Thoughts to inform USAID’s Effective Partnering and Procurement Reform

Jul 19, 2018 by Jessica Ziegler Comments (1)
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The afternoon session of MTN’s Managing Adaptively track really epitomized why USAID holds the Moving the Needle event. “Adaptive Partnering: A Conversation with USAID” was a significant opportunity for more than 40 participants to share their experience and help shape USAID’s procurement practices by providing candid feedback and input into the reforms under consideration through the Agency’s Transformation effort on Effective Partnering and Procurement Reform (EPPR). EPPR is one of the ways that USAID is trying to create an agile and flexible Agency that can adapt to changes on the ground to improve the effectiveness and impact of its activities, including in fragile states and non-permissive environments. EPPR is also concerned about diversifying the Agency’s partner base and empowering its partners.

EPPR representatives Randy Tift, Senior Advisor, Office of Acquisition and Assistance (OAA), Gayle Girod Chief Innovation Counsel, Office of the General Counsel, and Stephanie Fugate, Branch Chief and Supervisory Contracting Officer (OAA) briefly kicked off the session by explaining the EPPR effort, but the bulk of the time was dedicated to deeply engaging table conversations on four key topics of interest to EPPR:

  1. Adaptive Strategies and Culture
  2. Adaptive Activity Design Tools
  3. Adaptive Activity Management Tools
  4. Data/Evidence-Driven Adaptation

Here are some highlights from those discussions (NB: Not verbatim quotes):

Adaptive Strategies and Culture

"Providing staff with necessary skills and incentives comes up a lot. There is a common concern about the lack of time."Here

Adaptive Activity Design Tools

"We can also diversify the partner base so that smaller and more nimble organizations can take part in the process. Often times, they can partner with traditional, big player partners to help them get involved."

Adaptive Activity Management Tools

"Being able to adapt is so critical because if your whole context changes and you’re stuck with what you planned, it could cause harm, so we are appreciative of Agency direction toward more flexibility."

Data/Evidence-Driven Adaptation

"The policy architecture exists for data/evidence-drive adaptation and the data exist, but the challenge is to change data usage. Investing in a system will not necessarily create this change."

To read about the morning session of MTN’s Managing Adaptively track, “From Learning to Action: Adaptive Management in Support of Self-Reliance,” check out my Learning Lab blog post.

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Managing Adaptively: It’s About the People! Reflections from MTN 2018

Jul 16, 2018 by Jessica Ziegler Comments (0)
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There were so many good sessions at this year’s Moving the Needle event that I know people had a hard time choosing, but those who joined us in one or both of the ‘Managing Adaptively’ breakouts were not disappointed. In the morning, Lisa Whitley, USAID/PPL’s Project Design Team Leader, moderated a really insightful panel from USAID Washington and the field, on how to partner and manage adaptively to empower local organizations and stakeholders.

Photo of panel, including David Jacobstein, Karim bin-Humam, Stephanie Fugate, Andre Mershon, and panel moderator Lisa WhitleyLeft to right: David Jacobstein, Karim bin-Humam, Stephanie Fugate, Andre Mershon, and panel moderator Lisa Whitley. Photo credit: USAID LEARN.

David Jacobstein (Democracy Specialist, USAID Center of Excellence on Democracy, Human Rights, and Governance) spoke about Thinking and Working Politically (TWP), connecting relationships with political stakeholders to program management and keeping pace with the complexity of political change. In the TWP mindset, development outcomes are seen less as a product of technical knowledge transfers and more as a contested decision between winners and losers. The lesson for managing adaptively, then, is that power dynamics and incentive structures have to be taken into account and we may have to change our approaches as we learn more about how those dynamics and incentives really affect the system we are trying to influence.

Karim bin-Humam (Senior ICT Specialist, DAI) represented a winning case from the 2017 Case Competition—“Learning and Adapting Enables Civil Society Innovations in Cambodia”—and shared how the Development Innovations activity in the case developed an adaptive management approach based on a strong, collaborative relationship with USAID/Cambodia. The activity aimed to spur innovation within Cambodia's civil society and build its capacity to design and use information and communication technologies (ICTs). At the activity’s mid-point, it was clear that the services they were offering CSOs and what CSOs actually needed were very different. As a result, the team worked closely with USAID to adapt its offerings and began conducting quarterly internal programmatic assessments through “pause and reflect” events and semi-annual sessions with local partners to check in on progress. Findings from both helped DAI adapt programming and write responsive workplans. Karim also spoke about how the mid-term findings also necessitated a big shake-up in staffing and in the management restructuring, they prioritized skills rather than formal qualifications on CVs, which is how they ended up a senior manager who’s immediate past experience was at MTV!

Stephanie Fugate (Branch Chief and Supervisory Contracting Officer, USAID Office of Acquisition and Assistance ) and Andre Mershon (Resilience Advisor, USAID Center for Resilience) discussed their work in designing adaptive, shock responsive activities and implementing mechanisms in ever-changing environments. Their plea to the session participants and their colleagues throughout USAID was to plan flexibility into activities right from the earliest design and make sure that the mechanism choice and details align and support that need for flexibility. While we can find ways to adapt mid-course, it is much easier if expectations for adaptive management are established from the beginning (and see here for helpful resources in the CLA toolkit). Stephanie also encouraged us to remember the people—it’s not just the words on the paper, but the adaptive management skills of staff on both the USAID and partner sides of the question. This led to a lively discussion, echoing Karim’s points about needing to re-staff in Cambodia, about the skills of an adaptive manager.

Some of the skills and mindsets that Stephanie, Andre, Karim and David flagged as important in managing adaptively included:

  • Being vested in the development outcomes as a development practitioner, not just a contract manager

  • Systems thinking and understanding the development context

  • Active listening and openness to feedback and new ideas (such as those that DAI collected through their internal “pitch” mechanisms)

  • Understanding operations enough that you know when and how to ‘hack’ them to change a process

  • Building good relationships and cultivating networks in order to draw resources and expertise from others

These are good additions/reinforcements to the skills listed in the Adaptive Management Discussion Note: curiosity, communication and listening skills, critical thinking, and comfort with uncertainty and change.

Confused about the difference between the CLA Framework and Maturity Tool?

Oct 16, 2016 by  Comments (0)
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If so, you aren't alone. But I hope to convince you that it isn't as confusing as it may appear, so I'm keeping it as simple as I can.

The CLA Framework (left) is a graphic depiction of the universe of elements we include when we think about CLA. It's a circle in order to reinforce the idea that we try to take a holistic approach to CLA. We call the outer two halves building blocks and they include CLA in the Program Cycle and Enabling Conditions. We call the next ring in components: Collaborating, Learning, Adapting, Culture, Processes, and Resources. These are further articulated through 16 subcomponents in the inner ring of the framework.

The CLA Maturity Tool (right) builds off of the framework and is a physical tool intended to help teams hold in-person conversations on self-assessment and action planning. For each of the 16 subcomponents in the Framework, the Maturity Tool includes key concepts and facilitation aid and 5 spectrum cards. The key concepts and facilitation aid card broadly describes what the subcomponent covers (front) and offers clarifying explanations helpful in framing the subcomponent (back). The 5 spectrum cards describe how the subcomponent might show up in your work along a spectrum of practice, ranging from Not Yet Present to Institutionalized

Connection between the CLA Framework and the CLA Maturity Tool

I hope this helps!

CLA in Action: Five Missions Gather to Learn from Each Other

May 2, 2016 by Jessica Ziegler Comments (0)
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As my colleague Monalisa Salib had previously discussed, we on LEARN feel strongly that it is important to “walk the talk” and so I was excited when I was invited to join USAID staff in a CLA Peer Sharing Event last week. USAID/Uganda, a mission on the forefront of CLA, hosted representatives from four other missions in the region—Ethiopia, South Sudan, Southern Africa, and Tanzania—for a 3-day gathering to exchange “experiences, learning, examples of how CLA is being conceptualized and put into practice” across the five missions.

Image of people meeting together

Participants worked together ahead of the event to crowdsource topics of particular interest to the group that could benefit from a peer-assist approach. Among the list, these included integrating monitoring, evaluation, and learning (MEL); operationalizing CLA; and knowledge transfer to smooth staff transitions. Here are just a few of the examples that the missions shared of their CLA in Action:

  • USAID/Ethiopia: Although relatively new to the CLA conversation, the mission has tried to address the very challenging knowledge transfer issue, in part, by piloting a 3-day orientation for new staff to provide an overview on Ethiopia’s context and culture.
  • USAID/South Sudan: The mission had convened an Advisory Council with representation from all geographic areas, ethnic groups, and sectors. This gender-inclusive council meets regularly, facilitated by the Deputy Mission Director, to help the mission understand the country context and public policy issues to inform its operational framework.
  • USAID/Southern Africa: This mission is one of a relatively few to have in-house KM capacity. Having already developed an intranet platform, the Learning Team (which includes the Senior MEL Specialist, the Regional Organizational Learning Advisor, and the Knowledge Manager) is now developing a robust KM strategy that includes a focus on change management to improve uptake.
  • USAID/Tanzania: With a strong mission focus on integration, USAID/Tanzania is designing an “integrated activities hub” for one of its districts. In the very early stages of development, this hub will be directed by a steering committee of staff from all of the mission’s Development Objective teams who will work with implementing partners and local government authorities to craft “development services packages” that can be delivered in the target district in Phase 1.
  • USAID/Uganda: Working with its Monitoring, Evaluation, and Learning Contract, the mission recently piloted an innovative MEL training course for mission staff and USAID/Uganda implementing partners. The course was conducted in two parts with time in between to apply selected MEL improvements so that participants could share their experience implementing these changes during part 2 of the course.

Beyond the peer exchange, the event also included the opportunity for visiting staff to hear from USAID/Uganda’s Mission Leadership Council, other mission technical staff, and a panel of activity Chiefs of Party about how they implement and leverage CLA at their various levels.

We will share more takeaways from the CLA Peer Sharing Event in future posts here on Learning Lab, but in the meantime, these graphic notes from the sessions offer a great snapshot of rich conversation:

CLA Week Graphic Notes - April 2016 from USAIDLearningLab. These graphic notes were produced with the support of the USAID/Uganda Monitoring, Evaluation and Learning Program, implemented by The QED Group, LLC.
Filed Under: CLA in Action

Exploring the CLA Framework

Dec 1, 2015 by Lauren Leigh Hinthorne, Monalisa Salib, Jessica Ziegler Comments (0)

This blog is the introduction to an ongoing series exploring the components of USAID's CLA Framework. Here is the first blog on organizational culture, the second on effective learning, the third on the resources necessary for CLA to take hold, and the fourth on effective collaboration.

For those of you who read the October 2015 edition of Learning Lab’s Learning Matters newsletter, hopefully you noticed the promo for the Collaborating, Learning, and Adapting (CLA) Maturity Matrix. If you didn’t see the post, the CLA Maturity Matrix is “a new tool being developed to provide a clear picture of what systematic, intentional, and resourced integration of CLA is throughout the USAID Program Cycle and within an organization's culture and processes.” The Matrix is based on a framework that stresses the holistic and integrated nature of the various components of CLA. 

CLA Framework GraphicPPL and its LEARN mechanism have been working on this framework for nearly a year, and began by digesting USAID’s work on CLA since 2010, documenting and analyzing the examples of CLA to understand what it has looked like. We did additional stocktaking with 14 missions and with implementing partners to gain an even deeper understanding of what good CLA looks like on the ground. 

In the simplest terms, the framework asks us to consider:

  • Are we collaborating with the right partners at the right time to promote synergy over stovepiping?
  • Are we asking the most important questions and finding answers that are relevant to decision making?
  • Are we using the information that we gather through collaboration and learning activities to make better decisions and make adjustments as necessary?
  • Are we working in an organizational environment that supports our collaborating, learning and adapting efforts?

The CLA framework disentangles the various components of CLA to help you think more deliberately about what approach to CLA might be best tailored to your organizational or project context. The components include:

Collaborating: When we talk about collaboration what we really want to know is whether we working with the right people at the right time for the right reason. Are we being deliberate and intentional about which partners we are engaging, and how? 

Culture: In order to create the space for and get the most out of collaboration, there needs to be a culture that supports it. A culture that values openness, relationship-building, and continuous learning will be more likely to create opportunities for collaboration and continuous improvement through adaptive management. 

Learning:  A commitment to continuous improvement must be grounded by broad contextual awareness as well as a deep understanding of the questions that matter most, but it would be unreasonable to try to keep on top of every new development relevant to a local context or technical sector. Creating a learning agenda is one way to decide on priority questions and consider how monitoring, evaluation, and other types of analysis can help answer those questions. 

Processes: The question then becomes, once we have learned something, what do we do with it? What processes are in place to make sure we go from documenting our knowledge to actually acting upon it? Having clearly articulated processes for things like decision making can help.

Adapting: One approach to determining what to do with new learning is to deliberately take time out to pause and reflect. This can happen in a number of ways, and who participates will depend on what you are trying to achieve, but it helps to consider how the activity advances your learning agenda and when you need to surface lessons so they can feed into design and implementation schedules. 

Resources: CLA takes resources, including financial resources for things like space, travel, and probably most importantly, staff time. It also requires having staff and consultants with the skills necessary to help us collaborate intentionally, learn systematically, and manage adaptively. 

The framework remains a work in progress. As we continue to develop it, we are practicing what we preach in terms of piloting, collecting feedback, and iterating. What remains constant, though, is that the framework and related CLA Maturity Matrix celebrate the diversity of what CLA can look like in various missions and projects, but still gives CLA structure, clarity, and coherence. 

This post was written by Lauren Leigh HinthorneMonalisa Salib, and Jessica Ziegler.

Music to our ears: Spotify’s culture and how it sounds like CLA

Jul 16, 2015 by Jessica Ziegler Comments (1)
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A colleague recently shared this two-part video about music streaming service Spotify’s engineering culture with me and I was both impressed with the mindset at Spotify and struck by how much the concepts sound like those embedded within USAID’s collaborating, learning, and adapting (CLA) approach. If you haven’t seen the videos yet, I encourage you to take the 26 minutes to watch them. Agile/Lean Coach Henrik Kniberg, who works with companies like Spotify and Lego, provides a really wonderful overview of the “journey in progress...somewhere between ‘How Things Are Today’ and ‘How We Want Things To Be’.”

     

Spotify Engineering Culture - part 1 and Spotify Engineering Culture - part 2 from Spotify Training & Development on Vimeo.

In case you aren’t familiar with Agile and Lean, the former is a type of project management style often used in software development and based on “incremental, iterative work cadences1,” while the latter is more often associated with manufacturing and basically focuses on maximizing customer value while minimizing waste2. As you’ll see in Kniberg’s videos, Agile and Lean are key elements of Spotify’s culture. This allows the company’s engineers and developers to work in loosely coupled, but tightly aligned groups with lots of opportunities for cross-pollination. Their smaller and more frequent product releases enables them to get stuff into production early and often.

This focus on cross-pollination over standardization and self-service over handoffs made me think about the collaboration in CLA. It suggests that if we want many different activities to optimally contribute to a broader development goal, collaborating might be more effective if we emphasize alignment rather than prescriptiveness. And while our type of development may not have open source code the same way that software development does, we have many great knowledge hubs (like Learning Lab, Agrilinks, K4Health, and others) where we can share information about what we are doing, what’s working, and what isn’t. This, however, requires a high level of trust—”agile at scale requires trust at scale” says Kniberg— which is why, in CLA, we often talk about building relationships between USAID and its implementing partners based on openness, transparency, and innovation rather than fear of failure and predictability.

Failure and innovation are also addressed in part 2 of the Spotify videos. Spotify is an explicitly fail-friendly and experiment-friendly environment, but they consciously “limit the blast radius” of potential experiments so that one unsuccessful pilot can’t negatively impact other parts of an activity or project by using the decoupled approach mentioned earlier. Spotify gradually scales up those successful pilots through data-driven decision-making, prioritizing impact over speed. When things are less successful, they track needed improvements using Improvement Boards and Toyota Improvement Kata3. These techniques could be one insightful way to frame a “Pause & Reflect” activity as part of a broader CLA approach. For a given general area where improvement is needed, a Spotify Improvement Kata chart outlines:

  • The current condition or problem(s)
  • The definition of awesome (their way of describing the desired outcome)
  • The next target condition
  • The concrete actions to get to the next step in the road to awesome

These charts are written on whiteboards and use Post-it notes so that they can be updated as progress is made. It is easy to see how this technique could be applied systematically as part of intentional learning and adapting within a mission or implementing partner’s work.

A stick figure balances on a pile of rocks between the fire of chaos and the spikes of bureaucracyAlthough a streaming music company may not be an obvious place to looks for tips on collaborating, learning, and adapting, I think that the cultural ideals and practical approaches discussed in these videos are really relevant as we think about adaptively managing for results. Spotify leverages Agile methods and their commitment to a healthy culture to avoid falling into either raging chaos or stifling bureaucracy. This is a challenge familiar to us in development and one that CLA hopes to help address. Henrik Kniberg’s call to action at the end of his video—”You are the culture. Model the behavior you want to see.”—works equally well for us!


1 http://agilemethodology.org/
2 http://www.lean.org/WhatsLean/
3 https://en.wikipedia.org/wiki/Toyota_Kata

Who Matters to You?: Mapping Your Stakeholders

Jul 14, 2015 by Jessica Ziegler Comments (0)
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This improved tool will help you visualize relationships with key stakeholders.

Collaborating—one of the three pillars of the USAID collaborating, learning, and adapting (CLA) approach— is a critical aspect of development work. Effective collaboration ensures that the Agency establishes and leverages relationships with key stakeholders, identifies areas of shared interest and potential cooperation, avoids duplicating efforts, shares knowledge about what works and what needs adjustment, and develops new, innovative ideas to address shared development challenges.

A collaboration map is one approach, developed by the USAID/Rwanda Mission, to graphically depict USAID’s relationships with its key stakeholders. The mission first applied collaboration mapping in 2012 to guide their thinking during the development of their Country Development Cooperation Strategy (CDCS). In particular, it helped technical staff to identify what organizations would influence, support, or otherwise affect achieving the objectives of the strategy.

As a learning tool, collaboration mapping helps a mission or bureau create a shared understanding of who its key stakeholders are, what their levels of interaction and influence are with USAID, and based on these findings, where USAID should strategically place time and effort cultivating relationships. This tool, however, is not USAID-specific, and could be equally relevant to USAID’s implementing partners or other development actors.

An example of a collaboration map with legend describing the elements of the map
Regular Learning Lab or ProgramNet users may already be familiar with collaborating mapping as it has been featured on USAID’s platforms before. If you haven’t yet watched the webinar presented by Preston Sharp (USAID/Rwanda), I encourage you to do so, but if you are more of a hands-on learner like me, you may prefer trying collaboration mapping for yourself or, even better, with your team.

Expanding on previous Agency work by Preston Sharp and Zan Larsen, LEARN—a mechanism funded by USAID’s Learning, Evaluation and Research (LER) Office in the Bureau of Policy, Planning and Learning (PPL)—has developed a new Excel-based collaborating mapping tool that can automatically generate digital collaboration maps. Along with this interactive Collaboration Mapping Excel Worksheet, Learning Lab also features a new Collaboration Mapping Facilitation Guide that will walk you through the steps of conducting a collaboration mapping exercise with your team, whether you use the tool or draw your map by hand.

A screenshot of the Excel-based Collaboration Mapping worksheet
We welcome your feedback and input as you use this to create your own collaboration maps so that we can improve the instructions based on field experience. You can provide your feedback by posting comments on the resource page on Learning Lab or by contacting a member of the PPL/LER Strategic Learning team at learning@usaid.gov. We also welcome sharing of collaboration maps after they have been created so that others may use them as models.

Lessons from the Maze

Mar 16, 2015 by Jessica Ziegler Comments (2)
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During a recent trip to a USAID Mission to support their development of a Learning Plan, the USAID/LEARN team had the opportunity to test a new (to us) experiential learning activity. Taken from Teampedia, the exercise was called “The Maze” and was intended to explore the topics of communication, collaboration, and team strategy—perfect for a short-term assignment focused on collaborating, learning, and adapting (CLA)

In this exercise, participants took turns trying to find their way through a masking tape maze on the floor of the mission’s training room. Our maze was a 7x7 grid and the hidden path to get across it was only 12 small steps, but the group quickly found that it was not as easy as it looked.

The object of the activity was for the whole group to move from the marked entrance square to the marked maze exit, with each person taking turns and the facilitator letting them know if they had successfully stayed on the path. Once a participant made an incorrect move, the next person in line got a chance, beginning from the entrance square. We played it out in two rounds with slightly different rules for each.

Participants in the first round were not allowed to talk and could not use any materials to mark the correct path. Quickly realizing that they had to find a way to mark and communicate the right path, many of the participants immediately dropped to the ground and put their hands on the correct squares, guiding their colleagues with emphatic gestures.

The MazeIn the second round, a new path was chosen and both talking and breadcrumbs were fair game. Lots of discussion of strategy ensued as to whether calling out cardinal directions would be easiest (and if so, which way was north) and what path markers they would use. Colored M&Ms were chosen for their convenience, but prompted a subsequent discussion on what the colors meant. Although we did not keep track of the number of attempts it took for the team to cross the maze (a personal lesson learned for next time), everyone agreed that it went more quickly the second time around, but not substantially so.

As in most exercises like these, the true learning emerged in the discussion afterwards as the participants compared experiences of the two rounds and discussed the applicability to mission’s work. Here are the main reflection points that they identified:

Communication—The team agreed that their non-verbal communication in round one had been very effective and admitted that speaking did not actually help them. Rather, it led them to over-complicate their interactions. Lesson: Communication is critical, but does not need to be complicated. If a process is working, do not abandon it to a new method unless there is a good reason to do so.

Assumptions—When giving verbal cues using the cardinal directions, it was immediately clear that some participants did not know which way was north and selected a direction at random. Once someone alerted everyone to true north, they were all back on the same page. Lesson: It is important to clarify assumptions and establish guiding facts before beginning an activity.

Institutional Memory—At one point during round one, when the team was using their hands to mark the path, one of the participants accidentally lifted his hands and could not remember where they had been. It was a big setback for the team and reminded everyone of what can happen when mission staff rotate to a new post. Lesson: Find a way to capture critical tacit knowledge.

Leapfrogging—Along with the discussion about institutional memory, one participant noted the potential for leapfrogging to speed up the process if they had been allowed to start from where the last person left off, rather than starting back at the beginning every time. Lesson: We are rarely starting from scratch in development work. It is important to leverage and build upon the work done before (knowledge about which should come from the mission’s institutional memory bank).

Failing Fast—Once the participants got going, they moved through the line quickly, queuing up ready to jump in and take their turn. They encouraged one another not to overthink their next step, but to try a path and if it did not work out, the next person would have one more data point to guide their decision. Lesson: We cannot be so afraid of failure that we do not move; we just have to quickly learn from our mistakes and let them inform our next actions. This can only happen in a supportive environment.

Goals—When asked if it had helped at all to have the exit square marked, the participants had mixed feelings. On one hand, it saved them one step and gave them a very general idea of direction. On the other hand, since the path could (and did) move forwards, horizontally, diagonally, and even backwards, the connection between each individual step and the exit was much less clear. Lesson: USAID operates in complex environments often requiring nonlinear interventions. There are many ways to achieve targets, but we must be flexible and adapt to the context in order to be effective. 

This experiential exercise helped to demonstrate the concepts of learning from our work, the benefits of adaptive management, and the value of collaborating as a group. Starting with the Maze set the tone for more practical discussions on creating a learning plan for the mission.

If you try The Maze out for yourself, please let us know what lessons you take away. Share them in the comments below.

How Nutri-Salud Is Using APRECIE to Improve Health

Feb 10, 2014 by Jessica Ziegler Comments (0)
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As part of USAID/Guatemala’s Western Highlands Integrated Program (WHIP), the Nutri-Salud: Community Nutrition and Health project, implemented by University Research Co., LLC,  works closely with other WHIP partners, government, and civil society. Following a previous Learning in Action article on USAID/Guatemala's perspective on learning within WHIP, Elena Hurtado, Chief of Party for Nutri-Salud, provides insights from the implementing partner perspective. She discusses how the team has embedded collaboration and learning within its implementation as it seeks to expand coverage of quality, integrated primary health care services and engage communities and local government in improved health and nutrition. APRECIE (Aprendizaje Colaborativo e Intercambio de Evidencia y Experiencia), which means Collaborative Learning and Exchange of Evidence and Experience—and also “appreciate” in Spanish— is a key part of Nutri-Salud’s quality improvement approach. In the APRECIE methodology, evidence and experience are gathered through participatory data collection methods for decision-making about program and performance support priorities.

About the Project

Nutri-Salud: the USAID/Guatemala Community Nutrition and Health activity, managed by University Research Co., LLC (URC), is a 5-year (2012-2017) effort, which aims to improve community nutrition and health of women and children in 30 municipalities in 5 departments of the Western Highlands of Guatemala, where the population is predominantly rural and indigenous Maya. Nutri-Salud works to improve nutrition among women of reproductive age and children under five to strengthen maternal, neonatal, and child health (MNCH) and family planning services; and to engage communities in finding active solutions to their health care needs. 

1. What was the primary goal of the learning approach/project/event?

Using APRECIE, Nutri-Salud defines standards and indicators of prenatal, postnatal, and neonatal child care; measures them in a sample of each type of clinical record; and undertakes planned actions to improve the levels of compliance with these standards and indicators. Likewise, at the community level, indicators on knowledge and practices of mothers are also defined, then knowledge and practices are measured through lot quality assurance sampling (LQAS), and behavior change actions are planned to improve results. 

To operationalize the methodology, the 30 municipalities in the Western Highlands included in WHIP were divided into 110 supervision areas (SA), each with a population of approximately 10,000, served by 5 health posts and/or community convergence centers.  A continuous quality improvement team (CQIT) was formed in each SA, and the team leads the measurement, sharing and discussion of the findings, and the development of improvement plans for health and nutrition activities in the SA. 

The CQITs are formed by health providers from the five health facilities that are in the SA. Usually, teams include five auxiliary nurses, two to five health educators and two to five rural health technicians, depending on the types of personnel available at the various facilities. These teams examine both clinical quality of care (in health posts through review of a sample of health records) and maternal knowledge and practices indicative of the “quality of behavior change interventions.” 

The methodology is already showing positive results. For example, the percent of mothers who could correctly state the ideal birth interval (3–5 years) rose from 57 to 72 percent, and the percent of clinical records showing that postpartum women received a home visit within 48 hours of birth rose from 31 to 69 percent (derived from baseline measurements to the second round of data collection three months later). Improvement plans and activities that CQITs carried out to achieve these outcomes included developing key messages and talks on the ideal inter-pregnancy interval for use at every clinic visit and during household visits.  In order to increase early postnatal visits, a “notification chain” has been established in communities where health providers and the health commissions track the probable delivery dates of pregnant women in any given week; as soon as a woman is in labor they are notified via cell phones.  

2. What are some lessons learned?

A similar collaborative learning and evidence exchange methodology had been applied prior to Nutri-Salud by URC in secondary health facilities (health centers) in Guatemala. Evaluation found that it not only improved the quality of neonatal and obstetric care, but that providers who participated on the CQITs were very positive about the methodology. CQIT members mentioned that it helped them to provide better services by promoting teamwork and group communication and by focusing work on fulfilling established standards of care.  However, providers in the same facilities who did not participate in the CQIT had minimal understanding of the methodology and communication and sharing between team members and non-team members was weak.  

In order to build a greater understanding among all health providers, not just CQIT members, Nutri-Salud created the name APRECIE to distinguish the methodology from its previous application to maternal and neonatal care (previously called ProCONE for “obstetric and neonatal care and promotion” in Spanish).  In its new iteration, Nutri-Salud has adopted the methodology for first-level health services, grouping them by the aforementioned SAs to promote better understanding and knowledge sharing across facilities.  

3. What was the biggest value for those involved?

The biggest value for those involved is that they can measure their performance, learn from it, and plan improvement.  It empowers health providers.  

4. Are you attempting to measure learning? If so, how?

Yes, Nutri-Salud is planning to have learning sessions where project staff and the CQITs not only discuss achievements based on quantitative indicators, but also assess and discuss learning by participants in the process. Nutri-Salud would like each SA to also become a “learning area” (a learning lab, if you will) through competency-based training, tutoring, and follow-up.  This new phase will be called APRECIE+.   

5. How are you sharing learning with other implementers, local stakeholders, and/or USAID based in the Western Highlands?

Nutri-Salud has shared APRECIE with the Ministry of Health (specifically the Vice Ministry of Primary Health Care) and has now trained the central level Ministry personnel in the methodology.  They are extremely interested in expanding the use of APECIE to the rest of the country, although there are resource challenges that constrain a national roll-out. 

Nutri-Salud has also presented the methodology to rural value chain activity implementers and other USAID health partners. Coordination with the latter group has led to more complete geo-referencing and mapping of their activities in the SAs, which supports coordination between members in the larger USAID Western Highlands Integrated Program.

Project team works together to analyze data

6. How will this approach/activity/event connect to future project work?

Nutri-Salud faces the challenge of monitoring community integrated management of childhood illness (IMCI) and community-based family planning, and will try to do it using APRECIE.  The project will also use the LQAS surveys of community knowledge and practices to monitor its renovated behavior change intervention. This activity focuses on a set of 19 behaviors during the first 1,000 days of life (or from conception to 2 years, also called the 1,000 Days Window of Opportunity), using a “behavior wheel” as the main support material at the household level.

 

 

CLA in Action articles are intended to paint a more detailed picture of what collaborating, learning, and adapting (CLA) looks like in practice. Unlike other disciplines, CLA is not a technical "fix;" it looks different in different contexts. This series will showcase examples of intentional collaboration, systematic learning, and resourced adaptation, some of which you may find applicable to your own work. The case studies, blogs, and resources represented in this series document the real-world experiences of development practitioners experimenting with these approaches for the benefit of sharing what's possible.

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