Insights

When delivering targeted capacity strengthening activities to local organizations working in health, we aim to increase their knowledge, develop skills, and improve performance. Knowing what contributes the most to improve performance will give us the best route to see positive changes in health outcomes. The tricky part is, how do we know what contributes the most to improved performance when so many factors can impact one particular intervention? If we deliver capacity strengthening activities at individual and organizational level, how do we know those activities improve effectiveness, efficiency or help the organization become more sustainable?

NPI EXPAND’s learning agenda includes a question about what capacity development (CD) activities, including networking activities, contribute the most to improved performance.  We will use a mixed-method approach to answer the learning question. This will include the application of the Organizational Performance Index (OPI) through a facilitated approach with local organizations supported by NPI EXPAND in different countries, including Mali, Senegal, Liberia, and Tanzania. We will collect OPI results at least twice to observe any change in the organization’s performance in four domains: effectiveness, efficiency, relevance and sustainability. Where NPI EXPAND’s support includes networking activities, we will capture progress in improving relational strength using the Organizational Network Assessment (ONA) tool. We will also administer semi-structured interviews with key informants to capture perspectives and the most salient factors that contribute to performance improvement.

Even with a solid plan, we recognize the challenges of unpacking the CD black box and measuring performance improvement. CD is not a linear process, and most likely will face one-step forward and two-steps backward scenarios that do not fit neatly with annual project cycles and progress reporting. As context matters a lot, capacity change at all levels is influenced by myriad contextual factors (multiple programs implemented by different partners and donors, poverty levels, education attainment, gender barriers, social norms, and many others) making attribution to any set of inputs difficult. And the reporting of CD outcomes tends to rely on metrics that do not tell the whole story.

CD has been used as a major approach for achieving results and improving health outcomes in low- and middle-income countries (LMICs). However, despite significant health improvements in LMICs over the last few decades, we still have a long way to go in achieving positive health outcomes in specific health areas like family planning and reproductive health (FP/RH); maternal, newborn and child health (MNCH); HIV/AIDS; malaria; tuberculosis; and non-communicable diseases.

The presumed logic behind the use of CD for health goes like this. First, we strengthen capacity through targeted and tailored CD activities to local organizations working in health, including FP/RH, MNCH, HIV/AIDS, or other health areas. The immediate results of the CD activities translate into increased knowledge and skills at different levels; either individual, organizational or systems levels of the organization receiving CD activities. In addition, we provide resources to the local organizations through grants to facilitate the opportunity to apply the improved skills. These in turn result in improved organizational performanceassuming that the organization has the opportunity and motivation to use their increased knowledge or skills or improved systems. And lastly, the improved performance translates into better health outcomes for the target population groups of the supported organization.

As this this process takes place in complex settings, many factors come into play that may either accelerate or hamper the expected changes in knowledge, skill gain, performance, outcomes, and ultimately impact. At NPI EXPAND we use a dual approach (see the Dr. Jekyll and Mr. Hyde in Capacity Strengthening blog) to deliver CD activities and the necessary resources for local organizations to improve performance and achieve results.

CD takes many forms and may include in-person training sessions, workshops, coaching, mentoring, virtual training, leadership development, and others. In addition, investing in assets or giving the organization and their staff the opportunity to practice by doing will increase their capacity. Overall, the CD community has moved from the classic approach of focusing primarily on enhancing internal organizational management practices (Capacity 1.0) to improving engagement with stakeholders, influencing decisions that affect the organization and its mandate, achieving outcomes, leveraging resources, sharing ownership, networking, and learning and adapting (Capacity 2.0). In health programming, CD has been and continues to be a major implementation approach to improve performance and achieve health outcomes. Yet, the big question remains: how does this happen? And other questions follow: How much time should we invest in CD? What variations of CD are the most appropriate for the local organization? What opportunities should we leverage to increase the likelihood of improving performance? What sequence should we use in delivering a range of CD activities? How do we adapt our CD approach in the face of shocks (i.e., COVID-19, new Ebola outbreaks, etc.)? How should we refine our CD approach with the new normal post-COVID-19? Answering these questions will give us the best bang for the buck in our efforts to support local organizations to improve performance and achieve positive health outcomes.

The evidence suggests there is not a one-size-fits-all approach if we want to be successful in developing local capacity. Good practices tell us we need to conduct an initial assessment to identify current knowledge and skills, and set a point of reference by which change –hopefully positive– will be measured through a good set of metrics. And deliver tailored approaches that will need to be further improved and adjusted as the CD process moves forward.

I have seen many examples where CD approaches strictly follow the delivery of prescribed solutions for a particular gap. My own experience has taught me many times that the “best practice” approach is not necessarily the “best” for a given organization. Many programs tend to replicate the best practice without sufficient tailoring  to the needs and opportunities of a particular organization. Take the example of how much time to invest in CD. For some organizations, the process for adopting a good practice may take years, while for others it may take a few months. It all depends on the type of CD gap to address, the context under which the organization is operating, leadership, good governance, staff motivation, and the opportunities available to the organization.

While CD for performance improvement is certainly not an easy nut to crack, I propose four recommendations for increasing the likelihood of improving performance through CD.

1. Focus on a specific capacity gap that the organization is facing. Results from a capacity assessment will most likely reveal multiple areas to address or strengthen. Take one or a small number at a time, considering available resources, opportunities and how critical the issue is for the organization at its current juncture.
2. Leverage the existing strengths and opportunities within the organization. Opportunities show up in various ways, shapes, and forms. In some cases, a leader will take the organization to the next level by inspiring and mobilizing her/his team with additional resources, and an expanded network. In other cases, an investment in operational systems will be enough to move the needle and improve performance.
3. Do pay close attention to the context and overall environment. As context matters a lot for any development intervention, any CD plan adopted should take into account the overall health ecosystem where the organization is operating.
4. Learn and adapt as you go through the CD process. As CD does not follow a linear pathway, build and use feedback loops or similar mechanisms to assess whether or not progress is being made; even incremental improvements in skills and performance. And do this regularly within available resources. Don’t wait until the end of the process to make this assessment – it may be too late by then.

We will not start from scratch. We at Palladium have used multiple approaches in delivering CD interventions in different contexts and settings for development programs in health and other sectors. We will document what is working and promising approaches amid complexity and the new normal throughout and post-COVID-19. And we will add to the collective experience of the CD community with lessons from NPI EXPAND programs working with local partners in different settings.  As local organizations will continue to navigate within complex adaptive health systems, organizational performance improvement will become more and more an important precursor for getting the best bang for the buck: contributing to health outcomes and positive health impact.

We invite your comments and suggestions as we embark on this exciting effort to answer the question of local capacity development for improved performance to achieve better health outcomes.