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Category: Policy Briefs

Description

Social accountability refers to “an approach towards building accountability that relies on civic engagement, i.e. in which it is ordinary citizens and/or civil society organizations who participate directly or indirectly in exacting accountability” (Malena et al., 2004:3). Social accountability tools and methods remain instruments of broader processes of social mobilization, voice, engagement and negotiation in the public sphere to improve effective planning for services, the functioning of services or service outcomes. This includes a growing emphasis on beneficiary engagement in monitoring and assessing government performance—particularly in providing feedback on, and voicing demand for, improved service delivery—and thus contributing to greater service effectiveness.
This kind of engagement—also referred to as social accountability—enables beneficiaries and civil society groups to engage with policymakers and service providers to bring about greater accountability and responsiveness of health services to specific beneficiary needs.
AGHA over time has used the strategy of community score cards to assess and strengthen health service delivery improvement advocacy in two districts of Pallisa and Lyantonde - all rural hard to reach and live districts. Community scorecards have been proved to increase transparency (through access to information about health related entitlements as nuanced in the national health policy and Uganda National Minimum Healthcare Package), strengthen citizen voice (through the scorecard process and interface meetings) and support user monitoring and oversight (through the development and monitoring of joint action plans). Similarly, support to health user management committees have not only served to mobilize user voice but also support oversight of drug stocks, health workers absentism and health facility budgets.
Process of our community score
Awareness creation and popularisation of Community score cards using community meetings and local radio stations as a process of introducing the conceptual understandi ng of community score cards, objectives but as well manage expectations early
Training of target beneficiaries and service providers on the CSC and data collection process: The training was intended to provided them with the skills and knowledge to analyse and monitor the performance of service providers
Input tracking Matrix: At the local level, objective data on the priority sector identified e.g. health , service scope and, beneficiaries in collaboration with user committee members, and were recorded in a systematic manner using an input tracking matrix which compared available inputs against the national minimum standards.
Community Generated Performance Scorecard: A minimum of 60 community members, the health unit management committee composed of community represenattives together with community members, as well as village leaders, collaboratively generated the scorecard. They are organized into three focus groups (divided into women, men, and the elderly/youth), and at least one third of the community members participating were women. Each focus group scored their service according to their own indicators for service delivery performance and also four standard indicators: access to services, quality of services, engagement of the user committee in financial management, and equal treatment. They scored each indicator using a five-level qualitative scale.
Service Providers Self Evaluation Scorecard: Service providers go through a similar, but separate, exercise to carry out a self-evaluation of the quality of basic services they offered.
Interface Meeting: A meeting to discuss service quality, identify gaps in service provision and manage expectations with regard to service improvements are organized
Joint Service Improvement Plan (JSIP): The collaborative space of the interface meeting allows community members and service providers to work together, negotiate and mutually agree on an action plan to improve services.
Community endorsement of the JSIP: A general assembly is called during which the wider community is given an opportunity to become acquainted with the plan, to propose amendments if needed, and ultimately to approve it.
Line Ministry and local government endorsement of the JSIP: Once approved by community members, the JSIP is shared with all relevant local stakeholders, including local government officials and line ministry staff.

Lessons
Growing space for user voice in health systems: Expanding space for dialogue: Ultimately, the project has opened up space for dialogue on issues that are generally deemed to be too sensitive to discuss publicly in the Uganda context, and shown that it is possible to make progress even in highly restrictive environments.
Improving communication: Some problems arising from lack of information sharing between providers and users or providers and district level authorities can be resolved fairly easily
User awareness of their health rights: Investment in raising users’ awareness about their rights and entitlements scales up utilisation indirectly
Stakeholder engagement: Health district authorities and healthcare providers may not be motivated to make changes if they are not engaged from the beginning of the process or do not face sanctions for inaction. Engagement by local authorities is particularly challenging
Monitoring and Evaluation: Given the experimental nature of many community scorecard interventions, particular attention should be paid to monitoring and evaluation, particularly at the design phase. It is important to invest in developing a theory of change and identifying progress markers or performance indicators which can be tracked over the lifetime of the intervention. By building opportunities for learning about the changes stimulated by these initiatives, the pathways through which they occur and the contextual factors contributing to their success or failure, implementers are able to better understand how social accountability interventions operate and make more informed decisions regarding their scale-up and sustainability
Champions of change: The CSC approach inevitably created grassroots leaders who often challenged local power dynamics and in some areas created tensions and posed threates to existing leaders within the locality. These new champions were viewed as competitors in next elections and animosity was really visible directed towards community score cards champions. It therefore required highly skilled facilitation on the part of program staff

Social accountability in health; AGHA Uganda Community score cards experiences in Pallisa and Lyantonde districts

Social accountability refers to “an approach towards building accountability that relies on civic engagement, i.e. in which it is ordinary citizens and/or civil society organizations who participate directly or indirectly in exacting accountability” (Malena et al., 2004:3). Social accountability tools and methods remain instruments of broader processes of social mobilization, voice, engagement and negotiation in the public sphere to improve effective planning for services, the functioning of services or service outcomes. This includes a growing emphasis on beneficiary engagement in monitoring and assessing government performance—particularly in providing feedback on, and voicing demand for, improved service delivery—and thus contributing to greater service effectiveness.
This kind of engagement—also referred to as social accountability—enables beneficiaries and civil society groups to engage with policymakers and service providers to bring about greater accountability and responsiveness of health services to specific beneficiary needs.
AGHA over time has used the strategy of community score cards to assess and strengthen health service delivery improvement advocacy in two districts of Pallisa and Lyantonde - all rural hard to reach and live districts. Community scorecards have been proved to increase transparency (through access to information about health related entitlements as nuanced in the national health policy and Uganda National Minimum Healthcare Package), strengthen citizen voice (through the scorecard process and interface meetings) and support user monitoring and oversight (through the development and monitoring of joint action plans). Similarly, support to health user management committees have not only served to mobilize user voice but also support oversight of drug stocks, health workers absentism and health facility budgets.
Process of our community score
Awareness creation and popularisation of Community score cards using community meetings and local radio stations as a process of introducing the conceptual understandi ng of community score cards, objectives but as well manage expectations early
Training of target beneficiaries and service providers on the CSC and data collection process: The training was intended to provided them with the skills and knowledge to analyse and monitor the performance of service providers
Input tracking Matrix: At the local level, objective data on the priority sector identified e.g. health , service scope and, beneficiaries in collaboration with user committee members, and were recorded in a systematic manner using an input tracking matrix which compared available inputs against the national minimum standards.
Community Generated Performance Scorecard: A minimum of 60 community members, the health unit management committee composed of community represenattives together with community members, as well as village leaders, collaboratively generated the scorecard. They are organized into three focus groups (divided into women, men, and the elderly/youth), and at least one third of the community members participating were women. Each focus group scored their service according to their own indicators for service delivery performance and also four standard indicators: access to services, quality of services, engagement of the user committee in financial management, and equal treatment. They scored each indicator using a five-level qualitative scale.
Service Providers Self Evaluation Scorecard: Service providers go through a similar, but separate, exercise to carry out a self-evaluation of the quality of basic services they offered.
Interface Meeting: A meeting to discuss service quality, identify gaps in service provision and manage expectations with regard to service improvements are organized
Joint Service Improvement Plan (JSIP): The collaborative space of the interface meeting allows community members and service providers to work together, negotiate and mutually agree on an action plan to improve services.
Community endorsement of the JSIP: A general assembly is called during which the wider community is given an opportunity to become acquainted with the plan, to propose amendments if needed, and ultimately to approve it.
Line Ministry and local government endorsement of the JSIP: Once approved by community members, the JSIP is shared with all relevant local stakeholders, including local government officials and line ministry staff.

Lessons
Growing space for user voice in health systems: Expanding space for dialogue: Ultimately, the project has opened up space for dialogue on issues that are generally deemed to be too sensitive to discuss publicly in the Uganda context, and shown that it is possible to make progress even in highly restrictive environments.
Improving communication: Some problems arising from lack of information sharing between providers and users or providers and district level authorities can be resolved fairly easily
User awareness of their health rights: Investment in raising users’ awareness about their rights and entitlements scales up utilisation indirectly
Stakeholder engagement: Health district authorities and healthcare providers may not be motivated to make changes if they are not engaged from the beginning of the process or do not face sanctions for inaction. Engagement by local authorities is particularly challenging
Monitoring and Evaluation: Given the experimental nature of many community scorecard interventions, particular attention should be paid to monitoring and evaluation, particularly at the design phase. It is important to invest in developing a theory of change and identifying progress markers or performance indicators which can be tracked over the lifetime of the intervention. By building opportunities for learning about the changes stimulated by these initiatives, the pathways through which they occur and the contextual factors contributing to their success or failure, implementers are able to better understand how social accountability interventions operate and make more informed decisions regarding their scale-up and sustainability
Champions of change: The CSC approach inevitably created grassroots leaders who often challenged local power dynamics and in some areas created tensions and posed threates to existing leaders within the locality. These new champions were viewed as competitors in next elections and animosity was really visible directed towards community score cards champions. It therefore required highly skilled facilitation on the part of program staff

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