RESUMO
BACKGROUND: Social accountability approaches, such as the community scorecard (CSC), can improve the performance of health systems in low-income countries by providing a mechanism for obtaining and incorporating community input. This longitudinal study assessed the effects of CSCs implemented by primary health care units (PHCUs) on health system performance in Ethiopia. METHODS: This study used a pre-post design and was conducted from October 2018 to September 2019 in 159 PHCUs in 31 districts in Amhara and Southern, Nations, Nationalities and Peoples' regional states. The data were extracted from a routine health information management system database at baseline, midterm, and endline stages over 12 months for statistical analysis. The effects of implementing CSCs on health system performance were evaluated against selected key performance indicators (KPIs). RESULTS: The CSC measurement results were based on input from 38,556 community representatives. The mean CSC score with standard deviation (±SD) was 60.8%±12.5%, 66.3%±10.8%, and 70.6%±10.0% at baseline, midterm, and endline, respectively. The mean KPI score was 54.9%±17.4%, 61.9%±15.1%, and 67.6%±14.6% at baseline, midterm, and endline, respectively. The average CSC and KPI values were positively correlated (r>0.37). Using a nonparametric Friedman's test, we found a statistically significant difference in CSC and KPI scores at baseline, midterm, and endline (P=.001). Post hoc analysis with Wilcoxon signed-rank tests was conducted with a Bonferroni correction and the results showed higher CSC and KPI values from baseline to midterm and from midterm to endline (P<.017). CONCLUSIONS: The use of CSCs in Ethiopia contributed to the health system's performance in terms of maternal and child health services. The responsiveness of health workers and utilization of basic health services by community members were found to increase significantly with CSC use. We recommend continued implementation of the CSC intervention at PHCUs.