CARE Community Score Card
- Scope of Implementation
- Level of Polarization This Method Can Handle
CARE Community Score Card (CSC) is a method of participatory governance developed by CARE, an international assistance and relief organization. The CSC method focuses on improving a local government service or process.
Problems and Purpose
CARE Community Score Card (CSC) is a method of participatory governance developed by CARE, an international assistance and relief organization. The CSC method focuses on improving a local government service or process. CARE International's use of Community Score Cards involves a multi-step process and thus constitutes its own methodology, separate from the use of community score cards as a tool for public oversight and evaluation of public services. Using the five-stage, facilitated CSC method, community members meet to develop criteria for evaluating the government service or process, score the service or process on each criterion using a scale from 0 to 100, state reasons to justify each score, and propose improvements concerning each criterion. Those who provide or administer the government service or process meet separately and perform the same evaluation, but using their own criteria. Then community members and service-providers/administrators gather in an "interface meeting" to share their findings, identify and prioritize issues for improving the service or process, and create an action plan for carrying out those improvements. The CSC method is then repeated every six months to monitor and evaluate the action plan and to enable ongoing improvement to the service or process.
According to the original report on the CSC, the CSC method was initially designed to address two problems: (1) the inadequate quality of local government services and processes -- especially concerning health care -- in places in which CARE performs development work, and (2) deficiencies in existing participatory methods for evaluating and improving local government services and processes.
The CSC was designed in particular to improve upon the Citizens' Report Card method of participatory service evaluation, in two respects. First, whereas the Citizens' Report Card method was conducted and controlled "by an external agency," the CSC gave control of the evaluation process -- including control over the evaluative criteria to be used -- to citizens and service providers or administrators of the government process in question. Second, whereas the policy response to Citizens' Report Card evaluations may be subject to delay, the CSC method was designed to enable "immediate decisions and the preparation of a mutually agreed action plan"  to address the issues raised by the evaluation.
Principles informing the design of the CSC method include:
- recognizing the health-related rights of citizens
- fostering cooperation and partnership between users and providers of health services
- increasing citizens' access to health-related information
- enabling citizens to participate in decision making about health services
- increasing accountability and transparency of health services
- promoting equity in health services
- recognizing shared responsibility for health and health services, among users and service providers.
Origins and Development
The CSC method was developed by CARE International in Malawi in the early 2000s. Influences on the method include Citizens' Report Card, described above, and possibly also Participatory Rural Appraisal, which seems to be referred to several times by Kaul Shah (2003) with the phrase "participatory appraisal."
The CSC method was developed as part of a project -- called Local Initiatives for Health -- conducted in Lilongwe District, Malawi, to improve local health care in rural areas. After one year of implementation, the CSC method showed promise, which was manifested especially in the increases in citizens' scores of local health services between the first round of CSC evaluations in August 2002 and the second round in March 2003."
Since 2003, the CSC method has been applied many times in Malawi as well as in other countries including Tanzania, Ethiopia, Rwanda, Egypt, and Afghanistan. In addition to health services, the CSC method has been applied to the improvement of education, economic issues such as the effect of HIV/AIDS on citizens' livelihoods, and governance matters such as microfinance, water, sanitation, infrastructure, and gender-based violence.
CARE developed a "governance programming framework" that serves as a theoretical model or "theory of change" for the CSC method. This framework promotes the principle of "sustainable development with equity," and has three elements:
- (1) "empowered citizens"
- (2) "effective, accountable and responsive service providers and power-holders"
- (3) "expanded, inclusive and effective spaces for negotiation."
The CSC method is designed to put this framework into practice.
CARE has created an initiative focused on the CSC method as part of the United Nations' (UN's) activities concerning the UN Sustainable Development Goals (SDGs), called "Everyone Counts: Using citizen-generated data to monitor progress against the SDGs."
CARE personnel have recently begun to publish formal evaluations of the CSC method in scholarly journals. These include qualitative evaluations  and results of a randomized controlled trial. CARE personnel and affiliated researchers have also published scholarship on the quantitative measures CARE uses to evaluate applications of the CSC.
Participant Recruitment and Selection
Participant selection in the CSC process is generally open to all, and there is targeted recruitment to ensure that participants represent all stakeholders in the community. Targeted recruitment is conducted by having community members draw a social map of the community to identify stakeholders, and then to compare community members currently participating to the social map, to determine whether any stakeholders are not currently represented among participants. However, at times, random selection is also part of participant selection. For example, in a small community all community members can be invited, whereas in a large community, random selection or targeted selection may be more appropriate; and if a community includes a large number of villages and staffing limits prevent including all of them in the process, random selection or purposive sampling might be used to select villages to be included in the process.
How it Works: Process, Interaction, and Decision-Making
Phase I of the CSC process is devoted to preparation. Preparation takes place for up to one month, in which organizers meet with community leaders and stakeholders to learn about key issues concerning governmental services or processes that are of concern to community members. Organizers conduct interviews with stakeholders to identify issues and the range of local perspectives on them. Organizers determine the scope of the community to be included in the process, choose approaches for including community members in the process, determine the budget for the process, train or invite facilitators, and determine how community units will be approached and how groups of community members will be organized.
In Phase II of the CSC process, members of the community meet in groups, each led by two facilitators. Each group identifies issues concerning the government service or process, develops indicators to evaluate the service or process, and scores the service or process on each indicator on a scale of 0 to 100. Then group members gather in a "cluster consolidation meeting" to reconcile differences between the different issues and indicators identified by the groups, identify reasons to justify the score for each consolidated indicator, create a consolidated score for the community, reflect on the results, prioritize issues that require immediate action, and suggest improvements regarding each indicator and issue.
In Phase III of the CSC process, the providers or administrators of the government service or process conduct a parallel evaluation of the service or process, again using facilitators but developing their own indicators.
In Phase IV of the CSC process, community members and service providers/administrators gather together in an "interface meeting." During that meeting, both groups share the results of their evaluations, identify common findings, and negotiate a list of issues that are priorities for action. Then the community members and service providers/administrators together create an action plan to implement improvements concerning the priority issues, assign tasks in the plan to particular community members and service providers/administrators, and create deadlines for implementation and reporting.
In Phase V of the CSC process, community members and the service providers/administrators implement the action plan, and monitor and assess improvements to the service or process.
The CSC process is then repeated every six months to enable ongoing evaluation and improvement of the service or process, in a partnership between community members and service providers/administrators.
Influence, Outcomes, and Effects
Several outcomes have been identified in studies of the CSC method (Edward et al., 2015; Gullo et al., 2016, 2017), including:
- enhanced citizen voice in governance
- more collective action to address community needs
- greater participation of citizens in governance
- greater accountability of service providers and administrators
- improvements in citizens' access to information
- gains in citizens' knowledge of their rights, of limitations that service providers face, etc.
- changes in citizens' expectations of government services
- improvements in communication and relationship between citizens and service providers
- more respectful and welcoming treatment of citizens by service providers
- enhanced responsiveness and transparency of government services
- gains in service-provider capacity and commitment
- improved trust between citizens and service providers
- increased availability and quality of services
- increased use of services by citizens
- greater citizen satisfaction with services
- improved outcomes in health, agriculture, and education.
Analysis and Lessons Learned
Researchers have identified several challenges to using the CSC method (Edward et al., 2015; Kaul Shah, 2003). First, competent facilitation is a key component of the method, so the method requires time or resources for employing or training facilitators. Facilitation is needed in particular to prevent conflict, which is often a concern in CSC processes. Second, the successful application of the method seems to depend on many context-specific factors, so substantial preparation and the thorough exercise of the first phase of the method seem necessary. Third, although allowing citizens and service providers to create their own indicators for evaluating services is the key to many of the desirable dynamics and consequences of the method, that customization of indicators can at times cause administrative difficulties in reconciling differences in indicators between citizens and service providers or among different groups of citizens. Fourth, the CSC method can be quite demanding on citizens, particularly the deliberative process of reconciling diverse indicators. Finally, whereas the CSC method has been especially effective at realizing improvements that are within the control of the local community, at times improvements that depend on more distant regional or national governments have been more difficult to implement.
 CARE (2013); Gullo et al. (2016).
 Kaul Shah (2003).
 Kaul Shah (2003, p. 5).
 Kaul Shah (2003, p. 5).
 Gullo et al. (2016); Kaul Shah (2003).
 Kaul Shah (2003).
 See, e.g., Ravindra (2004).
 See, e.g., Kaul Shah (2003, pp. 7-8).
 Kaul Shah (2003, pp. 16-17).
 Edward et al. (2015); Gullo et al. (2016).
 Gullo et al. (2016, p. 1471).
 Gullo et al. (2016); Sebert Kuhlmann et al. (2017).
 Gullo et al. (2016, p. 1470).
 Gullo et al. (2016).
 Everyone Counts: Using citizen-generated data to monitor progress against the SDGs. Retrieved from https://sustainabledevelopment.un.org/partnership/?p=11910 .
 Edward et al. (2015); Gullo et al. (2016).
 Gullo et al. (2017).
 Sebert Kuhlmann et al. (2017).
 CARE (2013).
 CARE (2013); Edward et al. (2015); Gullo et al. (2017).
 CARE (2013); Edward et al. (2015).
 CARE (2013); Edward et al. (2015).
 CARE (2013); Gullo et al. (2016).
CARE. 2013. The Community Score Card (CSC): A Generic Guide for Implementing CARE's CSC Process to Improve Quality of Services: Toolkit. Lilongwe: CARE Malawi. Retrieved from http://governance.care2share.wikispaces.net/file/view/CARE%20Community%20Score%20Card%20Toolkit.pdf/433858992/CARE%20Community%20Score%20Card%20Toolkit.pdf
CARE. 2017. Community Score Cards. Retrieved from https://www.careinternational.org.uk/fighting-poverty/care-know-how/community-score-cards
Edward, Anbrasi, Kojo Osei-Bonsu, Casey Branchini, Temor shah Yarghal, Said Habib Arwal, and Ahmad Jad Naeem. 2015. "Enhancing Governance and Health System Accountability for People Centered Healthcare: An Exploratory Study of Community Scorecards in Afghanistan." BMC Health Services Research 15:299. doi:10.1186/s12913-015-0946-5
Gullo, Sara, Christine Galavotti, and Lara Altman. 2016. "A Review of CARE's Community Score Card: Experience and Evidence." Health Policy and Planning 31(10):1467-78. doi:10.1093/heapol/czw064
Gullo, Sara, Christine Galavotti, Anne Sebert Kuhlmann, Thumbiko Msiska, Phil Hastings, and C. Nathan Marti. 2017. "Effects of a Social Accountability Approach, CARE's Community Score Card, on Reproductive Health-Related Outcomes in Malawi: A Cluster-Randomized Controlled Evaluation. PLoS ONE 12(2):e0171316. doi:10.1371/journal.pone.0171316
Kaul Shah, Meera. 2003. Using Community Scorecards for Improving Transparency and Accountability in the Delivery of Public Health Services: Experience from Local Initiatives for Health (LIFH) Project, CARE-Malawi. [S.l.]: CARE International in Malawi. Retrieved from https://namati.org/resources/using-community-scorecards-for-improving-transparency-and-accountability-in-the-delivery-of-public-health-services-experience-from-social-initiatives-for-health-lifh-project/
Ravindra, Adikeshavalu. 2004. An Assessment of the Impact of Bangalore Citizen Report Cards on the Performance of Public Agencies. Washington, DC: World Bank. Retrieved from http://documents.worldbank.org/curated/en/777451468752769088/An-assessment-of-the-impact-of-Bangalore-citizen-report-cards-on-the-performance-of-public-agencies
Sebert Kuhlmann, Anne K., Sara Gullo, Christine Galavotti, Carolyn Grant, Maria Cavatore, and Samuel Posnock. 2017. "Womens' and Health Workers' Voices in Open, Inclusive Communities and Effective Spaces (VOICES): Measuring Governance Outcomes in Reproductive and Maternal Health Programmes." Development Policy Review 35(2):289-311. doi:10.1111/dpr.12209
Community Score Card Community of Practice Wiki, http://governance.care2share.wikispaces.net/The+Community+Score+Card+CoP
Everyone Counts: Using citizen-generated data to monitor progress against the SDGs, https://sustainabledevelopment.un.org/partnership/?p=11910
Care International Community Score Cards, https://www.careinternational.org.uk/fighting-poverty/care-know-how/community-score-cards
Lead image: Gullo S, Galavotti C, Sebert Kuhlmann A, Msiska T, Hastings P, Marti CN | PLOS one https://goo.gl/yP7M9z