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EP09 Exploring Bottleneck Analysis with Pratik Sourav
Deborah Onakomaiya: Hey guys, and welcome to another episode of I AM GPH. I am your host Deborah Onakomaiya. In this episode we'll be talking to Pratik Sourav who's a second year MPH student here at NYU. Pratik is a physician by training from Bangladesh and currently works at the College of Dentistry here at NYU. Our conversation with Pratik today is going to focus on bottleneck analyses, why they're important in public health, and how it might affect a health system. Let's go to our conversation with him. All right, let's get started. Thanks for being here Pratik.
Pratik Sourav: Thanks for inviting me.
Deborah Onakomaiya: All right, awesome. Let's dive right in. So I've heard a lot about your work and a lot of what you've been doing in and outside of NYU. Most importantly is the bottleneck analysis. So for our listeners, what is a bottleneck analysis?
Pratik Sourav: Well, bottleneck analysis you can say it's a tool that we can use to analyze gap in a health system. You can also use bottleneck analysis to find out why a program or project or intervention is not being effective in a country or in a community or in any settings.
Deborah Onakomaiya: Okay. All right, awesome. So as a global health student, you know you're required to do a capstone, but if someone was to do a bottleneck analysis, how would you go about it?
Pratik Sourav: So I'll give you an example how it works. So let's take vaccination for an example. So we all know how vaccination is an effective way to reduce under five mortality. And now all the countries in the world have a vaccination program in place. But if you look into that, you'll find out that they're not equally effective all around the world. Bottleneck analysis actually helps you to identify why it's not equally effective. That's one of the use of bottleneck analysis. It takes different things into account. There could be different reasons why a program is not effective in a country, which is amazing. The example of vaccination here, it could be an availability issue. Maybe the country does not have enough manpower or does not have enough vaccines in stock to cover it’s entire population.
Deborah Onakomaiya: And when you say manpower, like community health workers?
Pratik Sourav: It could be a community health worker, it could be the physicians or nurses because sometimes they are also involved in the vaccination program. So health care worker in general, could be community health workers, could be physicians, nurses or just trained personnel just for the vaccination purpose. It could be the vaccines itself. Now if they're not in stock then it's an issue an availability problem. It also could be an accessibility problem. So let's say for example that, the health facility where the vaccination program is taking place, it's far away from the community that you're trying to serve. In that case, accessibility is a major issue, which is common in the rural areas, in a poor population or in a poor country. It could also be an affordability problem. Maybe there is an out of pocket fee for that vaccination and if you belong to a low socioeconomic condition, it's tough for the parents to afford that. Or sometimes the parents have to give up their day's work to bring their kids to the health facility to get vaccinated. And if you're living from day to day, that's a tough task to do. It could also be a socio-cultural acceptability problem. Maybe that the vaccination program that you have in place, it's working fine, but the parents don't want their kids to get vaccinated because of religious or social reasons, which is even common in the United States as well.
Deborah Onakomaiya: Is that kind of like the measles, the MMR thing? The measles one where in California they were not vaccinating their kids with measles?
Pratik Sourav: Correct, because they're, sometimes they have religious reasons, sometimes they have false beliefs such as the use of mercury in the vaccines will result in autism. That's a common perception that's going around, but again, there is no proof behind it. So that's one of the bottlenecks behind the vaccination program not being effective. It could be just a continuity problem. It could be, maybe we know how the vaccination programs require boosted dose. So maybe a parent is bringing their children to get vaccinated for their first time, but if they're not bringing them for the second or third visit, then your program ended up being not effective. Or it could be just a pure quality problem. Maybe the cold chain system that's required to keep the vaccines potent they're not effective, which is resulting in an ineffective vaccination program. So basically a bottleneck analysis take all of those problems that I just mentioned. Availability, accessibility, acceptability, affordability, continuity, and a quality of service into account and quantified these problems. And once you quantify these problems, you know exactly where the problem lies in a system or in an intervention or in a project. And then you know where to spend your money, where to allocate your resources once you know where the problem lies.
Deborah Onakomaiya: So you've mentioned affordability, but in particular, speaking in a particular context, not all of these are going to be present. So first, what is the first step you take when you want to do this analysis or like you're assigned to somewhere in Ghana, what's the first step you take in doing that type of analysis?
Pratik Sourav: You have to collect data. So all these points that I made, all the bottleneck that I mentioned, you have to collect data in context to that. So you have to find your indicator. For example, for availability you can take into account of the number of nurses or physicians or committed health workers per thousand population or per 100,000 population. So you choose your indicator for each of those bottlenecks and collect data for it. And that's how you quantify the bottlenecks.
Deborah Onakomaiya: Okay. And this is just like quantitative data.
Pratik Sourav: It's actually a mixed method because the data that you collect are from surveys. It's called, most of the times for a low and medium income countries. They're collected from a survey called demographic and health survey that's been mostly used so far. You can also use other survey data. The good part about that survey, it's a mixed method. The people from the community are asked such as what do you say is the major obstacle to get service, a healthcare service? Is that too far? Is that because you have to find transportation to get there? Do you have better or good transportation method in place in your community or do you have to walk there? So that's how the...it's a mixed method. They take both qualitative and the quantitative part.
Deborah Onakomaiya: It's sometimes it's hard to get data. So in places where it's kind of hard to get data or there's no data, how are you able to do a bottleneck analysis?
Pratik Sourav: So for bottleneck analyses, first of all, you will need data. If you don't have data, you go to the field, you collect data.
Deborah Onakomaiya: So you have to go to that actual country.
Pratik Sourav: Correct. So good thing is our surveillance system in countries are getting better and better. Again, the DHS survey that I mentioned, they are actually are placed in the poor countries, low and middle income countries, and there are financed by DWO, different UN agency and getting at the same time they're getting technical support from USAID and other organizations. Yeah. I mean most of the countries are, for now have those data, but even for some countries such as the United States that approach that we're taking in the low and middle income countries, the indicators that we're using for those countries, sometimes those indicators are not applicable in the United States. So for that you have to find a different way. You have to go do a little research, find out barriers to a certain service and find your indicators according to that.
Deborah Onakomaiya: Yeah, that's very interesting. And I mean you've mentioned a lot of what it takes to do a bottleneck analysis. You know, what gaps to look for. But in your experience, what bottleneck analysis have you done?
Pratik Sourav: What bottleneck analysis have I done? Okay, so that goes back to my professional experience. I'll say for the last one year I've been working with UNICEF on one of their projects, called Narrowing the Gap. Narrowing the Gap, it's actually, they collected data to prove that the most cost effective way to reduce infant mortality is by reducing the coverage gap between rich and poor. So my job in that project was to do a country analysis as a case study and the country that I was given was Bangladesh, where I'm from. So for that country, I had to perform bottleneck analyses. That was that. On top of that currently we're doing a study from the Applied Global Public Health Initiative where I'm also part of, we're doing a whole systems bottleneck analyses again for Bangladesh. As a matter of fact, this actually the first time ever any study that's being done on an entire whole system of a country.
Deborah Onakomaiya: In Bangladesh?
Pratik Sourav: For all around the world, that's going to be the first time bottleneck analysis on a health system has been done before, but on a subdistrict level or on a regional level, but never for an entire country.
Deborah Onakomaiya: That's a lot of work.
Pratik Sourav: That's a lot of work.
Deborah Onakomaiya: And you just have one country. So that's going to be, so will that involve you looking at regional data, district data and then going to the national level?
Pratik Sourav: Oh we'll be doing all. But the good part about Bangladesh is their health system is centralized even though the country is divided into different regions, but the health system itself is centralized.
Deborah Onakomaiya: So for our listeners, what do you mean by centralized?
Pratik Sourav: Centralized means all the policy, all the strategy come from the central government. Whereas for example, the United States, you have state governments where they have a lot of power.
Deborah Onakomaiya: That's really, really interesting. You sound like an expert in it. You've worked with UNICEF, you're in a lab doing that for Bangladesh. That's really, really interesting. I understand that you've worked on products with the WFP, it's such a prestigious organization. In addition to UNICEF, how were you able to make those connections with these prestigious organizations and what has that been like for you?
Pratik Sourav: For example, I'll give you the WFP. I'll talk about the WFP part. So I was part of a course that's also for our MPH program. It's called Systems Approach to Food Access. Three credit course that's offered here at NYU and they offered that in almost every semester. In this course, the NYU grad students are placed alongside with the WFP officials.
Deborah Onakomaiya: Wow. So it's like a group of NYU students and actual officials from the organization?
Pratik Sourav: Correct. And they're pretty high up there. They're country directors from the country offices and from the regional offices and they're here as a student alongside of the NYU grads. So they are mixed and placed into different groups and each group is assigned a specific country. And we were supposed to come up with a strategy to address a food access related issue for that country, which is most of the time stunting. It's a condition that's a mostly measured in infant mortality, it's measured by a growth for height.
Deborah Onakomaiya: If you're not tall for your actual age.
Pratik Sourav: Exactly, exactly. So that's how there is a measurement, a complex measurement. I'm not going to go into detail for that. And it’s measured in under five population. So we are supposed to come up with this strategy and our assigned country for my group when I was in that class was Indonesia. Keep in mind the strategies that we come up with, they're based on real life data on real life scenarios.
Deborah Onakomaiya: Actually making actual change,
Pratik Sourav: They are actually projects correct. And sometimes the WFP officials take these projects back to their country and sometimes they end up being the national strategy for their country office.
Deborah Onakomaiya: And the director or the officer, the regional officer that you were paired with, was that person from Indonesia?
Pratik Sourav: In my group, yes. I had the deputy country director from Indonesia, deputy country director from India and also from Guatemala.
Deborah Onakomaiya: So all three were on your team. Wow. How were you guys able to coordinate that? Cause I'm sure some people might have vested interests for their country. How were you able to balance that out in your group?
Pratik Sourav: I did not have a problem because luckily my country assigned was Indonesia and I had somebody from my group from Indonesia. So, I mean we all had similar interests so and they all align at the same time for the same goal. So we never had that conflict of interest.
Deborah Onakomaiya: Wow. And then from you know, working in the group, what discoveries did you guys find in terms of addressing that issue of stunting in Indonesia?
Pratik Sourav: Right. So I'll say the best part about this class, it's the learning experience. This class teaches you how to think practically I would say. When you address a problem for a country or for a region, by keeping in mind the budgetary constraints and the geopolitical context of the country in mind because you have different audience, different stakeholders, and you have to keep in mind when you're coming up with the proposition, you have to address each of their interests at the same time. So you have to be, I'll say political and that's what exactly what it teaches.
Deborah Onakomaiya: You don't get taught that in school though.
Pratik Sourav: It, that's the reason why it's more, it's a hands on class.
Deborah Onakomaiya: So you would recommend that people...
Pratik Sourav: If you're somebody who wants to work in a, for any UN agency or on international settings, I strongly recommend this class. Yeah.
Deborah Onakomaiya: From that experience alone, how were you, because I understand that you continued to work with WFP after that?
Pratik Sourav: Correct. So the connection, that's another best part about this class. The connection that you make. It goes a long way. For example, for my class. after completing the class, I got an internship offer from WFP India, which I end up did not taking, but I had better opportunities here too, so I had to balance them out, not just that I'm even now, I'm still in touch with those people that I went to class with. I mean, even though they're senior than me, they're more experienced than me, but they're really friendly. After a few months the WFP Indonesia office, since I, one of my teammates was from the WFP in Indonesia, sent us an evaluation report on their school meal program, their school feeding program, and they wanted us to validate that report. So these are the chances that you're looking at that you can get from this class.
Deborah Onakomaiya: So that class alone opened up opportunities for you in India and Indonesia. I need to take that class.
Pratik Sourav: You should.
Deborah Onakomaiya: Wow, that's amazing. And you said you're still in contact with them. How do you keep that connection going? Because I mean it can be kind of weird when someone's in a different country on a different time zone. How do you maintain that connection? What do you guys talk about?
Pratik Sourav: So you have to be proactive. First of all, the connection does not happen automatically just by being part of that class. It's not going to ensure you those connections. So you have to be proactive about that. So the way it worked for me, since I made a good relationship with them while I was in the class. I send an email saying that, Hey, do you have anything for me? Do you have a project for me that I can be a part of since maybe they like my work when I was part of their group, they were proactive and they started by little and it grew and then they ended up sending me that school feeding evaluation report. Again, they want us to validate that school meal evaluation report, which I felt like was a big deal for me too. So again, you have to be proactive. You have to make those connections because nobody's going to make that for you. You have to show genuine interest when you're talking to these people and they catch up on it.
Deborah Onakomaiya: You have such an amazing resume. You've worked with UNICEF, WFP, you're a medical doctor.
Pratik Sourav: Yes I am.
Deborah Onakomaiya: I understand that you don't want to practice, how were you confident enough to be sure of not wanting to practice and to go to public health route? Because I'm sure there are a lot of medical doctors in your shoes. What focus did you have or how were you able to make that particular decision to switch to the global health space?
Pratik Sourav: Correct. So for me, I mean right after graduating from medical school from Bangladesh, I did a mandatory internship that you have to do back there and practice for a year. And then I moved to the United States and I started the program. But I feel being a physician that's great. You have your own practice, you're helping people, that's part of public health as well, but you can only make an impact or change on let's say a hundred or max 1000 people's life. But being a public health professional, you make a bigger impact. You can see you have the power to change the life for an entire population of a country. Again, my background as a medical doctor, I feel like empowers me to learn what I'm learning right now or in the future to implement what I'm tasked to implement.
Deborah Onakomaiya: I have to ask this question. A lot of the times we say, Oh, where do you see yourself in five years? It's a corny question, but I have to ask you that because you have such an amazing background. Where do you see yourself 10 years from now?
Pratik Sourav: That's definitely an agency, most preferably UNICEF as a program director if possible. That'd be great.
Deborah Onakomaiya: Why UNICEF? What drives your passion for public health?
Pratik Sourav: Correct. I mean, my long term goal is to work in the prevention and controlling of our iron deficiency anemia in South Asian countries. I don't even know that or not, but over 50% of the population over there are suffering from iron deficiency anemia, which is one of the main causes of stunting and one of the main causes of maternal mortality because that are kind of accelerate the progression of maternal hemorrhage during childbirth. So it leads into different issues, different problems resulting in a loss of lives, loss of productive days as we call dollies. So it has a vast effect in the population and particularly if you're from a poor country or low income country from South Asia, that burden is really, really high. So my goal is to work in that field and that's where UNICEF plays a major role because they are a hands on, on the field agency.
Deborah Onakomaiya: UNICEF?
Pratik Sourav: Correct, and WFP as well.
Deborah Onakomaiya: Oh, okay. Wow. I guess in 10 years I'll be asking you for a job at UNICEF or WFP.
Pratik Sourav: Most likely you're going to be my coworker at that time.
Deborah Onakomaiya: Yes, for sure. Thank you so much for being on the show Pratik. It was wonderful to have you. I learned so much and I mean you're inspiring me to want to get out there and be part of a community that makes change. Thank you so much.
Pratik Sourav: It was my pleasure. Thanks for having me.