Organisation mondiale de la santé (OMS) · Publications

Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation

7 avril 2017 Organisation mondiale de la santé

Le texte intégral est hébergé par l’organisation qui le publie. lawenc.com indexe les métadonnées et renvoie vers la source officielle.

Texte intégral

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health

A Toolkit for Implementation Module 2: Facilitator’s Guide to the Orientation Workshop on the IFC Framework

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health:

A Toolkit for Implementation

Module 2: Facilitator’s Guide to the Orientation Workshop on the IFC Framework

Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation Contents: Module 1: An overview of implementation at national, province and district levels; Module 2: Facilitator’s guide to the orientation workshop on the IFC framework; Module 3: Participatory community assessment in maternal and newborn health; Module 4: Training guide for facilitators of the participatory community assessment in maternal and newborn health; Module 5: Finalizing, monitoring and evaluating the IFC action plan. ISBN 978-92-4-150852-0 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-partyowned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Graphic design and Print: Imprimerie Villière - 74160 Beaumont - France Cover photo credits: Enfants du Monde.

Module 2

ACRONYMS IFC MoH MNH NGO PCA UN UNICEF WHO Individuals, Families and Communities (In reference to the World Health Organization’s framework for Working with Individuals, Families and Communities to Improve Maternal and Newborn Health) Ministry of Health Maternal and newborn health Non-governmental organization Participatory community assessment United Nations United Nations Children’s Fund World Health Organization

Tell us what you think! All comments on this document are welcome. Please let us know if you find the content useful, your experience in using this guide, if there is any information missing, or if there is anything else you would add to this guide. Please send all comments to the Department of Maternal, Newborn, Child and Adolescent Health (MCA), World Health Organization (WHO), Geneva, to mncah@who.int.

Module 2

THE STORY OF THE TOOLKIT In 2003, The World Health Organization (WHO) published a concept and strategy paper entitled Working with individuals, families and communities to improve maternal and newborn health,1 herein referred to as the “IFC framework”. The IFC framework was developed in response to the observation that a robust and systematic health promotion component was largely absent from most maternal and newborn health (MNH) strategies in countries. Soon after its publication, countries began to ask how to implement the Framework and how to operationalize the key themes of empowerment and community participation. This is where the story of the five modules included in this document, Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation, begins. The work of all five modules was done under the technical supervision of Anayda Portela, WHO/ Department of Maternal, Newborn, Child and Adolescent Health (WHO/MCA) in Geneva. The modules related to the participatory community assessment (PCA) were developed under the guidance of Anayda Portela, Carlo Santarelli of Enfants du Monde and Vicky Camacho, then the Regional Advisor on Maternal Health to the Pan American Health Organization (PAHO). Each module has a series of authors, reviewers and country experiences. We have attempted to mention all the teams and moments involved below. Some individual names may not be cited, however we wish to convey our gratitude to every person and country team who has contributed, and regret any contributions which may have been overlooked or not specifically mentioned. The first work on the PCA and the corresponding Guide to train facilitators began in 2005. In response to country requests in Latin America, Vicky Camacho proposed an adaptation of earlier MotherCare work and of the Strategic Approach developed by WHO/Department of Reproductive Health and Research. Veronica Kaune, a consultant from Bolivia, developed the first guide for PCA, which was reviewed by an expert group including Fernando Amado, Angela Bayer, Lola Castro, Colleen B. Conroy, Julio Córdova, Luís Gutiérrez, Martha Mejía, Rafael Obregón, and Marcos Paz. A meeting was held in El Salvador in September 2005 to review the PCA with representatives from Bolivia, El Salvador, Honduras, and Paraguay. After the first pilot experiences in El Salvador and Paraguay, the PCA was modified to simplify the process and reporting to ensure that a country could integrate it into its ongoing planning processes. Kathryn Church, a consultant supported by funding from Enfants du Monde and PAHO, then went to El Salvador to support the national IFC committee in a next country experience. The MIFC committee included representatives of the Ministerio de Salud Pública y Asistencia Social (MSPAS), Concertación Educativa de El Salvador (CEES), Fundación Maquilishuat (FUMA), CREDHO, and PAHO EL Salvador. The PCA was conducted in Izalco and Nahuizalco with support from local facilitators, the health units and the SIBASI of Sonsonate.

Please see http://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/

VII

vii

The Story of the Toolkit

Special mention is made of the work in El Salvador who was a pioneer in leading the IFC implementation in the Americas Region, and the PCA was subsequently reformulated on the basis of these experiences. The El Salvador team included: Jeannette Alvarado, Tatiana Arqueros de Chávez, Carlos Enríquez Canizalez, Luís Manuel Cardoza, Virgilio de Jesús Chile Pinto, Hilda Cisneros, Morena Contreras, Jorge Cruz González, William Escamilla, Jessica Escobar, Elsa Marina Gavarrete, Melgan González de Díaz, Edgar Hernández, María Celia Hernández, Pedro Gonzalo Hernández, José David López, José Eduardo Josa, Carmen Medina, Emma Lilian Membreño de Cruz, Ana Dinora Mena Castro, Ana Ligia Molina, Sonia Nolasco, Xiomara Margarita de Orellana, Ever Fabricio Recinos, Guillermo Sánchez Flores, Lluni Santos de Aguilar, Luís and Valencia. Maritza Romero of PAHO was instrumental in supporting the process. Kathryn Church was subsequently hired by WHO Geneva to work with Anayda Portela to simplify the PCA based on the El Salvador experience; thereafter what are now Modules 1, 3 and 4 were produced. Carlo Santarelli of Enfants du Monde also provided important input into this work. Subsequent experiences led to further refinement of these Modules: 1) in Moldova and Albania with the support of WHO Europe and Isabelle Cazottes as a consultant, and 2) in Burkina Faso with the support of the Ministry of Health (Minstère de la Santé), Enfants du Monde and UNFPA. Isabelle Cazottes was then hired by WHO Europe to work with WHO Geneva (Anayda Portela and Cathy Wolfheim) to develop an Orientation Workshop for the IFC framework and implementation, which served as the basis for what is now Module 2.

The workshop was based on training guides developed for the introduction of the IFC framework and implementation process used in regional workshops in Africa, Europe, Eastern Mediterranean, the Americas and Southeast Asia (workshops organized by the WHO Regional Offices of Africa, America, Europe, Eastern Mediterranean, South East Asia and Western Pacific). Module 2 was subsequently finalized by Janet Perkins, consultant to WHO, Anayda Portela, and Ramin Kaweh. A version was tested by the Enfants du Monde team with the local IFC committee in Petit-Goâve, Haiti. Module 5 was begun by the health team at Enfants du Monde including Cecilia Capello, Janet Perkins and Charlotte Fyon, working with Anayda Portela of WHO. Carlo Santarelli and Alfredo Fort, Area Manager for the Americas Region, WHO Department of Reproductive Health and Research at the time, provided inputs. Different sections of the module were subsequently reviewed by the regional coordinators of Enfants du Monde, the national MIFC committee in El Salvador, Ruben Grajeda of PAHO, Aigul Kuttumuratova of WHO/EURO, Raúl Mercer and Isabelle Cazottes. The module was finalized by Janet Perkins as a consultant to WHO Geneva. Janet Perkins, as a consultant to WHO Geneva, did a final technical review and edit to harmonize all five modules. Jura Editorial copyedited Modules 1, 3 and 5. Yeon Woo Lee, an intern with WHO/MCA, updated the references to ensure compliance with the WHO style guide. Pooja Pradeep, an intern with WHO/MCA, reviewed all the modules after the editor changes were incorporated. Amélie Eggertswyler, intern with Enfants du Monde, and Hanna Bontogon, intern with WHO/MCA, reviewed the layout of Module 1. Francesca Cereghetti, also intern with Enfants du Monde, reviewed the layout of Modules 1 and 5, and Saskia van Barthold, intern with Enfants du Monde, reviewed the layout of Modules 2, 3 and 4.

viii

Module 2

The toolkit, in different stages of development and in various degrees, has been used in the following countries: Albania, Bangladesh, Burkina Faso, Colombia, El Salvador, Guatemala, Haiti, Kazakhstan, Lao People’s Democratic Republic, Paraguay and the Republic of Moldova. We have learned from each of these experiences and have tried to incorporate the learning throughout the toolkit’s development. Such a document can only be useful if it is adapted to each context, and we have intended for it to be a living document – that improves with each use and each reflection. Thus this story will continue.

Financial support for the development of the modules over the years has been received from Enfants du Monde, WHO, PAHO, WHO/EURO, the EC/ACP/WHO Partnership and the Norwegian Agency for Development Cooperation.

IX ix

Module 2

INTRODUCTION TO MODULE 2 This document is the second module of a series entitled Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation, designed to support the implementation of the World Health Organization (WHO) framework “Working with individuals, families and communities (IFC) to improve maternal and newborn health”,2 herein referred to as the “IFC framework.” The IFC framework, originally elaborated in 2003, was developed in response to the observation that a robust and systematic health promotion component was largely absent from most maternal and newborn health (MNH) strategies in countries. Grounded on the foundational principles of health promotion as outlined in the Ottawa Charter,3 the framework and the interventions it proposes were formulated based on an examination of evidence and successful experiences in working with individuals, families and communities to improve MNH. This evidence was updated in 2015 and we refer the reader to the publication WHO recommendations on health promotion interventions for maternal and newborn health, available at http://who. int/maternal_child_adolescent/documents/ health-promotion-interventions/en/. To date, the IFC framework has been implemented in a number of countries spanning the six world WHO regions, including: Bangladesh, Burkina Faso, Colombia, El Salvador, Guatemala, Haiti, Kazakhstan, Lao People’s Democratic Republic and the Republic of Moldova. The aim of the toolkit is to support public health programmes in launching a process to work with and empower individuals, families and communities to improve MNH.

See the following strategic document: Working with individuals, families and communities to improve maternal and newborn health, WHO, 2010. 3 See WHO, 1986. 2

Introduction

Module 3: Participatory Community Assessment in Maternal and Newborn Health (PCA)

Module 4: Training Guide for Facilitators of the Participatory Community Assessment (PCA) in Maternal and Newborn Health Module 5: Finalizing, Monitoring and Evaluating the IFC Action Plan

As outlined in the above table, this module contains a guide for conducting a workshop to orient actors to the key concepts, principles and interventions of the IFC framework. This is a critical step in IFC implementation as

it contributes to gaining the support of key actors, institutionalization of the Framework and building in-country capacity to manage implementation processes.

Module 2

Participants This workshop is designed for MNH programme managers and actors who may be involved in implementation of the IFC component of the MNH strategy at the national and province level and by district actors whose district(s) have been selected for initial implementation of the component. These actors may be from Ministry of Health (MoH), Ministry of Education, representatives from international organizations (WHO, UNFPA, UNICEF, etc.) representatives from non-governmental organizations (NGOs) and others working in MNH. Ideally it will include decision makers to assure that the plans developed during the workshop can move forward. When to hold the workshop? This workshop is designed to be held as one of the first steps of IFC implementation when the Framework is first introduced in a country or province. During the workshop the participants will make preparations for the PCA and for coordination and moving the IFC component forward in the country. As such, it is ideally conducted early on in the process so as to facilitate implementation. Facilitators An expert facilitator will be responsible for conducting the workshop. The expert facilitator should be very familiar with the IFC framework and will ideally have experience in its implementation in different countries. The expert facilitator may be supported by international experts. In addition, there will ideally be 2-3 other facilitators working under the direction of the expert facilitator. These facilitators will assist in organizing the workshop, present sessions and support groups during the group work.

Tips for facilitators It is important to encourage all participants to actively participate in the workshop, in particular members attending from the district who may feel less comfortable in this environment. Try to remain within the agenda timing and be sure to prioritize health and lunch breaks and ending on time. As the facilitator it is important to pay attention to the energy level of the group. We suggest that you conduct energizers throughout the workshop to keep the group motivated and build relationships between participants. A couple of ideas for energizers can be found in Annex 1 and 2. Adapting the workshop Prior to conducting the workshop, carefully review the contents of this resource manual and tailor it to the country context and needs. For example, review the Power Walk and try to use characters and statements to reflect local realities. Also particularly for Day 2, for the morning sessions “IFC framework: Key concepts, strategies and interventions” or “Community and intersectoral participation in maternal and newborn health programmes”, you may have relevant interventions or programmes being implemented in the country which you would like to share with the participants. You should do so, but will need to remove or adjust other content according to the allotted time.

Introduction

Navigation Meeting Participation is an important focus of the IFC framework and, as such, it is important to maintain principles of participation and allow participants to have a voice in the workshop. To ensure that there are mechanisms for participants’ feedback and shared decisionmaking, we suggest organizing “Navigation Groups”. At the end of each day, divide the plenary into 4-5 groups. Ask them to discuss the following questions: 1. What went well today during the workshop? 2. What could be improved? 3. Do you have suggestions for other issues (e.g., logistics, breaks, etc.)? Each Navigation Group selects one Navigator to represent them during a Navigation Meeting. The Navigation Meeting is conducted immediately after the close of the day. The Navigators meet with the facilitators for approximately 30 minutes to provide feedback. This meeting provides workshop facilitators a chance to understand the opinions of participants and respond to their needs in order to improve the workshop. The following morning, the Navigators who attended the Navigation Meeting give a brief summary of the discussion and the changes proposed. Ideally, Navigators should change on a daily basis, i.e., a participant should serve as a Navigator only one time, allowing multiple participants to act as Navigators. This feedback mechanism gives participants a voice by adjusting the workshop programme and ensuring that the participants’ learning needs are met. Personal Diary We suggest providing each participant with a notebook to serve as a personal diary. They can use the diary to take notes during the sessions. In addition, you can leave some time at the end of each day for them to write down their reflections. A special session is reserved for the final day for participants to write down commitments to changes to themselves (their own way of working) and in their workplace (changes they can promote or facilitate within their working environment or within the team with whom they work).

Module 2

WORKSHOP AGENDA DAY 0 Time 15.00-19.00

Activity Arrival of participants • Welcome • Registration • Distribution of materials Facilitators’ meeting • Final review of the agenda (order, material, logistics, flow, introduction, etc.) • Prepare room

Materials

19.00-20.00

• Table/chairs • Material on table • Beamer/projector, computer, laser pointer • Flipchart/markers • Other props

DAY 1 Time 8.00-8.30 8.30-9.30

Sessions Welcome Tea & Coffee Workshop opening • Opening ceremony • Opening speeches • Workshop welcome

Materials Tea and coffee

Presenter

Chairperson Ministry of Health WHO representative Representatives from other partner organizations Facilitator Beamer/projector PowerPoint 1: The national and district maternal and newborn health strategies PowerPoint 2: Maternal and newborn health data and key indicators at national and district level National and district MNH strategy documents Tea and coffee Facilitator Beamer/projector Flipchart/markers “Why did Mrs X die?” video or story translated in local language with illustrations to be projected as overheads Worksheets for group work Facilitator National or district Ministry of Health

9.30-10.30

1. Overview of maternal and newborn health • The national and district maternal and newborn health strategies (25 minutes) • Key indicators and data at the national and district level (20 minutes) • Plenary discussion (15 minutes)

10.30-11.00 11.00-12.30

Health Break 2. Analysis of challenges and solutions for maternal and newborn health • Why did Mrs X die? (30 minutes) • Group Work 1 (60 minutes)

Workshop agenda

DAY 1 Time 12.30-14.00 14.00-14.30

Sessions Lunch 2. Analysis of challenges and solutions for maternal and newborn health • Presentations in plenary (30 minutes) 3. Power Walk • Power Walk exercise (30 minutes) • Power Walk discussion (30 minutes)

Materials

Presenter

Groups

14.30-15.30

Large space Power Walk roles for participants on cards Flipchart/markers Tea and coffee Personal diaries Sheets of paper on every desk

Facilitator

15.30-16.00 16.00-16.30

Health Break Day 1 Recap and Navigation Meeting • Review of Day 1 • Diary reflections • Group work in Navigation Groups End of Day 1 Navigation meeting • Roundtable discussion among facilitators and Navigators

Facilitator

16.30 16.30-17.00

Facilitator takes notes

Facilitator and 4-5 Navigators

DAY 2 Time 8.00-8.30 8.30-9.00

Sessions Welcome Tea & Coffee Welcome and Day 1 review • Recap of Day 1 • Navigation meeting debrief 4. IFC framework: Key concepts, strategies and interventions • Present PowerPoint 3: IFC framework key concepts and principles (20 minutes) • Plenary exercise: Empowerment case studies (25 minutes) • Present PowerPoint 4: Key interventions of the IFC framework (20 minutes) • Plenary exercise: IFC intervention case studies (25 minutes) Health Break

Materials Tea and Coffee

Presenter

Facilitator Rapporteur

9.00-10.30

PowerPoint 3: Invited specialist IFC framework key concepts and principles PowerPoint 4: Key interventions of the IFC framework Case studies Flipchart/markers

10.30-11.00

Tea and coffee

Module 2

DAY 2 Time 11.00-12.00

Sessions 5. Community and intersectoral participation in maternal and newborn health programmes • Present PowerPoint 5: Community and intersectoral participation (30 minutes) • Group work 2: Review of current and potential community and intersectoral collaboration (15 minutes) • Presentations in plenary (15 minutes) 6. Introduction to the Participatory Community Assessment (PCA) • Present PowerPoint 6: Introduction to the PCA (30 minutes) Lunch Energizer (Optional) 6. Introduction to the Participatory Community Assessment (PCA)(cont.) • Discussion in plenary (30 minutes) • Group work 3: Review of PCA guides (30 minutes) • Presentations in plenary (30 minutes) Health Break 6. Introduction to the Participatory Community Assessment (PCA)(cont.) • Presentations in plenary, cont. (30 minutes) Recap and Navigation Meeting • Brief review of topics from the day • Diary reflections • Group work in Navigation Groups End of Day 2 Navigation Meeting • Roundtable discussion among facilitators and Navigators

Materials Beamer/projector PowerPoint 5: Community and intersectoral participation Flipchart/markers

Presenter Invited specialist

12.00-12.30

PowerPoint 6: Introduction to the PCA

Facilitator

12.30-13.30 13.30-14.00 14.00-15.30

See Annex 1 or 2 Flipchart/markers PCA guides for each participant

Facilitator Facilitator/groups

15.30-16.00 16.00-16.30

Tea and coffee Flipchart/markers Groups

16.30-17.00

Personal diaries Sheets of paper on every desk

Facilitator

17.00 17.00-17.30

Facilitator takes notes

Facilitator and 4-5 Navigators

Workshop agenda

DAY 3 Time 8.00-8.30 8.30-9.00

Sessions Welcome Tea & Coffee Welcome and Day 2 review • Recap of Day 2 • Navigation meeting debrief 7. Monitoring and evaluation: Brief overview • Present PowerPoint 7: Monitoring and Evaluating the IFC component (20 minutes) • Discussion in plenary (10 minutes) 8. Planning for IFC implementation • Presentation of activities before, during and after the PCA (10 minutes) • Group work 4 (50 minutes)

Materials Tea and coffee

Presenter

Facilitator Rapporteur

9.00-9.30

PowerPoint 7: Monitoring and Evaluating the IFC component

Invited specialist

9.30-10.30

Table: “Summary of activities before, during and after the PCA” for each participants Terms of Reference for National IFC Committee Terms of Reference for the District IFC Committee Tea and coffee

10.30-11.00 11.00 -12.30

Health Break

8. Planning for IFC implementation (cont.) Flipchart/markers • Presentations in plenary (60 minutes) • Define the next steps in IFC implementation (30 minutes) Lunch 9. Commitment: Personal Next Steps Closing • Recap of workshop • Evaluation sheets • Final bang • Closing remarks and speeches End of Workshop Facilitators’ meeting/debrief Personal Diaries Evaluation sheets for each participant

12.30-14.00 14.00-14.30 14.30-15.30

15.30 15.30-16.00

Module 2

DAY 1 WORKSHOP OPENING Time: 1 hour Objectives • To welcome participants to the workshop; • To familiarize participants with the objectives of the workshop.

Instructions to facilitator The facilitators will be responsible for organizing the workshop opening according to local norms; however, it will typically include the following: • Opening ceremony (20 minutes) • Opening speeches (20 minutes): These may be delivered by Ministry of Health; a representative of WHO; representatives from other partner organizations; etc. • Workshop welcome (20 minutes): This is delivered by the facilitator. You may want to provide an overview of the content and the purpose of the workshop and briefly go through the agenda. It is important that the participants know what to expect from the workshop. You may also wish to discuss organizational issues.

Day 1

SESSION 1: OVERVIEW OF MATERNAL AND NEWBORN HEALTH (MNH) Time: 1 hour Objectives Participants will: • Become familiar with the national and district MNH strategies; • Understand key indicators and data on MNH at the national and district level.

Instructions to facilitators • Present PowerPoint 1: The national and district MNH strategies (25 minutes). This PowerPoint will need to be prepared ahead of time and will typically include the MNH polic, characteristics of the MNH system, and a summary of key activities underway in the country to address MNH. Ideally it will highlight any community components of the strategy. Provide participants with the related strategic documents if possible. • Present PowerPoint 2: MNH data and key indicators at national and district level (20 minutes). This presentation is to be prepared by the national team and will ideally include the following: An overview of MNH data including morbidity and mortality, causes, data related to use of care (routine and emergency), to care in the household – if there is specific data from the district this should also be presented. • Questions and group discussion (15 minutes): Ask the group whether they have any questions for the presenters or any insights they would like to contribute.

Module 2

SESSION 2: ANALYSIS OF CHALLENGES AND SOLUTIONS FOR MNH Time: 2 hours Objectives Participants will: • Understand the general MNH context; • Understand the factors contributing to poor MNH; • Brainstorm, discuss and identify key MNH challenges and potential solutions; • Produce a table outlining challenges and solutions.

Instructions to facilitators • Briefly introduce the session: Many factors influence health. This is particularly true in MNH. This session will help us to better understand the different factors which influence MNH and to understand why it is important to work with individuals, families and communities to improve MNH. • Tell the story (see Annex 1) or watch the video4 of “Why did Mrs. X die?” (30 minutes): The video is available in English and may be accessible in other languages as well. If the video is not available in the required language, have the story translated prior to the workshop. Project the illustrations as the story is read. • Ask the participants if they have any questions. Explain that you will not go into a plenary discussion on the story, but they will be able to use it as a reference during the upcoming group work. They will be able to discuss the story in greater detail during the Group Work presentations. • Introduce Group Work 1 (60 minutes for group work): Mention that often there are many problems encountered at each of the different moments in Mrs X’s story, and you would like them to discuss in small groups some of the different problems that are faced in assuring the appropriate care at each moment and then discuss some of the solutions. Explain that the participants will be divided into six small discussion groups (“buzz groups”) as follows: 1. Care of the woman in the household 2. Care of the newborn in the household 3. Support in the community for the woman’s health 4. Support in the community for newborn health 5. Care received from the health services for the woman 6. Care received from the health services for the newborn 4

“Why did Mrs. X Die, Retold” video can be accessed at: https://vimeo.com/52622204

Day 1

Each group will fill out the worksheet on the next page in their buzz group. They should consider the data reviewed earlier this morning in their discussions: 1. Ask each group to list two possible reasons for insufficient/inappropriate care or support of the woman and the newborn and the possible reasons for this in their country context. 2. For each reason identified, ask the groups to propose two possible ways to address each reason at the household level, at the community level, at the service level and at the policy level. 3. The buzz groups should now sit together to review the different suggestions and reach consensus on two main reasons and possible actions for each problem, as follows: a. GROUP 1 – Buzz groups 1 and 2 b. GROUP 2 – Buzz groups 3 and 4 c. GROUP 3 – Buzz groups 5 and 6

Module 2

Two main reasons

Possible solutions

At the household level 1. Self-care/ household care of women 1. 2.

At the community level

At the service level

At the policy level

2. Care of the newborn at home

1. 2.

3. Support in the community for the woman

1. 2.

4. Support in the community for the newborn

1. 2.

5. Care received from the health services for the woman

1. 2.

6. Care received from the health services for the newborn

1. 2.

Day 1

• Presentation of Group Work 1 in plenary (30 minutes): Allow each group 10 minutes to present their work. Allow for discussion. Discuss with the participants whether this analysis helped them to realize the importance of working with individuals, families and communities, with other sectors beyond the health sector and think about some other key actors that they need to work with. [Note to facilitators: The analysis should bring out that health strategies need to go beyond just improving services and that health education is important, but limited in addressing the determinants of poor MNH. The strategy should bring together what can be done at the level of policy, health services, and individuals, families and communities and linkages between the different levels.] • Wrap up: Explain that throughout the course of the workshop, you will discuss more about interventions and processes to address the different problems and needs related to MNH and how to work with the different partners in the solutions. A main point throughout will be that women, husbands/fathers, families and communities are key partners, and that it is therefore important to learn how to work with them.

Module 2

SESSION 3: POWER WALK Time: 1 hour Objectives

Participants will: • Identify and understand different roles and power structures within society; • Understand the interactions of gender with other determinants of health; • Identify key health stakeholders and patterns of health inequalities.

Instructions to facilitators • Prior to the Power Walk: Review the list of “characters” and “statements” of the Power Walk and adapt to local contexts and realities to ensure maximum impact for participants. We have included suggestions here which are not to be considered exhaustive. Your goal is to reveal interactions between gender and other determinants of health and highlight local, vulnerable populations. Select the best characters and statements to achieve this. • Introduce the Power Walk (30 minutes for exercise): Ask all participants to stand up and move to a large open area (be sure to arrange a room/garden/terrace beforehand). • Ask for 12 volunteers and randomly give them each a small piece of paper with one character listed, such as those suggested in the following table. Ask them to act as the character they selected. Instruct participants not to divulge their “identity” to others in the group. Doctor in a rural health facility, male, aged 36 Midwife in a rural health facility, aged 28

Nurse working in an urban health facility

Health facility manager, male, in a urban health facility

Pregnant woman, age 22, with secondary education

Mother of five children, age 29, with no secondary education Grandmother taking care of 4 orphans in rural area, no income, no assets Female sex worker aged 19, living in city, no secondary education Country Representative of NGO, Christian female, 42, living in the capital, university-educated Army general, Muslim male, aged 52 Ethnically-discriminated male, aged 40, lost a leg in an ambush, 3 wives, 10 children, no income

Health committee chairman

Primary school teacher, female, aged 45 Young unmarried mother of 2, aged 21, living in the capital Village leader, male aged 39, no secondary education Country representative of NGO, Christian female, 42, living in the capital, university-educated

Adapted from: Gender mainstreaming for health managers: a practical approach. Geneva: World Health Organization; 2011.

Day 1

• Ask all the participants acting in character to stand horizontally behind the line of the ground, as if starting a race. Explain that you will read a number of statements out loud and ask them to do the following based on their character:

“If you think this statement is true for you, take one step forward”. “If you think this statement is not true for you, keep standing where you are.” “If you think that this statement is partially true for you, take a small step forward.” Agree on the size of the step beforehand. • The rest of the group observes and will comment on their reactions following the exercise. • Read the following statements (or others based on the context): 01. I feel comfortable to visit the clinic if I have a problem. 02. I can influence the organization of the clinic so that services for maternal health care and newborn health care are improved. 03. I can influence whether or not a baby is exclusively breastfed up to the age of six months. 4. I feel confident that true dialogue and understanding takes place between the health care providers and myself. 05. I am convinced that if I pay, I will get better service. 06. I have access to family/household resources if I need to pay for health care. 07. I feel that health workers treat me with respect. 08. I know my rights. 09. My opinion is considered important by municipal or district health officials where I live. 10. I have completed secondary school. 11. I am allowed to be treated by a health care provider of the opposite sex. 12. I have a say in health decisions in my community. • After the last statement, ask participants to reveal their identity to the group. Instruct them to stay in formation while you discuss the exercise. • Power Walk discussion in plenary (30 minutes): Select a couple of characters from the front cluster to describe their experience and what it felt like to be in those positions. After the group

Module 2

on the “front cluster” has spoken, tell them that these characters often have the most decision making (and other) power. Note these characters on a flipchart and discuss how women and men are represented in this group. • Follow a similar process of discussion with characters from the middle cluster. Usually these are community organizations and workers (health and otherwise) – sometimes even including nurses and other health professionals. Note these characters on a flipchart and discuss how women and men are represented in this group. • Remind participants that these are also important partners to engage with when we want to reach the people at the back. We also want them to be able to say yes more often to the Power Walk statements. Ask participants what strategies could help to accomplish this. • Use the same process for characters from the back cluster. Note these characters on a flipchart and discuss how women and men are represented in this group. Ask how they felt as they watched others moving forward. If no one else points it out, say that the people at the back are usually those that we are trying to directly benefit with the programmes and policies we develop and usually the most difficult to reach. These are the women and men whose health we are supposed to promote and protect. Why are they at the back? • Ask participants to now look at how women and men are distributed throughout the Power Walk outcome. Are all the women at the back? All the men at the front? What does this mean in terms of gender? After allowing some discussion, point out that the Power Walk confirms that gender norms, roles and relations can affect men and women in different ways. It also shows that gender interacts with other determinants of health. Use examples within the Power Walk to demonstrate how education, profession, income, age, sex and gender can influence the ability of Power Walk characters to move forward or not. • Briefly introduce the concept of empowerment: Ask why some characters at the back may not have been able to take a step forward. Introduce the definition of empowerment: Empowerment is the capacity of individuals or groups to make choices and to transform these choices into desired actions or outcomes. • Emphasize the following: ° The characters in the back cluster often have lower levels of empowerment, which sometimes explains why they have difficulty moving forward. ° Make the links between empowerment, reducing unequal power relations, and addressing gender inequalities. ° Ask participants whether they felt empowerment was an obstacle to moving forward. • Wrap up: Tell participants that you will be discussing empowerment in more depth tomorrow and that you will be asking them to refer back to the Power Walk.

Day 1

DAY 1: RECAP AND NAVIGATION MEETING Time: 30 minutes Briefly review the topics addressed during the day (5 minutes) Diary reflections (10 minutes): Ask participants to take their diaries out. They will have 10 minutes to reflect and record some of their thoughts from Day 1 of the workshop. They may want to write about the most important thing they learnt during the day or how they plan to apply what they have learnt to their work. Navigation Group Work (15 minutes): Ask the plenary to divide into 4-5 “Navigation Groups”. Ask them to discuss the following questions: 1. What went well today during the workshop? 2. What could be improved? 3. Do you have suggestions for other issues (e.g., logistics, breaks, etc.)? Each Navigation Group will need to select one Navigator to represent them during a Navigation Meeting. This meeting will be held immediately after the close of the workshop and will last approximately 30 minutes. The Navigators will then brief the group on the meeting the next morning. Ideally each Navigator will serve no more than one time in order to allow the maximum number of participants to serve in this function.

Module 2

DAY 2 WELCOME AND DAY 1 REVIEW Time: 30 minutes • Recap of Day 1. • Navigation meeting debrief.

SESSION 4: IFC FRAMEWORK KEY CONCEPTS, PRINCIPLES AND INTERVENTIONS Time: 1 hour 30 minutes Objectives Participants will: • Become familiar with health promotion key concepts; • Review empowerment and the importance of empowerment at the individual and community level; • Become familiar with the key concepts, strategies and interventions of the IFC framework.

Instructions to facilitators • Present PowerPoint 3: IFC framework key concepts and principles (20 minutes) • Explain that health promotion and the Ottawa Charter provide the conceptual basis of the IFC framework. Explain that health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. You may want to refer to the story of “Why did Mrs X die?” from the previous day to briefly discuss socioeconomic determinants of health. • Explain that “empowerment” is a key component of health promotion. As they may recall from the Power Walk yesterday, empowerment can be understood as the process of increasing capacity of individuals or groups to make choices and to transform these choices into desired actions or outcomes. Empowerment occurs at two levels which interact: 1. The individual level: this involves increasing personal resources, capacities, knowledge, competencies. 2. The collective level: This involves improving collective actions for access and use of social, economic and political resources.

Day 2

• Discuss powerlessness and power: Refer back to the Power Walk from the previous afternoon. • Highlight that participation is essential to empowerment. Participation is the process whereby community members are involved as partners in assessing needs and problems, selecting priorities, developing strategies, planning, implementing, monitoring and evaluating solutions in close cooperation with the formal health sector and other actors. • Exercise in plenary (25 minutes): Explain to the group that you will now review several case studies in plenary. For each study, you would like the group to answer the following questions: 1. What are the health implications of this situation? 2. Who has the power and who needs to be empowered? 3. What actions or interventions can be undertaken to address individual empowerment? 4. What actions or interventions can be undertaken to address group or community empowerment? 5. What actions or interventions can be undertaken to address any related policy issues? • Present Exercise 1: Power and household decision making (Read Case study of ‘Maria’). Case study of Maria in a small rural community Women do not make decisions in isolation from the context of their lives and this often involves asking or receiving advice from other family members in their household. Maria, a young mother, has been advised by the health provider to exclusively breastfeed her child until six months. The health provider has explained the nutritional and protective benefits of breastfeeding and showed her how to hold the baby, ensure the baby latches onto the nipple correctly, etc. However, Maria’s mother is encouraging her to give the baby honey and telling her that by one month the baby will need to eat a cereal gruel. This is Maria’s first child and she is very anxious about giving her baby the best start in life but feels under considerable family pressure to give the baby the cereal gruel.

Module 2

° In plenary discuss the five questions in relation to this case study. ° You may want to use the following diagram to discuss the different influences on a pregnant woman. Her husband Her sisters Her cousins and other family Her parents

NGOs Her other children The Church and the Priest

Community Health workers Policemen Friends Teachers Nurses Neighbours The mayor

Doctors

• Present Exercise 2: Power and community participation Case study in Country X Small rural traditional communities in the northern part of Country X are very poor and have limited access to sexual and reproductive health services and poor access to clean water. The government recognizes the need to increase use of family planning methods and to increase demand for maternity care services. Educational materials will be printed and health providers will be trained. ° Ask the plenary to answer the five questions in relation to this case study. • Present Exercise 3: Power and quality of care Case study of Pavel in a family health centre Health providers often work in situations with limited resources, including small number of staff, which affects their ability to perform. Pavel is a family health doctor, responsible for the health centre in an urban neighbourhood. His supervisor at the central level just came back from an important meeting and feels there are some things they need to improve and he knows how. A new health education campaign will be launched and Pavel and the midwife are to hold participatory discussions in the community as part of the campaign efforts. Thus they will need to work two additional nights a week. The midwife said that her family would not agree to this. Pavel felt frustrated and raised his voice and told her there was nothing to discuss. ° Ask the plenary group to answer the five questions in relation to this case study.

Day 2

• Present PowerPoint 4: Key interventions of the IFC framework (20 minutes) • Explain that the IFC framework was developed based on a review of experiences in different countries and regions and in consultation with international experts. The framework was designed to complement other efforts in the broader MNH strategy which address the service and policy level. • Present the two primary objectives of the IFC framework: 1. To contribute to the empowerment of women, families and communities to improve MNH; 2. To increase access to and utilization of quality health services. • Introduce the priority areas of intervention: 1. Developing CAPACITIES to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies; 2. Increasing AWARENESS of the rights, needs and potential problems related to maternal and newborn health; 3. Strengthening LINKAGES for social support between women, men, families and communities and with the health care delivery system; 4. Improving QUALITY of care and health services and of their interactions with women, men, families, and communities. Emphasize that ideally interventions from each priority area will be implemented simultaneously in order to achieve maximum benefit. • Introduce the IFC priority areas of health systems strengthening: 1. Contributing to PUBLIC POLICIES favourable to MNH; 2. Contributing to the COORDINATION of actions within the health sector as well as between the health sector and other sectors; 3. Promoting COMMUNITY PARTICIPATION in the management of MNH problems; 4. Contributing to CAPACITY BUILDING of the health workforce in the IFC framework; 5. Implementing an interinstitutional system of MONITORING AND EVALUATION for the IFC component. Explain that experience has shown that strengthening the health system within these areas optimizes implementation of interventions by assuring that a foundation for implementation is in place and also contributes to the primary aims of the IFC framework directly. Moreover, action in these areas serves to reinforce the broader health system, paves the way for scaling-up and

Module 2

fosters sustainability of the IFC framework. Whereas interventions are typically planned for each of the priority areas of intervention, this may not be the case for the areas of health systems strengthening. IFC partners are advised to use the areas for self-assessment on an ongoing basis and plan actions within them when necessary. • Exercise in plenary (25 minutes) (this could also be conducted as group work if time permits): Hand each participant a worksheet with the table below. Explain that you will now use case studies to discuss how the IFC interventions could contribute to improving MNH. Ask the participants to think of one intervention from each of the priority areas of intervention which could contribute to improving MNH as you read each case study and write each intervention under the appropriate area of intervention. Developing CAPACITIES to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies Increasing AWARENESS of the rights, needs and potential problems related to maternal, newborn health Strengthening LINKAGES for social support between women, families and communities, and with the health care delivery system Improving QUALITY of care, health services and interactions with women, families and communities

Priority Area of Intervention

• Read Case Study 1: Eclampsia Case Study 1: Eclampsia During her pregnancy, Sujatmi experienced bad headaches, swelling and blurred vision. Things got worse when she started having seizures, so her mother called a traditional birth attendant (TBA) and a Kyai (Muslim Priest). Evil spirits were blamed for the symptoms, and herbs, water and prayers were prescribed to prevent the early birth of the baby. Only when Sujatmi failed to respond to this treatment, her family decided to take her to a hospital. Her relatives had to borrow a car to take her to the facility located two hours away. Overall it took the family four hours to reach the hospital. Upon arrival, Sujatmi received prompt treatment but the health staff could not prevent the death of her baby inside the womb. Afterwards, Sujatmi started convulsing, her condition worsened and she died on the following day. Medical cause of death: COMPLICATIONS OF ECLAMPSIA (POISONOUS DEATH) Source: A case in East Java adapted from “Riwayat Ibu Meninggal Akibat Kehami-Ian”, Booklet Depkes RI, WHO, 1997.

Day 2

• Explain to the participants that while the medical cause of Sujatmi’s death was eclampsia; there were many factors that contributed to her death. State that interventions in the IFC framework aim to address these underlying causes. • Refer participants to the table with the four priority areas and the interventions. Ask the group to brainstorm interventions from each of the four priority areas which could help women to avoid the fate of Sujatmi. Ask them to also think of any interventions not listed in the framework which are being implemented locally and to note these. List these interventions on a flipchart. • Read Case Study 2: Ignoring danger signs Case Study 2: Ignoring danger signs Kade was 39 years old and pregnant with her third baby. She had primary school education and worked as a farmer. The birth of her first born daughter, now 14, was assisted by a TBA; during the birth of her second born son she was assisted by a midwife and had a prolonged labour of more than two days. Kade received antenatal care on a regular basis and had no problems until her fifth visit when she felt tightening in her belly. She called the midwife and a TBA who told her the waters had broken but the baby’s head was not yet in the right position for birth. The midwife suggested taking Kade to the hospital but the TBA said Kade would give birth the next day, so her husband refused to move her. The TBA felt the progress would be the same as it had been with the birth of Kade’s second baby. Time was passing - by now 16 hours of vital time had gone by. The midwife monitored Kade who was stable. And then suddenly she became very pale and sweaty and started shivering and vomiting. She was started on an intravenous drip of glucose (sugar) but after 30 hours of labour her heart rate and blood pressure weakened and she became unconscious. Sadly she died half an hour later. Medical cause of death: PROLONGED LABOUR

Source: a case study in East Java adapted from “Bunga Rampai Audit Maternal Perinatal di Prop Jawa Timur”. Dinas Kesehatan Daerah Propinsi Jawa Timur, 1999

• Explain to the participants that just as in the case of Sujatmi’s, the causes of Kade’s death go beyond prolonged labour. State that interventions in the IFC framework aim to address these underlying causes. • Refer participants once again to the table with the four priority areas and the interventions. • Ask the group to brainstorm interventions from each of the four priority areas which could help women to avoid the fate of Kade. Ask them to also think of any interventions not listed in the framework which are being implemented locally and to note these. List these interventions on a flip chart.

Module 2

• Read Case Study 3: Programme Summary

Case Study 3: Programme Summary The area of Triángulo Ixil is located in the remote highlands of Guatemala, a zone bound by mountains to the south and the west and from the north surrounded by hills over the tropical forest of Petén. Different barriers were identified that restricted the use of health services, including the women’s and the community’s lack of confidence in the health services, fear and language barriers. Also, the health personnel were not sensitive to the difficulties in transport, to the time families can take in deciding to seek care, and to the important role that the TBAs can play. The baseline study showed that many women did not have good knowledge of danger signs in newborns in the first hours and days of life. Women also did not know when to seek care for their own health, and decisions makers, such as the husbands, often delayed taking action in the case of obstetric emergencies. Coverage of antenatal care with a skilled provider is low; most births are not delivered by a skilled attendant. Also, Mayan women practice a rite at birth during in which the child is bathed on the floor in extremely cold water.

Source: Adapted from Project Maya Salud Neonatal, part of the Saving Newborn Lives Initiative of Save the Children Guatemala. http://www.comminit.com/en/node/42455

• Referring participants to the table with the four priority areas and the interventions, ask the group to brainstorm interventions from each of the four priority areas which could help improve MNH in Triángulo Ixil. Ask them to also think of any interventions not listed in the framework which are being implemented locally and to note these. List these interventions on a flipchart. • Wrap up: Verify that participants are comfortable with the information from this session. Explain that now that they have an understanding of the IFC framework, its aims and the priority areas of intervention you will now be moving into discussion on how to concretely move the IFC framework forward in the country.

Day 2

SESSION 5: COMMUNITY AND INTERSECTORAL PARTICIPATION AND CURRENT PLANNING Time: 30 minutes Objectives Participants will: • Become familiar with community participation; • Understand principles of participation in planning processes; • Discuss current planning processes in the country.

Instructions to facilitators • Present PowerPoint 5: Community and intersectoral participation (30 minutes) • What is community participation for MNH? The process whereby community members are involved in assessing needs and problems, selecting priorities, developing strategies, planning, implementing, monitoring and evaluating programmes in close cooperation with the formal health sector and other concerned sectors and actors. • Degrees of participation: ° Outreach: Some community involvement; communication flows from one to the other, to inform; provides community with information; entities coexist. Outcomes: Optimally, establishes communication channels and channels for outreach. ° Consult: More community involvement; communication flows to the community and then back, answer seeking; gets information or feedback from the community; entities share information. Outcomes: Develops connections. ° Involve: Better community involvement; communication flows both ways, participatory form of communication; involves more participation with community on issues; entities cooperate with each other. Outcomes: Visibility of partnership established with increased cooperation. ° Collaboration: Community involvement; communication flow is bidirectional; forms partnerships with community on each aspect of project from development to solution; entities form bidirectional communication channels. Outcomes: Partnership building, trust building. ° Shared leadership: Strong bidirectional relationship; final decision making is at community level; entities have formed strong partnership structures. Outcomes: Broader health outcomes affecting broader community. Strong bidirectional trust built. Point out that the IFC framework aims for the Involve/Collaborate levels of community participation. Consider the following statement: Community participation in health is a process. It is the process of initiation and sustaining dialogue with various members of a particular community in a structured

Module 2

manner with the view to genuinely consulting them as equals in a programme of activities. The aim is to build a team between programme managers and community members to jointly understand health problems in the community, to find common solutions to such problems and to act together to solve these problems. • How to promote community participation: ° IFC Coordinating Committees; ° Participatory planning processes and involving communities in the whole action planning cycle and in decision making; ° Identify community leaders (political, religious or informal), community groups, community health volunteers, village committees, religious leaders and discuss MNH needs and how they can collaborate; ° Link with other partners who have experience in participatory and interactive processes and in working with the community; ° Develop the capacity of health workers to lead participatory and interactive processes, promote partnership and community involvement; ° Establish mechanisms for ensuring community perceptions of quality of care are gathered and used in quality improvement processes; ° Gain political support within the health sector and the district level. • Not only is it important to collaborate with the community, it is also important to collaborate with different sectors and actors. Go back and look again at the different problems and solutions identified in our analysis on Day 1, when we thought about why MNH required an integrated approach. One of our key reflections in that session and throughout has been that MNH requires the active role of other partners in addition to health services. • Discuss that there are a number of advantages of community and intersectoral participation, including: ° Collective review of existing information, knowledge and experience leading to a deeper understanding of the situation and clear course of action. ° It allows for increased understanding of what different groups can contribute. ° It helps to clarify roles and avoid duplication of efforts. ° It leads to a more effective use of resources. ° People find the most appropriate solutions, make their own decisions and have the ownership of these decisions because they are directly related to their lives.

Day 2

° Participation can develop self-esteem and self-confidence which are prerequisite to decisionmaking and follow-through. ° Sustained changes at community level cannot be achieved without real commitment from and involvement of the community. ° Interactive involvement of many people lead to cumulative learning. ° Collective learning contributes to a normative shift and eventually a change in behaviour that is sustainable because it is socially accepted or endorsed. ° Communities gain awareness through analysing the MNH situation. ° Communities participate in determining their priorities for health and finding solutions. ° Implies partnership between health services and community, and a proactive role of the community. ° Supports social networks and builds a sense of community. • While there are many advantages to participation, it can also be very challenging. It will help them to anticipate challenges that have already been identified in the past. These include the following: ° Collaboration and forming partnerships is a challenge and it takes time to learn to work together. ° Participatory processes require time to implement. Accommodating timing between various organizations working collectively with common objectives while respecting each agency’s independence demands more time than anticipated to achieve project sustainability, establish measurable impact and utilize participatory processes. A short term project time frame is not realistic. ° We discussed earlier the degrees of participation – this highlights not only that the level of participation can change over time but also that the dynamic of the participation will change over time. Initially perhaps the health services will have a major role and impetus for moving forward with the participatory processes. This role may later change to a more facilitative role as the dynamics change, as other groups gain more experience, as partners change, etc. ° Although you have community representatives who participate, this may not mean you are able to hear everyone’s voices. As a programme you have to be aware of marginalized populations, power relations, and those who may be excluded, and think how to make sure their voice and interests are included. ° Communities lose interest if long periods of time pass without follow-up by the health committee, particularly during the initial phases. The programme can risk losing the participation and interest of the leaders and women organized into groups in the process and momentum is lost.

Module 2

• Introduce Group Work 2 (15 minutes for group work): Now you will be asking participants to work together in groups to discuss current and potential community and intersectoral participation in MNH. Divide the plenary into three groups. Ask the groups to discuss the following questions: Group 1: Do current planning processes in MNH allow for the participation of communities? If yes: How so? Does it work? How could their participation be strengthened? If no: How do you envision including community participation in MNH planning? Group 2: Who are some of the key actors and organizations that are currently involved in MNH at the national level? What other actors and organizations should/could be included? Group 3: Consider the importance of intersectoral participation. What are some key institutions that should be involved at the district level and how could they contribute? • Presentations in plenary (15 minutes): Ask each group to present their outcomes to the plenary group (five minutes each). Allow the plenary group to discuss and add other ideas. • Wrap up: Explain that the outcomes of the group work will be useful for the district team to determine how to promote community participation. (Note to facilitators: the same type of analysis can be done specifically in each district when planning the IFC component.)

Day 2

SESSION 6: INTRODUCTION TO THE PARTICIPATORY COMMUNITY ASSESSMENT (PCA) Time: 2 hours 30 minutes Objectives Participants will: • Have an understanding of the planning process at district level; • Understand the purpose and rationale of the PCA; • Become familiar with the process of conducting the PCA; • Conduct an initial adaptation of the PCA tools to the country context.

Instructions to facilitators • Present PowerPoint 6: Overview of the PCA (30 minutes) • The PCA is a tool that the district health services can use to assess the MNH situation and needs in a participatory manner through collaboration within the health sector and with other sectors, such as education and transport, district authorities, NGOs, religious organizations, and other community groups. Using the results of the PCA, partners can then plan actions together to help create an enabling environment for care of the mother and newborn in the home and in the community and to increase access to quality MNH services. PCA process Step 1: Step 2: Step 3: Step 4:

Situation Analysis Fill out 6 forms and prepare a short summary

PCA Training Workshop To train on the facilitation and analysis of the roundtable discussions

5 roundtable discussions: 1. Women of reproductive age (WRA) 2. Mothers, mothers-in-laws and grandmothers of WRA 3. Male partners of WRA 4. Health care providers 5. Community leaders

Institutional roundtable Prioritization workshop involving local authorities, key actors and community roundtable representatives

Final report • Situation analysis • Summary of the roundtable findings • Institutional roundtable recommendations (inputs to develop action plan)

• The PCA helps to initiate a process of empowerment among women, their partners, families and communities as they participate actively in assessing their problems and needs in MNH, as well as in identifying potential actions and district resources that can be leveraged to address these problems and needs. This meaningful participation in developing the interventions designed for their benefit is a right of women, men, families and communities. The PCA can also be instrumental in reorienting health services in their relations and interactions with non-health actors including the community thus contributing to the realization of rights through the institutionalization of participatory processes. The PCA is not intended to be a research tool, but rather a participatory process in which different actors become sensitized to the importance of collaborating with each other, of listening to each other, and of jointly planning interventions and solving problems

Module 2

together. By helping people and groups better understand their situation and participate in finding solutions the PCA becomes an important first step in a health promotion process that empowers them to make choices and transform those choices in to action to improve their health and quality of life. Introduce the figure which lists the steps involved in conducting the PCA. • As can be seen in the image of the PCA process, the final report from the assessment process includes data collected in the situation analysis, the findings from the roundtable discussions, and a draft intervention plan developed during the institutional forum. • The PCA ideally will be integrated into ongoing processes. The health services network, together with the community social network, can conduct regular assessments to provide information and feedback to health programme managers on changing MNH needs, and to conduct informed health planning processes. • The output of the PCA will be a final report (to be completed by the district committee) which will form the principle input into the joint planning process. • Discussion in plenary (30 minutes): in plenary, ask the following questions: ° How applicable is the proposed planning process in the country context? ° How would you modify this process? ° How applicable or feasible is the PCA? If it is not applicable in its entirety, what options could be suggested for the district level in your country? If there is a different planning process, how will you ensure the participation of community members? ° What skills would be needed at district level to involve communities and community groups in planning, and how would you go about identifying these? • Allow participants to discuss for 30 minutes and write down their main points on a flip chart. • Introduce Group Work 3 (30 minutes): Explain that you are now going to take some time to review the question guide for the PCA. You would like the group to read through the questions and consider the following: ° What modifications would you make to the guide to make it more appropriate for the context? ° Are there any questions which should be removed? ° Are there any questions which should be added?

Day 2

• Divide the plenary into three groups. Each group will review one section of the PCA guide as follows: Level of care GROUP 1: Care of the pregnant woman, mother and newborn at home (DEVELOPING CAPACITIES) Questions to guide discussion 1. How does a woman care for herself during her pregnancy? (think about diet/nutrition, alcohol and other drugs, workload/activities, hygiene, going to antenatal care visits, etc.) Are there any special beliefs or traditions in the community about care during pregnancy? How is the newborn cared for in the home? (think about breastfeeding practices, keeping the baby warm, hygiene, etc.) How does a woman look after herself after birth? (think about diet/ nutrition, workload/activities, hygiene family planning and birth spacing, attending postpartum visits for the mother and postnatal visits and vaccinations for the newborn, etc.) What happens when there are complications or problems with the woman or newborn? How is the decision made to seek care? Are there any special beliefs or traditions in the community about care after birth? Are women and their families prepared for birth and/or complications related to pregnancy and birth? (think about saving money for expenses, care of children, identifying a health care facility, identifying transport, a skilled attendant, a companion during birth, having adequate supplies, etc.) Do women and their families know the danger signs during pregnancy, childbirth, after birth, and for the newborn? Which ones? Do women in this community often give birth at home? If so, who is with her and helps her during the birth? (think about who attends her, where she gives birth, etc.)

2. 3. 4.

5. 6. 7.

8. 9.

10. What influences the decision to seek skilled care? (think about costs of services, quality of services, transport availability and cost, cultural factors that affect care-seeking, gender relations between men and women, etc.) 11. Who in the family helps to care for the mother and her newborn? What do they do? 12. Are husbands/male partners supportive in caring for the woman and newborn? Do men and women discuss these types of things? 13. Is violence in the home common during pregnancy?

Module 2

Level of care GROUP 2: Support in the community for the pregnant woman, mother and newborn (INCREASING AWARENESS and STRENGTHENING LINKAGES)

Questions to guide discussion Awareness in the community of MNH rights, needs and problems 1.

Explain that many governments have signed an international agreement on human rights which means that pregnant women, mothers and children have the RIGHT to special care and assistance*: Is anything done here to ensure this right is respected? If yes, what is done to help to fulfil this right? If not, what happens? Are people in the community aware of this right? Do you think men are supportive of this right? Are women in this community free to decide when to marry, to decide when to start a family, or to decide how many children they would like? If not, why do you think these rights are not being respected? Do people think that MNH is a priority? Do people know when and why a mother or baby dies in the community? Are there community meetings about health or MNH specifically?

3. 4. 5.

Links between services and the community: 1. Do women have problems reaching care? What are some of the problems they have? What is done to help resolve these problems? (think about distance to care, transport costs, state of the roads, availability of public transport, ambulances, partner permission to seek care, etc.) 2. Who in the community supports the health of pregnant women, mothers and newborn? What do they do? (think about community health workers, TBAs, support groups, any other people or groups, etc.) 3. Are there any individuals or groups in the community who work with the health services? What do they do? (think about collaboration with education, transport, local authorities, churches or other religious groups, etc.) 4. Are there any people or groups in the community who are particularly vulnerable or who are not reached by the health services? If so, what sources of support could be used to help them? (think about social support from the state, community funds, etc.)

* The Universal Declaration of Human Rights states that “motherhood and childhood are entitled to special care and assistance.”

Day 2

Level of care GROUP 3: The care received from the health services (IMPROVING QUALITY)

Questions to guide discussion 1. How do people in the community feel about the quality of care pregnant women, mothers and newborns receive from the health services? (think about costs, waiting times, how providers treat women and families, availability of medicines and supplies, numbers of midwives, doctors and nurses, cultural differences between the community and the services, etc.) Do people have to pay for maternal and newborn health services? How do people feel about these costs? Do these costs stop people from using the services? What information do the health services give to women and their families about pregnancy, childbirth and the newborn? Is this information useful? Does it reach everybody? If not, why not? Do doctors, nurses, health promoters or community health workers visit pregnant women, new mothers and babies in their homes? How often? What do they do? Are there any groups who don’t receive care or who need additional support? If women give birth in the health centre or hospital, how are they treated? (think about allowing a companion of choice at birth, choosing the birthing position, etc.) How are people referred from one health service to another? Is the community involved in evaluating the quality of services or in suggesting how to improve the quality of services?

6. 7.

• Presentations in plenary (1 hour): Ask each group to present their section of the guide and the modifications which they suggest. If others in the plenary group have further suggestions during the presentation, note these. Allow each group approximately 20 minutes for their presentation and the ensuing discussion. • Wrap up: Emphasize the importance of the PCA within the IFC framework. Highlight that the assessment is intended not only to guide the development of IFC interventions but also to initiate a process of dialogue between the health services and communities which will ideally become ongoing.

Module 2

DAY 2 RECAP AND NAVIGATION MEETING Time: 30 minutes Briefly review the topics addressed during the day (5 minutes) Assign homework (optional): If you have not had the time to lead the group in the Forest Chat energizer (see Annex 2), you may want to ask them to do this on their own in the evening. If you do this, allow some time for discussion during the Workshop Welcome on Day 3. Diary reflections (10 minutes): Ask participants to take their diaries out. They will have 10 minutes to reflect and record some of their thoughts from Day 2 of the workshop. They may want to write about the most important thing they learnt during the day or how they will able to apply what they have learnt to their work. Navigation Group Work (15 minutes): Ask the plenary to divide into 4-5 “Navigation Groups”. Remind them that for the next 15 minutes you would like them to discuss the following questions: 1. What went well today during the workshop? 2. What could be improved? 3. Do you have suggestions for other issues (e.g., logistics, breaks, etc.)? Remind them that each Navigation Group will need to select one Navigator to represent them during a Navigation Meeting. This meeting will be held immediately after the close of the workshop and will last approximately 30 minutes. The Navigators will then brief the group on the meeting the next morning. Groups should select Navigators who did not serve in this role yesterday.

Day 3

DAY 3 WELCOME AND DAY 2 REVIEW Time: 30 minutes • Recap of Day 2. • Navigation meeting debrief.

SESSION 7: MONITORING AND EVALUATION Time: 30 minutes Objectives Participants will: • Understand the reasons why monitoring and evaluation the IFC component is important; • Be familiar with the basic elements of a monitoring and evaluation system specific to the IFC component; • Discuss how monitoring and evaluation of IFC can fit into monitoring and evaluation of the broader MNH programme.

Instructions to facilitators • Present PowerPoint 8: Monitoring and evaluating the IFC component of the MNH strategy • Definition of terms: What are planning, monitoring and evaluation? ° Planning can be defined as the process of setting goals and objectives, developing strategies to reach these goals and objectives, outlining the arrangements for implementation of interventions, and identifying and allocating resources. Stress that during this session we are referring to developing a plan for implementation of IFC interventions following the PCA. This plan, however, is based on the preliminary plan developed during the institutional forum. ° Monitoring is the ongoing process by which stakeholders gather information to determine whether actions are being implemented as planned and the progress made toward reaching the stated objectives. ° Evaluation is the rigorous assessment which serves to measure the impact that the interventions have had toward reaching the goals and objectives of the IFC component.

Module 2

• Planning, monitoring and evaluation are distinct yet closely interrelated processes. Together they play a major role in enhancing the effectiveness of the IFC component and its interventions. Optimal planning helps actors focus on achieving the identified objectives both within the four priority areas of interventions and the strategic areas. A clear plan facilitates monitoring and evaluation, while monitoring and evaluation provide evidence to inform decision making throughout the intervention timeframe and for scaling of the IFC component to other districts and provinces. • Use the following diagram to discuss key moments in IFC planning, monitoring and evaluation: Planning, monitoring and evaluating the IFC component

Coordination and monitoring Action plan: Logical framework Activities plan

Baseline study Implementation Intermediate evaluation Implementation, cont.

Final evaluation

• Participatory monitoring and evaluation: Explain that, as in all phases of IFC implementation, it is important to prioritize participation in monitoring and evaluation. • Note some of the characteristics of participatory monitoring and evaluation which are different from other approaches. In contrast to traditional methods of monitoring and evaluation, participatory monitoring and evaluation is: ° Focused on processes and measurement, rather than exclusively on measurement; ° Oriented towards the needs of intervention participants and community members, rather than exclusively on donors and policy makers; ° Promotes a relationship between evaluators and participants, rather than objectivity and distance; and ° Conducted for the purpose of empowering participants, implementers and those that the actions aim to benefit alike, rather than simply judging shortcomings.

Day 3

• Briefly discuss the following principles of participatory monitoring and evaluation: ° Participation: Monitoring and evaluation of the IFC component emphasizes the participation of various stakeholders within the process. This principle is facilitated by IFC committees, in which different sectors and actors are represented. A particular emphasis is put on ensuring the participation of community members. All stakeholders, including community representatives, can participate in developing and providing input on tools for monitoring and evaluation, organizing and supporting the process, and analysing and using results. Moreover, monitoring and evaluation of IFC interventions is ideally conducted in collaboration with both internal (i.e., IFC committee members, community members, etc.) and external (i.e., research institutions, external consultants, etc.) actors. This ensures that the interventions are assessed from the viewpoints of both those directly involved in the component and those with a more independent position. ° Learning: Participatory monitoring and evaluation stresses practical and action-oriented learning throughout the process. Monitoring and evaluation of the IFC component is optimized when it is approached as an ‘educational experience’ for all stakeholders. Participating actors, including community members, become aware of what is working and where weaknesses lie, contributing to empowering them to create conditions conducive to change and action. ° Negotiation: Participatory monitoring and evaluation is a social process in which participating actors negotiate between varying needs, expectations and worldviews. This approach recognizes the complex interrelationships between stakeholders. It is intended to contribute to the empowerment of those stakeholders who are traditionally less likely to have their needs and expectations included in decision-making processes, with an emphasis on community members, particularly marginalized groups (minorities, indigenous people, poor people, people with disabilities, elderly people, among others). ° Flexibility: In order for monitoring and evaluation to be participatory, it needs to be approached with flexibility. Monitoring and evaluation of the IFC component will need to be adjusted to the specific context of the implementation district, province and country, assuring that the process itself responds to stakeholder needs and expectations. • Introduce a sample logical framework. If possible, display a logical framework that is already used in the country. If this is not possible you may use the following logical framework as provided in Module 5 of this toolkit. Keep in mind that your purpose is to briefly introduce a logical framework without going into too much depth on its preparation as the allotted time does not allow for this.

Module 2

Narrative summary

Indicators

Means of Verification

Assumptions/Risks

Goal [Outcome]

Contribute to the improvement of maternal and newborn health

Purpose [Output/Outcome]

Empower women, families and communities to improve MNH and increase utilization of MNH services

Outcome 1 [Outcome] [Input/Process/Output] [Outcome] [Input/Process/Output] [Outcome] [Input/Process/Output] [Outcome] [Input/Process/Output]

Capacities developed

Planned Output 1.1…

Outcome 2

Awareness increased

Planned Output 2.1…

Outcome 3

Linkages strengthened

Planned Output 3.1…

Outcome 4

Quality of care improved

Planned Output 4.1…

Day 3

• Selection of indicators: Indicators are empirically measurable conditions used to assess how well activities have been carried out and whether outcomes/outputs have or are being been achieved. They are critical not only to measuring progress, but also to assuring accountability among stakeholders. There are different types of indicators: Type of indicator Outcome Purpose Measures changes at the population level which may be attributable in part to IFC interventions. For example, as one of the primary aims is to increase the use of skilled care at birth, a common outcome indicator may be, “Percentage of births attended by a skilled birth attendant.” Measures the results of activities at the intervention level that directly result from the inputs and processes. For example, if one intervention is to educate women on danger signs, an appropriate indicator may be, “Percentage of women who are aware of three danger signs during pregnancy.” Measures the multiple activities carried out to achieve the objectives. Again using the example of educating women on danger signs, an appropriate indicator may be, “Number of women educated on danger signs during pregnancy.”

Output

Process

Input

Measures the means required to implement the interventions. These may include human and financial resources, physical facilities, operational guidelines, training workshops, educational materials distributed, etc.

• If time permits, it may be useful to briefly look at the list of illustrative IFC indicators in Annex 3 of Module 5. • Mention that it is ideal to conduct an impact evaluation when introducing the IFC framework into a country for the first time. Such an evaluation will provide evidence linking interventions with results and equip policy makers and managers with information to improve operation and guide scale-up. We suggest using a quasi-experimental design and a mixed methods approach (employing both quantitative and qualitative methods of data collection) comparing the intervention district to a matched control district where IFC activities are not being implemented. • Discussion in plenary (10 minutes): Open the plenary to questions and discussions. • Wrap up: Emphasize the importance of monitoring and evaluating the IFC component. Highlight that these are actually very complicated processes and that you have only been able to deal with them superficially during this workshop. Advise them that depending on the experience and expertise of the IFC team, it may be beneficial for them to seek the assistance of external consultants and experts when finalizing a plan and during key moments of monitoring and evaluation.

Module 2

SESSION 8: PLANNING FOR IFC IMPLEMENTATION Time: 2 hours and 30 minutes Objectives Participants will: • Develop a plan for moving forward on the implementation of the IFC component at the national and district levels.

Instructions to facilitators • Present the table below to participants. Explain that the table contains a summary of the different activities that should be undertaken before, during and after the PCA, by the different levels involved (district and national/province). Summary of activities before, during and after the PCA National and Province Levels • Define the Terms of Reference of the coordination

District level • Review and revise the Terms of Reference of the district committee (see Module 1; Annex 1). • With the support of the province and national committees, develop an initial plan for the implementation of the IFC framework at the district level, and identify resources (human and financial) which are required. • Present the IFC framework to local actors in the community and identify the “strategic partners” and the “stakeholders” for the district committee (or broaden the existing district MNH committee). • Select the IFC committee chair(s). • Identify a local IFC coordinator. • Identify local facilitators for the PCA.

committees (see Module 1; Annex 1). • Identify the “strategic partners” and “stakeholders” for the IFC component at national level. • Develop a plan for implementation of the IFC framework at national and province levels, and identify the required resources (human and financial). • Identify one or two expert facilitators at national or province level. • Conduct a national inventory of experiences in IFC-related work. • Identify the initial IFC intervention district, in coordination with province and district level actors, according to the specified criteria (see Module 1). • Identify the key moments of interaction between the district, province and national levels. At province level, identify a representative to participate in the district and national committees. • At national level, review the PCA instruments for a first adaptation to the national context.

Before the PCA

Day 3

National and Province Levels

District level

• Support the district level in the different stages of • Conduct the situation analysis: the PCA. ° Collect data and pertinent reports; • Find pertinent information for the situation ° Organize meetings for filling in and/or reviewing analysis (national statistics, research in the area, data collection forms; programme/project reports in the area). ° Write up the draft report. • With the district level, organize a training workshop • Organize with the national/province level a training for the PCA, and participate in the training. Organize workshop for the PCA and participate in the training. follow-up, according to needs. • Review the roundtable discussion guide, taking into • Participate in pertinent meetings during the PCA account the results of the situation analysis (with (situation analysis, roundtable discussions, analysis support from the national and province committees). meetings, institutional roundtable). • Organize the roundtable discussions, including • Review and comment on the PCA reports. identification of participants, logistics and facilitation. • Carry out the five individual roundtable discussions, including meetings for analysis, and writing up reports. • Write up the summary report of the five roundtables. • Organize and conduct the institutional forum, including compiling the report with information collected. • Write up the final report.

During the PCA

• Present results of the PCA, including the draft action plan, to national and province MNH committees and other strategic partners. • Organize a workshop for documentation of lessons learnt from the PCA, jointly with the district level, including the revision of PCA instruments. • Support the district level in the joint planning process to develop a detailed action plan. • Review and adapt tools for monitoring and evaluating the IFC component. • Support the district level in evaluating the results of IFC interventions and coordinate and disseminate these results. • Organize a workshop for documentation of lessons learnt from IFC implementation, jointly with the district level. • At national level, develop a process for scaling-up IFC implementation to other districts and provinces.

• Present the results of the PCA to the district MNH/ IFC committee(s) and other strategic partners and community actors. • Organize a workshop for documentation of lessons learnt from the PCA, jointly with the national level, including the revision of PCA instruments. • Organize, jointly with the province level, a process to develop a detailed action plan based on the draft plan. • Manage the implementation and regular monitoring of IFC activities. • Evaluate the initial implementation of the IFC component. • Disseminate results from monitoring and evaluation. • Organize a workshop for documentation of lessons learnt from IFC implementation, jointly with the national level. • Support the scaling-up of the IFC framework to other districts within the province.

After the PCA

Module 2

• Introduce Group Work (1 hour for group work): Divide the plenary group into three groups. If possible, divide two of the groups by those actors working at national level and those at district level. The third group can be a mix of the two. GROUP 1 has three tasks: ° Review the national level activities before and after the PCA and modify according to national realities. ° Propose a draft timeline for the different activities. ° Review the Terms of Reference (see below) for the National IFC Committee and suggest modifications. Reflect on who could be part of the National IFC Committee. Terms of Reference for IFC National Coordination Committees Note: Generally the IFC National Coordination Committees will be integrated into a pre-existing national MNH committee, or may be a subcommittee of it. If separate IFC committees are formed, one of the representatives may be selected to represent the IFC component in the MNH committees.

Objective of the National Coordination Committee: Supervise, provide technical support to and coordinate the development and implementation of the “National Plan” for the IFC component within the national MNH strategy. Scope of Work: 1. Identify partners for implementation of the IFC component (including other sectors and relevant programmes within MoH itself, NGOs, universities and other relevant groups). 2. Represent the IFC component at national level, within other national, regional and international initiatives. 3. Advocate on the importance of this health promotion component for MNH strategies within MoH and with other sectors and groups and assure its integration into and coordination with broader strategies. 4. Coordinate the development of the national IFC plan, including planning of interventions; management and administration of financial, technical and human resources of the interventions; and assuring adequate financing for each phase of its operationalization. 5. Develop a system for monitoring and evaluating the IFC component at the national level. 6. Identify the necessary experts and support at various administrative and technical levels (national, province and district) for implementation of the national IFC plan.

Day 3

7. Provide technical assistance throughout the implementation of the national IFC plan at all levels of the health system (province, district authority, community). 8. Develop coordination mechanisms and maintain communication with all strategic partners (at district, province and national levels) and with district committees during the different phases of development and implementation of the national plan. 9. Review and analyse existing strategies, programmes, and activities which work with women, their families and the community to improve MNH at national level. 10. Document and organize the experiences and lessons learnt in the area of IFC, for scale-up at national level. Members of the National Coordination Committee: The National IFC Coordination Committee involves the participation of representatives of organizations that work on MNH issues at the community level, including representatives of: ° MoH (one or two decision-makers in the MNH or health promotion programmes); ° WHO (national offices); ° other governmental agencies (education, water/sanitation, youth, etc.); ° NGOs (national or international); ° women’s groups; ° universities; ° national champions in MNH or health promotion; ° representatives of the province and district IFC committees. Skills and knowledge required within the Committee: ° knowledge of current MNH activities, social sciences and health education; ° familiarity with quantitative and qualitative research methods; ° experience in educational processes at community level; ° experience in community health (links between communities and services; community participation in health care improvement); ° knowledge of participatory mechanisms at the community level; ° must include or have relationships with political decision-makers, or include representatives who have the ability to influence key decision-makers. 44

Module 2

Coordination: The committee will select a coordinator and a secretary for a specified period of time. The committee should be limited to 10-12 members to allow the group to work effectively. It may be useful to consider forming subcommittees to carry out specific actions. The large group could meet two to three times a year to provide suggestions and oversight. GROUP 2 has three tasks: ° Review the district level activities before and after the PCA and modify according to national realities. ° Propose a draft timeline for the different activities. ° Review the Terms of Reference for the District IFC Committee (see below) and suggest modifications. Reflect on who could be part of the District IFC Committee. Terms of Reference for District IFC Committee Note: It is recommended to form a subcommittee of the existing district MNH committee (where one is present) of five to ten persons for the coordination of IFC activities.

Objective of the District IFC committee: Coordinate the implementation of the IFC component at district level. Scope of Work: 1. Identify partners for the local implementation of the IFC component (including other relevant sectors and programmes within MoH, NGOs, and other pertinent groups at the district level). 2. Coordinate the different phases of the implementation of the IFC component, including the PCA, development of the district plan, identification of interventions, implementation of activities, monitoring and evaluation and documentation of lessons learnt. 3. Identify participants for the roundtable discussions. 4. Maintain communication and develop mechanism for effective coordination with all strategic partners during the implementation of interventions, including district, province and national stakeholders. 5. Assist in the identification of experts and support required at various administrative and technical levels in the local area, for the implementation of the IFC framework. 6. Participate in the joint planning process, specifically the planning of activities for implementation, and the identification of indicators for monitoring and evaluation of the IFC component.

Day 3

7. Review and comment on proposals developed for funding IFC activities before submission. 8. Assure the integration of participatory mechanisms within routine health service planning processes. 9. Review and analyse existing strategies, programmes and activities at the district level that work with women, their families and the community for the improvement of MNH. Members of the District IFC Committee: The Committee should comprise a maximum of ten people, and may include: ° MoH (including representatives from the district health centre); ° health service providers with experience in MNH at district level (for example, doctors, nurses, health promoters or midwives); ° NGOs working in MNH in the area; ° representatives of community groups, local health committees and women’s groups; ° local political representatives; ° the education sector; ° other selected relevant professionals in the local area; ° religious leaders. Skills and knowledge required within the committee: ° knowledge of current activities in MNH and in health education; ° experience in educational processes at community level; ° experience in community health (links between the communities and services; community participation in the improvement of quality of health care); ° knowledge of participatory mechanisms at community level; ° skills in negotiation and facilitation; ° ability to represent the voice of women, families and communities; ° must include or have relationships with local political decision-makers, or with people who have the ability to influence key decision-makers.

Module 2

Duration of service: Each committee member will ideally be able to commit to at least two years of service on the IFC committee, after which time they may choose to rotate off and new members may be elected. Committee chair(s): The district committee may be chaired by the district health services director or the head of MNH services. It may also be appropriate for the committee to elect a “community co-chair”, a representative of a community group who is not part of the health sector. The committee will also need to appoint or elect a local IFC coordinator, responsible for work related to the IFC component (see next page). This committee will also elect a secretary for a specified period of time. One or two people from this District Committee may be identified to represent it on the national and/or province committees (usually the chair or co-chairs). GROUP 3 will develop a draft plan for conducting the PCA: ° Ask them to review the PCA main steps: 1. Situation analysis 2. Training workshop 3. Five roundtable discussions 4. Institutional forum 5. Final report ° Ask them to develop a plan for the following components of the PCA: 1. Situation analysis - Who will be responsible for conducting the situation analysis? Who will coordinate and who will participate? - When will it be done? Define a target for completion. 2. Training on PCA - List of PCA facilitators to be trained. - When will it be done? 3. PCA roundtable discussions - What groups will be targeted for the roundtable discussions? (Women of reproductive age, mothers or mother-in-laws of women of reproductive age, male partners of women of reproductive age, adolescents, healthcare providers, community leaders?) How will they select participants? - Where will they conduct the roundtable discussions (rural or urban areas)? - When will they conduct the roundtable discussions? - Who will write the report? When will they do it?

Day 3

4. Institutional forum - How will it be prepared? - When to conduct? - Support needed? 5. Final report writing - Who will write it? - When will they write it? Be sure to note their responses and decisions on a flipchart. • Presentations in plenary (60 minutes): Invite each group to present the results of their group work. Allow each group 20 minutes. • Define the next steps in IFC implementation (30 minutes): In plenary discuss the next steps for implementation. During this discussion also address the following questions: 1. What support do the districts need for implementing the IFC component from the national level? What type of support mechanisms can be set up? 2.It is considered important to establish a system for sharing experiences between districts. What kind of mechanisms can be set up? What support is needed from the national level to facilitate the exchange between the districts? • Wrap up: Thank them for their efforts during the group work and explain that the results of their work will be used for moving forward implementation of the IFC framework in the country.

Module 2

SESSION 9: PERSONAL NEXT STEPS Time: 30 minutes Objectives Participants will: • Reflect on how they will apply what they have learned in the workshop to their work.

Instructions to facilitators • Tell the participants that before closing the workshop they will now have a few moments to reflect on what they have learnt during the workshop and how they will apply it to their work. • Personal next steps (20 minutes): Ask participants to take a few minutes to think about the following questions and write their answers in their diary: 1. What were the most useful things that you learnt during the workshop? 2. How will apply what you learnt to your work? 3. How will you try to increase the participation of different actors (including communities) in your work following the workshop? • Allow 20 minutes for participants to reflect and write. • Discussion in plenary (10 minutes): Ask if there is anyone that would like to share some of their thoughts from this exercise.

Day 3

WORKSHOP CLOSING Time: 1 hour Objective • To close the workshop

Instructions to facilitators • Recap of workshop (10 minutes): Briefly discuss the major takeaways from the workshop (i.e., the contribution of the IFC framework to the MNH strategy; the importance of participation; etc.). • Final evaluation (10 minutes): Distribute the final evaluation forms (see Annex 3) and ask participants to complete them. Tell them to please answer honestly as it will help you to improve future workshops. Let participants know that they will have 10 minutes to complete the form. • Final bang (5 minutes): Think of something that could be done that would leave the participants on a positive not at the end of the workshop. This could be singing a local song together; distributing a sweet or a small token; etc. • Closing remarks and speeches (25 minutes): Arrange with the appropriate individuals and authorities beforehand to deliver closing remarks and speeches.

Module 2

ANNEXES Annex 1: Why did Mrs X die? Annex 2: ENERGIZER-Bingo Annex 3: ENERGIZER-Forest chat Annex 4: Final evaluation form

Annex 1: Why did Mrs X die?

ANNEX 1: WHY DID MRS X DIE?

This is the story of one case of maternal death. For the sake of anonymity, let us call our unfortunate woman, Mrs X. Mrs X died during labour in a small district hospital. The physician in charge had no doubt why Mrs X died. It was a straight forward clinical diagnosis - a case of antepartum haemorrhage due to placenta praevia, which means that the placenta, or what we call the “afterbirth”, was situated too low down in the uterus. A woman with this condition will inevitably develop bleeding in the latter part of pregnancy or before delivery. The physician was satisfied with the diagnosis, looked up the book of International Classification of Diseases, entered the right code number for the condition and closed the file on Mrs X. 1

But the question is not completely answered, and there are others who are still looking for other answers. The obstetric profession has a small committee which is making confidential inquiries into the causes of maternal deaths according to standards that have been developed by the International Federation of Gynaecology and Obstetrics. The committee met, asked for the complete hospital record of Mrs X and examined the record in more detail. The file on Mrs X was re-opened.

From: The midwife in the community: midwifery education module 1 (Foundation module). Geneva: World health Organization, 2008.

Module 2

On reading the file of Mrs X, the committee found out that there were two striking points in her hospital record. The first point was that although she was admitted to hospital as a case of severe bleeding and in a condition of shock, she received only 500 cc, or ½ litre of blood by transfusion. That was all the blood the hospital had available to give her and that amount was barely sufficient to compensate for her severe blood loss. The second point was that Mrs X had to undergo caesarean section in the hospital to stop the bleeding. That operation was carried out three hours after her admission. Mrs X died during the operation.

The committee looked into the case which said that the death of Mrs X was avoidable. The committee argued in its report that, if blood transfusion had been more readily available, and if the service had been better prepared to deal with emergencies, a life would have been saved. It took Mrs X four hours to reach hospital from the time she started bleeding severely, because transport was not readily available to take her to the hospital.

Annex 1: Why did Mrs X die?

It was also revealed that this was not the first time she suffered bleeding. In fact she had two minor episodes of bleeding during the same month and on both occasions the bleeding stopped spontaneously. This is a very dangerous signal in late pregnancy. It always indicates that a severe attack of bleeding is imminent, yet Mrs X was never warned about this and no action was taken.

Mrs X was not a very healthy woman. Even before pregnancy, she suffered from chronic iron deficiency anaemia caused by malnutrition and parasitic infestations. That severe anaemia must have contributed to the fact that she could not endure the additional severe blood loss. Her reserves of blood were already at a very low level.

Module 2

Mrs X is 39 years old, five of her children are still living, three of them are males, and Mrs X did not want another child.

In addition, because of her age and because of her parity, her pregnancy carried a much higher risk than her previous pregnancies. Mrs X never had access to any family planning information, education or services, and therefore never had the opportunity to use any method of family planning in her life.

Annex 1: Why did Mrs X die?

If this unwanted pregnancy of Mrs X had not taken place, she would not have died from the cause she died from.

Module 2

Mrs X was also a housewife, and her husband a poor agricultural labourer.

Annex 1: Why did Mrs X die?

She was an illiterate woman and she lived with her husband in a remote village.

A woman of Mrs X’s socioeconomic position has a relative risk of maternal mortality: 5 times more than the average in the whole country. 10 times more than a woman in a higher socioeconomic position in the country in which she is living. 100 times more than a woman living in a developed country.

Module 2

The real reason why Mrs X died was because of her socioeconomic position:

Mrs X died because of poverty.

Mrs X died because of lack of knowledge and information.

Mrs X died of social injustice.

Annexe 1: Why did Mrs X die?

If Mrs X had been an educated woman, if she had been gainfully employed, and if she had had her fair share of nutrition within society, her risk of dying would have been much less.

Module 2

It is clear that there are different perspectives in the way one looks at the causes of maternal mortality. In order to answer the question “Why did Mrs X or other Mrs Xs die?” we need to take all these perspectives into consideration. In other words, we need to reconstruct the story of Mrs X. We need to retrace the steps of Mrs X along what one can describe as The Road to Maternal Death.

Life-threatening complications

Accessible first-level referral services

Mrs X did not voluntarily go on that Road to Maternal Death. She was led to the start of the Road by the poor socioeconomic development of the community in which she was born, and in which she lived. But it is not just the general level of socioeconomic development that matters. Even more important is the equity with which the benefits of socioeconomic development are made available to members of the community. As a female, Mrs X did not get an equal share of whatever little benefits of socioeconomic development were available in her community.

Raising the status of women

Annex 1: Why did Mrs X die?

At that stage on The Road to Maternal Death there was a way out for Mrs X. If Mrs X had had the opportunity for some education, for gainful employment, or for proper nutrition she would probably have found her way off The Road to Maternal Death. Unfortunately, that exit was not available to Mrs X and she had to continue along the Road The next stretch of the Road for Mrs X was excessive fertility.

Excessive fertility

Accessible family planning services

Her fertility, and childbearing, was her only acknowledged contribution to the society in which she lived. Children were the only goods she could produce and the only goods she could deliver. Her status as a woman in her community depended completely on her role as a mother. Excessive fertility not only increased her chances of travelling further along The Road to Maternal Death, but because of advancing age and parity she was at increasingly higher risk during pregnancy and childbirth. Still at this stage on The Road to Maternal Death there was a way out. If Mrs X had access to family planning information, education and services, she could have found her way off the dangerous Road. Mrs X was denied that exit and had to continue her march along the Road.

Accessible family planning services

Module 2

Now, because of her advanced age, because of her advanced parity, because of her poor nutrition, because of her severe anaemia, she came under what we call an obstetric category – the category of high risk pregnancy. By high risk pregnancy we mean that small group of women who have most of the complications. That was the stage Mrs X found herself at, yet even at that stage there was still a way out.

High-risk pregnancy

Accessible community-based maternity services

If community-based maternity services had been available; her high risk category would have been detected by simple screening; her anaemia would have been corrected; warning signals such as her episodes of bleeding would have been carefully noted; and she would have been referred to the nearest hospital service in time while she was still in a good condition. That exit was not open to Mrs X and she had to continue along the Road.

High-risk pregnancy

Accessible community-based maternity services

Life-threatening complications

Accessible first-level referral services

Annex 1: Why did Mrs X die?

And that was the critical part of the Road, that was the stage of what we call life-threatening complications. These include conditions such as haemorrhage, eclampsia, sepsis, obstructed labour, complicated abortion and other less common but serious conditions. The inevitable happened. Mrs X developed her life-threatening complication, her antepartum haemorrhage. Even at this stage there was a last way out. If she had access in time to good services at first referral level so that her serious life-threatening condition could have been properly managed, Mrs X could have been saved. But that was her last chance and Mrs X lost that last chance.

Life-threatening complications

Accessible first-level referral services

That was the unfortunate journey of Mrs X along the slippery, dangerous Road to Maternal Death. The journey has left us with a vision of how women die and how women can be rescued. Women risk death when they step onto The Road to Maternal Death at any stage. Women can be rescued if they can be helped to follow one of the ways off the Road. It may not be possible to restrict completely the access to The Road to Maternal Death. It is certainly possible to let women off the Road through its various exits, but any successful strategy for mothers’ survival

will have to effectively utilize every exit along The Road to Maternal Death. If we try to emphasize only the earlier exits then we are going to miss the women who join the Road later on or who continue along it. If we emphasize only the later exits, the medical exits, and we do not give equal emphasis to the earlier social exits, the load on those medical exits will be too much for the medical services to cope with. Mrs X is dead.

Module 2

ANNEX 2: ENERGIZER-BINGO Time: 30 minutes Objective: • Have fun playing a game; • Move around and be active; • Get to know one another other. Hobbies-arts: Has written a poem; has written a song; likes to dance; likes to paint; enjoys arts/crafts; etc. Hobby-music: Plays the guitar; plays [local instrument]; likes to sing; etc. Hobby-sports: Plays football; plays basketball; plays cricket; loves to watch the Football World Cup; etc. Personal: Has been in love; has married their love; loves to eat chocolate; has a tattoo; is afraid of snakes; is afraid of rats; loves to eat hamburgers; loves to eat pizza; hates to cook; loves to cook; etc. • Ask all participants to stand up and come to the centre of the U-shape tables. Alternatively, you can go outside on a terrace, a garden, etc., where there is a large enough space for the group to move around freely. • Give instructions for the Energizer: “We will be playing “BINGO” now. Who has played Bingo before? As a child or with your children now? It is a game, and we will have a winner at the end. Your task is to go around and find the person who can sign one of the boxes on the sheet. The winner will be the one who has checked out all the boxes of the sheet first. Once you are done, scream BINGO, so we know you are finished. Are there any questions?” • Hand out the sheets for each participant (see Annex 1) • Give participants time to check the boxes (20-25 minutes). • Once there is a winner, stop the game and have all participants stand in the inside circle of the U-shape table.

Instructions to facilitators: • Prior to the workshop, prepare a Bingo sheet (see sample sheet below). You will need to adapt the Bingo sheet to the local/national context being sensitive to the group’s background and culture. Below are a few examples of what one could include on a Bingo sheet. The number of boxes on the Bingo sheet will depend on the group size. For a group of 30-35 participants, a Bingo sheet with 25 statements, in a sheet of 5x5 boxes would be appropriate. If the group is significantly smaller, you may choose to prepare 16 statements on a sheet of 4x4 boxes. Below are some possible statements for the Bingo sheet: Family/Children: Has five children; has five grandchildren; has three girls; has three boys; knows or has met their great-grandmother/ father; etc. Travels: Has lived in the capital; has travelled outside of the country; has seen the ocean/ mountain/desert/local natural monument, etc.; has been on a mountain top; has visited a national or regional monument, etc. Skills/movement: Has ridden a bicycle; has ridden in a truck; has ridden a horse; has flown on an airplane; etc.

Annex 2: ENERGIZER-Bingo

• Debriefing: ° Congratulate the winner or winners. Give them a little gift (e.g., chocolate bar etc.) ° Ask them who they found, how the game was for them. Sample Bingo Sheet Often stays up past midnight during the week Once worked at a restaurant Knows the French national anthem Has been to India Knows how to Salsa dance Has jumped out of an airplane ° Ask a few questions from the sheet (For example: So who has seven children? Bravo.)

Is a vegetarian

Is an only child

Never planned to study in Paris

Enjoys sleeping

Reads the “Economist” magazine Hates the theatre and opera Born outside the country of their parents

Loves the World Cup football championship

Loves Chinese food Watches the news every night Owns a motorcycle

Has four siblings or more

Loves to buy new clothes

Paris Hilton fan

Plays the piano

Has a tattoo

Afraid of snakes

Has been to the Taj Mahal

Rides a bike to university

Module 2

ANNEX 3: ENERGIZER–FOREST CHAT Time: 30 minutes Objective: • To reflect on their lives and motivations; • To get to know one another better; • To share their dreams and reconnect with their ideals. Ask them to think back and reflect. • Invite them to go on their Forest Chat to discuss these questions. (Be clear about where they should walk.) Each participant should be allowed 10 minutes to respond to these questions. • Ask participants to return in 20 minutes. • After 10 minutes have passed, give a signal (i.e., ring a bell) to remind them to switch to the other person. • Let them know when 3 minutes and then 1 minute remain. • When all are back in plenary, ask: 1. What did you learn about your Forest Chat partner? 2. What did you learn about yourself? • Invite 3-4 people to debrief and discuss their experience.

Instructions to facilitators: • Explain to the group that they will now go on a “Forest Chat”. • Ask participants to please pair up with one other person who they do not know very well and/or worked little with either in the past or the during the day. • Ask them do discuss the following questions: 1. Why did you get involved in improving the well-being of your population, your community? What were your original ideals? 2. What did you get involved to do, and what are you doing now?

Annex 4: Workshop final evaluation form

ANNEX 4: WORKSHOP FINAL EVALUATION FORM 1. Please circle the answer you feel is most appropriate for each of the following aspects of the training course, using the following ratings: 1 – Insufficient Statements 1. Achievement of course objectives 2. Achievement of personal expectations 3. Relevance of workshop to your work 4. Usefulness of workshop materials 5. Workshop methodologies 6. Organization of the course 7. Workshop facilities 8. Administrative support 9. Facilitators 2 – Poor 3 – Satisfactory 4 – Good 5 – Excellent

Rating scale 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5

Module 2

2. Course length:

Too long

Too short

Just right

3. What topics covered in this training do you think will be most useful to you? ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

4. On which topics would you have liked more information or preferred to spend more time? ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

5. On which topics would you have liked less information or preferred to spend less time? ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

Other comments or suggestions: ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

THANK YOU!

Department of Maternal, Newborn, Child and Adolescent Health 20 Avenue Appia 1211 Geneva 27 Switzerland E-mail: mncah@who.int Website: http://www.who.int/maternal_child_adolescent/en/

ISBN 978 92 4 150852 0

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health

A Toolkit for Implementation Module 3: Partcipatory Community Assessment in Maternal and Newborn Health

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health:

A Toolkit for Implementation

Module 3: Participatory Community Assessment in Maternal and Newborn Health

Module 3

TABLE OF CONTENTS Acronyms ............................................................................................................................................................. The Story of the Toolkit . ..................................................................................................................................... Introduction to Module 3 . ................................................................................................................................... 1. Overview of the Participatory Community Assessment (PCA)................................................................. 1.1 What is the PCA?................................................................................................................................. 1.2 Characteristics of the PCA. ................................................................................................................. 1.3 Summary of Topics to be Assessed ................................................................................................... 1.4 Local Coordination of the PCA ........................................................................................................... 1.5 Overview of PCA Methodology............................................................................................................ 1.6 Presentation of the IFC Framework to the Community..................................................................... 1.7 Principles of the PCA.......................................................................................................................... 1.8 The PCA Training Workshop............................................................................................................... 2. Situation Analysis....................................................................................................................................... 2.1 Aims of the Situation Analysis............................................................................................................ 2.2 When to do the Situation Analysis?.................................................................................................... 2.3 Content of the Situation Analysis . ..................................................................................................... 2.4 Sources of Information....................................................................................................................... 2.5 Who Should Complete the Situation Analysis?.................................................................................. 2.6 Report of the Situation Analysis......................................................................................................... 3. The Roundtable Discussions ..................................................................................................................... 3.1 Why Conduct Roundtable Discussions?............................................................................................. 3.2 Overview of the Roundtable Discussion Groups................................................................................. 3.3 Review of the Roundtable Facilitation Guide...................................................................................... 3.4 Voluntary Participation....................................................................................................................... 3.5 Identification of Participants and Roundtable Locations................................................................... 3.6 Organization of the Roundtable Discussions. ..................................................................................... 3.7 Structure of the Roundtable Discussions........................................................................................... 3.8 Facilitation and Note-taking during the Roundtable Discussions..................................................... 3.9 Analysis and Report of the Roundtable ............................................................................................. 3.10 Summary Report from the Roundtables ........................................................................................... 4. The Institutional Forum.............................................................................................................................. 4.1 Aims and Objectives of the Institutional Forum................................................................................. 4.2 Timing of the Forum........................................................................................................................... 4.3 Institutional Forum Participants........................................................................................................ 4.4 Preparing for the Institutional Forum................................................................................................ 4.5 Facilitation of the Institutional Forum................................................................................................ 4.6 Report of the Institutional Forum....................................................................................................... 5. Final Report and Results Dissemination .................................................................................................. 5.1 Write-up of the Final Report............................................................................................................... 5.2 Finalization of the Programme of Work............................................................................................. 5.3 Results Dissemination........................................................................................................................ References........................................................................................................................................................ Annexes . ........................................................................................................................................................... Annex 1: Terms of Reference for PCA Facilitators...................................................................................... Annex 2: Forms for the Situation Analysis.................................................................................................. Annex 3: Facilitation Guide for the Roundtable Discussions...................................................................... Annex 4: Analysis Form for the Individual Roundtable Discussions. .......................................................... Annex 5: The Institutional Forum................................................................................................................ Annex 6: Checklist for Organization of the Roundtables/Institutional Forum. ........................................... Annex 7: Additional Participatory Exercises for Roundtable Discussions.................................................. vi vii 1 5 5 5 6 7 8 9 10 12 14 14 14 15 15 16 16 18 18 19 20 20 21 23 25 26 27 28 30 30 30 30 31 32 32 33 33 34 34 35 38 39 40 57 68 72 82 83

ACRONYMS CHW EmOC HIV/AIDS IFC Community health worker Emergency obstetric care Human immunodeficiency virus/Acquired immunodeficiency syndrome Individuals, Families and Communities (In reference to the World Health Organization’s framework for Working with Individuals, Families and Communities to Improve Maternal and Newborn Health) Integrated Management of Childhood Illness Maternal and newborn health Non-governmental organization Participatory community assessment Traditional birth attendant United Nations Population Fund United Nations Children’s Fund World Health Organization

IMCI MNH NGO PCA TBA UNFPA UNICEF WHO

Tell us what you think! All comments on this document are welcome. Please let us know if you find the content useful, your experience in using this guide, if there is any information missing, if there is anything else you would add to this guide. Please send all comments to the Department of Maternal, Newborn, Child and Adolescent Health (MCA), World Health Organization (WHO), Geneva, to mncah@who.int.

Module 3

Please see http://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/

VII

vii

The Story of the Toolkit

viii

Module 3

IX ix

Module 3

INTRODUCTION TO MODULE 3 This document is the third module of a series entitled Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation, designed to support the implementation of the World Health Organization (WHO) framework “Working with individuals, families and communities (IFC) to improve maternal and newborn health”,2 herein referred to as the “IFC framework.” The IFC framework, originally elaborated in 2003, was developed in response to the observation that a robust and systematic health promotion component was largely absent from most maternal and newborn health (MNH) strategies in countries. Grounded on the foundational principles of health promotion as outlined in the Ottawa Charter,3 the framework and the interventions it proposes were formulated based on an examination of evidence and successful experiences in working with individuals, families and communities to improve MNH. This evidence was updated in 2015 and we refer the reader to the publication WHO recommendations on health promotion interventions for maternal and newborn health, available at http://who. int/maternal_child_adolescent/documents/ health-promotion-interventions/en/. To date, the IFC framework has been implemented in a number of countries spanning the six world WHO regions, including: Bangladesh, Burkina Faso, Colombia, El Salvador, Guatemala, Haiti, Kazakhstan, Lao People’s Democratic Republic and the Republic of Moldova. The aim of the toolkit is to support public health programmes in launching a process to work with and empower individuals, families and communities to improve MNH.

See the following strategic document: Working with individuals, families and communities to improve maternal and newborn health, WHO, 2010. 3 See WHO, 1986. 2

Introduction

Module 3: Participatory Community Assessment in Maternal and Newborn Health (PCA)

Module 4: Training Guide for Facilitators of the Participatory Community Assessment (PCA) in Maternal and Newborn Health Module 5: Finalizing, Monitoring and Evaluating the IFC Action Plan

This third module provides guidance on conducting a PCA. Based on the results of this assessment, collaborating partners can use the IFC framework as a health promotion tool to strengthen the broader MNH strategy. They do so through planning actions together to contribute to creating an enabling environment for care of the woman and newborn in the home, for support from the community and for quality care in the health facility during pregnancy, childbirth and after birth. Those reading this guide who are planning to undertake a PCA in MNH will benefit from having already studied Module 1 of this toolkit, as well as having participated in an orientation workshop on the IFC framework (see Module 2). These

initial steps will provide actors participating in the PCA with a foundation of the principles and processes of the IFC framework and will contribute to ensuring that a useful, effective and participatory assessment is carried out. The assessment process outlined in this guide is designed to be used the first time that the IFC framework and the PCA are implemented in a country or province. Certain aspects may be adapted once districts in a province have experience in participatory processes and in integrating the IFC component into the broader MNH strategy. Suggestions for scaling up the IFC framework to other districts are discussed in Module 1 (see Module 1, section 2.16).

Module 3

Who should use this module? The IFC implementation process at the district level, including the PCA, is typically led by a district IFC coordination committee. The district process will ideally be supported and sustained by the national and province levels, and we therefore also recommend that representatives from these levels be familiar with the steps required to conduct the PCA. Since the PCA aims to obtain information that may influence national or province policies, the PCA final report will be of use to decision-makers at all levels. This module is intended to be used by national, province and district teams and assumes that these actors have little or no experience in participatory health planning processes. Those involved in the PCA should be prepared to learn from and with community members. It will be beneficial for all involved in conducting the PCA to have their own copy of this guide for study. Adapting the process and instruments The participatory process outlined in this guide is a generic one. Therefore IFC coordinators, committee members and others involved in conducting the PCA are advised to review and adapt this guide and its instruments to suit their national and local situations, needs, and objectives according to their context.

Structure of the module Section 1 provides an overview of the PCA, including a summary of the topics to be assessed, as well as the coordination mechanisms for conducting a PCA. It also presents an overview of the methodology and the training required to conduct the PCA. Section 2 describes the process of conducting the situation analysis, the first step of the PCA. Section 3 provides guidance on the roundtable discussions, including the various preparatory activities needed, the roundtable methodology, and report writing. Section 4 provides guidance on conducting the institutional forum, the final step in the PCA. Section 5 outlines the components of the final report and suggestions for disseminating results. The annexes at the end of the document are the assessment instruments that may be adapted to be used during the PCA.

Module 3

1. OVERVIEW OF THE PARTICIPATORY COMMUNITY ASSESSMENT (PCA) 1.1 WHAT IS THE PCA? The PCA is a mechanism for initiating collaboration between the health system and the community. It supports local actors, including women, family and other community members, in assessing problems and needs in MNH, as well as identifying potential actions and local resources that can be leveraged to address these problems and needs. The PCA is not intended to be a research tool, but is a participatory process in which different actors can learn to work together, listen to each other, and jointly plan to address their needs. The PCA is a systematic process that helps people and groups better understand their situation and participate in finding solutions. Thus it becomes an important first step in a health promotion process that empowers people to improve their health and quality of life. The PCA can also serve as an important tool in the promotion of the rights of women and community members. As participation is a right that community members are entitled to, the PCA provides a concrete tool to encourage their participation in the identification of their needs and in the design of interventions aiming to benefit them. As such, the PCA will ideally be conducted with the broader vision of contributing to a realization of these rights. Although the PCA has been designed as one step in the IFC implementation methodology, it should be underlined that participatory assessments and processes will ideally be integrated into the routine health planning cycle, if not already present. The health services network, together with the community social network, can conduct regular assessments to provide information and feedback to health programme managers on changing MNH needs in order to inform health planning processes (see Module 1, section 3.8). The institutionalization of these processes can greatly contribute to the realization of rights of community members and ultimately to their empowerment.

1.2 CHARACTERISTICS OF THE PCA Some of the basic characteristics of the PCA are as follows: 1. It utilizes a participatory approach that includes members of the community and different stakeholders in the collection and analysis of information on the local MNH situation (see Box 1.1) and is intended to be the first step in the empowerment of individuals, families and communities. 2. It contributes to the promotion of rights of women and men by allowing them to meaningfully participate in voicing their needs and designing interventions meant to benefit them. 3. It combines different methods for compiling a wide range of information and experiences, such as a situation analysis and roundtable discussions with different actors who are influential in MNH matters.

Section 1: Overview of the PCA

4. It encourages a detailed analysis of the MNH situation, supporting the identification of feasible interventions from the IFC framework that can strengthen the local MNH strategy.

5. It supports programme managers and other actors to take the next steps in implementation of the IFC component, playing a central role in the design and implementation of interventions.

Some of the potential benefits of the PCA are summarized in Box 1.1. Box 1.1: The benefits of a community-based participatory assessment in MNH • Community members are enabled to participate in a health assessment process and thereby develop capacities in working together for their own benefit. • Communities identify their priority health concerns and needs (which may differ from those identified by a national health authority or external researchers), and plan interventions consistent with these needs. • Linkages are built or strengthened between local health services and their users, thereby promoting use of services and improving quality. • Understanding and trust between different stakeholders, such as women, men, health service providers, community leaders, and religious leaders is increased. • Interest among community members in MNH and awareness of the issues affecting it is increased. • Programme activities and results are more likely to be sustained after project funding or other outside support comes to an end.

Source: Adapted from Howard-Grabman and Snetro (2003) and Palmer (2006).

1.3 SUMMARY OF TOPICS TO BE ASSESSED In accordance with the IFC framework, Table 1.1 suggests topics to be addressed during the PCA, based on the four priority areas of intervention: developing capacities, increasing awareness, strengthening linkages and improving quality of care. Note that while the IFC priority areas of health systems strengthening (see Module 1, section 1) are also central to the IFC framework, they are considered primarily by IFC coordinators and partners and therefore not discussed during the course of the PCA. Inspired by the priority areas of intervention, the themes to be discussed during the PCA will ideally be tailored and adapted to suit the local MNH context. For example, some programmes have preferred to begin by focusing on only one thematic area of the framework such as quality of care. Those actors who are participating in the PCA process (either as facilitators, note-takers or observers, or providing input) will be best able to select and adapt themes when they are well-acquainted with the IFC framework and its interventions.

Module 3

Table 1.1: Themes to be reviewed during the PCA Thematic areas of the IFC framework 1. Developing CAPACITIES to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies Themes to review during the PCA • Care in the home during pregnancy, childbirth and after birth • Utilization of health services during pregnancy, childbirth and after birth • Recognition of the danger signs indicating obstetric and neonatal complications • Decision-making processes to seek care in the case of obstetric and neonatal complications • Preparation for childbirth and potential obstetric or neonatal complications (birth preparedness and complication readiness) • Awareness of the rights associated with sexual and reproductive health and maternal health • The role of men (i.e. husbands, partners, fathers) and other influential family members (i.e. mothers, mothers-in-law, grandmothers) related to the health during pregnancy, childbirth and after birth • Participation of community members in reviewing health information and in maternal and perinatal death reviews • Financial barriers in preventing access to MNH services and community responses to this barrier • Geographic and transportation barriers preventing access to MNH services and community responses to these barriers • Role of traditional birth attendants (TBAs) in linking women and families to the formal health delivery system • The perspective of women, families and communities of the quality of MNH services • Mechanisms for community participation in the definition, monitoring and evaluation of quality of MNH services • Support during birth by a companion of the woman’s choice • The interpersonal and counselling skills of health care providers

2. Increasing AWARENESS of the rights, needs and potential problems related to maternal and newborn health

3. Strengthening LINKAGES for social support between women, families and communities and with the health delivery system 4. Improving QUALITY of care, health services and interactions with women, families and communities

1.4 LOCAL COORDINATION OF THE PCA The district IFC committee (see Module 1, section 3.4) has the overall responsibility for the PCA. As mentioned, if a local health committee already exists, this IFC committee can be a sub-group of the larger committee. When overseeing the PCA it will ideally include at least the following persons: • the district health authorities; • a representative from a health, education, rights or women’s non-governmental organization (NGO); • a representative from the local political authority office (e.g. mayor’s office); and • a representative from a community group. The district committee will usually identify (and possibly hire) a local IFC coordinator (see Module 1, section 3.5). A smaller PCA team can also be formed, under the authority of the district committee, to be responsible for the organization and implementation of the PCA. The PCA team could include: • the local IFC coordinator: to coordinate all aspects of the PCA; and • two local facilitators: to support the data collection for the situation analysis and the organization and facilitation of the roundtable discussions.

Section 1: Overview of the PCA

This team would ideally have support from: • one or two expert facilitators, usually from the national or province level with experience in qualitative and participatory processes and in documenting these experiences; and • a representative from the province and/or national committees.

Including equal numbers of both women and men is an important goal when forming the PCAs teams. This contributes to ensuring that a gender perspective is maintained throughout the entire process of the PCA. There is more information on the role of the facilitators in sections 3.7 and 3.8, and Annex 1 provides sample terms of reference.

1.5 OVERVIEW OF PCA METHODOLOGY The four key steps of the PCA outlined in Fig. 1.1 are designed to be followed sequentially as the results from one stage will be used for the next. As can be seen in the figure, the workshop to train Fig. 1.1: The PCA process Step 1: Situation analysis Fill out six forms and prepare a short report PCA Training workshop Training on the facilitation and the analysis of the roundtables Step 2: 5 roundtable discussions 1. Women of reproductive age (WRA) 2. Mothers, mothers-in-law and grandmothers of WRA 3. Male partners of WRA 4. Health care providers 5. Community leaders Step 3: Institutional rountable Prioritization workshop involving local authorities, key actors and community roundtable representatives Step 4: Final report • Situation analysis • Summary of the roundtable findings • Recommendations from the institutional roundtable discussion (inputs to develop action plan)

facilitators and note-takers for the roundtables will ideally take place after the situation analysis has been conducted (see section 1.8).

Each of these four steps will be discussed in more detail in the following sections of this guide. Table 1.3 contains a summary of the different activities to be undertaken before, during and after the PCA by the different levels involved (district, province and national). The amount of time required to conduct the PCA will depend on how much time and how many resources are available, and the team’s experience in participatory processes. In most cases the process of a complete PCA in a district, from the planning stage to dissemination of results, will take between three and four months. A suggested timeframe is provided in

Table 1.2, but note that different activities may run concurrently. When expanding the IFC framework to new districts in a province that has already conducted a PCA, actors may agree on an alternative methodology for planning IFC interventions after reviewing the PCA results. However, it is important to maintain the core principles of the IFC framework in the adaptation process, including participation and collaboration (see Module 1, section 2.16 and Module 5, section 2.1). Planning interventions based on results of a PCA requires less time and effort (usually a maximum of two to three months).

Module 3

Table 1.2: PCA timeframe Activity Situation analysis and report Training workshop (preparation and workshop) Preparation for the roundtables, including identification of participants Five roundtable discussions Summary report and preparation of institutional forum Institutional forum (preparation and implementation) Final report Timeframe 2-3 weeks 2 weeks 2 weeks 3 weeks (1-2 per week) 2 weeks 1 week 2 weeks

1.6 PRESENTATION OF THE IFC FRAMEWORK TO THE COMMUNITY Module 1 describes the need for advocacy and partnership-building activities to engage local actors in MNH generally and the IFC framework specifically. Once the district IFC committee and PCA team have been formed, an important preparatory step before starting the assessment is to engage local community members in the process. The district committee can organize community meetings with different groups and individuals to explain that there is interest in improving MNH in the community, to briefly present the IFC framework and the need for action in this area, and to raise interest and obtain support for the process. Community leaders need to be convinced that their involvement will not only create a successful MNH programme, but will also be worthwhile for them and their mission to serve their communities. Interested and relevant groups and individuals may also be integrated into the district committee. Mechanisms to keep the community informed of progress and to receive their ideas and feedback should be discussed – emphasizing that communities have a right to this information and to participate in the actions implemented in their community. Experience has shown that this first important step of sensitizing others to the work that is to be done is often overlooked, and affects collaboration in later steps.

Section 1: Overview of the PCA

1.7 PRINCIPLES OF THE PCA Partnership and collaboration The PCA and the IFC component are optimized when based on collaborative partnerships and intersectoral action at all levels (district, province and national). In order to achieve this, partnerships are built or strengthened both within the health system and with other sectors including: • local development committees, local health committees; • social networks and civil society organizations (e.g. women’s groups, NGOs, cooperatives, indigenous groups); • other public sector institutions (e.g. education, transport and local authorities); • religious groups and institutions; • different types of health services (e.g. hospitals, health centres, health posts, public and private, traditional healers); • other health programmes (e.g. Integrated Management of Childhood Illness (IMCI), sexually transmitted infections (STIs), HIV/ AIDS, immunizations, malaria, family planning, tuberculosis); • the private sector.

Capacity building The facilitation of the participatory process aims to develop the skills and knowledge of community members through a process of learning, sharing and analysing. The different actors involved in the PCA share their knowledge as well as their perspectives on problems, needs and local assets. The process allows the community to develop their capacities, as well as helping the health services develop an understanding of their communities. The PCA is therefore not simply a process of obtaining information from the community, but rather a first step in a process of dialogue, sensitization and empowerment.

Non-judgmental The PCA involves open discussion about the situation at the community level, and will at times explore sensitive topics. It is important to encourage people to talk and demonstrate that their views and knowledge are valued. The facilitators must avoid being critical or judgemental about people’s beliefs, values or behaviours. It is not intended to be an evaluation, but a forum for dialogue to identify needs and solutions.

Realistic expectations It is important to provide community members with clear information about the assessment and the objectives and likely results need to be explained clearly. Some situations are likely to raise expectations. Expectations should be addressed openly and honestly, and promises that may not be kept should be avoided. High and unrealistic expectations will lead to disappointment and loss of interest in participatory processes.

Listening and learning It is important that both facilitators and participants of the PCA be open to learning from each other, overcoming biases, allowing the learning process to happen in its own time, and to listening rather than lecturing.

Module 3

Voluntary participation Participation in the roundtables must be voluntary, (i.e. there must not be any coercion or pressure to participate). Participants can only make a decision to participate after having been fully informed of the PCA process. Participants need to know that they can withdraw their participation at any time without any consequences.

Gender equity Gender considerations are integral to the PCA, and the process tries to promote gender equity by assessing the views and opinions of both male and female participants. Particularly in those roundtable discussions where both men and women participate (such as providers or community leaders), facilitators should be aware of any gender inequities during discussions – for instance, if women are not participating and men are dominating the discussion. Any difference between the opinions of men and women should also be noted and taken into account when analysing results. Moreover, gender considerations will ideally remain prominent throughout the process of conducting the PCA and analysing results. This may include reflecting on how gender roles, identity and stereotypes for both men and women influence MNH (e.g. men’s involvement in MNH or women’s involvement in household decision-making processes).

Confidentiality A PCA may involve discussion of sensitive subjects. Facilitators must respect the confidentiality of community participants at all times during the process. It is the responsibility of the PCA team to agree beforehand how information will be shared in reports (e.g. names should not be used). They are also advised to develop a procedure for storing documents (such as the registration forms or the notes of the discussions) with potentially sensitive information and when these documents will be destroyed. It is essential that community members do not suffer any consequences as a result of disclosing personal information during the discussions. This can be avoided by focusing discussions on “typical people” rather than on the individual participants. For example, rather than asking participants to discuss their own problems, the facilitator can ask participants to discuss problems considering their own reality as well as others in the local area. It is important that all participants in the PCA are aware that the information discussed is confidential and not to be shared outside the roundtable. Nevertheless, it is also important that participants understand this confidentiality cannot be guaranteed; for instance, the IFC committee and PCA team do not have control should a participant break this confidentiality rule.

Cultural considerations The PCA team will ideally be living in the local area. However, the team members will benefit from an awareness of differences between themselves and other members of the local communities they are working with, including gender, socio-economic status, religious orientation, ethnic group and language. Understanding these differences will help not only in discussing MNH issues with the different community groups, but also in analysing the information and determining appropriate action plans. An intercultural assessment process must be sensitive to the history, needs, strengths and resources of different community groups, and consider how to address the situation and needs of these groups.

Section 1: Overview of the PCA

1.8 THE PCA TRAINING WORKSHOP An essential aim of the IFC framework is to build the technical capacity of all those working in MNH to work within the IFC framework and with participatory processes. In many settings, those working in MNH have no experience in processes such as the PCA, and therefore it will be important to conduct a training workshop. The training guide is presented in Module 4 of the IFC Implementation Toolkit, and includes detailed session guides for trainers and handouts for participants. The training workshop is designed to span 4.5 days and includes a practice roundtable discussion with analysis and feedback. Timing of the training: Ideally, the situation analysis will be conducted prior to the training workshop, so that the PCA team can share preliminary results during the workshop. If possible, those attending the training will have previously attended the IFC orientation workshop. Participants: The PCA team (including coordinators and facilitators) from the district level, as well as those working on the IFC implementation at the province and national levels that will be supporting the district level are invited to attend the workshop. Trainers: The expert facilitator will generally be responsible for training the local group, with support from national and province partners. In order to optimally perform this role, the expert facilitator should be familiar with the IFC framework and have previously conducted a PCA training. Training objective: To train the district PCA team and other provincial and national representatives on the PCA methodology and instruments to be used. Key themes/sessions: • A review of the IFC framework and the key concepts; • Review of the situation analysis results; • Review and adaptation of roundtable discussion guide(s); • Training on facilitation, group management, and note-taking skills for the roundtable discussions, including communication skills and synthesis skills for facilitators; • Analysis and report-writing from the roundtable discussions; • Preparation for the roundtable discussions (including logistics and participant identification); • Practice roundtable discussion with a community group, including analysis and report-writing; • Preparation for the institutional forum; • Preparation of the final report. The practice roundtable discussion provides an opportunity for the facilitators and note-takers to run through an entire roundtable discussion, as well as for the PCA team to ensure the organizational and logistical requirements have been met. If the practice discussion goes well, the results can be used in the final report and it will not be necessary to repeat that roundtable.

Note: It is important that the PCA team ensures that participants are invited to this practice roundtable ahead of time, and will therefore need to organize it before the training workshop begins. The national and province coordinators can help the PCA team to organize this, if needed.

Module 3

Table 1.3: Summary of activities before, during and after the PCA National and province levels • Define the terms of reference of the coordination committees (see Module 1, Annex 1). • Identify the “strategic partners” and “stakeholders” for the IFC component at national level. • Develop a plan for implementation of the IFC framework at national and province levels, and identify the required resources (human and financial). • Identify one or two expert facilitators at national or province level. • Conduct a national inventory of experiences in IFC-related work. • Identify the initial IFC intervention district, in coordination with province and district level actors, according to the specified criteria (see Module 1). • Identify the key moments of interaction between the district, province and national levels. At province level, identify a representative to participate in the district and national committees. • At national level, review the PCA instruments for a first adaptation to the national context. • Support the district level in the different stages of the PCA. • Find pertinent information for the situation analysis (national statistics, research in the area, programme/ project reports in the area). • With the district level, organize a training workshop for the PCA and participate in the training. Organize followup, according to needs. • Participate in pertinent meetings during the PCA (situation analysis, roundtable discussions, analysis meetings, institutional forum). • Review and comment on the PCA reports. District level • Review and revise the terms of reference of the district committee (see Module 1, Annex 1). • With the support of the province and national committees, develop an initial plan for the implementation of the IFC framework at the district level, and identify resources (human and financial) that are required. • Present the IFC framework to local actors in the community and identify the “strategic partners” and the “stakeholders” for the district committee (or broaden the existing district MNH committee). • Select the IFC committee chair(s). • Identify a local IFC coordinator. • Identify local facilitators for the PCA.

Before the PCA

• Conduct the situation analysis: ° Collect data and pertinent reports ° Organize meetings for filling in and/or reviewing data collection forms ° Write up the draft report. • With the national/province level, organize a training workshop for the PCA and participate in the training. • Review the roundtable discussion guide, taking into account the results of the situation analysis (with support from the national and province committees). • Organize the roundtable discussions, including identification of participants, logistics and facilitation. • Carry out the five individual roundtable discussions, including meetings for analysis, and writing up reports. • Write up the summary report of the five roundtables. • Organize and conduct the institutional forum, including compiling the report with information collected. • Write up the final report. • Present the results of the PCA to the district MNH/ IFC committee(s) and other strategic partners and community actors. • Organize a workshop for documentation of lessons learnt from the PCA, jointly with the national level, including the revision of PCA instruments. • Organize, jointly with the province level, a process to develop a detailed action plan based on the draft plan. • Manage the implementation and regular monitoring of IFC activities. • Evaluate the initial implementation of the IFC component. • Disseminate results from monitoring and evaluation. • Organize a workshop for documentation of lessons learnt from IFC implementation, jointly with the national level. • Support the scaling-up of the IFC framework to other districts within the province.

During the PCA After the PCA

2. SITUATION ANALYSIS 2.1 AIMS OF THE SITUATION ANALYSIS The situation analysis provides an overview of the situation of MNH and community structures at the district level. The data collected during the situation analysis is used for the following purposes: • to orient the district, province and national IFC committees to the situation in the district related to MNH, including some of the key challenges and opportunities for improving the situation; • to identify the local actors (organizations and individuals) that can be invited to participate in some of the roundtable discussions; • to provide information that will help the PCA team determine which themes to explore in more depth during the roundtable discussions; • to provide information on MNH and the IFC component in the district that will be presented during the roundtable discussions and during the institutional forum (see Annex 3 and Annex 5); • to provide important information that can then be studied during the institutional forum and the joint planning process (after the PCA).

2.2 WHEN TO DO THE SITUATION ANALYSIS? The situation analysis is ideally conducted after a district IFC committee has been formed, after the members of this committee have attended an orientation workshop on the IFC framework, and after the members of the PCA team have been identified (see section 1.5). Preferably it is conducted before the training on the PCA so that the results from the situation analysis can be presented and reviewed at the PCA training workshop (see Module 4). Information compiled and analysed in this phase will be used in the roundtable discussions, and therefore the situation analysis is not designed to be conducted at the same time as the roundtables.

Module 3

2.3 CONTENT OF THE SITUATION ANALYSIS Annex 2 contains the forms used to conduct the situation analysis. These forms are designed to facilitate the analysis of the local situation by organizing the information available: Form 1: Description of the local area Form 2: Statistics on maternal and newborn health in the local area Form 3: Health services in the district Form 4: Inventory of institutions and organizations present in the local area Form 5: Inventory of experiences in community health and participation Form 6: Inventory of research in the local area Map of the district: During the collection of data for the situation analysis, it is advisable to create a map of the implementation site to locate various different elements. This is described on the first page of Annex 2.

2.4 SOURCES OF INFORMATION It is important to note that many countries have previously carried out studies or evaluations of the MNH situation or of social and economic development indicators. Form 6 will help the local group identify the studies and evaluations that might contribute to the situation analysis. The following sources of information can also be considered: • demographic and health surveys; • vital statistics; • epidemiological surveillance systems; • government censuses; • service statistics (health centres, hospitals, health posts); • household surveys; • quantitative and/or qualitative research or published studies of the area carried out by the Ministry of Health, NGOs, universities or others (identified using Form 6); • reports on human or social development (e.g. from United Nations Development Programme (UNDP), United Nations Children’s Fund (UNICEF), the World Bank); • published studies of the area (identified using Form 3); • reports of community dialogues or focus groups; and • municipal/district authority reports or surveys.

Section 2: Situation analysis

2.5 WHO SHOULD COMPLETE THE SITUATION ANALYSIS? Generally the local coordinator is responsible for collecting the information, with support from the local facilitators. In some settings, the PCA team may need support in conducting the situation analysis. The national and/or province committees can organize support for this process as required. Representatives of the province and national committees may support the local team by helping to identify sources of data, to understand the meaning of the data collected, or identify any problems with the data. Once the data has been collected, the forms can be filled in by one or two people. The coordinator can then organize a meeting to allow other committee members to review what has been compiled and make suggested changes.

2.6 REPORT OF THE SITUATION ANALYSIS The suggested format for the situation analysis report comprises five key components: 1. Methodology (brief description of the process of data collection and sources used) 2. The six data collection forms (and map, if available) 3. Summary paragraph on the MNH situation 4. A written summary of “Challenges and opportunities for MNH” 5. A PowerPoint presentation summarizing the key data After the forms have been completed, we suggest that the PCA team synthesize the data collected. First, they may write up a one-paragraph summary of the current situation of MNH in the local area, using the key MNH statistics collected in Form 1. They can note here if there are any differences between the local situation and the national situation. Then they can summarize the data in a section on “Challenges and opportunities for MNH”. By reviewing the forms, they can make an assessment of the challenges to MNH in the local area, as well as the positive factors that have been identified. Then they can determine whether the data can tell them anything about the challenges and opportunities in each of the four priority areas of intervention of the IFC framework. Finally, in addition to this written synthesis, the team is also advised to prepare a PowerPoint presentation of the results of the analysis. This presentation can be reviewed during the PCA training workshop and modified according to the input received by participants. This presentation will then be used during the roundtable discussion and may also be used as an advocacy tool, such as when introducing the IFC framework to other stakeholders. It is preferable to prepare a presentation that is concise, generally not exceeding 15 slides (see Box 2.1 for suggested format).

Module 3

Box 2.1: Suggested format for situation analysis PowerPoint presentation 1. Description of the local area (3 slides): Characteristics of the location and population; economic activity; education levels; transport services; other basic services; communications and media (Form 1). 2. Description of the national, province and district situation in MNH (3 slides): Recent trends in MNH; current situation in MNH; any differences in MNH between the district area and the national situation (if applicable); any differences in MNH between urban and rural areas; other important health trends in the local area (e.g. breastfeeding, use of family planning, HIV/AIDS, abortion, female genital mutilation, violence); utilization of maternal and child health services (Form 2). 3. Health services in the area (3 slides): Service network; health personnel; communication and referral systems between the different levels of the health system; availability of health education materials; monitoring, evaluation and epidemiological surveillance (Form 3). 4. Institutions and organizations in the area (1 slide): Description of present institutions, organizations, stakeholders, and level of coordination between the different groups (Form 4). 5. Activities in MNH and IFC (1 slide): Summarize what is being done to improve MNH in the local area (Form 5). 6. Summary of key research findings in the local area (1 slide): Discuss any important or relevant research findings (if any were identified) (Form 6). 7. Summary of challenges and opportunities for MNH in the district (2 slides): Use the synthesis described above to summarize key challenges and opportunities found in the data. When preparing the presentation it is important to adapt it to the audience being addressed, assuring that the information presented is accessible and easily understood. For example, if used during the roundtable discussions, it may need to be substantially simplified, such as in making complex statistics or terminology understandable to the lay person.

3. THE ROUNDTABLE DISCUSSIONS 3.1 WHY CONDUCT ROUNDTABLE DISCUSSIONS? to benefit them. This PCA contributes to allowing them to become “actors” rather than “beneficiaries”. Roundtable discussions allow the opportunity for: • understanding the cultural and social context of the community from the perspective of different stakeholders; A roundtable discusión in Sonsonate, El Salvador

The second stage of the PCA is a series of roundtable discussions with different community groups. Before presenting the methodology for these roundtable discussions, it is important to identify the rationale for using this approach. Roundtable discussions provide a platform to listen to what various stakeholders within the health system (women, families, representatives of community groups, decision-makers, NGOs, etc.) wish to communicate with respect to the MNH situation and possible solutions. It is a forum to initiate the process of empowerment of different stakeholder groups by supporting their active participation in the IFC implementation. It is also an important part of a right-based approach as it allows community members to not only have a voice but also to participate in designing the interventions that are meant

• identifying socioeconomic determinants of MNH in the area that do not easily surface during non-participatory analyses; • listening directly to women and their families on their MNH needs and the changes and improvements expected by the community; • exploring possible solutions to respond to these needs; • promoting dialogue between women, their families and community representatives and health service providers, and giving participants the opportunity to relate to different people, exchange ideas, and reflect on what has been said and heard; and • identifying other stakeholders who can collaborate in the process of improving MNH.

Module 3

3.2 OVERVIEW OF THE ROUNDTABLE DISCUSSION GROUPS Each discussion group ideally includes 15-20 participants. We suggest holding five roundtable discussions, one for each of the following groups: 1. Women of reproductive age 2. Male partners of women of reproductive age 3. Other influential family members/household decision-makers (i.e. mothers, mothersin-law and grandmothers) of women of reproductive age4 4. Community leaders 5. Health care providers See Table 3.1 and section 4.3 for more information on the profiles for each roundtable and the identification of the participants. In roundtable discussions where the group includes women and men (e.g. community leaders, health-care providers), the PCA team is advised to aim for achieving gender parity to attain a balance in gender perspectives. The district, province and national committees may consider adding roundtables with other groups or eliminating some of the roundtables, to adapt to the local context and characteristics of the area. For example, if the situation analysis indicates that adolescent pregnancy is a significant problem and cause of maternal mortality and morbidity, discussion groups could be organized with adolescents and parents of adolescents. Or the situation analysis may show that certain groups such as TBAs play a very important role in maternal and newborn care, and so a separate discussion could be held with them. We suggest organizing the roundtables to take place in locations within the community itself. This contributes to providing a neutral and natural environment where power relationships are minimized and also reduces the burden of travel for participants. Each roundtable is designed to run like a workshop with a mix of plenary sessions and group work and to last a maximum duration of four and a half hours.

These influential family members will generally be women; however, if the IFC committee determines that it would be worthwhile to invite male household decision-makers who are not partners, it is advisable to hold a separate roundtable discussion for this group.

Section 3: The roundtable discussions

3.3 REVIEW OF THE ROUNDTABLE FACILITATION GUIDE Before beginning to organize roundtables, we strongly suggest that the PCA team review the roundtable facilitation guide (provided in Annex 3) in order to adequately prepare for the discussions. A first review and adaptation of the guide will generally have already been carried out by national representatives. Based on this adaptation, the PCA team and district committee can make further adaptations using their knowledge of the local situation and the findings from the situation analysis. It is also important to adjust the guide so that the session does not last more than four and a half hours. Time is set aside during the PCA training workshop for review the guide, but it may be helpful for the team to conduct an initial review and suggest changes. Box 3.1 provides some considerations for adapting the PCA guide.

Box 3.1: Considerations for adapting PCA guides Terminology: Replace generic terms with more appropriate local terms. If local groups speak their own dialect or language, the roundtable discussion guide will also need to be translated. Health problems/needs: After conducting the situation analysis, the group will have a clearer idea of some of the key health problems affecting local communities. The guiding questions can be adapted to ensure that important local problems are discussed and addressed. For example, the situation analysis may show that violence during pregnancy is a major concern. If this is the case, then specific questions could be added. Cultural practices: Questions can be added to the roundtable facilitation guide to ensure discussion of cultural practices and beliefs that exist in certain areas, for example, adding questions on female genital mutilation.

3.4 VOLUNTARY PARTICIPATION Informed consent is a term used in research to ensure that researchers follow principles of ethics, in particular that they recognize a participant’s right to make an informed choice to participate in the research. Although the PCA process is not research, it is important to make sure that roundtable participants know the purpose of the PCA, are participating of their own free will and understand that they can decide to withdraw at any point without consequences. There are several moments that voluntary participation can be addressed: when recruiting participants, when registering the participants, and when opening the roundtable. Some points to cover when explaining the voluntary nature of their participation include: • describing the objectives of the PCA; • describing the process of the PCA; • explaining what the results of the roundtables will be used for; • explaining what will be done with the infor-

Module 3

mation collected following the roundtables (i.e. registration forms how will they be stored, when will they be destroyed); • explaining that their participation is voluntary and they can withdraw their participation in the roundtable at any time without any consequences;

• explaining that participants will be reimbursed for their travel expenses; • providing participants with contact information for a person who can be contacted if they have questions (i.e. a local PCA coordinator).

3.5 IDENTIFICATION OF PARTICIPANTS AND ROUNDTABLE LOCATIONS With the support of the local coordinator, the PCA team identifies who will represent each category of community stakeholder in the individual roundtable groups. Table 3.1 below indicates the different profiles suggested for each roundtable discussion (including the institutional forum). The district coordinator generally is responsible for managing the process of identifying and inviting participants. Since the roundtables aim to assess the situation of a large and diverse population within a district, the local coordinator and PCA team are advised to take measures to ensure that the roundtables are representative of the different geographic, ethnic and socio-economic “communities” living in the district. For the roundtables involving health care providers and community leaders, as well as the institutional forum, it will usually be easiest to organize the meeting in a central location in the district, and to invite participants from a range of locations (urban and rural) within the district. Forms 3 and 5 from the situation analysis (Annex 2) can be used to help identify providers and community leaders who could be invited to the meetings. For the roundtables involving women, husbands/ partners and influential family members, it is particularly important to ensure the representation of poor and marginalized groups, and specifically of communities that have a high burden of maternal and neonatal morbidity and mortality. This is critical to a rights-based approach and can contribute to reducing health inequities. Usually, participants from these groups live in rural villages and may find it hard to travel to a central location. Therefore, it is important to try to organize these roundtables in villages or small towns that are more accessible to participants. To ensure a diverse group that can touch upon different situations, it is advisable to invite participants from at least two or three different villages nearby. Where relevant, transport costs for participants may be provided and the agenda organized so that participants can have adequate time for travel.

Section 3: The roundtable discussions

Box 3.2: Tips for organizing roundtables • Determine the date, hour and location for the roundtables before inviting participants. Choose convenient dates and times for the community, and an accessible location. • Invite 20-25 persons for each roundtable, aiming for a minimum of 15 persons per roundtable. • Aim to have at least one person per specified characteristic for the roundtable (see Table 3.1). • Explain the importance of participation, however emphasize that their participation is voluntary. They have a right to stop or withdraw their participation at any time. • Assure participants that the discussions will be confidential. • Guarantee the participants payment of transport and refreshments, as well as childcare for the children of female participants. • Confirm that the roundtable will last approximately four and a half hours. • For the roundtables with health care providers and/or community leaders, it may be necessary to prepare invitation letters or conduct personal visits to explain the discussions and the importance of their participation. • Give a reminder leaflet to each participant, with the place, time and date of the roundtable. • Fill out a registration form for the identification of the participants (name and address, assigned roundtable and profile (Table 3.1), number and ages of accompanying children).

In areas where there are many poor people in central urban areas, the team is strongly encouraged to ensure that participants from these neighbourhoods are represented. In this case, there are two options: either organize the roundtables in a central location, and invite both rural and urban participants (with transport arranged for rural participants), or alternatively, organize an extra set of roundtables to consider an urban setting and a rural setting. The PCA team and district IFC committee can weigh the costs and benefits of organizing the roundtables in different ways. When deciding whom to invite, the group can enlist the assistance of local community members who know the area well and can help

the team identify participants who represent the criteria in Table 3.1. The local health services may also have records of families who have had an obstetric or neonatal emergency. Community health workers (CHWs) are also a good source of knowledge to identify participants. When inviting participants, explain the objectives of the roundtable and how results will be used. Also explain that participation is voluntary and confidential (see section 3.4). Ask if they have any questions and provide them with contact information of a person connected to the roundtables.

Module 3

3.6 ORGANIZATION OF THE ROUNDTABLE DISCUSSIONS A checklist for organization of the roundtables is included in Annex 6. The steps to be followed for organizing the roundtable discussions are as follows: 1. Develop a specific timeline of activities for the organization of each of the individual roundtable discussions and the institutional forum. 2. Identify the venue for the roundtables – a comfortable, private, and well-ventilated room with a roundtable or rectangular tables that can be placed in a u-shape, with comfortable chairs or benches. If the room does not have a table, place the chairs in a circle in such a way that all the participants can see each other. Make sure that there are areas for small group work, either in the same room or in separate rooms. Section 3.5 above provides some guidance on where in the district roundtables may be held. 3. The meeting place should have an additional room where the child minders can care for the children of the women who are participating. 4. Organize for child minders to be present during the roundtables that require this service, normally the roundtables with women and maybe those with other influential family members (grandmothers, mothers-in-law). Organize materials that they will need including diapers/nappies, paper and colouring crayons, etc. so the children can draw and play. 5. Make arrangements for refreshments for the participants, their children, child minders, facilitators, note-takers, and observers. It is important to remember that community members arriving at the roundtables may be hungry because of travel time, poverty or food shortages, so you may want to have a snack ready before starting the roundtable work. 6. Organize transport or payment of transport for the participants, where relevant. 7. Purchase and prepare the required materials (see Annex 6). 8. Ensure that facilitators and note-takers have a copy of the revised roundtable facilitation guide. 9. Prepare a short presentation on the situation analysis, the MNH strategy and the roundtable objectives (see Annex 3). 10. Have educational materials on MNH available to distribute to the participants after the roundtables. 11. Prepare the flipchart sheets to be used in the discussions (see Annex 3). 12. Prepare blank name cards that participants can use to write their names on.

Section 3: The roundtable discussions

Table 3.1: Proposed participant profiles, with their characteristics, for the roundtable discussions The PCA team is advised to ensure that the roundtables include people with the specified characteristics listed below. Some people may represent several characteristics (for example, a woman may be selected who has a newborn, and who had an obstetric emergency) 1. Women of reproductive age * 2. Husbands and partners of women of reproductive age 3. Other influential family members (i.e. mothers, mothers-in-law, grandmothers) of women of reproductive age Influential family members of: • Pregnant women with at least one child younger than four years old • Women who have newborn babies • Women who gave birth at home assisted by a TBA • Women who gave birth at home with a skilled attendant • Women who gave birth in a health facility • Women who had an obstetric emergency • Women whose newborns had some type of emergency

• Pregnant women with at least one child younger than four years old • Women who have newborn babies • Women who gave birth at home assisted by a TBA • Women who gave birth at home with a skilled attendant • Women who gave birth in a health facility • Women who had an obstetric emergency • Women whose newborn had some type of emergency * Excluding: women awaiting their first birth; well-known leaders in women’s organizations, community, religious and/or political groups; TBAs 4. Community leaders • Representative of TBAs • Representative of health volunteers • Representative of traditional healers or doctors • Representative of community/ neighbourhood leaders • Representative of women’s groups • Representative of neighbourhood councils or rural syndicates • Representative of civic or communal committees • Representative of religious groups • Representative of political groups • Representatives of indigenous groups

Husbands or partners of: • Pregnant women with at least one child younger than four years old • Women who have newborn babies • Women who gave birth at home assisted by a TBA • Women who gave birth at home with a skilled attendant • Women who gave birth in a health facility • Women who had an obstetric emergency • Women whose newborns had some type of emergency

5. Health care providers • Midwives • Obstetricians/gynaecologists • Paediatricians • Doctors (generalists) • Nurses • Health promoters • CHWs • Nurse and midwife auxiliaries • Administrative personnel • Pharmacists • Health educators • Psychologists or social workers

6. Institutional forum • Representative of district political authorities (mayor, governor, etc.) • Representative of district health authority • Representative of district education authority • Representative of district transport authority • Representative of religious institutions • Representatives of NGOs that work in health and especially in MNH • Representatives of the private/ business sector • Representatives of indigenous leaders • Community representatives (two participants elected from each individual roundtable) • Representative of mass media

Module 3

3.7 STRUCTURE OF THE ROUNDTABLE DISCUSSIONS The facilitation guide for the individual roundtables can be found in Annex 3. Those organizing and facilitating the roundtable are advised to study this annex in detail. It is estimated that each roundtable will last four and a half hours (half a day’s work). The aim of the roundtables is to discuss the situation and problems in the community related to MNH. Participants will work in three small groups to discuss issues related to the four priority areas of intervention of the IFC framework: 1. Care of the pregnant woman, mother and newborn at home (i.e. developing CAPACITIES) 2. Support in the community for the pregnant woman, mother and newborn (i.e. AWARENESS of MNH rights, needs and problems AND LINKAGES for social support). 3. Care received from the health services for pregnant women, mothers and newborns (i.e. improving QUALITY). Participants first discuss the current situation in their community in these areas, and then identify a list of problems in each area. They also identify and note any positive factors (opportunities) in their community. Afterwards in plenary they select three priority problems in each priority area together. They also brainstorm about possible actions to help solve these problems. The institutional forum, discussed in section 4, will focus more on actions than these discussions. At the conclusion of the discussion, the group will need to select two representatives who will present the outcomes of their discussion and represent their group during the institutional forum. Since the time for the roundtable is limited (half a day), the agenda contains only group work and plenary discussion. It is possible, however, to adapt the guide to make it more interactive. Some suggested participatory activities are contained in Annex 7.

Section 3: The roundtable discussions

3.8 FACILITATION AND NOTE-TAKING DURING THE ROUNDTABLE DISCUSSIONS The local coordinator is typically responsible for organizing the facilitation teams for each roundtable discussion, according to availability and needs. For each roundtable a team of six is recommended, which would generally include: • Three facilitators: One facilitator for each small group. During the plenary sessions, one can facilitate while the others help take notes on the flipcharts and help to organize participants. See Box 3.3 on guidance for the selection of facilitators. • Three note-takers: One note-taker per small group. During the plenary two can take notes and the other can help organize the room and participants. Note-takers must have the capacity to synthesize and summarize the ideas with precision. The facilitators and note-takers can also assist with the registration of participants, the organization of the refreshments, the child minders and payment of transport costs, among other tasks. The note-takers and facilitators can switch roles, so long as each group has a skilled facilitator.

Box 3.3: Selection of facilitators ✓ Have experience in managing groups (group dynamics, active listening, managing situations of conflict or that involve the imposition of opinion or power of participants) ✓ Are dynamic ✓ Are familiar with the facilitation guide ✓ Are of the same sex as the group (female facilitators for women’s groups, and male for men’s groups), if feasible or if required ✓ Have a thorough knowledge of MNH and the IFC framework and its interventions ✓ Are neutral (they should not display political or religious affiliations or ideologies during the discussion) ✓ Are not well-known in the local area, such as well-known health facility staff or a well-known local leader (if well-known health services staff or public figures facilitate, participants may fear to criticize or speak their opinions about health and other public services) ✓ Are non-judgmental, unprejudiced, open-minded and willing to learn from the community ✓ Have good communication skills, including use of appropriate, simple and clear language and good listening skills ✓ Are able to speak local language(s) (if applicable) ✓ Are patient and able to work in a team ✓ Are culturally sensitive, and aware and respectful of local customs, norms and beliefs

Module 3

Observers may also be present, although it is recommended not to have too many observers during the roundtables. If interested, selected representatives of the province or national committees could attend some of the roundtables. We suggest no more than two observers. Carefully consider whether they will have any effect on the dynamic of the group or the participants’ ability to speak freely (for example, a well-known health authority representative). They can assist by taking notes and with analysis of the discussions. At no time should they participate directly in the discussion. Some points to remember during the facilitation of the roundtable discussions are: • The task of the facilitators is to promote the exchange of ideas, accepting that there are no correct or incorrect answers or comments. The task is to promote a dialogue among the participants that will identify MNH needs, problems and possible solutions.

• If during the session the participants have questions regarding MNH or if someone provides incorrect information, the team should make note of the point and clarify any doubts and points discussed at the close of the meeting. The facilitators can also provide leaflets on MNH, where possible. • The facilitators should be prepared to adjust the agenda in response to sudden changes, such as late arrival of participants, lack of a meeting space, shortage of materials, the unexpected absence of a team member. Keeping the objectives in mind will help the assessment team decide how to respond to changes and challenges. • The facilitators should remember to inform each group what the next steps are in the process after the roundtable discussions.

3.9 ANALYSIS AND REPORT OF THE ROUNDTABLE Soon after each roundtable discussion, preferably the same afternoon or next day, the PCA team meets to discuss the roundtable and analyse the discussion and the information that was collected. Observers from the province and national committees who participated in the discussion can also help in the analysis of information. Annex 4 contains the analysis form that can be filled in after each individual roundtable. Each analysis form, once filled in, will serve as a report of the discussion.

Section 3: The roundtable discussions

3.10 SUMMARY REPORT FROM THE ROUNDTABLES After the roundtables have been completed, a summary report of all five discussion groups needs to be written. We suggest keeping the report concise, limiting it to ten pages. A suggested format for the report is provided in Box 3.4. To summarize the problems, opportunities and actions from the five different groups, the team can use Table 3.2. They can write up four tables, one for each priority area of intervention of the IFC framework. They should eliminate repetition of problems, opportunities and actions among the different groups and ensure that they are placed in the relevant area of the IFC framework. After the summary report has been written, it is useful to have the entire PCA team who participated in the roundtable discussion review it.

Box 3.4: Suggested format for roundtable summary report 1. Short summary of participation in each roundtable (including characteristics of participants and the dynamic of the discussion) 2. Summary of the table of priority PROBLEMS, OPPORTUNITIES and ACTIONS for MNH in the community: • Care in the home of the pregnant woman, mother and newborn; • Awareness of the rights, needs and potential problems related to MNH; • Linkages for social support between women, families, communities and between; communities and the health delivery system; • Quality of care received from the health services. Annex: • Analysis forms from each individual roundtable.

Module 3

Table 3.2: Compilation of priority problems, opportunities and solutions from the roundtables (with example included from Topic 2) Fill out one table for each priority area of intervention of the IFC framework (developing CAPACITIES, increasing AWARENESS, strengthening LINKAGES and improving QUALITY). The classification scheme below may be used to identify the roundtables. These will later be used for the analysis of the roundtable (see Annex 4). Below is an example of “Strengthening Linkages”. Priority area of intervention 3: Strengthening LINKAGES for social support between women, families, communities and between communities and the health services Priority problems identified (and by which group?) Pertinent quotes on this problem (said by which group?) Opportunities to help solve this problem Actions identified to help solve this problem (and by which group?)

For example: • Difficulties in travelling to the health facilities (W, G, M, P)

For example: • “There is no point even trying to get to the hospital…it takes at least four hours to get there and by that time it will be too late” (M)

For example: • New mayor committed to improving the state of the roads

For example: • Adapt public transport schedule to the needs of the population (W,P) • Free of charge transport for children and pregnant women (M, P, G) • Repair the roads (L,G)

W = woman’s group, G = grandmothers and mothers-in laws, M = men’s group, L = community leaders, and P = health care providers

4. THE INSTITUTIONAL FORUM

4.1 AIMS AND OBJECTIVES OF THE INSTITUTIONAL FORUM The institutional forum is very similar to the other roundtable discussions in structure, but it has a slightly different aim. The aim of the institutional forum is to bring together local community members, community decision-makers and representatives of relevant institutions to present the IFC framework within the local MNH strategy, review the findings of the individual roundtables, and reach a consensus on the actions needed to help address the problems identified.

4.2 TIMING OF THE FORUM The institutional forum is longer than the other roundtable discussions as it is designed to last 1.5 days. It is ideal to organize it at least two weeks after the final individual roundtable in order to allow enough time to finalize the summary report, invite participants and prepare for the meeting.

4.3 INSTITUTIONAL FORUM PARTICIPANTS The institutional forum will include more participants than the roundtable discussions; however, it is advisable to not exceed 30 participants. As noted in Table 3.1, the institutional forum may include the following institutional stakeholders from the community: • representative of district political authorities (mayor, governor, etc.); • representative of district health authority; • representative of district education authority; • representative of district transport authority; • representative of religious institutions; • representatives of NGOs that work in health and especially in MNH; • representatives of the private/business sector; • representatives of indigenous leaders; and • representative of mass media. In addition to these different local stakeholders, this roundtable will normally also include: • two representatives from each individual roundtable (ten in total); • members of the district IFC committee who are not already participating as facilitators or note-takers; and • one or two representatives of the province and national IFC committees.

Module 3

4.4 PREPARING FOR THE INSTITUTIONAL FORUM The following steps are important for preparing for this forum: 1. The PCA team delivers the invitations to the selected representatives and asks them to confirm their participation, both in verbal and written form. Inform them of the location, date and time of the session. It is important to inform them that the workshop will last 1.5 days. Participants representing the individual roundtables should be reminded of the date of the institutional forum. 2. The PCA team meets with the participants representing the individual roundtables to brief them on what will happen at the institutional forum. They explain that the purpose of the institutional forum is to provide an opportunity for policy-makers to meet and discuss the findings from the different community roundtables. The role of the representatives is to help explain the findings of the community roundtables and to make sure these are considered during the institutional forum. Remind them that the same rules will apply, including maintaining anonymity and confidentiality (i.e. do not mention specific names) of the other participants from the community roundtable which they are representing. 3. The PCA team prepares presentations in advance. They may also need to revise the presentations prepared for the individual roundtables, taking into consideration that the educational level of this group may be higher. Since this workshop lasts 1.5 days, there is also more time available. They are advised to prepare: a. presentations of the MNH strategy at national and/or province level and district level (including the IFC component); b. a presentation of an overview of the IFC framework, the PCA and their objectives; and c. a presentation of the situation analysis findings (see section 2.6). The team should select in advance who will prepare these presentations, and practice them beforehand if needed, remembering to use simple language and terminology (see Annex 5 for more information). 4. They will also need to prepare other workshop materials, including: a. flipchart sheets summarizing the problems identified in the individual roundtable discussions (see Table 1 in Annex 5); b. handouts (photocopied) summarizing the priority problems and actions identified in the individual roundtable discussions (see Table 2 in Annex 5); c. a scoring chart for actions, either as photocopies or as a large flipchart (see Table 3 in Annex 5); d. activities charts, either as photocopies or as a large flipchart (see Table 4 in Annex 5); and e. copies of the IFC framework strategic document for group work. It may be helpful to practice a run-through of the forum, to ensure all the preparations have been made.

Section 4: The institutional forum

4.5 FACILITATION OF THE INSTITUTIONAL FORUM The workshop agenda and facilitation guide for the meeting is contained in Annex 5. The local coordinator needs to decide who is going to facilitate this forum. Since four small groups will be involved in this workshop, eight facilitators/ note-takers will be required. The province or national committee members may be able to help facilitate the group work. The institutional forum involves the following steps: 1. Introduction of the IFC framework, its objectives and priority areas of intervention; 2. Review of the results of the situational analysis and the five individual roundtable discussions (including priority MNH problems and actions); 3. Reaching a consensus on the priority problems and needs facing the communities of the district; 4. Review of the solutions proposed in the individual roundtable discussions and reaching an agreement on the recommended priority actions to contribute to improving MNH; and 5. For each priority action selected, identification of specific activities, actors to be involved and their roles, and the necessary resources, including the existing resources that can be leveraged in the development of subsequent plans.

4.6 REPORT OF THE INSTITUTIONAL FORUM It is advisable for the facilitation team to meet soon after the workshop to write up a brief summary of the meeting. They may want to include the following information: 1. The meeting participants: • verify that the participant registration form is complete and annex it to the report; and • write a summary of participants including number of participants, where they come from, age ranges, and characteristics/ profile. Also note the number of facilitators, note-takers and observers. 2. Reflection on the dynamic of the discussion: • Did some people participate more than others? Who participated more? Who participated less? What were the reasons? • Were there any interruptions? • Were there any problems in the discussion? (points of disagreement, problems reaching consensus, issues that need to be resolved in later discussions) 3. Type up the results of the meeting into clean tables: • the list of prioritized problems; • the actions identified and the actions prioritized; • Table 3: The scoring chart, including the prioritized problems and prioritized actions; and • Table 4: The activities chart.

Module 3

5. FINAL REPORT AND RESULTS DISSEMINATION

5.1 WRITE-UP OF THE FINAL REPORT The final PCA report contains the compiled information from the three key PCA activities: • the situation analysis; • the roundtable discussions and summary report; and • the prioritized problems and actions from the institutional forum. Box 5.1: Suggested format for PCA Final Report 1. Executive summary (one page) 2. Background information on the PCA (including objectives) 3. Situational analysis a. Methodology of the situation analysis, including sources used b. Situation analysis report 4. Roundtable discussions a. Methodology for the individual roundtable discussions b. Summary report of the five roundtable discussions 5. Institutional forum a. Methodology for the institutional forum discussion b. Summary report 6. Conclusions and recommendations of the PCA 7. Annexes a. Completed forms from the situation analysis b. Summary description of the participants from the roundtable discussions c. Analysis forms of the five roundtable discussions d. Tables from institutional forum The local coordinator can draft the report, including the concluding paragraphs, and then meet with other team members to allow for review and comments. The expert facilitators and representatives from the province and national level can also help review the document. The report will usually be written by the local coordinator, with support from the PCA team and expert facilitator(s), as well as from the national and province committees. As with the previous reports prepared, it is important that it be concise, normally not exceeding 30 pages. Box 5.1 provides a suggested reporting format.

Section 5: Final report and results dissemination

5.2 FINALIZATION OF THE PROGRAMME OF WORK Once the final report has been developed, the district IFC committee will move into the phase of finalizing an action plan in order to commence implementation of IFC activities and set up a system for monitoring and evaluating interventions. This process is introduced in section 3.7 of Module 1 and described in detail in Module 5 of the toolkit.

5.3 RESULTS DISSEMINATION Ideally it is best to disseminate the results of the PCA once the district committee has developed its final action plan (see Module 5). This will help the community feel that the committee is acting rapidly on the findings. If results are disseminated earlier, the committee is strongly advised to move swiftly into the joint planning process. At the district level, the results of the PCA and finalized action plan may be presented to the district and MNH committees. It may also be necessary to arrange face-to-face meetings with decision-makers who were not able to attend the institutional forum to present the PCA results to them. It may be helpful to reproduce copies of the report, or it could also be helpful to prepare a brief one-page summary of the PCA and its results. It is also important to disseminate the results to the community. This contributes to accountability and transparency within the IFC component and also serves to maintain participation throughout implementation. The district IFC committee determines a strategy for dissemination to the community. For example, the results may be discussed with community groups, including those who participated in the PCA itself. At the province and national levels, the results of the PCA and finalized plan should also be presented and discussed with the respective IFC and MNH committees. This meeting can also provide an opportunity to address the scale-up strategy of the IFC framework to other provinces or communities (see Module 1, section 2.16).

Module 3

REFERENCES Anderson T (1991). The reflecting team: dialogues and dialogues about the dialogues. New York: Norton. Bateson G (1979). Mind and nature: a necessary unity. New York: Bantman. Becker L, Pickett J, Levine R (2006). Measuring commitment to health: global health indicators working group report. Washington (DC): Center for Global Development. Bhattacharyya K, Murray J (1999). Participatory community planning for child health: implementation guidelines. Arlington (VA): Basics Project. Cecchin G (1987). Hypothesizing, circularity, and neutrality revisited: an invitation to curiosity. Fam Process. 26:405–413. Cernea M (1992). Re-tooling in applied social investigation for development planning: some methodological issues. In Scrimshaw NS, Cleason GR, editors. Rapid assessment procedures: qualitative methodologies for planning and evaluation of health related programmes. Boston: International Nutrition Foundation for Developing Countries. Comité Promotor por una Maternidad sin Riesgos en México (2006). Hacia la prevención de la mortalidad materna: guía para una estrategia comunitaria [Towards the prevention of maternal mortality: a guide for a community strategy]. Mexico City: Comité Promotor por una Maternidad sin Riesgos en México (in Spanish). Commonwealth of Australia (2006). Cultural competency in health: a guide for policy, partnerships and participation. Canberra: Commonwealth of Australia. Cornwall A, Pratt G, Scott-Villiers P (2004). Participatory learning groups in an aid bureaucracy. Brighton: Institute for Development Studies (Lessons for Change Series, No. 11). De Negri B, Thomas E (2003). Making sense of focus group findings: a systematic participatory analysis approach. Washington (DC): Academy for Educational Development. EngenderHealth (2001). COPE® for maternal health services: a process and tools for improving the quality of maternal health services. New York: EngenderHealth. Family Health International (2010). Research ethics training curriculum, 2nd edition. Durham (NC, USA): Family Health International (http://www.fhi360.org/training/en/RETC2/index.html, accessed 17 January 2013). Gonzales F, Arteaga E, Howard-Grabman L (1998). Scaling up the WARMI project: lessons learned mobilizing Bolivian communities around reproductive health. Washington (DC): Basics Project. Hafeel A, Tagadur S, Payyappapallimana U, Shankar D (2001). Evaluación participativa rápida sobre las tradiciones locales de salud [Rapid participatory evaluation on local health traditions.] Revista Compas. No.4 Por el Desarrollo Endógeno (in Spanish). Hanley B (2005). Research as empowerment? Report of a series of seminars organised by the Toronto Group. York: Toronto Group,Joseph Rowntree Foundation. Howard-Grabman L, Snetro G (2005). How to mobilize communities for health and social change, a health communication partnership field guide. Baltimore: Health Communication Partnership. International HIV/AIDS Alliance, FRONTIERS Prevention Project (2006). Tools together now: 100 participatory tools to mobilise communities for HIV/AIDS. Brighton (United Kingdom): International HIV/AIDS Alliance, FRONTIERS Prevention Project. Laverack G (2005). Health promotion practice: power and empowerment. London: SAGE Publications.

References

Marsten C, Renedo A, McGowen CR, Portela A (2013). Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review. PLoS ONE. 8(2):e55012. Maturana HR (1978). The biology of language: the epistemology of reality. In Miller G, Lennenberg EH, editors. Psychology and biology of language and thought. New York: Academic Press. Maturana HR, Varela FJ (1987). The tree of knowledge. Boston: New Science Library. Mielke E, Bradley J, Becker J (2001). Improving maternal and child health services through COPE. QA Brief. 9:(2). MSPAS, CEES, OPS. Diagnóstico comunitario participativo en los municipios de Izalco y Nahuizalco, Departamento de Sonsonate, El Salvador [Participatory community assessment in the municipalities of Izalco and Nahuizalco, Department of Sonsonate, El Salvador.] San Salvador: Ministerio de Salud Pública, Concertación Educativa de El Salvador, Organización Pan Americana de la Salud (in Spanish). Oltheten T (1995). Participatory approaches to planning for community forestry: results and lessons from case studies conducted in Asia, Africa and Latin America. Rome: Food and Agricultural Organization of the United Nations (Community Forestry Working Papers, No. 2). Ottolenghi E, Riveros P, Blanding S (2008). Assessment of the Bolivia postabortion care community mobilization program. Washington (DC): United States Agency for International Development, Acquire Project. PAHO (2002). Regional strategy for maternal mortality and morbidity reduction, Washington (DC): Pan American Health Organization. PAHO (2005). Guía para el diagnóstico local participativo: componente comunitario de la estrategia AIEPI. [Guide for the participatory local assessment community component of the IMCI strategy]. Washington, (DC): Pan American Health Organization (in Spanish). Palmer L (2006). Addressing the social dynamics of sexual and reproductive health: CARE’s exploration with social analysis and community action. Atlanta: CARE. Portela A, Santarelli C (2003). Empowerment of women, men, families and communities: true partners for improving maternal and newborn health. Brit Med Bull. 67:59–72. SAFE International Research Partnership (2003). SAFE strategy development tool: a guide for developing strategies to improve attendance at delivery. Aberdeen: University of Aberdeen, The Dugald Baird Centre for Research on Women’s Health. Scrimshaw NS, Cleason GR, editors (1992). Rapid assessment procedures: qualitative methodologies for planning and evaluation of health related programmes. Boston: International Nutrition Foundation for Developing Countries. Segal L (1986). The dream of reality: Heinz von Foerster’s constructivism. New York: Norton. UNHCR (2009). Resolution 11/8. Preventable maternal mortality and morbidity and human rights. In: United Nations Human Rights Council, eleventh session, New York, 17 June 2009. New York: United Nations Human Rights Council. UNICEF, WHO, UNFPA (1997). Guidelines for monitoring the availability and use of obstetric services. New York: United Nations Children’s Fund. WHO (1986). Ottawa Charter for Health Promotion. Geneva: World Health Organization (WHO/HRP/HEP/95.1). WHO (1994). Information support for new public health action at district level. Report of a WHO expert committee. Geneva: World Health Organization (WHO Technical Report Series, No. 845). WHO (1996). Safe motherhood needs assessment. Geneva: World Health Organization.

Module 3

WHO (2002). Making decisions about contraceptive introduction: a guide for conducting assessments to broaden contraceptive choice and improve quality of care. Geneva: World Health Organization (WHO/ RHR/02.11). WHO (2004). Child health in the community “Community IMCI”, briefing package for facilitators. Geneva: World Health Organization. WHO (2005a). Making pregnancy safer through district/municipality team approach: a problem solving process. Geneva: World Health Organization. WHO (2005b). The world health report 2005: make every mother and child count. Geneva: World Health Organization. WHO (2006a). Quality information in field research: training manual on practical communication skills for field researchers and project personnel. Geneva: World Health Organization. WHO (2006b). Reproductive health indicators: guidelines for their generation, interpretation and analysis for global monitoring. Geneva: World Health Organization. WHO (2010a). Working with individuals, families and communities to improve maternal and newborn health. Geneva: World Health Organization (WHO/MPS/09.04). WHO (2010b). Indicators for assessing infant and young child feeding practices, part 1, definitions. Geneva: World Health Organization. WHO (2011). Research policy: developing proposals that meet ERC requirements. Geneva: World Health Organization (http://www.who.int/rpc/research_ethics/guidelines/en/index.html, accessed 17 January 2013). WHO, UNFPA, UNICEF, Averting Maternal Death and Disability programme of Columbia University (2009). Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization.

ANNEXES

Annex 1: Terms of reference for PCA facilitators Annex 2: Forms for the situation analysis Annex 3: Facilitation guide for the roundtable discussions Annex 4: Analysis form for the individual roundtable discussions Annex 5: The institutional forum Annex 6: Checklist for organization of the roundtables/institutional forum Annex 7: Additional participatory exercises for roundtable discussions

Module 3

ANNEX 1: TERMS OF REFERENCE FOR PCA FACILITATORS To carry out the PCA, it is important to identify facilitators for the roundtable discussions. It is useful to identify one or two expert facilitators who can support two local facilitators. Profiles for these persons are found in the table below. Each country will pay or compensate facilitators in accordance with their specifications. Expert facilitators (one or two persons) Profiles • Knowledge of MNH issues • Significant experience in the execution and analysis of focus groups, systematic observation, community dialogue, roundtable discussions, life histories, among others • Experience in preparation of reports with conclusions, recommendations and findings • Significant experience in participatory and community processes • Experience in management of groups with diverse characteristics; skills in negotiation and facilitation • Experience in training on participatory methodologies • Minimum education: Bachelor’s degree or equivalent • Located in the intervention district or know it well • Demonstrate interest in MNH and/or are familiar with current activities in the district • Experience in participatory and community processes • Skills in interpersonal communication • Experience in management of groups • Analytical skills to participate in the analysis of information collected • Ability to review and comment on reports • Computer skills • Minimum experience: 2-5 years Local facilitators (two persons)

Scope of work 1. Attend meetings of the national committee and if appropriate, present progress on support provided 2. Support the local coordinator in carrying out all phases of development and implementation of the PCA, in particular the roundtable discussions, their analysis and preparation of reports 3. Train local facilitators and the PCA team on the different stages of the PCA 4. If required by the national, province or district committees could be a part of the team for design of intervention strategies at the local level 1. Be trained in the different aspects of the PCA 2. Participate in the activities for each phase of the PCA 3. Identify participants for the roundtable discussions 4. Assist the local coordinator in the organization of the individual roundtable discussions and the institutional forum 5. In working groups with the expert facilitators and the local coordinator: • Collect information for the situation analysis • Analyse information collected in the different phases of the PCA • Review and comment on the reports

Annex 2: Forms for the situation analysis

ANNEX 2: FORMS FOR THE SITUATION ANALYSIS Form 1: Description of the local area Use this form to describe various different aspects of the intervention zone, including characteristics of the district area and population, economic activities, education, transport services, other basic services and media. Form 2: Statistics on maternal and neonatal health in the local area Use this form to record important statistics on maternal, perinatal and neonatal mortality and morbidity; other health indicators; and the coverage and use of services. If possible, provide data from national, province and district levels for the key statistics. Also, try to include data for both urban and rural populations or any information available disaggregated by wealth or socio-economic levels, where possible (usually available through Demographic and Health Surveys (DHS), for example). Form 3: Health services in the local area Use this form to record information about the health services network operating in the intervention area, especially with information on MNH provision. Specific information required includes the network of services, the health personnel working in the district area, communication and referral systems between different levels, availability of educational materials, and the monitoring, evaluation and epidemiological surveillance in the area. Form 4: Inventory of institutions and organizations present in the local area Use this form to identify the different social actors and stakeholders working in the intervention area. This information will also be very important when planning interventions after the PCA. Form 5: Inventory of experiences in community health: a listing of programmes and projects Use this form to document different programmes and projects in community health that have recently been or are currently being implemented in the intervention area. Try to document programmes that have had similar objectives to the IFC framework (for example maternal health education, community transport schemes, community involvement in quality of care). Also document the lessons learnt from these programmes so that successful initiatives can be built upon or unsuccessful approaches avoided. A summary sheet is available at the end to summarize the various different programmes and projects. Form 6: Inventory of research in the local area It is helpful to undertake a short review of studies that have been conducted in the intervention zone. This form can help summarize the results. The team should ask all the various partner institutions at national, province and district levels for any research reports related to MNH they might have.

Module 3

Map of the district Throughout data collection for the situation analysis, it will be useful to prepare a map of the district which locates: • The health service network • Distances to the referral hospital in case of neonatal and obstetric emergencies • Principal towns or villages with population estimates • Geographical obstacles to accessing services (mountains, rivers, etc.) • Populations with special needs such as indigenous groups, extreme poverty areas, excluded groups, ethnic groups, marginalized populations, linguistic groups, etc. Title page Name of the local area: ....................................................... Persons completing the forms: . ......................................................................................................................................................... . ......................................................................................................................................................... . ......................................................................................................................................................... Date: .....................................................................................

Annex 2: Forms for the situation analysis

FORM 1: Description of the local area Sources used: A. CHARACTERISTICS OF DISTRICT AND ITS POPULATION: Type and size of population (urban, peri-urban, rural) Total population Number of women of reproductive age Population growth rate and/or total fertility rate Estimated number of pregnant women Number of newborns (<30 days) Names of areas with high poverty indices Identify and locate populations with special needs, such as indigenous groups, high poverty levels, excluded, ethnic, marginalized, linguistic groups Migratory trends (male and female) B. ECONOMIC ACTIVITY Average household income (indicate range, if possible) Employment: • % employed • % unemployed • % working in the informal sector Principal sources of income (e.g. agricultural, private enterprise, informal) % households headed by women C. EDUCATION Illiteracy Overall rate: Male rate: Female rate: Primary Overall: Boys: Girls: Overall: Boys: Girls: Male: Female:

School enrolment rates

Secondary

Average years of school attendance Number of primary schools in the local area (locate them on the map) Total number of secondary schools in the local area Total number of private schools in the local area

Module 3

D. TRANSPORT SYSTEMS Are there areas without a public transport system? Which? Type(s) of transport used by inhabitants to travel to nearest health service Average cost to travel to nearest health facility Time required via public transport to reach nearest health facility (indicate range for different localities in the district and indicate if this differs by season) Time required on foot to reach nearest health facility (indicate range for different localities in the district and indicate if this differs by season) E. OTHER BASIC SERVICES % of population with sustainable access to improved water sources % of households with electricity % of households without waste disposal Status of dwellings: % households with dirt floors % households with cement floors % households with telephone F. MEANS OF COMMUNICATION % households with radio % households with TV Number of local newspapers and magazines Number of local radio stations Local televisions channels Other means of communication, such as telephone, megaphones, word of mouth, cell phones, amateur radio

Annex 2: Forms for the situation analysis

FORM 2: Statistics on maternal and neonatal health in the local area Sources used:

Note: If you have data disaggregated by rural/urban population or by wealth index/quintile, then include it in these forms. A. MATERNAL mortality and morbidity • National target for maternal mortality: INDICATOR National level Current Total and absolute number of maternal deaths Maternal mortality ratio* *Maternal mortality ratio: Number of maternal deaths per 100,000 live births. Estimate may not be available at province and district level. INDICATOR National level Causes Principal causes of maternal mortality 1. 2. 3. 4. 5. % 1. 2. 3. 4. 5. Province level Causes % 1. 2. 3. 4. 5. District level Causes % 5 years ago Province level Current 5 years ago District level Current 5 years ago

What are the most frequent causes of maternal morbidity in the local area?

Module 3

B. PERINATAL, NEONATAL and INFANT mortality and morbidity • National target for perinatal mortality: • National target for neonatal mortality: INDICATOR National level Current Perinatal mortality rate (week 22 of gestation through 7 days postpartum) Stillbirth rate Neonatal death rate (through 28 days postpartum) Infant mortality rate (during first year of life) % of neonatal deaths occurring in the first 7 days postpartum Perinatal death rate: Number of perinatal deaths per 1,000 total births (live and still births) Stillbirth rate: Number of stillbirths per 1,000 total births (live and stillbirths) Neonatal mortality rate: Number of neonatal deaths per 1,000 live births Infant mortality rate: Number of infant deaths per 1,000 live births during the reporting year INDICATOR National level Causes Principal causes of perinatal mortality 1. 2. 3. 4. 5. Principal causes of perinatal mortality 1. 2. 3. 4. 5. % 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. Province level Causes % 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. District level Causes % 5 years ago Province level Current 5 years ago District level (if available) Current 5 years ago

What are the most frequent causes of neonatal morbidity at district level?

Annex 2: Forms for the situation analysis

C. Other indicators in maternal and newborn health INDICATOR Life expectancy at birth Total fertility rate Median spacing interval between births (in months) % live births with low birth weight (less than 2.5 kg) Breastfeeding: Median duration of breastfeeding (in months): • All breastfeeding • Exclusive breastfeeding • Predominant breastfeeding Among those children who were breastfed, the % who: • Began breastfeeding within an hour of birth • Began during the first day following birth • Received solid foods before 4 to 6 months Median age of women at first birth % of all pregnancies to women under 18 years of age Abortion ratio (no. of abortions per 1,000 live births) % of women (15 to 44) using a MODERN method of contraception Condom use (%): • Men • Women HIV prevalence: • In the general population • Among pregnant women % of women reporting violence in the home during the previous year per type: • Verbal/psychological • Property and belongings • Physical • Sexual Other indicators relevant to the local area: National level Province level District level

Module 3

D. Coverage and use of health services COVERAGE Antenatal care • % of pregnant women having at least one visit • % of pregnant women having at least four visits • Average week of pregnancy at first visit Average # of antenatal visits received by pregnant women % of pregnant women who have a plan for birth and complications % of births assisted by a skilled attendant % of institutional births (hospital/ health centre) % of births at home and assisted by: • Skilled attendant • Unskilled attendant % of deliveries by caesarean section % of women attending postpartum care: • Within the first 24 hours following birth • On day 3 (48–72 hours) following birth • Between 7–14 days following birth • At 6 weeks following birth % of newborns attending postnatal care: • Within the first 24 hours following birth • On day 3 (48-72 hours) following birth • Between 7-14 days following birth • At 6 weeks following birth Other indicators relevant to the local area: National level Province level District level

Annex 2: Forms for the situation analysis

FORM 3: Health services in the local area Sources used: A. Service network Total number Name/ location Provide antenatal care with a skilled attendant? Provide childbirth care with a skilled attendant? Provide post-partum care for women with a skilled attendant? Provide post-natal care for newborns with a skilled attendant? Emergency obstetric care*

Basic

Comprehensive

Health posts

Health centres

Hospital

Maternity waiting homes

Private care facilities

* A basic emergency obstetric care (EmOC) facility is one that is performing these seven signal functions: 1. Administer parenteral antibiotics; 2. Administer uterotonic (i.e. parenteral oxytocin) drugs; 3. Administer parenteral anticonvulsants for pre-eclampsia and eclampsia, (i.e. magnesium sulphate); 4. Manually remove the placenta; 5. Remove retained products (e.g. manual vacuum aspiration, dilatation and curettage); 6. Perform assisted vaginal birth (e.g. vacuum extraction, forceps delivery); 7. Perform basic neonatal resuscitation (e.g. with bag and mask). Source: WHO, UNFPA, UNICEF, and AMDD, 2009. **Comprehensive EmOC has nine signal functions: In addition to all of those included in basic EmOC, a comprehensive EmOC facility is one that also performs surgery (e.g. caesarean section) and blood transfusion. Source: WHO, UNFPA, UNICEF, and AMDD, 2009.

Module 3

B. Health personnel in the local area Total Area and location of work number Public or private? Trained during the previous 3 years in: • Community health • Health education • Health counselling • Other topics Specify which topics were covered.

Traditional birth attendants Other traditional providers (e.g. shaman or medicine men) Promoters/ health educators Auxiliary nurses/ auxiliary midwives Nurses

Midwives

General medical practitioners OB/GYNs

Neonatologists/

Paediatricians

Anaesthesiologists

Others:

Are there sufficient health personnel to meet the maternal and newborn health needs of the district? Is sufficient staff available at all times? Are there any population segments excluded?

Annex 2: Forms for the situation analysis

C. Communication and referrals TOPICS Communications mechanisms between health services and the community CHWs, health talks, radio, etc.) Description

Communication and referral mechanisms between traditional birth attendants/CHWs and health services

Communication and referral mechanisms between health centres and the referral hospital Health services in the district that have a functioning ambulance and a budget for fuel to operate it, for the transportation of obstetric/neonatal emergencies to the next level of referral

D. Educational materials If possible, collect copies of the educational materials that are used in the health services at the different levels of care. Complete the table Materials on: Do they exist? (Yes/No) Are they available and in use by health services? Indicate name of the materials and service which is using. Are they used in the communities. Indicate name of the material and agency which is using.

Care during pregnancy Birth and complications plan Post-partum care Care of the newborn Breastfeeding Family planning HIV/AIDS Malaria in pregnancy Violence in the home Other topics: Specify

Module 3

Make a list and briefly describe any educational activities carried out in the local area during the last 12 months: E. Monitoring, evaluation and surveillance Describe the surveillance system for maternal and neonatal health, and the information and data transmission systems between the different levels (including the community):

Annex 2: Forms for the situation analysis

FORM 4: Institutions and organizations present in the local area Sources used: A. Inventory of institutions and organizations Note: Review Form 2 to help in identifying the organizations working in the district. Institutions and organizations (names) 1. NGOs that work on health issues Location Director Main activities

2. NGOs that work on education issues

3. NGOs that work on other related issues (including rights, social support, etc.) (specify)

4. Community groups (for example, health committees, women’s groups (mother clubs, work groups, etc.), school parent groups, groupings of neighbourhood councils, associations, or farmer associations)

5. Public institutions and local authorities (for example mayor’s offices, police, social security, education)

6. Religious institutions (for example churches, mosques)

7. Private sector (large and small businesses who employ persons from the community, institutions, etc.)

8. National and international organizations (including universities, international NGOs, donors)

Module 3

B. Institutional and organizational communication: 1. What means of coordination exist between the identified institutions/organizations and the community? 2. What activities are carried out in the community that promote health care? What person/institution is in charge of these activities? 3. What health promotion activities are being carried out by local NGOs? Do they coordinate their activities with health services and the community?

Annex 2: Forms for the situation analysis

FORM 5: Inventory of experiences in community health Sources used: (a) Inventory of experiences: Summary table Name of programme or project Objectives Period of Geographic implementation area Organizations institutions involved

(b) Individual programme/project listings (photocopy form as required) Name of programme, project or initiative:

Implementing organization: Partners:

Implementation period:

Contact (name, email or physical address, telephone):

Module 3

1. Geographic areas Province(s) District Villages or communities Health service(s) (names) Urban/rural

2. Financing and other assistance: Financed by Amount Other technical assistance

3. Target population characteristics: Number of communities Ethnic group(s) Poverty index Target populations, groups or segments (pregnant women, adolescents, adults, etc.) Size of populations

4. Intervention Programme/project objectives Summary of specific interventions

Expected or achieved results

Lessons learnt

Partnerships or collaboration with: • Community organizations • Other organizations (specify) • The health sector • The education sector (specify) • Other actors (specify)

Annex 2: Forms for the situation analysis

Other comments: FORM 6: Inventory of research in the local area Prepare a list of research, including maternal or perinatal death reviews or “near-miss” analysis, studies about local MNH-related practices and beliefs and on other themes of health, education and social development that have been carried out in the past 5-10 years in the district. Title of research activity Main issues under study Specific year(s) of study Population being studied/ geographical area Type of study (epidemiological, sociological, ethnographic, qualitative, etc.) Name of research organization with contact information

Module 3

ANNEX 3: FACILITATION GUIDE FOR THE ROUNDTABLE DISCUSSIONS Roundtable discussion overview with materials needed5 Total time required: 4 hours 30 minutes Time 15 minutes 40 minutes Activity Participant registration with refreshments Introduction: • Presentation of MNH strategy and objectives of the roundtable discussion • Verification of voluntary participation • Overview of the agenda • Presentation of participants • Presentation of the discussion rules • Presentation of the situation analysis results Group work: Problems and opportunities (three working groups) • Introduction to the group work • Group discussion on situation, problems and needs: 1. Care in the home for the pregnant woman, mother and newborn 2. Support in the community for the pregnant woman, mother and newborn: (a) Awareness of MNH rights, needs and problems (b) Linkages for social support 3. Care received from the health services for the pregnant woman, mother and newborn Refreshments Materials required • Registration form • Snack • Flipchart with objectives • Prepared presentation • Flipchart with discussion rules • “Care of the pregnant woman, mother and newborn” diagram • Name cards for participants (with marker pens) • Flipcharts and markers • Speaker timer symbol

1 hour and 30 minutes

30 minutes 1 hour and 15 minutes

Food and drinks

• Flipchart and markers Plenary: Situation, problems and needs, and possible actions • Coloured dots/stickers • Reports from groups with comments, questions, clarifications after each group report • Speaker timer symbol • Discussion and consensus on the three main problems for each area • Brainstorm on solutions Closing: • Short summary of the discussion • Selection of two group representatives for the institutional forum • Evaluation of the discussion • Thank-you • Payment of transport costs • Contact information • Money and receipts for transport costs

20 minutes

Note: If more time is available for the roundtables, the agenda can also be adapted. Annex 7 contains participatory tools that can be used in addition to the sessions listed above or that can be used to facilitate these sessions.

Annex 3: Facilitation guide for the roundtable discussions

Sessions in detail 1) Introduction (40 minutes)

Note: The presentations listed below will need to be prepared in advance. • Presentation of MNH strategy and the roundtable objectives (10 minutes): First, briefly introduce the broader MNH strategy that the Ministry of Health and its partners are undertaking in the district area or nationally to address MNH needs. Explain that as part of this strategy consultations are being organized with different community members to get their perspective on the problems and needs, as well as possible solutions. Explain to the participants which group they are representing (mothers, grandmothers, men, etc.), and what the objectives are. Write the objectives on a flipchart beforehand.

Objectives 1. To discuss the health of pregnant women, mothers and newborns in our community. 2. To identify the key problems that prevent pregnant women, mothers and newborns from receiving the care and attention they need. 3. To identify some possible actions to help solve these problems.

• Describe the process (3 minutes): Explain that today they will work in small groups to identify problems that prevent pregnant women, mothers and newborns from receiving the care and attention they need. A facilitator will ask questions and a note-taker will record what they discuss. They will then work with the larger group and share the different problems and solutions identified. Emphasize that NOT all the problems are going to be discussed today, but that this discussion is a starting point. Explain that a report will be written of all the different roundtables held and will be presented at the institutional forum. During the forum, different representatives from local authorities and local organizations will develop a plan to improve MNH based on the different inputs received. Explain what will be done with the information collected following the roundtables (i.e. how the registration forms will be stored, and when they will be destroyed). • Verification of voluntary participation (2 minutes): Explain to the participants, as was already mentioned to them when they were recruited and registered, that their participation is voluntary. They can decide to withdraw at any time without any consequences. Before explaining the schedule, confirm that all participants feel comfortable and agree to participate. If they have any questions or concerns, they may bring them up at any time. • Overview of the agenda (5 minutes): Review the agenda with the group and ask if they feel comfortable with it. Confirm that the entire meeting should take about four and a half hours. Explain that there will be a session where they will work in smaller groups and then come back to the larger group for plenary discussion.

Explain that their opinions are very important in planning actions to improve MNH in their community. In addition, it is their right to participate in determining the needs that they think are most important to address and plan the activities meant to benefit them and the community. This discussion today can be part of fulfilling this right.

Module 3

• Presentation of the participants (5 minutes): Ask each participant to present themselves (name, where they are from, what they do, etc.). You can use a group dynamic (keeping in mind time constraints) or ask participants to say something original about themselves. Ask all the facilitators, note-takers and observers to present themselves as well. • Presentation of the discussion rules (5 minutes): Explain that their participation is appreciated and valuable to the process.

Explain that it is important to hear from everyone and to make sure that everyone feels comfortable presenting their views. In order to assure an open discussion and a comfortable environment, go over the discussion rules with the group (see box), and ask them if they agree or would like to remove or add other rules. Show the participants the “speaker timer symbol” (for example a smiley face) that means they have talked for more than 3 minutes, and should allow others to talk instead.

Discussion rules for the roundtables • All ideas, opinions and suggestions, whether positive or negative, are welcome. • Everybody has the right to express their opinions and participate. • Tell the facilitators if something is unclear. • It is important not to dominate the conversation, and to give others the opportunity to express their ideas. • Let each person finish his/her idea. • Everything discussed is confidential and should not be talked about with others outside of the meeting. Do not mention the names, surnames, or situations that were discussed. • It is important to listen and to be listened to. • Language used must be respectful and not threatening. • Participants should only talk about the topic under discussion. • Participants should not talk for more than three minutes at one time. • Participation is voluntary, therefore you may withdraw your participation at any time.

• Presentation of the situation analysis results (10 minutes): The facilitators provide a brief and simple presentation of some of the key findings from the situation analysis. We recommend that the key data on MNH from Form 2 (Annex 2) be presented. Since participants may not understand percentages,

rates or other complex statistics, the team should try and keep the data simple and/or use pictures or drawings to help demonstrate key points. A flipchart or PowerPoint can be used. If PowerPoint is used, it is advised to not exceed five slides.

Annex 3: Facilitation guide for the roundtable discussions

2) Small group work: MNH problems and opportunities (1 hour and 30 minutes) Introduction to the group work: Show the image “Care of the pregnant woman, mother and newborn” on a flipchart or poster (see below). The image shows four levels of care or support that affect the health of pregnant women, mothers and newborns. Explain the four areas to the group. 1. Care in the home for the pregnant woman, mother and newborn: The first level is the care the pregnant women, mother and baby should receive in the home. This includes care during pregnancy, childbirth, after childbirth and for the newborn, for example: • eating enough healthy foods; • washing regularly; • avoiding heavy work; • knowing the danger signs during pregnancy, after birth and for the baby; • seeking care from health services; • discussing in the home what to do in an emergency; • using family planning to space births; • exclusive breastfeeding; and • receiving support from husbands/male partners and other family members, etc. 2. Awareness in the community of the rights, needs and problems of the pregnant woman, mother and newborn: The second level of care includes: • awareness in the community of the rights of the pregnant woman, mother and baby to appropriate care; • awareness in the community about the problems that the pregnant woman, mother and baby face; and • awareness among men of their role in MNH. 3. Links between services and the community: The third level is also at the community level, and focuses on the social support linkages between the community and individual families and women, as well as social support linkages between the community and the health services. It includes: • care and support for women and newborns from community groups, local authorities and institutions; • the ability to reach health services in the community, for example, being able to reach health workers or the clinic/hospital, or having support to get to care; • making sure that costs for care do not impede women and babies from using care; and • relations and communication between the community and health services to ensure that services respond to community needs. 4. Care received from the health services: Finally, the last level of care is received from the health services themselves, for example: • costs of services; • the hours that services are open; • the way the providers interact with women and their families; • the number of doctors, nurses and midwives; • the availability of medicines; and • the way health services take women’s and community perceptions into consideration.

Module 3

1. CAPACITIES to care for pregnant women, mothers and newborns at home

2. AWARENESS in the community of the rights, needs and problems of mothers and newborns

3. LINKAGES for social support between women, families, communities and health services

4. QUALITY of care received from the health services for mothers and newborns

Diagram: Care and support of the pregnant woman, mother and newborn

Mention that often there are many problems at each of the levels and we would like to discuss them in small groups. Explain that Group 1 will work on level 1 (care in the home), Group 2 will work on levels 2 and 3 (awareness and linkages) and that Group 3 will work on the fourth level (quality of health services). Divide the participants into 3 groups. Each group will ideally have one facilitator and one note-taker. The group work process: 1. Before starting, ask each group to select a representative who will report the group’s work to the plenary group. If the group does not feel comfortable presenting in plenary, then tell them that you (the facilitator) can present on their behalf. 2. Prepare a large flipchart and put the group name at the top. On one sheet write “problems” and on another sheet write “opportunities”. 3. Help the group to discuss what the current situation is in their community related to this topic, and what some of the key problems are. It is important to take into account the different needs of: • pregnant women;

• women and their babies during birth; • women after birth; • newborns. A list of questions to guide the discussion of each theme is proposed in the table below. You can complete the list or adapt it, but it is important that the main issues be addressed. As they discuss their situation, help them write this up into a list of problems on the flipchart. Keep probing to help them define the problem more clearly, for example, “Why do women not eat well?”, “Why do women prefer to give birth at home instead of in the health centre?”, etc. Try to write down related problems together and avoid repeating the same points. 4. If they mention any positive things about the situation, write these on the “opportunities” sheet (although they may not necessarily identify any). 5. NOTE: It is important to remember to keep the discussion focused on MNH, and help the group to write down problems and needs related to MNH. 6. Help the group prepare the presentation to the plenary, by doing a summary on a flipchart.

Annex 3: Facilitation guide for the roundtable discussions

The discussion guide: (To be adapted at the national and local level) Level of care GROUP1: Care of the pregnant woman, mother and newborn at home (DEVELOPING CAPACITIES) Questions to guide discussion 1. How does a woman care for herself during her pregnancy? (think about diet/nutrition, alcohol and other drugs, workload/activities, hygiene, going to prenatal check-ups, etc.) 2. Are there any special beliefs or traditions in the community about care during pregnancy? 3. How is the newborn cared for in the home? (think about breastfeeding practices, keeping the baby warm, hygiene, etc.) 4. How does a woman care for herself after birth? (think about diet/nutrition, workload/activities, hygiene family planning and birth spacing, attending postpartum visits for the mother and postnatal visits and vaccinations for the newborn, etc.) 5. What happens when there are complications or problems with the woman or newborn? How is the decision made to seek care? 6. Are there any special beliefs or traditions in the community about care after birth? 7. Are women and their families prepared for birth and/or complications related to pregnancy and birth? (think about saving money for expenses, care of children, identifying a health-care facility, identifying transport, a skilled attendant, a companion during birth, having adequate supplies) 8. Do women and their families know the danger signs during pregnancy, childbirth, after birth, and for the newborn? Which ones? 9. Do women in this community often give birth at home? If so, who is with her and helps her during the birth? (think about who attends her, where she gives birth) 10. What influences the decision to seek skilled care? (think about costs of services, quality of services, transport availability and cost, cultural factors that affect care-seeking, gender relations between men and women) 11. Who in the family helps to care for the mother and her newborn? What do they do? 12. Are husbands/male partners supportive in caring for the woman and newborn? Do men and women discuss these types of things? 13. Is violence in the home common during pregnancy? Awareness in the community of MNH rights, needs and problems 1. Explain that many governments have signed an international agreement on human rights that means that pregnant women, mothers and children have the RIGHT to special care and assistance: Is anything done here to ensure this right is respected? If yes, what is done to help to fulfil this right? If not, what happens? Are people in the community aware of this right? Do you think men are supportive of this right? 2. Are women in this community free to decide when to marry, to decide when to start a family, or to decide how many children they would like? If not, why do you think these rights are not being respected? 3. Do people think that MNH is a priority? 4. Do people know when and why a mother or baby dies in the community? 5. Are there community meetings about health or MNH specifically? Links between services and the community: 1. Do women have problems reaching care? What are some of the problems they have? What is done to help resolve these problems? (think about distance to care, transport costs, state of the roads, availability of public transport, ambulances, partner permission to seek care) 2. Who in the community supports the health of pregnant women, mothers and newborn? What do they do? (think about CHWs, TBAs, support groups, any other people or groups?) 3. Are there any individuals or groups in the community who work with the health services? What do they do? (think about collaboration with education, transport, local authorities, churches or other religious groups) 4. Are there any people or groups in the community who are particularly vulnerable or who are not reached by the health services? If so, what sources of support could be used to help them? (think about social support from the state, community funds)

GROUP 2: Support in the community for the pregnant woman, mother and newborn (INCREASING AWARENESS and STRENGTHENING LINKAGES)

Module 3

GROUP 3: The care received from the health services (IMPROVING QUALITY)

1. How do people in the community feel about the quality of care pregnant women, mothers and newborns receive from the health services? (think about costs, waiting times, how providers treat women and families, availability of medicines and supplies, number of midwives, doctors and nurses, cultural differences between the community and the services, etc.) 2. Do people have to pay for MNH services? How do people feel about these costs? Do these costs stop people from using the services? 3. What information do the health services give to women and their families about pregnancy, childbirth and the newborn? Is this information useful? Does it reach everybody? If not, why not? 4. Do doctors, nurses, health promoters or CHWs visit pregnant women, new mothers and babies in their homes? How often? What do they do? Are there any groups who don’t receive care or who need additional support? 5. If women give birth in the health centre or hospital, how are they treated? (think about allowing a companion of choice at birth, choosing the birthing position, etc.) 6. How are people referred from one health service to another? 7. Is the community involved in evaluating the quality of services or in suggesting how to improve the quality of services?

Note-taking during the group discussion During the group discussion, the note-takers should take careful notes of the discussion, including: • the discussion of the current situation; • the problems and needs identified (from the flipchart); • pertinent quotes that support the points being made; • positive opportunities that are present in the community. The note-takers can use special sheets to capture these elements from the discussion (see next page for example).

Annex 3: Facilitation guide for the roundtable discussions

Sample note-taking form ROUNDTABLE: GROUP: DATE:

Question/topic area

What is the current situation?

What problems and needs are identified?

Supporting quotes

Opportunities to improve the situation

For example, write: Care in the home of the woman during pregnancy

Module 3

------------------------------------ REFRESHMENT BREAK ----------------------------------------During the break, the facilitators and note-takers are advised to take some time to review the list of problems identified in the group work, and check that they are clearly defined. If opportunities were identified, they can review these as well. They should also verify that there is no repetition in the problems identified by the group or between groups. --------------------------------------------------------------------------------------------------3) Plenary session: Problems, needs and actions (1 hour and 15 minutes) Ask one facilitator to facilitate the session, one to take notes on the flipchart, and two can take notes of the discussion. Prioritizing problems: 1. Ask the representative (or facilitator) from each group to present a summary of the discussion with the list of problems identified. Try to limit each presentation to five minutes. 2. After each topic is presented, tape the flipchart sheet(s) to the wall. Put up all the “problem” sheets next to each other. 3. After each presentation, ask the plenary group if they have questions or comments, whether they agree with the problems identified, and/ or if they would like to add or remove any problems for this topic. 4. Explain that they now must prioritize this list of problems, i.e. they have to select the most important problems. To help identify the most important problems, they should think about the problems that most affect the health of mothers and newborns, particularly for the poorest families. 5. Hand out a strip of 12 coloured dots (stickers) to each participant. Ask everyone to come up to the flipcharts, and select three problems from each group/level that they think are the most important (stick one dot next to each priority problem). If the same problems are repeated on different sheets, they should try not to choose the same problem more than once. Help those who cannot read by identifying the problems they feel are important. If there are many people who cannot read, then work with the larger group and read each list of problems and try to come to a consensus by discussing in plenary. 6. After they have voted with the dots, add up the tally and circle the priority problems identified by the group. Let the group review and reflect on the priorities selected and see if there are any objections or points to clarify. Identifying actions to help solve the problems 7. Next, ask the group to brainstorm about actions to help solve the priority problems they have just identified. 8. Prepare flipcharts as follows:

Annex 3: Facilitation guide for the roundtable discussions

Table 3.2: Action grids Level of care or support: e.g. Care received from the health services Priority problems identified Problem 1: Actions to help solve the problems*

Problem 2:

Problem 3:

9. Write the three priority problems just identified in the left-hand column. 10. Ask each group representative or note-taker to present the list of opportunities that they identified during the group discussion. 11. The group should then brainstorm actions to help solve their problems. Remind them to think about: • the opportunities that they have discussed in their group work; • any other ongoing activities and programmes in their community, and whether these should be continued and/or strengthened; and • actions at various levels, including policy actions, health service actions, community actions, and household actions.

12. Write the responses on the flipcharts. They can put a star next to actions that are ongoing in the community. 13. Once they have finished discussing and brainstorming, read over the sheets again to check that they agree with their recommendations.

*Note: Mark ongoing or existing actions with a star

Module 3

4) Closing (20 minutes) • Short summary of the discussion (5 minutes): Briefly summarize what has been discussed, and thank participants for their contributions and participation. • Selection of group representatives for the institutional forum (5 minutes): Explain that a roundtable discussion with institutional representatives and decision-makers (give examples) will be held later to review the results of all the roundtables and propose some possible actions. Explain that you would like to select two representatives from this roundtable to represent the community at that workshop. Explain that the institutional forum will last one and a half days, and that the people chosen should be able to dedicate this amount of time. If nobody can attend for the whole meeting, ask if anybody can attend for the first day only. The facilitators should help the group select two representatives (usually two of the more active participants). Once the participants have been selected determine a time to meet with them to discuss and prepare them for their participation in the institutional forum (see above section 4.4). • Evaluation of the discussion (5 minutes): Explain to the group that other activities like this will be held with other groups and in other communities and you would like to ask them to help improve it. Ask the following questions to the group: • What is your opinion of this roundtable discussion? • Was there good participation? Why yes, or why not? • Did you feel comfortable with the themes discussed? • Are there other themes that we should have included? • What would you suggest to improve this roundtable discussion? • Thank you (5 minutes): Thank the participants for attending the discussion and giving their time to contribute to a process that aims to improve the health of women and newborns in the community. • Payment of transport costs: Pay transport costs to participants (only to those who require it). • Contact information: Repeat the information for the person the participants should contact in case of additional questions.

Annex 4: Analysis form for the individual roundtable discussions

ANNEX 4: ANALYSIS FORM FOR THE INDIVIDUAL ROUNDTABLE DISCUSSIONS Overview 1. Comment on the organization of the roundtable (including logistics, organization, facilitation and note-taking), and write up any suggestions for changes that can be taken into account for the next discussion group.

2. From the registration forms create a registration table that includes the participant profiles (such as sex, age, marital status, education level, ethnicity, profession, location (rural vs. urban, etc.). However, do not include the participant’s names, but instead insert “P1” or “Mrs X”. This can help ensure the anonymity of the participants. Once the registration table is complete (annex it to this form) and write a summary including the number of participants, where they come from, age ranges, and characteristics/profile. Also note the number of facilitators, note-takers and observers.

3. Write a reflection on the dynamic of the discussion: • Did some people participate more than others? Who participated more? Who participated less? What were the reasons?

• Were there any interruptions?

Module 3

Analysis of problems and needs 4. Take the flipchart sheets for each of the groups, and read through the notes from the note-taker. Fill in Table 1 below. Make sure that the problems are clearly defined when you write them up. If the meaning is not clear, check if the note-taker captured the meaning of the discussion. If there is still repetition of problems within one group, try to delete repeated statements. Put an asterisk (*) next to the problems identified as “priority” during the plenary.

Table 1: Overview of current situation, problems and opportunities Summary of the current situation List of problems identified (asterisk the priority problems) Supporting quotes Any opportunities identified?

Care of the pregnant woman, mother and newborn in the home

Awareness in the community of MNH rights, needs and problems

Linkages for social support

The quality of care received from the health services

Annex 4: Analysis form for the individual roundtable discussions

Analysis of actions 5. Take the flipchart sheets from the actions plenary session and write up the results in Table 2 below. Table 2: Priority problems and actions Level of care/support Priority problems Actions identified

Care of the mother and newborn in the home

Support in the community

Care received in the health services

Module 3

Conclusion 6. Were there any problems during the discussion? (points of disagreement, problems reaching consensus, issues that need to be resolved in later discussions)

7. Was there anything discussed in the group that you feel should be discussed in subsequent roundtables? If so, you may wish to adapt your question guide.

8. Is there anything that was discussed that will be important to highlight during the institutional forum?

Annex 5: The institutional forum

ANNEX 5: THE INSTITUTIONAL FORUM Overview of the materials needed Total time required: 1.5 days Day 1 Time 15 minutes 45 minutes Activity Participant registration with refreshment Introduction: • Presentation of participants • Presentation of the objectives of the roundtable discussion • Overview of the agenda • Presentation of the discussion rules Presentation of the national and district MNH and IFC work plans: • Presentation of national MNH and IFC plans • Presentation of district MNH and IFC plans Refreshments Materials required • Registration form • Snack • Flipchart with objectives • Flipchart with discussion rules • Name cards for participants (with marker pens) • Prepared presentations • Overhead projector Food and drinks

30 minutes

30 minutes 30 minutes

• Prepared presentation Presentation of the IFC framework and PCA • Presentation of the objectives of the IFC framework the four priority • Overhead projector areas of intervention • “Care of the pregnant woman, mother and • Presentation of the PCA objectives and methodology newborn” diagram • Questions and discussion Presentation of the situation analysis results • Presentation by local coordinator or other district IFC committee members • Questions and discussion Plenary: Prioritization of problems • Overview of the problems identified in the roundtables, for the four priority areas of intervention: 1. Care in the home for the pregnant woman, mother and newborn 2. Awareness of MNH rights, needs and problems 3. Linkages for social support 4. Care received from the health services for the pregnant woman, mother and newborn • Discussion • Prioritization exercise Lunch • Prepared presentation • Overhead projector • Copies of slides or report for participants • Flipcharts and markers • Table 1 prepared as four flipcharts. • Coloured dots/stickers • Markers

30 minutes

1 hour and 30 minutes (total)

1 hour 30 minutes 30 minutes 2 hours

Food and drinks • Handouts with priority problems and actions identified in the individual roundtables (Table 2) • Four copies of the IFC framework • Scoring chart (either photocopies or as a flipchart) (Table 3) • Flipchart and markers

Plenary continued… Group work: Review of recommended actions • Four groups review actions identified in the individual roundtables • Discussion • Finalization of list of actions for the two retained priority problems • Scoring exercise

Module 3

Day 2 Time 1 hour 30 minutes Activity Plenary: feedback from group work on actions • Each group presents back their prioritized actions using Table 3 • Questions and discussion Refreshments Group work: Activities and resources • Four groups fill out Table 4 on activities and resources Plenary: feedback from group work on activities and resources Closing: • Next steps • Short summary of the discussion • Evaluation of the discussion • Thank-you • Payment of transport costs • Money and receipts for transport costs • Evaluation forms • Copies of Table 4 (activity chart) or large flipcharts Materials required • Flipcharts and markers • Speaker timer symbol

30 minutes 1 hour

45 minutes 30 minutes

Annex 5: The institutional forum

Sessions in detail 1) Introduction (45 minutes)

Note: The presentations listed below will need to be prepared in advance. • Introduction of the participants (20 minutes): Ask the participants to introduce themselves (name, where they are from, position, what they do, etc.). Ask all the facilitators and observers to present themselves as well. • Presentation of the objectives of the institutional forum (5 minutes): Explain to the participants why they have been invited to the discussion, and what the objectives are. Write the objectives on a flipchart beforehand: Objectives 1. To understand the local maternal and newborn health strategy, including the framework Working with individuals, families and communities to improve maternal and newborn health (IFC). 2. To review the findings from the situation analysis and the individual roundtable discussions. 3. To use this information to identify priority problems and key actions for working with individuals, families and communities to improve maternal and newborn health. 4. To identify actions and resources to support the development of the IFC action plan.

Highlight that they are providing inputs for developing an action plan. Their inputs will be reviewed by the district committee who will then use their draft to finalize an action plan. It is important to underline that their draft plan will be changed and is not final. • Overview of the agenda (10 minutes): Review the agenda with the group and ask if they feel comfortable with it. Confirm that the entire meeting should last about one and a half days. Explain that there will be sessions where they will work in smaller groups and then come back to the larger group for plenary discussion. • Presentation of the discussion rules (10 minutes): Go over the discussion rules with the group (see box below) and ask them if they agree, or would like to remove or add other rules. Show the participants the “speaker timer symbol” (for example a smiley face) which means they have talked for 3 minutes, and should allow others to talk instead.

Module 3

2) Presentation of the national and district MNH and IFC plan (30 minutes): • National and/or province presentation (15 minutes): A member of the national and/ or province IFC committees presents their programme of work on MNH, including the IFC framework. • District presentation (15 minutes): A member of the district IFC committee (either the committee chair or coordinator) presents their work on MNH and the IFC framework.

Discussion rules for the institutional forum • All ideas, opinions and suggestions, whether positive or negative, are welcomed. • Everybody has the right to express opinions and participate. • When something is unclear we will tell the facilitators. • It is important not to dominate the conversation, giving others the opportunity to express their ideas. • Let each person finish his/her idea. • Everything talked about during the meeting is confidential and should not be discussed with others outside of the meeting. This includes the names, surnames, or situations that were discussed. The topics can be talked about in general, but not the people or the specific situations discussed. • It is important to listen and to be listened to. • Language used must be respectful and not threatening. • Participants should only talk about the topic under discussion. • Participants should not talk for more than three minutes at one time. 3) Presentation of the IFC framework and the PCA (30 minutes) • Present the IFC framework including the objectives and priority areas of intervention. • Introduce the four levels of care and support, e.g. care in the home, awareness in the community, links between the community and health services, and quality of health services. Use the image “Care and support of the pregnant woman, mother and newborn” (on a flipchart or poster). • Present the objectives of the PCA and the methodology used. • Ask the participants whether they have questions or comments.

Annex 5: The institutional forum

4) Presentation of the situation analysis results (30 minutes) • The local coordinator presents the key findings from the situation analysis (maximum 10 slides). • Distribute copies of the PowerPoint presentation to all the participants. • Questions and discussion.

5) Plenary: Review of problems identified in the five roundtables and prioritization (1 hour 30 minutes)

Before the roundtable: Prepare four large flipcharts with the prioritized problems in the five different roundtables for each level of care and support, and the group who identified those problems as per Table 1 below. Table 1: Summary of problems (to prepare and fill in BEFORE the meeting) Topic : e.g. Care and support of the pregnant woman, mother and newborn at home Priority problems identified Groups that identified them

For example: Women and families are not aware of danger signs during pregnancy Women do not eat properly during pregnancy due to lack of time and money etc. Women, groups that identified them and mother-in-laws, providers Grandmothers and mother-in-laws, men

During the roundtable: • The facilitators present the problems prioritized by the different groups on four large flipchart sheets prepared before the meeting (one for each level of care and support, e.g. household, awareness, links and health services) as shown in Table 1. They may also choose to present these findings in a PowerPoint presentation. The presenter can elaborate the reported problems using some of the quotes written up from the meetings (see Table 3.2, section 3). S/he also asks the group participant representatives to confirm if the findings are correct, and if they have anything to add about their roundtable discussion. • Ask the participants to review the problems identified during the roundtables for each level of care, one at a time. Highlight problems that were identified by many groups and ones that were not. Also highlight problems that are common to more than one theme and appear in more than one flipchart (for example, poor quality health services may affect the decision to seek care, as well as the care received in the health facility). Elaborate or reformulate the problems if necessary. • Ask the plenary group whether they feel there are any other priority problems that may not

Module 3

have been considered by the previous groups that they feel should be added. See if others agree, and if so, add them to the list. • Next, ask the plenary group to prioritize these problems. To help identify the most important problems, they should think about the problems that most affect the health of mothers and newborns, particularly for the poorest families.

• Hand out a strip of eight coloured dots/stickers to each participant. Ask them to come up to the flipcharts and use the dots to prioritize two problems for each level of care. • When they have finished placing their dots, count up the dots and circle the two priority items for each level of care. Check whether the group is happy with its decision.

6) Group work: Review of recommended actions (2 hours) Before the roundtable: • Prepare handouts with the problems prioritized from the five different roundtables and actions identified for each level of care and support, as per Table 2 below. Remember to include the group who identified those problems and actions. • Prepare copies of the IFC framework strategic document6, one per group.

Table 2: Compilation of priority actions from the roundtables, with examples included (to prepare and fill in BEFORE the meeting) Topic : e.g. Links between the community and health services Priority problems identified (and by which group) Actions identified (and by which group)

For example: Difficulties in travelling to the health facilities (W, G, M, P)

For example: • Adapt public transport schedule to the needs of the population (W,P) • Free of charge transport for children and pregnant women (M, P, G) • Repair the roads (L,G)

W = Women, G = Grandmothers and mothers-in-law, M = Men, L = Community leaders, and P = Health care providers.

Working with individuals, families and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. http://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/index.html

Annex 5: The institutional forum

During the roundtable: • Briefly explain that five community roundtable discussions were held, the different profiles of each (e.g. women of reproductive age, etc.), and provide a summary description of the participants as noted in number 2 in Annex 4 above. Group discussion: • Divide the participants into four groups: 1. Care and support of the pregnant woman, mother and newborn in the home (developing CAPACITIES) 2. Awareness in the community of MNH rights, needs and potential problems (increasing AWARENESS) 3. Links between the community and health services (strengthening LINKAGES) 4. The care received from the health services (improving QUALITY) • Ask each group to nominate a representative to present their work in plenary. • Distribute one copy of the IFC framework strategic document to each group and ask them to look at the page with the priority areas of intervention (page 12). Explain that the IFC interventions are recommended at a global level because they have proven to have an impact on MNH. The group facilitator should review each IFC intervention in detail with all the participants. Emphasize that actions are needed in the four priority areas of intervention for improving the capacity of households for care in the home and to increase the use of skilled care. • Distribute the handouts with the actions for all the prioritized problems from the five roundtables (Table 2) and ask the participants to review them.

• Each group should work on the two problems that were prioritized in the previous plenary session. Write each problem at the top of a flipchart. Ask the group to review the actions that were identified in the individual roundtables for these priority problems and ask them whether they would like to add to the list or to reformulate some of the actions listed. They may also wish to consider some of the actions listed under problems that were not prioritized. • Ask the group to think about whether any of the IFC interventions that have not yet been mentioned are relevant, and whether they want to add them in order to address the priority problems. The group should produce a revised list of actions for each prioritized problem. Check with the group to see if there is anything else to add as a possible action that wasn’t already considered. Scoring exercise: • Once they have a final list of problems and actions, they should score each action in order to reach a consensus on two interventions for each problem. • Using Table 3 below, ask the group to discuss each action for each problem according to the following criteria: Feasibility of implementing the intervention according to available human, financial and other resources and based upon existing experiences in the area or in the country. Avoiding negative impact: some interventions may have negative impacts as well as positive ones, or may impact some groups negatively. Benefiting the poorest: it is important that the interventions chosen benefit the poorest members of society, as well as wealthier individuals.

Module 3

Replicability (potential for scaling up), i.e. elaboration of a project that is not too complicated or expensive and that can be replicable on a larger scale in other areas by NGOs or by the government. • Ask each participant in the group to score the interventions on a scale of 1 to 3 for each criterion according to their definition above: Feasibility: 3 – highly feasible, 2 – some feasibility, 1 – little feasibility Avoiding negative impact: 3 – should have no negative impacts, 2 – may have one or Table 3: Prioritization of actions Group: e.g. Developing capacities Interventions Feasibility e.g. Problem A e.g. Action A1 e.g. Action A2 e.g. Action A3 e.g. Action A4 e.g. Problem B e.g. Action B1 e.g. Action B2 e.g. Action B3

two negative impacts, 1 – may have several negative impacts Benefiting the poorest: 3 – should benefit the poorest, 2 – may have some positive benefit for the poorest, 1 – unlikely to benefit the poorest Replicability: 3 – highly replicable, 2 – some replicability, 1 – little replicability • The group should add up the points for each action and identify the two actions for each priority problem that have the highest score.

Criteria (1 to 3 points for each criterion) Avoiding negative impact Benefiting the poorest Replicability Total Score

7) Plenary: Presentation of group work on actions (1 hour 30 minutes) • Ask the representative of each group to present the results of their group work (Table 3) in plenary. Allow time for discussion after each presentation. • Ask the other participants whether they have questions, clarifications or comments and whether they agree with the prioritization done by the other group. Give the participants time to reflect on the actions in the different areas, and to see if they make sense together. Thinking about synergy between the actions may generate some additional suggestions or modifications. • Ask one facilitator to facilitate the session, one to take notes on the flipchart, and the other two to take notes of the discussion.

Annex 5: The institutional forum

8) Group work: Identifying activities for the implementation plan (1 hour) • Divide the participants into four groups again. Ask each group to nominate a representative to present their work in plenary. Explain they should get as far as they can in the time allocated. • In each group, use Table 4 to discuss the activities required to implement the priority actions selected. Ask the participants to identify the following: Activities required to implement each action; Actors to be involved with each activity and their role; Resources necessary to implement the activities (list available resources and from where these resources come); If the resources are not available, how to mobilize them.

Table 4: Activity Chart Group: e.g. Increasing awareness Selected key Activities required Actors and roles Actor Role Necessary resources Resources Available resources Where are resources from? How to mobilize additional resources

e.g. Problem A • • • •

Module 3

9) Plenary: Group presentations and next steps (45 minutes) • Ask the representative of each group to present the group report on activities in plenary. • Ask the other participants whether they have questions, clarifications or comments. • Lead a discussion on how the district IFC committee can mobilize support for this work, and what recommendations they have for moving forward. • Explain to the participants that their inputs and their recommendations have contributed a first draft of the IFC implementation plan and that the next step will be for the district IFC committee to continue working to refine this plan. • Ask the participants if any of them would be interested in still being involved and in providing their support to the district IFC committee in the process.

10) Closing (20 minutes) • Short summary of the discussion. • Evaluation of the discussion: hand out the evaluation form to all the participants to complete. • Thank-you: thank participants for their participation. • Payment of transport costs.

Annex 6: Checklist for organization of the roundtables and institutional forum

ANNEX 6: CHECKLIST FOR ORGANIZATION OF THE ROUNDTABLES/INSTITUTIONAL FORUM No. 1. 2. 3. 4. 5. 6. 7. 8. Task Identify venue for roundtables (ensure it has a separate area for children, an area for roundtable, and an area for refreshments) Ensure venue has good sized table(s), chairs Invite participants Organize transport for participants Organize child-minders for women’s groups Organize food and drinks for every roundtable Ensure there are flipchart stands (at least 3) Organize materials for roundtables: - flipchart paper - notepads - pens/pencils - coloured dots/stickers - masking tape and sellotape - scissors - coloured marker pens (lots!) - name badges for facilitators and note-takers - card/paper for name cards Create or photocopy leaflets on maternal, newborn and child health (if these are wanted) Create/photocopy the registration forms for the roundtables Photocopy sufficient copies of the finalized facilitation guides (Annex 3) (with the final list of questions) Organize a laptop and projector for doing the analysis after the roundtable (if possible, otherwise, organize multiple copies of the analysis forms (Annex 4)) Identify and confirm facilitators and note-takers for each roundtable (with roles assigned for group work as well) Prepare a short presentation of the situation analysis and MNH programme for the roundtables Prepare flipcharts for the group work and plenary in the roundtables Prepare the presentations for the institutional forum Prepare the flipcharts for the institutional forum Meet with representatives from the community roundtable to prepare them for the institutional forum Status (check if completed) Person responsible By when?

9. 10. 11. 12.

13. 14. 15. 16. 17. 18.

Module 3

ANNEX 7: ADDITIONAL PARTICIPATORY EXERCISES FOR ROUNDTABLE DISCUSSIONS The roundtable methodology included in Annex 3 is designed according to a half-day discussion. The methods used are group and plenary discussions. If the PCA team has additional resources to organize longer roundtables with community groups, the sessions can be made more participatory and interactive. The following exercises are suggested for those who are able to time-table longer sessions7. Group 1: CAPACITIES • Beginning: “Mary was tired after a long day working. Now in her eighth month of pregnancy, she was finding it harder to carry on with her normal daily activities. Her husband was due to return later that evening. She went into her kitchen to see what food she had in the cupboard... • Alternate endings: (a) ....Mary felt so happy. Her baby boy was now 6 weeks old and was fit and healthy – the doctor had given him the all clear at her check-up! (b)....Mary’s mother wept deeply. Her own sister had died during childbirth, and now she was grieving at the funeral of her own daughter. Ask the group to invent two different stories to describe what might have happened in these two situations. The facilitator can help write the story down if nobody in the group can write. Again, they could be divided into two groups to write the alternative stories. They should present their stories in plenary with the facilitators leading the discussion. Group 2: AWARENESS and LINKAGES

Picture work “Story with a gap” Provide the participants with the following three pictures: 1. A pregnant woman 2. a) A woman with a healthy newborn baby b) A grave or funeral procession (or similar) Explain that pictures 2. a and 2. b represent two alternative outcomes from a pregnancy. Ask them to draw six pictures: three for outcome 2. a and three for outcome 2. b to illustrate what might have happened in between these events. You could divide them into two groups to draw each scenario. Ask them to think about the themes they have just discussed, and what might happen when women die during pregnancy or childbirth. Afterwards, ask the group to explain their drawings in plenary. Lead a discussion on what happens in these tragic circumstances when women or babies die.

Identifying “rights” During the plenary, give a brief explanation of the meaning of human rights. Human rights are basic rights and freedoms to which all human beings are entitled. It is the duty of governments to protect the rights of their citizens, and many international legal documents have been signed to defend human rights. Among human rights is the right to health. The right to health is an inclusive right that does not only include access to health care but also a wide range of factors that can help 83

Story telling This exercise is similar to the pictures exercise above. Facilitators invent the beginning and ends of a story, for example:

Annex 7: Additional participatory exercises for roundtable discussions

us lead a healthy life, such as education. The right to health contains freedoms such as the right to choose health providers. It also contains entitlements from the state, for example equal opportunity for all to enjoy high quality services. There are also specific rights for maternal, newborn and child health: the Universal Declaration of Human Rights establishes that “motherhood and childhood are entitled to special care and assistance”. In addition, the United Nations Office of the High Commissioner for Human Rights has declared that maternal mortality and morbidity is not solely an issue of development, but a matter of human rights (United Nations Human Rights Council; 2009). It is important to understand that neither maternal health or newborn health are personal benefits, they are human rights that concern each and every person. Then explain that the national Ministry of Health believes that human rights are important and that many of these rights apply to MNH. Next, read out the following scenarios and ask participants to discuss if this is a violation of rights and why. To support the facilitator, the relevant rights for each scenario are indicated between brackets. Encourage discussion and help participants make sure that a variety of rights are considered throughout the session.

3. An adolescent has to leave school because she is pregnant - right to education and information: an adolescent has a right to receive an education whether or not she is pregnant; - right to be treated equally [age and sex discrimination]: an adolescent should be treated with the same respect as an older woman even if she is pregnant and have the same opportunity to be in school as a boy; - right to choice: an adolescent has the right to decide whether she wants a child.

4. A woman has to ask permission from her husband and/or mother-in-law to access health services - right to health and security: health services can improve the woman’s health and prevent disease; - right to choice: a woman has a right to seek help and counsel where and from whom she wishes; - right to information: a woman has a right to access information without restraint; - right to be treated equally [sex and gender non-discrimination]: a woman has the same right as a man to seek access to health services without needing permission. You can then encourage the group to identify situations they have heard about or lived related to MNH in which some human rights were not respected.

1. A woman is denied emergency obstetric care because she cannot afford the services - right to life and right to health: a woman should not be deprived of her right to life on the basis of her earnings.

2. A woman would like to continue breastfeeding her newborn but has to go back to work - right to earn an income and support a family: a woman has a right to support a family without this activity jeopardizing her livelihood; - right to health [of newborn]: a mother has a right to take time to give her newborn a healthy life.

Map of social support In advance, prepare a large flipchart sheet with a picture of a pregnant woman in the centre, with a series of concentric rings around it.

Module 3

Ask the participants to think about all the different types of people or organizations that could provide support to the pregnant woman or the woman after birth to care for herself and her newborn. Explain that those who provide the most support should be placed within the circle closest to the woman, while those who provide little or no support should be placed at the last ring. Use the results of the situation analysis to prompt the group to think of the different organizations or institutions in the community, if they do not think of them themselves. They may end up with a drawing like this one:

Ranking line of social support Similar to the map, ask the participants to rank (i.e. put in order) the different people or institutions who help pregnant women and new mothers and newborns.

Social support for the pregnant woman and newborn Most support

Her sisters

Her mother The village midwife

Her husband Her sisters Her cousins and other family Her parents

Her husband Community Health workers

Her friends

NGOs Her other children The Church and the Priest

The nurse in the clinic The doctors

Policemen Friends Teachers

NGOs

The priest

Nurses

Neighbours The mayor

Doctors

Her neighbours The teachers Social workers The mayor and local council Least support

Annex 7: Additional participatory exercises for roundtable discussions

Group 3: QUALITY OF CARE

Role-plays Divide the participants into two groups and ask them to create a short 5-minute role-play demonstrating what is (a) good quality care; or (b) poor quality care for pregnant women and newborns within the health services. You can give them paper, cardboard, old newspaper and marker pens to help create props for the role-play. Afterwards, they can present their role-play in plenary. Ask the participants to reflect on the meaning of high quality care within the health services.

Department of Maternal, Newborn, Child and Adolescent Health 20 Avenue Appia 1211 Geneva 27 Switzerland E-mail: mncah@who.int Website: http://www.who.int/maternal_child_adolescent/en/

ISBN 978 92 4 150852 0

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health

A Toolkit for Implementation Module 4: Training Guide for Facilitators of the Participatory Community Assessment in Maternal and Newborn Health

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health:

A Toolkit for Implementation

Module 4: Training Guide for Facilitators of the Participatory Community Assessment in Maternal and Newborn Health

Module 4

TABLE OF CONTENTS Acronyms...................................................................................................................................................................................... The Story of the Toolkit............................................................................................................................................................ Introduction to Module 4 ......................................................................................................................................................... Training Agenda. ........................................................................................................................................................................ DAY 1 ........................................................................................................................................................................................... Session 1: Introduction ............................................................................................................................................. Session 2: Review of the IFC component of the MNH strategy .................................................................... Session 3: Review of IFC activities to-date ......................................................................................................... Session 4: Results of the situation analysis . ..................................................................................................... Session 5: First review of the roundtable question guide .............................................................................. Session 6: Overview of the individual roundtable discussions and identification of participants .... Session 7: Introduction to facilitation skills training ....................................................................................... Daily evaluation and homework assignment ..................................................................................................... DAY 2 ........................................................................................................................................................................................... Summary of previous day’s evaluation ................................................................................................................ Session 8: Facilitation “micro-skills” training .................................................................................................. Session 9: Group management and promotion of dialogue .......................................................................... Session 10: The role of note-takers and observers ......................................................................................... Session 11: Demonstrating facilitation and practice with note-taking ..................................................... Daily evaluation and homework assignment ..................................................................................................... DAY 3 ........................................................................................................................................................................................... Summary of previous day’s evaluation ................................................................................................................ Session 12: Overview of group work and practice . .......................................................................................... Session 13: Overview of plenary and practice ................................................................................................... Session 14: Opening and closing the roundtable discussion ........................................................................ Overview of the following day, daily evaluation and homework assignment ........................................... DAY 4 ........................................................................................................................................................................................... Summary of previous day’s evaluation ................................................................................................................ Session 15: Preparing for the roundtables . ....................................................................................................... Session 16: The practice roundtable .................................................................................................................... DAY 5 ........................................................................................................................................................................................... Session 17: Feedback session ................................................................................................................................ Session 18: The analysis form ................................................................................................................................ Session 19: The summary report .......................................................................................................................... Session 20: The institutional forum ...................................................................................................................... Session 21: The PCA final report, results dissemination and post-PCA activities ................................ Workshop closing ....................................................................................................................................................... Annexes......................................................................................................................................................................................... Annex 1: PCA training daily evaluation form . .................................................................................................... Annex 2: Training final evaluation form . ............................................................................................................. Annex 3: Handout 1 – Notes on facilitation skills and group management ............................................. Annex 4: Handout 2 – Icebreakers and energizers .......................................................................................... Annex 5: Handout 3 – Observation checklist for facilitation skills ..............................................................

vi vii 1 5 9 9 10 11 12 14 15 17 18 19 19 19 27 37 39 40 41 41 41 43 45 48 49 49 49 50 51 51 52 53 54 60 62 63 64 65 67 73 75

ACRONYMS IFC MNH PAHO PCA WHO Individuals, Families and Communities (In reference to the World Health Organization’s framework for Working with Individuals, Families and Communities to Improve Maternal and Newborn Health) Maternal and newborn health Pan American Health Organization Participatory community assessment World Health Organization

Module 4

Please see http://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/

vii

The Story of the Toolkit

viii

Module 4

IX ix

Module 4

INTRODUCTION TO MODULE 4 This document is the fourth module of a series entitled Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation, designed to support the implementation of the World Health Organization (WHO) framework “Working with individuals, families and communities (IFC) to improve maternal and newborn health”,2 herein referred to as the “IFC framework.” The IFC framework, originally elaborated in 2003, was developed in response to the observation that a robust and systematic health promotion component was largely absent from most maternal and newborn health (MNH) strategies in countries. Grounded on the foundational principles of health promotion as outlined in the Ottawa Charter,3 the framework and the interventions it proposes were formulated based on an examination of evidence and successful experiences in working with individuals, families and communities to improve MNH. This evidence was updated in 2015 and we refer the reader to the publication WHO recommendations on health promotion interventions for maternal and newborn health, available at http://who. int/maternal_child_adolescent/documents/ health-promotion-interventions/en/. To date, the IFC framework has been implemented in a number of countries spanning the six world WHO regions, including: Bangladesh, Burkina Faso, Colombia, El Salvador, Guatemala, Haiti, Kazakhstan, Lao People’s Democratic Republic and the Republic of Moldova. The aim of the toolkit is to support public health programmes in launching a process to work with and empower individuals, families and communities to improve MNH.

See the following strategic document: Working with individuals, families and communities to improve maternal and newborn health, WHO, 2010. 3 See WHO, 1986. 2

Introduction

Module 3: Participatory Community Assessment in Maternal and Newborn Health (PCA)

Module 4: Training Guide for Facilitators of the Participatory Community Assessment (PCA) in Maternal and Newborn Health Module 5: Finalizing, Monitoring and Evaluating the IFC Action Plan

As outlined in the above table, this module contains a guide to train teams that will be responsible for conducting the participatory community assessment (PCA) in maternal and newborn health (MNH) (see Module 3 of this toolkit). The PCA is a critical step in the implementation of the IFC framework.

The course contained in this guide is designed to last five days, and assumes that the participants have little or no previous experience in facilitating group discussions. The training will prepare the participants to conduct a series of roundtable discussions and a final institutional forum that are suggested for the PCA. This includes training on facilitation skills, analysis and report writing, and the organizational requirements for these discussions, as well as one half day of the course set aside for a practice roundtable discussion.

Module 4

Participants This training course is designed to be attended by the entire PCA team, including coordinators, facilitators and note-takers (see Module 3; section 1.5) and other members of the district committee who will be involved in the PCA. Those working on the IFC component of the MNH strategy at the province and national levels may also attend, in particular those who will be responsible for scaling up the IFC framework to other districts and provinces. When to hold the workshop? The training is intended to be conducted following the initial preparation phase of IFC implementation (see Module 1; Figure 2.1: IFC Implementation Framework), which includes orienting key partners to the framework (see Module 2) and laying the groundwork for coordinating the IFC component. Moreover, we highly recommend that the PCA team complete the situation analysis prior to attending this training, as one of the steps within the training is to review the analysis and use it as a tool for preparing the roundtable discussions. If the situation analysis has not been conducted, then some minor adaptations to this guide will be required. Although this is the recommended timeline, we encourage IFC actors to be flexible and open to adapting the process to their specific context.

The practice roundtable This training course includes a practice roundtable that is scheduled to be held in the afternoon of Day 4. This roundtable is organized with one of the community groups (usually women, men or mothers-in-law/grandmothers). In order for this practice roundtable to take place, the local coordinator will need to arrange for participants to come to this roundtable prior to the training course (see Module 3, sections 3.5, 3.6, and Table 3.1). They will also need to ensure that there are logistical arrangements for this discussion including organization and/or payment of transport, food (afternoon snack) and child minders (if women participants are selected). If this practice roundtable goes well and results in a meaningful and well-recorded discussion, then the results can be used in the final report. If this is not the case, then the roundtable can be repeated at a later date (with different participants) to ensure that the results are meaningful.

Introduction

Trainers The expert facilitator is generally the actor responsible for training the local PCA team, with support from national and province partners. The expert facilitator is expected to be familiar with the IFC framework and will ideally have experience in training on participatory research methods. They may be supported by international experts. Tip for trainers Remember that your own facilitation skills will be “on display” during this training course, so it is important to practice many of the skills that you are promoting among the group. For example, it is important to encourage all participants to actively participate in the training, in particular members of the district committee who may feel less comfortable in this environment; it is important to stick to the agenda timings; and it is also important to use energizers and icebreakers to keep the group motivated, which may also be used during the roundtable discussions if needed (see Handout 2 provided in Annex 4).

Adapting the training The training agenda contained in this manual may need to be adapted to the training needs of groups in different contexts. Trainers are encouraged to review the agenda carefully and tailor the sessions to meet the needs of the group.

Module 4

TRAINING AGENDA DAY 1 Time 9.00-9.45

Sessions 1. Introduction • Introductions by facilitators • Presentation of participants • Workshop objective

Materials Flipchart with objectives

Module 3 section

9.45-10.15

2. Review of the IFC component of the MNH strategy (refresher) • Review of key concepts • Review of the priority areas of intervention • IFC implementation (including roles of national, province and district teams) • Short overview of the PCA • Questions and discussion

PowerPoint Presentation “Care of the pregnant woman, mother and newborn” image IFC framework strategic document

10.15-10.45 10.45-11.30

Coffee Break 3. Review of IFC activities conducted to-date • Short presentations by national, province and district teams on what has been done to-date • Questions and discussion Flipchart or PowerPoint presentations

11.30-12.30

4. Results of the situation analysis • Intro to the situation analysis and its aims • Presentation of key findings (max. 15 slides), with questions • Small group work to review report

PowerPoint presentation Copies of the situation analysis report or forms Flipcharts

Section 2 and Annex 2

12.30-14.00 14.00-14.30

Lunch 4. Results of the situation analysis (continued) • Presentation by groups in plenary • Questions and discussion Copies of the situation analysis report or forms Flipcharts for groups Revised question guides (latest version) Annex 3 (or the latest adapted version of the question guide)

14.30-15.30

5. First review of roundtable question guide • Review in groups the roundtable question guide (three groups), and make suggestions for modifications based on situation analysis • Report back in plenary

15.30-16.15

6. Overview of the roundtable discussions Review of PCA guide sections and identification of participants • Short presentation by facilitators (overview of the methodology, voluntary participation, facilitation and note-taking, participants) • Group work and feedback in plenary

Section 1

Training agenda

DAY 1 Time 16.15-16.30 16.30-16.45

Sessions Coffee Break 7. Introduction to facilitation skills training • What does facilitation mean? • What a facilitator SHOULD and SHOULD NOT DO

Materials

Module 3 section

16.45-17.00

Daily evaluation and homework assignment

Evaluation form

DAY 2 Time 9.00-9.15 9.15-10.20

Sessions Summary of previous day’s evaluations 8. Facilitation “micro-skills” a. Values and attitudes clarification b. Tips on communication Coffee

Materials Flipcharts Agree/Disagree poster

Module 3 section

10.20-10.45 10.45-12.15

8. Facilitation “micro-skills” (continued) Handout 1: Notes on facilitation skills and group management c. Clarifying and paraphrasing (see Annex 3 of this guide) d. Questioning and probing e. Practicing facilitation micro-skills 9. Group management and promotion of dialogue a. Overview of group management Handout 1: Notes on facilitation skills and group management (See Annex 3 of this guide) Handout 2: Energizer and icebreakers (see Annex 4 of this guide

12.15-12.30

12.30-13.45 13.45-15.30

Lunch 9. Group management and promotion of Handout 1: Notes on facilitation skills and group management dialogue (continued) (see Annex 3 of this guide) b. Participant management and group dynamics c. Management of the discussion d. Identifying key points, defining problems and achieving consensus 10. The role of note-takers and observers • The role of note-takers • Brief overview of analysis report • The role of observers Coffee 11. Demonstrating facilitation and practice with note-taking Flipcharts Note-taking form Annex 3 (note-taking form) Annex 3 (note-taking form) Annex 4

15.30-16.00

16.00-16.15 16.15-17.00 17.00-17.15

Daily evaluation and homework assignment

Evaluation form

Module 4

DAY 3 Time 9.00-9.15 9.15-10.30

Sessions Summary of previous day’s evaluations 12. Overview of group work and practice • Introducing the group work • Practice session on small group work

Materials

Module 3 section

Image of “Care of the pregnant Annex 3 woman, mother and newborn” Table and chairs set up Note-taking forms and/or notepads; pens Observation checklist

10.30-10.45 10.45-12.30

Coffee break 12. Overview of group work and practice Image of “Care of the pregnant (continued) woman, mother and newborn” • Introducing the group work Table and chairs set up • Practice session on small group work • Feedback Lunch 13. The plenary sessions on prioritization and actions • Prioritization using the flipcharts and coloured dots • Prioritization for semi-literate groups • Presentation of “opportunities” and brainstorming on actions • Practice session on the plenary Annex 3 3 flipchart sheets prepared with some problems identified 3 flipchart sheets with the “actions grid” Strips of coloured dots Flipcharts prepared Actions grid Table and chairs set up Note-taking forms and/or notepads; pens Observation checklist Annex 3

12.30-13.30 13.30-14.45

14.45-15.30

14. Opening and closing the discussion Flipchart sheets and markers • Overview • Group work to prepare the opening presentations TIME OFF!

17.00-17.20

Daily evaluation and homework assignment

Evaluation form

* It is assumed that most participants in the roundtables will be literate. If this is not the case, please inform us.

Training agenda

DAY 4 Time 9.00-9.15 9.15-10.30

Sessions Summary of previous day’s evaluations 15. Preparing for the roundtables • Revision of the question guide • Review of the roundtable preparation checklist. Coffee break 15. Preparing for the practice roundtable • Preparation of the presentations and flipcharts • Any other preparations Lunch

Materials Flipchart sheets Markers Masking tape Stickers

Module 3 section Annex 3 Annex 6

10.30-10.45 10.45-11.45

11.45-12.30 12.30-17.15

16. Practice roundtable (to start at 13.00) Table and chairs set up Flipchart sheets Markers Masking tape Stickers

Annex 3

DAY 5 Time 09.00-10.45

Sessions 17.Feedback session • Feedback from facilitators • Feedback from note-takers • Feedback from observers • Feedback from trainers • Adjusting to problems Coffee break

Materials Flipcharts

Module 3 section

10.45-11.15 11.15-12.45

18. The analysis form PowerPoint projector and laptop • Group fill in analysis form from the practice roundtable together

Annex 4

12.45-13.45 13.45-14.00

Lunch 19. The summary report • Overview of summary report • Compilation Table 3.2 20. The institutional forum • Aims and objectives • Participants • Preparations • Agenda overview 21. The PCA final report, results dissemination and post-PCA steps Section 5 Section 3.10

14.00-16.00

16.00-16.45 16.45-17.15

Closing and final evaluation

Final evaluation form

Module 4

DAY 1 SESSION 1: INTRODUCTION Time: 45 minutes Objectives • To introduce workshop participants and the objective of the training course.

Instructions to facilitators • Trainers and any other members of the facilitation team introduce themselves. • Ask participants to introduce themselves. Preferably, use a dynamic exercise that you aware of. Handout 2 (see Annex 4) contains a list of possible icebreakers; however, remember to keep the exercise short and take into account the allocated time. • Write the workshop objective on a flipchart and ask the group if they feel comfortable with it or if they would like to modify it. Workshop objective To train those who will be involved in conducting the PCA on the methodology and the instruments to be used.

• Go over the training agenda with the group and ask if there are questions or suggested modifications. • Present a list of rules of participation. Ask if participants would like to modify the list. Rules of Participation • Switch off phones • Arrive on time • Start on time • Be quiet and listen while others are talking • Do not talk too long (e.g., limiting comments to three minutes) • Switch wireless off on computers • Be respectful to other participants • Stick to the agenda

Day 1

SESSION 2: REVIEW OF THE IFC COMPONENT OF THE MNH STRATEGY Time: 30 minutes References: The IFC framework strategic document and Module 1 Objectives • To review the IFC framework, its key concepts and priority areas of intervention. • To review the IFC implementation framework, including the different roles of national, province and district committees.

Instructions to facilitators • Presentation by trainers: The IFC framework, the image “Care of the pregnant woman, mother and newborn” and the IFC implementation framework. • Questions and discussions from the group.

Module 4

SESSION 3: REVIEW OF IFC ACTIVITIES TO-DATE Time: 45 minutes Reference: Module 1 Objectives • To review the activities that have taken place in the district, province and at national level to prepare for IFC implementation.

Instructions to facilitators • Short presentations by the national, province and district committees (10 minutes each) on what has been done to-date to implement the IFC framework (30 minutes). One representative from each level presents what they have done to prepare for the PCA up until now. They may reflect on challenges they have faced and lessons learnt in the process. Key issues to present and discuss are: ° How the IFC component fits into the broader MNH strategy; ° Formation of the IFC committees; ° Engagement with other sectors (NGOs, education, local authorities, transport, rights, etc.); and ° Preparations for the PCA (if any). • The trainer can go through the IFC implementation framework image (see figure 2.1 of Module 1) to verify with the group which activities have been completed. • Questions and discussion (15 minutes).

Training agenda

SESSION 4: RESULTS OF THE SITUATION ANALYSIS Time: 1 hour 30 minutes Reference: Module 3; Section 2 and Annex 2 Objective • To better understand the current situation of MNH, and discuss what information is missing or could be better captured in the situation analysis report.

Instructions to facilitators • Presentation of key findings (maximum 15 slides) (15 minutes). Members from the district IFC committee present a summary of the key findings from the situation analysis. They should not present all the data collected. Ideally, the presentation will focus on the six key areas of the situation analysis report, plus the synthesis of challenges and opportunities (see box). Keys areas to cover in situation analysis presentation: 1. Description of local area 2. Description of the MNH situation 3. Health services in the district 4. Institutions and organizations 5. Ongoing activities in the district 6. Existing research on MNH and health promotionin the district 7. Synthesis of challenges and opportunities to improve MNH

Module 4

• Present Group Work 1 (see box). Group Work 1

Time: 45 minutes Aim: To review and reflect on findings of the situation analysis Divide participants into three groups and provide each group with two of the six situation analysis forms. Ask each group to: • Review their allocated forms as well as the synthesis of challenges and opportunities. • Discuss if they agree with the data provided and whether they have further recommendations for this situation analysis report. • Reflect on the summary of challenges and opportunities and see if they agree. • Reflect on what they do NOT yet know about MNH, and what they would like to discuss with community groups.

• Presentation by groups in plenary (30 minutes).

Day 1

SESSION 5: FIRST REVIEW OF THE ROUNDTABLE QUESTION GUIDE Time: 1 hour Reference: Module 3; Question guide in Annex 3 and/or any locally-adapted version Objective • To revise the guide to be discussed during roundtable discussions, and adapt questions based on the results of the situation analysis.

Instructions to facilitators • Present Group Work 2 (see box). Group Work 2

Time: 40 minutes Aim: To review the PCA question guide and adapt it to the local context Divide the participants into three groups and ask each group to review one of the following set of questions: 1. Care in the home 2. Awareness and linkages for social support in the community 3. Care received from the health services Ask them to think about: • Whether the questions need further adaptation. • Whether there are any questions that need to be added, based on the findings from the situation analysis. • Whether any questions should be removed.

• Presentation by groups in plenary (20 minutes): Ask each group to report their recommendations to the plenary, and see if others agree with their suggestions.

Module 4

SESSION 6: OVERVIEW OF THE INDIVIDUAL ROUNDTABLE DISCUSSIONS AND IDENTIFICATION OF PARTICIPANTS Time: 45 minutes Reference: Module 3; Section 3 and Annex 3 (including Table 3.1 with list of participants) Objective • To familiarize participants with the complete roundtable methodology.

Instructions to facilitators • Short presentation (20 minutes) by facilitators on: ° Overview of methodology for individual roundtables (review Module 3; section 3) ° The importance of informing about voluntary participation (review Module 3; section 3.4) ° The importance of facilitation and note-taking (review Module 3; section 3.8) ° Identification of the participants for the roundtables (review Module 3; section 3.5) • Present Group Work 3 (see box) if time permits. If there is not enough time, the questions can be discussed in plenary.

Group Work 3

Time: To be determined based on available time Aim: To reflect on considerations to be made when inviting participants to roundtables Divide participants into two groups. Invite the groups to do the following: • Group 1: Discuss how they would identify the participants for the various roundtable discussions and institutional forum (e.g., how to identify women and their families, how to invite or identify the community leaders and institutional representatives) and where they would organize them. Remind the group that while selecting a good representation of participants from the community is important, they will also want to ensure that the poorest and most vulnerable are represented (see Module 3, section 3.4). • Group 2: Discuss how to best ensure that voluntary participation is achieved (e.g. is it enough that note takers explain this during the registration process; what is the best way to explain voluntary participation to potential participants; when should the concept of voluntary participation be reinforced, etc.) (see Module 3, section 3.4 and Annex 3, section 1) Each PCA committee will determine the best way to ensure voluntary participation in their community.

Day 1

• Presentation by groups in plenary (25 minutes). • Verify that participants have been identified and invited to the practice roundtable to be held on Day 4 of the workshop (see the Introduction section of this guide).

Module 4

SESSION 7: INTRODUCTION TO FACILITATION SKILLS TRAINING Time: 15 minutes Reference: Module 3; Section 3.8 Objective • To understand the meaning of facilitation.

Instructions to facilitators • What does facilitation mean? Lead a discussion on the meaning of facilitation. Ask the group what they understand by the term “facilitator” (review Module 3; section 3.8). • Make it clear to the group that facilitation is a learned skill. While some people might naturally be good facilitators, most people have to practice to develop their skills as facilitators. Explain that they will have some time to practice during the training and that the expert facilitator will be able to give them feedback during the practice roundtable discussion. This will not be the end of the learning process, however, and the more facilitation they do, the more skilled and comfortable they will become. • What a facilitator SHOULD DO/ What a facilitator SHOULD NOT DO Set up 2 flipcharts, with the titles above. Ask the group to brainstorm on what a facilitator should do, and what a facilitator should not do.

Check that the following points are covered: What a facilitator SHOULD DO Listen Be nice and respectful to participants Make participants feel comfortable Ask questions Guide the discussion Encourage all participants to speak Promote discussion Verify that participants can understand Use simple language Be sympathetic Arrange the table and chairs well Manage time well Assess if participants are tired or bored What a facilitator SHOULD NOT DO Give their opinions Allow participants to be argumentative Be an interviewer Judge participants Tell participants that their answer is right or wrong Interrupt participants Show disrespect Encourage one-to-one dialogue Ignore participants Give complicated explanations Talk a lot Be nervous

Day 2

DAILY EVALUATION AND HOMEWORK ASSIGNMENT Time: 15 minutes • Conduct the daily evaluation of the training course (see Annex 1 of this guide). • Assign homework: Read Section 3 and Annex 3 of the Module 3.

Module 4

DAY 2 SUMMARY OF PREVIOUS DAY’S EVALUATION Time: 15 minutes • Share the results (confidentially) of the previous day’s evaluation, and discuss how you will respond to any issues raised.

SESSION 8: FACILITATION “MICRO-SKILLS” TRAINING Time: 3 hours 30 minutes Overall objective: To develop skills to facilitate roundtable discussions. 8a. Values and attitudes clarification

Time: 30 minutes Objectives • To understand how one’s own beliefs, values and attitudes can affect a discussion. • To be aware of one’s own beliefs, values and attitudes in order to avoid imposing them on participants.

Instructions to facilitators • Prepare a set of ten belief statements to read out loud. Some examples are provided in the box. You may choose some other beliefs or attitudes that are common in your country or community. • Prepare two large pieces of paper with the following words on them: AGREE and DISAGREE. Post them to the wall in an open space, where people can walk around freely, with AGREE and DISAGREE at opposite ends of the room. • Bring all the participants into the open space in the room, in between the AGREE and DISAGREE posters. • Explain that you will read some statements to them, and will ask them to judge the statement with their own beliefs, values and attitudes. Ask them to wander around. Explain that there are no right answers. • Read each statement, one at a time. Ask the participants to move to the end of the room towards either AGREE or DISAGREE—whichever they feel most comfortable with.

Day 2

• No discussions about the statement or choice are allowed. Encourage participants to ignore what other people are doing and to make a decision based on their own beliefs. Examples of statements: • Antenatal care is only necessary if the woman has complications. • Women should ask their husband’s permission to go to the clinic. • It is safer to give birth at home. • Girls should leave school if they get pregnant. • There is no such thing as rape within marriage. • Family planning is only a woman’s responsibility. • People should pay for quality health care. • Women who are beaten by their husbands have usually done something to deserve it. • The community authorities should do more to support pregnant women. • Looking after babies is the woman’s responsibility. • Young couples get little support from their relatives. • Adolescent girls should not be educated about sex. • A woman has the right to choose whether to terminate her pregnancy. • After reading all the statements, ask the group to return to their seats. Ask the group: ° How did you feel about the exercise? ° Was it easy or difficult to decide which side to go to? ° Why is it important, for us as facilitators, to be aware of our own values, beliefs and attitudes? ° What happens when facilitators hold differing beliefs about MNH issues? ° What can we do as facilitators, when our beliefs make it hard discussing certain topics with people in our communities?

Module 4

8b. Tips on communication

Time: 35 minutes Objective • To learn some of the key communication skills required for group facilitation.

Instructions to facilitators • Using SIMPLE LANGUAGE (10 minutes): Read the following statement to the group:

“We have conducted epidemiological studies that show that this community suffers from a high rate of infant and maternal mortality. One of the principal causes of maternal mortality is postpartum haemorrhage.” Ask if they think it would be acceptable to present information like this to community groups. Ask them how they would reword the statement to make it understandable. Emphasise that all complex terms need to be said in a simple way. They can make suggestions for the following examples: Technical terms Maternal mortality Sexually transmitted infection Newborn health Exclusive breastfeeding Postpartum haemorrhage Antenatal care Skilled birth attendant Simplified terms Deaths of mothers during pregnancy or childbirth Sexual diseases Health of babies Feeding the baby only breast milk Heavy bleeding after birth Check-ups during pregnancy Qualified nurse or doctor during the birth

• TONE OF VOICE (5 minutes): Explain to the group that the tone of voice they use can influence how the group feels, and most importantly how comfortable they feel in voicing their opinion. While talking, use different tones of voice to give some examples of how your tone of voice is a powerful communication tool (for example, speak aggressively, speak sympathetically, speak sadly, speak excitedly, etc.) Explain that when facilitating the roundtables, they should NOT be threatening, loud or aggressive, but rather use a relaxed, gentle, sympathetic, enquiring tone of voice.

Day 2

• ACTIVE LISTENING (10 minutes): Explain that 90% of the way we communicate is through non-verbal communication, while only 10% is through the words we use. This means that our body language and our expressions are very important for good facilitation. Explain to the group that there are other types of non-verbal communication that facilitators must master. Lead a brainstorm on some of the key ways of showing interest and disinterest. Write up the results on a flipchart. Examples of disinterest Examples of interest

• No eye contact • Looking at a watch • Reading papers on the desk • Yawning • Fidgeting

• Maintaining acceptable eye contact • Nodding the head • Smiling • Leaning in • Frowning • Expressing surprise by moving eyebrows • Writing notes

Remind the group of the values and attitudes session earlier in the workshop: facilitators should avoid showing any judgment if they personally disagree with statements being made. 8c. Clarifying and paraphrasing

Time: 20 minutes Objective • To practice asking for clarification and paraphrasing.

Instructions to facilitators • Explain that active listening must go beyond just listening; explain that it is important to clarify what has been said. One way to clarify is to paraphrase back to a speaker, to check understanding. • On a flipchart, write the heading “Ways to clarify and paraphrase”. Ask the group to brainstorm about phrases they can use to clarify. Examples include: ° Do I understand you correctly to say….? ° So you are saying that …., is this right? ° I hear you saying that…, is that right? ° Have I heard you correctly to say….? ° I’m not sure I understood that clearly. Did you mean that….? 22

Module 4

• Remind the group that they should use SIMPLE language with any clarification and paraphrasing. Demonstrate the point by asking one participant in the training a question, for example, “So please tell us, Mrs. X, why do you think many households in this village do not have piped water?” Wait for the response, and then paraphrase back the answer for the rest of the group to understand. • Ask them to form pairs to practice clarifying and paraphrasing. Ask the pairs to discuss “My favourite food”; one person should ask questions and the other should answer. The questioner should clarify and paraphrase what the respondent says. They can swap roles after three minutes. 8d. Questioning and probing

Time: 30 minutes Objective • To understand different ways of questionning.

Instructions to facilitators • Explain that the facilitators need to encourage discussion among the group, and need to know how to use the question guide correctly. • Prepare flipcharts or overheads in advance with the meaning of closed- and open-ended questions. Question types: • A closed-ended question can be answered by short one-word answers (usually “yes” or “no”). • An open-ended question allows the respondent to tell you about how they feel, what they think or what they believe. They allow the person to express freely to the facilitator or group. • On flipcharts, write the following three examples. Ask the group to try and convert these questions into open-ended questions for you. Help them if they have trouble. Closed-ended Do you like going to the health centre? Does the community help pregnant women? Do couples communicate about family planning? Open-ended How do you feel about going to the health centre? How does the community help pregnant women? How do couples discuss family planning?

Day 2

• Explain that sometimes closed-ended questions are needed. Ask them to look at the roundtable question guide (Annex 3 of the Module 3, “Questions to guide the discussion”). Show them that some of these questions are closed-ended questions. Closed ended questions for roundtable discussions 1. Developing Capacities: Are there any special beliefs or traditions in the community about care during pregnancy? 2. Increasing awareness and strengthening linkages: Do people think that maternal and newborn health is a priority? Do women have problems reaching care? 3. Improving quality: Is the community involved in evaluating the quality of services or in suggesting how to improve the quality of services? • Explain that when you ask a closed-ended question, it is often important to probe further on the answer. Ask the participants to imagine an onion with its many layers. Explain that probing is like peeling the layers off an onion, with the aim to get to the core answer. • Prepare a flipchart or overhead with the meaning of a probing question and the six helpers for probing. Probing questions: A probing question seeks to discover more after an initial response. Six helpers for probing: WHY? WHAT? WHEN? WHERE? WHO? HOW? • Explain that these “helpers” are important probing questions to ask, but can also be threatening – they must be said in the right TONE OF VOICE and may need to be softened with language.

Example: A participant in a roundtable says “I just don’t like going to the health centre.” If a facilitator says, “Why don’t you like going?” in an aggressive way, this can be threatening to the participant, and may question their opinion. Instead you can say “What are the reasons that you don’t like the health centre?” (using a respectful tone of voice), this can make them feel more comfortable to explain their answer. • Remind the group that probing can be used when people are hesitant to respond to the questions you are asking – you need to probe to get them to open up to you.

Example: A facilitator may ask: “How do women care for the newborn in the home?” One or two participants may answer, “Quite well” or “They look after them okay.” Ask the group to suggest probes now, such as: “Do you think they have time to care for newborns?” or “How exactly do they care for them?”

Module 4

• Brainstorm about other ways to probe, for example: ° But why do you think this is? ° Can you explain further to us what you mean by this? ° So if this is the case….what does it mean if….? ° Can anybody else help explain the reason for this? • Reflect that facilitators also have to avoid asking LEADING questions. Prepare a flipchart or overhead with the definition of a leading question. Leading questions tend to orient the group to answer in a certain way that often results in answers that affirm the position expressed in the question. • Write the following list of questions on the flipchart. Ask the group to identify which of these are leading questions. Help them convert the leading questions into more neutral questions: Original question Do you agree that women don’t breastfeed for long enough? Revised question Leading; convert to “For how long do women usually breastfeed?”

Do you think women have problems reaching health Leading; convert to “What problems do women face in services because of the state of the roads? reaching the health services?” How is the quality of health services? Are women treated badly by doctors in the hospital? How do women prepare for birth? Not leading Leading; convert to “How are women treated by doctors in the hospital?” Not leading

• Explain that it is important to keep the discussions as impersonal as possible to avoid emotional distress for participants. Impersonal questions (in the 3rd person) ask respondents to talk about a general situation rather than their own experiences. • Give examples of personal and impersonal questions, for example: Personal Impersonal How do you care for your baby? Do you have any problems getting to the health centre? How do people in your community care for their children? Do people in your community face any problems getting to the health centre?

Day 2

8e. Practicing facilitation micro-skills

Time: 40 minutes Objective • Practice facilitation micro-skills.

Instructions to facilitators • Present Group Work 4 (see box). Group Work 4

Time: 25 minutes Aim: To practice facilitation micro-skills Split participants into groups of three. Each group should take turns with one questioner, one respondent and one observer. Ask each person to pick one of the following themes and take two or three minutes to come up with a list of questions related to their theme. Then ask them take turns in questioning for five minutes each: 1. The quality of health services for pregnant women in this community 2. Public transport in this community 3. Men’s role in the care of pregnant women and newborns Ask them to focus on practicing the following skills, with the observer taking notes on how the questioner performs (write them on a flipchart to remind them): Active listening, tone of voice, clarifying, paraphrasing, asking open-ended questions, probing, avoiding leading questions. Have them swap roles after five minutes – do this twice – so that everybody gets a turn to ask questions. • After they have finished, bring them back to plenary, and ask them to reflect on their experience. Of these different skills, which do they feel they had the most problems with and need more practice in? Ask how they felt as observers, questioners and respondents. • WRAP UP: Summarize for the group the importance of (1) the way that you communicate, and (2) how you respond to the communication of others.

Module 4

SESSION 9: GROUP MANAGEMENT AND PROMOTION OF DIALOGUE Time: 1 hour 55 minutes Objectives • To understand group dynamics and know how to manage them. • To know how to promote dialogue during roundtable discussions. 9a. Overview of group management

Time: 15 minutes Instructions to facilitators • Draw a picture of a face with antennae on a flipchart (see below). (Or alternatively, make some antennae to wear!) Explain that a facilitator has to behave like an insect with feelers – to sense or feel the mood of the group, to watch them very carefully in order” to understand the group dynamic. Managing the group well is just as important as knowing how to communicate with the group.

• Ask participants to “put their antennae” on, and comment on how they sense the dynamic of the training group is now. • Brainstorm with the group about what things they have to monitor when managing a group. • Possible answers: ° Time management; ° How hungry people are, when they need to eat or drink; ° Participation: people who talk too much, people who are not participating; ° Promoting lively and participatory discussion;

Day 2

° Obtaining different opinions; ° Conflict between participants; ° Boredom/energy levels; ° People who arrive late/leave early. •Do an energizing activity with the group now. You can review the activities in Handout 2 (see Annex 4 of this guide) to see if these are suitable, or pick another one.

Time management • Ask the group to look at the agenda in the Facilitation guide for the roundtable discussions (Module 3, Annex 3, page one). Explain that the guide is designed to allow them to cover the four sessions in 4 hours 30 minutes (Introduction, Group work on problems, Plenary for prioritization, Actions to help solve the problems, and Closing). • Explain that they will practice each of these four sessions later in the training. • Ask them to brainstorm on how they can stick to the time limits. For example by: ° Keeping a clock visible in the room; ° Reminding participants of their time limits (3 minutes) (show the group the speaker timer symbol, usually a smiley face); ° Asking the co-facilitator to manage the time; and ° Being organized to ensure they start on time. • Discuss what to do if they go over their time allocated, for example: ° Checking if participants can stay a while longer; and ° Rescheduling another date and time to finish the discussion. (NOTE: Neither of these solutions is ideal, so it is very important to try and stick to time).

Module 4

9b. Participant management and group dynamics

Time: 45 minutes Instructions to facilitators • Ask eight volunteers to come around a table in the middle. Give each volunteer a role card (try and assess which participant would play which role best). Ask them not to tell others what their role is: Role The conversation dominator The quiet one The disappearing act Description Always talking Never talks Leaves the meeting halfway through, comes in at the end and starts to give opinions

The side conversation (give this card to two “participants”) Those who whisper or talk on the side The repeater The rambler The “know it all” Repeats others comments Talks for a long time without making a point Thinks they are superior to other participants

• Facilitate a group discussion with this group. Pick one of the three group discussions from the roundtable discussion guide (Annex 3 of Module 3). Let them discuss, while playing their roles, for about five minutes. Manage the group, according to their roles, for example, by encouraging the silent member to talk (see recommendations below). • Afterwards, ask the group to reflect on what happened and to comment on the different roles they observed. • On a flipchart, identify the roles that were played, and ask for suggestions on how to effectively deal with them:

Day 2

Role The conversation dominator

How to manage the participant(s) • When there is a pause, thank the member and invite someone else to speak • If the person carries on, interrupt • Remind the group of the “rules of discussion”, in particular the 3 minute time limit • During a break, quietly ask him/her to give others a chance to speak • When there is a pause, ask for other comments or opinions, looking directly at the quiet participant • When the group is coming to a consensus or making decisions, double check that everyone agrees • Explain that it is very important for everyone to participate and share their ideas • Ask directly if the quiet participant(s) have any further thoughts • During a break, check that the participant feels able to participate in the discussion • At the beginning, tell participants how long the discussion will last, and check that everyone is able to stay for that long • If the person seems upset, consider asking another facilitator/note taker to follow them and check whether they feel alright • If they return at the end, consider asking why they had to leave • Remember to go over the rules of discussion at the beginning, including the need to respect other group members • Catch their eye (it may be enough to get them to stop) • Bring them into the discussion, by asking them directly if they have comments or opinions to share with the broader group • Ask them during a break to try and keep quiet while others are talking • Confront them openly during the discussion and ask them to listen to other participants • Thank the speaker, and ask her/him if s/he thinks differently or if they agree with what their neighbour said • Remind the group that if they agree with someone else, then they can express their agreement, rather than repeating the same point(s) • Thank the speaker for their comment, but remind them of their time limit (3 minutes) • If participants stray from the discussion topic, remind them of the question and topic • If many people are rambling, ask the group to try and be concise • When there is a pause, thank the member and invite other members of the group to speak • During a break, politely ask them to respect the rules of discussion, and to respect other participants in the group

The quiet one

The disappearing act

The side conversation

The repeater

The rambler

The “know it all”

Module 4

• Remind the group that the community members may not be used to participating in formal meetings like the roundtable discussions. Some people are very enthusiastic and may be ramblers, i.e. they talk on and on, without realizing that they should let others speak. Others may feel very intimidated, and may find it hard to speak. The facilitator needs to try and encourage everybody to voice their opinion. • Note: If a participant becomes upset during the discussion, take a break from the discussion and support the participant – ask if they want to continue or if they would prefer to take some time until they feel ready to participate in the again. 9c. Management of the discussion

Time: 20 minutes Instructions to facilitators • Explain to the group the importance of managing the roundtable discussions, in particular the following key skills: 1. Promoting dialogue between participants; 2. Avoiding topics that have already been discussed.

1. Promoting dialogue • Show the “dialogue” images below and explain the two different types of dialogue. The first image shows a facilitator-interviewer discussion, where the facilitator asks a series of questions to different members of the roundtable. There is little discussion between participants. The second image shows a scenario where the facilitator promotes dialogue between participants. This is the kind of dialogue that we are aiming for with the PCA. 1. Facilitator interviewing 2. Group dialogue with facilitation

Day 2

• Discuss what facilitators can do to promote dialogue among participants. Possible suggestions include: ° “Would anybody else like to respond to Mr X’s statement?” ° “Mrs X has made the point that… Do you all agree with this point of view?”

2. Avoiding topics that have already been discussed • Explain that a common mistake that new facilitators make is to follow a question guide “by rote”, as if it were a script, and as a result asking questions on topics that have already been discussed. • Emphasize that the question guide is just that – a guide. The art of the facilitator is to be able to cover the different questions depending on the way the discussion develops. • Consider the following three scenarios: Scenario What to do?

1. Question in the guide has not yet been discussed at all Ask the question as per the question guide. Acknowledge that the group has already mentioned this 2. The question and the topic have been touched upon, but topic, then explain that you would now like to ask some without much detail more questions to find out more about the situation. 3. The question has already been fully discussed Do not ask the question, but move on to the next topic.

• You can give an example from the question guides in Annex 3 of Module 3. Ask them to look at the question guide for Group 1 (Care of the pregnant woman, mother and newborn at home). Point out the question, “Do women and their families know the danger signs during pregnancy, childbirth, after pregnancy, and for the newborn? Which ones?” Here, participants might start telling you that they know that if she starts bleeding then they realize that she has to get to the doctor or hospital fast, and they may go on to explain how they get to the hospital in course of their discussion. The next question then asks “What happens when there are complications or problems?” Here, the facilitator could say “You have already mentioned that you know it is important to get to the health centre when there are problems…can you tell me who makes that decision to go to the health centre”. The important message here is that facilitators must be flexible in discussing topics which includes adapting to what has been discussed. • Ask if there are questions or a need for clarification.

Module 4

9d. Identifying key points, defining problems and achieving consensus

Time: 40 minutes Instructions to facilitators • Explain that facilitators not only have to manage and lead the discussion, but they also have to help capture the key points from this discussion, with the aim of helping the group write up the problems identified related to MNH. • Explain that the note-takers also have a role in this process by recording everything that is being discussed by the group. • Take a flipchart, and write the heading “Problems” and “Opportunities” on two flipchart sheets. • Hand out the example dialogue (see box) to four participants, and ask each one to take one of the roles. Explain to the rest of the group that they should listen, and try and write down the “key points” that are being discussed. Ask them to then read out the dialogue. • Afterwards, take the flipchart called “Problems”, and ask the group to list some of the key problems they heard during the discussion. They should note issues like: ° Lack of ambulances; ° Lack of support from neighbours to help women reach care; ° Heavy drinking in the community; ° Poor public transport system; ° Bad state of the roads; ° Cost of health services (including the ambulance service); and ° Poverty in the community.

Day 2

Example dialogue

Facilitator: “What happens if there are problems during childbirth?” Mrs A: “If we see that there is a problem, we decide to go to the health centre… but the problem is that there aren’t enough ambulances, so then we go to the neighbour who has a car… but then sometimes they can’t be bothered to go, or sometimes they are even drunk.” Mrs B: “And don’t forget about the public transport…there is none! It happened to a friend of mine that they had to take her on a horse and cart to the main road, and you know that the state of the small roads is terrible.” Mrs A: “Exactly – it’s a disaster. The other thing is that if the ambulance does come, which you know sometimes it does not come, then we also have to pay for it – but why should we pay?” Mrs C: “Well I think that if we had a car on duty in our village, that would be much better; then we could all be sure to get to the hospital if there was an emergency, otherwise people just can’t get there and they die on the way.” Facilitator: “Hmm, it sounds like a difficult situation for you. Are there any other problems that people face in getting to see a doctor or midwife?” Mrs B: “Yes, the other thing I forgot to say is that sometimes the husbands don’t let their wives go, because they are worried about the money. You know, it’s difficult these days, people just can’t afford it; they just don’t have any spare money for paying for doctors. It’s not like it used to be.” Mrs C: “Yes… and that also means that some women won’t go because they are ashamed about their clothes… some won’t go because they don’t have a proper dress.” • Point out that there are often many problems mentioned in a short period of time, and that it can be difficult to clearly capture everything. Therefore, facilitators will not be able to write down everything that is being said simultaneously (this would be impossible!), but should take time to clarify, paraphrase and probe further. For example, they may say:

“So, some of you feel that the state of the roads is a problem preventing women reaching care… does everybody agree with this?” or “But why is it a problem with their husbands? Why do they prevent them using the health services for pregnancy care?” (The facilitator needs to probe to find the real issue here; perhaps it is because husbands do not understand the importance of antenatal care and therefore do not see why she should take the time to go.) • Write up some key TIPS FOR IDENTIFYING PROBLEMS on the flipchart: 1. Take quick “reminder” notes during the discussion, so you don’t forget things. 2. Stop between sets of questions in order to record the key problems well. This presents an opportunity to check that everybody in the group agrees with what has been said.

Module 4

3. Remember to clarify, paraphrase and probe around what has been said. 4. Make sure everybody is in agreement with the problems being identified, and that they represent a consensus opinion. 5. Ask the note-taker if you have missed anything when you are recording the key problem statements about one issue. 6. Always try and keep the problem statement related to MNH; for example, if people mention that emigration is a serious problem, make sure you write how it was related to MNH (e.g. “Many men migrate for work leaving women on their own during pregnancy and with newborns.”) 7. Remember that defining problems is hard at first, but becomes easier with practice! • Take the flipchart with the original list of issues, and show how they can be made into clear problem statements: ° During emergencies, women cannot reach health services because there are no ambulances. ° People in the community with vehicles do not support women to reach care in an emergency. ° The poor road conditions make it difficult to reach health services. ° There is a poor public transport system which makes it difficult to reach health services. ° Poor people do not go to health services because they do not have the funds to pay for them. ° Health services are not welcoming to families who have dirty or worn-out clothes. • Explain that in some cases, participants may not be in agreement about the problems. There are various scenarios on different discussion points. Go over these scenarios with the group: Scenario What the facilitators do?

1. Participants identify the same problems or clearly agree • Double check that everyone is in agreement. with each other. • Note the agreed and clearly defined problem on the flipchart (where needed). 2. Most participants agree, though one or two disagree. • Note the problem that the majority have agreed on the flipchart, but acknowledging that some people feel differently. Explain that they will have an opportunity to vote on priority problems during the plenary.

3. Participants are divided; about half feel one way, while • Restate the points that are agreed upon. the other half feels a different way. • Probe to find the root of the disagreement, and see if you can help them come to consensus. • See if one side of the argument can be modified or reworded to make others happy. • If you are uncertain about how some people feel, you can organize a vote.

Day 2

• Tell the group that they also have to capture the positive elements that are mentioned during the discussion, not only the problems. These opportunities should be written up on another flipchart, so that the group can think about them when they come to thinking of actions to help solve the problems. The facilitator can choose to write them up on the flipchart at breaks during the discussion, or may take note of them, and then go back to write them up with the group at the end of discussion. Since the discussion is focused on problems, there will be less of them, but they may include ideas such as: ° There is a new system of community health committees which discuss a range of health issues; ° The local authority has started building a new road; ° The health service has recently developed a new education programme for young mothers; and ° There is now a suggestion box for improvements in the health centre, etc. • Ask if there are questions. Sum up the discussion by stating again that the skill of capturing the opinions of the group takes time to master, but that it will become easier with practice. Reemphasize the importance of encouraging everyone in the group to speak and to state their opinions and points of view.

Module 4

SESSION 10: THE ROLE OF NOTE-TAKERS AND OBSERVERS Time: 30 minutes Reference: Module 3; Section 3 and Annex 3 Objectives • To understand the role of note-takers and how to take notes. • To understand the role of observers.

Instructions to facilitators • Explain that during each session (plenary or group work), note-takers need to capture several key elements of the discussion. • Ask the group to review the “Note-taking sheet” at the end of Annex 3 of Module 3. Highlight that note-takers should write: ° The question/topic area being discussed (they can use a numbering system if they prefer); ° What the participants are telling about the current situation during the discussion; ° The problems and needs that are identified (both during the discussion and the ones recorded on the flipchart); ° Any supporting quotes: Explain that quotes can be a good way of capturing a true meaning of a situation, and help to illustrate well some of the problems. For example, “women here don’t know how to value themselves…they don’t know how to value what they have inside them,” this illustrates the lack of self-esteem that women have; or “if the traditional birth attendant (TBA) doesn’t tell her that she has to go [to the hospital] then she won’t move,” illustrating the important role of TBAs in the health of pregnant women; and ° Opportunities to help solve the situation. • Tell them that they can adapt the form to their needs, and to the easiest way of writing. Some people may prefer to just write out everything on one sheet, and afterwards to go through and highlight the different components (for example with different colours, or highlighter pens). • Ask the participants to look at the analysis form in Annex 4 of Module 3. Explain that the information from each roundtable will need to be recorded in this report format after the meeting. Go through the different questions in the analysis form (briefly), in particular Table 1, and explain that the notes will be important for filling in this form. • Note-takers should also be aware of non-verbal signals that may communicate meaning (remind them that gestures and expressions can also communicate feelings and attitudes).

Day 2

• Note-takers should keep careful records of their notes, for example by writing the title, date and time of the discussion on their note pads. • Remind them that the note-takers also act as supporting facilitators during the group work – helping to register participants, organizing refreshments, organizing the child-minder, paying transport costs, etc. • Explain that one or two observers may be present during the roundtables. They can help by taking notes, and may also help with the analysis of the discussion. However, it is suggested to keep observers to a minimum - participants may feel intimidated, and their presence may limit the discussion.

Module 4

SESSION 11: DEMONSTRATING FACILITATION AND PRACTICE WITH NOTE-TAKING Time: 45 minutes Reference: Module 3; Annex 3 Objective • To observe the trainer facilitate a discussion among the group.

Instructions to facilitators • Select about 8-10 participants to join a discussion. • Photocopy the note-taking forms and distribute copies to the other participants (or ask them to draw up a page with the same headings). • Lead a discussion on one section of the question guide (pick one of the three groups of questions). Ask the participants to not act in special character as before but to be themselves and discuss their opinions. It is important that you as a trainer demonstrate good facilitation skills in this session. • Ask the other participants to take notes of the discussion. Write up the problems identified on the flipchart. • Afterwards ask some participants to read back their notes, including any quotes that they noted down. Ask them to reflect on the experience.

Day 2

DAILY EVALUATION AND HOMEWORK ASSIGNMENT Time: 15 minutes Instructions to facilitators • Conduct the daily evaluation of the training course (see Annex 1 of this guide). • Assign homework: Ask them to read through Annex 3 of Module 3 and the question guide again.

Module 4

DAY 3 SUMMARY OF PREVIOUS DAY’S EVALUATION Time: 15 minutes • Share the results (confidentially) of the previous day’s evaluation, and discuss how you will respond to any issues raised.

SESSION 12: OVERVIEW OF GROUP WORK AND PRACTICE Time: 3 hours Reference: Module 3; Annex 3 Objectives • To know how to introduce the group work. • To practice facilitating and note-taking in the group work.

Instructions to facilitators • OVERVIEW OF THE GROUP WORK: Ask the group to review Annex 3 of Module 2, Section 2 “Group work: problems and needs.” Explain the following points to the group: 1. At the end of the opening, before dividing into groups, the facilitators will need to explain the group work to participants. Facilitators need to explain the image “Care of the pregnant woman, mother and newborn” and what the different levels mean. 2. Next, the facilitators will divide the roundtable participants into three small groups: discuss different ways to divide up groups, for example by numbering them off. 3. Each group will be assigned one facilitator and one note-taker. 4. The facilitator asks the group to select a representative who will present their findings to the whole group. 5. The small group has 1 hour 30 minutes to discuss the different questions. Remind the group that 1 hour 30 minutes should be sufficient time for this discussion, and they will not need to rush through the questions. Many facilitators are scared by the length of the guide, and miscalculate the amount of time they have. The supporting facilitator should write down the list of identified problems related to MNH on a flipchart. The selected representative will then present these key problems in plenary.

Day 3

• Introduce Group Work 5 (see box). Group Work 5

Time: 1 hour 30 minutes Aim: To practice facilitating and note-taking in group work Divide participants into three groups. Explain that they will now conduct a practice roundtable discussion and ask if they have any questions. Then: • Identify the participants that will play the different roles as facilitators and notetakers during the discussion. Ideally, the six facilitators who will be involved in the roundtable discussions should take turns at facilitating. (NOTE: The local coordinator and trainers may need to select the facilitators who are best able to facilitate the group work.) • The “participants” should not play roles, but rather discuss the questions as themselves. • Remind the note-takers to use their forms to keep careful notes. • All other trainees should take a role as participants at the roundtable. They should do the complete roundtable – opening, group work, plenary, closing. • Distribute the observation checklist (Handout 3 in Annex 5 of this guide) for all those who are not facilitating or participating. Ask them to try and note how facilitators perform on the different skills. They can give different marks to different people if they wish (hand out several copies of the form). • If there is time, go through all the sections of the question guide, swapping around facilitators and note-takers, so that everybody gets a chance to practice. If it is already determined who will be the three facilitators, ensure that they will do all the practice facilitation. • After the group work ask participants to discuss the experience. Ask facilitators, note-takers/ support facilitators, participants and observers how they felt, as well as any problems they encountered. You may need to re-emphasize important points or go back over certain agenda items if it was unclear. • Give all trainees a copy of the observation checklist and ask them to review the skills they should practice before each roundtable until they are proficient in the technique.

Module 4

SESSION 13: OVERVIEW OF PLENARY AND PRACTICE Time: 1 hour 15 minutes Reference: Module 3; Annex 3 Objectives • To understand how to facilitate the plenary session on prioritization of problems, and brainstorming on actions. • To practice facilitation of the plenary.

Instructions to facilitators • OVERVIEW OF THE PLENARY: Ask the participants to look at Section 3 of Annex 3 of Module 3 “Plenary session.” Explain the following points: 1. The plenary is facilitated by one of the facilitators. The other two facilitators help mark changes on the flipcharts. One or two of the note-takers are responsible for taking notes. 2. The roundtable facilitator asks the representative from each of the three groups to present their findings. They can tape the group’s flipchart sheets to the wall. 3. After each presentation, the facilitators ask if there are questions or comments (encourage discussion) by asking, “Does everyone agree with these findings?” or “Do you think there are any points that have been missed?” 4. Explain how to prioritize with the coloured dots – use three flipcharts with example points to demonstrate how to do it. The facilitator distributes nine coloured dots to each participant, and then asks everyone to pick three priority problems from each group. The facilitator also advises on how to select the important problems: Priority problems should be the problems that most affect the health of mothers and newborns, particularly for the poorest families. 5. Ask the group if they think there will be participants with reading difficulties at the meetings – and discuss with them how they can support these participants. 6. Once the participants have indicated their priorities, facilitators add up the dots and circle the top three priority problems for each level at the end (demonstrate how to do this). 7. Facilitators then fill in the “Action Grids” (Table 3.1 in Annex 3 of Module 3), demonstrating how to transfer these three problems into the three grids.

Day 3

8. Facilitators ask the group representatives to present the opportunities they had identified during their group discussions. 9. Afterwards, they facilitate the roundtable participants to brainstorm on solutions to solve these problems, considering the opportunities mentioned. Remind them to also think about actions at different levels, as well as ongoing programmes in their community. Explain that they can put an asterisk (*) next to ongoing programmes. 10. Facilitators read over the sheets again and verify that there is consensus in the group. • PRACTICE ON THE PLENARY: Next, ask one or two of the participants to practice facilitating a plenary run-through with the whole group. They can use the sheets that were written up during Group Work 4.

Module 4

SESSION 14: OPENING AND CLOSING THE ROUNDTABLE DISCUSSION Time: 45 minutes Reference: Module 3; Annex 3

Objective • To understand how to facilitate the opening and closing of roundtable discussions.

Instructions to facilitators • OPENING THE DISCUSSION: Ask the group to brainstorm on how they might open a meeting. They can think about how this training course opened. Write ideas on a flipchart. Answers include: ° Registering participants (explain that they will need to create registration forms, to be discussed in the logistical preparations tomorrow); ° Verification of voluntary participation; ° Explaining the objectives; ° Setting the rules of participation; ° Thanking participants for coming; ° Asking participants to introduce themselves; and ° Facilitators and observers introduce themselves. • Ask them now to look at Annex 3 of Module 3, part 1 (Introduction). Go over each of the key bullet points that need to be discussed during the roundtable opening. Explain that these tasks can be undertaken by one or two of the facilitators – they may interchange in the different sections (opening, plenary, closing). ° Remind the group that they need to have registration forms to register the participants. ° Explain that objectives can be written on a flipchart for all to see. Explain that they should also present how the roundtable fits into the broader IFC implementation framework and MNH strategy (see exercise below to identify key points). ° Explain very clearly that the roundtable will last 4.5 hours, and introduce the main agenda items (group work and plenary). ° To introduce participants, explain that they can use one of the introductory icebreakers they have discussed yesterday (remembering to keep it as short as possible).

Day 3

° Ask them to review the “rules of discussion” and determine if they agree with them, or if they have suggested changes. ° Explain that they need to present key points of the situation analysis to participants (see exercise below). • Present Group Work 6 (see box). Group Work 6

Time: 20 minutes Aim: To practice the presentations of the opening session of the roundtable discussions Divide the participants into two groups, and ask each group to work on a short presentation: 1. Group 1: Presentation of the MNH strategy and the roundtable objectives. 2. Group 2: The short presentation of the situation analysis. Remind them to keep their presentation simple. The group working on the situation analysis should present the main information from Form 2 of the situation analysis. • After the group work, ask one group member to present in plenary as if it were a roundtable. Write up their suggestions on a flipchart. See if the others have comments or suggestions. • Check if there are questions or concerns on the opening session. Remind them that the opening of the meeting should not take more than 30 minutes. • CLOSING THE DISCUSSION: Ask them to look at Annex 3 of Module 3, part 4, and review the five key steps for closing: ° Short summary of the roundtable discussion; ° Next steps: Describe the institutional forum, explain the need to select group representatives for this meeting, and plan a meeting with the roundtable representatives to prepare them for their participation in the forum; ° Evaluation of the roundtable: explain they can evaluate the discussion as a group in plenary, writing points on a flipchart; ° Thank-you; ° Payment of transport costs; ° Provide contact information if there are further questions;

Module 4

Facilitators may also distribute leaflets from the MNH strategy at the end of the meeting if they have them available. Also, at this time facilitators can discuss any misconceptions or incorrect statements related to health concerns made during the roundtable discussion at the closing.

Day 3

OVERVIEW OF THE FOLLOWING DAY, DAILY EVALUATION AND HOMEWORK ASSIGNMENT Time: 20 minutes Instructions to facilitators • Explain to the group what will happen the following day, and prepare them for the practice roundtable discussion. • The trainers and local coordinator should already have determined by this point who will be facilitating and note-taking in the roundtable discussion on the following day. • Conduct the daily evaluation of the training course. • Assign homework: Ask them to read through section 3.6 of Module 3 and the checklist in Annex 6 of Module 3.

Module 4

DAY 4 SUMMARY OF PREVIOUS DAY’S EVALUATION Time: 15 minutes • Share the results (confidentially) of the previous day’s evaluation, and discuss how you will respond to any issues raised.

SESSION 15: PREPARING FOR THE ROUNDTABLES Time: 2 hours 15 minutes Reference: Module 3; Annex 3 and Annex 6

Objective • To make preparations needed for the practice roundtable discussion as well as subsequent roundtable discussions.

Instructions to facilitators • Introduce Group Work 7 (see box). Group Work 7

Time: 2 hours and 15 minutes Aim: To prepare for the practice roundtable discussion as well as subsequent roundtable discussions Divide the participants into two groups, and ask: 1. Group 1 to take the question guide and revise it based on their experience of practice in using the guide. Since the content was already reviewed on the first day, they should focus on the terminology and language of the questions. The three facilitators should be involved in this group. 2. Group 2 to review the checklist in Annex 6 of Module 3. They should check that all the necessary preparations have been made for the practice roundtable, and make a list of the preparations that are needed for subsequent roundtables. Ask them to then take time to prepare the flipchart sheets and presentations that they will need for the practice roundtable discussion, and any other preparations needed, including: • Flipchart sheets or PowerPoint presentation with the MNH situation • Flipchart sheets or PowerPoint presentation of the situation analysis • Flipchart sheets ready to identify problems during the group work • Flipchart sheets to identify opportunities • Flipchart sheets with the “Action Grid” for the plenary

Day 4

SESSION 16: THE PRACTICE ROUNDTABLE Time: 4 hours 45 minutes Reference: Module 3; Annex 3 Objectives • To conduct a first roundtable discussion with community participants. • To practice roundtable organization and facilitation and note-taking skills.

Instructions to facilitators • The group follows Annex 3 of Module 3 to conduct the roundtable discussion. • At the end of the roundtable, the trainer conducts a quick debriefing to ask the group how it went for them, how they felt, etc.

Module 4

DAY 5 SESSION 17: FEEDBACK SESSION Time: 1 hour 45 minutes Objective • To obtain feedback on the practice roundtable discussion.

Instructions to facilitators • The facilitators, note-takers, observers and trainers all provide feedback on the different elements of the practice roundtable discussion and suggest improvements regarding: ° Overall organization; ° Welcoming and registration of participants; ° The opening, including presentation of the MNH situation and the situation analysis; ° The group work; ° Prioritization of problems in plenary; ° Action brainstorm in plenary ; and ° Closing. • Adjusting to problems during the roundtable: Ask them to reflect on potential problems that may affect the roundtables, and discuss how to deal with them. Possible answers include: ° Participants don’t show up: evaluate whether enough participants have come to have a discussion (minimum should be nine participants (three for each small group)) – if not then you will need to reschedule. ° One of the facilitators or note-takers is sick or doesn’t arrive: ensure there are enough facilitators in case of this problem. ° If a participant becomes upset during the discussion: take a break from the discussion and support the participant – check if they want to continue or if they would prefer to sit out of the discussion until the feel like joining again.

Day 5

SESSION 18: THE ANALYSIS FORM Time: 1 hour 30 minutes Reference: Module 3; Annex 4 Objective • To understand how to analyse the roundtable discussion using the analysis form.

Instructions to facilitators • Project Annex 4 of Module 3 on a screen from a computer, and fill in the table together with the group, based on the information collected during the practice roundtable discussion. • Tell participants that they can fill in their forms as they go along too. • Ask if there are any questions.

Module 4

SESSION 19: THE SUMMARY REPORT Time: 15 minutes Reference: Module 3; Section 3.10 Objective • To understand how to write up the report.

Instructions to facilitators • Look at Module 3; section 3.10 of Module 3 - “Summary Report from the Roundtables”. • Explain that after they have finished the five roundtables, they will need to review the five analysis forms from the different groups, and synthesize the information together into one report. • Show them Table 3.2 of Module 3 and demonstrate how they can fill it in. • Remind them that it is essential that this report is written BEFORE the institutional forum.

Day 5

SESSION 20: THE INSTITUTIONAL FORUM Time: 2 hours Reference: Module 3; Section 4 and Annex 4 Objective • To understand the aims of the institutional forum and know the methodology, as well as the preparations required.

Instructions to facilitators • Ask the group to look at Module 3; section 4 and review the aims of the institutional forum, as well as the different participants they can to invite to this forum. • Next ask them to look at section 4.3 of Module 3 and highlight the following points: 1. This forum is longer than the roundtable discussions, lasting 1.5 days. 2. They may need to strongly encourage the participants to come - experience has shown that the “institutional actors” are usually very busy and do not have flexible schedules. They may find it hard to dedicate time to this type of meeting. They need to understand its importance. It may even be necessary to develop some advocacy materials on the topic for them. 3. The team needs to prepare presentations and flipchart sheets in advance (Tables 1, 2, 3 and 4 in Annex 5). 4. It may be helpful for the facilitators and note-takers to do a practice run-through of this meeting beforehand, to make sure all preparations have been made and to make sure it runs smoothly. 5. It is advisable to arrange a meeting with the representatives of the community roundtable discussions to review the participants’ role at the institutional forum. • Next, review the institutional forum facilitation guide (Annex 5 of Module 3) together with the group: 1. INTRODUCTION • Ask the group to identify differences between the institutional forum and the other roundtables. • You can point out that the forum has slightly different objectives: During the institutional forum they are reviewing the results of the five roundtables (including problems and actions), and working to reach a consensus on these priority problems and actions. • Highlight that this discussion will provide inputs for developing a draft plan of action. The inputs will be used by the district committee who will then finalize an IFC action plan (see Module 5; section 2). It is important to underline that the draft plan will be reviewed by the IFC committee and is not final. 54

Module 4

2, 3 & 4. PRESENTATIONS IN PLENARY • Highlight that the district and national/province representatives will need to prepare presentations in advance on the MNH strategy and the role of the IFC component within this strategy. • One of the facilitators will also need to prepare a presentation on the IFC framework and the PCA. • Finally, a member of the district IFC committee should also present the situation analysis results. • The trainees should review the presentation of the situation analysis and MNH strategy and consider if more information should be presented during the institutional forum. Write down points suggested. Ideally they should present more information on the IFC framework during this forum. 5. PLENARY • Point out that the forum starts with a plenary, not group work. • First, facilitators present the “Care of the pregnant woman, mother and newborn” image.

Presentation of problems identified • Then facilitators should present flipchart sheets summarizing the problems identified in the different groups. Show them how they would do this with example sheets. You can use the problems identified in yesterday’s practice discussion. Remind them they need three sheets, one for each level of care (before the discussion). Table 1: Summary of Problems Topic : e.g. Care of the pregnant woman, mother and newborn at home Priority problems identified Group(s) which identified them

For example: Women, Grandmothers, Providers Women do not go to prenatal care until late in pregnancy

• Explain how facilitators should point out where problems have been identified by several groups, or those which only one group identified.

Identification of other problems and prioritization • Next facilitators should check if the institutional actors also have other problems they would like to add; demonstrate how they can be added to this list. • Highlight that each participant will now have eight coloured dots to prioritize problems (in the five roundtables each participant had only three remember!). They have to pick two problems from each level of care. • As before, then we count up the dots, and circle the priority problems.

Day 5

6. GROUP WORK ON ACTIONS • As before, the group selects a representative to present findings in plenary. • Facilitators need to have prepared two sets of flipchart sheets in advance: Table 2: to summarize and review the results from the five roundtables. Table 3: a new table with recommended actions from this institutional forum. • Demonstrate how the facilitation team should fill in Table 2 (before the meeting): Facilitators can use a classification system, such as in the example provided in Table 2, to identify the groups which selected the different problems and actions. Table 2: Summarize and review the results from the five roundtables Topic : e.g. Links between the community and health services Priority problems identified (and by which group) Actions identified (and by which group)

For example: For example: Difficulties in travelling to the health facilities (W, G, M, P). • Adapt public transport schedule to the needs of the population (W,P) • Free of charge transport for children and pregnant women (M, P, G) • Repair the roads (L,G)

W = Woman’s group, G = Grandmothers and mothers-in laws, M = Men’s group, L = Community leaders, and P = Health care providers

During the break (before the group work), facilitators should also add into these tables any other problems that the institutional actors have just added in their plenary discussion. • Highlight that they have two hours for a group discussion on actions. The facilitators divide them into four groups - one works on each priority area of intervention to review one table. • The facilitator presents the flipchart (Table 2) or handouts with compiled actions to the group. They should also distribute a copy of the IFC framework concept paper to each group, and explain the IFC interventions to the group. • After presenting, the facilitators lead a group discussion on whether these actions are appropriate and/or sufficient to address the problems identified. • Point out the following factors to consider for each action (see Module 3, Annex 5): ° Feasibility of implementing the intervention according to available human, financial and other resources and based upon existing experiences in the area or in the countr ;

Module 4

° Avoiding negative impact: some interventions may have negative impacts as well as positive ones, or may impact particular groups negatively; ° Benefiting the poorest: it is important that the interventions chosen benefit the poorest members of the society, as well as wealthier individuals; and ° Replicability (potential for scaling up) e.g. elaboration of a project which is not too complicated or expensive and that can be replicable on a larger scale in other areas by the government or by NGOs. They should help the group reflect on each action, but particularly those that the facilitator feels may be unrealistic. • During the discussion, facilitators should fill in Table 3. Demonstrate how they would complete this table, using an example. Table 3: Prioritization of actions Group: e.g. Developing capacities Interventions Criteria (1 to 3 points for each criteria) Feasibility Avoiding negative impact Benefiting the poorest Replicability Total Score

e.g. Problem A e.g. Action A1

e.g. Action A2

e.g. Action A3

e.g. Action A4

e.g. Problem B e.g. Action B1

e.g. Action B2

e.g. Action B3

Day 5

• Once the facilitators have filled in the group name, the two problems, and the actions being discussed, invite the group members to score each action between 1 and 3: ° Feasibility: 3 - highly feasible; 2 - some feasibility; 1 - little feasibility; ° Avoiding negative impact: 3 - should have no negative impacts; 2 - may have one or two negative impacts; 1 - may have several negative impacts; ° Benefiting the poorest: 3 - should benefit the poorest; 2 - may have some positive benefit for the poorest; 1 - unlikely to benefit the poorest; and ° Replicability: 3 - highly replicable, 2 - some replicability, 1 - little replicability. The group should then add up the points for each action and identify the two priority actions with the highest points for each priority problem. 7. PLENARY: FEEDBACK ON ACTIONS • Explain that, as before, the group representative presents their findings. • Facilitators should encourage discussion on each group presentation, and check if everyone agrees with their findings. Give the participants time to reflect on the actions in the different areas, and to see if they make sense together. Thinking about synergy between the actions may generate some additional suggestions or modifications. 8. GROUP WORK: IDENTIFYING ACTIVITIES • Explain that the last group work session is about identifying the specific activities needed for each of the actions suggested. • Facilitators should help the four groups to fill in the activity chart in Table 4 of the Institutional Forum Guide (see Section 4 of Module 3). This includes: ° The activities required to implement each action; ° The actors to be involved in each activity and their role; ° The resources necessary to implement the activities: list available resources and where these resources come from; and ° How to mobilize resources if not available. 9. FINAL PLENARY: GROUP FEEDBACK AND NEXT STEPS • Again, the group representatives report to the plenary, and the facilitators lead a discussion. Facilitators focus on how the district IFC committee can mobilize support for this work, and what recommendations they have for moving forward.

Module 4

• Explain that it is very important for the facilitators to discuss the next steps, in particular how the district committee will move this plan forward, finalize the plan and adapt it for the project implementation. 10. CLOSING • Explain that the closing session is similar to other roundtables. • Review the key steps for closing: ° Short summary of the roundtable discussion; ° Next steps: explain the role of the local health committee in finalizing the plan and the steps to submit the plan for approval; ° Evaluation of the forum: explain they can evaluate the discussion as a group in a plenary, writing points on a flipchart; ° Thank-you; and ° Payment of transport costs (if applicable). Facilitators may also distribute leaflets on the MNH strategy at the end of the meeting if they have them available. Also, it is important for facilitators to correct any misconceptions or incorrect statements made during the forum at the closing. • After the overview of the institutional forum, remind the group that they may need to do a practice run-through of this meeting to ensure they have made all the preparations. ANALYSIS OF THE ROUNDTABLE: • Explain that section 4 of Module 3 describes how to write up the report from this roundtable. As before, the facilitators need to write up some comments on the dynamics of the discussion and the participants. The tables generated during the discussion will serve as the basis of the report.

Day 5

SESSION 21: THE PCA FINAL REPORT, RESULTS DISSEMINATION AND POST-PCA ACTIVITIES Time: 45 minutes References: Module 3; Section 5 Module 1; Sections 2.1, 2.15, 3.6, 3.7, 3.8

Objectives • To become familiar with the content needed in the final report, and how the results can be disseminated. • To become familiar with the next steps required for IFC implementation after the PCA.

Instructions to facilitators • Go over the final report format in section 5 of Module 3. • Highlight the new sections that need to be written up, and those sections that can be taken from existing documents: ° Use existing material: Situation analysis report, Summary report from the five roundtables, Draft interventions plan from the institutional forum; ° New sections to be written up: Executive summary, Introduction to the IFC component and to the PCA, Methodology of the PCA, Conclusions and Recommendations of the PCA; and ° Following the completion of the report all documentation that contains personal information (i.e. registration forms), which is no longer needed for administrative purposes should be destroyed or stored in a secure location to ensure participant anonymity. • Emphasize that the report should be concise, generally not exceeding 30 pages. • Review the possible dissemination mechanisms in section 5.3 of Module 3. Explain that dissemination of results should generally occur after the institutional forum. They will reflect on how much information they should share and with which groups. Remind them that disseminating the results can serve as a form of health education with communities. • Finally, ask the group to review the Figure 2.1 of Module 1 (the IFC Implementation Framework). Explain again that the PCA is one step in a larger process, and that using its results, the district committee will embark on a detailed “Joint Planning Process”. This process is described in detail in section 2 of Module 5. • Go over the different mechanisms that can be used to scale-up the IFC framework to other districts or provinces (see section 2.16 of Module 1) highlighting that it may not be necessary to conduct a PCA in every district.

Module 4

• Give a brief overview of next steps after the PCA, including dissemination and discussions of the results to a broader audience.

Day 5

WORKSHOP CLOSING Time: 1 hour Objective • To close the workshop

Instructions to facilitators • Recap of workshop (10 minutes): Briefly discuss the major takeaways from the workshop (i.e., the importance of the PCA in MNH programme planning; the importance of facilitation skills; etc.). • Final evaluation (10 minutes): Distribute the final evaluation forms (see Annex 2) and ask participants to complete them. Tell them to please answer honestly as it will help you to improve future workshops. Let participants know that they will have 10 minutes to complete the form. • Final bang (5 minutes): Think of something that could be done that would leave the participants on a positive not at the end of the workshop. This could be singing a local song together; distributing a sweet or a small token; etc. • Closing remarks and speeches (25 minutes): Arrange with the appropriate individuals and authorities beforehand to deliver closing remarks and speeches.

Module 4

ANNEXES Annex 1: PCA training daily evaluation form Annex 2: Training final evaluation form Annex 3: Handout 1 – Notes on facilitation skills and group management Annex 4: Handout 2 – Icebreakers and energizers Annex 5: Handout 3 – Observation checklist for facilitation skills

Annex 1: PCA Training Dailyl Evaluation Form

ANNEX 1: PCA TRAINING DAILY EVALUATION FORM 1. The one thing that I learned today that I do not want to forget is: ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

2. The information or activity that I found most interesting and useful was: ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

3. The one suggestion that I have for improving today’s agenda is: ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

4. Additional comments or suggestions: ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

THANK YOU!

Module 4

ANNEX 2: TRAINING FINAL EVALUATION FORM Please circle the answer you feel is most appropriate for each of the following aspects of the training course, using the following ratings: 1 – Insufficient Statements 1. Achievement of course objectives 2. Achievement of personal expectations 3. Relevance of training to your work 4. Usefulness of workshop materials 5. Training methodologies 6. Organization of the course 7. Training facilities 8. Administrative support 9. Facilitators 2 – Poor 3 – Satisfactory 4 – Good 5 – Excellent

Rating scale 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5

2. Course length:

Too long

Too short

Just right

3. What topics covered in this training do you think will be most useful to you in conducting the PCA? ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... ......................................................................................................................................................................................................................

Annex 2: Training Final Evaluation Form

THANK YOU!

Module 4

ANNEX 3: HANDOUT 1 – NOTES ON FACILITATION SKILLS AND GROUP MANAGEMENT What a facilitator SHOULD DO Listen Be nice and respectful to participants Make participants feel comfortable Ask questions Guide the discussion Encourage all participants to speak Promote discussions Check that participants can understand Use simple language Be sympathetic Arrange the table and chairs well Manage time well Assess if participants are tired or bored What a facilitator SHOULD NOT DO Give their opinions Allow participants be argumentative Be an interviewer Judge participants Tell participants that their answer is right or wrong Interrupt participants Show disrespect Encourage one-to-one dialogue Ignore participants Give complicated explanations Talk a lot Be nervous

ACTIVE LISTENING Ways to show interest in what someone is saying: ✓ Maintaining eye contact ✓ Nodding the head ✓ Smiling ✓ Leaning in ✓ Frowning ✓ Expressing surprise by moving eyebrows ✓ Writing notes Remember that BODY LANGUAGE is very important when facilitating - be open, move around the room, maintain eye contact, be expressive!

Annex 3: Handout 1 – Notes on facilitation skills and group management

SOME WAYS TO CLARIFY AND PARAPHRASE: • Do I understand you correctly to say…? • So you are saying that …, is this right? • I hear you saying that …, is that right? • Have I heard you correctly to say …? • I’m not sure I understood that clearly. Did you mean that …? QUESTIONING AND PROBING A closed-ended question is answered by short one-word answers (usually “yes” or “no”). For example “Do you like going to the doctor?”; “Do you often breastfeed your infant?” An open-ended question allows the respondent to tell you about how they feel, what they think, or what they believe. They allow the person to express freely to the facilitator or group. For example, “What do you like about the doctor?”; “How often do you breastfeed your infant?” Closed-ended Do you like going to the health centre? Does the community help pregnant women? Do you like going to the health centre? Open-ended How do you feel about going to the health centre? How does the community help pregnant women? How do you feel about going to the health centre?

A probing question seeks to discover more after an initial response. Probing can be used when people are hesitant to respond to the questions you are asking – you need to probe to get them to open up to you. The six helpers for probing: WHY? WHAT? WHEN? WHERE? WHO? HOW? Probing questions can also be THREATENING – they must be said in the right TONE OF VOICE and may need to be softened with careful language. Some ways to probe: • But why do you think this is? • Can you explain further to us what you mean by this? • So if this is the case… what does it mean if…? • Can anybody else help explain the reason for this?

Module 4

Leading questions tend to orient the group to answer in a certain way that often results in answers that affirm the position expressed in the question (e.g., Do you agree that women don’t breastfeed for long enough?). They should be avoided. Impersonal questions (in the 3rd person) ask respondents to talk about a general situation rather than their own experiences. You should use impersonal questions in roundtable discussions. • Personal: How do you care for your baby? Do you have any problems getting to the health centre? • Impersonal: How do people in your community care for their babies? Do people in your community face any problems getting to the health centre? GROUP MANAGEMENT Key things to monitor when managing a group: • Time management; • How hungry people are, when they need to eat or drink; • Participation: people who talk to much, people who are not participating; • Promoting lively and participatory discussion; • Obtaining different opinions; • Conflict between participants; • Boredom/energy levels; and • People who arrive late/leave early. Other tips: • Make sure you can be heard; • Make sure any visual aids you use can be seen; • Ask the audience for feedback as to whether they can see and hear; • Talk slowly and clearly; • Use an interesting and animated style of talking to keep people’s attention; • Maintain appropriate eye contact;

Annex 3: Handout 1 – Notes on facilitation skills and group management

• Change the tone of your voice; • Move around; • Allow time for group to ask questions; and • Ask questions to test whether the topic has been understood. DEALING WITH TOPICS THAT HAVE ALREADY BEEN DISCUSSED Scenario What to do?

1. Question in the guide has not yet been discussed at all Ask the question as per the question guide. Acknowledge that the group has already mentioned or said 2. The question and the topic have been touched upon, about this topic, then explain that you would now like to ask but without much detail some more questions to find out more about the situation. 3. The question has already been fully discussed Do NOT ask the question, but move on to the next topic.

TIPS FOR IDENTIFYING PROBLEMS • Take quick “reminder” notes during the discussion, so you don’t forget things. • STOP BETWEEN SETS OF QUESTIONS in order to record the key problems well. This presents an opportunity to check that everybody in the group agrees with what has been said. • Remember to clarify, paraphrase and probe around what has been said. • Ask the note-taker if you have missed anything when you are recording the key problem statements about one issue. • Always try and keep the problem statement related to MNH, for example, if people mention that emigration is a serious problem, make sure you write how it was related to MNH (e.g. “Many men migrate for work leaving women on their own during pregnancy and with newborns”). • Remember that defining problems is hard at first, but becomes easier with practice!

Module 4

PROMOTING DIALOGUE 1. Facilitator interviewing 2. Group dialogue with facilitation

SEARCHING FOR CONSENSUS AMONG DIFFERENT PARTICIPANTS Scenario What to do? What the facilitators do? • Double check that everyone is in agreement. • Note the agreement on the flipchart (where needed).

1. Participants identify the same Write down the agreement. problems or clearly agree with each other.

2. Most participants agree, though one Write down the agreement, and the • Note the majority agreement on the or two disagree. points made by those disagreeing. flipchart, while acknowledging that some people feel differently. Explain that they will have an opportunity to vote on priority problems during the plenary. 3. Participants are divided; about half Write down the disagreement, and the • Restate the points that are agreed. feel one way, while the other half different points made by participants. • Probe to find the root of the feels a different way. disagreement, and see if you can help them come to a consensus. • See if one side of the argument can be modified or reworded to make others happy. • If you are uncertain about how some people feel, you can organize a vote.

Annex 3: Handout 1 – Notes on facilitation skills and group management

PARTICIPANT MANAGEMENT Role The conversation dominator (always talking) How to manage the participant(s) • When there is a pause, thank the member and invite someone else to speak. • If the person carries on, interrupt. • Remind the group of the “rules of discussion”, in particular the 3 minute time limit. • During a break, quietly ask him/her to give others a chance to speak. • When there is a pause, ask for other comments or opinions, looking directly at the quiet participant. • When the group is coming to consensus or making decisions, double check that everyone agrees. • Explain that it is very important for everyone to participate and share their ideas. • Ask directly if the quiet participant(s) have any further thoughts. • During a break, check that the participant feels able to participate in the discussion. • At the beginning, tell participants how long the discussion will last, and check that everyone is able to stay for that long. • If the person seems upset, consider asking another facilitator/note-taker to follow them and check whether they feel alright. • If they return at the end, consider asking why they had to leave. • Remember to go over the rules of discussion at the beginning, including the need to respect other group members. • Catch their eye (it may be enough to get them to stop). • Bring them into the discussion, by asking them directly if they have comments or opinions. • Ask them during a break to try and keep quiet while others are talking. • Confront them openly during the discussion and ask them to listen to other participants. • Thank the speaker, but remind the group that if they agree with someone else, then they can express their agreement, rather than repeating the same point(s). • Thank the speaker for their comment, but remind them of their time limit (3 minutes). • If participants stray from the discussion topic, remind them of the question and topic. • If many people are rambling, ask the group to try and be concise. • When there is a pause, thank the member and invite other members of the group to speak. • During a break, politely ask them to respect the rules of discussion, and to respect other participants in the group.

The quiet one (never talks)

The disappearing act

The side conversation

The repeater The rambler

The know it all

Module 4

ANNEX 4: HANDOUT 2 – ICEBREAKERS AND ENERGIZERS Icebreakers and energizers are activities the facilitators use to encourage participant involvement and interaction. These activities may be used at the beginning of a roundtable to begin work on a positive note. They may also be used during the meeting to recharge the group (e.g., after a break). Look at this list, and see if there are other local energizing games or exercises that you know that you could use. Add them to this page. 1) The animal game: Ask participants to make a drawing of an animal which has a characteristic similar to those that they want to be identified with; ask them to write their name on the drawing. Bring them to an open space, and ask each person to find a partner. They should explain the drawing to their partner and why they chose this animal. They can also add any other information about themselves that they would like to share with others. The partner should prepare to introduce their partner. After five minutes, bring the group back into plenary. Each person should then introduce their partner to the rest of the group showing the drawing. You can hang the drawings on the wall. 2) Introducing through a partner: A simpler version of number 1 is to split participants into pairs, and ask them to introduce themselves. Afterwards, bring the group back to plenary, and ask each person to introduce their partner. 3) Introducing with a ball of wool: Get participants to stand in a big circle. The facilitator starts off by introducing her/himself. S/he then takes hold of one end of the ball of wool, and tosses the ball to someone else in the room, who then introduces her/himself. Keep doing this until all have been introduced. Afterwards, reflect on the web of wool, to show how all the group is interconnected now. 4) Expectations: The trainer gives the participants slips of paper, and asks them to write down at least three things they would like to learn during the discussion. The participants attach their slips to a poster board or piece of flipchart paper, which is posted in the classroom. The trainer can then review these expectations with the group and tell them which topics will and will not be covered. 5) Local song: The trainer gets participants to join in singing a local song together. 6) Tell a story: The participants stand in a circle. The purpose of this activity is to build a story with each participant contributing one sentence that must: • make sense and at the same time add some fun to the activity; • build on to the last sentence; and • be grammatically correct.

Annex 4: Handout 2 – Icebreakers and energizers

For example: #1: “I was walking to breakfast this morning.” #2: “A dog came up to me.” #3: “I said good morning to the dog.” #4: “The dog asked me what I was going to have for breakfast.” The activity continues until all of the participants have contributed or until the facilitator feels that the group has been energized. 7) The last word: The participants stand in a circle. One participant moves and stands randomly in front of another. S/he makes a statement (e.g., “It is such a lovely day”). The person spoken to will move to another person and make a statement starting with the last word in the statement s/ he received (e.g., “Day one of the course was very tiring”). Each participant takes turns to ensure that everybody gets a chance to participate. 8) Ball toss brainstorming: Announce a topic (things associated with a topic, a holiday, the course content, etc.). Then, toss around a ball. When someone catches the ball, they shout out something related to the topic and then toss the ball to someone else. Continue the exercise until everyone has had a chance to speak.

Variations: When they catch the ball, each person tells what they thought was the most important learning concept was in the session just finished. Continue the exercise until everyone has caught the ball at least once and explained an important concept of the material just covered. If the previous session had taught a process, each person can tell one step of that process or concept when the ball is tossed to him or her. The trainer or participant, in turn, writes it on a flipchart. For example, after covering “decision-making”, the trainer would start the ball toss by having everyone give one step in the decision-making process. 9) Lifeboats: The participants should come to an open space in the room and start walking around. Tell them that they are on the Titanic ship, and the boat is beginning to sink. They must get to the lifeboats as soon as possible! The lifeboats can only hold a certain number of people. As the participants are walking round, shout out the maximum lifeboat capacity each time: e.g., “Lifeboats for three!” The participants then must form groups of three to get into the boats. Anyone who cannot find a “boat” drowns, and must leave the game. For each round, choose a different sized boat. At a certain point, shout out that this is the last boat, and anyone who makes the last boat will survive. End the game there.

Module 4

ANNEX 5: HANDOUT 3 – OBSERVATION CHECKLIST FOR FACILITATION SKILLS Note: this checklist can be used by observers to assess the facilitation skills or others, or as a self-assessment tool. A. Give the facilitator a mark out of 3 for the following performance indicators Score (please circle) 1=not done/not done well 2=done, but needs improvement 3=done well N/A=Not applicable

Facilitator performance

1) When starting the roundtable, the facilitator: a) makes participants feel comfortable and valued b) explains the objectives of roundtable c) asks participants to present themselves d) gives a simple summary of the IFC framework and situation analysis results e) explains the agenda f) explains the rules of the discussion g) introduces the group work h) checks that participants have understood 2) When communicating, the facilitator: a) listens actively b) scans the room c) speaks clearly and loudly d) uses simple language e) shows empathy f) paraphrases and clarifies what has been said g) is respectful and kind to participants h) uses body language effectively i) uses visual aids 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 N/A N/A N/A N/A N/A N/A N/A N/A

Annex 5: Handout 3 – Observation checklist for facilitation skills

Facilitator performance

Score (please circle) 1=not done/not done well 2=done, but needs improvement 3=done well N/A=Not applicable

3) When managing the group, the facilitator: a) encourages participation from silent members b) stops dominant members from talking too much c) promotes discussion among the group d) prevents and manages conflict e) is aware of the group’s interactions f) keeps the group energized and enthusiastic 4) When guiding the small group discussion, the facilitator: a) guides the group through the questions b) uses open-ended questions c) probes further on some questions d) keeps questions impersonal (“3rd person”) e) promotes discussions f) covers all the themes g) strays from the question guide if necessary h) does not repeat themes that have already been discussed i) searches for agreement j) does not give their own opinion k) writes up the list of problems on the flipchart 5) When managing priority-setting in plenary, the facilitator: a) does not allow a group presentation to go over 5 minutes b) checks for questions and comments from the group c) explains clearly the priority-setting exercise using coloured dots d) checks if all participants can read, and if not, offers help to those with difficulty e) circles the priority problems on the flipcharts f) promotes discussions 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 N/A N/A N/A N/A N/A N/A 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 N/A N/A N/A N/A N/A N/A

Module 4

Facilitator performance

Score (please circle) 1=not done/not done well 2=done, but needs improvement 3=done well N/A=Not applicable

6) When facilitating the discussion on actions, the facilitator: a) reminds the group to think about actions already ongoing and whether these should be continued b) asks them to think about actions at different levels (policy, health services, community, household) c) encourages all participants to comment or give ideas 7) When closing the meeting, the facilitator: a) presents a short summary of the discussion b) corrects misconceptions or false statements that were said during the discussion c) explains the next steps, including the institutional roundtable and the planning meeting d) helps the group evaluate the discussion e) thanks participants for coming f) arranges payment of transport costs 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 N/A N/A N/A N/A N/A N/A 1 1 1 2 2 2 3 3 3 N/A N/A N/A

B: Answer these questions (either as self-assessment or as an observer): 1. Overall, what skills were strongest?

2. What skills were weakest?

3. How will you go about improving these skills?

Department of Maternal, Newborn, Child and Adolescent Health 20 Avenue Appia 1211 Geneva 27 Switzerland E-mail: mncah@who.int Website: http://www.who.int/maternal_child_adolescent/en/

ISBN 978 92 4 150852 0

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health

A Toolkit for Implementation Module 5: Finalizing, Monitoring and Evaluating the IFC Action Plan

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health:

A Toolkit for Implementation

Module 5: Finalizing, Monitoring and Evaluating the IFC Action Plan

Module 5

ACRONYMS ANC CHW DHS ICT IFC HIV/AIDS MICS MOU MNH NGO PCA PNC TBA ToR WHO Antenatal care Community health worker Demographic and Health Survey Information and communications technology Individuals, Families and Communities (in reference to the World Health Organization’s framework for Working with Individuals, Families and Communities to Improve Maternal and Newborn Health) Human immunodeficiency virus infection/acquired immunodeficiency syndrome Multiple Indicator Cluster Surveys Memorandum of understanding Maternal and newborn health Non-governmental organization Participatory community assessment Postnatal care Traditional birth attendant Terms of reference World Health Organization

Tell us what you think! All comments on this document are welcome. Please let us know if you find the content useful, your experience in using this guide, if there is any information missing, if there is anything else you would add to this guide. Please send all comments to the Department of Maternal, Newborn, Child and Adolescent Health (MCA), World Health Organization (WHO), Geneva, to mncah@who.int.

Module 5

Please see http://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/

vii

The Story of the Toolkit

viii

Module 5

INTRODUCTION TO MODULE 5 This document is the fifth module of a series entitled Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation, designed to support the implementation of the World Health Organization (WHO) framework “Working with individuals, families and communities (IFC) to improve maternal and newborn health”,2 herein referred to as the “IFC framework.” The IFC framework, originally elaborated in 2003, was developed in response to the observation that a robust and systematic health promotion component was largely absent from most maternal and newborn health (MNH) strategies in countries. Grounded on the foundational principles of health promotion as outlined in the Ottawa Charter,3 the framework and the interventions it proposes were formulated based on an examination of evidence and successful experiences in working with individuals, families and communities to improve MNH. This evidence was updated in 2015 and we refer the reader to the publication WHO recommendations on health promotion interventions for maternal and newborn health, available at http://who. int/maternal_child_adolescent/documents/ health-promotion-interventions/en/. To date, the IFC framework has been implemented in a number of countries spanning the six world WHO regions, including: Bangladesh, Burkina Faso, Colombia, El Salvador, Guatemala, Haiti, Kazakhstan, Lao People’s Democratic Republic and the Republic of Moldova. The aim of the toolkit is to support public health programmes in launching a process to work with and empower individuals, families and communities to improve MNH.

See the following strategic document: Working with individuals, families and communities to improve maternal and newborn health, WHO, 2010. 3 See WHO, 1986. 2

Introduction

The implementation toolkit contains five modules, as described in the following table: Module Module 1: An Overview of Implementation at National, Province and District Levels Module 2: Facilitators’ Guide to the Orientation Workshop on the IFC Framework Description An introduction to the process of initiating implementation of the IFC framework at national, province and district levels. A resource guide for conducting a workshop to orient national, province and district actors to the key concepts, processes and interventions of the IFC framework. An overview on conducting the PCA, a participatory tool designed to support districtlevel actors to assess the MNH situation and needs and to identify priority interventions for IFC implementation. A guide to support training of facilitators to conduct the PCA. A guide to support the finalization of the IFC action plan based on the PCA, including suggestions for monitoring and evaluation. in IFC implementation and is scaling up the framework to new districts. Some elements will be adapted when moving from this initial experience to a phase of scaling-up; therefore we distinguish between initial implementation sites and expansion sites throughout this module. For example, while planning in the initial implementation sites will generally be based on a full PCA, it may be advisable to use a simplified participatory planning process in the expansion sites. Additionally, in the initial implementation districts we advise that programmes include plans for a rigorous impact evaluation, while this may not be necessary or feasible in the expansion sites.

Module 3: Participatory Community Assessment in Maternal and Newborn Health (PCA)

Module 4: Training Guide for Facilitators of the Participatory Community Assessment (PCA) in Maternal and Newborn Health Module 5: Finalizing, Monitoring Evaluating the IFC Action Plan and

As outlined in the above table, the fifth module provides an orientation to finalizing an action plan for IFC implementation based on the results of the participatory community assessment (PCA). It is designed to provide MNH actors, in collaboration with other actors and sectors, the tools to organize and implement the IFC component effectively and efficiently and to develop a plan for monitoring and evaluation. This module describes the processes of planning, monitoring and evaluating the IFC component in two different scenarios: (1) when the IFC framework is introduced in a country or province for the first time and is being implemented in the initial district(s); and (2) after a country or province has experience

Module 5

Who should use this module? This module is designed to be studied by MNH programme coordinators and committee members at national, province and district levels in order to acquaint them with the steps and considerations to effectively plan, monitor and evaluate the IFC component. It is not intended to be an exhaustive resource on the general programme cycle, emphasizing rather those considerations to be made in the context of the IFC framework. IFC committee members (or MNH committee members) at the national and province levels will find this guide useful as they support the districts in IFC implementation and work toward institutionalization of the IFC framework at their respective levels. Their role is critical as they plan national/province level actions to facilitate work at the district level, assist the district in planning and implementing activities, coordinate monitoring and evaluation systems in the different districts, and monitor and evaluate the contribution of the IFC component within the national MNH strategy. IFC committee members at the district level will be able to use this guide to understand more concretely how they can move ahead in planning IFC activities, monitoring their progress and evaluating their results once the PCA team has provided a preliminary plan for interventions. Readers of this module at all levels will benefit from having a thorough understanding of the fundamentals of the IFC framework. This may involve having previously studied the IFC

framework strategic document that provides its theoretical underpinnings, as well as Module 1 of this toolkit that offers an overview of the IFC implementation processes. Previous participation in a workshop introducing the IFC framework (see Module 2) would be advantageous. Familiarity with the PCA process (Modules 3 and 4) would also be beneficial, as this module completes the continuum of implementation phases following this essential step. These preliminary efforts are important as they provide a foundation and global perspective of the IFC framework. Further assistance Planning, monitoring and evaluation are complicated processes. As such, this module is not expected to respond to all the planning, monitoring and evaluation needs of any project or programme because contexts vary significantly and processes need to be adapted accordingly. Also, the processes will need to take into account and compensate for the varying levels of expertise and experience of the actors participating in IFC implementation. Experience has shown that IFC committees often lack experience in the areas of planning, monitoring and evaluation, and they benefit from external assistance. When members of the IFC team have limited experience, we strongly encourage IFC coordinators to seek the support of external experts and consultants during key moments, such as during the development of an action plan following the PCA. As IFC committees increasingly build their capacities, their reliance on external consultants will decrease accordingly.

Introduction

Adapting the process The processes outlined in this guide are suggested processes — they will need to be reviewed and adapted within each country to suit the national and local contexts, and in consideration of available resources. The IFC component is a complex system that is being introduced into an already complex MNH system, which is embedded in a broader complex social system. Each country must take into account and adapt the processes according to its ongoing strategies and initiatives, the coordination efforts between these different initiatives, as well as the implementation environments.

Structure of the module Section 1 provides an overview of finalizing an IFC action plan and monitoring and evaluating IFC activities; it underscores the principles of participation of the community and other actors in these processes. Section 2 describes the process of finalizing the IFC action plan by elaborating a logical framework and detailed activities plan. Section 3 presents some core elements of monitoring and evaluating the IFC component. Section 4 provides considerations for documenting lessons learnt throughout the implementation process. Section 5 describes the process of disseminating and using monitoring and evaluation results. The annexes provide sample tools and guides for planning, monitoring and evaluating the IFC component.

Module 5

1. IFC PLANNING, MONITORING AND EVALUATION OVERVIEW 1.1 POST-PCA PHASES OF THE IFC IMPLEMENTATION FRAMEWORK Once the IFC framework has been introduced in a country or province and the PCA completed, the district IFC committee moves into the next phases of the IFC implementation consisting of the joint planning process, participatory implementation and participatory evaluation. The PCA provides the foundation for planning IFC interventions by generating many ideas for improving MNH within the context of the IFC framework. The joint planning process is undertaken to organize the PCA results and determine how priority interventions will be implemented in practice. It also lays the groundwork for effective monitoring and evaluation. These processes feed back into each other, as monitoring and evaluation are used to adjust current plans and guide future planning – they are therefore, more appropriately viewed as a complex trajectory with transactions and decision-making processes at each stage of the process (see Fig. 1.1).

Fig. 1.1: Planning, monitoring and evaluating the IFC component

PCA Action plan: Logical framework Activities plan

Base-line study

Coordination and monitoring Intermediate evaluation Implementation (cont.)

Final evaluation

Implementation

Meanwhile, national and province level MNH actors continue to provide support to the district; strengthen coordination among partners; bridge communication among the different districts implementing the IFC component; monitor and evaluate activities at these respective levels; and work towards scale-up of the IFC framework in the country. Activities at all levels are complementary; the districts receive support from national and province levels while also providing the evidence necessary and lessons learnt to guide scale-up of the framework. Fig. 1.2 highlights the steps of the IFC implementation process at the national, province

and district levels that are addressed to varying degrees in this manual. It is important to note that the sequence between monitoring and evaluation, knowledge generation, dissemination and policy-making for scaling-up is not a straightforward process. It is subjected to many contingencies (e.g. political will, windows of opportunity). It is important for IFC partners to try to account for this during the planning process, particularly considering the lack of continuity among administrations and the need to ensure means for sustainability of the process.

6 Fig. 1.2: Focus on post-PCA steps of IFC implementation DISTRICT LEVEL: PHASE 3: Joint planning process • District committee designs interventions based on IFC framework • Budget and action plan • Resource mobilization • Selection of indicators • Baseline evaluation • Coordination • Monitoring PHASE 4: Participatory implementation PHASE 5: Participatory evaluation • Process and impact evaluation

AWARENESS-RAISING

SKILLS-BUILDING

RESOURCE MOBILIZATION

PHASE 1: IFC Preparation

PHASE 2: Participatory Community Assessment (PCA)

• Orientation workshop • IFC coordination • Advocacy & partnership building • PCA preparation (presentation to community, identifying facilitators, adapting instruments)

Explore health needs and set priorities:

• Situation analysis • Training workshop • Five roundtable discussions • Institutional forum • Final report

PROVINCE AND NATIONAL LEVELS: Ongoing activities • Advocacy and partnership-building • IFC coordination • Ongoing support to district level • Integration of IFC component and participatory methods into ongoing planning process Scale-up activities • Documenting lessons learnt • Monitoring and evaluation • Scale-up strategy design • Mechanisms for communication and exchange (between districts levels, provinces and internationally)

Initial activities

• Advocacy and partnershipbuilding • Orientation to the IFC framework • Incorporation of IFC component within national and district health strategies • Site selection for local implementation

Section 1: IFC planning, monitoring and evaluation overview

See Module 1, Fig. 2.1

Module 5

As the IFC framework is designed to form a complementary health promotion component of a broader MNH strategy, it is difficult to measure the specific contribution of the framework to the overall improvement of MNH. An ultimate,

measurable improvement in MNH will be the result of the complex interplay of multiple factors, including the availability and performance of health services, policy considerations and, to a large extent, the socioeconomic and cultural context.

Fig. 1.3: IFC framework objectives and priority areas IMPROVE MATERNAL AND NEWBORN HEALTH (MNH)

Primary aims of the IFC framework 1. Contribute to the empowerment of individuals, families and communities to improve MNH. 2. Increase access to and utilization of quality health services, particularly those provided by skilled birth attendants.

IFC priority areas of interventions 1. Developing CAPACITIES to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies; 2. Increasing AWARENESS of the rights, needs and potential problems related to potential problems related to MNH; 3. Strengthening LINKAGES for social support between women, families and communities and with the health care delivery system; 4. Improving QUALITY of care, health services and interactions with women, families and communities.

IFC priority areas of health systems strengthening 1. Contributing to PUBLIC POLICIES favourable to MNH; 2. Contributing to the COORDINATION of actions within the health sector as well as between the health sector and other sectors; 3. Promoting COMMUNITY PARTICIPATION in the management of MNH problems; 4. Contributing to CAPACITY BUILDING of the health workforce in the IFC framework; 5. Implementing an interinstitutional system of MONITORING AND EVALUATION of the IFC component.

Implementation of the IFC framework intends to directly impact the four priority areas of intervention outlined in the conceptual framework as well as the five priority areas of health systems strengthening, which also serve to strengthen the foundation for implementing

actions within the priority areas of intervention. The combination of actions within these nine areas is intended to contribute to the primary aims of the IFC framework, which in turn are expected to contribute to improving MNH (see Fig. 1.3).

Section 1: IFC planning, monitoring and evaluation overview

IFC coordinators will want to assess the process of IFC implementation and how implementation may be influencing change in the aims and priority areas of the framework. Effectively

carrying out these assessments will be facilitated by designing appropriate tools and outlining a plan for monitoring and evaluation at the outset of implementation.

1.2 RELATIONSHIPS BETWEEN PLANNING, MONITORING AND EVALUATION As in any programming cycle, IFC planning, monitoring and evaluation are inextricably linked components of the implementation process (see Box 1.1). Planning can be defined as the process of setting goals and objectives, developing strategies to reach these goals and objectives, outlining the arrangements for implementation of interventions, and identifying and allocating resources. Monitoring is the ongoing process by which stakeholders gather information to determine whether actions are being implemented as planned and progress is being made toward reaching the stated objectives. Evaluation is the rigorous assessment that broadens the understanding of the contribution of the IFC component to change in the primary aims and priority areas of intervention and health systems strengthening of the IFC framework, and how and why IFC implementation is influencing change. Planning, monitoring and evaluation are distinct yet closely interrelated processes. Together they play a major role in enhancing the effectiveness of the IFC component and its interventions. Optimal planning helps actors focus on achieving the identified objectives within the priority areas. A clear plan facilitates monitoring and evaluation, while monitoring and evaluation provide evidence to inform decision-making throughout the intervention and for scaling-up, both “horizontally” (i.e. to other districts and provinces) and “vertically” (through greater institutionalization) (see Module 1, sections 2.15 and 2.16).

Box 1.1: Links between planning, monitoring and evaluation • Without proper planning and clear articulation of intended results, it is not clear what should be monitored and how; hence monitoring cannot be done well. • Without effective planning (i.e. developing clear frameworks), the basis for evaluation is weak; hence evaluation cannot be done well. • Without careful monitoring, the necessary data are not collected; hence evaluation cannot be done well. • Monitoring is necessary, but not sufficient, for evaluation. • Monitoring facilitates evaluation, but evaluation uses additional data collection and different frameworks for analysis. • Monitoring and evaluation of interventions will often lead to changes in planning. This may mean further changing or modifying data collection for monitoring purposes. Source; UNDP, 2009.

Module 5

1. 3 PARTICIPATION IN PLANNING, MONITORING AND EVALUATION As in all other phases of the IFC implementation, planning, monitoring and evaluation of the IFC component is intended to be undertaken with the participation of actors from various sectors and institutions, with special attention given to community participation. Active and meaningful participation is not only consistent with the principles of health promotion, but fundamental to a rights-based approach and necessary for empowerment. To participate, people (women, their partners and families) need to be informed and empowered. This requires establishing transparent and democratic rules to govern the planning, monitoring and evaluation processes. While particular aspects of participation will be highlighted throughout this module, this section provides an overview of these participatory processes and the guiding principles that may be kept in mind in order to lay the groundwork for assuring participation. including the community, and is shared with all stakeholders before activities are implemented. In addition, monitoring and evaluation results are shared with the community throughout the implementation timeframe allowing community members to provide input on how plans can be adjusted to better respond to their needs. This ensures a natural continuum of participation throughout all phases of IFC planning.

Participation in monitoring and evaluation The emphasis on participation in the IFC framework is also maintained in monitoring and evaluation. Preserving this participation necessitates some fundamental variations from more conventional approaches to monitoring and evaluation. Box 1.2 highlights some of the major differences between participatory monitoring and evaluation and traditional monitoring and evaluation. In order to ensure these distinctions, monitoring and evaluation of the IFC component is underpinned by the broader principles of participatory monitoring and evaluation. These are: • Participation: Monitoring and evaluation of the IFC component emphasizes the participation of various stakeholders in the process. This principle is facilitated by IFC committees, in which different sectors and actors are represented. All stakeholders, including community representatives, can participate in developing and providing input on tools for monitoring and evaluation, organizing and supporting the process, and analysing and using results. Moreover, monitoring and evaluation of IFC interventions is ideally conducted in collaboration with both internal (e.g. IFC committee members, community members) and external (e.g. research institutions, external consultants) actors. This ensures that the interventions are assessed from the viewpoints of both those directly

Participation in planning Participation in planning is initiated during the PCA. The PCA promotes the active participation of community members, leaders and IFC partners in working together to define MNH priorities and propose activities to address these priorities. This participation initiates a process of empowerment as women, families and communities are directly involved in making decisions and designing actions that are meant to benefit them. The PCA is a particularly beneficial tool for promoting participation as it not only builds the capacities of community members to participate, but also the capacities of actors within the health system to institutionalize participatory processes. This participation continues following the PCA as the IFC committee elaborates the action plan, detailing how interventions will be implemented, monitored and evaluated. This action plan is developed with input from stakeholders,

Section 1: IFC planning, monitoring and evaluation overview

involved in the component and those with a more independent position. • Learning: Participatory monitoring and evaluation stresses practical and actionoriented learning throughout the process. Monitoring and evaluation of the IFC component is an “educational experience” for all stakeholders. Participating actors, including community members, become aware of what is working and where weaknesses lie, contributing to empowering them to create conditions conducive to change and action. • Negotiation: Participatory monitoring and evaluation is a social process in which participating actors negotiate between varying needs, expectations and worldviews. This approach recognizes the complex interrelationships between stakeholders. It is intended to contribute to the empowerment of those stakeholders who are traditionally less likely to have their needs and expectations included in decision-making processes, with an emphasis on community members, particularly marginalized groups (minorities, indigenous people, poor people, people with disabilities, elderly people, among others).

• Flexibility: In order for monitoring and evaluation to be participatory, it needs to be approached with flexibility. Monitoring and evaluation of the IFC component will need to be adjusted to the specific context of the implementation district, province and country, ensuring that the process itself responds to stakeholder’s needs and expectations. When using a participatory approach, monitoring and evaluation contributes to the primary aim of the IFC framework to empower women, their partners, families and communities to improve MNH. It also strengthens collaboration and increases trust among IFC partners, reinforcing coordination to improve MNH. Moreover, it contributes to ensuring transparency and accountability, which are central to a rightsbased approach, throughout the implementation process as all stakeholders are consistently informed of developments and progress within the IFC component. While the potential benefits of participatory approaches to monitoring and evaluation are great, all actors involved should be aware that such an approach generally requires a greater time commitment, particularly as more actors are involved, and they will want to account for this when outlining plans and timelines.

Box 1.2: Characteristics of participatory monitoring and evaluation In contrast to traditional methods of monitoring and evaluation, participatory monitoring and evaluation is: • focused on processes and measurement, rather than exclusively on measurement; • oriented towards the needs of intervention participants and community members, rather than exclusively on funders and policy-makers; • promotes a relationship between evaluators and participants, rather than objectivity and distance; and • conducted for the purpose of empowering participants, implementers and beneficiaries alike, rather than simply judging shortcomings. Source: Estrella, M and Gaventa J, 1997.

Module 5

Using visual tools for participation in planning, monitoring and evaluation In many cases, community members will not have experience with the tools used for planning, monitoring and evaluation and will not be comfortable with abstract concepts such as rates and proportions. One way to bridge differences in experience and background and allow for meaningful participation of all actors is to use visual tools. Tools that allow for the Year Number of newborn visual representation of concepts ordeaths data can Year 1 23 contribute to creating a common platform where Year 2 Year 3 Year 4 Year 5 25 22 21 18

all actors are able to share an understanding and provide meaningful contributions. Graphs, such as histograms and pie charts can be useful for sharing data with community members. A histogram, or bar chart, can help participants understand how the situation is changing over time. For example, it could be used to assist community members to understand changes in the number of maternal and newborn deaths or in the utilization of health services (see Fig. 1.4).

Fig. 1.4: Example histogram

Number of newborn deaths Number of newborn deaths 30 25 20 15 10 5 0 Year 1 Year 2 Year 3 Year 4 Year 5 23 25 22 21 18

endant eal 56 nal 38 6

56 38 6

Fig. 1.5: Example pie chart

TypeType of attendant of attendant at birth atat birth Type of attendant birth

Skilled Skilled healthhealth provider provider Traditional Traditional birth birth attendant attendant Other Other

A pie chart can help people visualize the situation at a given point in time. They can be especially useful when presenting information on percentages, such as the percentage of women or newborns receiving skilled care (see Fig. 1.5 for an example).

Section 1: IFC planning, monitoring and evaluation overview

While these graphs provide a visual representation of the current situation or specific indicators, other tools can visually represent processes. A spider diagram or “spidergram” (see Fig. 1.6) can be useful in this regard4. For example, a spidergram could be used by stakeholders to examine the processes of IFC implementation within the priority areas of health systems strengthening. In order to do this, participants could examine each priority area of health systems strengthening and select a score ranging from 1-6 (1 corresponding to

little development and 6 corresponding to a high degree of development), plotting this on the line corresponding to the appropriate area. They can then connect the scores with a line. The “web” that it creates illustrates the current status of processes in these areas with a broader web indicating greater progress and a narrower web indicating less progress. These can also be plotted over time to represent changes throughout the implementation timeframe. This exercise can help programme partners identify strengths and areas for improvement.

Public policies 6 5 4 3

Public policies

Montoring and evaluation

2 1 0

Coordination

Capacity building

Community participation Community participation

Capacity building

Using the IFC priority areas of health systems strengthening is simply one example of how a spidergram may be used to chart processes. The IFC committee can agree to use it to plot any processes that are relevant to their particular context.

IFC coordinators and committee members will be in the best position to determine which visual tools will be most beneficial for promoting the participation of a diverse array of stakeholders. Ideally this will be done in collaboration with representatives of the target audience. We suggest approaching these exercises with creativity and developing tools that respond to the local realities.

Adapted from Rifkin et al. 1988.

Module 5

2. FINALIZING THE IFC ACTION PLAN 2.1 THE DISTRICT IFC ACTION PLAN Completing the district IFC action plan in the initial implementation site During the institutional forum of the PCA, participants develop a priority list of problems and a draft list of solutions aiming to address these problems. The local coordinator and district committee use this draft plan as the foundation to develop a detailed district action plan, generally for the following 3–5 years. Ideally, IFC coordinators will be able to directly integrate the IFC interventions into the MNH programme at the district level, or will use the planning tools that are accepted and utilized in the country and at the respective level to elaborate a plan for IFC interventions. It is important that IFC coordinators use the tools that will facilitate an integrated approach to implementation of the IFC component and that they are comfortable using the selected tools. However, if standardized tools are not currently being used, the matrices proposed in Annexes 1 and 2 of this module may be adapted and adopted. These matrices are illustrative; they contain the fundamental components of an IFC action plan (described in detail below). Regardless of the particular tools utilized, the district IFC coordinator is responsible for ensuring that all the basic elements of a strong plan for the IFC component are in place. A strong plan will facilitate a shared vision among stakeholders, lay the groundwork for smooth implementation and contribute to ensuring accountability and transparency. The planning method for the IFC component that we suggest in this module involves elaborating two central tools: the logical framework (logframe) and the activities plan. These are complementary instruments that facilitate the implementation, monitoring and evaluation of interventions. These tools are particularly useful for the management of IFC implementation and can help to build consensus among partners, promote a shared vision of what is planned and contribute to promoting accountability. However, in proposing these tools, it is also necessary to stress their limitations. The IFC component is a complex health initiative that is introduced into an already complex MNH system, which is itself embedded in its own complex social system. These tools tend to imply a linear cause-and-effect relationship between inputs and outputs/outcomes, while in reality change processes are generally non-linear, and inputs can contribute to change while not mechanistically causing it per se. They also are by necessity overly simplistic and are unable to capture all the factors that will come into play that lie beyond the scope of the planned initiative. In order to compensate to some degree for these limitations, when using these or similar tools, it is important for partners to clearly recognize that they are not in fact dealing with a selfcontained system and that the tools provide an overly simplistic, one dimensional view of a complex reality. Rather, partners are managing a complex initiative intervening in a complex social system on the basis of a simplified logical model. The benefits of the tools are therefore optimized when they are used flexibly and are adapted on an ongoing basis to respond to unforeseen changes in the context and to experience. In addition, it is also important to seriously consider the assumptions that the models are based on and their inherent risks. Finally, they will ideally be used as learning tools for all actors rather than for judgement and criticism. To plan the objectives and activities of the IFC component, the team refers to the results of the PCA. Throughout the course of the institutional forum the participants ideally will have selected

Section 2: Finalizing the IFC action plan

one to two priority interventions to implement within each of the four IFC areas of intervention. The district team can review the plans and verify that the plan is focused, feasible and that the interventions are appropriate and well adapted to the objectives of the IFC framework. They will also want to verify that the IFC planned interventions are coherent with the district MNH programme. With these considerations in mind, they will be able to modify the plan generated through the PCA as necessary (see Module 3, sections 4 and 5). In addition, IFC coordinators and partners will generally want to identify actions to implement and measure within the IFC priority areas of health systems strengthening. When implementing the IFC component for the first time, it may be beneficial to determine actions for each of these areas, though this may not be necessary in future implementation.

The IFC action plan in the expansion sites Planning in the IFC expansion districts will be very similar to the process conducted in the initial implementation sites. The primary difference will be that planning in these districts will generally not be based on a full PCA. Rather, the IFC committees in these sites may instead base intervention planning on alternatively agreed upon methods (see Module 1, section 2.16). A validation workshop may be conducted with district actors to review the results of PCAs previously conducted in similar sites and to base the planning on relevant results. Otherwise, IFC committee members may agree on other methods, such as meetings with local actors. In all cases, partners will need to work together to determine how to maintain the core principles of the IFC framework. This will include keeping the principles of participation at the forefront of the planning processes and ensuring that the voices of various actors and community members in particular are represented. The district IFC committee may proceed to develop an action plan based on the results surfacing during these alternative discussions and planning processes. They will also want to include actions within selected priority areas of health systems strengthening based on needs identified by partners.

Module 5

2.2 DEVELOPING THE DISTRICT IFC LOGFRAME A logframe, or similar tool, outlines the “logic” of the interventions, demonstrating the way in which interventions are expected to lead to certain results in order to contribute to the objectives (see Annex 1 for a proposed logframe). In sum, the logframe provides a coherent and cohesive summary of key elements of the interventions. While this linear representation is arguably overly simplistic, when used appropriately the logframe can prove particularly useful in increasing stakeholder understanding of the project, decreasing ambiguity and increasing accountability and transparency. Box 2.1 highlights some of the benefits of a logframe that can guide actors in its elaboration and can be used as criteria in its assessment before its finalization. Suggested components of a logframe include the following: • Goal: This is the ultimate objective to which the implementation of the IFC component is expected to contribute. Within the IFC framework, the goal is to “contribute to the improvement of MNH.” It is common to all IFC work plans. • Purpose: This is the immediate impact on the intervention area or target group. Within the IFC framework, the purpose refers to the overarching aims, i.e. “to contribute to the empowerment of individuals, families and communities to improve MNH and increase access to and utilization of quality MNH services.” • Outcomes: Outcomes are the specific changes or benefits the implementation of the IFC component is expected to achieve. These will typically be formulated based on the four priority areas of intervention and the five areas of health system strengthening of the IFC framework (see section 1.1 and Module 1, sections 1.2 and 1.3). • Outputs: Outputs are the main interventions that are intended to contribute to reaching the outcomes. For example, if one of the planned outcomes is that women have the capacity to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies, a related planned output may be “Community health workers (CHWs) assist women and their families to develop a plan for birth and potential complications.” Note that the specific activities conducted under each of these outputs are not included here in the logframe, but rather in the activities plan (see section 2.5).

Box 2.1: Goals of a logframe The purpose of the logframe is to: • bring together in one place a clear, concise and accessible explanation of all of the key components of the interventions. • clarify how the interventions are expected to work and what they are expected to achieve, ensuring that inputs, activities, outputs and objectives fit together; • identify some of the factors that will be required for the success of the interventions by summarizing the assumptions and the risks that can be foreseen; and • clarify how progress and change will be assessed, providing the basis for monitoring and evaluation. Source: DFID, 2003a.

• Indicators: Indicators are measures used to demonstrate change in a situation, or the progress in, or results of, an initiative or interventions. A list of illustrative IFC indicators is provided in Annex 3.

Section 2: Finalizing the IFC action plan

• Means of verification: These are the sources of information and means of data collection related to indicators (discussed in detail in section 2.4). • Assumptions and risks: Assumptions are the necessary and positive conditions that are required in order for objectives to be reached. They are related to the overall context and environment of the implementation site. For instance, continued cultural, social and political stability are generally assumed. Risks are the possible negative events and occurrences that could potentially compromise the achievement of results. These may be related to political unrest, changes in the political orientation of the governmental administrations towards sexual and reproductive health, or natural disasters, among others. Identifying assumptions and risks allows stakeholders to acknowledge the factors lying outside their influence and discuss contingency plans in case assumptions do not hold or risks are realized. Clearly not all risks and assumptions will be able to be identified in advance as many changes in the system are unpredictable. However, this component of a logframe should be seriously considered during planning as success will be largely dependent

on these factors and on IFC coordinators’ and partners’ abilities to appropriately respond and adjust to them. The terms that we have selected to refer to each component of the logframe may be referred to differently in other tools used for the same purpose. It is important that IFC coordinators keep this in mind when using local tools and in verifying that all necessary components are in place. Once the logframe is complete, the team can test the logic of the interventions. Box 2.2 provides questions that may be useful in this exercise. The team will want to honestly recognize when the link in the logic does not work and revise the logframe accordingly. Table 2.1 provides a sample logframe for the IFC component. This provides an example of each of the logframe elements and ideally will be integrated into the logframe of the district health action plan. Once again, we strongly suggest that the logframe be used flexibly and that IFC coordinators take the time to review it on an ongoing basis to adjust it when necessary and assure that it remains relevant. Use of the logframe will be optimized when it is used as a tool for learning by all partners.

Box 2.2: Questions to test the logframe logic 1) If the outputs are carried out, can we reasonably expect the outcomes to be produced? 2) If the outcomes are produced, can we expect this to contribute to the purpose of the IFC framework? 3) If positive change in the purpose is achieved, will this contribute to the overall goal of the IFC component?

NARRATIVE SUMMARY # of maternal deaths # of newborn deaths # of health facilities performing Health services survey activities to mobilize community actors in MNH Continued political commitment to the IFC component at district level Need for skilled birth attendants can be met within the health services Weather conditions remain stable allowing for target group to be reached % of births attended by a skilled Health information system attendant PRIORITY AREAS OF INTERVENTION % of women who are aware of three danger signs during pregnancy % of women who sought care at Baseline and end-line survey a health facility for obstetrical, postpartum and/or postnatal complications % of pregnant women having discussed a plan for birth and complications with their partners and/or other household members Men’s awareness of women’s right to access quality MNH services % of partners who accompany the woman to the health facility for birth Focus group discussions with men Baseline and end-line survey Baseline and end-line survey CHWs are willing and able to add efforts in birth preparedness and complication readiness to their current tasks Target group is amenable to changes in gender relations Baseline and end-line survey Health information system Health information system Continued political commitment in favour of MNH and the IFC component

INDICATORS

MEANS OF VERIFICATION

ASSUMPTIONS/RISKS

Module 5

Goal

Contribute to improved MNH

Purpose

Empower women, families and communities to improve MNH and increase utilization of MNH services

Outcome 1 Women have the capacities to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies

Planned Output 1.1

CHWs assist women to develop a plan for birth and potential obstetric and neonatal complications

Table 2.1: Example of a district IFC logframe

Outcome 2 Families and communities are aware of the rights related to MNH

Planned Output 2.1

Awareness campaign conducted to sensitize men to rights and needs related to MNH % of women accompanied at the health facility by a TBA for birth or for an obstetrical/ neonatal complication

# of meetings held with men on Routine monitoring data MNH rights and needs

Men are disposed to participate in meetings on MNH

Outcome 3 Linkages for social support between women, families and communities and with the health care delivery system are strengthened

Baseline and end-line surveys

Health facility policies and health care provider attitudes are favourable to allowing TBAs to accompany women receiving MNH services

18 INDICATORS # of TBAs oriented on referring and accompanying women to health services Annual reports TBAs are willing to adopt new role in MNH Degree of satisfaction of TBAs with their new role in MNH % of women who mention an improvement in how they are received by health care providers % of health care providers trained to improve their interpersonal and intercultural skills PRIORITY AREAS OF HEALTH SYSTEMS STRENGTHENING % of public budget dedicated to IFC component within the MNH programme District health reports Orientation of health policies remain favourable to the incorporation of health promotion within health programmes Health officials value the contribution of the IFC framework within MNH Sectors outside of the health sector have human resources available to participate in the IFC component Annual report IFC District Committee terms of reference available Meeting minutes Implementation of the IFC component is prioritized at the local level Health services surveys Health facility managers agree to have providers trained to improve their interpersonal and intercultural skills Baseline and end-line surveys Health care providers have time and structural support to counsel women on MNH issues Focus group discussions with TBAs MEANS OF VERIFICATION ASSUMPTIONS/RISKS # of meetings with health officials to discuss integrating the IFC component in the MNH programme Meeting minutes Active functioning of Annual report district level intersectoral/ interinstitutional IFC committee Open-ended questionnaires with an annual action plan with IFC committee members # of IFC committee members identified Terms of reference for IFC committee finalized # of quarterly IFC meeting held Section 2: Finalizing the IFC action plan

NARRATIVE SUMMARY

Planned Output 3.1

Workshops are held with TBAs to orient them to refer and accompany women to health facilities for birth or an obstetrical/neonatal complication

Outcome 4 Health providers’ interactions with women, families and communities are improved

Planned Output 4.1

Health care providers are trained to counsel women on MNH issues and improve their interpersonal skills

Outcome 5 The IFC component integrated in the district MNH programme

Output 5.1

IFC committee advocates for IFC component to be integrated into the district MNH programme

Outcome 6 Coordination of IFC actions within the health sector as well as between the health sector and other sectors strengthened

Output 6.1

District level IFC committee formed

NARRATIVE SUMMARY % of community members who can name three activities in favour of MNH within their community Annual reports/field visits # of health facilities that collaborate with community health committees to guarantee community participation in health services planning and management Meeting minutes Tools for participatory planning available Annual reports/field visits Health official and provider attitudes favourable toward communities and the importance of their participation Health workers have time available to participate in IFC training/workshops Qualified individuals to be trainers are available at the local level Baseline and end-line surveys Health official and provider attitudes favourable toward communities and the importance of their participation

Module 5

INDICATORS

MEANS OF VERIFICATION

ASSUMPTIONS/RISKS

Outcome 7 Community participation is strengthened in the management of MNH problems

Output 7.1

# of meetings conducted with Health facilities are supported to institutionalize participatory community health committees processes for MNH programme Tools developed to conduct planning participatory processes Presence of a training programme on the IFC component at the district level # of active training team members # of workshops conducted by the training team Monitoring and evaluation tools for the IFC component developed and agreed upon by partners Mechanisms/processes established for assuring community participation in the monitoring and evaluation process Finalized logframe Finalized activities plan Annual reports Annual reports/field visits

Outcome 8 Capacity of the health workforce is built to implement the IFC component

Output 8.1

A team of trainers is formed to train the health workforce on the IFC component

Outcome 9 Monitoring and evaluation of the IFC component strengthened

Availability of monitoring and A shared consensus and evaluation documents and tools vision of IFC monitoring and evaluation is reached Monitoring and evaluation tools

Output 9.1

IFC component monitoring and evaluation tools are finalized

Logframe available Activities plan available

A shared consensus and vision of IFC monitoring and evaluation is reached

Section 2: Finalizing the IFC action plan

2.3 INDICATOR SELECTION Once the objectives have been formulated in the logframe, the team will want to organize a system for measuring change related to the implementation of the IFC component. A central feature of this measurement will be carefully selected indicators. Indicators are empirically Table 2.2: Indicator description measurable conditions used to assess how activities are being carried out and if there are any changes in the defined outcomes/outputs. A continuum of performance indicators can be used to track the progress of the interventions at different levels, as described in Table 2.2.

TYPE OF INDICATOR

PURPOSE Measures long-term results generated by outputs related to the goal of the IFC framework to improve maternal and newborn health. Impact indicators measure results from transformative changes to the system, including the contribution of integrating the IFC component. Measures the intermediate results generated by the outputs, often corresponding to changes in behaviour, such as self-care and careseeking behaviour, to which interventions have likely contributed. One example within the IFC framework is “Percentage of births attended by a skilled birth attendant.” Measures the results of activities at the intervention level that directly result from the inputs and processes. These are often related to changes in knowledge or opinions. For example, if one intervention is to educate women on danger signs, an appropriate indicator may be, “Percentage of women who are aware of three danger signs during pregnancy.” Measures the progress of activities and the way they are carried out. Again using the example of educating women on danger signs, an appropriate indicator may be, “Number of women educated about danger signs during pregnancy.” Measures the means required to implement the interventions. These may include for example, human and financial resources, physical facilities, operational guidelines, training workshops, educational materials distributed.

Impact

Outcome

Output

Process

Input

Carefully selecting indicators will optimize the chance that they will accurately reflect the results of the interventions. One way to aid the selection process is by using the “SMART” criteria, suggesting that indicators be: specific

(focused and clear), measurable (quantifiable and reflecting change), attainable (reasonable in scope within the set time-frame), relevant (pertinent to the review of performance) and time-bound (progress can be charted within the

Module 5

set time-frame). Box 2.3 provides questions that can be asked to assist in ensuring that indicators are appropriate using the SMART criteria. To facilitate the selection of indicators, Annex 3 provides an illustrative list of outcome and output indicators representative of the IFC framework. This list is intended to facilitate the formulation of indicators related to IFC interventions; however, it is not exhaustive and other indicators may be considered as appropriate and relevant to the interventions in each specific context. This will be especially true in regions where certain specific health concerns (e.g. violence against women, adolescent pregnancy, HIV/AIDS) merit a particular emphasis within the IFC efforts. A mix of both quantitative and qualitative indicators may be selected in order to more fully capture the changes resulting from the interventions and to compensate for the limitations of each type. Quantitative indicators are used to numerically measure the effect of programme interventions. They are typically expressed as numbers, percentages, rates and ratios. Qualitative indicators are descriptive Box 2.4: Example quantitative and qualitative indicators Quantitative indicators: • % of pregnant women having at least four antenatal care visits • % of pregnant women having discussed a birth and emergency preparedness plan with their partners and/or other household members • % of partners who accompany the woman to the health facility for birth Qualitative indicators: • Partners’ awareness of danger signs during pregnancy • Women’s awareness of their right to access maternal health services

Box 2.3: SMART indicators Specific: Is the indicator likely to measure exactly the condition or event it is expected to measure? Measurable: Is data collection feasible? Is the data source readily available? Attainable: Are the results in which the indicator seeks to chart progress realistic? Relevant: Is the indicator relevant to the intended output/outcome? Time-bound: Can the indicator be collected within the programme time period? and are therefore not measured numerically. They may be expressed as extent, level, quality or compliance. They may be used to explore attitudes, behaviours or actions through observational methods, focus group discussions or other participatory methods. Box 2.4 provides some examples of these two different types of indicators. The proposed list of indicators found in Annex 3 includes both quantitative and qualitative indicators, but it is worth noting that it is often possible to modify an indicator to represent the other category of indicator. Fig. 2.1 provides an example of indicator modification. This modification will take place primarily based on the plan for measuring the indicator. Quantitative methods will generate data to measure quantitative indicators while qualitative methods will generate data to measure qualitative indicators. Quantitative and qualitative approaches are not mutually exclusive, but rather complementary. Using both will allow for the greatest insight into what is occurring in response to the IFC efforts, as well as why and how, illuminating both results and processes. When formulating indicators, we strongly advise including indicators to measure empowerment, as it is one of the primary aims of the IFC framework and also central to a rights-based

Section 2: Finalizing the IFC action plan

approach. This can generally be achieved through proxy indicators that may demonstrate whether the capacities of women, families and communities are developed to make choices and to transform these choices into desired outcomes (see Module 1, section 1.1). Indicators related to awareness can often be used in this way, as knowledge is fundamental to being able to make appropriate decisions. Indicators used to measure changes in the environment allowing women to make health-promoting decisions can also be used, as without a supportive environment it is much more difficult for women to transform their choices into desired actions. IFC coordinators and stakeholders will need to determine how best to capture these changes and this may be a particularly salient moment for consulting with community members to understand what empowerment means to them. While participation of stakeholders is important throughout the development of these tools, this

is particularly true for the selection of indicators. It is important that community members are able to voice their opinions as to how progress in certain areas could be captured and ensure that they are satisfied with the indicators chosen to measure progress. Also, as their empowerment is one of the main objectives of the IFC component, they will ideally be given a voice to express how they envision empowerment. When selecting indicators, it is advisable to ensure that they are limited in number. Limiting the number of indicators to a manageable level increases the chance that they will be measured appropriately within the planned timeframe, avoids the collection of unnecessary data that is less likely to be used and is conducive to more focused results. It is therefore important to aim to select the few indicators that are most likely to accurately reflect the results of IFC interventions. One or two indicators per output/ outcome are generally sufficient.

Figure 2.1: Adapting quantitative indicators

INDICATOR TYPE

QUANTITATIVE

QUALITATIVE

INDICATOR

% of pregnant women who are aware of three danger signs in newborns

Modify as qualitative indicator

Pregnant women’s understanding of danger signs in newborns

DATA COLLECTION

Quantitative methods, such as household surveys

Qualitative methods, such as focus group discussions or interviews

Module 5

2.4 MEANS OF VERIFICATION During the process of identifying indicators, it is essential to determine how the data related to the indicator will be collected. This is done through selecting a means of verification and specifying it in the logframe. It is crucial to ensure that each indicator has a reliable means of verification that will allow for data to be collected at the planned intervals. It is important that the data source used for a specific indicator remains consistent throughout the planning timeframe as changing the source will likely lead to inconsistencies and Table 2.3: Existing means of verification DATA SOURCE Routine health information system DESCRIPTION Data collected by facility-based staff and recorded on standard reporting forms that are sent to higher levels in the system where they are aggregated. Data are most often service statistics such as the number of cases seen by category, the number of deaths at the facility, the number of pregnancies and births, estimates of coverage using local population data, and the number of outreach visits conducted. Records maintained by health facilities that may track the number of antenatal care (ANC) and postnatal care (PNC) visits, births, diagnoses, etc. They can be used to measure indicators of coverage. interpretational errors. In order to save time, effort and resources, data are collected through existing sources when possible, particularly in IFC expansion sites. However, it will be necessary to collect primary data in certain cases, especially in the initial implementation site when conducting an impact evaluation or implementation research. Table 2.3 provides a description of existing data sources that may be used as means of verification.

Health services surveys, medical records, and administrative files Registry systems of the civil state Demographic and Health Surveys (DHS) Multiple Indicator Cluster Surveys (MICS) Population censuses

Registries at the municipal/district level that record routine data such as births, deaths, migrations. They may have sub-registries in some cases (e.g. remote areas, abortion, early infant deaths). Comprehensive large sample surveys that include information on maternal and child health, reproductive health, and mortality. A national sampling frame is usually used, although data are sometimes disaggregated to the level of smaller administrative units such as districts. Comprehensive large sample surveys that include information on maternal and child health, reproductive health and mortality. Data collected from the entire population at a certain point in time. Depending on the country, the census may include indicators on health topics, including maternal and child health.

Section 2: Finalizing the IFC action plan

While a great deal of data can be collected through these or other existing information systems, particularly in relation to the utilization of MNH services, many of the activities conducted within the IFC priority areas of intervention will require the collection of complementary data. This will

generally be the case for interventions seeking to impact on knowledge, attitudes and practices related to MNH. Table 2.4 provides a description of suggested methods for collecting this type of data within the context of IFC monitoring and evaluation.

Table 2.4: Complementary means of verification METHOD OF DATA COLLECTION Quantitative Household surveys DESCRIPTION These surveys allow for the collection of specific information among an appropriate sample of the target population. For example, surveys may be used to collect information concerning knowledge, attitudes and practices related to MNH and specifically to the selected themes within the four IFC priority areas. These groups are conducted with approximately 6-12 participants and led by a facilitator. Group members discuss certain topics freely and spontaneously. These discussions provide the opportunity to explore a range of opinions and practices related to the IFC component, including rights and gender. They may also provide a platform to explore local perceptions of the IFC interventions and the implementation process, its strengths and weaknesses, thus promoting participation. These may be conducted with varying levels of structure, although semi-structured guidelines are advised in this context. The interviewer follows a set of prepared topics, allowing the interviewee to speak freely and openly concerning the defined topics. They are used to explore informants’ perceptions and beliefs, as well as the context and structures affecting their behaviour and practices, including aspects related to rights and gender. These may prove especially useful when inquiring about sensitive issues (e.g. abortion, adolescent pregnancy, violence against women). Like the focus group discussion, this method should be used in a manner that promotes participation. TARGET PARTICIPANTS Community members, e.g. women having recently given birth; husbands/partners of women having recently given birth. Intervention target populations, e.g. women having recently given birth; husbands/partners; influential family members (e.g. mother, mothers-inlaw, grandmothers); health workers, including TBAs; and community leaders. Key informants, including women of reproductive age and their husbands/ partners; community members/leaders; health workers, including facility based health care providers and community health workers, including TBAs; and local authorities.

Focus group discussions

Qualitative 24

In-depth interviews

Module 5

Client-exit interviews

These interviews are conducted to understand experiences of and opinions about the health care services received. Within the context of the IFC framework, these interviews would most likely be used to explore the woman’s interactions with the health care provider, as well as her awareness and enjoyment of her rights related to maternal health. Designed to allow participants to provide additional information regarding their opinions and perceptions related to survey questions. They may be used with IFC partners to explore their experiences and satisfaction participating in the IFC component or with the actors and health workers involved and to better understand the degree that rights and gender perspectives are mainstreamed into the implementation processes. Not strictly limited in number of participants, these discussions provide a platform for IFC actors to meet to discuss their experiences participating in the IFC component, their general opinions and satisfaction, as well as other strategic issues such as the degree of incorporating rights and gender perspectives within the management of IFC implementation.

Women having received antenatal care, postnatal care or given birth in a health facility.

Open-ended questionnaires Qualitative

IFC partners; health workers.

Group discussions

IFC partners.

In the spirit of participatory monitoring and evaluation, qualitative methods may be used not only as sources of data collection, but also as opportunities to promote the participation of various stakeholders in monitoring and evaluation, to better understand their needs and experiences and initiate change based on their opinions. Whenever possible, it is advisable to use data that can be disaggregated or design data collection tools so that the indicators can be disaggregated.

Disaggregated data contributes to the detection of inequities and/or discrimination that is critical to a rights-based approach and may also be used to identify what groups are benefiting most from implementation of the IFC component and who may not be benefitting but should be. Data may be disaggregated according to socio-economic status, ethnicity, gender or other relevant factors.

Section 2: Finalizing the IFC action plan

2.5 THE DISTRICT IFC ACTIVITIES PLAN Once the logframe is complete, it is necessary to consider how the IFC interventions will take shape in terms of timing, resources and responsible actors in order to facilitate implementation. This can be done by developing an activities plan. A sample activities plan is provided in Annex 2. To elaborate the activities plan, the team details the practical aspects of the implementation of interventions as suggested in the steps below: 1) List the planned outcomes and outputs: These are found in the logframe. 2) Under each output, list the corresponding activities: For example, if one of the planned outputs is to train health care providers to improve their interpersonal skills, sub-activities may include developing/ adapting training materials, conducting a training of trainers, and finally conducting the actual training workshops for health care providers. 3) Clarify sequences and relationships between activities in terms of timing: Some activities are dependent on other activities being completed first. It is necessary to specify these dependencies and list the activities in the appropriate order. For example, if birth preparedness and complication readiness are among the selected interventions, the necessary tools, including a training manual for those who will assist women in developing a plan and potentially a card, or other planning tool provided to women, will generally be developed before one-to-one education with women begins. 4) Specify the timing: This involves estimating the duration of each task and establishing the likely start-up and completion dates. 5) Identify responsible actors and their role: This is intended to reduce ambiguity and increase accountability among partners. 6) Outline the necessary resources and the source: This may include human, material and financial resources. The currently available resources should be specified as well as a preliminary strategy for mobilizing additional resources. Moreover, the resource mobilization for the IFC component will ideally be linked to the broader effort for mobilizing resources for the district MNH programme. To facilitate the implementation and the monitoring of interventions, the team may also elaborate an annual action plan apart from the three- to five-year action plan. It contains the activities planned for the course of the year in question, detailing activity implementation by month. This may be done with the logframe as well. Generally, the first year of the annual action plan will be more detailed than subsequent years, as certain activities are repeated and routines established.

Module 5

2.6 FINALIZING AND PRESENTING THE DISTRICT IFC ACTION PLAN After having elaborated the IFC action plan, we suggest that the team review the plan with participating actors and the community before its finalization. This promotes transparency in planning as well as the participation of stakeholders, including the community, throughout the process, ensuring that IFC planning is indeed a joint planning process. One systematic way to approach this process may be to invite representatives from among the community and institutional actors who participated in the PCA to a joint meeting. Separated into subgroups, they may look through the logframe and activities plan, contributing amendments according to their competencies and personal experiences. This meeting will ideally result in an action plan that is satisfactory to the participants and that may be finalized. With the action plan finalized, the district IFC committee presents it to MNH actors and other sectors. As mentioned in section 5.3 of Module 3, it is ideal to disseminate the finalized plan simultaneously with the PCA results in order to demonstrate the committee’s capacity to act quickly on the basis of results. Next, the action plan and the PCA results may be presented to the IFC and MNH committees at the province and national levels. These meetings can also provide an opportunity to coordinate the IFC component planning, monitoring and evaluation at these levels and begin discussing a strategy for scaling-up the IFC framework (see section 2.16 of Module 1). The process of presenting the action plan can also provide a platform for integrating IFC activities into the broader MNH programme.

2.7 THE NATIONAL AND PROVINCE IFC ACTION PLANS In addition to the district IFC action plans developed to guide implementation of the IFC component at this level, the national and province levels are also advised to elaborate a plan for implementation of the IFC component at their respective levels. As in elaborating the district action plan, whenever possible the IFC work will be directly integrated into the broader national or provincial MNH work plan. In the absence of this possibility, due to timing or other impediments, it is preferable to use the tools utilized for the in-country MNH strategy for the IFC component. However, once again, if this is not feasible, IFC committees can adapt and use the logframe (Annex 1) and the activities plan (Annex 2) provided in this module, remembering to use them flexibly and recognizing and compensating for their limitations. As at the district level, it is important that planning processes at the national and provincial levels be transparent and that the resulting tools facilitate accountability. The IFC action plans at national and province levels will generally focus on: 1) Plans for rolling out the IFC component: This includes selection of provinces/districts for implementation and actions related to scaling-up. 2) The five priority areas of health systems strengthening: For example, the national and province action plans may include action on public policies (e.g. institutionalization of the IFC component); coordination of the IFC component (e.g. creating and/or strengthening the IFC committees, establishing communication between actors involved in IFC implementation both horizontally and vertically); promotion of community participatory processes in the country; building the capacity of in-country actors on the IFC framework; and monitoring and evaluation of the IFC component.

Section 2: Finalizing the IFC action plan

3) Centralized interventions: While many of the planned activities based on the PCA or other participatory mechanisms will be specific to a district and implementation focused at this level, some activities may be amenable to centralization at the national or provincial levels. Activities that may be centralized include modifications of national programmes, mass media campaigns and the production of didactic materials related to health. For example, if multiple districts are identifying a need for birth preparedness and complication readiness, or if actors at national or province levels see the need for such interventions more broadly than in one district, they may develop a centralized strategy for rolling out the intervention. This would facilitate the creation of the tools necessary to effectively promote birth preparedness and complication readiness and avoid the duplication of efforts. Centralized interventions will preferably be integrated into the national MNH action plan so as to ensure the complementary nature of the IFC component in the broader MNH strategy. They will also need to be carefully adapted before being applied to the local level. At these levels, as at the district level, IFC actors will want to ensure that these activities are appropriately implemented, monitored and evaluated. At the national and provincial level it is

critical to select indicators to measure progress toward achieving planned outcomes and outputs. Particularly when selecting outcome indicators related to the objective of the IFC component at the national and province levels, the respective committees will generally want to select from those that the IFC component contributes to (e.g. use of services) and that are already used within the existing MNH strategy. This means that they will ideally already be part of the monitoring mechanisms and processes employed by the MNH programme. Any new indicators related to the IFC framework that the IFC committees at these levels would like to see measured would ideally be completely integrated into the existing MNH monitoring and evaluation system. At all levels, IFC committees will want to carefully avoid creating parallel systems of monitoring and evaluation. When certain indicators important to the IFC component are not already included, committee members may consider advocating for their inclusion in the current monitoring and evaluation system, in censuses or other regularly conducted data collection systems. In WHO regions where monitoring and evaluation tools for MNH have been developed5, IFC committee members can use these as a starting point for determining how to incorporate IFC indicators into the national MNH monitoring and evaluation system and use the strategy in advocacy.

For an example see PAHO, 2011.

Module 5

3. MONITORING AND EVALUATING THE IFC COMPONENT 3.1 OVERVIEW OF MONITORING AND EVALUATING THE IFC COMPONENT Monitoring and evaluation are critical elements of the IFC implementation process. As such, actions and budgeting for monitoring and evaluation will ideally be included in the IFC action plan. Typically, the foundation for monitoring and evaluation will have been laid during the planning processes at district, provincial and national levels. Monitoring and evaluation will serve to assess whether and how activities are being implemented and how they are contributing to change. They also contribute to assuring accountability to stakeholders. Monitoring will generally be conducted in the same manner regardless of the type of implementation site, whether an initial implementation site or expansion site. Evaluation, on the other hand, may be more rigorous in the initial implementation sites allowing for an impact evaluation, and potentially implementation research while simplified processes will typically be employed in expansion sites. The monitoring and evaluation of the component will need to be adapted to the context of the country, province and district. However, a coordinated approach between different levels of the health sector will facilitate the collection, analysis and comparison of data between districts. With this goal, the national level can play an important support role in selecting appropriate monitoring and evaluation tools and instruments to be used by the districts.

Box 3.1: Provincial and national roles in monitoring and evaluation While the majority of the monitoring and evaluation of the IFC component will occur at district level, there are certain areas that the national and provincial IFC committees will be responsible for. These include: • monitoring the national and province actions related to the IFC component within the MNH strategy; • evaluating the contribution of the IFC component to the achievement of national and provincial MNH goals and strategy; • agreeing on an IFC monitoring and evaluation framework and overseeing its implementation; • promoting partnerships and coordination between ongoing IFC efforts in different districts. This gives partners a common vision of the outputs and outcomes to which the various in-country IFC interventions are contributing; • carrying out, participating in, and ensuring the overall quality of IFC evaluations and ensuring that the processes and products meet international standards; • ensuring the centralization of monitoring and evaluation results generated from all district level IFC efforts in the country; • ensuring effective use and dissemination of monitoring and evaluation information in future planning and decision-making for improvements.

Section 3: Monitoring and evaluating the IFC component

3.2 MONITORING OF THE IFC COMPONENT Monitoring consists of the continuous tracking of activities throughout the implementation period. It reveals whether activities are being implemented according to the plan and shows progress toward the planned outputs. It allows IFC partners to assess whether interventions are on course, provides information to support continuous decision-making and supports accountability throughout the implementation period. IFC committee members at the various levels will need to work together to determine the tools that they will use for monitoring. The national IFC committee generally assumes a role in assuring consistency in the monitoring tools used in different districts in which the IFC framework is being implemented. Typically these tools will include the action plan, field visits and annual reports. It is not realistic to expect that any one monitoring tool will be able to fulfil all monitoring needs; therefore, a mix of tools will generally be beneficial. In addition, monitoring tools may be used differently in different contexts. It is important that IFC committee members and partners agree on which tools will be used and how the tools will be used, and that they have a shared vision of monitoring of the IFC component. While all IFC committee members have a shared responsibility in monitoring, the primary responsibility lies with the IFC coordinator. It is especially important that monitoring be conducted in the spirit of learning. Partners will be able to make the best use of monitoring activities and data when they feel that they are being employed for their benefit rather than judgement. IFC coordinators can play a key role in creating a learning-focused monitoring environment through their attitudes and leadership. In order to collect data for monitoring, the IFC committee can use the action plan for the given period. The activities plan is an especially useful tool in this exercise, as it lays out the specifics of what was expected to have occurred during a certain time frame: the planned activities, the partners responsible for conducting the activities, the resources that were to be used for the activities, and ultimately the outputs to which the activities were expected to contribute. IFC coordinators can examine each activity planned for the time period and first determine whether the activity was conducted. If the activity was conducted, they can collect data on the input and process indicators related to the activity, as specified in the logframe. For example, if during the time period one of the planned activities was to train health care personnel in counselling women and families on MNH issues, the IFC coordinator can first determine whether the training was conducted, and if so, if it was conducted according to plan. They can then track how many health personnel were trained. If a pre- and post-test was conducted during the training they could also collect these results. This process is facilitated when the actors responsible for a given activity submit the data related to the activity directly to the IFC coordinator. They can then compare what was planned to what actually took place (e.g. did each responsible actor fulfil their role? Were the planned number of health personnel trained, or more, or less?). Preferably, IFC partners will collect monitoring data related to the input, process and output indicators on a quarterly basis. If the activity was not conducted or certain indicators are not as expected (such as, from our previous example, fewer health care providers were trained than anticipated), the IFC committee can explore reasons for this and learn from these unexpected results. Often the reasons will be related to complexities in implementation that were not anticipated. The success of implementation will largely depend on the partners’ and stakeholders’ abilities to

Module 5

respond to these complexities appropriately. Monitoring provides the opportunity to identify these complexities and then make decisions and take action to address them effectively. Some information may be collected by health authorities, such as those related to the utilization of health services. Ideally, the IFC committee will work with health authorities to integrate indicators specific to the IFC framework into the monitoring grids used in routine supervision within the health services. Other data will be accessible through local and national health information systems. The IFC coordinator will generally be responsible for compiling the data submitted by IFC partners and those collected from the health system. It is advisable for the coordinator to compile and prepare this data prior to each IFC committee meeting. Field visits may also be used as a monitoring tool. Field visits serve to validate the results reported by partners and involve assessing progress, results and problems. At the district level, the IFC coordinator will generally be responsible for conducting field visits within the district. These visits may be conducted jointly with other IFC partners or health authorities monitoring MNH activities in order to optimize ownership. Field visits to the district level may also be conducted by IFC coordinators at national and province levels. Results from these visits may be shared and analysed during IFC committee meetings. Finally, it is strongly encouraged to develop annual reports as part of the monitoring process. Normally, this report will be used for assessing performance, learning and decisionmaking. It also serves to ensure transparency and accountability within IFC implementation. The format of this report will be determined and agreed upon by the IFC committee. However, it is advisable to base the format on a generally accepted reporting format already utilized in the country. This report serves as a self-assessment of the IFC committee and implementation of the

IFC component. Ideally it will present the most up-to-date results of the IFC component, identify major constraints and propose future directions. Optimally, a draft of the report will be developed and circulated to IFC committee members prior to holding the annual monitoring meeting so that the report can be discussed at this time. Box 3.2: Monitoring of the IFC component Monitoring of the IFC component is part of the IFC implementation framework and not an addition to it. It is not to be regarded simply as a management or reporting requirement, but rather as an opportunity to: • engage IFC partners and stakeholders, with an emphasis on the community, so that they feel ownership of the results being achieved and are motivated to sustain them; • demonstrate progress toward the achievement of IFC objectives, how the IFC interventions are benefiting women and families, and leverage support of the community and other stakeholders to address any challenges faced; and • nurture an inclusive and purposeful monitoring culture to make implementation and management effective and interesting, as well as to ease the gathering of objective data and evidence to support achievements and make decisions. Adapted from: UNDP, 2009. Quarterly and annual IFC committee meetings at the district level and annual IFC committee meetings at the national level help to ensure that monitoring is a joint process involving the collaboration of various stakeholders (see Annex 4 for draft guides for quarterly and annual IFC committee meetings). During these meetings, the IFC committee analyses the monitoring data gathered using the action plan and from field visits and may review the annual report and any other report submitted

Section 3: Monitoring and evaluating the IFC component

to the committee (e.g. training and workshops reports, other activity reports). Based on these monitoring tools they determine whether the actions are on target for achieving the outputs and outcomes, what complexities may exist in the context both internal and external to the implementation process that effect implementation and plan adjustments to the interventions, optimizing their implementation. In addition to analysing monitoring data, they can also use these monitoring meetings as an opportunity to assess the functioning of IFC implementation and coordination more generally. Box 3.3: Key questions that monitoring seeks to answer • Are the pre-identified outputs being produced efficiently and as planned? • What are the issues, risks and challenges that we face or foresee that we can adjust for in order to facilitate the achievement of results? • What decisions need to be made in subsequent stages concerning changes to the work already planned? • Will the planned and delivered outputs continue to be relevant to achieve the envisioned outcomes? • Are the outcomes we envisioned still relevant and effective for achieving the purpose of the IFC framework? • What are we learning? Source: UNDP, 2009. In sum, monitoring of the IFC component will generally identify the following: • progress towards results – this involves periodically analysing the extent to which intended results have been achieved or are being achieved; • factors contributing to or impeding achievement of the outcomes – this requires a

broader perspective taking into consideration the complexity and factors lying outside the IFC actors and action plan, such as economic, social, political and other developments; • partner contributions to IFC interventions; • partnership within the IFC committees – this requires the review of current partnerships within the IFC committees and their functioning as well as the consideration of new actors and sectors as needed. This helps to ensure that all partners have a common perspective of the needs and problems within the IFC component and that the action plan is known and accepted by all partners. Annex 5 contains two tools for assessing the district IFC committee: a self-assessment questionnaire and an IFC committee assessment discussion guide. Administering the self-assessment questionnaire can be a useful exercise for determining committee members’ knowledge and understanding of the IFC component and to reveal their experience collaborating on the committee. This questionnaire is designed for participants to complete anonymously so that they feel comfortable answering honestly. When administering the questionnaire, ensure that all partners are able to participate. If some IFC committee members are unable to read and/or write, for example, you may want to bring in an external person to assist them in completing the questionnaire. The IFC committee assessment discussion guide can be used to lead the IFC committee through an exchange on collaboration and committee functioning. Monitoring meetings can also provide an opportunity to look at issues related to gender (such as whether the IFC committee adequately represents a gender balance and integrates gender perspectives) and the level and functionality of community participation (this is critical at all levels); and • lessons learnt (see section 4). Using information gained through monitoring, district coordinators and partners can analyse and

Module 5

take action on activities to ensure that the intended results of the IFC component are achieved. It is important that each member of the IFC committee is involved in monitoring. In practical terms, monitoring as a joint process with IFC actors involves the following: • regular data collection related to activities by all partners and submission of data to the IFC coordinator; • assessing during IFC committee meetings the progress towards results already stated in the logframe and sharing information gathered by partners (see Annex 6); • planning and conducting joint field monitoring missions to gauge achievements and constraints; • identifying lessons learnt, sharing them, and promoting their use by all IFC actors; • identifying capacity development needs among IFC partners for fulfilling their roles in implementation; • reporting regularly to stakeholders and IFC committees;

• bringing lessons learnt to the attention of policy-makers; and • contributing to common reports. It is important to maintain participation throughout the process of monitoring, and IFC partners will need to keep this in mind when developing their monitoring strategy. Assuring that community leaders or representatives of women’s groups or other community-based organizations are included in the district IFC committee and participate in quarterly and annual review meetings is one way to ensure participation in monitoring. Community participation may also be promoted by integrating participatory methods in routine data collection. For instance, health workers could be trained to conduct focus group discussions with women and men on an annual basis and report the results to the IFC coordinator to ensure that community members’ opinions and experiences are included in monitoring on a regular basis. In addition, the IFC committee is strongly encouraged to share monitoring results with the community in order to allow the community to participate in interpreting the data. This process also promotes transparency and accountability. These activities are critical to promoting the rights of the community members.

3. 3 EVALUATION OF THE IFC COMPONENT Evaluation overview Evaluation, while closely related to monitoring, is a more extensive and detailed assessment generally conducted by independent actors. Evaluation seeks to assess the extent to which implementation of the IFC component is contributing to planned outcomes in the four priority areas of intervention and the priority areas of health systems strengthening, the component’s contribution to improving MNH, and an assessment of the general functioning of implementation processes. It provides information on what is and is not working in implementation and provides objective information allowing IFC coordinators to make informed decisions about next steps and expansion to other sites.

Evaluation in the initial implementation site In the initial implementation site(s), the IFC committee is strongly advised to consider conducting an impact evaluation or implementation research. This is done to provide evidence linking interventions with

Section 3: Monitoring and evaluating the IFC component

results, to provide insight on what is working, in what context and for whom and to equip policy-makers and managers with information to improve operation and guide scale-up. The IFC committee will need to determine the main objectives and primary evaluation or research questions that will largely guide how to best conduct the evaluation or research. In many cases either a cluster-randomized controlled trial or a quasi-experimental design can be used to generate actionable information, preferably comparing the intervention district to a matched control district where IFC activities are not being implemented. Indicators are measured before and after implementation to capture changes in the intervention district. It is important to try to shed light not only on what has changed, but how, for whom and what factors of the context have either enhanced or deterred implementation and results. Accomplishing this will require a mixedmethods approach using both quantitative and qualitative methods in order to leverage the unique contributions of each type of method.

The IFC committee will be involved in supporting the evaluation team and in managing the process. Key roles of the IFC coordinator and IFC committee members include the following: • draft the terms of reference (ToR) for the evaluation team – sample ToR are provided in Annex 6 to aid the IFC committee; • brief the evaluators on the purpose and scope of the evaluation and explain expectations of the IFC committee and other stakeholders in terms of the required quality standards of the conduct of the evaluation and the deliverables; • make all necessary information available to the evaluators; • if asked by the evaluators, provide a preliminary list and contact information of stakeholders whom they should meet; • organize a meeting to introduce the evaluation team to IFC partners and stakeholders and key informants to facilitate the initial contact. The evaluation team can also take this opportunity to receive inputs from the stakeholders in the formulation of the evaluation questions, seek clarifications in the ToR and exchange ideas about the ways in which to conduct of the evaluation; • arrange interviews, meetings and field visits when requested; and • provide comments on and ensure the quality of the work plan and the protocol prepared by the evaluation team.

Selecting and supporting an evaluation team The impact evaluation or implementation research in the initial implementation site will generally be conducted independently and require a specific set of technical skills and expertise. Therefore, the IFC committee will generally choose to engage an external evaluation institution to conduct it. IFC coordinators and committee members will need to carefully select the evaluators as this will largely determine the quality of the evaluation. Box 3.4 provides some areas for consideration in this selection process. The IFC committee is advised to select evaluators who are open to participatory approaches to evaluation. This will require the evaluators to work closely with IFC committee members and other stakeholders, including community members. The evaluators will need to be aware and accepting of the implications of this participatory approach in terms of methods and time.

Module 5

Box 3.4: Some consideration when selecting the evaluation team • Proven expertise and experience in conducting evaluations; • Technical knowledge and experience in MNH and preferably in community-based MNH programmes; • Knowledge of the national, province and district situations and contexts; • Experience in social science research; • Expertise in both quantitative and qualitative research methods; • Open attitude toward participatory approaches in evaluation; • Familiarity with the IFC framework is advantageous. In many ways, the success of the evaluation will depend on the level of cooperation and support that the evaluation team receives from the IFC coordinator and committee. In keeping with the principles of participation, the IFC committee will want to verify that opportunities for community members to participate in the evaluation are present in the protocol. This may include ensuring that community representatives have a say in what they would like to see evaluated, that participatory methods are part of data collection, allowing community members to voice their opinions and including community representatives in data analysis. Equity should be a primary concern of the evaluation, and it should explore the question of who is benefitting from the implementation. It is important to identify whether certain groups are being excluded from the benefits and take action to remedy the situation. In addition, it is important to take gender issues into account within the evaluation, including in the context the evaluation and within the evaluation methods. For example, ideally the evaluation team will

include both women and men to ensure that gender perspectives are taken into consideration throughout the entire evaluation process. In addition, evaluation methods should be designed to allow to accommodate to the opinions and experiences of both women and men in relation to the IFC component. The IFC committee will have a central role in verifying that gender considerations are integrated in the evaluation.

Evaluation in the expansion sites Evaluation that occurs in the expansion sites will generally be simpler than in the initial site, it will focus more on monitoring than evaluation, and will require fewer resources, both human and financial. The IFC committee will need to work together during planning to determine the local evaluation needs and a strategy, in line with available resources. Quantitative indicators measuring output and outcome indicators can often be gathered in coordination with health monitoring conducted in the district or province. It may be possible to work with health officials to integrate indicators particular to IFC interventions. Complementary data collection using participative methods such as group discussions, in-depth interviews, clientexit interviews and reflection meetings with partners can be used to complete evaluations in expansion sites and to maintain participation in the evaluation process. It may be possible to train health workers to dialogue with communities and to conduct some data collection activities.

4. DOCUMENTATION OF LESSONS LEARNT Throughout the course of IFC implementation, many lessons will be learnt. They will be learnt both through strengths and successes, as well as through weaknesses and failures. These lessons, when documented and disseminated, will be useful for others to build on what worked well or avoid similar mistakes. It is advisable to establish a process of documenting lessons learnt from the outset of IFC implementation, particularly in the initial implementation sites. These lessons will be particularly instructive as the IFC framework is scaled up. Documentation of lessons learnt will likely be less rigorous in expansion sites, unless IFC partners are testing or introducing something new or the site is considerably different from sites where lessons learnt have been thoroughly documented. Learning lessons can only happen when there is time to reflect on practice, identify lessons and disseminate them to others, allowing them to absorb and apply the lessons. IFC committees can schedule time during quarterly and annual meetings for this type of reflection on lessons and record them in monitoring information. This process requires open-mindedness among IFC partners in reviewing experiences so that difficulties and complexities are acknowledged rather than ignored. A discussion of lessons learnt can form a part of each quarterly district IFC committee meeting, allowing partners to discuss the lessons from the previous quarter before they are forgotten. One systematic way to go about this is to review each of the priority areas of intervention and priority areas of health systems strengthening, including those which are not included in the logframe, and discuss the following: • What was learnt about what went well? • What was learnt about what did not go well? • What was learnt about what needs to change? • How can this implementation? be incorporated into

Based on this discussion, the key points can be highlighted and documented. A sample template for documentation of lessons learnt can be found in Annex 7. It is suggested to include the following: • implementation district and IFC coordinator contact information; • priority area of intervention/health systems strengthening concerned; • activities conducted during the period; • what went well; • what challenges were faced; • the results; and • a generalizable summary of the lesson learnt. The IFC committee can also discuss and document lessons learnt that may fall outside of the scope of the priority areas of intervention and the priority areas of health systems strengthening when the need arises. It will be beneficial to share lessons learnt at the district level with IFC committees at the province and national levels during annual IFC committee meetings. Before sharing these lessons, it is recommended that the district coordinator reviews the documentation of all lessons learnt from the specified time period, ensuring their relevance and consolidating documented lessons when appropriate. Lessons learnt by definition are to be generalizable and therefore not specific to the context. They are also independent of the actual results of interventions (see Box 4.1 for some examples of lessons learnt).

Module 5

In addition to their documentation at district level, lessons learnt will also be discussed and documented at the province and national levels following a similar process. These lessons at all three levels can be incorporated into annual reports and disseminated to stakeholders along with results from monitoring and evaluation (see section 5).

National actors may need to support district and province level teams in documenting lessons learnt when these teams are not experienced in this process. The national team will also generally be responsible for assuring that the lessons are made available to actors involved in IFC implementation throughout the country, so that they can be used to optimize effectiveness and avoid pitfalls that have already been experienced.

Box 4.1 Lessons learnt from IFC implementation in Kazakhstan • At the district level the concept of involving communities as well as other sectors to improve maternal, newborn and child health is perceived as very innovative but requires a shift in thinking at several levels and a significant amount of time to adopt. • Districts often require a high level of support from the national and province level at the outset of IFC implementation. • At the national and province levels, advocacy for the IFC component is critical to its success. • Financing the IFC component is an issue of concern. Securing the support of decision-makers at all levels is a long process and is facilitated by continuous advocacy and involvement during the PCA process. National level decision-makers’ commitment is key to ensuring that budgets are allocated to the IFC component.

5. DISSEMINATION AND USE OF IFC MONITORING AND EVALUATION RESULTS 5.1 RESULTS DISSEMINATION Ideally, disseminating the results from monitoring and evaluation will occur as soon as possible after the monitoring results are compiled or after evaluation is complete so that the findings remain relevant and in order to assure accountability and transparency. It is important to include results dissemination as a budget line when planning monitoring and evaluation to ensure that the resources will be available to do so effectively. Table 5.1: Results dissemination audiences TARGET AUDIENCE Province/ district IFC committees PURPOSE • Allow partners to ask questions and receive clarifications from evaluators • Discuss implications for implementation redirection, funding and expansion • Prepare actionable next steps National MNH committee • Preparation to coordinate the dissemination of results to other provinces and districts • Preparation for compilation of the results of all in-country evaluations of IFC interventions • Institutionalization of the IFC framework at country level • Guide scale-up • Meetings with evaluators at the national level • Meetings with district/ province coordinators and partners • Workshops to prepare actionable next steps • Information and communication technologies (ICTs), such as a blog developed for the IFC component, information networks for knowledge management, social networks, learning communities METHODS • Meetings with evaluators who present results and recommendations • Workshops in which partners prepare actionable next steps There are many different audiences to consider when designing a dissemination strategy. Table 5.1 presents some of the audiences that may be considered. In all cases, it is important to ensure that the results are disseminated in an easily understandable manner to the intended audiences so they can learn from it. This may be facilitated by using visual tools (see section 1.3).

Stakeholders

Module 5

TARGET AUDIENCE Other provinces and districts in which the IFC framework is being implemented

PURPOSE • Provide a broader vision of the results of the IFC interventions throughout the country • Optimize implementation, building on success and avoiding pitfalls

METHODS • National level meetings/ workshops with participation of various district/province IFC partners • ICTs, such as blogs, information networks for knowledge management, social networks, learning communities • Community meetings with the district coordinator, community representatives and evaluators to allow community members to ask questions and present suggestions based on the results; visual methods to present data, etc. • Dissemination through health centres/providers • Print material (carefully considering literacy status and local languages of the target audience) • ICTs, such as a blog developed for the IFC component, information networks for knowledge management, social networks, learning communities (carefully considering literacy status, local languages and access to technologies of target audience)

Community

• Increase accountability to the community • Increase community awareness of the results of the IFC component in order to increase motivation to participate • Contribute to the empowerment process and ensure that inventions are not “done to” the community, but rather “done with” the community • Provide communities the opportunity to comment on the results and contribute to a strategy of using the results for improving interventions

Stakeholders

Section 5: Dissemination and use of IFC monitoring and evaluation results

TARGET AUDIENCE Local: community groups, religious organizations, health workers, government officials, local NGOs, etc.

PURPOSE • Increase local awareness of the IFC component • Inform about what is taking place in the district and the results of the initiative • Increase the support of the IFC component at district level • Enlist new actors from various sectors

METHODS • Oral presentations • Meetings with organization representatives • Written reports, fact sheets, etc. • ICTs, such as blogs, information networks for knowledge management, social networks, learning communities, visual methods to present data • Oral presentations • Meetings with organization representatives • Written reports, press releases, fact sheets, etc. • ICTs, such as blogs, information networks for knowledge management, social networks, learning communities • News articles, journal publications • Presentations delivered at international congresses • ICTs, such as blogs, information networks for knowledge management, social networks, learning communities

Province/ national: policy-makers, country offices of international organizations, national NGOs and funding agencies

Outside audiences

• Increase country-level awareness of the IFC component • Inform about what is taking place in the country and the results of the initiatives • Increase the support of the IFC component • Increase collaboration

International: actors and organizations involved in maternal and child health, communitybased interventions

• Contribute to a broader understanding of what works in improving MNH • Advance the field by building a body of lessons learnt and best practices that can strengthen MNH programmes around the world

The national IFC committee, in its role in coordinating the monitoring and evaluation system, generally takes the lead in ensuring that the results obtained from monitoring and evaluation are compiled, understood and incorporated into future interventions to contribute to the success of the expansion of the IFC component to other districts and provinces.

When disseminating results, it is suggested to highlight both strengths and weaknesses, as there are valuable lessons to be learnt by various audiences based on both successes and shortcomings. Disseminating experiences in dealing with, or failing to deal with, complexity can be particularly instructive to those involved in MNH programming. In addition, reporting both strengths and weaknesses can reinforce accountability and increase credibility.

Module 5

While mentioned in the table, we would again like to highlight the importance of prioritizing dissemination of results to the community. Sharing information gained from monitoring and evaluation with community members is fundamental to participatory processes and to ensuring transparency and accountability, which are core elements of a rights-based approach. The participation of the community in the IFC component can only be meaningful and relevant

if they have access to timely information. This information must be accessible to community members, taking into account their gender, ethnic, religious and cultural background as well as their literacy status. The IFC committee will want to address these considerations to be sure that results are accessible to community members and that they have the opportunity to provide input on results in a meaningful way (see section 1.3).

5.2 USING MONITORING AND EVALUATION RESULTS While dissemination and knowledge generation is a critical first step in the utilization of monitoring and evaluation results, use of information will ideally extend far beyond this. When IFC monitoring and evaluation is exploited effectively, it will support improvements, vertical and horizontal scale-up of IFC framework, advocacy and accountability. • horizontal scale-up: monitoring and evaluation results will be particularly instructive in scaling up the IFC framework to new areas. This will help policy-makers identify the best strategy for expanding, and help other IFC coordinators and committees understand what has previously been effective and avoid mistakes that have already been made; • identify needs: existing needs may not become evident until identified through monitoring and evaluation. Once identified they can be incorporated into future plans. An implementation strategy for improvements based on monitoring and evaluation results will ideally be developed jointly with IFC committee members, after which the IFC coordinator will generally be responsible for following up to ensure that the strategy is implemented. As IFC partners take time to reflect on implementation and make necessary adjustments, they are also more likely to feel supported by the monitoring and evaluation process.

Intervention improvements Monitoring and evaluation results will help IFC partners improve interventions and make decisions about the best use of resources. Specifically, results may be used to: • highlight strengths and accomplishments: this will allow IFC coordinators to build on and reinforce assets; • improve management and planning of the IFC component: as the IFC framework promotes a high level of interagency and intersectoral collaboration, evaluation is critical in assessing the functioning of this collaboration and making needed changes to improve what can sometimes prove to be a complicated process; • identify implementation weaknesses: once IFC implementation weaknesses are identified, appropriate corrective action can be taken to overcome these shortcomings;

Vertical scaling-up: institutionalization Monitoring and evaluation results can help stakeholders and communities understand what the programme is doing, how well it is meeting its objectives and whether there are ways that progress can be improved. Sharing results can help strengthen the social, financial and political

Section 5: Dissemination and use of IFC monitoring and evaluation results

commitment to the IFC component within the MNH strategy and establish or strengthen the network of actors and sectors working within the IFC component in the country. This can lead to an increased level of institutionalization of the IFC framework at all levels.

and donors by providing an unbiased account of intervention implementation and use of resources. Learning from past lessons and taking corrective action is also a critical component of accountability. Use of monitoring and evaluation results will ideally be institutionalized within IFC processes. This can occur through the sharing of knowledge and information at regular IFC committee meetings, reporting and management of evaluation results. It is also possible to use information and communication technologies to increase accountability and build a sense of transparency by making information available on the internet and electronically as soon as possible after it becomes available. Ensuring that results are used effectively to strengthen the IFC framework at all levels and that they feed back into planning will optimize and complete the IFC implementation cycle.

Advocacy Disseminating monitoring and evaluation results can raise awareness of the IFC framework among the general public and help build positive perceptions about community participative strategies in improving MNH. Results can also be used to lobby for policy changes that relate to MNH by pointing out unmet needs or barriers to success of the IFC component.

Accountability Monitoring and evaluation results can be used to strengthen accountability to stakeholders

Module 5

REFERENCES Adamchak S, Bond K, MacLaren L, Magnani R, Nelson K, Seltzer J (2000). A guide to monitoring and evaluating adolescent reproductive health programs. Washington (DC): FOCUS on Young Adults. Agyepong IA, Kodua A, Adjei S, Adam T (2012). When solutions of yesterday become problems of today: crisis-ridden decision making in a complex adaptive system (CAS) – the Additional Duty Hours Allowance in Ghana. Health Policy Plann. 27:iv20–iv31. Collumbien M, Busza J, Cleland J, Campbell O (2012). Social science methods for research on sexual and reproductive health. Geneva: World Health Organization. CORE Initiative (2005). Participatory monitoring and evaluation of community- and faith-based programs: a step-by-step guide for people who want to make HIV and AIDS services more effective in their community. Washington (DC): CORE Initiative. DFID (2003a). The logical framework. London: Department for International Development. DFID (2003b). Tools for development: a handbook for those engaged in development activity. London: Department for International Development. Dieleman M, Kane S, Zwanikken P, Gerretsen B (2011). Realist review and synthesis of retention studies for health workers in rural and remote areas. Geneva: World Health Organization. Estrella M, Gaventa J (1997). Who counts reality? Participatory monitoring and evaluation: a literature review. London: International Institute for Environment and Development. EuropeAid (2004). Aid delivery methods: volume 1: project cycle management guidelines. Brussels: European Commission. Fisher A, Laing J, Stoekel J, Townsend J (1998). Handbook for family planning operations research design, 2nd edition. New York: Population Council. Gage AJ, Ali D, Suzuki C (2005). A guide for monitoring and evaluating child health programs. MEASURE Evaluation. North Carolina, USA: Carolina Population Center, University of North Carolina at Chapel Hill. Gertler P, Martinez S, Premand P, Rawlings L, Vermeersch C (2011). Impact evaluation in practice. Washington (DC): World Bank. Global Fund to Fight AIDS, Tuberculosis, and Malaria, World Health Organization, Joint United Nations Programme on HIV/AIDS, World Bank Global HIV/AIDS Program (2003). Framework for operations and implementation research in health and disease control programs. Geneva: World Health Organization; Guidance notes No. 4: logical framework analysis. London: Bond Network for International Development. OHCHR (2012). Human rights indicators: a guide to measurement and implementation. Geneva: Office of the United Nations High Commissioner for Human Rights. Örtengren, K (2004). The logical framework approach: a summary of the theory behind the LFA method. Stockholm: Swedish International Development Cooperation Agency. PAHO (1999). Monitoring of project implementation: a manual. Washington (DC): Pan-American Health Organization. PAHO (2011). World Health Organization. Plan of action to accelerate the reduction of maternal mortality and severe maternal morbidity. Washington (DC): Pan-American Health Organization. IDS (1998). Participatory monitoring and evaluation: learning from change. Brighton: Institute of Development Studies; (IDS Policy Briefing, No. 12). Pawson R, Greenhalgh T, Harvey G, Walshe K (2005). Realist review - a new method of systematic review designed for complex policy interventions. J Health Serv Res Po. 10:21–34.

References

Pawson R, Tilly N (1997). Realistic evaluation. London: Sage. Peters DH, Tran N, Adam T (2013). Implementation research in health: a practical guide. Geneva: World Health Organization. Rifkin SB, Muller F, Bichmann W (1988). Primary health care: on measuring participation. Soc Sci Med. 26(9):931–40. Schmidt DH, Rifkin SB (1996). Measuring participation: its use as a managerial tool for district health planners based on a case study in Tanzania. Int J Health Plan M. Oct–Dec;11(4):345–58. UNDP (1997). Who are the question makers? Participatory evaluation handbook. New York: United Nations Development Programme. UNDP (2009). Handbook on planning, monitoring and evaluation for development results. New York: United Nations Development Programme. UNFPA (2004). Programme manager’s planning, monitoring & evaluation toolkit. New York: United Nations Population Fund. UNICEF, WHO, The World Bank, United Nations Population Division (2013). Levels and trends in child mortality: Report 2013. New York:United Nations Children’s Fund. USAID (2011). Evaluation: learning from experience: USAID evaluation policy. Washington (DC): United States Agency for International Development. Vincent, R (2012). Insights from complexity theory for the evaluation of development action: recognising the two faces of complexity. Bonn: Information and Knowledge Management Emergent Research Programme, European Association of Development Research and Training Institutes (IKM Working Paper No. 14). World Bank (2004). Monitoring & evaluation: some tools, methods and approaches. Washington (DC): World Bank. WHO (1986). Ottawa Charter for Health Promotion. Geneva: World Health Organization (WHO/HRP/HEP/95.1). WHO (2010a). Nine steps for developing a scaling-up strategy. Geneva: World Health Organization. WHO (2010b). Working with individuals, families and communities to improve maternal and newborn health. Geneva: World Health Organization. WHO (2011). Research policy: developing proposals that meet ERC requirements. Geneva: World Health Organization (http://www.who.int/rpc/research_ethics/guidelines/en/index.html, accessed 17 January 2013). World Bank. (2005). The logframe handbook: a logical framework approach to project cycle management. Washington (DC): World Bank. WHO, World Bank, UNICEF, USAID, United States of America Department of State, Department of Health and Human Services (USA), Center for Disease Control, Global Fund (2004). Monitoring and evaluation toolkit: HIV/AIDS, tuberculosis and malaria. Geneva: World Health Organization. WHO, UNICEF, UNFP, World Bank (2012). Maternal Mortality Estimation Inter-Agency Group. (2012) Trends in maternal mortality 1990-2010. Geneva: World Health Organization. Yin RK. (2013). Case study research: design and methods, 5th edition. London: Sage Publications, Inc.

Module 5

ANNEXES 1. Sample IFC Logframe 2. Sample IFC Activities Plan 3. List of illustrative IFC indicators 4. Draft Guides For Quarterly and Annual IFC Committee Meetings 5. District IFC Committee Assessment Tools 6. Sample Terms of Reference For Evaluation Institution 7. Documentation Form for Lessons Learnt

ANNEX 1: SAMPLE IFC LOGFRAME

NARRATIVE SUMMARY

INDICATORS

MEANS OF VERIFICATION

ASSUMPTIONS/RISKS

Goal

Contribute to the improvement of MNH [Outcome]

[Impact]

Purpose

Empower women, families and communities to improve MNH and increase utilization of MNH services PRIORITY AREAS OF INTERVENTION

Outcome 1

Capacities developed [Input/Process/Output] [Output/Outcome] [Input/Process/Output] [Output/Outcome] [Input/Process/Output] [Output/Outcome] [Input/Process/Output]

[Output/Outcome]

Planned Output 1.1…

Outcome 2

Awareness increased

Planned Output 2.1…

Outcome 3

Linkages strengthened

Planned Output 3.1…

Outcome 4

Quality of care improved

Annex 1: Sample IFC logframe

Planned Output 4.1…

Module 5

PRIORITY AREAS OF HEALTH SYSTEMS STRENGTHENING

Outcome 5

Public policies favourable to MNH [Input/Process/Output] [Output/Outcome]

[Output/Outcome]

Planned Output 5.1…

Outcome 6

Coordination of IFC actions within the health sector as well as between the health sector and other sectors strengthened [Input/Process/Output] [Output/Outcome]

Planned Output 6.1…

Outcome 7

Community participation is strengthened in the management of MNH problems [Input/Process/Output] [Output/Outcome]

Planned Output 7.1…

Outcome 8

Capacity of the health workforce is built to implement the IFC component [Input/Process/Output] [Output/Outcome]

Planned Output 8.1…

Outcome 9

Monitoring and evaluation of the IFC component strengthened

Planned Output 9.1…

[Input/Process/Output]

ANNEX 2: SAMPLE IFC ACTIVITIES PLAN

TIMEFRAME (YEAR)

ACTORS AND ROLES

RESOURCES

ACTIVITY 3 4 5 RESPONSIBLE ACTOR(S) ROLE NECESSARY RESOURCES AVAILABLE RESOURCES

HOW TO MOBILIZE ADDITIONAL RESOURCES

PRIORITY AREAS OF INTERVENTION

OUTCOME 1: CAPACITIES OF WOMEN DEVELOPED

Output 1.1…

OUTCOME 2: AWARENESS INCREASED

Output 2.1…

OUTCOME 3: LINKAGES STRENGTHENED

Annex 2: Sample IFC activities plan

Output 3.1…

Module 5

OUTCOME 4: QUALITY IMPROVED

Output 4.1… PRIORITY AREAS OF HEALTH SYSTEMS STRENGTHENING

OUTCOME 5: PUBLIC POLICIES

Output 5.1…

OUTCOME 6: COORDINATION

Output 6.1…

OUTCOME 7: COMMUNITY PARTICIPATION

Output 7.1…

OUTCOME 8: CAPACITY BUILDING OF HEALTH WORKFORCE

Output 8.1…

OUTCOME 9: MONITORING AND EVALUATION

Output 9.1…

Annex 3: List of illlustrative IFC indicators

ANNEX 3: LIST OF ILLUSTRATIVE IFC INDICATORS This annex presents a list of illustrative indicators pertinent to the IFC framework. This list of indicators is the result of a detailed examination of numerous documents pertinent to the IFC framework and to the monitoring and evaluation of MNH programmes. Almost all the indicators mentioned in this document are already used at the national and international levels to measure the impact of MNH programmes and the results of interventions in the area of MNH. As such, using the list as a guide is expected to facilitate data collection and allow the use of existing information systems (such as health information systems, Demographic and Health Surveys) while avoiding the implementation of parallel systems and non-sustainable data collection. When possible, indicators used to measure interventions related to the IFC component will be incorporated directly into the monitoring and evaluation system of the MNH programme at national, province and district levels (see sections 2.3 and 2.4 of this module for more information on selecting indicators and means of verification). This list identifies impact, outcome and output indicators exclusively. Input and process indicators are not included as these will be numerous and specific to planned actions. Note also that while we have divided outcome and output indicators, in reality this distinction is not always clear-cut. Whether an indicator is considered an outcome or output will often depend on the level of progression of interventions and the defined objectives. In order to keep the list of indicators to a manageable number we have identified the indicators among the most representative of the IFC component, without addressing themes that, although impacting MNH, are either common to several programmes or specific to certain countries. These include violence against women, sexually transmitted infections, HIV/ AIDS, malaria, malnutrition, female genital mutilation, adolescent pregnancy, sexual and reproductive health and abortion. As a result this list is not designed be exhaustive and IFC coordinators will often be working with indicators outside the scope of this list when formulating indicators specific to the interventions in a particular county or district. The majority of the indicators presented in this list can be applied to the district level, while some can be used at all three levels (district, province and national) and a few can only be used at the national level, notably those related to mortality rates. In general, the majority of indicators at the national and province levels will fall within the IFC priority areas of health systems strengthening while the majority of indicators at the district level will fall within the four IFC priority areas of intervention. We would like to emphasize once again that these indicators are illustrative. When using this list as a reference, IFC coordinators will need to carefully adapt indicators to ensure that they are specific to their particular interventions, and also that the chosen indicators are able to measure processes, outputs and outcomes directly related to implementation of the IFC component in their area.

LIST OF ILLUSTRATIVE IFC INDICATORS SOCIAL IMPACT INDICATORS Improved status of women (Indicator to be determined at country level) Neonatal mortality rate # of maternal deaths # of neonatal deaths Perinatal mortality rate Stillbirth rate Adolescent birth rate Postpartum depression prevalence Improved social cohesion (Indicator to be determined at country level) Reduced inequity and discrimination (Indicator to be determined at country level) Maternal mortality ratio

Module 5

GOAL

HEALTH IMPACT INDICATORS

Contribute to the improvement of maternal and newborn health

PURPOSE % of women involved in the decision regarding maternal and newborn health care-seeking % of women who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care* % of women subjected to physical, sexual or psychological violence by a current or former intimate partner in the previous 12 months* % of women/men reporting improved family dialogue around maternal and newborn health Increased accountability and community participation in health services

SOCIAL OUTCOME INDICATORS

HEALTH OUTCOME INDICATORS % of pregnant women having at least eight antenatal care visits per income quintile % of pregnant women initiating antenatal care within the first 12 weeks of pregnancy per income quintile % of births attended by a skilled attendant/in a health facility per income quintile % of women/newborns receiving postnatal care from a skilled attendant, within the first 24 hours, on day 3 (38-72 hours), between days 7-14, at six weeks Coverage of essential maternal and newborn health services (index based on composite of antenatal care, skilled attendance at birth and postnatal care utilization)*

Contribute to the empowerment of individuals, families and communities to improve maternal and newborn health and increase access to and utilization of quality health services

* Sustainable Development Goal indicator

52 LIST OF ILLUSTRATIVE IFC INDICATORS OUTPUT INDICATORS % of pregnant women who are aware of self-care practices during pregnancy (e.g., reducing workload, nutrition, malaria/HIV/syphilis treatment and prevention, etc.) % of women breastfeeding exclusively for 6 months postpartum % of women taking iron folate tablets % of women reducing workload during pregancy % of pregnant women having at least eight antenatal care visits % of pregnant women initiating antenatal care within the first 12 weeks of pregnancy % of births attended by a skilled attendant/in a health facility % of women/newborns receiving postnatal care from a skilled attendant (within the first 24 hours, on day 3 (38-72 hours), on day 7-14, at six weeks) % of women seeking care for obstetric complications % of pregnant women who have a card (or similar tool) to prepare for birth and obstetrical and neonatal complications % of pregnant women having discussed a plan for birth and complications with a healthcare provider % of pregnant women who are aware of three danger signs during pregnancy/after birth % of pregnant women who are aware of three danger signs for newborns % of pregnant women who are aware of accessible health services in case of obstetrical and neonatal complications % of pregnant women having discussed a plan for birth and complications with their partners and/or other household members % of pregnant women who save money for birth % of pregnant women having identified a companion of choice to accompany them during birth % of pregnant women having identified a birthplace % of pregnant women having identified a mode of transportation to reach the birthplace % of pregnant women who are aware that infants should be exclusively breastfed for the first 6 months % of women who are aware of self-care practices postpartum (e.g., reducing workload, nutrition, etc.) % of pregnant women who can state at least two benefits of antenatal/postnatal care visits % of pregnant women who are aware of labour signs % of infants who were breastfed within the first hour of birth

PRIORITY AREAS OF INTERVENTION

OUTCOME INDICATORS

Self-care/ care in the household

Care-seeking behaviour

Developing CAPACITIES to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies

Annex 3: List of illlustrative IFC indicators

Birth preparedness and complication readiness

LIST OF ILLUSTRATIVE IFC INDICATORS OUTPUT INDICATORS % of women/partners/mothers/mothers-in-law who mention the support of household members for women during pregnancy and/or after birth % of women who mention household member support for exclusive breastfeeding % of partners/mothers/mothers-in-law who are aware of the plan for birth and complications of their partner/ daughter/daughter-in-law % of partners/mothers/mothers-in-law who are aware of three danger signs during pregnancy/after birth % of partners/mothers/mothers-in-law who are aware of three danger signs in newborns % of partners/mothers/mothers-in-law who are aware of the importance of exclusive breastfeeding for the first 6 months after birth % of women who are aware of rights related to maternal health (e.g. right to access quality maternal and newborn health services, right to respectful maternity care, rights related to decision-making, rights related to family planning, etc.) % of men who are aware of rights related to maternal health (e.g. right to access quality maternal and newborn health services, right to respectful maternity care, rights related to decision-making, rights related to family planning, etc.) % of health care providers who are aware of rights related to maternal health (e.g. right to access quality maternal and newborn health services, right to respectful maternity care, rights related to decisionmaking, rights related to family planning, etc.) # of health facilities that have a maternal and perinatal death surveillance system Presence of community representative on the maternal and perinatal death review committee Mechanism/process established to share information with community on the results of the maternal and perinatal death review Activities carried out by health services and/or the community based on maternal and perinatal death surveillance Mechanism/process to share information between health services and the community on the results of data and/or research on maternal and newborn health (e.g., information from the health information system, community epidemiological surveillance, verbal autopsies) % of women reporting depression symptoms during pregnancy % of partners/mothers/mothers-in-law who participate in antenatal care visits/birth preparation/postnatal care visits % of partners who accompany the woman to the health facility for birth % of partners/mothers/mothers-in-law who accompany the woman to antenatal and/or postnatal care visits

Module 5

PRIORITY AREAS OF INTERVENTION

OUTCOME INDICATORS

Male involvement and family support

Increasing AWARENESS of the rights, needs and potential problems related to maternal and newborn health

Promotion of human, sexual and reproductive rights

Community participation in maternal death surveillance and response

54 LIST OF ILLUSTRATIVE IFC INDICATORS OUTPUT INDICATORS % of women/men/community members who are aware of the new role of traditional birth attendants % of traditional birth attendants satisfied with their relationship with health care providers % of traditional birth attendants satisfied with their new role in maternal and newborn health Mechanism of dialogue established between health services and traditional birth attendants to define the new role of traditional birth attendants in maternal and newborn health New role of traditional birth attendants integrated in the local health strategy (district, regional, or health services level) # of health facilities that recognize the new role of traditional birth attendants # of health facilities that organize regular meetings with traditional birth attendants % of women/men/community members who are aware of the existence of a maternity waiting home % of women/men/community members who have a positive opinion regarding the existence of a maternity waiting home Education activities conducted at maternity waiting home % of women/partners/mothers/mothers-in-law who mention activities at the community level to overcome transportation barriers to accessing health facilities % of women who have used a maternity waiting home % of women satisfied with their stay in a maternity waiting home % of women accompanied at health facility by a traditional birth attendant for birth or for an obstetrical/neonatal complication

PRIORITY AREAS OF INTERVENTION

OUTCOME INDICATORS

Partnership with traditional birth attendants

Strengthening LINKAGES for social support between women, families and communities and with the health care delivery system

Maternity waiting homes

Community organized transport schemes # of active groups

Annex 3: List of illlustrative IFC indicators

Community mobilization through participatory learning and action cycle with women’s groups

% or groups with participation of 30% of pregnant women

% of women/partners/mothers/mothers-in-law who mention community activities to overcome financial barriers to accessing health services % of women who mention difficulties in accessing health facilities for obstetrical and neonatal complications and/or birth

LIST OF ILLUSTRATIVE IFC INDICATORS OUTPUT INDICATORS Consultation mechanism/process with women and with the community established concerning their satisfaction with the quality of maternal and newborn care % of women giving birth in the health facility who expressed satisfaction with the health services Community participation institutionalized in defining and monitoring of quality care % of women who know that they have the option of being accompanied by a companion of choice during birth % of partners/mothers/mothers-in-law who know that women have the option of being accompanied by a companion of choice during birth % of health care providers favourable toward women being accompanied by a companion of choice during birth Health facility level consultation process established to identify women’s preferences/satisfaction related to maternal and newborn health care services % of women giving birth in the health facility who did so in a labour position of their choice # of health facilities that have mechanisms in place to take into consideration the cultural preferences of the community related to maternal and newborn health % of women accompanied by a companion of choice during birth Presence of a companion of choice authorized in health facilities % of all births attended where the woman had a companion of choice % of women who mention three positive changes in the quality of care received during antenatal care visits/birth/postnatal care visits

Module 5

PRIORITY AREAS OF INTERVENTION

OUTCOME INDICATORS

Community participation in quality-improvement processes

Improving QUALITY of care, health services and interactions with women, families and communities

Companion of choice at childbirth

# of health facilities that have responded to intercultural perspectives in the birth process % women giving birth in the health facility who were satisfied that their choices and preferences were respected % women giving birth in the health facility who would recommend childbirth in that facility % of women giving birth in the health facility who reported that their needs and preferences were taken into account during labour, childbirth and postnatal care

Providing culturally appropriate skilled maternity care

56 LIST OF ILLUSTRATIVE IFC INDICATORS OUTPUT INDICATORS % of women satisfied with the responses/explanations they receive to their questions from health care providers during antenatal care visits/birth/postnatal care visits % of healthcare staff in the health facility who demonstrated the following skills: active listening, asking questions, responding to questions, verifying women’s and their families understanding, and supporting women in problem-solving % of women giving birth in the health facility who report they were given the opportunity to discuss their concerns and preferences % of women undergoing examination or procedures in the health facility who reported that their permission was sought before the examination or procedures % of women receiving care in the health facility who were aware that they have the right to choose, accept or decline treatment % of women examined and treated in the health facility who expressed satisfaction with the level of privacy during examination and treatment % of women giving birth in the health facility who were satisfied with the level of privacy during the stay in the labour and childbirth area % of women giving birth in the health facility who reported having been treated with respect and dignity % of women giving birth in the health facility who report that they were satisfied with the health education and information they received from the care providers

PRIORITY AREAS OF INTERVENTION

OUTCOME INDICATORS

Improving QUALITY of care, health services and interactions with women, families and communities

competence of health care providers

Interpersonal

PRIORITY AREAS OF HEALTH SYSTEMS STRENGTHENING OUTPUT INDICATORS

OUTCOME INDICATORS The IFC component integrated in the maternal and newborn health programme/strategy Community participation integrated in the maternal and newborn health programme/strategy IFC component maintained in revised maternal and newborn health programme/strategy % of public budget and/or budget of international agencies dedicated to IFC component within the maternal and newborn health programme/strategy Laws and regulations in place that guarantee women (aged 15-49) access to sexual and reproductive health care, information and education*

Annex 3: List of illlustrative IFC indicators

Contributing to PUBLIC POLICIES favourable to maternal and newborn health

* Sustainable Development Goal indicator

Module 5

PRIORITY AREAS OF HEALTH SYSTEMS STRENGTHENING OUTPUT INDICATORS % of committee members who are aware of committee functioning (e.g., annual action plan, timing of meetings) Active functioning of a sub-national (regional/ provincial) intersectoral/interinstitutional IFC committee (e.g., regular meetings, annual action plan) Active functioning of a district-level intersectoral/ interinstitutional IFC committee (e.g., regular meetings, annual action plan) Functioning mechanisms of communication and coordination between the different committees (e.g., vertically between national, sub-national and district level committees, horizontally between the different regional/district level committees) % of community members who can name three activities in favour of maternal and newborn health within their community # and % of health facilities with a consultation mechanism for community members (e.g., opinions related to maternal and newborn services) # of health facilities performing activities to mobilize community actors in maternal and newborn health # of health facilities working or collaborating actively with community actors in maternal and newborn health (e.g., in-service management, service provision, resource allocation) # of districts that use participatory community assessments or a similar strategy to guarantee community participation in health services planning and management Participation of national actors in training related to the IFC component Presence of a group of trainers at the national level Presence of training programmes on the IFC component at the national/sub-national/district level Integration of the IFC monitoring and evaluation system in the existing system Evaluation results shared with stakeholders including community members Baseline/endline evaluation results used by IFC committees at different levels in the planning process Mechanisms/processes established for assuring community participation in the monitoring and evaluation process Active functioning of a national intersectoral/ interinstitutional IFC committee (e.g., regular meetings, annual action plan)

OUTCOME INDICATORS

Contributing to the COORDINATION of actions within the health sector as well as between the health sector and other sectors

Promoting COMMUNITY PARTICIPATION in the management of maternal and newborn health problems

Contributing to CAPACITY BUILDING of the health workforce in the IFC framework

Monitoring and evaluation tools for the IFC component developed and agreed upon by partners

Implementing an interinstitutional system of MONITORING AND EVALUATION for the IFC component

Annex 4: Draft guides for quarterly and annual IFC committee meetings

ANNEX 4: DRAFT GUIDES FOR QUARTERLY AND ANNUAL IFC COMMITTEE MEETINGS The following guides can be adapted and used to conduct quarterly and annual IFC meetings at the district, province and national level. They provide a general outline of areas for discussion during meetings at each level. Before using them, however, it is important to review them and assure that they will respond to local needs. Draft guide for quarterly monitoring meetings The district IFC committee is advised to meet regularly to monitor the IFC component. We suggest a quarterly meeting; however, the IFC committee may decide to meet more or less often based on their needs. The following guide can assist IFC coordinators and committee members in approaching this monitoring meeting in an organized way. (1) Review of IFC activities plan: The team reviews the activities plan containing the details concerning what activities were planned for the time period, how they were to be implemented and responsible actors. They can compare this plan with actual performance and analyse discrepancies between the two. The following questions can fuel this discussion: • To what degree have planned activities been implemented? • Are there differences between what was planned and what took place? If yes: ° How can these be explained? ° Are there problems with the implementation of interventions (their conception, management, etc.)? ° Are there problems in the environment, outside of the control of the IFC committee? ° Are there any unintended consequences, positive or negative, related to activity implementation? (2) Review of input, process and output indicators: The committee assesses the process and output indicators of the interventions as found in the logframe. It is important to note that data related to some indicators may be collected on an ongoing basis, while others will only be collected at specified times, such as during the baseline and end-line evaluations. The committee compares actual data against targets and examines variations observed between periods. The following questions can fuel this discussion: • How do actual data related to indicators compare against targets? • Are targets being reached? ° If yes: What internal and external factors are contributing to this? ° If no: Why not? Can it be explained by unanticipated factors in coordination and implementation efforts? Can it be explained by problems outside of the control of the IFC coordinators and committee? Were targets unrealistic? (3) Review of the IFC priority areas of health systems strengthening: The team then verifies that they have thoroughly considered all the components of context conducive to the implementation of the IFC framework and the improvement of MNH. This can be done by systematically considering the five priority areas of health systems strengthening, regardless of whether these have been included in the action plan:

Module 5

• Public policies: Is the IFC framework integrated into the broader MNH strategy at the district level? Does the committee need to take action to see that it is better integrated? Are local policies favourable to MNH? • Coordination: Are MNH actions within the health sector and between the health sector and other sectors well-coordinated? Are the IFC activities coordinated in these efforts? Is action required to achieve better coordination? • Community participation: Is the community actively participating in the IFC component? Is community participation present in the management of MNH overall? Is action required to promote community participation? • Capacity building of the health workforce: Is the training of health workers and other actors in topics related to MNH and the IFC framework taking place? Does this need to be strengthened? • Monitoring and evaluation: What is the status of monitoring and evaluation of IFC interventions at the district, province and national levels? Is monitoring and evaluation of the IFC component integrated in the MNH monitoring and evaluation system? Does this need to be improved? Based on this discussion, the committee can decide whether action in these areas should be taken in order to improve implementation. (4) Identification of lessons learnt: The committee discusses what lessons have been learnt during the previous quarter (see section 5) and determines whether there are lessons that should be documented for future consideration and sharing. If lessons are identified for documentation, the team agrees on what should be documented and the IFC coordinator takes responsibility to document this or delegates this responsibility to another committee member.

(5) Planning of corrective action: Finally, the committee elaborates a revised plan based on their analysis. With the analysis as a backdrop, the team reviews the action plan for the upcoming period and proposes adjustments. In addition, if the monitoring results indicate that there are significant problems or obstacles that make the achievement of the final goals of the interventions improbable, the committee may plan an evaluation to specifically analyse a certain aspect of implementation in order to address it appropriately.

Draft guide for annual district IFC meetings At the district level, the annual IFC meeting, which generally includes IFC committee members and other key stakeholders, provides a platform to: (1) Present the implementation of the IFC component and an overview of the progress throughout the previous year to partners. The district committee addresses each of the domains of the IFC component by discussing: • achievements; • the measures in which the targets have been reached; • the challenges encountered in the implementation and environment of implementation; and • solutions planned to address these challenges for the coming year/period. (2) Inform the district of the progress of the implementation of the IFC framework in the country. The national IFC committee presents the state of the implementation of the IFC framework at the country level to their district level partners. They inform them specifically of the manner in which the activities implemented locally contribute to changes in the national plan and on the

Annex 4: Draft guides for quarterly and annual IFC committee meetings

situation of the district compared to other districts. (3) Understand the opinion of the partners on the implementation of interventions. Each step of the meeting is ideally followed by a time for exchange and discussion, but a specific period of the meeting agenda will be dedicated to free expression of partners’ opinions on the implementation of the IFC component. (4) Use a spidergram or another visual tool (see section 1.3 of this module) to discuss and plot the status of the IFC implementation processes. (5) Draw lessons learnt from the experiences of the implementation of the IFC framework for the completed year in the district and formulate suggestions and recommendations for the coming period. Documented lessons from the quarterly meetings are reviewed to assess relevance and to determine those which should be retained and shared at the annual meetings at the province and national levels. The committee can also formulate additional lessons learnt from the year that did not surface during the quarterly meetings if appropriate. (6) Based on these analyses, the action plan for the coming period is reviewed and adapted. This information will be shared with other districts during the annual meeting at the national level.

• Are partners fulfilling their roles and responsibilities in the implementation of the IFC component? What are some areas for improvement? Are there areas where they could benefit from capacity building? • What changes has implementation of the IFC component contributed to? • What unanticipated complexities have been encountered? • What solutions are envisioned? • What lessons can we draw from the experiences? • What are some suggestions/recommendations? (2) Understand the opinions of partners on the implementation of the component. As during the meetings at the district level, each step of this meeting is followed by a time for exchange and discussion but it is also useful to dedicate a specific time period in the agenda for the free expression of partners’ opinions. (3) Draft the profile of the IFC framework at the national/province level. Draft a summary of implementation of the IFC component at the national/province level. The planned IFC interventions at the district level as defined in the various logframes can be compiled to demonstrate how action undertake at the national/province level intends to contribute to implementation at the local level. The committee can then jointly analyse the results of action at their level and determine whether these efforts are indeed facilitating local implementation. (4) Share lessons learnt from each district and draw lessons learnt jointly, share experiences of implementation in the country from the completed year and formulate suggestions and recommendations at a national scale to be integrated in the action plan for the coming year.

Draft guide for province/national IFC meetings The annual meeting at the national/provincial level provides the platform to: (1) Share with all actors the experiences in the implementation of the IFC component in the country. The committee of each district presents its own experience of implementing the IFC component. The following questions can help to prepare the discussion:

Module 5

ANNEX 5: DISTRICT IFC COMMITTEE ASSESSMENT TOOLS IFC SELF-ASSESSMENT QUESTIONNAIRE

This self-assessment questionnaire is designed to be completed by partners participating on the IFC committee.

Please answer honestly as your responses are anonymous and will help us to improve the work of the IFC committee.

UNDERSTANDING OF THE IFC FRAMEWORK

1. I know the primary aims of the IFC framework. They are:

Y/N

2. I can name the four priority areas of intervention of the IFC framework. They are:

Y/N

3. I can name the IFC priority areas of health systems strengthening. They are:

Y/N

Annex 5: District IFC committee assessment tools

IFC COORDINATION 4. I can name the District IFC Coordinator. The coordinator is: 5. I know who is coordinating implementation of the IFC component at the national and province levels. Please list: 6. I can name non-health sector representatives on this committee. Please list sectors represented: Y/N Y/N Y/N

7. I know when and how often meetings are held. How often are meetings held? PARTICIPATION IN IFC IMPLEMENTATION 8. I participated in developing the IFC component action plan. 9. I have seen the terms of reference for the IFC committee. One key function of the IFC committee is: 10. I have met the MNH and IFC coordinators from the province and national teams. 11. I know what my roles and responsibilities are in IFC implementation. 12. I feel that my participation is valued on the IFC committee. 13. Community participation is prioritized within the IFC committee. If yes, how?

Y/N

Y/N Y/N

Y/N Y/N Y/N Y/N

Module 5

SATISFACTION 14. How satisfied are you with your participation on the IFC committee? (1 = not satisfied, 5 = very satisfied) 15. How effective do you think communication and coordination is within the IFC committee? (1 = not effective, 5 = very effective) 16. Do you want to continue your participation on the IFC committee? Suggestions for improvement:

12345

Y/N

Thank you for your participation!

Annex 5: District IFC committee assessment tools

IFC committee assessment discussion guide

The guide below can be used to lead the IFC committee through a discussion regarding the committee functioning. This discussion will ideally be used to generate recommendations and a plan for improving coordination of implementation of the IFC component. 1. What do you see as some of the strengths of the IFC committee? 2. What do you see as some of the weaknesses of the IFC committee? 3. How do you feel about the communication and coordination within the IFC committee? 4. What could improve the communication and coordination within the IFC committee? 5. How well do you feel the IFC committee communicates and coordinates with IFC committees in different districts and at different levels (i.e. province/national levels)? 6. What could improve the communication and coordination between different committees, either between districts or between levels? 7. Do all partners know when and where meetings are held? 8. How regularly are committee meetings held?

9. Are you satisfied with the regularity of meetings? Why or why not? 10. Have you seen the terms of reference for the IFC committee? 11. Do you feel that the work of the IFC committee is in line with the terms of reference? Why or why not? 12. How many sectors are represented on the IFC committee? 13. Do other sectors outside of the health sector have equal voice and clear responsibilities? 14. What sectors not currently participating on the IFC committee could be invited to participate? 15. How is community participation assured within the IFC committee? 16. Does community participation need to be strengthened? How could it be strengthened if it needs to be? 17. Did all partners participate in developing the action plan? How is the IFC action plan used within IFC implementation? 18. What support or capacity building could the IFC committee benefit from to strengthen committee functioning?

Module 5

ANNEX 6: SAMPLE TERMS OF REFERENCE FOR EVALUATION INSTITUTION TERMS OF REFERENCE (ToR)6 EVALUATION OF WORKING WITH INDIVIDUALS, FAMILIES AND COMMUNITIES (IFC) TO IMPROVE MATERNAL AND NEWBORN HEALTH 1. BACKGROUND AND CONTEXT [The background section makes clear what is being evaluated and describes the implementation site including the MNH situation. This description should be focused, highlighting the issues most pertinent to the evaluation. The key background and context descriptors that should be included are listed below: • brief description of the IFC framework; • description of the IFC interventions that are being evaluated; • purpose and objectives of the IFC component, including when and how it was initiated, who it is intended to benefit, what outcomes or outputs it is intended to achieve, the duration of the interventions and their implementation status within that time frame; • the geographic context and boundaries, such as the region, country, landscape and MNH challenges where relevant; • key partners involved in implementing the IFC component, including IFC committee members, other key stakeholders and their interest concerns and the relevance for the evaluation; • how the IFC framework fits into the government’s strategies and priorities; international, regional or country development goals; strategies and frameworks, etc.; and 6 7

• description of how this evaluation fits within the context of the IFC implementation process. More detailed background and context information (e.g. initial funding proposal, strategic plans, logic framework or theory of change, monitoring plans and indicators) should be included in annexes.] Although the most recent assessment of global maternal deaths revealed a drop in mortality from an estimated 500,000 to 287,000 deaths per year between 1990 and 2010, the burden of mortality has remained unchanged, with 99% of maternal deaths occurring in developing countries.7 Nearly the same distribution is exhibited for the 2.9 million annual newborn deaths worldwide, with 98% in low- and middleincome countries.8 The World Health Organization (WHO) has developed a framework for working with individuals, families and communities (IFC) to improve MNH. The IFC framework is designed to form a health promotion component of a broader MNH strategy in countries. Within this framework, a combination of community, health services and policy level interventions are implemented in order to develop the capacities of women, men, families and communities to identify and address MNH needs, mobilize local resources to address these needs, and increase access to quality skilled care to ultimately improve MNH.9

Adapted from: UNDP, 2009. WHO, UNICEF, UNFPA, World Bank, 2012.

8 9

UNICEF, WHO, World Bank, UN, 2013. WHO, 2010.

Annex 6: Sample terms of reference for evaluation institution

The following four priority areas form the basis of interventions identified within the IFC framework: 1) Developing capacities to stay healthy, make healthy decisions and respond to obstetric and neonatal complications: including care of pregnant women and newborns, careseeking behaviour related to MNH services and birth preparedness and complication readiness; 2) Increasing awareness of the rights, needs and potential problems related to MNH: including awareness of human and reproductive rights, the role of men and other influentials, and use of community epidemiological surveillance and maternal-perinatal death reviews; 3) Strengthening linkages for social support between women, families and communities and with the health delivery system: including community financing and transport schemes, maternity waiting homes and the role of traditional birth attendants within the health system; 4) Improving quality of care, health services and interactions with women and communities; including community involvement in the quality of care, a companion of choice during childbirth and interpersonal and intercultural competence of health care providers. Through a participatory planning process, several interventions within the framework that respond to local needs and resources are selected and then implemented. These community prioritized interventions are integrated into ongoing activities to address MNH services and they may ultimately affect policy. As a result, women and communities are empowered to improve the care of women before, during and after childbirth as well as newborns, while simultaneously increasing the use of skilled care during this period, thus improving MNH.

In addition to the four priority areas of intervention, five priority of health systems strengthening are identified within the IFC framework that serve to contribute to an environment conducive to implementation of action within the areas of intervention and also contribute directly to the primary aims of the IFC framework. They are as follows:

1) Contributing to PUBLIC POLICIES favourable to MNH; 2) Contributing to the COORDINATION of actions within the health sector as well as between the health sector and other sectors; 3) Promoting COMMUNITY PARTICIPATION in the management of MNH problems; 4) Contributing to CAPACITY BUILDING of the health workforce in the IFC framework; 5) Implementing an interinstitutional system of MONITORING AND EVALUATION for the IFC component. Robust evaluations are required to assess the contributions of the implementation of the IFC component in reaching planned outcomes and outputs, and in improving MNH. It is expected that these evaluations will be used nationally to guide MNH programming and scaling-up of the framework as well as contribute to the body of evidence regarding the IFC framework and Health Promotion in MNH.

[To add detailed information on the implementation site and interventions specific to the context.]

Module 5

2. EVALUATION PURPOSE [This section should explain clearly why the evaluation is being conducted, who will use or act on the evaluation results and how they will use or act on the results. A clear statement of purpose provides the foundation for a welldesigned evaluation.] The purpose of the evaluation is to measure and asses the changes in knowledge, attitudes and practices, particularly MNH services utilization, associated with the implementation of the IFC component. The results will be used to make strategic decisions by stakeholders in relation to the IFC implementation and will contribute to the body of knowledge regarding the IFC framework and safe motherhood programming.

3. EVALUATION OBJECTIVES [This section states the general and specific objectives of the evaluation. These will be formulated based on the goal and planned outcomes designated in the logframe.] General objective: • To assess the contribution of the IFC component to the improvement of MNH and to the empowerment of women, families and communities Specific objectives: • To measure changes in MNH knowledge and household level care practices of women and their male husbands/partners pre- and post-intervention • To evaluate changes in care-seeking practices during pregnancy, birth and the postpartum/ postnatal period pre- and post-intervention • To assess functioning and change within the IFC priority areas of health systems strengthening

4. EVALUATION QUESTIONS [Evaluation questions define the information that the evaluation will generate. This section proposes the questions that, when answered, will give intended users of the evaluation the information they seek in order to make decisions, take action or add to knowledge. Evaluation questions must be agreed upon among users and other stakeholders and accepted or refined in consultation with the evaluation team.] • Were stated outcomes and/or outputs achieved? • What factors have contributed to achieving or not achieving intended outcomes? • Has the intersectoral and interagency collaboration strategy within the IFC framework been appropriate and effective? • What factors have contributed to effectiveness or ineffectiveness?

Annex 6: Sample terms of reference for evaluation institution

5. METHODOLOGY [The final decisions about the evaluation design and methods should be made jointly by the IFC committee, the evaluators, and key stakeholders. Together they will determine what is appropriate and feasible to meet the evaluation purpose and objectives and answer the evaluation questions, in light of limitations of budget, time and existing data. It is important to keep the principles of participation in mind when designing the methodology.] The final decisions regarding methodology will be made jointly by the evaluators and the IFC committee. A mixed-methods approach employing both quantitative and qualitative methods is requested in order to provide a more complete picture of the results and challenges in IFC implementation. The IFC committee requests that the evaluators prioritize the participation of multiple stakeholders, including the community, throughout the evaluation.

6. EVALUATION DELIVERABLES [The evaluators will be responsible for producing the documents listed in this section and submitting them to the IFC committee.] The evaluators will be responsible for submitting the following to the IFC committee for the baseline, intermediate and end-line evaluations: • an evaluation protocol: specifying the expected results of the study, the methodology, a proposed work plan and a Gantt chart. A draft of the protocol will be submitted to the IFC committee before being finalized. The protocol is an important document that will assure the quality of the evaluation; • a draft report: a draft report of the study should be submitted to the IFC committee two weeks after the completion of field work. The different stakeholders will have one week to provide comments on the draft report; • an oral presentation: in the presence of the IFC committee; • an executive summary: the analytical executive summary should be a maximum of five pages and should be able to stand on its own. It should be organized according to the following format: Introduction, Methods, Principal results, and Conclusions; • a final report: the final report includes the executive summary (5 pages) and the details of the study (maximum 50 pages). [A format for the final report may be provided in the annex.]

7. EVALUATION TEAM REQUIRED COMPETENCIES [This section details the specific skills, competencies and characteristics needed in the evaluator or evaluation team specific to the evaluation. The section also should specify the type of evidence that will be expected to support claims of knowledge, skills and experience. The ToR should explicitly require that the evaluator be free from conflicts of interest.] The evaluator should: • be competent in conducting scientifically rigorous evaluations/implementation research; • be competent in conducting community-level evaluations/implementation research;

Module 5

• have experience in social science research methods; • have experience and knowledge in MNH; • have experience in participatory monitoring and evaluation; and • have no conflicts of interest related to the evaluation.

Members of the evaluation team should provide the following: • current curriculum vitae; • references; • work samples, if requested.

8. EVALUATION ETHICS [The ToR should clearly outline how ethical approval will be obtained and how participants will be protected, including the process of obtaining informed consent.] As the evaluation will include human subjects, measures will need to be taken to ensure that ethical requirements are met in order to protect participants. Central to protecting participants will be obtaining informed consent. Researchers will inform potential participants of the scope of the study, the type of questions that may be asked, how the results will be used, how the participants’ words may be used in reports, the method of keeping participants anonymous that will be employed, and that they may withdraw consent and discontinue participation at any time. After having been thoroughly informed, potential participants will then be given time to reflect and ask questions to the researcher before signing a written consent form. The consent form will be translated into the local language and illiterate participants will be thoroughly briefed on the contents of the informed consent form and may sign using their fingerprint. Two consent forms will be signed by each participant and a member of the research team. The research team will keep one of the forms while the other form will be retained by the participants for their personal records. Consenting participants will be informed that they may withdraw consent and discontinue participation at any time. Ethical approval will be obtained from the necessary institutions (national, intra-institutional, WHO, etc.) prior to data collection.

9. ROLES AND RESPONSIBILITIES [This section defines the roles and responsibilities of all parties involved in the evaluation process. This will include the evaluators, the IFC committee and any other institutions or parties participating in the evaluation. Clarifying this in the ToR is intended to eliminate ambiguities and facilitate an efficient and effective evaluation process.] Evaluator responsibilities: • review and comment on the ToR; • elaborate the evaluation protocol detailing the study design, methodology, tools to be developed, data analysis, etc.; • prepare guidelines and questionnaires;

Annex 6: Sample terms of reference for evaluation institution

• recruit and train staff; • develop evaluation instruments for data collection (to be reviewed by the IFC committee before finalization); • manage the evaluation operations; • administer evaluation instruments; • review documentation; • submit deliverables to the IFC committee; and • adhere to the timeline of the consultancy.

IFC committee responsibilities: • draft the ToR for the evaluation team; • brief the evaluators on the purpose and scope of the evaluation and explain expectations of the IFC committee and other stakeholders in terms of the required quality standards of the conduct of the evaluation and the deliverables; • provide all necessary information to the evaluators; • arrange interviews, meetings and field visits when requested; and • provide comments on and assure the quality of the work plan and the inception report prepared by the evaluation team.

10. TIMELINE FOR THE BASELINE/END-LINE EVALUATIONS [This section describes the timeline for the baseline and end-line evaluations, listing when various activities related to the evaluation will MONTH 1

be conducted, including the data collection, data analysis and submission of deliverables.] MONTH 2 MONTH 3 MONTH 4 MONTH 5

ACTIVITIES

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Preparation of protocol Submission of protocol Recruitment and training of staff Quantitative data collection Qualitative data collection Data transcription and coding Data analysis Report preparation Submission of 1st draft of report Final report submission

Module 5

11. COSTS [This section should indicate the total dollar amount and other resources available for the evaluation. It is not meant to be a detailed budget but should provide the evaluators with an understanding of financial limitations so they can propose an appropriate and feasible evaluation methodology. If the available amount is not sufficient to ensure a high-quality evaluation, discussions can take place between the evaluators and the IFC committee early on in the process.]

12. ANNEXES [Other relevant information should be included as annexes. These could include: • a list and contact information of IFC partners and key stakeholders; • documents to be consulted before finalizing the evaluation protocol (e.g. IFC framework documents, intervention reports, MNH national strategy documents, the logframe and activities plan, memorandums of understanding (MOUs) among partners, previous evaluations and assessments); • evaluation matrix: this is a tool that details the questions that the evaluation will answer, indicators, data sources, data collection, analysis tools or methods appropriate for each data source, and the standard or measure by which each question will be evaluated; • format for the evaluation report.]

Annnex 7: Documentation form for lessons learnt

ANNEX 7: DOCUMENTATION FORM FOR LESSONS LEARNT The form below can be used to document lessons learnt throughout the course of IFC implementation. Lessons to document and information to include will generally be agreed upon during IFC committee meetings.

DOCUMENTATION OF LESSON LEARNT GENERAL INFORMATION Title: [Working with Individuals, Families and Communities (IFC) to improve maternal and newborn health (MNH)] Time period of lesson: Country: Province: District: Date of recording: IFC Coordinator: Address: Phone: Email: Which priority area of intervention/health systems strengthening is concerned?

What activities were conducted during the period?

What went well?

Module 5

What challenges were faced?

What solutions were put into place to address these challenges?

What were the results?

Please provide a generalizable summary of the lesson learnt.

Department of Maternal, Newborn, Child and Adolescent Health 20 Avenue Appia 1211 Geneva 27 Switzerland E-mail: mncah@who.int Website: http://www.who.int/maternal_child_adolescent/en/

ISBN 978 92 4 150852 0

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health

A Toolkit for Implementation Module 1: An Overview of Implementation at National, Province and District Levels

Working with Individuals, Families and Communities to Improve Maternal and Newborn Health:

A Toolkit for Implementation

Module 1: An Overview of Implementation at National, Province and District Levels

Module 1

CONTENTS Acronyms ............................................................................................................................................................ The Story of the Toolkit ...................................................................................................................................... Introduction to Module 1 .................................................................................................................................... 1. Overview of the IFC Framework .................................................................................................................. 1.1 Principles of the IFC Strategic Framework.............................................................................................. 1.2 IFC Framework Priority Areas of Action ................................................................................................. 1.3 IFC Priority Areas of Intervention............................................................................................................. 1.4 IFC Priority Areas of Health Systems Srengthening................................................................................ iv v 1 4 4 6 7 9

1.5 How IFC fits into the Broader MNH Strategy .......................................................................................... 10 2. National and Provincial Support to IFC Implementation ............................................................................ 11 2.1 The IFC “Implementation Framework”.................................................................................................... 11 2.2 What do we mean by National, Province and District Levels? ................................................................ 13 2.3 Orientation to the IFC Framework at the National Level........................................................................ . 14 2.4 National and Province IFC Coordination ................................................................................................ . 14 2.5 Advocacy and Partnership Building........................................................................................................ . 15 2.6 Incremental Implementation of the IFC Component .............................................................................. 17 2.7 Inventory of Ongoing Initiatives Related to IFC Work ............................................................................. 17 2.8 Site Selection for Initiating IFC Implementation .................................................................................... . 17 2.9 Adaption of the Process and Methodology ............................................................................................. . 18 2.10 Ongoing Support to the District Level ................................................................................................... 19 2.11 Planning Interventions at National and Province Levels ...................................................................... 20 2.12 Mechanisms for Comunication and Exchange ...................................................................................... 21 2.13 Monitoring and Evaluation at National and Province Levels ................................................................ 21 2.14 Documenting Lessons Learnt ............................................................................................................... 21 2.15 “Vertical” Scaling-up: Institutionalization of the IFC Framework and Participatory Methods............. 22 2.16 “Horizontal” Scaling-up: the IFC Framwork to other Districts and Provinces ..................................... 22 3. Overview of the IFC Framework at the District Level ................................................................................. 24 3.1 Community Participation in Health Planning ......................................................................................... 24 3.2 Orientation to the IFC Framework at the District Level .......................................................................... 26 3.3 Advocacy and Partnership-Building at the District Level ....................................................................... 26 3.4 District IFC Coordination Committee ...................................................................................................... 26 3.5 The Local IFC Coordinator ....................................................................................................................... 28 3.6 Conducting the PCA ................................................................................................................................. 29 3.7 The Joint Planning Proccess ................................................................................................................... 30 3.8 Participatory Implementation, Monitoring and Evaluation ..................................................................... 31 3.9 Institutionalizing the IFC Framework and Participatory Methods into Ongoing Programming at the District Level .................................................................................................................................. 31 3.10 Summary of Steps for IFC Implementation .......................................................................................... 32 References .......................................................................................................................................................... 35 Annexes .............................................................................................................................................................. 38 Annex 1: Terms of Reference ........................................................................................................................ 39 Annex 2: IFC Implementation Timeline ......................................................................................................... 44

ACRONYMS IFC MMR MNH MoH NGO PAHO PCA UN UNICEF WHO Individuals, Families and Communities (In reference to the World Health Organization’s framework for Working with Individuals, Families and Communities to Improve Maternal and Newborn Health) Maternal mortality ratio Maternal and newborn health Ministry of Health Non-governmental organization Pan American Health Organization Participatory community assessment United Nations United Nations Children’s Fund World Health Organization

Tell us what you think! All comments on this document are welcome. Please let us know if you find the content useful, your experience in using this guide, if there is any information missing, if there is anything else you would add to this guide. Please send all comments to the Department of Maternal, Newborn, Child and Adolescent Health (MCA), World Health Organization (WHO), Geneva, to mncah@who.int.

Module 1

Please see http://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/

The Story of the Toolkit

Module 1

vii

Module 1

INTRODUCTION TO MODULE 1 This document is the first module of a series entitled Working with individuals, families and communities to improve maternal and newborn health: a toolkit for implementation, designed to support the implementation of the World Health Organization (WHO) framework “Working with individuals, families and communities (IFC) to improve maternal and newborn health”,2 herein referred to as the “IFC framework.” The IFC framework, originally elaborated in 2003, was developed in response to the observation that a robust and systematic health promotion component was largely absent from most maternal and newborn health (MNH) strategies in countries. Grounded on the foundational principles of health promotion as outlined in the Ottawa Charter,3 the framework and the interventions it proposes were formulated based on an examination of evidence and successful experiences in working with individuals, families and communities to improve MNH. This evidence was updated in 2015 and we refer the reader to the publication WHO recommendations on health promotion interventions for maternal and newborn health, available at http://who. int/maternal_child_adolescent/documents/ health-promotion-interventions/en/. To date, the IFC framework has been implemented in a number of countries spanning the six world WHO regions, including: Bangladesh, Burkina Faso, Colombia, El Salvador, Guatemala, Haiti, Kazakhstan, Lao People’s Democratic Republic and the Republic of Moldova. The aim of the toolkit is to support public health programmes in launching a process to work with and empower individuals, families and communities to improve MNH.

See the following strategic document: Working with individuals, families and communities to improve maternal and newborn health, WHO, 2010. 3 See WHO, 1986. 2

Introduction

The implementation toolkit contains five modules, as described in the following table: Module Module 1: An Overview of Implementation at National, Province and District Levels Module 2: Facilitators’ Guide to the Orientation Workshop on the IFC Framework Description An introduction to the process of initiating implementation of the IFC framework at national, province and district levels. A resource guide for conducting a workshop to orient national, province and district actors to the key concepts, processes and interventions of the IFC framework. An overview on conducting the PCA, a participatory tool designed to support districtlevel actors to assess the MNH situation and needs and to identify priority interventions for IFC implementation. A guide to support training of facilitators to conduct the PCA. A guide to support the finalization of the IFC action plan based on the PCA, including suggestions for monitoring and evaluation. Who should use this module? Although the focus of implementation efforts is at the district level, the IFC framework is designed to be integrated as a health promotion prong of a broader MNH strategy. As such, operationalization of the framework is facilitated by the actions and the leadership of actors at the national and province levels. This module is designed with programme managers and MNH actors at national, province and district levels in mind to assist them in launching an effective IFC strategy.

Module 3: Participatory Community Assessment in Maternal and Newborn Health (PCA)

Module 4: Training Guide for Facilitators of the Participatory Community Assessment (PCA) in Maternal and Newborn Health Module 5: Finalizing, Monitoring and Evaluating the IFC Action Plan

This first module of the toolkit, “An overview of implementation at national, province and district levels”, provides guidance on initiating implementation of the IFC framework in a country. The module contains a brief overview of the IFC framework and its objectives, and then presents steps that will facilitate implementation at the national, province and district levels.4 The process presented is intended to be used the first time that the framework is introduced in a country or province. Certain aspects will be adapted once a country has experience in participatory processes and in integrating the IFC framework into the broader MNH strategy.

The definitions of national, province and district are presented in section 2.1.

Module 1

Adapting the process The process outlined in this guide is a suggested one and is intended to be approached with flexibility. Participating actors are encouraged to review its contents and then adapt the process within each country to suit the national and local context. Although the proposed steps will help to ensure the successful implementation of the IFC framework, each country must take into account its ongoing strategies and initiatives, and coordinate efforts.

Structure of the module Section 1 presents an overview of the IFC framework and its role within an MNH strategy. Section 2 outlines a process of IFC implementation at the national and province levels. Section 3 describes a process of IFC implementation at the district level.

1. OVERVIEW OF THE IFC FRAMEWORK 1.1 PRINCIPLES OF THE IFC STRATEGIC FRAMEWORK Based on the principles of health promotion as outlined in the Ottawa Charter (1986), the WHO IFC framework emphasizes working with individuals, families and communities as a critical link in ensuring the recommended continuum of care throughout pregnancy, childbirth and after birth for women and newborns. The continuum of care is optimized when it extends from the woman, the household and the community to the health provider and health services, and includes access to a skilled attendant at birth. The continuum of care also requires access to the appropriate services when obstetric and neonatal complications arise, which is one of the most critical health care delivery determinants for the survival of mothers and newborns. However, the availability of services alone will not improve MNH where there is no possibility for women, men, families and communities to make and act on health-promoting decisions. The IFC framework emphasizes the positive and active role that individuals and groups can play to improve health, as well as the wide array of influences on health, including social, cultural and economic determinants. Within this perspective, individuals, families and communities are an essential component of the health system (see Fig. 1.1).5 Box 1.1: Aims of the IFC framework: 1. To contribute to the empowerment of individuals, families and communities to improve maternal and newborn health. 2. To increase access to and utilization of quality health services, particularly those provided by skilled birth attendants.

Fig. 1.1: Individuals, families and communities within the health system

Health system

Individuals, families and communities

Maternal and newborn health strategy

Health services provision

In accordance with the WHO Framework for Health System Performance Assessment (1999), individuals, families and communities in their decisions and actions for health and their expectations of health services are important actors and resources of health systems.

Module 1

The IFC framework is designed to be integrated as a health promotion component of the national MNH strategy. It aims to complement its other pillars, including health services strengthening and policy development. The IFC framework, like health promotion, is anchored within a rights-based approach to health. A rights-based approach recognizes that effective and sustainable development occurs only when people participate in designing the policies, programmes and strategies that are meant to benefit them. The involvement of the community in setting priorities and designing, implementing and evaluating programmes and actions relevant to health is not only a right – it also leads to more effectively meeting the community’s needs. This participation is also key to empowerment (see more below), which is essential for individuals to claim their rights. At the heart of a rights-based approach is addressing unjust power relations, rooting out inequity, including gender inequity, and empowering individuals to participate in and control the resources fundamental to their well-being. Increasingly, the international community is recognizing that preventable maternal mortality and morbidity is not only a matter of development, but first and foremost a matter of human rights. As such, creating the conditions in which women can experience pregnancy and childbirth safely is not charity but is fundamental to assuring their basic human rights. Governments are under obligation to respect, protect and fulfil these rights to which women have legitimate claim. The following seven human rights principles have been identified as fundamental to addressing preventable maternal morbidity and mortality: accountability, participation, transparency, empowerment, sustainability, international cooperation and non-discrimination.6

The IFC framework aims to directly impact the principles of participation and empowerment, while indirectly impacting the other principles throughout the implementation process. Empowerment within the IFC framework is recognized as an end in itself as well as a process to help achieve increased access to and utilization of health services. Empowerment can be understood as the process of increasing capacity of individuals or groups to make choices and to transform these choices into desired actions or outcomes.7 This occurs at both the individual and the collective levels as women, families and communities become aware of their rights and needs related to MNH and take action to address them. One way to contribute to the empowerment of individuals, families and communities is to enlist their participation throughout the health programming cycle, beginning at planning and continuing through the implementation of interventions, monitoring and evaluation. The participatory community assessment (PCA) is a suggested tool that can be used to initiate empowerment processes by engaging community members at the outset of planning at the district level (see Modules 3 and 4). Module 5 provides insight on maintaining participation throughout the subsequent stages of IFC planning, monitoring and evaluation. All those embarking on a process to work with individuals, families and communities to improve MNH are advised to read the IFC framework strategic document and become familiar with its principles and recommended interventions. The document can be accessed at : http://www. who.int/maternal_child_adolescent/documents/ who_fch_rhr_0311/en/index.html

See See Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights, 2010. 7 See Alsop and Bertelsen, 2006. 6

Section 1: Overview of the IFC framework

1.2 IFC FRAMEWORK PRIORITY AREAS OF ACTION The IFC framework aims to empower at the community level, and thus the focus of actions within the framework is at the district level. However, experience has shown that simultaneous efforts to strengthen the health system optimize the effectiveness of the district level interventions. These efforts pave the way for scaling up the IFC framework and foster sustainability of the processes and results. Therefore, within the framework four priority areas of intervention and five priority areas of health systems strengthening have been identified. This combination of actions works synergistically to contribute to change in the primary aims of the framework, which are ultimately to improve MNH, and contribute to the broader goals of the survive, thrive and transform agenda as outlined in the Global strategy for women’s, children’s and adolescents’ health (2016-2030) 8 (see Fig. 1.2).

Fig. 1.2: IFC framework objectives and priority areas IMPROVE MATERNAL AND NEWBORN HEALTH (MNH)

Available from: http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1

Module 1

1. 3 IFC PRIORITY AREAS OF INTERVENTION The main areas for action at the district level are grouped into four IFC priority areas of intervention (see Fig. 1.3). The priority areas of intervention provide a context for thinking about and exploring the different domains in which action will ideally be taken – capacities, awareness, linkages and quality. The interventions were identified in 2003 based on a review of the literature and country programmes experiences and through discussions in an expert meeting. These interventions are discussed in more detail in the IFC framework strategic document. In addition, the evidence base for these interventions and for the participatory approach embraced in this Toolkit has recently been updated by WHO. (Please see WHO recommendations on health promotion interventions for maternal and newborn health 2015.9)

Fig. 1.3: Interventions in the four IFC priority areas of interventions Priority areas of intervention Developing CAPACITIES to stay healthy, make healthy decisions and respond to obstetric and neonatal emergencies • Self-care/care in the household* • Care-seeking behaviour* • Birth preparedness and complication readiness Increasing AWARENESS of the rights, needs and potential problems related to maternal, newborn health • Male involvement and family support • Promotion of human, sexual, and reproductive rights† • Community participation in maternal death surveillance and response† Strengthening LINKAGES for social support between women, families and communities, and with the healthcare delivery system • Partnership with traditional birth attendants • Maternity waiting homes‡ • Communityorganized transport schemes§ • Community mobilization through participatory learning and action cycle with women’s groups Improving QUALITY of care, health services and interactions with women, families and communities • Community participation in quality-improvement processes • Companion of choice at childbirth • Providing culturally appropriate skilled maternity care • Interpersonal competence of healthcare providers*

Interventions

*Health education and counselling were not specifically reviewed in the 2015 systematic review; however, these interventions are recommended and supported by other WHO documents. †Evidence regarding these interventions is limited, which led to a research recommendation in the 2015 publication; however, these interventions are recommended as a matter of principle while awaiting further data. ‡Recommended to be established close to a health facility where essential childbirth care and/or care for obstetric and newborn complications is provided for populations living in remote areas or with limited access to services. §Recommended to be implemented with caution in settings where other sources of transport are less sustainable and not reliable. However, measures should be taken to ensure the sustainability, efficacy and reliability of these schemes while seeking long-term solutions to transport.

Within the IFC framework, developing capacities refers to the reinforcement of competencies oriented towards self-care and care of women during and after pregnancy and newborns in the home. These include healthy lifestyle, care-seeking behaviour and responding to obstetric and neonatal complications. This area of intervention arises from the assumption that women, families and communities have capacities related to MNH and that appropriate 9

interventions can strengthen these capacities and develop those that may be lacking. Greater awareness means that all stakeholders recognize that safe motherhood, safe birth and access to quality care are human rights. Governments have a legal obligation to assure that these rights are respected, protected and fulfilled. In addition, a broad array of other actors in the home and the community can participate

Available from: http://www.who.int/maternal_child_adolescent/documents/health-promotion-interventions/en/

Section 1: Overview of the IFC framework

in assisting women and families in exercising these rights. Increasing awareness is a first step in building the capacities of women to demand their rights and in building the capacity of government and other actors in fulfilling their obligations. Moreover, when community members are aware of the causes of maternal and newborn mortality and morbidity, they understand that these are often preventable. Increased awareness of the health needs and potential problems of pregnant women, mothers and newborns permits individuals, families and communities to become involved in actions to address these needs and problems. It is also the right of community members to have access to key MNH information. Strengthening linkages among social networks can result in greater social support among women, men, families and communities. It also promotes the relationship between such social networks and the health service delivery system. These social and health networks enhance community capacity to participate in the resolution of problems and increase access to MNH services. Finally, the quality of care provided by health services influences the decisions of community members to seek these services. Involving the community in defining and monitoring services can contribute to reorienting services so that they are culturally appropriate and respond to local needs. Creating a warm and welcoming environment for women and families by allowing a companion of choice at childbirth and developing the capacities of health service providers to interact with women and families can also influence community perceptions of health services. Note that within the IFC framework, improving quality is addressed from the perceptions of women and the community in order to increase demand for skilled care. It is assumed that other quality issues will be addressed through other components of the MNH strategy.

The interventions implemented may include education (health education through alliance with the education sector), community action for health, partnerships, institutional strengthening and local advocacy. The complex nature of MNH, and of empowering individuals, families and communities at the local level, requires an integrated approach, with interventions from each of the four priority areas, and an intersectoral approach, in particular with education, transport, sanitation and incomegenerating programmes. MNH programme managers and IFC partners are encouraged to implement at least one intervention from each priority area to promote a synergistic effect and to assure that each area is taken into account. This will maximize the health promotion effort at the local level.

Module 1

1. 4 IFC PRIORITY AREAS OF HEALTH SYSTEMS STRENGTHENING In order for the IFC component to be effectively integrated into the health system and ensure an environment conducive to local implementation, it is equally important for programmes to consider and plan efforts within five IFC priority areas of health systems strengthening. Strengthening the health system within these areas will also contribute directly to the primary aims of the IFC framework. Moreover, action in these areas will serve to reinforce the broader health system, pave the way for scaling up and foster sustainability of the IFC initiative. Contributing to public policies favourable to MNH involves efforts to integrate the IFC component or some of its elements into public policies designed for MNH. These efforts effectively ensure that health promotion is an integrated component of the MNH strategy. Ideally it will not only be included in policy, but financial resources will also be secured to implement it. Contributing to the coordination of actions within the health sector, as well as between the health sector and other sectors, refers to efforts to assure that the IFC component is implemented as an integrated component of the MNH programme. These efforts will largely be facilitated through building and strengthening IFC committees at the national, province and district levels (see sections 2.4 and 3.4). Promoting community participation in the management of MNH problems within the IFC framework not only includes giving community members a voice throughout implementation, but also institutionalizing community participation within the health system. This may include establishing mechanisms and processes for the participation of community actors in MNH programmes or building the capacity of the health services to collaborate actively with community members and to use participatory planning processes, such as the PCA. Contributing to capacity building of the health workforce is critical in order to assure the presence and availability of actors proficient in implementation and management of the IFC component. Capacity building will often take the form of training actors at the district, province and national levels. Implementing an inter-institutional system of monitoring and evaluation will allow for measuring and assessing the processes and results of the IFC component. The findings can inform decision-making, advocate for further support and pave the way for scaling up. IFC monitoring and evaluation will ideally be integrated in the existing monitoring and evaluation system for MNH. It will often be advisable for programme managers to take explicit steps to integrate IFC monitoring and evaluation into the existing system and strengthen the system overall. It is also important that IFC monitoring and evaluation allow for the participation of community and institutional actors. Module 5 of this toolkit provides more details on IFC monitoring and evaluation. While we suggest that action be taken in each of the four priority areas of intervention, explicit action may not be necessary in each priority area of health systems strengthening. Programme managers and IFC partners are advised to consider each of the areas of health systems strengthening in order to identify where specific measures would be beneficial for reinforcing the system. Regardless of where programme managers decide to focus their efforts within these areas, we strongly encourage partners to assess these areas on a recurring basis in order to identify when action is needed.

Section 1: Overview of the IFC framework

1. 5 HOW IFC FITS INTO THE BROADER MNH STRATEGY The IFC framework is an important component of the broader national or sub-national MNH strategy. It is not intended to be implemented as an isolated set of interventions, but is complementary to a range of other critical MNH areas of work including: (a) achieving political commitment (b) promoting a favourable policy environment (c) ensuring adequate financing (d) strengthening health care services (e) empowering individuals, families and communities (f) strengthening monitoring and evaluation for decision-making The identified interventions that are conducted outside of a broader MNH strategy will be less likely to achieve the stated objectives. This would also be true for an exclusive focus on improving health services without the IFC efforts. Improved care in the home and an increase in the demand for services require an effective, high quality and sustainable response from the health sector to respond to the newly created demand. Ideally, efforts in all areas of a comprehensive MNH strategy will be undertaken simultaneously to maximize the impact on MNH.

Module 1

2. NATIONAL AND PROVINCIAL SUPPORT TO IFC IMPLEMENTATION 2.1 THE IFC “IMPLEMENTATION FRAMEWORK” Although the focus of IFC activities is at the district level, the first steps of IFC implementation will occur at the national level when possible. District actions, then, can be supported by and integrated into national and provincial MNH strategies and actions. Fig. 2.1 illustrates the IFC implementation framework, outlining the five phases of the process occurring at the district level, as well as the support activities designed to be undertaken at province and national levels. Before discussing in detail the activities outlined in Fig. 2.1, it is important to point out that the framework contains a process for IFC implementation that is to be used the first time the framework is integrated into a national, provincial or district MNH strategy. As will be discussed in more detail below, we suggest undertaking IFC implementation in one or two districts initially. Experience with IFC implementation and with other participatory processes has exhibited that the initial implementation in a country will have its challenges and can be resourceintensive, but that the process becomes easier with experience.10 Careful monitoring and documentation of lessons learnt can facilitate fine-tuning of the process and subsequent scaling up of the framework (see sections 3 and 4 of Module 5). The district (defined in the next section) is the focus of IFC activities as it is the most fullyorganized unit of local government that is small enough for health staff to observe and understand important problems and developments. As such, working at this level offers important opportunities for action to improve the health of women and newborns. Benefits of working at the district level include the availability of intersectoral mechanisms, a network of health facilities with at least a district hospital, the presence of non-governmental organizations (NGOs), and other informal mechanisms that enable registering maternal deaths.11 It is also important that the national team have a national vision of IFC implementation from the outset. This means ensuring scale-up mechanisms that support institutionalization and expansion are integrated into the design from the beginning. As the component is scaled up to cover new areas, the initial model may need to be modified to make implementation achievable. Careful evaluation of the priority areas of health systems strengthening and planning actions in these areas will facilitate sustainability and scaling-up. Some considerations and some possible strategies for scaling up the IFC framework are discussed further in sections 2.6, 2.15 and 2.16. Countries need to consider how far they want to decentralize and what are the most efficient ways to organize the work at different administrative levels. For example, it may not be feasible, or advisable given the resources required, for all districts in a province to conduct their own PCA. Instead the results of the PCA from a neighbouring district can be discussed and used to inform planning of interventions (see section 2.16 of this module and Module 3; section 1.5). The activities for IFC implementation at the national and province levels described in this section are also outlined in the chart found in Annex 2.

10 11

See MSPAS, 2006 and Ottolenghi et al., 2007. See Tarimo, 1996.

12 Fig. 2.1: IFC implementation framework12 DISTRICT LEVEL: PHASE 3: Joint planning process • District committee designs interventions based on IFC framework • Budget and action plan • Resource mobilization • Selection of indicators • Coordination • Monitoring PHASE 4: Participatory implementation PHASE 5: Participatory evaluation • Process and impact evaluation

AWARENESS-RAISING

SKILLS-BUILDING

RESOURCE MOBILIZATION

PHASE 1: IFC Preparation

PHASE 2: Participatory Community Assessment (PCA)

• Orientation workshop • IFC coordination • Advocacy & partnership building • PCA preparation (presentation to community, identifying facilitators, adapting instruments)

Explore health needs and set priorities:

• Situation analysis • Training workshop • Five roundtable discussions • Institutional forum • Final report

PROVINCE AND NATIONAL LEVELS: Ongoing activities • Advocacy and partnershipbuilding • IFC coordination • Ongoing support to district level • Integration of IFC component and participatory methods into ongoing planning process Scale-up activities • Documenting lessons learnt • Monitoring and evaluation • Scale-up strategy design • Mechanisms for communication and exchange (between districts, provinces and internationally)

Initial activities

• Advocacy and partnershipbuilding • Orientation on IFC framework • Incorporation of IFC component within national and district health strategies • Site selection for district implementation

Note: This image depicts the process of an initial implementation experience of IFC in a district. For subsequent districts in a selected province, a modified process may be desired (see section 2.15).

Module 1

2.2 WHAT DO WE MEAN BY NATIONAL, PROVINCE AND DISTRICT LEVELS? Countries have differing political and organizational boundaries, and they organize their health system and structures following various models. Health policy decision-making occurs at different levels of the health system depending on the context, including the level of decentralization and management policies. The structure and terminology of IFC framework implementation described throughout this toolkit will need to be adapted to the specific situation of each particular country. The processes and structures described in this document are based on the following assumptions and terminology: • The national level includes actors from the national Ministry of Health (MoH) as well as partners from other national government agencies, national NGOs, universities, WHO and other United Nations organizations, and other international agencies. We assume that the MoH determines national health strategies and policies that will be adapted and implemented at the other levels of the system. This includes the decision to incorporate an IFC component into the national MNH strategy and policies. In large nation states, however, the MoH may have little involvement in IFC activities, and most responsibility will be assumed by a state, sub-national or regional body that has an important and independent role. • The province level corresponds to a sub-national geographical region, state, or governorate with a functioning provincial health authority. The provincial health authority oversees and supports the functioning of the district health authorities. • The district level (WHO, 1988) corresponds to a local political authority within a province, usually with a town or small city as its administrative centre. It is generally politically administered by an elected district authority (such as a mayor or local governor), while health services are organized by a district health authority, under the supervision of the provincial and/or national health authority. When considering the ideal “level” for IFC implementation, the population of the district would be between 50,000 and 100,000 in order to facilitate local accountability and ownership of the interventions and to capture true local community experiences in the assessment process. If the district populations in a province are considerably larger than this, those responsible for implementing the IFC component may choose to use the next lowest administrative level (such as a ward or sub-district) as the focus for IFC implementation. If the populations are considerably smaller than 50,000, there may not be sufficient management capacity to effectively organize and implement the IFC component. When determining coordination and management mechanisms for implementation of the IFC framework, the responsible programme managers and partners will need to carefully consider where and by whom decisions are made. The teams must also take into account the requirements for scaling-up the IFC component, and the implications for action at different levels.

Section 2: National and provincial support to IFC implementation

2.3 ORIENTATION TO THE IFC FRAMEWORK AT THE NATIONAL LEVEL It is important to orient key stakeholders at the national level to the IFC framework and its interventions before embarking on the process. A short workshop (2 to 3 days) involving relevant programme managers from the MoH, other relevant ministries (e.g. education), as well as NGOs working in MNH is important to introduce the key concepts of the IFC framework and the different steps of implementation. This meeting will help orient those involved at the national level to the IFC framework and their potential roles in implementation. Module 2 of this toolkit contains an orientation package to help conduct this workshop. As already mentioned, the IFC framework is designed to be integrated into a broader national or sub-national MNH strategy. Options for integration include the following depending on the status of the country’s MNH strategy: 1. If the national or sub-national MoH is developing or revising an MNH strategy: Programme managers and decision-makers can be oriented to the IFC framework, which may subsequently be used to support the development of the health promotion and community component of the overall MNH strategy. This gives those working on the IFC component a clear mandate to proceed with implementation. 2. If the MoH is in an interim period of MNH strategy development: An orientation workshop on the IFC framework (see Module 2) can be organized by the MoH or otherkey actors and policy-makers working within MNH with support from WHO. If the decision-makers feel it is important to proceed with IFC implementation before the development of a new national MNH strategy, they can plan and coordinate how the IFC component will fit with other MNH components, policies and interventions.

2.4 NATIONAL AND PROVINCE IFC COORDINATION After an initial national orientation, the national actors involved are encouraged to plan out a process of IFC coordination. Ideally, the MoH will take a lead role in IFC implementation in order to ensure integration into both the broader MNH strategy as well as other standard health planning processes, in partnership with other organizations and actors working in MNH. Focusing on the IFC priority areas of health systems strengthening at this level will foster the integrated implementation of the IFC component within the MNH strategy. To ensure a synergistic effect, we suggest that actions at the community level be undertaken in conjunction with both policy and health services actions that are part of the broader national MNH strategy. Moreover, as one of the primary aims of the framework is to increase access to and utilization of health services, it is necessary to assure that the created demand can be met effectively by the health system. Efforts directed at the health services are ideally implemented simultaneously through other components of the MNH strategy. A common programme of work with all the partners involved is the best way to move the IFC component forward at the national level. In order to coordinate the IFC component and develop a common workplan at the national level, it is advisable to form/ reactivate/strengthen a National Coordination Committee. Sample terms of reference for this committee are provided in Annex 1. This committee would ideally be a subcommittee of an existing national MNH committee. A Province Coordination Committee may also be

Module 1

formed, or the existing province MNH committee strengthened. It is generally important to assign national and province coordinators who are responsible for leading the IFC component and coordinating between different actors. It may be necessary to reassign or hire new staff for this role. When identifying staff to compose teams responsible for managing the IFC component at different levels, it is important to prioritize the inclusion of both women and men. This will contribute to the integration of gender perspectives throughout the management of the IFC implementation processes. It is important that the gender composition of the committees allow for gender perspectives to be integrated at all levels of management and decision-making within the IFC component. This will also contribute to the broader goal of achieving gender equity.

Coordination of IFC work includes: • development of a common workplan between different partners; • management of national and provincial budgets and human resources; • selection of intervention sites for IFC • support to district committees; • documentation of lessons learnt; • monitoring and evaluation; • the development of a scale-up strategy. These activities are discussed in more detail below.

2.5 ADVOCACY AND PARTNERSHIP BUILDING In order for implementation of the IFC framework to proceed, it will usually be necessary to advocate within the MoH, as well as with other key MNH and IFC actors, on the importance of and rationale for implementing the IFC component. Advocacy may need to be undertaken by programme managers within the MoH, or by NGOs who wish to work with the MoH on the IFC component. It is typically important to gain the commitment of top-level decisionmakers for the IFC framework to be successfully integrated and implemented. In the process of IFC committee formation, it is advisable to build partnerships with other stakeholders working to improve the health of communities. Many countries have national and provincial committees for MNH, and it is important to assure the appropriate representatives and skills to integrate IFC work within these committees. It is also advisable to strengthen partnerships with other sectors or organizations, for example the education sector, or NGOs working in social development at the community level. Advocacy activities may include: • individual visits to key partners to introduce the IFC framework and to try and gain their commitment to the process, for example by securing their involvement in an IFC committee; • organizing workshops on MNH and the IFC component; and • organizing meetings with the attendance of international experts on health promotion and the IFC framework.

Section 2: National and provincial support to IFC implementation

All those planning to implement the IFC framework will want to consider both the importance and implications of working with partners. Working with other organizations and institutions is one of the fundamental principles of the IFC framework and is expected to contribute to successful outcomes from IFC implementation. However,

the individual groups must be aware that collaborative working can be time-consuming and require more energy than individually managed projects. Some of the key lessons learnt from working with partners on IFC implementation are described in Box 2.1.

Box 2.1: Lessons learnt from IFC partnerships in countries These lessons have been documented from experiences in implementing the IFC framework in Bangladesh, Burkina Faso, Colombia, El Salvador, Guatemala, Kazakhstan, Lao People’s Democratic Republic and the Republic of Moldova. • Workplans need to take into account the time and effort that collaborative processes and coordination require. This includes processes for obtaining partner consensus in developing, reviewing, and finalizing different documents (terms of reference, instruments, etc.). The IFC workplan will be more easily endorsed by different partners when they are part of the overall MNH workplan. • Financing the IFC component is an issue of concern. National level decision-makers’ commitment is key to ensure that budgets are allocated for the IFC component. • Enlisting the support of decision-makers at all levels is a long process and is ideally triggered through continuous advocacy and involvement during the PCA process. • As different partner agencies and groups consider who should represent them in the programme, other demands and activities should be considered. Some duties may need to be reassigned to assure that the person designated has the time and motivation to actively participate and assume his/her responsibilities. • Commitment and consistent participation is required from the key actors. Otherwise progress is curtailed and decisions cannot be made as each session requires time to bring new participants up to date. It is thus useful to provide prior detailed information on the process and what kind of involvement it entails. • Most actors, including international agencies, government agencies, NGOs and community groups, are more comfortable working on individually developed projects, with very punctual collaboration, rather than developing a common programme of different actors. • In countries where the IFC framework was initiated by local NGOs, these organizations faced obstacles in approaching the government services for collaboration, particularly to obtain national authorization of provincial and district level involvement. • In some countries, government ministries and community-based NGOs may not have experience in working together. It may take time for each actor to learn how to dialogue and to work as a coordinating body with other actors. • Different actors bring varying strengths to the process and often each contributes to diverse and complementary domains of knowledge. It takes time for each to value the possible contributions of the other and also to develop a common working language and vision. Larger and more visible organizations often tend to feel justified in asserting the importance of their involvement and views which affect the group dynamic. • Processes and mechanisms also need to be in place to assure on-going communication between the international organizations and their joint communication with the national organizations. Often each international organization has had more contact with one particular national actor, and there can be a tendency to establish bilateral communication. It is important for the international organizations to support the group in working together, being aware of the different power relations between local partners. • An IFC committee (or subgroup of the MNH committee) is a key element for coordinating the implementation of the IFC plan interventions. It is ideally institutionalized and its role (described in detail in the terms of reference in Annex 1) needs to be emphasized from the beginning of the process.

Module 1

2.6 INCREMENTAL IMPLEMENTATION OF THE IFC COMPONENT It is advisable to implement the IFC framework incrementally, starting in one province to gain experience and gather lessons learnt, and then scale up to other provinces and regions. This type of “validation” process has several advantages; notably it allows for: • examination of the feasibility and acceptability of incorporating the IFC component into national health initiatives; • evaluation of the process and its impact on basic health and social development indicators within a broader MNH strategy; • adaptation of generic processes and instruments to a national or local context; • development of collaborative partnerships between the health sector and other sectors, as well as between governmental and non-governmental organizations; • planning for long-term national scale-up based on lessons learnt; • building the skills and capacities of national ministries of health and other key stakeholders to implement the IFC framework and promote the empowerment of individuals, families and communities; and • development of regional, national and local communication networks for sharing of lessons learnt and the developing collaborative strategies.

2.7 INVENTORY OF ONGOING INITIATIVES RELATED TO IFC WORK Before selecting sites for initiating IFC implementation, it may be helpful to conduct a brief inventory of on-going initiatives related to IFC work at the national level. As discussed in the PCA guide (see Module 3), one step in the situation analysis at the district level is an inventory of programmes and projects. The same forms can also be used by the national committee to collect information on other MNH initiatives focusing on health promotion activities. The national coordinators can ask each partner organization within the national MNH committee to provide information on different programmes with interventions related to the IFC component. The group may then decide to select an intervention site where advances have already been made to promote MNH by working with individuals, families and communities. Knowing what exists and building on experience is a major principle of implementation at each level.

2.8 SITE SELECTION FOR INITIATING IFC IMPLEMENTATION As mentioned above, when initiating implementation of the IFC framework in a country, it is advisable to begin in one province only and preferably in one or two districts within this province. Box 2.2 outlines some suggested criteria for selecting appropriate sites for an initial experience with the framework in a province or country. Once a country has an initial experience with IFC implementation and lessons learnt about the process, sites for expansion can be selected based on other criteria (see section 2.16). Site selection is ideally conducted jointly by national, province and district levels, and may also be in response to local requests for assistance.

Section 2: National and provincial support to IFC implementation

As discussed, in order to assure a relevant first experience in IFC implementation, it is suggested that the initial district selected for implementation have a population size of 50,000 to 100,000 people. It is also recommended that the IFC component be initially implemented in areas that already have functioning MNH services. This is because an important aim is

to increase utilization of skilled care, and also because it is advisable to focus initially on those areas with a limited set of needs to gain experience in IFC implementation. Later, when skills are cemented, the methodology can be adapted to other types of areas with differing needs.

Box 2.2: Selection criteria for initial IFC implementation site(s) • Intervention area is accessible to stakeholders from both national and province levels. • District administrative area of 50,000 to 100,000 inhabitants. • Need for improvement of MNH (high maternal and perinatal/neonatal mortality, high morbidity). • High proportion of socially excluded population. • Local and intersectoral political will. • Available essential and emergency MNH services for pregnancy, childbirth and after birth (or referral facilities). • Presence of community organizations.

2.9 ADAPTATION OF THE PROCESS AND METHODOLOGY Before proceeding with IFC implementation and before conducting a PCA in a district, it is important to consider adaptation of the IFC process. This guide assumes a three-tiered health infrastructure, with the IFC framework applied at national, province and district health system levels. Some countries may have different health planning systems, and naturally adaptations to the process will be made accordingly. It may also be important to adapt the process to allow for its integration into existing plans and strategies, and thus prevent duplication of efforts. For example, if participatory planning or assessment processes are already ongoing in other health domains, can MNH be added to it? The instruments contained in the PCA guide are also designed to be adapted to the district context. Before introducing the PCA instruments at the district level, the national, province and district committee members are advised to conduct an initial review to ensure use of local terminology and that relevant themes are explored. There will be other moments to review and revise the instruments once the process is under way (see Module 3; section 3.3 and Module 4). An example of IFC adaptation from the Republic of Moldova is described in Box 2.3. Tools used for finalizing an action plan for the IFC component and for monitoring and evaluation will need to be adapted and appropriate to the context. Sample tools are provided in Module 5. However, ideally programme managers will be able to directly

Module 1

integrate the IFC component into the broader MNH monitoring and evaluation system and/or use tools that are already accepted and utilized

in-county. When possible, these tools will be adapted and agreed upon at the national level before district level implementation.

Box 2.3: Adaptation of the IFC framework and PCA instruments in Moldova The Republic of Moldova is a small country in Eastern Europe with a population of about 3.5 million. Although Moldova’s maternal mortality ratio (MMR) has declined over the past decade, it has the highest maternal mortality in Europe, with the most recent MMR of 21 per 100,000 live births. The national MoH had recognized the importance of increasing community involvement in health efforts and decided to adopt the IFC framework as a core part of its MNH strategy in 2005. Working in partnership with the local WHO office and the United Nations Children’s Fund (UNICEF), the Ministry decided to adapt the IFC framework. Firstly, this involved deciding to work only at two administrative levels (national and “rayon”) rather than three. Also, they decided to include infant and child health, as well as MNH. This resulted in selected child health interventions being added to the four areas of the IFC framework (capacities, awareness, linkages and quality). The PCA instruments were also adapted, not only to add some questions on child health, but also to make the assessment specific to the local context in Moldova.

2.10 ONGOING SUPPORT TO THE DISTRICT LEVEL Throughout all phases of IFC implementation, the district team will benefit from having technical support from the national and province levels. The province level may also receive ongoing support from the national level. This support may include the identification of one or two expert facilitators to support the PCA. It may also include technical support during the orientation workshop and the joint planning process, as well as during implementation, monitoring and evaluation of the IFC component. The role of the expert facilitators in the PCA is discussed in depth in Module 3 (see Module 3, section 1.8 and Annex 1). It may be advisable to reassign staff or contract new staff with expertise in community health, community participation and empowerment strategies to help coordinate the efforts at the national level and province level. Again, it is important to include both women and men when identifying staff to fill these roles.

Section 2: National and provincial support to IFC implementation

2.11 PLANNING INTERVENTIONS AT NATIONAL AND PROVINCE LEVELS The assessment processes undertaken in districts will generate a series of proposed actions to resolve the problems identified. Some of these actions will be specific to the district level. Others actions, however, will ideally be undertaken at the provincial or national levels, or will be local actions requiring action and support from these levels. Working in partnership with the district or multiple districts, the national and provincial authorities will draw up a coordinated plan of action to ensure improvements are achievable locally. Activities such as changes to national curricula, mass media campaigns or development of health education materials may be coordinated centrally. Results from the PCA can be used for advocacy to mobilize resources for these national activities. Box 2.4 illustrates some national and provincial actions that were identified from initial PCAs in El Salvador and Moldova.

Box 2.4: Examples of national or provincial actions identified in Moldova and El Salvador • Develop and implement laws and policies restricting availability and use of alcohol. • Increase the social support allowance for mothers and children. • Develop a system of continuous medical education for doctors. • Review salary scales of health care providers. • Include health issues within the national school curriculum. • Advocate with the government to demand the right to free health care. • Develop a mass media campaign on prenatal care, emphasising risks, skilled attendance and breastfeeding. • Develop a mass media campaign on domestic violence for young people. • Improve the national water quality monitoring system. • Develop networks between organizations working on gender and male involvement. • Evaluate the technical capacity of staff trained in the health centres. • Improve the interpersonal and counselling skills of health care providers. • Develop support materials for communication interventions. • Develop orientation and training guidelines for Village Health Committees and community- level actors. • Support the implementation of the district IFC action plan. • Integrate communication activities in outreach clinics guidelines.

Module 1

2.12 MECHANISMS FOR COMMUNICATION AND EXCHANGE The national and province committees will generally be responsible for creating and sustaining adequate communication mechanisms, both among different partners at each level, and among the national, province and district levels. Since the IFC framework is being implemented in several different countries, international exchange of experiences may also be helpful. WHO can provide support in making links with other countries and programmes that are implementing the IFC framework.

2.13 MONITORING AND EVALUATION AT NATIONAL AND PROVINCE LEVELS Monitoring and evaluation will be needed at the district level, the province level and the national level (see section 3.8 of this module and Module 5). Monitoring and evaluation are essential for assuring accountability and transparency throughout the IFC implementation process and for making adjustments and improvements. A system for monitoring and evaluation is generally developed during the planning of IFC interventions. Ideally this system is integrated into the monitoring and evaluation framework of the broader MNH strategy so as to avoid creating parallel systems. At the national and province levels, monitoring and evaluation will typically be focused on the priority areas of health systems strengthening. It is also important to monitor who is involved (which partners), who makes decisions, and how the district level is supported and empowered. The national level will ideally keep their district partners informed about how the IFC component is progressing at the national level, and specifically about how local activities are contributing to changes nationally. They can also provide information on how different districts are progressing. More information on the role of the national and province levels in monitoring and evaluation can be found in sections 2.7 and 3.1 of Module 5.

2.14 DOCUMENTING LESSONS LEARNT Documenting lessons learnt and sharing experiences facilitates successful scale-up of the IFC framework to other districts or provinces after an initial experience in IFC implementation (see Module 5, section 4). Lessons learnt can be gathered to make modifications both to the process being applied, as well as specific instruments and tools being used. In both Moldova and El Salvador, for example, the national and district committees documented the fact that not enough effort was made to involve non-health sector actors in the district IFC committees. This was particularly problematic in Moldova, where the district IFC committee was almost entirely composed of doctors and nurses. Both countries learnt that a significant investment of time is required to build alliances at both national and district levels in order to achieve multi-sectoral collaboration. Some of the other lessons learnt from partnership-building in various countries are listed above in Box 2.1.

Section 2: National and provincial support to IFC implementation

2.15 “VERTICAL” SCALING-UP: INSTITUTIONALIZATION OF THE IFC FRAMEWORK AND PARTICIPATORY METHODS Introduction of the IFC framework in a country will ideally occur within a broader vision of scalingup. There are several forms of scaling-up, but for our purposes we will be primarily concerned with “vertical” and “horizontal” scale-up. Vertical scale-up involves the institutionalization of an IFC component through policy, regulatory, budgetary, or other health system changes – in other words, the complex process of embedding the process in the institutional structure of a health system. Once the IFC framework has been implemented and evaluated in the initial implementation district(s), the approach and the participatory planning methods that accompany it may be integrated into ongoing health planning processes. This ensures that the IFC framework is integrated into the broader MNH strategy, and that the IFC component is not delivered as a stand-alone vertical programme. In this way community involvement in identifying problems, setting priorities, and designing solutions can become standard procedures in health planning and thereby contribute to the promotion of rights. At the national and provincial levels, this could be achieved in several ways, for example by: • incorporating participatory assessments and planning processes into national or provincial health policies and guidelines; • conducting yearly or biennial national or provincial quality audits which use the results of district-level PCAs; and • reviewing health promotion strategies across a range of technical areas (for example MNH, reproductive health, child health, hygiene and sanitation, HIV, tuberculosis, malaria) and designing integrated assessment and planning processes. Efforts toward vertical scale-up of the IFC component can typically be organized within the priority areas of health systems strengthening. Strategies to integrate the IFC component at the district level are discussed in section 3.9.

2.16 “HORIZONTAL” SCALING-UP THE IFC FRAMEWORK TO OTHER DISTRICTS AND PROVINCES From the outset, it is also important to plan for “horizontal” scaling-up, referring to the geographic expansion of the IFC component to new provinces and districts. The process of IFC implementation that has been outlined in this section, and which is described in detail for the district level in the following section, is designed to be used the first time the component is introduced in a country or province. As noted above, the first implementation of the IFC framework and the first PCA will be an intensive process that requires the teams involved to learn new participatory and collaborative methods for health programming. During the implementation process in this first site, the national, province and district teams will have ideally documented lessons learnt in order to make adaptations to the process for other districts and provinces. The national and province teams can then determine an appropriate approach for scaling-up. Actors involved in planning IFC interventions in these districts will need to agree on alternative planning mechanisms that maintain principles of participation and collaboration. Some options are presented here.

Module 1

1. Review of original PCA results in other districts of the same province Communities within the same province that have a similar socio-cultural, economic and political context as the original PCA site may be able to rely on those results. A process can be developed to examine the results of the original PCA in the new community. Preparatory steps for IFC implementation would still be relevant, including advocacy and partnership building, sensitization of community groups, and formation of a district committee (see section 3). The district committee could then organize a process to review the PCA results with different stakeholders and community groups to determine whether the prioritized problems and actions identified are pertinent for their area and make necessary adjustments to fit their local context. We suggest that these committees organize a dissemination meeting with community groups to present and discuss the results. They may also want to conduct face-to-face meetings with district authorities to enlist their collaboration and involvement. Organizing a new institutional forum is advisable to review the original findings and discuss the similarities and differences between the new district and the PCA district. If the group feels there are many differences, the district committee can decide to investigate further, either through individual interviews with different stakeholders, or by organizing a separate series of roundtable discussions. If the institutional forum does not feel there are many differences with the PCA district, they may proceed with the joint planning and implementation processes (discussed below). When using an alternative method to the PCA, IFC coordinators will want to carefully ensure that the process allows for the participation of community members and for the integration of gender perspectives.

2. Extending to areas with different needs in the same province In communities that demonstrate marked differences from the initial IFC implementation site (for example, different ethnic groups, religious groups, migrant populations), it may be advisable to conduct a new PCA. Ideally, each province will benefit from at least one full PCA. It may be worthwhile, however, to conduct multiple PCAs within one province where the situation and needs differ. Programme managers will want to consider these decisions carefully, particularly in light of the human and financial resources required to conduct a complete PCA. In addition, section 2.8 listed criteria for selecting a district for the first application of the IFC framework and the PCA in a country or province. Some areas may not meet these criteria and adaptations in the process may be required. For example, when extending to an area without functioning or with ineffective MNH services, the PCA will need to be integrated into broader quality improvement initiatives within the health services. Or when extending to areas with no political or institutional commitment to MNH, further actions will be needed prior to undertaking the PCA to advocate for change. 3. Replicate the PCA in other provinces As discussed, it will generally be advantageous to conduct one full PCA in each province. The province committees should review the need to conduct multiple PCAs within the province where situation and needs differ. Time and resources will need to be allocated to oversee the IFC component as it is scaled up, and programme managers and their political leaders must be committed to an approach that ensures participatory processes become the standard in health planning.

3. OVERVIEW OF THE IFC FRAMEWORK AT THE DISTRICT LEVEL Fig. 2.1 in section 2.1 above outlines the various phases of IFC implementation at the district level: 1. Preparation 2. The Participatory Community Assessment (PCA) 3. Joint planning process 4. Participatory implementation 5. Participatory evaluation As discussed earlier, this process has been designed for the initial experience implementing the IFC framework within a district or province. The PCA, in particular, may not need to be replicated in every district of every province (see section 2.16).

3.1 COMMUNITY PARTICIPATION IN HEALTH PLANNING Community action for health is one of the key strategies of the IFC framework. The framework defines a community as a “pertinent group of people, sharing common needs and problems.” Within one geographic “community” such as a district, there exist smaller communities that share common identities, for example based on ethnic, religious, geographic, or work-based identities. As stated in the IFC framework, it is important to remember that a community is not always one homogenous entity with shared values and norms, and its inhabitants will not automatically have a willingness to work together to solve problems within that community. Since IFC’s focus is at the district level with populations of up to 100,000 people, this point becomes even more important to bear in mind. The IFC approach outlined in this document, beginning with a process such as the PCA, is an attempt to help generate collective action among key “community” actors who have a stake and a role in MNH. Enabling this collective action always sounds easier to achieve than it is in reality, and requires effort and dedication from IFC coordinators and programme managers. It will also depend on the historical, political and social context of the country or region, since experience with community engagement is greater in some areas than others. Fig. 3.1 illustrates a spectrum of community participation, whereby community members are increasingly involved in health-related actions in their community. The IFC framework aims to reach the “involve” or “collaborate” level of collective action, as described in the figure, since much emphasis is placed on building a relationship between the services and the community. To ensure institutionalization, health service planning ultimately must be led by the health services. Nonetheless if a programme goal is to contribute to the promotion of rights and empower communities, then processes must ensure that community participation is not limited to a consultative or advisory role, but that joint planning and decisions can be made with key actors including community representatives.

Fig. 3.1: A spectrum of community participation in health planning13 Module 1

INCREASING LEVELS OF COMMUNITY PARTICIPATION

Outreach Better community involvement Community involvement Communication flow is bidirectional. Communication flows both ways, participatory form of communication. Involves more participation with community on issues. Entities cooperate with each other.

Consult

Involve

Collaborate

Shared leadership Strong bidirectional relationship Final decision-making is at community level. Entities have formed strong partnership structures.

Some community involvement

More community involvement

Communication flows from one to the other, to inform.

Provides community with information.

Communication flows to the community and then back, answer seeking.

Entities coexist.

Gets information or feedback from the community.

Forms partnerships with community on each aspect of project from development to solution. Entities form bidirectional communication channels.

Outcomes: Optimally, establishes communication channels and channels for outreach. Outcomes: Visibility of partnership established with increased cooperation.

Entities share information.

Outcomes: Develops connections.

Outcomes: Partnership building, trust.

Outcomes: Broader health outcomes affecting broader community. Strong bidirectional trust built.

Modified from the International Association for Public Participation, 2004.

Section 3: Overview of IFC framework at the district level

3.2 ORIENTATION TO THE IFC FRAMEWORK AT THE DISTRICT LEVEL As with the national level, it is important to orient local health services and other community groups to the IFC framework before launching into any kind of assessment process. This also provides the opportunity for local actors to review the IFC framework and to determine if any adaptations are needed. Once the initial IFC implementation site has been identified and agreed upon by national, province and district stakeholders, the orientation workshop can be replicated at the district level. Provincial programme managers may attend either the national or district workshops, or both. Although a district IFC committee may not have been formed yet (see below) it is still important to identify a range of different local actors who have a stake in MNH and IFC processes. If others become involved in the IFC implementation process after the orientation, those who attended are advised to spend time with their colleagues to explain the aims and objectives of the component, the principles and strategies of the IFC framework, and its interventions to improve MNH. Since health promotion and empowerment may be new concepts and may propose a different modality of work and relations, this orientation is important for newcomers. It may also be necessary to repeat the orientation workshops at a later date.

3.3 ADVOCACY AND PARTNERSHIP-BUILDING AT THE DISTRICT LEVEL Advocacy and partnership-building are just as important, if not more important, at the district level than at the national level. In some geographical areas, district health services have extensive experience involving communities in health planning, and may already have pre-existing health committees that include different actors and community leaders and representatives. However, they may need to strengthen efforts including reinforcing inter-sectoral action, or developing relationships with district government authorities, NGOs or the education sector. In other areas, district health services may have very limited experience in working with others beyond the health sector. Although they may appreciate the value of the IFC component, they may not fully understand the implications of inter-sectoral collaboration and community involvement that the IFC framework promotes.

3.4 DISTRICT IFC COORDINATION COMMITTEE It is advisable to form a District IFC Committee to oversee the implementation of the IFC component. Many district health systems will already have an existing MNH committee, and efforts to strengthen the IFC component of the strategy may be integrated into on-going work. It will usually be necessary, however, to review the composition of any existing MNH committee to ensure participation of relevant partners and community stakeholders. Within the district committee it is advised to involve stakeholders from various sectors, including health and education, as well as district authorities and community groups. It may be necessary to actively seek out representatives of marginalized groups: those who are “invisible” or discriminated against and whose voices are typically absent from on-going community or political decision-making. These groups may not be immediately identified by

Module 1

community leaders who may not necessarily represent their needs. It is critical to ensure that groups who experience social exclusion have an opportunity to be involved in the process to express their voice, needs and solutions. This may involve representation on the district committee or ensuring involvement at other stages of the IFC process. It is also important to ensure participation from those working in urban, peri-urban and rural zones. Ensuring this participation is critical to the promotion of rights and equity. When initiating IFC work at the district level, we suggest first forming a smaller subcommittee of an existing MNH committee to ensure there is sufficient focus on the process and participation from relevant stakeholders. This subcommittee can be expanded during the PCA or during the planning stage after the PCA to include other interested or relevant groups, and/or can be fully integrated into the existing MNH committee. Sample terms of reference for the district committee, together with the listing of different groups who may be represented on it, is provided in Annex 1. We suggest that the committee remain small (maximum 10 people), at least in the initial phases of IFC implementation, to facilitate efficient coordination within the process. Again, when considering the composition of the district committee it is important to include equal numbers of women and men in order to maintain a gender perspective throughout all phases of IFC implementation and decision-making.

Committee Chair(s) The district committee, in consultation with province and national partners, can determine how to organize itself. Two options are: 1.The district health centre director or the head of MNH services (if different) may chair the district IFC committee. 2. The district committee may choose to elect two co-chairs, one representing the health sector, and the other representing non-health sector or community groups. Once a committee has been formed, and members have been oriented to the IFC framework (either through the orientation workshop or by colleagues), it will be useful for the group to review the terms of reference and modify them according to their needs. They may also choose to select ground-rules for participation on the committee (e.g. if someone does not show up at more than two consecutive meetings, then action must be taken to renew their involvement or find a replacement). If the representation of various sectors and agencies on the committee are initially limited, for example only two non-health sector members, then the group can decide how to expand the membership and increase its representation. They can also determine a strategy for increasing the number of women who participate if there is a gender imbalance when initially organizing the IFC committee.

Section 3: Overview of IFC framework at the district level

3.5 THE LOCAL IFC COORDINATOR The local coordinator is the person responsible for implementation of the IFC framework at the district level, including the preparation and organization of the PCA, the joint planning process, implementation of activities, and monitoring and evaluation. In some cases the coordinator may be on or even chair the health district committee. It often will be advisable, however, to identify (and possibly hire) a separate individual for this role. Since the PCA is an intensive phase of the IFC process, the committee may decide to assign or employ a person to work exclusively on the PCA, after which the committee may choose to continue IFC implementation without this support. The district may need support in identifying an appropriate person. Sometimes it may be necessary for the national or province level to identify persons with the required level of experience and skills. If the national or province level plans to assign or recruit personnel to support the IFC process it is important to note some potential challenges: • those recruited from outside the implementation district may not be inclined to relocate to more rural and remote areas and may prefer to have a post in the capital or regional capital with occasional travel to the district; • those who live outside the district and who commute may not be able to spend sufficient time working with the IFC committee and other community groups; and • those who come from outside the district may not have a full understanding of the local community dynamics or knowledge of the diverse community actors and may take time to develop the relationships and confidence with the different actors. External coordinators, however, may have extensive previous experience of communitybased projects, qualitative research skills and valuable participatory management skills. Committees must therefore weigh the value of employing a coordinator who lives in the implementation site over the benefits of having a more qualified person who comes to the area for extended periods. Sample terms of reference for the local coordinator are in Annex 1.

Module 1

3.6 CONDUCTING THE PCA The PCA is a tool that the district health services can use to assess the MNH situation and needs in a participatory manner, through collaboration within the health sector and with other sectors (such as education and transport), with district authorities, NGOs, religious organizations, and other community groups. Using the results of the PCA, partners can then plan actions together to help create an enabling environment for care of the mother and newborn in the home and in the community and to increase access to quality MNH services. The PCA process is described in detail in Module 3 of this toolkit. The PCA helps to initiate a process of empowerment among women, their partners, families and communities. Empowerment is strengthened as they participate actively in assessing their problems and needs in MNH, as well as in identifying potential actions and district resources that can be leveraged to address these problems and needs. This meaningful participation in developing the interventions designed for their benefit is a right of women, men, families and communities. The PCA can also be instrumental in reorienting health services in their relations and interactions with non-health actors, including the community, thus contributing to the realization of rights through the institutionalization of participatory processes. The PCA is not intended to be a research tool, but rather a participatory process in which different actors become sensitized to the importance of collaborating with each other, of listening to each other, and of jointly planning interventions and solving problems together. By helping people and groups better understand their situation and participate in finding solutions, the PCA becomes an important first step in a health promotion process that empowers them to make choices and transform those choices into actions to improve their health and quality of life. Fig. 3.2 lists the steps involved in conducting the PCA.

Fig. 3.2: PCA process STEP 1: Situation analysis Fill out six forms and prepare a short report PCA Training workshop Training on the facilitation and the analysis of the roundtables STEP 2: 5 roundtable discussions 1. Women of reproductive age (WRA) 2. Mothers, mothers-inlaw and grandmothers of WRA 3. Male partners of WRA 4. Health care providers 5. Community leaders STEP 3: Institutional rountable Prioritization workshop involving local authorities, key actors and community roundtable representatives STEP 4: Final report • Situation analysis • Summary of the roundtable • Recommendations from the institutional roundtable discussion (inputs to develop action plan)

Section 3: Overview of IFC framework at the district level

As can be seen in the image, the final report from the assessment process includes data collected in the situation analysis, the findings from the roundtable discussions, and a draft intervention plan developed during the institutional forum. Since the PCA aims to assess the situation of a large and diverse geographical region, those planning the roundtables must ensure that the participants represent the interests of the whole population, in particular the poorest and most vulnerable. It is important to conduct the PCA in such a way as to promote equity. This is discussed in more detail in Module 3. The PCA ideally will be integrated into ongoing processes. The health services network, together

with the community social network, can conduct regular assessments to provide information and feedback to health programme managers on changing MNH needs, and to conduct informed health planning processes. The output of the PCA will be a final report (to be completed by the district committee) that will form the principle input into the joint planning process. We strongly recommend sharing the results of the assessment with members of the community as this provides a platform to discuss priority problems and advocate further for the need for joint action on MNH. It is also important for maintaining accountability and transparency.

3.7 THE JOINT PLANNING PROCESS After completing the PCA the IFC committee ideally elaborates a 5-year action plan for IFC interventions. A 5-year action plan will generally allow for interventions to be fully implemented and results measured. This plan typically involves: • a PCA (or PCA review) at the beginning; • a baseline study (possibly); • quarterly meetings of the district IFC committee; • an annual meeting of all local partners; • a mid-term review; • a final evaluation. The process should also have built-in feedback mechanisms to hear community voices and monitor progress and processes. Once the final report of the PCA has been written, reviewed (by district, province and national committees), revised and finalized, the district committee and local coordinator will be responsible for organizing a process to develop the detailed action plan for IFC interventions. The institutional forum during the PCA, composed of different local stakeholders, will produce a priority list of problems and a draft list of interventions aiming to address these problems. Using this draft action plan, the local coordinator and district committee, with the support of province and national levels, develops the detailed action plan. This action plan will facilitate implementation, monitoring and evaluation of IFC interventions. The IFC plan will preferable be directly incorporated into the MNH workplan. We suggest constructing an action plan consisting of a logical framework (logframe) and a detailed activities plan. The logframe is used to identify goals, objectives, expected outputs of interventions, as well as the different indicators to measure progress. This is a central tool for monitoring and evaluation. The activities plan, in contrast, provides the details for each activity, including responsible actors, resources required and a time frame. Determining these details in

Module 1

advance will facilitate implementation. When using local tools, IFC coordinators will need to verify that all necessary elements are in place. A clear action plan facilitates implementation of interventions and is essential to assuring accountability. This process is described in detail in Module 5 and sample planning frameworks (a logframe and an activities plan) are provided in Annexes 1 and 2 of that module. It is important

for the district committee to be comfortable with and understand the planning frameworks selected. It will be important to identify overall intervention goals, as well as intermediary results, and to visualize the chain of results needed to achieve the objectives. The planning frameworks are flexible tools to be modified to respond to changes in the situation and the context of the district.

3.8 PARTICIPATORY IMPLEMENTATION, MONITORING AND EVALUATION Participation is emphasized throughout implementation of activities, as it is throughout all phases of the IFC framework. The district committee continues to oversee the interventions and discusses the results and progress on a continuous basis with a broader group of community stakeholders. Throughout the implementation process, it is advised that the group conduct on-going monitoring to determine progress and make necessary adjustments to selected interventions. Although monitoring of activities will be conducted throughout the process, we suggest conducting an evaluation after a pre-determined period of time to measure the results of the interventions and their impact on selected health indicators. Results from the evaluation can be fed back into the planning processes and inform strategic decision-making (see Module 5, section 3).

3.9 INSTITUTIONALIZING THE IFC FRAMEWORK AND PARTICIPATORY METHODS INTO ONGOING PROGRAMMING AT THE DISTRICT LEVEL It is important to emphasize again that the IFC framework is designed to be integrated into MNH and on-going planning processes after this first experience (see section 2.16). At the district level, this institutionalization can involve: • developing policies to ensure community involvement in annual service progress reviews; • expanding the scope of the district IFC committee to ensure oversight and review of all local health activities (i.e. moving beyond MNH into a wider range of health promotion activities); • integrating a PCA or similar participatory needs assessment and planning methodology into the MNH programming cycle, to be conducted at 3-5 year intervals; • integrating a PCA into broader health planning cycles. Expanding the scope of the IFC framework and the PCA to include other areas of health may serve as an important step to allow the community to participate in setting and determining their own health priorities. This also implies that the methodology and instruments of the PCA be reformulated to identify and investigate priority health needs.

Section 3: Overview of IFC framework at the district level

3.10 SUMMARY OF STEPS FOR IFC IMPLEMENTATION In conclusion, the steps of implementing the IFC framework in a country can be summarized as follows: • presentation of the IFC framework to national and district authorities; • formation or strengthening of a national IFC sub-group of the national MNH committee; • inventory of IFC experiences in the country; • strengthening or formation of an IFC sub-group within each district health committee; • orientation workshop of the IFC component for the district health committee; • training on how to conduct a PCA; • PCA (or PCA review) conducted in each district by the district group, supported by national and provincial levels; • participatory planning; • baseline evaluation; • activity implementation (overseen by the local committee with support from the national committee), including ongoing monitoring; • evaluation, lessons learnt, dissemination of results at the national and local levels; • vertical and horizontal scale-up.

Module 1

Table 3.1: Summary of activities before, during and after the PCA National and province levels • Define the terms of reference of the coordination committees (see Module 1, Annex 1). • Identify the “strategic partners” and “stakeholders” for the IFC component at national level. • Before the PCA District level • Review and revise the terms of reference of the district committee (see Module 1, Annex 1).

• • •

• With the support of the province and national committees, develop an initial plan for the implementation of the IFC framework at the district level, and identify resources (human Develop a plan for implementation of the IFC and financial) that are required. framework at national and province levels, and identify the required resources (human • Present the IFC framework to local actors in the community and identify the “strategic and financial). partners” and the “stakeholders” for the Identify one or two expert facilitators at district committee (or broaden the existing national or province level. district MNH committee). Conduct a national inventory of experiences • Select the IFC committee chair(s). in IFC-related work. • Identify a local IFC coordinator. Identify the initial IFC intervention district, in coordination with province and district level • Identify local facilitators for the PCA. actors, according to the specified criteria (see Module 1).

• Identify the key moments of interaction between the district, province and national levels. At province level, identify a representative to participate in the district and national committees. • At national level, review the PCA instruments for a first adaptation to the national context. • Support the district level in the different stages of the PCA. During the PCA • Find pertinent information for the situation analysis (national statistics, research in the area, programme/project reports in the area). • With the district level, organize a training workshop for the PCA and participate in the training. Organize follow-up, according to needs. • Conduct the situation analysis: o Collect data and pertinent reports; o Organize meetings for filling in and/or reviewing data collection forms; o Write up the draft report. • With the national/province level, organize a training workshop for the PCA and participate in the training. • Review the roundtable discussion guide, taking into account the results of the situation analysis (with support from the national and province committees).

Section 3: Overview of IFC framework at the district level

National and province levels • Participate in pertinent meetings during the PCA (situation analysis, roundtable discussions, analysis meetings, institutional forum). • Review and comment on the PCA reports.

District Level • Organize the roundtable discussions, including identification of participants, logistics and facilitation. • Carry out the five individual roundtable discussions, including meetings for analysis, and writing up reports. • Write up the summary report of the five roundtables. • Organize and conduct the institutional forum, including compiling the report with information collected. • Write up the final report.

During the PCA

• Present results of the PCA, including the draft action plan, to national and province MNH committees and other strategic partners. • Organize a workshop for documentation of lessons learnt from the PCA, jointly with the district level, including the revision of PCA instruments. After the PCA • Support the district level in the joint planning process to develop a detailed action plan. • Review and adapt tools for monitoring and evaluating the IFC component. • Support the district level in evaluating the results of IFC interventions and coordinate and disseminate these results. • Organize a workshop for documentation of lessons learnt from IFC implementation, jointly with the district level. • At national level, develop a process for scaling-up IFC implementation to other districts and provinces.

• Present the results of the PCA to the district MNH/IFC committee(s) and other strategic partners and community actors. • Organize a workshop for documentation of lessons learnt from the PCA, jointly with the national level, including the revision of PCA instruments. • Organize, jointly with the province level, a process to develop a detailed action plan based on the draft plan. • Manage the implementation and regular monitoring of IFC activities. • Evaluate the initial implementation of the IFC component. • Disseminate results from monitoring and evaluation. • Organize a workshop for documentation of lessons learnt from IFC implementation, jointly with the national level. • Support the scaling-up of the IFC framework to other districts within the province.

Module 1

REFERENCES Alsop R, Bertelsen M, Holland J (2006). Empowerment in practice: from analysis to implementation. Washington (DC): World Bank. Anderson T (1991). The reflecting team: dialogues and dialogues about the dialogues. New York: Norton. Bateson G (1979). Mind and nature: a necessary unity. New York: Bantman. Becker L, Pickett J, Levine R (2006). Measuring commitment to health: global health indicators working group report. Washington (DC): Center for Global Development. Bhattacharyya K, Murray J (1999). Participatory community planning for child health: implementation guidelines. Arlington (VA): Basics Project. Brager G, Specht H (1973). Community organizing. New York: Columbia University Press. Cecchin G (1987). Hypothesizing, circularity, and neutrality revisited: an invitation to curiosity. Fam Process. 26:405–413. Cernea M (1992). Re-tooling in applied social investigation for development planning: some methodological issues. In Scrimshaw NS, Cleason GR, editors. Rapid assessment procedures: qualitative methodologies for planning and evaluation of health related programmes. Boston: International Nutrition Foundation for Developing Countries. Comité Promotor por una Maternidad sin Riesgos en México (2006). Hacia la prevención de la mortalidad materna: guía para una estrategia comunitaria [Towards the prevention of maternal mortality: a guide for a community strategy]. Mexico City: Comité Promotor por una Maternidad sin Riesgos en México (in Spanish). Commonwealth of Australia (2006). Cultural competency in health: a guide for policy, partnerships and participation. Canberra: Commonwealth of Australia. Cornwall A, Pratt G, Scott-Villiers P (2004). Participatory learning groups in an aid bureaucracy. Brighton: Institute for Development Studies (Lessons for Change Series, No. 11). De Negri B, Thomas E (2003). Making sense of focus group findings: a systematic participatory analysis approach. Washington (DC): Academy for Educational Development. EngenderHealth (2001). COPE® for maternal health services: a process and tools for improving the quality of maternal health services. New York: EngenderHealth. Every Woman Every Child (2015). Global strategy for women’s, children’s and adolescents’ health (20162030). New York: Every Woman Every Child. Gonzales F, Arteaga E, Howard-Grabman L (1998). Scaling up the WARMI project: lessons learned mobilizing Bolivian communities around reproductive health. Washington (DC): Basics Project. Hafeel A, Tagadur S, Payyappapallimana U, Shankar D (2001). Evaluación participativa rápida sobre las tradiciones locales de salud [Rapid participatory evaluation on local health traditions.] Revista Compas. No.4 Por el Desarrollo Endógeno (in Spanish). Hanley B (2005). Research as empowerment? Report of a series of seminars organised by the Toronto Group. York: Toronto Group,Joseph Rowntree Foundation. Howard-Grabman L, Snetro G (2005). How to mobilize communities for health and social change, a health communication partnership field guide. Baltimore: Health Communication Partnership. International Association for Public Participation Australia (1994). IAP2 Public Participation Spectrum. (https://www.iap2.org.au/documents/item/84, accessed 14 April 2014). Laverack G (2005). Health promotion practice: power and empowerment. London: SAGE Publications.

References

Marston C, Renedo A, McGowen CR, Portela A (2013). Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review. PLoS ONE. 8(2):e55012. Maturana HR (1978). The biology of language: the epistemology of reality. In Miller G, Lennenberg EH, editors. Psychology and biology of language and thought. New York: Academic Press. Maturana HR, Varela FJ (1987). The tree of knowledge. Boston: New Science Library. Mielke E, Bradley J, Becker J (2001). Improving maternal and child health services through COPE. QA Brief. 9:(2). MSPAS, CEES, OPS. Diagnóstico comunitario participativo en los municipios de Izalco y Nahuizalco, Departamento de Sonsonate, El Salvador [Participatory community assessment in the municipalities of Izalco and Nahuizalco, Department of Sonsonate, El Salvador.] San Salvador: Ministerio de Salud Pública, Concertación Educativa de El Salvador, Organización Pan Americana de la Salud (in Spanish). OHCHR (2010). Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights. Geneva: United Nations, Office of the United Nations High Commissioner for Human Rights (http://www2.ohchr.org/english/bodies/hrcouncil/docs/14session/A. HRC.14.39.pdf, accessed 28 March 2014). OHCHR (2012).Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. Geneva: Office of the United Nations High Commissioner for Human Rights (UN Doc. A/HRC/21/22). Oltheten T (1995). Participatory approaches to planning for community forestry: results and lessons from case studies conducted in Asia, Africa and Latin America. Rome: Food and Agricultural Organization of the United Nations (Community Forestry Working Papers, No. 2). Ottolenghi E, Riveros P, Blanding S (2008). Assessment of the Bolivia postabortion care community mobilization program. Washington (DC): United States Agency for International Development, Acquire Project. PAHO (2002). Regional strategy for maternal mortality and morbidity reduction, Washington (DC): Pan American Health Organization. PAHO (2005). Guía para el diagnóstico local participativo: componente comunitario de la estrategia AIEPI. [Guide for the participatory local assessment community component of the IMCI strategy]. Washington, (DC): Pan American Health Organization (in Spanish). Palmer L (2006). Addressing the social dynamics of sexual and reproductive health: CARE’s exploration with social analysis and community action. Atlanta: CARE. Portela A, Santarelli C (2003). Empowerment of women, men, families and communities: true partners for improving maternal and newborn health. Brit Med Bull. 67:59–72. SAFE International Research Partnership (2003). SAFE strategy development tool: a guide for developing strategies to improve attendance at delivery. Aberdeen: University of Aberdeen, The Dugald Baird Centre for Research on Women’s Health. Scrimshaw NS, Cleason GR, editors (1992). Rapid assessment procedures: qualitative methodologies for planning and evaluation of health related programmes. Boston: International Nutrition Foundation for Developing Countries. Segal L (1986). The dream of reality: Heinz von Foerster’s constructivism. New York: Norton. Tarimo E (1996). Safe motherhood and district health systems. Eur J Obstet Gyn R B. 69(1):5–10. Tones K, Green J (2004). Health promotion: planning and strategies. London: Sage Publications.

Module 1

UNHCR (2009). Resolution 11/8. Preventable maternal mortality and morbidity and human rights. In: United Nations Human Rights Council, eleventh session, New York, 17 June 2009. New York: United Nations Human Rights Council. UNICEF, WHO, UNFPA (1997). Guidelines for monitoring the availability and use of obstetric services. New York: United Nations Children’s Fund. Wallerstein N (2006). What is the evidence on effectiveness of empowerment to improve health? Copenhagen: WHO Regional Office for Europe. WHO (1986). Ottawa Charter for Health Promotion. Geneva: World Health Organization (WHO/HRP/HEP/95.1). WHO (1988). Report on the interregional meeting on strengthening district health systems based on primary health care. Geneva: World Health Organization. WHO (1994). Information support for new public health action at district level. Report of a WHO expert committee. Geneva: World Health Organization (WHO Technical Report Series, No. 845). WHO (1996a).Diagnostico cualitativo de la atención en salud reproductiva en Bolivia [Qualitative diagnosis of reproductive health care in Bolivia.] Geneva: World Health Organization (WHO/HRP/ITT/96.1). WHO (1996b). Safe motherhood needs assessment. Geneva: World Health Organization. WHO (2002). Making decisions about contraceptive introduction: a guide for conducting assessments to broaden contraceptive choice and improve quality of care. Geneva: World Health Organization (WHO/ RHR/02.11). WHO (2004a). Child health in the community “Community IMCI”, briefing package for facilitators. Geneva: World Health Organization. WHO (2004b). Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO. Geneva: World Health Organization. WHO (2005a). Making pregnancy safer through district/municipality team approach: a problem solving process. Geneva: World Health Organization. WHO (2005b). The world health report 2005: make every mother and child count. Geneva: World Health Organization. WHO (2006a). Quality information in field research: training manual on practical communication skills for field researchers and project personnel. Geneva: World Health Organization. WHO (2006b). Reproductive health indicators: guidelines for their generation, interpretation and analysis for global monitoring. Geneva: World Health Organization. WHO (2010a). Nine steps for developing a scaling-up strategy. Geneva: World Health Organization. WHO (2010b). Working with individuals, families and communities to improve maternal and newborn health. Geneva: World Health Organization (WHO/MPS/09.04). WHO (2015). WHO recommendations on health promotion interventions for maternal and newborn health 2015. Geneva: World Health Organization. WHO Regional Office for Europe (2002). Community participation in local health and sustainable development – approaches and techniques. Copenhagen: WHO Regional Office for Europe (European Sustainable Development and Health Series: No. 4; EUR/ICP/POLC 06 03 05D [rev.1]).

ANNEXES Annex 1: Terms of reference A) National and Province Coordination Committees B) District IFC Committee C) Local coordinator Annex 2: IFC implementation timeline

Module 1

ANNEX 1 : TERMS OF REFERENCE The following pages include the terms of reference for the groups and individuals who will implement the IFC framework at national, province and district levels.

A. IFC NATIONAL AND PROVINCE COORDINATION COMMITTEES Note: Generally the IFC National and Province Committees will be integrated into pre-existing national and province MNH committees, or they may be a subcommittee of them. If separate IFC committees are formed, one of the representatives may be selected to represent the IFC component in the MNH committees. This section focuses on the National Committee. It will be necessary to review the roles of the National Committee and Province Committees and assign responsibilities to each. Some roles and responsibilities will overlap at national and province levels. Normally the province committee will be smaller than the national committee (maximum of five people). Objective of committee: the national coordination groups and assure its integration into and coordination with broader strategies. 4. Coordinate the development of the national IFC plan, including planning of interventions; management and administration of financial, technical and human resources of the interventions; and assuring adequate financing for each phase of its operationalization. 5. Develop a system for monitoring and evaluating the IFC component at the national level. 6. Identify the necessary experts and support at various administrative and technical levels (national, province and district) for implementation of the national IFC plan. 7. Provide technical assistance throughout the implementation of the national IFC plan at all levels of the health system (province, district authority, community). 8. Develop coordination mechanisms and maintain communication with all strategic partners (at district, province and national levels) and with district committees during the different phases of development and implementation of the national plan. 9. Review and analyse existing strategies, programmes, and activities that work with women, their families and the community to improve MNH at national level. 10. Document and organize the experiences and lessons learnt in the area of IFC for scale-up at national level.

Supervise, provide technical support to and coordinate the development and implementation of the “national plan” for the IFC component within the national MNH strategy. Scope of work: 1. Identify partners for implementation of the IFC component (including other sectors and relevant programmes within the MoH itself, NGOs, universities and other relevant groups). 2. Represent the IFC component at the national level, within other national, regional and international initiatives. 3. Advocate the importance of this health promotion component for MNH strategies within the MoH and with other sectors and

Annex 1: Terms of Reference

Members of the national coordination committee: The national IFC coordination committee involves the participation of representatives of organizations that work on MNH issues at the community level, including representatives of: • MoH (one or two decision-makers in the MNH or Health Promotion programmes); • WHO (national offices); • other governmental agencies (education, water/sanitation, youth, etc.); • NGOs (national or international); • women’s groups; • universities; • national champions in MNH or health promotion; • representatives of the province and district IFC committees.

Skills and knowledge required within the committee: • knowledge of current MNH activities, social sciences and health education; • familiarity with quantitative and qualitative research methods; • experience in educational processes at community level; • experience in community health (links between communities and services; community participation in health care improvement); • knowledge of participatory mechanisms at the community level; • must include or have relationships with political decision-makers, or include representatives who have the ability to influence key decision-makers. Coordination: This team will select a coordinator and a secretary for a specified period of time. The committee should be limited to 10-12 members to allow the group to work effectively. It may be useful to consider forming subcommittees to carry out specific actions. The large group could meet two to three times a year to provide suggestions and oversight.

Module 1

B. DISTRICT IFC COMMITTEE Note: It is recommended to form a subcommittee of the existing district MNH committee (where one is present) of five to ten persons for the coordination of IFC activities. Objective of the District IFC Committee: Coordinate the implementation of the IFC strategic framework at district level. Scope of work: 1. Identify partners for the local implementation of the IFC framework (including other relevant sectors and programmes within the MoH, NGOs, and other pertinent groups at the district level). 2. Coordinate the different phases of the IFC implementation framework, including the PCA, development of the district plan, identification of interventions, implementation of activities, monitoring and evaluation and documentation of lessons learnt. 3. Identify participants for the roundtable discussions. 4. Maintain communication and develop mechanisms for effective coordination with all strategic partners during the implementation interventions, including district, province and national stakeholders. 5. Assist in the identification of experts and support required at various administrative and technical levels in the local area for the implementation of the IFC framework. 6. Participate in the joint planning process, specifically the planning of activities for implementation, and the identification of indicators for monitoring and evaluation of the IFC component. 7. Review and comment on proposals developed for funding IFC activities before submission. 8. Assure the integration of participatory mechanisms within routine health service planning processes. 9. Review and analyse existing strategies, programmes and activities at the district level that work with women, their families and the community for the improvement of MNH.

Annex 1: Terms of Reference

Members of Committee:

the

District

Coordination

• knowledge of participatory mechanisms at the community level; • skills in negotiation and facilitation; • ability to represent the voice of women, families and communities; • must include or have relationships with local political decision-makers, or with people who have the ability to influence key decision-makers. Duration of service: Each committee member will ideally be able to commit to at least two years of service on the IFC committee, after which time they may choose to rotate off and new members may be elected. Committee chair(s): The district committee may be chaired by the district health services director or the head of MNH services. It may also be appropriate for the committee to elect a “community co-chair”, a representative of a community group who is not part of the health sector. The committee will also need to appoint or elect a local IFC coordinator responsible for work related to the IFC component (see next page). This committee will also elect a secretary for a specified period of time. One or two people from this district committee may be identified to represent it on the national and/or province committees (usually the chair or co-chairs).

The Committee should comprise a maximum of ten people, and may include: • MoH (including representatives from the district health centre); • health service providers with experience in MNH at the district level (for example, doctors, nurses, health promoters or midwives); • NGOs working in MNH in the area; • representatives of community groups, local health committees and women’s groups; • local political representatives; • the education sector; • other selected relevant professionals in the local area; • religious leaders. Skills and knowledge required within the committee: • knowledge of current activities in MNH and in health education; • experience in educational processes at community level; • experience in community health (links between the communities and services; community participation in the improvement of quality of health care);

Module 1

C. LOCAL IFC COORDINATOR Note: The local IFC coordinator will work closely with the chair(s) of the district committee. In some cases they may be the same person. It is usually helpful, however, to select an IFC coordinator who will be responsible for the organization and implementation of the IFC action plan. Profile of the Coordinator: • has lived or worked in the selected implementation site for a period of at least three years and knows the area well; • has experience implementing interventions and projects at community level, especially in MNH, and has knowledge of current activities; • has knowledge of qualitative and quantitative research methods; • has contact with and knows the local health providers and decision-makers; • is recognized as a leader at district level; • has knowledge of participatory mechanisms; • has knowledge of educational communication in health; • has negotiation, facilitation and group management skills.

Scope of work: 1. Organize meetings of the District IFC Committee together with the committee chair(s). 2. Support and report on progress at meetings of the National Coordination Committee. 3. Support the District IFC committee in the identification of partners for implementation of IFC interventions. 4. Maintain communication and develop mechanisms for effective coordination with all the strategic partners during the different phases of development and implementation of the different activities. 5. Support the identification of facilitators at the district level. 6. Coordinate all stages of the PCA: a. Support to the PCA team in the situation analysis; b. Support the review of the PCA instruments; c. Present the IFC framework and PCA to relevant persons at the district level; d. Coordinate the identification of the participants for the roundtable discussions; e. Organize the roundtable discussions; f. Facilitate the roundtable discussions, along with other facilitators; g. Process and analyse the information generated by the roundtable discussions; h. Prepare the PCA reports; i. Document and evaluate the PCA experience, including lessons learnt and presentation of findings to the community, health care providers and decision-makers. 7. Be a part of the design team for intervention strategies at district level and support for developing a system of monitoring and evaluating the IFC component. 8. Be a resource for the scale-up of the IFC framework to other areas after the initial phase.

Annex 1: Terms of Reference

ANNEX 2: IFC IMPLEMENTATION TIMELINE IFC Implementation Continues 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

ACTIVITIES NATIONAL AND PROVINCIAL LEVELS National IFC orientation workshop (preparation and workshop) Formation of national committee, identification of national and/or province IFC coordinator(s) and ongoing coordination work Advocacy and partnership building Resource mobilization Inventory of national experiences in IFC-related MNH work Development of a project proposal for IFC initial implementation Selection of the initial intervention zone(s) Identification of expert facilitators Review and adaptation of the IFC methodololgy and instruments Ongoing support to local implementation of IFC, including PCA Documentation and discussion of lessons learned from IFC implementation Post-PCA adaptation of methodology Extension of IFC to other districts and local areas DISTRICT LEVEL Formation of district IFC committee, selection of local coordinator(s), and ongoing committee work Advocacy and partnership-building Local orientation to IFC (preparation and workshop) Identification of the PCA team and PCA coordinator Situation analysis (data collection plus local review) Local revision of PCA instruments PCA training workshop (including practice roundtable) Individual roundtables (5) Summary report from the roundtables Institutional forum PCA final report Presentation and dissemination of PCA report Documentation of lessons learnt from IFC and the PCA Development of detailed IFC activity plan (including indicators) Resource mobilization for local activities Baseline evaluation Project implementation Ongoing monitoring and evaluation

IFC coordinator(s) and ongoing coordination work Advocacy and partnership building Resource mobilization Inventory of national experiences in IFC-related MNH work Development of a project proposal for IFC initial implementation Selection of the initial intervention zone(s) Identification of expert facilitators Review and adaptation of the IFC methodololgy and instruments Ongoing support to local implementation of IFC, including PCA

Key implementation time

YEAR 1 YEAR 2 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 ACTIVITIES NATIONAL AND PROVINCIAL LEVELS National IFC orientation workshop (preparation and workshop) Formation of national committee, identification of national and/or province IFC coordinator(s) and ongoing coordination work Advocacy and partnership building Resource mobilization Inventory of national experiences in IFC-related MNH work Development of a project proposal for IFC initial implementation Selection of the initial intervention zone(s) Identification of expert facilitators Review and adaptation of the IFC methodololgy and instruments Ongoing support to local implementation of IFC, including PCA Documentation and discussion of lessons learned from IFC implementation Post-PCA adaptation of methodology Extension of IFC to other districts and local areas DISTRICT LEVEL Formation of district IFC committee, selection of local coordinator(s), and ongoing committee work Advocacy and partnership-building Local orientation to IFC (preparation and workshop) Identification of the PCA team and PCA coordinator Situation analysis (data collection plus local review) Local revision of PCA instruments PCA training workshop (including practice roundtable) Individual roundtables (5) Summary report from the roundtables Institutional forum PCA final report Presentation and dissemination of PCA report YEAR 1 Documentation of lessons learnt from IFC and the PCA 1 2 3 4 5 6 7 8 9 10 11 12 Development of detailed IFC activity plan (including indicators) ACTIVITIES Resource mobilization for local activities NATIONAL AND PROVINCIAL LEVELS Baseline evaluation National IFC orientation workshop (preparation and workshop) Project implementation monitoring and evaluation FormationOngoing of national committee, identification of national and/or province

YEAR 1

YEAR 2

YEAR 3

Ongoing activities

Department of Maternal, Newborn, Child and Adolescent Health 20 Avenue Appia 1211 Geneva 27 Switzerland E-mail: mncah@who.int Website: http://www.who.int/maternal_child_adolescent/en/

ISBN 978 92 4 150852 0

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 7 avril 2017

Source Organisation mondiale de la santé