Improving Health Service Delivery Through Community Monitoring and Non-Financial Awards

Maternal and child health in poor countries suffers from failures in supply and demand. Health workers face weak incentives to provide quality services, while patients under-utilize what health services do exist, due to cost, lack of information, and perceived low quality of services. We propose to conduct an investigation of two innovative, social accountability interventions that aim to address these shortcomings by incentivizing health workers and stimulating demand for health services. In the first, "top-down" intervention, maternal and child health clinics compete on service provision criteria and receive non-financial government awards for performance. In the second, "bottom-up" intervention, clinic staff and community residents are motivated to jointly develop action plans to improve key maternal and child health indicators. Both interventions make use of an innovative scorecard tool and uniquely adapt non-financial incentive mechanisms, which have demonstrated significant advantages over comparable strategies. Based on recent evidence that workers respond exceptionally well to public recognition and community involvement, we expect significant improvements in maternal and child health outcomes, and across markers of service provision and utilization. Our study employs the most rigorous methodology available, a randomized controlled trial, and the data produced will permit a comparison of the interventions based on cost-effectiveness and key health outcomes. Our study will directly inform the Government of Sierra Leone's decision in bringing these interventions to scale nationally and will yield rich, policy-relevant information for public health professionals, researchers, and policymakers in the health sector around the world.