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Randomized Controlled Trial
. 2018 Nov 14;18(1):858.
doi: 10.1186/s12913-018-3651-3.

Creating spaces for dialogue: a cluster-randomized evaluation of CARE's Community Score Card on health governance outcomes

Sara Gullo  1 , Anne Sebert Kuhlmann  2 , Christine Galavotti  3 , Thumbiko Msiska  4 , C Nathan Marti  5 , Philip Hastings  5
Affiliations
Randomized Controlled Trial

Creating spaces for dialogue: a cluster-randomized evaluation of CARE's Community Score Card on health governance outcomes

Sara Gullo et al. BMC Health Serv Res. .

Abstract

Background: Social 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.

Methods: We 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.

Results: Among 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.

Conclusions: CARE'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.

Keywords: Family planning; Malawi; Maternal health; Patient satisfaction; Reproductive health; Social accountability.

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Conflict of interest statement

Ethics approval and consent to participate

Malawi’s National Health Science Research Committee reviewed and approved this study (Protocol #1056). This was a program evaluation, not a trial. This was deemed so by Malawi’s National Health Science Research Committee. Per the approved protocol, all women provided verbal informed consent prior to the start of the survey given the nature of the program evaluation and the relatively low literacy rates, particularly among women. Similarly, the inclusion criteria were set as women of reproductive age (15–44 years) who had given birth within the past 12 months and whose baby was still living. In Malawi, prevailing culture considers such women adults, so all women consented for themselves.

Consent for publication

Not applicable for this study.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Community Score Card Theory of Change [17]
Fig. 2
Fig. 2
Randomization design flowchart [17]. HF: health facility; GV: group village; PMTCT: Prevention of Mother to Child Transmission of HIV; bEmOC: basic emergency obstetric care. aOne GV consisted of a large number of individuals that used a HF in a different catchment area; a second GV was participating in another maternal and child health project. These GVs were replaced with alternative GVs. bEight GVs were selected from a high population HF, which could not be implemented feasibly within one area. Thus, four GVs were eliminated and the PPS sample for this HF was obtained from the remaining four GVs in the HF catchment area
See this image and copyright information in PMC

References

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