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. Photo: MSH Staff Impact of the Leadership Development Program Plus on Maternal and Child Health Outcomes in Madagascar Author Sylvia Vriesendorp, Aishling Thurow, and Karina Noyes Background It is widely recognized that strengthening governance and management at all levels of Madagascar is one of 40 states participating in a health system significantly contributes to The USAID-funded the Campaign for Accelerated Reduction of improvements in health indicators by improving Leadership, Management, Maternal Mortality in Africa (CARMMA). The staff motivation and efficiency, service delivery, and Governance (LMG) Campaign focuses on using positive messaging, and the quality of the care. Thus, to help the Project strengthens health sharing good practices and lessons learned, Madagascar meet its ambitious reproductive, systems to deliver more and intensifying program and communication maternal, newborn, and child health (RMNCH) responsive services to more activities to significantly reduce the number of objectives, USAID’s Leadership, Management, and people by developing inspired preventable deaths among mothers, infants, and Governance (LMG)/Madagascar Project provided leaders, sound management children. Through its Ministry of Public Health technical assistance to the MOPH between systems, and transparent (MOPH), Madagascar is seeking to use CARMMA October 2015 and June 2017. and accountable governing as a foundation for reducing maternal deaths boards with individuals, from 478 to 200 per 100,000 live births between The LMG Project delivered its Leadership networks, organizations, and 2012 and 2019, and neonatal mortality rates Development Program Plus (LDP+) to improve governments. from 26 to 16 per 1000 live births over the the capacity of (a) central- and regional-level same period.1 To achieve these objectives, the MOPH managers to coordinate the delivery of MOPH must prioritize improving skilled care essential quality RMNCH services, (b) district to prevent maternal and child deaths, expanding managers to support the effective delivery of vaccination coverage, increasing the number of those services at health facilities, and (c) health deliveries assisted by a skilled birth attendants, facility staff to improve the quality and reach of and increasing the number of pregnant women their services. The LDP+ guides teams in using attending antenatal care (ANC) visits. a Challenge Model to solve health challenges, including building an understanding of the existing 1 Baseline statistics drawn from the MADAGASCAR health care situation (defining challenges as MILLENNIUM DEVELOPMENT GOALS NATIONAL opposed to problems), formulating a desired facebook.com/LMGforHealth MONITORING SURVEY, 2012 – 2013, pg. 36-39. National result, analyzing the root causes of past failures in Statistics Institute, Ministry of Economy and Industry, @LMGforHealth Antananarivo, Madagascar. http://madagascar.unfpa.org/sites/ achieving that result, and developing strategies for resolution. @LMGforHealth esaro/files/pub-pdf/OMD_Summary_0.pdf. TECHNICAL BRIEF1 www.LMGforHealth.org The LDP+ is an essential part of the LMG Project’s mission to jointly establish an implementation plan, customized to strengthen health systems and improve health for all to fit the project timeline, available resources, and other by improving leadership, management, and governance constraints. The plan included: practices in health organizations and networks. A study ■ Recruitment of a local facilitation team, consisting of undertaken in Cameroon2 showed that combining the the LMG Project/Madagascar project director and two LDP+ with clinical training led to a statistically significant consultants, to work closely with MOPH focal points increase in the number of women who received postpartum assigned by the Secretary-General family planning counseling during ANC and postnatal care, ■ Development of a modular three-workshop version compared with clinical training alone. of the LDP+, with workshops held consecutively in the capital cities of the three regions selected by the Context MOPH (Analamanga [also referred to as Central re- The LDP+, a flagship leadership development program gion], Atsninanana, and Haute Matsiatra) developed by MSH, supports teams of health workers to ■ Selection by MOPH regional directors of the districts apply leadership, management and governance (L+M+G) and facilities to be invited to travel to regional capitals practices to overcome their health service delivery to participate challenges. Health workers accomplish this by developing ■ Coaching visits at all three systems levels, including shared visions, analyzing inhibiting factors, and identifying facilities where distance, weather, and travel conditions and implementing innovative solutions through team-based allowed projects. Participants develop action plans to reach their The LDP+ curriculum delivered in Madagascar consisted of desired measurable result (DMR). By implementing these the following elements: plans, they use their newly acquired skills as they work to Alignment meeting with key stakeholders: improve service delivery outcomes within their facilities. ■ Overview of the LDP+ The LDP+ methodology makes the learning process ■ Creation of a shared vision interactive and experiential; it is a model that emphasizes ■ Practices of leading, managing, and governing active participation, practice and feedback to ensure a conducive learning environment. The program is also Workshop 1 with program participants: designed to be easily transferrable and sustainable, with a ■ Overview of the LDP+ manual that provides detailed step-by-step guidance on how ■ Practices of leading, managing, and governing to facilitate the program. This 6-month process can be an ■ Introduction of the Challenge Model, and first four effective tool in improving organizational and team work steps: mission, vision, current situation, and desired climate, as well as in institutionalizing management systems measurable result) to overcome challenges in health service delivery. Workshop 2 with program participants: The LDP+ is generally delivered through a series of up to ■ Reports from coaches ten workshops, each between a half day and three days in ■ Sharing of work done at workplace regarding first four length and separated by a lag time to allow participants steps of the Challenge Model to apply what they have learned during each step of the ■ Personal versus positional power process. At each workshop, participants report to their ■ Gender, sex, equity, and equality peers on progress toward their desired outcomes and share ■ Sphere of influence lessons learned and best practices, fostering collaborative ■ Next steps in Challenge Model: Root cause analysis, problem-solving. formulation of the challenge, selecting priority actions, M&E plan, implementation plan In this case, the LMG Project/Madagascar Program Manager ■ Priority matrix and her team worked closely with USAID and the MOPH ■ Filling in M&E and planning templates 2 Conlin, M., Baba Djara, M., & Shukla, M. The Added Value of Combining a Leadership Development Program with Clinical Training on Postpartum Family Planning Service Delivery, 2016. Management Sciences for Health. 2 www.LMGforHealth.org Workshop 3 with program participants: In April and May, 2017, LMG Project/Madagascar visited ■ Presentation of final Challenge Model (with modifica- 16 LDP+ participant teams at their workplaces across the tions made in the workplace) three intervention regions to evaluate the progress and ■ Review of implementation plan impact of the LDP+. The project used quantitative data ■ Practicing coaching collection to measure progress towards the CARMMA ■ Compliance versus engagement indicators and qualitative data collection to understand the ■ Aligning and mobilizing behavioral and organizational changes that led to results. ■ Managing conflicts Improving data collection, recording, and quality is part of ■ Inspiring other, larger initiatives, and could not be integrated into ■ Presenting results this intervention for budgetary reasons; thus, data quality ■ Giving and receiving feedback has not been verified, and the project was not otherwise formally evaluated. Results Below, selected results are framed within the context of The table below shows the number of teams that achieved, the CARMMA indicators. Most results cover the period surpassed, or did not achieve their intended measurable between July 2016 (two months after the first workshop) results. Those that surpassed their goals, or that achieved and December 2016 (the end of the LDP+), and are results faster than expected, set new, more ambitious goals compared with a baseline from the same six-month and/or focused on other challenges, thus continuing to timeframe in 2015. contribute to attaining the CARMMA objectives. Those that Child health achieve their goals, or that made good progress by reaching at least 75% of their targets, continued with their improved Neonatal Mortality practices for four months after completion of the LDP+. The participating members from the University Hospital Teams that did not achieve their goals either dropped out, Center for Mothers and Children (Centre Hospitalier had no data available when asked, had undergone a change Universitaire Mere Enfant, or CHUME) hospital in in personnel, or simply stopped coming to the workshops. Ambohimiandra (Central Region), mobilized their colleagues to improve the hospital’s visibility and reputation, Table 1. Achievement status of teams participating

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