8
Getting There from Here: Priorities, Plans, and Progress
The seven-point IMPACTS approach provides a framework for saving lives in global health. Frameworks and models, however, don’t save lives. People do. It is only when frameworks and models inform the development of plans that guide the actions of people and organizations do we create impacts that change and save lives.
As we’ve seen throughout this book, the people and organizations that are creating impacts in global health are not acting alone or in isolation. They work in partnership with governments, businesses, NGOs, donors, and others. Though the goals of these various efforts may be very different, such as immunizing children, preventing cervical cancer, or providing affordable care to the poor, they contain common features. They are innovative, entrepreneurial, guided by a plan, and monitored closely. When they hit roadblocks, they find ways around them. When they veer off course, they adjust and get back on track. They are designed to produce impacts.
Many books focus on creating business plans, stimulating innovation and entrepreneurship, managing health systems, and monitoring and evaluation. A number of them are included in the bibliography. Our goal here is to complement those sources with a brief overview of an IMPACTS-guided approach to setting priorities, creating plans, and ensuring accountability. Each is an essential component to helping ensure that time and resources are used efficiently and effectively to achieve output, outcomes, and impacts in global health.
On the Road to IMPACTS: Planning the Trip
Impact planning requires clarity on priorities both external and internal to the organization. Knowledge of these makes it easier to identify the many opportunities to create impacts in global health that are in alignment with external and internal priorities and needs.
External Priorities and Needs
Numerous challenges with limited resources force governments, communities, and families in developing nations to prioritize multiple competing needs. When roads are impassable, electricity is intermittent, jobs are few, schools are poor, babies are dying, and the government’s coffers are bare, everything is a priority. Regardless of whether you are from business, an NGO, or government, there are tremendous challenges in the environment.
All needs are pressing, and health concerns may not be seen as the most critical. There are also priorities within health—AIDS, childhood vaccinations, strokes, cancer, and malaria, among others. The priorities are many, and the resources to meet them are few.
Understanding priorities and needs, as well as the human and financial resources that they are being directed toward, is critical from an IMPACTS perspective, because it helps identify opportunities in unmet needs, opportunities to create impacts.
Creating Opportunities: Filling the Gap
In many ways, the larger the gap, the more opportunities may exist for a particularly innovative and entrepreneurial organization to create impact.
When Bangladesh became independent in 1971 it faced substantial challenges not only in health, but in virtually every other sector as well. Many wondered openly whether Bangladesh would survive. Today, though the country remains poor, even in comparison to its relatively poor neighbors—the average income of Pakistan is nearly 50 percent higher and the average income of India is nearly twice as high—it surpasses these countries in terms of life expectancy, maternal and child health indices, and literacy for girls.1 In the gap between needs and resources in Bangladesh, social innovators and entrepreneurs saw an opportunity to change not only Bangladesh, but the world.
One NGO, BRAC, began as a provider of microloans and basic self-empowered programs to help the poor. However, it has grown into the world’s largest NGO serving the poor in terms of the number of people it reaches, 126 million people per year in its microfinance, health, education, and agriculture programs. Innovation is a core pillar of the BRAC approach, so important that this organization, born from a desire to help the poor have better lives, has its own Social Innovation Lab. The lab permits it to test innovative ideas before implementing, disseminating, or scaling them.
Related to the work of BRAC in Bangladesh are the efforts of the Grameen Bank and Muhammad Yunus. Grameen Bank, along with BRAC, helped launch the microfinance movement. Though the movement has not eliminated poverty, it now provides more than $25 billion in microloans to mainly poor but entrepreneurial women throughout the world.2 In 2006, Grameen Bank and its founder, Muhammad Yunus, won the Nobel Peace Prize for their work related to creating impacts for the poor.
Also in Bangladesh is Smiling Sun, the social franchise network discussed in chapter 5, which provides 25 million people, mostly women and children, with health care each year through its more than 9,000 networked franchise health outlets operated by entrepreneurs. This work is partially supported by self-generated revenue.
Part of the reason that BRAC, an NGO; Grameen, a private bank; and Smiling Sun, a social franchise network, have succeeded is that their work has historically involved a strong, coordinated partnership with government. They were many with the same goal—government, businesses, and NGOs working together to achieve common goals and create global impacts.
Some may see the work that was incubated in the need–resource gap in Bangladesh as an exception to the rule that defines what is possible. We view it, rather, as an example of what can be done when we use innovative and entrepreneurial people to recognize external priorities and then find opportunity in unmet need. This approach has been recognized all over the world, from Bangladesh to Zambia.
When some resources are available to begin to meet needs, there is still a need to prioritize how to do so using IMPACTS. In some countries, mainly in Africa, there are now resources to battle HIV/AIDS, an epidemic that only a decade earlier many thought would destroy the continent. However, great impacts are being made today, thanks to PEPFAR, the Global Fund, developing countries, and many others. In these government-led efforts, government ministries generally work with stakeholders—NGOs, businesses, providers, and consumers—to set national priorities, strategies, and targets. Each program is slightly different, since each country’s priorities, needs, and resources differ. However, together these innovative programs have helped lead to decreases in new HIV infections, enabled 7 million people in developing countries to get on lifesaving antiretroviral medicines, and saved millions of people throughout the world.
Once external priorities are clear, opportunities for change can be found in the gap of unmet need.
Internal Priorities
Internal priorities are also critical. They determine which of the external priorities are in line with the organization’s mission, strategies, and resources. Internal priorities will differ based on the organization and may focus on maternal health, diseases such as HIV, or smoking, and are driven by financial, social, religious, or other reasons, or some combination of them.
Available resources and constraints simply influence how opportunities are created rather than whether they can be created. Community culture, existing infrastructure, availability of mobile technology, literacy, and preconception of need are all among the factors to be considered when determining what opportunities and which solutions may be most appropriate and most likely to succeed.
Once priorities have been identified, organizations must put an effective plan in place.
Planning the Trip
It is critical for any organization, whether it is a government agency, a business, or an NGO, to have an effective plan if it is to understand where it is, where it wants to go, what the key milestones are, when it is going off course, and when it has reached the destination. We have provided an exercise (see Probes to Create IMPACTS Now on page 156) that any program or organization leader can complete to identify the key components of an IMPACTS plan. The exercise will help leaders who develop and implement health programs to think about their goals, challenges, and potential opportunities and solutions. We have outlined a number of questions to help managers brainstorm the different IMPACTS elements with peers, stakeholders, and partners. These questions are by no means exhaustive; they simply serve as a starting point. The exercise also will serve as a foundation for a business plan and can be used to create a logic model.
These questions were also provided at the end of each chapter in parts 1 and 2. However, as we noted earlier, the most impact occurs in partnerships, so we encourage you to review these questions with your teams, peers, stakeholders, and partners.
There are no right or wrong answers to these questions. Responses will differ based on external and internal circumstances and the people who are engaged in the process. While we believe it is most helpful to think through all seven points, you may identify one or more as most critical at a particular point in time. If so, focus there and return to the others later.
The questions should inform the development of a business action plan based on your logic model. These plans should be working documents that are reevaluated regularly to ensure that the desired impact is being achieved. Your plan should be clearly laid out, but at the same time it should be flexible enough to allow you to make course corrections.
The Road to IMPACTS
The importance of a clear logic model for global health and for individual projects cannot be overemphasized. Field research has consistently documented that many organizations and projects do not have well-developed logic models. We reemphasize this point since a clear definition of success is necessary to ensure accountability. Pharmacy on a Bicycle has focused on how to use existing technologies, human and financial capital, systems, and infrastructure to do this. Accountability measures are important not only to determine program success, but as tools for learning how to improve program design and implementation.
The specific logic model designed for each program or project provides the basis for measuring what matters. It must be tailored to individual organizations and the environment in which they operate. A clear logic model should allow you to effectively evaluate success and to identify areas for improvement so you can address them. It provides the elements, including the inputs, processes, outputs, outcomes, and impacts that should be part of the accountability system. The goal is to measure the impacts, but the inputs, processes, outputs, and outcomes are leading indicators of success that also should be measured. The Global Health Impacts Logic Model (Figure 9) presented in Part 1 serves as a visual representation of the relationships among the available resources, needed activities, and desired results.
Figure 9 Global Health Impacts Logic Model
The inputs include both the internal environment in which an organization operates and its leadership, management structure and capacity, and the mission guiding its strategic decisions. The organization’s internal structures, processes, and systems by which it operates support these and its financial and human resources. Program processes are the internal activities with the given inputs. We recommend using the IMPACTS approach for optimal results, which we discussed in detail in Part 1. The outputs in the logic model are the immediate results of the organization’s processes. From here, we trace the desired outcomes, which are the specific changes to target populations and communities. Ultimately, this achieves long-term impact, or fundamental changes to communities as a result of the organization’s activities. Using a logic model allows organizations to effectively visualize the relationships between activities and evaluate program success.3
Driving Success and Ensuring Accountability
Ensuring accountability is a critical element of improving global health. Accountability requires monitoring and evaluating organization activities and determining if you are having the impact you desire. We need to develop clear metrics for measuring progress and providing milestones. Identifying, acknowledging, and communicating both successes and failures are important for reducing illnesses and saving lives. The logic model should guide these activities.
Accountability measures allow your organization to track progress toward its impact goal. They allow you to identify where in the logic model your organization is falling short, enabling corrective action to be specific and targeted. They allow you to identify areas of inefficiency and ineffectiveness, providing visibility into program functions so you can identify what isn’t working and what can be done better. Measuring accountability allows you to ensure that all your resources—financial, human, time—are being allocated appropriately.
The logic model provides a critical articulation of what drives success, whereas the metrics indicate to what extent success has been achieved. It is important to measure the impact, but it is also important to measure the inputs, processes, outputs, and outcomes, since these are the leading indicators of success. If the logic model is thought out carefully, each of the elements should be a critical driver of success that culminates in an increase in impact. Further, since measurement of impact is often difficult, measuring these leading indicators may be the best way to evaluate whether your organization is on a path toward success. If some of the leading indicators show weak inputs, processes, outputs, or outcomes, it is likely that you will not achieve the desired impacts.
Developing clear and precise metrics is required on the front end and during the program. Before embarking on the project, we need to assess its feasibility. Can we measure progress? Can we measure successful impact? (See Table 12 for sample metrics.) During the program, we have to be able to monitor progress milestones. This method allows corrective action to be taken early and at multiple junctures during the course of the project. That way, we won’t have to wait until we have reached a terminal point before determining that a program did not work.
Table 12 Sample Global Health Metrics
And after the program goals are met, precise metrics allow us to do rigorous internal and external evaluation. This leads to more effective programming in the future, identifies unforeseen outcomes, and demonstrates efficacy that may not be immediately visible—such as the fact that fewer infections lead to healthier future populations, which leads to a long-term strengthening of society.
Table 13 The Difference Between Monitoring and Evaluation
Once a program is developed, it is important to monitor and evaluate your progress. There are important differences between monitoring and evaluation. Monitoring is about measuring progress toward milestones/goals. Monitoring requires clear metrics for measurement. Evaluation, on the other hand, is about measuring impact. The process of effective monitoring is what enables evaluation (Table 13).
Effective performance evaluation and management systems are needed, along with the sharing of information on success and failure. More scaling and replication of existing programs for different geographies, populations, and diseases form a central theme of this book. Program managers need to share successes and failures with others so they can adopt and adapt successful programs in their own environments.