The Digital Community Score Card

In Malawi, like in many lower- middle-income countries, citizens - especially the most marginalized - are not able to fully realize their right to health because the public health systems and policies that govern them are not addressing these populations’ needs. There are many underlying factors contributing to ineffective and inequitable health systems, such as political, structural and financial challenges. Poor governance in national health systems has also been identified as a major barrier to equitable health care systems. In fact, the quality of governance is a key mediator for whether public spending on health care influences health outcomes positively[1] and a key pillar to good governance is transparent social accountably mechanisms[2].   

With one of the highest maternal mortality ratios globally, and adolescents comprising 15% of these deaths[3], it is critical that decision makers in Malawi understand and consider the real needs of these and other marginalized populations within health systems and policies in order to meet the government’s commitment to Universal Health Coverage by 2030. For example, despite Malawi’s reduction in total fertility rate, teenage pregnancies are on the rise and little progress has been made in reducing the unmet need for family planning among youth. This example highlights the disconnect between service providers, policy makers and the community. This disconnect is due in part to a lack of real-time data to inform decision-makers and a lack of agency of communities and marginalized populations to use their collective voice to inform government priorities and hold duty-bearers accountable.

In Malawi, the Health Information System (HIS) infrastructure does not collect citizen-generated feedback, and there are limited citizen consultations or feedback mechanisms which could inform and hold accountable duty-bearers and government systems for providing more appropriate services. Additionally, to-date mechanisms for citizen engagement, like the highly effective Community Score Card, have been localized to a particular facility or unit of service delivery - preventing escalation of locally generated priorities to district or national policy decisions (Fox, 2014; Holland et al. 2016).

 [1] National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Board on Global Health; Committee on Improving the Quality of Health Care Globally. Crossing the Global Quality Chasm: Improving Health Care Worldwide. Washington (DC): National Academies Press (US); 2018 Aug 28. 6, The Critical Health Impacts of Corruption. Available from: https://www.ncbi.nlm.nih.gov/b...

[2] https://www.who.int/health-top...

[3] https://www.usaid.gov/malawi/global-health/maternal-neonatal-and-child-health#:~:text=Malawi%20has%20one%20of%20the,deaths%20per%20100%2C000%20live%20births.

The Digital Community Score Card (CSC) is comprised of an application and data visualization platform, which allows for easy and efficient data collection and aggregation, and hub that supports data analysis and visualization.   

The app works on-and offline – either on a browser or an Android device and provides a simple and consistent way to collect and manage data. Data is collected by community-based volunteers (including youth/women groups) and primary health care facility site-based government staff through routine score card cycles. The user interface includes guidance and training materials and prompts to guide teams on data collection at key stages of the process. The app helps decentralize the process of entering and reviewing data and allows for easy follow up on missing data by providing data at-a-glance for specific scorecards, and identifying who entered it, and who reviewed it. The app improves quality of current data collection processes, by standardizing data to be collected, automatically validating data entered, and providing email alerts for those reviewing entered data. It also allows for easy aggregation and visualization of data.   

The platform uses dashboards to visualize data, giving both a real-time picture of data quality and an insight into what the data tells us, and how we can act on it. It additionally provides a range of tools to analyze and filter data quickly and easily. Since the data is derived from a standard methodology, the data is easy to disaggregate and verify. This type of real-time data collection, visualization, and analysis does not currently exist and would fill a critical gap for civil society organizations, NGOs, INGOs, private and government stakeholders who currently rely on data that is neither timely nor necessarily relevant to the needs of citizens, especially marginalized groups.  

A human-centered design process is currently underway, with user interviews from Malawi, Rwanda, Nepal, and Burundi, informing the refinement of both the app and data platform.    

The Digital Community Score Card will benefit all Malawian citizens, but especially marginalized populations such as women who make up 51%, youth who make up 80%, and People Living with HIV/AIDS who make up 8%[1] of the population, by providing easily digestible, citizen-generated data to bolster local civil society activism and inform government decision makers.

Developed in Malawi, the Community Score Card (CSC) is a paper-based social accountability approach that has benefited over 8.2 million people in 33 countries with better health care, stronger food systems, and safer justice systems.

Implementation and research have effectively demonstrated the CSC’s ability to empower citizens, including the most marginalized, to act collectively and engage with government constructively, contribute to greater social cohesion, build understanding between different groups, and increase the perceived legitimacy of service providers and state authorities; all leading to strengthened relations and trust between citizens and duty-bearers (Tembo, 2014; Chambers, 2016; Robinson,2016). Other studies show that social accountability approaches, such as the CSC, lead to better quality services for the poor at the local level. Ghana, Rwanda, Malawi and Sierra Leone present examples where the CSC has been integrated into local governance and built critically important  partnerships at various levels, inclusive of the most marginalized groups.   

With the understanding that information and communication technology (ICT) has significant potential to amplify citizens’ voices (Gigler, Bailur, and Anand, 2014), The Community Score Card Consulting Group is pivoting to the Digital Community Score Card. The vision of the Digital Community Score Card is to support SDG citizen-monitoring, build more accountable and responsive national systems, and improve the quality of service provision, especially for those left behind. The Digital CSC is a much-needed platform and service that will collate individual and community data from multiple geographies, allowing for analysis and dissemination of real-time community priorities and elevate marginalized voices to higher-level decision-makers. The aggregated data will provide a rich evidence base to guide decision-makers on the wider community’s health priorities and inform policy and services.

While Malawi is ground zero for this solution, the Community Score Card Consulting Group intends to scale globally through CARE’s network of country offices and partners. As a social enterprise originating from a CARE program, The Community Score Card Consulting Group is in a unique position of truly being locally led and globally connected. We believe that by digitizing the data collected via the CSC we can help other actors across the globe use the score card effectively, thus potentially reaching 10-100x greater scale.

[1] UNAIDS 2021 statistics https://aidsinfo.unaids.org/

CARE has been operational in Malawi since 1998 and in 2002 it developed the Community Score Card to bring together community members, health service providers, and local government to identify health service utilization and provision challenges, mutually generate solutions, and develop an on-going partnership to implement and track the effectiveness of solutions identified.

CARE’s work is embedded in human rights principles, including the right to reproductive self-determination and bodily integrity, and the principles of equality, non-discrimination, and accountability. All CARE programs are underpinned by a Gender Equality Framework, which places equal importance on building the agency of people of all genders and life stages, changing relations between them, and transforming structures so that they realize their full potential in their public and private lives. Within health, CARE’s strategies work to empower women and couples to achieve their reproductive goals, strengthen health systems, empower health workers to be effective and responsive, and build trust and mutual responsibility for positive health outcomes between the community and the health system through inclusive spaces for dialogue and participatory monitoring.

Born out of this ethos, the Community Score Card (CSC) Consulting Group retains these guiding principles, historical knowledge and technical expertise; and ensures robust monitoring and evaluation, participant engagement and feedback, and nimble processes to allow for testing and revision. Led by social accountability experts, the CSC Consulting Group provides organizations, projects, and initiatives with technical assistance for implementing the CSC with fidelity and high quality. The CSC Consulting Group supports clients by designing programming for proposal development, providing capacity building on CSC tools, providing technical assistance, as well as monitoring, evaluation and learning on the impact of the CSC. The CSC Consulting Group has led the initial development and piloting of the Digital CSC, in partnership with CARE and private tech consultants.

The CSC Consulting Group has, and will additionally leverage CARE’s, longstanding partnerships at the national, district, and local levels.

At the national level, CARE participates in several Technical Working Groups (TWGs), networks, and alliances.  For example, CARE served as the Civil Society Organization (CSO) focal point person for FP2020 in Malawi and actively engages with donors, government, youth groups, and various CSOs. The CSC Consulting Group partnered with Malawi Health Equity Network (MHEN) which focuses on health systems strengthening, governance, research, and evidence-based advocacy. CARE also engages with women forums, youth networks, and key sector networks to enhance capacity and influence policy.

At the district level, CARE is actively engaged with the District Executive Committee (DEC) and sub-TWGs, and District Networks (SRHR, Youth) in its areas of operation. At the sub-district level, CARE works closely with Area and Village Development Committees (ADC/VDC), Community Health Action Groups (CHAGS), Health Center Management Committee (HCMC) and Community Health Action Groups, mother groups, Community-Based Organizations (CBOs), support groups, Village Savings and Loans Associations, and custodians of the formal and informal local system (i.e. chiefs, traditional and faith-based leaders).

The CSC Consulting Group has maintained relationships with youths that are still implementing the CSC in Ntcheu district 7 years after closure of the project. These youths provided the CSC Consulting Group with insights on the sustainability of the impact of interventions and were integral to the piloting the Digital CSC. 

The Community Score Card has been implemented for 20 years in over 30 countries, across different contexts within the humanitarian-development continuum. Research and evidence proves that the CSC model is effective at achieving social accountability within the public health sector and improving health outcomes[1] in Malawi and beyond. Even multilateral entities like the World Bank have seen the efficacy of the model and adopted it themselves[2].

Led by social accountability experts, the Community Score Card Consulting Group provides organizations, projects, and initiatives with technical assistance for implementing the CSC with fidelity and high quality. The team has led the development of the initial Digital CSC and conducted a pilot to test its efficacy around data collection and analysis for effective improvement to service delivery. During COVID-19, the team adapted the Digital CSC for remote use to allow citizens, community and religious leaders, and service providers to voice their concerns about the vaccine and health services, ultimately aiding stakeholders in creating locally-driven solutions to combat vaccine hesitancy and misinformation[3]. Finally, in partnership with CARE, the CSC Consulting Group is currently undertaking a human centered design approach - including user interviews from Rwanda, Nepal, Burundi, and Malawi – to refine our platform.

Despite proven efficacy and adaptability of the Community Score Card, and the technical expertise housed within the CSC Consulting Group, we still face serious financial barriers to sustainability and needed improvements to the Digital Community Score Card based on our current human-centered design process.

With funding from the Challenge, the CSC Consulting Group would be able to take the next steps in developing a truly transformational tool that would facilitate the use of data for improved and responsive health services. These include further adapting the application based on finding from our current human-centered design process; building out a data visualization platform that allows citizen-generated data to be accessible by government, civil society, academia, donors, and citizens themselves; training stakeholders in how to use this data for good, use by civil society groups in advocacy efforts, use by NGOs and INGOs in program design, and use by duty bearers for more equitable and responsive health policies and services. The CSC Consulting Group will equally benefit from MIT Solves’ expertise in business strategy, media and marketing, networking, and legal services.

[1] Gullo S, Galavotti C, Sebert Kuhlmann A, Msiska T, Hastings P, Marti CN (2020) Effects of the Community Score Card approach on reproductive health service-related outcomes in Malawi. PLoS ONE 15(5): e0232868. https://doi-org.ezproxyberklee.flo.org/10.1371/journa...

[2] https://documents1.worldbank.o...

[3] https://www.careevaluations.or...

Dialogue and influencing works best when backed up by timely and relevant locally-generated evidence, however civil society organizations are often under-resourced and struggle to provide consistent and timely data. Further, data from social accountability approaches are often non-comparable and difficult to aggregate for influencing decision-makers. At the same time, official data is often incomplete, inconsistent, and neither pertinent nor timely, making it difficult for decision-makers to use it and for ordinary people to understand it. Real-time, citizen-generated data can fill these existing data gaps. Evidence shows that citizen-generated data can effectively inform local decision-making and policy at the national level, potentially contributing to the achievement of global goals like the SDGs.

In order to achieve this, citizen-generated data needs to be produced in accordance with commonly accepted standards and purposefully support official data systems. This data also needs to be produced at scale so that it reaches an acceptable threshold of representativeness for public officials. Tapping on existing social accountability methods and using contextually appropriate technology to create a hub of real-time data for those who need it most, in formats that make the data accessible and relevant, is critical in realizing citizen-informed health policies and services.

The Digital Community Score Card platform has the power to bring together a significant number of organizations implementing social accountability programming and generate relevant data at scale. With the support of media allies, the Digital Community Score Card will facilitate tailored citizen-generated data for dissemination to various public, community, and non-profit stakeholders. Media is also an important vehicle for disseminating citizen-generated data to the public (including radio, tv, newspaper, etc.). High quality and credible data products that take into account the incentives of users and are tailored to their needs will be a more effective channel to provide visibility to poor people and amplify their voices, leading to greater openness and diversity.

Long term

• Authorities at local, district and national level have an increased access to, and  utilization of citizen generated data
• Increased capacity of citizen groups including marginalized groups to engage with and demand accountability from duty bearers’ public health service delivery
• Strengthened stakeholder network  that is utilizing data and evidence to advocate and influence decision making at national and local level.
• District and national level planning process create formalized spaces and moments to engage with the citizen generated data.

Immediate term

• Analytics, reports, and visualizations will be synthesized  into accessible formats for a diverse audience (including policy makers) that documents the drivers and barriers to integrating citizen priorities in the local, district and national level health system.
• Local actors that include volunteers and most marginalized groups are trained on how to use the digital CSC.
• Based on the digital CSC data and analysis, various actors including communities and citizen groups are working together to influence decision making on improved public health plans and budgets.

Our ability to measure progress towards our commitments and to explain how the project is contributing to lasting change has led to the establishment of an evidence system. To manage this process, we have a set of guiding indicators applicable to the project, allowing for the collection and consolidation of coherent and comparable outcome and impact data. These indicators have been crafted in the light of Sustainable Development Goals (SDGs) as in consideration of relevance and measurement. The following is a list of indicators that the project uses to track progress over time.

• Number of organizations, coalitions or networks using the platform
• Policy briefs/asks developed
• Spaces created for engagement of citizens and policy makers at all level
• # and % of people of all genders who have meaningfully participated in formal (government-led) and informal (civil society-led, private sector-led) decision-making spaces.
• # and % of initiatives that link or work with strategic alliances and partners to take tested and effective solutions to scale
• Number of favorable legislation/reform measures passed related to program goals
• Number of community members attending Community Score Card meetings
• # and % of people that have actively engaged in development initiation dialogues between rights holders and duty bearers.
• # and % of joint action plans developed by community members and service providers.
• # and % of action items that have been completed in action plans
• Number of organizations involved in the project’s initiated coalition 
• # of health service assessment review and reflective sessions conducted in a year.
• # and % of health workers trained on social accountability mechanisms
• # of national level advocacy meetings conducted in a year.
• # and % of local partners adopting digital CSC into their programs

IF government and other key decision makers have access to real time citizen generated data that highlights their priority needs AND use this data to inform policy and to design and monitor programs THEN government will be more responsive to the needs of citizens yielding improved health outcomes, especially for the most marginalized groups.

The Digital Community Score Card provides a mechanism for constructive conversations between citizens, including the most marginalized groups, and power holders to identify and interrogate service utilization and delivery challenges in public health and identify realistic contextually appropriate solutions. State and nonstate actors at local, district and national levels will use the data to identify priorities as well as to demand government accountability. This will lead to more equitable health policy and quality health service delivery leading to improved uptake of services, and ultimately improved health outcomes.  

The CARE Digital Community Score Card utilizes Apps, SMS technology, interactive voice calls, and data visualization platform.

Primary health care data collection is done by community-based volunteers (including youth/women groups) and primary health care facility site-based government staff with support from district level government officials who facilitate with coaching and mentorship.

Their incentive to collect this data is to spotlight stakeholder voices from the communities where they live, which are diverse and often ignored in order to advocate for their experiences. Further, by establishing direct lines of communication and trust, community health workers are better able to provide care to citizens, improving satisfaction in their services. Other use cases have enabled community health workers to intervene in situations of GBV, distribute vouchers to vulnerable women, and empower women and youth to take charge of their health. Due to increased access to services, citizens are incentivized to willingly and truthfully provide data as well. 

CARE works around the globe to save lives, defeat poverty, and achieve social justice. CARE puts women and girls in the center because poverty cannot overcome until all people have equal rights and opportunities. CARE’s core values of transformation, integrity, diversity, excellence, and equality have been adopted by the Community Score Card Consulting Group. We are 100% Malawian-led, with 50% of staff identifying as women. The Community Score Card approach was developed specifically to address inequity and exclusion within the public health system. Addressing the marginalization of groups of people will always be at the center of our work and our approach. 

The Community Source Card (CSC) Consulting Group is a social enterprise focused on social accountability. Our approach is based on lessons learnt from working with community members, service providers and local authorities who become allies in engaging with national decision makers, we have pioneered a solution to a problem that development actors are struggling to address, and our approach is adaptable to the specifics of each political, social and economic context.

The CSC Consulting Group has a team of social accountability experts that have experience in project design, implementation, evaluation, capacity building and advocacy.

The CSC Consulting Group runs development programs and sells technical services on Community Score Card, including design, capacity building, implementation and evaluation. The proceeds are used to run the CSC Consulting Group and further develop CSC products. 

The key components of the CSC Consulting Groups service offering are, design, training, and follow-up support. The team also captures learnings and innovations from their work to be shared with other practitioners as part of a process of continued investigation, adaptation and improvement. The services (“product”) offered by the Community Scorecard Consulting Group have been developed through its experience on assignments in a wide range of sectors across Africa, Central America and Southeast Asia.

The team was working on a 7 year plan for financial sustainability, with peak revenues over $300,000 in 2018. However with the departure of focused business development staff, the pipeline has slowed. Looking forward, the team can reach financial sustainability if we are able to secure a range of contracts, from a single anchor contract worth at least $100,000 and a mix of 10 mid- and small-contracts ranging from $15,000 to $40,000. 

We know that donors have interest in quality service delivery and efficient use of funds and would pay for a tool which improves these components in the service delivery they fund through NGOs and governments. Governments have interest in a tool which can support how their limited funding is spent for greatest impact and mechanisms that can improve delivery as to avoid community feedback through other channels. The Digital CSC can provide this. 

Since 2016, the team has successfully provided a range of services to a number of clients. During this time they have worked with NGO and governmental clients including WWF Mozambique, Options Malawi and Kenya, Children International in Guatemala and the Dominican Republic, WFP Malawi, Plan International Malawi, UNICEF Malawi, CDC/USAID Malawi, Save the Children humanitarian consortium Malawi, and Interaid Zambia.

Additionally, funding from private and public grants have been awarded over the years. However, these have been inconsistent.