Developing a culture of learning in Malawi

For the York-Zomba partnership, it began with designing their monitoring and evaluation system collaboratively so that all stakeholders were committed to the principle of learning and how monitoring and evaluation is integral to it.

Zomba Mental Health Services and the Department of Health Sciences at the University of York worked together on a project designed to strengthen the system of community mental health care in Zomba District, Malawi.

The project aimed to develop the role of local village-based health workers (known as Health Surveillance Assistants) through training and support in delivering mental health interventions.

Chikayiko Chiwandira is the Project Manager in Zomba. Jerome Wright is a Senior Lecturer in Mental Health at the University of York, and one of the project leads.

Learning from this project was greatly assisted by all involved having a pre-existing commitment to both the principle of learning and the importance of monitoring and evaluation.

Although this commitment to learning existed, as asking Health Surveillance Assistants (HSAs) to begin delivering mental health interventions was an innovative are of work, it was unclear at first exactly what information would need to be collected to help make the learning happen.

Jerome recalls that the first thing the UK project team did was to ask questions, and help others to ask questions.

It was particularly important for us not to say that we had all the answers. We didn’t!

Planning and delivery of the project involved key professionals in Zomba from mental health services and District Health Offices,

as well as discussions with the HSAs. By encouraging this group to ask questions, Jerome aimed to develop a level of curiosity amongst all stakeholders.

This increased curiosity, along with encouragement for all stakeholders to contribute, lead to more interest and involvement in learning, and ensured that the project team were ultimately able to develop better solutions.

For example, Jerome realised that the work being undertaken would probably have an impact on the number of admissions to the hospital in Zomba, but it was unclear whether this would be an increase or decrease.

The team in Malawi were encouraged to develop a hypothesis, which, following reflection and consideration, helped to ensure that Chikayiko was able to capture appropriate data regardless of whether admissions went up or down.

With the HSAs village-based, the most reliable way of capturing monitoring information for learning purposes was for Chikayiko to visit HSAs on a monthly basis to collect the relevant data and to discuss it with them. According to Jerome, the workers enjoyed the fact that the monitoring and evaluation wasn’t just a paper exercise, and welcomed the chance to discuss the findings face to face.

The monitoring process itself helped to engage HSAs in the project as a whole. “It enthused people, kept them motivated and interested, and kept the momentum of the project going. This wouldn’t have happened if we hadn’t built in face-to-face visits.”

All projects find that certain things don’t work as planned. Acknowledging problems allows partners to look for solutions and turn challenges into lessons learned. There were some practical difficulties in the speed at which the data required for monitoring and evaluation was made available. Chikayiko had planned to capture all data on his laptop on the monthly visits, but this proved too time-consuming. Having realised the system wasn’t working, the team agreed that paper copies of the data would be taken off-site between visits, and that the timescales would have to slip a little.

A further change in practice, based on the learning from monitoring, related to the input of HSAs’ line managers. Although these managers were involved in the initial training of HSAs, in the belief that this would help them commence and sustain their mental health work, they were not involved in regular monthly supervision meetings with workers to discuss the project. After an initial increase in HSA mental health work activity, the momentum began to reduce in the second year.

Having used the monitoring data to notice the issue, Chikayiko and colleagues in Malawi questioned the reasons for the decrease in activity, and proposed involving managers in the supervision meetings.

Once this was implemented, managers were able to help the HSAs prioritise the mental health intervention work within the context of their other work, and the momentum duly picked up again.

Chikayiko believes that learning has been facilitated by the partners having respect for each other’s views and ideas, and making decisions collectively. “The UK partner was very supportive of our new ideas on the implementation of the work. This has helped the partnership to work better together for one common goal, evidenced in the successful results. In the process the Malawi partners have gained knowledge and learnt skills, including in relation to good project and financial management, and analysis, interpretation and reporting of data.”