The impact of locally led community score cards on improved health services in a low- and middle-income country: an evaluation study

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OBJECTIVES AND IMPORTANCE OF STUDY: The use of community score cards (CSC) in collaboration with local organisations and the health sector is a novel approach to improving the performance of reproductive, maternal, newborn and child health (RMNCH) services. The goal of the New Partnership Initiative Expand (NPI) program was to increase the availability and demand for high-quality, high-impact RMNCH services in rural Ethiopia. METHODS: An independent evaluation of the NPI program was completed in 2024 using a mixed-methods evaluation design. The CSC process engaged 355,220 community representatives and 1557 client councils. The quantitative data included routine service delivery data extracted from Ethiopia's District Health Information System, baseline versus end-of-project CSC standards of care, RMNCH indicators and measures of organisational capacity. The qualitative data included 69 in-depth interviews, 27 focus group discussions with 218 community participants, and interviews with local organisations, health officials, client councils and CSC administrators. RESULTS: The mean CSC scores and standard deviations were 47.2 ± 11% at baseline, 67 ± 6.6% at midterm and 72.3 ± 7.6% at endline. The RMNCH scores were 58% for contraceptive acceptance rate (CAR), 59% for antenatal care (ANC) and 76% for postnatal care (PNC) at baseline, and 71% for CAR, 65% for ANC and 80% for PNC at endline. Applying paired t- and Z-tests, we found a statistically significant difference in CSC and RMNCH scores over time (P < 0.000 in all cases). The self-reported indicators used to measure the organisational and technical capacity to conduct the CSC processes increased by 12%. CONCLUSIONS: The inclusion of local organisations in the CSC process led to increased measures of community engagement, positive perceptions of health system standards of care and improvements in organisational capacity. Health worker responsiveness and increased utilisation of RMNCH services also increased. We recommend efforts to further engage local organisations in the application of CSCs in low- and middle-income countries, and expansion by the Ministry of Health in Ethiopia.