Incorporating costing study results into district and service planning to enhance program performance – a Zambian Case Study

Executive summary

Zambia participated in the EPIC 1 study which undertook comprehensive costings of its routine immunization program and new vaccine introduction. After the results were reported to national level stakeholders, Zambia requested that the results of the study be disseminated to district level managers. The process of dissemination to districts and development of this case study had three main objectives: 1) validation of the interpretation of EPIC I costing results, and contextual and other underlying influences on EPI efficiency; 2) understanding of the planning, financing and management context which will influence efforts to enhance EPI efficiency; and 3) exploring how districts can use costing information to enhance planning and management to increase outputs and coverage with limited available resources. This report highlights key aspects of the Zambian context as well as the costing study results which are relevant to EPI performance management at district and service levels. The report then identifies a number of systems in the areas of planning of health services and the EPI; financial, HR and procurement and supply management; and performance reporting and management. Despite an established “bottom-up” decentralized planning system, decisions over key resources that affect performance of the EPI, such as vaccines and staff costs, are not under the direct control of managers at decentralized levels. However, investigation using a “complex systems” framework revealed a number of other factors that can both constrain and facilitate action to improve the performance of the EPI system with available resources. Constraints that have major overall effects include unpredictability of disbursement of budgets, which undermines ability and motivation for active planning and management, and limited availability of experienced managers along with declining resources for supportive supervision, mentorship and training. Importantly, the case study found that experienced managers, using insights from the costing study, can identify reasons for inefficient resources and ways to address them, and act to improve performance, despite the various constraints and limited information. Further dissemination of results through mechanisms that cultivate peer learning and ongoing support is recommended. Other recommendations aim as much as possible to build on existing systems and initiatives to strengthen EPI in ways that do not overburden available capacity and also enhance overall PHC system performance. Further exploration of certain EPI policies and incentive systems is recommended. Other issues for consideration include where more central initiatives in areas such as procurement, stock management or reliable budget disbursement, may have larger yields than district or facility level interventions. Support for better use of existing if imperfect information may also prove more efficient than developing more complex information systems and indicators