Table 2.

Key constraints and operational solutions within the health care system

Level	Constraint	Cause	Solution
1. Health service delivery level (demand-side)	Shortage of appropriately qualified staff	Inadequate training	Strengthen pre-service and in-service training, develop standardized training plans, use cascade training and increase supervision
			Provide sufficient per diem for supervision
			On-the-job training and mentoring
		Limited number of ethnic group healthcare staff	Human-resource plans including specific affirmative action policies and strategies to attract men and women from different ethnic groups
		Limited number of staff with appropriate language skills	Provide additional education to identified men and women from ethnic groups to facilitate entry into formal training programs
		Poor understanding of some policies and standards	Simple, standardized policies, training and supervision and feedback loops for staff
		Reliance on VHVs	Creation of more paid positions, provide remuneration, per diem for outreach, training and supervision, on-the-job training and mentoring
		VHVs struggle to balance health duties and livelihood needs
	Insufficient basic supplies, drugs and equipment	Weak supply system an poor financial planning	Strengthen management and supply and provide supervision
			Pre-service and in-service training, supervision and mentoring
			Standardized procurement and disbursement mechanisms
		Distant location of facilities	Deploy trained staff to peripheral health units
			Establish and maintain waiting homes
	Insufficient budget	Insufficient budget allocation	Advocate for increased government budget allocation to health
2. Community and household level (supply side)	Low demand, delayed use of services and poor compliance with treatment	Inadequate affordable transport	Develop community transport schemes
		Household resources and willingness/ability to pay	Develop and promote appropriate finance schemes
		Limited cash flow/livelihood demands – associated with seasonality	Strengthen social health insurance (SHI) and social health protection (SHP) schemes which are inclusive of the poor
		Delayed decision making	Promote birth and emergency preparedness plans
		Language	Strengthen education for ethnic groups
			Recruit from ethnic populations
		Cultural norms	Integrate cultural appropriateness into MNCH program planning and design
3. Policy and strategic management	Weak management, administration and coordination	Few managers	Strengthen district level management capacity
		Limited management training	Clear guidelines and manuals
		High administrative burden relative to skills	Streamline reporting
4. Cross-sectoral,	Limited infrastructure (e.g. electricity, roads, communication networks)	Insufficient cross-sectoral action	Promote cross-sectoral collaboration and strengthen coordination with different technical working groups
	Limited access to education for ethnic groups and women