Can Transparency and Accountability Programs Improve Health? Experimental Evidence from Indonesia and Tanzania

Can Transparency and Accountability Programs Improve Health? Experimental Evidence from Indonesia and Tanzania

We assess the impact of a transparency and accountability program designed to improve maternal and newborn health (MNH) outcomes in Indonesia and Tanzania. Co-designed with local partner organizations to be community-led and non-prescriptive, the program sought to encourage community participation to address local barriers in access to high quality care for pregnant women and infants.

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Power to the People?: Learning from the Case of Citizen Voice and Action

Essential services often fail because citizens are unable to hold governments accountable. By studying the case of Citizen Voice and Action, a social accountability intervention introduced by the World Vision aid organisation, my thesis asks how impoverished citizens can be empowered to increase accountability for essential services and how to improve empowering intervention processes. Findings from twelve countries explain which citizen capabilities influence official behaviour and consequently, how to combine competing theories of accountability. Improving practice requires finding which localized cultural capabilities amplify collective power to enable change.

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Effects of a community scorecard on improving the local health system in Eastern Democratic Republic of Congo: qualitative evidence using the most significant change technique

Background

More than a decade of conflict has weakened the health system in the Democratic Republic of Congo and decreased its ability to respond to the needs of the population. Community scorecards have been conceived as a way to increase accountability and responsiveness of service providers, but there is limited evidence of their effects, particularly in fragile and conflict-affected contexts. This paper describes the implementation of community scorecards within a community-driven reconstruction project in two provinces of eastern Democratic Republic of Congo.

Methods

Between June 2012 and November 2013, 45 stories of change in the health system were collected from village development committee, health committee, community members (20 men and 18 women) and healthcare providers (n = 7) in 25 sites using the Most Significant Change technique. Stories were analyzed qualitatively for content related to the types and mechanisms of change observed.

Results

The most salient changes were related to increased transparency and community participation in health facility management, and improved quality of care. Quality of care included increased access to services, improved patient-provider relationships, improved performance of service providers, and improved maintenance of physical infrastructure. Changes occurred through many different mechanisms including provider actions in response to information, pressure from community representatives, or supervisors; and joint action and improved collaboration by health facility committees and providers.

Conclusions

Although it is often assumed that confrontation is a primary mechanism for citizens to change state-provided services, this study demonstrates that healthcare providers may also be motivated to change through other means. Positive experiences of community scorecards can provide a structured space for interface between community members and the health system, allowing users to voice their opinions and preferences and bridge information gaps for both users and frontline healthcare providers. When solutions to problems identified through the scorecard are locally accessible, users and healthcare providers are able to work together to implement mutually acceptable solutions that improve quality of health services, and make them more responsive to users’ needs.

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Do Interventions that Promote Awareness of Rights Increase Use of Maternity Care Services? A Systematic Review

Twenty years after the rights of women to go through pregnancy and childbirth safely were recognized by governments, we assessed the effects of interventions that promote awareness of these rights to increase use of maternity care services. Using inclusion and exclusion criteria defined in a peer-reviewed protocol, we searched published and grey literature from one database of studies on maternal health, two search engines, an internet search and contact with experts. From the 707 unique documents found, 219 made reference to rights, with 22 detailing interventions promoting awareness of rights for maternal and newborn health. Only four of these evaluated effects on health outcomes. While all four interventions promoted awareness of rights, they did so in different ways. Interventions included highly-scripted dissemination meetings with educational materials and other visual aids, participatory approaches that combined raising awareness of rights with improving accountability of services, and broader multi-stakeholder efforts to improve maternal health. Study quality ranged from weak to strong. Measured health outcomes included increased antenatal care and facility birth. Improvements in human rights outcomes such as availability, acceptability, accessibility, quality of care, as well as the capacity of rights holders and duty bearers were also reported to varying extents. Very little information on costs and almost no information on harms or risks were described. Despite searching multiple sources of information, while some studies did report on activities to raise awareness of rights, few detailed how they did so and very few measured effects on health outcomes. Promoting awareness of rights is one element of increasing demand for and use of quality maternity care services for women during pregnancy, birth and after birth. To date efforts have not been well documented in the literature and the program theories, processes and costs, let alone health effects have not been well evaluated.

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Scorecards and social accountability for improved maternal and newborn health services: A pilot in the Ashanti and Volta regions of Ghana

Background

With the limited availability of quality emergency obstetric and newborn care (EmONC) in Ghana, and a lack of dialogue on the issue at district level, the Evidence for Action (E4A) program (2011–2015) initiated a pilot intervention using a social accountability approach in two regions of Ghana.

Objective

Using scorecards to assess and improve maternal and newborn health services, the intervention study evaluated the effectiveness of engaging multiple, health and non‐health sector stakeholders at district level to improve the enabling environment for quality EmONC.

Methods

The quantitative study component comprised two rounds of assessments in 37 health facilities. The qualitative component is based on an independent prospective policy study.

Results

Results show a marked growth in a culture of accountability, with heightened levels of community participation, transparency, and improved clarity of lines of accountability among decision‐makers. The breadth and type of quality of care improvements were dependent on the strength of community and government engagement in the process, especially in regard to more complex systemic changes.

Conclusion

Engaging a broad network of stakeholders to support MNH services has great potential if implemented in ways that are context‐appropriate and that build around full collaboration with government and civil society stakeholders.

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More than just ‘demand’: Malawi’s public-service community scorecard

This policy briefing by ODI and Plan raises the following key points:

  • Community scorecard approaches that are adapted to local realities can lead to improved service delivery

  • They are often presented as tools for citizens’ empowerment and voice, but this can sell these initiatives short

  • There are many ways in which scorecards can support change, including through collective problem solving and bringing together supply and demand

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Improving social accountability processes in the health sector in sub-Saharan Africa: a systematic review

Social accountability is a participatory process in which citizens are engaged to hold politicians, policy makers and public officials accountable for the services that they provide. In the Fifteenth Ordinary Session of the Assembly of the African Union, African leaders recognized the need for strong, decentralized health programs with linkages to civil society and private sector entities, full community participation in program design and implementation, and adaptive approaches to local political, socio-cultural and administrative environments. Despite the increasing use of social accountability, there is limited evidence on how it has been used in the health sector. The objective of this systematic review was to identify the conditions that facilitate effective social accountability in sub-Saharan Africa.

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How Systemic Inquiry Releases Citizen Knowledge to Reform Schools: Community Scorecard Case Studies

Despite the relevance of systemic practice for repairing broken public systems, documented instances where it empowers marginalised groups en masse to be action researchers are rare. Public school systems that fail to educate millions of pupils are ripe for systemic inquiry. Using evidence, this article identifies conditions under which such inquiry fosters school system accountability and increases pupil learning. By tracing the emergence of a type of community scorecard practice called Citizen Voice and Action (CV&A), it explains how and why marginalised groups use CV&A’s systems-enhanced participatory research to engage with and reform unresponsive public systems. It also shows how soft systems thinking and further action research enhanced scorecard methodology. Brief case studies of CV&A use in Ugandan primary schools illustrate and explain how communities reform schools by using CV&A to systematically foster accountability. Discussion identifies how processes free them to create and use systemic knowledge. This theorising helps explain conditions under which systemic inquiry into school and other public systems is being generalised and scaled up.

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Turning old problems into new problems: the role of young citizens in improving accountability in education in Malawi and Kenya

Accountability is increasingly recognised as the key mediating variable that encourages service providers to deliver efficient and effective local services. In the context of education, accountability strategies do not always explicitly consider young citizens as the primary users of education services. In this paper, a client approach to accountability is compared to a citizenship approach. Drawing on community scorecard and social audit research in Malawi and Kenya, the author explores whether education services are more responsive and accountable when young people access information and exercise their voice. The paper outlines a refreshed ‘accountability framework’ for education, placing young citizens at the centre, and argues that a citizenship-led approach in education governance is likely to be more realistic and effective than a ‘client power’ approach. This article makes an important contribution to the development community’s understanding of what constitutes an effective approach for promoting more transparent and responsive education governance.

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Creating spaces for dialogue: a cluster-randomized evaluation of CARE’s Community Score Card on health governance outcomes

Social accountability interventions such as CARE’s Community Score Card© show promise for improving sexual, reproductive, and maternal health outcomes. A key component of the intervention is creation of spaces where community members, healthcare workers, and district officials can safely interact and collaborate to improve health-related outcomes. Here, we evaluate the intervention’s effect on governance constructs such as power sharing and equity that are central to our theory of change.

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Effects of a social accountability approach, CARE’s Community Score Card, on reproductive health-related outcomes in Malawi: A cluster-randomized controlled evaluation

Social accountability approaches, which emphasize mutual responsibility and accountability by community members, health care workers, and local health officials for improving health outcomes in the community, are increasingly being employed in low-resource settings. We evaluated the effects of a social accountability approach, CARE’s Community Score Card (CSC), on reproductive health outcomes in Ntcheu district, Malawi using a cluster-randomized control design.

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Enhancing governance and health system accountability for people centered healthcare: an exploratory study of community scorecards in Afghanistan

The premise of patient-centered care is to empower patients to become active participants in their own care and receive health services focused on their individual needs and preferences. Afghanistan has evidenced enormous gains in coverage and utilization, but the quality of care remains suboptimal, as evidenced in the balanced scorecard (BSC) performance assessments. In the United States and throughout Africa and Asia, community scorecards (CSC) have proved effective in improving accountability and responsiveness of services. This study represents the first attempt to assess CSC feasibility in a fragile context (Afghanistan) through joint engagement of service providers and community members in the design of patient-centered services with the objective of assessing impact on service delivery and perceived quality of care.

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Management and Motivation in Ugandan Primary Schools: An impact evaluation report

Among the various challenges that the Ugandan government is facing to improve educational outcomes and achieve Universal Primary Education (UPE) in the country, is the necessity to improve the “quality of education”. Service delivery in education in Uganda has been proven to suffer, in great part, from the “weakness of accountability mechanisms between school administrators, teachers and the communities”. In order to assist national decision-makers in solving these issues, a team of local researchers set out to test and assess the effectiveness of two types of community-based monitoring interventions in improving general educational outcomes, using methods of randomized controlled trials (RCTs) on a sample of 100 rural public primary schools in the country. This paper presents the main findings from this experimental impact evaluation project.

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SDG DIGITAL INVESTMENT FRAMEWORK: A Whole-of-Government Approach to Investing in Digital Technologies to Achieve the SDGs

SDG DIGITAL INVESTMENT FRAMEWORK: A Whole-of-Government Approach to Investing in Digital Technologies to Achieve the SDGs

This paper calls for countries to take a whole of government approach to investing in digital technology. It illustrates how the methodology developed can be used to identify which technologies matter most to achieve the SDGs. It highlights the use cases that have been implemented; the digital technology infrastructure and building blocks needed to deliver education, health and agricultural services; and where these can be shared across sectors to increase impact and reduce costs. Finally, it calls on governments and the private sector to work together to fund and deliver the digital solutions required to meet the goals.

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Technology Landscape for Digital Identification

Technology Landscape for Digital Identification

Robust, inclusive, and responsible identification systems can increase access to finance, healthcare, education, and other critical services and beneficiary identification systems are also key to improving efficiency and enabling innovation for public- and private-sector services, such as greater efficiency in the delivery of social safety nets and facilitating the development of digital economies. However, the World Bank estimates that more than 1.1 billion individuals do not have official proof of their identity. New technologies provide countries with the opportunity to leapfrog paper-based systems and rapidly establish a robust identification infrastructure. As a result, the countries are increasingly adopting nationwide digital identification (ID) programs and leveraging them in other sectors.

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Policy Brief: The potential of open data to impact resource allocation for poverty eradication in Kenya and Uganda

Policy Brief: The potential of open data to impact resource allocation for poverty eradication in Kenya and Uganda

Between January 2013 and May 2014, Development Initiatives and Development Research and Training were part of the Open Data in Developing Countries (ODDC) study, a multi case study initiative funded by the WWF and IDRC that sought to ascertain the impact Open Data is having in transforming developing countries. The Uganda/Kenya case study investigated Impact of Open Data on resource allocation for poverty eradication in Uganda and Kenya.

This case study was premised on the experiences of countries that have been involved in Open Data since the beginning.

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Opening Government Data through Mediation: Exploring the Roles, Practices and Strategies of Data Intermediary Organisations in India

Opening Government Data through Mediation: Exploring the Roles, Practices and Strategies of Data Intermediary Organisations in India

In early 2012, Government of India approved the first policy in the country governing proactive disclosure of government data, and especially of born-digital and digitised data. This National Data Sharing and Accessibility Policy (NDSAP) extends the mandate of the Right to Information (RTI) Act to establish policy and administrative support to enable informed citizenship, better decision-making and heightened transparency and accountability.

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