Inside the Maternity Ward in Muembe, near Lichinga

Imagine not feeling well, being unable to walk, and taking a road path to a health clinic.  Yet, when you arrive there, you realize you will not receive any medical care as the medical technician went to the nearest town for shopping a few days ago and still hasn’t come back. In Mozambique, Concern Universal (CUMoz) is working on this very problem, helping citizens to identify crucial gaps in health service delivery. The goal is not only to have a healthier population, but also to create sustainable dialogue between community members and key government stakeholders. Since 2013, CUMoz has been training the community on the use of social audit tools and has helped to organize public auditoriums  to empower them to involve government in meaningful engagement. Supported by the GPSA to embed political thinking and adaptive approaches into the implementation of its grants and delivery support, CUMoz’s Social Accountability Knowledge, Skills, Action and Networking in Mozambique (SAKSAN) project provides useful takeaways as it’s ongoing:

Politically informed action gives a tremendous edge to social accountability interventions

SAKSAN’s strategy is a civil society-led social accountability effort that builds on the experience of local civil society groups. Its implementation has also benefited from its linkages to the World Bank’s broader health work in Mozambique.  The World Bank Task Team Leader based in Maputo, Dionisio Nombora, played an important role in facilitating dialogue with national and regional government representatives. The World Bank’s relationship with governments creates an opportunity to open doors for CSOs that would otherwise have very limited pathways for discussion with officials.

Resulting from this engagement, in 2013 the Provincial Level Government signed agreements with CUMoz to collaborate on issues related to health service delivery in six identified rural districts. SAKSAN thus supports the creation of citizen-led data, specifically on Maternal Child Health (MCH) and HIV-treatment (ARV) issues. The data collection process includes some innovative forms of collaboration: the questionnaires address citizen concerns, such as availability of drugs, corruption, and quality of attendance, among others, but were also designed with critical input from government health officials.  Notably, the data collection process includes self-assessment, where health officials are given an opportunity to assess the quality of services they provide. The process then allows for dialogue and collaboration even when different stakeholders may disagree on the specific answers to a question. Ultimately, health officials’ feedback about the questionnaires has been quite positive.

In this process, the local Community Based Organizations (CBO) leaders also learned. They understood that completing the questionnaire was not the ultimate goal of the social accountability strategy, but rather the validation of the concerns raised by users of health services. These collaborative social accountability interventions provide a window into understanding how a strategy of actively engaging the government and providers and paying attention to ongoing reforms, concerns, and incentives can help address a common challenge for social accountability programs in achieving broader change in service delivery: the lack of government responsiveness to citizen-generated data. 

Finding the nexus with citizens, health providers, governments and local CBOs is effective and in fact, life-saving

Finding the intersections in incentives and goals between different stakeholders enables the possibility of joint follow-up on the key findings of the surveys, and greatly enhances the probability of improvement in service delivery.   As SAKSAN’s  2015 midterm report states, “The relationship and agreements made with provincial governments, district governments and representatives of the health sector under the SAKSAN proved to be crucial for the success and consolidation of good practice. The local authorities, impressed with the benefits generated by the program, have supported and encouraged the work of civic groups and focal points under the program.”

The 88 CBOs/CSOs trained on the use of social accountability tools are conducting social audits, and the results were publicly presented and discussed with the Government in public auditorium health sessions.  Since the beginning of the project, six social audits in the health sector were undertaken. Many of the findings presented were publicly recognized and adopted by the local governments, which has shown commitment to take corrective measures.

In the Muembe District alone, the District Director of Health expressed his high satisfaction with the SAKSAN project, where citizens have been able to take advantage of services offered, such as vaccines and treatment of malaria, while nurses improved their bedside manner. As he explains in the video, improvements have been shown when it comes to MCH and ARV in the districts where SAKSAN is being implemented, albeit at a small scale, reinforcing the understanding that these approaches can indeed save lives.

Spillover impact counts as success too

The success of the collaborative strategy did not go unnoticed. On the government side, the Niassa Provincial Directorate of Health urged CUMoz to scale their project up to include additional districts. Moreover, the Mozambican Minister of Health recognized the value of this approach, emphasizing that “SAKSAN is an important project to promote constructive engagement between health units and communities to improve health services.”

Beyond CUMoz’s SAKSAN project, the GPSA’s approach has also influenced CUMoz’s as they have integrated principles learned from this approach into their other work – an issue we discuss in a separate post. As lightheartedly expressed by Aly Lala, a researcher at Concern Universal Mozambique, they launch social accountability interventions where “the bark and the bite match,” or in other words, CUMoz promotes approaches that have considered both tactical and strategic angles, coupled with understanding the public sector actors’ incentives involved. Most recently, this was applied to their Municipal Social Accountability Monitoring work.

While thoughtful interventions matter, cultivating relationships matters too

SAKSAN embarked on actively working with two large CBO networks during its implementation, the Forum of Non-Governmental Organizations of Niassa (FONAGNI) and Núcleo das Associações Femininas da Zambézia (NAFEZA), collectively bringing together over 150 CBOs. Likewise, considering their population’s limitated access to media, SAKSAN also teamed with community radios to broadcast their strategic social accountability approaches. The SAKSAN midterm report (2015) read, “The strategy of using local partners in the implementation of the activities has contributed significantly to the reduction of the burden of the program and could, by the end of the program, reach quite satisfactory levels in the cost/benefit relations and value for money.” Furthermore, it sustains the efforts of SAKSAN long after the project formally ends.  

According to the SAKSAN team, “One of the most important activities that took place was the first public auditorium, [where] it created a unique space for promotion of dialogue and evidence-based engagement between civic groups and government around health issues, [convening] almost 200 people.” During the event, one of the civic groups presented the findings identified in health facilities and the community members had the opportunity to interact in a frank, open and direct way with the district director of health, district administrator and the representative of provincial health director. Understated but critical, creating a climate of trust and openness has enabled the SAKSAN project to move forward with improvements in the system through the process of inclusion and understanding.

The Big Takeaway?

Political thinking and adaptability are challenging to employ in the frenzy of the day-to-day on-the-ground reality. Nevertheless, those who are working on these issues and take the time from the onset to absorb these concepts might find their work all the more effective and sustainable in the long run.

To learn more about SAKSAN, watch these videos:

With World Bank Group funding, UP supports citizens to monitor quality of health sector delivery

Public Auditorium, Nicoadala - Mozambique                                                                                                 



By Seema Thomas (Operations/Water, GPSA), with input from Florencia Guerzovich (Capacity Building, GPSA), Tammy Mehdi (Communications, GPSA), Emilie Fokkelman (Knowledge & Learning, GPSA), and Helena Skember (Country Director, CUMoz). This blog post is part of a series  aimed at capturing the progress of GPSA projects. These highlight key aspects of conversations between the civil society groups leading the projects, their World Bank partners and the GPSA. They offer key lessons about the project’s implementation to dateincluding some examples of adaptive management and learning for strategic social accountability