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Effects of the Community Score Card approach on reproductive health service-related outcomes in Malawi.

ABSTRACT: BACKGROUND:Social accountability approaches are increasingly being employed in low-resource settings to improve government services. In line with the continuous quality improvement (CQI) philosophy that quality is the product of a linked chain, collaborative social accountability approaches like the Community Score Card (CSC) aim to empower clients and frontline service providers to transform their own lives and hold public officials to account for state obligations. Despite being a critical focus of collaborative social accountability approaches, to our knowledge, a quantitative survey of health workers to understand the impact of these approaches on their self-reported responsibilities and service provision has not been conducted. To fill this gap, we carried out a quantitative survey with health workers to assess the CSC's impact on health worker-reported service responsibilities and provision and complement women's self-reports. METHODS:We evaluated the effect of the CSC on reproductive health-related outcomes using a cluster-randomized design in Ntcheu district, Malawi. We matched 10 pairs of health facilities and surrounding catchment communities; one from each pair was randomly assigned to the intervention and control arms. The intervention communities and health workers each completed 3-4 cycles of the CSC process by endline. We then surveyed all health workers in the 20 intervention and comparison sites at endline (n = 412) to estimate the intervention's impact. RESULTS:Significantly (p < .05) more health workers in the CSC intervention areas compared to control areas reported responsibility for antenatal care, comprehensive antenatal care counseling, recording of the number of pregnant and postpartum women seen each month, and the average age of their last family planning client was younger. In addition, marginally significantly (p < .10) more health workers in treatment versus control areas report visiting women at their home at least once during their pregnancy. However, health worker-reported responsibility for HIV testing was significantly lower in intervention areas than in control. CONCLUSIONS:The CSC aims to empower health workers to collaborate with the community and rest of the health system to identify and overcome the diverse and context-specific range of performance barriers they face. In doing so, it aims to support them to demand and ensure quality care for themselves from the health system so they can, in turn, deliver quality services to clients. Our results contribute to the evidence that the CSC may hold promise at improving service provision. While there is increasing evidence that collaborative social accountability approaches like the CSC are effective means to improving reproductive health-related service provision and outcomes in low-resource settings, additional research is needed.

SUBMITTER: Gullo S

PROVIDER: S-EPMC7236973 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Effects of the Community Score Card approach on reproductive health service-related outcomes in Malawi.

Gullo Sara S Galavotti Christine C Sebert Kuhlmann Anne A Msiska Thumbiko T Hastings Phil P Marti C Nathan CN

PloS one 20200519 5

<h4>Background</h4>Social accountability approaches are increasingly being employed in low-resource settings to improve government services. In line with the continuous quality improvement (CQI) philosophy that quality is the product of a linked chain, collaborative social accountability approaches like the Community Score Card (CSC) aim to empower clients and frontline service providers to transform their own lives and hold public officials to account for state obligations. Despite being a crit ...[more]

PMID: 32428027

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Project description:BackgroundSocial 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.MethodsWe 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.ResultsDiD 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.ConclusionsBy 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.

Project description:BackgroundCoverage of prevention of mother-to-child transmission of HIV (PMTCT) services has expanded rapidly but approaches to ensure service delivery is patient-centered have not always kept pace. To better understand how the inclusion of women living with HIV in a collective, quality improvement process could address persistent gaps, we adapted a social accountability approach, CARE's Community Score Card© (CSC), to the PMTCT context. The CSC process generates perception-based score cards and facilitates regular quality improvement dialogues between service users and service providers.MethodsFifteen indicators were generated by PMTCT service users and providers as part of the CSC process. These indicators were scored by each population during three sequential cycles of the CSC process which culminates in a sharing of scores in a collective meeting followed by action planning. We aggregated these scores across facilities and analyzed the differences in first and last scorings to understand perceived improvements over the course of the project (z-test comparing the significance of two proportions; one-tailed p-value ≤ .05). Data were collected over 12 months from September 2017 to August 2018.ResultsFourteen of the fifteen indicators improved over the course of this project, with eight showing statistically significant improvement. Out of the indicators that showed statistically significant improvement, the majority fell within the control of local communities, local health facilities, or service providers (7 out of 8) and were related to patient or user experience and support from families and community members (6 out of 8). From first to last cycle, scores from service users' and service providers' perspectives converged. At the first scoring cycle, four indicators exhibited statistically significant differences (p-value ≤ .05) between service users and service providers. At the final cycle there were no statistically significant differences between the scores of these two groups.ConclusionsBy creating an opportunity for mothers living with HIV, health service providers, communities, and local government officials to jointly identify issues and implement solutions, the CSC contributed to improvements in the perceived quality of PMTCT services. The success of this model highlights the feasibility and importance of involving people living with HIV in quality improvement and assurance efforts.Trial registrationTrial registration: ClincalTrials.gov NCT04372667 retrospectively registered on May 1st 2020.

Project description:Malawi faces challenges with retaining women in prevention of mother-to-child HIV transmission (PMTCT) services. We evaluated Cooperative for Assistance and Relief Everywhere, Inc. (CARE's) community score card (CSC) in 11 purposively selected health facilities, assessing the effect on: (1) retention in PMTCT services, (2) uptake of early infant diagnosis (EID), (3) collective efficacy among clients, and (4) self-efficacy among health care workers (HCWs) in delivering quality services. The CSC is a participatory community approach. In this study, HCWs and PMTCT clients identified issues impacting PMTCT service quality and uptake and implemented actions for improvement. A mixed-methods, pre- and post-intervention design was used to evaluate the intervention. We abstracted routine clinical data on retention in PMTCT services for HIV-positive clients attending their first antenatal care visit and EID uptake for their infants for 8-month periods before and after implementation. To assess collective efficacy and self-efficacy, we administered questionnaires and conducted focus group discussions (FGDs) pre- and post-intervention with PMTCT clients recruited from CSC participants, and HCWs providing HIV care from facilities. Retention of HIV-positive women in PMTCT services at three and six months and EID uptake was not significantly different pre- and post-implementation. For the clients, the collective efficacy scale average improved significantly post-intervention, (p = 0.003). HCW self-efficacy scale average did not improve. Results from the FGDs highlighted a strengthened relationship between HCWs and PMTCT clients, with clients reporting increased satisfaction with services. However, the data indicated continued challenges with stigma and fear of disclosure. While CSC may foster mutual trust and respect between HCWs and PMTCT clients, we did not find it improved PMTCT retention or EID uptake within the short duration of the study period. More research is needed on ways to improve service quality and decrease stigmatized behaviors, such as HIV testing and treatment services, as well as the longer-term impacts of interventions like the CSC on clinical outcomes.

Project description:IntroductionThis paper aimed at estimating the resources required to implement a community Score Card by a typical rural district health team in Uganda, as a mechanism for fostering accountability, utilization and quality of maternal and child healthcare service.MethodsThis costing analysis was done from the payer's perspective using the ingredients approach over five quarterly rounds of scoring between 2017 and 2018. Expenditure data was obtained from project records, entered and analyzed in Microsoft excel. Two scale-up scenarios, scenario one (considered cost inputs by the MakSPH research teams) and scenario two (considering cost inputs based on contextual knowledge from district implementing teams), were simulated to better understand the cost implications of integrating the Community Score Card (CSC) into a district health system.ResultsThe total and average cost of implementing CSC for five quarterly rounds over a period of 18?months were USD 59,962 and USD 11,992 per round of scoring, respectively. Considering the six sub-counties (including one Town Council) in Kibuku district that were included in this analysis, the average cost of implementating the CSC in each sub-county was USD 1998 per scoring round. Scaling-up of the intervention across the entire district (included 22 sub-counties) under the first scenario would cost a total of USD 19,003 per scoring round. Under the second scaleup scenario, the cost would be lower at USD 7116. The total annual cost of scaling CSC in the entire district would be USD 76,012 under scenario one compared to USD 28,465 under scenario two. The main cost drivers identified were transportation costs, coordination and supervision costs, and technical support to supplement local implementers.ConclusionOur analysis suggests that it is financially feasible to implement and scale-up the CSC initiative, as an accountability tool for enhancing service delivery. However, the CSC design and approach needs to be embedded within local systems and implemented in collaboration with existing stakeholders so as to optimise costs. A comprehensive economic analysis of the costs associated with transportation, involvement of the district teams in coordination, supervision as well as provision of technical support is necessary to determine the cost-effectiveness of the CSC approach.

Project description:BACKGROUND:The majority of documented social accountability initiatives to date have been 'tactical' in nature, employing single-tool, mostly community-based approaches. This article provides lessons from a 'strategic', multi-tool, multi-level social accountability project: UNICEF's 'Social Accountability for Every Woman Every Child' intervention in Malawi. METHODS:The project targeted the national, district and community levels. Three Civil Society Organisations (CSOs) were engaged to carry out interventions using various tools to generate evidence and political advocacy at one or more levels. This article focuses on one of the social accountability methods - the bwalo forum (a meeting based on a traditional Malawian method of dialogue). A detailed political economy analysis was conducted by one of the co-authors using qualitative methods including interviews and group discussions. The authors conducted in-country consultations and analysed secondary data provided by the CSOs. RESULTS:The political economy analysis highlighted several ways in which CSO partners should modify their work plans to be more compatible with the project context. This included shifting the advocacy and support focus, as well as significantly expanding the bwalo forums. Bwalos were found to be an important platform for allowing citizens to engage with duty bearers at the community and district levels, and enabled a number of reproductive, maternal, newborn, child and adolescent health issues to be resolved at those levels. The project also enabled learning around participant responses as intermediate project outcomes. CONCLUSIONS:The project utilised various tools to gather data, elevate community voices, and facilitate engagement between citizen and state actors at the community, district and national levels. This provided the scaffolding for numerous issues to be resolved at the community or district levels, or referred to the national level. Bwalo forums were found to be highly effective as a space for inter-level engagement between citizens and state; however, as they were not embedded in existing local structures, their potential for sustainability and scalability was tenuous. A key strength of the project was the political economy analysis, which provided direction for partners to shape their interventions according to local and national realities and be sensitive to the barriers and drivers to positive action.

Project description:BackgroundWomen seeking family planning services from public-sector facilities in low- and middle-income countries sometimes face provider-imposed barriers to care. Social accountability is an approach that could address provider-imposed barriers by empowering communities to hold their service providers to account for service quality. Yet little is known about the feasibility and potential impact of such efforts in the context of contraceptive care. We piloted a social accountability intervention-the Community Score Card (CSC)-in three public healthcare facilities in western Kenya and use a mix of quantitative and qualitative methodologies to describe the feasibility and impact on family planning service provision.MethodsWe implemented and evaluated the CSC in a convenience sample of three public-sector facility-community dyads in Kisumu County, Kenya. Within each dyad, communities met to identify and prioritize needs, develop corresponding indicators, and used a score card to rate the quality of family planning service provision and monitor improvement. To ensure young, unmarried people had a voice in identifying the unique challenges they face, youth working groups (YWG) led all CSC activities. The feasibility and impact of CSC activities were evaluated using mystery client visits, unannounced visits, focus group discussions with YWG members and providers, repeated assessment of score card indicators, and service delivery statistics.ResultsThe involvement of community health volunteers and supportive community members - as well as the willingness of some providers to consider changes to their own behaviors-were key score card facilitators. Conversely, community bias against family planning was a barrier to wider participation in score card activities and the intractability of some provider behaviors led to only small shifts in quality improvement. Service statistics did not reveal an increase in the percent of women receiving family planning services.ConclusionSuccessful and impactful implementation of the CSC in the Kenyan context requires intensive community and provider sensitization, and pandemic conditions may have muted the impact on contraceptive uptake in this small pilot effort. Further investigation is needed to understand whether the CSC - or other social accountability efforts - can result in improved contraceptive access.

Dataset Information

Effects of the Community Score Card approach on reproductive health service-related outcomes in Malawi.

Publications

Effects of the Community Score Card approach on reproductive health service-related outcomes in Malawi.

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