Abstract
Social accountability approaches, such as the community scorecard (CSC), can improve the performance of health systems in low-income countries by providing a mechanism for obtaining and incorporating community input. This longitudinal study assessed the effects of CSCs implemented by primary health care units (PHCUs) on health system performance in Ethiopia. This study used a pre-post design and was conducted from October 2018 to September 2019 in 159 PHCUs in 31 districts in Amhara and Southern, Nations, Nationalities and Peoples' regional states. The data were extracted from a routine health information management system database at baseline, midterm, and endline stages over 12 months for statistical analysis. The effects of implementing CSCs on health system performance were evaluated against selected key performance indicators (KPIs). The CSC measurement results were based on input from 38,556 community representatives. The mean CSC score with standard deviation (±SD) was 60.8%±12.5%, 66.3%±10.8%, and 70.6%±10.0% at baseline, midterm, and endline, respectively. The mean KPI score was 54.9%±17.4%, 61.9%±15.1%, and 67.6%±14.6% at baseline, midterm, and endline, respectively. The average CSC and KPI values were positively correlated (r>0.37). Using a nonparametric Friedman's test, we found a statistically significant difference in CSC and KPI scores at baseline, midterm, and endline (P=.001). Post hoc analysis with Wilcoxon signed-rank tests was conducted with a Bonferroni correction and the results showed higher CSC and KPI values from baseline to midterm and from midterm to endline (P<.017). The use of CSCs in Ethiopia contributed to the health system's performance in terms of maternal and child health services. The responsiveness of health workers and utilization of basic health services by community members were found to increase significantly with CSC use. We recommend continued implementation of the CSC intervention at PHCUs.
Highlights
Social accountability approaches, such as the community scorecard (CSC), can improve the performance of health systems in low-income countries by providing a mechanism for obtaining and incorporating community input
Two-thirds (67.7%) of the districts and the majority (128; 80.5%) of primary health care unit (PHCU) were located in South Wollo administrative zones of Amhara region
Districts Primary health care units Population Number of villages Client councils Villages that implemented community scorecard Client council members participated in focus group discussions Community members participated in focus group discussions
Summary
Social accountability approaches, such as the community scorecard (CSC), can improve the performance of health systems in low-income countries by providing a mechanism for obtaining and incorporating community input. This longitudinal study assessed the effects of CSCs implemented by primary health care units (PHCUs) on health system performance in Ethiopia. We recommend continued implementation of the CSC intervention at PHCUs. The World Development Report of 2004 highlighted the benefits of listening to citizens to improve pro-poor targeted service delivery.[1] Following this report, the global community showed an eagerness to institutionalize social accountability approaches to help improve the performance of health systems in developing countries.[2,3,4]. CSCs have been most commonly used in health sectors in different African countries as a way for communities and service providers to work together on the planning and monitoring of specific health services and to jointly gear efforts toward improving service equity, quality, and access to services in resource-limited settings.[4,10,11,12,13,14,15]
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