Social Accountability in Action

Service providers and service recipients in four districts make joint plans to improve the functioning of 16 health posts using Community Score Cards

The Context and the Problems

Health posts operate at the level of every VDC in Nepal - Primary Health Centers, Health Posts, and Sub-Health Posts. There are many stakeholders in the operation of a health post – Health Post In-charge, Health Staff, Local Users of the services, Health Service Management Committees, Village Development Committees, District Health Office, and the Department of Health. Considerable problems arise where there is no good communication between them, and, if this problem is not tackled, can escalate into poor relations, which diminish the quality of the health services to the rural populations. The Program for Accountability in Nepal (PRAN) encouraged the use of the social accountability tool “Community Score Cards” to improve health service delivery in rural areas.

Typical examples of problems from the side of service deliverers are:

  • Insufficiently trained staff, and lack of training opportunities
  • Lack of medicines at needed times – particularly vaccines
  • Inadequate equipment
  • More staff needed for health education and sanitation
  • Inability to provide emergency services
  • Lack of counseling service for family planning, and lack of contraceptive devices

Typical examples of problems from the side of those receiving the services are:

  • Vaccines and vaccination services not available at important times
  • Medicine names not written in Nepali
  • Lack of refrigerator for the cold chain process
  • Lack of knowledge about free medicines
  • Lack of outreach clinics for more remote people
  • Lack of information on the budgets and expenditures of health posts
  • Health post staff are not polite to patients
  • Clean toilets at health post
  • Health post staff should be in attendance at agreed times.

PRAN worked with CSOs and Government health personnel from 16 VDCs to bring together service providers and service receivers to discuss their separate problems, and then come together to find the common areas of agreement which led them to a mutually agreed action plan. The tool to enable this to happen was the Community Score Card. This was a new approach for all of them and required facilitation by Pro-Public, PRAN’s partner.

What actually happened?

In a joint meeting between CSOs, local villagers and health personnel the process of Community Score Cards was explained – that service providers and service receivers would select issues important to them, score them, share their findings, and try to seek a jointly agreed plan for improvements.

Firstly, the topics of most interest to all were identified and listed. These were, typically, human resources, medicine, buildings and equipment, immunization, and budgets. This list, once agreed, was then discussed by service providers and service receivers separately, and the items in the list were scored by the participants from 1-10 separately – a process which takes considerable time and needs good facilitation.

Once the scores were agreed by both sides separately, they were invited to come together and to show each other the issues that were important to them, and the scores that had been given. This required even better facilitation to make sure that people were speaking openly and honestly but were not being aggressive and confrontational. The need for a joint action plan agreeable to both sides was emphasized.

Eventually a joint action plan with responsibility and start date was agreed, and shared with all parties.

Here is a typical Joint Action Plan - from Lakhatari Sub-Health Post, Lakanthari VDC, Morang District:

  • All staff will be in the office on time and follow office hours
  • Out-patients service will be provided from 1000 to 1400
  • Iron capsules will be available free
  • A family planning awareness service will be started
  • The Ministry of Health will be requested to provide regular vaccines
  • An awareness program for nutrition will be started
  • Medicine for ARI will be provided

What does this illustrate?

It illustrates that both service providers and service receivers have problems and they can be helpful to each other in solving these problems e.g. if there is a lack of vaccines, the local people and the VDC can add their pressure to the Health Post in requesting more vaccines on time. If the local people appreciate the need for family planning advice, then a family planning service is likely to be taken up.

What does this lead to?

This leads to joint agreement between villagers and health post staff about what needs to be done, and joint commitment by them to follow up on the action plan that they have agreed. It also educates each side about the problems that are experienced by the other. Greater understanding reduces an accusatory and confrontational attitude. Finally, it leads to an educated citizenry that can take responsibility for some of the services they receive and deliberate what they can do to improve the situation.

What did not happen?

In scoring issues important to the service providers, or the Health Post personnel, were defensive about their scores, frequently scoring high, even though in subsequent conversation, when they were asked what needed to be improved, it was clear that things were not so good. It takes time and good facilitation to get people to appreciate that honesty about problems and shortcomings is valuable, because it can lead to agreement for better performance.

How does this illustrate PRAN’s purpose?

PRAN’s purpose is to promote more accountable, honest, transparent and responsive government agencies delivering quality public services through the use of social accountability tools. The staff of the Ministry of Health who participated in this pilot was highly impressed. In their opinion, it provides an example of how those who receive health services can provide useful and relevant feedback to those who deliver health services with the result that the services overall can improve. It is relatively inexpensive and light in terms of its human resource requirements, and has the added advantage of providing the opportunity of citizens to engage with the government about the development of the country. It is worth considering further roll out of this idea to other districts of the country.