Community scorecards for accountability

In Bungoma County, Kenya, the percentage of women who deliver their babies in health facilities is lower than the national average. This is a result of long waiting times at health facilities, disrespect and abuse from health providers, staff shortages, inadequate facilities, and fees for services which should be free.

MANI is using a Community Score Card approach to improve relations between members of the community – the service users – and the health facility staff – the service providers.  The scorecard is a very accessible way to help health facility staff and patients talk about their experiences with health services.

What is the Community Score Card?

The Community Score Card (CSC) is a social accountability approach designed by CARE, and used to monitor the availability, access and quality of public services.  The CSC process provides a framework for discussion and negotiation between community members, service providers, and local officials, who then develop specific actions to address identified concerns or issues. There are five phases: planning and preparation, conducting the score card with the community, conducting the score card with service providers, interface meeting and action planning, and implementation and monitoring.

Improving Accountability at Tongaren Model Health Centre

Tongaren Model Health Centre in Bungoma County was among the first group of facilities to participate in the CSC process in 2016, and is now completing the second cycle in 2017.

Using a scale of 1 to 5, patients score the health centre against specified criteria. A meeting is then organised for patients and other community members and health centre staff to review positive changes and explore the issues which remain challenging for the facility and the community.

As a result of these discussions, many changes were  at the Tongaren Model Health Centre.  Most notably:

• New staff have been hired:  staff shortage was a big problem discussed in the first round. The health centre had only nine nurses, instead of 20 required for such a big catchment area.   Since the first CSC, they have hired one clinical officer and one lab technician.  Shortage of staff is still a big challenge, but both the community and facility noted the progress.
• Uptake of services has improved:  more women are visiting the facility now that they have a new lab technician.  This means lab tests can be done more promptly.
• More health education sessions:   prior to the first CSC there was a lack of community health education.  Now health education sessions take place each morning for the community.
• Improved emergency referrals:  emergency ambulance services should be free for maternity patients, but due to poor ambulance coordination and fuel allocation sometimes patients are asked to pay.  Tongaren Model Health Centre now ensures that fuel is available so that no maternity patient has to pay for ambulance services in an emergency. Fees for other ambulance services are clearly displayed.

During the discussion meeting in June 2017, community members and health centre staff also spoke positively about the changes that have taken place in the maternity ward regarding privacy.  Mothers described the lack of privacy they had previously experienced in the old maternity ward where everything was open, with no private space, and with male workers passing through the labour room when women were giving birth.

Emma, a community member said, “There was a serious problem with the maternity ward, but now things are better.   Before, the maternity room was somewhere that everyone could see and pass by.  Now it’s safe and private if you want to dance around during labour pains.  The maternity room has moved to a different section.  Health staff are much friendlier.   Even with cleanliness there is an improvement.”

Risper, a nurse from the facility added, “Last year there were two male workers here and the mothers didn’t feel their privacy was protected.  These two men were from the same communities as our patients and they were talking about patients outside the facility.   The CSC process has helped a lot – we didn’t know that women didn’t want to be attended by these two men. The CSC process raised a lot of issues, now we give the women hot water and sanitary pads after labour.  We fixed the toilet inside the facility so that women don’t have to go outside.  Male involvement used not to be possible, but now because we have screens around the labour bed, now they accompany their wives.   This process has helped us to find out what mothers think.”

What happens next?

During the meeting, agreed actions are recorded into a plan.  This is a great tool for the facility management and board to use to monitor progress and also to escalate issues with the Ministry of Health.

Chairman of the board at Tongaren Model Health Centre, Mr. Andrew Wekesa, explains how he sees the CSC, “The CSC has made our work straight forward. The action plan that it generates identifies issues that direct our attention and focus. The CSC can work to support other feedback mechanisms such as client exit interviews and client satisfaction surveys. The CSC however remains superior due to capturing more feedback. It goes beyond just the generation of feedback and allows for negotiation over it. In this way, it has improved communication with communities. Prior to CSC, the health facilities had no means of communicating with the public except through funerals.”