District health planning

•Planning- Def- ‘Planning is the selecting information and making assumptions regarding the future
to formulate activities necessary to achieve organizational objectives.’

• District health plan -Def- A district health plan set out the goal and strategies that will enable the
health district to best meet the health needs of its population. It is based upon the challenges
identified in an annual report for the previous year, and includes details of the funding allocate to
implement the proposed strategies.

•Health planning is necessary for the economic utilization of material ,manpower and financial
resources.
•The purpose of health planning is to improve the health services.
•The district health plans should contain an analysis of the present situation and the health priorities
that need to be tackled. on the basis of this knowledge the DHMT,local government, community
organization and nongovernment agencies can then allocate the money ,manpower, and facilities
needed to implement the necessary health programmes.

Survey/Assessment-
•Present health situation-

A. The starting point for district planning ,for both annual and medium –term plan ,is a detailed analysis
of the present situation in the district in order to produce the district health profile which helps to
answer the planning question, where are we now?

B. Health indicators are essential for analyzing the present situation in the district, for expressing specific
targets and for assessing whether these targets are being met or not.

C. In addition ,there is a great deal of other information about the district, such as –its
history,geography,socioeconomic condition, and political system, also need to know in order to make a
realistic health plans.

D. The following items of data are the essential requirements for district health planning.-

1. The population, its age and sex structure.

2. Statistics of morbidity and mortality.
3. The epidemiology and geographical distribution of different diseases.

D. Medical care facilities such as- hospital, health centers, and other health agencies,- both public and
private.

E. The technical manpower.

F. Attitudes and beliefs of the population towards disease, its cure and prevention.
G. Assessment of resources- The term resources implies the manpower, money, materials, skills,
knowledge and techniques needed or available for the implementation of the health programmes.

The analysis and interpretation of the above data brings out the health problems, the health
needs and the health demands of the population.

The district health profile lists important indicators under the following categories

1. District population
2. Health status
3. Health resources
4. Health programmes

1. District population-

a. Total estimated
b. Total by age group
c. Total births estimated-
• Crude birth rate
• General fertility rate
• Rate of growth

2. Health status
A. Nutritional status

a. Infants-%with low birth wt

b. b.Childrens-wt for age.

B. Morbidity

a. Selected specific diseases by number of new cases diagnosed.

b. b.Diseases requiring prolonged therapy.
c. Epidemic diseases
d. Rehabilitation

c. MortalitY

• Total deaths.
• Total deaths estimated for district.
• Estimated age-specific death rates.
• Maternal mortality.
• Disease- specific mortality.
3. Health resources
A. Facilities-

• Health stations, posts No needed for district.

• Hospitals-Total no of hospital beds in district, population bed ratio.
• In-service education(training according need)

B. Personnel

• Primary health care

• Workers needed, workers in post, No of TBAS in district, No of TBAS trained, No of doctors
needed , No of doctors in post.
• No of lab and technical personnel needed.

C. Finance-

• Total health system expenditure in district.

• Per capita expenditure.
• Expenditure on primary care.
• Expenditure on hospital care.
• Total budget by government, NGO, INGO.

4. Health programmes

A. Management of pregnancy

• Total no of expected deliveries in district.

• No of pregnant women who received prenatal care.
• No of deliveries attended by trained TBAS or health personnel.
• No of deliveries in health centres or hospital
• Estimated no of couples using birth spacing/family planning services.
• No of Reproductive age couple.

B. Child care

Infants

Immunization

• No of infants born in the year.

• No of receiving DPT vaccine%, polio vaccine, measles vaccine and BCG vaccine.

Nutritional assessment

• No of infants weighed at least once during a year.

 • Breast feeding
• Iron , folic acid
• Vitamin ‘A’
• Growth monitoring

C. Environmental health

• Water supply
• Excreta disposal
• Refuse disposal

D. Clinical care

• Clinic visits
• Sub centre visits
• Health centre visits
• Hospital admissions
• No of deaths in hospital
• No of maternity admission.

PLANNING
Planning always involves a collaborative process when working with the community, key
community or population group representatives, members of the interdisciplinary health team,
and representative of community organizations and agencies all participate in the planning
process. Nurse or other members of the health team may be functioning as consultants to the
community, project managers, or coordinators for a specific community or population based
initiative, or be part of an interdisciplinary service team working with the community or local
health care agency.

Planning has been defined as continuous, systematic, coordinated, planning for the investment
of the resources of a country (men, money and material) in programmes aimed at achieving the
most rapid economic and social development possible.

Health planning is a concept of recent originThe propose of the planning

a. To match the limited resources with many problems.

b. To eliminate wasteful expenditure or duplication of expenditure.
c. To develop the best course of action to accomplish a defined objective.

1. To improve the health services.

• Health planning is the orderly process of defining community health problems, identifying
unmet needs and surveying the resources to meet them establishing priority goals that are
 realistic and feasible and projecting administrative action to accomplish the purpose of the
proposed programme.

Principles areas of planning

• Objectives
• Activities
• resources

Planning decision about activities:

• What problem?
• Which priority?
• Why problem (gap)?
• Who is at risk – catchment area?
• Where they can be reached?
• How much is it to be made?

Planning decisions about activities:

• What first decision concern?
• Which broad heading of services?
• Whom the activities is directed?
• How much?
• How?
• By whom?

Planning decisions about resources:

• Which?
• How ?
• Where?
• When?
• Who?

Planning health activities:

1. Looking at the situation (sources of the information)
2. Recognizing problem.
3. Setting objectives.
4. Reviewing obstacles-people, equipment, information, money, time, geographical features,
climate, technical difficulties, social factors.
5. Scheduling the activities.
Planning processes:
• Analyzed the present situation, including health status, in the district.
• Developed the priorities for the next annual and medium-term plans.
• Decided on which high-risk group should receive priority.
• Made plan to improve access and coverage for the priority health programmes.
• Decided on the objectives and indicators to evaluate progress.

MoH guidelines for district planning:

• Choose a strategy.
• Undertake consultations on the proposed strategy.
• Identify all the necessary activities.
• Establish a timetable.
• Assign responsibility to staff.
• Allocate funds.
• Monitor progress.
• Display and communicate the plan.

Planning cycle
1. Analysis of the health situation.
• Collection, assessment and interpretation of information.
2. Establishment of objectives and goals.
• Cost – benefit analysis and input – output.
3. Assessment of resources.
4. Fixing priorities.
5. Write up of formulated plan.
6. Programming and implementation.
7. Monitoring.
8. Evaluation.

Epidemiology and district health planning

Planning: is an intellectual process which requires manager to think in advance in terms of
forecasting or predicting the course of action that will be taken to achieve the desired results. ‘Plan
is trap to capture the future.’ by allen

• Health planning: is necessary for the economic utilization of material, manpower and financial
resource the purpose of health planning is to improve the health services.

• Plan is a blue print for taking action. It consists of five major elements, objectives, policies,
programmed, schedules and budget.
Planning cycle:
1. Analysis of the health situation:

 The population ,its age and sex structure.

 Statistics of morbidity and mortality.

 The epidemiology and geographical distribution of different diseases.

 Medical case facilities such as hospitals, health centers and other health agencies both public
and private.

• Analysis Cont…

 The technical manpower of various categories.

 Training facilities available.

 Attitudes and beliefs of the population towards disease, its care and prevention.

 The analysis and interpretation of the above data brings out the health problems, the health
needs and health demands of the population.

2. Establishment of objective and goals:

Objectives and goals are needed to guide efforts. Unless objectives are established, there is likely to be
haphazard activity, uneconomical use of funds and poor performance.

-Objectives must be established at all levels down to the smallest organizational unit.

-in setting these objectives, time and resources are important factors. Objectives are not only a guide to
action but also a yard stick measure work after it is done.

3. Assessment of resources:

The term resources implies the manpower,money,materials,skills. Knowledge and technique needed or
available for the implementation of the health programmed. These resources are assessed and a
balance is stuck between what is required and what is available or likely to be available in terms of
recourses.

4. Fixing priorities:

The resources always full short of the total requirement. In fixing priorities, attention in paid to financial
constraints, mortality and morbidity data, diseases which can be prevented at low cost, saving the lives
of younger people in whom there has been considerable social investment and also political and
community interests and pressures.
Once priorities have been established, ALTERNATE PLANS for achieving them are also formulated and
assessed in order to determine whether they are practicable and feasible. Alternate plans with greater
effectiveness are chosen

5. Write up of formulated plan:

 The next major step in the planning processes the preparation of the detailed plan or plans. The
plan must be complete in all respects for the execution of a project.

 For each proposed health programmed, the resources (inputs) required are related to the
results (output) expected. Each stage of the plans is defined and costed and the time needed to
implement is specified.

 The plan must contain working guidance to all those responsible for execution. It must also
contain a built- in system of evaluation.

 It will be left to the central planning authority and the government to consider modifications of
the plan relating to allocation of resources.

6. Programming and implementation.

7. monitoring.

8. evaluation.

Implementation of health plan of action

Introduction

Without implementation, plans remain theoretical.

Participation of the community plays a vital role in the implementation of certain health programme.

After planning for the health programme, it should be implemented at different levels of health
problem.

There will be a development of the strategies of implementation, which make the implementation
programe appropriate, effective and successful.

The strategies are following:

1. Building commitment

2. Training of manpower

3. Mobilization and utilizing resources

4. Organization of community
5. Monitoring the programme

6. Supervising the health workers

7. Keeping records and reports

1.Building commitment

Commitment is the feeling of need and responsibility and willingness to co-operate

Community people along with the health workers should be ready mentally, physically and
socially to implement the programme successfully and to reach the target or goal.

Different methods can be supplied for this, such as health education, seminar for exchanging
information, ideas and experiences

2. Training of manpower

Many well- considered plans have fallen down due to the lack of trained manpower.

If the manpower is trained according to the programme to be implemented, they can contribute
more for such programmes.

Training is given in two different ways such as basic and refresher training.

Training helps to develop appropriate attitudes so that they can carry their job responsibility
successfully.

3. Mobilizing and utilizing of resources

Man, money, materials are considered as the resources for health progrmmes.

The locally available resources should be properly mobilized and utilized to reduce the cost and
for better achivement.

Sort out all the activities and tasks and determine the implications for staffing, facilities,
supplies, transport and budgets

Consider also implications for community participation, intersectoral coordination and

collaboration of all other health care providers

Estimate the time required for all the activities and then fixes starting and completion dates.

These should be realistic and, if possible, contained in the annual plan.

Funds are always limited, so the district management health team needs to estimate costs very
carefully. Recurrent and capitol costs are usually estimated separately.

4. Organization of the community

Community mobilization and participation of local voluntary association through a co-
ordination is very important for the development community.

As part of the management function the health worker:

 Reviews the plan’s objectives.

 Reviews activities for each objective and target.
 Checks the timetable
 Verifies assignment of responsibilities to staff according to the activity schedules and job
descriptions.
 Discuss the implementation with representatives of the community health service staff and
workers in other sector, where appropriate. The community decides how it can participate.

To coordinate the work of the health team the health worker in-charge must

 Coordinate the functions of the members of the health team

 Coordinate the activities
 Communicate the decisions

Coordinating the functions of the health team

Coordination is easier if there is a clear organizational chart, describing the relationships of the
members of the service to one another.

Organizational structure determines how communication takes place between the different
levels of a system for the purpose of coordinating a programme and the activities of a health
team

Coordinating the activities

Work plan must state the time for beginning and completing each activity and who is
responsible for seeing that it is completed on time

Work plans and activity schedule may need frequent revision and adjustment.

To make work plan, the programme must be reviewed as follows:

What should be done? Programme content: antenatal programme

How it should be done? Procedures: technical, administrative,

managerial
Why should do it? People responsible for the different task
When it should be done? Time targets to be followed
How much it costs? budgets
 Communicate the decisions

Well planned activities are communicated to all health team members.

An organizational chart may be placed on the wall of the health centre and discossed with the
members. Each health worker should have an individual job description in writing.

The activities schedule should be reviewed and discussed with the health team and with
community to determine whether the time targets are feasible and realistic.

3. Monitoring the programme

Monitoring is the process of collecting and analyzing the information about the programme
implementation.

It is regular checking at frequent interval to see whether the programmes, activities are carried
out in accordance with planning or not

Monitoring and control are concerned with:

 Work progress
 Staff performance
 Service achievement

6. Supervising health workers:

Supervision of health workers make to learn better skills and perform their responsibilities well,
and develop greater capabilities and confidence in performing their duties

Supervision helps to know staff performance, staff motivation, staff competence and resources
need for logistic or financial support.

The frequency of supervisory visits will depend on the local situation, the state and stage of the
programme,and the availability of transport and personnel.

7.Recording and Reporting:

Recording is the system of documentation of the information regarding programme activities

including progress and problems.

The information of work activities, any changes in activities and programme should be properly
recorded.

Reports are written information communicated to the higher level of office about programme
activities, progress of activities, problems and suggestion for improvement
 Recording and reporting help in evaluation of the programme whether it is going in progressive
way or not, and any changes has to be taken for betterment of the programme ,and good
decision making in improvement of the programme.

Conclusion
 While conducting the programme according to the plan of action, the people should be
given responsibilities and should be involved in such activities.
 Without active participation of the community people the health programme cannot be
successful.
 Health worker have to be clearly explained about their present health situation and
their actual health needs such that they themselves are aware of their needs

Evaluation
 A process that attempts to determine systematically and objectively the relevance, effectiveness
and impact of activities related to objectives.

 Evaluation is often carried out separately for inputs, processes outcomes and impacts.

 Evaluation is to judge the value of the results /effectiveness achieved by the health teems
according to the stated objective of a pregame, its adequacy. its efficiency and its acceptance by
all involved.

 It is mostly concerned with final outcome and with factors associated with it.

Evaluation

• Good planning will have a built in evaluation to measure the performance and effectiveness for
feedback to correct deficiencies or fill up gaps discovered during implementation.

• Evaluation measures the degree to which objectives and targets are fulfilled and the quality of
the results obtained.
• It measures the productivity of the available resources in achieving clearly defined objectives,
measure cost effectiveness and possible reallocation of priorities and resources on the basis of
changing health needs.
• District health management team should be able to evaluate its progress in implementing health
program activities but it is much more difficult problem to assess change in health status. DHMT
uses epidemiological health information and its own knowledge &experience to make judgment
and draw conclusion.
• When a serious of activities has to be performed over the 12 months a useful technique for
monitoring progress is to use a cumulative graph. Total activity to be performed in 1 year is
divided by 12 to give target for 1 month.
 Evaluation is a continuous function. Evaluation is performed by health staff that will be
given specific tasks mainly connects with collecting and analyzing the information needed to
make the evaluation.

District health plan can be evaluated in two main ways.

• Assess what program activities have been achieved compared to proposed district plan.

• Improvement in the indicators of health status although it needs extensive planed activities
implemented for several years.

The approach of evaluation consists of following steps:

• Decide what is to be evaluated and selects indicators of effectiveness.

• State the objectives.
• Collect the necessary information needed to provide evidence.
• Compare the results achieved with target has been met.
• Review the strategy and district health plan and make new annual plans for next yrs.
• Decide whether to continue the programmed, unchanged, to change or to stop it etc.

1. Decide what are to be evaluated and select indicators of effectiveness:

In principle, while planning is prepared, it should indicate how each programme or activity should be
evaluated and what should be accepted as evidence of satisfactory achievement; basically the target or
indicators

2. Collect the necessary information:

Evaluation requires the necessary information needed to monitor and evaluate progress so, information
is made continuously available. Arrangements must be made to obtain the information reliably and in
good time, e.g., once a week, or once a month on a fixed date.

Someone (e.g., a health volunteer) must be made responsible in each village for recording and reporting
the information, and a health centre staff member, e.g., the public health nurse/midwife, would be
made responsible for collecting and processing the information at the end of every quarter.

3. Compare the results with the targets or objectives:

At each monitoring point (e.g., each quarter or at the of each year) the figures obtained by the
information process are compared with the targets that had been set for that period or point in time.
The data recorded in the table in absolute figures must later be changed into rates (%) to enable
comparisons to be made, unless the targets are expressed in figures instead of rates.

 If the only targets indicated in the plan is a final target for a date several years ahead, the
monitoring and evaluation group will need to set up interim (usually yearly ) targets to enable
progress towards the final target to be monitored.
  Comparing these data on a year to year basis shows whether the district decreases or
increases with the targeted;

 The time to make this comparison might be in the last quarter of each fiscal year

4. Judge the degree to which the results achieved

Once the measurement and comparison have been made the evaluation group must judge the value to
the community of what has been achieved. It is usually advisable to hold a meeting to discuss the results
and how they were obtained even when an objectives or target has been achieved. For instance it may
be that the target could have been achieved sooner with no more effort or that a better target could
have been achieved with the same effort. At any rate, the experience gained in achieving a target or
objective is likely to be valuable for other programme. When the result achieved falls below what was
expected the reason for the shortfall must be explored and analyzed. This should take place before the
annual report is made so that remedial action may be proposed to the higher, supervising level.

5. Deciding on the further course of the programme and uses of the evaluation finding

When targets and objectives have been satisfactorily achieved, on the principle of 'management by
exception' no new decisions are needed, except to continue as before. When achievement has not been
satisfactory, one type of decision may be to investigate in depth the causes of the shortfall by means of
assessment, appraisal of staff performance, management audit. They should be made promptly and
communicated to all concerned for immediate action.

References
Rosemary Mc Mahon, Elizabeth Barton & Maurice Piot, On being in charge, WHO, 1992, 2 nd
edition

J.P Vaughan, R.H Morrow, Manual of epiemiology for district health management, WHO,1993

Ramjee prasad pathak, Ratna kumar Giri, A textbook of public health and primary health care
development, 2007

k park, preventive and social medicine 20 th edition