Discovering advocacy successes through participatory evaluation

By Catherine Lalonde and Kathleen Schaffer

Catherine Lalonde is the senior program officer for the Francophone Africa program, and Kathleen Schaffer is the senior program officer for the Anglophone Africa program.

This post is the second in a blog series on the evaluation of FCI’s multi-year advocacy project, Mobilizing Advocates from Civil Society. Find the first post here.

Evaluating advocacy is far from simple. Advocacy is not straightforward, as advocates often need to readjust strategies to influence decision-makers when government leaders and policies change. So it’s often difficult to attribute a policy success to a specific advocacy effort. We are grappling with these challenges firsthand as we evaluate our advocacy project Mobilizing Advocates from Civil Society (MACS).

Continue reading “Discovering advocacy successes through participatory evaluation”

Reflections on evaluating advocacy

Catherine Lalonde is the senior program officer for the Francophone Africa program.

Saving the lives of women and children around the world is a team effort. It takes the voices of community and religious leaders, health professionals, concerned citizens, young people, and impassioned activists to effect change. Prioritizing women’s and children’s health requires sustained advocacy.

Yet, determining whether certain advocacy efforts are actually achieving desired results—evaluating an advocacy program—is challenging. Through the evaluation of our Mobilizing Advocates from Civil Society (MACS) project, which brings together civil society organizations and equips them with skills to be effective advocates, we are reflecting on what it means to evaluate advocacy.

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Making connections: Ensuring access to reproductive and maternal health supplies

Shafia Rashid is Senior Program Officer for Global Advocacy at Family Care International. This post originally appeared on the Maternal Health Task Force blog.

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

The past ten years have witnessed impressive gains in the availability and use of reproductive health supplies like condoms and oral contraceptives that allow men and women to safely and effectively prevent or space pregnancies. As a result of concerted efforts by many partners, contraceptive prevalence rates have risen over 60% in countries around the world.

These dramatic successes in improving access to reproductive health supplies can shed important lessons and guidance for those working to ensure that life-saving maternal health medicines — including, oxytocin, misoprostol and magnesium sulfate — are available to all women, when they need them and wherever they give birth. These medicines — which can save lives by preventing or treating the leading causes of maternal death — remain out of reach for many women, particularly for poor, rural, indigenous and other vulnerable women. Many countries lack clear, supportive policies and adequate budgets to make essential maternal health medicines widely available, or have weak supply chains and logistical systems. Inadequate regulatory capacity, poor quality of medicines and lack of information and guidance on correct use are other barriers to access.

In order to summarize lessons learned and provide concrete tools to improve access to maternal health supplies, the Reproductive Health Supplies Coalition tasked Family Care International to create seven policy briefs that show policy makers and program managers real-world examples of successful interventions. Importantly, there is a brief dedicated to each of the three most critical maternal health supplies: oxytocin, misoprostol and magnesium sulfate. Other briefs cover the cross-cutting issues of policy and financing, supply and demand generation.

Lessons learned from successful efforts to improve access to family planning commodities can help to effectively address the challenges related to maternal health medicines. Family planning advocates have, for example, tracked government expenditures on reproductive health supplies: in Indonesia, budget analysis and concerted advocacy led the mayors of five districts to increase their family planning budgets by as much as 80%. Similarly, many countries — including Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua and Paraguay — have established contraceptive security committees that bring together multiple supply chain stakeholders to support coordination, address long-term product availability issues and reduce duplication and inefficiencies. These committees have advocated for increased financial support for contraceptives, improved inventory management, developed standard operating procedures, published reports and provided technical assistance. These efforts to increase budgets and ensure commodity security for contraceptives can be effectively adapted and expanded to improve financing and security for maternal health supplies as well.

A wide range of tools and resources can support countries in strengthening their forecasting, procurement and other supply chain functions. Tools originally developed with a sole focus on reproductive health supplies now include or can be adapted to apply to maternal health supplies as well and can be used by country managers working to improve the supply of maternal health medicines.

Finally, many countries are moving toward integrating their supply chains to include family planning commodities and other essential medicines, including medicines for maternal health. In Ethiopia, for instance, the government (with the support of in-country partners) integrated their supply chain to include all health commodities and to connect all levels of the supply chain with accurate and timely data for decision-making. In Nicaragua, where the supply chain was separated vertically by health issue and type of commodity until 2005, the health ministry has integrated the essential medicines system with the contraceptives’ supply chain and has now fully automated the system and expanded it to include all essential medicines.

There are many parallels and potential synergies between reproductive and maternal health supply chains and processes. The reproductive and maternal health communities must take the following actions to address the interrelated barriers that prevent access to and use of life-saving commodities:

  • Advocate for development and implementation of supportive policies at the national and sub-national levels,
  • Advocate for dedicated budget lines to enable monitoring and evaluation of policy implementation
  • Improve government systems and procedures for procuring high-quality medicines and maintaining their quality throughout the supply chain
  • Invest in a streamlined, coordinated supply chain across sectors and levels, reducing inefficiency and duplicative efforts
  • Strengthen the knowledge and skills of health providers so that they are aware of evidence-based policies and guidelines and can effectively administer these essential medicines

More information can be found in Essential Medicines for Maternal Health: Ensuring Equitable Access for All, a set of briefs that highlight challenges and strategies for increasing the availability of these maternal health medicines and identify linkages with reproductive health supplies. You can download the Essential Medicines for Maternal Health policy briefs in English, French and Spanish.

Tracing the money: A new tool to impact the budget process

Kathleen Schaffer is senior program officer for Anglophone Africa at Family Care International.

A dilapidated clinic, falling tiles, a never-ending leak. Barren and disorganized medicine shelves. An overcrowded maternity ward with desperate, soon-to-be mothers crying out for help. One nurse scrambling to meet the needs of the many patients who have come through the doors. When clients lament the clinic’s disrepair, or doctors request more supplies and personnel, they’re met with the same hopeless reply: “There’s no money.”

Through Family Care International’s (FCI) Mobilizing Advocates from Civil Society (MACS) project in Kenya, international, national and grassroots organizations as part of the Reproductive, Maternal, Newborn, and Child Health (RMNCH) Alliance are demanding better facilities, adequate and respectful maternity care, and especially, more health personnel. Kenya has only 11.8 health workers per 10,000 people–more than 40% fewer health workers than the World Health Organization’s minimum recommendation of 22.8 health workers per 10,000 people.

Of course any effort to increase the quantity and quality of health workers will have to be paid for, and that means dealing with the budget. For many of us, budgets seem abstract and intimidating, but it’s vital to engage with them since they reflect the government’s priorities and determine where the public’s money goes.

In order to make realistic demands, we need access to information about Kenya’s budget. However, over the last few years Kenya decentralized many decision-making processes, including budgeting, to the county-level. This recent decentralization has made it difficult for us to intervene effectively during the budget process.

Kenya calendar 2

But now, civil society organizations in Kenya can engage with budget decision-makers at the right moments thanks to a new Annual Budget Cycle Calendar, developed by the MACS project.

This new easy-to-read calendar shows the key dates for the Kenyan Annual Budget Cycle at both the national and county levels, enabling citizens to participate in both the setting of priorities and in accountability processes.

It is a great resource not only for maternal health advocates but also for the broader health community and county government officials, such as those from the Health and Finance Committees. The RMNCH Alliance will distribute the calendar in counties all over the country, and we hope to see it on many office walls as a constant resource for advocacy opportunities.

Ultimately, by being able to participate in and monitor the budget process more effectively, we will ensure that the government fulfills its commitments to maternal, newborn, and child health, and that the budget reflects the needs and priorities of the community and not just politicians.

Budget accountability in the midst of the Burkina Faso revolution

By Manuela Garza

Manuela Garza is an independent consultant and is co-founder of Colectivo Meta. She is currently engaged as a consultant to FCI’s Mobilizing Advocates from Civil Society (MACS) project, on which she works to build the budget analysis skills of health-focused civil society organizations in Burkina Faso.

For the past seven years, it was my good fortune to work at a job that allowed me to work with brave and committed activists in interesting and beautiful places. As a staff member of the International Budget Partnership, I found myself in Mombasa, Kenya, where ordinary citizens conducted ‘social audits’ to claim their communities’ fair share of government financial resources; in Abbottabad, Pakistan, where 500 women and men voiced their priorities for spending of earthquake rehabilitation funds; in Beijing, where civil society groups were trained to pursue budget transparency and accountability in a context where silence rules; and in Abbra, a remote region in the Philippines, where rural villagers have advocated for and achieved truly participatory budgeting.

In recent months, FCI’s MACS initiative has been working in Burkina Faso to strengthen the capacity of civil society groups to effectively advocate for more and smarter spending of public funds to improve reproductive, maternal, newborn, and child health in their communities. Last October, I was engaged, together with my Malian colleague Boubacar Bougodogo and Burkinabé budget researcher Hermann Doanio, to develop and facilitate a weeklong workshop to train grassroots advocates to understand and engage with public budgets. We arrived in Ouagadougou, Burkina’s capital, on a calm and warm West African evening, all of us ready with our slides on the budgeting process, our spreadsheets, our budget calculation formulas, and our case studies. Business as usual, or so we thought.

Little did we know that, in the course of that week, the citizens of Burkina Faso would overthrow the dictator who had been ruling the country for the past 27 years. Thousands of people (young people, mostly) took to the streets with a very clear message for President Blaise Campaoré: they wanted him out, for good. They were no longer willing to tolerate corruption and abuse of power, they declared: Burkina is ready for democracy.

In the midst of these historic events, you may be wondering, what did our Burkinabé colleagues, who had put this week aside for budget training, do? Was the workshop still relevant during these revolutionary days? Of course, every participant was closely watching the dramatic events taking place outside the training venue; each participant was concerned and worried about what they would mean for their families and their country. At the same time, however, they remained committed to take full advantage of this unique opportunity to learn about a new tool that will enable them to carry out evidence-based advocacy. They stuck around, they learned, and they questioned; they talked about their country, about change, and about what these new skills could help them achieve. They discussed the potential for how things could change, including in the way that the government sets priorities and spends public money— that is, the people’s money!

Civil society plays a key role in ensuring that governments prioritize spending on women’s and children’s health.
Civil society plays a key role in ensuring that governments prioritize spending on women’s and children’s health.

Is budget accountability still relevant in a context of earthshaking change? My experience says that it is. Revolutions are tricky things: countries and their institutions can change either for better or for worse, and conditions may take a long time to stabilize. If change is managed wisely and stability returns quickly, as seems to be happening in Burkina, revolution can provide an opportunity for a fundamental shift in the balance of power—toward the people. This can vastly increase the possibility of reshaping inefficient and corrupt institutions, of fostering new structures that institutionalize transparency and accountability. In a country like Burkina Faso, accountability for public resources is an essential element of overall accountability.

In this context, investing in building the skills of civil society groups is crucial, because the significance and sustainability of positive change largely depends on a well-organized and well-prepared civil society. These are the times when advocates and grassroots organizations most need support, when citizens most need to develop new knowledge and skills in civic participation, when accountability and participation-related processes are more necessary than ever. The MACS project is doing just that, and FCI’s local partners in Burkina Faso will continue to arm themselves with new tools such as budget analysis, so that their advocacy has more impact, their voices are heard, and they can be effective forces for real, sustainable change.

Good luck to them and to Burkina Faso–a country that many people cannot even locate on a map but which has a lot to teach us when it comes to citizen power!

 

Health workers in many Kenyan clinics brave community health care alone

By Melissa Wanda

Melissa Wanda is Advocacy Program Officer for FCI Kenya. This article originally appeared on the blog for the Frontline Workers Health Coalition

In a village in rural Kenya, a woman in labor travels miles along rutted dirt roads to get to the nearest health center. She wants to give herself and her baby the greatest possible chance of surviving childbirth and returning home to begin new and healthy lives. When she arrives however, the gates are locked; the nurse has gone home.

Kenya, with only 11.8 health workers per 10,000 people (more than 40% below WHO’s recommendation of 22.8 per 10,000), is one of 57 countries — including 36 in Sub-Saharan Africa — with a critical shortage of health workers.

Many local health facilities have only one health worker, often a nurse, to provide all patient care. This puts a heavy strain on the health worker, and means that many intended 24-hour health facilities are often closed for extended periods of time. Kenya’s news media has also reported recent health worker strikes in reaction to late or non-payment of wages.

The Government of Kenya has committed to strengthening human resources for health in the public health system. Several civil society organizations (CSOs) working to improve reproductive, maternal, newborn, and child health (RMNCH) have come together to advocate for the fulfillment of this urgently important promise. This alliance, co-led by Family Care International (FCI) and the African Women’s Development and Communication Network (FEMNET) under FCI’s Mobilizing Advocates from Civil Society (MACS) project, is conducting advocacy at the county level in Kenya, since counties are responsible for making many health spending decisions in Kenya’s recently decentralized administrative structure and health system.

With support from the MACS project, Deutsche Stiftung Weltbevoelkerung (DSW), a member of the advocacy alliance in Kenya, has surveyed community perceptions of the need for more health workers, and explored how effectively county governments have invested in addressing those needs. Working in two urban and two rural counties, DSW conducted research at various levels of the health system, including outpatient dispensaries, health centers, and hospitals. DSW found that counties are not budgeting or investing spending adequately enough to ensure that facilities have enough health workers to provide high-quality services. Although special funding has been set aside nationally to hire new health workers, counties have mainly been spending this money to pay current staff. DSW is sharing these findings with MACS and county health authorities, leading to one county already committing to hire an additional 72 nurses.

Kenyan health workers share frustrations and challenges of working at understaffed health centers.
Kenyan health workers share frustrations and challenges of working at understaffed health centers.

DSW also brought together community members and health facility staff to discuss the state of care at local health facilities. Community members complained that lack of staff meant an absence of essential services, especially at night and on weekends. Health workers expressed the frustrations of working alone, often lacking the drugs and supplies they need to treat their patients, and the low morale that comes from working under those conditions. For example, one nurse described a recent evening when she was the lone nurse caring for six women in labor!

These community meetings opened new channels of communication, fostering greater understanding and accountability between health workers and the communities they serve. This enabled health system users and health workers to join together in search of practical solutions.

Peter Ngure, DSW’s project lead, shared with me a story about one community in which participants said they prefer to come to the hospital — a long distance from their homes —in the afternoon, so they have time in the morning to travel there. In response, the hospital rearranged staff work schedules, deploying more nurses in the afternoon than morning hours. Similarly, community members learned that the hospital holds Monday afternoon staff meetings, helping to explain why appointments are often unavailable at that time, which had been a repeated source of frustration and confusion.

“This dialogue between community members and health workers helped to build much-needed goodwill during these very challenging times,” said Mr. Ngure.

FCI, DSW and the members of the civil society advocacy alliance will use these findings and experiences to hold county governments accountable for addressing the health worker shortage. When the Kenyan Ministry of Health releases its upcoming human resources for health strategy, which will provide specific guidance on exactly how many health workers should be assigned to each health facility, alliance members will work to make sure that counties follow that national policy, so that every Kenyan mother, seeking care for herself and her baby, will be greeted by open gates and a health worker with the skills and resources to ensure their survival and good health.

 

Budgeting for better maternal and child health

Catherine Lalonde is FCI’s senior program officer for Francophone Africa.

I just returned from a week in Senegal where I attended a regional workshop to train civil society, parliamentarians and the media on budget analysis and advocacy for maternal and child health.

For years now, countries across the globe have said that maternal health is one of their top priorities; they’ve made statements, built coalitions, and developed strategies. On the surface, it seems as though a lot is happening in the realm of reproductive, maternal, newborn and child health (RMNCH). Despite all the rhetoric, little progress has been made in improving the health of mothers and children, especially in the poorest countries in the world.

Since I started working at FCI a year ago, I have mainly been involved in advocacy projects aimed at keeping governments accountable to their commitments. In Burkina Faso, Mali and Kenya, we and our partners are constantly asking governments to invest in and implement programs that will improve RMNCH in their countries.  Whenever we question why contraceptives aren’t available in the villages or why health centers are not staffed with qualified personnel, we almost always gets the same answers: there’s no money, we don’t have the funding, and we can’t afford it.

A budget is the single best indicator of a country’s priorities and the best way to tell whether a country is putting its money where its mouth is and whether or not it has taken steps towards fulfilling its maternal and child health commitments.

Fatimata Kané
Fatimata Kané, FCI-Mali national director, explains the importance of budget advocacy in improving RMNCH outcomes.

Organized by Harmonization for Health in Africa, UNICEF, WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH), Save the Children, the InterParliamentary Union and FCI, the three-day budget advocacy workshop brought together members of local NGOs and reporters, along with parliamentarians and representatives from the ministries of finance and of health from the Democratic Republic of the Congo, Niger, Mali, Burkina Faso and Senegal.

A budget is public property; it represents the money that belongs to each and every citizen of a country and therefore, the public should have a genuine say in how the money is distributed and spent. But the countries represented in the workshop had budgets that rank among the least transparent in the world, according to the International Budget Partnership’s Open Budget Survey, which reveals what information is made public and when, as well as who gets to contribute to the process and how often. Of the workshop’s participating countries, Burkina Faso’s budget had the best transparency score– a measly 23 out of a 100; Niger, with the least transparent budget, scored a depressing 4 out of 100, with zero meaningful opportunities for civil society to contribute to the country’s budgeting process.

The workshop facilitators emphasized the important role the budget plays in RMNCH and the financial costs of not investing in RMNCH. It also taught how good health policies are developed and costed, and provided options for increasing fiscal space – the money to fund these policies – within the existing budget. This workshop provided participants with an outline of the budgeting process, and all of the opportunities in which civil society should be able to contribute. At the end, each of the delegations developed advocacy objectives and strategies to improve civil society’s contribution to the budgeting process in order to prioritize health. For example, the Burkina Faso delegation chose to advocate for increased investment in information systems to better track health data while the Malian delegation chose to focus advocacy on ensuring that Mali meets the Abuja declaration pledge to dedicate 15% of its budget to health.

A good friend of mine who works in finance once told me that talking about money scares people, that people often feel as though they don’t have enough knowledge to contribute and are too embarrassed to say so. The organizers and I were afraid that the workshop would be too long, too technical and hard to follow, but we couldn’t have been more wrong. The participants lapped up every word on every slide, and were thrilled to be equipped with the knowledge of the role they can play in ensuring that their country’s budget prioritizes maternal and child health.

The presentation on increasing fiscal space even got a standing ovation!

 

 

Join FCI at CSW event — Friday, March 2nd, NYC

Please join FCI and our partners at a side event to this week’s meetings of the UN Commission on the Status of Women.  1,000 Days: Improving the Nutrition of Rural Women will focus on the crucial time between a woman’s pregnancy and her child’s 2nd birthday. These 1,000 days offer a unique window of opportunity to shape healthier and more prosperous futures. By investing in improving nutrition for mothers and children in this 1,000-day window, we can help ensure that a child can live a healthy and productive life, and we can also help families, communities and countries break out of the cycle of poverty.

When: 

Friday, March 2, 2012 10:30 a.m. – 12:00 noon

Where:

Salvation Army (Downstairs Conference Room)
221 E. 52nd Street (between 2nd and 3rd Avenues)
New York City

Free and open to the public.

RSVP at www.thp.org/csw56

Questions? Please contact Carolyn Ramsdell at 212-251-9130 or Carolyn.ramsdell@thp.org

March 2nd CSW Parallel Event 1000 Days: Invitation

Healthy Families, Healthy World: The Global Strategy for Women’s and Children’s Health and the MDGs

Ann Starrs is FCI’s president. The remarks below were delivered by Ann at the United Nations Association of the USA’s Members’ Day, at the UN on February 10, 2012.

I’m going to start this talk with a story. It’s the story of a family in Afghanistan, several years ago. The wife was pregnant for the seventh time; she died of postpartum hemorrhage, the most common cause of maternal death in poor countries. Because her husband couldn’t cope with the responsibilities and cost of caring for a large family on his own, one of their daughters, aged 13, was married off, to a much older man. At the age of 15, she gave birth to twins. One of the infants died right after birth, and the young mother developed fistula, a horrifying complication in which a woman develops a hole between her urethra and vagina, and leaks urine for the rest of her life unless the hole is surgically Ann Starrs at the UN (Photo: Arnold Gallardo/UNA-USA)repaired. Because of her smell, her husband sent her back to her father, with the weak and ailing surviving infant. They had to spend what was, for them, a significant amount of money trying to get care for the baby.

This is just one family’s story, but it is representative of millions more. Around the world, a woman dies from preventable causes related to pregnancy and childbirth a thousand times every day. A child dies, of similarly preventable causes, every 3 seconds. Add these stories up, and the annual death toll is staggering: 350,000 maternal deaths a year, each one leaving grieving parents, husbands, or children, and 7.6 million children dying before the age of 5. Forty percent of these children are lost in their first month of life, and again, nearly all of these deaths are preventable.

The tragedy of this Afghan family is representative in another way. It portrays, in a nutshell, the multiple reasons why the world must invest in women’s and children’s health. There is a clear moral imperative to prevent these needless deaths, but no less clearly there is an economic imperative. A healthy woman — who is able to decide on the number and spacing of her children, who can deliver them safely, who can see them through childhood in good health — is someone who can contribute to the economic productivity, and to the social and cultural stability, of her family, her community, her nation, and the world. A family destroyed by the loss of a mother or daughter, made desperate by the loss of a breadwinner, or burdened by the tragedy of a lost child, is far too often a family that finds itself trapped in an inescapable cycle of poverty.

This is a challenge that advocates, NGOs, and UN agencies have been working on tirelessly, for decades. My organization, Family Care International, has been working in partnership with governments, other NGOs, donors, academics, and others to raise attention and mobilize commitment — and funding — to address the multiple causes and prevent the horrifying consequences of maternal death. Much of our work is done through and with the Partnership for Maternal, Newborn, & Child Health (known as PMNCH), which has worked to great effect to focus the world’s attention on the powerful and crucial concept of the continuum of care.

The Global Strategy for Women’s and Children’s Health was launched by UN Secretary-General Ban Ki-moon at the General Assembly in September 2010.  The Global Strategy was an expression of the Secretary-General’s recognition that the health MDGs — and particularly MDG 4 (Reduce child mortality) and MDG 5 (Improve maternal health) ­— were headed for failure, and that this dire circumstance presented the world with an urgent moral imperative. The Global Strategy, and the Every Woman Every Child effort that aims to generate commitments to the Global Strategy, represents the compelling moral power of the UN and its Secretary-General to mobilize the world into focused action. Its stated goal was to save 16 million lives between 2010 and 2015.

The Global Strategy has, so far, provided a much-needed jumpstart to international efforts to bring about real progress on women’s and children’s health. It has bought together key UN and other multilateral agencies (including WHO, UNICEF, UNFPA, UNAIDS, and the World Bank) around a coherent, comprehensive vision of what needs to be done to save lives. The Global Strategy set clear, measurable targets, and mechanisms have been established to keep track of whether targets are being met and to ensure accountability. It has mobilized a broad range of stakeholders — from civil society organizations to corporations, from all of the most important international donors to the governments of dozens of developing countries — to commit themselves to take specific, concrete, and significant actions. Many of these commitments have been pledges of money, which is desperately needed, but many have also been commitments in kind: pledges to build new midwifery schools, to achieve specific increases in national skilled childbirth attendance or immunization rates, to institute free emergency obstetric and child health care, or to increase access to and use of contraceptives.

UN Association members' day, February 2012 (Photo: Arnold Gallardo/UNA-USA)This is a multi-year effort, and one whose goals are both ambitious and urgently necessary, and much more still needs to be done. In this time of limited and constrained resources, we must bring about greater efficiency and effectiveness in the ways that aid is allocated and programs are implemented, with a particular focus on the integration of services, so that women and families can meet their health care needs at a single health center offering high-quality, comprehensive services across the continuum of care. We must work in a targeted way, focusing our resources and efforts on key countries, where the burden is highest, and on key, proven interventions. We must ensure that governments, donors, and all other stakeholders are held to account for fulfillment of their commitments: the Global Strategy only becomes truly meaningful when its promises are kept, and advocates (including my organization) are working hard to make sure that they are. And we must have sustained, vocal, visible, high-level leadership — from the Secretary-General himself, from heads of state, and from celebrities; but also from dedicated and often unsung individuals in ministries of health, in civil society organizations like the United Nations Association, in hospitals and clinics, and in the villages and communities where so many women and children are still dying.

So what am I —an advocate from an NGO, and not a representative of the UN — doing here, in front of the United Nations Association, describing an initiative of the UN Secretary-General? I’m here because a great part of the power of this initiative is the way it focuses on the value of partnership to get things done. An engaged, empowered civil society — both here at the global level, and at the grass roots in every country with a high burden of maternal and child death — must play, and is playing, a central role in that partnership. The voice of civil society is key to making change happen, in every corner of the world.

In 2000, the world committed itself in the Millennium Declaration to bring about momentous change by the year 2015, to address the historic challenges of poverty, hunger, disease, inequality, and environmental degradation that deform or end so many lives in the developing world. Much progress has been made, but it is clear that the goals related to health will not be fulfilled. And MDG 5 is the furthest from success. As we begin to talk about an international framework for continued, and accelerated, progress beyond 2015, that framework must include special attention to the health, well-being, and education of children and women. The United Nations, under the leadership of Ban Ki-moon, has set a visionary, progressive agenda. It is our obligation to build on that legacy, to build a world where no woman and no child dies a preventable death, simply because they were born in the wrong place, because they are poor, because we pretend we can’t afford to save them. The Global Strategy has been an essential first step, and its urgent, essential work will continue until it is done.

Follow the money: exploring the realities of health financing in Kenya

Robinson Karuga is research coordinator at FCI-Kenya.

In Kenya, when someone in a poor, rural community needs health care, she goes to a health center — a facility in a nearby market town, offering a broad range of primary health services — or to a dispensary — a lower-level facility, typically staffed by a single nurse and providing only limited services.  For most Kenyans, health centers and dispensaries are their only contact with the health system, and the only available source of primary care. For Kenya to make meaningful progress in reducing its high rates of maternal and child mortality, the services offered in these primary-level facilities must be strengthened, and more Kenyans must be persuaded to use them: more than half of Kenyan women still give birth without help from a skilled attendant, a statistic that has actually become worse over the past 20 years.

Unfortunately, primary-level facilities often have not had the money they need to support consistent, high-quality services — in Kenya’s centralized national health system, allocated funds rarely filtered down to facilities through inefficient district disbursement channels characterized by leakages and mismanagement. In recent years, this funding shortfall was made worse by the government’s reduction and ultimate abolition of official user fees for many essential health services: ironically, a policy designed to increase poor people’s access to services often resulted in poorer service quality, as the facilities’ lost revenue was not replaced.

Beginning in 2010, the Ministry of Health addressed this problem with a program of ‘Direct Facility Funding’ (DFF), by which funds are provided directly from the national government to cover facilities’ core expenses, so that they can provide high-quality services that are responsive to communities’ needs. This is a potentially powerful reform, but facilities face significant challenges in implementing it, including managers with insufficient budgeting and money management skills and a lack of transparency in how money is allocated and spent.  There is also a lack of community awareness and monitoring of the DFF process, which minimizes community input on priorities for quality‐of‐care improvements.

This year, with support a from the Transparency and Accountability Program of the Results for Development Institute, FCI-Kenya will evaluate communities’ knowledge and understanding of the direct facility funding system and their level of satisfaction with health facilities’ quality of service and accountability. FCI will work in two counties (one rural and one urban), using “citizen report cards” to collect quantitative and qualitative data from health facility clients and from members of Health Facility Management Committees, community-based groups that are charged with managing funds at the facility level.

FCI will then work with government partners to develop an advocacy and community mobilization strategy to provide Health Facility Management Committee members with the knowledge and skills to manage funds effectively, and to ensure that community members have input into how funds are spent. Based on lessons learned from the project, the Ministry of Health — which enthusiastically supports this first-ever evaluation of the DFF reforms —plans to introduce the citizen report card throughout the country. It will serve as a continuous social accountability tool, creating a feedback loop between the national health financing structure and the community, and giving users of the health system a real voice in the services it provides. By empowering communities and building financial management capacity in the facilities themselves, this project offers a new and meaningful opportunity both to improve the quality of care and to increase demand for high-quality services.