The Role of Social
Accountability in Improving
Health Outcomes
OVERVIEW AND ANALYSIS OF SELECTED INTERNATIONAL NGO EXPERIE...
Social accountability
 Involves ongoing, collective action by civil society groups, including NGOs,
to hold public offici...
Critical factors for social accountability
Social Accountability Sourcebook. Chapter 4: Social Accountability in the Healt...
How does it work?
 Social accountability initiatives often interface with varying agencies and
divisions of government.
...
Social accountability and health
 Accountability is a prominent theme of the U.N. Every Woman Every Child
campaign
 Enga...
Overview of selected INGO
approaches
 Citizen Voice and Action, implemented by World Vision
 Partnership Defined Quality...
World Vision: Citizen Voice and Action
Citizen Voice and Action
 Where applied: The site must be a place
where the government is providing
services
 Applicable...
Citizen Voice and Action
 Length of process: The preparation
phase, called “enabling citizen
engagement” can take the lon...
Save the Children: Partnership Defined
Quality
BUILDING SUPPORT
WORKING IN PARTNERSHIP
FOR QUALITY
IMPROVEMENT
COMMUNITY
D...
Partnership Defined Quality
 Where applied: Best in projects lasting
2 years or more, with enough staff and
budget to ade...
Partnership Defined Quality
 How it increases social accountability:
Intended to improve quality at the
community level f...
CARE: The Community Score Card (CSC)
PHASE II: Conducting the Score Card with the
Community
Community Score Card:
• Commun...
The Community Score Card
 Where applied: Used at the local level to
address local-level barriers; the score
card is imple...
The Community Score Card
 How it increases social accountability:
If citizens are empowered; if power
holders are effecti...
Common themes across models (1)
 Preparation and planning
 Involvement of marginalized
populations and the poorest of
th...
Common themes across models (2)
 Interface meetings between
civil society and
governmental/public sector
 Focus on accou...
White Ribbon Alliance
 WRA uses a variety of tools to promote social
accountability, including: participatory budgeting; ...
Recommendations (1)
 Expand existing evidence base: While partners are continuously strengthening
the rigor of their moni...
Recommendations (2)
 Consider critical factors in achieving successful outcomes
 Highlight the importance of community o...
Annex
 References Cited and Additional Resources with Websites
 World Vision, Save the Children, CARE, World Bank, and o...
Questions?
khoffmann@insightglobalhealth.com
Mobile: (202) 247 - 1227
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Evidence of Social Accountability_Kamden Hoffmann_5.7.14

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  • According to the World Bank, there are four factors that are critical to any social accountability program: opportunities for information exchange, dialogue and negotiation between citizens and the state; the willingness and ability to seek government accountability among citizens and civil society; transparency and open information sharing, attitudes, skills and practices supporting listening and constructive engagement among service providers and policy makers with citizens; and anenabling environment, with apolicy, legal and regulatory atmosphere for civic engagement. The figure illustrates the critical factors associated with social accountabilityaccording to the World Bank
  • Bullet 1: Some international non-governmental organization (NGOs), for example, participate in programs and activities to support the involvement of national NGOs and citizens in social accountability processes to strengthen capacity bringing together government and nongovernment actors.Other civil society organizations include advocacy and campaigning, while at the community level, examples exist of local groups enhancing citizenship through awareness of rights and increased capacity for political participation, while social movements have, in some places, successfully pressed for state receptiveness to citizens' rights and agendas
  • Bullet 1: Governments with high maternal and child mortality made commitments to invest in maternal child and newborn health programs to accelerate the rate of mortality decline to contribute to achieving Millennium Development Goals (MDGs) as well as A Promise Renewed – a vision of ending preventable child deaths by 2035. Bullet 2: The post-2015 agenda will presumably change its approach to measuring results and provide many opportunities for strengthened accountability mechanisms that involve citizens in varying capacities.
  • The CORE Group solicited input from partners regarding those using social accountability approaches in their programmatic work. Methods of data collection included key informant interviews among partners and a review of documents shared by partners, which is available in the references section.
  • World Vision’s model seeks to improve the relationship between communities and government, in order to improve services that impact the lives of children and their families. Their view is that each citizen has the right to communicate with, and have a relationship with, their government. Active citizenship and engagement with government helps governments to work effectively and to provide quality services. The approach catalyzes an alliance between community members and government officials, based on those officials who are willing to participate
  • Can be based at a facility, clinic, or school, and expanded from there.
  • Bullet 1: Experience varies from two weeks to one year, depending on the amount of time it takes to engage civil society and/or government involvement. Bullet 4: Most recent evaluation indicators focus on: improved services; increased engagement between citizens and government; and improved relationshipsBullet 5: In some cases, governments at various levels may not inform local officials that they should participate, so there may not be a true willingness to engage
  • PDQ aims to improve quality and accessibility of services, allowing more involvement of the community in defining, implementing and monitoring the quality improvement process. This includes the recognition that quality may be defined from different perspectives among clients and providers. It focuses providers and clients working together as allies to address problems and work to overcome any possible blame.
  • Bullet 1: The process works best at the community level in the catchment area around a health post or health center, however, it could also be used at district levelBullet 3: At least 30% of participants need to be from marginalized groups or else their voices will not be heard.There must be clear identification of two “partners,” meaning a clear group that uses a service, and a clear group that is has the responsibility to provide that service.
  • Bullet 1: The community takes ownership to improve health using existing resources, and client satisfaction and provider performance increases together with overall health status.Bullet 3: Some examples of indicators monitored include: client satisfaction; standard measures of the quality and availability of health services; utilization of health services and promoted health behaviors; and improved equity in health services deliveryBullet 4: Sometimes there can be a lack of investment in the community, mostly due to self-interest and in the case when people involved are not from that particular community, or if providers are not interested in their communities
  • The CSC is an approach that brings together community members, service providers, and local government to identify service utilization and provision challenges, and to mutually generate solutions, and work in partnership to implement and track the effectiveness of those solutions in an ongoing process of improvementCARE’s Governance Programming Framework Theory of Change is the high level 'theory of change' that guide and underpin CARE's governance work, including CARE’s CSC work: If citizens (i.e. health service users) are empowered, if power holders (i.e. health providers and government) are effective, accountable and responsive, if spaces for negotiation are expanded, effective and inclusive, then sustainable and equitable development (i.e. improvement in health care coverage, quality and equity and improved health outcomes) can be achieved.
  • Bullet 1: Evidence from the CSC can be used to take uncovered issues to a higher level. District government are involved throughout the entire CSC process. They help with the preparation and planning, and really are the co-implementers.Bullet 3: For example, youth, reproductive health, maternal health, etc.
  • Bullet 1: The CSC approach can be used to facilitate good governance through promotion of participation, transparency, accountability and informed decision-makingBullet 2: Also will depend on how many staff members are needed to facilitate; The cost of a CSC cycle varies depending on the scale and the scope of the CSC project. The only cost is facilitating the processBullet 3: CARE also ensures measurement of governance outcomes, including improved decision-making, transparency, and accountability. The governance outcomes act as enablers for improved services. ‘Bullet 4: Among government/power holders, questions arise regarding whether the process is beneficial or damaging to them, the amount of time allotted to the process, as well as understanding the benefits of the process. NGOs and civil society may be weary of participating in this process based on perceptions that the process could lead to adversarial relationships with the government
  • Bullet 1:As part of preparation and planning, context analysis or political economy analysis to understand potential challenges that may happen in the process, and development of processes that can mitigate potential conflict among partners and power dynamicsBullet 2: CVA an extension of their regular programming, which involves marginalized groups. CARE and World Vision use their community score card models specifically with marginalized populations. Bullet 3: Through a variety of quantitative and qualitative methods, including score cards and focus groups, bottlenecks and challenges are defined separately by government partners and civil society.
  • Bullet 1:The government/public sector and civil society are brought together to compare perceptions from the problem identification phase. These issues are often disaggregated for marginalized groups. Bullet 2: Indicators are developed and measured that focus on accountability functions such as collective capacity, collective action, community empowerment, budget changes, social cohesion, and social capital. Alongside social accountability indicators, sector specific indicators are developed and measured including access to and quality of health services, primary school enrollment, utilization of health services and promoted health behaviors.Bullet 3: Skilled facilitators with negotiation skills is critical for these activities to succeed. Toolkits and field guides exist for partners in the field to adapt when implementing the activitiesBullet 4: All three organizations have undertaken a level of rigor in evaluating various outcomes of their respective interventions, including RCTs and operations research
  • WRA India is using a Social Watch approach to promote accountability for safe motherhood. Social watch is a ‘people-centered’ strategy that mobilizes civil society to hold governments accountable to their commitments. Social watch techniques mobilize citizens and engage them to hold duty bearers accountable for transforming maternal and newborn health commitments and policies into improved access to quality services. Of the 204 sub-centers and 102 primary health centers assessed under the Deliver Now campaign, results included: an increase in postnatal visits by auxiliary nurse midwives to new mothers and their babies from 15 to 25 percent2013, WRA Uganda launched a campaign to hold the Government accountable to its commitment to provide basic emergency obstetric and newborn care (EmONC) at all health centres and comprehensive emergency obstetric and newborn care (CEmONC) at 50% of health centreIvs. As part of the campaign efforts, WRA- Uganda, in partnership with the Kabale, Lira and Mityana District Local Governments, organized participatory Health Facility Assessments using checklists to evaluate the provision of Emergency Obstetric and Newborn Care Provision (EmONC).
  • Bullet 3: An emphasis on identification of these barriers could help develop solutions for more effective scale up.
  • Bullet 1: This refers to the elements discussed at the beginning of the presentation 1) citizen-state bridging mechanisms; 2) ability and willingness of citizens–and their representatives/civil society organizations (CSOs)–to engage in effective social accountability and demand government and service provider accountability; 3) ability and willingness of the state–politicians and bureaucrats–and service providers to be accountable and responsive to the public and civil society; 4) and presence of a broader enabling environmentBullet 2: While building community capacity at the local level allows for community ownership, the data generated may not be significant at a national levelBullet 3: It may be helpful to create a database of terms as the World Bank has done in their glossary of Social Accountability Tools and Approaches. It may be beneficial to develop an information repository that contains such a glossary, as well as the evidence-based articles, theoretical and practical tools available among organizations for practitioners,allowing for an opportunity to build synergy, and harnessing a repository of lessons learned. Bullet 4: For example, elements may include World Vision’s ability to bring the CVA approach within area development programs, CARE’s repeated score card process for institutionalization, and Save the Children’s focus on tested indicators for community capacity.
  • Evidence of Social Accountability_Kamden Hoffmann_5.7.14

    1. 1. The Role of Social Accountability in Improving Health Outcomes OVERVIEW AND ANALYSIS OF SELECTED INTERNATIONAL NGO EXPERIENCES TO ADVANCE THE FIELD KAMDEN HOFFMANN, PHD, MA, INSIGHT HEALTH, LLC CONSULTANT TO THE CORE GROUP MAY 7, 2014
    2. 2. Social accountability  Involves ongoing, collective action by civil society groups, including NGOs, to hold public officials and service providers accountable for the provision of public goods  Affirming and operationalizing direct accountability relationships between citizens and the state  Broad range of actions and mechanisms beyond voting that citizens can use to hold the state to account, as well as actions on the part of government, civil society, media and other societal actors that promote or facilitate these efforts Social Accountability Sourcebook, Chapter 2. Social Accountability: What Does it Mean for the World Bank? 2002
    3. 3. Critical factors for social accountability Social Accountability Sourcebook. Chapter 4: Social Accountability in the Health Sector. Participatory Public Expenditure Management at the National Level. World Bank. 2002.
    4. 4. How does it work?  Social accountability initiatives often interface with varying agencies and divisions of government.  The United States Agency for International Development (USAID) emphasizes the importance of participation and inclusion of citizens in governance and prioritizes this within the USAID Strategy on Democracy, Human Rights, and Governance, with a strong focus on citizen engagement and accountability
    5. 5. Social accountability and health  Accountability is a prominent theme of the U.N. Every Woman Every Child campaign  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
    6. 6. Overview of selected INGO approaches  Citizen Voice and Action, implemented by World Vision  Partnership Defined Quality, implemented by Save the Children  The Community Score Card, implemented by CARE  White Ribbon Alliance, various approaches
    7. 7. World Vision: Citizen Voice and Action
    8. 8. Citizen Voice and Action  Where applied: The site must be a place where the government is providing services  Applicable sectors: Agenda-neutral process; has been applied in education and health, HIV/AIDS, water and sanitation, and is now expanding into the private sector  Who is involved: World Vision may facilitate with the objective of handing over to local partners. World Vision identifies an existing group and equips them with the tools needed to carry out CVA, .e.g. a local CBO, village committee, etc. Constructive evidence based dialogue in order to improve government services, government performance, and relationships Catalyzes alliances between community and key government officials CVA encourages collective action, driven and managed by civil society Embedded within Area Development Programs Ability to leverage ongoing work for greater impact Existing relationships provide groundwork for institutionalization of programming
    9. 9. Citizen Voice and Action  Length of process: The preparation phase, called “enabling citizen engagement” can take the longest, as it depends on the level of civil society development  How it increases social accountability: CVA equips citizens to engage in evidence-based dialogue with health workers and local government in order to improve the accountability of health services  Financial considerations: Costs range per program, per year. Costs decline significantly over time as citizens drive the bulk of the process  Monitoring and evaluation: World Vision builds the CVA process into its existing Area Development Programs (ADP); evaluation is built into the design of the ADPs  Challenges or barriers to implementation: The enabling environment is the key to implementation.
    10. 10. Save the Children: Partnership Defined Quality BUILDING SUPPORT WORKING IN PARTNERSHIP FOR QUALITY IMPROVEMENT COMMUNITY DEFINED QUALITY HEALTH WORKER DEFINED QUALITY Better Health Improve provider job satisfaction Improve client satisfaction Increase communities’ sense of ownership of health facility Increase community capacity for social change Shared rights and responsibilities for better health outcomes BRIDGING THE GAP
    11. 11. Partnership Defined Quality  Where applied: Best in projects lasting 2 years or more, with enough staff and budget to adequately support the PDQ process as related to the size of the catchment area involved  Applicable sectors: Health, adapted in education (including non-formal education), youth, adolescent sexual and reproductive health, and HIV/AIDS  Who is involved: Led by project staff members who are working to improve the quality of services in order to achieve project outcomes.  Community based solutions with community resources, with limited external financial support and outside solutions, for social change  “Duty bearers” – rights based work  Quality Improvement Teams (QITs) are a key component  Builds on community capacity, organically grows as the PDQ process is carried out in the community  As quality has very different meanings, quality is defined by the partners in the context of their community setting, e.g. what keeps people from going to the health center?
    12. 12. Partnership Defined Quality  How it increases social accountability: Intended to improve quality at the community level from the perspective of the consumer (client) and more than anything, the marginalized client. Marginalized members address duty bearers  Financial considerations: Intends to use local solutions to community- provider challenges. While costs can range depending on the context, many of the PDQ programs have used local resources as a result of this process  Monitoring and evaluation: The PDQ Monitoring and Evaluation Toolkit provides a set of tools including supervisory checklists, mapping tools and an exit interview to support the implementation of PDQ  Challenges or barriers to implementation: It is intensive and time consuming. Frequent transfers in health staff, lack of political will and commitment to the PDQ process can deter successful implementation.
    13. 13. CARE: The Community Score Card (CSC) PHASE II: Conducting the Score Card with the Community Community Score Card: • Community level assessment of priority issues in one village – what are the barriers to accessibility and delivery of quality services • Develop indicators for assessing priority issues • Complete the Score Card by scoring against each indicator and giving reason for the scores • Generate suggestions for improvement = complete community Score Card for the village Cluster consolidation meeting: • Feedback from process • Consolidate scores for each indicator to come up with representative score for entire village • Consolidate community priority issues and suggestions for improvement = complete (consolidated) Score Card for the cluster PHASE IV: Interface Meeting and Action Planning PHASE I: PLANNING AND PREPARATION PHASE III: Conducting the Score Card with Service Providers • Conduct general assessment of health service provision – what are the barriers to delivery of quality health services? • Develop indicators for quality health service provision • Complete Score Card by scoring against each indicator • Identify priority health issues • Generate suggestions for improvement Repeatcycle CSC Process PHASE V: Action Plan Implementation and M&E • Execute action plan • Monitor and evaluate actions • Repeat cycles to ensure institutionalization Action planning: • Develop detailed action plan from the prioritized issues – agreed/negotiated action plan • Agree on responsibilities for activities in the action plan and set time frames for the activities Interface meeting: • Community at large, community leaders, committee members, health center staff, district officials and process facilitators • Communities and health center staff present their findings from the Score Cards • Communities and health center staff present identified priority health issues • Prioritize the issues together (in a negotiated way)
    14. 14. The Community Score Card  Where applied: Used at the local level to address local-level barriers; the score card is implemented at the intersection between the community and health facility; however, in other sectors this can vary  Applicable sectors: Food security, education, health, HIV/AIDS, infrastructure, agriculture, water and sanitation, gender based violence  Who is involved: Participants in the CSC process is dependent on the focal issue and the improvements and/or changes anticipated  CARE’s Governance Programming Framework reflects a theory of change, grounded in both the literature and practical experience in social accountability  Underlying principles for a rights based approach include Participation and inclusion of voice; Accountability and transparency; Equity; and Shared responsibility and obligation  Community Score Card (CSC) is also used as an internal or forward accountability mechanism to gain feedback on CARE’s accountability from communities  CSC repeated measurement: continuous feedback loop for monitoring and evaluation every six months and institutionalization of process
    15. 15. The Community Score Card  How it increases social accountability: If citizens are empowered; if power holders are effective, accountable and responsive; if spaces for negotiation are expanded, effective and inclusive; then sustainable and equitable development can be achieved  Financial considerations: Dependent upon what unit the score card is done at, e.g. one facility in a catchment area, and what part of the process, e.g. preparation and planning or issue generation  Monitoring and evaluation: CSC process focuses on improved services as an outcome, and improved human development as an impact  Challenges or barriers to implementation: Fear of negative fallout among providers and/or citizens; lack of supervisory support for providers after changes are initiated;
    16. 16. Common themes across models (1)  Preparation and planning  Involvement of marginalized populations and the poorest of the poor  Identification of barriers from civil society and governmental/public sector  Established presence for entrée: World Vision’s Area Development Program is their process of implementing long- term (15 years), local programming that contributes to the sustained well-being of the population. The approach supports local advocacy. World Vision incorporates CVA directly into the Area Development Programs where trust and alliances may already exist due to World Vision’s presence. Save the Children also seeks to implement PDQ in communities where long term programming is established. This includes communities with child sponsorship funding, where Save the Children is typically in a community for 10-15 years. The reason this is effective is that the implementing NGO (in this case Save the Children) becomes a trusted partner for long term change. Save the Children has adapted PDQ for use with adolescents in many of its sponsorship communities worldwide. CARE incorporates the CSC into its projects and programs.
    17. 17. Common themes across models (2)  Interface meetings between civil society and governmental/public sector  Focus on accountability and health outcomes measurement  Facilitation and guides  Rigor of evaluation of interventions  Value of a score card in measuring services: CARE developed the community score card; World Vision adapted the score card in its CVA approach, and PDQ uses another method of scoring. A score card allows for both users of public services as well as providers of public services to use a simple method of assessing the performance of service delivery and offering proposals to improve the quality of service. The score card data is usually collected through focus group discussions among particular interest groups, e.g. women, men, youth, children, community leaders, PLWH/A, health center committee, etc. The score cards help develop a set of indicators for monitoring and evaluation, and can also serve as a baseline for service improvement. The scorecard can be used as a tool to generate issues to advocate for to help integrate some solutions into local policies and systems for sustainability of results. In addition, community member’s health behaviors and actions can be evaluated.
    18. 18. White Ribbon Alliance  WRA uses a variety of tools to promote social accountability, including: participatory budgeting; social audits; participatory planning; public expenditure tracking surveys; citizen report cards/community score cards; budget analysis; citizen-based vigilance committees; public hearings; checklists; and verbal autopsies  Numerous WRA National Alliances have utilized social accountability approaches under several initiatives to increase accountability and improve health outcomes  Social Watch: India  Participatory Health Facility Assessment: Uganda Practical solutions recommended by WRA: Ensuring upfront investment; accessible information made available to citizens (not just donors); direct feedback and communication loops; value placed on local data and evidence; and institutionalization of social accountability approaches into formal mechanisms.
    19. 19. Recommendations (1)  Expand existing evidence base: While partners are continuously strengthening the rigor of their monitoring and evaluation of social accountability interventions, more evidence is needed regarding the effectiveness of different interventions at the community, district, regional, and national levels  Clarify financial and human resource inputs: It would be helpful if partners could formally cost out essential elements in programs for other practitioners and host countries interested in adapting or applying these social accountability interventions  Identify barriers to scale up: State actors are involved in each of these models, however, once action plans are implemented and evaluated, what further involvement should the government have to ensure more sustainable outcomes? This includes a better understanding of the influence of the larger social, economic and donor interests.
    20. 20. Recommendations (2)  Consider critical factors in achieving successful outcomes  Highlight the importance of community owned progress: it is very important for communities implementing the changes to identify their role in ongoing, measureable improvements in outcomes in order to continue their involvement and ownership of the process  Develop similar definitions and a central location for well-known social accountability approaches in health and development  Explore highlights among different models for promising practices: Each model reviewed by this analysis is comprised of unique elements that merit further exploration. To the extent possible, these elements should be analyzed further for their effectiveness and sustainability
    21. 21. Annex  References Cited and Additional Resources with Websites  World Vision, Save the Children, CARE, World Bank, and others  Case studies  Tables of key elements and activities among the social accountability models
    22. 22. Questions? khoffmann@insightglobalhealth.com Mobile: (202) 247 - 1227

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