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	Low
1.1 Product design	Easy of storage	No special requirements	Low
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	Moderate
1.3 Equipment	Technology equipment	No high technology equipment or infrastructure needed Households require a spoon or small container	Low
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	Low
2.2 Human resources	Knowledge	Requires provider orientation and training, aided by a frequently asked questions repository with standardized responses	Moderate
2.2 Human resources	Professional services	Requires individuals skilled in monitoring and in maintaining product supplies	Moderate
2.3 Communications and transport	Infrastructure	Requires a product promotion and distribution infrastructure that reaches retail outlets and supplies health facilities	Moderate
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	Low
3.2 Management systems	Monitoring	Capacity required to effectively monitor the quality of the zinc products available over the counter	Moderate
3.3 Collaborative action	Inter-sectoral	Must be able to maintain equitable, socially responsive pricing that reaches the poor	Moderate
3.3 Collaborative action	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)	Moderate
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	Moderate
4.1 Manufacturing	Distribution	Distribution systems that reach drug and general retail outlets required	Moderate
4.2 Marketing	Communication networks	Widespread access to mass media networks (TV, radio), especially among poor and rural households, is needed	Moderate
4.2 Marketing	Expertise	Requires professional skills in preparing and delivering marketing messages that target households at greatest risk (urban slums and rural poor)	Moderate
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)	Moderate
4.3 Health care providers	Access	Easy access and widespread availability of unregulated providers at little cost	Low
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	Moderate
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%)	High
5.2 Pre-existing demand	Need for promotion	This is a largely unknown intervention, therefore requiring large-scale provider and mass media promotion	Moderate
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	Low

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.