Content » Vol 41, Issue 10

Original report

Chapter 4: A policy process and tools for international non-governmental organizations in the health sector using ISPRM as a case in point

Jan D. Reinhardt, PhD1,2,3, Per M. von Groote, MA1,3, Joel A. DeLisa, MD, MS4,5, John L. Melvin, MD, MMSc6, Jerome E. Bickenbach, PhD, LLB1,3,7,8 and Gerold Stucki, MD, MS1,2,3,9

From the 1Swiss Paraplegic Research, Nottwil, 2Seminar of Health Sciences and Health Policy, University of Lucerne, 3ICF Research Branch of WHO FIC CC (DIMDI) at SPF Nottwil, Switzerland and at IHRS, Ludwig Maximilian University, Munich, Germany, 4Department of Physical Medicine and Rehabilitation, UMDNJ – New Jersey Medical School, Newark, NJ, 5Kessler Foundation Research Center, West Orange, NJ, 6Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA, 7Queen’s University, Department of Philosophy, Kingston, Ontario, Canada, 8World Health Organization, Geneva, Switzerland and 9Department of Physical and Rehabilitation Medicine, Munich University Hospital, Ludwig Maximilian University, Munich, Germany

Summary

The politics of international non-governmental organizations (NGOs) such as the International Society of Physical and Rehabilitation Medicine (ISPRM) serve the function of selecting and attaining particular socially valued goals. The selection and attainment of goals as the primary function of political action can be structured along a policy process or cycle comprising the stages of strategic goal setting and planning of strategic pathways, agenda setting, resource mobilization, implementation, evaluation and innovation. At the various stages of this policy process different policy tools or instruments, which can be used to influence citizen and organizational behaviour in the light of defined goals, can be applied. The objective of this paper is to introduce and describe policy tools of potential relevance to ISPRM with regard to different policy functions and stages of the policy process.

INTRODUCTION

The International Society of Physical and Rehabilitation Medicine (ISPRM) operates within a complex space of international negotiations and power relations, where international governmental organizations (IGOs) and non-governmental organizations (NGOs), nation states and private companies compete (1). In this situation, ISPRM as an international NGO in official relation with the World Health Organization (WHO) clearly has an international political mandate to realize professional, scientific and humanitarian development goals within the realms of Physical and Rehabilitation Medicine (PRM) and rehabilitation at large (1). Along the process of developing and implementing policies, a set of policy tools is at the disposal of international NGOs operating within the health sector. Policy is mainly about getting individual and corporate actors to do things they otherwise would not have done, or to enable actors to do things they might or could not have done otherwise (2). Against this backdrop, policy tools can be seen as instruments that can be used to influence citizen and organizational behaviour in the light of defined goals (2). The selection and attainment of goals as the primary function of political action (3–5) can be structured along a policy process or cycle. At the various stages of this policy process different policy tools can be applied.

The objective of this paper is to introduce and describe policy tools of potential relevance to ISPRM with regard to different policy functions and stages of the policy process.

The specific objectives are: (i) to review the societal function of political systems; (ii) to describe different stages of the policy process of international NGOs in terms of a designated policy cycle; (iii) to discuss various policy tools suitable for the goal selection, agenda setting, resource mobilization, implementation and evaluation of international NGOs, such as ISPRM.

This outline can serve as a long-term strategic framework and a future reference for ISPRM.

FUNCTIONS OF POLICY AND THE POLICY CYCLE

Deriving from classical sociological theory, political systems mainly serve the procedural function of goal selection and attainment (3–5). Against this backdrop, organizations are even seen as social systems specializing in the attainment of particular goals (4, 6). Furthermore, they also fulfil other (latent) functions, such as the integration of different coexisting activities and networks (6). Following a newer version of sociological systems theory (7), integration may be conceived as the mutual reduction in degrees of freedom in the organization itself and in internal and external environmental systems (1, 7). For example, by defining the core competencies of a PRM physician or by building alliances with local rehabilitation services initiatives in developing countries, ISPRM makes a commitment to these standards and activities and, at the same time, sets an agenda and rules, towards which other internal or external actors need to orientate. Through latent pattern maintenance (3, 6, 8) and continuity of an organization’s policy through symbolic action, the organization creates a common identity and collective memory (9).

The organization’s own procedures and applied policy tools are also generators of perceived internal and external effectiveness, cohesion, trust, confidence (10) and legitimacy (4, 11). For example, an ISPRM discussion paper may be seen as a policy tool, as it outlines current policy initiatives as well as their expected effects, reinforces common identity, and enhances the legitimacy of ISPRM’s activities through transparent dialogue (12, 13).

Following the chronology of the policy process yields a policy cycle, along the different stages of which policy tools may be structured. Against the background of environmental factors and the organization’s own structures, the policy process commences with strategic goal selection derived from the organization’s vision and mission and the assessment of the situational opportunity structure. In the following sections, strategic pathways to goal attainment are defined. These can be divided into agenda setting, resource mobilization, implementation, evaluation and, finally, readjustment of the strategy and innovation activities, which impact on the environment and may even lead to organizational change (Fig. 1).

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Fig. 1. Policy cycle.

In the phases of goal selection, agenda setting and resource mobilization, most policy tools are non-specific, in that they are both applicable to internal and external policy procedures (1). At the implementation stage, however, internal policy tools aimed at ISPRM’s members can often be distinguished from tools designed for external policy relations (1, 14).

GOAL SETTING

The first, and most important, task of any organization is the negotiation and formulation of goals. This goal setting process is led by a collection of motives, themselves fused by institutional memory, experience, views, perception of role and role expectations from members, partners and competitors as well as the larger constituency; e.g. ISPRM will not be expected to build cars or drill wells. ISPRM hereby defines its vision (15) as the general purpose of the organization (what we want), for example rehabilitation for all. The realization of the vision can thus, in terms of decision theory (16, 17), be seen as the decision problem (4). A vision is not realized yet and it is not exactly clear how it can be realized in the future. Conversely, its mission (15) is understood as the core activities of the institution (what we do); for instance, fostering the development of rehabilitation in low resource settings. It can thus be understood as the general preferences of the organization.

Strategic goals and development of strategic pathways

On one hand, strategic goals are derived from the organization’s vision and mission, yielding a hierarchy of preferences and sub-goals (4, 16, 17). On the other hand, the opportunity structures presenting themselves to the organization need to be analysed (18) (Fig. 1). This should involve an assessment of the current state of affairs, the calculation of available and additionally needed resources, and a time budget. Strategic goals are thus more concrete than vision and mission, but are still long-term goals of the institution. An example would be the development of guidelines for the approval of community-based rehabilitation (CBR) projects within the next 2 years.

Strategic pathways, in turn, state sequences of actions of the institution that are compatible with its mission and that shall be undertaken in the light of the perceived opportunity structure in order to reach a strategic goal; for instance: (i) the assignment of a task group; (ii) the review of existing and planned CBR projects; (iii) the creation of a respective database; (iv) contact with local decision makers and involved organizations; (v) involvement of the latter in the design of a certification process, and so forth.

Vision and the mission of an organization can only be changed if its identity is altered as well. Once formulated, they thus have a long-standing validity. Strategic goals and pathways can be adapted more easily and are valid for a time frame of approximately 2–4 years (presidential term). On strategic pathways towards strategic goals the institution’s internal and external goals can in turn themselves be broken down into smaller operational units; namely waypoints or milestones and tasks assigned to a schedule, e.g. first, second and final draft of a guideline (19). Concrete suggestions for ISPRM specific strategic goals and pathways, ISPRM’s policy agenda, are presented in an accompanying paper in this special issue (20).

When selecting strategic goals and pathways, ISPRM may, as an organization in official relation with WHO (1, 14, 15, 20), orientate towards the WHO agenda. This is facilitated through ISPRM’s right to attend sessions of WHO governing bodies (1, 21, 22). Surprisingly, this possibility is currently used by only one-third of the NGOs in official relation with WHO (23).

Identification of options: assessment of state of affairs, resources and time frame

Against the background of the organization’s hierarchy of preferences, goal setting starts with an assessment of a given situation or setting and its challenges, for instance through the exploration of the state of affairs in literature reviews, e.g. on CBR in low resource settings, or expert consulting, e.g. through interviews with the directors of respective rehabilitation programmes. This then leads to the identification of alternative options for action, e.g. ISPRM letters of support vs supervision or approval of existing community-based rehabilitation initiatives (certification) vs starting own initiatives, and expected consequences. In a trade-off, these options are then weighed with the organization’s hierarchy of preferences, perceived uncertainties in the environment and available resources (internal vs external financing) in connection with a desirable time frame in relation to the perceived urgency of the goal. For example, is adequate funding for visiting CBR settings in developing countries available and are there ISPRM members who are willing and able to engage in such activities? The resulting decision focuses on the best and realistic alternatives. The actual project management (19) follows. It begins by breaking down the vision and mission into strategic pathways. These include scheduled milestones towards strategic goals, such as the development of a checklist for the approval of community-based rehabilitation projects. Strategic pathways in policy usually include an agenda setting strategy, efforts to mobilize resources, an implementation, and a monitoring and evaluation strategy. It is important to note that, from the beginning, indicators and means for the evaluation of goal attainment need to be considered and defined. This can be, for example, done with a balanced scorecard concept including predefined quantitative and qualitative measures (24).

AGENDA SETTING COMMUNICATION

An opus entitled “The Making of Rehabilitation. A Political Economy of Medical Specialization, 1890–1980” (25) concludes with a chapter on “The Fall from Power” of Physical Medicine and Rehabilitation (PRM). One physiatrist is quoted with the following remark: “To be blunt, it is much easier to obtain visibility and acceptance with academic colleagues and medical students as a specialist in sports medicine or in the diagnosis and management of ambulatory patients with muscle diseases, than as a manager of rehabilitation services to the same patients”. Unfortunately, much of this is still true.

Therefore, the dedication of appropriate communication tools for setting the internal and influencing the external media, public and policy agenda (26, 27) is not a “soft” matter of taste, but of utmost importance. Whilst goal selection is a matter of values on the one hand and of opportunity on the other, combining both through decision analysis, agenda setting is a matter of communicating the selected goals and related issues.

ISPRM must seize the window of political opportunity opened through the World Health Assembly (WHA) Resolution on Disability and Rehabilitation (28), the United Nations (UN) Convention on the Rights of Persons with Disabilities (29), and the increasing significance of transnational collaborations involving IGOs and international NGOs (1) to place and consolidate rehabilitation on the global health agenda.

The primary function of agenda setting communication is the integration of communications and activities of organizational subunits, partner organizations and allies. By focusing on specific topics and actions, the degrees of freedom of systems in the internal and external environments are reduced (7). For example, by bringing the importance of disability issues onto the public agenda respective political action may be triggered. At least in democratic states, political actors have little chance of ignoring media and public agenda items given their interest in being (re-)elected (26, 27). Corporate or individual actors within the internal or external environment of the organization reward this specialization with higher degrees of perceived accountability and eligibility of the organization to address these topics and perform respective tasks (13). Another function of agenda setting communication is to create collective identity (30) and social memory (9). This leads, in turn, to a gain in internal legitimacy. International NGOs are moral entrepreneurs (31) “whose primary concern is enacting, codifying, modifying, and propagating world cultural structures” (32), meaning internationally agreed upon principles, such as the International Classification of Functioning, Disability and Health (ICF), or access to rehabilitation for all people experiencing disability. Legitimacy of an international NGO is herein at least as important as its cost-effectiveness or efficiency (4, 11, 32).

Agenda setting tools are diverse in nature as their purpose is tailored to serve specific communication pathways. These encompass oral and written communication as well as direct and indirect communication in face-to-face interactions and information transfer by technical media such as e-mail or television, respectively. Also, media for individual communication comprising a defined group of recipients, e.g. ISPRM members, need to be distinguished from mass media, which aim at a previously unknown circle of mostly unrelated recipients (dispersed audience) (33), e.g. the larger constituency of ISPRM. Agenda setting tools include publications in scientific journals as well as newspapers, television, World Wide Web and so forth, statements before WHO governing bodies, congresses and meetings as well as public relations initiatives.

Publications

The publication of documents allows an international NGO to shape the international discourse on political issues including the perception of problems through observers relevant to the issues in question (34). In this context, definitions and conceptual descriptions, e.g. of disability (29, 35–37) or the area of PRM and rehabilitation (38, 39) are pivotal to an internationally consistent and coherent development of PRM and beyond. By disseminating them, discourses are created that “systematically form the object of which they speak” (40). Moreover, conceptual descriptions may reconcile different viewpoints within an area (34) and allow tailored definitions for specific purposes (38, 39).

Different types of publications. Memos, statements and comments are short items informing and replying to specific measures and activities laid out in brief. State of the art, discussion and position papers are long items with in-depth analysis and argument design from the constituency at large and, in the case of position papers, from institutional bodies eligible to speak with authority. These are mainly published in scientific journals as the main mass medium of an international professional and scientific society (15, 41, 42). However, publications in the wider mass media, e.g. in the form of newspaper interviews, are also possible and desirable.

ISPRM position, discussion and state-of-the-art papers. Besides information on its official website, ISPRM should place emphasis on the publication of related issues in journals relevant to the PRM community and other stakeholders. In this context, one can distinguish between ISPRM position papers and discussion papers. Position papers are official statements of the board of ISPRM and are published on behalf of the board in the official journal of ISPRM. ISPRM discussion papers, such as the paper at hand, are statements of ISPRM members or other scholars commissioned by the board of governors, the president’s cabinet or council, the executive or other committee. They may be published in ISPRM’s official journal, another PRM journal or any other journal suitable for the topic, sometimes reaching out beyond ISPRM’s constituency.

Also, state of the art papers in areas that ISPRM has identified to be of major relevance for its policy agenda, e.g. on CBR in developing countries, are instruments for setting the agenda. They can be based on literature reviews or expert consultations and need to be planned in the long run, including the identification and invitation of appropriate author teams. Publication in ISPRM’s official journal (Journal of Rehabilitation Medicine) would be appropriate. An alternative is publishing international reports or perspectives on certain issues or conditions relevant to PRM in edited books. An example from the WHO is the World Report on Disability and Rehabilitation (43). State of the art papers may also play a role in the goal selection process outlined above.

Submission of memoranda and statements to the World Health Organization

The submission of memoranda to the WHO Director General and placing statements before WHO governing bodies such as the World Health Assembly (WHA) is a powerful agenda setting tool at the disposal of international NGOs in official relation with WHO (1, 15, 42). A WHO analysis (23) shows that this policy tool is not widely used. From 1998 to 2002 for instance, only 20.6% of the NGOs attending a WHA session made a statement before this body. Also, the use of this policy tool varies strongly between individual NGOs. Whilst one NGO placed 10 statements over the period 1998 to 2002, 18 NGOs did this only once. An example of an ISPRM statement is given in an accompanying paper in this special issue (15). It seems advisable that such statements are prepared by the publication of discussion and position papers that they may then refer to.

Congresses and meetings

Congresses and meetings of internal institutional bodies, such as the Executive Board, and of mixed internal-external working groups are policy tools of first rank. They allow the identification and preparation of upcoming issues, the recruitment of members and the deployment of information to the PRM community. They evoke inter-regional exchange and obligation in less resourced regions. Congresses spark scientific and political co-operation and alliances on the international, regional, sub-regional, national, and local level. The envisioned future of ISPRM world congresses has been outlined in an accompanying paper in this special issue (42).

Public relations initiatives

As congresses and meetings assure face-to-face interaction in order to produce scientific exchange and organizational development, so too do public relations (PR) initiatives assure that a wide array of relevant audiences is reached face-to-face or by mass media. PR activities of international societies try to embrace the dilemma of breaching global boundaries whilst addressing a local constituency and individuals alike (44). The mass media should be used both to review relevant trends in news and their impact and to then trigger public interest in the core field of competence of ISPRM. Interest can be created by personalizing the agenda using prominent ambassadors (26) speaking for ISPRM and its goals. They may be placed on the ISPRM website, in interviews printed or screened as part of mass media’s news coverage of societal or PRM relevant events. Making the public aware of ISPRM’s activities can also be achieved by advertisements in digital and print mass media.

RESOURCE MOBILIZATION

The mobilization of resources is a necessary prerequisite of goal attainment (4). It is prepared by agenda setting in terms of interest management, i.e. the creation and concretization of interests to donate resources, such as money or technology, to the NGO (45) and the motivation to voluntarily engage in the NGO’s activities on the side of the members (46). “The basic building block for [international] NGOs is the interested individual” (47). As far as financial resources are concerned, many different strategies, apart from member fees, are available to an international NGO in order to mobilize appropriate resources (48). We want to highlight event-oriented fundraising, co-funding, and sponsoring. Clearly, funding from industries contributing to ill-health and disability, such as the tobacco industry, or to armed conflicts, such as the weapons industry, will not be accepted by ISPRM.

Event-oriented fundraising

PRM congresses, particularly ISPRM’s world congresses (15) can be used for event-oriented fundraising (49), for which representatives from PRM relevant industries and foundations are invited. Industrial exhibitions as well as lectures on innovative PRM products and technology including drugs are desirable and need to be fostered in order to acquire new funding possibilities from the health industry. Public and private foundations dedicated to addressing world problems in the health sector and beyond can be induced to attend an ISPRM conference by providing opportunities to discuss PRM issues in the light of more general global and regional developments. This can be done by means of brain trusts or specific panels. Specifically, event-orientated fundraising (48) activities constitute a win-win situation for an organization in terms of utilization of media coverage and reaching fundraising goals.

Co-fundraising and cross-subsidization

The regional connectedness and knowledge of ISPRM’s members allows ISPRM to perceive relevant health topics, make them part of the policy agenda and, in turn, identify good cause for action, resource allocation and development initiatives. These good causes can be used as trigger topics, funnelling public interest through ISPRM as the responsible intervening organization. For example, ISPRM may decide to support CBR projects in developing countries in a joint effort with regional and national societies. ISPRM may offer know-how in consultations and its name as the internationally pre-eminent PRM organization. It may also guarantee appropriate supervision of the assignment of funding streams. If clearly communicated to potential donors, the funds raised can then be used in part for ISPRM’s work, e.g. 20%, and in part for the project in question. Potential donors might not see why they should subsidize a professional organization’s get-togethers, but if this organization is attributed to building rehabilitation hospitals or CBR services in a developing region, then the donors might consider funding such initiatives.

A related topic is cross-subsidization, meaning that an NGO may charge higher prices for some goods and services, e.g. for the certification of rehabilitation hospitals in high resource settings. The surplus can then be used to lower the price for other goods and services or to provide the same goods in low-resource settings (50).

Sponsoring and cause-related marketing

Sponsoring is an attractive tool for the assurance of continuously available financial measures. It includes contractual arrangements between one or several private companies and the NGO in question. As a reward for providing finances or technology for the organization’s activities, the sponsor’s logo may be placed on the organization’s website or the sponsor may be allowed to advertise its products at events or in publication organs of the NGO. Sponsors, however, need to be reviewed and chosen with care, otherwise a loss in credibility of, and trust in the organization is highly probable. Trust is difficult to gain but easy to lose (51).

An interesting idea is the linkage of sponsoring and cause-related (52) or social marketing (53), i.e. gaining a sponsor for a specific project in conjunction with a wider marketing and fundraising strategy.

IMPLEMENTATION AND APPLICATION

Once goals have been negotiated, the pathways to goal attainment selected, an agenda set and communicated internally and externally, then a set of tools and measures help to implement the approved amendments to existing, and the creation of new standards, procedures and structures.

In the end, it lies in the hands of elected officials and bodies with their authority to decide on policy proposals for internal and external application (14). They vote – or reach agreement by others means deemed appropriate to pass legislation – on the adoption of standards and guidelines, and confirm goals of their organization’s agenda. These policies are then expressed, at one end of a formal scale, in an amended constitution, law or bylaw or, at the other end, via publication in the minutes of a respective session.

Implementation activities constitute the original value creation of an international NGO. The value added may be based on the production of goods such as research results, the delivery and distribution of goods and services, and the dissemination of goals, codes of conduct and information.

Implementation strategies start with the assignment of tasks and the allocation of the mobilized resources, which can be done in designated work plans. Such plans can be agreed upon with other organizations, making their elements mandatory and excluding other issues. The example of the ISPRM-Disability and Rehabilitation (DAR) work plan (20) is provided in an accompanying paper of this special issue.

In the following sections, internal and then external policy implementation tools are presented.

Adoptions, endorsements, and recommendations

Although in official WHO terminology, ISPRM cannot formally adopt conventions, resolutions, or standards such as the ICF as it is expected from states, it is suggested that an adoption should nonetheless be possible from the internal perspective. External goals and standards such as the UN Convention (29) may thus be adopted by vote at relevant ISPRM bodies such as the Board of Governors – ISPRM’s Assembly of Delegates (14). The publication of the voting results in minutes of the sessions as decision papers, e.g. on ISPRM’s website, thereby ensures transparency with regard to the constituency at large. Respective modifications of the bylaws may then follow. Likewise, references to such international standards can be made in a preamble to the bylaws. The strongest case of an adoption is such an integration of the statement in ISPRM’s guiding documents, i.e. By-Laws and Policy Principles, whilst the weakest case is an ISPRM position statement published on ISPRM’s website. ISPRM can then bring its members also to ratify these documents so that they are obliged to make respective amendments to their By-Laws as well.

Also, new internal standards, such as ICF Core Sets (54, 55) or minimal standards for PRM doctors and facilities, as well as technical guidelines, such as guidelines for the education of PRM specialists (56) can be endorsed by ISPRM’s Board of Governors. They need to be published in a wide range of international, regional and national journals, including translations into different languages. For ISPRM’s external constituency, as well as other groups within the external environment, such as state parties or other medical societies, they obtain the character of recommendations.

Ratifications through International Society of Physical and Rehabilitation Medicine members

Standards and guidelines adopted or endorsed by ISPRM may become more or less binding for ISPRM’s membership, which is expected to ratify them. Apart from the exclusion of members from the organization or monetary penalties, ISPRM has, however, no formal sanctions at its disposal to enforce such ratification.

Signatures. To legitimately represent an international NGO in official relation with the WHO, ISPRM must be accessible to all. Resource limitation in some regions and countries can, however, hinder participation in the implementation of international health standards as required by ISPRM and alienate potentially interested parties.

It may thus be advisable to employ a signature process similar to that of the UN. Also, this process will allow the consideration of the specific situation of low resource countries in which the will to implement standards may be present but the means might not be available in the near future. Furthermore, it may be possible to differentiate between signatures that signify a general commitment to the standard and those implying an obligation to implement the standard within a given time frame. In the latter case, some countries may decide to sign the standard or guideline not immediately but after a clarification of the resource situation and the mobilization of resources. ISPRM may grant a generous time frame, say 30 years, within which the signature may be submitted without the need for formal sanctions. Signing societies may, however, be obliged to implement the standard or guideline within a shorter period of time, say 4 years. Perhaps motivated by the desire to be at the forefront of an innovation (57), societies from high resource countries may decide to sign immediately, whilst other societies will have the opportunity to postpone the signature in accordance with their resource situation. Signatures as a means to facilitate ratification have the important advantage that they lead to a self-commitment of the signing parties, making the deviation a matter of cognitive dissonance (58).

Regional agency

It is nowadays commonplace in sociological theory that power is not a zero sum game (5). A powerful principal, e.g. ISPRM, is able to delegate tasks to powerful agents and set incentives so that these tasks are accomplished in the principal’s sense (59, 60).

ISPRM will thus have little chance of success in implementing its long-term policy goals without the help of powerful regional and national agents (59). ISPRM can, for instance, adopt the UN Convention on the Rights of Persons with Disabilities, or endorse ICF Core Sets for vocational rehabilitation, and recommend their use. Ultimately, an initiative for the application of any ICF Core Sets in everyday practice or for the access to rehabilitation services will need to leave the global policy level and influence grass-root life situations, interactions and behaviours. It is thus of ISPRM’s utmost interest to strengthen regional and national PRM societies.

Existing regional ISPRM member society structures (regional agencies) can be used to create new, and utilize existing, regional contacts and networks including both official governmental bodies and other NGOs or grass-root social movements as well as the private economy. It must be clear, however, that ISPRM cannot directly work with governments that are not democratically legitimized and that contribute to disability by suppressing part of their population. ISPRM would not place itself in a situation where it could be seen to be endorsing these regimes. Indirect links might, however, be carefully considered in order to help populations in need of PRM expertise.

The ISPRM regional and national members may implement ISPRM’s policies by establishing formal relationships with other regional or national NGOs or in a Global Private Public Partnership (GPPP) (61–63). Examples include consultation contracts with rehabilitation hospitals, health service providers and health ministries to implement ICF (64, 65), the delivery of training tools to local health professionals (66), certification programmes (47) for hospitals and services, the monitoring of standards and implementation of guidelines (47), and the evaluation of health service delivery (47, 67). Such regional and national agency can be furthered by ISPRM’s adoption or endorsement of standards and guidelines, which then can be referred to by the projects in question, by letters of support, by consultation contracts with ISPRM and by ISPRM certification programmes. Of particular importance are regional PRM societies, since they may function as a mediator between ISPRM and national or local PRM initiatives. It is thus advised to allow the affiliation of regional PRM societies as ISPRM members (14).

Regional agency can also help ISPRM link agenda setting and fundraising goals in the form of the above-depicted co-fundraising.

Regional vice presidents of ISPRM (68) hereby serve as a direct link between the regional societies and ISPRM via interlocking directorates (14, 69). They may promote ISPRM’s agenda goals, communicate its decisions and activities to national societies, encourage national societies within the region in question to remain or become members of ISPRM as well as be figureheads in the recruitment of individual members. Their involvement in ISPRM congress organizations can strengthen ISPRM’s regional ties and enhance the identification of the regional societies with the topics set by ISPRM.

Organizational challenges are evident when thinking towards the future of this regional cooperation in terms of real subsidiarity or partial delegation, supervision and legal liabilities, budgetary accountability, knowledge transfer (including tacit knowledge), empowerment of regional institutions, and cultural diversity and sensitivity.

Approval and certification

In order to support regional, national and local PRM institutions and projects, ISPRM may decide to design an approval process and certification programme (47). The institutions and projects may be reviewed by ISPRM officers with regard to their adherence to ISPRM standards and guidelines. ISPRM certification may facilitate fundraising for the regional, national or local project. In turn, ISPRM may, as mentioned above, in the case of high resource settings receive a salary for the certification or be granted part of the raised funds.

Networks

Sustainable networks with other public and private, profit and non-profit organizations are central to ISPRM’s political influence and performance. Organizational networks can be seen as collective entities governed by a common goal and/or leadership structure (69, 70). They establish their own organizational structures, both constraining and enabling joint activities (69, 70). In general, networking or hybrid organizational arrangements between market and hierarchy can be transaction cost saving (71). For NGOs, they are often the only alternative for collective action. In many cases no possibility for vertical integration is given, no market for the products or services exists, or economic or ethical “market failure” is probable (50), e.g. when the price of medicines makes them unaffordable in the low resource settings most in need of them.

Networks are, moreover, generators of social capital (72) and may produce a win-win situation in terms of the mobilization of resources and complementary know-how balancing mutual resource dependencies (73). In particular, sustainable networking arrangements create trust (74) and enhance the flow of information from the larger environment (75). Furthermore, feedback from networking partners on relations with the constituency or other institutions constitute a “third party” situation fostering a more objective perspective on the organization’s activities (76).

Different forms of informal and formal networks exist, but this will not be discussed in detail here. For an overview, see: (69, 70). We do, however, highlight some selected networking arrangements below.

In the context of all organizations, various informal networks exist in the form of (web-based) forums, informal working groups comprising individuals from different organizations and the like. In the long run, a formalization and institutionalization of networking relations may ensure a greater sustainability of the networking arrangement.

Bridging groups. Bridging groups comprised of members of different organizations committed to the attainment of a common goal or the solution of a particular problem, are an instrumental tool in starting up more formal network structures. They provide basic information on the situation in particular settings and on other participants of potential relevance. In particular, they create personal trust, sparking confidence (10) in the development of joint systems approaches. Since, for instance, in Sub-Saharan Africa no PRM societies or adequate services appear to exist (77), the set-up of a bridging group including African physicians and policy players as well as ISPRM representatives seems desirable.

Interlocking directorates. Interlocking directorates (69) or advisory boards with other institutions are one interesting means of fostering information flows, taking into account other organizations’ perspectives, and making personal contacts that can be of utmost importance in the light of fundraising goals. As ISPRM may want to send its officials into the supervisory or advisory boards of other organizations relevant to human functioning and rehabilitation, it may also decide to create its own supervisory board or advisors’ council inviting influential advisors from related fields (14). Of particular importance to ISPRM seems to be input from disabled persons and their advocacy organizations (78). This holds all the more true since we undoubtedly face a paradigm change from a medical supply model of the needy to a rights-based approach of disability services (35, 79).

Strategic alliances, joint ventures and Global Private Public Partnership. Strategic alliances (80–82) can be seen as networks of organizations that formally have agreed upon contributing to the attainment of joint strategic goals by allocating knowledge, resources and manpower to a common strategic pathway. Legally, strategic alliances can, for example, be realized within a designated joint venture. In a joint venture 2 or more parties “pool a proportion of their resources within a common legal organization” (83, 84) in order to pursue joint projects with predefined goals, resource allocation, time schedule and outcome evaluation based on a contract between them (85). Joint ventures appear to be a legal form well suited to the realization of GPPPs fusing the resources of private corporations with the knowledge and moral standing of civil-societal partners (61–63, 86).

EVALUATION AND INNOVATION

Evaluation means the assessment of the organization’s goal attainment. It can be based on retrospective or concurrent evaluation of implementation activities and, in the ideal case, on prospective impact assessment of outcomes such as functioning within the organization’s environment (67, 87). Proof of successful problem-solving policies is quite difficult for international NGOs since the success of their global activities may strongly vary across countries. Most importantly, the ultimate ends of international NGOs are non-monetary and qualitative in nature. The implementation of a particular policy may be described, but to measure its success with hard figures in any way can be next to impossible. If IPSRM, for instance, were to help build a CBR programme, it then may be a huge step towards measuring and linking an increase in function in the population to that initiative. Evaluation of goal attainment in NGOs thus often has a ceremonial and ritual character aimed at confirming that one is on the right track (11).

Indicators

Yet, if evaluation strategies have been prospectively integrated into the organizations’ strategic planning, some hard or quantitative as well as soft or qualitative indicators may be available within a balanced score card concept (24). For example, this could be the number of guidelines endorsed divided by the number of planned guidelines, the enhancement of membership in percent, or the satisfaction of the members with ISPRM’s work. Fundraising evaluation can help to identify areas where public interest has focused and where it might be heading. A prospective definition of the indicator in question as well as the pursued goal in terms of the same indicator is, however, a necessary pre-condition. Otherwise, self-fulfilling prophecies and ad-hoc confirmations of the status quo are highly probable.

Member and consumer feedback: survey and web-based exchange forum

A regular, say yearly, member survey seems to be an appropriate evaluation tool with which a constant feedback loop regarding the ISPRM membership can be institutionalized. Such a survey should contain some continuously recurring questions in order to assess change within ISPRM’s member attitudes over the course of time. Another part of the questions could, conversely, focus on current problems and decisions at stake.

Also, a forum on the ISPRM website would allow more spontaneous input from member and consumer side. A systematic strategy for the analysis of such data needs to be pre-defined in order to avoid the forum ending up in “much ado about nothing”.

Innovation: re-adjustment, impact, and organizational change

Innovation may be based on evaluation procedures, but also on negotiations with internal and external actors, or more spontaneous discussions and the creativity of focal actors.

In most cases, the evaluation of an organization’s goal attainment leads to an adjustment of goals and pathways at the strategic decision level and leaves the organizational vision and structures untouched. Similar re-adjustments may also be stimulated by the organization’s impact on the environment and respective alterations within the perceived opportunity structure.

In extreme and revolutionary cases, often triggered by the creativity of influential leaders or changes in the balance of power between different member groups, organizational change occurs, eliciting major alterations within the organization’s formal structure and, even more seldomly, within the organization’s vision and mission. In the latter case, a new organization is born.

CONCLUSION

Using the model of a policy cycle comprising the elements of goal selection, agenda setting, resource mobilization, implementation, evaluation and innovation, different policy tools of potential relevance to ISPRM have been introduced and discussed. Fig. 2 provides a detailed overview of how these different policy tools are intertwined along the policy cycle.

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Fig. 2. Policy tools in the policy process. NGO: non-governmental organization; IGO: international governmental organization.

The presented policy tools are based on a quite voluntary selection of the authors. Not all of these might be of equal relevance to ISPRM’s activities. Also, there will be many more instruments of assistance in attempting to realize ISPRM’s mission.

The presented overview is, however, a promising starting point for a more systematic policy development of ISPRM.

REFERENCES

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