The community score card tool is a hybrid tool used across sectors to elicit feedback from end users the quality and access to services. It is a two-way and ongoing participatory tool for assessment, planning, monitoring and evaluation of health services bringing together the demand side ("service user") and the supply side ("service provider") to jointly analyze issues underlying health service delivery and find a common and shared way of addressing identified health service delivery bottlenecks.
Through funding from the Open Society Initiative for Eastern Africa (OSIEA), AGHA has been implementing a public health advocacy project in the districts of Pallisa and Lyantonde. During this project the community score card was applied to positively influence the quality, efficiency, and accountability with which health services were provided. At the clinic: Inputs and infrastructure, medical personnel: effort and knowledge, funding, effort in the supply chain and the feedback from the users are critical determinants that shape the quality of health services. However, we also note that heavily centralized planning i.e. planning where the central government determines priorities and local government resources are released to local governments with conditionality can drastically affect social accountability outcomes.
With this approach, we have seen improved health workers’ staffing, change in health workers’ attitude, a four in one staff house constructed at Agule health center III, a new delivery bed provided for Nagwere HC III, electricity finally connected to Agule Health Center III, Community member donated land for development and expansion of Kyenshema health center II, strengthened capacity of health unit management committees, re-orienting radio programming towards community radios to promote health rights.
At the start of the community score card implementation, average health workforce staffing in the two districts was at 69% of approved staffing norms. Cases of absenteeism were rampant and led to a deterioration of relations with communities due to workload. However, over the implementation period over 70% posts of approved norms have filled in Pallisa and 82% filled in Lyantonde district. Major staffing increments were also achieved at health center III levels with each having an average staffing of 84% of approved posts by 2017.
The Health Service Act, 2001 (under Part IV) spells out the Code of Conduct for all health workers in Uganda. Under Section 30 of this Act, a health worker is obliged to take the health, safety, and interest of patients to be of paramount importance at all times and in all circumstances, and to ensure that no health worker's action or omission is detrimental to the patient. Section 30(7) makes it illegal for a health worker to ask for, or accept, a bribe; while Section 30(9) provides that a health worker shall not abandon a patient under his or her care. Over the period there has been a noted improvement in relations between health workers and communities in some incidences health workers have had to be transferred away arising from poor workmanship. This improved relation is mainly a result of the feedback given by communities on health workers attitude to work and towards patients.
Through the efforts of community score card assessment and advocacy, additional 04 in one staff house has been constructed at Agule health center III in Pallisa district. This brings to a total of 06 staff houses at the health facility that previously had only a 02 in one dilapidated house. Once the new block is completed, it will go a long way in motivating health workers and improving health service delivery at the sub county as a result of more health workers residing within the health facility. At the start of the community score card joint assessments in Pallisa, Agule health center III was noted to be one of the facilities with the lowest number of staff accommodated at the health facility compared to the other health facilities with just 02 in one dilapidated staff house accommodating the Midwives.
At the introduction of a community score card assessments at Nagwere Health center III, the midwife continued to use an examination couch as a delivery bed visibly old and rusted having served for a very long period 15 years to be specific. To date, the delivery bed has been assembled and currently being used to conduct deliveries at the health facility.
Up to the period before the community score card in Agule health center III, the maternity section, Outpatient department and staff quarters lacked lighting and according to an eye witness account of the local council chairperson III of the sub county, she had had encounters where deliveries were conducted using a mobile phone flash light. At the review of action plan after 03 months of implementation, the sub county purchased a solar panel for the maternity and in financial Year 2016/17, the sub county budgeted 08 million for wiring and connection of electricity to the health center III –covering the outpatient department, maternity ward and staff quarters.
Located just 30kms away from Lyantonde town headquarters, Kyenshema health center II is a community identified and rented facility that provides basic health services. By every measure of health facility infrastructure, the facility did not meet the basic minimum standards of a public health facility. Together with the local leadership, the score card assessment rated every indicator on infrastructure Bad. For the success and community ownership of the initiative, the area local leaders were put at the forefront of leading the discussion. From the three community meetings conducted so far, the community has contributed land equivalent to two Acres, ten pieces of iron sheets and 17 bags of cement ten bags of cement and 03 trips of sand. The sub county has assumed the responsibility for the initiative of this community initiated the project that will help elevate the poor infrastructure at kyenshema health centre II to kick start the construction process that will relieve the community from monthly rent for the current structure but also provide additional modest accommodation for the 02 health workers at the facility.
At the initiation of the community score cards in Pallisa and Lyantonde districts, assessment of the health unit management committees as oversight bodies of the health facilities showed weak capacities to play their roles effectively. Some committees were not fully constituted, lacked minutes of their meetings and did not provide regular updates to the sub county councils that constituted and approved them to assist in overseeing health service delivery at the health facility on their behalf. Across the facilities assessed, only 20% had records of committee meetings and in all facilities assessed, none of the committees provided documented reports to the sub county. Together with the respective district health offices, partnership plans were developed to conduct training of HUMCs at respective health facilities on the roles and responsibilities of health unit management committees and where they were not fully constituted, the sub counties were tasked with fully constituting the committees at health facilities. A two week’s training schedule was then developed and facilitated by both the district health office and AGHA Uganda. To date, 95% of HUMC committees have reported improvements in their oversight functions and have verifiable reports of their meetings. Health unit management committees now provide regular updates to the sub county councils about the status of health facilities and according to a poll question survey conducted by AGHA in partnership with the local radio stations in the districts, when asked where they prefer reporting their cases health right violation, majority preferred reporting to the health unit management committees.
As AGHA – Uganda, we have come to a tested conclusion that service delivery outcomes are influenced by the relationships of accountability between policymakers, service providers, and citizens.