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

1. 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

2. 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

3. Words and numbers are of equal value, for, in the cloak of 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. • Juster, N. (1962) • The phantom tollbooth. • London: Collins. • p.74

4. Between heart and mind … 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.

5. 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 .

6. TOWARDS DEVELOPMENT AID EFFICIENCY: The PPP project • 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).

7. Bangladesh is … • 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

8. 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.

9. 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)

10. PPP AT START: A PILOT SCHEME TO DEVELOP PARTNERSHIP BETWEEN: THE PUBLIC (HEALTH) SERVICES And PRIVATE FOR-PROFIT PROVIDERS

11. But … ‘Private’ provider problems • 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

12. And … ‘Public’ limitations • 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

13. 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.

14. PPP in Operation • 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

15. LIMITED EVALUATIVE RESEARCH

16. Evaluation overview (Annexes are contained only in the full PPP Policy Review report)

17. SUSTAINABILITY PARTNERSHIP QUALITY PPP MANAGEMENT MODALITIES

18. EVALUATION OUTCOMES • 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).

19. Global and national Influences CHANGING HEALTHCARE CHANGING LIFEWORLDS Emerging Futures SUSTAINABILITY PARTNERSHIP QUALITY PPP MANAGEMENT MODALITIES

20. EXCLUDING STAKEHOLDER VOICES FROM DESIGN EXCLUDING STAKEHOLDER VOICES FROM IMPLEMENTATION EXCLUDING STAKEHOLDER VOICES FROM EVALUATION EQUALS FAILURE! AN EXTENSION OF EVALUATION, IN TERMS OFTHEORYANDACTION, WAS THEREFORE REQUIRED

21. RELEVANT THEORETICAL UNDERPINNINGS CAN BE SEEN TO EMERGE AS DRIVING FORCES

22. I 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

23. II 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.

24. III 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.

25. Adapted from Yanow (2000)

26. SEEKING THE UNHEARD VOICES … 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.

27. Richard Kearney on stories: • 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.

28. THE LISTENING GUIDE 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.

29. MARRIED AND AT HOME IN RURAL BANGLADESH 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)

30. 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)

32. 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.