The intervention also built the capacity of the CCs in the two pilot districts to form RMCH Action Groups (RAGs) to lead the implementation of the community scorecard process with the service users, service providers and other multistakeholders. They received training from Black Sash on relevant content to ensure they could engage in an accountability process to strengthen demand for MNCH.

The training focused on:

  • the roles and responsibilities of CCs, the health system in South Africa,
  • MNCH service entitlements and challenges undermining the health of women and their babies, and
  • how to implement a community scorecard process to address these challenges at community level.

Following extensive planning and preparation the Black Sash worked with the RMCH Action Groups to conduct the Community Scorecard process in the implementation districts, and through the multi-stakeholder meetings, discussed and identified key challenges, as well as jointly developed solution-focused action plans.

A major challenge of this project was getting clinic staff to participate and talk openly about their issues. In some instances, it was also very challenging to access and include key health officials in the various stages of implementation of the project. The commitment, passion and engagement of the RMCH Action Groups in both districts were crucial factors contributing to the success of this project. In OR Tambo 3 facility staff members (including a midwife) were also part of the RMCH Action Group. This made conducting the community scorecard with the health facility in that district a lot easier than it was in uMgungundlovu. This highlights the importance of including health facility staff in the scorecard process.

Key lessons

  • A key lesson learnt from this project is that joint monitoring and accountability through Clinic Committees is important. To facilitate partnerships especially between facility staff and the community, exploring communication and joint problem solving between different levels of health care staff and facility management is a key recommendation.
  • Using this intervention, monitoring maternal and child health outcomes (as identified in the agreed upon action plan) has to be repeated several times over a long period of time, to observe any changes and impact.
  • The RMCH Action Groups in the districts have the capacity to implement the community scorecard process independently, but require adequate support and resources to do so.
  • Emphasis should be placed on government providing adequate financial support to CCs so that they need not rely on project cycle funding from CSOs, which is not sustainable in an environment of reduced donor support to South Africa’s civil society sector.

Going forward, existing partnerships with Civil Society Organisations (CSO), who are members of the RMCH Action Group, will assist with sustainability and potentially allow RMCH Action Groups to repeat the scorecard process and follow up on the actions developed and agreed upon.

The Black Sash RMCH Project identified clinic committees as the accountability mechanism on which to focus the overall RMCH intervention. Clinic Committees together with service providers such as community and facility based health care workers and outreach staff - Community Health Workers (CHWs), Community Care Givers (CCGs) and District Clinical Specialist Teams (DCSTs)- play an important role in addressing demand side barriers. Black Sash piloted the Community Scorecard intervention in two health sub-districts Port St John’s in Nyandeni SubDistrict of OR Tambo District in the Eastern Cape (EC), and in Bruntville in Mpofana Sub-District of uMgungundlovu district in KwaZulu-Natal (KZN), to test this intervention. The project thus contributed to the RMCH Demand and Accountability objectives in addressing challenges at community and health facility level, which contribute to high mortality rates of mothers and their babies.

Situational Analysis and Literature Review

The project started out with an extensive situational analysis in 2013, resulting in a Baseline Report on the functionality of existing accountability structures and challenges relating to Maternal and Child Health in OR Tambo and uMgungundlovu. It also conducted a literature review on experience in strengthening clinic committees and on possible interventions to strengthen demand and accountability for MNCH services such as community scorecards, safe motherhood groups and participatory budgeting, as intervention methodologies. These findings were shared with stakeholders in OR Tambo and uMgungundlovu districts during several workshops held in February 2014 and together with stakeholder input, a preferred intervention strategy was chosen.

Community Scorecard Methodology

The community scorecard methodology was chosen as the most appropriate method to be tested under the RMCH project. This methodology aimed to monitor the district’s delivery and the community’s uptake of MNCH services through the joint identification of problems, solutions and action. To implement the community scorecard initiative, Black Sash developed several products including training materials and manuals, as well as information pamphlets on MNCH services.