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The Tanahashi Model to assess system bottlenecks
What is a bottleneck, and why analyze it??
2
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
3
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