Abstract
ABSTRACTBackground: Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. However, there is limited understanding of health system barriers to utilization and delivery of appropriate, high-impact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. In this study we illustrate the use of the bottleneck analysis approach, which could be used to identify bottlenecks in service delivery within the district health system.Methods: A modified Tanahashi model with six determinants for effective coverage was used to determine bottlenecks in service provision for maternal and newborn care. The following interventions provided during antenatal care were used as tracer interventions: use of iron and folic acid, intermittent presumptive treatment for malaria, HIV counseling and testing, and syphilis testing. Data from cross-sectional household and health facility surveys in Mayuge and Namayingo districts in Uganda were used in this study.Results: Effective coverage and human resource gaps were identified as the biggest bottlenecks in both districts, with coverage ranging from 0% to 66% for effective coverage and from 46% to 58% for availability of health facility staff. Our findings revealed a similar pattern in bottlenecks in both districts for particular interventions although the districts are functionally independent.Conclusion: The modified Tanahashi model is an analysis tool that can be used to identify bottlenecks to effective coverage within the district health system, for instance, the effective coverage for maternal and newborn care interventions. However, the analysis is highly dependent on the availability of data to populate all six determinants and could benefit from further validation analysis for the causes of bottlenecks identified.
Highlights
Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system
The model emphasizes the importance of effective coverage, which is defined as coverage of sufficient quality to reach a defined health impact [14,16,17] and not merely geographic access [18].The model incorporates coverage according to five measures, each reflecting a stage in provision of services, that can be used to assess the potential of a health system to provide effective coverage [15]
We address, firstly, the most important empirical findings related to the tracer interventions, and secondly, more general observations from using the modified Tanahashi model at the district level in a low-income countries (LIC)
Summary
Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. There is limited understanding of health system barriers to utilization and delivery of appropriate, highimpact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. There is limited understanding of health system barriers to delivery and utilization of these affordable and effective interventions in districts and sub-districts in low-income countries [9], where service delivery takes place [8]. Tanahashi’s concept of health services coverage and evaluation [14] is one of the models that can be used to identify gaps in service delivery The gap, in this case, refers to the proportion of the target population that does not receive effective coverage [15]. The model emphasizes the importance of effective coverage, which is defined as coverage of sufficient quality to reach a defined health impact [14,16,17] and not merely geographic access [18].The model incorporates coverage according to five measures, each reflecting a stage in provision of services, that can be used to assess the potential of a health system to provide effective coverage [15]
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