The World Vision team in Zambia wanted to make better use of their work at community level to inform policy. They analysed the context and stakeholders, then used aspects of the ROMA process, including identifying an objective, identifying outcomes including developing progress markers, generating entry points to intervene (strategy development) and assessing internal capacity to do so.
Developing an objective
Child health was identified as a priority area. The team visited two communities, where it worked to facilitate a number of focus group discussions using a list of 34 questions prepared under four headings (child health, awareness, access and coverage). A short summary encapsulated the various discussions that took place, noting the following issues:
- Long distance from health centre;
- Very few qualified health personnel;
- Low-level understanding of prevention of parent-to-child transmission;
- Immunisation preventing diseases that lead to child mortality (e.g. measles, polio, chickenpox) thereby keeping children healthy;
- Strengthening health care system at the community level: this would require training community-based health care workers and establishing a referral system with rural health care centres and district medical officers;
- Nutrition: government should formulate deliberate policies to encourage the integration of nutrition into health service provision.
Through discussion, participants agreed that a ‘high prevalence of childhood diseases’ was the most important issue the team should address. Drawing on the ‘five whys’ technique, the team was asked to answer the following questions: 1) why is this issue important? 2) who is it a problem for? 3) how are government, donors and civil society responding to the issues? 4) what needs to change and how? and 5) what evidence do we have and need to collect to inform policy development on this issue?
Several recommendations were made, including:
- Improve the citizen voice and (downward) accountability mechanism at local level for better delivery of health care (e.g. between local government and health care centres and between health care centres and the community).
- Increase government grants to health care centres.
- Improve salaries, housing allowances and transport provision for health care workers.
- A key criterion when prioritising recommendations was whether the issue needed to be taken forward at a national level. After further discussion, the team decided to work on ‘improving accountability mechanisms at the local (district) level and promoting better and more participation in the delivery of local health care services’.
Participants were asked to develop actor-specific outcomes, and found this a challenging process. Initially, they favoured phrases such as ‘improve policy implementation, or policy formulation’; after some coaching, they tended to specify in greater detail, coming up with phrases such as ‘the minister of youth, sport and child development proposes a bill to parliament to develop a policy on vulnerable children’.
Table 5 lists the outcomes identified for different priority actors.
Developing a strategy
Assessing internal capacity
The team worked through Table 7, which outlined their capacity to implement a specific activity, what capacity was needed, what actions were required to meet those capacity needs and who would be responsible for doing so.
The World Vision team in Zambia found that generating the information to intervene in the most appropriate and relevant way was not a linear process. A step often required information they did not yet have, which meant doing additional work on a previous step. Often, the team found it had to move to the next step before it had a complete understanding of the current one. The key message was to use the approach flexibly to fit within the constraints presented by the context and the problem at hand.