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Evidence of Social Accountability_Kamden Hoffmann_5.7.14
1. The Role of Social
Accountability in Improving
Health Outcomes
OVERVIEW AND ANALYSIS OF SELECTED INTERNATIONAL NGO EXPERIENCES TO
ADVANCE THE FIELD
KAMDEN HOFFMANN, PHD, MA, INSIGHT HEALTH, LLC
CONSULTANT TO THE CORE GROUP
MAY 7, 2014
2. Social accountability
Involves ongoing, collective action by civil society groups, including NGOs,
to hold public officials and service providers accountable for the provision
of public goods
Affirming and operationalizing direct accountability relationships between
citizens and the state
Broad range of actions and mechanisms beyond voting that citizens can
use to hold the state to account, as well as actions on the part of
government, civil society, media and other societal actors that promote or
facilitate these efforts
Social Accountability Sourcebook, Chapter 2. Social Accountability: What Does it Mean for the World Bank? 2002
3. Critical factors for social accountability
Social Accountability Sourcebook. Chapter 4: Social Accountability in the Health Sector. Participatory Public Expenditure Management at the National Level. World Bank.
2002.
4. How does it work?
Social accountability initiatives often interface with varying agencies and
divisions of government.
The United States Agency for International Development (USAID)
emphasizes the importance of participation and inclusion of citizens in
governance and prioritizes this within the USAID Strategy on Democracy,
Human Rights, and Governance, with a strong focus on citizen
engagement and accountability
5. Social accountability and health
Accountability is a prominent theme of the U.N. Every Woman Every Child
campaign
Engaging communities and community-based workers in the process of
measuring health status of children, in assessing causes of deaths, in
defining high-risk groups, and in measuring changes in mortality over time
will enable governments to achieve levels of under-5 mortality according
to their commitments
6. Overview of selected INGO
approaches
Citizen Voice and Action, implemented by World Vision
Partnership Defined Quality, implemented by Save the
Children
The Community Score Card, implemented by CARE
White Ribbon Alliance, various approaches
8. Citizen Voice and Action
Where applied: The site must be a place
where the government is providing
services
Applicable sectors: Agenda-neutral
process; has been applied in education
and health, HIV/AIDS, water and
sanitation, and is now expanding into
the private sector
Who is involved: World Vision may
facilitate with the objective of handing
over to local partners. World Vision
identifies an existing group and equips
them with the tools needed to carry out
CVA, .e.g. a local CBO, village
committee, etc.
Constructive evidence based dialogue in order
to improve government services, government
performance, and relationships
Catalyzes alliances between community and key
government officials
CVA encourages collective action, driven and
managed by civil society
Embedded within Area Development Programs
Ability to leverage ongoing work for greater
impact
Existing relationships provide groundwork for
institutionalization of programming
9. Citizen Voice and Action
Length of process: The preparation
phase, called “enabling citizen
engagement” can take the longest, as it
depends on the level of civil society
development
How it increases social accountability:
CVA equips citizens to engage in
evidence-based dialogue with health
workers and local government in order
to improve the accountability of health
services
Financial considerations: Costs range
per program, per year. Costs decline
significantly over time as citizens drive
the bulk of the process
Monitoring and evaluation: World Vision
builds the CVA process into its existing
Area Development Programs (ADP);
evaluation is built into the design of the
ADPs
Challenges or barriers to
implementation: The enabling
environment is the key to
implementation.
10. Save the Children: Partnership Defined
Quality
BUILDING SUPPORT
WORKING IN PARTNERSHIP
FOR QUALITY
IMPROVEMENT
COMMUNITY
DEFINED
QUALITY
HEALTH WORKER
DEFINED QUALITY
Better Health
Improve provider job
satisfaction
Improve client
satisfaction
Increase communities’
sense of ownership of
health facility
Increase
community
capacity for
social change
Shared rights and
responsibilities for
better health outcomes
BRIDGING THE GAP
11. Partnership Defined Quality
Where applied: Best in projects lasting
2 years or more, with enough staff and
budget to adequately support the
PDQ process as related to the size of
the catchment area involved
Applicable sectors: Health, adapted
in education (including non-formal
education), youth, adolescent sexual
and reproductive health, and
HIV/AIDS
Who is involved: Led by project staff
members who are working to improve
the quality of services in order to
achieve project outcomes.
Community based solutions with community
resources, with limited external financial support
and outside solutions, for social change
“Duty bearers” – rights based work
Quality Improvement Teams (QITs) are a key
component
Builds on community capacity, organically grows
as the PDQ process is carried out in the
community
As quality has very different meanings, quality is
defined by the partners in the context of their
community setting, e.g. what keeps people from
going to the health center?
12. Partnership Defined Quality
How it increases social accountability:
Intended to improve quality at the
community level from the perspective
of the consumer (client) and more
than anything, the marginalized client.
Marginalized members address duty
bearers
Financial considerations: Intends to
use local solutions to community-
provider challenges. While costs can
range depending on the context,
many of the PDQ programs have used
local resources as a result of this
process
Monitoring and evaluation: The PDQ
Monitoring and Evaluation Toolkit
provides a set of tools including
supervisory checklists, mapping tools
and an exit interview to support the
implementation of PDQ
Challenges or barriers to
implementation: It is intensive and time
consuming. Frequent transfers in
health staff, lack of political will and
commitment to the PDQ process can
deter successful implementation.
13. CARE: The Community Score Card (CSC)
PHASE II: Conducting the Score Card with the
Community
Community Score Card:
• Community level assessment of priority issues in one
village – what are the barriers to accessibility and delivery
of quality services
• Develop indicators for assessing priority issues
• Complete the Score Card by scoring against each
indicator and giving reason for the scores
• Generate suggestions for improvement
= complete community Score Card for the village
Cluster consolidation meeting:
• Feedback from process
• Consolidate scores for each indicator to come up with
representative score for entire village
• Consolidate community priority issues and suggestions
for improvement
= complete (consolidated) Score Card for the cluster
PHASE IV: Interface Meeting and Action Planning
PHASE I: PLANNING AND PREPARATION
PHASE III: Conducting the Score
Card with Service Providers
• Conduct general assessment of
health service provision – what are
the barriers to delivery of quality
health services?
• Develop indicators for quality
health service provision
• Complete Score Card by scoring
against each indicator
• Identify priority health issues
• Generate suggestions for
improvement
Repeatcycle
CSC Process
PHASE V: Action Plan Implementation and M&E
• Execute action plan • Monitor and evaluate actions • Repeat cycles to ensure institutionalization
Action planning:
• Develop detailed action plan from the
prioritized issues – agreed/negotiated
action plan
• Agree on responsibilities for activities
in the action plan and set time frames
for the activities
Interface meeting:
• Community at large, community leaders, committee members, health center
staff, district officials and process facilitators
• Communities and health center staff present their findings from the Score
Cards
• Communities and health center staff present identified priority health issues
• Prioritize the issues together (in a negotiated way)
14. The Community Score Card
Where applied: Used at the local level to
address local-level barriers; the score
card is implemented at the intersection
between the community and health
facility; however, in other sectors this can
vary
Applicable sectors: Food security,
education, health, HIV/AIDS,
infrastructure, agriculture, water and
sanitation, gender based violence
Who is involved: Participants in the CSC
process is dependent on the focal issue
and the improvements and/or changes
anticipated
CARE’s Governance Programming Framework
reflects a theory of change, grounded in both the
literature and practical experience in social
accountability
Underlying principles for a rights based approach
include Participation and inclusion of voice;
Accountability and transparency; Equity; and
Shared responsibility and obligation
Community Score Card (CSC) is also used as an
internal or forward accountability mechanism to
gain feedback on CARE’s accountability from
communities
CSC repeated measurement: continuous
feedback loop for monitoring and evaluation
every six months and institutionalization of process
15. The Community Score Card
How it increases social accountability:
If citizens are empowered; if power
holders are effective, accountable
and responsive; if spaces for
negotiation are expanded, effective
and inclusive; then sustainable and
equitable development can be
achieved
Financial considerations: Dependent
upon what unit the score card is done
at, e.g. one facility in a catchment
area, and what part of the process,
e.g. preparation and planning or issue
generation
Monitoring and evaluation: CSC
process focuses on improved services
as an outcome, and improved human
development as an impact
Challenges or barriers to
implementation: Fear of negative
fallout among providers and/or
citizens; lack of supervisory support for
providers after changes are initiated;
16. Common themes across models (1)
Preparation and planning
Involvement of marginalized
populations and the poorest of
the poor
Identification of barriers from
civil society and
governmental/public sector
Established presence for entrée: World Vision’s Area
Development Program is their process of implementing long-
term (15 years), local programming that contributes to the
sustained well-being of the population. The approach supports
local advocacy. World Vision incorporates CVA directly into
the Area Development Programs where trust and alliances
may already exist due to World Vision’s presence. Save the
Children also seeks to implement PDQ in communities where
long term programming is established. This includes
communities with child sponsorship funding, where Save the
Children is typically in a community for 10-15 years. The reason
this is effective is that the implementing NGO (in this case Save
the Children) becomes a trusted partner for long term change.
Save the Children has adapted PDQ for use with adolescents in
many of its sponsorship communities worldwide. CARE
incorporates the CSC into its projects and programs.
17. Common themes across models (2)
Interface meetings between
civil society and
governmental/public sector
Focus on accountability and
health outcomes measurement
Facilitation and guides
Rigor of evaluation of
interventions
Value of a score card in measuring services: CARE developed
the community score card; World Vision adapted the score
card in its CVA approach, and PDQ uses another method of
scoring. A score card allows for both users of public services as
well as providers of public services to use a simple method of
assessing the performance of service delivery and offering
proposals to improve the quality of service. The score card
data is usually collected through focus group discussions
among particular interest groups, e.g. women, men, youth,
children, community leaders, PLWH/A, health center
committee, etc. The score cards help develop a set of
indicators for monitoring and evaluation, and can also serve as
a baseline for service improvement. The scorecard can be
used as a tool to generate issues to advocate for to help
integrate some solutions into local policies and systems for
sustainability of results. In addition, community member’s health
behaviors and actions can be evaluated.
18. White Ribbon Alliance
WRA uses a variety of tools to promote social
accountability, including: participatory budgeting; social
audits; participatory planning; public expenditure
tracking surveys; citizen report cards/community score
cards; budget analysis; citizen-based vigilance
committees; public hearings; checklists; and verbal
autopsies
Numerous WRA National Alliances have utilized social
accountability approaches under several initiatives to
increase accountability and improve health outcomes
Social Watch: India
Participatory Health Facility Assessment: Uganda
Practical solutions
recommended by WRA:
Ensuring upfront investment;
accessible information made
available to citizens (not just
donors); direct feedback and
communication loops; value
placed on local data and
evidence; and
institutionalization of social
accountability approaches into
formal mechanisms.
19. Recommendations (1)
Expand existing evidence base: While partners are continuously strengthening
the rigor of their monitoring and evaluation of social accountability
interventions, more evidence is needed regarding the effectiveness of different
interventions at the community, district, regional, and national levels
Clarify financial and human resource inputs: It would be helpful if partners
could formally cost out essential elements in programs for other practitioners
and host countries interested in adapting or applying these social
accountability interventions
Identify barriers to scale up: State actors are involved in each of these models,
however, once action plans are implemented and evaluated, what further
involvement should the government have to ensure more sustainable
outcomes? This includes a better understanding of the influence of the larger
social, economic and donor interests.
20. Recommendations (2)
Consider critical factors in achieving successful outcomes
Highlight the importance of community owned progress: it is very important
for communities implementing the changes to identify their role in
ongoing, measureable improvements in outcomes in order to continue
their involvement and ownership of the process
Develop similar definitions and a central location for well-known social
accountability approaches in health and development
Explore highlights among different models for promising practices: Each
model reviewed by this analysis is comprised of unique elements that merit
further exploration. To the extent possible, these elements should be
analyzed further for their effectiveness and sustainability
21. Annex
References Cited and Additional Resources with Websites
World Vision, Save the Children, CARE, World Bank, and others
Case studies
Tables of key elements and activities among the social accountability
models
According to the World Bank, there are four factors that are critical to any social accountability program: opportunities for information exchange, dialogue and negotiation between citizens and the state; the willingness and ability to seek government accountability among citizens and civil society; transparency and open information sharing, attitudes, skills and practices supporting listening and constructive engagement among service providers and policy makers with citizens; and anenabling environment, with apolicy, legal and regulatory atmosphere for civic engagement. The figure illustrates the critical factors associated with social accountabilityaccording to the World Bank
Bullet 1: Some international non-governmental organization (NGOs), for example, participate in programs and activities to support the involvement of national NGOs and citizens in social accountability processes to strengthen capacity bringing together government and nongovernment actors.Other civil society organizations include advocacy and campaigning, while at the community level, examples exist of local groups enhancing citizenship through awareness of rights and increased capacity for political participation, while social movements have, in some places, successfully pressed for state receptiveness to citizens' rights and agendas
Bullet 1: Governments with high maternal and child mortality made commitments to invest in maternal child and newborn health programs to accelerate the rate of mortality decline to contribute to achieving Millennium Development Goals (MDGs) as well as A Promise Renewed – a vision of ending preventable child deaths by 2035. Bullet 2: The post-2015 agenda will presumably change its approach to measuring results and provide many opportunities for strengthened accountability mechanisms that involve citizens in varying capacities.
The CORE Group solicited input from partners regarding those using social accountability approaches in their programmatic work. Methods of data collection included key informant interviews among partners and a review of documents shared by partners, which is available in the references section.
World Vision’s model seeks to improve the relationship between communities and government, in order to improve services that impact the lives of children and their families. Their view is that each citizen has the right to communicate with, and have a relationship with, their government. Active citizenship and engagement with government helps governments to work effectively and to provide quality services. The approach catalyzes an alliance between community members and government officials, based on those officials who are willing to participate
Can be based at a facility, clinic, or school, and expanded from there.
Bullet 1: Experience varies from two weeks to one year, depending on the amount of time it takes to engage civil society and/or government involvement. Bullet 4: Most recent evaluation indicators focus on: improved services; increased engagement between citizens and government; and improved relationshipsBullet 5: In some cases, governments at various levels may not inform local officials that they should participate, so there may not be a true willingness to engage
PDQ aims to improve quality and accessibility of services, allowing more involvement of the community in defining, implementing and monitoring the quality improvement process. This includes the recognition that quality may be defined from different perspectives among clients and providers. It focuses providers and clients working together as allies to address problems and work to overcome any possible blame.
Bullet 1: The process works best at the community level in the catchment area around a health post or health center, however, it could also be used at district levelBullet 3: At least 30% of participants need to be from marginalized groups or else their voices will not be heard.There must be clear identification of two “partners,” meaning a clear group that uses a service, and a clear group that is has the responsibility to provide that service.
Bullet 1: The community takes ownership to improve health using existing resources, and client satisfaction and provider performance increases together with overall health status.Bullet 3: Some examples of indicators monitored include: client satisfaction; standard measures of the quality and availability of health services; utilization of health services and promoted health behaviors; and improved equity in health services deliveryBullet 4: Sometimes there can be a lack of investment in the community, mostly due to self-interest and in the case when people involved are not from that particular community, or if providers are not interested in their communities
The CSC is an approach that brings together community members, service providers, and local government to identify service utilization and provision challenges, and to mutually generate solutions, and work in partnership to implement and track the effectiveness of those solutions in an ongoing process of improvementCARE’s Governance Programming Framework Theory of Change is the high level 'theory of change' that guide and underpin CARE's governance work, including CARE’s CSC work: If citizens (i.e. health service users) are empowered, if power holders (i.e. health providers and government) are effective, accountable and responsive, if spaces for negotiation are expanded, effective and inclusive, then sustainable and equitable development (i.e. improvement in health care coverage, quality and equity and improved health outcomes) can be achieved.
Bullet 1: Evidence from the CSC can be used to take uncovered issues to a higher level. District government are involved throughout the entire CSC process. They help with the preparation and planning, and really are the co-implementers.Bullet 3: For example, youth, reproductive health, maternal health, etc.
Bullet 1: The CSC approach can be used to facilitate good governance through promotion of participation, transparency, accountability and informed decision-makingBullet 2: Also will depend on how many staff members are needed to facilitate; The cost of a CSC cycle varies depending on the scale and the scope of the CSC project. The only cost is facilitating the processBullet 3: CARE also ensures measurement of governance outcomes, including improved decision-making, transparency, and accountability. The governance outcomes act as enablers for improved services. ‘Bullet 4: Among government/power holders, questions arise regarding whether the process is beneficial or damaging to them, the amount of time allotted to the process, as well as understanding the benefits of the process. NGOs and civil society may be weary of participating in this process based on perceptions that the process could lead to adversarial relationships with the government
Bullet 1:As part of preparation and planning, context analysis or political economy analysis to understand potential challenges that may happen in the process, and development of processes that can mitigate potential conflict among partners and power dynamicsBullet 2: CVA an extension of their regular programming, which involves marginalized groups. CARE and World Vision use their community score card models specifically with marginalized populations. Bullet 3: Through a variety of quantitative and qualitative methods, including score cards and focus groups, bottlenecks and challenges are defined separately by government partners and civil society.
Bullet 1:The government/public sector and civil society are brought together to compare perceptions from the problem identification phase. These issues are often disaggregated for marginalized groups. Bullet 2: Indicators are developed and measured that focus on accountability functions such as collective capacity, collective action, community empowerment, budget changes, social cohesion, and social capital. Alongside social accountability indicators, sector specific indicators are developed and measured including access to and quality of health services, primary school enrollment, utilization of health services and promoted health behaviors.Bullet 3: Skilled facilitators with negotiation skills is critical for these activities to succeed. Toolkits and field guides exist for partners in the field to adapt when implementing the activitiesBullet 4: All three organizations have undertaken a level of rigor in evaluating various outcomes of their respective interventions, including RCTs and operations research
WRA India is using a Social Watch approach to promote accountability for safe motherhood. Social watch is a ‘people-centered’ strategy that mobilizes civil society to hold governments accountable to their commitments. Social watch techniques mobilize citizens and engage them to hold duty bearers accountable for transforming maternal and newborn health commitments and policies into improved access to quality services. Of the 204 sub-centers and 102 primary health centers assessed under the Deliver Now campaign, results included: an increase in postnatal visits by auxiliary nurse midwives to new mothers and their babies from 15 to 25 percent2013, WRA Uganda launched a campaign to hold the Government accountable to its commitment to provide basic emergency obstetric and newborn care (EmONC) at all health centres and comprehensive emergency obstetric and newborn care (CEmONC) at 50% of health centreIvs. As part of the campaign efforts, WRA- Uganda, in partnership with the Kabale, Lira and Mityana District Local Governments, organized participatory Health Facility Assessments using checklists to evaluate the provision of Emergency Obstetric and Newborn Care Provision (EmONC).
Bullet 3: An emphasis on identification of these barriers could help develop solutions for more effective scale up.
Bullet 1: This refers to the elements discussed at the beginning of the presentation 1) citizen-state bridging mechanisms; 2) ability and willingness of citizens–and their representatives/civil society organizations (CSOs)–to engage in effective social accountability and demand government and service provider accountability; 3) ability and willingness of the state–politicians and bureaucrats–and service providers to be accountable and responsive to the public and civil society; 4) and presence of a broader enabling environmentBullet 2: While building community capacity at the local level allows for community ownership, the data generated may not be significant at a national levelBullet 3: It may be helpful to create a database of terms as the World Bank has done in their glossary of Social Accountability Tools and Approaches. It may be beneficial to develop an information repository that contains such a glossary, as well as the evidence-based articles, theoretical and practical tools available among organizations for practitioners,allowing for an opportunity to build synergy, and harnessing a repository of lessons learned. Bullet 4: For example, elements may include World Vision’s ability to bring the CVA approach within area development programs, CARE’s repeated score card process for institutionalization, and Save the Children’s focus on tested indicators for community capacity.