CARE USA, Atlanta, Georgia, United States of America.
College for Public Health & Social Justice, Saint Louis University, St. Louis, Missouri, United States of America.
PLoS One. 2020 May 19;15(5):e0232868. doi: 10.1371/journal.pone.0232868. eCollection 2020.
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.
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.
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.
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.
社会问责制方法在资源匮乏的环境中被越来越多地采用，以改善政府服务。与持续质量改进（CQI）理念一致，即质量是链接链的产物，像社区记分卡（CSC）这样的协作社会问责制方法旨在赋予客户和一线服务提供者权力，以改变他们的生活，并要求公职人员履行国家义务。尽管这是协作社会问责制方法的关键焦点，但据我们所知，尚未对卫生工作者进行定量调查，以了解这些方法对其自我报告的责任和服务提供的影响。为了填补这一空白，我们对卫生工作者进行了定量调查，以评估 CSC 对卫生工作者报告的服务责任和提供的影响，并补充妇女的自我报告。
我们在马拉维恩特凯区采用了一项基于群组的随机设计，评估了 CSC 对与生殖健康相关结果的影响。我们将 10 对卫生设施和周围的集水区社区进行匹配；每对中的一个被随机分配到干预组和对照组。干预社区和卫生工作者在终点分别完成了 3-4 轮 CSC 流程。然后，我们在终点调查了 20 个干预和对照地点的所有卫生工作者（n = 412），以估计干预的影响。
与对照组相比，CSC 干预区的卫生工作者明显（p <.05）报告了更多的责任，包括产前护理、全面产前护理咨询、记录每月接受产前和产后护理的孕妇人数，以及上一个计划生育客户的平均年龄更年轻。此外，在治疗组与对照组相比，更多的卫生工作者报告在怀孕期间至少一次家访。然而，与对照组相比，干预区卫生工作者报告进行 HIV 检测的责任明显较低。
CSC 的目的是赋予卫生工作者与社区和整个卫生系统合作的权力，以确定和克服他们面临的多样化和特定于背景的绩效障碍。在这样做的过程中，它旨在支持他们向卫生系统要求和确保优质护理，以便他们能够反过来为客户提供优质服务。我们的研究结果为 CSC 可能有助于改善服务提供的证据做出了贡献。虽然越来越多的证据表明，像 CSC 这样的协作社会问责制方法是改善资源匮乏环境中与生殖健康相关的服务提供和结果的有效手段，但还需要进一步的研究。
