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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. [ABSTRACT FROM AUTHOR]

Background: The Malawi government encourages early antenatal care, delivery in health facilities, and timely postnatal care. Efforts to sustain or increase current levels of perinatal service utilization may not achieve desired gains if the quality of care provided is neglected. This study examined predictors of perinatal service utilization and patients' satisfaction with these services with a focus on quality of care.Methods: We used baseline, two-stage cluster sampling household survey data collected between November and December, 2012 before implementation of CARE's Community Score Card© intervention in Ntcheu district, Malawi. Women with a birth during the last year (N = 1301) were asked about seeking: 1) family planning, 2) antenatal, 3) delivery, and 4) postnatal care; the quality of care received; and their overall satisfaction with the care received. Specific quality of care items were assessed for each type of service, and up to five such items per type of service were used in analyses. Separate logistic regression models were fitted to examine predictors of family planning, antenatal, delivery, and postnatal service utilization and of complete satisfaction with each of these services; all models were adjusted for women's socio-demographic characteristics, perceptions of the closest facility to their homes, service use indicators, and quality of care items.Results: We found higher levels of perinatal service use than previously documented in Malawi (baseline antenatal care 99.4%; skilled birth attendance 97.3%; postnatal care 77.5%; current family planning use 52.8%). Almost 73% of quality of perinatal care items assessed were favorably reported by > 90% of women. Women reported high overall satisfaction (≥85%) with all types of services examined, higher for antenatal and postnatal care than for family planning and delivery care. We found significant associations between perceived and actual quality of care and both women's use and satisfaction with the perinatal health services received.Conclusions: Quality of care is a key predictor of perinatal health service utilization and complete patient satisfaction with such services in Malawi. The current heightened attention toward perinatal health services and outcomes should be coupled with efforts to improve the actual quality of care offered to women in this country. [ABSTRACT FROM AUTHOR]

We evaluated the sustainability of CARE's Community Score Card© (CSC) social accountability approach in Ntcheu, Malawi, approximately 2.5 years after the end of formal intervention activities. Using a cross-sectional, exploratory design, we conducted 41 focus groups with members of Community Health Advisory Groups (CHAGs) and youth groups and 19 semi-structured interviews with local and district government officials, project staff, and national stakeholders to understand how and in what form CSC activities are continuing. Focus groups and interviews were audio-recorded, transcribed and translated into English. Thematic coding was done using Dedoose software. Most groups were continuing to meet and implement the CSC, although some made modifications. CHAGs, youth and local government officials all attributed their continued implementation to the value that they saw in the process that allows marginalized groups within the community, including women and youth, a safe space for sharing their ideas and issues and the initial results this generated. However, lack of access to resources for implementation and challenges in convening and facilitating the interface meeting phase created barriers to continued sustainability. The CSC is sustainable by communities 2.5 years after the end of formal intervention activities. For future interventions, health systems and non-governmental organizations should plan for a transition phase with periodic refresher trainings and a small fund to support implementation, such as refreshments and transportation, to increase the likelihood of community-driven sustainability., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: Social 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., Methods: We 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., Results: DiD 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., Conclusions: By 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., Competing Interests: The relationship with Far Harbor, LLC, the firm that conducted data analysis and assisted with the preparation of the manuscript, does not alter our adherence to PLOS ONE policies on sharing data and materials.