Enhancing Service Quality and Empowerment in Government Clinics Through Continuous Quality Improvement of Community Score Cards: A Case Study From the Dominican Republic.

Abstract

Background: The Dominican Republic offers universal, government-run health care through primary, secondary, and tertiary levels. Reliability and confidence in care have lower user satisfaction than other dimensions. Thus, the government aims to enhance relationships between service users and providers as a key health systems strengthening priority to improve primary care services.

Program description: From 2018 to 2023, a global nonprofit organization implemented social accountability, using an adapted Community Score Card (CSC) process, in 10 government-run clinic sites in the Dominican Republic. Each site implemented multiple CSC cycles, which involved a facilitated dialogue process among service users, providers, and community leaders, prioritization, action planning, and implementation. We developed a comprehensive monitoring and evaluation toolkit to facilitate ongoing analysis and use of data for continuous quality improvement of the social accountability approach and sharing of the results with stakeholders. The toolkit includes components that span all steps in the CSC process, including tracking participation of key stakeholder groups, assessing CSC facilitation quality, scoring clinics on 4 defined global indicators (quality of care, availability of medical staff, availability of medicines, and community participation), tracking progress on action plans, tracking participants' level of empowerment over time, and assessing how interventions impacted change through periodic use of the Most Significant Change monitoring and evaluation technique.

Process improvements: The data generated from the toolkit supported process improvements in the CSC approach, including the importance of youth leadership in social accountability and of achieving concrete change early on to drive the capacity for more complex change requiring vertical support. These iterative improvements to the CSC process resulted in empowerment and engagement of community members to drive change in government-run primary health clinics and improved perceptions of service quality. Case study data from the Dominican Republic show ongoing stakeholder participation, improvement across the 4 global indicators, and community empowerment, which collectively contribute to strengthening local health care services. The comprehensive toolkit supports efforts for continuous quality improvement while producing evidence locally, nationally, and globally for health systems strengthening and demonstrating the effectiveness of the CSC approach.

Conclusions: Three key lessons emerged from the development of a CSC monitoring toolkit. First, a comprehensive toolkit centralizes data in one place and pulls together evidence from multiple sources. Second, a standardized toolkit allows for analysis at multiple levels. Finally, ensuring data are actionable locally is central to gathering complete, accurate data for continuous quality improvement.