Interesting lessons are emerging from the work of the BACKUP Health Initiative
A lack of effective community engagement often results in a mismatch between what an intervention is trying to achieve and local needs. Community monitoring initiatives in Zambia and Francophone West Africa are helping to improve the delivery of local health services and strengthen accountability between communities and health sector decision-makers.
Why does community engagement matter?
Most people would agree that communities should be at the heart of efforts to improve the quality and accessibility of the health services they use. However, not enough is known about what meaningful community engagement really looks like on the ground, or how exactly it works to improve health outcomes. Community-based monitoring (CBM) sits within the broad spectrum of community engagement systems and responses. It entails people coming together to collect and analyze data on issues that are important to their communities and – importantly – using this analysis to advocate for the changes they want to see, not only in health service delivery but also in the governance and financing of those services. Ultimately, it is about improving the ways in which people access and experience healthcare within their communities as well as strengthening the social accountability of public services and wider health systems.
Multilateral institutions, such as the Global Fund, Global Financing Facility and Gavi – the so-called “3Gs” –as well as the World Bank and UN organisations strongly advocate for the involvement of communities in the day-to-day monitoring and oversight of health programmes. Enabling communities to hold decision-makers to account, empowering them to have a say in the direction of health initiatives, and helping to ensure that funds and services reach intended local beneficiaries, are some of the ways in which these programmes aim to leverage the power of community-based monitoring.
Working on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), Germany’s BACKUP Health Initiative has been supporting partner institutions in their work with the Global Fund since 2001, seeking to ensure grants are used in a way that strengthens health systems and focuses on key and vulnerable groups. Developing the structures and systems for more sustainable involvement of communities in national accountability processes is an important element of this support.
Can community-based monitoring improve public health services?
Academics and development practitioners have grappled with the questions of, (1) whether community-based monitoring really works to improve public services, and (2) where there are improvements, how these changes came about. Based on randomised controlled trials in India’s education sector by economists including Nobel laureates Abhijit Banerjee and Esther Duflo (2010), as well as in Uganda’s health sector, the answer to the first question is both ‘yes’ and ‘no’. Research in India provided no evidence of impact from community monitoring, and positive results in Uganda (Börkman & Svensson, 2009; Nyqvist, de Walque & Svensson, 2017) have proved tricky to replicate (i.e. Raffler, Posner & Parkerson, 2019). The fact that many community monitoring initiatives lack rigorous evaluation frameworks is a potential limitation to building a more robust evidence base.
The answer to the second question is more complex. While randomised controlled trials are considered to be a particularly rigorous and reliable method of evaluation, there are arguments for using multi-pronged approaches that look at both processes (i.e. process evaluation) and outcomes of community monitoring initiatives. Process evaluation methods allow for changes both in the underlying context of an intervention, as well as how the intervention itself is adjusted over time, and can throw light on complex causal pathways of change (de Savigny & Adam, 2009).
Some interesting findings are starting to emerge from this broader approach. A systematic review of community monitoring interventions, encompassing both quantitative and qualitative research studies across various sectors, found that a combination of ongoing, collaborative contact between the communities undertaking monitoring and those being monitored (i.e. service providers or managers) and provision of the necessary tools for monitoring performance, had higher potential effects on service quality, corruption and accountability (Molina et al., 2017).
Community-based monitoring has not always been seen as a priority by either governments or development practitioners and, as a consequence, the necessary funding to scale up successful approaches and place them on a more sustainable footing has been hard to come by. This has begun to change in recent years as policies and strategies aimed at enhancing active participation of communities have become increasingly popular, particularly those aimed at building demand for services and strengthening accountability of local health systems (Nyqvist, de Walque & Svensson, 2017).
The Global Fund has followed a similar journey and its 2017 – 2022 Strategy demonstrates a stronger focus on strengthening community systems and responses, both within disease-specific funding and as part of ‘resilient and sustainable systems for health’. Community-based monitoring is one of four priority areas for strengthening community systems and responses (Global Fund 2019).
According to Keith Mienies, Technical Adviser, Community Systems and Responses at the Global Fund, strengthening community systems is now widely acknowledged to be an important component to health systems strengthening when it comes to ensuring access to quality health services at the local level:
‘Through increased investments in community systems, information about the barriers and bottlenecks to accessing services directly informs and contributes to improvements in the health service delivery model – ensuring no one is left behind. This is particularly relevant for key and vulnerable populations and otherwise marginalized communities.’
Engaging young people in the Global Fund country dialogue process
As a young woman in Zambia, you are more likely to contract HIV than your male peers and colleagues, and young people in general face a high risk of infection (Nkazwe et al., 2019). However, engaging young people in the Global Fund country dialogue process on issues that directly affect their health has proved to be a huge challenge. To address this, the Zambian Youth Platform developed an innovative Accountability Framework for use by young people, with funds from the Global Fund’s Communities, Rights and Gender Department. Through the Youth Accountability Project, the framework is being implemented in the districts of Limulunga and Mazabuka with the support of BACKUP.
The Zambian Youth Platform
Created in 2015, the ZYP is the largest youth network in Zambia, and works to unify the voices of adolescents and young people to contribute to social and economic change. The Platform’s coordinator acts as the youth representative on the Country Coordinating Mechanism (CCM) and channels findings from its projects to inform the CCM and implementing partners about the quality of their interventions and the extent to which they address the rights and needs of adolescents and young people.
Using the framework, young people from ‘host’ community organisations – particularly those with a focus on young women – are trained to investigate the quality of health services in their area using ‘social audit’ techniques, such as key informant interviewsand focus group discussions. The Youth Platform then helps them to report back to key policy forums, such as the National Technical Working Group on Adolescent Health.
Weekly radio broadcasts produced by and for young people provide a dynamic forum for discussions and debate on key topics uncovered by the research. National Coordinator of the Zambian Youth Platform, Sibu Malambo, describes their work:
‘with the support of BACKUP, we help the young people to direct their findings to the most important policy forums in the country. But we don’t just do this, we also encourage learning and sharing between young people from different areas by bringing them together and helping them to talk with one voice’.
Civil society advocacy platforms strengthen community voices
In Burkina Faso, Niger and Guinea, innovative citizens’ advocacy platforms are working to strengthen health systems by engaging in monitoring of health policies and services, and using their findings to advocate with key national decision-makers. The platforms were established and are supported by BACKUP through the Citizens’ Strategic Monitoring of Health Policies project or 2SCPS for short, led by the civil society organisation RAME, based in Burkina Faso.
RAME supports the platforms both organisationally – i.e. in terms of their structure, vision and scope of work – and technically, across three thematic areas of health service delivery, health finance and budgets, and health governance and transparency. As Executive Director Simon Kaboré says ‘the idea is to bring together the key organisations in each country in order to promote learning and demonstrate to them that ‘singing with one voice’ is more powerful than the dispersed activities which were going on’.
Each platform has around 20 members, including umbrella civil society organisations with wide-reaching networks to ensure the platforms represent as wide a constituency of community voices as possible. The Platform’s structure grew out of extensive discussions on the type of forum that would best serve the needs of each country context, and membership was informed by national mapping exercises of civil society organisations.
The platforms share a common brand – DeS-Ici – which stands for Démocratie Sanitaire et Implication Citoyenne (literally Health Democracy and Citizen Involvement), but is also a clever play on words meaning ‘from here on’, signalling the focus on improving health services for future generations. Strong awareness raising and communications skills – soon to include a DeS-Ici website – are essential for the success of the platforms’ advocacy work.
Advocacy responds to the local context so, for example, in Guinea, the platform has focused on widespread absenteeism among health workers, including those paid for through the Global Fund, and in Burkina Faso, the platform has thrown a spotlight on the costs of health sector corruption. In Niger and Burkina Faso, the platform is contributing to the community health strategy, asking important questions about inclusivity and ensuring definitions of communities correspond to the realities on the ground.
It is early days but some interesting results are emerging
It is clear that community-based monitoring has the potential to work on two important levels: it can provide a ‘short route’ to effective advocacy and change at the community level, resulting in small changes such as improved access to care or quality of services that can nonetheless have a significant impact on people’s lives; and at the national level, effective community monitoring can help to shape health programmes, policies and strategies in the longer-term, as well as holding decision-makers to account for promises made.
Having a seat at key national forums means that information about the ‘lived experiences’ of key and vulnerable groups can be included in decision making processes related to activities of the Global Fund and other multilateral partners at country level. In Niger, four DeS-Ici platform members were included in the recent renewal of the Country Coordinating Mechanism, and member organisations in all three countries where the platforms are operating are starting to be regularly invited to national level meetings. This is a significant achievement in a short space of time.
This is also important for the Global Fund CCMs and other national coordinating bodies which must demonstrate they understand how the funds they manage impact on the lives of those they support. Dr. Francine Sanou, BACKUP’s Technical Adviser in Burkina Faso who oversees the support to RAME’s multi-country initiative, says
‘While the CCMs might look at whether services are available, they don’t really look at issues of governance, corruption or financing, even though they are tasked with this responsibility. They simply lack the resources. So we widen the field of enquiry and enable more complete monitoring and feedback’.
Improving access to healthcare for young people at the local and national level
Monitoring by youth groups at rural health facilities in Zambia identified a number of challenges for young people in accessing healthcare, including a complete lack of signs in health facilities, making it difficult to find one’s way around – a particular disadvantage for young people living with HIV who may feel too stigmatised to ask for directions. The Youth Platform was able to address this issue swiftly at the local level, and feedback could also be directed to national decision-makers to push for more structural and hence sustainable change.
The Youth Platform is also focusing on access to healthcare for young disabled people after the monitoring highlighted the case of a deaf girl, Mutinta (a fictional name), who had gone to a facility to pick up her antiretroviral medicine but was unable to explain to health workers that the drugs were making her sick, because no one could use sign language. Further monitoring demonstrated that Mutinta’s experience was common among disabled people in Zambia. After attending a presentation highlighting analysis of the data, the Health Minister invited representatives of the Youth Platform to discuss their findings at a breakfast meeting. He then committed to introducing sub-titles and sign language in the Ministry’s health communication campaigns, and is now also considering the use of braille materials. These examples aptly demonstrate that the right data, analysed and presented in the right way, can open doors and generate interest by key decision-makers.
Community monitoring is not without challenges
It is important not to overlook the potential challenges of working with such diverse groups; community monitoring initiatives need to take into account the locally available resources and capacities and to plan realistic timelines. Community groups may know what they want to monitor, but most will need time to develop the skills to design research plans, seek ethical approval, develop the tools and collect and analyse the data securely. This is particularly important when working with sensitive health data of key and vulnerable groups.
Intensive inputs may be required in the early stages of an initiative and, once external financing is withdrawn, they can falter and run out of steam. This is why the Global Fund and BACKUP prioritise community-led and -owned initiatives over those introduced by external partners, and are supporting the development of systems and structures that will enable longer-term engagement by communities. This is particularly important for countries which are transitioning out of Global Fund support.
BACKUP’s plans for the next few years
From 2020 onwards, BACKUP will provide focused support to a smaller number of countries, as well as to regional initiatives. Working with both government and civil society organisations to help strengthen health systems and deliver better quality care, BACKUP will support partners to leverage funding from the Global Fund as well as other global financing mechanisms such as Gavi and the Global Financing Facility. This is already bearing fruit in Zambia where the Youth Platform is starting to attract the much needed backing of additional funding partners, and in West Africa, Côte d’Ivoire, Senegal, Mali and Cameroon have all shown interest in establishing DeS-Ici platforms.
Corinne Grainger, June 2020