ICCO has recently published reports of their impressive pilots on Client Satisfaction Instruments. It’s a wonderful example of a serious pilot by an NGO on client feedback – and a great contribution to sector-wide learning.
Thank you, ICCO!
From 2009-12, they ran pilots with partners in Malawi and Ethiopia, and generated some fantastic results.
The Uchembere Network in Malawi, a consortium of 27 health programmes, used Citizen Report Cards and a Client Panel. They got feedback from patients on maternal health services – and used it to improve what they do.
The Farmers Marketing Organisation Consortium in Ethiopia chose used a Client Satisfaction Survey and a Client Panel. They got feedback from their 100 member organisations about the support that the consortium provides to them – and also used it to improve what they do.
More women go to hospital
ICCO’s report Are You Being Served describes how feedback was used to improve services. For instance, in 2010, people around Embangweni Hospital in Malawi reported that many women stayed away from hospital, because they felt nurses and midwives were rude to them. They gave birth at home instead, with all the attendent risks to maternal and child health.
In response, the hospital trained their staff on clients’ rights. They also increased outreach services and successfully recruited more nurses. A follow up survey in 2011 found that the attitude of health workers had improved significantly, more women were delivering in hospital and that maternal mortality had dropped.
The report also describes wider changes in attitude, for instance of hospital leaders seeing patients as clients to be served rather than beneficiaries to be grateful.
In Ethiopia, feedback identified ‘misbehaviour’ by two field staff, who were subsequently fired.
Various factors are seen to have contributed to these successes. In particular, ICCO emphasises that local senior managers have to be committed to using client satisfaction – and acting on the results. The Malawi case suggests that the tool may support internal reform, rather than necessarily driving all the reform itself.
The report also emphasises the need to explain the purpose of the exercise to everyone involved. Various people said that clients may not always feel comfortable making criticisms. Once they realised that the goal was to help improve services, they were more open.
Apparently it was particularly useful to ask “If you were to pay for this service, would you still be equally satisfied or would you want something done differently?”
The next step: from pilots to systems?
ICCO’s work raises a wider question.
The pilots involved dedicated support to each partner on the ground. ICCO provided an introductory workshop and the choice of a range of instruments, followed by on-going support. The instruments had to be adapted to the local context. It’s not clear how expensive or sustainable this is.
The report notes that the approach has not yet been widely taken up in ICCO, due to ‘stormy weather’ in the form of an internal reorganisation and uncertain funding. Without clear incentives for ICCO’s senior management, and reduced costs, wider adoption may remain as elusive for ICCO as it has for others.
The pilots are reported as having strengthened ‘downward accountability’ (to clients). It is not clear how they were used to strengthen ‘upward accountability’ (to senior managers and donors).
It may not be enough for them to be reported as case studies. A further step could be to be report feedback data systematically, right up to the top of the organisation, so senior decision makers are seen to use it. This would drive adoption. It would also change the process by requiring standard tools and increasing the pressure to report positive results.
This feels like the emerging agenda for further practical research on using client feedback to improve both the delivery and the oversight of programmes.