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Effects of a community scorecard on improving the local health system in Eastern Democratic Republic of Congo: Qualitative evidence using the most significant change technique


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More than a decade of conflict has weakened the health system in the Democratic Republic of Congo and decreased its ability to respond to the needs of the population. Community scorecards have been conceived as a way to increase accountability and responsiveness of service providers, but there is limited evidence of their effects, particularly in fragile and conflict-affected contexts. This paper describes the implementation of community scorecards within a community-driven reconstruction project in two provinces of eastern Democratic Republic of Congo. Between June 2012 and November 2013, 45 stories of change in the health system were collected from village development committee, health committee, community members (20 men and 18 women) and healthcare providers (n = 7) in 25 sites using the Most Significant Change technique. Stories were analyzed qualitatively for content related to the types and mechanisms of change observed. The most salient changes were related to increased transparency and community participation in health facility management, and improved quality of care. Quality of care included increased access to services, improved patient-provider relationships, improved performance of service providers, and improved maintenance of physical infrastructure. Changes occurred through many different mechanisms including provider actions in response to information, pressure from community representatives, or supervisors; and joint action and improved collaboration by health facility committees and providers. Although it is often assumed that confrontation is a primary mechanism for citizens to change state-provided services, this study demonstrates that healthcare providers may also be motivated to change through other means. Positive experiences of community scorecards can provide a structured space for interface between community members and the health system, allowing users to voice their opinions and preferences and bridge information gaps for both users and frontline healthcare providers. When solutions to problems identified through the scorecard are locally accessible, users and healthcare providers are able to work together to implement mutually acceptable solutions that improve quality of health services, and make them more responsive to users' needs.
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R E S E A R C H Open Access
Effects of a community scorecard on improving
the local health system in Eastern Democratic
Republic of Congo: qualitative evidence using
the most significant change technique
Lara S. Ho
, Guillaume Labrecque
, Isatou Batonon
, Viviana Salsi
and Ruwan Ratnayake
Background: More than a decade of conflict has weakened the health system in the Democratic Republic of
Congo and decreased its ability to respond to the needs of the population. Community scorecards have been
conceived as a way to increase accountability and responsiveness of service providers, but there is limited evidence
of their effects, particularly in fragile and conflict-affected contexts. This paper describes the implementation of
community scorecards within a community-driven reconstruction project in two provinces of eastern Democratic
Republic of Congo.
Methods: Between June 2012 and November 2013, 45 stories of change in the health system were collected from
village development committee, health committee, community members (20 men and 18 women) and healthcare
providers (n= 7) in 25 sites using the Most Significant Change technique. Stories were analyzed qualitatively for
content related to the types and mechanisms of change observed.
Results: The most salient changes were related to increased transparency and community participation in health
facility management, and improved quality of care. Quality of care included increased access to services, improved
patient-provider relationships, improved performance of service providers, and improved maintenance of physical
infrastructure. Changes occurred through many different mechanisms including provider actions in response to
information, pressure from community representatives, or supervisors; and joint action and improved collaboration
by health facility committees and providers.
Conclusions: Although it is often assumed that confrontation is a primary mechanism for citizens to change
state-provided services, this study demonstrates that healthcare providers may also be motivated to change
through other means. Positive experiences of community scorecards can provide a structured space for interface
between community members and the health system, allowing users to voice their opinions and preferences and
bridge information gaps for both users and frontline healthcare providers. When solutions to problems identified
through the scorecard are locally accessible, users and healthcare providers are able to work together to
implement mutually acceptable solutions that improve quality of health services, and make them more
responsive to usersneeds.
Keywords: Community scorecard, Democratic Republic of Congo, Social accountability, Community participation,
Fragile and conflict-affected health systems, Most significant change, Health committee
* Correspondence:
International Rescue Committee, 1730 M Street, Suite 505, Washington, DC
20036, USA
Full list of author information is available at the end of the article
© 2015 Ho et al.
Open Access
This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
( applies to the data made available in this article, unless otherwise stated.
Ho et al. Conflict and Health (2015) 9:27
DOI 10.1186/s13031-015-0055-4
More than a decade of conflict has weakened the already
fragile health system in the Democratic Republic of
Congo (DRC) and decreased its ability to respond to the
needs of the population. In 2013, the DRC ranked last
out of 168 countries on the Human Development Index
[1]. With 74 % of the population living more than five
kilometers from a health center [2], health services are
often inaccessible and essential inputs such as drugs and
personnel are often unavailable. Lack of funds, along
with poor financial management and corruption, have
led to a reliance on high user fees and unofficial pay-
ments by users to help cover staff salaries, operational
costs, and health zone management. The majority of
households have difficulty paying for healthcare [3]. This
translates into low utilization rates [3].
As in many fragile or conflict-affected states, there is
a weak culture of accountability in DRC, characterized
by the absence of a social contract between citizens and
the state [4, 5]. In the health system, there are few
mechanisms through which healthcare providers and
accountable, answer questions from users, or be sanc-
tioned. Weak management and absent accountability
relationships lead to corruption, lack of motivation, ab-
senteeism, poor planning, and inadequate implementa-
tion of health services and policies [6]. There is limited
budget transparency, making it difficult for citizens to
hold the government accountable for spending [7].
Communities, and at times service providers them-
selves, lack information about national health stan-
dards, entitlements, and performance, which limits
their capacity to monitor service delivery and health-
care providersperformance. There are few structured
and non-partisan spaces for users to dialogue with
healthcare providers; in addition, mechanisms to ad-
dress grievances are rare and often seen as ineffective.
Health facility committees can serve as a vehicle for
user feedback and demands for service improvements
[8], but in the DRC these structures are rarely func-
tional or have often been co-opted by service providers.
In this context, efforts to strengthen accountability of
healthcare providers to users are seen as important
given their potential to increase access and improve
service quality [9].
Since 2007 the International Rescue Committee
(IRC) and its partner CARE International, have imple-
mented a large-scale community-driven reconstruc-
tion project in eastern DRC, named Tuungane (Lets
Unitein Kiswahili). The aim of the project is to
ensure that community priorities and well-being are
sustainably supported by a capable and accountable
local governance system. The theory of change postu-
lates that peoplesneedsarebestmetwhenpublic
authorities are capable of providing basic services,
when they are responsive to citizensneeds and prior-
ities, and when the general public can engage in deci-
sion making and hold them to account. Tuungane is
currently implemented in 1,025 communities across
four provinces (Katanga, Maniema, North Kivu, and
South Kivu) and had reached 2.6 million people by
December 2014.
In 2011, Tuungane revised its implementation strategy
to ensure greater sustainability through a focus on ser-
vice delivery and engagement with existing user commit-
tees as well as local authorities. As part of this effort,
Tuungane introduced the Community Scorecard (CSC)
for communities that chose to invest in the education or
health sector. Community scorecards were developed to
increase accountability and responsiveness to users [10]
by providing a space for dialogue between users and ser-
vice providers, with the goal of improving service deliv-
ery. In fragile and conflict-affected contexts where
existing levels of trust and accountability may be low,
CSC may have the potential to make even greater gains,
or alternately may be limited by a lack of confidence and
willingness of communities to engage with state institu-
tions [11]. However, as with many social accountability
interventions, there is limited evidence of the impact of
CSC on the quality and accessibility of services, and on
which factors contribute to their success [12]. Even less
is known about the effects of social accountability tools
in fragile and conflict-affected contexts. Gaventa and
McGee (2013) note that [a] number of good, specific
studies exist, using a range of methods, but there are
[currently] not enough of these, across enough settings
and methods, to begin to point unequivocally to overall
patterns or to draw higher-order conclusions[13].
This paper describes the implementation of a commu-
nity scorecard approach for the health sector in Katanga
and South Kivu provinces in eastern DRC and partici-
pantsperspectives on how it affected service delivery
within the local health system as documented by stories
collected using the Most Significant Change (MSC) tech-
nique, a form of participatory monitoring and evaluation.
Communities included in Tuungane were rural, with
populations ranging from 350 to 8,750. Most inhabitants
who are not service providers (i.e. teachers or healthcare
workers) depend on agriculture for their livelihoods. The
majority of health facilities in target communities were
health posts, under the supervision of a health center
staffed by at least one skilled nurse, as well as auxiliary
staff. The remaining structures were health centers
staffed which should be staff by multiple skilled staff.
Skilled staff in the targeted health structures are likely to
Ho et al. Conflict and Health (2015) 9:27 Page 2 of 11
come from other parts of the province, but auxiliary staff
are most likely to be local staff from the community.
Each community involved was made up of one to three
villages participating in Tuungane.
ACSC siteis a health facility and the community
engaged in the CSC process targeting that facility (13
villages). The sampled CSC sites were located in South
Kivu province (Minova and Kalehe health zones) and
Katanga province (Kambove, Kapalowe, and Kilela
Balanda health zones). These areas were targeted be-
cause they included both conflict-affected and more
stable areas; were accessible to project staff and had
completed at least the baseline scorecard in the CSC
process at the time of the launch of the MSC exercise.
The Tuungane process
Community members in each of the 1,025 communities
were informed that they would receive a 24,000 USD
grant for investment in one of five sectors of their
choosing: health, education, roads, markets, and water &
sanitation. These sectors were pre-selected because of
the technical capacities of the implementing organiza-
tions to ensure effective support to community project
implementation. Tuungane staff facilitated a general as-
sembly to identify a priority sector for investment. At
least 20 % of the community attended, and staff ensured
women, men, elders, girls, boys, and vulnerable popula-
tions were represented. One hundred and fifty-one
(15 % or 151/1,025) communities chose to invest their
funds in the health sector.
Once the priority sector had been identified, each
community elected a Village Development Committee
(VDC) to manage implementation of the infrastructure
and service improvement project. VDCs are composed
of a president, vice-president, secretary, treasurer, and
community mobilizer. Women must hold two or three
of these five positions to ensure a gender balance. There
were five criteria to run for elections: not being a civil
servant or a village chief, not being a member of the
health facility committee (HFC), being at least 18 years
old and being a respected member of the community,
and volunteering for the position. The treasurer and sec-
retary also had to be able to read, write, and count. For
communities choosing the health sector, the VDC was
expanded to include four additional members (2 men
and 2 women) chosen by the HFC from among their
existing HFC members in order to embed the process in
the existing health system structure. In instances where
HFCs were defunct or had exceeded their mandate, the
health zone authorities were engaged by the project to
facilitate new HFC elections. HFCs are mandated by the
DRC Ministry of Public Health (MoPH) and their par-
ticipation in the VDC was considered necessary to en-
sure the sustainability of projects after the end of
Tuungane. It is part of the health zone authoritiesre-
sponsibility to supervise and support HFCs.
The Tuungane Community Scorecard (CSC) process
The CSC involved multiple, participatory steps as shown
in Fig. 1. After election of the VDC, VDC members and
service providers (head nurse, nurses, and other medical
personnel) were trained on the CSC process and data
collection (Step 1). The VDC then compared the MoPH
standards for health facilities to actual available re-
sources using an input tracking matrix (Step 2). Next,
the community generated their performance scorecard,
which involved a minimum of 60 community members
as well as the VDC and HFC members, and the village
leaders. The community participants were a convenience
sample of those interested in the process and/or mobi-
lized ahead of time by the Village Chief and the VDC.
They were organized into three focus groups (divided
into women, men, and the elderly), and at least one third
of the community members participating were required
to be women. Each focus group generated their own in-
dicators and scores for service delivery performance (for
example, cleanliness of the facility, feeling welcomed by
providers, or state of infrastructure). In addition, partici-
pants provided scores for four standard indicators: ac-
cess to services, quality of services, engagement of the
HFC in financial management, and equal treatment
(Step 3). Service providers also developed their own per-
formance indicators and responded to the community-
generated indicators and also the four standard indica-
tors (Step 4). Next, there was an interface meeting be-
tween the VDC, village leaders, HFC members, services
providers, and at least two representatives of each focus
group to identify priority issues emerging from the two
scorecards, as well as the input tracking matrix (Step 5).
The resulting joint service improvement plan (JSIP) in-
cluded priority actions, such as advocacy towards the
health zone for increased personnel or construction of a
birthing room (step 6). The JSIP was validated by a gen-
eral assembly of 60 to 100 community members and
later endorsed by line ministry and local government au-
thorities prior to implementation (Step 7). The VDC was
responsible for overseeing the implementation of the
JSIP using Tuungane and community resources (com-
munity memberstime and labor and at times materials
such as bricks produced by the community). Approxi-
mately six months later (corresponding with 50 % com-
pletion of the infrastructure project), the first CSC
review was conducted (Step 8), followed by a second re-
view at the end of the Tuungane project cycle (usually
69 months after the first CSC review Step 9) to gauge
progress on the implementation of the JSIP. A few weeks
after the second review of the scorecard, VDC represen-
tatives from multiple communities presented their
Ho et al. Conflict and Health (2015) 9:27 Page 3 of 11
respective JSIPs to local line ministries and officials to
share progress and secure ongoing support beyond the
duration of the Tuungane project (Step 10). Tuungane
staff facilitated the process through the first review in
close collaboration with VDC members who took the
lead for the second review of the CSC and the meetings
with local authorities.
Most significant change technique
The Most Significant Change (MSC) technique is a par-
ticipatory process [that] involves the collection of stories
on the most significant change at the field level, and the
systematic selection of these stories by panels of desig-
nated stakeholders or staff [14].This method was
chosen for program monitoring because of its participa-
tory approach which aligned well with the community-
driven focus of the project and to help identify the na-
ture of changes that resulted from the CSC, as perceived
by those directly involved in the scorecard process. The
MSC technique was selected because of its potential to
benefit from the wealth of knowledge and experience ac-
quired by Tuungane staff during the implementation of
the project in the field, in a systematic way. For this pur-
pose, the staff were requested to contact beneficiaries
who they felt had been highly engaged in the process
and would be able to reflect on it, from communities
that experienced significantchanges following the CSC
process, instead of collecting feedback from beneficiaries
chosen at random. The technique therefore brought to
light the most significant changes resulted from the CSC
process, identified by staff members and told through
the voice of beneficiaries. While not necessarily repre-
sentative of the CSC implementation as a whole, these
contributions allowed for a better understanding of the
CSCspathways of change in the cases significant
changes actually materialized.
A total of 125 stories from 79 CSC sites were col-
lected in two rounds for the project; of those, 45 stories
were collected from community members and health-
care providers in 25 out of a total of 151 sites that
chose the health sector. A group of Tuungane field staff
(14 of 17 of whom were male) were trained to collect
stories using a structured questionnaire that asked what
were the most significant changes in service delivery
observed by the respondent since the start of the pro-
ject, and included standard follow up probes, including
whether there were any negative effects of the change.
Staff were explicitly told to focus on significant
Fig. 1 Tuungane Community Scorecard Timeline
Ho et al. Conflict and Health (2015) 9:27 Page 4 of 11
changes, not successfulchanges. The sampling of the
participants by the Tuungane field staff was purposeful
to ensure inclusion of men and women, healthcare pro-
viders, community leaders, VDC and HFC members, as
well as other health service users. However, VDC and
HFC members were oversampled because of their level
of engagement with the project and their ability to
speak to how and why changes happened in addition to
having witnessed them. Similarly, while the wording of
the question did not specifically ask about positive
changes, project staff generally selected respondents
who they knew had participated actively in the score-
card process and could report changes taking place in
their community. Although there was a broader partici-
patory process conducted with project staff to examine
toring and implementation, this paper focuses on a sep-
arate content analysis conducted on the stories. All
stories collected were used in the content analysis.
Data collection and analysis
There were two rounds of data collection in June-
September 2012 and May-August 2013. IRC staff were
trained in the MSC methodology and conducted the
data collection. Thirteen stories were collected in the
first round, and 32 in the second. During the first
round respondents were asked to describe the most sig-
nificant change they had observed since the baseline
scorecard, and this sometimes resulted in several
changes being mentioned in a single story. In the sec-
ond round, the interview guide was modified to focus
on a single change and probe further into how the
change came about. The interview guide was written in
French and translated into Kiswahili. Interviews were
conducted in Kiswahili and Kihavu. Notes were re-
corded in French or Kiswahili, and the final write-ups
and analysis were conducted in French.
Two of the authors conducted thematic analysis of
story transcripts from the education and health sectors
for project purposes, using Saturate [15] to code for
types of change. Three authors conducted additional
analysis focused on the health stories by regrouping
codes and stories, and comparing results. The original
coding framework was not pre-determined, but was de-
veloped using an emergent, iterative approach. These
codes were categorized in the subsequent analysis ac-
cording to domains of health service quality and build-
ing blocks of the health system.
Interview respondents were asked if they consented
to participate, to the publication of their story, and to
have their real name used. All stories were collected as
part of routine program monitoring and evaluation.
Upon deciding to publish the results, the IRC applied
for and received post-hoc ethical review approval from
the Catholic University of Bukavu. There was minimal
views was not sensitive or personal in nature.
A total of 45 stories of change were collected in the
health sector: 20 from ten CSC sites in South Kivu, and
25 from 15 CSC sites in Katanga. Up to five stories were
collected from each CSC site. The profiles of the respon-
dents are presented in Table 1.
Types of changes
Although not all respondents from the same CSC site
cited the same change, most identified similar types of
changes. Increases in community participation in the
management of the health facility, in particular through
greater engagement of health facility committees, and
increases in quality of care were recurrent themes. There
were several dimensions of quality of care highlighted by
these changes, including increased access, improved
patient-provider relationships, improved technical per-
formance, and improved maintenance of infrastructure.
Increased participation of health facility committees in
promoting transparency and improved management
Increased transparency and participation was the most
frequently mentioned change. A common theme was the
positive shift in the involvement of the HFC in the man-
agement of health services or re-activation of dormant
HFC. For healthcare providers, changes in the manage-
ment of their facilities, particularly increased cooper-
ation with the HFC and community, dominated the
responses. One healthcare provider described it this way:
Since the creation of the health center, the [HFC]
existed in name only. The members knew nothing
about their roles. They were even afraid of
approaching the head nurse to share complaints from
the community, or even to ask about the status of the
medical supplies. Worse, no one had the courage to
Table 1 MSC story respondents
(% among
(% among
(% of
all respondents)
Healthcare provider 6 (23) 1 (5) 7 (16)
Traditional chief 3 (12) 0 (0) 3 (7)
Village development
committee member
8 (31) 6 (32) 14 (31)
Health user
committee member
6 (23) 8 (42) 14 (31)
Other health service user 3 (12) 4 (21) 7 (16)
TOTAL 26 (100) 19 (100) 45 (100)
Ho et al. Conflict and Health (2015) 9:27 Page 5 of 11
ask how the center operated. So everything was done
without the knowledge of the [HFC], and it was the
private domain of the head nurse and his nurses. For
the head nurse, the data collected on the sector raised
his awareness of the lack of involvement of the [HFC]
in the management of the health center. For the
president and other members of the [HFC], they
realized through the community scorecard process that
they were not very active, even during the interface
meeting. That is why the president [of the HFC]
organized a meeting to be coached and take on more
leadership. Since then, [HFC] members play their roles
easily, they work closely with the health staff, they are
also available to respond to complaints from the
community and to raise these at the health center.
Healthcare Provider, Katanga
Improved maintenance of physical infrastructure
One of the responsibilities of the HFC is to mobilize
the community to help maintain the health facility and
its compound, but in many communities this does not
happen. Following the CSC process, some respondents
reported greater involvement of the HFC in health
facility maintenance, as illustrated below:
I now notice that theres a new energy in our
community. The [HFC] is present to oversee the
cleanliness of our health post and now participates in
its management without difficulty. The community is
mobilized to work together and is more united that it
was two years ago. VDC member, Katanga
Improved performance
Users had previously been discouraged by the unavail-
ability of drugs and healthcare providers, and instead
went to traditional healers or private drug sellers. After
the CSC process, some healthcare providers solicited
and received support from health zone management
teams, other NGOs, and the HFC to address these is-
sues. One health provider described the following
Now, there is the accounting that we do at the end of
each day together with [the HFC]. We plan together
and assess our current needs. This new management
system has the advantage that we no longer have
stockout of drugs and equipment. We have also
managed to put in place a rotation system that allows
healthcare providers to alternate night and day shifts
for service provision, which partially solved the
problem of motivation [of healthcare providers who
used to feel overworked]the population has also
regained its confidence in modern [medicine]
gradually abandoning [shamanistic healers], this was
a result of sensitization conducted by the [HFC].
Healthcare Provider, Katanga
Improved rapport and fairness
Community members reported that healthcare providers
were more willing to listen and more respectful in their
dealings with users. This increased communication helped
create a more welcoming atmosphere at the health facil-
ities. Women often focused on improvements in quality of
care, particularly the attitude and behavior of providers, as
the most significant change. One HFC member reported
these changes after the baseline scorecard:
[we see] a warm welcome is reserved for patients by
providers. Indeed, the reception given to patients
influences healing, we see that now providers
demonstrate consideration for, esteemfor their
patients[we see] fair treatment of the sick, that is to
say that before Tuungane came, most often in the
waiting lines some people were privileged to jump the
line for consultations given their influence in society
(local authorities, merchants) and relationships with
the nurses (friends, husbands, wives, people close to
them). The most significant change is the warm
welcome reserved to patients by nurses, something that
has not only strengthened cooperation, the
consideration of, and esteem for, but also the healing
of the sick. Finally, a good building, equipment,
withouta welcoming staff in the facility it leads to
nothing because if the impression of the welcome is
negative, the rest is irrelevant. VDC and HFC
member, South Kivu
Improved financial access to services
There was increased access to services reported in many
communities, primarily because of changes in user fee
policies or a reduction in bribes requested from users.
This change was mostly one identified by male respon-
dents. In some cases, HFC members and frontline service
providers advocated for increased oversight from the
health zone management team to encourage the regular
payment of salaries for service providers and to dissuade
health providers from demanding bribes. Most respon-
dents stated that decreases in user fees or informal pay-
ments resulted in increased utilization such that providers
did not suffer from decreased income. One HFC member
described the situation in his village:
The situation of our health center before was really
catastrophic mainly because there was a very high
user fee for receiving health care services. This was due
to the fact that the management of the health center
was done exclusively by the head nurse. He, with his
staff, did what they wanted. This is what has been
Ho et al. Conflict and Health (2015) 9:27 Page 6 of 11
done to resolve this situation: we, members of the
[HFC], with the VDC members, have organized a
meeting with the frontline service providers to discuss
a reduction in the health care cost. The head nurse
told us that it is very difficult to reduce user fees, and
yet most nurses are not registered by the State. Our
resolution to this meeting was to send a
correspondence to the health zone. The letter was
signed by the president of the VDC and [HFC], as well
as the head nurse and the local authority [Village
Chief]. In the letter, all the difficulties of the health
center which could be addressed by the health zone
were presented, among others the construction of a
nutrition [hangar], the lack of registration of nurses by
the State, and the lack of medical supplies. After the
change, user fees were significantly reduced to
approximately 0.5 USD for a child, and approximately
1 USD for an adult. HFC member, South Kivu
Mechanisms of change
Most stories report a change in the relationship be-
tween the HFC and healthcare providers. They offer
examples of committee members acting collectively to
improve service delivery, applying pressure on their
healthcare providers, and advocating to health zone
level management and external actors. Figure 2
sents several, non-mutually exclusive mechanisms of
change observed in the stories. There may have been
multiple changes and pathways in each village, and
there may be other mechanisms that have not yet been
documented. Examples of more prominent mechanisms
are described below.
Healthcare provider response to information and pressure
Some stories indicate that healthcare providers changed
their behavior in response to social or hierarchical pres-
sure, economic interests, concern for the communitys
well-being, or a combination of these. For example, one
VDC and HFC member reported during the course of
the CSC that the head nurse became aware that some
health facility staff were not respecting posted user fees,
and were asking for bribes or additional payments. The
head nurse felt that this would discourage users from
coming to the facility. He organized a meeting with his
Fig. 2 Conceptual framework of mechanisms influencing changes in the health system
Ho et al. Conflict and Health (2015) 9:27 Page 7 of 11
staff and community members to demand that his staff
respect payment procedures while asking the HFC mem-
bers to encourage users to frequent the facility. Because
the community was informed of this initiative, they re-
ported any staff who asked for bribes. In another village
the VDC, the HFC and the village chief were able to
convince the nurse at their health post to return drugs
that he had stolen.
Improved collaboration between HFC and healthcare
Many HFC and healthcare providers became better in-
formed of their roles and responsibilities. Empowered
HFC were able to work with healthcare providers who
were willing to make changes. In one village a health
user reported that the HFC started meeting monthly
with the healthcare providers to troubleshoot problems,
including user complaints and management of drug
stocks, and information from these meetings was shared
with the population. The improved relationship between
HFC and healthcare providers led to a decrease in user
fees in another village, which helped increase utilization
of services.
Users and healthcare providers jointly seeking support from
other actors
As described above, some committees and providers
sought support from the health zone level for fee reduc-
tion. Other examples of collaborative efforts include com-
mittees who sought assistance from non-governmental
organizations to improve services or asked the health zone
management team for training for healthcare providers.
Discussion and limitations
Fragile and conflict affected states do not provide a con-
text conducive to civic engagement [11]. The findings
demonstrate pathways through which the CSC process
can improve accountability and influence the quality of
health services in one such setting. This includes in-
creased participation of health facility committees in
promoting transparency and good management, im-
provements in physical infrastructure, improved per-
formance of providers, better rapport between providers
and patients, and increased financial access to services.
Several of these changes are interrelated, for instance,
improved infrastructure may make providers happier
about working, which inclines them to be kinder to pa-
tients, and more willing to negotiate user fees. The in-
creased participation of HFC may also contribute to
improved conditions for providers and improve their at-
titudes toward community members. All of these factors
may improve access to and equity of services. Although
there is limited literature on the effectiveness of CSC
specifically, the finding of improved access is consistent
with literature on community participation in health and
HFCs [8]. While the data presented here do not object-
ively measure outcomes such as increases in utilization
or decreases in drug stock-outs, they show how commu-
nity participation in health can produce improvements
through facilitating flows of information, increasing col-
laboration, and supporting user demands regarding their
Effects of improved access to information
In CSC interventions in India and Madagascar, a change
in the providersresponsiveness to users was a result of
improved channels of communication and mutual un-
derstanding [12]. In Uganda, Nyqvist, et al. (2014) also
found that a participatory intervention that included
both participation and information on staff behavior had
short and long-term effects, while interventions that did
not include information on staff behavior had no impact
on quality [16]. The Tuungane CSC process provides in-
formation on MoPH standards and entitlements, as well
as wider community perceptions of service delivery per-
formance in a way that is unprecedented in most of the
targeted communities. By introducing a discussion on
broader service delivery issues than they might otherwise
have considered, the CSC allowed service users and pro-
viders alike to gain access to information that they
otherwise would not have had and to consider and act
on critical service delivery issues such as staffing, user
fees and patient-provider relationships, in addition to
the common focus of infrastructure. Sharing information
on services publicly may have compelled individuals
with responsibility in the community to act.
Joint problem solving
In a fragile state where line ministries may lack the cap-
acity or will to provide adequate oversight to peripheral
parts of the health system, the impact of the CSC on
governance is particularly important. Both service pro-
viders and HFCs embraced their mandated roles and
responsibilities in a process where the VDC members
represented the broader community, and where all par-
ticipants were informed of MoPH standards. Commit-
tee members were able to monitor adherence, and seek
redress from higher levels. In the DRC, health zone
management teams receive no direct financial support
from the MoPH, other than their salaries, and these are
low and irregular, if paid at all. Lacking resources to
pay for fuel if they even have a vehicle or motorcycle to
conduct supervisions, they may rarely visit peripheral
health facilities. Through the CSC, communities have
demonstrated how they can empower HFCs to monitor
and take action to improve health facility performance
whether or not they receive reinforcement from the
health zone management team, at least for those
Ho et al. Conflict and Health (2015) 9:27 Page 8 of 11
problems that can be solved at the very local level,
similar to findings from Bjorkman and Svensson in
Uganda [17]. It is important to note how the context in
which this project took place may have affected the re-
sults [18]. Although the DRC has not devolved manage-
ment of health services officially, the weak presence of
the state in remote areas may have made it easier for
these local changes to happen.
Perspectives and participation of different stakeholders
Given the lack of community engagement in the man-
agement of health facilities prior to the project, it is not
surprising that for providers the increased participation
of community members in health facility management
was the most notable change. That more women
highlighted the changes in quality of care including the
attitudes and behaviors of providers, is also not surpris-
ing given that women frequent health facilities and use
services more often than men, especially to accompany
their children. The economic considerations of access
may have been more noticeable a change for men be-
cause in this context they tend to dominate household
decision-making around economic resources. Neverthe-
less, women and mens responses might have been two
reactions to the same phenomenon of nurses abusing
their power. However, women would rather highlight
that the nurses’“unwelcoming behaviorresulted in
them (or their children) not having access to services;
men on the other hand might have shown more sensi-
tivity to issues related to power dynamics within the
village, and illicit gains. We did not observe any vari-
ation in response by membership in HFC or VDC. The
Health Service Delivery Community of Practice [19]
recently put forward 12 recommendations for renew-
ing the health district in Africa in order to advance
universal health coverage [20]. These included a
greater role for individuals, households, and communi-
ties as co-producers of their own healththrough em-
powerment, freedom, and citizen voice; and a more
flexible, open approach to the district health system to
allow for localized responses to the populations needs.
Through the CSC process, communities adapted pol-
icies to their context and negotiated local solutions to
improve their health services. More than one commu-
nity was able to increase access to services by negoti-
ating changes in the health facility user fee policy.
Although there is clear evidence of the potential posi-
tive effects of fee exemptions on health outcomes,
top-down policies implemented without careful plan-
ning and engagement of stakeholders have encoun-
tered many challenges such as confusion or lack of
information among the population regarding overlap-
ping policies and inadequate measures to overcome
equity issues [21]. Where user fees were modified in
Tuungane, the process was negotiated between the
parties most directly affected by the change - community
members and providers - which is more likely to lead to a
mutually acceptable result.
The literature suggests that the selection and compos-
ition of HFCs can have an influence on their impact,
with lack of transparency being a potential challenge
[22]. Although the HFCs were not systematically re-
elected under Tuungane to ensure that they represented
the community, the participation of the freely elected
VDC and wider community in the process ensured a
certain level of transparency and oversight in the imple-
mentation of the JSIP.
Role of the community grant
While the CSC directly affected power imbalances be-
tween users and healthcare providers through informa-
tion sharing, as part of the Tuungane program the
community also received a grant of 24,000 USD for im-
plementation of the service improvement plan. This
plan was managed by the VDC which included mem-
bers of the HFC, giving them control and oversight
over an enormous financial resource that was also val-
ued by providers. In order to access this resource,
healthcare providers needed to work with the VDC,
and this may have been a motivation for them to im-
prove relationships with VDCs as working conditions
are important to providers and the grants were gener-
ally used to improve this However, given the broad
range of changes elicited through the project, particu-
larly in terms of the relationships between users, health
workers and HFCs, it is reasonable to suggest that some
of these changes would continue to manifest them-
selves beyond the life of the project and the community
grant. Particularly in terms of information gained by
users about their entitlements- although the sums
would not be as large as the grant, because of the cost
recovery system and lack of salary paid by the state,
users still have leverage over providersincome if they
Assumptions about state-society relations at local level
The types of collaboration illustrated through the MSC
stories has brought to light an observation that was not
explicit in the original theory of change, that often the
disconnect at the local level was not between commu-
nity members and providers, but between them collect-
ively and higher level authorities. That is, the
conceptual divide between citizen and state was not ne-
cessarily so useful when examining community mem-
bers and local healthcare providers. Local healthcare
providers live in these communities and may have so-
cial incentives to get along with community members,
and in most cases they were not even on the state
Ho et al. Conflict and Health (2015) 9:27 Page 9 of 11
payroll, as is the case across much of the DRC. In some
cases when providers and communities came together,
they were more confident and more capable of de-
manding entitlements or support from zonal health au-
thorities. As is highlighted in the conceptual framework
of mechanisms influencing changes in the health sys-
tem, healthcare providers are not always motivated by
self-interest and change does not always come about
through confrontation with users. While the power dif-
ferential between health workers and users cannot be
underestimated, it is also true that the status quo is
often maintained, not necessarily by a desire on the
part of health workers to hold on to privileges and ex-
ploit users, but often just by poor information flows
and a lack of understanding of shared needs and prior-
ities. In addition, the CSC process demonstrated that
top-down health system accountability was not the only
mechanism for improvement of services, and that
changes could happen at the local level through infor-
mation sharing, without higher level state intervention
or punitive measures. In line with the original theory of
change though, responsiveness of providers was key to
many of the mechanisms and types of changes
There are some limitations to the data presented. HFC
members were the source for 31 % of the stories (14 out
of 45), which may have biased the types of changes re-
ported or the roles they played in these changes. Only
16 % (7 of 45) stories were from users who were not a
VDC or HFC member or community leader. At the
same time, the objective of the collection of MSC was to
explore what kinds of changes can result from the CSC
process and what the mechanisms of change were. As
the average service user did not participate in all steps of
the CSC process, they would not have as much insight
into the mechanisms of change, particularly around the
changes in governance of health facilities. VDC and
HFC members were better placed to understand the
process through which the intervention stimulated
change and comment on how changes occurred. In
addition, the stories of change were conceived as part of
routine project monitoring and were not originally
intended for research.
The scope of this paper focuses on the content of the
stories and not the entire MSC process and its influ-
ence on program implementation. There are strengths
and weaknesses to using this methodology for collec-
tion of qualitative data. Decisions about participants
were made by field staff with the intention of identify-
ing significantchanges, and respondents were also
asked about any negative effects of the changes. This is
very useful for explaining how changes unfolded when
the program worked as intended, but does not explain
failures of the CSC to stimulate desired outcomes. As
such we can expect that many participants would solely
focus on successful stories. As the purpose of the
process was to explore mechanisms of change, the
selection of respondents necessarily focused on com-
munities that had experienced change, rather than
communities that did not observe changes. Also, stories
were collected by IRC staff, which may also have influ-
enced the responses if respondents felt that this could
affect continued support from the IRC.
Finally, the perspectives of Tuungane staff on ac-
countability have changed over the lifetime of the pro-
ject. Observations of how change is taking place
suggest that a collaborative approach to accountability
is just as likely as a confrontational approach in the
local DRC context. Our initial assumption, and the one
that is often put forward when discussing accountabil-
ity, is of users needing to reign in the formal power of
corrupt or inept health workers. However, program
staff saw more examples of what Booth (2012) describes
as collective action problems
on the supply and de-
mand sides that need to be overcome [23]. Account-
ability therefore becomes about efforts among users
and health workers and between them to collectively
solve problems that plague local health services.
This study focused on examining changes perceived as
significant by the staff and the beneficiaries involved in
data collection, and showed some of the mechanisms
by which CSC can improve the functioning of local
health systems in fragile and conflict-affected settings
by providing information to users and providers and
encouraging them to engage in making health services
more responsive to their needs. It brings into question
whether frontline healthcare providers are part of the
state or society, depending on the context and perspec-
tive of the observer, and how this influences how they
act and respond to users. In the setting of the DRC
where the central government has limited influence on
many aspects of what happens in the periphery, the
divisions between frontline healthcare providers and
community members can be bridged by facilitating
space for interface, exchange, and collaboration. Fur-
ther studies should include both qualitative and quanti-
tative data to understand the objective effects of CSC,
the mechanisms by which they work in each context,
and whether changes are sustained over time. Also,
given the limited evidence on social accountability tools
such as CSC, program implementers should carefully
design their monitoring and evaluation systems to en-
sure data is collected for the purpose of future
Ho et al. Conflict and Health (2015) 9:27 Page 10 of 11
evaluation. This would help researchers to rigorously
assess the impact of such tools and better understand
how and why they work.
This figure is adapted from a briefing paper by Leni
Wild and Marta Foresti (2012): More than just de-
mand: Malawis public-service community scorecard.
Collective action problems can occur in situations
whereby multiple individuals would all benefit from a
certain action but such action has an associated cost
making it implausible that any one individual can or will
undertake and solve it alone. These problems are over-
come when a coordination mechanism is put in place
that allows these costs to be shared.
CDR: Community-driven reconstruction; CSC: Community scorecard; DfID: UK
Department for International Development; DRC: Democratic Republic of
Congo; HFC: Health Facility Committee; IRC: International Rescue Committee;
JSIP: Joint Service Improvement Plan; MoPH: Ministry of Public Health;
MSC: Most Significant Change; VDC: Village Development Committee.
Competing interests
The authors declare they have no competing interests.
LSH conceived of the paper, participated in the analysis, and drafted the
manuscript. GL participated in the original design of the study, writing the
briefing paper on which part of this manuscript is based, additional data
collection, and performed the original analysis. IB participated in the design
of the original study and writing the briefing paper on which part of the
manuscript is based. VS designed and coordinated the original study and
performed the analysis. RR participated in the conceptualization of the
paper. All authors read and approved the final manuscript.
The authors would like to acknowledge the support of Tuungane and the
International Rescue Committee staff in the Democratic Republic of the
Congo in collection of data and review of the manuscript (in alphabetical
order): Valentin Bajoje, Machozi Balingene, Rene Balume, Gregoire Bauma
Kaniki, Albert Bukasa, Marie-France Guimond, Lucien Kalend, Adolph Kimbadi,
Petronie Kipempo, Jospin Mapenzi, Christophe Mpunga, Martin Mulamba,
Marie-Claire Mujinga, Michel Mumba, Dimitry Ngoie, Kambale Nzanzu, Dana
L. Olds, Dany Sahenga. In addition we appreciate the support provided by
Dr. Laura Seay in the early phase of the analysis of MSC data analysis as well
as her support with pursuing research initiatives in eastern Congo. Finally,
we would like to thank the individuals who took the time to participate in
Tuungane activities and share their inspiring stories of change.
Tuungane is funded by the UK Department for International Development
(DFID) and supported Guillaume Labrecque, Isatou Batonon, and Viviana
Salsi. DFID was not directly involved in design, collection, analysis, or writing
of the manuscript. LSH and RR are supported by numerous IRC donors.
Author details
International Rescue Committee, 1730 M Street, Suite 505, Washington, DC
20036, USA.
International Rescue Committee Nairobi, P.O. Box
62727-00200Galana Plaza 4th Floor, Galana Road, Nairobi, Kenya.
International Rescue Committee Islamabad, House 11 Street 4 F6/3,
Islamabad, Pakistan.
International Rescue Committee New York, 122 E 42nd
Street, New York, NY 10168, USA.
Received: 15 May 2014 Accepted: 13 August 2015
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... Studies have found that improved quality of care, including perceived quality of care, improves health-seeking behaviors, retention in care, and ART adherence [11][12][13]. One means of addressing persistent and modifiable barriers to quality care is using social accountability approaches to empower clients and communities [14,15]. ...
... The CSC is a social accountability approach which uses a two-way, ongoing participatory approach for assessment, planning, monitoring, and evaluating public services. The CSC brings together the demand side (i.e., 'client') and the supply side (i.e., 'HCWs') of a service or program to jointly analyze issues underlying service delivery problems, find a common and shared way of addressing those issues, and continuously track commitments toward the implementation of those solutions in an ongoing process of quality improvement [15]. ...
... Age at first ANC visit (years) 15 1 Retention in PMTCT services is defined as having attended a clinic visit before the specified time (3-or 6-months after first ANC visit) and having a scheduled clinic visit after the specified time. A seven-day window was given to account for individuals with a clinic visit within one week before or after. ...
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Malawi faces challenges with retaining women in prevention of mother-to-child HIV transmission (PMTCT) services. We evaluated Cooperative for Assistance and Relief Everywhere, Inc. (CARE’s) community score card (CSC) in 11 purposively selected health facilities, assessing the effect on: (1) retention in PMTCT services, (2) uptake of early infant diagnosis (EID), (3) collective efficacy among clients, and (4) self-efficacy among health care workers (HCWs) in delivering quality services. The CSC is a participatory community approach. In this study, HCWs and PMTCT clients identified issues impacting PMTCT service quality and uptake and implemented actions for improvement. A mixed-methods, pre- and post-intervention design was used to evaluate the intervention. We abstracted routine clinical data on retention in PMTCT services for HIV-positive clients attending their first antenatal care visit and EID uptake for their infants for 8-month periods before and after implementation. To assess collective efficacy and self-efficacy, we administered questionnaires and conducted focus group discussions (FGDs) pre- and post-intervention with PMTCT clients recruited from CSC participants, and HCWs providing HIV care from facilities. Retention of HIV-positive women in PMTCT services at three and six months and EID uptake was not significantly different pre- and post-implementation. For the clients, the collective efficacy scale average improved significantly post-intervention, (p = 0.003). HCW self-efficacy scale average did not improve. Results from the FGDs highlighted a strengthened relationship between HCWs and PMTCT clients, with clients reporting increased satisfaction with services. However, the data indicated continued challenges with stigma and fear of disclosure. While CSC may foster mutual trust and respect between HCWs and PMTCT clients, we did not find it improved PMTCT retention or EID uptake within the short duration of the study period. More research is needed on ways to improve service quality and decrease stigmatized behaviors, such as HIV testing and treatment services, as well as the longer-term impacts of interventions like the CSC on clinical outcomes.
... The implementation level consists of 516 health districts, with a network and health centers and district hospitals managed by district teams [34]. The health system in the DRC was weakened by more than a decade of conflict and due to this fragile context, the state is unable to widely deliver quality care to the population [35,36]. Similar to Haiti, government expenditure on health per capita is one of the lowest in the world [37]. ...
... Similar to Haiti, government expenditure on health per capita is one of the lowest in the world [37]. Often, drugs and personnel are unavailable and given the low investment and poor financial management, providers rely on unofficial payments by users as well as high user fees [35]. As a result, in the DRC, there are still excessive fee-for-service payments for primary health services [36]. ...
Full-text available
The World Health Organization recently articulated a number of challenges faced by health systems due to unreliable access to energy services. Reliable energy availability at rural health facilities is understood to be an enabler of access to quality healthcare, owing to its potential impacts on medical services, health and safety, disease prevention and treatment, staff recruitment and retention, and administration and logistics. However, little is known empirically about the intersections of energy and healthcare, often due to the lack of availability of facility level data. Moreover, the gender implications of energy access (or lack thereof) for women as providers and seekers of primary healthcare have not been investigated. In this study, using a gender lens, we explore the linkages between energy and healthcare in three Francophone countries in the Caribbean and sub-Saharan Africa: Democratic Republic of the Congo (DRC), Haiti and Senegal. All three countries have faced serious challenges to the provision of quality health services, including infrastructure problems and specifically unreliable access to electricity. We use Demographic Health Survey data from all three countries to present detailed descriptions of the association between (a) the availability and reliability of electricity sources, and (b) availability of health services, equipment and medical personnel at different levels of the respective health systems. We find that the unavailability and unreliability of electricity is associated with lower availability of medical equipment and basic health services, especially among facilities at the primary care level in DRC and Haiti. Our findings highlight the opportunity to create more dependable and sustainable health systems by integrating decentralized clean energy technologies into health infrastructure, which can facilitate providers in female-dominated cadres such as nursing the ability to provide the care they are tasked with.
... The measurement results of CSCs were positively correlated and had statistically significant higher differences, which may have occurred due to the responsiveness of the health system to the needs and demands of community members in terms of health worker behavior, availability of services, and improvements in supplies, infrastructure, and waiting time. This finding was in line with an article by Ho et al. 24 on CSC implementation in the DRC, which showed improved patient and health provider relationships as well as improved quality of and access to primary health care services. 24 Tabish (Figure 3). ...
... This finding was in line with an article by Ho et al. 24 on CSC implementation in the DRC, which showed improved patient and health provider relationships as well as improved quality of and access to primary health care services. 24 Tabish (Figure 3). These results could have been achieved through negotiations between community members and health workers in which detailed action plans were developed, implemented, and evaluated (Supplement 2). ...
Full-text available
Background: Social accountability approaches, such as the community scorecard (CSC), can improve the performance of health systems in low-income countries by providing a mechanism for obtaining and incorporating community input. This longitudinal study assessed the effects of CSCs implemented by primary health care units (PHCUs) on health system performance in Ethiopia. Methods: This study used a pre-post design and was conducted from October 2018 to September 2019 in 159 PHCUs in 31 districts in Amhara and Southern, Nations, Nationalities and Peoples' regional states. The data were extracted from a routine health information management system database at baseline, midterm, and endline stages over 12 months for statistical analysis. The effects of implementing CSCs on health system performance were evaluated against selected key performance indicators (KPIs). Results: The CSC measurement results were based on input from 38,556 community representatives. The mean CSC score with standard deviation (±SD) was 60.8%±12.5%, 66.3%±10.8%, and 70.6%±10.0% at baseline, midterm, and endline, respectively. The mean KPI score was 54.9%±17.4%, 61.9%±15.1%, and 67.6%±14.6% at baseline, midterm, and endline, respectively. The average CSC and KPI values were positively correlated (r>0.37). Using a nonparametric Friedman's test, we found a statistically significant difference in CSC and KPI scores at baseline, midterm, and endline (P=.001). Post hoc analysis with Wilcoxon signed-rank tests was conducted with a Bonferroni correction and the results showed higher CSC and KPI values from baseline to midterm and from midterm to endline (P<.017). Conclusions: The use of CSCs in Ethiopia contributed to the health system's performance in terms of maternal and child health services. The responsiveness of health workers and utilization of basic health services by community members were found to increase significantly with CSC use. We recommend continued implementation of the CSC intervention at PHCUs.
... The evaluative sub-cluster contains mainly empirical quantitative studies such as quasiexperimental, randomized-controlled or matched interventions designs (pre and post intervention) [145][146][147]. The effectiveness of mechanisms are commonly measured against the improvement of quality of care and coverage indicators [145,148,149]; health outcome indicators [147,150] and indicators of (degree of) voice/participation [150][151][152][153]. While this review does not assess the validity of study findings, on the whole, there are significantly fewer reports of evaluated 'success' of mechanisms (in achieving intended outcomes, or showing improvement in responsiveness), than reports of mechanisms failing to achieve intended effects/outcomes/impact. ...
Full-text available
Background The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems’ functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness. Methods A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts. Results Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of ‘health system responsiveness’, which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system. Conclusions This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.
... In the Democratic Republic of the Congo, community scorecards bridged the divisions between frontline health care providers and community members by providing opportunities for exchange and collaboration at the community level. 17 Community scorecards can increase the availability of information about maternal and neonatal health services. 18 Effective facilitation of the community scorecard process requires skilled application, but the use of community scorecards needs to be expanded. ...
... In the Democratic Republic of the Congo, community scorecards bridged the divisions between frontline health care providers and community members by providing opportunities for exchange and collaboration at the community level. 17 Community scorecards can increase the availability of information about maternal and neonatal health services. 18 Effective facilitation of the community scorecard process requires skilled application, but the use of community scorecards needs to be expanded. ...
Full-text available
Background: Community clinics (CCs) staffed by community health workers (CHWs) represent an effort of the Government of Bangladesh to strengthen the grassroots provision of primary health care services and to accelerate progress in achieving universal health coverage. The Improving Community Health Workers (ICHWs) Project of Save the Children piloted a CC-centered health service (CCHS) model that strengthened community and local government engagement, harmonized the work of different CHW cadres who were working in the same catchment area of each CC, and improved the accountability of CHWs and the CC to the local community. Methods: We describe the process for developing and implementing the CCHS model in 6 unions in Barishal District where the model was piloted and provide some early qualitative and quantitative findings pertaining to the model's effectiveness. Data were collected from CCs in the 6 pilot unions and 6 other unions that served as a control. Qualitative data were collected from the intervention area during the pre-pilot (October 2017-September 2018) and pilot phase (October 2018-September 2019). Document review, key informant interviews, and focus group discussions were also conducted. Maternal and child health service utilization data were extracted from the government health information system in both the intervention and control areas. Results: Community group meetings ensured engagement with local government authorities and supported resource mobilization. There was greater coordination of work among CHWs and increased motivation of CHWs to better serve their clients. The analysis showed that the increase in maternal health consultations was substantially greater in the intervention area than in the control area, as was the number of referrals for higher-level care. Conclusion: The CCHS model as applied in this pilot project is effective in engaging local key stakeholders, increasing CHW capacity, and improving client satisfaction. The model demonstrated that a community health system can be strengthened by a comprehensive approach that engages communities and local government officials and that harmonizes the work of CHWs.
Delivering quality primary health care requires reliable energy access. In rural health facilities, electricity is often unreliable or absent. Low energy access has a gendered impact, affecting the ability of mothers to experience safe childbirth, for which basic lighting and sterilization are essential. Moreover, low energy access acts as a barrier to attract and retain female medical staff, who constitute women-predominated nursing and midwifery cadres that are critical for providing care to women. Using quantitative facility-level data, we explore the intersection of energy, health care, and gender in Haiti, Senegal, and the Democratic Republic of the Congo.
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Background: Women seeking family planning services from public-sector facilities in low- and middle-income countries sometimes face provider-imposed barriers to care. Social accountability is an approach that could address provider-imposed barriers by empowering communities to hold their service providers to account for service quality. Yet little is known about the feasibility and potential impact of such efforts in the context of contraceptive care. We piloted a social accountability intervention - the Community Score Card (CSC) - in three public healthcare facilities in western Kenya and use a mix of quantitative and qualitative methodologies to describe the feasibility and impact on family planning service provision. Methods: We implemented and evaluated the CSC in a convenience sample of three public-sector facility-community dyads in Kisumu County, Kenya. Within each dyad, communities met to identify and prioritize needs, develop corresponding indicators, and used a score card to rate the quality of family planning service provision and monitor improvement. To ensure young, unmarried people had a voice in identifying the unique challenges they face, youth working groups (YWG) led all CSC activities. The feasibility and impact of CSC activities were evaluated using mystery client visits, unannounced visits, focus group discussions with YWG members and providers, repeated assessment of score card indicators, and service delivery statistics. Results: The involvement of community health volunteers and supportive community members – as well as the willingness of some providers to consider changes to their own behaviors - were key score card facilitators. Conversely, community bias against family planning was a barrier to wider participation in score card activities and the intractability of some provider behaviors led to only small shifts in quality improvement. Service statistics did not reveal an increase in the percent of women receiving family planning services. Conclusion: Successful and impactful implementation of the CSC in the Kenyan context requires intensive community and provider sensitization, and pandemic conditions may have muted the impact on contraceptive uptake in this small pilot effort. Further investigation is needed to understand whether the CSC – or other social accountability efforts – can result in improved contraceptive access.
This thesis examines the relationship between institutional quality and regional economic development in African countries. It analyses three elements of institutional quality: the impact of institutional quality on economic development, the drivers of poor institutional quality, and interventions that can be adopted to improve institutional quality. The first paper of this PhD, published in the Journal of Development Studies and co-authored with Neil Lee and Andrés Rodríguez-Pose, examines the relationship between sub-national government quality and economic development across 356 regions in 22 African countries. We create a novel index of sub-national government quality using Afrobarometer survey data, and we use high resolution night-time satellite images as a proxy for economic activity. We find that a reduction in sub-national government quality causes decreases in regional economic activity. In the second paper, I examine one of the drivers of sub-national government quality in African regions – armed conflict. I find that armed conflict leads to a deterioration in sub-national government quality. Contrary to the existing literature which suggests that armed conflict leads to a loss of government legitimacy, I find that this occurs because sub-national governments divert resources away from delivering services and towards crisis response. As a result, I find that armed conflict does not lead to a reduction in national government quality as national governments possess much greater resources. Therefore, national governments are able to respond to crises without significantly reducing the quality of service delivery. The third paper, co-authored with Neil Lee, examines the impact of national government quality on spatial inequality within African provinces. We create, for the first time, an index of within-province inequality using high resolution satellite imagery. We find that national government quality is just as important as differences in geographical endowments in driving spatial inequality within provinces. This is primarily because national governments in African countries have a history of city-specific favouritism – i.e. creating policies that benefit a particular city (typically due to corruption, nepotism or clientelism). This city-specific favouritism does not spill-over and benefit the wider province. Instead, it creates and exacerbates inequality within provinces.
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Malgré ses ressources naturelles abondantes, la République démocratique du Congo (RDC) se classe au bas de l’échelle de divers indicateurs de développement humain et économique et son revenu moyen actuel est de l’ordre de 40 % de sa valeur au moment de l’indépendance en1960. En utilisant la plateforme de modélisation International Futures, ce rapport présente les perspectives probables de développement humain et économique de la RDC jusqu’en 2050 sur sa trajectoire actuelle. Par la suite, le rapport modélise divers scénarios complémentaires qui explorent l’impact des améliorations sectorielles sur l’avenir du pays.
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by Rick Davies and Jess Dart, 2005
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Several countries have recently introduced maternal health care fee exemptions as a quick win approach to reach MDG 5 goals. It has also been argued that these policies were relevant first steps towards universal health coverage (UHC). The scope and contents of the benefits package covered by these policies vary widely. First evaluations raised questions about efficiency and equity. This article offers a more comprehensive view of these maternal health fee exemptions in Africa. We document the contents and the financing of 11 of these policies. Our analysis highlights (1) the importance of balancing different risks when a service is the target of the policy – C-sections address some of the main catastrophic costs, but do not necessarily address the main health risks to women, and (2) the necessity of embedding such exemptions in a national framework to avoid further health financing fragmentation and to reach UHC.
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Public accountability has re-emerged as a top priority for health systems all over the world, and particularly in developing countries where governments have often failed to provide adequate public sector services for their citizens. One approach to strengthening public accountability is through direct involvement of clients, users or the general public in health delivery, here termed 'community accountability'. The potential benefits of community accountability, both as an end in itself and as a means of improving health services, have led to significant resources being invested by governments and non-governmental organizations. Data are now needed on the implementation and impact of these initiatives on the ground. A search of PubMed using a systematic approach, supplemented by a hand search of key websites, identified 21 papers from low- or middle-income countries describing at least one measure to enhance community accountability that was linked with peripheral facilities. Mechanisms covered included committees and groups (n = 19), public report cards (n = 1) and patients' rights charters (n = 1). In this paper we summarize the data presented in these papers, including impact, and factors influencing impact, and conclude by commenting on the methods used, and the issues they raise. We highlight that the international interest in community accountability mechanisms linked to peripheral facilities has not been matched by empirical data, and present a conceptual framework and a set of ideas that might contribute to future studies.
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This paper presents a randomized field experiment on community-based monitoring of public primary health care providers in Uganda. Through two rounds of village meetings, localized nongovernmental organizations encouraged communities to be more involved with the state of health service provision and strengthened their capacity to hold their local health providers to account for performance. A year after the intervention, treatment communities are more involved in monitoring the provider, and the health workers appear to exert higher effort to serve the community. We document large increases in utilization and improved health outcomes—reduced child mortality and increased child weight—that compare favorably to some of the more successful community-based intervention trials reported in the medical literature.
Transparency and accountability initiatives (TAIs) have emerged as a key strategy for improving public services, but the links between transparency and accountability and their impact on service delivery are often largely assumed. This article reviews several TAIs to assess their impact. It finds evidence suggesting that a range of accountability initiatives have been effective in their immediate goals and have had a strong impact on public services in a few cases, but that overall evidence of impact on the quality and accessibility of services is more mixed.
This issue of Development Policy Review arises from a study of the impact and effectiveness of transparency and accountability initiatives (TAIs) in different development sectors. It analyses existing evidence, discusses how approaches to learning about TAIs might be improved, and recommends how impact and effectiveness could be enhanced.
Zaire, apparently strong and stable under Presdident Mobutu in the early 1970s, was bankrupt and discredited by the end of that decade, beset by hyperinflation and mass corruption, the populace forced into abject poverty. Why and how, in a new african state strategically located in Central Africa and rich in mineral resources, did this happen? How did the Zairian state become a "parasitic predator" upon its own people? © 1985 The Board of Regents of the University of Wisconsin System. All rights reserved.