Identify bottlenecks Facilitators’ Workshop on District Health Performance Improvement Lilongwe,...
-
Upload
milo-booker -
Category
Documents
-
view
223 -
download
0
description
Transcript of 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
Determinants from supply
Determinants from demand
Determinants from quality
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
Determinants from supply
Determinants from demand
Determinants from quality
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
PRIVATE SECTOR
Unless the private sector provides a major contribution to coverage
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
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
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)
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
Determinants from supply
Determinants from demand
Determinants from quality
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
No commod. No HR No GA
Population not using the services (demand issues)
No commod. No HR No GA
No initial util.
Population lost at follow up or dropping out
No commod. No HR No GA
No initial util.
No continuity
Population receiving low quality (not effective)
intervention
No commod. No HR No GA
No initial util.
No continuity
No quality
No commod. No HR No GA
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.
No commod. No HR No GA
Population lost at follow up or dropping out
No initial util.
No continuity
No commod. No HR No GA
Population receiving low quality (not effective)
intervention
No initial util.
No continuity
No quality
No commod. No HR No GA
No initial util.
No continuity
No quality
No commod. No HR No GA
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
Determinants from supply
Determinants from demand
Determinants from 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
Determinants from supply
Determinants from demand
Determinants from quality
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
Determinants from supply
Determinants from demand
Determinants from quality
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
Determinants from supply
Determinants from demand
Determinants from quality
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
Determinants from supply
Determinants from demand
Determinants from quality
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
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
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
Determinants from supply
Determinants from demand
Determinants from quality
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
Determinants from supply
Determinants from demand
Determinants from quality
2
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
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
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