REPORT. Tanahashi Round-11

Transcription

1 Tanahashi Round-11 8th July 2014 Secretariat Center of Excellence for niversal Health (CoE-UHC) project, James P Grant School of Public Health (JPGSPH) Level-6, icddr,b, Mohakhali Dhaka, Bangladesh Ms. Noreen Prendiville and Ms. Hedy Ip from UNICEF Bangladesh presented Round 11 Using bottleneck analysis as a planning and monitoring tool to accelerate progress in effective coverage of Direct Nutrition Interventions The 11th Tanahashi round was held on 8th July, 2014 in the Video Conference room of BIGH. The two speakers, Noreen Prendiville, Chief of Nutrition and Hedy Ip, Nutrition Specialist, both from UNICEF, presented on the use of bottleneck analysis as a planning and monitoring tool to accelerate progress in effective coverage of Direct Nutrition Interventions. Ms Ip started by presenting the 14 Direct Nutrition Interventions (DNIs), and then explained standard indicators to monitor DNIs. She went on to highlight that the rationale for measuring coverage levels of nutrition services is to monitor quality of services, to ensure equitable provision of services, to assess whether targets are being met and standards adhered to. As an example, coverage indicators for IFA supplementation during pregnancy were defined from availability up to effective coverage. IFA supplementation was chosen as a tracer intervention to track coverage of nutrition interventions in two unions (Bhola and Sunamgonj) in The results show drop-offs in coverage between availability and accessibility as well as utilization and adequate coverage (which dropped to 0%).

2 Figure Example 1: Example of coverage of coverage graph graph for bottleneck of bottleneck analysis analysis of of IFA IFA supplementation during pregnancy preganancy (2 (2 unions) Target Availability Accessibility Utilization Adequate 0 0 Effective Target Availability Accessibility Utilization Adequate Effective The presenter then went on to discuss an exercise conducted in preparation for the Mid-Term Review of UNICEF-GoB Country Program in 2014 which involved the use of existing data to estimate coverage levels for selected DNIs for the 20 UNDAF districts. Proxy indicators and estimations were used to fill data gaps and determinants of bottlenecks were identified by Nutrition Zonal officers and local level partners (based on field visits, key informant interviews and focus group discussions). Figure 2 shows effective coverage of key nutrition interventions across a continuum of care. Subsequently Ms Ip, identified opportunities and challenges of monitoring effective coverage of interventions. Opportunities: - The exercise of monitoring effective coverage using existing data demonstrates it is possible to use various sources of existing data for routine monitoring of coverage; - The analysis informs and facilitates responsive real-time programming and adjustments based on bottlenecks and barriers identified; - It demonstrates that significant changes in coverage are possible in a short amount of time; - Monitoring effective coverage identifies gaps in information systems and data for nutrition, to be addressed. Challenges: - Limited data and disaggregation at district and sub-district levels; - Limited recent data on hard-toreach and deprived areas like urban slums, CHT; - Interpreting various sources of data (from different periods, aggregated levels) The second part of the presentation focused on the strategic use of coverage and bottleneck analysis to

3 Figure 2: Effective coverage of key nutrition interventions across a continuum of care, in selected project and non-project supported areas improve results for nutrition in Bangladesh. Ms Noreen Prendiville, Chief of Nutrition, outlined the current status quo of monitoring which tends to focus on inputs, outputs and processes, but rarely relates to the effective coverage of evidence-based interventions. Therefore, programme monitoring rarely provides information on what is working and whether the specific focus of our support is appropriate or effective. Furthermore, she described the tendency to design interventions before the context has been analysed and without systematically developing a Theory of Change. Finally, there is frequently insufficient data on coverage related to ongoing interventions. In order to mainstream monitoring of effective coverage in the Government of Bangladesh-UNICEF programme, as of 2014, District Nutrition Support Officers who are trained to use and interpret bottleneck analysis have been deployed to 25 districts. Combined with improved data collection methods, this has facilitated bottleneck analysis informing programming in a more systematic way. Ms Prendiville went on to demonstrate how bottleneck analysis has allowed UNICEF and partners to question assumptions in relation to factors contributing to low coverage, observe differences among population groups; observe change over time as a result of interventions and, most importantly, to refocus resources where they are most needed. Thus, bottleneck analysis has not only been used as a monitoring tool, but also as a communication and advocacy tool to move all part

4 ners towards a common understanding of effective coverage. It has also reinforced UNICEF s shift from direct implementation towards strengthening Government systems, among other things by supporting establishment of a Nutrition information, Monitoring and Planning Unit. In terms of challenges in applying bottleneck analysis, the presenter highlighted a disproportionate focus on prescribed models and terminology rather than emphasizing the concepts of equity and effective coverage. She also mentioned that many perceived the analysis as being too process heavy. Before closing the presentation, Ms Prendiville shared lessons learned from the use of bottleneck analysis to monitor progress and results towards effective coverage of Direct Nutrition Interventions. She highlighted the need to reflect on scaling-up when taking action on bottlenecks and to integrate monitoring into existing systems wherever possible. This also requires investment in information and monitoring systems while keeping in mind that the information needs to be good enough to inform decisionmaking. In the discussion that followed the presentation, several points were emphasised: Participants emphasized the importance of increasing the analysis and use of monitoring data produced through nutrition programmes. Although data is routinely collected throughout the duration of a programme, frequently it is not analyzed thoroughly until the end of a program. At this stage it is too late to make adjustments to the programme intervention to change its course in response to data. Therefore there is an urgent need to further develop the capacity of programme implementers to conduct critical analysis of data and contribute to an action-oriented feedback loop. A second set of discussions focused

5 on the reasons for the significant drop-off between availability and accessibility and then effective coverage in the area of Nutrition the following reasons were cited: - The district did not receive enough IFA supplies from national level; - Health workers and managers do not know how many IFA tablets they should have in stock; - Health workers forget which quantity and dose of IFA to provide to mothers at each ANC visit; - Health workers are not recording the number of IFA tablets they give to mothers so it is difficult to measure adequate coverage; - Mothers are not aware of the correct quantity of IFA tablets they should receive and consume. The need to stimulate demand for data through donors as well as decentralized levels of government down to the community level. Greater demand for data would also allow a stronger emphasis on monitoring projects on an ongoing basis rather than focusing efforts on a final evaluation at the end of the project. This also requires developing data literacy among district-level officials. The importance of providing feedback on data to the community level, including communities who are performing well, so that communities can become agents of change in overcoming demand-side bottlenecks to effective coverage.

6 Tanahashi Round-11 Dr. Sadia A. Chowdhury and Ms. Louise Mvono chaired the session Tanahashi organizing team: Overall Supervision: Dr. Sadia A. Chowdhury Dr. Syed Masud Ahmed Overall coordination and Report preparation: Alexandra Illmer Haein Cho Invitation and Reception: Md. Tarek Hossain Nabila Chowdhury Design/Communications: Imran Jamal IT support: Tapan Biswas A. Rouf Sarker Logistics: Sohel Rana Support: Mansura Akter Shah Ali Contact Nadia Ishrat Alamgir Lecturer III Center of Excellence for Universal Health (CoE-UHC) project JPGSPH, Level-6, icddr,b, Mohakhali