Abstract
The Community Score Card© (CSC), a social accountability approach, brings together community members, service providers, and local government officials to identify issues, prioritize, and plan actions to improve local health services. In addition, young people in Ntcheu, Malawi have been using the CSC approach to mobilize their communities to bring change across varying issues of importance to them. An earlier cluster randomized trial in Ntcheu showed the CSC effectively increased reproductive health behaviors, improved satisfaction with services, and enhanced the coverage and quality of services. Building upon this evidence of effectiveness, this study aims to evaluate if and how young people were able to sustain implementation of the CSC, and the improvements it brings, approximately 2.5 years after the randomized trial ended. As part of a larger evaluation of CSC sustainability in Ntcheu, we conducted 8 focus groups across 5 health catchment areas with 109 members of mixed-gender youth groups (58 females and 51 males, ages 14–29 years) who continued to engage with the CSC. Audio recordings were transcribed, translated into English, and coded in Dedoose using an a priori codebook augmented with emergent codes and a constant comparative approach. Although the 8 youth groups were still actively using the CSC, they had made some adaptations. While the CSC in Ntcheu initially focused on maternal health, young people adopted the approach for broader sexual and reproductive topics important to them such as child marriages and girls' education. To enable sustainability, young people trained each other in the CSC process; they also requested more formal facilitation training. Young people from Ntcheu recommended nationwide scale-up of the CSC. Young people organically adopted the CSC, which enabled them to highlight issues within their communities that were a priority to them. This diffusion among young people enabled them to elevate their voice and facilitate a process where they hold local government officials, village leaders, and services providers accountable for actions and the quality of healthcare services. Young people organized and sustained the CSC as a social accountability approach to improve adolescent sexual and reproductive health in their communities more than 2.5 years after the initial effectiveness trial ended.
Highlights
Social accountability encapsulates both citizen engagement and governance [1]
We focus explicitly on the role of young people in the sustainability of the Community Score Card© (CSC), seeking to understand what drives the continuation of the CSC by groups of young people in Ntcheu district, Malawi approximately 2.5 years later
In mid-2018, around two and a half years after the end of Maternal Health Alliance Project (MHAP) and of formal support by CARE to facilitate the CSC process, we used purposive sampling to identify groups of young people across health center catchment areas who had been involved in the implementation of the CSC during the initial study
Summary
Social accountability encapsulates both citizen engagement (the social) and governance (the accountability) [1]. Social accountability approaches are mechanisms designed to engage those systematically and historically excluded from power within communities, such as young people. These approaches strive to enable citizens a voice around issues related to quality, equity, and governance of local services by facilitating safe spaces in which to express that voice and negotiate actions to address concerns. As CARE was conducting a community randomized trial on social accountability in Malawi, an unexpected development emerged: without prompting or intention on behalf of the trial, groups of young people were adopting the social accountability approach and modifying it for their own use and objectives. This organic adoption of the approach offered an opportunity to explore not just how social accountability can engage youth meaningfully but how such engagement of young people could enhance the sustainability of these tools
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