We evaluated the effectiveness of a smartphone absence monitoring technology in reducing doctor absenteeism at clinics in Punjab, Pakistan. In partnership with the Government of Punjab, we conducted a randomized evaluation of a smartphone attendance monitoring application to determine a) whether technology-based monitoring can improve health worker attendance and b) whether the impact of monitoring depends on the degree of political competition in a given area.
In 2011, the Government of Punjab introduced the "Monitoring the Monitors" program, which replaced the paper-based monitoring system with an android-based smartphone application that could transmit data on facility utilization, resource availability, and worker absence to a central database in real time. The application ensured accuracy by requiring all data to be geotagged, time-stamped, and accompanied by photographs of the health staff and inspector. Clinics where three or more health staff were absent were highlighted in red on an online dashboard, and we measured whether senior health officials responded to this information.
In order to measure the relationship between doctor attendance and political patronage, we constructed an index of political competition using data from the 2008 Punjab Provincial Assembly elections. The index classified constituencies as having low, medium, or high degrees of political competition depending on the vote share for each political party. From a representative sample of 850 health clinics in 35 districts of Punjab, we randomly selected 427 clinics in 18 districts to receive the smartphone monitoring program. The rest of the clinics served as the comparison group and continued to use the paper-based monitoring system. We ensured that treatment and comparison districts had a comparable number of constituencies classified as having high, medium, or low levels of political competition. We collected clinic-level data through three unannounced visits in November 2011, June 2012, and October 2012.