kenya contextualised theory of change

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KENYA CONTEXTUALISED

THEORY OF CHANGE

25 September 2016

Report Author

Heather Budge-Reid

Contributors

Gavin Stedman-Bryce

Email: [email protected]

Web: www.pamoja.uk.com

mailto:[email protected]

http://www.pamoja.uk.com/


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TABLE OF CONTENTS

LIST OF BOXES AND FIGURES ......................................................................................................... 1

ACRONYMS AND ABBREVIATIONS ............................................................................................... 2

EXECUTIVE SUMMARY .................................................................................................................... 3

1. CONTEXT .................................................................................................................................. 4

2. EXAMINING HOW TO CREATE CHANGE IN KENYA .................................................... 10

3. OUTCOMES ............................................................................................................................. 12

APPENDIX 1: PROBLEM TREE EXERCISE RESULTS .................................................................. 17

APPENDIX 2: SPIDER DIAGRAM EXERCISE RESULTS .............................................................. 21

APPENDIX 3: BALLOONS AND STONES EXERCISE RESULTS ................................................ 22

APPENDIX 4: AGENDA ..................................................................................................................... 24

LIST OF BOXES AND FIGURES

Figure 1 Short-, medium- and long-term outcomes Figure 2 Problem tree for 'Low implementation' Figure 3 Balloons and stones diagram for 'County work' Figure 4 Problem tree for 'Health system weakness' Figure 5 Spider diagrams Figure 6 Balloons and stones diagrams Figure 7 Detailed Theory of Change indicating Accountability Threshold


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ACRONYMS AND ABBREVIATIONS

CSO Civil society organisation

HSA Health Systems Advocacy Partnership

HSS Health system strengthening

SRH Sexual and reproductive health

SRHR Sexual and reproductive health rights

ToC Theory of Change


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EXECUTIVE SUMMARY

Following a three-day residential meeting that focused on group work and plenary

discussions, the Kenya HSA Partnership and guests from a wide range of stakeholder

organisations came to a set of conclusions around a contextualised Theory of Change.

While the theory of change process was new to most in the room, all were open to the idea

of examining the concepts and re-examining previously developed lists of activities in the

light of questions about what change was desired and how that change was going to be

created. This led to the identification of some key contexts for the Kenyan team:

Health policies in Kenya were deemed good health polices but, as in Uganda, there

were challenges around implementation. As a result, work focused on

implementation rather than policy change.

The regions being targeted by the Kenya Partnership are undergoing an exciting

change as a result of the decentralisation process. This change is part of an exciting

moment of opportunity for influence that the HSA Partnership has in Kenya, to

support accountability, empowerment and policy implementation.

Each of the counties being targeted is undergoing a rapid urbanisation as the central

towns grow rapidly into cities and people move from the land to the urban areas. This

puts a particular pressure on the health systems in counties that were previously

rural. This peri-urban setting is not a unique challenge in Africa but by being involved

in this process the HSA team believe they will identify some important lessons.

After much discussion, the following statement summarises the contextualized theory of

change.

If we work at community, county and national levels to create/improve a well-informed space

for dialogue and dissent that improves accountability and empowerment

Then the health system at county level will be strengthened

Because health polices will implemented, financing of health will be more effective, planning

improved, commodities and HR better managed and the county-level decision-makers better

informed.

Figure 1 Short-, medium- and long-term outcomes

Long-term outcome of a sustainable local system of dialogue that continues

to develop accountability and empowerment and thus full implementation of

existing policies

Mid-term outcome of creating an empowerment and accountability space in

peri-urban environments and the research that will inform that space

Short-term outcome of an effective partnership between HSA members and

an effective, integrative approach between all stakeholders


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1. CONTEXT

There remains a challenge in the adaptation of the existing plans developed at the Kampala meeting

for the HSA Partnership and the results of the contextualised Theory of Change. These challenges are

not insurmountable but do illustrate the need to carry out the theory of change development process

before settling to specific plans. There is little evidence that the key contexts in Kenya are included in

the planning of activities. However, it will be straightforward enough to adapt activity lists to the

context as revealed in the three-day workshop.

1.1. Key issues

1.1.1. Implementation not policy change

Key to the context in Kenya is the understanding that there is no perceived need for policy change in

health and thus the activities currently targeted at policy change outcomes do not need to be

undertaken. However, there is a need to address the challenges of implementation – the financial

resources needed for implementation need to be made available, alongside the guidance and approach

necessary to see full implementation of existing policies. The diagram below is the result of group

work and reviews the causes and effects of poor implementation of good health policies in Kenya as

listed here. There is one further aspect of policy analysis that needs to take place – are the policies that

exist appropriate for the rapidly expanding peri-urban nature of growth in Kenya?

Problem tree results for 'Low implementation'

Causes Effects

Lack of guidelines

Poor dissemination of information

No timeframe

Poor formal and informal supervision

Poor allocation of resources

Poor planning

Lack of accountability

Corruption

Lack of public awareness

Misuse of resources

Lack of quality performance

Spread of corruption

Demoralised population

Lack of empowerment

Lack of awareness of rights


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Figure 2 Problem tree for 'Low implementation'

1.1.2. Decentralisation

The HSA Partnership begins work at an exciting moment of decentralisation of decision making and

finance allocations for health, with county-level structures taking local decisions about allocation of

funding and the development of the local health system. This has led to an understanding of the

importance of informing county structures about the value of strengthening health systems as well as

raising their capacities to make decisions in the new county structures. While new people are

becoming decision-makers, health related information needs to reach them about health systems and

health needs as well as the nature of health systems and challenges in their county.

1.1.3. The peri-urban health environment

Health needs change rapidly as an area's population changes from mainly rural to mainly urban, e.g.

the number of traffic accidents increases; population proximity increases TB; and, as structures such

as water and waste systems degrade under pressure, other health dangers alongside population growth

place demands on services that were previously serving a rural area.

There is a need to inform the county-level decision makers about the peri-urban health needs of their

areas. The group drew up a list of five topics of research that would need to be carried out in each

county in order that decision makers are informed about the conditions of the entire health system,

including the for-profit and not-for-profit sectors as well as the government sector.

Research topics:

1. What amount of funding is coming into the area that strengthens the health system?

2. What score does the health system in the area have and what should it have?

3. What is the commodity availability in the area?

4. What is the gap in human resources in the area?

5. What is the level of implementation of existing policies in the area?


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1.1.4. County-level implementation

Work in the chosen counties not only requires access to information but also the communication of

information to decision makers. In addition, county-level work faces some challenges as well as

positive factors. Group work through the Stones and Balloons exercise suggests that the following

issues will be important positives and negatives, and this illustrates why informing policy makers is so

important.

County work

Stones Balloons

High turnover of county leaders

Competing interests/priorities at county

level

Outbreaks of disease or epidemic

Severe unrest

Supportive political will

Existing health structures

Established and interested CSOs

Established and existing community

structures

Figure 3 Balloons and stones diagram for 'County work'

1.2. Identifying change relationships in the context of Kenya

The Problem Tree exercise (see Appendix 1) allowed the group to explore in more detail the causes

and effects surrounding key areas of the health system. The diagram below takes the example of the

weakness of the health system.

Health system weakness

Causes Effects

Lack of prioritisation by government High morbidity rates


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Lack of transparency of supply chain

Inadequate funding

Inadequate human resources for health

Inadequate political goodwill

Poor information flow in every

direction

Poor planning

Stock outs

Burnout and low morale

Misdiagnosis and poor patient

management

High turnover of staff

Uncontrolled population growth

Services that don't respond to

community needs

Figure 4 Problem tree for 'Health system weakness'

During the feedback session, it became clear that, while there was no need for a change in policies,

implementation is the key issue and access to information is going to be a fundamental part of

creating change in a system that has only recently become decentralised.

It was clear that, with the focus on specific counties where rapid urbanisation is going on, there will

need to be a specific target for advocacy work through county structures around implementation and

responses to local needs. While the main focus would be at county level, the issue of financing the

health system throughout the nation remains important and an aspect of work to be undertaken.

In addition, there was a clear need to carry out evidence-based advocacy relating to the needs of

specific areas, as well as increasing the capacity of county-level decision makers to take well-

informed decisions.

The decentralisation process was seen to create an exciting opportunity to develop an inclusive health

system that unites the government, not-for-profit and profit-based service providers in a coherent

system that serves rapidly changing local needs.


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1.3. Estimating the current situation

This work was carried out by using Spider Diagrams to draw out estimates of the current situation

surrounding the priorities of human resources for health, commodities, and the health system itself.

Each group was asked to identify eight areas of influence and then estimate the current situation

giving a score of 0 as very poor and 10 as ideal.

Figure 5 Spider diagrams


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Given that the aim of the programme of work is to address the issues on the spider 'legs' and raise

their score to 10, a clear picture emerged of the target areas for activities, particularly when priorities

were considered in the context of advocacy work rather than work to provide physical infrastructure.

1.4. Assumptions and risk

Throughout the three-day workshop, assumptions and risks were identified – they are brought

together here.

1.4.1. Assumptions

That the policy in place is good policy but lacks implementation

That HSS as a precondition is generally accepted by actors in health but that it is ignored in

strategizing for results

That if county-level decision makers are well informed then they will strengthen the health

system

That lessons can be captured that enable the roll-out of the programme's approach to other

physical areas in Kenya

That finance issues still need to be discussed at the national level

That peri-urban forces create specific health demands

That the decentralisation process has created a positive environment for decision on health

system strengthening.

1.4.2. Risks

That political changes could change the policies on which this work is based

That there will be informal resistance to integrative approaches from private and public health

service providers

That there will be a failure to capture lessons in real time, reducing effectiveness and long-

term impact

That county-level decision makers only focus on government health services.


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2. EXAMINING HOW TO CREATE CHANGE

IN KENYA

By feeding the results of the Spider Diagram exercise into a Balloons and Stones exercise, it was

possible to identify those issues that would support and hinder success for the Partnership.

Figure 6 Balloons and stones diagrams


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Discussions after this exercise raised the issue of how the new county system would work and the

potential for increased efficiency in, for example, the commodity distribution system. In addition,

there were discussions around the problem of health staff not wanting to work outside the capital and

how the new county system might allow for county-based colleges producing staffing for local needs

where the trained staff may want to work.

3. OUTCOMES

1.5. Achieving the short-term outcome

Short-term outcome of an effective partnership between HSA members and an effective,

integrative approach between all stakeholders.

Discussions around how to create a strong partnership between HSA members continued throughout

the three days. While it was clear that certain outcomes were needed, there was a search for a more

detailed approach. It was recommended that the K* approach be examined because that drew focus to

the roles of a partnership rather than just the actions of signing agreements, as well as providing an

important way to evaluate the strengths of the Partnership. It was also recommended that the role of a

partnership broker should be reviewed and that good practice in partnerships should be examined.

In addition, participants wanted the stakeholder group, including health stewards, duty bearers and

representative organisations, to work together. This wider partnership is integral to the success of

implementing the integration policies that already exist in Kenya. Key to integration success is the

bringing together, at the six local areas, of all health providers, from not-for-profit, faith-based

organisations and for-profit pharmacies, from the government service providers to local CSOs. This

challenge needs more investigation but is a clear activity area.


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1.5.1. Activities

Initial

Discover the legal context of partnership

Carry out capacity analysis of partnership members at national and county levels

Discover how to make partnership meetings work

Schedule a set of meetings

Develop a shared vision.

Then

Sign MOU

Set budget

Put in place a conflict resolution system

Clearly define responsibilities

MEI plans for Partnership and its activities

Communication systems designed and implemented

Create a joint work plan

Increase relevant partner capacities.

Having created transparency and trust these two aspects will create commitment, harmonised

understanding of the project and the capacity development of partners.

1.6. Achieving the medium-term outcome

Medium-term outcome of creating an empowerment and accountability space in peri-urban

environments and the research that will inform that space.

It was recognised that an empowerment and accountability space needs to be put in place that mirrors

the county system. There was also a focus on the need to inform both the space in which

empowerment and accountability takes place, and county-level decision makers. Therefore, research

and communication of evidence has taken a high priority in activities.

Initial

Inform the decision makers on health system strengthening

Inform decision makers about the results of research:

o Research into the amount of funding coming into the area that strengthens the health

system

o Research into what score the health system in the area has and should have

o Research into commodity availability in the area

o Research into the gap in HR in the area

o Research into the level of implementation of existing policies in the area

Develop a county-level coordination mechanism inclusive of government, for-profit and not-

for-profit health providers

Create a comprehensive Kenya-wide and county-level review of financing for health system

strengthening

Develop the tools for social accountability, e.g. citizen scorecard, community and health unit

self-assessment.

Then


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Advocate for evidence-based health system strengthening approaches

Advocate for efficient and effective county-level HRH and commodity approaches

Facilitate a county-wide dialogue space inclusive of communities and all health service

providers

Apply scorecard approach to monitoring.

1.7. Achieving the long-term outcome

Long-term outcome of a sustainable local system of dialogue that continues to develop

accountability and empowerment and thus full implementation of existing policies.

Create a sustainable mechanism for informing new decision makers at county level as they

come to power

Sensitise the community about health rights and responsibilities

Develop a sustainable community-based monitoring system for implementation levels

Develop and implement an exit strategy

Capture lessons learnt and start a roll-out process to one other county

Develop scorecard results dissemination for sustainability.

Figure 7 Detailed Theory of Change indicating Accountability Threshold


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APPENDIX 1: PROBLEM TREE EXERCISE

RESULTS

Low implementation

Causes Effects

Lack of guidelines

Poor dissemination of information

No time frame

Poor formal and informal supervision

Poor allocation of resources

Poor planning


Corruption

Lack of public awareness

Misuses of resources

Lack of quality performance

Spread of corruption

Demoralised population

Lack of empowerment

lack of awareness of rights


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Lack of advocacy for HSS

Causes Effects

Poor information management

Lack of skills

Misconception about advocacy

Poor coordination of advocacy efforts

Competition among actors

Weak health system

Inadequate funding for HSS

Weak advocacy platform

Weak health leadership

Weak governance

Poor stewardship


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Health system weakness

Causes Effects

Lack of prioritisation by government

Lack of transparency of supply chain

Inadequate funding

Inadequate human resources for health

Inadequate political goodwill

Poor information flow in every

direction

Poor planning

High morbidity rates

Stock outs

Burnout and low morale

Misdiagnosis and poor patient

management

High turnover of staff

Uncontrolled population growth

Services that don't respond to

community needs.


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Poor SRH services

Causes Effects


Attitude of workers and population

Culture

Lack of enforcement on law

Religion

Poor legislation laws

Poor policy implementation

Poor supplies

Poor equipment

Low capacity of workers

Lack of information for the public

Distance to health services

Early pregnancies

Counterfeit or fake drugs

Fake health staff

Corruption

Harmful cultural practises

Poor quality of services

Poverty

Slow economic growth


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APPENDIX 2: SPIDER DIAGRAM EXERCISE

RESULTS

The data below is presented as diagrams in Chapter 1.

Human resources

Staff retention 2

Career progression opportunities 6

Terms and conditions 4

Standardisation across public/private 2

Distribution of staff 2

Social accountability 3

Training 5

Numbers of staff 2

Commodities

Community perception 3

Access 2

Finance 3

Supply chain 3

Information availability to population 2

Information from health units to support

planning

2

Policy implementation 5

Human resource capacity 5

Health system

Policy implementation 4

Health systems delivery 2

Information about health systems 2

Financing for health systems 7

Social accountability 3

Governance and leadership at high levels 3

Commodity availability 5

Governance and leadership at service delivery

level

4


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APPENDIX 3: BALLOONS AND STONES

EXERCISE RESULTS

The data below is presented as diagrams in Chapter 2.

Health system strengthening

Stones

o Poor political will

o Inadequate budget allocation

o Culture and perceptions

o Poor policy implementation

Balloons

o Existing community structures

o Favourable policies

o Enabling conducive environment

o Coordinated management structures for the Partnership

Commodities

Stones

o Weak distribution system

o Poor storage

o Infiltration of counterfeit drugs

o Inadequate implementation policies

Balloons

o Existing policies

o Synergy within the Alliance

o Community commitment

o Goodwill of duty bearers

County work

Stones

o High turnover of county leaders

o Competing interests/priorities at county level

o Outbreak of disease or epidemic

o Severe unrest

Balloons

o Supportive political will

o Existing health structures

o Established and interested CSOs

o Established and existing community structures

Human resources for health

Stones

o Competing development priorities

o Elections

o Project delay

o Brain drain

Balloons


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o Existing platforms

o Strong representative bodies

o Good working relations with national policy makers

o Existing CSO coalitions


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APPENDIX 4: AGENDA

Learning goals Outputs Shared understanding of ToC methodology Contextualised theory of change

Shared understanding of Indicators First draft indicators for contextualised theory

of change

Summary

Day 1 – Overall Theory of Change, identifying the change desired and understanding the details

of the problem.

Day 2 – Context, the logic of change and advocacy in the Theory of Change.

Day 3 – Activities, assumptions, indicators.

Day One: 4th

July

Timing Session Detail

09.00 – 09.15 Arrival

Tea and coffee will be available

09.15 – 09.45 Welcome and introductions

09.45 – 10.30

Working together

Individual brainstorm and vote exercise – What makes a good partnership?

10.30 – 11.30 Introducing Theory of Change

Presentation – An introduction to the Theory of Change approach and its relevance in

good impact practice

11.30 – 11.50 Comfort Break

11.50 – 12.30

Looking at the HSAP Theory of Change

Group work card sort exercise to aid understanding the current overall Theory of Change

12.30 – 13.00

Looking at a contextualised Theory of Change

Group work card sort with the example of the Netherlands Theory of Change

13.00 – 14.00 Lunch Break

14.00 – 14.30

The change the programme wants to achieve

Individual headline success stories exercise

Shout-out exercise and group work to support the articulation of goals

14.30 – 15.30

Problem analysis

Group work around the problem trees to develop understanding of the problem the

programme seeks to address


15.50 – 16.50

Problem analysis (continued)

Breaking the cycle of cause and effect for the problem the Partnership is seeking to

address

16.50 – 17.00

Reflections and wrap up

17.00 Close


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Day Two: 5th

July


09.00 – 09.15 Arrival


09.15 – 10.00

Welcome back

Time to reflect on the session from Day One

10.00 – 11.30

The context of the Partnership's work

A Spider Diagram Exercise to help articulate the influences on the project that the

Kenyan context imposes


11.50 – 13.00

Power analysis An exercise to help identify the outcomes for the programme to create the change it wants


14.00 – 14.30

Identifying the logical flow of change

If-Then-Because exercise

14.30 – 15.00

Overview of advocacy activities

Presentation

15.00 – 15.30

Conversations that create change

Fish bowl exercise

15:30 – 15.50 Comfort Break

15.50 – 16.45 The evidence basis

Exercise to support research planning in the advocacy context

16.45 – 17.00 Wrapping up

17.00 Close

Day Three: 6th

July


09.00 – 09.15 Arrival


09.15 – 09.45

Remembering where we have got to

09.45 – 10.30 Understanding outputs, outcomes and impacts

Presentation

10.30 – 11.30

Activities and outcomes

Exercise to develop activity plans


11.50 – 12.30

Indicators and baselines

Presentation

12.30 – 13.00

Creating indicators

Exercise to define indicators


14.00 – 15.00

Assumptions and Risks exercise

Plenary discussion

15.00 – 15.30

Headline success exercise

What will success look like?


15.50 – 16.30

Reviewing the contextualised Theory of Change

16.30 Close

kenya contextualised theory of change

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