identify bottlenecks facilitators’ workshop on district health performance improvement lilongwe,...

Identify bottlenecks

Facilitators’ Workshop on District Health Performance Improvement

Lilongwe, 25th – 27th March 2015

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

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

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

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

quality

/ effecti

ve co

verag

e0

20

40

60

80

100

Determinants from supply

Determinants from demand

Determinants from quality

Bars graph for bottlenecks identification

commodities

human re

source

s

geogra

phic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 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

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100





PRIVATE SECTOR

Unless the private sector provides a major contribution to coverage


commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




Same denominator (target population)

Or unless the indicators for the supply side use different denominators

Different denominators(e.g. delivery points)

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




Cascade between initial utilization, continuous utilization and effective coverage

Same denominator (target population)

Example of bars graph with common denominator

(ideal but infrequent)

The health districtExample of BA using same denominator (population)

Target population for a specific intervention

in the health district

Population left out for lack of commodities

No commod.

Population left out for lack of human resources

No commod. No HR

Population left out for difficult geographic access

No commod. No HR No GA

Population not using the services (demand issues)


No initial util.

Population lost at follow up or dropping out


No initial util.

No continuity

Population receiving low quality (not effective)

intervention


No initial util.

No continuity

No quality

Example of bars graphwith different denominators

(not ideal but frequent)

The health districtExample of BA using different denominators

Target population for a specific intervention

in the health district

Health facilitiesin the health district

Health facilities with stock outsin the health district

No commod.

Health facilities with lack of HRin the health district

No commod. No HR

Settlements without a nearby health facility

No GANo commod. No HR

Population not using the services (demand issues)

No initial util.


Population lost at follow up or dropping out

No initial util.

No continuity


Population receiving low quality (not effective)

intervention

No initial util.

No continuity

No quality


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

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




1

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




1

2

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…

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




1

What to expect when a bottleneck is reduced

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




1

The reduction of a key bottleneck should bring an increase in effective coverage

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




1

15 35


commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




2

What to expect when a bottleneck is reduced

commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




2


commodities

human re

source

s

georga

rphic acce

ss

initial utiliza

tion

continuous u

tilization

effective

cove

rage / q

uality

0

20

40

60

80

100




15 35 55

2


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.

Determinant IndicatorCommodities Proportion of HF with no stock-outs of newborn care kits lasting more than 1

week during the past 3 monthsHuman resources Proportion of Health Professionals trained in home care and management of the

newbornGeographic access Not known: outreach to individual householdsInitial utilization Proportion of children 0-5 months who received postnatal care at home for cord

care and identification and referral of illnessesContinuity N/AEffective coverage Proportion 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

0%10%20%30%40%50%60%70%80%90%

Post natal care visits within 48 hours20122013

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