THE PHC MAP SERIES OF MODULES, GUIDES AND REFERENCE MATERIALS Each module includes: a User's guide a Facilitator's guide computer programs Module 1 Assessing information needs Module 2 Assessing community health needs and coverage Module 3 Planning and assessing health worker activities Module 4 Surveillance of morbidity and mortality Module 5 Monitoring and evaluating programmes Module 6 Assessing the quality of service Module 7 Assessing the quality of management Module 8 Cost analysis Module 9 Sustainability analysis Manager's guides and references Better management: 100 tips Problem-solving Computers The computerised PRICOR thesaurus Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva and Thongchai Sapanuchart, Somboon Vacharotai Foundation, Bangkok, Thailand Co-Editors: Jennifer Sharples, Colin De'Ath, Bangkok, Thailand Design & Layout: Helene Sackstein, France Desktop Publishing: Marilyn J. Murphy, Suracha Suntarasut, Somboon Vacharotai Foundation, Bangkok, Thailand Printing: Thai Wattana Panich, Bangkok, Thailand Published in 1993 by the Aga Khan Foundation USA, Suite 700, 1901 L Street N.W., Washington DC and the Aga Khan Foundation, P.O. Box 6179, 1211 Geneva 6, Switzerland. Additional copies are available at the Aga Khan Foundation Canada in Toronto; Aga Khan Foundation (United Kingdom) in London; and AKF offices in Dhaka, Bangladesh; Delhi, India; Nairobi, Kenya; Karachi, Pakistan; Lisbon, Portugal; and Dar-es-Salaam, Tanzania; the Aga Khan University Faculty of Health Science in Karachi, Pakistan; the Somboon Vacharotai Foundation and the ASEAN Institute for Health Development in Thailand SUSTAINABILITY ANALYSIS MODULE 9 FACILITATOR'S GUIDE Dedicated to Dr. Duane L. Smith (1939-1992), Dr. William B. Steeler (1948-1992) and all other health leaders, managers and workers who follow their example in the effort to bring quality health care to all in need. The Primary Health Care Management Advancement Programme has been funded by the Aga Khan Foundation Canada, the Commission of the European Communities, the Aga Khan Foundation U.S.A., the Aga Khan Foundation's head office in Geneva, the Rockefeller Foundation, the Canadian International Development Agency, Alberta Aid, and the United States Agency for International Development under two matching grants to AKF USA. The first of these grants was "Strengthening the Management, Monitoring and Evaluation of PHC Programs in Selected Countries of Asia and Africa" (cooperative agreement no. OTR-0158-A-00-8161-00, 1988-1991); and the second was "Strengthening the Effectiveness, Management and Sustainability of PHC/Mother and Child Survival Programs in Asia and Africa" (cooperative agreement no. PCD-0158-A-00-1102-00, 1991-1994). The development of Modules 6 and 7 was partially funded through in-kind contributions from the Primary Health Care Operations Research project (PRICOR) of the Center for Human Services under its cooperative agreement with USAID (DSPE-6920-A-00-1048-00). This support is gratefully acknowledged. The views and opinions expressed in the PHC MAP materials are those of the authors and do not necessarily reflect those of the donors. All PHC MAP material (written and computer files) is in the public domain and may be freely copied and distributed to others. Contents FOREWORD 1 SESSION 1: INTRODUCTION AND OVERVIEW 7 Transparencies 9-1: Workshop objectives 13 9-2: Sustainability is 14 9-3: Why consider sustainability 15 9-4: Sustainability analysis includes: 16 9-5: Steps in sustainability analysis 17 SESSION 2: PLANNING THE SUSTAINABILITY ANALYSIS (STEPS 1, 2 AND 3) 19 Transparencies 9-6: Session 2: Objectives 25 9-7: Facets of the sustainability objective 26 SESSION 3: STRATEGIC ASSESSMENT (STEPS 4 AND 5) 31 Transparencies 9-7: Session 3: Objectives 36 9-8: Terms 37 9-9: Types of sustainability factors 38 9-10: Threat/opportunity codes 39 9-11: How to develop strategies 40 SESSION 4: FINANCIAL ASSESSMENT (STEP 6) 43 Transparencies 9-12: Session 4: Objectives 46 9-13: Types of changes 47 SESSION 5: ACTION PLANNING (STEP 7) 51 9-14: Session 5: Objectives 55 Foreword What is the purpose of the Facilitator's guide? The Facilitator's guide contains a suggested workshop design for use by individuals who will help PHC managers and staff learn how to use the Primary Health Care Management Advancement Programme (PHC MAP) series. There is a Facilitator's guide for each module in the PHC MAP series. What information does it contain? Each Facilitator's guide contains instructions for conducting a workshop on one of the modules in the PHC MAP series using the information contained in the User's guide. The instructions are arranged in one to two hour sessions. The number of sessions depends on the amount of information and/or the number of steps contained in the User's guide. The first page of each session lists session objectives, major topic headings, time required, and materials and equipment. The following pages describe the instructional activities in outline form. The outline is divided into two columns. The right-hand column indicates what the facilitator says or does to conduct the session. The left-hand column lists the handouts, overhead transparencies, or other materials needed to support the activity. Copies of these materials, suitable for duplication, appear at the end of the session in which they are first used. Some transparencies are used in more than one session. How are the workshops organised? The first session of each workshop contains activities designed to introduce the PHC MAP series and explain its importance to PHC programmes, present an overview of the workshop, explain the purpose of the module, review specific terms or concepts used in the module, and acquaint the participants with the organisation and content of the User's guide. The final session of each workshop contains activities designed to review key points of the User's guide, if appropriate, help participants prepare an action plan, and brings the workshop to a formal conclusion. The sessions in between present the steps required to accomplish the purpose of the module and provide an opportunity for participants to apply those steps to their own programmes. Each workshop is designed to be given on consecutive days, uninterrupted except for breaks, meals, and rest, if the workshop is longer than one day. It is recognised, however, that situations vary and the PHC MAP modules will be used singly or in combination by individuals and organisations in the field and on university campuses. Therefore, it is expected that the workshops described in the Facilitator's guides will be adapted to fit a range of circumstances. Indeed, those who facilitate PHC MAP workshops are encouraged to make adaptations to meet the needs of participants and/or specific PHC programmes. Who can be a facilitator? Ideally, the person who serves as facilitator has training and experience in the fields of public health, management, planning, and evaluation, as well as sampling and survey design. It is recommended that this person also be skilful in working with small groups. The facilitator should be someone from outside the PHC programme, perhaps from another agency or a university. As a person with no direct interest in the programme, the facilitator can be neutral in disagreements that may arise and help the group members resolve an issue objectively. Having an outside person as facilitator also allows the programme director, who usually has a leadership role, to contribute his or her knowledge and experience as a full participant in the work of the group. It is also recommended that a facilitator have a full set of PHC MAP User's guides and Facilitator's guides. It is sometimes necessary, in the course of completing one module, to refer to information in another module. Who should participate in the workshop? The primary audience for the PHC MAP series is the team that manages PHC programmes or other population-based health programmes in either the public or private sector. An example of a PHC management team in the public sector is the core staff of a district ranging from 100,000 to 300,000 in size of population served. An example of a PHC management team in the private sector is the core staff of an NGO that provides PHC services to a specific population in a given geographic area. The average size of the service population may range from 40,000 to 60,000, but may be as small as 10,000 or more than 100,000. In either case, the management team should have: the knowledge and skills needed to complete the steps in the module the time and resources required to collect and analyse the required data the authority to plan and implement improvements in management systems and procedures based on this analysis. If feasible, teams from several districts or from several PHC programmes within a given NGO, may work simultaneously with one facilitator to complete a module. It is recommended that one facilitator work with no more than four teams or 20 people at one time. What does the facilitator do? Understands the needs of participants. If the facilitator is working with one PHC programme, the most efficient way to gather information about participants and the programme in which they work is to meet with the PHC director to determine: the nature of the PHC programme (services provided, size and description of area served, number and type of facilities, number and qualifications of staff, community involvement, computer capability, strengths, major problems, etc.) if information needs have been clearly identified previous staff training in management information systems or related topics resources available for training (time, space, equipment) possibility for subsequent technical assistance to workshop participants. Understands the content of Module 1. Read the User's guide and Facilitator's guide for Module 1 and consider options for workshop delivery. The purpose of Module 1 is to help participants select priority information needs and to review some basic concepts underlying management information systems. Depending on participant background, the amount of time available, and the need to establish priorities among management information needs, Module 1 can be presented in its entirety, limited to Level 1: Quick start, limited to the PHC MAP systems framework, or in summary form as contained in the first session of the Facilitator's guides for Modules 2 through 9. If information needs have not been clearly identified and participants have no background in systems, then Module 1 should be presented in full. The selection of the next module will depend upon priorities set by the participants as they complete the steps in Module 1. If information needs have been clearly identified and participants have no background in systems, then that portion of Module 1 can be added to the first session of the selected module. If information needs have been clearly identified and participants have a background in systems, then the overview of PHC MAP in the selected module will be sufficient. Understands the content of the selected module. Read the User's guide and Facilitator's guide for the selected module and consider options for workshop delivery. Depending upon the length of the module and the availability of staff for training, the workshop sessions may be presented as described in the Facilitator's guide, or workshop sessions may be delivered at intervals (for example, every morning for a certain number of days, one session per week, or one day per week for three or four weeks). If follow-on technical assistance is available, the content of the module could be presented in the workshop and the application of the procedure to the PHC programme could be conducted on the job. Participants could plan steps in the workshop, complete them on the job, and bring the results to the next workshop session. This approach is particularly applicable to Module 2 which requires development of a questionnaire, selection of a survey sample, training of data collectors, and data collection. These steps cannot actually be carried out within the time limits of the workshop as contained in the Module 2 Facilitator's guide. Other options are possible depending upon the circumstances of each situation. Determines what programme information, if any, is needed for completion of the module. For example, census data and lists of households are required to complete some of the steps in Module 3. Determines the most appropriate people to attend the workshop. For example, Module 7 is best completed by those responsible for planning, training, supervision, logistics, and other management services. Discusses the delivery options and participants with the PHC manager and make decisions regarding the most appropriate option and participant selection. Also determines if the needed information is available and if it is not, the alternatives for obtaining the information. Notifies participants of the date, time, and purpose of the workshop and confirms attendance. Initial notice of the meeting may come from the PHC manager, with follow-up by the facilitator. Prepares the agenda, using as a model the sample in Session 1 of the Facilitator's guide for the selected module. Inspects the room where the workshop will be held and answers these questions: Is the room large enough to seat all the participants? Can chairs and tables be arranged in a variety of ways; all participants around one table; participants in groups of three or four at smaller tables? Is the lighting adequate? Can temperature and humidity be controlled? Is there an electrical outlet for an overhead projector? Is a microphone necessary for everyone to hear and to be heard? Are toilets conveniently located? Is the site convenient to parking, restaurants and public transportation? Are supporting facilities available and convenient: duplication, word processing, computers? Prepares notes to conduct the workshop using the session outlines in the Facilitator's guide for the selected module, and makes the necessary adaptations. Refer to the appropriate User's guide for content. Duplicates the worksheets and other handouts as indicated in the Facilitator's guide and obtains the necessary equipment. Conducts the workshop as planned. Provides follow-on assistance, if appropriate. Session 1: Introduction and overview Objectives: Participants will be able to: Explain the purpose of Module 9. Define sustainability in relation to PHC programmes. Give at least two reasons why sustainability is important to PHC managers. Session outline: I. Introduction (30 minutes) II. Overview of Workshop (10 minutes) III. Purpose of Module 9 (20 minutes) IV. Module 9 User's guide (15 minutes) Materials: Module 9 User's guide Handout 9-1: Agenda Transparency 9-1: Workshop objective Transparency 9-2: Sustainability is... Transparency 9-3: Why consider sustainability? Transparency 9-4: Sustainability analysis includes: Transparency 9-5: Steps in sustainability analysis Facilitator Reference 9-1: Flowchart of sustainability analysis Equipment: Flip chart, stand, markers, masking tape, overhead projector, and screen Introduction (30 minutes) Note: Omit section I if you have presented Module 1, or some other module, immediately prior to the presentation of Module 9. A. OPENING REMARKS Introduce self and other staff, as necessary. Explain your role in the workshop. If you do not know the participants, ask each one to state his or her name, position title, and job location. Note: If the group is larger than 6 or 8, you may wish to have them wear name tags or set cards with their names at places where they are sitting. Ask each participant to complete this sentence: "As a result of attending this workshop, I expect..." and write their responses on the flip chart. When all responses have been recorded, say that you will return to this list after giving an overview of the workshop. B. OVERVIEW OF PHC MAP Explain why information is important for PHC programmes. Summarise PHC MAP programme, including: Purpose of PHC MAP. Title and purpose of each module and other materials. Make the following points about PHC MAP: Has been field tested and revised to ensure usefulness to PHC programme staff. Modules can be used in any sequence. Checklists and other materials can, and should, be adapted to fit a particular situation. The procedures outlines in the modules can be adopted as routine monitoring activities in a PHC programme. Explain why MAP is being introduced in this PHC programme. Note: The remarks here should be tailored to the specific programme and should provide the answers to these questions: Why are we doing this workshop? What do we expect to achieve? It may be appropriate for the PHC manager to make these remarks. Overview of workshop (10 minutes) Review the workshop objective. Distribute and review the workshop agenda, describing the activities that will take place to accomplish the workshop objectives. Review the expectations contributed by participants at the beginning of the session. Indicate which ones will be met and which ones will not and why. Suggest, if possible, alternatives for meeting the expectations that will not be met in this workshop. Ask for questions or comments. Purpose of Module 9 (20 minutes) Explain that the purpose of Module 9 is to provide PHC managers and others with guidelines and tools to develop and analyse sustainability strategies. Present the definition of sustainability and explain that within this broad definition, each PHC programme must define its own sustainability objectives. The procedures and tools to do that are contained in this module. The importance of sustainability Present the reasons why sustainability is important to PHC programme managers. Ask participants if they have been asked about the sustainability of their programmes or when they expected that the programme, or a service offered by the programme, would be able to function without funding from a particular source. The two aspects of sustainability analysis Explain strategic assessment and mention population size and political commitment as two examples of factors that influence sustainability. Explain financial assessment and mention that the computer programs included in the module make financial assessment easy and fast, though it can be done without a computer. Present the seven steps in sustainability analysis that will be the focus of the remaining sessions in the workshop. Ask for questions or comments about sustainability and sustainability analysis. Explain what Module 9 does and does not do. Module 9 does not tell you what to do to make a PHC programme sustainable. Module 9 does not develop a strategy for you. Module 9 contains tools to help you examine a large variety of options relatively quickly as a basis for developing your own strategy. Module 9 User's guide (15 minutes) Distribute a User's guide to each participant. Refer participants to the Introduction and explain that most of the content of this section has already been presented and discussed. Refer participants to page 11 and explain the levels of analysis that can be performed, including Quick start. In this workshop you will complete Level 1 and receive an orientation to Levels 2 and 3. Refer participants to the appendices and explain the content and purpose of each. Ask for questions and comments on the user's guide. Explain that the next session will cover the first three steps in sustainability analysis. Session 1:Introduction and overview Session 1:Introduction and overview Name tags or place cards Flip chart See the Module 1 User's guide for this information Transparency 9-1: Workshop Objective Handout 9-1: Agenda Transparency 9-2: Sustainability is... Transparency 9-3: Why consider sustainability? Transparency 9-4: Sustainability analysis includes: Transparency 9-5: Steps in sustainability analysis Module 9 User's guide SAMPLE AGENDA MODULE 9* Session 1(1 hr,, 15 mins), Introduction and overview Session 2(1 hr,, 30 mins), Planning the sustainability analysis (Steps 1,, 2 and 3) Session 3(2 hrs,, 30 mins),Strategic assessment (Steps 4 and 5) Session 4(2 hrs), Financial assessment (Step 6) Session 5(1 hr,, 30 mins),Action planning (Step 7) * For actual presentation, substitute actual clock hours in the first column. WORKSHOP OBJECTIVE Conduct a sustainability analysis for a PHC programme using the steps and materials contained in the Module 9 User's guide SUSTAINABILITY IS... the ability of a PHC programme to continue providing services to meet the needs of its target populations WHY CONSIDER SUSTAINABILITY? Decreasing funding for development Diversion of funds to other areas Need to reallocate resources Move toward community-controlled PHC Need to increase community awareness in continuing health care SUSTAINABILITY ANALYSIS INCLUDES: Strategic assessment: examine the effects of 10 factors that influence sustainability Financial assessment: examine the effects of the 10 factors on future revenues and expenses STEPS IN SUSTAINABILITY ANALYSIS 1. Identify users; specify purpose and scope 2. Clarify objectives 3. Select level of detail 4. Conduct strategic assessment 5. Consider response 6. Conduct financial assessment 7. Select strategy; develop action plan Session 2: Planning the sustainability analysis (Steps 1, 2 and 3) Objectives: Participants will be able to: Specify users, the purpose, and the scope of the analysis. Clarify sustainability objectives. Decide on the level of detail needed. Session outline: I. Introduction (5 minutes) II. Specify users, purpose, and scope of analysis (25 minutes) III. Clarify sustainability objectives (45 minutes) IV. Decide on level of detail needed (15 minutes) Materials: Module 9 User's guide Transparency 9-6: Session 2: Objectives Transparency 9-7: Facets of the sustainability objective Handout 9-2: Worksheet for specifying the purpose of the analysis Handout 9-3: Worksheet for specifying the sustainability objectives Handout 9-4: Worksheet for specifying the restrictions on sustainability Handout 9-5: Worksheet for selecting the type of assessment and level of detail Equipment: Overhead projector and screen Introduction (5 minutes) Review the session objectives. Explain that the session objectives parallel the first three steps in sustainability analysis. Identify users, purpose, and scope of sustainability (25 minutes) Distribute the worksheet and introduce the three sections: user, purpose, scope. Discuss the considerations and alternatives available for the choices in each section. Refer participants to the sample worksheet on page 16 in the User's guide to see the choices one programme made. Ask for questions or comments on completing this step. Direct participants to complete the worksheet for their programme. Ask one group member to present the choices made and give the highlights of the discussion that led to those choices. Clarify sustainability objectives (45 minutes) Present the three facets of sustainability. Explain how the three facets are inter-related. Explain that one facet is selected as the main objective and influences how the other two must be adjusted to achieve the main objective. Explain that the ideal approach is to decide the desired level of health status and coverage, identify the services and management functions needed to provide that outcome, and identify the resources needed toprovide the services. If the budget is fixed, it may be necessary to start with resources. If the services/institutions are the primary focus of sustainability, it may be easy to lose sight of the purpose of the institution which is improvement of health status. For the purpose of this workshop, health coverage will be the first priority for the sustainability analysis. Distribute the worksheet and note that the priorities have already been indicated. Refer participants to the sample worksheet on page 20 in the User's guide to see how it might be filled out. Direct participants to check the target populations their programme currently serves and the coverage objective for each. Direct participants to consider whether they wish to maintain the level of coverage or increase or decrease it for any of the target populations. If so, that should be indicated in the third column. Direct participants to next check the categories of services to be sustained to support the coverage objective and list the specific ones for each category checked. Direct participants to check the categories of resources to be sustained to support the required services. Ask for questions or comments on the sustainability objectives worksheet. Explain that it is important to clarify whether sustainability means self-sustaining or if external support is permitted. Refer participants to the sample worksheet on page 21 in the User's guide and direct them to check the appropriate categories and make the appropriate notes. Decide on the level of detail (15 minutes) Explain that the first decision required in this third step is whether to do a strategic assessment, a financial assessment, or both. Explain that the second decision is to decide whether to conduct a Level 1, 2, or 3 analysis or to do all three. Level 1 will be completed in the workshop so that participants have an understanding of the entire process of sustainability analysis. Levels 2 and 3 require information that participants may or may not have readily available. Refer participants to the two charts on page 14 in the User's guide. Level 1 is based on information participants have from their experience of working in the programme. The more detailed information indicated by the X in Levels 2 and 3 can be obtained by using other MAP modules. For example, Modules 6 and 7 contain procedures for assessing quality of services and management functions. Module 8 contains procedures for determining expenditures by PHC service. Distribute the worksheet and explain that the three levels of analysis are summarised for both strategic assessment and financial assessment of sustainability. Explain that for this workshop Level 1 is selected for both types of sustainability assessment. Suggest that participants retain the worksheet for future use. Ask participants to state which level of sustainability analysis they will choose to perform after the workshop and explain the reason for their choice. Ask for questions or comments on the three steps included in planning a sustainability analysis. Explain that the next session will address Steps 4 and 5 on conducting the strategic assessment. Session 2:Planning the sustainability analysis (Steps 1, 2 and 3) Session 2:Planning the sustainability analysis (Steps 1, 2 and 3) Transparency 9-6: Session 9: Objectives Handout 9-2: Worksheet for specifying the purpose of the analysis Transparency 9-7: Facets of the sustainability objective Handout 9-3: Worksheet for specifying the sustainability objective Handout 9-4: Worksheet for specifying the restrictions on sustainability Transparency 9-4: Sustainability analysis includes: Handout 9-5: Worksheet for selecting the type of assessment and level of detail SESSION 2: OBJECTIVES Specify users, purpose, scope Clarify objectives Decide on level of detail FACETS OF THE SUSTAINABILITY OBJECTIVE What is to be sustained? Health outcome/coverage Services/institutions Resources What level is to be sustained? What are the restrictions, if any, on the sources of support? WORKSHEET FOR SPECIFYING THE PURPOSE OF THEANALYSIS 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 ___________________ WORKSHEET FOR SPECIFYING THE SUSTAINABILITY OBJECTIVES Priority What is to be At what sustained? level? 1.Health coverage __Children << 2 years ___________________ = __Children << 5 years ___________________ = __Pregnant women ___________________ = __Married women 15-49 ___________________ = __Other: ___________________ 2.Services/institutions = __PHC outreach services (list) ___________________ = __PHC clinical services (list) ___________________ = __Management services (list) ___________________ = __Agency/institution/unit (list) ___________________ = __Other: ___________________ 3.Resources = __Funding (specify) ___________________ = __Contributions (cash, in-kind) ___________________ = __Personnel ___________________ = __Technical capability ___________________ = __Other: ___________________ WORKSHEET FOR SPECIFYING THE RESTRICTIONS ON SUSTAINABILITY Sustainability restrictions = __No restrictions ___________________ = __Donor restrictions ___________________ = __Other ___________________ = __Self-sustaining ___________________ 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 10 factors ____ Level 2: A general analysis of 8 of the factors plus a detailed assessment of two of them. You assess each PHC service and each management service. ____ Level 3: A general analysis of 6 of the factors plus a detailed assessment of four of them. You assess the effects of changes in target population size and target population KAP (coverage) for 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 10 factors on future revenues and expenditures. ____ Level 2: A detailed analysis of revenues by source and expenditures for each PHC service and management service; and a What-if analysis of the effect of changes in the 10 factors on future revenues and expenditures. ____ Level 3: A detailed analysis of revenues by source and expenditures for each PHC service and management service taking into account changes in target population size and target population KAP (coverage); and a "what-if" analysis of the effect of changes in the ten factors on future revenues and expenditures. Session 3: Strategic assessment (Steps 4 and 5) Objectives: Participant will be able to: Analyse selected factors for their effect on programme sustainability. Identify strategies for dealing with threats and opportunities. Session outline: I. Introduction (5 minutes) II. Conduct strategic assessment (1 hour) III. Identify strategies (45 minutes) IV. Financial implications (40 minutes) Materials Module 9 User's guide Transparency 9-7: Session 3: Objectives Transparency 9-8: Terms Transparency 9-9: Types of sustainability factors Transparency 9-10: Threat/opportunity codes Transparency 9-11: How to develop strategies Handout 9-6: Sustainability factors worksheet<%0> Facilitator Reference 9-2: Brainstorming guidelines Equipment: Overhead projector and screen Introduction (5 minutes) Review the session objectives Give an overview of the activities of the session. Conduct strategic assessment (1 hour) Identify sustainability factors Define sustainability factor, threat and opportunity and give an example of each. Ask participants to give an example of each from their own experience. Present and explain ten types of factors, noting that this is not an exhaustive list. Assess factors Refer participants to Appendix A which contains checklists for each of the ten factors and explain how the checklists are organised. Distribute the worksheet and explain that it will be used to record their strategic assessment of their programme. Direct each participant to select a sustainability factor that they think is particularly important to their programme. Each participant should choose a different factor and enter it in the first column headed "Factor." Note: If there are 8 or more participants in the group, form teams of two for each factor. Direct each participant to determine whether that factor presents a threat or an opportunity to their programme using the information on the corresponding checklist about why this factor is important and key indicators. Tell participants to use their best judgement inmaking the determination and, if they think more information is needed, indicate what that information is and record both in the column headed "Threat/Opportunity Description." Explain the codes and direct participants to enter the appropriate code for each factor in the third column on the worksheet headed "Effect." Note: See page 55 in Appendix B for a full explanation of the codes. Ask if anyone has questions about the task. Each participant completes columns two and three for the factor he or she selected. Ask a participant to read aloud the description of the threat/opportunity and the code they assigned, explain the basis for the determination, and identify, if appropriate, the additional data needed for a final determination. Invite other participants to comment or ask questions and facilitate discussion to help participants reach consensus on the description. Repeat steps 9 and 10 until all participants have reported. Review the information needs identified by participants and suggest other MAP modules that will help them gather that information, referring to the information on page 26-27, as needed. Identify strategies (45 minutes) Explain alternative methods for developing strategies to offset threats or take advantage of opportunities presented by factors that influence sustainability. Attacking the problem not the symptoms is essential for threats such as adequate supplies are not always available or health workers are not supervised regularly. Attacking the problem is less applicable for threats beyond the programme's control, such as increase in the size of the target population or withdrawal of donor funds. Review of solutions that have worked before is useful for increases or decreases in target population or need to improve target group KAP. The checklists in Appendix A contain examples of useful solutions. Brainstorming is useful when the tried and true solutions are not always applicable, such as cutting costs and taking advantage of opportunities. Review the threat/opportunity descriptions with participants and select three: one amenable to the "five why" analysis, one amenable to an existing solution, and one amenable to brainstorming. Facilitate strategy development using the most appropriate method for each of the three descriptions. Note: See the Facilitator Reference 9-2 at the end of this session for brainstorming guidelines. You may wish to duplicate this reference for participants to use after the workshop to conduct their own brainstorming sessions. Direct participants to enter the strategy for the selected factors in the fourth column on the worksheet. Direct participants to estimate the degree to which the strategy will neutralise or offset a threat or enhance an opportunity and enter the appropriate code in column five. Financial implications (40 minutes) Refer participants to the questions on the first checklist in Appendix A under "Financial implications." The questions are the same for all factors. Give examples of how strategies affect costs and revenues using the information on page 56 in Appendix B. Refer participants to page 56 in Appendix B and review with them the definitions and examples for one-time, recurrent, and compounded costs and revenues. Ask for questions or comments on financial implications. Direct participants as a group to estimate financial implications for the strategies they have developed and enter them in the last column on the worksheet. Ask one member of the group to report the financial implications estimated by the group and the rationale to support that estimation. Make suggestions to modify any estimates you have reason to think may not include some important considerations. Ask for final questions or comments on strategic assessment. Session 3:Strategic assessment (Steps 4 and 5) Session 3:Strategic assessment (Steps 4 and 5) Transparency 9-7: Session 3: Objectives Transparency 9-8: Terms Transparency 9-9: Types of sustainability factors Handout 9-6: Sustainability factors worksheet Transparency 9-9: Threat/opportunity codes User's guide Transparency 9-11: How to develop strategies SESSION 3: OBJECTIVES Analyse selected factors for their effect on sustainability Identify strategies for dealing with threats and opportunities TERMS Sustainability factor: a condition that may affect the continued existence of a programme Threat: a sustainability factor that may hinder or interfere with the continued existence of a programme Opportunity: a sustainability factor which supports the continued existence of a programme and may contribute to its improvement or expansion TYPES OF SUSTAINABILITY FACTORS 1. Size of target population 2. Target group's demand for services 3. PHC service quality 4. Management support 5. Organisational capacity 6. Political commitment 7. Personnel 8. Programme revenues 9. Programme expenditures 10.Environment Threat (negative) --- Life-threatening, must overcome -- Serious and significant - Minor, but should be dealt with 0 Neutral; neither a threat nor an opportunity + Minor advantage, opportunity to pursue ++ Significant opportunity, very advantageous +++ Golden opportunity, must follow up Opportunity (positive) HOW TO DEVELOP STRATEGIES 1. Attack problems, not symptoms 2. Review what has worked 3. Brainstorm SUSTAINABILITY FACTORS WORKSHEET, , , , Effect Strategy FINANCIAL IMPLICATIONS Classify each factor, identify strategies where appropriate, estimate financial implications Effect Factor: Threat/opportunity; description Expenditures Revenues Cmpnd. Rev. Rcrnt. Rev. 1-Time Costs Cmpnd. Costs Rcrnt. Costs 1-Time Rev. PHC services and management support services BRAINSTORMING GUIDELINES Definition: Brainstorming is a technique used by small groups to generate a variety of ideas, to identify problems, theories for the cause of problems, proposed remedies, or obstacles to problem solutions. Principles: No idea can be criticised or evaluated. The aim is to produce the greatest number of ideas in the shortest time. An idea already presented can be expanded, modified, or used as a trigger to produce other ideas. Pitfalls: Using brainstorming as a substitute for data. Once a list of ideas has been produced, they must be processed to: set priorities among them; analyse symptoms; test theories; identify root causes; or verify the effectiveness of a solution. The group may have difficulty suspending judgement. This can be helped by conducting a warm-up session with a neutral subject, such as "How many means of transportation for people can we name?" or "Which objects in your house have handles?" Procedure: Phrase the statement to be specific, focused, broad enough to encourage creativity, and without bias. For example,"For the past two months, the rural health centres have been running short of antibiotics at least a week before the new delivery comes. What could be the causes?" Prepare ahead of time, if possible, by communicating the statement to participants at an earlier time. A group of six to eight participants is ideal. Review the principles: no criticism; think unconventionally; aim for quantity; build on others' ideas. Review the rules: make contributions in turn; only one idea per turn; you may skip a turn; do not explain your idea. Conduct the brainstorming: lead a warm-up, if necessary; write the statement where all can see; have a recorder write all contributions where they are visible to all; end after 10 or 15 minutes. Process the ideas: clarify each solution; combine and group similar ideas; agree on evaluation criteria; collect additional data as needed. Session 4: Financial assessment (Step 6) Objectives: Participants will be able to: Identify options for increasing revenues and/or decreasing costs. Conduct a "what-if" analysis. Session outline: I. Introduction (5 minutes) II. Identify options (1 hour) III. Conduct "what-if" analysis (55 minutes) Materials: Module 9 User's guide Transparency 9-12: Session 4: Objectives Transparency 9-13: Types of changes Handout 9-7: Revenue and expenditure projections worksheet Handout 9-8: What-if analysis worksheet Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen, hand calculator Note: The lesson plan for this session is written for a Level 1 financial assessment using a hand calculator. If the programme you are working with has the appropriate computer capability, follow the directions in Appendix B. Introduction (5 minutes) Review session objectives. Present highlights of session activities. Identify options (1 hour) Refer participants to page 31 in the User's guide and review the content and organisation of Table 3. Distribute the worksheet and direct participants to prepare an estimate of programme revenues and expenditures for the next 5 years based on past experience and their judgment of changes in the foreseeable future. Direct participants to prepare a graph on the flip chart similar to the one on page 32 and determine when, if at all, costs exceed revenues. Refer participants to the options for increasing revenues and decreasing costs on page 32 and check those that are feasible to consider for their programme. Direct participants to select two options for increasing revenues and two for decreasing costs and estimate the percent of change they would expect for each. Conduct "what-if" analysis (55 minutes) Explain the types of changes that can be made in revenue and expenditures and give an example of each, using the information on page 33. Refer participants to Table 4 on page 37 and explain it using the information contained on page 33. Distribute the worksheet and direct participants to determine whether the options they selected are one-time, recurrent or compounded and enter the estimated percentages of change in the appropriate places. Distribute a second blank worksheet and direct the group to recalculate their 5 year projections using one option for increasing revenue and one option for decreasing cost. Direct participants to prepare another graph similar to the one on page 36 and identify any changes in the relationship of cost and revenue. Explain that depending on the results of the what-if analysis, participants can: Revise their estimates of change in revenue or expenditure until revenue equals or exceeds expenditure. Revise one or more strategies for achieving sustainability. Modify the sustainability objectives defined on Handout 9-3 to fit the projected budget. Explain that in the next session participants will review sustainability objectives and strategic and financial assessments and select a strategy to put into action. SESSION 4: OBJECTIVES Identify options for increasing revenues and/or decreasing costs Conduct a "what-if" analysis TYPES OF CHANGES One-time: occurs only once Recurrent: a permanent change that is continued year after year Compounded: a recurrent change that increases or decreases over time by a fixed amount REVENUE AND EXPENDITURE PROJECTIONS WORKSHEET, , , ,CYYr 1 Yr 2 Yr 3 Yr 4 Yr 5 REVENUES Fees Contributions Government subsidies Grants/contracts Outside income Other TOTAL TOTAL EXPENDITURES Personnel Travel/per diem Supplies Equipment Other direct costs Indirect costs Other TOTAL SUMMARY Revenues Expenditures BALANCE WHAT-IF ANALYSIS WORKSHEET FINANCIAL FACTORS, 1-Time Revenue, Recurrent Revenue, Compound Revenue Revenue categories, ^, ^, ^ Fees, , , Contributions, , , Government subsidies, , , Grants/contracts, , , Outside income, , , Other, , , Other, , , Expenditures categories, 1-Time Costs, Recurrent Costs, Compound Costs Personnel, , , Travel/perdiem, , , Supplies, , , Equipment, , , Other direct costs, , , Indirect costs, , , Other, , , Other, , , Other, , , Other factors affecting expenditures, , , Inflation, , , In-kind contributions, , , Session 5: Action planning (Step 7) Objectives: Participants will be able to: Select an optimum strategy for sustaining the programme. Describe the essentials of a plan to implement the selected strategy. Session outline: I. Introduction (5 minutes) II. Select sustainability strategy (30 minutes) III. Develop an action plan (10 minutes) IV. Next steps (30 minutes) V. Conclusion (15 minutes) Materials: Module 9 User's guide Transparency 9-14: Session 5: Objectives Equipment: Flip chart, stand, markers, masking tape, overhead projector, and screen Introduction (5 minutes) Review session objectives. Present an overview of session activities. Select sustainability strategy (30 minutes) Direct participants to assemble the worksheets that summarise the decisions they have made in performing the sustainability analysis: Handout 9-3: Worksheet for specifying sustainability objectives Handout 9-4: Worksheet for specifying restrictions on sustainability Handout 9-6: Sustainability factors worksheet Handout 9-7: Revenue and expenditure projections worksheet (both initial and adjusted versions) Remind participants that they also may review the graphs that they prepared to display the results of the revenue and expenditure projections. Direct participants as a group to review these materials, make adjustments in objectives, strategies, and/or estimates of change in revenue and expenditure projections, and select the optimum strategy or strategies for achieving sustainability. Direct participants to prepare a written summary of the selected strategy in the format display on page 38 in the User's guide. Ask one group member to present the selected strategy and describe the adjustments, if any, that were made, and the rationale for those adjustments. Explain the importance of expanding this summary into a detailed document which includes assumptions that were made so that they are not forgotten and can be referred to periodically to monitor progress and make adjustments as necessary as the sustainability plan is implemented. Develop an action plan (10 minutes) Explain that if sustainability is to be achieved, the strategy must be implemented and monitored. Emphasise that implementation must involve all staff, using the guidelines mentioned on page 38. Invite participants to discuss briefly how the sustainability strategy planning can be incorporated into their existing planning activities. Next steps (30 minutes) Ask participants to identify the steps, if any, in sustainability analysis where they need to do more work because of lack of information. Direct participants to consider what they need to do immediately after the workshop to: Complete and/or refine one or more steps in sustainability analysis and/or incorporate the selected strategy into their routine planning activities. Involve other staff in implementation. Direct participants to list what they need to do to implement those actions and then develop an action plan which includes: Tasks in order of accomplishment. When each task must be completed. Who is responsible for each task. Ask participants to review their action plan, anticipate any problems the might occur, and suggest a way to deal with each problem. Ask for questions and comments on the action plan. Conclusion (15 minutes) Review the expectations that it was agreed would be met by the workshop and ask them to assess how well they think those expectations have been met. If any were not met, ask how the workshop could be improved to make that happen. Thank participants for their time and attention, congratulate them on the results of their work, and wish them good luck in implementing their action plans. Note: Indicate what follow-on assistance will be available, if appropriate. Session 5:Action planning (Step 7) Session 5:Action planning (Step 7) Transparency 9-14: Session 5: Objectives Flip chart of expectations from Session 1 SESSION 5: OBJECTIVES Select a strategy for sustainability Describe essentials of a plan to implement the selected strategy