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Citizens' Involvement in Health Governance

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Citizens' Involvement in Health Governance CITIZENS’ INVOLVEMENT IN HEALTH GOVERNANCE (CIHG) Endline Data Collection Final Report September 2020 This report was prepared with funds provided by the U.S. Agency for International Development under Cooperative Agreement AID-675-LA-17-00001. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development. Contents Executive Summary ...................................................................................... 1 I. Introduction ............................................................................................... 5 Overview ...................................................................................................... 5 Background................................................................................................... 5 II. Methodology ............................................................................................ 6 Approach ...................................................................................................... 6 Data Collection ............................................................................................. 7 Analysis ....................................................................................................... 10 Limitations .................................................................................................. 10 Safety and Security ..................................................................................... 11 III. Findings ................................................................................................. 12 Outcome Harvesting ................................................................................... 12 Household Survey ....................................................................................... 20 IV. Conclusions ........................................................................................... 28 Acronyms ANAFIC Agence Nationale de Financement des Collectivité Locales (National Agency for Financing Local Communities) ANSS Agence National de Sécurité Sanitaire (National Agency for Health Security) CATI Computer-Assisted Telephone Interview CIHG Guinea Citizens’ Involvement in Health Governance COSAH Comité de Santé et d'Hygiène (Health and Hygiene Committee) COVID-19 Coronavirus Disease 2019 CSO Civil Society Organization ET Endline Team FGD Focus Group Discussion GGB Good Governance Barometer GoG Government of Guinea IR Intermediate Results KII Key Informant Interviews M&E Monitoring and Evaluation MOH Ministry of Health OH Outcome Harvesting SCS Global Strengthening Civil Society Globally Search Search for Common Ground SI Social Impact, Inc. USAID United States Agency for International Development Figures and Tables Figure 1: Map of Guinea with survey sample sizes ....................................... 6 Figure 2: OH process overview ..................................................................... 9 Figure 3: Outcomes harvested by social actor, scope, and type ................ 13 Figure 4: Outcomes harvested by year and location .................................. 15 Figure 5: Satisfaction with aspects of government health services ............ 20 Figure 6: Percentage of respondents reporting paying for free services, by prefecture................................................................................................... 21 Figure 7: Household reported likelihood of seeking government health services in case of illness ............................................................................ 22 Figure 8: Reasons respondents reported for not using government health services, 2020 (N=456 ................................................................................ 22 Figure 9: Percentage of respondents reporting some or much reluctance by community members in interacting with those who have had COVID-19, by prefecture (N=1,530) .................................................................................. 23 Figure 10: Percentage of respondents that are aware of efforts by authorities to improve the health sector range (N=1,801) and are involved in improving their local health facility (N=1,254), by age ........................... 24 Figure 11: Percentage of respondents that have never engaged with their COSAH or RECO before, by prefecture ....................................................... 25 Figure 12: Extent to which women’s perspectives are taken into account, percentage of respondents reporting (N=1,680) ....................................... 26 Figure 13: Respondent-reported, trustworthy information sources on COVID-19 (N=1,822) ................................................................................... 27 Table 1: Survey sample sizes by prefecture .................................................. 7 Table 2: KII participants and sample size ...................................................... 8 Table 3: Overview of outcome statements ................................................ 12 Table 4: Alignment with CIHG results framework ...................................... 19 EXECUTIVE SUMMARY CIHG ENDLINE STUDY Overview This report shares results of the endline study for Citizens’ Involvement in Health Governance (CIHG), a three-year activity (2017–2020) implemented by FHI 360, Search for Common Ground (Search), and Social Impact (SI). Funded by the United States Agency for International Development in Guinea (USAID/Guinea), the activity’s overall objective was to improve citizens’ understanding and participation in Guinea’s health system reforms. The CIHG endline utilized mixed methods, with quantitative data gathered via a 1,823 person, phone-based survey and qualitative data through outcome harvesting (OH). OH was implemented in three phases: 1) drafting outcomes; 2) review of outcomes; and 3) substantiation. Several data collection tools were used as part of the OH process, including: key informant interviews (KIIs); focus group discussions (FGDs); a questionnaire; and working groups. Key Findings OUTCOME HARVESTING In total, the endline team collected 20 outcome statements. Analysis of the findings revealed several trends in what has been achieved, the significance of those outcomes in terms of health services and health governance in Guinea, CIHG’s level of contribution, and the extent to which outcomes align with the CIHG results framework. Categories of change: Community members and national government officials (e.g. the National Assembly’s Health Commission, Ministry of Health (MOH) leadership and staff, etc.) are the primary social actors in CIHG outcomes, with each featured in seven separate outcome statements (14 total). The majority of changes (12 of 20 outcome statements) take place at the community level, driven primarily by individual community members, health facility staff, and other key local actors (e.g., practitioners of traditional medicine, members of a Comité de Santé et d'Hygiène [COSAH], mayors, etc.). Regional changes occur largely among the media and civil society actors, while all national-level outcomes involve government officials. Apart from central-level outcomes, most changes are noted in the Kindia, Kankan, and N'zérékoré regions, and started to develop in 2018 and 2019—though four outcomes began before implementation of CIHG in 2017. Finally, the outcome statements reflect a wide variety of change types, with different or new “practices” most commonly observed. Significance and contribution: The majority of changes harvested show a high level of significance to the health sector in Guinea, while the CIHG activity type most frequently linked to change is trainings and capacity building. CIHG’s contribution is “medium” for 15 outcome statements—meaning that both CIHG and an outside actor or enabling environment condition played a role in sparking the change. For example, one outcome statement describes the renovation, construction, and cleaning of health facilities that took place following field visits organized by CIHG of the Ministry of Health and other government officials to rural areas (see #6 in Table A). These visits certainly contributed to the overall outcome by providing an opportunity for government officials to speak with community members and see the conditions of health facilities firsthand. At the same time, the National Agency for Financing Local Communities (Agence Nationale de Financement des Collectivité Locales, or ANAFIC), a government agency that works on Citizens’ Involvement in Health Governance Endline Study Page 1 of 30 decentralization and local governance, also invested heavily in health center infrastructure development, leading to more construction and renovations. Table A provides an overview of the categories of change, significance, and CIHG contribution for each of the 20 outcome statements. Table A: Overview of outcome statements Outcome Statement Scope Type Year* Location** Social Actor Significance Contribution 1. Community members Community Local Knowledge 2019 5+ informed on healthcare member ● ◐ 2. Collaboration with Local Relationship 2018 2-4 Health staff traditional medicine ◐ ◐ 3. Civic engagement in Community Local Behavior 2020 5+ communities member ◐ ◐ 4. National government National Practices 2018 Central Government transparency ● ◐ 5. Improved COSAH Local key Local Practices 2019 2-4 management actor ● ◐ 6. Health facility renovation Local Institutional 2018 2-4 Government ● ◐ 7. Greater role of key local Pre- Local key Local Practices 5+ actors in health governance
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