Community-Based Monitoring of Primary Healthcare Providers in Uganda
Nearly 11 million children under five die each year, many from preventable diseases. One possible reason for this may be ineffective systems of monitoring and weak accountability relationships between the service providers and those whom they are serving. Researchers conducted a randomized evaluation in Uganda to see whether community monitoring could impact health worker performance and subsequent health utilization and outcomes. They found community monitoring led to better quality and more frequently utilized health services, and ultimately improved health outcomes for patients.
Nearly 11 million children under five die each year, many from preventable diseases such as pneumonia, malaria, and measles. Though prevention and treatment for such diseases is relatively cheap, many do not have access to the necessary services. One possible reason for this may be ineffective systems of monitoring and weak accountability relationships between the service providers and those whom they are serving. Poor incentives for public providers to deliver quality services may result in high absenteeism and low-quality patient care. Participation of beneficiaries in the monitoring of public service delivery may be important for improvement, given that they have the most to benefit from improved health services.
Uganda, like many newly independent countries in Africa, had a functioning healthcare system in the early 1960s, but saw a collapse of government services as the country underwent political upheaval. The government has been implementing major infrastructure rehabilitation programs in the public health sector, but improved outcomes have remained elusive.
Rural dispensaries, which are the lowest tier of the Ugandan health system, provide preventive outpatient care, maternity, and laboratory services. A number of actors are responsible for supervision and control of the dispensaries including the Health Unit Management Committee, who monitor the day-to-day running of the facility, but have no authority to sanction workers. The Health Sub-district, one level above, is supposed to monitor funds, drugs, and service delivery, but this monitoring is infrequent. Only the Chief Administrative Officer of the District and the District Service Commission have the authority to suspend or dismiss staff. Usually staffed by one medical worker, two nurses, and three aides, dispensaries provide no incentives for their workers to increase their efforts.
Researchers conducted a randomized evaluation at 50 dispensaries from nine districts in Uganda to see if community monitoring could impact health worker performance and subsequent health utilization and outcomes.
In the area around 25 randomly selected dispensaries, local NGOs facilitated three sets of meetings. In the first, approximately 150 community members, both the disadvantaged and the elite, discussed the status of their health services and means of identifying steps the providers should take to improve health service provision. Second, a provider staff meeting was held to contrast the citizen' s view on service provision with that of the health worker. The third, an interface meeting, allowed community members and health workers to discuss patient rights and provider responsibilities. The outcome was a shared action plan, or a contract, outlining the community' s and the service provider' s agreement on what needs to be done, how, when, and by whom. These three sets of meetings aimed to kick-start the process of community monitoring. After six months, community and interface meetings were held to review progress and suggest improvements.
A survey was administered to both the service providers and a randomly selected subset of households around each dispensary prior to the intervention and again one year later. This information was supplemented by administrative records and visual checks of the dispensary.
Impact on Quality Care: A year after the first round of meetings, health facilities in treatment villages were 36 percent more likely to have suggestion boxes and 20 percent more likely to have numbered waiting cards, relative to the comparison facilities. There was a 12 minute reduction in wait time, a 13 percentage point reduction in absenteeism, and the overall facility cleanliness of the facility improved.
Impact on Health Outcomes: Utilization of general outpatient services was 20 percent higher in the treatment group. Specifically, 58 percent more people came for child birth deliveries, 19 percent more patients sought prenatal care, number of patients seeking family planning increased by 22 percent, and immunizations increased for all age groups, especially newborns. Households also reduced the number of visits to traditional healers and the extent of self-treatment. Relative to the comparison group, intervention communities saw a 0.14 z-score increase in infant weight and a 33 percent reduction in the mortality of children under 5 years old. Variation in treatment intensity across districts shows a significant relationship between the degree of community monitoring and health utilization and outcomes.
Bjorkman, Martina, and Jakob Svensson. 2009. "Power to the People: Evidence From a Randomized Field Experiment on Community-Based Monitoring in Uganda." The Quarterly Journal of Economics 124(2): 735-69.