Key Messages from the End-line Evaluation. Malawi Health Sector Programme – Technical Assistance Component

1. Health Centre Advisory Committee (HCAC)
Pilot Capacity Strengthening Project
Key Messages from the End-line Evaluation
BRIGHT B. SIBALE
CENTRE FOR DEVELOPMENT MANAGEMENT
P.O BOX 301810
LILONGWE 3
BBSIBALE@GMAIL.COM

2. Introduction
HCAC pilot conducted in three districts: Mulanje (4 facilities), Mwanza (3
facilities) and Rumphi (4 facilities) in 2016 and 2017
The aim was to strengthen community-facility level engagement in health sector
governance.
Scale up of pilot in 2017/18:
• 9 additional facilities in Rumphi
• Two rounds Community Score Card (CSC) to increase HCAC effectiveness and
community engagement, in Mwanza and Rumphi
• Health Centre Improvement Grants (HCIG) piloted in three sites in Mwanza
• Evaluations: Baseline (2016), Midline (2017) and Endline including SROI
(2018)

3. Evaluation questions and findings
Improvements in HCAC functionality: regular meetings; signed minutes; action points
documented and followed up; DMSC utilising drug monitoring tools
Improvements in facility functionality: use of facility functionality form led to higher morale
among staff, longer opening hours, reduced waiting time & improved relationship with
community
Improvements in drug accountability: signing off on drug deliveries, DMSC involvement in
monthly drug inventory, enforcement of 3 lock system; following up with discrepancies
Improvements in duty bearers’ responsiveness: HCACs engaging with VDC, ADC, MPs and
Councillors; lobbying for funds to make improvements; health sector opening up to other funding
sources
National and District Level Influence: HCACs more visible; aligned to CHSS; articulated in NCHS;
HCAc TOR, guidelines and training manual developed
Economic Return/SROI: Investing in HCAC training and mentoring is a good return on investment.

4. Key SROI findings (original 4 Rumphi HCACs)
Social Return on Investment/SROI calculates and applies a monetary value to social
and economic achievements of the HCACs e.g: successful lobbying, repairs, getting
bills paid etc.
When the cost of the project was deducted, and converted into an ratio, the SROI
ratio was Mk8.45 : Mk1.
For every 1Mk invested by the HCAC pilot, a social value of Mk8.45 was created,
with a payback period of 4 months.

5. Key HCIG outcomes (3 Mwanza HCACs)
All HCACs completed planned purchases and constructions within 1.5 months of receipt of the grant funds
(MK500,000 per facility)
HCACs were able to act rapidly and get quick results
HCACs found cost effective ways of achieving their outcomes
Transparency of expenditure and public access to information meant strong sense of ownership and little
opportunity for abuse of resources
Community control over health spending empowers them to fulfil their responsibilities
How HCACs used their grants
 Tulonkhondo built 3 toilets including one for the maternity ward. They budgeted Mk500,000 and spent Mk470,000.
 Kunenekude completed a maternity unit toilet and bathroom (Mk410,000). With the remainder they built an access ramp to OPD
 Thambani bought minor medical equipment and stationery, including a blood pressure machine, torches, rechargeable batteries.
 HCACs also spent small amounts on minor maintenance - fixing door handles and locks to enhance facility security.
 A 10% budget limit was placed on administration costs

7. CSC contribution
Community members became more engaged and supportive
HCACs became more effective
District officials became more responsive
CSC process helped service users, service providers, HCACs and District officials
work together

8. What were the drivers of success?
Development of HCAC draft ToRs and comprehensive draft training manual
Depoliticising HCAC membership
Regular mentoring and some tangible non-monetary incentives (certificates of
attendance, visibility materials, a bit of stationery etc)
Working closely and together with the MoHP and Local Government
(Decentralisation Policy Holder), starting as early as possible.
Dedicated technical team, which facilitated the design and implementation of the
pilot
Local level community support, given the importannce of the health sector
Outcome: Contribution to community health and accountability

9. Conclusions: What are the wider policy
implications?
1. If a longer-term perspective is taken, it doesn’t take long to build the capacity of HCACs.
What are the implications for scale-up?
2. SROI showed that investing in structures such as HCACs brings in a range of benefits for both
government and service users. What are the implications for limited budgets?
3. HCIG worked very well, only minor fine tuning needed: Is there a way of scaling it up to more
facilities? What is the possibility of creating a HCAC budget line in the national budget?
4. How can the health sector galvanise resource mobilisation at local level, as part of scale-up?
What synergies and linkages should we focus on?
5. CSC can be effective in increasing accountability. But it is costly. How can local partners such
as HCACs/CBOs/CSOs build their own internal capacity to implement it?