“…the standard monitoring conducted through Citizen Voice and Action has opened our eyes that in fact our condition is still far from the standard.
There are many things to improve. We hope that when we could fix ourselves to be better, we could hear the voice of the people better,
we will serve them better.”
– Okseline Iku, Midwives Coordinator
Over the last decade, the maternal mortality rate has decreased significantly worldwide thanks to a number of initiatives aimed at improving maternal, newborn, child health, and nutrition (MNCHN) services, but there is still a long way to go. That is why in 2013, to improve MCNCHN services in Indonesia, the World Bank’s Global Partnership for Social Accountability (GPSA) funded the Citizen Voice and Action for Government Accountability and Improved Services: Maternal, Newborn, Infant and Child Health Services project in three districts in the Nusa Tenggara Timur province.
Wahana Visi Indonesia, the implementing CSO, uses the Citizen Voice and Action approach to enable villagers and local health centers’ staff to assess services against both official standards and villager-determined standards (gathered through scorecards and focus meetings). Local action plans are then developed to remedy inadequacies in MNCHN service delivery, such as few health workers, limited opening hours and poor service monitoring.
The idea underlying this social accountability process, that has been applied in many regions, is to improve dialogue and relationships between communities and government in order to improve services. So what are we learning in the initial 30 villages, involving 278 health services of various kinds in villages, sub-districts and districts?
Key Achievements of the Initial Year
The project conducted a mid-term evaluation to find out what worked, how it worked and in what contexts. It used survey data and an adapted Most Significant Change (realist evaluation) methodology, based on the collection and analysis of the most significant stories about changes from different stakeholders. This process is also informed by broader findings on the impact of empowerment and accountability.
Some early outcomes found include:
1) Behavioral changes:
- There has been an increase in giving birth at local health facility such as Polindes, Pustu or Puskesmas (local health center) rather than at home.
"Previously, there were some mothers who gave birth at home. Currently, after we raise[d] the awareness of pregnant mothers, they come to give birth at [the] health facility." – Health worker in the Sikka district.
- In some districts, village heads have become more active, opening Posyandu earlier, or joining activities to increase villager awareness.
2) Improved access to services:
- An increase in tetanus vaccination for pregnant women;
- Survey respondents reported a 16.8% increase in the provision of health checks for pregnant women in Posyandu from 2014 to 2015;
- An increase in supplementary feeding programs which not only provide a healthy meal, but more importantly, teach parents how to cook healthy foods for their children using local ingredients.
3) Changes in policy and budgeting:
- “In terms of Posyandu, [the] village government has responded [to the] community proposal by allocating village budget in 2015 to [building] three units of new Posyandu and to increase supplementary feeding.” – Village head in Sikka district
Learning for Improved Results
Overall, the evaluation points to early wins but with room for improvement. The idea is to take emergent patterns and feed into the next cycle of awareness raising, conduct an initial assessment of services against standards and score cards, and develop and implement plans for improvement. This will improve how the project is working. The real-time evaluation of the project, along with regular reflection activities, will support this adaptive learning and management process.
Could patterns provide food for thought for your social accountability intervention?
The evaluation’s focus on most-significant change stories provided a deeper understanding of perspectives of different stakeholder groups. For example, mothers , value these services and may have seen most changes in availability and quality, while others most commonly reported use of services and aspects of their own work that support availability, quality and use of services. Conversely, Village Heads know about all kinds of changes in their villages and this may account for them reporting more and most significant changes overall. Heads of the District Health Service reported least changes which might reflect their access to information – being furthest from the village level, they may have less exposure to the variety of changes being made.
In the long-term, empowering communities to advocate on their own is what will hold service providers and governments accountable for service provision, and thus for their contributions to child and maternal health. However, as can be expected in the first year of a program, the project processes themselves generated the outcomes. The challenge now is to develop a coherent exit strategy for strengthening the empowerment aspects over the next couple of years, to ensure that communities and local civil society groups and coalitions are able to carry the work forward beyond the project. This issue was raised during the GPSA workshop at the OGP Global Summit.
The social accountability approach has been applied in all 30 Phase 1 villages, but positive indicators are uneven across topics and regions. For instance, there was greater change in responsiveness than in budget and policy. This may reflect resource constraints - it may be easier for local governments, with relatively restricted budgets, to change what they do within existing frameworks rather than increasing resources or introducing new regulations. This requires putting the projects’ multi-pronged strategy in the broader context. We discuss this issue in other stories from the field. Another reason is due to limited capacity and concern of village head to produce MCH policy at the village.
Share how you are employing social accountability to improve service delivery and your own practice on the GPSA Knowledge Platform.
By Seun Sonubi (Operations, GPSA) and Florencia Guerzovich (Capacity Building, GPSA), with input from Andreas Sihotang (GPSA Project Manager, Wahana Visi Indonesia) and Tammy Mehdi (Communications, GPSA). This blog post is part of a series aimed at capturing the progress of GPSA projects. These highlight key aspects of conversations between the civil society groups leading the projects, their World Bank partners and the GPSA. They offer key lessons about the project’s implementation to date, including some examples of adaptive management and learning for strategic social accountability.