Putting it into practice

Think of "change" as the long-term effect you want to have in a community. Take as an example the 2022 Programs of Scale award recipient, Together for Healthy Families in Nigeria, which is aiming to reduce maternal and neonatal mortality rates by increasing the use of maternal care and family planning services and improving care for pregnant women, mothers, and newborns in the country. For this program, the "change" is decreasing maternal and neonatal mortality.

The "theory" part is meant to convey that you have a reason for taking the actions you are proposing to reach the change you want. In other words, you believe that certain actions (or outputs), given certain conditions (preconditions and key assumptions), will lead to outcomes that ultimately contribute to the goal — in this example, reducing these deaths in Nigeria.

Here is what the idea looks like for the Nigeria initiative. Evidence from the World Health Organization shows that giving birth at a health facility rather than at home can reduce maternal and neonatal deaths in the country. Thus, an outcome for this program is for more births to happen at health facilities instead of at home.

You may see that and think: We must build more health facilities! However, Rotary members in Nigeria know that building and equipping a new health facility alone will not lead to a reduction in maternal mortality. Why? They know that the clinic staff members would have to be trained how to use the equipment, and pregnant women and their families would have to want to travel to the clinic to receive services. If pregnant women are unable or unwilling to access the clinic, the quality of the staff and equipment at that clinic will not matter.

This is why many of the program’s actions are geared toward something different than building more facilities. Instead, they are intended to change behavior. These actions include improving the quality of care available at the health facilities, creating a referral system to encourage families to visit them, and increasing awareness of the maternal and child health services available at the sites.

Actions lead to outcomes

One way the program raises that awareness is through meetings with traditional leaders to encourage them to think of safe childbirth as a community responsibility. Another is training health workers to recognize when it’s necessary to refer women to health facilities for treatment.

In one of the program’s communities, Alhaji Ayuba Barau, a traditional leader involved in the effort, holds regular community dialogue meetings with men to encourage them to not only contribute money for prenatal services, but also to accompany the mother to the nearest health facility for classes before the birth.

Additionally, traditional leaders work with health facilities to ensure they provide quality services. The attitudes in this community are shifting, and there has been a gradual increase in families seeking care from health facilities.

A theory of change is not static. The Nigeria program began implementation in early 2023 and is continually monitored. If the outcome of more births occurring at health facilities is not realized, the program team will revisit its interventions to understand how to modify its theory to stay on track to see the overall desired impact.

A great exercise for your club or district is to draft a theory of change as a tool to help your group achieve success in your next Rotary project.