ILO

Preliminary feedback report for ILO Society

Reconciling organisational intent and local strategies - Health workers and client perspectives in an urban leprosy project in India

By Kristine Harris LSHTM Research Degree Student Supervisor: Dr. John Porter

April 2008

1 Preliminary Report for ILO – “Reconciling organisational intent and local strategies - Health workers and client perspectives in an urban leprosy project in India”

Executive Summary This preliminary report for ILO Society draws on the observations made during the researchers PhD fieldwork. The primary focus of the research lay with the role and social identity of the community health organisers (CHOs), with the process of implementation, changes in the leprosy policy landscape and with identifying links between client and organisational perspectives. This reports aims to summarise some of the strengths and weaknesses of CHOs in order to demonstrate how these are can be utilised by the organisation to build the capacity to implement new and innovative interventions and to move towards interventions that focus on participation and client involvement far beyond what is being actualised in leprosy work at present. The report argues that CHOs through their frequent and intimate contact with clients and communities build a relationship of trust and respect by going beyond their official work remit and addressing the needs of communities on the ground. Going beyond the remit can be seen as both an expression of CHOs dedication to their work and to ‘social service’ but, this researcher argues, is also imperative to establishing the level of access, respect and trust necessary to achieve successful outcomes for the organisations interventions. As they have few material resources to utilise in this process the CHOs transform themselves into ‘human resources’ relying on time, pre-existing community capacity and networks of referrals as tools to fulfil the needs of the community in a manner satisfactory to the community. Much of this work goes undocumented, unrecognised and unrewarded. However, this flair for improvisation is something the organisation might well need to draw on in the future. However, CHOs do not exist in a vacuum and in order to understand their work and function one must look at the wider context they exist within, the organisation, nationally and internationally. Leprosy discourse is approaching a paradigm shift: for decades organisations almost exclusively focused on service delivery and disease control, but as the prevalence rate fell focus shifted to sustainability and integration into general health services. Now leprosy discourse and leprosy organisations are starting to focus on interventions with a stronger focus on empowerment, participation and rights based approaches. ILO Society is amongst these organisations. This report argues that talk of rights and empowerment tends to be centralised in upper management whilst workers are committed to fulfilling their present operational parameters which still focus on sustainability and service delivery. This threatens to create a schism in organisational culture within the organisation which may ultimately compromise the organisations ability to achieve its desired outcomes unless it is addressed. If ILO Society is to engage productively with this new paradigm it must aim to bridge this gap by more effectively translating intentions from management down through the organisation and by utilising the existing skills and strengths of its ground level staff to realise innovative interventions. Ground level staff cannot be seen as backward leprosy workers to be ‘carried forward’ into new initiatives but may instead hold many of the keys to the organisations ability to develop successful interventions within this new paradigm. The success of this venture relies largely on establishing effective and meaningful channels of communication within the organisation as well as platforms of equal dialogue with its various partners. Within the organisation rigid hierarchy and fear threatens to hinder this process, beyond the organisation issues of trust and respect may be at stake. This is a difficult time of transition for leprosy organisations, but the first step must be to take constructive control over this process of change and recognise that the organisation possesses the skills and capacities necessary to succeed if it can find a way to utilise all the skills and capacities it possesses and apply these to a unified vision of its desired goals and core values.


Table of content Executive Summary ...............................................................................................................1 Table of content......................................................................................................................2 Introduction ............................................................................................................................3 1. Recap of research objectives, method and focus...........................................................4

1.1 Objectives ................................................................................................................4 1.2 Methodology ............................................................................................................4 1.3 Study focus..............................................................................................................5

2. CHO – lived reality and potential impact..........................................................................7

2.1 Strengths..................................................................................................................7 2.1.1 Work beyond remit ...................................................................................7 2.1.2 Building Rapport.......................................................................................8 2.1.3 Limited Resources....................................................................................9 2.1.4 Community health ..................................................................................10

2.2 Impact.....................................................................................................................10 2.2.1 Quality and quantity ..............................................................................10 2.2.2 Working to targets, working around targets ........................................11 2.2.3 False dichotomies ..................................................................................12

2.3 Weaknesses...........................................................................................................13 2.3.1 Organisational Issues ............................................................................13 2.3.2 The house that we built… ......................................................................14 2.3.3 Stigma of leprosy work ..........................................................................14

3. Context: Community, policy, organisation ....................................................................16

3.1 Changing organisational structure......................................................................16 3.2 Leprosy discourse and organisational culture...................................................17 3.3 Two ways to bridge the gap .................................................................................19 3.4 CHO lessons for transforming paradigm............................................................20

4. Communication – bottom-up, channels, barriers .........................................................22

4.1 Communication is king.........................................................................................22 4.2 Barriers to translation from root ..........................................................................23 4.3 Opening the channels and moving forward........................................................24

5. Recommendations ...........................................................................................................26

5.1 Recommendations: Communication...................................................................26 5.2 Recommendations: Organisational culture ........................................................27 5.3 Recommendations: Core values..........................................................................27 5.4 Recommendations: Operational issues..............................................................28

Acknowledgment..................................................................................................................30


Introduction It is the researchers firm belief that a coordinated and sustained feedback process is crucial to the success of any research project. Thus, when the thesis work has been completed a copy of the full report will be submitted to the organisation and those involved with the work for their perusal and review. However, as a side product of the work carried out towards the PhD thesis “Reconciling organisational intent and local strategies ─ Health workers and client perspectives in an urban leprosy project in India” I have aimed to summarise findings of particular interest to the organisation from a policy as well as a operational point of view. These findings are summarised in the below report. However, first I would like to take this opportunity to thank you all, and especially the staff at ULP for being so open, for giving so freely of your time and love and for making me feel part of ‘the family’. The below report aims to highlight some of the strengths and weaknesses of the work of field level staff at ILO Society, but it goes beyond this by looking at the potential impact of these realisations, both operationally and for the organisational culture and core values in this difficult time of transition. Secondly, the report looks at the wider context, both organisationally and in terms of international leprosy policy, that form the context within which the work of the field staff is being carried out. An increased awareness of this context can aid us in gaining a better understanding of the organisation, its strengths and future challenges. The report argues that ILO has within it the capacities and skills required to develop into whatever it wants to be but that a schism in organisational culture and barriers to communication could potentially block the organisations full potential coming to fruition. Subsequently the report tries to make some tentative suggestions at how these barriers to communication can be addressed in order to enable the organisation to draw on all its skills and capacities to take a conscious step into the future. This is an difficult and exciting time in leprosy work. The achievement of the past and the challenges ahead are multitudinous but there is a real opportunity to build on the achievements of the past towards the accomplishments of the future. I, for one, am very excited to be able to be part of this transition, have utmost faith in the integrity and drive of ILO Society and look forward to seeing what the future will bring for the organisation and its partners as it takes change into its own hands and, to paraphrase Gandhi, ‘embodies the change that it wants to see in the world’.

But firstly, lets start by recapping the original objectives, methodology and focus of the research to get a better understanding of the researchers perspective going into the research that forms the basis of this preliminary report:


1. Recap of research objectives, method and focus Before we start discussing the findings of the report it might be useful to remind ourselves what the methodology and remit of the research was in the first place, as this will have had a profound effect on the nature of the findings in this report. 1.1 Objectives The research was carried out with 4 primary objectives in mind:

Objective 1: To chart recent changes in leprosy policy. Objective 2: To investigate how recent policy changes have affected health workers’ daily work and tasks Objective 3: To investigate how recent policy changes have affected how health workers perceive their role relative to organisation and clients Objective 4: To investigate the potential role of health workers as a link between organisational intent and client perspectives

In other words to map the context within which the current work of the organization takes place and how this has changed over time, secondly to investigate what ground level staff do on an everyday basis and any changes to these procedures; thirdly to explore the social identity of ground level staff and how this is maintained internally and affected by external changes; and lastly, to look at the potential for bottom-up communication and the potential role and impact of ground level staff in this process. 1.2 Methodology The work was carried out over 12 months – between October 2006 and September 2007. My primary methodology was participant observation carried out with a specific project and group of health workers. However this methodology was supplemented by a number of other approaches, as summarized below::

Ethnographic research with Health Workers Participant Observation – 12 months Time allocation study Work/life narrative interviews with CHOs Semi-formal interviews with management Project Management Regional and National Management Document Review Project specific documentation – annual reports, proposals etc. Organisational documents – policy, reports, training manuals, etc. National and International guidelines, policy documents, etc.


1.3 Study focus The focus of this study lies squarely with the Community Health Organisers (CHO). On the lived reality of CHOs as experienced through their everyday work, and on their social reality and how they perceive their role within the organisation. However, CHOs cannot be understood outside of their context. So in order to gain an understanding of their work we also need to understand their interactions with the larger context – from the international policy that shapes their work context through the organisational culture they work within to the communities they work alongside. And lastly the study aimed to focus on the channels of and barriers to communication within the organisation. Bottom up communication from ground level staff through out the organisational structures, but also on the policy interpretation from international and national level through organisational structures and projects. Through these areas of focus to look at the role of the CHO as an interface between organisational intent and local strategies as these are played out in the everyday activities of CHOs and reflected in their social identity. However, throughout the research the focus remains on the CHO, and all the other perspectives were viewed from a vantage point of CHOs. It is important to bear this in mind when considering the other aspects of this report. But, of course, the concept of study focus goes beyond the practical to the approach that the researcher takes to the material he or she engages with. This research set out to look at the process by which health interventions are implemented on the ground. It specifically aimed to look beyond the stated intentions in reports, proposals and policy papers to what is actually happening in the field. In that respect it aimed to shift the focus from outcome to process, from planning to implementation and from theory to practice.

There is often a tacit assumption of a linear progression from plan to outcome. That if we plan well and execute this plan – we will necessarily achieve planned outcomes. However the process of

X

Plan

X

Outcome

X

Plan

X

Outcome


executing a plan is complex and subject to constant adjustment. By understanding this process we may be able to plan more efficiently – but also to gain access to the desired outcomes of our target population – one which draws on their strengths and capacities by engaging in the reality of their lived experience in a way that the ground level implementation is forced to do on a daily basis. Thus the researched aimed to gain an understanding of how it is that health workers do ‘That thing they do’. How they achieve their goals through an applied ‘simple complexity’. Their work is often dismissed as common sense, but in reality, and this report hopes to demonstrate this, it constitutes a subtle diplomatic skill that comes with years of experience and extensive networking. And which cannot easily be coded in training manuals or policy. Or as the French philosopher Voltaire phrased it “common sense is not so common” and we must learn to recognise it and utilise it where it can be found in abundance. In addition this report hopes to demonstrate that through a better understanding of the implementation process and the role of health workers on the ground can aid the organisation in creating more realistic and practicable plans as well as increase the likelihood of achieving the desired outcome. Further to this an understanding of the work of health workers can be instrumental in developing an organisational culture capable of dealing with the challenges ahead.


2. CHO – lived reality and potential impact As the research has its primary focus on CHOs it is only natural to start by looking at the everyday work patterns of the CHOs and try to describe the strengths and weaknesses inherent in these practices, for then finally to try to describe what impact these insights might carry for future interventions and the future role of CHOs within the organisation itself. However, in order to understand the work of CHOs it is necessary to acknowledge that the circumstances within which they carry out their work, and thus the work tasks themselves, have changed dramatically over the last few years. This is not the place to go into details regarding the nature of these changes as most of you will be intimately familiar with them. Suffice to say that the falling leprosy prevalence rate and the organisation’s choice to diversify its activities to include TB, malaria and HIV/AIDS has obviously had a dramatic impact on the day to day activities of CHOs in terms of acquiring new skills and tasks. Less obvious is the role this diversification played in changing the ‘face’ of CHOs – in terms of how they see themselves and more importantly, in terms of how the community sees them. 2.1 Strengths Let us begin by examining some of the strengths identified in the work of CHOs. 2.1.1 Work beyond remit When the activities of the organisation were diversified and the remit of the CHOs increased from pure leprosy work to include other diseases, it marked a radical shift in their activities but also changed how they were viewed by the community. From being seen as ‘leprosy workers’, or ‘patches doctors’ to being viewed as to ‘multipurpose health workers’. This in turn meant that though CHOs are still often seen as ‘leprosy workers’ or more broadly as ‘disease workers’ within the organisation – as people who are ‘limited’ (and I use the word limited intentionally because it tends to be seen as a negative thing) to working with disease be it leprosy, malaria, TB or HIV – the community see only persons of authority who may be able to help them with a broad range of problems – specific and general. Though the organisation might define the CHOs remit according to disease and set targets according to epidemiological indicators or official priorities, the community see their presence as an opportunity to address any ill – social, economic, structural, or other. CHOs routinely deal with anything from earache to marital issues, school attendance, bumps and bruises, pensions, ration cards, water access, kidney problems, fevers, etc. These generally fall well beyond the remit of the CHOs, yet they cannot afford to ignore them as their interactions with the community are interactions with the lived reality of the community and their interactions with individuals are interactions with the complex embedded lives of individuals. Thus the everyday work tasks of CHOs engage with issues that go beyond distinctions of health and development, go beyond health to issues of life. As health determines life and life determines health their approach, even to specific health issues, must be a holistic one, one which is determined by the demands of the community not by the targets of specific projects. The CHOs themselves will use the word ‘social service’ to describe the work they do and why they got involved in leprosy work in the first place. Though their performance is evaluated officially by their ability to meet preset targets relating to specific diseases they acknowledge that their work cannot be achieved through this narrow focus but, rather, presupposes an engagement with wider issues of concern to the community and individuals. Thus their daily tasks go far beyond the remit set by the organisation in order to establish rapport with the community, but also in order for them to achieve what they term ‘social


service’ – for the successful implementation of their work, but also for their own personal salvation. As the great Gandhiji said: "Leprosy work is not merely medical relief; it is transforming frustration of life in to joy of dedication, personal ambition into selfless service“ . However, as this work falls outside of the official remit it is also not governed by any pre-existing budget and it falls to each CHO to utilise their rapport with the community, their networks with other NGOs or official bodies in order to set up systems of referrals capable of addressing the myriad and multitudinous concerns of the various communities they work with. 2.1.2 Building Rapport Beyond the rhetoric of personal salvation and the desire to execute social service there is a more practical need to address the concerns of the community. The successful execution of the work of CHOs relies on good rapport with the community. This word – good rapport – is something that comes up in almost all conversations with CHOs and which is almost ubiquitous in planning proposals etc. As a first step in most implementations is ‘establishing rapport with the community’ and when asked about how they achieve successful implementations the CHOs brought up building rapport with the community as one of the fundamental cornerstones of any successful implementation. Yet what is meant by this phrase is rarely explained, nor is specific time or resources allocated to the activity. Rather it is treated as something which is a ‘natural’ part of the implementation process. However, during my observations of the work of CHOs it became abundantly clear that this was not a ‘natural’ or ‘automatic’ process. Far from it. In fact it was one which required more time and manoeuvring than most of their other tasks, yet one which there was very little clarity of purpose in. When pushed on the subjects the CHOs identified a variety of different aspects which they saw as fundamental to establishing rapport with the community – to speak to them in their own language which shows respect for their lived reality, to listen to their views and to treat people and their views with dignity, to take time and to work to the communities time table, to show empathy and take them and their lives seriously, to demonstrate a willingness to touch their lives as they had touched the leprous body in the past, to build credibility in the community, to show respect and gain respect in return. Again, these are broad terms. Terms which cannot easily be codified or included in training manuals. Abstract terms which gives us few clues as to how this is achieved in practice. However, the everyday working practices of CHOs offer just these clues. Their willingness to go beyond the remit of their work to engage with the problems of the community shows respect for the concerns of the community, and their utilisation of pre-existing knowledge and referral networks allows them to help the community to solve their problems in creative ways. Once some of these issues have been addressed, regardless of successful outcome, the CHO has in turn demonstrated that they respect the interests of the community and their credibility as resource persons. And in return they gain the respect and credibility which allows them to carry out the tasks which they are officially charged with. Again, these are broad terms. Specifically it is very often the little things that matter. To take the time to have a glass of water with the local Basti leader, to drink from the community water source, to look at family photographs and listen to people’s stories. To speak their local dialect or slang. To take the time, it matters less what the time is spent on for the significance lies in the giving, effectively communicating ‘you are important enough for me to spend a few minutes quietly sitting in your world’. Hundreds of subtle yet crucial clues communicated by the everyday interactions of CHOs whilst they are in the community ‘working’. I use inverted commas in the term ‘working’ because this is very often not termed as ‘work’, but rather seen as a means to an end, when in reality it is often more important than the ends in themselves.


Why is it important? Why is rapport important at all? In simplistic terms it is required in order for the CHOs to be able to impart the ‘knowledge’ which is their official capacity – to gather people in health forums or community meetings in order to carry out health education or other community activities. But is that it? I would argue that the process itself is what is important in this respect, and it is the process that often gets forgotten. The process by which rapport is established with a community can be read as a bartering for credibility, using time and trust as bargaining chips. If one shifts the emphasis of analysis to the process rather than the specific outcome of the negotiation it becomes apparent that in many respects the ‘product’ the CHOs are bartering for is not knowledge or simply the ability to impart knowledge but an issue of establishing the credibility required to gain access to the community and the respect required for the community to accept the knowledge they are trying to impart as not only correct, but also relevant to their lives. This access then becomes the primary outcome of interest to the organisation, as this access grants access to the community for any number of activities and the credibility of the CHO increases the likelihood of meaningful uptake of the knowledge which is imparted. In addition the increased access and respect creates a forum in which the community is willing to share their concerns and problems in a semi-open forum. These concerns can then be addressed through these same channels. Once established, these channels can be utilised to identify potential within the community and develop this to empower people to access available help through referrals and coaching. Thus, if we shift the focus from outcome to process we can see that the ‘product’ ILO offers as an organisation is not so much structural services as it is ‘human services’. It is not so much structural interventions or material resources which is crucial to the outcome – but rather the investment of time and empathy by the CHOs which enable the organisation to achieve the desired outcomes on the ground – yet, human resources are more often than not classed as an expense rather than as an asset within the organisation. But more on this later. 2.1.3 Limited Resources One day whilst visiting a local slum and engaging in exactly the kind of activity described above, i.e. sitting in a local slum leaders house, taking some water and looking at photographs of her children she told me about the sense of community in the slum, and she said:

“do not look down on us because we are poor, we have small huts but big hearts” On many levels a similar statement can be made about the work of CHOs. In their daily tasks they are faced with a myriad of community problems. Their ability to address these are limited by a very small budget, restrictive targets and narrow parameters. It is often said that you cannot make those who do not want to listen – so you must build respect and credibility to make people want to listen. You cannot teach to those who cannot listen. The hungry hear only the rumbling of their own stomachs, a community without water must first wet their lips. So, by enabling people to satisfy their basic needs and desires, one will make them able and interested in listening. But there are no resources allocated for this usage, so health worker must rely on his/her experience, innovation and networks to make the impossible possible. Without specific resources or official training CHOs rely on networks and referrals to other NGOs who deal with these issues, off the cuff advice on a range of problems and empowering people to approach government for that which they are entitled to. There is great individual variety among the CHOs in terms of skill and approach to engaging with the community and building rapport. However, they all share a commitment to what they term ‘social service’, or what I might term a willingness to engage with peoples lived reality, which


drives them to find creative ways of addressing the needs of the community. What drives this commitment is empathy. A shared, deep empathy with the situations and problems faced by the many individuals and communities with which they interact. Driven by this empathy they have built extensive networks of resource persons – governmental and non-governmental – to which they can refer people with problems that ILO cannot address due to lack of resources or differences of remit, thus transforming themselves into powerful ‘human resources’ in the face of limited material resources. Though these networks can be documented for future use within the organisation the personal contact network is harder to replicate – and more importantly, there are no training manuals to teach empathy. 2.1.4 Community health So, what is the implication of CHOs working so far outside of their official remit? One important implication is the extent to which, in the field, CHOs are doing community health, in all but name. There have been concerns within ILO about a lack of capacity and training in community health, but when we analyse the work carried out by CHOs it comes much closer to community health than many ‘official’ community health interventions. One of the reasons for this might be the extent to which the roles and relationships are worked out continuously at ground level rather than divided up prior to engagement with community. It is based on partnerships through necessity rather than stated intention as both parties have something to gain form the process. For the community it might be accessing material resources whilst for the CHOs it might simply be a matter of access to the community. The partnership is structured around the ‘real’ rather than ‘perceived’ needs and capacities of communities and constantly renegotiated at field level – something which many ‘community health’ interventions are too rigid in their focus on plan and outcome to achieve. Innovation, partnership and negotiation rely on organic flexibility and individual approaches which are difficult to plan for, rely on trust in the skills of workers which is difficult for projects to imbue or truly believe in. As the concerns of the community change over time so the relationship must be constantly re-negotiated and adjusted. It is not simply a matter of establishing rapport and leaving it at that. Relationships, much like gardens, must be tended. In addition the partnership is embedded in the physical locality of the community and is navigated in real-time. It is not planned or scheduled in board rooms or encoded in ATPs. Rather they unfold in real-time in the field and must thus be flexible and responsive enough to deal with all eventualities without becoming hostage to them. The ability to navigate this partnership relies on a good rapport with the community, on respect for their needs and belief in their potential as well as empathy for their lived reality. 2.2 Impact Though an analysis of the strengths of CHOs is important in its own right, in order for it to be truly useful for the organisation we must look beyond the practical to the lessons that can be drawn from this analysis for the wider organisation. In this respect I have singled out 3 distinct areas – distinctions between quantity and quality of work, relationship to targets and false dichotomies in planning. There are, however, countless other instances where these and other insights drawn from fieldwork may be fruitfully applied. 2.2.1 Quality and quantity

CHOs are doing qualitative work within a quantitative reporting structure which in reality means that there is little understanding of the actual work carried out in the field as this is rarely


documented.

In a report an ulcer is an ulcer. 3 ulcers healed is a tangible and measurable achievement which can be reported to management or to funding bodies. However, a report of 3 ulcers healed tell us very little about the work that went into healing that ulcer. How many hours, how much counselling, detailed knowledge of life / constraints/ activity patterns, home visits, coaching, follow up, trust, respect, empowerment. Not to speak of years of relationship built previous to the appearance of the ulcer… Thought the quantitative outcomes are impressive enough in their own right it is to a large extent the ‘soft outcomes’ that make ILO as an organisation great. The notion of ‘quality’ is emphasised as an USP by everyone from the very bottom of the organisation to the top. However, the quality of the work often goes unreported. It is retained in the attitude of patients, staff and the organisations reputation. There is a tacit understanding of what ‘quality’ means within ILO but the notion is not coded into policy thereby creating consensus of the meaning of ‘quality’ in ILO. This could constitute a point of stability in a period where the organisation is undergoing rapid changes and some have expressed concern that ‘quality’ will be the first casualty of this process. Secondly, documentation of quality is important as a signifier that this is truly something that the organisation sees as an important part of the implementation. At present only quantitative outcome measures are recoded which places the emphasis on targets and achieving the numbers for the reports rather than for the ‘real’ outcome which can be seen in more complex qualitative reporting processes. Documentation of quality is important because, as demonstrated above in relation to CHO work, many of the lessons of best practice retained within ILO lie in the unreported qualitative work. For the benefit of others, within and outside of the organisations, qualitative reporting should be encouraged and disseminated when completed. However, qualitative reporting is a skill and must be treated as one. Training must be provided to the concerned persons in the projects – and the staff at field level who carried out the work in the first place must be involved in the process in order to transforming the data into a narrative of information which can be of benefit to others. There has been great emphasis put on the need to recognise the strengths and capacities of clients in order to improve interventions. I would argue that it as important that the organisation be equally mindful of the strengths and capacities of staff at all levels, including the staff at field levels and utilise these in order to grow as an organisation. The quality behind the quantity, the story behind the ulcer, lies in the heads of fieldworkers. The organisation and others outside need to hear these stories. In addition to the lessons to be learnt, it is important for how CHOs and the work they do is perceived within the organisation.

2.2.2 Working to targets, working around targets

Building on from the previous point there is a conflict between the official targets and what is seen as the real work of ILO, as one of the CHOs phrased it: “Numbers. They collect numbers. Like account. Like bank. But you cannot calculate human service. Ok, we can have targets. But this is not what ILO does. What we do. (…) Targets are not outcome. Outcome is in our mission statement, not in the monthly report” CHOs work to targets as this is how their performance is reviewed and also because they agree with these targets. However, they see the limitations in the application of these targets and would often say that even if you achieve you targets it does not mean that you have achieved anything,


you can achieve your targets without having provided social service, and it is in the social service that the real test of your achievements lies. It is also worth noting that whilst CHOs habitually speak of respect, understanding and humanity, programmatically and internationally we speak of targets! In this respect targets are both something that you work towards and something that you work around when they are perceived as counterproductive to ‘social service’. E.g. when filling in the Governments SIS reporting system the CHO would often have to weight the consideration for the needs of the person affected by leprosy against that of the needs of the reporting structure. Recognising both as equally important they would find a way to make space for the individual in the structure by manipulating the system to make space for both. On the government SIS patient cards there is no space for comments or notes, however the CHOs would often have to make individual allowances e.g. when it came to the timing of distributing pulses. For example, a patient is going home to their village for a festival and needs their pulse two weeks early. The CHO would give them the pulse and make a note in ILO’s internal records, then fill in the SIS records with ‘correct’ or ‘anticipated’ date two weeks later – in their mind satisfying both parties. This is only one arbitrary example of such individual accommodation. Though working around the targets in this manner can never be included into plans or quantitative reports but is often crucial for the success of interventions in that it offers flexibility and responsiveness to individual needs at a level of complexity which you cannot plan for. Yet is often of the utmost importance to the success of the intervention in qualitative terms. This is not merely a question of administration or documentation practices. It is a question of social identity and where the emphasis is placed in the intervention and in the organisation – on achieving the targets or on doing social service. There has to be a balance of both in order for an intervention to be successful. In addition an understanding of this process and these delicate balances at field level is crucial as the organisation moves towards more client driven and rights based approaches in new initiatives.

2.2.3 False dichotomies As CHOs work with embedded individuals and complex lived realities a thorough understanding of the work they do sheds light on some false dichotomies which often become stumbling blocks in organisations. Here I have selected a few merely as examples, but in reality the same premises could be applied to a number of dichotomies. Recently there has been much talk within ILO as to which direction to move in the future – towards interventions that focus on community health or towards ones which focus more on strengthening existing health systems. From the vantage point of the field this dichotomy falls away as you cannot separate one from the other on the ground – health systems depend on good community health, e.g. in terms of awareness, just as much as community health depends on good health systems. Another point of discussion is often the need to move away from a disease perspective towards a health perspective, or more recently from a health perspective to a development perspective. Yet, in the field the success of any intervention often depends on the fieldworkers ability to effectively juggle all at the same time. Communities still need attention to diseases and they need development and poverty reduction as well. An intervention that fails to recognise this and do its best to pull together as many aspect as possible utilising its own or pre-existing resources will likely fail. If it does not offer services for diseases, even if it is just advice, it risks being seen as irrelevant by the community, yet if it does not address the wider determinants of health through a focus on development issues it risks being little more than a band aid.


Lastly, the dichotomy between public health and the individual is ubiquitous in public health literature and debates. Recently at the 17th ILC in Hyderabad one of the presenters urged us all to remember that “every foot is attached to an individual in context”. And it is the kind of statement one would read in academic articles or policy reports from time to time. And it is a good sentiment. But to the best of my knowledge no fieldworker has ever treated a disembodied foot. And unsurprisingly most of the owners of these feet talk about their lives and their problems as they are having their ulcers treated or whatever they came for, so to forget about them is difficult, even if one might want to sometimes. There is also talk of the need to remember the needs of individuals in interventions. But for a fieldworker what else is there, but an endless stream of individuals in need of assistance – individuals which, when seen as a whole, become the public. Thus, from the perspective of the field this distinction between the public and the individual becomes, well, ‘academic’ and largely a false dichotomy.

2.3 Weaknesses

So far I have been focusing on highlighting the positive aspects of the work of CHOs as I believe this is the area where the most beneficial lessons for the organisation can be harvested. However, there are also a number of weaknesses which, by being aware of these, we can address and hope to avoid in the future. Often the lessons regarding what not to do are as important as those highlighting good practice. 2.3.1 Organisational Issues In response to paradigm shifts within leprosy discourse there is a need to develop interventions which involve people affected by leprosy in a more fundamental manner. Though the thinking in relation to leprosy and the involvement of leprosy affected persons has come a long way, there is a qualitative difference between interactive PoD services and equal involvement. Though dedication to quality services is one of the core capacities of ILO one must take care to ensure that a dedication to service does not ground the organisation purely in the role of provider rather than enabler. One way to do this is to utilise the creativity displayed by the CHOs in the field to move beyond conservativism and identify innovative new approaches, though issues of bottom-up communication and hierarchy need to be addressed before this can be put into practice. Valuable lessons could certainly be learnt from HIV/AIDS projects when it comes to moving towards more projects that involve people affected by leprosy in decision making processes and in interventions themselves – in moving the organisation forward from being a provider to being an enabler. Due to the different natures HIV/AIDS and leprosy discourse there are many potential lessons to be learnt and pitfalls to be avoided by drawing on insights from HIV projects. Already one can notice a marked difference in the approaches of fieldworkers with some experience working in HIV projects alongside leprosy work. CHOs have demonstrated their ability to absorb new approaches during the diversification of activities associated with the EC project which was crucial to the transformation of leprosy workers into health workers, a transformation which had wide ranging implications for their interactions with clients and communities. However, a tendency to keep these interventions separate within the organisation, at least in terms of exchange of fieldworkers, could pose a barrier to the effective skill sharing between these two groups of interventions. I will deal with this topic in detail later but, in brief, there is a gap developing between the organisational culture of higher management and that of the workers in the field. This can prove a


serious liability to the organisations capacity to carry out effective intervention in the future unless it is addressed at an early stage. Lastly, in terms of organisational issues there is a feeling among some staff that the focus on leprosy and dedication to leprosy services is being withdrawn just as they have the finishing line in sight, and that without sustained effort we might see a resurgence in the future and 20 years of hard work will be wasted. It is important that the organisation addresses these concerns, monitors and analyses the situation. There are some worrying epidemiological indicators, but of a greater concern is the effect this belief is having on morale on the ground.

2.3.2 The house that we built… As a result of the organisation’s success in leprosy elimination work and the reputation it built for itself through these efforts the organisation gained access to projects in other fields such as tuberculosis, malaria and HIV. These opportunities were largely given to new recruits. As funding for leprosy projects is dwindling there is a feeling among staff in the more leprosy focused projects that there is no room for them in ‘the house that they built’. The success of the leprosy interventions came off the back of their hard work, yet now that there is less leprosy work they are facing redundancy at the same time as others benefit from their hard work by being given opportunities in the new projects. The fieldworkers feel that they are no longer seen as the ‘pillars of the organisation’ and that promises of job security and reward for hard work in combating leprosy have been betrayed. This creates a feeling of insecurity on the ground. Dignity, hope, motivation and a sense of duty/calling are hard to maintain in an atmosphere where people feel that the project is unravelling around them. The issue of job security is on everyone’s lips, and the lack of it is causing demoralisation in the ground level staff.

“Mission statement says give hope and dignity – but how can we give hope and dignity when we ourselves have none?” (as expressed by one CHO)

It is clear that the organisation is facing a period of change and that the position of implementing staff in the organisation is changing. However, it bears remembering, in this process, that staff retention is about more than sentimental attachment or moral obligation to staff that have given more than 10 years of service, it is also about retaining some of the qualities discussed above.

2.3.3 Stigma of leprosy work For years individuals and organisations have been warning of leprosy affected people being marginalised within leprosy organisations as these organisations continue to diversify their activities. However, so far few people have discussed the marginalisation of leprosy workers within these same organisations. This marginalisation is encountered primarily in two ways – when trying to access work outside the organisation, and when evaluated for their capacities and potential within the organisation. The stigma against leprosy workers outside of leprosy organisation is not a new phenomenon and has been reported by many over the years. However, the feeling of stigma against leprosy staff within leprosy organisations themselves is a rather new phenomenon. As discussed above there is a feeling among field level staff that there is no room for them in the house that they built and that new staff members are recruited to do jobs they have the skills and capacities to perform.


However, staff now feel that they face an additional challenge in the fact that ILO is working extensively in other fields. As they attempt to access employment in other organisations they have to contend not only with a prejudice against their past in leprosy work, but also the stigma implied by the fact that their own organisation cannot see their potential.

“They will say like this: ‘If ILO has so many projects why have they put you out? Because of some mistake you make?’ If ILO close tomorrow, then OK. We have good reputation and good contacts. But ILO will not close, only us put out. How can we find work like this?” (CHO)

Essentially, the question becomes, if a leprosy organisation fails to recognize the capacities and potential of leprosy staff, how can other organisations be expected to? There has been great encouragement for field level staff to develop their skills and capacities in the recent years – one which has been taken up enthusiastically by most of the staff as they have pursued post-graduate degrees in sociology or psychology and diplomas in counselling, HIV or other related fields. However, despite this self-development there is a lack of appreciation of their skills and capacities within the organisation – based not in lack of capacity but in stigma and lack of understanding of their work and their qualifications. This can in turn be seen as related to the lack of qualitative reporting which results in a lack of understanding of the work carried out by field staff and, thus, in a lack of appreciation of their skills.


3. Context: Community, policy, organisation Thought the study focuses primarily on CHO and their role, one must bear in mind that in order to gain an understanding of their role it is important to appreciate the greater context they exist within. Having briefly dealt with their relationship to the community this section will focus on the relationship to international policy, organisational structure and national/international organisations. 3.1 Changing organisational structure Increase funding available in the international public health market, though not for leprosy specific work, and increased funding pressure leads to an increase in the number of projects instigated or co-ordinated by ILO. There is also a desire for short-term high impact interventions which leads to a preference for projects for relatively short duration, usually between 2-5 years. Thus the funds available to the organisation tends to be projects based rather than core funding. Staff hired on contract basis for the duration of a project may or may not be utilised again for future projects – which leads to reduced revolving overheads in the organisation, a wider range of skills available to the organisation at any time and in greater flexibility in what kind of projects ILO Society chooses to engage with. However there is also a distinct danger that increased staff turnover can lead to loss of continuity and organisational memory within the organisation. Funder demand for ever larger interventions run through lead and implementing NGOs has led to an increase in the number of projects that ILO Society has taken up in the capacity of managing NGO. It is felt that the organisations relatively horizontal pay structure precludes the organisation from taken up these projects as a direct implementing NGO as the overheads would be too high and the interventions would not be cost-effective. Rather these projects are ‘outsourced’ to implementing NGOs, some of which will be ILO Society direct projects. Increased total number of projects and increased projects where ILO Society play the role of facilitating NGO has lead to a rapid growth in middle management over the last 5 years and a trend towards a more vertical pay structure within the organisation to make their implementing staff more competitive in relation to other potential implementing partners. This growth in middle management has changed the staffing structure of the organisation. However, in the eyes of the field staff it has also changed the way they are perceived within the organisation. Or as expressed by one member of staff:

“Before 20 fieldworkers and 5 people in head office. Now 5 fieldworkers and 20 people in head office”.


The field staff feel that in the past they were always described as the pillars of the organisation. As the overall number of direct implementing staff is reduced and the role of co-ordinators for the facilitation projects increases there is a tendency towards the Project Co-ordinators becoming the new pillars of the organisation. As the point of contact between the organisation and the implementing branches, in facilitating NGOs the middle management become the new pillars, the new front-line workers : This is to a certain degree a reflection of pure growth in number of projects and increased administration needs but can equally be seen as a reflection on the nature of projects now taken on by the organisation. Change is natural, and change is necessary. However we must ask ourselves what is the role of fieldworkers in ‘this’ organisations? Do they still have a pivotal role to play or are they merely contract/project based staff that compete against other implementing NGOs on the same terms as these? And if so, how will this impact on the social identity of existing fieldworkers within the organisation and their ability to exercise the strengths discussed above? Strengths which I will later argue may be crucial to the organisations ability to move into more participatory and client based projects that draw on the existing strengths and capacities of the local communities themselves. Will the organisation have the appropriate staff to access this level?

3.2 Leprosy discourse and organisational culture For a very long time the primary focus of leprosy organisations and, indeed, leprosy discourse internationally was on service provision and the control of a very significant public health problem. The focus was on leprosy as a disease and on interventions based on epidemiological and bio-medical tools for detection and treatment. As the prevalence rate fell and the WHO leprosy elimination target was meet globally and nationally, in India, the focus changed to how these achievements could be maintained in a cost-effective manner in the face of a now much smaller public health problem. The talk was of structural interventions, strengthening health systems, integration and sustainability of services. The focus now shifted from a single disease to health in general as leprosy organisation supported the integration of a previously vertical service into the general health system working in close partnership with national governments and other stakeholders with an interest in health. For the individual person affected by leprosy the services offered by most leprosy organisation now grew to include social and economic rehabilitation schemes to address the wider determinants of disease and stigma. International leprosy discourse, and perhaps ILO Society’s internal discourse in particular, is now facing a new paradigm shift – towards a more ‘rights based’ approaches which emphasize empowerment, participation and partnerships. The challenge now is to try to find an approach

Pillars


which will enable increased involvement of affected persons in the decision making process, perhaps one integrated with other disability movements. The emphasis here will go beyond health to issues of development. This thinking is slowly taking hold in international leprosy discourse, but the process is moving much faster within ILO Society than in many other forums. ILO Society has long been at the forefront of innovative thinking and interventions within the leprosy field and now have a real chance to develop model interventions and really influence the direction of leprosy discourse internationally for years to come. The field needs innovative and brave leaders on this issue. However it is also a process which will require different strengths and capacities than ILO Society has traditionally been used to mobilizing in the past. Leprosy organisations that have diversified their activities to include HIV/AIDS interventions have an advantage here as this type of discourse is far more prevalent in HIV/AIDS projects than it has ever been in leprosy work. However, there also a danger in this transition as the talk of ‘rights’ and ‘empowerment’ etc tends to be concentrated in the ranks of higher and middle management within the organisation. The organisation is talking about development and rights but it is failing to translate these concepts effectively throughout the ranks of the organisation where the primary focus still lies with service delivery and sustainability. This is not the fault of the projects, or ‘backward’ leprosy workers, as they are merely fulfilling the objectives and targets set for them within their current operating parameters. However, this could potentially lead to a schism in organisational culture which could threaten the organisation ability to effectively plan and implement projects with a unified vision and predictable outcomes. Of course, any successful organisation must be a balanced mix between these three different aspects of leprosy discourse (dedication to service, sustainability and rights), it is merely a question of timely and appropriate emphasis.


An organisation needs to utilize all the aspects of their capacities. It is not merely a question a transforming the organisation from provider of services to a focus on the role as enabler. A successful organisation needs to be able to balance these roles without creating a hierarchical relationship of priority between them. One of ILO Societies great strengths is it’s technical expertise and, both as an organisation and for the sake of leprosy affected people, it cannot afford to disregard these skills. One of the ways that this can be achieved is by creating a strong, unified organisational culture where all staff are aware of the relative importance of all these aspects. The organisation must be able to implement a range of different projects, some of them with a clear service provision focus others with more of an enabler focus, without becoming fragmented itself. Even in projects with a strong service provision component the importance of the other aspects of the work must be made clear to all staff through a shared organisational culture, thereby ensuring that all staff feel part of the wider remit of the organisation and that they can contribute effectively and meaningfully to the broader picture of the organisation, and that their actions at ground level are driven by the same core values and intentions as the rest of the organisation. This way diversity in perspective and activities can become a strength rather than a danger to the organisation and create a situation where all staff are pulling in the same direction rather than pulling the organisation apart.

An organisation’s ability to survive over time depends on its ability to adapt to changing environments and new conditions. However, the organisation ability to effectively respond to these depends on its ability to create a unified vision of the challenges the organisation faces and the solutions proposed to overcome these. Staff at all levels, as well as leprosy affected persons and their communities, must be involved in the decision making process and there must be translation of intention as well as targets to all levels of the organisation. 3.3 Two ways to bridge the gap

Addressing the developing schism is crucial for the future development of the organisation, to avoid the development of two competing organisational cultures and to ensure unity of purpose. A gap can be overcome in a multitude of ways but an emphasis on the removal of barriers to communication is a good start. Communication must come from both parties. From higher and middle management a great effort must be put into effective leadership and translation of intention as well as targets. Systems must be put in place to encourage free and open dialogue between different levels in the organisation. Emphasis must be put on the motivation of field level staff by a shared vision of the development of the organisation and a clear understanding of their role in this development. This motivation


also serves to maximise the output of field staff by creating op-in and dedication to the ideals represented by their work and by making their role/work part of a more encompassing vision and a larger context.

But it is equally important that the organisation establishes channels of bottom–up communication and better documentation practices to build a more thorough understanding of the work carried out at ground level. By increasing the organisations understanding of the strengths and capacities of field staff one can isolate elements, such as the strengths of CHOs discussed above, which may be crucial in the paradigm shift ahead. It is often said that ‘we are what we do’. A similar statement can be made about interventions that aim towards greater representation, participation and empowerment. As long as these remain words in policies and plans rather than actions and intentions on the ground their impact will be limited and the interventions staged in their name will fail to reach their intended outcome. It can be exceedingly difficult to realise these seemingly simple goals through action. It is crucial that there is a consensus in the organisation of what these terms mean –what is empowerment, what constitutes participation, what does it mean to empower someone, who should be trusted to make decisions and responsibility, what is the role of advocacy in this process, what do we mean by advocacy and capacity building, what does it mean that a project is rights based? All these and scores of similar questions must be answered from the organisation’s point of view. What does the organisation mean by these terms, what values is the organisation committed to? Two points are of utmost important here – firstly there must be consensus within the organisation about these terms, throughout the ranks. The intentions behind interventions must be translated down through the levels – to make sure that the actions carried out in the field correspond to the intentions behind them but also in order to maximise motivation. ILO Society upholds the idea that if people pay a nominal sum for footwear they will care for it and cherish it more than if it was given for free. The same can be said to apply to field staff. If the organisation can find a way of imparting the ideas behind interventions in this new paradigm to people at field level they will feel greater opt-in, motivation and dedication to their work – which will lead to greater personal satisfaction but also help the organisation realise its goals and reach the intended outcomes. It cannot simply be a question of teaching people the ‘right thing’ but must be treated as a process of translation through which the field staff are agents in their own, as well as the organisations, transformation.

3.4 CHO lessons for transforming paradigm As I have argued above, this must be a two-way process. On the one hand it is up to higher management to create a communal platform for the organisation, but on the other hand the field staff must be seen as more than passive recipients of organisational culture as they possess capacities and skills which are essential to the success of any such venture. Taking the skills of CHOs as an example I will attempt to demonstrate how these may be crucial in moving forward towards a new paradigm with greater emphasis on partnership and involvement. Without drawing on the skills and capacities of field staff the organisation might not have the required competencies to realize interventions of this nature on the ground. In order to start this process the organisation needs to change the way field staff are perceived within the organisation – and especially, to address the stigma attached to leprosy workers. Only this way can the organisation truly access the potential and expertise of field staff.


Skills CHOs apply in the field and the outcomes they achieve – outcomes which can be essential to new initiatives.

CHOs have developed to make their presence in the field, their ‘human service’, into a resource and this is a perspective the organisation might well benefit from adopting, thus, changing the way field staff are perceived from an overhead to a resource. Moving from a sustainability paradigm into a ‘rights’ paradigm means transforming the organisation from provider into enabler – in many ways the CHOs have already tackled this challenge – though they would not use those phrases to describe what they do in the field. So, by examining the strengths of CHOs discussed above it is clear that CHOs interactions with community already include the seeds of these changes and that they can play an instrumental part in the development of future initiatives. But in order for this to be achieved the organisation must come to see leprosy workers not as a ‘backward burden’ to be cumbersomely ‘carried over’ to new initiatives, but an essential resource and as the carriers of the very skills that will allow the organisation to make the transition in a meaningful way. To some extent CHOs already ‘talk the talk and walk the walk’ to a much greater extent than the rest of the organisation – unfortunately these skills often get lost in translation between the different levels. Thus, steps must be made to reconcile the skills of the fieldworkers and the discourse of management in order to establish the unity of purpose that will imbue the organisation with the capacities it will need to take on these new challenges. Even so, the road ahead might be difficult and is best approached as a continuous process of change and adaptation rather than as a one time ‘shift’. Even with unity of purpose it will be a continuous challenge to ensure that policy language and intentions in terms of empowerment, participation etc. are translated into meaningful action and desired outcomes at ground level. However, by drawing up clear lines of communication and encouraging greater input from all stakeholders, both within the organisation and outside, the organisation can ensure that the process remains flexible and adaptable enough to tackle new challenges along the way So, let us talk about communication – which was the last main pillar of my study focus…

Phpukhar

Pencil


4. Communication – bottom-up, channels, barriers Good communication is one of the fundamental pillars of good operating practice. However, it is one that is very often taken for granted and rarely given the level of attention it warrants. There is an assumption that if it is left to its own devices it will sort itself out, and that any effort to improve communication will seem forced and may even be counterproductive. However, communication is not about convincing or coercing consensus – but rather a process by which we can establish shared emotional involvement in a shared project. “The colossal misunderstanding of our time is the assumption that insight will work with people who are unmotivated to change. Communication does not depend on syntax, or eloquence, or rhetoric, or articulation but on the emotional context in which the message is being heard. People can only hear you when they are moving toward you, and they are not likely to when your words are pursuing them. Even the choicest words lose their power when they are used to overpower. Attitudes are the real figures of speech.” – Edward H. Freidman – However, it is not merely a question of increased communication. Efforts must be taken to ensure that what is established is meaningful communication rather than merely a confusing sea of voices – that we achieve polyphony without cacophony. Communication can lead to communion and community, to intimacy and shared values, but it does so through the process of listening rather than through speaking, listening and trusting people at all levels of the organisation and the communities one is trying to reach.

4.1 Communication is king Changes in policy and discourse are leading leprosy organisations towards interventions and programmes with a heightened level of involvement by communities and clients themselves. Research shows that interventions based on the strengths and capacities of communities have a greater impact as they utilise pre-existing systems and potential in the communities. However, this kind of intervention presupposes the organisation having a detailed knowledge of the partnering communities and individuals. This can only be achieved through proper channels of bottom-up communication which allow for an appropriate access to communities and insight into their capacities and strengths. However, these interventions must also manage to be participatory in practice, rather than merely in intention or as a token gesture. These intentions must be borne out in the intervention’s actions, reflecting the organisation’s willingness to create a platform. A platform for people to express their needs and desires rather than merely speaking ‘on their behalf’. A platform for community voice and action, but equally a platform where the organisation is committed to being an active listening audience. If there has been a tendency towards conservativism within leprosy service provision in the past, the willingness to listen to needs and desires of communities and to form open channels of dialogue may just give ILO Society the innovative edge it requires to succeed in these interventions. Thus communication forms the route to embedded rights discourse and empowered participation. In this, the lessons one can draw from CHO strengths, the need for a flexible and embedded involvement based on trust and respect, will be essential.

It is essential that, within the organisation as well as outside, one must, at all times, be ‘speaking with equals’. This can be achieved by enabling people to speak for themselves and ensuring an attentive and respectful listening environment. It is exceedingly easy to fall into the trap of speaking for people, assuming that one knows what is best for people and teaching people the right thing – rather than actually listening and enabling people to be agents in their own change process. In order to avoid this trap it is imperative that one considers ‘who is speaking for whom’ when defining strategy and determining goals. The internal consultation process must be involved


and participatory rather than merely a token mechanism to access the ‘authentic’ views from the field, views which can then be utilised to confirm predefined agendas. The views of staff at all levels of the organisation must be taken into consideration and listened to without prejudice. It must be a process of consultation rather than extraction, partnership rather than utility. In addition, the feedback process attached to these exercises must be improved, as few things are as demoralising as being consulted only to be ignored. As one member of staff at ILO phrased their concern over the consultation process to me: “They keep coming and asking CHOs for concepts and ideas for proposals. And they keep coming up with issues. But they never hear anything back. Already they have come so many times, and still there is no funds for after December. Now they are coming again. How they can feel?” Communication must be based on trust and respect, transcending issues of control and hierarchy. The same standards and ideals must apply to communication within the organisation as to communication with the community – through building platforms for open dialogue where negotiation, co-operation and skill-sharing is possible without fear or recrimination.

These are grand ambitions and promising words, but why is it so difficult to realize in practice…?

4.2 Barriers to translation from root There are many barriers to open communication within any organisation. Whether these perceptions of contraindications to openness are ‘true’ or not, they determine behaviour within the organisation and, thus, their effect is very real.

Primary amongst these barriers is a deeply entrenched sense of hierarchy and appropriate behaviour at each level of the organisation which hinders free and open dialogue between staff. Despite a rhetoric of ‘open doors’ there is a feeling that one is best served by keeping any objections to oneself and doing what one’s direct line managers suggest without objections. That it can be dangerous to hold opinions other than those held by people in positions of authority. One member of staff invoked a popular Hindi proverb to describe the situation:

“जल में रहकर मगर से बरै करना ठीक नहीं”

(Living in water and being an enemy of the crocodile is not good) This implies that in order to survive in the organisation, one is best served by keeping one’s head down and recognising who holds the power in a relationship. This, in turn, breeds an environment where it is safest to heed the three CCC – conformity, comfort and conservativism - not exactly the qualities of a dynamic and daring organisation of ILO Society’s calibre. This creates a climate where people are afraid to take initiative and act on their convictions for fear of being made into scapegoats should anything go wrong. This is in sharp contrast to the stated intention of higher management to be facilitators and enablers allowing people at project level to act on their own initiative under management guidance. This fear also prevents people from speaking out when they think something is wrong, as they feel there is a risk that they might get blamed for bringing the problem to attention – shooting the messenger. However, if everyone is afraid to point out that there is a ‘hole in the roof’ then eventually everyone drowns, as the problem goes unaddressed.

This fear to step forward also impacts on reporting and documentation of qualitative work as there are strong sanctions against ‘bringing yourself forward’, i.e. to emphasise yourself or your achievements. Quantitative reporting is anonymous, taking the achievements of a project or the


organisation as a whole and reporting this without emphasising any one project or person. Though this aversion to individual emphasis is in some way an indication of a strong team spirit, it also prevents more qualitative reporting – for, when qualitative reporting is of good quality, it will describe the problem faced, the action taken and the result achieved. It will focus on specific people or situations and will necessarily bring out the achievements of a few. But what can be done about these barriers to create a climate more conducive to open dialogue and communication without fear of recrimination? 4.3 Opening the channels and moving forward There is no one solution to creating improved channels of communication within an organisation, each must find their own mechanisms which are suitable to their own cultural context, history and working practices. Perhaps the most important step to take is to recognise that communication plays a crucial role in the development and success of the organisation. Secondly, the organisation needs to address issues of trust, respect and control within the chain of command, from higher management to field staff but equally from field staff towards management. These barriers and perceptions must not be seen as something superimposed on junior staff by those higher up in the management. Rather, it is an atmosphere which all levels are complicit in creating and maintaining. Thus, open dialogue about how to address these communication issues must involve staff from all levels. It matters little how many open hands are extended or doors opened by higher management unless steps are taken to address the perceptions of field staff. Conversely, it will have limited effect for field staff to find the courage to speak their mind, unless higher management in the organisation addresses their perception of field staff and the value of their opinion. Thirdly, it might be helpful for the organisation to take on board a more service oriented model of evaluation, utilised by many commercial businesses, in order to see the value of each staff member in terms of their contribution to the end product. For example, in a retail environment the success of all the staff in the organisation is evaluated in terms of their ability to increase sales. Administrative staff and management would then be evaluated in terms of their ability to provide customer facing staff with the support they need in order to maximise their sales figures. In the case of ILO Society this end product must be understood as the outcomes of interventions as in terms of services rendered to the end-user. In this perspective, management provide support for field staff which are ‘selling’ the organisation’s ‘product’ – service delivery. By looking at the situation in this way, the added value of management lies in their ability to further the activities of field staff and projects. Within this perspective, status and hierarchy remains unchanged, but perhaps it can help in creating an environment more conducive to two-way communication rather than silent compliance. However this issue is addressed, it is again important that the intention, rather than merely the goal, is transmitted and that the process itself is inclusive. Through this process the organisation can build on existing capacities and move from being providers to becoming enablers – both within the organisation and in interventions, both vertically and horizontally. But the process must be guided by open dialogue, driven more by an open mind and open ears than by open mouths. The future challenges for ILO Society and leprosy organisations in general are substantial, but we stand at a crossroads in history and the possibilities for substantial benefit and meaningful change are tremendous. However, this change must be approached consciously and with both eyes wide open. It is not for me to say what needs to be done or in which direction the organisation ought to move forward. This report has tried to highlight some of the strengths and


weaknesses of ILO Society as seen by one researcher, and I hope that some of these opinions of an outsider might be of benefit to the organisation as you plan the road ahead. At this point I would like to give the floor to two statements by Dr. Arole and Nicholls & Smith as their expertise and wisdom exceeds my own, but the vision they paint of the future is one that I share: “A change of paradigm is needed, recognising people as subjects, not objects, and workers as enablers and not providers. Interventions must be supportive and responsive, empowering rather than diagnostic. They must include addressing the needs and resources of the community and extending its capacity” - Dr Arole ILC Beijing 1998 - “A ‘listening and learning’ approach is essential. Such an approach requires a radical shift away from traditional hierarchical management. To build understanding, project managers must be ready to learn from field staff and other professionals. Fieldworkers must learn to respect the point of view of their clients. This open-minded approach must extend to a willingness to change project priorities or to reconsider long-standing assumptions.” - Nicholls & Smith - This is an difficult and exciting time in leprosy work. The achievement of the past and the challenges ahead are multitudinous but there is a real opportunity to build on the achievements of the past towards the accomplishments of the future. I, for one, am very excited to be able to be part of this transition, have faith in the integrity and drive of ILO Society and look forward to seeing what the future will bring for the organisation and its partners as it takes change into its own hands and, to paraphrase Gandhi, ‘embodies the change that it wants to see in the world’.


5. Recommendations This report aims only to be a preliminary summary of my impressions thus I am wary of giving recommendation that are too specific, nor do I feel that this is my place. But if I may, I would like to make some general suggestion regarding a few fields:

5.1 Recommendations: Communication

“The ear of the leader must ring with the voices of the people.” Woodrow Wilson (28th Pres. of USA) I would like to start with communication as I feel that good communication is the key.

• Initiate negotiation with all stakeholders, not merely in the board room.

This will help ensure that the organisations vision is one that can be shared by all involved.

• Create unity of purpose. Intentions are useless without opt-in at all levels. ILO Society’s mission statement is a very powerful symbol, carrier of meaning, within the organisation. Utilise it a as rallying point, but through dialogue with staff at all levels, not as passive recipients of message.

• Establish internal consultation process. Identify and implement appropriate alternative channels of communication that can cross-cut traditional lines of hierarchy. Anonymous if necessary. Things like suggestion boxes, e-mail queries, designated phone line, HR support person etc... Will also aid transparency of the organisation.

• Identify mechanisms for open dialogue. Staff rarely feel comfortable talking openly in the traditional open forum setting. If one could identify means of making people more comfortable, or brainstorm alternative means of interaction, then one might succeed in creating a platform where people could express their ideas and opinions more freely so that all could benefit from them.

• Translate intention, as well as targets, to all staff. These established platforms could also serve as effective channels of communication for discussion surrounding intentions and core values of the organisation – to translate the intentions of new interventions into motivation of field staff through unity of purpose.

• Show respect, demonstrate trust, relinquish control. These three principles must be considered in any situation where communication is discussed. Respect and trust, vertically and horizontally, for our colleagues is essential for creating a platform for open dialogue. And, once on that platform, all involved must be willing to give up a degree of control over the proceedings in order for all ideas to be heard and treated as equal.

• Allow for polyphony without allowing this to become cacophony. Too many voices can drown each other out. Need ‘channels’ to direct streams of communication to become meaningful dialogue.

These are not drastic or novel ideas but their impact on organisational culture and the success of future interventions should not be underestimated. The primary recommendation of this preliminary report is that the organisation invests time and resources into improving communication within the organisation, both for the sake of the organisation and its core values and for the organisation’s ability to execute the kind of interventions that it aspires to implement.


5.2 Recommendations: Organisational culture I have attempted to demonstrate the danger I see from a potential schism in organisation culture. Again, organisational culture is often taken for granted or seen as a static attribute of an organisation. However, organisations are given meaning through continuous negotiation of meaning through everyday routines. This constant process of negotiation is what constitutes an organisation’s culture. Organisational culture is not something an organisation has, it is something an organisation is. Who gets to be part of the process of defining what this culture should be at any given moment can be as important to the nature of the organisation as what is decided.

• Discuss new directions with staff – don’t ‘explain’.

Being part of the process of decision making is as important as a thorough understanding of the decisions made. Translation of intention is easier when starting from a shared vantage point.

• Motivate staff through creation of shared organisational culture. In addition shared organisation culture creates solidarity and unity of vision which translates to motivation and, very possibly, increased success in reaching desired outcomes.

• Bridge schism in organisational culture. As argued above – the organisation should take care to draw on its existing capacities as embodied by the field staff and to create unity of vision in order for all staff to be ‘pulling in the same direction’ rather than ‘pulling the organisation apart’.

• Maintain commitment to provision of quality services. One of the strengths of the field staff as well as ILO Society in general is dedication to quality service provision and outstanding technical expertise. The issue of service provision is also contentious within the organisation because it has become the symbolic carrier of dedication to the provider role. The organisation must recognise both the inherent strengths and weaknesses of the provider role.

• Recognise diversity of activities as a core strength. Any successful organisation must be able to balance the different influences of dedication to service, sustainability and rights all at the same time. ILO Society must come to terms with internal variety and recognise that there is nothing wrong with certain parts of the organisation being more or less committed to one or more of these. As long as there exists an established, shared organisational culture where everyone is aware of, and sensitive to, the varying influences of these three perspectives at any given location or occasion. Different projects fulfil different functions, but all add to the value of the organisation.

5.3 Recommendations: Core values

Whenever two good people argue over principles, they are both right. - Marie Ebner von Eschenbach Change is constant and necessary. It is not always easy, but it is ever present and, fight as we might, there is little we can do except accept this. However, we can make change a conscious process with a clear aim to work towards rather than going wherever the current carries us. All change will eventually feed back to the very core principles of the organisation, and how we approach this change as much as which path we decide to take will have an effect on the core values of the organisation. I cannot give you recommendation of where you ‘ought’ to go from here, where your path should lead you. All I can do is raise some issues for your consideration as you approach this change. Change can happen to us, but we can also make the decision to change – only the latter of these processes allows us much control over our own fate and the resulting core values of the organisation.


• Appreciate the limitations of project-based work. Funding pressure may be driving more short term, high impact projects. But ILO Society needs to be mindful that the increasing staff turnover rate and outsourcing to implementing NGOs may have an impact on the core values of the organisation.

• Recognise that staff, not policy papers, are the carriers of Core Values. Staff are the real carriers of core values, not policy papers or reports. As a managing NGO can the organisation guarantee the quality of work which it feels is fundamental to its identity as an organisation and how it is perceived by others? DDD – dedication, devotion, determination – was singled out as one of the organisations core capacity in the strategic planning meeting, but who will embody these qualities if the majority of staff are employed on a short term basis?

• Balance impact of knowledge retention/organisational memory vs. flexibility/specialisation. Project based work and high staff turnover may threaten knowledge retention and organisational memory, but on the other hand it enables greater flexibility in the skills and capacities held in the organisation at any moment. Also new blood may bring fresh perspectives whilst long term staff may tend to be more conservative. A balance needs to be struck.

• Recognise that the core values of the organisation are expressed through its actions. As the name considered by the organisation, Health in Action, implies: as an organisation you are what you do. The core values are embedded in the interactions between field level staff and communities and clients. The organisations actions at ground level embody the core values to a much greater extent than the rhetoric of policy papers – actions speak louder than words. Thus the kind of staff and their understanding of the intentions of the interventions they are carrying out has a direct impact on the practical core values of the organisation.

• Work towards a shared organisational culture. Thus, to ensure that these actions represent the desired core values the organisation must ensure that there is a shared understanding of what these core values are through creating a shared organisational culture. Essentially ensuring that everyone is ‘on the same page’.

• Actively manage legitimacy and reputation as scarce resources. For organisations, legitimacy and reputation is one of the most valuable, but also one of the scarcest resources, they possess. It enables funding and productive partnerships with other NGOs as well as national and international agencies. This reputation and legitimacy is created and maintained through the organisation’s ability to successfully achieve intended outcomes as well as the quality of the services provided at ground level. ILO Society has developed a very good reputation and an abundance of legitimacy over the years. It is crucial that this is maintained through expression of core values at ground level as well as continued transparency of processes and finances at organisational level.

As an organisation ILO Society must be dedicated to a conscious approach to change, to ensure that the change takes the organisation in the desired direction and that all involved are on board with these changes.

5.4 Recommendations: Operational issues Now, finally, for a mixed bag of general points relating mainly to operational issues. Again, these must be seen as issues for consideration rather than as recommendations as they are intricately linked to the core values and changes discussed above:


• Run evaluations based on service model principle. As discussed above this could help open up channels of communication, but it would also help to shift focus back to front line staff – be they field staff or project co-ordinators – and reinstate these as the pillars of the organisation. When one comes to realise that, in practice, the core values of the organisation are expressed in the meeting between front line staff and their partners, be they implementing organisations or communities, the importance of this interaction and the front line staff is reinforced. This is only one possible model, and there are many other equally good modes of analysis which can be utilised to similar effect.

• Keep leprosy at the centre – keep leprosy workers at the centre The organisation expresses a desire to keep leprosy work at its core. It is difficult to keep leprosy at the core if the majority of projects will be run by staff or implementing NGOs that have no experience working with leprosy. Thus, by retaining leprosy staff and deploying their considerable skill to projects focusing on other issues the organisation could achieve a continuous focus on leprosy without undue training and input. Of course the staff must have the appropriate skills for the role they are placed in, but I hope that my discussion of CHO strengths will have made an argument that ‘leprosy workers’ have many and varied, if somewhat underappreciated, skills and capacities.

• Build internal and external partnerships for effective service provision CHO working practices demonstrate how effective networks can be for addressing needs which fall beyond the remit of the organisation – both NGO and government resources. However, these are maintained and managed almost exclusively by individuals and their personal relationships. Efforts should be made to streamline, consolidate and expand this referral base, both on organisational and project basis. This is highly cost-effective, will aid in building new partnerships for the organisation, provide quality of services for the clients and avoid duplication of work.

• Establish skill sharing mechanisms through internal and external partnerships. These types of partnerships also open for skill sharing. This is primarily of interest internally within the organisation, but novel staff exchange projects with similarly minded organisations can also be instigated. Considering the changes underway in the field of leprosy work skill sharing internally with HIV/AIDS projects may be of particular use to field staff. There is still a tendency within the organisation to think that ‘persons get HIV whilst patients get leprosy’ due to predominance of service provision and project management thinking within leprosy. The organisation provides drop-in centres to people living with HIV/AIDS and footwear to persons affected with leprosy! Thus, by instigating skill sharing projects that go beyond training, the organisation could achieve knowledge and attitude translation across specific disease interventions.

• Involve ground level staff in documentation to translate data into information. In order to go beyond quantitative reporting to more qualitative documentation it is essential to involve staff from all levels. The process of transforming data into information is a process of translation that requires the involvement of the persons involved in the work in the first place. However, it is important to recognise that not everyone is a ‘writer’, thus, this will need to be a collaborative process. The accounts produced this way can be an important tool for addressing the perception of the work of ground level staff and for documenting best practice models.

• Review ever increasing documentation burden for impact vs. workload. More information is not necessarily a good thing. Projects are easily weighed down by reporting burden, whilst many of the most important aspects of the work go unreported. The organisation needs to review burden of reporting, in terms of workload, impact and official requirements, and utilise project staff to ask the pertinent questions for their project and produce reports which reflect the qualitative as well as quantitative aspects of the work done.


Thank you Thank you all for the wonderful opportunity to work with you, it has truly been a pleasure and a privilege. I hope we can have many fruitful interactions in the future and that this report can offer you some points of consideration as you face the challenges ahead and move forward as an organisation. Please bear in mind that this is a preliminary report based on primary observations meant for the internal interest of the organisation only. Although, some of the points raised in this report may be experienced as controversial, or just plain incorrect, I must offer my assurances that it is not, nor was it ever, the intention of the researcher to cause offence. If I have managed to do so unintentionally, I offer my humblest apologies. As for any incorrect statements I can only say that any limitations in the powers of perception are entirely those of the researcher and should not reflect negatively on anyone else. I would like to express again my desire that this be a collaborative effort and that this report form part of a continuous feedback process. I would therefore greatly appreciate any comments, thoughts, criticisms from anyone within the organisation.

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