Social Accountability in SRHR

Social Accountability in SRHR

Governance is the exercise of power in the management of public affairs. It is a dynamic, political process through which decisions are made, conflicts are resolved and diverse interests are negotiated. CARE defines good governance as the effective, participatory, transparent, equitable, and accountable management of public affairs guided by agreed upon procedures and principles, to achieve the goals of poverty reduction and increasing social justice. States operating with good governance are accountable (taking responsibility for actions) and transparent (providing relevant and timely information to the public), and they supply inclusive spaces where citizens can participate in decision-making that directly impacts their lives.

CARE’s governance work aims to assist communities in sustainably improving the performance, accountability, and responsiveness of their health systems, to ensure quality, coverage, and equity of health services. This is critical to our sexual and reproductive health and rights (SRHR) programming, because we know that sexual and reproductive health services can only be as good as the health system that supports them. We know that participatory governance and social accountability approaches can link the community and the health system to support the development of local solutions for service utilization and delivery challenges, as well the development of strategies for successful, sustainable, and scalable program implementation. The SRHR team uses one key social accountability approach to improve SRHR and rights outcomes: CARE’s Community Score Card© (CSC).


Community Score Card©

CSC is a citizen-driven accountability approach for the assessment, planning, monitoring, and evaluation of service delivery. It is designed to enable community members, health providers, and government officials to work together to identify and overcome health coverage, quality, and equity obstacles. The approach is simple to use, can be adapted for varied contexts, and can systematically pinpoint and address the specific challenges women face in accessing sexual and reproductive health services. (Watch this video for a simple overview of the CSC process).

CARE Malawi pioneered the CSC methodology 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 recognized social accountability tool, spreading within CARE and beyond. CARE now has over a decade of experience implementing CSC across a range of sectors, including health, food security, water and sanitation, education, and governance, and countries including Cambodia, Rwanda, Tanzania, Malawi, Ethiopia, Nepal and Egypt.  

In 2015, CARE completed a rigorous cluster‐randomized control trial to evaluate the effectiveness of CSC for improving maternal health services in Ntcheu, Malawi. Results demonstrated significant changes in measures of service utilization, provision, and satisfaction. Further, our experience has demonstrated that the CSC is particularly well‐suited to improving patient‐centered dimensions of quality of care, including building trust, and strengthening relationships between communities and service providers, which research shows drives women’s health utilization behavior.


Key CSC resources

CSC Toolkit (available in English and French)

CSC Overview Brief

Growing Promise Brief (CSC and Reproductive Health Outcomes in Malawi)

CSC Implementation Guidance Notes

Evidence of Impact: Stories from the Field

Making every voice count through the Community Score Card approach

Raising the Score (videos)

Generating local solutions: How CARE’s Community Score Card is helping achieve health access for all (blog post)


Peer-reviewed articles

Creating spaces for dialogue: a cluster-randomized evaluation of CARE's Community Score Card on health governance outcomes (Gullo et al., 2018)

Effects of a social accountability approach, CARE's Community Score Card, on reproductive health-related outcomes in Malawi: a cluster-randomized controlled evaluation (Gullo, Galavotti, Sebert Kuhlmann, Msiska, Hastings, & Marti, 2017)

A review of CARE’s Community Score Card experience and evidence (Gullo, Galavotti, & Altman, 2016)


CARE Projects Using CSC Include: 

Maternal Health Alliance Project (Malawi)
This project aims to identify broadly applicable strategies, approaches and methodologies for systematically improving implementation of evidence-based reproductive, maternal and newborn health interventions.

Abdiboru (Ethiopia)
This project aims to address structural determinants (agency, government institutions, and social norms) that act as barriers to empowerment in order to improve health, education, and economic outcomes for adolescent girls.

Community Score Card for PMTCT (Malawi)
This project aims to improve key prevention of mother-to-child transmission of HIV (PMTCT) outcomes including adherence and retention in treatment and early infant diagnosis of HIV while increasing dialogue between consumers of PMTCT services, providers delivering services, and government officials providing oversight of health services.

TAMANI (Tanzania)
This project aims to empower regional and district level health planners to effectively plan for, and deliver respectful and skilled reproductive health care, improve the skills of health care workers to effectively manage labor and delivery, and support communities to address local barriers that impede access to sexual and reproductive health care, especially for women and girls.

Vijana Juu (DR Congo)
This project aimed to improve quality of and access to reproductive health services for adolescents while increasing their agency and capacity to create positive change in their lives and communities.


For more evidence, information, and guidance on CSC, visit our resources page.

Our Approach:

SRHR How 1: Gender Equality

Improve Gender Equality

Transformative change for gender justice.

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Nang Kam Phone, 24 years, Auxiliary Midwife and babies who were delivered by her at Nam Htan Ma village, Lashio, Myanmar

SRHR How 3: Resilience and Risk Reduction

Increase Resilience and Risk Reduction

Equipping communities to rebound quickly after crisis.

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Residents of Bafodia wait their turn at a maternal health care center supported by CARE.

SRHR How 4: Form Strategic Partnerships

Form Strategic Partnerships

We cannot increase global health access alone. 

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Kanat Kebele, South Gondar. Nigist* (name has been changed) is 9 years old and in grade 3 at school. She likes math and wants to be doctor.

SRHR How 3: Resilience and Risk Reduction


Keeping sexual and reproductive health and rights on the agenda.

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