This is Dr. Sita Sharma. She is a medical doctor working for a small health NGO in Rukum district in Nepal. She is a program officer responsible for maternal health activities in one cluster. In that cluster, there are seven villages with a population of around 2,300 people. She coordinates with two field staff: Ramesh, who is her field officer, and Rashmi, who is her female community health volunteer (FCHV) coordinator.

So she manages this cluster — seven villages in a remote district, population 2,300, a three-person team. There are five health posts in the cluster with 10 government health workers, and seven female community health volunteers.

Don't worry if you don't know a lot about the health sector or maternal health. The challenges that Sita faces are the same challenges that even the most experienced of us face, whatever sector we are working in — whether that is WASH, education, agriculture, livelihoods, and so on.

What keeps Sita awake at night?

Firstly, is she reaching the right people? Is she reaching the most vulnerable, or is she just providing services to those who are easy to reach? It is very easy to be distracted by delivering services to those who are more accessible, rather than reaching out to those where it requires extra effort or consideration.

She wonders if she is really making a difference. She feels busy all the time, but how does she know if she is really creating positive change?

How does she know where her support is needed most — which villages need her attention, extra services, or a different approach?

And this is a very common worry: how are we going to demonstrate the impact and positive changes of our project at the end? How can we base that on evidence?

She needs a system to answer these questions, and that system is MEAL — Monitoring, Evaluation, Accountability, and Learning.

The Four Components of MEAL

MEAL answers four types of questions throughout your project:

Monitoring asks whether things are on track. Is implementation happening as planned? It lets us know what is happening on the ground, when we meet roadblocks, and when things do not unfold the way we expect — and why.

Evaluation is more reflective. It asks: did it work? Did we achieve the change that we set out to create? If monitoring asks "are we on track?", evaluation asks "does that track lead where we thought it would?"

Accountability is about listening and communicating. Do communities have any complaints? Do they have any issues? Are they facing any challenges accessing services? Are we listening, and are we transparent around our project implementation and decision-making?

Learning asks: what should we change? What do we need to do differently to deliver positive results for our target groups and communities?

MEAL is not just a performative act for donor reporting. MEAL is how we manage our work and our projects effectively.

The Problem Sita is Trying to Solve

In her cluster, only 31% of pregnant women attend four or more antenatal care visits. This is the basic minimum standard we should be aiming for.

A donor has just provided new antenatal care equipment — blood pressure monitors, handheld ultrasound devices, examination supplies — to the five health posts in her cluster. The equipment is installed and ready to use.

Sita's job is to manage a 12-month project to increase antenatal care attendance from 31% to 55%. She will train health workers to deliver quality care, and mobilize communities through education and awareness sessions so that women actually show up for their check-ups.

That sounds simple, right?

The Complexity

The terrain is very difficult. Two of the villages have no health posts at all — women need to travel to a neighbouring village or wait for a mobile health worker to visit. Some households are still two hours' walk from the nearest post, which is quite a challenge, especially late in pregnancy. Some villages require crossing a river to access care.

The community also has varying attitudes towards antenatal care and varying levels of awareness. Some communities may never have heard of this, or they may prefer to seek out an auntie, grandmother, or local elder rather than turn to a health post. There are issues of awareness, attitudes, and trust of government health services.

This is messy, real-world complexity. Sita needs to improve attendance across all of it — not just the easy-to-reach people.

This complexity is exactly why she needs MEAL: to track what is working and where, to adapt to what she discovers, and to prove impact despite those challenges.

Pause and Reflect

Think about your own context. How do things like geography, religion, culture, tribal differences, economic disparities, education, and language make your working environment more complex?

Which of Sita's worries resonates most with your current situation?