To empower clients in improving their own health services, Pact turns to community-led monitoring

Last year, Pact’s health programming reached nearly 2 million people. From Africa to Asia, we supported communities as they accessed better maternal and child health care, improved and expanded the reach of local HIV services, and much more.

In the old days of global health programming, those we reached often were unfortunately viewed as passive recipients of services. Thankfully, today, we recognize that the people we serve have so much to teach us about how we can do our work better. At every stage, we must work together, listen and adapt. This is at the heart of decolonized development, and it is a huge part of what Pact means when we say that we focus on engaging communities and on building local ownership of development solutions. 

In the area of health, and especially HIV programming, community-led monitoring (CLM) is a powerful tool for doing just this, and I’m thrilled that Pact is integrating CLM into our programs, beginning with the USAID-funded ACHIEVE project, which is working to reach and sustain HIV epidemic control among pregnant and breastfeeding women, adolescents, infants and children. 

What is CLM?
CLM is defined as a mechanism, process or practice whereby service users or local communities regularly gather, analyze and use information to improve access, quality and impact of services. It is implemented by local community-based organizations and other civil society groups, networks of key populations, people living with HIV, and other stakeholders to gather quantitative and qualitative data about HIV services. The focus is on gathering community input in a routine and systematic manner that will translate into action and change to diagnose persistent issues and barriers to service uptake. In the few years that it has been in use, CLM has been found to be a successful model for collaboration, continuous and systematic advocacy, and education.

Why CLM?
For Pact and our partners, it is important to acknowledge health care recipients as agents capable of holding service providers accountable and advocating for optimal care that meets their needs. CLM provides an opportunity to fill the gap where systems and institutions are unable to document shortfalls and rectify them. CLM also allows for a greater focus by service providers on the entire system for service delivery, and it supports a reflection practice that builds trust. CLM also incorporates elements of social and behavioral change that examine the needs and perspectives of both the recipient and service provider to ensure overlapping efforts that achieve the best results. In short, CLM is essential to putting communities at the heart of our implementation approach at Pact. This idea of engaged communities moves beyond surveillance into decision-making, collaboration and actionable impact that promotes accountability for health outcomes.

Piloting CLM
While Pact frequently builds participatory feedback loops into our programs, CLM offered the opportunity to take a more systematic approach to engaging communities in assessing service quality and strengthening relationships with service providers. In 2021, a core design team collaborated in the creation of a community-led monitoring toolkit. Led by a consultant, the team was made up of staff from ACHIEVE and other programs in seven countries, including DREAMS and HIV and gender-based violence services for orphans and vulnerable children (OVC) and/or adolescent girls and young women. The purpose of the toolkit is to strengthen community systems with guidance, while enabling communities to use data to celebrate service successes while identifying challenges in a supportive environment to improve services. The tools were designed to mirror the socio-ecological model to emphasize self-leadership, leadership of others and organizational leadership.

The design team met over a period of three months to craft a vision for implementing CLM in their respective portfolios. This process included a literature review of existing CLM tools, stakeholder analyses and a review of best practices linked to behavior change in CLM. Program participants, caregivers/parents, service providers and local leaders in Eswatini, Nigeria and Rwanda participated in consultative meetings to share their experiences and ideas. Finally, more than 120 stakeholders were engaged in a four-country pilot in August and September in which the draft toolkit was tested and feedback was obtained via focus group discussions and key informant interviews.

Overall, the pilot was a success. It showed that CLM is an effective way to support real-time adaptation and to allow clients to reflect on services, set goals and determine the long-term impacts of interventions.

Managers in Nigeria shared that “the tools are relevant for building a culture of engagement, improving experience sharing and receiving feedback. This will help to understand the challenges that clients face, in decision-making and better programming, and in addressing the special needs of those we serve.” Our team in Eswatini reflected that community-led monitoring is showing itself to be a practical embodiment of inclusion, a core Pact value.

Lessons learned
We learned many important lessons through the pilot process. Among them:

• More sensitization is needed about how CLM is different from routine monitoring and evaluation, as a key of part of the process is using feedback received to adjust programming.
• It is critical to engage local networks or associations to lead and support the rollout among clients and caregivers to help sustain the practice.
• It is important to translate the toolkit to local languages and contexts and to provide videos to support trainings for the toolkit, such as animations for youth.
• CLM requires financial resources and technical expertise, which are essential for capacitating communities with knowledge about CLM.
• We should ensure training for community case workers on tools for caregivers and youth to enable them to lead the rollout process.
• There is a potential for clients to provide socially desirable feedback depending on who administers tools, highlighting the need for unbiased feedback loops that foster learning for quality improvement.

Looking ahead
In Nigeria, ACHIEVE plans to soon roll out CLM through CSO networks such as the Association of OVC NGOs in Nigeria. Feedback from the community will be collectively channeled through the OVC Technical Working Group at the local government and state levels for solutions to issues requiring government support. As such, the toolkit will be used across various Nigeria programs funded by various donors and partners. In Eswatini, the CLM toolkit is being used by Pact’s Strategic Information team in their quarterly verification exercises for monitoring of program participant experiences, with plans to use the feedback received in subsequent program adaptations. These are just a few examples of how CLM can incorporate advocacy based on community priorities, ultimately putting the power of development initiatives in communities’ hands.

To learn more about Pact’s community-led monitoring toolkit for OVC and DREAMS programming, watch a recording of our recent webinar. To download the toolkit, go here.

Manji Ephraim Rengshwat and Nosipho Gwebu Storer contributed to this article.