guide for national diabetes plans final -...

CHRODIS-JAactivitiesupdate(1-31October2014)

ThisdocumentarisesfromtheEUCHRODISJointActionwhichhasreceivedfundingfromtheEuropeanUnion,inthe

frameworkoftheHealthProgramme(2008-2013).SoleresponsibilitylieswiththeauthorandtheExecutiveAgency

forHealthandConsumersisnotresponsibleforanyusethatmaybemadeoftheinformationcontainedtherein

JA-CHRODISWorkPackage7

Diabetes:acasestudyonstrengthening

healthcareforpeoplewithchronicdiseases

GuideforNationalDiabetesPlansLessonslearntfromNationalDiabetesPlanstosupportdevelopmentand

implementationofnationalplansforchronicdiseases

FinalversionSeptember15th2016

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www.chronicdiseases.eu

Tableofcontents

Introduction1.Topicsandprocesses,thatthatshouldbeaddressedinNationalPlans52.Settinguptheleadership:top-downleadership93.Settinguptheleadership:bottom-upleadership124.Settinguptheleadership:leadershipforsupportinglinkageacross

existingboundaries155.Topics,processesandleadershipcombinedinthePlan’sorganisational

designandstructure17

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Introduction

Thisdocumentaimstoinspirethosereaders,whoseethatthesituationinhealthcarecouldbeimprovedandwhoarewillingtotakeapartinthechange,forexamplepolicymakers, healthcare institutions, patients and their associations, healthcareprofessionalsandtheirassociations.Itcouldalsobeusedforexampleasabackgroundmaterial for leading workshops at critical moments when strengthening of theimplementationor thesustainabilityofexisting plans isneeded,orwhennewplansareunderdevelopmentandthemajorchallengeisseeninhowawrittenplanshouldresultinactualimplementation.Thedocumentarises from theexpertiseofpartnersofworkpackageof JointActionCHRODIS, that was focused on diabetes to serve as a model disease to study theconceptsandapproachestostrengthenhealthcareforpeoplewithchronicdiseases.Two workshops, one with partners of this work package and the other withrepresentativesofMemberStatesMinistriesofHealth,werealsoconductedinordertogetdifferentviews,perspectivesandinputs.Guide isacompaniontootherpublishedresultsofourworkpackagethatshouldbealso consulted and used. “Policy Brief - National Diabetes Plans in Europe. Whatlessons are there for the prevention and control of chronic diseases in Europe?”(available at http://emsa-europe.eu/ja-chrodis-policy-brief-on-national-diabetes-plans/) identifies a range of factors that appear to facilitate the development,implementation,andsustainabilityofnationaldiabetesplans,thatservedasacasetostudy this topic. “Recommendations to improve early detection, preventiveinterventions, and the quality of care for people with diabetes” (available athttp://www.chrodis.eu/outcomes-results/) are among others defining the set ofcriteria,thatshouldbetakeninconsiderationwhenimprovingpreventionandcareofchronicdiseases,suchasdesignofthepractice,promotiontheempowermentofthetargetpopulation,definitionofanevaluationandmonitoringplan,comprehensivenessofthepractice,inclusionofeducationandtraining,ethicalconsiderations,governanceapproach, interaction with regular and relevant systems, and sustainability andscalability.“SWOTanalysis.Overviewofnationalorsubnationalpoliciesandprogramsonpreventionandmanagementofdiabetes”(availableathttp://www.chrodis.eu/our-work/07-type-2-diabetes/wp07 activities/overview/) gives a qualitative overview ofthe current policies and programs on prevention and care of diabetes, includingsuccessful strategies, what makes a policy/program applicable, sustainable, andeffective fromapublichealthand fromthestakeholders’perspectives,whatare thenecessarypreconditions for its implementationandwhatarethe lessons learnt fromtheexperience. Italsoprovidesabackgroundperspectiveof thesettingwheregoodpracticesaredeveloped.

Weasco-leaderandleaderofthisworkpackagewouldliketospeciallyacknowledgethe work performed by David Somekh and Špela Selak. For active participation indevelopment of this documentwe are also acknowledgingVendula Blaya-Nováková,Alain Brunot, Bruno Caffari, Roberto D’Elia, Angela Giusti, Theodoros Katsaras, SilkeKuske, Jaana Lindström, Konstantinos Makrilakis, Mayur Mandalia, Ulf Manuwald,

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Vanessa Maria Moore, Mar Polo, Isabel Saiz, Antonio Sarria, Monica Sørensen,Valentina Strammiello, Theodore Vontetsianos, Anne-Marie Felton, Manuel AntonioBotanaLopez,ValentinaStrammiello,MayurMandalia,VanessaMariaMoore,DimitriVarsamis, Milivoj Piletič, Jolyce Bourgeois, Karen Budewig, Paloma Casado, ElviraFoteva, Ghebremerain Ghebreigzabiher, Raniero Guerra, Ieva Gudanaviciene, FofoKaliva, Kaija Lukka, Marija Magajne, Petter Ogar, Tamara Poljicanin, Sirpa Sarlio-lahteenkorva,WilDeZwart.

JelkaZaletel,NationalInstituteofPublicHealth,SloveniaandMarinaMaggini,IstitutoSuperiorediSanità,Italy

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1.Topicsandprocesses,thatshouldbeaddressedinNationalPlansDiabetesishereusedonlyasamodeldiseasetostudytheconceptsandapproachestostrengthen health care for people with chronic diseases. Topics can be easilygeneralisedtootherchronicdiseases,ortoanationalplanthatcoversbroaderchronicdisease framework. Please, consult also Box 1 on development, implementation andevaluationoftheNationalplan.

ANationalDiabetesPlan(NDP)makesaclearcaseadvocatingfordiabetespreventionandcare.

TheNDPaddressesenvironmentalinterventionsaimedatreducingandminimisingriskfactors for diabetes, including healthy urbanisation, healthy food, healthy business,healthy public policy, healthy schools at all educational levels, and cross-sectoralcoordination.Sincemajorrisksaresharedamongmostcommonchronicdiseases,thisfocusmaybecoveredinanationalchronicdiseasepreventionplan.

TheNDPshouldinvolveacommunityawarenesscampaign.

TheNDPincludesapproachestoidentifyhigh-riskindividuals/groupsandinterventionsaimedat reducingandminimisingriskamongthese. Therearestrategies to identifyhigh-riskindividuals,toprevent/delaydiabetesamonghigh-riskindividuals,toidentifyhigh-riskcommunitygroups,toprevent/delaydiabetesinhigh-riskcommunitygroups,toidentifyhigh-riskindividuals/groupsatworkplacesandtoprevent/delaydiabetesatworkplaces.

TheNDPhasastrategyforearlydiagnosisoftype2diabetes.

Routine continuous care of diabetes (Type 2, Type 1 and gestational diabetes) isaddressed in theNDP, includingdietarymodification, physical activity, complicationscreeningatdiagnosis,medicationsandmedicaldevices,regularclinicalmanagementofmultifactorialtreatment(glycaemia,bloodpressure,bloodlipids)andfortheearlydetection of diabetes complications, setting and disseminating standards of care,health care services, appropriately staffed and equipped, monitoring the processesandoutcomesof care and self-care education.Adequatediabetes careduring acuteepisodesandinin-patientfacilitiesneedstobeassured.

TheNDPshouldaddressearlydetectionandtimelycomprehensivecareofthechroniccomplications of diabetes, in particular cardiovascular disease, eye damage, kidneydamage,neuropathy(includinglowerlimbamputation).

The NDP considers the role of patients, their carers and families and througheducation, ensures that they become empowered to care for their own health andwell-being.

TheNDPaddressesthepossiblementalhealthburdenofdiabetesandensuresaccesstopsychologicalandothertherapiesifneeded.

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The NDP aims to assure equality of access to routine care and education withparticular emphasis on essential medicines and medical devices, and to diabetesresearch.

TheNDP includes/supports thedevelopmentanduseof guidelines fordiabetes careand prevention including: prevention at whole population level, prevention forchildren and adolescents, prevention before and during pregnancy, high-riskindividuals/groups atwhole population, high-risk individuals/groups for children andadolescents,high-riskpregnantwomen,type1forchildrenandadolescents,type2forchildrenandadolescents,gestationaldiabetes,type1foradults,type2foradults.

The NDP addresses the needs and perspectives of vulnerable population, such asethnicminoritiesandthosefromalowereconomicandsocialstatus.Italsoaddressesgenderissues.

Issues related to training and developing diabetes healthcare professionals andservices are addressed in the NDP, including education on how to work inmultidisciplinaryteamsandoutsideoftraditionalprofession-specificsilos.

TheNDP includes strategies formeaningful diabetes-related data collection, sharinganduse.

The NDP seeks linkages with other chronic disease plans, for overlaps,complementarity,humanresourcesharingandmutualoutcomes.

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Box1:Development,implementationandevaluationoftheNationalPlan• Developmentandendorsementofnationalplan

o Developedthroughextensiveconsultationswithallrelevantstakeholders–multi-sectoralplanning,havingcarefullyconsideredthesituationanalysisoftheburdenandhealthsystemcapacitytorespond,nowandinthefuture

o Identifyingwhowillcarryouttheaboveprocess,underwhoseauthority?

o Highlevel(political)commitment/endorsement(forthedurationofplan–withstandingpoliticalchanges)

• Financialresourceso Allocatedbudget(ear-marked),ideallyfrommultiplesourcestoreduce

riskofshortfallo Expenditureframework(forthedurationoftheplan)o Ifnotfullyfinanced–planforattractingfunding,eitherasborrowingor

other–inlinewithcurrenteconomicconditionsaswellasgrowthofdiseaseburden

§ Haveprioritiesforspendingifbudgetshortfallo Procurement(medicines,medicaldevices,equipment,etc.)covered,

includingprojectionsuntiltheendoftheplan,possiblybeyond• Implementationandmanagement

o Communicationstrategytopublicizetheplan-tothepublic,politicalleaders,publichealthexperts,etc.

o Leadagency,authority,organisationidentifiedtooverseeallaspectsofplanimplementation

o Allimplementingpartnersunderstandtheirroleandresponsibilities,inlinewithoverallplanobjectivesanddesiredoutcomes

o Ensuringadequatehumanresourcesforimplementation–makingavailablewhererequired

• MonitoringandEvaluationo Indicatorsandtargetssetagainstgoalsandobjectiveso Datacollectiontakesplacetoservepurposeofevaluationaswellas

nationaldatarepository(ifapplicable)o Regularreviews,periodicalassessmentstomaintaintrackortoadjust

services/intervention/resourcestowardsaspectsrequiringfurthersupport

o Processofmonitoringandevaluationwovenintonationalplano Responsibilitiesassigned–independentevaluationo Structuredevaluation:process–outcome-impact

• Linktootherchronicdiseaseplans

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o Exploredandidentifiedpossibilitiestocombinepreventionmeasures,humanresources,facilities,implementingactors

o Sharefinancialresourcesandinfrastructure,notcompromisingobjectivesandgoalsforanydisease-specificapproach

Source:InternationalDiabetesFederation.AGuidetoNationalDiabetesProgrammes

2010.Availableathttp://www.idf.org/publications/guide-national-diabetes-

programmes

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2.Settinguptheleadership:top-downleadershipTop-downleadershipisneeded.Successfulleadershipforchangecreatesclearfocus,andconsistent,ongoinginitiatives.Leadershipclarifiespriorities,createsenergyandsignals commitment to change. It translates the broad objectives into specific,focusedgoals.Ithasafulloverviewoftheactivities,assurestheircomplementarity,integratesthemandtakescareofthebalance.Leadershavetheskillstodefinethegoalsinawaythatengagespeople,andtodothatcontinually.

Asfarastop-downleadershipisconcerned,whetherthesamepersonorpersons(thescope of the Plan suggests perhaps the need for more than one) are sustainedthroughouttheprocess,thePlanneedstoproceed.Aleaderorleadersneedalliesonalllevels,butownstheabilitytoengageandinfluenceotherstoparticipateinthetask.

Top down leadership is needed at a policy level but needs supplementing from thebottomup. Information should be continuously shared in bothdirections, top-downand bottom-up. ‘How to do’ is a job for front line teams – there needs to beunderstanding between the leader and those front line teams on a common set ofgoals.

Therearethreefundamentalaspectsoftop-downleadership,vision,inclusivenessandspecificskills.Aleaderorleaders‘walksthetalk’asfarascommitmenttothemissionofdiabetesprevention,havingavisionofdiabetesprevention for thewholecountryandbeingabletoconveythatvisiontoothersinanunderstandablemanner.Asarolemodel, there will be a proven track record from before, an ability to inspire, awillingnesstotakerisks,basedonconfidenceintheirabilitiesandtotalcommitmenttothetask.

• fulloverview• complementarity

• integrapon• balance

• peopleengagement• conpnuousprocess

• broadobjecpvesintospecificfocusedgoals

• clearfocus• consistentandongoinginipapves• prioripes• energy• signalsofcommitmenttochange

Creates Translates

AcpvipesLeaders

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Forinclusiveness;thereisaneedforunderstandingandsynthesizingtheperspectivesofthosefromdifferentbackgrounds,toallowmoreeffectiveimplementation.Awiderange of partners supports this. Hence leadership should not shy away from inter-sectorialcooperationandeffectiveengagementofallstakeholderswouldbeapartoftheimplementationprocess,withoutpreconditions.

Forspecificskills;whiletheleaderorleadersneedtoknowwhat’sgoingonatalllevelsand to review activity, they shouldn’t be dictatorial, but be seen as facilitating andavailable for problem solving. Good communication skills are essential, beingsupportive but also showing appreciation of achievements. Leadership needs to bedelegated also at different levels to share responsibility in an appropriate manner.Otherskillsincludecoordinatingtheprocesswhileleavinganopenflowofideaswhichmightleadtomodificationofobjectives,andensuringimplementationrelevanttotheindividualcontextsofthetargetgroups.

ExamplesofquotesfromMinistriesofHealthrepresentatives:“Changeof structure inmyorganisationneeded top-down leadershipbecauseotherlevels were not as convinced. Better communication of structure beforehand couldhavebeenneeded.”

“In order to engage people you have to be clear about the objectives youwant toachieve.“

“Nationalstrategyonnutritionandphysicalactivity.Thestrategyhelpedtomakemoreactivitiesofthisarea.“

“Activities/commitmentatthefederal/regionallevelisrequiredon/of/attheinitiatingchanges of the legal framework, an example recently in Germany is the PreventionAct.”

“Umbrellaisneededinordertosuperviseimplementation.Feedbackmechanismsformultisectorialcommunicationareinplaceatthatlevel.Caseexample:Preventionlaw,Germany2015-legalframeworkforbodiesforgovernance.”

“Top-downleadershipcanonlybesuccessful,ifitmanagestobringacrossthemessageabout why things are important to happen. A second criterion for success is theflexibility to change plans even in a top-down approach in order to get people onboardandimprovetheoriginalplan.”

“Iagreewiththesesentences.Theabsenceofaclearandstrongguidemostprobablyleadstoaworstoutcomes.Therealsuccessisreachedwhentheleaderisabletoreachthefinalobjectivetakingintoaccountquestionsandsuggestionsofhis/herteam.”

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“Firstly a common goal needs to be set in place. In defining the common goal allmembersneedtofeelitas"theirproject".Top-downonlyworkswhenyoumaketheproject"theirproject"andactasthatwastheirplaninitially.”

“Experienceofnationalplanfornutrition&physicalactivityandhealthstartedfromacommitted team with a lot of expertise - it went through years of differentgovernment cabinets and build an enduring and clear vision helping stakeholdersunderstandthestakesandgoals.“

“LawonTobaccoconsumptioninclosedplacesinSpainisagoodexample.”

“Topdownleadership:1)politicalagreementonthevision,wheretogo,towardsourfuture health care system, "towards integrated care". 2) inspiring, motivationalspeakerwithaclearvision,whoisawareofthechangeprocessanditsbarriersandcanmanagethoseuncertainties.”

“Be sure that youhaveevidence, researches, statistics to createa senseofurgency.Ministershouldpresentthisdata inpublic(not inthefirstplace inparliamentbutatthe opening of hospital etc.). Message of minister should be clear and short andrepeatedinseveraloccasions.Involveexperts,besureoftheircommitment.IthelpsiftheymeetwithMinister.”

“From my experience maybe the best experience (most successful) wasimplementation of quality management in organization when leader of projectsuccessfullyimplementeditalthoughatthebeginningoftheprocesstheresistancetothechangeswasreallybig.”

“Strategies - collaboration - participation. Governance of strategies on health as acollaborative and participative way of defining strategic lines, goals andrecommendations.Itisaninclusivemodeltoincludeallstakeholders.”

“Making a law for Antimicrobial Resistance Control and Health Care AssociatedInfections.WeimplementthelawandaregulationonownHealthCareUnits.”

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3.Settinguptheleadership:bottom-upleadershipTop-downleadership,ifsuccessful,createsfocusandthenecessarypreconditionsforthe change, but alone cannot achieve it. To achieve successful implementationofinitiativesthatrequirefundamentallynewwaysoffunctioning,theapproachhastoinclude actions tailored to specific challenges, skills and change readiness of largenumbers of people implementing the action at the front-line. The leadership forbottom-up initiatives is successful if it supports goal-setting, determination of thegaps, understanding the root causes, brainstorming and trying out solutions,monitoringtheresultsandmakingadjustments.Ithastoacknowledgethatinitially,inertiawillexist,thatknowingisnotenough,andthatpeopleadoptnewbehavioursbyexperiencingthem.

Keyfunctionsthathavebeenidentified,inordertoachievetheaboveare:

Good coordination among the partners involved in development, delivery andimplementation,especiallyinvolvinglocalleaderstoempowerthem.

Anadaptableframeworktotranslatethevisionandhigh-levelplanfordifferentlocalenvironmentsandcircumstances,sensitivetothelocalcultures.

A participatory style that promotes bottom-up consensus-building and promotesmutual trust and also acknowledges that some changes need time, to help peopleadjusttonewbehavioursthatmayberequiredofthem.

Peopleadoptnew

behavioursbyexperiencing

them

Changereadinessofthelargenumberofpeople

Goals,gaps,rootcauses

Brainstorm,tryout,monitor,adjust

Ini\ally,iner\awill

exist

Knowingisnotenough

Focusandprecond\\onsforthechange

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Arecognitionoftrainingneedsandtheabilitytomeetthem

Acommitmenttoevaluatingresultsaswellastrackingtheprocessofchange

Effective,regularandstructuredcommunicationthroughandacrossalllevels

Sincereandmeaningfulattentiontobothgenderissuesandthoseofvulnerablegroupsratherthanpayinglip-servicetopoliticalcorrectness

ExamplesofquotesfromMinistriesofHealthrepresentatives:“People are experts of their own life; this is what has to be acknowledged also byhealthcare system ad local leader. Empowering patients, reviewing and evaluatinglocalconditionsandbasinglocalstrategiesonthisinfoiscrucial.Localstrategiesneedto be in local political agenda and linked to budgetary decisions & reporting ofimplementationofstrategies.Wehavethatsince2010.”

“Agree with last part of last sentence ("and that people adopt new behaviours byexperiencing it"). If you have a good product/concept/action, you need to convincepeopletoexperienceitandletwordofmouth.Alsogivethewordtocommunities,letthem say what they want/could focus on. For example - World Diabetes Day.InternationalDiabetesFederationgavethemessagebutdiabetescommunitieswouldworkontheirownactivities.“

“Germanybeingfederalstateneedsbottomupactivitiesandoverallleadershipwhenimplementingmeasuresatthecommunitylevelwithaviewtochangingbehavioursatthepopulationlevel(ExampleinForm-ActionPlanonPhysicalActivityandNutrition).”

“Clear definition of needs and existing gaps. Flexibility to incorporate other's needs.Flexibility to adapt several actions to change in the context factors & differentoutcomesofimplementations.Overviewisneededtonotgetlostintoomanydetails.”

“The key is finding the leaders in the system. Local incentives cannot be put down.Currentlywehaveagreatexperienceinonelocalcommunityhospital,wheremanageriswilling to take the lead inpilotinganew integratedcaremodel.This initiativehasbeenwelcomebytheministryandwillalsobeseparatelyfinancedbytheministry.”

“Iagree.Inacommunity(+/-200.000inhabitants)aprojectleaderinahospitalcouldmotivate different partners to participate in brainstorm sessions and got theagreementofmostofthepartnerstosubmitaproposalthataffectsthewholeregion(healthcare&socialcare).“

“EverydayworkinmygrouprisesupmanyideaswhichIasaleaderhavetostructureandprepareforaction.“

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“Ifchangeisgoingtohappen,youhavetogetalllevelsintheorganisationwithyou.Thereareseveralwaysofdoingthat-butsomekindofinvolvementthatensuressomekind of ownership is essential. Remember also that the patients are the strongestagentsofchange.”

“PreparationandimplementationoffirstNationalDiabetesprogrammeinCroatiawasa good example of bottom up leadership when initiative rise from professionalorganizationsanddoctorsfromclinicalpractice.”

“Healthscreeningatschoolisagoodexampleinourcountry.Areformhasstartedatschoolsbydoctorsandparents.”

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4.Settinguptheleadership:leadershipforsupportinglinkageacrossexistingboundariesTop-down and bottom-up efforts are very important, but work within existingorganizational boundaries. Some changes, however, can happen only wheninstitutions,people,activitiesandinformationarelinkedinnewways.Leadershipforthesechangesissuccessfulifitsupportscommunicationandlinkageamongexistingsilosesandcarethatiscurrentlyfragmented.

To achieve new kinds of linkages, the leader(s) need to be open to inter-sectorialthinkingwherepeople’s issuesareviewedwithin thebroaderperspective.Change iseasierifitincludessomechangeinorganisationalboundaries.

However, it isnecessary to respect thenatural tendencyofpartners toprotect theirareaofinfluenceandresources.Thebestsolutionforthispotentialbarrierisincreasedcommunication.

Networkingopportunitiesandincentivesfornetworkingneedtobedevelopedinordertofacilitatetheexchangeofinformationandideas,andthestructurestosupportthis.Leadershipmayneedtoestablishcompletelynewcommunicationstructurestocreatenewlinksbetweenpartners

Finally, the task of identifying and addressing barriers to change, especially oforganisationalboundaries,issomethingthatcaninvolveallpartnersworkingtogether.

Insideexis\ngboundaries:•top-down•boaom-up

Linkedinnewways

Communica\onandlinkage

accrossexis\ngsiloses

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ExamplesofquotesfromMinistriesofHealthrepresentatives:“Create opportunities for face to face meetings within the same organisation toprovidepeoplewiththepossibilityofdirectlylinkwitheachother.Facilitateexchangeacrosshierarchies.”

“I think this type of changes needs a person or group in the organisation that ispersonally driven/involved in them. Personal enthusiasm helps to start changes andputsissuesontheagenda.“

“You need to have structures to support linkages.We in Finland have the law thatmultisectoral committees (including NGO's) at municipality level have to beestablished. Committee for public health is established at national governmentallevel.”

“Communicate your approach clearly and gather experiences from people who areexperiencingthechangesandcommunicatealsothoseexperiences.”

“Organizing a Diabetes Forum has brought together ministry, patient organizations,doctors, universes, health care system…and this event had some very importantconclusions.”

“Detailedexchangeofproblems,obstacles,encouragingresultsetc.isneededinordertoenablemembersofprojecttohavetheothers'perspective.Ittakestimetobridgethegapbetweendifferentperspectives.“

“Clearcommunicationfromalllevelsneeded.Andopennesstolistentotheothers.”

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5.Topics,processesandleadershipcombinedinthePlanorganisationaldesignandstructureThePlanorganisationaldesignandstructure,as setupbelow,maysupportall threetypesofleadershipthataimatimplementationandsustainabilityofthePlan.

ThePlanexistsandispubliclyavailable.

The Plan involves all core partners. Partners are involved in the development andimplementationofthePlan.

Nationalpolicylevelcommitmentisinplace.

Advocacyfrompatients'associationsandscientificsocietiesisinplace.

ThePlaninvolvespartnersfromsectorsoutsidehealthcare.

ThegoalsandobjectivesofthePlanareclearlydocumented.

In the Plan, the extent of the problem is described and there is analysis of what ishappeningnowandwhatneedstohappeninordertoachievethegoalsisperformed.

There is a documented implementation/ action plan, tailored to the context of theStateorRegion.

Theresourcesforitsimplementationareallocated.

Anappropriatelyconstitutedsteeringcommitteeortaskgroup(i.e.involvingpartnerslike government authorities, patients' representatives, specialists and primary carehealthcare professionals and other relevant national health organisations) preparesand oversees the implementation of the Plan. Voices of vulnerable groups arerepresented.Theresponsibilitiesofthepartnersaredefined.

Leadership should combine a top-down approach that is focused, consistent andongoing, and a bottom-up process that addresses the large number of peopleimplementing the Plan, and supports communication and linkage across the(organisational)boundaries.

Leadership acknowledges that for successful implementation and sustainability,sometimes existing structures may need to be changed fundamentally. Neworganisational boundaries are identified and links established. Front-line individualsneedtobeinvolved.

The culture of change is created; the room for change is identified. Communicationandcooperationarefundamentalcharacteristicsforthis.

There is a communication strategy of the Plan, internal and external. Internalcommunicationamongthepartnersiscontinuous.

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There is an evaluation strategy of the Plan, with processes for continuousimprovement in place. Successes are defined and celebrated; failures are taken assignstolearntofindanotherway.Failuresarenotpunished.Ifgapsareidentifiedintheprocess,theplanisadaptedaccordingly.

Theplanisflexibleandcanbeeasilyadaptedforlocalusewithindifferentcontexts.

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