Abstract

In low-income countries, the unmet need for family planning contributes to high rates of maternal and infant mortality. In Kenya, there are nearly 500 maternal deaths per 100,000 live births and 37 infant deaths for every 1,000 live births. Despite the critical role of family planning service providers, many providers engage in negative behaviors that inhibit family planning use. Poor accountability may enable these negative behaviors. This study evaluates a social accountability intervention—the Youth Community Score Card—in three communities in Kisumu County, Kenya to understand whether it can lead to better relations between patients and providers and improve service delivery.

Policy Issue

In low-income countries, one in four women with a desire to delay or avoid pregnancy are not using any contraceptive method. This unmet need for family planning results in nearly 90 million unplanned pregnancies each year, contributing to high rates of maternal and infant mortality. More than 300,000 women die each year from complications related to pregnancy and childbirth and 2.7 million newborns die annually within four weeks of birth. Fulfilling unmet need for family planning in low-income countries could result in a 73 percent decline in maternal deaths and an 80 percent decline in newborn deaths.

Despite the critically important role played by family planning service providers, a growing body of research shows that healthcare providers in low-income countries engage in negative behaviors that inhibit family planning use, especially among young and unmarried women. There is increasing recognition among development practitioners that poor accountability may enable these negative behaviors. Although limited rigorous studies exist, there has been interest in using social accountability interventions to enable beneficiaries to monitor service providers and hold them to account.

Context of the Evaluation

Despite the success of family planning programs in many other regions, the prevalence of contraceptive use in sub-Saharan Africa (SSA) remains low. In Kenya, the total fertility rate is about four children per woman and one out of every five women will give birth before she turns 18. This high and early fertility corresponds to high maternal and infant mortality: there are nearly 500 maternal deaths per 100,000 live births and 37 infant deaths for every 1,000 live births. Increasing contraceptive use among Kenyan women with an unmet need for family planning could reduce maternal and neonatal mortality in the country.

Prior research indicates that barriers to adequate family planning can be found at the health facility level in parts of SSA. Among Tanzanian and Ghanaian service providers, many restrict access to modern contraceptive methods based on age, parity, and third-party consent. In Western Kenya, providers often invoke unnecessary menstrual requirements, charge informal payments, and are frequently absent from work during business hours.

A social accountability approach in Uganda that included citizen feedback led to a 33 percent reduction in under-5 mortality, increased community engagement, and improved service provider performance. A similar approach in Malawi increased service delivery and client satisfaction and led to 57 percent higher contraceptive use. Assessments of this type of “community score card (CSC)” approach in Tanzania, Rwanda, and Ethiopia found consistently positive impacts on contraceptive use. However, there have been no evaluations of social accountability interventions in the Kenyan context.

Details of the Intervention

This is not a randomized evaluation

Researchers seek to gain a detailed understanding of the process of implementing a CSC in Kisumu, Kenya and whether it can lead to better relations between patients and providers and improve service delivery. Researchers will build on the CSC approach through the development of a Youth Community Score Card (YCSC) for family planning provision. The YCSC is a score card that allows young--between 18-26 years--and unmarried family planning clients to document their concerns and challenges when attempting to access services from public facilities. The YCSC project will be piloted in three public facilities among the four to six providers working in each facility. Youth Working Groups (YWGs) will lead implementation of the YCSC, designing the system for collecting feedback and determining the content and dissemination of the scorecards.

Based on the challenges identified, researchers will develop indicators that produce a score for the facility. This score will be shared with the community. Following this, youth, unmarried women, key community members, and service providers will initiate a collaborative process to develop feasible solutions and corresponding action plan.

Following implementation, researchers will evaluate facility performance using two or three “mystery client” visits and one or two unannounced visits to each facility. The data from these visits will be compared to data from a recent study in the same facilities. The resulting changes in service delivery will be shared and widely discussed with county health officials and leaders within the national family planning program. Results will inform a larger CSC intervention conducted across all public-sector facilities in Kisumu.

Results and Policy Lessons

Research underway/results forthcoming