Modeling Impact of a Pro- Sustainability Investment...
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icfi.com CedarsCenter.com CedarsCenter.blogspot.com Modeling Impact of a Pro- Sustainability Investment Strategy in a Child Survival Project in Guinea— Lessons for sustainability planning of health, food security and nutrition programs Building Evidence for Sustainability of Food and Nutrition Intervention Programs in Developing Countries American Society for Nutrition’s (ASN) Scientific Sessions at Experimental Biology 2013 23 April, 2013 Eric Sarriot MD PhD [email protected]
Transcript of Modeling Impact of a Pro- Sustainability Investment...
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Modeling Impact of a Pro-Sustainability Investment Strategy in a Child Survival Project in Guinea— Lessons for sustainability planning of health, food security and nutrition programs
Building Evidence for Sustainability of Food and Nutrition Intervention Programs in Developing Countries
American Society for Nutrition’s (ASN) Scientific Sessions at Experimental Biology 2013
23 April, 2013
Eric Sarriot MD PhD
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Disclosures for: Eric Sarriot AFFILIATION/FINANCIAL
INTERESTS
CORPORATE ORGANIZATION
Grants/Research
Support:
The Community Health Initiative for the Districts of Kouroussa and Mandiana, Guinea project was funded in part by the US Agency for International Development cooperative agreement No. FAO–A–98–000024–00.
Scientific Advisory
Board/Consultant:
N/A
Speakers Bureau: N/A
Stock Shareholder: N/A
Other Financial or
Material
Support/Honorarium:
N/A
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Acknowledgements
Eric Swedberg (Save the Children US) and Jim Ricca (JHPIEGO)
USAID/Child Survival and Health Grants Program The Community Health Initiative for the Districts of Kouroussa and Mandiana, Guinea project was funded in part by the US Agency for International Development cooperative agreement No. FAO–A–98–000024–00.
Sudhir Wanmali, Sharon Arscott-Mills and Anne Siegle (ICF/CEDARS)
Reference: Pro-sustainability choices and child deaths averted: from project experience to investment strategy Health
Policy and Planning 2010;1–12.
http://cedarscenter.com/resources/pro-sustainability_and_lives_saved.pdf
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Presentation
1. Context
2. Method
3. Results
4. First conclusions
5. Expanding Lessons Learned to Sustainability in Food Security and Nutrition Programming
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A district level capacity building intervention focused on Maternal & Child Health
M K
Guinea
Health Districts
Local NGOs
CHWs
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Method – Step 1 / Benchmarks
Guinea
Mandiana
Kouroussa
1998 2006 2002
KPC surveys Phase 1 Phase 2
National DHS surveys (1999, 2005)
M K
3 Benchmarks (“impact”) Children Under 5 Lives Saved per $100k
Entry Project = Mandiana 1
Continuation Project = Mandiana 2
Expansion Project = Kouroussa 2
LiST (Lives Saved Tool): U5 deaths averted based on Δ in coverage indicators
Estimate $ inputs per district and per phase
• Mandiana 1: ~ $1.5 mil • Mandiana 2: ~ $.5 mil • Kouroussa 2: ~ $1 mil
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Method – Step 2: Project Investment Scenarios
$1,500
$0$0
$0$0
Traditional Project Investment Scenario (in $ 1,000)
District A District B District C District D District E
Total Investment: $7.5 millions
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Method – Step 2: Maximizing Sustainability Scenario Phase 1
District A District B District C District D District E
$1.2 mil
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Method – Step 2: Maximizing Sustainability Scenario Phase 2
District A District B District C District D District E
$
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Method – Step 2: Maximizing Sustainability Scenario Phase 3
District A District B District C District D District E
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Method – Step 2: Maximizing Sustainability Scenario Phase 4
District A District B District C District D District E
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Method – Step 2: Maximizing Sustainability Scenario Phase 5
District A District B District C District D District E
Total Investment: $7.5 millions
Entry Project
Expansion Project
Continuation Project
Note: no funding for 5th district
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Method – Step 3: Modeling
Apply benchmark lives saved/$ to the 2 investment scenarios
– Traditional
– Maximizing sustainability
Sensitivity Analysis:
– Vary level of sustainability of outcomes (post funding) within possible and plausible ranges
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Results – Benchmarks
21
37
100
0
20
40
60
80
100
120
Mandiana 1 Kouroussa 2 Mandiana 2
Lives Saved per $100k
In the first phase of intervention, $100,000 of project funding led to 21 lives saved on average. This corresponds to $4,761 per life saved. Limited comparability but UNICEF costs at $4,169 per life saved the implementation of a basic package of services through the Marginal Bottleneck Budgeting. More precise and conservative estimates by UNICEF in recent publication – see other slides. But much greater differential 1/15 instead of 1/5.
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Results - Comparing Investment Scenarios
Traditional Scenario U5 Lives Saved:
2,530 [1,569 – 6,167]
Total Investment: $7.5 millions
Maximizing Sustainability Scenario U5 Lives Saved:
8,485 [4,169 – 8,909]
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Final Result – A Testable Hypothesis
Pro-sustainability investment strategy is 3.4 [2.2-5.7] times that of a traditional one over the long run
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Expanding Lessons Learned to Sustainability in Food Security and Nutrition Programming
Think inside the [black] box?
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Adapted by the author from the Complexity Matrix Conept: Geyer and Rihani Complexity of the Expected Change
More complex More orderly
Sustainability as
Emergence
Planned Capacity
Development
Sustaining population
health through political
and institutional
changes
Achieving high
utilization of quality
services by
disenfranchised
groups
Appropriate staffing of
NGO / Clinic / District
Office for full range of
services
Improving referral /
counter-referral
processes
Proper and safe
administration of
immunizations in
facilities
Sustaining health and
nutrition outcome
through promoting an
essential nutrition
package at household
level and livelihood
interventions
District capacity for
nutrition surveillance
and health care
continuous quality
improvement
Sustained adoption of
new crop by farmers’
association
Establishing exclusive
breastfeeding as new
social norm
Building CHW
nutrition counseling
skills
Developing and
managing new
partnerships while
keeping focus on
accepted public good
Diversifying and
scaling up NGO
mission
Municipal allocation of
tax revenue to support
Health Department
Strengthening
leadership in NGOs
Building essential
management
structures and
functions in local NGO
Meeting registration
criteria for small
CBO/NGO
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Sustaining Food Security & Nutrition of Vulnerable Groups
The objective is not to measure everything, but to measure enough to indicate possible levels of sustainability
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Sustaining complex social progress (health or food/nutrition)
1. Time is not interchangeable with money
2. Project investment strategies--not just projects— affect sustainability
3. Sustainability Evaluation is not just one thing: looking forward vs. looking back
4. Sustainability as behavior of a complex adaptive system
A. Understand the level of complexity being targeted,
B. Understand our position vis-à-vis local “systems”,
C. Deal appropriately and with consistency of purpose with this complexity
• Support the framing of common compatible visions / scenarios for progress
• Watch for perverse incentives, cognitive dissonance between explicit vs. implicit objectives and ‘business as usual’ tendencies
• Invest in learning and negotiation processes
• Use data to support learning, reinforce value of public good | Consistency of purpose
• Learn to differentiate between non-negotiable (few) and probabilistic elements of success
CONCLUSION
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Additional Slides
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Study Strengths and Limitations
External validity of benchmark values?
Not a cost-benefit study / relative benefits comparison Possible over-estimation of amplitude of difference between the 2 models, but not its direction
Discussion: The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach. Carrera C, Azrack A, Begkoyian G, Pfaffmann J, Ribaira E, O'Connell T, Doughty P, Aung KM, Prieto L, Rasanathan K, Sharkey A, Chopra M, Knippenberg R, UNICEF Equity in Child Survival, Health and Nutrition Analysis Team. Lancet; 2012 Oct 13;380(9850):1341-51.
Assumptions in the two scenarios?
– Paper suggests both over and under estimations
Role of Time in the model?
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Approaches and Tools
– Sustainability Framework for Sustainability Planning and Evaluation in primary health care and nutrition projects (http://www.cedarscenter.com/sfoverview.cfm)
– Creative Holism / System of System Methods (Jackson; Williams)
– Measuring Capacity Development / Outcome Mapping / MSC (Watson, Lafond)
– Use of scenarios / expected roles / Develop-Distort-Dilemna (Peters 2012; JHU www.futurehealthsystems.org)
– Pathways for scaling up (Paina and Peters, 2011 + Subramanian, 2011)
– ‘Sustainability Readiness’ for innovations (stakeholder capacity; system capacity; innovation attributes) (Knowlton Johnson)
– Transformation change for health system strengthening (Swanson)
– More on Learning Systems, Systems Approaches, etc:
• http://cedarscenter.blogspot.com/
– Register on CEDARS and contribute:
• http://www.cedarscenter.com/contribute.cfm
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