Research Article: Effects of a social accountability approach, CARE’s Community Score Card, on reproductive health-related outcomes in Malawi: A cluster-randomized controlled evaluation

Date Published: February 10, 2017

Publisher: Public Library of Science

Author(s): Sara Gullo, Christine Galavotti, Anne Sebert Kuhlmann, Thumbiko Msiska, Phil Hastings, C. Nathan Marti, Massimo Ciccozzi.


Social accountability approaches, which emphasize mutual responsibility and accountability by community members, health care workers, and local health officials for improving health outcomes in the community, are increasingly being employed in low-resource settings. We evaluated the effects of a social accountability approach, CARE’s Community Score Card (CSC), on reproductive health outcomes in Ntcheu district, Malawi using a cluster-randomized control design.

We matched 10 pairs of communities, randomly assigning one from each pair to intervention and control arms. We conducted two independent cross-sectional surveys of women who had given birth in the last 12 months, at baseline and at two years post-baseline. Using difference-in-difference (DiD) and local average treatment effect (LATE) estimates, we evaluated the effects on outcomes including modern contraceptive use, antenatal and postnatal care service utilization, and service satisfaction. We also evaluated changes in indicators developed by community members and service providers in the intervention areas.

DiD analyses showed significantly greater improvements in the proportion of women receiving a home visit during pregnancy (B = 0.20, P < .01), receiving a postnatal visit (B = 0.06, P = .01), and overall service satisfaction (B = 0.16, P < .001) in intervention compared to control areas. 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. By facilitating the relationship between community members, health service providers, and local government officials, the CSC contributed to important improvements in reproductive health-related outcomes. Further, the CSC builds mutual accountability, and ensures that solutions to problems are locally-relevant, locally-supported and feasible to implement.

Partial Text

Social accountability approaches have been growing in popularity in the health sector over the last decade. These approaches engage citizens in processes that strive to improve public sector performance and hold service providers and other actors accountable for delivering on their commitments [1]. Social accountability approaches aim to help service users voice their needs and concerns and hold service providers accountable for the provision of quality services. These approaches may be particularly effective at improving the patient-centered aspects of quality of care (for example, maintaining privacy and confidentiality, and providing respectful maternity care). Evidence suggests that a variety of social accountability approaches designed to achieve global maternal newborn health goals have improved community engagement in monitoring health services and increased service use, quality, and effectiveness [2, 3]. Although small in number, randomized controlled trials (RCTs) of social accountability approaches used in the health sector have demonstrated significant reductions in health provider absenteeism, and significant improvements in use of family planning and of health facilities for childbirth, attendance at prenatal care, child weight, and under-five child mortality [4–7]. The social accountability evidence base is limited, however, and results overall are still mixed [8–10]. A review of the mixed empirical evidence for social accountability argues that ‘more promising results emerge from studies of multi-pronged strategies that cultivate enabling environments for collective action and bolster state capacity to actually respond to citizen voice,’ but highlights the that both social accountability research and conceptual work are significantly lagging behind practice [8]. Therefore, there have been calls for additional evaluation research and evidence to ensure that these approaches ‘actually deliver benefits for women and children’ [2].

This is the first study to use a rigorous cluster-randomized controlled design to evaluate the effectiveness of CARE’s CSC on a wide range of reproductive health-related outcomes. We found that in rural Malawi our CSC intervention increased CHW visits to women during pregnancy by 20% and during the postnatal period by 6%, compared to control. Further, women’s satisfaction with reproductive health services increased significantly, compared with control areas. In addition to these outcomes, our LATE analysis suggests the CSC also had a significant effect on use of modern contraception, with an estimated 57% greater use in the intervention versus control condition at endline. The 13 CSC indicators developed by community members and health providers to drive reproductive health progress also improved, many significantly, providing additional insight into how the CSC may have affected outcomes.

Increasing evidence suggests that social accountability interventions like the CSC are an effective way to improve maternal and reproductive health services and outcomes in low-resource settings. 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.




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