Trying to advance sustainability in the planning, design, implementation and evaluation of health programs--community health programs, or health system strengthening interventions--is our meat and potato at CEDARS. Some regular conversation topics keep coming back. One of the most critical and reasonable one comes up when someone says: "I like these ideas; it makes sense, and it does or would make sense to our local partners. But really, that's not how we work. We have 30 to 60 days to write a proposal, then staff up and kickoff a project and get deliverables. When exactly would you introduce those ideas?"
I've had these discussions so many times, so let me try to summarize the three lines of rationale these will gravitate toward:
- [1] It is actually possible to bring the steps of the Sustainability Framework (SF) process into the life of a project, and it doesn't have to be done as a ritual, design-along-the-dotted line kind of a thing.
- [2] The SF doesn't suggest a set of steps because we somehow missed how projects were planned for, designed, awarded, and implemented.
There's a large body of evidence that the traditional way we end up running our projects has an inherent bias AGAINST sustainability (
this may provide a useful, albeit long, reminder).
The proposed steps of the SF are trying to
re-introduce in project designs some elements, which are
naturally neglected and which have shown to have a
major contribution to sustainability in multiple settings. We really did not invent anything, but having observed and learned from practitioners' best practices in the field, the SF is offered as a set of tools to attempt to intentionally force within our non-sustainable projects, some elements, which have a much better-than-average chance of improving the sustainability of health achievements in the communities where our projects place their heavy boots (rather Firestone or Dunlop 4x4 tires) on the ground.
- [3] The main issue is really again a - wait for it - system issue, but hear me out - I'm talking about a different 'system.'
Through the SF we often speak of the "local system" -- these actors / stakeholders who hold the future in their hands, on whose social capital, trust, cohesion, and then capacity, skills and performance, positive outcomes will rest long after we're gone. But, we are all are part of a global development system. Some call it an industry. This term denigrates the value of what a lot of people are doing day-to-day, but it reflects a basic truth: we operate in a system of agencies, funding streams, implementing mechanisms, country offices and project structures, private and government sponsors, marketing strategies, bids, projects, pursuit of "results", writing of promises in glamorous proposals, funding of some of these proposals as objectively as possible based on evidence, though sometimes not totally immune to fads, evaluations--the good, the bad and the ugly--and more lessons learned, and re-learned, and re-learned.
If I turn to those of us on the implementation side of thing (whether direct, partnership-capacity building, or just your friendly neighborhood beltway bandit Technical Assistance provider), of course we are on the receiving end of donor funds. This creates imperatives for survival (institutional, jobs, livelihoods). And this creates a necessity to be "responsive" (you cannot have great implementation of a project you did not win!). But we also influence and bring some learning to the overall system, even to our donors. If I look at USG language on sustainability, for example, I was struck last year by how the language had changed from old RFPs, concept notes and strategies, to how the Global Health Initiative writes about sustainability.
Years of experience, activism (think Global Fund), Paris Declaration, and maybe evaluation-research seem to have influenced how the language of sustainability is written up. Donors have their own systemic constraints, but over the long run, we are all eager to learn about what works and how.
If our traditional project approaches and the way we deal with sustainability as an afterthought or through literary prowesses in our applications and evaluation reports have not been working (for the long-term of societies we serve), and just feed into an empty cycle (actually working quite well for the development system we're a part of), it has consequences on those we call beneficiaries. Shediac-Rizkallah, much referenced in the sustainability literature, really drove that point clearly: except for emergency situations, unsustainable approaches do cause harm in the long run. I think we tried to make that point--numbers attached!--in last year's
Health Policy and Planning paper. Sustainability is not the only thing, and there are times when compromises need to be made. But by and large, as we get resources to deliver results, we need to strive to inform the system we are a part of, about what maximizes sustainable benefits for communities and societies. Being more intentional, explicit, rigorous (honest?) in our dealings with the S-word will influence how our global development machine will operate tomorrow. And in the meantime, we will be doing a better job on the ground, in the local system which we are disrupting.
So, projects might inherently not be designed to maximize sustainability; and it might take a little work to introduce more intentionally some fundamentals, which successful 'sustainable' projects have implicitly integrated. And yes, the broadening of the M&E lens, which this requires is an additional challenge.
In the current context of increased country ownership, the main question is going to be how seriously we want to take the sustainability question at the local and global levels. After that, let's just find the tools that get the job done.
Eric
