3.3 Key findings from the 2019 Kuunika midline evaluation specific to decentralization

cessation of such work by Kuunika represents an opportunity missed. • Of note is that Kuunika and other donor funding (at the time of the baseline, the midline and in 2021) supports many health activities at District level; it was pointed out that such programs, all too often with vertical M&E and reporting systems, may well have greater impact on Districts and Health Facilities than any action on decentralization, especially if that process continues to be significantly underfunded. • Related to the point immediately above about proliferation of donors, programs and data systems: one significant issue noted by a number of baseline key informants was that certain of the original Kuunika consortium members were also implementing CDC programs, including in the five Kuunika Districts. This led to some confusion, feelings of 'double dipping' in terms of collection and use of data, as well as (reportedly) tension. Such comments were not subsequently made during data collection for either the midline or the endline.

More general comments on decentralization and the health sector included:

• Weariness over the length of time that was being taken over bringing about decentralization of health systems: 'We continue to await the euphoria of decentralization' (District Health

Management Team (DHMT) member). • A number of respondents pointed out that more knowledge was needed on how budgetary and decision-making powers would/could be devolved specific to HIV and health and which government bodies at which level or levels would have the final say. • Decentralization (to the extent it had happened by 2017) had ushered in more involvement of village and Ward level committees. Zonal, District Health Management Team (DHMT) and

District Council respondents described how such community structures often sought to put forward their own health agendas, without any basis in data quality and verification. • Decentralization might usher in more District ownership of data; however, unless digital and other health data are reliable, such ownership might be somewhat redundant in terms of usefulness in planning and improving service delivery and outcomes.

3.3 Key findings from the 2019 Kuunika midline evaluation specific to decentralization

• Information from midline KII was that there continued to be some reluctance on the part of some project consortium members to engage at District level. While some work was being done to change this viewpoint, much energy was being given to developing the project paper entitled Project Implementation Plan - operationalizing Kuunika sustainability (finished on 31st

July 2019). This diverted time and capacity away from District engagement. This was considered to have been a (further) missed opportunity to engage properly with the District level. • The unlocking of all four 'key capabilities' as set out in the 2019 - 2020 Kuunika sustainability causal pathways cannot genuinely and sustainably be achieved without attention to support at all levels: training, data management, data use and development of a knowledge management organizational culture. • As at the baseline, the midline found very little use of financial or HRH data by those supported by the project, in part for sure reflecting the limited nature of fiscal decentralization to date. • The development of the Local Authority MIS (LAMIS) was described as a potentially valuable tool for decentralized ownership of data, not least because information is that it will include a number of databases, not least DHIS2. • A range of views were expressed on the relevance and usefulness of the DHIS2: o Respondents on DHMTs and at the District Councils referred to the District Implementation Plans as opportunities for using DHIS2 data to provide tailored and specific evidence to inform planning and budget allocations. o There continued to be a widespread perception of ‘data gathering for data extraction’.This was a consistent theme at District level. Both EMR and DHIS2 data were perceived to ‘funnel up’ data from facilities and districts to the national level. Such extraction and exclusion were felt to inhibit the use of analysed data for administrative, service delivery or planning purposes, and limit opportunities for the growth of evidence-based planning. o Less than one in five (18%) of all midline respondents used DHIS2 to look up data. A common concern was that the DHIS2 contains ‘too many indicators’. A majority of District respondents felt that the DHIS2 was ‘one size fits all’ with no scope for districts to tailor it to

include indicators of particular relevance to their work or geographical area. o Poor quality of data was seen as having repercussions for district level planning, including the ability to argue robustly for budget and human resource allocations The quality of routine data was said to be a fairly regular topic of concern at district level meetings where DHMT, other clinicians and/or District Council staff worked together. There were concerns at national, zonal and district levels over the time lag between data collection and feeding into the DHIS2 system. • Key to genuinely effective decentralization is engagement with ALL levels of the health system. Therefore, a midline finding of concern was that most Health Facility Advisory

Committee members had inadequate knowledge of data collection and use and could not independently determine if data were of good quality. HSAs also described barriers to knowledge and use of data, despite being key partners in data collection for HIV (at the time, the Kuunika use case) and other data. HSAs were not included in any data use decisionmaking at Health Facility level. The majority of HSAs had not been trained on data entry.

One point discussed both at the midline and more coherently during endline data collection by key informants with a longitudinal perspective on the entirety of Kuunika, is that in 2019 a 'convening point', i.e. an organizational center and management hub, did not really exist. The development and strengthening of the MoH Digital Health Division is now seen as an integral component of digital data governance and national ownership. The same key informants were less positive about the extent to which such organizational framework building has so far been expanded down to District level.

As from November 2019 the core package work was extended into phase 2, with expressed increased attention to sustainability (including at District level). District Health Offices (DHOs) were then discussing how Kuunika could best support them to address District-level priorities. At the time it was planned that DHOs were to be more fully and actively involved in the project. Indeed this was a midline finding and a recommendation followed to ensure greater engagement of DHOs.

The 2019 Kuunika Implementation Plan notes that 'Feedback provided by subnational MoH during planning meetings for the final year work schedule and budgets pointed to the lack of full awareness and leadership involvement in implementation of activities. To address this, the Kuunika secretariat also embarked on a consultation progress with the five Kuunika districts to share the activities planned for 2019/2020 and receive feedback on district-level stakeholder priorities' (p. 3).

Of relevance here is that such consultation was to occur at least 2.5 years into project implementation; this begs the question - why not during planning or inception phase? The 2019 midline evaluation amplified such lack of dialogue and effective ownership and that is a feature finding of the endline too. Such incomplete focus on decentralized structures has deep roots, in that the June 2018 Kuunika core package pivot to 'unlock the 5 key capabilities' did not explicitly refer to District engagement, ownership, governance.

Nonetheless, one clear sign of progress at this stage of the project is that towards the end of 2018/early 2019, more District activities were underway, because recruitment of Kuunika officers to be sited at DHOs had been completed. The data use campaign was launched. So, District activities were achieving some momentum. In addition, at the time of the midline there were indications of Districts becoming slightly more active partners in Kuunika, with DHO staff members feeling they had space to discuss addressing context-specific priorities.

Post-2019 opportunities specific to entrenching structures and systems for digital data at District level appear to have been missed - or more feasibly, been (partially or wholly) overtaken by the Covid-19 pivot.