3.2 Key findings from the 2017 Kuunika baseline evaluation specific to decentralization

Thus the Ministry of Health (MoH) has been described as the prime beneficiary and owner of the project throughout Kuunika implementation. This refers chiefly to the central level.

Kuunika has had a somewhat intermittent experience in its focus on, and direct relations with, participating Districts. District HIV and AIDS services and their clients have been intended Kuunika beneficiaries from the project start in early 2017. Capacity development of health workers and District health officials remains one of the three unchanging pillars of the project. Yet the August 2016 Kuunika Proposal and initial Implementation Plan make few explicit references to centralDistrict relations.

It was not until the first ‘pivot’ in Kuunika implementation in 2018 that District Health Offices (DHO) became involved in the project Steering Committee and DHO priorities were taken into account in project plans. That pivot to the 'core package' focused on the development of key capabilities to support data use at national, District, facility and community levels during the remainder of phase 1 of Kuunika.

Organizational change at District level has received at best modest attention from Kuunika. A significant body of research literature identifies an intermediate stage (or on-going process) of organisational culture change which is necessary to translate more and better data into better decision-making and outcomes. This process of organizational change has not been fully articulated or addressed by Kuunika. Organizational change represents a core area where actual decentralization processes, however limited, need to be acknowledged and where the project should ideally have been flexible and responsive to realities on the ground at District level.

Examined through the lens of health system decentralization and District engagement, how should the twists and turns in the progress of Kuunika – primarily a digital HMIS intervention - be regarded? A number of published studies analyze the functional effectiveness of decentralization, in terms of bureaucratic capabilities, using concepts of ‘decision space’, innovation and performance.

Our evaluation work to date suggests that as a digital data systems project, Kuunika might be most usefully regarded as sitting in the ‘functions and capabilities’ space, its contribution (where possible) to decentralization of health services lying in its ability to empower Districts via access to better data to plan and manage - and to provide evidence of improvements in both. This presupposes effective sharing of data, horizontally as well as vertically, and by all partners, all necessary components of genuine aid effectiveness (for consideration of this, see 4.5).

These are issues to be explored in sections 3 and 4 of this study. In 3.2 and 3.3 we provide first of all a brief overview of key points that emerged from the independent Kuunika baseline and midline evaluations. Section 4 discusses endline/Special Study findings.

3.2 Key findings from the 2017 Kuunika baseline evaluation specific to decentralization

These were the most pertinent findings made about the processes and implications of decentralization as linked to the project:

• Lack of initial engagement with Districts: certain members of the original project consortium did not prioritize working with the Districts. The initial focus of Kuunika was on building data systems and not who at which level (other than the national) might have access or indeed ownership. As a result, communication between Districts and national levels was lacking. • Kuunika was seen as having been designed somewhat in a 'vacuum', without sufficient attention to how best to develop and apply communication, reporting and feedback channels between the funder, the GoM/MoH, project consortium partners and actual data collectors and users. • Concern over lack of precise information about the Kuunika structures and decision-making channels in support of Districts was apparent. • The points above are underlined by the view of one 2021 key informant with knowledge of the entirety of project implementation: to start with, Kuunika was almost entirely working at the national level. Significant activities at District level were deployment of EMRs and data quality improvement inputs. This was the situation for the first two years of implementation - and the