PSP Sustaining the Benefits: A field guide for sustaining reproductive and child health services

Publication date: 2006

THE CEDPA TRAINING MANUAL SERIES THE ENABLING CHANGE FOR WOMEN'S REPRODUCTIVE HEALTH THE CENTRE FOR DEVELOPMENT AND POPULATION ACTIVITIES enable PROJECT sustaining the benefits: a field guide for sustaining reproductive and child health services Sustaining the Benefits: A Field Guide for Sustaining Reproductive and Child Health Services ii Sustaining the Benefits Sustaining the Benefits: A Field Guide for Sustaining Reproductive and Child Health Services Authors Abrar A. Kahn, MA Lisa Hare, MPH Other contributors Xiaopang Tian, PhD Mary Jo Larson, PhD Marta Levitt-Dayal, MPH, PhD Tom Leonhardt, PhD This publication was supported by the United States Agency for International Development under Cooperative Agreement # HRN-A-00-98-00009-00. The contents of this document do not necessarily reflect the views or policies of the U.S. Agency for International Development or The Centre for Development and Population Activities (CEDPA). Introduction iii Abbreviations ANC Antenatal Care CASP Community Aid and Sponsorship Program CBD Community-Based Distribution CBHMO Community-Based Health Management Organization CBO Community-Based Organization CEDPA The Centre for Development and Population Activities COPE Client-Oriented, Provider-Efficient Services CPR Contraceptive Prevalence Rate CQI Continuous Quality Improvement CYP Couple Years of Protection DHS Demographic Health Survey FADE Focus, Analyze, Develop, Execute FEMAP The Mexican Federation of Private and Community Development Associations FGC Female Genital Cutting GEM Global Excellence in Management IDB Inter-American Development Bank IEC Information, Education, and Communication MIS Management Information Systems MSH/FPMD Management Services for Health/Family Planning Management Development NGO Non-Governmental Organization ORS Oral Rehydration Salts PAI Population Action International PD Positive Deviance iv Sustaining the Benefits PDI Positive Deviance Inquiry RCH Reproductive and Child Health RH Reproductive Health SERVOL Services Volunteered for All SIFPSA State Innovations in Family Planning Services Agency UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization Introduction v Acknowledgements Sustaining the Benefits: A Field Guide for Sustaining Reproductive and Child Health Services was made possible through funding from the United States Agency for International Development (USAID) under the Enabling Change for Women’s Reproductive Health (ENABLE) Project and the Bill and Melinda Gates Foundation, which supports the Women’s Leadership Program implemented through the Centre for Development and Population Activities (CEDPA). CEDPA appreciates their generous support of this publication and CEDPA’s program activities. This guide evolved from the excellent assistance the CEDPA/India office provides its partners in enhancing the sustainability of their community-based programs. Their efforts to test and document their ideas made the guide possible. Many people contributed to the development of the guide. Tom Leonhardt prepared the chapter on Strategic Communication, drawing from years of facilitating CEDPA workshop sessions on the same topic. Mary Jo Larson and Xiaoping Tian wrote the Leading Change chapter. Timothy Skaggs helped to test many of the initial concepts and made valuable contributions to the guide’s development. A special word of appreciation goes to Marta Levitt-Dayal who championed the guide from its conception, through its drafting, testing and final review. Her support was critical to the guide’s completion. Margaret Phillips, as the technical editor, organized and simplified the text, making the guide’s complex ideas easier to digest. Oma McLaughlin provided editorial and graphic support. Christine Haenn completed the copyediting. Critical to the guide’s development were the insights CEDPA’s partners and workshop participants from around the world provided as they applied the concepts presented in the guide. Their experiences helped to refine CEDPA’s understanding of sustainability and the complexities involved in building enduring community-based reproductive health services. Two agencies in India—the Community Aid and Sponsorship Program (CASP) and State Innovations in Family Planning Services Agency (SIFPSA)—implemented many of the approaches presented in the guide, shared their experience with CEDPA and validated many of the premises underlying the guide. We would also like to acknowledge the support and encouragement received from the USAID/India Mission and in particular Mr. Samaresh Sengupta for testing/piloting sustainability strategies. The guide’s reviewers supplied fresh ideas and thoughts. Bhagyashri Dengle, CASP/India, and Gladys Sama, Integrated Education in Development Programs (IEDP)/Cameroon provided meaningful suggestions and insights. Mary Jo Larson and Victoria Wells suggestions were invaluable to improving the final product. Abrar A. Kahn Lisa Hare Senior Training Specialist Senior Advisor, Sustainability CEDPA/India CEDPA/Washington Introduction vii Table of Contents Sustaining the Benefits: A Field Guide for Sustaining Reproductive and Child Health Services Abbreviations . iii Acknowledgements . v Introduction .I Sustainability—Some Underlying Beliefs .II Section by Section, Chapter by Chapter. III Section 1: Unpacking Sustainability Chapter 1 Defining Sustainability. 3 What Are We Trying to Sustain? . 5 Why Is Sustainability Important?. 6 Chapter 2 Pillars of Sustainability. 9 How Can Sustainability Be Achieved? . 9 Functioning as a Social Enterprise . 13 The Changing Roles of Donors, Community, and Organizations. 14 Case 1: Lumbini Eye Care Project . 15 Case 2: Banking on Youth: SERVOL. 19 Case 3: FEMAP—A Mexican Case Study. 22 Section 2: How Sustainable Is Your Organization? Chapter 3 Sustainability Assessment. 29 What an NGO Needs to Do to Become Sustainable . 29 Assessing Sustainability—The Matrix. 30 Using the Results for a Broader Assessment. 32 NGO Sustainability Assessment Matrix . 35 Score Sheet . 39 Sustainability Profile Matrix . 40 viii Sustaining the Benefits Section 3: Institutional Aspects of Sustainability Chapter 4 Values, Mission, and Vision. 45 Values. 46 Mission . 47 Elements of a Mission Statement . 48 Vision . 51 Chapter 5 Good Governance. 53 Governance and Boards. 53 Why Have Boards?. 53 Primary Responsibilities of Boards. 54 Chapter 6 Strategic Communication . 59 What Is Strategic Communication?. 59 Strategic Communication—Essential for Sustainability. 59 Steps in Strategic Communication . 60 Section 4: Programmatic Aspects of Sustainability Chapter 7 Community Participation and Ownership. 73 Community Participation and Sustainability. 73 The Levels of Community Participation . 74 Best Practices for Facilitating and Creating Community Participation and Ownership . 75 Chapter 8 Improving Quality. 87 Quality and Why it Is Important. 87 Approaches to Working on Quality Issues. 89 Tools for Improving Quality . 90 Chapter 9 Marketing. 99 Marketing and Its Contribution to Sustainability. 99 The Four “Ps”. 100 How to “Do” Marketing. 101 Section 5: Financial Aspects of Sustainability Chapter 10 Financial Analysis for Sustainability. 113 What Is Financial Analysis? Why Is it Important to Sustainability? . 113 Introduction ix Steps in Analyzing Expenditures . 115 Steps in Analyzing Income. 119 Putting Income and Expenditure Together. 125 Chapter 11 Reducing Costs . 131 Choosing Less-Costly Delivery Approaches . 131 Trimming Unfunded Services that Cannot Recover Costs . 131 Improving Quality and Eliminating Re-Work and Waste. 132 Using Excess Capacity to Your Advantage . 132 Reducing the Costs of Inputs. 133 Chapter 12 Charging Fees for Services and Products . 135 Setting Prices. 135 Protecting Low-Income Clients . 140 Chapter 13 Leveraging Resources . 143 What Is Leveraging? . 143 How to Leverage Support. 144 Section 6: Implementing Sustainability Chapter 14 Crafting Strategies for Sustainability. 161 Our Approach . 161 The Value of this Approach . 162 Preparing for an Organizational Inquiry into Sustainability . 163 How to Conduct the One-Day Strategy Development Workshop . 167 Chapter 15 Leading Change Efforts. 171 The Organizational Challenge. 172 Chapter 16 And One More Thing—Monitoring . 179 What to Measure . 179 Data Collection and Analysis . 182 Telling Your Story. 182 Introduction I Introduction Welcome to Sustaining the Benefits: A Field Guide for Sustaining Reproductive and Child Health Services. This guide is a reference for nongovernmental organization (NGO) leaders, board members and program managers who wish to build enduring community-based programs. It explains the term “sustainability” and accompanies readers through a process of transforming that understanding into organizational action. Although it can stand alone, users of the guide may find it useful to explore the sustainability concepts in a workshop setting. CEDPA has prepared a companion piece to the guide, called Reproductive Health Awareness: A Wellness, Self-Care Approach, as part of its quality of care series. Using the two manuals together allows NGOs to share experiences and ideas during a participatory workshop while having a reference that provides more depth on the topics covered. The guide emerged from CEDPA’s work in India; first under the USAID-funded project ACCESS and then under the follow-on project, ENABLE. CEDPA worked with NGO partners to build their capacity to provide community-based reproductive and child health (RCH) services. A critical issue faced by the partners—whether a training organization or dairy cooperative—was how to continue their RCH programs once donor support was withdrawn. The process of exploring this issue with partners, drawing both on their own experiences and best practices from around the world, resulted in the key concepts and tools presented in this guide. These were further developed and tested in international workshops and work with partners in Africa and Central America. Although written for organizations working in reproductive health, the ideas and approach presented in the guide can apply to any development organization that is interested in sustaining its programs. The guide’s underlying premise is that sustainability efforts should emphasize continuing community-level benefits rather than the survival of the organization. Sustaining the benefits means that the services remain available and that the intended population, often the poor or disadvantaged, continue to have access to them. From this perspective if an organization survives after a donor leaves by serving the middle class rather than its intended population, it has not sustained the benefits. The guide presents two ways to achieve enduring benefits— 1. Develop an entrepreneurial, mission-driven organization that effectively responds to changing community needs through the provision of valued services, and 2. Build the capacity of the community to own and manage the program, so the organization might exit while leaving the benefits behind. Both scenarios require that organizations change the way they view and interact with their communities and their donors. The guide uses a social enterprise model, introduced in Chapter 2, to describe the transformation an organization must undertake to sustain its benefits. Social enterprise marries an organization’s social objectives—expanding RCH services in underserved populations—with basic business practices—lowering and recovering costs. While building on some aspects of commercial operations, social enterprises focus on generating value and change for society rather than II Sustaining the Benefits generating profits. So while terms typically associated with commercial activities including client, fees, efficiency, cost reduction, marketing and leveraging are used in social enterprise, the emphasis is on how these help a NGO to better serve its community and provide sustained benefits. The social enterprise model builds on best practices, which are presented in three case examples at the end of Chapter 2. These cases demonstrate that social enterprises are able to achieve both their social and financial objectives, resulting in lasting benefits for their communities. Sustainability—Some Underlying Beliefs The organizational transformation toward social enterprise reflects five sustainability ideas that informed the development of this guide. They provide the platform upon which the guide’s sustainability approach rests. You will see them woven through the guide as you work your way from chapter to chapter. 1. Sustainability is Desirable Sustainability is the logical culmination of the NGO participatory process and development philosophy. NGOs can make a difference, but this is only true when they operate with a clear intention of making lasting changes and creating conditions that facilitate self-determination and ownership. For example, when a NGO promotes the use of condoms it is not just advocating that couples try using them one or two times. It wants the couples to see the advantages of using condoms to plan their families, valuing condoms enough to continue to use them even if they must pay. Only then can the NGO say with certainty that its efforts have been effective and it has made a lasting difference. The guide explains how sustainability empowers your organization and community to make a lasting difference. 2. Sustainability is Achievable It is possible for organizations to achieve a level of sustainability where they are not reliant on external sources of funding to continue their most effective programs. The guide includes several examples of organizations that have taken decisive action toward sustainability with tremendous success. The guide will help you to deliver a quality service or product that responds to clients’ needs, leading you to this level as well! 3. Sustainability is a Process Sustainability is not an end state but an ongoing process of understanding and adapting to the community’s changing needs. It is led by a vision that results in deliberate actions. While there are some common activities to enhance sustainability, there is no one answer. Each organization must adapt its sustainability approach to reflect the unique characteristics of its intended population, environment and programs. Working through this process requires a shared commitment within the organization and between it and the donor agencies, government (public sector) and community. The guide provides a tool to determine where your organization is on the sustainability continuum and some ideas on how to move along it. Introduction III 4. Sustainability is about Ensuring that Those Who Need Services Receive Them Many believe that sustainability is in conflict with serving the poor. They fear that the poor will not have access to services as donors phase out and organizations increasingly emphasize cost recovery. Fortunately, this is not necessarily true, especially if the focus is on sustaining the benefits. It is possible to reduce dependence on donors and still serve the poor. By providing valued services and managing costs, you can charge your intended population affordable fees for quality programs. You can guarantee that no one goes without services by exempting the poorest of the poor from paying, using the fees you charge those who can pay to subsidize services for those who can not. The three case examples included in the guide illustrate this. Each agency was able to expand its services to the poor while lessening its dependence on donors. They did so by building demand for services, providing quality programs, charging affordable fees and leveraging community resources. The guide will show you how to do the same in your organization. 5. Sustainability is Not Just About Money Sustainability is about a long-term organizational direction, a clear vision and mission, dynamic leadership, a strong image, and committed staff (institutional aspects). It is about responsive program planning and monitoring, provision of services valued by the community and community-level capacity building (programmatic aspects). Without these, you will not be able to generate sufficient resources to sustain the program benefits. Money is necessary but is not sufficient for sustainability. The guide highlights the interdependence between the institutional, programmatic, and financial aspects of sustainability. Each aspect is critical to enhancing sustainability. The guide will help you to assess and strengthen all three areas. Section by Section, Chapter by Chapter Following the Introduction, there are six sections that each build on the preceding information, beginning with Unpacking Sustainability. Section 1: Unpacking Sustainability This section explores the various meanings of “sustainability” and invites you to think about exactly what it is that you are trying to sustain. Examples are given of organizations that have been successful in enhancing their sustainability, and the elements and activities critical to this success are highlighted. • Chapter 1: Defining Sustainability shares several definitions of sustainability and differentiates between sustaining benefits and sustaining the organization. • Chapter 2: Pillars of Sustainability builds on several best practices for sustainability drawn from true case studies. It introduces the concept of “social enterprise” and links this vision of operation to achieving an organization’s social mission in a sustainable manner. IV Sustaining the Benefits Section 2: How Sustainable Is Your Organization? It is important to understand the features of your organization that contribute to its sustainability and those that undermine it. This section presents assessment tools for doing just that. • Chapter 3: Sustainability Assessment provides a tool for rating your capacity along three aspects of sustainability: institutional, programmatic, and financial. By rating your organization you can identify sustainability strengths and prioritize areas that require improvement. Section 3: Institutional Aspects of Sustainability There are many different kinds of actions and measures that organizations can take when working toward sustainability. This section introduces those related to institutional sustainability: values, mission and vision, good governance and strategic communication. Each chapter contains references to additional resources on the topics presented. • Chapter 4: Values, Mission, and Vision reviews various sustainability strategies and provides the opportunity to revise them if required. The way your organization perceives and interprets the various strategies presented in this guide will depend on its mission and values. These act as a kind of lens. • Chapter 5: Good Governance explores the role governance plays in a sustainable organization and specifically focuses on building an effective board of directors. • Chapter 6: Strategic Communication walks you through the steps of developing communication strategies that are planned, focused on achieving an objective and issues-based. Being strategic in your communications will help promote the image of your organization and facilitate partnerships and community dialogue. Section 4: Programmatic Aspects of Sustainability This section presents different measures you can take to strengthen your organization’s programmatic sustainability. This includes improved quality, marketing, and community participation. Each chapter contains references to additional resources on the topics presented. • Chapter 7: Community Participation and Ownership shares best practices and steps for community participation and ownership that sustain program benefits through self-governed community structures. • Chapter 8: Improving Quality describes how to continually improve quality using a problem-solving cycle. Adhering to technical standards and meeting client perceptions of quality are important aspects of quality improvement. This chapter presents tools to assess and monitor both aspects. • Chapter 9: Marketing demonstrates how you can use marketing to meet client needs. It reviews a process of identifying needs, tailoring your products and services to meet those needs and communicating the benefits of your services and goods to clients. Introduction V Section 5: Financial Aspects of Sustainability Money is often the first thing one thinks of when discussing sustainability. This section describes how to analyze and use financial data for planning, mobilizing resources, and managing costs. Each chapter contains references to additional resources on the topics presented. • Chapter 10: Financial Analysis for Sustainability covers the various approaches to examining financial data and determining what the data imply. It looks at both expenditure and income data over time and links costs to program outputs. • Chapter 11: Reducing Costs explores the different measures you can take to lower overall costs or lessen unit costs. • Chapter 12: Charging Fees for Services and Products works though the process of setting fees for your services while limiting the impact of those fees on your poorest clients. • Chapter 13: Leveraging Resources presents different options for mobilizing support from the community and donors. It addresses identification, cultivation, and solicitation of support. Section 6: Implementing Sustainability Having reviewed the various options to strengthen sustainability it is now time to select and tailor the options to your own organization. This section describes the actions you can take to form and implement a sustainability strategy that links the options with the priority areas you identified in the sustainability assessment. It also provides some suggestions on managing the change required for enhancing sustainability and for monitoring the progress you make. • Chapter 14: Crafting Strategies for Sustainability shows how to develop a sustainability goal with related objectives, strategies and action steps, and encourages you to make this process part of the overall organizational planning process. • Chapter 15: Leading Change Efforts asserts that translating the sustainability strategy into action will certainly require that some changes be made. Change can be disturbing and intimidating unless thoughtfully managed. This section outlines ways that organizations can be helped to maneuver through the turbulence of change. • Chapter 16: And One More Thing— Monitoring describes how documenting the results of sustainability help to explain your achievements and enhance your image. This chapter explains the importance of documenting progress towards sustainability, demonstrates different ways to do this and shows how to use the results to “tell your story” for the benefit of both your organization and others. Approach this guide in a spirit of curiosity. It contains proposals and options, not recipes and directives. Some ideas and concepts might work well for certain areas of your program but not for others. Learn all you can and apply what seems most appropriate. Section 1: Unpacking Sustainability Before launching into any exercise to become sustainable it is worth making a brief excursion into definitions and descriptions. What exactly are we talking about when we refer to sustainability, why is it a desirable state to aim for and what might it look like when we reach there? This section of the guide deals with these questions. Chapter 1 outlines what is meant by the term “sustainability” and the importance of this concept to NGOs working in the area of reproductive health, while Chapter 2 elaborates on the nature of sustainability and identifies the key components (or “pillars”) of any successful effort to become sustainable. By the end of Chapter 1, Defining Sustainability, you will be able to— • Define what sustainability means in a reproductive health project • Consider what it is that you want to sustain • Describe why sustainability is important By the end of Chapter 2, Pillars of Sustainability, you will be able to— • See new possibilities in the nature of your NGO’s relationships to donors and the people it serves • Describe NGO characteristics that contribute to sustainability • Explain what social entrepreneurship means and how it builds on exchanging value for value • Understand how sustainability can improve an organization’s ability to achieve its social mission 2 Sustaining the Benefits Table of Contents Section 1: Unpacking Sustainability Chapter 1 Defining Sustainability. 3 What Are We Trying to Sustain? . 5 Why Is Sustainability Important?. 6 Chapter 2 Pillars of Sustainability. 9 How Can Sustainability Be Achieved? . 9 Functioning as a Social Enterprise . 13 The Changing Roles of Donors, Community, and Organizations. 14 Case 1: Lumbini Eye Care Project . 15 Case 2: Banking on Youth: SERVOL. 19 Case 3: FEMAP—A Mexican Case Study. 22 Defining Sustainability 3 Chapter 1 Defining Sustainability The term “sustainability” means different things to different people and can evoke a range of feelings, not all of which are positive: confusion, uncertainty, and even cynicism about the feasibility of achieving sustainability are not uncommon responses. 1. What words come to mind when you think about sustainability? 2. What feelings does the word “sustainability” evoke in you? Now take a moment to reflect on the descriptions of sustainability in Box 1.1 and then provide your own definition, drawing on those in the box if you wish. 3. What do you understand by the term “sustainability?” 4 Sustaining the Benefits The definitions in Box 1.1 share some common elements including an emphasis on— • Continuing benefits/services at a steady or growing level • Maintaining or increasing a specific client or community base • Lessening dependence on donor support Review your definition to determine whether it addresses these points. Whichever definition you choose, remember that sustainability is a matter of degree, a progression rather than an end point. BOX 1.1 Some Definitions of Sustainability “Sustainability is defined as a program’s continuing to deliver services or sustain benefits after the donor’s technical, managerial, and financial support has ended.” —SHIRLEY BUZZARD, DEVELOPMENT ASSISTANCE AND HEALTH PROGRAMS: ISSUES OF SUSTAINABILITY, (WASHINGTON, DC: AID PROGRAM EVALUATION DISCUSSION PAPER NO. 23, OCTOBER 1987), P. 2. “Sustainability is considered to be the capacity of a national family planning program and the institutions within it to provide its current and potential clients with the information and services necessary to obtain the benefits of family planning -- on a continuing basis and without external aid.” —RUTH E. LEVINE & JOANNE BENNETT, SUSTAINABILITY OF FAMILY PLANNING PROGRAMS AND ORGANIZATIONS: MEETING TOMORROW’S CHALLENGES (WASHINGTON, DC: OPTIONS FOR POPULATION POLICY II, JANUARY 1995), P. 3. “Sustainability has two dimensions. The first is institutional sustainability, which considers whether a provider has the capability and resources (i.e. infrastructure, staff, administrative systems, and stature) to provide effective services on a permanent basis without outside help. The second dimension of sustainability is financial sustainability, the ability of a provider to generate enough income to support itself when AID funding is no longer available.” —RICHARD MARTIN, AID’S CHILD SURVIVAL PROGRAM: A SYNTHESIS OF FINDINGS FROM SIX COUNTRY CASE STUDIES, (WASHINGTON, DC: AID PROGRAM & OPERATIONS ASSESSMENT REPORT NO. 5, OCTOBER 1993), P. 20. “Development activities are sustainable when they produce outcomes of sufficient value and the program generates adequate local resources to support the continuation of benefits at a steady or growing level.” —THE SUSTAINABLE DEVELOPMENT SERVICES PROJECT, DETAILED IMPLEMENTATION PLAN, 1996 “The capacity of an institution and its reproductive health program to provide its current and potential clients the information and services necessary to obtain the benefits of maternal and child health, including family planning, on a continuing basis beyond the project period with adequate income from diversified financial resources.” —CEDPA/INDIA Defining Sustainability 5 What Are We Trying to Sustain? There is no simple answer to this question. Different parties will have different perspectives. For example, communities would like to see benefits continued, while NGOs might be more interested in having program levels, staff, and the organizational base maintained. Sustaining benefits is not necessarily the same as sustaining the organization. It is quite possible for the organization to phase itself out while the community continues to benefit�the program could be handed over to the public sector, to a community-based organization or services could be privatized, for example. It is also possible for the organization to continue while benefits deteriorate. So it is important to be clear which—organization or benefits—is the primary focus of efforts for sustainability. In many organizations the perception of what should be sustained shifts over time. Most organizations are established because a group of people identify a common need that can be achieved more easily or efficiently by coming together1. Their focus is on the benefits they can provide. To deliver these benefits, programs are developed and an organization is established which oversees the programs. This development stage of an organization might be represented as in Figure 1.1 below. Notice how the focus is clearly on the benefits to the community. Rarely do people come together and then try to decide a purpose for organizing. Figure 1.1 Focus on the Benefits After an organization becomes well established, however, something peculiar often happens. Organizational members become more focused on maintaining the organization itself than on preserving the benefits to the community. You can see this, for example, when NGOs face the loss of grant money. They scramble for finance and will even accept a new project that contributes little to the original purpose as long as it allows the organization to continue. With 1 In the case of reproductive health NGOs, for example, will organize themselves for the purpose of improving access and quality of goods (such as condoms, pills, maternal delivery kits) or services (such as information, education, counseling, or antenatal care) in order to address unmet health needs or facilitate adoption of healthy practices (such as child spacing, consistent use of contraceptives, or taking iron/folic acid tablets daily during pregnancy). Benefits Program Organization 6 Sustaining the Benefits this focus on organizational survival, sustaining the benefits can be forgotten. This arrangement might look more like Figure 1.2. Figure 1.2 Focus on the Organization Although it is important to keep in mind the distinction between benefits and organizations when trying to enhance sustainability, in practice the two tend to go hand-in-hand at least in the short to medium term. Even if it is sustainability of benefits that is the goal, this can often only be achieved by having sustainable NGOs. The reason for this is that transferring ownership successfully is a gradual process with the tutelage and mentoring of a support organization continuing over a long period of time. And in some cases, the NGO may be so rooted in the community that there is no intention of leaving even in the long-term. Why Is Sustainability Important? The fact that you are reading through this guide suggests that you probably have some idea as to why sustainability is important for your organization and its programs. Take a moment here and write down some of those thoughts. Why is sustainability important for my organization and its programs? “Sustainability” is a word that has been in the development lexicon for years. However, it is only relatively recently that attention has been paid to understanding, concretely, how sustainability can be achieved. The renewed focus on sustainability is driven by two important changes. Firstly, for development activities in general and reproductive health activities in particular, Benefit Program Organization Defining Sustainability 7 donor funds both have been shrinking2. Secondly, and at the same time, the number of NGOs has grown. Naturally, these two developments have led to fierce competition for limited funding. Issues of sustainability have come to the fore. NGOs do not want to find themselves at the mercy of donors whose limited funds and changing priorities can play havoc with the NGO’s control over its programs. And communities want consistent, enduring programs that address their needs as well as those of the donor. NGOs’ desire for independence has led many organizations to seek alternatives to donor support as a means of empowering the organization and the communities they serve. 2 Official development aid (ODA) declined by US$600 million between 1998 and 2000 (OECD 2002). Pillars of Sustainability 9 Chapter 2 Pillars of Sustainability How Can Sustainability Be Achieved? Fortunately for you, your organization is not the first that has struggled with the issue of sustainability and there is much that can be learnt from the experience of others. Lumbini Eye Care Hospital (Lumbini), Services Volunteered for All (SERVOL), and The Mexican Federation of Private Health and Community Development Associations (FEMAP) are three real organizations that have taken decisive action toward sustainability and have had considerable success. Their stories are included at the end of this chapter and referred to throughout this guide. These cases show that becoming sustainable is a process that requires the focused attention of an entire organization. They also illustrate that there are some transformations, particularly in the way an organization relates to its community and the role it sees for itself, that are critical to achieving sustainability. We call these foundations of sustainability “pillars.” Read now through each case study (at the end of this chapter) and note those critical characteristics or “pillars” that you think supported the sustainability efforts of the organizations. Once you have done this, compare your findings with ours below. Sustainability pillars: The four sustainability pillars we have identified from our experience are— 1. Becoming community driven. Past experience in implementing reproductive health programs has revealed the critical role that communities play in the development of sustainable programs. Community involvement in whatever form—monetary, volunteer time, donated materials, information—has been shown to be important from the planning phase through to implementation and evaluation. Such involvement helps to ensure that program services are of value not just to direct clients, but also to the community at large. And this broader base of support can be vital especially when, as is often the case, clients alone are 10 Sustaining the Benefits unable to bear the full cost of the programs they want. The case studies and examples in Chapter 7 demonstrate this point. • Lumbini sought and maintained broad community support for its program, working closely with government and quasi-governmental agencies, and in so doing, was able to get approval to charge for services. • SERVOL was clearly community driven from the outset. All community members were asked to contribute in some way to its programs. Local corporations donated materials, space, and expertise. Others contributed money or labor. SERVOL’s staff even worked for salaries much lower then they could have earned elsewhere. This strong community involvement was not only a direct support to SERVOL but could be cited in applications made further a-field and allowed SERVOL to leverage funds from international donors and government. • FEMAP has always been strongly community driven. Its affiliates were founded by a community patron and were developed to serve the communities. Volunteer community outreach workers have been the mainstay of the operation. The strong community base allowed FEMAP to lower costs by scaling back its central office and has also helped FEMAP to network with community business leaders and gain their monetary or partnership support. 2. Committing to a business orientation. To become sustainable, an NGO needs to shift from a welfare perspective to one that rests more on some basic business principles. These include raising cost consciousness among staff, clients, and the community; keeping track of efficiency so that as many services as possible can be provided with the available resources; developing and implementing financial plans that are linked with strategic plans. This does not mean the NGO loses sight of its social objectives—its mission (Chapter 4). This is the reason why the organization was formed in the first place, why staff work there, and why the NGO has received donor support in the past. It is perfectly possible to marry the two and have an organization that is both true to its mission and operated along business lines, as the case examples illustrate. • Lumbini began its sustainability efforts by agreeing that it still wanted to provide eye care services to the poor. With this in mind, the management team began planning how it could do this without donor support. As a grant-dependent organization, it had followed donor requirements for financial accountability and reporting but had not used financial information to help shape its program and determine cost-effective strategies for operating. The management team decided to change this. They prepared a detailed breakdown of costs, segregated fixed and variable costs, and began calculating depreciation. They linked this cost information with service delivery data and used this information for financial planning, setting prices, and monitoring results. With this new orientation, Lumbini was able to increase the number of poor they served. • SERVOL applied basic business practices early on in its operations. It brought leaders in from the private sector to sit on its board and so ensured that SERVOL had sound management, financial, and legal systems. As a result, SERVOL was aware of its costs and sought opportunities to keep them low by offering moderate salaries, Pillars of Sustainability 11 utilizing the services of volunteers, and soliciting in-kind contributions from the community and private businesses. This efficient use of its resources and solid management helped SERVOL to leverage additional support for its programs including donor grants and an endowment. These ensured that SERVOL could provide more services to greater numbers of disadvantaged youth. • FEMAP began its sustainability effort by reviewing its mission and restating its purpose as continuing to provide quality services to the poor. It then developed a plan that incorporated basic business principles. Cost awareness among all staff was raised, unit costs were calculated, and used as the basis for making efficient decisions, existing human resources and supplies were better utilized, and both fixed and variable costs were reduced. Lower costs meant that FEMAP could lower its prices and attract more clients. FEMAP also set up commercially oriented enterprises and used the income earned to cross-subsidize services to the poor. The profile of their clients remained the same while the number of services they provided increased more than 600 percent! 3. Developing a client/market focus. Commercial enterprises will often say, “the customer comes first” or “the customer is always right.” They know that if they want to stay in business they need to understand their current and potential clients. And they need to use this knowledge in the way they design goods and services and market them. This is true of NGOs as well. It is, in fact, at the heart of sustainability. The better your organization can define its client-base and tailor or develop services and products of value to them, the greater its chance of remaining viable. You can see this market focus in each of the case studies. • Lumbini realized that if it were to begin charging for its services, it needed to know more about its current clients and to identify additional clients. Using market research techniques, it looked at client perceptions of quality, the scale of services, willingness and ability to pay, and the services provided by alternative providers. This information allowed Lumbini to restructure its services and prices to meet the demand for its services. By charging higher fees to wealthier community members, it was able to subsidize the cost of the services provided to the poor. • SERVOL adopted a very broad view of who its clients were. By including corporate, government, and international donors as well as the community as part of its client- base and understanding what each of these stakeholders valued about their relation with SERVOL, it was able to leverage continued support for its youth training programs. • FEMAP began its sustainability efforts by learning more about its clients and other service providers through market research. The information obtained helped FEMAP to develop plans to achieve high-quality, low-cost services to attract additional clients. It also helped in identifying other income-generating opportunities that contributed to its social mission. FEMAP found this information to be so valuable that it began conducting market surveys biannually. 4. Emphasizing high-quality programs. Studies around the world have shown that people are willing to pay in exchange for quality services. Too often NGOs neglect this aspect or they define quality as performing to standards that do not necessarily match clients’ perceptions. 12 Sustaining the Benefits Much of the success of the three case studies can be attributed to the emphasis they placed on quality. • Lumbini paid attention to both client perceptions of quality and to technical quality. It brought in ophthalmology experts to provide up-to-date medical training and provided ongoing training for paramedics. It also monitored client satisfaction and spoke with clients to understand their perceptions of quality and so identify ways to make the services provided, more valuable. For example, based on feedback received from these clients, it added private wards for those patients who were willing to pay significantly more for the service. Figure 3.1. Exchanging Value for Value • SERVOL measured the quality of both its youth programs and its relations with corporations, donors, and the government. It adapted and expanded its programs to reflect feedback from the community and corporations. It drew on expertise from the private sector in designing new programs and developed parental involvement to ensure that the state-sponsored program met the educational needs of the children. • FEMAP believed that high-quality services are a fundamental right of the population. It regularly monitored quality through client feedback, clinic inspections, and periodic evaluations. It not only collected information but took action, even firing a technically competent physician because of client complaints about the way he treated them. Developed for the Sustainable Development Services Project Social Mission Business Objectives Social EnterpriseClients Donors Venture CapitalProduct/Service Meets needs Delivers value Return on Investment Reduced Dependency (Exit Strategy) Pays for Services Creates Impact Needs Wants Pillars of Sustainability 13 Functioning as a Social Enterprise By constructing these pillars, an NGO is essentially applying traditional business practices to the “business” of achieving its social mission. In other words, it is operating as a social enterprise. This involves a shift both in the way an NGO views its relationship with its donors and beneficiaries and in the way it operates. Instead of behaving as a charity organization that gives recipients what it believes they need, the NGO must see itself as providing something of value to the community in exchange for their support. Social enterprise is built on the concept of exchange. As depicted in Figure 2.1, donors invest in NGO programs in exchange for producing results that meet their development goals (return on investment). NGOs use this investment to provide services and products that meet the needs and wants of clients and the community. In exchange, the clients and community pay (money or in- kind) for the reproductive health services they value. This exchange enables NGOs to address both their social-mission, through the impact created in providing needed services, and their business objectives through the revenue they earn. By meeting their business objectives, they reduce their dependency on donors. This view of relationships as an exchange is very different from the traditional one where the benefits were seen to flow one-way—a donor providing money to an NGO that then provides services to the community. The case studies show how NGOs can operate as social enterprises— • Lumbini, recognizing that its services were valuable to clients, asked clients to pay. Basic business practices were adopted so that services could be affordable and tailored to clients’ expectations. By operating as a social enterprise, Lumbini was able to achieve its mission, expanding the number of poor served, while also satisfying the financial objectives of decreased dependence on donors. In fact, a surplus was generated every year after 1994. • SERVOL viewed itself from the beginning as a development organization rather than a charity, asking its beneficiaries to contribute their time and resources in exchange for the benefits it provided. Through this approach, SERVOL was able to leverage support from the community, businesses, government, and donors to expand its program and achieve its mission. • FEMAP developed an entrepreneurial approach toward fulfilling its social mission. Clients were studied to understand what they found valuable about the services, and management practices were adopted to improve current services. FEMAP identified opportunities to address social needs and assembled the required resources to take advantage of these opportunities. Through this transformation it was able to lower costs and prices, increase the amount of services provided, ensure access for the poor, and improve cost recovery. These cases demonstrate that organizations operating as social enterprises do not need to choose between serving needy populations and becoming financially viable. They can do both. Indeed, the two go hand-in-hand; a financially viable organization is better placed to serve its clients and serving clients well is likely to generate resources. 14 Sustaining the Benefits The Changing Roles of Donors, Community, and Organizations In order for benefits to be sustained, relationships with donors, other organizations, and communities have to change (Figure 2.2). The old scenario, shown as the charity level in Figure 2.2, looked something like this— An NGO, seeing itself as uniquely capable of addressing the needs of the people and assuming that its services would always be required, decides to provide a certain kind of service, and searches for a community willing to receive the service. Believing that poor people cannot pay for reproductive health services, the NGO decides to deliver the programs at no cost to the consumer. To fund its operations, the NGO sells itself to a donor and finds that it has to develop programs that meet the needs of the donor, needs that are often shifting. In effect, the donor is hiring the NGO as an instrument to help fulfill its mission. Financial accounts are kept simply to satisfy donor requirements and the NGO remains ignorant of its finances. It has no expectation of recovering costs or generating revenue, and its main financial strategy is to apply for donor funding. And where is the community in all this? The community is basically a passive recipient taking whatever services the NGO provides. It has no leverage to demand high-quality services and is at the mercy of donor-driven agendas and programs that are periodically suspended because of lack of funding. A sustainable scenario, shown as the social enterprise level in Figure 2.2, would look rather different— Following careful market analysis the NGO searches for opportunities to satisfy important needs in a community. It then approaches those donors supportive of its mission to obtain “investments”—start-up funding for its social enterprise, being careful from the beginning to plan an “exit” strategy for weaning itself from donor funds. A marketing plan is put in place to tailor products and services to match client expectations and needs. The NGO’s social mission and financial requirements are met when quality services are delivered in a sustainable manner. The community is transformed into clients and the client is leader. Since the client is paying, s/he feels free to demand quality products and responsible service delivery and is prepared to give feedback about the quality of services as well as stating desires for additional services. This may evolve even further to a point where the community can manage and deliver the services itself, relying on the NGO only for guidance, and access to funds (the top level in Figure 2.2). The community is now the owner of the program. The NGO can exit and begin the process in another needy community. Most NGOs today lie in between these two scenarios—the charity and social enterprise levels. They work in partnership with their donors and communities, but are not yet at the level where their services are fully valued by either (the development level in Figure 2.2). At this limited level of exchange, the benefits will not be sustained. To move to the sustainable scenario (either the social enterprise or community ownership level), there must be increasing exchange that results in a dramatic shift in roles for all parties involved. Donors, instead of being contractors or Pillars of Sustainability 15 partners, become modest investors or an irrelevance! NGOs no longer act as providers or facilitators but as entrepreneurs and investors. The community is transformed from recipient or, at best, participant, to client or even owner. The level that you aim for—social enterprise or community ownership—depends on your agency’s mission and vision. If your mission is to address the needs of a given community, then the social enterprise level is probably appropriate. If it is national or regional in focus, then community ownership is probably more suitable. Figure 2.2: Changing Roles with Increasing Exchange For an NGO to engineer this shift in roles, functioning as a social enterprise and building the pillars of sustainability requires changes in the way it operates. The next chapter discusses what these specific changes in practice are and presents a matrix for assessing how well an NGO is doing in its attempts to become sustainable. Case 1: Lumbini Eye Care Project3 The Decision to Change The Lumbini Eye Hospital is located on the Nepal/India border, in one of the poorest regions of the world, where cataracts account for 80 percent of the blindness in the region and are a major public health problem. It serves the needs of approximately 2 million people in southern Nepal and 25 million in northern India. The SEVA Foundation and other donors, who donated equipment and consumables, particularly intra-ocular lenses, a key commodity in cataract surgery, supported the hospital for many years. At that time, the prevailing view of ophthalmologists, medical staff, and most donors was that charging fees was inappropriate, especially when serving moderate to low-income populations. The hospital made no charges for its services, which included around 6,000 surgeries and 88,000 outpatient visits a year. 3 This case study was developed by David Green of the SEVA Foundation and William LeClere of the Institute for Development Research. Social Enterprise Donor NGO Community Exist/Reinvest Partner Contractor Investor Investor Entrepreneur Facilitator Provider Owner Client Participant Recipient Development Community Ownership Sustainability Level Charity In cr ea sin g Ex ch an ge In cr ea sin g Ex ch an ge 16 Sustaining the Benefits In early 1993, the Lumbini Eye Care Hospital decided to change its strategy. It had observed that the Aravind Eye Hospital in India (at the time the largest eye care program in the world, performing more than 70,000 surgeries per year) was operating with little or no dependency on donor support from the outside. It charged some patients but was able to provide its services to the truly poor (who accounted for 65 percent of total patient volume) at no charge. Under the leadership of Dr. S. P. Dhital, and with the continued support and encouragement of the SEVA Foundation, Lumbini Eye Hospital embarked on a journey to transform itself into a largely self-sustaining program. A transition management team was put in place, including the SEVA Foundation Director in Nepal, the SEVA Technical Director for Blindness Prevention and Dr. Dhital. This transition management team met for three sessions over a period of six months in 1993–94, with each planning session lasting for several weeks. Consultants from Aravind assisted the team in technical planning; management consultants from Katmandu helped assess management needs and conducted a survey of the socioeconomic needs and capabilities of the populations to be served. Establishing Policy Objectives Lumbini’s mission remained essentially the same, and the hospital continued to provide preventive and curative eye care services to the poor of the area. However, in the review of its mission, the transition management team agreed on some new policy objectives— • The Lumbini management team would be responsible for all major decisions. • Free eye care and surgery would be given to those who could not afford to pay. Charges to patients would be defined at the outset and made high enough to cover all operating costs. Those paying more would receive greater privacy than those paying less or nothing, while patient care (frequency of staff visits, the quality of attention) and the types of surgery provided would remain the same regardless of the client’s ability to pay. Any surpluses would be used to subsidize services or clients where needed and for future project development. • Lumbini would become independent of donor assistance within five years. The SEVA Foundation agreed to support the project with decreasing levels of funding each year over that five-year period. • Planning would be open, communications straightforward and decisions would be arrived at after full consultation with all affected parties. These policy objectives were circulated widely and discussed before being adopted by staff and community leaders in those communities to be served in the newly developed programs. Getting agreement on these policy objectives involved heated negotiations, behind the scenes in the beginning, with government and quasi-government authorities. The thorniest issues related, not surprisingly, to the hospital’s right to charge fees for service and to be empowered with authority over the use of the resulting revenues. The concept of financial self-sustainability through charging fees to some in order to subsidize care for others is not always well received by government authorities. Nor is it seen, in many countries, to be politically desirable to promote the withdrawal of externally provided donor funds. Pillars of Sustainability 17 Strategic and Business Planning Once agreement was reached on policy directions, the team identified four strategic activities to support these policies: conducting market research, determining the cost of services, exploring alternative price setting arrangements, and improving management and organizational practices. Conducting market research. Lumbini undertook market research to find out what different clients could afford to pay for services. The research was not complicated or expensive. In the beginning, it amounted to finding ways to communicate with and listen to patients and potential clients and then having discussions to find out from these clients how their needs could best be served and what might be acceptable ways to make the program more financially sustainable. This information was supplemented by information gathered from specially commissioned formal surveys among various socioeconomic groups, and by examining existing epidemiological and demographic data available for both Nepal and India. Prices for similar services in India and Nepal, including what wealthier clients were paying to alternative providers for high-quality services, were reviewed. Costs, prices, and organizational structures in other self-sustaining organizations serving poor people were researched and analyzed. Informal surveys of staff were also used to determine appropriate pricing structures. Determining the current and future cost of services. As is often the case with grant-dependent organizations, the hospital started with little idea of the costs of its operations. The accounting systems that did exist were designed to suit the needs of the donors and lacked information vital to any organization aiming for sustainability; fixed and variable costs, for example, were not distinguished and no allowance was made for depreciation of buildings and equipment. Appropriate changes were therefore made in the accounting systems to enable the hospital to calculate the full costs of its current service delivery and the costs per patient served. These data were then used to project likely future costs by putting them together with different reasonable assumptions about the volume of patients served, the kinds of services they would need, and the different mixtures of staff, consumables, and equipment that would be required to provide those services. This information on the costs of different service provision, together with the results of market research concerning patients’ ability to pay, made it possible to undertake the third objective, namely to estimate likely revenues under different price setting arrangements. Projecting market revenues and price setting scenarios. Projections were made of the likely demand for services (i.e. the volume of patients) at different price levels by patients in differing economic circumstances. From these estimates it was possible to calculate both expected costs and income from different price structures. More than 30 spreadsheets were developed to test for various scenarios. Each scenario included the following variables: costs of consumables, salaries, maintenance, utilities, vehicles, building, and equipment depreciation; income from cataract surgery, outpatient, laboratory, glasses, pharmacy; and, patient volume (by service type.) 18 Sustaining the Benefits After reflecting on the results of these projections and in light of the hospital’s philosophy to set affordable prices, a multi-tiered pricing structure was proposed and gradually established. Developing improved management and organizational practices. The transition management team reviewed organizational practices and management capabilities and found them wanting in some respects. It therefore developed a plan to reorganize the hospital with the purpose of improving efficiency and productivity, maintaining high staff morale, and delegating authority, responsibility, and accountability more widely among staff. This plan involved— • Establishing new departments in order to spread the managerial load and, whenever possible, filling the resulting new management positions from within the hospital. • Making substantial investments in training in both technical and managerial areas by having regular visits from ophthalmology experts, training paramedics in ophthalmic skills, and preparing supervisors to take on additional administrative responsibilities. • Encouraging new attitudes, specifically— - People should take responsibility, not wait for it to be granted - Improved quality on a continuing basis would be everyone’s job - Mistakes, particularly by those in new roles, would be expected and corrected • Establishing special management practices. These included weekly departmental meetings to help clarify staff members’ roles and responsibilities, and improve inter- staff communications; reporting systems to enable staff to monitor their own productivity on a daily basis; productivity incentives for professional staff, including changes in the compensation arrangements with ophthalmologists to enable the hospital to attract and keep critical surgical staff; and systems to track customer satisfaction and ensure quality of service. Outcomes from the Sustainability Transition The results from these various measures have been impressive. Lumbini has expanded its facility by 75 beds, increased its outreach by 30 percent to more than 125,000 patients, and doubled the number of surgeries it performs. This increase in demand for services has occurred despite the fact that most patients (75 percent) now pay for their treatment, with some (5 percent) actually paying significantly more than the treatment costs. Indeed, one could argue that it occurred, at least in part because of the fees charged—those fees enabling the hospital to invest and improve the quality of surgical outcomes. At the same time, Lumbini continues to serve the poor, with 20 percent of its patients still receiving free services. And Lumbini’s financial position? The hospital and its satellite clinics have managed a financial surplus every year since 1994. These surpluses have approximated, and sometimes exceeded, projections in the business plans. “Luck” has played some part. During the transition period, the most expensive consumables in cataract surgery—the intra-ocular lenses—became available locally through a non-profit manufacturer of lenses in India, bringing down the costs considerably. But there is no doubt that careful planning and the adoption of good management practices have been crucial ingredients in the hospital’s financial success. Pillars of Sustainability 19 It is sometimes said that ‘money attracts money,’ and Lumbini is evidence that this might be true. In the three years prior to the transition the hospital sought a grant from a donor to extend its outreach facilities. Each time it was turned down. The hospital reapplied as a financially autonomous institution after the transition to a sustainable operation and received a $700,000 grant to build new outpatient facilities! Case 2: Banking on Youth: SERVOL4 SERVOL (Services Volunteered for All) is a youth-focused NGO in Trinidad and Tobago. It was established over 30 years ago and today has activities in more than 200 preschools and adolescent training centers. SERVOL began with the dream of one man—Mr. Gerard Pantin. Pantin was working as senior rector at St. Mary’s College, the country’s premier secondary school for the sciences. He decided to leave this job and move to a very poor neighborhood to work among the disadvantaged. Once there he approached one of the biggest private organizations in the community—a local distillery—and asked for their support in carrying forward a plan. He asked them if he could “borrow” the services of one of their spokesmen, Wesley Hall, a world champion in cricket, well-known and respected in the community. Mr. Hall agreed to join Pantin and together they walked the streets of Lanvenville talking with the community about its needs and how to address them. Pantin and Hall did not give money. Instead, they offered to work with the communities and personally help them accomplish what they wanted. From the beginning Pantin saw his work as development rather than charity. He always asked the community to commit its own time and resources and so to claim ownership of whatever good resulted. For example, when a request was made for a basketball so that young people could be taught how to behave in a team and how to build on each other’s talents, Pantin and his partner agreed, but only after those young people had provided some small money of their own. Similarly, when a request came for a basketball court, Pantin and his partner agreed on condition that the community covered half of the cost. Pantin and his partner then used this opportunity to introduce the idea of fundraising to the community. SERVOL and the Community Fundraising Challenged to find half of the funds to build the basketball court, the community youth organized a dance and a bake sale to raise some cash and established work teams to clean up and lay asphalt on an area previously used for garbage. They approached local merchants who agreed to provide the building materials at a significant discount. Volunteerism Besides encouraging young people to be more organized and to maximize their abilities, Pantin also asked the privileged of Trinidad’s society to support the youth initiatives. His request for 4 Adapted from: Weber, Ron. Grassroots Development. Volume 21/2. 1998, pp. 28-36. 20 Sustaining the Benefits assistance was responded to handsomely. A building was donated by one of the wealthiest men in the community. Soon men and women had volunteered their time and expertise by offering classes in art and public health and teaching various life skills to the young people in their community. SERVOL expanded and it became necessary to employ some professional staff, many of whom gave up higher-income jobs to dedicate their time to this youth development program. Volunteers, however, continue to play a significant role in SERVOL through their involvement in community boards, teaching, and fundraising. Annual Poor People’s Dinner After mobilizing the community and raising awareness of the issues facing youth, Pantin’s next goal was to help people to take a new look at their attitudes and values. SERVOL organized a very unusual event. It invited some high-profile community businessmen and women to a “poor person’s dinner.” For a $50 ticket, guests received a bowl of soup, a slice of bread and a glass of water. Pantin said, “For once in their lives well-off people would eat what the poor eat at Christmas and they would pay for this privilege.” Guests included the Prime Minister, members of parliament, and diplomats, along with poor community members. This occasion was so successful that the Hilton Hotel, where the dinner was held, agreed to host this event for SERVOL every year, and even provide the food. Gradually, it became a national event, widely covered by daily newspapers, radio stations, TV, and received the support and attention of government agencies, religious groups, white-collar workers, and many different community members. The function proved to be a major source of financial support for SERVOL especially in the early years when more than 80 percent of SERVOL’s total income came from this source. SERVOL continued to hold the dinner, even after it became a relatively small part of its total income (see table below), as much to raise awareness and community support for its programs as to earn income. Poor Person’s Dinner as Source of Annual SERVOL Income Year Total Income (US $) Dinner Proceeds (US $) 1970-71 1971-72 1972-73 1973-74 1978-79 1989-90 1996-97 $4,856 $5,652 $38,307 $42,590 $178,075 $747,696 $2,832,898 $4,053 $4,225 $3,921 $7,502 $5,731 $10,994 $22,522 Building on these successes, Pantin continued to cultivate community supporters through publicity, expanding circles of contacts and sending out newsletters to previous and current supporters. However, Pantin had long realized that the problems facing youth were so immense that community support alone was not enough. SERVOL and the Business Sector Pantin actively sought the support of the business sector. He took a realistic approach, noting that “the average businessman is concerned with running his business and maximizing profits. Any Pillars of Sustainability 21 bleeding-heart approach on behalf of the poor will be met with token financial support.” Pantin, therefore, looked to capitalize on what the business could provide and match it with SERVOL’s needs. He invited business people to join the board of directors. This provided SERVOL with sound management, fiscal, and legal advice, and pushed it into taking a business approach to its operations. Pantin also asked businesses to provide support through tax-deductible donations called deeds of covenant that raised $20,000 annually. The interaction with the business sector was a two-way affair. SERVOL listened to the business sector and oriented its training programs to help meet the needs the business sector expressed. Skill development and capacity building among the youth became a much larger priority. Its Adolescent Development Program was designed so that youth that graduated from it would be able to join and remain in the adult professional job market. When the business sector needed people with computer skills, SERVOL set up a Youth Computer Training Center. SERVOL and International Donors As a result of its active corporate cooperation and strong community ties, SERVOL was able to leverage increased support from international donors. While SERVOL’s goal was to become independent of international donor support, it realized that donors would still play a role as investors in its programs. Over the years it had developed collaborative relationships with various donors. It needed to manage the separation process to conserve all the insights and achievements built up during two decades of partnership. Together with its main partner/donor, the Bernard Van Leer Foundation, SERVOL set up an endowment fund. The foundation agreed to match dollar for dollar, every local donation that was made. Many contributors (business firms, insurance companies, and private firms) found this a bargain. The endowment now has a total of US$4.4 million and generates over $300,000 in income annually. Another example of leveraging support was the Inter-American Development Bank’s (IDB) agreement to provide a grant of $3.2 million to establish three Hi-Tech Centers to which business provided over $350,000 in volunteer consulting services and equipment. The IDB agreed to provide the grant because “…the endowment fund provided a secure reserve to draw on… and SERVOL had taken special care to use business principles in setting up the operation… …making it likely the centers would soon become self-sustaining. Second, SERVOL’s recognized skills in working with disadvantaged youth ensured that the money being invested would reach the right people. And finally, SERVOL had reached out to the private sector to draw on their expertise in designing the project.” SERVOL and the Government SERVOL understood the need to diversify its stakeholder base and build a larger constituency. It tightened its links to the government by agreeing to train instructors and to provide equipment for preschools and adolescent life-centers throughout the country if the government would finance its programs and pay the teachers. SERVOL’s partnership with the government was a wise move, especially in a country where the state felt threatened by the expansion of non- governmental organizations. 22 Sustaining the Benefits Even though the government agreed to support SERVOL’s expansion efforts, its fear of losing operational authority slowed the growth rate of SERVOL. SERVOL faced a significant threat when, with a change of leadership, the new government decided to reduce appropriations for SERVOL by 40 percent. Instead of giving up, Pantin started to mobilize the community by building a wide constituency and by encouraging a much broader involvement of the local board and the parents. The grassroots support together with the organizational skills and dedication of its stakeholders enabled SERVOL to lobby the government more effectively. Community members successfully organized a march to the Parliament in the city of Port of Spain to express their support for the SERVOL cause and to argue the case for “banking on youth” as the way to improve Trinidad and Tobago’s future. SERVOL’s ability to understand and respond to the needs of all its stakeholders—the community, business, international donors, and government—has allowed it to adapt and grow, reaching the needy youth of Trinidad and Tobago. Case 3: FEMAP—A Mexican Case Study5 The story of FEMAP (The Mexican Federation of Private Health and Community Development Associations) is an account of one non-profit organization’s efforts to reach sustainability through entrepreneurial thinking, strategic planning, and good management. FEMAP is a voluntary federation of 44 affiliates that offer a wide range of medical and community services to Mexico’s poorest citizens. The affiliates voluntarily associate with a central office that supports them in a management capacity. Affiliates retain their autonomy as independently incorporated organizations, participating in the federation as part of a general assembly and as board members. FEMAP carries out its mission through the work of promotoras (volunteer community outreach workers), service providers, managers, and volunteer patrons (community leaders who guide its work). The promotoras serve as a model and information source for the rest of the community. They empower other women to make similar changes and serve as the principal link between families and FEMAP’s community health services. Community health is at the center of FEMAP’s services. Attention is also paid to the connection between broad community development and improved health care. Affiliates offer ecological education, clean water and sanitation services, recycling campaigns, home improvement programs, and community banking in an effort to transform neighborhoods into thriving communities. In 1992, USAID informed FEMAP that its bilateral population assistance of $1 million per year would end in five to six years’ time. FEMAP would have to learn how to survive without its main source of external assistance. It would have to develop into a sustainable organization. 5 This case was adapted from Building Sustainable Health Services: The Story of FEMAP, Management Sciences for Health, (Boston: 2000) and was supplemented with information from FEMAP’s website, To order a copy of Building Sustainable Health Services: The Story of FEMAP, please e-mail Management Sciences for Health at or order a copy through their website, Pillars of Sustainability 23 How FEMAP Enhanced Its Sustainability FEMAP started by re-examining its mission and as a result renewed its commitment to serve the poorest of the poor and decided to strengthen its client focus. It also developed a new strategy and began to implement it by focusing on three main areas: developing management practices, building capabilities at the central level and identifying new opportunities to generate revenue. The role of the central office was redefined, staff numbers were reduced and the central office began charging for its services, selling products, and developing central capabilities rather than giving away assistance to its affiliates. Developing Management Practices to Sustain Services FEMAP studied the market by conducting surveys to learn about its clients’ characteristics, their reaction to services, the amount they would pay, and the competitive environment in which the organization functioned. The results supported a plan to develop high-quality, low-cost services to attract more clients. FEMAP acted on the belief that accessible, high-quality health services are a fundamental right of the population. It identified ways to evaluate quality of care from its clients’ experiences in health facilities. The central office also worked to institutionalize service quality in its affiliates by encouraging positive attitudes of staff toward clients and building technical competence of staff at all levels. The improved quality led, as expected, to increases in the volume of services. To serve this growing number of clients, FEMAP had to adjust its use of resources to ensure that quality standards continued to be met. FEMAP systematically analyzed its cost structure (with assistance from the Population Council and MSH/FPMD). This enabled it to do several important things: identify opportunities for cutting unnecessary expenditures; assign priority to services that generated net income; eliminate nonessential services that did not generate a profit; improve and, if necessary, cross-subsidize, essential services; and set prices or fees as low as possible, just slightly above cost. Building Capabilities to Support Expanded Services The central office encouraged its affiliates to expand and develop, supporting them through a revolving loan system established with seed funds provided by donors. Loans were provided for purchasing construction materials and medical equipment, indeed anything that assisted growth. The central office took over the ordering and handling of supplies, establishing a system to consolidate the affiliates’ purchases and handle all logistics through an electronic ordering system. By pooling procurement services, the central office was able to obtain quantity discounts for large-volume orders, reduce affiliates’ unit costs for supplies and services, and generate fees for handling supplies. To deal with all the information from their expanded network of clients, FEMAP invested in the development of a proprietary management information system in partnership with a local computer-programming specialist. 24 Sustaining the Benefits Identifying New Opportunities to Generate Revenue FEMAP’s local board of directors networked intensively in the private sector, developing new contacts, and identifying regional opportunities for new services. As a result it was able to diversify its funding sources. New local and international donors were attracted by its recent success in generating income. FEMAP established a foundation in the U.S. to raise funds for its programs. By the end of 1998, the foundation had an endowment of $1.5 million. To further diversify its income and address community needs, FEMAP added an array of community development services, such as micro-financing for small enterprises, to its health program. Using social entrepreneurship, FEMAP launched several new programs, including laboratory and imaging services, social marketing for contraceptives and health products, a factory-based health program, and a network of social pharmacies. FEMAP’s Sustainability Achievements Over a six-year period (1992 to 1998), FEMAP increased its total revenue by 40 percent. At the same time the composition of its income shifted away from international and local donations, which fell respectively from 25 percent to eight percent and from 15 percent to 12 percent, while service fees increased from 60 percent to 80 percent of total revenue. Its cost recovery rate increased from 72 percent to 91 percent. FEMAP significantly lowered costs and passed the savings on to clients in the form of lower fees (Graph 1). It increased the utilization of its medical services by over 600 percent (Graph 2)! At the same time it managed to maintain its core services (Graph 3) and remain true to its mission, namely to provide services to the poor. All this was achieved by careful planning and execution of a strategy to generate more income by using resources efficiently and for the benefit of clients and by integrating its mission, structure and systems to support this strategy. Pillars of Sustainability 25 Graph 1. Performance of Seven High-Performing FEMAP Affiliates 1993-1996 20 15 10 5 0 200 150 100 50 0 1993 1995 1996 Pesos 1993 71.913 103.807 160.768 Number of ambulatory visits Unit cost to FEMAP to provide service Fee charged to client 7.29 16.05 10.60 4.38 3.28 1.59 Affiliates: Acapulco, Cd. Juárez, Irapuato, Matamoros, Mazatlán, Tapachula, Veracruz These high-performing affiliates achieved significant gains in efficiency by reducing costs by 85 percent and fees for visits by 80 percent. Source: Building Sustainable Health Services, MSH, 2000 Graph 2. Increased Volume and Revenue from Fees in FEMAP’s Clinics and Hospitals 50 45 40 35 30 25 20 15 10 5 0 1400 1200 1000 800 600 400 200 0 1992 1993 1994 1995 1996 1997 1998 Volume of medical Services Fees from medical services Services Provided (thousands) Fees (millions of pesos) FEMAP made dramatic gains of 634 percent in the volume of medical services provided, from 160,158 services in 1992 to 1,175,175 services in 1998. Services included consultations and laboratory tests. Revenue from medical service fees increased from 6.7 to 46.1 million pesos, which represented a real increase of 123 percent. Source: Building Sustainable Health Services, MSH, 2000 26 Sustaining the Benefits Graph 3. FEMAP’s Gains in Couple Years of Protection ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 Couple years of protection (CYP) achieved by FEMAP’s family planning program remained relatively constant from 1995 to 1998, despite a decline in promotoras in 1998 resulting from the temporary decline in the availability of low-cost contraceptives. 250 200 150 100 50 0 250 200 150 100 50 0 Section 2: How Sustainable Is Your Organization? How do you know whether you are successfully on the path to sustainability? How do you know which areas need strengthening? How can you judge if you have made any progress? These are the issues addressed in this second section of the guide. Chapter 4 presents a tool—an Assessment Matrix—that enables NGOs to assess their sustainability. The matrix is not designed to provide a comprehensive evaluation of the program, management systems, or functioning of the organization. It has the more limited purpose of assisting organizations to reflect on those current practices that have implications for achieving sustainability. These reflections will then serve as the basis for discussions about possible actions that could be taken to enhance sustainability. Three broad aspects must work well for an organization to be sustainable—institutional, programmatic, and financial aspects. The Assessment Matrix is structured to reflect this. By the end of Chapter 3, Sustainability Assessment, you will be able to— • Recognize the specific features and actions that make an organization more likely to be sustainable • Understand the process involved in assessing an organization’s sustainability • Assess how sustainable your organization is and where its weaknesses lie 28 Sustaining the Benefits Table of Contents Section 2: How Sustainable Is Your Organization? Chapter 3 Sustainability Assessment. 29 What an NGO Needs to Do to Become Sustainable . 29 Assessing Sustainability—The Matrix. 30 Using the Results for a Broader Assessment. 32 NGO Sustainability Assessment Matrix . 35 Score Sheet . 39 Sustainability Profile Matrix . 40 Sustainability Assessment 29 Chapter 3 Sustainability Assessment What an NGO Needs to Do to Become Sustainable For an NGO to become sustainable it has, somehow, to put into practice the business of becoming a social enterprise. It has to build the four sustainability pillars. To do this the NGO has to make specific changes in the way it operates. This needs to happen in three key areas—the program, institution, and finances. All three are equally critical and have to be addressed simultaneously if efforts to become sustainable are to be successful. At the institutional level, the NGO needs to establish the internal systems, structure, and work culture that promote strong leadership and a positive organizational image, foster the belief that people are willing to support products and services they find valuable, and facilitate the development of plans for sustainability. At the program level, the NGO needs to carefully analyze the market and encourage community participation at all stages from design through implementation to evaluation of the program in order to offer quality services at reasonable prices. At the financial level, the NGO needs to have systems and strategies for generating adequate levels of finance and managing these resources well. It requires a good grasp of the nature and level of its costs and a preparedness to sustain its programs through a combination of cost reduction, cost recovery, and leveraging support from the community and donors. To develop a sound institutional base, a strong programmatic approach, and sufficient funds, the NGO must undertake a number of different specific activities or practices within each of these areas. We have drawn up a list of 75 such practices and grouped them into 15 elements (five practices each element). Of the 15 elements, five relate to institutional sustainability. 1. Organizational commitment to sustainability—the board and the senior leadership thinking and acting in terms of becoming self-reliant and decreasing donor dependency. 2. Strategic planning for sustainability—preparing long-term action plans based on market data and linking programmatic activities with their financial implications. 30 Sustaining the Benefits 3. Governance and leadership—having governance arrangements that generate commitment, inspire and reward outstanding performance, and ensure accountability to their stakeholders. 4. Human resources and personnel management—establishing systems to attract, develop and retain competent and highly motivated staff. 5. Image, external relations, and networking—cultivating and maintaining a positive image among NGOs, government organizations, donors, and clients. Another five of the elements relate to programmatic sustainability. 1. Community participation and ownership—preparing the community to assume greater responsibility for and ownership of the benefits. 2. Program quality—having systems to plan, monitor, and continuously improve quality in the provision of commodities and services. 3. MIS and data based planning and decision making—having systems to capture changing program and financial realities and to utilize such data for making timely decisions. 4. Marketing/information, education, and communication (IEC)—implementing marketing and communication strategies in order to understand changing demand and to promote services with a client focus. 5. Logistics—having systems that are effective in forecasting, procuring, stocking, and delivering supplies without delays and stock-outs. The last five relate to financial sustainability. 1. Financial management—having financial systems and procedures that provide clear and timely accounts of the financial position of the organization. 2. Cost reduction—reducing the costs of providing services. 3. Cost recovery—recovering costs of service provision from clients and the community. 4. Revenue/income generation—raising resources through institutional earnings. 5. Leveraging—using assets to attract and leverage resources from the community, the government, and diverse donors. Assessing Sustainability—The Matrix For each of these 15 elements we have devised a set of five questions (i.e. 75 questions in total) to assess the extent to which an organization is doing well in relation to that element. We have taken these 15 elements with their 75 questions and put them down the vertical axis of a matrix. On the horizontal axis of the matrix we have placed four columns describing different Sustainability Assessment 31 frequencies ranging from “not practiced” to “almost always practiced.” This is our Sustainability Assessment Matrix. The matrix is best completed by involving a cross-section of staff and board members together with the support of a facilitator. The first few steps are undertaken separately by each individual involved, then the group discusses its findings and draws conclusions. Step one. INDIVIDUALLY. Get an idea of the overall structure of the matrix and then go to the first point or practice described in the first column “The organization has a vision of itself as….” To what extent do you think this is true of your organization? Not at all? Somewhat? Mostly? Almost always? Tick the appropriate column. Go to the next point or practice and do the same. Continue until you have assessed all the points in the matrix. If the answer for any particular practice is that it is “almost always true,” then specify more precisely what it is that your organization does in relation to that practice. We will want to refer back to these more successful aspects of your organization at a later stage (Chapter 14, Crafting Strategies). Step two. INDIVIDUALLY. Calculate the score for the different elements. Above each column there is a number that indicates the score to give each practice depending on whether the practice is common in your organization or not. The more common the practice in your organization the higher the score it will get, as follows. Frequency Score Not true or not in practice 0 Somewhat true or being considered 1 Mostly true or often in practice 3 Almost always true or currently in practice 4 Add up the scores of the five practices in each element to get an “element score.” You should have 15 element scores. Enter this score on the Score Sheet (at the end of this chapter) in the Individual Score column. Continue until all practices and elements have been scored and recorded. Step three. AS A GROUP. Now come together as a group to discuss your findings. Compare the individual scores you each have for the 15 elements. Agree on a common score. This may take some time particularly if staff and board members are in disagreement about several points. The debate may be quite revealing of differences in understanding and perceptions of the organization. The facilitator will need to judge just how much of the discussion is fruitful. 32 Sustaining the Benefits Step four. AS A GROUP. Plot common scores for each element on the Sustainability Profile Matrix (at the end of this chapter). Step five. AS A GROUP. Identify the priority elements that your organization should work on to enhance its sustainability. Identify those elements in the Sustainability Profile Matrix that scored less than ten (out of a possible 20). These elements ideally need attention. But having a low score is not the only factor to consider in assessing which ones should have priority. For each of those low-scoring elements consider also the feasibility of making improvements. Give a higher priority to those low-scoring elements where it is easier to see how improvements can be made in the current circumstances, or where the biggest improvements can feasibly be made. Record your conclusions in the score sheet giving “1” to the highest priority element. Using the Results for a Broader Assessment The results from the matrix can also be used to develop a better understanding of the sustainability of the whole organization. Somewhat arbitrarily we have defined levels of organizational sustainability as follows— • Sustainable: 11 or more elements are above 15 • Progressing Toward Sustainability: 11 or more elements are above 10 • Poised to Become Sustainable: 11 or more elements are above 5 • Presently Not Sustainable: 11 or more elements are below 5 Refer back to your Sustainability Profile and identify which category your organization is in. These stages are not permanent categories. It is quite possible to move from the “Not Sustainable” to a more sustainable category. It is also possible to move down the continuum if you do not continue to adapt to the changing needs of your clients and the community. Below is an example of what each of the sustainability stages might look like in one country. The specifics will vary somewhat from country to country depending on the context, particularly the current level of key reproductive and child health indicators, people’s willingness to pay for services, and the availability of other options for generating income to subsidize services. Sustainable All board and management decisions within the organization are driven by a concern for sustainability, there is a long-range business plan, and collaboration and working in partnerships are the norm. The external image of the organization is favorable and its good performance has attracted the attention of the government and multiple donors. Staff members enjoy a sense of security and a culture that recognizes and promotes merit and performance. Community ownership and management, in conjunction with public, private medical and commercial sectors, ensure continuity of program benefits and maintain contraceptive prevalence rates and other maternal and child health indicators at a high level. Most clients walk to or pay for services. Sustainability Assessment 33 There is a high level of client satisfaction; services meet set standards of quality and the recipients of services continue to be the poor. Operating costs have been substantially reduced, revenues are generated within the community, and donor support requirements have been reduced to less than 20 percent of total expenses on the program. Progressing Towards Sustainability Concern for sustainability has been developed within the board, management, and staff and sustainability plans have been developed and are being implemented. The staff is competent, highly motivated, and is beginning to experiment with innovative ways of reducing cost, generating earnings, and tapping into community contributions. The organization provides benefits to the intended population, maintaining the contraceptive prevalence rates, and maternal and child health indicators at greater than 50 percent utilization. Standards of quality are met and the recipients of the services continue to be the poor. One quarter to one half of the clients either walk to or pay for services. Linkages to the public, private medical, and commercial sectors are being strengthened. The community is interested in and being prepared for taking over management roles and responsibilities. The organization continues to depend on alternative external donor support (more than 20 percent) of total expenses on the program. Poised to Become Sustainable or Emerging The organization has a strong commitment to provide benefits to the intended population, to maintain the contraceptive prevalence rate, scale, and coverage of reproductive health indicators, to meet reasonable standards of quality and to maintain the client profile (serving the poorest sections, low parity). It has dynamic leadership, a team of dedicated and competent staff, a strong program, a positive image, and efficient systems and linkages with the community and the public sector. It needs support in the area of financial management including cost analysis, managing overheads and indirect costs, and cost value ratios. It is currently dependant on a single donor and preparing to incorporate sustainability measures through cost reduction and revenue generation as well as looking for other donors. Currently Not Sustainable The organization may continue to exist, but would not be able to provide benefits to the intended population when the current donor support discontinues. Substantial strengthening is needed in areas of program development, management systems, and financial management. The organization has no significant source of revenue outside the existing donor funds and there is no active seeking of alternate funding. The organization would continue to require substantial investments from donors. Su sta in ab ili ty A ss es sm en t 35 N G O S us ta in ab ili ty A ss es sm en t M at ri x In st itu tio na l E le m en ts a nd P ra ct ic es 0 N ot T ru e or in P ra ct ic e 1 So m ew ha t Tr ue o r B ei ng C on si de re d 3 M os tly T ru e or O fte n in Pr ac tic e 4 A lm os t A lw ay s Tr ue o r C ur re nt ly in P ra ct ic e V er ifi ca tio n W he n th e ra tin g is 4, sp ec ify in di ca to r fo r v er ifi ca tio n 1. O rg an iz at io na l C om m itm en t t o Su st ai na bi lit y � Th e or ga ni za tio n ha s a v is io n of it se lf as se lf- su st ai ni ng a nd is m ak in g ef fo rts to d ec re as e do no r de pe nd en ce a nd d iv er si fy re ve nu e so ur ce s � Th e or ga ni za tio n ha s a b us in es s- lik e ap pr oa ch to p ro vi di ng so ci al se rv ic es (e .g . c on ce rn ed w ith ef fic ie nc y an d th e va lu e of se rv ic es a nd is re sp on si ve to th e cl ie nt n ee ds ) � Th e or ga ni za tio n vi ew s c ha rg in g us er fe es a s a cc ep ta bl e an d vi ab le � Th e or ga ni za tio n is p re pa re d to re du ce c os ts � Th e or ga ni za tio n is p re pa re d to e lim in at e lo w -p er fo rm in g co st c en te rs El em en t S co re 2. S tr at eg ic P la nn in g fo r Su st ai na bi lit y � Th e or ga ni za tio n’ s v is io n an d m is si on a re k no w n, u nd er st oo d, a nd sh ar ed b y th e st af f a nd c om m un ity � St ra te gi c pl an s e xi st a nd a rti cu la te g oa ls , o bj ec tiv es , k ey a ct iv iti es , a nd fi na nc ia l i m pl ic at io ns o f t he ac tiv iti es � St ra te gi c pl an s a re b as ed o n m ar ke t d at a, re sp on si ve to c ha ng es in e xt er na l e nv iro nm en t, an d us ed to re vi ew p ro gr es s a nd k ee p pe rfo rm an ce o n tra ck � Pr og ra m st af f a nd c om m un iti es p ar tic ip at e in st ra te gi c pl an ni ng e xe rc is es � St ra te gi c pl an s i nc lu de a ct iv iti es fo r r ev en ue g en er at io n an d co st re du ct io n El em en t S co re 3. G ov er na nc e an d Le ad er sh ip � Th e bo ar d ha s a d iv er se m em be rs hi p (in te rm s o f d is ci pl in es , a ge , a nd g en de r) � B oa rd m em be rs a re a ct iv e in p ro m ot in g th e or ga ni za tio n’ s i m ag e an d fu nd ra is in g fo r t he o rg an iz at io n � Th e bo ar d is d is tin ct fr om m an ag em en t a nd su pp or tiv e of th e R H p ro gr am � Sy st em s a re in p la ce fo r p ar tic ip at or y de ci si on m ak in g, d el eg at io n, a nd te am w or k � Pe rfo rm an ce a nd a cc ou nt ab ili ty a re p ro m ot ed o r r ew ar de d El em en t S co re 4. H um an R es ou rc es a nd P er so nn el M an ag em en t � D oc um en te d pe rs on ne l p ol ic ie s a re a va ila bl e an d kn ow n � Pe rs on ne l p ol ic ie s a re c on su lte d w he n hi rin g, su pe rv is in g, o r r ev ie w in g st af f p er fo rm an ce � C le ar ly -d ef in ed , w rit te n jo b de sc rip tio ns a nd w or k pl an s e xi st a nd a re c on si st en t w ith th e tra in in g an d ca pa bi lit ie s o f s ta ff � St af f d ev el op m en t p la ns e xi st to im pr ov e st af f’s p er fo rm an ce , m ot iv at io n, a nd te am w or k � M ea su re s e xi st fo r r et ai ni ng k ey st af f a nd m ai nt ai ni ng o rg an iz at io na l c on tin ui ty th ro ug h pr om ot io ns , tim e, a nd c os t-s ha rin g of st af f a nd tr an sf er s b et w ee n pr og ra m s El em en t S co re 36 Su sta in in g th e Be ne fit s In st itu tio na l E le m en ts a nd P ra ct ic es 0 N ot T ru e or in P ra ct ic e 1 So m ew ha t Tr ue o r B ei ng C on si de re d 3 M os tly T ru e or O fte n in Pr ac tic e 4 A lm os t A lw ay s Tr ue o r C ur re nt ly in P ra ct ic e V er ifi ca tio n W he n th e ra tin g is 4, sp ec ify in di ca to r fo r v er ifi ca tio n 5. Im ag e, E xt er na l R el at io ns , a nd N et w or ki ng � Th e or ga ni za tio n do cu m en ts a nd w id el y di ss em in at es e xp er ie nc es a nd a ch ie ve m en ts in th e pr og ra m v ia re po rts , a rti cl es , s em in ar s, w or ks ho ps , c on fe re nc es , a nd e xh ib its � Th e or ga ni za tio n ha s a p os iti ve im ag e w ith th e co m m un ity , g ov er nm en t o rg an iz at io ns , a nd d on or s � Th e or ga ni za tio n ha s s tro ng li nk ag es a nd n et w or ks , c re at in g op po rtu ni tie s f or c ol la bo ra tiv e ac tiv iti es � K ey in di vi du al s d em on st ra te c ha ris m a an d co m m itm en t a nd e m pl oy th em to fo st er n et w or ks � St af f a re a ss ig ne d re sp on sib ili ty fo r d ev el op in g m es sa ge s t ha t c om m un ic at e th e or ga ni za tio n’ s d ire ct io n an d th e is su es it a dd re ss es El em en t S co re 6. C om m un ity P ar tic ip at io n an d O w ne rs hi p � C om m un ity -b as ed o rg an iz at io ns o r g ro up s e xi st a nd th ei r c ap ac iti es h av e be en e m pl oy ed to a ss is t t he or ga ni za tio n an d its p ro gr am s � V ol un te er s h av e be en id en tif ie d, tr ai ne d, a nd m ot iv at ed to sh ar e pr og ra m re sp on si bi lit ie s � Th e co m m un ity is in vo lv ed in n ee ds a ss es sm en t, pl an ni ng , m on ito rin g, a nd e va lu at io n � Th e co m m un ity is in vo lv ed in m ak in g de ci si on s a bo ut h ow p ro gr am fu nd s a re e xp en de d an d ge ne ra te d � Pe op le in th e co m m un ity m ak e co nt rib ut io ns (i n- ki nd , m on ey , l ab or ) t o th e pr og ra m El em en t S co re 7. P ro gr am Q ua lit y � El ig ib le c ou pl es a re in re gu la r c on ta ct w ith c om m un ity h ea lth w or ke rs d ur in g w hi ch th ey a re g iv en co rr ec t a nd c om pl et e in fo rm at io n on th e us e of c on tra ce pt iv es (e ith er th ro ug h ho m e vi si ts o r d ep ot s) � Sy st em s a re in p la ce fo r t ra in in g se rv ic e pr ov id er s a nd p ro vi di ng fa ci lit at iv e su pe rv is io n to e ns ur e co m pl ia nc e w ith se rv ic e gu id el in es a nd p ro to co ls � Th er e ar e a va rie ty o f f am ily p la nn in g m et ho ds a nd re pr od uc tiv e he al th se rv ic es b ei ng p ro vi de d to cl ie nt s w ith e m ph as is o n cl ie nt c ho ic e an d sa tis fa ct io n � Th er e ar e lo w d ro po ut a nd h ig h cl ie nt c on tin ua tio n ra te s � Th er e ar e st ro ng re fe rr al li nk ag es w ith th e pu bl ic se ct or o r N G O fa ci lit ie s t ha t r es ul t i n ef fe ct iv e re fe rr al s El em en t S co re 8. M IS , D at a B as ed P la nn in g, a nd D ec isi on M ak in g � D at a ex is ts a nd a re u pd at ed to a ss es s t he sa tis fa ct io n an d R H n ee ds o f c lie nt s � D at a ex is t t o id en tif y cu rr en t a va ila bi lit y an d ut ili za tio n of R H se rv ic es � St af f u se d at a fo r p la nn in g, m on ito rin g, a nd p ro vi di ng fe ed ba ck o n se rv ic e de liv er y � In di ca to rs e xi st fo r m on ito rin g im pl em en ta tio n an d ev al ua tin g pr og ra m im pa ct � M an ag er s u til iz e in fo rm at io n ga th er ed fr om th e M IS to re gu la rly m on ito r b ud ge ts v s. ex pe nd itu re s a nd pr og ra m p er fo rm an ce El em en t S co re Su sta in ab ili ty A ss es sm en t 37 In st itu tio na l E le m en ts a nd P ra ct ic es 0 N ot T ru e or in P ra ct ic e 1 So m ew ha t Tr ue o r B ei ng C on si de re d 3 M os tly T ru e or O fte n in Pr ac tic e 4 A lm os t A lw ay s Tr ue o r C ur re nt ly in P ra ct ic e V er ifi ca tio n W he n th e ra tin g is 4, sp ec ify in di ca to r fo r v er ifi ca tio n 9. M ar ke tin g/ In fo rm at io n, E du ca tio n, a nd C om m un ic at io n (I E C ) � Th e or ga ni za tio n ha s a m ar ke tin g/ co m m un ic at io n st ra te gy fo r r ep ro du ct iv e he al th p ro m ot io n � A sy st em e xi st s f or c on du ct in g m ar ke t a na ly si s a nd u sin g th e fin di ng s t o ta ilo r p ro du ct s a nd se rv ic es � A v ar ie ty o f c om m un ic at io n m at er ia ls a re a va ila bl e an d ar e us ed a t t he c om m un ity le ve l � A h ig h aw ar en es s o f a nd d em an d fo r r ep ro du ct iv e he al th se rv ic es h as b ee n cr ea te d � M an ag er ia l a nd fi el d st af f h av e m ar ke tin g/ co m m un ic at io n sk ill s El em en t S co re 10 . L og ist ic s � Sy st em s e xi st fo r f or ec as tin g co nt ra ce pt iv e an d su pp ly re qu ire m en ts � C on tra ce pt iv es a nd su pp lie s a re p ro cu re d fo llo w in g w rit te n gu id el in es a nd p ro ce du re s � A sy st em e xi st s fo r i nv en to ry c on tro l a nd m ai nt ai ni ng st oc ks � Th er e ha ve b ee n no o cc as io ns in th e la st 6 m on th s w he n an it em h as ru n ou t o f s to ck (r es po nd 0 if th er e w as a n oc ca si on o f n o st oc k or 4 if st oc k w as a lw ay s a va ila bl e) � M an ag er ia l a nd fi el d st af f h av e be en tr ai ne d in lo gi st ic s m an ag em en t El em en t S co re 11 . F in an ci al M an ag em en t � Th e pr og ra m u se s c os t a na ly si s t o de te rm in e un it, fi xe d an d va ria bl e co st s, an d tra ck s c os ts a ga in st be ne fit s t o de te rm in e op er at io na l e ffi ci en cy � Fi na nc ia l r ep or ts a re c on si st en tly u se d fo r m an ag em en t d ec is io ns � Th e or ga ni za tio n pr ep ar es lo ng -r an ge fi na nc ia l p la ns w ith p ro je ct ed in co m e an d ex pe nd itu re s � Fi na nc ia l d at a on in co m e an d ex pe nd itu re a re ro ut in el y co lle ct ed a nd se gr eg at ed b y co st c en te rs � R ou tin e au di ts a re c on du ct ed o f t he e nt ire o rg an iz at io n, n ot o nl y in di vi du al p ro je ct s El em en t S co re 12 . C os t R ed uc tio n � Sy st em s fo r c om pe tit iv e an d bu lk p ro cu re m en t a re in p la ce � Ef fic ie nt o pt io ns fo r d el iv er y of se rv ic es a re a ss es se d an d im pl em en te d � Th e or ga ni za tio n m in im iz es h ie ra rc hy a nd u nn ec es sa ry m an ag em en t l ev el s � W he n ut ili za tio n is lo w , f ix ed c os ts a re sh ift ed to v ar ia bl e co st s ( e. g. p ay n ur se s b as ed o n nu m be r o f cl ie nt s s ee n ra th er th an a fi xe d sa la ry ) � R es ou rc es a re sh ar ed w ith o th er o rg an iz at io ns to m in im iz e co st s El em en t S co re 38 Su sta in in g th e Be ne fit s In st itu tio na l E le m en ts a nd P ra ct ic es 0 N ot T ru e or in P ra ct ic e 1 So m ew ha t Tr ue o r B ei ng C on si de re d 3 M os tly T ru e or O fte n in Pr ac tic e 4 A lm os t A lw ay s Tr ue o r C ur re nt ly in P ra ct ic e V er ifi ca tio n W he n th e ra tin g is 4, sp ec ify in di ca to r fo r v er ifi ca tio n 13 . C os t R ec ov er y � Sy st em s/ pr oc ed ur es fo r c ha rg in g fe es fo r s er vi ce s e xi st � A sy st em o f e xe m pt io ns e xi st s f or th e be ne fit o f t he p oo re st c lie nt s � A c lie nt su rv ey h as b ee n do ne to d et er m in e th e be ne fic ia rie s’ c ap ac ity to p ay � B en ef ic ia rie s v al ue th e qu al ity o f s er vi ce s a nd a re w ill in g to p ay fo r t he m � Pr ic es fo r p ro du ct s a nd se rv ic es p ro vi de d by c om pe tit or s a re ro ut in el y m on ito re d El em en t S co re 14 . R ev en ue /In co m e G en er at io n � Th e or ga ni za tio n se lls p ro gr am -r el at ed g oo ds a nd se rv ic es to n ew se ts o f c lie nt s ( e. g. se ll pr oj ec t m at er ia ls o r c ha rg e pr of es si on al fe es fo r s er vi ce s s uc h as tr ai ni ng ) � A se pa ra te c om m er ci al v en tu re is b ei ng u nd er ta ke n or c on si de re d � St af f h as b as ic b us in es s s ki lls � A nn ua l t ar ge ts a re se t a nd sy st em s a nd p ro ce du re s e xi st fo r i nc om e ge ne ra tio n � In ve st m en ts , r es er ve s, or a ss et s a re u se d to g en er at e in co m e El em en t S co re 15 . L ev er ag in g � Th e or ga ni za tio n re ce iv es su pp or t f ro m a v ar ie ty o f d on or s, go ve rn m en t a ge nc ie s, an d in di vi du al s � C ap ac ity e xi st s t o w rit e ne w p ro po sa ls fo r d on or o r g ov er nm en t a ge nc ie s � En do w m en ts h av e be en e st ab lis he d w ith c on tri bu tio ns fr om c om m un ity o rg an iz at io ns o r d on or s � Lo ca l d on or s a re c ul tiv at ed th ro ug h sp ec ia l e ve nt s a nd o th er lo ca l f un dr ai sin g ac tiv iti es � In co m e fro m u nr es tri ct ed so ur ce s i s u se d to su bs id iz e th e co st s o f o th er p ro je ct s o r t o ra is e ad di tio na l fu nd s El em en t S co re Sustainability Assessment 39 Score Sheet INSTITUTIONAL ELEMENTS IndividualScore Team Score Priority order for low- scoring elements (1 = highest priority) Organizational Commitment to Sustainability Strategic Planning for Sustainability Governance and Leadership Human Resources and Personnel Management Image, External Relations, and Networking PROGRAMMATIC ELEMENTS IndividualScore Team Score Priority order for low- scoring elements (1 = highest priority) Community Participation and Ownership Program Quality MIS, Data Based Planning, and Decision Making Marketing/IEC Logistics FINANCIAL ELEMENTS IndividualScore Team Score Priority order for low- scoring elements (1 = highest priority) Financial Management Cost Reduction Cost Recovery Revenue/Income Generation Leveraging **Plot the scores in the Sustainability Profile Matrix. 40 Sustaining the Benefits Sustainability Profile Matrix INSTITUTIONAL PROGRAMMATIC FINANCIAL 20 18 16 14 12 10 8 6 4 2 0 O rg an iz at io na l C om m itm en t St ra te gi c Pl an ni ng G ov er na nc e an d Le ad er sh ip H um an R es ou rc es a nd P er so nn el M an ag em en t Im ag e, E xt er na l R el at io ns , a nd N et w or ki ng C om m un ity P ar tic ip at io n an d O w ne rs hi p Pr og ra m Q ua lit y M IS , D at a B as ed P la nn in g, a nd D ec is io n M ak in g M ar ke tin g/ IE C Lo gi sti cs Fi na nc ia l M an ag em en t C os t R ed uc tio n C os t R ec ov er y R ev en ue /In co m e G en er at io n Le ve ra gi ng Section 3: Institutional Aspects of Sustainability The characteristics of an organization’s internal systems, structure, work, and culture play a key role in ensuring its long-term survival. These institutional features underpin much of what makes an organization sustainable. Three important elements of institutional sustainability are addresses in this section—the organization’s vision, mission, and values, the way the organization is governed, and how the organization builds its external relations and image. These “big picture” features of an organization shape and guide “what the organization is,” “what it does,” and “why it does it.” Values, Mission, and Vision (Chapter 4) defines the kind of organization an NGO is or aims to be. They guide the actions of individuals, teams, and groups and focus energy towards the accomplishment of common goals. They help the organization create a distinctive image and identity, clarify strategy, and inspire commitment. And, they are critical to defining what should be sustained and how. Good Governance (Chapter 5) is a key component in overall organizational effectiveness, vitality, and dynamism. Organizations that have systems of good governance tend to act in accordance with their mission, utilize resources efficiently, and balance the interests of external stakeholders and internal constituencies. They are also much better placed to achieve sustainability. The growing complexity of NGOs—in terms of range of services, size of operation, and multiplying sources of funding—makes governance a particularly pressing issue. Strategic Communication (Chapter 6) promotes a positive organizational image and facilitates strong external relations. Organizations that communicate their successes, advocate for their issues and explain the benefits of collaboration are more likely to receive the support necessary to sustain and expand their programs. By the end of Chapter 4, Values, Mission, and Vision, you will be able to— • Clarify values that give life to your organization • State, and if necessary modify, the mission of your organization • Define the vision for the organization By the end of Chapter 5, Good Governance, you will be able to— • State the importance of governance in helping organizations become sustainable • Identify the primary responsibilities of an NGO board of directors • Define board effectiveness 42 Sustaining the Benefits By the end of Chapter 6, Strategic Communication, you will be able to— • Describe strategic communication • Understand how strategic communication can enhance your organization’s image • Recognize the steps involved in devising a strategic communication strategy Section 3: Institutional Aspects of Sustainability 43 Table of Contents Section 3: Institutional Aspects of Sustainability Chapter 4 Values, Mission, and Vision. 45 Values. 46 Mission . 47 Elements of a Mission Statement . 48 Vision . 51 Chapter 5 Good Governance. 53 Governance and Boards. 53 Why Have Boards?. 53 Primary Responsibilities of Boards. 54 Chapter 6 Strategic Communication . 59 What Is Strategic Communication?. 59 Strategic Communication—Essential for Sustainability. 59 Steps in Strategic Communication . 60 Values, Mission, and Vision 45 Chapter 4 Values, Mission, and Vision It is important to lay on the table the fundamentals of your organization before taking steps towards sustainability. This is true for two reasons. First, you need to be sure to always have the basic purpose and rationale of the organization in mind before embarking on any change. What is it that is worth sustaining? Secondly, you need to consider the underlying values of the organization so that these can inform any proposals for action that emerge. Are the kinds of strategies you are proposing compatible with the organization’s guiding values? Perhaps you might even consider revising the values and mission of your organization, or at least opening a debate about them, if they appear unreasonably in conflict with sustainability strategies that emerge. 46 Sustaining the Benefits Values Organizations working in the field of public health and social development exist because the board, senior leadership, and the staff in general share a set of values and beliefs. These values provide the inspiration to carry on working even under the difficult conditions that prevail from time to time. Values fuel commitment. They also define the boundaries of what is negotiable and what is not—specifying the central core that is essential to the distinctiveness and integrity of the organization. It is likely that you remain in your job as a board member or a staff person in part because you share some personal values with the organization. These might be people-oriented values such as honesty, social commitment, trust, sharing, consideration, compassion, courage, or human service. Or perhaps they are work-oriented values such as accomplishment, efficiency, responsibility, learning, client focus, or responsibility. Values are beliefs and judgments about what is worthy, important and desirable and are expressed through individual behaviors and organizational culture. Values determine the intent and form the basis of defining core priorities. List three or four deeply held values you have and would want to see expressed through your organization’s work. These are values that come from the heart and that you would care about, no matter where you worked. Consider values in relation to clients, customers, community, colleagues, stakeholders, and donors. There may be tension between the organization’s values and some sustainability strategies. For example, charging for services might be seen as undermining the value an organization places on serving the poor and staff might resist implementing that strategy. To build commitment to sustainability within the organization, these tensions must be addressed either by discussion on how the strategy fits within the values or by selecting different strategies. Values, Mission, and Vision 47 Mission Mission means purpose. An organization’s mission statement is a description of why the organization exists and what, in broad terms, it does. The mission statement clearly charts the future direction of the organization and establishes a basis for decision making. Organizations with financial, operational, and image problems can often trace their troubles to the lack of focus that comes from not having or not communicating a clear institutional mission. A mission statement describes the purpose of the organization and the reason for its existence. A mission statement has multiple uses. It is a management tool constantly referred to by those making management and policy decisions, a guide for action helping to define the way the organization conducts its activities. (It should, for this reason, be clearly understood by all staff of the organization.) Image building and “brand-marking” for an organization often draw on the mission statement for inspiration. Individuals donate money and become volunteers primarily because they identify with the mission of the organization. It can also guide the choice of sustainability strategies. For example, if the organization’s mission is to reduce maternal and infant deaths, then it would be appropriate to seek funds from USAID or UNICEF. If you have a mission statement, write it out or attach it here. Then consider the guidance provided in the following paragraphs and see how you might improve it. If you don’t have a mission statement, read the following paragraph, and prepare one. 48 Sustaining the Benefits Elements of a Mission Statement WHAT? (Goods and services offered to satisfy customer needs) HOW? WHO? (Activities, technologies) (“Customer groups” competence) The mission statement should address the following questions— • What are the basic needs that this organization fills? • Whom does this organization serve? Who are its clients? • How does the organization meet the needs of those it serves? • What makes this organization unique? • What values does this organization seek to promote? The style of the mission statement should be— • Clear, concise, and simple so that people within and outside the organization can easily understand it • Brief enough for most people to keep in mind • Focused on a single strategic thrust though broad enough to allow flexibility in implementation • Able to energize the organization Values, Mission, and Vision 49 Box 4.1 Sample Mission Statements Population Action International (PAI) Population Action International (PAI) is dedicated to advancing policies and programs that slow population growth in order to enhance the quality of life for women and their children. It advocates the expansion of voluntary family planning, other reproductive health services, and educational and economic opportunities for girls and women. To these ends, PAI seeks to increase global political and financial support for effective population policies and programs grounded in individual rights. Whitman-Walker Clinic Whitman-Walker Clinic is a non-profit, volunteer-based, lesbian and gay, community health organization serving the Washington, D.C. metropolitan area. Our volunteers and staff are dedicated to providing or facilitating the delivery of high-quality, comprehensive, and accessible health care services. Our services are directed to all gay men and lesbians. We are proud of the Clinic’s substantial contribution in the fight against AIDS. Our historic commitment to accessible health care moves us also to share our programs with anyone in need of HIV-related services. Global Excellence in Management (GEM) GEM’s goal is to encourage and support new forms of cooperation between PVOs and NGOs and to build organizational capacities in order to promote sustainable, long-term development. HIV Community Coalition To educate, support, advocate, and voice concerns on HIV/AIDS related service, programs, and policies within the Washington metropolitan areas. Children’s Defense Fund The mission of the Children’s Defense Fund is to Leave No Child Behind® and to ensure every child a Healthy Start, a Head Start, a Fair Start, a Safe Start and a Moral Start in life and successful passage to adulthood with the help of caring families and communities. Pact Pact’s mission is to contribute to the growth of civil societies—where citizens acting together can express their interests, exchange information, strive for mutual goals and influence government. Having agreed on a mission-statement continued effort is required to make it a living template for day-to-day action. To achieve this— • Ensure that those in leadership positions are seen using the mission statement daily, visibly, and consistently • Recognize that it takes time before the mission becomes ingrained 50 Sustaining the Benefits • Incorporate the mission statement in training exercises, teaching staff why it is there and how to use it Although a mission statement provides an anchor in the policy and decision making processes it is not immutable, cast in stone. It should be reviewed annually to see whether changes in the external or internal environments render the mission or parts of it obsolete. When considering a radical change in mission, consult lawyers or attorneys to ensure that the changes do not conflict with the requirements of registrations and other forms of legal documentation. Too many changes or changes that are too drastic could jeopardize the organization’s tax-exempt status, for example. Values, Mission, and Vision 51 Vision The “vision” of an organization is the image of what the organization will be like in the future some three to five years from now. It is a dream created in waking hours that captures what the organization could be or possibly become based on the best of the organization’s accomplishments. It describes what desired change will be achieved when the organization’s accomplishments are sustained. It is a bold statement that goes beyond the present and challenges the organization to new levels of excellence. When guided by a vision, people believe their efforts can make a difference, and they work with greater commitment. Effective leaders create and communicate an inspiring image of the future and enroll others in its pursuit. Vision: A living picture of a future desirable state. What are the accomplishments of your organization that provide a sense of pride for the people associated with it? Based on this, describe your vision for your organization and the community it serves. Bear in mind that vision— • Comes from the heart • Is radical and compelling • Provides a sense of pride for the people associated with the organization Good Governance 53 Chapter 5 Good Governance Governance and Boards Governance is a term used to describe the processes and structures that direct the operations and activities of organizations. An organization’s board of directors plays a key role in governance. The board—comprising several individuals who work for a fixed term on a voluntary basis—is the governing and the policy-setting body that bears legal responsibility for the organization it serves. The nature of a board changes as organizational needs change, and it is possible to observe a “life cycle” in the transformation of many boards over time. In the early stages of an organization the board will often follow a visionary leader or be steeped in hands-on work. As the organization grows, this arrangement becomes strained, compelling the board to take a stronger role in governance, be less of a cheerleader for the founding member and hand over the operational involvement to a strong chief executive. In this evolution from an “organizing” board to a “governing” board, a committee structure may develop, and the board begins to understand and accept the fundraising role. If the organization grows further, the board might transform into an “institutional” board with many well-connected members and a focus on fundraising. Why Have Boards? All organizations, including yours, have boards. What purpose do you think they serve? Boards represent the ownership of the organization and act as trustees of public good, protecting the integrity of those trustees not physically present. They bear legal responsibility for the organization. They are also a vital connection with the larger community of different stakeholders and constituencies such as management, staff, volunteers, governments, donors/funding agencies, communities, and clients. Board members provide policy direction and leadership. They create operational frameworks that help ensure that the organization’s mission is being accomplished, adequate resources are being 54 Sustaining the Benefits mobilized and spent efficiently, assets are well managed, and the image of the organization is fortified. Primary Responsibilities of Boards The board should be a key resource in any organization. Unfortunately, however, boards sometimes perform only the minimum legally required—these are known as “sleeping boards.” Others totally dominate the organization’s functioning, blocking staffs’ ability to do their jobs, or are totally subservient to and manipulated by staff. To avoid this, board members should, from the beginning, understand and agree upon their roles and responsibilities, including those that go beyond the requirements stipulated in the law. The key responsibilities of boards follow— 1. Establish and oversee the mission and purpose of the organization. The board has a fundamental role in articulating and endorsing the mission of the organization in a manner that helps staff and others become familiar with it. It oversees organizational planning and decision making to ensure that it is guided by the mission. The board also reviews the mission statement periodically to verify its relevance and responsiveness to changing conditions in the environment and, when necessary, revises it. 2. Select, support, and review performance of the chief executive. The way the board chooses and interacts with the chief executive has a lasting impact on the development and effectiveness of any institution. The chief executive together with board members constitutes a leadership team that will determine program direction and efficiency, public image, and fundraising. The board and the management functions are different and complementary. The board offers direction and a policy framework while the management, headed by the chief executive, conducts day-to-day business. The board oversees and supports the chief executive and staff. Mutual respect and support should be the keystone. 3. Provide long-range direction and evaluate programs. The board of directors drives the organizational planning processes. By their proactive engagement, its members are able to define and shape rather than just react to and ratify program directions and plans. Strong, dynamic, sustainable organizations need a focus on the long-range vision that the board should provide. It should also ensure that all programs are consistent with the mission of the organization, meet the needs of stakeholders, are cost- effective, of good quality, and responsive to the shifts and trends in community needs. 4. Ensure the financial stability of the organization. An organization can be effective only when it has adequate financial and human resources. Attracting resources is an important duty of the board members requiring skill, commitment, and influence. Board members should actively participate in fundraising, often beginning by contributing money themselves or asking friends and colleagues to do so (Box 5.1). They have a significant contribution to make in preparing the case for supporting the organization and persuasively presenting this case to prospective donors. Good Governance 55 Fiscal management is another element of board responsibility that contributes to the financial stability and fiscal health of organizations. Usually, boards approve and adopt annual budgets. They also protect and manage financial assets and verify that fiscal policies are in place and are followed. They ensure compliance with funding policies and regulations and scrutinize the reports of certified public accountants. Box 5.1 Board’s Role in Fundraising: The Three “Gs” The active role boards should play in fundraising is captured in the three “Gs.” Give: Board members should themselves make a donation of their money or expertise. This makes them much more persuasive when asking others to donate. Get: Individuals are often invited to serve on a board because they are influential members of the community. They should use their connections to attract additional donations. Go: If a board member is not willing or able to give directly or raise funds through their connections, then their role should be re- assessed. If they do not clearly contribute in some way to the organization, then it may be time for them to leave and for another active member to be recruited. 5. Promote the image of the organization. Board members have a very special role in shaping the organization’s public image and creating awareness about it. They command public attention because of their commitment, convictions, and contacts and can add value to the public relation efforts of the management and staff. Individual members should be well informed of the organization’s programs and plans and should speak for the organization at appropriate opportunities. They should also participate in the variety of promotional strategies an NGO utilizes, including annual reports and documentation, speeches, and positive media coverage. 6. Assess its performance systematically. The board of directors needs to step back and review its functioning periodically. As organizations mature, the leadership, governance styles, and structures need to evolve. New types of skills or expertise may be necessary, requiring training of existing board members or the recruitment of new ones. 56 Sustaining the Benefits 7. Serve as a court of appeal. Boards do not get involved in personnel issues and conflicts. Their role is to ensure the existence of a framework of clear and comprehensive personnel policies to assist the chief executive and administration to manage these situations. Occasionally boards may have to seek legal counsel and in some exceptional situations may be required to serve as a court of appeal. Worksheet 5.1 provides a checklist designed to test the effectiveness of your board of directors. Worksheet 5.2 provides a checklist for board members to assess their fundraising activities. References BoardSource, formerly the National Center for Nonprofit Boards, is the premier resource for practical information, tools and best practices, training, and leadership development for board members of nonprofit organizations worldwide. A number of publications are free and can be downloaded from the BoardSource web site and other publications can be purchased. Web address: Brinkerhoff, Peter C., Mission-Based Management, (Oak Park, IL: Alpine Guild, 1994). Mathiasen, Karl III, Board Passages: Three Key Stages in a Nonprofit Board’s Life Cycle, (Washington, DC: National Center for Nonprofit Boards, 2000). Good Governance 57 Worksheet 5.1 Checklist for Board Effectiveness An effective board of directors should demonstrate most of the following features. Use this checklist to identify areas where your board needs to grow. Each member— • Is able to state the mission and goals of the organization and supports them consistently • Has up-to-date information on the organization’s activities • Is aware of and understands the primary responsibilities of boards of directors • Concerns itself with policy direction and maintains checks and balances; leaves day- to day management to the chief executive and staff • Understands the role and duties of the chief executive; supports and monitors his/her performance • Is aware of board and committee structures and the roles of different members and the activities of committees • Is aware of the process for recruiting, rotating, and replacing members • Is well versed in the by-laws and the procedures and processes for amendments • Knows how and when meetings are scheduled and always completes the quorum • Contributes to well-planned agendas and well-facilitated meetings that conduct business in a timely and professional manner • Oversees the fiscal management of the organization and actively engages in fundraising • Actively engages in protecting and promoting the image of the organization • Recruits new members in accordance with the changing needs of the organization • Periodically reviews individual and group performance to make and implement plans for board development • Provides leadership in defining long-range direction and organizational planning for sustainability • Negotiates key stages in the board’s life cycle 58 Sustaining the Benefits Worksheet 5.2 Board Fundraising Checklist An effective fundraiser should be able to answer most of the following questions in the affirmative— • Do I understand the plans and program for fundraising? • Do I fully understand and endorse the case for why someone should contribute? • Do I contribute to the fullest measure within my means? (i.e. make a “stretch gift”) • Do I continually offer suggestions of other names to add to the mailing list? • Do I assist staff in identifying and evaluating prospects—individuals, corporations, and foundations? • Do I share in cultivating key prospects? • Do I make introductions to enable others to make solicitation visits? • Do I accompany others on solicitation visits? • Do I write follow-up and acknowledgement letters? • Do I write personal notes on annual appeal letters? • Am I prepared to make a solicitation myself? Adapted from: F. Howe, Fund Raising and the Nonprofit Board Member, (National Center for Nonprofit Boards, 1990). Strategic Communication 59 Chapter 6 Strategic Communication What Is Strategic Communication? Communication involves conveying a message or idea to an audience—some group having a stake in the organization, its community, clients, collaborators, or donors (i.e. one of the organization’s “publics”). Strategic communication is communication that is planned, focused on achieving an objective, and issues-based. It is generally pro-active with opportunities being sought to deliver messages. But when a spokesperson put on the spot reacts by delivering a message, this can also be part of a strategic communication strategy. The key element is that some planning is involved. As well as being planned, strategic communication seeks to achieve a communication objective such as “to create awareness,” “to inform,” or “to change behavior.” In general, strategic communication is issues-based. It addresses some specific topic—usually one that is having or might have an impact on the organization—and its messages are targeted to the audience that needs to hear about that issue. Strategic communication is both an art and science. There are steps to follow, but much of what contributes to the process is subjective and personal. It is a long-term and ongoing process. Strategic Communication—Essential for Sustainability An organization needs to create a positive image in the minds of its various publics. Their perception of the organization, whether true or false, will determine, to a large extent, the success and survival of that organization. This perception is formed by what the organization does, what it says about itself and what others say about it. The public makes judgments based on all the different “messages” they receive from the organization. When the name of the organization is mentioned or when someone sees the name of the organization on a poster or in a brochure, it should evoke positive thoughts and images, a feeling of trust. Strategic communication seeks to increase the amount of trust between the organization and its publics. Organizations often have limited resources. Networking with other groups to leverage resources or coordinate services requires good communication skills. For example, a spokesperson attempting to establish linkages and collaboration with other organizations needs to know how to communicate the benefits of collaboration or how to define “what’s in it for them and us.” Finally, organizations need to maintain excellent external relations, not only with their community and other organizations with similar or complementary missions, but with other 60 Sustaining the Benefits stakeholders as well. Ministries, foundations, community activist groups, and other donors will bring needed support to the cause if they feel they have a good working relationship with the organization. Everyone needs allies. The key ingredient in all these activities is good communication—the ability to send appropriate messages targeted to the audience. Steps in Strategic Communication The steps involved in strategic communication are similar whether one seeks to create a positive public image, to network with partners, or to create better external relations. Those steps revolve around three key areas—the issue, the audience, and the message. They are as follows. The Issues 1. Identify the Issues An issue is anything people are talking about that is having or might have an impact (positive or negative) on the way an organization does its business. Conduct as wide as possible a “scan” of the environment in which the organization operates, using everyone from the director to the drivers, housekeepers, and guards. All staff should be encouraged to keep their “ears to the ground,” listening to what people are talking about. In particular, attention should be paid to— • Informal communication in the form of gossip and overheard conversations • Professional and technical sources including conferences, workshops, and journals • Formal communications, such as speeches, letters, and telephone calls • Policy, legislative, and regulatory actions • Media in the form of news reporting and magazine coverage Staff meetings should devote time to identifying the issues when a staff person notes activity or “buzz” from any of these sources. 2. Assess the Issues Once identified these issues need to be assessed. This is best done by engaging different levels of the organization in the discussion of these topics. Ask— • Who is doing the talking? Is it Mothers? Media? Nurses? Market vendors? Doctors? • Are these publics important? • What is the level of “buzz?” Lots of talk? Only one or two people? The whole town? At this stage it is the level of “buzz,” not the intensity or passion which is of interest. Classify the issues as “hot,” “warm,” or “cool,” depending on whether they need attention immediately, need careful watching, or can be put aside for the moment. Strategic Communication 61 3. Frame the Issues Framing issues involves asking two questions. The information generated from this process will contribute directly to the content of the messages. The first question is “Why is this an issue?” This question should be repeated and reconsidered until a clear understanding of the issue is reached. All aspects of the issue should be developed. Sometimes an issue will be so large that it will have sub-issues. Express issues in neutral terms without qualifiers. For example, use “resources” rather than “lack of resources” as the definition of the issue. This avoids biasing the discussion. The second question is “What will happen if we don’t address this issue?” The answers to this question should address the issue’s potential impact on the organization’s business. 4. Prioritize the Issues Review the information generated during the identification, assessment, and framing of the issues and choose those that need to be addressed first. There is no harm in consulting “gut feelings.” Remember that warm or even cool issues, when framed, may turn out to be a priority. The Audiences 5. Identify the Audiences Brainstorm to determine who needs to hear about this issue. Make and circulate a list. Start with those audiences closest to the organization (e.g. clients) and move outward, possibly ending, for example, with ministry officials and foreign donors. 6. Prioritize the Audiences Based on the information gathered during steps one to four, determine who needs to hear about this issue right away. Establish some priorities. Once a primary audience(s) is identified, messages destined for other audiences may only need to be tweaked or adjusted. Try to be as specific as possible in defining audiences. “Community,” “pregnant women,” or “adolescents,” for example, may be too broad as categories of audience. Try to narrow it down further (e.g. poor, young, pregnant women) as this will help in targeting your message. 7. Analyze the Audiences This is a critical part of the strategic communication process. The better known the audience is, the more likely it is that a message can be crafted that will “hit home” and be well received. Your audience will be interested in one main thing—what’s in it for them. All other messages that fail to address this question will be quickly tuned out. So it is important to discover what are the audience’s concerns, values, problems, issues, hopes, fears, worries, preoccupations, and dreams. See the world through their eyes. 62 Sustaining the Benefits Three tools that may help are described in the worksheets at the end of the chapter— • What’s In It for Me? (Worksheet 6.1) • Likert Scales (Worksheet 6.2) • The Trust and Agreement Grid (Worksheet 6.3) Complete the three worksheets for each target audience. Work with a variety of individuals within the organization to gain different perspectives on the audience. Once the worksheets are completed, draw up a narrative profile or portrait of the audience based on conclusions drawn from the worksheets and developed by discussion in a group. The Message 8. Set a Communication Objective for Your Message Ask, “What do you want to achieve by communicating with the target audience?” Is it basically to inform or to persuade or is it to get agreement or motivate. Is it, more ambitiously, a call to action or an attempt to change a behavior? Three critical points to remember when establishing communication objectives— • Objectives such as “inform” or “create awareness” are easier to achieve than “changing behavior.” • Communication objectives are cumulative. Audiences that are aware, have sufficient information, and are persuaded and motivated will be more likely to change their behavior. This means that you should tackle the easier objectives before attempting the more difficult ones. • Limit to one, or at most, two, your message’s communication objective. Trying to achieve too many objectives dilutes the message. 9. Design the Message Research shows that messages have a better chance of being “heard” by the audience if they are crafted so as to include the following three components— • A general statement—a memorable, attention-getting phrase that is concise and broad in tone (i.e. a “sound-bite”) • Supporting facts—data that support and add credibility to the general statement • Pertinent examples—locally relevant, audience-suited, “real-life” illustrations or anecdotes Successful messages are also— • Relevant to the audience and answer the audience’s question “what’s in it for me?” • Factual (i.e. truthful, no matter how painful) Strategic Communication 63 • Consistent with other messages disseminated from the organization • Concise so that audience doesn’t lose interest • Timely (i.e. delivered at the right moment) • Believable • Crafted in positive terms with the “nots” left out • In plain language (i.e. no jargon) Box 6.1 illustrates some of these important features. Box 6.1 Example of a Message Clinic Anon wanted to attract couples who were interested in beginning to plan their families. Analysis of that target revealed that husbands were concerned about going to the clinic with their wives and about taking time off work and loss of income. Wives were worried about whether they would be able to get a contraceptive method that suited them. A message was developed targeted at these couples. It was structured in such as way as to inform and persuade. It begins with a GENERAL STATEMENT of the services offered by the clinic. This is followed by supporting facts that address some of the concerns voiced by the target audience. A story or example helps to flesh out the reality of the clinic and the message concludes with a return to the GENERAL STATEMENT (or a close variation of it) as a way of reinforcing the essential message with the listener. FOR STATE-OF-THE-ART FAMILY PLANNING SERVICES AND THE BEST CARE IN TOWN, VISIT CLINIC ANON. • We offer the full range of family planning options for men and women. • Our trained counselors and providers will help you pick the best method for you. • We are open when you need us and payment is what you can afford. Mamadou and Fatimata are interested in planning their family. They were worried and somewhat embarrassed about going together to the clinic. They heard through friends about Clinic Anon and went when Mamadou had finished work. At the Clinic, they were warmly received by a counselor. In separate facilities, each was able to talk freely with a provider. They were then counseled together to determine the best way to help them plan their family. Upon leaving the Clinic, they paid only what they could afford. FOR THE BEST CARE IN TOWN AND FOR STATE-OF-THE-ART FAMILY PLANNING SERVICES COME SEE US AT CLINIC ANON! 64 Sustaining the Benefits 10. Deliver the Message There are two types of vehicles that can be used to deliver a message: direct vehicles and indirect vehicles. Direct vehicles involve people either in person as spokespersons (through speeches, meetings, one-on-one conversations, demonstrations, or rallies) or though the medium of letters, memos, live television, taped television, video conferencing, radio, email, or phone calls. If you are the vehicle, be aware of how body language and delivery style support or undermine your message. Indirect vehicles include newsletters, posters, T-shirts, articles in a journal, briefing papers, radio reports, television coverage, advertising, and billboards. Direct vehicles are generally more expensive (per individual touched by the message) but are often more effective in getting the message across. You will want to identify the vehicle that will have maximum impact for any given level of resources available (i.e. the most efficient). (Item 11 is optional) 11. Link the Message with an Activity or Call to Action Combining the message and audience with an activity (e.g. inviting adolescents to a clinic open house) is the ultimate in strategic communication and requires a lot of planning on all levels. If the decision is made to engage in such an activity, consider the following criteria. Does the activity— • Contribute to the organization’s mission or strategic goals? • Provide ways to communicate your message using a variety of vehicles? • Increase visibility and contribute to a more positive image? • Demonstrate to the audience the organization’s unique niche? • Involve employees as ambassadors to the customers and community? • Have high impact for the resources expended? • Involve stakeholders? Strategic Communication 65 Worksheet 6.1. Audience Analysis Tool—WHAT’S IN IT FOR ME? Put yourself inside the head of your audience. Why is the issue you want to communicate important to them? How will the information you convey help them? How might a change in their behavior benefit them? Complete this exercise for each of your potential audiences. Issue (e.g. Increase support for family planning services): ___________________________________ Audience Why is this issue important to them? e.g. parents Healthier families, family resources not spread over many children e.g. policy makers Cost of providing public services (water, trash collection, health, education) increases with large population growth 66 Sustaining the Benefits Worksheet 6.2. Audience Analysis Tool—LIKELY RESPONSIVENESS It is vital that you know your audience’s interests and concerns. It is also helpful to know something about the way in which they are likely to respond to any communication strategy. Consider the following characteristics and rate your audience using a scale of (1) Low to (5) High. Specify which particular audience you are addressing. Characteristic Rating (1 to 5) Level of awareness of your organization Level of knowledge of your organization Level of awareness and knowledge of the issue Level of prior communication they have had from your organization Level of willingness to listen based on past experiences Level of receptivity to messages Strategic Communication 67 Worksheet 6.3. Audience Analysis Tool—TRUST AND AGREEMENT GRID There are two features of the relationship that you have with your audience that have an important effect on the impact of any communication strategy you devise. They are trust and agreement. Agreement is the degree to which the audience is in agreement with your goals, plans, vision, mission, strategies, and cause. Trust is the degree to which the audience perceives your organization to be credible, predictable, and reliable. FOR ANY GIVEN ISSUE—and this should be done on an issue-by-issue basis—rate your audiences from low to high on both the “trust” and “agreement” dimensions. The following grid will show in which of five categories they can be placed: ally, opponent, bedfellow, fence sitter, and adversary. Someone, for example, who trusts your organization but is not in agreement with you on this particular issue, is an “opponent.” A “concurrer” is someone who, on the other hand, doesn’t trust your organization though s/he happens to agree with you on this issue. A goal of good communication is to convert as many people as possible into “allies” by increasing the level of trust and agreement. Sharing information to encourage agreement and ensuring that statements are followed by actions to foster trust are good strategies. Strategic Influencing TRUSTLow High A G R EE M EN T Lo w H ig h Concurrers Agree with your ideas. Low degree of trust between you. Unpredictable whether they will support you. Allies Agree with your ideas. You trust them and they trust you. Likely to be your most enthusiastic supporters. Adversaries Don’t agree with your idea. You don’t trust them and they don’t trust you. Negotiations of trust and agreement have not worked. Opponents Disagree with your ideas. You trust them and they trust you. You are “critical supporters.” Fence sitters Unclear whether they agree. You don’t trust them, don’t know if they trust you. Never firmly for or against. Interest is self- protection. 68 Sustaining the Benefits References Alies, Roger, You Are the Message, (Currency/Doubleday, 1995). Berg, Andy and Gilman, Karen, Get to the Point: How to Say What You Mean and Get What You Want, (Kendall/Hunt Publishing, 1995). Lukaszewski, James E, Influencing Public Attitudes, (Issue Action Publications, 1992). Section 4: Programmatic Aspects of Sustainability Programs are the hearts of organizations. They are how an organization achieves its mission. The other aspects of sustainability, while important, exist to support the provision of high-quality programs. The institution provides the structure to implement programs effectively and efficiently and finance provides and manages the required resources. The ability to provide high- quality services and products, that respond to clients’ needs and to promote community ownership of the program, are critical to sustaining both the benefits and the organization. This section explores how to improve the quality of programs, use marketing to understand needs and tailor and promote services, and facilitate community participation and, in some cases, eventual ownership. These three elements enable organizations to provide services and products that are valued by clients, the community, and donors. Valued services contribute to achieving the mission and meeting financial objectives, leading to sustainability. Community Participation and Ownership (Chapter 7) explains how to mobilize community resources to support and eventually sustain programs. Organizations that build community capacity to plan, implement, and monitor programs have a solid foundation for continuing benefits. If done well, organizations can phase out of a community knowing that the program will be sustained. Improving Quality (Chapter 8) includes technical and client perspective elements. It is a continual process built around a quality improvement cycle. There are a number of quality tools that can be used at the various stages of the cycle to identify and analyze problems, develop and implement solutions, and monitor results to ensure that quality has improved. Marketing (Chapter 9) is a tool for understanding current and perspective client needs and translating them into valued services and products. It goes beyond advertising and promotion to underlie program development and implementation. By addressing the market mix of product, price, place, and promotion, organizations can effectively address client and community needs. By the end of Chapter 7, Community Participation and Ownership, you will be able to— • Explain participation and ownership concepts and draw their vital link to sustainability of program benefits • Describe best practices for facilitating dynamic community participation and creating ownership (asset-based community development, positive deviance approach) • Identify different steps in the process of creating sustainable community efforts and structures to maintain program benefits • Assess the level of community participation and ownership 70 Sustaining the Benefits By the end of Chapter 8, Improving Quality, you will be able to— • Describe what quality means and how it relates to sustainability • Explain the quality cycle and the activities associated with each stage of the cycle • Identify some tools to help you collect and analyze quality data By the end of Chapter 9, Marketing, you will be able to— • Explain the relationship between marketing and sustainability • Identify the key elements in a marketing mix • Describe the steps involved in marketing Section 4: Programmatic Aspects of Sustainability 71 Table of Contents Section 4: Programmatic Aspects of Sustainability Chapter 7 Community Participation and Ownership. 73 Community Participation and Sustainability. 73 The Levels of Community Participation . 74 Best Practices for Facilitating and Creating Community Participation and Ownership . 75 Chapter 8 Improving Quality. 87 Quality and Why it Is Important. 87 Approaches to Working on Quality Issues. 89 Tools for Improving Quality . 90 Chapter 9 Marketing. 99 Marketing and Its Contribution to Sustainability. 99 The Four “Ps”. 100 How to “Do” Marketing. 101 Community Participation and Ownership 73 Chapter 7 Community Participation and Ownership “Go to the people. Live among them. Learn from them. Start from where they are. Work with them. Build on what they have. But of the best leaders, when the task is accomplished, the work completed, the people all remark: ‘We have done it ourselves’.” —LAO TSU Community Participation and Sustainability As discussed in Chapter 2, Pillars of Sustainability, the transformation towards sustainability requires a shift in roles between the donor, the NGO, and the community. With growing sustainability the community moves from a passive recipient having no say in programs to a client who directly contributes to programs—in particular those programs and services that they value. This requires that the NGO truly understands community needs, builds on community assets, and provides programs that address identified needs. As the community’s capacity grows, it may eventually own and manage the program, drawing on outside resources only for expansion and improvement. When the community reaches this point, the NGO is free to move to another community, assured that the program benefits will be sustained. By actively engaging the community, you can build their self-esteem, their knowledge, and their skills. They in turn help you to achieve your mission by ensuring that your programs respond to 74 Sustaining the Benefits priority needs and by providing the local resources required for running them. This ability to marshal community resources, exchanging valued programs for community support, underlies all NGOs’ efforts for independence from donors and the sustainability of benefits. The Levels of Community Participation Community participation can be viewed along a continuum. At one end is a welfare-oriented approach in which the community receives prescribed benefits. At the far end, the community ultimately owns and manages the programs and benefits. To enhance the long-term impact and sustainability of programs, you must foster a higher level of participation, working with your communities to move up the continuum. The first level of participation is appropriate to meet immediate, short-term needs of the community, for example earthquake or famine relief efforts. There is a lot of good work done at this level, but research has shown that it does not empower communities to act on their own nor will it likely lead to sustained benefits. In the next level the NGO consults the community and receives feedback on program ideas. This is an important step in community involvement and is a necessary prerequisite in the higher levels of participation as well. Listening and even incorporating feedback, though, does not promote the level of learning and community empowerment necessary for sustainability. This learning begins in the third level. Here the NGO works with the community to generate and analyze information, define priorities, and identify strategies. Through this process, the community learns new knowledge and skills and understands the rationale for the changes they must make. They value the benefits because they address needs the community identified. The NGO is continually building the capacity of the community as it promotes their participation. Once the community understands the value of the service and has the expertise to manage the program, the final level of participation is achieved. Moving along the continuum is not any easy task for a number of reasons. It is a time-consuming process, and many NGOs are working within short project periods. It also is more difficult to control as the NGO must let the community learn and make decisions, which are not always predictable. The community may not identify the NGO’s core program as a priority need. Even so, the benefits of greater participation—responsive programs that the community values and contributes toward—reward those NGOs that find their way around the challenges. Level 1: Identification of community needs, program design and definitions of success all come externally from the community. The community receives benefits but contributes nothing. Level 2: The community is sensitized to the issues the planned program will address. There is an exchange of information between the community and the NGO. Community members may volunteer time to raise awareness of the importance of the program. Level 3: The community is actively involved in identifying priorities and designing programs. They provide financial and other resources in exchange for valued services. Level 4: The community runs the program, drawing upon external financial and technical assistance as required. Community Participation and Ownership 75 Best Practices for Facilitating and Creating Community Participation and Ownership Asset-Based Community Development6 One approach to fostering community participation and ownership is called asset-based community development. This strategy, developed from work done in “devastated communities” in the United States, has been successfully applied in many countries—Northern and Southern— since then. The asset-based strategy begins by valuing what works in the community rather than focusing on its problems. This appreciative approach breaks the problem-solving cycle, where community members view their community and often themselves as a problem that can only be solved by outsiders. By emphasizing problems, NGOs place communities in a recipient role. By instead building on the existing assets in a community, the community members feel empowered and able to address their issues. There are five steps to asset-based community development— 1. Mapping Assets Instead of entering your community and listing all of its problems, you begin by mapping out its assets. There are several levels of assets that you need to explore. The first is individual assets. What skills, expertise, experience, and abilities do individual members of the community bring? How can these strengths be used to address community problems? Besides individuals themselves, family members, and neighbors are sources of information on individual assets. At this juncture, you may want to identify positive deviants— those individuals or families from within the community who despite being poor exhibit positive behaviors or outcomes (e.g. family planning acceptors) well-nourished children, parents who do not practice female genital cutting (see next sub-section for details on positive deviance.) Next are community-based groups such as trade associations, religious groups, self-help groups, health committees, cooperatives, youth groups, and cultural gatherings. Make an inventory of all the groups located in the community—both formal and informal. You can begin by asking community members about the groups to which they belong and then share that list with those associations and add any missing groups and activities. Once you have a comprehensive list of the groups in your community, identify the key activities of each. Be sure to include both formal and informal activities. For example, a church group for women may meet regularly for fellowship and prayer and also provide social services to church members such as help with household chores if someone falls ill. You can also use a mapping exercise such as those used in participatory rural appraisal or other participatory data collection approaches. Local institutions form the final level. These include schools, private clinics, other NGOs, public-sector health facilities, private health providers, medical shops/pharmacies, and private 6 Material in this section was drawn from Kretzmann, John P., and McKnight, John L., Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets. (Chicago: ACTA Publications, 1993). 76 Sustaining the Benefits businesses and shops. These organizations may be more or less engaged in community activities, but they each have assets that help their communities address problems. The process of discovering these institutions is similar to the one you followed for community-based groups. The assets of your local organizations go beyond the activities they undertake. Some assets may include facilities, equipment, stocks of commodities and supplies, staff expertise, financial capacity, and connections with outside decision makers. Once you have completed your mapping exercise with the community, you need to share the results with them. This is a powerful moment, when the community discovers all the strengths that exist within its individuals, local groups, and institutions. The community realizes that by drawing on its assets it can address its priority needs. However, this exercise should not be a one- time activity. As you and your community work together, the community will continue to develop its assets. With each new challenge, the response should be what community assets will help us to overcome this challenge. 2. Building Relationships Now that you have collected information on all the resources available within the community, you need to begin linking those resources together to address the community-identified priorities. Explore possible ways to begin connecting the community assets together. How might the community draw on the gifts that various community members bring? Could the skills of individuals strengthen the work of local associations? Are there under-utilized assets or unrecognized groups, such as youth, that can contribute to the program? What different roles might the current associations and groups take in the community? How might they be connected to local institutions and individuals to magnify their potential? As the community begins to see the possible links, its true potential becomes much clearer. 3. Mobilizing for Information Sharing Information exchange is critical to moving along the participation continuum. It is not only important to share the results of the mapping exercises; there must also be an ongoing mechanism to share information between individuals, local groups, and community institutions. To facilitate this, build on existing communication patterns. Where does the community currently have its public conversations? Is it at the village well? At an intersection? A barber shop? Build on these existing communication channels and work with the community to exchange information on their hopes, plans, priorities, and skills. Share examples of success stories, best practices, and technical knowledge from other communities to create well-informed community members. This will help with the next step, planning, and will be critical to the success of those plans. 4. Developing a Vision and Plan As the community better understands what strengths exist within it, it is better positioned to become actively involved in planning for the future. First, there is a sense that there is something valuable in the community that is worth preserving. Second, community members begin to believe that they each have something to contribute. It is from this base that planning can begin. Knowing the range of assets also helps to determine who should be involved in the planning. You should ensure that representatives of community assets are part of the planning. If you have broad representation, you will have more resources to draw on during the planning. And any plan Community Participation and Ownership 77 they develop is more likely to appeal to a larger section of the community. Finally, keep the planning realistic. Aim for small activities that will show immediate results. If the community sees that it can make positive changes, it will be energized to continue contributing. This will eventually lead to sustained benefits. Pulling it Together: An Example Assets: Many women have developed health care skills from caring for their family members; local clinic has skilled nursing staff and educational materials; a number of local associations provide general support to members. Priority need: A number of people are infected with HIV/AIDS and their families and community clinic are not able to provide all their care needs. Linking assets: The individual women could join together. The nurse from the clinic could provide them with more information on nutrition and infection prevention. These women could provide home care, rotating various aspects of care among the group. Other community associations could support the women by working their gardens when they are busy providing care. As more and more of such relationships are built and their success demonstrated, the community will have more confidence to take on other priorities and manage programs themselves. 5. Leveraging Community-Based and Outside Resources to Support the Community’s Efforts When the community knows its strengths, understands how the different assets might work together to solve problems, shares information, and begins to plan and implement strategies to address priorities, it is ready to take full ownership and management of the program. They are now ready to use their assets to reduce costs, recover costs, generate revenue, network, and create linkages. Before exiting, however, you must ensure that the community is able to attract the required outside resources—to address new problems or expand current efforts. This means transferring the skills described in Chapter 13. 78 Sustaining the Benefits Positive Deviance Approach to Sustainable Development7 Another approach that promotes community participation and ownership and ensures sustainability of program benefits is the positive deviance (PD) approach. Save the Children USA has used this approach extensively and describes PD and its uniqueness as follows. “Positive deviance is a development approach based on the premise that solutions to community problems already exist within the community. The positive deviance approach thus differs from traditional ‘needs-based or problem solving approaches’ in that it does not focus primarily on identification of needs and the external inputs necessary to meet those needs or solve problems. Instead, it seeks to identify and optimize existing resources and solutions within the community to solve community problems. Through a positive deviance inquiry (PDI) program staff and their community partners identify the unique practices of some community members that set them apart from others within the same community and allow them to cope more successfully within the same resource base. Based on identification of these successful practices, program staff and their community partners develop strategies to enable all members of the community not only to learn about these practices, but also act upon them.” —M. STERIN, J. STERIN AND D. MARSH, 1998 7 Adapted from Sterin, M., Sterin, J. and Marsh, D., Designing a Community-based Nutrition Program Using the Hearth Model and the Positive Deviance Approach—A Field Guide, (Save the Children, 1998). Community Participation and Ownership 79 The cornerstone of the PD approach is in fact community participation and ownership and finding realistic solutions from within the community. Save the Children (Save) utilized the PD approach to reduce childhood malnutrition in Vietnam, and a sustainability plan was built into the program. From the onset of their work in a community, they informed the community that Save would work in partnership with the community for a two-year period and develop the skills of the community to independently implement the required interventions. After that period, Save would move on to other communities. Save describes how they integrated sustainability and community participation. “The program sustainability is ensured by the identification of solutions to nutritional problems based on existing resources accessible to all community members. Involvement of local community leaders, and local women volunteers, also reinforces the sustainability of impact of the program.” “The Save the Children’s Hearth program in Vietnam encouraged full community participation in assessing local resources and in designing and taking part in the program. All relevant groups in the community gained full ownership of the program through the following processes. • Mobilization to carry out household registrations and growth monitoring and promotion sessions • Identification of practices which affect positively or negatively the nutritional wellbeing of their children • Discovery of community-based solutions through the PD identification • Elaboration of community-based strategies to solve community-based problems • Involvement in the program as volunteers, parents of malnourished children, or village health community members” This approach resulted in the reduction of second and third degree malnutrition by 80 percent among children less than three years old. These benefits continued as long as two years beyond Save’s participation, and the younger siblings of the children enrolled in the program continue to benefit. The positive deviance approach follows what are known as the six “Ds.” The Six Ds of the Positive Deviance Approach Define What is the problem? What are the perceived causes and related community behavioral norms? What would a successful solution/outcome look like (described as a behavioral or status outcome)? Determine Are there any individuals/entities in the “community” who ALREADY exhibit desired behavior or status (PD identification)? 80 Sustaining the Benefits Discover What are the unique practices/behaviors that enable PDs to outperform/find better solutions to problems than others in their “community?” Design Design and implement intervention that enables others in “community” to access and PRACTICE new behaviors (focus on “doing” rather than transfer of knowledge). Discern What is the effectiveness of the intervention (determined by ongoing monitoring and evaluation)? Disseminate Make intervention accessible to wider constituency (replication/scaling up). Steps in the Process of Creating Sustainable Community Efforts Local ownership through a process of developing a sustainable community effort is key to sustaining program benefits. Based on elements of self-help, autonomy, and independence, community mechanisms respond to a challenge or an opportunity for improving the quality of life of people in any of the development sectors of health, education, livelihoods, and environmental protection. Effective community ownership is more than just stakeholders’ participation and partnership building. It requires the development of an ongoing governance structure for sustaining community efforts for continuing need-based program activities that people value. Communities develop initiatives to sustain program benefits in many different ways. To illustrate this process, a sample of the most commonly used steps is as follows— 1. Evolving a Structure for Ongoing Governance Often any effort at participation by a community is the result of a few enthusiastic individuals or a small group of persons who help motivate others to join in this process. To begin with, the structure functions in a loose manner, hinging on a core group of volunteers who operate like a committee with intensive encouragement and support from an external agency. The transition to a more sustainable community effort that could take over the need for ongoing governance would depend on the level of readiness among people in the community to work in a democratic manner, meet regularly to take decisions and be open and accountable to the public at large. 2. Creating a Community Vision for Sustaining Program Benefits A common preliminary step in creating community ownership is that the determined need of the people is being met to their satisfaction through a program mechanism/response. There exists a demand in the community to avail services on an ongoing basis, for example family planning supplies, ANC check-ups for pregnant women, Tetanus Toxoid, iron supplementation, and immunization. In this step a wide range of potential beneficiaries and other stakeholders in the community would be approached to answer the question “What is to be sustained?” or “What service/benefit does the community consider to be of value?” and is willing to exchange with something of value that they possess—their own money, time, or effort. Community Participation and Ownership 81 This process frequently includes a series of focus group discussions, public meetings, consultations, and consensus building to create a shared community vision for sustainability. As a result of this process, communities can create their own unique definitions of what they wish to sustain and how. 3. Developing Guiding Principles for Sustainability Values, beliefs, and assumptions are important drivers in the kind of choices people make when it comes to determining what needs to be sustained and how. To help in the process of determining acceptable and unacceptable choices, some communities develop guiding principles for sustainability. Examples of such are: ensure financial viability through cost reduction and use of local resources; equalize benefits and burdens; pay for services at doorsteps; walk for free supplies from designated depots; draft criteria for providing free services; and determine the extent of subsidization for serving the poor. 4. Setting Goals and Objectives The group defines the goals and objectives and estimates the resource requirements for sustaining agreed levels of program benefits. This too is an inclusive process in which different stakeholders deliberate to reach some consensus. 5. Choosing and Implementing Activities Committees, subcommittees, and task forces are often used to generate ideas and take decisions. What resources could be mobilized internally? What support would be necessary from outside? Where could we network? Where could costs be cut? Community-based organizations (CBOs) require assistance in establishing criteria for choosing appropriate activities that do not compromise legal, ethical, or technical principles and guidelines and enable them to weigh the costs and benefits of an activity. Case Study: Legal, Ethical, and Technical Considerations for CBOs in Choosing Activities A CBO proposed setting up ultrasound services in its community clinic to bring in revenue. However, the country was experiencing a significant decline in sex ratios that had been linked to the use of ultrasound services for sex determination, resulting in sex-selective abortions. The government was cracking down on misuse of ultrasound equipment, and development organizations were actively advocating measures to curtail this misuse. Therefore, the financial objectives of the CBO had to be balanced against accomplishing the intent of the program, which was to improve reproductive and child health. The proposal to establish ultrasound services was clearly in conflict with the goals and technical guidelines of the program, could result in legal difficulties, was ethically questionable and thus was rejected as an option. 6. Evaluating Progress and Revising Activities Communities need to periodically review their progress and revise activities. The move towards sustainability is an evolutionary process and there are no cut and dried solutions. When communities are engaged in a process of measuring the effectiveness of their activities, the process ensures consolidation of the successes and a deeper awareness of lessons learned in the process of difficulties or failures. 82 Sustaining the Benefits Not all sustainability processes happen in the same way. Each community, depending on its situation, has a unique pathway in its journey towards sustaining community efforts to sustain program benefits. These process steps constitute a broad generalization of some of the most common elements from the experiences of communities that have managed successful transitions towards sustainable community efforts. Creating Effective CBOs One fairly common approach to ensure long-term community participation and ownership is through the formation of CBOs. CBOs are informal or formal groups comprised of democratically elected community representatives who have the credibility, skill, time, and commitment to work for the betterment of the community or to address a specific community issue or opportunity. CBOs begin to work effectively only after a process of group development, consensus building, and team building, leading to a shared vision for sustainability. This requires considerable capacity building and support so that CBOs acquire the requisite skills they need to manage a certain level of program effort to sustain benefits. Thus it is necessary to initiate strategies for community participation and create ownership at an early stage of program implementation. When CBOs are involved from the outset, as the program matures by way of increased demand and greater utilization of services, they concurrently mature and increasingly take over responsibility and control in leading and managing the program. The Community Aid and Sponsorship Program (CASP) in Delhi, India offers an example of the process necessary to form effective CBOs— • CASP organized cluster meetings to explain the rationale for forming CBOs and their link with CASP and the community • The community elected one representative for every 400 family clusters. The criteria were literacy, influence, free time, and enthusiasm • CASP held a joint meeting of 15-20 cluster representatives to form one CBO and create a shared purpose and identity • Elected representatives were trained on CBO Formation and Functioning of Cooperatives (benefits of cooperative effort, basic norms for success of cooperative efforts, process of democratic working) and sustainability • CASP worked closely with the CBOs to help clarify roles, set up a system for regular elections and election procedures to ensure rotation of leadership, establish by-laws, develop and implement protocols for holding effective meetings, decision making, and recording minutes • The CBO made a resolution to charge fees for clinic services as a way of generating revenue and opened a bank account to manage these funds • The CBO members organized themselves into subcommittees and established duty rosters to accomplish different tasks (e.g. clinic management, ambulance management, community mobilization, and IEC) Community Participation and Ownership 83 • The CASP field and professional staff maintained contact with the CBO for encouragement, support, problem-solving, and the management of group dynamics • CASP and the CBOs established a mechanism for monitoring financial transactions and guidelines for purchasing, procuring, and storing commodities • The CBO applied for and obtained a registration as a legal entity Assessing Levels of Community Participation and Ownership As programs mature, it is important to assess progress towards community participation and ownership. Levels of community participation and ownership can be measured through quantitative and qualitative methods. Below are two tools that may assist you in determining your program’s current level and determine what needs to be done to move to the next level of community participation and ownership. Tool 1: Quantitative Analysis of Community Participation and Ownership Involvement of Clients/ Community Members in Never Occasionally Frequently Most of the Time Always Score 0 1 2 3 4 Implementing program interventions Program administration Needs assessment Program planning Taking leadership roles in programs Resource mobilization for program Monitoring or evaluation of the program Decision making about policies and changes in the program Score Levels of Community Participation and Ownership 0-6 Low 7-13 Some 14-20 Average 21-27 Good 28-32 Excellent 84 Sustaining the Benefits Tool 2: Qualitative Analysis of Community Participation Focus group discussion guidelines for clients, community members, or CBO members— • How much does the community know about the program? • How much do they know about the organization implementing the program? • How often do they come face to face with program personnel? • What responsibilities does the community carry out on behalf of the program? • What kind of difficulties do they find in undertaking these responsibilities? • How satisfied are they with their involvement in the program and why? • Do they have any suggestions to improve their participation in the program? • Are all sections of the community equally involved in the program? • Is there a differential advantage to some group? Why does it happen and who gets the preferential advantage? Community Participation and Ownership 85 Increasing Community Contribution and Participation Through Community-Based Organizations: The Example of CASP in Urban Slums of Delhi, India At the end of its Child Survival Project, CASP needed to hand over responsibilities and management for reproductive and child health activities. A feasibility study that investigated sustainability options suggested the community come up with a structure for an organized body with democratically elected members. The CASP project staff shared the results of a feasibility study with the community and the community health guides. The result was the formation of Community-Based Health Management Organizations (CBHMOs) comprised of 16-18 members from among Community Health Guides and members of existing community-based organizations. CEDPA provided the members with an orientation to sustainability and trained them in various aspects of organizational management. CASP assisted the CBHMO to— • Prepare by-laws • Open a bank account • Form sub-committees for various tasks (e.g. clinic management, operating the ambulance, and social marketing) • Network with the private sector, private voluntary organizations (PVOs), and governmental organizations to generate revenue, provide services, and update skills • Shift costs from project to community by introducing fees for services, social marketing of health commodities, and implementing revenue generation activities • Manage services, including ensuring continuous quality improvement of services at clinics, the collection and management of clinic and laboratory earnings, and procurement, storage, and sales of social marketing stocks As a result of the community taking over management of the clinic and ambulance, the ambulance service, which was no longer functioning after the child survival project ended, was revived. Costs for maintenance and operations were reduced by 60 percent from Rs. 10,000 to Rs. 4,000 per month and ambulance cost recovery increased from 14.3 percent to 34.9 percent between April 2000 and January 2002. In addition, the CBHMO recovered 70 percent of the laboratory service fees in 2002, compared with 10 percent in 2000. With experience, time, and technical assistance, the CBHMOs are gradually on their way to taking complete responsibility of the management of the health services in their respective units. Source: CEDPA, Building Sustainable Reproductive and Child Health Services, (New Delhi: CASP and CEDPA, 2002). 86 Sustaining the Benefits References CEDPA, Building Sustainable Reproductive and Child Health Services, (New Delhi: CASP and CEDPA, 2002). For additional information on CASP’s work visit their website: Kretzmann, John P. and McKnight, John L., Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets, (ACTA Publications: Chicago, IL, 1993). Sterin, M., Sterin, J. and Marsh, D., Designing a Community-based Nutrition Program Using the Hearth Model and the Positive Deviance Approach—A Field Guide, (Save the Children, December 1998). Improving Quality 87 Chapter 8 Improving Quality Quality and Why it Is Important There are many different definitions of quality. Most of them focus on performing to some standard or defined level of acceptability. For reproductive health, the Ministry of Health or an international organization such as the World Health Organization (WHO) typically sets these standards. By following these standards an organization is understood to be providing technical quality. In community-based programs there is another dimension of quality, called perceived quality. This acknowledges that clients may be concerned about other dimensions to quality not normally captured in technical definitions, such as the responsiveness of the health worker, privacy, and convenience. Both perceived and technical quality are reflected in the Box 8.1 definitions. Box 8.1 Some Definitions of Quality “Service delivery, according to accepted protocols/standards via monitoring of (1) provider performance and/or (2) support systems, i.e. training, supervision, logistics, information.” —USAID’S DEFINITION OF QUALITY OF CARE “…conformance to requirements or specifications.” —PHIL CROSBY, 1979 “…proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question, and have the ability to produce an impact on mortality, morbidity, disability, and malnutrition.” —M.I. ROEMER AND C. MONTOYA AGUILAR, WHO, 1988 “Doing the right thing the first time. Doing it better the next time.” —ODI CONSULTING “…meeting/exceeding needs of customers.” —JURAN INSTITUTE, INC. “…that which meets the customer’s expectations. Quality isn’t asserted by the supplier; it’s perceived by the customer.” —GUASPARI 88 Sustaining the Benefits A quality orientation is one of the four pillars of sustainability. It lies at the heart of exchanging value for value. People do not value low-quality products and services and will not use them even when they are free, preferring instead to turn to the commercial sector, where they feel assured of product and service quality. Providing high-quality services helps achieve the impact you desire. It is also important for meeting financial objectives. Studies have shown that clients are willing to pay for those products and services that they believe are high quality. Donors also fund programs that they believe are high quality because they anticipate they will have greater impact. Box 8.2 An Example of an NGO Addressing Quality Issues The Houghton Park Private Clinic in Harare provides an example of the linkages between quality and sustainability. Four months after beginning to keep service statistics, the staff noted a decline in the number of family planning clients. They also had received six letters complaining about the rising cost of birth control pills. The clinic’s quality team designed a questionnaire and distributed 150 copies to clients attending the clinic and homeowners in the area. From the 110 returned questionnaires they learned that, while clients were happy with the clinic’s services, they preferred to buy pills in the public sector where they cost less. Staff did some research on the “real” cost of the public sector services and wrote the following letter. Dear Valuable Client, Houghton Park Clinic wants you back. …Pills are only Zim$15 per packet. This may sound expensive, but if you buy pills elsewhere…you need to catch a lift, imagine the stress of waiting, the queue at the public clinic. By the end of the day, you will have paid Zim $20 and [experienced] four hours of stress. You could save this by walking to Houghton Park where you get served coffee, tea, or a cold drink while you wait. Or watch the 6 o’clock news on our TV. Time spent is less, amount paid is only $15. The strategy worked. Clients came back and attendance returned to previous levels and grew from there. Source: Mainstreaming Quality Improvement, Family Planning Service Expansion and Technical Support (SEATS II) Project, January 2000. Improving Quality 89 Approaches to Working on Quality Issues Four approaches to tackling issues of quality are described in Box 8.3. Box 8.3 Approaches to Quality Improvement • Continuous Quality Improvement (CQI): quality (measured in terms of client satisfaction) is improved through a problem-solving cycle that focuses on systems and processes. • Client-Oriented, Provider-Efficient Services (COPE): a practical set of tools for improving the quality of family planning services at a clinic or hospital. • Performance Improvement: a step-by-step method to analyze performance problems and set up a system to ensure good performance. • Quality Assurance: in which standards are set and performance monitored and improved so that the care provided is as effective and as safe as possible. They all share some common elements. They— • Focus on the process, not the provider, they recognize that people work in systems and if something is not done well it is best to look first at the system rather than the individuals involved • Are data based, data driven, using tools to assess, analyze, plan, and monitor quality • Are team-based and require input from many levels • Focus on the client or customer And they all follow a cycle or are continuous. They may use different terms for the steps in the cycle but generally cover the same activities: identifying quality successes and issues, analyzing them (root causes, contributing factors), developing and implementing improvements, and monitoring results. If the results indicate that an improvement has been effective in addressing the selected quality issue, another area would be identified on which to work and the cycle would start over. If not, a new approach to the issue would be developed and the cycle continued from there. One of the clearer cycles is FADE (Focus, Analyze, Develop, Execute), used by Federal Express to improve the quality of its services (outlined below). If you do not already know and feel comfortable with another quality analysis cycle, you might like to use this one. “Focus” is the first phase in the quality improvement cycle. In this phase you develop a written statement of the problem by— • Generating a list of quality issues • Selecting one issue • Verifying and defining the issue 90 Sustaining the Benefits “Analyze” is the second phase of the cycle. In this phase you examine your issue using data and— • Decide what you need to know • Collect baseline data and questions • Determine influential factors “Develop” is the third phase in the cycle. In this phase you start developing solutions for the issue identified by— • Generating promising solutions • Selecting a solution • Developing an implementation plan “Execute” is the final phase in the cycle. In this phase you implement your solutions by— • Gaining commitment for your implementation plan • Executing the plan • Monitoring impact Tools for Improving Quality To implement a cycle of quality improvement, such as FADE, involves a rather daunting number of steps. Most of them, fortunately, are not very difficult, and many are possible to do satisfactorily in a number of different ways. We have selected and described below a few tools that can be used to implement some of those steps. Identifying Quality Issues and Possible Solutions When identifying issues one of the first places to begin are your program records. Routine record reviews would highlight potential problems such as changes in utilization or the profile of clients. These changes may or may not be related to quality, but as your records are an easily available source of data they are a good place to start. Another very useful strategy for identifying issues and possible solutions is to TALK with those involved in the service. Client interviews, community focus groups, provider interviews, and brainstorming with colleagues are all very useful techniques for generating lists of quality successes, issues, and possible improvements as well as some sense of relative importance. If you are following the FADE approach you may wish to do interviews in two stages—the first to concentrate on identifying successes and issues, the second to tease out some detailed possible improvements once the priority areas have been identified. It is always useful to at least touch on the question of possible solutions in the first round, since the feasibility of a solution is very likely to influence the choice of priority areas to focus on. Improving Quality 91 If the interviews are conducted both before and after initiatives are taken to improve quality then they can also serve as a method for monitoring progress. With all interviews it is important to have good records of any relevant characteristics of interviewees (e.g. age, sex, education, and marital status of clients or community members; qualifications, experience, and age of providers). Interviews can be used in two ways— The first is by collecting information that directly measures the quality of the service or related indicators or causes of quality. • Client interviews provide the opportunity to assess the quality of the service by looking for the kind of outcomes one would expect to find in clients if the service were a good one: what level of knowledge and what attitudes do clients have concerning the health issues and the NGO’s services, what access do they have to the services and how appropriate is their use of the services? • Community focus groups provide an opportunity to generate some useful indicators of the overall quality of the services (e.g. what proportion of the community are users of the service) as well as addressing community-related issues such as the overall involvement of the community in the NGO’s initiatives, the level of support from community leaders, and the degree of community approval for what is taking place. • Provider interviews are an opportunity for assessing the competence of staff delivering direct services, their level of information and understanding, and their attitudes and the circumstances in which they work. This can then be compared with available standards and protocols. Interviews are not the most reliable method for assessing behavior, and it may be desirable (though it will usually be more effort) to supplement interviews with direct observation of reported behavior. This is usually difficult to do outside the clinic setting but is perfectly possible within the clinic. Both specific provider-client contacts and general clinic procedures can usefully be observed directly to identify strengths and weaknesses and pinpoint obstacles. The second use of interviews is to directly ask the opinion of the interviewee about the problems of quality in the service and possible solutions they might perceive. • Clients, who after all have an intimate experience of the service, may have very clear ideas about what is or is not working well and how important those factors are to them. Issues that are important to the client must be important to the organization as well, whether or not they correspond to any technical definition of quality. They are likely to be crucial factors in determining the use of the service. • The community’s views are equally important but for a rather different reason— information can be gathered from individuals who are not necessarily users of the service. These may be the very individuals who are particularly sensitive to quality issues (which keeps them away from the service) and that perspective can be a very useful one to tap. 92 Sustaining the Benefits • Providers deal on a daily basis with technical shortcomings. Brainstorming with colleagues is a very useful way to generate a list of quality issues. Determining the Influential Factors Some tools primarily used to guide users when attacking an identified problem

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