2. ACT Health Premise
Changes
within
Society
(Empowerment
of Individuals)
Changes
within State
(Inclusive and
Responsive
Institutions)
Changes at
State &
Society
Interface
(Space for
participation
and collective
Voice)
Increased
Accountability
and
Responsiveness
3.
4. Where
Pilot in Bugiri District Eastern Uganda
Population : 426, 800
33 Health Facilities
5 National partners
Started January 2012
6. Citizen Report Card (CRC) Excerpt
Attendance of Health Staff at health centers
Percentage of households who said staff are always at work 43%
Percentage of households who said staff occasionally do not come to work 36%
Percentage of households who said staff are rarely at work 21%
Household rating of medical staff attendance at government health centers
Medical staff attendance at government health centers on survey day
Total number of medical staff allocated to government health centers II.
(National Standard; 3medical staff per HC II X 23= 69)
52 (75% of
what is
required)
Total number of medical staff present in the health centers on the survey days 43 (83%)
Total number of medical staff out for outreach and/or training on the survey
day
0 (0%)
Total number of medical staff out on leave on the survey day 6 (12%)
Total staff absent 3 (6%)
7. Community Voices
Second Phase
• 5,912
Households
surveyed for
development
of the CRC
CRC
•2718 engaged
in action plan
development
Interface Meetings
/Action Plans
8. A sample Action Plan
Issue Action (incl timeline & person
responsible)
Status of action Challenges Proposals or Changes to actions
Community unaware of the
services offered at the H/C
The HUMC to establish the sign
post not exceeding August 2013
Not achieved Inadequate and delayed release of PHC fund The in charge should prioritize the issue of
establishing a sign post and act accordingly
upon receiving PHC fund 1st April 2014
HUMC, Local leaders and VHTs
to inform community about the
services offered during static
days at the H/C
Achieved done every
Tuesday and Thursdays in
the week
None HUMC and in charge should write on manila
papers the services offered at the health facility
and pin it against the walls by the 30th of Feb
2014
Health workers to make
appropriate referrals
Achieved by health
workers explaining to the
clients why they are
referred to other Health
facilities
None No change to the proposal
H/C closed when H/Ws go for
outreaches/workshops
At least one health work should
be left at the H/C effective August
2013.
Achieved as a health
worker is always left
behind
Community members come at the health centre
during time of closure
The VHTS should always inform the Community
members to visit the H/C in the right operating
hours i.e. from 8:00am-5:pm effective
14th/02/2014
9. Community Voices
Third Phase
• 5,912
Households
surveyed for
development
of the CRC
CRC
•2718 engaged in
action plan
development
Action Plans • 25 most
significant
change
stories
collected
Results
10. Why Most Significant Change (MSC)
Stories
• Facilitate community involvement in monitoring and
evaluation
• Track unexpected outcomes
• Support the light touch monitoring approach
• Contribute to program evaluation
11. MSC Collection and Analysis
• In-depth interviews with people are household
level
• 1 story per month from each health facility
• Analysis categorizes stories into four domains:
• Changes in service quality
• Changes in the community/service provider relationship
• Changes in health outcomes
• Other changes.
12. Final MSC Story Selection
MSC collected
one story per
health facility
every six months
33 over six months
Categorized in
Domains
for each health
facility one story
for each domain
132 stories
Regional Stories
Chosen
1 story from each
domain
Final Review of
regional stories
and a final MSC is
chosen every six
months
13. Example MSC
Name of storyteller: Naigaga Irene
When did the change happen? May 2013
Changes in health workers’ supervision improves service quality
“In June the in charge was demoted and a new in charge was
posted to the health centre. The new in charge is always at the
centre and this has resulted into improved service quality because
the health workers arrive on time, very active on duty and give
appropriate referrals. The high level of supervision has even led to
the health workers operating on Sunday which was not the case
before.
This story is very significant to me because the community can
now be sure to find health workers at the health centre and
receive health services.”
14. Example MSC
Name of storyteller: Kagoya Rebecca
When did the change happen? May 2013
Improved client care for mothers!
I raised the mother’s concerns and they were captured in the
action plan. This meeting allowed us present these issues directly
to the health workers who were present. The midwives have since
improved the way they handle mothers and stopped asking for
money. This has increased the number of mothers delivering at
the health centre.
This story is significant to me because the number of mothers
delivering at the centre has increased .”
16. ACT Health Scale Up
16 districts across Uganda
329 health facilities
7 different national partners
In conjunction with an RCT to answer the following
research questions:
Does the ACT Health Program lead to greater access to
services and an increase in health seeking behavior?
Does the ACT Health Program contribute to downwards
accountability among duty-bearers for health services?
17. Scale Up: Community Voices
ACT Health scale up has the potential to involve:
150,000 households in CRC
19,800 community members in action plan
development and interface meetings
367 MSC stories collected every six months
Talking Points Will use this slide to go through the various aspects of the projectCitizen report Cards (CRC- ) how they are developed and disseminated to the community Interface meetings – who attends – where they take place Action Plans- how they are developed and what happens to themLight touch Monitoring – what it is and why it is necessary
Talking PointsIn the Bugiri Pilot of the ACT Health Program: Blank households surveyed for the development of the Citizens Report Card, which gives information on service delivery and citizens perceptions of service delivery for each health centre (and corresponding target communities) in the program. The estimated population of the subcounties that would be considered in the catchment areas of the clinics involved is 426,800 (estimated for 2012). The 5,912 sample size, then, represents 1.4% of the total population in the clinic catchment areas.
Talking Points Other questions include : Utilisation Patterns ; Where does the community go , how the health centres pattern differ (local , district and national), why do the community not go Community’s utilisation of antenatal care, immunization and family planning services Services in general: Attendance community perception and day of the survey,
Talking PointsIn the Bugiri Pilot of the ACT Health Program: 2718 participants were engaged in the development of action plans to improve the quality of service delivery at their local health centerWe do not have information about proportions of community members vs. health workers involved in action plan development. We do have the 2,718 disaggregated by gender, though: 1,313 males and 1,405 females
The whole essence of my presentation in the community voice so this is an important slide in terms of looking at that aspect and each step of the processTalking PointsIn the Bugiri Pilot of the ACT Health Program: Blank most significant change stories collection, which explain and describe how and why changes have occurred in the lives of participants over the course of the program.
Talking PointsThe use of Most Significant Change stories in the monitoring and evaluation of ACT Health not only explains and describes why and how changes have occurred in the lives of participants over the course of the program, but does the following things: Tracks unexpected outcomes from program implementationTracks outcomes noted in the ACT health theory of change that the can either not be measured quantitatively, or that the program is not clear can be affected by the interventionFacilitates community involvement in the tracking and documentation of changes in the targeted programme areas, in other words, in monitoring and evaluation of the programFacilitate the programme desired light touch qualitative monitoring which allows the partners to take the lead in tracking activitiesContributes to a final program evaluation
Talking PointsMost Significant Change stories are collected in the following way: Stories are collected through in-depth interviews with a number of program participants including community members, community leaders, health workers, and village health team members, among others1 story is collected per month from each health facility (33 facilities times 6 blank comes to 198 stories collected per what unit during the Bugiri PilotThe analysis of MSC stories categories each story into one of four domains: Changes in service quality (for example reduced waiting time, polite health workers) Changes in relationships between service providers and community members (for examples better communication between health facility staff and community) Changes in health outcomes (for example, HUMC members supervise the health facility, or an increase in the number of community members visiting the health facility) Other changes
What is a domain?Changes in service qualityChanges in the community/service provider relationshipChanges in health outcomes Other changes.
The quality of services at Nabukalu HC III was for long poor because the in charge was rarely at the centre and as a result most of the health workers used to neglect duty and came late for work. This made it difficult for the community to access drugs and there were cases of pregnant mothers delivering outside the health centre because midwives were not available. Community members lost confidence in seeking health services from the health centre. In May 2013 I attended and presented these issues at the interface meeting in which the community, health workers and sub-county leaders were present.
“I live in Nabukalu sub-county near the health centre and my neighbor is a traditional birth attendant who delivered many babies at her home. I asked these mothers why they preferred delivering at the traditional birth attendant and not the health centre and they gave the same reason. For a long time the midwives at Nabukalu HC III were arrogant, rude to patients and asked for money especially from the mothers and insulted anyone who tried to caution them. I once witnessed a pregnant mother in labor being ignored by a midwife. When her husband raised the complaint to the chairperson of the Health Unit Management Committee the woman was rebuked by health workers to the extent that at every visit after her delivery, she was told to seek treatment from the chairperson. This made mothers hesitant to deliver at the centre.
FG: on what evidence did we base this decision? (Pilot still running and not proven?) this might come up as a question and we need to be prepared for it
Developed the approachSuccessfully implemented the Bugiri Pilot