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FRONTIERSLegacyDocuments Financial Sustainability of RHServicesDetermineCostsEarlytoEnhance Sustainability Asexternalsupportforinnovativeinterventionscontinuestodecline,programmanagersneedtoconsiderlong‐termusefulnessand sustainability of anyneworrevisedinterventionsbeingpilot‐tested;thereislittlepointintestinginterventionsthatarenotaffordable.Somestrategiesprogramscanusetoassesscost of testingandexpandingreproductivehealthprojects,aswellasways of assessingpotentialincome‐generatingstrategies,follow.Considercosts of implementingandscalingupinterventionsfromearliestplanningstages.Implementinginterventionsandinstitutionalizingeffectivepracticesinvolvecosts—includinglabor,capitol,materials,technicalassistance,andopportunitycosts—all of whichneedtobebornebygovernment,NGOs,donors,orserviceusers.Thus,whendesigningapilotproject,plannersshouldattempttoestimatecosts of institutionalizingandscalingupinterventionsbeforeembarkingonimplementation.Suchplanningcanhelptoavoidpilotingunsustainableinterventions.Thiscanbedonebyidentifyingandcostingresourcerequirementsaccordingtothethreemainphases of apilot–test:planning;introduction of intervention;andongoingservicedelivery(Janowitzetal.2007).Thisreducescomplexity of costingbybreakingprojectimplementationdownintocomponentpartsandfocusingoncostsassociatedwitheachphase.Scaling‐upcostscanthenbeestimatedonthebasis of thesecondtwophases,whicharelikelytorepresentcosts of expandingintonewsites(introduction of intervention)andsustainingservicesonaroutinebasis(ongoingservicedelivery).Calculatefirst‐phaseandscale‐upcostsseparately.Costs of routinelyimplementingscaled‐upinterventionsarenotsimplemultipliers of costs of pilotprojects,butusuallyarelowerthanthepilotprojectonaper‐sitebasisbecause of economies of scale,streamlining of activitiesandsubstitution of lower‐costresources(Boatengetal.2006;Birungietal.2008).Numerousfactorsaffectthecost of scalingupasuccessfulpilotinterventiontomultipleservicedeliverypoints(SDPs)—includingnumberandsize of SDPs,whoprovidesresourcesandatwhatprices,andchangesininterventionalteringcostcalculationsinscale‐up.Modelingthescale‐up of apilotprojecttoimproveFPclient‐providerinteractionsinEgyptianclinicsshowscostperclinicforimplementationwoulddropsignificantlyfrompilottoscale‐up,inpartbecausemanyplanningmeetingsandpreparatoryactivities—about25percent of cost of thepilotproject—canbereduced,orcancoveralargernumber of clinics.Economies of scalealsoreducecost of otheractivities,suchastraining,becauselargernumbers of providerscanbetrainedtogether.Forexample,modelingscale‐upfrom24to567clinicsreducesprojectedcosts of planningfrom$1,018perclinicto$40perclinicbecauselittleadditionalworkisneededtoplanfor567comparedwith24clinics.Bycontrast,supervisioncostsmightnotchangeafterscale‐upascontinualsupervisionisusuallynecessarytoensurecorrectimplementation of intervention(Janowitzetal.2007).FRONTIERSLegacyDocuments Financial Sustainability of RHServicesUseexistinginstitutionstopilot‐testactivitiesthatcouldbescaledup.InKenyaandSenegal,multisectoralapproachesforimprovingyouthreproductivehealthwereintroducedthroughpublic‐sectorministriesbecauseexistingstructuresaresustainableandalreadyreachthevastpopulationmajority.Stafffromthreeministriesineachcountryplannedandimplementedinterventions;communityleadersandexistingyouthorganizationsparticipatedinplanningandplayedmajorrolesinoutreachandeducation.Thisapproachnotonlycontainedcostspilot‐testingdonorsthroughenormousresourcecontributions of ministrystafftime,infrastructureandfacilities,butalsoenabledexpansionandscale‐upcoststobeinstitutionalizedwithinannualbudgetsandministryworkplans(Joyceetal.2008).CapacityBuildingtoHelpNGOsAchieve Financial Sustainability Itisdifficulttofindtrainedprofessionalsinnongovernmentalorganizations(NGOs)withexperiencecollectingandanalyzinginformationonservicedeliverycosts.Moreover,fewhealthNGOspossessessentialbusinessskillsincosting,break‐evenanalysisandmarketresearch,skillsnecessaryforplanningandevaluatinginterventionstocontrolcostsandincreaseincome.FRONTIERSpartner,FamilyHealthInternational,implementedthe Financial Sustainability CapacityBuildingInitiative”(FSCBI)from1999to2008tobuildskillsineconomicanalysistohelpNGOsimprove sustainability. StaffandmanagersfromparticipatingNGOsinAfrica,Asia,andLatinAmericaattendedweek‐longregionalworkshopscombiningtrainingoneconomicanalyseswithresearchproposaldevelopment(Box2);thosewhoseproposalswereacceptedreceived financial andtechnicalassistancetoconductcapacitybuildingandresearch(Bratt,Janowitz,Homan,andForeit2008).Box ... FRONTIERSLegacyDocuments Financial Sustainability of RHServicesDetermineCostsEarlytoEnhance Sustainability Asexternalsupportforinnovativeinterventionscontinuestodecline,programmanagersneedtoconsiderlong‐termusefulnessand sustainability of anyneworrevisedinterventionsbeingpilot‐tested;thereislittlepointintestinginterventionsthatarenotaffordable.Somestrategiesprogramscanusetoassesscost of testingandexpandingreproductivehealthprojects,aswellasways of assessingpotentialincome‐generatingstrategies,follow.Considercosts of implementingandscalingupinterventionsfromearliestplanningstages.Implementinginterventionsandinstitutionalizingeffectivepracticesinvolvecosts—includinglabor,capitol,materials,technicalassistance,andopportunitycosts—all of whichneedtobebornebygovernment,NGOs,donors,orserviceusers.Thus,whendesigningapilotproject,plannersshouldattempttoestimatecosts of institutionalizingandscalingupinterventionsbeforeembarkingonimplementation.Suchplanningcanhelptoavoidpilotingunsustainableinterventions.Thiscanbedonebyidentifyingandcostingresourcerequirementsaccordingtothethreemainphases of apilot–test:planning;introduction of intervention;andongoingservicedelivery(Janowitzetal.2007).Thisreducescomplexity of costingbybreakingprojectimplementationdownintocomponentpartsandfocusingoncostsassociatedwitheachphase.Scaling‐upcostscanthenbeestimatedonthebasis of thesecondtwophases,whicharelikelytorepresentcosts of expandingintonewsites(introduction of intervention)andsustainingservicesonaroutinebasis(ongoingservicedelivery).Calculatefirst‐phaseandscale‐upcostsseparately.Costs of routinelyimplementingscaled‐upinterventionsarenotsimplemultipliers of costs of pilotprojects,butusuallyarelowerthanthepilotprojectonaper‐sitebasisbecause of economies of scale,streamlining of activitiesandsubstitution of lower‐costresources(Boatengetal.2006;Birungietal.2008).Numerousfactorsaffectthecost of scalingupasuccessfulpilotinterventiontomultipleservicedeliverypoints(SDPs)—includingnumberandsize of SDPs,whoprovidesresourcesandatwhatprices,andchangesininterventionalteringcostcalculationsinscale‐up.Modelingthescale‐up of apilotprojecttoimproveFPclient‐providerinteractionsinEgyptianclinicsshowscostperclinicforimplementationwoulddropsignificantlyfrompilottoscale‐up,inpartbecausemanyplanningmeetingsandpreparatoryactivities—about25percent of cost of thepilotproject—canbereduced,orcancoveralargernumber of clinics.Economies of scalealsoreducecost of otheractivities,suchastraining,becauselargernumbers of providerscanbetrainedtogether.Forexample,modelingscale‐upfrom24to567clinicsreducesprojectedcosts of planningfrom$1,018perclinicto$40perclinicbecauselittleadditionalworkisneededtoplanfor567comparedwith24clinics.Bycontrast,supervisioncostsmightnotchangeafterscale‐upascontinualsupervisionisusuallynecessarytoensurecorrectimplementation of intervention(Janowitzetal.2007).FRONTIERSLegacyDocuments Financial Sustainability of RHServicesUseexistinginstitutionstopilot‐testactivitiesthatcouldbescaledup.InKenyaandSenegal,multisectoralapproachesforimprovingyouthreproductivehealthwereintroducedthroughpublic‐sectorministriesbecauseexistingstructuresaresustainableandalreadyreachthevastpopulationmajority.Stafffromthreeministriesineachcountryplannedandimplementedinterventions;communityleadersandexistingyouthorganizationsparticipatedinplanningandplayedmajorrolesinoutreachandeducation.Thisapproachnotonlycontainedcostspilot‐testingdonorsthroughenormousresourcecontributions of ministrystafftime,infrastructureandfacilities,butalsoenabledexpansionandscale‐upcoststobeinstitutionalizedwithinannualbudgetsandministryworkplans(Joyceetal.2008).CapacityBuildingtoHelpNGOsAchieve Financial Sustainability Itisdifficulttofindtrainedprofessionalsinnongovernmentalorganizations(NGOs)withexperiencecollectingandanalyzinginformationonservicedeliverycosts.Moreover,fewhealthNGOspossessessentialbusinessskillsincosting,break‐evenanalysisandmarketresearch,skillsnecessaryforplanningandevaluatinginterventionstocontrolcostsandincreaseincome.FRONTIERSpartner,FamilyHealthInternational,implementedthe Financial Sustainability CapacityBuildingInitiative”(FSCBI)from1999to2008tobuildskillsineconomicanalysistohelpNGOsimprove sustainability. StaffandmanagersfromparticipatingNGOsinAfrica,Asia,andLatinAmericaattendedweek‐longregionalworkshopscombiningtrainingoneconomicanalyseswithresearchproposaldevelopment(Box2);thosewhoseproposalswereacceptedreceived financial andtechnicalassistancetoconductcapacitybuildingandresearch(Bratt,Janowitz,Homan,andForeit2008).Box ... One‐weekworkshopscombiningdidactictrainingineconomics‐relatedoperationsresearchwithproposaldevelopmentandsubsequenttechnicalsupportcanbuildeconomicscapacityinNGOs.Institutionalization of skillslearnedinworkshopsrequiresrepeatedpracticethroughsubsequentapplications.Practicerequiresnotonlyresources,butalsocommitmentfromseniormanagerswhomustbeconvincedconductingORtodevelopandtestways of improving financial sustainability isappropriateuse of scarceresources.Asupportiveenvironmentisessentialtonurturenewly‐formedtechnicalcapacitybuiltinaweek‐longworkshop;thisenvironmentismorelikelywhenan NGO hasstrongandsupportiveleadershipandminimalstaffturnover.OnlytwoFSCBIparticipants(ProsaludinBoliviaandCHAGinGhana)movedbeyondthefirstroundtocarryoutsecond‐generationprojects.Inbothcases,substantialtechnicaland financial assistancewasstillrequiredtodevelopandimplementthesestudies.Thissuggestsneedforlong‐termcommitmentto financial capacitybuildinginitiatives(Boatengetal.2006;Meridaetal.2006).FRONTIERSLegacyDocuments Financial Sustainability of RHServicesManagementsupportandcommitmentarecritical.Ultimately,organizationalcapacityresidesinindividualsfreetoleaveforbetteropportunities.Thusitiscritical NGO managersparticipateinandsupport financial analysiscapacitybuildingsowhentrainedstaffleave,skillsareretained.SomeNGOsinFSCBIlostkeystaffduringimplementation,whichstoppedprojectsorreducedlikelihood of resultuse.InBolivia,Prosalud’schampion of testingalternativemarketingplansleftandwasreplacedbystaffwhoassignedlowerprioritytodevelopingnewmarketingstrategies.Asaresult,one of twosecond‐generationORprojectswasdropped,andanotherwascompletedwithlittledirectinvolvement of Prosaludseniormanagement(Meridaetal.2006;Bratt,Janowitz,Homan,andForeit2008).NGOsattemptingtogenerateadditionalincomehadlittlesuccess.Costcontrolandincomegenerationarethetwomainpathsto financial sustainability availabletoNGOs.OrganizationsworkingwithFSCBItendedtoshowmoreinterestingeneratingincomethancontrollingcosts,butincome‐generationinterventionsfailedtoproducemuchadditionalrevenuefromRHservices.ASHONPLAFAinstitutedsystematicscreening1inHonduras,forexample,butidentifiedonlysmalldemandforadditionalfamilyplanningandRHservices;income‐generationeffortsshouldfocusonothertypes of services,suchasdentalcare,optometryservices,andinternalmedicine.InstudieswithChildInNeedInstitute(CINI)andChhetrapatiFamilyWelfareCenter(CFWC)NGOsinIndiaandNepalrespectively,additionstorevenuewereverysmall,indicatinglargeincreasesinvolumewouldbeneededtomakesubstantialimpacton sustainability (Dasetal.2007;Shresthaetal.2007).Donorexpectationsfor NGO financial sustainability arenotalwaysrealistic.Donorsencourage financial sustainability whilesimultaneouslyexpectingincreasednumber of servicestothepoor.However,servingthepoormayinhibitan NGO sself‐sustainingefforts,becausethepoorareoftenunabletocontributetocosts of services.Consequently,NGOsneedtocross‐subsidizesomeservicesforthepoorthroughrevenuesearnedfromprofitableservicesorfromexternaldonorsupport.OrganizationsattendingFSCBIworkshopsfromBangladesh,GhanaandNepalwereseverelyconstrainedbygovernmentanddonorrequirementstheyreducedependenceonexternalgrantswhilekeepingfeeslowand/orincreasingnumber of servicesprovidedtothepoor(Bratt,Janowitz,Homan,andForeit2008).NGOsmaycontinuetosupportineffectiveinterventionsdespitenegativefindings.Itiscommonlyassumedutilizationfollowsnaturallyfromsuccessfulintervention,butinFSCBI,thiswasnotalwaysthecase.Inone NGO, complementary(paired)productssalesdidnotincreaserevenues,buttrainingwascontinuedbecauseitcouldwithoutcost,andseniormanagementcontinuedtobelieveinit,despitenegativeresults(Bruceetal.2006).AsystematicscreeninginHonduraswasscaledupalthoughonly11percent of clientswerescreened(Vernonetal.2005).Trainingin financial researchandanalysiscannotresultin sustainability unlessseniormanagershavestrongunderstanding of theirpurposeandvalue....