The bottleneck analysis framework in EQUIST assumes that eight conditions (coverage determinants) must be met to provide effective coverage of any health intervention. Each coverage determinant, from the supply and demand side, will determine the level of bottlenecks:
- Availability of commodities: Essential commodities and inputs required to deliver a service or adopt a practice.
- Availability of human resources: Physical access to adequately staffed health services (either at static facilities or mobile services).
- Geographical accessibility: A problem of infrastructure, personnel, or both.
- Financial affordability: target population cannot afford the intervention.
- Sociocultural acceptability: the intervention is not desirable, or the target population is not aware of it.
- Initial utilization: the amount that a service is utilized when supply is first given to target population.
- Adequate coverage: continuous use of a service or practice of a behavior.
- Effective coverage: the right amount of coverage level for target population to ensure optimal health outcomes.
There must be supplies in place at accessible, adequately staffed and equipped facilities. The target population must be aware of the health service or desirable behavior and be willing and able to seek care when indicated. Finally, the service must be provided (or health behavior performed) with adequate quality to have its intended impact on health. This framework has been employed by UNICEF, the World Bank and others for many years and was originally adapted from Tanahashi et al 1978. In EQUIST, bottlenecks are divided into eight coverage determinants, which can be better understood as supply or demand determinants, as categorized in the table below. These determinants are highly inter-related, and the relationships between these are further described below: