Transcript Slide 1

Participatory Governance –
An Approach for Improving
Maternal Health Outcomes
SWAP Review 2013
Thumbiko Wa-Chizuma Msiska
CARE International in MALAWI
PRESENTATION OUTLINE
1. CARE in Malawi
2. Theory of change that guides CARE’s governance
and Health
3. Design of Muuni Wauchemebere Wabwina
4. Community Score Card (CSC)
5. Community Scotrecrad Process
6. Achievements
7. Challenges
8. lessons learnt
9. Conclusion
10.Resource material
CARE in Malawi
• Established in 1998, working in food security,
health and education sectors with women’s
empowerment underpinning all our programs
• Our vision is to seek a world of hope, tolerance
and social justice, where poverty has been
overcome and people live in dignity and security.
• Through our mission, we strive to serve
individuals and families in the poorest
communities in the world, promote innovative
solutions and advocate for global responsibility.
Our Approach
• We promote lasting change by:
• Strengthening capacity for self-help
• Providing economic opportunity
• Delivering relief in emergencies
• Influencing policy decisions at all levels
• Addressing discrimination in all its forms
• Guided by the aspirations of local communities, we
pursue our mission with both excellence and compassion
because the people whom we serve deserve nothing
less.
CARE’s Theory of Change on
Governance and Health Outcomes
Sustainable
Development
with Equity
• ‘Theory of Change' to guide and
underpin CARE's governance
outcomes:
If citizens are empowered,
Expanded,
Inclusive
& Effective
Spaces
for Negotiation
if power holders are effective,
accountable and responsive,
Empowered
Citizens
 if spaces for negotiation are
expanded, effective and inclusive,
Accountable
& Effective
Power Holders
= then sustainable and equitable
development can be achieved.
For health this means…
5
improvements in
health coverage,
quality and equity
can be achieved.
Alliance for Improved MNH Outcomes
2011
MDG 5. Maternal Mortality Ratio still unacceptably high in many countries; Source
Estimates of MM levels 1990-2008 WHO/UNICEF/World Bank 2010
How to prevent maternal
mortality
How to effectively &
feasibly implement
solutions
Goal:
Known
Not Known
(Implementation Science)
Develop broadly applicable strategies, tools, approaches and methodologies for systematically
improving implementation of evidence-based MNH and HIV strategies to maximize reductions in
maternal and newborn deaths and maternal to child transmission of HIV infection
Q: Will a governance approach through the Scorecard process improve MNH, FP,
and PMTCT outcomes of interest (coverage, quality, equity) through changes in
implementation and utilization of services???
MWWa 2012 -2015
MOH –
RHU, HIV
TWG
X
District Health Office
X
District
Go's
Hospital
T
X
T
T
T
T
C
C
C
= Group Villages,
Villages
T
Interfac
e HF /
Comm
T
C
= Comparison
10 total
Other Stakeholders Ministry
of Youth , Community
Development., BLM, District
Health Network, FPAM
T
T
= Excluded
C
CHAM
Hospital
C
C
C
= Treatment
10 total
T
C
C
C
T
Community level:
Traditional Leaders
Youth Clubs
Community MNH committees
What is the Community Score Card
(CSC) ?
• The CSC is a participatory governance tool…
• that brings together community members, service
providers, and local government to identify service
utilization and provision challenges, and to mutually
generate solutions, and work in partnership to
implement and track the effectiveness of those
solutions in an ongoing process of quality improvement
Underlying Rights Based
Principles
 Participation and
inclusion of voice
 Accountability and
transparency
 Equity
 Shared responsibility
Scorecard Process
Scorecard process to identify implementation barriers & solutions:
Preparatory Groundwork and
Organization
Community Scorecard:
 Community level assessment of priority
health issues
 Develop indicators for assessing
priority issues
Complete scorecard by scoring against
each indicator
Generate suggestions for improvement
Consolidate Scores to come up with
community representative scorecard
Health center level Scorecard:
 Conduct assessment of health service
provision – barriers to quality service
delivery
Develop indicators for quality health
service provision
Complete scorecard by scoring against
each indicator
Generate suggestions for improvement
Interface meeting:
Communities and service providers present their findings from
scorecard
Communities and service providers present priority health issues
Issues prioritized jointly in a negotiated manner
Action Planning:
 Develop detailed action plan from prioritized issues
Agree on responsibilities in the action plan and set timeframes for
activities
Scorecard Action Plan’s solutions
implemented & studied:
Action
Act
Learn
Plan
Solution 1
Action
Act
Plan
Solution 1
Study
Do
Study
Act
Plan
Act
Solution 2
Study
Do
Learn
Do
Plan
Solution 2
Study
Do
•MNCH implementation and outcome
improvements (menu of ‘high impact’
ideas)
• Participatory Governance
improvements
PHASE I:Planning and Preparation
Set-up
Train CSC facilitators
District partnership
CSC intro to
health workers
Focus area selection
CSC intro for
Local leaders
CSC intro for
community
District mapping
& site selection
Community
Mapping
Process
FocusCSC
Group Participants
---Focus
PHASE
Conducting the
Score
Card with the .
GroupII:Discussion
Issues
Identified
Community  Issue generation
Women
Men
Youth
Local leaders
Vulnerable
groups
1. What is going well?
2. What is not going
well?
3. What improvement
is needed?
•Lack of space in maternity-no
waiting home, few delivery beds
•Poor male involvement and
support
•Family planning myths and norms
•Favoritism when treating clients
•Disrespectful treatment of women
•Poor relationship between health
workers and communities
•Poor DHMT supervision and
response to other issues
•Shortage of staff
•Shortage of drug supplies, gloves,
test kits for HIV, hospital linen
•Payment for services that are
supposed to be free
•Health facility hours
PHASE II: Indicator Development in the Community
Scorecard template
Indicator development
Indicator
1.
Providers
laugh at my
beliefs
6.
Availability and accessibility
to information (MNH, FP,
PMTCT)
Level of male involvement in
MNH, FP, PMTCT
Level of youth involvement in
reproductive health issues
Reception of clients at the
facility
Relationship between
providers and communities
Health seeking behavior
7.
Fertility levels
8.
Commitment of service
providers
2.
Providers don’t 3.
listen to my
concerns
4.
Providers yell
at me
Relationshi
p between
providers
and
community
5.
Score
Reason
PHASE II: Community Scorecard scoring and
consolidation
Consolidated Community Score Card
Community 2
Community 1
Indicator
Community 1
Consolidated Score Card
Community 2
Consolidated Score Card
13
Score
Reason
1.Availability and
accessibility to
information
40
-MNH available at health
center
-No community based MNH
2.Level of male
involvement in
MNH, FP, PMTCT
3. Level of youth
involvement in
reproductive health
issues
20
-Men do not birth plan with
wives
15
-Youth are kept out of
discussions about health
-Youth turned away from
clinic
4.Reception of clients
at the facility
25
-Clients are not treated
equitably
5.Relationship
between providers
and communities
15
-Women are yelled at if come
late for birth
-Women are treated with
disrespect at clinic
6.Health seeking
behavior
30
-Women attend ANC
regularly, but not early
7.Fertility levels
20
-Women start childbearing
too early
-Women have too many
births
8.Commitment of
service providers
35
-Providers do not come to
July 17, 2015
work on time
PHASE III: Conducting the Score Card with
Service Providers
Nurses
HSA
Attendant
Indicator
Guards
Reason
1.
Availability and accessibility to
information)
60
-MNH available at health center
-No community based MNH
2.
Level of male involvement in
MNH, FP, PMTCT
10
-Men do not go for HIV testing with wives
-men do not present themselves for counselling
on PMTCT,
3.
Level of youth involvement in
reproductive health issues
Reception of clients at the
facility
Relationship between
providers and communities
20
-Youth not welcome in clinic for FP issues
25
-Sometimes clients are turned away
-No formal queuing system
20
-Women do not listen to providers
-traditional leaders and community do not take our
advice; we are strangers to their community
6.
Health seeking behavior
30
-Women come to ANC late
-Women do not follow-up for PMTCT
7.
Fertility levels
20
-Women start childbearing too early
-Women have too many births
8.
Commitment of service
providers
35
-Providers do not come to work on time
-Providers don’t provide 24/7 care
-Providers not compensated for work
9.
Availability of supervisory
support (for the health center)
20
-Supervisors only meet with staff 1-2 times a year
-Supervisors are not responsive to health center
needs
-Supervisors do collect reports and provide
supplies
- Do not use standard tools for supervision
4.
5.
Environ.
Health officers
Score
Health providers
District Gov’t &
Power holders
Catchment Area
Communities
PHASE IV: Interface Meeting & Action
Planning
Joint Action Plan
Action
Items
Other
NGOs &
Service Providers
15
Process
Resources
Required
Responsible
Time
frame
Achievements
Created space for negotiation and understanding
between the service providers and users - promoting solution
in joint and participatory manner. ‘ we can raise our concerns
with health workers through these forums without leading to
reprisals/retribution’ woman from Kasinje HC
Enhanced the culture of accountability among providers
in a negotiated manner e.g. health workers feeling
obliged to explain to service users on like drug stock outs
Enhance collective responsibility to address barriers to
delivery and utilization of quality service; development of
negotiated joint action plans
Achievements
Enhanced collaboration of various stakeholders at different
levels – Various Stakeholders including parliamentarians,
Traditional leaders, other NGOs in the health sector engaging
to identify issues arising from scorecard process
Promoted realization of ownership of public entities
including Health facilities. One chief from Ntcheu said during
an interface that he now appreciates that the community owns
the facility shown by their assessment of performance
Enhanced knowledge of District managers on local issues
affecting service utilization and delivery. DNO for Ntcheu said:
This process is enlightening we didn’t know what is happening
in our facilities, we just need to act now.
Communities venturing into other developmental initiative
outside the health sector – proceeds from by-laws supporting
vulnerable pregnant women, VSL
Challenges
Potential to be destructive if not properly handledmanaging emotions vs building relationships
Creating demand which does not match with the
available resources (human and material)
Buy-in among authorities leading overwhelming
demand for scale up vis a avis limited resources or
conflicting with research agenda
Culture of protecting domains of power/influence
especially among power holders – resistant to
creation of spaces for negotiation
Demonstrating Impact of the scorecard
Lessons Learned
Provided practical and negotiated ways for engagement of
various stakeholders at different accountability levels and
strengthened decentralization - Community, Health Center,
District and Policy level
 Issues generated – being valued for grassroots based
evidence for advocacy e.g. parilamentarians convinced of their
role to influence resource allocation to the district and health
sector, LDF fund to include health interventions ??
Replicable and sustainable e.g. Dowa experiences where
community members are using it (three years after CAREs pull
out) with traditional leaders to monitor performance of
developmental activities and challenge providers and traditional
Potential for use in various sectors and political contexts,
agriculture natural resources, health, education in different
countries
Creates pool of information for further research endeavors
In Conclusion
CARE’s experience has shown that the CSC can be used
 As a tool to improve service implementation
 As a tool to improve service quality (like respectful
care, etc.)
 As a mechanism for enhancing accountability in
service delivery (at local level)
 As an approach to strengthening local governance
with a human rights lens.
 As a tool for strengthening decentralisation
 As an approach for engaging policy makers in local
level processes
 As an approach to generate evidence for advocacy
purposes
Products from the project
• Activity and quarterly report
• CARE’s Community Score Card (CSC) Toolkit – this toolkit
(originally developed by CARE Malawi) outlines the CSC
methodology.
• CSC Guidance Notes - these guidance notes include
CARE CSC experts’ practical recommendations on
implementing the CSC.
• CSC Community of Practice Wiki –CARE’s work with the
CSC.
21
July 17, 2015
Thank You!
For more information contact:
Country Director: Michael Rewald
[email protected]
Project Manager: Thumbiko Msiska
[email protected]