Ellen Hagerman
Social Development Direct-UK

1) Objective of Output 3
2) Background to Output 3
3) Outputs and Outcomes of Output 3
4) Added Value of the Work of Output 3
5) Legacy
6) Recommendations
7) Follow-up to RMCH for Output 3

Support the improvement of demand and accountability (D & A) for maternal and child health services at the community level by engaging civil society organizations (CSOs) through a grants mechanism to learn, document and disseminate innovative approaches to D & A.

 Low uptake of MCH services due to barriers such as patient transport, long waiting times in clinics, cultural norms and negative attitudes of HWs
 Weak systems of accountability
 Widening inequality: poor and marginalized women have greater challenges with access
 Need for increased community engagement

• 10 grants awarded: 4 large grants, 5 small grants, 1 special grant for FP song
• TA support to implementation including gathering & documenting lessons learned, preparation of products, planning for dissemination & added value

Indicators Target by April 2015 Progress
Number of functional multistakeholder mechanisms supported by Civil Society Organisations
(CSOs) in the 25 districts through the
RMCH grants mechanism
15 multi-stakeholder mechanisms supported
Number of innovative initiatives that have been documented and shared in the form of mixed method tools across the 25 RMCH districts to improve demand and accountability for MNCWH services
10 mixed method tools developed
Number of grants provided to civil society organizations to improve
Demand & Accountability of
MNCWH services in the RMCH sector
10
28 multi-stakeholder mechanisms have been supported in 12 districts as part of the programme.
ACHIEVED
83 mixed method tools have been produced by grantees and RMCH
Output 3 technical team. ACHIEVED
10 grants. ACHIEVED

Finding
Cultural Barriers
Response
Testing an approach that fosters openness, joint prioritization of issues and action planning
By Whom?
FAMSA/ChoiceTrust
RMCH Output 3
Weak Accountability
Structures
1) Capacity Building of Clinic Committees
2) Promoting Community engagement
3) Fostering Mutual Accountability and joint ownership
4) Taking issues to action
Teenage Pregnancy 1) Improving communication along the CoC
2) Improving AYFS
3) Addressing attitudes of HCWs
4) Gathering an improved understanding
5) Promoting the use of peer educators
Weak Health Communications 1) Gathering information on preferred forms of communication
2) Testing innovative approaches
Understanding and strengthening the key role played by CHWs
1) Testing CHW training
2) Developing and delivering complementary training
1) Black Sash & FAMSA
2) Soul City
3) Black Sash, Mindset &
FAMSA/ChoiceTrust
4) Mindset, Black Sash &
FAMSA/ChoiceTrust
1) CMT, Mindset, JHHESA
2) THCA
3) Mindset, THCA, SARC
4) SARC, CMT, Mindset
5) SARC
1) CMT, Mindset, JHHESA
1) FAMSA/ChoiceTrust
2) CMT W2

Finding
Inefficiencies in the health system e.g. long queues
Response
1) Testing the integrated model
2) Gather information on patient behaviour
By Whom?
1) CRH
2) SARC, CRH,
FAMSA/ChoiceTrust
Transport as a key barrier to demand
1) Testing, gathering evidence and documenting an innovative approach to transport
1) SARC
Need for a balanced focus between rights and responsibilities
1) Raising awareness about rights and responsibilities
2) Training on rights and responsibilities
3) Giving space to HCWs and patients to recognize their rights and responsibilities
Addressing attitudes of HCWs 1) Providing psycho-social support
2) Training of HCWs
3) Gathering an understanding of the causes
Need to link supply and demand
1I Training and awareness raising of the supply side
2) Consultations that incorporate demand & supply
3) Addressing issues from supply & demand perspective
1) Black Sash, Mindset, SCI
2) Black Sash, Mindset
3) Black Sash, Mindset
1) ChoiceTrust
2) Mindset, SARC, CMT
3) THCA/CMT, Mindset, SARC
1) Output 3 DCST training
2) FAMSA/ChoiceTrust, Black
Sash, Mindeset
3) SARC, FAMSA/ChoiceTrust

Grantee Deliverables/Products
Soul City A model of community-based monitoring of
MCH services
South Africa Red Cross Society-KZN
Centre for Rural Health-UKZN
Documentation of models and tools for peer education and CCG volunteers to prevent teenage pregnancy; case study and policy brief of transport fund’s impact and sustainability
A good practice case study on integration of
MCH services
Community Media Trust
FAMSA
A model on master training for
CHWs/lessons learned for CHWs/Tools and modules on MCH for CHWs
Policy brief on improving DOH training for
CHWs; a model of psycho-social support for
CHWs and health professionals; tools for district clinic committees

Grantee
Community Media Trust/THCA
Mindset Network & Population Council
Black Sash Trust
JHHESA
Deliverables/Products
District-based communications strategy on teenage pregnancyy; family planning and early antenatal booking brochures ; recommended interventions to improve the delivery of youthfriendly services
District-based communications strategy on teenage pregnancy; family planning and EANC; district based tools and policy briefs to facilitate multi-stakeholder forums to improve accountability in the health sector
Case study, model and polcy brief on good practices of public and alternative accountability in the district health system. Training manual for clinic committees
Tools, models and policy briefs on health communications for districts; district-based MCH communications strategies in 3 districts (Central
Karoo, Waterberg & Ekurhuleni)

• Training manual to address attitudes of Health Workers towards teen clients as well as for teens to reflect on their own roles and responsibilities: pilot tested in 6 districts
• Consultation guides on culture and malnutrition and analysis of findings: pilot tested in 2 districts
• Fact sheets and knowledge sharing re: NGOs working on teen pregnancy
• Training of DCSTs in 8 provinces on demand & accountability and community mobilization

• Web site: D & A documents uploaded; listserv
• Research & analysis & documentation of D & A issues to complement grant work e.g. teenage pregnancy; malnutrition; drivers of child mortality
• Pattern Analysis: Gathering information and analyzing trends of key D & A issues for evidence & guidance for follow-up
• Input into NDOH MCH initiatives e.g. AYFS policy

a. GRANTS PROGRAMME: D & A initiatives in 17 districts b. NETWORKS of LEARNING:
1.
Teenage pregnancy : Ugu, uMgungundlovu, Gert Sibande
2.
EANC/PNC/Action Plan : Capricorn & Mafikeng;
3.
Drivers of Child Mortality/Action Plan : Uthungulu; Ugu
4.
Peer Education : Ethekwini (included Ugu, uMgungundlovu and Uthungulu) c. DCST TRAINING: on community mobilization in Limpopo

1.
DCST have greater awareness of D & A and how to integrate into supply-side work
2.
Findings on Patient and Teen Behavior have been shared e.g. presentation of findings to universities
3.
Input into NDOH initiatives e.g. AYFS Policy & Strategy, work on clinic committees, health communications
4.
More detailed and robust understanding of demand barriers: teen pregnancy, EANC/PNC, cultural practices and Drivers of Child Mortality

1.
28 mixed method tools from grantees on D & A
2.
Training Manual to address attitudes of health workers towards teens: pilot tested in 5 districts and delivery of
Training of Trainers program
3.
Consultation guides on culture & malnutrition
4.
Pattern Analysis on: 1) culture; 2) malnutrition; 3) teen pregnancy to provide evidence on demand barriers
5.
Fact Sheets/Info on teen pregnancy

• “Just because you fix it, patients may still not come”
• Constant reality checks grounded in patient and community perspectives are needed
• Information provision is not behaviour change
• Issues such as teenage pregnancy are not just a medical/ health issue but social and economic
• Demand-side evidence is not only qualitative

• More flexibility should be built into such projects from the inception stage to accommodate and adjust for the right mix of skills within consultant team.
• RMCH’s strategic investments in LOE and TA support to partners demonstrate that sufficient LOE is required to develop tailored capacity building programs and provide on-going TA and mentorship
• The placement of TA in the field is needed to integrate D & A into all aspects of MCH services and delivery
• More technical support and capacity building needs to be provided to district personnel on issues of D & A

• Accountability approaches should:
 Be a balanced focus on rights and responsibilities from both the patient and HW perspective to move away from the patients as passive beneficiary and to reduce HW backlash
 Foster mutual dialogue & prioritization to foster collective action
• Clinic committee training should equip stakeholders with a range of practical tools that can be adapted to tackle the reallife issues of communities
• To ensure that community accountability dialogues & collective problem solving are taken to action, follow-up support is required

• Pilot test health communications material and strategies
• Understanding and addressing root causes is a key first step to identify and tackle demand barriers
• Undertaking action research on demand barriers at the community level is key to cross-checking supply actions
• Allocate more resources to understanding and addressing demand-side barriers – this will often contribute to some of the most cost-effective solutions and interventions

• Lessons and best practices should be shared across borders with other Southern Africa countries that share similar MCH challenges – learn from the innovations of others!
• Innovation requires an openness to learning from failure
• Innovation is as much about doing things differently as it is about doing something new
• The baseline process should gather more disaggregated data
(on vulnerable groups, violence against women and girls, social determinants of health, etc.) to produce targeted interventions that address the needs of the most marginalized people.

• There is much to be learned from the successes of better-performing districts - interventions should not just target the weakest districts
• For a learning grant to produce richer, more compelling evidence, a focus on fewer innovation districts makes sense (to be able to go more deeply into a targeted range of priority issues)

• Further capacity-building around integration of D & A at district and national level
• Follow-up with grantees to gather lessons learned and best practices and secure additional funding to enable them to continue work on MCH activities on D & A
• Review and disseminate grantee products as well as additional tools developed on D & A
• Build on the work done on teenage pregnancy as a critical
MCH issue for all districts e.g. roll-out of HCW for Teens

• Networks of Learning follow-up: taking action plans to action
• Continued support to DOH & districts
• Strengthen and promote partnerships & networks e.g. on teen pregnancy
• Undertake follow-up research on key demand issues e.g. cultural practices, malnutrition
• Explore ways to integrate traditional and allopathic health systems