3. What is “Citizen Voice and Action”?
Citizen Voice and Action
is a social accountability approach
designed to improve the relationship
between communities and
government,
in order to improve services,
like health care and education,
that impact the daily lives
of children and their families.
6. CVA Phase One:
“Enabling Citizen Engagement”
“Enabling Citizen Engagement”
is an awareness raising phase
(up to 1 year). Begin with
human rights, but focus on
their articulation under local
law (“what vaccines should be
available at my clinic? “What
7. CVA Phase Two:
The “Community Gathering”
The “Community
Gathering” is a series
of four participatory
meetings that equip
communities to monitor
service provision at the
schools and clinics
they use every day
8. CVA Phase Two:
The “Monitoring Standards”
Process
In the
“monitoring
standards”
session,
communities,
service
providers, and
civil society visit
brick-and-mortar
facilities (like
clinics and
schools) to
compare reality
against the
commitments
that
9. Sample “Monitoring Standards”
Data
Keembe
Mushikili RHC
Midwives
1 per RHC
None
ORS
Free and
available
Vaccines for
children
Free and
available
Available,
but with
fee
Free and
available
Beds
3
2
Left in
June
1 broken
not replaced
10. CVA Phase Two:
The Community Scorecard
In the “score cards”
session, we invite
focus groups
(government,
service providers,
marginalized
groups, etc.) to rate
facilities against
criteria that they
themselves
generate.
Communities use a 5point “smiley scale”
that encourages
participation by
12. CVA Phase Two:
The Interface Meeting
The “Interface
Meeting”
convenes100-200
participants from
government, civil
society, and the
community to
review the
results of the
monitoring
exercise and
create an action
plan to improve
services.
13. CVA Phase Three – How will we
address the issues identified?
14. Citizen Voice and Action Scale Up –
227 Programmes in 34 countries in
FY13
CVA activity in FY13
16. Social Accountability - Impact on
Health Outcomes –
Bjorkman/Svennson 2009
J-PAL researchers used Randomized Control Trials to study
the impact of an approach like Citizen Voice and Action at
50 clinics in 9 districts of Uganda:
Quality of Care. After one year, relative to comparison
villages, health facilities in treatment villages:
Experienced a 12-minute reduction in average wait time
Experienced a 13% reduction in absenteeism
Health Outcomes. After one year, relative to the comparison
villages, the treatment villages showed a:
33% drop in under-five mortality
58% increase in use of skilled birth attendants
19% increase in number of patients seeking prenatal care
Results holding after 4 years.
Bjorkman, M and Svensson, J, 2009. Power to the People: Evidence from a
Randomised Field Experiment on Community Based Monitoring in Uganda.
17. Social Accountability - Impact on
Education Outcomes – Zeitlin 2011
Oxford University researchers used Randomized Control
Trials to study the impact of the CVA Score Card in100
Ugandan primary schools. After one year, in the schools
using the CVA score card, they found:
• Test scores rose by an average of 9%
• Pupil attendance increased by 8-10%.
• Teacher absenteeism dropped by13%.
• Cost: $1.50/student
• A “standardized” score card had no significant
impact.
Andrew Zeitlin, Management and Motivation in Ugandan
Primary Schools: Impact Evaluation Final Report (2011).
18. Citizen Voice and Action in Uganda
In 13 of the 17 clinics where CVA has been introduced,
staff have increased; 7 of the clinics showed staff
increases of more than 2 staff.
In 3 clinics, the number of women in a month attending
for antenatal services and to give birth more than
doubled.
In 4 clinics, dedicated maternity services were initiated.
In 3 of the clinics, Prevention of Mother to Child
Transmission (PMTCT) services either started or were
expanded.
Communities, clinic staff, and local government officials
attribute the changes to increased advocacy by the
community.
19. Citizen Voice and Action in Zambia
4 out of 5 targeted facilities have reported deployment of
additional staff
Community members in 5 sites reported reduced waiting
hours (average reduced from 6 hours to 2 hours).
The Community of Milopa, in Lufwanyama District,
successfully pressured for the construction of a new
clinic by 2015.
Construction of clinic has resumed in Chibombo District.
# of deliveries at health centres increased by 64% in
Lufwanyama District between 2011-12.
Chibombo recorded an upward movement of 3% in
under-5 immunization between 2011 and 2012.
Governments, communities, and service providers
attribute improvements to increased engagement
21. “Vertical” Citizen Voice and Action:
Linking communities to policy
influence
• Uganda: Practitioners used data from CVA to
demonstrate inadequate clinic staffing on MNCH.
• Result: Coalition work ultimately persuaded
parliament to forgo drastic cuts in health budget.
Prime Minister committed to hire of 6100 new
health workers.
• Armenia: Practitioners and coalition partners used
CVA data to identify problems in MoH pay structure
that were discouraging doctor visits to poor rural
areas.
Result: Policy-level reform of pay structure of
doctors.
23. Playing the Investment Banker
1. Each person will be given one voucher.
2. You can invest your voucher in one of 2
accounts (a “private” or “group” account).
3. These accounts pay returns in points in different
ways.
4. Your investment is anonymous. You cannot
discuss your investment choice with other
participants.
24. Playing the Investment Banker
If you invest your voucher in the Private Account you will
earn:
(A) a fixed return of XX points; PLUS
(B) 1 point for every voucher that the other participants
have decided to invest in the Group Account.
If you invest your voucher in the Group Account you will
earn 1 point for every voucher that you and the other
participants have invested in the Group Account.
25. Instructions:
Playing the Investment Banker
Instructions:
1. Write your name on your voucher.
2. Write “Private” or “Group” on your voucher to indicate
where you will invest.
3. Pass your voucher to our broker.
Your investment is anonymous. You may not indicate
your choice to any other investor or plan your investment.
26. Playing the Investment Banker
1. Why did you invest as you did?
2. What if the stakes had been higher? Would higher
stakes have changed your investment behavior?
3. Do you think it would have changed the outcome if
you had had a chance to discuss with your fellow
investors prior to investing?
27. Playing the Investment Banker
1. Why did you invest as you did?
2. What if the stakes had been higher? Would higher
stakes have changed your investment behavior?
3. Do you think it would have changed the outcome if
you had had a chance to discuss with your fellow
investors prior to investing?
28. Voluntary Contribution Mechanism
game – why does it matter?
Propensity to invest
in the group bank
correlates with other
measures of group
cohesion and ability
to solve collective
action problems.
29. Field Experiment results from
“Voluntary Contribution Mechanism”
game:
• Over the course of an academic year, 30 schools
used the score card, 40 schools served as a control
group.
• At the end of the year, researchers from Oxford and
Makerere University played the “Voluntary
Contribution Mechanism” game with the School
Management Committee from each school.
• “Group” bank pays 1,000Ushs for every participant
who invested in the first bank.
• “Private” bank pays 6,000Ushs, plus 1,000Ushs for
every participant who invested in the group bank.
30. Field Experiment results from
“Voluntary Contribution Mechanism”
game:
• Participants who had participated in the score card
exercise during the school year were 16% more
likely to invest in the group bank.
• These schools also exhibited a 9% increase in test
scores, and drops in student and teacher
absenteeism by 10% and 13%, respectively.
• World Vision and Johns Hopkins SPH have
extended this study to 16 sites in four countries to
examine how CVA contributes to collective action for
health outcomes.
31. Collective Action among
communities: strengthening local
leadership
“I have more confidence and
knowledge to speak at the District
and I have the support of the
community members and the
community health clinic…. At first
they didn’t have the confidence to
speak. (But) the community have
more courage to speak up in
community meetings. The women
also speak. They have more ‘fight’.”
Yoseph Marianus,
village head of Flore Island
