SCS Guinea: Citizen Involvement in Health Governance
Funding provided by: United States Agency for International Development Cooperative Agreement No. AID-675-LA-17-00001
Baseline Assessment:
Submitted: January 19, 2018
Washington, DC
Submitted to:
Ruben Johnson Agreement Officer Representative USAID/Guinea [email protected]
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 ACRONYMS ...... ii I. EXECUTIVE SUMMARY ...... 1 II. BACKGROUND ...... 3 2.1 Citizens’ Involvement in Health Governance Activity ...... 3 2.2 Guinea Background ...... 4 III. ASSESSMENT PURPOSE AND QUESTIONS ...... 12 IV. BASELINE ASSESSMENT METHODOLOGY...... 13 4.1 Nationwide Household Opinion Survey ...... 13 4.2 Focus Group Discussions (FGDs) ...... 16 4.3 Key Informant Interviews (KIIs) ...... 17 4.4 Stakeholder Roundtables ...... 17 4.5 Study Limitations ...... 18 V. FINDINGS AND CONCLUSIONS ...... 19 5.1 Health Governance ...... 19 5.1.1 Findings...... 19 5.1.2 Conclusions ...... 26 5.2 Citizen Perceptions of, Use of and Satisfaction with Healthcare Services ...... 27 5.2.1 Findings...... 27 5.2.2 Conclusions ...... 36 5.3 Citizen Knowledge of and Involvement in the Health System ...... 37 5.3.1 Findings...... 37 5.3.2 Conclusions ...... 42 5.4 Civil Society Engagement on Health Reform ...... 43 5.4.1 Findings...... 43 5.4.2 Conclusions ...... 45 5.5 Media Engagement on Health Reform ...... 46 5.5.1 Findings...... 46 5.5.2 Conclusions ...... 50 VI. CONSIDERATIONS FOR PROGRAM IMPLEMENTATION...... 51 Annex A: Household Survey Questionnaire ...... 57 Annex B: Margin of Error Table ...... 65 Annex C: Focus Group Discussion Protocol ...... 66 Annex D: Roundtable Protocol ...... 69 Annex E: Bibliography ...... 70 i
ACRONYMS
AGIL Alliance pour la Promotion de la Gouvernance et des Initiatives Locales AGUIFPEG Guinean Women Association for Governance ANAFIC National Agency for the Financing of Local Communes CCSS Health Sector Coordination Committee CDCS Country Development Cooperation Strategy CENAFOD Centre Africain De Formation Pour Le Developpement CIHG Citizens’ Involvement in Health Governance CNOSCG Le Conseil National des Organisations de la Société Civile Guinéenne COSAH Comités de santé et d’hygiène CSM Civil Service Ministry CSO Civil Society Organization DHS Demographic and Health Survey ECOWAS Economic Community of West African States ENAPGUI L’Enquête Nationale sur la Perception des Guinéens EU European Union EVD Ebola Virus Disease FEGUIPAH Federation of Persons with Disabilities (PWD) Associations FGDs Focus Group Discussions FHI 360 Family Health International 360 GoG Government of Guinea GPS Global Positioning System GNF Guinean Franc HC3 Health Communication Capacity Collaboration Project HFG Health Finance and Government Project KIIs Key Informant Interviews MATD Ministry of Territorial Administration and Decentralization MEL Monitor, Evaluation, and Learning MICS Multiple Indicator Cluster Survey MOE Margin of Error MOH Ministry of Health NA National Assembly NGO Non-governmental Organization NLDF National Local Development Fund P2P Proportional-to-Population POSSAV Platform for the Promotion of Health and Vaccinations PDES Programme de Developpement Economique et Sociale PNACC Programme National d'Appui aux Communes de Convergence PNDS Plan National Developpement Sanitaire POSSAV Plate-forme des Organisations de Société Civile pour le Soutien à la Santé et La Vaccination PRODEJ Programme Décennal pour le Développement de la Justice PWD Person with Disabilities
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RAJ-Gui Guinean Youth Associations Network REFMAP Réseau des Femmes Ministres et Parlementaires SFCG Search for Common Ground SI Social Impact TL Team Leader UNDP United Nation’s Development Program UNICEF United Nations International Children’s Emergency Fund USAID United States Agency for International Development USD United States Dollars
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I. EXECUTIVE SUMMARY
The Citizens’ Involvement in Health Governance (CIHG) Activity, funded by the United States Agency for International Development (USAID), aims to improve citizen understanding of and participation in Guinea’s health system reforms. The program was started July 28, 2017 and is led by Family Health International (FHI 360), in partnership with Search for Common Ground (SFCG) and Social Impact (SI). Since the 2014 outbreak of Ebola Virus Disease (EVD), the Government of Guinea (GoG) has made strides to improve health governance and prevent a future epidemic, as evidenced by the 2015-2017 Post-Ebola Socio-Economic Recovery and Resiliency Strategy, efforts to decentralize health services, and reviews of current health legislation. Even with these positive steps, civil society, the media and government must collaborate more effectively and more extensively to advance health reform substantively and improve health services for Guineans. CIHG is therefore partnering with civil society, the media and government actors in all of Guinea’s eight administrative regions, providing technical assistance and targeted grant support, so that they can improve health governance, heath services and thus health outcomes for Guineans.
The purpose of this baseline assessment was to gather evidence to inform activity implementation and allow CIHG to be responsive to the needs of Guineans. The baseline also provides a snapshot of citizen, media, civil society, and government perceptions of health governance and their capacities. This baseline will also provide a benchmark against which to measure the effects and outcomes of CIHG’s interventions. The baseline assessment gathered quantitative and qualitative data related to a number of questions: 1. What is the current status of Guinea’s health governance and what is needed to improve it? 2. To what extent are citizens satisfied with and to what extent do they use health services? 3. What is the level of citizen knowledge of health governance and recent reforms? 4. From where do citizens receive information about health governance? 5. How are citizens, the media and civil society currently involved in health governance? 6. What factors influence participation in health governance? 7. What capacities do civil society and the media possess and what must they strengthen to more effectively contribute to improved health governance? 8. Where should CIHG target its program implementation?
Data were disaggregated and analyzed by age, ethnicity, geography, sex, and education status. Where applicable, relevant differences across these variables are highlighted in the report. Disaggregation allowed us to better understand the specific gaps and barriers to civic engagement for various population groups, and to ensure activity design and implementation is socially inclusive in terms of gender, youth, and beyond.
The baseline assessment covered Guinea’s seven regions and the five communes of Conakry. The mixed-method approach combined quantitative data collection through a 1750-person, nationwide household opinion survey with qualitative data collected through 18 focus group discussions (FGDs), seven multi-stakeholder roundtables, and 40 key informant interviews
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(KIIs) engaging over 250 additional Guineans. The FGDs, roundtables and KIIs were conducted with representatives from community members, civil society, the media, health professionals, and a wide range of government officials from the national to local levels, and international actors. The assessment team also consulted related projects funded by USAID and others. A literature review of existing, relevant information was conducted, and is cited through this report to supplement assessment findings.
This assessment’s findings largely reflect and complements those of other recent studies. Health governance remains a significant challenge in Guinea. To improve the effective design and implementation health policy and the effective management of government-run health facilities, the stakeholders throughout the country and from different sectors will require additional support. Despite significant legislation pushing forward health sector reforms, greater investment in the health sector and decentralization of health services, budgets, and decision making is needed. Guineans are largely unaware of recent policy changes, and many of the legal reforms have not yet been implemented. The Ministry of Health (MOH) and the Ministry of Territorial Administration and Decentralization (MATD) are working together but continue to face problems of coordination and management affecting staffing and delivery of health services and medicines. Important steps to strengthen local health committees known as Comités de Santé et d’Hygiène (COSAHs) provide an opportunity to bring greater local control, transparency, and accountability to decentralized health services.
The baseline's data on citizen perceptions and use of health services confirm several earlier studies. Guineans use of health services is low, even compared to their neighbors in the region. While use of health services have largely recovered since their sharp decrease during the EVD outbreak in 2014, usage rates do not appear to have dramatically increased since 2012 despite the introduction of free pre-natal care and birthing services. Top citizen concerns include distance to health facilities, poor training and availability of skilled health personnel, the high cost of treatment, and shortages of essential medicines. Women and people with disabilities (PWDs) are slightly more likely than men to complain about corruption and poor treatment at health facilities.
Citizens, including healthcare providers, and members of the National Assembly (NA) have low knowledge of health governance and low awareness of reforms. Even among MOH and NA representatives, many clearly lacked knowledge of key issues. Citizens were most familiar with COSAHs, and this familiarity may be an opportunity to strengthen health governance at the local level. Youth were also the most enthusiastic about engaging in health governance activities. However, most citizens do not see a role for themselves in health governance and believe the responsibility for implementing reforms, and even including citizens in these reforms, lies firmly with the government. While the Minister of Health has publicly called for greater citizen engagement in health governance and advocating for the implementation of health reforms, political will remains a concern as many individuals stand to lose power and resources if reforms advance.
The baselines found, as have other studies including USAID's Civil Society Sustainability Index, that civil society in Guinea is weak and has low capacity. The low capacity of civil society organizations (CSOs) and their historical politicization are significant barriers to further civil
2 society engagement in health governance. While civil society has not invested heavily in health in the past, since their interventions during the EVD outbreak, a number of CSOs are shifting their attention and advocacy to the health sector. With an increased focus on health, however, and growing public confidence in civil society following their strong performance during the EVD outbreak, there is an opportunity for civil society to advocate effectively for improved health governance.
The media sector also struggles with challenging operating environment. The legal framework restricts media and journalists have faced repression and attacks including several deaths in recent years. The economic situation makes financial viability of independent media outlets difficult and media professionals need to deepen their skills to improve the quality of their journalism. While many Guineans have little access to media, even radio, over the past several years media penetration has grown steadily throughout the country. Media use patterns vary by region, rural-urban location, and age, requiring media programming adopt a variety of formats and approaches to reach a broad cross-section of Guineans. In our research, we found that the most important source of information about health reform and other issues was radio. A number of media outlets and associations of journalists are eager to improve their reporting on health issues including health reform. While many topics are difficult for the media to cover in Guinea as they require addressing corruption and patronage, there is a degree of civic opening for increased and high-quality coverage of health reform and health topics.
Based on these findings, CIHG will focus on the following considerations in implementation. CIHG will look to build off of existing successes and ongoing efforts including the MOH- MATD Communes de Concertation and well-functioning COSAHs, and improve the capacity building for elected and appointed government officials, CSOs, and media to advance health reform. CIHG should also prioritize inclusion and targeting of specific populations in program activities so that the rich diversity of Guineans may all contribute to improving health services. CIHG and related actors should encourage improved coordination and dialogue within and among civil society, government and the media at the local, regional and national level as well as among related health projects. CIHG’s program component investing in media and increasing citizen knowledge of health governance issues is critical. Lastly, CIHG must remain flexible and prepared to take advantage of new opportunities, such as the upcoming local elections. As new champions for improved health governance emerge, CIHG should move where feasible to support them. As respondents noted throughout the research process, the success of health reforms to improve health services and thus health outcomes ultimately depends on strong political will and robust civic engagement. II. BACKGROUND
2.1 Citizens’ Involvement in Health Governance Activity The Citizens’ Involvement in Health Governance program, funded by the USAID, aims to improve citizen understanding of and participation in Guinea’s health system reforms. The program was started July 28, 2017 and is led by FHI 360, in partnership with SFCG and SI. Since the 2014 outbreak of EVD, the Government of Guinea has made strides to improve health governance and prevent a future epidemic, as evidenced by the 2015-2017 Post-Ebola
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Socio-Economic Recovery and Resiliency Strategy, efforts to decentralize health services, and reviews of current health legislation.
Even with these positive steps, civil society, the media and government must collaborate more effectively and more extensively to advance health reform substantively and improve health services for Guineans. CIHG is therefore partnering with civic, media and government actors, providing technical assistance and grant support in all of Guinea’s eight administrative regions to: 1. Engage government officials so they better understand critical next steps in health reform, the roles of various government actors, and how civic engagement can help champions of health reform to succeed. 2. Collaborate with media outlets and community theater troupes to increase citizen understanding of health reform and facilitate issues-based conversations about reform within communities and between citizens and government officials. CIHG will work with partners to aggregate conversation notes, distill key themes and concerns, and share them with civic and government reformers to inform advocacy efforts. 3. Support civil society organizations and networks to strengthen their advocacy skills (e.g., core management practices, planning, constituency engagement, constructive government dialogue) and coalition-building skills. CIHG will also train civic groups at the national and local levels to use social-accountability tools and evidence to shape their health reform agendas. By the end of the program, Guineans will better understand the health reform process. At the national level and beyond the capital, civic-governmental dialogue will have expanded in breadth and depth. Government stakeholders will be better positioned to champion health reform, and partner media outlets and civic organizations will be stronger in terms of their technical competencies and core management capacities. Working together, these actors will collaborate more effectively to advance health reform, thereby building greater public trust to address health governance and other development challenges.
2.2 Guinea Background As is the case with too many countries around the world, Guinea faces some significant challenges in terms of poverty. A country of 12 million, Guinea is one of the world’s poorest, and ranked among the bottom ten nations on the United Nation’s Development Program’s (UNDP) Human Development Index for the last decade.1 Gross National Income per capita is US $670 per year.2 Life expectancy in Guinea is 59 years for both men and women, and 52% of the population is under 18 years old. 3 Sixty-six percent of heads of households have had no education.4 Guinea’s 2012 Demographic and Health Survey (DHS) found that two thirds of Guineans were illiterate, with illiteracy rates significantly higher among women (73%) than men
1 UNDP, “Human Development Report”, 2016, http://hdr.undp.org/en/countries. 2 World Bank, “Guinea | Data”, https://data.worldbank.org/country/guinea. 3 Institut National des Statistiques, République de Guinée. "Guinée : Enquête Par Grappes à Indicateurs Multiples : Rapport final : Suivi de la situation des enfants et des femmes", July 2017, pp.11-12. 4 Ibid., p.13.
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(53%) and rural populations (80%) with higher illiteracy rates than urban areas (53%).5 The illiteracy rate is by far the lowest in and around Conakry (35%), and ranges between 60 and 80% for all other regions.6 Connectivity is also low, with only 48% of households owning a radio; approximately 84% of households have a mobile phone, 22% of households have a smartphone,7 and only 5% of individuals connect to the internet.8
Despite recent improvements in gender equality, Guinea continues to score among the worst countries in Sub-Saharan Africa for gender equity, with fewer than seven girls in secondary school for every ten boys.9 In 2015, Guinea was among the three worst countries in the world for educational gender equity.10 In the 2012 DHS, two-thirds of women reported that their husbands alone make their health decisions, and 92% of women surveyed expressed a belief that men were justified in beating their wives for one of the reasons cited in the survey, versus two-thirds of men.11
While Guinea formally transitioned to democracy in 2010, the legacy of Lansana Conté’s autocratic rule and accompanying political and inter-ethnic violence persists. Political institutions remain weak, and decisions are heavily centralized in Conakry. Given this history, Guineans’ low levels of trust in government left the GoG and its health system ill prepared to respond to the 2014-2015 EVD outbreak. Four thousand Guineans were infected, causing significant social, economic, and political disruption from which the country continues to recover. During the EVD outbreak, violence erupted in the most affected regions – Basse Guinée and Guinée Forestière – over the misunderstood efforts of the GoG and international community to curb the virus’s spread. In some areas, actions to stop GoG interventions resulted in the deaths of public officials and humanitarian agents, bringing to light the fragile relationship between the GoG and its citizenry. These incidents reflect, in part, citizens’ deep-seated mistrust in the national government.12
Even before the EVD outbreak in 2014, however, Guinea faced many governance and human development challenges. In 2015 the Fund for Peace ranked Guinea as the twelfth most fragile country out of 178 countries,13 and its endemic corruption has made it ripe for exploitation by
5 Institut National des Statistiques, “Guinée : Enquête Démographique et de Santé à Indicateurs Multiples 2012”, November 2013, p.5, http://dhsprogram.com/pubs/pdf/FR280/FR280.pdf. 6 Ibid. 7 Institut National des Statistiques, République de Guinée, “Guinée : Enquête Par Grappes à Indicateurs Multiples : Rapport final : Suivi de la situation des enfants et des femmes, July 2017, p.4. 8 République de Guinée, “Stratégie de Relance Socioéconomique Post-Ebola 2015-2017” June 2015, p.14. 9 Africa Renewal Online, “Closing Africa’s ‘Elusive’ Gender Gap”, http://www.un.org/africarenewal/magazine/december-2015/closing-africa%E2%80%99s- %E2%80%98elusive%E2%80%99-gender-gap. Accessed 26 December, 2017. 10 World Economic Forum, “Results and Analysis, Global Gender Gap Report, 2016”, http://wef.ch/2exnfhd. 11 Institut National des Statistiques, “Guinée : Enquête Démographique et de Santé à Indicateurs Multiples 2012”, November 2013, p.305 and p.313. https://dhsprogram.com/pubs/pdf/FR280/FR280.pdf 12 Stillman Sarah, “Ebola and the Culture Makers,” New Yorker, November 11, 2014, https://www.newyorker.com/news/daily-comment/ebola-culture-makers. 13 The Fund for Peace, “Fragile States Index 2015”, Washington, DC, 2015. http://library.fundforpeace.org/library/fragilestatesindex-2015.pdf.
5 unscrupulous politicians, narcotics traffickers, and unprincipled, exploitative mining interests. Despite greater stability in Guinea's post-conflict neighbors, Cote d'Ivoire, Liberia, and Sierra Leone, security and governance remain a challenge for both Guinea and its neighbors. Compounding matters yet further, a number of economic crises before and after the transition to democracy have also battered Guinea. Guinea’s low level of socio-economic development also extends to government service provision and effectiveness. Guinea routinely scores among the worst 10-20% of countries in terms of government effectiveness on a range of indices. These scores are remarkably low, even compared to several of its neighbors - Burkina Faso ranks 20- 40%, Senegal 25-45%, Cote d’Ivoire 20-40%, and Mali 20-40%. Guinea’s scores are routinely in line with its post-conflict neighbors, Sierra Leone (10-20%), and Liberia (0-20%).
In addition to these challenges, Guinea’s health services are notoriously under-resourced and understaffed. In 2012, the DHS found only one nurse and one doctor for every 10,000 inhabitants in Guinea.14 Like many of its neighbors, Guinea suffers from brain drain; in 2006, 898 doctors were working in Guinea compared to 115 Guinean doctors working abroad, and 3,847 nurses were working in Guinea compared to 267 nurses working abroad.15 Despite an injection of $260 million to fight and recover from the EVD outbreak,16 the health system remains woefully under- resourced and under-equipped. In its 2016 audit, the Guinean Ministry of Health (MOH) found that there were 5,871 community health workers active in Guinea, only 26% of whom were women, and that the country requires 18,000 community health workers to achieve a desired ratio of 650 people per community health agent.17 Available health services are often inaccessible for the largely rural population. Forty-seven percent of Guineans live more than five kilometers—an hour’s walk—from any facility.18 Of these health facilities, 65% do not have electricity.19 Figure 1 provides a map of Guinea’s health facilities.
Following the EVD outbreak, Guinea faced a loss of medical staff who had been infected by EVD, left their posts, or fled to neighboring countries for safety. While the government recruited 3000 health practitioners in 2017 (doctors, nurses, and community health workers), personnel remains an issue amongst other challenges. In its Country Development and Cooperation Strategy 2015-2020, USAID summarized the key risks and constraints in the health sector as follows: “inadequate human resources, poor quality of health services, inadequate access to essential medicines, weak health information system, weak epidemiological surveillance
14 Institut National des Statistiques, “Guinee Enquete Demographique et de Sante et a Indicateurs Multiples 2012,” 15 Devesh Kapur and John McHale, “The Global Migration of Talent: What Does It Mean for Developing Countries?” CGD Brief (Center for Global Development, October 2005), https://www.cgdev.org/sites/default/files/4473_file_Global_Hunt_for_Talent_Brief.pdf. 16 World Bank, “World Bank Group Ebola Response Fact Sheet”, http://www.worldbank.org/en/topic/health/brief/world-bank-group-ebola-fact-sheet. Accessed January 4, 2018. 17 Ministère de la Santé, Direction Nationale de la Prévention et de la Santé Communautaire, “Rapport de La Cartographie Des Agents de Sante Communautaires et Les Structures de Sante En Guinée.” 18 République de Guinée, “Rapport de l’Audit Institutionnel, Organisationnel et Fonctionnel du Ministère de la Santé”, November 2016. 19 Ministère de la Santé, Direction Nationale de la Prévention et de la Santé Communautaire, “Rapport de La Cartographie Des Agents de Sante Communautaires et Les Structures de Sante En Guinée.”
6 systems, a lack of coordination, ineffective health financing system, [and] harmful health practices, which result in low health-seeking behavior”.20
Figure 1: Guinea Ministry of Health 2016 Map of Health Facilities
Figure 1: Guinea Ministry of Health Map of 2016 Guinea Health Facilities
Source: Ministère de la Santé, Direction Nationale de la Prévention et de la Santé Communautaire, “Rapport de laCartographie des Agents de Santé Communautaires et les Structures de Santé En Guinée”, May 2016
Heath Governance. Legal reforms over the past three decades have codified Guinean citizens’ right to healthcare, and the government’s responsibility to provide appropriate care. These reforms have also slowly pushed Guinea’s health system towards a theoretically more decentralized and deconcentrated system. The process leading towards a decentralized health system in Guinea dates back to 1985, one year after the death of Guinea's first president Ahmed Sékou Touré, and the military takeover. The Minister of Health and the then-State Secretary for Decentralization developed a plan that put the community directly in charge of healthcare facility management and service delivery improvement. In 2006, the GoG adopted the Code des Collectivités Locales—a key piece of legislation decentralizing power to local governments. Among the areas of intervention decentralized to local collectivités were several related to the provision of healthcare, including hygiene and sanitation, environmental protection, control of vermin and wild animals, community development projects, management of waste collection, and, most importantly, primary health services. The new code also handed over the responsibility of hiring health professionals to the collectivités. Unfortunately, three decades later, Guinea
20 USAID, "USAID/Guinea CDCS 2015-2020", p.6, https://www.usaid.gov/sites/default/files/documents/1860/Guinea_CDCS_May_2020.pdf. Accessed 26 September, 2017. 7 offers one of poorest-performing health service delivery systems in the region. As reported in key informant interviews, one critical factor undermining health governance was the insertion of partisan politics and patronage systems in local healthcare management, leading to the appointment of non-qualified personnel and community representatives to the health management committees.
Prior to 2014, the International Monetary Fund (IMF) had pushed the GoG to reduce its health expenditures to focus its attention on building foreign exchange reserves to pay down its debt, but following the EVD outbreak, regional and international actors have pressured Guinea to increase its health spending.21 While the GoG declared in the 2015 National Health Development Plan that it will spend 15% of the national budget on the health system in line with the Abuja Declaration target – current expenditures remain under 10%, despite a sharp increase in funding during the EVD outbreak,22 which includes external investments of $260 million to combat EVD.23 The 2017 health budget was 7% of the total budget, and the GoG is planning to allocate 6% of the 2018 budget to health spending.24 In real dollar terms, the amount of the health budget in 2018 will be roughly the same, with the percentage decline being because the overall budget 25 has grown by 33%. Total expenditures on salaries increased by nearly one-third year-over-year, and a new budget line has been added to provide salaries for new community health workers. Key informants have stated that the MOH has had difficulty disbursing funds, which may account for why the health budget did not see an increase in line with the overall budget increase. Sources say that the MOH is trying to address this issue. Among the causes cited were that donor funds, which account for roughly 39% of the health budget are transferred at different times based on each donor’s budget system. The Guinea government was late on certain decentralization actions which impacted MOH disbursements linked to these reforms and a new billing and payment system was rolled out, further complicating payment as many vendors had to learn the new invoicing requirements to receive payment.
In addition to increasing the health budget, the GoG has put forward several recent reforms, as presented in the 2015-2024 National Health Development Plan and the 2015-2017 Post-Ebola Socio-Economic Recovery and Resiliency Strategy. These documents were designed to: 1) increase decentralization of the health system, with new divisions of responsibilities to be put in effect among the central, regional, and prefectural levels; 2) implement, review, and adapt current legislation, including but not limited to the pharmaceutical law and the Public Health Code; and 3) strengthen the leadership of the MOH by increasing its citizen outreach and communications, launching public-private partnerships, improving monitoring and evaluation of its work, and establishing both the National Health Observatory and the National Platform for
21 Kentikelenis et al., Alexander, “The International Monetary Fund and the Ebola Outbreak”, The Lancet Global Health 3, no. 2 (February 1, 2015), pp. 69-70, https://doi.org/10.1016/S2214-109X(14)70377-8. 22 World Bank, “Health Expenditure, Public (% of Government Expenditure) | Data,”, https://data.worldbank.org/indicator/SH.XPD.PUBL.GX.ZS?locations=GN. Accessed 19 December 2017. 23 World Bank, “World Bank Group Ebola Response Fact Sheet”, http://www.worldbank.org/en/topic/health/brief/world-bank-group-ebola-fact-sheet. 24 République de Guinée, “Projet de Loi de Finance 2018”, http://www.mef.gov.gn/wp- content/uploads/2017/11/Projet-de-Loi-de-Finances-2018-.pdf. Accessed 29 December, 2017. 25 Ibid.
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Political Dialogue in Health. These reforms have created a crucial opening to build trust between the GoG and citizens, many of whom have long felt marginalized by the government’s legacy of poor governance. In November 2017, international donors committed $21 billion to support Guinea’s new Social and Economic Development Program (Programme de Developpement Économique et Sociale or PDES 2016-2020), adopted by the NA in June 2017, which includes significant attention to health services.26 Together, these initiatives represent a significant opportunity to strengthen civic-governmental relations and improve service delivery.
Figure 2: WHO Graph of Total Health Expenditure Per Capita (PPP, in USD) 2000-2013
Civil Society. Over the past decade, Guinea’s civil society achieved a number of noteworthy accomplishments. It played an important role in propelling Guinea’s 2006-2010 transition to democratic rule, and many civic leaders joined the transition government in January 2010. A recent European Union (EU) funded study conducted by International Consulting Expertise mapped CSOs in Guinea. The study identified 43 networks encompassing the areas of human rights, democracy and governance, education, and environment; 12 platforms; 11 federations; and 941 formally registered Non-governmental organizations (NGOs) operating in Guinea.27 Of these, 81 NGOs, one network, and a federation are working in the health sector. 28
Civic organizations are actively represented at the national level in the major multi-sectoral platforms led by the MOH. Civil Society Organizations (CSOs) participated in the development
26 Paris Donor Summit on the PDES 2016-2020. 27 Network is defined as a formal organization comprised of several different CSOs; federation is an organization comprised of chapters within the same organization (e.g. unions, certain associations); platform is a forum created on a specific issue or topic and not a formal organization. 28 EU-PASOC, “Etude sur la Cartographie des Organisations de la Société Civile en Guinée”, 2017. 9 and validation of the Sanitary Development Plan, the National Health Policy, and the National Community Health Policy. Civil society is represented on the Health Sector Coordination Committee (CCSS), presided over by the Minister of Health; the World Health Organization (WHO)-created Health Sector Political Dialogue; and the Community Health Platform of Implementing Partners (Plate-forme des Intervenants en Santé Communautaire).
CSOs also lead several public policy and government monitoring initiatives: the Citizen Center for the Analysis of Public Policies at the Guinean National Council of CSOs (Le Conseil National des Organisations de la Société Civile Guinéenne [CNOSCG]); a health-related accountability platform in Kankan; the CSO Platform for the Promotion of Health and Vaccinations (Plate-forme des Organisations de Société Civile pour le Soutien à la Santé et La Vaccination [POSSAV]); and several regional platforms including three that monitor health and education policies. Other active CSOs include the Federation of the Assocations for PWDs (Fédération Guinéenne pour la promotion des Associations de /ou des personnes Handicapées [FEGUIPAH]), Guinean Youth Associations Network (Réseau Afrique Jeunesse de Guinée [RAJ-Gui]), women networks such as the Mano River Women for Peace Network, Réseau des Femmes Ministres et Parlementaires (REFMAP), the Coalition of Guinean Women and Girls for Peace and Development, the Guinean Women Association for Governance (AGUIFPEG) and the Group of Women Parliamentarians. The National Order of Medical Doctors and the National Order of Pharmacists are two professional associations that have the potential, given their memberships, to be champions for health reforms to improve the quality of services, and to potentially build off of their work to combat black market pharmaceuticals, and advocacy on health bills currently pending in the NA. The distribution of CSOs throughout given Guinea is uneven, with a strong concentration in Basse Guinée, especially Conakry and the two regions closest to it: Boké and Kindia. International donors are based in the capital likely contributing to this phenomenon. According to EU funded research, Guinea has 1014 civic organizations of which over a third are in Conakry alone and 53% in Basse Guinée (see Table 1.)29
Table 1: Guinean Civic Organizations by Region and Type Type of Civil Organization by Guinean Legal Categorization Region NGO Union Coordination Forum Federation Platform Network Total Boke 64 0 0 0 1 0 0 65 Conakry 324 5 1 3 5 12 30 380 Faranah 78 0 0 0 1 0 1 80 Kankan 97 0 0 0 2 0 2 101 Kindia 91 0 0 0 0 0 0 91 Labe 83 0 1 0 1 0 1 86 Mamou 55 0 0 0 0 0 0 55 N’Zérékore 149 0 0 1 1 0 5 156
Yet, civil society is not without its challenges. It is hampered by politicization, inadequate financing and the same shortage of skilled professionals that affects other sectors. Even compared to its immediate neighbors Guinea’s fledging civil society has much room for growth. Despite legal protections for rights to association, assembly, and speech, CIVICUS finds these
29 West African Consultants, “Étude sur la cartographie des organisations de la société civile en Guinée,” February 2017, p. 27
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30 rights are “obstructed” in practice. As with other Figure 3: CSO Sustainability Index development indicators, Guinea is perennially ranked among the lowest countries in terms of civil society vitality, including the legal and institutional environment, the effectiveness of civic advocacy, CSO organizational capacity, sectoral sustainability and financial viability. Across all elements, the USAID CSO Sustainability Index rated Guinea’s civil society as “sustainability impeded,” and Guinea consistently fell near the bottom of most of the sub-elements in Sub-Saharan Africa (see Figure 3).31
The weaknesses of the CSO sector and low levels of civic engagement reflect citizens’ long-held self- protection strategies of avoiding confrontation with a violent and authoritarian state.32 Even today, as government policies increasingly promote CSO engagement, participation, and cooperation, this legacy of authoritarianism influences citizens’ willingness to engage with CSOs and government. Recent developments, including the USAID-funded Faisons Ensemble program, have improved civic- governmental collaboration and begun to create new norms for civil society partnerships.33 Although most Guineans have not worked directly with a CSO, Afrobarometer found that 69% of citizens had participated in a community meeting,34 indicating that a certain degree of community engagement and participation, if not formal involvement in CSO activities, is part of Guinean life. However, as the USAID/Guinea Country Development Cooperation Strategy (CDCS) found, “much of the [CSO] sector is more responsive to donor trends than to indigenous demands of citizens.”35
30 CIVICUS, "Tracking Conditions for Citizen Action", https://monitor.civicus.org/country/guinea/. Accessed 20 September 2017. 31 USAID, “2015 CSO Sustainability Index for Sub-Saharan Africa”, Bureau for Democracy, Conflict, and Humanitarian Assistance, Center of Excellence on Democracy, Human Rights and Governance, Bureau for Africa, Office of Sustainability, 2015, https://www.usaid.gov/africa-civil-society. 32 “USAID/Guinea Country Development Cooperation Strategy 2015-2020”, p.7. 33 Charlick, Robert et al., “Report of the Faisons Ensemble Evaluation March 2011”, RTI, 13, May 2011), http://pdf.usaid.gov/pdf_docs/pdacr868.pdf. 34 “Guinea | Afrobarometer,” accessed December 19, 2017, http://afrobarometer.org/countries/guinea-0. 35 "USAID/Guinea Country Development Cooperation Strategy 2015-2020", p.7. 11
III. ASSESSMENT PURPOSE AND QUESTIONS The purpose of the CIHG baseline assessment is twofold. First, the data gathered from this assessment and described in this report will be used to inform program implementation. Specifically, baseline data will be utilized to better understand the context in which this program will be implemented to: identify key issues that CIHG must address to design effective activities; prioritize areas where CIHG interventions can most influence change on both the supply and the demand side of health governance; and identify constructive, collaborative partnerships. Second, the baseline will provide quantitative and qualitative benchmarks with which to compare at CIHG’s endline.
The baseline assessment provided data related to a wide variety of issues including: Guineans’ perceptions about health governance; their opinions related to trust in, quality of and satisfaction with health service delivery; and citizen understanding of and engagement in health reform and health governance. Citizen engagement was explored both at the individual level and in terms of civic organization. The assessment also investigated the status of health governance. Data were disaggregated and analyzed by age, ethnicity, geography, sex, and socio-economic status. Where applicable, relevant differences across these variables are highlighted in the report. Disaggregation allowed us to better understand the specific gaps and barriers to civic engagement for various population groups, and to ensure activity design and implementation is socially inclusive in terms of gender, youth, and beyond.
The assessment also focused on the media sector to gain understanding of the media enabling environment, challenges faced by media partners, media coverage of health governance issues, and citizen access and use of media. These findings will help CIHG assess community-level communication practices to ensure that future project communications capture the interests and attention of listeners, and determine the training needs of target media partners. Finally, the assessment provides insight on opportunities in communities where CIHG will work to advance project goals.
The research questions addressed by this baseline assessment were: 1. What is the current status of Guinea’s health governance and what is needed to improve it? 2. To what extent are citizens satisfied with and to what extent do they use health services? 3. What is the level of citizen knowledge of health governance and recent reforms? 4. From where do citizens receive information about health governance? 5. How are citizens, the media and civil society currently involved in health governance? 6. What factors influence participation in health governance? 7. What capacities do civil society and the media possess and what must they strengthen to more effectively contribute to improved health governance? 8. Where should CIHG target its program implementation?
The baseline assessment covered Guinea’s seven regions and the five communes of Conakry. The mixed-method approach combined quantitative data collection through a nationwide household opinion survey with qualitative data collected through focus group discussions (FGDs) and multi-stakeholder roundtables. Key informant interviews (KIIs) were conducted
12 with representatives from the MOH, NA, civil society, health facilities, USAID and related projects to identify opportunities for expanded engagement between government and citizens, and to understand the existing health-related legal and regulatory framework and its level of implementation. A literature review of existing, relevant information was conducted, and is cited through this report to supplement assessment findings. The baseline assessment team was comprised of a Team Leader (TL), a Monitoring, Evaluation, and Learning (MEL) Specialist, a local data collection firm (Stat View International), and both SI and FHI 360 staff (see Table 2 below).
Tools were drafted and finalized by the TL, MEL Specialist and Stat View International with support from FHI 360 and SI. Tool development was informed by the literature review; tools were developed to complement existing data while capturing additional data pertinent to CIHG implementation. USAID was briefed and provided with an inception report prior to field deployment to ensure consensus on the approach. IV. BASELINE ASSESSMENT METHODOLOGY 4.1 Nationwide Household Opinion Survey FHI 360 subcontracted a local data collection firm, Stat View International, to conduct the nationwide household survey. Stat View International worked jointly with CNOSCG, a civic network that is well represented in the seven regions and 33 prefectures, to select, hire and train enumerators. CIHG’s MEL Specialist approved the training materials and supported a training of trainers’ session in Conakry where eight master trainers were trained. These master trainers conducted subsequent training of 58 women and men with previous survey experience. These enumerators were then deployed to interview Guinean citizens in rural and urban areas. Enumerators communicated with citizens in local languages Pulaar, Kpèlè, Malinke, and Soussou) as well as in French. The survey questions addressed a variety of issues including the quality of health service delivery, level of knowledge of health policies and reforms, perceptions and attitudes related to health services, and level of citizen engagement in local health committees (see Annex A). The tools were piloted during the training of trainers and subsequently edited to address issues such as translation into local languages, questions understanding and questionnaire setup into tablets for data collection. s for data collection.
Sampling. The assessment team employed a proportional-to-population (P2P) random sampling methodology based on region, prefecture, age, and sex (see Annex B for margin of error [MOE] calculations for each demographic). The population estimates were taken from the 2017 projected population of ordinary households in Guinea, based on data from the 2014 Guinean General Census using a random selection of 82 demographic regions in both rural and urban areas (see Figure 4 for additional information). The initial target sample size was reviewed by the Guinean National Institute of Statistics and their recommendations were incorporated into the final target sampling frame, both of which are presented below. The sampling framework took into account the combined P2P methodology based on location, sex, and age and is provided in Table 2 below. Survey respondents were randomly selected per a selection protocol that was developed in collaboration with the surveying firm.
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Figure 4: Sample Methodology Overview
Table 2: Sampling Framework Revised Proportion Initial Target Number of Region Prefecture Target Sample by Region Sample Size Enumerators Size Conakry Total 16% 257 255 260 7 Boffa 19% 30.6 31 31 1 Boké 41% 66.0 66 66 2 Fria 8% 12.9 13 13 1 Boké Gaoual 19% 30.6 31 31 1 Koundara 12% 19.3 19 20 1 Total 10% 161 160 161 6 Dabola 20% 29.0 29 29 1 Dinguiraye 21% 30.5 30 31 1 Faranah Faranah 29% 42.1 42 43 2 Kissidougou 29% 42.1 42 43 2 Total 9% 144.45 143 146 6
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Revised Proportion Initial Target Number of Region Prefecture Target Sample by Region Sample Size Enumerators Size Kankan 23% 70.2 70 71 2 Kérouané 10% 30.5 31 31 1 Kouroussa 14% 42.7 43 43 2 Kankan Mandiana 17% 51.9 52 52 2 Siguiri 37% 112.9 113 113 3 Total 19% 304.95 308 310 10 Koubia 10% 16.1 16 17 1 Labé 32% 51.5 52 52 2 Lélouma 18% 29.0 29 29 1 Labé Mali 29% 46.7 47 47 2 Tougué 12% 19.3 19 20 1 Total 10% 161 163 165 7 Dalaba 18% 20.3 20 21 1 Mamou 42% 47.5 47 48 2 Mamou Pita 41% 46.3 46 47 2 Total 7% 112 113 116 5 Beyla 21% 47.25 47 48 2 Gueckédou 18% 40.5 41 41 2 Lola 11% 24.75 25 25 1 N'zérékoré Macenta 17% 38.25 38 39 1 N'zérékoré 25% 56.25 56 57 2 Yomou 7% 15.75 16 16 1 Total 14% 225 223 226 9 Coyah 19% 45.79 46 46 2 Dubréka 25% 60.25 60 61 2 Forécariah 14% 33.74 34 34 1 Kindia Kindia 25% 60.25 60 61 2 Telimele 17% 40.97 41 41 1 Total 15% 241 241 243 8 TOTAL 1605 1606 1627 58
Data Collection and Entry. Enumerators randomly selected households and interviewees through a methodology developed by Stat View International and approved by the MEL specialist36. The enumerators worked individually, utilizing Open Data Kit for electronic data collection. Stat View International originally planned on using global positioning system (GPS) technology to track enumerators as an additional layer of data verification. However, the unavailability of internet in rural locations prohibited monitoring enumerators via GPS. For data collection
36 To select the households, a starting point was randomly selected on a grid map grid, after which a table of random number pairs were used to plot subsequent X-Y coordinates and the intersection points were used to determine locations. 15 oversight, Stat View International had a supervisor for each administrative region who could visit any enumerator as needed for oversight and technical guidance as needed. Data were only forwarded to Stat View International headquarters once validated by the supervisors daily. The CNOSCG also head a supervisor whose role was to ensure timely data collection in each administrative region. CNOSCG supervisors ensured that enumerators acted in accordance with the sampling frame and survey protocols. Each survey took approximately 30 minutes to complete. Questionnaires were coded to allow for control answers to minimize data entry errors.
4.2 Focus Group Discussions (FGDs) Protocols for FGDs were designed to elicit information to help CIHG better understand: ● The status of government health initiatives: for example, EVD recovery efforts, newly adopted public health policies, pending legislative measures, decentralization and its impact on local health committees; ● Citizen expectations of health facilities and health governance and citizen participation in health governance; ● Citizen knowledge of recent health reforms; ● Civil society’s current involvement in local governance and health-related activism; ● Recommendations for addressing obstacles to civic activism on health issues; and ● Strategic points of entry for civic health advocacy.
FGDs were conducted by trained facilitators using a FGD protocol to address baseline research questions (see Annex C). Criteria for selecting FGD participants was determined in consultation with CNOSCG, which assisted in selecting FGD participants (see Table 3). Eighteen FGDs were conducted in total, with separate groups comprised of women, youth, media representatives, and health service providers (See Table 4). Discussions were led by one facilitator and note-taker recorded the discussions. Transcripts of the FGDs were coded and analyzed using Dedoose.
Table 3: Focus group and the selection criteria Focus group Criteria Women Married women in household Members of women’s associations People with Disabilities Member of PWD associations PWD heads-of-household Media Media workers Administrators Members of print media Journalists Health services providers Medical doctors Nurses Health administrators Midwives Others health practitioners in public and private sector Youth Age between 18-25 Members of youth associations
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Table 4: Distribution of FGDs by Administrative Region and Stakeholder Group
Administrative Service People with Region Women Youth Providers Disability Media Total FGD Conakry 1 - 1 1 1 4 Faranah - 1 1 - - 2 Kankan 1 0 0 0 1 2 Kindia - 1 - 1 - 2 Labé 1 1 - - - 2 Mamou - 1 1 - - 2 Boké 1 - - 1 - 2 N'Zérékoré 1 - - - 1 2 Total 5 4 3 3 3 18
4.3 Key Informant Interviews (KIIs) Members of the Assessment Team conducted 40 interviews with a range of actors, including government officials from the NA Administrative Secretariat and Health Committee, the MOH, the Ministry of Territorial Administration and Decentralization (MATD), the Ministry of Environment, the Ministry of Social Welfare, Women's Empowerment, and Children, the Ministry of National Unity, and local municipal council members. KIIs were also conducted with health labor union leaders; private and public health service providers; public and private media; and civil society leaders involved in health reform, community development and anti-corruption and consumer rights. KIIs were conducted by the baseline TL and key CIHG staff, and were documented for qualitative analysis.
4.4 Stakeholder Roundtables Seven stakeholder roundtables were organized with local civil society networks and conducted in all of Guinea’s administrative regions, excluding Conakry. Each roundtable brought together 20- 25 participants, including health sector representatives (public and private), elected and non- elected government officials (e.g. Governors, Regional Health Directorates, mayoral representatives), civil society (women, youth, PWDs), and representatives from related international development projects in the region. In total, 175 people participated in roundtables. Organizers received an orientation and guidelines for the roundtables and were given a precise quota of participants (see Annex D) as well as selection criteria for roundtable participants, which was determined in consultation with CNOSCG. Roundtable participants were invited based on the following criteria: ● One individual representing youth groups ● Two individuals representing women's groups ● Two individuals representing a NGO working in the health sector (one male, one female) ● One individual representing PWDs ● Four health professionals from the public and private health facilities ● One practitioner of traditional medicine
17
● Two individuals representing Delegations Speciales37 (one male, one female) ● Two local appointed political officials working in the townhall (mairie) ● One individual from the Governor's office ● Two individuals representing the decentralized MOH employees (DPS and DRS) ● The Secretary General of Decentralized Communities (Le Secrétaire Général des Collectivités Décentralisées) ● The Director of Micro-Development (Directeur des micro-réalisations) ● One person representing the media ● Four representatives from major international development projects in the health field (Haute qualité des services de Santé pour le Développement (HSD) implemented by JHPIEGO, Projet de lutte contre le Paludisme implemented by Catholic Relief Services, Stop Palu implemented by Research Triangle Institute and Projet d'appui à la Santé (PASA) implemented by Terre des Hommes.
The roundtables were facilitated by experienced CSO leaders, assisted by a rapporteur, and addressed the following topics: ● Level of participant understanding of health policies and health reform; ● Recommendations for supporting health reform in their communities; ● Citizen opinions of key elements of health governance in Guinea; ● Identification of communities and health clinics with specific needs in their localities; ● Identification of existing mechanisms for recording citizen needs and recommendations or gauging their levels of participation; and ● Recommendations for improving health service delivery and increasing citizen usage and trust.
Roundtables were modeled after similar forums designed to promote dialogue in Guinea. Participants worked together in sector-specific groups. Reporting templates were provided and completed by working groups to facilitate concise data collection and presentation to other groups during a plenary discussion session. Results were triangulated with the qualitative data collected through the FGDs and KIIs and used to complement the quantitative data collected through the household survey.
4.5 Study Limitations Sampling. The sampling framework employed a P2P random sampling methodology, considering the data points of region, prefecture, age, and sex alone. While other variables may have been included as well, financial constraints limited the number of variables that we could include.)
Satisficing Answers. Household survey responses on levels of satisfaction with health facilities are higher than anticipated and contradict secondary quantitative data sources. Given other quantitative and qualitative data from this baseline and other studies, the degree of satisfaction reported in the household survey is likely due to the respondent “satisficing” response, a documented phenomenon in which respondents choose socially desirable responses (among other satisficing tactics). Satisficing responses may also account for the reported low use of
37 As local officials have not been elected since 2005, these individuals were appointed to serve in the Mairies.
18 traditional medicine, especially in rural areas. Additionally, low knowledge of healthcare services and management – demonstrated throughout this report – may also contribute to these high percentages.
The issue of satisfaction was also addressed during qualitative data collection. In a number of FGDs, some respondents provided initial comments that seemed to indicate a degree of satisfaction that was often contradicted by later, more specific comments as the discussion progressed. Since the later comments were more specific, the presumption is that many comments that were initially more positive were also satisficing responses. When reviewing the aggregate of the qualitative findings, overall, they reflect those taken from secondary data sources and not the responses of the CIHG household survey for this particular question. Another factor may relate to the numerous translations that had to be done for this report: survey and interview questions were finalized in French and then translated into several local languages. Responses in non-French languages had to be back translated into French and then ultimately presented in English in this report. V. FINDINGS AND CONCLUSIONS
5.1 Health Governance 5.1.1 Findings As noted above, according to a number of international indices, Guinea routinely scores among the worst 10-20% of countries on government effectiveness.38 It also ranks very low in terms of public perception of transparency and corruption. In Transparency International’s 2016 Corruption Perception Index, Guinea was ranked 142 out of 176 countries.39 USAID has also identified poor governance as a key obstacle to Guinea’s stability, democratic growth, and economic development.40
The NA is still a nascent institution in Guinea. Although it has benefited from some assistance since its establishment in 2013, it is still operating at a fraction of its potential. Donor support to the NA has included hiring staff to assist the NA’s General Secretariat (its administrative body) and Parliamentary Committees (called commissions in French) and the creation of a Parliamentary Radio, but the need for capacity building remains acute. KIIs with members of the Secretariat and Parliamentarians working in the Health Commission reported that the ministerial policy and strategy documents are often not share with NA members and staff. For example, legislators stated that they were not involved in the development and adoption of the national health policy. In the past, these interviewees noted, members of the NA Health Committee were not experts on health. This year, however, 4 out of 6 of the NA Health Committee staff have a background in health. Interviewees also noted that many legislators have a limited understanding of their role as parliamentarians, and elected officials do not demonstrate adequate attention to
38 World Bank, “Worldwide Governance Indicators", http://info.worldbank.org/governance/wgi/#reports. 39 Transparency International, “Corruption Perceptions Index - Guinea,” https://www.transparency.org/country/GIN. 40 “USAID/Guinea Country Development Cooperation Strategy 2015-2020,” 5; “USAID Guinea: Strategy Statement 2006-2008,” n.d., 12. 19 constituency accountability. The USAID-funded Health Finance and Governance (HFG) project provided budget preparation and monitoring technical assistance to the NA, but as we heard in KIIs, need for further support remains acute. In addition, in KIIs with senior government officials, we heard that NA members do not closely monitor budget appropriations and spending, nor are they pro-active in preparing legislation. These weaknesses are significant, but given Guinea’s political history it is important to note that the NA does provide an open, peaceful forum for debate that did not previously exist.
The assessment also revealed that that the NA’s Health Committee is interested in strengthening its efforts to improve health governance. Under another program, committee members visited several healthcare facilities across the country. They returned with clear recommendations such as improved communication between the MOH and the population about health reforms, and improved collaboration between the MOH and the Civil Service Ministry (CSM) to strengthen governance in the management of human resources. The Health Committee also expressed a desire to work with civil society in several areas including the revision and design of new legislation, opening communication channels with constituents, and advocacy issues such as budget analysis, government spending, and public policy monitoring. Moreover, female parliamentarians have formed a dynamic working group to address a variety of issues related to women, including health. They are already collaborating with women’s civil society networks to reinforce advocacy campaigns supporting increased participation of women in all decision- making platforms.
Three decades since the decentralization process began in 1985 and a decade after the 2005-2006 legislative changes were enacted, decentralization has not been fully realized.41 Local government officials’ roles and responsibilities are not clear to them, and local health budgeting processes are not being implemented as conceived in decentralization legislation. While the Code des Collectivités Locales has been in place for over a decade, the law has not yet been translated into local languages and made widely available in easy-to-understand language for the general population. In roundtables with health workers in Conakry, some health workers reported that they did not know that there was a new decentralization policy, and were not familiar with the other new health policies described below. Many local government officials also do not adequately understand their roles and responsibilities, nor the local budgeting process as conceived in the decentralization legislation. At the Ministerial level, however, KIIs indicated that senior individuals were familiar with the legal changes, but also saw a need for these policies to be better communicated to health workers and the population.
The following table is a summary of the legal and regulatory framework for Guinean health governance.
Table 5: Legal and regulatory framework for Guinean health governance Select Health and Reference or Year Description Decentralization Laws / Policies Discours-Programme December 1985 Lansana Conté’s program introducing Cadre decentralization for the first time, placing rural
41 Appui à la Décentralisation et la Déconcentration. Cooperation Guinee-UE. 20
Select Health and Reference or Year Description Decentralization Laws / Policies communities at the forefront of local development, including healthcare service management. Constitution of the May 10, 2010 Recognizes the right of every citizen to have Republic of Guinea access to healthcare, and the government’s duty to provide healthcare for all. Arrêté portant gratuité A/2012/428/MSHP/CAB/ Free care in public health clinics for the des soins obstétricaux SGG of February 10, 2012 following obstetric services: dans les établissements ● Prenatal consultation de soins publics ● Childbirth ● Caesarean section National Health Policy November 2014 Emanating from Les États Généraux de la 2015-2034 Santé held in 2014, it envisions "A Guinea where all people are healthy, economically and socially productive, with universal access to quality health care and services with full participation of the population." Following the EVD outbreak in 2014, the policy was revised. Plan National March 2015 The framework for implementing the Health Developpement Sanitaire Policy for the next 10 years. This plan focuses (PNDS) on three strategic goals: 2015-2024 ● Strengthening the prevention and management of diseases and emergency situations; ● Promoting the health of mothers, children, adolescents and the elderly; and ● Strengthening the national health system. Loi de Finances initiale N°2016/001/AN 15% of state mining revenues will be allocated 2016 January 18, 2016 to the local development budget of the communes, which, combined with the revised Code des Collectivités, should lead to increased funding for healthcare facilities. Health System Recovery May 2016 The first three years of this policy (three-year Plan 2015-2017 plan) were devoted to the Post-Ebola Recovery and Resilience Plan. This framework defines a two-year program to implement the Health System Recovery Plan. Code des Collectivités March 2006, revised July The Local Government Code (of March 26, Locales 2017 2006) and the Revised Code (of February 24, 2017) define local communities and make them the institutional framework for citizen participation in local democratic life (including health governance).
Cadre de référence de July 2017 Defines the composition, roles, responsibilities l’organisation et du and mode of appointing members. Not yet fonctionnement des implemented. Comités de santé et d’hygiène (COSAH) en Guinée 21
Health governance is closely tied to the decentralization and deconcentration process42, and “I have hope that local elections if is therefore tied to legislative and local elections. In held correctly can really create 2005, amid growing political dissatisfaction, a change. Local elected representatives series of governance reforms were proposed could actually be an answer to the including the creation of local communes and deficit of trust which exists amongst elected councils to allow more local autonomy. 43 COSAH members (literate vs illiterate, healthcare service and commune vs The local elections that followed were not community representatives). recognized as being free and fair by a majority of – Regional CSO leader Guineans and the international community. Local councils were nevertheless seated. They had a five- year mandate but stayed in place until 2016 when the government appointed, under pressure from opposition parties, special political delegations proportionally based on results of the 2013 legislative elections.44 A revision of the Electoral Code, proposed by both the government and the main opposition parties, was adopted by the National Assembly in February 2017, opening the door for the much-awaited local elections, now scheduled to take place in early 2018. These elections may serve as a key opportunity to advance decentralization, providing more Guineans a voice in governance issues, health-related and beyond.
Following the crisis after Lansana Conte’s death and the military rule of Moussa “Dadis” Camara, a new constitution was adopted in 2010, enshrining the rights of citizens to access healthcare and physical well-being, and the responsibility of the government to fight against epidemics and “social plagues.”45 Also in 2010, a contentious presidential election divided the country and led to violence in advance of the runoff in October 2010. The results, eventually accepted by all international observers (the EU, African Union, and Economic Community of West African States), saw the ruling party assemble a coalition to form a majority and take control of the NA. The 2010 Presidential elections and 2013 legislative elections exposed a major cleavage in Guinean society as the two largest ethnicities, Malinke and Peuhl, split along party lines. The split was further magnified as numerous Malinke, of which Condé was a
42 République de Guinée, “Rapport de l’Audit Institutionnel, Organisationnel et Fonctionnel du Ministère de la Santé”, November 2016. « Déconcentration » and « Décentralisation » are defined as follows in above GoG document: ● Décentralisation : La décentralisation est une politique de transfert des attributions de l'Etat vers des collectivités territoriales ou des institutions publiques pour qu'elles disposent d'un pouvoir juridique et d'une autonomie financière. ● Déconcentration : La déconcentration désigne un mode d'organisation de l'administration dans lequel certains pouvoirs sont délégués ou transférés d'une administration centrale vers des services répartis sur le territoire, dits services déconcentrés ou services extérieurs. « Le but est d'améliorer l’efficacité de l'Etat en décongestionnant l'administration centrale et en accélérant les prises de décisions au niveau local. A la différence de la décentralisation, les services déconcentrés dépendent directement du pouvoir central et font partie de la même personne morale que celui-ci. » 43 Arandel, Christian, Bell Marissa, and Gerber Dan, “Does Better Governance Improve Service Delivery? Evidence and Lessons Learned from the Guinea Faisons Ensemble Project.” International Working Group Working Paper Series, Research Triangle Park, North Carolina, RTI, March 2014. https://www.rti.org/sites/default/files/resources/faisonsworkingpaper_2014-02_arandel-bell-gerber.pdf. 44 Ibid. 45 Constitution of the Republic of Guinea, Article 15. 22 member, received many top ministerial positions. Parliamentary elections were delayed until September 2013, where President Conde’s party received a majority of seats.
The Code des Collectivités Locales was revised considerably in 2017, theoretically increasing the level of citizen responsibility and augmenting opportunities for citizen participation. It devolved management and ownership of local healthcare facilities to communes, including hiring of staff. Hiring for regional and prefectural hospitals remains under the regional jurisdiction. The Code des Collectivités Locales also now provides for a share of the budgets from the Ministries of Health, Education, and Environment to be distributed down to the local level. The Code also transferred some budgeting and administrative responsibilities from MOH to MATD. The stated objective is to decentralize and deconcentrate health services, allowing communal governments to control local health budgets, including local salaries, to improve transparency and reduce chronic problems such as absenteeism among clinicians and non-clinical health staff drawing their salaries from Conakry with little oversight. Whether this goal is achieved remains to be seen as the promulgation of the code is still pending.
In 2016, a National Local Development Fund (NLDF) was instituted to consolidate all financial resources meant for local governments. In 2016, the Loi de Finance Initiale 2016 allocated 15% of all government mining receipts to be allocated directly to local governments, as stipulated in the Mining Code. In October 2017, the MATD finalized a decree establishing a National Agency for the Financing of Local Communes (ANAFIC) which will be responsible for the management of the Fund. Money has not yet been released to local communities but several sources anticipate that fund will be distributed following the validation of the February 4, 2018 municipal elections.
Since 2015, the GoG has adopted a series of new health policies, and implementation strategies, including the 2015-2017 Post-Ebola Socio-Economic Recovery and Resiliency Strategy, and the National Development Plan for Health (PNDS) 2015-2024. The initial implementation of the PNDS coincided with the EVD outbreak, and led the GoG to review the policy and, with the support of USAID and the EU, undertake an audit of the health system and recommit to decentralizing health services and investing in the health system.46 These developments show the GoG can make strides forward to improve health governance. However, both the MOH’s institutional audit and our research found that overall, the MOH struggles with poor control over human resources and finances, over-centralization, and poor support structures, and that consultative structures are weak.47 There is a lack of effective implementation of the new health policies, and decentralization and deconcentration of decision-making power and budgeting remain a challenge.48 The reality is that many decision makers and other actors in the health system benefit from how power and resources are currently controlled and would lose access to them if reforms advance. For this reason, one key informant stressed that there is no real desire for decentralization to move forward from leaders in the central government. While the 2018
46 République de Guinée, “Rapport de l’Audit Institutionnel, Organisationnel et Fonctionnel du Ministère de la Santé”, November 2016. 47 “Audit Institutionnel, Organisationnel et Fonctionnel Du Ministere de La Sante--Republique de Guinee,” Rapport Final (Conakry, Guinea: Delegation de l’Union Europeenne, Ecorys Consortium de Sante, October 21, 2016). 48 Ibid.
23 health budget splits costs between deconcentrated services in Conakry and the rest of the country, costs for goods and services are only slightly lower for Conakry than for all other urban centers in the country combined.49 Despite holding roughly one-fifth of the population, Conakry consumes half of the country’s health spending.
Several structures were created in the 1980s to increase local control of health facilities and still exist. Regional Health Directorates (direction régionale de la santé) is led by a Regional Director and supervises Prefectural Health Directorates (direction préfectorale de la santé) that also called health districts/district sanitaire in the WHO nomenclature. The Director of the Prefectural Directorate leads the District Health Management Teams (équipe-cadre de district sanitaire) comprised of Directorate staff who are responsible for the management of health services and health problems in their districts, called communes in Conakry and prefectures outside the capital.
The GoG also created COSAHs to provide a formal structure to incorporate citizen input into health governance50. These groups operate at the local level and provide oversight to a specific health facility, and are the latest iteration of health committees that were first created in the 1980s. In July 2017, the composition and terms of reference of COSAHs were redefined to make them more operational.51 By reanimating the COSAHs with the intention of providing them with capacity-building assistance and incentives for participation and good management, the GoG hopes to address the lack of governance at the local level in a key sector, and to advance decentralization and deconcentration.52 The new framework (Cadre de Reference de l’Organisation et du Fonctionnement des Comités de Santé et d’Hygiene en Guinée) describes the composition of COSAHs as follows: ● President, elected by the communal council ● Vice-President: a representative from civil society ● Three community leaders from each of the following categories: religious, women and youth ● Treasurer, appointed by the local council ● Head of the Local Health Facility Like members of communal councils, COSAH members serve for five-year terms, and dysfunctional and under-performing COSAHs may be dissolved by the Préfet (an appointed position). Despite setting aside seats for women and youth on COSAHs, the “Synthèse du Diagnostic Situationnel des Communes de Convergence” finds that women’s and youth voices are poorly represented and are not taken into account in local governance decisions. Moreover, respondents indicated that many COSAHs are run by the President and the Treasurer without input from other members, who do not understand their roles and are unable to fully participate in the COSAHs.
49 Ministère de la Santé, Budget 2018, p.118. 50 Note: There are health committees that exist that are not COSAHs. 51 République de Guinée, Ministère de la Santé, Direction Nationale de la Prévention et de la Santé Communautaire, Cadre de Référence de l’Organisation et du Fonctionnement des Comités de Santé et d’Hygiène en Guinée, July 2017. 52 Ibid. 24
COSAHs are a key component of the MATD and United Nations International Children’s Emergency Fund (UNICEF) partnership on the Programme National d'Appui aux Communes de Convergence (PNACC). Under this program they are focusing on 40 particularly needy communes, and are re-invigorating the COSAHs in their 40 target communes. During the 2014 EVD outbreak, many Comités Villageois de Veillle took on the fight against EVD and worked closely with the government, civil society organizations, such as Programme Décennal pour le Développement de la Justice (PRODEJ), AGIL, and international organizations, such as UNDP. As these groups were strengthened, others (i.e. COSAHs) were not, creating some duplicative structures. A number of study participants shared their frustration that COSAHs did not benefit from the same support, and see the missed opportunity as the reason for the low performance of many COSAHs.
Prefectural Health Directorates are responsible for providing technical support to COSAHs and to ensure that they function correctly. This represents a notable shift from the previous hierarchical structure in which these health authorities had sole oversight over all public health workers. These sweeping reforms, with significant changes in responsibility and authority, are likely to affect all stakeholders. Some stakeholders will, in fact, be resistant to these changes as a result. Several projects and international organizations are seeking to work with COSAHs but respondents reported insufficient coordination among these different partners working to strengthen COSAHs: for example, the United States Government’s President’s Malaria Initiative implemented by Research Triangle Institute (RTI,) USAID’s Health Service Delivery Project implemented by Jhpiego, Catholic Relief Services, and Médecins Sans Frontières.
Government Officials’ Perceptions of Health Governance and Civic Participation
In KIIs, government officials expressed that both the need and desire for improved health governance and further implementation of reforms within the GoG. They cited numerous health- related initiatives that are being advanced, including the hiring and distribution of new health workers, renovation and building of health infrastructures, and new regional epidemiological centers. Government respondents also indicated that the perception among GoG officials is that health governance is not solely the affair of the MOH, but should also involve other key departments, such as MATD, as well as civil society. They noted that GoG and MOH reforms encourage greater civic participation not only through COSAHs, but also health sector coordination committees in the regions and prefectures, which bring together representatives from the government, international organizations and CSOs to discuss health issues.53
However, study participants identified a number of health governance challenges that need to be addressed. While USAID has supported the National Democratic Institute to host regional roundtables on civic engagement, the Code des Collectivités Locales has not been broadly disseminated nationwide and participants cited the need for more awareness activities. Collaboration between the MATD and MOH to further the decentralization process and increase community engagement and ownership of local healthcare facilities is ongoing. At noted above, in December 2017, the MATD and MOH began a pilot of National Communal Convergence Program in 40 rural communes, drawing on a new, holistic approach to development and social
53 Politique Nationale de la Santé. Ministry of Health. Government of Guinea. 25 assistance supported by UNICEF. Target communes were selected according to their high degree of vulnerability in all sectors. Le Programme National d’Appui aux Communes de Convergence (PNACC), aims to create a favorable environment to the consolidation of decentralization. It aims to pool the interventions of the donors and development partners to maximize the impact and activities and thereby improve communities’ socio-economic development.
Study participants noted that coordination of various health initiatives was insufficient. MATD and MOH is collaborating through the new PNACC program to increase community engagement and ownership of health facilities. The specific activities under PNACC and detailed mechanics of MATD/MOH collaboration at the working level are still under design. To maximize impact, health officials as well as international partners articulated the need for strategic, constructive coordination with stronger leadership from the MOH. Numerous coordination committees and platforms exist and operate at different levels of management. While USAID’s Health and Governance Project is working diligently to improve coordination within the MOH and with other ministries, respondents noted that overlapping initiatives remained an issue and coordination an area for continued attention. Participants found management of the MOH General Secretariat to be weak. MOH offices often do not inform one another of their coordination efforts with other organizations. Several participants stressed the need for the MOH to lead strategic, constructive coordination and monitoring to avoid duplication, improve geographic distribution and maximize programs’ effectiveness.
Government officials in KIIs, participants in roundtable discussions, media members in FGDs, and youth in FGDs stressed citizen engagement and involvement to improve health governance. As a government official declared in a KII, “in reality, it is up to the public to go to the health services to claim their right,” placing the responsibility for change with the population, not with the government. “Civil society advocacy is no longer Civil society leaders were also focused on citizen sufficient. We need to think in terms engagement, but tended to believe there was a need for of mass mobilization, a mass advocacy. One civil society leader said, “Civil society movement; federate towards one goal. Reforms are slow in the advocacy is no longer sufficient. We need to think in making.” terms of mass mobilization, a mass movement; federate – Regional CSO leader towards one goal. Reforms are slow in the making.” In a KII another civil society leader emphasized that “There is a political will, but it is insufficient. It must be accompanied by a real political commitment and a real engagement on the part of citizens.”
5.1.2 Conclusions Guinea’s governmental institutions face a significant number of hurdles to improve performance in governance, both in the health sector and overall. Government capacity is low, budgets are insufficient for the country’s needs, and institutions are not adequately staffed. New democratic, inclusive norms of collaborations must continue to be built across political, ethnic, gender, and other differentiating lines. The GoG lacks transparency, local elections are long delayed, and the government is not aggressively moving to build the systems and structures necessary to support decentralized local governance. Additionally, the NA does not serve as a check on executive branch performance, or as a strong channel for constituents’ needs and priorities; it also fails to educate the electorate on health reform and other policies. Addressing any and all of these
26 problems will require demonstrated political will. Government representatives express interest in reform, but may be hindered by the political consequences of highlighting performance weaknesses among fellow government officials and preventing the use of government positions for personal gain.
Implementation of health decentralization will encounter further hurdles as current power holders must necessarily cede their power to less powerful outsiders for decentralization to be successful. This will in turn result in a loss of benefits and power for the current MOH and central government authorities. Political interests at the local and national level will continue to interfere with the independent, transparent management of healthcare facilities, as patronage systems are endangered by greater transparency and accountability. A decentralized system is not, by definition, more transparent, effective, or accountable than a centralized system. Indeed, decentralized corruption is much more challenging for civil society and other watchdogs to track and manage. Health reform advocates will also need to carefully analyze the many stakeholders who will lose power and resources in health reform and assume that most will actively work against it.
The broad cross-section of stakeholders involved in health governance need more information about health governance and health reforms and training on how to more effectively use their role to contribute to improved health services. COSAH members must better understand their role and ways to create wider citizen engagement. COSAHs themselves are also unlikely to function effectively and be sustained without a minimum of operational funding from the local development budget. Furthermore, proper channels of communication among the NA, MOH, MATD and civil society will need to improve.
The MOH and MATD’s ongoing collaboration merits the support of donor community as it offers a point of entry to a consolidated approach to decentralization, placing the community at the helm of service delivery. While HFG and other projects have achieved significant successes, this Guinean government led effort to increase coordination to maximize impact is a noteworthy initiative. Similarly, as with all major democratic institutions in Guinea, the NA must energetically work to address the NA’s limitations to bring itself up to par with other countries such as neighboring Burkina Faso and Senegal. For example, NA members and staff need to better use the health commission as a tool for health governance accountability. They must strengthen their legislative skills and health policy expertise to prepare or request new or revised healthcare legislation. Additionally, they must better monitor the implementation of existing legislation, policies, budget allocation and spending.
5.2 Citizen Perceptions of, Use of and Satisfaction with Healthcare Services 5.2.1 Findings This study’s qualitative findings and most of the quantitative findings reflect the same challenges identified in previous surveys carried out by the GoG and its international partners in the last five years, such as the 2012 DHS, the 2016 Multiple Indicator Cluster Survey (MICS) and the L’Enquête Nationale sur la Perception des Guinéens (ENAPGUI, 2013). As in 2013, top concerns remain the cost of treatment, poor training of personnel, distance to health facilities and shortages of essential medicines.
27
Citizen Use of Health Services
This study’s findings are similar to Figure 5: Percent of births assisted by other recent research on healthcare trained personnel from MICS surveys usage and barriers to accessing care. Guineans health utilization rates are 90% appreciably lower than many of its 80% neighbors, although improvements are being made. Based on recent 70% health surveys, 63% of Guinean 60% women report having births assisted by trained personnel in the 2016 50% MICS, compared to 45% in 2012 40% (see Figure 5). 54 The World Health Organization (WHO) identifies large 30% health disparities in Guinea by both 20% income level and rural-urban 10% divides.55 Despite holding only 15% of the country’s population, Conakry 0% hosts 55% of Guinea’s health Guinea Côte d'Ivoire Burkina Faso Sierra Leone personnel.56 As of 2015, 53% of the population lived more than 5 km from any health facilities.57 This number rose from 47% the year before with the closure of 94 health facilities during the EVD outbreak due to health personnel death and abandonment of their posts, with the forest regions most affected by these closures.58 Of the health centers that remained open, the 2016 institutional audit of the Ministry of Health found that only 56% offer the “Paquet Minimum d’Activités,” or Package of Essential Services.59 On average, 65% (70% rural, 59% urban) of household survey respondents indicated that their communities have a community health facility.
To understand broader healthcare utilization rates, household survey respondents were asked health-seeking behavior questions of both them and anyone in their household; this allowed the CIHG team to account for services such as child vaccinations and child births (when interviewing male respondents). As with the responses on satisfaction, the findings differ from other studies that found lower usage of health facilities. CIHG survey respondents universally responded that their household had accessed health services in the last year, with 67% of respondent households reporting that a household member had sought care within the previous month or more recently (see Figure 6). If confirmed by other studies, this may indicate that
54 Data from MICS studies available at: https://data.unicef.org/topic/maternal-health/delivery-care/. 55 World Health Organization, http://apps.who.int/gho/data/view.wrapper.HE-VIZ11a?lang=en&menu=hide 56 République de Guinée, “Rapport de l’Audit Institutionnel, Organisationnel et Fonctionnel Du Ministere de La Sante.”“Rapport de l’Audit Institutionnel, 25. 57 République de Guinée, p.22. 58 Ibid. 59 République de Guinée, “Rapport de l’Audit Institutionnel, Organisationnel et Fonctionnel Du Ministere de La Sante.”p.23. 28 reforms are increasing service delivery. In addition, if this high use of health facilities is accurate, information distribution through health centers may be a promising avenue.
In FGDs, participants reported that they and their families interacted with health facilities most often when they were sick, for maternity care, and for vaccinations. Despite pre-natal and maternity services being cited as a top reason for seeking care at a health facility, in 2012 only 40% of births in Guinea took place at a health facility,60 and since the EVD outbreak, many Guineans have chosen not to utilize health centers for maternity care.61 During the EVD outbreak, researchers in Macenta found district family planning visits declined by 51%, antenatal visits declined by 41%, and delivery visits declined by 62%.62 Overall, during the 2014 EVD outbreak there was a 58% drop in outpatient visits, and a 54% drop in hospital admissions.63
While family planning visits recovered post-EVD, antenatal visits only recovered to 63% of their pre-EVD levels, and deliveries in health facilities only recovered to 66% of their pre-EVD levels.64 Another study in Guinee Forestière found a similar pattern for maternal and child health visits, with visits declining sharply during the EVD outbreak, and recovering once it was over,
60 Institut National des Statistiques, “Guinée : Enquête Démographique et de Santé à Indicateurs Multiples 2012”, November 2013, p.128, http://dhsprogram.com/pubs/pdf/FR280/FR280.pdf. 61 Michiel Hofman and Sokhieng Au, eds., The Politics of Fear: Médecins sans Frontières and the West African Ebola Epidemic, 1 edition (New York, NY, United States of America: Oxford University Press, 2017). 62 Camara, Bienvenu S. et al., “Effect of the 2014/2015 Ebola Outbreak on Reproductive Health Services in a Rural District of Guinea: An Ecological Study,” Transactions of The Royal Society of Tropical Medicine and Hygiene 111, no. 1 (January 1, 2017), pp.22-29, https://doi.org/10.1093/trstmh/trx009. 63 WHO, “Health Systems Situation in Guinea, Liberia and Sierra Leone” (Ebola and Health Systems Meeting, Geneva, December 10, 2014), 13, http://www.who.int/csr/disease/ebola/health-systems/health-systems-ppt1.pdf. 64 Ibid.
29 but not to pre-EVD usage.65 In 2015, two areas hit very hard by the EVD epidemic had closed 31% (Macenta) and 49% (Lola) of health posts due to a lack of personnel.66
While the GoG has prioritized vaccination coverage and pre- and post-natal care, with support from donors, basic health services such as vaccinations, primary preventative and treatment of communicable diseases, pre- and post-natal care, childbirth services, and family planning fall far short of needs even according the 2014 National Health Policy noting that in some places key services may not exist. The FGD and roundtable participants did not speak about receiving preventive health services other than vaccinations and pre-natal visits. Only 37% of 12-23- month-old children in Guinea were vaccinated in 2012 according to the recommended schedule and only 26% according to the 2016 MICS survey.67 During the EVD outbreak, vaccination rates dropped by 30% and the government chose to delay the opening of school by four months to prevent the further spread of disease and by 2016, the vaccination rate had dropped from 37% to 26%.68 Health service providers in FGDs and roundtables emphasized the need to focus on vaccination coverage to improve health outcomes and identified vaccination as an area for improved services, echoing the GoG-identified health priorities (PNDS). In FGDs, participants highlighted their use of vaccination services and expressed the greatest confidence in vaccination campaigns among all health services. Respondents were particularly impressed that the vaccination services are free and that vaccination workers go from house to house to ensure vaccination coverage. Several emphasized the importance of getting down to the household level.
Factors Impacting Usage Rates
Service Provision / Access to Medicines. Access to key services and equipment is lacking in health facilities across Guinea. The 2016 institutional audit found that 70% of necessary equipment is not available in public health facilities, and that only 34% of equipment that is “When us mothers arrive at the health available in health facilities conforms to center, we are not welcomed properly. established standards.69 Participants in FDGs Pharmaceuticals are expensive, it is and roundtables reported that many services that discouraging! Even with a sick child, they are supposed to be free of charge are often won’t begin the treatment unless the money is there.” unavailable, including prenatal care, childbirth – Siguiri FGD services and caesarian sections.70 People
65 El Ayadi. Alison M, Delamou, Alexandre and et al, Sidibe, Sidikiba, “Effect of Ebola Virus Disease on Maternal and Child Health Services in Guinea: A Retrospective Observational Cohort Study,” The Lancet Global Health, n.d. 66 Bienvenu S. Camara et al., “Effect of the 2014/2015 Ebola Outbreak on Reproductive Health Services in a Rural District of Guinea: An Ecological Study,” Transactions of The Royal Society of Tropical Medicine and Hygiene 111, no. 1 (January 1, 2017): 22–29, https://doi.org/10.1093/trstmh/trx009. 67 Ibid., p.139 ; République de Guinée, “Enquête par grappes 1a indicateurs multiples MICS 2016”, p. vii. 68 République de Guinée, “Stratégie de Relance Socioéconomique Post-Ebola 2015-2017” June 2015. 69 République de Guinée, “Rapport de l’Audit Institutionnel, Organisationnel et Fonctionnel du Ministère de la Santé”, November 2016. 70 Guaranteed in Arrêté portant gratuité des soins obstétricaux dans les établissements de soins publics A/2012/428/MSHP/CAB/ SGG du 01 février 2012.
30 reported being unable to access health services because they did not have money to pay for care.71 Similarly, FGD participants reported appropriate materials for caesarian sections to be widely unavailable.
Shortages of key medicines were mentioned in reviewed literature, earlier studies—including the institutional audit72—and by respondents in the household survey, KIIs, and FGDs. Many respondents shared personal stories of traveling from health center to health center seeking specific medicines, and finding them out of stock. The shortage of medicines, one FGD participant explained, “turns health agents into a drug salesman, rushing to the patient” to sell them drugs first.73 FGD participants, especially women, believe shortages in medicine in healthcare facilities are due to the inefficiency of the Government Central Pharmacy. A number of respondents expressed concern about mismanagement of medicine stocks, especially those far from Conakry. They stated that their health centers were not receiving adequate amounts of medicines and that even the regional pharmacy depot was not being appropriately stocked.74 According to a USAID’s Global Health Supply Chain Program, the average stock-out for anti- material treatments as of December 2017 was 13%.
Despite these shortages, the household survey shows that a small percentage of Guineans use traditional medicine, with under 4% of household survey respondents saying they seek traditional medicine when they become ill, and 89% saying they go to government or private health clinics (see Figure 7). There was also no appreciable difference between urban and rural respondents in the use of traditional medicine or self-medication following illness. Regional differences emerged in the use of traditional medicine and self-medication: in Kankan, the survey found 13% of respondents relied on traditional medicine and on self-medicating, and in N’Zérékoré 10% of respondents self-medicate as the first response to illness. Another key variance relates to survey respondents with disabilities who reported using traditional medicine at a higher rate than the general population, with 31% saying they use traditional medicine first when they become ill.
71 FGD. Boke, October 2017. 72 République de Guinée, “Rapport de l’Audit Institutionnel, Organisationnel et Fonctionnel du Ministère de la Santé”, November 2016. 73 FGD, Conakry, November 2017. 74 FGD, Faranah, November 2017. 31
Staffing. Under-staffed clinics, especially in rural areas, and long wait times were frequent complaints among FGD and roundtable participants. FGD participants frequently highlighted absenteeism as problem, especially outside of Conakry, and reported often finding that even when they make it to a health facility, the personnel are absent. Men, women, PWDs, healthcare providers, and media representatives all reported dissatisfaction with how they are welcomed to health facilities. Participants shared that they are not properly received upon arrival, ignored for long periods, and their treatments and diagnoses are not well explained to them. One participant in N’Zérékoré remarked, “there are lots of deaths in the waiting room because they [health workers] take too long” in responding to sick patients.75 Mismanagement was another issue flagged by respondents: “Staff recruitment is poorly done. [We should] establish a system of control and report to people; to avoid recruitment by affinity, health workers should be recruited through “The Health Ministry appointed new exams.” Other data corroborates respondents’ concerns medical professionals, doctors, nurses, midwives to some healthcare about staffing as discussed in the background section of centers. A (new) doctor sent to run our this report. In regions far from Conakry, such as center has no clue how to manage N’Zérékoré, roundtable and FGD participants stressed and the center is not working properly. the need for local recruitment of health workers, 76 as They need training before coming (…) many come from outside the region and are not Many just abandon their posts, there is no control.” committed to the work, often absent, and unable to – Kankan Roundtable connect with the local population. In addition, the MOH’s Rapport De La Cartographie des Agents de Santé Communautaires et les Structures de Santé en Guinee found that there are fewer than one-third of the necessary community health workers, and that 13% of these community health workers had received no training whatsoever.77 Eighty-six percent of community health workers reported receiving cash payment for their work, but these payments are not harmonized or coordinated.78 As reflected in the 2018 MOH Budget, these community health workers have funds allocated for their salaries in 2018.79
Concerns about the training of medical staff, diagnostic capabilities, and appropriateness of care were expressed consistently by an audience of health workers, members of the media, and leaders interviewed in KIIs, and were also mentioned in most FGDs. In KIIs and FGDs with health workers, participants identified inadequate training and poor treatment of doctors and other medical professionals as drivers of poor care and widespread corruption. In roundtable discussions, healthcare providers and media representatives explained that interns (who are licensed to practice medicine, but have little experience), medical students, and nursing students provide much of the patient care at certain facilities. These medical professionals-in-training are not equipped to provide the degree of care asked of them, and their supervisors do not appropriately oversee their work. Describing public hospitals, one focus group member said that public health centers are lacking because of “the absence of doctors for emergency cases—there
75 FGD, N’Zérékoré, October 2017. 76 FGD, Mamou, October 2017. 77 Ministère de la Santé, Direction Nationale de la Prévention et de la Santé Communautaire, “Rapport de la Cartographie des Agents de Santé Communautaires et les Structures de Santé En Guinée”, May 2016. 78 Ministère de la Santé, Direction Nationale de la Prévention et de la Santé Communautaire, “Rapport de la Cartographie des Agents de Santé Communautaires et les Structures de Santé En Guinée”, May 2016. 79 Ministry of Health, Budget 2018, pp. 118-123. 32 are always more interns who take calls instead of the full doctors,” going on to say that many doctors will send patients from public clinics to their private clinics to increase their income and payment for the provision of medicines.
In roundtable discussions, participants recounted stories of misdiagnoses and/or inadequate care of loved ones, which then led them to Dakar or further destinations for additional or corrective treatment. In a media roundtable one member noted that “the practices for consultation and prescription of medicine are done without a thorough examination.” Another reinforced this concern, saying, “…most diagnoses are made on “The quality of care does not exist; the the basis of the declaration/self-expressed concern of the doctors is not to cure the patients, but to make money! At the problem of the patient. Health policies are not hospital pharmacy, products are 80 respected.” Respondents also complained of a expensive; we also find drugs picked lack of equipment and “inadequate up on the black market.” infrastructure.” All FGDs and roundtables noted – Labé FGD that health facilities are in poor repair, and that they are often dirty and unhygienic.
Cost. In the household survey, FGDs and KIIs, the high cost of health care was a top concern among all groups. People consistently noted how expensive care is, often questioning health service providers’ motives, i.e.: “the nurses are more interested in money than in their profession of giving care.”81 A lack of transparency about the cost of services, medications, and materials was also reported in the research. Although prices are officially set at the national level, they vary from one health facility to another, and sometimes vary by client. This lack of transparency weighed most heavily on women. Even when the prices are posted, as one FGD participant noted, health service providers, “find arguments to pull more money out of patients.”82 Later in the same discussion, a FGD participant exclaimed, "It is only today that I learned hospitals give receipts!"83
Corruption impedes commerce and service provision throughout Guinea, and also emerged as a significant concern among respondents. In 2013, the Afrobarometer found that 45% of Guineans have paid bribes to access water or sanitation services,84 and more than 40% have paid a bribe for services at a pharmacy or hospital in the last 12 months.85 Corruption was a common theme in the KIIs and FGDs, whether addressed head-on (e.g., “There is lots of corruption and there is complete impunity”) or in more circumspect ways. People referred to corruption as “cases of abuse” or situations that should not happen. Women spoke more openly about problems related
80 Media Roundtable, Conakry, November 2017. 81 FGD, Conakry, November, 2017. 82 FGD, Conakry, November 2017. 83 FGD, Conakry, November 2017. 84 Afrobarometer, “Guinea | Afrobarometer”, http://afrobarometer.org/countries/guinea-0. Accessed December 19, 2017. 85 Afrobarometer and Stat View International, “Résultats de la 5ieme Série Des Enquêtes Afrobaromètre en Guinée, Troisième Dissémination,”, 17 December 17 2013, http://afrobarometer.org/sites/default/files/media- briefing/guinea/gui_r5_presentation3.pdf.
33 to corruption, especially related to payments or bribes to health service providers for medicines, medical supplies and health services, including childbirth for which, officially, no fees should be charged. As one health professional lamented in Faranah, “we must stop midwives from asking for money, because now the women prefer to give birth at home; people are going to traditional midwives” who provide services outside the formal health system.86
Patient Services. Clientelism and discrimination were also described in the FGDs, as participants from around the country reported being refused service or others receiving preferential treatment. One woman in N’Zérékoré complained of health workers refusing emergency cases, selectively choosing whom to assist based on familial/ethnic lines.87 Women reported challenges with the health system with far greater frequency than men, and highlighted dissatisfaction in the public system when giving birth. Problems noted included lack of preparation by some midwives and being required to pay for standard materials used during labor and delivery, which should be free. In a KII, a senior MOH official reported that the Ministry had made a significant effort to publicize that childbirth was free. However, this individual also noted that associated services and materials are not all covered and that these costs have not been as well-publicized.
Women, along with people with disabilities (PWDs), were the most vocal in FGDs to express their distrust of the health system. They reported several different issues ranging from child delivery practices to PWDs not receiving proper consideration or being able to physically access health facilities. As one PWD said in a FGD in Kindia, there are times when, “people with disabilities are abandoned at the hospital [and do not receive care], even if they are the first ones to arrive. We find it hard to be satisfied [i.e., to receive appropriate care].”88 PWDs also reported feeling disrespected by health providers; as one reported in a FGD, “I go to the health services when I am sick, but they don’t care about me as a handicapped person, and I leave unsatisfied.”89
Management and Accountability. In FGDs, health workers offered explanations for poor management, staffing, and supplies in national and regional hospitals and in small clinics. They described a lack of management skills and appropriate devolution of duties to the regional and local level, insufficient specialization among medical professionals, overconcentration of Guinea’s limited specialists in Conakry, and problems incentivizing medical workers. Even service providers remarked that a lack of transparency hinders their work and that materials are not appropriately transferred to regional hospitals.90 They also offered positive examples of individual leaders creating new procedures to ensure accountability, such as daily staff meetings.
Accountability, including absence of control, monitoring and evaluation of health services and lack of sanctions for poor performance, were the most commonly cited problems in roundtables and focus groups across all stakeholders. The EVD outbreak further eroded faith in health workers and reinforced a sense of a lack of accountability, with respondents citing health
86 Roundtable, Faranah, October 2017. 87 FGD, N’Zérékoré, October 2017. 88 FGD, Kindia, November 2017. 89 FGD, Kindia, November 2017. 90 FGD, Faranah, November 2017.
34 workers abandoning their posts during that period as a reason for their lack of confidence in health workers and the health system.91
Women respondents in all-female FGDs brought up accountability more than men or women in mixed groups. They emphasized the low quality of health services and placed the responsibility for improving the health system on the government. In KIIs and in the roundtables, male and female respondents recommended that the central government and governors insist on greater accountability from health officials.
Satisfaction
The data collected for this baseline on citizen satisfaction was mixed, making it difficult to assess the degree of citizen satisfaction with certainty. When asked specifically in the household survey to characterize their level of satisfaction with all health services received, only 4% of citizens reported being dissatisfied, 28% of citizens reported being very satisfied with healthcare services and 52% reported being satisfied with services. Only 16% said they were a little satisfied and 4% said they were not satisfied. Responses were similar even when disaggregated by a variety of differentiators (age, sex, region, etc.). The one key variant related to PWDs who reported less satisfaction with health services: 36% of PWDs reported being very satisfied and 25% satisfied with health services compared to 28% of all respondents who were very satisfied, and 52% who were satisfied.
However, other data from the household survey, this study’s qualitative data and other reports do not support these responses, as highlighted by the findings shared above. Participants complained of poor and opaque management, a lack of accountability and widespread corruption in the health system. Participants in qualitative methods often started with less critical comments before sharing issues of concern and specific examples of dissatisfaction. While participants described using health services, and indicated that they were satisfied with some specific services, especially as it related to vaccination campaigns, qualitative feedback consistently showed dissatisfaction with the quality of healthcare and low confidence in both healthcare providers and the MOH, including the national pharmacy. This sentiment was shared by participants from all regions. Guineans with higher socio-economic status were particularly critical of access to and quality of public healthcare services.
When asked to identify issues of concern, participants noted the need for further training of personnel, availability of services, and behavior of health center staff, high and inconsistent prices for services and medicines, corruption and a lack of accountability. A triangulation of quantitative data collected through the household survey and data collected qualitatively through roundtables, FGDs, and KIIs identify other factors that may contribute to low quality healthcare and low levels of confidence in the system, including a lack of transparency in the medical system and a hesitancy in discussing healthcare. Many participants in the FGDs were initially more reserved and circumspect in their comments early the discussions and only opened up with more detailed feedback as the conversations evolved. Further, as both a public medical doctor and civil society activist put it, the health sector is not very “open.” KIIs stated that many
91 FGD, Conakry, November 2017. 35
Guineans neither saw health care as a right nor believed that one can, much less should, ask questions of a health professional about care. As youth focus group participant noted: “The population does not know if they have the right to ask what is happening in the health services so we must raise awareness of the population for them to understand that they have the right and the duty to ask when they use health services.”
5.2.2 Conclusions The data indicate that many if not most Guineans share a common understanding of the challenges facing health service delivery. The issues discussed were similar across different respondent groups: government and communal representatives, medical professionals and community members including women, youth and PWDs. Healthcare utilization rates are very low compared to neighboring countries and are impacted by both supply and demand factors. Health facility management directly impacts low utilization rates. Unavailability of adequate medical practitioners and medicines were commonly cited by respondents, along with limited transparency and accountability. Women, the most frequent users of the healthcare system, and PWDs faced more obstacles accessing quality healthcare than their male and/or non-disabled counterparts. Similarly, discrimination and perceptions of poor client services influence low utilization rates. Women and PWDs also encounter higher levels of discrimination, and are more frequently asked to pay bribes or other illegal fees for services and materials.
The low quality of care provided by healthcare structures is a top concern across social groups in Guinea. Access to and the quality of healthcare is determined by wealth and geography. Guineans with higher socio-economic status were very critical of the healthcare system, Pe, have access to higher quality services. Rural Guineans encounter a myriad of obstacles to accessing quality healthcare including long travel distances, and the facilities that they use are less likely to have adequate health personnel, equipment, and medicines.
While COSAHs exist in most communities, health service providers, media representatives, youth, women and PWDs all find they are not creating the accountability required to improve the level of care across health facilities in Guinea. For example, the practice of charging more for services than the official prices is common.
The degree of satisfaction reported in the household survey is likely a “satisficing” response, a documented phenomenon in which respondents choose socially desirable responses (among other satisficing tactics), given other quantitative and qualitative data from this baseline and other studies. When satisfaction was addressed in FGDs, roundtables and KIIs, trends of dissatisfaction, quality, integrity, and discrimination emerged as respondents gained confidence that they could engage in open discussion. For example, women participating in focus groups offered many examples of problems with maternity services. The finding of satisfaction with specific services such as vaccinations is more likely to be valid given the specificity provided by respondents about their satisfaction with those services. In addition, it should be noted that only 42% of respondents mentioned having information on how their local health facility is managed, and that community expectations are likely low. Thus, the data likely indicates that satisfaction is neither uniformly positive or negative but, rather, that Guineans have nuanced attitudes about satisfaction. As a result, reliance on the statistic that 80% of Guineans reported satisfaction with health services as a guide to inform programming or as a measurement of performance would
36
lead to poorly-designed initiatives and is unlikely to be indicative of the degree of improvement in health service delivery and user recognition thereof.
5.3 Citizen Knowledge of and Involvement in the Health System 5.3.1 Findings Knowledge among Guineans of health policies and ongoing reform efforts is low based on survey and qualitative data. This finding is valid not only for citizens, but also for members of the NA, NA staff, state officials, health professionals and journalists. Even communication within the NA appears to be less than adequate, as some interviewees who are important to advancing health reform were not aware of colleagues’ work on health issues.
In the household survey, 42% of household respondents (38% urban, 49% rural) indicated that they were aware of how their health facility is managed. This is higher than the 2012 DHS that found, regardless of education status and literacy, fewer than 25% of all Guineans (23% urban, 18% rural) identified as being informed about the functioning of their health facilities. Knowledge of local health service management varied by gender and ethnicity in the household survey. Men in the household survey were 9% more likely to report knowing how their health systems are managed (46%) than women (37%) (see Figure 8).
Figure 8: Respondents with Figure 9: Respondents reporting knowledge of health facility knowledge of health facility management by gender and management by ethnicity 60% majority/minority ethnicty 90%
50% 80% 77% 50% 70% 38% 40% 60% 34% 35% 50% 46% 47% 30%
40% 33% 35% 20% 28% 28% 30% 22% 10% 20% 10% 0% Dominant Minority Dominant Minority 0% Ethnic Ethnicities - Ethnic Ethnicities - Groups - Females Groups - Males Females Males
Although PWDs comprise only 5% of the total survey responses, it is useful to note that they were less likely than other respondents to report knowledge of how their local health facility functions, with 62% of respondents saying they were aware of their health facility management. Forty-seven percentage of Malinké respondents and 46% of Peuhl reported that they knew how their local health facility functions with a drop among Soussou at 35%. Non-dominant ethnic
37 group respondents were less likely to report that they understood the functioning of their local health facility with one exception: 77% of Landouma responded affirmatively (see Figure 9). Gender differences in reported knowledge of health facility functioning were more significant among Soussou (22% women reporting affirmatively versus 46% of men).
Of the 42% of respondents who reported knowing how their local health facility operates, 37% said they received information about how health facilities work on the radio, 23% from members of health committees. Table 6 on the following page provides details on sources of information by place of residence.
As mentioned above, most respondents reported that they did not know how their local health facilities was managed and therefore could not report on their satisfaction. Of all survey respondents, only 33% of respondents (29% urban, 40% rural) believed that the health facilities are well managed with little variance across sex, age, and ethnicity. Respondents with more than a secondary school education were less likely than other respondents to believe the health facilities they use are well managed. These data also varied by region. Response rates with those reporting that they found their local health facility to be well managed: Mamou: 62%; Labé: 52%; Boké: 45%; Kankan: 45%; %; Kindia: 32%; Faranah: 20%; Conakry: 17%; Nzérékoré: 15%. Nationally, of those who reported being unsatisfied with these services, the most common complaints were high prices (73%) and a lack of medications (50%).
Table 6: Source of information about health facilities by place of residence Information Sources Urban Rural National Average Associations 9% 7% 8% Other sources 9% 11% 10% Health committees 19% 29% 23% Family/Friend 20% 19% 20% Written press 0% 0% 0% Radio 40% 34% 37% TV 3% 0% 2% Total 100% 100% 100%
Fifty-seven percent of survey respondents (female, 54%; male, 60%) reported awareness of the government’s efforts to improve the health sector in their communities. Levels of awareness varied across the seven regions. Whereas 75.6% and 75.4% of respondents in Labé and Mamou, respectively, reported awareness of ongoing improvement efforts, only 37.7% and 37.6% of respondents in N’Zérékoré and Conakry, respectively, reported awareness of these efforts.
Respondent populations reported highest levels of awareness regarding the existence of health committees. According to some participants, this widespread awareness was an outgrowth of the EVD outbreak. However, few respondents knew how members are selected, the responsibilities
38 of committees, or the activities implemented by committees.92 Qualitative data complement these findings that many Guineans do not understand how community health committees work.
Data also suggests that reported Demographic Urban Rural knowledge of health system management does not translate Woman representative 13% 19% into high civic participation. Just Youth (18-30) representative 13% 16% as the majority of Guineans Older (51+) person 8% 4% surveyed were not familiar with Local elected official 8% 6% the management of their health Health worker 43% 25% facilities, few were involved in Community member 11% 27% the management of these health Other 4% 3% facilities. The household survey found citizen involvement in Table 7: Survey of citizen involvement in local health local health system management system management to be low. Only 14% of household respondents (12% urban, 18% rural) who stated knowledge of their health facility management also reported involvement in their health systems. Ten percent of female respondents and 17% of male respondents reported being involved in health facility management, with regional differences evident (see Table 7).
Low civic participation in health governance was confirmed by KII respondents. Nearly 40% of survey respondents reported a lack of interest in participating in the management of local health facilities. Only 24% reported feeling excluded from participation, with the highest rates of exclusion reported in Labe (41%) and among respondents 51 years of age and over (35%). Figure 10 provides additional information disaggregated by reason for non-participation and region. Among respondents who reported that members of their community participate in the management of local health facilities, the majority (36%) reported participation through health committees. This was particularly true in Kankan, with 53% reporting involvement in health
92 FGD, Conakry, November 2017. 39 committees, and Mamou, with 44% reporting involvement in health committees. In contrast, Labe reported the highest rate at 48%.
To the extent citizens are involved in health governance, the household survey and qualitative research indicated that the minority of active Guineans are primarily involved through health committees – the most common type being the government-created Health and Hygiene committees. Participation was not strictly limited to being a member, but worded more inclusively to capture other forms of involvement with committees such as contacting a member or attending a committee meeting. Survey respondents also reported being involved in local information-sharing activities and community forums, although to a much lower degree. A number of FGD and roundtable participants also stated a need for suggestion boxes in health facilities as a means for increasing civic engagement and documenting issues with service provision to promote improvements (see Figure 11).
While COSAHs represent the primary point of entry for civic engagement in health governance for most Guineans, they are a not a panacea. Study participants who had observed or engaged with a COSAH reported feeling frustrated and excluded from meaningful participation in COSAHs. Respondents shared that they were unable to participate as they were not part of the small clique within the committee that makes decisions.93 The small size of COSAHs may contribute to this dynamic - as noted earlier, the 2017 Health Policy reduced the composition of the COSAHs to seven members. Even if a COSAH has full membership, respondents indicated that the majority of COSAHs are not operational, and that active COSAHs are primarily managed by a few individuals.94
Further impairing the functioning of COSAHs and effective participation of community members is the high level of illiteracy. Some study participants suggested that illiteracy impedes more robust participation. For example, they noted that when illiterate community members are appointed to COSAHs, they are excluded because management procedures, to the extent they are written and distributed, are usually only understood by literate committee members who can thus more readily control the work of the committee itself. Eventually, feeling excluded, members who are illiterate stop attending meetings.
93 FGD, Boke, October 2017. 94 FGD, Kindia, October 2017. 40
Youth study participants were the most vocal about the lack of civic participation related to health reform and the need for citizen engagement to improve health services. They expressed an eagerness to be involved, but said that they were that are not taken seriously and not invited to take part in discussions in committees or other forums. Participants had differing views on the extent to which women’s participation is welcome, another factor that may affect participation rates. In discussion groups, men were more likely than women to that believe women’s points of view are taken into consideration in health-related meetings.
In FGDs, youth emphasized the importance of awareness raising and education, seeing it as a necessary first step before citizens can claim their rights. As one Youth FGD participant in Mamou expressed, “The people must be involved and make them understand that the hospital is for them, but we are never included (…) It is necessary to invite the actors involved, go through the media to inform.”95 A youth FGD participant in Kindia echoed this sentiment: “The population does not know if they have the right to ask what is happening in the health services so we must raise awareness of the population for them to understand that they have the right and the duty to ask when they use health services.”96 Some health workers echoed these sentiments. One FGD participant said that, to create dynamic health committees, citizens must be made aware of laws and policies so that they can take ownership of the ongoing reforms.97 Media members saw an important role for media in increasing awareness and improving services. As one member of the media said, “For the implementation of a better communication policy, we need the effective involvement of grassroots citizens, raising awareness and encouraging citizens to come to the hospital, building trust between citizens and health staff, transparency.”98
A number of respondents noted that the economic situation for most Guineans is not favorable to community service, and that the lack of remuneration is a barrier to participation. People’s time must be in large part focused on earning a living. To demonstrate this point, a COSAH member reported that health committee members in a prefecture were given 7,000 GNF (80 cents) for transport and per diem to attend a COSAH regional coordination meeting. The individual went on to say that the community representatives felt belittled by more educated COSAH members and generally unvalued by them, which discouraged their participation. Other respondents also commented that health committee members would need financial incentives to participate in these local and regional structures.99
Despite these barriers and challenges to civic participation, the GoG officially welcomes civil society engagement in the implementation of health reforms, and health providers and government officials reflected this view in FGDs and Roundtables. In his opening to the PNDS, Minister of Health Abdourahmane Diallo wrote, “I invite all actors working at the community level to put their efforts together in the service of the community, while respecting the guidelines outlined in the policy. I am convinced that the actions carried out at the grass-roots level will
95 FGD, Mamou, October 2017. 96 FGD, Kindia, October 2017. 97 FGD, Faranah, October 2017. 98 FGD, Conakry, October 2017. 99 FGD, Kindia, October 2017. 41 have a significant impact on the well-being of the population.” Media representatives in FGDs also frequently mentioned the importance of citizen engagement for the success of reforms.
However, CSO leaders, civic activists and community representatives emphasized the importance of the government in spearheading health reforms and noted that more robust civic engagement would require government action to promote citizen involvement. Similarly, several FGD and some roundtable members placed the bulk of the responsibility on the government for educating the population on the new reforms and their rights and responsibilities, and for enforcing appropriate standards of care and creating accountability among health service providers. As one woman said in a FGD in Boke said, “The government needs to put a structure within the neighborhoods that can convey our recommendations.”100 A PWD shared this view, and said, “We are asking the government to improve the current health system to provide hygiene and supply hospitals with basic necessities […] Also, sanctions must be imposed whenever there is serious misconduct.”101
5.3.2 Conclusions Citizen knowledge of the health system and ongoing reforms is low. A large share of Guineans admits to not having knowledge of health reforms and management of their local health facility. The lack of understanding about how COSAHs are supposed to function can translate into a perceived lack of transparency and create a sense of exclusion. Even those who have basic knowledge about health governance may not consider their knowledge to be sufficient to assume leadership in their community. Only a small minority of citizens are active trying to improve health governance. While health and governmental stakeholders state that civic engagement is welcome and even necessary, the extent to which citizens themselves hear that message and see it being put into practice is unclear.
COSAHs are seen as the primary mechanism for citizen engagement in health governance, and for fostering greater accountability in health service delivery. However, COSAHs’ limited functionality and their failure to create opportunities for citizen feedback beyond their memberships means that COSAHs have not lived up to the expectations articulated by the MOH and MATD that the COSAHs will serve as a robust instrument for citizen engagement. Even if a COSAH is fully staffed, a seven-person committee it will not serve as a significant means of citizen engagement unless the committee members energetically reach out to the community. It is also not clear that the MOH has adequately staffed positions and trained personnel to support the effective functioning of COSAHs. Persons assigned to such positions do not appear to have incentives or other administrative levers to use to induce better performance of the COSAHs they are supposed to support.
Socio-economic factors such as income and education level pose additional obstacles limiting citizen understanding of and ability to effectively participate in health reform. Moreover, it is important to recognize the high opportunity cost of volunteerism for individuals of limited economic means who must work long hours to secure life’s necessities. In addition, the extent to
100 FGD, Boke, October 2017. 101 FGD, Boke, October 2017. 42 which the participation of women and youth is universally welcomed and valued also merits further attention given that many reported the opposite experience.
Although many citizens describe a desire for involvement in health service oversight and reform, it was clear that citizens place the responsibility for improving health services squarely on the shoulders of government. Guineans surveyed did not articulate an understanding of citizen responsibility to ensure effective service delivery, and their comments suggested a passive view of citizen engagement. For instance, respondents often named suggestion boxes as an important tool for increasing civic engagement. Suggestion boxes can be helpful if decision makers respond to recommendations and communicate how they are being responsive. However, even in these cases the boxes do not represent an example of sustained engagement. Moreover, the ability of Guineans to use them broadly is limited by the high illiteracy rate.
Moreover, it is important to acknowledge Guinea’s recent political history when assessing civic participation in health governance, and the extent to which Guineans rely on public health facilities for health care. Since independence, civic activism has largely come at great personal risk. While Guinea is no longer an autocratic state, civic engagement to promote health reform is likely perceived to involve some risk. It is challenging in any context to criticize a person or institution on which one is reliant. In this case, health reform advocates should carefully consider the personal implications for Guinean citizens who become more active in health governance and respect partners decisions on what challenges they want to tackle. These individuals are likely going to have to criticize the performance of medical professionals to whom they must later turn for health services. To the extent that the formal health system is used, most Guineans rely on public health facilities and cannot afford private care.
Despite these challenges, assessment findings indicate one clear point of entry to increase civic engagement in health reform. Youth seem eager to participate if meaningful opportunities are offered to them. Women are also critical stakeholders in health reform, as they are the primary caregivers in their families. Persons working to improve health services need to consider how to effectively reach and engage women as advocates for health reform in a way that is empowering and does not reinforce culture norms limiting caregiving to women.
5.4 Civil Society Engagement on Health Reform 5.4.1 Findings Guinean CSOs have played pivotal roles in recent years, contributing to the peaceful resolution of an electoral crisis in 2015,102 and responding to the EVD outbreak, even as the health system failed to provide adequate information on preventing and containing the disease. This increased effectiveness has strengthened their public image as reported in previous studies,103 and as seen
102 USAID, “2015 CSO Sustainability Index for Sub-Saharan Africa”, Bureau for Democracy, Conflict, and Humanitarian Assistance, Center of Excellence on Democracy, Human Rights and Governance, Bureau for Africa, Office of Sustainability, 2015,“2015 CSO Sustainability Index for Sub-Saharan Africa”, Bureau for Democracy, Conflict, and Humanitarian Assistance, Center of Excellence on Democracy, Human Rights and Governance, Bureau for Africa, Office of Sustainability, 2015, p.89. 103 Ibid.
43 in KIIs. As one CSO leader recounted in a KII, since the EVD outbreak, CSOs have increased their focus to development activities, especially health governance and community involvement, and are less focused on political aims than they were before the crisis.
In addition, CSO partnerships with government have increased.104 CSOs participated in the revision of several laws and policies (for example, the Mining Code, the Electoral Law, and recent Security Sector and Civil-Military Relations reforms). CSO networks and national NGOs have undertaken a number of initiatives to promote civic engagement, monitor public policy implementation, and advocate for greater governmental transparency and accountability. CSO- led public policy and government action monitoring initiatives include the creation of the Citizen Center for the Analysis of Public Policies at the headquarters of Le Conseil National des Organisations de la Société Civile Guinéenne and the CSO Platform for the Promotion of Health and Vaccinations (POSSAV). CNOSCG and the Alliance pour la Promotion de la Gouvernance et des Initiatives Locales (AGIL) are actively represented at the national level in all the major multi-sectoral platforms led by the Ministry of Health. They participated in the development and validation of the Sanitary Development Plan, the National Health Policy, the National Community Health Policy. As we heard in KIIs, they are members of the Health Sector Coordination Committee, presided over by the Minister of Health, the WHO initiated Health Sector Political Dialogue, and the Community Health Implementing Platform (Plateforme des Intervenants en Santé Communautaire).
Study participants echoed Afrobarometer's 2016 finding that 65% of Guineans believe they have a civic responsibility to complain to government officials if public services are not of good quality.105 Media, health workers, and appointed and elected government officials stated that they expected the engine for increased accountability in the health system should come from civil society. Many respondents identified the key role civil society can play in educating the public about health reforms, especially by making information about the reforms available in simplified language. Civic groups will need to improve their outreach to these populations and demonstrate their potential to them to increase participation.
Findings from interviews with Guinean civil society leaders indicate that CSOs played an instrumental role during the EVD outbreak. In many cases, CSOs and CSO networks responded rapidly to the EVD outbreak, serving as a conduit between communities, health officials and international partners, and focusing on awareness and information programs.106 CSOs that worked with international donors during the EVD outbreak, especially those working with international donors for the first time, increased their organizational capacity.107 CSOs also highlighted their capacities for promoting citizen education and mobilization during the
104 Ibid. 105 Afrobarometer, “La Moitié des Guinéens sont Intéressés par les Affaires Politiques ; la Plupart Déclarent Être Libres d’adhérer à une Organisation de leur Choix. http://afrobarometer.org/press/la-moitie-des-guineens-sont- interesses-par-les-affaires-politiques-la-plupart-declarent-etre. Accessed 19 December 2017. 106 Richards, Paul, Ebola: How a People’s Science Helped End an Epidemic, Reprint edition (London: Zed Books, 2016). 107 USAID, “2015 CSO Sustainability Index for Sub-Saharan Africa”, Bureau for Democracy, Conflict, and Humanitarian Assistance, Center of Excellence on Democracy, Human Rights and Governance, Bureau for Africa, Office of Sustainability, 2015, p.89, https://www.usaid.gov/africa-civil-society. 44 epidemic. Having successfully implemented a range of activities nationwide, civil society succeeded in supporting communities, especially those hard-hit by the EVD epidemic, to overcome resistance to outside assistance and increase their understanding of the disease. Government officials as well as international interviewees confirmed that CSOs such as AGIL and Centre Africain De Formation Pour Le Developpement (CENAFOD), to name just a few, were key players in preparing communities to accept outside intervention during the EVD outbreak. CSOs established stakeholder coordination platforms and citizen watch committees and conducted community trainings. CSOs’ success confirmed for state officials and service providers the importance of civil society in the implementation of health reforms. As a result, CNOSCG, PRODEJ and CSOs such as CENAFOD and AGIL have modified their strategic planning and programming to prioritize health issues, governmental accountability and civic engagement, building on their community development experience. Thus, CSOs are now better prepared to continue health-focused activities thanks to the hard-earned organizational capacity gained during the EVD outbreak.
Despite these advances, the sector continues to face numerous challenges. Feedback elicited during interviews with civil society leaders and other informed Guineans noted that many CSOs are politicized or perceived as such, making it difficult to build vibrant networks and constructive dialogue. Personality politics and leadership quarrels were also cited as impeding stronger collaboration across organizations, with individuals vying for position over working together to address mutual priorities. Networks also struggle to differentiate their role from those of their member organizations, failing to define and articulate the network’s distinct benefits for their members. For example, respondents indicated that the CSO network CNOSCG operates more as an NGO, rather than a CSO network. They further stated that CNOSCG does not adequately focus on representing the interests and voices of its member organizations. Additionally, civic organizations of all kinds face organizational constraints. Capacity gaps include low data utilization and analytical capabilities, limited use of evidence-based decision- making, insufficient monitoring and evaluation, and weak financial and organizational management. Finally, CSOs have not yet cultivated a culture of social accountability and transparency through their engagement with individual members and/or organizations that they seek to represent. For example, one of the prime responsibilities of several medical professional associations is to foster high ethical standards and ensure quality service delivery. The Association of Private Medical Doctors, the National Order of Medical Doctors and the National Order of Pharmacists have not yet promoted health reform energetically within their respective memberships.
5.4.2 Conclusions Despite civil society’s important contributions to Guinea’s political transition and marked improvements in the operating environment since 2010, Guinea’s civic organizations continue to face numerous barriers to improving the effectiveness of their initiatives. Engagement levels among citizens, CSOs, and government remain low. At the same time, the EVD outbreak did push civil society to grow, as civic-governmental collaboration increased and EVD provided the impetus for CSOs to expand further into the health sector. During the EVD outbreak, CSOs proved instrumental in ending the epidemic by engaging with the citizens of Guinea; and, as a result, relations between the GoG and civil society improved. This strengthened relationship has created a more conducive environment for civil society to engage in governance and health
45 reform issues. Additionally, CSOs who received donor funding during the EVD outbreak are well-placed, both organizationally and operationally, to continue working in the health sector. Post-EVD, CSOs have retained their interest and engagement in the health sector and local governance, reinforced by projects such as Faisons Ensemble.
For civil society to deepen its involvement in health governance, a number of challenges must be addressed. While there is an increase in CSO engagement and interest in the health sector, only nine percent of all registered CSOs in Guinea are dedicated to or specialize in the health sector. To promote citizen engagement in health reform nationally, CSOs must position themselves to represent their constituents across all regions and communes. In addition, CSOs must devise strategies to overcome individual obstacles to increased civic engagement. Two-thirds of Guinea’s citizenry believe they have a civic duty to complain about the low quality of public services,108 but our research has found that they do not view citizens as responsible for improved governance, nor do they know how to engage, particularly in an organized fashion, which is likely to have a greater impact. Women, youth and PWDs do not identify CSOs as key actors in health governance, and do not recognize CSOs as a conduit for their own engagement in health governance. To increase the scale and effectiveness of civic engagement, CSOs will have to find the key for translating Guineans’ latent interest in improving health services into activism.
In addition, civic organizations and civil society as an ecosystem must build a variety of core capacities for it to be more effective and more sustainable. Core competencies from project, financial and administrative management need to be deepened. CSOs and their networks must learn how to better collaborate with one another and communicate more effectively. CSOs must also better engage and listen to the constituencies that it seeks to represent which, in turn, will help them to better mobilize those constituencies. Other advocacy skills would also help CSOs to advance health reform: improving research and use of evidence as well as media engagement and learning to create free earned media to increase public awareness and research.
5.5 Media Engagement on Health Reform 5.5.1 Findings Enabling Environment
Guinean media work in a challenging operating environment. Guinea is consistently ranked among the worst countries for transparency and freedom of the press. Freedom House classifies Guinea as “Partly Free” and Guinean media as “Not Free.”109 Constitutional and legislative changes in 2010 did improve the legal framework for media, for example by providing for press freedom in the constitution, removing prison penalties for press offenses, and narrowing the definition of defamation. Yet, legal framework problems remain. Defamation against the head of state, members of parliament, the military, and other government institutions, as well as against particular ethnic and religious groups, are criminal offenses, as is reporting falsehoods. In June
108 Afrobarometer, “La Moitié des Guinéens sont Intéressés par les Affaires Politiques ; la Plupart Déclarent Être Libres d’adhérer à une Organisation de leur Choix. http://afrobarometer.org/press/la-moitie-des-guineens-sont- interesses-par-les-affaires-politiques-la-plupart-declarent-etre. Accessed 19 December 2017. 109 Freedom House, “Freedom in the World 2017,” 24 January, 2017, https://freedomhouse.org/report/freedom- world/freedom-world-2017. 46
2015, the NA moved to strengthen punishments for several of these offenses, advancing legislation that provides for up to five years in prison and heavy fines for insulting or publishing false news about the president and other public officials. These changes were incorporated into new criminal code, passed in 2016. Additionally, in June 2016 a cybersecurity law was passed that criminalized online defamation of public figures and the dissemination of false information. This law was presented as a national security measure and included punishment for information “likely to disturb law and order or public security or jeopardize human dignity.”110 Media professionals also face government repression of press freedom as evidenced by the closure of radio stations during the 2015 electoral campaign, as well as physical attacks on journalists that resulted in four documented deaths since 2014 and cast a shadow over the Guinean media landscape111. Media professional also face significant difficulties in sustaining financially-viable media operations. Moreover, it is common to pay journalists to cover an event, and some radio stations have a clear pricing list for such coverage.
Guinean use of media
Despite these difficult working conditions, the media is vital to meeting the Guinean information needs. Radio is the primary source of information for most Guineans, as documented in multiple studies including the CIHG household survey and a June 2017 SFCG report. The same SFCG report found that Guinea has 60 public and private radio stations nationwide. The CIHG survey found that radio is the primary source of health reform information for 59% of Guineans, with little variation among ethnic groups and sexes and no notable difference between rural and urban populations. The key variation in radio as the primary source of information was by region. In Boké, Faranah, Kankan, Labé and Mamou, the percentage of respondents relying primarily on radio was 60-69%. However, in Conakry, it was 52% of respondents, while in Kindia and N’Zérékoré it was only 42% and 39%, respectively. Word of mouth, the second most common source of health information (19% overall), did not vary greatly between rural and urban respondents, yet survey revealed high variances between urban/rural respondents in their use of television for information. While urban Table 8: Sources of Information on Health citizens rely on television, their rural Sector Reform counterparts are more likely to turn to their Mode Urban Rural places of worship. This complements Radio 60% 58% television ownership data that skews overwhelmingly urban. Twenty-six percent TV 10% 1% of Guinean households had a television in Press (including writing) 1% 0% 2012: 68% of urban households had a Social media 3% 2% television, compared to 5% of rural Word of mouth 18% 22% households.112 Most respondents did not cite Mosque/Church 6% 12% written media as a key source of information Other 4% 5% (see Table 8).
110 Ibid. 111 CIVICUS, “CIVICUS - Tracking Conditions for Citizen Action”, and Freedom House, “Freedom of the Press 2016 Report”, https://cpj.org/data/killed/, https://freedomhouse.org/report/freedom-press/2016/guinea. 112 Institut National des Statistiques, “Guinée : Enquête Démographique et de Santé à Indicateurs Multiples 2012”, November 2013, p.21, http://dhsprogram.com/pubs/pdf/FR280/FR280.pdf. 47
Media program listening habits differ by region. In the interior of the country, including in the urban communes, the most listened to/followed broadcasts are community programs in local languages, entertainment programs, street interviews and the national news broadcast. In Conakry and other major cities, listening habits are much more focused on news programs on social, economic and political issues, interactive programs such as quizzes, and entertainment programs.113
Youth and adult media users also report different listening preferences. Youth are more focused on interactive programming (broadcasts where people react online or by phone by asking questions or giving their point of view) and entertainment radio programming while adults tend to focus more on street interview programming (interviews representing the voice of the population, or programs where journalists interview people on the street on a specific topic). However, both youth and adult listeners follow news broadcasts.114
In terms of telecommunications and internet access, connectivity is far from universal. Yet, telephone access is increasing rapidly. One 2012 study found that an estimated 50% of individuals had access to telephones.115 Another 2012 report found that 95% of urban households and 51% of rural households had access to a mobile phone,116 but a 2016 study found that 84% of households have access to a mobile telephone.117 Internet access is estimated to be far less. with only 5% of the population connecting to the internet in 2015.118 This is a decrease from 2013, when Afrobarometer found that 91% of Guineans never connected to the internet.119 Internet access, especially via smartphone, is increasing at a rapid pace with 22% of Guinean households reporting access to smartphones120. A SFCG study found that users in this age group spent two hours browsing the web during the workday and on average 3.75 hours during the weekend. Among this age group, 38% connect at the cyber cafe level, 48% through their smart phones and 15% through personal computers.121
Access to these technologies is likely to be highly gendered. While specific statistics are not available for Guinea, there is an estimated 45% gender gap in mobile phone ownership in Niger. In Kenya, the gap is estimated at 8%.122 Based on these and other studies, it is highly probable
113 SFCG Analysis of Media Ratings in Guinea 114 ibid. 115 “Guinea Telephone Statistics: Number of Fixed Lines, Mobile Phone Penetration Rate | Economic Statistics and Data Points,” accessed March 28, 2018, http://www.economywatch.com/economic- statistics/Guinea/Telephone_Statistics/. 116 Institut National des Statistiques, “Guinée : Enquête Démographique et de Santé à Indicateurs Multiples 2012”, November 2013, p.20, http://dhsprogram.com/pubs/pdf/FR280/FR280.pdf. 117 Institut National des Statistiques, “Guinée : Enquête Démographique et de Santé à Indicateurs Multiples 2016”, July 2017, p.iv. 118 République de Guinée, “Stratégie de Relance Socioéconomique Post-Ebola 2015-2017” June 2015, p.14. 119 “Guinea | Afrobarometer.” 120 Institut National des Statistiques, “Guinée : Enquête Démographique et de Santé à Indicateurs Multiples 2016”, July 2017, p.iv, 121 SFCG Analysis of Media Ratings in Guinea 122 GSMA, Connected Women 2015, Bridging the Gender Gap: Mobile Access and usage in Low- and Middle- Income Countries, https://www.gsma.com/mobilefordevelopment/wp- content/uploads/2016/02/GSM0001_03232015_GSMAReport_NEWGRAYS-Web.pdf, 48 that a gender gap also exists in Guinea related to ownership and usage control of family phones, radios and televisions.
Health Reporting Guineans see the media as an important actor in advancing health reform. Complementing the survey data described above regarding media programs and health reform information, focus group respondents and roundtable participants frequently mentioned media as critical vehicle for promoting health reform implementation. While media was frequently mentioned as a critical component of health reform implementation, few qualitative respondents identified media as a medium for improving health facilities.
As stated above, radio is an important source of information for Guineans about health and health reform. All but one CIHG’s 31 partner radio stations (half of the national total) broadcast a program on health. SFCG has Sixty-three percent of radio stations interviewed for this study indicated that they report on pathology-related topics such as malaria, EVD, heart disease, and diabetes. Thirty-seven percent indicated that they have broadcast programs on health reforms. Health reform programming was created with support from international partners such as the USAID-funded Health Communication Capacity for Collaboration project and UNICEF. To a lesser degree, radio stations report on health reform issues: less than 20% of respondents indicated that they have ever broadcast a program on health reform. In terms of frequency, all radio health programs broadcast weekly; 60% of stations reported rebroadcasting these programs at the request of listeners. CIHG media partners interviewed reported that they have received very positive listener feedback on these programs, and said they believed their health programs to be among the most popular programs. While some radio stations reported collaboration with other stations to cover topics of national interest, such as elections and the EVD outbreak, similar collaboration on health governance programming has not yet occurred.
In addition to radio, respondents mentioned the Association of Health Journalists as an important media player. The Association represents audio-visual media, online and printed press actors that focus on providing quality information on health issues. The assessment also surveyed members of the Guinean Association of Bloggers (ABLOGUI), a group of journalist bloggers working on social issues in the mining regions, and the Association of Journalists for Sustainable Development, which focuses on investigative journalism in the areas of public health and environment. All expressed interest in promoting better quality health services, but did not mention health reforms. When asked why, respondents mentioned their lack of knowledge of health reforms.
To overcome these and other challenges, media actors require improved access to improved access to information, and improvements in reporting capacity and investigative journalism. Media respondents cited the lack of documentation and data on reforms and lack of communication with reform authorities as a primary barrier to expanded reporting. Respondents similarly indicated that journalists are not proactive and do not seek out information; instead, they report on readily accessible information. In return, media respondents stated that they are not opposed to increased health reporting if they have access to credible information. It was also noted that journalists need capacity building, including education on health sector reforms. Other respondents, especially in the interior of the country,
49 expressed needs that affect not only health reporting but journalism overall: reporting kits, motorized vehicles for journalists to collect news, communication/phone credits for contacting speakers in broadcasts and news sources, etc. Rural media outlets face additional obstacles such as access to appropriate infrastructure and equipment for broadcasting.
When asked about the relationship between civil society and the media, respondents reported regular cooperation between the sectors. They stated that CSOs routinely contact media when they have events to publicize, and that media outlets regularly reach out to CSOs for information in turn. In the case of health reform, media professionals from throughout the country expressed concern that CSOs, like the community in general, were not well informed and therefore could not help journalists to better report on health reform. Media participants reported receiving most of their information from international organizations such as UNICEF, Plan International, Jhpiego and the USAID-funded Health Communication Capacity Collaboration (HC3) project.
5.5.2 Conclusions
Despite the 2010 improvements in the media enabling environment, some of which survived beyond the 2015-2016 legislative changes, Guinean media actors continue to work in a challenging context. The press repression and attacks on journalists described above present significant risks to media professionals when covering difficult topics. As a result, there are sensitivities around more in-depth coverage of health reform and the resulting implications for government officials – for example, coverage of misappropriation of health funding or delays in decentralization of funding because of competing interests in control over the budget.
At the same time, there is potential space for increased coverage of health reform, and there are journalists and media platforms successfully covering health issues and other key sectors. Based on feedback from study participants, Guineans are eager for news programing, including information about health reforms. Given this finding, it seems that media is an under-utilized tool in disseminating relevant information, especially news regarding civic efforts to improve health services and opportunities for community involvement. Many journalists and outlets appear eager to increase and improve their health reform coverage, but require support to better understand the link between health reform and improvements in health services, thereby incentivizing expanded coverage.
Radio, the primary source of information for Guineans, already includes health programming, and media respondents are interested in expanding their subject content to include health reforms. However, the lack of a requisite knowledge base to develop quality programming around health reform issues remains a challenge. Media outlets often do not have the financial bandwidth to hire health-specific reporters and pay for in-depth reporting. Journalists are not proactive in seeking out health-related information for use in reporting, sometimes due to a lack of demand, and health officials fail to use communication mechanisms to keep the media informed on health reforms, policies and performance results.
Information sharing is challenging in a low-literacy and low connectivity environment. Based on feedback from study participants, it appears that Guineans have an appetite for news programing including information about health reform and that the media is an under-utilized tool in
50 disseminating relevant information, especially news regarding civic efforts to improve health services and opportunities for community involvement. Radio, the primary source of information, is underutilized nationally with less than half of the population utilizing radio as an information source in the past week.
When considering media’s role in health reform, it is critical to bear in mind the varied media usage patterns by age, region and sex. No one programming approach will reach all Guineans and meet the needs of all Guineans. For example, while radio is the most important information source nationwide, television and newspaper/online outlets nevertheless play important roles in shaping the opinion of capital city residents and governing elites. Television usage is highest in Conakry, a critical population center. Likewise, written materials may be read by only a small percentage of Guineans, but if that readership is close to and/or has ready contact with the country’s decision makers then newspapers and online media have the potential for significant impact. By better understanding how different populations access information, people trying to advance health reform can improve their media strategies to improve health governance and service delivery.
Beyond traditional media, Guineans continue to rely on word-of-mouth information exchange, likely supported by mobile phone access. The majority of both rural and urban households have access to a phone. Thus, information from a family member watching television in Conakry may still influence someone in a rural area. Similarly, places of worship such as a mosque or church are also information sources, and social networks are becoming an effective platform for reaching urban youth. In rural Guinea, traditional communicators (such as oral historians, musicians and town criers) remain important sources of information as well. The Réseau National des Communicateurs Traditionnels (RENACOT), a network of traditional communicators, played an important role in the fight against Ebola. For those committed to advance health reform, attention to these other means of distributing information will be critical in reaching a wider cross-section of Guineans.
Civil society / media collaboration on promoting knowledge of and engagement in health reform issues is promising. Media and civil society have self-reported positive working relationships. CSOs regularly work together with the media as a tool for spreading news and educating the population. However, civil society and media seem to overlook the respective that roles both can play in monitoring stakeholders or denouncing distortions of the system. The potential of media and CSO interaction for promoting civic engagement in health reform is also largely unrealized. For example, civil society could better share their stories with media outlets so that they can report on civic efforts to advance health reform and explain how others might become involved in that particular initiative or in their own communities.
VI. CONSIDERATIONS FOR PROGRAM IMPLEMENTATION
The purpose of this baseline assessment was to capture the current status of health governance in Guinea, the reform process, citizen understanding of health governance and health reforms, and Guinean involvement in health governance as individuals, through civic organizations or via the media, and thus to provide qualitative and quantitative information to monitor the overall context
51 and assess program delivery over time. The team also identified several issues and opportunities to carefully consider to improve health governance.
Targeting CIHG Work. To select CIHG target areas, the analysis focused on three selection criteria: 1. Localities identified during the baseline where participation in COSAHs or other mechanisms for community participation in health facility management was low. 2. Alignment to the 40 pilot communes under the MATD-MOH Integrated Communal Development Project that cover all eight administrative regions (and which also overlap with some places where USAID is already working)123. 3. Complementarity and synergy with SFCG and other USAID projects.
Using the above criteria, CIHG presented the following table of target localities to USAID prior to publishing a request for proposals to support Guinean CSOs working towards CIHG’s program objectives. CIHG project will work in synergy with USAID funded projects in the following localities:
• Maternal and Child Survival Program and Health Service Delivery Project implemented by JHPIEGO in the following regions: Conakry, Kindia, Boke, Mamou, Labe, Kankan, and Faranah. • StopPalu implemented by Research Triangle Institute in Coyah, Forecariah, Kindia, Dubreka, Fria, Boffa, Boke, Gaoual, Koundara, Lelouma, Koubia, Labe, Tougue, Mali and Conakry’s communes of Ratoma, Matoto, Dixinn, Matam, Kaloum • Advancing Partnership and Communities implemented by John Snow in Kindia, Mamou, and Faranah. • Conflict Mitigation and Management by CRS in Kouroussa, Kankan, Matam, Matoto and Ratoma.
Table 9: Recommended Target Localities Urban Communes Rural Communes Region MATD-Convergence Other Communes Communes Kaloum, Dixinn, Ratoma, Conakry Not Applicable Matam, Matoto Kindia Samayah, Bangouya Forecariah Kindia Coyah Kouria, Maneah Telemelé Daramagnaky, Sarekaly Dubreka Boké Kamsar, Sangaredi-Tanene Boké Boffa Koba-Tatema, Doupro-Mankountan-Tougnifili
123 Among the criteria that the government itself used to identify the 40 communes were: their economic potential; the degree to which they lack basic social services and local public services; and community absorption capacity of a new influx of resources from this initiative. 52
Urban Communes Rural Communes Region MATD-Convergence Other Communes Communes Fria Saraboïdo, Koundara Youkounkoun Gaoual Mamou Dounet, Oure-Kaba Mamou Dalaba Pita Labé Daralabe, Sannoun Lelouma Djountou, Parawol Labé Koubia Fafaya, Gadha Woundou Tougué Fello Koundoua, Kollet Mali Balaki, Donghol Sigon Faranah Kissidougou Bardou Faranah Dinguiraye Banora Dabola Kindoye Kankan Gberedou-Baranama, Tokounou Kouroussa Balato, Baro Kankan Kérouané Banankoro, Damaro Mandiana Dialakoro, Kinieran Siguiri Norassoba, Siguirini N'Zérékoré Kobéla, Womey Gueckedou Bolodou, Fangamadou Macenta Semgbédou N'Zérékoré Beyla Gbackédou, Nionsomoridou Lola Bossou Yomou Bignamou
Augmenting transparency in health service delivery and health governance. Increased transparency in health governance is critical to improve citizen satisfaction and service delivery. The MOH – from the national level down to local health centers – needs to increase its transparency, especially regarding prices for services, services that are free of charge and other key points of information for patients and their families. Such information should be well- publicized. Transparency is also needed in the areas of budget allocations, spending and pharmaceuticals. COSAHs can also strengthen citizen confidence in their work if they are more transparent about and better publicize their work.
Pairing political will with strategic investments in the health system. For the health system to improve, political will must be paired with strategic investments in more personnel, training for that personnel, and materials and systems needed to ensure that personnel can effectively perform their duties. For example, improved systems for addressing absenteeism and motivating
53 staff would contribute towards improved service delivery.
Promoting multiple avenues for civic participation. Guineans have varying interest in and availability to be involved in health governance, but given the heavy reliance on the public health system, all citizens have an interest in seeing its performance improve. Respondents expressed a desire for more direct feedback systems for health services and mechanisms for consumers to report abuse. People dedicating to improving health services and outcomes them should explore the development of different modes of civic involvement in health service oversight and reform.
Expanding participation of women, youth and PWDs. Interested stakeholders should investigate how best to increase the participation of women, youth and PWDs in COSAHs and other opportunities for civic engagement on health reform. Youth articulated the greatest interest in increased participation, PWDs rely more on the health system given their health conditions and women expressed greater criticism of the health system than men. Engaging these populations in meaningful roles could increase overall citizen confidence in the health system. Women parliamentarians expressed strong interest in increasing women’s participation and, with support, could become more effective champions for social inclusion in health governance.
Helping COSAHs and decentralized government structures thrive. COSAHs, regional and prefectural coordination committees, commune administrators, health and administrative officials and community members will need training and support to fulfill their respective responsibilities in improving health governance and service delivery. People dedicated to improving services and outcomes need to foster dialogue, communication and coordination across these various groups. Moreover, stakeholders should seek to complement the efforts of the MATD-MOH Integrated Communal Development Project to create synergies and increase impact.
Identifying the keys to effective, sustainable COSAHs. Guinean stakeholders from across sectors (government, academic, civil society) must examine the performance of COSAHs to date and the impediments to their functionality as a tool to improve health service delivery. Guinean stakeholders should draw on successes and missteps of comparative initiatives elsewhere, especially countries with similar socio-economic and political conditions. In a number of countries similar health and education committees have been attempted, with varying degrees of success. COSAHs can offer a means by which to increase citizen engagement and serve as engines for reform, but that will not happen without designing strategies to address the challenges facing COSAH functionality. Existing research should be mined and, as necessary, additional research conducted to address knowledge gaps. For example, COSAHs may function better when manuals regulating COSAHs are in local languages, with guidance given for supporting the meaningful participation of illiterate individuals in COSAH activities, since in most cases, this demographic constitutes the majority of the population.
Coordinating health reform initiatives. Guinean and international partners working on health reform, especially support to COSAHs, should meet to discuss their initiatives and how to optimize coordination, collaboration, synergies and learning over the long term, not just for a one-time coordination meeting. For this effort to be as effective as possible, stakeholders will need to ensure that the voices and experiences of COSAH members themselves be incorporated
54 into this dialogue. While including those voices is logistically challenging, it is critical to listen to both the experiences of those working with COSAHs and the COSAH members themselves. As it relates to this project, CIHG should also be an active member of the relevant MOH-led thematic coordination committees and the Community Health Project Implementers’ Platform.
Mapping health reform opportunities. Donors and international projects should work with Guinean stakeholders to identify, create as necessary, and communicate the different opportunities to advance health reform, targeting stakeholders from diverse sectors (government, health providers, civil society, media, etc.). While collaboration is preferable, it is important that champions in each sector understand actions that they can take independent of others, as well as how to reach out to champions or potential champions in other sectors.
Expanding civic-governmental dialogue. Community members and civic leaders look to government for reform; government claims that it is civil society’s responsibility to push for improved health services. Both have roles and may only better understand their own agency when talking to one another. This dialogue can also help to build trust and model new norms of civic-governmental collaboration.
Advancing strategic research to further propel health reform. This assessment reveals a need for more research to inform next steps in health reform. Some possible areas of investigation are: examining budget absorption capacity of the government, especially the MOH; identifying legislative and regulatory opportunities to improve health governance; analyzing implementation of existing policies; and analyzing the private and public health sectors and how they may better complement one another to improve access to quality health services.
Bolstering CSOs and Guinea’s civic ecosystem. International organizations should focus on strengthening not only individual civic organizations but also the sector overall. This systems approach entails recognizing the importance of strengthening the connections and inter- relationships across organizations and working with both CSO networks and CSOs/community- based organizations in ways that foster and deepen relationships and capabilities of the sector, as opposed to just individual parts. In addition, international actors should partner with civic organizations to build a range of competencies to effectively advance health reform: collection and use of evidence, aggregation of and responsiveness to constituency needs, constituency mobilization, advocacy, networking, media and communications, management (project, financial, administrative) and MEL, to name a few. Likewise, supporting civil society to better understanding the users of different media will allow Guineans who want to advance health reform to better strategize on their use of media and communication strategies to advance their cause. Lastly, CSOs should be supported with grants and technical assistance to conduct health- reform research, budget monitoring, monitoring of policy implementation monitoring, and citizen mobilization so government officials feel the deep civic demand for improved health services.
Strengthening media’s role in improving health governance. Media outlets, especially radio stations, will need training to understand the link between health reform and improved health services and to effectively report on it. Fortunately, media outlets have found their health-related programming to be popular and are receptive to these interventions. To the extent that Guinean
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CSOs have or gain expertise in health reform through their involvement with CIHG and other initiatives, they can help increase the health governance knowledge of CIHG partner media outlets. In addition to helping individual outlets, CIHG and other programs should support journalist associations and platforms, be they formal or non-formal structures, to strengthen the network of journalists who are reporting on health governance issues. As journalists strengthen their skills to effectively report on health governance, they will build skills that can be applied to their coverage of other sectors as well.
Increasing citizen awareness about health reform. Citizens need more information about health reform, with an emphasis on the delegation of health facility management to communities and existing opportunities for civic engagement in health governance and reform. Communication materials prepared by CSOs and government, as well as reporting by journalists, need to take into account the varied information sources presented in the media findings of this report.
Reinforcing government capacity. CIHG and other programs should work to deepen the effectiveness of government entities such as the MOH, MATD, the NA Administrative Secretariat and NA Health Committee so that they can more effectively use their respective authorities to advance health reform. For instance, implementers can provide assistance to the NA Administrative Secretariat to build the capacity of the Parliamentary Radio in collaboration with SFCG to design and produce health governance related programming.
Capitalizing on local elections. CIHG and other actors should monitor local elections and their outcomes to capitalize on opportunities that emerge, such as highly motivated council members who are eager to show their constituents that they can bring improvements to their communities. Identifying these new champions, supporting them and then showcasing their success may increase Guineans’ expectations of local governments and enthusiasm for becoming more involved themselves. Those working to improve health governance should also consider how to motivate prospective champions in the first place: training new communal councils on health decentralization, their responsibilities for health governance, and the benefits of citizen participation in health governance.
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Annex A: Household Survey Questionnaire
CIHG_Etude de base_Enquête quantitative, Octobre 2017
INTRODUCTION124
Bonjour, je m’appelle ……………………. Je viens de la part du Projet Implication des citoyens dans la gouvernance du secteur de la santé en Guinée. Un projet qui est mis en œuvre par le consortium FHI 360, Search for Common Ground et Social Impact. Nous menons une enquête de perception dans le cadre des reformes liées au secteur de la santé en Guinée, l’utilisation et la satisfaction des services de santé. Vous avez été choisi de manière aléatoire pour participer à cette étude qui nous aidera à mieux comprendre la situation dans votre communauté. Nous sollicitons votre coopération pour répondre à certaines questions. Les informations que vous nous partagerez seront strictement confidentielle, c’est-à-dire que nous parlerons en privé. Toutes les informations que vous nous partagerez seront anonymes – je ne noterai ni votre nom ni votre adresse. A l’issue de cette étude personne ne sera capable de vous identifier. Il n’y a pas des mauvaises ou bonnes réponses à nos questions. Vous avez le droit de refuser de répondre à une ou plusieurs questions ainsi que d’arrêter ce questionnaire à tout moment. Il y aura des questions que vous pouvez juger sensibles mais la connaissance de vos expériences serait très utile pour contribuer à la réforme du secteur de la santé en Guinée. Enfin, aucune compensation monétaire n’est offerte aux participants et participantes à l’étude. Aussi, prenez note que la présente enquête n’est pas un enregistrement pour un appui futur de notre organisation. Est-ce que vous avez des questions ? L’entretien prendra environ 30 minutes. Etes-vous d’accord d’y participer ? Si OUI : est-ce que c’est un bon moment pour parler ? Il est important que nous parlions en privé. Est-ce que cet endroit un bon pour vous de parler ?
IDENTIFICATION GEOGRAPHIQUE
- Conakry_Ratoma=1 ; Conakry_Matoto=2 ; Conakry_Kaloum=3 ; [__] Conakry_Dixinn=4 ; Connakry_Matam=5
- Boké_Boffa=6 ; Boké_Boké=7 ; Boké_Fria=8 ; Boké_Gaoual=9 ; Boké_Koundara=10 ;
- Faranah_Dabola=11 ; Faranah_Dinguraye=12 ; Faranah_Faranah= 13 ; Faranah_Kissidougou=14 Kankan_Kankan=15 ; Kankan_Kerouane=16 ;
- Kankan_Kouroussa=17 ; Kankan_Mandiana=18 ; Kankan_Siguiri= 19 ;
124 Lecture de la partie introductoire a(u) participante(e) est obligatoire avant chaque entretien.
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- Kindia_Coyah=20 ; Kindia_Dubreka=21 ; Kindia_ Forecariah=22 ; Kindia_Kindia=23 ; Kindia_Telimele=24 ;
- Labé_Koubia=25 ; Labé_Labé=26 ;Labé_Lelouma=27 ; Labé_Mali=28 ; Labé_Tougue=29 ;
- Mamou_Dalaba=30 ; Mamou_Mamou=31 ; Mamou_Pita=32 ;
- N'Zérékoré_Beyla=29 ; N'Zérékoré_Gueckedou=30 ; N'Zérékoré_Lola=31 ; N'Zérékoré_Micenta=32 ; N'Zérékoré_ N'Zérékoré=33 ; N'Zérékoré_Yomou=34
ADMINISTRATIF N° Enquêteur [__|__]__] N° Superviseur [__|__]__] Date de l’enquête : jj/mm Date vérifié : jj/mm [__|__]/[__|__] [__|__]/[__|__] Signature: ______Signature: ______
Heure de début : [__|__]__|__] Remarques : Heure de fin : [__|__]__|__]
I. PROFIL SOCIO-ECONOMIQUE
No. Question Modalités 1 Sexe 1. Masculin [__] 2. Féminin
2 Age 1. 18-30 [__] 2. 31-50 3. 51 et plus
3 Etat civil 1. Marié (e) [__] 2. Célibataire 3. Divorcé (e) 4. Veuf (ve) 5. Séparé (e)
4 Niveau d’étude 1. Aucun [__] 2. Primaire 3. Formation en métier 4. Secondaire 5. Supérieur/Universitaire
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5 Ethnicité (0 si le participant ne veut 1. Kpêle [__] pas répondre à la question) 2. Kissi 3. Toma 4. Könö 5. Mano 6. Konian 7. Lélé 8. Soussou 9. Baga 10. Landouma 11. Malinké 12. Poular 6 Handicapé 1. Oui [__] 2. Non
II. Connaissance sur les réformes du secteur de la Santé en cours Réponse
No. Question Réponses /modalités 9 Connaissez-vous comment 1. Oui [__] fonctionne votre structure 2. Non sanitaire au niveau local
10 Si oui à la question 9, 1. Radio [__] Comment avez-vous été 2. TV informé? 3. Presse écrite 4. Comité de santé 5. Tontine 6. Famille (amis) 7. Autre à préciser…………………………….. 11 Pensez-vous que la structure 1. Oui [__] sanitaire que vous fréquentez 2. Non est bien gérée?
Êtes-vous impliqué dans la 1. Oui [__] 12 gestion de la structure 2. Non sanitaire?
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Si Oui à la question 12, 13 Par quel moyen y participez- 1. Comité local de [__] vous? santé 2. Forum communautaire 3. Cadre de concertation local 4. Autre à préciser…………………. Si non à la question 12, 14 Connaissez-vous quelqu’un 1. Oui [__] qui participe dans la gestion 2. Non de la structure sanitaire dans votre communauté?
15 Si Oui à la question 14, 1. Femme À quel titre y participe-t-il ou 2. Jeune elle? 3. Personne âgée [__] 4. Élu local 5. Agent de santé 6. Autre à préciser………………………………
III. La confiance des citoyens dans leur système de santé Réponse No. Question Réponses /modalités 16 Quand un membre de 1. Allez à une structure sanitaire [__] votre famille tombe étatique/privée malade que faites-vous? 2. Allez à une structure des soins traditionnels 3. Allez consulter un médecin traditionnel 4. Priez 5. Automédication 6. Autre à préciser………………………………………… 17 Est-ce que vous ou un 7. Oui [__] membre de votre famille 8. Non utilise les services de santé?
18 Si oui à la question 17, 1. Poste de santé (privé ou public) [__] Quels services? 2. Centre de santé (privé ou public)
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3. Hôpital (privé ou public) 4. Médicine traditionnelle (indigénat) 5. Autre à préciser………………………………………… 19 Si oui à la question 17, 1. C’est moins cher [__] Pourquoi? 2. C’est trop proche de la maison 3. Les services sont de qualité 4. Autre à préciser………………………………………… 20 Si Oui à la question 17, 1. La semaine en cours [__] C’est quand la dernière 2. La semaine passée fois que vous les avez 3. Le mois passé utilisé? 4. Le trimestre passé 5. Le semestre passé 6. L’année passée 21 Si oui à la question 17, 1. Aussi tôt que la maladie apparaît [__] Quand utilisez-vous les 2. Quand la maladie devient grave services de santé? 3. Lorsque la médecine traditionnelle n’a pas fonctionné 4. Seulement quand les moyens financiers sont disponibles 5. Uniquement pour la vaccination 6. Uniquement pour l’accouchement 7. Autre (à préciser) ……………………………………………………. 22 Êtes-vous satisfait des 1. Très satisfait [__] services reçus? 2. Satisfait 3. Un peu satisfait 4. Pas satisfait
23 Si non à la question 22, 1. Insuffisance de personnel [__] Pour quelles raisons 2. Personnel non qualifié n’utilisez-vous pas le 3. Coût trop élevé des soins service de santé? 4. Centre situé trop loin de la résidence 5. Autre à préciser………………………………….
IV. Les attitudes-habitudes des citoyens face aux services de santé Réponse
No. Question Réponses /modalités
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24 Votre communauté dispose-t-elle 1. Oui [__] d’une structure de santé ? 2. Non 3. Je ne sais pas 25 Si Oui à la question 24, 1. Oui [__] Est-ce que les membres de votre 2. Non communauté participent à la 3. Je ne sais pas gestion de la structure locale de santé ? 26 Si non à la question 25, 1. Pas intéressé (e) [__] Pourquoi? 2. Exclus 3. Manque de temps 4. Autre à préciser……………………… …………………………………… 27 Si Oui à la question 25, 1. Cellule d’éveil citoyen [__]
À travers quel mécanisme ? 2. Comité d’hygiène et assainissement 3. Comité de santé 4. Comité d’éveil villageois 5. Autre à préciser………………………. 28 Si oui à la question 25, 1. Oui [__] Participez-vous à ce comité ou 2. Non cadre ?
29 Si oui à la question 28 : 1. Personnel de santé [__] À quel titre vous y participez ? 2. Femme 3. Jeune 4. Élu local 5. Autre à préciser……………………… ………………………………….. 30 Si Oui à la question 29, 1. Oui [__] Est-ce que les femmes sont 2. Non représentées? 3. Je ne sais pas
31 Si non à la question 30 : 1. Pas intéressées [__] Pourquoi? 2. Pas informées/Invitées 3. Pas assez de temps 4. Pas de permission (Mari, Père, Tuteur…) 5. Autre à préciser……………………… …………………………………..
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32 Si oui à la question 30 : 1. Oui [__] Est-ce que le point de vue des 2. Non femmes est pris en compte? 3. Je ne sais pas
33 Si non à la question 32 : 1. Pas autorisées à parler [__] Pourquoi? 2. Trop timides pour parler 3. Autre à préciser……………………… …………………………………… 34 Si oui à la question 25, 1. Oui [__]
Est-ce que les jeunes sont 2. Non représentés dans ce comité ou cadre ? 35 Si non à la question 34, 1. Pas intéressés [__] Pourquoi ? 2. Pas informés/Invités 3. Pas assez de temps 4. Autre à préciser……………………… …………………………………… 36 Si oui à la question 34, 1. Oui [__] Est-ce que le point de vue des 2. Non jeunes est pris en compte? 3. Je ne sais pas
V. Médias Réponse
No. Question Réponses /modalités 37 Etes-vous au courant de la gestion 1. Oui [__] de votre structure sanitaire locale 2. Non et les efforts du gouvernement à améliorer le secteur de la santé ? 38 Par quel canal recevez-vous les 1. Radio Priorité1 informations sur la gestion de votre 2. TV [__] structure sanitaire local et autres 3. Presse (y compris Priorité 2 questions liées au secteur de la écrite) [__] santé ? (Cochez jusqu’à trois 4. Réseaux sociaux Priorité 3 réponses selon la plus importante) 5. Bouche à oreille [__] 6. Autre à préciser………………………
39 Parmi les canaux que vous venez de 1. Radio Priorité1 citer, lesquels préférez-vous ? 2. TV [__]
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(Cochez jusqu’à deux réponses par 3. Presse (y compris Priorité 2 ordre d’importance) écrite) [__] 4. Réseaux sociaux 5. Bouche à oreille 6. Autre à préciser……………………… 40 Les informations reçues sur la 1. Oui [__] gestion de votre structure 2. Non sanitaire local et autres questions liées au secteur de la santé, vous incitent-elles à participer dans la gestion de votre structure ? 41 Les informations reçues vous 1. Oui [__] permettent-elles de connaître 2. Non votre rôle dans la gestion de votre structure locale de santé?
42 Qu’est-ce qui peut vous motivez 1. Recevoir régulièrement [__] aujourd’hui dans la gestion de les informations sur les votre structure sanitaire local? changements dans la gestion de la structure 2. Réduction du coût des soins 3. Rapprochement de la structure sanitaire de ma résidence 4. Autre à préciser……………………….
Remerciez le répondant pour la participation, en l’assurant que l’entretien était très intéressant et outil et que tous ses réponses restent confidentielles.
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Annex B: Margin of Error Table
The following calculations are based on an even split, which is the highest margin of error calculation. Below are the relevant tables, as well as the equation. Note, margin of error was calculated at a 95% degree of confidence. For the calculation, “p” represents a given proportion of respondents answering a question a particular way, and “q” = (1-p). “N” refers to the sample size. The margin of error is simply the standard error multiplied by 1.96, yielding a 95% confidence interval. “P” and “Q” are assumed to be equal to 0.5. This would occur if 50% of the respondents agreed with a statement and 50% disagreed. This is a conservative estimate, as less equal variation would result in smaller standard errors.
Sample Margin of Sample Margin of Ethnicity Gender size Error size Error Other 59 12.8% Female 845 3.4% (specify) Male 905 3.3% Baga 8 34.6% Kissi 118 9.0% Konian 80 11.0% Region Sample Margin of Könö 11 29.5% Name size error Kpêle 60 12.7% Landouma 31 17.6% Conakry 171 7.5% Lélé 4 49.0% Boké 287 5.8% Malinké 482 4.5% Faranah 243 6.3% Mano 15 25.3% Kankan 312 5.5% No response 7 37.0% Labé 239 6.3% Peulh 544 4.2% Mamou 160 7.7% Soussou 294 5.7% N'zérékoré 118 9.0% Toma 37 16.1% Kindia 220 6.6% Total 1750 2.3%
Sample Margin of Location size Error Urban 1087 3.0% Rural 663 3.8%
Sample Margin of Disability size error Yes 92 10.2% No 1658 2.4%
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Annex C: Focus Group Discussion Protocol
Guide des bonnes pratiques pour l’organisation des focus groups
C’est quoi un focus group (groupe de discussion) ? ● C’est une discussion guidée avec un groupe d’approximativement 7 à 10 personnes sur leurs expériences, sentiments et préférences se rapportant à un sujet ou un domaine particulier ● Le facilitateur rappelle. une à une les grandes questions qui doivent être discutées pour solliciter des points de vue, des idées et d’autres informations ● Les sessions de discussion doivent durer une à deux heures Etapes pour conduire les focus group avec les participants
1. Choisir l’équipe ● Demande une équipe très réduite au besoin juste un facilitateur et un preneur des notes ● Le facilitateur doit parler correctement les langues pour mettre à l’aise les participants ● L’équipe doit bien connaître les thèmes à discuter.
2. Sélection des participants ● Chaque groupe de discussion doit comprendre entre 7 et 10 personnes ● Les participants doivent être homogènes, issus de milieux socioéconomiques et culturels similaires et partager des traits communs liés au sujet de discussion ● Identifier les types de groupes et d'institutions qui devraient être représentés (c'est- à-dire pour notre cas, les fournisseurs de services, les représentants du gouvernement, les membres de la communauté, etc.), puis identifier les personnes les plus appropriées dans chaque groupe ● L'une des meilleures approches consiste à consulter les informateurs clés qui connaissent le contexte local Décider sur le temps et le lieu ● Les discussions durent une à deux heures ● Doit être conduit dans un endroit qui convient avec un minimum de confidentialité ● Les lieux ouverts ne sont pas appropriés pour les discussions (les infiltrés peuvent arriver/perturber) Utiliser le Guide de discussion ● Le guide de discussion est un schéma qui couvre les sujets et les questions à discuter ● Il contient peu d'éléments, permettant à la conversation de circuler naturellement et permettant d'explorer des questions imprévues mais pertinentes
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● Initier chaque sujet avec la question conçue pour aider à garder la discussion dans le bon sens Ouvrir les discussions ● Briser la glace : commencez par expliquer le but et le format de la discussion, y compris le fait que la discussion est informelle, que tout le monde doit participer et que les opinions divergentes sont les bienvenues Bienvenu ● Introduire le facilitateur et le rapporteur et leurs rôles durant les discussions Donner un aperçu du sujet ● L’objectif de ces discussions est de connaître vos points de vue sur le système de santé, les réformes en cours pour informer notre projet Participation des Citoyens dans la Gouvernance de la Santé pour que les actions que nous mènerons puissent répondre aux besoins des populations. ● Dans le cadre de la décentralisation, les structures de santé doivent être gérées par les collectivités décentralisées ● Les résultats seront utilisés pour enrichir notre étude de base et aussi pour nous aider à mettre les éléments en place pour que les citoyens s’impliquent davantage et s’approprient les réformes en cours. Donner les lignes directrices pour les discussions ● Il n’y a pas de bonne ou mauvaise réponse, seulement des différents points de vue ● Vous n’avez pas besoin d’être d’accord avec les autres, mais vous devez suivre respectueusement les points de vue des autres ● Encourager les participants de parler à d’autres participants Prise des notes ● On devra avoir un preneur des notes séparé pour cette tâche ● Idéalement on pourra avoir les enregistrements numériques en plus des notes écrites ● Les notes doivent être complètes et refléter le contenu de la discussion ainsi que le comportement non verbal (expressions faciales, mouvements de la main) Informer les participants Tous les participants devraient être informés de leurs droits à la confidentialité
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MÊME CHOSE POUR LES FOCUS GROUPS : FOCUS GROUP (JEUNES ET FEMMES SERONT DANS LE TRONC COMMUN) 1. Dans quel cas utilisez-vous les services de santé? (Appréciation, Satisfaction…)
2. Comment trouvez-vous la qualité des services de soin de santé dans votre entité? 3. Quels mécanismes existent ou devraient exister pour transmettre les recommandations- points de vue des citoyens dans les réformes du secteur de la santé (Comment les préoccupations et recommandations des citoyens sont transmises auprès des autorités?) 4. Éléments clés d’une bonne gouvernance dans le secteur de la santé 5. Est-ce que les ressources financières sont bien gérées? 6. Est-ce que la communauté s’implique dans la gestion des ressources dans le secteur de la santé 7. Suggestions et recommandations pour améliorer le système de santé actuel en Guinée
Questions spécifiques pour les catégories des FGDs
✓ FOURNISSEUR DES SERVICES ● Quels sont les besoins en matière de services de santé ● Dans quelle mesure la société civile participe à l’élaboration ou révision des lois dans le secteur de la santé ● Connaissez-vous les politiques de la santé et les principaux points de la réforme en cours ✓ PERSONNES VULNÉRABLES ● Dans quelle mesure les politiques de réforme actuelle ont pris en compte les besoins de toutes les catégories sociales? ✓ MÉDIA ● Comment les médias sont associés dans la vulgarisation des nouvelles reformes du secteur de la santé ? ● Quels rôles pensez encore les médias devraient jouer pour appuyer les reformes actuelles et la gouvernance du secteur de la santé ● Comment les médias collaborent avec les autres corporations de la société dans le secteur de la santé? (Existe-t-il des mécanismes, des partenariats…) ● Comment vous faites-vous pour déterminer les thèmes à utiliser dans vos émissions ? ● Quels formats utilisez-vous souvent dans les sujets liés à la santé?
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Annex D: Roundtable Protocol
CONCERTATION SUR LA PROBLÉMATIQUE DE LA GOUVERNANCE DANS LA SANTÉ
DEROULEMENT DE LA RENCONTRE
9H00-9H30 ARRIVEE DES PARTICIPANTS
9H30-10H00 MOT DE BIENVENUE, REPRESENTANT DU CROSCG Brève présentation du projet Participation des citoyens dans la gouvernance en santé et de l’Enquête en cours, Représentant de CIHG Objectif de la rencontre : Échanger sur l’enjeu de la gouvernance en santé (facilitateur) Présentation de l’enjeu à discuter : La problématique de la participation des citoyens dans la gouvernance de la santé, leur appropriation des réformes en cours et leur responsabilisation dans la gestion des services de santé dans leur communauté
10H00-11H15 DISCUSSION DIRIGEE Problématique : La crise de Ebola a mis en lumière les faiblesses de la gouvernance dans le secteur de la santé en Guinée et suscité une volonté affirmée du Gouvernement de mettre en œuvre des réformes importantes. Les nouvelles politiques ainsi que le nouveau Code des Collectivités décentralisées repose en grande partie sur la responsabilisation et l’implication des communautés dans la gestion de leurs services de santé. Le facilitateur présente une question à la fois aux participants pour encourager les échanges (tour de table 15 minutes par questions) ● Qu’est-ce qu’il faudrait à votre avis pour rehausser la confiance des citoyens dans le système de santé? ● Que dire sur les nouvelles politiques de la santé et les réformes en cours, et leur niveau d’application? ● Quels sont à votre avis les éléments d’une bonne gouvernance dans le secteur de la santé en Guinée? Comment faire selon vous pour instaurer une bonne gouvernance de la santé? ● Quels éléments doivent être mis en place pour que se réalise la transmission de la gestion des services de santé de l’État aux populations, tel que prévu par le nouveau Code des collectivités décentralisées? ● Quels sont les intérêts tant pour les autorités que pour les citoyens qui les motiveraient à soutenir l’application des nouvelles politiques de la santé.
11H15-11H30 PAUSE-CAFE
11H30-13H30 TRAVAUX DE GROUPES PAR SECTEURS Les groupes se dotent d’un président et d’un rapporteur Les résultats sont inscrits sur la fiche et le flip chart
13H30 -14H30 PAUSE-DEJEUNER
14H30-16H00 MISE EN COMMUN DES TRAVAUX DE GROUPE
16H00 FIN DES TRAVAUX, CLOTURE
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