Bottleneck Analysis(BNA) to Improve Access and Effective Coverage of SAM Management Services UNICEF HQ/NIE/PD March 2016

Outline of Presentation Background and context Determinants of coverage and Approach to BNA for SAM management services BNA for SAM management services initiatives and progress to date Main challenges Way forward

Back ground and Context

BNA for SAM - Why the focus on bottleneck analysis for SAM? Coverage for SAM cases management is low (3.2M admissions in 73 countries in 2014,i.e < 20 % of the global burden). Current SAM services routine monitoring systems not designed to indicate bottlenecks/obstacles to effective coverage. Existing coverage methods, (SQUEAC and SLEAC assessments) only implemented sporadically due to the cost and time required for implementation. Not real-time. Essential to complement existing methods with tools that can support routine (or more frequent) monitoring of bottlenecks.

“Theory of Change” MoRES(Monitoring of Results for Equity System) & BNA ANALYSIS Identify deprivations (e.g. high rate of under 5 mortality) Identify underserved groups and causes (e.g of high SAM rate in 6-59 children) Identify interventions to address deprivations (e.g. SAM management) Identify bottlenecks and their root causes Solutions and strategies RESULTS Reduction of deprivation Priority causes of deprivation in underserved groups addressed Coverage of key interventions and quality improved / Effective coverage Bottlenecks reduced Causes of bottlenecks addressed IMPLEMENTATION

Determinants of Coverage and Approach to BNA for SAM management Services

Tanahashi Model :Determinants of Health Services Coverage Six coverage determinants, from supply to demand side to analyze bottlenecks. A bottleneck is a loss of system efficiency. Effective coverage – quality/Impact Adequate coverage – continuity/completion Initial utilization – first contact of multi-contact services Accessibility – physical access of services Availability – human resources Availability – essential health commodities Target Population Adapted from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2)

Social norms Availability of essential commodities Geographical access to staffed services Enabling Environment Policies/ legislation Budget/ expenditures Management/ governance Initial utilization Continuity and timeliness in use Quality of care Effective coverage Supply Demand Quality Target population Determinants of effective coverage Identification of bottleneck Analysis of its causes Prioritization of evidence based solutions Financial accessibility Social & cultural practices Determinant framework of MoRES

BNA Approach: Key Steps Step 1: - Define Indicators -Identify information sources and collect data Step 2 Identify bottlenecks Step 3 Analyse root causes of bottlenecks Step 4 Find solutions and corrective actions at national, provincial and district levels Step 5 Develop Action Plan and Implement

Step 1: BNA for SAM generic indicators DeterminantIndicator Commodity % of health facilities that did not have stock outs of supply in the last 6 months/ year Human Resources % of health workers who have been trained on CMAM/IMAM in the past year % of health workers (by cadre) who have been trained on CMAM in the past year Geographical Access % of health facilities offering SAM management services(OTP) Community Outreach % of CHVs trained on CMAM/IMAM % of CHVs trained on CMAM/IMAM who are active % of children screened for SAM using MUAC Utilization% of children 6-59 months in need of SAM treatment who are admitted Continuity % of children 6-59 months in need of SAM treatment who did NOT default from SAM treatment Quality % of children 6-59 months in need of SAM treatment who were cured

Indicators for BNA of SAM Management Services in Afghanistan(1) DeterminantsIndicatorsCalculation Supply Commodities% of HFs providing OPD- SAM services and did not encounter stock outs of (RUTF) for two or more consecutive weeks in the last 6 months # HFs with OPD-SAM - HFs with OPD-SAM with RUTF stock out # HFs with OPD-SAM HR% of clinician trained on IMAM since 2014 # of clinicians trained on IMAM Total # of clinicians % of CHS trained on IMAM since 2014 # of CHS trained on IMAM Total # of CHS Geographic Access % of HFs providing OPD-SAM services # of HFs providing OPD- SAM # of HFs targeted for IMAM Outreach% of CHW ever trained on MUAC # of CHWs trained Total # of CHWs

Indicators for BNA of SAM Management Services in Afghanistan(2) Determinants IndicatorsCalculation Demand Initial Utilization % of children months with SAM who were admitted in the SAM management service in the last 6 months # of SAM admissions Estimated SAM burden Continuous Utilization % of children 6-59 months who did NOT default from SAM management service in the last 6 months # SAM admissions - defaulters Estimated SAM burden Quality Effective coverage % of children months with SAM who were cured in the SAM management service in the last 6 months # SAM Cured Estimated SAM burden

Step 2: Identification of Bottlenecks(1) Determinants from demand Determinants from quality Determinants from supply

Step 2: Identification of Bottlenecks(2) Determinants from supply Determinants from demand Determinants from quality

National BNA bar graph for SAM management-Afghanistan Supply DemandQuality

Threshold setting for rating the Performance Indicators Categories Supply RUTF Human Resources (Clinicians) Human Resources (CHS) Geographic Access OPD- SAM Outreach Initial Utilization Continuous Utilization Quality / Effective coverage Good>=80%>=60% >=80%>=50% < 2% Drop from Initial Utilization < 3% Drop from Initial Utilization Fair50% -79%40%-59% 60 %-79%40%-49% 2%-5% Drop from Initial Utilization 3 % - 8% Drop from Initial Utilization Poor< 50%< 40% < 60%< 40% > 5% Drop from Initial Utilization > 8 % Drop from Initial Utilization Set with consultation with MoH and partners

Afghanistan SAM BNA National dashboard RegionProvincesSupply RUTFHuman Resources (Clinicians) Human Resources (CHS) Geographic Access OPD-SAM Out-reachInitial UtilizationContinuous Utilization Quality / Effective coverage Provinces Priority level with in the region Central Logar N/A0.0%3.6%0.0%28.2%18.9%18.6%14.4%1 Panjsher N/A0.0% 86.1%14.6%12.6%12.7%1 Parwan N/A4.9%20.9%0.0%99.6%8.1%7.8%7.1%1 Kabul 0.0%2.0%2.6%1.0%14.4%1.4%1.0%0.9%1 Kapisa 50.0%38.7%21.1%5.4%69.6%6.8%6.4%6.2%1 Daykundi 0.0%14.9%53.3%87.9%43.6%116.0%98.4%97.3%2 Bamyan 98.2%63.0%77.1%98.3%89.1%189.5%183.3%131.7%3 Wardak 71.4%86.8%77.5%35.0%55.6%3.5% 2.2%3 South East Ghazni 75.0%13.7%3.2%5.1%8.7%9.2%7.7%5.3%1 Paktika 42.9%35.4%44.4%40.0%43.7%95.7%94.9%44.3%2 Khost 0.0%58.0%100.0%96.2%97.1%28.5%28.1%22.8%4 Paktya 21.1%42.5%86.4%40.4%64.8%25.1%23.1%18.6%3 Eastern Kunar 66.7%41.3%28.1%42.0%29.7%44.6%44.1%42.0%2 Laghman 26.1%80.2%100.0%95.8%100.0%16.8%14.4%13.2%3 Nangarhar 21.4%69.0%37.0%34.4%81.3%14.0%13.9%11.4%1 Nooristan 100.0%78.7%85.7%100.0%91.9%35.6%34.3%30.3%4 Northern Baghlan 35.7%24.9%22.2%21.5%30.5%41.9%41.3%25.5%1 Faryab 66.7%33.6%85.7%83.7%100.0%226.1%217.8%192.7%2 Badakhshan 21.1%29.8%13.8%36.5%0.0%100.4%99.6%90.3%1 Balkh 100.0%33.0%14.8%20.0%3.6%33.2%30.6%11.3%1 Jawzjan 100.0%39.7%73.9%82.4%83.3%81.9%80.4%62.7%3 Kunduz 88.9%56.7%80.4%27.7%91.3%69.6%68.6%10.9%3 Samangan 62.5%29.3%23.4%19.0%9.1%25.9%23.1%13.5%1 Sar-e-Pul 100.0%44.2%86.7%97.0%80.9%146.9%139.9%106.0%3 Takhar 0.0%26.4%10.9%42.9%0.1%12.3%11.8%1.2%1 Southern Nimroz 10.0%35.9%33.3%58.8%49.8%173.4%159.7%105.3%1 Helmand 100.0%46.5%60.0%100.0%59.1%85.2%82.9%61.7%4 Zabul 53.8%4.6%6.7%41.9%0.0%69.5%66.0%44.2%2 Kandahar 100.0%56.5%54.5%78.6%86.0%30.0%28.1%25.8%5 Urozgan 100.0%39.8%47.4%71.0%28.3%23.3%22.6%18.5%3 Western Herat 77.8%14.4%25.0%20.2%65.8%28.7%26.3%23.9%4 Ghor 78.6%5.5%22.9%22.6%48.7%83.9%73.5%51.6%2 Farah 16.7%79.1%4.8%15.8%0.0%6.5% 5.6%1 Badghis 5.6%1.2%0.0%40.0%58.7%23.2%20.8%19.7%3 National 60.5%34.8%36.5%38.0%50.7%34.5%33.1%24.7%

Summary of provincial performance status for determinant indicators in Afghanistan Determinant Indicators PoorFairGood No.% % % Commodities (RUTF) 1342%929.0%9 Human Resource Clinician %720.6%617.6% CHS %411.8%1132.4% Geographic Access %720.6%1132.4% Outreach %38.8%1235.3% Initial Utilization %25.9%1235.3% Continuous Utilization 617.7%823.5%2058.8% Effective Coverage 1647%926.5%9

Step 3: Analysis of root causes of bottlenecks X Why? Legislative/ Policy* Environment Budget/ Expenditure Management/ Coordination Social Norms X X X

Step 4: Identification of evidence based-solutions 2 1 How? Causality analysis Identification of solutions Effective solutions need to be identified

Causal analysis and exploring solution –Afghanistan Supply Demand Quality

Step 4: Prioritization of Solutions Key questions: – Is the proposed solution feasible? – Is the proposed solution cost-effective? – Is the proposed solution acceptable? – Is the proposed solution equitable? – Is the proposed solution can be implemented timely? – Is the proposed solution likely to overcome probable crisis/hazards/emergencies?

Summary of Bottlenecks, Root Causes and Solutions-Afghanistan DeterminantBottlenecksRoot causes of bottlenecksProposed solutions Human Resources 34.8% Clinicians 36.5% of CHS trained on IMAM  Lack of costing for IMAM training in BPHS package  Inadequate capacity of PNO- planning, coordination & monitoring trainings  Estimation of cost per capita for nutrition intervention  Building managerial & technical capacity of PNO Geographic Access 38% HFs provide OPD-SAM services  Lack of clear and detailed plan for expansion of IMAM  Developing comprehensive IMAM scale up plan Quality9.8 % drop from IU - cases not cured  Lack of post training follow up and supportive supervision  Strengthen supportive supervision  Improving recording & documentation

Supply Availability of commodities Availability of human resources Geographic access Outreach activities Demand Initial utilization Continuity Quality Effective coverage (adherence to guidelines) Identification of bottlenecks Identification of causes Root causes and enabling environment Qualitative information Additional indicators 5 WHYs Identification of solutions Solutions to address the causes of bottlenecks Initial brainstorming Prioritization Feasibility, acceptability, affordability, equity focus, timeline Why? 24

Step 5: Develop Action Plan and Implement Based on prioritized solutions, action plan has to be developed for each solutions. The action plan has to be implemented timely by setting targets and indicators to track the progress.

Action plan to address bottlenecks-Afghanistan ‘s experience

Feedback loop: from monitoring…... to corrective actions ①Have activities been adequately implemented? ② Is the bottleneck being reduced? ③ Is the coverage increasing? Continue good job YES Review why and strengthen implementation Repeat CAUSALITY analysis and consider new solutions and activities Repeat BOTTLENECK analysis and consider new solutions and activities NO

BNA for SAM management Services Initiatives and Progress to date

BNA for SAM initiatives UNICEF has been implementing the broader BNA approach since 2010 globally as part of its organizational equity refocus approach. BNA for SAM management services has been introduced since 2014 with aim to complement the existing tools(SQUEAC and SLEAC). A set of generic indicators were developed by UNICEF and started to be rolled out in six countries. Ongoing evidence building and refinement of indicators is being piloted by ACF-UK, CMN, UNICEF and David Doledec (consultant) - with initial inputs from FANTA - in selected country contexts.

Country SAM management BNA exercises and outputs to date DateCountryDescriptionOutput 2014MalawiCMAM-specific exercise done nationally to inform national CMAM Operational Plan National CMAM costed operational plan KenyaMulti-sectoral exercise (health, nutrition, WASH) in 8 counties to date 8 County level actions plans Feb – July 2015SudanNational, desk-based CMAM- specific exercise Multi-sectoral exercise (health, nutrition, WASH) in 4 States Informed national SAM scale up strategy 4 State level work plans August-Sept 2015 AfghanistanSAM-specific bottleneck analysis workshop at national level Inform annual national partner work plan October 2015TanzaniaSAM-specific bottleneck analysis to inform national scale-up strategy National SAM management scale up strategic plan July 2015 / March 2016 PakistanSAM-specific bottleneck analysis workshop at national level TBC – to inform annual national work plan

Main Challenges Advocacy with government for buy in of the BNA process as planning tool. Collection of missing data ( Commodities, HR, outreach ). Estimation of case burden in the absence of recent Nutrition Survey result and population census data. Scaling up-causality analysis to provincial level. Ensuring full ownership and progressively shifting technical lead of the exercise to MoH. Mainstreaming of BNA in yearly planning as well as M & E processes. Integrating the missing data for BNA in to programme database.

Lesson Learnt BNA can be effectively implemented both in stable and emergency/security fragile contexts. Participatory Threshold Setting for performance of indicators improve results ownership. BNA create opportunity for quality improvement of IMAM/CMAM data –identify weakness & plan for improvement. BNA supports capacity building & strengthen performance monitoring. Trigger action – reference point discussions on QI & Annual plans.

Way forwards ✓ Experience sharing and refining indicators Organizing webinars and sharing compendium doc Finalizing the pilot study and developing the set of recommended indicators ✓ Scaling up BNA for SAM management services Partners and donors are interested Enthusiasm from CO to introduce the concept HQ is committed to strengthen the BNA exercise for SAM management and provide support to RO and CO ✓ Scaling up BNA for other nutrition interventions Using BNA for SAM management service as entry point for introducing other nutrition interventions (IYCF, MN) Support multi-intervention/sectoral initiatives

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