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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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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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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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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The Role of Social Accountability in Improving Health Outcomes: Overview and Analysis of Selected International NGO Experiences to Advance the Field

The Role of Social Accountability in Improving Health Outcomes: Overview and Analysis of Selected International NGO Experiences to Advance the Field

The 1993 World Development Report (WDR), Investing in Health, deemed strengthening accountability as one of the core elements of health sector reform. Engaging communities and community-based workers in the process of measuring health status of children, in assessing causes of deaths, in defining high- risk groups, and in measuring changes in mortality over time will enable governments to achieve levels of under-5 mortality according to their commitments.

Models involving International NGOs that used a social accountability approach in various sectors and at different levels including community, district, and national level, were reviewed as part of this paper and are presented regarding the processes undertaken to increase accountability and improve health outcomes. This paper presents common themes, challenges, and recommendations to expand and bring this approach to scale in the context of health and development.

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Citizen Voice and Action: Guidance Notes

Citizen Voice and Action: Guidance Notes

Citizen Voice and Action is an approach that aims to increase dialogue between ordinary citizens and organisations that provide services to the public. It also aims to improve accountability from the administrative and political sections of government (both national and local) in order to improve the delivery of public services. 

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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

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

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.

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Institutionalising Social Accountability in Devolved Governance

Institutionalising Social Accountability in Devolved Governance

Kenya’s adoption of the devolved system of governance places citizens at the core of governance and with elevated hopes for improvement in the delivery of public services. Being cognizant that among the objects of Kenya’s devolution are: to give powers of self-governance to citizens and enhance their participation in the exercise of the powers of State and in making decisions affecting them; to recognise the right of communities to manage their own affairs and to further their development; and to promote social and economic development and the provision of proximate, easily accessible services throughout Kenya. A fundamental principle of democracy is that citizens have the right to exact accountability and public officials have a duty to be accountable.

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Power to the People: Evidence from a Randomized Field Experiment of a Community-Based Monitoring Project in Uganda

Strengthening the relationship of accountability between health service providers and citizens is by many people viewed as critical for improving access to and quality of health care. How this is to be achieved, and whether it works, however, remain open questions.

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From Corporate Governance to Local Governance: Stakeholder‐Driven Community Score‐Cards for UK Local Agencies?

This paper compares the methodology of the “comprehensive performance assessment”, recently proposed by the Audit Commission for all UK local authorities, with the “community score‐card” approach which has been used in the United States of America for a number of years. It suggests that the Audit Commission approach should be altered to take on board some of the more imaginative aspects of the community score‐card, particularly in relation to the inclusion of those quality of life measures, which local people regard as important, and measures of the quality of local governance.

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