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SOARS Poster

Sustainability of Public Health Services

Blog #5: Doctoral dissertation poster presentation

A SYSTEMATIC REVIEW OF THE SUSTAINABILITY OF PUBLIC HEALTH SERVICES CARRIED OUT BY NGOS IN DEVELOPING COUNTRIES

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ABSTRACT

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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.

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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).

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 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.

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[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.

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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).

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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.

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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.

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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.

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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.

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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.

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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).

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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.​

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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.

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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).

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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.

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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.

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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. The primary focus of the dissertation was to identify management strategies that foster the sustainability of public health services that NGOs help put in place even after the NGO’s lifespan.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 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. In essence, the study evaluated how the legacy of an NGO, via the services they have helped established in a community, can continue to serve those communities.

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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 student researcher utilized a search strategy that entailed the organization and structuring of key terms, in the form of words and phrases, used to search a database to retrieve relevant results in a systematic way. The dissertation's search strategy included the identification of evidence associated with the context, intervention, mechanism, and potential outcome or the study, as suggested by the CIMO-logic (Denyer et al., 2008). The main keywords include NGOs, management strategies, and sustainability. The researcher searched a total of 20 databases. The choice of databases was based on the recommendations made by the university’s (UMGC) library for topics that are covered by health and medicine, business and management, and human resource management. Examples of the databases include ABI/INFORM Complete, Academic Search Ultimate, Business Source Complete, Emerald Insight, JSTOR, PubMed Central, and Scopus. 

A search string was developed from the identified key terms and entered into each of individual databases using Boolean logic to retrieve the best evidence for the research question. The search string included service sustainability, organizational sustainability, NGO, and their derivative terms. Limiting terms in the research question such as developing countries and public health were excluded in the search string because the investigation enlisted a realist synthesis. This omission allows the search to identify evidence in different contexts or geographic settings including developing and developed countries. The omission also allows the search to identify evidence on management strategies by topic areas, beyond just public health. The Boolean search string is as follows:

sustainab* n5 (service* OR organi?ation OR institut* OR association*) AND (ngo* OR "non government* org*" OR "non-government* org*" OR "nongovernment* org*")

The original search yielded 837 results including peer-reviewed articles, conference proceedings, book chapters, and grey literature (see PRISMA diagram). Grey literature studies are research studies or investigations that are carried out by organizations outside of traditional academic publishing channels. The types of grey literature included reports, working papers, government documents, white papers, and evaluations. Three databases: ABI/INFORM Complete, Academic Search Ultimate, and Scopus; yielded the most relevant evidence for inclusion in the review. 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. 

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Figure 6. The preferred reporting items for systematic reviews and meta-analysis (PRISMA) flow diagram illustrating the researcher’s search strategy. Adapted from “The preferred reporting items for systematic reviews and meta-analysis: The PRISMA statement,” by Moher, Liberati, Tetzlaff, and Altman, (2009). Adapted under the terms of the Creative Commons Attribution License.

In order to maintain relevance, the search criteria only included studies conducted in the last 10 years. All included studies also had to be written in the English language. The search allowed for a diverse organizational focus, including those addressing social issues such as health, clean water, sanitation, and education, and the reported outcome must have to do with sustainability. Studies conducted in conflict zones or refugee situations, individuals with disabilities, or those focused on government policies were all excluded. The original search yield of 837 articles was reduced to 326 and further reduced to 89 when the inclusion and exclusion criteria were applied. 

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Figure 7. Schematic view of original database search results to the quality appraisal phase

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Step 3: Quality appraisal. In the third step, the quality of the selected studies was assessed. The selected set of studies were subjected to a more refined quality appraisal that assessed for quality, relevance, and trustworthiness of the evidence. Quality appraisals are carried out using various tools to facilitate a systematical assessment of the quality, trustworthiness, and relevance of published research. The completion of this step contributed to the overall credibility of the investigation by ensuring that only high-quality evidence evaluated against the outlined criteria were included.

 

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. Each of the base studies were scored on a scale of 1 (lowest) to 3 (highest) on all seven criteria that make up TAPUPAS. The highest attainable score is 21. Only studies that attained a score of 17 or higher were retained for the review, a total of 30, while all others were excluded.

Transparency. The transparency criterion asks whether the study is open to scrutiny. It assesses the clarity of the methods and processes used to conduct the research. Along with accuracy, transparency may be one of the most salient criteria in a systematic review.


Accuracy. The accuracy criterion asks whether the research is well-grounded. It assesses how clearly and justifiably the data back up the claims of the research findings. For the evidence to meet this standard, it should demonstrate that all assertions, conclusions, and recommendations are based on relevant and appropriate information.


Purposivity. The purposivity criterion asks whether the research is a good fit for the purpose, i.e., the premise of the research question that it is used to answer. Purposivity is the match between the methods of the research, and the research question one is seeking to answer. For the evidence to meet this standard, it should demonstrate that the inquiry has followed the appropriate approach to meet the stated objective or research question.


Utility. The utility criterion asks whether the research is a fit for use in answering the research question. The evidence should be appropriate to the decision setting in which it is intended to be used. For the evidence to meet this standard, it should be a good fit for what it will be used for, providing answers that are as closely matched as possible to the question.


Propriety. The propriety criterion asks whether the research is carried out is legal and ethical, helping promote the idea that research should be created and managed legally, ethically and with careful consideration of the relevant stakeholders. For the evidence to meet this standard, it should present adequate evidence of informed consent.


Accessibility. The accessibility criterion asks whether the research is intelligible. Accessibility describes how well the research report can be understood by the intended audience. A study is not sufficiently accessible if it is full of explained statistical analyses, using a common language.


Specificity. The specificity criterion asks if the evidence meets source-specific standards. Specificity indicates how well the research lives up to standard within its content area  (Pawson et al., 2003).

Step 4: Analyze and summarize the evidence. After carrying out the quality appraisal, the evidence retained for the review were coded and analyzed. Evers (2016) defines a code as “typifying a data segment with one or several catchwords, aiming to make the data set searchable, manageable, interpretable, and manipulable” (Evers, 2016, p. 6). Coding is the primary process for developing themes as they help identify patterns and make connections in the data. Evers (2016) further postulates that coding asks a how-question: “How is the researcher working the data in order to answer the research question?” (Evers, 2016, p. 6). In this dissertation, the researcher commenced with the coding process by first reading the articles, interpreting them, and re-reading them in consideration of earlier texts, before assigning codes.


The dissertation enlisted both ‘a priori’ and ‘emergent’ coding in the line-by-line coding and the development of descriptive themes. A priori codes are established prior to the analysis and based upon the enlisted theories theory (Stemler, 2001, p. 2), i.e., dynamic capabilities and stakeholder theory. They include key terms such as stakeholders, value, capabilities, relevance, and sustainability. Emergent codes, on the other hand, are based on categories that are established following some preliminary examination of the data (Stemler, 2001, p. 2). Examples of the emergent codes include sustainability definition, funding diversity, collaboration, and partnership. Two main categories of codes emerged from both the a priori and emergent coding exercise: stakeholders and management strategies.

The coding and analysis for this review were conducted in ATLAS.ti software, a computer-assisted qualitative data analysis software. The software-assisted in the management of textual, graphical, audio, and video data. The use of a computer software can not only facilitate the coding process but also assist with the analyses and synthesis of the body of work (J. Thomas & Harden, 2008, p. 1). Atlas.ti helped the dissertation accomplish a major goal of achieving order and structure in the data analysis process. 
 

Step 5: Interpret findings using a realist synthesis. In the fifth step, the dissertation enlisted a realist synthesis in analyzing and interpreting the findings of the systematic review. Management research studies seldom tackle the same problems or ask the same research questions. This diverse nature of management studies precludes the combining of results and the effectiveness of the interventions (Tranfield et al., 2003, p. 212). A “fit-for-purpose” approach (Briner & Denyer, 2012, p. 124) that utilizes a realist synthesis is thus selected for use in this investigation.

 

Realist synthesis is an approach to reviewing research evidence to provide an explanatory analysis of how and why an intervention or strategy work or does not work, and in what contexts or settings they do work. The realist approach is not simply interested in which interventions work, but which mechanisms work in which context (Gough et al., 2017, p. 54). Realist synthesis is not defined by topic boundaries as it aims to identify different situations in which the same program mechanism may work. It can, therefore, range across a wide area. Rather, the synthesis is concerned with hypothesizing, testing, and refining the context-mechanism-outcome (CMO) configurations with the overall intention of creating a model for how and why programs work and to empirically test is against the research evidence (Gough et al., 2017, p. 54). 

 

A realist synthesis’ process of inquiry is designed to investigate the mechanisms (M) incorporated in the research, the contexts (C) in which the actors operate, and the outcomes (O) generated (Rycroft-Malone et al., 2012, p. 2). The mechanisms in a realist synthesis are identified as theory or theories applied that then serve as the framework for how the intervention will achieve the desired results (Hewitt et al., 2012, p. 251). Since this dissertation focused on a broad management problem of sustainability, a realist synthesis approach is a logical choice in exploring the myriad of management strategies that can be adapted for use in different contexts.

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:

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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.

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Figure 8. Management strategies enlisted by organizations
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Figure 9. Stakeholders consulted by organizations

Management Implications

NGO managers should first identify key stakeholders and build trust with them. To achieve sustainability of public health services, NGOs must also enlist the key management strategies found to promote sustainability. These strategies include: forming partnerships and collaborations with other organizations and governments able to support or take over public health service provision; exploring ways to reduce NGO's of dependency on donor funds by seeking other types of support such as adopting user fees and carrying out fundraisers; and implementing accountability practices that will help promote organizational credibility.

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