Sustainability: some reflections

The scope of my discussion will be limited to the last answer, knowing, of course, that it can only be subordinated to the preceding ones, and admitting that the distinction between specific projects/activities and health care delivery systems is by no means clear. I will discuss the question of how to induce and secure sustainable change from three angles: the local potential to raise the necessary resources; the technical and cultural "sense content" of the change; and the "appropriation" of the change.

The local resource situation

I would like to link the intentions of an external development agency with the socio-economic potential of the community in which they intend to introduce a set of activities, expected to have a beneficial effect on health. "Socio-economic potential" means the local availability of resources, present or to be foreseen. I think this kind of relation can be usefully represented in the (highly simplified) form of a table:

Obviously there cannot be much sense in initiating something that will certainly consume additional resources and then leave the local community to itself to handle it, when we know that the necessary additional resources are not there. In the best case, such an initiative will fade away and die its natural death; in the worst case, it will replace more fundamental needs and be then be even harmful.

In reality, the local socio-economic potential is not always known with a sufficient degree of precision, and the distinction "sufficient vs. insufficient" is not always as dichotomous as it may look. There are examples of this kind of potentially harmful initiatives. The most obvious ones are the type of "white elephant" hospitals, which have in many cases succeeded in effectively blocking the development of much more needed and adapted infrastructures. However, these "white elephants" are only the visible top of the iceberg. Lots of other "projects" may be of less spectacular idiocy, but are nevertheless, to varying degrees, inadapted to the local resource situation.

A second situation, indicated in the table as "questionable", that should make us think, is the permanent resource support (linked or not with physical presence) by external development agencies (be they NGOs or government-linked organisations), when the local population’s resource potential is clearly sufficient for them to handle things on their own. I would hesitate to qualify this situation as clearly harmful, like the former one. But if we restrict the discussion to the field of transfer of (external) resources, there is an evident problem of opportunity cost: these resources may have been better used elsewhere. The least we can say is that the external agency, in such a situation, should reflect seriously on the validity and internal coherence of its motives.

The two remaining situations, still in terms of this first variable which is the resource potential, appear more clear-cut: temporary external support towards initiatives for which the needed additional resources will be available locally, or permanent external support for initiatives in situations where local resources are insufficient and can be expected to remain so. In these cases, external support will be a rational expression of solidarity, provided the intrinsic qualities of the initiative are sufficient to justify it.

Which brings us to the second theme of this discussion: the content of the change.

The sense of the change

The question to be asked of any kind of initiative to introduce change (for the better), and especially in the field of so-called development work, is: Does it make sense? Although a simple - or even colloquial - formulation like this hints at 'common sense', the answer to such a question is by no means simple. "Making sense" appears to have more than one dimension, and we will try and explore two of them.

Does it make sense conceptually? Health care organisation practice is not just a matter of good intentions. In order for a project (an attempt to induce improvement, or change for the better) to be conceptually sound, and coherent, it should be subjected to critical evaluation and be fitted to a system's model that makes good use of notions such as effectiveness, efficiency, opportunity cost, ensurance of continuity and comprehensiveness of care, stated (common) objectives, etc., as well as a somehow correctly understood concept of participation. It should be well planned and the capacity for its implementation should be prepared and followed up. In order to do all this correctly, a sufficient level of professionalism is needed, and a wide variety of skills. Some useful questions to be asked in this field are: Is what we propose to do internally coherent (does it not contain contradictions)? Are we making use of past experience (not only ours)? Do we have the necessary management capacity to carry it out - or can we create this capacity? and a host of other questions, pertaining to the domain of the health care organisation practitioner's art. And although common sense is a great help in these matters, most interventions turn out to be so complex that common sense alone is not going to be enough.

If a project is not conceptually sound, or proposes to make the same mistakes that have been made many times before, or is not considered carefully from the angle of present and future management..., then the question of sustainability is not even relevant. It can better abort.

Does it make sense culturally? The word "cultural" is also one of those that reach out in all sorts of directions. I would like to use it here in its very wide sense: all that determines the acceptability of the action or the set of actions that is being proposed, from the point of view of those for which they are meant.

It is very well possible for an intervention to be conceptually and technically 'state of the art', but at the same time to be culturally unacceptable and therefore doomed. Cultural understanding is of course especially difficult for expatriates. I would like to stress, however, that it is not necessarily self-evident for nationals either. The cultural gaps between western-trained intellectuals and ordinary people of the same country can be very wide indeed.

If we can be assured of an appropriate local resource situation (and have accepted the consequences), if we are reasonably sure that the proposed change makes sense technically or conceptually, and that it is culturally understood and acceptable, there is still one more essential condition in order to make it work in the long run - to make it 'sustainable'.

The appropriation of the change

Most of us will know from experience that 'projects' are rarely refused by partners in the South. This kind of acceptance, however, this non-refusal, is not the same thing as real appropriation. Appropriation means that the people have made the project - the change - theirs, that they have committed themselves to it. It also implies that it is accepted to "make sense" by all - or most - of those involved. As a rule, such a process takes time.

What makes sense for an outsider does not necessarily make the same sense for a local community. Acceptance of something new, without (or before) real appropriation, easily leads to situations in which a potentially marvellous novelty is deviated from its purpose, or even perverted. An experience that I can recite as an eye-opener for me personally was the introduction of a flat-fee-per-episode for under-fives in Mali, which was immediately very popular, but which turned out to be far from sufficiently understood by the health workers themselves, and deviated by the users into some kind of short term insurance scheme with very high adverse selection. One can ask even to what extent "modern medicine", with its objectivating and rather typically western characteristics, is appropriated by all its clients. Our modern type of medical practice, widely accepted to be very effective in producing relief from suffering, has progressed and continues to progress because (among other things) it studies and examines suffering as an object, separate from its subject. It does not, however, give any sense to this suffering, which is something people also appear to need when they are distressed.

If we want to avoid too little appropriation (this is not a yes-or-no phenomenon, thresholds are involved), we must be willing to spend the necessary time and effort for a broad dialogue - and we should not be shy to involve a maximum of people. There really is no time for haste. Moreover, as outsiders we need to understand as well as possible local ways of looking at things, local values and social relations, in short: 'local culture'. But we do not seem to be able to do so as long as we do not understand our own values and our own cultures; which means that we should make those as explicit and as clear as we can. And since this is - again - a rather long and difficult personal process, we can only hope to make progressively less, and less important, mistakes, and continue to learn.

*Guy Kegels, Chairman of Medicus Mundi Belgium, is an Assistant at the Unit of Reserarch and Training in Public Health of the Institute of Tropical Medicine in Antwerp, Belgium.

The text is an update of the input by Guy Kegels to the 1995 General Assembly of Medicus Mundi International at Geneva, focusing on "Sustainability of NGO Health Projects" (first published in: MMI Newsletter