Evidence of Social Accountability_Geraldine McCrossan_5.7.14
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  • Talking Points Will use this slide to go through the various aspects of the projectCitizen report Cards (CRC- ) how they are developed and disseminated to the community Interface meetings – who attends – where they take place Action Plans- how they are developed and what happens to themLight touch Monitoring – what it is and why it is necessary
  • Talking PointsIn the Bugiri Pilot of the ACT Health Program: Blank households surveyed for the development of the Citizens Report Card, which gives information on service delivery and citizens perceptions of service delivery for each health centre (and corresponding target communities) in the program. The estimated population of the subcounties that would be considered in the catchment areas of the clinics involved is 426,800 (estimated for 2012). The 5,912 sample size, then, represents 1.4% of the total population in the clinic catchment areas.
  • Talking Points Other questions include : Utilisation Patterns ; Where does the community go , how the health centres pattern differ (local , district and national), why do the community not go Community’s utilisation of antenatal care, immunization and family planning services Services in general: Attendance community perception and day of the survey,
  • Talking PointsIn the Bugiri Pilot of the ACT Health Program: 2718 participants were engaged in the development of action plans to improve the quality of service delivery at their local health centerWe do not have information about proportions of community members vs. health workers involved in action plan development. We do have the 2,718 disaggregated by gender, though: 1,313 males and 1,405 females
  • The whole essence of my presentation in the community voice so this is an important slide in terms of looking at that aspect and each step of the processTalking PointsIn the Bugiri Pilot of the ACT Health Program: Blank most significant change stories collection, which explain and describe how and why changes have occurred in the lives of participants over the course of the program.
  • Talking PointsThe use of Most Significant Change stories in the monitoring and evaluation of ACT Health not only explains and describes why and how changes have occurred in the lives of participants over the course of the program, but does the following things: Tracks unexpected outcomes from program implementationTracks outcomes noted in the ACT health theory of change that the can either not be measured quantitatively, or that the program is not clear can be affected by the interventionFacilitates community involvement in the tracking and documentation of changes in the targeted programme areas, in other words, in monitoring and evaluation of the programFacilitate the programme desired light touch qualitative monitoring which allows the partners to take the lead in tracking activitiesContributes to a final program evaluation
  • Talking PointsMost Significant Change stories are collected in the following way: Stories are collected through in-depth interviews with a number of program participants including community members, community leaders, health workers, and village health team members, among others1 story is collected per month from each health facility (33 facilities times 6 blank comes to 198 stories collected per what unit during the Bugiri PilotThe analysis of MSC stories categories each story into one of four domains: Changes in service quality (for example reduced waiting time, polite health workers) Changes in relationships between service providers and community members (for examples better communication between health facility staff and community) Changes in health outcomes (for example, HUMC members supervise the health facility, or an increase in the number of community members visiting the health facility) Other changes
  • What is a domain?Changes in service qualityChanges in the community/service provider relationshipChanges in health outcomes Other changes.
  • The quality of services at Nabukalu HC III was for long poor because the in charge was rarely at the centre and as a result most of the health workers used to neglect duty and came late for work. This made it difficult for the community to access drugs and there were cases of pregnant mothers delivering outside the health centre because midwives were not available. Community members lost confidence in seeking health services from the health centre. In May 2013 I attended and presented these issues at the interface meeting in which the community, health workers and sub-county leaders were present.
  • “I live in Nabukalu sub-county near the health centre and my neighbor is a traditional birth attendant who delivered many babies at her home. I asked these mothers why they preferred delivering at the traditional birth attendant and not the health centre and they gave the same reason. For a long time the midwives at Nabukalu HC III were arrogant, rude to patients and asked for money especially from the mothers and insulted anyone who tried to caution them. I once witnessed a pregnant mother in labor being ignored by a midwife. When her husband raised the complaint to the chairperson of the Health Unit Management Committee the woman was rebuked by health workers to the extent that at every visit after her delivery, she was told to seek treatment from the chairperson. This made mothers hesitant to deliver at the centre.
  • FG: on what evidence did we base this decision? (Pilot still running and not proven?) this might come up as a question and we need to be prepared for it
  • Developed the approachSuccessfully implemented the Bugiri Pilot

Transcript

  • 1. Global Health Practitioners Meeting “Health Starts at the Community” Silver Springs May 5th -9th 2014
  • 2. ACT Health Premise Changes within Society (Empowerment of Individuals) Changes within State (Inclusive and Responsive Institutions) Changes at State & Society Interface (Space for participation and collective Voice) Increased Accountability and Responsiveness
  • 3. Where  Pilot in Bugiri District Eastern Uganda  Population : 426, 800  33 Health Facilities  5 National partners  Started January 2012
  • 4. Community Voices – First phase • 5,912 Households surveyed for development of the CRC CRC
  • 5. Citizen Report Card (CRC) Excerpt Attendance of Health Staff at health centers Percentage of households who said staff are always at work 43% Percentage of households who said staff occasionally do not come to work 36% Percentage of households who said staff are rarely at work 21% Household rating of medical staff attendance at government health centers Medical staff attendance at government health centers on survey day Total number of medical staff allocated to government health centers II. (National Standard; 3medical staff per HC II X 23= 69) 52 (75% of what is required) Total number of medical staff present in the health centers on the survey days 43 (83%) Total number of medical staff out for outreach and/or training on the survey day 0 (0%) Total number of medical staff out on leave on the survey day 6 (12%) Total staff absent 3 (6%)
  • 6. Community Voices Second Phase • 5,912 Households surveyed for development of the CRC CRC •2718 engaged in action plan development Interface Meetings /Action Plans
  • 7. A sample Action Plan Issue Action (incl timeline & person responsible) Status of action Challenges Proposals or Changes to actions Community unaware of the services offered at the H/C The HUMC to establish the sign post not exceeding August 2013 Not achieved Inadequate and delayed release of PHC fund The in charge should prioritize the issue of establishing a sign post and act accordingly upon receiving PHC fund 1st April 2014 HUMC, Local leaders and VHTs to inform community about the services offered during static days at the H/C Achieved done every Tuesday and Thursdays in the week None HUMC and in charge should write on manila papers the services offered at the health facility and pin it against the walls by the 30th of Feb 2014 Health workers to make appropriate referrals Achieved by health workers explaining to the clients why they are referred to other Health facilities None No change to the proposal H/C closed when H/Ws go for outreaches/workshops At least one health work should be left at the H/C effective August 2013. Achieved as a health worker is always left behind Community members come at the health centre during time of closure The VHTS should always inform the Community members to visit the H/C in the right operating hours i.e. from 8:00am-5:pm effective 14th/02/2014
  • 8. Community Voices Third Phase • 5,912 Households surveyed for development of the CRC CRC •2718 engaged in action plan development Action Plans • 25 most significant change stories collected Results
  • 9. Why Most Significant Change (MSC) Stories • Facilitate community involvement in monitoring and evaluation • Track unexpected outcomes • Support the light touch monitoring approach • Contribute to program evaluation
  • 10. MSC Collection and Analysis • In-depth interviews with people are household level • 1 story per month from each health facility • Analysis categorizes stories into four domains: • Changes in service quality • Changes in the community/service provider relationship • Changes in health outcomes • Other changes.
  • 11. Final MSC Story Selection MSC collected one story per health facility every six months 33 over six months Categorized in Domains for each health facility one story for each domain 132 stories Regional Stories Chosen 1 story from each domain Final Review of regional stories and a final MSC is chosen every six months
  • 12. Example MSC Name of storyteller: Naigaga Irene When did the change happen? May 2013 Changes in health workers’ supervision improves service quality “In June the in charge was demoted and a new in charge was posted to the health centre. The new in charge is always at the centre and this has resulted into improved service quality because the health workers arrive on time, very active on duty and give appropriate referrals. The high level of supervision has even led to the health workers operating on Sunday which was not the case before. This story is very significant to me because the community can now be sure to find health workers at the health centre and receive health services.”
  • 13. Example MSC Name of storyteller: Kagoya Rebecca When did the change happen? May 2013 Improved client care for mothers! I raised the mother’s concerns and they were captured in the action plan. This meeting allowed us present these issues directly to the health workers who were present. The midwives have since improved the way they handle mothers and stopped asking for money. This has increased the number of mothers delivering at the health centre. This story is significant to me because the number of mothers delivering at the centre has increased .”
  • 14. MoH Voices  Health Facility Assessments ( 3 times)  Interface Meetings  MSC  Outcome Mapping  Quarterly Reviews with partners
  • 15. ACT Health Scale Up  16 districts across Uganda  329 health facilities  7 different national partners  In conjunction with an RCT to answer the following research questions:  Does the ACT Health Program lead to greater access to services and an increase in health seeking behavior?  Does the ACT Health Program contribute to downwards accountability among duty-bearers for health services?
  • 16. Scale Up: Community Voices ACT Health scale up has the potential to involve:  150,000 households in CRC  19,800 community members in action plan development and interface meetings  367 MSC stories collected every six months
  • 17. Acknowledgments
  • 18. Questions