Sustaining Ability of the Physical Rehabilitation Sector Dorothy Boggs, OT, MScPH, Knowledge Management Unit, Handicap International

The Sustainability Analysis Process Introduction to Sustainability and the Study Overview of methodology SAP initiatives to date AHP sustainability indicators Nepal and Somaliland SAP case study examples Successes and challenges Next steps

Sustainability is … One of the key indicators for project evaluation Identified by nearly all organisations working on global health Essential component for good project management to ensure positive impact Rarely applied effectively in practical terms Very few practical methods or tools to support implementation and monitoring of sustainable interventions

“The sector of physical rehabilitation is usually not at the top of policy- makers’ agendas in fragile states, which makes the task of building sustainability even more challenging for the actors in the system” Blanchet, Karl, Boggs, Dorothy (2012) “The Sustainability Analysis Process: the case of physical rehabilitation” Lyon: Handicap International

The Sustainability Study Four year joint study on the sustainability of the physical rehabilitation sector in five post-conflict states Partners: Handicap International and International Centre for Evidence on Disability (ICED) at London School of Hygiene and Tropical Medicine (LSHTM) Funders: AFD and Luxemburg Ministry of Foreign Affairs

5 countries selected Liberia Sierra Leone Somaliland Nepal Cambodia

The Sustainability Analysis Process Coordinated planning approach to develop a collective vision on what the rehabilitation sector should be working towards as a whole by analysing and measuring system sustainability Combines a scientific approach with a participatory approach through engagement with key sector actors

Key rehabilitation sector actors Disabled People’s Organisations (DPOs) Service providers Professional associations Donors Authorities International organisations

The Sustainability Framework Based on holistic and multidimensional view of sustainability Sarriot et al., 2008

SF Components ComponentFocus on C1 Health and rehabilitation outcomesPopulation of the local health system C2 Service delivery Providers of health, rehabilitation and social services: number and coverage of services and personnel, number of outputs, quality of services C3 Ministry organisational capacity and viability Managers of services, finance, leadership, coordination, team management C4 Local NGO or provider organisational capacity and viability Managers of services, finance, leadership, coordination, team management C5 Community capacity Community: acceptance and relevance of services, involvement of community in activities C6 Enabling environmentContext: socio-economic and political situation

The Sustainability Analysis Process Eight SAP steps 1.Overview of context 2.System boundaries 3.Consensus on vision of sustainability 4. Selection of sustainability indicators (SI) 5. Measurement of SIs 6. Reference system for sustainability 7. Illustrating the indicators on radar diagrams 8. Analysis of sustainability levels

Sustainability Analysis Process Available on Sustaining Ability website

13 SAP workshops Cambodia21 Nepal1111 Somaliland111 Sierra Leone11 Liberia11 Burundi1 Haiti1 Laos1 Bolivia1 Chad1 Policy analysis: Interviews, document review, social network analysis Workshops: SAP participatory consensus methods, interviews Policy environment SAP workshops Workshop follow-up

Results online

Key SIs relating to AHPs and rehab service delivery Response to demand and referrals Human resources Coverage, production and distribution of ADs

Key SIs relating to AHPs and rehab service delivery Quality and efficiency of services At National level National level certification Code of ethics Rehabilitation councils Guidelines/standards Professional associations

Nepal’s participation in SAP research Initial field trip by a Researcher from LSHTM workshop was organised by LSHTM and HI Assessment of physical rehabilitation sector organised by consultants 2nd workshop was jointly organised by LSHTM and HI to follow-up progress Intl Sustainability Seminar in Nepal 3 rd SAP workshop Possible 4th SAP workshop

Example: Nepal SAP III 2 day workshop held in Kathmandu, Nepal in August 2014 Objectives of workshop: Identify events that affected sustainability in the rehabilitation sector Analyse challenges met during the 2012 sustainability measurement exercise Revise the 2012 list of sustainability indicator definitions and standards Measure the revised 2014 sustainability indicators Illustrate the 2014 measures on Star diagrams

Nepal Social Network Analysis 2014

SAP III key rehabilitation sector actors 5 Ministries representatives (Ministry of Health and Population; Ministry of Children, Women and Social Welfare; Ministry of Peace and Reconstruction; Ministry of Federal Affairs and Local Development; Ministry of Youth and Sport) Managers of centres and local NGOs Managers of DPOs Rehabilitation staff (Physiotherapists, occupational therapists and P&O technicians) Representatives of International NGOs, agencies and development partners Professional associations Donors

C2 Sustainability indicator lists 2014 Component 2IndicatorSustainability Standard Current measurement

Sustainability radar diagrams 2014

Somaliland’s participation in SAP research SAP I workshop 2010 SAP II workshop in 2012 Sustainability indicators were not a priority due to… Small centralised stakeholder network Individual actors’ survival strategies: competing priorities, funding sources and financial risk  Lack of consensus on a common vision of sustainability  NO progress towards self-defined sustainability

SAP successes Rehabilitation actors reach contextual consensus on sustainability priorities Shift in thinking from project level  system level Deeper understanding of all actors’ contribution to overall sector

SAP successes Provides more holistic perspective for national planning generating sector specific information Actors can use the SAP to strategically plan & monitor their contributions and progress in relation to the whole rehabilitation sector Initiated data collection activities useful for strategic rehabilitation sector and wider health & social system planning

SAP successes IS KEY to coordinate next steps following workshop, as evidenced in Nepal workshops Sustainability Champion

SAP challenges/limitations Lack of coordination of next steps following workshop when a sustainable champion is not identified Often the first time the rehabilitation sector is working together and defined Sometimes all actor groups are not well- represented Rehabilitation sectors constantly evolving and changing in challenging contexts so need to establish better links along the contiguum

Next SAP steps …  Continue to support SAP workshops where Handicap International works  Country-level indicators to assist with planning  Wider cross-country analysis to be completed and shared with global rehabilitation sectors and UN cluster systems in emergencies  Link SAP with WHO Health System Blocks & Disability Acton Plan  Ongoing: development of tools in different languages; monitoring of methodology; analysis of results; planning for future SAP workshops

Thank you! Any questions