SUSTAINABILITY ANALYSIS
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Primary Health Care Management Advancement Programme
SUSTAINABILITY ANALYSIS
MODULE 9
USERS GUIDE
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AGA KHAN FOUNDATION
THE AGA KHAN UNIVERSITY
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Primary Health Care Management Advancement Programme
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SUSTAINABILITY ANALYSIS
Jack Reynolds
Wayne Stinson
University Research Corporation
MODULE 9
USER S GUIDE
Aga Khan Health Services
University Research Corporation
Center for Human Services
C ° '^t^istainability of health outcomes requires teaching about and sustaining
behaviour. In Peru, a nurse visits a home to advise the mother
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on the proper care and feeding of her children
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Photo by WHO
Library ^f,Cqhgress Catalog Number: 92-75468
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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.
Posters can help to improve and sustain good health behaviour. In
China, posters are used to teach women about water treatment, food
selection and preparation, as well as the prevention of common
diseases
Photo by Jean-Luc Ray for AKF
An overview of PHC MAP
The main purpose of the Primary Health Care Management Advance
ment Programme (PHC MAP) is to help PHC management teams collect,
process and analyse useful management information.
Initiated by the Aga Khan Foundation, PHC MAP is a collaborative programme of
the Aga Khan Health Network1 and PRICOR . An experienced design team and equally
experienced PHC practitioner teams in several countries, including Bangladesh, Chile,
Colombia, the Dominican Republic, Guatemala, Haiti, India, Indonesia, Kenya, Pakistan,
Senegal, Thailand and Zaire, have worked together to develop, test and refine the PHC
MAP materials to make sure that they are understandable, easy to use and helpful.
PHC MAP includes nine units called modules. These modules focus on essential
information that is needed in the traditional management cycle of planning-doing-eval
uating. The relationship between the modules and this cycle is illustrated below.
PHC MAP modules and the
planning-evaluation cycle
MODULE 1
PHC MAP
MODULES
1. Information needs
2. Community needs
3. Work planning
4. Surveillance
5. Monitoring indicators
6. Service quality
7. Management quality
8. Cost analysis
9. Sustainability
Module a
1. The Aga Khan Health Network includes the Aga Khan Foundation, the Aga Khan Health Services, and
the Aga Khan University, all of which are involved in the strengthening of primary health care
2. Primary Health Care Operations Research is a worldwide project of the Center for Fluman Services,
funded by the United States Agency for International Development
ii
Managers can easily adapt these tools to fit local conditions. Both new and
experienced programmers can use them. Government and NGO managers, man
agement teams, and communities can all use the modules to gather information
that fits their needs. Each module explains how to collect, process and interpret
PHC-specific information that managers can use to improve planning and moni
toring. The modules include User’s guides, sample data collecting and data
processing instruments, optional computer programs, and Facilitator’s guides, for
those who want to hold training workshops.
The health and management services included in PHC MAP are listed below.
Health and management services
MANAGEMENT
SERVICES
HEALTH SERVICES
GENERAL
OTHER HEALTH CARE
PHC household visits
Health education
Water supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Breast-feeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
Several Manager’s guides supplement these modules. These are: Better manage
ment: 100 tips, a helpful hints book describing effective ways to help managers
improve what they do; Problem-soluing, a guide to help managers deal with common
problems; Computers, a guidebook providing useful hints on buying and operating
computers, printers, other hardware and software; and The computerised PRICOR
thesaurus, a compendium of PHC indicators.
Module 9: Sustainability analysis
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Sustaining community-level health services means providing ongo
ing CHW training and technical support. In Bangladesh, a health
worker teaches volunteer mothers how to weigh an infant, monitor
weight-for-age, and detect and treat undernutrition early
Photo by Jean-Luc Ray for AKF
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 Foundation, the
Canadian International Development Agency, Alberta Aid,
and the United States Agency for International Develop
ment under two matching grants to AKF USA. The first of
these grants was "Strengthening the Management, Monitor
ing and Evaluation of PHC Programs in Selected Countries
of Asia and Africa” (cooperative agreement no. OTR-0158A-00-8161-00, 1988-1991); and the second was "Strength
ening the Effectiveness, Management and Sustainability of
PHC/Mother and Child Survival Programs in Asia and
Africa" (cooperative agreement no. PCD-0158-A-00-110200,1991-1994). 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.
Module 9: Sustainability analysis
Contents
QUICK START................................................................................................. 1
INTRODUCTION
What is the purpose of this module?....................................................... 5
Who should use this module? ...................................................................6
What is sustainability? .............................................................................. 7
HOW TO USE THIS GUIDE
How it is organised ....................................................................................9
How to begin............................................................................................. 12
SUSTAINABILITY ANALYSIS PROCEDURES
Step 1: Identify the users and specify the purpose and scope of the
analysis ..................................................................................... 15
Step 2: Clarify the objectives .............................................................. 17
Step 3: Decide on the level of detail needed...................................... 22
Step 4: Conduct strategic assessment ............................................... 23
Step 5: Identify strategies for addressing threats and opportunities ... 28
Step 6: Conduct financial assessment ............................................... 31
Step 7: Select a strategy and develop an action plan....................... 38
APPENDICES
A. Sustainability factors, indicators and strategies........................... 41
B. Worksheets and spreadsheet templates ........................................ 55
Level 1 ................................................................................................ 60
Level 2 ................................................................................................ 68
Level 3 ................................................................................................ 77
C. Blank worksheets ............................................................................ 85
ACRONYMS AND ABBREVIATIONS ................................................... 103
GLOSSARY ................................................................................................ 104
Module 9: Sustainability analysis
Acknowledgements
A number of people and institutions have contributed to the development,
review and testing of this module.
The first draft of this module was reviewed by Khatidja Husein, Asif Aslam,
Melvyn Lobo, Inam-ul-Haq and Jack Bryant, all of the Aga Khan University; Ronald
Wilson and Pierre Claquin of the Aga Khan Foundation, Geneva, and William
Steeler, Secretariat of His Highness the Aga Khan, Aiglemont, France. A revised
version was reviewed and tested in a workshop at the International Conference on
Management and Sustainability of PHC Programmes, held in Bangkok in May 1992.
Significant changes in the organisation and emphasis of the module were made as
a result of feedback received at that Conference.
Field tests:
Countries
Participating organisations; field test facilitators
Bangladesh
Aga Khan Community Health Programme, Dhaka; Social Market
ing Programme; The Asia Foundation; Facilitator: Barkat-e-Khuda,
URC/Bangladesh.
Junagadh PHC Project; Sidhpur Sustainable Health System Proj
ect, Gujarat; Facilitator: Neeraj Kak, URC, Bethesda, Maryland,
USA
India
Kenya
Mombasa PHC Project; Facilitator: Maria Francisco, URC,
Bethesda, Maryland, USA
Module 9: Sustainability analysis
Quick start
Basic sustainability analysis
(Do either or both parts)
Part 1: Strategic Assessment
This mode! assumes that your goal is to continue your current PHC
programme as it is now, without any changes. That is, the objectives would
be to: a) maintain current health status; b) maintain the current PHC
services; and c) maintain the current resource mix. Enter your target group,
services and objectives below.
Table 1: Coverage objectives and services - Example
Target group
PHC services
Coverage objectives
Children <2, <5 yrs
Child immunization
Growth monitoring
Oral rehydration
Nutrition education
Antenatal care & TT
Family planning
70% < 24 mos fully immunized
55% < 5 yrs weighed
65% < 5 used ORT last episode
<10% < 2 yrs low weight-for-age
70% pregnant enrolled in ANC
65% current users
Married women 15-49 yrs
Instructions; Examine the ten factors listed below. Identify those that
you believe will affect sustainability over the next five years. Note whether
the factor is a threat, neutral, or an opportunity. Describe it and estimate
the magnitude of its effect (use 1-3 |-J for threats; or [+) for opportunities;
and [0] for neutral.). Develop strategies to deal with serious and moderate
threats so as to reduce their impact on sustainability. Develop strategies
to take advantage of opportunities so as to increase their impact on
sustainability. In the far right column, indicate the change in effect due to
the strategy. In the effects columns, indicate the changes due to the
strategies.
Revise and update these assumptions and strategies as often as you wish until
you have an "optimal" strategy. That is one that will produce the best results possible
given the available funds and other constraints that the project faces Ideally, your
strategy should neutralise all threats and take advantage of as many opportunities as
possible. Summarise your strategy in writing and develop an action plan to
implement it.
Part 2: Financial Assessment
This module assumes that your goal is to continue your current PHC
programme as it is now, without any changes. That is the objectives would
be to: a) maintain current health status; b) maintain the current PHC
services; and c) maintain the current resource mix. Enter your target group,
services and objectives as in Table 1 on page one;
Module 9: Sustainability analysis; quick start
2
Table 2: Sustainability Factors Worksheet-Example
Classify each factor, identify strategies where appropriate, estimate effect
Factor: Threat/Opportunity;
Description
1. Target population size
Effect Strategy
Increase services: Raise
revenues through increased
fees, contributions; reduce
costs via community inkind contributions
Threat: In-migration of 2%
annually projected
2. Target group KAP (coverage)
Strategy: Add special 1EC
sessions for new clientele.
0
+
TQM already installed:
Quality should improve;
costs may decrease.
+
+
Expect increase in
efficiency; Should lower
costs later.
+
+
No strategy at present:
Could expand into other
areas.
+
-
Hold 2-3 education/PR
sessions in each community.
0
-
Develop improved
compensation package.
0
-
Develop alternative source
of funds: fees, fund-raising,
training.
+
-
Increase revenues > 3%.
+
Opportunity: Improving steadily
4. Management support
Opportunity: Strong and
improving
5. Organisational capacity
Opportunity: Strong
6. Political commitment
Threat: Lack of community
support
7. Personnel resources
Threat: May lose key staff as
donor support ends
8. Revenues
Threat: Losing some donor
support in 1993
9. Expenditures.
Threat: Inflation of 3% annually
(see revenues) Other lines
increasing, some decreasing
10. Environmental.
Neutral: No changes expected
0
-
Threat. New clientele needs
education, counselling
3. PHC service quality
Effect
0
Module 9: Sustainability analysis; quick start
3
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Instructions: Load the computer file (MOD9_QS.WQ1) into Quattro Pro
Press Ctrl + W to widen columns.
1 In Table 3 (shown below), enter the revenues and expenditures for the
current year (CY) (or the last 12 month period). The program will copy
those figures into the following five years and compute the balances for
you.
2. Move to Table 4 and enter any changes that you think are appropriate,
based on the strategy that you developed in Part 1. For example, if you
expect revenues to increase 5% each year, enter .05 in that cell. Make
other changes in the Services and Coverage boxes as appropriate.
3.
Conduct a "What-if analysis by changing any or all of the revenue, cost,
and other assumptions in Table 4. Observe the effects of these changes
in Table 3.
4. If you want to see a graph of this table, press F10. Then press <ESC> to
return to this screen. Save the file under a different name so that you
can use this file again.
Table 3: Input-estimates
Enter revenues and expenses for the current year
Current Yr
Revenues
Expenses
Balance
Yr 2
Yrl
343
365
(22)
370
381
(U)
400
399
1
Yr 3
432
417
15
Yr 4
467
435
32
Yr 5
504
455
49
Make changes in the assumptions by entering percent changes in the
What-if analysis cells (Table 4). For example you expect to increase coverage
by 5% each year, then enter .05 in Coverage. You may expect to increase
Revenues by 6% annually. If so, enter .2 in Revenues. You may expect to
decrease PHC services by 3% each year (enter -.03). If you increase
Organisational capacity (efficiency) or In-kind contributions that will DE
CREASE costs. Your objective is to find a realistic combination of assump
tions that will produce a positive balance That is when revenues exceed
expenditures. When you reach this point, revise or update your strategy
(Part 1) as appropriate.
Table 4: What-if analysis
Enter projected annual % increase (+) or decrease (-)
Negative factors
Positive factors
A4- will increase revenues or decrease costs A4- will increase costs or decrease revenues
A- will decrease revenues or increase costs A- will decrease costs or increase revenues
Revenues (4-R)
Organisational capacity (-E)
In-kind contributions (-E)
Political commitment (4-R)
Environmental factors (4-R)
6.0% Expenses (+E)
3.0% Inflation (4-E)
0.0% Target group size (+E)
5.0% Target group coverage (4-E)
-3.0% Personnel resources (+E)
PHC service quality(+E)
Management support (4-E)
Module 9: Sustainability analysis; quick start
3.0%
5.0%
3.0%
5.0%
1.0%
-5.0%
-4.5%
4
Projected revenues and expenditures ( 5 Years)
E9
Revenues
Expenditures
Manual calculation: You can do the "what-if' analysis by hand also. To
do this total the percentages in the Revenues, Political commitment and
Environmental factor columns. Notice that these are all labeled (+R),
meaning that a positive entry will increase revenues (and a negative entry
will decrease revenues). Using the table, the formula would be: 6% + 5% +
(-3%) = +8%. Add this percentage to 343 to get 370.44, which is the new
projection for Yr 1. Do the same for the next column. Multiply 370.44 ’ 8%
to get 26.64. Sum that to get 399.64 for Yr 2. A short cut is to multiply
the percentage plus 100% x the amount in Table 3. For example: 1.08'343;
and 1.08 • 370.
Compute the changes in expenditures the same way. Add up all of the
remaining factors. The first two, Organisational capacity and In-kind
contributions, are negative. As they increase expenses decrease. All the
other factors: Expenses, Inflation, etc. are positive. As they increase, so do
expenditures. You only need to remember to change the signs for two
factors (Organisational capacity and In-kind contributions). Thus, the first
two factors would be -4 and -0. All of the remaining factors would be
entered as they appear. Thus the first formula would be (-3.0+3+5+3+5+15-4.5) or 4.5. Multiply 1.045'365 = 3814. then multiply 381.4'1.045, and
so on.
Module 9: Sustainability analysis; quick start
5
Introduction
What is the purpose of this module?
This module will provide PHC managers (and others) with
guidelines and tools that they can use to develop and analyse
sustainability strategies.
Many PHC programmes are being asked to develop strat
egies for sustaining their services. Donors are especially inter
ested in such strategies. They are asking when they can phase
out their support — when the PHC programmes will be able
to stand on their own.
Programme managers are starting to consider sustainability
in planning their programmes, for a number of very good
reasons, including:
• Decreases in funding from developed countries
• Diversion of available funds to Eastern Europe
• A need to reallocate resources to operate at more
affordable levels
• Shifts from donor-initiated interventions to communitycontrolled PHC
• Promotion of community self-awareness in health care as
the basis for continuity
The module shows how to carry out a strategic assessment
as well as a financial assessment of sustainability. The manager
can choose to do one or both of these analyses. The strategic
assessment shows how to analyse future sustainability by
examining the effects of ten factors:
1.
2.
Population size and composition
3. PHC service quality
Target group knowledge, attitudes 4. Management support
and practice (coverage)
Module 9; Sustainability analysis; introduction
5.
6.
7.
Organisational capacity
Political commitment
Personnel resources
8. Revenues
9. Expenditures
10. Environment
It describes how to identify those that are potential
threats and those that are opportunities to enhance sus
tainability. It also describes strategies for overcoming such
threats and taking advantages of opportunities. Then it
shows how to alter projections by changing assumptions and
strategies.
The financial assessment shows how to assess the effects
of the factors on future revenues and expenses, and how to
project revenues and expenses over the next five years. The
computerised version of the assessment includes a "what-if'
analysis feature that lets you change your assumptions and
immediately see the effects on projected revenues and expendi
tures.
The goal of the sustainability analysis is to find a strategy that
will produce an acceptable level of services at a cost the
programme can afford while minimising the threats to sus
tainability.
This sounds like a complex undertaking, but the module
presents some simple computer programs that can help man
agers make projections and changes in assumptions easily and
quickly.
The module does not tell you what to do to become sustain
able. And it does not develop a strategy for you. Rather, it is a
tool that you can use to develop your own strategy. It helps you
examine a large variety of options relatively quickly, using rough
estimates of key variables. Once you have settled on a general
strategy, you can develop a detailed plan, either as part of your
regular planning process, or as a special task.
Who should use this module?
The module can be used by anyone who is interested in
analysing the sustainability of a PHC programme. Typically,
that will be managers, administrators, boards of directors,
and others who are responsible for setting policy and pro
gramme goals. Donors and consultants may find the module
to be a helpful aid for stimulating strategic planning by PHC
managers and staff.
IB
Module 9: Sustainability analysis; introduction
7
Ideally, users should have a background in planning,
evaluation, MIS, and/or finance. A team approach is best,
because a large number of assumptions and projections need
to be made, and a knowledgeable and experienced group can
do that better than an individual.
Sustainability is often of greater concern to private PHC
programmes than government ones. Yet, public pro
grammes can benefit from sustainability analysis, also. The
information can be especially helpful in defending budget
submissions.
The module can be used without a computer, but a
computer is strongly recommended, especially for the finan
cial assessment. That is because the computer is a great tool
for doing "what-if" analyses quickly. A sustainability analysis
often involves making many changes in assumptions to see
their effects on revenues and expenses. When the manager
wants to change an assumption, e.g., "What if the population
grows by five percent instead of eight percent?"; this can be
done easily and quickly on a computer. But it requires
tedious calculations if done by hand. The computer pro
grams are written in Lotus 1-2-3 and Quattro Pro and are
not complicated. But someone on the team should have a
working knowledge of this programme.
What is sustainability?
Sustainability is a relatively new word. In fact, it doesn’t
appear in any dictionary. However, Webster’s dictionary
defines "sustain" as, to "keep up, prolong." It usually implies
maintaining something that already exists. The term is often
equated with "self-sustaining" and "self-sufficient," which
means that no outside support is needed.
When people ask how sustainable a PHC programme is,
they usually want to know what the chances are that the
programme can be continued. When donors ask that ques
tion they usually want to know whether the programme will
be able to continue after donor support ends.
These are legitimate questions, since many programmes,
in education, agriculture, as well as health, have collapsed
when donors withdrew their support. Thus the interest in
sustainability is first and foremost an interest in ensuring
that the PHC services, and the benefits they produce, can
Module 9: Sustainability analysis; introduction
8
be continued.
While sustainability has a general definition, as suggested
above, each user of this module will need to define his or her
objectives and identify any restrictions on the definition of
sustainability as it applies to the specific programme. The
issues that users must address are discussed in Step 2.
Module 9: Sustainability analysis; introduction
9
How to use this guide
How it is organised
This User’s guide includes a series of procedural steps that
describe how to do a sustainability analysis, explanations of
sustainability factors you should examine, and instructions
for carrying out simple and more detailed analyses. There
are also illustrative worksheets and checklists. There is also
a computer disk with spreadsheets for the Quick start and
Levels 1-3. You may elect to perform a comprehensive
assessment of both financial and strategic factors or to limit
your attention to one or the other.
Sustainability analysis is presented as a series of seven
steps, as described below.
Step 1: Identify the users and specify the purpose and scope of the
sustainability analysis. You decide why and for whom you are conducting the
analysis, and identify what to include.
Step 2: Clarify your objectives. Decide what you want to sustain and at
what level. Also identify any restrictions on future funding sources.
Step 3: Decide on the level of detail needed. Decide if you want to do one
or both of the assessments - strategic and financial. Then decide how detailed
the assessment should be - select Levels 1, 2, or 3 for each assessment.
Step 4: Conduct a strategic assessment. If you selected a strategic
assessment, this step shows you how to do it. You will assess the positive and
negative effects of ten factors on the sustainability of your programme.
Module 9: Sustainability analysis; use of guide
10
Step 5: Consider strategic responses to threats and opportunities. In
this step you develop strategies to neutralize threats and to take advantage
of opportunities.
Step 6: Conduct a financial assessment.
If you selected a financial
assessment, this step shows you how to do it. You project revenues and
expenditures over the next five years and then conduct a "what-if"
analysis. This allows you to see what would happen to sustainability if
you varied one or more of the ten factors.
Step 7: Select a sustainability strategy and develop an action plan.
You finalize your projections and assumptions and summarize your strategy
for neutralizing threats and taking advantages of opportunities.
You are likely to repeat several of these steps as your
analyses become more refined. Just follow the instructions
and examples, use the worksheets and templates, and you
can carry out an analysis, either by hand or using a computer.
Strategic and financial assessments.
The module separates sustainability into two indepen
dent, but inter-related assessments. The first is a non-financial examination of the big picture, which we call a strate
gic assessment. You are shown how to define what you
want to sustain, and then how to assess the effects of ten
sustainability factors on your objectives. You are then shown
how to develop strategies to neutralise threats and to take
advantage of opportunities.
That may be all you need to do. However, you may also
want to do a financial assessment. You are shown how
to make financial projections of revenues and expenditures
for the next five years, and how to adjust those projections
to take account of expected changes such as the end of a
grant and inflation. If you wish to link the financial assess
ment to the strategic one, you can do that by making
adjustments to your projections. You are shown how to
estimate the financial implications of each of the ten sus
tainability factors. Finally, you can make changes in those
estimates in a "what-if" analysis. This will allow you to
see the effects of different strategies on financial sustainabil
ity-
Module 9. Sustainability analysis;;
Like several modules, this one also offers several levels of detail,
which we call Level 1, Level 2 and Level 3. In addition, there is
the Quick start version.
Quick start is the simplest and easiest to use. This is
designed to provide a quick analysis of current sustainabil
ity. It may be all that you need. It only takes a few hours. There
is a section on strategic assessment and another on financial
assessment. If you want to do the latter quickly, use the computer
file that accompanies this module, named M0D9 QS.WK1 or
M0D9 QS.WQ1.
Level 1 allows you to make more detailed assessments. The
strategic assessment is the same as in the Quick start except
that you can also make assessments of the financial implications
of each factor. The financial assessment enables you to make
projections of revenues and expenditures based on your
programme’s "General Ledger Items," (which are often called line
items in your budget). You use a ”what-if' analysis to adjust your
projections so that you can reach a "break-even" point, where
revenues equal expenditures.
Level 2 expands the analysis to make more detailed assess
ments of PHC and management services. You assess the
threats to and opportunities for each of your PHC services, such
as child immunization, ANC, family planning, and so on. You do
the same for your key management services: planning, training,
supervision, community participation, and so forth.
Level 3 is the most comprehensive assessment. It permits
you to develop more detailed estimates of demand and need
for PHC services. This level of analysis is especially import
ant if significant changes are expected in the size and composi
tion of the programme’s target populations. These changes
could be due to migration, expansion or reduction of the target
area, inclusion or exclusion of PHC services, population growth,
and so forth.
You can do a more precise assessment of your sustainability
options as you move up through each level of detail. But, of
course, it takes more time and is more complex. You can also
mix your analyses. For example, you can do a detailed Level
3 Strategic assessment, but a less detailed Level 1 Financial
assessment. You might prefer this if, for example, your financial
system doesn’t break costs out by type of PHC service.
Module 9: Sustainability analysis; use of guide
12
The
appendices
Sustainability factors: Each of the ten sustainability
factors is described in more detail in Appendix A, with sug
gested indicators for assessing each factor, and suggested strat
egies for dealing with factors that threaten sustainability.
Computer templates: For those who want to conduct
their sustainability analysis via computer, copies of the Levels 1,
2, and 3 templates are included on the Module 9 computer disk.
They are illustrated in Appendix B, which also includes instruc
tions for their use. These templates run on Lotus 1-2-3, Quattro
Pro or almost any other compatible spreadsheet
Worksheets: Many of the steps ask you to decide what you
are going to do. The worksheets offer a handy place to record
those decisions. There are also some checklists to help you
remember key points or options. A blank set of these work
sheets and checklists is included in Appendix C for reproduc
tion.
How to begin
Read the next section, Sustainability analysis proce
dures, and decide what you want to analyse and the amount
of detail you want. You can select any of the three levels of
analysis: Levels 1, 2, or 3. However, you may find it easiest to
begin with the Quick start to get a quick picture of your
sustainability prospects. Then move to Level 1. You can limit
your initial analysis to a single PHC service or geographic area,
or you can look at the entire programme.
We have assumed that most users will want to look five
years into the future. However, you can adapt the spreadsheets
to fit whatever time period you choose. You can even do a
long-range 25-year analysis by making five, five-year projections
Yxj can limit your analysis to the strategic assessment, or you can
go straight to the financial assessment. It is best to do both, of
course, starting with the strategic assessment
Yau will be asked to make a number of estimates, using your
best judgement These estimates do not have to be precise, since
you are examining broad sustainability options over an uncertain
future. The objective is to work out a general strategy, not a
detailed plan. Once you have settled on a general strategy, then
you can work out a detailed plan as part of your regular planning
process. Therefore, do not be too concerned if your esti
mates are not exact.
Module 9: Sustainability analysis; use of guide
13
After completing the Quick start, we recommend that you
begin with the basic analysis in Level 1 and project what it would
require in both strategic and financial adjustments to continue
your PHC programme exactly as it is today. This is the most
logical place to start. You can examine options for expanding or
contracting services later.
Move on to Levels 2 and 3 as you see the need. Each takes
more data and time, but each provides more data for decision
making, also.
You should continue your analyses until you achieve an
"optimum" sustainability strategy. That is a strategy that is the
best that your programme can do, given the constraints it faces,
that is, limited revenues, increasing population growth, etc. \bur
strategy will include a number of assumptions and requirements
that will have to be met for it to be effective. These should be
recorded and carefully examined to determine whether or not
they are realistic. Examples of important assumptions could be:
the Ministry of Health will provide vaccines for immuniza
tion; political support for MCH will continue; and, in-migra
tion will be limited to "X" percent per year.
Finally, once a reasonable sustainability strategy has been
agreed to, your staff can prepare a detailed plan and budget
as part of the normal programme planning process. A
special "action plan" should be developed to describe what
will be done to ensure that the sustainability assumptions
and/or requirements are met.
Sustainability planning is likely to be an iterative and ongoing
activity. Assumptions, goals and strategies should be re-exam
ined and updated annually, at least. Some programme objec
tives, target populations, or technical interventions may have to
be dropped so that resources can be concentrated on those more
likely to survive. Thus, it would be helpful to conduct at least a
Level 1 analysis each year.
Module 9; Sustainability analysis; use of guide
An iterative,
ongoing activity
to do at least
annually
Flow chart of sustainability analysis
Step 3
Level of detail
LI
2
3
________ _________ _________
— — —
Step 4:
Analyse factors
Strategic assessment
Table 2: Step 5
Summarise
results of
analysis and
strategy
Step 7
Summarise
strategy,
action plan
!
Table 1: Sustainability objectives
PHC service
Coverage obj.
Target group
fF
I
FA
$ Tl R W 'R 'Fl R
H fl
SA
Tl Tl
Sustainability
objectives
Users,
purpose
scope
$
Step 2
Step 1
fl 'Fl
14
15
Sustainability analysis
procedures
This part of the User’s guide describes how to carry out
a sustainability analysis. Appendix B provides more detailed
guidelines, organised by level of detailed analysis, but even
experienced users should start by reviewing these general
procedures.
The first three steps help managers define the objectives,
scope, and level of detail of the analysis. Since "sustainabil
ity" means different things to different people, these steps
can also help you reach consensus on an operational defini
tion for your specific analysis.
The next three steps describe how to set up, analyse, and
manipulate data to examine sustainability options. The last
two steps provide suggestions for selecting a sustainability
strategy and developing an action plan to carry it through.
s
3
■a
Step 1: Identify the users and specify the
purpose and scope of the analysis
Before beginning a sustainability analysis, the manager
needs to decide: who will be the user/audience of the
analysis, the purpose of the analysis, and the scope, that is,
the services and geographic area to include, and the time
frame.
• The user or audience. The manager, board of directors
or central directorate in a public programme, and donors
are likely users. Don’t forget community representatives.
It can help to develop "ownership" of the sustainability
strategy if they are involved from the beginning, especially
Module 9: Sustainability analysis; procedures
Users, purpose
and scope
16
WORKSHEET FOR SPECIFYING THE PURPOSE
OF THE ANALYSIS
User/audience:
Management learn
Especially chairman, treasurer
X Manager
x Board of directors
Central directorate
X Donors
Community
Other
___________________________________
Foundation rep
Purpose:
General knowledge
Monitoring progress
X Planning for the future
Decision-making
Other
_______
Need 5-10 year strategy
Scope:
X Geographic area
X Programme/project/activity
X Time/duration
Entire project area
All services, entire project
five years
if the communities are expected to play a significant role
in programme activities.
• Purpose. Is the information simply desired for general
knowledge, to evaluate progress in achieving sustainabil
ity, or to make a specific decision? The last is the most
serious, and the decision to be made should be clearly
stated so that the analysis can concentrate on providing
information needed for that decision. Typical decisions
are: continue or close the programme or its components;
expand or contract the scope and size of the programme;
and restructure the programme to become self-sufficient.
• Scope. The manager should determine:
What geographic area(s) will be included; the entire
country, a region, a city, several rural sites?
How much programmatic detail is desired? Is it suffi
cient to look at the overall PHC programme, or does the
user want to examine the sustainability of specific health
outcomes or services (ANC, ORT, training, etc.).
Module 9: Sustainability analysis; procedures
17
•a
j
j
-
What time frame should the analysis cover: the next
year, the next five years, the next six months, the next 25
years?
If there are multiple users/audiences, it would be helpful
to get each one to state their purposes and desired scope,
since each one could have different objectives that would
require distinct analyses.
Step 2: Clarify the objectives
Sustainability is a new term, and people have differing
views as to its meaning. The important thing is to agree on
a definition for this analysis rather than for the term as it is
used more generally.
There are at least three facets of your sustainability
objective that you should define clearly. The first is what
you want to sustain. Is it the end result (health outcomes/coverage), the intermediary mechanisms (services/institutions), or the resources (income/staff/facilities,
etc.)? The second is the level or magnitude to be sus
tained. It could be the same as now, somewhat higher, or
somewhat lower. The third is to identify any restrictions
on the sources of support. That is, to what degree must the
programme be self-sustaining?
Although many people think only of money when they
hear the word sustainability, that is not the perspective taken
here. We look at sustainability as consisting of three inter
related parts; the desired outcomes (health/coverage), the
services (or institutions), and the required resources.'
Resources -»
-3
PHC services ••
Objectives
Health outcomes
In developing a sustainability strategy, the manager must
select one of these as the principal objective. That is because
the three are inter-dependent and a change in any one
affects the other two. For example, if a manager wants to
sustain a certain package of PHC services, that determines
what the outcomes will be, and the resources that will be
needed. However, if the manager wants to sustain certain
outcomes, that determines the services needed, which in
turn determines the resource requirements. If the manager
Module 9: Sustainability analysis; procedures
IB
18
wants to sustain a certain mix and level of resources, that
determines the type and amount of services that can be
provided, which in turn affects the outcomes that will be
produced.
Thus, the manager must set the level desired for resources,
services or outcomes and then calculate the effects on the
other two.
Ideally, we should begin at the end of this resource-ser
vice-outcome chain, with the desired outcomes. We should
first ask, "What levels of health status and coverage does the
programme want to sustain?" Then, we can calculate the
types and levels of PHC services needed to achieve those
outcomes, and then the types and levels of resources needed
to provide those services. This is basically what we do in
planning.
OPTIONS: WHAT TO SUSTAIN
• Health outcomes/coverage. If this is your priority, then identify the priority target
groups. The worksheet lists the most common target groups for PHC. Check off those
that apply, or write them in. Write in the coverage objective for each target group, e.g.,
70% of children under two fully immunized. If you have gone through Module 1 recently,
copy the information from Worksheet A.
If this is the priority, identify the PHC services and
management support activities or institution(s) that need to be sustained. If health
coverage is your primary objective, then list the essential services as your secondary
objective. Identify those services that need to be sustained in order to achieve coverage
objectives. Typical services for children are ORT, immunization and growth monitoring,
Typical PHC services for women are antenatal care, tetanus toxoid, and family planning.
If you are planning to sustain clinical and outreach services, be sure to state this. Identify
the management functions to be sustained: planning, supervision, training, etc.
Sometimes the users are interested in sustaining service agencies or institutions. Examples
are; the Ministry of Health’s outreach department, a local hospital, a Red Cross chapter, a
community health worker association. There may also be certain parts of organisations
that the user wants to make sure are sustained, and they should be identified, also.
Examples are a regional training unit, a research and evaluation unit, a library, a laboratory,
and a school health unit.
• PHC services/institutions.
• Resources. It is also helpful to know if there are any specific resources that the user
wants to sustain. Obviously, funding is essential, but there may be specific sources of
funding that the user has in mind, for example, state grants, training fees, and income
generation revenue. Some types of contributions may be important to sustain as well.
High on the list of many PHC programmes are in-kind contributions from community
organisations, CHWs, health committees, space, equipment, furniture, etc.
Finally, there may be some specific types of personnel that are essential and must be
sustained if the programme is to be effective. Examples are outreach workers, clinic nurses,
an MIS specialist, trainers, administrators, etc.
If
Module 9. Sustainability analysis; procedures
19
"3
"3
3
3
3
3
=3
-3
3
-3
’3
3
'-3
3
Realistically, many managers work with fixed budgets
(resources). They may have to work forward, starting with
available resources and then the questions are: 1) what
services can we sustain with the available resources; and 2)
what health outcomes can we expect to sustain through
those services?
Still other managers are primarily concerned with sus
taining their existing services and institutions. They may
want to begin in the middle with PHC services. Their
questions would be, "What resources will be needed to
sustain these services or this institution?" and, "What health
outcomes can we expect to achieve through these services
or this institution?"
Managers who are inclined to focus on sustaining their
institutions (organisations) rather than services and health
outcomes, should carefully consider whether the services are
more important than the implementing institution, or viceversa. Some organisations truly are essential for future
health outcomes, but others are not. In any case, the
importance of a single organisation may change as people
turn to other sources for services, or as community or
ganisations and families take increased responsibility for
their own health.
Use the worksheet on the following page to define what
you want to sustain and the level for your first priority.
Obviously, if the objective is to sustain the programme,
services, institutions and resources exactly as they are right
now, then all of these elements do not need to be listed
individually. But if changes are expected through expansion --------------------or contraction, then it will be important to note that here.
Define what to
"Sustain" usually implies maintaining current outcomes,
sustain
services and the resources required to do so. If coverage is
80 percent, the question will usually be, "How can we
maintain that level of coverage?"
But what is to be sustained in the future could be more
or less than what exists currently. If coverage is low, say
20%, the objective may be to increase it in the future to, say
50%, not merely maintain the current low level. But this
may not be realistic; 25% may be realistic. Some PHC
programmes have had to reduce services to sustain them-
Module 9: Sustainability analysis; procedures
20
WORKSHEET FOR SPECIFYING OBJECTIVES
WHAT TO SUSTAIN AND AT WHAT LEVEL
Priority health coverage:
Indicators
Level
__ Children < 5
X Children < 2
See Worksheet A, Module 1 for list
Same
X Pregnant women
See Worksheet A, Module 1 for list
Same
X Married women 15-49
See Worksheet A, Module 1 for list
Same
__ Other
Services/institutions:
X PHC outreach services
GM, ORT, Nutrition education
X PHC clinical services (list)
Immunization, ANC, FP
__ Management functions (list)
__ Agency/institution/unit (list)
__ Other
Resources:
__ Funding (specify)
__ Contributions (cash, in-kind)
Core technical staff
X Personnel.
__ Technical capability
__ Other:
selves at a more affordable level. A reduction to 15% may
be necessary. Others have added new services to attract
revenues from other sources. For example, some PHC
programmes have added maternity centres, training centres,
and income generating activities to the standard PHC ser
vice package.
Thus, the manager must not only specify what is to be
sustained, but also the level — which could be the current
level, something less, or something greater.
The results could be summarised in a simple table, as
shown in Table 1 of the Quick start chapter on page 1. It is
the same format as used in Module 1. In fact, you could use
that table if it reflects your sustainability objectives.
if
Module 9: Sustainability analysis; procedures
21
In that example the manager simply wants to sustain the
current programme for another five years. There is no intent
to expand, increase services or coverage, but just to survive.
Thus, the objective is to maintain the current level and
mix of PHC services to the current target popula
tion.
Finally, the manager must clarify whether "sustainability"
implies restrictions on sources of support or not. As noted
above, donors tend to be interested in seeing projects con
tinue after their support ends. They may be willing to
provide support initially only if the project can demonstrate
that it will become "self-sustaining" at some point in the
future. This could mean "without any external support,"
which is a very serious restriction. Strictly speaking, a
project that is self-sustaining would operate entirely on
income generated from sales of its services and products. It
would not need grants, in-kind contributions, donations, or
any other unearned resources. Private sector providers
usually fall into this category. If they do not generate
enough income to pay all of their bills, they go out of
business.
Many projects consider themselves sustainable if they can
generate grants from other donors to replace those of
current donors. These grants could come from local phi
lanthropists, businesses, tax revenues, fund-raisers, as well
as national and international foundations, UN agencies,
foreign assistance agencies, and the like. Some donors frown
on "substitution grants," but some believe they are legitimate,
depending on the source.
Therefore, to avoid any misunderstanding between donor
and grantee over the meaning of sustainability, these three
facets of the term must be defined to. make sure that the
results of the analysis are acceptable to all of the users.
WORKSHEET FOR SPECIFYING THE RESTRICTIONS
___________________________ON SUSTAINABILITY________________
Sustainability restrictions
No restrictions
X Donor restrictions
Other
Self-sustaining
Donor wants to phase out in 3-5 years
Module 9: Sustainability analysis; procedures
Specify
restrictions
Strategic assessment: Check the level of analysis to be undertaken
X
____
____
Level 1: A general analysis of each of the ten factors
Level 2: A general analysis of eight 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 six of the factors plus a detailed assessment of four
of them. You assess the effects of changes in target population size and target
group KAP (coverage) on each PHC service and each management service.
Financial assessment: Check the level of analysis to be undertaken
X
____
____
Level 1: A general analysis of revenues by source and expenditures by general
ledger items; and a "what-if1 analysis of the effect of changes in the ten factors on
future revenues and expenditures.
Level 2: A detailed analysis of revenues by source and expenditures by PHC
service and management service; and a "what-if" analysis of the effect of
changes in the ten factors on future revenues and expenditures.
Level 3: A detailed analysis of revenues by source and expenditures by PHC
service and management service taking into account changes in target
population size and target group KAP (coverage), and a "what-if" analysis
of the effect of changes in the ten factors on future revenues and expenditures.
W *FI ‘Fl R
'Fl ’Fl 'Fl ’Fl
WORKSHEET FOR SELECTING THE TYPE OF ASSESSMENT AND LEVEL
OF DETAIL
‘F
l ‘Fl ‘Fl ‘Fl
Decide level of
detail
At this point the manager and other users must make two
preliminary decisions:
• whether to conduct a strategic assessment, a financial as
sessment, or both; and,
• which level of detail to select for each.
As mentioned previously, a strategic assessment allows you
to look at the "big picture" to determine the combined effect
of the ten sustainability factors on your programme. A finan
cial assessment enables you to make projections of future
revenues and expenditures, and then to adjust them to see the
effects of changing assumptions.
You also need to decide whether to conduct a Level 1, 2, or
3 analysis - or all three. We have already recommended that
everyone do a Level 1 analysis, since it is quick and simple.
After completing this, you may decide to do a Level 2 or 3
analysis, also. Or you can decide now which level or levels you
want to conduct If you haven’t done so already, you may want
to glance through Appendices A and B, which provide the
instructions for each level. This may give you a good idea of
what is involved in each Level.
The boxes that follow summarise the data you will need
to have for each level of analysis.
■
'
Step 3: Decide on the level of detail needed
!
i
f? fFI ‘11 ‘Fl ‘Fl
22
K~
if
Module 9: Sustainability analysis; procedures
23
assessment. The one on the right summarises the data you
would need for different levels of financial assessment.
You will need to provide some minimal information,
summary estimates, on the indicators for each of the ten
sustainability factors. For some factors, such as revenues
and expenditures, you will need to provide more detail. As
the chart shows, the amount of detail required increases with
each level.
Strategic assessment
Sustainability
Level Level
factors
1
2
Population size
Target group KAP
PHC service quality
Management support
Political commitment
Personnel resources
Revenues
Expenditures
Environmental factors
‘
' Summary estimates only
X Detailed estimates
X
X
Level
3
X
X
X
X
N.B. Don't forget that you can mix levels of
analysis. You can do a Level 3 Strategic
assessment and a Level 1 Financial
assessment, for example.
Financial assessment
Sustainability
Level Level
2
1
factors
•
Population size
Target group KAP
PHC service quality
Management support
Political commitment
Personnel resources
X1
Revenues
X2
Expenditures
•
Environmental factors
' Summary estimates only
X Detailed estimates
•
X
X
•
X1
X3
•
Level
3
X
X
X
X
■
•
X1
X3
1 Revenues by source
2 Expenditures by general ledger item
3 Expenditures by PHC service and
management activity
Step 4: Conduct strategic assessment
Although the "bottom line" in any sustainability strategy
is money - bringing in enough revenues to meet expendi
tures - money is not the only consideration. As noted earlier,
sustainability can be profoundly influenced by managerial
and political factors, some of which are discussed below. If
one or more of these is a threat, then it will have to be
removed or "neutralised" to make the sustainability strategy
successful. Factors can also be positive and enhance sus
tainability. Then they can be seen as opportunities to
expand or improve the programme.
This module identifies ten sustainability factors, which are
summarised as follows:
Module 9: Sustainability analysis; procedures
Assess strategy
24
• Target population size: The degree to which the size, composition
and distribution of your programme’s target populations are likely to
change in the future. Rapid and large increases or decreases in the size
of the target populations can be threats to sustainability.
• Target group knowledge, attitudes and practice (coverage): The
degree to which the principal target groups of the project are and will
continue to be knowledgeable about PHC services and their benefits;
motivated to utilise those services; and, actually practice healthful
habits, including utilising PHC services and institutionalising healthful
behavior at home. Low knowledge, poor motivation and poor health
habits are threats to sustainability. High levels of KAP can reduce the
need for continued services.
• PHC service quality: The degree to which high quality PHC products
and services can continue to be provided in the future. Low quality
and/or the absence of key services can be a threat, while high quality
may increase demand for services and support of them.
• Management support: The degree to which important PHC project
management activities, such as planning and supervision, can be main
tained at current or increased levels of effectiveness and efficiency. Weak
or missing support services can be a threat to sustainability.
• Organisational capacity: The degree to which strong parent and
collaborating PHC organisation(s) can be maintained in the future. Even
well-managed and financed programmes may collapse if implementing
organisations are weak or inefficient. Well-managed organisations con
tribute greatly to the sustainability of individual programmes. Commu
nity organisations may be particularly critical for the sustainability of
certain programmes.
• Political commitment: The degree to which influential individuals,
groups and organisations will support the project in the future. High,
broad-based commitment is conducive to sustainability; low, narrow
based commitment is a threat.
• Personnel resources: The degree to which skilled management, tech
nical and field staff can be retained in the future. Loss of key staff is a
threat to sustainability Retention of key staff can ensure continuity and
stimulate interest in expansion and growth.
• Programme revenues: The degree to which needed monetary income
will be maintained in the future. Inadequate income is obviously a threat
(Note that the strategic assessment of this factor is limited to a broad
assessment of revenue trends, threats and opportunities in the future.
Detailed assessment of revenue amounts and sources is left to the
financial assessment.)
• Programme expenditures: The degree to which costs can be con
trolled in the future. High programme costs'are a threat. As with
Revenues, the strategic assessment concentrates on the broad picture.
Detailed analysis would be done in the financial assessment.
• Environment: The degree to which changes in such contextual factors
as weather, the economy, political stability, transportation systems, etc.,
are likely to change in the future. Small and gradual changes can usually
be absorbed, but large and sudden changes can have a significant positive
or negative effect on sustainability.
Module 9; Sustainability analysis; procedures
25
Appendix A contains checklists for each of the ten
sustainability factors. It can help you define that factor;
identify key indicators to assess whether it is a threat to (or
opportunity to enhance) sustainability^ identify several strat
egies for coping with the threat; and, estimate the financial
implications of the strategy. An excerpt from one of these
checklists is shown on the following page.
Gather data
In some cases, you may already know enough about these
factors to move to the next step. Sometimes you will need
to gather additional information on at least a few of the
factors. Hopefully, most of the data you need will already
be available from a recent census, surveys, baseline assess
ments, your household registration system, clinic records,
government estimates of morbidity, mortality and coverage,
financial reports, and ad hoc studies.
Formally gathered data may need to be supplemented
from informal sources, especially with regard to organisatio
nal capacity, political commitment and other factors that are
not easily quantified. You probably have a variety of infor
mal "experts" that you can call on for this information. These
"key informants", as they are called, can include CHWs,
politicians, community leaders, your own staff, consultants,
university specialists, programme clients, and any others
who have specific and credible knowledge about one of the
factors. You may want to gather a cross-section of such key
informants together to help you brainstorm sustainability
factors and then assess their likely affect on your pro
gramme.
Do not underestimate the value of informed opinion. It
can be very accurate, especially when presented in a diverse
group. It is also a fast and inexpensive way to gather needed
information. You do not need precise estimates for these
factors, though, of course, your projections will be more
accurate if your data are precise. Remember that the
objective of this exercise is to conduct a general assess
ment of sustainability and to develop a general strategy
for achieving sustainability. You don’t need exact figures for
that, only reasonable estimates. Once you have an acceptable
strategy, then you can prepare a detailed sustainability plan.
Module 9: Sustainability analysis; procedures
Collect essential
data
26
EXCERPT FROM CHECKLIST ON TARGET GROUP KAP (COVERAGE)
Target group knowledge, attitudes and practice - (coverage); The degree to which
the principal target groups of the project are and will continue to be knowledgeable about
PHC services and their benefits; motivated to utilise these services; and actually practice
healthful habits, including utilising PHC services and institutionalising healthful behaviour at
home. Low knowledge, poor motivation and poor health habits are threats to sustainability.
High levels of KAP can reduce the need for continued services.
Key indicators: For the PHC programme overall and/or for each PHC Service. Also see
Modules 2 and 5 for extensive lists of KAP indicators for each PHC service.
1. Is knowledge about PHC adequate to sustain
• demand for services?
• correct PHC practices at home?
2. Is motivation adequate to sustain
• demand for services?
• correct PHC practices at home?
3. Is there adequate
• demand for services?
• correct PHC practices at home?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
Adapt the programme to traditional practices
Link low-demand with high-demand services
Emphasise healthful changes that have obvious benefits
Plan continued, but gradually reduced support for behavioural changes
Educate all family members, not just mothers, about PHC
Educate community and political leaders about PHC
Launch a public relations or advertising campaign
Sponsor a PHC Week, PHC Baby Contest, or similar event to attract public atten
tion to PHC
9. Increase home visits to those who aren’t participating in PHC
10. Use satisfied mothers to recruit others to PHC
11. Set up a 10-household PHC Communicator system
12. Involve school children in promoting PHC at home
1.
2.
3.
4.
5.
6.
7.
8.
Financial implications: For each strategy selected, determine what are, if any, the fi
nancial implications for the project.
1. Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
2. Will these be: one-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
If you do not have all of the required data and you don’t
feel comfortable about making estimates, you may want to
take some time to collect the needed data. Some of the other
PHC MAP modules may be of help to you. Module 8 (Cost
analysis) can help you collect and classify data for the
Module 9: Sustainability analysis; procedures
27
revenue and expenditure factors. Modules 6 and 7 can help
you assess PHC service quality and management activities.
Module 5 can help you select additional indicators for all of
the factors. Modules 2 and 4 can help you gather important
information on target group KAF; coverage, and morbidity
and mortality priorities.
Based on the above information, you should now deter
mine which sustainability factors are threats, which present
opportunities, and which are unlikely to have any effect.
You should also make rough judgements regarding their
importance. The following excerpt from one of the work
sheets in Appendix B shows how each factor might be
assessed using one or more (-) to indicate a threat, (+) to
indicate an opportunity, or (0) to indicate it is neutral.
Threat/opportunity factor:
Description
Target population size; Threat:
In-migration of 2%
annually projected
Target group KAP (coverage); Threat: New clientele
needs education, counselling
PHC service quality; Opportunity:
Improving steadily
Effect
——
—
+
The first factor reveals a threat to sustainability. The
programme’s target population will increase by two percent
per year. This will increase the burden on the programme
to provide services. The second factor also reveals a threat.
New clients are less knowledgeable about PHC than current
ones and will need extra IEC and counselling if they are to
adopt healthful practices. The third factor reveals a positive
indicator. PHC service quality has been improving, perhaps
due to management attention to staff training among other
things. Improved quality should mean that there will be
fewer programme-induced side-effects, fewer unnecessary
return visits, greater demand, greater consistency of use of
PHC, and so forth. This could have a positive effect on
coverage and reduce costs as well.
Working as a group, the management team should review
each factor, calling upon data, experience and brainstorming
to identify those that pose threats and those that present
opportunities. Remember that the analysis should keep in
mind the sustainability objectives. You are attempting to
Module 9; Sustainability analysis; procedures
Determine
threats and
opportunities
28
identify threats to the achievement of those objectives, and
opportunities that might make it easier to achieve them, as
well.
Step 5: Identify strategies for addressing
threats and opportunities
Revise, refine
strategy
Next you identify strategies to deal with serious threats
and to take advantage of opportunities. In reality, this step
will probably be done in conjunction with Step 4, but you
may want to identify all of the threats first and then develop
strategies to deal with the overall problems that you identify.
Strategy development is one of those activities that lends
itself to group work. There are also several simple tools that
you can use to stimulate ideas. Three of them are listed
below. Consult the Problem-solving guide for others.
When a strategy has been selected, it is relatively easy to
determine if it has financial implications, and if so, to
estimate their costs for the financial assessment. This is the
same procedure that managers would follow in costing out
any other PHC project activity. It will be important to
distinguish between one-time, recurrent and compounded
costs (discussed in Step 6 and in Appendix B). And do not
forget revenues. Some strategies may earn money for the
project.
Module 9: Sustainability analysis; procedures
29
•3
HOW TO SELECT STRATEGIES
• Understand and attack the root problem, not the symptoms Ask "Why" at least
five times. Example:
J
3
73
□ij
The community doesn’t support the programme.
Why?
The community leaders are against it.
Why?
They think it’s being imposed on them.
Why?
Because they don’t understand the philosophy of PHC.
Why?
Because it hasn't been made clear to them.
Why?
Because no one has discussed it with them.
Although the "why" questions could go on forever, at some point the cause of the
problem is made clear, and the solution is fairly obvious. In this example, the likely
solution would be for senior project staff to meet with the community leaders to explain
the programme’s goals, philosophy, procedures, the community role, and to solicit their
involvement.
• Review lists of solutions that have worked before. The literature on PHC and
related areas (community development, family planning, agriculture extension) is full of
examples of problems that others have encountered and solutions they have tried. These
"lessons learned" are invaluable for managers who are seeking solutions. Consult the
PHC MAP Problem-soluing guide for some ideas.
• Brainstorm solutions. Gather the staff, CHWs, community leaders and others
together to brainstorm solutions to significant problems. For example, here are some
ideas for making PHC services more efficient:
Reduce the frequency of household visits to low-risk cases
Limit services to high and medium-risk cases
Conduct a time analysis to find ways to reduce unproductive time
Reorganise home visit and clinic session schedules to save time, travel and avoid
duplication
Provide incentives to staff to become more efficient
Hire contract staff to provide evening and weekend services
The following worksheet (taken from Appendix B)
illustrates how each of the ten sustainability factors can be
analysed in terms of threats/opportunities, strategies, and
financial implications. For example, the target group is
expected to increase significantly due to in-migration, and
that is a significant threat (-). The strategy for dealing with
it is to increase services, which will, of course, raise costs.
The strategy for paying for this is to increase revenues
through increasing service fees; soliciting more contribu
tions; and reducing service costs by increasing community
in-kind contributions.
The "0" in the "Effect" column on the right indicates that
this would neutralise the threat. The entries in the Financial
implications columns indicate that revenues would be in-
Module 9: Sustainability analysis; procedures
\° Table 2: Sustainability factors worksheet
LEVEL 1
FINANCIAL IMPLICATIONS
File M0D9SA1.WQ1 or MOD9SA1.WK1
Classify each factor, identify strategies where appropriate, estimate financial implications
Threat/opportunity factor; description
1.
Target group size. Threat: In-migration of
5% annually projected
2.
Target group KAP (coverage). Threat New
clientele need education and counseling.
PHC service quality. Opportunity:
Improving steadily
Management support Opportunity: Strong
and improving
Organisational capacity. Opportunity:
Strong organisation
3.
4
5.
Module 9: Sustainability; procedures
6.
Political commitment. Threat. Lack of
community support
7.
Personnel resources. Threat: May lose key
staff as donor support ends
8.
Revenues. Threat; Losing some donor
support in 1993
9
Expenditures. Threat: Inflation of 3%
annually. Other line item costs increasing.
some decreasing
10. Environment. Neutral: No changes expected
E fl
Effect
+
+
+
■
0
Strategy
Increase services. Raise revenues through
increased fees, contributions; Reduce costs
via community in-kind contnbutions
Add special IEC sessions for new IEC
clientele
TQM already installed: Quality should
improve; costs may decrease
Expect increase in efficiency: Should lower
costs later
No strategy at present Could expand into
other areas
Expenditures
Revenues
Effect
1-Time
Rev.
Rcrnt
Rev.
Cmpnd. 1-Time
Costs
Rev.
Rcrnt.
Costs
+5%
1.0%
0
Cmpnd.
Costs
+2%
0
+
+
+
Hold 2-3 education/PR sessions in each
community
0
+1%
Develop improved compensation package
0
+3%
Develop alternative sources of funds: Fees,
fund-raising, training, contributions.
Recurrent Fees 5%, grants 20%, outside
income 200%
Compounded- Contrib 10%: govt 596, grants
5%, outside 20%
Increase revenues > 3% (see revenues).
Recurrent: Indirect costs - 10%; in-kind
contrib +10%
Compound.- Personnel +2%; travel +2%;
supplies -3%, ODC -5%, in-kind +5%
+
+
+5%
+20%
+200%
+10%
+5%
+5%
+20%
-10%
+10%
+2%
+2%
-3%
-5%
+3%
+5%
0
Entries cannot be made in shaded cells in the computer program.
S fl ■' fl! fl! fl fli fl fl. fl! fl fl fl. fl' (fl fl fl fl fl fl', fl fl
31
•3
ji
3
creased one percent per year (as a result of increased service
fees), and costs would increase some five percent annually.
The additional revenues needed to offset the increased costs
would be raised through other means, which are summarised
in the "Revenues" row.
See Appendix B for more detailed instructions on using
the worksheets.
Step 6: Conduct financial assessment
,ts
*
s
' JB
-■«
'3
3
Make 5-year projections. A Financial assessment of
sustainability focuses on projections of future revenues and
expenditures. There are many ways to make such projec
tions. The simplest is to use the current year’s figures for
each of the next five years. The most complex is to do a
strategic assessment first and then compute the revenues
and expenditures for various scenarios.
The following example, uses current year (CY) revenue
and expenditure figures to make projections for the next five
years. The line items, general ledger account lines, are
Assess finances
Table 3: Initial projections of revenues and expenditures
(in ’000)
3.1 Revenues
CY
Yrl
Yr 2
Yr 3
Yr 4
Yr 5
Total
Fees
Contributions
Govt, subsidies
Grants/contract
Outside income
Total
17
22
21
220
2
282
18
23
20
215
3
279
19
24
25
205
2
275
20
25
23
200
2
270
21
26
25
185
2
259
23
28
25
175
2
253
101
126
118
980
11
1,336
3.2 Expenditures
CY
Yrl
Yr 2
Yr 3
Yr 4
Yr 5
Total
Personnel
Travel/Per diem
Supplies
Equipment
Other direct costs
Indirect costs
Total
143
35
29
45
10
16
278
148
38
28
35
12
16
277
155
40
32
25
13
16
281
155
35
28
30
14
16
278
151
38
27
27
15
16
274
150
35
26
25
16
16
268
759
186
141
142
70
80
1,378
3.3 Summary
CY
Yrl
Yr 2
Yr 3
Yr 4
Yr 5
Total
Revenues
Expenditures
Balance
282
278
4
279
277
2
275
281
-6
270
278
-8
259
274
-15
253
268
-15
1,366
1,378
-42
Module 9: Sustainability analysis; procedures
32
Figure 1: Initial projections of revenues and expenditures (5 years)
shown in Table 1. Obviously, these figures should be as
realistic as possible if they are going to be of any use.
The above graph, Figure 1, illustrates the relationship
between the revenues and expenditures in this table. It also
shows the "break-even" point, where costs and revenues are
equal. Prior to this point the programme was sustainable.
Subsequent to this point it isn’t, as costs are expected to
exceed revenues. This concept of a "break-even point,"
which is commonly used in business, is a useful summary
measure of financial sustainability.
Examine the results; identify options for increas
ing revenues and/or reducing costs. If the initial esti
mates show that the programme will be sustainable, then
further analysis is probably not needed. If it shows, as this
example does, that expenditures are going to exceed reve
nues significantly, then the analysis should continue. Basi
cally, this involves looking for ways to "balance the budget."
The manager should examine as many options as necessary
to reduce costs and increase revenues. Some suggestions
are shown in the accompanying box.
Module 9: Sustainability analysis; procedures
33
CHECKLIST OF OPTIONS FOR INCREASING REVENUES AND
DECREASING COSTS
Increasing revenues
• Increase service fees
• Add non-PHC products that are in demand by the clientele
• Start community funds to offset costs
• Solicit government contributions
• Develop a fund-raising campaign/strategy
• Submit proposals for grants and contracts for training, research, demonstrations
• Add or upgrade services to attract a higher-income clientele
• Add a proven income-generating activity to the project
• Stratify services for different target groups, based on willingness and ability to
pay
Decreasing costs
• Increase in-kind contributions:
Traditional (labour, transportation, supplies, etc.)
Non-traditional (telephone, utilities, uniforms, food, school children to
assist CHWs, etc.)
• Keep inventories low, do not overstock.
• Delay/postpone capital expenditures, expansion plans
• Transfer responsibility for selected services, tasks, staff, vehicle maintenance, etc.,
to others: Ministry of Health, other NGOs, and community organisations.
• Close unaffordable facilities
• Rent out unused facility space
• Revise objectives and service strategies to fit new donor interests
• Reduce or eliminate high-cost activities
• Combine staff roles
• Identify low-cost substitutes for supplies, equipment, etc., especially expensive
imported items
• Use local, rather than international consultants
You can make the adjustments to the initial table by hand,
using a hand calculator. For example, if you have identified
a way to increase revenues by five percent each year, just
adjust the figures in the revenue columns of your projections.
Revenues and expenditures can change in three major
ways. There can be one-time changes, recurrent changes,
or compounded changes. The worksheets allow you to
specify which type of change you anticipate.
Module 9: Sustainability analysis; procedures
34
• One-time: The change occurs only once and is
neither continued nor imposed again.
Revenue: A one-time assessment of all households.
Expenditure: A one-time bonus paid to all staff.
• Recurrent: The change is made permanent. It is
continued.
Revenue: Household assessments are levied each
year, but the amount of the assessment stays the same.
Expenditure: Staff are given a five percent salary
increase which is continued for as long as they stay in
the programme. It is neither increased nor decreased
each year.
• Compounded: The change increases or decreases over
time by a fixed amount or percentage.
Revenue: Household assessments go up an additional
five percent each year.
Expenditure: Staff salaries are raised five percent each
year.
You can enter these estimated changes in a "what-if"
analysis table, such as the one shown below and then make
your adjustments to your financial projections. If you use
the computer programs that come with this module, you can
examine a variety of different economic assumptions very
quickly to see their effects on revenues and expenditures.
You can see, for example, WHAT would happen IF fees were
increased by 6% annually (or by any other percentage). You
can see what would happen if personnel expenses increased,
or decreased, if travel costs changed, and so forth. The
results would be shown in another table (similar to Table 3
above), computed automatically. You can "play" with these
assumptions, changing them over and over. Obviously, these
changes have to be realistic. The changes can continue to
be made until an acceptable break-even point is reached, at
which point the programme reaches sustainability.
Module 9: Sustainability analysis; procedures
35
What-if analysis table: Financial factors
Revenue categories
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Other
Other
Expenditures
categories
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
A(+) increase revenues
1-Time Recrnt Cmpnd. A(-) decrease revenues
revenue revenue revenue
5.0%
10.0%
5.0%
20.0%
5.0%
200.0%
20.0%
1-Time
costs
Recrnt.
costs
Cmpnd. A(+) increase costs
A(-) decrease costs
costs
2.0%
2.0%
-3.0%
-5.0%
-10.0%
Other factors affecting expenditures
Inflation
X
X
In-kind contributions
10.0%
A(+) increase all costs
3.0% A(-) decrease all costs
5.0%
In our example, the manager is trying to respond to an
expected increase in the demand for services by expanding
PHC services. Obviously, this will increase costs. Personnel,
travel and other direct costs are expected to increase annu
ally by 2-5%. Inflation will increase all costs by 3% annually.
Some savings will be made in supplies. They will decrease
3% annually. The increases in costs will be offset by increas
ing revenues from five sources: A five percent increase in
service fees; and, annual increases in contributions, govern
ment subsidies, grants/contracts and outside income. A key
feature of the strategy is a large annual increase in in-kind
contributions from communities. This will help the project
expand services without hiring more staff and in other ways
increasing costs. If this strategy can be successfully im
plemented, it will enable the project to remain sustainable
while expanding services and cutting costs.
Module 9: Sustainability analysis; procedures
36
Figure 2: Adjusted projections for revenues and expenditures (5 years)
Develop strategy;
project costs and
revenues
ii
Figure 2 shows the dramatic change in revenue and
expenditure projections that this strategy will produce.
Although the strategic and financial assessments can be
done independently, they should be linked. We recommend
that you do the Strategic assessment first and then prepare
your financial projections and assumptions to fit that strat
egy. You may find that you have to revise parts of the
strategy to achieve financial sustainability. If so, revise the
strategy accordingly.
The computer programmes for Levels 1-3 include an
option that lets you link the strategic and financial assess
ments directly. To do this you first estimate the financial
implications of each part of your strategy. You enter these
estimates to the right of your worksheet (Table 2). Then you
transfer those estimates to the "what-if analysis table (Table
4). You can then change those assumptions to see the effect
on overall financial sustainability. See Appendix B for
examples and instructions.
Module 9: Sustainability analysis; procedures
37
Table 4: What-if analysis worksheet
MOD9L1.WQ1 or MOD9L1.WK1
LEVEL 1 WORKSHEET
Enter projected annual % increase (+) or decrease (-). See results in Table 5.
Non-financial factors
1-Time Rcrnt Compnd. 1-Time
Rcrnt. Compnd.
rev.
rev.
rev.
costs
costs
costs
(See notes below)
Target population size
1.0%
Target group KAP (coverage)
X
X
X
PHC service quality
Management support
Organisational capacity
X
X
X
X
X
X
X
X
X
Political commitment
Personnel resources
Environment
X
X
X
5.0%
1.0%
3.0%
Total pop size: A(+) in revenues increases fees; A(+) in expenditures increases all costs
Political commitment. A(+) increases all revenue; A(+) in expenditures increases all costs
Environment: A(+) increases all revenues; A(+) in expenditures increases all costs
All other factors: No effect on revenues; A(+) in expenditures increases all costs
By this time you should have your basic analysis com
pleted. All of your basic assumptions, strategies, projected
expenditures and revenues should have been entered into
worksheets, or the computer program, and the first calcula
tions made.
If the projections are satisfactory, you can stop. If they
are not, you will want to experiment with changes in one or
more of the assumptions until you arrive at an acceptable
solution. To make changes in the strategic assessment, just
enter your new estimates. This is a "paper and pencil"
exercise, very "low-tech." Make sure you have a group help
you with this reassessment, however. The results are more
likely to be closer to reality and acceptable if a number of
knowledgeable people participate in the analysis.
Changes in the financial assessment can be made most
easily by using the computer program. Just enter the new
revenue, expenditure and/or assumption figures in the ap
propriate template to see the results. The calculations can
be done by hand, but as we have said before, that is a
cumbersome procedure. If you use the computer program,
the calculations will be made automatically and shown in an
output table. See Appendix B for examples of this "what-if"
analysis for each level.
Module 9: Sustainability analysis; procedures
All of the key assumptions should be included in a more
detailed documentation to make sure that they are not
forgotten or overlooked.
Finally, an action plan should be developed to make sure
that the sustainability strategy is implemented. This will
often include two actions. First, a detailed plan needs to be
developed. That plan can be developed as part of the normal
planning strategy, but it should incorporate the assumptions
made in the strategy.
Second, the staff, management, directors, etc., need to
build sustainability thinking and action into their day-to-day
work. Everyone can and should contribute. Managers and
policy-makers are the likely ones to develop political com
mitment, contact other agencies for funds, negotiate with
other providers to take over unsustainable project tasks, and
develop new ideas for increasing revenues.
if
Module 9: Sustainability analysis; procedures
fl fl fl fl fl fl fl F 'R 'R Fl fl ff 'R ’fl W « tf
Assumptions: A significant amount of in-migration is ex
pected over the next several years. New clients will need additional
counselling if PHC coverage is to be maintained. Community
support for the programme is not strong enough. Some donor
support will be lost in 1993, and this could affect our ability to retain
key staff. Inflation is expected to be mild, but this will also affect
costs.
A possible strategy: Clearly, services will have to be ex
panded to meet expected increases in demand, but that will raise
costs. New revenue sources will be sought (fund-raising, raising
service fees, seeking local contributions, offering training in PHC
management for a fee). An important part of the strategy will be
to raise community involvement in providing PHC services. This
will enable the programme to expand services without increasing
staff and other associated costs.
*?l W
Manipulation of the variables and assumptions should
eventually lead to an "optimal" strategy. This is one that will
produce the best results with the funds available, given all of
the constraints that the project faces.
That strategy should be written down. A general sum
mary might look as follows;
I
Strategic action
plan
f
Step 7: Select a strategy and develop an
action plan
Fl Ti
38
39
Line staff can help by identifying and implementing ways
to reduce costs, increase efficiency, and solicit in-kind con
tributions from local organisations and communities.
It would also be prudent to review the sustainability
strategy and plan each year, both to make sure that it is still
realistic, and to update it, and possibly extend it beyond the
five-year projection period.
Turn to Appendices A and B for more details. Appendix
A contains checklists for assessing each of the 10 Sus
tainability factors. Appendix B contains instructions for
carrying out each level of analysis. The computer files you
need for Appendix B are on the accompanying disk. Blank
worksheets can be found in Appendix C.
Module 9: Sustainability analysis; procedures
41
Appendix A: Sustainability factors,
indicators and strategies
This appendix defines ten common factors that affect sustainability. Its purpose is to
provide you with checklists that can help you identify and assess factors that could be threats
to sustainability, and then work out a strategy for dealing with each threat. Each factor is
presented on a separate page and follows a standard format:
• What the factor is
• Why it is important and indicators for assessing the factor
• Strategies for dealing with it
There is also a standard suggestion for determining the financial implications of strategies
that are selected to be implemented.
The ten sustainability factors:
See also:
• Target population size, composition and distribution
• Target group knowledge, attitudes and practices (KAP)
Module 2
• PHC service quality
Module 6
® Management support
Module 7
•
•
°
•
®
Organisational capacity
Political commitment
Personnel resources
Programme revenues
Programme expenditures
Module 8
Module 8
• Environment
Module 2 can help you examine target group KAP in much more detail. It contains
questionnaires that can be used to assess the knowledge, attitudes and practices (coverage) of
the most common PHC target groups for the most common PHC services. The KAP
indicators are also summarised in Module 5.
Modules 6 and 7 can help you assess each PHC service and each management support
activity in much greater detail. The indicators in these modules are also summarised in Module
5 and cover the following components:
Module 9: Sustainability analysis; appendix A
42
PHC services
Management services
Antenatal care
Tetanus toxoid
Delivery/postnatal care
Family planning
Breast feeding
Growth monitoring
Nutrition education
Child immunization
Acute respiratory infections
Diarrhoeal disease control
Oral rehydration therapy
Water, sanitation, hygiene
Malaria treatment
Tuberculosis
Child disabilities
Sexually-transmitted diseases
HIV/AIDS
Treatment of minor ailments
Planning
Training
Supervision
Personnel management
Financial management
Logistics
Information management
Community organisation
Finally, Module 8 can help you gather more information on two other factors: revenues
and expenditures.
if
Module 9: Sustainability analysis; appendix A
43
Target population size, composition, and distribution
What it is: The degree to which the size, composition and distribution of the target
population is likely to change in the future. Rapid and large increases or decreases in the
size of the target populations can be threats to sustainability.
Why it is important: When the general population increases or decreases, there is a
corresponding change in the size of the PHC target groups in that population - women
aged 15-49, children 0-2, 3-5 years, and so forth. A rapid or large increase can increase
workload significantly, and this can lead to increased costs and/or a decline in service quality.
A rapid or large decrease can reduce demand for services, which can affect revenues and
political support for the project.
Key indicators: Are the sizes of the target groups likely to increase or decrease
significantly (10%) over the next five years due to:
1. Population growth
Natural increases due to birth and death rates.
2. Migration
In-or-out migration
3. Socio-economic status
Improvement or decline in the SES of target
groups
4. Change in catchment areas
Expansion or shrinkage of the project area
5. Health needs
Emergence of new health priorities (AIDS) or de
cline of current priorities (TB).
Strategies: For each problem or opportunity, identify a strategy Some examples:
1. Concentrate services on selected geographic areas
2 Reduce coverage targets
3. Reduce services offered to keep coverage of remaining services high
4. Transfer services of population groups to other agencies or to the private sector
5. Strengthen family planning to reduce 2-yr old growth rates
6. Triage services to those most in need
7. Reduce outreach services
8. Enlist support of communities to handle outreach
9 Expand services to meet needs
10. Reclassify target groups (raise eligibility standards)
11. Develop collaborative arrangement with other providers to increase/expand
services
12 Reduce frequency of services per person
Financial implications: For each strategy selected, determine what are (if any) the
financial implications for the project.
1.
2.
3.
Will costs increase?
For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
Will these be: One-time, recurrent, or compounded costs?
Will revenues increase? From what source(s) and by how much?
Module 9: Sustainability analysis; appendix A
What it is: The degree to which the principal target groups of the project are and will
continue to be knowledgeable about PHC services and their benefits; motivated to utilise
those services; and actually practice healthful habits, including utilising PHC services and
institutionalising healthful behaviour at home.
Why it is important: Mothers, in particular, need to know enough about PHC, and be
motivated enough, to both demand essential services for themselves and their children, and
to sustain proper health practices in their homes. If they do not, then the demand for PHC
and the practice of PHC will be insufficient to improve health.
Key indicators: For the PHC programme overall and/or for each PHC service. Also see
Modules 2 and 5 for extensive lists of KAP indicators for each PHC service.
1.
Is knowledge about PHC adequate to sustain:
3 demand for services?
3 correct PHC practices at home?
2. Is motivation adequate to sustain:
3 demand for services?
3 correct PHC practices at home?
3. Is there adequate:
3 demand for services?
3 correct PHC practices at home?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
1. Adapt the programme to traditional practices
2. Link low-demand with high-demand services
3 Emphasise healthful changes that have obvious benefits
4. Plan continued, but gradually reduced support for behavioural changes
5 Educate all family members, not just mothers, about PHC
6. Educate community and political leaders about PHC
7. Launch a public relations or advertising campaign
8. Sponsor a PHC Week, PHC Baby Contest, or similar event to attract public attention
to PHC
9. Increase home visits to those who aren't participating in PHC
10, Use satisfied mothers to recruit others to PHC
11, Set up a 10-household PHC communicator system
12. Involve school children in promoting PHC at home
Financial implications: For each strategy selected, determine what are the financial
implications, if any, for the project.
Will costs increase? For which items, and approximately how much?
3 Personnel
• Travel/per diem
• Other
3 Equipment
• Supplies
2. Will these be: One-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
1.
Module 9: Sustainability analysis; appendix A
’
Target group KAP
$ fl f) fl fl fl f| fl If Fl fl H fl If fl fl TJ 'fl F
44
45
PHC service quality
What it is: The degree to which the project will provide products and services which meet
technical standards and user expectations. Low quality products and services can be a
threat
Why it is important: Low quality and/or the absence of any essential product or service
discourages utilisation. Good quality attracts paying clients and encourages public confi
dence in and use of effective PHC interventions.
Key indicators: See Modules 5 and 6 for extensive lists of indicators for each PHC service.
1. Diagnosis
2. Education
3. Treatment
4. Counselling
5. Client satisfaction
6 Products
Do health workers (HW) adequately screen and accurately diag
nose clients’ conditions?
Do HWs provide correct and complete information about PHC
services and products to clients?
Do HW follow treatment protocols correctly?
Do HW provide correct and complete advice to clients?
Are project clients satisfied with the quality of services and
products?
Do health facilities have appropriate and sufficient
® Medical facilities, equipment and furnishings?
® Medical supplies and drugs?
® IEC materials?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
1.
Concentrate resources on effective services so as to maintain minimum quality
services
2. Clarify, communicate, and enforce quality standards
3. Decentralise problem-solving capacity and authority
4. Strengthen managerial support systems for PHC services
5 Increase client participation in routine program planning and evaluation
6. Provide continued access to technical ideas and professional education
7. Develop and institutionalise job aids
8. Provide continuing education and in-service training to staff to upgrade skills
9. Monitor inventories to ensure that products are sufficient and not out of date
10. Develop standards manuals for each PHC service
11. Set up a quality assurance team, involve client representatives
12. Conduct periodic spot checks of service delivery using standard checklists
13. Hold periodic meetings to share lessons learned and ideas about ways to improve
quality
Financial implications: For each strategy selected, determine what are
the financial implications, if any, for the project.
Will costs increase? For which items, and approximately how much?
° Personnel
° Travel/per diem
° Other
° Equipment
° Supplies
2. Will these be; one-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
1.
Module 9: Sustainability analysis; appendix A
Management support_______________________________________
What it is: The degree to which important management support services (planning,
supervision) will be maintained at current or increased levels of quality in the future. Weak
or missing support services are threats.
WHO has identified good management as one of the critical
elements of successful PHC programmes. When it is strong, the programme operates
smoothly, effectively and efficiently. When management is weak the programme is weak
and can eventually lose support
Why it is important:
Key indicators: See Modules 5 and 7 for extensive lists of indicators for assessing each
management support activity.
1.
Support services
2.
Client satisfaction
3.
Resources
Are all necessary management support services in place and
likely to continue?
Are employees satisfied with the quality of management sup
port services?
Does the project have sufficient and appropriate
• Management personnel?
• Supplies and equipment?
• Information?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
1 Emphasise locally-available supplies, e.g., cereal-based ORT rather than ORS packets
2. Encourage appropriate private sector activities
3 Simplify the information system to collect only data that is used
4 Standardise equipment to reduce maintenance requirements
5. Conduct group, rather than individual supervision
6. Provide continuing education and training to management staff
7. Consider using computers to simplify routine administration and reporting
8. Set up a management quality assurance team to come up with ways to improve
management support
9 Talk with health and field staff regularly about their needs and install procedures to
meet them
10. Try exchange programmes with other projects to share experiences and learn from
one another
11. Subscribe to and read management journals
Financial implications: For each strategy selected, determine what are the financial
implications, if any, for the project.
1 Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
2 Will these be: One-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much’
Module 9: Sustainability analysis; appendix A
-3
47
Organisational capacity
What it is: The degree to which strong collaborating and parent organisations will be
maintained in the future. Weak organisations are a threat.
-3
Why it is important: Most PHC programs are part of a larger organisation or collaborate
with other agencies to provide PHC. If these organisations become weak and collapse, that
jeopardises the program as well as the other collaborating agencies. Strong organisations
can supplement one another's strengths and cover for their weaknesses
Key indicators: For each collaborating or parent organisation (NGO, MOH, affiliate, etc.)
assess the following:
“3
^3
1.
Finances
2.
Structure
3.
Support
Are financial reserves adequate to continue core functions over
the next five years?
Does the organisation have a stable structure and manage
ment?
Does the organisation have broad-based support?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
^3
Work with well-established organisations, rather than create parallel groups
Affiliate with private sector organisations when government is weak, and vice versa
Minimise burdens on new or weak organisations, including those at the community
level
4. Strengthen technical links between local and external agencies
5. Train the organisation's staff
6. Hold periodic meetings to examine current and future trends and to reassign roles,
if appropriate
1.
2.
3.
3
3
“3
Financial implications: For each strategy selected, determine what are, if any, the
financial implications for the project.
"3
3
3
3
3
3
3
"3
Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
2. Will these be: One-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
1.
Module 9: Sustainability analysis; appendix A
48
Political commitment
______________________________________
What it is: The degree to which important individuals, groups and organisations will
support the programme in the future. High, broad-based commitment is conducive to
sustainability; low, narrow-based commitment is a threat
Why it is important: Support from influential people is essential to ensure that your
programme is promoted, has a positive public image, is respected, recommended, and
receives financial support to keep operating. Loss of such support can quickly result in
isolation and decline.
Key indicators: For each important individual, group or organisation (community,
political, religious, philanthropic, civic, government, the press, etc.) assess the following:
1.
Knowledge
2.
3.
Image
Behaviour
4.
Access
Is their knowledge about the programme complete and accu
rate?
Is their image of the programme positive?
Did they in the past, and will they in the future,
• Speak publicly in favour of the programme?
• Help to get favourable policies, rules, laws passed?
• Contribute financially to the programme?
Do you have open access to this group?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
Drop unpopular components
Avoid activities that might create opposition among non-beneficiaries
Avoid unnecessary challenges to influential groups, especially landowners and the
private sector
4. Reduce dependency on groups whose support is weak
5. Emphasise components which need limited outside support, such as household
based PHC, low-maintenance water systems, community-managed services
6. Set up special promotional campaigns for opinion leaders: politicians, news
reporters, religious leaders, etc.
7. Strengthen the MIS to measure and report programme achievements quickly to
influential groups
8. Devote additional resources to community participation
9. Design the programme to emphasise highly popular components (e.g., curative
care, services for influential populations, water supply)
10. Assist communities to express their needs to political leaders and donors
11 Involve influential groups from the start in programme planning and evaluation
12. Integrate new activities into established institutions and programmes
13. Invite the press to tour tire programme, do a series on the programme and its clientele
14. Appoint influential leaders to the Board or an Advisory Committee
Financial implications: For each strategy selected, determine what are the financial
implications, if any, for the project.
1.
2.
3.
Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
2. Will these be: One-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
1.
Module 9: Sustainability analysis; appendix A
-3
49
Personnel resources
What it is: The degree to which skilled management, technical and field staff can be
retained in the future. Loss of key staff is a threat to sustainability.
Why it is important: Staff are probably the most important resource a PHC programme
has. They often account for 50-70% of the budget. It takes a long time to recruit, train
and coach staff to do their jobs well. If skilled staff leave the programme this can affect the
quality of services, morale of other staff, and costs. If a number of key staff leave at the
same time, this can seriously threaten political support for the programme and the ability
of the organisation to survive.
Key indicators: For all key staff, management, technical and field, assess the following:
1.
2.
3.
4.
^3
Job performance
Skill level
Turnover
Morale
Is current job performance adequate or better?
Are job skills adequate or better?
Are staff staying in their jobs for a reasonable length of time?
Is staff morale good or better?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
1.
2.
3.
4.
5.
6.
7.
8.
Provide staff with continuing education and in-service training to upgrade skills
Improve the compensation plan and benefits
Develop/improve career ladders, promotion opportunities
Replace volunteers with paid staff, or vice versa
Implement a staff incentive plan
Recognise achievement, special contributions, birthdays to boost morale
Meet with staff regularly to get feedback on their needs and take action
Delegate authority and demonstrate confidence in staff
Financial implications: For each strategy selected, determine what are the financial
implications, if any, for the project.
Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
2. Will these be: One-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
1.
3
3
3
&
3
Module 9: Sustainability analysis; appendix A
50
Programme revenues
_____________________________________
to-
What it is: The degree to which needed monetary income will be maintained in the
future. Inadequate income is a threat to sustainability.
Why it is important: All organisations need to have enough money to pay staff, space,
supplies and other expenses. If they do not, they will steadily deteriorate until they go out
of business. On the other hand, organisations with surpluses can reinvest their funds to
expand services, test new ideas, improve quality, etc.
&■
SP
Key indicators:
1.
Income
2.
Reserves
3.
Sources
Is annual income adequate to cover expenditures this year
and for the next 5 years?
Are there sufficient reserves to cover deficits over the next 5
years?
Are the sources of income stable, broad and likely to continue
for the next 5 years?
Strategies: For each problem or opportunity, identify a strategy. Some examples.-
1. Set up a membership and patron system to raise funds from supporters
2. Increase service fees
3. Add non-PHC products that are in demand by the clientele
4. Start community funds to offset costs
5. Solicit government contributions
6. Develop a fund-raising campaign/strategy
7. Submit proposals for grants and contracts for training, research, demonstrations
8. Rent out unused facility space
9. Revise objectives and service strategies to fit new donor interests
10. Add or upgrade services to attract a higher-income clientele, use the profit to cross
subsidise services for the lower-income clientele.
11. Add a proven income-generating activity to the project
12. Stratify services for different target groups, based on willingness and ability to pay
gz
&
Ena....
UM
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s.,:
LU-'
Financial implications: For each strategy selected, determine what are the financial
implications, if any, for the project.
Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
2 Will these be: One-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
1.
&
gi:
&
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$-•
Module 9: Sustainability analysis; appendix A
51
'"3
Programme expenditures_________________________________ ______
What it is: The degree to which costs can be controlled in the future. High costs, especially
if they exceed revenues, are a threat to sustainability.
Why it is important: Costs have to be kept lower than revenues, otherwise the
organisation will operate at a loss and eventually go out of business. It may be able to
continue by using reserves or selling assets, but only for a short period. If costs are kept
low, then the surpluses can be held in reserve for bad times or used to expand and upgrade
services.
Key indicators:
1. Expenditures
Are annual monetary expenditures less than annual revenues
this year, and for the next five year projections?
2. Stability
Are expenses stable and likely to stay at the same levels over five
years?
3. Line items
Are all lines within budget; are any much higher or lower than
expected?
Strategies: For each problem or opportunity, identify a strategy. Some examples:
1. Negotiate discounts on volume purchases
2. Buy direct from the manufacturer or wholesaler to reduce costs
3. Pay bills on time to avoid penalties and take advantage of discounts
4. Relocate project offices and clinics to lower-cost areas
5. Increase in-kind contributions
• Traditional (labour, transportation, supplies, etc.)
• Non-traditional (telephone, utilities, uniforms, food, etc., school children, girl
scouts to assist CHWs)
6. Keep inventories low, do not overstock
7. Delay/postpone capital expenditures, expansion plans
10. Transfer responsibility for selected services, tasks, staff vehicles maintenance, to
others, e.g., Ministry of Health, other NGOs, and community organisations
11. Close unaffordable facilities
12. Reduce or eliminate high-cost activities
13. Combine staff roles
14. Identify low-cost substitutes for supplies, equipment, especially costly imported items
15. Use local, rather than international consultants
16. Provide incentives to staff to become more efficient
17. Hire contract staff to provide evening and weekend services
18. Reduce the frequency of household visits to low-risk cases
19. Limit services to high and medium-risk cases
20. Conduct a time analysis to find ways to reduce unproductive time
21. Reorganise home visit and clinic session schedules to save time, travel and
duplication
Financial implications: For each strategy selected, determine what are the financial
implications, if any, for the project.
1. Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
° Other
3
2.
3.
• Equipment
• Supplies
Will these be: One-time, recurrent, or compounded costs?
Will revenues increase? From what source(s) and by how much?
Module 9: Sustainability analysis; appendix A
lug • i
52
Environment_______________________ ________________________ _
What it is: The degree to which changes in such contextual factors as weather, the
economy, political stability, transportation systems, etc. are likely to change in the future.
Why it is important: Programmes can be. greatly affected by factors beyond their control.
Economic decline can reduce local funding sources, while growth can increase both
utilisation and the potential for user payments. Political instability can cause rapid staff
turnover or loss of community support.
Key indicators:
1. Economy
2. Political stability
3. Transportation
Is the programme heavily dependent on the local economy,
through user payments, or other fluctuating revenue source?
Are any major political changes likely to affect government
commitment to primary health care or to specific activities?
Will changes in geographic accessibility affect use of pro
gramme services?
Strategies: For each potential problem or opportunity, identify a strategy. Some examples:
1 Seek broad public and leadership support independent of political parties
2. Diversify financial support to reduce dependency on any specialised portion of the
economy
3. Make allowances for future changes in use due to transport improvements
Financial implications: For each strategy selected, determine what are the financial
implications, if any, for the project.
1. Will costs increase? For which items, and approximately how much?
• Personnel
• Travel/per diem
• Other
• Equipment
• Supplies
2. Will these be: One-time, recurrent, or compounded costs?
3. Will revenues increase? From what source(s) and by how much?
Module 9: Sustainability analysis; appendix A
55
Appendix B: Worksheets and spreadsheet
templates
This appendix is organised into three sections, one for each level of analysis. Each section
consists of four tables, or worksheets. You list your principal PHC target groups, PHC services
and coverage objectives in Table 1. This is a summary of what you want to sustain. Later on
in the analysis, you may decide to change one or more of these objectives.
Strategic assessment
In Table 2 you summarise the results of your analysis of the sustainability factors. First,
you determine whether each one is a threat, opportunity, or neutral, and then you estimate
the magnitude of the effect of that factor on your programme, positive or negative.
You can use any rating system you want to assess the effects. The following is one
suggestion:
Threat (negative)
—
—
0
4-
Life-threatening, must overcome
Serious and significant
Minor, but should be dealt with
Neutral: neither a threat nor an opportunity
Minor advantage, opportunity to pursue
Significant opportunity, very advantageous
Golden opportunity, must follow up
Opportunity (positive)
Next, you devise one or more strategies to deal with each factor and reassess the net effect
after implementing the strategies. Ideally, your overall sustainability strategy should neutralise
the threats and take advantages of opportunities. You should then summarise your strategy
in writing and develop an action plan to implement it.
If you are doing a Level 1 analysis, all ten factors are on one worksheet (Table 2). The
Level 2 worksheet has two worksheets. The first contains eight of the factors, and you use
the second to list your principal PHC and management support services. You then do an
assessment of the strengths and weaknesses of each service.
Level 3 also has two worksheets The first contains six factors. You use the second to list
your principal services, just as in Level 2. But in addition to assessing the threats and
opportunities, you estimate the changes that are likely to occur in target population size and
coverage - for each service.
You need to fill out the Worksheet for Selecting Target Groups to make the population
and coverage estimates in the Level 3 analysis.
If you are only doing a strategic assessment, you do not need to use the remaining tables.
They are for the financial assessment.
Module 9: Sustainability analysis; appendix B
56
Financial assessmen t ____________________________________________________________
Table 2 has an optional section six columns to the right that you can use to estimate the
financial implications of each of your strategies. Use these if you are going to do a financial
assessment. In general, you need to determine whether there are any costs, or possible effects
on revenues, of each strategy. If a factor is neutral, or if you are not going to do anything
about a threat or opportunity, then there should be no financial implication. But if you are
going to do something, there could be a cost associated with it. A strategy could increase or
decrease costs. It could also increase or decrease revenues. Here are some examples:
Low political commitment: Assume that the strategy is to do intensive lobbying of
legislators and community leaders to build up support. If this can be done by members
of the programmes board of directors, then there may be little or no additional cost to the
programme. However, if another staff person needs to be hired to work with the
community leaders and to contact legislators, then this would increase costs (salary, travel,
office space, etc.).
® Target group KAP (coverage) low: Health status could be badly affected if mothers
do not bring their children for immunization, pregnant women do not enroll in ANC, and
couples do not space their children. Assume that the strategy is to increase the frequency
of health education and counseling contacts with mothers. This will require additional
CHWs, supervisors, 1EC materials, and so forth.
® PHC service quality is improving: Assume that there has been an effort to instill
principles of "Total Quality Management" in the staff, and that it is having an effect. The
strategy might be to continue TQM training (which would have a cost: consultants, staff
time), but the expected benefits are: better services, that will attract more middle-class
clients who will be willing to pay for services; and more efficient services as staff learn to
solve problems themselves, which will reduce costs.
Make your estimates of financial implications in percentages. For example, an increase
in the size of the target group by 5%, would increase costs by about the same amount. An
increase in service fees of 10% would increase revenues. An increase in the use of community
volunteers might reduce personnel costs by 15%.
Finally, you need to decide whether the change in revenues or expenditures will be a
one-time only occurrence, it will be recurrent, or it will continue to change (compounded).
•
®
•
One-time: the change occurs only once and is neither continued nor imposed again.
Revenue: a one-time assessment of all households
Expenditure: a one-time bonus paid to all staff
Recurrent: the change is made permanent. It is continued.
Revenue: household assessments are levied each year, but the amount of the
assessment stays the same.
Expenditure: staff are given a 5 percent salary increase which is continued for as long
as they stay in the programme. It is neither increased nor decreased each year
®
Compounded: the change increases or decreases over time by a fixed amount or
percentage.
Revenue: household assessments go up an additional 5 percent each year.
Expenditure: staff salaries are raised 5 percent each year.
Enter these estimates in the appropriate columns on the right side of Table 2. Later these
will be transferred to the "what-if" analysis table (Table 4).
But first you need to enter your financial data into Table 3. This is a five-year projection
of revenues and expenditures. You should make your projections based on your current
Module 9: Sustainability analysis; appendix B
57
3
experience, your general forecasts for the economy, and the financial implications of your
sustainability strategy.
If you are using a computer, you can enter your current year figures into the computerised
version of Table 3 and it will copy those figures to each of the next five years. You can make
appropriate changes in the line items, or you can make them indirectly through the "what-if
analysis. The figures you enter into Table 3 should be your core budget estimates for the next
five years.
The Level 1 worksheet is limited to general ledger items (GL1) For Levels 2 and 3 you
will estimate the costs of each PHC and management service. There is a computerised
worksheet that will make the initial estimates for you if you know the approximate percentage
of the cost of each service.
Table 4, also computerised, is the "what-if" analysis table. You should enter the figures
from the financial implications (Table 2) into the program. If your initial projections already
took those implications into account do not enter them again. Instead, use this table to see
what would happen if you adjusted some of those assumptions.
The results of any changes you make will be displayed in Table 5. This will enable you to
keep your original projections in Table 3 and to compare the effects of your changes on your
financial sustainability.
Save your assumptions and the results (Tables 4 and 5) or print them out so that you can
remember what you did.
Computer assumptions
3
*3
If you use the computer program for the "what-if" analysis (Table 4), it may be important
to you to know the assumptions built into the computer program’s formulae. The figures you
enter in each box increase or decrease revenues or expenditures by the amount you enter.
For example, if you estimate that inflation will be 5% each year, the computer takes the
expenditures for the previous year and increases them by five percent. It does the same for
each subsequent year.
All of the assumptions are programmed to change expenditures or revenues by the same
amount that you enter. You can make some adjustments by entering lower (or higher)
percentages to take some of your qualifications into account. For example, if you do not think
that it will cost you anything to increase coverage by 2% each year, then enter 0% in that
box rather than +2%. If you estimate that it will cost much more than 10% to increase
coverage by 10%, then enter a larger figure.
The following are brief explanations of the assumptions written into the computer
program for each of the ten sustainability factors and two special variables (Inflation and
In-kind contributions).
•
Target population size, composition and distribution
Assumes that you will serve X% more (or fewer) people each year. This will increase (or decrease)
all of your costs by X% because you will have to increase (or decrease) services. It will also
increase (or decrease) one revenue line (service fees) by X%. Example: a 3% increase in target
population size will increase all costs by 3% and the revenue from service fees by 3%.
3
’3
3
a
°
Target group KAP (coverage)
Assumes that you will increase (or decrease) the percentage of people in the target group
who are fully covered. That is, you will increase effectiveness by increasing (or decreasing)
services. That will increase (or decrease) your costs by an amount that you estimate. There
will be no effect on revenues. Example: you plan to increase immunization coverage 5
percent. That will increase the cost of immunization services by 5% or an amount you
estimate. It will have no effect on revenues.
Module 9: Sustainability analysis; appendix B
58
•
PHC service quality
Assumes that you will increase (or decrease) the amount and quality of services provided
to each target group by X%. The number of people served would remain the same, but
they would get more (or less) attention than before. \bur costs would increase (or decrease)
by the percentage you designate. There would be no effect on revenues. Example, you
reduce the number of home visits by 25%, which reduces overall costs by 5%.
•
Management support
Assumes that you will increase (or decrease) the amount of management support activities
(training, supervision, etc.) each year by the percentage entered. Costs will increase (or
decrease) by the same percentage. There would be no effect on revenues. Example:
training for CHWs is expanded by 10%, which increases total costs by 15%.
•
Organisational capacity
Assumes that you will decrease (or increase) the amount of effort it takes to carry out the
programme. Performance would remain the same, only the amount of effort required to
achieve that level of performance would change. The less effort required, the more efficient
the organisation. Costs would decrease (or increase) by the amount of improvement (or
deterioration) in efficiency. There would be no effect on revenues. Example: you increase
overall efficiency by 5% each year, which reduces overall costs by the same amount each
year.
•
Political commitment
Assumes that the support for (or against) the programme increases (or decreases) by a set
amount and that this affects resources (revenues) by a percentage that you designate. The
effort required to achieve political commitment can be increased or decreased, and costs
will change by an amount you designate. Example: you increase lobbying by 10%, which
you estimate will increase costs by 5% and result in increased overall revenues of 10%.
•
Personnel resources
Assumes that a loss or gain of key personnel will result in an additional expense or savings
in costs of a designated percentage. Example: loss of key medical staff will increase costs
of recruitment, training, supervision, which you estimate will increase personnel costs by
6%.
®
Revenues
Assumes that overall revenues will increase (or decrease) each year by the indicated
percentage. You can make changes in each revenue category (fees, contributions, etc.).
The category will change by the percentage you enter. Example, if you increase fees by
2% each year, only the fee line will be affected, and it will increase 2% annually.
•
Expenditures
Assumes that overall expenditures will increase (or decrease) each year by the indicated
percentage. As with revenues, you can make changes in each expenditure category. In
Levels 2 and 3 you can also change cost estimates for each PHC and management service.
The change is made in the line item selected. Example: if you increase travel by 6%, only
the travel line is increased.
°
Environment
Assumes that changes in the overall environment have an indirect effect on revenues and
costs, by the amount you designated. Examples: you expect the economy to improve
steadily, which will lead to an average increase in government grants by 7%; you expect
that there will be at least one serious storm that will result in damage to the project (which
will raise costs 4%).
•
(SC
B-
B-
lu
in
SK?
L
Inflation
Assumes that total costs will rise (or fall) each year by the indicated percentage. This is
independent of changes in the other variables. If inflation is already included in your initial
U?
12.
Module 9: Sustainability analysis; appendix B
59
budget projections you should not enter it in this cell, also. However, you can enter a
number to see the effects of a lower or higher rate of inflation. Example: inflation is
projected to be 10% annually, which will increase total costs by that amount each year.
•
In-kind contributions
Assumes that total costs will fall (or rise) as in-kind contributions increase (or decrease).
The assumption is that most in-kind contributions are of labour, and that this will only
affect personnel costs. As in-kind contributions increase, personnel costs can be main
tained or reduced by the designated percentage. Example: in-kind contributions are
projected to increase by 5% annually, which will allow you to reduce personnel costs by
the same amount.
As you will see from the worksheets, there is an assumption that certain factors will have
no effect on revenues, and that others will only affect one portion of revenues or expenditures.
You can make adjustments for this assumption if it does not fit your situation. Just enter a
special revenue or expense category in one of the "Other" lines in Table 3. Then enter your
projections for the five-year period in the table. You will be able to revise them either directly
(by changing the figures in Table 3) or indirectly (by adjusting the lines in the "what-if analysis
table (Table 4).
Sometimes you may want to see the effects of a single variable. To do this, enter zero for
all of the assumptions in Table 4 except the one that you want to vary.
Module 9: Sustainability analysis; appendix B
60
LEVEL 1 ANALYSIS
The following diagram shows how the four tables (and two graphs) in the computer
spreadsheet are arranged. Since you will only be able to see a portion of the tables on your
computer screen, this guide may help you locate the tables you need. You can also go to any
table quickly by using the Name command and typing in one of the following: Table 3, Table
4, Table 5, and Graph. Also note that Tables 1 and 2 are not included in this computer file,
but there are blank worksheets in Appendix C and in separate computer files, if you would
like to print them out.
Layout of Level 1 spreadsheet (MOD9L1.WQ1)
Table 4
ya.
ml
Table 4
(con’t)
LL?
©
e
&
Module 9; Sustainability analysis; appendix B
61
■J
Level 1 Worksheet
Strategic assessment
Summarise your sustainability objectives for your principal target groups, PHC services
and coverage in Table 1.
Use this to remind you what you are attempting to sustain.
Table 1: Coverage objectives and services - example
Target group
PHC services
Coverage objectives
Children <2, <5 yrs
Child immunization
Growth monitoring
70% < 24 mo fully immunized
55% < 5 yrs weighed
65% < 5 used ORT last episode
Married women 15-49 yrs
&
s
4S
Oral rehydration
Nutrition education
<10% < 2 yrs low weight-for-age
Antenatal care & TT
Family planning
70% pregnant enrolled in ANC
65% current users
Summarise your assessment of each sustainability factor in Table 2. Identify those that
are threats (-), neutral (0), or opportunities (+) and devise strategies to neutralise the threats
and take advantage of the opportunities.
If you are planning to do a financial assessment, fill in your estimates of the financial
implications of each strategy. These should be in percentages and marked positive or negative.
That is, will they increase or decrease revenues and/or costs. Some changes may affect both
revenues and expenditures. For example, an increase in clients could increase costs but also
increase service fees.
Decide if the change will be one-time only, a recurrent (permanent) change, or a
compounded change (one that changes by a fixed amount or percentage each year). See the
Introduction for examples.
In the example, the target population is expected to increase by five percent each year
Assuming this new group receives all the services now offered, that would increase costs about
5% each year. An increased clientele may also increase revenues slightly by paying fees. In
this example only about 20% of clients pay any fees. Thus a 5% increase in clients would
only raise fees by about 1% each year.
Develop general strategies for the penultimate two factors (8. Revenues and 9. Expendi
tures) but enter the detailed effects on each line item in Table 2.
Summarise your assessment of the current situation and your overall sustainability
strategy.
&
&
•a
a
Module 9: Sustainability analysis; appendix B
IB
Table 2: Sustainability factors worksheet
LEVEL 1
File MOD9_SA1.WQ1 or MOD9_SA1.WK1
FINANCIAL IMPLICATIONS
Classify each factor, identify strategies where appropriate, estimate financial implications
Threat/opportunity factor, description
1.
Target group size. Threat: In-migration of
5% annually projected
2.
Target group KAP (coverage). Threat New
clientele need education and counseling
PHC service quality. Opportunity:
Improving steadily
Management support. Opportunity: Strong
and improving
Organisational capacity. Opportunity:
Strong organization
3.
4.
5.
Effect
-
+
+
Strategy
Increase services: Raise revenues through
increased fees, contributions: Reduce costs
via community in-kind contributions
Add special 1EC sessions for new IEC
clientele
TQM already installed: Quality should
improve: Costs may decrease
Expect increase in efficiency: Should lower
costs later
No strategy at present- Could expand into
other areas
Rcrnt.
Costs
0
+2%
+
+
+
Module 9; Sustainability analysis; appendix B
0
+3%
+
7
Personnel resources. Threat May lose key
staff as donor support ends
Revenues. Threat. Losing some donor
support in 1993
-
0
Cmpnd.
Costs
+5%
1.0%
Develop alternative sources of funds: Fees,
fund-raising, training, contributions.
Recurrent Fees 5%: grants 20%, outside
income 200%
Compounded: Contrib 10%: govt 5%, grants
5%, outside 20%
Increase revenues > 3% (see revenues).
Recurrent Indirect costs - 10%; in-kind
contrib +10%
Compound: Personnel +2%; travel +2%;
supplies -3%, ODC -5%, in-kind +5%
Hold 2-3 education/PR sessions in each
community
10. Environment Neutral: No changes expectec
0
Cmpnd. 1-Time
Rev.
Costs
Develop improved compensation package
■
Expenditures. Threat Inflation of 3%
annually. Other line item costs increasing.
some decreasing
Rcrnt
Rev.
+1%
Political commitment. Threat: Lack of
community support
9.
1-Time
Rev.
0
6.
8.
Expenditures
Revenues
Effect
+
+5%
+20%
+200%
+10%
+5%
+5%
+20%
-10%
+10%
+2%
+2%
-3%
-5%
+3%
+5%
0
Entries cannot be made in shaded cells in the computer program.
[Si [<i pi ET pi ESI pi pi pi p pi pi
pi pi A’ p
pi $ pi fl) &
63
Financial assessment
Enter your program revenue and expenditure figures for the most current year (CY) in
Table 3. If you are using the computer program, it will copy these to Years 1-5. Later, you
will be able to adjust these figures. However, you can do so now, if you wish. If so, make your
changes in the appropriate line items of 3.1 and 3.2. (fees, contributions, etc.). Just type in the
new figure. For example, if you expect fees in Year 1 to be 20, just type that in. The remaining
years will remain the same. The computer will compute the totals for 3.1 and 3.2 and all the
figures for 3.3. The example shows figures that have been adjusted to project current
expectations. These figures have not been adjusted to reflect the sustainability strategy
summarised in Table 2. This will be done next.
If you expect significant one-time increases or decreases in either revenues or expenditures
in any specific year, then you should enter them in Table 3. For example, if a large government
grant ends in Year 3, the amount of the grant should be subtracted from Years 4 and 5.
Likewise, if you expect to spend a large sum on equipment in Year 1, that should be entered in Year 1
You can return to this table anytime you wish to make any adjustments in your initial
projections Table 3: Initial projections of revenues and expenditures (in ’000).
Table 3: Initial projections of revenues and expenditures
(in ’000)
LEVEL 1 WORKSHEET
3.1 Revenues
CY
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Other
Other
Total
17
22
21
220
2
0
0
282
3.2 Expenditures
CY
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
Total
143
35
29
45
10
16
0
0
0
278
3.3 Summary
CY
Revenues
Expenditures
Balance
282
278
4
Yrl Yr 2
18
19
23
24
20
25
215 205
2
3
0
0
0
0
279 275
Yrl Yr 2
155
148
40
38
32
28
25
35
12
13
16
16
0
0
0
0
0
0
281
277
Yrl Yr 2
279 275
277 281
-6
2
Note: can also be used for table 5
Module 9: Sustainability analysis; appendix B
Yr 3
MOD9L1.WQ1
Yr 5
Yr 4
20
25
23
200
2
0
0
270
21
26
25
185
2
0
0
259
Yr 3
Yr 4
155
35
28
30
14
16
0
0
0
278
151
38
27
27
15
16
0
0
0
274
Yr 3
Yr 4
270
278
-8
259
274
-15
Total
101
23
126
28
118
25
175
980
11
2
0
0
0
0
253 1,336
Yr 5 Total
150
759
186
35
141
26
142
25
70
16
80
16
0
0
0
0
0
0
268 1,378
Yr 5 Total
253 1,336
268 1,378
-42
-15
64
What-if analysis___________________________________________________________________
Next, transfer the estimated financial implications (from Table 2) to the "what-if analysis
table, shown below. If you use the computer file that comes with this module, it will
automatically calculate the effects of these changes on the initial projections you made in
Table 3. The results will be shown in Table 5.
'
—
,
'
Table 4: What-if analysis worksheet
LEVEL 1 WORKSHEET
MOD9L1.WQ1 or MOD9L1.WK1
a**—
Enter projected annual % increase (+) or decrease (-). See results in Table 5.
eh-”
Non-financial factors
1-Time Rcrnt Compnd. 1-Time
Rcrnt. Compnd.
rev.
rev.
rev.
costs
costs
costs
(See notes below)
Target population size
Target group KAP (coverage)
PHC service quality
Management support
Organisational capacity
Political commitment
Personnel resources
Environment
1.0%
5.0%
2.0%
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
'gljClf...
1.0%
3.0%
SL
Target pop size: A(+) in revenues increases fees; A(+) in expenditures increases all costs
Political commitment: A(+) increases all revenue; A(+) in expenditures increases all costs
Environmental: A(+) increases all revenues; A(+) in expenditures increases all costs
All other factors: No effect on revenues; A(+) in expenditures increases all costs
51,..
Now you can make changes in these assumptions to see their effects on costs and revenues.
You can see, for example, WHAT would happen IF fees increased by 6% annually (or by any
other percentage). You can see what would happen if expenses increased, or decreased; if the
target population increased, and so forth. The results will be shown in Table 5, recomputed
automatically. You can "play" with these assumptions, changing them over and over, and in
various combinations. Obviously, these changes have to be realistic. Such changes can
continue to be made until an acceptable break-even point is reached, at which point the
programme reaches sustainability.
There are two graphs that have been prepared to display the total revenue and expenditure
data for Table 3 and Table 5. This will give you a graphic "before and after" comparison. Press
F10 to view the graph. Use the Name command to switch between graphs. They are called
Figure 1 and Figure 2. In the Quattro Pro version of the spreadsheet, these two graphs are
also embedded in the spreadsheet. They are located just below the Instructions and to the
left of Table 5.
HL.
Module 9: Sustainability analysis; appendix B
IS*“-
Jr.
r'-wi-..
e
HL
to.
&
65
Financial factors
Revenues categories
1-Time
rev.
Fees
Contributions
Govt, subsidies
Grants/ contracts
Outside income
Other
Other
Expenditures
Categories
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
Rcmt
rev.
A(+) increases revenues
A(-) decreases revenues
5.0%
1-Time
costs
20.0%
200.0%
10.0%
5.0%
5.0%
20.0%
Rcmt.
costs
Cmpnd.
costs
2.0%
2.0%
-3.0%
A(+) increases expenditures
A(-) decreases expenditures
-5.0%
-10.0%
Other factors affecting expenditure
X
X
Inflation
In-kind contributions
Compnd.
rev.
10.0%
Module 9: Sustainability analysis; appendix B
3.0% A(+) increases all costs
A(-) decreases all costs
5.0%
66
Table 5: Adjusted projections of revenues and expenditures
MOD9L1.WQ1 or MOD9L1.WK1
Yr 4
Yr 3
Yr 5
Total
LEVEL 1 WORKSHEET
3.1 Revenues
CY
Yrl
Yr 2
Fees
Contributions
Govt, subsidies
Grants/ contracts
Outside income
Other
Other
Total
17
22
21
220
2
0
0
282
19
25
21
229
37
0
0
332
20
29
27
231
44
0
0
351
21
33
26
237
53
0
0
371
23
37
30
234
63
0
0
387
25
43
31
236
76
0
0
410
108
166
136
1,168
273
0
0
1,851
3.2 Expenditures
CY
Yrl
Yr 2
Yr 3
Yr 4
Yr 5
Total
Personnel
Travel/PD
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
Total
143
35
29
45
10
16
0
0
0
278
149
44
31
41
13
17
0
0
0
295
167
51
37
35
15
18
0
0
0
323
179
52
36
44
16
20
0
0
0
347
187
61
38
45
18
22
0
0
0
371
199
66
39
48
20
24
0
0
0
396
881
273
181
214
82
102
0
0
0
1,733
3.3 Summary
CY
Yrl
Yr 2
Yr 3
Yr 4
Yr 5
Total
Revenues
Expenditures
Balance
282
278
4
332
295
37
351
323
28
371
347
24
387
371
16
410
396
14
1,851
1,733
118
Module 9: Sustainability analysis; appendix B
67
-3
Figure 1: Initial projections of revenues and expenditures (5 years)
3
Module 9: Sustainability analysis; appendix B
68
LEVEL 2 ANALYSIS
The layout of the Level 2 spreadsheet is similar to that for Level 1 There are differences
in the tables, however. The computer file for Level 2 is MOD9L2.WQ1 or MOD9L2.WK1.
Strategic assessment
As in Level 1, summarise your sustainability objectives for your principal target groups,
PHC services and coverage in Table 1. Use this to remind you what you are attempting to
sustain.
Table 1: Coverage objectives and services - example
Target group
PHC services
Coverage objectives
Children < 2, <5 yrs
Child immunization
Growth monitoring
70% < 24 mos fully immunized
55% < 5 yrs weighed
Oral rehydration
Nutrition education
65% < 5 used ORT last episode
<10% < 2 yrs low weight-for-age
Antenatal care & TT
Family planning
70% pregnant enrolled in ANC
65% current users
Married women 15-49 yrs
There are also two parts to Table 2 in this Level. The first consists of eight sustainability
factors (everything except PHC service quality and management services). You write in your
principal services in the second part of Table 2. The example shows antenatal care, family
planning, and others, including supervision and community organisation, two of the manage
ment support services. It also includes income generation and training, two services that
might generate income for the project.
Summarise your assessment of each sustainability factor in Table 2. Identify those that
are threats (-), neutral (0), or opportunities (+) and devise strategies to neutralise the threats
and take advantage of the opportunities.
If you are planning to do a financial assessment, fill in your estimates of the financial
implications of each strategy. These should be in percentages and marked positive or negative.
That is, will they increase or decrease revenues and/or costs. Some changes may affect both
revenues and expenditures. For example, an increase in clients could increase costs but also
increase service fees.
Decide if the change will be one-time only, a recurrent (permanent) change, or a
compounded change (one that changes by a fixed amount or percentage each year (see the
Introduction for examples).
In the example, the target population is expected to increase by five percent each year.
Assuming this new group receives all the services now offered, that would increase costs about
5% each year. An increased clientele may also increase revenues slightly by paying fees. In
this example about one of five clients pay fees. Thus, revenues will increase about 1% each
year.
Develop general strategies for revenues and expenditures, but enter the detailed effects
on each service listed in the second part of Table 2.
Summarise your assessment of the current situation and your overall sustainability
strategy.
Module 9: Sustainability analysis; appendix B
Table 2: Sustainability factors worksheet
Level 2
File MOD9SA2.WQ1 or MOD9._SA2.WK1
FINANCIAL IMPLICATIONS
Classify each factor, identify strategies where appropriate, estimate financial implications
Factor Threat/opportunity; description Effect Strategy
Ex penditures
Revenues
Effect
1-Time
Rev.
Rant
Rev
Cmpnd 1-Time
Rev.
Costs
Rcrnt. Cmpnd.
Costs Costs
Increase services: Raise revenues through increased
fees, contributions; reduce costs via community Inkind contributions
0
Add special 1EC sessions for new 1EC clientele
0
5. Organisational capacity. Opportunity.
Strong organisation
No strategy at present: Could expand into other
areas
+
6. Political commitment. Threat: Lack of
community support
Hold 2-3 education/PR sessions in each community
0
+1%
7. Personnel resources Threat: May lose key
staff as donor support ends
Develop improved compensation package
0
+3%
8. Revenues Threat- Losing some donor
support in 1993
Develop alternative sources of funds: Fees, fundraising, training, contributions
Recurrent. Fees 5%; grants 20%, outside income
200%
Compounded: Contrib 10%; govt 5%, grants 5%,
outside 20%
Increase revenues > 3% (see revenues)
Recurrent- Indirect costs -10%; in-kind contrib
+10%
Compound: Personnel +2%; supplies -3%,
ODC -5%, in-kind +5%
+
+5% +10%
+20% +5%
+200% +5%
+20%
+
-10%
+10%
1. Target group size. Threat. Migration of 5%
annually projected
2. Target group KAP (coverage). Threat: New
clientele need education and counseling
-
9. Expenditures. Threat Inflation of 3%
annually. Other line item costs increasing,
some decreasing
10. Environment Neutral: No changes expected
0
+1%
+5%
+2%
+2%
+2%
-3%
-5%
+3%
+5%
0
Entries cannot be made in shaded cells in the computer program.
o
Table 2: Sustainability factors worksheet
File MOD9 SA2.WQ1 or MOD9 SA2.WK1
LEVEL 2
Classify each factor, identify strategics where appropriate, estimate financial implications
PHC services and management support Effect Strategy
services
Factors: Threat/opportunity; description
FINANCIAL IMPLICATIONS
Revenues
Expenditures
Effect 1-Time Recrnt. Cmpnd. 1-Time Recrnt Cmpnd.
Rev.
Rev.
Rev.
Costs
Costs Costs
Module 9: Sustainability analysis; appendix B
Antenatal care and tetanus toxoid: ANC
medications and TT vaccines too expensive
Turn these over to MOH over next 5 years
0
Family planning: Resistance from religious
leaders
Hold annual seminar for religious leaders
0
Growth monitoring and nutrition education:
Lack of food supplements
Refer to CARE and MOH Nutrition Center
0
Child immunization- Vaccines and services too
expensive
Turn over to MOH over next 5 years: Continue
1EC
0
-15%
Oral rehydration: ORS packets low quality, not
liked
Switch to cereal-based ORT, home remedies
0
-20%
Develop training courses for staff from other
projects, for fee. See Table 3 for cost and
revenue projections for this component. Startup
costs, operating expenses for first 2-3 years
might be financed by donor
Hire community organisation specialist
0
Phase out over next 5 years (-20%/yr)
0
Training-. Strong capability in staff training
+
Community organisation Weak project
capability in this area
■
Income generation: Projects not effective
Losing money. No return to project
-15%
+2%
+5%
+25%
-20%
Entries cannot be made in shaded ceils in the computer program.
ig p g g g g g g $ m ra n tn $ g tci ig
rt
71
3
J
3
3
■3
3
Financial assessment
Enter your program revenue and expenditure figures for the most recent year. The revenue
estimates are the same as in Level 1. However, expenditures are different. In Level 2 you need
to estimate the cost of each PHC service and management activity. You should enter amounts,
not percentages in this section. If you do not know the amounts, you can estimate percentage
distributions first and multiply them by the total expenditures or revenues. There is a computer
file in this module that will do that for you. Simply enter the total expenditures for the current
year, and then enter your estimates of the percent spent on each PHC service and management
activity. The following example allocates the costs among eight PHC services and seven
management functions. The computer calculates the amount allocated to each service and
activity. When you have these figures, enter them in Table 3 (see 3.2).
EXPENDITURE DISTRIBUTION WORKSHEET
Total expenditures CY Enter here: 225,320
PHC SERVICES
%
Amt.
MANAGEMENT
%
Amt
Tetanus toxoid (pregnant)
Antenatal care (pregnant)
10
20
23,500
47,000
Planning
Personnel mgmt
3
7,050
11,750
Training
Supervision
Financial mgmt
12
5
6
3
28,200
14,520
7,050
2
1
4,700
2,350
3
7,050
18
2
42,300
4,700
Logistics mgmt
Information mgmt
Community organ.
Training centre
Other
Other
Subtotal
4
6
9,400
4,000
37
77,270
Total PHC + MGT
100
225,320
Safe delivery
Family planning
Breast feeding
Growth monitoring
Nutrition education
Acute respiratory infection
Child immunization
Oral rehydration therapy
Vitamin A
-3
Childhood disability
3
Water supply
Tuberculosis treatment
Malaria prevention/treatment
3
3
3
3
■3
MOD9 EXP.WQ1
Diarrhoea disease control
STD/HIV
Minor ailments
Other: IGA
Subtotal
5
63
11,750
148,050
The computer program will fill in the projections for Years 1-5. You can adjust these figures if
you wish. Make your changes in the line items of 3.1 and 3.2, just as in Level 1 The computer will
compute the totals and the figures for 3.3. The example (Table 3) shows adjusted figures.
If you anticipate a new source of revenue, make sure to add it to your initial projections. Just
type it into one of the "Other" lines in Table, and enter your projected revenues for each year. In
this example, two items have been added to the revenue sources: income generation activities, and
a training centre.
Module 9: Sustainability analysis; appendix B
72
Table 3: Initial projections of revenues and expenditures
(in ’000)
LEVEL 2 WORKSHEET
CY
3.1 Revenues
Yrl
Yr 2
MOD9L2.WO1
Yr 5
Total
Yr 3
Yr 4
24,000
35,000
25,000
150,000
5,000
2,345
5,000
26,000 28,000
40,000 45,000
26,000 27,000
140,000 130,000
6,000
7,000
2,345
2,345
5,000
5,000
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Income gen. act.
Training centre
Other
Other
Total revenues
17,232
22,410
21,020
180,000
2,169
2,345
5,000
20,000 22,000
25,000 30,000
23,000 24,000
170,000 160,000
3,000
2,500
2,345
2,345
5,000
5,000
250,176
247,845 246,345
3.2 Expenditures
CY
Yr 1
Yr 2
Yr 3
Yr 4
Yr 5
Total
23,500
47,000
11,750
4,700
2,350
42,300
4,700
11,750
24,000
47,500
12,500
5,200
2,400
44,000
4,700
11.750
25,896
47,000
13,589
4,589
2,560
45,000
4,700
11,750
24,000
49,000
15,000
4,589
2,560
46,500
4,700
11,750
27,890
50,000
17,895
5,900
2,400
47,800
4,700
11,750
28,795
52,000
15,000
6,100
2,389
48,000
4,700
11,750
130,581
245,500
73,984
26,378
12,309
231,33
23,500
58,750
0
0
0
7,050
28,200
14,520
7,050
7,050
9,400
4,000
7,050
28,000
14,520
7,050
7,050
9,400
4,000
7,050
27,000
14,520
7,050
7,050
9,400
4,000
7,050
28,200
14,520
7,050
7,050
9,400
4,000
225,320
229,120 231,154
235,369
35,250
139,600
73,080
36,200
35,250
47,000
20,000
0
0
245,605 247,434 1,188,682
PHC SERVICES
Tetanus toxoid
Antenatal care
Family planning
Growth monitoring
Nutrition ed.
Child immun.
Oral rehydration
Income gen. act.
Other
Other
Other
MANAGEMENT
SERVICES
Planning
Training
Supervision
Financial mgmt
Logistics mgmt
Community organ.
Training centre
Other
Other
Total expend.
3.3 Summary
CY
Revenues
Expenditures
Balance
250,176
225,320
24,856
Yrl
Yr 2
247,845 246,345
229,120 231,154
18,725 15,191
120,000
175,000
125,000
750,000
23,500
11,725
25,000
0
0
246,345 245,345 244,345 1,230,225
7,050
28,200
14,520
7,050
7,050
9,400
4,000
7,050
28,200
15,000
8,000
7,050
9,400
4,000
Yr 3
Yr 4
Yr 5
246,345
235,396
10,976
245,345 244,345 1,230,225
245,605 247,434 1,188,682
41,543
(260) (3,089)
Total
Module 9: Sustainability analysis; appendix B
73
What-if analysis
Now you can transfer the financial implications, from Table 2, to the "what-if" analysis
table, shown overleaf. If the manager uses the computer file that comes with this module, it
will automatically calculate the effects of these changes on the projections shown in Table 5.
You can make changes in these assumptions to see their effect on costs and revenues.
You can see, for example, what would happen if ANC costs increased by 2% annually (or by
any other percentage). You can see what would happen if expenses increased, or decreased;
if the target population increased, and so forth. The results would be shown in Table 5 (See
5.3 below), computed automatically. The manager can "play" with these assumptions,
changing them over and over, and in various combinations. Obviously, these changes have
to be realistic. Changes can continue to be made until an acceptable break-even point is
reached, at which point the programme reaches sustainability.
Table 4: What-if analysis worksheet
LEVEL 2 WORKSHEET
MOD9L2.WQ1
Enter projected annual % increase (+) or decrease (-)• Results seen in Table 5.
Rcrnt.
Cmpnd.
Rcmt
Cmpnd.
1-Time
Non-financial factors
1-Time
costs
costs
rev.
rev.
costs
rev.
See notes below
1.0%
5.0%
X
X
X
X
X
X
2.0%
X
X
X
Target population size
Target group KAP (coverage)
Organisational capacity
Political commitment
Personnel resources
Environment
1.0%
3.0%
Target pop size: A(+) in revenues increase fees; A(+) in expenditures increases all costs
Political commitment: A(+) increases all revenue; A(+) in expenditures increases all costs
Environmental: A(+) increases all revenues; A(+) in expenditures increases all costs
All other factors: no effect on revenues; A(+) in expenditures increases all costs
Ctrl + W to widen columns - Entries cannot be made in shaded areas (with X)
Module 9: Sustainability analysis; appendix B
Financial factors
Revenues categories
Rcmt
1-Time
revenue revenue
Tetanus toxoid
Antenatal care
Family planning
Growth monitoring
Nutrition education
Child immunization
Oral rehydration
8.0%
5.0%
-2.0%
5.0%
20.0%
A(+) increases expenditures
A(-) decreases expenditures
-15.0%
-15.0%
5.0%
2.0%
-15.0%
-20.0%
-20.0%
25.0%
Other factors affecting expenditures
Inflation
X
X
In-kind contributions
20.0%
1-Time Rcurnt. Cmpnd.
costs
costs
costs
Income generating activities
Other
Other
Other
Planning
Training
Supervision
Financial management
Logistics management
Community organisation
Training centre
Other
Other
A(+) increases revenues
A(-) decreases revenues
6.0%
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Income generating activities
Training centre
Other
Other
Expenditures
Categories
Cmpnd.
revenue
10.0%
3.0% A(+) increases all costs,
5.0% A(+) decreases PHC service costs
but management services not
affected
Module 9: Sustainability analysis; appendix B
75
Table 5: Adjusted projections of revenues and expenditures
LEVEL 2 WORKSHEET
5.1 Revenues
CY
21,206 23,418
26,793 33,936
24,051 26,254
166,400 153,072
2,608
3,239
2,345
2,345
9,446 11,336
0
0
0
0
252,850 253,600
Yrl
Yr 2
25,652
41,651
28,566
140,011
5,401
2,345
13,603
0
0
257,229
Yr 3
Yr 4
Yr 5
Total
23,500
47,000
11,750
4,700
2,350
42,300
4,700
11,750
0
0
0
20,240
39,980
13,205
5,153
2,377
37,232
3,713
9,283
0
0
0
20,112
35,482
15,380
4,800
2,655
34,509
3,156
7,890
0
0
0
16,205
33,934
18,328
5,040
2,788
32,558
2,683
6,707
0
0
0
18,474
31,540
23,056
6,603
2,767
30,602
2,280
5,701
0
0
0
17,532
30,386
22,467
7,133
2,895
27,742
1,938
4,846
0
0
0
92,563
171,323
92,436
28,728
13,482
162,643
13,770
34,425
0
0
0
7,050
28,200
14,520
7,050
7,050
9,400
4,000
0
0
225,320
8,841
8,037
31,948 34,143
14,553 18,208
8,841
8,037
8,841
8,037
10,716 11,788
5,016
4,560
0
0
0
0
221,420 222,245
9,725
38,757
20,029
9,725
9,725
12,966
5,518
0
0
227,530
35,250
10,697 11,767
139,600
42,633 46,896
22,032 24,715
73,080
12,717
36,200
10,697
35,250
10,697 11,767
47,000
14,263 15,689
6,069
6,676
27,839
0
0
0
0
0
0
241,241 248,607 1,003,589
5.2 Expenditures
CY
Revenues
Expenditures
Balance
MOD9L2.WQ1
Yr 5
Total
Yr 3
17,232
22,410
21,020
180,000
2,169
2,345
5,000
0
0
250,176
5.3 Summary
Yr 4
Yr 2
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Income gen activities
Training centre
Other
Other
Total revenues
PHC SERVICES
Tetanus toxoid
Antenatal care
Family planning
Growth monitoring
Nutrition education
Child immunization
Oral rehydration
Income gen activities
Other
Other
Other
MANAGEMENT
SERVICES
Planning
Training
Supervision
Financial mgmt
Logistics mgmt
Community organ.
Training centre
Other
Other
Total expenditures
Yrl
CY
250,176
225,320
24,856
Yr 2
Yr 3
252,850 253,600
221,420 222,245
31,430 31,355
257,229
227,530
29,699
Yrl
Module 9; Sustainability analysis; appendix B
128,374
27,909 30,188
49,983 58,982
211,345
143,410
30,995 33,544
701,359
127,210 114,666
8,004
6,671
25,923
2,345
2,345
11,725
16,323 19,588
70,296
0
0
0
0
0
0
261,436 267,318 1,292,433
Yr 4
Yr 5
Total
261,436 244,345 1,292,433
241,241 248,607 1,003,589
20,196
18,711 288,843
76
Amount
Figure 1: Initial projections of revenues and expenditures (5 years)
Amount
Figure 2: Adjusted projections to revenues and expenditures (5 years)
Module 9: Sustainability analysis; appendix B
77
LEVEL 3 ANALYSIS
Assessing changes in population size and coverage
Level 3 uses the same forms and procedures as Level 2. The only difference is that you
will need to estimate changes that may occur in the size of your target groups, and in
your coverage objectives.
Your programme probably has only 3-5 target groups, and the change in the size of each
group is likely to be similar However, coverage levels are likely to vary by service, and you
may decide to increase coverage for some services more than others. You may also decide to
reduce coverage for some services in order to become more sustainable. You can use the
following worksheet (a computerised version is available with this module) to make your
estimates.
In the following example, the programme has five principal target groups: pregnant women
(tetanus toxoid and antenatal care); married women aged 15-49 (family planning), children
under age five (nutrition education and ORT), and children under age two (growth monitoring
and immunization).
LEVEL 3 Worksheet for selecting target groups
Target groups (age or
Current Annual
%
condition)
pop size
change
WOMEN
Tetanus toxoid (pregnant)
• 1,419
Antenatal care (pregnant)
• 1,419
Safe delivery
Family planning (married 15-49) • 9,460
Total
coverage
Annual
%
change
change
• 5%
• 5%
•
• 8%
• 15%
• 15%
•
• 25%
•0
•0
•
.5%
• 5%
• 5%
•
• 13%
•
• 5%
■ 4%
• 45%
• 65%
• 5%
• 4%
. 65%
• 55%
•
• 5%
• 4%
•
• 5%
• 4%
•
•
Current
%
%
CHILDREN
Breast-feeding
Growth monitoring (0-2yr)
• 4,400
Nutrition education (0-5yr)
• 9,900
Acute respiratory infection
Child immunization (0-2yr)
• 4,400
Oral rehydration therapy (0-5yr) • 9,900
Vitamin A
Childhood disability
•0
•
•0
■0
•
•
ALL GROUPS
Diarrhoeal disease control
Water supply
Tuberculosis treatment
Malaria prevention/treatment
STD and HIV/AIDS
Treatment of minor ailments
Other
•0
•
Module 9: Sustainability analysis; appendix B
•
78
The size of each target group may change because of in- or out-migration, changes in
births and deaths, expansion or contraction of the projects catchment area, and changes in
socio-economic status; as some people move up and out of the target group, or others move
into the target group. In this example, the target groups are expected to grow from 4-8
percent each year.
Coverage levels are shown in percentages, and range from 15-65 percent currently. The
project does not plan to increase coverage, except for family planning, which would expand
five percent per year. That is, at the end of five years, family planning coverage would reach
about 50 percent.
Enter the projected annual changes in population size and in coverage objectives, then
total the annual changes in the last column.
Next, add these changes to the Table 2 worksheet. The worksheet is reproduced on the
next page. In this example the effects of an increase in the size of the ANC target group will
be dealt with by expanding services. That will have financial implications. A 5% increase in
the number of people needing ANC services will increase the cost of the ANC component by
5%. No change is planned in the coverage objective. It will remain at 15%. Thus, there is no
financial effect for that factor.
The overall effect of these changes can be added to previous changes identified, which in
this case was to turn the costs of medications and vaccines over to the MOH. Thus, the net
effect will be to decrease costs 10% per year over the next five years.
In the ANC/TT example, the target population is expected to increase by five percent
each year. Assuming this new group receives all the services now offered, that would increase
costs about 5% each year. An increased clientele may also increase revenues slightly by paying
fees. In this example the clients pay about 1/5 of the costs of service in fees. Thus, revenues
will increase about 1% each year.
Develop general strategies for the revenue and expenditures but enter the detailed effects
on each service listed in the second part of Table 2.
Financial assessment
The financial assessment is exactly the same as in Level 2. Please follow those instructions
and use those worksheets.
What-if analysis
The what-if analysis is also the same as in Level 2. Just enter the figures that you
generated in your Table 2 worksheet. An example of that worksheet follows. Please note
that this is exactly the same as the Level 2 table, except that two of the non-financial factors
(Target population size and Target group KAP) are not included. This is because they have
been combined with PHC and management service factors and included directly in the revenue
and expenditure cells.
As usual, you can make changes in any of these assumptions to see their effect on costs
and revenues. The results would be shown in Table 5 (not displayed here, but see the computer
file for illustrative data).
Module 9: Sustainability analysis; appendix B
Table 2: Sustainability factors worksheet
LEVEL 3
FINANCIAL IMPLICATIONS
File MOD9 SA3.WQ1 or MOD9 SA3.WK1
Classify each factor, identify strategies where appropriate, estimate financial implications
Factor: Threat/opportunity; description
5. Organisational capacity. Opportunity-.
Strong organisation
Effect
+
Expenditures
Revenues
Effect 1-Time
Rev.
+
No strategy at present Could expand into other
Strategy
Rant
Rev.
Cmpnd. 1-Time
Rev
Costs
Rcrnt. Cmpnd.
Costs Costs
areas
6. Political commitment. Threat. Lack of
community support
Hold 2-3 education/PR sessions in each
community
0
+1%
7. Personnel resources. Threat May lose key
staff as donor support ends
Develop improved compensation package
0
+3%
8. Revenues. Threat: Losing some donor
support in 1993
Develop alternative sources of funds: Fees, fundraising, training, contributions.
Recurrent. Fees 5%; grants 20%; outside income
200%
Compounded: Contrib 10%; govt 5%, grants 5%.
outside 20%
+
9. Expenditures. Threat; Inflation of 3%
annually. Other line item costs increasing,
some decreasing
Increase revenues >396 (see revenues),
Recurrent Indirect costs - 10%; in-kind contrib
+10%
Compound: Personnel +2%; travel +2%;
supplies -3%, ODC -5%, in-kind +596
10. Environment. Neutral: No changes expected
0
+5% +10%
+20% +5%
+200% +5%
+20%
-10%
+10%
+2%
+2%
-3%
-5%
+3%
+5%
0
Entries cannot be made in shaded cells in the computer program. The program assumes that
these factors do not affect revenues
00
\' Table 2: Sustainability factors worksheet
LEVEL 3
FINANCIAL IMPLICATIONS
File MOD9 SA2.WQ1 or MOD9_SA2.WRI
Classify each factor, identify strategies where appropriate, estimate financial implications
Turn these over to MOH over next five years
Expand services: client pays 2096 (revenue up 1/5 = 1%)
No change
NOTE: cannot phase out completely; change affects
both ANC and TT
Hold annual seminar for religious leaders.
Antenatal care and tetanus toxoid. ANC
medications and TT vaccines too expensive.
Population size Increase 5%/year
Coverage objective: No change
Module 9: Sustainability analysis; appendix B
Family planning. Resistance from religious
leaders
Population size: Increase 8%/year
Coverage objective: Increase 5% annually for
next 5 years
Growth monitoring and nutrition education.
Lack of food supplements
Pop size: GM group will grow 4% year:
nutrition ed will grow 5%; Ave = 45%
Coverage objective: No change
Child immunization. Vaccines and services too
expensive
Population size Increase 5%/year
Coverage obj-. No change
Oral rehydration: ORS packets low quality, not
liked
Population size 4% annual increase
Coverage obj: No change
Training: Strong capability in staff training
Community organisation: Weak project
capability m this area
Income generation: Projects not effective
Losing money. No return to project
1-Time
Rev.
■
Rant
Rev.
Crrprrl 1-Time Rcmt
Costs Costs
Rev
+1%
0
+16%
Cmpnd.
Costs
-15%
+5%
0
+5%
+2%
+8%
+5%
+1%
Expand services- client pays 20% (revenue up 1/5 = 1%)
Expand services: client pays 20% (revenue up 1/5 = 1%)
-
Ex senditures
Revenues
Effect
PHC services and management support Effect Strategy
services
Factor: Threat/ opportunitv; description
Refer to CARE and MOH Nutrition Center
Expand services: client pays 0% (revenue unchanged)
No change
0
Turn over to MOH over next 5 years; continue 1EC
Expand services; client pays 0% (revenue unchanged)
No change
0
-15%
+5%
Switch to cereal-based ORT, home remedies.
Expand services; client pays 0% (revenue unchanged)
No change
0
-20%
+4%
Develop training courses for staff from other projects
for fee.
See Table 3 for cost and revenue projections for this
component.
Startup costs, operating expense for first 2-3 years
might be financed by donor
Hire community organisation specialist
0
Phase out over next 5 years (-20%/yr)
0
$1 f£l fB Jjf [fl ® [Fl fgi nn
w ire
+4.5%
+25%
0
-20%
«
$ [’
rT
J3
Table 4 What-if analysis worksheet
LEVEL 3 WORKSHEET
MOD9L3.WQ1 or MOD9L3.WK1
Enter projected annual % increase (+) or decrease (-). Results seen in Table 5
4.1 Non-financial factors
1-Time
rev.
Rcrnt.
rev.
Cmpnd. 1-Time
rev.
costs
Organizational capacity
Political commitment
Personnel resources
Environment
Rcrnt.
costs
Cmpnd.
costs
+1%
+3%
Total pop size: A(+) in revenues increase fees; A(+) in expenditures increases all costs
Political commitment: A(+) increases all revenue; A(-F-) in expenditures increases all costs
Environmental: A(+) increases ail revenues; A(+) in expenditures increases all costs
All other factors: no effect on revenues; A(+) in expenditures increases all costs
Ctrl 4- W to widen columns - Entries cannot be made in shaded areas (with X)
(Crl+W to widen columns)
Financial Factors: Enter general adjustments in 4.2 and 4.3 only if not included
in 4.4 PHC Services or 4.5 Management Services
1-Time Rcrnt. Cmpnd 4.3 Expenditure
1-Time Rcrnt. Cmpnd
4.2 Revenue
Rev.
Rev.
Rev. Categories
Costs Costs Costs
Categories
Fees
5%
2%
Personnel
Contributions
10% Travel/per diem
2%
Government
subsidies
Grants/contracts
5% Supplies
-3%
20%
5% Equipment
Outside income
200%
20% Other direct costs
Other:
Indirect costs
-5%
-10%
3%
Inflation
In-kind
contributions
& ib
!
tei ik’ iM iki tel tel tel tel tel tel te
1
te te tei tel tel tei
81
Module 9: Sustainability analysis; appendix B
10%
5%
82
Service factors: enter adjustments specific to services. Enter general
adjustments in 4.2 and 4.3 on previous page.___________ __ _______ _________
1-Time Rcrnt. Cmpnd. 1-Time Rcmt Cmpnd
4.4 PHC Services
Costs
Costs
Costs
Rev.
Rev.
Rev.
4.5 Management
Services
Planning
Personnel mgmt.
Training
Supervision
Financial mgmt
Logistics mgmt.
Information mgmt.
Community organ.
Other
-10%
-10%
+1%
Tetanus toxoid
Antenatal care
Safe delivery
Family planning
Breastfeeding
Growth monitoring
Nutrition education
Acute respiratory
infection
Child immunization
Oral rehydration
therapy
Vitamin A
Childhood disability
Diarrhoea disease
control
V.bter supply
Tuberculosis treatment
Malaria
prevention/treatment
Sexually transmitted
disease/ HIV
Treatment of minor
ailments
Income generation
Other
Other
+1%
+2.6%
18%
2%
4%
4%
-10%
-16%
-20%
1-Tnrte
Rev.
Rcrnt.
Rev.
Cmpnd. 1-Time
Rev.
Costs
Rcrnt
Costs
Cmpnd.
Costs
25%
Module 9: Sustainability analysis; appendix B
Appendix C: Blank worksheets
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
ik
'
1
iW itf
k k k k k
ife
!
k k k ki k! k kl k! Ik' k! ih! k! iL
1
85
Module 9: Sustainability analysis; appendix C
WORKSHEET FOR SPECIFYING OBJECTIVES,
WHAT TO SUSTAIN AND AT WHAT LEVEL
Priority health coverage:
Indicators
Level
Children < 5 yrs
Children < 2 yrs
Pregnant women
Married women 15-49 yrs
_.Other:
Services/institutions:
PHC outreach services.
PHC clinical services (list)
Management functions (list)
Agency/institution/unit (list)
Other
Resources:
Funding (specify)
Contributions (cash, in-kind)
—Personnel,
Technical capability
Other
WORKSHEET FOR SPECIFYING THE RESTRICTIONS
___________________________ ON SUSTAINABILITY_________________
Sustainability
restrictions
No restrictions
Donor restrictions
Other
Self-sustaining
Module 9: Sustainability analysis; appendix C
87
TOTAL EXPENDITURES CY: (Enter here)
WORKSHEET FOR SELECTING THE TYPE OF ASSESSMENT AND LEVEL
OF DETAIL
Strategic assessment: Check the level of analysis to be undertaken
------- Level 1: A general analysis of each of the ten factors
------- Level 2: A general analysis of eight 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 six of the factors plus a detailed assessment of four
of them. \bu assess the effects of changes in target population size and target
group KAP (coverage) on each PHC service and each management service.
Financial 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" analysis of the effect of changes in the ten factors on
future revenues and expenditures.
Level 2: A detailed analysis of revenues by source and expenditures by PHC
service and management service; and a "what-if analysis of the effect of
changes in the ten factors on future revenues and expenditures.
Level 3: A detailed analysis of revenues by source and expenditures by PHC
service and management service taking into account changes in target popu
lation size and target group KAP (coverage); and a "what-if analysis of the
effect of changes in the ten factors on future revenues and expenditures.
Strategic assessment
Sustainability
Level Level Level
factors
12
3
Financial assessment
Sustainability
Level Level Level
factors
123
Population size
Target group KAP
PHC service quality
Management support
Political commitment
Personnel resources
Revenues
Expenditures
Environmental factors
' Summary estimates only
X Detailed estimates
N.B. Don’t forget that you can mix levels of
analysis. You can do a Level 3 Strategic
assessment and a Level 1 Financial
assessment, for example.
Population size
Target group KAP
PHC service quality
Management support
Political commitment
Personnel resources
Revenues
1
1
Expenditures
Environmental factors
*
’ Summary estimates only
X Detailed estimates
1 Revenues by source
2 Expenditures by general ledger item
3 Expenditures by PHC service and
management activity
Module 9: Sustainability analysis; appendix C
1
Table 2: Sustainability factors worksheet
00
File MOD9 SA1.WQ1 or MOD9_SA1.WRI
LEVEL 1
FINANCIAL IMPLICATIONS
Module 9; Sustainability analysis; appendix C
1
Target population size
2.
Target group KAP (coverage)
3.
PHC service quality
4.
Management support
5.
Organisational capacity
6.
Political commitment
7.
Personnel resources
8.
Revenues
9.
Expenditures
10
Environment
Revenues
1-Time
Rev.
Expenditures
Rcrnt Cmpnd. 1-Time
Rev.
Rev.
Costs
Rcrnt.
Costs
Cmpnd.
Costs
L evel o n e w o rk sh eets
Classify each factor, identify strategies where appropriate, estimate financial implications
Threat/opportunity factor description
Effect Strategy
Effect
Entries cannot be made tn shaded cells in the computer program.
®
If!
JI
fl)
®
ipj
fl)
TO
M
II)
Ji
TO
(Il
I® i||
(j>|
m
jp
89
Table 1: Coverage objectives and services
Target group
PHC services
Coverage objectives
Table 3: Initial projections of revenues and expenditures
(in ’000)
LEVEL 1 WORKSHEET
3.1 Revenues
CY
Yrl
Yr2
Yr3
Yr4
MOD9L2.WQ1
Yr5
Total
CY
Yrl
Yr2
Yr3
Yr4
Yr5
Total
CY
Yrl
Yr2
Yr3
Yr4
Yr5
Total
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Other
Other
Total
3.2 Expenditures
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
Total
3.3 Summary
Revenues
Expenditures
Balance
Module 9: Sustainability analysis; appendix C
90
Table 4: What-if analysis worksheet
LEVEL 1 WORKSHEET
MOD9L1.WQ1
Enter projected annual % increase (+) or decrease (-). Results seen in Table 5.
Recrnt. Cmpnd.
4.1 Non-financial factors 1-Time Recrnt. Cmpnd. 1-Time
costs
rev.
costs
costs
rev.
rev.
(See notes below)
Target population size
Tarqet group KAP (coveraqe)
PHC service quality
Management support
Orqanisational capacity
Political commitment
Personnel resources
Environment
Total pop size. A{+) in revenues increases fees; A(+) in expenditures increases all costs
Political commitment: A(+) increases all revenue; A(+) in expenditures increases all costs
Environmental: A(+) increases all revenues; A(+) in expenditures increases all costs
All other factors: No effect on revenues; A(+) in expenditures increases all costs
Financial factors
Revenues categories
1-Time
rev.
Rcmt
rev.
Cmpnd.
rev.
A(+) increases revenues
A(-) decreases revenues
1-Time
costs
Rcrnt.
costs
Cmpnd.
costs
A(+) increases expenditures
A(-) decreases expenditures
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Other
Other
Expenditures
categories
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
Other factors affecting expenditure
Inflation
In-kind contributions
A(+) increases all costs
A(-) decreases all costs
Module 9: Sustainability analysis; appendix C
k) iw
o iw is mj !ii !mi Hi 'a Hi la Hi H Hi H H H U Hi H H &
LEVEL 2
File MOD9 SA2.WQ1 or MOD9 SA2.WK1
FINANCIAL IMPLICATIONS
Classify each factor, identify strategies where appropriate, estimate financial implications
Factor Threat/opportunity; description
1 Target population size
2. Target group KAP (coverage)
3. PHC service quality
4. Management support
5. Organisational capacity
6. Political commitment
7. Personnel resources
8. Revenues
9. Expenditures
10 Environment
Effect
Strategy
Revenues
Effect
1-Tme
Rev.
Rant
Rev.
Cmpnd.
Rev
Ex penditures
1-Time
Costs
Rcmt.
Costs
Cmpnd.
Costs
LEVEL 2 W O R K SH EETS
Module 9: Sustainability analysis; appendix C
Table 2: Sustainability factors worksheet
Table 2: Sustainability factors worksheet
Level 2
File MOD9_SA2.WQlor MOD9_SA2.WK1
Classify each factor, identify strategies where appropriate, estimate financial implications
PHC services and management support Effect Strategy
services
Factor: Threat/ opportunity; description
FINANCIAL IMPLICATIONS
Revenues
Effect
T-------
Expenditures
1-Time Rcrnt. Cmpnd. 1-Time
Rev.
Rev.
Rev.
Costs
Rcrnt. Cmpnd
Costs Costs
Module 9: Sustainability analysis: appendix C
it
ffi ffi rm tr ii igi
rsi rgi iki isi
iss pf
s'
ctI /pi
93
Expenditure distribution worksheet
PHC SERVICES
%
MOD9 EXP.WQ1
AMT MANAGEMENT
Tetanus Toxoid (pregnant)
Planning
Antenatal care (pregnant)
Personnel mgmt
Safe delivery
Training
Family planning
Supervision
Other
Financial mgmt.
Breast-feeding
Logistics mgmt.
Growth monitoring
Information mgmt.
Nutrition education
Commun. organ.
Acute respiratory infection
Training centre
Child immunization
Other
Oral rehydration therapy
Subtotal, Mgt. services
Vitamin A
Childhood disability
Other
V\tater supply
Tuberculosis treatment
Malaria prevention/treatment
STD/HIV
Minor ailments
Other: IGA
Subtotal, PHC services
Module 9; Sustainability analysis; appendix C
Total, PHC + Mgt
%
AMT
94
Table 3: Initial projections of revenues and expenditures
(in 000)
LEVEL 2 WORKSHEET
3.1 Revenues
CY
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Income gen act.
Training centre
Other
Other
Total
3.2 Expenditures
Tetanus toxoid
Antenatal care
Family planning
Growth monitoring
Nutrition education
Child imrnun.
Oral rehydration
Income gen. activities
Other
Other
Other
Planning
Training
Supervision
Financial mgmt
Logistics mgmt
Community organ.
Training centre
Other
Other
Total
3.3 Summary
Revenues
Expenditures
CY
Yr 1
Yr 2
Yr 3
Yr 1
Yr 2
Yr 3
MOD9L2.WQ1
Yr 4
Yr 5
Yr 4
Yr 5
Total
Total
gg
£3
W
E
CY
Yr 1
Yr 2
Yr 3
Yr 4
Yr 5
Total
Balance
Note: can also oe used lor table 5
gr
S3
g/
Module 9: Sustainability analysis; appendix C
BP
95
Table 4: What-if analysis worksheet
LEVEL 2 WORKSHEET
MOD L2.WQ1
4.1 Non-financial factors
1-Time
Rev.
Rcrnt. Cmpnd 1-Time
Rev.
Rev.
Costs
Rcrnt. Cmpnd.
Costs
Costs
Target group size
Target group KAP (Coverage)
Organizational capacity
Political commitment
Personnel resources
Environmental factors
(Ct! + W to widen columns)
Financial Factors: Enter general adjustments in 4.2 and 4.3 only if not included in 4.4 PHC
series or 4.5 Management Services
1-Time Rcrnt Cmpnd.
Financial factors
4.2 Revenues categories revenue revenue revenue
Fees
Contributions
Govt, subsidies
Grants/contracts
Outside income
Other
Other
4.3 Expenditures
Categories
1-Time
costs
Rcurnt Cmpnd.
costs
costs
A(+) increases revenues
A(-) decreases revenues
A(+) increases expenditures
A(-) decreases expenditures
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Other
Other
Other
Other factors affecting expenditures
Inflation
In-kind contributions
A(+) increases all costs
A(-) decreases all costs
Mgmt services not affected
Module 9: Sustainability analysis; appendix C
96
li Hi w Hi ki 14 (a Hi (ti
Service Factors: Enter adjustments specific to services. Enter general adjustments
in 4.2 and 4.3 above.
Rcrnt.
1-Time
Cmpnd.
4.4 PHC services
1-Time Rcrnt Cmpnd.
rev.
rev.
rev.
costs
costs
costs
Tetanus toxoid
Antenatal care
Safe delivery
Family planning
Breast feeding
Growth monitoring
Nutrition ed.
Acute resp. infect.
Child immunization
Oral rehydration
Vitamin A
Child disabilitv
Diarrhoeal control
Tuberculosis
Malaria
STD/H1V/AIDS
Minor ailments
Income generation
Other
Other
4.5 Management support 1-Time
services
rev.
Rcrnt.
rev.
Cmpnd.
rev.
1-Time
costs
Rcrnt.
costs
Cmpnd.
costs
Planning
Personnel Mgmt.
Training
Supervision
Financial mgmt.
Logistics mgmt.
Information mgmt.
Community org.
Other
Other
Other
E? ■
s-
S'Module 9: Sustainability analysis; appendix C
97
LEVEL 3 WORKSHEETS
WORKSHEET FOR SELECTING TARGET GROUPS
Target groups (age or
Current Annual
Current
Annual
condition)
pop size %change %coverage ^change
WOMEN
Tetanus toxoid (preqnant)
Antenatal care (preqnant)
Safe delivery
Family planning (married 15-49)
CHILDREN
Breast-feedinq
Growth monitorinq (0-2yr)
Nutrition education (0-5yr)
Acute respiratory infection
Child immunization (0-2yr)
Oral rehydration therapy (0-5yr)
Vitamin A
Childhood disability
ALL GROUPS
Diarrhoeal disease control
Water supply
Tuberculosis treatment
Malaria prevention/treatment
STD and H1V/AIDS
Treatment of minor ailments
Module 9: Sustainability analysis; appendix C
Total
Table 2: Sustainability factors worksheet
LEVEL 3
File MOD9 SA3.WQ1 or MOD9_SA3.WK1
Classify each factor, identify strategies where appropriate, estimate financial implications
Factor: Threat/opportunity; description Effect
Strategy
FINANCIAL IMPLICATIONS
Revenues
Effect 1-Tme
Rev.
Rant
Rev.
Expenditures
Gnpnd 1-Time
Rcu
Costs
Rcrnt. Cmpnd.
Costs Costs
5. Organisational capacity
6. Political commitment
7. Personnel resources
8. Revenues
Module 9: Sustainability analysis; appendix C
9. Expenditures
10. Environment
Hi in [fl pH f III $ B
III 151 $1 (SB
$ B fl* $
p
Table 2: Sustainability factors worksheet
Level 3
File MOD9 SA2.WQ1 or MOD9 SA2.WK1
Classify each factor, identify strategies where appropriate, estimate financial implications
PHC services and management support Effect Strategy
services
Factor: Threat/opportunity; description
FINANCIAL IMPLICATIONS
Revenues
Expenditures
Effect 1-Time Rcrnt Cmpnd. 1-Time
Rev.
Rev.
Rev.
Costs
Rcrnt Cmpnd.
Costs Costs
100
Table 4: What-if analysis worksheet
LEVEL 3 WORKSHEET
MOD9L3.WQ1 or .WK1
Enter projected annual % increase (+) or decrease (-). Results seen in Table 5 — >
1-Time
Rcurnt. Cmpnd.
4.1 Non-financial factors 1-Time Rcurnt Cmpnd.
rev.
rev.
costs
costs
costs
rev.
Organisational capacity
Political commitment
Personal resources
Environmental factors
(Crl + W to widen columns)
Financial Factors: Enter general adjustments in 4.2 and 4.3 only if not included in 4.4 PHC
Services or 4.5 Management Services
4.2 Revenue categories
1-Time
rev.
Rcmt
rev.
Compnd.
rev.
1-Time
rev.
Rcmt
rev.
Cmpnd.
rev.
Fees
Contributions
Government subsidies
Grants/contracts
Outside income
Other:
4.3 Expenditure
categories
Personnel
Travel/per diem
Supplies
Equipment
Other direct costs
Indirect costs
Inflation
In-kind contributions
HI
Module 9: Sustainability analysis; appendix C
101
Service Factors: Enter adjustments specific to services. Enter general adjustments
in 4.2 and 4.3 above.____________________________
____
4.4 PHC services
1-Time Rcrnt Cmpnd.
1-Time
Rcrnt.
Cmpnd.
rev.
rev.
rev.
costs
costs
costs
Tetanus toxoid
Antenatal care
Safe delivery
Family planning
Breast feeding
Growth monitoring
Nutrition ed.
Acute resp. infect.
Child immunization
Oral rehydration
Vitamin A
Child disability
Diarrhoeal disease control
Tuberculosis
Malaria
STD/HIV/AIDS
Minor ailments
Income generation
Other
Other
4.5 Management support 1-Time
rev.
services
Rcrnt.
rev.
Cmpnd.
rev.
1-Time
costs
Rcrnt.
costs
Cmpnd.
costs
Planning
Personnel Mgmt.
Training
Supervision
Financial mgmt.
Logistics mgmt.
Information mgmt.
Community org.
Other
Other
Other
o
• IOO
Module 9: Sustainability analysis; appendix C
" > /'
103
Acronyms and abbreviations
AIDS
AKF
ANC
CHW
CY
FP
GLI
GM
HW
IEC
IGA
KAP
MCH
MIS
MOH
NGO
ODC
ORT
PD
PHC
PHC MAP
PRICOR
SES
TB
TT
TQM
URC
WHO
Acquired immune deficiency syndrome
Aga Khan Foundation
Antenatal care
Community health worker
Current year
Family planning
General ledger items
Growth monitoring
Health worker(s)
Information, education, communication
Income-generating activities
Knowledge, attitudes, practice (behaviour)
Maternal and child health
Management information system(s)
Ministry of health
Non-governmental organisation
Other direct costs
Oral rehydration therapy
Per diem
Primary health care
Primary Health Care Management Advancement Programme
Primary Health Care Operations Research
Socio-economic status
Tuberculosis
Tetanus toxoid
Total quality management
University Research Corporation
World Health Organization
Module 9: Sustainability analysis; acronyms
104
Glossary
Module 9: Sustainability analysis; glossary
W
IBl (W
Ill
IB)
lil
fl W Tl 11) Is ill ip
411
munity who provides basic preventive and curative health services to
members of the community. Includes village health workers, health guides,
and other terms
Compounded: A change that increases or decreases over time by a fixed
amount or percentage
Costs(s): The value of a good or service, which is conceptually defined as
the value that could be gained by using the resource in a different way. For
example, the cost of drugs could be seen as the value of using the resources
to purchase some other commodity or service.
Coverage: The percent of a target group that has received a service or is
protected from a disease or health problem
Effectiveness: The degree to which desired outcomes are achieved
Efficiency: The degree to which desired outcomes are achieved without
wasting resources
Factor: One of the elements that produces a result
Indicator: An indirect measure of an event or condition. For example, a
baby’s weight-for-age is an indicator of the baby’s nutritional status.
Inputs: Resources (personnel, materials and equipment, information and
money)
Institution: An established organisation, group, agency or other formal
entity
Management: The art and science of getting things done through people
Objectives: The output and/or effect that a programme hopes to achieve
One-time: A change that occurs only once and is neither continued nor
repeated
Opportunity: A favourable circumstance
Outcomes: Results of programme, including outputs, effects and impacts
Outputs: Products and services provided by a PHC programme
Effects: Changes in knowledge, skills, attitude and behaviour,
(including coverage) as a result of a PHC programme
Impacts: Changes in health status, (mortality, morbidity, disability,
fertility) as a result of a PHC programme
IS)
Assessment: An evaluation or judgement
Break-even: The point at which revenues equal expenditures
Community health worker (CHW). A person indigenous to the com
105
y
Primary health care: Essential health care, accessible at affordable cost
to the community and the country, based on practical, scientifically sound
and socially acceptable methods. It includes at least eight components:
health education, proper nutrition, clean water and basic sanitation, mater
nal and child health care, immunization, control of common diseases and
injuries, prevention of local endemic diseases, essential drugs.
Processes: Activities or tasks carried out in programme
Projection: An estimate of future status
Recurrent: A change that is made permanent
Resource: Available means, usually personnel, material, funds,
information
Revenue: Money received
Strategy: A general plan for obtaining an objective
Sustainability: The ability or prospect to continue, prolong,
keep something up
System: A set of discrete, but interdependent, components designed
to achieve one or more objectives
Target group: Specific groups of people designated to receive a PHC
service, such as children under age 2 designated to receive immunizations
Threat: A menace or constraint to achieving an objective
Module 9; Sustainability analysis; glossary
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. Neerai Kak
Ms. Lori DiPrete Brown
Ms. Pam Homan
Dr. Lynne Miller Franco
Ms. Mary Millar
MODULE 9
USER S GUIDE
Primary Health Care Management Advancement Programme
- Media
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