The various partners should agree to obtain and analyse as much information as possible about the experience to date in Zambezia. They should agree to work together to understand the real costs of the various components (transport, education, supervision, management etc.) in different geographical areas and how these activities could be carried out in the most cost-effective manner.
3. Health challenges in Mozambique
The Mozambique office of UNICEF should decide how it could best support the Government of Mozambique in developing effective strategies for reaching people who live at a distance from Health Units. As a UN agency with a mandate to work with the Government, but with also the possibility of working with donors and with other partners such as NGOs in the implementation of projects, UNICEF is in a position to support policy-level work based on experience and operational research from project implementation.
If UNICEF decides to take this approach, UNICEF should advocate with donors to help develop a system at the community level for the delivery of a variety of health services, rather than continue to think in terms of vertical programmes delivering services to communities.
UNICEF should work with the Ministry of Health in analysing the experience with Community Councils in the areas where they have been introduced to understand better what they have achieved and any constraints.
Where UNICEF has the opportunity to be involved with projects that include Community Councils, UNICEF should advocate for objectives that include the development of a sustainable strategy for reaching people who live at a distance from Health Units. This would involve taking an operational-research approach, so as to identify how a community-based strategy can best be developed. Consensus should be reached beforehand before the various partners (such as UNICEF, commercial companies, NGOs and the DPS) about the fact that operational research is required.
An operational-research approach would need to explore how Community Councils (and other community health workers), Mobile Brigades and Health Units can share responsibilities and work together effectively. It would need to explore how much they cost to function effectively and any other constraints, in different contexts.
4. Community Capacity Development and the Human Rights' Approach to Programming
UNICEF should further invest in Community Councils as an approach to community development. However, if UNICEF is committed to an HRAP or CCD approach, the Mozambique office should understand that this implies a long-term engagement to build community capacity in stages and in parallel to build the capacity (and attitudes) of other actors to effectively work with communities. It should understand that short-term, vertical programmes, on their own, are difficult to reconcile with an HRAP or CCD approach as the costs of a long-term engagement with community institutions (and with the State and private structures that interact with them) can be difficult to justify within the frame of a vertical programme. The sustainability of Community Councils will require investing in them and in the government structures that will interact with them and support them.
It should understand that specialist technical staff of vertical programmes will have difficulty in implementing an HRAP or CCD approach unless they have the full-time support of staff with an HRAP or CCD background. The Mozambique office of UNICEF should consider more integrated inter-sectoral programming in particular areas in which different sectors can together support capacity building of communities and service providers. It should alternatively consider general CCD programmes in particular areas into which sectoral programmes fit. It should consider having specialist staff in CCD and HRAP who can design and manage CCD programmes and support sectoral staff ensuring, for example, that the role and capacity analysis of the various duty bearers is adequately carried out and capacity building plans devised. It should also consider having a presence of staff at a Provincial level in areas with CCD programmes, to improve coordination between the various actors involved in programmes (training centres, implementing agencies, government agencies, UNICEF) and to assist in monitoring inputs (quality, quantity and timeliness), progress, outputs (immediate results), outcomes (changes in behaviour, knowledge and attitudes of the various duty bearers) and impact.
The Mozambique office of UNICEF should invest in monitoring systems for CCD and HRAP programmes that cover, and distinguish between, inputs, progress, outputs, outcomes and impact. CCD programmes pay particular attention to outcomes, that is to the behaviour, knowledge and attitudes of the various parties (their willingness and ability to carry out their roles). The technique of Outcome Mapping has been designed for monitoring changes in behaviour, relationships, actions and activities by people, groups and organisations involved in programmes.
If UNICEF is committed to an HRAP or CCD approach, Community Councils are a possible entry point to a long-term programme. Community Councils do represent a realistic approach to CCD and a methodology in which UNICEF should invest more resources in the future, though little of the potential has been realised as yet.
As a UN agency with a mandate to work with the Government, but with also the possibility of working with donors and with other partners such as NGOs in the implementation of projects, UNICEF is in a position to support policy-level work based on experience and operational research from project implementation. UNICEF could work with various Ministries to support the transformation of the present Community Councils (that focus on health activities) into Community Councils or Community Leaders' Councils with a wider remit. It could help in analysing the experience with Community Councils to understand better what they have achieved and any constraints, and in developing and ratifying a government Community Strategy that goes beyond the health field.
In particular, the Mozambique office of UNICEF should be able to provide assistance to the various Ministries in developing a "partnership for change" approach, in which Ministry staff work in cooperation with community organisations rather than an "information giving" approach. This should tackle the natural tendency of government institutions to see their links with community institutions as being a one-way "conveyor-belt" of information (and sometimes instructions) from government to communities. It should assist in the development of an understanding of the mutual rights and responsibilities of communities and those working with them.
There are many tools available that can support this change in attitude, such as the REFLECT literacy method developed by the NGO "Action Aid", the SARAR methodology and various tools for participative health education. However, tools on their do not guarantee the change in attitudes by those working with communities, and there will always be a risk that the tools will be used to support "information giving" rather than "partnership for change". UNICEF will need to accompany programmes closely so as to monitor how far, in practice, they help to develop relations of mutual respect, rights and responsibilities between communities and the various institutions working with them. This implies some change in the way in which UNICEF works in practice. Partnerships will be required with Ministries and NGOs and training institutions that, while being codified in contracts, will go beyond the "contract culture" and will involve a high level of interaction during the planning, implementation and evaluation of programmes.
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