Effective project feedback mechanisms and mobile technology in the Karnataka Beneficiary Verification System are profoundly changing the quality of public health services in this Indian state. Under this new system, the local public health officials are better able to monitor service delivery, evaluate beneficiary experience, identify service delivery gaps, and respond promptly to concerns such as supply shortages, lack of community involvement, and needs for further training.
In the 1990s despite a booming economy a number of vulnerable groups--women, children, rural households, and members of lower castes--in India's southern state of Karnataka continued to suffer from limited access to state healthcare services due to a combination of market failures, constrained public facilities, and reliance on costly private sector care. While Karnataka’s prosperous northern region was achieving excellent health outcomes, its impoverished southern region suffered from human development indicators on par with India’s poorest states.
The health disparities in Karnataka were further complicated by the inability to obtain feedback on project operations. Although public officials were attempting to address the state's challenges, they had no system in place to obtain information on why their efforts were not working.
In the 2000s, the government of Karnataka took a series of steps to improve basic health among its vulnerable groups and help meet India’s Millennium Development Goals to reduce maternal and child mortality by creating an independent Health Task Force, setting health-related human development targets, and crafting a new health sector policy. A key component of this policy shift was establishing a fully functioning system for monitoring and evaluation.
“It was very clear to policymakers that addressing the health disparities was going to require improving the ability to track and verify service delivery,” said Deepak Bhatia, Lead E-Government Specialist for the World Bank.
In response to this need, the World Bank has been providing support to the Karnataka Department of Health and Family Welfare through the International Development Association (IDA), the World Bank's Fund for the Poorest. The project is making use of advances in mobile technology and handheld devices to create a system capable of monitoring in real-time the quality and quantity of health services delivered to pregnant mothers.
“The beneficiary verification system being piloted in Karnataka is unique in that it brings beneficiary feedback, ground-level data on service delivery, and challenges to service delivery in one place and in real-time,” said Pratheep Ponraj, Senior Information Officer at the World Bank.
In contrast to traditional monitoring systems, which determine effectiveness by focusing almost exclusively on input from service providers, this new system determines effectiveness by putting more emphasis on ensuring that feedback is coming directly from beneficiaries. Expecting mothers receive a photo ID and smart card. When they receive services, the community health worker scans the smart card using the hand-held device and enters any data or feedback on the services provided.
Community health workers then use hand-held devices to record data on services provided, with acknowledgement from beneficiaries, as well as collect feedback from pregnant mothers about the services they receive or to report problems.
“Rather than the service provider saying ‘I delivered services,’ it is the beneficiary saying, ‘I have received services,’” said Bhatia. “The beneficiary is the one who confirms that the service has been delivered.”
In addition, the project has also prepared the government of Karnataka to initiate a voice-based survey that will independently verify service delivery and measure satisfaction among beneficiaries on a regular basis.
The beneficiary verification system is being piloted with nine primary health clinics serving more than 3,000 beneficiaries in two districts. Although small in scale, the pilot project has been highly successful in winning over once-skeptical supporters by demonstrating how systematic beneficiary engagement and handheld mobile technology can yield data that is timely, reliable, and actionable.
“Now I don’t have to wait for data on performance for two years,” said Dr. Ramana Reddy, Health Secretary for the State of Karnataka. “The Beneficiary Verification system shows our performance in real-time – which is what I always wanted. This helps me see where we are in terms of service delivery to beneficiaries. We would like to replicate this across the state in 27 districts.”
In addition, health workers are able to pass along important information on the challenges they face in the field.
“We are getting a much better understanding of common service delivery gaps,” said Bhatia. “For example, we kept getting reports from community health workers that when they went to an expecting mother’s house to do follow-up visits, the door was locked and they couldn’t find them at home. The project received so many reports like this that we investigated what was happening. We eventually discovered that the local cultural norm was that the expectant mother always returns to her parents’ home to deliver her first child. We learned that we needed to adjust our services to account for this issue of migration.”
Similarly, the beneficiary verification system has also enabled nurses to quickly generate reports identifying obstacles to service delivery such as insufficient medical supplies or the lack of a doctor. Such reports are flagged in the monitoring system and used by the health department to make decisions on how to best reallocate resources and address service gaps.
Although the project faced some initial challenges, it has since gained the level of government support necessary to ensure sustainability.
“When we first tried to sell the idea of proactively seeking beneficiary feedback, there was not much clarity on how this information will be useful, among various stakeholders,” said Bhatia. “Now it is different – the government sees this as supporting their work”
World Bank Contribution
The World Bank is working with the Karnataka Department of Health and Family Welfare under the auspices of the Karnataka Health Systems Development and Reform Project (KHSDRP). The World Bank provides US$142 million in financial assistance through a Specific Investment Loan, within the IDA portfolio. The World Bank provided technical assistance in the design of the results monitoring framework and the Information Communication Technology (ICT)-based feedback component through a partnership with Governance Partnership Facility (GPF).
The Indian government is contributing US$65 million in matching financing to the leadership of the implementing agency, the Karnataka State Department of Health and Family Welfare. The project also cooperates in varying degrees with numerous levels of local government.
The World Bank has helped to facilitate additional funding to support further innovation, pilot projects, and evaluation from sources such as the Health Results Innovation Trust Fund (HRITF), the Governance Partnership Facility (GPF), and the Japan Social Development Fund (JSDF). The bilateral and multilateral donors contributing to these funding sources are also important partners in the project’s success.
This project has served as an important proof of concept for several key principles outlined in the World Bank’s World Development Report 2004: Making Services Work for the Poor. These same principles have the potential to be applied to other public services—agriculture, education, sanitation—both at the national and state government levels. Already, the World Bank and the Karnataka state government are developing plans to replicate this pilot project across the state of Karnataka and expand its reach to cover approximately one million beneficiaries.