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THE PROGRAM DEVELOPMENT PROCESS FOR URBAN HEALTH
PARTICIPANT WORKBOOK
Urban Health: The Global Challenge
October 19 - November 6, 1992
Management Sciences for Health
Boston, Massachusetts 02130
Developed by:
Diana Silimperi
Laurel Cobb
Jana Glenn-Ntumba
11/2/92
THE PROGRAM DEVELOPMENT PROCESS FOR URBAN HEALTH
PARTICIPANT WORKBOOK
Urban Health: The Global Challenge
October 19 - November 6, 1992
Management Sciences for Health
Boston, Massachusetts 02130
Developed by:
Diana Silimperi
Laurel Cobb
Jana Glenn-Ntumba
11/2/92
ACKNOWLEDGEMENTS
We would like to thank the many individuals who have contributed their time and creative energy toward the
development of The Program Development Process for Urban Health Participant Workbook, particularly the members
of The Management Training Program of MSH and the other Urban Health Course instructors including Jaime
Benavente, Nancy Murray Cunningham, Marianne DiMascio, Joyce Goodman, Saul Helfenbein, Richard Laing, Barry
Levy, Stephen Sacca, Sara Seims, David J. Sencer, James R. Williams, and James A. Wolff who contributed technical
knowledge and practical advice for the application of this knowledge. In addition, special mention and thanks must
be given to Alan Yost, Nancy Troland and Kim Berman without whose able efforts and long hours of labor, this
workbook would not have become a reality (especially after the midnight computer crash!). Your dedication and
support is greatly appreciated.
Diana Silimperi
Laurel Cobb
Jana Glenn-Ntumba
THE PROGRAM DEVELOPMENT PROCESS FOR URBAN HEALTH
PARTICIPANT’S WORKBOOK
TABLE OF CONTENTS
Page
Introduction
1
The Program Development Process for Urban Health
2
Step I:
Identify the Problem
5
Step II:
Define Goal and Establish Objectives
17
Step III:
Select Strategies
23
Step IV:
Develop Institutional Framework
38
Step V:
Develop Plan of Operations
49
Step VI:
Implement Plan of Operations
81
Step VII: Monitor and Evaluate
87
Closing Remarks
96
Participation in Urban Health Network
97
Workbook Evaluation
99
Workbook and Course Glossary
101
INTRODUCTION
This Workbook has been created for those working in urban health (program managers, service providers, health policy makers and planners). It
is an instructional Workbook designed to help an individual or a team clearly identify the urban problem(s) they wish to address, and then develop
a program plan, using a systematic process. The steps in this process take into consideration the complexity of urban settings.
"The Program Development Process for Urban Health" is an adaptation of a participant Workbook which Jana Glenn-Ntumba designed for use
in courses offered through the Management Training Program of Management Sciences for Health (MSH). The Workbook represents a synthesis
of materials produced by experts in the field of management development since the 1960’s. Although the original work upon which this Workbook
is based has been used with modifications by numerous trainers, we would like to recognize here those versions which we used most directly,
including "Force Field Analysis Program" by Saul Eisen; Exercise Manual: The Problem Solving Process, developed by Training Resources Group
for the U S Department of Agriculture; "Force Field Analysis Inventory" adapted from material in A Handbook of Structured Experiences for
Human Relations Training by Ellen Eiseman and Marc Mitchell, and the Hip Pocket Guide to Planning and Evaluation by Dorothy P Craig. The
information on an institutional framework come from the work of Richard Beckhard, Wendy Pritchard, and Roger Fisher.
It is our hope that this Workbook will serve as a useful tool for participants in this urban health course who wish assistance in the systematic
identification of problems as well as the development and implementation of urban health programs to address them. We are very interested in
comments from those who use the Workbook once back on the job. Please contact us with your suggestions and recommendations for
improvements, as well as with stories about how you have used the Workbook successfully. We would be very interested to hear about the urban
health problems you address and any programs you develop.
THE PROGRAM DEVELOPMENT PROCESS FOR URBAN HEALTH
One of your important functions as a person involved in urban health program development is to identify problems on a regular and ongoing basis.
You then have to develop strategies and plans to address the problems, and often institutionalize them within new or existing programs. You may
have to work with a variety of people from different levels within one institution, or representatives from multiple organizations and sectors. More
than likely, resources will be scarce! Without a systematic and logical development process, your chances for success in the complex, challenging
urban environment are minimal.
In this Workbook, we present the urban health program development process as a seven-step cycle which begins with identifying a problem, works
through the definition of goals, establishing objectives, selecting strategies, developing an institutional framework and plan of operations, and ends
with the implementation of the plan, monitoring, and evaluation of the program. There is special emphasis on Step 1 "Identify the Problem",
Step 3 "Select Strategies", Step 4 "Develop Institutional Framework", and Step 7 "Monitor and Evaluate", addressing the needs of urban
environments. Urban Health problems are often multi-faceted and of extreme magnitude. There are usually an overwhelming number of problems,
which makes setting priorities difficult The selection of strategies is also complex for urban program developers because of the range and number
of alternatives as well as the intricacy of feasibility analyses, and the variety of forces which must be considered. Step 4 "Develop Institutional
Framework", is perhaps the most difficult step in the urban process, given the inter-sectoral, multi-institutional affiliations necessary for
implementation; the division of responsibility; and the lack of a vehicle for coordination between sectors. Considering the mobility of urban
populations and the dynamics of change in uiban environments, program monitoring and evaluation is especially critical. One must be sure that
programs are "on track”, leading toward the goal and objectives, despite an ever changing environment. The fact that circumstances may change
significantly in a short time increases the need for constant monitoring to know when rapid alterations in strategies, plans or program design are
necessary. We would like to stress that the program development process is cyclical; one can enter into the process at any point in the cycle.
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The Program Development Process for Urban Health
Step I
Identify the Problem
Step VII
Monitor and Evaluate
Step II
Define Goal and
Establish Objectives
Step VI
Implement Plan
of Operations
Step III
Select Strategies
Step V
Develop Plan of
Operations
Step rv
Develop Institutional
Framework
The Program Development Process for Urban Health
Step VII
Monitor and Evaluate
A. Describe the problem
B. Collect vital information
C. Define and clarify the problem
D. Analyze the cause(s) & effect(s)
E. Refine the problem statement
Step VI
Implement Plan
of Operations
Step V
Develop Plan of
Operations
Step II
Define Goal and
Establish Objectives
Step III
Select Strategies
Step IV
Develop Institutional
Framework
STEP I: IDENTIFY THE PROBLEM
Those active in urban health face a myriad of inter-related and intersectoral problems. Some can be resolved in the short term; others require
long term solutions. The number and magnitude, complexity and multi-faceted etiologies of urban problems can overwhelm the most energetic
planner. Thus, an organized process to identify precisely and clarify problems is a crucial, albeit difficult, step in the process of developing an
urban health program. The first step in our cycle is to describe which problem you will address.
A. DESCRIBE THE PROBLEM
This first step is often difficult in an urban setting because there are so many problems, often inter-related. Review the definition for problem
in the glossary of this Workbook. Start with the general description of your problem, broadly describing the situation. Then, underline key words.
You may have difficulty selecting only one problem. In that case, start with one and follow substeps A through D; you will undoubtedly find
during the clarification and analysis, that one of the problems stands out, either because of the information collected, the consequences if no one
attends to this problem, or perhaps because your organizational mandate doesn’t allow you to address the real causes of the problem, etc. Thus,
by following substeps A through D for each of your identified problems and comparing the results at each substep, you should he able to decide
upon the problem which merits your attention. There is no reason you cannot analyze several problems following the process in this Workbook.
In some cases, you may find that several problems are related and can be linked together for the purpose of your program development. However,
we recommend that you keep it simple at first. Initially, try to clearly identify one key problem upon which you can focus program development.
After you are skillful in using the urban health program development process, you can adapt it to your particular needs as appropriate.
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A. DESCRIBE THE PROBLEM
Write the rough description of your problem situation below.
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B. COLLECT VITAL INFORMATION
This substep is to collect vital information. You want to be sure that you are identifying the appropriate problem in a specific urban context and
to quantify that problem to the extent possible. Collecting some basic information helps frame the right questions and assures that you will begm
by addressing the most important urban issues. It helps you identify which problem is important, relevant and feasible to address at this point in
time.
Different types of uitian data used for analysis and planning come from a variety of sources. The Urban Information and Data for Planning Table
on the following page presents several types of information useful to urban health programs. It indicates the uses for such data in analyzing and
planning, and gives likely sources of the data.
Use this table to identify data sources for your problem. Also, fill in the blank table on page 9, identifying the type of data or information you
want to collect, possible uses, as well as potential sources.
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URBAN INFORMATION AND DATA FOR PLANNING:
THE EXAMPLE OF MATERNAL & CHILD HEALTH AND FAMILY PLANNING PROGRAMS
INFORMATION/
DATA
USE
SOURCES
Family Planning or
other Health
Information
Determine for Family Planning: current knowledge and use of
modem and traditional methods; method preference and problems;
attitudes on family limitation and child spacing; indicators of
expressed or latent demand for family planning; attitudes of men,
community leaders, and school authorities.
Determine for MCH Issues: Mortality and Morbidity, major causes
of sickness and death, etc.
Demographic and Health Surveys, Contraceptive prevalence
surveys; Knowledge Attitudes & Practices (KAP) surveys (check
with the Ministry of Health, national family planning
organizations); family planning & MCH service statistics;
commodities distribution statistics from service facilities or from
regional or central warehouses; operations research reports;
epidemiological studies on breastfeeding practices and method
side effects; statistics on STDs and abortions; client interviews
and observations; focus group research annual reports from family
planning organizations, projects or programs.
Socioeconomic
Information
Determine: sources of income; income fluctuations; social and
ethnic affiliations; religious affiliations; authority structure within
the family and the community; means of communication and
transportation; accessibility of regions; status of women.
Household surveys (census data); socioeconomic indicators from
the Ministry of Economic Affairs; sociological and
anthropological studies; interviews and community surveys;
geographical maps; universities; and international organizations.
Existing Plans in
Population and
Health Sector
Determine goals and objectives of similar or related programs,
organizations, projects. Ensure compatibility of program goals and
objectives with broader development goals and objectives.
National five-year plan; Ministry of Health plan; population sector
plan if available; regional health and population plans; local
(district) plans; plans from private sector agencies working in the
population or health field; related program & project plans;
country strategies of donors; interviews with major donors &
health care providers.
Policies and
Regulations
Determine obstacles to and opportunities provided by various
service delivery strategies.
Ministry of Health regulations; population policy and regulations
where available, such as those relating to paramedical personnel,
importation of contraceptives, and distribution of contraceptives.
Demographic and
Health Indicators
Determine population profile, that is: population size of area; size
of target group(s); health status of target group(s); attitudes about
health and preventive health measures.
Census data from Ministry of (Economic) Planning. When
available, refer to: civil registration system; Demographic and
Health Surveys; World Fertility Survey (WFS); epidemiological
studies on sexually transmitted diseases (STDs), infertility, teenage
pregnancies, abortion, breast feeding practices.
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Fill in your planning information in the tables below.
PROBLEM
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INFORMATION/ DATA
9
SOURCE
ADVANTAGES &
DISADVANTAGES
Management Sciences for Health
URBAN HEALTH INFORMATION AND DATA FOR PLANNING
THE EXAMPLE OF URBAN ENVIRONMENTAL HEALTH PROGRAMS
This second Table presents types of information useful for identifying one subset of problems particularly critical in urban and peri-urban areas:
environmental health problems.
INFORMATION/DATA
EXPOSURE/
USE
MORTALITY/MORBIDITY
FREQUENCY
SOURCES OF DATA
SEVERITY
Housing
Indoor Air Pollution
Outdoor Air Pollution
Water Supply
Sanitation
Occupational Health and Safety
Toxic and Hazardous Substances in
Environment
Traffic Safety
Food Hygiene
Vector Control
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C. DEFINE AND CLARIFY THE PROBLEM
The third substep, following the collection of planning data, is to define the problem you will address as clearly and specifically as possible. In
urban settings, you may have to divide the original problem described into several more precise problem statements. Factors to consider in selecting
one problem rather than another include your institutional mission, your resources, the urgency of the problem, the feasibility of making significant
change, etc.
First, review the underlined sections of the broad description of your problem in Substep A. Now try writing a more concise statement of your
problem.
Next, ask yourself who is affected by the problem - include yourself as well as subsets of the community, such as women or children,
disadvantaged sectors of the society, politicians, certain ethnic groups, etc. In the space below, identify who is affected by your problem.
List those affected by the problem:
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Now, ask yourself if the problem is an appropriate one for you and your organization. First, ask yourself what is the purpose of your organization
and, second, does this problem fit into the purpose of your organization? It may be that you are not certain. If so, note that. However, if you do
see a link between the problem and your organization’s purpose, it’s important to acknowledge it.
In the following space, answer these questions about your organization’s purpose.
What is the purpose of your organization?
Does the problem "fit” the purpose of your organization?
Yes?
No?
Unclear?
How is the problem related to your organization’s purpose?
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D. ANALYZE THE CAUSE(S) AND EFFECT(S) OF PROBLEM
In order to clearly identify your problem, it is important to determine both its causes and effects or consequences. This is a particularly useful step
in addressing health problems in urban areas where health managers face many intersectoral problems, involving numerous agencies with
overlapping jurisdiction, in a context of rapid change. Thus, there may be many causes, only some of which you can alter. However, some of the
effects of the problem may be so extreme as to merit immediate attention, despite complex causes. This substep will be of special significance
in helping you set priorities if you started with several problems that seemed important.
Fill out the Problem Analysis Worksheet on the next page, using the step-by-step process outlined below:
1. Write the problem statement in the center column. Think about the direct causes of the problem. What brought about the problem? What caused
it? List as many of the direct causes you can think of in Column A, entitled "Direct Causes."
2. Now focus on the problem again. What are the direct effects of the problem? What are the direct consequences? Brainstorm as many
possibilities as you can think of and list them in Column B, entitled "Direct Effects."
3. Next you will determine the indirect cause: first, look at the direct causes you have elaborated. Think about what made them happen. What
caused the direct cause? Another way to approach this is to think about each direct cause you have listed and view it as a problem. What
caused it? Your answers should be listed in Column C, entitled "Indirect Causes."
4. Now look at the direct effects you listed. What are the effects or results of the items you listed in that column? In other words, what are the
effects of the direct effects? Yom responses should be listed in Column D, entitled "Indirect Effects."
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CAUSE(S) AND EFFECT(S) OF PROBLEM
PROBLEM ANALYSIS WORKSHEET
Column C
Column A
DIRECT
INDIRECT
CAUSES
CAUSES
(Cause of the Cause)
Urban Health: The Global Challenge
STATEMENT
OF THE
PROBLEM
14
Column B
Column D
DIRECT
EFFECTS
INDIRECT
EFFECTS
(Effect of the
Effect)
Management Sciences for Health
E. REFINE THE PROBLEM STATEMENT
The previous four substeps have helped you collect information in order to identify and define the problem. Now, after critical examination, it
is time to use that information to rewrite the problem in one concise statement. The following five basic elements should be included in your
problem statement
1. Future point in time that you are concerned about
2.
Geographic area or parts of the organization that the problem affects.
3. Nature of the problem.
4. Estimate of the size of the problem.
5. Individuals or groups of people that the problem affects.
In the space below, try to re-write your problem statement, including the five basic elements, drawing from the information you have examined
in the preceding four substeps. It may be difficult for you to estimate the size or the extent of the problem, even with the vital information you
have collected. Nonetheless, you should make some estimate so that later you will have a way to measure how effective you have been in
influencing or reducing the problem.
Refined problem statement:
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The Program Development Process for Urban Health
Step I
Identify the Problem
nJ..
_
- -
iaOi
Step VII
Monitor and Evaluate
Step VI
Implement Plan
of Operations
Step V
Develop Plan of
Operations
h Obi
A. Restate problem
B. Develop goal statement
C. Establish objectives
D. Identify criteria for success
Step III
Select Strategies
Step IV
Develop Institutional
Framework
STEP H: DEFINE GOAL AND ESTABLISH OBJECTIVES
A. RESTATE PROBLEM
After this analysis, you probably have a better understanding of the context in which the identified problem exists, including its causes and effects.
You now need to look at the problem in terms of the difference between the way things are and the way you would like things to be. The problem
statement often describes the situation in more negative or undesirable terms, but goals and objectives are written to focus on the improved, more
desirable situation.
Restate the problem now so that it will describe the two situations mentioned below:
1. The situation in the city you would like to change, AS IT IS NOW.
2. The situation in the city, AS YOU WOULD LIKE IT TO BE IN THE FUTURE.
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B. DEVELOP GOAL STATEMENT
Looking at the problem in terms of the situation as it is now and the situation as you would like it to be in the future can help you define your
goal. A goal is a broad, general statement of what youi are trying to accomplish, of your intended outcome or impact. Using your refined problem
from the preceding page, written as you would like it to be in the future, write your goal below:
GOAL STATEMENT:
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C. ESTABLISH OBJECTIVES
An objective is a specific, measurable statement of a quantifiable, time-limited outcome expected by a program or project; in other words, what
you hope to accomplish by a given point in time. It is sufficiently limited in scope and definition that one can logically expect its achievement
by the end of the time period. A program can include several objectives.
The definition of an objective is often similar to the definition of a problem since, in fact, the objective is basically to reduce or eliminate your
problem. Objectives, therefore, have to include the same essential elements as your problem statement: what, when, where, whom and how much.
A simple definition of objectives includes: (1) a situation or condition, (2) of people or the organization, (3) that will exist in the future and (4)
that is desirable, (5) by the members of the organization. Two simple ways to remember the differences between a problem statement and the
objective follow.
(1) The problem generally states the situation in negative or undesirable terms, while the objective addresses a more positive desirable situation.
(2) Since problems can rarely be totally eliminated, the size of the situation or the condition is smaller in the statement of the objective. You
will be trying to limit your objective to a realistic level that is still considered desirable, but is also measurable and attainable.
There are several types of objectives including: those which may aim to solve a problem external to the organization, ones that aim to solve
problems internal to an organization, objectives directed to changing the skiUs, knowledge or attitudes of people, and objectives aimed at
maintaining or changing a condition in a community or organization.
State your objectives as clearly as possible, according to the following SMART criteria:
(S) = Specific
(M) = Measurable
(A) = Attainable
(R) = Relevant
(T) = Time-bound
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OBJECTIVE:
OBJECTIVE:
OBJECTIVE:
Are your objectives really objectives? To determine this, ask yourself these questions for each of your objectives noted above. If the answer is
"no" to any of these questions, you are not ready to proceed. Continue to refine your objectives until you can answer "yes" to each of these
questions.
YES
NO
(1) Is it specific?
(2) Is it measurable?
(3) Is it attainable?
(4) Is it relevant?
(5) Is it time-bound
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D. ESTABLISH CRITERIA FOR SUCCESS
The final check for your objectives is to establish initial criteria for your success. Remember that you are trying to answer the question, "How
will I know when I have reached my objective?" Thus, if you can’t identify your criteria for success, you have not defined your objective in a
concrete enough way. "If you don’t know where you’re going, how will you know when you’ve arrived?"
Therefore, take some time now and identify several criteria which will determine the success of each objective. Note them below.
CRITERIA FOR OBJECTIVE 1:
CRITERIA FOR OBJECTIVE 2:
CRITERIA FOR OBJECTIVE 3:
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The Program Development Process for Urban Health
Step I
Identify the Problem
Step VII
Monitor and Evaluate
Step VI
Implement Plan
of Operations
Step V
Develop Plan of
Operations
Step II
Define Goal and
Establish Objectives
A. Describe existing & desired situations
B. Identify restraining forces
C. Identify driving forces
D. Prioritize forces
E. Identify possible strategies
F. Assess feasibility of strategies
G. Make decision to select final strategy
Step IV
Develop Institutional
Framework
STEP III: SELECT STRATEGIES
In order to select the most appropriate strategies to accomplish your goal and objectives, you must first do a thorough diagnosis of the dynamics
affecting your situation. A useful tool for doing such a diagnosis is a force field analysis. The Force Field Analysis model, developed by Kurt
Lewin in the 1940’s, suggests that social situations are dynamic rather than static. Any given situation - or problem - occurs in a context where
forces are interacting. A force is any element which acts on a given situation, either a material or a non-material aspect. A physical improvement
as well as an idea can be a force insofar as they both exert an influence on a given situation. In other words, a given situation which may appear
stable is, in fact, maintained in a state of equilibrium by a dynamic field of opposing forces. One might say, therefore, that the situation is semi
stable because it results from a relative equilibrium between different forces acting simultaneously.
Symbolic Representation of Forces in Interaction
►
Situation X
Relatively Stable
—►
►
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One way to represent the interaction of the forces in a force field would be to consider the situation or problem as a board kept stable by two sets
of springs exerting pressure on the board from two different directions.
Equilibrium in a Force Field
0
Springs
Q
QQJ
O
Q 0
Springs
0 0
Board
In this illustration, it is clear that one need only modify the pressure of the springs to change the position of the board. It is the same thing with
the force field. All that is required is that one force or another be increased or decreased to change the situation more or less significantly
depending on the forces involved.
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For the force field model to be useful, it is necessary to add one additional component. The situation which is in a state of equilibrium must be
considered in relation to another situation which could exist in the future. When you hope to bring about change, you must consider the existing
situation in relation to a desired situation. In other words, the existing situation is unsatisfactory. It is a "problem”. And you seek to change it
to the desired situation. In relation to the desired situation, you can categorize forces acting on the existing situation as "driving" or "restraining"
forces.
FORCE HELD
Desired
Situation
Actual
Situation
Driving Forces
Restraining Forces
As you can see from the figure above, driving forces are those which act in such a way as to bring the existing situation closer to the desired
situation. Restraining forces are those which act in such a way as to prevent the existing situation from moving closer to the desired situation and
which may even tend to bring it closer to another undesirable situation.
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A. DESCRIBE THE EXISTING SITUATION AND THE DESIRED SITUATION
When doing a force field analysis the first thing to do is to describe as precisely as possible the existing situation which you find unsatisfactory
and the desired situation which you hope to achieve. This is basically what you have done in Step I and II — identifying the problem and defining
the goal and objectives.
In the space below, describe your existing situation and your desired situation.
Desired Situation
(Goal)
Existing Situation
(Problem)
B. IDENTIFY RESTRAINING FORCES
Secondly you need to explain the gap between the existing situation and the desired situation, beginning by identifying the restraining forces which
prevent the existing situation from being closer to the desired situation. You are not identifying forces which could act on the situation but rather
forces which are currently acting on the situation. Between the existing situation and the desired situation there are a certam number of restraining
forces which prevent the existing situation from improving.
On the next page, write in all the restraining forces affecting your problem.
Urban Health: The Global Challenge
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Management Sciences for Health
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C. IDENTIFY DRIVING FORCES
Now you need to do an inventory of the driving forces acting on the existing situation. If there were only restraining forces operating in the
situation, the situation would not be in its current state of equilibrium. It would move further and further toward a situation which is 100%
undesirable. In effect, since these forces are not static but rather dynamic; they will continue to exert their influence on to infinity.
If the situation does not improve, it is due to the presence of restraining forces. On the other hand, if it does not get worse, this means there are
forces operating in the reverse sense; that is, driving forces. These are the ones which prevent the situation from deteriorating completely and
which push toward change.
What are your driving forces? Go back to the previous page and write in all the driving forces affecting your problem.
D. PRIORITIZE FORCES
Now that you have completed the inventory of driving and restraining forces acting on the situation you wish to change, you have a total
representation of your situation in dynamic terms which is a fairly advanced diagnosis of your situation. You can go further with your diagnosis
by identifying forces which currently have the greatest impact on the problem situation. These forces will be given top priority when you begin
to identify possible strategies to achieve your goal and objectives. Underline those forces which seem to have the most impact right now.
Depending on your city and the problem, there may be one specific force which stands out, or there may be two or three driving forces and two
or three restraining forces which are particularly important. For example, if your problem is access and availability of family planning services
in peri-urban areas, you might identify the demand for such services, significant donor funds and national Ministry of Health policies as driving
forces. Restraining forces could include cultural norms limiting family planning advertising and lack of public transportation in the peri-urban
areas.
Once your diagnosis of the situation is complete, you want to begin considering appropriate strategies to adopt to bring about the desired situation.
But before you can do that you need to be realistic about what you can and cannot do. At this point, you need to identify those priority forces
which you will be able to affect. Place an asterisk by each force you can affect. Identifying forces on which you can realistically exert some
influence will help you avoid investing time and energy on aspects of the problem which you really cannot change.
E. IDENTIFICATION OF POSSIBLE STRATEGIES
You have seen that the existing situation or problem maintains itself through a state of equilibrium in a dynamic force field. If you want the
problem to evolve in the direction of the desired situation, you need to bring about a dis-equilibrium in the force field. Basically, there are three
ways to do this: 1) act on the restraining forces, 2) act on the driving forces, or 3) transform some driving forces into restraining forces.
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Management Sciences for Health
The first type of strategy is that which will diminish the intensity of or totally eliminate one or more of the restraining forces. This will allow the
driving forces which exist to continue to exert their influence on the situation without interference from counteracting forces and thus move it
toward the desired situation. A second type of strategy is that which increases the intensity of one or more driving force, or even adds additional
driving forces to the field. This creates a significant pressure on the restraining forces which might bring you closer to the desired situation. The
third type of strategy is one in which you transform one or two restraining forces into driving forces.
Experience has shown that the most lasting changes are those which are brought about by the first type of strategy - that is a decreasing of the
intensity of the restraining field. When you proceed in this way you are allowing natural forces in a situation to exert their influence. On die
contrary, when you add driving forces you are adding elements which were not part of the initial situation, and often, you can provoke a reaction
of strong resistance on the side of the restraining forces. In the final analysis one can say that the most effective strategies are probably those which
combine both a decrease in the restraining forces and an increase in the driving forces.
At this stage you want to begin identifying strategies you might adopt. For each FORCE you have underlined and by which you have placed an
asterisk, list some possible strategies which you might be able to plan and carry out which would reduce the effect of the restraining forces, or
would increase the effect of the driving forces. "Brainstonn" as many strategies as you can without thinking of how effective or practical they
would he. DO NOT LIMIT YOURSELF TO ONLY ONE OR TWO STRATEGIES AT THIS POINT IN THE PROCESS. You wifi have an
opportunity later to decide which ones are most appropriate.
Continuing the example above of family planning services for peri-urban women and men, a strategy to increase the effect of available donor
funding (a driving force) might be the development of a proposal for new funds, while a strategy to reduce the effect of a lack of public
transportation in peri-urban areas (a restraining force) might be the development of a Community Based Distribution program.
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FORCE:
STRATEGIES:
FORCE:
STRATEGIES:
STRATEGIES:
FORCE:
STRATEGIES:
FORCE:
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F. ASSESS FEASIBILITY OF STRATEGIES
You have just completed your analysis of driving and restraining forces. Now you want to assess the feasibility of alternative strategies. There
are a variety of issues to consider in deciding whether a given strategy is feasible in a given context, some of which are listed below.
Meets objectives
Within acceptable policy framework
Appropriate timeframe
Acceptable capital investment
Acceptable recurring costs
Political support at necessary levels: national, municipal and/or community
Administrative feasibility
Acceptable physical maintenance requirements
Availability of trained personnel
Environmental effects
Cultural (Religious and Social) acceptability
Your own ability to create an institutional framework to support the strategies.
Now, review the strategies you have listed and UNDERLINE those which seem appropriate after considering the issues mentioned above. When
you have identified several strategies which you think are possible to implement in your city, list them on the following page.
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List of most appropriate strategies:
A.
B.
C.
D.
E.
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After considering the feasibility of each possible strategy, you want to compare alternative strategies by analyzing them in terms of cnteria that
can later be applied to the overall program.
Below is a final set of questions to assist you in deciding whether a given strategy is appropriate in the urban context - the final reality check to
help you compare which of several alternative strategies is the most realistic and should be used in the development of your program.
(1) Appropriateness:
Is it right for you to use this kind of strategy?
(2) Adequacy:
Given the magnitude of the problem, will your strategy make enough of a difference to make it worth doing?
(3) Effectiveness:
How successful will your strategy be in reaching the stated objectives?
(4) Efficiency:
How costly is the strategy in comparison to the benefits obtained?
(5) Side Effects:
What are the effects or consequences - both positive and negative - of your strategy?
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Fill in the following grid to compare your strategies in terms of these key evaluative criteria.
YOUR OBJECTIVE:
STRATEGY
APPROPRIATE
Yes/No/Maybe
ADEQUACY
High/Medium/Low
EFFECTIVENESS
High/Medium/Low
EFFICIENCY
High/Medium/Low
SIDE EFFECTS
Good/Bad
Alternative A:
Alternative B:
Alternative C:
Alternative D:
Alternative E:
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G. MAKE DECISION TO SELECT FINAL STRATEGIES
You now have very concrete, comparative information available in order to make a decision as to which strategies will be selected. However, it
is important to recognize who makes this decision and how such a decision is made within your organization. Although some of this will be
discussed in more depth in Step 4, "Develop Institutional Framework", it is important, even at this step of strategy selection, to give some
consideration to who in your organization (be it yourself or some supervisor) will be responsible for the decision and what process will be used
for decision making.
Recognize that no matter who makes the decision or how it is made, it is important to be clear about the reasons for the decision. All individuals
involved should understand these reasons, particularly in terms of defining the problem and related objectives. A brief list follows that will help
you make a final decision and make clear to others why your decision was the best one.
1. Organizational constraints
2. People required for implementation
3. Location of resistance (if appropriate)
4. Visibility
5. Possibility of success
6.
Personal choice
" one organization may not be best for another, since organizational
It is important to recognize that the decision which is best for you or for
■ j are quite different; however, it is always essential to have a method for comparing the alternatives
purposes, objectives, strengths and constraints
and to be able to state your rationale for the final choice.
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List the selected strategies below and write your rationale for the decisions you made.
YOUR STRATEGY SELECTION
YOUR RATIONALE
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The Program Development Process for Urban Health
Step I
Identify the Problem
Step VII
Monitor and Evaluate
Step II
Define Goal and
Establish Objectives
Step VI
Implement Plan
of Operations
Step III
Select Strategies
I
Step V
Develop Plan of
Operations
■iii
A. Do institutional analysis
B. Manage change
C. Negotiate agreement
STEP IV: DEVELOP INSTITUTIONAL FRAMEWORK
Typically, in health programs in urban areas there is overlapping institutional authority and responsibility for different aspects of the programs.
In order to successfully achieve your goals, you will want to understand and manage the inter-institutional linkages and to plan activities to
generate support for your goals and objectives. Often, in urban areas this may involve mobilizing support, leading change and negotiating
agreement with different institutions.
A. UNDERTAKE AN INSTITUTIONAL ANALYSIS
The first substep in developing an institutional framework is to identify essential institutional collaborators with whom you must work to address
the urban problem. To do so:
1. List the agencies (national, provincial, municipal, local/community-based etc.) which have authority or responsibility in the technical areas
you have identified in your strategies. Note: some of these institutions and/or agencies might be public sector, some private for-profit
(commercial) sector, and others private non-profit. Still others might be international donors such as the World Bank or USAID. Use the
matrix on the following page and list your strategies, and then relevant critical institutions.
2. Identify their role in this technical area. For example, in an urban cholera program, the Ministry of Health might have authority for policy
and planning; a second agency might have responsibility for health education; a third agency might be the hospital for treatment and a fourth
agency, the Municipal Sanitation Department, would be critically involved in the success of control efforts. A fifth institution might be USAID
which is providing the funds for the program.
With this matrix, you will have an institutional framework identifying the colleagues and collaborators, with different levels of authority and
responsibility, with whom you must work to address the urban problem.
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MATRIX OF TECHNICAL AUTHORITY AND RESPONSIBILITY
STRATEGIES
INSTITUTION/AGENCY AND ROLE
1.
2.
3.
4.
5.
A = has authority for policies, procedures or over resources
R = has responsibility in your city for implementing activities
P = must approve: has the power to veto the action
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B. MANAGE CHANGE
Program development in an urban context often means leading and managing change among and with the institutions/agencies you have just
identified as well as with significant groups within those institutions or agencies. (For instance, strategies to decentralize health services may mean
motivating your employees who will have changed working conditions as a result of the decentralization, or strategies to initiate family planning
programs for adolescents may involve mobilizing support for the new programs among conservative factions in the city.) Because managing change
is such a critical aspect of program development, it is useful to build in plans for managing the change process from the very beginning. There
are four activities required to manage change.
1. The first is to create the "vision." With the goals, objectives and strategies you have developed, you have created a vision of an improved
situation.
2. The second activity is mobilizing support among critical decision makers for that vision; that is, for your urban health goals, objectives and
strategies. Consider the following for each strategy:
•
Assess who are the critical decision makers and key players (including critical decision makers in the institutions listed m the Matrix of
Authority and Responsibility and critical sub-groups or individuals within the institution, as appropriate) in the intended change and hst
them in the following matrix.
•
Assess their present state of commitment to such change and indicate it in the matrix with an "x".
•
Judge what level of commitment is necessary to achieve the desired change and indrcate it in the matrix with an o .
•
And then, when developing activities to carry out your strategies, design activities to achieve that level of support This exercise should
be helpful in once more, examining the feasibility of a proposed strategy or in comparing alternative strategies. (If you have identified
a strateev with eight key players, all of whom have no commitment to your strategy and among whom a high level of commitment is
necessary, you may want to choose a more feasible strategy or complement it with other strategies where the present and necessary level
of commitment are closer in line.)
Now, fill in the matrix of these assessments on the following pages.
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STRATEGY 1:
LEVEL OF COMMITMENT
KEY PLAYERS
No commitment
Let it happen
Help it happen
Make it happen
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
X = present state of commitment
O = necessary level of commitment
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STRATEGY 2:
LEVEL OF COMMITMENT
KEY PLAYERS
No commitment
Let it happen
Help it happen
Make it happen
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
X = present state of commitment
O = necessary level of commitment
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STRATEGY 3:
LEVEL OF COMMITMENT
KEY PLAYERS
No commitment
Let it happen
Help it happen
Make it happen
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
X = present state of commitment
0 = necessary level of commitment
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STRATEGY 4:
LEVEL OF COMMITMENT
KEY PLAYERS
No commitment
Let it happen
Help it happen
Make it happen
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
X = present state of commitment
O = necessary level of commitment
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B. MANAGE CHANGE (continued)
3. The third activity in managing change is motivating staff and colleagues to participate in and commit to the change. You have been provided
with readings and handouts on motivation and sources of support for change agents. Use this page for notes on how you will motivate the
key players in your problem situation to support the changes you are strategizing.
NOTES:
4. The fourth and last activity is managing the change process itself. Many of the remaining steps presented in the remainder of this Workbook
can be used to support technical activities, but also should be used to manage the change process. That is, you will want to supervise, monitor
and evaluate your progress in mobilizing support and motivating staff, just as you will want to supervise, monitor and evaluate technical
components such as a Community Based Distribution program in family planning.
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C. NEGOTIATE AGREEMENT
Negotiating agreement on institutional roles and on program objectives, strategies and targets is a vital part of the program development process.
Defining for yourself where such negotiation will be necessary, and planning for such activities from the onset, will make the process smoother
in the long run.
You have been given readings and handouts on negotiation. Use the matrix on the following page to define for yourself and for the other party
with whom you are negotiating, these essential elements in negotiation: interests, objectives and the best alternative to a negotiated agreement.
Interests are what motivate people. They are the why people or institutions do certain things or take certain positions. (Interests of a municipal
employees union might include job security, salaries and benefits and working conditions. Those of the Ministry of Health in the same city might
include cost control and access to services.)
Objectives are what people or institutions would like to obtain. (The Union mentioned above might like a 25% across the board salary raise while
the Ministry of Health is aiming to increase total costs by no more than 10%.)
The Best Alternative to a Negotiated Agreement (BATNA) is your alternative to reaching agreement, if agreement is not possible on terms
minimally acceptable to you. (The BATNA for the union above might be to go on strike if they are not able to negotiate at least a 15% salary
increase, which they figure is their "bottom line.")
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SITUATION NEEDING AGREEMENT:
NEGOTIATING PARTIES
The other side
My party
Basic interests or issues
Interest in common
Objectives
Best alternative to a Negotiated
agreement (BATNA)
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The Program Development Process for Urban Health
Step I
Identify the Problem
Step VTI
Monitor and Evaluate
Step II
Define Goal and
Establish Objectives
Step VI
Implement Plan
of Operations
Step III
Select Strategies
Step IV
Develop Institutional
Framework
A. List activities
B. Review activities
C. Determine a schedule
D. Calculate resources;
develop budget
E. Assign responsibility
E Plan specific tasks
G. Develop plan of
operations
STEP V: DEVELOP PLAN OF OPERATIONS
As we have seen, it is important for you to be able to identify and analyze problems and to select strategies which can lead to their solutions.
In order for a strategy to be implemented effectively, you must also be able to develop a concrete Plan of Operations which includes a list of
activities ordered in a logical sequence, necessary resources, a budget and a timeframe.
Before you begin this exercise, review definitions of the following key terms in your glossary at the end of this Workbook in order to avoid later
confusion: activity, task, resources, strategy.
A. LIST ACTIVITIES AND RESOURCES NEEDED FOR EACH STRATEGY
Begin on the next page by listing below all the activities which would be included in the implementation of each strategy you have selected.
Identify also any relevant resources (human or material) which will be needed for carrying them out. This is a "brainstorming” activity. Activities
do not need to be in a logical sequential order at this stage. Feel free to be creative.
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A. LIST ACTIVITIES FOR EACH STRATEGY (continued)
STRATEGY 1:
RESOURCES NEEDED
ACTIVITIES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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A. LIST ACTIVITIES FOR EACH STRATEGY (continued)
STRATEGY 2:
RESOURCES NEEDED
ACTIVITIES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
1
LIBRARY
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o
A. LIST ACTIVITIES FOR EACH STRATEGY (continued)
STRATEGY 3:
RESOURCES NEEDED
ACTIVITIES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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A. LIST ACTIVITIES FOR EACH STRATEGY (continued)
STRATEGY 4:
RESOURCES NEEDED
ACTIVITIES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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B. REVIEW ACTIVITIES
Now review the list of activities and resources needed from the previous pages and think about how they might each fit into a comprehensive plan.
You may need to look back at your force field analysis in Step HI to help you get additional ideas. You may also begin to group your activities
and to prioritize them in terms of those which seem to be the most important In fact, to some extent, the feasibility questions that you have used
in the selection of your strategies can also be applied to each activity.
Cross out or delete those activities which do not seem to fit into the overall plan. Then add any new activities which are still needed, and indicate
the relevant resources for each. Use the space below for notes and revised or new activities and resources.
RESOURCES NEEDED
NOTES/REVISED OR NEW ACTIVITIES
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B. REVIEW ACTIVITIES (continued)
STRATEGY #:
RESOURCES NEEDED
NEW OR REVISED ACTIVITIES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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B. REVIEW ACTIVITIES (continued)
STRATEGY #:
RESOURCES NEEDED
NEW OR REVISED ACTIVITIES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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C. DETERMINE A SCHEDULE
There are several ways to organize your activities into a logical, sequential order or a schedule. Using the "work backward method, starting from
your objective you can literally place your listed activities in boxes, beginning with the one most directly necessary to complete the objective,
and asking your "backward" question, "If this is where I am, what did I do just before I got to this point?" Insert the correct activity. If you think
of these activities as building blocks hooked together (shown by arrows on your chart), they will ultimately lead to your desired outcome or your
objective.
Now, try to group your activities in this very rough, sequential schedule in the space below.
MAJOR ACTIVITIES PLANNED TO CARRY OUT SELECTED STRATEGIES
(7)
(6)
(5)
(3)
(4)
(2)
(1)
H
U
M
A
N
R
E
S
O
U
R
C
E
S
OBJECTIVE
NOTE: Activities (shown in boxes) that will occur simultaneously should be lined up vertically. Human resources who are perfonning the activities
can be listed in different rows at the left. You may have different groupings, i.e. staff, task force committees, consultants, etc.
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Once you have begun to organize these activities, the next task is to set some general deadlines, or time for completing each activity. Thus, you
will begin to assess how much time each activity or set of activities will require. To do this, you will have to state the activity in the form of the
process to be completed by a certain point, and be able to answer the question, "How will I know when I’ve completed this activity?"
There are many different techniques for scheduling activities. This Workbook will focus on Gantt scheduling and the PERT Chart
GANTT CHART
Gantt scheduling uses a bar chart to show actual completion dates for each activity. In addition, horizontal dotted lines or "Xs" are drawn to show
the planned duration of each activity. In this way, progress on any activity can be monitored by drawing solid lines parallel to and below the dotted
lines or "Xs" to reveal both actual and planned duration for completed activities. Your activities are listed in the column on the left and the calendar
timeframes on the top row. In general, you work from left to right, plotting your activities as they should occur over time in relationship to other
activities, and showing the actual or planned completion date for each activity. The calendar timeframe changes according to the overall timeframe
of the program. Often used are quarters, months or weeks.
Now, use the sample Gantt chart below to insert your activities with the deadlines that you have just determined for each.
GANTT CHART
TIMEFRAME
MONTH/YEAR
ACTIVITY
Q
1
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Q
1
Q
2
Q
3
Q
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Q
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Q
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Q
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PERT CHART
PERT charting is a bit more sophisticated and was developed by the US government to help keep track of very intricate processes that have many
tasks occurring in sequence, and that have to be completed in the shortest possible time. It is well suited to group planning when cooperation is
essential to get many tasks done by a given deadline. This is particularly true in urban settings where there may be several sectors or organizations
involved in a strategy (or program), and it is quite useful to be sure that the various inputs are occurring in a timely and coordinated fashion. The
PERT chart identifies activities which culminate in events. Again, we work backwards from the deadline. The time needed for each recurring
activity is then calculated. Because activities that occur simultaneously, as well as those that are occurring in sequence can be shown by this
method, your chart will quickly reveal a critical path. The critical path is the shortest time needed to complete the project. An advantage of this
technique is that it helps group members focus their energies on essential tasks, and continually re-evaluate to see if they are on schedule. PERT
stands for Program Evaluation and Review Technique. Using the chart below, try to insert your activities into a PERT format.
DEADLINE
Draw the critical path in a heavy line.
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You are now ready to complete the overall schedule for your major activities. In fact, a modification of the PERT chart may be useful. You have
identified key activities and ordered them into a sequence by working backward from the objective. You have examined how much time each
activity will take, and established deadlines for the completion of each one. You are, therefore, ready to create an overall schedule starting from
each objective and working backward. Place each event or completed activity in boxes. Use arrows to represent the activities that are in process
over the indicated time period (or according to the calendar at the top of the chart). Use the blank schedule that follows to finalize your own
modified PERT schedule for the major activities of each selected objective.
SCHEDULE FOR COMPLETING MAJOR ACTIVITIES
Starting Activities
Intermediate Activities
Deadline or Target Date
Starting Calendar Dates
OBJECTIVE
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D. CALCULATE RESOURCES; BUDGETING
Now that you have an idea of what activities you would like to undertake, you must begin to calculate resources and develop a budget for those
activities. Perhaps, following the budgeting exercise, you will want to revise some of your activities.
Once the human and material resources have been listed for each objective (and corresponding activities), a money amount has to be attached to
them For example, when considering human resources, one has to consider the salaries of staff, as well as the associated benefits which an
organization provides or is required by law. In addition, costs for travel and per diem, training workshops, supervision of staff, cost of equipment,
supplies, vehicles, buildings and support services all have to be considered.
1. In order to create a budget which is consistent with an Action Plan, cost categories and specific cost elements must be established which
correspond to the plan. It is important that the cost categories and elements also correspond with the accounting system of your organization,
noflinet
thp the
hiidpet
Examnles
of cost
categories
and and
costcost
elements
are are
as follows:
so that actual expenditures can ntndifw
be modified
against
budget.
Examples
of cost
categories
elements
Vehicles & Transport
• Vehicle Purchase
• Maintenance and Fuel Costs
• Motor Bikes
Salaries
• Professional Staff
Physicians
- Nurses
• Administrative Staff
Accountant
Receptionist
• Outside consultants
Workshops
• Transport for Participants
• Materials Development
• Lodging for Participants
• Meals for Participants
• Workshop Supplies
Staff Benefits
• Retirement
• Holiday, Sick time, Annual Leave
Other Costs
• Office Rent
• Office Utilities
• Office Supplies
• Postage, Shipping
Travel Costs
• Air fare
• Ground Transport
• Per Diem
Equipment
• Furnishings
• Automated Office Equipment
2. Once the Cost categories and cost elements have been established, a quantity and unit cost must be established.
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a.
If possible, a quantity measurement should be selected that is consistent with other cost elements and is easy to associate a unit cost to.
For example, the unit of a month is a typical measure for salaries, since many people are paid on a monthly basis. The monthly unit is
also convenient for office rent and utilities, since this is the frequency which these costs are quoted and paid. For travel costs, the quantity
measurement is the one complete journey by air, bus or train, since it this is the way this cost element is priced.
b. Unit costs can typically obtained from historical data; that is what a particular cost element has been priced at in the past. Histoneal data
can come from other budgets or from information collected from an organization’s accounting system. In instances where this information
is can not be easily obtained, an estimate of unit cost will be acceptable.
3. The final stage of developing a budget consists of multiplying the unit costs of each cost element by the unit quantity. If the activities span
greater than one year (or other time measurement used by an organization), then the budget should be created in such a way so that the quantity
of that element is allocated to the time period and unit cost specified for that element reflects the anticipated cost during that penod.
4. When the Action Plan consists of several objectives, it may be useful to develop a budget for each activity, then producesummary budget
which includes the total cost for each budget category (salaries, benefits, travel, etc.) which specifies the cost for each activity. For examp e.
Salaries
• Activity One
• Activity Two
Total Salaries
$XXX
$XXX
$xxx
• ; could be budgeted, beginning at the most basic level, the
Sample budget fonnats follow. They provide examples of how a Plan of Operations
for the entire Planof Operations. You may use these or develop your own to fit your specific
activity, then t
needs.
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URBAN HEALTH: THE GLOBAL CHALLENGE
SAMPLE BUDGET FORMAT FOR PLAN OF OPERATIONS
BUDGET WORKSHEET WHICH COLLECTS COSTS FOR EACH ACTIVITY WITHIN AN OBJECTIVE
NAME OF OBJECTIVE
NAME OF ACTIVITY
quantity
RATE
TOTAL
t SALARIES
A. PROFESSIONAL STAFF
SUBTOTAL
B. ADMINISTRATIVE STAFF
SUBTOTAL
TOTAL SALARIES
&staff wrnis
A. PROFESSIONAL STAFF
SUBTOTAL
B. ADMINISTRATIVE STAFF
SUBTOTAL
TOTAL STAFF BENEFITS
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QUANTITY
RATE!
TOTAL
Iff. HiAVEL COSTS
A. AIRFARE
SUBTOTAL
B. GROUND TRANSPORT
SUBTOTAL
C. PER DIEM
SUBTOTAL
TOTAL TRAVEL COSTS
IV. ELEMENT AND COMMODITIES
A. CLINICAL EQUIPMENT
SUBTOTAL
B. DRUGS & MEDICAL SUPPLIES
SUBTOTAL
C. AUTOMATED OFFICE EQUIPMENT
SUBTOTAL
D. OFFICE AND CLINICAL FURNISHINGS
SUBTOTAL
TOTAL EQUIPMENT AND COMMODITIES
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QUANTITY
RATE
V. VEHICLES & TRANSPORT
A. VEHICLE PURCHASE
SUBTOTAL
B. MAINTENANCE AND FUEL COSTS
SUBTOTAL
C. MOTOR BIKES
SUBTOTAL
TOTAL VEHICLES AND TRANSPORT
VL WORKSHOPS
A. TRANSPORT FOR PARTICIPANTS
SUBTOTAL
B. MATERIALS DEVELOPMENT
SUBTOTAL
C. LODGING FOR PARTICIPANTS
SUBTOTAL
D. MEALS FOR PARTICIPANTS
SUBTOTAL
E. WORKSHOP SUPPLIES
SUBTOTAL
TOTAL WORKSHOPS
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QUANTITY
RATE
TOTAL
VII. OTHER COSTS
A. OFFICE RENT
SUBTOTAL
B. OFFICE SUPPLIES
SUBTOTAL
C. OFFICE UTILITIES
SUBTOTAL
D. POSTAGE & SHIPPING
SUBTOTAL
TOTAL OTHER COSTS
TOTAL COSTS FOR ACTIVITY
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URBAN HEALTH: THE GLOBAL CHALLENGE
SAMPLE BUDGET FORMAT FOR PLAN OF OPERATIONS
BUDGET WORKSHEET WHICH SUMMARIZES COSTS FOR EACH OBJECTIVE BY ACTIVITY
NAME OF OBJECTIVE
ACTIVITIES
QUANTITY
RATE
TOTAL
I. SALARIES
ACTIVITY ONE
ACTIVITY TWO
ACTIVITY THREE
TOTAL SALARIES
IL STAFF BENEFITS
ACTIVITY ONE
ACTIVITY TWO
ACTIVITY THREE
TOTAL STAFF BENEFITS
III. TRAVEL COSTS
ACTIVITY ONE
ACTIVITY TWO
ACTTVITY THREE
TOTAL TRAVEL COSTS
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QUANTITY
RATE
TOTAL
IV. EQUIPMENT AND COMMODITIES
ACTIVITY ONE
ACTIVITY TWO
ACTIVITY THREE
TOTAL EQUIPMENT AND COMMODITIES
V. VEHICLES & TRANSPORT
ACTIVITY ONE
ACTIVITY TWO
ACTIVITY THREE
TOTAL VEHICLES AND TRANSPORT
VI WORKSHOPS
ACTIVITY ONE
ACTIVITY TWO
ACTIVITY THREE
TOTAL WORKSHOPS
VH. OTHER COSTS
ACTIVITY ONE
ACTIVITY TWO
ACTIVITY THREE
TOTAL OTHER COSTS
TOTAL COSTS FOR OBJECTIVE
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URBAN HEALTH: THE GLOBAL CHALLENGE
SAMPLE BUDGET FORMAT FOR PLAN OF OPERATIONS_______________________________
BUDGET WORKSHEET WHICH SUMMARIZES COSTS FOR AN ACTION PLAN BY OBJECTIVE
PLAN OF OPERATION FOR:
OBJECTIVES
QUANTITY
RATE
TOTAL
I. SALARIES
OBJECTIVE ONE
OBJECTIVE TWO
OBJECTIVE THREE
TOTAL SALARIES
IL STAFF BENEFITS
OBJECTIVE ONE
OBJECTIVE TWO
OBJECTIVE THREE
TOTAL STAFF BENEFITS
HI. TRAVEL COSTS
OBJECTIVE ONE
OBJECTIVE TWO
OBJECTIVE THREE
TOTAL TRAVEL COSTS
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QUANTITY
RATE
TOTAL
IV. EQUIPMENT AND COMMODITIES
OBJECTIVE ONE
OBJECTIVE TWO
OBJECTIVE THREE
TOTAL EQUIPMENT AND COMMODITIES
V VEHICLES & TRANSPORT
OBJECTIVE ONE
OBJECTIVE TWO
OBJECTIVE THREE
TOTAL VEHICLES AND TRANSPORT
VI. WORKSHOPS
OBJECTIVE ONE
OBJECTIVE TWO
OBJECTIVE THREE
TOTAL WORKSHOPS
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QUANTITY
RATE
TOTAL
VII. OTHER COSTS:
OBJECTIVE ONE
OBJECTIVE TWO
OBJECTIVE THREE
TOTAL OTHER COSTS
TOTAL COSTS FOR PLAN OF OPERATIONS
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E. ASSIGN RESPONSIBILITY
After figuring the costs involved and overall resources necessary for activities and objective, the next step will be to assign responsibility for each
of the major activities. The person who is responsible for each one will have to then continue with the more detailed planning of how to implement
each activity. Use the space below to define who is responsible for each activity and the completion date.
You may need to note if, in fact, you do not have a staff member to carry out the activity. Put an asterisk next to such an activity that requires
additional staff; you will need to consider it at a later point in terms of the feasibility of finding an individual to perform the activity and further
task development. (It may be that you can "borrow" staff resources from another department or organization. Deputation is a common form of
augmenting staff resources in urban areas.) Be sure to consider the qualification of the individual and that they are suitable for the activity assigned.
ASSIGNMENT OF RESPONSIBILITY
ACTIVITY
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COMPLETION DATE
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F. PLAN SPECIFIC TASKS
’> are to be done, who needs to be involved, when the tasks will occur, and what specific
For each activity, now begin to plan what specific tasks
resources will be needed. You can use the task planning sheet that follows.
TASK PLANNING SHEET
Your Strategy:
Your Activity:
TASKS
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WHY?
WHEN?
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WHO?
RESOURCES?
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G. DEVELOP PLAN OF OPERATIONS
1. Develop Draft Plan
Use the following to develop your draft plan of operations. You may want to continue developing a separate plan of operations for each alternative
strategy if you have not been able to decide a single one by this point. You may also choose to combine several strategies together into an overall
plan, as long as it is presented in some general chronological order. Remember to include necessary activities in terms of managing the change
process itself.
PLAN OF OPERATIONS (FIRST DRAFT)
NAME:
DATE:
ORGANIZATION:
ACTIVITIES
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PERSON
RESPON
SIBLE
OTHER
CRITICAL
INSTITUTIONS
74
RESOURCES
Available
Needed
TIMEFRAME
Begin
Finish
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PLAN OF OPERATIONS (FIRST DRAFT) continued
ACTIVITIES
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PERSON
RESPON
SIBLE
OTHER
CRITICAL
INSTITUTIONS
75
RESOURCES
Available
Needed
TIMEFRAME
Begin
Finish
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G. DEVELOP PLAN OF OPERATIONS (continued)
2. Review and Revise
Review and revision of your draft Plan of Operations should now be undertaken in light of the financial realities brought out during the budgeting
exercise, and to incorporate feedback from colleagues or experts. A person who is not directly affected by a given situation is sometimes able to
perceive flaws or weaknesses in a plan which the person facing the problem may not recognize.
Therefore, make revisions as the budgeting process has indicated and secondly, spend some time with one or more colleagues with whom you
can discuss your plan, raise questions of its feasibility, etc. You may want to take notes on their comments on this page.
NOTES FROM DISCUSSIONS
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G. DEVELOP PLAN OF OPERATIONS (continued)
3. Final Plan of Operations
Development of the Final Plan of Operations should now be undertaken. First review the material from all of the preceding substeps and ask
yourself the following questions:
a.
Are all activities organized into a logical sequential order?
b.
Has a timeframe (beginning and completion dates) for each activity been developed, and ideally, put into a formalized schedule such as
a PERT chart?
c.
Has responsibility been assigned to persons, initially for the further development activities, and ultimately for their full implementations?
d.
Have I detennined other critical institutions or groups which need to be involved in planning or implementation? (Refer back to your
institutional analysis -- Step IV)
e.
Have I identified which relevant resources are currently available and which are still needed?
f.
Have I considered a system for supervision and a means of verification for the accomplishment of each activity (initial monitoring and
evaluation)?
Although question f should be considered, and associated activities initiated at this point, it will be answered and brought to more completion
during die next 2 steps in the program development. Step VI - Implementation and Step VU - Monitoring and Evaluation. However, you should
be aware that the foundation for these important activities was actually laid as early as Step I, during the identification of your problem and mitral
development of evaluative criteria.
After considering these questions, proceed to write the final version of your Plan of Operations on the following pages.
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PLAN OF OPERATIONS
ACTIVITIES
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PERSON
RESPON
SIBLE
OTHER
CRITICAL
INSTITUTIONS
78
RESOURCES
Available
Needed
TIMEFRAME
Begin
Finish
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PLAN OF OPERATIONS
ACTIVITIES
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PERSON
RESPON
SIBLE
OTHER
CRITICAL
INSTITUTIONS
79
RESOURCES
Available
Needed
TIMEFRAME
Begin
Finish
Management Sciences for Health
The Program Development Process for Urban Health
Step I
Identify the Problem
Step VII
Monitor and Evaluate
Step II
Define Goal and
Establish Objectives
Step III
Select Strategies
A. Supervise
B. Establish quality assurance
Step V
Develop Plan of
Operations
Step IV
Develop Institutional
Framework
STEP VI: IMPLEMENT THE PLAN OF OPERATIONS
As we have seen previously, the final two steps in the program development process are to implement, and to monitor as well as evaluate your
urban health activities/programs. However, a thorough explanation of all aspects of implementation or monitoring/evaluation is not possible within
the scope of this Workbook or MSH’s Urban Health Course. This Workbook does not attempt to include all of the important issues or substeps
under each of these steps. Focus is given to those substeps which are essential to the process of urban health program development.
Implementation is the carrying-out of the carefully developed goals, strategies and activities. With the intent of assuring the program is successful
and goals and objectives achieved, an effective manager undertakes two vitally important responsibilities during implementation. The effective
manager:
• supervises staff on a regular basis, and
• establishes a quality assurance system.
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A. SUPERVISE
Supervision is a critical management task which requires a clear understanding between the supervisor and die person being supervised, the
supervisee, on what the supervisee is expected to do and accomplish during a set period of time. The basis for this clear understanding is a human
resource management system with a number of inter-related components, of which supervision is one. The entire human resource management
system typically includes:
•
an organizational structure which is congruent with organizational goals and strategies,
.
an analysis of the work and tasks which must be accomplished to achieve goals and objectives;
an analysis of the personnel qualifications for that work;
•
recruitment of appropriate and necessary staff;
•
hiring and orienting staff;
•
personnel planning, supervision and evaluation;
•
staff development;
•
a system of rewards and compensation for staff.
Time does not permit us, in this MSH course or in this Workbook, to deal with the design, development and implementation of a human resource
management system. We would like to highlight the importance of such a system, however, for die successful implementation of an urban program.
Use the Checktist on the following page as a starting point for your development of a supervisory plan/system.
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CHECKLIST FOR SUPERVISING AND SUPPORTING YOUR STAFF*
1.
Set specific performance objectives for and with each staff member.
2.
Develop a supervisory schedule showing the date and time of supervisory sessions and distribute it to staff.
3.
Supervisory sessions, at a minimum, consist of:
A review of the activities for the past three to six months;
A plan for future activities;
A discussion of employee concerns.
4.
Review the notes of the supervisory sessions immediately following the sessions; write down the follow-up activities that were
promised during the session and carry them out
5.
Handle performance problems in a timely and equitable manner, and find reasonable solutions with the help of the employee in
question.
6.
Pay attention to the quality of the work environment and make adjustments as needed.
7.
Use staff motivation techniques.
8.
Provide constructive feedback on a regular basis.
9.
Conduct scheduled employee performance appraisals, providing employees with the time and opportunity to comment on the
effectiveness of their supervisors.
*The Family Planning Manager's Handbook. James A. Wolff, et al.
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CHECKLIST FOR SUPERVISOR’S SELF-ASSESSMENT*
1.
Set a friendly and positive tone. Don’t carry your own problems and anxieties to the people you supervise.
2.
Review problems, areas of concern, and level of knowledge on various primary health care or family planning topics. You can choose
different topics for each visit.
3.
Provide staff with immediate feedback on their performance, emphasizing both their strengths and the areas that need improvement
4.
Offer encouragement and appreciation and share information on the program’s progress.
5.
Review a pre-selected topic and perhaps areas of weakness found during observation.
6.
Discuss and attempt to solve problems facing the staff. You can deal with the urgent problems immediately. If you don’t have enough
time to deal with all the problems, leave the least urgent for the next visit
7.
Check to see if new supplies are needed and whether there are expired supplies in the inventory.
8.
Review records for quality and completeness.
9.
Summarize the main conclusions of the visit and schedule the next supervisory visit.
*The Family Planning Manager's Handbook. James A. Wolff, et al.
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B. ESTABLISH QUALITY ASSURANCE (QA) SYSTEM
This topic is one which requires an entire workbook itself. Hence, it is obviously not possible for this workbook to completely address QA.
However QA is an important activity throughout implementation, and the foundation is laid during program development. Below is a brief list
of 10 steps used to ensure quahty of care in a medical service delivery program. You may find them useful when you begm to implement your
urban health program.
TEN STEP MONITORING AND EVALUATION PROCESS OF QUALITY ASSURANCE
Dates of Implementation*
Expected
Actual
Assign responsibility.
2.
Delineate scope of care.
3.
Identify important aspects of care.
4.
Identify indicators related to these aspects of care.
5.
Establish thresholds for evaluation related to these indicators.
6.
Collect and organize data.
7.
Evaluate data.
8.
Take actions to improve care and service.
9.
Assess the effectiveness of the actions and document improvement.
10.
Communicate relevant information to the organizational-wide QA
program, to include an annual review of individual QA programs.
*Be sure to note dates of expected and actual implementation.
Monitoring and regular evaluation are important components in a quality assurance system. Because of their importance, each will be discussed
in more depth in the following Step VII.
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The Program Development Process for Urban Health
Step I
Identify the Problem
Monitor a
Step II
Define Goal and
Establish Objectives
A. Monitor
B. Evaluate
Step VI
Implement Plan
of Operations
Step V
Develop Plan of
Operations
Step III
Select Strategies
Step IV
Develop Institutional
Framework
step vii:
A monitoring and evaluation system is the link between planning and reality; it is the way that managers know whether programs which were
designed to meet specific targets are likely to accomplish their objectives, or whether some type of mid-course correction is needed to
accommodate unforeseen problems or changes in the operating environment. Although both rural and urban programs need a good monitoring
and evaluation system, the operating environment of urban programs is typically changeable, and sometimes, volatile. Accurate, timely and
relevant information is essential to successful implementation and achievement of urban program goals.
Additionally, due to the numerous institutions working in overlapping technical areas in urban health programs, it is essential to strive for
consistent terms among institutions if you wish to share and compare information.
Three mechanisms are presented in this final step of the program development process to help measure achievement against proposed objectives
and activities: an Indicators Table, an Evaluation Matrix and a Gantt Chart of Activities. Worksheets for these tools are presented on the following
pages.
There are eight action steps in a monitoring and evaluation system, the first two of which have already been addressed in this Workbook. The
eight action steps are:
•
Set objectives
List activities
Select indicators
•
Set targets
Collect data
•
Analyze data
•
Generate reports
•
Make decisions and take action
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Selecting indicators, action step three above, is a most critical part of the process of designing a monitoring and evaluation system. Indeed,
indicators are the key to a monitoring and evaluation system, since they define what is being measured and how successful a program is at meeting
its objectives. To identify indicators to monitor the effectiveness of your program, consider the following:
Indicators must be:
•
Representative: they tell us something about the status of our program;
•
Measurable: they must tell us if we have made any progress in meeting our objectives;
•
Economical: the cost of collecting indicators must be balanced with the value we get out of them; and
•
Temporal: they have a time dimension.
In general, indicators fall into one of four time dimensions.
•
Baseline indicators: define the status at the baseline period.
.
Leading indicators: measure changes that occur early in the program when internal systems are changing. These indicators describe the
resources allocated or scheduled for allocation, which are necessary before changes in outputs or behavior can be expected.
.
Coincident indicators: measure changes that occur in the middle years of a program as it is increasing in both size and effectiveness.
.
Lagging indicators: measure changes in the impact period, which occurs late in a program. These indicators measure the long term results
the program has had on the target population.
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A. MONITORING
Monitoring is the ongoing, continuous review of activities during the implementation of a program. Monitoring is built upon data collected during
routine program activities. It should provide the information to identify emerging problems needing resolution and should result in mid-course
implementation changes, if necessary. In this way, monitoring is a step in the cyclical program development process where the manager is involved
in a constant cycle of identification, analysis, and resolution of problems.
At this point you are ready to develop a Table of Indicators for monitoring your Plan of Operations.
a. Refer back to STEP V-G: FINAL Plan of operations. Transfer the activities listed there to the column titled ”Activities” in the Table on the
following page.
b. For each activity, identify indicators, the periodicity and planned source of your data.
c. At the planned intervals, review the level of achievement of each activity.
d. The Gantt Chart, presented in STEP V-C will serve as another means to schedule and monitor the completion of activities.
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A. MONITORING (continued)
TABLE OF INDICATORS FOR AN URBAN HEALTH PROGRAM
INDICATORS
OBJECTIVES/ACTIVITIES
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PERIODICITY
DATA SOURCE
Management Sciences for Health
GANTT CHART
TIMEFRAME
ACTIVITY
MONTH/YEAR
Q
1
Q
2
Q
3
Q
4
MONTH/YEAR
Q
1
Q
2
Q
4
Q
3
MONTH/YEAR
Q
1
Q
2
Q
3
Q
4
MONTH/YEAR
Q
1
Q
2
Q
3
Q
4
MONTH/YEAR
Q
1
Q
2
Q
3
Q
4
=11
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B. EVALUATE
While monitoring refers to reviewing, on an ongoing basis, the degree to which programmed activities are completed, evaluation refers to analyzing,
at a predetermined point in time, progress made toward meeting established objectives.
As in monitoring, selection of indicators is key to designing an evaluation plan. Evaluation indicators, like monitonng indicators, should be:
representative, measurable, economical and fall within a time dimension.
At this point, the development of an evaluation plan, which is the final step in the cyclical program development process, refer back to STEP II-C,
ESTABLISH OBJECTIVES.
a. Transfer the objectives listed there to the column titled ’’Objectives" in the Evaluation Matrix on the following page.
b. For each objective, identify indicators to help measure to what degree you expect to meet the established objectives. An indicator is data that
can be used to gauge progress.
c. Explain the method of evaluation to be used to evaluate progress made toward fulfilling the established objectives.
d. As evaluations are conducted, fill in "Yes" or "No" to indicate whether or not findings from the evaluations suggest that certain indicators were
met
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B. EVALUATE (continued)
METHOD OF EVALUATION
OBJECTIVES
INDICATORS
MEANS OF
MEASUREMENT
INDICATORS MET
YES, NO
1.
2.
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METHOD OF EVALUATION
OBJECTIVES
INDICATORS
MEANS OF
MEASUREMENT
INDICATORS MET
YES, NO
3.
4.
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GANTT CHART OF ACTIVITIES
The Gantt Chart is a useful tool for summarizing and monitoring activities. Because it functions as a chronogram, it is easy to review the planned
sequence of events to see where they might overlap, and to make sure that activities that are precursors to others are in the appropriate order. The
Gantt Chart also serves to monitor the timely completion of programmed activities.
To develop a Gantt Chart for monitoring your urban activities, review the directions in Step V-C.
a. Now, refer back to STEP V-G: FINAL Plan of Operations. Transfer the activities listed there to the column titled "Activity" in the Gantt Chart
below.
b. Then look back again to STEP V-G: FINAL Plan of Operations. Under the column "timeframe" there should be dates indicating when activities
will take place. Using the dates specified, transfer the information to the Gantt Chart by placing an "X" or a dotted line in the time interval
during which the activity is planned to take place. It is important to note that some activities require preparation time, while others are ongoing
throughout the year.
c. Using a shaded line or a solid line/bar, indicate the week during which the activity actually took place. This should be done on a quarterly
basis to check actual progress against the Plan of Operations.
GANTT CHART
TIMEFRAME
MONTH/YEAR
ACTIVITY
Q
1
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Q
2
Q
3
Q
4
MONTH/YEAR
Q
1
Q
2
Q
3
95
Q
4
MONTH/YEAR
Q
1
Q
2
Q
3
Q
4
MONTH/YEAR
Q
1
Q
2
Q
3
Q
4
MONTH/YEAR
Q
1
Q
2
Q
3
Q
4
Management Sciences for Health
CLOSING REMARKS
Congratulations. You have now completed at least the foundation of your urban health program plan. Good luck as you proceed to refine and
implement your strategy. We would be delighted to hear about your progress, and welcome your participation in MSH’s URBAN HEALTH
NETWORK. If you desire to be part of this network of urban PHC and Family Planning Program policy makers, planners, managers and service
providers, please fill in the information on the form on the next page and send it to:
Management Sciences for Health
Urban Health Initiative
Dr. Diana Silimperi
165 Allandale Road
Boston, MA 02130
FAX (617) 524-2825
Telephone (617) 524-7799
There are three extra forms; if you know others who may be interested, please share them.
Also if you desire more information about MSH’s URBAN HEALTH INITIATIVE activities or Urban Health courses, please tell us. We will
be glad to answer questions and assist you in any way we can. Thanks for your interest in Urban Health: The Global Challenge! We look forward
to hearing from you.
Diana R. Silimperi, MD
Course Director
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REQUEST FOR PARTICIPATION IN URBAN HEALTH NETWORK, MSH
Name:.
Name:.
Title:
Title:.
Address:
Address:.
FAX:
FAX:
Telephone:.
Telephone:.
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Management Sciences for Health
REQUEST FOR PARTICIPATION IN URBAN HEALTH NETWORK, MSH
Name:.
Name:.
Title:.
Title:
Address:.
Address:.
FAX:
FAX:.
Telephone:.
Telephone:.
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WORKBOOK EVALUATION
Course: URBAN HEALTH: THE GLOBAL CHALLENGE
Date:
Please circle the number which corresponds best to your evaluation of each educational aspect as indicated on the scale below.
Satisfactory
Outstanding = Greatly exceeded Participant’s
Expectations
Met Participant’s Expectations Poor = Below Participant’s Expectations
Poor
Satisfactory
Outstanding
Achievement of
Stated Objectives
9
8
7
6
5
4
3
2
1
Relevance of Content
for my Job
9
8
7
6
5
4
3
2
1
Effectiveness of
Training Methodology
& Techniques
9
8
7
6
5
4
3
2
1
Organization of
the Material
9
8
7
6
5
4
3
2
1
Usefulness of
Material
9
8
7
6
5
4
3
2
1
Quality of
Materials
9
8
7
6
5
4
3
2
1
Was the length of the Workbook:
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Just Right — Too Short
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WORKBOOK EVALUATION (continued)
Which additional aspects would you like to have included in the Workbook?
Suggestions for improvements:
Overall impressions:
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WORKBOOK AND COURSE GLOSSARY
ACTIVITY:
A specific procedure or process completed at a certain point in time that is carried out by an organization’s
personnel as part of a strategy for reaching the desired objective.
BATNA:
A term used in negotiation to mean the Best Alternative to a Negotiated Agreement.
DATA:
The numbers you get when you take a measure.
EVALUATION:
Refers to analyzing, at a predetermined point in time, progress made toward meeting established
objectives.
FORCE FIELD
ANALYSIS:
A tool to identify and analyze forces which enable change and forces which block change.
GOAL:
A general statement of intended outcome or impact; what you are trying to accomplish.
INDICATORS:
What is being measured. They should be representative, measurable, economical and temporal.
MEASURE:
The amount of something that exists at a certain time.
MONITORING:
Reviewing, on an ongoing basis, the degree to which programmed activities are completed.
NEGOTIATION:
A sequential process of discussions between two or more parties held with the aim of reaching agreement
on issues in which they have a joint interest but sources of disagreement.
OBJECTIVE:
A specific measurable statement of a quantifiable, time-limited outcome expected by a program or project,
what you are trying to accomplish by a given point in time. It is sufficiently limited in scope and
definition that one can logically expect its achievement by the end of the time period.
ORGANIZATIONAL
STRUCTURE:
Urban Health: The Global Challenge
The formal system of working relationships within an organization, showing the reporting relationships
between different functions and positions of the management and staff.
Management Sciences for Health
LIBRARY 10.
1 I
*N0
1 < Y DOCUMENTATION J r*
08517
PLAN:
An organized framework including resources, strategy, and objectives addressing a well-defined problem
situation.
GLOSSARY (continued)
POVERTY:
Definitions vary widely between counties, but essentially the life condition in which an individual does
not have revenue or alternative buying power to maintain adequate food (for growth, or recognized
minimal standards of essential nutrition), shelter and clothing.
PROBLEM:
A situation or condition of people or the organization that will exist in the future and that is considered
undesirable by the members of the organization.
PURPOSE:
Reason why you are involved.
QUALITY
ASSURANCE:
A management term which indicates an ongoing process which involves the setting of standards to
promote client safety; measuring performance and identifying problem areas; and taking corrective action.
RESOURCES:
Tangible things (like personnel, money, equipment, facilities) and intangible things (like time, knowledge,
skill, political influence, prestige, legitimacy, control over information, and energy) used by an
organization’s personnel to carry out a strategy or activity that is designed to reach a desired objective.
STRATEGY:
The methods (or a series/group of activities) combined with resources which an organization or program
will use to achieve its goals and objectives.
SUPERVISION:
A system, including methods and procedures, used to measure the volume and quality of work performed
by subordinate staff, as well as to provide necessary support to staff.
TASK:
A specific procedure or process, including what will be done, when, and by whom, that is part of a larger
’’activity.”
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