PRESENTATION OUTLINE

1. Participatory Governance –An Approach for Improving Maternal Health Outcomes SWAP Review 2013Thumbiko Wa-Chizuma MsiskaCARE International in MALAWI

2. PRESENTATION OUTLINE • CARE in Malawi • Theory of change that guides CARE’s governance and Health • Design of Muuni WauchemebereWabwina • Community Score Card (CSC) • Community Scotrecrad Process • Achievements • Challenges • lessons learnt • Conclusion • Resource material

3. 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.

4. 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.

5. Sustainable Development with Equity Expanded, Inclusive & Effective Spaces for Negotiation Empowered Citizens Accountable & Effective Power Holders 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. For health this means… improvements in health coverage, quality and equity can be achieved.

6. Known Not Known How to prevent maternal mortality How to effectively & feasibly implement solutions (Implementation Science) 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 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 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???

7. MWWa 2012 -2015 MOH – RHU, HIV TWG District Health Office = Comparison 10 total = Treatment 10 total C T = Group Villages, Villages X = Excluded X District Go's Hospital CHAM Hospital T X Other Stakeholders Ministry of Youth , Community Development., BLM, District Health Network, FPAM Community level: Traditional Leaders Youth Clubs Community MNH committees T C T C T C T T C C Interface HF / Comm T T T C C C C C T

8. 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

9. Scorecard Process Scorecard process to identify implementation barriers & solutions: Scorecard Action Plan’s solutions implemented & studied: 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 Solution 1 Solution 1 Solution 2 Solution 2 • 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 • MNCH implementation and outcome improvements (menu of ‘high impact’ ideas) • Participatory Governance improvements • Action Planning: • Develop detailed action plan from prioritized issues • Agree on responsibilities in the action plan and set timeframes for activities

10. PHASE I:Planning and Preparation Set-up District partnership District mapping & site selection Focus area selection Train CSC facilitators CSC intro to health workers CSC intro for Local leaders CSC intro for community Community Mapping

11. CSC Process --- PHASE II: Conducting the Score Card with the Community  Issue generation Focus Group Participants Focus Group Discussion Issues Identified . • 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 Men Women • What is going well? • What is not going well? • What improvement is needed? Youth Local leaders Vulnerable groups

12. PHASE II: Indicator Development in the Community Scorecard template Indicator development

13. PHASE II: Community Scorecard scoring and consolidation Consolidated Community Score Card Community 1 Community 1 Consolidated Score Card Community 2 Community 2 Consolidated Score Card

14. PHASE III: Conducting the Score Card with Service Providers Nurses HSA Attendant Environ. Health officers Guards

15. PHASE IV: Interface Meeting & Action Planning Catchment Area Communities Joint Action Plan District Gov’t & Power holders Other NGOs & Service Providers Health providers

16. 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

17. 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

18. Challenges • Potential to be destructive if not properly handled-managing 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

19. 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

20. 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

21. 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.

22. Thank You! For more information contact: Country Director: Michael Rewald mrewald@co.care.org Project Manager: Thumbiko Msiska thumbiko.msiska@co.care.org