MCH Needs Assessment:MCH Needs Assessment:Capacity to CompetencyCapacity to CompetencyDonna J. Petersen, ScD, MHSMCHB Partners MeetingFebruary 26, 2009

Imagine this . . .Imagine this . . .A state MCH program produces

an elegant needs assessment filled with tables and tables of data but there is little analysis, little stakeholder input and no discussion of what the state might do about the problems suggested by the data

Imagine this . . .Imagine this . . .A state MCH program produces an

elegant needs assessment complete with data and information gleaned from constituents with clear areas of focus identified but the state priorities bear little relation to these areas of need and instead look suspiciously like the organization chart of the state MCH program

Imagine this . . .Imagine this . . .A state MCH program produces an

elegant needs assessment complete with quantitative and qualitative data, a full analysis of the nature and scope of needs, a set of priorities clearly derived from this analysis, but no change in structure or function of the central office, no change in resource allocation, no clear plans to engage in any new efforts

Do we have to imagine Do we have to imagine this?this?Have any of us been in these

situations?What do these have in common?

What do these have in What do these have in common?common?One thing, I would argue, is that

they possibly reflect a lack of capacity to engage in the full range of activities related to needs assessments, from gathering and analyzing data, to engaging constituents, to setting priorities, to devising plans to action, to acting on those plans in meaningful ways

Needs Assessment in MCHNeeds Assessment in MCHWe recognize

◦That our mission as MCH professionals is to secure for the families in our states all that they need to develop, grow and thrive

◦That we shape this mission by pursuing information on the nature of those needs

◦That needs are revealed both through data collection and through open discussion, listening and observation

Needs Assessment in MCHNeeds Assessment in MCH

We further recognize◦That the authors of OBRA 89 put in place a

mechanism to assure we had the means to conduct comprehensive needs assessments

◦But that needs assessment is an ongoing, continuous process, not just every five years

◦AND, that that process does not stop with the compilation of “needs” but with the articulation of priorities and the development and execution of a plan of action

Needs Assessment . . .Needs Assessment . . .Since 1989, we collectively have

made tremendous progress in our ability to collect, analyze, manage, disseminate and optimize data and information◦Most state MCH programs now have

expert staff, data or policy analysis units, data sharing agreements with other agencies, automated collection systems for our grantees and partners, and a system for qualitative information gathering

. . . to Action in MCH. . . to Action in MCHWhere we have difficulty is in

◦Identifying strategies to combat problems

◦Achieving consensus on direction ◦Making the tough decisions◦Garnering political will◦Managing change◦Executing the plan of action

Why is This Difficult?Why is This Difficult?

Over-committed staffOver-committed staffLack of political will Lack of political will Committed to present activitiesCommitted to present activitiesPrevious planning failuresPrevious planning failuresLimited expertiseLimited expertiseNo readily available solutionNo readily available solutionInsufficient resources Insufficient resources Competing priorities/desiresCompeting priorities/desires

thanks, Bill Sappenfieldthanks, Bill Sappenfield

Disconnect between Desire Disconnect between Desire and Realityand RealityPerhaps the biggest challenge we

face is reconciling the vision - the wishes and hopes generated by a comprehensive needs assessment - with the practical reality of what we actually have the ability to accomplish

A Need does not a Priority A Need does not a Priority makemakeIf you’ve been with me before,

you’ve heard me champion the idea that you must have a solution to address an identified need that you believe may work, that won’t cost you the bank and that will be acceptable to the public and to policy makers

Without a reasonable strategy there is little point in selecting the need as a priority . . .

New Step in the Needs New Step in the Needs Assessment Process?Assessment Process?Perhaps in addition, we need to more

deliberatively assess, as part of our comprehensive assessment of needs,◦ our ability to achieve the dream◦ the elasticity of our resources◦ the level of political will that exists for

change◦ our true ability to adapt to a new

directionEven where a solution exists!

Opportunities . . . Opportunities . . . We don’t always take themWhy? Because we’re pragmatic

◦If you have no one to nominate to the new task force on x, you’ll decline

◦If you have no one with the right expertise to write the grant, you won’t apply

◦If you know you can’t act on the promise, you won’t make the promise

◦It’s a matter of capacity

CapacityCapacityCapacity

◦The ability to hold, receive, store or accommodate A measure of content Maximum production or output

◦Legal qualification, competency, power or fitness

◦Power to grasp and analyze ideas and cope with problems

◦Position or character assigned or assumed

Capacity AssessmentCapacity AssessmentWhat, in the starkest light of day,

can we really do to move in a new direction?

How can we objectively assess our reality?

How do we measure our capacity for success?◦Our ability to accommodate◦Our competency and fitness◦Our power to cope with change◦Our positional authority

Capacity Assessment 101Capacity Assessment 101• This would be a whole lot easier if

there was some kind of guidebook that clearly stated what every state MCH program should look like

• But it is one of our great strengths that we are allowed to organize and function in response to the needs and circumstances of our states

• “if you’ve seen one MCH program, you’ve seen one MCH program”

Capacity AssessmentCapacity AssessmentThe tremendous variability in our

states . . . geographic, demographic, historic, economic, social and cultural, environmental, behavioral, etc adds to the complexity of attempting to characterize sufficient “capacity” for a state MCH program

Not to mention the different ways we choose to structure our state governmental agencies

Capacity AssessmentCapacity Assessment

• Where is MCH in the health department hierarchy? Is CSCHN with MCH or somewhere else?

• What else is aligned with MCH? Family planning? WIC? Immunizations? Lead? Injury prevention? Tobacco? Mental health? School health? Home visiting? Substance abuse?

• What else is/is not within the health department?

• Where is Medicaid? Early Intervention? Environmental health?

Capacity AssessmentCapacity AssessmentLike everything else we do, this we

do not do alone in isolationWe are masters at building

partnerships, forming coalitions, persuading others to do what is right for children and families, seeking and securing support for our broad efforts

So let’s think about what we need in order to better meet the needs of our populations

Capacity Assessment 101Capacity Assessment 101

1. Internal to the central office2. Within the home agency3. Within related state agencies4. Within local jurisdictional offices5. Within local communities– Usual suspect partners– Non-traditional partners

6. Within decision-making bodies

Capacity Assessment 101Capacity Assessment 101

What are you looking for?1.Skill sets2.Resources (money is not the only

currency)◦ Time◦ Talent◦ Support/Partners/Infrastructure

3.Interest

First ExerciseFirst Exercise• SKILL SETS–Think about the skill sets you would like to

have in your ideal state MCH central office–Don’t worry about the number, just

brainstorm the skills you would like to have available to you–Think about the entire needs assessment

process (which, we have already established, is in effect your entire program planning ,advocacy, implementation, evaluation, communication process for MCH activities in your state)

First ExerciseFirst Exercise• Think of these as “fixed assets”, skill

sets you need regardless of the direction of your programs

• Feel free to advocate for what you believe while imagining the ideal team

• DO NOT worry about where these will come from

• Select someone at your table to report back your consensus conclusions

Skill Sets Report Back

If you don’t have these skill sets in the If you don’t have these skill sets in the MCH central office, where else might MCH central office, where else might you find them?you find them?First think about your governmental

partnersOther units within your agency?Other state agencies?Local agencies?Then think about other partnersGrantees?Community organizations or

groups?Academic institutions?

Second ExerciseSecond Exercise

Now we have to get a little real . . . Brainstorm for awhile where you might

find the skill sets you identifiedThink first about whether it even exists,

where, and then rate your ability to gain access to it◦Relatively easily, maybe, probably not

Is training available in the skill set?Select a different reporter from the table

Sources of Skill Sets Report Back

Capacity AssessmentCapacity Assessment• Note that we have made no attempt

to link these desired skill sets to any particular set of needs, or programmatic initiative

• That’s because you need to know the full menu of possible assets in order to determine whether you have the capacity to respond to a particular challenge

• Needs change, your efforts will change, your capacity to change will change . . .

Capacity Assessment: Capacity Assessment: ResourcesResources• Resources–Yes, it would be lovely to have more

money• And you should definitely be thinking about

that as you evolve your plans in response to needs and your growing knowledge of your capacity to respond

• Who might fund this? The legislature? A federal agency? A national foundation? A local foundation? Can you partner with another agency who may fund portions of the effort?

• The big question: Can you stop funding something else in order to fund this?

ResourcesResources• Also important to figure out where any

extra time may be stashed away . . . This refers to your own staff Others with the skill sets you need Local grantees Community partners

• Do you have capacity where you no longer have need? You may have skill sets that are no longer

relevant C H A N G E . . . is really hard

Delivery or Deployment Delivery or Deployment CapacityCapacityDo you have networks through which

you can deploy new initiatives?◦Do you have local agents?◦Do you have accessible media markets?◦Do other agencies have local offices?◦Can you work through schools? Through

health care providers, hospitals, clinics?◦Are there academic institutions outside

the metro areas?

Resource InventoryResource InventoryIdentify local service delivery

capacity◦Reveal gaps in services from lack of

availability, access, continuity, appropriateness

◦Reveal underutilized capacity as wellHelp you clarify who is currently or

potentially capable of meeting the service delivery needs you have identified, typically at the local level

Resource InventoryResource InventoryThese can be conducted in

several ways◦Via a survey (paper, telephone, on-

line)◦Via an audit◦Via information provided at the time

of application for funding or preparation of an annual report (for those agencies you fund)

Resource InventoryResource InventoryTypically want to learn:

◦Type of services offered◦To what client mix◦At what level of intensity (quantity)◦At what level of coordination across

providers◦With what type of follow-up◦At what cost (or eligibility limits)◦At what location, over what hours◦By what types of providers

Resource InventoryResource InventoryCoupled with a good assessment

of need, resource inventories help fill in your ‘capacity map’ or are part of an assets inventory

These inventories can give you clues into not only where you might have obvious gaps but also where you might have potential to add a service, link services, or modify client/service mix

Changing the Resource Changing the Resource InventoryInventoryIf you find areas in need of

“enhancement” the next question is, of course, how do you get these agencies to change what they’re doing

Remember, they don’t like change any more than you do

ChangeChangeIf you fund them, you may have

some leverage◦Best not done without some serious

conversation◦They will surprise you if you give them

a chance to help you work through these issues

◦Often better done as a carrot and not a stick, i.e. if you will do x, I will also let you do y (or stop doing z, which they’ve never liked)

ChangeChangeIf they are somehow accountable to

you (the ‘royal you’ in this case) you might be able to back into it by changing the performance measures◦If they are told they must achieve a

certain level of performance or reach a certain outcome, they will have to adjust their efforts to accomplish that

◦Again, better done as a carrot, i.e. reward them for doing it rather than punishing them for not

ChangeChange A little bit of money goes a long wayIf you have no other “authority”,

trying offering some funding, either seed funding through a competitive mechanism, or a small amount of planning money to get something going◦i.e., $1 per birth in a county or locality to

gather information, analyze it and develop a plan to improve pregnancy outcomes

Case ExerciseCase Exercise

Case Exercise Report Back

Capacity Assessment: Capacity Assessment: Interest Interest Policy theorists and analysts often

speak of “policy windows”, i.e. the moment of opportunity when a policy agenda has the greatest likelihood of being adopted

They also speak of the “softening up” process and suggest that the time-lag between when an issue is clearly identified and when action is actually taken, can be quite long indeed

Capacity Assessment: Capacity Assessment: InterestInterestKotelchuck and Richmond wrote

of three necessary elements for policy action: ◦Knowledge base (data, science)◦Effective strategies ◦Political will

Capacity Assessment: Capacity Assessment: InterestInterest• Part of your capacity assessment has to be

judging the relative political will for action around the issue(s) you have identified

• Part of this depends on the issues themselves–What “issues” might be more difficult to

champion?• Part of it depends on competing priorities– Is something else going on that detracts

attention from your issues? (gee, does this ever happen?!)

Capacity Assessment: Capacity Assessment: InterestInterestBut part of it also depends on how

prepared you are to seize a policy window◦Have you accumulated sufficient

evidence, both scientific and political, to support your agenda? Have you sustained a coalition of support?

◦Have you engaged in that “softening up” process using your ability to educate and inform elected officials?

◦Are you on the look-out for those focusing events that draw attention to your issue?

Capacity Assessment: Capacity Assessment: InterestInterestSo, interest refers to the

willingness of elected officials to support your agenda and perhaps stick their necks out

But before this, it also speaks to the interest of the public (the sine qua non of your ability to label something a true “need”)

AND the interest of those you work with, partner with and fund

Capacity Assessment: Capacity Assessment: InterestInterestThankfully, these all come together as

part of the usual suspect needs assessment efforts you have been putting forth for nearly 20 years◦You know the data alone does not indicate

need◦You know you need to engage your

constituents◦You know you need to form strong stakeholder

coalitions to move the full agenda forward◦You know to gauge the political will on the

issue

Capacity Assessment: Capacity Assessment: InterestInterestSo while this may have seemed

the most difficult to get a handle on, it may in fact be easier

It’s a test of your political savvy to know when the winds are blowing for change and to seize those moments

The challenge, interestingly enough, usually is back home at the office

Capacity for Internal Capacity for Internal ChangeChange

Capacity for Change = Capacity for Change = Organizational CultureOrganizational CultureOrganizational culture:

◦the attitudes, experiences, beliefs and values of an organization

◦the values and norms that are shared by members of an organization and that control how they interact with each other and with stakeholders outside the organization

Is yours a “change-ready” culture?

Change-Ready CultureChange-Ready CultureStrong Culture

◦where staff respond based on their alignment to organizational values and where people do things because they believe it is the right thing to do

Weak Culture◦where there is little alignment with

organizational values and control must be exercised through extensive procedures and bureaucracy

Culture, Change and Culture, Change and LeadershipLeadership

Culture is nurtured through leadership, therefore:

We need leadership to effect change!◦Formulate a clear strategic vision◦Display top-management commitment◦Model culture change at the highest level◦Modify the organization to support cultural

change◦Select and socialize newcomers and terminate

deviants◦Be sensitive to tensions between

organizational and individual interests

Capacity LimitationsCapacity LimitationsWhat do you do when you run into a

wall?Obviously you can’t take on more

than you are capable of doing◦If you can’t get the skill sets you need

internally or through your partnerships◦If you can’t identify resource

opportunities◦If there is insufficient interest

These issues need to go on a back burner (remember the “softening up” process)

When Priority and Capacity When Priority and Capacity CollideCollide

You will identify needs that are not yours to act on, e.g. housing, jobs, crime

You will identify needs that are yours but for which no good solution has yet been found effective, e.g. early preterm birth, obesity, meth

You will identify needs that are yours that have a solution but for which you have no capacity, i.e. no local network, no skills, no time, no will

What to do?What to do?They remain priorities because they

emerged from your needs analysis but they require a different kind of response◦The first set requires an advocacy response

– only you know how effective you might be

◦The second set requires a data or research strategy . . . again, only you know if you have those skills or contacts

◦The third set requires infrastructure changes

Capacity as PriorityCapacity as PriorityNEVER be afraid to include capacity

needs in your top priorities!Once you’ve done this assessment

back home, you should be able to articulate areas of lesser capacity that must be shored up if you are to effectively address the population needs you have identified

It is not wrong to include in a list of priorities the need to improve your basic infrastructure

Do the Best You CanDo the Best You CanRemember “the perfect is the

enemy of the good”?Everything is the enemy of

somethingBetter to do a few things well,

than a lot of things poorly or not at all◦And better to be honest about what

you can do and what it would take for you to do more

Capacity for External Capacity for External ChangeChange• We have focused on the State MCH

program and your more or less direct sphere of influence

• As we know, our responsibility extends to the entire system that supports families in our communities

• As such, part of our capacity assessment has to focus on the extent to which that system exists and is both enduring AND flexible

What is “the MCH What is “the MCH system?”system?”

System CapacitySystem CapacityWoven throughout what we’ve

discussed is the need to attend to this –◦Where are your partner agencies?◦What could they be doing differently to

support families in your state?◦Where are there huge gaps around

which you might advocate together?◦Do you have sufficient local capacity?◦What about health manpower in the

state?

ConclusionsConclusionsPriority/Need

Skill Sets in the Central Office

Local Network/ Service Delivery

Partners/ Resources

Political Will/ Interest

Teen Pregnancy

Prenatal Depression

Physical Fitness in Children

Partner Violence

HPV Vaccine

2010 Block Grant Needs 2010 Block Grant Needs AssessmentAssessment“To thine own self be true”You must know yourself, your

strengths and your limitations before you can effectively fulfill your MCH responsibilities

I encourage you to consider assessing your capacity while you are assessing your needs

And to be realistic when setting your priorities

They can and should include steps to address both population needs and capacity needs

Good luck and GodspeedWe are ALL counting on you

Thanks for your generous attention