Takingcommunitymobilizationtoscale:TheevolvingapproachtocommunitymobilizationoveradecadeofUSAID-fundedprogrammingbySavetheChildreninBangladesh

Submittedto:

SavetheChildren,USAMarch2018ErinC.Hunter,CHES,MSPHSavetheChildrenUSAGuyerFellow2017

AcknowledgementsThisdocumentationactivitywasconceptualizedbyAntjeBecker-Benton(SeniorAdvisor/TeamLeader,BehaviorChangeandCommunityHealth,DepartmentofGlobalHealth,SavetheChildrenUSA)andImteazMannan(SeniorAdvisorAdvocacyandCommunication,MaMoniHSSProject,SavetheChildrenBangladesh).WiththegeneroussupportofaGuyerFellowship,IwasaffordedtheopportunitytoassistinbringingtheirvisiontofruitionbyreviewingextensiveprojectdocumentationandinterviewingkeyplayersinvolvedintheUSAID-fundedandJhpiego-ledprojectsACCESSBangladesh,MaMoniISMNC-FP,andMaMoniHSS,whereSavetheChildrenperformedasthetechnicallead.Thisreportwouldnothavebeenpossiblewithouttheirvision,guidance,andinsight.Iwouldalsoliketoacknowledgethehostofindividualswhogavetheirtimetobeinterviewedabouttheirexperienceworkingwithinthedocumentedprojects.TheircandiddiscussionswereinvaluableinallowingustobetterunderstandthehistoryoftheseprojectsandthedecisionsthatweremadeovertimethatledtothemodelsofcommunitymobilizationinusetodaybySavetheChildrenBangladesh’sUSAID-fundedhealthprojects.Finally,thanksareduetothosewhoreadandprovidedconstructivefeedbackonearlierdraftsofthereport:AntjeBecker-Benton,ImteazMannan,JobyGeorge,andJosephJohnson.SavetheChildreninBangladeshacknowledgesthefundingofthedocumentedprojectsbytheUnitedStatesAgencyforInternationalDevelopment(USAID).

AcronymsAC ACCESSCounselorACCESS Accesstoclinicalandcommunitymaternal,neonatal,andwomen’s

healthservicesAHI AssistantHealthInspectorAL AwamiLeagueANC AntenatalcareBNP BangladeshNationalPartyCAC CommunityActionCycleCAG CommunityActionGroupCCS CommunitycapacitystrengtheningCDC CommunityDevelopmentCommitteeCG CommunityGroupCHW CommunityhealthworkerCL CommunityLeadercMPM CommunityMicroplanningMeetingCmSS CommunitySupportSystemCPR ContraceptiveprevalencerateCSA CommunitySalesAgentCSG CommunitySupportGroupCSM CommunitySupervisors-MobilizersDGFP DirectorateGeneralFamilyPlanningDGHS DirectorateGeneralHealthServicesEMNC EssentialmaternalandnewborncareESP EssentialServicesPackageFIVDB FriendsinVillageDevelopmentBangladeshFP FamilyplanningFPI FamilyPlanningInspectorFWA FamilyWelfareAssistantHA HealthAssistantHPSP HealthandPopulationSectorProgramHPSS HealthandPopulationSectorStrategyHSS HealthsystemsstrengtheningIPC InterpersonalcommunicationISMNC-FP Integratedsafemotherhood,newborncare,andfamilyplanningMCHIP MaternalandChildHealthIntegratedProgramMIS ManagementinformationsystemMMR MaternalmortalityratioMNCH/FP/N Maternalandnewbornhealth,familyplanning,andnutritionMNCSP MaternalNewbornCareStrengtheningProjectMNH MaternalandnewbornhealthMOH&FW MinistryofHealthandFamilyWelfare

MPV MultipurposeHealthVolunteerNGO Non-governmentorganizationNIPORT NationalInstituteofPopulationResearchandTrainingPNC PostnatalcareProjahnmo ProjectforAdvancingtheHealthofNewbornsandMothersSACMO SubAssistantCommunityMedicalOfficerSBCC SocialandBehaviorChangeCommunicationSCBD SavetheChildrenBangladeshSEARCH SocietyforEducation,Action,andResearchinCommunityHealthSMC SocialMarketingCompanySNL SavingNewbornLivesTFR TotalfertilityrateUH&FWC UnionHealthandFamilyWelfareCentersUPPR UrbanPartnershipsforPovertyReductionUSAID UnitedStatesAgencyforInternationalDevelopmentVDC VillageDevelopmentCommittee

TableofContents

Acknowledgements............................................................................................................2Acronyms............................................................................................................................3Executivesummary............................................................................................................6Introductionandmethods.................................................................................................8

Introduction................................................................................................................................8Methods......................................................................................................................................9Challengesandlimitations........................................................................................................10

Background.......................................................................................................................11StatusofmaternalandnewbornhealthinBangladesh............................................................11GovernmentofBangladesh’sprimaryhealthcaresystemandlocalgovernmentstructure....12Overviewoffoundationalresearchinformingthehighlightedprojects...................................14

Historyandevolutionofcommunitymobilizationapproaches.......................................15ACCESS/BangladeshSafeMotherhoodandNewbornCareProject(2006-2009).....................16MaMoniIntegratedSafeMotherhood,NewbornCareandFamilyPlanningProject(2009-2013).........................................................................................................................................23MaMoniHealthSystemsStrengtheningProject(2014-2018)..................................................29

Communitymobilizationatscale:Strengthsandchallenges...........................................32Evolvingapproachesinstepwithshiftingpoliticalprioritiesforhealth....................................32Evaluatingoutcomesofcommunitymobilization:Challengesinmeasurement......................34

Waysforwardforfutureprogramming............................................................................35References........................................................................................................................37ANNEXI:Keyprojectdocumentsreviewed......................................................................40ANNEXII:Listofkeyinformants.......................................................................................43ANNEXIII:Samplekeyinformantquestions.....................................................................45ANNEXIV:Summarytable................................................................................................46

ExecutivesummarySince2006,SavetheChildrenBangladeshhasbeenactiveinaddressingcommunityhealthneedsthroughaseriesofthreelarge,USAID-fundedprojectstosupportmaternalandnewbornhealth,familyplanning,andnutrition.Thisreportexaminestheevolutionandcontributionsofthoseprojects’approachestocommunitymobilizationatincreasingscale.Itisouraimthatbydocumentingtheprojects’experiences,learnings,anddecisionsthatledtothisevolutionovertime,SavetheChildrenstaff,donors,andotherimplementersmayhaveabetterunderstandingofhowSavetheChildrenBangladesharrivedattheircurrentapproachtocommunitymobilization,andwhatmightbeexpectedwhenattemptingsuchworkinthefutureorinothercontexts.Despitethecommonassumptionthatcommunitymobilizationcannotbeimplementedatscale,thelateriterationsofSavetheChildrenBangladesh’sprojectshighlightedinthisreporthavearguablydoneso.However,amodelthatsustainscommunitymobilizationatscaleintheBangladeshcontexthascometolookverydifferentthanitdidwhenoriginallyconceptualized.Throughmakingcertainshiftsandcompromisesandbuildinguponsuccesses,SavetheChildrenBangladeshhas,overthelastdecade,movedfromimplementingaboutiqueprojectbasedonanintensiveproject-ledcommunitymobilizationmodeltoachievingscalethroughinstitutionalizingcommunitymobilizationactivitieswithinexistinggovernmentstructures—andtherebybetterensuringresponsivenessofthesystemtocommunityhealthneeds.TheACCESSproject(2006-2009)usedanintensiveproject-drivenapproachtocommunitymobilizationthatusedhomevisitorstoprovidehealtheducationtomothersandestablishedCommunityActionGroups.ThesegroupsfollowedaprescriptiveprocessknownastheCommunityActionCycletoidentifyandaddresstheirowncommunity’smaternalandnewbornhealthissues.Asacommunity-basedprojectwithoutlinkedfacility-basedinterventions(asmandatedbythedonor),ACCESSwassuccessfulinincreasingknowledgeaboutmaternalandnewbornhealthandcreatingdemandforservices,butimprovementsinhealthservicesutilizationwasminimalduetotheunavailabilityofmanyservices—causedbywidespreadstaffvacanciesandotherserviceconstraints.Inordertoscaleupanddevotefocustoensuringtheprovisionofservices,theMaMoniIntegratedSafeMotherhood,NewbornCare,andFamilyPlanningproject(2009-2013)expandedtoincludefacility-basedserviceimprovement,simplifiedandshortenedtheCommunityActionCycle,andreliedincreasinglymoreonCommunityVolunteerstofacilitateCommunityActionGroupmeetingsratherthanprojectstaff.Theprojectintroducedcommunitymicroplanningmeetingsinordertoprovideadirectinterfacebetweencommunitymembersandthehealthsystem.TheseregularmeetingsenabledCommunityVolunteerstoshareinformationfromtheircommunitieswiththegovernment’soutreachworkerstobetterensureaccuracyoftheirregistersandtomake

actionplanstoaddressspecificbarrierstoservicesintheirlocality.Theprojectalsobeganengaginglocalgovernmenttomobilizeresourcesforimprovingpublicsectorfacilities.BuildinguponthesuccessofthefirstMaMoniproject,thefollow-onprojectMaMoniHealthSystemsStrengthening(2013-2018)furtherinstitutionalizedthecommunitymicroplanningmeetingsandgaveincreasedattentiontoleveragingtheinvolvementoflocalgovernmenttoaddressbarrierstoserviceutilization.TheprojectreactivatedthedefunctUnionEducationHealthandFamilyPlanningStandingCommitteemeetingsofUnionParishadsandorientedlocalgovernmentofficialsontheirauthorizedrolesandresponsibilitiesasoutlinedbytheGovernmentofBangladesh.TheprojectensuredUnionParishadmembersandstandingcommitteememberswereawareoftherangeofactivitiesthatwerewithintheirscopetosupportandsuccessfullyadvocatedforUnionParishadfundsbeallocatedtoaddresslocalhealthneeds.SavetheChildrenBangladesh’sapproachestocommunitymobilizationatscaledidnotevolveovertimeinisolationaccordingtoastrictideology.Rather,theapproacheswerenecessarilyresponsivetotheshiftingprioritiesofthelargerprojectsinlinewiththegovernment’sevolvingprioritiesforhealthandchangesingovernmentstructures.SavetheChildrenbeganbyinfusingtremendousprojectsupportintoestablishinganinitialheavily-structuredmodelforcommunitymobilizationappropriatefortheBangladeshicontextunderACCESS,andthensubsequentlystreamlinedtheapproachandsoughtwaystointegrateitintoexistingsystemsatanationalscale.UnlikewhenACCESSwasfirstimplemented,communitymobilizationisnowpartoftheGovernmentofBangladesh’shealthstrategy,andgovernmentstructureshavebeenestablishedtofacilitatetheengagementofcommunitymembersandlocalrepresentativesinidentifyingservicegaps,providingfacilityoversight,andmobilizinglocalfundstoaddresshealthandfamilyplanningneedswithinlocalcommunities.SavetheChildrenBangladesh,alongwithothernon-governmentalorganizationsinthecountry,hasmadekeycontributionsinidentifyinguniqueopportunitiesformeaningfulinterfacesbetweengovernmentandcommunitiesandworkingtoinstitutionalizethosemodelsofengagementatdistrictandnationalscales.SavetheChildren’supcomingproject,MaMoniMaternalNewbornCareStrengtheningProject(2018-2023)willfocusonsupportingtheexistinggovernmentstructuresandremovingrelianceonparallel,project-drivensystemsforcommunitymobilizationwhichmaynotbeassustainable.

Introductionandmethods

IntroductionSince2006,SavetheChildrenBangladesh(SCBD)hasbeenactiveinaddressingcommunityhealthneedsthroughaseriesofthreelargeUSAID-fundedprojectstosupportmaternalandnewbornhealth,familyplanning,andnutrition.SavetheChildrenconceptualizescommunityhealthprogrammingascomprisingthreecomponents[Figure1&Table1]:communityservicedelivery,communitycapacitystrengthening,andcommunity-ledsocialandbehaviorchangecommunication(SBCC).1Overthecourseofthepastdecade,therelativeemphasisofeachofthesethreecomponentswithinSCBD’sprojectshasvaried.However,communitycapacitystrengtheninghasconsistentlyplayedarole—evenasSCBD’sapproachsignificantlyevolvedovertheyearsasimplementationexperiencegrew,governmentprioritiesandstructureschanged,anddonorinterestsshifted.Table1:Definitionofcommunityhealthprogrammingcomponents

Componentofcommunityhealthprogramming

DefinitionusedbySavetheChildren

Communityservicedelivery

Theprovisionofacontinuumofhealthpromotion,diseaseprevention,andcurativeservicesbyacadreofcommunityhealthworkersandcommunitygroupsresponsivetocommunityneedsandcontext;thisincludesconceptsofaccountabilityandqualityimprovementsfromacommunityperspective

Communitycapacitystrengthening

Theprocessthroughwhichcommunitiesobtain,strengthenandmaintainthecapabilitiestosetandachievetheirowndevelopmentobjectivesovertime2

Community-ledsocialandbehavior

changecommunication

Thesystematicapplicationofinteractive,theory-based,andresearch-drivenprocessesandstrategiestoaddresssocialandbehavioralchangeattheindividual,community,andsociallevels,includingthecrosscuttinguseofstrategiccommunication1

Communitycapacitystrengtheningreferstoaprocessthroughwhichcommunitiesobtain,strengthenandmaintaintheircapabilitiestosetandachievetheirowndevelopmentobjectivesovertime.2CommunitymobilizationisacommonlyusedapproachinmanySavetheChildrenprojectstohelpstrengthencommunitycapacitytoeffectimprovementsincommunityhealth.3SavetheChildren’sdefinitionofcommunitymobilizationreferstoaprocessthroughwhichcommunitymembers,groups,ororganizationsplan,carryout,andevaluateactivitiestoachieveacommongoal—throughtheirowninitiativeorstimulatedbyothers.2Communitymobilizationcan

Figure1:ComponentsofCommunityHealthProgramming

enablecommunitymemberstobetterunderstandthehealthissuesimportantintheirlocality,identifywhatissuesmaybeinhibitingtheuseofinformationorservices,engageincollectiveactiontoaddressthem,andinsodoingultimatelyincreasedemandforanduseofservices.4ThisreportexaminestheevolutionandcontributionsofthreeSavetheChildrenBangladeshprojects’evolvingcommunitycapacitystrengthening/communitymobilizationactivities.BecauseofthesesuccessionalUSAID-fundedprojects,SavetheChildrenBangladeshpresentsauniqueopportunitytoexploresuchanevolutionofapproachesatincreasingscaleoveranextendedperiodoftime.Despitethecommonassumptionthatcommunitymobilizationcannotbeimplementedatscale,thelateriterationsofSavetheChildrenBangladesh’sprojectshighlightedinthisreporthavearguablydoneso.However,amodelthatsustainscommunitymobilizationatscaleintheBangladeshcontexthascometolookverydifferentthanitdidwhenoriginallyconceptualized.Throughmakingcertainshiftsandcompromisesandbuildinguponsuccesses,SavetheChildrenBangladeshhas,overthelastdecade,movedfromimplementingaboutiqueprojectbasedonanintensiveproject-ledcommunitymobilizationmodeltoachievingscalethroughinstitutionalizingcommunitymobilizationactivitieswithinexistinggovernmentstructures—andtherebybetterensuringresponsivenessofthesystemtocommunityhealthneeds.Itisouraimthatbydocumentingtheprojects’experiences,learnings,anddecisionsthatledtothisevolutionovertime,SavetheChildrenstaff,donors,andotherimplementersmayhaveabetterunderstandingofhowSavetheChildrenBangladesharrivedattheircurrentapproachtocommunitymobilization,andwhatmightbeexpectedwhenattemptingsuchworkinthefutureorinothercontexts.Thereport’sbackgroundsectionbeginswithanoverviewofthematernalandneonatalhealthcontextinBangladeshandthenprovidesabriefintroductiontotheGovernmentofBangladesh’scommunityhealthsystemandlocalgovernmentstructures—anunderstandingofwhichareimportantbecauseofsubsequentdiscussionsregardingSavetheChildrenBangladesh’sworktolinkcommunitymemberswithexistinggovernmentstructuresfortheimprovementofhealth.ThebackgroundsectionconcludesbyhighlightingkeyresearchstudiesthatformedtheinitialfoundationsofSavetheChildrenBangladesh’smaternalandneonatalhealthprojects.Thesubsequentsectionoutlinesthehistoryandkeyhighlightsofeachofthethreeprojects’approachestocommunitymobilization.ThereportconcludeswithadiscussionofthekeyfactorsthathaveemergedovertimeasimportantforcommunitymobilizationatscaleinBangladeshandrecommendedwaysforwardforfutureprogramming.

MethodsThisdocumentationactivitywaslargelyconductedinlate2017andcomprised1)areviewofkeydocuments,2)keyinformantinterviews,and3)aseriesofanalysisworkshopmeetings.

TheauthorreviewedkeydocumentsregardingSavetheChildren’scommunitymobilizationworkglobally,aswellasproject-specificdocumentsconcerningthreelargeUSAID-fundedprojectsledbyJhpiegoandimplementedbySavetheChildrenBangladeshsince2006.Thesedocumentsincludedprojectproposals,monitoringandevaluationplans,quarterlyandannualreports,PowerPointpresentations,communitymobilizationstrategydocuments,andreportsofpreviousdocumentationactivities,amongothers(AnnexI:Keyprojectdocumentsreviewed).Basedoninitialplanningmeetingsandapreliminaryreviewofkeydocuments,theauthorcompiledalistofkeyinformantsfamiliarwiththecommunitymobilizationworkofthetargetedprojectsanddevelopedalistofquestionstoguideinterviews.ThoseparticipatingininterviewswereprimarilystafffromSavetheChildrenBangladesh,SavetheChildrenUSA,andpartnerNGOsimplementingtheprojectsinSylhetandHabiganj,Bangladesh(AnnexII:Listofkeyinformants&AnnexIII:Keyinformantquestions).AseriesofanalysisworkshopswithAntjeBecker-Benton(SeniorAdvisor/TeamLeader,BehaviorChangeandCommunityHealth,DepartmentofGlobalHealth,SavetheChildrenUSA)andImteazMannan(SeniorAdvisorAdvocacyandCommunication,MaMoniHSSProject,SavetheChildrenBangladesh)attheSavetheChildrenBangladeshofficeinearlyDecember2017werecriticalinreachingconsensusonthemainconclusionsanddevelopingaframeworkforthereport.

ChallengesandlimitationsThedocumentationactivitywasoriginallyplannedforSummer2016.However,duetolocalsecurityconcerns,SavetheChildrenBangladeshimplementedtravelrestrictionsforforeignersmovingwithinthecountry.TheGuyerFellowship,whichfundedthisactivity,wasputonholduntillate2017whenthefellowwasavailabletoconductthedocumentationactivityandhadfreedomtotravelwithinBangladesh.TheauthortraveledtoSylhetandHabiganjtointerviewkeyinformantsknowledgeableaboutprojectactivities,butwasunabletodirectlyobservecommunitymobilizationactivities.Thereportsynthesizesfindingsofpriordocumentationactivities,reportstofunders,internalprojectdocumentsandopinionsexpressedbykeyinformantsfamiliarwiththeprojects—itdoesnotattemptareanalysisofmonitoringandevaluationdata.Furthermore,itisnotintendedtobeanexhaustivedocumentationofthecommunitymobilizationstrategiesofeachproject(suchdocumentsarealreadyavailable);ratheritfocusesontheirevolutionovertime.Asthereporttouchesonoveradecadeofprogramming,thereisthechancethatkeyinformants’recallofearliereventsordecisionsmadeinearlierprojectscouldbebiasedorincomplete.

Background

StatusofmaternalandnewbornhealthinBangladeshThe2010BangladeshMaternalMortalityandHealthCareSurveyshoweda40%declineinthematernalmortalityratio(MMR)overthenineyearsprior—fallingfrom322/100,000livebirthsin2001to194/100,000livebirthsin2010.5By2010,27%birthswereattendedbytrainedprovidersand23%wereconductedinfacilities(10%public,11%private).5Thirty-onepercentofmaternaldeathswereattributedtopostpartumhemorrhageand20%toeclampsia.5

Therecentlyreleasedpreliminaryresultsofthe2016BangladeshMaternalMortalityandHealthCareSurveyshowedanincreaseinfacility-baseddeliveriesfromthe2010figurestoacurrent47%(14%public,29%private),howevertheMMRincreasedto196/100,000livebirths.6Postpartumhemorrhageandeclampsiaremainthelargestcontributorstomaternaldeaths,andtheriskofdyingfromthesecomplicationshasremainedvirtuallyunchangedsince2010.6SavetheChildrenBangladeshinterpretsthepreliminaryfindingsofstagnatingMMRdespiteanincreaseinfacility-baseddeliveriesasaclearindicationthateffortshavebeensuccessfulinincreasingserviceutilizationacrossthecountry,yetthemajorityoffacilitiesarenotfullyreadytoprovidehighqualitymaternitycare.6The2014BangladeshDemographicandHealthSurveyfoundthatBangladeshachievedtheMillenniumDevelopmentGoal4byreducingtheirunder-5mortalityto46deathsper1,000livebirths.7Infantmortalityis38deathsper1,000livebirthsandneonatalmortalityis28per1,000livebirths—meaningneonataldeathscomprise61%ofallunder-5deaths.7Neonatalmortalityhasfallenby46%overthepasttwodecadesinBangladesh.7Accordingtothe2014BangladeshDemographicandHealthSurvey,keynewborncarepracticeshaveimprovedsince2007.7Amonghomebirths,theuseofboiledinstrumentsforcordcuttinghasincreasedfrom62%to83%,dryingwithinfiveminutesofbirthhasincreasedfrom6%to67%,andthepracticeofdelayingbathinguntilafter72hourshasincreasedfrom17%to34%.7

Thetotalfertilityrate(TFR)inruralareasis2.4,whiletheurbanTFRis2.0birthsperwomanofreproductiveage.7Thecontraceptiveprevalencerate(CPR)ofanymodernmethodhasincreasedfrom47.5in2007to54.1in2014.7InthelowperformingdivisionofSylhet,theratehasincreasedfrom24.7in2007to40.9in2014.7Thepercentageoflastlivebirthsinthethreeyearsprecedingthesurveyforwhichwomenreceivedfourormoreantenatalcare(ANC)visitsfromanyproviderincreasedfrom22.0%in2007to31.2%in2014.7

GovernmentofBangladesh’sprimaryhealthcaresystemandlocalgovernmentstructureCommunityClinicsInthemid1990s,theBangladeshgovernmentreformeditsMinistryofHealthandFamilyWelfaretomovefromaproject-drivenapproachtosector-wideprogramming,management,andfinancing.TheHealthandPopulationSectorStrategy(HPSS)wasapprovedin1997,andtheinitialimplementationplanforthestrategy,knownastheHealthandPopulationSectorProgramme(HPSP),beganimplementationin1998.OneofthekeycomponentsoftheHPSPwastoestablishanEssentialServicesPackage(ESP)designedtoaddressthehealthandfamilyplanningneedsofthemostvulnerable—particularlypoorwomenandchildreninruralareas.8

TofacilitatedeliveryoftheEssentialServicesPackage,asystemofCommunityClinicswasestablishedacrossthecountry(1per6000population).Asthelowesttierhealthfacilitywithinthepublicsector,CommunityClinicswereoriginallydesignedtoprovidefree-of-chargehealtheducationandpromotion,treatmentofminorailments,firstaidofminorinjuries,screeningfornon-communicablediseases,andreferralstohigher-levelfacilitiesinthecaseofemergenciesorcomplications.8EachCommunityClinicwastobestaffedbycommunity-basedfieldworkers—aHealthAssistant(HA)andaFamilyWelfareAssistant(FWA)accountabletotheDirectorateofHealthServicesandtheDirectorateofFamilyPlanningrespectively(duetotheMinistryofHealthandFamilyWelfare’sdichotomousstructure).

Withtheacknowledgementthatpublicsectorservicescouldnotalonemeetalltheneedsofthepopulation,effortwasmadetobuildpartnershipswithcommunitiestoensureparticipatorysupportandsustainabilityoftheCommunityClinics.9Thegovernmentprovidedresourcesfortheclinics’construction,staffsalaries,equipment,andmedicines,butcommunitieswereresponsiblefordonatinglandfortheclinicsandforestablishingCommunityGroups(CG)tosuperviseclinicconstruction,provideoperationalmanagement,ensureregularmaintenanceandrepairs,andtomotivatecommunitymemberstoseekservices.9

By2001,10,723CommunityClinicshadbeenconstructed,butonly8,000hadbegunfunctioning.10Withthechangeingovernmentin2001,theCommunityClinicsclosedforseveralyearsasprioritiesshifted.11Since2009,thegovernmenthasbeenundertakingarevitalizationoftheCommunityClinicsystem.Astudyin2012toassessthedevelopmentandfunctioningoftheclinicsfoundthemtobecontributingpoorlytotheEssentialServicesPackage.8Alargeproportionofclinicswereclosedorpoorlymaintained,thereweresevereshortagesofsupplies,staffhadinsufficientskills,andcommunitiesconsideredtheservicestobeoflowquality.8

TheGovernmentofBangladeshisnowimplementingitsfourthsector-wideprogram(2017-2022),andeffortshavebeenmadetoincreasecommunityengagementthroughtheCommunityClinics.InadditiontoCommunityGroupsthataremeanttoplay

managerialroles,CommunitySupportGroups(CSG)arebeingestablished(3perCommunityCliniccatchmentarea)toraiseawarenessincommunitiesregardingbasichealthbehaviorrecommendationsandtheavailabilityofservicesattheclinic.12TheCommunitySupportGroupsweredirectlymodeledafterCAREBangladesh’sCommunitySupportSystem(CmSS).13

Box1:CAREBangladesh’sCommunitySupportSystem(CmSS)13

In1999,CAREBangladeshcreatedtheCommunitySupportSystem(CmSS)tohelpcommunitymemberstakeownershipoftheirrolesinimprovingmaternalandnewbornhealthinpoor,ruralareasofthecountry.TheCmSSconsistsofaprocesstoidentifylocalcausesofmaternaldeaths,involvecommunitymembersinidentifyingtheirrolesinpreventingsuchdeaths,andestablishlinkageswiththehealthsystemandlocalgovernmenttoaddressconcerns.TheCmSStracksallpregnantwomenandsupportsthemasneededtoensuresafepregnanciesanddeliveries.

Furthermore,thelatestsectorprogramalsosupportstherevitalizationofunion-levelfacilitiesknownasUnionHealthandFamilyWelfareCenters(UH&FWC)thatarestaffedwithprovidersmorehighlyskilledthanthoseatCommunityClinics.Thesefacilitiesperiodicallyconduct“satelliteclinics”whereUH&FWChealthworkersprovideservicessuchasimmunizations,antenatalandpostnatalcare,andfamilyplanningtoremotepopulationsthatareunabletoaccessfacilitieswithintheircommunities.LocalgovernmentstructureBangladeshcompriseseightmajoradministrativedivisions(knownasstatesorprovincesinothercountries).Thesedivisionsaredividedfurtherinto64districts,whicharefurtherdividedintosubdistrictsorupazilas.Inruralareas,subdistrictsarefurtherdividedintounions—thesmallestruraladministrativeunit.ThesmallestlocalgovernmentunitisknownastheUnionParishad(UnionCouncil)[Figure2],whichconsistsofanelectedchairmanandtwelveelectedmembers—threeofwhichmustbewomen.14

Figure2:BangladeshLocalGovernmentStructure

Inadditiontotheelectedboardofmembers,UnionParishadsaremandatedtohaveatleast13standingcommitteesonissuessuchashealth,familyplanning,education,agriculture,andsocialwelfare.Althoughstandingcommitteesshouldmeeteverytwomonths,mostofthesestandingcommitteesacrossthecountryarenonfunctioningduetochairmen’sandmembers’lackofawarenessorinterestabouttheirfunctions.

OverviewoffoundationalresearchinformingthehighlightedprojectsSavetheChildrenBangladesh’sworkhighlightedinthisdocumentationactivityleveragedlearningsfromanumberofprecursorresearchstudiesonpreventingmaternalandneonatalmortality.Mostdirectly,thefindingsandexperiencefromtheSEARCHfieldtrialinGadchiroli,IndiaandtheProjahnmoIstudyinSylhet,BangladeshformedtheevidencebaseuponwhichSavetheChildren’sUSAID-fundedmaternalandnewbornhealthprojects,particularlytheACCESSproject,werecreated.Thefollowingsectiongivesabriefoverviewofthesetwoseminalstudies.SEARCHfieldtrial(1995-1998)From1995-1998,SEARCH(SocietyforEducation,Action,andResearchinCommunityHealth)withfundingfromTheFordFoundationandTheJohnDandCatherineTMacArthurFoundationconductedafieldtrialinGadchiroli,MaharashtraState,India.Coveringapopulationof81,147,thestudycatchmentareacomprised39interventionvillagesand47controlvillagesinanextremelyunderdevelopeddistrictwhereroads,communications,education,andhealthserviceswerepoor.15Withhealthservicesoutofreach,thetrialsoughttotestthehypothesisthatahome-basednewborncarepackagethatincludedat-hometreatmentofneonatalsepsisthroughinjectableantibioticsbycommunityhealthworkerscouldreducetheneonatalmortalityratebyatleast23%overthreeyears.15Thehome-basednewborncareandhealtheducationprovidedtomothersandgrandmotherswasshowntobeacceptableandfeasibleinthe

studycontext,andsurpassedexpectationsbyreducingtheneonatalmortalityrateby62%.15TheseresultsinspiredtheBillandMelindaGatesFoundationtofundSavetheChildren’sSavingNewbornLivesprogramandhelpedtoinformthedevelopmentoftheProjahnmostudiesinBangladesh.ProjahnmoIStudy(2001-2006)TheProjahnmoStudyGroupwasestablishedbyDr.AbdullahBaquiin2001asapartnershipamongJohnsHopkinsUniversity,theBangladeshMinistryofHealthandFamilyWelfare,BrighamandWomen’sHospital,icddr,b,andtheChildHealthResearchFoundation.16WithfundingfromUSAIDandSavetheChildren’sSavingNewbornLivesprogramthroughagrantfromBillandMelindaGatesFoundation,Projahnmo(ProjectforAdvancingtheHealthofNewbornsandMothers)conductedastudyin2001-2006aimingtoreplicateSEARCH’sfindingswithasimilardeliverymodelatalargerscaleinBangladesh.ImplementedinthreesubdistrictsofSylhetDistrictwith113,816studyparticipantsacrossthreestudyarms,thetrialtestedthehypothesisthatbothahome-caremodelandacommunity-caremodelforpromotingneonatalhealthinruralBangladeshwouldinfluencekeyhealthcarebehaviorsandresultina40%reductioninneonatalmortality.17SylhetDivisionhadthehighestmortalityrateofthesixdivisionsinBangladeshatthetime,andthestudypopulationhadpooraccesstohealthservices.Inthehome-carearm,communityhealthworkers(CHWs)visitedhouseholdstoprovideantenatalcare(ANC)andpostnatalcare(PNC)andtreatedsuspectedcasesofsepsiswithinjectableantibiotics.CommunityMobilizershostedcommunitygroupmeetingsthroughwhichtheydisseminatedbirthandnewborncarepreparednessmessages.Thesemeetingswerealsohostedinthecommunity-carearmoftheintervention,butratherthanprovidingin-homecarebyCHWs,communityresourcepeoplewereidentifiedandtrainedinthecommunitytoencourageattendanceatthecommunitygroupmeetingsandtoencourageMNHcare-seekingamongcommunitymembers.17

TheProjahnmoIStudysawa33%reductioninneonatalmortalityinthehome-carearmandanon-significantreductionof9%inthecommunity-carearm.17Theauthorspostulatedthatthecommunitymobilizationactivitieswerenotdoneintensivelyenoughandthatthecommunity-caremodelneededmoretimetobecomesufficientlywellestablishedinordertoseepositiveresults.ThesignificantreductioninneonatalmortalitywasattributedlargelytothesuccessfultreatmentofsepsiswithinjectableantibioticsbyCHWsinthehome.ProjahnmoprovidedtheevidencebaseinBangladeshthathome-basedcareofnewbornshasthepotentialtosignificantlyimprovenewbornsurvivalandhassubsequentlyformedthefoundationformanyorganizations’programstrategiesaimingtoaddressnewbornhealthinthecountry.

Historyandevolutionofcommunitymobilizationapproaches

OntheheelsoftheProjahnmoIStudy,SavetheChildrenBangladeshbeganimplementingaseriesoflargeUSAID-fundedcommunityhealthprojectsatincreasingscaletoimprovematernalandnewborncarebehaviorsandsurvival.ThethreeprojectsprimarilyhighlightedinthisreportincludetheACCESS/BangladeshSafeMotherhoodandNewbornCareProject(2006-2009),theMaMoniIntegratedSafeMotherhood,NewbornCareandFamilyPlanningProject(2009-2013),andtheMaMoniHealthSystemsStrengtheningProject(2014-2017).Thefollowingsectionprovidesahistoricaloverviewoftheprojectswithkeyhighlightsoftheirevolvingapproachestocommunitymobilization.

ACCESS/BangladeshSafeMotherhoodandNewbornCareProject(2006-2009)ACCESSProjectObjectives:

1. Increaseknowledge,skills,andpracticesofhealthy,andnewbornbehaviorsinthehome

2. Increaseappropriateandtimelyutilizationofhome-andfacility-basedessentialMNHservices

3. Improvekeysystemsforeffectiveservicedelivery,communitymobilization,andadvocacy

ScalingupProjahnmoTheACCESSProgramwasaglobalprogramsponsoredbyUSAIDaimedatreducingmaternalandnewborndeathsandimprovingthehealthofmothersandnewborns.TheACCESSProgramwasawardedtojhpiego,whileSavetheChildrenservedastheleadimplementingorganizationinBangladeshalongwithShimantikandFriendsinVillageDevelopmentBangladesh(FIVDB)aslocalimplementationpartners.The$6millionACCESS/BangladeshprojectwasconceivedasanattempttotaketheProjahnmomodeltoalargerscalewithinaprogrammaticcontext.Theprojectreachedapopulationof1.5millioninfivesubdistrictsofSylhetDistrict—theconservativedistrictwhereProjahnmohadtestedtheircaremodels.AlthoughUSAIDwasinterestedtoseeiftheProjahnmomodelwouldtranslateintoprogrammaticsuccessesoutsideofthecontrolledresearchenvironment,onlyafewconsultationswereheldwithmembersoftheProjahnmoteam,andACCESSwaslargelyplannedbeforethefinalresultsoftheProjahnmoIStudywereavailable.ThefinalanalysesledthestudyauthorstoconcludethattheprovisionofinjectableantibioticsinthehomebyProjahnmo’sCHWswaslargelyresponsibleforthesignificantreductioninneonatalmortalityinthehome-carearm,andthatthecommunity-carearmwasnoteffectiveatreducingnewborndeaths[personalcommunicationviakeyinformantinterview].However,thegovernmentcadreofCHWs—FemaleWelfareAssistants(FWA)andHealthAssistants(HA)—arenotauthorizedtoprovideinjectableantibioticslikethe

study-trainedCHWshadbeen,andthereforetheProjahnmomodelinitsfullformwouldnotbedirectlyscalablewithoutcreatingparalleldeliverysystems.Ratherthanaddressingcommunityservicedelivery,ACCESSfocusedprimarilyondemandcreationformaternalandnewbornhealthservicesthroughcommunity-basedsocialandbehaviorchangecommunicationandcommunitycapacitystrengtheningthroughcommunitymobilizationactivities.ACCESSbuiltupontheProjahnmomodelofhomevisitors(thoughremovingthehome-basedtreatmentofneonatalsepsisandinsteadencouraginghealthfacilityreferrals,perdonordecision)andsignificantlyintensifiedtheapproachtocommunitymobilizationbyemployingtheSavetheChildren’smodelknownastheCommunityActionCycle(CAC)[Figure3]thathadbeenpreviouslytestedinothercountries.1Projahnmo’scommunity-caremodelhadprovenineffective,soACCESStookitsdirectionforcommunitymobilizationfromtheevidenceprovidedbytheWARMIProjectinBoliviaandtheMakwanpurStudyinNepal--whichhadbothindicatedthatintensivecommunitymobilizationthroughfacilitatingcommunitygroupstoconductCommunityActionCyclescouldleadtoreductionsinmaternalandneonatalmortality.18

Figure3:CommunityActionCycle

Box2:TheCommunityActionCycleinBoliviaandNepal:Successesinimproving

maternalandnewbornhealth

TheWARMIProject

TheWARMIProjectwasimplementedbySavetheChildreninBoliviafrom1990to1993within50rural,isolatedcommunitiesofInquisiviProvincewithlimitedaccesstohealthservices.Theprojectsoughttoreducematernalandperinatalmortalitybyworkingatthecommunitylevel.ThroughenactingCommunityActionCyclesandtherebyfacilitatingcommunitymemberstoimplementtheirownstrategiestoaddressmortality,theprojectwassuccessfulinreducingperinatalandnewbornmortalityby67%.Knowledgeandpracticesregardingprenatalcare,breastfeeding,immunization,newborncare,andfamilyplanningalsoimproved.18TheMakwanpurStudy

TheMakwanpurStudywasaclusterrandomizedcontrolledtrialconductedbytheNGOMIRAinthepoor,ruraldistrictofMakwanpur,Nepalfrom2001-2003.The30-monthtrialtestedwhetherCommunityActionCyclesfacilitatedbywomenfacilitatorswithinVillageDevelopmentCommittees(VDC)—eachcoveringapopulationof7500—couldreduceneonatalandmaternalmortalityandimprovenewborncarepracticeswhencomparedtocontrolareas.Thetrialshoweda30%reductioninneonatalmortalityandareductioninthematernalmortalityratiofrom341/100,000livebirthsinthe12controlVDCsto69/100,000livebirthsinthe12interventionVDCs.18Althoughquantitativemeasureswerenotusedtoassesschangesincommunitycapacity,qualitativeresearchsoughttounderstandhowthecommunitymobilizationworkstimulatedchange.Thewomen’sgroupslearnedaboutmaternalandnewbornhealthtopics,establishedhealthfundsformothersandchildren,facilitatedemergencytransport,producedandsoldcleandeliverykits,andimprovedlocalhealthfacilitiesbyensuringprivacycurtainsandnecessaryfurniture,amongotheractivities.19Twoyearsafterthecloseofthetrial,95%ofthewomen’sgroupswerestillmeetingregularly.18

Project’skeycommunitycomponentsTheACCESSprojectwasprimarilyacommunity-basedactivitywithtwomaincomponents,thefirstbeinghomevisitationprovidedbyACCESSCounselors(AC).Theseyoungfemaleworkerscoveredacatchmentareaof5,000-7,000populationandcounseledpregnantandrecentlydeliveredwomenandtheirfamilymembersandbirthattendantsonnewbornhealthandhygiene.Atotaloffourhomevisitswereconductedperhousehold:twiceduringpregnancy,oncewithinthefirst24hoursofbirth,andoncefromfivetosevendaysafterdelivery.ThesecondmaincomponentofACCESSwascommunitymobilizationusingtheCommunityActionCycle(CAC)approach.Thespecificcommunitymobilizationobjectiveswereasfollows:20

Objective1:EmpowerpregnantwomenandmarriedwomenofreproductiveageinparticularandthecommunityingeneraltomakeinformeddecisionsregardingmaternalandneonatalhealthcareObjective2:HelpchangesocialnormsthatresultinorarerelatedtoharmfulpracticesObjective3:Strengthenthesocial-supportnetworks/systemsforpregnantwomenObjective4:IncreasecollectiveefficacytodealwithobstetricemergenciesObjective5:Strengthenand/ordevelopcommunity-basedreferralsystemstoincreasetheuseoftrainedprofessionals/healthworkersand/orhealthfacilitiesforantenatalandpostnatalcareandsafedelivery.

Strategydocumentsstressedthatthecommunitymobilizationcomponent’srolewastostrengthenthecommunity’scapacitytocollectivelyanalyze,plan,implement,andevaluatetheirownactionstoimprovematernalandnewbornhealth.However,keyinformantinterviewswithprogramstaffsuggestedthatinclusionoftheCACwasseenfromtheoutsetoftheprojecttobenecessaryprimarilyinorderfortheprojecttogainaccessandacceptanceinthecommunityfortheiractivities.NewborncarepracticesprevalentinSylhetatthetimeoftheprojectdifferedsubstantiallyfromrecommendedbestpractices,andevenfrompracticesinotherregionsofthecountry.TherewasconcernthathouseholdsintheconservativecommunitieswithinSylhetwouldnotbereadilyacceptingoftheproject’shealthbehaviorrecommendationsthatweremarkedlydifferentthantheircurrentpractices.Forinstance,therecommendationgivenbyACCESSCounselorsthatbabiesnotbebathedforthefirst72hoursoflifetopreventhypothermiahadreligiousimplicationsforsomefamilies,sincenewbornbabiesareconsideredrituallyunclean/impureuntilaftertheirfirstbath.ACCESSalsoencouragedwomentogotoANCcheckups,receivetetanustoxoidvaccinationsfromsatelliteclinics,andtakenewbornbabiesimmediatelyforpostnatalcheckups—allofwhichrequiredmobilityofwomenoutsidethehome.Recommendationsliketheserequiredmorethanjustbehaviorchangeofindividualswithinhouseholds—itwasnecessarytobuildcommunitybuy-inforsuchpractices.Furthermore,counselingregardingmaternalandnewbornhealthissueswasconsideredamatterforwomenonly,pregnancyandchildbirthwerenottobediscussedinpublic,anddirectcommunicationbetweenunrelatedmalesandfemaleswasdiscouraged.TheCACwasthereforeseenasawaytobreaktheicebydirectlyengagingmalesonthetopicofmaternalandnewbornhealthandtofacilitateacceptanceoftherecommendedcarebehaviorswithinthecommunitybyhelpingtocreateenvironmentswherechangedbehaviorscouldbesustainedbysupportivesocialnorms.

IntensivelystructuredCommunityActionCycleforcommunitymobilizationUnderACCESS,theCommunityActionCycle(CAC)wasimplementedatthevillagelevel.FemaleCommunitySupervisors-Mobilizers(CSM)andmaleCommunityMobilizers(CM),hiredasprojectstaffandtrainedbylocalpartnerNGOs,facilitatedtheCommunityActionCyclewithineachvillageprioritizedforcommunitymobilizationactivities.CommunitySupervisors-MobilizersandCommunityMobilizerswereassignedtovillageswheretheytookresponsibilitytomeetwithgatekeepers(e.g.religiousleaders,socialelites,schoolteachers,etc.)toobtainpermissiontoworkwithinthecommunity.Theythenhostedanorientationmeetingwithineachvillagetowhichallcommunitymemberswereinvited.Duringtheorientationmeeting,CSMsandCMsexplainedthepurposeoftheACCESSproject,discussedthestatusofmaternalandnewbornhealthintheregion,andexplainedhowtheCommunityActionCyclewouldbefacilitatedwithintheircommunity.Marriedwomenofreproductiveagedeemedmostvulnerabletomaternalandnewbornhealthissues,alongwiththeirhusbandsandmothers-in-law,wereprioritizedforinvitationtoparticipateinCommunityActionGroups(CAG).Whereexistingcommunitygroupswereactive(e.g.microcreditgroups,etc.),CSMsandCMsfirstdeterminedwhetherthosegroupswouldbeinterestedincarryingouttheCommunityActionCycleactivities.Ifnot,newgroupswereestablished.Duetosocialconservatism,separategroupswereestablishedformenandwomen.CommunitySupervisors-Mobilizers(female)hadthedualroleoffacilitatingtheCommunityActionCycleactivitiesoffemalegroupsandsupervisingtheACCESSCounselorswhoprovidedhomevisitstopregnantandrecentlydeliveredwomen.CommunityMobilizers(male)tookresponsibilityforfacilitatingtheactivitiesofmalegroups.Manyfamiliesinthedistrictreceivedremittancesfromabroad,whichfreedsomemaleheadsofhouseholdsfromdailywork.Akeyinformantsuggestedthismighthaveplayedaroleinallowingthemtoparticipateincommunitygroupmeetings.TheseCommunityActionGroupsfollowedaprescriptive11-12monthprocesstocompleteoneCommunityActionCycle,heavilyguidedbytheCMsandCSMsateverystep.Eachmeetinghadaspecificnameandlistofobjectivestoaccomplish,alongwithassociatedtoolssuchascharts,informationcards,andbodymappingmaterialstoguidemeetingactivities[Table2].Afterthefirstcyclehadbeencompleted,CommunityResourcePeople(CRP)whoemergedasnaturalleaderswithinthegroupswouldstarttotakemoreofasupportiveroleinhelpingtofacilitatetheCAGs.Table2:KeyMeetingsoftheCommunityActionGroups20

CACPhase Meetingname MeetingobjectivesOrganizetheCommunityforAction

Communityorientationmeeting § Orientcommunitymembersontheproject,goal&objectivesofCMprocess

§ InitialselectionoffocalCRPs

CACPhase Meetingname Meetingobjectives Coregroupformationindividual

consultationsandmeeting§ Discussionofcoregroupmembers’rolesand

responsibilities,CACprocessetc.§ Finalselectionofcoregroupmembers§ SelectCRPasafacilitatorofthegroup

ExploretheHealthIssuesandSetPriorities

Problemidentificationmeeting:Pregnancy&deliveryperiod

§ Identifytheproblemsduringpregnancyanddelivery

Problemidentificationmeeting:Postnatal&Newborn

§ Identifytheproblemsduringpostnatalperiodandnewborn

Prioritysettingmeeting § SettingtheprioritiesofproblemPlanTogether Planningmeetingwithcoregroups

andothercommunityresourcepeople

§ Developacommunityactionplan§ OrganizeCommunityActionGroup(CAG)withCore

groupandothercommunityresourcepeopleActTogether

Planningmeetingforcommunitycapacitystrengthening

§ Todevelopcommunitycapacitystrengtheningplan

Monitoringplanningmeeting § DevelopcommunityprogressmonitoringplanMonitoringfindingssharingmeeting

§ Sharemonitoringteam’sfindingswithCAGandothercommunitypeople

EvaluateTogether

Evaluationmeeting § Evaluatecommunityprogressaccordingtoactionplan§ Planfornextcyclebasedonevaluationfindings

KeyresultsMonitoringandevaluationofthecommunitymobilizationcomponentofACCESSfocusedrathernarrowlyonprocess/outputindicatorsofhowmanygroupswereformedandmeetingregularly.Attheendoftheproject,55.3%ofinterventionvillageshadaCAG,69.1%ofthoseCAGshadmetwithinthelasttwomonths,66.7%ofCAGshadactionplanstoadvocateforimprovedessentialmaternalandnewborncare(EMNC)services,42.8%hadimplementedatleasttwoactionplanswithinsixmonthsofdevelopingthem,and39.4%ofCAGshadatleastonerepresentativefromthenearesthealthfacilityasamember.21Manygroupstooktheirowninitiativetocreateemergencyfundsanddevelopemergencyreferraltransportsystemstosupporttheircommunitymemberswhowereunabletoaffordservicesintimesofgreatneed.Monitoringdatashowedthat56.9%ofCAGsestablishedemergencytransportsystemsand43.4%ofCAGsdevelopedemergencyfinancesystems.21

AlthoughthemidlineassessmentteamandprojectstaffdiscussqualitativelytheirimpressionsthatCAGswerepositivelyinfluencingsocialnormsandcatalyzingchangewithincommunities,achievementstowardsthestatedobjectivesofthecommunitymobilizationcomponentwereunabletobemeasured.Thiswasbecauselatentconstructssuchasempowerment,collectiveefficacy,socialnorms,andsocialsupportwerenotassessedbytheproject.USAIDhadinvestedheavilyinrobustresearchunderProjahnmo,andwasmoreinterestedindirectingACCESSfundstoimplementationratherthanallottingbudgetforoperationsresearch[perkeyinformantinterview].Doingsocouldhaveallowedforthetestingandvalidationofmeasuresforthelocalcontexttoenableassessmentofimportantoutcomelevelindicatorsforprojectlearning.

Ultimately,keyinformantsrelayedhowACCESSwassuccessfulinincreasingknowledgeaboutMNHandcreatingdemandforMNHservices,butimprovementsinhealthservicesutilizationwasminimal[Figure4]duetotheunavailabilityofmanyservices—causedbywidespreadstaffvacanciesandotherserviceconstraintsinthepublicsector.22Forinstance,thepercentageofwomenintheprojectareawhocouldnotlistanydangersignsduringpregnancywhenaskeddecreasedfrom3.0%in2007tojust0.2%in2010,thoseunabletoidentifydeliverydangersignsdecreasedfrom6.7%to0.7%,andthoseunabletolistanypostpartumdangersignsdecreasedfrom3.5%to0.6%atendline.23,24However,skilledbirthattendanceincreasedonlyslightlyfrom1.6%in2006to2.4%by2010,andhavingoneormoreANCvisitsroseonlyto49.8%in2010comparedto48.8%in2006.22Thissupportedtheshiftinfocustoincludingservicedeliveryimprovementundersubsequentprojects.

KeylearningsandlessonstakenforwardACCESS’smodelwasheavilyproject-drivenandneededrevisionbeforeincreasinginscale.AnexternalassessmentteamatprojectmidlinemaderecommendationsonhowtosimplifyACCESS’sapproach.25TheheavilystructuredCACutilizedbulkyEnglishterminologysuchas“OrientationMeeting,”“CommunityResourcePerson,”etc.andcomprisedcomplexmeetingsandactivitiesthatreliedontheuseofprintedcards,posters,maps,andothertoolsthatappearedforeigntothelargelyilliterategroupmembers.AlthoughCommunityResourcePersonswereidentifiedwithingroupstosustainactivities,theywerenotwellempoweredtomaintainthecomplexCACsystemofmeetingsanduseoftoolswithoutstrongsupportfromprojectstaff.EvenfieldlevelstaffhiredbytheprojectfoundtheCACtooprocess-heavyandintricateandfeltthatcommunitymembersstruggledtounderstandtheCACinaconceptualway.Amember

Figure4:Healthindicatorsin5SylhetUpazilascoveredbyACCESS22

ofthemidlineassessmentteamsharedhisperceptionthattheoverlyprescriptiveCACprocessattimesmayhaveinhibitedcommunitycreativitybydirectingfocustoonarrowlyontheprescribedmeetingsandrequiredregisters.ThemidlineassessmentteamrecommendedtheremovalofmanyoftheCACtoolsusedduringmeetings,astreamliningofmonitoringdatarequiredfromtheCAGs,andthattheCACbeshortenedtoa7-9monthprocessratherthantheoriginal10-12months.25

MaMoniIntegratedSafeMotherhood,NewbornCareandFamilyPlanningProject(2009-2013)MaMoniISMNC-FPProjectObjectives:

1. Increaseknowledge,skillsandpracticesofhealthymaternalandneonatalbehaviorsinthehome

2. Increaseappropriateandtimelyutilizationofhomeandfacility-basedessentialMNHandFPservices

3. IncreaseacceptanceofFPmethodsandadvanceunderstandingofFPasapreventivehealthinterventionformothersandnewborns

4. Improvekeysystemsforeffectiveservicedelivery,communitymobilizationandadvocacy

5. Mobilizecommunityaction,supportanddemandforthepracticeofhealthyMNHbehaviors

6. Increasekeystakeholderleadership,commitmentandactionfortheseMNHapproaches

TransitionfromACCESStoMaMoniISMNC-FPMaMoniIntegratedSafeMotherhood,NewbornCare,andFamilyPlanningProject(MaMoniISMNC-FP)wasanassociateawardsupportedbyUSAIDinBangladeshthroughtheMaternalandChildHealthIntegratedProgram(MCHIP)andimplementedbySavetheChildrenandtwolocalnon-governmentalorganizations:ShimantikandFriendsinVillageDevelopmentBangladesh(FIVDB).The$13millionprojectextendedACCESSactivitiesforaperiodoftimeinfivesubdistrictsofSylhetDistrict,butexpandedcoverageunderanewmodeltoeightsubdistrictsinHabiganjDistrict.Reachingapopulationof3.5million,thecatchmentareaincludedaflood-pronehaorarea,urbanslumsintheHabiganjmunicipality,andteaestatecommunitieswherelow-wagelaborersliveinsettlementsontheestatesforwhichtheywork.Habiganjwasanextremelydeprivedareawithdilapidatedpublichealthfacilities,littletonoservicesavailable,andnofunctioningprivatehealthsector.WithACCESShavingshownthatincreasingdemandforMNHservicesalonewouldnotbesufficientforimprovingutilization,thefollow-onprojectusedamoreintegratedcommunityhealthapproachbydirectingfocustowardssupportingpublicsectorservicedelivery.RatherthaninvestinginaparallelsystemofhomevisitorsasACCESShaddone,

MaMoniISMNC-FPreliedonexistinggovernmentcadresoffrontlinehealthworkers(FemaleWelfareAssistants)toprovidehealtheducationandpromotionandassistedintemporarilyfillingcriticalvacanciesforthoseposts.Furthermore,womenhadroutinelytakenACCESSCounselorsasidetodiscreetlyrequestfamilyplanningmethodsduringhomevisits,andthusfamilyplanningwasformallyincorporatedintoMaMoniISMNC-FPprogrammingtoaddressthisunmetneed.Theprojectalsoincludedtheadditionofhandwashingandinfantandyoungchildfeedingrecommendationsfrom2012onwards.

Project’skeycommunitycomponentsCommunitymobilizationwasmuchsimplifiedunderMaMoniISMNC-FP,aimingprimarilytosupportreferralsforgovernmentMNHandFPservicesandtocollectcommunitydataofvitaleventstosharewithfrontlineoutreachworkers(FemaleWelfareAssistantsandHealthAssistants)insupportoftheMinistryofHealthandFamilyWelfare’s(MOH&FW)managementinformationsystem(MIS).Althoughtheapproachwasmodified,theobjectivesofthecommunitymobilizationwork(accordingtostrategydocuments)remainedthesameasinACCESS—butwiththeadditionofanobjectiveregardingfamilyplanning:26

Objective6:Increasetheuseoffamilyplanningbydevelopingcommunity-basedreferralsystemsandsystemstoensureeasyaccessandsupplyoffamilyplanningservicesclosetothehome.

StreamlinedCommunityActionCycleUnderMaMoniISMNC-FP,thecommunitymobilizationapproachwassimplifiedfromACCESSinanumberofways.CommunityVolunteers(CV),selectedbyUnionParishads,establishedandfacilitatedCommunityActionGroups(CAG)intheirowncommunitiesfromtheoutsetwithmorelimitedfacilitationfromprojectstaff.UnionParishadsselectedoneCommunityVolunteerper300population,whichcreatedmanageablecatchmentareasandprovidedthemrecognizedauthorityasorganizers.CommunitymembersfromthecatchmentareasofthreeCommunityVolunteers(total900population)formedoneCommunityActionGroup.CommunityActionGroupsfollowedasimplifiedversionoftheCommunityActionCycleovera6-monthperiod,withreducedrelianceoncomplextoolsandregisters.CommunityVolunteersweretrainedtopromotekeyMNHbehaviorsamongtheirconstituents,andhada12-hourworkloadpermonth.

Box3:Listofmeetingswithincondensed6-monthCommunityActionCycle(CAC)

1.CommunityOrientation 2.MNHProblemIdentification&Prioritization 3.FPandServiceFacilityRelatedIssueIdentification&Prioritization 4.ActionPlanningandCAGFormation 5.SharingofMonitoringFindings 6.Evaluation

AdaptingthecommunitymobilizationapproachforvariedgeographicalareasWithinHabiganj,MaMoniISMNC-FPwasimplementedacrossthreegeographicalareas:1)ruralareas,2)withinteaestates,and3)urbanandsemi-urbanareas.ThemainCommunityActionCyclemodelforcommunitymobilizationwasimplementedintheruralareas;however,specialmodificationsweremadeforthosepopulationsresidingwithinteaestatesandthosewithinmunicipalities.27

Theownersofteaestateswerewaryofcommunitymobilizationworkbecauseofthepotentialtheysawforittoleadtouprisingsamonglaborers.Becauseofthis,theprojectwasunabletoimplementtheCACwithinteaestateareas.Instead,moreemphasiswasplacedonprovidingsocialandbehaviorchangecommunicationthroughchannelssuchascommunitytheaterandfilmshows.AtthetimeMaMoniISMNC-FPwasbeingimplemented,HabiganjSadarMunicipalitywasincludedintheUnitedNationsDevelopmentProgram’sUrbanPartnershipsforPovertyReduction(UPPR)projectarea.TheUPPRprojectsupportedcommunitymobilizationworkthroughtheestablishmentofCommunityDevelopmentCommittees(CDC)facilitatedbyCommunityLeaders(CL).ThesecommitteesdevelopedtheirownCommunityActionPlanstoidentifyandaddresstheircommunity’sneedsinregardstoimprovinglivingconditionsandreducingpoverty.28MaMoniISMNC-FPleveragedtheseexistingCommunityDevelopmentCommitteeswithinthemunicipalityandconsideredthemasCommunityActionGroups(CAG)analogoustothoseestablishedinruralMaMoniareas.MaMoniprovidedsupplementaltrainingfortheCommunityLeaderstoorientthemtotheproject’sobjectivesandbuildtheircapacitytodiscussMNHandfamilyplanningissueswithintheircommunities.Thus,inadditiontotheworkCDCsweredoingtoaddresspovertyreduction,theybecameactiveinaddressingMNHandfamilyplanningissueswiththesupportofMaMoni.IntheremainingmunicipalitieswithinHabiganj,therewerewidevariationsinpopulation,density,andlocalservicestructures.Accordingly,MaMoniISMNC-FPdidnotimplementthestructuredCommunityActionCycleapproachintheseareas.Rather,CommunityVolunteerswereselectedandtrainedtoparticipateinCommunityMicroplanningMeetings(cMPM)[describedbelow]andwereencouragedtoassistinreferringmothersandnewbornstoservicefacilities.

NewapproachesforcommunitymobilizationInnovationsforcommunitymobilizationwereintroducedinMaMoniISMNC-FP,tobetterfacilitatelinkagesamongCommunityActionGroupsandthehealthsystem.CommunityVolunteerscollectedvitaldatafromtheirconstituentsduringCommunityActionGroupmeetings,whichtheythensharedduringCommunityMicroplanningMeetings(cMPM)heldmonthlywiththefrontlineoutreachworkersfromtheDirectorateGeneralHealthServices(DGHS)andDirectorateGeneralFamilyPlanning(DGFP).Thesemeetings,adaptedfromtheWorldHealthOrganization’sReachEveryDistrictapproach,29providedforumsduringwhichgovernmentFemaleWelfareAssistants(FWA),HealthAssistants(HA),andCommunityVolunteerscouldaddressdiscrepanciesintheircountsofnewmarriages,pregnancies,births,deaths,andotherinformation.BecauseoftheMinistryofHealthandFamilyWelfare’sdichotomoussystemofseparatehealthandfamilyplanningdirectorates,twosetsofdataareroutinelycollected.WithamandatetoservethreedayseachweekintheCommunityClinicandthreedaysconductingoutreachinhouseholds,FWAs(DGFP-supported)andHAs(DGHS-supported)arechronicallyoverburdenedandoftenareunabletosufficientlycovertheircatchmentareaeachmonthtomaintaincompleteregistersofcommunitydata—resultingincountsthatarehighlydiscrepantbetweenDGHSandDGFP.Asanillustration,inHabiganjfromJanuarytoJune2012,DGHSreported49,016pregnantwomenandDGFPreported38,396—asubstantialdifferenceof10,620women.22

Box4:PurposeofCommunityMicroplanningMeetings

1.ShareMNH/FPinformationandupdateregisters 2.Updatelistofpregnantandhigh-riskmothers 3.Updateunitmaptofacilitateservicedelivery 4.Preparemonthlyactionplanforservicedelivery 5.Identifyproblemsandplanforsolutions

Inadditiontosynchronizingdata,theCommunityVolunteersalongwithFWAsandHAsidentifiedproblemsraisedbycommunitymembersoverthepastmonthandjointlypreparedmonthlyactionplansforservicedeliverytoaddressgaps.Theseactionplanstargetedspecificindividualsforfollow-up—forinstance,ifaCommunityVolunteeridentifiedawomaninhis/hercatchmentareaexhibitingpregnancydangersignswhowasunabletoaccessservices,thenaplanwasmadeforspecificfollow-upwiththatindividualtoaddressherneeds.Furthermore,FWAsandHAsshareda“messageofthemonth”withtheCommunityVolunteersduringeachCommunityMicroplanningMeeting,whichtheCommunityVolunteersthenpromotedduringtheirsubsequentCommunityActionGroupmeeting.UnionFollow-upMeetingsthenprovidedforumswherealltheFWAsandHAsinaUnionexchangedinformationgleanedfromtheirrespectiveCommunityMicroplanningMeetingsinthepresenceoftheirunionlevelsupervisors(e.g.AssistantHealthInspector(AHI)andFamilyPlanningInspector(FPI)).

Theydevelopedunionlevelactionplansthataddressedneedsoftheoutreachworkersandissuesconcerningunionlevelfacilities.AnotherinnovationincommunitymobilizationwithinMaMoniISMNC-FPwastheengagementoflocalgovernment(UnionParishad)—abodythathadpreviouslybeenlittleinvolvedwithMNHandfamilyplanningissues.MaMonihelpedactivatetheUnionParishadEducationHealthandFamilyPlanningStandingCommittee,whichhadagovernmentmandatetomeeteverytwomonthstodiscusslocalhealthissuesbutinmostunionsdidnotdoso.AsmembersoftheUnionParishadEducationHealthandFamilyPlanningStandingCommittee,theAssistantHealthInspector,FamilyPlanningInspector,andtheunionlevelserviceproviderSubAssistantCommunityMedicalOfficer(SACMO)wereabletoraiseconcernsduringmeetingsthathadnotbeensuccessfullyaddressedthroughcMPM.CommunityVolunteersadvocatedwiththelocalgovernmenttoallocatefundinginresponsetoneedsidentifiedduringCommunityActionGroupdiscussions,anddecisionsmadeattheunionlevelweresharedupwardswithdecision-makersatthesubdistrictlevel.UnionParishadswerealsoengagedtoprovideoversightforhealthfacilityandhealthworkerperformancetohelpensurecommunitymembershadincreasedaccesstoservices.KeyresultsByNovember2013,93%ofMaMonivillagesinHabiganjhadestablishedCommunityActionGroups(CAGs).30HabiganjwaslessconservativethanSylhet,whichallowedmenandwomentoparticipatetogetherdirectlyincommunitygroupmeetings.However,sincefewerfamiliesrelyonremittancesfromabroadinHabiganjascomparedtoSylhet,theprojectfoundparticipationbymentobegreatlyreduced—presumablybecauseahigherpercentageofmeninHabiganjwererequiredtoworkduringthedayandthereforeunavailabletoparticipateincommunitygroupmeetings[personalcommunicationfromkeyinformant].OnehundredpercentofCAGshadatleastonememberwhowasahealthworker,98%ofCAGshadaUnionParishadmemberparticipating,100%ofCAGshadestablishedemergencytransportsystems,and89%hadestablishedemergencyfunds.Collectively,CAGshadsetasideroughlyBDT1millionforemergencyfunds.22Inadditiontohelpingwomenaccesscarewhentheycouldnotaffordit,someofthesemonieswereusedtosupportlocalhealthfacilitiesbyrepairingtubewells,facilityaccessroads,providingbloodpressuremonitors,weightscales,furniture,andprivacycurtains.22

MaMoniISMNC-FPbeganphasingoutimplementationinSylhetDistrictinSeptember2011inordertofocusimplementingthenewprojectmodelinHabiganjDistrict.ThisgaveanopportunityoverthelifeofMaMoniISMNC-FPtoobservehowactivitiesfairedonceprojectsupportwasremoved.AsofJuly2013,54%ofCommunityActionGroupsthathadbeenformedinSylhetDistrictwerecontinuingtofunctionwithminimalsupport.30

CommunityMicroplanningMeetings(cMPM)wereastandoutsuccessoftheMaMoniISMNC-FPprojectandexperiencedrapiduptakeandhighcoveragerates.Communitymicroplanningwasintroducedineachofthe396familyplanningunitsinHabiganjDistrictand257unitsofSylhetDistricts,andmeetingsoccurredregularlyin79%oftheprojectareasin2011,96%by2012,and99%by2013.22BetweenJune2011andApril2013,theNationalInstituteofPopulationResearchandTraining(NIPORT)conductedoperationsresearchinthreesubdistrictswithintheprojectareaandsawimprovementsinconsistencyofdatareportingbetweenDGHS(registerskeptbyHAs)andDGFP(registerskeptbyFWAs)regardingnewpregnanciesandbirthreporting(althoughimprovementswerenotseeninreportingofnewly-wedcouplesordeathreporting).ThestudyindicatedthatservicecoverageformaternalcareincreasedasaresultofcMPM,particularlyANC(66%increaseinMuriaukUnion,34%increaseinKurshiUnion,noimprovementinUmarpurUnion).22AsaresultofMaMoni’seffortstoorientUnionParishadsabouttheirrolesandresponsibilitiesregardingcommunityhealth,77UnionParishadsactivatedtheirEducation,Health,andFamilyPlanningStandingCommitteesandweremeetingeverytwomonthsby2013.22Thiswasupfrom56UnionParishadsinthefirstquarterof2012.ByDecember2012,90%ofUnionParishadsinMaMoniprojectareashadallocatedfundstowardsMNH/FPefforts.30BetweenJuly2012andMarch2013,UnionParishadscontributedBDT81,406tosupportFamilyWelfareCenters(Union-levelhealthfacilities),andBDT170,834tosupportCommunityClinics.30Furthermore,UnionParishadsbeganissuingdeathcertificatesfornewbornsasaresultofMaMoniadvocatingforbetterdocumentationofnewborndeaths.22Encouragingly,someCommunityVolunteerswhowereproactiveandhighlyengagedwereelectedasMemberstotheirUnionParishadsduringsubsequentelections.SincetheywerewellversedontheMNHissuesfacingtheircommunities,theywereabletogreatlycontributetoMNHsupporteffortsduringtheirserviceontheUnionParishad.MaMoni’srelianceonthegovernmentcadreofcommunityhealthworkers(FWAs)toprovidehome-basedcounselingtopregnantandrecentlydeliveredwomenprovedchallenging—likelydueinparttotheworkers’largecatchmentareasandmandatetospendthreedaysperweekattheCommunityClinic.22Datafromtheproject’smidlineassessmentin2012showedthatonly39.7%ofmothershadcontactwithanFWAduringpregnancy,andonly6.9%receivedinformationondangersigns.22Accordingtotheproject’sfinalreport,22MaMoniendeavoredtoaddressthisidentifiedgapbypiloting

theuseofalternativechannelsofcommunication(billboards,signboards,filmshowsforteagardens,videoshowsinmedia-darkareas,cableprovidersforurbanareas)topromotehealthybehaviorsincommunities,butafocusedassessmentofthechangesinknowledge,attitudes,andpracticesspecifictothesecommunicationinterventionswasnotcompleted.(pg.13)

Keylearningsandlessonstakenforward

ByshorteningandsimplifyingtheCommunityActionCycleandmakingitlessprescriptive,theprojectteamfelttheywereaffordedtheflexibilitytoadaptMaMoni’scommunitymobilizationapproachtomoreappropriatelyrespondtheneedsofthevariedcommunitiescoveredintheproject’scatchmentareas.Ratherthanusingaone-size-fits-allapproach,thecommunitymobilizationworknecessarilydifferedamongtheruralareas,urbanandsuburbanareas,andwithinpopulationsresidingonteaestates.Furthermore,theprocessofCommunityMicroplanningwasquicklytakenup,andthemoretargetedgoalofcollectingspecificinformationfromcommunitymembersandliaisingwiththefrontlinegovernmentworkersduringmonthlymeetingsstrengthenedCommunityVolunteers’andCommunityActionGroups’capacitiestomakeeffectuallinkageswiththehealthsystem.Additionally,anecdotalevidenceofthepromiseofengagingwiththelocalgovernmentstructuretosupportmaternalandnewbornhealthemergedduringMaMoni,andsothefollow-onprojectwasplannedtomoreheavilyinvestinsuchanapproach.KeyinformantsdescribedhowseverelydestitutethecommunitieswithintheMaMoniprojectareawere—manywithnohealthservicesavailableorgovernmentfacilitiesthatwereextremelydilapidatedandtheabsenceofaprivatesector.Theteamquicklysawthatanysmallincreaseintheavailabilityofbasichealthservicessupportedbytheprojectresultedinquickandsubstantialincreasesinserviceutilization.Becauseofthis,focusbeganshiftingfurtherawayfromthecommunitymobilizationworkasoriginallyconceptualized(theCommunityActionCycle)andmoreheavilyontosupportingservicedelivery.

MaMoniHealthSystemsStrengtheningProject(2014-2018)MaMoniHSSProjectObjectives:

1. Improveservicereadinessthroughcriticalgapmanagement

2. Strengthenhealthsystemsatdistrictlevelandbelow

3. Promoteanenablingenvironmenttostrengthendistrictlevelhealthsystem

4. Identifyandreducebarrierstoutilizationofhealthservices

TransitionfromMaMoniISMNC-FPtoMaMoniHSSWiththeimprovementofserviceutilizationindicatorsseenduringMaMoniISMNC-FPresultingfromsupportingtheprovisionofbasichealthservices,thefollow-onproject—MaMoniHealthSystemsStrengthening(HSS)—focusedevenmoreextensivelyonincreasingqualitypublicsectorservicedeliveryandsignificantlystreamlineditsapproachtocommunitymobilization.The$53millionprojectwasanAssociateAwardunderMCHIPandcoveredapopulationof12.5millionacrosssixdistricts(Habiganj,Noakhali,Laksmipur,Jhalokati,Pirojpur,andBhola).MaMoniHSSsoughttosupporttheMinistryofHealthandFamilyWelfare(MOH&FW)to“introduceandleveragesupportforthescale-upofevidence-basedpracticesalreadyacknowledgedinBangladesh”toimprovematernalandnewbornhealth,familyplanning,andnutrition(MNCH/FP/N).31

Project’skeycommunitycomponentsShiftingrolesofCommunityActionGroupsandCommunityVolunteersAlthoughtheCommunityActionCycleapproachhadbeenshortenedandsimplifiedduringMaMoniISMNC-FP,itstillrequiredalargeinvestmentofresourcesandprojectstaffsupportinordertomonitoractivities.WiththeshiftinfocusunderMaMoniHSStowardssupportinggovernmentsystems,thestructuredCommunityActionCyclewasdiscontinuedandCommunityActionGroupsinsteadfocusedmoredirectlyoncollectingvitaleventdatatoshareduringCommunityMicroplanningMeetingsandservingasforumsformonthlyhealtheducationmessages.Thus,analysisofcommunityinformation,thedevelopmentofactionplans,andreviewofresolutionstoidentifiedproblemswereundertakenprimarilyduringmicroplanningsessionsandnotduringCAGmeetings.CommunityVolunteersweretrainedandsupportedtofacilitatetheCommunityActionGroups,promotehealthymaternalandnewbornhealth,familyplanning,andnutritionbehaviorsandcareseekingwithintheircommunities,andtoliaisewithFWAsandHAsduringthemonthlyCommunityMicroplanningMeetings.ThecatchmentareaperCommunityVolunteerwasreducedto250populationtomakeitevenmorefeasibletoremainincontactwithconstituentsandtoallowmaximumparticipationofcommunitymembers.UnlikeMaMoniISMNC-FPwherethecatchmentareasofthreeCVsformedaCommunityActionGroup,eachCommunityVolunteerunderMaMoniHSSfacilitatedtheirownCommunityActionGroup.FurtherinstitutionalizationofCommunityMicroplanningCommunityMicroplanningMeetingsandunionfollow-upmeetingswereheldastheywereunderMaMoniISMNC-FP,howeverincreasinglythegovernmentfrontlineserviceproviders(FWAsandHAs)tookonfacilitationandreportingrolesfromprojectstaffandprovidedtheirCommunityMicroplanningMeetingreportsdirectlytotheUpazilaHealthComplex.Inyearfouroftheproject,MaMoniHSSpilotedinvolvingthegovernmentmandatedCommunitySupportGroupsasforumsforCommunityMicroplanningMeetingsinthreeunionsofthreedistricts.TheyhaveexpandedthepilotingtothreemoredistrictsinyearfiveinanticipationofstrictlyimplementingcMPMthroughthisbodyinthenextfollow-onproject.31Resultsavailablesofarfromthepilotingindicatethatthemeetingswereheldregularlyasplanned,althoughtheCommunityHealthCareProvider(healthserviceprovideroftheCommunityClinic)wasunabletoattendallofthecMPMsintheCommunityCliniccatchmentarea(3-4cMPMsperCommunityCliniccatchmentarea).IncreasedefforttoengagelocalgovernmentMaMoniHSScontinuedtoencouragelocalgovernmentbodiestoengagewiththepublichealthsectorandaddressbarrierstoserviceutilization.Projectstafffacilitatedbi-monthlyUnionEducationHealthandFamilyPlanningStandingCommitteemeetingsoftheUnionParishadsintheprojectarea.Projectstafforientedlocalgovernmentofficials

ontheirauthorizedrolesandresponsibilitiesasoutlinedbytheGovernmentofBangladesh,whichincludethefollowing:1)theyaretoholdserviceprovidersintheirunionaccountableandensuretheyarenotchargingforservices;2)theyaretohelppopularizetheclinicsandpromoteserviceutilizationwithintheirunion;and3)theyaretomobilizeresourcestoaddressMNCH,familyplanning,andnutritionneedswithintheircommunities.MaMoniHSSprojectstaffensuredUnionParishadmembersandstandingcommitteememberswereawareoftherangeofactivitiesthatwerewithintheirscopetosupport.Keyresults[Atthetimeofthiswriting,MaMoniHSSwascomingtoacloseandtherewasnotafinalreportavailable.Therefore,keyresultshighlightedherearepreliminary.]Atthetimeofthe4thAnnualReport(September2017),therewere23,929CommunityVolunteers/CAGsactiveintheMaMoniHSS’shighintensityinterventionupazilas.32OftheseCAGS,18,452hadestablishedemergencytransportsystemsforMNCHcarewithintheircommunities.32HealthAssistantsandFamilyWelfareAssistantswereservingasfacilitatorsandrecordersfor85%oftheCommunityMicroplanningMeetingsintheprojectareas.32

EngagementoflocalgovernmenthasbeenasignificantachievementofMaMoniHSS.ByactivatingtheUnionParishadstandingcommitteesandorientingthemtotheirrolesandresponsibilities,MaMoniHSSwasabletoadvocatefortheallocationofgreaterproportionsoftheirannualbudgetstohealth,familyplanning,andnutrition-relatedactivities.Table3,takenfromMaMoniHSS’s4thAnnualReport,givesasnapshotofthebudgetallocationsUnionParishadshaverecentlymadeforsuchpurposes.32Inalignmentwiththecurrentgovernmentsectorplanthatstipulatesunion-levelfacilitiesshouldbemadefunctional,someUnionParishadshaveprovidedfundstodeployadditionalserviceproviders(paramedics)intheirUnionHealthandFamilyWelfareClinicstofillvacancies.ThegreatestachievementshavebeenininvolvingUnionParishadstomobilizefundstoupgradeandensurecontinuityofservicesattheUnionHealthandFamilyWelfareClinics.Fundsareprimarilyusedforconstruction,facilityrepairsandmaintenance,purchasingemergencymedicineduringstock-outs,purchasingsmallmedicalandnon-medicalequipment,workonapproachroadstofacilitateeasieraccesstofacilities,andsupportingtemporarysupportstaffwhenneeded(e.g.staffforcrowdcontrolduringpeakhours,cleaners,etc.).32SomeUnionParishadChairmenhavebegunvisitingtheUH&FWConadailybasistoprovideoversightandhavestriventopopularizetheclinicsbyprovidingsmallbirthdaygiftstothebabiesborninthefacilities.IntheremoteislandofHatiya,thelocalgovernment’soversightandcontributionstoserviceimprovementresultedinafive-foldincreaseininstitutionaldeliveriesbetween2014and2017.33

Table3:UnionParishadbudgetallocationandutilization(July2016toJune2017)32

District NumberofUnions

Numberofunionsallocatedbudget

Percentageofunionsallocatedbudget

Totalbudgetallocated(BDT)

Totalbudgetutilized(BDT)

Percentageofbudgetutilization

Habiganj 77 57 74 7,298,945 4,449,311 61Jhalokathi 32 21 65.6 3,080,069 1,009,640 33Lakshmipur 58 42 72.4 6,035,208 5,887,871 98Noakhali 44 38 86.4 4,518,000 6,260,098 139Total 211 158 74.9 20,932,222 17,606,920 84.1

*Note:FundutilizationwaslowerduetoUnionParishadelectionsduringtheyearKeylearningsandlessonstakenforwardMaMoniHSS’sexperienceofengaginglocalgovernmentwithincommunitieshasdemonstratedthecriticalrolesuchabodycanplayinremovingbarrierstoserviceutilization.TheGovernmentofBangladeshhasmademovestocommititselftoensuringuniversalhealthcoverageforitspopulationoverthenextfewdecades,andhasacknowledgedMaMoniHSS’suniquecontributiontowardsthisaim.TheMinistryofHealthandFamilyWelfarehastakenuptheMaMoniHSSmodelintwodivisionsofBangladesh(covering1,200unions),wheretheyarenowprovidingtargetedadvocacyandsensitizationmeetingsontherolelocalgovernmentcanplayinthehealthsector.33UnionParishadChairmenwhohavebeenchampionsofthiscauseunderMaMoniHSShavebeenprovidedforumsbytheMOH&FWtosharetheirexperiencesandsuccesseswithintheirsubdistrictssothatadditionalunionsmaylearnfromtheirexamples.

Communitymobilizationatscale:Strengthsandchallenges

EvolvingapproachesinstepwithshiftingpoliticalprioritiesforhealthSavetheChildrenBangladesh’sapproachestocommunitymobilizationatscaledidnotevolveovertimeinisolationaccordingtoastrictideology.Rather,thestrategyevolvedtoaddressthegapsincommunityengagementapproachesinthegovernmentprogram,andtofacilitatetheinterfacebetweencommunitiesandgovernmenthealthworkers.SavetheChildrenbeganbyinfusingtremendousprojectsupportandfundingintoestablishinganinitialheavily-structuredmodelforcommunitymobilizationappropriatefortheBangladeshicontextunderACCESS,andthensubsequentlystreamlinedtheapproachandsoughtwaystointegrateitintoexistingsystemsatanationalscale.TheACCESSprojectwasdesignedandimplementedduringatimewhentheGovernmentofBangladeshhadnostrategyregardingtheroleofcommunitymobilizationinthehealthsystemandCommunityClinicswereshuttered.Now,communitymobilizationispartoftheGovernmentofBangladesh’shealthstrategy(includedinthefourthsector-wideprogram),andgovernmentstructureshavebeenestablishedtofacilitatetheengagementofcommunitymembersandlocalrepresentativesinidentifyingservicegaps,providingfacilityoversight,andmobilizinglocalfundstoaddresshealthandfamilyplanningneedswithinlocalcommunities.WhilemanyNGOsacrossBangladeshhad

theirownmodelsofcommunitymobilizationoverthesametimeperiod,rarelyweretheyintegratedwiththegovernmentsystem.SavetheChildrenBangladeshpositsthatthisistheirkeycontribution—learningfromprojectexperiencesandsuccessesalongthejourneythathavehighlighteduniqueopportunitiesformeaningfulinterfacesbetweengovernmentandcommunitiesandworkingtoinstitutionalizethosemodelsatdistrictandnationalscales.CommunityActionGroupsandCommunityMicroplanningDirectlyengagingcommunitymembersthroughCommunityActionGroupsunderACCESSshowedpromiseforincreasingdemandformaternalandnewbornhealthservicesandaddressingbasicbarrierstoaccessingcare.However,withahealthsystemstrugglingtoprovideevenbasicservicesinmanyareas,SavetheChildrenBangladeshnecessarilyshiftedemphasisintheirprogrammingtohelpingensuregovernmentserviceswereavailable.Aimingtosupportthegovernmentsystemsandworkatincreasingscale,itbecamequicklyapparentthatusingprojectstafftointensivelyfacilitateCommunityActionGroupstofollowacomplexCommunityActionCycleprocesswouldnolongerbethebestuseofprojectfunding.SimplifyingthetasksofCommunityActionGroupsenableduneducatedgroupmembersandCommunityVolunteerstohavesuccessfulandfocusedmeetingsandtotakeownershipoftheirmeetings’results.Theybeganfocusingoncollectingmeaningfulinformationdirectlyusefulforlocalplanningbythehealthsystem,andthroughCommunityMicroplanningmeetings,gainedtheabilitytodirectlyinterfacewiththesystemonaregularbasis.Arguably,itappearsthattherestructuringofCommunityActionGroupsovertimecompromisedtheoriginalfocusonstrengtheningcommunities’capacitytoidentifyandaddresstheirownissuesinabroadsense—acapacityusefulbeyondthecontextofaspecificproject-drivenhealthgoal.However,itcouldbearguedthateventhemorestreamlinedworkofCommunityActionGroupsandCommunityVolunteersprovidedopportunitiestoimprovetheirsenseofcollectiveefficacytoinfluencelocaldecision-makingandaddresstheirprioritizedproblems.TheestablishmentofCommunityMicroplanningMeetings(cMPM)allowedforapreviouslyunseenlevelofcommunicationamongstcommunitymembersandhealthandfamilyplanningserviceproviders.SocialautopsiesshowedthatcollectinginformationforcMPMwasnotjustaboutsimplyregisteringpregnantwomen—rather,sharingofsuchinformationallowedfordirectfollow-upwhenwomendied.Communityleadersvisitedthehouseholdswherematernaldeathstookplace—whichinadvertentlyhelpedtochallengethenormthatbeingpregnantisjustawoman’saffair.Localleadersandthegovernmenthealthsystemwereabletobedirectlyresponsivetothecommunity’sactualneedsbecauseofCommunityActionGroups’grassrootssurveillance.LearningsfromthecMPMexperiencehavebeenleveragedtoestablishateam-basedtrainingprogramattheNationalInstituteofPopulationResearchandTraining(NIPORT),throughwhichthegovernment’sfrontlineproviders(FemaleWelfareAssistants,HealthAssistants,andCommunityHealthCareProviders)learntoworkmoreeffectivelytogetherandimprovedatareportingwithintheircatchmentareacommunities.

Additionally,CommunityVolunteers’capacitieswerestrengthenedthroughorientationtrainingsandbybeingprovidedopportunitiestoliaiseamongcommunitymembersandgovernmentoutreachworkers.ManyCommunityVolunteersgainedtheabilitytobeconsideredforbetterjobs,orwereelectedtolocalgovernmentpositionsastheirrapportwithcommunitymembersgrewduringtheirservice.EngagementoflocalgovernmentUnionParishadsarepowerfulnon-healthactorsthatSavetheChildrenBangladeshhassuccessfullyengagedtohelpmobilizelocalresourcesforhealthwithincommunitiesintheirprojectareas.ThroughMaMoniISMNC-FPandMaMoniHSS,localpoliticianshavereceivedpressuretouseUnionParishadmoneyforhealthandfamilyplanningneeds.Thisisadeparturefromtheirpreviouslynarrowfocusonfundingsanitationprojects—whichafewkeyinformantssaidareknowntoallowmorespaceforcorruption.Asaresult,keyinformantsinvolvedinfieldimplementationexpressedhowsomelocalgovernmentrepresentativeshavedevelopedapublicreputationforbeinglesscorruptintheeyesoftheirconstituents,andarenowcompelledtokeepupthereputationbycontinuingtodirectfundstowardshealthandfamilyplanningneedsevenintheabsenceofdirectpressurefromtheproject.AsCommunityVolunteersfromSavetheChildrenBangladesh’sprojectshavegainedrespectintheircommunitiesandbeenelectedasmembersintheirUnionParishads,thismomentumcontinuestogrow.Sincelocalgovernmentofficialsareheldaccountabletotheirconstituentsandmustmaintaintheirreputationsinordertobere-elected,theyareideallysuitedtoprovideoversighttothelocalhealthfacilitiesandproviders.Oncetheyallocatefundstoalocalfacilityinresponsetoneedsidentifiedbythecommunity,theyareinvestedinensuringthosefundsareusedappropriately.Asaresultofengaginglocalgovernmentinthisway,UnionChairmenarenowplayingmoreactiverolesinvisitingfacilities,ensuringstaffarepresenteachdayandservicesarefunctional.BasedonSavetheChildrenBangladesh’smodel,theGovernmentofBangladeshhasrecentlyincorporatedtheengagementoflocalgovernmenttosupportunionlevelfacilitiesintotheMinistryofHealthandFamilyWelfare’ssectorplan.Usinganadvocacytoolkittheydevelopedforthispurpose,SavetheChildrenBangladeshisnowsupportingDGFP’sdirectimplementationofthemodelintwoprioritydivisions.Furthermore,MaMoniHSSsiteshaveservedaslearningsitesforotherdistrictstovisitandlearnhowthelocalgovernmentmembersweremobilized.

Evaluatingoutcomesofcommunitymobilization:ChallengesinmeasurementKeyinformantinterviewsrevealedhowprojectteammembersacknowledgeinhindsighthowitwasmisguidedtooriginallyfocussonarrowlyontrackinghowmanyspecificCommunityActionGroupswerecontinuingtomeetatregularintervalsovertheyearsandfollowingtheprescriptiveCommunityActionCycleprocessindetail.Inpractice,asgovernmentstructuresbecomemoreresponsivetocommunityneedsovertime,socialnormsgraduallyshift,andmorewomenseekservicesatfacilities,itis

reasonablethattheveryCommunityActionGroupsoriginallyestablishedneednotcontinuetomeeteverytwoweeksinaformalizedway.Moreover,astheuseofmobilephoneshasproliferatedsinceACCESSwasfirstimplemented(from21.76millionusersin200634to143.103millionusersasofNovember,201735),communitymembersandvolunteershavechangedthewaysinwhichtheyinteract.Nolongerisitnecessarytomeetinpersoneverytimesomethingneedstobecommunicated;rathercommunitymemberscanshareinformationoverthephoneandevencommunicatewithoutreachworkersofthegovernmentorelectedrepresentativesusingtheirmobilephones.Projectsshouldacknowledgethischangeandcontinuetoinnovatewaystoincorporatemobilephonetechnologyintotheirapproachestocommunitymobilization.ACCESSandMaMoniISMNC-FPhadcomprehensivecommunitymobilizationstrategiescompletewithambitiouscommunitymobilizationcomponentspecificobjectives.However,progresstowardstheseobjectiveswasunabletobemeasuredwiththemonitoringdatacollected.Thischallengeisnotuniquetothedocumentedprojects.AsLippman36highlights,communitymobilizationapproachesareincreasinglybeingusedascomponentsofhealthprograms,yettheyareoftenpoorlyevaluated.Movingbeyondsimpleprocessindicatorstomeasuretheoutcomesofcommunitymobilizationactivitiesischallengingduetoalackoftoolsandconstraintsontimeandfunding.Communitymobilizationoutcomesarelatent(notdirectlyobservable)innature,andrequirescalesadaptedtoandtestedwithinaproject’slocalcontextinordertobemeasuredreliably.Ideally,fundingforprojectsimplementingcommunitymobilizationapproacheswouldalsosupportoperationsresearchthatcouldallowforthevalidationofmeasuresappropriatefortheproject’scontextsothatlatentconstructssuchascollectiveefficacy,collectiveaction,socialcapital,socialcohesion,andotherscouldbeaccuratelyandreliablymeasuredatprojectbaselineandendline.Moreover,sinceprocessestofacilitatecommunitymobilizationarelengthyandoutcomesandimpactsarenotimmediate,experiencesuggeststhatprojectsimplementingapproachestocommunitymobilizationshouldnotbelessthanfiveyearsinduration.

WaysforwardforfutureprogrammingSavetheChildrenBangladeshwillsoonbeginimplementationofthenextfollow-onprojectknownasMaMoniMaternalNewbornCareStrengtheningProject(MNCSP),whichwillcontinuethrough2023.A$50millionUSAID-fundedproject,MaMoniMNCSPwillcoverapopulationofroughly21.5millionpeopleacrosstendistricts:Brahmanbaria,Chandpur,Lakshmipur,Feni,Noakhali,Faridpur,Manikganj,Madaripur,Kushtia,andHabiganj.MaMoniMNCSPaimstocutbackproject-drivenactivitiesevenmoredrasticallythanMaMoniHSSandfocusonhowtosupportthegovernmentstructuresthathavebeenmorerecentlycreatedtoengagecommunitymembers.ThenewCommunitySupportGroupsthathavebeenestablishedbytheMinistryofHealthandFamilyPlanning(threeperCommunityClinic)asameansofmobilizing

communitymemberstoparticipateinsupportingthehealthsystemarenotyetfunctionalontheirown,anddonothavetheirownfundstodirectlyaddressbarrierstoservicedelivery.Inordertomakethesebodiesactiveandsustainable,SavetheChildrenBangladeshrecognizesthebenefitoffacilitatinglinkagesbetweentheCommunitySupportGroupsandlocalgovernmentbodies.UnionParishadshavetheirownincomeandtheauthoritytooverseegovernmentoutreachworkersandpublichealthandfamilyplanningfacilities,shouldtheybemotivatedtodoso.SinceUnionParishadmembersareaccountabletotheirconstituentsandhavestakeinensuringlocalneedsareaddressed,theyareidealfortakingontheroleofensuringCommunitySupportGroupsarefunctioningandmobilizingresourceswhennecessary.Intheprojectareas,MaMoniMNCSPwillinjectaninitialinvestmentintoensuringthegovernmenthasthecapacitytomobilizecommunitymembersthroughtheirestablishedstructures,andthensupportasneededduringthelifeoftheprojectwhiletakingcaretoavoidestablishingparallelsystems.CommunitySupportGroupswilltaketheplaceofproject-specificCommunityActionGroups,communitymicroplanningwilltakeplacethroughtheCommunitySupportGroups,andthenewlyestablishedgovernmentcadreofMultipurposeHealthVolunteers(MPV)willperformtherolesofCommunityVolunteers.AlthoughtheMPV’sfullscopeofworkwilldifferfromMaMoni’sCVs,theMinistryofHealthandFamilyWelfarecouldbenefitfromMaMoni’slearningsregardingguidelinesforselection,training,supportandlinkstofrontlineworkers.SavetheChildreninBangladeshisalreadyinvolvedindiscussionsrelatedtotheestablishmentofthenewMPVcadre,andthetrainingmanuals,registers,andjobaidsdevelopedbyMaMoniwillbehelpfultotheMinistry.SavetheChildrenBangladesh’sexperiencesthusfarhaveshownthatengagementoflocalgovernmentinhealthcanbetremendouslysuccessfulingeneratinglocalresourcesandstrengtheningpublicfacilities.However,movingforwarditwillbenecessarytonotonlyfocusonhowtheycanbeleveragedtosupportcommunityservicedelivery,butalsotheroletheymayplayinshiftingsocialnormsandhelpingtocreatesupportiveenvironmentsforsustainablebehaviorchangewithinhouseholdsintheircommunities.Advocatingthataportionoflocallymobilizedfundsbeinvestedinhealthpromotionactivitiesratherthansolelytowardsinfrastructurecouldbeonewaytohelpensureamoreintegratedapproachtosupportingcommunityhealth.Furthermore,theprojecthasalongwaytogoinexploringhowbesttoensurelocalgovernmentofficialsareeffectivelyseekingandprocessingfeedbackfromtheircommunitiesandthattheirengagementinthepublichealthsectordoesnotsolelyhingeontheproactivityandinterestoftheUnionChairmanalone.Localelectedofficialsholdinfluenceintheircommunities,andtheprojectwilldowelltobetterunderstandandcapitalizeuponthevariouspathwaysthroughwhichlocalgovernmentcaneffectchangeinregardstohealth.Developingacomprehensivesocialandbehaviorchangestrategyfortheprojectthatexplicitlylaysouttheunderlyingtheoryofchangethroughwhichlocalgovernmentisseentoresultindesiredoutcomeswillbecrucialinhelpingtoidentifythemostappropriateindicatorsforassessingthecontributionsofvariousprojectcomponents.

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35. BangladeshTelecommunicationRegulatoryCommission.(2018).MobilephonesubscribersBangladeshNovember3017.Retrievedfromhttp://www.btrc.gov.bd/content/mobile-phone-subscribers-bangladesh-november-2017

36. Lippman,S.A.,etal.(2016).Development,Validation,andPerformanceofaScaletoMeasureCommunityMobilization.SocSciMed,157,pp.127-137.

ANNEXI:KeyprojectdocumentsreviewedHoward-Grabman,Lisa.DemystifyingCommunityMobilization:AnEffectiveStrategytoImproveMaternalandNewbornHealth.February2007.TheACCESSProgram,USAID.Storti,Charlotte.HowtoMobilizeCommunitiesforImprovedMaternalandNewbornHealth.April2009.TheACCESSProgram,USAID.Howard-Grabman,Lisa&Snetro,Gail.HowtoMobilizeCommunitiesforHealthandSocialChange.2003.HealthCommunicationPartnership,USAID.Riggs-Perla,Joy;Mannan,Ishtiaq;Kak,Lily;&Chakraborty,Krishnapada.ACCESS:SafeMotherhoodAndNewbornCare(SMNC)ProjectAssessment.April2008.USAID.ACCESS/Bangladesh.CommunityMobilizationStrategy.SavetheChildren.ACCESS/Bangladesh.RevisedCommunityMobilizationProcessandScale-up/SustainabilityPlan.June2008.SavetheChildrenSen,Rita.RoleofCommunityActionGroups(CAGs)inImprovingMNHSituation.June2011.SavetheChildren.ACCESS/Bangladesh.ACCESSinBangladeshCloseoutReport.SavetheChildren.ACCESS/Bangladesh.YearOneAnnualReport.October2006.SavetheChildren.ACCESS/Bangladesh.Semi-AnnualReport.March2007.SavetheChildren.ACCESS/Bangladesh.YearTwoAnnualReport.October2007.SavetheChildren.ACCESS/Bangladesh.Semi-AnnualReport.March2008.SavetheChildren.ACCESS/Bangladesh.YearThreeAnnualReport.September2008.SavetheChildren.ACCESS.AccesstoClinicalandCommunityMaternal,NeonatalandWomen’sHealthServicesProgram:YearThreeAnnualReport.October2007.ACCESS.Projectproposalfor:IntegratedSafeMotherhood,NewbornCareandFamilyPlanning(ISMNC-FP)Project.January2009.SavetheChildren.ACCESS/Bangladesh.CommunityActionGroup:BenchmarkofCommunityCapacityAssessment.SavetheChildren.

ACCESS.CommunityMobilization:AnEffectiveStrategytoImproveMNH.Availableathttp://www.mchip.net/sites/default/files/h_Community_Mobilization.pdf.ICDDR,B.EvaluationoftheACCESSBangladeshprogramme:ReportofBaselineSurveyACCESSproject,Sylehet-2007Ullah,Saif.AnEconomicEvaluationofCommunityActionGroups(CAGs)inSylhet,Bangladesh.January2011.SavetheChildren.Daulatuzzaman,Md.InstitutionalizationofCAGfroImprovingMNHSituation.May2011.SavetheChildren.TheRoleofCommunityVolunteersinImprovingMaternalandNeonatalHealthinNortheasternBangladesh.February2013.SavetheChildren.MaMoniISMNC-FP.OperationalGuidelinesonCommunityMobilization.June2010.SavetheChildren.MaMoniISMNC-FP.UnionParishadOrientationMeetingGuidelines.March2010.SavetheChildren.MaMoniISMNC-FP.CommunityMobilizationStrategy.February2010.SavetheChildren.MaMoniISMNC-FP.FinalReport.2014.SavetheChildrenRoss,S.R.,Ahmed,J.U.,McLellan,I.,&Campbell,W.MaMoniISMNC-FPFinalEvaluation.2014.USAID.MaMoniISMNC-FP.ProcessDocumentationofCommunityMicroplanningMeetingsinMaMoniArea.SavetheChildren.MaMoniISMNC-FP.ProcessDocumentationofCommunityMicroPlanningMeeting(CMP)inMaMoniArea:Strategyandprocess.SavetheChildren.ICDDR,B.EvaluationoftheACCESS/BangladeshandMaMoniPrograms:Population-BasedSurveysintheSylhetDivisionofBangladesh:Mid-lineEvaluationonMaternal&NewbornHealth,2010.MaMoniHSS.MonitoringandEvaluationPlan.April2015.SavetheChildren.MaMoniHSS.AnnualReportSeptember23,2013-September30,2014.MCHIP,USAID.MaMoniHSS.AnnualReportOctober01,2016-September30,2017.MCHIP,USAID.

CommunityActionCycle-Indicators.SavetheChildren.Underwood,Caroletal.Communitycapacityasameanstoimprovedhealthpracticesandanendinitself:Evidencefromamulti-stagestudy.2013.InternationalQuarterlyofCommunityHealthEducation,Vol.33(2)105-127.“ExperienceonworkingwithCommunityVolunteers.”[PowerPointslides].October20,2011.SavetheChildren.“EngagingCommunitiesforMNH-FPThroughCommunityActionCycleApproach:ExperiencesfromMaMoniProject.”[PowerPointslides].SavetheChildren.“CommunityMicroplanning:MaMoniExperienceandWayForward.”[PowerPointslides].October13,2014.“ProcessDocumentationofCommunityMicroplanninginMaMoniAreaOctober2011-March2013.”[PowerPointslides].July13,2016.Becker-Benton,Antje.“Community-ledBehaviorChangeFrameworkStrategy.”[PowerPointslides].July17,2017.SavetheChildren.Becker-Benton,Antje.“UpdatesonSocialandBehaviorChange.”[PowerPointslides]December7,2017.SavetheChildren.

ANNEXII:ListofkeyinformantsName Designation OrganizationImteazMannan Sr.AdvisorAdvocacyand

Communication,MaMoniHSSProject

SavetheChildrenBangladesh

AntjeBecker-Benton TeamLead/SeniorAdvisorBehaviorChange&CommunityHealth

SavetheChildrenUS

JosephJohnson SeniorAdvisorMNH SavetheChildrenUSJobyGeorge ChiefofPart,MaMoniHSS

ProjectSavetheChildrenBangladesh

ShumonaShafinaz SeniorAdvisor,ProgramManagement;MaMoniHSS

SavetheChildrenBangladesh

MarufaAzizKhan SeniorManager,OperationsResearch;MaMoniHSS

SavetheChildrenBangladesh

Md.EklasUddin DeputyProgramManager,CommunityMobilization;MaMoniISMNC-FPProject

SavetheChildrenBangladesh

JatanBhowmick DeputyProgramDirector,DistrictImplementation;MaMoniHSSProject(FormerlyDeputyProgramManagerMNHunderACCESS/Bangladesh)

SavetheChildrenBangladesh

HomayunKabir HealthDirector ShimantikJamilAkhtar Manager,SBCC SavetheChildren

BangladeshMohammodShihabUddin [Former]Upazila

Coordinator,ACCESSandMaMoniISMNC-FP

Shimantik

MohammedKamalHossain [Former]DeputyManager,CommunityMobilization,ACCESS/Bangladesh[Current]ProjectDirector,HOPE

SavetheChildrenBangladesh

IshtiaqMannan DeputyCountryDirector SavetheChildrenBangladesh

RowshonJahan Manager,Community-basedServices;MaMoni

SavetheChildrenBangladesh

HSSMd.JalalUddin UpazilaFacilitatorQuality

Improvement&ServiceDelivery;MaMoniHSS

SavetheChildrenBangladesh

JesminAkter UpazilaFacilitatorQualityImprovement&ServiceDelivery;MaMoniHSS

SavetheChildreninBangladesh

BashirAhammad SeniorProgramOfficer;Habiganj

SavetheChildreninBangladesh

AngelaBrasington [Former]CommunityMobilizationSpecialist[Current]SeniorTechnicalAdvisor,BureauforGlobalHealth

[Former]SavetheChildrenUSA[Current]USAID

ANNEXIII:SamplekeyinformantquestionsThefollowinglistcomprisesbasicquestionsaskedofallkeyinformants.Morespecificprobingquestionswereaskedofeachkeyinformantinaccordancewiththeirroleandknowledgeofvariousprojectcomponents.

1. CanyoutellmeaboutyourroleinACCESS/MaMoni/MaMoniHSS?a. ProbespecificallyonCMcomponent

2. WhatwasyourunderstandingoftheroleCMplayedinACCESS/MaMoni/MaMoniHSS?(e.g.Whatdidyoufocusonandmeasure?)

3. Canyoutellmeyourthoughtsonhow“mobilized”thecommunitiesbecame?4. WhatdidCMlooklikeinACCESS/MaMoni/MaMoniHSS?(Andspecificallywhat

roledidtheCAGsplay?)a. HowdidthiscomparetothewayCMwasconceptualizedattheproject’s

outset?(ComparetotheCMstrategydocuments)i. Reasonsforanydeviations?

b. Whatstrategiesweredeveloped?Whatisstillinuse?c. Whattoolsandmaterialsweredeveloped?

5. Canyoutellmehowthiscomparedtopreviousiterations(ACCESS/MaMoni)?a. Reasonsforevolution?(Whowerethedrivers?Actors?)

6. WhatconstitutessuccessfulCM?a. Howisthismeasured?b. Whatgapswerethere?

7. WhatchallengesdidtheprojectfaceregardingCM?8. WhatabouttheCMcomponentworkedwell?9. Whatlessonsdidyou/yourteam/theprojectlearnregardingtheCMprocessasa

resultoftheproject?WhatlessonsshouldbesharedwithothersinterestedinimplementingCMortakingitscale?

10. WhatisdifferentaboutCMwhenimplementedatasmallscalevs.largescale?a. Why?b. Whatdowegain?c. Whatdowelose?d. Howarethepros/consweighed?

ANNEXIV:Summarytable

Increasingprojectscaleandinstitutionalizationofcommunitymobilization

Precursorresearchprojectscontributingto

evidencebaseThreegenerationsofUSAID-fundedMNHprojectsincorporatingcommunity

mobilizationactivitiesbySavetheChildreninBangladesh Newproject

ProjectSEARCHFieldTrial

[India](1995-1998)

ProjahnmoIStudy(2001-2006)

ACCESS(2006-2009)

MaMoniISMNC-FP(2009-2013)

MaMoniHSS(2014-2017)

MaMoniMNCSP(2018-2023)

Funding TheFordFoundationand

TheJohnDand

CatherineTMacArthur

Foundation

USAIDandSavethe

Children’sSaving

NewbornLivesprogram

throughagrantfromBill

andMelindaGates

Foundation

USAID

($6million)

USAID

($13million)

USAID

($53million)

USAID

($50million)

Geographicscale(numberofsubdistricts)

GadchiroliDistrictof

MaharashtraState,India

(39interventionvillages;

47controlvillages)

Studypopulationof

81,147

SylhetDistrict(3)

113,816studyparticipants

SylhetDistrict(5)

Populationof1.5million

SylhetDistrict(5)

HabiganjDistrict(8)

Populationof3.5million

Highintensityinterventionareas:HabiganjDistrict(8)

NoakhaliDistrict(4)

LaksmipurDistrict(5)

JhalokatiDistrict(4)

PirojpurDistrict(2)

Healthsystemcapacitystrengtheningareas:BholaDistrict(7)

NoakhaliDistrict(5)

PirojpurDistrict(5)

Populationof12.5million

BrahmanbariaDistrict(9)

ChandpurDistrict(8)

LakshmipurDistrict(5)

FeniDistrict(6)

NoakhaliDistrict(9)

FaridpurDistrict(9)

ManikganjDistrict(7)

MadaripurDistrict(5)

KushtiaDistrict(6)

HabiganjDistrict(8)

Populationof21.5million

Projectobjectives

Testthehypothesisthat

ahome-basedpackage

ofnewborncare,

includingthe

managementofsepsis,

canreducetheneonatal

mortalityratebyatleast

23%in3yearscompared

tocontrolareas.(Banget

al.,1999)

Testthehypothesisthat

bothahome-caremodel

andacommunity-care

modelforpromoting

neonatalhealthinrural

Bangladeshwouldaffect

keyhealthcarebehaviors

andresultina40%

reductionintheneonatal

mortalityrateversusthat

Objective1:Increaseknowledge,skills,andpractices

ofhealthymaternaland

newbornbehaviorsinthe

home

Objective2:Increaseappropriateandtimely

utilizationofhome-and

facility-basedessentialMNH

Objective1:Increaseknowledge,skillsandpractices

ofhealthymaternaland

neonatalbehaviorsinthe

home

Objective2:Increaseappropriateandtimely

utilizationofhomeandfacility-

basedessentialMNHandFP

Objective1:Improve

servicereadinessthrough

criticalgapmanagement

Objective2:Strengthenhealthsystemsatdistrict

levelandbelow

Objective3:Promotean

enablingenvironmentto

TBD

ANNEXIV:Summarytable

Increasingprojectscaleandinstitutionalizationofcommunitymobilization

Precursorresearchprojectscontributingto

evidencebaseThreegenerationsofUSAID-fundedMNHprojectsincorporatingcommunity

mobilizationactivitiesbySavetheChildreninBangladesh Newproject

inacomparisonarm.

(Baquietal.,2008)

services

Objective3:Improvekey

systemsforeffectiveservice

delivery,community

mobilization,andadvocacy

Objective4:Mobilize

communityaction,support,

anddemandforthepracticeof

healthyMNHbehaviors

Objective5:Increasestakeholderleadership,

commitment,andactionfor

thesematernalandneonatal

healthapproaches

services

Objective3:IncreaseacceptanceofFPmethodsand

advanceunderstandingofFP

asapreventivehealth

interventionformothersand

newborns

Objective4:Improvekey

systemsforeffectiveservice

delivery,community

mobilizationandadvocacy

Objective5:Mobilize

communityaction,supportand

demandforthepracticeof

healthyMNHbehaviors

Objective6:Increasekeystakeholderleadership,

commitmentandactionfor

theseMNHapproaches

strengthendistrictlevel

healthsystem

Objective4:Identifyandreducebarriersto

utilizationofhealth

services

Keycommunitycomponents

•Villagehealthworkers

providedhome-based

newborncareincluding

diagnosisandtreatment

ofneonatalsepsis

•Healtheducation

providedtomothersand

grandmothersregarding

careofpregnantwomen

andofneonates

•CommunityMobilizers

hostedcommunitygroup

meetingstodisseminate

birthandnewborncare

preparednessmessages

•Inthecommunity-care

arm,volunteer

communityresource

peopleworkedto

encourageattendanceat

communitymeetingsand

careseekingforMNH

•CommunityActionGroups

(CAG)facilitatedbyproject

staffandsupportedby

CommunityResourcePersons

(CRP)

•1femaleCAGand1male

CAGpervillage

•CAGsfollowedintensive11-

monthCommunityAction

Cycle(CAC)

•CommunityVolunteers(CV)

selectedbyUnionParishadsto

facilitateCAGs

•CommunityActionGroups

(CAG)followedsimplified6-

monthCAC

•1CVper300population;3

CVsperCAG

•CommunityMicroplanning

Meetings(cMPM)

•CommunityVolunteers

facilitatemonthly

CommunityActionGroups

(CAG)meetingstoshare

healtheducation;collect

datatoshareduringcMPM

•1CVper250population;

1CVperCAG

•Community

MicroplanningMeetings

(cMPM)

TBD

ANNEXIV:Summarytable

Increasingprojectscaleandinstitutionalizationofcommunitymobilization

Precursorresearchprojectscontributingto

evidencebaseThreegenerationsofUSAID-fundedMNHprojectsincorporatingcommunity

mobilizationactivitiesbySavetheChildreninBangladesh Newproject

•Inthehome-carearm,

CHWsvisitedhouseholds

toprovideANC/PNCand

treatmentwithinjectable

antibiotics

•HomevisitsbyACCESS

Counselors(AC)

•Localgovernment

engagement

•Localgovernment

engagement

•Interactivecommunity

videoshows

Lessonslearned

Home-basedneonatal

care,including

managementofsepsis,is

acceptable,feasible,and

reducedneonatal

mortalityby62%among

theruralstudy

population

33%reduction(home-

carearm)andnon-

significant9%reduction

(community-carearm)in

neonatalmortality

showedthatcommunity-

caremodelneedslonger

timeperiodtobecome

wellestablished

Governmentcadreof

CHWsnotauthorizedto

provideinjectable

antibiotics,therefore

completemodelnot

directlyscalableoutside

researchcontext

Modelsuccessfulinincreasing

knowledgeanddemandfor

services,butnotinimproving

keyserviceutilization

indicatorsduetounavailability

ofservices

cMPMemergedasapromising

interfacebetweencommunity

andexistinggovernment

structures

Localgovernmentbecame

keyresourcefor

strengtheningfacilitiesand

addressingbarriersto

servicedelivery

Notyetavailable