Special Study 3: Kuunika and the Districts

This study examines the extent to which the Kuunika project may have responded to, or influenced, decentralization processes and outcomes. It considers whether and how the project has supported health service delivery at the district level, and whether decentralization processes have had any bearing on such work.

Key findings

● Decentralization of the health system and digital data is beyond the control of any single project, including Kuunika. Information is that there are currently (mid-2021 onwards) changes being made at national government level specific to what might be seen as a (re) centralization of digital health data management and (re) focus on DHIS2. ● The partial, piecemeal and stop-start implementation of the government policy on decentralization is sometimes perceived as a cause of poor governance in the health sector.

Governance challenges are a significant barrier to achieving a more effective and equitable health system in three key domains: accountability (enforceability; answerability; stakeholder-led initiatives); health resource management (healthcare financing; drug supply); influence in decision-making (unequal power; stakeholder engagement). ● Districts are the ‘missing middle’ in many aspect of government and donor / partner engagement with the health sector in Malawi. In recent years, there has been an increased focus on community engagement (not least for equity considerations). Districts remain the main entry point for the majority of health services delivered to Malawians. ● When Kuunika was being designed, the Government of Malawi (GoM) was proposing to decentralize the health system; however, most decisions and human resource management have remained at the central level. There is a centralized ‘push system’ in health. Most donor projects at district level have had to work very closely with the MoH, regardless of a primary focus on districts – this may have been the case for Kuunika too. ● The institutional arrangements for the Digital Health Division could determine its level of impact at the district level. These institutional arrangements are underpinned by competing political perspectives and alliances. However, we note some stakeholders believe the current location of the Digital Health Division under the MoH Directorate of Planning and Policy

Development has implications for the strategies the Division can adopt – especially for embedding digital health solutions to improve data quality and use for decision-making at district and facility levels. ● Cumulative evidence from successive Kuunika evaluations points to the need for greater genuine ownership of data at the district level and effective use of DHIS2 as a platform for more effective evidence-based planning. This necessitates buy-in from all partners working national and sub-national levels. However, the donor landscape has remained fragmented; this, in turn, has had implications for effective coordination of digital health initiatives. District

Health Offices should ideally be integral partners in dialogue with donors on digital health solutions for data collection and use.

● Kuunika has invested a great deal of time, effort and resources in district-level capacity development, including training on and access to DHIS2 and digital data hardware and systems (e.g. dashboards, the mobile App, Cluster meetings). This was most apparent before 2019, at which point changes in consortium partners and project management, coupled with the sustainability pivot, led to Kuunika being perceived as more distant from the districts (except in Zomba). More recent support to horizontal engagement (e.g. through support for Cluster meetings), is often not recognized as having Kuunika inputs.

Nevertheless, these initiatives are reported to be useful channels for debate and processes of decision-making.

● Despite an explicit district-level focus in the early phases, Kuunika appears to have given relatively limited attention to support to decentralized structures in the sustainability phase.

The temporary involvement of the districts in Kuunika planning after the first pivot appears to have been short-term. At this stage, Kuunika might most usefully be regarded as sitting in the ‘functions and capabilities’ space – with its contribution to decentralization of health services lying in its ability to empower districts through functional district health systems that improve access to quality data for decision-making. ● The decision to focus on HIV as the data use case, meant there was little space for the district level to engage as an equal partner in management and use of digital data. This was largely because the HIV and AIDS program is highly vertical, with key datasets collected and managed by the Department of Nutrition, HIV and AIDS (DNHA) and not routinely uploaded to DHIS2. Indeed, at one time the Kuunika Project fell under the Department of HIV and

AIDS, so operated within this vertical (somewhat “parallel”) structure. ● Initially the primary focus of Kuunika was data systems (including improved data quality and data use). However, the emphasis on the HIV use case meant there was a particular focus on patient outcomes and use of data to support comprehensive HIV service delivery.46If fully embraced going forward, this approach would fundamentally require full engagement of districts to ensure sustainable improvements in service delivery. ● From the endline survey and DQA analysis, we found little evidence of sustained or systemic improvements in data use for health sector decision making at district level. Similarly, from the desk review, there was little evidence that key planning and service delivery documents (such as District Implementation Plans) are being progressively informed by quality data derived from DHIS2.

● At midline and endline, we found that there are some DHIS2 ‘data super users’ at district and facility level. Data super users are highly able and motivated individuals who are exceptionally engaged and active in data use to inform professional decision-making. These data super users have the potential to become champions of change.47 However, the question remains about how to maximize this potential without placing an unrealistic burden on individuals.

● The Blantyre Prevention Strategy provides a potential model for best practice. Since 2020,

BMGF has funded the Blantyre Prevention Strategy. This strategy was co-developed with local and national government and a consortium of partners and supports the development of an optimal system for the sustained prevention of HIV infection that is fully embedded in local structures, and led by the District Health Officer. Stakeholders report that the design of the strategy was informed by lessons from the Kuunika experience: “we re-thought the process, based on Kuunika challenges with decentralization.”

Figure 10 below provides an overview of key lessons identified from Special Study 3.

46 This was in keeping with Malawi’s commitment to achieving UNAIDS 90-90-90 targets and cascade of care approaches. See: Avert. (2020). HIV and AIDS in Malawi. Available at: https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/malawi 47 Shea, C. M. et al. (2016). Quality improvement teams, super-users, and nurse champions: a recipe for meaningful use? Journal of the

American Medical Informatics Association, Volume 23, Issue 6, Nov. 2016, pp. 1195–1198,