The Tanahashi Model to assess system bottlenecks

What is a bottleneck, and why analyze it??

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Six coverage determinants, from both supply and demand side, applied to analyze health system bottlenecks and develop strategies

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

Initial utilization first contact of multi contact

services

Accessibility physical access of services

Effective coverage -quality

Target Population

Availability human resources

The seminal work of Tanahashi (1978) and Piot (1982) to develop coverage models for the evaluation of health services and in the case of Piot, tuberculosis control, has been adapted here to determine the marginal cost of increasing coverage.

1. Availability of essential commodities: Assesses the availability of critical health system inputs such as drugs, vaccines and supplies. The information is frequently obtained from systemic review of stock registers and/or facility surveys.

2. Availability of human resources:Assesses availability of human resources (e.g. doctors, nurses, community health workers) for the adequate functioning of the health system and specifically the delivery of evidence based interventions. Data is frequently drawn from employment databases and / or facility surveys.

3. Geographical accessibility:Assesses the physical access of health services to the clients, including the number of villages reached regularly served by outreach services (for population oriented outreach services) and the time taken or distance to reach a facilities providing basic and emergency obstetric and neonatal care services (for clinic based individual care services). Estimates for accessibility are frequently drawn from DHS or similar population based surveys. Often an expert judgment is needed.

4. Initial utilization:Assesses the first use of multi-contact health services, that can also be influence by the financial accessibility of the services as well as the knowledge on the service (for example, a child suffering of ARI taken to the skilled health provider at the health facility).Household surveys and service statistics reported at facilities are the main sources of information on initial utilisation. Service records, when used, should be validated before use in the tool.

5.Timely continuous utilization:Assesses the utilisation pattern compared to recommended contacts for services. the child treated at facility and receiving antibiotics treatment. This determinant measures continuity and compliance of multiple visits for care, thus sometimes referred to as the continuity determinant or adequate coverage.

6. Effective, quality coverage:Assesses the proportion of the population in need of an intervention who have received all adequate components of an intervention in a timely and complete manner, i.e, the child treated at facility and receiving antibiotics treatment from a Skilled health provider trained on IMCI or a child having completed the whole Antibiotic course and either cured or referred. Effective coverage are defined as a minimum amount of inputs and processes that are expected to produce desired health effect if used by individuals or applied to the population at large. In some cases, effective coverage is assessed as the proportion of timely continuous utilization delivery with quality inputs. In effect, it measures health system performance and quality of care. DHS, facility surveys and expert opinion are frequent sources of this data.

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The Tanahashi Model to assess system bottlenecks

Availability of commodities

Physical accessto services

Initial Utilization

Full/continuousutilisation

Quality coverage

HR availability

IMPACT

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

Target Population

The core of the Marginal Budgeting for Bottlenecks (MBB) approach is the bottleneck analysis. This analytical method identifies constraints hampering a health system from achieving a desired level of coverage for an intervention or package of interventions. Based upon work by Piot (Piot, 1967) and Tanahashi (Tanahashi, 1978), the MBB defines six core coverage determinants that help describe the capacity of a health system to increase the utilization of effective interventions.

Coverage determinantDefinition

1 Availability of essential commodities 1a Availability of critical health system inputs

2 Availability of human resources 2a Availability of human resources for the adequate functioning of the health system.

3 Physical access 3a Physical access of health services to the users and vice versa.

4 Initial utilization 4a The first use of multi-contact services.

5 Timely continuous utilization 5a Utilization considering continuity and compliance of multiple visits for care.

6 Effective coverage 6a Utilization of a combination of inputs and processes produce a desired health effect

The seminal work of Tanahashi (1978) and Piot (1982) to develop coverage models for the evaluation of health services and in the case of Piot, tuberculosis control, has been adapted here to determine the marginal cost of increasing coverage.

1. Availability of essential commodities: Assesses the availability of critical health system inputs such as drugs, vaccines and supplies. The information is frequently obtained from systemic review of stock registers and/or facility surveys.

2. Availability of human resources:Assesses availability of human resources (e.g. doctors, nurses, community health workers) for the adequate functioning of the health system and specifically the delivery of evidence based interventions. Data is frequently drawn from employment databases and / or facility surveys.

3. Geographical accessibility:Assesses the physical access of health services to the clients, including the number of villages reached regularly served by outreach services (for population oriented outreach services) and the time taken or distance to reach a facilities providing basic and emergency obstetric and neonatal care services (for clinic based individual care services). Estimates for accessibility are frequently drawn from DHS or similar population based surveys. Often an expert judgment is needed.

4. Initial utilization:Assesses the first use of multi-contact health services, that can also be influence by the financial accessibility of the services as well as the knowledge on the service (for example, a child suffering of ARI taken to the skilled health provider at the health facility).Household surveys and service statistics reported at facilities are the main sources of information on initial utilization. Service records, when used, should be validated before use in the tool.

5.Timely continuous utilization:Assesses the utilisation pattern compared to recommended contacts for services. the child treated at facility and receiving antibiotics treatment. This determinant measures continuity and compliance of multiple visits for care, thus sometimes referred to as the continuity determinant or adequate coverage.

6. Effective, quality coverage:Assesses the proportion of the population in need of an intervention who have received all adequate components of an intervention in a timely and complete manner, i.e, the child treated at facility and receiving antibiotics treatment from a Skilled health provider trained on IMCI or a child having completed the whole Antibiotic course and either cured or referred. Effective coverage are defined as a minimum amount of inputs and processes that are expected to produce desired health effect if used by individuals or applied to the population at large. In some cases, effective coverage is assessed as the proportion of timely continuous utilization delivery with quality inputs. In effect, it measures health system performance and quality of care. DHS, facility surveys and expert opinion are frequent sources of this data.

MBB at the country level Module 2

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0%10%20%30%40%50%60%70%80%90%100%

% District with

LLITN's or nets +

insecticide in stock

% villages with HR

providing LLITNs

% villages selling or

distribution LLITN or

nets + insecticide

% households

having at least one

bed net

% pregnant women

using MN last night

% pregnant women

using ITMN

Nigeria application 2006

Chart7% District with LLITN's or nets + insecticide in stock% villages with HR providing LLITNs% villages selling or distribution LLITN or nets + insecticide% households having at least one bed net% pregnant women using MN last night% pregnant women using ITMN

Nigeria application 2006

0.7

0.6

0.5

0.3

0.2

0.09

Sheet1Pregnant Women in Nigeria100%% District with LLITN's or nets + insecticide in stock70.0%% villages with HR providing LLITNs60.0%% villages selling or distribution LLITN or nets + insecticide50.0%% households having at least one bed net30.0%% pregnant women using MN last night20.0%% pregnant women using ITMN9.0%% PHC's with sufficient stocks of vaccines and injection material76.0%% villages regularly receiving outreach for EPIplus76.0%Children 12-23months DPT143.2%Children 12-23months DPT3- measles36.0%Children 12-23months DPT3- measles