Phase I: Defining the Need for Change

Changing the way things are done can upset existing balance and power structures, and some stakeholders might feel threatened. Political will and support must be strong to overcome such challenges. In Phase I of the process, the coordination team recognizes that a practice or set of practices is causing a problem and needs to be changed if the program is to meet its health goals. The team then identifies the underlying reasons that the problematic prac­tices persist. They reformulate the problem as a challenge by asking, “How can we achieve the desired result in the face of the obstacles we have to overcome?” This turn of phrase provides the context within which to move positively towards needed change.

Step 1. Identify the problem

Establish the need for change and the reasons for making that change in order to cultivate ownership of the change process ahead. The activities in this step turn complaints into positive actions and focus on causes rather than symptoms to set a foundation for sustainable changes.


  • Leaders can be reluctant to highlight problems within their organization.
  • Demonstrating that change is beneficial and should be prioritized can be difficult.
  • Reaching agreement on one practice or set of practices to prioritize for change can be challenging.
  • It is important to thoroughly explore the reasons for the problem and not settle for superficial analysis.
  • Discouragement can lead to inactivity.

Underlying causes of the challenges

  • Leaders sometimes feel that they are expected to have ready answers for all problems.
  • Some people are open to change, while others are not.
  • The negative impact of the current practice on service performance might not be widely understood.
  • Different perspectives will yield conflicting views of which practices are most detrimental to performance.
  • Some influential people might be benefiting, directly or indirectly, from the current situation.
  • It is not always easy or comfortable to look below the surface of a problem, name the fac­tors that are causing it and actively seek ways to address those factors.
  • Without analysis, the cause of the problem is not well understood.

Key activities to address the challenges

  • Discuss with the team the impact of various practices on performance and, ultimately, on the population to be served.
  • Reach consensus on one practice or set of practices that, if changed, could make a big impact.
  • Analyze the root causes of the persistence of the practices.
  • Reframe the problem as a challenge to be overcome, and encourage team members to share this information with appropriate staff in their own organizations or units.
  • Work with organizational leaders to identify and eliminate or significantly reduce the benefits gained from maintaining the undesirable practice.
  • Understand and address the psychology related to resistance to change.
  • Consider sustainability from the beginning as well as during later scale up stages.

Step 2. Identify and agree on the desired change, its purpose, the antici­pated results and the potential obstacles.

This step gives everyone on the coordination team a common goal and acknowledges that meaningful change will require coordinated effort and is seldom easy. 


  • Enabling people with different institutional or program perspectives to agree on one change or set of changes that they will undertake together.
  • Fostering a belief in and enthusiasm for the agreed-upon change that will persist through­out the process.

Underlying causes of the challenges

  • Cultural, political or professional differences can result in divergent views of how best to institute the change or whether it is needed or desirable. 
  • People are weary of unsuccessful change efforts and skeptical that meaningful change will happen.

Key activities

  • Emphasize that there might be a few options in your approach to change.
  • Openly and respectfully discuss the different views on the desired change.
  • Identify one changed practice or set of practices that all participants agree has the potential to improve their organizations or programs.
  • Ask the questions: Why are we doing this? How will service providers and their clients benefit? What challenges lie ahead?
  • Clarify what success will look like and how everyone will know it has been achieved.
  • Use examples of successful changes to counter skepticism.