Evidence of Social Accountability_Thumbiko Misiska_5.7.14
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  • -the practice around what to deliver in MNH is well established is well established, but despite this evidence approx. 800 women die everyday from pregnancy and childbirth amounting to 287,000 maternal deaths a year. In Malawi, a women’s lifetime risk in of maternal death is 1 in 36 (MMR is 460 in 100,000 live births) (WHO - http://www.who.int/gho/maternal_health/countries/en/index.html#M)-PMTCT. The transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is called mother-to-child transmission. Yearly there are 430,000 new pediatric HIV cases a year do to MTCT. In the absence of any interventions transmission rates range up to 45%. This rate can be reduced to levels below 5% with effective interventions.In addition, HIV contributes to 42,000 maternal deaths yearly & in Malawi is responsible for 29% of all maternal deaths. Number of maternal (2009 http: //apps. who.int/iris /bitstream/10665 /75341/1/9789241504270_eng.pdf) & (http://www.who.int/hiv/topics/mtct/en/) & -Family planning- Use of modern methods of family planning will prevent more than a third of maternal deaths and ten per cent of child deaths. Worldwide 222M women have an umet need for contraceptives. In Malawi, 26% of women who want to use contraceptives cannot get them. This translates into an unacceptably high number of unintended pregnancies with all the risks that comes with it. ((TFR) in Malawi is 5.7, quarter of teens have begun childbearing).
  • Ntcheu district – 471,589 population with 23,579 expected births annually Cluster – randomized control evaluation10 intervention clusters 20 intervention GVHs selected using probability proportional to size (PPS). These will participate in the intervention and baseline. (Pop = 58,164) 20 spillover GVHs selected using (PPS). These will only participate in the baseline. (Pop = 69,450)10 control clusters 20 control GVHs selected using (PPS). These will only participate in the baseline (Pop = 68,241)
  • The CSC consists of 5 phases: I- Planning and preparation, II- Conducting the Score Card with the community, III- Conducting the Score Card with service providers, IV- Interface meeting and action planning, and V- Action plan-The CSC is done between a service user unit and service provider unit – in our case between the health center and catchment area-CSC process is not a one off process but done repeatedly every 6 months
  • Created space for engagement between the service providers and usersEnhanced communities knowledge and demand for entitlements in a subtle manner- starting from the analysis of issues hindering delivery and accessibility of services. Enhanced the culture of accountability among providers in a negotiated mannerEnhance collective responsibility to address barriers to delivery and utilization of quality service.

Evidence of Social Accountability_Thumbiko Misiska_5.7.14 Evidence of Social Accountability_Thumbiko Misiska_5.7.14 Presentation Transcript

  • Community Score Card Evidence of Impact in Malawi Thumbiko Wa-Chizuma Msiska Project Manager CARE Malawi
  • Presentation Outline 1) Background on project utilizing the Community Score Card (CSC) in Malawi 2) CSC Evaluation 3) Community Score Card Process 4) Evidence of Impact to date 5) Challenges
  • What we want to achieve? Why are women still dying in childbirth? What is needed?
  • Maternal Health Alliance Project Intervention: Community Score Card (CSC) Goal: develop & test broadly applicable approaches to improve family planning and maternal health implementation and outcomes. Maternal Health Alliance Project (2011-2015) Supported by Sall Family Foundation Location: Ntcheu district, Malawi  social accountability approach innovated by CARE in 2002
  • Evaluation -10 intervention health facilities w/ catchment communities -10 control health facilities w/ catchment communities Mochocho Chiwfiri Yesaya Kasinje Health Facility
  • Evaluation Components Component Target population Sample size Women’s survey (& medical chart review) Women who have given birth within the last year 1950 total: -650 treatment -650 comparison -650 spillover areas in treatment Health worker survey All health workers in treatment and comparison catchment areas ~327 (all health workers in treatment and control)
  • Theory of Change Accountable, effective, responsive service providers & policy makers Women & community members empowered Maternalandnewbornmortality Health behaviors Health service coverage, quality & equity Negotiated space expanded & inclusive and effective Community Score Card
  • Intervention: Community Score Card A social accountability approach that brings together community members, service providers, and local government to  identify service access, 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 improvement Underlying Rights Based Principles  Participation and inclusion of voice  Accountability and transparency  Equity  Shared responsibility
  • PHASE II: Conducting the Score Card with the Community PHASE IV: Interface Meeting and Action Planning PHASE I: PLANNING AND PREPARATION PHASE III: Conducting the Score Card with Service Providers Repeatcycle PHASE V: Action Plan Implementation and M&E Catchment Community Health providers Local gov’t & decision makers MethodologyIndicator Score Sample Reasons for Score 1- Referral system – availability of transportation for pregnant women from health center to hospital 45 Ambulance is rarely available in cases of emergency  Providers make clients use public transport  2- Availability of transport from the community to the health facility 20  Long distance to health facility  Sometimes women delay doing to the facility during delivery 3- Availability of resources (i.e. drugs, supplies, space) 50 HIV test kits stock outs occur regularly  Clients told to buy medication which should be free  4- Availability and accessibility of health services (MNH, FP, PMTCT) 80 Most service are available  FP long acting term methods provided rarely No MNH services provided in community 5- Availability and accessibility to information 80 The messages are only available at the health facility not in the community  6- Level of male involvement in MNH, FP, PMTCT 50 Few men accompany their wives to antenatal care  Most men refuse HIV test 7-Level of youth involvement in reproductive health issues 10  There are no youth clubs so most youth have little information on family planning, MNH or youth friendly services 8-Reception of clients at the facility 40 Some health workers have good attitudes and respect clients  Some women are shouted at during delivery 9- Relationship between providers and communities 40 There is no health advisory committee or village health committee  Meetings between health providers and clients is rare
  • Example Actions Resulting from CSC Process… May 13, 2014 10 -Train community health workers on MNH issues -Train Community Action Groups -Reflection session with district gov’t partners -Follow-up on action plan implementation, keep diary, review health facility data
  • Evidence of Impact
  • Improvements in Score Card Indicators (ex. Relationship between providers and communities) Indicator Score Dec 2012 Score Jun 2013 Score Dec 2013 1- Referral system 2- Availability of transport from the community to the HF 3- Availability of resources (i.e. drugs, supplies, space) 4- Availability and accessibility of health services 5- Availability and accessibility to information 6- Level of male involvement in MNH, FP, PMTCT 7-Level of youth involvement in reproductive health issues 8-Reception of clients at the facility 9- Relationship between providers and communities Mochocho Chiwfiri Yesaya Kasinje Health Facility
  • Improved relationship and communication between service users and providers increased demand for services 0 10 20 30 40 50 60 70 80 90 Health Workrs Mchocho Chifwiri Yesaya Relationship between users and providers 12-Dec Relationship between users and providers 13-Jun Relationship between users and providers 13-Dec
  • The challenges and complexities of using CSC? • Potential to be destructive if not properly handled-managing emotions vs building relationships • Constrained resource environment (human and material) failing to meet the generated demand • Culture of protecting domains of power/influence especially among power holders – resistant to creation of spaces for negotiation • Limited policy influencing due to following the small evidence base- only one of the 28 districts covered • Chiefs/committees being gatekeepers on who participates in the CSC
  • For more information contact: Michael Rewald CARE Malawi Country Director mrewald@co.care.org Thumbiko Msiska MHAP Project Manager thumbiko.msiska@co.care.org