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The sustainability of healthcare projects has been a major concern in developing countries. Claeson and Walden (2000) proposed that sustainability is a major issue that affects how healthcare projects are designed, managed and executed. The importance of sustainability issues in healthcare projects is based principally on how future generations will enjoy the benefits of a project that was executed many years before they where born (Bossel, 1999). The aim of this paper is to show how sustainability issues plays a major factor in the management of healthcare projects in developing countries.
Brundtland(1987) suggested that a healthcare project is sustainable if it meets the needs of its present stakeholders without compromising the needs of its future stakeholders. In other words, for a healthcare project to be sustainable, the ability of future generations to enjoy the benefits of the project should not be compromised.
Prior to the 1990's, the definition of sustainability for healthcare projects was based principally on the achievement of economic self-sufficiency when the initial project budget is exhausted. This particular line of thinking has now been abandoned based on the work of Lafond(1991) who proposed that the issue of sustainability should be looked at holistically rather that using a single factor in defining it. Nebarro(1990) also suggested that economic self-sufficiency is only one factor amongst several that should be looked at in defining what sustainability really is.
Other definitions of sustainability in healthcare projects include that proposed by Stefanini and Ruck(1991) who defined a healthcare project as sustainable if the short term outputs it produces are valued so much by its stakeholders that they are willing to commit resources to the project to ensure that it produces long term outputs. It can be deduced from this definition that sustainability should be viewed as an iterative process rather than it been viewed as an end state.
Due to the multiplicity of definitions of healthcare sustainability, there is a need to integrate all these definitions into a single holistic model; we need to understand that unlike other projects, healthcare projects cannot be phased out at the end of the project life cycle. Basic services need to be maintained indefinitely to meet individual/ public needs (Olsen, 1998). Hence, a holistic definition of sustainability was proposed by Olsen(1998) which takes into account the multiple indicators for monitoring sustainability that contribute towards making a project sustainable. It was adduced that a healthcare project is sustainable if managed by a system that possess the long term ability to mobilize sufficient resources (Manpower, technology, information, finance) for activities that meet individual and public health needs. This definition takes into account that there are three main indicators for monitoring sustainability ; these include systemic, project benefits and social development indicators.
INDICATORS FOR MONITORING SUSTAINABILITY
From the definition of sustainability proposed by Olsen(1998), there are three main indicators for monitoring sustainability; they include the systemic, activity, and the social development indicators for monitoring sustainability. Shediac-Rizkallah and Bone(1998) suggested that from this indicators for monitoring sustainability can be derived the factors that affect the sustainability of healthcare projects; the three factors are organizational factors, factors associated with the project design and implementation, and environmental factors. These indicators for monitoring sustainability should be taken note of critically in the planning and design of a healthcare project for it to be sustainable;
SYSTEMIC INDICATORS :
Schaffer(1974) and Katz(1965) proposed that systemic indicators for monitoring sustainability such as processes, structure, technology and culture are critical in ensuring the sustainability of healthcare project. Schaffer(1974) suggested that to appreciate sustainability an open systems model based on inputs from the environment leading to outputs to the end users should be used. This model means that a sustainable healthcare project derives its inputs from the environment, converts this inputs to outputs for the end users, and maintains a feedback linkage between inputs and outputs via the structure, processes, technology and culture.
Taking the systemic indicators for monitoring sustainability into consideration, a healthcare project is sustainable when it is flexible enough to adapt to changes in the environmental conditions, stakeholder demand, while ensuring that desired outputs agreed with stakeholders are continuously been met.
PRIVATE SECTOR FUNDED HEALTHCARE PROJECT
In order for a private sector funded healthcare project to be sustainable, the local beneficiaries of the project need to accept it as their own. Russel(1995) suggested that to ensure the sustainability of these kinds of projects, there has to be a paradigm shift from the traditional project management approach. The traditional project management approach lays emphasis on the achievement of the goals of the project while local "Buy-In" comes last. The problem with this approach is that the local beneficiaries of the project will feel left out as equal stakeholders and hence will not contribute to the future of the project.
A new methodology for managing private sector funded healthcare projects was proposed by Taylor-Ide and Taylor(2002) that places local stakeholders in the front burner of the project plan while project goals was integrated within the pre-existing local systems for sustainable healthcare. This methodology ensures that the local stakeholders who are the ultimate beneficiaries of the healthcare project take charge at the beginning of the project lifecycle and are involved in the planning and implementation of the project in order to ensure long term sustainable results. This goes beyond the traditional project management approach of planning healthcare projects.
PUBLIC SECTOR FUNDED HEALTHCARE PROJECT
Olsen(1998) proposed that for us to address the issue of sustainability in public sector funded healthcare projects we need to consider the critical role being played by the organisational system. For public sector funded healthcare project the organizational system is not just the specific healthcare units, but it is also comprising of the necessary support systems set up to ensure continuous inputs of resources, along with the local community structures already in place.
Brownstein et al(2005) espoused the critical roles been played by Community health workers. These are persons within the community where the healthcare project is sited who are well respected within the local community. The community health workers role in ensuring the sustainability of healthcare projects include patient and community education, creating a link between the patient and health services, and ensuring adherence to prescribed care. Zuvekos et al(1999) suggested that the integration of the community health workers roles into the overall healthcare project plan is critical in ensuring sustainability.
Another area of an organizational system critical in ensuring sustainability for public sector funded healthcare projects is investment in Computer based health information systems (CHIS). Bhatnagar(1992) proposed that there is a direct link between the use of computer based health information systems and improvement in health indicators leading to sustainable healthcare projects. Mackenzie(1999) also shared the view that the integration and use of computer based health information system can help healthcare project managers in the planning and monitoring of healthcare projects as well as in effective communication among all members of the healthcare project team.
Morse(2006) proposed a third aspect of the organizational system necessary for sustainability of public sector projects. This involves the use of community health insurance schemes. The schemes involves using monetary contributions of local stakeholders to make a healthcare project sustainable. The local contributions can then be used as a source of long term resource to finance the activities of healthcare workers and other activities in the healthcare project lifecycle.
HEALTHCARE PROJECT BENEFITS INDICATORS:
The healthcare project benefits indicators relate to how the choice of activities to be carried out by the healthcare project will determine its sustainability. The main factor in this case is the benefits that the stakeholders would derive from the project. It has been noted by Cooke-Davies(2002) that failure to accurately define and focus on the benefits of a project to its stakeholders plays a critical role in determining the success or failure of that project. The OGC(2007) defines a project benefit as outcomes that are positive and advantageous to the organisation. For healthcare projects, the benefits to be derived are iterative throughout the project lifecycle; hence it is common for some of the benefits of a healthcare project not to be realised until many years after execution of the project (Stelios et al., 2008).
Glynne(2007) suggested that for projects to be managed in a sustainable way, the focus should not only be on the cost, quality and time indicators for project success but also on achievement of the project benefits. The real question is "How does the benefits derivable from a project affect its sustainability?". For a healthcare project to be sustainable, the local stakeholders who are the beneficiaries of the project need to appreciate the positive benefits derivable from the project. It is only when this positive outcomes are fully appreciated by the local stakeholders will they be able to mobilize resources to ensure the continuity of the project. Hence the project benefits need to be agreed by all stakeholders at the beginning of the project lifecycle.
Shediac-Rizkallah and Bone(1998) proposed that when viewed from the project benefits perspective, sustainability is the maintenance of these benefits over time. There has to be inculcated in the project plan a method to ensure continuous control of the targeted area in question e.g. disease. This can be achieved via two main mechanisms; the first is through continuous education in order to ensure a modification in the health habits and attitudes of the local stakeholders (Prasad and De L Costello,1995); the second is to ensure that educational messages to the local stakeholders remains in place for future generations to benefit from them.
To ensure sustainable project benefits, there has to be continuous monitoring and supervision of disease trends throughout the duration of the project lifecycle. This means that there has to be a long term strategy for disease control rather than short term solutions (Shediac-Rizkallah and Bone,1998). Inability to have a long term strategy for a healthcare project has been blamed for the resurgence of tuberculosis in some developing countries.
SOCIAL DEVELOPMENT INDICATORS:
Two key aspects of social development indicators are; Community participation in the healthcare project, and Project financing. It is a fact that change is most likely to occur if the local stakeholders who are to benefit from the change are an integral part of the change process. The planning and design of a sustainable healthcare project has to involve the participation of the local stakeholders for it to work. Community participation has been defined to be a social process where groups within a geographical area possessing needs in common take steps together to identify those needs, plan and execute solutions to those needs (Rifkin et al., 1988). Honora et al (2007) proposed that there is a link between healthcare and socioeconomic development, hence to some extent low income countries tend to have poor healthcare as compared to high income countries. The lack of a sustainable healthcare project in a community can be said to be as a result of lack of participation by the local stakeholders in the process of planning and execution. Lankester(2000) suggested a vital way of ensuring community participation in healthcare projects that involves the training of key opinion leaders in the community on key aspects of the project lifecycle.. The key opinion leaders are nominated by the community and use the skill gained through the training to ensure the sustainability of the healthcare project. Lankester(2000) also proposed that to ensure long term project financing, the beneficiaries of the healthcare project should be encouraged to pay a token in cash or kind, this fee will then be ploughed back into the project lifecycle as part of the long term project cost.
PLANNING FOR SUSTAINABLE HEALTHCARE PROJECTS
In order for us to plan for sustainable healthcare project, we need to first identify the factors that may influence the sustainability of healthcare projects. Shediac-Rizkallah(1998) identified three main factors that influence the sustainability of healthcare projects. They include project design factors, organizational factors, and environmental factors.
PROJECT DESIGN FACTORS
PROJECT COST: The sources of project financing differs for both public and private
sector projects. Private sector projects derives its funding from private sponsors e.g. NGO's; while for public sector projects the funding is derived from national or regional governments. For most public projects, the cost of the entire project through the project lifecycle is borne by the Government. For private projects, the initial project planning and execution cost is provided by the private sponsors but the cost to make these private projects sustainable is usually transferred to the local stakeholders or the regional government. Abel-Smith and Dia(1988) suggested that the presence of weak government structures in developing countries has led to an increased reliance on the community to finance the sustainability of healthcare projects. Some of the methods proposed to augment project cost by the host communities include a diversification of the services provided by the healthcare project, alternative sources of funding, and the need to ensure that the project deliverables are of high quality in order to motivate the local beneficiaries to pay a token for the services.
PROJECT SCOPE: The healthcare project scope has to do with the type of project
and the ability of the project to produce its deliverables. Bossert(1990) suggested that healthcare projects that are curative are most likely to be sustainable than those that are preventive. This is due to the fact more resources tend to be allocated to curative healthcare projects. In terms of project effectiveness, the project goals should be evaluated in line with the project results.
PROJECT TIME: Barnbeger and Cheena(1990) have acknowledged that short
term projects are more likely to receive private or public sponsorship as compared to long term projects. This is due to the fact that the sponsors want immediate results for their investment; this attitude tends to affect sustainability negatively. Studies have shown that if the project duration is crashed it tends to affect the ability of the local stakeholders to internalize the benefits of the project which negatively affects its sustainability.
This has to do with factors within the project implementing organization that could affect the sustainability of the project. Two key aspects of organizational factors identified by Bossert(1990) include a strong organizational leadership and strong technical and project management skills sets. The sustainability of a project is most likely in the presence of these factors.
Healthcare projects in Africa are less likely to be sustainable when compared to projects in developed countries. This is due to the fact that multiple socioeconomic factors such as poverty, crime, corruption are widely prevalent on the African continent. Rifkin(1988) suggests that even in the presence of these environmental factors, sustainability is most likely if the community are involved in all aspects of the project life cycle. A sense of project ownership should be inculcated in the mindset of the host communities (Flynn, 1995)
In this paper, I have presented an integrated definition of the concept of sustainability as it relates to healthcare projects in developing countries. Sustainability means different things to different people and I have shown here what it means as far as healthcare projects is concerned.
I have also talked about the three indicators used to assess sustainability. The indicators are synonymous with the different perspectives of sustainability. I also made reference to the factors that affect sustainable healthcare project and how to plan and design sustainable healthcare projects with these factors in mind.