1. Community Score Cards Empowering Marginalised Communities to Negotiate for Better Service Delivery Abhijit Das Centre for Health & Social Justice, India

2. 2 Introduction to Presentation What is a Community Score Card Steps for developing a Community Score Card based feedback mechanism Example of using Community Score Card methodology –mechanism and results Challenges

3. Part 1 What is the Community Score Card Method

4. 4 What is a Community Score Card A Working Definition: –A Community-owned process –Where the community collates its experience –Related to a mandated public service –Systematically, and –Presents it to providers and managers of the public system for feedback, review and planning Community Score Card may be used as a component of Evidence Based Advocacy

5. 5 Score Card : Working definition A score card is a summary document of performance of a system The parameters of the score card are drawn from conditions necessary for the fulfillment of rights/ needs It allows for community experience ( of enjoying rights or of rights violations) to be converted into a quantitative measure It allows for comparison against a benchmark It allows for comparison over time Useful of feedback, planning and monitoring

6. 6 Some Conditions for success of CSC Community Level Conditions –Mobilised community with knowledge of its own health related issues and problems (rights) –Knowledge of publicly supported health policies and programmes –Ability to compile evidence of programme/ policy implementation Service Provision Level Conditions –Openness to feedback and sense of accountability –Respect for community and non-judgemental approach –Ability to provide quality services

7. 7 Key Principles : CSC Both parties believe in the developmental nature of the process, otherwise it can become an opportunity for preparing a list of complaints or a confrontation, or tokenism Jointly accepted set of parameters for monitoring – patient charters, Quality of Care standards, treatment protocols, programme guidelines Orientation and capacity building of both parties. Programme flexibility to incorporate new suggestions

8. Part 2 Developing a CSC based Feedback System

9. 9 Developing CSC based advocacy What is the advocacy issue - What is the change desired in service delivery? Services – Mandated by law or policy? Any Standards and Guidelines? Competency standards? Reach and effect of services? Availability, Accessibility, Acceptability and Quality of Services? Community Experiences, Adverse outcomes? Status of the community - Are they aware of their entitlement/rights? Are they mobilised?

10. 10 Steps of Implementing the CSC methodology 1.Identifying the issue and the evidence base needed 2.Developing an appropriate methodology for gathering evidence 3.Mobilising and building capacity in community to generate the evidence 4.Supporting the process of evidence generation, collation of Score Cards develop an advocacy plan 5.Organising interface with providers and develop a plan of action 6.Follow up

11. 11 Community Experience Poor / Absent Service/ Denial Consolidate collective community experience into a score cared Share Score Card with Providers Plan for improved service delivery – provider and community responsibilities outlined New Experience of service delivery Consolidate New collective community experience into a new score cared

12. Part 3 Using Community Score Cards to improve service delivery and utilisation in India

13. 13 Conditions in India Government of India introduced a National Rural Health Mission (NRHM) in 2005 to provide equitable, affordable, accountable and effective primary healthcare to the poor It includes provisions for decentralised management community participation – including planning and monitoring NRHM includes service delivery standards (Indian Public Health Standards) and Concrete Service Guarantees that spell out the range of services that will be available at different levels of care.

14. 14 The Community Monitoring Process Community Monitoring is a process included within the NRHM to increase community ownership/accountability. It involves a systematic process through which community members provide feedback about services to the providers The feedback includes parameters which are included within the range and quality of services that the provider is expected to provide The primary purpose of the feedback is to improve service delivery It was done over 9 states and covered 1600 villages

15. 15 Frameworks and Processes  Entitlements under the Maternal Health Scheme;  Roles and responsibilities of the Community Health Volunteer  Indian Public Health Standards for different facilities like Sub centre, Primary Health Centre, Community Health Centre  Concrete Service Guarantees, Citizen’s Charter and so on. Block Provider’s Orientation Village Health and Sanitation Committee Training – Entitlement Awareness and Frameworks Community Enquiry Community Score Cards Community Sharing Joint Sharing / Jan Sanwad

16. 16 Key Activities and Issues Activities Orientation of Programme Managers Orientation of Health Providers Training of Community Leaders ( Village Health and Sanitation Committee) Community Awareness Community Enquiry Public Sharing Key Issues Maternal Health Child Health Disease Surveillance Curative Care Untied Funds Utilisation Quality of Care Community Participation Functioning of Community Volunteer

17. 17 Mechanism of Enquiry Group Discussion with Women Group Discussion with Community Group discussion with Mothers who delivered recently Maternal Health, Child Health, Quality of Care, Commuity Health Volunteer functioning and Janani Suraksha Yojana* Disease Surveillance, Quality of Care, Untied Fund Utilisation, Community Participation *a set of services used by the Indian government to reduce maternal & infant mortality

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19. 19 Group discussion with Women who had a recent delivery Ask each woman -Did she receive the Ante natal or post natal service she was supposed to received, including blood and urine examination -Did she receive the financial support she was supposed to receive -How the nurses and doctors behaved with her at the hospital -Whether she had any complications and whether those complications were treated. -….and so on

20. 20 Group discussion with Community on General Health Situation Ask the participants about Child Health –Are immunisation camps regularly held –Are children regularly weighed –Is nutritional supplement provided regularly Ask the participants about their experience of the services received and the Quality of Care at the nearest dispensary Ask the participants about the services of the Community Nurse ……….. And so on

21. 21 Converting the results of a Group Discussion into a Score Card Scoring Each sub-question that is discussed is given a score or a rank. Eg. Does the Community nurse come regularly to your village – every month- 3, every other month 2 occassionaly-1, never -0. or Did you receive 2 injections of Tetanus Toxoid injections – Yes- 1, No-0 Traffic Light - All questions under one broad heading are scored together. All the questions relating to maternal health is clubbed together and the scores added up. This figure is divided by the maximum possible score for this section. If the answer is more than 75% it is converted to a green Traffic Light, if it is between 50% and 75% it is converted into a yellow traffic light, if it is less than 50% it is converted into red traffic light.

22. 22 Filled in Score Card with Traffic Lights

23. 23 Sharing of the Score Card Village Sharing –Sharing of the Community Score Card with providers –Planning for Improved Service delivery Jan Samvad (Public Dialogue) –Conducted at Block or District level –Presentation of Cumulative Score Card –Discussion on implementation of outreach services, improving facility level service utilization

24. Part 4 Results

25. 25 Change in Health services in a Public Health Centre area after six months of monitoring - Maharashtra October 08 April 09

26. 26 Anganwadi services: 21% ↑ in good Experience of Public Health Centre services: 53% ↑ in good Public Health Centre staff behaviour: 42% ↑ in good Untied funds & patient transport: 23% ↑ in good Services showing marked improvement with Community Based Monitoring

27. 27 Changes – Story from Orissa There have been changes in the range of services provided to women for ante-natal and post natal services. In both villages with Community Monitoring and those without Community Monitoring, village level Fixed health day, Iron Folic Acid tablet distribution and Tetanus Toxoid injection was being done but check- ups of abdomen, Blood Pressure and measurement of weight is being done primarily in villages where Community Monitoring was taking place Most mothers received counseling in these villages but not so in other villages Mothers from villages without Community Monitoring hardly received any Pre Natal Care or Neo Natal Care services

28. Part 5 Challenges

29. 29 Challenges At the Programme/ Macro level Scale Institutional Inertia Time bound programme At the Implementation /Micro level Capacity of Community Leadership and facilitators Get providers ready to listen – not dismiss Manage community relationship with providers – avoid ‘blaming’ Follow up

30. Thank you Acknowledgements All members of Advisory Group on Community Action and all State Nodal Agencies, Special thanks to Maharashtra State Nodal Agency and Bangriposi Block Nodal Non Government Organization for sharing their results.