These approaches promote effective institutions that are inclusive of and accountable to diverse peoples across genders and other identities. This work supports community, community, market and state agencies and actors to integrate gender equality and justice in their leadership, formal rules and institutional practice, and services. This involves working directly with government and community decision-makers, service providers and the private sector, building more inclusive and resilient community governance, and support to social accountability and other processes that bring power-holders and different groups together – centering those most impacted by exclusion and marginalization – to discuss rights and services.
These approaches help citizens engage systematically with power-holders of different kinds – including service providers, government and the private sector– to increase dialogue, transparency and accountability. These approaches often focus on improving services for poor and marginalized people, including citizen oversight and other social accountability activities (i.e. public audits, citizen charters and community scorecards)and .
- CARE’s Social and Economic Transformation of the Ultra-Poor (SETU) and the subsequent project, Journey for Advancement in Transparency, Representation and Accountability (JATRA) in Bangladesh engages with Union Parishads (local government) and extremely poor communities, and facilitates spaces for the two sets of groups to engage in dialogue and negotiate entitlements. Among the extreme poor, groups are formed to build solidarity and natural leaders are identified. These natural leaders mobilize communities to negotiate with landlords, or with employers for fairer wages, and represent community needs to Union Parishads. SETU and JATRA projects also helped reestablish Ward Shava budget planning meetings to help influence spending decisions in line with the priorities of the most marginalized communities (para). The project ensured consultations and social audits with local decision-makers and marginalized groups of women to ensure poor women's perspectives are taken into account. 
- In the remote highlands of Peru, CARE trained community health monitors to regularly visit health centers (generally 2-3 visits per week) and discuss with female patients how they had been treated, how long they had waited to be seen, whether information was provided in their native language, etc. This was part of a citizen monitoring project to promote quality healthcare. This information was documented and then the regular reports were analyzed with ForoSalud (Peru’s largest civil society health network), the regional Ombudsman’s office, CARE and others. This process helped citizens to voice their concerns, hold service providers to account and promote constructive dialogue on the quality of services.
- CARE’s Community Score Card© (CSC) bring together service users, service providers and local government to identify challenges to access, utilization and provision challenges, and generate solutions that can be collectively tracked. CSC facilitators are trained, and then use the CSC with focus groups (i.e. men, women, youth) to identify their issues and experiences using the service that is in focus. In parallel or subsequently, the CSC is used with service providers to record the issues and barriers they face. Then, an interface meeting is held with community members, service provider and government staff, and a joint action plan is developed to resolve the problems identified. The implementation of the action plan is monitored in much the same way, on a six-month cycle. The citizen report card process supported by the World Bank in Uganda follows a similar process, though uses community-based facilitators to ensure representation across gender, age groups, and different abilities to meet and share their experiences with services. The Community Score Cards can help mainstream good governance in women and value chains projects, as well.
- Community Support System (CmSS), developed by CARE Bangladesh in 1999, is a community mobilization mechanism that builds community capacity and participation to demand, negotiate and utilize health services. CmSS has been used in Bangladesh to track pregnant women and provide need-based support to ensure pregnancies are safe and timely use of emergency obstetric care. CmSS conducts community surveillance for tracking, registration of pregnancy and violence against women; facilitates birth preparedness; mobilizes local funds and resources to support emergency transport and referral; promotes accountability and responsiveness through community feedback and advocacy; links with local government and health system; and creates an enabling environment for communities to become “watch dogs” to prevent harmful practices.
What does the evidence indicate?
These approaches gave marginalized people a channel to voice their needs, preferences and experiences with service provision, where before they had none.
- SETU’s work (and the work of natural leaders) helped to increase diversity of livelihood strategies and greater benefits from government safety net programs. There was less reliance on exploitative labor. This did not lift households out of poverty, but reduced vulnerability to shocks. SETU’s development of self-help groups helped women build assets, and helped communities to led collective action in fisheries and vegetable/banana cultivation; Union Parishads facilitated access to public lands and ponds. While results from JATRA are still being assessed, the project has seen gains in broader participation among poor women and men in social audit processes and meetings.
- The Union Parishad Act of 2009 stipulates that at least 5% attendance. By tracking attendance records, among the 130 wards that conducted Ward Shava budget meetings in year 1 of the project, a study found that a total of 49,761 community members (25,184 men and 24,577 women) participated. And this represents just over 10% of the total voting population of these wards – double the mandated number and significantly more than in other wards. Likewise, there is initial evidence which suggests that a higher proportion of resources has been allocated towards issues women raised in these meetings as a result of this citizen engagement .
- In Peru, in health centers where social monitoring was introduced, users have a four times higher awareness of complaint mechanisms and percentage of users with complaints was twice as high. Social monitoring has driven a rise in expectations and an improvement in the quality of services, but the latter has not kept pace with the former. Monitors have worked with participatory budgets to successfully advocate for the construction of birthing houses where women can stay before delivery. This work also increased transparency in health facilities: for example, which services and medicines were provided free of charge, and that birth certificates are free. There is also an increased receptivity to user preferences: for example, there has been a two-fold increase (from 194 births in 2008 to 437 in 2009) in the number of vertical birth deliveries (the preferred method of many rural indigenous women). Greater confidence in the quality of care has translated into increased demand for services. CARE’s quantitative assessment in 2010 (comparing data between 2007 and 2009), comparing micro-networks with control facilities in Azángaro, found an increase in:
- pre- and post-natal controls;
- women’s access to laboratory exams;
- institutional birth delivery;
- the proportion of women affiliated with the national health insurance programme. In Ayaviri, improvements were found only in women’s access to laboratory examinations. This difference is largely attributed to greater problems in the quality of attention in the Ayaviri hospital, related to a greater staff rotation than in Azángaro. 
- Citizen monitoring can have an important impact on the quality of service delivery. Beyond empowering monitors themselves, the citizen monitoring model has improved transparency in health facilities, ensured greater respect for users’ preferences in birth delivery, and helped reduce corruption; and this improved quality has generated greater demand for health services. Moreover, in comparison with other social accountability models such as Community Score Cards, the mobilization of community monitors means that there is regular community engagement to check that whatever promises are made by service providers are met.
- A review of evaluations of Community Score Card© projects in Malawi, Tanzania, Ethiopia, Rwanda and Egypt reported overall increases in utilization of health services. CSCs improve the user-centered dimension of quality in several ways, including by increasing respectful treatment of patients by health providers. This helps to increase service utilization, and whether women deliver in facilities with skilled providers. Several projects also suggested that the CSC process unlocked resources (i.e. human, material, financial) from the system, improved the ability of citizens to hold providers to account, improved the relationship between providers and citizens, and shifted power to citizens. Several projects also indicated that CSCs providers working in unsupportive work environments found citizen pressure useful to shift resources and be more effective. Some areas for improvement on CSCs are: ensure that marginalized groups participate (e.g. have separate focus groups for women); consider how to not only focus on accountability at the local level, but also at the national level; and build bridges between citizens and public policy making processes from early on.
- Through the Community Score Card© (CSC) approach, the Maternal Health Alliance Project (2011-2015) empowered community members, health providers and local government officials in Ntcheu, Malawi to identify reproductive health service utilization and provision challenges, to mutually generate solutions, and to work in partnership to implement and track the effectiveness of those solutions in an on-going process of improvement. CARE’s cluster-randomized control evaluation revealed that compared with communities where the CSC was not implemented, the proportion of women receiving a home visit during pregnancy increased by 20%, while satisfaction with health services increased by 16%. Use of modern family planning methods was also estimated to be 57% higher in the intervention area, showing how inclusive governance approaches such as scorecards can make important contributions to the health outcomes that CARE and others are seeking.
- In a review of a Uganda community-based health clinic monitoring and social contract initiative using Citizen Report Cards, treatment communities observed a reduction in infant mortality (33%), increased use of outpatient services (20%) and overall improvement of health treatment practices (immunization rates, waiting time, absenteeism).
- In Bangladesh, the Safe Motherhood Promotion Project sought to develop community capacity to improve safe motherhood practices at the local level and strengthen emergency obstetric care services at sub-district health complexes. The project used community mobilization activities that aimed to increase awareness and demand for maternal health services through the development of the Community Support System (CmSS), and established regular meetings between community members, service providers and sub-district level policy makers. As a result, women and the community have a greater voice with respect to governance of the local health system, and service providers are more accountable to the community for the quality of care. An impact study found that CmSS resulted in 71% antenatal care access for women in the lowest wealth quintile compared to 30% in the non-CmSS area.
1. Hinton, R. (2011). Inclusive governance: transforming livelihood security. Experiences from Bangladesh. CARE International UK; CARE (2016). Results in Citizen Participation in Local Governance. Project Highlights.
2. CARE International UK (2015). Learning and policy series: Citizen monitoring to defend maternal health rights in Peru. Briefing Paper, 6.
3. CARE Malawi. (2013). The Community Score Card (CSC): A generic guide for implementing CARE’s CSC process to improve quality of services.
4. Fox, J. A. (2015). Social Accountability: What Does the Evidence Really Say? World Development, 72, 346-361. doi:10.1016/j.worlddev.2015.03.011
5. Mondelez International, Cocoa Life, & CARE International. (2016, October). Women's Leadership in Cocoa Life Communities.
6. Hossain, J., Dr. (2015, March). Project Summary: Community Support System.
7. Hinton, R. (2011). Inclusive governance: transforming livelihood security. Experiences from Bangladesh. CARE International UK; CARE (2016). Results in Citizen Participation in Local Governance. Project Highlights.
8. CARE (2016). Results in citizen participation in local governance: Journey for Advancement in Transparency, Representation and Accountability (JATRA).
9. Aston, T. (2015). Learning and policy series: Citizen monitoring to defend maternal health rights in Peru. Briefing Paper, 6.
10. Gozzo, G. (2015). The power of participatory monitoring in making the Sustainable Development Goals a reality.
11. Aston, T. (2015). Learning and policy series: Citizen monitoring to defend maternal health rights in Peru. Briefing Paper, 6.
12. Aston, T. (2015). Learning and policy series: Citizen monitoring to defend maternal health rights in Peru. Briefing Paper, 6.
13. Gullo, S., Galavotti, C., & Altman, L. (2016). A review of CARE’s Community Score Card experience and evidence. Health Policy and Planning, 31(10), 1467-1478. doi:10.1093/heapol/czw064
14. Chen, L., Evans, T., Anand, S., Boufford, J. I., Brown, H., Chowdhury, M., Wibulpolprasert, S. (2004). Human resources for health: overcoming the crisis. The Lancet, 364(9449), 1984-1990. doi:10.1016/s0140-6736(04)17482-5
15. Gullo, S., Galavotti, C., & Altman, L. (2016). A review of CARE’s Community Score Card experience and evidence. Health Policy and Planning, 31(10), 1467-1478. doi:10.1093/heapol/czw064
16. Gullo, S., Galavotti, C., Kuhlmann, A.S., Msiska, T., Hastings, P. and Marti, C.N. “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.
17. Björkman-Nyqvist, M., De Walque, D., & Svensson, J. (2014, August). Information is Power: Experimental Evidence of the Long Run Impact of Community Based Monitoring (Rep. No. WPS 7015).
18. Hossain, J., Dr. (2015, March). Project Summary: Community Support System.
Human rights education for political change
- The Human Rights Education Program (HREP) for Women, a project of Women for Women’s Human Rights and the Umraniye Women’s Center, took part in poor urban areas of Turkey with its first pilot in Umraniye, a poor area on the outskirts of Istanbul. Heavily informed by action research with women across Turkey, the program developed a participatory curriculum that lasts 16 sessions. HREP used a human rights framework to facilitate sessions, touching on civil, economic, political, sexual and reproductive rights, as well as topics like child rights, ending gender-based violence and gender-sensitive parenting. HREP worked with closed groups of women and eventually linked with the state to implement the program via trained social workers who facilitated HREP in community centers in cities across the country. Through this space, women involved In the project organized at the grassroots level to advance their needs and interests, and HREP took an activerole to support HREP cohorts in networking, fundraising, capacity-building and linking with broader movements for women’s rights.
- At a broader scale, Mulher e Democracia, a joint effort of 3 Brazilian feminist NGOs (AGENDE, Casa da Mulher do Nordeste and Brazilian National Congress), established a program for women leaders in local, national and state levels of government to undergo a series of trainings on history, political economy and economics with strong feminist analyses and group-based learning. This work specifically sought to build relationships of solidarity among women leaders, and raise consciousness around women’s rights, which they could apply in their roles in public service and decision-making.
What does the evidence indicate?
- Results from Mulher e Democracia’s program are still nascent. However, surveys from 1992 and 2012 show that those who have undergone the program have increasingly expressed commitment to represent and support women as a motivation for their work (from 3-13.8%). However, a challenge remains in terms of how women view support from their broader political parties, which have not supported their leadership in practice. As noted by Cornwall, this highlights the importance of pressure groups and organized movements to demand greater commitment and accountability for women’s rights.
- Evaluations of HREP identified impacts across personal, family and community levels. At the personal level, about 90% of respondents who participated in HREP increased self-confidence and problem solving abilities. Home lives also improved. 72% of participants reported more positive relationships with husbands and 93% reported more positive attitudes toward their children. 73% of women reported greater say in family decision-making. 63% of women who had faced domestic violence before the project reported that they were able to stop it, and 22% reported they were able to reduce domestic violence in their lives.30% of women participants reported entering the workforce while 54% discussed returning to formal and informal education opportunities following the program. At the community level, 88% women participants reported they have become resource people in their communities. In at least 7 cities where HREP was implemented, women started their own associations from which to they organized economic cooperatives, local counseling centers, campaigns to raise community consciousness and support for local women’s leadership.
1. Amado, L. E., & Pearson, N. L. (2005). The Human Rights Education Program for Women (HREP): Utilizing state resources to promote women’s human rights in Turkey
2. Cornwall, A. (2014). Women’s empowerment: what works and why? (WIDER Working Paper 2014/104) [PDF]. Helsinki: United Nations University-WIDER.
3. Cornwall, A. (2014). Women’s empowerment: what works and why? (WIDER Working Paper 2014/104) [PDF]. Helsinki: United Nations University-WIDER.
4. Amado, L. E., & Pearson, N. L. (2005). The Human Rights Education Program for Women (HREP): Utilizing state resources to promote women’s human rights in Turkey
Gender integrated adaptation and resilience
As natural disasters and climate change affect people in distinct ways based on their status, gender and livelihoods, it is critical to ensure equity remains at the center of decision making, participation, access to resources and services and interventions.
- CARE’s Adaption Learning Programme (ALP) works off a Community-Based Adaptation (CBA) framework that brings together development, risk management, and humanitarian response to work to ensure communities can adapt to, and reduce their vulnerability to the impacts of climate change. This approach is grounded in participatory analysis with village-based groups to identify climate change vulnerability and adaptive capacities, who then develop and implement community adaptation action plans. These plans are also used to influence the local development planning of government structures. Promoting gender equality and diversity is now a large component of the CBA approach. In the Sahel region, a combined CBA/VSLA approach has been investigated as a way to increase long-term resilience of communities to future crises.
- CARE’s Disaster Risk Reduction (DRR) work in Vanuatu from 2013 to 2015 aimed to increase the resilience of at-risk communities and schools to the impact of natural disasters. This included an explicit aim to build women’s leadership in disaster preparedness and response through setting up and training Community Disaster and Climate Change Committees (CDCCCs) and supporting them over time with planning, capacity building and coordination. The CDCCCs aimed to not only be gender balanced in membership, but to provide training to CDCCC members on gender and protection.
What does the evidence indicate?
- A 2015 study suggests that combining the VLSA approach with CBA programming appears to offer more sustainable, effective results to building resilience to the crises brought about by environmental changes. Whereas VSLA activities indicate numerous benefits for decreasing the vulnerability of women such as the improved social capital and economic situation of members, it doesn’t in itself strengthen the capacity of communities to adapt to environment change that are significantly impacting food and income security. It appears that combining VSLA with a CBA approach can ensure that environmental changes that are particularly serious for women and marginalized groups.
- An evaluation of the gender sensitive approach of the DRR in Vanuatu found that the inclusion of women in Climate Change Committees (CDCCCs) led to an increased representation of women in community leadership roles, and increased respect for women’s membership and leadership in disasters in comparison to communities without the CDCCCs. The evaluation also found evidence that greater involvement of women in disaster leadership contributed to more inclusive preparedness and response – with specific actions taken to seek out and support women, children and people with a disability in preparing, responding and recovering from the Tropical Cyclone Pam.