Opinion: How Responsive Feedback can improve programs and change lives

Planned social change programs such as public health interventions have substantially improved quality of life across the world. Yet, permanent, wide-scale and self-sustaining change remains out of reach for too many. As such, there has been increasing scrutiny of traditional approaches. This scrutiny is focused on rigid program designs, lack of theory of change, and unquestioned top-down approaches that limit participation from critical stakeholders.

Current dominant models of intervention design in the development sector often do not account for the complexity and unpredictability of implementation challenges, particularly in low- and middle-income countries where health systems can be under-resourced and fragmented. Key elements to make interventions more effective — such as monitoring, learning and evaluation — also often operate in silos. Moreover, decision-makers and implementers need timely feedback as programs are rolled out to enable course corrections to achieve intended outcomes.

To maximize the impact of interventions, we need an alternative approach — one that is agile, flexible, and adaptive.

A new approach

The Responsive Feedback approach is a solution to these shortcomings. By incorporating feedback, continuous learning, and engagement under one integrated framework, we can promote social and behavioral change in a more systematic way, so programs can get better faster.

By interrogating the assumptions underlying why and how program activities are anticipated to be successful and embracing course correction, development programs can accelerate intended change.

How Responsive Feedback has improved maternal, newborn, and child health in Nigeria

Nigeria’s Kano State has an estimated 13.4 million people, with more than 70% of the population living under the poverty line, with little access to health insurance coverage. The limited access and low uptake of health care services result in poor health indicator performance, with less than 16% of women delivering at a health facility and only 51% of women completing at least four antenatal care visits during pregnancy.

Antenatal care, or ANC, plays a central role in the continuum of care between maternal, newborn, and child health. However, ANC in Kano remains ineffective due to poor retention of pregnant women already attending. Following randomized controlled trials, evidence suggests that group ANC, or G-ANC, as a pregnancy-centering model can improve the uptake of ANC and other maternal health services in LMICs.

Since 2020, the Clinton Health Access Initiative, with funding from Technical Advice Connect, has provided technical assistance to the Kano State Primary Health Care Management Board, or KSPHCMB, to adopt the G-ANC model. By replacing traditional one-on-one ANC with small group meetings of eight to 10 pregnant women with similar due dates, health providers are able to provide continuity of care, while clients benefit from peer-to-peer support and knowledge sharing.

During the implementation, CHAI used the Responsive Feedback approach to inform program redesign to achieve maximum impact. First, CHAI and KSPHCMB reviewed the program design and identified mechanisms necessary to inform iteration of G-ANC adoption and to promote local ownership and sustainability of the program. Following the first phase of the program, a joint review by the CHAI team, KSPHCMB, and ministry of health revealed a persistently low enrolment of pregnant women into G-ANC groups. In collaboration with other state stakeholders, two key insights were endorsed to modify the approach, which included enrolling all pregnant women and not just those in the 16-20 weeks gestational age group which was the original guidance, as well as introducing simple reproductive, maternal, newborn and child health, or RMNCH, messaging for health workers that covers all topics for G-ANC sessions.

Following the rollout of the modified approach, there was a dramatic increase in women who enrolled for the G-ANC sessions. As of February 2022:

• Over 220,000 women enrolled into 18,406 G-ANC cohorts, an increase from 13% in December 2020 to 98% in February 2022.

• Pregnant women counseled on essential RMNCH services increased by 25%.

• Facility deliveries increased by 15%.

• Postnatal care clinic visits from the fourth quarter of 2020 to the fourth quarter of 2021 increased by 113%.

KSPHCMB has since integrated the modified G-ANC approach into the state’s reproductive, maternal, newborn, child, adolescent health plus nutrition — or RMNCAH+N — strategy and annual operational plan. Existing state funding streams have also been leveraged to support continuous on-the-job learning and mentoring across facilities.

When used to guide program implementation, Responsive Feedback increases the sense of ownership and promotes sustainability of health programs. However, for it to be truly transformational, commitment is needed from all parties, including donors, decision-makers, researchers, project designers, implementers, and stakeholders responsible for the design and implementation of health programs. We are calling for a wider adoption of the responsive approach to enhance the effectiveness of interventions and transform lives. If we keep learning, we can keep improving.

To learn more and access the e-learning platform, visit The Curve.