DOES PARTICIPATION IMPROVE DEVELOPMENT OUTCOMES?
Incentives did not affect education indicators, however, and some health impacts also disappeared by endline. For example, the project had large impacts on reducing neonatal and infant mortality at midline, but these impacts disappeared by the endline. The endline results also show no impact on learning. Importantly, nontargeted indicators also improved across the board, with an average improvement of 0.0362 standard deviation, with statistically significant improvements in indicators such as facility-based deliveries. The grant also appears to have been most effective in more disadvantaged areas. In looking at the mechanisms through which the project worked, the authors suggest that Generasi appears to have had the greatest impact on community effort. It mobilized cadres working at village health posts and ratcheted up participation in meetings about health education and related topics. Households in Generasi areas also felt that both health and education services had improved. In terms of overall service provision, however, there were no statistically significant impacts. If anything, there was a slight decrease in health provider inputs and effort and some increase in the prices charged by providers. There is also some evidence of deterioration in the quality of care. Combined with the fact that the main effects come from greater community effort in direct service provision, these results are disturbing from the point of view of sustainability, as is the finding that there was no impact of the program on any indicator of community outreach or monitoring and no spillover to other community activities.
. . . but many results were not sustained.
Community monitoring of health care providers.
Perhaps the bestknown assessment of the efficacy of community monitoring in improving health service delivery is of a randomized citizen’s report card project in Uganda (Bjorkman and Svensson 2007). The main objective of the project was to improve the quality of basic health services by improving community capacity to monitor service providers. The report card intervention was randomly assigned to half of 50 rural communities across 9 districts. Meetings of users and providers were held at which the information collected in the report cards was disseminated together with practical information on how best to use this information.40 The authors find large and significant improvements in a number of treatment practices, from staff absenteeism to waiting time and the quality of preventive care. They find a 16 percent increase in the use of health facilities, along with greater community satisfaction with
Following the introduction of citizen report cards in Uganda, the under-five mortality rate fell 33 percent and vaccination rates and infant weight rose. 205