A Model for Community Based Monitoring in the Provision of Quality Maternal and Child Health Services

Published by Soul City Institute for Health and Development Communication (SCI) as part of the Reducing Maternal and Child Mortality through Strengthening Primary Health Care in South Africa Programme (RMCH), this document describes the model for community based monitoring in Maternal and Child Health (MCH) services as piloted by the SCI. It explores the implementation process of the model and shares lessons learned from an application of the model.

The community based monitoring (CBM) pilot programme forms part of the South African government's efforts to improve the implementation of primary health care through its Primary Health Care Re-Engineering (R-PHC) strategy. This pilot concentrates on addressing the demand side as opposed to the supply side of health care services, which has received more attention and includes developing infrastructure, improving clinical care, addressing staff shortages and improving efficiency in supply chain management. On the other hand, the demand side puts people at the centre of the delivery of these services as they are given the opportunity to engage with health workers and hold them accountable for the delivery of quality services.

According to this publication, "CBM is a form of public oversight that uses local information to describe and track changes within the health care system. It is aimed at promoting accountability through increased involvement of users in the delivery of health care services. Within the CBM framework, ordinary citizens are given an opportunity to evaluate and critique services, identify areas of improvement and systematically collect data and use it to advocate for changes in the system. As a tool, CBM has been shown to strengthen local capacity, promote public participation and inclusive decision making and promote accountability."

As stated in the document, "the aim of the SCI pilot programme is to build the capacity of and create an enabling environment for communities to monitor the quality of PHC and particularly maternal and child health services. Through this process, communities generate local information in a systematised manner and use it to engage with health workers, holding them accountable for the delivery of quality services. Through information sharing and constructive dialogue, this process results in an improvement in the quality of health services and in turn, improved maternal and child health outcomes."

The document goes on to describe the application of the model (including diagrammes) and some of the lessons learned related to issues such as: the need for consultations at government and community level; the selection and training of CBM teams; the importance of inception community dialogues in order to get community involvement; the actual monitoring process of health services and the use of data collecting tools; working with existing accountability structures in the health system, such as suggestion boxes; the facilitation of public dialogues, which provide a forum where the clinic staff and ward and district officials can be given an opportunity to make input into the process and shed clarity on the issues arising out of the monitoring process, and where dialogue can happen on how the quality of services can be improved; as well as the use of local media to raise public awareness and involvement in the process and to report back on public dialogues.

The document cites the following key lessons learned:

1. "Extensive consultation and buy-in at national and provincial level is important and facilitates smooth implementation at local level.
2. The training and skills building of CBM teams is very important and prepares them for their roles. As part of the training, a tour of the facility and orientation to clinic staff is crucial for smooth implementation and relationship building between CBM teams and health care workers.
3. It is important that CBM team members volunteer their services and understand the importance of the initiative and are not motivated by any stipends or rewards.
4. CBM teams have to be guided to create a system for users of the services to provide feedback and the facility to address the issues; caution should be taken by them not to try to solve problems by doing things.
5. The inclusion of members of clinic committee and other health care cadres such as community health workers onto the CBM teams enhance the way that they work, with due caution not to raise expectations for stipends and other similar remuneration paid to these staff.
6. The facilitatory role of working with community based structures should be strengthened. These should be mapped at initiation.
7. The public dialogues should be well facilitated and issues to be dealt with should be shared and agreed before-hand to enable proper investigation of cases and prepared responses by the relevant people. In addition, the dialogues should deal with issues within the control of the facility and district and any other issues should be escalated appropriately."