Publications

Community Empowerment using the Score Card: A Story of Transformation in Chigodi

Part of the Chigodi Youth Group

Picture 1: Part of the Chigodi Youth Group

“Things were bad here in Chigodi, for everyone but most especially for pregnant women. Many women gave birth at home, and some died during birth. At the time, there wasn’t much that could have been done. The clinic required money the women didn’t have and the district hospital is too far,” says Mary Sipiliano, a member of the Chigodi Youth Group in Ntcheu District in the Central Region of Malawi.

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Picture 2: New shelter for the under five clinic at Chigodi

Chigodi is a village of about 13,303 inhabitants located 56 kilometres from the Ntcheu District Hospital. All Chigodi residents, as well as those of surrounding communities rely on a local health centre run by a faith-based organization (FBO) because there are no public health facilities in the vicinity. However, the residents of Chigodi faced several challenges when it came to accessing health care. Due to the size of the facility, patients were asked to wait for assistance outside especially on clinic days and when the weather was bad, the clinic was cancelled. The facility pit-latrines and bathrooms were in bad condition posing additional health risks to patients. The clinic had no water reserve and during the dry season when the bore holes had dried up the centre could not operate. In addition to these problems, the health centre required payments for services which most of the Chigodi residents could not afford to pay. As a result, many people in the community were unable to seek healthcare for treatable illnesses. Because of inability to pay, many women in the community delivered babies at home, and if there were complications that traditional birth attendants did not know how to deal with, some of them died.

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Picture 3: New bathroom and toilets at the health centre

CARE Malawi’s Community Score Card (CSC) team first visited Chigodi in 2016.Working with Mary’s youth group, they conducted three rounds of CSC with the community and health service providers. By the end of the third round, the relationship between the community and the health facility had been transformed. As the community members’ understanding of the constraints faced by the health centre grew with their participation in CSC, they actively engaged with Government to negotiate a service level agreement for the health centre under which Government pays the centre MWK 375,000 each month to provide free maternity and under-five child health services to the community. Now that the problem of fees was resolved, the community turned its attention to the quality of services provided by the centre.

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Picture 4: Water storage tanks in final installation stage.

With support from their Ward Councillor, the community spearheaded efforts to improve the health centre. Villagers provided bricks for the construction of a new shelter for the under-five clinic, and the Councillor mobilised resources for the purchase of corrugated iron sheets for the roof. The Councillor successfully lobbied to have the health centre selected for the construction of new borehole, thus resolving the water problem that has plagued the centre for years.

The need for proper bathrooms and toilets had also been raised a priority issue during the CSC process. Both the community and health centre personnel agreed that the facility did not have bathrooms and toilets fit for a health centre. As the picture (Picture 3) shows, resources were jointly mobilized by the community and government, and the facility now boasts state-of-the-art sanitary facilities. Even with the bore hole and new, improved toilets, water supply during the dry season remained a big challenge causing sanitation levels to drop and increasing the risk of infections and other problems in the health centre. So, the purchase and installation of water storage tanks was listed as a priority in the CSC action plan. The installation of the tanks is in its final stages (Picture 4) and the community can look back with satisfaction, assured of safe and sanitary health services.

The less tangible impact on community members as a result of their participation in the CSC process can be felt in the opennessof their discussions about critical issues of youth sexual and reproductive health stemming from the active involvement and leadership of young peoplein the process. Information gained about the benefits of quality healthcare is also changing health seeking behaviours in the community. More and more pregnant women are attending antenatal care in the first trimester; and sick children are rushed to the clinic at the first sign of illness.

This is just the beginning for our community, we are feeling very positive and we will work together to bring change to the different sectors in our community.” – Chigodi Youth Group member Patrick Masula

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Community Score Card empowering communities for better maternal health care.

CARE has implemented the Community Score Card (CSC) in various communities in Malawi in the quest to improve maternal health. The link below takes you to a raising the score video that shows an empowered community on a mission to improve maternal health. The CSC provided an open forum for the community members, service providers and government officials to engage in discussions about the maternal health problems plaguing the community. The community and the service providers together formulated an action plan and tasks to achieve safe motherhood. The CSC process has built a strong sense of ownership among the community members and determination to work towards safe motherhood.

Many people in the community gave birth at home and many women died during birth,  but now they come together to solve these problems.

Watch Video

“Safe motherhood, we own it”

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CSC leads to an estimated 57% increase in the use of modern contraception.

“Effects of a social accountability approach, CARE’s Community Score Card (CSC) on reproductive health-related outcomes in Malawi: A cluster-randomized controlled evaluation.”

The cluster-randomized controlled evaluation assessed the CSC’s effect on reproductive health related outcomes in Ntcheu, Malawi. Results demonstrated a large and significant effect on use of modern contraception, with an estimated 57% greater use in the intervention versus control condition at end line.  The evaluation also showed that the CSC increased community health workers’ home visits during pregnancy by 20% and after pregnancy by 6%, compared to control areas. In addition to this, women’s satisfaction with reproductive health services increased significantly, compared with control areas. Further, it was found that the CSC builds mutual accountability, and ensures that solutions to problems are locally-relevant, locally-supported and feasible to implement.

This is the first study to use a rigorous cluster-randomized controlled design to evaluate the effectiveness of CARE’s CSC on a wide range of reproductive health-related outcomes. Click on the link below to read the full article.

Read Evaluation Article

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ODI Research into CSC “CARE’s experience with Community Score Cards”

CARE’s experience with Community Score Cards.

What works and Why?

by Joseph Wales and Leni Wild

This policy brief explores the experience of CARE International in implementing community score card programmes in four countries – Ethiopia, Malawi, Tanzania and Rwanda – and aims to address the significant research gap around cross-country comparative analysis of social accountability programmes.

The key findings of the research are that:
•• CARE’s Community Score Card programmes have contributed to strengthening service provision and community-state relations in each of these countries
•• Often this requires high levels of engagement with, and working through, different levels of the state apparatus. For support based on the idea of civic engagement, this is a counter-intuitive finding.
•• Reinforcing this, impacts are often ‘stuck’ at the local level and have only translated into national level impacts where they have plugged into existing government reforms.

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Review of 8 CSC Projects in 5 countries

A review of CARE’s Community Score Card experience and evidence” Sara Gullo, Christine Galavotti and Lara Altman, Health and Policy Planning, 2016

While the evaluations had many limitations, consistency of the results, as well as the range of outcomes, suggests that the CSC is contributing to significant changes. All projects reported CSC-related governance outcomes and service outcomes. There is promising evidence that the CSC can contribute to citizen empowerment, service provider and power-holder effectiveness, accountability and responsiveness and spaces for negotiation between the two that are expanded, effective and inclusive. There is also evidence that the CSC may contribute to improvements in service availability, access, utilization and quality. The CSC seems particularly suited to building trust and strengthening relationships between the community and service providers and to improving the user-centred dimension of quality. All of the projects reported challenges, with ensuring national responsiveness and inclusion of marginalized groups in the CSC process proving to be the most intractable. To improve health system performance and accelerate health progress we recommend further CSC use, enhancements and research.”

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What money cannot buy: Transforming relationships to transform health

A district government official recently told CARE that at first they were not happy that ‘hardware’, like medical equipment was not part of the project; however, they have since seen that the Score Card has brought other benefits that ‘money cannot buy’ – it has improved relationships at all levels

Our efforts in testing the Community Score Card approach have paid off: we have solid evidence that the Score Card has improved the lives of women and health workers in Ntcheu, Malawi.

At the start of the project, the community and health providers identified 13 BARRIERS that put women’s lives at risk. The graph below shows the scores the community and health providers assigned to these issues during the first round of the Score Card compared with the last round. At the start, the community and health providers gave the indicators low scores – even failing scores – but after two short years of implementation, all the scores rose significantly. For example, the relationship between providers and the community rose by 36 percent and the availability of transportation by 21 percent. The improvement in these scores indicates important progress in health access, use and quality.

For more case studies go to:http://governance.care2share.wikispaces.net/CSC+Case+Studies%2C+Briefs%2C+Reports%2C+Videos

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Community Action Groups rising to the challenge to improve maternal and new-born health in their communities

Community Action Groups have formed to support implementation of the ac on plans that result from the Score Card process. These groups have increasingly taken on responsibility to address barriers to maternal and new-born health in their villages:
In Chigodi, it was identified there was no house for the health worker, nor an ante- natal clinic. So the group mobilized them- selves to haul in the sand and make bricks and they petitioned members of the community to contribute a small amount of money for cement and construction costs. Now they are working to find funds to purchase the iron sheets needed to build the roof.
In Gwedeza, faced with the challenges of transporting women to the hospital during delivery the community mobilized resources to build a stretcher to carry women to the hospital.
In Katsekera, community ac on group along with the health workers jointly mobilized resources to rehabilitate a bridge so women and their children have better access to the health facility by foot or ambulance.

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Post-disaster shelter in India (Summary): Conclusions and recommendations

The introduction, conclusions and recommendations from the full report.

The study evaluates the medium- to long-term effectiveness of post-disaster shelter responses and recommends measures to strengthen future shelter programmes, whether undertaken by CARE or other agencies, to most effectively address the complex and interconnected needs of disaster-affected women, girls, men and boys. Recommendations cover impact (scale and coverage); shelter and settlements; accountability; specific needs and capacities of women, girls, men and boys; relocation projects; and the shelter sector in India.

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Connecting the World’s Poorest People to the Global Economy: New Models for linking savings groups to formal financial services

Despite the many benefits that CARE’s Village Savings and Loans schemes bring to poor communities, they are not a panacea. As groups mature they seek the security of a bank account, or wish for larger loans than the group can provide. This report looks at eight different models that CARE has explored to connect savings groups with formal financial services. Including Barclays, Vision Finance, Vodacom and Mwanga Community Bank, Orange and Equity Bank and Jubilee Insurance.

High uptake of savings, credit and insurance products have allayed concerns that products might prove too expensive for very poor communities. A total of 4,200 groups, or 105,000 individuals have been linked to the new products developed. Businesses too are benefitting, with increased customer bases and strong repayment rates. The report does recognise however, that overall transaction costs of linking savings groups to formal institutions remains high, albeit mobile banking offers opportunities to reduce this cost. The report also recommends that customer protection must be maintained. It outlines a set of ‘Linkage Principles’ that CARE has designed to help guard their interests.

Read and Download Full Publication on Care International Website

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The Community Score Card (CSC): A generic guide for implementing CARE’s CSC process to improve quality of services

CARE Malawi developed the Community Score Card (CSC) in 2002 as part of a project aimed at developing innovative and sustainable models to improve health services. Since then, the CSC has become an internationally recognised participatory governance approach for improving the implementation of quality services. This toolkit gives practical, step-by-step guidance on using the CSC approach. The toolkit is generic in nature and can be applied in any sector including health, education, water and sanitation, and agriculture.

The Community Score Card (CSC) approach can be used to facilitate good governance through promotion of participation, transparency, accountability and informed decision-making. The approach brings together community members, service providers, and local government to identify service utilization and provision challenges, and to mutually generate solutions, and work in partnership to implement and track the effectiveness of those solutions in an ongoing process of quality improvement.

Read and Download Full Publication on Care International Website

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