adolescent clinics. The National Oral Health Survey 2002/2003 revealed that the DMFT (Decayed, Missing or Filled Teeth) for 12 year olds is 0.9 which we must try to bring down further or least maintain at tat level. The equipment in most Government Dental Clinics is mostly outdated and we cannot expect a satisfactory service unless they are replaced with modern ones gradually. The problem of Fluorosis is affecting a considerable number of young adults in the North-Western, North-Central and Southern Provinces who cannot afford treatment for their ailment. The establishment of Fluoride treatment centres in these areas and separate interventional machinery possibly integrated for other sectoral approaches to a timely need. The working condition of the existing school dental Clinics managed by School Dental Therapists need much improvement 2. Important Assumptions/Risks/Conditions: The government shows total commitment in developing oral health care in an equitable manner. 3. Project Objective: Objective Indicators Means of Verification To reduce the oral diseases burden to a level which would be manageable with service programme Prevalence and severity indices of common oral diseases Surveillance programme and national survey 4. Project Output/Product: Outputs Indicators Means of Verification Children at the age of 1 ½ years, 3 years screened for early childhood caries and necessary interventions done % of registered children screened and treated Community dental services returns 8
11 Children at grade 1,4,7,10 and 12 screened for oral diseases and interventions done Per natal mothers orally healthy and convinced on oral health promotion of their offsprings Morbidity and mortality due to oral cancer reduced Quality, accessibility and affordability of dental treatment improved % of registered children screened and treated % of registered mothers treated % of reduction of pre-cancer and severe forms of oral morbidity Proportion of extraction to restorations in oral health care delivery system dental services returns Community dental services returns Oral cancer surveillance Returns 5. Related Projects: Project No. Project Title Cancer control programme Mother and child care programme School health programme 6. Relevant Agencies to be Coordinated: Ministry of Health, Provincial Ministries of Health, Faculty of Dental Sciences, University of Peradaniya, Ministry of Education 7. Monitoring & Evaluation: 1. Who? DDG (Dental Services), Regional Dental Surgeons 2. When? Regularly in specified intervals. 3. What actions to be taken based on results of monitoring & evaluation? Planning for continuous improvement 9
12 8. Activities: Activities Expected Results Process Indicators 1 Establishment of a community dental service in a phased out manner 2 Provide dental equipment and necessary materials to hospitals, school dental clinics and community dental clinics Oral health services for antenatal mothers, pre school children improved Quality,acessability and affordability of dental treatment improved No of MOH areas with community Dental Surgeons No. Of dental clinic with updated technology 3 Establishment of advance restorative laboratory and the National Institute for Cosmetic Dentistry, Dental Public Health and Oral Epidemiology at Maharagama 4 Improve the referral system in the school and community dental services 5 Establish a dental flurosis intervention campaign 6 Establish a programme for prevention and early detection and treatment of oral cancers 7 Promote private-public partnership for advance dental treatment procedures Advance dental treatment made available and national dental public health programme coordinated Referral system improved Dental flurosis intervention campaign launched Disease burden of oral cancers reduced Improved accessibility for advanced dental treatment to public Training programmes conducted and no. Of advanced treatments given No. of dental clinics in tertiary care hospitals with facilities to receive referrals Develop the proposal Develop material No. Of districts in which the surveillance in operation Endorse relevant policy changes Develop operational mechanisms for private and public partnerships 10
13 4 FINANCING, RESOURCE ALLICATION & UTILIZATION 4.2 PROGRAMME FOR STRENGTHENING OF THE HEALTH FINANCIAL MANAGEMENT SYSTEM Strengthening & reorganising the financial system & capacity of the PDHS office and other current & future autonomous programmes & institutions A Focal Point Provincial Director of Health Services - WP B Implementing Agencies All members in the Provincial Administrative structure C Target Areas & Beneficiaries All administrators and financial managers (Accountants) in the Department of Health in the WP, from the provincial to the institutional level will be targeted Community and the country at large would benefit Project Summary: In the process of strengthening and reorganization of the Financial System and capacity of the PDHS office, not only the Department of Health but all parties involved in the different stages in mobilization of funds from the Chief Secretary, to the lowest level manager who is the implementing agent plays an important role. In mobilizing resources, adherence to a set of guidelines considering the national policy and expectations according to the local needs may help in an equitable distribution of available resources among the identified sectors. Capacity building of all health managers, including financial managers, in the establishment of a comprehensive financial information system, development of an internal auditing procedure and an efficient system of monitoring and outcome evaluation is imperative for effective utilization of resources. 1. Justification: Financial management plays an important part in the development process. It has been observed that, throughout the past no proper guidelines have been laid down for compiling estimates, allocation of resources have taken place with no standard criteria, capital expenditure unlike recurrent expenditure has not achieved the expected targets and poor accountability especially with regards to the effectiveness of programmes. When considering the financial system the whole province has to be taken as one unit starting with the Chief Secretary of the province who plays a major role in financial matters. Resource mobilisation which occurs at this level has to be made by a competent body on identified equitable criteria that would distribute resources equitable to all the sectors in the province. In concurrence to the above, bottom up planning has to be strengthened, with reorganisation of the financial and administrative capabilities and capacities of all the Heads of Institutions from 11
14 the smallest institution such as Central Dispensaries in the curative sector and Medical Officer of health in the public health Sector, including Accountants on planning and management skills. The above reforms would enable each responsible authority to progress systematically in achieving identified objectives both locally and at provincial level. 2. Important Assumptions/Risks/Conditions: A policy decision be made on vesting selected powers on all heads of institutions depending on each ones capacity in relation to financial and administrative authority, identification of benchmarks on equity at the level of the Chief Secretary in relation to resource management. Te potential risks are transfers of trained personnel, political influence on resource mobilisation, mishandling of funds with delegation of powers to the inexperienced and difficulties faced with accountability. 3. Project Objective: Objective Indicators Means of Verification Strengthening and Number of PDHS offices Reports fro m PDHS reorganising the Financial strengthened and re-organized Offices System and Capacity of Number of PDHS offices Periodic Financial the PDHS Offices and other related institutions. releasing financial information in a timely manner Statement 4. Project Output/Product: Outputs Indicators Means of Verification Legislation authorising lower level managers on administrative and financial authority formulated Number of circulars issues and legislation passed Circulars issues and legislation passed A set of well trained managers made available form the smallest institution to the Chief Secretary level especially on financial matters A general and financial information system established Five-year development plans in respect of construction, cadre projections, service delivery projects developed Guidelines for monitoring and evaluation with an internal auditing mechanism developed Number of institutions with trained managers to handle financial mattes Number of institutions linked to the financial information system Number of institutions that have developed five year development plans Availability of guidelines for monitoring and evaluation within the internal auditing mechanism Reports Functional linkage Availability of five year development plans Availability of guidelines 5. Related Projects Project No. Project Title Capacity building programmes Advocacy on the reorganisation of the financial system 12
15 Establishment of the information system Guidelines on financial management Setting out of policies at the provincial level ( Chief Secretary) 6. Relevant Agencies to be Coordinated: National Policy Planning, Finance Commission, Chief Secretary, Provincial Ministry of Health. 7. Monitoring & Evaluation: 1. Who? PDHS, DPDHS 2. When? Monthly, quarterly and annually 3. What actions to be taken based on results of monitoring & evaluation? Revision of training guidelines, legislation and monitoring mechanisms. Feedback reports 8. Activities Activities Expected Results Process Indicators 1 Develop guidelines on mobilisation of resources from both governmental and NGOO 2 Develop of guidelines on financial procedures including Legislation authorising lower level managers on administrative and financial authority formulated 3 Train health managers and accountants on financial matters with planning inputs 4 Develop a general and health financing information system 5 Develop guidelines for monitoring and evaluation with an internal auditing mechanism 6 Establish a mechanism to develop five year development plans in respect of construction, cadre projections, service delivery projects etc Guidelines developed and used Guidelines, legislation and circulars developed and used Financial managers trained General and health financing information system developed Guidelines developed and used Five year development plans in respect of construction, cadre projections, service delivery projects etc developed Identify areas Consultative meetings Guidelines Identify areas Consultative meetings Guidelines Training Needs Assessment Develop Training Programme and Training Identify areas for development System development Pilot testing Identify areas Consultative meetings Guidelines Identify areas for 5 year plans. Develop plans Add to a data base 13
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