Doctoral Dissertation Poster
Sustainability of Public Health Services
Blog #5: Doctoral dissertation
A SYSTEMATIC REVIEW OF THE SUSTAINABILITY OF PUBLIC HEALTH SERVICES CARRIED OUT BY NGOS IN DEVELOPING COUNTRIES
Research Question
What management strategies can be implemented by local NGOs operating in developing countries to foster the sustainability of public health services?
Main Findings
NGOs engaged in a number of strategies in order to promote sustainability. The management strategies found to be most salient in the analysis included:
a. collaborative service provision;
b. reduction of donor dependency by adopting user fees and seeking other types of support;
c. implementing accountability practices to promote organizational credibility;
d. leadership; and
e. training.
ABSTRACT
Constraints such as corruption, poverty, lack of resources etc., prevent governments in developing countries from meeting its citizens’ public health needs, thus creating gaps in health service provision. These gaps are typically filled by non-governmental organizations (NGOs). In filling these gaps, a major management problem is the sustainability of the services that the NGOs put in place. In the public health context, sustainable public health services are defined as services that meet the needs of people through “routinization” or “long-term expansion” of the services. The purpose of this dissertation was to identify management strategies that NGOs can implement to foster the sustainability of public health services, addressed by the research question: What management strategies can be implemented by local NGOs operating in developing countries to foster the sustainability of public health services? Following an evidence-based management approach, the dissertation applied a systematic review with realist synthesis and theoretical lenses of dynamic capabilities and stakeholder theory to address the research question. Study findings revealed strategies NGO managers can enlist to promote sustainability, including enlisting collaborative service provision; eliminating donor dependency by adopting user fees and seeking other forms of financial viability; and implementing transparency and accountability in their operations. To promote the sustainability of public health services, it is recommended that NGO managers work closely and build trust with key stakeholders: community members and government entities; to put the aforementioned strategies into practice in order to achieve their service delivery and sustainability goals.
Keywords: dynamic capabilities, management strategies, non-governmental organization, NGO, public health, realist synthesis, stakeholder theory, sustainability, systematic review
Background and Overview
Sustainability is the epitome of long-lasting development ventures, and yet strategies and management practices to effectively support the transition of services and/or programs from donor-funded NGOs into the hands of the community are missing in the sustainability equation. This dissertation aims to identify NGO management strategies that stand to further the sustainability of services, even after the NGO’s obligation to the community has ended.
The United Nations (UN) defines sustainable development as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs” (United Nations, 1987, p. 32; United Nations Sustainable Development, 2018) in the Brundtland Commission.[1] In a similar vein, sustainability is defined as meeting the needs of people through “routinization” or “long-term expansion” of services (Edwards & Roelofs, 2006, p. 46). Researchers qualify this “long-term expansion” as and the extent to which local communities are able to maintain the services or efforts, about three years after external support of the NGO has been withdrawn (Gibbs, Campbell, & Maimane, 2014, p. 115). Similarly, Horn and Brysiewicz (2014) define the sustainability of services as a program that has been in place for over 5 years, and all the while able to continue delivering or expanding “services that were outlined initially by the respective goals” of the organization (Horn & Brysiewicz, 2014, p. 2).
Sustainable development has historically been defined simply as environmental sustainability. Although the concept of sustainability originated in forestry and is present in dialogues about the environment, the idea of sustainable development has evolved over time. Sustainable development include efforts that take into consideration a long-term perspective that is essential to the idea of planning for the future generation (Fifka, Kühn, Loza Adaui, & Stiglbauer, 2016, p. 1097). The sustainable development concept is, therefore, the understanding that economic, environmental, and social objectives, the three pillars of sustainable development, are complementary and interdependent in the development process (Dalal-Clayton & Bass, 2002, p. 12). The economic objective is the ability of an economy to support a defined level of economic production, foster investment, and productivity, and increase economic growth. The social objective is the equality of opportunities, the welfare of individuals, including a high quality of life, the ending of poverty, and the attainment of social cohesion. The environmental objective includes the ability to use natural resources without undermining the integrity of the ecosystems and a reduction of the burden put on the environment. This dissertation is focused on the long-term perspective of sustainable development efforts that are essential to international development. It does not focus specifically on forestry or on environmental science.
[1] The “Brundtland Commission” is a comprehensive document entitled “Our Common Future,” also known as the Brundtland Report. The report was drawn up in 1987 by the United Nation’s World Commission on Environment and Development (WCED). The report is named after the commission’s chair, Gro Harlem Brundtland.
Problem Statement and Significance of the Problem
It is increasingly accepted in many developing countries that the government can no longer be the sole provider of goods and services for addressing a host of developmental problems including health, education, and poverty eradication (Lekorwe & Mpabanga, 2007). Accordingly, NGOs have stepped in to take active and complementary roles in addressing the concerns of the people (Okorley & Nkrumah, 2012, p. 330), including filling the gaps in public health service provision. NGOs are known for their “efforts to reach, serve, and impact disenfranchised communities” (Garrity & Martin, 2018, p. 939), but they cannot do this in a financial vacuum.
NGOs are typically funded by international development aid from private philanthropies, the UN groups, and foreign governments, with the United States being the biggest donor country (Parker, 2016). Development aid monies, unfortunately, are limited as donors, particularly the U.S. government, are experiencing budget cuts on the aid awarded to the developing countries. For example, the United States Agency for International Development (USAID), the State Department’s vehicle for administering civilian foreign aid and development assistance is experienced budget cuts as high as 33% (Morello, 2018). Additionally, funding programs are often short-term and are sometimes linked to constraining targets and requirements that the NGO must meet, (Harvey et al., 2019; Hayman, 2016; S. R. Khan & Khan, 2012; Khieng & Dahles, 2015; Kiptot & Franzel, 2019), leaving the NGO with “little room for core development” (Seyfang & Smith, 2007, p. 596). Having control over the flow of resources affords donors a remarkable amount of influence (Brown, 2016, p. 386), leading to the possibility of an NGO’s loss of autonomy over its mission as contributions from donor organizations typically come with sets of conditions or ‘strings’ attached. These conditions can affect the goals and missions of recipient NGOs. For example, an NGO may have to re-align their original goals or program priorities in order to meet the requirements of the donor organization, a goal displacement effect (Froelich, 1999, p. 250).
Dissertation Research Question
The study will evaluate how the legacy of an NGO, via the services they have helped established in a community, can continue to serve those communities. The primary focus of the dissertation is to identify management strategies that foster the sustainability of public health services that NGOs help put in place even after the NGO’s lifespan. The dissertation research question is as follows:
What management strategies can be implemented by local NGOs operating in developing countries to foster the sustainability of public health services?
Significance of Study to Management Practice and Scholarship
The implication for incorporating management strategies includes the fostering of public health service sustainability as well as cost-savings for the donor organizations whose monies are stretched further to cover better address their mission and guiding principles. On the other hand, factors found to hinder sustainability include poor organizational coordination, low community involvement, and low strategic partnering (De Neve et al., 2017; Edwards & Roelofs, 2006).
The dissertation research question will be addressed through two evidence-based management theories: dynamic capabilities and stakeholder theory. Dynamic capabilities and stakeholder theory can be applied to the understanding of formal and informal organizations, such as NGOs (Lauffer, 2011). Each theory provides insights into different features of sustainability, including considerations for stakeholders and the creation of value and benefit for them (Harrison & Wicks, 2013), and the development of a competitive edge (Teece, Pisano, & Shuen, 1997) that will contribute to the sustainability of public health services and potentially keep the NGO a viable entity.
Management Theories
Dynamic capabilities. Dynamic capabilities are a “firm’s ability to integrate, build, and reconfigure internal and external competences to address rapidly changing environments” (Teece et al., 1997, p. 516). It is a promising approach for management practitioners interested in harnessing a competitive advantage, considering stiff competitors, e.g., other NGOs vying for the same limited international development funds. Dynamic capabilities require three capacities: (1) the capacity to sense and shape opportunities and threats, (2) the capacity to seize opportunities, and (3) the capacity of an organization to transform itself (Teece, 2007, p. 1319). Dynamic capabilities are well-positioned to help to problem-solve at the management level and are routinely used to identify threats and opportunities and to modify an organization’s resources. And although essential for generating sustainable competitive advantage, dynamic capabilities must go hand-in-hand with an adequate strategy in order to be effective (Amui et al., 2017, p. 311). The three capabilities make up the dynamic capabilities’ framework, which provides a source of competitive advantage over time as well as a sense of relevance in the marketplace or field of expertise.
Sensing. This is the identifying and shaping of new opportunities that entails a “scanning, creation, learning, and interpretive activity” (Teece, 2007, p. 1322). This capability requires a commitment to research on the part of the organization, to help explore their areas of interest.
Seizing. Once an opportunity is sensed, the organization must invest in the development of the identified opportunities (Teece, 2007, p. 1326). Thus, the first two capacities cover what is recognized as “research and development” or R&D.
Transforming. To drive long-term sustainability, organizations must be able to transform (Teece, 2007, p. 1335) and innovate (Amui et al., 2017, p. 309) its practices.
Figure 1. Foundations of dynamic capabilities and business performance. Adapted from Teece, D. J. (2007). Explicating dynamic capabilities: The nature and microfoundations of (sustainable) enterprise performance. Strategic Management Journal, 28(13), 1319–1350. https://doi.org/10.1002/smj.640. Copyright 2007 by Strategic Management Journal.
Stakeholder theory. Stakeholders are described as “groups and individuals who have an interest in the activities and outcomes of an organization and on whom the organization relies (on in order) to achieve its own objectives” (Harrison, 2013, p. 763). Organizations create value for their stakeholders by providing utility or benefit to the stakeholders (Harrison, 2013, p. 764). This advances the notion that organizations that take “good care” of their stakeholders (e.g., customers, suppliers, employees, communities) will function in an effective manner and also become valuable (Harrison, 2013, p. 763). For this reason, stakeholder theory may be applied to a wide variety of management topics, including public health service provision.
Stakeholder theory is originally concerned with value creation in trade, setting out to create as much value as possible for the stakeholders, without resorting to financial trade-offs (Freeman, Harrison, Wicks, & Parmar, 2010, p. 28). When presented with the question of what it means to create value for stakeholders, Harrison (2013) postulates that organization creates value by providing utility or benefit to its stakeholders (Harrison, 2013, p. 764). For example, customers benefit from the use of the products and services of the organization, employees may receive personal enrichment and growth as benefit from the work that they perform, and communities may benefit from the services provided to them by the organization. This value may then be used to sustain and grow the organization (Harrison, 2013, p. 763). The theory advances the notion that organizations that take “good care” of their stakeholders (e.g., customers, suppliers, employees, communities) will function effectively and thus create value for those stakeholders (Harrison, 2013, p. 763).
Figure 2. The stakeholder view of firm. Adapted from Freeman, R. E. (1984). Strategic management : A stakeholder approach. Boston, MA: Pitman. Copyright 1984 by Pittman.
Below is a visual representation of the theoretical framework of how dynamic capabilities and stakeholder theory will guide the dissertation inquiry into management strategies that can be implemented by NGOs to foster the sustainability of those services beyond their contractual. It is theorized that the presence of both a sense of relevance of the NGO and the value creation for the NGO’s stakeholders will yield sustainable public health services. The three capabilities under Teece and colleagues’ dynamic capabilities: sensing and shaping opportunities and threats; identifying and seizing those opportunities; and transforming the organization as needed (Teece et al., 1997) will help make the NGO relevant to the stakeholders they serve. And Freeman’s stakeholder theory (Freeman, 1984), where benefits are presented to the main stakeholders, will make the NGO valuable.
Figure 3. A theoretical framework for the sustainability of public health services implemented by local NGOs in developing countries.
Conceptual Framework
The proposed conceptual framework (see Figure 4) is a visual representation of the key concepts from dynamic capabilities and stakeholder theory that will be explored in the dissertation. The framework is best understood when read first from the top; secondly, from the right side, then downwards; thirdly, in a clockwise manner; and lastly, downwards, to the bottom.
Figure 4. A conceptual framework for the sustainability of services implemented by NGOs.
Methodology
Systematic reviews help answer a well-defined research question, using outlined procedures for collecting all available empirical evidence (i.e., high-quality research studies that are verifiable), critically appraising the evidence, and synthesizing the findings. The systematic review process has been developed as a rigorous and transparent approach to identifying and synthesizing high-quality research findings of a specific research question or subject. These reviews are carried out when the broad overview of the scholarship in the field is necessary to provide direction for further studies and the expansion of new theories (Petticrew & Roberts, 2006, p. 21). Systematic reviews are designed to provide a complete, exhaustive investigation of current evidence relevant to a research question and therefore represent an important component of management research for evidence-based practice (Rousseau, 2012, p. 7).
This dissertation employed a realist synthesis approach within the systematic review framework. The realist synthesis allowed the researcher to draw conclusions across multiple organizational settings to help answer the research question. The methodology involved identifying the causal mechanisms of an intervention, exploring how they work, and under what conditions (Rycroft-Malone et al., 2012, p. 1). This dissertation’s systematic review aimed to “unpack the mechanisms” (Pawson, Greenhalgh, Harvey, & Walshe, 2004, p. 1) for how an NGO’s management strategies work or fail to yield sustainable services in particular contexts and settings. The dissertation explored which strategies worked (or did not work), the circumstances in which they are effective, and the extent to which they are effective.
This dissertation adopted a five-step process for carrying out systematic reviews (Khan et al., 2003) for its simplicity. These steps also tie closely with Briner and Denyer’s description of the systematic review methodology of conducting a scoping review, appraising the quality of the evidence, and drawing appropriate conclusions (Briner & Denyer, 2012, p. 112). Khan and colleagues’ five-step enlisted for this dissertation investigation is illustrated in Figure 5.
Figure 5. The steps in a systematic review. Adapted from “Five steps to conducting a systematic review,” by K. Khan, R. Kunz, J. Kleijnen, and G. Antes, 2003, Journal of the Royal Society of Medicine, 96, p. 118. Copyright 2003 by Journal of the Royal Society of Medicine.
Step 1: Frame the research question. The first step taken in the systematic review was framing the research questions. This step drew upon the “context-interventions-mechanisms-outcomes” framework or CIMO-logic (Denyer et al., 2008). The CIMO-logic process was used to form a clear, unambiguous, and structured research question. The research question investigated is as follows: What management strategies can be implemented by local NGOs operating in developing countries to foster the sustainability of public health services? The “context” for the research question is local communities in developing countries where NGOs operate. Two “interventions” were proposed: the stakeholder intervention perspective and the NGO operations intervention perspective. The dissertation enlisted dynamic capabilities and stakeholder theory to help forecast “mechanisms” that helped to drive the outcome of sustainability. Finally, the “outcome” proposed is the ability of NGOs to achieve sustainable public health service delivery to the community beyond the NGO’s lifespan.
Step 2: Identify the evidence. The relevant studies were identified in the second step. An extensive search for evidence was carried out in relevant databases available at the University of Maryland Global Campus (UMGC). The identified studies underwent an initial abstract screening to determine if they were relevant to the research question. The most relevant studies, a total of 89, were then collated and prepared for the next step.
Step 3: Quality appraisal. In the third step, the quality of the selected studies was assessed. The selected set of studies should be subjected to a more refined quality appraisal that assessed for quality, relevance, and trustworthiness of the evidence. The appraisal tool, TAPUPAS (Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility, and Specificity) (Pawson, Boaz, Grayson, Long, & Barnes, 2003, p. 3) was enlisted for this purpose. TAPUPAS enabled the researcher to assign quality scores to each study, which were used to weight the study’s contribution to the evidence. A total of 30 studies remained in the review for analysis.
Step 4: Analyze and summarize the evidence. The evidence derived from the 30 retained studies were summarized in the fourth step.
Step 5: Interpret findings by synthesis. In the fifth step, the dissertation enlisted a realist synthesis in analyzing and interpreting the findings of the systematic review.