Menu
Menu
Menu
Menu
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.
MHAP employed the CSC, a social accountability approach that includes five phases, as the intervention strategy. Phase 1 of the CSC involves planning and preparation and entails identifying issues, as well as securing cooperation and buy-in, from all participating groups, including community and government stakeholders; understanding the context and barriers encountered by service providers and users and determining the geographic scope of the initiative. During Phases 2 and 3, the CSC is facilitated separately with community members and service providers. These groups meet separately to identify and prioritize issues faced within their communities and workplaces, respectively. The identified issues are organized into indicators, which are then scored separately by the same community members and service providers. Phase 4 consists of the ‘interface’ meeting where community members and service providers, along with local government officials, come together to share their identified and prioritized issues and how they scored these issues to generate solutions and to develop joint action plans to implement these solutions. Phase 5 involves the implementation of the joint action plan, as well as monitoring and evaluating progress on the indicators. A complete cycle of Phases 1–5 is considered a ‘round’ of the CSC. After the first round, the CSC process, from Phase 2 to Phase 5, is repeated every 6 months (see Figure 1). Further details of the intervention are provided elsewhere (CARE Malawi, 2013). CARE’s CSC process MHAP was implemented from 2012 to 2015 in partnership with the Government of Malawi’s Ministry of Health. A cluster-randomized control trial of the CSC was conducted as part of the project. During MHAP, CARE Malawi trained existing community health action groups (CHAGs) within the 10 health facility catchment areas in the intervention arm to co-lead the CSC process. In addition, over the course of the project, youth groups in Ntcheu began independently implementing the CSC in their communities, as did members of the local government District Health Management Team in order to integrate greater accountability measures into their family planning and maternal and child health programs. CHAGs comprised most of the intervention groups because those were targeted during the implementation of MHAP as opposed to the youth groups that arose organically. CHAGs and youth groups ranged from approximately 15 to 20 members each. During MHAP, CARE resourced the implementation of the CSC process, e.g. travel costs, facility rentals and supplies like stationary, but did not fund action items. Instead, CARE helped facilitate discussions around who could help fund and execute the prioritized actions. CARE supported up to six rounds of the CSC per intervention catchment area during MHAP. While the five-phased CSC process was implemented identically regardless of the group leading the approach, the action plans varied by group depending on prioritized issues and identified action items. This study utilized an exploratory, cross-sectional design comparing the sustainability of various partner-led approaches (i.e. local government, youth and CHAGs) of CSC implementation. We used qualitative methods—focus group discussions, semi-structured interviews and key informant interviews—to collect data, which allowed for in-depth exploration and better understanding of the continued uptake and implementation of the CSC by the various partners. Using purposive sampling across 10 health centre catchment areas, we identified a mix of CHAGs, youth groups and frontline health workers still actively implementing the CSC, those using a modified version and those no longer using it. We conducted 33 focus groups with CHAGs (n = 14 active groups, 10 mixed/partially active groups and 9 passive/non-active groups) and 8 focus groups with youth, representing over 95% of all the groups known to have been implementing the CSC at the conclusion of MHAP. Focus group discussions ranged in size from 8 to 18 participants. In addition, we conducted 13 semi-structured interviews with district and local officials and 6 key informant interviews with staff and national stakeholders for a total of 467 participants (n = 191 male, n = 276 female). Prior to the start of data collection, facilitators, interviewers and note-takers contracted from a local research consulting firm participated in a week-long training focused on both the CSC process and the principles of qualitative data collection. Focus group discussions took anywhere from 60 to 90 minutes; the interviews required between 45 and 60 minutes. Verbal informed consent was obtained prior to the start of the focus groups and interviews. The focus groups were conducted in the local language, Chichewa, transcribed and then translated into English in preparation for analysis. Interviews were conducted in either English or Chichewa depending on the preference of the interviewee. This study was reviewed and approved by the institutional review board of Malawi’s National Commission for Science and Technology. Focus groups and interviews were audio-recorded, transcribed in Chichewa and translated into English. An initial codebook with a priori codes was developed in alignment with the research questions and then augmented and refined with emergent codes during the analysis. The qualitative data were coded and analysed using the Dedoose software. TS and ASK led the coding and checked for consistency across coders and cases. Thematic analysis was used to identify major themes arising from the data that aligned with predetermined research questions, and supporting quotes were selected to help illustrate those themes (Babbie, 2015). Analysis summaries by theme were drafted and shared among the authors, discussed, discrepancies resolved and then themes finalized. The final analytic themes were presented and discussed during a dissemination workshop in Lilongwe, Malawi, in December 2019 that included participants in the CHAG and youth focus groups, local leaders from Ntcheu and national stakeholders. This dissemination meeting provided an opportunity for the triangulation and validation of the findings. These final analytic themes are presented here.
N/A
