Background

The scorecard for accountability and action is a mechanism used by ministries of health and their partners, across Africa, to track and improve the delivery of health services including for reproductive, maternal, newborn, child and adolescent health (RMNCAH), neglected tropical diseases (NTDs), nutrition and malaria. Scorecard tools are developed by the country ministry of health with indicators tailored to the priorities from their national strategic plan’s monitoring and evaluation framework.

The colour-coded tools make them easy to interpret by all stakeholders, from high level decision makers to community members. They are integrated into existing management processes at national and subnational level and used by health leadership and programme heads and staff, health workers, partners, civil society, as well as community engagement forums. Learn more about country scorecard tools.

Key success factors

Evaluation of best practices and impact of country scorecard tools has shown that their effectiveness and agency to bring change increases when they are:

1. used as a management tool at all levels to track progress, identify bottlenecks and drive action, with the Scorecard Web Platform management functionalities (such as the Action Tracker and Workplan Manager) used to enhance accountability
2. decentralised sub-nationally and used at the community level so members of the community can identify bottlenecks, make recommendations and track action
3. disseminated and shared widely to a range of stakeholders from national leaders to members of the community for increased accountability and ownership
4. integrated into existing national and subnational processes to enhance sustainability and drive action, and used with political leaders to drive policy change and mobilise resources
5. evaluated, with best practices documented and shared within the countries

1. Use as a management tool at all levels

Best practices have shown that the use of the scorecard as a management tool nationally and sub-nationally, enhances ownership at all levels, strengthens performance monitoring and stimulates action.

Best practices from countries who use the scorecard as a management tool at national, regional/county/state and district/sub-county/LGA level include:

• The country scorecard is updated every quarter in a timely manner, usually 30 days after the end of the quarter or immediately after data has been validated.
• At least 80% of indicators are fully populated.
• Indicators have been reviewed based on the latest strategic plans. Future Wave indicators have been identified.
• A wide range of stakeholders have accounts on the Scorecard Web Platform, including programme managers and health teams at the national and subnational level and partners. They regularly login to the platform to review the scorecard.
• Other functionalities of the Scorecard Web Platform are used including the Action Tracker, the Workplan Manager and the SMS notifications to enhance accountability. Actions are being entered regularly by users at national and subnational level and the progress of actions are regularly updated. The national level uses the Action Tracker to monitor and provide support to the actions at subnational level. The Workplan Manager is used at subnational level and partner plans are added for enhanced partner coordination.
• The scorecard is linked to DHIS2 and health facility level data is added to the scorecard.
• Data audits are regularly conducted based on the review of the scorecard and feedback is provided to data entry officers to correct errors to improve data quality.
• DHIS2 super users can configure missing scorecard indicators in DHIS2 or correct indicator misconfiguration issues identified in the scorecard.

Country examples

Several countries are using the Scorecard Web Platform developed by ALMA to manage their scorecards and actions. The web platform includes data visualisation and management functionalities and can be linked to countries’ health management systems like DHIS2.

Kenya, Ghana, Senegal and Mali have used the Action Tracker to track actions and thus strengthen the accountability cycle. Use of the Action Tracker increases transparency and accountability through specifying responsibilities and timelines and clarifying actions or activities to be implemented to progress towards programme goals. The Action Tracker can also be used to archive and review actions implemented for performance management over a period of time, as has been done in Ghana.

Zambia has used the Workplan Manager extensively at national and sub-national levels to improve implementation and coordinate activities to support achievement of the national malaria strategic plan’s (2017 to 2021) objectives and goals. The use of the Workplan Manager in Zambia has facilitated translation of the strategic plan into clear operational plans, aligned implementation plans across levels (national, provincial and district) and implementers and other partners and enabled transparent and real-time tracking and identification and resolution of implementation bottlenecks. Use of the Workplan Manager is associated with an increase of the implementation rate of interventions from 36% achieved at the end of the 6-year implementation of the national malaria strategic plan for 2011 to 2015, to 80% in 2019.

2. Decentralisation of the scorecard and use at the community level

Successful decentralisation and effective use of the scorecard at all levels is the main determinant of the scorecard impact on indicator and programme performance, as has been shown in many countries.

Best practices from countries who have decentralised the scorecard:

• The scorecard is being used at all levels, including community and facility level and by local partners and civil society organisations.
• There is a mechanism in place to train more stakeholders on the use of the scorecard. Training and orientation workshops have been conducted to orient stakeholders on the use of the scorecard at the decentralised level down to the district/LGA/subcounty level. Training of trainers have taken place at district level.
• For countries using the Scorecard Web Platform, there are national, regional, district and community level administrators that can add user accounts.
• Partners at both national and subnational levels use the scorecard to monitor progress and support action implementation, including providing resources to address bottlenecks identified through the review of the scorecard.
• The scorecard rollout and strengthening is fully financed. There is a plan for scorecard implementation and further decentralisation to encourage local ownership and management.

Country examples

How the decentralised use of the scorecard in Kenya has contributed to the improvement of maternal and child health across the country

Under the devolved system of governance in Kenya, the county level is responsible for health service provision, planning, budgeting and financing. Between 2015 and 2017, the Kenya RMNCAH scorecard was rolled out to the country’s 47 counties where it is widely used, including at sub-county levels in several counties.

At these sub-national levels, the scorecard is used to monitor routine programme performance and trigger action in response to underperformance. Counties also use the scorecard to support prioritisation of resources, programme planning and management, and for discussion and mutual accountability with communities. Use across county level has enabled scrutiny of programme progress and a wide range of actions, including:

• health systems strengthening such as linking the scorecard to revitalisation of community units in Siaya and Migori counties.
• improving service delivery such as package of actions in Garissa county to increase immunisation outreach, Emergency Obstetric and Newborn Care (EmONC) training and increased community referral of mothers for skilled delivery. These actions were corelated to increases in immunisation coverage from 48% to 82%, and skilled birth delivery from 28% to 45%. In Bungoma county, training low-skilled delivery led to training of 400 traditional birth attendants and subsequently 14,900 mothers supported for referral for skilled delivery.
• resource mobilisation, such as in Migori country, where the country mobilized KSH 14 million ($140,000) to increase availability of family health commodities in the county in response to shortages of coverage of family planning.

How the use of the community quality of care scorecard in Ethiopia and Ghana has strengthened the quality of health services and enhanced ownership within communities

Community scorecards (CSC) are used for communities to be actively involved in evaluating the performance of health service delivery. Members of the community are asked on a quarterly basis to rate the health facility using quality of care indicators. The health facility then responds with the creation of an action plan to address the community’s feedback. The community scorecard mechanism therefore acts as a platform for the community, providers and commissioners to interact and jointly plan for the improvement of services which is then monitored by the community.

In Ethiopia, this has led to increased contributions from community members to improve their local health facility. In one zone alone, 54 ambulances were purchased by communities to respond to some of the feedback collected during the community scorecard process. Other types of community contributions include the provision of labour, in-kind donations and safety-net funds to ensure health access for the poorest members of a community.

In Ghana, the scorecard has also led to greater community involvement and local contributions to improve local infrastructure and service delivery. In Ashanti region, for example, the scorecard found a maternity block was in a poor condition. As a result, the local committee organised volunteers and contributed money to repair and improve the building. The scorecard has provided direct feedback from citizens to national, regional and district-level health managers, allowing them to identify gaps and address bottlenecks. The scorecard has strong support from high-level government leaders and is has been integrated into routine community health workers training.

3. Integration into existing management processes and use at political level

The sustained use and impact of the scorecard relies on implementation of the tool being fully embedded into existing national and subnational accountability mechanisms.

Best practices from countries include:

• The scorecard is reviewed at all levels in existing management meetings. The scorecard is included as a standing agenda item of key management and decision-making meetings at national and sub-national levels.
• Actions are captured in meeting minutes and/or the Action Tracker, and their implementation is tracked.
• Scorecard is incorporated into community engagement and townhall discussions.
• The country has integrated the scorecard into pre-service training for health workers.
• The scorecard is used for supervision and performance management. The scorecard has been incorporated into the terms of reference of ministry of health staff, who are held accountable for performance by supervisors. The scorecard concept is integrated into pre-service and in-service training for health professionals.
• The scorecard is used in planning and budgeting processes at subnational level to inform resource allocation and strengthen social accountability in the health system.
• The scorecard is used at the political level to galvanise support for the programme and mobilise resources. High-level decision and policymakers (such as the minister of health, MPs, district assemblies, members of End Malaria Councils) and subnational level actors (such as regional and district teams) have been trained on the use of the Scorecard Web Platform or the Country Scorecard mobile app.

Country examples

How countries embed the scorecard management tool into existing accountability mechanisms to enhance data-driven decision making and stimulate action

In Ethiopia, the community scorecard tool has become fully integrated into routine government systems. In Amhara region, the scorecard is a standing agenda item for routine quarterly performance review meetings held by zones with all districts. In addition, the tool has been integrated into the official Joint Supervisory Visit Checklist used during existing semi-annual federal ministry of health support visits to health facilities.

Rwanda, Mali, Ghana and Ethiopia have included use of scorecard tools within health and programme policies and plans, as a primary mechanism for accountability or monitoring and evaluation. This has enabled formal introduction and use of the tool as an integrated action-oriented accountability mechanism and has facilitated consistent institutionalisation in national and subnational meetings. For example, in Rwanda, malaria scorecard reviews are a standing agenda item during malaria technical working group meetings at national level, and quarterly meetings between the ministry of health and district heads of health and other key officials. Also in Rwanda, the country’s RMNCAH scorecard is included in the strategic plan as a key monitoring tool for the government to track progress.

How the scorecard can be institutionalised by ensuring it is included in pre- and in-service training

In Ghana, community scorecard training materials have been included in the community health worker training manual for routine delivery. Additionally, the community scorecard will be integrated into the curriculum for nurses completing their last year at the University of Ghana’s School of Nursing. Also in Ghana, the scorecard was integrated into the planning and budgeting process at district assemblies. This allows citizens to participate in the planning and financial management process by providing data in a simple and clear format. Through the scorecard process, citizens identify and validate activities systematically each quarter to improve the health system, providing the perfect opportunity for government to receive feedback from citizens.

How the scorecard is used at the political level to improve the quality and access to health services

In Kenya’s Siaya county, county officials also shared the scorecard with members of county assemblies (MCAs) and high-profile religious leaders to advocate for greater RMNCAH resources and spur policy change. This led to the county assembly fast-tracking passage of the County Health Services Act resulting in significant increases in the county health budget for infrastructure, staff and operationalisation of existing, but under-utilised, infrastructure.

In Zambia, the malaria scorecard is reviewed every quarter by the Zambia End Malaria Council, a mechanism that convenes senior level multisectoral leaders to complement the national malaria elimination programme in attaining the goal of malaria elimination in Zambia. The use of the scorecard has enabled the council to track progress, identify bottlenecks and find solutions. As an example, during an October 2019 End Malaria Council meeting, the national malaria elimination programme presented the national malaria scorecard, which indicated very low coverage of pregnant women receiving three doses of intermittent preventative treatment of pregnant women (IPTp3) due to a national commodity stock-out. Commitments following the meetings were made and by the next meeting it was confirmed that 2,450 tins of the commodity (SP) worth $230,000 USD were received and distributed to the provinces. As a result of this intervention, IPTp3 coverage returned to the level of service prior to the stock-outs.

In Tanzania, 150 members of parliament were trained by the national malaria control programme to use the Country Scorecard mobile app to enhance lobbying and advocacy for fighting malaria. Giving access to real-time data to parliamentarians has allowed them to be aware of implementation issues, demand action and advocate to increase domestic funding in parliament. Indeed, during the COVID-19 pandemic, parliamentarians from high burden malaria regions who had been given access to the malaria scorecard tool made references in speeches in Parliament to the latest data and the need to keep a focus on malaria.

4. Wide dissemination and public sharing

The impact of scorecard tools is increased when they are shared widely within the health sector at the levels of policy, planning and supervision, and the level of implementation with providers and consumers of health services.

Best practices from countries include:

• The scorecard is shared regularly with a wide variety of stakeholders, including decision-makers and partners (such as on a quarterly bulletin).
• The scorecard is shared publicly on the ministry of health website and on the ALMA Scorecard Hub.
• An analysis report or presentation is presented every quarter alongside the scorecard at management meetings at all levels.

Country examples

Several countries are sharing their scorecard on the ALMA Scorecard Hub. The Scorecard Hub also publishes experiences and best practices in the use of scorecard tools (currently over 45 publications featuring national, subnational and community use of malaria, NTD nutrition and community scorecards).

In Kenya’s Migori county, the RMNCAH scorecard and action plans are shared with partners and the county health management teams during quarterly performance reviews. A printed version of the scorecard is also shared during meetings. This has led to significant achievements, including the mobilisation of resources from partners for family planning, improved stakeholder coordination and improved data quality.

Similarly in Nigeria, the RMNCAH scorecard is shared with state and local government leaders to advocate for increased resources for programmes. As a result, a number of local and state governments have provided increased funding such as N 6 million for stipends for persons conducting immunisation in Kebbi State, N 2 million to support activities of an underperforming facility in Irapa East LGA and N 300,000 for materials for newborn care in Oluyole local government area.

5. Evaluation and documentation of best practices

Best practices from countries include:

• Conducting an evaluation to document best practices, challenges and recommendations for strengthening the use of the scorecard.
• Preparing an action plan following the evaluation to scale up best practices within the country to further institutionalise the scorecard for action, advocacy and accountability.
• Capturing experiences in a video for easy dissemination.
• Publishing case studies and videos on the Scorecard Hub so other countries can learn from the successes.

Country examples

A number of countries have published best practices on the ALMA Scorecard Hub. Check out our best practices to learn about how countries have used the scorecard accountability mechanism to improve health services.

Scorecard Maturity Framework

ALMA has developed a Scorecard Maturity Framework to support the development and strengthening of RMNCAH, Malaria, NTD, Nutrition and Community Scorecards across 40 countries in Africa. The tool was developed based on best practices and lessons learned from the use of scorecard tool, recognising that scorecards are at different stages of maturity and institutionalisation.

Originally designed to tailor the support offered by ALMA to help countries strengthen their use of the scorecard as a management tool, we have now developed an online-self assessment tool for countries to perform their own assessment of the maturity of the scorecard.