Contents
1 Introduction
2
Task Guides Task 1 Task 2 Task 3 Task 4 Task 6 (NB: there is no Task Guide for Task 5)
3
Generic Letters of Remit For Task 2 For Task 3 and 4 For Task 5 For Task 6 (NB: there is no Letter of Remit for Task 1) Examples of Letters of Remit from the Pilot Courses
4
Guidelines for the Group Tutor
5
Guidelines for the Resource Person
6
A Generic Schedule for Resource Persons
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Annotated Generic Programme for Field Trips
8
List of Books and Documents available in the Course Library
9
CD-ROM with Electronic Files of Course Relevant Documents
TASK 1
Constructing a Framework for Comprehensive Development Planning
TASK GUIDE FOR THE TRAINING COURSE
Health Opportunities in Water Resources Development
Constructing a Framework for Comprehensive Development Planning Task 1
Contents
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Timetable .............................................................................................. Introduction to the Tasks ..................................................................... Important points to consider at the start ............................................ An overview .......................................................................................... Outline Table ........................................................................................ Water resources planning, development and management ............... Essential definitions .............................................................................. Horizontal and vertical dimensions of planning ................................. Categories of water resources development ....................................... Identification ........................................................................................ Pre-feasibility ........................................................................................ The feasibility study .............................................................................. Environmental impact assessment ....................................................... Appraisal ............................................................................................... Negotiations ......................................................................................... Resource allocation during the negotiations phase ............................ Construction, operation and maintenance .......................................... Where should health be considered? .................................................. Checklist of the information you generated ........................................
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 TASK 1
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Timetable A total of six hours and thirty minutes is available for Task 1, starting with the briefing. This means your group will need to discuss conceptual issues, exchange factual information, reach a consensus on planning procedures for water resources development and complete its Table fairly rapidly.
Introduction of Task 1 Group work 3 hours
30 minutes
Group work Plenary: presentation of the Table by each group
3 hours
2 hours
50 minutes
Resource material Tiffen, M. (1991). Guidelines for the incorporation of health safeguards into irrigation projects through intersectoral cooperation. PEEM Guidelines 1. Document WHO/CWS/91.2. World Health Organization, Geneva. (Referred to as PEEM 1) TASK 1
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Introduction to the Tasks Welcome to Task 1 ! This is the first of six Tasks you will be undertaking as an intersectoral group. Before starting with Task 1, we should like to give you some general information to help you carry out the Tasks effectively. Throughout the course you and your fellow group members will provide mutual support in completing your assignments. Each of your colleagues will contribute expertise and experience in accordance with his/her professional background and sectoral affiliation (e.g. the Ministy of Health, the Drinking Water Supply Authority, the Environmental Protection Agency). In the process, you will all develop and use negotiating skills to arrive at decisions as a group. Just as importantly, you will be practising how to scan documents in an organized manner, how to arrive at reasoned conclusions in aspects that are not necessarily within your own expertise and how to pass justified recommendations to your senior colleagues.
TASK 1
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You have probably by now gone through informal introductions with the other members of your group. This is a good moment to go around your group and give each member an opportunity for a more formal introduction of him/herself. Think of professional training, current position, past experience and other areas of interest. Then, turn to the next page for more information to help you get started.
Important points to consider at the start Please bear in mind the following important points for this Task and for the Tasks that follow: Local experts are available to assist you with issues that the group is unable to resolve. The experts can be consulted at any time if you feel you cannot continue the Task without their input. As a general rule, we encourage you to collect the questions that do not require an immediate answer. morning and afternoon, for the benefit of all participants. The course library contains selected, relevant publications and documents. Together with the documents each individual participant has received and the project documents provided to each group, these will give you access to the information you are looking for. Time management is the key to the successful completion of all six Tasks. For Tasks 2 to 6 you will receive "letters of remit" with a clear deadline. You will have to plan each Task and monitor your progress at regular intervals. To assist you in the planning, all Task Guides contain an overview of the steps in the Task. To facilitate monitoring, each page carries a reminder of these steps. There is no Guide for Task 5. You will carry out that Task on the basis of instructions given in the letter of remit. Your non-expert tutor will not be able to help you with the technical subject matter. The role of your tutor is to guide your group in procedural matters, clarify possible misunderstandings, assist in time management and consensus building and help in conflict resolution. The tutor is also the group's formal link with the course organizers. You will complete Task 1 by following this Task Guide step-by-step. given. At the TASK 1
Such ques-
tions can then be discussed during the plenary sessions, at the start of each
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bottom of each page one or more questions will be raised and/or instructions These should be dealt with to the satisfaction of the group before turning to the next page. Document your findings for your report as you go along !
If you have any question about the above explanations, please raise it now with your tutor. If all is clear, turn to the next page.
An overview Aim of the Task The aim of Task 1 is to agree on what the planning procedures in your country are, with reference to water resources development projects.
What does the Task consist of ?
The Task is broken down into the following activities: 1. Agreeing on concepts and definitions 2. Identifying types of water resources development projects 3. Identifying responsible authorities, referred to as "actors", and procedures in the phases of planning, design and implementation for the most important types of projects 4. Deciding when health should be considered in the context of these procedures
Output The output of this Task is a Table representing a framework for comprehensive planning procedures for water resources development in your country. It will be a permanent reference for the other Tasks. The Table should indicate the actors that are responsible for decision making as the process proceeds through various phases of planning, design and implementing until the project becomes operational. The outline of the Table is presented on the next page. When the Table has been completed, important decision-making moments can be identified. Each decision may offer an opportunity to incorpoYou should reach agreement on the quesrate concerns about health. dress these concerns. In the concluding plenary session of this Task each group will present the information it has generated and thus contribute to a comprehensive table for national planning procedures. TASK 1
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tion of which decision(s) are crucial and offer an optimal opportunity to ad-
Many public sector bodies (ministries, regional, provincial and district authorities) have authority over water resources or represent interest groups that use water. Please prepare a tentative list of all public sector bodies in your country that have responsibilities in the planning, development and/or management of water resources. Keep your list for reference further on in this Task. Then turn to page 6.
Project category ________________________________ Externally/internally funded Phase 3 Feasibility Phase 4 Appraisal Phase 5 Negotiations Phase 6 Construction Phase 7 Operation & Maintenance
Table of planning procedures for water resources development in ___________________ Phase 2 Prefeasibility/ design
Phase 1 Initiation/ identification
1. Central Government
2. Provincial or regional government
3. Local government
4. NGO and/or community
Proposed action for health protection and promotion
TASK 1
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Planning, development and management of water resources 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
One of the most vital resources for any country is water. The availability of good quality water is becoming increasingly constrained, while the human population continues to grow, and with it the demand for domestic water. The same problem applies to water for agricultural production, for energy generation and for industrial use. There are a number of user groups which have a claim on water resources. Each user group will belong either to the private sector or to the public sector. Within the public sector, they may be found in different ministries, for example: agriculture, water resources, local government, industry, energy. The environmental authority or river basin authorities will also be involved in water resources development and management, for instance to ensure the protection of fresh water resources or the conservation of wetlands. Planning the development of natural resources is a complex matter. Consider the following: In most countries, it takes place within a national development policy framework, with predominantly macro-economic criteria. TASK 1
Several countries have recently formulated a national water policy and a national strategy for integrated water resources development, but in many others there continues to be a lack of intersectoral coordination in planning such development. The planning criteria and procedures in the different public sectors will be derived from the national policy framework, but they are not necessarily compatible. The role of public sector agencies in water resources development may be regulatory, operational or both. Moreover, many water projects are of an informal nature. Usually because of their smaller scale, their planning does not fall within the formal planning procedures. Community initiatives and projects supported by Non-Governmental Organizations (NGOs) come into this category. In this complex structure of planning procedures a common understanding of key concepts is essential for a successful intersectoral dialogue.
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Question How would you define policies, strategies, programmes and projects ?
Discuss your definitions and then turn to the next page.
Essential definitions 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
We propose the following: Policy A course of action adopted by an authority for the achievement of an objective, guided by well-defined criteria for decisionmaking Strategy The allocation and deployment of resources and the establishment of institutional arrangements in pursuit of a policy Programme Project A definite plan of intended procedure with measurable targets within a realistic timeframe Within a development programme, projects are the "units" of activities leading to a specific goal
The planning, development and implementation of a project follows a standard pattern: a sequence of events, where the output of one phase serves as the input to the next. This sequence of events is known as the project cycle. See PEEM 1 (pages 30 and 31) for a diagram of the project cycle and for a detailed description of the phases. Different stakeholders may have different perceptions of the project cycle. For example, for a multilateral development bank (such as the World Bank or one of the Regional Development Banks) the project cycle comes to an end with the evaluation phase, when it is ascertained that funds have been disbursed and used. For an irrigation authority the emphasis will be on the operational phase, which is proportionally much longer than the project planning, design, appraisal and construction phases together. From that perspective, the cycle stretches over a much longer period and re-starts when the irrigation scheme is in need of rehabilitation. TASK 1
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Types of water resources development
In order to develop your Table of the planning procedures for water resources development projects, the first important step is to make a complete list of types of such projects that are relevant in your country.
List the different types of water resources development projects in your country. Each type of project can be described by a number of characteristics. Identify characteristics you feel are important in the context of project planning and prepare a list of options for each characteristic. Then, turn to page 9.
Types of water resources development 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
Purpose, scale and source of water are three important characteristics of water resources development projects. these characteristics: Following are lists of options for each of
(i) Purpose Irrigation for agricultural production Hydropower generation Domestic drinking water supply Industrial use Aquaculture (fish and shrimp cultivation) Ecosystem conservation Flood control Drinking water for cattle Navigation improvement Recreation
(iii) Source Groundwater Run-off water Natural springs Water from impoundments Urban waste water Industrial waste water Seawater (through desalination plants)
(ii) Scale 1 Large Medium Small 1
TASK 1
(Note: these designations are not absolute: what is considered to be a large scale irrigation project
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in one part of the world may be only small to medium scale by standards applied in another part !)
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Make sure you have included in your list all types of water resources development projects in your country, based on the above characteristics (e.g. smallscale irrigation using groundwater sources, rural drinking water supply from impoundments). Look again at the Table on page 6. Note that, over time, a project will go
through different phases. The actors in each phase may belong to different sectors and to different levels in the administration.
Question What would determine whether different actors should become involved in the different phases ? Don't forget to consult PEEM 1 !
Discuss this question. Then, copy the Table onto a flip chart. From your list, select the most important type of water resources development projects in your country. At the top of the Table, fill in the name of your country and the project type you will work on. Now, turn to page 10.
The dimensions of planning 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
A development project may be initiated by a ministry; it may pass by the National Planning Bureau for appraisal and approval; its environmental impact may be assessed by the Environmental Authority; and, it may end up with the Ministry of Finance for loan negotiations with donors. Therefore, over time, a sequence of decisions is made by authorities in different sectors. This is referred to as the horizontal dimension of the project cycle. Planning has a second important dimension. At one or more times during
the planning process, the project proposal may move up or down between the national planning authorities and the local community, through intermediate levels of regional, provincial and local government authorities. This is the vertical dimension of the project cycle. Many countries have adopted a Where river basin district development focus; district councils may be instrumental in initiating project proposals, often with support from local NGOs. authorities play a role in planning, the discrepancy between administrative boundaries (for example, provinces) and the natural boundaries of the river basin may complicate the process. It is important to keep in mind both the horizontal and the vertical dimensions of the decision-making processes when developing the Table. On the following pages you will identify actors and procedures in each of the phases. TASK 1
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Please carry out the instructions on pages 11 to 19 inclusive. You should organize your time in such a way that you can repeat this part of the Task at least for the second most important project type. Then, turn to page 11.
Phase 1 Identification 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
Given a certain development goal, e.g. increased food production, the first step in the project cycle is to identify where and how this goal is to be met. This is called the identification phase and the tangible output is a project document. Those who propose a project (the proponents) will also have undertaken the identification phase. On page 5 you created a tentative list of public sector institutions involved in water resources development projects.
TASK 1
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Question Who would normally be the proponent of your type of project ?
Add this information in the Phase 1 column of your Table before you turn to the next page.
Phase 2 Pre-feasibility 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
Your project will have to be considered in the light of national policies and priorities. The pre-feasibility phase has policy appraisal as its main objective. If a project idea is approved as being in line with the Government's policies and within its priorities, then Terms of Reference (TOR) for the next phase (the feasibility study) are drawn up. Here are a few different scenarios, depending on who is the project proponent: If the project proponent is a ministry responsible for policy making (for example, the Ministry of Agriculture, the Ministry of Energy, or the Ministry of Water Resources), the project will automatically be compatible with the policies and priorities of that ministry. ning authority. If the project proponent is an executing agency, such as a water authority or a river basin authority, or if the project originates from an NGO, it will have to be validated both by the relevant ministry and the national planning authority against sectoral and national policies and priorities. Projects that originate at a level below that of the national government (provincial or regional government, municipalities, district councils or communities) may, in a centralized government structure, have to go to the relevant ministry and the national planning authority for policy appraisal and priority setting. In a more decentralized structure, and depending on the scale of the project, decision making may take place at one of the lower administrative levels. Even if a project fits national policies and priorities, but it can be foreseen that it will grossly exceed the economic capacity of the country or, if it is expected to lead to major environmental degradation or social disruption, the proposal can be stopped in this phase. TASK 1
It will only have to be ap-
praised against the national development plan, usually by a central plan-
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Question Is there a national water policy and an integrated water resources development and management strategy in your country ?
If your country has a national water policy, please indicate this in a footnote at the bottom of your Table. In the Phase 2 column of your Table, indicate where the initial plan for your water resources development project would be sent for policy appraisal. Then turn to the next page.
Phase 3 The feasibility study 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
In the pre-feasibility phase a project proposal is approved from a policy viewpoint, normally by a planning authority. It should fit in the national development policies, and it should not clash with the policies of other ministries. The resources available to governments to achieve their development goals are limited. Before it is decided that government funds will be spent on a project, a feasibility study will have to establish its economic viability and its sustainability. Again, different scenarios are possible: The feasibility study is the responsibility of either the proponent, which will have to submit the results to the planning authority and the Ministry of Finance, or the feasibility study is commissioned by the planning authority. It is beneficial (imperative in the case of large projects, for which external support is essential) to involve prospective donors or banks in the feasibility study. They would normally cover the cost of the feasibility study and it is more likely to be carried out in accordance with the specifications and requirements of the donor(s). Environmental Impact Assessment (EIA) tends to run in parallel with the feasibility study. TASK 1
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Questions What is an Environmental Impact Assessment ? In your country, is EIA part of feasibility studies ? Is there a legal basis for EIA ? If so, is an EIA always, sometimes or never required for your type of project ? What criteria apply in deciding whether an EIA is required or not ?
Document this information well - you will need it when you are identifying opportunities to include health considerations in the project cycle at the end of Task 1. Then turn to page 14.
Environmental Impact Assessment (EIA) 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
EIA is concerned with identifying and assessing the environmental consequences of development policies, plans, programmes and projects, with a view to ensuring optimal efficiency in the development of limited natural resources and the incorporation of environmental management measures to mitigate possible adverse impacts on the environment. Most countries have legislation that defines the criteria which make EIA an obligatory element in the planning of development projects. Many countries, however, do not yet have the capacity to carry out their own impact assessments and, therefore, have to rely on international consultants. Most bilateral donors and multilateral development banks have established criteria which make EIA a condition for their support. In the context of a conventional EIA, human health is usually considered the exclusive responsibility of the health sector. The way the activities of other sectors affect community health is seldom fully appreciated. Health is, therefore, rarely considered the responsibility of other sectors (a "cross-cutting" issue). As a result, recommendations do not tend to address the impact of environmental change on the human health status (and the relevant safeguards). Any such recommendations would normally focus on strengthening the health services. HIA should not be carried out in isolation. It should be done in the intersectoral context of EIA and requires the input of health professionals into the actual assessment. TASK 1
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Question In your country, which agency formulates the TORs for feasibility studies for your type of project ?
Document the answer in your Table before turning to page 15.
Phase 4 Appraisal 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
Feasibility studies are commissioned from independent consultants whose task is guided by TORs. The output is a report which serves as the basis for decision making about the project, for example, whether or not a drainage component is included in an irrigation project, or whether the height of a dam and the design of its spillway are adequate. A conventional feasibility study will, in its conclusions, stress the economic viability of a project. If the Terms of Reference only prescribe economic and design criteria, then the consultants will not consider any other aspect ! Appraisal is a critical review by the appropriate government authorities of the report of the feasibility study and of the way in which it was performed. It will result in a decision whether the project is approved to be submitted for funding or not. You will look into this procedure in detail in Tasks 3 and 4. Usually, considerable resources have been spent on the preparatory work by the time a project reaches the appraisal stage. Complete rejection of a project is, therefore, rare. More commonly, individual recommendations for corrective measures are appraised and accepted, amended or rejected. TASK 1
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Question In your country, is the appraisal of proposed water resources development projects based on economic and design criteria only ? If not, which other criteria are applied ?
Indicate in column 4 of your Table, which ministry or authority is responsible for appraisal. Make a note of the criteria that are applied. Also indicate the role of the Environmental Authority, if any. Then continue on the next page.
Phase 5 Negotiations 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
The final negotiations aim to settle resource requirements within the limits of what is economically feasible and technically sound. the Ministry of Finance. Water resources development projects may be funded from the Government budget, from external sources, through loans from international development banks, or through grants from bilateral donor agencies, or by NGOs. The nature of the negotiations will depend on whether the project under review will be internally or externally funded. Local politics and inter-ministerial rivalries may influence negotiations about internally funded projects. A local politician may be instrumental in obtaining the financial support for small, local projects for the benefit of his constituency (for example, small-scale irrigation development proposed by a district development council). In negotiations with external support agencies, the policies of banks or donors will influence the process. In the case of international loans, governments may be reluctant to accept additional liabilities, for example to cover environmental or health safeguards. role in such negotiations. International politics may also play a TASK 1
They usually involve
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Question How can a ministry ensure that its interests are successfully taken into account in the allocation of resources ?
In the heading of your Table, give an indication whether your type of project is usually funded internally or externally. In column 5 of the Table, indicate whether the negotiations for your type of project are the sole responsibility of the Ministry of Finance, or whether other ministries are also involved. Then turn to the next page.
Resource allocation during the negotiations phase 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
The decision about the financial support for an internally funded project will be made by the Ministry of Finance. Ideally, other ministries that are directly affected by a development project should be consulted by the Ministry of Finance. This should lead to the allocation of funds, allowing them to play their role in the project. Mechanisms for direct consultations seldom exist. Other ministries may actively pursue the allocation of such funds to their sector, by taking the initiative to submit a memorandum on the subject to the Ministry of Finance, by bringing the issue to the agenda of the Council of Ministers (this mechanism can only be used in exceptional cases) or by bringing it to the attention of parliament. In the case of externally funded projects, more ministries may be involved in the negotiations (Foreign Affairs, Economic Affairs, Finance and the project proponent). Other ministries may argue their case to be included in the negotiating team. They should prepare a well-documented case which justifies the need for funds and presents the planned activities and the expected outputs. In negotiations with bilateral donors it helps to investigate the areas of their special interest for which they may make additional grants available. For example, timber-producing countries may be keen to support reforestation activities, oil-producing countries may have a preference for studies on chemical safety. Two more pieces of information are now needed for completion of the Table.
TASK 1
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Questions Which agency is responsible for construction in your type of project ? And, which agency is responsible for operation and maintenance ?
Include the answers to these two questions in the appropriate columns of your Table. This information completes the Table. Check your answers against the information on the next page.
Phases 6 and 7 Construction, operation and maintenance 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
Once a project reaches the construction phase, the project proponent may hand over responsibility to another ministry (for example, public works or infrastructure), to an executing agency (for example a water authority or river basin authority) or to a local authority. Monitoring will be needed, to ensure that technical specifications are adhered to, that recommendations resulting from the Environmental Impact Assessment are implemented and that health is safeguarded. The transition from construction to operation sometimes calls for passing responsibilities to another authority. Large dams may stay under the control of river basin authorities, and urban water supplies will be operated and maintained by the municipal authorities who also constructed them. Small and medium-scale irrigation schemes, however, may be turned over to the local farmer cooperative, which will have to recover the costs of operation and maintenance. In the process of handing over responsibilities, adequate institutional arrangements will have to be maintained to ensure that the interests of other sectors continue to be addressed. You now have a comprehensive idea of the project cycle for one of the key types of water resources development projects in your country. You have organized this information in your Table and this will facilitate your understanding of how your next Tasks relate to the complete process of planning, construction and operation. TASK 1
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All development projects affect health.
Key question In which of the planning phases is it crucial to give specific attention to issues of health ?
This question deserves full discussion. Now fill in the relevant boxes at the bottom of the Table: the proposed action for health protection and promotion. Then check your proposals against the information on the next page.
When should health be considered? 1. 2. 3. 4. Agree on definitions Identify types of projects Identify actors/procedures When does health matter ?
There are two crucial moments in the project cycle when human health must be considered: In the prefeasibility phase, when the TORs for the feasibility study and the EIA are formulated. Possible health implications of the project are sure to be considered if a health impact assessment is included in this phase. As a consequence, salient health issues will be discussed during appraisal. At the time of negotiating the allocation of funds. In this Phase it will be decided which health safeguards and health promotional measures will be implemented. And it will also be determined to what extent the health sector will be given a role in the next phases.
Clearly, there are other factors which will facilitate the effective consideration of human health in the planning process. For example, a policy framework which requires intersectoral collaboration is essential. Environmental policies and strategies should explicitly consider the human health aspects of environmental change caused by development. All ministries, including the Ministry of Health, should become fully aware that the quality of human health is a collective responsibility. TASK 1
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If you have documented everything as you worked through this Task, your Table will be ready for presentation. As a final control, compare your findings with the checklist on the next page. These items of information will be needed at the plenary session. This check concludes Task 1 for your most important type of project. If time permits, return to page 11 and follow the same instructions for the next most important type of water resources development project in your country.
To check your information For the Table Type of water resources development project Project proponent of your type of water resources development project Ministry/agency responsible for policy appraisal Ministry/agency responsible for formulating the TORs for the feasibility study and the associated EIA Ministry/agency responsible for the feasibility study Ministry/agency responsible for appraisal Ministry/agency responsible for resource allocation Ministry/agency responsible for project construction Agency responsible for operation and maintenance. Role of the Environment Authority Type of funding (internal or external) TASK 1
Additional information for your presentation
Horizontal/vertical dimensions
National water policy National water resources strategy EIA requirements
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– and for incorporation into the Table, when all columns have been completed: The phases when health should be included, with a justification. This concludes Task 1.
TASK 2
Rapid Health Impact Assessment A preliminary step
TASK GUIDE FOR THE TRAINING COURSE
Health Opportunities in Water Resources Development
Rapid Health Impact Assessment A preliminary step Task 2
Contents
PAGE Timetable ................................................................................ An overview ............................................................................ The purpose of Health Impact Assessment (HIA) ................. The hidden costs of development ......................................... An HIA procedure ................................................................. A rapid HIA method .............................................................. Health hazard identification .................................................. National health data for hazard identification ..................... Health risk assessment ........................................................... The scope of the impact assessment ..................................... Summary Health Impact Assessment Table .......................... Scope ...................................................................................... What community risk factors are involved ? ........................ What environmental risk factors are involved ? .................... Which institutional risk factors should be considered ? ....... Justification of your entries into the summary HIA Table .... About the field trip ................................................................. Completing the rapid HIA ..................................................... Measures for health risk management .................................. Health opportunities .............................................................. Report writing and presentation ........................................... 2 3 4 5 6 7 8 9 10 11 12 13 15 16 17 19 20 21 22 23 24 TASK 2
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Timetable A total of 22 hours and 55 minutes is available for Task 2, starting with the briefing. In addition, an eight hour field trip is an integral part of this Task. On completing the Task, two hours will be available for the presentation of group reports and discussions. A breakdown is presented below to assist you in planning your work on the Task.
Briefing on Task 2 Plenary Group work Plenary Group work Plenary Group work Plenary: briefing for field trip Preparing for field trip Field trip Plenary: field trip debriefing Group work Plenary Group work (report writing) Oral presentation, discussion, submission written reports 2 hours 3 hours 3 hours 3 hours 8 hours 3 hours 3 hours 3 hours
25 minutes 30 minutes
30 minutes 30 minutes 30 minutes
45 minutes 15 minutes
30 minutes TASK 2
30 minutes 30 minutes
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Resource material Birley, M.H. (1991). Guidelines for forecasting the vector-borne disease implications of water resources development. PEEM guidelines 2. Document WHO/ CWS/91.3. World Health Organization, Geneva. (Referred to as PEEM 2) Birley, M.H. (1995). The Health Impact Assessment of Development Projects. HMSO, UK. Birley, M.H., M. Gomes and A. Davy (1997). Health aspects of environmental assessment. Environmental Assessment Sourcebook Update (# 18, July 1997), Environment Department, World Bank, Washington DC
An overview In Task 2 you will be looking at a proposed development project. You will receive the project documents and you will carry out a fact-finding field visit to the project or to a project which features many of the characteristics generally found in areas where water resources development is about to take place. Unresolved questions will be discussed at daily plenary sessions. So bring the group’s questions with you to these sessions. There are specialists available for you to consult, do make use of them ! Do remember to write down every decision made by the group and the reasons for the decisions. In this way the group’s report is virtually written by the time you have completed the Task ! You may find it difficult to work within the time allotted to this Task, so plan it carefully.
Aim of the Task You will undertake a rapid health impact assessment. Your output will be a reasoned argument recommending whether a full health impact assessment is needed or not. In order for you to make reasoned arguments, this Task TASK 2
focuses on questions which illustrate that: Development projects can change health risks. Plans and operations can be modified to promote health. A simple method of assessment can be used. Intersectoral discussion and collaboration are possible. The Task is made up of three components: Procedure. Method. Presentation of results.
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The Letter of Remit The end-result of this Task will be a report that satisfies the letter of remit. Take a look at that letter now. How will the group tackle this request ? The question below will help you to make a start.
Question What is health impact assessment and what is its purpose ?
Discuss this question and then turn to the next page.
The purpose of Health Impact Assessment (HIA) HIA is an examination of a development project, in order to assess whether it will affect the health of a community1. Safeguards and mitigating (harm reducing) measures can then be proposed to protect the health of that community. In addition, the assessment can consider opportunities for health promotion within the community. Development projects are designed to confer benefits on a community, including improved standards of living and health. Sometimes, however, there are unintended and indirect negative effects. These may affect the environment, the socio-economic condition or the health status of some community groups. Increases in ill-health represent a hidden cost of the project which, ultimately, must be borne by the health sector. HIA provides an early warning, so that decision-makers can review and modify project plans, design and operations by negotiation.
TASK 2
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Question How could an increase in ill-health represent a hidden cost of the project ?
Discuss this question before continuing.
1) The official WHO definition is: "Health is a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity".
The hidden costs of development Ill-health caused by a development project can lead to reduced productivity, school absenteism, increased consumption of medicine and more visits to health centres. Such hidden costs can be reduced or avoided by safeguarding human health. Therefore, it is necessary to assess the potential health impacts of new development projects. Assessment also has its costs. In order to contain the costs of assessment, a rapid HIA should precede a full HIA. The rapid HIA is cheap. The full HIA is expensive, time-consuming and may not be required. The main output of the rapid assessment is a decision about whether a full assessment is needed or not. You must justify your decision.
TASK 2
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Question What procedure do you need, in order to make this decision ?
When your have discussed this, turn to the next page.
An HIA procedure 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
As you read through the following procedure, compare it with your own suggestions. The HIA procedure is similar to the Environmental Impact Assessment (EIA) procedure. Preferably, HIA should be part of EIA. Development projects are proposed by a project proponent to a regulatory authority. The proponent is a private company or government department that wants to undertake a project. For example, the agriculture department may wish to build an irrigation project. The regulatory authority is a government planning agency that regulates the kind of development that can take place, e.g. the Environmental Protection Agency. The regulatory authority decides whether a rapid health impact assessment is needed.The decision is based on a list of the types of project that require such an assessment. For example, irrigation projects beyond a certain size are usually on the list. The regulatory authority then asks the proponent to prepare a rapid health impact assessment. A letter of remit may be provided by the regulatory A decision is authority that specifies what the assessment should contain. the steps above are referred to as the screening process. A full health impact assessment is similar in content to a rapid health impact assessment, but it is guided by detailed Terms of Reference (TORs) and based on more accurate information. The process of deciding what should be in the TORs is called scoping. The full assessment may be undertaken either by private consultants or by government departments. When the assessment has been prepared it is appraised by the regulatory authority. This means that it is critically examined to decide whether it was carried out in accordance with the TORs and whether the recommendations meet a number of criteria. In this Task you will make a rapid assessment. You will consider appraisal in Tasks 3 and 4, and TOR preparation in Task 5. TASK 2
made as to whether a full health impact assessment is required, or not. All of
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Question What method would you use to make a rapid health impact assessment?
Discuss this question and then turn to the next page.
A rapid HIA method 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
There are many possible methods of assessing health impact and many questions to consider. It is helpful to divide the assessment into smaller and more manageable components. The method will involve: Identifying health hazards. Assessing health risks associated with the project. Proposing measures for health risk management. Considering opportunities for the improvement of health.
Definitions A health hazard is an agent that may cause harm. A health risk is a measure of likelihood that an identified hazard causes harm to a particular group of people at a particular time and place. A health impact is a change of health risk associated with a project.
Examples 1. The malaria parasite is a health hazard in the tropics. However, malaria may be a very small health risk in the middle of many large cities in the tropics, because the mosquitoes that transmit the infection are likely to be absent. 2. Electricity is a health hazard in the workplace. The risk of electrocution, however, depends on: An environmental factor: a live wire. A vulnerable person who does not appreciate the hazard and whose behaviour causes contact with the wire. A lack of health protection: no warning signs.
TASK 2
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Question Can you think of another example to illustrate the difference between a health hazard and a health risk ?
Discuss this question before turning to the next page.
Health hazard identification 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
Health hazards can be classified in many different ways. you use the following categories: Agents of communicable diseases. Agents/causes of non-communicable diseases. Causes of malnutrition. Causes of injury. Causes of psychosocial disorders.
It is proposed
Many examples within these categories can be found in Birley (1995).
TASK 2
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Questions What kind of health hazards are commonly associated with the kind of development project that you have been asked to consider ? How could you determine whether the development project is in a location associated with particular health hazards ?
List the health hazards associated with your project and classify them under the different categories. Discuss the second question and then turn to the next page.
National health data for hazard identification 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
You have probably decided that you need regional or district health data and a map. See how much of the following data are available to you now. The map should enable you to locate the project within a particular health district or subdistrict. It should indicate major geographical features such as rivers, forests, roads and mountains. You may also need a map indicating district health administrative boundaries and the location of health centres, towns and villages. The health data should enable you to determine some of the health hazards that are currently important in the project area. Indicators of health hazards are the disease prevalence rate (the number of disease cases divided by the total number of people at risk at one particular moment in time) or disease incidence (the number of new cases over a given period, usually a year). In order to obtain the total number of people at risk, you will require population data. You should also have access to published research findings based on limited, but more accurate surveys. You may wish to interview health officers from the district where the project is located. Plan this for your field trip. TASK 2
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Questions Does the information that is available to you inform you about the particular health hazards in the project location? Remember, your challenge is to decide what the health data will look like in the future, when the project has been developed and when it is in operation. Is there anything wrong with the data? Hint: consider under-reporting. How could you establish the reliability of the data? Hint: compare with other data or ask someone who might know.
Take time (perhaps an hour) to study the available information and then discuss these questions.
Health risk assessment 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
In order to assess the health risks you will need to: 1. Decide the scope of the assessment. This includes geographical boundaries, time boundaries and affected communities. 2. Break the assessment into its main components: Community risk factors are characteristics of a community or community group, which determine its vulnerability to a health hazard. Environmental risk factors are characteristics of the physical or social environment, which determine the level of exposure of a community to a health hazard. Institutional risk factors are the strengths and weaknesses of public and private institutions that play a role in protecting health prior to the project. 3. Identify key questions to ask about each component. TASK 2
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Questions The following questions are about the scope of the assessment. How would you determine the number of years that have to be considered by the assessment ? And how would you define the geographic boundaries for your project ?
Discuss these questions, note the answer for your report and turn to the next page.
The scope of the impact assessment 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
You need to decide what to include and what not to include in the assessment. For this decision you need to consult other line ministries and members of the public. Let’s concentrate on what to include.
You should consider: 1. The number of years into the future Some diseases spread slowly through a community and may not become a widespread cause of ill-health for many years. Others spread very quickly and are an immediate cause of ill-health. Examples: Malaria is a "fast" disease but schistosomiasis is a "slow" disease. Malnutrition can be a long term problem, leading to stunting, or a short term problem, leading to wasting.
2. The geographic boundaries The health hazards associated with a development project may move considerable distances. They may be carried by wind, water or infected hosts. Examples: Some insects that transmit disease causing agents can migrate several hundreds of kilometers downwind (See PEEM 2, Table 1-5, chapter 1, page 28 for vector flight ranges). Migrant workers carrying disease agents can come from and go to different countries. TASK 2
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You will make an assessment of the changes in health associated with your project by filling in the outline Table on the next page.
Please start by filling in the name of the project and its location. In the left column fill in upto five health hazards that you would regard as important. As you work through the following pages, you can fill in the four remaining columns. Then turn to page 13.
Summary Health Impact Assessment Table Project title Location Community group Health hazards Community risk factors Environmental risk factors Institutional risk factors (prior to the project) Expected change in health risks attributable to the project
TASK 2
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Scope (continued): Vulnerable community groups 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
There are many different community groups associated with the project. They include the people living in and around the project area, people resettled from other areas and temporary migrants. They are among the stakeholders, because they have a stake, or interest, in the project.
TASK 2
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Identify up to five different community groups that may be affected by the project. Then go on to page 14.
Scope (continued): Community groups 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
The communities that will be associated with the project during the construction and operational phases may be different from the communities already settled in the area before the start of the project.
Examples Subsistence farmers and their dependants may be displaced from the development project site. Many may be offered resettlement or re-employment on the scheme, the rest will move into uninhabited areas, or drift into town. Groups providing support services such as teachers, health workers and their dependents may move into the project area. Settlers such as cash crop farmers plus dependants may be settled on new agricultural schemes. These will include members of displaced communities and some town dwellers. Construction workers are usually males who are separated from their partners for many months or even several years. Camp followers are attracted to construction sites and include food sellers and sex workers plus their dependants. Fishing folk plus dependants may be attracted to new reservoirs. Migrant labourers will establish a circulation pattern linked to cropping and harvesting seasons.
TASK 2
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Question What characteristics of the groups in the above examples would make them vulnerable to health hazards ?
Discuss this question. Enter the name of one of the groups you identified in row 3 of the Table. You will fill in the rest of the Table as we go along, referring to this group. Then, turn to the next page.
What community risk factors are involved ? 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
The vulnerability of community groups to health hazards depends on risk factors, such as poverty, behaviour, education, occupation and immunity. Behaviour will depend partly on their knowledge and their attitudes. The community risk factors vary with each hazard and each community group.
Examples: Practising irrigated agriculture in Africa may lead to occupational exposure to schistosomiasis. Believing that malaria is caused by bad air may reduce the desire to use nets as a protection from mosquitoes. Driving a vehicle without proper training increases vulnerability to traffic injuries.
TASK 2
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Summarize the community risk factors of the group in your Table for each health hazard and enter this information in column 2. For example, if the health hazard of a farming community is the introduction of agricultural machinery, then you might write in the corresponding box of column 2: "increased risk of injury for lack of training." Now, turn to the next page.
What environmental risk factors are involved ? 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
For each of the health hazards that you have identified, the next step is to determine the nature of the environmental risk factors (both social and physical), as illustrated in the examples below. 1. Communicable diseases, e.g.: Will the development project change the environment and increase vector breeding sites ? Will the transmission season be extended ? Water-borne diseases are associated with poor domestic water supply and sanitation. Will there be changed exposure to contaminated water ? 2. Non-communicable diseases, e.g.: Will there be changed exposure to toxic chemicals ? 3. Injury, e.g.: Will there be any fast moving machinery, including vehicles ? 4. Malnutrition, e.g.: How will the project affect subsistence crops and the division of entitlements within the household ? 5. Psychosocial disorder, e.g.: Is it likely social disruption could lead to a change in the suicide rate ? Whilst some environmental risk factors are localized, others are widespread.
TASK 2
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Questions What will you need to say about environmental risk factors in your report ? What could you learn from visiting existing and similar development projects in the region ? What do the feasibility study report or other project documents tell you about the changing environment ?
Document your answers for the final report and complete the third column of the Table with a summary. For example, if the hazard is an agent of communicable disease: "decreased breeding sites for malaria vector mosquitoes." Then turn to the next page.
Which institutional risk factors should be considered ? 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
This component of the assessment asks the question: what is currently being done to protect health ? Many government and non-governmental agencies carry responsibility for protecting human health. In addition to the health services, which are the responsibility of the Ministry of Health, the areas covered by government agencies may include: Occupational safety (Ministry of Labour). Pesticide use (Ministry of Agriculture). Pollution monitoring and control (Ministry of Environment, or Environmental Protection Agency). Water supply and sanitation (Ministry of Public Works or local government). Ministries or agencies responsible for health-related issues can be judged in terms of: Capacity, i.e. the resources available in terms of staff and equipment. Capability, i.e. the knowledge, skills and experience of the staff and the procedural framework that allows them to operate as efficiently as possible. Jurisdiction, i.e. their power to regulate or control a particular aspect of the project. These constitute the institutional risk factors Jurisdiction is important because in projects for the development of natural resources there may be areas where institutional responsibility and accountability are lacking. For example, the occupational safety of farmers may not be the responsibility of the Ministry of Labour, because it is only concerned with labour conditions in industry. The Ministry of Agriculture will support farmers' well-being in terms of income, but not in terms of safety and the Ministry of Health may not have occupational safety specified in its remit. Who, then, is responsible ? The existing institutional risk factors provide an indicator for the ability of health protection agencies to cope with the present and future demands in the project area. TASK 2
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Question What do the various agencies concerned do at present to protect the health of your community group from the health hazards you have identified ?
Document your answer, then turn to the next page.
Which institutional risk factors should be considered ? (continued) 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
There are important variations in the quality and coverage of delivery of curative services, preventive services and health promotion. The following examples illustrate some of the problems which you will need to consider for your report.
Examples Drug supplies for rural health centres are often irregular and insufficient. The ability to diagnose the cause of ill-health accurately is limited by the level of training of health personnel and the diagnostic tools available. Health surveillance: health centres usually supply monthly statistical summaries to district headquarters. These summaries are often inaccurate, as the purpose for collecting the data is seldom made clear to the staff. National health statistics are published annually but may be several years out-of-date. National disease control organisations are often under-funded and city-based. Their vehicles may not be functional when they are needed. Local disease control may be the responsibility of a primary health care system that lacks the resources, staff and expertise to concentrate on more than one disease. Health education units may focus on family planning. National planning procedures for considering health impact and for acting on information generated by impact assessment may not yet be well developed. There may be no communication between the development planners, the local health service, or the local public works department responsible for water supply and sanitation. Project planners may be relying on the health sector to deal with health problems and may not be giving these problems any attention themselves. TASK 2
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For each of the health hazards you identified, write notes on these factors for your report and include a summary in column 4 of the Table. For example: "limited stocks of anti-malarial drugs in health clinics, no preventive measures in operation." Then turn to the next page.
Justification of your entries into the summary HIA Table 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
You have examined the three main components of health impact assessment. Your notes should justify the summary points made in the Table. The evi-
dence listed in your notes will have different degrees of validity, such as: Calculable. Estimable. Definite but not measurable. Speculative. Anecdotal. Hypothetical. Try to be clear about each of them.
TASK 2
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Document the justifications for your final report. The remainder of the Task will be completed after your field trip. There will be a briefing about the field trip. Turn to the next page for some general information.
About the field trip 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
The aims of the field trip are: To assist you to understand the concept of a feasibility study and visualize the issues to look for in an area where a project is proposed. To observe features of the community, environment and health services, which may be relevant to the Health Impact Assessment. To collect data from key informants representing the health service, the community, the irrigation department and others as appropriate. The methods used will be interviews with key informants and direct observations. The key informants include both officials and members of the community. Each interview will last 20-30 minutes. Key informants are likely to A compresent biased views based on their own perspective and interests.
parison will be necessary between what different key informants tell you. Remember that the community may be culturally different from your own. Aspects of their culture may affect their vulnerability.
TASK 2
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Now make a list of questions to ask on the field trip that will help to fill some of the gaps in your information. If you have time before the field trip you should do some background reading in the library as another way of filling the gaps.
Completing the rapid HIA 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
The changes in health risk associated with each of the hazards have to be recorded in the last column. These are the changes associated with the project that are expected if no additional safeguards are included. Conclusions should be supported by facts and observations. For example, you may conclude that the project will increase the number of malaria mosquito vectors, make no provision for prevention and introduce susceptible people into the project area. increase for those susceptible people. As a result, the risk of malaria will
TASK 2
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Use the results of the field visit, plenary discussions, further reading and consultation with local experts to complete and justify your conclusions. Consider and list possible safeguards and mitigating measures that may be included in the project to avoid the increased risks listed in your Table and to improve the health of your community group. Then, turn to the next page.
Measures for health risk management 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
Do any of the following interventions apply to your project? Irrigation and drainage channel design and maintenance: The purpose is to improve water flow, prevent leakage and stagnation and prevent vector breeding. This requires action during the design, operation and maintenance phases. Maintenance is cheap if the community participates, but it may be difficult to motivate the community. Sanitation: The purpose is to ensure safe excreta disposal, prevent contamination of open water and prevent filariasis vector breeding and fly breeding. This requires action during the construction stage. Proper storage of chemicals and training of workers: The purpose is to prevent poisoning. This requires action during the construction and operation phases. Stores for pesticides and other chemicals can be constructed cheaply. Improved drug distribution: The purpose is to cure individuals who become clinically ill. It may be difficult to recruit trained staff and to maintain drug supplies. Settlement location: The purpose is to reduce exposure to localized health hazards. Action is required at the design phase. This can be cheap if government owns the land and socially acceptable if distance between the settlement and the workplace is not excessive. TASK 2
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Sort your proposed interventions into the following categories: Cheap or expensive. Easy or difficult. Socially acceptable or not acceptable. Maintenance cheap or expensive. Then turn to the next page.
Health opportunities 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
You have taken the first step towards safeguarding the health of the affected communities. The health of these communities could, however, also be further improved. Please consider whether additional aspects of design could be modified or added, that would substantially improve the community health status. This approach is referred to as promoting health opportunities to distinguish it from health risk management. A classic example is the incorporation of a drinking water supply component in an irrigation project. This may not have been included in the original design and the community may have to rely on unsafe sources of water. Housing improvement, such as screening of windows to keep out insects, is another example.
TASK 2
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List the health opportunities that you can identify for your project. Finally, decide whether a full HIA is needed and justify your decision.
Report writing and presentation 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
To complete Task 2 your group now needs to prepare its written report and plan its oral presentation for the plenary session. You should be able to do this by reassembling the notes you have been making. Try to limit your report to a maximum length of seven pages. The oral presentation should only contain three main messages, not the whole report. Divide the task among the members of the group. Title Names of writers Date 1. Introduction (one paragraph). Who is the assessment for and what are they expected to do with it? 2. List of community groups affected by the project. Description of the community selected for detailed analysis. 3. Summary Table listing all the hazards you have considered and the conclusions concerning risk (one page). 4. Explanation of the conclusions presented in the Summary Table. Under each hazard use the following subheadings: a. Community risk factors (one paragraph). b. Environmental risk factors (one paragraph). c. Institutional risk factors (one paragraph). remain the same and how this conclusion was reached (one paragraph). 5. Analysis of health risk management measures and health opportunities. Distinguish between planning and operation stages and consider whether each measure is cheap/expensive, easy/difficult, and socially acceptable/not acceptable). Headings include: a. The project design. b. Environmental management measures. c. Strengthening of health services (what is inadequate and what can realistically be improved?). d. Monitoring and surveillance activities (how will the data be used ?). 6. Recommendation whether a full HIA is needed with a convincing justification. d. Conclusion: whether the health risk will increase, decrease or TASK 2
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If any of your questions remain partly unanswered, bring these to the next plenary session. You can judge your Report and Presentation by using the checklist on the next page. This concludes Task 2.
Basis for evaluating reports 1. 2. 3. 4. 5. 6. Procedure Hazard identification Risk assessment Risk management Health opportunities Presentation
Your written reports will be judged according to the following criteria: Did the introduction state who the report was for and what they were expected to do with it ? Was the report concise and to the point ? Was the Summary Table completed as intended ? Was a firm conclusion reached whether a full HIA is needed ? Was the conclusion supported by convincing justifications ? Did the justifications cover all components ? Were facts and assumptions distinguished and was missing information noted ? Were realistic health risk management measures and opportunities proposed and justified in relation to health risks as well as to costs, acceptability and ease ? TASK 2
PAGE Your oral presentations will be judged according to the following criteria: Visual materials (overhead transparencies, flip chart sheet) contain no more than 15 words per sheet/transparency in large writing. The presenter faces the audience and speaks loudly and clearly. More than one member of the group is involved in the presentation. Only the main points are discussed.
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TASK 3
Appraisal of a Health Impact Assessment Report Assessment Procedure and Conclusions
TASK GUIDE FOR THE TRAINING COURSE
Health Opportunities in Water Resources Development
Appraisal of a Health Impact Assessment Report Assessment procedure and conclusions Task 3
Contents Timetable ............................................................................... An overview ........................................................................... Introduction ........................................................................... Terms of Reference ................................................................ Report objectivity .................................................................. Conflict of interest ................................................................. Timing .................................................................................... Budgeting .............................................................................. Access to information ............................................................ Procedural rigour ................................................................... Health hazard identification ................................................. Vulnerable communities ........................................................ Community risk factors ......................................................... Environmental risk factors ..................................................... Institutional risk factors ......................................................... The overall health risk assessment ........................................ Conclusions ............................................................................ Justification and evidence base ............................................. Outcome of the first part of the appraisal ............................
PAGE 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Timetable A total of eleven hours and thirty minutes is available for Task 3, starting with the briefing.
Briefing on Task 3 Group work 3 hours
30 minutes 30 minutes
Plenary session Group work Plenary session Group work 3 hours 3 hours
30 minutes
30 minutes 30 minutes
Plenary session
1 hour
20 minutes
Group presentations (10 minutes of presentation followed by 10 minutes of discussion per group)
Resource material Tiffen, M. (1991). Guidelines for the incorporation of health safeguards into irrigation projects through intersectoral cooperation. PEEM Guidelines 1. Document WHO/CWS/91.2. World Health Organization, Geneva. (Referred to as PEEM 1) Birley, M.H. (1991). Guidelines for forecasting the vector-borne disease implications of water resources development. PEEM guidelines 2. Document WHO/ CWS/91.3. World Health Organization, Geneva. (Referred to as PEEM 2) Birley, M.H. (1995). The Health Impact Assessment of Development Projects. HMSO, UK. Birley, M.H., M. Gomes and A. Davy (1997). Health aspects of environmental assessment. Environmental Assessment Sourcebook Update (# 18, July 1997), Environment Department, World Bank, Washington DC TASK 3
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An overview Aim of the Task The aim of this Task (and the next) is for you to learn how to appraise a Health Impact Assessment (HIA) which has been carried out in association with an Environmental Impact Assessment (EIA). The outcome of the appraisal will be one of the following decisions: Reject the HIA as inadequate. Require that the HIA be improved. Accept the HIA with minor corrections. Accept the HIA as it stands. Your decision should be accompanied by an adequate justification.
Output The output of Tasks 3 and 4 will be an appraisal report. Task 3 focuses on the appraisal of the assessment procedure and the conclusions drawn on the basis of the summary impact assessment. At the end of this Task, you will present a brief oral summary of your findings so far. At that point in the appraisal you will have to decide whether the quality of the assessment procedure and the conclusions warrant appraising the recommendations. Task 4 addresses the appraisal of the recommended measures for health risk management and health promotion. Each step in both Tasks ends with the requirement to write a paragraph for the appraisal report. In this way the report is written as the group goes along. TASK 3
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Questions What is meant by an appraisal ? What is the purpose of appraising a Health Impact Assessment ?
Discuss these questions, then turn to the next page.
Introduction Take a look again at the letter of remit which the group has received. Appraisal is the quality assurance component in the HIA procedures. Its objective is to establish and maintain independent quality standards. The HIA report needs to be appraised against the Terms of Reference (TOR) that were given to the consultant(s). TOR may be found in an annex to the reports of the HIA, EIA and/or feasibility study. In order to reach the objectives of this Task you will need to carry out the sequence of activities listed below: 1. Decide whether the assessment conforms to the original TOR and whether these were adequate. 2. Verify the objectivity of the assessment and identify any important biases or unforeseen obstacles. 3. Decide whether the assessment procedure allowed for the data and their interpretation to be sufficiently comprehensive and credible to support the conclusions. 4. Decide whether the conclusions follow logically from the data collected, and whether they are accurate, comprehensive and probable. 5. Write the section of the appraisal report dealing with the assessment procedure and conclusions. You will need to consider and agree on criteria for your appraisal as you come to each step in turn. TASK 3
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If you can find one or more sets of TOR, please read them carefully. List any items that specifically refer to or are relevant to health. Then turn to the next page.
Terms of Reference 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
At the end of this Task we will take another look at the list you have just produced. You have familiarized yourselves with the available TOR for the feasibility study, environmental impact assessment and possibly health impact assessment. PEEM 1 explains why it is crucially important to include human health as a specific item in the TOR for a feasibility study/environmental impact assessment. In many instances, it is even preferable to formulate TOR for a distinct HIA in the context of an EIA. In relation to the questions below, you need to identify appropriate criteria for judging the adequacy of the TOR. For example, in terms of scope they may be too general (just a reference to "health" in a checklist) or too restrictive (limited to a small number of specific health hazards or even a single disease).
TASK 3
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Questions In your judgement, were the TOR adequate for a meaningful HIA ? Which items in the TOR are addressed in the HIA report and which items are not ?
Record your answers for your appraisal report. Then turn to the next page.
Report objectivity 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
A good report should be objective. Even with adequate Terms of Reference as the starting point for the HIA, objectivity can be compromised by: Consultant's conflict of interest. Inappropriate timing. Inadequate budgeting. Consultant's lack of expertise. Lack of access to information. Analysis of each of these problems will help you to make a reasoned judgement of the objectivity of the HIA report that can be entered into your appraisal.
TASK 3
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Question How could the above problems affect the objectivity of an HIA report ?
Document your answers and use them to compare your expectations with your judgement of how each of these potential problems influenced the HIA report. Then go on to the next page.
Conflict of interest 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
Consultants depend on their clients and may not want to be too critical of their clients' projects. The issue of client relationship is most sensitive when the consultant is paid by the project proponent. into the project by order of the funding agency. It is less prominent when the consultant is paid by the funding agency and the assessment is included
Example
UN technical cooperation agencies
Multilateral and bilateral donors
Irrigation Development Authority
Health consultant
Consulting engineering firm
TASK 3
PAGE Agencies involved in the planning of an irrigation project and the most commonly encountered position of a health impact assessment consultant.
7
Question In your project, which agency was the client of the consultant for the HIA ?
Construct a diagram to indicate the relationships in your project. Write a paragraph for the appraisal report with your judgement of the level of independence of the consultant's assessment. Then, turn to page 8.
Timing 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
If an HIA is requested after the concrete has been poured, the analyses will be limited to questions related to the operational phase of a project. As a consequence, its outcome will focus on remedial rather than preventive health measures. More optimistically, if the assessment is initiated during the general planning surveys or feasibility studies of a project, then there is an opportunity to determine the most cost-effective way to reach both the economic and the health objectives during the entire project cycle. The timing of an HIA in relation to other planning and design activities in the project cycle crucially determines its value. Often this is out of the consultant's control. Inappropriate timing may easily render the entire study useless. In many instances, timing in relation to cyclical events is another essential determinant of the value of an assessment. For example, the seasonality of disease transmission needs to be considered when planning the direct collection of field data.
Questions When was the HIA carried out in relation to the rest of the planning process? Were there opportunities for the consultant to interact with the planners in the early stages of planning? How much time do you estimate the consultant spent on the project site and how much interaction could the consultant realistically have had with planners, other consultants and the community ? Planning calendar for the Project Year (in quarters) Surveys Feasibility study Project preparation and final design Construction Operation EIA HIA TASK 3
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8
Fill in the above bar chart, indicating when the HIA was probably undertaken. Write a paragraph for the appraisal report. Indicate any reservations about the HIA due to problems with the appropriateness of its timing and the time available for interactions with the planners. Then, turn to the next page.
Budgeting 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
Next, consider whether sufficient money was spent on the HIA for your project. Poor budgeting can have important repercussions for the objectivity of the HIA report. The cost of an HIA ought to be a reasonable percentage of the total planning cost of the project. This is illustrated by the example below:
Construction and planning costs of the Jubba River dam, Somalia Construction of concrete dam, irrigation and flood control feasibility and final design socioeconomic, environment and health impact assessment health and water quality impact assessment US$ 200,000 TASK 3
US$ US$
100,000,000 of which 15,000,000 of which
US$
3,500,000 of which
PAGE
9 Questions US$ or local currency What are the expected construction costs of the project whose HIA you are appraising? What was the cost of the feasibility study and final design? What was the cost of the HIA? (Base your estimate on the number of staff, time, salaries, expenses) What was the cost of the HIA as a percentage of the total planning cost? ................................... ................................... ................................... ...................................
Considering its relative cost, was the HIA adequately funded ?
Write a paragraph in the appraisal report on the adequacy of the budget for the HIA. Then proceed to the next page.
Access to information 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
How can you be sure that the information in the HIA report is sufficiently comprehensive and credible ? There may be many obstacles to obtaining information. Informants from different ministries may have been reluctant to share reports and data with the consultant. There may have been prejudices, for instance associated with gender or race. Communication may have been hampered by language barriers. Local communities may have provided the consultant with information reflecting their expectations rather than reality. The issue of reliability of data will be addressed in the next section on procedural rigour. In the HIA report itself, you may find direct or indirect indications of lack of access to information. You may also know from your own experience of sources of information that have been missed.
TASK 3
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Questions Does the HIA report indicate that existing reports from relevant ministries or other authorities were obtained and cited ? Information was cross-checked ? Local consultants were employed ? A wide range of key informants were interviewed ? All sections of the community were consulted and considered ?
Write a paragraph in your report about the comprehensiveness and credibility of the information obtained, before going on to the next page.
Procedural rigour 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
Whatever health impact assessment method the consultant used, it must have sufficient breadth and depth. In one form or another, it needs to include information on the components considered in Task 2: (i) Health hazards. (ii) Vulnerable communities. (iii) Community risk factors. (iv) Environmental risk factors. (v) Institutional risk factors. (vi) The overall health risk assessment, with conclusions. (vii) Recommended measures for health risk management and health promotion. Points (i) to (vi) are individually covered in the following pages. The technical adequacy, social acceptability and economic feasibility of the recommended measures will be appraised in the next Task.
TASK 3
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Examine the structure of the HIA report to ensure all essential components are covered and note down your observations. Then turn to the next page, for a detailed appraisal of the first component.
Health hazard identification 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
The health hazards associated with a development project can be grouped conveniently as follows: Agents of communicable diseases. Agents/causes of non-communicable diseases. Causes of malnutrition. Causes of injury. Causes of psychosocial disorders. It is likely that examples from each of these categories can be identified for any development project.
TASK 3
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Questions What health hazards are identified in the HIA report ? Consider the data used to support the identification of the most important health hazards. Are they recent ? Are they reliable ? In your judgement, do you consider that the consultant identified all the important health hazards that could be associated with the project ?
Write a paragraph for the appraisal report on the adequacy of health hazard identification. Then turn to the next page.
Vulnerable communities 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
Vulnerable communities include any community group that is affected by the project. Development projects change the size and composition of the community through changed birth and death rates, displacement, resettlement and/or migration. The change in composition may be reflected in the gender balance, age composition and/or ethnicity. The health risk management recommendations that will be appraised in the next Task need to take these changes into account.
TASK 3
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Questions Did the report identify all the vulnerable communities ? Were current size and composition of these communities determined and was impact of the project on these characteristics estimated ?
Write a paragraph for the appraisal report as to whether the issue of vulnerable communities was adequately handled. Then proceed to the next page.
Community risk factors 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
Some community groups are more vulnerable to specific health hazards because of their initial health or immune status, or because of their occupation, poverty, educational status, age or gender.
TASK 3
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Questions Does the report identify how different community groups would be affected by the project ? Does the report identify the risk factors associated with each vulnerable community group ?
Write a paragraph for the appraisal report on the adequacy with which community risk factors were discussed. Then move on to the next page.
Environmental risk factors 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
The project may create new hazardous environments or modify existing ones. Examples may include faulty chemical storage facilities, contaminated drinking water, new habitats promoting disease vectors, industrial sites as sources of pollution, unguarded machinery, contaminated food supplies, poor siting of human settlements, social environments conducive to promiscuity, alcoholism and violence. The associated environmental risk factors may vary geographically and temporally. You will find more examples in the resource materials listed at the beginning of the Task.
Geographical changes The effect of physical changes can extend over considerable distances away from the project, especially downstream or downwind. The construction of a dam, for example, may affect the flood patterns downstream, with repercussions for agricultural production and nutritional status.
Temporal changes Exposure to health hazards can vary seasonally and over a longer time scale. Many vector-borne diseases, such as malaria, constitute a seasonal health risk with transmission associated with certain climatic conditions (see also Task 2, page 11). TASK 3
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Questions Does the report describe the geographical distribution of health risks ? In this connection, does it discuss downstream effects ? Does it identify potential zones of transmission or exposure ? Does the report give details of the seasonal distribution of health risks ? Does the report distinguish the risk factors in construction, early operation (first five years) and late operation (5-20 years) ?
Write a paragraph for the appraisal report commenting on the adequacy of the predictions regarding exposure to environmental risk factors, taking into account geographical and temporal variation. Then turn to page 16.
Institutional risk factors 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
Many different institutions have a responsibility for health.
In the specific
context of your project, a number of government and non-governmental institutions are concerned with health. Their capacity, capability and jurisdiction is variable.
TASK 3
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Questions Does the report identify all the relevant institutions ? Does it identify their strengths and weaknesses ? Does the report identify needs for extra health services that could arise from the project ?
Write a paragraph for the appraisal report on the adequacy of the description of existing services. Then turn to the next page.
The overall health risk assessment 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
The one-but-last-step in the health risk assessment procedure is a synthesis of the findings for each health hazard into combined health risk factors. These findings need to be weighted for their relative importance. Some risk factors related to an individual hazard may re-inforce one another (for example, migration of non-immune resettlers into an area where irrigation development has boosted malaria vector populations), others may cancel each other out (the risk of injury due to the introduction of agricultural machinery will be reduced if there is sufficient capacity within the agricultural extension services to launch an effective training programme). A correct synthesis will depend on the capacity of the consultant to weight the various risk factors attributed to each hazard and to consider the ways in which these risks may interact in an integrated picture.
TASK 3
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Questions Does the report provide sound arguments to support the synthesis of risk factors for each hazard ? Is the report transparent about the weighting and integration of risk factors for each hazard ? And, does the overall health risk assessment provide a solid basis for accurate conclusions concerning the health impact of the project ?
Write a paragraph on the adequacy of the final synthesis of health risk factors. Next, examine the conclusions of the HIA report and consider the criteria that can be applied to appraise whether the results of overall health risk assessment have been translated adequately into conclusions. Then turn to the next page.
Conclusions 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
The HIA report should acknowledge that different community groups will be affected in different ways. It should present changes in health risks for each community group whose health status will be significantly affected by the proposed project. The report should also acknowledge that risks will vary for each community group during the different project phases. The final conclusions should sum up the risks and rank them for each project phase.
Examples During the construction phase of an agricultural development project the construction workforce and the camp followers will be especially exposed to sexually transmitted infections (STIs). It is expected that during the operational phase this community group will have dispersed and will have been replaced by a community of intended project beneficiaries. The stable family structure of this farming community will result in a reduced exposure to STIs. They may, however, be especially exposed to agricultural pesticide poisoning. In large projects, temporary health facilities may be constructed for ex-patriate workers. The availability of these facilities will counterbalance certain health risks identified to affect the project beneficiaries during the operational phase, provided they can be kept operational by the local authorities. In addition to specific health risks, the conclusions should also highlight the health benefits and opportunities for health promotion that are associated with each project phase. TASK 3
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Question To what extent have the conclusions been correctly justified and are they based on solid evidence ?
Discuss this question and formulate your observations for your report. Then turn to the next page.
Justification and evidence base In the earlier part of your appraisal, you considered whether the assessment of 1. 2. 3. 4. Terms of Reference Objectivity Procedural rigour Conclusions
community risk factors, environmental risk factors and institutional risk factors was sufficiently justified. To complete your appraisal, you need to make sure that the process of drawing up final conclusions is equally justified and based on solid evidence. Even if the procedure up to this point has been flawless, this final step may still allow bias, prejudice or convention to creep in. Sound statistics, reference to experience in previous projects (with a clear indication of the similarities and the differences) and a list of assumptions made will permit you to appraise this part of the procedure. This is the moment to test how variations in the assumptions affect the final conclusions. If variations in the assumptions do not significantly alter the conclusions, then they can be considered robust. You will revisit the assumptions at the end of Task 4 for a sensitivity analysis of the overall assessment, including its recommendations.
TASK 3
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Questions Does the report clearly list the assumptions made in reaching its conclusions ? Are the assumptions reasonable and to what extent will changes in the assumptions affect the conclusions ?
Now, write a paragraph on the robustness of the conclusions. Then turn to the last page.
Outcome of the first part of the appraisal Go back to the list you made at the beginning of this Task (page 3) and look at the items you originally thought most important for the TOR. How does your original list look now, after completion of this Task? You may now summarize your findings concerning the assessment procedure and conclusions in a final paragraph in the appraisal report. Don't forget to justify the outcome of your appraisal. Also, prepare a preliminary recommendation concerning the rejection, the need for improvement or the acceptance of the HIA based on the appraisal of procedure and conclusions. Should you have encountered major flaws that warrant rejection or the need for a major improvement of the HIA, then there would obviously be little point in appraising the consultant's recommendations.
TASK 3
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Summarize your appraisal report for a brief presentation of not more than ten minutes in the next plenary session. This concludes Task 3.
TASK 4
Appraisal of a Health Impact Assessment Report Technical, Social and Economic Aspects of Recommended Measures
TASK GUIDE FOR THE TRAINING COURSE
Health Opportunities in Water Resources Development
Appraisal of a Health Impact Assessment Report Technical, Social and Economic Aspects of Recommended Measures Task 4
Contents
PAGE Timetable ............................................................................... An overview ........................................................................... Health risk management and health promotion .................. Table 1: Proforma for Summary of Recommendations ........ Design .................................................................................... Operation and maintenance ................................................. Community characteristics .................................................... Knowledge, attitude and practice ......................................... Participatory action ............................................................... Economic evaluation ............................................................. Cost estimation ...................................................................... Affordability ........................................................................... Value for money .................................................................... Effectiveness indicators ......................................................... The cost of risk management versus the cost of health services .......................................... Synthesis of your findings ..................................................... 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Timetable A total of eleven hours and thirty minutes is available for Task 4, starting with the briefing.
Briefing on Task 4 Group work Plenary session Group work Plenary session Group work Plenary session 3 hours 2 hours 3 hours 3 hours
30 minutes 30 minutes 30 minutes 30 minutes 30 minutes
Group presentations (10 minutes of presentation followed by 20 minutes of discussion per group)
Resource material Jobin, W.R. 1999. New York Oomen, J.M., de Wolf, J. and Jobin, W.R. 1990. Health and Irrigation: Incorporation of disease control measures in irrigation, a multi-faceted task in design, construction, operation. ILRI publication 45, Volumes 1 and 2, International Institute for Land Reclamation and Improvement, Wageningen, Netherlands Phillips, M. , Mills, A., and Dye, C., 1993. Guidelines for Cost-effectiveness TASK 4
Dams and disease: ecological design and health impacts of E & FN Spon, London / Routledge,
large dams, canals and irrigation systems.
PAGE
2
Analysis of Vector Control Programmes. PEEM guidelines 3. Document WHO/ CWS/93.4. World Health Organization, Geneva (referred to as PEEM 3). WHO, 1982. Environmental Management for Mosquito Control, with special reference to malaria. WHO Offset Publication 66, World Health Organization, Geneva
Task 4 An overview Aim of the task In the previous Task you appraised the assessment procedure and conclusions, and reached one of four positions on these: 1. Acceptable. 2. Requires minor revision. 3. Requires major revision. 4. Unacceptable. In the current Task you will learn how to appraise the recommendations made in a Health Impact Assessment (HIA) report by considering the technical, social and economic aspects. In principle, you will only undertake this part of the appraisal, if the HIA procedure and the conclusions in the HIA report have been found to provide reliable evidence on which to base recommendations. Take a look again at the letter of remit you have received. Also, consider where you are in the comprehensive development framework that you prepared in Task 1. It will help you to anticipate the needs of the next phase in the project cycle at this stage of the appraisal. TASK 4
PAGE
Output The output of Tasks 3 and 4 together will be an appraisal report. The first part of this report was formulated as you worked on Task 3 and should therefore be ready by now, possibly with some adjustments resulting from the plenary discussions. In Task 4 you follow the same procedure (write a paragraph on completing each step in the Task). This time, however, you should address the recommended measures for health risk management and health promotion.
3
Questions HIA reports should result in recommendations for health safeguards, mitigating measures and health promotional measures. How would you distinguish between these three ? Anticipating the needs of the next phase in the project cycle, which of the three aspects, mentioned above, should be emphasized ?
Discuss these questions, then turn to the next page.
Health Risk Management and Health Promotion Too often, HIA reports simply state that "the project is acceptable if health services are improved". Such a general recommendation provides no useful information for planners to improve the project design or operation. It places the responsibility for dealing with the additional burden of disease entirely on the health services. Specific recommendations should address the health risks that have been identified, for a particular project phase and for a particular community or community group: Health safeguards divert the risk entirely and prevent a negative health impact to occur. Mitigating measures minimize, to the extent possible, any predicted adverse health effects. Health promotional measures add value to a project by making use of health opportunities offered by the project. The recommendations that achieve these outcomes may be: Technical design and operational changes. Regulations. Economic tools (subsidies, taxes, incentives). Strengthening of health services. The first three types of recommendations are unlikely to be sufficient, so strengthening of health services will normally be required, taking into account the new community health status that is forecast. In this part of the appraisal you will pay a great deal of attention to the economic evaluation of recommended measures, in anticipation of the next phase in the project cycle, when negotiations will take place. In these negotiations economic arguments are likely to carry a lot of weight. TASK 4
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Now, in general terms, appraise the level to which recommendations for the strengthening of health services take into account the impact of project development and the effect of recommended risk management and promotional measures. Write a paragraph for your report. Then, list the recommendations made in the HIA report in the first row of the Table on the next page. The Table will facilitate a step-by-step appraisal of each recommendation. Then, proceed to page 5 and start the appraisal exercise.
Table 1 Summary of recommendations Expand this Table for recommended measures as appropriate. The next sections of the guide elaborate on the issues of technical adequacy, social acceptability and economic soundness
Recommendation
1.
2.
3.
Safeguard or health promotional measure
Project stage
Community addressed TASK 4
Technical adequacy
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5
Social acceptability
Economic soundness
Design 1. 2. 3. Technical adequacy Social acceptability Economic soundness
The technical adequacy of the recommendations depends on: Design. Operation and maintenance implications. Geo-physical setting. Climate. Local availability of materials. For example, cement lining of irrigation canals can prevent seepage and the formation of stagnant pools where mosquito vectors breed. Cement may, however, crack if it is of low quality or stressed by seismic activity. Experience has shown that mosquito breeding sites resulting from cracked cement-lined canals are more localized and more limited in number, but their average surface area tends to be larger. Some species of Anopheles mosquitoes prefer to breed in rock pools that appear in rivers during the dry season or in canals during periods when irrigation is interrrupted. Flushing small rivers and canals has proven effective in eliminating vector breeding. Managing malaria risks in this way is, however, only possible in areas where there is enough water available even in the dry season. The design of flushing devices (e.g. automatic syphons) should therefore allow for an optimal flushing schedule within the limitations of water availability. TASK 4
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Questions Is the design of the proposed risk management and/or health promotional measures technically adequate ? Could there be other reasons why the technical adequacy of the design might be doubtful ?
Write a paragraph on the technical adequacy of the design of the recommended measure you are appraising and add a brief note in the relevant box of the summary table. Then go on to the next page.
Operation and maintenance 1. 2. 3. Technical adequacy Social acceptability Economic soundness
The design of recommended measures may be excellent, but their performance can still be jeopardized by poor operation and maintenance or poor estimation of resources needed.
Examples Water contact patterns are an important behavioural determinant of infections with water-based parasites such as schistosomal worms. Electric pumps for irrigation water distribution can reduce water contact and, thereby, infection risk. They depend, however, on a reliable supply of electricity. An unreliable supply of piped drinking water can lead to domestic storage in recipients that support breeding of Aedes mosquitoes that transmit the dengue virus. Ambulances can strengthen health services, but only if properly maintained and if fuel availability is guaranteed.
TASK 4
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Question Are the recommendations for operation and maintenance adequate ?
Write a paragraph on the technical adequacy of the operation and maintenance aspects of the measure under appraisal and add a brief note in the relevant box of the summary table. Then go on to the next page.
Community characteristics 1. 2. 3. Technical adequacy Social acceptability Economic soundness
The technical adequacy of measures recommended in the HIA report becomes irrelevant if the measures meet with resistance from the local or affected communities. Community characteristics may change as a result of the project. The acceptance level for certain interventions may be different in a changed community.
Example Residual spraying of houses for vector control has suffered as much from decreasing social acceptance as it has from technical problems such as insecticide resistance. Improvement of the socio-economic status of the community will result in increased buying power including access to health services, medicine and personal protection measures.
TASK 4
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Question Were demographic changes explicitly considered in the formulation of HIA recommendations ?
Write a paragraph on your findings in your appraisal report. Then, turn to the next page.
Knowledge, attitude, practice and belief 1. 2. 3. Technical adequacy Social acceptability Economic soundness
A first indicator of whether or not the consultant has considered social acceptability in the formulation of his recommendations is the performance of a Knowledge, Attitude and Practice (KAP) study of affected communities as part of the HIA. Based on the information resulting from KAP studies and on demographic forecasting, specific social issues can be tackled in detail, and the social acceptibility of recommended measures can be appraised.
Knowledge Did the consultant investigate the knowledge of the community when designing certain measures ? For instance, there is little point in relying on the labelling of pesticides as a safeguard against poisoning if the illiteracy rate in a community is high.
Attitude In rural communities in many parts of the world, the attitude towards sexuality hampers open discussions on sexual issues. This reduces, for example, the effectiveness of promoting the use of condoms among groups at risk from sexually transmitted infections (STIs). TASK 4
Practice Agricultural practices may be based on deep-rooted traditions. They may also imply important health risks. To change these practices with the objective of reducing exposure to health hazards, it is essential to understand their background. Also, the identity of the person proposing the changes is important: an agricultural extension worker is likely to have more credibility with local farmers than the community health worker when it comes to recommending changed agricultural practices aimed to reduce health risks.
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Belief Religious convictions may hamper the impact of health safeguards and health promotional measures. For certain religious groups, for example, western medicine is not compatible with their beliefs. Strengthening of health services along the principles of western medicine will not have significant impact as long as this belief persists.
Questions Was a full KAP study of affected communities performed as part of the HIA and was the outcome used in support of the design of recommended measures ?
Add your observations and findings as a paragraph to your report. Then proceed to page 10.
Participatory action 1. 2. 3. Technical adequacy Social acceptability Economic soundness
Affected communities should be involved in a health impact assessment. This can have a beneficial effect on the sense of ownership and on social acceptability of measures that are subsequently recommended for health protection and promotion. Designing measures in such a way that the community can also participate in their implementation will contribute to the success and the sustainability of the interventions. It is good practice to involve an anthropologist or cultural geographer in the process to ensure a professional approach to participatory action. Community members can play an important role not only in the implementation of recommended measures, but also in the monitoring of health risk indicators during the construction and early operation phases.
TASK 4
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Questions Was there an input from appropriate social scientists into the development of recommended measures ? Are the recommended measures participatory in nature ?
Write a paragraph about participatory action as part of your appraisal report. Now consolidate your observations on social acceptability in a final statement and add an abbreviated note in the summary table. Then proceed to the next page.
Economic evaluation 1. 2. 3. Technical adequacy Social acceptability Economic soundness
Economics is the third aspect that needs attention in the appraisal of recommended measures. The HIA report should contain a section in which the economic evaluation of the recommended measures is properly presented. Appraisal of the economic aspects will help ensure that The cost estimate of recommended measures is complete. The recommended measures are affordable. The most cost-effective option has been chosen and there are no hidden costs. The costs of the recommended measures are significantly offset by the cost that would have been incurred to the health sector in case no measures were taken. The next pages will guide you through a brief appraisal of the economic evaluation contained in the HIA report. You would need the help of a health economist to look at it in more detail. For a comprehensive economic evaluation of the various options for health risk management measures, cost-effectiveness analysis is the preferred method. Other sectors, such as the irrigation department in the agriculture sector, will use cost-benefit analysis in their project planning. In that case the benefit is always expressed in monetary terms. In the case of measures with dual (health and agricultural) benefits, it is acceptable to make the two methods compatible by estimating their agricultural benefits in monetary terms and to deduct this amount from the costs incurred by the measures, before completing the cost-effectiveness analysis. For more information refer to PEEM 3. TASK 4
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Questions Does the HIA report include an economic evaluation of the recommended measures ? Which of the above points is covered by the economic evaluation ?
Write a paragraph about the comprehensiveness of the economic evaluation contained in the HIA report. Then, go to page 12.
Cost estimation 1. 2. 3. Technical adequacy Social acceptability Economic soundness
You are probably familiar with the estimation of financial costs of project activities. Financial costs are actually incurred by an activity and are paid for from funds contained in a budget and earmarked for that activty. For example, nurses' salaries are paid for from the health sector budget. It is important to check whether the budget accompanying the recommended safeguards, mitigating measures and health promotional activities adequately covers all cost items. A list of financial cost items is likely to include: Salaries for professional and support staff. Buildings: construction and/or maintenance. Other infrastructural work. Vehicles: purchase, maintenance, fuel. Equipment and materials. Energy, water and other operational costs.
The costs of not including measures also needs to be estimated. The absence of adequate health safeguards can incur direct costs (e.g. the expenditures of the health sector for health services delivery) as well as indirect costs (productivity or development losses associated with illness, typically valued by using a proxy such as loss in income earnings, or the level of school absenteeism).
TASK 4
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Questions Are the cost estimates of the recommended measures suffiently complete ? Has the cost of non-compliance with the measures been raised in the report ?
Write a paragraph on cost estimation for your appraisal report and add your view in the summary table. Then turn to the next page to consider affordability.
Affordability 1. 2. 3. Technical adequacy Social acceptability Economic soundness
The affordability of recommended measures is to a large extent, but not exclusively, dependent on their direct costs. The financial costs should, therefore, be considered in the context of the overall project budget, the national budget for health services and the national foreign debt and annual debt payments. Measures of an infrastructural nature (environmental modification) involve mainly capital costs (costs for goods with a useful life longer than one year), while measures that require regular and repeated operations incur recurrent costs (costs for goods and services that are used or replaced within a twelve month time span). This differentiation of costs is relevant in relation to the economic concept of the discount rate. This concept is explained in more detail in PEEM 3. It means that future expenditures can be discounted at very much the same rate at which money saved in the bank gains interest. The implication is that at a low discount rate, capital investments in risk management measures of an environmental modification nature are economically more attractive than a commitment to recurrent expenditures for on-going environmental manipulation measures (or health services, for that matter). The opposite is true at high discount rates. Many countries have limited foreign (hard) currency reserves which they need to buy essential commodities (such as oil or medicine) on the world market. The foreign currency requirements of the recommended measures need to be evaluated in this context, and the appraisal should pay attention to this aspect. TASK 4
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Questions Did the consultant(s) place the cost of the recommended measures in the context of the project, national budgets and the foreign currency reserves ? Was the discount rate considered in the evaluation of recommended measures ?
Write a brief section for the appraisal report on how the issue of affordability of recommended measures is dealt with in the HIA report. Then turn to the next page.
Value for money 1. 2. 3. Technical adequacy Social acceptability Economic soundness
As a solid basis for the ensuing negotiations, the HIA report should contain a cost-effectiveness analysis comparing the recommended measures with feasible alternatives. An appraisal of that analysis had best be done with the help of a health economist, but two key issues are mentioned on this page and the next: economic costs and estimating effectiveness.
Economic costs Economic costs reflect the real value of all resources used, not just the value of the financial inputs. An important concept in this connection is that of opportunity costs. This covers, for example, the value of voluntary labour involved in the implementation of recommended measures. People providing voluntary labour forego the opportunity of other production-related activities. The cost of this lost opportunity should be reflected in the overall economic picture. Market prices of certain goods or services may be distorted because of government policies (fixed exchange rates, food subsidies, taxation on imported vehicles). In order to overcome such distortions and arrive at the real economic costs of these goods and services, economists adjust these to "shadow prices". Donated items do not incur a financial cost, but they should still be given a value in terms of economic costs. TASK 4
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Questions Does the HIA report provide a cost-effectiveness analysis of at least the most important recommended measures ? Does the cost part of the analysis only consider financial costs or does it elaborate on economic costs as well ?
Discuss these questions, write a paragraph for your report and proceed to the next page to finish your appraisal of the costeffectiveness analysis of alternative measures.
Effectiveness indicators 1. 2. 3. Technical adequacy Social acceptability Economic soundness
Each intervention aimed at safeguarding or promoting health has an output that leads to an outcome. The outcome, in turn, leads to an impact on community health status. The choice of an effectiveness indicator from this sequence of events is important for the sensitivity of the cost/effectiveness analysis. For very similar interventions, output can be the indicator, while for more disparate interventions the impact on community health status may be the first common denominator. The further down the chain of events, the greater the risk of confounding factors. For example, in a malaria vector control programme based on indoor spraying of houses with a residual insecticide, the output is the number of houses sprayed, the outcome is the reduced vector lifespan and the impact is a reduced incidence of malaria.
TASK 4
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Question Considering the effectiveness indicator selected, has the estimate of effectiveness been carried out satisfactorily ?
Now, write a paragraph on the cost-effectiveness analysis applied on the recommended measures. Then, proceed to page 16.
The cost of risk management versus the costs of health services 1. 2. 3. Technical adequacy Social acceptability Economic soundness
One of the main goals of HIA is to ensure that "hidden" costs for the health sector, incurred by a development project, are eliminated by the incorporation of health safeguards and health promotional measures in the project design and operation. It is therefore worth checking whether the consultant(s) investigated to what extent the costs of recommended risk management measures are offset by the reduction in health services costs. Sometimes, the assessment overshoots its target – it may be possible that the resources required to carry out the recommended measures allow for important improvements and efficiencies in the health services to be achieved, particularly if synergies or economies of scale are brought into the equation. There have also been cases where project designers disguised project components (for instance, a drainage system) as externalities such as health safeguards, in order to boost the Internal Rate of Return of a project. The HIA report should provide a final check of this point, if only to exclude that this could be used as a counter argument in the negotiations.
TASK 4
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Once again consider to what extent the costs of the health safeguards mirror the savings made in health service delivery and add a paragraph on this to your report. Then proceed to the last step in your appraisal: a synthesis of your findings.
Synthesis of your findings You have concluded the appraisal of the measures recommended in the HIA report for health risk management and health promotion. You have written your findings in a series of paragraphs that, together with the text you produced in Task 3, make up your appraisal report. The summary Table with the comments on the technical, social and economic aspects of each individual recommendations will facilitate the synthesis of your findings. Remember that there is no such thing as a perfect HIA report with water-tight recommendations. Your appraisal serves as much to improve the current report and recommendations as it does to ensure that flaws in the framework for the present report (for instance, inadequate TOR) are corrected in future assessments. You will now have to come to your final verdict: Rejection of the HIA as inadequate. Demanding major improvements in the HIA. Acceptance of the HIA with minor corrections. Acceptance of the HIA as it stands. TASK 4
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This completes the appraisal exercise of Tasks 3 and 4. Please complete your report and prepare your oral presentation.
TASK 6
Health Risk Management Measures and Monitoring A plan for intersectoral action
TASK GUIDE FOR THE TRAINING COURSE
Health Opportunities in Water Resources Development
Health Risk Management Measures and Monitoring A plan for intersectoral action Task 6
Contents Timetable ............................................................................................... Introduction ........................................................................................... An overview ........................................................................................... Inventory of monitoring activities ........................................................ Timetable ............................................................................................... Memorandum of Understanding ..........................................................
PAGE 2 3 4 5 6 7
TASK 6
PAGE
1
Timetable Task 6 is the last in this course. While it assists your learning, it also identifies how successful the course has been. Your group will be working without its tutor. A total of fifteen hours is available for this Task. In addition, a field trip may be made to a development project in operation. On completing the Task, you will present your Plan of Action and Memorandum of Understanding in a final plenary session, where they subsequently will be discussed.
Briefing for Task 6 Group work Plenary session (possibly including a briefing for next day's field trip) Group work 3 hours 3 hours
30 minutes
45 minutes 15 minutes
Field trip (if possible)
8 hours
Plenary session (may include a de-briefing of previous day's field trip) Group work Plenary session Group work 3 hours 2 hours 45 minutes 45 minutes 30 minutes 30 minutes TASK 6
Plenary session - presentation of reports from four groups 2 hours 30 minutes
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2 Resource materials Tiffen, M. (1991). Guidelines for the incorporation of health safeguards into irrigation projects through intersectoral cooperation. PEEM guidelines 1. Document WHO/CWS/91.2. World Health Organization, Geneva. (Referred to as PEEM 1) Hunter, J.M., Rey, L., Chu, K.Y., Adekolu-John, E.O. and Mott, K.E. (1993). Parasitic diseases in water resources development. World Health Organization, Geneva.
Introduction Your appraisal of the HIA report has resulted in the endorsement of a final list of measures for health risk management and health promotion. A structured list of activities, designating responsibilities and allocating resources (including a realistic and transparent budget) will now be needed. This is intended for submission to the appropriate authorities, so that it can be considered at the negotiation phase. You have received a letter of remit requesting you to assist in the formulation of an intersectoral Plan of Action. This should specify for each sector the obligations and expected benefits and the synergies that can be derived from intersectoral collaboration. At the end of Task 6, the group is expected to present the Plan of Action. Ideally, this should cover: 1. A list of agreed activities for health risk management and health promotion and the allocation of responsibilities and resources for their implementation. 2. Verification of compliance with the specifications for the measures and agreement on the authorities responsible for verification. 3. Monitoring of the health status of vulnerable communities both for identified health hazards and for new, unexpected health problems, and agreement on which authority is to be responsible for monitoring. Once your Plan of Action has been formulated, you will prepare a Memorandum of Understanding (MoU). This is a formal document setting the legal framework for the arrangements between institutions involved in the implementation of the Plan of Action. In the final plenary session, your group will make a brief oral presentation covering your Plan of Action and your Memorandum of Understanding. Both documents are to be handed over at the end of your presentation.
TASK 6
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Question Which sub-tasks are involved in formulating the Plan of Action ?
Discuss this question and then turn to the next page.
An overview In formulating the Plan of Action, you will want to consider each of the following sub-tasks: 1. Prepare an inventory of the activities to be carried out in order to implement the agreed health risk management and health promotional measures. 2. Do the same for the activities related to verification and monitoring. 3. Annotate each activity in the inventories with the responsible ministry or other authority (or, in some cases, the ministries/authorities sharing responsibility). 4. Agree on a timetable for the activities. 5. Decide on the allocation of resources that each ministry or authority needs for carrying out its agreed responsibilities.
Once the Plan of Action has been formulated, you can draft the Memorandum of Understanding.
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Complete the first of the above sub-tasks, then proceed to the next page.
Inventory of verification and monitoring activities 1. 2. 3. Inventory of tasks Timetable MoU
Two crucial types of activities during the construction and early operational phases of the project include:
Crucial activities Verification that the specifications of health risk management measures and health promotional measures are complied with; and monitoring the changes in the health status of vulnerable communities. The purpose of verification and monitoring is to allow for corrective adjustments to the project to be made.
Verification Verification involves the following activities: Report on compliance with agreed measures and standards. Evaluate the effectiveness of the recommended measures. Consult with the relevant parties to remedy unforeseen health effects. Review the adequacy of arrangements, resources and cash flows for appropriate implementation of the measures. Review operational plans and adjust legislation, if necessary. TASK 6
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Monitoring Monitoring the changes in health status involves measuring: Health indicators (such as infant and child mortality, incidence and prevalence of communicable diseases, the nutritional status). Environmental indicators (such as the disease vector densities, concentration of chemical pollutants, the coverage for adequate sanitation). Socioeconomic indicators (such as income levels), which will provide information on the affordability of health services for vulnerable groups.
Now complete the inventory of activities related to verification and monitoring of your project. Then proceed to the next page.
Timetable 1. 2. 3. Inventory of tasks Timetable MoU
For some of the activities, the execution will be limited in time. Others may have to be carried out continuously or on a recurrent basis. This will have important implications for the resources that are needed. activities. In order to design a timetable for health risk management and health promotional measures, for verification and for monitoring you will need to: Decide on the time when each activity should start. Decide on the time period over which each activity should be carried out. Relate the timetable to the phases of the project cycle. This is therefore the correct moment to decide on the timetable for the implementation of the
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Now, develop a comprehensive time table, based on the above decisions, and attach it to the Plan of Action. Next, you should allocate responsibilities and resources for the individual activities in your inventories to each ministry or other authority. Then the responsibilities and allocation of resources can be formalized in a Memorandum of Understanding.
Memorandum of Understanding 1. 2. 3. Inventory of tasks Timetable MoU
It is important to decide on the administrative arrangements and procedures that formalize the contact between ministries and other authorities that are involved in the project. A Memorandum of Understanding provides a legal tool to formalize such arrangements. A Memorandum of Understanding may contain any of the following elements: A list of collaborating partners. The rationale for collaboration in the project concerned. The objective(s) of the collaboration. A list of the main health risk management, health promotion and monitoring activities, with allocation of responsibilities and obligations to each ministry and authority, and resources needed for each activity. A mechanism to allocate external funds and other resources to various ministries and agencies.
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Now draft the Memorandum of Understanding and prepare your presentation for the plenary session. That will complete your final Task !
3 Generic Letters of Remit Introduction As explained in chapters 6 and 7 of Part II, the letters of remit are an essential instrument in creating a realistic and authentic context for the groups to carry out their tasks. On the following pages generic letters of remit are presented for Tasks 2, 3 and 4 combined, 5 and 6. Bracketed texts presents options to adapt the letters to specific needs. The purpose of each letter and the possible originating authorities are presented as an introduction. Ideally, letters of remit are prepared on authentic stationary of the originating authority. Examples of such letters used in the Ghana and Tanzania courses are included in the material and also included on the accompanying CD-ROM.
Letter of Remit for Task 2: Rapid Health Impact Assessment, a Preliminary Step Purpose of the letter of remit: 1) To inform the person addressed of the establishment of an intersectoral group/committee and of his/her appointment as a member, representing the ministry/authority with which he/she is affiliated. 2) 3) 4) To briefly explain the nature of the group’s task and the broader context within which this task, a preliminary rapid health impact assessment, has to be performed. To define the expected output(s) of the group’s work. To set a deadline for the submission of the group’s report.
Possible originating authorities (whose stationery should ideally be used), in order of desirability: • • • • A national authority operating intersectorally, such as a National Economic Planning Council, or a National Environmental Protection Authority. The Prime Minister’s Office. The proponent ministry of the development project in question. The Ministry of Health.
Proposed text:
Dear Sir/Madam, In a recent meeting of <the National Economic Planning Council> <the Environmental Protection Authority> <the Ministers of Health, Environment and –name of project proponent> it was agreed that an intersectoral group be established to assess the health impact of the <name of the project>. The <name of the project> in <location> has been proposed in the framework of <insert relevant macro-economic policy objectives, for example: the 7th Five-Year Development Plan, which aims at improved food security and sustainable livelihoods of rural populations>. In accordance with <relevant policy, regulation, legislation>, this project will be submitted to environmental impact assessment procedures. Past experience shows that this type of development project, in addition to possibly causing environmental degradation, can contribute to an important decline of the health status of affected communities. At the same time, it is also clear that projects of this kind provide opportunities to implement measures which actually help improve the health status of these communities in an efficient manner. The Ministry of the Environment has given general directives that the possibility for separate health impact assessments should be explored whenever appropriate, in connection with technical feasibility studies and environmental impact assessments. This led to the afore-mentioned agreement, by all parties concerned, to establish an intersectoral working group to address this question. The group is expected to present its conclusions concerning the desirability of a health impact assessment of the<name of the project>. I take pleasure in inviting you, herewith, to become a member of this working group. Your designation as a representative of <relevant ministry/authority> has been cleared by <your Minister/the executive head of the authority you work for>. I furthermore wish to inform you that the group will start its activities on <date, in accordance with dates for Task 2 in the course programme> at <course venue>. At the start of the first meeting of the group, you will receive more detailed information concerning the Task the group is asked to undertake. Your conclusions should provide a concise evidence base for the group’s final recommendation whether or not a full and in-depth health impact assessment of the <name of the project> should be carried out. Members of the group are asked to present the outcome of their work at a special session on <date, in accordance with dates for Task 2 in the course programme> and to submit a full written report on that occasion. Your efforts and inputs into this important assignment will be greatly appreciated. Yours sincerely, <Signed by head of the authority>
Letter of Remit for Task 3 and Task 4: Appraisal of a Health Impact Assessment Report:
Purpose of the letter of remit: 1) 2) 3) 4) With reference to the proposed project, to acknowledge and give credit for the work carried out by the group on Task 2. To summarise the status of the various assessment activities scheduled for the project’s feasibility phase. To briefly explain that the present assignment consists of two distinct tasks, what they are and to provide concise terms of reference for them. To set a deadline for the submission of the group’s report.
Possible originating authorities (whose stationery should ideally be used), in order of desirability: • • • • A national authority operating intersectorally, such as a National Economic Planning Council, or a National Environmental Protection Authority. The Prime Minister’s Office. The proponent ministry of the development project in question. The Ministry of Health.
Proposed text:
Dear Sir/Madam The <National Economic Planning Council> <National Environmental Protection Authority> <national environment and health authorities> <has> <have> taken note of the recommendations made by the intersectoral working assigned to consider the need for a comprehensive health impact assessment of the <name of the project>. I should like to thank you once again for your expert contribution to this important work. In accordance with the main recommendation, an in-depth health impact assessment was carried out as part of the package of feasibility and impact studies of the proposed project. These studies were commissioned from an external consulting firm. The consultants worked jointly with national counterparts and recently submitted their reports. The report of the feasibility study has been appraised by the appropriate national authorities from an economic and technical viewpoint. The <Environment Ministry> <Environmental Protection Authority> is currently appraising the Environmental Impact Assessment report. I herewith invite the intersectoral working group of which you are a member to reconvene and appraise the Health Impact Assessment report. A series of sessions is scheduled to start on <date, in accordance with dates for Tasks 3 and 4 in the course programme> at <venue>. To facilitate an efficient, yet comprehensive appraisal, this assignment has been organised in two parts: the appraisal of the assessment procedure and its conclusions, and the appraisal of the recommended measures. For the appraisal of the assessment procedure and its conclusions, the group will have to decide whether the assessment was carried out in conformity with its Terms of Reference, whether it was objective, accurate and comprehensive, and whether its conclusions are logically and credibly supported by the evidence collected. For the appraisal of recommended health safeguards, risk mitigating and health promotional measures, it will be critical to review their technical adequacy, social acceptability and economic soundness. More detailed instructions will be made available at the start of the first session of your group’s meeting. A copy of the Health Impact Assessment report and of relevant parts of the feasibility study report <has already been made available> <will be made available> to the members of the group. The group is requested to present the results of the first part of the appraisal at a special session on <date, in accordance with dates for Tasks 3 and 4 in the course programme> and those of the second part of the appraisal at a special session on <date, in accordance with dates for Tasks 3 and 4 in the course programme>. Written appraisal reports should be submitted on those occasions. Your contribution to this important task will be greatly appreciated by the Government of <county or state>. Yours sincerely,
<signed by the head of the authority>
Letter of Remit for Task 5: Construct Generic Terms of Reference for Health Impact Assessment Purpose of the letter of remit: 1) 2) 3) 4) With reference to the proposed project, to acknowledge and give credit for the work carried out by the group on Tasks 3 and 4. To announce the government’s intention to mainstream health impact assessment into development planning procedures. To convey the objectives and scope of the next Task: the formulation of generic HIA terms of reference. To set a deadline for the submission of the generic TOR draft.
Note: this is the only Task for which no Task Guide is provided. Possible originating authorities (whose stationery should ideally be used), in order of desirability: • • The National Environmental Protection Authority (assuming they are responsible for EIA Terms of Reference). The Ministry of Health.
Proposed text:
Dear Sir, Madam, I should like to thank you for your recent contributions as a member of the intersectoral working group established to look into the health aspects of the proposed <name of the project>. The Government has come to realise that health impact assessment should be a standard procedure for all proposed <types of projects, for example medium and large scale water resources development> projects, in conjunction with environmental impact assessment. In anticipation of the formulation of policies and legislation to provide a framework for HIA, we have identified the need for generic terms of reference for health impact assessment of development <policies, programmes and projects – the scope depends on the level of strategic assessment that is required->. The availability of such generic terms of reference is expected to facilitate the introduction of health impact assessment into the development planning process. After due consultation with relevant authorities, I am now pleased to invite all members of the working group to assist in the formulation of such generic TOR, which should contain the following sections: Preamble Describing the rationale for these Terms of Reference within the policy and decision-making framework of <name of the country>. Terms of Reference Describing the scope and nature of the activities that need to be carried out by those from whom the assessment is commissioned. Expected outputs Providing clear guidance on the expected outcome of the assessment exercise and the timeframe for its completion. Any annexes as deemed necessary The draft generic Terms of Reference prepared by the Working Group will be the subject of review and discussion at a meeting on <date; in accordance with dates for Task 5 in the course programme>. You are requested to submit your draft on that occasion. I should like to take this opportunity to express my gratitude, on behalf of the Government of <name of the county, state> for your continued support of the cause of incorporating health into national strategies for sustainable development. Yours sincerely,
<signed by the head of the authority>
Letter of Remit for Task 6: Health Risk Management Measures and Monitoring – a Plan for Intersectoral Action Purpose of the letter of remit: 1) 2) 3) 4) 5) To report on progress in the planning of the development project under scrutiny. To convey the views of the various sectoral authorities involved, concerning the impacts on health. To point out the problems and constraints perceived from the different sectoral perspectives in following up on the HIA recommendations, and the possible solutions to overcome these. To reconvene the working group to formulate an intersectoral action plan and to design institutional arrangements for its effective implementation. To set a deadline for the submission of the group’s outputs.
Note: This is the last Task of the course, culminating in key outputs. It is recommended one or more senior government officials are invited to attend the meeting where these outputs are presented, and
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to announce their attendance in the letter of remit. Possible originating authorities (whose stationery should ideally be used), in order of desirability: • • • • A national authority operating intersectorally, such as a National Economic Planning Council, or a National Environmental Protection Authority. The Prime Minister’s Office. The proponent ministry of the development project in question. The Ministry of Health.
Proposed text:
Dear Sir, Madam, The various government authorities and departments with an interest in the proposed <name of the project> and its health impact recently met to discuss a follow-up to the HIA report appraised by the intersectoral working group. Representatives of the Ministry of Health voiced their doubts over their capacity to follow up effectively on all recommended safeguards, mitigating measures and health promotional activities. Many of these, by nature, pertain outside of the area of competence of the Ministry of Health. Health sectorspecific interventions recommended may, though in principle cost-effective, still require considerable financial investment, and some a long-term financial commitment. Health sector resources are expected to remain very limited and difficulties are therefore foreseen in entering new commitments for the interventions and for intensified health monitoring. Representatives of the <name of proponent ministry> share the concerns of their health colleagues. Although the <name of proponent ministry> is prepared to collaborate with other ministries and with local community stakeholder groups in safeguarding health in the <name of the project>, the Finance <Ministry, Department> may not agree to authorizing health expenditures from the budget for <type of development>. The Finance <Ministry/Department> may also be concerned that integrated development projects could lead to conflicts over responsibilities and obligations between government departments. Having taken this into consideration, it is desirable that the various departments involved formulate an intersectoral action plan, with a realistic timetable for the implementation of the recommended measures, to scrutinise compliance with proposed project design and management modifications, and to monitor the health status of affected communities. To ensure that effective institutional arrangements are in place for the action plan to be carried out, a Memorandum of Understanding will also need to be agreed upon. This MoU should specify responsibilities, obligations, logistics, resource sharing and fund allocation. I should like to call upon you once again, as a member of the intersectoral working group, to carry out these tasks. A special session is scheduled on <date, in accordance with dates for Task 6 in the course programme> at <venue> for the presentation of the action plan and the draft MoU. This session is of critical importance and will therefore be attended by <name (s)> of one or more senior government officials>. Thank you in advance for your contributions to this important task. Yours sincerely,
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<signed by head of the authority>
Examples of Letters of Remit from the Pilot Courses
4 Guidelines for the Group Tutor Questions addressed: • • • What does this course try to achieve ? What is the role of the tutor ? What do the tutors do ?
What does this course try to achieve ? It does not try to make each of the participants into a specialist in any aspects of the topic of the course. It does set out to develop a comfortable feeling in collaboration and to develop skills in collaborating with colleagues from other professions in other Ministries. Feeling comfortable in collaborating depends on: • • • • • • Getting to know these colleagues well enough to come to trust them; Experiencing that information and advice from others with particular expertise can be very helpful; Experiencing that one’s own information and expert advice can be very helpful to others; Experiencing the excitement of seeing a problem or task quite differently through the perceptions of colleagues from different professional backgrounds and with different expertise; Experiencing the satisfaction of completing a task better and more quickly than would have been possible without the collaboration of others with their special knowledge and expertise; Reflecting with these colleagues on how collaboration has contributed to the success of the course. Feeling comfortable in collaborating, and skills for collaborating need to be developed in a relevant context. This course will thus present the participants with a series of tasks, where each new task builds on the previous task. The participants work in small groups with at least one member from each of the Ministries in each group. Each task has to be completed within a fixed timetable. The results of each task are written up as a report which is also presented orally by each group in front of their colleagues in the other groups. The presentations are discussed with their colleagues, with the course director and with resource persons1. The tasks are made as realistic as possible and relate to a problem which requires decisions and action from several Ministries. The group of officials from the participating Ministries are expected to make reasoned decisions. This they cannot do until they have acquired the necessary understanding, either from each other and/or from documents and relevant literature made available during the course. When the group cannot resolve a particular issue/question/problem in its task, the tutor can invite an appropriate resource person to meet with the group.
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1) A resource person is someone with special knowledge and expertise who has been invited to assist in the course.
A range of skills can thus be developed in the context of a realistic set of tasks. Of immediate benefit for each individual Ministry official will be the ability to apply a systematic, analytical approach to the review of national and more local problems, priorities and proposals against a spectrum of criteria. Further, related skills will include the ability to identify key issues; formulate questions and obtain additional information and new insights through critical thinking; as well as assemble and present conclusions and recommendations in appropriate written and oral form. Of particular benefit to their ministries will be the development of skills for collaborating within groups and with individuals from other professions in other sectors of government. These skills will include the ability to listen and comprehend a different point of view, based on different expertise and experience; the ability to seek additional information in a non-confrontational manner; to paraphrase, in order to obtain confirmation of understanding of what has been argued or proposed by someone else; the ability to advance a clearly presented argument and to respond constructively to counter-argument; the ability to negotiate, in order to arrive at an acceptable agreement. Perhaps the most difficult aspect to develop with the participants will be related to their personal image – how confident they feel in their own expertise, and their willingness to give up a part of their personal power – to give information and provide understanding that will empower others to make decisions and to take action which they could not have done before.
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What is the role of the tutor ? The tutor is not an expert in the main topic of the course. The tutor should not try to be a teacher or leader of the task group. The tutor should be a “facilitator” who helps the group to work as a team and who helps the group to manage their work with each of the tasks. The tutor should also be the friend of each member of the group and of the group as a whole.
What do the tutors do ? The tutors will be “non-experts”, so that they cannot answer their group’s questions in relation to the outcomes or results of their group’s tasks. However, the tutors will have made themselves familiar with the nature of each task. The tutors will have discussed the content of the guide of each of the tasks with the course director, so that they will be able to provide guidance if any of the contents appears ambiguous to the group. The tutors will also be familiar with the overall timetable, so that they can ensure that each task is completed in good time, and that their group is aware of other activities and events, e.g. the daily plenary sessions when any unresolved issues can be discussed with the resource persons. The tutors are the link between their groups and the course director. This responsibility will include logistics; timetable problems; resources, such as paper and pencils; access to documents or other reference material; and dealing with difficulties or dissatisfaction of any type.
The tutors are also the link between their group and the resource persons. When a specialist has been invited to meet with the group, the tutor will ensure that the resource person responds helpfully to the group’s questions, does not lecture the group, and leaves the group as soon as the questions have been discussed satisfactorily! The tutors encourage the smooth working of their group. This will include: • • • Helping members of their group to get to know each other at the start of the first task. Helping their group in the use of the guide for each task. Ensuring that all members of their group contribute collaboratively, e.g. contribute to the discussion, to information sharing, decision making, allocation of information seeking, and report writing. • • Fostering the “bonding” within the group, where the group develops a corporate identity, works as a team, and comes to rely on every member of the group. Being aware of how groups are built up, and aware of group dynamics – the relationship between members of the group, so that the tutors can identify potential problems within the group and take steps to rectify them. Perhaps the tutor’s most important and least easy task is to help in building confidence within the group through personal commitment to the group; encourage sharing of information within the group; fostering productive discussions, and sharing the work within each task. The tutors will meet for two days immediately before the course starts. This will give them an opportunity to become familiar with their role as tutor and to discuss the content of each task guide with the course director. The tutors will succeed in their responsibilities if they can show complete dedication to their group, identify themselves entirely with their group – during group meetings, during plenary sessions, during presentation of reports, during field visits, at meal times and leisure times in supporting individuals and making their group feel that its work matters and is valued. In addition to meeting with the course director to discuss each day’s work, you will also be asked to contribute to the evaluation of the course, so that the next course can be more acceptable for the participants, the tutors, the resource persons and the organizers; more effective in achieving its aims; and more efficient in the amount of time, effort and resources expanded by everyone in the course.
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5 Guidelines for the Resource Person Questions addressed: • • • What does this course try to achieve ? What is the role of the resource person1 ? What does the resource person do ?
What does this course try to achieve ? It does not try to make each of the participants into a specialist in any aspects of the topic of the course. It does set out to develop a comfortable feeling in collaboration and to develop skills in collaborating with colleagues from other professions in other ministries. Feeling comfortable in collaborating depends on:
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• • • • • •
Getting to know these colleagues well enough to come to trust them. Experiencing that information and advice from others with particular expertise can be very helpful. Experiencing that one’s own information and expert advice can be very helpful to others. Experiencing the excitement of seeing a problem or task quite differently through the perceptions of colleagues from different professional backgrounds and different expertise. Experiencing the satisfaction of completing a task better and more quickly than would have been possible without the collaboration of others with their special knowledge and expertise. Reflecting with these colleagues on how collaboration has contributed to the success of the course.
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Developing a comfortable feeling in collaboration and skills for collaborating need to be developed in a relevant context. This course will thus present the participants with a series of tasks, where each new task builds on the previous task. The participants work in small groups with at least one member from each of the ministries in each group. Each task has to be completed within a fixed timetable. The results of each task are written up as a report which is also presented orally by each group in front of the colleagues in the other groups. The presentations are discussed with their colleagues, with the course director and with resource persons. The tasks are made as realistic as possible and relate to a problem which requires decisions and action from several ministries. The group of officials from the participating ministries are expected to make reasoned decisions. This they cannot do until they have acquired the necessary understanding either from each other and/or from documents and relevant literature resources made available during the course. When the group cannot resolve a particular issue/question/problem in its task, the tutor can invite an appropriate resource person to meet with the group. 1) A resource person is someone with special knowledge and expertise who has been invited to assist in the course.
A range of skills can thus be developed in the context of a realistic set of tasks. Of immediate benefit for each individual ministry official will be the ability to apply a systematic, analytical approach to the review of national and more local problems, priorities and proposals against a spectrum of criteria. Further, related skills will include the ability to identify key issues; formulate questions and obtain additional information and new insights through critical thinking; as well as assemble and present conclusions and recommendations in appropriate written and oral form. Of particular benefit to their ministries will be the development of skills for collaborating within groups and with individuals from other professions in other sectors of government. These skills will include the ability to listen and comprehend a different point of view, based on different expertise and experience; the ability to seek additional information in a non-confrontational manner; to paraphrase in order to obtain confirmation of understanding of what has been argued or proposed by someone else; the ability to advance a clearly presented argument and to respond constructively to counter-argument; the ability to negotiate, in order to arrive at an acceptable agreement. Perhaps the most difficult aspect to develop with the participants will be related to their personal image - how confident they feel in their own expertise, and their willingness to give up a part of their personal power - to give information and provide understanding that will empower others to make decisions and to take action which they could not have done before.
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What is the role of the resource person ? You will not be expected to concentrate on giving detailed information. You will act primarily as a consultant, and as a wise participant in the discussion session. In both roles you will be more concerned with helping the participants to think creatively and critically and to make reasoned decisions. In order to fill this role effectively, you will wish to familiarize yourself with the Guide which participants use in working through their task.
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What does the resource person do ? You will be invited to contribute to: • • • The participants’ group work. The plenary sessions. Evaluating the course.
You may also be involved in one or both field visits. During the participants’ group work You will have been invited to assist in relation to one or more of the participants’ tasks in the course. As you familiarize yourself with the relevant task guide(s) you will be able to see how your special expertise can be of benefit to the participants, in order to make reasoned decisions.
You will be asked to make yourself available in a specific location, so that the group tutors will know where to find you when their group wishes to consult you. When you have identified the reason for a group’s consultation (e.g. clarification of a particular issue or explanation of a particular issue/ process/procedure/mechanism), you will want to assist them to think along with you, rather than merely give them the relevant information. It will help the group significantly, if you would leave the group as soon as the consultation has been concluded. The group does not need a mini-lecture and it will not wish to be observed in its work. During the plenary sessions I. Each day there will be at least one plenary session. This is intended to review briefly what work has been done since the previous plenary session, and what issues/problems/questions remain to be resolved. The course director/anchor will encourage the participants (who will be sitting in their groups) to contribute actively during the session. You may prefer to remain silent until the chairman or the participants invite your comments/suggestions/explanations. The more specifically your response is directed to the discussion, the more you will assist the participants’ thinking and subsequent work. The participants come from a wide range of ministries and professions, so that your expertise will be valued primarily for its direct application to the task in hand. II. At the end of each task there will be a plenary session when each group presents its results. When the other groups have commented, you will be asked to contribute your observations or corrections. This is intended to be an informal and relaxed occasion, when the participants can develop their self-confidence and their skills in oral presentation and discussion. During the field visit If you are invited to participate in one of the field visits you may be asked to demonstrate or answer questions at a particular location. It will be worthwhile to remember that this is the first real experience of rural conditions for some of these city-based officials, and that some may have no practical experience in your field of expertise. The field visits are planned to be of direct relevance and help in relation to the tasks in the course. Thus it would be helpful to restrict factual information and explanation to the tasks in hand. Evaluation of the course You will also be asked to contribute to the evaluation of the course, so that the next course can be more acceptable for the participants, the tutors, the resource person and the organizers; more effective in achieving its aims; and more efficient in the amount of time, effort and resources expended by everyone in the course. One last thought While your input on all these occasions will be invaluable, and we are indeed grateful for your specialist help, you may find that you will have ample time to pursue your own interests and work. You may, therefore, want to come to the course with some of your journals, books, correspondence and papers and to continue your own work. In this way we hope that you will enjoy your time with us at the course.
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6 A Generic Schedule for Resource Persons Task guide Task 1 Task 2 Task 3 Task 4 Task 5 Task 6 Resource person 1 2 3 4 5 1 2 3 4 5 6 7 8 Day 9 10 11 12 13 14 15 16 17 18
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Task guides Task 1 Constructing a Framework for Comprehensive Development Planning • • • • Agree on planning concepts and definitions. Identify types of water resources development projects. Identify responsible authorities and procedures in all planning phases. Decide when health should be considered in the project cycle.
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Task 2 Rapid Health Impact Assessment - A preliminary step • • Acquaint yourself with the basic concepts of HIA methodology. Go step-by-step through rapid HIA procedures.
Task 3 Appraisal of an HIA report: Assessment procedures and conclusions • • • Verify the HIA report against the TOR, using a number of criteria. Check the assessment outcome for community, environmental and institutional risk factors. Consolidate the findings into a comprehensive appraisal of HIA procedures and conclusions.
Task 4 Appraisal of an HIA report: Technical, social and economic aspects of recommended measures • • Appraise the recommendations for their technical, social and economic aspects. Synthesize findings into a final verdict combining the outcomes of Tasks 3 and 4.
Task 5 Preparation of generic HIA Terms of Reference • • • Discuss the gaps and deficiencies in the TOR used for the HIA appraised. Identify all elements essential to a robust TOR. Prepare generic TOR that are comprehensive and practical.
Task 6 Health Risk Management - formulation of a plan for intersectoral action • • • • • • Agree on a list of health protection and promotion measures. Agree on compliance verification mechanisms. Agree on health status monitoring. Formulate a Plan of Action. Draft a Memorandum of Understanding between ministries/authorities. Agree respective organizational and financial responsibilities.
Resource persons 1. Senior Planner: a planning expert who is well-informed about the current planning framework and procedures for natural resources development. 2. Ecologist: a senior biologist/ecologist with sound knowledge of environment/health linkages and experience in impact assessment. 3. Hydraulic engineer: a professional with a solid knowledge of his own field and a broader interest in how engineering affects environment and health.
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Agricultural Scientist: an agronomist or other agricultural scientist who can assess the essential requirements of agricultural production systems and their interface with environmental determinants and community health status.
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Health Systems Expert: a senior professional who can make judgements about the comparative (dis)advantages of medical/health sectoral interventions in an intersectoral perspective.
7 Annotated Generic Programme for Field Trips Safe and comfortable transport arrangements • Four-wheel drive vehicles will as a rule be required. There should be space left for guides or local officers to join the field trip on certain stretches. the vehicles meet with an emergency. The drivers should have clear instructions concerning directions and on staying together while travelling to be able to assist should one of
To take along • Catering should be provided, for lunch, and include plenty of liquid refreshments, as the temperature may rise considerably as the day advances (the key reason for an early departure). Alternatively, arrangements may be made for lunch in a restaurant en-route. Refreshments will in any case have to be carried. • • • Depending on local customs, small tokens of appreciation should be taken along for community leaders. Equipment needed for direct observations should be carried: dippers and suction tubes in areas where malaria is a health issue, boots and scoop-nets in schistosomiasis infested areas. A first-aid kit should be part of the equipment and materials carried.
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1. Early morning departure (07:30) • Breakfast before departure.
2. The trip (07:30 – 08:30) • • Travel to the selected project site should not exceed one hour (this is one of the criteria in the selection of field trip destinations). Members of the course organising team should be distributed over the vehicles and ideally there should be one person in each vehicle who has visited the project so that the participants’ attention can be drawn to points of interest on entering the project area.
3. On arrival (08:30 – 09:00) • A first, formal arrival event should have been planned, where the group is introduced to local authorities and representatives of the local communities. Formal introduction should be followed by an explanation of the purpose of the visit and a review of the actual programme of the visit. This is also the opportunity of exchanging small gifts or tokens of appreciation, in accordance with local custom.
4. Focus group discussions/direct observations (09:00-12:00) • This part provides “the meat” of the visit, and directly addresses its objective: to demonstrate the value of a structured field visit to strengthen the evidence base for a rapid assessment. Participant groups (with their tutors assuming their customary facilitating role in directing and timekeeping) will be given a programme for a rotational sequence of focus group discussions and direct observations. The programme provides a timetable and the location. At the end of the programme all groups will have covered all focus groups and observation points. An example of such a programme is presented below: Programme Element Timing 09:30 – 09:50 10:00 – 10:20 10:30 – 10:50 11:00 – 11:20 11:30 – 11:50 Health Centre Group 1 Group 5 Group 4 Group 3 Group 2 Irrigation Engineer Group 2 Group 1 Group 5 Group 4 Group 3 School Staff Group 3 Group 2 Group 1 Group 5 Group 4 Community Representation Group 4 Group 3 Group 2 Group 1 Group 5 Transmission Site near Dam Group 5 Group 4 Group 3 Group 2 Group 1
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5. There are a number of practical points in support of this part of the programme: • • • An individual introduction of group members at the start of focus group discussions will set the scene for a conducive discussion climate. Timekeeping is critical to avoid stagnation in the rotation process. In some cases, a visit to specific sites for direct observations will require transport by vehicle. Where these sites are at a considerable distance, it may be better to take this component out of the rotational part of the programme and take the whole group to the site before or after.
6. Lunch (12:30 – 13:30) (mid-day) • • At this stage of the visit, all will be ready for a break with refreshments and lunch. The host local authorities or community may extend an invitation for lunch. This issue should have been sorted out at the time of preparation, with sensitivity to local customs. In deciding on the issue, considerations of food safety and the question whether providing lunch would imply a heavy burden on the local community should prevail.
7. Rapid rural appraisal (13:30 – 14:30) • Following lunch there may be an opportunity for the individual course participants to wander into the local settlement to gather information in an unstructured, rapid rural appraisal fashion. The feasibility of this may depend on the local cultural setting and on the overall timeframe.
8. Return-trip (14:30 – 15:30) • An early return will allow the groups to carry out a rapid evaluation of the information they collected, synthesize it and feed it into the Task they are working on. A plenary discussion in the morning will allow a broad reflection on what has been learned and observed.
8 List of Books and Documents available in the Course Library
The following list represents books and documents available for course participants during course implementation (in brackets letters referring to availability at courses in Zimbabwe (Z), Ghana (G), Tanzania (T), Honduras (H) and India (I), respectively). An asterisk * indicates the document is included in the accompanying CD-ROM.
Anonymous (1983). Man-made lakes and bilharzia: lessons in control from the Volta. Africa Health 5, 24-25 (G) Barker, D.J.P. & Hall, A.J. (1991). Practical Epidemiology. Longman Group, UK (Z) *Birley, M.H. (1989). Guidelines for Forecasting the Vector-borne Disease Implications of Water Resources Development, PEEM Guidelines Series 2, PEEM Secretariat, WHO, Geneva (Z,G,T,H,I)
Coyne et Bellier (1991). Tokwe-Runde Project. Feasibility Study. Phase Two Report. Preliminary study and first economic assessment. Text and appendices. Republic of Zimbabwe. Ministry of Lands, Agriculture and Rural Assessment; Ministry of Energy and Water Resources and Development (Z) Danida (1989). Environmental Profile: Tanzania. Ministry of Foreign Affairs, Copenhagen (T) Food and Agriculture Organization of the United
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*Birley, M.H. (1989). Directrices para prever las Consecuencias de las Obras de Desarrollo de los Recursos Hídricos en cuanto a las Enfermedades Transmitidas por Vectores. Serie de Directrices CEOM 2. OMS, Ginebra (H) Birley, M.H. and Peralta, G. (1992). Guidelines for the Health Impact Assessment of Development Projects. ADB Environment Paper No. 11, Asian Development Bank, Manila (G,T,H,I) *Birley, M.H. (1995). The Health Impact Assessment of Development Projects. HMSO, London (T,H,I) Central Statistical Office. (1985). Main demographic features of the population of Zimbabwe: An advance report based on a ten percent sample. CSO Harare (Z) Chimbari, M., Chitsiko, R.J., Bolton, P. & Thomson, A.J. (1991). Design and operation of a small irrigation project in Zimbabwe to minimize schistosomiasis transmission. ODI Irrigation Management Network Paper 9 (Z)
Nations (1990). Irrigation subsector review and development strategy. (Zimbabwe TCP/ZIM/8955). Technical Reports and Annexes. FAO, Harare (Z) Cooper-Weil, D.E., Alibusan, A.P., Wilson, J.F., Reich, M.R. and Bradley, D.J. (1990). The Impact of Development Policies on Health. A Review of the Literature. WHO, Geneva (Z,G,T,) Derban, L.K. (1984). Health Impact of the Kpong Dam in Ghana . Water, Power and Dam Construction, October 1984 (G) Doumengue et al. (1987). Atlas of the global distribution of schistosomiasis. CEGET-CNRS/ WHO, Bordeaux/Geneva (G) Futa, A.B. (1983). Water resources development – organization of a resettlement programme (a case study of the Kpong resettlement programme in Ghana). Water International 8, 98-108 (G)
Ghosh, B. (ed.) (1991). Health Implications of Public Policy . Case studies, modules, methodologies. Indian Institute of Management, Bangalore, WHO, Geneva (Z,G,T,H,I)
Ministry of Health. (1990). Health Statistics – Annual Report 1990. Health Information Unit and Health Statistics Unit, Zimbabwe (Z) Ministry of Health (1991). Annual Report 1990.
*Hunter, J.M., Rey, L., Chu, K.Y., Adekolu-John, E.O. and Mott, K.E. (1993). Parasitic Diseases in Water Resources Development. The Need for Intersectoral Negotiation. WHO, Geneva (G,T,I) *Hunter, J.M., Rey, L., Chu, K.Y., Adekolu-John, E.O. and Mott, K.E. (1993). Enfermedades Parasitarias y Desarrollo Hidráulico. Necesidad de una Negociación Intersectorial. OMS, Ginebra (H) Irrigation Development Authority (1989). Kpong Irrigation Project. Detailed Study, Project Preparation and Design. Main Report and Annexes 4&5. M. MacDonald and Partners, U.K. (G) Japan International Cooperation Agency (1990).
Epidemiology Division, MOH, Accra (G) Ministry of Health (1993). Annual Report 1992. Epidemiology Division, MOH, Accra (G) Morgan, P. (1990). Rural Water Supply and Sanitation. A text from Zimbabwe’s Blair Research Laboratory. Macmillan Publishers, London (Z) *Oomen, J.M., de Wolf, J. and Jobin, W.R. (1990). Health and Irrigation: incorporation of diseasecontrol measures in irrigation, a multi-faceted task in design, construction, operation. ILRI Publication 45 Volumes 1 and 2. International Institute of Land Reclamation and Improvement,
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The Feasibility Study on the Nyakomba Irrigation Development Project. Main Report, Annex Report, Drawings. Republic of Zimbabwe (Z) Japan International Cooperation Agency (1990). The Feasibility Study on Lower Hai and Lower Rombo Agricultural Development Project. Volume I, Main Report, based on the agreement between the Regional Development Director, Kilimanjaro Region of the United Republic of Tanzania and JICA (T)
Wageningen, The Netherlands (Z,G,T,H,I) *Organización Mundial de la Salud (1982). Manual de Ordenamiento del Medio para la Lucha contra los Mosquitos, con especial Referencia al Paludismo. OMS, Ginebra (H) Organización Mundial de la Salud (1991). Desagües de Superficies Para Comunidades de Bajos Ingresos. OMS, Ginebra (H) Organización Mundial de la Salud (1992).
Jobin, W.R. (1992). Irrigation Planning and Prevention of Bilharzia. Blue Nile Handbook One. Blue Nile Associates, Foxboro, USA (Z,G,T,H,I)
Informe de la Comisión de Salud y Medio Ambiente de la OMS (Resumen). OMS, Ginebra (H) *Phillips, M., Mills, A. and Dye, C. (1993).
Jobin, W.R. (1992). Bilharzia Prevention and Hydroelectric Reservoirs. Blue Nile Handbook Two. Blue Nile Associates, Foxboro, USA (Z,G,T,H,I) Lipton, M. and de Kadt, E. (1988). AgricultureHealth Linkages. WHO, Geneva (Z,G,T,H,I) Mahmoud, A.A.F. (ed.). 1987. Baillière’s Clinical Tropical Medicine and Communicable Diseases. International Practice and Reseach. Volume 2, Schistosomiasis. Baillière Tindall, London (Z)
Guidelines for the Cost-effectiveness Analysis of Vector Control. PEEM Guidelines Series 3. PEEM Secretariat, WHO, Geneva (G,T,H,I) *Phillips, M., Mills, A. and Dye, C. (1993). Directrices Para el Análisis del Costo-Eficacia de la Lucha Antivectorial. Serie de Directrices CEOM 3. OMS, Ginebra (H) Pike, E.G. (1987). Engineering against
schistosomiasis/bilharzia. Guidelines towards control of the disease. Macmillan Publishers, London (Z)
Rollinson, D. & Simpson, A.J.G (eds.) (1987). The biology of schistosomes. From genes to latrines. Academic Press, London (Z) Salzgitter Consult GMBH, PTA Consulting Services (PVT) Ltd & Stewart Scott NCL. (1991) Medium Size Dam Study in the Communal Lands and Resettlement Areas of Mashonaland Central Province: Mupfure Irrigation Project. Feasibility Study. Main Report, Annexes, Drawings. Government of Zimbabwe, Ministry of Energy and Water Resources and Development (Z)
United Nations (1992). Earth Summit, Agenda 21. The United Nations Programme of Action from Rio. UN, New York, USA (H,I) Vaughan, J.P. and Morrow, R.H. (1989). Manual of Epidemiology for District Health Management. WHO, Geneva (Z,G,T,H,I) World Bank (1993). World Development Report. Investing in Health. Full Report and Summary, WB, Washington D.C. (I) *World Health Organization (1982). Manual on
Schorr, T.S. (1984). Las Represas y Sus Efectos Sobre la Salud. ECO/Mexico. Organización Panamericana de la Salud (H) Small, L. (1990). Irrigation service fees in Asia. ODI/IIMI Irrigation Management Network Paper 90/1e, London (Z) Taylor, P., Matanhire, D., Mbaya, G., Makoni, S. & Chandiwana, S.K. (1989). Community based schistosomiasis control in Zimbabwe. Ministry of Health, Blair Research Laboratory, Harare, Zimbabwe (Z)
Environmental Management for Mosquito Control with special Emphasis on Malaria Vectors. WHO Offset Publication 66, WHO, Geneva (Z,G,T,H,I) World Health Organization (1985). The control of schistosomiasis. Technical Report Series 728. WHO, Geneva (Z) World Health Organization (1987). Selected Working Papers for the Third, Fourth, Fifth and Sixth PEEM Meeting, Document VBC/87.3, PEEM Secretariat, WHO, Geneva (G,I) *World Health Organization (1988).
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Tiffen, M. (1990). Variability in water supply, incomes & fees: Illustrations of vicious circles from Sudan and Zimbabwe. ODI/IIMI Irrigation Management Network Paper 90/1b, London (Z)
Environmental Management for Vector Control. Training and Information Materials, VBC Slide Set Series. WHO, Geneva (G,T,H,I) World Health Organization (1989). The
Tiffen, M. (1990). Socio-economic parameters in designing small irrigation schemes for small scale farmers. Nyanyadzi case study. Report IV: Summary and conclusions on water distribution and farm incomes on the Nyanyadzi irrigation schemes, Zimbabwe, Hydraulics Research, Wallingford UK (Z) *Tiffen, M. (1991). Guidelines for the incorporation of health safeguards into irrigation projects through intersectoral cooperation. PEEM Guidelines Series 1. PEEM Secretariat, WHO, Geneva (Z,G,T,H,I) *Tiffen, M. (1991). Directrices para la Introducción de Medidas de Protección Sanitaria en los Proyectos de Irrigación a través de la Cooperación Intersectorial. Serie de Directrices CEOM 1. OMS, Ginebra (H)
implications of public policy on health status and quality of life. WHO South East Asia Regional Office (Z) World Health Organization (1990). Health education in the control of schistosomiasis. WHO, Geneva (Z) World Health Organization (1991).
Environmental Health in Urban Development, the Report of an Expert Committee. WHO Technical Report Series 807. WHO, Geneva (G) World Health Organization (1991). The Control of Chagas Disease, the Report of an Expert Committee. WHO Technical Report Series 811. WHO, Geneva (G)
World Health Organization (1991). Annual Report. WHO Harare, Zimbabwe (Z) World Health Organization (1992). Health. A Conditionality for Economic Development: Breaking the Cycle of Poverty and Inequity. WHO, Geneva (Z,G) World Health Organization (1992). The Role of Health Centres in the Development of Urban Health Systems, the Report of an Expert Committee. WHO Technical Report Series 827, WHO, Geneva (G) World Health Organization (1992). Our Planet, Our Health. Report of the WHO Commission on Health and Environment. Summary. WHO, Geneva (Z,G,T,H,I) World Health Organization (1992). Our Planet, Our Health. Report of the WHO Commission on Health and Environment. WHO, Geneva
Youdeowei, A. and Service, M.W. (1983). Pest and Vector Management in the Tropics – with particular reference to insects, ticks, mites, and snails . Longman, London (G)
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(Z,G,T,H,I) World Health Organization (1992). WHO Commission on Health and Environment. Report of the Panel on Food and Agriculture. WHO, Geneva (Z,G,T,H,I) World Health Organization (1992). Health Dimensions of Economic Reform. WHO, Geneva (Z,G,T,H,I) World Health Organization (1993). The Control of Schistosomiasis, the Report of an Expert Committee. WHO Technical Report Series 830, WHO, Geneva (G,T,) *World Health Organization (1997). Agricultural Development and Vector-borne Diseases. Training and Information Materials on Vector Biology and Control, Slide Set Series. WHO, Geneva Yoder, R. (1983). Non-agricultural uses of irrigation systems: Past experience and implications for planning and design. ODI Irrigation Management Network Paper 7e, London (Z)
9 CD-ROM with Electronic Files of Course Relevant Documents Numbers in the list below correspond to the respective file numbers on the CD-ROM.
1. 2.
Table of Contents (pdf) Manual Part I and II: Course basics and Course implementation (pdf) Manual Part III: Course materials (pdf)
35.
Annotated Generic Programme for Field Trips (pdf) List of Books and Documents Available in the Course Library (pdf) Examples of Course Evaluation Questionnaires (pdf) Selected Books, Documents and Slide Set Series in Full Text: Course Reports from Pilot Courses: Zimbabwe 1992 (pdf) Ghana 1994 (pdf) Tanzania 1995 (pdf) Honduras 1996 (pdf) India 1997 (pdf) Engel, C., Birley, M., Bos, R., Furu, P. & Gøtsche, G. (2000). Intersectoral Decisionmaking Skills in support of Health Impact Assessment of Development Projects. Final Report on the Development of a Course addressing Health Opportunities in Water Resources Development 1988-1998. WHO/ SDE/WSH/00.9 (pdf). Tiffen, M. Guidelines for the incorporation of health safeguards into irrigation projects through intersectoral cooperation. PEEM Guidelines Series 1: WHO, Geneva 1989 (pdf) Tiffen, M. Lignes directrices pour l’incorporation de mesures de protection de la santé dans les projets d’irrigation par la coopération intersectorielle. Série de lignes directrices TEAE 1: OMS, Genève 1993 (pdf) Tiffen, M: Directrices para la introducción de medidas de protección sanitaria en los proyectos de irrigación a través de la cooperación intersectorial. Serie de Directrices CEOM 1: OMS, Ginebra 1989 (pdf)
36.
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.
37. Task Guides (English): Task 1 (pdf) Task 1 (HTML) Task 2 (pdf ) Task 2 (HTML) Task 3 (pdf) Task 3 (HTML) Task 4 (pdf) Task 4 (HTML) Task 6 (pdf) Task 6 (HTML) Guides de Stage (French): Tâche 1 (pdf) Tâche 1 (HTML) Tâche 2 (pdf) Tâche 2 (HTML) Tâche 3 (pdf) Tâche 3 (HTML) Tâche 4 (pdf) Tâche 4 (HTML) Tâche 6 (pdf) Tâche 6 (HTML) Generic Letters of Remit: For Task 2 (pdf) For Task 3 and 4 (pdf) For Task 5 (pdf) For Task 6 (pdf) Examples of Letters of Remit from the Pilot Courses (pdf) Guidelines for the Group Tutor (pdf) Guidelines for the Resource Person (pdf) A Generic Schedule for Resource Persons (pdf) 48.
38.
39. 40. 41. 42. 43. 44. 45.
46.
47.
32. 33. 34.
CD-ROM Contents continued 49. Birley, M. Guidelines for forecasting the vector-borne disease implications of water resources development. PEEM Guidelines Series 2: WHO, Geneva 1991 (pdf) Birley, M. Lignes directrices pour prévoir les implications pour les maladies transmises par vecteurs du développement des ressources en eau Série de lignes directrices TEAE 2: OMS, Genève 1993 (pdf) Birley, M. Directrices para prever las consecuencias de las obras de desarrollo de los recursos hídricos en cuanto a las enfermedades transmitidas por vectores. Serie de Directrices CEOM 2: OMS, Ginebra 1991 (pdf) Philips, M., Mills, A. & Dye, C. Guidelines for cost-effectiveness analysis of vector control. PEEM Guidelines Series 3: WHO, Geneva 1993 (pdf) Philips, M., Mills, A. & Dye, C. Directrices para el análisis del costo-eficacia de la lucha antivectorial. Serie de Directrices CEOM 3: OMS, Ginebra 1993 (pdf) 64. 54. World Health Organization (1988). Environmental Management for Vector Control. Training and Information Materials, Slide Set Series (HTML) 65. 55. World Health Organization (1997). Agricultural Development and Vector-borne Diseases. Training and Information Materials on Vector Biology and Control, Slide Set Series (HTML) Birley, M.H (1995). Health Impact Assessment of Development Projects. HMSO London. (pdf) Birley, M. & Lock, K. (1999). The Health Impacts of Peri-urban Natural Resource Development. Liverpool School of Tropical Medicine (pdf) World Bank (1997). Environmental Assessment Source Book UPDATE No. 18. Health Aspects of Environmental Assessment. (pdf) 59. Hunter, J.M., Rey, L., Chu, K.Y., Adekolu-John, E.O. & Mott, K.E. (1993): Parasitic Diseases in Water Resources Development. WHO, Geneva (pdf) Hunter, J.M., Rey, L., Chu, K.Y., Adekolu-John, E.O. & Mott, K.E. (1994): Parasitoses et mise en valeur des ressources hydriques. Un impératif: la négociation intersectorielle. OMS, Genève (pdf) Hunter, J.M., Rey, L., Chu, K.Y., Adekolu-John, E.O. & Mott, K.E. (1994): Enfermedades parasitarias y desarrollo hidráulico. Necesidad de una negociación intersectorial. OMS, Ginebra (pdf) World Health Organization (1982). Manual on Environmental Management for Mosquito Control (WHO offset publication 66) (pdf) World Health Organization (1984). Manual de ordenamiento del medio para la lucha contra los mosquitos - con especial referencia a los vectores del paludismo. OMS Ginebra (pdf) World Health Organization (1985). Manuel de l’aménagement de l’environnement en vue de la démoustication eu égard plus spécialement aux vecteurs du paludisme. OMS, Genève (pdf) Oomen, JMV, de Wolf, J. & Jobin, WR (1990). Health and Irrigation. Volume 1. ILRI Publication 45, Wageningen (pdf), Oomen, JMV, de Wolf, J. & Jobin, WR (1990). Health and Irrigation. Volume 2. ILRI Publication 45, Wageningen (pdf) Birley, M.H., Bos, R., Engel, C.E. & Furu, P. (1995). Assessing health opportunities: a course on multisectoral planning. World Health Forum, 16, 420-422 (pdf) Birley, M.H., Bos, R., Engel, C.E. & Furu, P. (1996). Health opportunities in water resources development: a multisectoral task based training course. Education for Health, 9, (1), 71-83 (http://www.tandf.co.uk) (pdf) List of useful links (HTML)
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Health Opportunities in Development A Course Manual on Developing Intersectoral Decision-making Skills in Support of Health Impact Assessment
PART I Course basics PART II Course implementation
Robert Bos, Martin Birley, Peter Furu and Charles Engel
World Health Organization
Liverpool School of Tropical Medicine
Danish Bilharziasis Laboratory
Institute of Education University of London
Health Opportunities in Development A Course Manual on Developing Intersectoral Decision-making Skills in Support of Health Impact Assessment
PART I Course basics PART II Course implementation 1
Robert Bos, Martin Birley, Peter Furu and Charles Engel 2003
World Health Organization
Liverpool School of Tropical Medicine
Danish Bilharziasis Laboratory
Institute of Education University of London
2
Contents
Preface ........................................................... 7 PART I: COURSE BASICS 1 Introduction to the manual ........................ 11 2 The learning approach ................................ 13 3 Design of Task Guides ................................. 17 4 Structure of the course ................................ 21 5 Creation of an enabling environment ........ 27
PART II: COURSE IMPLEMENTATION 6 How to prepare a course .............................. 35 7 How to run a course .................................... 53 8 How to monitor and evaluate a course ....... 65
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PART III: COURSE MATERIAL Part III of this publication is in a separate volume and contains all course training materials. The two volumes are accompanied by a CD-ROM with the integral text of the manual in electronic format, together with the reports of all five pilot courses, background textbooks and visual training aids.
About PEEM
The joint WHO/FAO/UNEP Panel of Experts on Environmental Management for Vector Control (PEEM) was established in 1981 to create a framework for inter-agency and interinstitutional collaboration, with a view to promoting the extensive use of environmental management for disease vector control as a health safeguard in the context of land and water resources development projects and for the promotion of health through agricultural, water resources, environmental, human settlement and health policies, programmes and projects. The interagency collaboration originates from Memoranda of Understanding between the three agencies covering the areas of prevention and control of waterborne and water-associated diseases in agricultural development, rural water supply and waste water use, agriculture, forestry and aquaculture. Recently, the Executive Heads of WHO and UNEP re-affirmed their collaboration in this area under a broader Memorandum of Understanding. Current WHO activities in the context of PEEM cover the areas of health impact assessment of development (with inputs into the work of the World Commission on Dams, and a Memorandum of Understanding concluded with the International Association for Impact Assessment), research and development in the field of environmental management to promote reduced reliance on pesticides for vector control and contributing to an issues framework on biodiversity and its importance for human health. The PEEM network consists of eleven collaborating centres and its secretariat is based in the Water, Sanitation and Health Unit in WHO headquarters, Geneva. The International Health IMPACT Assessment Consortium is a joint initiative of the Department of Public Health, University of Liverpool, and the Liverpool School of Tropical Medicine. IMPACT provides research, training and technical assistance in health impact assessment. It runs training courses in the United Kingdom for agencies engaged in HIA, an annual conference and a website. IMPACT’s international projects include technical assistance and capacity building to regional and central offices of WHO, DFID, national governments, and other agencies. IMPACT is a WHO Collaborating Centre and, through its manager Martin Birley, it is linked to the International Association for Impact Assessment. More information can be found on its website www.ihia.org.uk The Danish Bilharziasis Laboratory (DBL) is an independent institution affiliated with the Danish Ministry of Foreign Affairs/Danish International Development Assistance (Danida) and officially associated with the Faculty of Science, University of Copenhagen and with the Royal Danish Veterinary and Agricultural University. DBL also serves as a WHO Collaborating Centre for Applied Medical Malacology and as a joint WHO/FAO/UNEP/UNCHS Collaborating Centre for Disease Vector Control in Sustainable Development. DBL is involved in training, research and technical co-operation within the field of human health in developing countries. DBL receives the majority of its financial support through Danida. More information can be found on its website www.bilharziasis.dk The Centre for Higher Education Studies is based in the School of Lifelong Education and International Development, Institute of Education, University of London, UK. The Institute offers a wide range of postgraduate degrees. Its candidates for Doctorates of Philosophy or Doctorates of Education come from all continents and engage in an extensive spectrum of research. The Centre for Higher Education Studies is also known for its assistance to institutions of higher professional education in developing as well as developed countries for the design and implementation of innovative curricula. Robert Bos is a scientist in the Water, Sanitation and Health Unit at the headquarters of the World Health Organization in Geneva, with responsibilities for the health aspects of water resources development and management. Martin Birley is an independent consultant for the IMPACT Consortium of the Liverpool School of Tropical Medicine and the School of Public Health of the University of Liverpool. Charles Engel is an emeritus Professor of Higher Education and continues to be associated with the Centre for Higher Education Studies of the University of London. Peter Furu is a Senior Advisor in environmental health at the Danish Bilharziasis Laboratory. Robert Goodland, who contributed the Preface, is retired Senior Environment Advisor of the World Bank and past President of the International Association for Impact Assessment (IAIA). The authors wish to give their special thanks to Mrs Grete Gøtsche for her outstanding administrative guidance and logistical support throughout the five trial courses. Support for the trial courses was received from the Danish International Development Assisstance (DANIDA) through grants to DBL, while WHO contributed through considerable staff time. Important technical inputs were received from Bill Jobin (Colorado, USA), while the credit for the term “Health Opportunities” goes to Professor David Bradley of the London School of Hygiene & Tropical Medicine. Niels Ørnbjerg Christensen, Director of DBL, deserves mentioning for his unabated support of this activity. Many other colleagues and friends had an input into this final product.
About IMPACT
4
About DBL
About CHES
About the authors
Acknowledgements
5
6
Preface
Healthy public policy is increasingly cited by development experts as a key aim of governments, bilateral agencies and multilateral development banks. By this they mean that all publicly funded development in any sector should contribute positively to human health. This helps maintain social or human capital which is essential if development is to become sustainable. It is an aim with which all should agree. But how is it to be achieved? There are many possible instruments. One of these is to use prospective impact assessment. Environmental Impact Assessment (EIA) is an established procedure, well known in most countries of the world, increasingly required by law and by international development agencies. Yet EIA does not cover all dimensions of human health. It often overlooks the cross-cutting nature of health. Consequently, Health Impact Assessment (HIA) has emerged as an instrument for ensuring healthy public policy. It is also an instrument to generate health safeguards in the planning and design stages of development projects. It may be integrated with other forms of impact assessment, or stand alone. Having such an instrument is critically important, but it is not enough; staff with responsibility for development planning need the skills to use it. What are those skills? Some are straight-forward and technical. Others require a new way of thinking. Impact assessment is an intersectoral activity. This means that professional staff from widely different disciplines need to work together, sharing questions and answers. That is how the project of PEEM (the WHO/FAO/UNEP Panel of Experts on Environmental Management for Vector Control) , which started out as a simple exercise in teaching new technical skills, became a course in the development of intersectoral decision-making skills that makes use of modern thinking on how adults learn. This outstanding manual explains what that means, presents methods and frameworks, and provides the generic materials for national authorities to adapt the course to their own needs using local resources. Beyond the context of Health Impact Assessment, it sets the stage for a learning process to develop skills that are required to tackle any problems of an intersectoral nature. In an increasingly interconnected world, such skills are rapidly becoming indispensible. In every country that aspires towards using Health Impact Assessment there is a need to train many professionals in these skills. International agencies, such as the World Health Organization, already help by running one or two short courses a year for 20-40 people. But this would not disseminate the skills widely enough. Therefore, a course was needed that could stand alone and run sustainably in local training institutes. This manual addresses that need. It is the authors’ hope that readers will use the material provided,
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adapt it in their own way, and create for themselves courses that can be run as often as needed to disseminate the ideas to an ever-widening audience in response to an ever-increasing demand. For that is the reality of today: the demand for these skills is increasing. International bodies such as the European Union, bilateral development agencies and multilateral development banks, and national governments themselves are adopting healthy public policy as part of sustainable development. They have recognised that health is not the responsibility of the health sector alone. They are searching for appropriate instruments and suitably skilled staff. This manual contains one approach in response to this demand. Not the only approach, nor the final approach, but a major contribution. I highly recommend it to public health specialists, environmentalists, education professionals, policy makers and human resources managers alike. It needs to become the cornerstone of health impact assessment by all development agencies.
8 Rober t Goodland Mclean, Virginia United States of America June 2002
PART I COURSE BASICS
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1 Introduction to the manual 1.1 Management-oriented capacity building
For what purpose?
The purpose of this manual is to provide guidance in the design, implementation and evaluation of a course that aims to build and strengthen capacity in reasoned decision-making, team building, and inter-professional and inter-sectoral collaboration. The context of the course is socio-economic development in its broadest sense. The content focuses on health impact assessment as part of the development project cycle.
1.2
For whom?
This manual is intended for a diverse readership. Broadly, the intended audience consists of those who wish to commission, support or offer a course with the above stated aims. This audience includes: Mid-level civil (public) servants
Intersectoral bridge building
• Educational institutions across the world that wish to establish or run a course of this kind. Examples of participants of such a course are midlevel staff of government ministries and agencies whose duties include the regulation of development projects. The education authorities will be in institutions that serve the training needs of professionals who meet this profile. • Ministries and technical assistance agencies that recognise the need for developing capacity in intersectoral collaboration and seek a means of addressing that need. • Those concerned with management training for building teams that bridge gaps between units of any size with competing aims or budgets; such units may include departments, divisions, companies or ministries. The manual will also be of interest to: • Agencies concerned with establishing or running short courses on any subject using a problem-based learning approach. • Students of education, management or development interested in the methods and procedures that the authors have adopted. • Those who are interested in the process of negotiation with other sectors on cross-cutting issues, such as health and environment. • Those whose duties include regulation of development projects, procurement, tendering, advising or planning. The course is appropriate for any development context; water resources development is used as the illustrative contextual example.
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Common problems
Conceiving and running a short course in a developing country for a diverse audience of professionals has a number of common problems independent of the content of the course. These problems range from understanding how professional people acquire new knowledge and selecting individuals to attend a course, to course sustainability. Sustainability, in
this context, means ensuring that the course can continue to run without international support. This manual sets out the steps that need to be taken to prepare for and organize the course. It also identifies potential problems, describes how they may be overcome, and indicates what approaches may be more, or less, successful. The proposed approach is based on a six-year course development period during which five pilot courses were held in Zimbabwe, Ghana, Tanzania, Honduras, and India.
1.3 Three parts: basics, practice and materials
Structure of the manual
Part I and II of this manual are divided into a number of distinct chapters as identified in the Table of Contents. Chapters in Part I focus on basic principles in a generic way, using experiences from the pilot courses to exemplify principles of developing intersectoral decision-making skills. Chapters in Part II describe the practical aspects of preparing for and running a course to develop such skills in the context of Health Impact Assessment (HIA) of development projects. In other words, Part I addresses method generically, Part II addresses process in a specific context. A method is required by which busy professional people can learn to apply new knowledge and skills through discussions with their colleagues. The process refers to planning and conducting a specific course in a step-by-step fashion. Both method and process are, however, generalisable and stand independently of the content. Part III of the manual contains the course materials (see separate volume). These were developed for and tested in the pilot courses. They address the concern that water resources development projects should not be designed, operated, or maintained in a way that would endanger human health.
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CD-ROM
The accompanying CD-ROM contains the complete text of parts I, II and III of the manual in electronic form. Moreover, it contains electronic files of relevant WHO publications, text books and visual training aids.
2 The learning approach 2.1 Building on participants’ experience and expertise
Course participants and aims
This course is designed for mid-level managers from a wide range of ministries, departments or local agencies. Typical examples include directors of departments, chiefs of units or heads of divisions. They are the professionals who translate government policy into programmatic activities and guide the planning and implementation process through monitoring and evaluation. They may be working at central, provincial or district level. The course builds on their considerable professional expertise and experience. In addition to extending the participants’ ability to make reasoned recommendations on submissions related to development projects, the course aims to develop important competencies necessary for inter-professional and intersectoral collaboration. From this perspective, the course needs to treat the participants as competent adults and as valued colleagues who will have much to contribute to each other’s learning. They will need to feel at ease and develop mutual respect and trust, if they are to value each other’s expertise and enjoy working together. At first, their colleagues’ way of thinking may be as unfamiliar as their “jargon”. Clearly, a classroom atmosphere, sitting in serried rows on uncomfortable seats and enduring less than interesting expositions from unknown experts, is unlikely to meet the requirements of the course. There is ample empirical evidence that adults learn best when they can be actively tackling situations/problems/tasks that they can accept as interesting and worthwhile. They learn most effectively when they are exposed to a useful experience in a recognisable context, and then can reflect on that experience. In addition, it is important to ensure that the learning is cumulative. This means that what they have experienced and learned already, is revived and reinforced, so the new learning can be added by building on their previous learning achievements. These requirements are met most effectively by problem-based task work in small groups. The formation of multi-sectoral groups of participants is, therefore, one of the critical starting points of this course. The participants are the key resource. The added value of group work lies in bringing participants of different sectoral affiliation together. Much of the participants’ learning will be influenced by emotion — how they feel — rather than by logical reasoning. Learning to work with others and to feel comfortable in exchanging information, in effect giving and receiving power, requires quite deliberate planning of the course. For example, the course starts with a straightforward sharing of knowledge and experience that is accessible to them all. This is the participants’ introduction to the other members of their group, each of a different profession and from a different sector. This is also their first experience of working together and pooling information, in order to accomplish a
The participants are valued colleagues
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Traditional teaching is inappropriate
Keys to effective learning
Group work
Emotion and logic: two important determinants
Information is the currency of power
common task. The first experience will be followed by increasingly more complex tasks that have to be completed in progressively shorter periods. This increasing intellectual and physical pressure fosters “bonding” within the group — the creation of mutual reliance within the group. As an expression of this process, one may find that by the third day participants no longer sit at breakfast with colleagues from the same ministry but with colleagues from their task group.
2.2 Participants learn from each other
Group work
What happens when the groups settle down to carry out their tasks ? Unlike conventional educational practice: • • • • • Pre-course reading materials are not provided. Seating is arranged in groups rather than rows. The participants are the main source of knowledge. Communication is through active participation rather than lectures. Outputs are joint responsibilities.
PART I
In the letter of invitation, participants are asked to collect and bring with them information on procedures that are followed in their sector when planning development projects. Pooling information — sharing power
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As there are no lectures from experts, participants will have to start by exploring what information is available within their group, share and qualify this information, and synthesize it into a final output, just as they would have to do in any real-life situation. As the group commences its work on a series of relevant tasks, the participants will identify what further information they need to obtain from documents that are made available to the group, from publications in the course library and from consulting the local resource persons (see Chapter 7). Each group of participants has a non-expert tutor, who will not act as a teacher but as a facilitator and who helps and supports the work of the group (see Section 4.2.1). The group will progress through the logical steps of the task by following an agreed procedure. The group will end each task by producing a report that includes their findings, conclusions and recommendations. Other task outputs may include Terms of Reference (TOR), procedural plans or a Memorandum of Understanding. This approach to learning is known as “problem-based learning” (Engel, 1997)1 . It is based on the process by which each of us learns quite naturally in everyday life. Each new task is introduced during a plenary session (never, however, in the form of a lecture !). The intersectoral groups of participants sit around separate group tables, to create a more informal atmosphere. This informal
Non-expert tutor/facilitator
Problem-based learning
Plenary introduction
1) Engel, C.E., 1997. Not just a method, but a way of learning. In: Boud, D. and Feletti, G. The Challenge of Problem-based Learning (2nd edition), Kogan Page, London
set-up encourages the groups to seek clarification from the course coordinator, so that everyone can be quite clear about the nature of the task ahead. Use of Task Guide
Following the plenary session, each group goes to its own workplace. The group tutor will start the group work by distributing a Task Guide. This is accompanied by a letter of remit and a timetable for the task. Task Guides have been designed to guide the group’s discussion. Questions and instructions at the end of each page guide the group’s thinking and decisionmaking. The next page may start with feedback — confirmatory information related to questions and/or instructions on the previous page. It would defeat the aim of the Task Guide if the group were to look at the next page before arriving at a consensus on the questions asked. Task Guides and letters of remit can be found in Part III of this manual. At any time, the group may decide that it needs clarification or expert advice. For issues requiring an immediate clarification to allow the group to proceed with its work, the tutor will arrange for a consulation with the appropriate resource person (see Chapters 6 and 7). Clarification of less urgent issues can usually wait until the next plenary session, when the discussion with the resource person will benefit members of the other groups as well. Every task will end with an oral presentation by each group of its report, followed by a plenary discussion with the course staff, including the resource person(s). The practical aspects of applying the above principles and methods in the implementation of the course are discussed in detail in Chapter 7.
Expert consultation
PART I
Oral report
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3 Design of Task Guides Steps in the development of Task Guides
The design of Task Guides requires six consecutive steps: • Definition of the aims of the course and specification of overall objectives — what the participants will be expected to be able to do by the end of the course. • The educational approach — how the participants will be helped to attain the objectives. • The overall design or construction of the course — the cumulative sequence of learning and the activities that are to support learning in a realistic context. • The specification of objectives for each sequence of learning, the knowledge, understanding and skills that will be needed. • An outline of the output of each step of the course. • The specification of any papers, documents or books that should be distributed to individual participants or made available in the course library. These steps are elaborated below using the design of the Task Guides for the pilot courses as a reference — the steps are, however, generically valid for the development of all materials for any task-oriented problembased learning course.
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3.1
Definition of the aims of the course and specification of the overall objectives
Aim of a course
The aim of a course of this type is to strengthen the capability of mid-level officials to engage successfully in an intersectoral dialogue irrespective of their own sectoral affiliation. In the case of the pilot courses, the aim was for participants to set the framework for the assessment of the health impact of proposed development projects, appraise reports of consultants describing such impacts and arrive at reasoned recommendations to senior colleagues, through active intersectoral dialogue. The objectives of the Task Guides specify what the participants are expected to be able to do by the end of the course. For example: • • • • Recommend whether a full HIA is necessary. Formulate Terms of Reference for consultants. Appraise consultants’ HIA reports. Formulate intersectoral health promotion plans.
Objectives and expected outcomes
3.2
Decide on the time available for the course and the educational approach
Experience from the pilot courses
The length of any course for adult learning will be a trade-off between achieving a number of objectives and the period of time a professionally active participant can be away from his or her duties. The resulting length has a bearing on the choice of learning approach to be used and the level
of detail to which the course covers its subject matter. As argued in Chapter 2, the aims and the essential objectives of such courses can be attained most satisfactorily through the use of a problem-based learning approach. Experience from running the pilot courses revealed that, in the case of developing skills for intersectoral decision-making in relation to assessing the health impact of water resources development, the complexity of the essential objectives required a course of at least 18 days in duration. Dividing the course in two parts
One option that was not tested in the pilot courses is to split the course in two parts, delivered with an interval of several months. This would overcome objections against an uninterrupted three-week absence of professional staff. Such a schedule would to some extent reduce the bonding process between professionals of different backgrounds. It also remains to be seen whether all participants would effectively be released to attend the second part. An interruption, most logically scheduled after completion of Task 2, would, however, allow for a real Health Impact Assessment to be commissioned and carried out. The participants would then have authentic material to work with in Tasks 3 and 4. The appraised HIA report would be a valuable additional output of the course.
3.3 PART I
Overall design of the course
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The task-based learning approach requires that the overall task should be subdivided into essential component tasks. The cumulative learning effect depends on the sequence of sub-tasks being similar to the order in which issues pertaining to the main task would normally be tackled. At appropriate points, brief tasks that consolidate or synthesize newly acquired knowledge may be added. In the pilot courses, the sequence was as follows: Sequence of Tasks
• Construct a framework for comprehensive development planning. • Explore the requirements and activities associated with a rapid health impact assessment. • Appraise a health impact assessment report. • Appraise the recommendations for health promotion and safeguards. • Construct generic Terms of Reference for health impact assessment. • Formulate an intersectoral plan of action and a Memorandum of Understanding. Other supporting learning experiences should be considered. The participants would here need opportunities for field visits to gain first-hand experience of the issues. These visits need to be integrated appropriately with the tasks and with time for relaxation.
Need for field visits
3.4 Aim of Task
Specification of objectives for each Task
The following example is an extract from the Task Guide for Task 3. The aim of this Task is to learn how to appraise a health impact assessment that has been carried out in association with an environmental impact assessment.
Main objective
The main objective of the Task is to decide whether the quality of the assessment procedure and the conclusions warrant appraising the recommendations. The enabling objectives are: • Decide whether the assessment conforms to the original Terms of Reference and whether these were adequate. • Verify the objectivity of the assessment and identify any important biases or unforeseen obstacles. • Decide whether the assessment procedure allowed for the data and their interpretation to be sufficiently comprehensive and credible to support the conclusions. • Decide whether the conclusions follow logically from the data collected, and whether they are accurate, comprehensive and probable.
Enabling objectives
Output
The output of Task 3 is an appraisal report focusing on the assessment procedure and its conclusions.
3.5 Define the learning questions
Questions PART I
The next step is to consider what knowledge, understanding and skills are needed for each of these enabling objectives. Continuing with the example of Task 3 enabling objectives, the following questions were considered to lead the participants to explore the desired learning: • Were the Terms of Reference adequate for a meaningful assessment? • Was objectivity compromised by conflict of interest, timing, budgeting, lack of expertise, or lack of access to information? • Was evidence collected from published and unpublished sources and cross-checked? • Was a wide range of key informants and all sections of the community consulted? • Were the scope and depth of the assessment sufficient? • Was the synthesis of the information collected adequate? • Were the conclusions justified? Such questions relate directly to the reality of the task at hand. The participants need to refer constantly to the contextual documentation (in the case of this example: the project documentation for planned water resources development) and to the HIA and Environmental Impact Assessement (EIA) consultant reports.
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3.6 References for further reading
Specification of books and papers
Each Task Guide is accompanied by a list of references for further reading. These are sub-divided into copies given to all participants for them to keep and copies available in the library. Participants are expected to consult these references as they carry out the task.
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4 Structure of the course 4.1 Acquired skills
Objectives
The design of the course is based on the objectives to be achieved by the participants — what they should be able to do as a result of completing the course successfully. At the end of the pilot courses, for example, participants were expected to have the capability to manage or contribute to the health impact assessment of water resources development projects through inter-professional and intersectoral collaboration. In this case, the skills to be acquired included: • • • • • • Critically appraise project proposals and consultants’ reports. Make reasoned recommendations. Write succinct, logically structured reports. Formulate Terms of Reference. Plan procedures, such as action plans. Establish institutional arrangements, for example through a Memorandum of Understanding. • Convincingly present the results of the above orally to senior colleagues.
PART I
A realistic context is essential
These objectives can only be achieved if they are fostered in a realistic context. The example materials in Part III of this manual focus on the health impact assessment of water resource development. Health is fundamental to the social and economic well-being of communities. Water resources development is closely related to health because it provides clean drinking water, may change pollution levels or affects vector-borne diseases. Water, in particular its equitable use, will be a major issue in the 21st century, in order to provide power, irrigation and drinking water for the world’s increasing population. This manual applies to any course with the aim of building capacity in intersectoral collaboration. The training materials in Part III can be adapted to any intersectoral development context.
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Generic and contextual materials
The training materials contained in this manual assist the process of the course, i.e. they are designed to take participants through their tasks in a logical, step-by-step sequence. For each individual course, a context will have to be selected within which the tasks are performed. In the case of the pilot courses, water resources development projects (usually irrigation development projects) were selected that were in the planning stage. Each group of participants was given a set of the essential project documents (basic project proposal, feasibility study, general surveys of the project area, report of the Environmental Impact Assessment -EIA- and others). These are the contextual materials that enable participants to carry out the task in a realistic setting.
4.2
The course programme
The structure of the course needs to consider: the programme, and the human and material resources. This section focuses on the course programme. The length of the course
PART I
The length of the course is determined by the number of tasks to be accomplished, their level of difficulty, and the amount of time needed to complete each task in adequate depth. Other considerations include the time needed for the induction of tutors, the opening and closing ceremonies, field visits, holidays, and other ancillary activities. The pilot courses occupied up to 20 days. The total time will be a trade-off between the needs imposed by the course objectives and the limits set on absences from normal duties by participants and course staff. Up to two full days are needed for the induction of the group tutors before the course can begin. Day one of the course programme corresponds to the first working day of the week. A more detailed description of the sequential activities and the programme of local resource persons are presented in Part III. In the following sections, components of the course programme are presented, in chronological order, in terms of their function in the overall course and their contribution to the course objectives. A generic timetable, derived from the experience of the five pilot courses, is presented in Table 1. 4.2.1 Induction of tutors The term “non-expert tutor” has been used to emphasise that these tutors should facilitate their group’s work but not act as instructors. The Guide for Tutors (see Part III) sets out their responsibilities. Chapter 6 describes how they are to be selected and recruited. Chapter 7 describes in detail their induction into the concepts, approaches and procedures of the course. They should be introduced to each task guide. This will enable them to pace their group, in order to complete the respective task within the allocated time. It will also enable them to clarify any ambiguities that the participants may identify in the Task Guides. The tutors need time to familiarise themselves with the natural history of group dynamics and group pathologies, so that they can facilitate smooth and enjoyable group interaction. They try to maintain a balance in the participation of individual group members, are alert to identifying signs of conflict and apply conflict resolution methods. They recognise situations where a group gets stuck in a dead-end and needs referral to a local resource person. Finally, at a different level, they provide an essential feed-back link for the day-to-day monitoring of group performance and the early detection of general as well as group-specific problems. 4.2.2. Registration of the participants This is the crucial first opportunity to make each participant feel valued as an individual. The course administrator will welcome each participant and help them to settle in and to familiarise themselves with the geography of the location and its facilities (for the practical aspects, see Chapter 7).
22 Facilitators not teachers
Pacing, clarification, referral and linkage.
Start at the same time
Every effort should be made to ensure that all participants start the course together. It can be very disruptive for a group if one of its members does
Table 1. Timetable of training course activities
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not arrive until after the start of the course, is absent during the course, or leaves before the end of the course. In the pilot courses, as a rule, participants who arrived after the start of Task 2 were denied access to the course, and those who chose to leave early were not given the Certificate of successful completion. 4.2.3. The official opening and closing ceremonies The degree of formality, or informality, required for the opening and closing ceremonies will depend on local circumstances. The opening ceremony may perhaps need to be rather more formal, particularly if co-sponsors, government and national or international agencies are represented. The host institution, the course staff, and the participants may wish to feel that their involvement is noted.
Reasons for opening ceremony
Aims of the closing ceremony
The closing ceremony is best scheduled on the evening of the final full course day. It should be more of a family affair. In essence, the closing ceremony should acknowledge and reinforce the bonding that has taken place. The participants have successfully completed what will have been a demanding course. They are now members of a group that can and is willing to collaborate with each other across the boundaries between ministries, departments, and agencies. The only formal event during the closing ceremony will be the presentation of the certificates of successful completion of the course. 4.2.4. The daily programme Each morning and afternoon starts with a plenary session. This serves a number of purposes.
Plenary sessions
• The plenary session can be used to introduce a new task or to resolve any outstanding queries about an on-going task that a group has not been able to deal with to its satisfaction. • It is used for the oral presentation of the task reports. • It ensures that all groups, their tutors, and resource persons are present at the programmed time. PART I
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Plenary for groups’ reports
The local resource persons (see also Chapters 6 and 7) are expected to attend these plenary sessions to correct misconceptions, to answer outstanding queries, and to relate the groups’ work to local conditions and circumstances. The groups will require guidance on how to present their written and oral reports. The tasks represent a logical set of learning activities associated with the intersectoral decision-making process. The group work on tasks will normally follow the morning and afternoon plenary sessions. The design of Task Guides is explained in the previous chapter and their use in Chapter 7. Three additional activities are included in the programme: field trips, a debate, and sessions to elicit the perceptions of the participants as part of monitoring and evaluating the course. 4.2.5. Field trips Two one-day field trips are designed to provide the participants with relevant practical exercises and invaluable experience of the environmental, occupational, social and health conditions that relate to the project proposal. In the spirit of the course, these trips are not simply events to get a visual impression of project sites. They entail interaction and discussion between course participants and members of local communities, and briefings followed by discussions with the technical staff of various ministries and local government working on the spot. The time at which the trips are scheduled in the course programme is crucial to the tasks that they support. For further details, see Chapter 7 and the Guide to Field Visits in Part III.
The tasks
Other activities
Careful planning of field visits
The plenary session of the afternoon prior to the field visit serves to brief the participants. This briefing should cover objectives, programme, logistics, and expected outcome of the visit. Another plenary session should be arranged to debrief the participants afterwards and let them reflect on what they have experienced. 4.2.6. The debate It is normal that the attendance of a lengthy and demanding course, away from home and family and from the daily workplace, has an impact on the state of mind of individual participants. This manifests itself in the atmosphere of the course as a whole. In the first week the mood tends to be upbeat and slightly nervous. There are many new things to be discovered: new people, a new subject, a new learning approach. There is also a sense of insecurity about individuals’ roles and their place in the order of things. In the last week excitement mixes with some nostalgia. Participants feel they are mastering the subject matter, roles have become clear and the end of the course (i.e. the Certificate and their return home) is in sight. The group bonding process will have done its work and there is, therefore, also the realization that new friendships may come to an end.
Ups and downs in course mood
It is during the second week that the barometer of the course mood usually hits a low. The pressure is on: there are difficult tasks to be completed, the available time to complete them is more limited than in the first week and the end of the course is still far off. Purpose of the debate
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At this point, a debate is organized. It is a light-hearted evening event intended to break the routine. Its purpose is to give the participants an opportunity to release the pressure that has built up and to interact with each other differently than in what has now become routine group work. It also serves to remind them that working on a serious issue does not imply one cannot have a good time as well. Doubts were raised, when this course component was introduced, whether it was sufficiently universal to cut across different cultures. While there certainly was a more instant recognition of debate procedures among participants from countries where there is an Anglo-Saxon teaching tradition, its success at the course in Central America proved such doubts to be unfounded. 4.2.7. Course monitoring and evaluation Monitoring and evaluation activities are fully integrated into the course programme.
Purpose of monitoring
The purpose of monitoring is two-told: • To correct any adverse commissions or omissions, or to exploit further any particularly successful elements in the conduct of the course as soon as they occur. • To gather information for the improvement of future courses. • To provide the participants and staff with an opportunity to “let off steam”.
Perceptions of the participants
Several methods are used to monitor the course as it proceeds. For example, at the midpoint of the course programme, the participants join in a Nominal Group Process. Adaptations and improvements can thus be included in the second half of the course (see Chapter 8). The purpose of evaluation is four-fold: • To establish the basis for a strategic decision about the future of the course. Is the outcome sufficiently successful in achieving course aims and objectives to justify further courses? Are major changes required? Should the course be abandoned altogether? • To clarify whether the conduct of the course was sufficiently acceptable to the funding agency, the organizers, staff, and participants of the course. • To confirm whether or not the course is sustainable in its balance of acceptability, effectiveness and efficiency - time, effort, facilities and resources that have been expended by all who have been involved in the course. Sustainability will be particularly important where the course depends solely on local resources. • To produce evidence in sufficient quantity and quality for further improvements to be made to the course. Both pre- and post-course questionnaires are used for course evaluation by the participants. The pre-course evaluation takes place during the course introduction. The post-course evaluation is scheduled for the final morning. Course evaluation by local resource persons and by non-expert tutors takes place at the end of their respective assignments. Further details can be found in Chapter 8.
Evaluation serves strategic decision making
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5 Creation of an enabling environment Key points in establishing the course
The course has special characteristics and requires an enabling environment that is different from that of conventional courses. The key points to be addressed include: • Establish effective links with all public sectors well in advance of the course, to ensure adequate identification, nomination and participation of mid-level management staff. • Ensure an optimal number of participants and an optimal composition of the group of participants in terms of public sectors represented and gender balance. • Obtain the services of the right resource persons at the right time. • Identify and induct tutors that can guide the group learning process without interfering in the technical issues. • Identify and/or adapt all course-specific learning materials and contextual materials, and have them available on time and in sufficient numbers. • Identify a venue that offers all necessary facilities and is sufficiently isolated, so that personal and professional obligations do not interfere with course attendance.
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Two important preconditions
Two vital determinants of the level of success in organising the course are: • The sectoral affiliation of the main organizer or organizing institution. • The geographical scope of the course: is it confined to one country or will it cover several countries in a region?
5.1 Special pleading
Sectoral affiliation of the organizer
This course aims at developing management skills that ensure that health is being addressed in development as a cross-cutting issue. Therefore, a course initiative that emerges from the health sector may be perceived by the other sectors as representing special pleading by public health authorities. Consequently, public sectors other than the health sector may be reluctant to nominate the most appropriate number and level of staff to participate. They may feel that the objectives of the course are of marginal importance to their sector and have little merit to receive support from their already limited training budgets. An important argument will be that improved intersectoral action to assess health impacts will reduce the transfer of hidden costs to the health sector. Such arguments will only be appreciated by ministries with a government-wide outlook such as planning or finance. The solution to this constraint is to ensure that the course is not perceived as a health sector initiative. The initial idea for the course will, most likely, arise in a health sector affiliated department or institution. A first important step, then, is to give the course a home in a sectorally neutral institution.
The hidden costs
Make the course relevant irrespective of any sectoral affiliation
Administration and management institutions
In most countries, institutions for public administration and management exist. They play a key role in the training of civil servants. Their focus may be inclined towards economic and finance disciplines, but they usually address issues of development and strengthening of management capacity for a range of public sectors, as well as, sometimes, for the private sector. In recent years, many of these institutions have included environmental impact assessment and environmental management into their training programmes. A course entitled “Health impact assessment of development projects” will, therefore, not be something entirely novel. It may not be difficult to include it in the institution’s training programme. This type of training institution will often have effective links with various public sector ministries and institutions. In fact, senior civil servants in most ministries are likely to have received part of their training at the institute, so that a natural bonds exists, based on confidence and credibility. This will further facilitate the organization of the course. Management training institutions usually also offer excellent facilities with the specific characteristics required for this course (see Chapter 6). If the course is initiated in the health sector context, the initiating person or unit may also have problems convincing their own ministry that this is a valuable endeavour in which to invest staff time. In a typical setting, the Environmental Health Unit in a Ministry of Health will be the health counterpart in this course. If they exist at all, such units are usually marginal, under-staffed, and under-resourced. Attitudes in the Ministry may be influenced favourably towards developing intersectoral decision-making skills by organizing an internal seminar on the subject of health in development. The seminar can focus on HIA, health risk management, health promotion, healthy public policy and/or community involvement in health and development, through ownership and empowerment. Other promotional activities in ministries of health may include: • Making information on HIA available to health sector planners and decision makers. • Collecting and publicizing case studies illustrating negative effects of development projects, preferably with a (health-)economic dimension. • Presenting evidence of the potential of HIA in preventing negative health impacts.
Effective links
Promotional activities within the health sector PART I
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Participants’ affiliation
The composition of the target audience of the course leaves some flexibility in the representation of certain development sectors such as agriculture, energy, infrastructure, industry, transport or housing. The more comprehensive the representation, the better ! It should be realized, however, that the two sectors that must be adequately represented for the course to be a success are the health sector and the environment sector.
5.2 Regional approach
National versus regional context
Normally, the initiative to organize this course will arise at the national level. In some instances, the idea to strengthen intersectoral decision-making skills related to health impact assessment arises in a regional context. This is likely to happen in the context of cross-boundary projects to develop or use a certain natural resource. Examples include water resources development in an international river basin, or the exploitation of oil reserves that extend over two or more countries. The pilot courses were carried out in both national and regional settings, the latter including a regional course comprising five countries in Central America, as well as a course for staff from departments in four States in India. There are a number of complications that make the option of a regional setting the least attractive of the two: • • • • Too many different contextual projects. National sensitivities. Complications in the selection of local resource persons. False economies.
PART I
Too many different contextual projects
The course tasks are carried out in the context of a real development project. Bringing in participants from a number of countries, or states in a federation, means that each group works on a different project. At the start of the course, a series of presentations will need to be inserted into the programme on the nature and characteristics of each project. This provides the basis for understanding the task reports that are presented throughout the remainder of the course programme. Even with this basic knowledge of each project, interest levels at plenary presentations will be less intense and the plenary discussions will be more shallow. An exciting aspect of the task-based learning is the competition between groups and the different outcomes that individual group discussions yield. Competition is an underlying determinant in the bonding process and supports effective learning. Therefore, a regional course may be expected to be less successful in achieving its goals than a national course. In some cases, natural resources and their development may be of strategic importance or they may even be considered a matter of national security. This puts a constraint on the frankness with which planning issues can be discussed. It also limits the availability of documentation. When this is the case, it augurs poorly for the success of a regional course: the need for openness and mutual trust is likely to be overshadowed by regional distrust and lack of transparency. Identifying local resource persons to provide technical support in a regional course is complicated. It is easier to find relevant and knowledgeable professionals for a national course than for a regional course. Chauvinism or other national sensitivities may obstruct the acceptance of a technical resource person from one of the other countries in the region. Resorting to
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National sensitivities
Complications in the selection of local resource persons
international staff from regional institutions (such as a regional development bank) defies the concept of local resource persons. False economies
Finally, the idea that organizing the course at a regional rather than a national level provides economies of scale is not correct. The travel involved makes the course more expensive to run, and while it will cover a number of countries, it will result in only one person per sector per country trained. Considering the high turnover of staff, particularly at the middle management level of public sector institutions, this is hardly going to have an impact. In contrast, a national course will ensure that each public sector represented will have at least four of its middle level management staff trained at one time. In the light of the above, it is strongly recommended that, even if the idea of organizing this course arises at the regional level, it be broken down in a series of national courses rather than one or more regional ones. Even where the geography of natural resources demands coordination between two or more countries on issues of health impact assessment, it is still recommended that the courses be held at the national level. At the same time, in each country, an enabling policy environment can be created that will allow mid-level staff that have participated in this training to engage in effective intersectoral action. Once this has been achieved, countries may work together, in order to harmonize their HIA policies. A development project that crosses international boundaries can then be planned with due attention to human health considerations.
Conclusion
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5.3 Implications of public sector reform
Decentralisation
In most countries, processes of structural adjustment are underway or have been completed, with the aim of improving the effectiveness of government while containing costs. Public sector reform includes, among other things, decentralisation. While the decentralisation of decision-making about operational issues is usually not contested, the responsibilities for resource allocation often remain at the central level, creating a rather unworkable situation. In principle, intersectoral collaboration should be facilitated by decentralisation, as the barriers that separate sectors at the central level (where competition for resources prevails) have little meaning at the district level (where teamwork is a daily routine, in order to deliver local solutions in response to local problems). It should, therefore, be easier to achieve the objectives of the course in a decentralised setting, with a more favourable climate for intersectoral action. In reality, the situation is more complex. To begin with, decentralisation is seldom absolute. In a situation as alluded to above, where decisions on resource allocation continue to be made at the central level, it will be essential to create an enabling policy environment (preferably with a budget appropriation) for intersectoral action at the district level to be viable. Otherwise, professionals who participated in the course will have little opportunity to put their newly acquired skills to practice. There may also be
discrepancies in the level of decentralisation between sectors. In some countries, ministries of health have fully decentralised their environmental health services, while irrigation management may still be the responsibility of a central parastatal agency. As a result, course participants with different sectoral affiliations may operate at different levels in the system. When to consider decentralisation
Decentralisation may also complicate the project planning process. Proposals for water resources development, for example, may not only move between ministries at the central level as the project cycle unfolds, but also between different administrative levels (central, provincial, district). This may complicate any impact assessment procedure. Options for intersectoral action in such a setting are described by Tiffen (1991)2. The issue of decentralisation, therefore, deserves attention in the initial preparation, in the selection of course participants and, during the course, in the appraisal of Task 1.
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2) Tiffen, M., 1991. Guidelines for the incorporation of health safeguards into irrigation projects through intersectoral cooperation. PEEM Guidelines Series 1, Document WHO/ CWS/91.2, World Health Organization, Geneva
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PART II COURSE IMPLEMENTATION
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6 How to prepare a course 6.1 Getting started Time and resources invested in laying the groundwork for this training course are time and resources well invested. The proposed subject and learning methodology are out of the ordinary and it is, therefore, important that the organizer: First steps
• Rapidly assesses the needs that can be addressed by the course and generates evidence for these needs. • Informs him/herself about the current status of relevant policies, programmes, projects and procedures in the different sectors. • Identifies allies and potential adversaries in each ministry who may influence the process of organizing the course. • Explores potential sources of funding that will make running the course a feasible and, possibly, sustainable option. Once the course has taken place a couple of times, the effort invested in the basic preparations for the first few courses will provide a solid basis for its continuation. In the various relevant sectors, supporters of the course will then increasingly outnumber the sceptics.
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The broad needs perspective
In most countries, Health Impact Assessment (HIA) of development policies and/or projects is a non-existent practice. Health may, however, be covered in a sectorally confined manner in Environmental Assessments. The needs for establishing HIA as a component of development planning, supported by an enabling policy environment, is best demonstrated by case studies of development projects that have had a negative impact on health. These are provided in the literature (e.g. Birley, 1995)3 , but there may be close-to-home examples that carry extra weight for government decision-makers. In the analysis of such case studies, it is important to highlight the fact that costly negative impacts could have been prevented by an early recognition of the health risks, and by incorporating health safeguards into project planning, design and development.
6.2 Capacity building needs
Needs assessment
A next step aims to assist the human resources managers of the various relevant ministries and other public sector institutions in identifying capacity building needs to achieve and sustain effective HIA procedures. The problem and solution trees presented in Figures 6.1 and 6.2 will be helpful in this undertaking. The course responds to the needs to achieve an enhanced understanding of both the potential and the limitations of HIA. It develops skills in intersectoral decision-making for a target audience of mid-level managers, among whom these are often so painfully lacking.
3) Birley, M.H., 1995. The Health Impact Assessment of Development Projects, HMSO, London
Figure 6.1. Problem tree - without health impact assessment
Project not sustainable
Educational impairement
Lost productivity
Hidden costs to health sector
Death and disability
Effects Health risks increase as a result of development Causes Missed opportunities for health improvement Inadequate health safeguards and mitigations
Inadequate health impact assessment procedure PART II
No technical skills to design or operate health safeguards
No budget for health safeguards and improvements
36 Health hazards of existing projects not evaluated No available skills No enabling environment
No project monitoring
No training courses
No intersectoral communication
No training of trainers
No training materials
No curriculum
No training institutions
No intersectoral arrangements Value of non-medical interventions not appreciated by health sector
No institutional requirement
No empowerment of project officers
No sensitization seminars
No policy framework
No resources for concept development
No political will
Figure 6.2. Solution tree - with health impact assessment
Sustainable projects
Educational improvement
Productivity gains
Benefits to the health sector
Longevity and quality of life
Benefits Health risks reduced as a result of development Upstream actions Opportunities taken for health improvement Health safeguards and mitigations always included
Health impact assessment standard
Technical skills to design and operate health safeguards
Budget for health safeguards and improvements always included PART II
37 Health hazards of existing projects well evaluated Institutional capacity built Enabling environment
Project monitoring normal
Sufficient staff trained
Procedures incorporated
Training courses running
Training materials disseminated
Curriculum standardised
Intersectoral communication skills common
Intersectoral arrangements
Institutional requirements
Empowerment of project officers
Sensitization seminars completed
Policy framework
Value of non-medical interventions well appreciated by health sector
Many resources for concept development
Political will
There are other factors that contribute to the unsatisfactory way health is dealt with in the context of development. One is the absence of specific policy frameworks for HIA and of a more general enabling policy environment to promote intersectoral collaboration. There is insufficient capacity in most ministries of health to respond adequately to HIA-related requests from other sectors. Ministries of health also frequently lack the capability to appraise an HIA report in a meaningful way. It should be pointed out that, while the course by itself will contribute importantly to addressing the capacity building needs for HIA, its effect will be synergistically enhanced if the other, above-mentioned capacity building needs are addressed simultaneously.
6.3 The development planning framework
Identifying course components
Many people in different ministries are involved in detailed steps of the development planning process, but very few have a complete overview of the structure and workings of the overall planning framework. It is important for the organizer of this course to obtain this overview, for a number of reasons as explained below: The overview will facilitate the early identification of key players in the development planning process. Without a comprehensive insight into this process, it is quite likely that ministries with a critical role on the health/ development interface are overlooked. As a result, no nominations will be invited from such ministries, their staff will not be among the participants, and the course will be handicapped in its methodology for lack of realism. For example, during one of the pilot courses in Africa, it became apparent that a lot of development planning takes place under the district development focus. The responsible Ministry, Community Development and Women’s Affairs, was, however, not represented at the course. Preparatory work for the pilot course in India revealed that resettlement of communities, imposed by development projects, is the responsibility of the Department of Revenue. Had preparations been less thorough, this Department would no doubt have been overlooked and would not have been represented at the course. This insight will also put the organizer in touch with potential resource persons for the course, particularly for Task 1, which deals with the construction of a framework for comprehensive development planning. Identifying the right local resource persons for this course can be a challenge. They need to be experienced professionals in their own field, but they also have to be accustomed to looking beyond their sectoral horizon. The most successful recruitment of a resource person for Task 1 occurred during the Central American pilot course, when the retired head of the Ministry of Planning of Honduras was found willing and available to participate. He was identified in the process of analysing the planning framework of that country. Insight into the development planning framework will also make it possible to adapt the generic training materials to country-specific idiosyncrasies of the planning process.
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Key players in development planning
Identifying the right resource persons
Finetuning materials
In their generic form, the Task Guides try to cover the planning procedures of development by taking a common denominator approach. Most countries follow the project cycle concept in development planning. In most countries, Environmental Assessment has been integrated into the planning procedures from the earliest stages. HIA fits quite easily into this model. In the decreasing number of countries with centrally planned economies, this model does not apply. Where development decision-making has been de-centralized to the provincial or district level, the course materials will need to be adapted (see Section 5.3). Similarly, where Environmental Assessment legislation and procedures have not been firmly established, the materials will need to be modified. Criteria for selection of relevant development projects
Based on a detailed understanding of the development planning framework, the organizer will be able to take into account national priorities and developmental relevance in the selection of projects that serve as the context for the tasks in the course. Many governments have established development priorities from a macroeconomic perspective. For example, a country without fossil fuel resources, plenty of water resources and an increasing energy demand will let dam construction for hydropower generation prevail over irrigation development. Where food security of a large rural population is at stake in the presence of a small and relatively wealthy urban population, the government will let agricultural development prevail over industrialization. Such priorities need to be a clear criterion in the selection of projects for use in the course. A proper analysis of development policies will bring them to light.
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Make friends and influence people
In every ministry, there will be staff that share the concern over health impacts of development in an implicit or explicit way. They are the people that have the capacity to “think out of the box”. They need to be identified and cultivated, because they are important allies in ministries that normally would not consider health as befitting their remit. Those who are in a position to influence decision making about their ministry’s participation in the course will require particular attention. The course organizer may want to take the initiative to invite such individuals from different ministries to an informal brainstorming session. This will generate new ideas and re-enforce their commitment. In the end, they may become designated focal points to play an active role in the detailed preparations for the course. This will include nominations, confirmation and release of staff, as well as action to be taken after each course. In all development sectors, there will be those who feel that health is the exclusive responsibility of the Ministry of Health. Similar feelings may exist among Ministry of Health staff, though perhaps for different reasons. Staff in the environment sector may feel that a distinct focus on HIA signifies encroachment of the health sector on their sometimes more conservation-oriented objectives in Environmental Assessment.
Build on positive forces
Strategic health/ environment alliance is fundamental
The course organizer would be ill-advised to engage in rear-guard conflicts with such elements. The climate in health ministries and environment ministries is likely to be relatively more favourable. Moreover, they are the two critical ministries when it comes to representation in the course. Less favourable climates in other ministries will have to be assessed for the liability they represent to the success of the course. Some ministries may not be ready for this concept or for the proposed learning approaches. In such cases, it is better to exclude them and let the course first build its own reputation, so that for future courses these ministries may themselves request to be included. Experience with the pilot courses has shown that interactions in the task groups will correct the negative attitude with which some individual participants come to the course. This can turn into a tense and emotional experience, and tutors need to be prepared for such events through their induction.
6.4 Putting in place a Steering Committee
Establishing formal arrangements
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An important first practical step towards the organisation of any course of this kind will be the establishment of a Steering Committee. In principle, each of the participating ministries should be represented in the Committee. This formal liaison between the course organizer and various ministries will serve for partners to act in a coordinated way on jointly made decisions, e.g. on the type and seniority of participants, on the composition of the group of local resource persons and on how to provide follow-up support for the participants after the course. Through their representation in the Steering Committee ministries are kept informed of progress in course preparation, of the achievements of the course and of any developments occurring in the wake of a course. A (semi)permanent Committee can also agree on a series of courses, to ensure that skills in intersectoral negotiation and decision making are acquired by new cohorts of ministerial officials. The Committee may consider and decide on the desirability of inviting representatives of relevant sponsoring, funding or technical cooperation agencies to join its membership. During the preparatory phase, a main function of members of the Steering Committee is to ensure that nominations from all ministries are received before the indicated deadline. The Committee will agree on criteria (see page 45) and use these to select course participants from among the nominees. Discussions and joint activities in support of course preparations will lead to a sense of course ownership by the participating ministries. They will also foster an informed climate of opinion in favour of intersectoral collaboration.
Ensure timely receipt of nominations
A sense of ownership
6.5 Budgeting
Resources in support of the course
The course has been designed on the principle that it can be organized with the exclusive use of local resources. There is no need to fly in international experts, and the course does not rely on sophisticated equipment or materials. In order to get the course established, a transparent budget will need to be prepared. In order to cover all essential components, the following budget lines are proposed: • Preparatory expenditures • Conference facilities, including a plenary room, tutorial rooms, audiovisual equipment, use of the library facilities, a secretariat room • Materials and equipment: training materials and books, calculators, stationary, equipment that may be used during the field trips • Secretarial services and communications • Salaries for course staff • Accommodation and full board for participants and course staff • Local transport for participants, tutors, resource persons and course staff to and from the course venue • Daily subsistence allowance (per diem) for 25 participants (18 days) 5 tutors (20 days) 6 local resource persons (average 4 days each) • Honoraria 5 tutors (20 days) 6 local resource persons (average 4 days each) • Field visits: pre-visits, actual visits, transport, refreshments, allowances • Expenditures linked to opening and closing ceremonies, including preparation of certificates • Organization of social events (tentative) • Contingency funds (5-10% of total)
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Sources of funding
Sustainability of the training course is best guaranteed if full cost recovery is achieved through tuition fees. This should be a long-term goal, but it is not realistic to consider it in the start-up phase. It is, therefore, important to invest in simple but effective (not necessarily glossy) promotion and information materials. These can be used to approach bilateral agencies, which are represented in many local embassies. Development assistance agencies of industrialized countries have been decentralized and decisions about granting financial support to development efforts are now frequently made at the embassy level. Not all bilateral agencies operate in all countries and each one has its own priority areas of interest. The organizer should invest time in profiling bilateral agencies in the country, and identify the ones with an interest in environment-health associations in the context of development, in capacity building and in impact assessment. An institutional affiliation with a well-regarded national training institution will prove beneficial when seeking financial support. Correct channels for
Ministerial clearance
submitting the course proposal to bilateral agencies will need to be investigated. In some countries, ministerial clearance may be required before a proposal can be submitted to an external support agency. National sources
The organizer should also explore national resources that may be tapped once the start-up phase is over and bilateral support is gradually phased out. Usually, ministries have a budget for human resources development, and it is useful to find out the criteria that apply. Other questions include: • Is there a centralized fund for the development of the civil service? • Are there NGOs operating in the country that would be interested in becoming a partner in the organization of this course and provide partial support? • Can private sector sponsorship be arranged and on what conditions? Whatever the opportunities may be, it is a good idea to set up a trust fund for the course during the start-up phase. Cash flow problems can easily arise and jeopardize continuity. The use of a trust fund on a revolving basis will, to some extent, hedge against such risks.
Other questions
Set up a trust fund
6.6 PART II
Specific preparations
42
Allow adequate time for preparations
An institutional framework has been created. Resources have been mobilized to hold the course. Next, a number of steps need to be taken as part of the detailed course preparations. It is recommended that, in the startup phase, these preparations take place over a period of at least five months. There may be major delays in obtaining clearance and nomination from ministries. The formal response to the invitations may be slow, and identifying and scheduling the resource persons may take time. Once the organization of the course has become more routine, the length of the preparatory phase may be reduced. It may be that the course proponent and organizer are the same person. In that case, the proponent/organizer can follow the guidance on specific preparations given below. If the organization of the course is outsourced, sufficiently detailed terms of reference must be prepared and attached to the contract, to ensure all necessary functions are carried out. It is virtually impossible for one person to take care of all preparations. A minimum setup would require one technical, one administrative and one secretarial member of staff to support the course from the first preparations until two weeks after its completion. Specialist training institutions will normally have their own support staff. The key activities at this stage are presented in chronological order below: • • • • • • Identification of a venue. Selection of participants. Recruitment of local resource persons. Recruitment of tutors. Preparation of field trips. Collection of documents.
Terms of reference for organiser
Key activities
Venue selection criteria
6.6.1. Identification of a venue The course venue should meet the following criteria:
• Sufficient isolation from pressures arising from personal and professional obligations. • Good meeting facilities, including a large meeting room, with flexible seating arrangements, that fits about 30 people comfortably for the plenary sessions. • Facilities for the task groups to work quietly. Tutorial rooms are one possibility, but in many tropical countries, an open air space where the groups can retreat on a gallery, on a veranda or under a tree may be preferred. • Office space for the temporary course secretariat. • Library space for the temporary library. • Rooms where the resource persons can do their own work until their services are requested by one or more groups. • The institute should be able to provide basic materials such as flip chart frames, an overhead projector, a slide projector, television and video equipment, computers, printers, a photocopier and possibly a beamer. • There should be basic but clean and comfortable lodging facilities for the participants and the course staff. • Food hygiene should be of good standard, and variation in the menu is important, as the course runs over a three-week period. • IT facilities for use by participants are desirable but are not yet universally available. Materials needed
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The course organizer should provide materials such as paper and pens for writing and flipcharts, overhead transparencies, floppy disks, and calculators. Recreational facilities are an important aspect to look for in the selection of a venue. Experience has shown that, once participants become enthusiastically involved in their tasks, they will be inclined towards continuing their group work in the evening hours after dinner. Because of its length and intensity, this course demands access for its participants to acceptable levels of recreation. The nature of this recreation is very much culturally determined. In some cases, a television and video equipment will suffice. In some of the pilot courses, there was a focus on card and board games. At the end of the pilot course in Honduras, the participants unanimously noted in their final evaluation the lack of sports facilities. In some countries, a choice may present itself between holding the course at a training institute or at a hotel. The pilot course in Ghana was held at the Volta Hotel, near the Akosombo Dam. The other candidate venues were considered too close to the capital city, Accra. A venue far from a capital city effectively prevents participants from returning to their offices and homes during the course. While the course in Ghana was successful in achieving its goals, the experience brought to light two major drawbacks of using a hotel as the venue: the incremental costs and the fact that meeting facilities in a hotel are often less suitable for this type of training course.
Recreational facilities
Flexible configuration of main course room
As participants spend a lot of time in plenary sessions for a number of different functions, flexibility in the configuration of the main course room is an important criterion in the selection of a venue. A standard meeting room with fixed theatre or horseshoe seating arrangements is not suitable. Most professional training institutes will provide rooms with flexible arrangements and tables that can be arranged in rows, in a horseshoe configuration or in small units. The small units are the preferred standard arrangement for plenary sessions: participants are seated with the members of their own group. This flexibility is an important feature to check when visiting a candidate venue. Finally, there should be a library space where the collection of course documents can be housed. The local librarian may be asked to take care of giving out books on loan to participants. The limited availability of documents will put real-life constraints on the research that participants want to do as part of their tasks. In the absence of a library, the organizers will have to improvise and one of the course staff (most likely the reserve tutor, see Section 6.6.4) will perform the role of librarian. Computer literacy among members of the course target audience is generally high and will further increase over the coming years. Not all training institutes will be able to provide IT facilities to accommodate all participants individually (moreover, this would not be desirable for a course based on task-oriented group work), but many will be able to offer adequate access to computer equipment for the four or five groups in the course. Groups will want to prepare their task reports as electronic files and print them out for formal submission. Tutors should monitor that time spent on form is not at the expense of time spent on substance. More importantly, group members may want to access the internet in search for relevant information to complete their task work. This potentially reduces the role of local resource persons, although they, in turn, may assist groups in finding their way to relevant web sites. Information technology will further develop in great strides. Course organizers will have to follow these developments and identify benefits and constraints for a course that is basically about improved information sharing between humans. 6.6.2. When and how to select participants The various ministries, departments, and other local agencies that will benefit from the course were identified when course preparations started. Participants will be selected from among the mid-level managers of these institutions. The initial course announcement and invitation will be addressed to their line managers or directors. The institutions will be asked to nominate a number of candidates for the course and submit their CVs to the course organizers. This should take place not later than four months prior to the planned course (see Table 6.1). The course organizers and members of the Steering Committee will make a final selection based on agreed criteria. They recommend to whom a formal invitation should be sent. A shortlist of reserve participants is also prepared for any last minute cancellations. In the preparations for the pilot courses staff members of country offices of WHO and FAO were co-opted on to the Steering Committee for this function.
Temporary library
IT facilities
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When to select participants
Table 6.1. Planning schedule for selection of participants Time Before the course starts 5-4 months Action Identification of relevant ministries and departments to receive course announcement and request to nominate candidates for the course Nominations of candidates by ministries and departments Selection of candidates and reserves by the Steering Committee Formal invitation and course details sent to selected participants Participants confirm their attendance Course implementation; participants are present throughout Final Course Report sent to participants, ministries and departments
4 months 3 months 2 months 2-1 months During the course After the course Day 1 - 18 2 months
Who should be selected as participant?
The profile of an acceptable participant should include solid professional training and experience, and active engagement in relevant work such as policy-making, development planning and programme implementation. The participant should also still have at least another 5-10 years of career perspectives. At a personal level, desirable features include a strong interest in working with professionals from different backgrounds. Participants should be assertive and good communicators. In order to secure a proper gender balance in the course the organizers should promote nominations of qualified female candidates. Letter of invitation to nominate participants The letter of invitation to nominate the participants should refer to:
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Content of letter inviting nominations
• Objectives, scope, expected outputs and tentative programme of the course. • Role of the Steering Committee and ministries represented in it. • Timetable of the course with a tentative starting date. • Summary of the learning methods used in the course. • Rationale for the need for each task group in the course to include an official from every relevant ministry. • Number and profile of participants. • The need to submit for each nominee a full Curriculum Vitae, emphasising the desirability of a balanced representation of each ministry’s mid-level staff according to experience, qualifications, interest and gender. • The absolute need for all participants to attend the course throughout and without pressures or distractions from their parent ministry. • A possible financial contribution from the Ministry for their participants towards the costs of lodging and board, transport during the course, local per diem, and reimbursement of travel expenses to and from the course (recognising that the release of the staff member also represents an opportunity cost). • A deadline by which the nominations should be received. Some of the above information, including the venue of the course, may be contained in a course brochure that will be enclosed with the letter requesting nominations.
Letter of invitation to participants In this respect the course may differ from normal practice for other courses, as the participants come from different ministries and are sent at the instruction of their ministry. Communication with the participants
The letter of invitation to individual participants will need to explain: • The dates, location, and all logistics and financial arrangements for the course; • The aims and special conduct of the course. • The importance of active participation throughout the course. • The need to return a confirmation of attendance by a set date.
Participants need to feel well-prepared.
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Again, some of the above information may be contained in an enclosed course brochure. The letter of invitation may refer to the fact that the nominee’s participation is in the capacity of “a valued colleague”. This will help create from the very outset the special environment which is essential for the success of the course. Once confirmations have been received, a follow-up letter will provide further logistical details (venue and how to get there, possible transport arrangements). In this letter, the participants will also be asked to collect information on development planning procedures in their sector/ministry in preparation for Task 1. Clearly, definitive arrangements for the course cannot proceed unless the budget is fully secured from non-government and/or government sources. Also, this is not the type of course where an individual can apply and be accepted without forming part of the group of participants nominated by her/his ministry. Even individuals wishing to attend as observers would be disruptive to the learning process. 6.6.3. How to recruit local resource persons The qualifications of the local resource persons will vary according to the context in which the course is run. The context of the pilot courses was water resource development and health in tropical countries. Local resource persons, therefore, included:
Who to recruit as resource persons
• A planning specialist (Task 1) • An ecologist (Tasks 2, 3 and 4) • An engineer (Tasks 3 and 4) • An agricultural scientist (Tasks 2, 3 and 4) • A health systems specialist (Task 6) all with personal knowledge of local conditions and regulations. When the resource persons are needed
The content of each of the Task Guides indicates when and what type of expertise will be needed by the groups. A list of resource persons with their respective schedule of work should be prepared three to four months prior to the course (see Part III). The initial contact with resource persons is established at about the same time (see Table 2). With their formal invitation, the resource persons should receive a copy of the “Resource Person’s
Guide”, which has details about the course concept and content (see Part III). In the letter of invitation they must be informed of the precise dates when they are expected to be available. They should be made aware of the fact that, on those dates, they are expected to be available throughout the working day. Their appointment, the timetable arrangements, and details concerning their honorarium and per diem entitlements must subsequently be confirmed in a formal letter from the organizers.
Table 6.2.
Planning schedule for recruitment of local resource persons Time Action Identification of relevant resource persons Invitations and Guide sent to resource persons Resource persons accept their invitation Resource persons receive written confirmation of their participation and logistical instructions Individual resource persons arrive in good time for discussion of their roles Letter of thanks sent by the course organisers 3-4 months 3 months 2 months 1 month
Before the course starts
During the course After the course
Day 1 - 18 1 month
What is the role of the resource person?
In the Guide, it is strongly emphasized that the resource person is not expected to give lectures in her/his field of expertise but rather act as a consultant to groups that request assistance with issues/problems/questions that they have not been able to resolve. In accordance with this consultancy role, the resource person should also provide information and guidance as appropriate during the daily plenary sessions. Following the presentations of each group’s task report the resource person will offer additional or corrective information or guidance (not a lecture) to the group and the plenary audience. Local resource persons are also asked to appraise the written task reports and provide feedback to the groups. Their appraisal will be used in the final course evaluation. Local resource persons are expected to familiarize themselves with the Task Guides and background materials. Their early arrival will allow the course organizer to brief them. It is important to explain in advance (and remind them at the briefing) that they will be needed only intermittently during the day or days of their participation. It is advisable for the resource persons to bring work of their own, so that they can avoid wasting uncommitted time; for that reason it is desirable to provide dedicated office space for the resource persons at the course venue. Towards the end of their participation, the resource persons will be asked to contribute to the evaluation of the acceptability, effectiveness and efficiency of the course from the perspective of their own role (see Chapter 8).
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Briefing
Profile of resource persons
The profile of the ideal local resource person should include the following features: • A subject expert with practical experience related to one or more of the tasks. • Sufficiently senior to be acceptable to the participants. • Sufficiently flexible to feel comfortable in the role of consultant instead of lecturer. • Available when needed during the assigned period. The number of resource persons to be recruited will depend on the number of topics within each task. The pilot courses employed between one and three per Task. 6.6.4. How to recruit non-expert tutors About three months before course implementation, an announcement and invitation should be sent to institutions that may be potential sources of “non-expert” tutors (see Table 6.3). This could be, for example, a university department that looks for opportunities for young staff to be exposed to novel learning approaches. Certain entities in the government structure or non-governmental institutions may also be potential sources of tutors. The latter may be interested in releasing junior staff if they can see the benefits for their institution in the longer term. The Tutor’s Guide (see Part III) should be given in advance to proposed tutors. It describes all aspects of the work expected from them, including a description of the content of a two-day induction for tutors immediately prior to the course. The potential tutors should be made aware that they will be expected to be available full-time during the entire course and for the two induction days. One month prior to the course, a letter is sent by the course organizers to the selected tutors (with a copy to their supervisor/employer ) confirming their participation. It is advisable to ensure that the initial inquiry about their availability and willingness to participate contains adequate information concerning the aims and conduct of the course, dates, venue, per diem entitlements, honorarium, and expected duties. These data will help them to make an informed decision about whether or not to agree to participate.
When to recruit tutors
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Table 6.3. Planning schedule for recruitment of tutors Time Before the course starts 3 months 2 months 1 month 2 days During the course After the course Day 1-18 1 month Action Call sent out for submission of tutor candidates Proposed tutors accept their invitation, joint selection of tutors by the Steering Committee Selected tutors receive written confirmation of their participation Tutors are inducted Tutors accompany groups during tasks 1-5; carry out their own assignment during task 6 Letter of thanks sent by the course organisers
Who should be recruited as tutors?
The number of tutors to be recruited for each course will depend on the total number of participant groups. There should be one tutor per group plus one reserve. The reserve will be needed in case one of the other tutors drops out for whatever reason and should be available as stand-in at short notice. While on stand-by, the reserve tutor can be given other assignments as part of the team. In order to act as a facilitator supporting the work of a group the tutor must have the following characteristics: • • • • • Not an expert in any major aspect of any of the tasks. Junior or equal to the participants in career status. Sufficiently mature and well-educated to be acceptable to the group. A good communicator, open and not shy. A sensitive, well-organized leader who can provide enthusiasm and gentle direction for a group of professionals from different sectors.
A final selection of tutors will be made jointly by the course organizer and Steering Committee, in consultation with the supervisor/employer, based on the above criteria. What are the roles of the tutors?
The tutors will be made familiar with the overall aim of the course, the problem-based learning approach and the detailed content of the Task Guides. This will be achieved through their participation in a two-day induction, described in detail in Chapter 7. Each tutor will be assigned permanently to one group. The tutor will assist his/her group in working through the sequence of tasks within a defined period of time. It must be stressed that the tutors should not provide subjectspecific information to the group members (this is the role of local resource persons). Throughout the course, the tutors will use their familiarity with each Task Guide and the overall aims of the course to: • • • • • • • Foster group bonding and collaboration within the group. Help their group to plan and organize its work. Encourage open discussion related to each task. Promote alternative ways of arriving at a consensus. Resolve any conflict within the group. Deal with unhelpful behaviour. Act as a link between the group and the resource persons and the course organizers. • Support inter-group competition. • Discuss each day’s work with the course “anchor person” (see Chapter 7). • Contribute to the evaluation of the acceptability, effectiveness and efficiency of the course from the perspective of her/his own role. 6.6.5. Preparation of field trips The course programme foresees two one-day field visits. The first coincides with Task 2, on rapid health impact assessment, and aims to allow participants to make direct observations in an area where a planned devel-
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Link between field trips and tasks
opment project will be implemented. The second field visit coincides with Task 6, the formulation of an intersectoral action plan for health protection and promotion. This visit to a fully operational development project allows participants to learn about its health impact, observe missed opportunities for the incorporation of health safeguards in its design and operation and learn about the community’s coping mechanisms. In the preparations leading up to the course, selection of field trip locations is the main challenge. The organizer will want to visit a number of short-listed locations to verify whether they meet the criteria. Criteria for selection of field visit sites
A number of generic criteria apply in the selection of sites for the field visit: • The site must be accessible within a day’s trip. • There must be development staff on the spot, especially on the site of the first trip. • The development projects visited must be of the same category as the project the groups use as the context for their tasks (ideally, the project visited in the first field trip is the one that serves as the context). • Local authorities must give their informed consent to the field visits. • The risks involved in these field trips must be properly assessed and reasonable. The detailed local arrangements are best made during the course, a couple of days before the trip is scheduled to take place (see Part III). 6.6.6. Collecting documents Abundant documentation is a pre-requisite for this course. The two main sources of written information available to the participants are the documents they receive on registration and the documents that are made available to them through the temporary library.
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On registration
The documentation the participants of the five pilot courses received on registration included a number of relevant textbooks and some of the important national policy documents covering development, environment and health. This not only made it possible for each individual participant to read information of interest whenever he/she wanted to (rather than waiting for a book to be available in the library), but it also provided each participant with his/her own private collection of resource books for future reference. This component obviously adds to the cost of the course and will have to be reflected in the tuition fee. If this model is followed, it is important to indicate in the letter requesting nominations that a package of textbooks will be part of the materials for each participant. A list of the textbooks provided in the pilot courses is presented in Part III. The course organizer should gradually build a collection of relevant documents and textbooks that will be made available to all participants in a temporary library. Such a collection will have to be updated regularly. It is also important to have more than one copy of some of the key textbooks, to facilitate access by the participants. A list of the textbooks that were available in the temporary library of the pilot courses is included in Part III.
The course library
6.7
Final preparations
A week before the start of the course, final preparations will become a fulltime occupation of the organizer and his/her team. Confirmation of attendance
The list of participants will be complete, but some participants may not have responded to the invitation. They or their supervisors in the ministry need to be contacted. In ministries where decentralization has been part of public sector reform, contacting participants who come from remote areas may complicate matters. In these cases, confirmation of attendance must be received no later than two weeks before the starting date of the course, to allow time for arrangements for alternative participants, should the originally selected ones drop out. Very important at this stage is the issue of maintaining a proper sectoral and gender balance. There are several good reasons why ministries may withdraw staff whom they initially nominated. There may be a sudden crisis at hand and presence of the person in question may be crucially important in the ministry’s response. Illness among colleagues may result in unexpected understaffing of a department. There may also be personal reasons (illness, family circumstances) preventing a participant to attend. At the time of inviting nominations for the course, it should have been made clear to the ministry in question that the success of this course crucially depends on an equal participation of all relevant sectors. It may be necessary to bring this point once more to the attention of the ministry’s human resources officer. At this stage, sectoral balance is more important than gender balance, but whenever a nominated and invited woman professional is withdrawn, an effort should be made to replace her with another woman. In ministries where professional staff is male dominated, this, however, may not be a feasible option. On the eve of the course, the definitive number of participants and composition of the group will be clear, and the course organizers can then make final adjustments to the arrangements. The course organizer will allocate participants to small groups of between five and eight persons for the duration of the course. In the case of a regional course this distribution of participants will be by nationality or State. The aim is to achieve a productive mixture of expertise from different ministries, as well as an acceptable gender balance. As there will be several participants from each ministry, optimal complementarity should be aimed for in the allocation process. Delays in arrival should be taken into account, particularly for participants coming from remote areas, but any participant arriving after day 2 of the course (when Task 1 is completed) should be categorically refused access. Bringing in participants at that stage usually requires re-arrangement of the groups and disrupts the group bonding process.
Need for final adjustments
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Allocation of participants to groups
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7 How to run a course 7.1 Anchor: role and characteristics
The anchor: concept and functions
The pivotal person in this course is the anchor man/woman – in short: the anchor. As the name indicates he/she provides the steady point around which the course revolves. The anchor combines the functions of general facilitator, coordinator and overall leader. The anchor liaises with the resource persons, inducts and de-briefs the tutors, prepares the daily programme update and facilitates the plenary sessions. In many instances, the organizer and the anchor will be one and the same person. The anchor’s position requires a person who knows the course in every detail, who has a multidisciplinary background and the capacity to look at issues from different (sectoral) perspectives. He/she should also have good skills in communicating and in interacting with people of all levels and backgrounds and the subtle authority that comes with natural leadership. The variety of responsibilities and activities is reflected in the schedule on page 54.
7.2 Purpose of induction
Induction of tutors
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Two days prior to the start of the course, the tutors are invited to attend a number of induction sessions. These sessions are coordinated and facilitated by the anchor. The purpose of this induction is to familiarize the tutors with the learning approach and the course materials, and to convey to them a number of techniques of practical use in facilitating the group process. The induction sessions should be informal. The anchor starts with an explanation of the course methodology. At the end of the series of pilot courses, it was clear that tutors who had completed their education recently had greater affinity with the problem-based learning approach. The tutors are given their copies of the Task Guides and are asked to go through them as the participants would in their groups. At the end of each page, the tutors discuss the issue and initially come up with technical questions. The anchor should slowly introduce ideas relating to the group process for discussion by the tutors. Issues in the Task Guides that are perceived as ambiguous are also discussed and tutors make notes about them in their copies.
Tutors’ facilitation roles
In the afternoon of the first day, the tutors will go through Task Guide 2 in an accelerated fashion. This is the moment to introduce them to some group management techniques, such as the Nominal Group Process (Delbecq et al., 1975)4. Other facilitation roles of the tutor are also highlighted:
4) Delbecq, A., van der Ven, A.M. and Gustafson, D.H., 1975. Group process for program planning: a guide to nominal group and Delphi processes. Glenview, Illinois: Scott Foreman
A typical day in the life of the anchor during the course 07:00 • • • • 07:30 Finalize the programme update for the day and arrange for its reproduction. Check whether all documents needed for that day are available in sufficient numbers. Check whether the resource person(s) that were scheduled to arrive the previous evening indeed have registered and contact them to set up an appointment for their briefing. Look into any administrative issues that may be pending.
Breakfast of participants and staff (N.B. it is important that participants and staff have their meals together: quality of staff-participant relations was significantly less in pilot courses where they were separated at mealtimes). • • Final word with the tutors about the programme of the day. Check the plenary session room to ensure that the configuration is as required for the function of today’s session. Plenary session starts (it is important from the very start to ensure punctuality and maintain this during the course). Introduction of today’s programme, distribution of course materials for today’s task. Introduction of newly arrived resource persons. Open discussions on difficulties encountered in yesterday’s group work. Question and answer on aspects of the materials presented. Groups start their group work; anchor meets with newly arrived resource person for detailed briefing. Anchor meets with administrator concerning the final logistical preparations for the next day’s field trip.
08:15
08:30
• • • • •
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09:45 10:30 10:50 11:30
Coffee break for participants, all course staff join in. • • Groups resume their work; anchor makes a round to get a feel how groups are doing. Final discussions with the resource persons who assisted in preparing the programme of, and arranging for, the field trip; preparation of copies of the programme for the next day’s field trip.
12:30 14:00
Lunch for participants and staff. • • Plenary session; stock taking of progress of individual groups; questions and answers on task-related issues the groups addressed in the morning. Briefing on the next day’s field trip: objectives, programme, logistical arrangements and recommendations on clothing, (e.g. sun caps and type of shoes). Groups resume their work. Anchor establishes contact with senior officials to confirm their attendance at the plenary session next week, when the groups will present their task reports. Discussion with the resource person about the marking of the task reports that will be handed in by the groups the day after tomorrow.
14:45
• • •
15:30 15:50 17:30
Coffee break for participants, all course staff joins in. • • • Groups resume their work; anchor makes a round to get a feel how groups are doing. Group work stops in accordance with programme (groups or individuals are free to continue to work without the benefit of their tutors). Half hour debriefing session of the anchor with the tutors, to review the events of the day and discuss problems and solutions.
19:30
Dinner for participants and staff. The challenges the anchor faces as the course proceeds are to avoid emotional attachment, maintain high standards, treat personal problems with empathy rather than sympathy and keep the course staff working in a product-oriented way.
• • • • • • • • The second day of the induction
Assisting the group in time management. Reminding the group members of the library and resource persons. Suggesting a division of labour within the group. Switching between different modes of working (round table discussions versus having one member of the group write items on a flipchart). Ensuring that the group is not dominated by one or two participants or, on the contrary, that there are no participants who play no role at all. Crisis management. Acting as liaison between their group, the course team and the anchor. Arranging access to local resource persons.
The second day of the induction starts with a recapitulation of issues, and questions and answers for the tutors. Then the remaining Task Guides are covered in a rapid fashion, pointing out moments where the groups may need special support. The tutors are also informed that groups will carry out Task 6, without their facilitation. Simultaniously, tutors will be assigned to consolidate the group outputs of Task 5. Usually the induction is finished by lunchtime or early afternoon. The anchor must use the interactions during the induction sessions to make a final assessment of the capacities and weaknesses of each individual tutor and come to a decision about who will be held in reserve. If the assessment is correct, the person in question usually accepts the decision, as he or she will have drawn his/her own conclusions at the end of the induction.
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Tutors’ monitoring role
The tutors should also be briefed about their monitoring role through daily de-briefing sessions with the anchor. They should be introduced to other members of the organising team and to local resource persons, and must be made to feel as valuable members of the course team
7.3 Registration
Arrangements for the opening session
Participants of the course will arrive the day prior to the start of the programme. Proper arrangements should have been made to direct them to a registration desk, where they are enrolled, receive the course materials, and are directed to their room. They should also receive an invitation to the opening ceremony and should be orally informed of this in case they don’t immediately read the materials they receive. The Task Guides and the project documentation are distributed to the participants in accordance with the course programme and not on the day of registration. It is recommended that any ceremonial opening of the course be held on the eve of the start of the programme. This will usually be the evening before the first working day of the week. While the presence of dignitaries at this function will certainly add glamour to the occasion and make participants feel that they are part of an important training event, too many dignitaries will kill the ceremony. To be avoided is a situation as occurred at the first in the series of pilot courses, when, following five lengthy opening statements by officials from national and international agencies, the
Please note
Make it special from the start
Minister of Health of Zimbabwe had to ask the audience to stand up and sit down again, lest they would fall asleep on him during his formal opening address. Whatever form the official opening may take, it is preferable to separate it into a formal and an informal part. For the informal part, a suitable location should be selected (some training institutes, for example, have a small outside amphitheatre), where at around 16:00 (before it gets dark) participants, local resource persons present, tutors and other course staff gather and introduce themselves briefly (though more than just by name). This occasion can also be used to convey some of the “household” messages concerning mealtimes, laundry, medical and recreational facilities and options for communication with the family. As the ice is broken, the group is now ready for the formal opening, and the evening is ideally rounded off by a joint buffet or barbecue dinner.
7.4 Introduction by the anchor
Kicking off
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The first day of the course sets the tone for a three-week period of intense and fruitful task work by the participants. From the very start, the participants should sit in their assigned groups with their tutor. The introduction by the anchor should briefly highlight key concepts. These include the methodology, punctuality, comradeship and the role(s) of the various course staff - resource persons, tutors, administrator and the anchor. The subject matter (for example, the health impact of water resources development projects) is best introduced by an illustrative video, to avoid a technical lecture that would conflict with the problem-based learning approach. Following the video, time should be spent on an open question and answer session. Alternatively, a more guided discussion of a quasi-nominal group format could explore the knowledge and opinions of the group as a whole on the subject area that provides the context for the course. The coffee break provides an easy transition to the first task assignment. All group members receive from their tutor a copy of the first Task Guide. The principles of the Task Guide, and the need to keep and manage time are briefly explained (the tutor can fill in the details once the groups have retired to their work place). With this, the actual task work has started and the course has taken off.
7.5 What is learning ?
Initial problems with the methodology
In spite of the fact that adults learn unwittingly on a daily basis through their experiences in solving problems and dilemmas, the task-oriented, problem-based learning approach may meet with adaptation problems at the start. Most participants have a conventional concept of training that relates to passive transfer of information. They are now faced with a situation where they have to take individual initiative in a group with unfamiliar people. The idea that this can represent a learning process at first meets with
disbelief. The tutor will have to provide room in the group’s first discussions to overcome this initial reaction, by letting participants express their misunderstandings, prejudices and insecurities. It will take the first couple of days to deal with wrong concepts. A common one concerns the role of the resource persons. During the first couple of days, most groups will resort to them in the expectation that they will receive a private lecture. The briefing of resource persons must emphasize that such requests are to be categorically refused. Groups will have to learn to formulate exact questions before they turn to a resource person. They will then receive concise and exact answers. Information overload
Information overload is another problem at the start of the course. Participants have just met a large group of new people; they are introduced to an unfamiliar learning procedure. They have to do a lot of reading to familiarize themselves with the development project that provides the context for their task work, they have to make an effort in time management and they have to remember the information sources that are available to them. It has been the experience in the pilot courses that participants need repeated reminders of the presence of resource persons and the temporary library before they start to make efficient use of them. In a more private sense, the anchor and the tutors will have to be alert to initial problems of insecurity and intimidation. For instance, some participants may feel they cannot express their ideas in a group of people with different disciplinary and professional backgrounds. Some may suffer from anxiety. Some may be fathers/ mothers who are for the first time away from their young children for an extended period. Informal settings such as the coffee breaks or mealtimes provide suitable moments to reassure participants struggling with such personal emotions.
Insecurity and intimidation
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7.6
Interacting with the tutors
The tutors have a dual role in this course: they are the group facilitators and have been inducted to perform this function up until the start of Task 6. The tutor is also expected to look after his/her group socially, at meal times and during field visits. They also perform a bridge function between the participants and the course management. Participants should be encouraged from the very start to communicate with the management through their group tutor. Daily de-briefing session with the anchor
From this dual-function perspective, it is important to make the tutors feel that they are part of the course management. This will provide a level of confidence that will benefit communications. The daily de-briefing session with the anchor is an important element in this process. The atmosphere should be kept informal, and the anchor should ensure refreshments are served after a hard day’s work. There will be other occasions for interactions that strengthen the link between the tutors and the management, but care must be taken not to create the impression towards the participants that the tutors are “on the side” of management. This would destroy the basis for their relationship with the group. By the time the groups have finished Task 5 (the formulation of generic Terms of Reference for
Health Impact Assessment), the tutors will have gone through a bonding process among themselves. This will facilitate their final assignment (while the groups work independently on Task 6): the consolidation of the generic TOR produced by the groups into one product. The consolidated generic TOR are a valuable output of the course. At the end of the pilot courses, they were forwarded to the national authorities responsible for impact assessment for their consideration as tools in support of effective Health Impact Assessment. Crisis management
Part of the role of tutors as facilitators is crisis management. This can be very demanding and may require backstopping support from the course management. The balance of power between group and tutor may also lead to abuse. Groups may use the tutor as a messenger, for getting refreshments or even for writing the report. Such situations need immediate correction. In extreme cases, where the relation between a tutor and his/ her group has become untenable, the reserve tutor may be rotated in, while the original tutor may take responsibility for other functions such as management of the temporary library.
7.7 PART II
Course routine
The stage has been set
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On completing the first Task, the construction of a comprehensive development planning framework, participants will have • • • • Become reasonably familiar with the learning approach. Understood the context within which they are carrying out their tasks. A clearer picture of the objectives of the course. Assessed their role in the group, and the roles of the various personalities involved in the course. • Overcome initial insecurities and inhibitions.
From introduction to routine
In several ways, the first Task is a stage-setting exercise, and the next Tasks will be more goal-oriented, directly and logically related to the planning procedures just discovered and familiar to the professional tasks addressed in people’s everyday responsibilities. The difference is the overriding need for intersectoral dialogue to arrive at a consensus that addresses the concerns of all and still satisfies every participant’s professional integrity. From here on, the task work takes on a regular routine: a new Task is introduced, tutors hand out a letter of remit and the Task Guide, groups set to work, morning and afternoon plenary sessions are used to raise issues of common interest, groups produce a report and they present their findings at a concluding plenary session.
Letter of remit
Every effort should be made to create a realistic atmosphere within which groups carry out their tasks. The letter of remit plays an important role in this respect. It is a simulated letter originating from a national authority presenting the group with a problem, explaining a number of policy and/ or procedural issues and requesting the group to carry out analytical work and report on its outcome by a given date. In various pilot courses, such letters were prepared on official ministerial stationary, but in some countries there were insurmountable sensitivities about this procedure. In a
perfect situation, an appropriate high level authority (for example a Director of Epidemiological Services in the Ministry of Health, or a Chair of the National Environmental Management Council) would agree to sign the letter of remit and attend the plenary session when groups present their Task report. This happened a couple of times in the pilot courses in Tanzania, Central America and India and proved to have a significant added value in terms of group motivation. In the pilot course in India, the sense of realism went to the extent that groups submitted their reports with a cover letter in response to the letters of remit they had received ! Generic letters of remit for the tasks are included in Part III, and examples of the letters used in the pilot courses in Ghana and Tanzania can be found on the CD-ROM. Distribution of labour
As groups get immersed in their tasks, time pressure and the level of challenge mount with each new Task and a certain level of competition between groups develops, there may be a tendency of groups wanting to continue their Task work in the after-dinner hours. They then carry on in the absence of their tutor, at the risk of gaining speed at the expense of the quality of the learning experience. This should definitely be discouraged. As an alternative, tutors may propose to groups at the end of the working day to assign individual research and reading tasks to each member that will help accelerate progress in the group’s task work the next day. This will allow groups to go more in-depth on certain subjects (this can be reflected in the final report !) and they also learn to appreciate the amplifier effect of individual efforts as inputs into the group work. At the beginning of the second Task, group bonding will have started and the procedure of assigning work to members of the group will be less tense. It is advisable that in this process a balance is achieved between comparative strengths and advantages of individual group members and “type-casting”, for example on the basis of gender. Particularly in groups with one female participant, the situation must be avoided that she is automatically assigned “secretarial” functions of note-taking and report writing. The tutor will have to play a vital role in guiding these issues along acceptable paths.
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Presentations
The Task Guides recommend their users to make notes of the consensus position arrived at by the group on the various issues it needs to consider, thus, as it were, writing the report while completing the Task. In the final write up of the Task report, responses and positions may be further qualified and backed up by more detailed information collected as part of the Task work. Tutors and local resource persons may give groups further guidance on the length, scope and focus of their reports. The reports must be submitted on the indicated date; groups should not be allowed to build up a backlog of task reports. The local resource person associated with a specific Task will be asked to appraise the reports and provide feed-back to the groups.
… require a formal setting,
In addition to the submission of a report, groups are asked to prepare an oral presentation of their findings and conclusions during a special plenary session. It is recommended that this session be made more formal, by re-arranging the seating into an auditorium style, by having the local resource persons sit at a table on the podium (like an expert panel) and by inviting one or more senior officials, among them preferably the functionary who signed the letter of remit. The anchor should also run this session in a formal way. Proper functioning of equipment for presenting (overhead projector, flipcharts, beamer) should be tested before the session starts. Groups will have six opportunities to present their findings during the course and again, rotation among participants in the group (or active participation by more than one group member in each presentation) should be encouraged.
… and allow for improvements in communications skills
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Participants will be able to effectively apply the intersectoral negotiating skills developed during the course to their full potential only, if they improve their capacity to convey the outcome of the negotiations to their superiors. While this is not an overt course objective, the presentation of task reports offers an opportunity to bring to their attention key points that will help increase the impact of their report. A member of the course staff or a local resource person may be asked to appraise the presentations, using a number of criteria such as: • Condensation to relevant points and key messages: the presentation should be a succinct and logical sequence of arguments without unnecessary details. • Effective speaking: participants may require guidance on how to direct themselves to the audience, their body language, and their speed, intonation and the loudness of their voice. • Projection of overhead transparencies: a transparency should contain a limited number of words and lines, and certainly not a full written page. Colours should be used judiciously. • Projected material may serve as a prompt, but the presenter should face the audience and not the projection screen. • Timing: the time allocated should be adhered to, and there should be time left for questions and discussion.
7.8 Field trip purpose re-visited
Field trips
As pointed out in Chapter 6, the focus of the first field visit is on conditions prior to the implementation of a project; it supports the screening and scoping tasks for an initial rapid Health Impact Assessment. The focus of the second visit is on conditions in an area where a project has been operational for some time, to illustrate missed opportunities, the need for maintenance and coping mechanisms of local communities; this supports the final Task of formulating an intersectoral action plan. The success of the field visit depends on careful prior exploration of potential sites, close liaison with local officials and communities and a welldeveloped plan of activities prepared by the participants. The final logistical
organisation includes transport and catering, as well as some formal recognition for the contributions made by the local officials and communities. The participants need to be familiar with what to expect and what to do during visits. Detailed preparations take place one or two days before each trip. Members of the course team visit the selected site with the following objectives: Pre-visit to field site
• To remind the local leadership of the fact that a group of training course participants will visit the project area (to which they have given their consent). • To identify representatives of different development authorities, of the health sector and of the community who can meet with the group. • To survey the development area (things may have changed since the last visit) and identify locations that are particularly illustrative in the context of the task. • To sort out the logistics, foresee any problems and assess possible risks involved in the trip. The objective of the trips is not just to give the participants a chance to observe a situation with their own eyes. The trip also serves to demonstrate that with proper preparation and well thought-out questions even a oneday trip can yield a wealth of information. Enough information, indeed, to provide a reasonably reliable evidence base that adds value to a screening/ scoping exercise in preparation for rapid health impact assessment or to allow the rapid appraisal of the impacts of a development project that has reached a new steady state. Before the field trips, a plenary briefing session is organized to present the objectives, programme, logistics and proposed way of working (see also the generic field trip programme in Part III). In short, on location the groups of participants will rotate to meet with various key informants and to make direct observations of specific environmental conditions and of local health facilities. They will have prepared a list of questions for each key informant (group) to ensure maximum benefit from 10-15 minute interviews. If time permits and it is socially acceptable, participants should also be encouraged to wander off in a local community by themselves, in a rapid rural appraisal fashion. The pilot course in Ghana included a visit to a local community where the development of irrigated rice production was proposed. In the official meeting with the community leaders the appreciation of this project was very positive. On a stroll through the village, some course participants met a group of young males who had purposely not been invited to the official meeting and whose opinions painted a very different picture ! On the morning following the field trip, the plenary session should in part be dedicated to a reflection on observations made so that the different impressions are shared and validated into a collective experience.
Briefing
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7.9 To reinvigorate and to motivate
The debate
The debate will take place approximately halfway through the course. It anticipates a low in enthusiasm and energy that tends to occur during a lengthy and strenuous course. The rationale has been explained in Chapter 4. The motion to be debated is “intersectoral collaboration is neither desirable nor practical”. The debate is intended to be light-hearted and enjoyable and to revive interest and energy. The participants are split into two groups and each elects three colleagues to speak on their behalf. These groups decide their arguments and the order in which the spokespersons will speak. A chairperson is provided by the course organizer. Each team has up to five minutes for its initial statement, three minutes to respond to the opposition, and two minutes for their final plea. Two neutral judges determine which team has won, based not only on the elegance of their argument but also on the energy displayed by the rest of the group in supporting their protagonists. Great care is taken to ensure that everyone is given a prize. The prizes are given first to the group that has been declared the winner.
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7.10 Final week and closing ceremony The final two tasks
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On completion of Tasks 3 and 4, the groups are requested, in a letter of remit, to formulate generic Terms of Reference (TOR) for Health Impact Assessment. This is Task 5 and the only Task for which no Guide is provided. The assumption is that, through the task work so far, participants will have (1) recognised that the lack of sound Terms of Reference often is one of the main causes for poor HIAs, and (2) identified items that must be included in an adequate TOR. This is the last Task for which the tutor accompanies the group. Task 6 is part of the course evaluation and will, therefore, be the sole responsibility of the members of the group. As already indicated above, tutors will be asked to consolidate the group products of Task 5 into one generic Terms of Reference document. This will be presented to the groups for their advice and decision whether or not to forward it formally to the relevant national authorities. Task 6, the formulation of an intersectoral action plan and the drawing up of a Memorandum of Understanding for the implementation of the action plan is not only of value for course evaluation. For the participants it is the culmination of all previous task work, and the generation of a forwardoriented product that would, in real life, be the start of an operational phase. It is, therefore, important to make special arrangements for the final plenary session. Certainly for this session an effort should be made to have a senior politician or ministry official in attendance. There should be a formal and at the same time festive atmosphere, conducive to successful and
Special products call for special arrangements
convincing presentations of the product of three weeks of hard labour. Others who played a role in the course may also be invited: Steering Committee members and representatives of communities that were visited during the field trips. Local resource persons can contribute with frank criticism and honest appraisal. The presentation of Task 6 findings, conclusions and recommendations are followed by a one hour evaluation session. In the pilot courses a final session of the anchor with all participants was included in the afternoon, where the group reflected on the significance of the course that had just come to an end, what they could do to implement the knowledge and skills they had acquired and what obstacles they might meet in working differently (i.e. more intersectorally) in future. The closing ceremony
The final evening is reserved for a joint dinner with the presentation of certificates of successful completion of the course as the formal highlight. The anchor presents the Certificate to each participant individually. There may be entertainment organized either by the course staff or by the participants or both. Levels of exhaustion are normally high and participants will usually retire for an early night.
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8 How to monitor and evaluate a course 8.1 How to monitor the course Acceptability
The key criteria for monitoring and evaluation of the course will be acceptability and efficiency. Acceptability looks for evidence that the conduct of the course is acceptable to those who participate in the course and to those who organize and deliver the course. Lack of acceptability reduces the quality of learning and teaching and thus the effectiveness of the course. Efficiency, that is the time, effort, facilities, and resources expended by providers and participants, is closely related to acceptability and affects the sustainability of the course. Clearly, neither the providers nor participants should be expected to devote more than a reasonable, sustainable amount of time, energy, facilities, and resources before, during and after the course. Methods of monitoring Three methods are used: a questionnaire, the Nominal Group Process, and interviews. Examples of methods can be found on the CD-ROM in Part III.
Efficiency
Questionnaire
A questionnaire is used when the course coordinator and the administrator need the participants’ perceptions of a range of specific aspects, e.g. the timing and length of the small group discussion sessions, timing, and quality of the different meals, recreation and accommodation. Because questionnaires do not necessarily provide the participants with an opportunity to express their personal concerns, likes and dislikes, the questionnaire is only used at the end of the course, in order to collect detailed information for the improvement of subsequent courses. Nominal Group Process The Nominal Group Process is used at the midpoint of the course, when the participants have gained adequate experience of both the content, the process and the environment of the course to be able to form a personal view of the acceptability of the course (also see page 53). The participants elect a chair and a rapporteur, and the anchor explains to them “the rules of the game”, as follows:
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Acceptability, participants’ own perception
(i)
The chairperson invites all the participants to write on a piece of paper three aspects of the course, which the individual has found so good/ pleasant/helpful that they should not be changed. Each participant is also asked to write down three aspects, which they have found so bad/ unpleasant/unhelpful that they must be changed. (ii) After a maximum of three minutes, when everything that is of real concern will have been written down, the chairperson invites each participant in turn to nominate one good and one bad issue - without explanation or justification. So that every individual can feel that she or he has a genuine opportunity to voice their views, there should be complete silence from the other participants. The participants’ comments should be phrased in not more than four words, e.g. “tutor
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interfered too much” or “evening meals awful” to allow the rapporteur to write all the comments on the blackboard or flipchart (the good in one column and the bad in a separate column) (iii) A new comment that has already been recorded, though perhaps in slightly different words, provides an opportunity to ask participants to cross it off from among their items. They should be instructed to do so for any item already nominated by another colleague. This helps to keep this monitoring session as brief as possible. (iv) When the first round has been completed, the chairperson will invite further nominations of a good and a bad aspect from each participant in turn. (v) Quite soon many participants will say “no further comments”. The chairperson can then call for those who have one or more comments yet to be recorded to raise their hand. (vi) When these residual comments have been noted, the chair will point to each recorded comment in turn. In case clarification of meaning is asked for by one or more participants, the person who made the original comment is invited to provide a brief example which explains the meaning - lengthy explanations or justifications should be discouraged. (vii) Lastly, the chair will call for a show of hands from those who agree that a comment is of major importance. The participants can vote for as many comments as they regard as important. The rapporteur will record the number of votes for each comment, so that the collective perceptions of the participants provide an order of priority for the good and the bad aspects respectively. (viii)This information is then shown to the anchor who will join this session to discuss the outcomes and any resulting changes in the course with the participants. Interviews Interviews with the tutors and with the local resource persons are undertaken by the anchor.
With tutors
The tutors meet as a group at the end of each day. They act as the official link between the participants and the coordinator, so that any problems that affect individuals or groups can be discussed and resolved on a daily basis. Support for tutors
A further subject for discussion is how each group is progressing within its current task. This also provides an opportunity for the tutors to exchange information in relation to their task as group facilitators and to obtain advice and support from the coordinator. This bonding with and by the tutors is a vital element in the overall success of the course. It is thus important that this debriefing session should be uninterrupted and in a private, relaxed setting with some form of refreshment.
Support for local resource persons
Repeated discussions by the anchor with each local resource person will also be important. These quite senior people may have travelled long distances, in order to contribute to the course. They need to feel that their input is valued and that due attention is paid to their comfort. These considerations are the more important, as the resource persons are not expected to give lectures but to act as consultants who respond to requests from the groups and who provide constructive feedback during plenary sessions. They may thus feel significantly underused. The anchor will keep detailed notes of his or her conversations with the tutors and the local resource persons. These notes will be a very fertile source of information for deciding on changes for subsequent courses.
Note keeping
8.2 How to evaluate the course Questionnaire For acceptability and efficiency
The methods used for the evaluation of this course follow: An end-of-course questionnaire to record the participants’ perceptions of specific aspects of course related expenditures of time and money. A similar questionnaire is completed by the local resource persons. A pre- and post-course questionnaire aimed to establish any change in the participants’ knowledge and attitudes in relation to intersectoral collaboration. Assessment of the groups’ output from Tasks 5 and 6
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For effectiveness
• A generic set of Terms of Reference for consultants. • An intersectoral plan of action with a draft Memorandum of Understanding. These documents should show to what extent the groups had been able to apply their understanding and knowledge. They should also provide evidence of the groups’ ability to work cooperatively to accomplish intricate tasks within tight limits of time. For this reason and to assess their capacity of intersectoral collaboration, the groups carry out their last task without their tutor. The course organizer needs to invoke the help of one or more appropriate experts to assess the work of the groups. A marking schedule may be helpful to judge the groups’ growing competence in their oral presentation of their end of task reports. The schedule might help to record whether • All members of the group participated in the presentations. • All pertinent information was presented in a logical sequence and with the omission of fine detail. • All presenters spoke audibly, not too slowly and not too fast, referring to, but not reading from legible overhead transparencies, facing the audience and not obscuring the projection screen. • Lay-out and contents of the presentation materials was adequate.
Progress and achievement
Oral report assessment
8.3 Long-term evaluation Long-term evaluation is highly desirable but may prove more difficult. It would aim to answer the following questions: • What use have the participants made of the competences, which they developed during the course? • What help did their senior colleagues provide to reinforce and develop further what they had learned, and to encourage them to practise intersectoral collaboration? Post course communication
Communication with the participants will also be desirable after the course to send them the results of monitoring and evaluating the course; to lend continuing support as the participants come to apply what they have learned; and to obtain information that relates to long-term outcome evaluation.
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