Abstract
BackgroundSocial accountability interventions such as CARE’s Community Score Card© show promise for improving sexual, reproductive, and maternal health outcomes. A key component of the intervention is creation of spaces where community members, healthcare workers, and district officials can safely interact and collaborate to improve health-related outcomes. Here, we evaluate the intervention’s effect on governance constructs such as power sharing and equity that are central to our theory of change.MethodsWe randomly assigned ten matched pairs of communities to intervention and control arms, administering endline surveys to women in each arm who had given birth in the last 12 months. Forty-six governance items were reduced by factor analysis into eight underlying scales. We evaluated the intervention’s impact on these constructs using local average treatment effect estimates.ResultsAmong intervention-area women who reported a community meeting, we further evaluated the influence of the governance constructs on health-related outcomes: home visit from a community health worker, modern family planning, and satisfaction with health services. A significantly greater proportion of intervention-area women compared to control reported the existence of community groups that provide and facilitate negotiated space between community members and healthcare workers (p = .003). Several governance constructs were positively associated with the health-related outcomes. Further, active participation in the intervention was also positively associated with several governance constructs.ConclusionsCARE’s Community Score Card© facilitated the creation and claiming of effective and inclusive negotiated spaces in which community members and healthcare workers could vocalize service delivery issues and prioritize actions for improvement. We argue that reliable measurement of governance concepts such as power sharing, equity and quality of negotiated space, collective efficacy, and mutual responsibility will enhance our ability to evaluate social accountability interventions and understand the processes by which they affect change.
Highlights
Social accountability interventions such as CARE’s Community Score Card© show promise for improving sexual, reproductive, and maternal health outcomes
The Community Score Card© (CSC) facilitates the development of local committees or groups that enable community members to share experiences, coordinate their voices, and interact with health workers and local government officials around maternal and newborn health issues of concern to them
Health workers, and local government officials collaborated within these spaces to achieve higher-quality, more transparent, and more accountable health services
Summary
Social accountability interventions such as CARE’s Community Score Card© show promise for improving sexual, reproductive, and maternal health outcomes. Despite general agreement that social accountability involves the intersection of citizen participation and engagement with governance or public sector oversight [1, 2], there have been limited efforts to develop theoretical frameworks for social accountability or to measure its impacts empirically [3, 4]. To address this gap, CARE developed a theory of change and a set of empirical measures for governance concepts that helps unpack this “black box” of what happens in between the implementation of a social accountability approach and health-related outcomes [5]. CARE’s Community Score Card© (CSC) process seeks to facilitate and improve the quality of negotiated spaces so community members and health workers can come together to voice issues, craft solutions, and hold each other mutually accountable for improvement
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