Government commitment through provision and maintenance of resources.

The government involvement from the beginning of the program implementation was seen to be key to ensure program sustainability. The government through the district councils were not only considered as the key drivers of implementation but also as the main catalyst for influencing the ownership and continuation of the m-mama program initiatives at the local levels; as one of the stakeholders stated;

“Government engagement from the beginning is important, it was very clear, we did handover training on how to train the dispatchers, capacity building for the government teams, it makes the government feel the ownership… Working together to get the best outcome given what we need for the system. The government is a part of it, they own it”

- stakeholder, Touch Foundation

For the program to be sustained, the government needs to be committed. The government has to make sure that the resources needed to run the program are available by including the program needs in the budgets at every level. For example, councils should have a budget to enable the provision of services introduced by the program. The health system in Shinyanga allows the district councils to develop and report their budgets through the Comprehensive Council health Planning (CCHP) for funding by the government; participants highlighted that the priorities should be placed at the council level to make sure that the program activities are well budgeted.

“The government should support the review of guideline. The CCHP at the councils should capture transport costs, if the costs are not captured in the CCHP, it will not be recognized by the government, this will make the funds available to sustain the program”

- stakeholder, Pathfinder

“Regarding sustainability, as councils we have to include the program in the budget so that we continue to get services from the drivers because they were trained and they are willing to volunteer so that we support each other in reaching our clients”

- Medical officer, Kishapu

Delayed funding from the government affects the sustainability of the program activities. One of the reported concerns was payments of community drivers involved in the emergency transportation.

“We still use this program, we still continue to sustain it but as I told you, the challenge is with our financial systems for paying these drivers, it becomes difficult at times, program sustainability will be inadequate compared to when they were paid by the funders, on the spot. They were paid as they transfer clients, this encouraged them to work. Currently, we only work with the drivers that are considerate and willing to help but not all of them are patient enough to continue providing services.”

– HCWs FGD, Kishapu

The delay of payments to the drivers causes them to leave the program activities and subsequently creating human resource shortage. This is demonstrated in the quote below:

“Another thing, I don’t know how to tell you this, most of the drivers currently have ran away because of the payment issues. If the driver transfers the patient, they are supposed to be paid by the facility, at the facility, they will have to wait for the basket funds for them to be paid.”

- Dispatcher General, Kishapu

Most of the community mobilization activities were done by the community health workers (CHWs). Most of these are not regularly paid by the government. The provision of incentives to the CHWs and dispatchers was reported as another initiative towards sustaining the new program interventions especially community-based activities.

“…due to the fact that they thought if we continue with this work, we might receive some income, some continue, and some had to stop. In order to help them earn at least an income, we can include them in the budget if possible. Initially results based financing (RBF) was helpful in this but currently RBF is unpredictable.”

- Community stakeholder, Kahama

“For these NGOs or the government, the government should see the role of including them in the monthly budget, those community-based workers, because they are doing volunteering work up to today. Since this is very important, lifesaving and it raises the national economy, if the mortality and morbidity are reduced, these people would be contributing in productive works so they should remember the people supporting the women…”

- FDG, Kahama

The m-mama emergency transportation program was mainly implemented through the available ambulances at the facilities and the community taxes. However, the ambulances at the facilities needed some renovations. The need to increase the number of ambulances was suggested by one of the stakeholders. It was argued that depending on community taxies alone is risky because they can be unpredictable.

“For this program to be sustained, the major thing is to increase the number of ambulances, I think ambulances are more important. Community tax drivers have other responsibilities, they have signed the contract but they have other responsibilities as humans. They may fall sick, or travel e.t.c, but with the ambulances in many facilities, it helps with the facility activities. Even if I go to holiday, someone else will keep working so it is more sustainable. It is different from relying on the community tax drives only. To make it easy, they should bring more ambulances in the facilities.”

–Medical Officer, Kahama

The government is called to improve the infrastructure especially roads. Good roads will enable smooth operation of the emergency transportation. Also, they will enable the transportation of medical supplies to the health facilities so that patients can get the services they need on time.

“For the councils near me, for instance, Msalala and Ushetu, infrastructures are still a big challenge especially for small cars, there was a day a car got stuck and the patient was delayed for about 8 hours and it had to be dragged. You might transfer the patient experiencing complications and you find the roads are bad and you get stuck… the infrastructures are not friendly at all…”

- Officer, Kahama

To curb the challenge of poor transport infrastructures, it was suggested that the government considers increasing the number of CEMONC centers so that reaching the health centers take a considerably short time.

“For what I think, improving the infrastructures with the way our district is, it may take a long time, but more CEMONC centers should be built, so that we reduce the distance, this is one of the ways to solve the problem”

–CCG facilitator, Kishapu

Support from different stakeholders played a significant role in supporting program continuation.

Throughout the implementation of the program and towards the end of program, the m-mama program team trained and involved the respective councils to promote the ownership of the program and government preparedness to take full responsibility of the program. However, participants thought that the donors are still needed for the program to achieve the desired impact and ensure sustainability.

"With regards to EmTS, if stakeholders would support, it means the project would be going on well, but for them to drop and leave the health facilities, it was too early. Therefore, they should continue to handle it because the government has many things to do. We should not say that the responsibilities of the project go back to the government. They have shown the way on what has to be done but sustainability is a challenge,”

- CCG facilitator, Kishapu

Regular program monitoring from the m-mama supporters and innovators was suggested so that the government continues to learn from the innovators and m-mama stakeholders. It was also perceived that the m-mama program is “their project, they started it” so it is crucial that they continue supporting it.

“For what I see, what is needed is continued support, even if the donors’ contract has ended, they are supposed to continue supporting because this is their projects, they started it. So, they should continue for some time to see how the program progresses while receiving support from the government too… Even now the government has taken over, but we had more drivers showing up initially when the donors were still supporting. They should observe what causes the drivers to exit the program, they should implement what the donors used to do and maintain it so that the program is sustained.”

- Facility Based Coordinator, Kahama

The government resources were seen as inadequate to ensure sustainability of the program, a call was made for other stakeholders to supplement what is implemented by the government.

“… For instance, for what I see, the services are ongoing but to a low standard because initially, the government was working with support from the stakeholders, for instance the referral system was there before, and even now it is there, but extent of service delivery is low because the high cost might overburden the system. For instance, the ambulances were very few so the funder introduces community taxes; so if the government fails to pay the tax drivers, then these services will not be provided adequately and we will end up depending on ambulances only. We might go back to how it was in the past before the program. The stakeholder’s involvement will really help because now the program is preforming poorly.”

–FDG, Kishapu

Capacity building as one of the core program activities provided during implementation of the m-mama program played a role in reducing maternal and neonatal deaths. This learning environment supported by the funders and stakeholders was seen as an initiative towards better maternal and child health outcomes.

"We wish that the project is brought back and continues to support us. It helped us to provide education to the community, and community members have started to understand what is supposed to be done. So, if they continue to support through this project, to reduce maternal and neonatal deaths, save lives of mothers and children, we will be happier,”

- a Community Based Coordinator reported.

Not only the involvement of multiple stakeholders is needed but also a well-coordinated partnership between the government and these stakeholders to ensure proper planning and utilization of resources

“The government is the key player in the Ministry of Health, it is stakeholders’ responsibility to see where the government has limited ability so that they can proceed from there. I don’t think it’s wise if the government provides gloves and the program also provides gloves (laughing), there will be overstock and it won’t have much impact. The important thing here is observing where the government efforts have ended so that the stakeholdesr can complement”

- Medical Officer, Kahama

However, others thought that the government is swamped with many responsibilities, therefore the donors should continue to support the program so that the community can continue to enjoy its success and benefits.

“Maybe if they can use the method they used initially, because it was Touch and pathfinder, they were good, they were the ones paying the drivers for a significant proportion and the drivers were paid timely. If they can improve and revert to how it was, then all will be well.”

–hospital attendant, Kishapu

“So, what to consider is… if the program is progressing well, they should strive to handle it themselves, the government has so much to do, we shouldn’t leave this to the government. Of course, they have shed some light on what is supposed to be done and how it should be done, but based only on that, sustainability will be low.”

- CCG facilitator, Kishapu

Continued capacity building and community awareness.

To continuously reap the benefits of this program, health care workers advised on the presence of regular capacity building and refresher trainings to ensure the possibility of responding to challenges faced during program implementation timely and efficiently.

“When it comes to training, I think they have done enough and we have understood. But there should be regular, short term refreshment courses to discuss on solving the challenges we meet, it shouldn’t take so long like 6 months but it can be every two months to evaluate on the challenges faced and address them timely.”

–dispatcher, Kahama

Regarding the trainings that were primarily done by the government, the commitment to make the curriculums more practical was suggested. The trainings are inherent responsibilities of the government and the respective councils; the m-mama program promoted timely and regular conduction of these trainings but the role lies inherently on the respective councils as stated;

“This is more of the government commitment; it is not a project issue. The government needs to change the curriculum for BEmONC, CEmONC and Neonatal Intensive care to be more practical rather than theory classes. This is championed by the MoH.”

- stakeholder, Pathfinder

Raising awareness of the community can contribute in stimulating the utilization of the program activities; this is crucial to ensure that the program is sustained. The community care groups led by the CHWs were the most utilized platforms for raising awareness among expecting mothers and encouraging proper practices towards safe delivery.

“… Our community needs to be educated adequately, some of the things we observe are due to lack of education, when you provide education at community level, the fruits and benefits are great as I said earlier….”

- CHW, Kahama

Since the CCGs were led by the members of the community, they were perceived to be easily sustainable.

“In forming these community groups, we used community care group facilitators, these are known in the particular societies in engaging and mobilizing their communities well… This was intentionally done so that sustainability is feasible, it is the community members themselves making the initiative to have such groups, we therefore expect that the knowledge is retained in the community and they maintain the services.”

- stakeholder, Pathfinder

“Also empowering the community has been a great success in raising awareness, women are now referring themselves through the community care groups”

- stakeholder, Touch Foundation

To ensure that all community members are covered by the program, it was suggested that the media platforms such as local radios be used to educate the community on the maternal and newborn health services provided.

“We can do advocacy, we may use the local radios, we can have sessions, health education, we can also organize community campaigns to educate the society on the presentation and what to do if they see such and such signs. So, both these things will help in informing the community on what to do in case of emergencies.”

–medical officer, Kahama

Community awareness to increase trust of the program and ultimately maintain the utilization of the services even without funders involved is crucial.

“But the community should cooperate and continue calling and utilizing the services. We usually have the perception that the program can only succeed if it is a white person leading it, but if it’s just African, people start to think nothing will work. So, they shouldn’t stop using this program, they should continue calling, we will continue serving them for 24 hours, seven days a week. The community leaders should keep helping us…”

- Transport Focal Person, Shinyanga MC

The m-mama program provided a toll-free contact number available 24 hours for reporting on maternal or neonatal emergencies. It was suggested that efforts on the provision of continuous community awareness should also include reminders on the toll-free numbers as other villagers may not know these numbers.

“Also, to improve and strengthen this program, education should be provided regularly in the community, we might assume that the toll-free number have been distributed but other people have never received them so it is important that we educate them frequently after every few months in the villages. People are informed and given the toll-free number…”

–HCWs FDGs, Kishapu

Everyone in the community should be aware and involved in the emergency transportation system. A call was made for the community leaders to be directly involved in increasing the visibility of the program and promote its utilization through the local platforms such as annual meetings.

“The community leaders should continue helping us. We still go back, asking them to encourage their societies in the community or government meetings, one of the agenda there should be to inform them that this program is to save the lives of mothers and newborns. Despite the donors exiting, the government has taken over and it is implementing it a hundred percent.”

- Transport Focal Person, Kahama MC

Male involvement is another area that was reported to play a key role in services utilization by the community. Community awareness activities were emphasized to be inclusive of males as they are the “main decision makers” in the families.

“We should find a way to make men feel as they are part of the program, because they used to think it is only for women and newborns, this brought up challenges… If we could then educate them too and not only women so that they are also involved, to include them even in the community groups. They used to say those are just for women, and their stuff, we should involve them because they are the main decision makers”

–CCG facilitator, Kishapu

Dissemination and sharing of evidence and lesson learnt from successful programs.

The need to continuously gather evidence throughout the program and share the impact with the decision makers was suggested so that people in the central government can understand what is happening and share the story in high level meetings to get a policy buy-in.

“Another lesson learned is that collaboration with the government is key, a key success factor, their enthusiasm is key to success, getting their buy in, that this isn’t something that only we are doing, we are doing it together”

– Program manager, Touch foundation

“In record keeping, the data that we keep, I know there are challenges. If we maintain those data well, others can visit and see what we do and learn through such data. This will help to showcase how this program helps a lot of people.”

- dispatcher, Kishapu

All service providers should be informed of the program and its contents. Orientation of the new staff employed in the facilities is crucial to ensure the continuity of care for patients and introduction of the program for those not in the cycle.

“For instance, I can say in the facility, if we get extra workers, we usually organize a meeting, we orient them on what will be going on so that if they are the ones on duty at the facility, they can provide services. When they come, we inform them on the ongoing support and organizations we work with…”

–HCWs FDG, Kishapu

Having actual evidence through gathered data and regular program outcomes monitoring is not only essential for sustainability but may also promote program scale up.

“We need to keep gathering evidence, we have communicated with the ministry and there is an agreement for us to expand into Lindi and Morogoro and have agreed for us to expand to 14 other regions. Direct financing did not come overnight, you need to gather evidence for them to see. We need to be do doing mid-term evaluations, if we don’t gather evidence well, we will fail to convince people”

–stakeholder, PORALG

Close monitoring of the implemented activities to ensure smooth and well-coordinated delivery of the proposed strategies.

The role of monitoring and evaluation was perceived as a paramount continuous process that will assist government and implementers to document lessons for future reference. This can be done through continuous learning and improving from the identified gaps, taking note of the lessons learnt throughout the process

“Aah, we need to stick to what we have now and maintain them, also to improve when we see there are gaps. Also, after implementing such interventions, to monitor on the remaining challenges and see how we can tackle them so that we can learn and implement what we have.”

–medical officer, Kahama