One more presentation on sustainability - at the ExpandNet (Scale Up) Community of Practice

Evidence to Action Video of the Dec 5th, 2018 presentation: Can we be serious about sustainability in the SDG era?

Attention - big reveal on the ties between sustainability and scale!!

Reposting - Scale 0 for change in health systems through social accountability

To be honest, the main reason I am reposting this blog that Karen Waltensperger and I wrote for the Frontline Health Worker Coalition is that I keep referring to it and not finding the link. But this allows me to illustrate one important point on social accountability.

Jonathan Fox (AU/ARC) speaks of 'vertical integration' of social accountability (link available on the original blog), not 'at scale', but 'at different scales.' This is a very important concept, and we're trying to address how these 'different scales' mean to the business of monitoring, evaluation, and learning through the CORE Systems for Health working group with our JHU colleagues. But it's important to understand what these different scales mean -- for example frontline services, districts, local government, national government, etc. It's not just that things get bigger "at scale", it's that -- as always -- 'more is different', aka the nature of the problem changes with the scale at which it is being tackled.

Think about it this way:

• Scale 1: you're working with primary health care facility and the users' community to engage in some dialogue, maybe use a scorecard, get some discussion and action points on improving quality, have first action steps, review, etc. You will have to deal with facilitation, potential conflict, sense making, data generation, mobilization (of community, of health workers), behavior change (of everyone around), quality improvement, and negotiating skills with different stakeholders.
• Scale 2: while you have similar motivations as at scale 1 (for example quality, equity, participation, empowerment, governance), you are now engaged in processes where the dialogues involve not a clinic in-charge and health committee leaders, but a district health officer and a local government representative. On the 'client' side, the work is lead or supported a local NGO leaders, or a coordination body for local CBOs or health committees. You will still have to deal with things addressed at Scale 1, facilitation, potential conflict, data, etc. But all these things will be very different qualitatively -- you'll need different facilitation skills, different rapport to power, etc. You'll be treading on very different waters; both mistakes and success will have very different consequences at Scale 2 than at Scale 1. It's not just 'more scale'; it's 'different scale'.

So, this blog from last year illustrates what happens at Scale 0 so to speak:why and how does a health leader in the broadest definition (health worker, clinic-in charge, officer, pharmacist, supervisor) change behavior leading to better health systems performance in the first place. As you move from Scale 0 (a person) to Scale 1 (a service structure), the boundary of your 'system' expands, and the number of relationships to take into account also expands. As the boundaries get bigger at Scale 2, the number of relationships will increase exponentially. At each level, it's largely about human behaviors -- but increasing scale = increasing complexity.

Research will need to continue taking us into the weeds, or stepping away to measure large effects.

Program evaluation and learning will need to zoom in on the most important parts to keep our eyes on, if we want to maintain some momentum.

In the meantime, here's a brainstorm about the weeds, 'inside the black box' of individual health leaders influenced by social accountability processes.

Eric

Social Accountability -- 2 short videos on a community scorecard for health services in Malawi

First a video featuring the excellent Helen Mwale (then with Save, and now with MSH) produced on the fly last year by the SC Malawi team, about the Community Scorecard approach -- Save the Children was one of the implementers of the USAID/SSDI project - in this case using the scorecard tool developed originally by CARE, and used globally by dozens of organizations.

[Of note: we had an interesting session at HSR2018 with Gail Snetro, Paula Valentine, and Allison Foster in Liverpool contrasting the scorecard and the Partnership Defined Quality approach. Both have critical elements, and my personal bet is that the methods might continue to converge. I also suspect that their differences actually provide a way to be more responsive to context, by allowing emphasis on different parts of a rich process. I'm also eager to hear about a full day session on social accountability, also at HSR2018, organized by Renee Loewenson.]

Enjoy this quick orientation video from Save the Children (2017):

And here's another (2013) CARE Malawi video, as part of the 'power to the people' series:

And here's a link to a series of presentations by speakers in a special session on Social Accountability held in 2017 at Save the Children's with the DC Health Systems Board. View videos.

The emergency-to-development continuum: left to right, or right to left?

As global health and international development professionals, our assumption is often that the continuum between emergency and development goes:

Emergency –> to –> Development,

left-to-right.

As global health and community health professionals, we have to or we tend to look at the situation as technicians, clinical technicians, social and behavior change technicians, health systems governance, and management technicians, leaving the questions of why fragility occurs to social change activists and advocates. We are now more often paying attention to public and private sector accountability to citizens, through the lens of the necessary governance and leadership of health systems, clearly delineated in a 'building block'. And we focus this attention on the need to ensure quality of services, the requirement that health systems be responsive to clients, so that utilization increases and our interventions reach scale. We trade very cautiously on these democracy and governance issues – actually, we generally like to focus on governance and say little about democracy. Our individual beliefs, motivations, and passions are still heavily humanitarian, socially-oriented, and democratic. But during office hours, we couch them in skilled technical language. After all, in terms of improving health outcomes, the best performing countries are not necessarily the most democratic ones.

Some of us at least, and certainly in polite company, enter the world as neutral technicians, even if we are passionate about democracy and global justice. And there’s a reason for it: our legitimacy and credibility stems from this neutral technicity; it allows us to come in, respond to human suffering, and act on the levers of health systems behaviors – including at community level – to redress the performance of health systems. We inherit a world full of emergencies, and now we are questioning how we can get better at moving along the continuum from left to right: Emergency – to – Development. That’s our job; that’s where we make a difference; and our activist, rambunctious, political self does well to leave the stage to the community health or health system professional that we are.

But what if the world was not going left to right, but more and more, in so many places, right to left:  development-back to-emergency, via a path of chaos?

Let’s consider examples related to both internal and external influences:

•        A country successfully moving on MDG and now SDG indicators, but creating substantial anti-democratic spaces: regional imbalance, presidency-for-life, ethnic blind spots if not repression, leading to an undercurrent of popular discontentment, one day resistance, uprising, violence, implosion of the national model…    
•       A relatively stable country with a functioning health system becomes a pile of rubble, sent back generations in its development due in large parts to foreign interventions and acts of wars, including by industrialized nations, who happen to also be well-meaning donors…
•       Global economic models come to prominence, with long ramifications and ripples in terms of the economic choices of nations, the potential corrupting factor of massive amounts of funds, displacement of social investments away from the poor, and increased national blind spots about the needs of the poor and vulnerable.
•       Unmitigated environmental destruction and global climate change hit large regions severely, leading to increased humanitarian crises, aggravated social, economic, and ethnic upheaval, increased numbers of refugees, and corollary decreased ODA funds for development.

If these are rare and unfortunate occurrences, then we are better off to leave this to the activists, peacemakers, and social justice advocates of the world. The world is still going left-to-right; our entry point into technical issues will allow us to play our role for progress, while ‘staying in our lane’.

But if these are trends and not exceptions, if more often than not such factors lead the world to go:

Emergency <– to <– Development,

right to left,...

...then our cautious neutrality may lead us to see a lot of our work undermined or even wrecked to ruins tomorrow. We will face constant degradation on a large scale, persistent and intractable emergencies, our left to right emergency-to-development continuum will revert to theory, overtaken by downward spirals and de-development. If this is the case, then our neutrality does not facilitate our work, but rather undermines the sustainability of any progress we achieve.

So, which is it? Left to right? Or right to left? And what does it mean for us?

The sustainment index - a new metric to inform ex post sustainability evaluations.

Greetings -

Reeti Hobson and I have recently published a paper in BMC Health Services Research proposing a measure of sustainment -- the sustainment index.

I'm an unlikely candidate for jumping on one quantitative indicator to solve complex questions, but this is -- as the title of the paper states -- a 'simple metric for a complex outcome'. It is free of causal inferences; it is simply a measure of how much an indicator improved from Time 0 to Time 1 continued to progress from Time 1 to Time 2 (presumably after a transition phase / end of a project). 

We call it the 'sustainment index' and the paper explains this choice of language. 

We've already made a strong case that empiricism about sustainability needs to move from 'is it sustainable?' -- binary, either reductive or existential -- to two types of questions:

1. Looking forward: what are the chances that progress will continue under new conditions (sustainability)?
2. Looking back: how much of initial progress has continued after transition and can we start to understand why and how (sustainment)?

The sustainment index is simply here to provide a reliable and valid measure to this "how much" question.

The story of its development links back to an unsuccessful attempt at an unsolicited proposal, where the concept of this metric was developed. It's really put out as a invitation to researchers to start testing the metric. If you've already collected baseline, endline, and post project service or outcomes' data, it's extremely easy to plot out the sustainment index. If you're designing an ex post study, consider its value as a dependent variable.

An interesting property of the index, which is not discussed in the paper, is that while the performance of a health indicator is affected by the initial conditions, baseline (i.e. improvements are harder to achieve when the baseline is higher), the sustainment index--since it tracks the evolution of the speed of progress -- does not seem affected in the same manner. The graph below (not in the paper) shows 3 trajectories from 3 different baseline points of a health indicator, with the same sustainment index.

If we've made some serious researchers out there curious... then our job is done.

All feedback - and study reports -  welcome.

Eric [esarriot AT savechildren DOT org]
Thanks to my former ICF/CEDARS home for getting this through completion, including Reeti Hobson, my co-author, and Jennifer Yourkavitch. Thanks to our reviewers.

Alma Ata Principles are turning 40

Johns Hopkins U and Future Health Systems have launched an anniversary event and movement on the theme of the 40th anniversary of Alma Ata, the enduring significance of its principles, and the challenges to its more comprehensive, some would say holistic, vision.

Visit the AlmaAta40 site and register to contribute.

Here is a 20 min interview of Dr Bishai that I carried out for our Save the Children team and the CORE Group.

Cheers all,

Eric

Abt and Save the Children event on Governance and Accountability for Strong Community Health Systems event

Governance and Accountability for Strong Community Health Systems

As we recognize the importance of community health systems in expanding access to care, especially to underserved populations, governance has become a key consideration towards realizing Universal Health Coverage. 

Abt Associates, Save the Children US, and UNICEF organized a panel discussion on the latest initiatives to improve governance for community health.

Some time stamps on this event

@10:15 – start - Bob Fryatt (Abt) intro, referencing the “institutionalizing community health conference” which took place in J’burg a year ago.

@12:50-30:45 Tim Evans (World Bank) – important comments on the need for decentralized self-organization [my words] in health systems, particularly community health systems management, the plurality of perspectives and visions and negotiations, and unintended factors affecting centralized planning to achieve universal health coverage, and the necessity of autonomy of local service delivery units.  Q&A after that.

@49:15 introduction of first panel – UNICEF (kindly acknowledging “whichever organization was involved in organizing this event"), Global Financing Facility, and USAID private sector innovations in HIV/AIDS care and treatment. I was particularly interested in the overview of the GFF and USAID’s Joe Tayag’s (@1:12) examples and discussion of needs-based approaches to specific key populations and their aspirations.

@1:41 Second panel with Carolyn Gomes (Caribbean Vulnerable Communities Association), Lisa Tarantino (Abt) and your servant (Save the Children). @1:42 - Carolyn made a powerful case for the role of community based organizations in HIV/AIDS and how the bottom up can lead to change upstream. @1:54 - Lisa provided 3 interesting examples in community health and health governance and health financing.  And if you want to see me in full effort, go to @2:05 and hear all about ‘Beyond the Building Blocks’.