2.5.1 Identifying a Complex Challenge

In their first review of the evidence, Reference Bryson, Crosby and StoneBryson, Crosby, and Stone (2006, p. 45) looked at the factors preceding cross-sector collaboration and explained two ways that organizations go about pursuing it:

These two characterizations are consistent with the findings from the literature review for this project (Reference 80KritzKritz, 2017, Reference Kritz2018). The developed-country evidence now offers a number of ways to assess the need for, and potential efficacy of, a cross-sector collaboration, which is recommended when there is a clear advantage to be gained – for example, when there is sector failure (Reference Bryson, Crosby and StoneBryson, Crosby, & Stone, 2006, Reference Bryson, Crosby and Stone2015). However, in a developing-country setting, where technical sectors are not as strong and indicators can vary widely based on the population, geography, and other factors, it was not clear how to identify sector failure.

In this project, the research director asked the initial stakeholders from multiple sectors, Boateng, Sr. Matilda, and Imoro Toyibu, to identify a challenge that they had not been able to address on their own to identify a true complex challenge and sector failure. They identified Old Fadama as the challenge that they wanted to address. However, because urban slums are such a pervasive and growing issue, it was not clear whether any slum would be perceived as sector failure – perhaps these were environments where each sector could point to another that had failed. Or, perhaps slums had replaced rural areas as the “end of the road,” areas the government needed to address, to take a next step in providing services, but not necessarily perceived as failures.

However, Old Fadama stood out for one particular reason: multiple times per year, cholera epidemics began in the slum and swept throughout the country. The local government received constant negative local media attention, and more recent epidemics had been reported in the international media, worrying high-level government officials that the reports would have a negative effect on tourism and the choice of Ghana as a venue for hosting international meetings. The director of public health had documented how similar efforts had combatted cholera in other slums but had not worked in Old Fadama. He perceived these repeated epidemics as reflecting sector failure.

2.5.2 Creating Shared Understanding

Cross-sector collaboration creates shared understanding of complex challenges (Reference Bryson, Crosby and StoneBryson, Crosby, & Stone, 2015), but it is not an easy task to create shared understanding in a high-conflict environment such as Old Fadama. This context requires a conflict-sensitive approach (Reference AndersonAnderson, 1999; World Health Organization, 2019). Conflict can be value neutral and is important in that it surfaces issues that need to be addressed for those in conflict to begin to collaborate (Reference CarpenterCarpenter, 2019). However, these conflicts need to be handled with care to achieve solutions (Reference BinghamBingham, 2009). The PAR interviews were used in part to infuse the process with references to local culture and values regarding the importance of working together, respecting others, and seeking understanding across divisions. The research team used the PAR process to build on these norms and create a shared understanding of Old Fadama’s challenges. To do so, the facilitator focused on the stakeholders’ shared interests rather than their “positions,” by identifying each stakeholder’s basic human and organizational needs and focusing attention on doing the best “for Mother Ghana” (see Figure 6). Thus, the PAR process was used to create a value-neutral understanding of the conflict between the government and the community, which provided the opportunity to develop a shared understanding of the challenges.

Figure 6 Old Fadama community meeting

These norms have further developed and include both a shared terminology and a value system based on mutual respect and understanding (Reference Thomson and PerryThomson & Perry, 2006). As the norms grow, new stakeholders are able to more rapidly expand their perspective, understand the PAR process, share their ideas, and see these ideas incorporated, because of the shared understanding of, and language around, Old Fadama’s challenges.

2.5.3 Middle-out Collaboration

In developing countries, cross-sector collaboration often works “top-down” consistent with the flow of development aid funding, or “bottom-up,” through work with communities (Reference 80KritzKritz, 2017). These processes are anchored in powerful constituencies that help to orient the work. Because of the conflicted relationship between the municipal government and Old Fadama, neither government nor community was positioned to lead the other. An organization was needed to bridge this divide, and the research director created the term “middle-out collaboration” to define this leadership role.

If government does not mandate cross-sector collaboration, the literature suggests starting with a small group of stakeholders and expanding the collaboration as the momentum grows (Reference Bryson, Crosby and StoneBryson, Crosby, & Stone, 2015). This approach requires strategic relationship building (Reference Magrab, Raper, Blau and MagrabMagrab & Raper, 2010). The research director designed the middle-out stakeholder identification to determine those organizations best positioned to bridge the divide around Old Fadama. Catholic sisters – because of their moral leadership, demonstrated the capacity to work with communities and had a long-term commitment to fill gaps in government social service delivery in Ghana – were enrolled as research participants to sit in the “middle” and build a bridge “out” between government and the community.

2.5.4 Emergent Design and Governance

Collaborative governance is an explicit strategy for incorporating stakeholders into government policy and planning through “multilateral and consensus-oriented decision processes” (Reference Ansell and GashAnsell & Gash, 2008, p. 548). The collaboration literature describes a range of design and governance possibilities from formal structures to informal interactions through which decisions can be made (Reference Bryson, Crosby and StoneBryson, Crosby, & Stone, 2006; Reference Provan and MilwardProvan & Milward, 1995; Reference Stone, Crosby, Bryson, Cornforth and BrownStone, Crosby, & Bryson, 2013). Employing deliberate, formal design and governance in the context of already planned interventions is consistent with the literature on developing-country collaborative projects (Reference 80KritzKritz, 2017). By contrast, emergent design allows missions, goals, roles, and action steps to emerge over time within a network of involved or affected parties to overcome problems in a system (Reference Bryson, Crosby and StoneBryson, Crosby, & Stone, 2015).

Leading journals identify a significant research gap around public participation in developing countries. When the gap is viewed from the field of psychology, it is clear that this sort of participation requires both processes and readiness of those whose participation is sought (Reference MoghaddamMoghaddam, 2016). Ideally, a citizen must be guided by a critical and open mind, while government must accept and respond to appropriate criticism. Emergent design addressed both the readiness of the governing (city government and slum leadership) and the governed (slum leadership and residents) to participate in a more transparent process that evolved to meet their needs at the same time (Reference Kritz and MoghaddamKritz & Moghaddam, 2018).

Because Old Fadama was an informal settlement that developed on land set aside as an eco-zone or preserve, government infrastructure planning did not include that geographic area. Civil servants had been unable to take up the challenge of infrastructure planning for a variety of reasons. For example, the government created its budgets around city planning maps that did not include the settlement, so creating a budget for slum improvement would require changing the city plan. A further complication was that solid waste pickup or installing water pipes and sanitation meant creating road access, which would displace residents with nowhere else to go.

More recent scholarship explains how informal norms of settlement and belonging – specifically the interaction between indigenous landowners and migrants – structure everyday politics and spill over into formal elections (Reference PallerPaller, 2019). Because the slum contained a large population of voters with ties throughout the country, politicians were wary about angering the community. Politicians had historically made promises about slum upgrading, but these promises had not been kept. Slum leadership had resorted to leveraging media attention to demand dialogue with the government and advocate for better infrastructure, but this had only created more tension and led to at least one failed infrastructure project.

Conflict is value neutral; if managed productively, it can be used as an opportunity to galvanize stakeholders to try different solutions (Reference CarpenterCarpenter, 2019). However, learning to use conflict productively takes time. Emergent design and governance, where stakeholders make strategic choices about research methodology, participants, context, and projects allowed stakeholders time to learn to work through their conflicts, thus building a strong PAR process.

2.5.5 Creating “Buy-In”

The evidence from psychology suggested that stakeholders’ investment in various projects would increase their likelihood of continuing to participate, thus strengthening their bonds to the projects (Reference FestingerFestinger, 1962). Thus, to increase stakeholder commitment or buy-in, the collaboration principle was that the stakeholders must find the necessary human and physical resources for their own participation and projects. Previously, the stakeholders had been accustomed to development projects, funded by northern governments and international donor organizations, that had supported all local participation and project costs. The idea of resourcing their own participation and projects challenged their thinking in a positive way. Early in this project, consistent with old expectations the international development projects had created, stakeholders made numerous requests for payments and asked for laptops, smart phones, and other tools. Over time, however, these requests diminished. As the facilitator introduced the project to new stakeholders, he explained that the project was a “public good” being done “for Mother Ghana,” so “we all should put in our own resources.” As new stakeholders “bought in” to this shared vision, they did so with the understanding that they would be developing projects based on the resources at their disposal or that they raised together.

2.5.6 Building for Sustainability

A growing body of research offers perspective on process-oriented studies such as this one (Reference Brownson, Colditz and ProctorBrownson, Colditz, & Proctor, 2012; Reference Peters, Adam, Alonge, Agyepong and TranPeters, D. et al., 2013; Reference SpiegelmanSpiegelman, 2016). However, implementation of sustainable projects in developing countries has proven to be challenging, despite the focus on this concept (Reference Gruen, Elliott, Nolan, Lawton, Parkhill, McLaren and LavisGruen et al., 2008; Reference Shediac-Rizkallah and BoneShediac-Rizkallah & Bone, 1998). A frequently documented challenge is that when northern international development funding ends, the projects stop working, thus erasing the supposed gains from the effort. One factor of this issue is that the international development funding drove the project. Stakeholders resourcing of their own participation through all phases of a project is one key to sustainability (Reference FowlerFowler, 2001). For this PAR project, the principle was that if the stakeholders resourced their own participation, the process would be created with local funds, building toward sustainability.

2.5.7 Facilitation

Collaboration requires a commitment to process that goes beyond the initial design (Reference Bryson, Crosby, Stone and Saunoi- SandgrenBryson, Crosby, Stone et al., 2011a; Reference Mintzberg, Ahlstrand and LampelMintzberg, Ahlstrand, & Lampel, 1998). The research director trained the local facilitator on the collaboration evidence and together they began to develop the PAR process. The evidence suggests that these kinds of “bridging social capital” roles are one important facet of development (Reference CarpenterCarpenter, 2019; Reference Woolcock and NarayanWoolcock & Narayan, 2000). The research director, facilitator, and community liaison (the research team) collected all data and engaged the stakeholders through interviews, focus groups, a survey, and continuous data collection and triangulation. Throughout the PAR process, the research team used the cross-sector collaboration evidence base as a guide, to support the PAR process, educate the stakeholders, and inform their decision making. The principle was that evidence-based facilitation of a PAR process would provide a level of rigor suitable for collaboration around a complex challenge.

2.5.8 Application of the Collaboration Principles

The research director introduced these collaboration principles and the concept of cross-sector collaboration at the outset of the project. The research team educated the stakeholders about the developed- and developing-country evidence base; supported the stakeholders through PAR in forming a cross-sector collaboration; and developed priorities, strategies, and projects with the stakeholders. This process generated the data that the research team collected, analyzed, and shared with the stakeholders so that they could understand their own decision making. Utilizing grounded theory helped to make sense of the data and to develop a theoretical account of the process. The social sciences employ grounded theory as an “inductive, theory discovery methodology that allows a researcher to develop a theoretical account of the general features of a topic while simultaneously, grounding the account in empirical observations or data” (Reference Martin and TurnerMartin & Turner, 1986, p. 141). Section 3 describes how the PAR process unfolded, and the role of these collaboration principles in expanding the process.

3.3.1 Phase I: Key Informant Interviews and Process Management Results

In February 2015, as described in Section 3.1, the research director conducted in-depth, semi-structured interviews that lasted between one and four hours, with a purposive sample of eleven potential stakeholders: five non-governmental (four congregations of Catholic sisters and NCHS), six governmental (three AMA and three Ghana Health Service), and one community member. The scholarly literature suggested interview themes including experience with collaboration, strategic interests of each individual and their organizations, and prior relationships among the interviewees (Reference 80KritzKritz, 2017). The interview protocol was later adapted (Appendix A) for use in initial interviews with new stakeholders. Interviews were recorded through note-taking, along with detailed notes on emerging issues, ideas, activities, and informal conversations with key actors. This practice enhanced reflexivity, supported active listening in the interview process, and enabled triangulation with other data during the analysis stage. The research director constructed the interviews to educate the interviewees about cross-sector collaboration.

Through the interviews, the three initial stakeholders described earlier agreed to enroll as research participants. The research director triangulated the interview data with follow-up email and telephone conversations for clarification and used qualitative content analysis to identify themes, areas of consensus, important strategies to explore, cultural norms around the idea of working together, as well as terminology, common expressions, and key concepts related to cross-sector collaboration in Ghana. Two themes emerged: (1) due to the volatile nature of the slum environment, process management of the collaboration required significant attention and (2) projects were needed to address community needs, which included understanding community priorities along with prior strategies and efforts to address them.

All interviewees were unfamiliar with the term “cross-sector collaboration.” When it was described to them, 100 percent said they had worked through cross-sector collaboration in the past. Each of the stakeholders understood cross-sector collaboration as a method through which they had naturally operated in some cases. They all understood that it is a very challenging approach and appreciated that it is valued as highly effective when it succeeds. Agreed-upon local terminology, common expressions, and key concepts resulting from the interviews were used and refined throughout the process.

The research participants reached consensus on several process results. The first was a decision to focus on the Old Fadama slum because it presented perhaps the greatest challenge to Accra’s development. This decision shaped Collaboration Principle 1, identification of a complex challenge. The second result was the stakeholders’ willingness to participate in cross-sector collaboration to solve problems with this community. This decision, along with an agreement to resource their own participation, became Collaboration Principle 5. The third result was consensus on the importance of engaging Old Fadama community leaders to design and implement a strategy, coupled with agreement on the importance of not contacting them until the stakeholders were ready to take action so as to not “disappoint” the leaders. This decision shaped Collaboration Principle 4, to employ emergent design and governance.

In June 2015, heavy rains caused floodwaters to rise to the tops of Old Fadama buildings. Flooding throughout the city killed or injured more than three hundred people. Many Accra residents believed the slum caused the flooding. They blamed the residents specifically for infilling and silting the river and lagoon. As a result, the AMA demolished the area of Old Fadama that encroached upon the river and lagoon. They provided transport for displaced residents, even paying some of them to return to their homes in northern Ghana. The resettlement effort was ineffective: many residents jumped from the transport before even leaving Accra, while others used the transport as an opportunity for a free ride to visit home, returning to Accra later in the year. The bulldozing and resettlement caused considerable tension that erupted into violence. These developments also demonstrated that bridge building between the municipal government and the community was absolutely essential, leading to the idea of middle-out collaboration that became Collaboration Principle 3. This project’s three initial research participants considered changing locations due to the increased violence and anger. However, they decided to continue to work in Old Fadama because, after the flooding and the failed resettlement, the residents’ need was even greater.

3.3.2 Phase II: Focus Group Discussions (FGDs)

As noted in Section 2.5.3, when cross-sector collaboration is not government mandated, the literature suggests starting with a small group of stakeholders and expanding as the momentum grows (Reference Bryson, Crosby and StoneBryson, Crosby, & Stone, 2015). Citizen participation in government planning is known to be increasingly important (Reference FagenceFagence, 2014). However, there is a gap in research around participation in government planning in Africa (Reference Kapiriri, Ole Frithjof and KristianKapiriri, Ole Frithjof, & Kristian, 2003; Reference MalukaMaluka, 2011). The PAR process was designed to build government capacity to incorporate citizen participation, so that data from the grassroots could inform government planning.

The research director and initial stakeholders agreed that the next step should be a meeting to involve community leadership. As described earlier, due to the conflicted relationship between the municipal government and the community, it was clear that neither could facilitate the collaboration due to a lack of trust. It was at this point that Batsa was engaged as a facilitator to collect data on the PAR process and to work alongside the Catholic sisters and build bridges between these conflicted parties. In all, there were four FGDs, designed to engage the community leadership, identify community priorities, align these priorities with government planning, create strategies, and implement a project. The research director and the facilitator designed the FGDs and collected the data, audio recording the focus groups for later analysis. Participant observation was important, so interactions were captured through note-taking, including recording nonverbal expressions.

Batsa facilitated each FGD, and the research director and he provided consultation on cross-sector collaboration theory and evidence to inform the research participants. During each FGD, the facilitator worked with existing research participants to identify new stakeholders, based on the criterion that they might play a long-term role in implementing the project strategy. Research participants achieved consensus on identifying additional participants to invite. Based on prior experiences with short-term interventions, the research participants’ criteria excluded international NGOs, which are generally funded for short project cycles that are unsuitable for complex challenges such as Old Fadama.

The research director and facilitator constructed the FGDs (Appendix B) to give all participants the opportunity to express their own thoughts about the collaboration process and projects. The research director used qualitative content analysis to understand participants’ shared opinions on process management, priorities, strategies, and projects. The results from each FGD were triangulated with the participants, as well as the facilitator and the initial stakeholders (Boateng, Imoro, and Sr. Matilda). Because the results captured decisions that had been made by consensus, triangulating usually meant ensuring that the language of the results matched the stakeholders’ intention and confirming their agreement (given a chance to think more about it) with the decisions they had made. This cross-checking was conducted with the initial stakeholders and other participants in each FGD, until the research team believed consensus was achieved. In this way, the results were continually updated based on developments in the community and among the stakeholders. The research team analyzed the data for each FGD separately and then together as a whole to understand differences in the FGD participants’ attitudes, beliefs, and opinions and how these changed over time. These results, too, were shared with the initial stakeholders and the participants in each FGD in an iterative way to continually update the research participants on the decision making.

3.3.3 Phase III: Stakeholder and Community Survey

The technical planning FGD results were cross-checked with the community leaders from FGD 2, who had been unable, for logistical reasons with transportation, to participate as planned. Having requested latrine installation from the AMA in prior years without success, the community leaders were very enthusiastic about moving forward. They requested a community survey to expand the number of stakeholders and engage community members on latrine construction. This perspective is consistent with the evidence on working with underserved communities (Reference Wallerstein and DuranWallerstein & Duran, 2010). The leaders wanted community member input on two focus areas: (1) latrine management to address maintenance, sustainability, and how the proceeds would be reinvested and (2) site selection with a needs assessment including factors such as migration, population density and movement, and the requirement of moving dwellings to create access for waste removal trucks. At this point, as described in Section 3, a Catholic sister, Sr. Rita Ann Kusi, HDR, joined the research team to serve in the important role of community liaison and to conduct the community interviews.

The research director’s goal for the survey (Appendix C) was to understand community needs and interests and explore ideas about cross-sector collaboration and participation. The research director constructed the interview guide to explain the process of cross-sector collaboration and the Catholic sisters’ role in installing and managing latrines in the Old Fadama community. The survey explored the relationship among the community members, community leaders, and the AMA. The research team used the survey to identify areas of consensus on the sanitation strategy so that the community, city, and sisters could move forward together. This was a chance, as described earlier, to inform the PAR process of the community’s ideas and concurrently create research results that would be useful for government planning.

For each of the two survey themes, collaboration process management and sanitation strategy, there were multiple statements on the questionnaire. There were specific questions about the residents’ perceptions on collaboration, as well as the latrine project. The questionnaire employed a Likert scale to measure opinions, followed by open-ended questions to further understand important details. The survey was pretested with sanitation and public health experts from Accra (in and outside Old Fadama) and the United States. The Department of Public Health’s officer-in-charge, Imoro Toyibu, who lived in Old Fadama and spoke the residents’ local languages, translated the interviews when necessary.

Conducting the survey was challenging for a variety of reasons. One complicating factor was that the latrine business was small and tightly controlled by a few community leaders. The practice was for latrine business owners to generally agree with one another upon a price for latrine usage, with a cost structure based on toilet paper, known as “t-roll,” usage: business owners charged the lowest price to provide nothing at all, a higher price for newspaper, and the highest price for t-roll. However, the pricing system broke down when a business owner was in need of extra money. Then, they would frequently and unilaterally raise their prices. Because of Old Fadama’s space limitations and indirect pathways, it was often challenging for customers to visit latrines in other areas, so they would either pay these higher prices or be forced to engage in public urination and defecation. The AMA’s June 2015 partial demolition had destroyed a number of latrines, creating a gap in service. Thus, business owners had raised their prices such that many slum residents were not able to access latrines, resulting in increased public defecation and urination.

The second challenge was that the AMA Department of Public Health had already failed in attempts to work with community leaders to install latrines. This negotiation had unfolded in an interesting way. While the AMA owned the land in Old Fadama, it had been subdivided so that each tribe had the right to use a particular area. Based on cultural custom from northern Ghana, the chiefs decided how to use their tribe’s allocated land. In the past, when the AMA attempted to locate a site for the latrine installation, a number of chiefs exercised their ownership interests for the site and the access. By the end of the negotiation, the project cost was more than doubled, which was both outside the AMA budget and not justifiable for ethical reasons. Thus, the AMA’s negotiation had ended without latrines being installed.

The third and most daunting challenge was that the upcoming elections cast slum improvement as a political issue. The atmosphere was extremely tense, and the community was frustrated with slum improvement promises from both major political parties, because neither party had delivered on improvements in the past. At the same time, political actors used their party organizations to enrich their constituents. This unhealthy cycle of political wrangling had jaded everyone’s perspective and caused community members to generally dismiss external development programs as being driven for the purpose of securing votes for the coming election. But for the presence of a Catholic sister as the community liaison, the cross-sector collaboration process would have undoubtedly stopped at this point. However, because Catholic sisters are perceived with a high level of regard in Ghana due to their historic work with communities’ most disadvantaged populations, Sr. Rita continued the interviews unimpeded. It was touching to observe the Muslim community members express themselves openly to the sister, although they had not met her prior to the survey, based on the historic relationship of trust between sisters and Muslim communities in northern Ghana.

A purposive sample of fifty-nine interviewees was selected in a snowball process. Many interviews lasted more than two hours and up to four hours. This was longer than expected, but the research team believed it was culturally appropriate. It seemed important to allow community members time to express their frustration with the slum conditions, their hopes and fears about working with the AMA, and their opinions about whatever else they wanted to discuss. Interviewees expressed willingness to share their opinions mostly because they trusted the Catholic sister. Interviews were audio recorded and portions were later translated and transcribed or used for notes. By the end of the process, the interview team (Sr. Rita, Batsa, and Toyibu) believed they achieved saturation.

The NCHS Research Department entered the data using MS Excel 2013 and exported and analyzed it using SPSS version 16. Results were presented in the form of tables, charts, frequencies, and cross tabulation (bivariate analysis). The NCHS research team analyzed the survey responses to identify the most important elements, both positive and negative, that should be taken into account during the development of a latrine installation and management plan.

Areas of consensus, which are defined as when 100 percent of the interviewees “Strongly Agree” or “Agree” with the statement, were:

• The community should support sanitation management.

• Members of the community should actively participate in implementing sanitation management.

• It is the duty of community members to participate in and work with any program that involves community development.

• Overall it is nicer to work in a group than to work alone.

Although there was disagreement about many aspects of the project, the research director thought the areas of agreement were important for building shared understanding, and these were relayed back to the stakeholders through the PAR process. The PAR process provided a level of transparency and built trust among the stakeholders when they found that their opinions aligned with those of others.

Following the survey, the collaboration – in this case all of the stakeholder organizations, including Georgetown University, NCHS, Sr. Matilda’s congregation the Handmaids of the Divine Redeemer, the AMA, the Catholic Archdiocese of Accra, and the Old Fadama Development Association – applied to the AMA for permits for two sets of twelve-seat latrines and two sets of four-cubicle bathhouses and accessories. As mentioned earlier, Sr. Matilda and Batsa served as key implementation partners, along with Boateng and the research director.

As noted, this research project did not have a budget for latrine installation. However, by this point, the stakeholders had contributed substantial resources to the PAR process: human resources (volunteer participation by all stakeholders), donated meeting space, and transport. The research team believed that this was an important step toward process sustainability, Collaboration Principle 6. These donations meant that funding was left in the research budget to begin latrine construction. The AMA donated latrine project costs, including design that included community input, architecture, budgeting, and permitting, all taking into account the challenging geography, flooding, and population density. Sr. Rita applied for additional funding to complete the project. These donations – first the human resources, then the project funds, then the successful application for funding – helped to validate Collaboration Principle 5, that a process resourced with local funds contributes to stakeholder buy-in on the outcomes as well as to project sustainability, Collaboration Principle 6.

4.1.1 Collaboration Framework Results

This section explains further details about the collaboration principles (Figure 5), especially as to challenges that they helped the research team and participants overcome.

4.1.2 PAR Intervention Results

The PAR intervention began with preliminary interviews that identified a location for the cross-sector collaboration, clarified the core challenges, and established the initial group of research participants – the initial stakeholders. The interviews were used to identify themes that the stakeholders believed to be important, and local ideas and terminology helped to create a shared language for the collaboration and the unique roles and responsibilities of each stakeholder. The FGDs were used to identify community priorities and triangulate these priorities with government strategies. By feeding back the data into the FGDs, the community and government (and other) participants developed a shared understanding of the priorities that the collaboration should address. The FGDs were then used to create a sanitation strategy and latrine installation plan. The interviews and FGDs informed how the survey was designed around local concepts of shared responsibility and the importance of working together. The survey results reflected these concepts, which the research team believed validated the survey design. The stakeholders (listed in Section 3.3.3) thought that the survey results validated the latrine strategy and project design.

4.2.1 Latrine Strategy and Project Results

Latrines were exciting for the community leaders because, as one of them said in FGD 2, “cholera is killing us today.” Two aspects of latrine installation impacted the broader cross-sector collaboration process: (1) the creation of policy change and (2) the stakeholders’ planning for latrine sustainability. As described, from the beginning of the Old Fadama project, participants from all sectors – government, non-governmental organizations, community, and citizens – were interested in creating sustainable solutions. They explored different strategies to address the sanitation priority; after discussing portable latrines, it became clear that installing permanent public latrines was the most sustainable option. However, as noted, there was a city policy against upgrading Old Fadama. Thus, in September 2015, the facilitator and community liaison, at the request of the collaboration, entered into negotiations with the AMA to change city policy so that the collaboration could work on the latrine strategy. Following the community survey, the collaboration filed an application for permits to install public latrines and bathhouses, formalizing the negotiation.

The permits required planning approvals from multiple AMA offices that reviewed the collaboration’s latrine proposal. The approvals had the gradual effect of changing AMA policy to allow slum upgrading in Old Fadama. For five months, the director of public health, facilitator, and community liaison contacted various city offices in turn, seeking approvals on the latrine and bathhouse permits. Each office provided input and then directed them to a different office for a new approval. It appeared that no office wanted to give the final approval for the plan, as no one wanted responsibility for finalizing such a change to city policy.

Although intense and frustrating, this protracted negotiation served the important purpose of improving the longer-term planning for sustainability (Reference KritzKritz, 2018). As the latrine proposal circulated from office to office receiving different levels of approval, stakeholders were called upon to identify and analyze key barriers to sustainability. For example, the government identified that Old Fadama was not included in city planning because the slum developed on city land that had been set aside as a floodplain. This meant, as noted earlier, that resources needed to be reallocated for the planning. In addition, the gap in city planning in the past meant that there were no roads to accommodate sanitation waste pickup trucks, so they would not be able to enter the slum due to access issues. However, the community leaders explained how the city’s partial demolition of the slum – which had destroyed latrines and created a newly cleared area – presented an opportunity by creating space for the new sanitation facility, and also opening up an access road.

The Catholic sisters, known for their long-term attention to communities in need, identified the importance of doing “what the community wants,” meaning that the project needed to respond to community requests if it were to ultimately achieve sustainability. The sisters have a long-held value of creating charitable networks to support communities in need. Thus, when funding was needed for latrine installation, the Catholic sisters were able to use their charitable networks to raise foundation funds to supplement the research funding that had been reallocated to latrine installation.

The facilitation and research team from NCHS determined that community leaders from multiple tribes regularly engaged in destroying one another’s infrastructure. For example, political leaders from multiple tribes had used the headquarters of the community association for years. However, after an election, they destroyed it in an act of supposed political vigilantism to keep another political party from using the facility as a place to meet. This cycle was attributed to political retaliation, but just as often these kinds of actions seemed to be a guise for other issues. Thus, latrine signage on joint participation helped to insulate the latrines from destruction (see Figure 11).

Figure 11 Latrine block inscription

And finally, through their forced analysis of government by having to work so slowly in each sector and office, all stakeholders identified the absence of a maintenance culture in the government, which meant that the stakeholders’ implementation planning needed a way to address this gap. The community survey bolstered the community leaders’ knowledge of the cross-sector collaboration process, coaching them on how to take responsibility for various aspects of latrine management. The city donated the land, approved infrastructure investment, and finally entered a long-term public-private partnership with the stakeholders – represented by Sr. Matilda and Batsa as key implementing partners – to manage the latrines.

At the same time, the outcomes of the PAR process continued to develop, unbeknownst to the research team and participants. During the time that the research team shuttled from AMA office to office seeking the necessary permits, AMA employees discussed the proposal with their colleagues in Accra’s sanitation business. As the sanitation business community took notice, the latrine project became a lively topic of conversation. The concept attracted the interest of multiple sanitation businesses that viewed the strategy as workable. They recognized a business opportunity.

The December 2016 national elections led to a new political administration with a specific policy and new ministry supporting slum improvement. Early in 2017, a new AMA political administration came into office. These new government officers expressed their gratitude for the collaboration’s willingness to take on the challenge of sanitation in Old Fadama and immediately approved the stakeholders’ latrine permits, formalizing the long-awaited policy change for Old Fadama slum improvement.

Having previously assessed the collaboration’s proposal, the local sanitation businesses observed the city policy change and wanted to participate. This is where the research team discovered some surprising outcomes. As the cross-sector collaboration began latrine construction, other sanitation businesses, aware of the strategy, adopted the plans for latrine installation: on their own initiative and with their own resources, they began latrine construction in other areas of the slum. To date, six additional latrine and bathhouse blocks have been installed by local businesses (see Figure 12), investing their own resources and providing sanitation coverage in new areas of Old Fadama, providing another path toward local sustainability.

Figure 12 Latrines installed by local sanitation business

Thus, the strategic prioritization and planning process created a workable plan that external organizations eagerly adopted and began to implement on their own, to the benefit of the community. This was a very positive, yet unintended result for a community that had been so long frustrated with short-term projects led by internationally funded foreign investigators or collaborators. The previous projects resulted in time and resources taken from community members – but “nothing changed.” Now all stakeholders could point to their own project results and community empowerment, having engaged multiple AMA offices and the community chiefs as well as survey participants in site selection and management. Over time, the community leadership built trust in the other stakeholders and took over management of the latrines from the sisters. While the latrine block is not yet a sustainable enterprise, the research participants believed that local sanitation businesses created a path toward sustainability on the broader issue of sanitation in Old Fadama. These developments led the research participants to turn their attention to other priorities and create new strategies and projects in the pilot phase.

4.2.2 Outputs, Outcomes, and Impact Sought

Cross-sector collaboration is personal to its stakeholders and thus can lead to different kinds of effects (Reference Bryson, Crosby and StoneBryson, Crosby, & Stone, 2006; Reference Innes and BooherInnes & Booher, 1999; Reference MooreMoore, 1995). The research team tracked outputs – concrete products of the cross-sector collaboration. The outputs were fairly straightforward and reflected the latrine project strategy and results.

The research team also collected data on what the stakeholders wanted to see, plan, or observe to capture outcomes sought. This step was important to understand what kinds of outcomes and impacts would generate enthusiasm among the stakeholders to expand their participation in the future, better understand the root cause of challenges that needed to be addressed, and therefore plan strategically.

One important outcome that the process created was policy change, in that the AMA reversed its position on upgrading Old Fadama. While this outcome itself was important, it was even more important in light of the fact that the policy change began in one political administration and was formalized when a new government was elected. Many international development projects fail due to government transitions. In this case, the rigorous PAR process and relatively large (three hundred) number of stakeholders seemed to support policy change. The research team observed that policy change was important to the participants, and also possible in a relatively short period of time. Thus, seeking policy change when needed is a goal for future collaborations.

Another important outcome was that local sanitation business solutions attuned the stakeholders to the possibility of creating business solutions for other challenges. Given their focus from the beginning on sustainability, this learning was extremely important to the participants. Most of the new projects have a business component geared toward long-term sustainability.

The developed-country literature describes impact as including “the extent to which a cross-sector collaboration achieves its overarching and subsidiary purposes, meets applicable mandates, and achieves lasting and widespread benefits at reasonable cost that no single organization could have achieved alone in a democratically accountable way” (Reference Page, Stone, Bryson and CrosbyPage et al., 2015, p. 716). In this concept phase, we documented the impacts sought that had begun to be developed through straightforward, visible, stakeholder-driven and supported projects that everyone could agree were necessary and measurably useful. The impacts sought mirror the research participants’ earliest conversations and continue as their long-term goals.

5.2.1 Health

The PAR intervention yielded a LEAP health strategy, and then a project to conduct basic health screening, vaccination, and insurance enrollments for 300 kayayei women, with funding provided by this research project. Sr. Angelina Gerharz, SSpS, served as this project’s facilitator. The LEAP stakeholders identified a new stakeholder, the local government polyclinic, which purchased the vaccines at a discounted rate. Nurses from the Catholic Health Guild provided volunteer medical services. The National AIDS Control and Tuberculosis Control Programs were informed of the collaboration and saw an opportunity to provide services to a population they had been unable to reach and cost-shared the setup for the screening and insurance registration. In this way, the collaboration expanded the number of beneficiaries from 300 to 1,534 kayayei. They provided resources to screen five. The National Health Insurance Scheme (NHIS) was similarly invited to attend the screening and cost-share. The NHIS representatives were excited by these developments, joined the collaboration, and paid the fees so that rather than enrolling 300 kayayei, 1,789 indigent kayayei were enrolled in national health insurance in three locations—Old Fadama, Madina, and Ashanti Region.

5.2.2 Education

Sr. Faustina Hasford, SIJ, facilitates this LEAP intervention. Forty-two children of kayayei excelled at school but could no longer attend because their families could not afford the fees. This project supported the fees to re-enroll all of these students, with the condition that they and their families commit to keeping them in school. A key question is whether the parents’ migration will impact the children’s attendance. Once the education program is evaluated, the stakeholders will decide whether or not to allocate proceeds from their businesses – both the latrine project and others to be determined – to the education of kayayei children.

5.2.3 Microfinance

Sr. Matilda Sorkpor, HDR, facilitates the microfinance project. The kayayei association began this community-driven intervention several years prior to the LEAP project. Leaders in the kayayei community explained how microfinance has helped a number of kayayei transition from selling goods on the streets to setting up kiosks, shops, and other businesses and have asked for resources to expand the number of grantees. The stakeholders are investing in and documenting the program’s scale-up.

5.2.4 Skills Development and Training

Sr. Rita serves as the facilitator for this project. In the concept phase, all stakeholders were seriously concerned that projects in Accra would draw more people from their rural communities into the urban slums. Starting with data from kayayei in Accra who wanted to return to their homes rather than remaining in Old Fadama indefinitely, the LEAP stakeholders identified earlier conducted a number of focus groups in northern Ghana. They used purposive sampling to identify four communities in need. They met with the chiefs in these communities and offered to work with them to create skills development projects around kayayei who wanted to return home if these communities were willing to make an investment. The sisters received substantial land and labor donations from community elders to build a structure for two operations, sewing and shea butter production. The kayayei have finished their first harvest and have expressed that they are happy to be able to remain in their communities between planting cycles rather than returning to Accra. The project is being evaluated. At the same time, Sr. Rita and the LEAP stakeholders, working with NCHS evaluation officers, are planning for project sites in four communities, with a number of ventures based on kayayei interests: sewing, trading, shea butter production, and soap making.

As in the concept phase, the LEAP projects will be evaluated at the process level regarding the collaboration. The evaluation model will also assesses the impact on the challenges the kayayei identified and whether this meets their and the stakeholders’ goals (Reference Pawson and TilleyPawson & Tilley, 1997). This is the first example of the process scaling to new regions, so the research team as well as the broader technical team from NCHS will employ observational research and grounded theory to continue to evaluate these results.