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Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda*
Abstract
This paper presents a randomized field experiment on community-based monitoring of public primary health care providers in Uganda. Through two rounds of village meetings, localized nongovernmental organizations encouraged communities to be more involved with the state of health service provision and strengthened their capacity to hold their local health providers to account for performance. A year after the intervention, treatment communities are more involved in monitoring the provider, and the health workers appear to exert higher effort to serve the community. We document large increases in utilization and improved health outcomes—reduced child mortality and increased child weight—that compare favorably to some of the more successful community-based intervention trials reported in the medical literature.
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“We are aware that, besides more direct impacts such as the reduction in the level of specific forms of corruption, interventions might also have indirect effects such as improved public integrity, improved quality or quantity of specific public services (Banerjee et al., 2010; Björkman & Svensson, 2009).”
From Public sector reforms and their impact on the level of corruption: A systematic review (2021) · cites this paper as Björkman & Svensson, 2009
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“With few exceptions, this literature studies the relationships of accountability of politicians to citizens and deal with one (periodic elections) mechanism through which citizens can make politicians and policymakers accountable (see for instance Strömberg, 2004; Besley and Burgess, 2002; Ferraz and Finan, 2005).”
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“An individual worker may still put in high e¤ort if shirking deviates from her ideal choice, given the behavior of other sta¤ and the situation (Akerlof and Kranton, 2005).”
Evidence-based, cost-effective interventions: How many newborn babies can we save?
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Can Civil Society Overcome Government Failure in Africa?
Devarajan, S., Khemani, S., & Walton, M. (2014) · doi:10.1093/wbro/lkt008 · Cited by 26
“Bjo¨rkman and Svensson (2009) undertake a randomized control trial of a citizen report card intervention in the health sector in Uganda.”
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The Sorry State of M&E in Agriculture: Can People-centred Approaches Help?
Haddad, L., Lindstrom, J., & Pinto, Y. (2010) · IDS Bulletin · doi:10.1111/j.1759-5436.2010.00177.x · Cited by 25
“Within the experiment, the cost per child death averted was $300, well below the average of $887 for 23 other interventions (Björkman and Svensson 2009).”
When a Doctor Falls from the Sky: The Impact of Easing Doctor Supply Constraints on Mortality
Okeke, E. (2023) · The American Economic Review · doi:10.1257/aer.20210701 · Cited by 25
“9For examples of prior work, see Bjorkman and Svensson (2009) on community accountability, Mohanan et al. (2020) on extrinsic motivation, Brock et al. (2016) on intrinsic motivation, and Okeke (2020) on peer monitoring.”
Participation in Social Policy
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“Certain international organisations have promoted greater community involvement in QI strategies in LMICs, such as community members managing accountability, oversight, and mobilisation of local resources (Björkman & Svensson, 2009; Bradley et al., 2012; Brinkerhoff, 2011; Peters, 2002).”
How Can We Build an Enabling Political Environment to Fight Undernutriton?
Haddad, L. (2013) · doi:10.1057/ejdr.2012.45 · Cited by 24
Social Incentives, Delivery Agents, and the Effectiveness of Development Interventions
Bandiera, O., Burgess, R., Deserranno, E., Morel, R., Sulaiman, M., & Rasul, I. (2022) · Journal of Political Economy Microeconomics · doi:10.1086/722898 · Cited by 23
“…design adjustments provide forms of bottom-up monitoring of DAs or enable the poor to improve their negotiating position with regards to elites [Bjorkman and Svensson 2009, Banerjee et al. 2019].23 21To reduce prediction noise, we use those assets that are owned most frequently and for which…”
Re-Inventing Africa's Development
Park, J. (2018) · doi:10.1007/978-3-030-03946-2 · Cited by 23
Combating corruption in global health
Mackey, T., Kohler, J., Lewis, M., & Vian, T. (2017) · Science Translational Medicine · doi:10.1126/scitranslmed.aaf9547 · Cited by 23
la Forgia, G. L., Raha, S., Shaik, S., Maheshwari, S., & Ali, R. (2014) · doi:10.1596/1813-9450-6953 · Cited by 23
“26 It is key to note, however, that although citizen participation has shown promising results elsewhere (see Tendler, 1997; Bjorkman and Svensson, 2009).”
Madajewicz, M., Tompsett, A., & Habib, M. (2021) · Journal of Development Economics · doi:10.1016/j.jdeveco.2020.102609 · Cited by 23
Electoral incentives to combat mosquito-borne illnesses: Experimental evidence from Brazil
Boas, T. C., & Hidalgo, F. D. (2018) · World Development · doi:10.1016/j.worlddev.2018.08.013 · Cited by 22
“Conclusions from this research program have been mixed; one study shows that efforts to facilitate citizen monitoring improve service delivery and health outcomes (Björkman & Svensson, 2009; Björkman Nyqvist, de Walque, & Svensson, 2017) , whereas other studies in the area of education have found null effects on citiz…”
Banerjee, A., & Duflo, E. (2008) · Annals of the New York Academy of Sciences · doi:10.1196/annals.1425.019 · Cited by 22
Can judiciaries constrain executive power? Evidence from judicial reforms
Chemin, M. (2021) · Journal of Public Economics · doi:10.1016/j.jpubeco.2021.104428 · Cited by 21
Public Services, Geography, and Citizen Perceptions of Government in Latin America
Bland, G. A., Brinkerhoff, D., Romero, D., Wetterberg, A., & Wibbels, E. (2021) · Political Behavior · doi:10.1007/s11109-021-09691-0 · Cited by 21
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Transparency by Chinese cities reduces pollution violations and improves air quality
Liu, M., Buntaine, M. T., Anderson, S. E., & Zhang, B. (2025) · Proceedings of the National Academy of Sciences of the United States of America · doi:10.1073/pnas.2406761122 · Cited by 20
Does top-down accountability promote responsiveness? Evidence from a survey experiment in China
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Pärli, R. (2022) · Environmental Science & Policy · doi:10.1016/j.envsci.2022.11.019 · Cited by 32
Fitzpatrick, A. (2021) · Journal of Health Economics · doi:10.1016/j.jhealeco.2021.102544 · Cited by 20
Influence of community scorecards on maternal and newborn health service delivery and utilization
Kiracho, E. E., Namuhani, N., Apolot, R. R., Aanyu, C., Mutebi, A., Tetui, M., Kiwanuka, S., Ayen, F. A., Mwesige, D., Bumbha, A., et al. (2020) · International Journal for Equity in Health · doi:10.1186/s12939-020-01184-6 · Cited by 20
Hamill, H., Dávid-Barrett, E., Mwanga, J., Mshana, G., & Hampshire, K. (2020) · BMJ Global Health · doi:10.1136/bmjgh-2020-003043 · Cited by 20
“First, in common with many LMICs, regulatory agencies in Tanzania (especially at local level) are often underresourced; their capacity outstripped by the enormity of the task.”
InfluentialMedia exposure and political participation in a transitional African context
Conroy-Krutz, J. (2018) · World Development · doi:10.1016/j.worlddev.2018.05.002 · Cited by 20
Determinants of Willingness to Bribe: Micro Evidence from the Educational Sector in China
Liu, Q.-J., & Peng, Y. (2015) · Jahrbücher für Nationalökonomie und Statistik · doi:10.1515/jbnst-2015-0205 · Cited by 20
The Geography of Governance in Africa: New Tools from Satellites, Surveys and Mapping Initiatives
Huntington, H., & Wibbels, E. M. (2014) · Regional & Federal Studies · doi:10.1080/13597566.2014.971774 · Cited by 24
Squires, F., Hilber, A. M., Cordero, J. P., Boydell, V., Portela, A. G., Sabin, M. L., & Steyn, P. S. (2020) · PLoS ONE · doi:10.1371/journal.pone.0238776 · Cited by 20
Balestra, G., Dasgupta, J., Sandhya, Y., & Mannell, J. (2018) · Global Public Health · doi:10.1080/17441692.2018.1464586 · Cited by 19
Erchick, D., George, A., Umeh, C., & Wonodi, C. (2016) · International Journal of Health Policy and Management · doi:10.15171/ijhpm.2016.150 · Cited by 19
Tapscott, R. (2017) · Development and Change · doi:10.1111/dech.12294 · Cited by 34
Gilmore, B., Vallières, F., McAuliffe, É., Tumwesigye, N. M., & Muyambi, G. (2014) · Implementation Science · doi:10.1186/s13012-014-0137-5 · Cited by 18
Management and Motivation in Ugandan Primary Schools: An impact evaluation report
Barr, A., Bategeka, L., Guloba, M., Kasirye, I., Mugisha, F., Serneels, P., & Zeitlin, A. (2012) · doi:10.22004/ag.econ.164412 · Cited by 19
Calland, R. (2010) · doi:10.2139/ssrn.2188163 · Cited by 19
Jain, M., Shisler, S., Lane, C. E., Bagai, A., Brown, E. E., Engelbert, M., Vardy, Y., Eyers, J. E., Anda, D., & Parsekar, S. S. (2022) · Campbell Systematic Reviews · doi:10.1002/cl2.1253 · Cited by 24
Joseph, C., & Maluka, S. (2021) · Reproductive Health · doi:10.1186/s12978-021-01225-5 · Cited by 18
Banerjee, Duflo, Kremer, and the Rise of Modern Development Economics*
Olken, B. (2020) · Scandinavian Journal of Economics · doi:10.1111/sjoe.12418 · Cited by 18
Butler, N., Johnson, G. A., Chiweza, A. L., Aung, K. M., Quinley, J., Rogers, K., & Bedford, J. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-05394-0 · Cited by 23
“Other studies have similarly found interface meetings that facilitate bi-directional information sharing to provide an important space for community members to voice their concerns and ask questions of duty bearers, and for duty bearers to provide information to citizens and respond to citizen’s concerns in real time…”
Implementation and effects of India's national school-based iron supplementation program
Berry, J., Mehta, S., Mukherjee, P., Ruebeck, H., & Shastry, G. (2020) · Journal of Development Economics · doi:10.1016/j.jdeveco.2019.102428 · Cited by 18
Dewachter, S., Holvoet, N., Kuppens, M., & Molenaers, N. (2018) · World Development · doi:10.1016/j.worlddev.2017.09.018 · Cited by 18
Mafuta, E., Hogema, L. M., Mambu, T. N. M., Kiyimbi, P. B., Indebe, B. P., Kayembe, P., Buning, T. D. C., & Dieleman, M. (2016) · BMC Health Services Research · doi:10.1186/s12913-016-1895-3 · Cited by 18
Gildemyn, M. (2014) · doi:10.1177/1098214014525257 · Cited by 18
Hollyer, J. R., Rosendorff, B. P., & Vreeland, J. R. (2014) · Political Analysis · doi:10.1093/pan/mpu001 · Cited by 232
Sonnenfeld, A., Stevenson, J., & Waddington, H. S. (2022) · Journal of Development Effectiveness · doi:10.1080/19439342.2022.2153380 · Cited by 23
“Interventions incorporating accountability mechanisms provided for citizen feedback and engagement in monitoring public services, such as community-based monitoring and report cards (e.g. Olken 2007; Björkman and Svensson 2009).”
InfluentialTasker, A. J., & Braam, D. (2021) · PLoS ONE · doi:10.1371/journal.pone.0254746 · Cited by 22
Fabbri, C., Dutt, V., Shukla, V., Singh, K., Shah, N., & Powell‐Jackson, T. (2019) · The Lancet Global Health · doi:10.1016/s2214-109x(19)30254-2 · Cited by 15
Public Financial Management and Health Service Delivery: A Literature Review
Goryakin, Y., Revill, P., Mirelman, A., Sweeney, R., Ochalek, J., & Suhrcke, M. (2017) · Global Health Economics · doi:10.1142/9789813272378_0007 · Cited by 17
Haque, A., & Fatema, K. (2022) · International Journal of Disaster Risk Reduction · doi:10.1016/j.ijdrr.2022.103229 · Cited by 27
Dodgson, G., Alderson-Day, B., Smailes, D., Ryles, F., Mayer, C., Glen-Davison, J., Mitrenga, K., & Fernyhough, C. (2020) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465820000661 · Cited by 16
Radio's Impact on Preferences for Patronage Benefits
Keefer, P. E., & Khemani, S. (2014) · World Bank, Washington, DC eBooks · doi:10.1596/1813-9450-6932 · Cited by 24
The Dynamic Effects of Information on Political Corruption: Theory and Evidence from Puerto Rico
Bobonis, G. J., Fuertes, L. R. C., & Schwabe, R. (2012) · doi:10.36095/banxico/di.2012.14 · Cited by 16
New routes to governance: a review of cases in participation, transparency, and accountability
Wittemyer, R., Bailur, S., Anand, N., Park, K. R., & Gigler, S. (2014) · doi:10.1596/978-1-4648-0191-4_ch3 · Cited by 16
Informing women and improving sanitation: Evidence from rural India.
Lee, Y. J. (2017) · Journal of Rural Studies · doi:10.1016/j.jrurstud.2017.07.012 · Cited by 15
Interventions addressing routine childhood immunization and its behavioral and social drivers
Parsekar, S. S., Vadrevu, L., Jain, M., Menon, S., & Taneja, G. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1364798 · Cited by 31
“The examples were Community Health Strategy in Kenya (124, 136), a multicomponent strategy using m-Reach platform in Uganda (125), and in Nigeria, sensitization and mobilization of mothers (97) and using trained community volunteers and CHWs as part of IMCI program (102).”
Making, A. H. I. P. C. F. D. U. F. D. (2022) · Global Health Science and Practice · doi:10.9745/ghsp-d-21-00666 · Cited by 20
Ding, Y., Lu, F., & Ye, X.-Y. (2020) · Economics of Education Review · doi:10.1016/j.econedurev.2020.101985 · Cited by 15
Steyn, P., Boydell, V., Cordero, J., McMullen, H., Habib, N., Nguyen, T. M. H., Nai, D., Shamba, D., & Kiarie, J. (2020) · Gates Open Research · doi:10.12688/gatesopenres.13075.2 · Cited by 15
Duchoslav, J., & Cecchi, F. (2019) · World Development · doi:10.1016/j.worlddev.2018.09.011 · Cited by 15
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Accountability in the 2015 Global Strategy for Women’s, Children’s and Adolescents’ Health
Schweitzer, J. (2015) · British medical journal · doi:10.1136/bmj.h4248 · Cited by 15
What Can Experiments Tell Us About How to Improve Government Performance?
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Learning (or Not) in Health-Seeking Behavior: Evidence from Rural Tanzania
Corno, L. (2014) · Economic development and cultural change · doi:10.1086/677724 · Cited by 15
Using Field Experiments to Understand Information as an Antidote to Corruption
Winters, M. S., Testa, P. F., & Fredrickson, M. (2012) · Research in experimental economics · doi:10.1108/s0193-2306(2012)0000015010 · Cited by 15
“Although not about corruption per se, Björkman and Svensson (2009) document how the provision of a citizens report card containing information on the performance of health clinics relative to other clinics and national standards resulted in increases in staffing, service provision, and cleanliness of clinics and ultim…”
Participatory Governance and Development: In Search of a Causal Nexus
Coelho, V. S., & Favareto, A. (2011) · Geography Compass · doi:10.1111/j.1749-8198.2011.00446.x · Cited by 15
“Institutional design Three projects – one on participation of rural populations on Health Unit Management Committees in Uganda, another on participatory budget in Brazil, and a third participatory experiment in the area of education in rural zones of Bangladesh – point to the effectiveness of institutional arrangement…”
Kesale, A., Mahonge, C., & Muhanga, M. (2022) · Health Science Reports · doi:10.1002/hsr2.611 · Cited by 14
“Country context and nature of decentralization undertaken by each county are some of the cited reasons for ineffective HFGCs in PHC.(13,14) For instance, Abimbola et al.”
Motivating bureaucrats through social recognition: External validity—A tale of two states
Gauri, V., Jamison, J. C., Mazar, N., & Ozier, O. (2021) · Organizational Behavior and Human Decision Processes · doi:10.1016/j.obhdp.2019.05.005 · Cited by 14
“Consistent with the transparency and decentralization literature (Gonçalves, 2014; Bardhan, 2016; Gauri et al., 2015; Olken, 2007; Björkman and Svensson, 2009), this also suggests that observation from the public may matter.”
Dhungana, N. (2020) · doi:10.17645/pag.v8i4.3154 · Cited by 14
“…to the more confrontational approaches, social accountability also involves citizens and public officials developing collaborative strategies to monitor the delivery of public goods and leverage local information to tackle public-sector underperformance (Björkman & Svensson, 2009; Caseley, 2006).”
Community monitoring and crime: Evidence from Chicago's Safe Passage Program
Gonzalez, R., & Komisarow, S. (2020) · Journal of Public Economics · doi:10.2139/ssrn.3604401 · Cited by 14
Implementing social accountability for contraceptive services: lessons from Uganda
Boydell, V., Nulu, N., Hardee, K., & Gay, J. (2020) · BMC Women's Health · doi:10.1186/s12905-020-01072-9 · Cited by 14
Working Hard or Hardly Working: Health Worker Effort and Health Outcomes
Okeke, E. N. (2019) · Economic Development and Cultural Change · doi:10.1086/706823 · Cited by 13
“Björkman and Svensson (2009) and Gertler and Vermeersch (2012) studied the effects of two interventions—community monitoring and pay for performance in Uganda and Rwanda, respectively—and found that both led to improvements in child health.”
Waddington, H., Sonnenfeld, A., Finetti, J., Gaarder, M., & Stevenson, J. L. (2019) · doi:10.23846/sr00043 · Cited by 14
Community-based approaches for neonatal survival: meta-analyses of randomized trial data
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Participation and Local Governance Outcomes: Evidence from Ukraine
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Jilke, S. (2013) · Public Administration and Development · doi:10.1002/pad.1659 · Cited by 14
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Mogues, T., Campenhout, B. V., Miehe, C., & Kabunga, N. (2023) · World Development · doi:10.1016/j.worlddev.2023.106374 · Cited by 13
Can patients improve the quality of care they receive? Experimental evidence from Senegal
Kovacs, R. J., Lagarde, M., & Cairns, J. (2022) · World Development · doi:10.1016/j.worlddev.2021.105740 · Cited by 13
Mohanan, M., Rajan, V., Swanson, K., & Thirumurthy, H. (2020) · Social Science Research Network · doi:10.2139/ssrn.3544786 · Cited by 13
Institutional Anticorruption in China: Effectiveness on Bribery Incidence
Ni, X., & Su, X. (2018) · Public Administration Review · doi:10.1111/puar.13007 · Cited by 15
The institutional components of political corruption
Golden, M., & Mahdavi, P. (2015) · doi:10.4324/9781315731377.ch28 · Cited by 13
Improved Quantile Inference Via Fixed-Smoothing Asymptotics And Edgeworth Expansion
Kaplan, D. M. (2015) · doi:10.1016/j.jeconom.2014.08.011 · Cited by 13
Abbott, J., McKiernan, K., & McNulty, S. L. (2023) · Comparative Political Studies · doi:10.1177/00104140231178725 · Cited by 12
“These conclusions are consistent with a broader body of scholarship that highlights the positive role played by increased information-sharing about government decision-making in improving governance and well-being (Bj¨orkman and Svensson, 2009; Grossman and Michelitch, 2018).”
Fang, H.-M., Hou, L.-K., Liu, M.-X., Xu, L., & Zhang, P.-F. (2022) · Journal of comparative economics (Print) · doi:10.1016/j.jce.2022.10.002 · Cited by 12
Steyn, P., Cordero, J., Nai, D., Shamba, D., Fuseini, K., Mrema, S., Habib, N., Nguyen, M., & Kiarie, J. (2022) · International Journal for Equity in Health · doi:10.1186/s12939-022-01736-y · Cited by 12
“The Accountability Can Transform Health (ACT Health) scaled up the Power to the People [37] study and found no statistically significant effects on utilization rates and robust null effects on health outcomes, including child mortality [38].”
InfluentialPlaying defense? Health care in the era of Covid
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Tirivanhu, P., Matondi, P. B., & Sun, D. (2016) · Systemic Practice and Action Research · doi:10.1007/s11213-016-9377-4 · Cited by 14
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Does Participatory Budgeting Improve Decentralized Public Service Delivery?
Beuermann, D., & Amelina, M. (2014) · doi:10.18235/0011662 · Cited by 12
How to reach every newborn: three key messages.
Houweling, T., Morrison, J., Azad, K., Manandhar, D., Alcock, G., Shende, S., Tripathy, P., & Costello, A. (2014) · Lancet Global Health · doi:10.1016/s2214-109x(14)70271-2 · Cited by 12
Metadata
- Authors
- Björkman, M., & Svensson, J.
- Affiliations
- Centre for Economic Policy Research (GB)
- Center for Economic and Policy Research (US)
- ORCID
- Svensson, Jakob
- Venue
- Quarterly Journal of Economics
- Publisher
- Oxford University Press (OUP)
- Published
- 2009-05
- Volume
- 124
- Issue
- 2
- Pages
- 735-769
- ISSN
- 0033-5533 (ISSN-L)
- 1531-4650
- OpenAlex
- W3123010330
- Cited by
- 739
- References
- 48
- Citations by year
- 2026: 32 · 2025: 38 · 2024: 28 · 2023: 28 · 2022: 61 · 2021: 66 · 2020: 47 · 2019: 32 · 2018: 41 · 2017: 53 · 2016: 50 · 2015: 52 · 2014: 64 · 2013: 54 · 2012: 36
- FWCI
- 26.07
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Quarterly Journal of Economics (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- Archivio istituzionale della Ricerca - Bocconi (submittedVersion)
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Systems and Reforms
- Social Sciences › Development › Poverty, Education, and Child Welfare
- Keywords
- community-based monitoring, primary care, community participation, village meetings, non-governmental organizations, health care utilization, child mortality, child weight
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