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Scorecards and social accountability for improved maternal and newborn health services: A pilot in the Ashanti and Volta regions of Ghana

Despite a decrease in maternal and newborn mortality in Ghana, progress has been slow. In 2011 only 17% of facilities in Ashanti region, and 15% in Volta region fully met Emergency Obstetric and Newborn Care (EmONC) status requirements (i.e. were able to perform relevant signal functions).  As a result, the Ghana E4A-MamaYe programme implemented a pilot multi-stakeholder social accountability intervention in these two regions. Social accountability is when ordinary people or civil society are involved in how the accountability operates.

The pilot study aimed to:

  • improve the provision of quality maternal and newborn care
  • build on the limited evidence around the success of this approach

Methods and social accountability intervention

A social accountability process was designed, using scorecards, to engage stakeholders from different sectors at district level, strengthen partnerships between clients, providers and the community for improved MNH care, and create a more enabling environment for EmONC.

Between July 2014 to July 2015, a scorecard assessment process was implemented twice in 37 health facilities in the Ashanti and Volta regions. This involved assessing the enabling environment for health facilities to provide EmONC services, including client perspectives and satisfaction. Assessment teams were diverse and included members of the district health management team, planning officers, staff from community-based organisations, and maternal and newborn health (MNH) council leaders. The study also included a qualitative component which assessed the impact of changes in policy, attitudes and practices over time. 

Facility assessment questionnaires were developed by the E4A team and the Ghana Health Service based on key MNH quality domains (e.g. infrastructure, available drugs and equipment) and through exit interviews with maternity clients. The questionnaire was piloted prior to implementation and representatives from each stakeholder group were trained. Results were translated into scorecards to enable each facility’s EmONC enabling environment to be easily visualised.

The results were used to facilitate multi-stakeholder feedback meetings at district, health facility and community level, aiming to create both demand and supply side partnerships and accountability. Meetings identified gaps, solutions and action plans for each facility which were made public to encourage transparency and accountability.

Results

Results showed improved accountability through engaging multiple stakeholders at different levels. This created shared ownership of problems and solutions, which led to improvements in quality of care, particularly in accessibility of maternity care, availability of essential drugs, followed by infrastructure improvements. The participatory methodology empowered both health facility staff and communities to know the state of MNH services and take action using evidence from scorecards. Assessments and interface meetings attended by community, district, regional and national  level actors led to the realisation that lack of commitment, communication and awareness of decision makers contributed to the poor EmONC status of facilities.

Discussion and Conclusion

The paper highlights that active engagement of multiple stakeholders to support MNH services, helps to create a culture of accountability for improved quality of care in MNH.  Strong leadership at district and community level was identified as key for engaging with regional and national government. Authors conclude that social accountability initiatives can have great potential if they are context appropriate and fully engage government and civil society stakeholders.

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Blake, C., Annorbah-Sarpei , N. A., Bailey, C., Ismaila, Y., Deganus, S., Bosomprah, S., Galli, F. & Clark, S. (2016). Scorecards and social accountability for improved maternal and newborn health services: A pilot in the Ashanti and Volta regions of Ghana. International Journal of Gynecology and Obstetrics, 135: 372-379.
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