Case study 3: Analysis of constraints and facilitators of project execution

Background: Execution of IR projects encounter numerous potential constraints, particularly in resource-limited settings. Therefore, it is essential that such constraints are identified before research commences. Several frameworks and guidelines have been developed to help identify specific constraints and facilitators at the various levels of project execution. One such framework, developed by Gericke and colleagues, can be applied to a wide range of interventions to help identify potential constraints to project execution. The framework describes: (i) Intervention characteristics (e.g. product design, supplies and equipment); (ii) Delivery characteristics (e.g. facilities, human resources, communications and transport); (iii) Government capacity (e.g. regulation, management systems, collaborative action); and (iv) Usage characteristics (e.g. easy to use, pre-existing demand and black market risks). This framework – with an additional category to address private sector capacity (e.g. manufacturing, marketing, health care providers, households) – was used to establish the constraints and facilitators to the success of the scale up of zinc treatment for childhood diarrhoea in Bangladesh. These constraints and some facilitators found to influence the zinc project scale up are summarized in the table below.

Table. Summary of constraints and facilitators influencing the scale up of zinc treatment for childhood diarrhoea in Bangladesh
1. Intervention characteristics
Category Criteria Intervention status Level of constraint
1.1 Product design Stability
  • Stable under conditions of high humidity and temperatures for up to 3 years in aluminium-PVC blister packs
Easy of storage
  • No special requirements
1.2 Supplies Supply needs
  • Must maintain a filled pipeline with regularly scheduled re-supply of retail outlets or health care facilities under conditions of uncertain product demand
1.3 Equipment Technology equipment
  • No high technology equipment or infrastructure needed
  • Households require a spoon or small container
2. Delivery characteristics
Category Criteria Intervention status Level of constraint
2.1 Facilities Retail sector levels
  • Feasible, given an existing distribution system is in place
  • Feasible at all facility levels of care and in homes
2.2 Human resources Knowledge
  • Requires provider orientation and training, aided by a frequently asked questions repository with standardized responses
Professional services
  • Requires individuals skilled in monitoring and in maintaining product supplies
2.3 Communications and transport Infrastructure
  • Requires a product promotion and distribution infrastructure that reaches retail outlets and supplies health facilities
3. Government capacity
Category Criteria Intervention status Level of constraint
3.1 Regulation/ legislation Regulation Several regulatory considerations: e.g.:
  • registration of the zinc tablet formulation
  • registration/approval of product branding and packaging
  • over-the-counter sales approval or waiver
  • approval for mass media advertising
3.2 Management systems Monitoring
  • Capacity required to effectively monitor the quality of the zinc products available over the counter
3.3 Collaborative action Inter-sectoral
  • Must be able to maintain equitable, socially responsive pricing that reaches the poor
External funding
  • If a high demand for zinc occurs in the government sector, the purchase of zinc will require external funding (unless passed on to the consumer)
4. Private sector capacity
Category Criteria Intervention status Level of constraint
4.1 Manufacturing Production
  • Requires a pharmaceutical laboratory that can maintain good manufacturing practices (GMP) certification, preferably in-country
  • Distribution systems that reach drug and general retail outlets required
4.2 Marketing Communication networks
  • Widespread access to mass media networks (TV, radio), especially among poor and rural households, is needed
  • Requires professional skills in preparing and delivering marketing messages that target households at greatest risk (urban slums and rural poor)
4.3 Health care providers Regulation/continuing education
  • The vast majority of health providers in Bangladesh are not licensed and are poorly regulated, but are represented by special interest groups that can organize continuing education
  • Primary source of information is through private sector medical representatives (drug salesmen)
  • Easy access and widespread availability of unregulated providers at little cost
4.4 Households
  • Cost
  • Health seeking
  • Demands
  • Expenditure
  • Licensed private providers limited to urban settings
  • Caregivers overwhelmingly seek help in the private sector
  • Consumers demand and expect a curative treatment
  • If burden to pay for zinc is passed onto households, then likely not to reach many of the poorest households
5. Usage characteristics
Category Criteria Intervention status Level of constraint
5.1 Ease of use Information
  • inc as a treatment for childhood diarrhoea will be universally unknown to caretakers and most providers, thus requiring comprehensive education of providers and caretaker orientation
  • Caretaker adherence with instructions regarding preparation is high (98%), but to duration given is low (<50%)
5.2 Pre-existing demand Need for promotion
  • This is a largely unknown intervention, therefore requiring large-scale provider and mass media promotion
5.1 Black market risks Resale/counterfeiting
  • If product is provided free of charge in public sector facilities, then risk of resale exists (MOHFW supplied blister packs are labelled ‘not for sale’)
  • The dispersible tablet formulation can be counterfeited, with lower quality products jeopardizing the reputation of the intervention

Lessons: The various categories of constraints to project execution should be identified before research takes place in order to devise mitigation measures for a comprehensive execution plan.

Source: Larson C.P., Koehlmoos T.P. and Sack DA,. Scaling Up of Zinc for Young Children (SUZY) Project Team. Scaling up zinc treatment of childhood diarrhoea in Bangladesh: theoretical and practical considerations guiding the SUZY Project. Health policy and planning. 2012; 27(2):102–14.