LESSONS LEARNT:
Lessons learnt from applying the PDQ model in Capricorn and Waterberg
Districts, Limpopo: Consultations on Nutrition, Culture and Maternal and Child
Health
Developed By1
Intended Audience
Development Date
FAMSA, Limpopo and CHoiCe Trust
Department of Health Programme Managers, NGOs, Development
Agencies
December, 2014
1. Introduction
In order to interrogate and unpack the role of nutrition and infant feeding practices, as well as culture
and traditional practices in the demand for and uptake of mother and child services, RMCH supported
FAMSA and CHoiCe Trust in the facilitation of community consultations with relevant stakeholders
from July to November 2014. Eight consultations took place in each of Waterberg and Capricorn
Districts in Limpopo Province, engaging groups of (i) men; (ii) women; (iii) health practitioners from
public health; (iv) traditional health practitioners (THP); and (v) Drop-in-Centre (DIC) personnel. Ten
stakeholders from within each group came together for multi-stakeholder consultations on malnutrition
and culture and maternal and child health respectively in both Waterberg and Capricorn, and one
multi-stakeholder consultation on malnutrition in Waterberg to further interrogate the findings of the
individual consultations and identify Action Plans and way forward.
The consultations adopted a dialogue methodology based on the Partnership Defined Quality (PDQ)2
model to explore different perspectives on potentially harmful infant feeding and cultural practices with
regard to maternal and child health. Lessons were learnt throughout the implementation of the project,
particularly through the implementation of the consultations. Key lessons have been extrapolated from
the project to inform future programming aimed at narrowing the gap between demand and supply in
health care provisioning.
2. Approach to the implementation of the model
FAMSA and ChoiCe Trust mobilised participants to attend the consultations. Each consultation was
facilitated by two facilitators (one lead and one co-facilitator) supported by two scribes. The
consultations adopted a dialogue methodology based on the Partnership Defined Quality (PDQ)
model to explore different perspectives on both harmful infant feeding practices as well as potentially
harmful cultural practices with regard to maternal and child health. The duration of each consultation
was an average of 6 hours. The individual consultations intended to provide a safe space for different
groups of people to formulate and express their views on the topics of infant feeding, culture and
maternal and child health. By asking a series of open ended questions and having people work in
small groups to discuss, write up on cards and flipcharts their views and ideas before sharing with
others, groups were able to express and capture what they do, experience and observe in respect to
1
This document was developed with the support of the Department of Health, Limpopo Province and the
stakeholders who shared their time and experiences during the consultations. The Okuhlekodwa Research and
Development Consultants was used to serve as a learning officer and document the process and tools.
2
This model was developed by Save the Children (Lovich, R., Rubardt, M., and Powers, M.B., 2005). The
methodology seeks to engage and link the supply side with the demand side through individual and multistakeholder consultations
[1]
infant feeding and cultural practices in relation to maternal and child health, and reflect on the ways in
which this is positive or harmful from a health point of view.
Once the individual consultations were completed, two multi-stakeholder consultations were
conducted in each district, whereby 10 representatives from each of the individual consultations were
selected to participate. The multi-stakeholder consultation on culture for Capricorn did not take place
due to time constraints. The multi-stakeholder dialogue session used as its starting point what the
individual groups had said were potentially harmful infant feeding and cultural practices and built on
this by agreeing on what the priority problems were; what the root causes of these problems are; and
what solutions participants would commit to, to address these challenges.
To do this, the multi-stakeholder dialogue session was built around three key exercises: the
prioritisation of challenges that everyone agreed needed to be tackled; root cause analysis of these
problems to unpack “why” behaviour and practices are this way; and development of an action plan
specifying what will be done, by whom and by when. In total 3 action plans were developed – 2 for
Waterberg and 1 for Capricorn.
Table 1: Profile of participants
Individual
groups
Men
Women
Health
Professionals
THPs
JOINT
CULTURE
CAPRICORN
22
42
22
WATERBERG
20
19
28
31
-
22
20
[2]
Individual
Groups
Men
Women
Health
Professionals
DICs
JOINT
MALNUTRITION
CAPRICORN
WATERBERG
22
56
37
48
23
23
38
38
39
21
3. Lessons learnt
3.1 Conceptualisation and design

Implementers and stakeholders of a project should be involved from the conceptualisation
and design phase of a project. This will firstly ensure that all the key stakeholders have a
common understanding about the rationale, purpose and expected outcomes of the project.
Second, it will ensure that the project is aligned to existing plans and interventions, and
avoid the project being viewed as a parallel initiative imposed on implementers and
stakeholders. For example, the districts had a list of priorities for addressing nutrition and
maternal and child health challenges which they felt superseded the project.

Of critical importance in the design and conceptualisation of a project is undertaking a skills
audit of the skills required to undertake the project viz viz the available skills. Executive
decisions should be taken as to whether existing staff in the implementing organisations
have the necessary skills to collectively undertake all the required activities related to the
project, and if not, whether there is scope and a budget to source the necessary skills. If
not, the project design should be reviewed and adapted to match available human resource
skills sets before it is finalised. This will avoid unrealistic expectations from project staff.

The timeframe for the project (4 months) as a whole was inadequate to impart knowledge.
One day for a multi-stakeholder consultation is only sufficient to introduce important
concepts such as nutrition, malnutrition, exclusive breastfeeding, mixed feeding,
complementary feeding, etc. to participants with low literacy levels or who are not subject
experts. Thus, no time was allocated for explaining the logic and reasoning behind the
concepts and practices to allow an in-depth understanding.
3.2 Planning

It is critical that a project is planned as a collective with funders, implementers and key
stakeholders such as government. This will ensure buy-in and ownership of the project by
all concerned. One critical aspect of planning is allocation of roles and responsibilities to
project staff. The RMCH project had a short time-frame of 4 months, which necessitated
that project staff be dedicated to the project on a full-time basis for the duration of the 4
months in order to successfully complete the project. This was agreed to in principle but the
necessary adjustments were not affected. One option was for project staff to be released of
all other responsibilities to allow them to execute their roles and responsibilities optimally in
[3]
the RMCH project, and for existing or temporary staff to take on the responsibilities they
were release from. Another option would have been to recruit temporary staff to support the
implementation of the RMCH project and thus sharing the workload equitably so that
existing staff could still fulfil their responsibilities to existing projects. This required a process
of meticulous and detailed planning and weighing of advantages and disadvantages of the
various options to decide on the most cost-effective and efficient option that would yield the
best results for the project without compromising the quality of other projects.

A key part of planning is collectively agreeing on deliverables and attaching responsibility for
deliverables, including ensuring that such are clearly stipulated in the MOA. Funders,
implementers and stakeholders should hold each other accountable for deliverables. In the
event that deliverables need to be changed, omitted or added, it should be done in
consultation with all of the above entities and agreed upon before being included in the
MOA, including responsibility for such deliverables.

FAMSA budgeted for action meetings as a sustainability strategy. However, the amount
does not come close to being adequate to support activities in the joint action plans
developed by participants. The expectation is that the initiates of the action plans, namely
FAMSA and ChoiCe, should provide financial and human resources to support the action
plans. Support required from FAMSA and ChoiCe includes finalising the action plans;
convening progress meetings; documenting progress and challenges; report writing, etc.
This support is particularly important considering the concerns raised by the districts that the
project has done well to open a dialogue but not much is being done to address the
challenges identified through the dialogues e.g. misperceptions, and misconceptions
regarding infant feeding practices.
3.3 Implementation

Building rapport and trust amongst participants that do not know each other and come from
different schools of thought takes time. Participants in the joint consultations only started
opening up after lunch which left very little time for substantial progress to be made. It is
important to allow adequate time for the process of building rapport and trust to unfold and for
participants to reach a point of mutual trust, respect and open, honest and genuine
deliberation about sensitive and contentious issues such as cultural practices, in order for
collective problem solving to take place naturally. One day is unrealistic for achieving this
outcome.

Capturing all the information from a consultation verbatim, especially when there are robust
discussions, is unfeasible and unrealistic on the best of days. It requires a combination of skill
and tools to decipher relevant information and to document it in a way that can be used to
enhance insights, increase knowledge and influence policy, programmes and interventions.
The scribes did not have specific guidelines and tools to standardise capturing and
documenting of information from the consultations. A vast amount of rich information was
shared by participants but not captured by co-facilitators during the process of facilitation.
This information should have been captured by the scribes. It is thus important for scribes to
be well versed with the subject matter (nutrition and maternal and child health), have skills in
documenting group consultations, and have time to review and edit the notes immediately
after each consultation to ensure that all the necessary information is captured accurately.

The timeframe of the project should have allocated sufficient time to identify and address risks
(risk management). For example, availability of government participants was dependent on
the day of the week. This was only observed halfway through the 4 month project period,
which left very little time to develop and apply a contingency plan to ensure that consultations
[4]
with government officials are synchronised with the days of the week that they are most likely
to be available.

Action plans should be initiated and led by stakeholders to ensure buy-in and ownership
thereof. Initiators of action plans are usually perceived as responsible for providing resources
to actualise them. In the absence of resources (human and physical), action plans remain on
paper, unimplemented.

It is important to create space for service providers to discuss challenges related to patient
behaviour, and the PDQ model had success in doing so through the consultations. Service
providers can only improve their services with the full understanding and appreciation for the
reasons which prevent clients from utilising their services or non-adherence to prescribed
practices.
3.4 Close-out

It is of pivotal importance to have a sustainability plan built into the project design. The
sustainability plan should include buy-in and ownership of the project by key stakeholders
such as government (districts and provincial). This process should commence during the
project conceptualisation and planning phase to ensure a smooth transition during the closeout phase and continuity.
4. Recommendations
FAMSA and ChoiCe have successfully built relationships with the district and provincial Department of
Health. A dialogue has been evoked through the consultations and pertinent issues have been
identified that have a direct bearing on infant feeding practices and the health of mothers and children
less than five years. The partnership between the two implementing organisations has also been
strengthened, providing a unique and complementary basket of services to address MCH issues at a
community level. The partnership needs to leverage the gains made through the RMCH project,
including its existing relationship with community organisations, to take the process that has been
initiated forward.
The District Clinical Specialist Teams (DCST) are an entry point to actualising the joint action plans
that were initiated during the multi-stakeholder consultations. FAMSA and ChoiCe need to develop an
intervention in collaboration with the two districts and provincial department to address all of the
issues that were identified in the consultations. Nutrition is an integral part of the Department of Social
Development’s services. Thus they should also form part of the partnership. The basis for the
proposed intervention should be to sustain the gains of the RMCH project. Remaining funds from the
RMCH project should be earmarked for solidifying the partnership between FAMSA/ChoiCe and the
Department of Health, especially the districts. For example, Capricorn District identified increasing
knowledge of communities on nutrition through the radio as a key priority to improving child health.
Support could be provided to use community radio as a medium to impart knowledge on nutrition and
MCH.
It is important that FAMSA and ChoiCe maintain the relationships forged with district and provincial
government and share deliverables of the project to inform government policies, strategies,
programmes and interventions. This is one important form of giving back to the districts and
communities for the time and effort they invested in the project.
[5]
District and provincial specific
It is important to actualise the action plans that were developed in the 3 multi-stakeholder
consultations. However, a prerequisite is for all stakeholders to have a common understanding of key
concepts. The districts need to take a step back from the action plans and implement a staged
approach which should essentially begin with explaining and interrogating key terms such as
exclusive breastfeeding, mixed feeding, signs and symptoms of malnutrition and more importantly
why certain practices are perceived potentially harmful to mothers and children. The consultations
identified potentially harmful practices without fully explaining and interrogating the reasons why they
are harmful in a simple and easy manner to understand. It was assumed that identifying practices as
harmful would suffice.
District-specific reference groups that are representative of the key stakeholders that participated in
the consultations should be established, to unpack and refine the action plans that were developed.
This process should be informed by available resources to ensure that the action plans are feasible
and translated into action. Resources should encompass both human and physical. It is critical that
decision-makers from the various groups of stakeholders constitute the reference groups. The
reference group should play a coordinating and oversight role in the implementation of the action
plans, in addition to providing both strategic and operational input to provincial management on
improving maternal and child health services in the Province.
This “sustainability” phase of the project should be institutionalised by being included in the business
plans and budgets of the MCWH&N programme so that it is not implemented as a parallel process.
[6]