Approximately 11 million children under five die each year. Almost half of these deaths occur in sub-Saharan Africa where roughly one in five children dies before reaching the age of five. More than half of these children nearly 6 million will die of diseases that could easily have been prevented or treated if the children had had access to a small set of proven, inexpensive services.

Why are these services not provided? While there is no simple answer, a wealth of anecdotal, and recently more systematic, evidence shows that the provision of public services to poor people in developing countries is constrained by weak incentives of service providers schools and health clinics are not open when supposed to; teachers and health workers are frequently absent from schools and clinics and, when present, spend a significant amount of time not serving the intended beneficiaries; equipment, even when fully functioning, is not used; drugs and vaccines are misused; and public funds are expropriated.

The traditional approach to accountability in the public sector relies on external control. This is a top-down approach where someone in the institutional hierarchy is assigned to monitor, control and reward/punish agents further down in the hierarchy. The tacit assumption is that more and better enforcement of rules and regulations will strengthen providers’ incentives to increase both the quantity and quality of service provision. But, in many poor countries, the institutions assigned to monitor the providers are typically weak and malfunctioning, and may themselves act under an incentive system providing little incentives to effectively monitor the providers. As a result, the relationship of accountability of provider-to-state is ineffective in many developing countries.

As a complementary strategy, it has therefore been argued that more effort must be placed on strengthening beneficiary control, i.e. strengthening providers’ accountability to citizen-clients (see e.g., World Bank, 2003). However, despite the enthusiasm for such an approach, there is little credible evidence on the impact of policy interventions aimed at achieving it (Banerjee and He, 2003; Banerjee and Duflo, 2005). This paper attempts to provide some.

To examine whether beneficiary control works, we designed and conducted a randomised field experiment in 50 "communities" from nine districts in Uganda. In the experiment, or intervention, communities were provided with baseline information on the status of service delivery, both in absolute terms and relative to other providers and the government standard for health service delivery. As a way to mitigate local collective action problems, community members were also encouraged to develop a plan that identified the most important problems in health service provision and ways to monitor the provider.

The intervention sought to relax two constraints typically faced by communities in monitoring providers: lack of access to reliable and structured information on the community’s entitlements and the status of service delivery, and inadequate local organisational capacity. Access to reliable and structured information about current status of service delivery and entitlements is critical for citizensability to monitor service providers. Although people know whether their own child died or not, and whether the health workers did anything to help them, they typically do not have any information on aggregate outcomes, such as how many children in their community did not survive beyond the age of 5 or where citizens, on average, seek care. Provision of information on outcomes and performance improves citizensability to challenge abuses of the system, since reliable quantitative information is more difficult for service providers to brush aside as anecdotal, partial, or simply irrelevant. But information provision may not have any considerable impact unless there are members of the community who are willing to make use of the new information. Exerting accountability (monitoring providers) is subject to potentially large free-rider problems. Elite capture further complicates the process of holding providers accountable. By enhancing local organization capacity and encouraging the community to develop its own monitoring strategy, these constraints are sought to be relaxed.

The community-based monitoring project increased the quality and quantity of primary health care provision. One year into the program, we find a significant difference in the weight of infants (0.17 z-scores increase) and a markedly lower number of deaths among children under five (a 33 percent reduction in child deaths) in the treatment communities. Utilisation (for general outpatient services) was 16 percent higher in the treatment compared to the control facilities. We also find significant differences in the number of deliveries at treatment facilities and the use of antenatal care and family planning. Treatment practices, as expressed both in perception-based responses by households and in more quantitative indicators (immunisation of children, waiting time, examination procedures, absenteeism), improved significantly in the treatment communities, thus suggesting that the changes in quality and quantity of health care provision are due to behavioral changes of the staff. We find evidence that the treatment communities became more engaged and began to monitor the health unit more extensively. No effect is found on investments, or the level of financial or in-kind support (from the government). Furthermore, supervision of providers by upper-level government authorities remained low in both the treatment and the control group. This reinforces our confidence that the findings on the quality and quantity of health care provision resulted from increased efforts by the health unit staff to serve the community in the light of better community monitoring.

The paper is organised as follows. The next section reviews the literature. Section 3 discusses the concept of community monitoring. Section 4 briefly describes the institutional environment in Uganda and in the project areas. The community-based monitoring intervention is described in section 5. Section 6 lays out the evaluation design and the results are presented in section 7. Section 8 concludes.