Transcript CSC presentation

Community Score Cards
Empowering Marginalised
Communities to Negotiate for
Better Service Delivery
Abhijit Das
Centre for Health & Social Justice, India
Introduction to Presentation
• What is a Community Score Card
• Steps for developing a Community Score
Card based feedback mechanism
• Example of using Community Score Card
methodology –mechanism and results
• Challenges
2
Part 1
What is the Community Score
Card Method
What is a Community Score Card
A Working Definition:
– A Community-owned process
– Where the community collates its experience
– Related to a mandated public service
– Systematically, and
– Presents it to providers and managers of the
public system for feedback, review and
planning
Community Score Card may be used as a
component of Evidence Based Advocacy 4
Score Card : Working definition
• A score card is a summary document of
performance of a system
• The parameters of the score card are drawn
from conditions necessary for the fulfillment of
rights/ needs
• It allows for community experience ( of enjoying
rights or of rights violations) to be converted into
a quantitative measure
• It allows for comparison against a benchmark
• It allows for comparison over time
• Useful of feedback, planning and monitoring
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Some Conditions for success of
CSC
• Community Level Conditions
– Mobilised community with knowledge of its own
health related issues and problems (rights)
– Knowledge of publicly supported health policies and
programmes
– Ability to compile evidence of programme/ policy
implementation
• Service Provision Level Conditions
– Openness to feedback and sense of accountability
– Respect for community and non-judgemental
approach
– Ability to provide quality services
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Key Principles : CSC
• Both parties believe in the developmental nature of
the process, otherwise it can become an
opportunity for preparing a list of complaints or a
confrontation, or tokenism
• Jointly accepted set of parameters for monitoring –
patient charters, Quality of Care standards,
treatment protocols, programme guidelines
• Orientation and capacity building of both parties.
• Programme flexibility to incorporate new
suggestions
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Part 2
Developing a CSC based
Feedback System
Developing CSC based advocacy
• What is the advocacy issue - What is the change
desired in service delivery?
• Services – Mandated by law or policy? Any
Standards and Guidelines? Competency
standards?
• Reach and effect of services? Availability,
Accessibility, Acceptability and Quality of
Services? Community Experiences, Adverse
outcomes?
• Status of the community - Are they aware of
their entitlement/rights? Are they mobilised?
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Steps of Implementing the CSC
methodology
1. Identifying the issue and the evidence base
needed
2. Developing an appropriate methodology for
gathering evidence
3. Mobilising and building capacity in community
to generate the evidence
4. Supporting the process of evidence generation,
collation of Score Cards develop an advocacy
plan
5. Organising interface with providers and
develop a plan of action
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6. Follow up
Community Experience
Poor / Absent Service/
Denial
New Experience of
service delivery
Plan for improved service
delivery – provider and
community responsibilities
outlined
Consolidate New
collective community
experience into a new
score cared
Consolidate collective
community
experience into a
score cared
Share Score Card
with Providers
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Part 3
Using Community Score Cards to
improve service delivery and
utilisation in India
Conditions in India
• Government of India introduced a National Rural
Health Mission (NRHM) in 2005 to provide
equitable, affordable, accountable and effective
primary healthcare to the poor
• It includes provisions for decentralised
management community participation –
including planning and monitoring
• NRHM includes service delivery standards
(Indian Public Health Standards) and Concrete
Service Guarantees that spell out the range of
services that will be available at different levels
of care.
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The Community Monitoring
Process
• Community Monitoring is a process included
within the NRHM to increase community
ownership/accountability.
• It involves a systematic process through which
community members provide feedback about
services to the providers
• The feedback includes parameters which are
included within the range and quality of services
that the provider is expected to provide
• The primary purpose of the feedback is to
improve service delivery
• It was done over 9 states and covered 1600
villages
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Frameworks and Processes




Entitlements under the Maternal
Health Scheme;
Roles and responsibilities of the
Community Health Volunteer
Indian Public Health Standards for
different facilities like Sub centre,
Primary Health Centre, Community
Health Centre
Concrete Service Guarantees,
Citizen’s Charter and so on.
Village Health and Sanitation
Committee Training – Entitlement
Awareness and Frameworks
Community Enquiry
Block Provider’s Orientation
Joint Sharing / Jan
Sanwad
Community Sharing
Community Score
Cards
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Key Activities and Issues
Activities
Orientation of Programme
Managers
Orientation of Health
Providers
Training of Community
Leaders ( Village Health and
Sanitation Committee)
Community Awareness
Community Enquiry
Public Sharing
Key Issues
Maternal Health
Child Health
Disease Surveillance
Curative Care
Untied Funds Utilisation
Quality of Care
Community Participation
Functioning of Community
Volunteer
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Mechanism of Enquiry
Group Discussion
with Women
Group discussion with
Mothers who delivered
recently
Group Discussion
with Community
Maternal Health, Child
Health, Quality of Care,
Commuity Health
Volunteer functioning and
Janani Suraksha Yojana*
Disease Surveillance,
Quality of Care, Untied
Fund Utilisation,
Community
Participation
*a set of services used by the Indian government to reduce maternal & infant mortality
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18 18
Group discussion with Women who
had a recent delivery
Ask each woman
- Did she receive the Ante natal or post natal
service she was supposed to received, including
blood and urine examination
- Did she receive the financial support she was
supposed to receive
- How the nurses and doctors behaved with her at
the hospital
- Whether she had any complications and
whether those complications were treated.
- ….and so on
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Group discussion with Community
on General Health Situation
• Ask the participants about Child Health
– Are immunisation camps regularly held
– Are children regularly weighed
– Is nutritional supplement provided regularly
• Ask the participants about their experience of
the services received and the Quality of Care at
the nearest dispensary
• Ask the participants about the services of the
Community Nurse
……….. And so on
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Converting the results of a Group
Discussion into a Score Card
• Scoring Each sub-question that is discussed is given
a score or a rank. Eg. Does the Community nurse come
regularly to your village – every month- 3, every other
month 2 occassionaly-1, never -0. or Did you receive 2
injections of Tetanus Toxoid injections – Yes- 1, No-0
• Traffic Light - All questions under one broad
heading are scored together. All the questions relating to
maternal health is clubbed together and the scores
added up. This figure is divided by the maximum
possible score for this section. If the answer is more than
75% it is converted to a green Traffic Light, if it is
between 50% and 75% it is converted into a yellow traffic
light, if it is less than 50% it is converted into red traffic
light.
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Filled in Score
Card with
Traffic Lights
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Sharing of the Score Card
Village Sharing
– Sharing of the Community Score Card with
providers
– Planning for Improved Service delivery
Jan Samvad (Public Dialogue)
– Conducted at Block or District level
– Presentation of Cumulative Score Card
– Discussion on implementation of outreach
services, improving facility level service
utilization
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Part 4
Results
Change in Health services in a Public Health Centre
area after six months of monitoring - Maharashtra
October 08
April 09
25
Services showing marked improvement with Community Based Monitoring
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
Good 1 Good 2 Part Sat Part Sat Poor 1
1
2
Anganwadi services: 21%
Good 1 Good 2 Part Sat Part Sat Poor 1
1
2
Poor 2
↑ in good
Poor 2
Untied funds & patient transport:
23% ↑ in good
90
100
80
80
70
60
60
50
40
40
30
20
20
10
0
Good 1 Good 2 Part Sat Part Sat Poor 1 Poor 2
1
2
Public Health Centre staff
behaviour: 42% ↑ in good
0
Good 1
Good 2 Part Sat Part Sat
1
2
Poor 1
Poor 2
Experience of Public Health Centre 26
services: 53% ↑ in good
Changes – Story from Orissa
•
•
•
•
There have been changes in the range of services
provided to women for ante-natal and post natal
services.
In both villages with Community Monitoring and those
without Community Monitoring, village level Fixed
health day, Iron Folic Acid tablet distribution and
Tetanus Toxoid injection was being done but checkups of abdomen, Blood Pressure and measurement of
weight is being done primarily in villages where
Community Monitoring was taking place
Most mothers received counseling in these villages but
not so in other villages
Mothers from villages without Community Monitoring
hardly received any Pre Natal Care or Neo Natal Care
services
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Part 5
Challenges
Challenges
At the Programme/ Macro level
• Scale
• Institutional Inertia
• Time bound programme
At the Implementation /Micro level
• Capacity of Community Leadership and
facilitators
• Get providers ready to listen – not dismiss
• Manage community relationship with providers –
avoid ‘blaming’
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• Follow up
Thank you
Acknowledgements
All members of Advisory Group on Community Action and all State Nodal
Agencies, Special thanks to Maharashtra State Nodal Agency and Bangriposi
Block Nodal Non Government Organization for sharing their results.