Overview of the approach

The Bottlenecks and Best Buys approach entails reviewing a health professional school’s current capacity and strengths in the nine core areas with a view toward suggesting ways to increase the number of qualified graduates responsive to national health priorities, particularly in underserved areas such as rural and periurban settings, and across all levels of the health care pyramid.

In 2011 and 2012 CapacityPlus applied the Bottlenecks and Best Buys approach at health professional schools in the Democratic Republic of the Congo, Ethiopia, Ghana, Mali, and Uganda. The on-campus process, including in-country preliminary meetings, interviews, draft assessment presentation, and finalization, ranged from three to five weeks, depending on the size of the institution, school leadership commitment, availability of individuals, and school calendar. In all countries, the process was led by a coordinator, either international or local, who had experience or training in the application of the approach. In all cases the government and schools provided critical support. In some cases additional resource persons were engaged to assist with the collection of data and information.

In each country, preliminary meetings were held to adapt the approach to the local context. School leadership and other stakeholders made decisions about the scope and depth of the assessment. They reviewed all nine assessment areas to decide which ones were relevant in their particular setting. The process followed a series of steps to ensure that school leadership and other stakeholders supported the assessment and that the results of the analysis were incorporated into school planning (see box below for a list of these steps).

The approach aims to provide key information to decision-makers—without taking up excessive staff, student, and partner time—so they gain further insight into education and training at the institution, and identify critical constraints that hold back the institution from successfully accelerating expansion, without loss of quality. The primary audiences are those engaged in policy and planning, those determining programmatic options, and those responsible for financing and sources of financing, as well as those charged with executive management tasks.

Information is collected through interviews with key informants, including school managers and clinical practice site managers, using a structured interview format. Complementary surveys of educators and students are carried out using self-administered written questionnaires. Observation of school facilities, including classrooms, skills labs, computer labs, and libraries, as well as clinical practice sites, is conducted using a predefined checklist.

The information collected is used to identify and prioritize interventions for overcoming constraints. The market cost of these priority interventions is estimated, and a final selection of interventions is then made, with the goal of selecting the least costly interventions with the largest potential for scaling up the production of quality graduates. CapacityPlus is piloting a more detailed costing approach in sub-Saharan African country settings that estimates the unit cost of producing a health worker and the most common cost constraints, which can be complementary to this process.

Steps in the Bottlenecks and Best Buys Process
Expressions of interest from appropriate authorities and a preliminary indication of what will be expected during and from the process Selection of a lead person/team responsible for organizing the assessment, confirming arrangements, drafting reports, and finalizing the recommendations Initial in-country meeting, during which an understanding is reached on the school counterpart lead, kinds of documentation, categories of individuals to be interviewed, types of questionnaires to be answered, and an estimated time frame for conducting the assessment Assessment based on confidentiality and informed consent documents, interviews, questionnaires, and facility observation Preliminary data analysis by the assessment lead with technical support Stakeholder meetings on draft findings, and identification of priority interventions including best buys cost estimates and consideration of proposed modifications Final assessment findings and recommendations provided to the institutional leadership and relevant stakeholders, including government officials, with discussion about translating findings of priority interventions and initial cost estimates into actions.

Steps in the Bottlenecks and Best Buys Process

Expressions of interest from appropriate authorities and a preliminary indication of what will be expected during and from the process
Selection of a lead person/team responsible for organizing the assessment, confirming arrangements, drafting reports, and finalizing the recommendations
Initial in-country meeting, during which an understanding is reached on the school counterpart lead, kinds of documentation, categories of individuals to be interviewed, types of questionnaires to be answered, and an estimated time frame for conducting the assessment
Assessment based on confidentiality and informed consent documents, interviews, questionnaires, and facility observation
Preliminary data analysis by the assessment lead with technical support
Stakeholder meetings on draft findings, and identification of priority interventions including best buys cost estimates and consideration of proposed modifications
Final assessment findings and recommendations provided to the institutional leadership and relevant stakeholders, including government officials, with discussion about translating findings of priority interventions and initial cost estimates into actions.

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