title: Effects of a social accountability approach, CARE's Community Score Card, on reproductive health-related outcomes in Malawi: A cluster-randomized controlled evaluation.
abstract: 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.
authors.affiliation: CARE USA, Atlanta, GA, United States of America.
authors.forename: Sara
authors.identifier: http://orcid.org/0000-0002-9192-5695
authors.initials: S
authors.lastname: Gullo
authors.affiliation: CARE USA, Atlanta, GA, United States of America.
authors.forename: Christine
authors.initials: C
authors.lastname: Galavotti
authors.affiliation: College for Public Health & Social Justice, Saint Louis University, St. Louis, MO, United States of America.
authors.forename: Anne
authors.initials: A
authors.lastname: Sebert Kuhlmann
authors.affiliation: CARE Malawi, Lilongwe, Malawi.
authors.forename: Thumbiko
authors.initials: T
authors.lastname: Msiska
authors.affiliation: Far Harbor, LLC, Austin, TX, United States of America.
authors.forename: Phil
authors.initials: P
authors.lastname: Hastings
authors.affiliation: Far Harbor, LLC, Austin, TX, United States of America.
authors.forename: C Nathan
authors.initials: CN
authors.lastname: Marti
mesh_terms: D003906:Developing Countries; D005260:Female; D006078:Government Programs / Q000592:standards; D006801:Humans; D007231:Infant, Newborn; D008295:Malawi; D008297:Male; D008427:Maternal Health Services / Q000592:standards* / Q000706:statistics & numerical data; D011247:Pregnancy; D015397:Program Evaluation; D011897:Random Allocation; D060728:Reproductive Health / Q000592:standards* / Q000706:statistics & numerical data; D012423:Rural Health / Q000706:statistics & numerical data; D012941:Social Responsibility