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Power to the People
Evidence from a Randomized Field Experiment on Community-Based
Monitoring in Uganda
Martina Björkman, IGIER, University of Bocconi, & CEPR
Jakob Svensson, IIES, Stockholm University, NHH, & CEPR
Background Millions of children die from easily preventable
causes
Weak incentives for service providers
Top-down approach to monitoring also lacks appropriate incentives
Recent focus on strengthening providers’ accountability to citizen-clients Beneficiaries lack information Inadequate participation by beneficiaries
Research Questions
Can an intervention that facilitates community-based monitoring lead to increased quantity of health care?
Increased quality of health care?
Did the intervention increase treatment communities’ ability to exercise accountability?
Did the intervention result in behavioral changes of staff?
Intervention
50 rural dispensaries in Uganda Drawn from 9 districts
Households w/in 5 km catchment area 18 local NGOs
Provide communities with information on relative performance
Encourage beneficiaries to develop a plan that identified steps the provider and community should take to improve service performance and ways to get the community more actively involved in monitoring
Intervention Specifics
Pre-intervention survey data used to compile unique “report card” for each facility Translated into community’s main language Posters by local artist for non-literate
Information provided to community through participatory / interactive meetings Community: suggestions summarized in action plan Staff: review & analyze performance Interface: contract outlining what needed to be done, how,
and by whom
Timing
Intervention intended to “kick-start” community monitoring
Mid-term review after 6 months, but no other outside presence in communities Not able to document all actions taken by communities
Data Pre-intervention survey to collect data for report
cards Quantitative service delivery data from facilities’ own
records Households’ health outcomes, perceptions of health facility
performance parameters Whenever possible supported by patient records
Post-intervention survey 1 year after intervention Child mortality (under 5) Weight of all infants
Roughly 5000 randomly-sampled households in each survey round
Evidence of Increased Monitoring More than 1/3 of Health Unit Management
Committees in treatment communities reformed or added members; no change in control communities
70% of treatment communities had some sort of monitoring tool (such as suggestion boxes, numbered waiting cards, duty rosters); only 16% in control communities
Performance of staff more often discussed at local council meetings in treatment communities NGO reports suggest that discussions shifted from general
to specific issues regarding community contract
Treatment Practices
At facilities in treatment communities significantly: More likely to have equipment used during exam (19%
increase) Shorter wait times (10% decrease) Less absenteeism (14%age points lower) More on-time vaccinations Larger share received information on dangers of self-
treatment and family-planning
Also possibility of less drug-leakage
Utilization
At facilities in treatment communities significantly: Higher utilization of general outpatient services
(16%) More deliveries at the facility (68%)
From household surveys: Consistent increases in use of treatment facilities Reduction in visits to traditional healers & the
extent of self-treatment
Health Outcomes
Child mortality 3.2% in treatment communities 4.9% in control communities 90% confidence interval for difference ranges from 0.3%-3.0% Corresponds to roughly 540 averted deaths (per 55,000
households in treatment communities) Infant weight
Compare distributions of weight-for-age (z score) Difference in means is 0.17 z score Reduction in average risk of mortality based on risk of death from
infectious disease among underweight children estimated to be 8%
Institutional Issues
Did district or sub-district management react to intervention?
Check that treatment & control communities have comparable: Monthly supply of drugs Funding Construction or infrastructure improvements Visits from government or Parish staff Employment (dismissals, transfers, hiring)
External Validity
Idiosyncratic process differed from community to community in experiment
In another context, process could play out entirely differently
Cultural factors key
Scaling Up
What actually caused the observed effects?
How to replicate the intervention? Process dependent on NGO facilitators No way to know which components of monitoring were
influential
An Alternative Explanation
Possible (but unlikely) that intervention directly influenced providers’ behaviors Outcomes not necessarily result of increased monitoring
Considered additional treatment of staff meetings only but decided against it Financial reasons Ethical reasons
Conclusion
Impressive effects, but intervention difficult to replicate
Important piece of causal chain undocumented
?