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Adoption and use of the bottleneck analysis approach in Ghana’s health sector
April 2015
Maternal, Newborn and Child Health
Working Paper
UNICEF Health Section, Program Division unite for children
ii
Adoption and use of the bottleneck analysis approach in Ghana’s health sector © United Nations Children’s Fund (UNICEF), New York, 2015 Knowledge Management and Implementation Research Unit, Health Section, Program Division UNICEF 3 UN Plaza, New York, NY 10017 April 2015 This is a working document. It has been prepared to facilitate the exchange of knowledge and to stimulate discussion. The findings, interpretations and conclusions expressed in this paper are those of the authors and do not necessarily reflect the policies or views of UNICEF or the United Nations. The text has not been edited to official publication standards, and UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. The editors of the series are Alyssa Sharkey and David Hipgrave of UNICEF Program Division. For more information on the series, or to submit a working paper, please contact [email protected] or [email protected]. COVER PHOTO: UNICEF Ghana, P1040313,Quarmyne
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Adoption and use of the
bottleneck analysis approach
in Ghana’s health sector
Rose Carole Muthoni Njiraini, Erasmus Agongo, John Koku Awoonor-Williams, Lilian Selenje, Hari Krishna Banskota, Victor Ngongalah,
Daniel Yayemain, Josephine Agborson, Thomas O’Connell
Keywords: Ghana, district health system strengthening, bottleneck analysis, equity,
child health, Tanahashi model, decentralized monitoring
Comments may be addressed by email to: Lilian Selenje ([email protected]) cc: Thomas O’Connell ([email protected]) and Hari Krishna Banskota ([email protected])
MATERNAL, NEWBORN AND CHILD HEALTH
WORKING PAPER
April 2015
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Acknowledgements
The authors would like to thank all contributors to the report. Particular appreciation is given to various key
informants within the Ghana Health Service (GHS) who graciously shared their story of how the bottleneck
analysis (BNA) approach was adopted and used within the organization.
The Deputy Director of the Policy Planning Monitoring and Evaluation (PPME) Division at GHS (Dr. Dan Osei)
took time out of his busy schedule to describe BNA applications within PPME. The Child Health Coordinator
at the GHS Family Health Division, Dr. Isabella Sagoe-Moses, shared information on how the BNA approach
helped to develop the National Newborn Strategy and Action Plan 2014-2018, which was accompanied by
regional and district operational plans.
Gratitude also goes to the Health Directorates of the Northern, Upper East and Eastern Regions of Ghana
who shared their experiences applying the BNA approach within their routine work. The Eastern Regional
Health Directorate facilitated field visits to the Upper Manya Krobo District and the New Juaban Municipality
to better understand how they used BNA for decentralized equity-focused program monitoring. BNA
workshop facilitators also shared lessons about using the BNA approach based on experiences of drafting
initial strategic plans during these workshops.
UNICEF provided funding to develop this working paper. The UNICEF Ghana Country Office facilitated the
process and engaged key informants interviewed. The UNICEF Ghana Field Office in Tamale facilitated
movement within the northern regions and also shared information on their work using the BNA approach.
UNICEF HQ supported the editing, review and finalization of this document, with thanks to Alyssa Sharkey,
David Hipgrave, and Emily White Johansson. Finally, various Monitoring and Evaluation experts in the UNICEF
Country and Regional Offices also provided technical contributions to this report.
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Executive Summary
This report comprehensively documents how the Ghana Health Service (GHS), with support from UNICEF,
adopted and used the Monitoring of Results for Equity System (MoRES) within the organization. MoRES is a
monitoring system developed by UNICEF as part of its equity focus to ensure that children’s rights to survival,
growth and development are protected by reducing barriers to the use of essential health services by the
most vulnerable groups. This system was introduced by UNICEF to its government counterparts in Ghana,
and was implemented using a Bottleneck Analysis (BNA) approach.
The Ghana Health Service was quite receptive to this equity-focused strategic planning approach for various
reasons, including its willing and committed leadership, previous use of the Marginal Budgeting for
Bottlenecks (MBB) tool, strong routine data collection systems (District Health Information Management
System (DHIMS), and regular performance monitoring mechanisms at all levels.
BNA adoption and implementation by GHS was carried out in three phases: (1) sensitization and advocacy,
(2) introduction and (3) scale-up. Sensitization and advocacy activities focused on raising awareness about
the value-added to strategic planning and health programming by the BNA approach. Introductory activities
entailed formally presenting the BNA approach to GHS leadership and staff, followed by its subsequent use
to develop strategic and operational plans within GHS programs and divisions. The scale-up process
supported GHS to adopt the BNA approach as its main method for strategic planning and performance
reviews, and helped to mainstream it within the organization at all levels. At the regional level, GHS health
directorates are using the approach to monitor program implementation by districts through routine GHS
program review mechanisms. At the district level, health directorates are using BNA to monitor changes in
equitable coverage by identifying and solving bottlenecks to service delivery.
Case studies in this report highlight various BNA applications within the Ghana Health Service – such as how
one district is using BNA to improve its community management of acute malnutrition (CMAM) program, or
how a municipality used BNA to advocate for a policy change to allow midwives to administer antiretroviral
drugs during antenatal care visits in order to expand service coverage. Based on these successes, the Ghana
Health Service plans to scale up the BNA approach to all districts, and to use of this tool in non-health
divisions as well such finance, administration, logistics and procurement.
There are many valuable lessons from the GHS experience with the BNA approach. First, this tool can be used
for various purposes ranging from strategic planning to equity-focused results monitoring. Second, the BNA
approach supports health system strengthening by highlighting struggling areas of service delivery. Third,
BNA should not be used as a stand-alone process, but instead needs to be integrated into existing planning
and monitoring systems. Finally, successful BNA introduction requires commitment from decision makers
and needs an ongoing cadre of trained BNA facilitators. The successful integration and adoption of BNA into
the GHS can be attributed to intense advocacy, high levels of political commitment among key government
leaders, sustained technical assistance from UNICEF and a cadre of well-trained BNA facilitators.
The report’s case studies draw on in-depth report reviews, meeting notes and other documents related to
BNA implementation in Ghana, along with expert interviews and field visits to districts using the BNA tool.
Table of Contents Executive Summary ................................................................................................................................ v
Tables.......................................................................................................................................................... ii
Abbreviations ............................................................................................................................................ i
Introduction .............................................................................................................................................. 1
Monitoring of Results for Equity Systems (MoRES) .......................................................................................... 1
Situation analysis ............................................................................................................................................ 2
Bottleneck analysis ................................................................................................................................. 4
Overview......................................................................................................................................................... 4
Adoption and implementation ........................................................................................................................ 5
Sensitization and advocacy .......................................................................................................................... 5
Implementation ........................................................................................................................................... 8
Scale-up ...................................................................................................................................................... 8
Case studies: Bottleneck analysis applications in the Ghana Health Service ......................... 9
Case study 1: Development of annual and multi-year strategic and action plans ............................................. 1
Case study 2: Development of the National Newborn Care Strategy 2014 – 2018 ............................................ 3
Case study 3: Monitoring program implementation in the Upper East Region ................................................. 7
Case study 4: MoRES in community-based health programs ............................................................................ 9
Case study 5: BNA for decentralized monitoring to address eMTCT bottlenecks ............................................ 14
Challenges and lessons learned ......................................................................................................... 15
Introduction, adaptation and buy-in .............................................................................................................. 15
Capacity building ........................................................................................................................................... 15
Data quality and use...................................................................................................................................... 16
Planning, development and program implementation ................................................................................... 16
Improved planning and monitoring processes ............................................................................................... 16
Increased coverage and reduced bottlenecks ................................................................................................ 17
Scale-up process ........................................................................................................................................... 17
Conclusion ............................................................................................................................................... 18
References ............................................................................................................................................... 20
Annexes .................................................................................................................................................... 21
Annex 1: BNA example presented at the Kumasi meeting in 2011 ................................................................. 21
Annex 2: BNA example of the eMTCT plans developed for the Eastern Region .............................................. 22
Annex 3: Progress after eMTCT plan implementation in Eastern Region (as of April 2014) ............................. 23
Annex 4: Newborn Care Operational Plan 2014-2016 (Upper East Region): tracer Interventions, bottlenecks
and outputs................................................................................................................................................... 24
Annex 5: BNA example from other Ghana government sectors ..................................................................... 25
Births registration ......................................................................................................................................... 25
Water, sanitation and hygiene (WASH) ........................................................................................................ 25
Education ..................................................................................................................................................... 26
Annex 6: List of persons interviewed ............................................................................................................. 27
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Tables
Table 1: MoRES determinants framework
Table 2: Bottleneck analysis applications in the Ghana Health Service – summary overview
Table 3: Coverage determinants and indicators for the National Tuberculosis Program
Table 4: Coverage determinants and indicators for CEmONC, Upper East Region
Table 5: Coverage determinants and indicators for EPI, Upper Manya Krobo District
Table 6: Coverage determinants and indicators for ANC, Upper Manya Krobo District
Table 7: Coverage determinants and indicators for CMAM, Upper Manya Krobo District
Table 8: Bottleneck causes that affect access to nutrition services, Upper Manya Krobo District
Table 9: Strategies to address bottleneck causes for nutrition services, Upper Manya Krobo District
Table 10: Results monitoring for nutrition, Upper Manya Krobo District (October 2013 – April 2014)
Figures
Figure 1: Bottleneck analysis as applied in the Ghana Health Service
Figure 2: Bottlenecks identified in the CEmONC operational plan, Upper East Region
Figure 3: Bottleneck analysis for CMAM, Upper Manya Krobo District
Figure 4: Unmet needs and geographic disparity in nutrition services, Upper Manya Krobo District
Maps
Map 1: Upper East Region, Ghana
Map 2: Upper Manya Krobo District, Ghana
Boxes
Box 1: The BNA approach for eMTCT strategic planning in the Eastern Region
Abbreviations
ANC Antenatal care
ARV Antiretroviral drugs
BEmONC Basic emergency obstetric and newborn care
BNA Bottleneck analysis
CBA Community birth attendant
CEmONC Comprehensive emergency obstetric and newborn care
CHPS Community-based health planning and services
CMAM Community-based management of acute malnutrition
DHIMS District Health Information Management System
DHS Demographic and Health Survey
EMTCT Elimination of mother-to-child transmission of HIV
EPI Expanded Program on Immunization
GHS Ghana Health Service
MDG Millennium Development Goal
MICS Multiple Indicator Cluster Survey
MNCH Maternal, newborn and child health
MoRES Monitoring of results for equity system
PNC Postnatal care
PMTCT Prevention of mother-to-child transmission of HIV
PPME Policy Planning Monitoring and Evaluation (Division of the Ghana Health Service)
SAM Severe acute malnutrition
UNICEF United Nations Children's Fund
WASH Water, sanitation and hygiene
WHO World Health Organization
Introduction
Monitoring of Results for Equity Systems (MoRES)
In 2010, UNICEF developed the Monitoring of Results for Equity System (MoRES) as part of its central focus
on equity to ensure that UNICEF is as effective as possible in supporting the protection and promotion of
children’s rights, particularly for the most vulnerable groups [UNICEF 2014]. MoRES aims to make more
intensive and strategic use of data in order to inform equitable policy development, to mobilize stakeholders
to identify and solve key bottlenecks to achieving equitable health outcomes, and to strengthen health
system performance at all levels, particularly for vulnerable populations.
MoRES builds on UNICEF’s experience, field presence and programmatic operations in order to link data to
evidence, and subsequently to actions, which is central to addressing child deprivation, reducing barriers to
service use, and promoting efficient resource use to improve children’s health and well-being.
The key elements of the system include:
Determinants framework, or an analytical structure that focuses on deprivation determinants
Indicator identification to measure bottlenecks to reaching vulnerable populations
Data collection and reporting on a frequent basis at sub-national levels for identified
indicators
The determinants framework is used to identify barriers, bottlenecks and enabling factors that either
constrain or advance the achievement of desired outcomes for vulnerable children. It is based on the
principle that certain conditions or determinants need to be fulfilled in order to achieve effective coverage of
services, practices and systems. Identifying these determinants and how they affect desired results for
disadvantaged children is therefore key to developing pro-equity health systems and implementing effective
programs with positive impacts. The framework has ten determinants of effective coverage, which are
grouped into four broad categories: (1) enabling environment (2) supply (3) demand (4) quality (Table 1).
2
Table 1: MoRES determinants framework
Category Determinant Definition Enabling Environment
Social norms Informal or formal rules followed within a society
Legislation/policy Appropriate and supportive laws and policies within a society
Budget/expenditure Adequate and equitable budgets and expenditures in favor of children and vulnerable populations
Management/coordination Effective management and coordination mechanisms
Supply Availability of essential materials/inputs
Regular supply and adequate quality of essential commodities and inputs to services and practices
Access to adequately staffed services, facilities and information
Appropriate infrastructure and qualified personnel of services and information channels
Demand Financial access Direct or indirect costs for available services or practices
Cultural practices and beliefs Social and cultural practices that mediate individual decisions to seek care or adopt desirable practices
Continuity of use Completion or continuity in service
Quality Quality of the intervention Adherence to national and international standards
Situation analysis
UNICEF Ghana has adopted this equity-focused approach in its work with the government to build systems
better able reach the most disadvantaged and deprived populations. As a first step, a situation analysis was
performed in 2011 to identify inequities facing women and children, which drew on updated equity data
collected for this effort.
The 2011 report: ‘A Situation Analysis of Ghanaian Children and Women, A Call for Reducing Disparities and
Improving Equity’ [Government of Ghana and UNICEF 2011] documented various equity issues affecting
women and children in the areas of (1) poverty (2) food security (3) maternal/child survival and development
(4) nutrition (5) water, sanitation and hygiene (6) education (7) child protection. The analysis highlighted
various disparities in the coverage, accessibility and quality of basic services accessed by women and children
across different sectors:
1. Poverty analyses demonstrated important geographical disparities between the southern and northern
parts of Ghana. For example, between 1992 and 2006, the number of people living below the poverty line
declined by 2.5 million in the south but increased by 0.9 million in the three northern regions [Government of
Ghana and UNICEF 2011].
2. Food security analyses documented geographical disparities across rural and urban populations, such that
19% of Ghana’s rural population was food insecure compared to 10% of the urban population. In fact,
geographical disparity in food security was more evident between the north and south regions. While 34% of
the population living in the Upper West region is considered food insecure only 15% are food insecure in the
Upper East region and 10% in the Northern region. Overall, 5% of the Ghana population is considered food
insecure at the national level [Government of Ghana and UNICEF 2011].
3. Maternal/child survival and development analyses highlighted geographical disparities in births attended
by skilled attendants across the north and south regions. In the Northern, Upper West and Upper East
regions, 27%, 46% and 47% births were delivered by skilled providers, respectively, compared to 84% in the
3
Greater Accra region and 73% in the Ashanti region. Moreover, 94% of women in living in the wealthiest
households used a skilled provider during their last birth compared to 24% in the poorest [Government of
Ghana and UNICEF 2011]. Data from the Ghana Multiple Indicator Cluster Survey (MICS) conducted in 2011
similarly showed that 89% of births delivered in the Greater Accra region had skilled assistance compared to
37% in the Northern region [Ghana Statistical Service 2011].
4. Nutrition analyses also indicated geographic and gender disparities such that male children were slightly
more likely to be stunted compared to female children (30% and 26% respectively). Moreover, stunting rates
were highest in the Eastern and Upper East regions (38% and 36% respectively) compared to the Greater
Accra region (14%). Finally, 35% of children living in poorest households were stunted compared to 14% in
the wealthiest [Government of Ghana and UNICEF 2011].
5. Water, sanitation and hygiene analyses showed that the greatest disparities in terms of access to water,
sanitation and hygiene services were between rural and urban populations. Only 6% of the urban population
did not have access to toilet facilities compared to nearly one-third (30%) of the rural population
[Government of Ghana and UNICEF 2011].
6. Education analyses found disparities by region, gender and income group. Results indicated that the
likelihood of a child in the poorest quintile never having gone to school was about 6 times that of a child in
the wealthiest quintile. Similarly, the chance of a child in a rural area never having gone to school was twice
that of a child in an urban setting. In addition, a child in the Northern region is 4 times more likely to not have
attended school compared to a child in the Ashanti region. In terms of gender disparities, It was noted that
Ghana will likely achieve MDG3 (eliminating gender disparities in primary and secondary education) by 2015
[Government of Ghana and UNICEF 2011].
7. Child protection analyses noted disparities by region such that child labour was high in agricultural
communities. Moreover, traditional and harmful practices (e.g. female genital mutilation) were primarily
found among ethnic groups living in northern Ghana. It was also documented that 50% of all street children
lived in Greater Accra and another 25% lived in Ashanti region’s city of Kumasi [Government of Ghana and
UNICEF 2011]. The 2011 Ghana MICS indicated that less than half (47%) of children under five living in the
poorest household had their births registered compared to 82% of children in the wealthiest households
[Ghana Statistical Service 2011].
4
Bottleneck analysis
Overview
After the situation analysis was completed, the Ghana Health Service (GHS) adopted the bottleneck analysis
(BNA) approach based on MoRES for planning equity-focused interventions and identifying bottlenecks in
their uptake (Figure 1). The Policy Planning Monitoring and Evaluation (PPME) Division of the GHS led these
activities, including implementation, capacity-building and advocacy efforts with important technical and
financial support from UNICEF.
The bottleneck analysis (BNA) was adapted from the Tanahashi’s health service coverage evaluation model
[O’Connell TS, Sharkey A 2013]. Tanahashi’s approach to assess health system bottlenecks moves attention
beyond access to health services to the actual use of these services by various sub-populations. This
approach forms the basis for assessing equity in outcomes across various at-risk groups. The adapted
approach used in Ghana examines both effective coverage and health services quality using six main
determinants of coverage, including:
Availability of essential commodities
Availability of human resources
Accessibility of distribution points for the interventions
Initial utilization of the intervention
Continuity/completeness in the utilization of an intervention
Quality of the intervention delivered
An important modification made to the original Tanahashi model was the introduction of the concept of a
tracer intervention. A tracer intervention is one that is representative of a larger set of related health service
interventions. An analysis of health system bottlenecks that impact upon the effective coverage of the tracer
intervention can reasonably be generalized to being a bottleneck that is faced by all the interventions in that
package. For example, assessing bottlenecks to effective coverage for polio vaccine can be a proxy for
assessing bottlenecks to coverage for all routine child immunizations [O’Connell TS, Sharkey A 2013].
Although the Excel-based BNA tool used in Ghana does not explicitly capture indicators on policy, legal, social
norms and budget-related factors that shape the determinants of coverage, these cross-cutting factors are
systematically considered as part of analyzing each identified bottleneck for its root causes. Importantly, the
adapted Tanahashi model, if used with data disaggregated by geographic area, wealth, or other population
attribute, could also identify disparities in access and use of services among sub-national groups. In addition,
when this analysis is combined with a causal examination of non-financial and financial barriers to service use
among at-risk populations, a more equity-focused set of health policies, strategies, and investments can
subsequently be developed.
5
The underlying principles of the bottleneck analysis approach have previously been used by the GHS as part
of the Marginal Budgeting for Bottlenecks (MBB) tool [Soucat A, Van Lerberghe W, Diop F, et al 2002]. This
tool was previously used to budget national-level strategies in order to expand coverage with essential health
services. The MBB, which is also a BNA-based approach, was adapted from the 1978 Tanahashi model and
developed by UNICEF, World Bank and the World Health Organization (WHO). Since 2002, that tool had been
used to help governments prioritize national strategies for overcoming bottlenecks by evaluating various
scenarios, their different health impacts and associated costs [Soucat A, Van Lerberghe W, Diop F, et al 2002].
Figure 1: Bottleneck analysis as applied by the Ghana Health Service
Source: Onyango S, Augustin R, Osborne C et al (2012) Application of the Bottleneck Approach in eMTCT. MNCH in Central and Eastern
Regions of Ghana
Adoption and implementation
UNICEF initiated discussions about the BNA tool with the PPME Division of the GHS in 2011. During these
meetings, evidence-based examples were provided to demonstrate how this approach had already been
used in northern Ghana to improve programming and focus attention on the most deprived groups. BNA
adoption and implementation was subsequently carried out in three phases: (1) sensitization and advocacy
(2) introduction (3) scale-up.
Sensitization and advocacy
Sensitization and advocacy activities focused on raising awareness about the approach, including its value-
added to strategic planning and health programming. These efforts began in December 2011 during the
GHS/UNICEF Annual Performance Review meeting in Kumasi. At this meeting, GHS senior management
review health system performance in the previous year, and plan work priorities for the upcoming year.
6
Participants represent officials from all Ghana regions including (1) Regional Director of Health Services (2)
Regional Deputy Director for Public Health and (3) District Directors for Health Services. This meeting was
selected since participants have the authority to either adopt or reject the BNA approach for their regions.
During this meeting, the BNA approach was introduced as a method for equity-focused strategic planning
and monitoring program results. The seven steps constituting the BNA approach were described to
participants, followed by a practical example demonstrating how the approach identifies health system
bottlenecks and disparities in service use. Methods were described on how to conduct a causal analysis of
major bottlenecks, to prioritize solutions addressing bottlenecks, and to implement proposed interventions.
Specifically, the example presented during the workshop was based on the Community Management of
Acute Malnutrition (CMAM) program conducted in the three northern regions (Annex 1). In 2010, the Wa
West district had been struggling with constant high defaulter and low cure rates for Severe Acute
Malnutrition (SAM). The District Director formed a committee to resolve the issue using the BNA approach.
Data analysis using this approach was done collaboratively through various consultations with the District
Health Team and community members. Major bottlenecks were identified, such as community perceptions
of malnutrition as a spiritual issue rather than a medical one, and low health staff motivation to address the
problem due to staff turnovers as well as skill gaps/poor training to run an effective CMAM program.
Solutions were implemented to address these barriers, and program results indicated an increase in SAM
cure rates from 55% in the first quarter of 2011 to 93% in the first quarter of 2012. This presentation greatly
interested participants who returned to their regions and debriefed staff on BNA and its benefits.
The second advocacy event on the BNA approach was conducted in July 2012 during the Annual District
Directors meeting held in the Wa District, Upper West Region. During this meeting, a UNICEF Health and
Nutrition specialist presented concrete examples of how the BNA approach could be used for strategic
equity-focused planning and monitoring program results. BNA templates were presented for the following
sectors: (1) skilled birth delivery (2) immunization (3) integrated community case management and (4)
community management of acute malnutrition.
On the second day of the meeting, District Directors and their teams gained hands-on experience with the
BNA approach using templates provided. Each district team used local data to develop action plans using the
BNA tool to address and monitor equity issues in their districts. This advocacy event successfully created an
understanding of the added value of the BNA approach, and how the approach could help achieve their
objectives to strengthen local health service delivery.
Following this event, BNA orientation and planning meetings were held in July–August 2012 for the Upper
East, Upper West and Northern regions during their semi-annual health review meetings. Participants to the
meetings were Regional and Deputy Regional Directors, District Directors, Public Health Officers, sub-district
leaders and various program managers in the three northern regions. The objectives included: (1) achieving a
common understanding of equity programming (2) describing the bottleneck analysis and monitoring at
decentralized (community and sub-district) levels (3) agreeing on tracer interventions and how to calculate
key indicators for the analysis (4) identifying initial districts and start dates for conducting more intensive
BNA training (5) outlining next steps and the way forward. Importantly, these meetings also highlighted how
the BNA approach could better structure performance review sessions and monitoring health indicators in
districts. For example, each district could present on their top and worst performing indicators along with
7
causes of this performance, and solutions to improve outcomes in struggling areas. Finally, each region
selected a team of facilitators to train districts and represent their region at national BNA activities.
These advocacy events resulted in great interest in the BNA approach by regional health directorates. For
example, in late 2012, the Upper East Health Directorate contacted UNICEF to support their use of the BNA
approach during mid-year reviews and performance reporting on health indicators. Similarly, the Eastern
Region Health Directorate also requested UNICEF support to use BNA to develop a plan to eliminate mother–
to-child-transmission (eMTCT) of HIV (Box 1).
Box 1: The BNA approach for eMTCT strategic planning in the Eastern Region
In 2011, the HIV Sentinel Survey Report showed that the Eastern region had a 3.6% prevalence rate, which
was the second highest in the country. This spurred their interest in using the BNA approach to develop a
plan to eliminate mother– to-child-transmission (eMTCT) of HIV and improve health outcomes in this sector.
The Central region was also included in the BNA training since it had the highest HIV prevalence in the
country.
The BNA training was conducted in September 2012 and included 206 participants from both regions (118
from the Eastern region and 88 from the Central region), and was facilitated by GHS staff and consultants.
This workshop emphasized how to use the BNA approach to develop strategic plans and targeted
interventions using local data. eMTCT plan development followed the seven steps of the BNA approach and
interventions recommended were also aligned with the National Prevention of Mother To Child
Transmission (PMTCT) of HIV Plan 2011 – 2015. The plan focused on the most deprived districts and the
most urgent issues identified as bottlenecks to service delivery:
Strengthen coordination mechanisms
Increase demand through community involvement
Improve quality of MNCH services, including PMTCT
Strengthen implementation capacity of health facilities
Implement innovative approaches
After the initial training, both regions held district training sessions to help develop their eMTCT plans.
These sessions resulted in 38 district eMTCT plans (21 and 17 for the Eastern and Central regions, see Annex
2). Performance reviews of progress made in removing bottlenecks for the period 2012-2014 showed
progress in the Eastern region. For example, the proportion of HIV-exposed infants exclusively breastfed for
the first six months of their life increased from 5% to 27% between October 2012 and April 2014. Similarly,
the number of health facilities collecting dried blood spot specimens for PCR tests rose from 5% to 73% in
the same period (Annex 3).
8
Implementation
The BNA approach was formally introduced to officials within the GHS through workshop settings. During
these workshops, the BNA approach was introduced to participants through presentations and plenary
discussions. Participants were then divided into groups by geographical area of operation. Each group was
assigned a facilitator for initial BNA practice sessions, which was followed by a practical assignment related to
their area of work. These assignments included the use of the BNA approach to develop district micro-plans
for specific health programs or to create action plans to feasibly and effectively address equity issues in their
districts. Groups also examined how to replicate the BNA approach nationwide.
Scale-up
Scale-up activities examined how lessons learned during pilot testing could help build an evidence-base for
applying the BNA approach throughout the organization, and/or could help guide strategic plan development
in other divisions within the GHS, such as procurement and finance.
The Director of the PPME Division facilitated the scaling up process, and appreciated the value that the BNA
approach brought to the work planning process. Indeed, it was his decision to use the BNA tool as the main
GHS planning and monitoring approach at all levels, which also benefitted from UNICEF’s technical and
financial support to help mainstream it within the organization.
On January 22, 2013, a technical meeting was held at PPME to formally introduce the BNA approach to its
staff. In February 2013, a five-day session was held to train a cadre of facilitators on the BNA approach who
would then be responsible for conducting all regional and district trainings. A training workshop at the
national level was subsequently held for all regions followed by various regional and district level trainings.
9
Case studies: Bottleneck analysis applications in the Ghana Health Service
The bottleneck analysis was applied in various ways within the GHS at the national, regional, district and
municipality levels. Table 2 highlights these different applications, which are the basis for more detailed case
studies in this section.
At the national level, the BNA approach was used to support development of GHS 2013 Annual Health Plans,
and was used again to create the GHS 2014 Annual Health Plans (and will be used in subsequent years as
well). The Family Health Division within GHS also used the BNA approach to develop a National Newborn
Strategy and Action Plan for 2014–2018. The BNA approach also helped to develop the GHS Five-Year
Medium-Term Strategic Plan 2014–2018. For this plan all GHS Divisions used the BNA approach for long-term
planning, including many health support areas such as procurement, logistics, finance and administration.
At the regional level, the BNA approach is being used to review program implementation across regions. At
district and municipal levels, this approach is being used to monitor results of programs to improve the
equitable provision and use of health services.
Table 1: Bottleneck analysis applications in the Ghana Health Service – summary overview
GHS Division, Directorate or Municipality
BNA application Bottleneck identified Solution/Outcomes
Case study 1 Program Planning Monitoring & Evaluation Division (GHS)
Development of annual and multi-year strategic and action plans
Various bottlenecks specific to regions and districts
Contextual plans specific to an area versus previous practice using a common template Strategic plans accompanied by budgets based on the various costs of eliminating bottlenecks versus prior plan where activities fit a budgetary figure BNA user manual
Case study 2 Family Health Division (GHS)
Development of strategies: One national newborn care plan accompanied by two regional and district operational plans
Various bottlenecks specific to regions and districts as per nine pre-identified tracer interventions
One National Newborn Care Strategy 2014 – 2018 Two regional Newborn Care Operational Plans, 2014 – 2016 13 District Newborn Care Operational Plans 2014 – 2016 Newborn care indicator dictionary
Case study 3 Upper East Health Directorate, Bolgatanga
Monitoring program implementation
Various bottlenecks specific to each district
Trainings, support, site visits and supervision individualized to a district’s needs
Case study 4 Upper Manya Krobo District Directorate
Decentralized results monitoring for equity
Supply and geographic access: Only 40% of communities live within 2 km of a health facility
Increased outreach and number of health posts to increase access to nutrition services
Demand and cultural practices and norms: community does not consider malnutrition a health issue, but spiritual issue
Key messages on nutrition developed and distributed to communities
Demand and initial utilization: Only 22% of the expected CMAM cases are seen
Community health workers trained on active case search for malnutrition cases
Quality: Quality of malnutrition counseling and active case search is affected by community perceptions of malnutrition as a spiritual issue, not a health issue
Training of health workers on how to overcome community’s perceptions of malnutrition
Case study 5 New Juaben Municipality
Decentralized results monitoring for equity
Enabling environment and policy framework: ARVs should be administered by doctors only
National policy amended to allow midwives to administer ARVs
Geographic access: Access to health personnel (doctors) who can give ARVs during ANC visits
Once the policy amendment took effect, midwives were trained to administer ARVs and health facilities were stocked with appropriate drugs
Case study 1: Development of annual and multi-year strategic and action plans
GHS PPME is using the bottleneck analysis approach for contextualized and targeted planning. This means
that instead of sending a planning template to its constituents, PPME is now asking all Divisions and
Programs to use the BNA approach to develop their own individualized plans.
As part of the planning process, guidance has been issued to Divisions and Programs regarding definitions of
the six determinants of coverage. Specific definitions of these determinants were uniquely issued to each
national program sector and for each tracer intervention. For example, Table 3 summarizes indicator
definitions used for each coverage determinant for case finding and treatment interventions within the
National Tuberculosis Program.
Table 3: Coverage determinants and indicators used in the National Tuberculosis Program
Coverage determinant
Indicator definition
Commodities Proportion of facilities in districts without a month stock-out of category 1 TB drugs or diagnostic kits
Human resources Proportion of health facilities with at least one staff trained within the past 3 years in the detection, management and treatment of TB cases
Access Proportion of sub-districts with at least one facility providing DOTS services
Initial utilization Proportion of TB cases detected and put on treatment
Continued utilization Proportion of TB cases with sputum smear microscopy done at 5 month who completed treatment
Proportion of TB cases who completed treatment
Quality Proportion of TB cases cured
According to PPME key informants interviewed as part of this study, the effect of using BNA for planning
purposes was as follows:
Process to improve plans
Individualized planning for each region and district. In previous years, sub-national plans were very
similar to each other since they were developed from a common template.
Targeted funding identified against solutions developed to solve specific bottlenecks, which is
different from previous years.
Teamwork spirit and togetherness because teams now have to sit together and use various BNA
tools to develop their plans.
Ownership by regions of their plans because they use their own data to develop them unlike
previous planning sessions where standardized templates were handed down for use.
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Lessons learned
Planning workshops need more time devoted to teams working and developing plans with the BNA
tools versus academic presentations on the BNA approach.
Pre-workshop assignments are needed for a more productive planning session, and teams should be
required to perform some pre-workshop activities (e.g. compile certain data for use in workshops).
No funding guarantee should be emphasized to teams, and that using the BNA approach for strategic
planning is not a guarantee of funding to implement those plans.
Challenges
BNA tool: Teams have found the BNA excel tool to be complicated and biased towards MNCH
interventions.
Data quality: Low quality or lacking data has affected the ability of teams to develop complete plans.
Funding expectations: Previously, regional teams linked the BNA to UNICEF so there was an
impression that funding of these plans would also come from UNICEF. Motivation was affected when
funding was understood to come through regular government mechanisms, which may be delayed.
Outputs
Focused and targeted plans that are also costed against identified solutions.
BNA manual has been developed by GHS PPME to serve as an aid to using the BNA approach for
planning purposes. The manual was made available at the end of 2014.
Scale-up and next steps
As indicated above, the GHS is using BNA in 2014 for annual planning work and to develop its
Medium-Term Strategic Plan (2014–2018). All GHS directorates will be required to use the BNA
approach for individual MTF plans including many non-health sectors such as procurement, logistics,
finance and administration.
For more information on this case study, contact Erasmus Agongo at +233 244 293 835 or
[email protected] or Dan Osei Deputy Director, PPME, GHS at +233 244 364 221 or
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Case study 2: Development of the National Newborn Care Strategy 2014 – 2018
Ghana has various child health focused policies, such as the National Health Policy; Expanded Program on
Immunization (EPI); and various programs on tuberculosis (TB), malaria and HIV. However, there is a gap on
specific policies focusing on newborn care.
Recognizing the gap in newborn care and taking advantage of a global newborn care strategy released in
2013, the Government of Ghana (with support from UNICEF) has developed a National Newborn Strategy for
2014–2018. UNICEF has also supported the development of 3-year operational plans for the Northern and
Upper East regions and 13 districts in those regions.
To facilitate plan development, the BNA methodology was used to enable national, regional and district
teams to use their own data to set targets and identify and solve bottlenecks that affect newborn care. As an
initial step, a national-level BNA training-of-trainers (ToT) was held for officers from the Family Health
Division and 10 regional representatives. This activity was followed by a five-day BNA training session for the
Northern and Upper East regional and district teams. There were subsequently more focused sessions for the
regions and districts to support them in developing and completing their plans.
During the plan development process, teams were required to use data derived from the District Health
Information Management System (DHIMS), Multiple Indicator Cluster Surveys (MICS) and Demographic and
Health Surveys (DHS). After compiling these data, teams entered data into the BNA tool and generated
outputs used to identify service coverage-related bottlenecks.
After prioritizing the most important bottlenecks, teams conducted a causal analysis, identified solutions, and
developed strategies to correct the situation. These strategies were then costed and used to develop action
plans in order to guide implementation and program monitoring at regional and district levels.
Specifically for the newborn care strategy, the BNA tool was modified with nine sub-sections representing
critical newborn tracer interventions, including:
1. Management of pre-term birth - focus on antenatal corticosteroids
2. Skilled care at birth - focus on the use of the partograph
3. Basic emergency obstetric and newborn care (BEmONC) - focus on assisted vaginal delivery
4. Comprehensive emergency obstetric and newborn care (CEmONC) - focus on caesarean section
5. Basic newborn care - focus on cleanliness including cord care, warmth, and feeding
6. Neonatal resuscitation
7. Kangaroo mother care - focus on skin-to-skin contact, breastfeeding and feeding support for
premature and small babies
8. Treatment of severe infections - focus on using injectable antibiotics
9. Inpatient supportive care for sick and small newborns - focus on IV fluids/feeding support and
safe oxygen
Once the tracer interventions were identified, six BNA coverage determinants were defined for each
intervention. Table 4 summarizes coverage determinants and indicators for CEmONC.
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Table 4: Coverage determinants and indicators for CEmONC, Upper East Region
Coverage determinant
Indicator definition
Commodities Proportion of hospitals with no stock-outs of blood products for transfusion, facilities for caesarean section and emergency package (oxytocin, magnesium sulfate) and over the last 3 months
Human resources Proportion of hospitals with at least one doctor able to conduct caesarean section in the last 6 months
Access Proportion of districts with hospitals providing CEmONC continuously in the last 3 months
Initial utilization Proportion of pregnant women who had assisted delivery in the hospital in the last 6 months
Continued utilization Proportion of pregnant women who delivered by caesarean section in the hospital in the last 6 months
Quality Proportion of pregnant women who had assisted deliveries with live births in the last 6 months
Once the determinants for each intervention were identified, bottlenecks were defined and discussed among
participants. Figure 2 provides an example of bottlenecks identified for CEmONC in the Upper East Region. In
this example, specific bottlenecks identified included: (1) few districts (6 of 13) in the UER had hospitals that
provided CEmONC continuously over the last year and (2) there was no data on the number of pregnant
women who had assisted delivery with live births, nor for the second PNC visit at day 6 or 7 in the last year.
In fact, few districts (7 of 13) even had hospitals, which was the main challenge to providing comprehensive
obstetric care in the region.
Limited data to monitor effective coverage, including initial and continuous utilization determinants, was
identified as a challenge. It was noted that service providers did not routinely report the following data: (1)
number of pregnant women who had assisted delivery with live births (2) one postnatal visit within 48 hours
after delivery during the last year and (3) number of pregnant women who had assisted delivery with live
births and a second postnatal visit at day 6 or 7 in the last year. These indicators were neither part of the
DHIMS nor key GHS performance indicators.
Figure 2: Bottlenecks identified in the CEmONC operational plan, Upper East Region
Source: GHS Upper East Region Directorate Bolgatanga; Upper East Region Operational Plan for Newborn Care 2014 - 2016
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After identifying bottlenecks, the teams specified outputs and activities needed to improve effective
coverage for tracer interventions.
Expected CEmONC outputs:
Increase the number of districts in the UER with health facilities providing CEmONC continuously in the past year from 6 to 13 (or 100% of all districts) by end-2016
Increase the proportion of pregnant women who had assisted delivery with live births and had a second PNC visit on day 6 or 7 in the past year to 60% by end-2016 (from no currently available data)
Establish a data capture system for information currently lacking, as described above Expected activities to achieve CEmONC outputs:
Equip health facilities in all 13 districts to provide CEmONC over the next 3 years
Strengthen referral and response systems through staff training
Set up blood banks in hospitals
Equitably distribute the limited number of doctors among health facilities in the region
Put basic measures in place to retain doctors in health facilities
Strengthen community engagement and education within districts in order to empower women and families to demand skilled birth attendants during delivery
A similar process was repeated for all tracer interventions and identified bottlenecks (Annex 4). Thereafter
each team developed a roadmap on how to implement the newborn strategy starting from 2014.
Process to improve plans
Participatory development of plans: Development of the National Newborn Care Strategy and
operational plans for the Northern and Upper East regions was participatory and involved key
stakeholders. Use of the determinant framework and the BNA tool ensured that bottlenecks to
newborn care were well identified and analyzed.
Targeted funding: According to key informants involved in this process, when the teams discussed
solutions to address bottlenecks and estimated the investment required to remove them, it
contributed to evidence-based decision-making for funding proposals. This was unlike previous
strategy development processes where plans would be made to fit a certain budget.
Ownership: At a regional level, teams had a high level of ownership of their developed plans in large
part due to using their own data to create plans that addressed local service delivery issues.
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Lessons learned
Data gaps: The development of the national strategy and operational plan using the BNA
methodology made the GHS/Family Health Division realize there were gaps in newborn care data
reported in routine data collection mechanisms.
Standard indicator definitions: The participatory approach used to develop the strategy and plans
also highlighted the need to standardize indicator definitions used in newborn care.
Challenges
Data gaps: As previously mentioned, using the BNA approach to develop the newborn care strategy
and operational plans was hampered by data availability and quality, which is critical to developing
accurate outputs.
Outputs
Well-targeted, focused and costed newborn care strategy and regional operational plans: Each
operational plan was unique to the region or district for which it was developed since it used local
data to identify local service delivery issues. Previous plans were often generic based on a template.
Improved data collection mechanisms: There was an overall recognition of the data gaps for this
process, either because routinely collected DHIMS data were lacking or low quality. A decision was
made to strengthen the quality of data collected and to add certain indicators that were considered
crucial to monitoring implementation of the newborn care strategy. The Family Health Division also
revised its registers to include the below indicators in their routine data systems, and is working on
adding other relevant indicators as well.
1. Post-natal visit within the first week of delivery
2. Two postnatal visits within six weeks of delivery
3. Causes of newborn death
Indicator dictionary: During this process, it also became evident to participants and key Ministry of
Health leadership that there was confusion about various indicator definitions. This prompted the
Family Health Division to develop an indicator dictionary in order to standardize indicator definitions
for newborn care.
For more information on this case study, contact Isabella Sagoe-Moses, National Child Health Coordinator,
GHS Accra, +233 244 646 065 or at [email protected]
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Case study 3: Monitoring program implementation in the Upper East Region
The Upper East Region is located in the north eastern corner of Ghana and borders Burkina Faso to the north
and the Republic of Togo to the east. The district is 8,842 sq. km in area and had an estimated 2010
population of 1,071,813 people organized into 911 highly dispersed communities. The region is divided into
13 administrative districts and 67 health sub-districts.
Map 1: Upper East Region, Ghana
Source Upper East Region Newborn Care Operational Plan 2014-2016
In 2012, the Upper East Region held a meeting for its districts and sub-districts to introduce the BNA concept
and to ask districts to report their annual performance going forward using this method. During the next
review meeting, as districts presented their data it was clear that certain districts performed poorly in all
indicators, while others performed well overall. The Regional Health Director expressed his support for the
BNA approach to monitor program performance and to highlight areas that needed improvements. He also
encouraged peer-to-peer learning processes, and welcomed district directors to learn from each other.
More recently in 2013, the UER had a similar BNA workshop aimed at sharpening the regional and district
directors’ ability to use the BNA approach for planning, implementing and monitoring health programs.
During this meeting, the need to focus on specific bottlenecks affecting performance was emphasized. Each
district then identified priority interventions to remove identified bottlenecks in health service delivery.
Monitoring results
Incorporating the BNA approach into existing review mechanisms: The existing GHS review mechanism is
being used to monitor progress in addressing these bottlenecks. As part of this process, each district uses an
excel spreadsheet to report on changes in bottlenecks and their indicators. Coverage indicators reviewed are
those submitted by the district to the GHS during annual plan submissions, and these determinants and
indicators vary by program. Districts are also asked to report on challenges faced during implementation as
part of reporting on how bottlenecks are being addressed. Districts that are unable to adequately address
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bottlenecks are supported through site visits and other mechanisms, such as peer-to-peer learning,
commodities/logistics support and other means where possible.
Evidence-based review and accountability mechanism: The BNA approach is an evidence-based method to
monitor district performance in program implementation, and to gauge overall performance and leadership.
Struggling districts can receive additional training and onsite supervision as per areas of need. This approach
also creates an enabling environment where regional and district workers are motivated to improve services
in part because senior leadership is empowered to assess performance and hold managers accountable.
Linking district performance to awards/motivation: The BNA approach also provides an opportunity to link
district performance to employee performance. Directors of well-performing districts may be further
motivated by opportunities for promotion, or the potential to attend conferences in and out of Ghana as a
reward mechanism. Indeed, awards were formally instituted to encourage best performing districts, and to
further challenge poor performing districts to improve services. For example, motorbikes (Yamaha AG
Models 100 and 200) were provided to the 4 best performing sub-districts during the 2013 Annual Review.
Renovation and expansion of two CHPS facilities and a health centre was carried out by the Regional Health
Management Team as part of rewarding and motivating staff for their good performance during the 2014
half-year performance review. In contrast, if poor district performance was consistently noted despite
coaching and support visits, staff reshuffle was carried out after the 2014 half-year performance review to
help improve district performance and staff output.
Lessons learned
There is a need to support districts struggling with program implementation, such as through site
visitation and supervision support. Importantly, financial and human resources need to be specifically
devoted to such supervisory activities, which are currently limited.
Scale-up and next steps
The Regional Directorate has gained experience on how to use BNA to identify, monitor and address
bottlenecks that affect program implementation, and to provide support to yield better performance results.
There is strong interest to act as a centre of excellence from which other regions and districts may learn.
For more information on this case study, contact Dr. J. Koku Awoonor-Williams, Regional Director of Health
Service, UER Bolgatanga, +233 24 456 4120, [email protected]
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Case study 4: MoRES in community-based health programs
This case study examines how the BNA tool was used for the decentralized monitoring of results and equity
system (MoRES) in maternal, child health and nutrition programs, including CMAM, EPI and antenatal care.
The Upper Manya Krobo District is located in the Eastern Region of Ghana and is divided into 6 sub-districts
with a total population of 78,342 people living in 198 communities.
Map 2: Upper Manya Krobo District, Ghana
Source: BNA Scale-up plan, April 2014
The district has 14 health facilities:
1 district hospital
4 health centres
2 maternity homes
1 Reproductive and Child Health (RCH) clinic
6 Community-based Health Planning and Services (CHPS) compounds, which is a facility embedded
within a community where members can access health and family planning services. A CHPS
compound’s catchment area is divided into CHPS zones, and there are 28 CHPS zones each assigned a
community health worker.
The district has successfully employed the BNA approach to address many bottlenecks in various health
areas, such as immunization (EPI), community management of acute malnutrition (CMAM) and antenatal
care (ANC). In 2012, the district received a BNA orientation from the GHS, which was followed by district-led
BNA planning sessions for its sub-districts. These sessions included field visits to all health centres to
introduce the BNA approach and how to use it for planning purposes. The BNA approach was then used by
each sub-district for EPI, CMAM and ANC program planning, and included the following indicators to assess
determinants of effective coverage (Tables 5-7):
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Table 5: Coverage determinants and indicators for EPI, Upper Manay Krobo District
EPI Coverage determinant
Indicator definition
Commodities Proportion of days in the last year with all necessary immunization supplies
Human resources Proportion of staff trained and available to provide immunization services
Access Proportion of population within 1km of an outreach point providing immunization services
Initial utilization Proportion of children aged 0 – 11 months who received PENTA1 vaccination
Continued utilization Proportion of children aged 6 – 11 months who received PENTA3 vaccination
Quality Proportion of children aged 0 – 11 months who received measles vaccination
Table 6: Coverage determinants and indicators for ANC, Upper Manay Krobo District
ANC Coverage determinant
Indicator definition
Commodities Proportion of days in the last 3 months with all necessary supplies
Human resources Proportion of midwives posts filled Access Availability of EmONC facilities (basic) against need/norm
Initial utilization Proportion of pregnant women attending ANC for the first time in the pregnancy
Continued utilization Proportion of pregnant women who had 4+ ANC visits during the reporting period
Quality Proportion of pregnant women who had 4+ ANC visits and received IPTp for malaria
For both EPI and ANC, a common bottleneck identified was geographic access, as communities in the district
are vastly dispersed with most separated by two kilometres. It was also discovered that the sub-districts with
the best geographic access were those that had markets sites with health clinics, namely Akateng, Asesewa
and Anyaboni. Their good geographic access was largely due to the health clinic held on market days.
After this discovery, the district made a decision to increase health access and outreach points. In April 2013,
the district had 89 access points, which increased to 104 by April 2014. Preliminary data suggest that
coverage for measles vaccination increased from 71% to 90% during this time due to these efforts.
In October 2013, following the same process for EPI and ANC, the district subsequently performed a more
detailed bottleneck analysis for CMAM, which included the following coverage determinants and indicators
(Table 7 and Figure 3):
Table 7: Coverage determinants and indicators for CMAM, Upper Manay Krobo District
CMAM Coverage determinant
Indicator definition
Commodities Proportion of days in the last 3 months the health facility had adequate stocks of Plumpy Nut
Human resources Proportion of communities in the sub-district with at least 1 active Community Birth Attendant (CBA) trained to identify SAM
Access Proportion of communities in the sub-district within 2 km of a facility providing CMAM
Initial utilization Proportion of SAM cases identified who initiated treatment in a 3-month period
Continued utilization Proportion of SAM cases who completed a full course of treatment
Quality Proportion of SAM cases who completed a full course of treatment and were cured
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Figure 3: Bottleneck analysis for CMAM, Upper Manya Krobo District
Source Upper Manya Krobo District BNA Scale-up Plan, April 2014
Figure 3 indicates that bottlenecks affecting malnutrition rates included geographic access, initial utilization
and service quality. Once these bottlenecks were identified, the team performed a causal analysis to better
understand the causes of these bottlenecks. The causes were analyzed at personal/household (immediate),
community (underlying) and national (structural) levels (Table 8).
Table 8: Bottleneck causes that affect access to nutrition services, Upper Manya Krobo District Tracer intervention
Bottleneck identified
Why 1 Why 2 Why 3 Management weaknesses Immediate
causes Underlying causes
Structural causes
Malnutrition Only 40% of communities live within 2 km of a health facility
Communities are scattered and far from health facilities
Communty members settle on farmlands
Poverty Absent advocacy for community empowerment and povery alleviation
Main source of income is farming
District has few health facilities
Inadequate funding and support for health facilities especailly CHPS compounds
Weak advocacy and lobbying to higher levels of government and partners
Source: Upper Manya Krobo District BNA Scale-up Plan, April 2014
The tracer intervention selected was malnutrition and the key bottleneck identified was geographic access,
or that only 40% of communities in the district are located within 2km of a health facility. The immediate,
underlying and structural causes were discussed and documented as shown in Table 8. Once the causal
analysis was done, the district developed strategies and activities to address identified bottlenecks (Table 9).
This table also links activities to their costs, and notes the responsible person for implementation.
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Table 9: Strategies to address bottleneck causes for nutrition services, Upper Manya Krobo district
Outputs Strategies Activities Responsible party Cost Increase rate of SAM cases seen
Improve quality of malnutrition information reaching communities
Develop key messages on malnutrition to be delivered to 198 communities
District Nutrition Officer 300
Train 100 health workers on education, promotional materials and communication skills
Training Coordinator 300
Organize monthly and quarterly durbars in communities
District Public Health Nurse 19000
Organize bi-annual local dialect trainings for health workers to promote communication
District Public Health Nurse 1200
Improve staff attitudes towards malnutrition and active case search
Orientation of 150 workers on customer care and patient charter
Training Coordinator 5000
Develop and disseminate active case search forms Health Information Officer 3000
Strengthen monitoring and evaluation at all levels
Develop composite monitoring, supervision and evaluation plans at all levels
Monitoring and Evaluation Officer
1000
Train staff at various levels on the M&E plan Monitoring and Evaluation Officer
2500
Research Conduct annual operational research on malnutrition to assess incidence, prevalence and impact of interventions
Health Information Officer 7000
Source: Upper Manya Krobo District BNA Scale-up Plan, April 2014
Once the district identified solutions, an analysis of met and unmet needs was conducted for each sub-
district in order to advise on equity issues and areas of concentration. Unmet needs were calculated by
analyzing populations per sub-district compared to the availability of nutrition services for populations living
within a 2 km radius. From the analysis, the districts identified with the greatest unmet need for CMAM were
Anyaboni (82%) and Sekesua (92%), which are also the most populated sub-districts (Figure 4).
Figure 4: Unmet needs and geographic disparity in nutrition services, Upper Manya Krobo District
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Source: Upper Manya Krobo District BNA Scale-up Plan, April 2014
Program implementation
Once bottlenecks and worst performing areas were identified, a decision was made that the greatest impact
on equity would be achieved by focusing on the two most populous sub-districts, which also had the greatest
unmet needs for CMAM. Job aids and surveillance tools were developed for implementation purposes. To
improve staff attitude towards malnutrition, the district held a one-day staff orientation to discuss good
customer care and the patient’s charter.
A major issue discussed at the orientation was the fact that community members do not perceive
malnutrition as a major and preventable health issue, as is perceived for diarrhea or malaria. Instead,
malnutrition is generally perceived as a spiritual issue caused by ancestors. It was found that health workers
needed sensitization and training to make them more aware that active malnutrition case searches would
require them to ask households about unwell children rather than a child sick due to illness. The district also
developed and disseminated active case search forms to be used as job aids by health workers.
To improve quality of malnutrition information to the community, the district developed key messages on
malnutrition for the 198 communities and trained health workers on how to use these materials to improve
the state of nutrition in their communities.
Results monitoring
Since the district initiated the BNA approach for CMAM and began program implementation to address
bottlenecks, communities located within 2km of a health facility increased from 40% to 45%; initial utilization
improved from 22% to 59%; and cure rates rose from 2% to 32% (Table 10).
Table 10: Results monitoring for nutrition, Upper Manya Krobo District (Oct 2013 – April 2014)
Coverage determinant and indicator October 2013 (%)
April 2014 (%)
Commodities Proportion of days in the last 3 months the health facility had adequate stocks of Plumpy Nut
100 100
Human Resources Proportion of communities in the sub-district with at least 1 active Community Birth Attendant (CBA) trained to identify SAM
83 90
Access Proportion of communities in the sub-district within 2 km of a facility providing CMAM
40 45
Initial Utilization Proportion of SAM cases identified who initiated treatment in a 3-month period
22 59
Continuous Utilization Proportion of SAM cases who completed a full course of treatment
- 41
Quality Proportion of SAM cases who completed a full course of treatment and were cured
2 32
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Lessons learned
The following challenges and lessons learned for the BNA approach were documented in this district:
Inadequate resources to address major bottlenecks
Difficult to address geographic access bottlenecks, such as bad road networks and rivers
Need to address underlying factors that affect CMAM cases, such as HIV/AIDS
Scale-up and next steps
The district wants to conduct another monitoring and supervisory visit to all health centres and collaborate
with health workers to conduct a bottleneck analysis for TB, PMTCT, surveillance and health information
systems. The district will also ask sub-districts to use the BNA approach for their 2014 work plans.
For more information on this case study, contact Kwame Agbeshie, District Health Information Office GHS,
Upper Manya Krobo, [email protected]
Case study 5: BNA for decentralized monitoring to address eMTCT bottlenecks
The BNA approach was used as a planning tool for eMTCT in the New Juaben Municipality. This municipality
recognized that there was low coverage with maternal ARVs among ANC clients in the area. This was largely
due to a key structural cause, notably a policy that ARVs could only be administered by doctors. Yet, doctors
within the local health system are mostly stationed at district hospitals and this limits access to maternal
ARVs for ANC attendants at lower level facilities manned by nurses or midwives.
To solve the problem, the municipality engaged in advocacy activities to have the policy amended so that
midwives would also have the authority to administer ARVs during ANC visits. While this process was already
underway, the municipality was instrumental in providing evidence to support the policy revision to allow
midwives to administer ARVs. Once the policy change occurred in 2013, all midwives in the municipality were
trained on how to administer ARVs, and all facilities were stocked with these medicines. Since this time, ARV
use among mothers attending ANC increased from 35% in October 2012 to 78% in April 2014.
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Challenges and lessons learned
Introduction, adaptation and buy-in
Audience selection for initial sensitization to the BNA approach is critical since the methodology can either be
well received or ignored. People selected for initial sensitization activities should include decision-makers
(e.g. Regional or District Directors of Health Services) or people that can influence decision-makers (e.g.
Deputy Directors).
As part of the introduction, concrete examples linked to evidence should be presented that show the BNA
approach’s value-added in terms of specific interventions and addressing equity issues. This introduction
needs to be in line with the language used by the target audience, and presenters need to be closely familiar
with the organization’s systems, services and needs.
For the GHS, UNICEF chose to introduce BNA during an annual meeting attended by Regional and District
Directors of Health Services and the Deputy Directors of Public Health. At this meeting, the BNA example
highlighted its use in the Northern Region to detect and solve bottlenecks affecting CMAM, and evidence was
shown of improved cure rates after implementing solutions to bottlenecks. This example showed the
practical use of the BNA approach in districts with proven success to improve services. After this meeting, the
Directors returned to their regions understanding the BNA approach, its practicality and how it may be used
to develop and implement equity-focused strategies, plans and interventions.
Capacity building
People selected to lead the process as trainers and/or facilitators should be knowledgeable about the BNA
approach, services offered by the organization and challenges to extending services into hard-to-reach areas.
The facilitators should also have a good understanding of data collected by the organization, how the data is
used to measure service provision targets and data challenges faced when not all people access services. This
knowledge is important because the BNA application includes the use of a quantitative tool to calculate
coverage, which uses different information sources to derive numerators and denominators. First-time users
will find these data issues challenging, and will need a knowledgeable facilitator to help navigate the
quantitative tool. The facilitators should also be able to guide participants on how to calculate coverage
when data quality is low and/or offer alternative data sources when information is missing. Such facilitators
are best sourced from within the organization.
Once there is a cadre of well-trained facilitators, it is important to maintain an appropriate number that can
conduct trainings around the country. It is also crucial to conduct regular refresher and cross-trainings among
staff to increase the number of facilitators. Regular staff transfers present a challenge to maintaining this
knowledge at facilities and may create a gap in trained facilitators, especially at the regional and lower levels.
In the case of GHS, most facilitators came from within the organization that included a mix of facilitators
from the central, regional and district levels.
Finally, financial resources to support effective training have also been a challenge. Ghana Health Service’s
own contribution to sustaining this effort is key in addition to support from various development partners.
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Data quality and use
Data must be available and complete to achieve an accurate bottleneck and causal analysis. As previously
mentioned, two information sources are generally used to calculate coverage (one to determine the
numerator and the other for the denominator), and care is needed to use correct data to derive coverage
estimates.
The key is to have a well-trained facilitator who can lead the process and help users navigate through the
various data sets. A major challenge faced during this process is data availability and quality. At the same
time, this process can reveal data system weaknesses and also highlight data routinely collected that is not
used, or data that would be more useful to routinely collect. This was clear during the development of the
National Newborn Care Strategy where certain indicators crucial to monitoring newborn care progress were
not routinely collected by the DHIMS. This made it impossible to calculate coverage of certain key
determinants of newborn care, and the bottleneck analysis was noted as lacking routine data for these
indicators. Upon this discovery, the indicators were added to the system.
In areas with limited routine data, other approaches were used to complement the BNA. For instance an
LQAS was conducted in the three northern regions in 2012 to evaluate coverage of selected child survival
interventions. Other quantitative and qualitative methods were used to complement BNA to monitor CMAM
program implementation. In November 2013, two surveys were conducted in six districts of the three
northern regions to evaluate access and coverage of CMAM programs, using both quantitative and
qualitative methods to identify bottlenecks and barriers. Implementation of action plans developed from this
process subsequently led to increased treatment of severely malnourished children in the first half of 2014.
Planning, development and program implementation
BNA is not a stand-alone concept, and its application both relies on and can strengthen ongoing performance
monitoring mechanisms. For strong implementation, BNA needs to draw on well-established and reliable
data collection systems in order to identify bottlenecks and interventions needed to address them. Regular
performance reviews and monitoring systems must also be in place to monitor the impact of these efforts.
While initial BNA discussions must include policymakers who can decide to adopt the BNA approach within
their organizations, subsequent strategic planning and training sessions need to include technical and
program, information management, and monitoring and evaluation officers as well as other key staff. At
these planning workshops, participants should be grouped by geographic area and assigned a trained
facilitator to guide the BNA application process. If BNA is used to analyze a specific outcome, pre-workshop
assignments may be needed, such as specific data collection activities. For district and sub-district BNA
planning sessions, it would be valuable to ask community members to participate, particularly in the causal
analysis discussions. Community members may have insights into bottleneck causes that district planners
may not well-understand. Community-based organizations in the district should also be included in sessions.
Improved planning and monitoring processes
According to key informant interviews, the BNA approach has improved the quality of planning and
monitoring health services within the GHS. For planning purposes, BNA allows users to develop interventions
17
based on specific bottlenecks identified in local communities. An action plan may then be developed to
implement identified interventions, including timelines, financial and human resource needs, and assigned
responsibilities. Moreover, the use of BNA has enabled regions and districts to develop individualized plans
based on identified bottlenecks, and to estimate a budget based on these individualized plans. In previous
years, regions and districts were simply given templates and budgets to help plan their work. In addition,
PPME also stated that the use of BNA promoted team spirit and togetherness because BNA encouraged
regional and district teams to work together to develop plans. Finally, teams that used BNA to develop their
annual work plans developed a sense of ownership. Unlike previous planning methods, BNA encourages
participants to develop solutions using local data for obstacles faced in local service provision.
Increased coverage and reduced bottlenecks
The BNA approach is able to reduce bottlenecks that hinder the achievement of high and equitable coverage
with key interventions, if implemented correctly. BNA applications discussed in this report show that the
approach is being effectively used by GHS for strategic planning purposes and to address bottlenecks
affecting the coverage and quality of service provision. At a central level, GHS is using the approach for
equity-focused strategic planning and for developing operational plans that address equity at sub-district and
community levels. These plans are then supported by regular data collection and review systems to monitor,
report and document the impact of progress to remove bottlenecks and to reduce coverage inequities.
For example, one application in this report shows how a region in Ghana is successfully using BNA to monitor
program implementation in its districts. In one BNA application, the tool enabled a district to identify met
and unmet needs for CMAM services, and found that the greatest unmet needs were in the most populous
sub-district. The district therefore was able to efficiently channel its resources to focus on improving
nutrition service provision in its most populous sub-district. In another example, the BNA approach provided
much needed evidence to advocate for a policy change to allow both doctors and other health personnel to
administer ARVs to pregnant women during ANC visits. This helped expand ARV coverage to clients
attending lower level facilities for ANC that are generally without doctors.
Scale-up process
In terms of the scale-up process, in addition to the above lessons learned, it is also important to tailor BNA
discussions and tools to different audiences and to make these tools generic such that they may be tailored
to suit different needs. To this end, it is important to understand the audience and their previous exposure to
BNA in order to avoid repetition, gauge the level of facilitation needed and better use their time for actual
planning work. At district and sub-district levels, regular coverage and impact monitoring with a focus on
equity should be emphasized. Regular support and on-site visits should be conducted by facilitators to
support districts in this work, and to ensure that the District Health Information Officer or the Monitoring
and Evaluation Officer is supported to act as the facilitator to sub-districts.
For more information on lessons and challenges, contact Dr. L. K. Senaya, Public Health Specialist Koforidua;
+233208117304
18
Conclusion
In the 2011 Situation Analysis of Ghanaian Children and Women, Honourable Juliana Azumah–Mensah,
Minister at the Ministry of Gender, Children and Social Protection writes: The achievements of the
Government will be measured not just by the improvement in the political and economic situation, but by how
successful it has been in helping women and children, especially the poorest and most vulnerable realise their
rights [Government of Ghana and UNICEF 2011]. The same report acknowledged that challenges remain in
providing basic services to women and children, especially in rural areas or northern regions, and for
orphaned or vulnerable children too. Challenges also remain in the sectors of nutrition, maternal mortality,
water sanitation and hygiene, child protection, among others.
Overall, the BNA approach used in the Ghana Health Service has been successful as highlighted in case
studies. The organization has used the methodology to reduce bottlenecks and improve service delivery,
particularly for poorest children. Specifically, the BNA approach has improved planning and monitoring
processes, supported development of individualized plans to address local service delivery issues, and
identified actions needed to remove barriers and increase service coverage.
The case studies cited in this report also highlights how the BNA approach has been used at different
government levels. At the national level, GHS must continue to encourage regions and districts to submit
annual work plans based on locally identified bottlenecks to reduce inequities faced by women and children.
Regions and districts, in turn, need to receive annual funding to address these bottlenecks and, in the long-
term, eliminate inequities in accessing essential health services. At the regional level, scaling up the BNA
approach allows regional directors to monitor the performance of different districts in addressing
bottlenecks and to provide support for struggling districts. At the district and sub-district levels, BNA has
been shown to effectively reduced coverage inequities for CMAM, ANC and ARVs as cited in case studies.
The BNA approach also relies upon and must be integrated with ongoing performance review and data
collection systems. For data collection, the existing DHIMS provides critical data for the BNA tool to assess
bottlenecks and monitor progress in removing them over time. DHIMS could also be strengthened by BNA by
highlighting additional information needed for the bottleneck analysis that is not routinely collected and
should be added to the system. For performance reviews, the mid-year and annual reviews are important
points to report on the impact of the BNA approach to address bottlenecks in service delivery, and to
monitor and report on equity results. These reviews are also an important advocacy platform, for sharing
challenges and lessons learned in the use of the BNA tool among districts and regions.
Finally, the BNA approach should not only be scaled up by the GHS to every district, but could also be rolled
out by other government agencies as well. Learning from the GHS experience, agencies dealing directly with
issues affecting women and children would show a positive change in their indicators by using BNA as an
equity-focused approach for planning and monitoring programs.
Indeed, the central issues affecting the lives of women and children in Ghana include: (1) maternal health, (2)
newborn care (3) child health (4) malnutrition, (5) HIV/AIDS including PMTCT (6) water, sanitation and
hygiene (7) access to quality education and (8) birth registration.
19
Government agencies that focus on these issues should also consider the BNA approach to improve
programs and strategic planning with an equity focus. For example, the Ministry of Water Resources, Works
and Housing could use BNA to achieve its mandate of equitably providing water, sanitation and hygiene
services [Government of Ghana and UNICEF 2009]. The Births and Deaths Registry can use BNA to achieve its
goal of registering 90% of all children under five by 2016 [Government of Ghana 2012]. The Ministry of
Gender, Children and Social Protection can use the approach to promote its mandate of achieving equal
status for women and promotion of children’s rights [Government of Ghana, Ministry of Gender, Children
and Social Protection 2014].
Importantly, these three agencies have already begun using certain components of the BNA tool with
UNICEF’s support (Annex 5). Advocacy efforts need to further encourage those agencies to fully adopt the
BNA approach in their programming work. These agencies could in turn learn from the GHS experience,
including the importance of reliable data collection systems and integration into ongoing performance review
mechanisms.
Indeed, an integrated planning approach across government agencies using the BNA tool could lead to
measureable improvements in the lives of women and children overall. It would then be incumbent upon the
government to monitor and report on progress using the BNA approach and through comprehensive data
collection mechanisms, such as the Demographic Health Surveys and the Multiple Cluster Indicator Surveys.
20
References
1. Dube C, Acaye G, Adams C et al (2012) An integration of decentralized monitoring for results and bottlenecks analysis into existing systems in the GHS in three Northern Region. Tamale field office: UNICEF Ghana.
2. Ghana Statistical Service (2008) Ghana Demographic and Health Survey. Accra: Government of Ghana.
3. Ghana Statistical Service (2011) Ghana Multiple Cluster Indicator Survey. Accra: Government of Ghana.
4. Government of Ghana (2012) Ghana births and deaths registry, coverage report. Accra: Government of Ghana.
5. Government of Ghana, Ministry of Gender, Children and Social Protection. Official website. Available at:
http://www.ghana.gov.gh/index.php/2012-02-08-08-18-09/ministries/255-ministry-of-gender-children-and-social-protection, accessed February 2015.
6. Government of Ghana, Ministry of Water Resources, Works and Housing (2014) Official website. Accra:
Government of Ghana. Available at: http://www.ghana.gov.gh/index.php/2012-02-08-08-18-09/ministries/274-ministry-of-water-resources-works-housing, accessed February 2015.
7. Government of Ghana and UNICEF (2009) UNICEF Ghana country status overview on water supply and
sanitation for the Ghana Annual Report. Accra: Government of Ghana.
8. Government of Ghana and UNICEF (2011) A Situation analysis of Ghanaian children and women: a call for reducing disparities and improving equity. Accra: Government of Ghana.
9. Government of Ghana and UNICEF (2014) Birth registration in Ghana: a bottleneck analysis that leaves no child
behind. Accra: Government of Ghana.
10. O'Connell TS, Sharkey A (2013) Reaching universal health coverage: using a modified Tanahashi model sub-nationally to attain equitable and effective coverage. Maternal, Newborn and Child Health Working Paper. New York: UNICEF.
11. Onyango S, Augustin R, Osborne C et al (2012) Application of the bottleneck approach in eMTCT. MNCH in
Central and Eastern Regions of Ghana. Unpublished document. 12. Soucat A, Van Lerberghe W, Diop F, et al (2002) Marginal budgeting for bottlenecks (MBB): a new costing and
resource allocation practice to buy health results. Washington DC: World Bank.
13. Soucat A, Van Lerberghe W, Diop F, et al (2004) Using health sector's budget expansion to progress toward the Millennium Development Goals in Sub-Saharan Africa. Washington DC: World Bank.
14. UNAIDS (2011) Terminology guidelines. Geneva: UNAIDS. Available at:
http://www.unaids.org/en/media/unaids/ contentassets/documents/unaidspublication/2011/JC2118_terminology-guidelines_en.pdf, accessed February 2015.
15. UN Development Group (2012) UNDAF action plan. Accra: United Nations.
16. UNICEF (2014) Evaluation of UNICEF’s Monitoring Results for Equity System (MoRES). New York: UNICEF.
17. World Bank (2011) Tackling poverty in Northern Ghana. Washington DC: World Bank.
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Annexes
Annex 1: BNA example presented at the Kumasi meeting in 2011
This annex highlights an example that was effectively used to advocate for adoption of the BNA Approach.
This example details how the BNA tool was used in 2010 to identify bottlenecks and their solutions in order
to improve use of the Community Management of Acute Malnutrition program in the Wa West Community.
Identified bottlenecks
Community members perceived malnutrition as a spiritual issue rather than a medical one.
Malnourished children were thought to have wronged one of their ancestors in some way.
Low motivation within the district directorate caused by uncoordinated personnel transfers, and
subsequently qualification and skill gaps needed to run an effective CMAM program.
Flawed discharge criterion that may inadvertently keep a healthy child still admitted.
Lack of proper training and supervision for community health workers leading to wrong data inputs
Solutions
To address the perception that malnutrition is not a disease, it was recommended that spiritual
healers be included in the treatment of malnutrition. It was found that most caregivers first go to a
spiritual healer when a child is malnourished. Spiritual healers could then be used as counsellors for
the CMAM program, which would be initiated by a one-day orientation for them. They were taught
how to counsel caregivers on malnutrition and to help caregivers administer Plumpy Nut to children.
To address skill gaps and uncoordinated personnel transfers, UNICEF supported the region to
undertake a needs assessment, which led to a second nutrition officer post to support districts.
To address the flawed discharge issue, the discharge protocol was amended to include a
measurement of the mid-upper arm circumference (2.5 or above for discharge) in addition to target
weight.
To address inadequate training and supervision, districts performed training needs audits for health
personnel. The regional office also established a regional CMAM training and mentorship team. The
team would also be responsible for training senior district personnel on supervision and would also
perform supervisions from time to time.
22
Annex 2: BNA example of the eMTCT plans developed for the Eastern Region
The plan is expected to achieve the following by the end of 2015: 1. HIV transmission from infected mothers
to their babies reduced to at least 5% by the end of the breastfeeding period
2. 90% of pregnant women provided antiretroviral therapy
3. 95% of HIV-infected infants identified and linked to antiretroviral therapy within the first 12 months of age
Specific objectives: 1. Increase the proportion of HIV infected children receiving
early HIV treatment from 5% to 90% 2. Increase the proportion of HIV exposed infants exclusively
breastfed at 6 months of age from 5% to 60% 3. Increase the proportion of HIV infected women who
received ARVs for PMTCT from 47% to 90% 4. Improve support systems in all districts for PMTCT services
Tracer Intervention 1: Exclusive breastfeeding for HIV exposed infants Only 43% of HIV exposed infants in the region were exclusively breastfed Bottlenecks
Human resources: 5% of active community health workers (CHW) had been trained on exclusive breastfeeding (EBF) and infant and young child feeding (IYCF) practices
Quality: 5% of HIV exposed infants were exclusively breastfed for the first six months of life
Tracer Intervention 2: Early infant diagnosis of HIV (EID) Only 2% EID in the region, and this low rate of identification has impact on antiretroviral treatment rates Bottlenecks
Geographic access: 5% of health facilities reportedly collect dried blood spot specimens for PCR tests Quality: 2% of HIV exposed infants tested by DNA/PCR at about 6 weeks of age
Tracer Intervention 3: Maternal ARVs for PMTCT Only 64% mothers had access to ARVs compared to the national target of 90%; need to strengthen programs to attain the eMTCT targets. Bottlenecks
Geographic access: 5% of the health facilities provided ARVs for PMTCT despite over 50% of ANC facilities with HIV testing and over 90% of pregnant women attending ANC at least one time
Quality: 47% of identified HIV positive mothers initiated ARVs for PMTCT early during pregnancy
Disparity analysis done as part of the BNA showed that:
Six districts accounted for 71% of unmet need in ANC1
Six districts accounted for 68% of unmet need in HIV testing for PMTCT
Six districts accounted for 67% of unmet need for skilled delivery care
Four districts had HIV prevalence of 3.7% – 8.5%. The greatest unmet needs were in the following 10 districts: Asuogyaman, Kwahu East, Akwapim South, Lower Manya, Upper Manya, Yilo Krobo, Kwabibirem/Denkyembour, Kwahu North, East Akim and Birim South.
23
Annex 3: Progress after eMTCT plan implementation in Eastern Region (as of April 2014)
% (October 2012)
% (April 2014)
Tracer Intervention 1: Exclusive Breastfeeding for HIV exposed infants Bottlenecks Human resources: Community health workers (CHW) trained on exclusive breastfeeding (EBF) and infant and young child feeding (IYCF) practices Quality: HIV exposed infants exclusively breastfed for the first 6 months of life
43 5 5
(survey not yet conducted) 29 (2013) 27
Tracer Intervention 2: Early infant diagnosis of HIV (EID) Bottlenecks Geographic access: Number of health facilities reportedly collecting dried blood spot specimens for PCR tests Quality: Number of HIV exposed infants tested by DNA/PCR at 6 weeks of age
2 5 2
19 73 82 (end 2013)
Tracer Intervention 3: Maternal ARVs for PMTCT Bottlenecks Geographic access: Number of health facilities providing ARVs for PMTCT Quality: Number of identified HIV positive mothers initiated ARVs for PMTCT early during the pregnancy
64 5 47
86 76 86
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Annex 4: Newborn Care Operational Plan 2014-2016 (Upper East Region): tracer Interventions, bottlenecks and outputs
Tracer intervention 1 Skilled attendant at delivery
Bottleneck 1.1 Only 4.1% of health facilities with no stock-outs of delivery kits and emergency packages within any quarter during the past year
Output 1.1.1 Proportion of health facilities with no stock-outs of delivery kits and emergency packages increased from 4.1% to 60% by end of 2016
Bottleneck 1.2 No routine data available on the proportion of pregnant women assisted by a skilled birth attendant and monitored with a partograph during the past year
Output 1.2.2 Establish a data capture system; Increase the proportion of pregnant women assisted by a skilled birth attendant and monitored with a partograph during the past year from currently no data available to 60% by end of 2016
Tracer intervention 2 Comprehensive emergency obstetric care (CEmONC)
Bottleneck 2.1 Only 46.2% (6 of 13) districts have hospitals providing CEmONC continuously during the past year Output 2.1.1 Proportion of districts with health facilities providing CEmONC continuously during the past year increased from 46.2% (6 of 13) to 100% by end of 2016
Bottleneck 2.2 No routine data on the number of pregnant women assisted by a skilled birth attendant and receiving a second PNC visit at day 6 or 7 during the past year
Output 2.2.2 Establish a data capture system; Increase the proportion of pregnant women assisted by a skilled birth attendant and receiving a second PNC visit on day 6 or 7 during the past year from currently no data available to 60% by end of 2016
Tracer intervention 3 Management of preterm births
Bottleneck 3.1 No health facility has at least 80% of midwives trained to manage preterm births within the past 24 months
Output 3.1.1 Proportion of health facilities with at least 80% of midwives trained to manage preterm births within the past 24 months increased from currently no data available to 60% by end of 2016
Tracer Intervention 4 Basic emergency obstetric care (BEmONC)
Bottleneck 4.1 No health facility has at least 80% of midwives trained in BEmONC within the past 24 months
Output 4.1.1 Proportion of health facilities with at least 80% of midwives trained in BEmONC within the past 24 months increased to 60% by end of 2016
Bottleneck 4.2 Only 68% of pregnant women had a normal delivery with a live birth in health facilities during the past year
Output 4.2.2 Proportion of pregnant women who had a normal delivery with a live birth in health facilities during the past year increased from 68% to 90% by end of 2016
Tracer Intervention 5 Treatment of severe newborn infections
Bottleneck 5.1 No facility has at least 60% of midwives trained to manage severe newborn infections within the past 24 months
Output 5.1.1 Proportion of health facilities with at least 80% midwives trained to manage severe newborn infections within the past 24 months increased to 60% by end-2016
Bottleneck 5.2 No routine or survey data on commodity stock outs for managing newborn infections and appropriately treated or recovered Output 5.2.2 Establish a data capture system; Increase the proportion of newborns with acute infection who sought care at a health facility and were appropriately treated or
recovered from currently not data available to 60% by end of 2016
Tracer Intervention 6 Coordination, monitoring and evaluation
Bottleneck 6.1 Limited accountability of results/data
Output 6.1.1 Increased capacity to implement and monitor the newborn care program
25
Annex 5: BNA example from other Ghana government sectors
Births registration
The BNA approach was used for the Ghana Births and Deaths Registry in order to identify bottlenecks
impeding birth registration for children under five years old. As a first step, a situation analysis was
performed to understand the state of birth registration in Ghana. This work was conducted in 2012 in 37
districts across Ghana’s 10 regions. Relevant qualitative and quantitative data on birth registration was
compiled and used in a BNA working session held that same year.
The BNA working session brought together various groups including traditional leaders, women and
community health workers from over 60 communities in Ghana’s 10 regions, along with key government
officials, academics, as well as UN and NGO staff. The main purpose of the session was to develop
interventions that could help achieve the goal of registering at least 90% of all children under five years by
2016. The BNA session also included a review of national polices, their effect on register quality and to
identify excluded populations for specific targeting in order to raise birth registration rates.
The BNA session identified key bottlenecks, such as inaccessibility of birth registration services, cost of birth
registration and shortages of essential birth registration materials. Solutions to the identified bottlenecks
were then discussed among participants, and an equity analysis was performed to focus on solving the most
pressing issues. Solutions identified included: (1) mobile registration to take birth registration services to
hard-to-reach communities (2) free birth registration periods increased from 21 days to 12 months (3) formal
policy change to identify the birth certificate as a legal government document to be printed by the
government controller and not the registrar. This latter recommendation for a change in printing was
identified as vital for ensuring that birth certificates would always be available on site when needed.
Since this time, these specific actions have been implemented in the most deprived areas of Ghana. Recent
data indicates that birth registration rates rose from 62% in the 2011 MICS to 65% in 2012 – or almost a 5%
improvement in the first year of implementation [Ghana Statistical Service 2011].
Water, sanitation and hygiene (WASH)
The Ghana Ministry of Water Resources Works and Housing has developed and piloted the WASH Bottleneck
Analysis Tool (BAT). BAT is designed to increase coverage and efficiency of WASH sector resources in order to
achieve more sustainable and equitable outcomes. BAT is designed to:
Identify bottlenecks that constrain sector progress
Identify activities for the removal of constraints
Estimate resource requirements and costs of bottleneck removal
Propose priorities for utilization of additional funds
Link bottleneck removal to sector and broader development objectives
In October 2012, the Ministry organized a four-day workshop to customize and pilot the tool in Ghana. By the
end of the workshop, the Ministry had identified constraints and bottlenecks affecting WASH service
provision and determined solutions needed to remove them.
26
As of April 2014, some solutions had already been implemented, such as staff capacity building, cost sharing
for annual reviews among stakeholders, development of WASH survey indicators and a rapid assessment
method of drinking water quality. Other solutions were still under development. Information is not yet
available on the impact of these solutions on WASH service delivery and its equity. The Ministry also plans to
conduct more in-depth BNA trainings at the regional and district levels for targeted actions in the most
deprived areas of Ghana, and to promote decentralized monitoring of results.
Education
The Ministry of Education used the BNA approach in 2011 to identify bottlenecks affecting education service
provision. The BNA session helped identify three strategic areas for improved focus: (1) textbook distribution
(2) teacher deployment/attendance (3) improving education quality.
These findings were presented to stakeholders at the National Education Sector Annual Review in May 2011,
and later at a high-level business meeting in June 2011. In the same month, the BNA tool was piloted in one
regional and two district education offices. Most officers found the tool to be useful for both planning
programs and monitoring results with an equity-focus. In terms of next steps, there is a need to further refine
the BNA tool and link its use to ongoing education initiatives, such as the School Report Cards Initiative. The
bottleneck analysis could also be expanded to district-level planning, budgeting and monitoring in least in ten
UNICEF focus districts.
In May 2014, the Ministry of Education conducted a three-day BNA workshop to determine bottlenecks in
the education system at district levels. It was also expected that each district would identify bottlenecks
impeding education service provision and develop action plans of how bottlenecks will be addressed.
Districts have now started to implement activities as specified in these action plans.
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Annex 6: List of persons interviewed
Name Organization Designation Phone # Email Address
Hari Krishna Banskota UNICEF Accra Health Specialist 0248493758 [email protected]
Lilian Selenje UNICEF Accra Nutrition Specialist 0548813107 [email protected]
Clemens Gros UNICEF Accra Monitoring and Evaluation Specialist 024 3486821 [email protected]
Victor Ngongalah UNICEF Accra Chief, Health & Nutrition 0244331043 [email protected]
Rushnan Murtaza UNICEF Accra Deputy Representative 0244327392 [email protected]
Josephine Agborson UNICEF Accra Program Officer 0542446315 [email protected]
Dan Osei GHS Accra, PPME Deputy Director, PPME, GHS 0244 364 221 [email protected]
Alfred E. Yawson GHS Accra Consultant 0244662711 [email protected]
George Bonsu GHS Accra EPI Program Manager 0244171537 [email protected]
Isabella Sagoe-Moses GHS Accra National Child Health Coordinator 0244646065 i_ [email protected]
Evelyn Ngaanuma UNICEF Tamale Knowledge Management Officer 0208721205 [email protected]
Prosper Dakura UNICEF Tamale Health and Nutrition Officer 0244179205 [email protected]
Felicia Mahama UNICEF Tamale Health and Nutrition Officer 0244602808 [email protected]
Gloria Nyam Gyang UNICEF Tamale WASH Specialist 0545560769 [email protected]
Clara Dube UNICEF Tamale Chief of Field Office 0244331908 [email protected]
Chetteau Barajei UNICEF Tamale WASH Officer 0244714650 [email protected]
Isaac Lartey GHS Tamale Regional Health Information Officer 0244825030 [email protected]
Jacob Mahama GHS Tamale Deputy Director of Public Health 0244027225 [email protected]
J. Koku Awoonor-Williams GHS UER Bolga Regional Director of Health Service 0244564120 [email protected]
Rofina Asuru GHS UER Bolga NewBorn Care Coordinator 0244704697 [email protected]
Augustine A. Owusu GHS UER Bolga Regional Accountant 0243259347 [email protected]
Kwame Bimpeh GHS UER Bolga Regional Health Information Officer 0208164590 [email protected]
Ali Baba GHS UER Bolga MAF Coordinator 0244449634 [email protected]
Joseph Osore GHS UER Bolga Deputy Director Public Health 0208112634
Peter Boateng GHS UER Bolga Deputy Director Administration 0208181061 [email protected]
Bismark Sarkodie GHS ER K’dua Regional Nutrition Officer 0244640527 [email protected]
McDamien Dedzo GHS ER K’dua Regional Director of Health Service 0244803792 [email protected]
Vincent Tawiah GHS ER K’dua Regional Accountant 0208134164 [email protected]
W. Fabi Addo GHS ER K’dua Deputy Director Clinical Care [email protected]
Asure Bedialo Micah GHS ER K’dua Deputy Director Administration [email protected]
Dela Asamany GHS ER K’dua Regional Health Information Officer [email protected]
Antobre Boateng GHS ER K’dua Public Health Specialist [email protected]
L. K. Senaya GHS, Municipal K’dua Public Health Specialist 0208117304
Kwame Agbeshie GHS Upper Manya Krobo District Health Information Officer [email protected]
Sarah S. Donker GHS Upper Manya Krobo District Director of Health Services, Acting [email protected]
Patience Asiedu GHS Upper Manya Krobo District Nutrition Officer [email protected]
Paul Twens GHS Upper Manya Krobo District Children Officer [email protected]
Sophia Dei GHS Upper Manya Krobo District Public Health Officer 0244682481 [email protected]
Clemens Adams UNICEF Somalia Child Survival Specialist [email protected]
Emelia Allan UNICEF Accra Child Protection Officer 0243132829 [email protected]
Erasmus E. A. Agongo GHS PPME Director 0244 293835 [email protected]
John Berton Eleeza GHS Greater Accra Deputy Director Public Health 0208 174578 [email protected]
28
