Measuring sustainability as a programming tool for health sector investments: report from a pilot sustainability assessment in five Nepalese health districts

Sustainability is a critical determinant of scale and impact of health sector development assistance programs. Working with USAID/Nepal implementing partners, we adapted a sustainability assessment framework to help USAID test how an evaluation tool could inform its health portfolio management. The essential first process step was to define the boundaries of the local system being examined. This local system—the unit of analysis of the study—was defined as the health district. We developed a standardized set of assessment tools to measure 53 indicators. Data collection was carried out over 4 weeks by a Nepalese agency. Scaling and combining indicators into six component indices provided a map of progress toward sustainable maternal, child, health, and family planning results for the five districts included in this pilot study, ranked from “no sustainability” to “beginning of sustainability.” We conclude that systematic application of the Sustainability Framework could improve the health sector investment decisions of development agencies. It could also give districts an information base on which to build autonomy and accountability. The ability to form and test hypotheses about the sustainability of outcomes under various funding strategies—made possible by this approach—will be a prerequisite for more efficiently meeting the global health agenda. Copyright © 2009 John Wiley & Sons, Ltd.     

基于项目理论的评估对儿童健康干预评估的启示

干预项目具有长期性、复杂性,对其进行适宜的评估是推动其可持续发展的关键.基于项目理论的评估在评估内容和方法上的综合性,不仅有助于对项目运行过程＂黑匣子＂的破解,提升评估研究的专业水平,同时也对项目评估研究和项目管理水平的提高有不容忽视的促进作用.我国儿童健康状况与发达国家仍有一定差距,且地区间发展不平衡问题较为突出.目前针对儿童常见疾病、健康生活方式、生长发育、儿童看护人保健认知和就医行为以及妇幼保健机构基础能力建设等开展了一系列干预项目,但项目评估相关研究较为欠缺,在评估思路和方法上存在不足.本文在对基于项目理论的评估和国内外儿童健康干预评估现状进行梳理和分析的基础上,提出转变传统儿童健康干预评估观念、从注重结果的鉴定性评估转向重视过程的诊断性评估、对儿童健康干预评估结果及时进行反馈与运用、注重加强儿童健康干预项目评估能力建设等建议.     

Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organizations

Sustainability continues to be a serious concern for Primary Health Care (PHC) interventions targeting the death of millions of children in developing countries each year. Our work with over 30 Non-Governmental Organizations (NGOs) implementing USAID's Child Survival and Health Grants Program (CSHGP)-funded projects revealed the need for a study to develop a framework for sustainability assessment in these projects. We surveyed NGO informants and project managers through semi-structured interviews and questionnaires. This paper summarizes our study findings. The NGOs share key values about sustainability, but are skeptical about approaches perceived as disconnected from field reality. In their experience, sustainable achievements occur through the interaction of capable local stakeholders and communities. This depends strongly on enabling conditions, which NGO projects should advance. Sustainability assessment is multidimensional, value-based and embeds health within a larger sustainable development perspective. It reduces, but does not eliminate, the unpredictability of long-term outcomes. It should start with the consideration of the 'local systems' which need to develop a common purpose. Our ability to address the complexity inherent to sustainability thinking rests with the validity of the models used to design interventions. A participant, qualitative research approach helped us make sense of sustainability in NGO field practice.     

Understanding community perceptions of health and social needs in a rural Balinese village: results of a rapid participatory appraisal

This article reviews the process and key recommendations derived from conducting a rapid participatory asset-focused health and social needs assessment in the small traditional rural village of Tulikup, Bali. The assessment aimed to develop recommendations for a community radio station based in Tulikup to promote social change and development. The health and social needs assessment utilized an asset-focused rapid participatory assessment cycle methodological framework, incorporating Annett and Rifkin's (1995) guidelines for rapid participatory appraisals (World Health Organization, Geneva), community-based action research (Sage Publications, California; Stringer, 1996) and asset-based community development. The study explored Tulikup's pre-existing assets and highlights the value of using rapid participatory appraisal techniques as a first step in involving communities in assessing needs and planning meaningful community development strategies. Data was collected over a 3-week in-country period and included interviews with key informants, informal individual and group discussions, field observations and reviews of existing secondary data sources. Triangulation using cultural interpreters, and participatory consultation processes with community members helped ensure data reliability and validity. Recent terrorist attacks in Indonesia and, most notably, Bali, have had widespread economic and social effects throughout Bali. In particular, secondary consequences of unemployment and a reduction in income have had negative impacts on population health and child labour at the village level. The findings and recommendations of the health and social needs rapid assessment have been utilized by the radio station to promote social change and development.     

Are reproductive health NGOs in Uganda able to engage in the health SWAp?

This paper explores the ability for reproductive health (RH) non-governmental organizations (NGO) in Uganda to survive in the context of SWAp and decentralization. The authors argue that, contrary to the perceptions that this context may increase NGO's financial vulnerability, a SWAp and a decentralized system may provide an opportunity that should be embraced by NGOs to enhance their sustainability and effectiveness by reducing their current dependency on donor funding. The paper discusses the systemic weaknesses of many NGOs that currently make them vulnerable, and observes that unless these weaknesses are addressed, such NGOs will lose their space in the SWAp and decentralization arena. The authors suggest that NGOs need to recognize the opportunities that participating in public-private partnerships through a SWAp can offer them for long-term and significant funding. They need also to develop their capacity to pro-actively participate in a SWAp and decentralized context by becoming more entrepreneurial in nature, through re-orienting their organizational philosophies and strategic planning and budgeting so as to be able to partner effectively with the public sector in accessing funds made available through health sector reform.     

Non-Governmental Organizations in the area of Child Healthcare - review of the literature

The second half of the twentieth century saw the emergence of organizations that reflected the mobilization of civil society for more effective participation in questions in the public interest and of a social nature. These became known as non-governmental organizations (NGOs) and they assumed their place as partners with public and private sectors to develop actions in different areas, including healthcare. Based on a review of the literature, the scope of this paper was to assess the status of scientific knowledge on the participation of NGOs in child healthcare and, by identifying and classifying their activities, establish if they are in line with the agenda of the field. Analysis of the publications took into consideration where the authors were from, the journal in question, the origins and area of activity of the NGOs and the source of the funds applied to the projects implemented. The nature of activities varied with the degree of development of the region where the NGOs operated and the themes, partnership between government and private sector agencies, sustainability and impact of actions on the favored communities were the main topics highlighted by the authors. The conclusion reached was that the performance of NGOs in child health is in the early stages and is a knowledge field to be explored.     

Sustainability of NGO capacity building in southern Africa: successes and opportunities

Despite an increase in organizational capacity building efforts by external organizations in low and middle income countries, the documentation of these efforts and their effects on health programs and systems remains limited. This paper reviews key frameworks for considering sustainability of capacity building and applies these frameworks to an evaluation of the sustainability of an AIDS non‐governmental organization (NGO) capacity building initiative. From 2004–2007 Bristol‐Myers Squibb Foundation's Secure the Future^TM initiative in southern Africa funded a five country program, the NGO Training Institute (NGOTI), to build capacity of NGOs working to address HIV/AIDS. Lessons learned from this project include issues of ownership, the importance of integrating planning for sustainability within capacity‐building projects, and the value of identifying primary capacity‐building objectives in order to select sustainability strategies that are focused on maintaining program benefits. Sustainability for capacity building projects can be developed by discussing key issues early in the planning process with all primary stakeholders. Copyright © 2010 John Wiley & Sons, Ltd.     

Closing the gap: building the capacity of non-government organizations as advocates for health equity

Seeking achievement of health equity has underpinned national government and global health policies for decades. However, major difficulties and challenges faced in the practice of achieving 'Health for All' has led to a recognition of the need to broaden the focus of efforts to improve health equity. Civil society groups have been identified as key stakeholders in attempts to achieve health equity, and the importance of strengthening their capacity to influence relevant government policy and practice has been highlighted. This paper presents the results of a qualitative study which examined the role of organizations outside government in advocating for health equity, and the capacities and conditions that were related to their success. In-depth, unstructured interviews were conducted with 26 non-government organizations (NGOs) who were active in three important health policy debates in Australia. The grounded theory method was used to direct data collection and analysis, and member checking was employed to ensure soundness and build ownership of the findings. Effective advocacy was found to be a dynamic process characterized by flexibility and opportunism within a framework of longer term goals. Two key ways of working were identified--in partnership and in conflict with government, with shifts in emphasis in response to organizational strengths and a changing environment. A number of domains of capacity, which together are termed 'capacity for advocacy', were also identified. It is clear that NGOs can learn a great deal from each other, but there needs to be investment by governments, international agencies and NGOs themselves if advocacy for health equity is to be strengthened.     

Issues in measuring health promotion capacity in Canada: a multi-province perspective

Significant international progress has been made researching and addressing the economic and social burden of cardiovascular disease, advanced particularly by international conferences and subsequent declarations, and the Canadian Heart Health Initiative (CHHI). The implementation focus of the CHHI on building capacity for heart health promotion is paralleled by efforts to measure capacity. Through the collective experience of Heart Health Programs in Nova Scotia, Saskatchewan, Alberta and British Columbia, critical issues in measuring health promotion capacity are identified and strategies for addressing them are presented. The provincial contexts for the programs vary, as do the conceptualizations of capacity and intervention strategies to build capacity. Yet, despite such differences across provinces, shared issues influencing measuring capacity number many. These include: multiple understandings of terms; evolving understanding of capacity; invisibility of capacity building; detecting change within a dynamic system; staff turnover; time course required for change; attribution for change in capacity; understanding a process through 'snap-shot' measurements; lack of existing 'gold standard' measurement tools; validity and credibility of instruments; evolving nature of measurement tools; gathering perspectives from multiple levels within organizations; dealing with conflicting perspectives; and managing and disseminating sensitive data. A number of strategies have been devised or adopted to address measurement issues, ranging from adopting participatory processes to the development of monitoring systems. Understanding and addressing issues in measuring capacity deserve attention as they may be potent influences in the dynamic interplay between research and intervention in the process of capacity building in the context of health promotion generally, and/or heart health specifically.     

The Eat Well SA project: an evaluation-based case study in building capacity for promoting healthy eating

The term 'capacity building' is used in the health promotion literature to mean investing in communities, organizations and structures to enhance access to knowledge, skills and resources needed to conduct effective health programs. The Eat Well SA project aimed to increase consumption of healthy food by children, young people and their families in South Australia. The project evaluation demonstrated that awareness about healthy eating among stakeholders across a range of sectors, coalitions and partnerships to promote healthy eating and sustainable programs had been developed. The project achievements were analysed further using a capacity-building framework. This analysis showed that partnership development was a key strategy for success, leading to increased problem-solving capacity among key stakeholders and workers from education, child care, health, transport and food industry sectors. It was also a strategy that required concerted effort and review. New and ongoing programs were initiated and institutionalized within other sectors, notably the child care, vocational education and transport sectors. A model for planning and evaluating nutrition health promotion work is described.     

Social contexts and children's health outcomes: Researching across the boundaries

While significant progress has been made on several fronts in child health research in recent years, research findings have not always been readily translated to better policies and programs for creating healthy conditions for children. Child health policies and research have not always aligned in a manner that would inform each other to the benefit of children. In this paper it is argued that child health research and interventions need to proceed from an explicit recognition of the fundamental causes of poor child health, namely parents’ socioeconomic status and the social context in which children live. A conceptual framework is presented that organizes the key domains of child health determinants and the possible causal pathways that link these domains to produce health outcomes. This framework assisted the development of a multi-method research program specifically linking community members, program developers and policy-makers in the research process. It also helped to identify methodological issues inherent in a comprehensive approach to child health research, which is commented on drawing from illustrative examples from the authors’ research program. The article concludes with some observations on the authors’ experience in engaging policy and civil society constituents in order to better align research, policy and intervention programs.     

Understanding the relationship of maternal health behavior change and intervention strategies in a Nicaraguan NGO network

Few studies of community interventions examine independent effects of investments in: (1) capital (i.e., physical, human and social capital), and (2) management systems (e.g., monitoring and evaluation systems (M&E)) on maternal and child health behavior change. This paper does this in the context of an inter-organizational network. In Nicaragua, international non-governmental organizations (NGOs) and local NGOs formed the NicaSalud Federation. Using Lot Quality Assurance Sampling (LQAS), 14 member organizations took baselines measures of maternal safe motherhood and child health behavior indicators during November 1999 and August 2000, respectively, and final evaluation measures in December 2001. In April 2002, retrospective interviews were conducted with supervisors and managers in the 14 organizations to explore changes made to community health strategies, factors associated with the changes, and impacts they attributed to participating in NicaSalud. Physical capital (density of health huts), human capital (density and variety of paramedical personnel) and social capital (density of health committees) were associated with pregnant women attending antenatal care (ANC) 3+ times, and/or retaining ANC cards. The variety of paramedic personnel was also associated with women making post-partum visits to clinics. Physical capital (density of health huts) and social capital (density of health committees and mothers' clubs) were associated with child diarrhea case management indicators. One safe motherhood indicator (delivery of babies by a clinician) was not associated with intervention strategies. At the management level, NicaSalud's training of members to use LQAS for M&E was associated with the number of strategic and tactical changes they subsequently made to interventions (organizational learning). Organizational learning was related to changes in maternal and child health behaviors of the women (including changes in the proportion using post-partum care). As the latter result would not have occurred without NicaSalud, we conclude that this inter-organizational network provided added value by instigating organizational learning.     

Social determinants of health: implications for environmental health promotion.

In this article, the authors draw on the disciplines of sociology and environmental and social epidemiology to further understanding of mechanisms through which social factors contribute to disparate environmental exposures and health inequalities. They propose a conceptual framework for environmental health promotion that considers dynamic social processes through which social and environmental inequalities--and associated health disparities--are produced, reproduced, and potentially transformed. Using empirical evidence from the published literature, as well as their own practical experiences in conducting community-based participatory research in Detroit and Harlem, the authors examine health promotion interventions at various levels (community-wide, regional, and national) that aim to improve population health by addressing various aspects of social processes and/or physical environments. Finally, they recommend moving beyond environmental remediation strategies toward environmental health promotion efforts that are sustainable and explicitly designed to reduce social, environmental, and health inequalities.     

Developing applied medical anthropology in Third World countries: problems and actions.

Recognition of the usefulness of ethnographic research in Third World community health projects and programs developed rapidly during the 1980s. As a result, the various agencies and organizations promoting community health programs (UNICEF, WHO, NGOs) have greatly increased their recruiting of social scientists, particularly medical anthropologists, for research and other programmatic activities in primary health care, child survival (especially diarrhea, acute respiratory infections, maternal and child nutrition, infectious disease, and AIDS). However, it has proved very difficult to identify well-trained anthropologists and/or other social scientists for these roles, particularly in Third World countries. This paper examines some of the background of this problem, and presents examples of methodological training (in both qualitative and quantitative research techniques) that seek to increase the skills of social scientists and other researchers in the arena of international community health.     

国际非政府组织参与全球健康治理的工具研究

非政府组织在全球健康治理中发挥着日益重要的作用。本研究筛选了10家在全球健康事务中有重要作用的关键非政府组织,总结非政府组织参与全球健康治理的工具,包括:"产生知识和证据"、"合作"、"参与"、"协商一致"、"透明性"、"组织建设"、"制定政策或战略方向"、"责任"和"规制"九个维度。实施型、倡导型、支持型和综合型非政府组织在参与全球健康治理的工具选择上具有共性和各自侧重点。中国应努力培育本土非政府组织,同时应注重其"透明性"、"参与"与"合作"。     

灾害及灾后公共卫生服务的社会评估

在汶川地震发生的初期,各级卫生机构做了大量的评估工作,但评估方式仍有很大的改进余地。灾后公共卫生服务评估可引入社会评估的模式,社会评估采用参与式方法,从当事人的视角出发为核心,以当事人确定的标准为主,并且通过对相关利益群体和机构的访谈,以及文件查阅等方式评估相关机构的工作效果及有关政策的影响。灾害初期的快速评估涉及的具体内容包括医疗健康服务、疾病防控服务、卫生设施服务、水供应服务、食品安全供应服务、临时安置点的卫生服务等。灾后重建过程中,社会评估可以应用于新建医疗机构和疾控体系恢复中,同时对重建组织开展社会评估。     

The growing influence of non governmental organisations (NGOs) in international health: challenges and opportunities

The growing influence of non governmental organizations (NGOs) in international health is occurring in the face of major challenges and opportunities. These challenges include the continued increases in global poverty status, the growing influence of private-funded health systems, the need for sustainability of external-funded programs, and the clamour for community participation in the planning and management of external-funded programs. Opportunities include the near universal recognition of the indispensable roles of NGOs by bilateral institutions and governments, the current emphasis on global trade by developed countries, and the need to develop political and economic systems that are equitable and promote social development. This article is an overview of these challenges and how these challenges can become excellent opportunities for NGOs to improve the health and social development of target communities in developing countries.     

Sustainability: the elusive dimension of international health projects

OBJECTIVE: The Canada-China Yunnan Maternal and Child Health Project (1997-2003) sought to improve the quality of village life and promote development of productivity and social prosperity in Yunnan province, China. PARTICIPANTS: The project targeted grassroots maternal and child health workers: new and in-service village doctors; traditional village midwives; doctors at township health centres; doctors at county maternal and child health hospitals; and provincial health staff. SETTING: Ten impoverished counties (population 2.2 million) in Yunnan province with high proportions of ethnic minority populations. INTERVENTION: There were three major innovations: training grassroots maternal and child health workers in participatory and community-based approaches and clinical skills; designing a model comprehensive referral system including provision of basic equipment; and introducing participatory monitoring and evaluation methods. Strategies to support sustainability were built into the project from the outset. OUTCOMES: Over 4,000 village, township, and county health workers received training. Maternal, infant, and under-five mortality rates declined over 30% in project counties. Project innovations were disseminated throughout the province, into other donor-funded initiatives, and integrated into national health projects by local partners. CONCLUSION: Maintaining the long-term benefits of international health interventions depends on sustaining innovations beyond short project timelines. Achieving sustainability poses a conundrum to implementing agencies. Three mechanisms influenced uptake in the Yunnan project: maintaining a good fit between core project elements and the existing health system; developing adequate organizational supports; and creating a handover plan from the outset. This project highlights some of the ways in which sustainability can be operationalized.     

Can developing countries achieve adequate improvements in child health outcomes without engaging the private sector?

The private sector exerts a significant and critical influence on child health outcomes in developing countries, including the health of poor children. This article reviews the available evidence on private sector utilization and quality of care. It provides a framework for analysing the private sector's influence on child health outcomes. This influence goes beyond service provision by private providers and nongovernmental organizations (NGOs). Pharmacies, drug sellers, private suppliers, and food producers also have an impact on the health of children. Many governments are experimenting with strategies to engage the private sector to improve child health. The article analyses some of the most promising strategies, and suggests that a number of constraints make it hard for policy-makers to emulate these approaches. Few experiences are clearly described, monitored, and evaluated. The article suggests that improving the impact of child health programmes in developing countries requires a more systematic analysis of how to engage the private sector most effectively. The starting point should include the evaluation of the presence and potential of the private sector, including actors such as professional associations, producer organizations, community groups, and patients' organizations.