Introduction

In less than two years, the Ministry of Health (MoH) of Ghana and the Ghana Health Service (GHS) – with support from the African Leaders Malaria Alliance (ALMA) – have initiated an innovative, high-impact program aimed at seeking regular input from communities on the quality of primary health services in the country. Known as the Community Scorecard (CSC), this initiative provides an opportunity to close the gap in communication and collaboration between the providers and consumers of community-based health services. It offers a systematic way to gather data, monitor and act on the demand side of service delivery in contrast to the conventional approach focused primarily on the supply side of the health sector.

What is a community scorecard?

The Community Scorecard (CSC) is a management and accountability tool completed on a quarterly basis by community representatives to provide qualitative and quantitative feedback to local health providers and MoH/GHS officials on the quality of care experienced by users of the public health system. Implementation of the CSC also involves as a key step creation of Community Health Action Plans (CHAPS) to address issues prioritized by the community and regular monitoring of the implementation of planned actions. The CSC is acknowledged for strengthening the operationalization of Ghana’s Community-based Health Planning and Services (CHPS) strategy. A number of partners are working closely with the MoH/GHS to roll-out the CSC across the country.

As of November 2019, impressive progress had been made with eight regions in the country initiating the CSC. Out of all 6,000 CHPS zones in the country, approximately 1,400 zones (23%) have already been trained on the CSC with partner support, particularly from WHO, USAID Systems for Health Project and the World Bank. Most of the trained CHPS zones are also reporting data into DHIMS2 and the scorecard web platform that has the capacity to not only show real-time scoring data but also actions taken in response to the quarterly action plans.

“It is strongly believed that the CSC has offered a platform for generating actions and decisions to address community-identified challenges quickly and effectively for the betterment of the entire health system of Ghana.”
Ghana’s CSC Program Evaluation and Documentation Report, 2019

Community empowerment and action

The CSC mechanism has led to greater community involvement and local contributions to improve local infrastructure and service deliver. The CSC is a mechanism that gives the community more influence and autonomy in relation to how health services are provided.

Through the scoring and action planning processes, the Community Health Management Committees (CHMCs) have the authority to request and monitor that specific actions are taken at the CHPS facility to improve service delivery. The CSC is also widely credited with increasing community engagement and action to improve local health and well-being. Use of the CSC is leading to greater community involvement and local contributions thereby reducing the burden of health system management on the government. 

Systems strengthening

The CSC has advanced community support for Ghana’s Community-based Health Planning and Services (CHPS).

The CSC is credited with advancing community support for Ghana’s Community-based Health Planning and Services (CHPS) initiative. CHPS is a national strategy conceptualized in 1999 and updated in 2016 aimed at delivering essential community-based health services with the active involvement of communities. Its objectives include:

1. Ensuring community participation, empowerment and ownership in the local health system;
2. Determining the package of CHPS services at any CHPS zone based on inputs from the community, and
3. Considering communities as social and human capital for quality health care delivery.

With the Community Scorecard (CSC) integrated into existing CHPS structures, participants report that the CSC tool has strengthened, and in some cases reactivated, regular discussion and action within these structures around local health issues. Essentially the CSC has become the core implementation pillar of the CHPS strategy in those locations where it has been introduced. Senior GHS officials, locally-based CHPS staff and Community Health Management Committee (CHMC) members, are of the view that the CSC had improved community ownership and contribution towards the health delivery system. 

CHMCs and communities were credited with showing ‘tremendous support’ to come together and score local health facility performance as well as contribute to solutions and ‘the way forward’. A significant change was noted in that communities using the CSC no longer were sitting on the sidelines believing that decisions related to operating the health system belonged only to service providers. Rather community members began to realize that they also have a stake and contribution to make in the performance of the health system. The communities’ ‘sense of belonging’ has increased and the CSC monitoring and accountability tool had ‘re-engaged them to see themselves as contributing to the quality-of-service delivery at their CHPS compound’.

Success story: Ashanti Region

A key observation from the Ashanti Region is that community members are now aware of a channel through which suggestions and concerns can be voiced, and actions taken, in relation to the quality of community health care services. Indeed, GHS staff providing community-based health services find that client feedback directed through the local CHMC is less threatening and results in better solutions to problems.

The majority of those interviewed at the district and community levels were of the view that the CSC is providing an important and transparent way for feedback to be given and joint action taken. Despite the GHS having tried earlier to gather community feedback through local durbars (chief-led village forums) and home visit reports from CHOs and CHVs, it was noted that those methods were not to be as robust, efficient nor effective as the CSC.

Service delivery improvements

The CSC is an instrumental decision-making tool at the lower level to improve service utilization and quality of care.

The CSC has also been described as ‘instrumental in important decision making at the lower level to improve healthcare services as well as action by district officers’. Following CSC introduction, the Quality Improvement (QI) Teams in the facilities were found to conduct more focused follow-up visits and work more closely with the Facility In-Charges/Community Health Officers to respond to the CMHC’s requests and action plans. At the district and municipal levels, CSC scores were also beginning to be discussed at routine quarterly performance review meetings with the CSC described as a key ‘comprehensive performance assessment and planning instrument for service improvement’.

The CSC has also become an important management tool that facilitates accountability and action

Service provider accountability

Within the target areas, Ghana’s Community Scorecard provides regular feedback to the CHMCs and CHPS facility staff as well as to the district, municipal, metropolitan and regional health directorates. Following use of the CSC, specific examples of greater accountability among health providers were reported:

• Improvement in health workers’ behaviour and attitudes: At Lemina CHPS in Nkwanta North District of Oti Region, after receiving low CSC scores from the community related to the provision of ‘Caring, Respectful and Compassionate Care’, health staff vowed to improve their behaviors and attitudes; and agreed to include this in their Action Plan. 
• Improvement in timeliness and professionalism: At the Adenkrebi CHPS compound in Ga East District of Greater Accra Region, an issue raised through use of the CSC was that the CHOs would leave the facility without communicating when they would return. The CHMC and the CHOs agreed to produce an itinerary wheel which was placed outside the door of the CHPS compound so clients would know the time during which services could be accessed.

Additionally, at the CHPS service delivery level, the CSC has generated healthy competition between facilities and CHMCs to respond to community feedback and obtain high CSC scores. This has been observed during WHO-sponsored Network Meetings, which bring together various CHMCs from different communities to share and discuss their CSC scores and action plans. 

All facilities want to be rated high, so facilities are putting in their best. They know if they are not putting in their best, the community will score them down

Data Manager, Family Health Division, Greater Accra Region

I quite remember the scorecards from other areas. The results I saw from Abokobi (Sub-Municipality) threw a challenge to us that if a community has been able to convert their CHPS (primary health unit) to a clinic then we can also do more. So, it does breed healthy competition

CHMC Chair, Musuku CHPS, GHS, Greater Accra Region

In Oti Region, for example, through the use of the CSC, it was identified that the Community Health Nurses (CHNs) and Community Health Volunteers (CHVs) were not doing home visits. An action plan was drawn and Home visits have started improving.