Mobilizing Action Against Corruption

Mobilizing Action Against Corruption

U. S Agency for International Development

Building Good Governance in Health and Education:

Workshops and Technical Assistance

Yerevan, Armenia

September 22-October 4, 2008

Final Report

Prepared by:

Taryn Vian, Health Governance Specialist and

Yemile Mizrahi, Governance Specialist

Casals & Associates, Inc.

1199 NorthFairfax

Alexandria, VA22314 USA

1. Objectives

On September 22, Taryn Vian, Assistant Professor at Boston University and Health Governance Specialist, and Yemile Mizrahi, Senior Associate at Casals and Associates, and Governance Specialist, traveled to Yerevan, Armenia to conduct a series of workshops and provide technical assistance to MAAC partners at USAID, selected USAID implementing partners, the Ministries of Health and of Education, representatives of the Anticorruption Strategy Monitoring Commission (ACSMC) Expert Group, and selected non-governmental organizations, NGOs.

The main objective of this training/technical assistance was to provide a basic understanding of the elements of good governance and of its importance for economic development to health and education specialists. Issues relating to capacity, transparency, accountability and political participation were introduced and discussed in an open forum. A conceptual framework to understand the problem of corruption, a serious governance problem, was introduced and the main vulnerabilities of corruption in the health and education sectors were identified. In an open and interactive process, participants identified and discussed corruption problems in the health and education sectors in Armenia, and then they were presented with a range of possible tools and strategies to address the problem of corruption based on successful experiences from other parts of the world. Lessons learned from these interventions were discussed. Through group discussions and individual consultations, participants were able to reach a common understanding on the significance of good governance for their work and were sensitized about the very important role they can play in addressing corruption issues in their country.

1. Activities

1. Conduct interviews with health experts and USAID to gather relevant background information prior to workshop.

2. Design and conduct a two-day workshop for USAID Health Team and selected implementing partners.

3. Design and conduct a one-day workshop for NGOs focused on community-based monitoring for anticorruption and health.

4. Design and conduct a one-day workshop for Ministry of Health (MOH) officials and the Anticorruption Strategy Monitoring Commission (ACSMC) Expert Groupto identify priorities for the MOH over the next 5 years.

5. Facilitate and be one of the key speakers at an Anticorruption Forum on the topic of the Free MaternityHealthcare Program. (This event had to be cancelled due to international travel of key MOH personnel.)

6. Provide consultative services in area of anticorruption and health to the representatives of the Ministry of Health, USAID, USAID health implementing partners, Armavir and other NGOs, as needed.

7. Design and conduct a one-day workshop for Ministry of Education (MOE) officials and the Anticorruption Strategy Monitoring commission (ACSMC) Expert Group to identify priorities for the MOE over the next 5 years.

8.Design and conduct a one-day workshop for NGOs focused on community based monitoring for anticorruption and education.

A. Interviews with health experts and review of documents

In preparation for the health sector workshops, Taryn Vian held phone interviews or discussions with the following experts and stakeholders:

• Mary Segall, PhD, RN, Technical consultant who has worked with the USAID Primary Healthcare Reform (PHCR) Project to help advance Armenia’s Quality Assurance Initiative;
• Kimberly Waller, USAID/Armenia Health Team Leader, and Mark Levinson (USAID/Armenia Democracy & Governance Officer;
• Roger Vaughan, Senior Health Advisor for the Moldova Governance Threshold Country Program;
• Frank (Rich) Feeley, Technical consultant who has worked with the PHCR Project to review health financing issues in Armenia.

Following discussions with USAID, Taryn Vian, Yemile Mizrahi and Francois Vezina finalized the goals, objectives, and agenda of the workshops(see Annex A). Discussions with the other experts covered health initiatives and governance issues in Armenia (interviews with Dr. Segall and Professor Feeley), anticorruption experience in Moldova (Roger Vaughan), and objectives and areas of focus for the workshop (Kimberly Waller and Mark Levinson). Observations on two particular health initiatives—the Quality Improvement Program and the Maternity Care Certificate Program—are included in the results section. A summary of Moldova’s efforts to prevent corruption in the health sector can be found in Annex H.

B. Workshops

Taryn Vian and Yemile Mizrahi developed training materials for several audiences:

• USAID staff (health and democracy & governance) and implementing partners
• NGO sector (including Amavir, an NGO selected by MAAC for a Small Grant under its APS program, Partnership and Training, another NGO selected for a Small Grant to develop transparency and accountability procedures for secondary school governance bodies).
• Expert Group on Anti-Corruption Monitoring (Government of Armenia)
• Officials of the Ministry of Health and Ministry of Education

A total of 65 participants were trained through the workshops, as shown in Table 1

Table 1: Participation in MAAC Workshops on Good Governance in Health, September /October 2008

• Armenian Eye Care Project (2)
• NOVA Project (1)
• Academy for Educational Development (1)
• Primary Healthcare Reform Project (9)

C. Technical meetings

Following the workshops, technical meetings were held with:

• Health advisor from Armenia’s Expert Group on Anticorruption Strategy, Ashot Melkonyan, who participated in the NGO workshop and the workshop for the Expert Group;
• PHCR project staff;
• World Vision project staff;
• Leading specialist from the Ministry of Health, Mother and Child Division.

Meetings were also held with the USAID Health Team Leader and MAAC staff, to discuss programming options to promote good governance.

IV. Results

This section first presents the workshop results, including evaluation findings and comments. This is followed by observations from pre-workshop interviews and post-workshops technical meetings held with PHCR project staff, Lead Specialist from Ministry of Health, Mother and Child Division, World Vision project staff, and a health expert from the Armenia’s Expert Group on Anticorruption Strategy.

A. Workshop Results

The Casals consultants prepared a set of three PowerPoint presentations and two break-out group discussion guides for each of the workshops related to the health sector. Parts of presentations were combined for some of the shorter workshops. The presentations included the following (PowerPoint files and related break-out tools submitted separately to USAID and available through MAAC (contact ):

PresentationTopics covered

• Building Good GovernanceOverview of governance concepts

• Governance and HealthGovernance principles for health sectors

• Tools and StrategiesReview of anticorruption strategies and international experience in AC and health

For the two workshops related to the education sector, the consultants prepared one long presentation that included an overview of governance concepts, vulnerabilities of corruption in the education sector, and a review of strategies and tools to address corruption problems in the health sector based on international best practices. The power point presentations are available through MAAC. The workshop also included break out discussion group sessions where participants identified major vulnerabilities in their sector, discussed several possible interventions to address these problems and adequate indicators to assess impact.

The USAID workshop was held in English, with whispered translation for 1-2 Armenian speakers. The NGO and Expert Group workshops were simultaneous translation.

Workshops were well received, with active small group work and large group discussions and question and answer period.

The main task of group work was to identify weaknesses in governance and possible corruption problems in the sector, and then to brainstorm ways in which the good governance principles presented might be applied to solve them. Annex A-Fcontains the output of all the different workshops.

Participant Evaluations

After each workshop, participants were asked to fill in an evaluation form. Part I of the evaluation consist of four questions were participants were asked to give numerical ratings for workshop content, approach/organization, quality of trainers, and meeting of expectations. Numerical ratings range from 1 to 5, where 1 is poor and 5 is excellent. Part II of the questionnaire consists of qualitative questions related to the knowledge acquired, the relevance of the workshop for participant’s work and general comments about the workshop.

Participants were highly satisfied with the workshops as reflected in their evaluations. Numerical results for each one of the workshops are presented in the following table. Due to the limited number of participants, evaluations were not passed at the end of the workshop with the members of the expert committee and representatives of the Ministry of Health. Comments from some of the participants are also described below.

• I found the workshop valuable; I learned a framework for thinking about corruption
• Group Discussions were particularly useful
• In designing and implementing health projects, I will be able to plan better anticorruption activities/components
• It would have been helpful to cover specific country related problems
• I found international experiences and practices particularly useful
• The workshop was good for its interactive nature; excellent expertise of trainers
• Would have liked to have the opportunity to develop a more concrete action plan
• Would have liked to receive articles, website, sources of information
• The workshop was excellent; I will look at how community awareness can be strengthened
• Before the workshop I thought we were corrupt because we are poor; now I understand that it is actually the reverse
• I found the selection of one particular project in health very useful; we identified the vulnerabilities problems and the possible solutions
• People were active until the last minute of the workshop which says how interesting the theme is and how well the workshop was facilitated
• I would have like it if presenters had more knowledge of local realities

• I think the workshop was very useful. Thank you.
• The warm environment contributed to the effectiveness of the workshop. All was perfect
• I enjoyed learning about Armenia’s position in the CPI as well as about anticorruption experiences in other countries
• I learned that cooperation, rather than confrontation with the government is more effective for civil society participation
• I was going to submit an application for a program and I feel now, after the workshop, that I will make some changes to my application, particularly with reference to monitoring and evaluation and indicators proposed
• I would have liked to learn more about anticorruption tools used by NGOs in other countries
• I feel more empowered to combat corruption; I will start to teach and explain to people what are the consequences of corruption
• The workshop covered topics that were explained in a manner I could understood
• It would be useful to organize similar workshops on an ongoing basis
• I am more informed as a result of this workshop. After the completion of projects, we should gather again and discuss results
• I found the break out session particularly useful

• The workshop was good; high quality
• Dialogue between experts and Ministry representatives was extremely useful. Presentation of international anticorruption experience was also useful
• I would like to see similar workshops being organized, with broader circles; bigger audiences
• The workshop will contribute to the development of next year’s anticorruption action plan
• Representatives from the Ministry should have been given more time to present
• I would like to see similar workshops in the future
• The results of the workshop should be publicized
• I would have liked a more participatory approach

• The workshop was conducted in an interactive environment; translation was excellent; break out groups were good; it was a pleasure to work with experienced personnel
• I learned a lot from international experiences; the workshop was very useful for my work; the workshop increased my faith that something can be done about corruption
• Corruption is everybody’s problem; every person has to be responsible for fighting corruption; we cannot accept corruption as normal
• All sessions were good, but I liked the break out groups
• I gained understanding on the concept of corruption
• The topic was presented in an interactive and interesting manner
• The workshop exceeded my expectations. It was very useful both on the presentation of the topic and the information of statistical data of Armenia and neighboring countries
• The introduction of anticorruption indicators for each activity was particularly useful. Identification of stakeholders who suffer or benefit from corruption was also useful
• The workshop could be more effective if it included films related to the topic, and then organize discussions related to the film
• I wish similar workshops were held more frequently
• Interesting examples from other countries were presented which I will use in my work
• The workshop was rather informative in terms of results and anticorruption programs already implemented. This gave me hope that one day we can also achieve our goals: reducing corruption
• I learned that corruption needs to be address in a step by step manner; not all at once
• The timing of the workshop was perfect since a new anticorruption strategy is being discussed and elaborated in the country
• Very interesting examples were provided from other countries
• We should organize similar workshops in the future; since corruption in education is endless, we could organize more frequent discussions to insure greater effectiveness in the implementation of our programs

B. Results from Interviews and Technical Meetings

1. Governance issues related to the Quality Improvement Strategy: Taryn Vian’s interview with Mary Segall, Technical Consultant who has worked with USAID Primary Healthcare Reform (PHCR) Project to help advance Armenia’s Quality Assurance Initiative.

The Government of Armenia approved a quality assurance strategy in June 2008[1], and is expected to soon approve an implementation plan. At the central and Marz level, Quality Boards will be created, along with a new position for Quality Coordinator. At the facility level, Quality Teams will conduct improvement activities using a Quality Improvement (QI) toolkit including mechanisms like clinical audit, patient satisfaction surveys, and self-assessment checklists with instructions. The Quality Coordinators will help the teams to access resources and use the tools from the toolkit.

The quality indicators will be linked to a performance-based financing mechanism which has already been proposed to the MOH. Financial incentives will be contingent upon indicators such as percentage of women enrolled in prenatal care during first trimester, immunization coverage, and use of EKG services. Six QI indicators have been chosen to start.Specific governance issues and vulnerabilities to corruption in this initiative include the following:

1. Tracking of funds from central level for the performance-based payment initiative. Are the facilities getting the funds? To improve governance, a procedure should be in place to measure the timeliness of flow of funds, and monitor whether funds are actually reaching facilities. This information should be compared across regions and the data should be made public.

2. Decisions for how the funds received are spent by the PHC facilities. How much autonomy will facilities have to share these funds among staff? Need to assure that spending is transparent and fair. This could be promoted by making sure that diverse staff and the Quality Board are involved in decisions, and that process is rule-based and made clear to all concerned.

3. Data from indicators evaluation. These indicators are used to decide if facilities will get a payment, so there may be an incentive for fraudulentreporting if the real performance data are not good enough. Strategies to minimize this incentive, and to detect fraudulent reporting, need to be in place. In the short run, PHCR plans to develop audit procedures for verifying manual reports. In the longer-run, the Government should aim for an automated primary health care encounter system which will be harder to manipulate in order to fraudulently inflate performance numbers.