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A case study of Tandabui Health Access Tanzania (THAT)

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March 2014 Unblocking Results: A case study of Tandabui Health Access Tanzania (THAT) Julia Tobias and Francis Omondi Acknowledgements The authors are grateful to the AcT team for their support to this
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March 2014 Unblocking Results: A case study of Tandabui Health Access Tanzania (THAT) Julia Tobias and Francis Omondi Acknowledgements The authors are grateful to the AcT team for their support to this research (Kate Dyer, Amani Manyelezi and Rehema Tukai for their inputs, and Layla Ghaid for coordinating the field trip logistics). We thank the team at THAT and Afya Radio for sharing their time and insights. We also thank Marta Foresti and Helen Tilley from ODI for their comments on previous drafts and Catherine Garson for editorial work. Finally, we thank all the interview respondents who gave their time to inform this study. We are also grateful to the UK Department for International Development (DfID) for its funding support. The views expressed in this paper and all responsibility for the content of the study rests with the authors. Contents Acknowledgements Executive summary ii iii 1 Introduction Background on THAT Background on AcT 2 2 The political context The political landscape The health sector The media and political voice 4 3 Governance constraints Policy and institutional coherence Top-down performance disciplines and bottom-up accountability mechanisms The enabling environment for local problem-solving and collective action 7 4 The intervention design Activities and theory of change How the engagement worked Conducting investigative journalism through radio and print media Consultative dialogues between local government, health service providers, and citizens Using a network of CCA volunteers The implementation approach 15 5 Challenges 17 6 Lessons and conclusions 19 References 21 Annex 1: Features of AcT s model 23 Annex 2: Unblocking Results methodology 24 A case study of Tandabui Health Access Tanzania (THAT) i Abbreviations AcT CCA CCM CSO DfID EDFO MKUKUTA RCH SARA THAT TOSA Accountability Tanzania Community Change Agents Chama Cha Mapinduzi (Party of the Revolution) Civil Society Organisation UK Department for International Development Education Development Foundation National Strategy for Growth and Poverty Reduction Reproductive and Child Health Service Availability and Readiness Assessment Tandabui Health Access Tanzania Tanzania Orphans Support Association A case study of Tandabui Health Access Tanzania (THAT) ii Executive summary This case study is part of the Unblocking Results case study series, 1 an ODI research project on aid and governance constraints. Unblocking Results seeks to gather evidence on whether, and how well, aid can help to resolve or mitigate governance problems that often hinder the delivery of broad-based public services in developing countries. Tandabui Health Access Tanzania (THAT), which is a partner organisation of Accountability Tanzania (AcT), was selected as a case study for the Unblocking Results initiative due to its innovative approaches and successes in addressing common governance constraints. The Unblocking Results research methodology has identified a set of potential constraints to effective governance which are common to many country and project contexts (Wild et al. 2012). The constraints are: the degree of policy and institutional coherence, the extent of top-down performance disciplines or bottom-up accountability mechanisms, and the enabling environment for locally anchored problem-solving and collective action. This report reviews these common governance constraints, assesses the extent to which these constraints were relevant to THAT s programming environment, and analyses some of the enabling factors and strategies used by THAT to overcome these constraints and unblock results. Working in collaboration with citizens, local government bodies, health service providers, and other stakeholders, THAT s mission is to mobilise citizens to make better health decisions and to demand greater accountability in the provision of quality health services. By helping to build awareness and facilitate communication between citizens, health service providers, local government officials, and other stakeholders, THAT s strategy aims to address these governance constraints with the ultimate goal of strengthening local health systems. It aims to achieve these goals through three main types of activities: raising awareness on basic healthcare rights and maternal health issues through print media and programming on its own community health radio station, Afya Radio; facilitating dialogues between local government, health service providers, and citizens to encourage local problem-solving; and using a network of Community Change Agent volunteers (CCAs) to educate communities directly about prenatal, antenatal, and other health needs. THAT is a partner organisation of Accountability Tanzania (AcT), a governance initiative supported by the UK Department for International Development (DfID) which seeks to achieve increased responsiveness and accountability of government through a strengthened civil society in Tanzania (outcome mapping brief). Applying the Unblocking Results framework of analysis, our research points to several aspects of the broad political economy landscape of Tanzania, and the political context of the health sector specifically, which are relevant to understanding the environment in which THAT operates. First, regarding policy incoherence and implementation gaps, local government initiatives in the health sector have tended to focus on visible initiatives aligned with political incentives, such as building health facilities, without always going a step further to ensure that facilities are adequately staffed and resourced. This pattern is exacerbated by low awareness among citizens, health providers and local government officials about maternal health services that are supposed to be available, which contributes to accountability constraints and limits the potential for collective action. As a result, pressures from citizens for improved delivery of health services are often lacking, and are sometimes channelled by the political system in ways that result in short-term policy responses that may not effectively address the underlying roots of the problem or may not ensure that the benefits of public services are distributed in a broadbased manner, including to poor and vulnerable groups. 1 Unblocking Results: using aid to address governance constraints in public service delivery (ODI, May 2013). Heidi Tavakoli, Rebecca Simson and Helen Tilley with David Booth. A case study of Tandabui Health Access Tanzania (THAT) iii THAT has used several innovative strategies to tackle these governance challenges. Overall, THAT s efforts have aimed to raise awareness about maternal health issues, related to addressing bottom-up constraints to accountability, which represents an important outcome as part of its theory of change. Innovative strategies to increase flows of information and communication in order to collectively solve local problems have also been implemented. Meanwhile, addressing policy coherence has been more challenging, particularly given that some health and governance issues have proved to be beyond the limits of what can be solved locally and that currently THAT has limited capacity to advocate for policy changes at the national level. Efforts to mobilise citizens to take collective action have also met some challenges, although some progress has been reported particularly at the level of health service providers, who have brought some problems to the attention of local government authorities through facilitated dialogues. Some of the enabling factors and strategies from the Unblocking Results framework that have been most relevant in efforts to address these governance constraints include: acting as a facilitator to support platforms that strengthen collective action and accountability, focusing on opportunities that align with political incentives, and using flexible approaches that enable adaptation to change. Alongside its successes, THAT has confronted several challenges that illustrate gaps between THAT s programming goals and its ability to address some of the governance constraints encountered. These challenges include the constraining effects of shortages of resources and policy incoherence, particularly as some health and governance issues have proved to be beyond the limits of what can be solved locally and THAT currently has limited capacity to advocate for policy changes at the national level. Looking forward, there may be potential for THAT to bring more of the experiences and lessons it has captured at the local level to the attention of nationallevel policy makers in order to achieve heightened impacts. In addition, the strategy of using bottom-up processes for identifying priority issues carries some risk of focusing on problems that are most visible or most easily heard. This approach may make sense as there is a need to prioritise, given the limited capacity of THAT and local government counterparts, but it may carry the risk that it is not always focusing on the concerns of the most needy citizens. In conclusion, several lessons learned from the models of THAT and AcT can be summarised as follows: Providing platforms for facilitated dialogues between multiple stakeholders has been an important component of THAT s strategy to overcome collective action problems and encourage locally anchored solutions. Through its consultative dialogues with diverse representation from communities, health facilities, and other local government offices, THAT s strategy recognises the political and cultural factors that often discourage citizens from taking initiative to bring problems to the attention of local authorities. THAT s focus on facilitating communication and informationsharing between different players in the system rather than aiming to provide solutions directly has been a promising approach towards addressing this constraint and achieving solutions. It also recognises that sharing information alone may not be enough to trigger action and the strategy helps to increase the political payoffs to improving service delivery. Focusing on opportunities where programme goals align with political incentives, while also playing a complementary goal to government by filling in gaps, has been another important lesson. Rather than shying away from the complexity of the governance environment and politics that inevitably affect its programming strategy, THAT s strategy encourages efforts to search for opportunities where programming can align with the incentives and priorities of local government and health sector workers. 2 At the same time, it is important for these strategies to be balanced with a focus on filling in the gaps resulting from low political prioritisation of certain issues that may have less visibility, particularly those affecting marginalised groups with weak political voice. An important feature of AcT s model involves empowering its partners with sufficient flexibility to design and adapt programming strategies as needed in response to changing governance dynamics encountered. In a complex, multi-stakeholder environment such as Tanzania, where governance-related outcomes are inherently uncertain and it is often difficult to directly attribute outcomes to specific activities or programmes, AcT s approach to evaluation has enabled THAT to adapt its programming strategies as needed over time rather than having to rigidly commit to a set 2 This insight on the usefulness of working with political realities echoes a theme emphasised in Wild and Foresti (ODI, 2013). A case study of Tandabui Health Access Tanzania (THAT) iv of pre-determined targets. Key to the success of this approach is a rigorous, competitive process for selecting CSO grantees, as well as good judgement in deciding which partners have strong potential for success. A case study of Tandabui Health Access Tanzania (THAT) v 1 Introduction This case study is part of the Unblocking Results series, an ODI research project on aid and governance constraints. Unblocking Results seeks to gather evidence on how aid can help to resolve or mitigate governance problems that often hinder the delivery of broad-based public services in developing countries. While the development community has long recognised that weak governance and incentive problems hinder the delivery of broad-based public services in developing countries (Keefer and Khemani, 2003; World Bank 2004; Collier 2007), the last decade has seen a growth in research that seeks to understand and diagnose the nature of these governance problems. In particular, this research builds on earlier ODI research by Booth (2010) and Wild et al. (2012) that categorises typical constraints and incentive problems to service delivery, and shows that a number of common constraints underlie much of the variation in service delivery performance in developing countries. However, there is little evidence on whether, and how well, aid can help to resolve or mitigate these governance problems. Research that does exist tends to focus on the impact of specific types of accountability structures on service delivery, rather than the design and delivery features of aid programmes necessary to address such constraints. This research project begins to address this gap in literature by studying the interaction between constraints and aid packages in particular country contexts. This research is exploratory and the findings should be treated as preliminary. It does not aim to evaluate the programmes against their stated objectives, nor measure their impact. Rather, it examines the types of aid-funded activities that seem most relevant to improving governance constraints, making some speculative conclusions about their ability to do so as well as about the elements of the design and implementation approach that have facilitated the execution of these activities. THAT, a partner organisation of AcT, was selected for the Unblocking Results initiative due to its innovative approaches and successes in addressing common governance constraints. A separate linked case study focuses on another of AcT s partner organisations: HelpAge International. The research is based on a desk review of relevant literature, combined with interviews with local stakeholders in two of the districts where THAT s programming operates (Ilemela and Nyamagana districts of Mwanza region) during a three-day period of fieldwork. Interview respondents included staff from THAT and THAT s partner organisations; several local government officials and health sector representatives; staff from two hospitals, one health centre, and one dispensary; and a focus group of patients at a local health centre. The AcT team based in Dar es Salaam was also interviewed. This report does not aim to assess such impacts or attribute them to THAT; the focus instead is on analysing different strategies used without necessarily making claims about their effectiveness. In fact, THAT does not necessarily always aim to separate out its own role in contributing to change as many of its key outcome indicators are about citizens and local governments taking action themselves. The section below provides some brief background information on both THAT and AcT. Section 2 provides a broad overview of the political context surrounding THAT and AcT s programming, followed by a discussion in Section 3 of three key governance constraints affecting the enabling environment. Section 4 covers the main part of the report, which identifies some of the key strategies and innovative aspects which THAT s model has used to address the governance constraints described in Section 3 in order to achieve progress. Finally, in the concluding section, a discussion of some of the challenges faced is presented along with lessons learned and recommendations. A case study of Tandabui Health Access Tanzania (THAT) 1 1.1 Background on THAT THAT seeks to improve access to quality health services of poor and vulnerable populations with a particular focus on maternal and child health. THAT was established in 2008 and started to receive funding from AcT in February THAT has a presence in three districts of Mwanza region (Nyamagana, Ilemela, and Geita) and a team of 17 staff. Working in collaboration with citizens, local government bodies, health service providers, and other stakeholders, THAT s mission is to mobilise citizens to make better health decisions and to demand greater accountability in the provision of quality health services. Tandabui (meaning spider web in Kiswahili) denotes the organisation s strategy of building institutional networks, linkages and partnerships in order to strengthen health systems. To achieve its goal of empowering citizens to advocate for and achieve their rights to basic health services, THAT conducts three main types of activities: raising awareness on basic healthcare rights and maternal health issues through radio and print media; facilitating dialogues between local government, health service providers, and citizens to encourage local problem-solving; and using a network of CCA volunteers to educate communities directly about prenatal, antenatal, and other health needs. One of the most innovative features of THAT s model is its strategic use of media to provide a platform for political leaders to make commitments to improve health services, coupled with efforts to follow up and hold local officials accountable for their promises. 1.2 Background on AcT AcT is a governance initiative supported by DfID which seeks to achieve increased responsiveness and accountability of government through a strengthened civil society in Tanzania (outcome mapping brief). With a portfolio of GBP 31 million over the period , AcT provides grants to large- and medium-sized CSOs that have demonstrated and/or have the potential to demonstrate positive results in strengthening accountability. Within the complex governance environment of Tanzania, AcT represents a unique model for donor support to CSOs addressing challenging governance goals such as improving transparency and strengthening citizens voice in society in order to embed sustainable changes within communities. It is hoped that this case study can help to build knowledge on some of the challenges encountered and strategies used to successfully achieve progress in these areas. To date, AcT has funded 27 CSOs, whose work cuts across a diverse range of sectors (including health, agriculture, natural resources and climate change) but is united by a shared focus on strengthening accountability in Tanzania. AcT s approach recognises that it would not make sense to advocate a single theory or model for strengthening civil society, given the diversity inherent in the goals of its partners. Thus, one of the defining characteristics of the model is the provision of funding to support the strategic goals of its partners (budget support) rather than specific project-based funding. 3 The model also recognises the capacity limitations of some of its partner organisations and particularly the constraints they face within the governance environment in which they operate. A flexible, tailored approach to working with its grantees (referred to as partner organisations ) is a central component of AcT s strategy for confronting these realities. Another notable feature of AcT s model, which is critically examined in this report, is the use of outcome mapping tools 4 to evaluate the achievements of its partner organisations, rather than standard logical frameworks. More details on AcT are provided in Annex 1. 3 One observation from our visit to one of HelpAge s partner organisations, PADI, however is that this model may not always get replicated downstream (i.e. the aid given by HelpAge to PADI was project-based support). As PADI receives multiple sources of funding from different donors, each with their own reporting requirements, the organisation usually tries to projectize funding. It therefore chan
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