Challenges

Most government social service delivery systems in the Eastern and Southern Africa region (ESAR) are characterized by traditional monitoring and evaluation systems that generally monitor inputs/outputs and conduct occasional end evaluations. Limited efforts had been made to monitor the intermediate results of service delivery programmes, for example, identifying and analysing bottlenecks at the appropriate level of decentralization and assessing progress towards outcomes. Furthermore, data was not used adequately to inform planning and programme strategies. This led to an inefficient use of resources by service delivery agencies, ineffective planning and budgeting, and large populations of children who are still underserved.

Thus, there was an urgent need to gather ‘early warning’ data so that intermediate results of government service programmes could be monitored. Moreover, local governments could utilize the monitoring data to make evidence-based decisions to adjust the delivery of public services in a timely manner during the implementation phase, instead of waiting for evaluation results.

Toward a Solution

In response to this challenge, the United Nations Children’s Fund (UNICEF), the U.S. Fund for UNICEF, and Bill & Melinda Gates Foundation supported the development of the ESAR Programme Monitoring and Response (PMR) Initiative in the region, focusing on service delivery programmes in the health and nutrition sectors. This is the first near real-time monitoring (NRTM) programme of its kind in UNICEF that combines subnational data with community feedback to strengthen evidence-based decision-making and planning to improve health and nutrition outcomes for women and children. Key to this initiative is support for decentralized governments to synthesize the NRTM of localized supply-side data in health and nutrition with demand-side community feedback. The programme is also striving to instil a culture of data use and application among health staff.

In 2015, the initiative was rolled out in four pilot countries – Kenya, Eswatini, Uganda and Zimbabwe. Each UNICEF country office has adapted the PMR initiative to its local context. In Kenya, the Government adopted a reproductive, maternal, newborn, child, and adolescent health (RMNCAH) scorecard as an accountability and management tool to drive improvements in child and maternal health. UNICEF Eswatini developed the country’s first Health Management Information System (HMIS) dashboards for use at the subnational level. UNICEF’s SMS-based citizen engagement platform, U-Report, is also used to generate feedback from health facility clients and to promote public health messages. In Uganda, UNICEF has fully automated the RMNCAH scorecard as a dashboard within the District Health Information Software (DHIS2), together with four other NRTM dashboards, including a data quality assurance dashboard, a bottleneck

analysis (BNA) dashboard, an action tracker dashboard, and a stock management dashboard. In Zimbabwe, UNICEF developed a community-based NRTM system to strengthen the evidence base of the Multisectoral Community-based Approach for Reduction of Stunting (MSCBARS) Programme.

Following these interventions, local health departments in Kenya have used the dashboard data effectively for evidence-based advocacy to raise resources for the heath sector. In Eswatini, UNICEF worked with the Government at the national level to standardize input fields in data entry, which has led to improvements in data quality. In Uganda, U-Report findings and data quality assessments at health facilities are having a positive impact on results in the target districts, including reduced drug stock- outs, reduced health worker absenteeism and increased uptake of RMNCAH services. In Zimbabwe, the data have further supported evidence-based planning by four Food and Nutrition Security Committees. This has resulted in more equitable distribution of the limited resources available and a prioritization of interventions to prevent stunting in children, both at the district and subdistrict levels.

The PMR initiative also has a central knowledge exchange component that supports peer-to-peer learning and sharing of solutions among implementing countries and beyond. By facilitating the transfer of knowledge to other countries in Africa and globally, the knowledge exchange system is a key driver for South-South cooperation on NRTM in health and nutrition interventions. At the heart of this knowledge exchange system is an online community of practice (known as the real-time monitoring community of practice, or RTM CoP), which facilitates the sharing of good practices, lessons and solutions that support further replication of the initiative in the region and globally. The knowledge exchange system also focuses on documenting lessons learned in each pilot country. Ten lessons learned and three case studies have been produced to date, providing valuable knowledge for each country and regionally. In addition, inception meetings, annual reviews and study exchange visits facilitate face-to-face, cross-country knowledge transfer.

To support scale-up and sustainability in each current pilot country, the national and decentralized administrations – not UNICEF – own and drive policy and action related to the use of near real-time data for action in health and nutrition. Moreover, all countries have scale and sustainability measures built into programme design. Going forward, UNICEF’s advocacy focuses on institutionalizing the PMR initiative in the national budget for each country.

Given the success of the pilot countries in ESAR and the efforts of the regional initiative to cross-fertilize solutions to other regions, the PMR initiative is currently being replicated in the West and Central Africa region (WCAR). Within ESAR, UNICEF is exploring the possibility of extending NRTM to Malawi, Tanzania and Zambia in 2018. UNICEF is also considering the application of NRTM in other sectors, such as education and water, sanitation and hygiene (WASH).