Using near real-time data to improve local health services

 

A community health volunteer diligently enters the details of every household into a mobile phone application. The most remote locations are reached on foot, so that every woman and child is counted and accounted for. These data provide actionable information about the resources needed to give children a fair start in life. Once put into the right hands, the data she enters will be used to hold decision makers to account and drive improvements in child and maternal health. They may result in the provision of lifesaving supplies or skilled health personnel at the understaffed clinic down the road. At the same time, the community health volunteer educates the household on the free healthcare services available to them, allaying any concerns, encouraging women to attend antenatal care appointments and arranging for them to give birth in a health facility. These interventions will give the best start in life to a newborn and could even save the life of mother and baby.

A recent project, the Programme Monitoring and Response (PMR) initiative, funded by the Bill and Melinda Gates Foundation seeks to contribute to improved health outcomes for women and children in Eastern and Southern Africa (ESAR) through decentralized data collection and use. For the first time, UNICEF is combining subnational, near real-time monitoring (NRTM) with community feedback to strengthen evidence-based decision-making and planning at the village, ward and district levels where services are delivered. UNICEF country offices in Kenya, Swaziland, Uganda and Zimbabwe are supporting governments to implement this approach, adapted to each country’s context to help inform sustainable and scalable approaches to decentralized data-collection and use, and promote citizen engagement in government service delivery.

The key objective of the initiative is to enhance programme performance through strengthening near real-time monitoring of community health and nutrition services, social accountability, evidence-based programme adjustments and citizen feedback loops, as well as peer-to-peer learning within and between countries.

The initiative is designed to foster continual learning by UNICEF, government staff, local communities and other partners in implementing countries to refine the project but also to capture and share the experience with others. Let’s take a closer look at some of the lessons that emerged from this initiative:

 

Use of the reproductive, maternal, newborn, child and adolescent health (RMNCAH) scorecard to strengthen data-driven service delivery in Kenya

Kenya has made significant progress in reducing child and infant mortality in the past decade, but significant challenges remain. The Government of Kenya has adopted an RMNCAH scorecard as an accountability and management tool to drive improvements in child and maternal health. Through the Programme Monitoring and Response Initiative in ESAR, UNICEF Kenya is providing technical assistance for further development and customization of the scorecard. UNICEF is supporting the roll-out of the RMNCAH scorecard at decentralized levels (county, sub-county, and ward), with near real-time monitoring of health services across all tiers of the health system. This includes providing support to decision makers based on near real-time monitoring data, and an action tracker dashboard to facilitate feedback to communities and health service delivery managers on resulting improvements to service provision.

Key lessons learned around needs include:

  • improving knowledge of monitoring and evaluation among government staff;
  • conducting causal analysis to identify effective actions to improve health services;
  • building further capacity for community health volunteers and health staff to use required technology;
  • and improving data visualization during community meetings.

 

Government leadership in ensuring citizen feedback on health in Swaziland

 The UNICEF Programme Monitoring and Response Initiative in ESAR is also supporting Swaziland to develop the first-ever subnational health dashboards. These dashboards display the status of important health indicators related to nutrition, immunization and antenatal care, among others, which are generated by near real-time monitoring of health facility data. The key focus of the initiative is strengthening the newly piloted electronic health Client Management Information System to generate reliable and quality real-time data, with staff capacity-building for the use of that data for planning and monitoring health interventions. UNICEF Swaziland has also introduced U-Report, an SMS-based citizen engagement platform, to generate feedback from health facility clients and to promote public health messages.

Key lessons learned around needs include:

  • engaging with the Government of Swaziland as a critical first step in introducing U-Report followed by explaining how the platform could be used as a health system strengthening platform to gain the trust and understanding of health workers;
  • and the significance of improving data quality as part of the near real-time monitoring process.

 

Promoting bottleneck analysis for action and accountability on maternal and child health in Uganda

 Uganda is generating a wealth of data to support maternal and child health while empowering district governments and health facilities to discuss and use these data for planning to improve service delivery for women and children. In support of this effort UNICEF Uganda has developed a customized set of integrated near real-time monitoring dashboards for District Health Information Software (DHIS2), including a bottleneck analysis tool to support evidence-based decision-making and action on the RMNCAH scorecard at the decentralized level. The initiative has yielded immediate results in decision-making based on bottleneck analysis data at the district level.

Key lessons learned around needs include:

  • promoting the multisectoral nature of near real-time monitoring beyond a focus on monitoring and evaluation;
  • accommodating the different speeds at which various components of the health management information system are developing by embracing a hybrid, automated and paper-based system which identifies gaps in data sources;
  • sustaining community dialogues through existing structures within the health system;
  • and meeting the expectations of communities and health workers through resource re-allocation or resource mobilization to address issues identified by bottleneck analysis and community dialogue.

 

Adaptive programming key to real-time monitoring for stunting reduction in Zimbabwe

 Malnutrition, particularly child stunting or low height for age, continues to be a major public health concern and socio-economic challenge in Zimbabwe, affecting nearly one in three children under the age of five years (27.6 per cent). A new approach to reducing stunting among children coordinates action across sectors, including nutrition, agriculture, health, water, sanitation and hygiene, education and social protection. The Multisectoral Community-based Approach for Reduction of Stunting (MSCBARS) Programme, managed by Zimbabwe’s Food and Nutrition Council, is being implemented in four pilot districts and seeks to make communities agents for stunting reduction, by enhancing the capacity of community-based Food and Nutrition Security Councils (FNSCs) to use near real-time monitoring and social accountability data for timely, local decision-making. The MSCBARS Programme previously relied on sporadic and paper-based data-collection.

Key lessons learned around needs include:

  • balancing delays in implementation;
  • improving the consistency and quality of data input into the near real-time monitoring system;
  • and the potential of near real-time monitoring to mainstream effective nutrition service delivery across sectors.

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