Description

In 2005, World Vision Uganda introduced communities, health clinics and local government to an approach aimed at addressing weak accountability of health services. Community dialogue was established with health and government staff over service standards such as staff numbers, midwives and drug supply.

Communities also came up with their own scorecards on the quality of the services. This social accountability approach, called Citizen Voice and Action (CVA), is now underway in 17 health clinics across 20 Districts in Uganda.
In 76 percent of the clinics where CVA has been introduced, there has been an increase of between one and 12 staff.

Of these clinics, 23 percent have appointed midwives. In more than half of the clinics, the increase in staff was of two or more. In 17percent of clinics, the monthly attendance of women coming in for antenatal and birthing services more than doubled.

Alternate reasons cannot be ruled out for these improvements, but the health workers and District government staff at these clinics credit the CVA approach for significantly contributing to these outcomes. In particular, there is a considerable improvement in the relationship between health workers and the community which has led to increased health seeking behavior, as demonstrated through higher outpatient numbers.

Some of the results mirror the successful outcomes of a very similar social accountability approach documented in an influential random control trial in Uganda that resulted in a 33 percent reduction in child mortality and a 58 percent increase in women giving birth at clinics.

In particular, in the case of CVA, key District staff report that their decision making to recruit additional health staff was strongly influenced by the combined pressure exerted by staff, community and local politicians during and after the CVA meetings.

John Willy Mungoma, Health education promoter at Tororo District, said, “Politicians at times they come and talk fast … we … act on what they have told us, but now as communities also raised their voices ... it was a combination of forces, so it .. forced us to do that [recruit more staff].”

Charles Wamala, Mpigi District Assistant Chief Administrative Officer, said, “There was a lot of pressure on the District, including from the politicians and the Health Management Committee of the facility. The dialogue was hot that we [were not acting on the] needs of the community members.”

David Wambura, Mbale District Chief Administrative Officer said, “All of us are on our toes now. We are under pressure to deliver and if we don’t, we have to explain why. We are waking up. We have taken them [the community] for granted for a long time.”

Increased staff numbers and improved patient staff relations have helped to attract substantially higher numbers of outpatients, especially women seeking to give birth at heath facilities, receive antenatal care, and bring their children for immunizations.

In 25 percent of the clinics, dedicated maternity services were initiated. In 50 percent of the clinics access to drugs improved, a situation also attributed to a District ‘push’ system introduced in recent years. In 18percent of the clinics, Prevention of Mother to Child Transmission (PMTCT) services either started or were expanded.

Many NGO health programs target the knowledge of community and health workers to increase health seeking behavior and outcomes, but CVA has also tackled the negative interaction between the community and health workers, which poses a significant barrier to health seeking behaviour.

“The attitude towards patients and the attitude towards health workers have greatly improved,” said Willy Mungoma, Tororo District health education promoter.