Participatory Governance –An Approach for Improving Maternal Health Outcomes

SWAP Review 2013

Thumbiko Wa-Chizuma MsiskaCARE International in MALAWI

PRESENTATION OUTLINE

1. CARE in Malawi2. Theory of change that guides CARE’s governance

and Health 3. Design of Muuni Wauchemebere Wabwina4. Community Score Card (CSC)5. Community Scotrecrad Process6. Achievements7. Challenges8. lessons learnt9. Conclusion10.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.

improvements in health coverage, quality and equity can be achieved.

CARE’s Theory of Change on Governance and Health Outcomes

• ‘Theory of Change' to guide and underpin CARE's governance outcomes:

If citizens are empowered,

if power holders are effective, accountable and responsive,

if spaces for negotiation are expanded, effective and inclusive,

= then sustainable and equitable development can be achieved.

5

Accountable & Effective

Power Holders

EmpoweredCitizens

Sustainable Development

with Equity

Expanded, Inclusive

& Effective Spaces for Negotiation

Alliance for Improved MNH Outcomes

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

MDG 5. Maternal Mortality Ratio still unacceptably high in many countries; Source Estimates of MM levels 1990-2008 WHO/UNICEF/World Bank 2010

(Implementation Science)

Known Not KnownHow to prevent maternal mortality

How to effectively &feasibly implement

solutions

Goal:

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???

2011

MWWa 2012 -2015 MWWa 2012 -2015

Interface HF /

Comm

DistrictGo's

Hospital

T

T

T

C

T

C

C

T

T

X

C

C

C

X

C

CHAM Hospital

District Health Office

T

T

T

T

C

C

C

MOH – RHU, HIV

TWGX

CT

= Treatment 10 total

= Comparison 10 total

= Excluded = Group Villages,Villages

Other Stakeholders Ministry of Youth , Community Development., BLM, District Health Network, FPAM

Community level:Traditional LeadersYouth ClubsCommunity 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:

Community Scorecard: Community level assessment of priority health issues Develop indicators for assessing priority issuesComplete scorecard by scoring against each indicatorGenerate suggestions for improvementConsolidate Scores to come up with community representative scorecard

Health center level Scorecard: Conduct assessment of health service provision – barriers to quality service deliveryDevelop indicators for quality health service provisionComplete scorecard by scoring against each indicatorGenerate suggestions for improvement

Interface meeting:Communities and service providers present their findings from scorecardCommunities and service providers present priority health issuesIssues prioritized jointly in a negotiated manner

Preparatory Groundwork and Organization

Action Planning: Develop detailed action plan from prioritized issuesAgree on responsibilities in the action plan and set timeframes for activities

Scorecard Action Plan’s solutions implemented & studied:

Solution 1

•MNCH implementation and outcome improvements (menu of ‘high impact’ ideas)• Participatory Governance improvements

Solution 1

Solution 2 Solution 2

Focus area selectionSet-up District partnership District mapping & site selection

CSC intro to health workers

Community Mapping

CSC intro for Local leaders

CSC intro for community

Train CSC facilitators

PHASE I:Planning and Preparation

Focus Group Participants Focus Group Discussion Issues Identified .

Women Men

Local leaders

Youth

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

CSC Process --- PHASE II: Conducting the Score Card with the Community Issue generation

PHASE II: Indicator Development in the Community

Indicator Score Reason

1. Availability and accessibility to information (MNH, FP, PMTCT)

2. Level of male involvement in MNH, FP, PMTCT

3. Level of youth involvement in reproductive health issues

4. Reception of clients at the facility

5. Relationship between providers and communities

6. Health seeking behavior

7. Fertility levels

8. Commitment of service providers

Indicator development

Scorecard template

PHASE II: Community Scorecard scoring and consolidation

April 21, 2023

13

Community 1 Consolidated Score Card

Community 2Consolidated Score Card

Consolidated Community Score Card

Indicator Score 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

20 -Youth not welcome in clinic for FP issues

4. Reception of clients at the facility

25 -Sometimes clients are turned away -No formal queuing system

5. Relationship between providers and communities

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

Nurses

HSA

Attendant

Environ. Health officers

Guards

PHASE III: Conducting the Score Card with Service Providers

PHASE IV: Interface Meeting & Action Planning

15

Other NGOs & Service Providers

Action Items

Process Resources Required

Responsible Time frame

Joint Action Plan

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

ChallengesPotential to be destructive if not properly handled-

managing emotions vs building relationshipsCreating 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 ConclusionCARE’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.

April 21, 2023

21

Thank You!

For more information contact:Country Director: Michael Rewald

mrewald@co.care.org

Project Manager: Thumbiko Msiskathumbiko.msiska@co.care.org