Insight Plus - Sightsavers

InsightPlusPositive Failure: learning from challenges

Issue 6 Dec 2012

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Front cover photo:Noria Moonga farms her land once again after receiving cataract surgery through the Livingstone to Lusaka Urban Eye Care Programme

ContentsForeword 2 Dr Caroline Harper

Developing human resources for the education of children with disabilities: learning from district based education projects in Rajasthan 4 Nitin Sharma

When systems don’t work in harmony: lessons from M&E system design in a complex setting 8 Taitos Matafeni

When targets are not met: lessons from an urban eye care programme in Zambia 11 Precious Chisebuka-Julius, Glenda Mulenga

Quality assurance in cataract management: learning from failure 14 Elizabeth Kurian

Implementing a CBR programme in Uganda: challenges when working with community development workers 17 Juliet Sentongo

Training refractive error personnel for project needs in Cameroon 21 Dr Joseph Enyegue Oye

Learning from failure: from negative to positive 24 Claire Jago

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From the editorClaire Jago, Learning Support Officer

Welcome to the sixth issue of Insight Plus, Sightsavers’ bi-annual learning review.

Working with partners across Africa, Asia and the Caribbean, Sightsavers’ aim is to eliminate avoidable blindness and promote equality of opportunity for disabled people. This series collates learning and best practice from across our programmes, with each issue focusing on a different thematic area.

In this issue, we have chosen to focus on what happens when a project doesn’t go to plan, or doesn’t produce the results that we expected to see. It is not always easy to acknowledge that things have gone wrong, especially when we are all striving to deliver the best that we can for our beneficiaries. However, by taking the time to reflect on our failures, as well as our successes, we can turn these experiences into valuable learning opportunities, helping us to improve the quality of our future work.

I hope you find Insight Plus useful, and welcome your comments and suggestions. Please send your feedback to [email protected]

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CopyrightAny Insight Plus material may befreely reproduced, provided thatacknowledgement is given to Sightsavers as the author.

ISSN 2044-4338

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Many organisations say they aspire to being ‘learning organisations’. This is true both within the NGO sector and elsewhere. I have been to many seminars and meetings which are meant to be learning opportunities, where people have reported back on their projects (of all types). There seems to be a remarkable reluctance to share the things that went wrong. At most someone may put a ‘challenges’ slide at the end of a presentation, but usually these are minimised whilst the ‘highlights’ are the focus of the presentation.

I would contend that we learn far more from mistakes, or from unexpected consequences,

ForewordDr Caroline Harper, CEO, Sightsavers

Dr Caroline Harper

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than we do from the things that go to plan. Yet often people feel that somehow if they share these experiences, they will be judged wanting in some way. So learning that could benefit others does not see the light of day. From failure could have come great steps forward, but these are then not made.

In this world it is rare that everything works out the way that we hope it will. All of us have these experiences and personally I immediately doubt anyone who says ‘oh it all went perfectly’. Nothing ever does. So if we are to be a genuine ‘learning organisation’, we have to share what went wrong, and what we

would have done differently, at least as much as we share our successes.

This document is a step towards doing that and hence is entitled ‘positive failure’, as it emphasises the positive learning that comes when things go wrong; ‘the silver lining in the cloud’.

I would therefore like to thank those contributors who have been willing to share their experiences. These will be of tremendous help to others, both within Sightsavers and outside. Such openness is a sign of real professionalism.

“If we are to be a genuine learning organisation, we have to share what went wrong, and what we would have done differently, at least as much as we share our successes”


IntroductionWorking with local partners, Sightsavers supports the implementation of education programmes for children with visual impairment. In 2009, Sightsavers’ North West India office initiated two education projects in the districts of Barmer and Jaisalmer. These projects focused at the district level and aimed to strengthen Government systems and support advocacy and networking with civil society organisations

working on education issues. This article discusses the implementation challenges faced by those projects, looking particularly at the need for high quality and sustainable human resources within an education system. The article reflects on the need for continued capacity building and support for inclusive education facilitators, and provides guidance to education planners on the benefits of developing sustainable human resources from within the project community.

Developing human resources for the education of children with disabilities: learning from district based education projects in RajasthanNitin Sharma, Programme Officer, North West India

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An Inclusive Education facilitator supports Devilal in class

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Project backgroundEducation is a human resource intensive activity and having sufficient skilled and motivated professionals is an important element of a quality education system. To support the education of children with visual impairment, district level programmes aim to have one special educator to every ten children needing support. These educators are expected to possess the necessary level of qualification, as laid out by the Government. They are also governed by the Rehabilitation Council of India (RCI), a statutory body enacted by parliament in 2000 to monitor services provided to people with disabilities. Section 19 of the act states that service providers must have received approved training and be registered with the RCI in order to deliver services to people with disabilities. The council holds the power to take punitive action against unqualified people delivering such services. In order to meet both Sightsavers’ standards and the requirements laid out by the Government of India, the district level education projects appointed 28 special educators who held either a bachelor’s degree in special education or diploma level training in this field. It was extremely challenging to secure such a skilled workforce due to a lack of specially trained educators in the region. Literacy levels are low in these areas and few people opt for special education as a profession. At the start of the project, there were only three qualified special educators in Barmer and one in Jaisalmer, and these people were already engaged with Government schools. However, with strong networking and referrals from training schools spread across India, the project was able to attract the desired number of qualified special educators, who became known as inclusive education (IE) facilitators. After an induction to the project, the team of facilitators were placed in clusters of around 20 to 30 villages, depending on the geographic spread and accessibility by various means of transport. Each facilitator was expected to support eight to ten visually impaired children, and their schools and communities, within their respective cluster. With the placement of IE facilitators on this scale, the human resource map for these districts was enhanced and a pupil-teacher ratio of 10:1 was achieved through the presence of these facilitators.

What went wrong? Although the scenario described above was ideal for promoting inclusive education, it wasn’t long before IE facilitators started to leave the project. The leavers were replaced with new recruits, but the pattern continued and, within a few months, the entire team of IE facilitators were planning to leave the project. The movement of a qualified team could have significant impact on the programme and so, working with our partner, Society to Uplift Rural Economy, Sightsavers decided to assess the causes that triggered this turnover of IE facilitators. The exercise provided some important clues:

Geography and terrainThe project districts fall under the Thar Desert region of Rajasthan state, which has a population density as low as 17 people per square kilometre. Consequently, the facilitators were required to travel long distances over difficult desert terrain in order to reach the children.

Cultural differencesAs the facilitators were sourced from across the country, almost all of them came from outside the state of Rajasthan, where the projects were based. Rajasthan has different social practices, including the typical caste and class system still being practiced, albeit secretly. Although the community extended housing and social protection to the IE facilitators, they found it difficult to bridge the differences in culture and community practices.

LanguageAcross the education system, Hindi is the official language of instruction in schools. However, local dialect is the preferred communication among communities, and young children typically understand their tuition better if it is delivered in the local dialect as well as Hindi. Being external to the region, it was difficult for IE facilitators to learn and communicate in the local dialect in such a short time. This language barrier prevented them from fully connecting with the local communities in which they were working.

Daily livingThe staple food in the Thar region is millet, which is eaten three times a day. The facilitators were more used to eating foods such as green vegetables and wheat, but these are not readily available the region. The


available level of accommodation also differed to the facilitators expectations. Overall, there was a perceived decline in their health status and living conditions, ultimately prompting them to move to other areas.

Market opportunitiesThere is shortage of specially trained educators across India and the Government had launched a drive to appoint more of the existing educators into Government schools. Special schools were also seeking to recruit more special educators, due to increased awareness of their services and increased enrolment of children with disabilities. Having worked as part of the Sightsavers IE programme, the facilitators were able to highlight this experience and take advantage of the increased opportunities available to them within Government and special schools, where conditions were less challenging than those found in Sightsavers’ project areas.

Way forwardThe situation analysis described above provided Sightsavers and our partner with important information about the sustainability of the programme and why the IE facilitators were deciding to move on. Working in an inclusive education setting requires strong commitment and high motivation, but it was difficult for the facilitators to maintain

their enthusiasm to work in challenging circumstances and within communities that they were not familiar with. As the local conditions and cultural factors could not be changed, it was clear that Sightsavers and our partner needed to develop an alternative strategy or face a severe human resource gap that would place the project in jeopardy. Building on Sightsavers’ experience of developing local human resources cadres in eye health and rehabilitation programmes, senior management decided to apply this strategy within an education setting and train local young graduates in special education. This new approach was designed to address the two major challenges of climatic conditions and socio-cultural barriers. Local people are more acclimatised to these conditions and customs, and are more aware of the needs of their community. It is also likely that they will be more motivated to support their local community and to remain resident there when the project period is over, thereby ensuring sustained support to local children. Initially, however, it was challenging to identify graduates who could be motivated for a career in special education. The project took the following steps to address this challenge:

Inspiration eventsThe project organised one day consultations with local graduates to increase their awareness of the need for inclusive education,

Devilal working on his homework in Braille

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the role of special educators and the opportunities for employment in this field. Success stories of children supported by facilitators were also shared to help the graduates understand the life changing impact of IE work.

Basic training and foundation coursesThe prospect of obtaining employment in Government services was attractive to the graduates and motivated them to attend basic training in disability and education. The young people were enrolled in a foundation course in disability management, an approved RCI qualification for rehabilitation professionals. Conducted over three months, the course included an initial period of class lectures and distance learning, followed by functional training in the education of visually impaired children, delivered by the National Association for the Blind, India. The functional training was conducted via a 30 day residential programme and covered teaching methods, Braille teaching, aspects of community-based rehabilitation and the social inclusion of children with visual impairment.

Motivation through scholarships After completion of the foundation course, all the trainees were motivated to join a graduate or diploma course in special education. They received initial training by an accredited institute and were then expected to practice their skills in the field, under the guidance of a supervisor. Those trainees who cleared the entrance test received support for up to 50 per cent of their course fees. As part of the scheme, they were also entitled to paid leave in order to attend classes in a training centre. Having received this financial support, it was mandatory for IE facilitators to then commit to the project for three years, or else refund the support given to them during their training. This scheme has been well received and there are currently 21 education project staff who are undergoing special education training.

Additional training and exposureAll IE facilitators were trained on the broad aspects of inclusive education, such as low vision service management, supervision and monitoring, and interventions for children with multiple disabilities. Subject enrichment training in Braille, mathematics and language teaching were also conducted. All training was coordinated by national level institutes such as the National Association for the Blind

and the National Institute for Visual Handicap. The entire project team has spent time with blind people’s organisations to gain a broader understanding of inclusion, and in special schools to learn about different models of education for visually impaired children.

Supervision and continuous feedbackThe IE facilitators are supervised by a team of coordinators and receive continuous technical support from external experts. On average, one supervisor guides four facilitators in the field and regular staff meetings are organised.

ConclusionThe major learning that emerged from this project is that implementation plans must be highly contextual, factoring in the ground realities of a socio-cultural and geographic setting. From our experiences, it is better to develop a local cadre of human resources, rather than trying to transplant human resources from other contexts, who are alien to the unfamiliar and challenging location. We also learnt that, in seeking to meet legal requirements, a short term strategy can be counter-productive. As described above, the project sought to attract qualified personnel from outside the region in order to comply with Government regulations and to commence delivery of services to visually impaired children. This approach was effective in the short term, but was not sustainable due to the challenges described above. Training local graduates involved a greater time investment, but proved more effective in the longer term. We therefore learnt the importance of considering the broader context of the project and taking a longer term view of how best to achieve the desired objectives. As a result of our changed strategy, and with continuous support to the IE facilitators through capacity building programmes, the project has seen a reduced turnover of facilitators. Over a period of time, the project has developed skilled human resources who are sensitive to the needs of their own community and equipped to support local children over the long term. Through initiatives such as the funding scholarships, the project has enabled local people to develop careers in special education and has increased the available pool of qualified personnel.


When systems don’t work in harmony: lessons from M&E system design in a complex setting Taitos Matafeni, Head of Effectiveness, Quality and Learning Systems

IntroductionThe need to improve programme level monitoring and evaluation has long been highlighted and talked about in Sightsavers. Prior to the onset of the current strategic framework in 2009, a monitoring and evaluation (M&E) situational analysis1 was carried out. This, along with discussions around the proposed new strategy, highlighted the need for a more robust, systematic and comprehensive M&E system for the organisation. Within Sightsavers, there already existed a mechanism to monitor progress on key organisational outputs. Monthly data was collected against key performance indicators, producing a series of output statistics. The onset of our new strategy saw the introduction of a new system to monitor organisational progress against this strategy. This was based on the balanced scorecard methodology and is known internally as the Strategy Monitoring and Implementation (SIM) Card. Work also started on developing a broader, more comprehensive M&E system, as recommended by the earlier situational analysis. This later became branded as the Sightsavers Adaptive Monitoring and Evaluation (SAME) system. SAME was designed with three main objectives: providing programme level evidence to validate organisational monitoring via the SIM Card, supporting local decision making and planning at partner level or programme level, and ensuring that we capture the right output statistics and remain accountable to our supporters. The system is made up of three interrelated processes as follows:i. systematic monitoring of progress against our organisational theory of change, our country level strategic plans, and our project

level operational plans and anticipated results. ii. systematic evaluation of our work, including impact monitoring and measurement.iii. systematic learning and reflection on the findings of monitoring, evaluation, impact and other programme management processes.The element that has failed to take root is the systematic monitoring. This paper will focus on factors that lead to that failure and what we have learnt from it.

What went wrong?Three years after the current strategy began, the monitoring side of SAME has failed to take off. Consequently, programme monitoring has not improved at the pace envisaged when the system was designed. Following in-depth reflection by the team involved in developing SAME, the following factors (not an exhaustive list) have been identified as some of the reasons leading to the failure of this system.

a. Poor engagement with stakeholders during design stageThe design of the system was, and is, the responsibility of the Effectiveness, Quality and Learning Systems (EQUALS) team. Although the team had undertaken an organisational wide M&E situational analysis, the results of which were used to back the design, there was no proper and in-depth analysis of potential linkages with other on-going systems and how these should be built into the design. In essence, EQUALS failed to engage sufficiently with different teams working on other aspects of monitoring in Sightsavers (i.e. teams working on the SIM card and output statistics) so as to agree on how a broader M&E system could support these

1 Matafeni T (2009) Through the lens: A situational analysis of monitoring and evaluation approaches, practices and perceptions in Sightsavers. http://www.sightsavers.org/in_depth/quality_and_learning/programme_quality_improvement/SAME/default.html

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processes and vice versa. This led to a ‘silo effect’ where SAME was viewed as an additional and separate system as far as monitoring was concerned, rather than one part of an overall M&E system with three interconnected elements. At the inception of SAME, a working group for the development of the system was put in place. However, the focus of this group was on the content of the system, rather than its interaction with other on-going work. This lack of harmony made it difficult to sell the broader M&E system later on, when it came to expanding it beyond the pilot phase. At this stage, other teams viewed it as a complicated system, which was separate from organisational level and output monitoring.

b. Lack of wider, systematic input during the pilot phaseAs part of the system design, a pilot approach was agreed, covering the key regions in which we work, as well as some strategic funding relationships we were engaged with at the time. The pilot included seven countries, with one staff member from each country being designated as a focal person for the pilot phase. Again there was a missed opportunity here for engagement and validation. Although the focal persons reported satisfaction with the system, the pilot phase soon became a technical exercise. It became focused on testing what tools were needed, rather than cross-checking what information those tools generated, how useful this was and how it worked with other systems. This could have been achieved through setting up regular update sessions with teams working on other systems and offering them an opportunity to feed in their perspective on what may be useful.In addition, we began to notice that input from the seven pilot countries was becoming fragmented, with feedback being received from both focal persons and other senior team members. This indicated a lack of effective communication about what was happening and how it would benefit country offices and the organisation as a whole.

c. Lack of clear terms of reference for the projectFrom the outset, the project lacked clearly defined terms of reference (TOR). There were no clear milestones, other than the

overall aim of producing an organisational M&E system. Had a clearly defined TOR been produced, it would have helped in gaining consensus on the scope of the system, the key milestones and ultimate deliverables. It would also have assisted the design team in staying on track with these targets and helped all other stakeholders to relate to the system as it developed.

d. Lack of focus on the engine that drives the systemThe organisation did not invest in ensuring that country office staff had the right support, guidance and resources to fulfil their duties in this area, which affected the scale up plan that was put in place. Until April 2013, the EQUALS team was made up of three individuals; the head of team, a monitoring and evaluation support officer and a learning support officer. The pilot phase of SAME was therefore based on a strategy of using focal persons, whereby programme managers from the pilot countries were co-opted into the pilot. Although programme staff are, by the nature of their role, meant to undertake monitoring and evaluation, the reality of what this means in practice had not been properly embraced. In addition to data collection and initial analysis (which should be part of the remit of all frontline programme staff), there are several activities which constitute an M&E system. When SAME was piloted, there was no analysis of what competencies were required from the focal persons who would be driving the system, what aspects of monitoring they needed to do, and how this would link to their current programme management responsibilities. In the pilot countries, all M&E activities were an additional responsibility for the focal person.In the same way, staff shortage within the EQUALS team was also part of the problem. During the pilot phase, countries needed hands on support for at least 12 months, to allow the focal person enough space to discuss the challenges of implementing the new M&E system. There was insufficient resource and capacity in the EQUALS team to provide this sustained support across all seven pilot countries and so the effectiveness of the pilot approach was compromised.


Lessons learntThe failure of the monitoring system has brought about several reflection points, which other professionals and organisations need to bear in mind when designing M&E or similar systems, especially in complex organisations. These lessons can be summed up as follows:

1. Achieving the right balance with other on-going systemsIn mature and complex organisations such as Sightsavers, it is highly probable that a variety of data collection and reporting systems are either already in place, or are in the process of development by different teams. Therefore, it is important to explore and build upon any possible synergies with these systems. This process increases ownership and allows interested parties to view the systems from a holistic perspective. For smaller and upcoming organisations where complexity may not be an issue and where few systems are already in place or in development, it is still important to start with the end goal in mind; i.e. what your broader organisational strategy looks like. You can then work your way backwards to map any potential systems which might interact with your proposed M&E system.

2. Putting in place the right support and coordination for the systemAny organisation seeking to achieve high quality programmes, and to invest in the area of monitoring and evaluation, must consider investments which ensure that programme level teams have the right support, guidance and resources to fulfil their duties in this area. Although M&E is rightly described as ‘everyone’s business’, there is often an assumption that the primary responsibility for all M&E activities lies with the programme officer. We need to challenge this assumption and to examine carefully where, and with whom, the different aspects should sit within the M&E system chain.

3. Clarity on what you want to achieve vs. what can be achievedThere needs to be a common and thorough understanding of terms such as ‘M&E system’, and of what is possible from this system over a given time period. This point ties in

well with factors (a) and (b) above, which highlight the importance of stakeholder engagement and buy-in. An M&E system is a complex interrelationship, made up of “a series of policies, practices and processes that enable the systematic and effective collection, analysis and use of monitoring and evaluation information”2. Depending on available resources, it may be ideal to cascade your system design so that overtime you will have developed policies, processes, and embedded practices which promote effective M&E. And, as demonstrated by our experiences with SAME, all the while one needs to keep in mind what is already happening within an organisation and how a proposed new system will bolt onto that.

2 Simister N (2009) Developing M&E Systems for Complex Organisations: A Methodology. Available from http://www.intrac.org/resources.php?action=resource&id=663

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When targets are not met: lessons from an urban eye care programme in ZambiaPrecious Chisebuka-Julius, Programme Officer, ZambiaGlenda Mulenga, Country Director, Zambia

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Nurse Jessie examines a patient at Lusaka Eye Hospital

IntroductionThe Livingstone-Lusaka Urban Comprehensive Eye Care project is a Sightsavers initiative supported by Standard Chartered Bank. The programme was launched on 11 July 2009 and operates in the Lusaka Province and in six districts in the Southern Province of Zambia; namely Livingstone, Kazungula, Kalomo, Choma, Monze and Mazabuka. The programme aims to scale up existing support for eye care services and ensure that cost effective, quality eye care is accessible to two million people living in these districts. The main project partners are Lusaka Eye Hospital, the University of Zambia clinic in Lusaka and the Livingstone General Hospital, which is the provincial referral and supervisory hospital for Southern Province.

Responding to the Zambia National Strategic Plan on the Prevention of Blindness, the programme set out to strengthen service delivery through improving human resource capacity, provision of equipment and infrastructure development at the district and provincial level, thereby ensuring the provision of quality and sustainable eye care services within the Government health structure. The project also aims to increase awareness of eye health issues within communities and to reach more people by strengthening the referral system. The programme has achieved some successes, but progress against targets has been slow and constrained by many factors. These are discussed below.


What went wrong?The urban eye care programme in Zambia has the potential to be a model eye care programme that fully engages communities and the Government in programme delivery. To date, the programme has met some of its targets, such as capital procurements and infrastructure developments, and has also reached the targeted number of children to be screened. However, although the programme has been successful in some areas, it has faced a lot of challenges, leading to under performance in other areas.

Surgical backlogThe programme was designed to have three main partners, with Lusaka Eye Hospital and the University of Zambia clinic providing comprehensive eye services in Lusaka province, and Livingstone General Hospital (LGH) spearheading the provision of services in Southern Province. It was intended that the ophthalmologist from LGH would provide referral surgical services to the districts in Southern Province, but this did not work out as planned. The ophthalmologist was appointed to the office of hospital superintendent, a very busy administrative position. The effect on the programme was massive, as surgeries could not proceed as scheduled due to the unavailability of the surgeon. Patients did not receive any services, despite being booked for surgery, and, as time passed, the number of patients needing surgery continued to increase.

Commitment of traineesAs a response to the shortage of qualified personnel, the project planned to train eight cataract surgeons during the project period, as well as ophthalmic clinical officers and nurses. However, because ophthalmic positions are not well established within the Ministry of Health, very few people were willing to enrol for the training programme. Graduating trainees were not being recognised for the extra skills they had developed and did not receive any career progression as a result of their training. Consequently, their commitment to the programme was reduced and other staff did not feel motivated to undertake training themselves. In addition, Sightsavers did not have a Memorandum of Understanding with the Ministry of Health at a national level. Graduates were therefore not bound to the programme by their

employer and this contributed to their lack of commitment.

Deployment of graduatesIn addition to the challenges of attracting trainees, those people who were trained were liable to be transferred with little regard to the needs of the institution from which they came. Some of the graduating trainees were therefore not fully utilised within the project area, which further added to the desperate need for staff and contributed to low outputs.

Management of resourcesDespite not meeting targets, the programme continued to spend funds. Measures were taken to reduce expenses that were not directly related to programme outputs, and to increase spending in areas that could serve to increase outputs. One area identified for cut backs was the practice of paying salary top ups. However, it was found that this contributed to low staff morale and so also had direct bearing on outputs. There has also been a high staff turnover within Sightsavers Zambia country office leading to poor monitoring and oversight of the project. In addition, the frequent changes have resulted in a lack of continuity and the loss of institutional memory. These changes have also affected the pace of project implementation. When it was realised that we would not be able to meet the project’s targets, Sightsavers sought permission from the funders to revise these downwards. We also worked to source surgeons from outside the project area, in order to increase outputs. However, this approach also increased the cost of project activities when compared to actual outputs.

What can be learnt from our experiences? Programme design and planningThe aim of this project was ‘to scale up existing support for eye care services and ensure that cost effective, quality eye care is accessible to the two million people living in urban areas from Livingstone to Lusaka’. Whilst this aim seems clear and simple enough, the strategy to achieve this should have been better explored and understood. It would have been useful to ask key questions, such as:i) What is the current level of eye care service

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provision in the project area?ii) What expertise is currently available in the districts to provide eye care services?iii) What resources are needed to provide a comprehensive eye care service?iv) Who is ultimately responsible for eye care service delivery? v) What gaps exist that can be met by the project?As part of the design and planning phase, a comprehensive situation analysis and base line should have been carried out, along with a stakeholder analysis. This would have revealed what human resources were needed and which institutions possessed the necessary expertise to implement the programme.

Partner capacity/ availability of resourcesThere was a presumption that the Ministry of Health would always have ophthalmologists available for the programme. However, current statistics show that there is a very high patient-to-ophthalmologist ratio across the country.

Target settingThe targets set for this programme may have been over ambitious, given the existing human resource base, management and planning capacity issues in public health institutions, and other logistical challenges. In addition, the programme targeted two million people, which is difficult to attain in one project. A phased approach with clear deliverable outputs that are planned and monitored might have been more achievable.

PartnershipEffective programme partnerships require commitment from both parties, but also the involvement of the highest level of command to ensure compliance. The programme was signed for by the Provincial Medical Officer and not the Ministry of Health Permanent Secretary, which posed challenges in getting civil servants to effectively support the programme.

AdvocacyThe creation of sustainable health systems heavily depends on the allocation of adequate resources by the Government and a sense of political leadership. This cannot be achieved with demonstration alone. Advocacy is still crucial in ensuring that eye health is taken on board like any other health issue.

Programme monitoring and managementConstant review and planning would have helped to identify the problem much earlier and enabled measures to address it before committing further resources. There is also the need for a smoother transition when a Sightsavers’ project officer moves on, to ensure continuity and minimum disruption to projects.

ConclusionAs this project moves into the final phase of implementation, the lessons from the last two years show that we underestimated the human resource challenges that face eye care services in Zambia. A careful analysis would have revealed the high patient to staff ratio and highlighted how the lack of established eye care career pathways within the Ministry of Health might constrain uptake of optometry and ophthalmology training by medical staff. Without key policy changes in these areas, the success of the project was much reduced and it was not possible to achieve the original project objectives and targets within the implementation period. For future projects, a baseline and situation analysis will be critical parts of the conception and design phase. We have also learnt the importance of engaging with partners at the appropriate level, in order to secure the necessary oversight and logistical support for the successful implementation of the project. We have now engaged at District Medical Officer level and hope that this will help in dealing with staff issues and other logistical support issues. Close monitoring of projects is also crucial in ensuring that problems are identified early on and that decisions can be made swiftly to rectify these through revisions to goals, targets and approaches. This project still has the opportunity to reach many people who need eye care services, but who ordinarily would not be able to afford them. The implementation challenges highlighted in this case study are now being dealt with collectively by Sightsavers and our partners, and we will also be able to apply our learning to future projects, ensuring that these are also as successful as possible.


Executive summaryOne morning in February 2004, the Sightsavers India regional office was shocked to learn that six out of 47 people operated on at a partner hospital had developed endophthalmitis, an intraocular infection that can occur after cataract and other eye surgery. All six patients went on to lose vision in their operated eye. The relevant programme officers immediately arranged to visit the partner involved and jointly investigate the situation, with technical assistance from a large centre of excellence in the country. Linked to inadequate quality control in cataract management, endophthalmitis can occur when bacteria enters the eye, causing infection, inflammation and often resulting in blindness in the operated eye. Unfortunately, at that

time, India did not have uniform guidelines to manage cataract or respond to outbreaks of cluster infection. In light of this outbreak, and a similar one occurring at a different partner hospital in 2005, Sightsavers’ India regional office decided that it was important to review the processes involved in cataract management at partner hospitals and strengthen them to robust measures of good practice.This article is based on our experiences of managing outbreaks of the dreaded endophthalmitis in India. It aims to examine the systemic failures that can lead to cluster infections at partner hospitals, and which propelled us, along with partners and professional bodies, to develop a clinical governance system and guidelines to promote best practice in cataract management in India.

Quality assurance in cataract management: learning from failureElizabeth Kurian, CEO, Sightsavers India

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Mr Gobarbhan Mahesh returning home after his cataract surgery

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IntroductionBlindness has profound human and economic consequences in all societies due to loss of independence, self-esteem and economic productivity1,2 among those affected and their families. Globally blindness affects approximately 45 million people3,4, two thirds of whom are women5. Cataract is the commonest cause of avoidable blindness and the second commonest cause of visual impairment after refractive error. The vast majority of individuals with visual loss due to cataract live in developing countries. The disproportionate magnitude of cataract in developing countries is due to the social determinants of health which are consequences of poverty in its broadest sense; i.e. greater exposure to risk factors on one hand and inadequate provision and/or access to and uptake of services on the other6,7,8,9. India has the highest number of blind people in the world. According to national studies, there are around 12 million blind people in India and cataract is the main cause of blindness, accounting for around 62 per cent of blindness among people over the age of 5010. Although cataracts cannot be prevented, they can be treated by highly cost effective surgery which typically leads to good visual outcomes11,

12. Studies have shown that, after successful cataract surgery, individuals can return to their previous activities including income generation.

Services for cataract therefore contribute directly to the achievement of the Millennium Development Goals13 as well as improving people’s quality of life.

Quality assuranceThere have been various outbreaks of endophthalmitis in India which have led to considerable loss of sight14. We also know from several population-based surveys that a significant number of cataract operations have a poor outcome, defined as presenting visual acuity of less than 6/60 after surgery. Poor vision after cataract surgery is usually caused by failure to detect pre-existing conditions, inadequate correction of post-operative refractive error, or surgical complications. Poor outcomes are distressing for patients and reflect badly on the surgical facility and on the surgical team. They also discourage others from seeking surgery and may affect the sustainability of services. All these factors support the need for quality assurance for cataract services.

Sightsavers’ initiatives in promoting quality assuranceSightsavers has been promoting good eye health and the eradication of avoidable blindness in India since the late 1960s, in

1 Frick KD and Foster A (2003) The magnitude and cost of global blindness: an increasing problem that can be alleviated. Am J Ophthalmol 135(4): p. 471-6.2 Gooding K (2006) Poverty and blindness: a survey of the literature. Sightsavers International: Haywards Heath3 Resnikoff S et al (2004) Global data on visual impairment in the year 2002. Bull World Health Organ 82(11): p. 844-51.4 Resnikoff S et al (2008) Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ 86(1): p. 63-70.5 Abou-Gareeb I et al (2001) Gender and blindness: a meta-analysis of population-based prevalence surveys. Ophthalmic Epidemiol 8(1): p. 39-56.6 Gilbert CE et al (2008) Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey, BMJ 336(7634): p. 29-32.7 World Health Organization CotSDoH (2008) Closing the gap in a generation: health equity through action on the social determinants of health. Geneva, Switzerland.8 Lewallen S et al (2009) Cataract surgical coverage remains lower in women. Br J Ophthalmol 93(3): p. 2959 Lewallen S (2008) Poverty and cataract--a deeper look at a complex issue. PLoS Med 5(12): p. e245.10 Faal H and Gilbert C (2007) Convincing governments to act: VISION 2020 and the Millennium Development Goals. Community Eye Health 20(64): p. 62-4.11 World Bank (1993) Investing in Health. World Development Report 1993 and world development indicators12 Lansingh VC, Carter MJ and Martens M (2007) Global cost-effectiveness of cataract surgery. Ophthalmology 114(9): p. 1670-8.13 Faal H and Gilbert C (2007) Convincing governments to act: VISION 2020 and the Millennium Development Goals. Community Eye Health 20(64): p. 62-4.14 Pinna A et al (2009) An outbreak of post-cataract surgery endophthalmitis caused by Pseudomonas aeruginosa. Ophthalmology 116(12): p. 2321-6 e1-4.


alignment with the National Programme for the Control of Blindness (NPCB). A lot of our efforts and indeed, that of other organisations, have gone into addressing the cataract backlog in the country, at first in an individual capacity, and more recently through VISION 2020: The Right to Sight India15. According to programme reviews, the main reasons for poor outcomes related to surgery are inadequate asepsis (the absence or exclusion of bacteria, viruses and other microorganisms), the shortage of skilled ophthalmologists in remote areas, resulting in the engagement of part-time ophthalmic surgeons who do not have sufficient time to monitor patients properly, and a lack of commitment to quality assurance from management. These findings highlight the importance of strengthening quality assurance in medical education. They also indicate the need for a policy emphasis on quality in the national programme in India and the necessity of standard protocols for cataract management in the country. Recognising this critical need, Sightsavers India regional office made a commitment to working with partners and professional bodies to ensure that clinical governance systems for cataract are in place, and that quality and safety standards for consumers and providers are adhered to. One of its first initiatives towards quality assurance was the development of guidelines to promote best practice in cataract management. The guidelines were developed during 2005 and 2006, through various consultations with partners and technical experts in the country. As most cataract work in India is carried out by secondary level eye centres, the guidelines were developed primarily for such centres.

They cover the following areas of cataract management:

v Standardisation

v Diagnosis and pre-operative process

v Surgical protocols

v Post-operative protocols

v Sterilisation

v Infection control in the operating room

v Monitoring of cataract surgery outcome

The guidelines were welcomed by NPCB and VISION 2020 India and are now published by the latter. They have been used in various training programmes, primarily for Government and NGO practitioners, and have helped raise considerable awareness on quality in cataract management. Learning from the process and its

outcomes has been presented at national and international fora.

ConclusionSightsavers’ founder, the legendary Sir John Wilson, said “People do not really go blind by the million. They go blind individually, each in his own predicament.” In striving to reach the goals of VISION 2020, NGOs and other professional bodies must promote a culture that values outcome as highly as the number of operations performed.The first responsibility of those engaged in cataract management, whether a service provider, manager or policy maker, is to provide good surgical outcomes through quality assurance. Sound management practices are essential to ensure that patients get the best visual outcome possible. Since the development of the guidelines, reviews and clinical audits of Sightsavers’ partner hospitals have shown a marked increase in positive attitudes towards quality assurance and the application of good practice approaches. The guidelines are expected to have a significant impact on raising surgical quality and, consequently, the standard of life of individuals and communities, not just in India, but also in other developing countries.

15 www.vision2020.org / www.vision2020india.org

The cataract management guidelines

World Sight Day 2011: the cataract guidelines are launched by the Joint Secretary, Ministry of Health and Family Welfare, Government of India (second from right)

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Implementing a CBR programme in Uganda: challenges when working with community development workersJuliet Sentongo, Programme Officer, Uganda

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Orientation and mobility with white canes

IntroductionThe 2005/2006 Uganda National Household Survey estimates that 7.1 per cent of the Ugandan population have a disability; this is equivalent to approximately 2.1 million people. Prevalence rates disaggregated by category show that visual impairment is the most prevalent disability. The rights of people with disabilities are explicitly recognised in the Ugandan national constitution and in progressive anti-discriminatory disability legislation, including the National Council for Disability Act (2004), the People with Disabilities Act (2006) and other mainstream legislation that fully recognises disability rights. As part of a project which ran from 2006

to 2007, Sightsavers Uganda country office worked with partners to identify blind people and provide training in orientation, mobility and daily living skills within their household and community environment. The project also aimed to build the capacity of district level blind and disabled people’s organisations (BPOs/DPOs) to support and mobilise their members, and to promote the inclusion of blind people in broader community development programmes within their communities. The Ministry of Gender, Labour and Social Development was a key partner in this project, having overall responsibility for providing the policy framework, technical supervision, quality assurance, coordination, monitoring


and evaluation of social inclusion/community-based rehabilitation (CBR) services. At the district level, the programme worked with District Rehabilitation Offices, which sit within local Departments of Community Services and are responsible for providing rehabilitation services. The District Rehabilitation Offices deploy community development officers (CDOs) at sub-district level and the project worked with these CDOs to extend rehabilitation services to people who are blind. The CDOs were also asked to support blind and disabled people’s organisations (BPOs/DPOs) and promote links with general development programmes and services being implemented in their communities.

What challenges did we face? Regular project monitoring visits and capacity assessments of the BPO/DPO partners showed significant challenges in meeting the project’s objectives.

Objective one: Orientation and skills training for blind peopleTraining in orientation, mobility and daily living skills was carried out, but the numbers of blind people reached was not as high as anticipated and the quality of the training was compromised at times. This was attributed to the fact that the CDOs had a number of responsibilities and tended to prioritise those which carried greater monetary reward. In some cases, particularly for newly recruited CDOs, the knowledge and skills required to fully support visually impaired people was lacking.

Objective two: Building the capacity of BPOs and DPOsAlthough the Departments of Community Services claimed to be supporting BPOs and DPOs to strengthen their capacities, an evaluation of the project did not find any evidence that this was happening. In light of this, capacity assessments were carried out for the four district BPOs/DPOs supported by the project. These assessments used the Sightsavers Capacity Assessment Tool and were administered by Action for Disability and Development (ADD), who had worked with the BPOs/DPOs and were known for conducting capacity assessments within the disability field.The capacity assessments confirmed that the BPOs and DPOs still had capacity issues; for example, no systems and structures to manage resources. The strategy of working with CDOs to support BPOs/DPOs had not worked.The project had made an assumption that all district level CDOs would have the necessary time, skills and motivation to both deliver CBR activities for blind people and to support local BPO/DPOs. However, some CDOs had only recently been recruited and did not have the necessary understanding of the social inclusion project or the capacity to undertake both these activities. As a result, whilst the objective of delivering CBR services was largely achieved, the CDOs did not make progress against the second objective.

Objective three: Promoting the inclusion of disabled people in broader community development initiativesThe project originally intended that CDOs would mobilise BPO and DPO members to participate in Government community development programmes such as the ‘Prosperity for All Programme’ and the National

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Cooking is a key daily living skill

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Agricultural Advisory Programme. However, in reality, the strategy did little to promote the inclusion of people with disabilities in general development programmes.The aim was for CDOs to engage with BPOs/DPOs and invite them to attend meetings for local development programmes. However, it was found that some CDOs regarded BPO/DPO participation in these meetings as merely an exercise on paper, designed to satisfy processes within the Poverty Eradication Action Plan, part of the Ugandan Government’s agenda. Consequently, they didn’t feel it was important to really engage with BPOs/DPOs and ensure their full involvement. In instances where BPOs/DPOs were invited to attend meetings, the CDOs mentioned that no funds were made available for their transport. BPO/DPO members would have had to travel some distance to attend the meetings, but, without provision made for transport, they were prevented from doing so. In addition, it was felt that some of the BPOs/DPOs lacked confidence and did not feel comfortable attending a broader community development forum. This relates back to objective two, where the aim was to develop the competence and self-assurance of these groups.

What did we learn from this?Having reflected on the implementation challenges described above, we noted the following learning points:

Capacity of partners/ delivery structureWe should first assess the capacity of the proposed implementation structure to deliver the programme objectives. In this case, it was assumed that CDOs, who are trained in social and community development, would be prepared to extend their remit to include working with visually impaired people. However, this didn’t happen and we learnt that, if a programme is to work with general community development workers, adequate training in programme interventions and approaches should be carried out from the start of the project. The monitoring of performance should also be an integral part of project monitoring activities.

Motivation of CDOsCDOs, being responsible for community mobilisation across all programmes in their respective communities, have multiple responsibilities and work with many programmes. They tend to spend more time with programmes which have more resources available and are able to offer better incentives. Given that resources for our social inclusion programme are comparatively small, less of the CDOs’ time was typically dedicated to working with people who are blind.

The need for specialist supportEmpathy and understanding are required when training people who are blind in mobility and daily living skills. While some CDOs developed these skills over time, the majority didn’t and were not particularly interested in learning about the needs of visually impaired people. We therefore learnt that working with visually impaired people is a speciality in itself and, if the project can identify and work with people who are already trained in this field, it will deliver better outcomes.

Need for engagement with peer agenciesDevelopment programmes in the community are generally willing to include people with disabilities. For Government programmes, there is legal framework that supports the inclusion of people with disabilities in all Government-aided programmes and we also

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Personal care such as washing and shaving


discovered that a number of international NGOs, such as Plan International, World Vision and Action Aid, have policies on disability. However, these policies are not always implemented within their community development programmes because their project staff are either not aware of the policy or lack skills in working with people with disabilities. In light of this, Sightsavers will now seek to work directly with these INGDOs to provide technical support and ensure that they include disabled people in their development programmes.

Working directly with BPOs and DPOsThe project aimed to build the capacity of BPOs and DPOs to provide services for their members, but the approach of working through CDOs did not achieve this aim. As a result of our learning, Sightsavers Uganda country office changed strategy and we are now working directly with BPOs and DPOs to deliver the social inclusion agenda. In conjunction with ADD, we are working to implement organisational development plans that will strengthen the capacity of these district BPOs and DPOs. This is in line with Sightsavers’ own organisational strategy, which has seen an important shift in our social inclusion work, with greater focus on working with DPOs and BPOs to strengthen their capacity to advocate for their members’ rightsUmbrella organisations such as the National Union of Disabled People of Uganda and the Uganda National Association of the Blind are also working with their district branches to advocate with district officials for the rights of disabled people to be included in development projects. A major outcome of this advocacy effort is that people with disabilities, who were previously excluded from the Government’s social protection cash transfer programme, have now been included.

ConclusionThe programme approach for this project was to work with Government Departments of Community Services, utilising their community development workers to deliver CBR services and promote the greater inclusion of blind people. The strategy of working with district staff aimed to embed the project into existing structures and systems, promoting integration with other district services and increased local Government ownership.

However, although the aims of the project were relevant to the target group, the approach of involving the CDOs did not lead to the results that we expected to deliver for our beneficiaries. Some CBR services were delivered to visually impaired people, but the reach of these activities was not as great as it could have been. In addition, the CDOs were not able to strengthen the district BPOs/DPOs or fully involve them in broader community development projects. From our experiences of this project, we have learnt the importance of assessing the capacity of partners that we wish to work with and forming a clear joint strategy to achieve the stated project objectives. From the outset, we must consider the capacity of the proposed implementation structure to deliver programme objectives. Having applied this learning, our current project approach is to collaborate with BPOs and DPOs as independent bodies and an extension of the district Government. This will ensure that support reaches the BPOs/DPOs directly, rather than via community development departments. Our current social inclusion project works with national-level BPOs and DPOs, supporting them to strengthen district and sub-county organisations. This approach is recommended, as the district organisations were formed out of national organisations, and so the latter are better placed to nurture their district branches to maturity. Going forward, our approach will focus increasingly on training in advocacy, proposal writing and the management of external funding. We will also focus on strengthening organisations working at the sub-county level.

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Training refractive error personnel for project needs in CameroonDr Joseph Enyegue Oye, Country Director, Cameroon

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In the optical workshop at Mamfe District Hospital

IntroductionThe Cameroon South West Eye Care project was started in 2001 with a VISION 2020 compliant design. The project aimed to provide comprehensive eye care services, including prevention, eye health promotion, medical and surgical treatment, refraction and low vision. This is the first and only Ministry of Health regional project in the country, targeting a population living in a defined geographical area.In order to deliver this comprehensive package of eye health services, the project needed refractionists, optical technicians and low vision technicians. However, putting in place this refractive error component of the project proved challenging, due to the fact that refractive error personnel were not a recognised cadre within the Ministry of Health and were therefore non-existent in the

project area and in the country as a whole. To meet this gap and ensure that the eye care needs of the population were met, the project management opted to train these personnel through a variety of short courses. This article discusses the challenges that arose from this approach, how they were overcome and what learning we can take forward from our experiences.

BackgroundIn order to ensure the availability of trained refractive error personnel within the project area, a two month training programme was designed and implemented, run by the project coordinator. An initial batch of six refractionists was trained in this scheme for the eye units of Mamfe, Kumba, Buea and Limbe. A seventh candidate from Limbe also received training as an optical technician.


Candidates were selected in collaboration with the head of the respective hospitals in which the personnel were to be posted after training. Entry requirements were communicated to hospital heads, who identified at least twice the number of personnel needed for the hospital. For example, if two trained personnel were needed, four candidates had to be identified. To qualify for entry, candidates had to be under 30 years of age and hold General Certificate of Education Advanced Levels in science subjects (including mathematics or physics). The identified candidates then sat a competitive test which included a written paper and orals. The best performing candidates were selected for training.The two month training course comprised of theoretical lectures and practicals at the Limbe eye unit. Upon completion, graduates were posted back to their respective eye units where they delivered refraction services to the catchment population. In order to deliver optical services through the project, one of the trained refractionists from Mamfe and one from Kumba, plus the additional candidate from Limbe, were sponsored to spend six months in Mali, training as optical technicians. For low vision services, three of the trained refractionists attended a week long low vision course in Ghana and received further on-the-job training from the Sightsavers Programme Development Advisor for low vision.Through these short courses, most of which were informal, the project was equipped with staff that could deliver adequate levels of refractive error and low vision services to their respective catchment populations. All these trained staff were non-civil servants and thus not on the Government payroll. They were paid monthly stipends by Sightsavers. This whole arrangement was exclusively service-driven and geared towards meeting the needs of the population. The concern was primarily about maximising service coverage in terms of both comprehensiveness and geography.

What challenges did we face? As described above, the project’s approach was to train the necessary refractive error personnel via a variety of short courses. This approach had the potential to deliver results within a short timeframe and with minimal costs, enabling us to expand the geographical coverage of refractive error and low vision

services in the south west region, including in the most remote communities.However, challenges with this approach emerged in the course of advocating for the enrolment of the trained staff by the Government; the short courses were not recognised by the Ministry of Health as they did not meet its minimum requirements for qualifying training. It is at this point that we undertook to study the Ministry’s requirements and standards in terms of training and academic qualifications. As far as the duration of training was concerned, the Ministry only recognised training of at least 18 months for any cadre of staff. This meant that the seven refractive error and low vision personnel within the project had no formal recognition or career prospects. This caused discontentment and frustration among the trained personnel and Sightsavers had to continue paying them stipends. The situation was compounded by the fact that refractive error personnel, in general, were not even a recognised cadre within the Ministry of Health at that time, regardless of the duration of their training. In order to resolve the problem, we engaged in advocacy with the Ministry of Health, pushing for recognition of the trained refractive error and low vision personnel. We also specifically carried out advocacy for the enrolment of the trained personnel and, as a result, three out of the initial seven candidates have been enrolled by the Government (two passed away and two have not yet been enrolled). More importantly, we also engaged with the Government to set up and run a school of optometry in Cameroon. After two years of relentless advocacy and engagement, we were successful; optometrists and optical technicians are now trained by the Ministry of Health, ensuring automatic recognition of their certificates and qualification to be enrolled as Government staff. There is also now the potential for country-wide scale up of refractive error services, given the availability of personnel who are trained and recognised by the Government.

LearningThe aim of this project was to increase available refractive error personnel in order to meet the service delivery needs of the target population. However, during the project design phase, sustainability of services and the career

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profile of the trained staff did not feature as important strategic priorities. It was hoped that the trained personnel would be absorbed by the Government, but there was no clear plan of how this might happen or whether it was feasible. From our experiences with this project, we have recognised that there is often tension between commencing immediate service delivery to meet the needs of an underserved population on the one hand, and the need to consider long term sustainability of those services on the other. We have learnt that sustainability should be considered right from the project design stage and that service delivery should not take precedent over long term implementation and sustainability strategies. Having a good understanding of partners’ policies and procedures is crucial for sustainability and scale up. In this initiative, we did not study the Ministry of Health’s policies and procedures during project design, but went ahead and provided training that was not

recognisable by the Ministry. The graduates were therefore limited in terms of their career progression prospects. This has highlighted that, when designing training programmes, the future career prospects of trainees should always be kept in mind. We also learnt that joined-up, systematic and persistent approaches to advocacy are key ingredients for success. It took more than five years of advocacy to ensure that the trained refractionists were enrolled by the Government and two years of relentless work and engagement for the Ministry of Health to create a training school for optometrists and optical technicians. It is therefore important to consider the advocacy element of a project at the outset, to ensure that clear advocacy targets are set and that sufficient time and resources are available to maximise the chances of success.

ConclusionThe South West Eye Care project equipped graduates to deliver quality refraction, optical and low vision services to the catchment population, including in remote areas, but their training was not recognised by the Ministry of Health. Consequently, the trained personnel had no career prospects, causing discontentment amongst them and a dependency on the Sightsavers stipend. The key lesson from this experience is to always study partners’ policies and procedures during the project planning phase, and to ensure that the recognition and career prospects of graduates are taken into account when introducing a training programme. These challenges have been overcome through sustained advocacy, which has led to the recruitment of some of the trained personnel within the Government system and the creation a new training school run by the Ministry of Health itself. From an initial short term, service delivery-focused approach, we have progressed to a longer term strategy by influencing systemic change which will ensure sustainable refractive error and low vision services that are embedded within the Government’s eye care provision as part of the overall health system.

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An optical technician at work


Learning from failure: from negative to positiveClaire Jago, Learning Support Officer

As demonstrated by the range of articles in this issue of Insight Plus, programme implementation is often complicated and can face many challenges and set-backs. There are known risks which must be mitigated as best we can, as well as unexpected factors that cannot always be predicted. In seeking to solve complex socio-economic problems, we also often employ new and innovative approaches, which, by their very nature, are experimental and unproven. The risk of failure is high. And yet, alongside the complexities of our work and the inherent risks involved, there is a great pressure to succeed. With any development programme, our goal is to deliver real improvement in the lives of our target beneficiaries, and to do so in the most cost-effective, relevant and sustainable way that we can. We are held accountable for our actions, both by the beneficiaries we serve to help and by the donors and supporters who entrust us with their funds. Given these high stakes, it is not always easy to admit when things have gone wrong; that an approach has not worked out how we had hoped, or has not produced the results we expected to see. There is often a temptation

to gloss over the problems and concentrate instead on our successes; after all, “when we openly acknowledge our failures we put ourselves at risk of being blamed and punished”1. However, as Caroline said in her opening words, we stand to “learn far more from mistakes, or from unexpected consequences, than we do from the things that go to plan”. By admitting to our failures, and taking time to reflect on them, we can turn a seemingly negative situation into something that can have a positive impact on our work, and that of our colleagues and peers. For that very reason, this issue of Insight Plus is titled ‘Positive Failure’. It is part of our drive to be more open and honest about our mistakes, to share them with each other and to use them as learning opportunities. As the articles in this issue show, ‘failure’ can come in many forms. However, our response should be a common one; to step back and ask ourselves why we didn’t see the change that we wanted. What could we have done differently? What lessons can we take forward to improve the quality of our work and to avoid making similar mistakes in the future? As the experiences documented here

1 http://www.admittingfailure.com/fail-forward/

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demonstrate, taking time to reflect on our set-backs enables us to move forward; to change our approach, to take a broader, longer term view of the situation, to advocate with partners to overcome obstacles, and to build better relationships. Out of the challenges described in this publication, have come real results. In North West India, training scholarships have been established to ensure local, sustainable human resources for inclusive education. In Cameroon, the Ministry of Health has recognised refractive error personnel as a health cadre and undertaken to provide in-country training in optometry. And across India, nationally-recognised guidelines have been established to ensure quality cataract services. Alongside these tangible results, has also come real learning, which can not only inform the direction of our programmes going forward, but can also be applied to future programmes implemented by us and by our peers. Although, as we have stated, development is complex and failure cannot always be avoided, the articles in this issue highlight the following key areas for reflection:

v The project design and planning stage is crucial, including the need to undertake

a thorough situation analysis, to map stakeholders and to understand how the local context might impact on the programme.

v The tension between responding to immediate service delivery needs and the benefits of taking a longer term, more sustainable view should be recognised.

v Fully engaging with partners is vital to ensure they are on board with plans and have the capacity to deliver the intended approach.

v Regular monitoring and reflection on progress enables problems to be spotted early and steps taken to rectify them.

It takes courage to acknowledge when things are not working and to take difficult decisions about the way forward. Project plans are not set in stone and often a flexible, proactive approach is needed. The articles in this issue of Insight Plus have demonstrated this and have shown the benefits to taking a critical, yet constructive, look at ourselves. We hope that they prove interesting reading and that they mark the beginning of a trend to share our experiences, both good and bad, more openly.

“By admitting to our failures, we can turn a seemingly negative situation into something positive”

www.sightsavers.orgPage 26www.sightsavers.org Registered charity numbers 207544 & SC038110

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