1. Identify bottlenecks Facilitators’ Workshop on District Health Performance Improvement Lilongwe, 25 th – 27 th March 2015

2. Steps Diagnose Select interventions Define indicators Identify information sources and collect data Identify the bottlenecks Identify areas lagging behind Analyse the root causes of bottlenecks Intervene Prioritize solutions with all stakeholders Define an implementation and monitoring plan Support implementation Verify Monitor frequently using existing opportunities Adjust Take corrective actions to ensure impact

3. The Bottleneck Analysis It is a systematic way to look at the main determinants of effective coverage for selected interventions to identify problem areas to purposely act on them

4. Six coverage determinants, from supply to demand side, analyze where health system bottlenecks exist. A bottleneck is a loss of system efficiency Adapted from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2) http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf Availability – essential health commodities Adequate coverage – continuity/completion Initial utilization – first contact of multi-contact services Accessibility – physical access of services Effective coverage – quality/impact Target Population Availability – human resources

5. Determinants from supply Determinants from demand Determinants from quality Bars graph for bottlenecks identification

6. Determinants from supply Determinants from demand Determinants from quality X X X X X X X X X X Same denominator Usually the demand side cannot be higher than the lowest determinant in the supply Functional access

7. Determinants from supply Determinants from demand Determinants from quality X X X X X X X X X X PRIVATE SECTOR Unless the private sector provides a major contribution to coverage

8. X X X X X X X X X X Determinants from supply Determinants from demand Determinants from quality Same denominator (target population) Or unless the indicators for the supply side use different denominators Different denominators (e.g. delivery points)

9. Determinants from supply Determinants from demand Determinants from quality Cascade between initial utilization, continuous utilization and effective coverage Same denominator (target population)

10. Example of bars graph with common denominator (ideal but infrequent)

11. The health district Example of BA using same denominator (population)

12. Target population for a specific intervention in the health district

14. Population left out for lack of commodities

15. No commod.

16. Population left out for lack of human resources

17. No commod. No HR

18. Population left out for difficult geographic access

19. No commod. No HR No GA

20. No commod. No HR No GA

21. Population not using the services (demand issues)

22. No commod. No HR No GA No initial util.

23. Population lost at follow up or dropping out

24. No commod. No HR No GA No initial util. No continuity

25. Population receiving low quality (not effective) intervention

26. No commod. No HR No GA No initial util. No continuity No quality

27. No commod. No HR No GA No initial util. No continuity No quality

28. Example of bars graph with different denominators (not ideal but frequent)

29. The health district Example of BA using different denominators

30. Target population for a specific intervention in the health district

31. Health facilities in the health district

33. Health facilities with stock outs in the health district

34. No commod.

35. Health facilities with lack of HR in the health district

36. No commod. No HR

37. Settlements without a nearby health facility

38. No GA No commod. No HR

39. Population not using the services (demand issues)

40. No initial util. No commod. No HR No GA

41. Population lost at follow up or dropping out

42. No initial util. No continuity No commod. No HR No GA

43. Population receiving low quality (not effective) intervention

44. No initial util. No continuity No quality No commod. No HR No GA

45. No initial util. No continuity No quality No commod. No HR No GA

46. How to identify bottlenecks using a bar graph with coverage determinants Start from left to right: supply first, then demand, then quality Identify the lowest bar in the supply side (weakest determinant in the existing system) Identify the biggest drop in the demand side and quality

47. Determinants from supply Determinants from demand Determinants from quality

48. Determinants from supply Determinants from demand Determinants from quality 1

49. Determinants from supply Determinants from demand Determinants from quality 1 2

50. In summary: 1.A bottleneck is a significant gap or drop in coverage determinant between the expected and the observed 2.Services must be available first before they are used. Therefore, bottlenecks are analyzed starting with supply, followed by demand and finally by quality 3.The cascade rule means that quality can not be higher than demand, and demand higher than supply 4.When the graph seems different from what we expect, care should be given to assess common factors e.g. using different denominators for supply, demand and quality; not counting the contribution of the private, overstretching of limited HR…

51. Determinants from supply Determinants from demand Determinants from quality 1 What to expect when a bottleneck is reduced

52. Determinants from supply Determinants from demand Determinants from quality 1 The reduction of a key bottleneck should bring an increase in effective coverage

53. Determinants from supply Determinants from demand Determinants from quality 1 15  35 The reduction of a key bottleneck should bring an increase in effective coverage

54. Determinants from supply Determinants from demand Determinants from quality 2 What to expect when a bottleneck is reduced

55. Determinants from supply Determinants from demand Determinants from quality 2 The reduction of a key bottleneck should bring an increase in effective coverage

56. Determinants from supply Determinants from demand Determinants from quality 15  35  55 2 The reduction of a key bottleneck should bring an increase in effective coverage

57. Comparing previous year’s data To assess the full picture: Have the bottlenecks identified been reduced? Has that reduction brought higher coverage and quality? Have new bottlenecks emerged? Only look at big (significant) changes. Be aware of non comparable data.

58. DeterminantIndicator Commodities Proportion of HF with no stock-outs of newborn care kits lasting more than 1 week during the past 3 months Human resources Proportion of Health Professionals trained in home care and management of the newborn Geographic access Not known: outreach to individual households Initial utilization Proportion of children 0-5 months who received postnatal care at home for cord care and identification and referral of illnesses ContinuityN/A Effective coverageProportion of children 0-5 months who received postnatal care at home within 48 hours of birth for cord care and identification and referral of illnesses

59. Partitioning When one intervention is provided through multiple delivery platforms, each delivery platform has to be analyzed separately. – The different delivery platforms may have different bottlenecks – Each delivery platform accounts for part of the total coverage for the intervention Only the addition of coverage through the different platforms can get to 100%

60. Determinants from supply Determinants from demand Determinants from quality i.e.: treatment for diarrhea

61. Facility based treatment of diarrhea Community based treatment of diarrhea

62. Facility based treatment of diarrhea Community based treatment of diarrhea

63. Facility based treatment of diarrhea 1 2

64. Community based treatment of diarrhea 1 2

65. Facility based treatment of diarrhea Community based treatment of diarrhea

66. Facility based treatment of diarrhea Community based treatment of diarrhea