Effects of a Social Accountability Approach, CARE's Community Score Card, on Reproductive Health-Related Outcomes in Malawi: A Cluster-Randomized Controlled Evaluation

"One of the greatest strengths of the CSC process may be that it helps build understanding and a stronger, more trusting relationship between the health system and the community. By getting both community members and frontline health providers involved and invested in governance over local health services, a new dynamic of working collectively to overcome challenges and improve outcomes is established."

Social accountability approaches, which emphasise mutual responsibility and accountability by community members, healthcare workers, and local health officials for improving health outcomes in the community, are increasingly being employed in low-resource settings. The Community Score Card (CSC), developed by CARE Malawi in 2002 as a social accountability tool, seeks to empower and support service users and service providers to work together to improve responsiveness of the health system to the community's needs. This cluster-randomised controlled trial (RCT) assesses the effectiveness of the CSC in improving reproductive-health-related outcomes in Ntcheu, Malawi.

The theory of change underlying the CSC intervention suggests that bringing together community members, health workers, and local officials to a) identify barriers and facilitators of service use and delivery, b) prioritise actions, and c) jointly monitor improvements will result in new and expanded spaces for inclusive, effective dialogue and negotiation. This, in turn, will empower both women and health workers in the community, leading to improved health behaviours, increased service utilisation, and higher-quality and more equitable service delivery. Ultimately, these changes, along with system and institutional changes, should decrease maternal and neonatal mortality in communities.

The CSC intervention consists of 5 phases:

1. Planning and preparation: identifying the sectoral and geographic scope of the initiative, understanding the context and barriers both service providers and users face, training facilitators, and securing cooperation and buy-in from all participating parties, including government officials.
2. Conducting the score card with the community: holding focus group discussions (FGDs) with community members (separated into groups such as men, women, youth, etc.) to identify and prioritise issues they are facing in accessing services. Identified issues are organised into themes, and a measureable indicator is developed for each theme. The indicators are then verified and scored by the community, who also indicates reasons for why a particular score was given and creates suggestions for improvement.
3. Conducting the score card with service providers: asking service providers to take part in FGDs in which they identify issues they are facing in delivering quality services, develop and score indicators, give reasons for the scores, and make suggestions for improvement.
4. Holding an interface meeting: gathering together community members, service providers, and local government officials and other power holders to share and discuss the respective score cards, issues, and priorities. This joint conversation gives way to locally identified solutions and a community-wide action plan for service improvement.
5. Implementing the action plan and conducting monitoring and evaluation (M&E): engaging community members, service providers, government staff, and additional power-holders in reviewing and monitoring progress on indicators.

This cycle is repeated (minus the initial planning and preparation stage) every six months.

Study sites were defined as a health facility and its surrounding catchment area. Among intervention health facilities, there were 56 group villages (GVs) that contained 290 villages with a total population of 228,029. Among control health facilities, there were 36 GVs that contained 228 villages with a total population of 170,201. The CARE Malawi team purposively identified 64 villages from the 16 intervention GVs in which to work, and randomly selected 64 villages in the 20 control GVs. They collected baseline data (n = 1,301) between November and December 2012, and endline data (n = 1,300) in November and December 2014. There were 650 eligible women per treatment condition.

Difference-in-difference (DiD) analyses showed significantly greater improvements in the proportion of women receiving a home visit during pregnancy (B = 0.20, P < .01) and receiving a postnatal visit (B = 0.06, P = .01). In short, the CSC intervention increased community health worker (CHW) visits to women during pregnancy by 20% and during the postnatal period by 6%, compared to control. There was also significant improvements in overall service satisfaction (B = 0.16, P < .001) in intervention compared to control areas. Local average treatment effect (LATE) analyses estimated significant effects of the CSC intervention on home visits by health workers (114% higher in intervention compared to control) (B = 1.14, P < .001) and current use of modern contraceptives (57% higher) (B = 0.57, P < .01).

All 13 community- and provider-developed indicators improved, with 6 of them showing significant improvements: Relationships between health workers and communities and reception of clients at the facility saw the greatest increases, with 37- and 36-point increases, respectively. Commitment of health workers gained 26 points. Other indicators with substantial increases included level of male involvement in maternal newborn health and family planning (33 points), level of youth involvement (23 points), and availability and accessibility of information (22 points). According to the researchers' analysis, these factors "may have contributed to the large increase in use of modern contraceptives" found in the intervention communities.

The researchers conclude: "Sustained improvements in coverage, quality and equity of services can only be achieved by shared responsibility and accountability for outcomes among key stakeholders. The CSC strives to improve stakeholder interactions by collaboratively engaging community members and service providers. Interface meetings provide a safe space where constituents can share concerns, think through solutions, and negotiate joint action plans. Our results demonstrate that this activity can enhance patient-centered care, community engagement, ongoing feedback, and availability of information about services....By improving the responsiveness of the health system to the self-identified needs of the population it serves, the CSC seeks to fundamentally change the relationship between the community and the health delivery system, ensuring that they work together as a complete system to improve maternal newborn health."