We evaluate the impact of a large-scale information and mobilization intervention designed to improve health service delivery in rural Uganda by increasing citizens’ ability to monitor and apply bottom-up pressure on underperforming health workers. Modeled closely on the landmark “Power to the People” study (Björkman and Svensson, 2009), the intervention was undertaken in 376 health centers in 16 districts and involved a three-wave panel of more than 14,000 households. We find that while the intervention had a modest positive impact on treatment quality and patient satisfaction, it had no effect on utilization rates or health outcomes (including child mortality). We also find no evidence that the channel through which the intervention affected treatment quality was citizen monitoring. The results hold in a wide set of pre-specified subgroups and also when, via a factorial design, we break down the complex intervention into its two most important components. Our findings cast doubt on the power of information to foster community monitoring or to generate improvements in health outcomes, at least in the short term.
In Uganda, researchers conducted a large-scale randomized evaluation of a program called Accountability Can Transform (ACT) Health. The program provided community members and health care workers information about the quality of their local health services and brought them together to create action plans for how to improve local health service accountability, delivery, and quality. The study built on previous research of a similar program called Power to the People, which was found to greatly improve child health.
Twenty months after the program began:1
- The program marginally improved the quality of treatment patients received and increased patient satisfaction.
- However, the program did not affect how often people sought health care (utilization rates) or improve health outcomes; child mortality rates were unchanged.
- Results were similar one and two years into the program and were consistent across different groups; no health effects were found in any subgroup.
- Contrary to the theory of change motivating the intervention, there was no evidence that the program caused citizens to more closely monitor or apply pressure on service providers.
- Overall, the findings suggest a combination of information provision and increased oversight can marginally change the behavior of frontline service providers, but cast doubt on the power of information to foster community monitoring or to generate improvements in health outcomes, including child mortality, at least in the short term.
1 On average the time between the launch of the program and the final survey was 20 months.
Designers and funders of payments for ecosystem services (PES) programs have long worried that payments flow to landholders who would have conserved forests even without the program, undermining the environmental benefits (“additionality”) and cost-effectiveness of PES. If landholders self-select into PES programs based on how much conservation they were going to undertake anyway, then those who were planning to conserve should always enroll. This paper discusses the less-appreciated fact that enrollment is often based on other factors too. The hassle of signing up or financial costs of enrollment (e.g., purchasing seedlings) can affect who participates in a PES program. These enrollment costs reduce overall take-up, and, importantly, they can also influence the composition of landholders who select into the program—and thereby the program’s environmental benefits per enrollee. Enrollment costs can increase a program’s benefits per enrollee if they are systematically higher for (and thus deter enrollment by) landholders who would have conserved anyway. Alternatively, enrollment costs can dampen per-enrollee benefits if their correlation with status-quo conservation is in the opposite direction. We illustrate these points with evidence from two studies of randomized trials of PES programs aimed at increasing forest cover in Uganda and Malawi. We also discuss how in other sectors, such as social welfare, policy designers have purposefully adjusted the costs of program enrollment to influence the composition of participants and improve cost-effectiveness. We propose that these ideas for targeting could be incorporated into the design of PES programs.
In 2008, Uganda granted hundreds of small groups $400/person to help members start individual skilled trades. Four years on, an experimental evaluation found grants raised earnings by 38% (Blattman, Fiala, Martinez 2014). We return after 9 years to find these start-up grants acted more as a kick-start than a lift out of poverty. Grantees' investment leveled off; controls eventually increased their incomes through business and casual labor; and so both groups converged in employment, earnings, and consumption. Grants had lasting impacts on assets, skilled work, and possibly child health, but had little effect on mortality, fertility, health or education.
Helping the ultra-poor develop sustainable livelihoods is a global priority, but policymakers, practitioners, and funders are faced with competing ideas about the best way to reduce extreme poverty. Innovations for Poverty Action conducted a randomized evaluation to test the impacts of diverse components and variants of the Village Enterprise microenterprise program, an integrated poverty alleviation intervention that provides poor households with a combination of cash transfers, mentorship, business training, and support with the formation of savings groups, over a one-year period.
- Village Enterprise’s microenterprise development program led to increased consumption, assets, and income, as well as improvements in nutrition and subjective well-being.
- Cost-effectiveness appears high: researchers estimate a full cost recovery within three to four years.
- A cost-equivalent cash transfer appeared to have less promising medium-term impacts on poverty reduction and subjective well-being than the microenterprise program, though estimates are more ambiguous.
- Adding a light-touch behavior change component to the cash transfer changed the investment patterns of cash transfer recipients and improved subjective well-being somewhat, but cannot be characterized as a substitute for the much more heavy-touch training and mentorship interventions of the microenterprise program.
- Overall, the results suggest that training and mentorship components of integrated poverty alleviation programs are sensible and cannot simply be removed (or substituted for cash transfers). But as they are complex, more research is needed on the issue of scaling them while maintaining their quality.
* These results are preliminary and may change after further data collection and/or analysis.