Elizabeth Villanueva
Evidence Base Practice
Abstract
Tuberculosis is a bacterial caused disease which majorly affects the respiratory system with its effects with time, affecting the body and the entire immune system. Tuberculosis in this age of HIV/AIDs is a major opportunistic disease which if not detected early can exacerbate the health of a patient with HIV/AIDS (National Tuberculosis Conference (Bangladesh), Hossain, S, & National Anti-Tuberculosis Association of Bangladesh, 2009). Immigrants have traditionally been the most vulnerable groups when it comes to tuberculosis. Immigrants globally have been a hot bed for the deadly disease. The level of exposure of Tuberculosis among immigrants around the globe is occasioned by a myriad of factors, including lack of proper medical care, poverty and congestion in refugee camps. Poor sanitation in areas majorly occupied by immigrants is another factor that most probably could lead to high infection rates among the immigrants. Policies and programs have been developed to curb the disease.Todrys (2011) suggests that for proper formulation and implementation of anti-tuberculosis policies and programs there has to be mechanisms that ensure that the affected groups are involved in the entire process of fighting TB. Studies show that involvement of affected groups in fighting any disease is a paramount aspect of curing a disease.
Introduction
Therefore, the aim of this paper is to design a program that ensures maximum involvement of populations affected by the disease in formulating policies and in their implementation. In many occasions, patients are left out when it comes to planning and implementing anti-TB policies (National Tuberculosis Conference (Bangladesh), Hossain, S, & National Anti-Tuberculosis Association of Bangladesh, 2009). The paper will thus look at the entire planning process and the implementation of at least two strategies that would meet the objective of the program, which is to involve all the stakeholders in the policies aimed at fighting the disease.
Stakeholders Involvement
Developing any strategic plan involves a series of actions whereby in of them that is ignored would render the whole process ineffective in the long run. Developing the Mission Statement, Goals, and Objectives for the immigrant population call for such an approach since it should be beneficial to the intended population now and in the future (Dyer, 2010). Similarly, it is crucial that representatives of these populations are immensely involved in developing these goals, objectives and mission statement.
These representatives have crucial knowledge of the problems affecting the people they represent and are, therefore, a crucial part of this program. These would include any individual or group of persons who are either involved in the operations of the program to be used, individuals who will be affected or served by the program and any other relevant group who can be deemed as the primary users of this program. It is quite important to realize that the role of the stakeholders will vary from one phase of the implementation process to another. The target is, therefore, to increase the credibility of the high priority stakeholders including those who will fund the program, implement or authorize changes to the program. These stakeholders will include program managers, health outreach workers, clinicians and nurses, patients, immigrant population members, community based organizations and community planning board, the policy makers, schools and universities, health care providers, the business community and health department administrators at all levels of administration.
According to the Public Health Agency of Canada (2013), each of the stakeholders has an important role to play. Despite the variation in the roles and priorities, none of them can be overlooked so as to ensure better results of the whole program. The patients for instance will be required to define the health problem in the context applicable to the program through guidance by the stakeholders such as nurses and clinicians who interrogate them during medical checkups or visits. The most primary information will, therefore, be provided for patients as they are the directly affected population of whom the program is meant to cater. On the other hand, the nurses and the clinicians together with all other medical personnel handling the patients will be required to take the patient through a thorough and effective interrogation section. They are also required to inform patients of the ongoing arrangements and notify them of their role in which case, it should be a voluntary process for any participating patients.
The medical practitioners will also be required to disseminate the data collected from the patients into the program. This involves defining the TB problem in the context applicable to the program for easy use by implementers of the next phase of the program. The program staff, on the other hand, will receive the information as it was fed into the system by the medical practitioners involved in the program and define the program processes to suit the primary objectives defined by the program (Reichman&Hershfield,2011). Their sole purpose is to ensure that the information is processed and presented to each of the stakeholders in the most relevant form so that they can be able to use it for the next phase of the program. The program administrators will then ensure that the information is disseminated to the community audiences, funding organizations or groups, agency leaders and policy makers in a manner that suits their role in the next phase of the program.
At this point, the role of the program administrators will broaden so that it brings the individual efforts and results of each stakeholder while providing a close follow up of the expected role of each stakeholder. An example of such, a follow up would be to creating an effective link between the policy makers and the health department/ministry. Similarly, Reichman andHershfield, (2011) suggest that they would be required to provide logical model of how the funds should be channeled along the program phases. The program administrators and staff are tasked with ensuring credibility of the whole program.
Developing Mission Statement, Goals and Objectives
The program consists of two strategies that will take four months to implement each.
Strategy one: create a liaison between community members and the health professionals.
Strategy two: Conduct research on Tuberculosis among immigrants and work on the recommendation in order to reduce the prevalence rate of the disease.
Mission statement
Engage various stakeholders in helping curb TB incidences among immigrant populations.
Objectives
- Inculcate Tuberculosis awareness in the community and the health sector.
- Ensure a sufficient pool of expertise to curb TB in future.
Strategy 1
As Reichman, (2011) states, that one of the strategies is to create a liaison between community members and the health professionals. As seen below, the only group of stakeholders involved in fighting who work outside the medical profession is the affected population /patients. Therefore, creation of a liaison between community members (immigrants) with the health organizations is a basic strategy in meeting the objective of the program. Community based organizations and schools come in handy in creating a liaison between the groups in hand with the health providers. Immigrants form a very timid group which may fear to disclose all the information to the health providers such as doctors. According to Anderson (2009), this lack of communication has stalled coordination between immigrants and other stakeholders when it comes to policy implementation. Community partners have a close contact with immigrants or are in touch with the situation on the ground.
Therefore, exchange of information between the two groups becomes a paramount aspect. This means that other stakeholders such as the policy administrators, IT professions and program managers are need for the objective of this program to materialize. Policy administrators will play a follow up role in the entire implementation process and the program managers will seek finances and create a link with the sponsors of the program such as the government or nongovernmental organizations.
Below is a tabular summary of the objectives of the strategy, activities involved in its formulation and implementation.
Strategy-1 Gantt chart
(Days)
0 30 60 90 120
Key
Activity 1: Bring together stakeholders
Activity 2: Problem definition
Activity 3: Defining roles
Activity 4: Creation of an IT-based liaison
Strategy –2 Gantt chart
0 30 45 75 90 105 120
Key
Activity 1: Involve stakeholders
Activity 2: Problem definition
Activity 3: Data collection
Activity 4: Data analysis
Activity 5: Presentation of findings
Activity 6: Implementing recommendations
Strategy 2
Conduct research on Tuberculosis among immigrants and work on the recommendation in order to reduce the prevalence rate of the disease.
Research is along an established method of finding solutions to problems facing humanity. A research on the factors that have contributed to the high prevalence rates among immigrants and consequently find out ways and means of curbing the disease is another resourceful strategy in combating the disease.
Budget Statement
A budget is a document for recording actual and projected income and expenditures over time. The budget statement is the pro-forma statement for all the possible expenditures and sources of income to cover those expenditures. Budgeting is the most common and widely used standard device for planning and control. In other words, budget statement incorporates all the possible incomes and expenditures associated with any project or business that facilitate the planning process in the organization. It includes all the sources of income, and all the possible expenditures the organization might bear for accomplishing a particular task or within a time frame in the organization. As the focal point for key resources decisions, the budget process is a powerful tool, the quality of decisions resulting from the budget process and the level of their acceptance depends on the characteristics of the budget process that is used.
Here, in the project, the major objectives are to inculcate tuberculosis awareness in the community and health sector as well as a sufficient pool of expertise to curb TB in future. The possible sources of income as per planned here is donation from different government, non-government, and public level institutions. Since, the program is non-profit motive, the only source of income here will be the donation or other grants from government side to cover the required cost of the project. The expenditures for the program shall be expenses on the human resources, and other tangible resources. The human resources here are the health persons who are directly involved in the awareness program, health practitioners to create the sufficient resource for the program and to curb the tuberculosis in the future, and health researchers to conduct researches on the exact health condition of people in society and find appropriate measures to reform it. The other associated expenses are the physical resources such as brochures, pamphlets to create awareness in the society, web based awareness programs, medicines, electronic devices and other resources to support the awareness program. The program also requires certain health devices to treat tuberculosis in order to completely curb it in future time.
The listed budget statement for all the income and expenditures associated with the programs are mentioned in the table as following:
The table above contained the budgeted revenue for the period of six month. Here, the major source of revenue is donations from the institutional and individual donors. The individual donors here incorporate all the donors at household level who tend to donate as per their wish and capacity. The institutional donors are the INGOs, corporate houses who tend to blend their corporate social responsibility with our programs, and other health related institutions. Apart from it, a portion of revenue is allocated for the government grant for conducting a social health related program in the country. This shall incorporate the government’s budget on health care program to have precaution against any long term communicable disease. There shall be different programs organized to educate people about the disease and its probable precautions. For this, several other institutions will be allowed to place their stall in program with a particular sum of money. This shall be the other source of income for the program allocated. Within the period of six months, at least three of such programs shall be organized to accumulate the required sum of money.
The expenditure side also incorporates some of the budget expenses as the expenses to conduct the programs based upon the main objectives. Some of the budged expenditures identified as per the preliminary studies are mentioned as following:
The major expenses here for the program are the cost of health practitioners. The major cost associated with the program is the cost of doctors and other health practitioners. Apart from it, medical instruments are one of such major expenses. There is significant amount allocated for medicines and other related labors for the program. The miscellaneous labors include the labors used for transportation and other activities that are supportive for the project. The miscellaneous expenses include the expenses that shall be incurred in the hidden headings not allocated at the time of planning. Such heading provides cushion for project to perform their task without any visible hassle in the future as the unforeseen contingencies are lot for the period of six months.
Break Even Analysis
Cost- Volume-profit analysis looks at how profit changes when there are changes in variable cost, sales price, fixed cost and quantity. The fixed costs associated with the projects are the cost of doctors, health equipment, education materials and medicines as these costs are bore by company at the time of starting of the project. The associated variable costs with the project are cost of health researcher, labors in the program, and miscellaneous expenses. Per unit revenue for the program is allocated to be $10 as the target audience here is fifty thousand. Similarly, variable cost per unit becomes $2.6 as the allocated variable cost is in total of $130,000 to be divided among 50000 target audiences. Thus the contribution margin per unit becomes $7.4. For break-even analysis, the total fixed cost of the project is $370,000 including the cost of doctors, education materials, health equipment, and medicine expenses. Thus, the break-even analysis for the number of target audiences that must be served in order to equalize the expenses in fixed cost can be calculated dividing total fixed cost divided by total cost generated from the contribution margin of the fund. Thus the break-even point for the project is 50000 audiences. Here all the target audience must be served in order to achieve the total cost of project. Since, the project is non-profit motive project, so the revenue beyond break even cost is profit. The budgeted statement is prepared in such a way that there is no additional revenue associated with the project other than the expenses to be incurred.
Budget Variances
The budget variances analyses that are favorable and unfavorable for the project are those that create positive value for the program. Any variances that reduce the income are unfavorable variances whereas any that reduces expenditures are the favorable variances for the project. The variances expected here in the project is ±5% than the estimated values as the costs and revenue expected are kept without much for the cushion fund. The miscellaneous expenses can be reduced with tight scrutiny of all the associated project cost. The reduction of miscellaneous cost can have favorable variance on the budget explained on the range as following:
Here, the total revenue generated can be up to the amount of $525,000 in case of favorable situation and can be reduced up to $475,000 in case of unfavorable situation.
For expenditure, the variance analysis can be presented as following:
Here, the favorable situation in budget reduced the expenses to $475,000 whereas the unfavorable situation in budget increases the expenses to the extent of $525,000.
Project Evaluation
Program evaluation is a systematic method for collecting, analyzing, and using information to answer question about projects, policies, and programs. Frequently, programs faced with budget constraints because most original projects do not include a budget to conduct an evaluation. There are several methods for program evaluation that include quantitative, qualitative, or social research methods. All of such measures are viable to measure the program included here in the project. The major dimension to be measured here can be the quantitative method that analyzes the variance of the actual income and expenditure to the budgeted income and expenditure and evaluate the effectiveness of the program. On the other hand, the evaluation technique such as qualitative method evaluates the effectiveness of the program compared on the ground of qualitative variables and evaluates the effectiveness of the program. These techniques are viable for both of the project. The social research method researches and illustrates the visible social changes through the implementation of the program. This method can be conducted using the research statistics of tuberculosis before and after the implementation of the program.
The program assessment technique as suggested by Rouda & Kusy, 1995 includes the following stepts in evaluating a project:
- Performing GAP analysis where the evaluators compares the current situation and the desired or necessary sitaution. This helps to identify the purpose, aim of the program and that defines the vision and mission of the program.
- Identify priorities and importance where evaluators define the number of interventions to address the identified need in the gap assessment. These needs are then examined on their significance of program’s goal and constraints in terms of cost effectiveness, executive pressurem and population.
- Identify cause of performance problem or opprotunitties to identify the problem areas within the program that need to be addressed or the are that are not performing as per the par situation as planned in the project.
- Identify the possible solution and growth opportunities that compares the consequences and the intervention required.
Here, the evaluation method followed for the estimation of program effectiveness can be using the budget constraint model for evaluation. According to the method suggested by Bamberger, 2004 suggest that The budget constraints may be addressed by simplifying the evaluation design, revising the sample size, exploring economic data collection methods or looking for relaiable source of data. In this methods, the evaluation of project is done on the basis of actual performance and the budget benchmarks at the planning level.
Evaluation Methods
The evaluation method followed here would follow the budgeting benchmark and the actual performance of the program. To facilitate this, the semi-annual budget (budget for six month as illustrated above) is broken into the budget of six consecutive months. For this, the budget is allocated as 50% for the first month where there are several startup costs associated and remaining five month include 10% of budget each. The evaluation of the project is started right from the second month of their performance, which is allocated in the chart as following:
1st Month 2nd Month 3rd Month 4th Month 5th Month 6th Month
Activity 1: Evaluation of First month’s individual performance
Activity 2: Evaluation of Second month’s individual performance
Activity 3: Evaluation of Third month’s individual performanceActivity 4: Evaluation of Fourth month’s individual performance
Activity 5: Evaluation of Entire Six month’s individual performance
Here, the activities from 1 to 4 include the evaluation of monthly performance on the basis of allocated monthly budget, whereas the activity 5 is parallel through all the process that evaluated the entire effectiveness of the program with reference to the total estimated six month’s budget. The Gantt chart suggested that every next month the performance of previous month’ s performance is measured on the basis of monthly budget as well as on the basis of the total semi-annual budget.
Evaluation Plan
The evaluation plan here in the budget is based upon the budget constraint model for program evaluation. In this model, we determine the effectiveness of the program on the ground of the allocated budget constraints and the actual performance of the program. As illustrated earlier, the variance analysis allocated the fluctuation range of ±5% between the actual and budgeted value for the project. The project must be reviewed thoroughly if the actual performance value is beyond that limit. If the performance value is above the favorable situation then the program must be reviewed adding additional values to the project whereas the unfavorable situation must be reviewed at the performance lagging associated with the program.
The evaluation plan can be divided into two measures i.e. short term evaluation method and long term evaluation method. Short term evaluation method shows positive result in the program as the regular use of medicine in tuberculosis patients may show positive impact upon their health condition. But in long term, the disease must be permanently cured in order to generate the favorable outcome out of the program. Thus, the evaluation method should incorporate both the long term and short term evaluation technique for evaluation.
The evaluation plan should include the evaluation of project on short term i.e. monthly basis as illustrated in the Gantt chart above and the long term plan i.e. the entire effectiveness of the project based upon the entire performance of program to meet its objectives to create social awareness on the tuberculosis and to eliminate tuberculosis from the society. Every month the values of performances must be measured in terms of the monthly budget and actual performance plan as well as parallels on the actual and total performance plan of the project. The project performance measurement should include the performance criteria to determine the overall feasibility and performance standards of the projects and the values that lagged behind. Every month the corrective measures must be identified to fill the gaps associated with the budgeted plan and the actual plan. The corrective measures must intend to fulfill the gaps between the actual performance and performance plan based upon both the monthly performance and the total performance of the project.
References
Acornlive. (2009). CVP. Retrieved January 19, 2014, from http://www.acornlive.com/demos/pdf/P2_PM_Chapter_5.pdf
Bamberger, M. (2000). The evaluation of International Development Programs: A view from the Front. American Journal of Evalutaion, 95 - 102.
Bamberger, M. (2004). Shoestring Evaluation: Designing Impact Evaluations under Budget, Time, and Data Constraints. American Journal of Evaluations, 1-5.
De, C. M., & Anderson, B. A. (2009). Caring for the vulnerable: Perspectives in nursing theory, practice, and research. Sudbury, Mass: Jones & Bartlett Publishers.
Dyer, C. A. (2010). Tuberculosis. Santa Barbara, Calif: Greenwood.
Kesdee. (2011). budgeting. Retrieved January 19, 2014, from www.kesdee.com: https://www.kesdee.com/pdf/budgeting.pdf
Lehigh. (2012). Budgeting. Retrieved January 18, 2014, from www.lehigh.edu: http://www.lehigh.edu/~sgb2/L3%20Budgeting.pdf
NACOSALB. (2010). Recommended Budget Practices . Government Finance Officers Association.
National Tuberculosis Conference (Bangladesh), Hossain, S, & National Anti Tuberculosis Association of Bangladesh (2009). "Political will plays the supreme role of curbing TB": National Tuberculosis Conference, 2009 : 27 June 2009, Saturday at the LEGD Conference Hall, Sher-e-Bangal Nagar, Dhaka. Dhaka: National Anti Tuberculosis Association of Bangladesh.
Public Health Agency of Canada (2013). Tuberculosis—Past and Present - The Chief Public Health Officers Report on the State of Public Health in Canada, 2013: Infectious Disease—The Never-ending Threat - Public Health Agency of Canada. Retrieved from http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/tuber-eng.php
Rouda, R. H., & Kusy, M. E. (1995). Needs assessment: The first step. Retrieved January 18, 2014, from alumnus.caltech.edu: http://alumnus.caltech.edu/~rouda/T2_NA.html
Reichman, L. B., &Hershfield, E. S. (2011). Tuberculosis: A comprehensive international approach. New York: Dekker.
Suchman, E. A. (1967). Evaluation Research: Principles and Practice in public serveice & social action programs.
Todrys, K. (2011). Imprisoned and imperiled: access to HIV and TB prevention and treatment, and denial of human rights. (BioMed Central Ltd.) BioMed Central Ltd.
