By Lara Ho, PhD, RN. Senior Technical Advisor for Health Programs. International Rescue Committee
As the recent Ebola crisis in West Africa is demonstrating so horrifically, health systems in many post-conflict countries aren’t able to address some basic needs. This may be due to political will, human resources, or financing. This gap is not insurmountable, however. Investing in strengthening local accountability can improve the situation by shifting power dynamics, and changing the way users and frontline health workers interact.
The International Rescue Committee (IRC) recently published a brief on the implementation of a community scorecard in eastern Democratic Republic of Congo (DRC) in the context of a larger DFID-funded community driven reconstruction program. The IRC’s brief examines whether the scorecard resulted in more responsive and accessible services. The scorecard serves to inform users and providers on service-delivery standards, ensure representative community participation, and facilitate collective problem-solving. The scorecard was introduced as part of a larger program called Tuungane, which also provides $24,000 sub-grants, and trains communities to undertake an infrastructure project. The scorecard and related activities enables communities to become more active agents of their own development, and to ensure that service providers address community priorities. To date, Tuungane has introduced the community scorecard at 151 health facilities.
Participants were asked about the most significant change resulting from the process. Many of them mentioned improved access to services. The cost of healthcare is a major barrier to access in the DRC where nearly three quarters of the population lives below the poverty line and the Ministry of Public Health neither supports fee exemptions nor exerts much authority over how much clients are charged. After working with the community scorecard, health and village development committee members in one community began actively participating in management of their health center, which had previously been run exclusively by the head nurse. They were eventually able to negotiate a reduction in user fees to approximately 0.50 USD for a child and 1 USD for an adult.
Other changes reported by users and providers in other villages included increased transparency and community involvement in management of health facilities, improved patient-provider relationships, and improved performance of providers. Some communities felt empowered to seek additional assistance from local authorities or other organizations to address the issues identified at their health facility.
In fragile and conflict-affected states, getting support from the central government can be a formidable challenge. The community scorecard project has shown that, in the meantime, local action is possible. Facilitating collaboration between users and frontline healthcare workers is a feasible and effective way for communities to address some of their self-identified needs.