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

Macro International Inc., Calverton, MD, USA.
International Journal of Health Planning and Management (Impact Factor: 0.97). 10/2009; 24(4):326-50. DOI: 10.1002/hpm.1012
Source: PubMed


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

Download full-text


Available from: Jim Ricca
  • Source
    • "Several studies developed quantitative indicators or indices for measuring benefits or outcomes produced by the programme as a proxy for sustainability (McDermott et al. 2003; Mancini and Marek 2004; Stephenson et al. 2004; Amazigo et al. 2007; Glisson et al. 2008; Sarriot et al. 2008). "
    [Show abstract] [Hide abstract]
    ABSTRACT: There is renewed concern over the sustainability of disease control programmes, and re-emergence of policy recommendations to integrate programmes with general health systems. However, the conceptualization of this issue has remarkably received little critical attention. Additionally, the study of programmatic sustainability presents methodological challenges. In this article, we propose a conceptual framework to support analyses of sustainability of communicable disease programmes. Through this work, we also aim to clarify a link between notions of integration and sustainability. As a part of development of the conceptual framework, we conducted a systematic literature review of peer-reviewed literature on concepts, definitions, analytical approaches and empirical studies on sustainability in health systems. Identified conceptual proposals for analysis of sustainability in health systems lack an explicit conceptualization of what a health system is. Drawing upon theoretical concepts originating in sustainability sciences and our review here, we conceptualize a communicable disease programme as a component of a health system which is viewed as a complex adaptive system. We propose five programmatic characteristics that may explain a potential for sustainability: leadership, capacity, interactions (notions of integration), flexibility/adaptability and performance. Though integration of elements of a programme with other system components is important, its role in sustainability is context specific and difficult to predict. The proposed framework might serve as a basis for further empirical evaluations in understanding complex interplay between programmes and broader health systems in the development of sustainable responses to communicable diseases.
    Preview · Article · Feb 2014 · Health Policy and Planning
  • Source
    • "In the late 1990s, a few scholars proposed introducing systems thinking in international health in order to take local perspectives and contexts into account [18,19]. The introduction of systems thinking and complexity science in international development is reflective both of the failure of international donors and NGOs to deliver long term benefits to the population. "
    [Show abstract] [Hide abstract]
    ABSTRACT: There is general agreement amongst major international policy makers that sustainability is a key component of health interventions in developing countries. However, there is little evidence on the factors enabling or constraining sustainability. Diffusion of innovation theory can help explain how the continuation of activities is related to the attributes of innovations. Innovations are characterised by five attributes: (i) relative advantage; (ii) compatibility; (iii) complexity; (iv) triability; and (v) observability. An eye care programme was selected as a case study. The programme was implemented in the Brong Ahafo region of Ghana and had been funded over a ten-year period by an international organisation. Sustainability in the study was defined as the level of continuation of activities after the end of international funding. Measuring the continuation of activities involved checking whether each eye care activity continued (i.e. out-patient consultation, cataract surgery, outreach, school health, and statistics) or was interrupted after the end of Swiss Red Cross funding the 11 district hospitals where the programme was implemented. The results showed a relationship between the level of sustainability and the attributes of every activity. The activities with the lowest score for the attributes were less sustained. School health screening was the least sustained activity after the end of international funding. This activity also held the smallest score in terms of attributes: they were the most incompatible and most complex activities, as well as the least triable and observable activities, amongst the four district activities. In contrast, compared to the three other district activities, facility-based consultations were more likely to be routinised because they were perceived by the hospital managers as very compatible, and not complex. Using diffusion of innovations theories can help predict the sustainability of specific activities within a health programme. The study also highlighted the need for disentangling the various components of a health programme in order to identify which activities are more likely to be continued within a health system. The same methodology could be used in a different setting and could help predict which innovations are more likely to be adopted and maintained over time.
    Full-text · Article · Feb 2014 · BMC Health Services Research
  • Source
    • "In other words, there is often no identifiable linearity between cause and ultimate effect, and so a desired ultimate effect does not always commend a clear intervention strategy or predict outcomes. This problem of causality, which is also at the heart of the research process (Argyris, 1997), especially in health (Dowd, 2011; Escarce and Flood, 2011), reaffirms the need to consider multiple interpretations based on ontologies that may operate simultaneously at different levels, as a precursor to choice of both analytical methods and intervention tools (Newbrander, Peercy et al., 2011; Sarriot et al., 2009), because as Dowd (2011) pointed out, 'the approaches to causal questions are discipline specific, often with little overlap', and may have little understanding of the fragility of trying to link the past to the present and the present to the future. This problem of interpretation, especially where there are competing interests, to define the interpretive lens (Pettit, 2010), as we have already outlined, for example, the approach of Morgan (2006), can perhaps be better understood by considering the competing ontologies and epistemologies that have emerged so far, starting with positivism, then the systems approach, complexity theory and by default, often in relation to Fragile States, chaos theory (Carment and Samy, 2011). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this paper is to consider capacity development for healthcare in Fragile States and its roles, for example, in securing civil and political stability, as well as improved health, within the various contexts prevailing in fragile settings across the world. As a precursor to this, however, it is important to understand how, in rapidly changing environments, the role and contribution of different donors will have an impact in different ways. This paper sets out to interpret these issues, and what becomes apparent is the need to develop an understanding of the value base of donors, which we demonstrate through the development of a value-based framework. This highlights the separate motivations and choices made by donors, but what is apparent is that all remain within the positivist perspective perhaps for reasons of accountability and transparency. However, the emergence of new interpretations drawing on systems thinking, and followed by complexity theory more recently, in understanding contexts, suggests that the favouring of any one of these perspective can be counterproductive, without a consideration of the contexts in which they occur. In seeking an explanation of these environmental contexts, which also address the perspectives in use, we suggest the use of wider multi-ontology sense-making framework such as Cynefin. Through this approach, analytical insights can be given into the interpretation, decision and intervention processes available in these different and often changing environments, thus enabling greater coherence between donor values and recipient contexts. Copyright © 2012 John Wiley & Sons, Ltd.
    Full-text · Article · Jul 2013 · International Journal of Health Planning and Management
Show more