Background
With the support of Health Extension Workers and community volunteers known as the Health Development Army, Ethiopia has rolled out a community scorecard (CSC) mechanism to improve quality of care within primary health care units. The CSC was initiated in July 2017 as a key component of the MoH’s Health Reform Agenda and piloted in 36 districts of the four most populous regions. As of December 2020, the CSC has been implemented in 55% of the districts of the country, touching all 10 regions and 2 city administrations. The scorecard is one tool used to monitor the progress towards implementing two of the MoH’s flagship initiatives: the Woreda (District) Transformation and the Primary Health Care Improvement Programmes.
How it works
30 citizens representing a community’s diversity (by gender, age, religion, etc) are identified on a rotating basis from each community (known as a Kebele) to meet and score their local health facility against 6 service quality of care indicators. After the discussion, scores are counted and a scorecard is produced. Representatives of the community, known as the Client Council, then go to the health facility to present and discuss the scorecard with health facility managers and workers. Together they produce an action plan to address priorities raised by the community. Periodically, a facilitated townhall meeting also takes place in which a wider group of people – including district council members, district health officers and other local leaders – discuss identified service issues and steps taken to implement the action plan as well as how to overcome barriers and service gaps that may persist. If solutions cannot be addressed locally, requests are made for responses to higher levels within the MoH: zonal, regional or federal.
Community Scorecard Evaluation Result from AkashKebele (Community), Godere Woreda (District), Gambela Region, October to December 2019
| Evaluation criteria (indicators) | Very low (1) | Low (2) | OK (3) | Good (4) | Very good (5) | Average score2 | Total score | Total score %3 |
| Caring, respectful and compassionate service | 31 | 20 | 27 | 20 | 15 | 2.8 | 85 | 56% |
| Waiting time for health care services | 121 | 4 | 30 | 4 | 25 | 2.5 | 75 | 50% |
| Availability of drugs, diagnostics and supplies | 21 | 4 | 15 | 4 | 5 | 1.63 | 49 | 32% |
| Infrastructure of facility (electricity, water, rooms) | 12 | 26 | 6 | 12 | 0 | 1.86 | 56 | 37% |
| Availability and management of ambulance | 6 | 18 | 0 | 24 | 45 | 3.1 | 93 | 62% |
| Clean and safe health facility | 0 | 18 | 27 | 28 | 25 | 3.3 | 98 | 65% |
| Scores of 30 citizens converted to (%) | 50% |
- The consolidated score from those citizens who gave a score of 1 (very low). This indicates 3 people scored 1 (3 x 1 = 3). A consolidated score of 20 for low, indicates 10 people scoring 2 each = 20.
- Average score is the total score/# of people = 30.
- Highest possible score of 30 citizens is 30 x 5 (very high) = 150. Actual score in % = Total Score/150.
Impact
Resource mobilisation
USAID-funded Transform Primary Health Care Units (PCHU) project, managed by Pathfinder and JSI, has provided technical and financial support for CSC piloting and scale-up in 5 regions since July 2017. From October 2019 to September 2020, a total of ETB 21,925,427 (~$592,597) was provided in performance-based grants to local actors (Client Councils, PCHUs, Districts) who requested funding in line with pre-established criteria. Grant decisions were made by a joint Federal Ministry of Health – Transform Project Committee.
In addition, the CSC initiative has increased contributions from community members to improve their local health facilities. In West Gojjam Zone of Amhara Region, ambulances have been purchased by communities with a promise by regional authorities to match the contributions. Other of community contributions include:
- the provision of labour to clean health centers and build latrines
- in-kind food donations for meals for pregnant women staying at Maternity Waiting Rooms
- safety-net funds to ensure medicines and health access for the poorest members of a community
Service delivery improvements
In Amhara region where the scorecard has been most fully rolled out, a number of examples show Primary Health Care Unit’s enhanced capacity to respond to citizen feedback:
- Maternity Waiting Rooms or Delivery Rooms were built or structurally improved in 95% of the Health Centres of West Gojjam Zone which led to increases in facility-based deliveries
- Health Centres in the region used internally-generated income from service fees to purchase generators
- Ninety-nine more health workers were hired in one district (Yilmana Densa Woreda) using budgetary resources provided by the District Assembly
- Innovative local solutions to drug stock-out challenges were developed by negotiating with drug distributors for ‘public pharmacy first purchase agreements’ before selling to private pharmacies
- Delivery rooms have been improved with wash basins and floor tiles for better hygiene
Key success factors
- Top Ministry of Health leadership support and attention at both the national and regional levels
- Systems approach: integrated into existing Ministry of Health management and accountability processes as well as routine data tracking systems
- Decentralised: community (kebele) owned and led with local facility and district support
- Data use: CSC scores and action plans reviewed by management with quarterly reporting of actions taken in response to citizen feedback
The CSC is an essential tool and accountability mechanism with full support from my ministry. It is a flagship reform program within the MOH Reform and Good Governance Directorate and one especially close to my heart. It provides critical, objective feedback to the MOH, particularly to the primary health care units, District Health Offices and District Administrative Councils.
Dr. Lia Tadesse, Minister of Health, Ethiopia