Community engagement in facility-based quality improvement in

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auxiliaries provide health education to their communitiesand mobilize them for disease prevention. These variedinstrumental forms of community participation, and theirassociated organizational mechanisms, remain widespreadfeatures of health service delivery in almost all developingand transitioning countries (see Morgan 2001).Experience in a variety of countries with citizenengagement in service quality demonstrates that it isnot appropriate or effective in all aspects of quality.For example, questions of technical standards, costcontainment, or health safety are quality issues thatrequire expertise beyond that of the average communitymember (see Charles and DeMaio 1993). Power andsocial distance factors between community membersand health providers can also limit the extent of citizeninvolvement in QA. In many societies, health professionalshold high social status, and lay individuals are reticentto challenge or confront them. However, participationcan potentially help to address quality issues related tocommunities’ direct experience with health facilities andproviders, including: access to services, effective utilizationof services, interpersonal relations and staff behavior,physical infrastructure, and service choice (see Brown etal. Undated).In health as in other sectors, beginning in the 1990s,views about participation reflected broader changesin the role of government, public sector reforms, andthe emerging emphasis on democratic governance. Atthis time, responsiveness and accountability began toenter the discourse. Market-driven reform metaphorsrecast communities from collective recipients of healthservices to individual consumers/customers – “users andchoosers” (Cornwall and Gaventa 2001). Democraticgovernance expanded the customer idiom to incorporatecommunities as rights-bearing citizens. Democratizationthrough decentralization brought governments closerto local citizens, and created mechanisms for localexpression of needs and exercise of rights, and publicdecision-making processes to respond to local demand(Brinkerhoff with Azfar 2010). Such changes created spacefor communities to participate as empowered “makersand shapers” of health decision-making (Cornwall andGaventa 2001, see also Church et al. 2002). For example,local health councils contribute to assessing health needsand setting priorities, and they help to identify localresources to address them. Associations of people livingwith HIV/AIDS lobby governments to enact policiesagainst stigmatization and to allocate funding for longtermtreatment.Today, communities (and their civil society counterparts)are central to health market and health governancereforms. Paying attention to increasing accountability andresponsiveness has become a stronger common thread inboth types of reforms. The most basic level of communityparticipation, which engages members in service codelivery– often at the invitation of government actors,remains widespread. However, there has been a shifttoward higher levels of participation where communitiesare actively engaged in expressing their preferences asconsumers and voters, providing input to health decisions,and exercising their rights as citizens (Murthy andKlugman 2004).This shift recognizes that communities are not simplysupply-side partners. They play a role in the demand sideof health governance by fulfilling functions that contributeto provider responsiveness and accountability, as well asto service quality. Communities are governance actorswhose direct connections to providers can enable themto express needs and preferences through “voice,” as wellas to serve as potential sources of accountability pressureon providers (Brinkerhoff and Bossert 2008). In a rangeof countries, citizens have been engaged in monitoringservice delivery performance in one way or another, usingtools such as citizen report cards, absenteeism tracking,and membership on facility boards.While community engagement to increase accountabilityand responsiveness is intrinsically desirable from a goodgovernance perspective, important questions for healthdecision-makers are: a) whether communities havethe capacity to exercise an accountability role giventhe information asymmetries and power differentialsbetween communities and health professionals; andb) whether community participation has impacts onefficiency, effectiveness, and health outcomes. Researchthat can credibly document links between governanceimprovements and service delivery or health outcomesfaces methodology and data challenges, although some2 HealthSystems20/20
Box 1.Evidence for the Impact of Community Participation in Monitoring Health Service DeliveryA randomized experiment with community participation in monitoring of public primary health providers in 50 facilities inUganda revealed important health and accountability results. Facilitated by local nongovernmental organizations (NGOs),community representatives in treatment villages worked with health providers to develop joint community “contracts” forservice improvements and then used citizen report cards, which compared facility performance with national standards andaverages, to monitor progress. After a year, treatment and control communities were compared. The study documented a 33percent reduction in child under-five mortality, as well as a number of other positive impacts on service utilization and healthoutcomes. Treatment communities were more engaged in holding providers accountable through monitoring, and healthworker behaviors changed to be more responsive to serving community health needs.Source: Björkman and Svensson (2009)studies have shown results. For example, Peters (2002)demonstrates that community engagement in oversight ofservice providers contributed to more effective, equitable,accountable, and affordable reproductive health servicesin India. Box 1 offers another example, and summarizesthe results of a study in Uganda that reveal health andaccountability impacts of community participation inmonitoring.The Philippines contextAn East Asian and Pacific nation with an estimatedpopulation of around 90 million people (2009), thePhilippines is a lower middle-income country witha democratically elected government. Total healthexpenditure per capita is US$36. Non-communicablediseases are a growing problem, while the country alsocontends with the communicable diseases common todeveloping countries, such as malaria, tuberculosis, denguefever, and diarrheas. The contraceptive prevalence rateis just over 50 percent (2008) and maternal mortalityis around 200 per 100,000 live births. Health statisticsindicate that the Philippines not making sufficientprogress to meet the 2015 Millennium Development Goalon MCH (figures from www.wpro.who.int/countries/phl/and healthsystems2020.healthsystemsdatabase.org/).Public health services in the Philippines have been a localgovernment responsibility since the passage of the LocalGovernment Code in 1991, which launched a significantdecentralization. Provinces, cities, and municipalitiesreceive intergovernmental fiscal transfers in the formof block grants (Internal Revenue Allotments, or IRAs)from the national government. Local governments have alarge amount of discretion in allocating IRAs: 80 percentof the funds are unconditional, with the remaining 20percent released subject to a centrally approved localdevelopment plan. Of the five devolved national agencies,the Department of Health (DOH) has had the largestamount of its revenue shifted to IRAs (Schwartz et al.2000). Local taxes plus a number of other dedicatedfunds also provide resources for health at the local level.The Local Government Code designated local healthboards (LHBs) to serve as the primary mechanism forcommunity participation in health. The Code stipulatedthat the community would be represented on the boardby a member of a health NGO; the majority of LHBmembers are local elected and public health officials.Boards fulfill an advisory function on health budgets,planning, and personnel issues (Ramiro et al. 2001).The national-level DOH retains responsibility for healthpolicy, surveillance and monitoring, standards and servicequality, management of donor-funded projects, as well asplanning and funding for a set of core health programs(MCH, nutrition, tuberculosis control, safe water andsanitation, etc.). QA and CQI have been elements ofthe DOH’s program strategy since the late 1990s. TheSentrong Sigla Certification (SSC) has driven QA andCQI through facility licensing and certification. SSC hascontributed importantly to health services utilization andhealth outcomes, and has stimulated local governmentengagement in raising the quality of health care in publichealth facilities. Today, SSC is complemented by theaccreditation programs of the national health insurance,3 HealthSystems20/20
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