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QHR Conference: Banff, Canada: 2004 The quality of sustainable development:. Evaluation at the edge of chaos Oliver Slevin University of Ulster, UK. Evaluation of a PPP healthcare project. Addresses:

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Qhr conference banff canada 2004 the quality of sustainable development

QHR Conference: Banff, Canada: 2004 The quality of sustainable development:

Evaluation at the edge of chaos

Oliver Slevin

University of Ulster, UK

Evaluation of a PPP healthcare project


Qhr conference banff canada 2004 the quality of sustainable development

  • Addresses:

  • The evaluation of an essential health services package in rural Bangladesh that utilized Public Private Partnership (PPP) working

  • Realistic evaluation as a context-bound approach that incorporates quantitative and qualitative methodologies

  • The qualitative dimension in such research

  • And … is accompanied by a paper providing detail of the presentation content with all references


Qhr conference banff canada 2004 the quality of sustainable development


Qhr conference banff canada 2004 the quality of sustainable development

Between heart and mind … knowledge, one is warp and the other woof. It is no more important to count the sands than it is to name the stars. Therefore let both kingdoms live in peace.

We approach the problems of human psychology as humans, and it seems a pity to waste that advantage.

Midgley, M. (1981).

Heart and mind: the varieties of moral experience.

London: Methuen.


Qhr conference banff canada 2004 the quality of sustainable development

Narratives not only help to humanize aliens, strangers and scapegoats … but also to make each one of us into an ‘agent of love’ sensitive to the particular details of others’ pain and humiliation.

Rorty, R. (1991). On ethnocentrism: A reply to Clifford Geertz.

In R. Rorty, Objecivity, relativism and truth: philosophical papers, Vol. I.

New York: Cambridge University Press

.


Qhr conference banff canada 2004 the quality of sustainable development

TOWARDS DEVELOPMENT AID EFFICIENCY: The PPP project scapegoats … but also to make each one of us into an ‘agent of love’ sensitive to the particular details of others’ pain and humiliation.

  • Investment in specific approaches that will establish sustainable health improvement, in the sense that following the initiative the arrangements will be economically viable after aid is no longer in place.

  • An emphasis on partnership working between the public, private and voluntary (including Non-Government Organisations – NGOs), so that resources are pooled and more effectively targeted.

  • A higher degree of technical assistance and monitoring during implementation.

  • A greater emphasis on evaluation, that is extreme in its adherence to a logical framework That is, evaluates in a logical and linear fashion the achievement of interim and ultimate goals in terms of objective criteria (thus the term LogFrame analysis).


Qhr conference banff canada 2004 the quality of sustainable development

  • Bangladesh is … scapegoats … but also to make each one of us into an ‘agent of love’ sensitive to the particular details of others’ pain and humiliation.

  • The most densely populated country in South Asia

  • 50% of the 125m population are at or below the poverty line and 35% are described as in extreme poverty or ultra poor

  • Maternal Mortality rate is one of highest in world at 392 per 100, 000 births

  • Infant Mortality Rate is 66 per 1000 live births

  • Only 12% births are attended by trained personnel

  • Low birth weights are second only to India

  • Stunted growth in the under-5s is second only to North Korea


Qhr conference banff canada 2004 the quality of sustainable development

Population characteristics are enjoined by an unfriendly environment with high levels of pollution and risks of disaster particularly from flooding.

Most of the pernicious tropical diseases (including Malaria) are endemic; AIDS is a threat and old diseases such as TB and Leprosy are on the increase.


The development response an essential services package esp
The development response: an Essential Services Package (ESP)

  • Reproductive health care

  • Child health care

  • Communicable diseases control

  • Limited curative care

  • Behavioural change communication

    Delivered on principles of Efficiency, Safety, Equity and Resilience (sustainability)


Qhr conference banff canada 2004 the quality of sustainable development

PPP AT START: (ESP)

A PILOT SCHEME TO DEVELOP PARTNERSHIP BETWEEN:

THE PUBLIC (HEALTH) SERVICES

And

PRIVATE FOR-PROFIT PROVIDERS


But private provider problems
But … ‘Private’ provider problems (ESP)

  • An amorphous group

  • Mainly unqualified (pharmacists, quacks)

  • Mainly men (so women ‘treated’ through male ‘proxies’)

  • Interested only in for-profit

  • Providing services of dubious quality


And public limitations
And … ‘Public’ limitations (ESP)

  • Services mainly absent, many facilities unused

  • High levels of unofficial absence (as high as 74% of time for doctors)

  • Lack of qualified personnel

  • Nurses (mainly women) excluded

  • Demand for unofficial fees the norm


Qhr conference banff canada 2004 the quality of sustainable development

The PPP Project therefore developed instead as a community empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.

The community would, with technical support from Nicare (the facilitating Development agency), set up its own local healthcare services best suited to its needs.


Qhr conference banff canada 2004 the quality of sustainable development

  • PPP in Operation empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.

  • There is only one operational model. The model incorporates:

  •  Community Schemes

  •  Funding and Commissioning Partnerships

  •  Health Provider partnerships

  • It is being introduced with the support of one of three groupings:

  • - Donor/contractors (Nicare)

  • - NGOs

  • - Local Government


Qhr conference banff canada 2004 the quality of sustainable development

LIMITED EVALUATIVE RESEARCH empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.


Qhr conference banff canada 2004 the quality of sustainable development

Evaluation overview empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.

(Annexes are contained only in the full PPP Policy Review report)


Qhr conference banff canada 2004 the quality of sustainable development

SUSTAINABILITY empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.

PARTNERSHIP

QUALITY

PPP

MANAGEMENT MODALITIES


Qhr conference banff canada 2004 the quality of sustainable development

EVALUATION OUTCOMES empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.

  • In Logical Framework (LogFrame) terms, the project failed to meet some of its main sustainability, management, quality and partnership criteria.

  • 2. The evaluations that had previously taken place, limited to LogFrame orientation, ‘valued’ only the imported goals

  • 3. Because of this, wider contextual issues had not been taken fully into account, so that unrealistic expectations were not met.

  • The exclusion of ‘voices’ within the context resulted in a project that, though modified to some extent in response to emerging local circumstances, lacked participation in terms of project design, delivery and evaluation.

  • Significant ‘voices’ excluded from the scheme were women, the ultra-poor, and private providers (the latter being the main traditional source of healthcare).

  • Significant ‘voices’ included were more affluent men (who dominated local schemes through ‘political capture’, the PPP Project Team, and Government officials (again largely men).


Qhr conference banff canada 2004 the quality of sustainable development

Global and national Influences empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.

CHANGING HEALTHCARE

CHANGING LIFEWORLDS

Emerging Futures

SUSTAINABILITY

PARTNERSHIP

QUALITY

PPP

MANAGEMENT MODALITIES


Qhr conference banff canada 2004 the quality of sustainable development

EXCLUDING STAKEHOLDER VOICES FROM DESIGN empowerment initiative - described within the project as a Public-Community Partnership or also as Grassroots PPP.

EXCLUDING STAKEHOLDER VOICES FROM IMPLEMENTATION

EXCLUDING STAKEHOLDER VOICES FROM EVALUATION

EQUALS FAILURE!

AN EXTENSION OF EVALUATION, IN TERMS OFTHEORYANDACTION, WAS THEREFORE REQUIRED



Qhr conference banff canada 2004 the quality of sustainable development

I DRIVING FORCES

The idea of critical consciousness and community empowerment as a process of conscientization, that liberates the voice of the previously ‘unheard’.

Aware-ness

Freire, P. (1993). Pedagogy of the oppressed. London: Penguin


Qhr conference banff canada 2004 the quality of sustainable development

II DRIVING FORCES

The idea that within each situation there are interpretive communities, each attributing meaning and with different values and goals

Other-ness

Yanow, D. (2000) Conducting interpretive policy analysis. Thousand Oaks, CA: Sage Publications.


Qhr conference banff canada 2004 the quality of sustainable development

III DRIVING FORCES

The idea that through dialogue , and as co-equals, differences can be acknowledged and consensuses reached

Together-ness

Habermas, J. (1987). The theory of communicative action. Boston: Beacon.



Qhr conference banff canada 2004 the quality of sustainable development

SEEKING THE UNHEARD VOICES DRIVING FORCES

… a movement from the homophonic voice (in this case, we might term this a ‘Western’ lens) to a polyphonic voice that “orientates itself responsibly toward the words and voices of others … the extent, in short, to which it adopts otherness as a value.”

Tarulli, D. (2000). Identity and otherness.

Narrative Inquiry, 10, 1, 111-126.


Qhr conference banff canada 2004 the quality of sustainable development

Richard Kearney on stories: DRIVING FORCES

  • Plot (Mythos): The human existence and experience that seeks a narrative.

  • Re-creation (Mimesis): The verbal recounting of what is experienced, in terms of its eidetic or essential elements.

  • Release (Catharsis): The way in which the story transports the listener into sympathetic alignment with the teller.

  • Wisdom (Phronesis): The practical wisdom the listener gains as a consequence of the cathartic alignment.

  • Ethics (Ethos): The moral call from the story, that demands an ethical response or indeed a decision of non-response.


Qhr conference banff canada 2004 the quality of sustainable development

THE LISTENING GUIDE DRIVING FORCES

Plot: What is taking place in the story.

Self: How the individual as a feeling, thinking, acting ‘I’ is enclosed within the story.

Supportive others: The positive sustaining relationships with sympathetic others.

Devaluing others: The relationships that would and oppress.

Brown, L. Mikel and Gilligan, C. (1992).

Meeting at the crossroads: women’s psychology and girls’ development. New York: Ballentine Books.


Qhr conference banff canada 2004 the quality of sustainable development

MARRIED AND AT HOME IN RURAL BANGLADESH DRIVING FORCES

She is one of the ladies in one of our community schemes – she is unwell, she would call for help but cannot (Mythos)

Her husband has been purchasing douches from the male village quack. She now attends the health clinic. The health assistant diagnoses thrush and prescribes one suppository and sends her home. Her actual ‘malady’ is severe uterine prolapse (Mimesis)

We experience, from our contact with her, the magnitude of her plight (Catharsis)

It becomes clear to us that the system put in place does not address the social and cultural influences that construct such circumstances (Phronesis)

By becoming aware, there is an immediate ethical demand to respond appropriately to explore the situation, to address the quality deficit (Ethos)


Qhr conference banff canada 2004 the quality of sustainable development

Life is pregnant with stories. It is a nascent plot in search of a midwife. For inside every human being there are lots of little narratives trying to get out.

Kearney op cit. (p. 130)


Qhr conference banff canada 2004 the quality of sustainable development

Nature is not just like a book; nature itself is a book, and the manmade book its analogue. Reading the man-made book is an act of midwifery … it is an act of incarnation. Reading is a somatic, bodily act of birth attendance witnessing the sense brought forth by all things encountered by the pilgrim through the pages.

Illich, I. (1993). In the vineyard of the text. Chicago: University of Chicago Press.