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

Innovations for Poverty Action
Organization Location: 
New Haven, CT USA

Sierra Leone ranks close to last in the UN Human Developing Index, and faces exorbitant rates of maternal and child mortality. As in other least developed nations, poor service delivery including weak incentives for health workers contributes to these outcomes, through problems such as worker absenteeism and low clinic utilization rates. We seek to examine how two types of social accountability interventions can improve health service delivery and outcomes for women and children under five. Our randomized control trial implements the interventions via a cross-cutting design. We pioneer the use of top-down non-financial awards to incentivize health workers: groups of maternal and child health clinics compete on service provision criteria, such as vaccination rates, assisted deliveries, and worker absenteeism. The best improving clinic receives public recognition, including letters of commendation for health facility staff. This will yield the first quantitative evidence on the extent to which non-financial incentives can galvanize health workers, an important question given previous qualitative evidence that recognition from the community figures prominently in health worker motivation. We also implement community monitoring, a bottom-up intervention in which information about the state of healthcare is disseminated via a community scorecard and an action plan is developed jointly between clinic staff and the community. By assessing the joint effectiveness of these two interventions, we are also able to assess the extent to which the carrot of the top-down award enhances the effectiveness of the bottom-up monitoring.