SUSTAINABILITY ANALYSIS
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Primary Health Care Management Advancement Programme
SUSTAINABILITY ANALYSIS
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MODULE 9
FACILITATOR S GUIDE
THE AGA KHAN UNIVERSITY
AGA KHAN FOUNDATION
Primary Health (are Management Advancement Programme
SUSTAINABILITY ANALYSIS
Mary Millar
University Research Corporation
MODULE 9
FACILITATOR S GUIDE
Aga Khan Health Services
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University Research Corporation
Center for Human Services
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Dedicated to
Dr. Duane L. Smith (1939-1992),
Dr. William B. Steeler (1948-1992)
and all other health leaders, managers and workers
who follow their example in the effort to bring quality health
care to all in need.
The Primary Health Care Management Advancement
Programme has been funded by the Aga Khan Foundation
Canada, the Commission of the European Communities,
the Aga Khan Foundation U.S.A., the Aga Khan
Foundation’s head office in Geneva, the Rockefeller Foun
dation, the Canadian International Development Agency,
Alberta Aid, and the United States Agency for Interna
tional Development under two matching grants to AKF
USA. The first of these grants was, "Strengthening the
Management, Monitoring and Evaluation of PHC Pro
grams in Selected Countries of Asia and Africa" (cooper
ative agreement no. OTR-0158-A-00-8161-00, 19881991); and the second was "Strengthening the Effective
ness, Management and Sustainability of PHC/Mother and
Child Survival Programs in Asia and Africa" (cooperative
agreement no. PCD-0158-A-00-1102-00, 1991-1994).
The development of Modules 6 and 7 was partially funded
through in-kind contributions from the Primary Health
Care Operations Research project (PRICOR) of the Center
for Human Services under its cooperative agreement with
USAID (DSPE-6920-A-00-1048-00).
This support is gratefully acknowledged. The views
and opinions expressed in the PHC MAP materials are
those of the authors and do not necessarily reflect those
of the donors.
All PHC MAP material (written and computer files) is
in the public domain and may be freely copied and
distributed to others.
Contents
FOREWORD .............................................................................................................
1
SESSION 1: INTRODUCTION AND OVERVIEW ............................... 7
Transparencies
9-1: Workshop objectives........................................................................... 13
9-2: Sustainability is ................................................................................... 14
9-3: Why consider sustainability ............................................................ 15
9-4; Sustainability analysis includes:...................................................... 16
9-5: Steps in sustainability analysis........................................................ 17
SESSION 2: PLANNING THE SUSTAINABILITY ANALYSIS
(STEPS 1, 2 AND 3) ..............................................................................................19
Transparencies
9-6: Session 2: Objectives........................................................................... 25
9-7: Facets of the sustainability objective ............................................26
SESSION 3: STRATEGIC ASSESSMENT (STEPS 4 AND 5)....31
Transparencies
9-7: Session 3: Objectives........................................................................... 36
9-8: Terms ...................................................................................................... 37
9-9: Types of sustainability factors.......................................................... 38
9-10: Threat/opportunity codes................................................................ 39
9-11: How to develop strategies................................................................ 40
SESSION 4: FINANCIAL ASSESSMENT (STEP 6).......................... 43
Transparencies
9-12: Session 4: Objectives ......................................................................... 46
9-13: Types of changes................................................................................. 47
Module 9: FG; contents
SESSION 5: ACTION PLANNING (STEP 7) .......................................... 51
9-14: Session 5: Objectives........................................................................... 55
Module 9: FG; contents
1
Foreword
What is the purpose of the Facilitator’s guide?
The Facilitator’s guide contains a suggested workshop design for use by
individuals who will help PHC managers and staff learn how to use the
Primary Health Care Management Advancement Programme (PHC MAP)
series. There is a Facilitator’s guide for each module in the PHC MAP series.
What information does it contain?
Each Facilitator’s guide contains instructions for conducting a workshop
on one of the modules in the PHC MAP series using the information
contained in the User’s guide.
The instructions are arranged in one to two hour sessions. The number
of sessions depends on the amount of information and/or the number of
steps contained in the User’s guide. The first page of each session lists
session objectives, major topic headings, time required, and materials and
equipment. The following pages describe the instructional activities in
outline form.
The outline is divided into two columns. The right-hand column
indicates what the facilitator says or does to conduct the session. The
left-hand column lists the handouts, overhead transparencies, or other
materials needed to support the activity. Copies of these materials, suitable
for duplication, appear at the end of the session in which they are first used.
Some transparencies are used in more than one session.
How are the workshops organised?
The first session of each workshop contains activities designed to
introduce the PHC MAP series and explain its importance to PHC
programmes, present an overview of the workshop, explain the purpose of
the module, review specific terms or concepts used in the module, and
Module 9: FG; foreword
4
summary form as contained in the first session of the Facilitator’s guides
for Modules 2 through 9.
• If information needs have not been clearly identified and participants
have no background in systems, then Module 1 should be presented in
full. The selection of the next module will depend upon priorities set by
the participants as they complete the steps in Module 1.
• If information needs have been clearly identified and participants have
no background in systems, then that portion of Module 1 can be added
to the first session of the selected module.
• If information needs have been clearly identified and participants have a
background in systems, then the overview of PHC MAP in the selected
module will be sufficient.
Understands the content of the selected module. Read the User’s
guide and Facilitator’s guide for the selected module and consider options
for workshop delivery.
• Depending upon the length of the module and the availability of staff for
training, the workshop sessions may be presented as described in the
Facilitators guide, or workshop sessions may be delivered at intervals (for
example, every morning for a certain number of days, one session per
week, or one day per week for three or four weeks).
• If follow-on technical assistance is available, the content of the module
could be presented in the workshop and the application of the procedure
to the PHC programme could be conducted on the job.
• Participants could plan steps in the workshop, complete them on the job,
and bring the results to the next workshop session. This approach is
particularly applicable to Module 2 which requires development of a
questionnaire, selection of a survey sample, training of data collectors,
and data collection. These steps cannot actually be carried out within the
time limits of the workshop as contained in the Module 2 Facilitator’s
guide.
• Other options are possible depending upon the circumstances of each
situation.
Determines what programme information, if any, is needed for
completion of the module. For example, census data and lists of households
are required to complete some of the steps in Module 3.
Module 9: FG; foreword
5
Determines the most appropriate people to attend the workshop. For
example, Module 7 is best completed by those responsible for planning,
training, supervision, logistics, and other management services.
Discusses the delivery options and participants with the PHC manager
and make decisions regarding the most appropriate option and participant
selection. Also determines if the needed information is available and if it
is not, the alternatives for obtaining the information.
Notifies participants of the date, time, and purpose of the
workshop and confirms attendance. Initial notice of the meeting may come
from the PHC manager, with follow-up by the facilitator.
Prepares the agenda, using as a model the sample in Session 1 of the
Facilitator’s guide for the selected module.
Inspects the room where the workshop will be held and answers these
questions:
• Is the room large enough to seat all the participants?
• Can chairs and tables be arranged in a variety of ways; all participants
around one table; participants in groups of three or four at smaller tables?
• Is the lighting adequate?
• Can temperature and humidity be controlled?
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• Is there an electrical outlet for an overhead projector?
• Is a microphone necessary for everyone to hear and to be heard?
• Are toilets conveniently located?
• Is the site convenient to parking, restaurants and public transportation?
• Are supporting facilities available and convenient: duplication, word
processing, computers?
Prepares notes to conduct the workshop using the session outlines in
the Facilitators guide for the selected module, and makes the necessary
adaptations. Refer to the appropriate User’s guide for content.
Duplicates the worksheets and other handouts as indicated in
the Facilitator’s guide and obtains the necessary equipment.
Conducts the workshop as planned.
Provides follow-on assistance, if appropriate.
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Module 9: FG; foreword
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Session 1: Introduction and overview
Objectives:
Participants will be able to:
• Explain the purpose of Module 9.
• Define sustainability in relation to PHC pro
grammes.
• Give at least two reasons why sustainability is
important to PHC managers.
Session outline:
I. Introduction (30 minutes)
II. Overview of Workshop (10 minutes)
III. Purpose of Module 9 (20 minutes)
IV. Module 9 User’s guide (15 minutes)
Materials:
Module 9 User’s guide
Handout 9-1:
Agenda
Transparency 9-1: Workshop objective
Transparency 9-2: Sustainability is...
Transparency 9-3: Why consider sustainabil
ity?
Transparency 9-4: Sustainability analysis in
cludes:
Transparency 9-5: Steps in sustainability
analysis
Facilitator
Reference 9-1:
Flowchart of sustainabil
ity analysis
Equipment:
Flip chart, stand, markers, masking tape, over
head projector, and screen
Module 9: FG; session 1
8
Session 1: Introduction and overview
I. Introduction (30 minutes)
Note: Omit section I if you have presented Mod
ule 1, or some other module, immediately prior to
the presentation of Module 9.
A. OPENING REMARKS
• Introduce self and other staff, as necessary.
• Explain your role in the workshop.
• If you do not know the participants, ask each
one to state his or her name, position title, and
job location.
Name tags
or place cards
Note: If the group is larger than 6 or 8, you may
Flip chart
• Ask each participant to complete this sen
wish to have them wear name tags or set cards with
their names at places where they are sitting.
tence: "As a result of attending this workshop,
1 expect..." and write their responses on the
flip chart.
• When all responses have been recorded, say
that you will return to this list after giving an
overview of the workshop.
B. OVERVIEW OF PHC MAP
See the Module 1 User’s
guide for this information
• Explain why information is important for
PHC programmes.
• Summarise PHC MAP programme, includ
ing;
Purpose of PHC MAP
Title and purpose of each module and other
materials.
• Make the following points about PHC MAP:
Has been field tested and revised to ensure
usefulness to PHC programme staff.
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Module 9: FG; session 1
9
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Session 1: Introduction and overview
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Modules can be used in any sequence.
Checklists and other materials can, and
should, be adapted to fit a particular situation.
The procedures outlines in the modules can
be adopted as routine monitoring activities in
a PHC programme.
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• Explain why MAP is being introduced in this
PHC programme.
Note: The remarks here should be tailored to the
specific programme and should provide the an
swers to these questions:
Why are we doing this workshop?
What do we expect to achieve?
It may be appropriate for the PHC manager to
make these remarks.
3
3
II. Overview of workshop (10 minutes)
Transparency 9-1:
Workshop Objective
Handout 9-1: Agenda
• Review the workshop objective.
and review the workshop
agenda, describing the activities that will take
place to accomplish the workshop objectives.
• Distribute
• Review the expectations contributed by par
ticipants at the beginning of the session.
Indicate which ones will be met and which
ones will not and why.
Suggest, if possible, alternatives for meet
ing the expectations that will not be met in
this workshop.
• Ask for questions or comments.
Module 9; FG; session 1
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Session 1: Introduction and overview
III. Purpose of Module 9 (20 minutes)
• Explain that the purpose of Module 9 is to
provide PHC managers and others with guide
lines and tools to develop and analyse sustain
ability strategies.
Transparency 9-2:
Sustainability is..
• Present the definition of sustainability and
Transparency 9-3: Why
consider sustainability?
• The importance of sustainability
Present the reasons why sustainability is
important to PHC programme managers.
Ask participants if they have been asked
about the sustainability of their programmes
or when they expected that the programme,
or a service offered by the programme, would
be able to function without funding from a
particular source.
Transparency 9-4:
Sustainability analysis
includes:
Transparency 9-5: Steps
in sustainability analysis
explain that within this broad definition, each
PHC programme must define its own sustain
ability objectives. The procedures and tools to
do that are contained in this module.
• The two aspects of sustainability analysis
Explain strategic assessment and mention
population size and political commitment as
two examples of factors that influence sustain
ability.
Explain financial assessment and mention
that the computer programs included in the
module make financial assessment easy and
fast, though it can be done without a com
puter.
• Present the seven steps in sustainability
analysis that will be the focus of the remaining
sessions in the workshop.
• Ask for questions or comments about sustain
ability and sustainability analysis.
• Explain what Module 9 does and does not do.
Module 9: FG; session 1
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-- ------------ ,------------------------
Session 1: Introduction and overview
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Module 9 does not tell you what to do to
make a PHC programme sustainable.
Module 9 does not develop a strategy for
you.
Module 9 contains tools to help you examine
a large variety of options relatively quickly as
a basis for developing your own strategy.
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IV. Module 9 User’s guide (15 minutes)
Module 9 User’s guide
• Distribute a User’s guide to each participant.
• Refer participants to the Introduction and
explain that most of the content of this
section has already been presented and dis
cussed.
• Refer participants to page 11 and explain
the levels of analysis that can be performed,
including Quick start. In this workshop you
will complete Level 1 and receive an orienta
tion to Levels 2 and 3.
• Refer participants to the appendices and ex
plain the content and purpose of each.
• Ask for questions and comments on the user’s
guide.
• Explain that the next session will cover the
first three steps in sustainability analysis.
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Module 9: FG; session 1
12
SAMPLE
AGENDA MODULE 9*
Session 1
(1 hr, 15 mins)
Introduction
and overview
fu-
Session 2
(1 hr, 30 mins)
Planning the
sustainability
analysis
(Steps 1, 2 and 3)
Session 3
(2 hrs, 30 mins)
Strategic assessment
(Steps 4 and 5)
Session 4
(2 hrs)
Financial assessment
(Step 6)
Session 5
(1 hr, 30 mins)
Action planning
(Step 7)
* For actual presentation, substitute actual clock hours in the first column.
Module 9: FG; session 1; handout 9-1
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WORKSHOP OBJECTIVE
Conduct a sustainability analysis for a
PHC programme using the steps and
materials contained in the Module 9
User’s guide
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Module 9: FG; session 1; transparency 9-1
14
SUSTAINABILITY IS...
the ability of a PHC programme to
continue providing services to meet Ss".
the needs of its target populations
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Module 9: FG; session 1; transparency 9-2
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WHY CONSIDER
’ SUSTAINABILITY?
• Decreasing funding for development
33 • Diversion of funds to other areas
• Move toward community-controlled
PHC
• Need to increase community awareness
in continuing health care
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• Need to reallocate resources
Module 9: FG; session 1; transparency 9-3
16
SUSTAINABILITY
ANALYSIS INCLUDES:
Strategic assessment:
© examine the effects of 10 factors that
influence sustainability
Financial assessment:
• examine the effects of the 10 factors on
future revenues and expenses
Module 9: FG; session 1; transparency 9-4
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STEPS IN
SUSTAINABILITY
ANALYSIS
1. Identify users; specify purpose and
scope
2. Clarify objectives
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3. Select level of detail
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4. Conduct strategic assessment
5. Consider response
6. Conduct financial assessment
7. Select strategy; develop action plan
Module 9: FG; session 1; transparency 9-5
18
Flow chart of sustainability analysis
Step 4:
Analyse factors
Strategic assessment
Table 2: Step 5
Summarise
results of
analysis and
strategy
Step 7
Summarise
strategy,
action plan
19
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Session 2: Planning the sustainability
analysis (Steps 1, 2 and 3)
Objectives:
Participants will be able to:
• Specify users, the purpose, and the scope of
the analysis.
• Clarify sustainability objectives.
• Decide on the level of detail needed.
Session outline:
I. Introduction (5 minutes)
II. Specify users, purpose, and scope of analysis
(25 minutes)
III. Clarify sustainability objectives (45 minutes)
IV. Decide on level of detail needed (15 minutes)
Materials:
Module 9 User’s guide
Transparency 9-6: Session 2: Objectives
Transparency 9-7: Facets of the sustainabil
ity objective
Handout 9-2:
Worksheet for specifying
the purpose of the analy
sis
Handout 9-3:
Worksheet for specifying
the sustainability objec
tives
Handout 9-4:
Worksheet for specifying
the restrictions on sus
tainability
Module 9: FG; session 2
20
Handout 9-5:
Equipment:
Worksheet for selecting
the type of assessment
and level of detail
Overhead projector and screen
Module 9: FG; session 2
21
Session 2: Planning the sustainability analysis (Steps
1, 2 and 3)
I.
Introduction (5 minutes)
Transparency 9-6:
Session 9: Objectives
• Review the session objectives.
. Explain that the session objectives parallel
the first three steps in sustainability analysis.
II.
Identify users, purpose, and scope of sustainability (25
minutes)
Handout 9-2: Worksheet
for specifying the
purpose of the analysis
• Distribute the worksheet and introduce the
three sections: user, purpose, scope.
• Discuss the considerations and alternatives
available for the choices in each section.
• Refer participants to the sample worksheet
on page 16 in the User’s guide to see the
choices one programme made.
• Ask for questions or comments on completing
this step.
• Direct participants to complete the work
sheet for their programme.
• Ask one group member to present the choices
made and give the highlights of the discussion
that led to those choices.
III.
Clarify sustainability objectives (45 minutes)
Transparency 9-7: Facets
of the sustainability
objective
• Present the three facets of sustainability.
• Explain how the three facets are inter-re
lated.
• Explain that one facet is selected as the main
objective and influences how the other two
must be adjusted to achieve the main objective.
Module 9: FG; session 2
22
ISession 2: Planning the sustainability analysis (Steps
1, 2 and 3)
• Explain that the ideal approach is to decide
the desired level of health status and coverage,
identify the services and management func
tions needed to provide that outcome, and
identify the resources needed toprovide the
services.
If the budget is fixed, it may be necessary to
start with resources.
If the services/institutions are the primary
focus of sustainability, it may be easy to lose
sight of the purpose of the institution which
is improvement of health status.
For the purpose of this workshop, health
coverage will be the first priority for the sus
tainability analysis.
Handout 9-3: Worksheet
for specifying the
sustainability objective
• Distribute the worksheet and note that the
priorities have already been indicated.
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• Refer participants to the sample worksheet
on page 20 in the User’s guide to see how it
might be filled out.
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• Direct participants to check the target popu
lations their programme currently serves and
the coverage objective for each.
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• Direct participants to consider whether they
wish to maintain the level of coverage or
increase or decrease it for any of the target
populations. If so, that should be indicated in
the third column.
• Direct participants to next check the catego
ries of services to be sustained to support the
coverage objective and list the specific ones for
each category checked.
• Direct participants to check the categories of
resources to be sustained to support the re
quired services.
Module 9: FG; session 2
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Session 2: Planning the sustainability analysis (Steps
1, 2 and 3)
• Ask for questions or comments on the sus
tainability objectives worksheet.
• Explain that it is important to clarify whether
Handout 9-4: Worksheet
for specifying the
restrictions on
sustainability
sustainability means self-sustaining or if exter
nal support is permitted.
• Refer participants to the sample worksheet
on page 21 in the User’s guide and direct
them to check the appropriate categories and
make the appropriate notes.
IV. Decide on the level of detail (15 minutes)
Transparency 9-4:
Sustainability analysis
includes:
• Explain that the first decision required in this
third step is whether to do a strategic assess
ment, a financial assessment, or both.
• Explain that the second decision is to decide
whether to conduct a Level 1, 2, or 3 analysis
or to do all three.
Level 1 will be completed in the workshop
so that participants have an understanding of
the entire process of sustainability analysis.
Levels 2 and 3 require information that
participants may or may not have readily
available.
• Refer participants to the two charts on page
14 in the User’s guide.
Level 1 is based on information participants
have from their experience of working in the
programme.
The more detailed information indicated by
the X in Levels 2 and 3 can be obtained by
using other MAP modules. For example, Mod
ules 6 and 7 contain procedures for assessing
quality of services and management functions.
Module 9: FG; session 2
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24
Session 2: Planning the sustainability analysis (Steps
1, 2 and 3)
Module 8 contains procedures for determining
expenditures by PHC service.
Handout 9-5: Worksheet
for selecting the type of
assessment and level of
detail
• Distribute the worksheet and explain that
the three levels of analysis are summarised for
both strategic assessment and financial assess
ment of sustainability.
• Explain that for this workshop Level 1 is
selected for both types of sustainability assess
ment. Suggest that participants retain the
worksheet for future use.
• Ask participants to state which level of sus
tainability analysis they will choose to perform
after the workshop and explain the reason for
their choice.
• Ask for questions or comments on the three
steps included in planning a sustainability
analysis.
• Explain that the next session will address
Steps 4 and 5 on conducting the strategic
assessment.
Module 9: FG; session 2
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* SESSION 2: OBJECTIVES
as
• Specify users, purpose, scope
3
• Clarify objectives
• Decide on level of detail
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Module 9: FG; session 2; transparency 9-6
26
FACETS OF THE
SUSTAINABILITY
OBJECTIVE
• What is to be sustained?
• Health outcome/coverage
® Services/institutions
• Resources
• What level is to be sustained?
• What are the restrictions, if any, on the
sources of support?
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Module 9: FG; session 2; transparency 9-7
27
WORKSHEET FOR SPECIFYING THE
PURPOSE OF THE ANALYSIS
User/audience:
Manager
.
Board of directors
_
Central directorate
Donors
Community
Other
Purpose:
General knowledge
Monitoring progress
Planning for the future
Decision-making
Other
Scope:
Geographic area
Programme/project/activity
Time/duration
Module 9: FG; session 2, handout 9-2
28
WORKSHEET FOR SPECIFYING THE
SUSTAINABILITY OBJECTIVES
Priority
What is to be
sustained?
At what
level?
1. Health coverage
Children < 2 years
Children < 5 years
Pregnant women
Married women 15-49
Other:
2. Services/institutions
PHC outreach services (list)
PHC clinical services (list)
Management services (list)
Agency/institution/unit (list)
Other:
3. Resources
Funding (specify)
Contributions (cash, in-kind)
Personnel
Technical capability
__
Other:
_____________________________
Module 9: FG; session 2; handout 9-3
29
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WORKSHEET FOR SPECIFYING THE
RESTRICTIONS ON
SUSTAINABILITY
Sustainability restrictions
No restrictions
Donor restrictions
Other
Self-sustaining
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Module 9: FG; session 2; handout 9-4
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WORKSHEET FOR SELECTING THE
TYPE OF ASSESSMENT AND LEVEL
OF DETAIL
Strategic assessment: Check the level of analysis to be
undertaken.
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Level 1: A general analysis of each of the 10 factors
Level 2: A general analysis of 8 of the factors plus a detailed
assessment of two of them. You assess each PHC service
and each management service.
Level 3: A general analysis of 6 of the factors plus a detailed
assessment of four of them. You assess the effects of
changes in target population size and target popula
tion KAP (coverage) for each PHC service and each
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management service.
rFinancial assessment: Check the level of analysis to be
undertaken.
_____
Level 1: A general analysis of revenues by source and
expenditures by general ledger items; and a "what-if"
s
analysis of the effect of changes in the 10 factors on future
revenues and expenditures.
_____
Level 2: A detailed analysis of revenues by source and
expenditures for each PHC service and management
service; and a What-if analysis of the effect of changes in
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the 10 factors on future revenues and expenditures.
B-
Level 3: A detailed analysis of revenues by source and
expenditures for each PHC service and management
service taking into account changes in target popula
tion size and target population KAP (coverage); and
B-
a "what-if” analysis of the effect of changes in the ten factors
on future revenues and expenditures.
Module 9: FG; session 2; handout 9-5
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Session 3: Strategic assessment (Steps
4 and 5)
Objectives:
Participant will be able to:
• Analyse selected factors for their effect on
programme sustainability.
• Identify strategies for dealing with threats and
opportunities.
Session outline:
I. Introduction (5 minutes)
II. Conduct strategic assessment (1 hour)
III. Identify strategies (45 minutes)
IV. Financial implications (40 minutes)
Materials
Module 9 User’s guide
Transparency 9-7: Session 3: Objectives
Transparency 9-8: Terms
Transparency 9-9: Types of sustainability
factors
Transparency 9-10: Threat/opportunity codes
Transparency 9-11: How to develop strategies
Handout 9-6;
Sustainability factors work
sheet
Facilitator
Reference 9-2:
Brainstorming guidelines
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32
Session 3: Strategic assessment (Steps 4 and 5)
I.
Introduction (5 minutes)
Transparency 9-7:
Session 3: Objectives
• Review the session objectives
• Give an overview of the activities of the
session.
II.
Conduct strategic assessment (1 hour)
Transparency 9-8:
Terms
Transparency 9-9: Types
of sustainability factors
• Identify sustainability factors
Define sustainability factor, threat and op
portunity and give an example of each.
Ask participants to give an example of each
from their own experience.
Present and explain ten types of factors,
noting that this is not an exhaustive list.
• Assess factors
Refer participants to Appendix A which
Handout 9-6:
Sustainability factors
worksheet
contains checklists for each of the ten factors
and explain how the checklists are organised.
Distribute the worksheet and explain
that it will be used to record their strategic
assessment of their programme.
Direct each participant to select a sustain
ability factor that they think is particularly
important to their programme. Each partici
pant should choose a different factor and enter
it in the first column headed "Factor."
Note: If there are 8 or more participants in the
group, form teams of two for each factor.
Direct each participant to determine
whether that factor presents a threat or an
opportunity to their programme using the
information on the corresponding checklist
about why this factor is important and key
indicators.
Module 9: FG; session 3
33
-----------------------------------------------------------------------------_------------------------------------------- —
Session 3: Strategic assessment (Steps 4 and 5)
_____
31
•______
..
.
Transparency 9-9:
Threat/opporfunity
codes
31
Tell participants to use their best judgement
inmaking the determination and, if they think
more information is needed, indicate what that
information is and record both in the column
headed "Threat/Opportunity Description.”
Explain the codes and direct participants
to enter the appropriate code for each factor
in the third column on the worksheet headed
"Effect."
Note: See page 55 in Appendix B for a full ex
planation of the codes.
Ask if anyone has questions about the task.
3
3
31
3)
31
3
30
__________________________ _______________
User’s guide
Module 9: FG; session 3
Each participant completes columns two
and three for the factor he or she selected.
Ask a participant to read aloud the descrip
tion of the threat/opportunity and the code
they assigned, explain the basis for the deter
mination, and identify, if appropriate, the ad
ditional data needed for a final determination.
Invite other participants to comment or ask
questions and facilitate discussion to help
participants reach consensus on the descrip
tion.
Repeat steps 9 and 10 until all participants
have reported.
Review the information needs identified by
participants and suggest other MAP modules
that will help them gather that information,
referring to the information on page 26-27, as
needed.
34
Session 3: Strategic assessment (Steps 4 and 5)
III.
Identify strategies (45 minutes)
Transparency 9-11: How
to develop strategies
• Explain alternative methods for developing
strategies to offset threats or take advantage
of opportunities presented by factors that in
fluence sustainability.
Attacking the problem not the symptoms is
essential for threats such as adequate supplies
are not always available or health workers are
not supervised regularly.
Attacking the problem is less applicable for
threats beyond the programme’s control, such
as increase in the size of the target population
or withdrawal of donor funds.
Review of solutions that have worked before
is useful for increases or decreases in target
population or need to improve target group
KAP The checklists in Appendix A contain
examples of useful solutions.
Brainstorming is useful when the tried and
true solutions are not always applicable, such
as cutting costs and taking advantage of op
portunities.
« Review the threat/opportunity descriptions
with participants and select three: one
amenable to the "five why" analysis, one
amenable to an existing solution, and one
amenable to brainstorming.
• Facilitate strategy development using the
most appropriate method for each of the three
descriptions.
Note: See the Facilitator Reference 9-2 at the
end of this session for brainstorming guidelines.
You may wish to duplicate this reference for par
ticipants to use after the workshop to conduct
their own brainstorming sessions.
Module 9: FG; session 3
35
3
3!
Session 3: Strategic assessment (Steps 4 and 5)
• Direct participants to enter the strategy for
the selected factors in the fourth column on
the worksheet.
• Direct participants to estimate the degree to
which the strategy will neutralise or offset a
threat or enhance an opportunity and enter
the appropriate code in column five.
3g
IV. Financial implications (40 minutes)
• Refer participants to the questions on the first
checklist in Appendix A under "Financial im
plications." The questions are the same for all
factors.
M!
M
• Give examples of how strategies affect costs
and revenues using the information on page
56 in Appendix B.
Ml
a
• Refer participants to page 56 in Appendix B
Ml
and review with them the definitions and
examples for one-time, recurrent, and com
pounded costs and revenues.
• Ask for questions or comments on financial
implications.
• Direct participants as a group to estimate
financial implications for the strategies they
have developed and enter them in the last
column on the worksheet.
» Ask one member of the group to report the
financial implications estimated by the group
and the rationale to support that estimation.
• Make suggestions to modify any estimates
you have reason to think may not include some
important considerations.
• Ask for final questions or comments on
strategic assessment.
Module 9: FG; session 3
SESSION 3: OBJECTIVES
@ Analyse selected factors for their effect
on sustainability
• Identify strategies for dealing with
threats and opportunities
Module 9: FG; session 3; transparency 9-7
37
&
* TERMS
Sustainability factor:
© a condition that may affect the continned existence of a programme
Threat:
4
4
© a sustainability factor that may hinder
or interfere with the continued existence of a programme
□3
Opportunity:
4
® a sustainability factor which supports
the continued existence of a programme and may contribute to its improvement or expansion
&
Module 9. FG: session 3; transparency 9-8
38
TYPES OF
SUSTAINABILITY
FACTORS
©•
1. Size of target population
2. Target groups demand for services
fX
B '
3. PHC service quality
4. Management support
p
.
5. Organisational capacity
6. Political commitment
&
7. Personnel
8. Programme revenues
©
&■
9. Programme expenditures
....
10. Environment
&
O.
Module 9: FG; session 3; transparency 9-9
jJL
ai
ii' & & Mi imi £i
*4 ii~lai"~!i UTHT ® Hi ® - Hi 1i H H H 8 8
Module 9: FG; session 3; transparency 9-10
THREAT/OPPORTUNITY CODES
Threat (negative)
—
Life-threatening, must overcome
—
Serious and significant
-
Minor, but should be dealt with
0
Neutral; neither a threat nor an opportunity
+
Minor advantage, opportunity to pursue
++
Significant opportunity, very advantageous
+++
Golden opportunity, must follow up
Opportunity (positive)
40
ti;
til
ti
1. Attack problems, not symptoms
til Ui
HOW TO DEVELOP
STRATEGIES
2. Review what has worked
ti) H Hi H
3. Brainstorm
Hi
H Hi H
Hi B
H H H H w,
Module 9: FG; session 3; transparency 9-11
Ai A id d id id id id id id id id id id id d d d d d d d d d
SUSTAINABILITY FACTORS WORKSHEET
Classify each factor, identify strategies where appropriate,
estimate financial implications
PHC services and management support
services
Factor: Threat/opportunity; description
FINANCIAL IMPLICATIONS
Revenues
Effect
Strategy
Effect
1-Time
Rev.
Rcrnt.
Rev.
Expenditures
Cmpnd. 1-Time
Rev.
Costs
Rcrnt
Costs
Cmpnd.
Costs
42
BRAINSTORMING GUIDELINES
Definition:
Brainstorming is a technique used by small groups to
generate a variety of ideas, to identify problems, theories for
the cause of problems, proposed remedies, or obstacles to
problem solutions.
Principles:
No idea can be criticised or evaluated. The aim is to produce
the greatest number of ideas in the shortest time. An idea
already presented can be expanded, modified, or used as a
trigger to produce other ideas.
Pitfalls:
Using brainstorming as a substitute for data. Once a list of
ideas has been produced, they must be processed to: set
priorities among them; analyse symptoms; test theories;
identify root causes; or verify the effectiveness of a solution.
The group may have difficulty suspending judgement. This
can be helped by conducting a warm-up session with a
neutral subject, such as "How many means of transportation
for people can we name?" or "Which objects in your house
have handles?"
Procedure:
Phrase the statement to be specific, focused, broad
enough to encourage creativity, and without bias. For example,
"For the past two months, the rural health centres have been
running short of antibiotics at least a week before the new
delivery comes. What could be the causes?"
Prepare ahead of time, if possible, by communicating the
statement to participants at an earlier time. A group of six
to eight participants is ideal.
Review the principles: no criticism; think unconvention
ally; aim for quantity; build on others’ ideas.
Review the rules: make contributions in turn; only one
idea per turn; you may skip a turn; do not explain your idea.
Conduct the brainstorming: lead a warm-up, if neces
sary; write the statement where all can see; have a recorder
write all contributions where they are visible to all; end after
10 or 15 minutes.
Process the ideas: clarify each solution; combine and
group similar ideas; agree on evaluation criteria; collect
additional data as needed.
Module 9: FG; session 3; facilitator reference 9-2
r.
S'
8®
IS'.
B'-
er
IS:
K;
43
Session 4: Financial assessment (Step 6)
Objectives:
Participants will be able to:
• Identify options for increasing revenues
and/or decreasing costs.
• Conduct a "what-if” analysis.
Session outline:
I. Introduction (5 minutes)
II. Identify options (1 hour)
III. Conduct "what-if" analysis (55 minutes)
Materials:
Module 9 User’s guide
Transparency 9-12: Session 4: Objectives
Transparency 9-13: Types of changes
Handout 9-7:
Revenue and expenditure
projections worksheet
Handout 9-8:
What-if analysis work
sheet
Equipment:
Flip chart, stand, markers, masking tape, over
head projector and screen, hand calculator
Note: The lesson plan for this session is written
for a Level 1 financial assessment using a hand
calculator. If the programme you are working with
has the appropriate computer capability, follow
the directions in Appendix B.
Module 9: FG; session 4
44
Session 4: Financial assessment (Step 6)
I.
Introduction (5 minutes)
Transparency 9-12:
Session 4: Objectives
• Review session objectives.
. Present highlights of session activities.
Identify options (1 hour)
II.
• Refer participants to page 31 in the User’s
guide and review the content and organisa
tion of Table 3.
Handout 9-7: Revenue
and expenditure
projections wor s eet
Flip chart
• Distribute the worksheet and direct partic-
ipants to prepare an estimate of programme
revenues and expenditures for the next 5 years
based on past experience and their judgment
of changes in the foreseeable future.
• Direct participants to prepare a graph on the
flip chart similar to the one on page 32 and
determine when, if at all, costs exceed re
venues.
• Refer participants to the options for increas
ing revenues and decreasing costs on page 32
and check those that are feasible to consider
for their programme.
• Direct participants to select two options for
increasing revenues and two for decreasing
costs and estimate the percent of change they
would expect for each.
III.
Conduct "what-if" analysis (55 minutes)
Transparency 9-13: Types
of changes
if
• Explain the types of changes that can be
made in revenue and expenditures and give an
example of each, using the information on
page 33.
Module 9: FG; session 4
45
:
' ' ~
.....
'
----
Session 4: Financial assessment (Step 6)
L.____ :___________________________ ________ __ _______
• Refer participants to Table 4 on page 37 and
explain it using the information contained on
page 33.
Handout 9-8: What-if
analysis worksheet
• Distribute the worksheet and direct partic
Handout 9-7: Revenue
and expenditure
projections worksheet
• Distribute a second blank worksheet and
Flip chart
ipants to determine whether the options they
selected are one-time, recurrent or com
pounded and enter the estimated percentages
of change in the appropriate places.
direct the group to recalculate their 5 year
projections using one option for increasing
revenue and one option for decreasing cost.
• Direct participants to prepare another graph
similar to the one on page 36 and identify any
changes in the relationship of cost and re
venue.
• Explain that depending on the results of the
what-if analysis, participants can:
Revise their estimates of change in revenue
or expenditure until revenue equals or exceeds
expenditure.
Revise one or more strategies for achieving
sustainability.
Modify the sustainability objectives defined
on Handout 9-3 to fit the projected budget.
• Explain that in the next session participants
will review sustainability objectives and
strategic and financial assessments and select
a strategy to put into action.
Module 9; FG; session 4
46
gl'
SESSION 4: OBJECTIVES
if-
e
o Identify options for increasing revenues
and/or decreasing costs
87
g
• Conduct a "what-if" analysis
**
g-
K
g:
r
8E
&
e
K:
Module 9: FG; session 4; transparency 9-12
S->
47
TYPES OF CHANGES
One-time:
occurs only once
Recurrent:
a permanent change that
is continued year after year
Compounded: a recurrent change that in
creases or decreases over
time by a fixed amount
Module 9: FG; session 4; transparency 9-13
REVENUE AND EXPENDITURE PROJECTIONS
WORKSHEET
CY
Yr 1
Yr 2
Yr 3
Yr 4
Yr 5
TOTAL
REVENUES
Fees
Contributions
Government subsidies
Grants/contracts
Outside income
Other
TOTAL
Module 9: FG; session 4; handout 9-7
EXPENDITURES
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Other
TOTAL
SUMMARY
Revenues
Expenditures
BALANCE
u. k ® n:
H $ fl ff fl fl fl fl fl fl R ® $ »
49
WHAT-IF ANALYSIS WORKSHEET
FINANCIAL FACTORS
1-Time
Revenue
Recurrent
Revenue
Compound
Revenue
1-Time
Costs
Recurrent
Costs
Compound
Costs
Revenue categories
Fees
Contributions
Government subsidies
Grants/contracts
Outside income
Other
Other
Expenditures categories
Personnel
Travel/perdiem
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
Other factors affecting
expenditures
Inflation
In-kind contributions
Module 9: FG; session 4; handout 9-8
51
Session 5: Action planning (Step 7)
Objectives:
Participants will be able to:
• Select an optimum strategy for sustaining the
programme.
• Describe the essentials of a plan to implement
the selected strategy.
Session outline:
I. Introduction (5 minutes)
II. Select sustainability strategy (30 minutes)
III. Develop an action plan (10 minutes)
IV. Next steps (30 minutes)
V. Conclusion (15 minutes)
Materials:
Module 9 User’s guide
Transparency 9-14: Session 5: Objectives
Equipment:
Flip chart, stand, markers, masking tape, over
head projector, and screen
Module 9; FG; session 5
IO- I 00
0 T L ffi
52
r~
Session 5: Action planning (Step 7)
I. Introduction (5 minutes)
• Review session objectives.
Handout 9-7:
• Remind participants that they also may re
view the graphs that they prepared to display
the results of the revenue and expenditure
projections.
• Direct participants as a group to review these
materials, make adjustments in objectives,
strategies, and/or estimates of change in re
venue and expenditure projections, and select
the optimum strategy or strategies for achiev
ing sustainability.
• Direct participants to prepare a written sum
mary of the selected strategy in the format
display on page 38 in the User’s guide.
Module 9: FG; session 5
pi
$ p
Handout 9-6:
®i
Handout 9-4:
Worksheet for specifying
sustainability objectives
Worksheet for specifying
restrictions on sustaina
bility
Sustainability factors
worksheet
Revenue and expenditure
projections worksheet
(both initial and adjusted
versions)
R
Handout 9-3:
$ $ $
sheets that summarise the decisions they have
made in performing the sustainability analysis:
pi
• Direct participants to assemble the work
$ $
II. Select sustainability strategy (30 minutes)
pi w
• Present an overview of session activities.
|R
Transparency 9-14:
Session 5: Objectives
53
'<1
Session 5: Action planning (Step 7)
• Ask one group member to present the
3
selected strategy and describe the adjustments,
if any, that were made, and the rationale for
those adjustments.
• Explain the importance of expanding this
summary into a detailed document which in
cludes assumptions that were made so that
they are not forgotten and can be referred to
periodically to monitor progress and make
adjustments as necessary as the sustainability
plan is implemented.
□fl
□3
Jfl
S3
□a
3
III. Develop an action plan (10 minutes)
□fl
• Explain that if sustainability is to be achieved,
<]
the strategy must be implemented and moni
tored.
□fl
• Emphasise that implementation must in-
volve all staff, using the guidelines mentioned
on page 38.
• Invite participants to discuss briefly how the
□fl
35
sustainability strategy planning can be incorporated into their existing planning activities.
IV. Next steps (30 minutes)
□fl
• Ask participants to identify the steps, if any,
jfi
in sustainability analysis where they need to
do more work because of lack of information.
0 Direct participants to consider what they
need to do immediately after the workshop to:
Complete and/or refine one or more steps
in sustainability analysis and/or incorporate
the selected strategy into their routine plan
ning activities.
Involve other staff in implementation.
□fl
□fl
□fl
—-a—
33
Module 9: FG; session 5
54
t~
.
Session 5: Action planning (Step 7)
• Direct participants to list what they need to
do to implement those actions and then
develop an action plan which includes:
Tasks in order of accomplishment.
When each task must be completed.
Who is responsible for each task.
• Ask participants to review their action plan,
anticipate any problems the might occur, and
suggest a way to deal with each problem.
• Ask for questions and comments on the ac
tion plan.
V. Conclusion (15 minutes)
Flip chart of
expectations from
Session 1
• Review the expectations that it was agreed
would be met by the workshop and ask them
to assess how well they think those expecta
tions have been met. If any were not met, ask
how the workshop could be improved to make
that happen.
• Thank participants for their time and atten
tion, congratulate them on the results of
their work, and wish them good luck in im
plementing their action plans.
Note: Indicate what follow-on assistance will be
available, if appropriate.
if
Module 9: FG; session 5
-jfl
55
33
30
:g
23
SESSION 5: OBJECTIVES
® Select a strategy for sustainability
35
-3
30
© Describe essentials of a plan to
implement the selected strategy
33
3J
33
31
33
30
3
33
3
3J
35
y
3
Module 9: FG; session 5; transparency 9-14
PHC MAP MANAGEMENT COMMITTEE
Dr. Ronald Wilson • Aga Khan Foundation, Switzerland (Co-Chair)
Dr. Jack Bryant • Aga Khan University, Pakistan (Co-Chair)
Dr. William Steeler • Secretariat of His Highness the Aga Khan, France (Co-Chair)
Dr. Jack Reynolds • Center for Human Services, USA (PHC MAP Director)
Dr. David Nicholas • Center for Human Services, USA
Dr. Duane Smith • Aga Khan Foundation, Switzerland
Dr. Pierre Claquin • Aga Khan Foundation, Switzerland
Mr. Aziz Currimbhoy • Aga Khan Health Service, Pakistan
Mr. Kabir Mitha • Aga Khan Health Service, India
Dr. Nizar Verjee • Aga Khan Health Service, Kenya
Ms. Khatidja Husein • Aga Khan University, Pakistan
Dr. Sadia Chowdhury • Aga Khan Community Health Programme, Bangladesh
Dr. Mizan Siddiqi • Aga Khan Community Health Programme, Bangladesh
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Yawarat Porapakkham • ASEAN Institute for Health Development, Thailand
Dr. Jumroon Mikhanorn • Somboon Vacharotai Foundation, Thailand
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India
PHC MAP TECHNICAL ADVISORY COMMITTEE
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India (Chair)
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Al Henn • African Medical and Research Foundation (AMREF), formerly of
the Harvard Institute for International Development
Dr. Siraj-ul Haque Mahmud • Ministry of Planning, Pakistan
Dr. Peter Tugwell • Faculty of Medicine, University of Ottawa, Canada
Dr. Dan Kaseje • Christian Medical Commission, Switzerland, formerly of the
University of Nairobi, Kenya
KEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICES
Dr. Jack Reynolds (PHC MAP Director)
Dr. Paul Richardson
Dr. David Nicholas
Dr. Wayne Stinson
Ms. Maria Francisco
Dr. Neeraj Kak
Ms. Lori DiPrete Brown
Ms. Pam Homan
Dr. Lynne Miller-Franco
Ms. Mary Millar
Primary Health (are Management Advancement Programme
SUSTAINABILITY ANALYSIS
MODULE 9
FACILITATOR S GUIDE
- Media
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