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.