Pomurje, Slovenia is one of the pilot regions within the HE2020 project. It conducted a capacity audit structured in two phases during May-June 2013 and the main goals were to:
- test some of the tools developed by the HE2020 project with regard to conducting capacity assessments and audits
- monitor the development of regional capacities in reducing health inequalities
- identify strengths and weaknesses of current support of capacities building available to stakeholders.
The Centre for Health and Development Murska Sobota, already had a well developed Regional Action Group (37 member institutions from different sectors). Identifying organizations / stakeholders that could take part in the capacity audit was a process based on: (1) a systematic review of the members of the already existing Regional Action Group (2) selecting stakeholders from variety of relevant sectors rather than focusing only on the health sector (3) assessing the prior / potential engagement and motivation of stakeholders. It included representatives from the Employment Agency, Regional Development Agency, Civic Society Representatives, important local business owners, a regional News Company, representatives from local community nurses, environment protection organizations, and rural development, and others.
The approach this capacity audit took was to conduct a series of 10 interviews with these major stakeholders following the NSW (2001) Framework to capture information on all capacity domains: Organization Development, Resource Allocation, Leadership, and Partnership. It used an adapted version of the Interview Guide for Capacity Assessment developed under the HE2020 project to be found in the appendix section.
Some relevant impressions with regard to the process of conducting interviews for a capacity audit include:
- The concepts of social determinants of health, capacities and cross-sector co-operation are more or less familiar to interviewees. It is therefore recommendable that the interviewer provides a brief explanation of health inequalities / capacity building through the use of diagrams and visuals.
- Some of the interviews followed a structured approach (similar to a questions and answers session) with specific questions for each capacity domain. Others were more flexible and took the form of a discussion. Therefore, interview style should be adapted as much as possible to the interviewee in order to enable him/her to share as much information as possible and create a relaxed atmosphere.
The capacity audit tool could deliver:
- contextual information about the situation in the region (e.g. economic situation, demographic situation, local culture and value system, political situation- relation to national or local level, education levels, access to services);
- an assessment of capacities (organization, workforce development – training, resources allocation, leadership, partnership) of the organization / other relevant actors / stakeholders
- the output of the capacity audit could be used as a step to set priorities for the development of capacities in agreement with the other stakeholders.
Main results and recommendations
Organizational Development. Cross-sector co-operation on health and health equity matters exists but at an informal level while knowledge about involvement in policy process is missing. One of the conclusions emerging is the clear need for community capacity-building. The system structures need to be more flexible, facilitate clear avenues of communication and co-operation and create a long-term commitment to shared goals for the region. There is no evidence-based decision making with regard to policies or interventions. However, using success stories and good practices has led to some results.
Workforce development. Resources for workforce development exist but there are many structural factors that make them unattractive to employees (lack of support from management, bad time management in parallel with work requirements; costs are sometimes covered by employees). With regard to health equity in particular there is only informal training. The “learning-by-doing approach” helps build experience and interactions between colleagues with greater expertise. One possible conclusion with regard to this is the importance of investing in individuals, education and growth as opposed to infrastructure investments (e.g. hospitals) with a limited return on investment.
Resource Allocation. The availability of funding does not seem to pose challenges to health and health equity projects but rather to budget allocation. The health system is not badly financed but the allocation of resources does not match the actual needs of the population or the system. Additional funding should be directed towards human resources, investing in know-how and expertise as well as basic infrastructure (internet, technology, space). This allocation should be done more at a regional or local level where needs can be better assessed. Moreover, feedback channels should exist between the central planning and communities in terms of how resources are allocated.
Leadership. It was possible to get a picture of the region and the legal background of structures. The responsibilities regarding addressing HI in the region are not clear. It was difficult for stakeholders to identify leaders, although The Centre for Health and Development Murska Sobota appears to have managed to take on the role of promoter. However, there is no joint vision for the region; managerial support remains a decisive factor for any initiative at a local level. There is a need to build motivation among stakeholders and give them sense of ownership about the decisions they make.
Partnerships. There is a wide network of NGOs at a local level but as they do not form a large network they do not have a strong voice within the region. Partnership is undertaken usually through informal rather than formal forms of co-operation. On the other hand, health professionals cannot put health and health equity on the discussion table alone. From this perspective there are opportunities for implementing a cross-sectoral approach and building stronger partnerships with stakeholders who have already demonstrated positive outcomes.
Lodzkie Region, Poland is the other pilot region within the HE2020 project. The capacity audit was conducted between September 2013 and April 2014. Medical University of Lodz, the organization conducting the assessment, produced 5 short reports based on interviews with members of the Regional Action Group (RAG): the National Health Fund, Department of Health (City of Lodz), Department of Health Policy (Regional Government), Department of Regional Policy (Regional Development) and Medical University of Lodz.
Using the interview as a benchmark, the interviewer also conducted a short report. One of the assessments was made virtually via emails but followed the same procedure. A general assessment was produced afterwards aiming to give a general picture of capacities at a regional level.
The capacity audit was done in parallel with the needs assessment. The two stages complemented each other very well as qualitative data also requires some statistical background and justification to make strategic decisions in terms of capacity building.
Impressions with regard to the process of conducting interviews for a capacity audit:
- Due to the flexibility of the NSW (2001) Framework, no major difficulties were encountered. Generally, an interviewer with a sociological background should be able to adapt the tool, describe its purpose to the interviewee and manage to conduct the capacity audit interviews successfully.
- It is advisable to provide some specific information about what capacities means and provide some useful terminology or definitions. This would make the auditing process more effective.
- Not all elements of the tool are applicable to all interviewers and presumably to all types of regions.
- The Capacity Audit proved particularly important for the identification the interests of stakeholder’s, who could also use this opportunity to build partnerships for common goals.
- As a first capacity audit / assessment done in the region for health equity purposes there was no benchmarking, criteria, prior assessments for comparison. Consequently, there was no clear view with regard to a clear road map to follow or clear goals to set. However, what the capacity audit did manage to achieve was: an important stakeholder analysis; an assessment of assets and gaps in terms of capacities available at a regional level for health and health equity; opportunities for future development.
Main results and recommendations:
Resource Allocation. There are no budget lines for reducing health inequalities although some financial resources are dedicated to socioeconomic intervention that could have an impact on health equity in the region. What would help investments in that direction is providing more evidence (data, indicators, statistics, measurements) on health inequalities and their impact.
Leadership. The lack of leaders in the area makes it very difficult to exchange and communicate possible strategies and good practices. When leadership can be identified in a specific area, political barriers also appear to limit their ability to transfer experience to the regional level.
Partnerships. Building partnerships at a local level is seen as a common activity for some of the sectors (the business sector) while for others it can be seen as a major challenge.