Reposting - Scale 0 for change in health systems through social accountability

To be honest, the main reason I am reposting this blog that Karen Waltensperger and I wrote for the Frontline Health Worker Coalition is that I keep referring to it and not finding the link. But this allows me to illustrate one important point on social accountability.

Jonathan Fox (AU/ARC) speaks of 'vertical integration' of social accountability (link available on the original blog), not 'at scale', but 'at different scales.' This is a very important concept, and we're trying to address how these 'different scales' mean to the business of monitoring, evaluation, and learning through the CORE Systems for Health working group with our JHU colleagues. But it's important to understand what these different scales mean -- for example frontline services, districts, local government, national government, etc. It's not just that things get bigger "at scale", it's that -- as always -- 'more is different', aka the nature of the problem changes with the scale at which it is being tackled.

Think about it this way:

• Scale 1: you're working with primary health care facility and the users' community to engage in some dialogue, maybe use a scorecard, get some discussion and action points on improving quality, have first action steps, review, etc. You will have to deal with facilitation, potential conflict, sense making, data generation, mobilization (of community, of health workers), behavior change (of everyone around), quality improvement, and negotiating skills with different stakeholders.
• Scale 2: while you have similar motivations as at scale 1 (for example quality, equity, participation, empowerment, governance), you are now engaged in processes where the dialogues involve not a clinic in-charge and health committee leaders, but a district health officer and a local government representative. On the 'client' side, the work is lead or supported a local NGO leaders, or a coordination body for local CBOs or health committees. You will still have to deal with things addressed at Scale 1, facilitation, potential conflict, data, etc. But all these things will be very different qualitatively -- you'll need different facilitation skills, different rapport to power, etc. You'll be treading on very different waters; both mistakes and success will have very different consequences at Scale 2 than at Scale 1. It's not just 'more scale'; it's 'different scale'.

So, this blog from last year illustrates what happens at Scale 0 so to speak:why and how does a health leader in the broadest definition (health worker, clinic-in charge, officer, pharmacist, supervisor) change behavior leading to better health systems performance in the first place. As you move from Scale 0 (a person) to Scale 1 (a service structure), the boundary of your 'system' expands, and the number of relationships to take into account also expands. As the boundaries get bigger at Scale 2, the number of relationships will increase exponentially. At each level, it's largely about human behaviors -- but increasing scale = increasing complexity.

Research will need to continue taking us into the weeds, or stepping away to measure large effects.

Program evaluation and learning will need to zoom in on the most important parts to keep our eyes on, if we want to maintain some momentum.

In the meantime, here's a brainstorm about the weeds, 'inside the black box' of individual health leaders influenced by social accountability processes.

Eric