Output 3 Presentation: RMCH SteerCom, January 2015

Ellen HagermanSocial Development Direct-UK

Outline

1) Objective of Output 32) Background to Output 33) Outputs and Outcomes of Output 34) Added Value of the Work of Output 35) Legacy6) Recommendations7) Follow-up to RMCH for Output 3

1. Purpose of Output 3 in RMCHSupport the improvement of demand and accountability (D & A) for maternal and child health services at the community level by engaging civil society organizations (CSOs) through a grants mechanism to learn, document and disseminate innovative approaches to D & A.

Background to Output 3

Low uptake of MCH services due to barriers such as patient transport, long waiting times in clinics, cultural norms and negative attitudes of HWs

Weak systems of accountability Widening inequality: poor and marginalized women

have greater challenges with access Need for increased community engagement

Outputs: Grant-making

• 10 grants awarded: 4 large grants, 5 small grants, 1 special grant for FP song

• TA support to implementation including gathering & documenting lessons learned, preparation of products, planning for dissemination & added value

Overview of Outcomes against logframeIndicators Target by April 2015 Progress

Number of functional multi-stakeholder mechanisms supported by Civil Society Organisations(CSOs) in the 25 districts through the RMCH grants mechanism

15 multi-stakeholder mechanisms supported

28 multi-stakeholder mechanisms have been supported in 12 districts as part of the programme. ACHIEVED

Number of innovative initiatives that have been documented and shared in the form of mixed method tools across the 25 RMCH districts to improve demand and accountability for MNCWH services

10 mixed method tools developed 83 mixed method tools have been produced by grantees and RMCH Output 3 technical team. ACHIEVED

Number of grants provided to civil society organizations to improve Demand & Accountability of MNCWH services in the RMCH sector

10 10 grants. ACHIEVED

Outcomes re: the Inception BaselineFinding Response By Whom?

Cultural Barriers Testing an approach that fosters openness, joint prioritization of issues and action planning

FAMSA/ChoiceTrustRMCH Output 3

Weak Accountability Structures

1) Capacity Building of Clinic Committees2) Promoting Community engagement3) Fostering Mutual Accountability and joint ownership4) Taking issues to action

1) Black Sash & FAMSA2) Soul City3) Black Sash, Mindset &

FAMSA/ChoiceTrust4) Mindset, Black Sash &

FAMSA/ChoiceTrust

Teenage Pregnancy 1) Improving communication along the CoC2) Improving AYFS3) Addressing attitudes of HCWs4) Gathering an improved understanding5) Promoting the use of peer educators

1) CMT, Mindset, JHHESA2) THCA3) Mindset, THCA, SARC4) SARC, CMT, Mindset5) SARC

Weak Health Communications 1) Gathering information on preferred forms of communication

2) Testing innovative approaches

1) CMT, Mindset, JHHESA

Understanding and strengthening the key role played by CHWs

1) Testing CHW training2) Developing and delivering complementary training

1) FAMSA/ChoiceTrust2) CMT W2

Outcomes re: Inception BaselineFinding Response By Whom?Inefficiencies in the health system e.g. long queues

1) Testing the integrated model2) Gather information on patient behaviour

1) CRH2) SARC, CRH,

FAMSA/ChoiceTrust

Transport as a key barrier to demand

1) Testing, gathering evidence and documenting an innovative approach to transport

1) SARC

Need for a balanced focus between rights and responsibilities

1) Raising awareness about rights and responsibilities

2) Training on rights and responsibilities3) Giving space to HCWs and patients to recognize

their rights and responsibilities

1) Black Sash, Mindset, SCI2) Black Sash, Mindset3) Black Sash, Mindset

Addressing attitudes of HCWs 1) Providing psycho-social support2) Training of HCWs3) Gathering an understanding of the causes

1) ChoiceTrust2) Mindset, SARC, CMT3) THCA/CMT, Mindset, SARC

Need to link supply and demand

1I Training and awareness raising of the supply side2) Consultations that incorporate demand & supply3) Addressing issues from supply & demand perspective

1) Output 3 DCST training2) FAMSA/ChoiceTrust, Black

Sash, Mindeset3) SARC, FAMSA/ChoiceTrust

Grantees Outputs: Window Two Grantee Deliverables/Products

Soul City A model of community-based monitoring of MCH services

South Africa Red Cross Society-KZN Documentation of models and tools for peer education and CCG volunteers to prevent teenage pregnancy; case study and policy brief of transport fund’s impact and sustainability

Centre for Rural Health-UKZN A good practice case study on integration of MCH services

Community Media Trust A model on master training for CHWs/lessons learned for CHWs/Tools and modules on MCH for CHWs

FAMSA Policy brief on improving DOH training for CHWs; a model of psycho-social support for CHWs and health professionals; tools for district clinic committees

Grantees Outputs: Window OneGrantee Deliverables/Products Community Media Trust/THCA District-based communications strategy on

teenage pregnancyy; family planning and early antenatal booking brochures ; recommended interventions to improve the delivery of youth-friendly services

Mindset Network & Population Council District-based communications strategy on teenage pregnancy; family planning and EANC; district based tools and policy briefs to facilitate multi-stakeholder forums to improve accountability in the health sector

Black Sash Trust Case study, model and polcy brief on good practices of public and alternative accountability in the district health system. Training manual for clinic committees

JHHESA Tools, models and policy briefs on health communications for districts; district-based MCH communications strategies in 3 districts (Central Karoo, Waterberg & Ekurhuleni)

Output 3 Outputs

• Training manual to address attitudes of Health Workers towards teen clients as well as for teens to reflect on their own roles and responsibilities: pilot tested in 6 districts

• Consultation guides on culture and malnutrition and analysis of findings: pilot tested in 2 districts

• Fact sheets and knowledge sharing re: NGOs working on teen pregnancy

• Training of DCSTs in 8 provinces on demand & accountability and community mobilization

Output 3 Outputs

• Web site: D & A documents uploaded; listserv• Research & analysis & documentation of D & A issues to

complement grant work e.g. teenage pregnancy; malnutrition; drivers of child mortality

• Pattern Analysis: Gathering information and analyzing trends of key D & A issues for evidence & guidance for follow-up

• Input into NDOH MCH initiatives e.g. AYFS policy

Legacy: Community Engagement on D & A

a. GRANTS PROGRAMME: D & A initiatives in 17 districts b. NETWORKS of LEARNING:

1. Teenage pregnancy: Ugu, uMgungundlovu, Gert Sibande 2. EANC/PNC/Action Plan: Capricorn & Mafikeng; 3. Drivers of Child Mortality/Action Plan: Uthungulu; Ugu4. Peer Education: Ethekwini (included Ugu,

uMgungundlovu and Uthungulu)

c. DCST TRAINING: on community mobilization in Limpopo

Legacy: Greater Understanding of D & A1. DCST have greater awareness of D & A and how to integrate into

supply-side work2. Findings on Patient and Teen Behavior have been shared e.g.

presentation of findings to universities3. Input into NDOH initiatives e.g. AYFS Policy & Strategy, work on

clinic committees, health communications4. More detailed and robust understanding of demand barriers:

teen pregnancy, EANC/PNC, cultural practices and Drivers of Child Mortality

Legacy: Tools1. 28 mixed method tools from grantees on D & A2. Training Manual to address attitudes of health

workers towards teens: pilot tested in 5 districts and delivery of Training of Trainers program

3. Consultation guides on culture & malnutrition4. Pattern Analysis on: 1) culture; 2) malnutrition; 3)

teen pregnancy to provide evidence on demand barriers

5. Fact Sheets/Info on teen pregnancy

Legacy: Strategies to engage on D & A

1. Strategy to address cultural barriers & malnutrition

2. Strategy on linking supply and demand3. Strategy on Accountability: Partner

Defined Quality (PDQ) Model

Lessons Learned: DEMAND

• “Just because you fix it, patients may still not come” • Constant reality checks grounded in patient and

community perspectives are needed • Information provision is not behaviour change• Issues such as teenage pregnancy are not just a

medical/ health issue but social and economic• Demand-side evidence is not only qualitative

Lessons Learned:ACCOUNTABILITY

• Make all voices count• Give voice to the health system • Accountability is a two-way street• Demand and accountability are

interdependent

Lessons Learned: Technical Assistance• More flexibility should be built into such projects from the inception

stage to accommodate and adjust for the right mix of skills within consultant team.

• RMCH’s strategic investments in LOE and TA support to partners demonstrate that sufficient LOE is required to develop tailored capacity building programs and provide on-going TA and mentorship

• The placement of TA in the field is needed to integrate D & A into all aspects of MCH services and delivery

• More technical support and capacity building needs to be provided to district personnel on issues of D & A

Recommendations: Accountability• Accountability approaches should:

Be a balanced focus on rights and responsibilities from both the patient and HW perspective to move away from the patients as passive beneficiary and to reduce HW backlash

Foster mutual dialogue & prioritization to foster collective action

• Clinic committee training should equip stakeholders with a range of practical tools that can be adapted to tackle the real-life issues of communities

• To ensure that community accountability dialogues & collective problem solving are taken to action, follow-up support is required

Recommendations: DEMAND

• Pilot test health communications material and strategies• Understanding and addressing root causes is a key first

step to identify and tackle demand barriers• Undertaking action research on demand barriers at the

community level is key to cross-checking supply actions• Allocate more resources to understanding and addressing

demand-side barriers – this will often contribute to some of the most cost-effective solutions and interventions

Recommendations:PROGRAM DESIGN• Lessons and best practices should be shared across borders with

other Southern Africa countries that share similar MCH challenges – learn from the innovations of others!

• Innovation requires an openness to learning from failure• Innovation is as much about doing things differently as it is about

doing something new• The baseline process should gather more disaggregated data (on

vulnerable groups, violence against women and girls, social determinants of health, etc.) to produce targeted interventions that address the needs of the most marginalized people.

Recommendations:PROGRAM DESIGN

• There is much to be learned from the successes of better-performing districts - interventions should not just target the weakest districts

• For a learning grant to produce richer, more compelling evidence, a focus on fewer innovation districts makes sense (to be able to go more deeply into a targeted range of priority issues)

FOLLOW-UP

• Further capacity-building around integration of D & A at district and national level

• Follow-up with grantees to gather lessons learned and best practices and secure additional funding to enable them to continue work on MCH activities on D & A

• Review and disseminate grantee products as well as additional tools developed on D & A

• Build on the work done on teenage pregnancy as a critical MCH issue for all districts e.g. roll-out of HCW for Teens

FOLLOW-UP• Networks of Learning follow-up: taking action

plans to action• Continued support to DOH & districts• Strengthen and promote partnerships &

networks e.g. on teen pregnancy• Undertake follow-up research on key demand

issues e.g. cultural practices, malnutrition• Explore ways to integrate traditional and

allopathic health systems

Motto of Output 3

“If you fix it, they still may not come”