Example of Tool 1 utilization

A tool-kit for the evaluation of sustainability processes and
sustainability levels of public health programs and projects

Example of TOOL 1 utilization.

This tool was used in different contexts, specifically in Canada and Haiti. The following is an example of its utilization in a health project in Haiti.

Centre for nutritional recuperation (Haiti)

« Terre des hommes » Foundation is a Swiss nongovernmental organization (NGO) that has been working in Haiti since 1989. This NGO is concerned with nutrition and providing direct aid to children. In 1997, the NGO implemented a unit to manage severe acute malnutrition in children. Five years later, after an evaluation conducted by the NGO and local health authorities, the Unit was altered to focus on issues of moderate malnutrition.

In 2003, the NGO was responsible for the Unit, and began to transfer this responsibility to the paediatrics service of the departmental hospital. To aid in this transition the NGO organized activities to increase the sustainability processes of the Unit in the hospital. At the end of 2004, the Unit was functioning within the hospital. Between 2005 and 2007, the NGO’s goal was to pass on sole responsibility of the Unit to the hospital. It is in this context that the NGO decided to perform an initial evaluation of the sustainability processes started in 2003. This evaluation was undertaken to promote necessary adjustment for the Unit’s sustainability.

Concerning the program/project Events (e.g. actions taken) Favourable Unfavourable
Specific sustainability events
Stabilization of organizational resources
  • The actual capabilities of the State and its failure to keep its promises during a project in 1999 are not taken into account.
  • Unlike what was planned, the NGO still pays the Unit salaries instead of giving the hospital a grant before official agents are nominated.

 

Organizational risk-taking
  • Two entities function separately in only one building.
  • Staff reduction in the Unit and asking parents to compensate.

Joint sustainability and implementation events
Incentives or benefits for people involved
Adaptation of the activities  Good reputation of the NGO concerning the quality of nutrition projects via past activities in this area of the country.
Objectives fit with those of the organization  Signing of a memorandum of understanding.
Transparent communication between people involved
  • Consultation for the writing of the protocol.
  • Setting up of a committee (board).
  • Lack of follow-up with the newly assigned Minister of Health.
  • Not enough meetings with all the hospital staff.

 

 

 

 

Sharing of culture and artefacts with the organization
Integration of rules into those of the organization  Hospital routines not taken into account (staff turnover).
Specific implementation events
Investment of adequate resources to complete the activities
  • Construction of a building; material supplies.
  • Training and practical training of nurses in two entities (NGO and hospital).
  • No practical training for hospital support staff.

 

 

 

Technical or practical compatibility of the activities with those of the organization  Addition of a joint building to the hospital with its staff.

 

With the information presented in the above synthesis-table, it was estimated that the sustainability process was moderate to low. In fact, more unfavourable events than favourable ones were mentioned during the evaluation process. The synthesis-table also shows that no “specific sustainability events” identified as favourable were mentioned.

It was also important to know the perspective of key people in relation to what immediate actions may be taken to promote the sustainability process of the Unit. The stabilization of resources and the operational imbrications of the Unit and the hospital were mentioned. The importance of collaboration between members of the Unit and the hospital was also stressed. This type of integration could be accomplished by sharing staff and material resources with greater transparency and confidence possible. Also, the NGO provided significantly more human and material resources to the Unit in comparison to the hospital. In order to make the Unit sustainable, the hospital needs to take more risks.

Example of Tool 2 utilization

A tool-kit for the evaluation of sustainability processes and
sustainability levels of public health programs and projects

Example of TOOL 2 utilization.

This tool was used in different contexts, specifically in Canada and Haiti. The following is an example of its utilization in a health project in Haiti.

Centre for nutritional recuperation (Haiti)

« Terre des hommes » Foundation is a Swiss nongovernmental organization (NGO) that has been working in Haiti since 1989. This NGO is concerned with nutrition and providing direct aid to children. In 1997, the NGO implemented a unit to manage severe acute malnutrition in children. Five years later, after an evaluation conducted by the NGO and local health authorities, the Unit was altered to focus on issues of moderate malnutrition.

In 2003, the NGO was responsible for the Unit, and began to transfer this responsibility to the paediatrics service of the departmental hospital. To aid in this transition the NGO organized activities to increase the sustainability processes of the Unit in the hospital. At the end of 2004, the Unit was functioning within the hospital. Between 2005 and 2007, the NGO’s goal was to pass on sole responsibility of the Unit to the hospital. It is in this context that the NGO decided to perform an initial evaluation of the sustainability level.

Tool 2. Sustainability level of the Nutritional care unit
Concerning the program/project Yes No Indicators (Justify your yes/no answers)
Memory (specific indicators)
Financial resources of the organization No resources supplied by the hospital; very low budgetary allocation from the State to the hospital.
Human resources of the organization No nomination by the State of civil servants required for the functioning.
FMaterial resources of the organization No resources supplied by the hospital.
Other resources of the organization No resources supplied by the hospital.
Adaptation (specific indicators)
Adaptation to the context The management of severely underfed children is the responsibility of a referred hospital.
Adaptation to the effects Tools are adapted to local capacities and to the context for follow-up and evaluation of the effects of the Unit.
Barriers to adaptation Relevance of the Unit’s activities was not challenged.
Values (specific indicators)
Coherence with the organization’s objectives Implicit sharing of objectives but absence of an established plan mentioning the Unit.
Symbols in the organization Presence of a symbol for the Unit but it was the NGO’s logo.
Rituals in the organization No formal meetings organized.
Specific language or jargon Existence of specific technical jargon but limited to a few people with a low degree of familiarity.
Rules (specific indicators)
Nomination of a supervisor from the organization No supervisor assigned to the coordination of all of hospital’s activities.
Inclusion in the organization’s planning No real inclusion in the planning, but in the memorandum of understanding.
Tasks description Very good task description for unit staff.
Written procedures Existence of a practical guide for nutrition monitoring and many therapeutic protocols.

With the collected information presented in the above synthesis-table, it was estimated that the sustainability level of the Unit in the hospital was low (see the five levels table at the How to use Tool 2 section). Official hospital activities are derived from the Unit, but they don’t posses all of the characteristics required to qualify as routinized. They are not routinized because they can drastically change on a short term basis. A large number of activities derived from the NGO’s program are still carried out by the Unit. However, they are far from integrated in the hospital’s functioning.

There were notable achievements in relation to some characteristics of sustainability: adaptation to context, nutrition management procedures, tasks description, follow-up system (monitoring). However, the low level of sustainability can partly be explained by the Unit’s implementation and partly by the lack of activities or events favourable to routinization (see the Example of Tool 1 utilization section). The implementation of the Unit was the responsibility of the NGO. Activities were carried out in the hospital’s facilities but were financed, staffed and supplied by the NGO. In order to insure a higher level of sustainability, the hospital needs to take more organizational risks.

How to use tool 1

A tool-kit for the evaluation of sustainability processes and
sustainability levels of public health programs and projects

 

How to use tool 1

Tool 1 helps you to evaluate the sustainability process of programs/projects. This evaluation is accomplished in two steps: collection, and information synthesis.

First step: Information collection

Information collection takes place in two phases.

1- Creation of an events and activities log

First, all of the program/project’s activities (e.g. a weekly specific physical exercise in school) must be listed as well as events (e.g. the implementation of these specific physical exercises) that happened in relation to the program/project. To identify these activities and events, you can use one or any combination of the following procedures: a) observation of the program/project, b) analysis of documents related to the program/project, c) individual interviews with key people, and d) group interviews with key people (focus groups). You may collect information from all observations in one Tool 1 form, and collect information from all documents analyzed in another form, while you may need to complete one form per interview.

The objective is to create an events and activities log for the program/project. It is possible to update this log at any time by documenting changes in activities as well as new events.

2 – Classification of program/project-linked events

The next step is to classify events that are related to the program/project by reviewing the log with the help of Tool 1. You can classify events a) by yourself, and/or b) by interviewing key people separately, and/or c) by interviewing key people in focus groups. These events should be classified as either favourable or unfavourable to the sustainability of the program/project.

In an interview you can ask the following question in relation to each event listed in the log:
–  Was this event favourable or unfavourable to the sustainability of the program/project (name the program/project)?

People often need prompting to describe the important aspects of these events. The nine questions included in the table below can help to illicit the desired information. The information gained from this process can be used to fill out the “Tool 1” form.

Sustainability process: Guide for information collection (e.g. interview guide)
  1. Were actions taken to stabilize organizational resources for program/project activities (financial, human, material, training)?
  2. Were organizational risks taken in favour of the program/project?
  3. Were the people involved encouraged to carry out program/project activities?
  4. Were program/project activities adapted to local context according to their effectiveness and to population needs?
  5. Were program/project activities designed with the goals of the organization in mind (name the organization)?
  6. Was there transparent communication between the people involved (enumerate people)?
  7. Was there a cultural sharing between the organization (name the organization) and the program/project (artefacts, myths, symbols, metaphors, rituals, jargon, values)?
  8. Were the rules related to the organization’s (name the organization) activities integrated to those of the program/project, or vice versa?
  9. Were the resources invested by the organization (name the organization) adequate to accomplish program/project activities (financial, human, material, training)?
  10. Were practices and techniques related to program/project activities compatible with those of the organization (name the organization)?

 

Additional questions can be used to gain a deeper understanding of events. For each event, try to answer the following questions:

  • What led to this event?
  • How did this happen?
  • Why?
  • With whom?
  • What was particularly positive or negative in relation with program/project activities?
  • How did the concerned parties feel?
  • How did concerned parties react?
  • What strategies were used?
  • What were the effects?
  • What happened next or what were the perceived consequences?

Second step: Information synthesis

The second step of the sustainability process evaluation consists of the analysis of collected information. First, a synthesis-table including all completed “Tool 1” forms must be created. For example, six individual interviews were conducted during the evaluation process, and six “Tool 1” forms were completed. These forms must then be synthesized into one form. An example of a synthesis-table is presented in “Example of Tool 1 utilization”.

The objective of the creation of a synthesis-table is twofold: a) to compare the amount of favourable and unfavourable events associated with the program/project, and b) to identify what types of actions may be taken to make the program/project (more) sustainable.

When examining a synthesis-table, three scenarios are possible: 1) more favourable events indicates a strong sustainability process, 2) an equal amount of favourable and unfavourable events indicates a moderate sustainability process, and 3) more unfavourable events indicates a low sustainability process.

You can validate the synthesis-table and its interpretation with people involved in the program/project in group meetings with key people for example. Meetings can also allow you to identify future events that would be favourable to the sustainability process of the program/project by asking the question:
– What actions may be taken in the next few weeks/months to make the program/project (more) sustainable?

Finally, you can periodically update the synthesis-table by integrating changes from the events and activities log for the program/project. Updating the synthesis-table will allow you to adjust the actions that may be taken.

How to use tool 2

A tool-kit for the evaluation of sustainability processes and
sustainability levels of public health programs and projects

 

How to use tool 2

Tool 2 helps you to evaluate the sustainability level of programs/projects. This evaluation is accomplished in two steps: information collection, and information synthesis.

First step: Information collection

In order to identify information corresponding to sustainability levels, you can use one or any combination of the following procedures: a) observation of the program/project, b) analysis of documents related to the program/project, c) individual interviews with key people, and d) group interviews with key people (focus groups). You may collect information from all observations in one “Tool 2” form, and collect information from all documents analyzed in another form, while you may need to complete one form per interview.The 15 questions included in the table below can be used to obtain indicator-related information that addresses the four characteristics of organizational routines (references).

 

Sustainability level: Guide for information collection (e.g. interview guide)
Memory – resources that preserve lessons learned

1 – Are financial resources used to accomplish program/project activities integrated in the organization’s (name the organization) budget?

  • Are these costs part of the budget of the organization (name the organization)?
  • If so, are these costs a permanent or temporary part of this budget?

2 – Who are the people hired by the organization (name the organization) to accomplish these activities?

  • Are these people hired full time or part time?
  • Are these people hired permanently or temporarily?

3 – What are the material resources provided by the organization (name the organization) (rooms, photocopies, medication, etc.)?

  • To which budget do these material resources correspond?

4 – Are there other resources allocated to these activities?

Adaptation and barriers to adaptation

5 – How are these activities adapted to the context of the organization (name the organization)?

6 – Are these activities organized in a way that we can evaluate their effects (e.g. according to follow-up reports, annual statement of accounts or evaluation outcomes)?

7 – Among these activities, which ones are still organized because “we like it” or for historical or any other reason, but for which there is doubt concerning the relevance (barrier to adaptation)?

Values – beliefs and codes

8 – Do these activities correspond to written objectives formalized by the organization (name the organization) (e.g. in the form of a logical frame for “project management”) (Ask to see them).

9 – What are the symbols attached to these activities such as logos (or any other symbol)?

10 – What are the rituals established concerning these activities such as periodic meetings (or any other ritual)?

11 – Did a specific language emerge around these activities, some sort of jargon?

Rules and acting decision

12 – Did the organization (name the organization) formally assign a supervisor for these activities?

13 – Are these activities included in the official planning of the organization (name the organization)?

14 – Do task descriptions exist for the organization (name the organization) workforce assigned to these activities?

15 – Are certain activities related to written rules as in a manual of procedure?

 

Second step: Information synthesis

The second step of the sustainability level evaluation consists of the analysis of collected information. First, make a synthesis of completed “Tool 2” forms. The synthesis-table summarizes all indicators according to the four characteristics of organizational routines (memory, adaptation, values, rules). An example of a synthesis-table is presented in “Example of Tool 2 utilization”.

This synthesis-table allows you to establish a sustainability level. The following five scenarios correspond to the five levels of sustainability.

5 levels of sustainability
High sustainability. Standardized activities stem from the program/project; they possess the four characteristics of organizational routines and are carried out in accordance with public policy.
Moderate sustainability. Routinized activities stem from the program/project; they possess the four characteristics of organizational routines; these activities are durable.
Low sustainability. Official activities stem from the program/project but they don’t possess all characteristics of organizational routines and so are not routinized; these activities can change in a radical way on a short term basis.
Precarious sustainability. Residual activities from the program/project are pursued unformally by members of the organization within a function that has nothing to do with the program/project; the continuation of these activities rely on these people.
No sustainability. No activities stem from the program/project in the organization.

 

You can validate the synthesis-table and its interpretation with people involved in the program/project in group meetings with key people. Finally, you can organize periodic meetings with key people to follow up on the sustainability level.

Glossary

A tool-kit for the evaluation of sustainability processes and
sustainability levels of public health programs and projects

 

Glossary

Activities: An activity is defined as the understandable behavior of individuals with respect to the behavior of others. Programs prescribe the activities required to achieve a set of objectives that direct the behavior of people involved. In turn, these activities consist of tasks to be completed while drawing on financial, human and material resources.

Adaptation: The notion of adaptation refers to a modification or adjustment aiming at coherence and harmony. Routinized activities are adapted to programs/projects’ and organizations’ contexts or environments. Adaptation is one of the four characteristics of organizational routines.

Event (e.g. actions taken): Events are relevant observation units for assessing processes. Events are defined as elements in sequences (ordered samples of phenomena, order being usually temporal). Events and their consequences may contribute to explaining organizational processes. Events are distinguished by what is set off in time by a before and an after, and there are multiple types of events (mergers, decision-makings, meetings, etc.).

Evaluation: Evaluation is a judgement process that takes a critical approach and utilizes systematic data collection in order to make decisions.

Indicator: An indicator is a significant parameter used to measure outcomes, resource utilization, works progression status, or context.

Institutional standards: Institutional standards are defined as social norms established by state-level authorities (professional corporations or public administration). Neo-institutionalists emphasize the legitimacy of institutional standards upon which organizations are based over power and coercion. These standards are public and exist legally for the social good. Institutional standards directly constrain organizations or people. State-level measures, principles, policies or regulations that constrain organizations and people make institutional standards operational. Examples of institutional standards include federal, state level, county level, and municipal government rules and policies, as well as professional guidelines and accreditation standards that might be set by universities, hospitals, or school districts.

Memory: Memories refer to shared interpretations of past experiences that influence present activities. Memory requires stable resources and includes three major components: social networks, paper-based resources, and electronic resources. Memory is one of the four characteristics of organizational routines.

Organizational routines: Organizational routines are defined in terms of memory, adaptation, values, and rules. A routine is a typical procedural operation. Routines are integrated in organizations like the memory of actions or procedures shared by the actors. Routines are adapted to suit their contexts. Routines reflect the values, beliefs, codes, or cultures by means of symbols, rituals, and language. Routines adhere to rules that govern action and decision-making such as manuals of procedure, rules of information transmission, or plans.

Program/project: A program/project is a coherent, organized and structured set of objectives, activities and resources (human, financial and material), which are carried out by people involved for achieving the objectives. It is justified on the basis of needs of individuals, communities or a society. It is usually controlled by one or many people who are responsible for the quality of its design and operation.

Program/project implementation: A program/project’s implementation consists of a mobilization of resources to set up activities to reach an objective.

Routinized program/project: A routinized program/project is defined by the presence of routinized activities, i.e. activities presenting the four characteristics of organizational routines: memory, adaptation, values, and rules. To be considered routinized, at least one activity stemming from a program/project must possess all four of these characteristics. Routinization is considered to be the first sustainability process, while standardization is considered to be the second.

Rules: Routinized activities follow rules that regulate decision making and action. Rules are one of the four characteristics of organizational routines.

Sustainability level: The notion of sustainability level refers to a ‘snapshot’ of the sustainability process at a certain moment in time. The presence of organizational routines makes it possible to evaluate the sustainability level of a program. The four characteristics of organizational routines are: memory, adaptation, values, and rules.

Sustainability process: The notion of sustainability process refers to the processes that allow for the continuation of effects and activities relating to programs and projects. This process begins with the first events that outline a program or a project, i.e. their planning and implementation.

Standardized program/project: A standardized program/project is defined by the presence of routinized activities in accordance with public policy. Program/project standardization is considered to be the second sustainability process. Standardized programs/projects are even more durable than routinized programs/projects.

Values: Values and collective beliefs are manifested through cultural artefacts such as codes, symbols, rituals, or jargon. The formulation of objectives is also based on values and collective beliefs. Values are one of the four characteristics of organizational routines.