5. CHAPTER FIVE DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
5.7. RECOMMENDATIONS
Recommendations for this study emerged from the findings of the evidence raised by participants’ perceptions of the sustainability of the eMTCT QIC program in the Mnquma sub-district. Recommendations are also based on the framework for conceptualizing program sustainability by Shediac-Rizkallah and Bone (1998:87-108).
5.7.1. Recommendation One: Project design and implementation
It is recommended that it before any new project or intervention is initiated, that the stakeholder or the funder needs to inform the implementing organisation about what the project entails, including, a clear vison, goal, aims and objectives. It is important that the implementing organisation knows the project duration, the start and end date of the new project, so that preparations can be planned for sustainability throughout the whole project. Research has shown that short, grant periods for an organisation with an innovation can delay progress. Goodman and Steckler (1989) suggested that a period of five years for supporting and funding a project would enhance sustainability. A gap identified by the researcher was that S2S did not prepare Mnquma sub-district from the start about a plan for sustainability and therefore the need is to have an action plan for sustainability as illustrated in figure 7.
According to Goodman and Steckler, (1989:63-78), not all successful program implementations guarantee sustainability, but it is only worth institutionalizing if it has been shown to be an effective program. To ensure project effectiveness while the project is in testing phase, regular data management by means of plotting of graphs must take place to assess for any improvements and, if no improvement is noted, the plan needs to be changed.
91
In the memorandum of agreement, it must clearly state what will be funded or excluded. It was clearly stated that S2S program is about the development and institutionalization of innovative capacity-building programs. One participant questioned why the program is only implemented in eMTCT, but is not implemented in other programs.When implementing a new project, funders must clearly identify what type of project it is, whether it is a preventative, curative program, clinic or community based. The S2S program was focused mostly on clinic intervention with the whole team, including community healthcare workers and lay counsellors, involved
Training for all healthcare workers is a very important component, as described by Bossert, (1990:1015-1023) because it is more likely to be sustained Those staff members who are trained on topics involving improvements can then train and support others to support program sustainability. S2S had six learning-session workshops, including many structured and unstructured modular training for all staff members, including community healthcare workers at clinics.
5.7.2. Recommendation Two: Factors within the organisational setting Factors that are related to the organisational and managerial structures can either help to sustain the gains or they can have a negative impact on the innovation program. Firstly, the researcher recommended that a new program must be well-integrated with other programs within a health clinic and with strong, skilled, leadership roles. Although S2S focus was on the eMTCT, clinics could integrate the QIC approach within other programs or services. Bossert (1990) stated that some programs that stand alone, also called vertical programs, are less likely to be sustained.
Management leadership and champions’ buy-in is very important to maintain sustainability in a program. Overall, there was a good presentation of sub-district managers involved with the implementation of the eMTCT quality improvement project and they attended most of the learning session workshops. Each clinic has to assign a quality improvement team member to run the quality improvement meeting and there was a QI champion at sub-district level. More supervisory visits need to be conducted by managers and supervisors and they need to be part of the quality improvement team.
92
Managers need more skills on quality improvement methodologies, because this program was implemented mostly at clinic level and the sub-district managers were not involved at every learning session and training. It means that the clinic staff are more exposed to the quality improvement methods and therefore, in order for the managers to understand the system including the project, they also need training and extra skills to take the lead in their sub-district. Staff development is important on all levels of staff at health facilities to provide them with extra skills and knowledge.The researcher noticed while in the field that acknowledgement, appreciation, motivation, behaviour towards people, communication and support to staff, are the key elements for the buy-in of any project for them to be change agents.
5.7.3. Recommendation three: Factors in the broader community environment
Sustainability can be influenced if the larger community are involved in an innovation because they can be the reason for improving on health outcomes.
It is vital from the start of a project initiation to involve the community stakeholders, for example school health, social development welfare, traditional healers, family and any other organisations involving the health of patients. The community needs to be informed about the challenges in the new program and that it will have challenges with sustainability and will require everyone to work together.
Community involvement in any project plays a crucial role in achieving the program goals of the organisation. It is recommended that the community takes ownership over a program, for example changing their health behaviour, and this can lead to the enhancement of program sustainability.