May 2016 Sierra Leone Decentralized Service Delivery Project (DSDP) 2 Activity Summary Report 2: Community Monitoring Intervention 105838 This short note will summarize the lessons learned from the community monitoring intervention (CMI) in health sector and progress made to date in scaling-up the CMI through the Decentralized Service Delivery Project 2 in Sierra Leone. Through the project, the phased scaling of CMI is currently taking place in four selected Local Councils and this phase is expected to complete in July 2016. This note will be updated upon the completion of this scaling phase. 1. Introduction with an aim of boosting community level dialogue and social The Government of Sierra Leone (GoSL) embarked on a mobilization for participatory development. LCs align their decentralization program in 2004 and committed to the services with sectors at the national level by subsidiary agreements with the relevant MDAs and need to comply with transfer of power, authority, and resources to local level the local development plans they approve. institutions. The World Bank has been supporting the GoSL’s devolution efforts through the Decentralized Service Delivery Project (DSDP) since 2008. The overall 2. Results and Social Accountability in objective of DSDP, which currently is at its second phase DSDP 2—Community Monitoring (DSDP 2), is to support decentralized delivery of basic During the phase 2, the project focuses on achieving services and to achieve this, it provides (i) block grants to results through selected social accountability (SA) LCs to deliver basic services in five focus sectors (health approaches and tools. Social accountability refers to the and sanitation; education; solid waste management; rural extent and capability of citizens to hold the state water; and social assistance for disabled and other accountable and make it responsive to their needs. vulnerable groups) and (ii) capacity development and Monitoring by non-state actors, including community technical assistance to LCs as well as central government. monitoring, is essential for achieving project outcomes and ensuring the development initiative’s reach to the Box 1. Sierra Leone’s Devolution and Local Councils intended beneficiaries. While traditional monitoring and Sierra Leone has been making a rapid recovery following a evaluation (M&E) mechanisms are do not fully account for decade-long civil war that killed 20,000 people and displaced the project beneficiaries’ perspectives, monitoring by non- half of its population. The country has been on a path of state actors, including community members, can reconciliation, reconstruction, and stabilization of its supplement M&E mechanisms and provide project economy and governance systems. That being said, the managers, service providers, and beneficiaries with a challenge to sustain political stability, address the striking better understanding of project results and effectiveness.1 human development deficits, and build infrastructure remains. There is a particular need to strengthen the The Community Monitoring Intervention (CMI) of DSDP 2 national and sub-national democratic institutions and is built upon the CMI pilot undertaken in the health sector translate the likely gains of economic growth into during the first phase of DSDP (see section 3 below). The improvements in poor and vulnerable peoples’ lives through current plan is to scale this up in new sectors beyond services delivered at the local level. To address shortfalls in health, including rural water, education, waste service delivery and poor human development outcomes, the management, and social services. The project indeed Parliament passed the Local Government Act (LGA) and its includes an intermediate results indicator on CMI in its attendant Statutory Instrument in 2004, effectively launching project appraisal document—“community monitoring a program of decentralization. The legislation provided for a mechanisms in four LCs in four sectors established�2—in phased transfer of service delivery functions from 17 order to ensure quality scale-up of this intervention during Ministries, Departments, and Agencies (MDAs) to the 19 Local the second phase. Councils (LCs). Regular elections to LCs have become a hallmark of decentralization in Sierra Leone. 3. Lessons Learned from Local Councils operate within the LGA framework, and have the Health Sector CMI quickly assumed major responsibilities in service delivery, As part of devolution effort in including education and health. The Decentralization health services, the GoSL launched Secretariat (DecSec) at the Ministry of Local Government and an ambitious initiative in 2010 to Rural Development (MLGRD) is in charge of supervising Sierra institute free health care for Leone’s decentralization agenda. DecSec assigns Resident Technical Facilitators (RTFs) to every LC to provide technical 1 assistance and to facilitate communication flows with “Monitoring by Non-State Actors� on Social Accountability E-Guide, World relevant MDAs. In turn, LCs operate with the Ward Bank, https://saeguide.worldbank.org/monitoring-non-state-actors (Retrieved on April 13, 2016) Committees (WDCs), which have been established under LCs 2 Project PAD, Page 38. 1 May 2016 pregnant women, new mothers, and children under age of models implemented, they include: Bombali, Tonkolili, Bo, five, while at the same time raising health workers’ and Kenema. In each district, 15 communities with DSDP 2 salaries. These reforms in health sector unfortunately supported projects were identified for the roll-out which is occurred without introducing institutional features to under implementation. improve oversight of health workers or changing underlining incentive systems, hence the health sector Lessons learned from the health CMI piloting were continued to face challenges including fee-charging, nurse incorporated at every step of the CMI scaling architecture. absenteeism, and poor health outcomes. Given these For example, a total of 12 local facilitators were trained on challenges, the GoSL implemented two interventions to CMI instead of contracting the CMI implementation out to influence the health outcomes, which were community international/ local NGOs with a hope of building in- monitoring and provision of non-financial awards. country capacity and sustainability. According to the CMI manual, the community monitoring processes has also While community monitoring of health care, facilities, and been modified from the previous round. The key steps are staff introduced an accountability interface between as follows: users/community members and health facility staff to collaboratively improve health service delivery through Step 1: Formation of a Community Monitoring Group (CMG), scorecards and face-to-face meetings, the non-financial where Ward members, local chief/chives, civil society award provided health facility staff an incentive to organizations, religious groups, youth groups, and staff of perform better by competition. Financed by the first five target sectors are represented. phase of DSDP, these two complementary interventions Step 2: Participatory monitoring of facilities and services by were designed and implemented by DecSec through three the CMG and the CMI facilitator(s) around pre-identified Non-Governmental Organizations (NGOs), and were sector indicators. A report will be prepared and submitted piloted in four selected districts (Bombali, Tonkolili, Bo, to the LC’s Social Accountability Team. Step 3: Identification of challenges and possible solutions to and Kenema) from May 2012 to February 2013. form a draft joint action plan among the CMG members. Step 4: Finalization of the joint action plan at a community Through the piloting, meeting to form a compact. the communities and Step 5: Implementation of the compact and follow-up health facility staff community meetings to hold each other account. established joint action plans (see photo) to The CMI communications materials have been delivered to hold each other the target communities and the CMG joint meetings as accountable to the well as the community meetings are starting to take place. promises made in Results and lessons learned of this CMI scaling are improving health service delivery at community level. The expected to emerge upon completion of this phase in evaluation of the interventions by the Innovations for October 2016. A rapid assessment of this phase is planned Poverty Action indicated the community monitoring to capture lessons learned, which is expected to be contributed in reducing illegal fee-charge practices, incorporated into a phased CMI scaling plan to other LCs. increasing the utilization of health clinics, improving child delivery at government facilities and clinics, and enhancing Photo of the joint action plan (left): From DecSec’s presentation “Mid-Term the nutritious status of under-five children. 3 Review Component 3� (Nov. 2015) Photo of the CMI poster (above): Found on the wall of the Kenema CL office (Nov. 2015) 4. Next Steps – Scaling of CMI in DSDP 2 This note was prepared by Saki Kumagai, Governance Specialist, under the The implementation of CMI scale up has been delayed due guidance of Randa El-Rashidi, Senior Social Protection Specialist. The author to the recent Ebola Virus Disease (EVD) outbreak. Plans are thanks Cerni Escale, Social Protection Consultant, for providing inputs. The underway to implement the scale up from April to October findings, interpretations, and conclusions expressed in this note are entirely those of the authors and do not necessarily reflect the view of the World 2016. In preparation for this, DecSec has: (i) updated the Bank, its Board, or its member countries. Last updated: May 19, 2016. CMI manual that applicable to all five sectors covered under DSDP2; (ii) established CMI communications materials (see photo); (iii) trained CMI facilitators; and (iv) held an implementation planning meeting with relevant stakeholders. The roll out of the scale up -out will take place in four districts that previously had health sector CMI 3 “Improving Health Service Delivery through Community Monitoring and Non-Financial Awards: Final Report� Innovation for Poverty Action, August 2014. 2