GLOBAL HEALTH & WASH - WHO · academic studies support social accountability as one of the best...

GLOBAL HEALTH & WASH

COMMUNITY-LEVEL ACCOUNTABILITY MECHANISMS

A WORLD VISION BRIEFING PAPER FOR THE PARTNERSHIP FOR MATERNAL, NEWBORN AND CHILD HEALTH

© World Vision International 2012

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GLOBAL HEALTH & WASH | COMMUNITY-LEVEL ACCOUNTABILITY MECHANISMS

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INTRODUCTION

Millions of children around the world are dying from preventable diseases. Millions more are missing out on their right to education. Despite government commitments to health and education, communities too often either miss out on essential services or must make do with substandard or inadequate services.

Governments, donors, non-government organisations (NGOs) and multilateral institutions frequently grapple with the difficult question of how to best deliver health interventions, especially regarding child survival and child well-being, in low-resource contexts.

Most major multilateral donors, the World Bank and a growing body of academic studies support social accountability as one of the best tools for supporting sustainable community development.

World Vision introduced the Citizen Voice and Action (CVA) approach in 2005, aiming to address weak accountability of essential services, particularly health and education. By June 2012, World Vision had initiated CVA methodology in 200 community programmes in more than 20 countries around the world.1 World Vision is able to leverage its broad geographic presence and grassroots connectivity to facilitate this community-based monitoring of essential services. CVA provides the opportunity to sustainably address the root causes of poverty while making a unique, and very practical, contribution to the field of human rights.

This briefing will consider evidence of the impact of community-level monitoring on the implementation of health policies as well as the quality of those services. The briefing will consider academic research into a large-scale community monitoring project in Uganda. It will also outline World Vision’s experience with social accountability through the CVA model. Two case studies from high-burden countries, India and Uganda, will highlight the impact of community monitoring both in the local context and at the national level. Finally, the briefing will conclude with discussion of the implications for all maternal, newborn and child health stakeholders.

1 CVA operates in communities in more than 20 countries including Armenia , Albania, Georgia, Pakistan, India, Indonesia , Philippines, Cambodia, Kenya, Malawi, Mozambique, Senegal, Sierra Leone, South Africa, Tanzania, Uganda, Zambia, Bolivia, Brazil and Peru.


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HOW CAN ACCOUNTABILITY MECHANISMS STRENGTHEN HEALTH SYSTEMS?

A recent influential randomised control trial of community-based monitoring in Uganda has shown that social accountability is an effective approach that can be used for significant and measurable improvements in the delivery of essential health services.2 The focus of the paper was to find a mechanism of accountability which enabled (poor) people to scrutinise whether or not those in authority have fulfilled their health responsibilities.

The study showed that the increase in monitoring and the improvement in provision of health services resulted in improved quantity and quality of care. A year after the intervention there was a significant difference in the weight of infants and a 33 per cent reduction in under-5 mortality. Use of general outpatient services was 20 per cent higher. Children and infants were significantly more likely to have received their vaccinations, and households in the treatment communities switched from traditional healers and self-treatment to the project facility.

In particular, the study found that the most vulnerable children benefitted from the community monitoring project. The increase in child weight was most evident for underweight children. Underweight children are at a higher risk of suffering from infectious diseases or of serious complications from infectious diseases; thus the most vulnerable children were helped the most by this intervention.

The project initiated a process of community-based monitoring which was then up to the community to sustain and lead. The project called for broad-based community monitoring. Those who were invited to attend the information sessions were encouraged to spread the word, resulting in a large number of uninvited attendees at the community meetings. Those who were invited represented a broad cross-section of society, including young, old, people with disabilities, women, mothers and leaders.

The focus was on making providers, rather than politicians, accountable. Specifically the project aimed to provide incentives for health workers to carry out their responsibilities through the use of social rewards or sanctions. Unlike other health studies, no new health interventions were introduced and there was no increase in resources available. The only

2 M. Bjorkman and J. Svensson, “Power to the People: Evidence from a randomised field experiment on community-based monitoring in Uganda”, Quarte rly Journal of Economics (May 2009, Vol.124, No.2), 735–769.

Community-based monitoring programmes have delivered substantial and measurable impacts on maternal, newborn and child health without the injection of significant new resources.


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change introduced into the communities was strengthened local accountability.

The study found that a number of elements are essential to ensuring successful improvement of health service provision through social accountability:

• Broad participation appears to be essential for effecting change – previous attempts at monitoring projects found no measurable impact when participation was limited to only one or a handful of people.

• There is a clear link between information dissemination and the coordination of expectations and accountability – after information sessions on patients’ rights and entitlements, communities were encouraged to develop a shared view on how to improve service delivery. This knowledge and coordination of expectations knocked down a significant barrier to individual and group action to pressure and monitor the providers.

• Social rewards and sanctions are key instruments available to the community to boost health workers’ efforts – the study found that the demand-driven mechanism (community monitoring) is more important than the supply-driven mechanism (health workers deciding to exert higher effort once they were informed that their efforts deviated from what was expected).

The study had a catchment population of approximately 55,000 households, showing that community-based monitoring of essential services is a project which can be brought to scale.

WORLD VISION’S CITIZEN VOICE AND ACTION APPROACH

CVA is a local-level advocacy methodology that transforms the dialogue between communities and government in order to improve services such as health and education that impact the daily lives of children and their families. It empowers local civil society to pursue good governance, thus attacking one of the root causes of poverty.

World Vision has found CVA to be transformative in the areas in which it operates. The vigilant work of communities to monitor government commitments tends to transform the behaviour of government. It transforms both citizen and government relations as well as transforming underperforming government systems.


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CVA imagines an activist community where fathers, mothers and children understand precisely what their government has promised to their communities. By using a simple set of tools, the citizens monitor the facilities in their communities and measure the reality against government commitments. It also facilitates a process to ultimately improve those services.

Social accountability models offer a good opportunity to include women and children in the implementation and monitoring of health (and education) services in their communities. The relevance of the services to their daily lives, as well as the use of a simple set of tools, makes participation in the design, implementation and quality of these essential services accessible.

World Vision has found that as essential services improve, so does the relationship between the government and its citizens. Accountability encourages good performance; trust unites duty-bearers and rights holders; and transparency guides decision-making. This transformation strengthens local-level health systems, resulting in improvements to maternal and child health.

The benefits of community-based monitoring can extend beyond the local community. World Vision has found that engaged communities are both likely and able to work with other communities to identify patterns of government failure and to engage provincial and even national governments. Their evidence-based advocacy enables the government and community to build health policy which is based on the real needs of the community. The process creates a clear link between community action and regional and/or national change.

As many NGOs aim to reduce their service delivery work, it is imperative to prepare communities to ensure that governments are able to take over the provision of those services. By facilitating ongoing dialogue about real community needs and priorities, CVA helps to prepare communities for this transition.

HOW CITIZEN VOICE AND ACTION WORKS

CVA is a structured advocacy element which complements other development models. It can be added as a specific project within an existing development design, especially health or education projects, or it can be used as an approach to guide all development work. The process is designed to function cyclically to create and sustain new, effective working


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relationships among communities, service providers and governments over the long term.

Citizen Voice and Action consists of one preparatory stage and three implementation stages.

1. Organisational and staff preparation – In this stage World Vision staff and partners make basic preparations to ensure that the staff capacity and organisational structure and strategy necessary to implement Citizen Voice and Action are in place. This stage includes understanding the political and social context of citizen and governance issues, training staff to facilitate the programme and contextualising Citizen Voice and Action materials. Offices are encouraged to adapt materials to respond appropriately to the civil society spaces that exist locally and to use context analysis tools to better understand local power structures.

2. Enabling citizen engagement – This stage builds the capacity of citizens to engage with issues of governance and provides the foundation for subsequent phases. A series of processes raise awareness of the meaning of citizenship, accountability, good governance and human rights. Citizens learn about how abstract human rights translate into concrete government commitments under national law. For example, the right to health (article 25 of the Universal Declaration of Human Rights) might include a child’s right to receive vaccinations at the local clinic.

3. Engagement via community gathering – This stage involves a series of linked participatory processes that focus on assessing the quality of public services and identifying ways to improve their delivery. Community members, service providers and local government officials are invited to participate. The process is collaborative and not confrontational. There is a series of sessions for the community to meet and gather information, to present findings to service providers and to create collaborative action plans. Community representatives are able to collect information and compare reality with the stated government commitments. Community members use simple tools such as scorecards to determine what an ideal school or health clinic might look like and compare it with reality. Information gathered from the monitoring visits and the scorecards is shared by the community with service providers and government officials. Proposals for improvement are developed at this stage and a joint advocacy action plan is created. This stage facilitates the building of essential relationships among communities, service providers and government.

4. Improving services and influencing policy – In this stage, communities begin to implement their action plans. As a result of their advocacy, communities tend to see marked improvements in the services that they depend upon on a daily basis. This success encourages citizens and other stakeholders to act together to influence policy at both local and higher levels. Often, communities will work with other communities to identify patterns of government failure across large geographic areas. Initial successes tend to encourage communities to repeat monitoring processes and to focus on increasingly complex and challenging issues.


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CITIZEN VOICE AND ACTION IN PRACTICE: CASE STUDIES OF INDIA

Despite ambitious government initiatives for health care and education in India, many children are missing out on these essential services. World Vision India runs a campaign called ‘Fully functional school or Anganwadi is my right’. The primary purpose of the campaign is to encourage children to participate in the facilities available to them and to create an awareness of what they are entitled to. This campaign enabled children to engage local, provincial and national levels of government to deliver on its promises.

Government of India education and health initiatives:

1. The Education for All/Sarva Shiksha Abhiyan (SSA) scheme aims for quality education for 192 million children in 1.1 million habitations across the country. The SSA is an attempt to universalise elementary education through community ownership of the school system. It attempts to be client centred and demand driven. Participation by local government, community and grassroots-level structures is considered an essential requirement.

2. The Integrated Child Development Services (ICDS) scheme aims to improve the nutritional and health status of children aged 0–6 years and lay the foundations for proper psychological, physical and social development of the child. ICDS is the world’s largest community-centred child development programme aimed at the holistic development of children. It aims to provide a package of services comprising supplementary nutrition and growth monitoring, immunisation, health check-ups, health referral services, pre-school education, and health and nutrition education. The belief is that good early child care and development centres could be run from a low-cost model even if located in an angan (courtyard).

a) The mechanism used is the anganwadi (daycare centre)

b) State government runs 1.4 million anganwadis across the country

References:

Ministry of Human Resources Development Department of School Education & Literacy, Government of India (http://mhrd.gov.in/schooleducation ) and Ministry of Women & Child Development, Government of India: Integrated Child Development Services (ICDS) scheme (http://wcd.nic.in/ )

http://mhrd.gov.in/schooleducation

http://wcd.nic.in/

http://wcd.nic.in/


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The campaign used a social audit methodology to enable the ultimate users to enforce accountability and transparency, providing them with an opportunity to scrutinise development initiatives. A social audit is an independent and participatory evaluation of the performance of a public agency or a programme or scheme. The results of the community monitoring were shared with government to help educate government authorities on basic and immediate needs of the community. This process also offered a mechanism for communities and World Vision to join hands with government authorities and likeminded NGOs to meet the needs of ICDS centres and schools.

The main tool used to monitor the two schemes was a pictorial scorecard designed for easy use by children.3 Children were involved in the scorecard assessment as well as in interactions with officials to explain the findings of their research. The children who participated in the data collection were drawn from existing networks of children’s clubs, child parliaments and similar groups that function in World Vision India programmes as well as in other NGOs. Special care was taken to ensure that girls had ample opportunity to participate. The lack of girls’ toilets in many schools has been identified as a barrier to their receiving education. Thus, the existence of girls’ toilet facilities was one of the five types of physical infrastructure monitored by the children.

The report card used a pictorial list of the facilities that each school or anganwadi should have under the SSA and ICDS programmes. The children physically verified that the facilities existed and gave marks on the quality of each component. It was felt that this form of assessment was more appropriate to use with children because ‘structures don’t lie but there is a possibility to mislead children if children were to interview [officials or others in authority]’.4

Children worked in teams, with a teacher or adult guide to accompany them on their assessment visits. Over 20,000 children from different organisations assessed the facilities of the two programmes. Almost 4,000 anganwadis and over 3,500 schools were assessed in 57 parliamentary constituencies across 16 states.

Teacher/adult guides were used to explain the children’s entitlements under the two programmes. They ensured that children were able to use the scorecard appropriately, accompanied the children on their assessment visits and facilitated a meeting between the child volunteers and the village

3 See Annex. 4 Fr. Pallithanam, PARA, Andra Pradesh, coordinator of country-wide campaign.

‘We, the children, came to know about our rights to question. I also acquired knowledge about the sanitation and hygienic situation of the school.’

Class 10 Pupil


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Sarpanch (elected head of a village-level statutory institution of local self-government) to share findings.

Children were also able to observe other features, such as road access to schools and quality of construction, as a part of their assessments. The children were able to identify areas of need in terms of physical infrastructure as well as identifying training and awareness programmes essential to the proper functioning of the two schemes.

The findings of the children’s research were initially presented at the village level and children lobbied for remedial action at that level. Having discovered similar deficiencies across a large number of states, national-level advocacy was also considered appropriate. Twenty-four child representatives went to Delhi to share their findings with the government and the media. Children met with the chairperson of the National Commission for Protection of Child Rights. Children shared their personal experiences and questioned why the money currently allocated was not used effectively.

Children also met with the Minister for Women and Child Development. The Minister asked the children about the solutions they had to offer. The children suggested the encouragement of participation and careful monitoring by communities and more allocation of funds to cover the two programmes. After being told of the disappointing state of pre-school education in anganwadis and the absence of play materials and educational aids for children, the Minister called upon her staff to follow up specifically on this issue. She also promised to follow up the allocation of funds at the state level. A press conference held by the children ensured that their desire for a serious monitoring committee to address funds allocation and budget issues was reported broadly in the press.

Another example from Dingerhedi, a community located approximately a two-and-a-half-hour drive from New Delhi in the state of Haryana in Northern India, demonstrates CVA effectiveness in breaking the barriers to community access to services provided by their government. Dingerhedi is one of the villages in Mewat Area Development Programme, where World Vision introduced CVA in 2008.

Before CVA was introduced, community members were not aware of their entitlements to the Government of India community-level programmes and schemes aimed to enhance access to maternal and child health. For example, before gaining knowledge and advocacy skills through the CVA community capacity enhancement processes, pregnant women paid ambulance drivers to transport them from the village to the hospital to deliver safely, although this is a free government service. In addition, due to

‘When we went and approached the Sarpanch and the BDO [Block Development Officer] and showed our school situation by the scorecard we became hopeful that this will definitely be fulfilled by the government, because we talked about the situation of our school with those people [who can] take steps for solving the problem.’

Class V pupil, Sapanchua Primary School


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lack of funds, some women failed to deliver in government birthing centres and to complete required vaccinations for pregnant women and infants, although the government had a programme to offer a sum of INR1,500 (US$29) to all pregnant women who gave birth in the government birthing centres and another INR1,500 to all mothers who completed the required series of vaccinations for themselves and their infants.

Equipped with negotiation skills and knowledge of their entitlement, the Dingerhedi community took action that has led to increase in health-facility-based skilled birth attendance and vaccination.

An anganwadi teacher interacting with the children. World Vision India has created a model Integrated Child Development Scheme (ICDS) centre (anganwadi centre), which is one of the world’s largest and most unique programmes for early childhood development. Photo: Theodore Sam/ World Vision


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CITIZEN VOICE AND ACTION IN PRACTICE: CASE STUDIES OF UGANDA

In 2005, World Vision Uganda introduced communities, health clinics and local government to an approach aimed at addressing weak accountability of health services. Community dialogue was established with health and government staff over service standards such as staff numbers (including midwives) and drug supplies. Communities assessed the performance of health services through the use of scorecards. The communities themselves generated the content of the scorecards, based on their assessment of the most pressing needs for their own community.

In 13 out of 17 clinics where CVA has been introduced, there has been an increase of between one and 12 staff.5 Of these clinics, four have appointed midwives. In more than half of the clinics, the increase in staff was two or more. In two of the clinics, the number of women attending for antenatal services and to give birth more than doubled in a one-month period.

At Kiyeyi Health Centre in Tororo District (Eastern Region), 230 kilometres east of the capital Kampala, a number of meetings were held where communities were introduced to national government health standards and scored their clinic based on community-generated measures. The meetings came after many months of education campaigns on government standards, civic obligations and entitlements. The meetings involved all the clinic’s stakeholders, including local politicians, clinic staff, government staff and the community. Since the meetings and the community lobbying that followed, staffing has increased from three to eight nurses, including two midwives. The clinic reports that outpatient numbers have increased by 500 a month to 1,500. On average, 15 women a month now give birth at the clinic, triple the number prior to the introduction of the CVA approach, although that number is still very low.

A nurse at Kiyeyi Health Centre directly attributes the recruitment of a second midwife in 2011 to CVA. ‘We had a dialogue [through] CVA last year between the community and the health workers, where we raised a complaint.... We were really so, so impressed when ... we raised that issue and immediately a midwife was brought [in].’

CVA has directly assisted the government to allocate resources in line with community needs. The Tororo District health education promoter said the combined force of the politicians, staff and community lobbying influenced the district’s decision to recruit an additional midwife. ‘When the complaint

5 Many of the clinics had had no new recruitment for more than six years prior to the CVA approach being introduced.


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came to us we saw that they really needed somebody else to go there and support them and that is how we decided to post the midwife.’ In addition, this district health education promoter said CVA had assisted the district to plan services and recruitment.

Similar changes have occurred across the country. Alternative reasons cannot be ruled out for these improvements, but the health workers and district government staff at these clinics credit the CVA approach for significantly contributing to these outcomes. In particular, there is a considerable improvement in the relationship between health workers and the community, which has led to increased health-seeking behaviour, as demonstrated through higher outpatient numbers.

In the Eastern Region, the Mbale District chief administrative officer said, ‘All of us are on our toes now. We are under pressure to deliver and if we don’t, we have to explain why. We are waking up. We have taken them [the community] for granted for a long time.’

Increased staff numbers and improved patient-staff relations have helped to attract substantially higher numbers of outpatients, especially women seeking to give birth at health facilities, receive antenatal care and bring their children for immunisations.

One mother of five first attended the Kiyeyi clinic in 2011 after hearing about it from her friend. She had never been to a health clinic before and had given birth to all of her children in her village. She said during the interviews, ‘[On my first visit] the children improved after they received the treatment. This encouraged me to return for a second visit to the clinic in January 2012 and I brought my two children ... ’

Many NGO health programmes target the knowledge of community and health workers to increase health-seeking behaviour and outcomes, but CVA has also tackled the negative interaction between the community and health workers, which poses a significant barrier to health-seeking behaviour. ‘The attitude towards patients and the attitude towards health workers have greatly improved,’ the Tororo District health education promoter said.

‘Service improvement is something that we are seeing because of this kind of effort from the district and from the community, where people are able to voice their concerns,’ said the medical officer in charge of Mpigi health clinic in Mpigi District, in the Central Region. ‘They [the community] are actually giving us very good feedback. With CVA things are getting better. It is a kind of an auditing system for our input.’


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DISCUSSION, CONCLUSIONS AND IMPLICATIONS FOR MATERNAL, NEWBORN AND CHILD HEALTH STAKEHOLDERS

Community-based social accountability programmes offer governments, donors, NGOs and multilateral institutions an effective method to transform the implementation and quality of essential services, such as health and education, in low-resource contexts.

The social accountability approach offers a number of particular benefits which translate into measureable and sustainable improvements in maternal, newborn and child health and well-being. Social accountability is a particularly effective method to target women and children to be active participants in the services that are essential to their well-being.

The social accountability method develops a functional relationship between citizens and government, or rights holders and duty-bearers. The development of a functional relationship between these actors lays the foundation for a long-term sustainable approach to both the implementation and quality of essential health and education services. It encourages government and local civil society to take ultimate ownership of health and education services.

An approach such as that of CVA operates as a well-structured advocacy element within development project models. It helps to ensure holistic development that recognises government and local civil society as crucial contributors to women’s and children’s health and well-being. It builds sustainable essential service provision by encouraging government and local civil society to take ultimate ownership of health and education services.

The experience of community-based social accountability projects has shown that the link between information dissemination and accountability is clear. When communities have access to information and are aware of their entitlements, they become active advocates for the provision of essential services. Access to information knocks down one of the most important barriers to effective social accountability. However, it is access to information in combination with the development of positive and functional relationships between duty-bearers and rights holders that differentiates social accountability from other forms of monitoring. It is this difference which leads to sustainable improvements in the implementation and quality of essential services and a sense of ownership of the services by both governments or other services providers and communities.

Community-based social accountability offers a grassroots, bottom-up approach. As this approach is still in its infancy, the long-term effects are


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unknown. It is likely that this approach, combined with top-down monitoring and reform, could yield even more effective improvements in the implementation and quality of essential services. This area needs more study.

It is apparent that some contexts are more appropriate than others for a social accountability approach like CVA. Contexts where government resources exist but are not being appropriately used are particularly suitable for a CVA approach. Contexts with severe dependency dynamics are more challenging but arguably are most in need of an approach like CVA. World Vision is currently exploring the use of CVA in fragile contexts. Early evidence suggests that, when properly adapted, CVA can play a positive role in many such places.


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ANNEX

Scorecards from the ‘Fully functional School or Anganwadi is my right’ campaign.

FOR FURTHER INFORMATION

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