SCS Guinea: Citizens’ Involvement in Health Governance
Period of Performance: July 28, 2017 – October 26, 2020
Funding provided by: United States Agency for International Development Cooperative Agreement No. AID-675-LA-17-00001
Final Performance Report
Submitted: January 25, 2021
Submitted to:
Mark Koenig, Agreement Officer’s Representative (AOR), [email protected] Souro Kamano, Alternate AOR, [email protected] Albert P. Asante, Agreement Officer, [email protected] Bernadette Daluz, Senior Acquisitions and Assistance Specialist, [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.
TABLE OF CONTENTS
Table of Contents ...... i Acronym List ...... ii Executive Sumary ...... 1 Project Overview ...... 4 Technical Approach ...... 5 Overall Strategy ...... 5 Summary of CIHG Activities ...... 6 Project Results ...... 45 Lessons Learned and Recommendations ...... 52 Annexes...... 59 Annex I: Performance Indicator Table ...... 59 Annex 2: Summary of CIHG Achievements ...... 63 Annex 3: CIHG Communications Poster ...... 64 Annex 4: List of CIHG CSO Partners ...... 65 Annex 5: List of CIHG Media Partners ...... 66 Annex 6: List of CIHG Listening Groups ...... 67 Annex 7: CIHG Success Stories ...... 68 Annex 8: Summary of Good Governance Barometer Key Phases ...... 72
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ACRONYM LIST
AFJ Association des Femmes Journalistes de Guinée (Association of Women Journalists in Guinea) AGIL Alliance Promoting Governance and Local Initiatives AGUIFPEG Association Guinéenne pour l’Implication des Femmes dans le Processus Electorale et la Bonne Gouvernance or Guinean Association for the Involvement of Women in the Electoral Process and Good Governance AIDE-Guinée Initiatives, Actions, and Development for Guinea ANSS Agence Nationale de Sécurité Sanitaire (National Health Security Agency) AP Action Plan CBO Community-Based Organization CCAP Citizen Control of Public Action CEGUIFORD Centre Guinéen pour la Formation, la Recherche et le Développement (Guinean Center for Training, Research, and Development) CENAFOD Centre Africain de Formation pour le Développement (African Training Center for Development) CIHG Citizens’ Involvement in Health Governance CJMAD Comité Jeunes Mon Avenir D’abord (Youth Committee My Future First) CNERS Comité national d’éthique pour la recherche en santé or (National Ethics Committee for Health Research) CNOSCG Conseil National des Organisations de la Société Civile Guinéenne (National Council of Guinean Civil Society Organizations) COSAH Comité de Santé et d'Hygiène (Health and Hygiene Committee) COVID-19 Novel Coronavirus 2019 CSO Civil Society Organization DMR Directions de Microréalisations or Directorates of Micro-Projects DO Development Objective DPS Direction Préfectorale de Santé (Prefectural Health Directorate) DRG Democracy, Human Rights and Governance DRS Direction Régionale de Santé (Regional Health Directorate) EPI Expanded Program on Immunization FEDIPHU Femmes pour le Développement Intégré et la Promotion Humaine (Women for Integrated Human Development) FY Fiscal Year GGB Good Governance Barometer (Baromètre de la Bonne Gouvernance) GoG Government of Guinea IR Intermediate Result KII Key Informant Interviews LGL Le Groupe Lyceum (The Lyceum Group) LOP Life of Project MATD Ministry of Territorial Administration and Decentralization MEL Monitoring, Evaluation, and Learning MOH Ministry of Health MP Member of Parliament
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MSS Mutuelle de Santé et Services (Mutual of Health and Services) NA National Assembly NA-HC National Assembly Health Commission OH Outcome Harvesting PNACC Programme National d’Appui aux Communes de Convergence (National Program of Support to Convergence Communes) PNC Prenatal Consultation POP Period of Performance RAJGUI Réseau Afrique Jeunesse de Guinée (African Youth Network of Guinea) RFA Request for Applications SCS Global Strengthening Civil Society Globally SFCG Search for Common Ground SI Social Impact THP Traditional Health Practitioner TMG Technical Monitoring Group URTELGUI Union des Radiodiffusions et Télévisions Libres de Guinée USAID United States Agency for International Development
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EXECUTIVE SUMARY
To support Guinea’s post-Ebola recovery and strengthen health governance, USAID determined that more effective and more extensive collaboration among Guinean civil society, media outlets and the government was critical to further improve health service delivery and enhance public confidence in the public health system. Therefore, USAID designed and launched the three-year Citizens’ Involvement in Health Governance (CIHG) project to improve citizens’ understanding and participation in Guinea’s health-system reforms, by expanding opportunities for civic- governmental dialogue, increasing access to information about health governance, and improving advocacy.
Led by FHI 360, in partnership with Search for Common Ground (SFCG) and Social Impact (SI), CIHG collaborated with Guinea partners from civil society, government, public and private healthcare professional at the national and local levels. CIHG is part of USAID’s on-going Strengthening Civil Society Globally (SCS Global) leader with associate award (LWA), with 18 associate award projects across the world.
The project supported numerous complementary activities: capacity building and multi- stakeholder collaboration opportunities for government officials, media outlets (namely radio), and civil society organizations (CSOs) through workshops, coaching, field visits, community theater, listening groups, and planning seminars. CIHG provided technical and financial assistance to produce extensive health-governance reporting, especially via radio. The grants program facilitated Guinean-led research to identify remaining reform priorities, implementation of coalition-mobilization activities, use of social accountability tools and advocacy.
CIHG significantly contributed to improving citizens’ understanding of and participation in Guinea’s health-system reforms as evidenced by monitoring, evaluation, and learning (MEL) data and the findings of the endline study. More than 175,000 Guineans engaged in initiatives to improve health governance. In total, 55,298 people participated in multi-stakeholder forums bringing together government officials, civil society representatives and the media to identify needed improvements in health governance and health service delivery. At least an additional 120,000 Guineans participated in mobilization activities designed specifically to engage community members both to increase citizen understanding of health reforms and to strengthen civil society participation in health governance. The total number of people mobilized is a conservative figure, using only verifiable data.
The findings from the endline study reaffirmed this increase in citizen engagement. In all, 22% of respondents reported direct involvement in activities to improve local health facilities, and 67% indicated knowing other community members engaged in these efforts. A majority of respondents reported that women and youth are participating in health governance activities: 68.7% reported that women are well or fairly well engaged, while 65% said that youth are well represented in health governance. Almost half of the outcomes identified through the endline outcome harvesting (OH) process link to CIHG’s objective, a strong indication of achievement. Added to this, many respondents know others in their community who are also actively involved. In addition, the vast majority of respondents believe that both women and youth are engaged in
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efforts to improve the health sector, a finding supported by OH outcome statements on women’s participation in health activities and improved civic engagement among youth.
The 2014 Ebola epidemic revealed significant distrust in government health services, and avoidance of healthcare as a result. The CIHG endline data show evidence of change in these attitudes and behaviors towards this overall goal. Several OH outcome statements reveal improvements, including increased trust in and more frequent use of health centers. Achievement of such outcomes is a long, complex process requiring engagement on a variety of levels. For example, OH participants emphasized linkages among community use of health services and capacity building of COSAHs, radio station trainings, radio broadcasts on healthcare, Good Governance Barometer (GGB) social accountability activities, government visits, and collaboration with practitioners of traditional medicine. Thus, the multi-faceted design of CIHG—with different types of social actors were engaged to spark change at the community level – seems to have been a key success factor.
Survey findings similarly support the conclusion that views on health services are improving. Though quantitative comparisons between the endline and the 2017 and 2018 surveys are not exact, notable and positive trends were shown in a wide range of service-related aspects, including the perceived quality of services, cost of care, and availability of supplies. In addition, respondents reported a higher likelihood of using government health services in the future. A majority of respondents also felt that efforts to improve health services have at least somewhat resulted in actual improvements. Improvements were additionally noted in access to free health services. The percentage of survey respondents reporting that they were charged for health services that should be free fell from 2018 to 2020 (73% in 2018 and 52% in 2020 for malaria treatment, and 62% in 2018 and 54% in 2020 for childbirth, respectively). Concerns about quality of care also persist.
CIHG succeeded in expanding collaboration among key stakeholders. Thanks to CIHG, a wide cross-section of Guineans leaders participated in 411 civic-governmental dialogues promoting constructive problem solving of health governance issues including multi-stakeholder social accountability forums, health governance workshops, participatory community theatre performances, community health strategy meetings, press conferences and media-CSO- governmental round tables (surpassing the project target by more than 800%).
CIHG found that many government officials at the national, regional and local levels were eager to participate in and even co-organize health governance forums, organized by CIHG and its partners. In addition, governmental officials led 41 new initiatives (410% over target) to promote health reform dialogue and to use information dialogue to improve health governance.
Data from the endline study emphasized the importance of supporting media in order to improve the flow of information on health to the public and foster participation. Media outlets were not a key social actor in many OH outcome statements, yet radio was one of the activities most frequently cited as contributing to change. This highlights the broader effects of CIHG’s work with radio stations (particularly training and capacity building)—increasing the capacity of radio stations to produce health broadcasts is linked to community-level changes in knowledge, attitudes and practices related to health.
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CIHG again exceeded its targets related to support to media outlets. Over the course of 1,738 training days, CIHG has enhanced the reporting skills of more than 470 journalists, surpassing both life of project (LOP) targets by 869% and 247% respectively. Media partners then put that training to use to produce 256 locally produced radio programs about a variety of health governance topics in a number of local languages: Guerzé, Kissi, Konian, Konianké, Kpêlê, Malinké, Pular and Soussou. Radio partners initially struggled to produce local content but as CIHG training and outreach accumulated, their production surged. Guineans also benefitted for access to CIHG productions what were broadcast throughout the country. In just three years, CIHG produce: 53 episodes of the radio show, Sissi Aminata, 47 episodes of the youth-focused radio show, Barada, 24 episodes of the radio drama, Wontanara, 8 episodes of the community theatre-focused television show, Taboulé, 16 episodes of the public affair television show, Guinée Forum, and 20 episodes of the television drama, Djembé. These programs were critical means through which CIHG disseminated information about health governance issues and contributed to the increased engagement discussed above.
Guineans have been able to lobby successfully for changes to health governance reforms and 100% of CIHG partners surveyed demonstrated improvement in their advocacy. Note, two partners declined to participate in the final data collection and therefore not included I the final calculation. As with most significant victories in such a complex domain, CIHG cannot claim sole responsibility as other actors are active in the sector. However, CIHG played a critical role in advancing a number of reforms. Our Guinean partners have implemented the following changes at the national and local level: • Guinea’s 2019 health budget was increased by 25% compared to 2018, constituting 8% of the national budget, following CIHG activities; the 2020 health budget was also 8% of the total. • Elimination of undisclosed line items in the law authorizing the health budget in 2019 and again in 2020, based on recommendations from civil society to national leaders. • Addition of budgetary lines to cover operating costs of regional public health directorates in the 2019 budget to advance decentralization and increase health governance accountability; generous funding for decentralization continued in the 2020 budget.
The graphic below shares four key legacies that CIHG will leave behind. Given the importance of access to information, the need for increased community ownership of health governance, the historical centralized, top-down approach to governance, and the much needed investment in the sectors, CIHG’s legacies – those presented below and more – provide a foundation on which Guinean health-governance stakeholders can continue to build.
Increased civic engagement and Strengthened norms of multi- ownership of health governance stakeholder collaboration CIHG Legacies
Expanded and improved media Health budgets better reflect coverage of health governance needs and community input
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PROJECT OVERVIEW
Under USAID-funded SCS Global LWA, USAID/Guinea awarded FHI 360 the three-year CIHG project (July 28, 2017 – October 26, 2020). After the Ebola outbreak in 2014, the Government of Guinea (GoG) made strides to improve health governance and preparedness for future health emergencies including putting in place the 2015-2017 Post-Ebola Socio-Economic Recovery and Resiliency Strategy, prioritizing efforts to decentralize health services, and reviewing current health legislation. However, even with these positive steps, USAID determined that more effective and more extensive collaboration among Guinean civil society, media outlets and the government was critical to further improve health governance, improve service delivery and enhance public confidence in the public health system. Therefore, USAID designed and launched CIHG. Led by FHI 360, in partnership with Search for Common Ground (SFCG) and Social Impact (SI), CIHG has supported Guinean efforts to strengthen multi-stakeholder collaboration to advance health sector reforms, vital for post-Ebola recovery and improving the health system.
CIHG’s results framework (RF) was designed by USAID and modestly revised in late 2017 with USAID’s approval. The RF is as follows:
Objective: To improve citizens’ understanding and participation in Guinea’s health system reforms. IR 1. Opportunities expanded for government officials and citizens to engage in constructive dialogue o Sub-IR 1.1. Government officials better prepared for engaging citizens’ in health reform dialogue o Sub IR 1.2. Media outlets’ and community theatre troupes’ skills for facilitating issued based discussion and constructive dialogue improved IR 2. More effective advocacy for health reform by partner CSOs o Sub IR 2.1. Skills of partner CSOs in advocacy, strategic planning and influencing public officials improved o Sub IR 2.2. Increased use of evidence by CSOs to influence public officials on health reform
CIHG’s objective and activities contribute to two of the USAID’s development objectives (DO) as described in the USAID/Guinea Country Development Cooperation Strategy: DO 1. “Utilization of Quality Health Services Increased” DO 2. “Governance and Economic Processes Strengthened” o Intermediate Result (IR) 2.1 “Transparent, Competitive, and Accountable Governance Strengthened”
To achieve CIHG’s objective and results, the three members of the consortium pooled their distinct abilities to act as one unified team. FHI 360 coordinated overall implementation and led technical activities related to advocacy, social accountability, civil society strengthening, training for government officials and oversaw day-to-day MEL during the second half of CIHG. SFCG strengthened media outlets, supported health reform information dissemination and citizen dialogue, thereby increasing access to quality information about health reform. Finally, SI led the initial design and implementation of MEL activities to ensure activity results are captured,
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communicated, and utilized to inform learning and improve programming and then led the endline study.
TECHNICAL APPROACH
Overall Strategy
CIHG’s technical strategy entailed several components: 1) support to government officials so that they better understand the key elements of health reform and how civic engagement can improve reform; 2) support for expanded opportunities for constructive dialogue between government and civil society on health reform; 3) support to media outlets and community theatre troupes and production of health governance content so citizens are better informed about health reform and involved in issues-based discussion about it; and 4) support to CSOs to provide evidence-based recommendations on health reform and more effectively lead health reform analysis and advocacy efforts.
Through this approach, CIHG aimed to ensure that civil society and media actors channelled citizen voices and served as both partners with government and watchdogs for health reforms, improving the culture of social accountability in Guinea.
CIHG’s design was premised on several core strategic principles that are summarized below.
A transparent sub-award process to ensure CSOs are positioned and prepared to channel citizen voices and serve as effective watchdogs. CIHG’s primary methodology for delivering assistance has been through transparent sub-awards designed to place Guinean civil society in the driver’s seat of health reform efforts, thereby increasing participation, ownership, and trust in the health system. CIHG sought to contribute to advancing health reform by supporting Guinean sub-awardees to lead reform efforts to the extent possible and by organizing CIHG-led activities as needed to complement CSO initiatives and optimize CIHG’s impact.
Targeted, user-driven mentoring to build civil society and media capacity and strengthen networks. CIHG followed a best practice of ensuring that capacity development trainings were targeted, and user driven. CIHG used select structured trainings but relied heavily on mentoring and learning-by-doing. Peer-to-peer learning events were also organized to deepen skills and forge stronger networks.
Fostering local ownership and multi-stakeholder dialogue. CIHG facilitated an array of different types of multi-stakeholder forums to deepen local ownership of CIHG’s objectives and strengthen the sustainability of CIHG’s results. In addition to working closely with local partners in the design and implementation of activities, CIHG also created an advisory committee comprised of CSO leaders, government officials, and representatives from other health and civil society projects. The committee reviewed annual implementation plans, offered recommendations to improve performance and shared information, rooting CIHG’s work in the Guinean context and needs and ensuring responsiveness to changing dynamics.
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Summary of CIHG Activities
IR 1: Opportunities Expanded for Elected and Appointed Officials and Citizens to Engage in Constructive Dialogue
Sub-IR 1.1: Elected and appointed officials better prepared for engaging citizens’ in health reform dialogue
CIHG organized numerous activities to enable GoG officials to increase and improve collaboration with civil society and the media.
Kick-starting multi-stakeholder mobilization. CIHG deferred a traditional project launch, instead organizing eight inter-active, multi-stakeholder forums to use the results of CIHG’s baseline study to increase understanding of health governance issues and mobilize reform champions. This included seven regional events in each of Guinea’s administrative regions on April 24-28, 2018 and a national forum on May 29, 2018 in Conakry. The forums brought together 508 key actors whose leadership is critical for improving health governance in Guinea: parliamentarians from the National Assembly Health Commission (NA-HC); administrative authorities at regional, prefectural and communal levels; representatives of deconcentrated health authorities; local government officials; representatives of civil society, including youth, women, and people living with disabilities; professionals in the public and private health sectors; traditional health practitioners; and representatives of the media. Participants discussed the results of the baseline and brainstormed next steps to increase citizen participation and improve health governance.
Strengthening NA-HC leadership in health governance. CIHG organized a strategic-planning workshop for the NA-HC on February 20-22, 2018, attended by 45 people, including 15 women, during which the NA-HC prepared and finalized both its three-year Strategic Plan (2018-2021) and its 2018 Operational Plan. The plans include activities for the committee to engage citizens, CSOs and the media. Participants included legislators and staff from the NA-HC, the National Assembly’s (NA) General Secretariat, several complementary legislative committees, and staff from the Ministry of Health (MOH) and Ministry of Youth and Sport. This collaboration was critical to designing stronger plans and building buy-in for their implementation. The workshop was also an opportunity for participants to deepen their knowledge of key health issues, which helped them to finalize the documents and will aid implementation.
To improve the NA-HC’s ability to draft future strategic plans, reports, memos and key correspondence, CIHG provided computer basics training from May-July 2018 for 19 people, including 7 legislators and 12 parliamentary assistants, at the express request of the NA-HC. The participants successfully completed training covering the fundamentals of Microsoft Word, Excel, PowerPoint, and using the internet to access information.
CIHG facilitated a workshop on February 15, 2019 for the NA-HC to prepare its 2019 Operational Plan, applying lessons learned from its 2018 plan. Six members of parliament (MPs) and 16 NA staff members participated. CIHG provided training (June 20-21, 2019) to 9 MPs on the NA-HC and 11 legislative staffers on legislative accountability, transparency, and leadership.
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Participants learned tactics for effectively communicating with constituents, tools for improving NA transparency with the public, tips for strengthening coalitions, and strategies for legislators to advocate for additional health reforms.
Improving NA-MOH local stakeholder dialogue. Between July-September 2018, members of the NA-HC, legislative staffers and representatives from the MOH (29 people in total) fanned out in four teams to visit more than 47 locations throughout the country, meeting with community members, listening to constituents, inspecting health centers and identifying how they can best use their positions to improve public health service delivery. These site visits sought not just to gather information but to mobilize citizen involvement in health governance. Community theatre groups performed to increase civic engagement, as officials met with local civic leaders, health professionals and local government officials. CIHG supported these national leaders in integrating their learnings from the field visits into the NA-HC’s Operational Plan and in executing that plan. CIHG helped these parliamentarians hold a press conference (September 14, 2018) to brief the media and constituents on the issues they identified to improve health governance.
Fostering a more participatory, transparent, and effective budget process. CIHG organized a two-day workshop on September 16-17, 2018 bringing together government officials and civil society to improve understanding of the budget process, identify the factors impeding more timely dispersal of the government health budget and pinpoint key actions to improve the Health Ministry’s spending of its allocated budget. The 68 participants came from the Ministries of Health, Budget, and Finance and Economy and also the NA, civil society and key international partners. Numerous attendees based outside Conakry received extensive amounts of new information, enabling them to better engage in the budget process in the future. Parliamentarians and their staffs can use that information to analyze health budgets against health performance indicators. Government officials at all levels can now use this information to overcome bottlenecks to ensure the timely transfer of funding to Guinea’s decentralized health structures and ensure financial accountability.
Improving NA-HC budget analysis. In November 2018, CIHG trained 30 people (legislators, legislative staff and journalists from Parliamentary Radio) on the budget process and budget analysis and provided technical assistance (TA) to help the NA-HC carefully analyze the 2019 budget to determine the extent to which the budget responded to the NA’s recommendations resulting from the CIHG-supported field visits. CIHG then facilitated an in-depth working session between the NA-HC and the MOH to discuss the elements of the budget about which the NA had concerns. The participants also discussed how the MOH would increase the disbursement of the health budget as underspending has been a significant problem in years past. The NA-HC and the MOH agreed to work on a reallocation of some budget line items to better meet identified needs. These achievements are the result not only of CIHG activities but also build on other investments from USAID.
Increasing GoG media engagement. To foster a closer relationship between the GoG and the citizens that it serves, CIHG supported four press conferences to increase government accountability and dialogue with citizens on health governance. Press conferences are not the norm for legislative commissions and require ministerial-level approval as well as involvement
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of the executive branch. On September 21, 2018, the NA-HC presented its formal report on the 2018 visits to health facilities, sharing recommendations with the MOH and media. The Minister of Health was present in a display of support and collaboration. The NA-HC held another press conference on February 27, 2019 with 61 participants in attendance when the NA-HC released its final report from the visits.
In a powerful display of governmental collaboration across institutions, the president of the NA- HC, the MOH Minister and the Ministry of Territorial Administration and Decentralization (MATD) Minister held a joint press conference after the forum on health decentralization on May 26, 2019 to stress the need for local actors to use their newly delegated authorities and work together to make health decentralization a success.
Another critical breakthrough was that CIHG overcame the MOH’s reluctance to engage with the media, based on negative experiences predating CIHG. MOH leadership agreed to meet with journalists to discuss health reform. CIHG organized the forum with the MOH and 35 CIHG- trained journalists on November 28, 2018. The MOH was represented by the Secretary General and the Health Minister’s Special Advisor on Health Policy. The Secretary General explained the government’s health reforms, and the MOH officials and journalists had a vibrant discussion.
In Year 3, CIHG adapted its approach and focused on working with local officials to sponsor and lead civic-governmental communications roundtables to increase government communication and discussion with the public about specific health-governance issues, with a particular emphasis on including journalists. Securing senior government officials’ participation in press conferences was particularly labor intensive, and the political climate in late 2019 and in 2020 was contentious. CIHG was eager to encourage government officials at all levels to engage stakeholders from the media and civil society without waiting for directives from senior officials. CIHG supported 15 roundtables led by different local officials and one co-organized with the media group Union des Radiodiffusions et Télévisions Libres de Guinée (URTELGUI). Overall, five took place in Kankan, five in Mamou, two in Dalaba, two in N’Zérékoré, and two in Boké. Most of these forums were broadcast by local radio outlets to reach a wider audience.
Strengthening health governance communications. CIHG organized a workshop from June 19-21, 2018 to increase collaboration and improve dissemination of key health-reform messages. The 15 participants were journalists, CSO representatives and officials from the Ministries of Communication and Health. Participants brainstormed tactics to increase media outlets’ production of more content focused on health reform and identified key messages. As a follow- on, CIHG worked closely with the MOH to organize a subsequent larger multi-stakeholder health communications workshop in April 2019. CIHG brought in the Association des Journalistes en Santé (AJS or the Association of Health Journalists) as a co-organizer to strengthen their relationship with MOH and strengthen their leadership in promoting health reform reporting. The event brought together 64 participants from the national and local levels, including MOH staff, MPs, CSO leaders, media outlets, and other technical and financial partners (TFPs) 1 working in the health sector. The group reviewed the MOH’s health- communication strategy and identified actions to advance its implementation. As some members
1 TFPs refers to bilateral and multilateral donors and international non-governmental organizations (NGOs) working in a particular sector.
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of the MOH have been reticent to work with groups outside of government, especially the media, the relationship and collaboration among participants was a key step in enhancing the MOH’s willingness to work with local partners and recognize them as essential allies to achieving MOH communications goals.
Improving MOH supervision of health reforms. To further support the MOH, CIHG staff, along with other TFPs, participated in the MOH-led supervision visits to health districts throughout the country to examine execution of the performance contracts signed with each district in June 2019. The team that CIHG joined visited the prefectural health directorates of Kouroussa, Siguiri, and Kankan as well as seven health centers in the area. This team’s experience was similar to that of other teams. While evidence of some improvements was found, the delays in disbursement of promised resources and data quality issues with selected indicators hampered the ability of the different missions to make definitive evaluations of health district performance. During the post-mission meeting convened by the MOH with TFPs, these challenges were discussed frankly, and the MOH said that it would examine how to address them.
Advancing decentralization. CIHG worked with the MATD and the MOH over the course of many months to organize a large, national health-governance-decentralization workshop. The event (March 25-26, 2019) brought together more than 150 Guineans who all have a critical role in ensuring that decentralization of the public health sector results in improved service delivery. The objective was to increase local officials’ (elected and civil servants) knowledge of their specific responsibilities in health reform and how to engage civil society in that process. Given Guinea’s long history of centralized power, it was critical for local officials to hear national leaders’ loud, clear and unequivocal support for decentralization and to see national leaders empowering local actors to use the authorities and responsibilities recently delegated to those at the local level to improve health governance. Forum participants included the MOH and MATD ministers and their general secretaries, representatives of the elected officials (NA-HC MPs and mayors of 40 convergence communes), public servants (governors, prefects, prefectural health directors, and directors of micro-projects), members of Health and Hygiene Committees (Comités de Santé et d'Hygiène or COSAHs), CSO representatives and the media.
Fostering local dialogue initiatives and reform. During the last year of performance, CIHG pivoted its support for GoG officials to engage in dialogue at the local level. Political unrest grew over 2019, and CIHG anticipated that it would worsen in the lead up to the much-contested legislative elections and constitutional referendum. CIHG anticipated that national leaders were much less likely to be available for CIHG activities. Moreover, the project had already provided extensive support for national actors. Therefore, CIHG identified 10 communes with local leaders championing improved health governance and provided support for them to initiate health governance dialogues with citizens and identify actions to improve health governance. The activity built upon CIHG’s health decentralization workshop held in March 2019 and research conducted by CIHG’s local partner, the Centre Africain de Formation pour le Développement (CENAFOD), regarding the functionality of local COSAHs. With CIHG support, officials in all 10 communes sponsored and led civic engagement forums. The participating communes were: Bangouya (Kindia Prefecture), Bardou (Kissidougou Prefecture), Baro (Kouroussa Prefecture), Bofossou (Macenta Prefecture), Bossou (Lola Prefecture), Dounet
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(Mamou Prefecture), Fria (Fria Prefecture), Gbérédou Baranama (Kankan Prefecture), Koubia (Koubia Prefecture), and Kounsitel (Gaoual Prefecture).
Supporting planning for the États Généraux de Santé (EGS). CIHG provided TA to the MOH to prepare the EGS so that the event might be an effective national forum for multi- stakeholder dialogue on health governance and advance specific health governance reforms. Guinea’s president announced the EGS in July 2019. The MOH requested CIHG’s assistance, to which we agreed, with USAID’s concurrence. The EGS was originally scheduled for September 2019. CIHG worked closely with the MOH leadership to identify opportunities for the MOH to meaningfully include citizen participation in the EGS and to effectively communicate the purpose and outcomes of the EGS to the public before, during, and after the event.
CIHG collaborated with the MOH to record and broadcast an episode of CIHG’s television program, Guinée Forum, focused on explaining the EGS and encouraging civic participation in it. CIHG recorded micro-interviews with citizens asking for their opinions on the status of health and health governance in Guinea and then compiled these “vox pops” to share with MOH so they could listen to average citizens’ views to inform preparations and the substance of the EGS. CIHG also began preparation of CSO partners who would participate in the EGS to ensure that they would be prepared to capitalize on this unique advocacy opportunity. EGS planning was well underway when the president delayed the event that was postponed indefinitely by the Health Minister.
Sub IR 1.2: Improved facilitation of health issues-based discussion and constructive dialogue by media outlets and community theatre troupes
Strengthening journalists’ skills to provide high quality content on health governance. Throughout CIHG’s period of performance (POP), we provided both in-person, structured training (often on-site at radio stations themselves) as well as follow-on coaching to journalists, including radio station managers. The bulk of CIHG’s TA was targeted at our 29 partner radio stations. However, additional training and peer exchanges were also organized to provide skills building and networking opportunities beyond this group of core media partners.
Radio training and coaching focused on improving journalists’ knowledge of good governance with an emphasis on health governance, journalism best practices and ethics, tactics for dispelling rumors, and conflict-sensitive reporting. In addition, participants worked to improve practical skills such as program planning, research, formatting affordable, inter-active format options, and facilitation of conflict-sensitive, participatory radio shows that foster constructive dialogue and problem solving. Facilitators used hands-on activities and tools to improve learning. Radio trainings also included journalists preparing a simulation of a show, and where possible, the production of a CIHG-related program to put new skills into practice. The week- long initial training sessions were followed by subsequent tailored training visits as well as virtual coaching. The follow-on visits and coaching focused on increasing the number of productions addressing health governance, improving the quality and objectivity of reporting, and strengthening the management of the radio stations. TA also focused on how to structure reporting and programming so that it fosters dialogue within the community and across
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stakeholder groups. CIHG also provided feedback on stories, programming ideas and management challenges.
In addition to this extensive training for radio partners, CIHG also organized two training workshops for online and print journalists in November 2018 to increase reporting on health reform and to improve the quality of news coverage among print and online outlets. As with the training for radio partners, the workshops focused on quality reporting on governance, especially health sector reforms, ethical, conflict-sensitive journalism, and methods for written content to contribute to constructive public dialogue on health sector reform and other key issues.
Dynamizing health governance reporting and networking journalists. CIHG designed Media Week and the Media Week Peer Learning Exchange to achieve several objectives: 1) to motivate journalists to produce more health governance reporting; 2) to improve the quality of the reporting; 3) to generate more discussion among Guineans about health governance; and 4) to improve journalism skills through peer learning. The event took extensive planning and required that CIHG make many adaptations over the preceding months to address numerous challenges, including attempts to synchronize Media Week with the EGS that was delayed at the last minute, seemingly temporarily and then indefinitely. Furthermore, this activity was initially planned as a media competition before Media Week was conceived as the alternative. When working with local media associations to design the competition, it became clear that the event as originally conceptualized would more likely sew tension rather than foster collaboration and attention. As such, we revamped and expanded the event.
In addition to coordinating a mass health governance reporting blitz the week of November 24 – December 2, 2018, with outlets synchronizing programs and articles to be broadcast and published all the same week, CIHG held a two-day peer learning forum the following week for the journalists who participated actively in Media Week, along with select government officials with whom CIHG had worked. Participants exchanged their experiences and lessons learned from Media Week, recommendations for improving programming and suggestions for sustaining increased health governance coverage.
Increasing public access to health governance news and information. CIHG provided technical and financial assistance to media partners to produce health governance content and produced complementary content itself that media partners then broadcast. CIHG-supported and CIHG-produced health governance programming and reporting sought to increase citizen knowledge of recent reforms and other health governance issues, to foster constructive dialogue on health governance through interactive programs and to motivate listeners, viewers and readers to become more involved in health governance in their communities.
Partner-produced programs. CIHG’s investment in its radio partners through the TA described above and financial support to defray the costs of production enabled radio partners to significantly increase health governance programming. CIHG documented 256 partner-produced programs in a variety of local languages such as Guerzé, Kissi, Konian, Konianké, Kpêlê, Malinké, Pular and Soussou. The shows were organized around themes identified by the radio partners during the communications workshops, coaching sessions with partners and other CIHG activities. Among the topics covered were reforms making certain health services free of charge,
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citizens’ involvement in the proper functioning of health centers, the role of COSAHs, the quality of health workers in rural areas, the retention of health professionals in their working place and patient reception at public health facilities. Partners’ improved capacity enabled them to quickly pivot programming to address the novel coronavirus 2019 (COVID-19), providing information related to the pandemic such as measures to reduce transmission, available care and treatment options, and dispelling rumors. Most shows were in a roundtable, interactive format to foster increased dialogue.
CIHG-produced programs. In addition to partner-led programming, CIHG produced complementary shows that were then broadcast by radio and television partners. The programs created and disseminated over the lifetime of CIHG include the following: • 53 episodes of the women-focused radio show, Sissi Aminata, which means “aunt” in many West African languages. • 47 episodes of the youth-focused radio show, Barada, which means “teapot” in Malinké, around which youth often gather to discuss issues with friends. • 24 episodes of the radio drama, Wontanara, which means “together we are strong” in Pular; the drama focused on two young men and their loved ones as a means to address a variety of health and health governance issues. • 8 episodes of the television show, Taboulé, which packaged recordings of participatory theatre performances about health governance topics with information about the location of each performance and interviews with a few local actors. • 16 episodes of Guinée Forum, a public affairs program during which leading officials were interviewed by a panel of journalists and responded to audience questions. • 20 episodes of the television drama, Djembé, that focused on two friends, a COSAH member and a shop keeper and used their adventures to discuss health governance issues. Djembé is the name of a very popular traditional musical instrument in Guinea. It is used for calling people together for celebrations and gatherings where information important to the community is shared.
Fostering dialogue on health governance through community theatre. CIHG used participatory community theatre to facilitate community dialogue on health reform and provide citizens a feedback mechanism to local leaders involved in health governance. CIHG competitively selected theatre partners and provided the troupes training and financial assistance to implement community theatre campaigns. Training addressed effective participatory performance, health governance issues so that performers understood the topics around which to craft performances, pre-event research to tailor the performances to priority topics for the community in question, pre-event outreach and publicity to maximize audience size, facilitation techniques to promote dialogue, and practicalities such as documentation of audience size. The theatre performances addressed a range of subjects related to health reforms and governance including: • Roles and responsibilities of COSAH members • Community involvement in health facility management • Prenatal and childbirth services for pregnant women • Childhood vaccinations and health services for children 0-5 years of age • Cost of pharmaceuticals • Patient reception at health facilities
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• Availability of healthcare personnel • Sanitation in healthcare facilities • Community ownership of health facilities • Health consequences of street medications.
Each year, one large campaign was conducted reaching communities across the country. Over the life of the project, CIHG supported 17 troupes who conducted a total of 219 performances mobilizing 49,270 people, of which at least 49% were women. Participant feedback was very positive. They found the issues raised pertinent their communities and the daily challenges they faced. The table below compiles some of the common issues raised during community theatre performances.
Common topics raised during community theatre performances
Overall Themes Specific Topics
- Charges for malaria treatment that should be free - Charges for cesarean section surgery that should be free - High cost of products and services at health centers Access to health care - Distance to health centers - Insufficient equipment at health facilities and lack of some supplies to treat common diseases - Treatment of patients according to their social status (affinity treatment) - Continued reticence of many Guineans to vaccinate children Lack of - Women’s reluctance to seek prenatal care confidence in the public health - Reluctance of health facilities to treat patients on credit because of non- system payment of some patients treated on credit in the past Reduced use of health facilities due to fear of Lassa fever infection - Poor reception of patients by health workers - Lack of specialists at health posts - Repeated reassignments of health workers Health Personnel - Lack of medical staff at night - Patient neglect in hospitals and health centers by health workers Repeated absences of staff at the health post - Lack of sufficient medical staff at health centers - Insufficient number of drinking water points; distance to water point Other public - Insufficient drinking water especially during the dry season services that - The high incidence of illnesses such as diarrhea due to the lack of potable contribute to water public heath - Insufficient number of latrines and garbage dumps - Inadequate management of water supply and garbage collection - Lack of community awareness of COSAHs - Need to encourage couples to seek medical treatment together and support one another’s medical care needs Other - Proliferation of private clinics and pharmacies sometimes without authorization, drawing staff away from public health system or fostering absences - Use of impregnated mosquito nets in vegetable gardens rather than in rooms
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The last CIHG community theatre campaign had to be adapted due to COVID-19 since large group gatherings were no longer permitted. Six of CIHG’s partner theatre partners conducted day-long, “traveling performance” in three different locations each. The troupes held small group, socially-distanced educational talks, door-to-door visits, and mobile messaging caravans, to continue sharing health governance information and encouraging civic engagement.
Increasing information access and dialogue for communities most in need. CIHG implemented three activities to increase access to information and foster increased dialogue in communities with less access to radio and television, the most common sources of information, as well as low-literacy populations.
Listening clubs. CIHG organized 35 listening clubs in geographically dispersed locations. The clubs then facilitated listening sessions in neighboring communities. For each session, a few club members would travel to a nearby location and bring together 20-25 participants (lowered to 15- 20 with the advent of COVID-19) from different health governance stakeholder groups (for example, civil society leaders, government officials, healthcare professionals). The facilitators played CIHG health governance radio shows on small loudspeakers and then fostered discussion in a local language among participants to enhance comprehension of the content and encourage participants to identify ways to apply the information learned in their daily lives.
To create the clubs, CIHG identified communities with limited radio coverage and narrowed the list to 35, spread across Guinea. CIHG held a series of meetings with stakeholders in each community during which individuals were nominated to participate. CIHG worked with its local contacts to finalize the club membership: nine people from different groups such as representatives of women's and youth associations, traditional and religious leaders, healthcare professionals, and representatives of people living with disabilities. CIHG trained each group on key health governance issues, dialogue facilitation and preparation and implementation of listening sessions. Each club was also provided audio equipment on which to play the radio shows.
The formation of the clubs was conducted over the first year of the project. The clubs were slow to organize listening sessions during the second year, so CIHG sent staff to meet with clubs and identify solutions to improve performance. Group members were happy to work as volunteers, but the cost of transportation limited their ability to reach neighboring communes. CIHG decided to provide a modest amount to defray transportation costs. As a result, the listening clubs dramatically increased their activity. Ultimately, the 35 clubs conducted 291 listening sessions reaching more than 4,000 people, estimating conservatively. As clubs were essentially volunteer driven, the quality of participation documentation was uneven. At the end of the project, CIHG provided the 35 listening clubs USB keys with 10 new shows, allowing the clubs to continue organizing sessions. CIHG also connected the clubs with radio stations nearby who could provide future content as well, and SFCG will continue to share shows produced under their ongoing World Bank funded project that continues through 2021 with the listening groups.
Mobile cinema forums. In Year 3, CIHG organized nine outdoor film screenings of CIHG’s television productions Guinée Forum and Djembé in communities with limited access to
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television. The forums targeting 100-200 people each were scheduled for the the second half of the year, based on the production calendar for completing all 20 Djembé episodes. CIHG facilitators would screen episodes of both shows and then faciliate discussion among the audience members. CIHG encouraged not just the general public to attend but also healthcare professionals, local officials, and CSO leaders. CIHG even secured the participation of religious leaders in Dounet and Kankan. The remaining 11 forums were not organized due to COVID-19 event size restrictions, in country travel restrictions, and infections among staff, among other complications.
Health governance graphic guide for low-literacy populations. CIHG produced a graphic guide on health governance and health issues that uses images and simple text to facilitate user mastery of key concepts. Five hundred durable, water resistant copies of the graphic guide were printed and distributed nationwide to a cross-section of CIHG stakeholders, including media partners, CSO partners, community theatre groups, and listening groups. Some copies of the publication were made available in key locations such as in Town Halls, regional and local directorate of health offices, and health care centers so that people can read them freely on the spot. As schools were closed, some copies of the graphic guide were given to the teachers’ trade union called Syndicat Libre des Enseignants et Chercheurs de Guinée -SLECG to disseminate when schools reopen. The graphic guide was also used by some theatre groups during their information campaigns on COVID-19.
IR 2: More effective civic advocacy for health reform
Summary of CIHG Grants program. The principal activity to achieve this result and both sub- results was through the grants program designed to provide CSOs financial and technical support to advance health reform through a variety of advocacy tools including research, civic mobilization and engagement of decision makers. CIHG focused resources on learning-by-doing, with extensive mentoring from CIHG staff, in lieu of overuse of training workshops. CIHG conducted pre-award assessments with all prospective grantees. These assessments were used to define special award conditions tailored to each grantee to ensure compliance. The results were such that CIHG had to put in place detailed conditions such as submission of complete supporting documentation and prior approval of procurements over $500. While the quality of financial reports did improve over time, CIHG had to retain many special award conditions throughout the entire POP for each grantee. The DUNS/SAM registration process took a long time to complete for several of the first awardees. Among the first awardees, several specifically declined CIHG support to complete the registration. Errors then led to delays. Fortunately, CIHG successfully convinced later partners to accept CIHG TA, significantly accelerating the registration process.
As grant implementation proceeded, CIHG made several significant adaptations to optimize partner performance. CIHG intensified its TA over time to the point that in the Year 3 implementation plan, CIHG prioritized support to CSOs and only included CIHG-led activities engaging government which we deemed absolutely essential for impact, to ensure that staff had the necessary time to support partners. Given the labor intensiveness of the technical, financial and administrative coaching and monitoring, CIHG strategically limited the number of subsequent grants to increase the effectiveness of partners’ implementation and ensure compliance.
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CIHG issued three types of grants: health policy reform research grants, coalition mobilization grants, and post-research advocacy grants. The research and mobilization grantees were selected through a competitive, open request for applications (RFA). CIHG offered a question period to increase the understanding of CIHG’s objectives and the competition process among prospective grantees. A pre-award conference was also held to disseminate answers to submitted questions and provide coaching on application preparation to increase the quality of the submissions. The RFA was widely disseminated and all materials were posted online. CIHG received an overwhelming response: 100 applications were submitted.
Due to the caliber of submissions to the RFA, the amount of work required to help each of the research and mobilization grantees to finalize high quality technical and financial plans and to document those negotiations was substantial. As a result, CIHG designed the third round of grants as a co-creation and issued a RFA targeting only the research partners. CIHG determined that the opportunity cost of another full and open competition was too high. The research grantees had completed their first awards, already had SAM/DUNS registrations, and had completed the pre-award assessments. The mobilization partners were already behind on their implementation so including them would likely have led to further delays to their existing commitments. Moreover, there were no applicants from the first RFA whose applications were sufficiently strong to merit inclusion in this targeted RFA.
Health policy reform research grants. The first group of grants funded research on health governance to help CSOs and other health governance stakeholders identify the priority issues on which they wished to focus future reform efforts. CIHG prioritized issuance of these grants so that the research could inform CIHG’s work (whether CIHG-led or partner-led) for the remaining POP. While initially CIHG had hoped to fund 10-20 research grants, of the 40 research proposals received, most were not strong, and no package was readily fundable with limited negotiations. CIHG worked for months with the leading candidates and was ultimately able to fund five, following USAID’s approval.
Summary of Research Grants
CSO Objective Locations Details To assess and analyze the level of women’s access to Region of Award (GNF): health service; to improve women’s access to services. Conakry, 308 520 000 AFJ Kindia and Period of performance: December 3, 2018 – June 2, Cost share: Boké 2019 40 945 000 To identity and analyze the factors that limit citizen participation and access to health services; to identify specific solutions to improve health system Prefecture of Award (GNF): AIDE-Guinée management; and to raise community awareness of Dinguiraye, 506 415 000 with support the local populations regarding their health rights. Mandiana et from Nimitè Cost share: Beyla 87 100 000 Period of performance: December 3, 2018 – July 2, 2019
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CSO Objective Locations Details To assess COSAHs performance and the extent to citizen participation; to identify best practices and other Award (GNF): recommendations to improve the effectiveness of 960,009,000 CENAFOD COSAHs and health governance. Nationwide Cost share: 147,410,000 Period of performance: February 1, 2019 – November 30, 2019 To access the level of access to malaria prevention and treatment services, the extent of CSO involvement in reducing malaria; and citizen knowledge about anti- Award (GNF): CJMAD with Regions of malaria efforts; and to identify recommendations to 364,920,000 support from N’Zérékoré improve the fight against malaria. CEGUIFORD and Faranah Cost share: 39,150,000 Period of performance: December 3, 2018 – June 2, 2019 12 PNACC To assess the involvement of rural communities and communes in their COSAHs in management of the health facilities; N’Zérékoré, Award (GNF): and to identify recommendations to improve health Kankan, 266,816,000 MSS facility management. Faranah, Cost share: Mamou, Period of performance: December 3, 2018 – June 2, 33,400,000 Kindia, Labé 2019 and Boké
● Association des Femmes Journalistes (AFJ or the Association of Women Journalists)
Research Process and Findings. AFJ’s research project carried out between December 2018 – June 2019 examined the level of women's access to health care in health facilities in Conakry, Kindia and Boké. Once AFJ’s research protocol was validated by the National Ethics Committee for Health Research (Comité national d’éthique pour la recherche en santé or CNERS) in January 2019, AFJ trained 25 data collectors and 3 regional supervisors (8 of whom were women) on the research methodology and data collection tools. During January-February 2019, the trained individuals surveyed 848 people through interview collection, in-depth interviews and focus group discussions. After the data was collected and analyzed, AFJ compiled a final research report in April 2019 which was revised and strengthened in coordination with the CIHG team as well as after a validation workshop. As detailed in the report, AFJ’s research yielded the following results among the population surveyed: • 90% of women have no knowledge of the vaccinations required prior to and during pregnancy. • 59% of women reported that no free health services exist. • In all three regions, there are health facilities that do not offer caesarean sections free of charge. • 70% of women reported lack of financial resources as the main reason they did not use health facilities. • In general, low public confidence in health care services and poor patient reception hinder women’s access to health care.
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Recommendations. To address these findings, AFJ compiled a list of recommendations to share and advocate for to various stakeholders. Most noteworthy among these was the proposal to officially display health care service costs in health facilities and to indicate which services are offered free of charge. Additionally, they suggested capacity building for health staff to improve patient reception in order to build trust with the population.
Research Dissemination and Advocacy. To further disseminate their research, AFJ organized two workshops, in collaboration with FHI 360 and SFCG, to brief journalists on the findings regarding women’s access to health care and to provide training on health governance reporting and Common Ground approach journalism. In May 2019, AFJ trained 13 journalists from public media (RTG) and private media outlets in Conakry and 15 journalists from rural radio and private media stations in Kindia. As a result of these events, several radio pieces on AFJ’s work were broadcast.
Furthermore, despite the end of the sub-award POP on June 2, 2019, AFJ met with management from Rural Radio of Guinea and with representatives from the NA-HC, on June 4 and 11, 2019 respectively, to present their research findings and advocate for these recommendations. Both stakeholders positively received AFJ’s recommendations, and the radio station even committed to increasing their coverage on health governance. In addition, AFJ emailed the research report to numerous stakeholders and posted it on WhatsApp and Facebook. With these research findings easily accessible, citizens will be empowered to advocate more effectively on behalf of women’s access to health care.
● Initiative Action pour le Développement de la Guinée (AIDE-Guinée or Initiative Action for Development of Guinea)
Research Process and Findings. From December 2018 – July 2019, AIDE-Guinée, in partnership with Nimité Theatre, carried out a research study with the objective of identifying factors that limit community participation and access to health services in the Beyla, Dinguiraye, and Mandiana prefectures. In February and March 2019, the consortium trained 34 data collectors and 6 supervisors on data collection techniques in the 3 prefectures as well as 18 individuals on using participatory theatre as a qualitative data collection method. This allowed data collection to take place in April in 17 locations; in total, they conducted 34 focus groups, 91 individual interviews, and 17 participatory theatre performances.
The research report resulting from this data collection and analysis was finalized in July after incorporating recommendations from CIHG staff as well as 69 various stakeholders during 3 workshops conducted in Beyla, Dinguiraye, and Mandiana in June. The research findings detailed in this report showed that the majority of the population agrees that the following factors limit access to health care: remoteness of health facilties, unqualified health personnel and absenteeism, poor patient reception, lack of necessary equipment, overcharging for certain services, and failure to offer childbirth services free of charge. The research found that citizen participation in the management of local health facilities is limited due to lack of communication from COSAH members, distrust between the population and health personnel and the perception that health facilities belong to healthcare professionals.
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Recommendations. On the basis of these findings, AIDE-Guinée developed the following recommendations to share with health officials: • Mobilize more resources and ensure prudent use of those resources to improve people's access to health services. • Reduce the distribution imbalance of health workers, both between regions and between urban and rural areas. • Strengthen collaboration between government officials and civil society by involving the latter in the process of developing policies and intervention strategies. • Work to restore trust between health workers and citizens by strengthening communication between communities and health facilities. • Address prejudices against the use of health facilities and participation in their management. • Motivate and strengthen the capacity of health workers on a regular basis.
Research Dissemination and Advocacy. After AIDE-Guinée incorporated these recommendations into their research report, they shared three copies of the final report with the DPS in Beyla, Mandiana, and Dinguiraye. Though their period of performance ended before they were able to carry out any specific advocacy related to their findings, the CSO continued this work under their advocacy grant in fiscal year (FY) 2020.
● Comité Jeunes Mon Avenir d’Abord (CJMAD or Youth Committee My Future First) with sub-partner Centre Guinéen pour la Formation, la Recherche et le Développement (CEGUIFORD or Guinean Center for Training, Research and Development)
Research Process and Findings. CJMAD, in partnership with CEGUIFORD, conducted research on access to malaria prevention and treatment services, CSO involvement in reducing malaria, and citizen knowledge about anti-malaria efforts in the regions of N’Zérékoré and Faranah. The consortium trained 24 data collectors and 6 supervisors in January before data collection took place across 6 prefectures in March. Six hundred forty-two people participated in focus groups and in-depth interviews that were conducted at health centers, including COSAH members and local authorities. A particular emphasis was placed on verifying the existence of free malaria products.
Research revealed that the access to prevention and treatment services is affected by poor patient reception at health facilities, health staff absenteeism, and the fact that anti-malaria products are often not offered free of charge. There are also disruptions in the supply chain of anti-malarial products, which sometimes results in a lapse in or expiration of products, and a lack of warehouses, which are otherwise too small or dilapidated in some communities. Thanks to awareness raising activities, the majority of citizens are aware of malaria symptoms and the factors that contribute to contracting malaria, though there are differences by prefecture.
Recommendations. CJMAD shared these research findings with 28 stakeholders during two validation workshops in May 2019 and analyzed participant feedback before finalizing their research report and compiling the following list of recommendations: • Utilize local budgets to support community health workers and COSAH members to increase their dynamism, community engagement and autonomy.
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• Encourage COSAHs and community health works with cash, in-kind bonuses, or public recognition. • Increase awareness around malaria by involving children, women, and grassroots community organizations in raising awareness among their peers. • Continue organizing community-led sanitation campaigns. • Streamline supply chains. • Translate reforms into local languages and disseminate them during meetings and on the radio. • Sanction health facilities and agents that do not provide free access to anti-malaria care.
Research Dissemination and Advocacy. To increase media coverage of the study findings and recommendations, CJMAD organized an outreach event in May 2019 for 15 journalists, including 4 women, from the targeted regions. They were briefed on the findings, and in-depth discussions were facilitated before the journalists then produced radio programs about CJMAD’s research.
● Mutuelle de Santé et Services (MSS), also locally referred to as Mutuelle de Guinée
Research Process and Findings. The objective of MSS’s research project carried out from December 2018 – June 2019 was to assess the involvement of rural communities and their COSAHs in the management of health facilities in 12 convergence communes in Guinea’s 7 administrative regions. In January, a group of data collectors and focal points were oriented and trained on the data collection tools as well as focus group and interview techniques before data collection took place in March. Two-hundred ninety people were reached through focus group discussions and interviews conducted by 14 data collectors and 7 supervisors, and 12 health centers were visited.
The research revealed that 8 of the 12 health centers visited no longer comply with community health standards or policy in terms of health coverage. Furthermore, the health centers in Siguirini and Bardou both received very low scores (20%) in relation to the existence of amenities such as water points and incineration pits. Communities are active in health center management (with 10 out of 12 receiving scores above 60%), participating in such activities as maintaining water points, raising awareness, supporting health workers, and providing construction labor. Among the barriers to participation for those not already involved are lack of information sharing about health center activities, poverty within the communities, and lack of transport.
After consulting a group of stakeholders through a research validation workshop, MSS put together the following recommendations to address these findings: • Improve the availability of medical personnel in late hours and make post-childbirth medicines free of charge. • Strengthen the capacity of health care workers in all health facilities to prevent and manage diseases. • Support funding for projects to build drinking water points primarily in health posts, incineration pits, and supply vaccine conservation equipment.
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• Involve COSAH members in monthly health center meetings to create a space for consultation.
Research Dissemination and Advocacy. In May 2019, MSS shared their research findings and recommendations with 57 stakeholders through a national validation workshop in Conakry and regional workshops in Boké and Kindia. To help communities address the issues identified by the research, MSS designed and shared a decision-making tool that would allow regional stakeholders to analyze the problems, propose potential solutions, and make implementation decisions. The participants, including local health officials, COSAH members, and local elected representatives, seemed highly motivated to use this tool to address the identified challenges.
● Centre Africain de Formation pour le Développement (CENAFOD or African Training Center for Development) with sub-partners Centre du Commerce International pour le Développement (CECIDE or Center for International Commerce for Development) and Initiative et Action pour l’Amélioration de la Santé des Populations (INAASPO or Initiative and Action for the Improvement of Populations’ Health).
Research Process and Findings. CENAFOD’s nation-wide project aimed to assess COSAHs’ performance and citizen participation in health governance to identify best practices and recommendations to improve the effectiveness of COSAHs. Across Guinea’s 7 administrative regions and the special zone of Conakry, CENAFOD trained 70 data collectors and 8 data collection supervisors from April-June 2018 and familiarized them with the questionnaires for COSAH members, local elected representatives and decentralized authorities, and community focus groups.
Data collection was conducted by two-person teams during May- July 2019. CENAFOD’s target sample size was enormous for a qualitative research project. They successfully conducted 1,495 documented interviews and focus groups and reached 211 COSAHs out of a total of 408 COSAHs nationwide or 52%, exceeding the target of 30%. A variety of factors contributed to the slight short fall in documented interviews and focus groups: inaccessibility of government officials, logistical hurdles to reaching certain villages in a timely manner due the rainy season and failures on the part of some data collectors to provide the required documentation.
The study findings revealed that none of the COSAHs are organized as planned within the framework of reference for the organization: 94% of COSAHs are made up of nine members instead of the seven outlined in the COSAH reference document; the makeup of COSAHs is not uniform, with the designated positions varying across COSAHs; 36% of COSAHs do not have meeting minutes; 48% do not possess the COSAH reference framework; and 66% do not have a written action plan. Furthermore, 52% of COSAH members stated that they are aware of the existence of a budget for COSAHs without knowledge of how it is developed and executed.
Recommendations and Research Dissemination. CENAFOD organized 34 workshops in the 33 prefectures throughout the country and the city of Conakry in October to bring together civic leaders, COSAH members, local government authorities, local MOH representatives, and heads of health centers to share the research findings and seek participant feedback on the draft recommendations. In all, 1,573 people participated (including 367 women). The workshops
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yielded numerous recommendations targeting several principal actors involved in health governance: • National government: Transfer finances to municipalities so that local officials have the resources to execute their responsibilities in heath governance, as provided by the MOH/MATD reference framework on health decentralization; adapt the structure of COSAHs to include community health workers, such as relais communitauires and agents communataires, whose responsibilities include engaging community members to increase use of health centers. • Municipal authorities: Allocate 15% of the munipality budget to health to pay such expenses as renovation of health centers, modest stipends for COSAH members, and to hire more employees for local health centers; require COSAHs to report their activities to the municaplity and the general public. • Guinean CSOs and TFPs: Train municipal councils and COSAH members to improve COSAH effectivensess and provide assistance to the MOH so it can put in place structures and practices to improve the functionality of COSAHs. • COSAH members: Organize monthly meetings to improve the functionality of health facilities, establish an effective consultation framework between COSAH and health providers, and organize periodic reporting sessions of COSAH activities at the municipal level for stakeholders and the general public.
CENAFOD incorporated these recommendations into the final version of their research report, and CIHG then worked with them to ensure that copies of the report were well disseminated throughout the country.
Coalition Mobilization Grants. The purpose of these grants was to mobilize constituencies throughout the country to advocate for health reform, monitor implementation of reforms, and help local actors to both implement reforms devolved to communities and to involve citizens in health governance. Among the activities conducted under these grants were: awareness raising caravans, data-driven briefings and lobbying, and capacity building of local leaders (civic and governmental) to implement decentralization and engage community members.
We had planned 5-10 grants that would be implemented during Year 2 and/or Year 3. Sixty proposals were submitted. As with the research proposals, the quality was such that extensive collaboration was required with the prospective partners with the strongest proposals to finalize a package that CIHG and USAID could approve. Implementation of these awards occurred as planned during Year 2 and Year 3, although work started later in Year 2 than initially anticipated due to the labor intensiveness of the grant finalization process.
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Summary of Mobilization Grants
CSO Objective Locations Details Increase the ownership capacity of local actors Award (GNF): (Territorial Administrators, Local Elected 1 422 082 700 AGIL 38 urban Officials, CSOs and Citizens) to adopt the communes health-decentralization approach. Cost share: USAID approval and 40 of 385 100 000 March 27, 2019 convergences Period of performance: April 15, 2019 – April 14, 2020 12 Months Mobilize citizen involvement, particularly of Award (GNF): AGUIFPEG women, in the decentralized governance of 38 urban 1 312 857 750 health in Guinea communes
USAID approval and 40 of Cost share: April 19, 2019 Period of performance: May 15, 2019 – August convergences 139 532 750 30, 2020 Award (GNF): CNOSCG Mobilize civil society in health governance 1 207 202 500 38 urban
USAID approval Period of performance: May 15, 2019 – July 31, communes Cost share: April 19, 2019 2020 114 940 000 Mobilize communities to use of maternal and Award (GNF): FEDIPHU child health services 1 223 207 000 N'Zérékoré
USAID approval region Period of performance: May 28, 2019 – July 31, Cost share: April 19, 2019 2020 122 645 000 Advocate for increased involvement of Award (GNF): LGL traditional medicine and traditional medicine Regions of 1 198 564 000 practitioners in Guinea’s health system reforms Kindia, Boke, USAID approval and Conakry Cost share: June 3, 2019 Period of performance: June 17, 2019 – August 121 780 000 31, 2020 Increase youth participation in health Regions of Award (GNF): RAJ-GUI governance Kindia, Boké, 1 252 626 000
Labé, Kankan, USAID approval Period of performance: September 26, 2019 – N’Zérékoré Cost share: Sept. 26, 2019 August 31, 2020 and Conakry 96,900,000 GNF
• Alliance Promoting Governance and Local Initiatives (AGIL)
AGIL’s one-year project supported the health sector decentralization process at the local level by strengthening the capacities of local actors (territorial administrators, local elected representatives, CSOs and citizens) in health governance. AGIL’s period of performance was April 15, 2019 – April 14, 2020.
The following are some of the most significant results from AGIL’s project2: • Creation of a guide that explains health decentralization reforms, including input from CSO leaders, local elected officials, the NA-HC, MOH, and MATD.
2 Note to USAID: Certain AGIL participation data cannot be validated. The information included here are best estimates. For any data that contributes to USAID indicators, only validated data is included.
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• 76 public health officials and 8 regional supervisors trained on AGIL’s health reform guide and training techniques for explaining the guide to citizens at the local level. • An estimated 588 COSAH representatives, CSO members, community counsellors, heads of health centers, and prefectural and sub-prefectural health directors trained on health reforms related to decentralization through 27 training sessions. 210 women (35%) participated in these trainings. • As estimated 520 people, including 115 women (22%), trained on the roles and responsibilities of COSAHs. • 55 COSAHs revitalized in the regions of Kankan, Labé, and N’Zérékoré.
Creation of health reform guide. Between July and November 2019, AGIL designed, drafted, and finalized a simplified guide explaining health decentralization reforms with support from CIHG staff. To solicit feedback and incorporate recommendations from key stakeholders before finalizing the guide, AGIL hosted a workshop for 45 participants including CSO leaders, local elected officials, NA-HC legislators, officials from the MOH, MATD, and the Prime Minister’s office, and representatives from donors and international non-governmental organizations.
Training of trainers. To increase the involvement of public health officials in the project, AGIL trained 76 officials nominated by MATD and MOH officials from each of the 33 target prefectures and 5 communes of Conakry. In December 2019, these public health officials as well as eight regional supervisors were trained on AGIL’s health reform guide and training techniques to prepare participants for the workshops that they would in turn lead at the local level. The involved of GoG officials in the selection trainers and as the trainers themselves increased GoG buy-in and support for subsequent activities.
Training local actors on health decentralization reforms. From January-March 2020, AGIL and its trainers planned and organized 27 follow-on training sessions for local actors on health decentralization. These sessions brought together an estimated 588 participants, including 210 women (35%) in the target municipalities. Trainees included COSAH representatives, CSO members, community counselors, heads of health centers, secretary generals of communes, and prefectural and sub-prefectural health directors.
Support for the revitalization of COSAHs. In April 2020, AGIL organized workshops to revitalize COSAHs in the regions of Kankan, Labé and N'zérékoré. Fortunately, the mayors of Kankan, Labé and N'zérékoré were so interested in improving COSAH performance in their communities that they asked AGIL to work with more COSAHs than originally planned. AGIL was able to respond favorably to this request, adding five more COSAHs than they originally planned. The COSAH revitalization events mobilized an estimated 520 people in total, including 115 women (22%). Participants learned about the roles and responsibilities of COSAHs and the required membership composition. Community representatives selected the members of each COSAH, the list of which was then shared with the DMR of the affected prefectures for validation. In all 55 COSAHs were reconstituted thanks to AGIL’s work.
GGB Implementation in Norassoba. AGIL successfully completed implementation of phases 1-6 of the GGB process in the rural commune of Norassoba. The stakeholders in Norassoba (CSO representatives, government officials, healthcare providers, and traditional and religious leaders)
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compiled a list of the commune’s major issues related to health services, the most prominent being insufficient adherence of parents to recommended vaccination schedules, low community use of health centers, and significant growth of private clinics that are not sufficiently monitored and regulated. They then analyzed the issues and selected the health governance question on which to focus their GGB collaboration: “What is the level of community use of health services in Norassoba?”
Participants then identified sub-criteria and local indicators according to the standard five criteria (Efficiency, Rule of Law, Accountability, Participation, Equity) and assigned baseline reference values to these before collecting data that revealed the gaps between the reference and actual data. The data was then used to prepare their health governance action plan.
Though AGIL’s grant closed on April 14, 2020, CIHG’s technical team continued to provide support to phase six of the GGB process in the community of Norassoba to build upon the existing momentum and engagement from local participants. In June 2020, CIHG facilitated the action planning workshop as well as setting up the local GGB technical monitoring group (TMG) that participants selected to oversee implementation of their GGB action plan (AP). The recommended actions identified by participants after analyzing each selected criterion were grouped into four strategic categories: communications, capacity building, mechanisms and tools, and institutional support. The individuals selected to be on the TMG were involved in the entire GGB process, demonstrated their motivation to continue GGB post-CIHG and expressed their availability to volunteer their time.
CIHG is providing support to TMG to implement elements of the AP (on-going).
Note to USAID: Additional information on GGB implementation during FY2020 Q4 will be provided in the final version of this report.
Additional social accountability activities. AGIL also conducted health governance evaluations in the following 10 rural convergence communes of Kankan: Balato, Banankoro, Baro, Damaro, Dialakoro, Gbérédou-Baranama, Kiniéran, Norassoba, Siguirini, and Tokounou. These evaluations required stakeholders to reflect on the situation in their communes and enabled them to identify areas for improvement.
• Association Guinéenne pour l’Implication des Femmes dans le Processus Electorale et la Bonne Gouvernance (AGUIFPEG or Guinean Association for the Involvement of Women in the Electoral Process and Good Governance)
AGUIFPEG implemented a nation-wide project entitled "Mobilization and Citizen Participation of Women in the Decentralized Governance of Health in Guinea." The objective was to increase women’s participation in health governance and to advocate for increased access to quality health care at the community level. AGUIFPEG’s period of performance was May 15, 2019 – August 30, 2020.
Note to USAID: the following paragraph will be deleted when uploaded to the DEC out of deference to AGUIFPEG.
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Implementation delays had already accumulated when COVID-19 arrived. The additional challenges presented by COVID-19 proved to be a heavy burden for AGUIFPEG’s leadership and the project team, leading to further delays. CIHG’s technical support was critical to ensure that core activities were completed, and that required documentation was submitted.
AGUIFPEG’s most significant result was: • 269 women leaders were trained on health governance reforms and the implementation of social accountability tools, in Guinea often referred to as contrôle citoyen de action public (CCAP).
Training of trainers and material preparation. AGUIFPEG prepared the materials and tools to be used to the trainings to be conducted under this project. The 76 lead trainers, all women, were all trained in August 2019 during three workshops in Conakry, Kankan and Mamou respectively. The lead trainers provided extensive feedback on the tools that AGUIPFEG decided to revise in the subsequent months, before proceeding with the follow-on trainings.
Training of women leaders on social accountability and advocacy. In February - March 2020, AGUIFPEG organized training workshops to prepare selected facilitators in Kindia, Mamou, Dabola, Kankan, N'Zérékoré, Conakry, and Boké. The seven training sessions gathered some 269 women leaders (207 facilitators and 62 trainers). Each training session covered health reform and governance, community participatory diagnosis, advocacy, and citizen oversight of government performance. Participants improved their understanding of the priorities and challenges of the public health system and the on-going reforms being implemented. They learned the steps of the participatory diagnostic process to facilitate in their communities and how to use social accountability tools to effectively advocate for additional action to improve health governance in their communities.
GGB Implementation in Sannou. With support from the CIHG technical team, AGUIFPEG effectively implemented phases 1-6 of the GGB process in the rural commune of Sannou. The Sannou stakeholders summarized the commune’s main health governance challenges as: "Improving citizen participation in the use of health services in the rural commune of Sannou" and to formulate their central GGB question: “What is the level of performance of governance in the supply and use of health services in the rural commune of Sannou?"
As with Norassoba, over several months, Sannou participants completed the remaining GGB steps. They identified sub-criteria and local indicators, collected data, analyzed the data, finalized scores, discussed solutions, created an action plan and formed a TMG to oversee AP implementation.
FHI 360 currently supporting the TMG in implementing specific action items during CIHG’s remaining POP.
Note to USAID: Additional information on AGUIFPEG’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
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• Conseil National des Organisations de la Société Civile Guinéenne (CNOSCG or National Council of Guinean Civil Society Organizations) The project, "Mobilization of Civil Society in Health Governance, " was implemented from May 15, 2019 – July 31, 2020. Its objective was to increase and strengthen civic participation in the development, implementation and monitoring of public health policies at the local level. Activities took place in all of Guinea’s administrative regions.
CNOSCG faced several challenges with implementation which deepened significantly in March 2020. Not only did COVID-19 arrives, but also two key technical staff members, the Project Coordinator and GGB Program Assistant, resigned. The only CNOSCG staff remaining that were 100% dedicated to the CIHG project were the MEL officer and the accountant. CIHG repeatedly to work with CNSOCG leadership to advance the recruitment of new staff, but the CSNOSCG struggled to hire or reallocate staff. On top of the staff shortage, CNOSCG did not submit sufficient supporting documentation for activities, preventing FHI 360 from advancing additional funding. As a result of these different factors, compounded further by the burdens of implementation during the COVID-19 pandemic, CNOSCG’s was not able to complete all activities as planned before the end of the period of performance.
Among CNOSCG’s most significant results are: • 76 community activists trained on public health policies, advocacy, and social accountability or CCAP. • 218 CSO leaders, including 80 women, were trained on facilitation of CCAP processes and health governance advocacy.
Training of local CSO trainers. CNOSCG organized three workshops in November - December 2019 to train 76 community activists on its simplified guide for public health policies, advocacy, and CCAP in the regions of Faranah, Labé, and Conakry.
Training CSO members on the content of the simplified action guide and engagement opportunities. In February – March 2020 March, CNOSCG organized 10, two-day training workshops for a total of 218 participants, including 80 women (37%). The local CSO members who participated were trained on the use of CCAP to more effective advocacy for health governance reform. All participants were provided action guides as reference tools to support their future work. Additional trainings may have been held but supporting documentation was insufficient to validate and therefore not included in the summary above.
GGB Implementation in Samaya. CNOSCG completed phases 1-3 of the GGB process in the rural commune of Samaya. The central challenge and central question on which to focus their GGB process were: • Central challenge: A better health system for a level of easy access of the population to quality care. • Central Question: What is the performance level of health system governance for easy access to quality care in Samaya in 2019?
CNOSCG supported stakeholders through the GGB steps that included identification of sub- criteria and indicators according to the standard five criteria during the scoring and modeling
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workshop in December 2019. CNOSCG prepared the two workshops to determine baseline values and collect baseline data, finalizing the core planning documents for the events with technical assistance from CIHG staff. Unfortunately, the implementation faltered due to the issued discussed above.
CIHG staff accompanied the commune of Samaya to complete the GGB process. Samaya finalized its AP and set up its TMG in August. The TMG is currently working on implementation of its AP.
Note to USAID: Additional information on CNOSCG’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
• Femmes pour le Développement Intégré et la Promotion Humaine (FEDIPHU or Women for Integrated, Human Development)
FEDIPHU’s implemented its project from May 28, 2019 – July 31, 2020. The objective was to increase the use of key maternal, neonatal, and child health services in the N’Zérékoré region – specifically, prenatal consultations (PNC), the expanded program on immunization (EPI), and nutrition promotion, all important health services to reduce maternal and infant morbidity and mortality. FEDIPHU implemented activities that increased citizens' understanding of the benefits of targeted health services and how to access them; improved implementation of the health centers’ “Advanced Strategies”3 in terms of PNC, EPI, and nutrition promotion; and strengthened citizen participation in local health governance in a target rural commune. FEDIPHU targeted 41 of the 66 communes in the N'Zérékoré region, complementing another ongoing project that is working in the other 25 communes.
Among FEDIPHU’s most significant results are: • 84 community mobilizers trained on techniques for promoting prenatal care, vaccinations, and nutrition. • 7,705 educational talks promoting PNC, EPI, and nutrition promotion: 42 teams held 7-8 talks per week for 6 months, averaging 16 people per talk, engaging an estimated 120,667 people (69% women). • 7 radio roundtables were produced and broadcast in local languages on PNC, EPI, and nutrition. • 155 community dialogues organized in the six prefectures of N’Zérékoré to identify key challenges to PNC, EPI, and nutrition promotion in an effort to improve these services: a total of 3,899 participants, of which 2,028 were women (52%).
Orientation of project prefectural supervisors and community mobilizers. FEDIPHU held orientation workshops in October - November 2019 in the communes of N’zérékoré and Macenta for a total of 89 participants (five project prefectural supervisors and 84 community mobilizers, including 35 women). Participants were trained on communication techniques for behavior change, the use of the health governance graphic guide, the use of the educational
3 “Advanced strategies” are detailed plans developed by health centers in collaboration with representatives from the communities they serve. The strategies are implemented by mobile teams so that health centers can meet their service targets, especially in areas with difficult access.
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discussion guide to promote prenatal care, vaccinations, nutrition, and project data collection tools and requirements. The Macenta workshop particularly enjoyed robust participation from local health authorities, including the MOH’s national coordinator for vaccinations, the prefectural doctor in charge of diseases (médecin chargé des maladies or MCM), the research and planning manager of the Direction Préfectoral de Santé (DPS), and the Director of Micro- projects.
Identification of Community-Based Organizations (CBOs). FEDIPHU through its prefectural supervisors and community facilitators to identify CBOs with influence in their communes to participate in planned educational talks and community dialogues, compiling the names of CBOs and their representatives as well as contact information. A total of 265 CBOs was identified around the 53 health centers, on average five organizations per health center. Identified members from each CBO participated in subsequent educational talks discussed below.
Conducting educational community talks. FEDIPHU facilitated educational talks called causeries at health centers, health posts and other grouping points in N’Zérékoré. These dialogues addressing PNC, EPI and nutrition promotion were led by FEDIPHU’s 84 community facilitators (two per commune) and conducted in local languages using the graphic manual (boite à image in French) prepared by FEDIPHU from existing public health materials. In each session, facilitators pointedly asked participants to discuss the reasons that people do not use these available critical health services and to identify potential solutions to increase use and thus improve community health. Over 6 months, November 2019 - April 2020, FEDIPHU’s 42 teams of community facilitators held approximately 7-8 causeries per week for a grand total of an estimated 7,705 talks engaging some 120,677 people, 82,818 of which were women (69%)4.
Producing and broadcasting radio roundtables. To further increase citizen understanding of the key services, FEDIPHU worked with community radio stations in the prefectures of Gueckédou, Macenta, Beyla, N'zérékoré and Yomou to produce roundtables shows in local languages. The first of these was produced and broadcast in November 2019. It brought together two doctors from the DPS, one from the DRS, two journalists, and FEDIPHU’s Executive Director and Project Coordinator. The guests discussed the benefits of using PNC, vaccinations, and nutrition services, ways to avoid unsafe deliveries, early signs of malnutrition, and referral of suspected cases. The six final radio round tables were produced and broadcasted in the Poular, Kissi, Toma, Mano, Kpèlè and Kono languages in April.
Organization of Community Dialogues. To improve implementation of the public health system’s advanced strategy to improve PNC, EPI and nutrition promotion, FEDIPHU organized a total of 155 community dialogues in the six prefectures of N’Zérékoré. A total of 3,899 people participated, of which 2,028 were women. Each event brought together people from grassroots community structures and larger CSOs, religious leaders, COSAH members, local authorities and local public health officials. Some of the key challenges identified by participants and their recommendations are presented below.
4 The participation numbers are referred to as “estimated” because FEDIPHU did not initially collect sufficient supporting documentation of the causeries, as requested by CIHG. CIHG and FEDIPHU worked with its team to improve reporting. Subsequent documentation was very strong. As initial data is consistent with the subsequent data with detailed supporting documentation, it was included in the numbers presented here.
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Summary of Community Dialogues’ Key Issues
Concerns Recommandations - People’s misbeliefs of vaccine side - Continue to raise community awareness of the effects benefits of using services - Inadequate quality of services - Improve service delivery by improving calibre of offered in health structures staff - Demand for payment for free - Guarantee the provision of services and free care services such as vaccination and - Improve staff reception of patients at health PNC facilities - Poor reception of patients by - Decrease the price of products and increase the service providers number of health infrastructures - Access to services in terms of price - Prepare a table of prices for services and and proximity of facilities disseminate to communities through COSAHs - Insufficient equipment, personnel - Provide health facilities (health centers and health and products in health centres and posts) with essential equipment health posts. - The expansion of private clinics in - Authorities to regulate the opening and operation of the communities. private clinics - Frequent shortages of vaccines - Regularly monitor stocks of medicines and and essential medicines vaccines and order them in a timely manner - Non-involvement of COSAHs in - Revitalize non-functional COSAHs community mobilization for the use of health services - Indiscretion of health workers to - Promote strict observance of patient confidentiality protect patient privacy secrecy and issue administrative sanctions when violated
GGB Implementation in Kobela. FEDIPHU completed phases 1-6 of the GGB process in the rural commune of Kobela. The Kobela stakeholders summarized into one central health governance challenge on which to focus their GGB process: “What is the level of governance performance in promoting supply and use of health services in Kobela?” Stakeholders worked through the GGB steps. The action planning workshop was held in June 2020 and the TMG formed. The Mayor was so satisfied with the GGB process that he expressed interest in being a member of the TMG. Ultimately, the group decided, with the Mayor’s agreement, that the TMG would be most effective if composed of other individuals who would brief the mayor on their work.
FHI 360 is currently supporting the TMG in implementing specific action items during CIHG’s remaining POP.
Note to USAID: Additional information on FEDIPHU’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
• Le Lyceum Groupe (LGL or The Lyceum Group)
LGL’s project, "Effective involvement of traditional medicine and traditional healers in the health system reforms in Guinea," was implemented from June 17, 2019 – August 31, 2020. The objective was to increase the participation of traditional health practitioners (THPs), key actors in Guinean healthcare, in advancing health governance reform and to ensure that those reforms
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address the traditional medicine sector. The project targeted the administrative regions of Boké and Kindia and the five communes of Conakry.
The following are some of the most significant results from LGL’s project: • Creation of a registry of 1,798 traditional health practitioners in the five communes of Conakry and five prefectures in both Kindia and Boké. • Creation of 15 THP associations. • 254 THPs in Conakry, Boké and Kindia improved their knowledge on recent health reforms and opportunities to participate in the public health system. • 941 people trained on health governance and traditional medicine’s role in health reforms.
Registry of traditional health practitioners in target locations. In November 2019, LGL identified traditional health practitioners in the five communes of Conakry and five prefectures in both Kindia and Boké. The LGL census documented 1,798 traditional healers, of whom 899 (50%) are women. Information of the traditional healers was recorded in a database to help LGL facilitate their participation in other parts of the project.
Mobilizing traditional health practitioners to organize and form associations. In December 2019, LGL on organized meetings with THPs identified through the census to discuss the benefits of creating formalized associations. Numerous practitioners expressed reservations, given some negative experiences with prior efforts to organize. However, LGL project leadership and local facilitators worked with local partners to convince reluctant practitioners of the benefits of more structured engagement with the public health system to improve health governance and community health outcomes.
In January 2020, LGL held a series of meetings with THPs to promote collaboration among THPs and establish THP associations. In total, THPs organized 15 organizations. LGL continued to support these THP associations in obtaining approvals and registrations. To date, only the association of the commune of Ratoma has obtained its approval, though applications for the 14 others are pending with the DMRs to which they were submitted.
Training and mobilization of THPs. LGL organized a two-day training workshop in Kindia in March 2020. Thirty participants attended, including 12 women (40%). Participants improved their knowledge of recent health reforms, the legal framework for traditional medicine, and opportunities for THPs to participate in the public health system, such as engagement with local technical health committees. Follow-on training was then held in Conakry, Boké and Kindia, reaching another 224 people, of which 48% were women.
Awareness campaign on health reforms and the role of traditional medicine. Also in March 2020, LGL organized three participatory theatre performances on governance of the public- health system, health reforms and the place of traditional medicine in those reforms. A total of 762 people, including 373 women (48%), took part in the forums that were held in the urban communes of Kindia, Boffa and Fria. These events brought together local authorities, civil society representatives, journalists and community members. In all three communities, the local authorities agreed to facilitate meetings between THPs and public health service providers. The
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Kindia Prefectural Director of Health was particularly specific in his commitment, promising not just to meet with THPs, but to involve them in the prefectural health committees and to support the establishment of the THP associations in his health district as best he could.
LGL’s facilitators led eight multi-stakeholder awareness raising sessions on the same topics in June 2020 in the rural convergence commune of Koba. A total of 179 people, including 52 women (29%).
GGB Implementation in Koba. LGL completed phases 1-6 of the GGB process in the rural commune of Koba. The selected GGB question was: “What is the level of governance performance of Prenatal and Postnatal Consultation in the Koba Convergence Commune in 2019?” By June 2020, Koba completed all the GGB steps, including the AP and formation of the TMG.
Implementation of the AP is ongoing.
Note to USAID: Additional information on LGL’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
• Réseau Afrique Jeunesse de Guinée (RAJGUI or African Youth Network of Guinea)
RAJGUI’s project sought to increase the participation of youth and youth CSOs in health governance in 13 prefectures in five administrative regions (Kindia, Boké, Labé, Kankan, and N’Zérékoré) as well as in the five communes of the special zone of Conakry. The POP was September 26, 2019 – August 31, 2020.
The following are some of the most significant results from RAJGUI’s project: • 45 youth leaders in Boké, Kindia, and Conakry trained on mobilization of citizens in health governance and use of health services. • 60 citizen and mobilization caravans conducted to encourage citizen participation in health governance, reaching an estimated 25,976 people. • 272 youth CBO members, including 111 women, trained on advocacy techniques, the roles and responsibilities of COSAHs, and the roles of CSOs in promoting citizen participation in health governance. • 43 action plans developed by youth to advocate for increased attention to youth needs in health governance. • Sanitation equipment provided to youth CBO members in 15 prefectures. • 414 youth, including 150 women, made aware of the importance of participation in health governance through 15 forums.
In October – December 2019, RAJGUI identified 45 youth leaders (15 of which were women) with whom to work in each of the 15 target localities: 5 each for prefectures in Boké, prefectures in Kindia, and communes of Conakry. They drafted the training module, graphic guide and other event preparation materials.
Workshop for Facilitators. RAJGUI organized a two-day workshop for the 45 identified youth leaders on January 25 – 26, 2020. Also in attendance were representatives from administrative
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and local authorities including the Deputy Inspector General of the Ministry of Youth and Youth Employment, the Vice-Mayor of Kaloum Commune, a representative of the National Directorate of School Health, and a representative from the National Directorate of Civic Education. The training focused on youth participation in health governance and communication techniques that encourage civic mobilization and behavior change so that the participants could conduct the caravans to encourage citizen participation in health governance and to use of public health services.
Citizen awareness and mobilization caravans. On February 14-20, 20 the 45 facilitators (three per municipality), conducted mobile caravans to raise awareness among citizens (specifically youth and women) about the use of and functioning of public health centers and to encourage citizen participation in basic health governance in the five municipalities of Conakry and the 10 prefectures of the Boké and Kindia regions. In these 15 communities, 60 caravans were conducted, reaching an estimated 25,976 people, including 16,007 women (62%). RAJGUI’s participation documentation was slow and incomplete but improved with CIHG’s coaching. Training youth CBO members on health governance. Throughout June 2020, RAJ-GUI organized training workshops in the 15 target localities for youth activists who are members of CBOs. In total, 272 youth, including 111 women (41%), each from a different CBO, were trained by RAJ-GUI focal points on advocacy techniques, the roles and responsibilities of COSAHs, the roles of CSOs in increasing citizen participation in health governance, and the importance of youth participation in health technical committees. Youth leaders were encouraged to form coalitions and drafted 43 action plans to advocate for increased attention to youth needs in health governance and increased involvement of youth in health governance decision making. As a result of their advocacy, several authorities committed to involve the trained youth in the implementation of commune activities, including those related to health governance.
Supporting youth CBO action plans. In order to accompany these CBOs in the implementation of their action plans, RAJ-GUI provided the following sanitation equipment (three of each item) to the youth CBO members in the target localities: wheelbarrows, shovels, rakes, brooms, pairs of gloves, protective helmets, and vests. These materials were made available to a designated CBO representative in the presence of a local authority. Young volunteers from trained CBOs in Boké and Kindia carried out community cleanup in public places in the two urban communes, an act highly appreciated by the communal, administrative and health authorities. The health and sanitation activities launched by RAJ-GUI’s CBO members brought RAJ-GUI positive attention from national services and national platforms working in the framework of health and public hygiene.
Public forums on youth participation in health governance. Also in June 2020, RAJ-GUI organized 15 forums in the target localities to raise awareness among youth about the importance of participation in health governance. In total, these forums mobilized 414 people, including 150 women (36%), from youth organizations, local and administrative authorities, media, and civil society. Each forum was facilitated by a health worker, local elected official, and COSAH member with discussions centering around the level of functionality of health centers, the roles of COSAHs, and the roles of CSOs in increasing citizen participation and accountability in health governance, including the rights of youth to access health services. Young people used these opportunities to advocate to mayors and prefectural and communal health directors,
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resulting in several informal commitments being made by certain authorities to increase the participation of youth in the management of health structures.
Community awareness raising and monitoring within health care facilities. To further increase youth participation in health governance, RAJ-GUI mobilized 30 youth leaders, members of youth CBOs, in the 15 target localities. For each prefecture, two leaders were deployed together to conduct door-to-door visits to engage youth in awareness raising dialogues regarding their right to health care, including free services and the actual prices for common medical needs as well as opportunities for youth engagement in health issues. During one such dialogue, a participant highlighted the importance of respecting free access to certain services as it can “promote attendance at facilities and improve community participation in the management of health facilities.” These youth leaders also visited health facilities to verify if certain vaccinations and prenatal consultations were being provided free of charge. At the health center in Télimélé, three different patients shared having to pay for at least one of these services, including a pregnant woman who paid 10,000 GNF for a prenatal consultation. The information from these monitoring visits was then used to inform the implementation of the youth CBO action plans.
GGB Implementation in Kamsar. RAJ-GUI completed phases 1-6 of the GGB process in the rural commune of Kamsar. The selected GGB question was: “How can governance in health service delivery be more efficient in Kamsar?” By July 2020, Kamsar completed all the GGB steps, including the AP and formation of the TMG.
Implementation of the AP is ongoing.
Note to USAID: Additional information on RAJGUI’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
Post-Research Advocacy Grants. There was only one candidate from the first RFA that CIHG wished we might have supported: a CSO representing PWD, given the importance of this consistency in health policy. Negotiations with the CSO on their technical application were not successful in adequately reducing weaknesses and the pre-award assessment results showed that a grant would be an exceptionally high risk. Therefore, in the post-research advocacy RFA, CIHG specifically required that applicants identify efforts to include PWD in their new applications.
Summary of Post-Research Advocacy Projects
CSO Project Summary Locations Details
Advocacy for reforms that improve access to health care Award: AFJ for women in the Conakry, Kindia and Boké regions Regions of Boké, Kindia 93,990,000
and Conakry GNF POP: March 1 – August 31, 2020 Advocacy to increase community participation in and Prefectures of Award: AIDE- access to health services Dinguiraye, Guinée Mandiana, 93,990,000 GNF POP: March 1 – August 27, 2020 and Beyla
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CSO Project Summary Locations Details
Advocacy for reforms and initiatives to reduce malaria Award: CJMAD Region of 93,975,000 Faranah POP: March 1 – July 31, 2020 GNF Advocacy to increase community involvement in the Regions of Award: management of their health facilities Kindia, MSS Mamou and 93,155,000 GNF POP: March 1 – August 31, 2020 Labé
• AFJ
Under this project, AFJ advocated for specific reforms to improve women's access to health care in Conakry, Kindia, and Boké. From March to April 2020, AFJ met with 17 key contacts from various MOH departments, media outlets, and CSOs to brief these potential stakeholders on the project, solicit their collaboration, and build support for the reforms AFJ would promote. The stakeholders expressed their enthusiasm in the project and agreed to support AFJ as requested with project implementation. Following these meetings, the various partners provided recommendations that the AFJ team incorporated into an advocacy document based upon their research conducted under their first CIHG grant.
AFJ management and staff struggled to adapt to the challenges presented by the COVID-19 pandemic from April to June due to the potential health risks associated with traveling, despite CIHG technical support. Ultimately, AFJ did successfully revise their implementation strategy and drafted and finalized detailed activity design plans and related technical documents for the following activities: (1) advocacy meetings with key MOH stakeholders, (2) multi-stakeholder community dialogues, (3) dialogues between journalists and representatives from health services, and (4) technical support for the production of journalistic pieces on health governance.
Note to USAID: Additional information on AFJ’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
• AIDE-Guinée
Under this project, AIDE-Guinée advocated for initiatives to increase community participation in and access to health services in the prefectures of Dinguiraye, Mandiana and Beyla. In March 2020, the CSO met with authorities at the national level, including the MATD, MOH, and NA, whose support can facilitate implementation at the local level. Overall, officials expressed their satisfaction with AIDE-Guinée’s approach and offered their support. However, due to the emergence of the COVID-19 pandemic, AIDE-Guinée was required to adapt its implementation strategies as several key activities involved large gatherings, including participatory theatre performances. As such, activity implementation was not able to begin until June.
Organization of community advocacy forums. Despite the challenges presented by COVID-19, the CSO successfully organized three community advocacy forums in June in coordination with local authorities in Beyla, Mandiana, and Dinguiraye. Eighty-two people – local elected officials,
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community leaders, CSO members, health workers, and local media – took part in these forums to identify actions that local actors can take to improve the quality and use of health services. The main topics discussed during the forums were: • The pricing of health services, including free services • Remedies in the event of health facilities’ non-compliance with official prices • Opportunities for community participation in the management of health structures • The responsibility of decision-makers and role of citizens to improve health services • Reducing the lack of confidence in health facilities and improving trust between healthcare personnel and patients.
To facilitate implementation of the identified actions, participants established prefectural monitoring committees comprised of one local elected official, one health center head, and one AIDE-Guinée focal point. They are responsible for regularly following up with local actors to ensure that progress is being made on the identified actions to improve community participation and access to health services. Of note, government participants in these forums expressed strong support for both increased citizen participation and improved health governance. At each event, the prefectural health directors and mayors stressed the importance of implementing the identified initiatives for the community itself and, more broadly, for the Guinean health system. Officials also encouraged health workers to be collaborative partners in improving community participation and access to health services. As a result, the head of the Nionsomoridou health center in Beyla prefecture even publicly committed to posting the costs of health services, including those that are free of charge.
Production and broadcasting of forum results. To disseminate the key points raised during each community forum and to share the actions identified to improve citizen participation and access to services, AIDE-Guinée collaborated with local community radio stations in the three prefectures to produce programs summarizing the topics discussed and actions identified during the forums. Three programs were broadcast, one in each prefecture, on the same dates of the forums. The directors at each radio station committed to continue integrating health governance topics into their radio programming.
Note to USAID: Additional information on AIDE-Guinée’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
• CJMAD, in partnership with CEGUIFORD
In its project, CJMAD advocated for government initiatives that will reduce the incidence of malaria and improve treatment of it in the administrative region of Faranah. With the emergence of COVID-19, the consortium adapted their project to also focus on initiatives to prevent the spread of COVID-19. As under its research project, CJMAD collaborated with CEGUIFORD to implement this award. The POP was March 1 – August 30, 2019. To secure GoG buy-in, prior to launching activities, CJMAD identified and lobbied key officials at the MOH and MATD who all expressed support for the project.
Multi-stakeholder community dialogues. The consortium organized community dialogues in March -April 2019 for stakeholders to identify local actions to prevent and treat malaria and
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COVID-19 and to increase the use of health services. Participants discussed the consortium’s research findings, government health reforms, current malaria prevention and management efforts, and additional actions to strengthen those efforts. The events also addressed COVID-19 prevention. Attendees included local elected officials and other governmental officials, COSAH members, community health workers, health center management, THPs, civil society leaders, journalists and religious leaders. Events were held in the prefectural centers of Dinguiraye, Faranah and Kissidougou and two rural communes per prefecture: Marela and Banian (Faranah), Férmessadou and Yéndè Milimou (Kissidougou) and Diatiféré and Kalinko (Dinguiraye). A total of 202 people, including 43 women (21%), took part in these meetings. Six of the groups prepared action plans and formed six monitoring committees to implement the recommended actions.
Building local stakeholder engagement and ownership. In Apil – May 2019, the consortium organized three meetings with local authorities in the prefectures of Faranah, Kissidougou, and Dinguiraye to advocate for their increased engagement to fight both malaria and COVID-19, using the research results and the outcomes of the community dialogues. In total, 30 people (10 per prefecture) took part in these strategic exchanges. Among the officials with whom the consortium met were prefectural health directors, directors of DMRs, doctors in charge of diseases (Médecins Chargés de la Maladie), DPS mobilization officers, malaria focal points, mayors, communal advisors, communal technical health advisors, and COSAH presidents. Officials expressed their willingness to work on these issues with community stakeholders. The consortium also donated hand washing kits to the three prefectural health directorates, consisting of 10 buckets and 30 pieces of soap per prefecture, to complement on-going COVID-19 prevention measures.
Production of interactive radio round tables. To further mobilize citizens in the fight against malaria and COVID-19 and deepen understanding of government health reforms, the consortium worked with local radio stations to produce three interactive round tables in Faranah, Dinguiraye and Kissidougou on the same dates as the strategic meetings. Each round table included the five following participants: a focal point from the National Malaria Control Program, a local elected official, a COSAH member, a CSO leader, and consortium member. The roundtable participants discussed the aforementioned topics, including opportunities for community members to help implement the actions identified in the community dialogues as well as measures that people can carry out in their personal lives that will reduce malaria and COVID-19 and promote community health. The panelists took calls from listeners. Callers provided positive feedback on initiatives identified during the community dialogues, expressed concerns about the malaria prevalence rate, offered their own suggestions, and posed questions to the panelists regarding such issues as the regional difference in malaria prevalence, the symptoms of malaria and COVID-19 and monitoring of symptoms.
Note to USAID: Additional information on CJMAD’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
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• MSS
Under this project, MSS advocated for reforms and initiatives to increase community involvement in the management of local health facilities in six prefectures in the regions of Kindia, Mamou and Labé. To secure support for project implementation, in March and April 2020, MSS met with stakeholders at the national level (MATD and MOH) and communal level (mayors, prefects, sub-prefects, municipal counsellors, heads of health centers, COSAH members, and CSO leaders including youth and women’s groups). Participants were very receptive to MSS and the project. The MOH and MATD also specifically requested that MSS disseminate additional copies of their research report to the forty communes de convergences and asked that the NDCH be invited to participate in MSS’s activities.
Organization of six multi-stakeholder dialogues. At the request of the mayors of the convergence communes of Bangouyah, Samayah, Ourékaba, Dounet, Daralabé and Sannou, MSS provided technical and financial support for the organization of six community forums in May. The forums brought together 120 participants, including 26 women (22%), namely mayors and municipality advisors, CSOs, administrative authorities, opinion leaders and other community members. After MSS presented their findings from their CIHG-funded research study on the functioning of health facilities in 12 rural convergence communes, participants were given the opportunity to reflect upon and discuss the functioning of their own health structures, analysing factors such as human resources policies, existence of necessary equipment and supplies, visitation rates, and management of the COVID-19 response.
The participants made the following observations about their health structures: • Low health center and post visitation rates due to the high cost of medicines • Lack of an incineration pit or incinerator • Breakdown of the borehole • Insufficient information in communities on health services • Battery problems with the panel system for the center's lighting and/or no lighting system at the health posts • No appropriate reception room and stock room • Absence of an ambulance for the transport of patients for emergency cases such as complicated childbirths and serious injuries • Insufficient supply of essential medicines • Lack of materials for laboratory tests and minor surgery • Lack of security • Insufficient space for patients • Lack of community awareness of the importance of social assistance and in-kind donations to motivate staff
Based on these findings, action plans were developed and recommendations were made by the participants to local elected officials to share the results of the forums with councils of elders and religious leaders to obtain their support for the implementation of the action plans and to integrate certain proposed activities into the communities' official annual investment plan. They also requested that MSS support the implementation of the action plans and organize activities to raise community awareness about the importance of using health centers, motivate health staff,
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and continue advocating for improved service delivery. These forums were significant in that they provided a venue for community members to advocate to authorities for specific actions to improve the functioning of their local health facilities.
Note to USAID: Additional information on MSS’s activity implementation during FY2020 Q4 will be provided in the final version of this report.
Sub IR 2.1: Skills of partner CSOs in advocacy, strategic planning and influencing public officials improved
As noted above, the primary activity through which CIHG improved partner CSOs’ skills was through the grants program: learning through doing with extensive CIHG coaching. Select, structured training was also provided mostly at the beginning of the grants programs so that the training could be applied during the grants’ POP. CIHG invited CSOs who were not prospective or current partners to spread the benefits of the seminars to a wider audience than could be supported through the grants program.
Improving strategic planning and core business management competencies. CIHG’s RFA requested that CSOs analyze their strengths and weaknesses and share their capacity building priorities. The self-evaluation forms and the PAAs informed CIHG’s coaching and the design of a several seminars for partners in such topics as strategic planning, administration, financial management, and monitoring and evaluation.
On June 27-29, 2018, CIHG conducted a workshop for 22 participants including 8 women. The workshop focused on organizational management and governance, leadership and gender- sensitivity to improve project design and implementation. On July 18-19, 2018, CIHG trained 23 CSO staffers, including accountants or finance officers from prospective grantees. The workshop focused on best practices in administrative, accounting and financial management to help CSOs to review their own administrative and financial procedures including management of accounting documents and to identify necessary revisions to strengthen organizational practices. Subsequently, CIHG organized training on monitoring, evaluation and learning (MEL) for 26 participants (MEL officers and project managers) from 24 CSOs participated on August 9-10, 2018 to improve their program implementation practices, reporting, analysis of results and adaptation. As with CIHG’s other training workshops, the participatory approach allowed for a rich exchange of practices among CSOs in terms of existing practices and suggestions for setting up or improving a monitoring and evaluation system.
The evaluation of applications identified two CSOs who represented two key stakeholder groups partners (one women-led and focused, one PWD-led and focused) and who were potential grantees. However, CIHG determined that both organizations would benefit from additional training on strategic and operational planning as well as organizational management to help them to deepen their capacity and improve their applications in the negotiation process. CIHG held a four-day session on September 18-21, 2018 to help the partners to design their 2019-2021 strategic plans and their 2019 operational plans. We also provided training leadership and organizational management. One partner was then able to sufficiently improve their application and internal systems to be awarded a grant.
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CIHG provided detailed information about grantees cost share requirements in the RFA and during the extensive budget negotiations. However, to help prospective partners finalize a realistic cost share plan, CIHG also organized a one-day session on cost-share on August 20, 2018 for the then prospective research and mobilization grantees so partners understood cost share, the documentation requirements and a process for monitoring achievement prior to signing their awards with cost share commitments. Despite this due diligence and CIHG’s subsequent support for partners on cost share, partners learned that their original assumptions about their ability to secure cost share and their ability to adequately document it were often overly optimistic. All partners struggled to achieve their cost share and most fell far short.
Based on the capacity issues identified in the PAAs, CIHG determined that additional organizational training was necessary for the search partners. CIHG organized workshop for 13 representatives from our research partners, including three women, on November 8-9, 2018. This workshop built on prior pre-award training offered to prospective partners. Participants from the CSOs and CIHG reviewed on the content, conditions and requirements of the sub-awards: technical, financial and administrative. Among the topics covered were payment terms, special award conditions, time and attendance, reporting requirements and tools, documentation, branding and marking. CIHG provided partners additional information about health reform and facilitated an in-depth discussion among participations on the topic.
To further improve CSOs’ MEL skills, another workshop was help on January 23-25, 2019. The seminar included 27 participants from 16 CSOs who were CIHG grantees, their consortium partners and other promising CSOs. At CIHG’s request, most CSOs sent the MEL officer and one other person with whom they must work to conduct MEL activities. While it resulted in attendees have different skill levels, the inclusion participation intention. MEL is a shared responsibility, so MEL officers must always work with non-MEL staff to collect, analyze and use data.
These formal sessions were complemented by extensive coaching to CSO sub-awardees. All partners were provided an sub-award orientation session to ensure that CSO mangement team of each partner understood their awards and its obligations. CIHG used its learns lessons from the on-boarding of the research partners in late 2018 to adapt the pre-award orientation sessions with provided the mobilisation and adovcacy partners. As the start of each grant, CIHG worked with partners to prepare the initial technical and financial deliverables and planning documents required to receive their first advances. We helped partners to recruit staff depending on each organization’s needs. Most CSOs had very few, if any, full-time, paid staff on an ongoing basis and so much formally recruit staff with each new grant. CIHG emphasized the importance of gender inclusion in the recruitment process. We provided TA to partners in their procurement processes help them institute stronger controls to ensure that financial resources are used wisely and that adequate documentation supporting purchases is in place. Over the lifetime of the grants, CIHG staff visited partners to review technical and financial reports, troubleshoots difficulties that the partner encountered, and identify solutions. Timely execution of grant activities and award requirements remained challenging as did report writing, procurement and systematic archiving of documentation.
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A number of partners continued work after the formal end date of their projects, taking time to strengthen their final reports and to organize additionl advocacy meetings, a testament to their commitment to the success of their projects. This local ownership of results is a cornerstone of USAID’s Journey to Self-Reliance.
Strengthening advocacy and communications. In addition to supporting advocacy through implement of the research, mobilization and post-research advocacy grants, CIHG organized a workshop to training 33 civic activists from 17 CSOs on advocacy and communications on June 17-19, 2019. The workshop enabled participants to strengthen their knowledge of advocacy and behavior change communications (BCC) and improve their mastery of tools for advocacy and BCC in the context of health governance.CIHG used the results of the research projects as the basis of the training’s practical exercises in advocacy and communications to maximize the applicability of the training and help the partners to digest those findings to inform their activities. Workshop evaluations noted this practical approach as one of the strengths of the training. The participants also used the event to revise their organization specific advocacy plans for their respective projects, whether funded by CIHG or not.
Sub IR 2.2: Increased use of evidence by CSOs to influence public officials on health reform
As with the above, this sub-result was primarily pursued through partner CSOs’ implementation of their grants, complemented by CIHG mentoring and a few structured seminars.
Improving CSOs’ operational research. One of the weaknesses identified in reviewing the research proposals was research expertise, even among the selected CSO partners. CIHG therefore decided that it would design a consultancy for a Guinean expert with both expertise in research and training. The scope of work was carefully crafted so that the research specialist would provide tailoring coaching to each CSO during each step of their research projects to ensure timely, high-quality implementation.
The specialist reviewed the research protocols for each project to identify improvements to the protocols and partner training needs. Overall, the consultant found the protocols—on which CIHG staff had worked extensively—to be strong. His primary recommendation focused on better targeting the sample sizes to better meet the research objectives. For AFJ, CJMAD and MSS, the modifications were not significant. For AIDE-Guinée, whose research is largely qualitative and thus very labor-intensive, the specialist recommended a significant reduction in sample size so that AIDE-Guinée can have the time and resources to collect and analyze the data well.
CIHG organized a research workshop for partners on December 3-7, 2018. Fifteen people from the research CSOs participated. The action-oriented seminar targeted the specific issues identified in the needs assessment meetings and based on the review of the protocols. The CSOs not only deepened their knowledge in key areas, they then worked together to apply that learning to their own research projects, such as working on the design of their data-collection tools. Among the topics covered were: principles of operational research in health, ethics of health research, formulation of research questions, principles of qualitative and quantitative collection, data analysis, and research administration (e.g. recruiting and training investigators and Guinea
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legal requirements). Participants applied their training to revise their own research protocols and data collection instruments.
Guinean law requires that all health-related research be approved by the CNERS. As the law is very general in its definition of health research, CIHG determined that we should support our partners to submit their protocols to CNERS for approval. As other health research projects have been stymied by this requirement, as a precursor to engaging CNERS, CIHG met with the National Institute of Public Health (Institut National De Santé Publique or INSP) Director General on November 26, 2018. CIHG explained the purpose of the project and the proposed research by partner Guinean CSOs and shared CIHG’s plan for supporting the CSOs to conduct quality research. CIHG presented the operational research specialist. The Director General commended CIHG for its attention to research rigor and the hiring of such a qualified consultant. The INSP Director General underlined the obligation to validate the protocols by the CNERS before any implementation. CIHG explained that we are already preparing to do so. CIHG also asked INSP to help CIHG’s partners with access to health facilities and to encourage local health administrators and service providers to cooperate with the project. In response, CIHG received a letter from the MOH designed a focal person within INSP to support CIHG implementation.
In early December 2018, our research partners made their final modifications to their research protocols, with CIHG help, and each submitted their protocols to CNERS on December 12, 2018. CIHG deftly secured a commitment from CNERS to expedite review of the protocols. CNERS met on December 24, 2018 to examine the protocols and sent feedback to all of our partners by December 28, 2018. CIHG worked with partners over December and January to further refine the sampling in the research protocols given the labor-intensiveness of qualitative research in all projects and based on feedback from CNERS. The fine-tuning helped partner to enhance the quality of their data collection and analysis, without changing the study objectives and the intended target groups. By February 2019, all research partners had received their CNERS approvals.
CIHG continued its TA to research partners as research was being conducted as well as in later stages: data analysis, data interpretation, preparation of feedback workshops with stakeholders to share findings and validate draft conclusions, and finalization of the research reports. With CIHG’s help, between May-October 2019, the partners completed their research reports and organized events for initial dissemination and advocacy.
The process of selecting research projects and supporting the implementation of our research partners’ work underlined that most Guinean CSOs do not have staff with a strong mastery of research. To ensure that not only CIHG’s research partners benefitted from capacity building in this critical area, CIHG organized a training session for CSOs who applied for grants but were not ultimately selected. The workshop, held on August 26-28, 2019 involved 24 participants from 12 CSOs. The training targeted program and MEL staff who were most likely to be involved in research activities. CSO staff is predominantly male and thus CIHG was only able to secure the participation of four women, even though we targeted the training to non-leadership staff. The training covered the basics of research, the process of writing a research protocol, the methodology of conducting operational research, and report writing.
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Expanding CSO expertise in social accountability tools. As CIHG worked through the process of reviewing and selecting mobilization grantees, it became clear that creating a separate, additional process for selecting partners with whom to work on social accountability would have a high opportunity cost. The RFA was structured so that FHI 360’s Good Governance Barometer (BBG), a social accountability tool, could be integrated into the applications if deemed appropriate. The organizations most likely to win such a competitive RFA were those that we selected for the mobilization grants. In addition, technical applications would be enhanced by the inclusion of a social accountability component. USAID agreed with the adaptation.
CIHG organized a GGB training for our selected mobilization partners so that they could decide whether they indeed wanted to integrate GGB into their proposals and how best to do so prior to submission of their grant packages to USAID. On December 11-13, 2018, CIHG trained 18 people from mobilization partners. CIHG Conakry-based staff also participated as they were to play a critical role supporting CSO partner implementation of GGB. While many of the participants were unfamiliar with social accountability tools and therefore uncertain as to the utility of GGB prior to the workshop, all six CSOs were strongly in favor of its inclusion to their projects after the training.
CIHG and the partners worked together to select target communes cross the country based on the CSOs’ existing contacts and GoG’s communes of convergence. Each mobilization partner targeted one commune to implement GGB, bringing together a cross-section of stakeholders such as civil society, government, healthcare professional to examine health governance in their communities, to identify priority actions that they can readily take to improve health governance and then to evaluate the impact of their efforts in improving health governance. Community participants in all six communes were very positive about the GGB process, in more than a few cases, overcoming an initial concern about the utility of the exercise.
MEL / CLA Activities
CIHG conducted a number of activities to better understand the context in which CIHG worked, to document project achievement, and analyze data and supporting information to improve performance.
CIHG Studies. Three major studies were conducted and submitted to USAID: the 2017 baseline study, the 2018 survey of public health user satisfaction, and the 2020 endline study. The baseline sought to complement existing secondary data with a national household opinion survey and qualitative data collected through focus groups, round tables and key informant interviews (KIIs) that were collected in October-November 2017. Prior to finalizing the design, CIHG submitted an inception report to USAID to ensure consensus on the methodology. CIHG briefed USAID on the key findings in December 2017 and submitted the written report in January 2018. The findings of the baseline were used to inform implementation and to foster consensus among stakeholders on priority issues, building momentum for CIHG’s objectives through a series of regional forums discussed below. CIHG disseminating the findings through the 2018 multi- stakeholder mobilization forums discussed earlier in this report.
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CIHG conducted additional research on satisfaction with the public health system at USAID’s request. The CIHG survey questions were added to a United Nations funded survey to dramatically reduce costs. Prior to initiating the survey, CIHG ensured that USAID reviewed the questionnaire and accepted the sample size and associated margin of errors. The survey was conducted to ask public health system users about their satisfaction with different components of health system delivery. The survey also included questions about engagement and satisfaction with local comités de santé et hygiène (COSAHs), payment for certain services, and their likelihood of using and referring others to use public health services in the future. Satisfaction was moderately positive, with more than two-thirds of the respondents reporting mixed to positive attitudes across the various factors explored in the survey. People reported relatively low interaction with COSAHs; but satisfaction among those who have engaged COSAHS was high (63%). Additionally, 65% of respondents paid for malaria treatment in the past 12 months for themselves or a family member, and 50% paid for childbirth services, though these services are supposed to be provided free of charge. More than two-thirds of respondents are likely to go back to government health facilities for treatment and recommend these facilities to others.
An endline study was also conducted. The design and timing were repeatedly adapted due to political situation, a dramatic spike in survey costs, and COVID-19. The final, USAID-approved design utilized mixed methods, pairing quantitative data collection via a 1,823 person, phone- based survey with qualitative data through outcome harvesting (OH), an innovative qualitative research methodology. The benefit of OH is that seeks to identify changes, whether intended per the results framework or unintended and outside the framework and seeks to identify the importance of those changes and CIHG's contributions to them. In total, the endline team collected 20 OH outcome statements. Analysis of the findings revealed several trends in what has been achieved, the significance of those outcomes in terms of the health services and health governance in Guinea, CIHG’s level of contribution, and the extent to which outcomes align with the CIHG results framework.
The endline found evidence of changing attitudes towards health services, resulting in more people seeking care as needed. In addition, some community members are more actively engaging in health issues. The endline also highlighted the importance of media in relaying information to the public. At the same time, lack of funding and other systemic issues can frustrate efforts to improve healthcare. As indicated by survey results on items such as people being wrongly charged for health services, room for improvement remains.
The majority of OH outcomes were determined to have a “medium” level of CIHG contribution—meaning that both CIHG and another actor played a role in creating the change. The implication is that programs will be more successful if implemented in a way that complements ongoing government, donor or other NGO initiatives, particularly given the complexity of CIHG’s goals. Many of the outcomes involving government also included a secondary social actor, an indication that CIHG’s ability to spark collaboration was a key factor leading to change. It is also notable that only a small number of outcome statements linked to CIHG IR 2 on CSO advocacy, yet many related to the overall objective – signaling that the objective was achieved but that not necessarily via the precise theory of change as articulated in the results framework. Elements of that theory of change may indeed be important but their impact less visible. Moreover, there were a significant number of “unintended’ changes that
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seem to have been stronger contributors to improving citizens’ understanding of and participation in Guinea’s health system.
Other MEL Activities. Close collaboration and ongoing capacity building were integral to CIHG’s way of doing business, building stronger partnerships and more sustainable results. CIHG therefore implemented a number of other learning activities. Multiple MEL training sessions were held with staff and partners over the POP to explain the results framework, MEL data collection requirements, and improve procedures: March 2018, May 2018, August 2018, January 2019, October 2019, November, 2019, December 2019, March 2020, April 2020. Internal data quality reviews were conducted in 2018, 2019 and 2020, in addition to continual data review and cleaning as data was submitted. Data was cleaned, validated and analyzed regularly particularly leading up to each quarterly performance report submission and when preparing annual implementation plans. CIHG staff retreats were held in March 2018 after most CIHG staff were on-boarded and again in January 2020 to optimize the last 10 months of performance. In addition, CIHG held a two-day learning summit with internal and external stakeholders in April 2019. Initially CIHG had planned to collect most significant change stories, but it was determined during the course of implementation, that this was not a priority MEL activities, given the level of support that partners required with their MEL responsibilities.
Advisory committee. CIHG also established an advisory committee. The advisory committee met roughly quarterly. Participants were briefed on activities, presented drafts of CIHG’s implementation plans, and asked to provide feedback that was used to improve activity design and performance. The committee’s collaboration with the CIHG team was very helpful, especially in review of annual implementation plans. The sharp increase in political protests beginning in October 2019, the then impending legislative elections and referendum eventually held in February 2020, and the arrival of the COVID-19 in March 2020 made it impossible to convene additional committee meetings from late 2019 onwards. Participants had numerous competing demands. Given that the project was ending, CIHG did not push members to continue to volunteer their time as the project was closing out.
PROJECT RESULTS
Overall results
Note to USAID: Data are still being collected and reviewed as CIHG continues to implement. Numbers will be revised when the Final Report is submitted. The data presented below are based on current, validated submissions.
CIHG’s activities significantly contributed to improving citizens’ understanding and participation in Guinea’s health system reforms as evidenced by MEL data and the finds of the endline study. More than 174,850 Guineans engaged in initiatives to improve health governance. Over 54,850 people have participated in multi-stakeholder forums bringing together government officials, civil society representatives and the media to discuss how to improve health governance and health service delivery. At least an additional 120,000 Guineans participated in mobilization activities designed specifically to engage community members to increase both citizen understanding of health reforms and strengthen civil society
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participation in health governance. The total number of people mobilized is a conservative figure and actual total is likely much higher, as CIHG excluded participation data from several activities for which data was incomplete, for example, the volunteer-led listening sessions.
The findings from the endline study reaffirmed this increase in citizen engagement. In all, 22% of respondents reported direct involvement in activities to improve local health facilities and 67% indicated knowing other community members engaged in these efforts. A majority of respondents reported that women and youth were involved in health governance: 68.7% reported that women are well or fairly well engaged, while 65% said that youth are well represented.
Almost half of the outcomes identified through the endline outcome harvesting (OH) process link to CIHG’s objective, a strong indication of achievement. Of these eight outcomes, four are multi-regional (i.e., taking place in six or more regions of CIHG implementation). Thus, while engagement is increasing, this change does not appear to be unfolding in the same manner in every region—to be expected given differences such as geography, resources, and local context. The ability to compare baseline and endline survey data for engagement questions was limited. Thus, a trendline is harder to draw; however, the endline reveals approximately half of citizens engaged in healthcare issues. Added to this, many know others in their community who are also actively involved. In addition, the vast majority of respondents believe that both women and youth are engaged in efforts to improve the health sector, a finding supported by OH outcome statements on women’s participation in health activities and improved civic engagement among youth.
The data indicate there is space for additional change. While it is difficult to say what an “optimal” percentage of the population “should” be participating in health-governance activities, it is clear that continued, sustained and deeper engagement from those who are involved could help further improve health governance. In addition, there is notable room for improvement regarding the extent to which the voices of women and youth are taken into account. As highlighted by OH interviewees, the types of attitude and behavior changes sought by CIHG take substantial time to develop (longer than the three years allotted for CIHG implementation). The complete list of results to which CIHG contributed is summarized below. Please see the complete CIHG endline report posted on the USAID Development Experience Clearinghouse (dec.usaid.gov).
In the endline study, nearly half of all survey respondents (45.7%) said they have at least some awareness of efforts to improve the health sector. These figures were highest in rural areas, among men, and among those ages 61 and over, respectively. A majority of respondents (62.4%) indicated that their awareness of improvement efforts increased the likelihood they would use government health services either “somewhat” or “a lot,” while 27.4% report it increases this likelihood “a little.” Only 10.3% indicated that these efforts had a “very limited” effect. At the same time, more than half of respondents (56.4%) said that the information they receive about the functioning of the health sector increased their likelihood of engaging in further improvement efforts “a lot.”
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Overview of Outcome Statements Outcome Statement Scope Type Year* Location** Social Actor Significance Contribution 1. Community members Community Local Knowledge 2019 5+ informed on healthcare member ● ◐ 2. Collaboration with Local Relationship 2018 2-4 Health staff traditional medicine ◐ ◐ 3. Civic engagement in Community Local Behavior 2020 5+ communities member ◐ ◐ 4. National government National Practices 2018 Central Government transparency ● ◐ 5. Improved COSAH Local key Local Practices 2019 2-4 management actor ● ◐ 6. Health facility renovation Local Institutional 2018 2-4 Government 7. Greater role of key local Pre- Local key ● ◐ Local Practices 5+ actors in health governance CIHG actor ◐ ◐ Pre- 8. Decentralization National Practices Central Government CIHG ● ◐ 9. Collaboration among National Relationship 2018 Central Government national government ● ● 10. Health budget increase National Institutional 2018 Central Government ● ◐ 11. Increased CSO capacity Regional Skills 2019 2-4 Civil Society 12. Trust between ● ● Regional Relationship 2019 5+ Government government and media ◐ ◐ 13. Increased radio capacity Regional Skills 2019 5+ Media 14. Improved attitudes Community ◐ ● Local Attitude 2019 5+ towards health centers member ◐ ◐ 15. Greater use of health Community Local Behavior 2019 5+ services member ● ◐ 16. Community more Community Local Attitude 2018 5+ involved in health issues member ● ◐ 17. Improved health Pre- Community Local Health 1 outcomes CIHG member ● ◔ 18. Better management of Pre- Local Practices 2-4 Health staff health centers CIHG ◐ ◐ 19. Government and CSO National Actions 2019 Central Government engagement ◐ ◐ 20. Participation of women Community Local Actions 2018 5+ in health issues member ● ● Low-Medium-High **Indicates number of regions ◔ - ◐ - ●
As stated, USAID’s original theory of change for CIHG was that increasing citizen engagement in and understanding of health governance would contribute to increased public confidence and satisfaction in public health services. The 2014 Ebola epidemic revealed significant distrust in government health services, and avoidance of healthcare as a result. The CIHG endline data show evidence of change in these attitudes and behaviors towards this overall goal. Several OH outcome statements reveal improvements, including increased trust in and more frequent use of health centers. Achievement of such outcomes is a long, complex process that required engagement on a variety of levels. For example, OH participants emphasized linkages among community use of health services and capacity building of COSAHs, radio station trainings,
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radio broadcasts on healthcare, GGB activities, government visits, and collaboration with practitioners of traditional medicine. Thus, the multi-faceted design of CIHG, with different types of social actors engaged to spark change at the community level, seems to have been a key success factor.
Survey findings similarly support the conclusion that views on health services are improving. Though quantitative comparisons between the endline and the 2017 and 2018 surveys are not exact, notable and positive trends were shown in a wide range of service-related aspects—from the perceived quality of services, to cost of care, to availability of supplies. In addition, respondents reported a higher likelihood of using government health services in the future. A majority of respondents also felt that efforts to improve health services have at least somewhat resulted in actual improvements. Improvements were additionally noted in the proportion of survey respondents charged for government health services that should be free.
Nevertheless, concerns linger regarding the cost, quality of care and sanitation. While fewer citizens report being wrongly charged for healthcare services at the endline versus the 2018 survey, this figure is still about 50%. As mentioned in OH interviews, in some cases structural issues such as lack of drainage systems can inhibit progress made in convincing community members to use health facilities. In addition, when asked to name trusted sources of information on COVID-19, official health sources such as the Agence Nationale de Sécurité Sanitaire (ANSS) and healthcare workers were less trusted than TV and radio.
IR 1: Opportunities expanded for elected and appointed officials and citizens to engage in constructive dialogue
CIHG was very successful in expanding collaboration among key stakeholders. Thanks to CIHG, a wide cross-section of Guineans leaders participated in 411 civic-governmental dialogues promoting constructive problem solving of health governance issues including multi-stakeholder social accountability forums, health governance workshops, participatory community theatre performances, community health strategy meetings, press conferences and media-CSO- governmental round tables (surpassing the project target by over 800%).
CIHG found that many government officials at the national, regional and local levels were eager to participated in, even co-organize health governance forums, organized by CIHG and its partners. In addition, governmental officials led 41 new initiatives (410% over target) to promote health reform dialogue and to use information dialogue to improve health governance. These initiatives include: • 15 on-the-record roundtables with civil society and the media that were also broadcast in their entirety in Boké, Dalaba, Kankan, Mamou and N’Zérékoré. • 9 local official dialogue initiatives in Bangouya, Baro, Bérédou Baranama, Bofossou, Bossou, Dounet, Fria Centre, Kounsitel, and Nionsomoridou. • 12 community dialogues organized by government officials who were eager for local stakeholders to collaboratively identify health service improvements, with the support of CIHG’s local partners MSS and CJMAD. • MOH conducted a budget review using citizen feedback from the 2018 field visits to review the 2018 budget and to prepare the 2019 budget.
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• The NA-HC engaged media outlets to organize inter-active “legislative accountability” radio and television shows during with legislators shared findings from their field visits and responded to citizens’ concerns about the health system. • Several local and regional governmental leaders from Kankan initaitied a process whereby they engaged the community and then worked together to operationalize the Baro health center. • The MOH’s Strategy and Development Office engagement of CSOs and media to prepare for the 2019 EGS including participation in a Guinée Forum. • Following a participatory theatre performance organized by CIHG, Kankan’s Secretary General engaged in dialogue with Bordo’s health center director surrounding challenges faced by the community and followed through by providing the health center with access to clean water.
The data from the endline study indicated that support to media contributed significantly to improving the flow of information on health to the public and fostering increased participation. Media outlets were not a key social actor in many OH outcome statements, yet radio was one of the activities most frequently cited as contributing to change. This highlights the broader effects of CIHG’s work with radio stations (particularly training and capacity building)—increasing the capacity of radio stations to produce health broadcasts is linked to community-level changes in knowledge, attitudes and practices related to health.
CIHG again exceeded its targets as it relates to support to media outlets. Over the course of 1,738 training days, CIHG has enhanced the reporting skills of more than 470 journalists, surpassing both LOP targets by 869% and 247% respectively. Media partners then put that training to use to produce 256 locally produced radio programs about a variety of health governance topics in a number of local languages: Guerzé, Kissi, Konian, Konianké, Kpêlê, Malinké, Pular and Soussou. Radio partners initially struggled to produce local content but as CIHG training and outreach accumulated, their production surged.
Guineans also benefitted from access to CIHG productions that were broadcast throughout the country. In just three years, CIHG produce: 53 episodes of the radio show Sissi Aminata, 47 episodes of the youth-focused radio show Barada, 24 episodes of the radio drama Wontanara, 8 episodes of the community theatre-focused television show Taboulé, 16 episodes of the public affair television show Guinée Forum, and 20 episodes of the television drama Djembé. These programs were critical means through which CIHG disseminated information about health- governance issues and contributed to the increased engagement discussed above. More than 420 health governance programs were produced in CIHG’s 3 years.
Community theater also proved very successful at fostering frank conversations that continued after the event, changing opinions, alternating behaviors and improving services. In a survey of 56 community theater participants a few months after the performances, 95% respondents said the events had demonstrably led to change, such as a decrease in inappropriate practices (such as deviation from the official billing structure) at health centers have been corrected, increased visits to health centers by those citizens (especially pregnant women) who often visit traditional healers, implementation of sanitation initiatives by citizens at health centers, and improved adherence to vaccination schedules. In fact, the directors of a number of health centers reported
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an increase in patients following CIHG activities – community theater performances and other CSO activities like those led by FEDIPHU. To provide some specific examples, in Kolla, Rosina had been convinced that medical staff were responsible for Ebola infections and did not trust public health centers. However, a CIHG community theater performance changed her mind and she now encouraging women in her village to take advantage of the pre-natal and childbirth services offered by the local health facility. In a commune of N’Zérékore, one “Just as my mother taught community was initially against having a performance. me to recognize plants, I However, the community theater troupe met with local leaders share what I learned through to ask about their reluctance and successfully organized a theatre. It is my role to bring performance that was very well received, with attendees women together and transfer expressing the importance of the information shared and knowledge that will enable dialogue foster by the theater troupe. Community theater also the younger generation to led local leaders to take action about the issues raised during the stay healthy and give birth to performance. For example, following a performance in Kankan, beautiful babies.” Rosina, the health center director was able to work with other officials to Resident of Kolla, N’zérékoré build a much-needed borehole for the Bordo Health Center.
Measuring objectivity is inherently difficult given the complexity of the elements that comprise objectivity. Moreover, objectivity and the perception thereof are not the same. Nevertheless, CIHG did attempt to monitor whether communities perceived that media outlets were perceived to be objective based on specific criteria. Out of the 11 prefectures included in both the midline and endline, 82% demonstrated an increase in their objectivity score from midline to endline5 due to CIHG activities. This achievement is just short of the 86% target. CIHG used the objectivity scorecard to analyze media’s performance in 16 of Guinea’s 33 prefectures. Objectivity scorecard data was collected at midline and endline in 11 of these prefectures, representing the final results’ denominator.6 Prefectures could not be reached during the endline due to safety precautions related to the COVID-19 pandemic. As a result, the overall score reported only includes the prefectures for which all outlets had a midline and endline score – or for 11 outlets.
Nine prefectures (Mamou, Labé, Boké, Boffa, Kindia, Guéckédou, N’Zérékoré, Faranah, and Kankan) increased their scores from midline to endline (82% of prefectures for which data was
5 Arriving at this result was a complex process due to differences in the administration of the baseline and the midline/endline data collection processes. A decision was made to change the method of data collection for midline and endline after limitations in the original data collect methodology were identified. CIHG moved to conducting focus groups about individual radio stations. To calculate change in objectivity scores by prefecture, the midline and endline scores for radio stations reached by the midline and endline data collection scores in each prefecture were averaged. It should be noted that each prefecture’s endline score takes into account a different number of radio stations. Kankan took 6 radio stations into account while other prefectures such as Guéckédou and Forécariah only took 1 into account. Without making modifications in the calculation process, of all 33 prefectures reached by the CIHG intervention, 16, or 57%, of prefectures’ media outlets had an increase in objectivity score between midline and endline. It should also be noted that USAID and its partners have not identified a best practice for documenting 6 Due to security issues and later COVID-19, data could not be collected in some prefectures. Faranah was not reached during baseline, Fria during midline, and Beyla, Fria, Kouroussa, Macenta, and Siguiri were not reached during the endline.
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collected at midline and endline or 57% of the oprefectures overall). Only one prefecture (Coyah) showed a decrease in its score, by only 0.08 points. One prefecture (Forécariah) demonstrated no change in score. Again, for five prefectures (Fria, Macenta, Beyla, Kouroussa, Siguiri), it is unknown whether their score increased or decreased as radio stations for these prefectures were not included in the endline. However, it should be noted that, despite not being included in the final result calculation, two prefectures - Kouroussa and Siguiri – had improved scores from baseline to midline. Labé deserves particular attention as all four of its radio stations increased their scores from midline to endline. This is the only prefecture with three or more radio stations that demonstrated a 100% improvement rate.
In addition to working on the objectivity of media outlets, CIHG was able to contribute to the increase the organizational and editorial capacity scores of 57% of radios between midline and endline7. Here again, data collection was hampered by COVID-19. Virtual data collection for this complex scorecard was not effective, so only 14 radio partners were visited. This represents eight radios who have increased their scores, while one radio showed no change and five showed negative change. The highest increases in capacity were in the domains of technological capacity (aggregate 16.2 point increase), strategic planning (aggregate 12 point increase), and digital security (aggregate 11.4 point increase). The largest decreases were in self- censorship (aggregate 7-point drop), editorial standards (aggregate 5.1 point drop), and governance and management (aggregate 3.5 point drop).
IR 2: More effective civic advocacy for health reform
Through CIHG activities, Guineans have been able to lobby successfully for changes to health governance reforms. As with most significant victories in such a complex domain, CIHG cannot claim sole responsibility as other actors are active in the sector. However, CIHG played a critical role in advancing a number of reforms. Our Guinean partners have implemented the following changes at the national and local levels: • Guinea’s 2019 health budget was increased by 25% compared to 2018, constituting 8% of the national budget, following CIHG activities; the 2020 health budget was also 8% of the total. • The MOH eliminated undisclosed line items in the law authorizing the health budget, based on recommendations from the NA-HC, in 2019 and again in 2020. • The MOH added budgetary lines to cover operating costs of regional public health directorates in the 2019 budget to advance decentralization and increase health governance accountability, based on feedback from communities during the NA-MOH field visits. Generous funding for decentralization continued in the 2020 budget.
CIHG partnered directly with 11 CSOs. The five CSOs which conducted operational research significantly increased their expertise in this area, all securing approvals from the governmental ethics board who commented on the high caliber of the research protocols. Four of these CSOs continued to partner with CIHG to implement additional post-research advocacy activities. Of
7 As for the objectivity scorecard, there were changes between the data-collection process at baseline and at midline/endline. Limitations of the original methodology for this complex, qualitative indicator were also identified, and methodological improvements instituted for the midline and endline.
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the six mobilization grantees, all six implemented social accountability activities. In addition, in 2019, seven CSO partners engaged in advocacy with the national legislature and its committees by presenting their research results on health system reforms, advocating for youth participation in health governance, and advocating to increase the capacity of local actors to take ownership of the health decentralization process. In 2020, with the turbulent political environment, the repeated postponed legislative elections (extending the campaigns), COVID-19 and the delays in seating National Assembly all made it exceedingly difficult for CSOs to secure meetings with the NA. Following months of trying to help CSOs negotiate meetings with the NA, in September 2020, a key official was diagnosed with COVID-19 further delaying CSO legislative engagement.
CIHG successfully increased the advocacy capacity of its partner CSOs: 100% of CSOs evaluated improved their advocacy scores between baseline and endline, or 82% of the total number of partners.8 Between baseline and midline and baseline data collection, data collection methods were adapted to strenthen rigor in the required supporting documentation. Endline scores increased across all categories evaluated, with the largest increase in scores between baseline and endline occuring in the domains of strategy (+1.67), communication (+1.30), and community mobilization (+1.00), respectively. The score increases were larger between midline and endline - strategy (+1.60), communication (+2.26), and community mobilization (+2.00), as scores initially dropped slightly at the midline due to the aforementioned methodlogy improvements. Overall, all organizations evaluated increased their scores by an average 1.00 between baseline and endline, and 1.83 between midline and endline.
LESSONS LEARNED AND RECOMMENDATIONS
CIHG’s activity implementation, the challenges faced, the adaptations required, the successes realized taught the project team much. Key lessons and recommendations for future programming are presented below.
Targeted solicitations and co-creation should be considered to accelerate grants programs, improve grant quality, and limit raising unrealistic funding expectations. In the interest of inclusion, transparency and competition, CIHG’s first RFA was full and open. The result was an overwhelming response of 100 proposals. Despite pre-award proposal training, most applications were weak, and even the strongest ones required months of very detailed exchanges and negotiations. Eighty-nine CSOs invested their valuable time in preparing an application that CIHG could not fund. Expectations were raised farther larger than we could ever meet.
The second RFA was done as a co-creation. While the projects were admittedly smaller, thanks to co-creation, the process of finalizing the packages took weeks instead of months. The co- creation process shortened the extensive negotiation process where comments are sent, and the organization are asked to respond. This standard type of exchange was stilted and much less effective than through co-creation, during which partners and CIHG brainstormed together often
8 Of the eleven partner organizations, data collection at endline was completed with only nine of eleven, or 82%, of all partner CSOs.
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identifying new ideas. The partners had final control of the revisions, and CIHG retained its right to fund or not fund, so both independence and teammate were simultaneously achieved.
In the future, USAID and implementing partners should consider targeted RFAs. For example, an RFA might be shared with 20 CSOs, in the hopes of funding 10-15 projects or an RFA is shared with a certain number of CSOs and the goal is that co-creation will all candidates to be awarded a grant. CIHG’s second RFA was done in this way which has the additional benefit of allowing the co-creation process to be collaborative across the network of future partners and not just bi-directional: CSO and funding organization. This more collaborative process strengthened the relationships among CSOs and the complementary of the activities.
Do not rush the pre-award process. Despite the length of the grant negotiations, a thorough pre-award process is vital to successful grant administration. The pre-award process was a critical step not only to ensure that the technical design and budget plan are sound, but also to build partner capacity building, to improve the quality of post-award reports and activity implementation, and to minimize compliance vulnerabilities and potential disallowed costs. Post- award coaching with specific, actionable guidance is also important, but it is almost impossible to recover from a per-award process that is inadequate.
Project designs should reflect the existing organizational capacity of partners and economy in which they work. Projects would be well served if designs reflected realistic, locally- meaningful definitions of success and sustainability. Most CSOs and radio outlets, especially community radio operate on shoe-string budgets. In Guinea, most CSOs do not have stable funding streams. They cannot hire and retain staff with the extensive competencies required to build and sustain the high standards required under USAID regulations. A handful of people are expected to have mastery of wide range of requirements that donors and international NGOs sustain with far larger teams paying much higher salaries and yet themselves do not have perfect compliance.
Most media outlets to small staffs as well, working for modest salaries, if not nominal stipends or as volunteers. Outlets understandably prioritize affordable programming for which they can earn the most – public service productions supported by donors and projects like CIHG and popular entertainment shows that are more attractive for local advertising.
If this is the context, projects should be designed to meet partners where they are and set expectations accordingly. This also requires looking differently at “sustainability.” Maybe an organization will not retain staff, but core staff retain actionable, quick guides that can sustain coaching beyond the available of the original coaches. Perhaps prime awards are longer to allow for successful CSOs to receive a series of awards through which core practices can be better institutionalized, than over the course of 12-24 months. Perhaps coaching staffs should be augmented in size within implementing partners and/or salaries increased for key positions in local CSOs to increase the likelihood of success.
Increased context-sensitivity also means grappling up front with risk. If a project is designed to work with nascent CSOs who are typically high-risk partners that USAID would not directly fund themselves, USAID and implementing partners should frankly discuss the processes that
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should be in place and the failures that will be accepted because of the nature of the objective and the target partners. Moreover, in high-risk contexts, it is all the more important that awards be structured to allow adaptation. To USAID/Guinea’s credit, USAID approved numerous adaptations such as when CIHG recommended that FHI 360 staff prioritize coaching of CSOs in Year 3 and when we decided to limit the number of grantees based on the caliber of application and not the initial number of target grantees, to name but two examples.
USAID should weight the opportunity cost between approvals and adaptation and adapt as appropriate. Any approval submitted to USAID by a partner takes time – USAID’s and the partner’s, time that could be otherwise used. The weight of the work for USAID’s Offices of Acquisition and Assistance is well known. USAID technical teams also have much work to oversee. Each approval package also took time for the partner. The polish required in an internal decision-making process is not the same as what is required once that discussion is with an external organization, especially a donor. The care that must be taken with explanations for those not involving in early parts of the process is greater.
As a result, there are a number of question that USAID may wish to consider tailoring the required approvals for each award. What is the current workload of USAID staff involved in the approval? What is the opportunity cost of prioritizing X or Y approval (for example, are procurements advancing along identified timelines?) Is the approval critical to ensuring the impact or effectiveness of the project? If an approval is needed, does OAA need to be involved or might AOR approval be sufficient? For what are you asking an AOR to provide approval (the scope of work for a consultant or entire consultant package?)
With each approval, an implementing partner must consider whether it is worth the labor and time that will elapse by the time the approval is secured or rejected, during which time, one cannot proceed. In the case of CIHG, political unrest and COVID-19 required numerous adaptations. Not all adaptations identified were pursued, due to the level of effort and delays for which the opportunity cost was too high. Those adaptations would have cost less than 1% of the total award budget: helping partners to buy face coverings not in the original grant budgets to protect both CSO staff and beneficiaries, increasing transportation costs again due to safety.
At CIHG’s request, in 2019, USAID authorized FHI 360 to make awards under $10,000 without USAID approval. This delegation of authority was crucial the success of Year 3 implementation. It enabled the advocacy grants to be awarded within 8 weeks of the release of the RFA.USAID should consider whether a higher dollar amount may be reasonable in future cases. If an approval is needed, may the partner have the right to modify the award by a certain percentage, as adaptations are required – like adapting to systemic political unrest and COVID-19. What if a need emerges for a local or international consultant and the total value is under a certain amount? Is USAID’s approval necessary or might a partner to responsible for managing personnel challenges such as illnesses, parental leave or surges in workload?
USAID may wish to consider asking partners for their recommendations and explanations for why as it could help USAID management determine how best to optimize precious staff time.
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Cost share can detract from project effectiveness and may not contribute to sustainability. The aim with cost share is to mobilize additional financial resources to increase the coverage and effectiveness of USAID’s limited budget resources and to enhance sustainability. ADS 303 notes that USAID may wish to include cost share in circumstances such as when it is critical that the activity continues after USAID assistance ends or to ensure that the partner has a financial stake in the success. However, without analysis of the context and the likely availability of alternative funding sources, cost share may not play the constructive role anticipated by USAID and, in fact, work against program effectiveness.
In the case of CIHG, other donors were not interested in many parts of CIHG’s objectives as defined by USAID. While some international donor funding was found for the media-specific parts of the project, donors had other priorities for their health-related funding which did not apply to CIHG’s objectives. Prior to award, FHI 360 could not identify probable cost share from other donors beyond the amount related to media activities. While CIHG continued, unsuccessfully, to secure cost share from other donors, CIHG’s strategy from the outset was that a large share would need to come from local CSOs. Seemingly, the goal is reasonable -- to help local CSOs diversity their funding. Yet, the objectives for which they had to look for additional funding were set by USAID and limited to CIHG’s results framework. CIHG coaching could have focused on helping CSOs to design market-focused funding raising strategies, but given the cost-share requirement, the focus needed to be on CIHG-specific opportunities.
Cost share was often taxing because of the supporting documentation required. Partners often did not have the procurement documents for the equipment that they would use to implement their project, so reasonable, credible alternatives had to be found – which takes time to identify and compile. Other types of cost share were just too difficult to prove. Partners discussed asking vendors for discounts as a contribution to the community, which seemed promising, but audit standards make it difficult to prove that the discount was done as a community service and not because the vendor was need of the business.
Given the local economy, the priorities of other donors, and the capacity of CIHG’s partners, securing and documenting cost share was incredibility labor-intensive. More than once, CIHG staff had competing urgent actions critical to performance and cost share. Cost share was prioritized because it is an award requirement. However, many project team members felt that cost share was diverting time that could have been more productively spent to maximize impact and build sustainability in ways not reflected in cost- share amounts.
Support for strategic adaptation is critical for success. While CIHG implementation was faithful to results framework, adapting tactics and activities was essential and the project team benefited from a USAID team that was supportive of those adaptations. From the first implementation plan to the last, and again with the advent of COVID-19, CIHG used its initial plan, but it never limited itself to that. When prospective improvements were identified, hurdles encountered, we strove to create plans that had the greatest likelihood of success. While COVID- 19 was exceptional, political unrest impacted activities from 2018 onwards and partner capacity challenges remained an on-going challenge through the POP.
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To maximize space for strategic adaptation, rather than using the detailed technical application as the program description in an award, USAID should consider asking the implementing partner to adapt the technical application to a summary program description appropriate for an award document. One USAID mission asked FHI 360 to do specifically this. The mission had noted that the level of detail in the technical application was critical to allow USAID to make the award, but that much of the detail was more appropriate for implementation plans. As implementation plans are subject to USAID approval, USAID does not lose control, but USAID does not lock into the award itself activities that both USAID and partner may later wish to change.
Ensuring adequate participation of women and attention to gender issues remains a key challenge in Guinea. While CIHG kept gender issues and women’s participation as a priority during implementation, effectively doing so was a challenge throughout, particularly as robust participation of women was difficult for a number of activities. First, many partners and stakeholders do not share this concern. Second, women’s participation is hampered by the simple fact that male participation in governmental posts and in civil society is much higher than that of women. For example, at regional and national forums when attendees are selected based on leadership positions, women’s participation was often about 20-30%. At many media outlets, there were few female journalists. The fewer women there are, the more demands that are made on the women who do hold leadership positions. Those women cannot, however, attend every event to help improve women’s participation rates.
Here, again, USAID was very understanding of the challenges faced. CIHG successfully ensured that strong women’s participation in a number of community mobilization activities such as community theatre and health service talks organized by FEDIPHU. USAID and partners will need to remain diligent, carefully considering how to adapt activities to maximize attention to gender and women’s participation. Frank discussion about if and how objectives might be adapted, the impact on certain indicator targets and whether those targets could be re- conceptualized with equity in mind. If pursuing “more” means less women’s participation, maybe that is acceptable. Five new policies on a particular issue may not matter if few women (or other key populations) were not meaningfully included in the process.
Limiting dependence on approvals from any one stakeholder is important to advancing implementation. Collaboration with government structures was very productive under CIHG, but often posed challenges. Events with the MOH, MATD and Parliamentary Radio were repeatedly delayed, and dates often finalized only at the last minute. In a number of cases, CSO partners had difficulty securing the participation of government officials in their research. However, because only some CIHG activities depends on government approval, other events could move forward.
Projects must understand the impact of centralized authority in Guinea. Historically, political power has been very centralized, so local officials often needed to know that it was “ok” to work with CIHG, even if they are very eager to do so. For example, we learned that journalists often had difficulty securing cooperation from public health care providers when trying to report on health issues. CIHG met with MOH staff to secure letters for partner outlets to present. Acknowledging these norms and adapting to them was important to helping Guinean stakeholders begin to develop new norms of civic engagement and community empowerment.
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Investing in multi-stakeholder collaboration and complementary activities can be an effective means to effect change for complex issues. The majority of outcome statements identified in the endline study determined to have a “medium” level of CIHG contribution – meaning that both CIHG and another actor played a role in creating the change. The implication is that programs will be more successful if implemented in a way that complements ongoing government, donor or other NGO initiatives (for example, CIHG organizing visits of government officials to health centers at the same time that the ANAFIC was investing in the renovation of these centers across the country).
Government was a key social actor in the OH outcome statements – despite most outcomes taking place at the community level. In addition, many of the changes involving government also included a secondary social actor. Thus, the ability of CIHG to produce government-related outcomes did not necessarily center on creating individual-level changes among government officials, but rather on sparking collaboration with other social actors. Given the influence of government, creating connections between officials and regional or local actors has an important ripple effect that leads to change at the community level.
It is also notable that only a small number of OH outcomes linked to CIHG IR 2 on CSO advocacy, yet many outcomes related to the overall objective—indicating that the objective was achieved but not via the results originally anticipated and not necessarily well perceived. Instead, there were a significant number of “unintended’ changes (many involving government institutions and relationships) that seem to have been stronger contributors to improving citizens’ understanding of and participation in Guinea’s health system.
Weigh carefully whether to pilot multiple, complex, innovative qualitative indicators. Democracy, human rights and governance (DRG) programming continues to struggle with monitoring and evaluation. The results sought under programs like CIHG are complex, systematic changes that are largely qualitative, and therefore not readily translated into numerical indicators. Numerous scorecards and indices have been created over the past two decades, yet none have emerged as the established, field-tested, recommended methodologies for capturing common DRG results like improved advocacy and improved journalism. Indeed, USAID has never updated the first DRG indicators manual in the 22 years since its publication in 1998.
In the interest of DRG MEL innovation, CIHG and USAID collaborated and selected several indicators to capture data that it was hoped would be more outcome-oriented for several of these complex, qualitative results and another result that seemingly would be feasible but in reality is very difficult to capture: improved objectivity, improved media outlet management, improved advocacy, and increased health governance programming. New methodologies were created for all these indicators. It was a worthy initiative in principal. The reality was the each of the new instruments required in-depth training for numerous skilled staff members to correctly apply the methodologies. They required that the partners understand these complex methodologies. The data collection also required in person meetings with all partners across the country each time given the complexity of the instruments. For a project with just three years and limited MEL staff, during which political unrest forced delays as early as 2018, piloting four sophisticated new
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methodologies proven exceedingly difficult. Efforts could have focused on one or two innovations and accepted indicators with more simple and verifiable data for other results.
Adapt consortium responsibilities and consortium collaboration practices to optimize performance. Throughout the lifetime of the project, CIHG consortium members collaborated closely to deliver high-quality, effective programming. In the course of that teamwork, there were many frank conversations about what we were doing well and what we might do better. Some practices proved very productive. For example, SFCG’s CIHG program manager worked from both FHI 360’s and SFCG’s offices, SI’s MEL advisor sat full time in FHI 360’s office, and select activities were jointly implemented by consortium members, such as the 2019 health communication workshop and the baseline study. Other areas required adaptation. To strengthen MEL and in response to regulatory issues with SI, a for-profit, to hire a Guinean employee, the consortium decided to restructure the MEL team, which impacted all three consortium members. The most significant change was that FHI 360 would take the lead on day-to-day MEL activities, including hiring of the Guinean MEL Advisor, a key personnel position, and SI would focus on the endline. USAID supported this changed, which provided instrumental to addressing MEL vulnerabilities and enabling CIHG to utilize SI’s remaining resources to conduct a sophisticated, mixed method endline study that USAID wanted but was not in the original project budget. Both the consortium’s professionalism and shared commitment to performance and USAID’s receptivity to the project teams recommended changes helped to improve performance.
Final Note
FHI 360 is honored to have been awarded the CIHG project and to have worked with all our partners: Guineans across the country, across diverse institutions, our consortium partners SFCG and SI, other technical and financial partners, and of course our donor, USAID, without whom CIHG would not have been possible.
We faced many challenges, but our staff and our partners worked together to identify solutions and ensure that CIHG would leave a lasting mark on the people and institutions with whom we worked. We believe that we have done just that and we hope that all of us who made that change a reality will use the lessons from CIHG to make future programs, in Guinea and elsewhere in the world, better.
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.” - Margaret Mead
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ANNEXES
Annex I: Performance Indicator Table
Frequency Indicator of Data LOP FY20Q1 FY20Q2 FY20Q3 FY20Q4
Collection Baseline FY18 Total FY19 Total FY20 Total Objective: Improved citizens’ understanding and participation in Guinea’s health system reforms 57% 72% 72% Target (Oct NA NA NA NA NA 57% (15% ) (15% ) Percentage of people who say they feel more Baseline/ 2017) (Oct informed about the health system in Guinea Endline 2017) Actual NA NA NA NA NA NA 68.5% 68.5% Achievement NA NA NA NA NA NA 95.14% 95.14% 47.6% 51% 25% 51% (50% Target (40% NA - NA 51% (50% ) (50% ) 34% ) i) Rate of media coverage on health reform issues Biannually See (Sept Not (television and radio) (Sept/Mar) Actual baseli 42%, NA NA 54% 54% 54% 2018) collected9 ne Achievement NA 88% NA - NA 107% 107% 107% IR 1: Opportunities Expanded for Elected and Appointed Officials and Citizens to Engage in Constructive Dialogue Target 18,800 34,400 - 19,000 - - 19,000 72,200 Number of people participating in CIHG-sponsored Quarterly NA Actual 12,401 26,627 266 12,947 2,639 418 16,270 55,298 forums promoting health governance and reforms Achievement 66% 77% - 68% - - 86% 77%10
9 Data collection was originally scheduled for March, rescheduled for April due to moving election calendar, only to be hampered by COVID-19. CIHG is examining a virtual collection for Q3, following by a possible standard data collection process in Q4, governmental anti-COVID measures permitting. 10 Achievement is less than anticipated because original estimates of average community theatre audience size outsized actual achievement and then the advent of COVID-19 requiring that an additional planned community theatre campaign be revamped and conducted in a way that we could no longer report data against this indicator. However, CIHG has mobilized more than 120,000 through additional activities that target civic mobilization. We determined that some activities to mobilize citizens would be more effective if government officials were not present, to allow participants to speak more frankly.
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Frequency Indicator of Data LOP FY20Q1 FY20Q2 FY20Q3 FY20Q4
Collection Baseline FY18 Total FY19 Total FY20 Total
Number of CIHG-supported public forums with civil Target 10 20 10 10 - - 20 50 society, government official, and/or citizens promoting Quarterly NA Actual 69 111 7 116 143 17 246 429 health governance and reforms Achievement 690% 555% 70% 580% - - 1245% 858% Sub IR 1.1: Government officials prepared for engaging citizens’ in health reform dialogue
Number of new initiatives taken by GoG officials to Target 0 5 - - - - 5 10 promote health reform dialogue as a result of CIHG Quarterly NA Actual 1 2 0 811 10 20 38 41 activity Achievement +1 40% - - - - 760% 410% Sub IR 1.2: Improved facilitation of issued based discussion and dialogue by media outlets and community theatre troupes 80% 86% 86% 57% Target NA (40% NA NA NA NA Percentage score of health issue publications/ (50% ) (50% ) Annually (Sept. ) programming on Objectivity Scorecard 2018) Actual NA 52% NA NA NA NA 82% 82% Achievement NA 5% NA NA NA NA 95.34% 95.34% Target NA 84% NA NA NA NA 90% 90%
60.4% Percentage of media partners demonstrating Actual NA 49% NA NA NA NA 57% 57% Annually (Sept. improved management capacity -11.4% 2018) Achievement NA NA NA NA NA 63.33% 63.33% 12
Target 70 70 30 30 - NA 60 200
Number of training days provided to journalists with Actual 555 794 95 105 189 NA 389 1738 USG assistance measured by person-days of training Quarterly NA (Mission PMP Indicator) Achievement 793% 1134% 317% 350% - NA 648% 869%
11 Achievement dramatically increased in FY2020 primarily due to activities designed to improve achievement of this outcome. The activity entails encouraging and supporting local government officials to organize round tables with civil society and the media to discuss health governance topics as identified by the officials. 12 CIHG required more supporting documentation from radio partners to justify scores than was done in the baseline. As a result, certain scores went down
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Frequency Indicator of Data LOP FY20Q1 FY20Q2 FY20Q3 FY20Q4
Collection Baseline FY18 Total FY19 Total FY20 Total Target 70 70 25 25 - - 50 190 Number of journalists trained with USG assistance Quarterly NA Actual 172 224 33 41 - - 74 470 Achievement 246% 320% 110% 136% - - 123% 247% IR 2: More effective advocacy for health reform by partner CSOs Number of public policies introduced, adopted, Target 1 3 2 2 NA NA 4 8 repealed, changed or implemented as a result of civil Annually NA 2 0 13 14 society organizations (CSOs) receiving USG Actual 0 0 0 0 0 2 assistance engaged in advocacy interventions Achievement - 67% - - - - - 25% 4 - - 6 Number of USG-assisted CSOs that engage in Target 4 - 14 advocacy with national legislature and its committees Quarterly NA Actual 0 7 0 015 0 10 10 17 (Standard Indicator DR 4.3-1) Achievement 0 175% 0% 0% 0% 0% 167% 121% Sub-IR 2.1: Skills of CSOs in advocacy, strategic planning and influencing public officials improved Target 25% 40% NA NA NA 50% 50% 50% Percentage of targeted CSOs that show improved Annually NA Not advocacy capacity Actual collect 0%17 NA NA NA 100% 100% 100% ed16
13 CSO advocacy to reform public policies was deeply impacted as a result of the socio-political situation in Guinea and the subsequent advent of COVID-19. CIHG is working with government allies to translate the actions identified during the dialogue initiatives into reforms that can be counted, even if they are not at the national level. 14 See footnote above. 15 See footnote above. 16 Baseline data could not be collected for this indicator until the sub-awardees were selected by CIHG and approved by USAID. USAID approved the first sub- awardees in late FY 2018. The response rate for the Request for Applications (RFA) was overwhelming. One hundred CSOs applied but none were immediately fundable. All selected application required extensive work to prepare packages adequate for FHI 360 and USAID approval. 17 No CSO partner achieved a higher score than the baseline because FHI 360 increased the supporting documentation requirements when FHI 360 took over data collection. The revamped MEL team determined that it was better to recalibrate the scores using a more rigorous methodology. The advocacy scorecard tool itself is unchanged. The CIHG team has identified three priority areas for tailored capacity building with organizations: how to use data and evidence within advocacy campaigns, how to constructively engage government through advocacy, and how to network and collaborate with partners on advocacy issues.
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Frequency Indicator of Data LOP FY20Q1 FY20Q2 FY20Q3 FY20Q4
Collection Baseline FY18 Total FY19 Total FY20 Total Achievement NA NA NA NA NA 200% 200% 200%
Number of civil society organizations (CSOs) Target 0 5 NA NA NA NA 10 15 receiving USG assistance engaged in advocacy Annually NA Actual 0 7 NA 618 2 4 10 17 interventions (Standard F DR4.2-2) Achievement 0 140% NA - - - - 113% Sub-IR 2.2: Increased use of evidence by CSOs to influence public officials on health reform Target 0 75% NA NA NA na 75% 75% Percentage of CIHG partner CSOs using social 19 20 Annually NA Actual 0 45% NA 55% 45% - - 55% accountability tools to advocate for health reforms Achievement 0 60% NA NA NA - - 73% Target 0 0 2 1 NA NA 3 3 Number of action plans implemented as a result of Biannually NA Actual NA NA 0 0 0 6 6 6 citizens' use of the social accountability tool (Sept/Mar) Achievement NA NA - - - - 200% 200%
18 Data reported annually, but data already collected included to show CIHG’s progress toward LOP target. Adding in the four new advocacy projects, the LOP target will be next over the coming quarter. 19 All six mobilization partners or 100% are now conducting GGB. The research partners were not expected to use social accountability tools in their research. However, this indicator definition requires that the research partners be included in the denominator to make the calculation 20 All five active mobilization partners or 100% are now conducting GGB. The research partners were not expected to use social accountability tools in their research. However, this indicator definition requires that the research partners be included in the denominator to make the calculation.
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Annex 2: Summary of CIHG Achievements
The Citizens’ Involvement in Health Governance (CIHG) project (2017 – 2020, $10 million) is a USAID-funded initiative to improve citizens’ understanding of and participation in Guinea’s health system reforms. By expanding meaningful opportunities for Guineans to engage in their country’s health reforms and see the impact of their participation, CIHG is contributing to strengthening public trust in Guinea’s health sector and improving health governance. Below are some of CIHG’s achievements.
Health budget reforms • Guinea’s 2019 health budget was increased by 25% compared to 2018 and now constitutes 8.2% of the national budget, following CIHG initiative. • The 2020 health budget was also 8% of the total budget. • The MOH eliminated undisclosed line items in the law authorizing the health budget in 2019 and 2020. • The MOH added budgetary lines and increased allocations in the 2019 and 2020 budgets to advance decentralization and increase health governance accountability.
Government officials and citizens expand constructive dialogue • Over 175,000 Guineans have mobilized. In total, 55,298 people participated in multi- stakeholder forums bringing together government officials, civil society representatives and the media to discuss how to improve health governance and health service delivery. At least an additional 120,000 Guineans also participated in civic mobilization activities designed to increase citizen understanding of health reforms and strengthen civil society participation in health governance. • 429 CIHG-sponsored civic-governmental dialogues promoting constructive problem solving of health governance issues (surpassing the project target by over 850%). • 41 government-led dialogue initiatives to involve civil society in and to improve health governance (410% over target).
Increasing media coverage of health governance to improve citizen understanding • Over the course of 1,738 training days, CIHG has enhanced the reporting skills of more than 470 journalists, surpassing both LOP targets by 869% and 247% respectively. More than 425 radio and television programs produced.
More effective, evidenced-based advocacy for health reform • CIHG has disbursed over $1,000,000 in sub-awards to 11 local CSOs to execute health governance research, launch the use of social accountability tools, and mobilize citizens to improve health governance. 100% of CSO partners demonstrated improved advocacy. • All 6 CSO mobilization partners are implementing the Good Governance Barometer to increase social accountability and advocate for health reforms in 6 priority rural communes and 100% of communes are implementing their GGB action plans, double the target.
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Annex 3: CIHG Communications Poster
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Annex 4: List of CIHG CSO Partners
Organization Name Office Location Grant Types Action et Développement pour la Guinée (AIDE- Research and follow- Kosa, Conakry Guinée) on advocacy Coalition mobilization Alliance pour la Promotion de la Gouvernance des Taouyah, Conakry including social Initiatives Locales (AGIL) accountability Association des Femmes Journalistes de Guinée Research and follow- Matoto, Conakry (AFJ) on advocacy Association Guinéenne pour l’Implication des Coalition mobilization Femmes dans le Processus Electoral et la Tombolia, Conakry including social Gouvernance (AGUIFPEG) accountability Centre Africain de Formation pour le Développement Lambagny, Research (CENAFOD) Conakry Research and follow- Comité Jeunes Mon Avenir D’Abord (CJMAD) Koloma, Conakry on advocacy Coalition mobilization Conseil National des Organisations de la Société Dixinn, Conakry including social Civile (CNOSCG) accountability Coalition mobilization Femmes pour le Développement Intégré et la N’zérékoré including social Promotion Humaine (FEDIPHU) accountability Coalition mobilization Le Groupe Lyceum (LGL) Boffa including social accountability Research and follow- Mutuelle de Santé et Service (MSS) Sonfonia, Conakry on advocacy Coalition mobilization Réseau Afrique Jeunesse de Guinée (RAJ-GUI) Kipé, Conakry including social accountability
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Annex 5: List of CIHG Media Partners
N° Media Outlet Area of Coverage Conakry Radio Stations 1 Radio Parlementaire Conakry (Public) 2 Radio Espace Conakry (Private) 3 Gangan FM Conakry (Private) Private Radio Stations outside of Conakry 4 Espace Labé Labé 5 Kania Zik FM Kindia 6 Sabari FM Kindia 7 Voix de Fria Fria 8 Milo FM Siguiri Siguiri 9 Bolivar FM Mamou Mamou 10 Espace Kakandé Boké Boké 11 Baobab FM Kankan 12 Bambou FM Faranah 13 Zaly FM N’Zérékoré 14 Pacifique FM N’Zérékoré 15 Niandan FM Kissidougou 16 Milo Kankan Kankan Rural Radio Stations 17 Radio Rurale Kissidougou Kissidougou 18 Radio Rurale Macenta Macenta 19 Radio rurale Beyla Beyla 20 Radio rurale Guéckédou Guéckédou 21 Radio Rurale N’zérékoré N’Zérékoré 22 Radio Rurale de Kouroussa Kouroussa 23 Radio Rurale Boké Boké 24 Radio Rurale Boffa Boffa 25 Radio Rurale Forécariah Forécariah 26 Radio Rurale Labé Labé 27 Radio Rurale Dalaba Dalaba 28 Radio Rurale Mandiana Mandiana 29 Radio Rurale Dinguiraye Dinguiraye Television Stations 1 Evasion National coverage 2 RTG Koloma National coverage 3 Gangan TV National coverage 4 Espace TV National coverage
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Annex 6: List of CIHG Listening Groups
Specific Location Préfecture GUINEE FORESTIERE 1 Loomou N’Zérékoré 2 Tamoé 3 Watanka Macenta 4 Bofossou 5 Fangamadou Guéckédou 6 Fromaro Beyla 7 Kpo Yomou 8 Guéasso Lola BASSE GUINEE 9 Bangouyah Kindia 10 Samaya 11 Sinta Télimelé 12 Kolet 13 Sikhourou Forécariah 14 Tondon Dubréka 15 Sarekaly Télimelé 16 Kouriah Coyah MOYENNE GUINEE 17 Kegneko 18 Saramoussaya Mamou 19 Porédaka 20 Kebaly Dalaba 21 Kaala 22 Bantighel 23 Timbi Madina Pita 24 Donghol Touma HAUTE GUINEE 25 Banora Dinguiraye 26 Gagnakaly 27 Konindou Dabola 28 Banko 29 Marella Faranah 30 Siguirini Siguiri 31 Niagassola 32 Balandougouba Mandiana 33 Cissela 34 Komola Koura Kouroussa 35 Douako
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Annex 7: CIHG Success Stories
One the subsequent pages are several success stories that provide explain some of CIHG’s specific success, often at a very personal level. They begin on the next page so as to remain consistent formatting for each one pager.
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Success Story
Participatory Theatre: Empowering
communities and resolving conflicts
Participatory theatre is an effective method of encouraging Citizen Involvement in citizen participation, information sharing and trust building on Health Governance Project important issues. USAID’s Citizen Participation in Health Governance (CIHG) project increasing civic participation in public health reforms to, in turn, improve service delivery and increase trust in the public health system. CIHG’s first theatre campaign focused on sharing information about recent reforms and facilitating dialogue on health issues that communities are facing. Through CIHG’s 23 theatre partners, over the life of the project, 49, 200 Guineans participated in these interactive forums. The power of participatory theatre was particularly bought into focus by the Zaly Theatri Troupe. Zaly Theatri organized a performance in September 2018 in Kola, a village located 35 kilometers from N’zérékoré. In the past, residents of Kola have been victims of scams, leaving the population skeptical of outsiders coming to their village and spreading what could be harmful disinformation. A young man in the village Residents of Kola during the disclosed a cause of this sentiment: “Young people like Zaly Theatri performance yourselves came here pretending to be members of an NGO and asked young graduates to pay 25 000 GNF in return for a job with a village farm corporation; then they vanished into thin air.” Because of this experience, the youth initially Youth from Kola: rejected Zaly Theatri’s proposed performance. Undaunted, the theatre troupe members met with the village leader to « These are the type of explain the details of the performance and then again with a initiatives that we want here. I wider group of community members, including youth leaders. learned a lot, and it helped us Zaly Theatri earned the community’s consent to perform. improve operations at our Their play addressed community participation in health health center … I request that governance and those public health services that are supposed to be free of charge, but often are not. The the theatre troupe return performance was very positively received, with audience several times to do other members staying afterwards into the evening to thank the performances. » troupe for sharing such important and much needed information. Improving access to information and building trust across communities, particularly those that are more isolated or have been historically marginalized is a critical component of strengthening Guinea’s resilience for future emergencies that may arise.
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Legislative Leadership in Health Reform:
Collaborative Dialogue with Communities
Citizen Involvement in Guinea is faced with significant problems related to the health system. Recent health reforms have created a critical Health Governance Project opportunity to establish increased trust between the Guinean government and its citizens. The Citizen Participation in Health Governance (CIHG) project, financed by USAID, aims to help citizens better understand these reforms and participate more fully in health system governance. To this end, FHI 360, Search for Common Ground and Social Impact, in collaboration with members of Parliament and the Ministry of Health (MOH), organized field visits in July and August 2018 in 47 communities throughout the country and in the capital city of Conakry. The purpose of these visits was for legislators and Ministry of Health officials to meet directly Residents of Doghol Sigon with citizens, health service providers and local officials to discuss with legislators and listen to their experiences with the public health system, its Ministry of Health challenges and their suggestions for how to improve it at the representatives their local and national levels. experiences with the public Around 2,500 people participated in these community health system discussions. These visits allowed citizens, many for the first time, to directly address members of parliament and health officials about their concerns. In Doghol Sigon, a community located 120 kilometers from the Labé region, a woman raised the issue of malaria treatments that are not always free as Resident of Doghol Sigon: they should be. She started by saying, “It is my first time “It is my first time seeing a seeing a visit from high-level officials coming to discuss with us the health issues of our community.” visit from high-level officials coming to discuss with us the Following the visits, the legislators and health officials health issues of our collaborated to identify a number of recommendations and have already started working on them. As a result, the 2019 community.” health budget was increased by 25% over the 2018 budget. The participants also successfully championed other budget improvements, such as urgent renovations for the health facilities most in need, and the removal of undescribed budget line items to increase transparency. CIHG’s partners in government and civil society recognize that these budget improvements must be followed by accelerated budget disbursement, a challenge highlighted during their field visits and on which they are now focused.
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Success Story
Participatory Theatre: Inspiring citizens
to raise health awareness
In 2013, the West African Ebola virus epidemic brought to Citizen Involvement in the surface an existing mistrust of health institutions in Health Governance Project Guinea. Instead of seeking medical attention at health centers, many families would hide the sick at home, making the epidemic all the more difficult to track and control. Rosina, a resident of Kolla in N’Zérékoré, recounted how villagers “were convinced that medical personnel were responsible for the transmission of Ebola” and that “even before that, most of [them] had never set foot in a health center,” instead relying on plants for treatment. The Citizens’ Involvement in Health Governance (CIHG) project, financed by USAID, worked to address this lack of confidence between citizens and the public healthcare Five years after the Ebola virus providers. Combining knowledge sharing with entertainment, epidemic, Rosina is regaining theatre troupes traveled to different villages throughout confidence in the health system. Guinea to organize participatory performances on health Today, she brings women together governance engaging community members, governmental to protect the health of the most officials, health workers and other local leaders. vulnerable. One of these performances in Kolla addressed prenatal care. Though only two kilometers away from the village, the health center, equipped with a delivery room and specialized staff, was not receiving many patients. According to Rosina, women “were all giving birth at home…. In case of complications, the young woman and her newborn often died.” Incorporating these real experiences into the plays, the actors invited audience members to adapt, change, or Rosina, Resident of Kolla: correct the problems presented to them to foster dialogue across stakeholder groups and to increase use of available “We became aware of the health services to improve the health and wellbeing of need for pregnancy community members. As the performances in Kolla and monitoring and essential care elsewhere were both engaging and easy to understand, by the end of the plays, those who participated better during childbirth. Today, the understood the health governance issues addressed and midwifery of the health center actions that they could take themselves. saves lives.” Though the performance has long since passed, Rosina continues to raise health awareness to girls and young women in her village: “Just as my mother taught me to recognize plants, I share what I learned through theatre. It is my role to bring women together and spread knowledge that will enable the younger generation to stay healthy and give birth to beautiful babies”.
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Annex 8: Summary of Good Governance Barometer Key Phases
Workshops/steps Deliverables Details The report of the meeting Short document specifying the name of the GGB implementation between the implementing 1. Advocacy Mission commune/municipality, the names of the key stakeholders, the implementation period, technical partner and the the name of the facilitating organization (FHI partner CSO) municipality 2. Workshop - Document presenting the “central question,” Understanding the The GGB's roadmap the existing governance tools, the GGB participants, and the agenda context (the different stages and dates) 3. Workshop - Modeling and The specific GGB model of Document presenting the GGB model specific to the commune/municipality (criteria, Scoring the municipality sub-criteria, sub-sub-criteria, and indicators approved by all stakeholders) 4. Workshop – Reference The table of reference values This table presents, for each sub-sub-criterion, the minimum and maximum values VR Max and VR Min values approved by all participants The table of reference This table presents, for each sub-sub-criterion, the minimum and maximum values 5. Workshop - Data analysis values: RV Max, RV Min, approved by all participants as well as the real values in terms of governance and scoring and Real values perception 6. Workshop - Analysis and Document presenting the action plan for the five criteria, approved by all stakeholders. The action plan action planning The document specifies the names of the GGB technical monitoring group members. The table of reference: This table presents, for each sub-sub-criterion, the minimum and maximum 7. Collecting data at the end Values RV Max, RV Min, and values approved by all participants as well as the real values at mid-term or end of of the project Real values project (governance perceptions). The document includes the above tables, the comparative data of the beginning and 8. Final Restitution The final report of the GGB the end of the process, the results achieved, the changes made, and the new governance tools/processes initiated in the commune/municipality.
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