This paper presents a randomized field experiment on increasing community-based monitoring. To examine whether beneficiary control works, a randomized field experiment in 50 ‘communities’ from nine districts in Uganda is designed and conducted.
In the experiment, or intervention, communities were provided with baseline information on the status of service delivery, both in absolute terms and relative to other providers and the government standard for health service delivery. The intervention sought to relax two constraints typically faced by communities in monitoring providers: lack of access to reliable and structured information on the community’s entitlements and the status of service delivery, and inadequate local organizational capacity.
Key findings from the literature :
- Evidence shows that the provision of public services to poor people in developing countries is constrained by weak incentives of service providers. Schools and health clinics are not open when supposed to; teachers and health workers are frequently absent from schools and clinics and, when present, spend a significant amount of time not serving the intended beneficiaries; equipment, even when fully functioning, is not used; drugs and vaccines are misused; and public funds are expropriated.
- The traditional approach to accountability in the public sector relies on external control. This is a top-down approach where someone in the institutional hierarchy is assigned to monitor, control and reward/punish agents further down in the hierarchy.
- In many poor countries, the institutions assigned to monitor the providers are typically weak and malfunctioning, and may themselves act under an incentive system providing little incentives to effectively monitor the providers. Results suggest that community monitoring can play an important role in improving service delivery when traditional top-down supervision is ineffective.
- Provision of information on outcomes and performance improves citizens’ ability to challenge abuses of the system, since reliable quantitative information is more difficult for service providers to brush aside as anecdotal, partial, or simply irrelevant. Information provision however, may not have any considerable impact unless there are members of the community who are willing to make use of the new information.
Results from the experiment:
- In response to perceived continued weak health care delivery at the primary level, a pilot project (Citizen report cards) aimed at enhancing community involvement and monitoring in the delivery of primary health care was initiated in 2004. The main objective of the Citizen report card project was to strengthen providers’? accountability to citizen-clients by enhancing communities’ ability to monitor providers.
- Although the Citizen report card project appears to be successful, it is too early to use the findings as a basis for continued or increased support and funding for various activities with the aim of strengthening beneficiary control. One important concern is to what extent the processes initiated by the Citizen report card project are permanent. At the same time, it is possible that the treatment communities ability to coordinate citizen actions has also been applied to other areas of concern (education, local road construction, etc.), in which case the aggregate return is even larger than what the above results suggest.
- One year into the program, average utilisation (for general outpatient services) was 16 percent higher in the treatment communities; the weight of infants higher, and the number of deaths among children under -five markedly lower. The intervention resulted in 1.7 percentage points fewer child deaths in the treatment communities during the first project year. To the extent that this number is representative of the total treatment population, this would imply that approximately 550 under-five deaths were averted as a result of the intervention.
- Treatment communities became more extensively involved in monitoring the providers following the intervention, and the results suggest that the health unit staff responded by exerting a higher effort in serving the community.
