Bottleneck Identification, Analysis & Setting up New Frontiers for Coverage

1. Bottleneck Identification, Analysis & Setting up New Frontiers for Coverage CONCEPT

2. Step1 Setup & Inputs Step 2 Bottleneckanalysis Step 3 Policy scenarios Step 5 Outputs Step 4 Budgeting and Financing Steps of an MBB-assisted analysis

3. Bottleneck analysis • Select tracer intervention • Define indicators of coverage determinants • Define Baseline coverage • Identify bottlenecks • Discuss causes • Select implementation strategies • Set new Frontiers

4. Bottleneck analysis • Select tracer intervention • Define indicators of coverage determinants • Define Baseline coverage • Identify bottlenecks • Discuss causes • Select implementation strategies • Set new Frontiers

5. Service delivery modes Family preventive/WASH services Family neonatal care Infant and child feeding Community management illnesses Preventive care for adolescents and adults Preventive pregnancy care HIV/AIDS prevention and care Preventive infant and child care Clinical primary level skilled maternal & neonatal care Management of illnesses at primary clinical Clinical first referral illness management Clinical second referral illness management Family oriented community based services Population oriented schedulable services Individual oriented clinical services 5

6. Bottleneck analysis • Select tracer intervention • Define indicators of coverage determinants • Define Baseline coverage • Identify bottlenecks • Discuss causes • Select implementation strategies • Set new Frontiers

7. The Tanahashi Model

8. Health Coverage Determinants Effective coverage- quality Adequate coverage- continuity Utilisation – 1rst contact with health services Accessibility – physical access to services Accessibility – to human resources Availability – critical inputs to health system Target Population 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

9. TANAHASHI MODEL level definitions IMPACT Target population: 100% Population which your specific project wants to cover and make 100% impact through interventions. EPI: 3,000,000 population under one EFFECTIVE COVERAGE ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

10. TANAHASHI MODEL level definitions IMPACT EFFECTIVE COVERAGE Essential commodities that are needed to deliver health MDG related interventions EPI: 2 million vaccines and syringes/needles ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

11. TANAHASHI MODEL level definitions IMPACT Human resources that are needed to deliver health MDG related interventions Every Health center has 3 trained nurses /10,000 EFFECTIVE COVERAGE ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

12. TANAHASHI MODEL level definitions IMPACT Geographic distribution and frequency of service. EPI: 10,000 outreaches and 2,500 health centers offering immunizations EFFECTIVE COVERAGE ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

13. TANAHASHI MODEL level definitions IMPACT Utilization of services, which are made available and further accessible, by target population, regardless of quality of service. EPI: 2.5 million measles or DPT1 vaccinations EFFECTIVE COVERAGE ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

14. TANAHASHI MODEL level definitions IMPACT Timely and Continued utilization of services, which are made available and further accessible, by target population, regardless of quality of service. EPI: 2 million children fully immunized by age 1 EFFECTIVE COVERAGE ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

15. TANAHASHI MODEL level definitions IMPACT Timely and continued utilization of services with optimum quality. EPI: 2.0 million children fully immunized by age 1 with potent vaccines and appropriate administration techniques. EFFECTIVE COVERAGE ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

16. TANAHASHI MODEL level definitions Ultimate impact made by the intervention. EPI: 100,000 averted measles cases. IMPACT EFFECTIVE COVERAGE ADEQUATE COVERAGE UTILIZATION GEOGRAPHICAL ACCESSIBILITY HUMAN RESOURCE AVAILABILITY AVAILABILITY COMMODITIES POPULATION

17. Bottleneck analysis • Select tracer intervention • Define indicators of coverage determinants • Define Baseline coverage • Identify bottlenecks • Discuss causes • Select implementation strategies • Set new Frontiers

18. Example: Bottleneck chart Tracer Indicators

19. Bottleneck analysis • Select tracer intervention • Define indicators of coverage determinants • Define Baseline coverage • Identify bottlenecks • Discuss causes • Select implementation strategies • Set new Frontiers

20. What is a “Bottleneck”? An obstacle, a constraint or an impediment along the service delivery process.

21. Example: Bottleneck chart Tracer Indicators

22. Bottleneck analysis • Select tracer intervention • Define indicators of coverage determinants • Define Baseline coverage • Identify bottlenecks • Discuss causes • Select implementation strategies • Set new Frontiers

23. Bottlenecks and causes at community level: ITNs: Rwanda Case 1. CHW training 2. Massive campaign and distribution of long lasting ITNs to children under five 3. Promoting the effective utilization of ITNs by including the utilization of bed nets as a performance indicator in Mayors’ performance contracts.

24. Bottlenecks and causes at outreach level: FP 1. To increase the number of youth friendly facilities 2. To fully fund family planning program at US$ 0.3 per capita per year 3. To involve men in family planning 4. To ensure free access to information, education and contraceptive services.

25. Bottlenecks and causes at clinical level: Skilled delivery 1. To include assisted deliveries in Mayors’ performance contracts 2. To increase the price of PBF for assisted deliveries by 50 percent 3. To implement conditional cash transfers for assisted deliveries.

26. Bottleneck analysis • Select tracer intervention • Define indicators of coverage determinants • Define Baseline coverage • Identify bottlenecks • Discuss causes • Select implementation strategies • Set new Frontiers

27. What is a “Frontier” • A frontier is an economic term indicating the maximum production level which a production process can reach; • In the case of MBB, it represents the highest possible coverage level for a health service.

28. Setting new frontier for “Supply side determinants – Commodities, HR Access”

29. Setting new frontier for “Accessibility”

30. Setting new frontier for “Initial Utilization”

31. Bottlenecks and causes at community level: ITNs

32. New frontiers at community level: ITNs Accessibility bottleneck reduction 60% Initial utilization bottleneck reduction 80% Timely continuous utilization bottleneck reduction 80% Effective quality bottleneck reduction 80%

33. Bottlenecks and causes at outreach level: FP

34. New frontiers at outreach level: FP Essential commodities availability bottleneck reduction 30% Initial utilization bottleneck reduction 50% Timely continuous utilization bottleneck reduction 50% Effective quality bottleneck reduction 50%

35. Bottlenecks and causes at clinical level: Skilled delivery

36. New frontiers at clinical level: Skilled delivery Human resources availability bottleneck reduction 10% Accessibility bottleneck reduction 20% Initial utilization bottleneck reduction 20% Timely continuous utilization bottleneck reduction 20% Effective quality bottleneck reduction 20% .

37. Thank you for your attention