The Alliance for Maternal Health

IMPLEMENTATION SCIENCE ALLIANCE FOR MATERNAL HEALTH IN MALAWI OVERVIEW OF CARE’S INTERVENTION

MUUNI WAUCHEMBERE WABWINO

NOVEMBER 2010 TO DECEMBER 2015

The Alliance for Maternal Health As a global community we know that the science around what to deliver in maternal and newborn health is well-established, but the science on how to do it effectively and efficiently for the greatest impact, is not. Implementation science can help inform the development of sound strategies for successful, sustainable and scalable program implementation. CARE is collaborating with others on the development of fast and flexible methods to improve the science of implementation and to share learning for rapid scale up. As part of this collaboration, we hope to demonstrate the value of working together in Malawi on a maternal and newborn health implementation science project. The overall goal of the Implementation Science Alliance for Maternal Health in Malawi is to identify broadly applicable strategies, approaches and methodologies for systematically improving implementation of evidence-based maternal and newborn health interventions.

CARE’s Role CARE is leading the development, implementation and evaluation of one key approach--participatory governance. The health system, properly understood, includes not only the health institutions that deliver health care, but also the community system, where health is produced or inhibited. CARE’s experience has shown that participatory governance is a key strategy to addressing important barriers to health, including socio-cultural barriers as well as coverage, quality, and equity in service delivery. Our approach to participatory governance brings together the community and the health care providers, as well as key stakeholders from the local and district authorities, in a mutual process of identifying needs, concerns, and barriers to effective service delivery and healthy outcomes. Working together to identify the problems and develop and implement solutions generates buy-in and motivation, leading to improved implementation and outcomes, as well as accountability and sustainability. To facilitate this process we use a tool called the Community Score Card (CSC), an internationally recognized participatory governance tool developed by CARE Malawi. (See http://health.care2share.wikispaces.net/alliance).

CARE’s Intervention in Malawi The CSC, outlined in the diagram below, cultivates participatory governance by bringing together community members, health service providers and local authorities, to work together to identify barriers to implementation of quality health services. Together, these groups identify challenges, generate solutions (called ‘change ideas’), and implement and track the effectiveness of those solutions in an ongoing process of quality improvement. The CSC helps support the development of a sustainable and equitable system for communities and power-holders to identify areas for improving implementation, generating locally applicable and innovative solutions, and holding each other mutually accountable for achieving quality. Solid implementation and robust monitoring and evaluation (M&E) of the Community Scorecard approach in Malawi will allow us to achieve the following: 1)fully demonstrate the value of the Alliance, 2) demonstrate in a compelling way the impact of CARE’s unique implementation science approach, the Community Scorecard, on maternal and newborn health implementation and outcomes, 3) develop a menu of high impact implementation improvement ideas, and, 4)improve maternal and newborn health implementation and outcomes in Malawi.

CARE’s Monitoring and Evaluation Plan CARE’s hypothesis is that the CSC process will cultivate participatory governance, including: 1) empowered citizens—citizens who are aware of their healthcare rights, have a stronger voice and contribute to change; 2) health service providers and local government who are effective, accountable, and responsive; and 3) spaces for negotiation between power-holders and citizens that are expanded, inclusive, and effective. With these elements in place, there will be a sustainable and equitable system for communities, service providers and local government to identify priority maternal and newborn health areas for improvement and generate locally applicable innovative solutions—in other words, community- and facility-level changes to improve maternal and newborn health service implementation, which in turn leads to improvements in maternal health coverage, quality and equity.

CARE is using a cluster-randomized control design to test this hypothesis. We chose the health center and its catchment population as our cluster unit for randomization because the allocation and loci of delivery of the intervention is at that cluster rather than individual level. The intervention and evaluation is being carried out in Ntcheu district in Malawi. The 20 health center/catchment areas that were eligible for inclusion in the study were matched into 10 pairs (matching characteristics included: services provided, health center administration, proximity to the Mozambique border, and catchment population size). After pairing, we randomly allocated one cluster in each pair to either intervention or comparison as outlined on the map. The interventional facilities include: Biriwiri, Nsipe, Kasinje, Katsekera, Tsangano, Champiti, Chigodi, Nsiyaludzu, Kapeni and Mikoke whilst control includes Manjawira, Lizulu, Ntonda, Gowa, Mlangeni, Ganya, Mzama, Bwanje, Senzani and Birira.

Intervention and evaluation activities will be distributed across the treatment and comparison sites. Across the 10 intervention health facility/catchment population sites, 20 group villages (GVHs) in total were selected using probability proportional to size (PPS) methodology. Communities in these 20 selected intervention GVHs, will participate in the CSC process with their respective health facilities. In the comparison health facility/catchment population area, 20 GVHs in total were selected using PPS for evaluation. Further, to examine spillover effects of the CSC intervention on those communities within the intervention catchment area but not participating in the CSC, an additional 20 GVHs were selected for evaluation. Women aged 15-19 who have given birth within the last 12 months will be surveyed at baseline and follow-up in 60 GVHs (treatment, comparison, and spillover). Further, all health workers associated with both the treatment and comparison health facilities will participate in baseline and follow-up surveys. The evaluation will be done through two cross-sectional surveys and a medical chart review at baseline (2012) and endline (2015): Component Target Sample Outcomes of Interest Women’s Women aged 15-49 Across the selected  Governance Survey who have given birth GHVs, a PPS sample -empowered communities (ex. social cohesion, social capital, knowledge of within the last 12 of 650 women in the rights, collective action, social participation) months and intervention villages, -accountable and effective service providers (ex. perceptions of health service 650 women in the quality) comparison villages, - spaces for negotiation between service providers and communities and 650 women in  Women’s empowerment (ex. gender attitudes and beliefs, self efficacy) spillover villages.  Maternal health, PMTCT, and family planning coverage, quality, equity (for ex. skilled birth attendants, health facility deliveries, postpartum care, family planning use, respectful care, male involvement) Health Worker Doctors, clinical and Census of all health  Governance- Survey medical officers, nurses, workers within the -empowered service providers (ex. knowledge of patient’s and provider’s rights, nurse/midwives, intervention and relationships with co-workers, social cohesion, social capital, perceived efficacy patient attendants, and comparison clusters of health services, perceived quality of services, health system inputs) community based - accountable and effective service providers (collective efficacy, attitudes (~400) health workers. towards clients, participation in social groups) -spaces for negotiation between service providers and communities  Maternal health, PMTCT, and family planning coverage, quality, equity (for ex. skilled birth attendants, health facility deliveries, postpartum care, family planning use, respectful care, male involvement) Labor & Record review of Subset of women’s  Skilled, quality care during labor and delivery Delivery women who have survey (~10%) Medical Record delivered in a facility in Review the last month TEAM COMPOSITION

Project Manager (1) based in Lilongwe for engagement at policy level

Team members based in Ntcheu

Research and Institutional Development Coordinator - District Team Leader (1)

Research and Institutional Development Coordinator – Community (1)

Research and Institutional Development Coordinator – Monitoring and Evaluation (1)

Administrative Assistant (1)

Driver (1)

The Project engages interns periodically to carry out specific tasks

ACHIEVEMENTS SO FAR  Established operations in Ntcheu district (population 471,589) and established partnerships with District level stakeholders( Ministry of Health, NGO, Ministry of Gender and Children Welfare), Health Center and Community  Designed cluster-randomized trial to evaluate the impact of the CSC on maternal health behavior  Collected baseline data in 10 treatment, 10 comparison, and 10 “spillover” health facility/catchment areas o Developed a unique set of quantitative measures of governance that will be validated in Malawi and shared broadly to support evaluation of CARE programming and to advance global learning  Completed 2 rounds of scorecard process in first cohort of 5 health centers and 1 round for the rest of the 10 interventional facilities – generation of issues, indicators, scoring and development of mutual action plans

 The project has supported formation and training of Community action Groups that are leading mobilization of community members in MNH issues and A total of 52 (27 female and 25 male ) Health Surveillance Assistants and 60 community action groups(of at least 15 members each) and chiefs were oriented to community based MNH and mobilization with support from the project.  Supported coordination meeting for health workers to address attitude issues which compromise quality MNH service delivery in the district

 For effective implementation of community and facility level action plans and to address identified issues that were beyond the scope of the health centers and community, the project has supported a series of reflection, review and planning meetings with various stakeholders at different levels. Such meetings involved District Health Management Team, Perinatal Care Project, parliamentarians, Traditional Authorities, CHAM, Banja La Mtsogolo, Family Planning Association of Malawi and other government departments.

 Supported community level reflective, review and planning meetings involving community based MNH committees, Chiefs, health center staff, program coordinators and project team.

 Supported cross sharing of effective change ideas/improvement ideas generated and being tested by Community Action Groups such include: formulation and implementation of by-laws, home based counseling of couples and pregnant women, registration of vitals in the village, village savings and loan

 Participated in the design of Care Malawi governance initiatives  With support from Washington University MPH student collected lessons on CSC sustainability in Malawi  Supported other projects in Malawi and other countries through capacity building on governance and CSC  CSC work featured in CARE’s Women’s Lives, Women’s Voices report launched at the FP Summit in London in July 2012 hosted by Melinda Gates and DFID.  Hosted Zambia and Tanzania team on a tour to learn about the scorecard  MHAP participated in a meeting that CARE USA, UK, and Canada co-hosted for CSC experts across CARE (January 2013 in Tanzania) to share learning and develop guidance for others across CARE and globally

PLANNED MAJOR ACTIVITIES FOR THE NEXT SIX MONTHS  Support coordination meeting for the District Health Management Team with parliamentarians and health sector NGOs in the district to identify synergies and tap on available resources to address resource gaps  Conduct Reflective Learning Sessions with partners at various levels, a process that brings out lessons and ideas to best improve implementation and desired results  Facilitate first round of scorecard process for second cohort of the remaining 5 interventional health centers  Conduct a project launch  Support training of selected health center staff in provision of long lasting family planning methods and management of youth health friendly services.  Finalize baseline analysis and disseminate the findings  Conduct data update and validation of project performance outcome level indicators using MoH facility data capturing tools  Conduct the next round of community scorecard process for all the 10 interventional health center in the study