CARE: Social and Economic Transformation of the Ultra-Poor (SETU, Bangladesh)
CARE’s Social and Economic Transformation of the Ultra-Poor (SETU) and the subsequent project, Journey for Advancement in Transparency, Representation and Accountability (JATRA) in Bangladesh engages with Union Parishads (local government) and extremely poor communities, and facilitates spaces for the two sets of groups to engage in dialogue and negotiate entitlements. Among the extreme poor, groups are formed to build solidarity and natural leaders are identified. These natural leaders mobilize communities to negotiate with landlords, or with employers for fairer wages, and represent community needs to Union Parishads. SETU and JATRA projects also helped reestablish Ward Shava budget planning meetings to help influence spending decisions in line with the priorities of the most marginalized communities (para). The project ensured consultations and social audits with local decision-makers and marginalized groups of women to ensure poor women's perspectives are taken into account. [1] Download the Citizen Monitoring in Peru - Guidance Note
What does the evidence indicate?
SETU’s work (and the work of natural leaders) helped to increase diversity of livelihood strategies and greater benefits from government safety net programs. There was less reliance on exploitative labor. This did not lift households out of poverty, but reduced vulnerability to shocks. SETU’s development of self-help groups helped women build assets, and helped communities to lead collective action in fisheries and vegetable/banana cultivation; Union Parishads facilitated access to public lands and ponds. While results from JATRA are still being assessed, the project has seen gains in broader participation among poor women and men in social audit processes and meetings.[2]
The Union Parishad Act of 2009 stipulates that at least 5% attendance. By tracking attendance records, among the 130 wards that conducted Ward Shava budget meetings in year 1 of the project, a study found that a total of 49,761 community members (25,184 men and 24,577 women) participated. And this represents just over 10% of the total voting population of these wards – double the mandated number and significantly more than in other wards. Likewise, there is initial evidence which suggests that a higher proportion of resources has been allocated towards issues women raised in these meetings as a result of this citizen engagement [3].
References:
1.Hinton, R. (2011). Inclusive governance: transforming livelihood security. Experiences from Bangladesh; 2. Hinton, R. (2011). Inclusive governance: transforming livelihood security. Experiences from Bangladesh. CARE International UK; CARE (2016). Results in Citizen Participation in Local Governance. Project Highlights; 3. CARE (2016). Results in citizen participation in local governance: Journey for Advancement in Transparency, Representation and Accountability (JATRA)
CARE: Community health monitors (Peru)
In the remote highlands of Peru, CARE trained community health monitors to regularly visit health centers (generally 2-3 visits per week) and discuss with female patients how they had been treated, how long they had waited to be seen, whether information was provided in their native language, etc. This was part of a citizen monitoring project to promote quality healthcare. This information was documented and then the regular reports were analyzed with ForoSalud (Peru’s largest civil society health network), the regional Ombudsman’s office, CARE and others. This process helped citizens to voice their concerns, hold service providers to account and promote constructive dialogue on the quality of services.[1]
What does the evidence indicate?
In Peru, in health centers where social monitoring was introduced, users have four times higher awareness of complaint mechanisms and the percentage of users with complaints was twice as high. Social monitoring has driven a rise in expectations and an improvement in the quality of services, but the latter has not kept pace with the former.[2] Monitors have worked with participatory budgets to successfully advocate for the construction of birthing houses where women can stay before delivery.[3] This work also increased transparency in health facilities: for example, which services and medicines were provided free of charge, and that birth certificates are free. There is also an increased receptivity to user preferences: for example, there has been a two-fold increase (from 194 births in 2008 to 437 in 2009) in the number of vertical birth deliveries (the preferred method of many rural indigenous women). Greater confidence in the quality of care has translated into increased demand for services. CARE’s quantitative assessment in 2010 (comparing data between 2007 and 2009), comparing micro-networks with control facilities in Azángaro, found an increase in:
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- pre- and post-natal controls
- women’s access to laboratory exams;
- institutional birth delivery;
- the proportion of women affiliated with the national health insurance programme. In Ayaviri, improvements were found only in women’s access to laboratory examinations. This difference is largely attributed to greater problems in the quality of attention in the Ayaviri hospital, related to a greater staff rotation than in Azángaro. [4]
Citizen monitoring can have an important impact on the quality of service delivery. Beyond empowering monitors themselves, the citizen monitoring model has improved transparency in health facilities, ensured greater respect for users’ preferences in birth delivery, and helped reduce corruption; and this improved quality has generated greater demand for health services. Moreover, in comparison with other social accountability models such as Community Score Cards, the mobilization of community monitors means that there is regular community engagement to check that whatever promises are made by service providers are met[5].
References:
1. CARE International UK (2015). Learning and policy series: Citizen monitoring to defend maternal health rights in Peru. Briefing Paper, 6; 2. Aston, T. (2015). Learning and policy series: Citizen monitoring to defend maternal health rights in Peru. Briefing Paper, 6; 3. Gozzo, G. (2015). The power of participatory monitoring in making the Sustainable Development Goals a reality; 4. Aston, T. (2015). Learning and policy series: Citizen monitoring to defend maternal health rights in Peru. Briefing Paper, 6; 5. Ibid
CARE: Community Score Card (CSC, multi-country)
CARE’s Community Score Card© (CSC) bring together service users, service providers and local government to identify challenges to access, utilization and provision challenges, and generate solutions that can be collectively tracked. CSC facilitators are trained, and then use the CSC with focus groups (i.e. men, women, youth) to identify their issues and experiences using the service that is in focus. In parallel or subsequently, the CSC is used with service providers to record the issues and barriers they face. Then, an interface meeting is held with community members, service provider and government staff, and a joint action plan is developed to resolve the problems identified. The implementation of the action plan is monitored in much the same way, on a six-month cycle.[1] The citizen report card process supported by the World Bank in Uganda follows a similar process, though uses community-based facilitators to ensure representation across gender, age groups, and different abilities to meet and share their experiences with services.[2] The Community Score Cards can help mainstream good governance in women and value chains projects, as well.[3] Download the Community Score Card Toolkit
What does the evidence indicate?
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- A review of evaluations of Community Score Card© projects in Malawi, Tanzania, Ethiopia, Rwanda and Egypt reported overall increases in utilization of health services. CSCs improve the user-centered dimension of quality in several ways, including by increasing respectful treatment of patients by health providers. This helps to increase service utilization, and whether women deliver in facilities with skilled providers.[4] Several projects also suggested that the CSC process unlocked resources (i.e. human, material, financial) from the system, improved the ability of citizens to hold providers to account, improved the relationship between providers and citizens, and shifted power to citizens. Several projects also indicated that CSCs providers working in unsupportive work environments found citizen pressure useful to shift resources and be more effective.[5] Some areas for improvement on CSCs are: ensure that marginalized groups participate (e.g. have separate focus groups for women); consider how to not only focus on accountability at the local level, but also at the national level; and build bridges between citizens and public policy-making processes from early on.[6]
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- Through the Community Score Card© (CSC) approach, the Maternal Health Alliance Project (2011-2015) empowered community members, health providers and local government officials in Ntcheu, Malawi to identify reproductive health service utilization and provision challenges, to mutually generate solutions, and to work in partnership to implement and track the effectiveness of those solutions in an on-going process of improvement. CARE’s cluster-randomized control evaluation revealed that compared with communities where the CSC was not implemented, the proportion of women receiving a home visit during pregnancy increased by 20%, while satisfaction with health services increased by 16%. Use of modern family planning methods was also estimated to be 57% higher in the intervention area, showing how inclusive governance approaches such as scorecards can make important contributions to the health outcomes that CARE and others are seeking.[7]
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- In a review of a Uganda community-based health clinic monitoring and social contract initiative using Citizen Report Cards, treatment communities observed a reduction in infant mortality (33%), increased use of outpatient services (20%) and overall improvement of health treatment practices (immunization rates, waiting time, absenteeism).[8]
SEE: Gender Integrated Value Chains.
References:
1. CARE Malawi. (2013). The Community Score Card (CSC): A generic guide for implementing CARE’s CSC process to improve quality of services; 2. Fox, J. A. (2015). Social Accountability: What Does the Evidence Really Say? World Development, 72, 346-361. doi:10.1016/j.worlddev.2015.03.011 ; 3. Mondelez International, Cocoa Life, & CARE International. (2016, October). Women's Leadership in Cocoa Life Communities ; 4. Gullo, S., Galavotti, C., & Altman, L. (2016). A review of CARE’s Community Score Card experience and evidence. Health Policy and Planning, 31(10), 1467-1478. doi:10.1093/heapol/czw064 ; 5. Chen, L., Evans, T., Anand, S., Boufford, J. I., Brown, H., Chowdhury, M., Wibulpolprasert, S. (2004). Human resources for health: overcoming the crisis. The Lancet, 364(9449), 1984-1990. doi:10.1016/s0140-6736(04)17482-5; 6. Gullo, S., Galavotti, C., & Altman, L. (2016). A review of CARE’s Community Score Card experience and evidence. Health Policy and Planning, 31(10), 1467-1478. doi:10.1093/heapol/czw064; 7. Gullo, S., Galavotti, C., Kuhlmann, A.S., Msiska, T., Hastings, P. and Marti, C.N. “Effects of a social accountability approach, CARE’s Community Score Card on reproductive health-related outcomes in Malawi: A cluster-randomized controlled evaluation.” PLoS ONE 12(2): e0171316.
8. Björkman-Nyqvist, M., De Walque, D., & Svensson, J. (2014, August). Information is Power: Experimental Evidence of the Long Run Impact of Community Based Monitoring (Rep. No. WPS 7015).
CARE: Community Support System (CmSS, Bangladesh)
Community Support System (CmSS), developed by CARE Bangladesh in 1999, is a community mobilization mechanism that builds community capacity and participation to demand, negotiate and utilize health services. CmSS has been used in Bangladesh to track pregnant women and provide need-based support to ensure pregnancies are safe and timely use of emergency obstetric care. CmSS conducts community surveillance for tracking, registration of pregnancy and violence against women; facilitates birth preparedness; mobilizes local funds and resources to support emergency transport and referral; promotes accountability and responsiveness through community feedback and advocacy; links with local government and health system; and creates an enabling environment for communities to become “watch dogs” to prevent harmful practices.[1]
What does the evidence indicate?
In Bangladesh, the Safe Motherhood Promotion Project sought to develop community capacity to improve safe motherhood practices at the local level and strengthen emergency obstetric care services at sub-district health complexes. The project used community mobilization activities that aimed to increase awareness and demand for maternal health services through the development of the Community Support System (CmSS), and established regular meetings between community members, service providers, and sub-district level policymakers. As a result, women and the community have a greater voice with respect to the governance of the local health system, and service providers are more accountable to the community for the quality of care. An impact study found that CmSS resulted in 71% antenatal care access for women in the lowest wealth quintile compared to 30% in the non-CmSS area.[2]
References:
1. Hossain, J., Dr. (2015, March). Project Summary: Community Support System Experimental Evidence of the Long Run Impact of Community Based Monitoring (Rep. No. WPS 7015) ; 2. Hossain, J., Dr. (2015, March). Project Summary: Community Support System.