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Projects to programmes: An international perspective
James Greene and John Kevany
The decision to move from a successful project outcome to large-scale programme operations in the prevention of vitamin A deficiency involves detailed consideration of technical, managerial, and financial implications. The comparability of demographic, epidemiological, and service conditions at the project and programme levels must be considered in predicting long-term outcomes; the criteria for problem definition and response measurement must also be consistent. Design changes may be required as the scale is expanded; interventions managed by a single sector at the project level may require multiple-sector inputs at the programme level. Training, supervision, and management requirements are more diverse at the programme level, and operations research has an important role in ensuring consistent service performance under varied conditions. It is concluded that the development of effective software systems at the programme level is central to reproducing the technical effectiveness demonstrated at the project level.
Three principal intervention options are available to control and prevent vitamin A deficiency (VITAD): administration of vitamin A supplements (usually mega-dose capsules), fortification of dietary staples at a central or local level, and dietary diversification supported by nutrition education and improvement of the quality of the food supply. With the possible exception of centralized fortification, the options depend in varying degrees on local delivery systems, usually in health, agriculture, education, and commerce.
Even in the case of fortification, however, the creation of demand through local systems can have an important role. This is particularly true when fortified and unfortified products compete in the marketplace, or when monopoly production encounters informal competition in the presence of a weak regulatory system. This review focuses particularly on the implications for local delivery systems in the transition from projects to programmes, assuming a distinction between the two kinds of operation based on the general characteristics listed in table 1.
TABLE 1. Characteristics of projects and programmes compared
|Short-term (3-5 years)||Long-term (10 years-indefinite)|
|Small-scale (district/area)||Large-scale (national, regional)|
|High unit costs||Low unit costs; high percentage recurrent costs|
|Low total cost (extra-budget)||High total cost (compared with project)|
|VITAD intervention prioritized||Integrated service activity|
|Specific VITAD objectives||Composite health objectives|
|Flexibility and innovation||Replication of a defined model|
|Special monitoring and evaluation||Integrated reporting|
|External funding||National agency budget(s)|
Framework for scaling up
Specialists in organizational behaviour have defined several basic models for scaling up; two are generally pertinent to this topic. One is an organizational growth model, and the other involves large-scale programme expansion from small pilot projects.
Three phases characterize the organizational growth model. The first usually involves building credibility with clients, considerable experimentation, an informal structure, team efforts, and evolution of practices. The second involves consolidation: a definite work pattern and clearly defined roles among team members that emerge from experience. Third is large-scale expansion that brings with it increased managerial demands and a need for functional specialization.
Scaling up from small pilot projects, which seems to characterize VITAD interventions, involves decisions on what is to be scaled upproducts, processes, or a combination of both; what key elements require special attention; what changes have to be made for effective expansion; and what resources physical, financial, and humanare required and how they will be made available. When this model runs into trouble, it is frequently due to a failure of strategic management and to mismatches between strategies and the programme environment or between strategies and the processes to implement them.
It is possible to look at either scaling-up model as arguably having four reasonably sequential stages that sometimes, and probably often, overlap: a process stage to test whether the proposed intervention will be effective under field conditions; a feasibility stage to determine the likelihood of achieving accepted output/outcome levels; an efficiency stage to establish optimum costs and effectiveness relationships; and, finally, a going-to-scale with the appropriate mix of services and resources.
In the process phase, an intervention that has proved efficacious in an experimental setting is tested under field conditions. Such field trials are often initiated by research institutions or groups seeking to demonstrate that experimental findings can be applied successfully in a service context. Their prime function, not unlike field trials in agriculture, is to see whether efficacy can be maintained under general service conditions applied to free-living (and free-choosing) populations. There is an inherent need in design and implementation to minimize the confounding effects of weak delivery systems.
Ideally, an effort of this kind should be located in the worst problem area (to demonstrate impact best) with the best delivery system (to ensure that the technical effect can be isolated). These conditions are elusive in practice because health status usually is worst where services are poorest, and vice versa. Choosing the best service conditions to highlight technical effectiveness may therefore reduce the magnitude of the impact because baseline health status is relatively good. Conversely, if the worst health conditions are chosen to display maximum impact, the delivery system may require strengthening in a way that cannot be replicated at the programme level.
Regardless of the choice made, field trials tend almost inevitably to optimize delivery systems in the project area, if only in the contexts of better information collection, improved training and management, and stronger motivation to obtain a positive result. They will also frequently add substantial resources to upgrade infrastructure and for staffing, training, supervision, supplies, and logistics, all of which are affordable in the context of a relatively small-scale, short-duration project but may be very costly at the programme level.
The main purpose of the second, or feasibility, phase is to identify the operational difficulties and resource constraints likely to be encountered under programme conditions. Feasibility efforts are usually initiated by the agency or agencies that will carry programme responsibility in the longer term. In the case of VITAD control this usually is the department of health, with collaboration from other departments such as agriculture, education, or rural development, singly or combined depending on the strategy. At this stage there is clear recognition of geographic variation in problem severity and in health-service performance at the field level. This raises a different dilemma: choosing a project site that best represents programme conditions and resource requirements as a basis for future planning. Above-average service conditions may conceal a future need for substantial resources to upgrade areas with poor services, and worst-case conditions may exaggerate the inputs required to deliver an effective intervention and so threaten the diversion of scarce resources from other priority activities.
Effectiveness and feasibility are not always defined as separate objectives, however. Sometimes the design at these stages reflects an optimistic mix of objectives; that is, it is hoped that the same model will demonstrate or validate effectiveness and at the same time provide useful information about programme requirements. The danger is that such a mixed approach may fail to provide the full range and quality of necessary information, particularly regarding programme requirements.
The progression from project-scale activities to full programme operations is therefore viewed differently according to the commitments and expectations of the different participants. Directors of successful effectiveness trials are rewarded by academic and professional recognition and want to know, where do we go from here? Managers, on the other hand, will inherit the strengths and weaknesses indicated by project performance and will be responsible for programme implementation and resource allocation; they want to know, what am I buying, how well will it work on a large scale, and can I afford it?
The efficiency stage is where the question of cost-effective workability on a large scale comes into play. It is at this point that operations research is usually required to provide the best relationships among inputs, outputs, and outcomes. Testing different delivery channels and processes becomes virtually essential to ensure the emergence of a good match between the VITAD strategy and its programme context and content.
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