Improving the health of community members is not just about providing specific treatments or information, but also ensuring that communities are able to hold health centres accountable for the services they provide. As part of the Global Fund project to strengthen health systems, CARE Cambodia has rolled out the Community Score Card – a social accountability tool originally developed by CARE in Malawi – to allow community members to provide feedback on the performance of their local health centre in a constructive way.
Kunthea, 43, is a mother of four children living in Mondul Kiri province. She has visited the local health centre often over the past few years for both herself and her children. She has encountered issues such as staff being rude, staff not being on duty when needed and the health centre not having enough medicine available to treat her. Sometimes this has meant she was forced to visit a private clinic, which can be over 100 times more expensive than the government clinic.
These experiences motivated her to join the Community Score Card meetings and Kunthea has attended every one of the meetings since they started in 2012. “I wanted to improve the health centre. I wanted to make sure there were always staff available and that they have a good stock of medicine available,” she says of her motivation to participate.
Working in groups at the Community Score Card meetings villagers such as Kunthea list comments about their local health centre on three colours of cards: red for problems; green for good points; and yellow for suggestions. Once the common issues – such as staff attitude towards patients – have been collectively identified, the groups agree on a score for each issue on a scale of one to five. Scores from across all villages covered by the health centre are consolidated to find an average which reflects their overall performance.
For Kunthea, the key aspect is that this is a group process. She says that previously villagers were cautious about complaining to the health centre or giving negative feedback through NGOs and government structures as they would be afraid about the reaction of the staff. “Many were scared that if they told the truth about their experiences and people at the health centre found out what they had said, they would be angry and refuse to treat them in the future,” she says. “The group setting gives group support. As all feedback is recorded on cards, people are not afraid to be truthful.”
Results are shared with health centre staff – who also perform a self-assessment – during an interface meeting, which is attended by representatives from both the health centre and each village. As the community feedback is presented collectively by a number of communities, no one person needs to fear reprisals from staff. While the Community Score Card was originally developed by CARE it has now been adopted by the Ministry of Health in Cambodia, meaning that health staff have been more willing to engage with communities as they are working through a government-approved tool. The formal setting and considered feedback also means the health centre is more likely to take complaints seriously.
The shared meeting includes time for developing an action plan for improvement, ensuring that communities are able to be actively involved with plans to improve the services available to them. The whole process is then repeated every six months. While changing attitudes and behaviours takes time, Kunthea reports that she has noticed changes and that she has not heard so many instances of staff being rude to patients. Improving staff attitudes and the overall experience of patients will ensure communities are not discouraged from accessing healthcare services when they need them.
By empowering communities to stand up for their rights as clients and providing a safe environment in which to do so, CARE’s Community Score Card is allowing people to have a say in the healthcare they receive without fear of retaliation.
For Kunthea, being part of this process is not just about making sure the services available to her family are of a better standard. Having her voice heard is just as important.