Accountability Can Transform (ACT) Health: A Randomized Evaluation of a Community-Based Monitoring Program of Healthcare Providers in Uganda

In the interest of faithfully replicating Power to the People (P2P), the intervention was designed to match the P2P protocols as closely as possible, with modifications made as necessary to accommodate the factorial design we employ. Whereas P2P had just two treatment arms (full treatment and control), ours has four: 1) full replication of P2P (information dissemination to community and health center staff; mobilization of and development of action plans by community and health center staff; and holding of interface meetings between community members and health center staff); 2) information dissemination and mobilization only; 3) interface only; 4) control.

Prior to the start of the intervention, baseline data was collected in each of the 379 study health centers and in their catchment areas. This information was summarized in a Citizen Report Card (designed to match that used in P2P), and was disseminated during the intervention in treatment arms 1 and 2. As in P2P, we partnered with local NGOs to disseminate this report card information to citizens and to work with them over several days to inform them of their rights and entitlements and to develop an action plan in light of this information. As in P2P, the local NGOs also worked with clinic staff to present and explain the results of the report card and to develop an action plan. In treatment arms 1 and 3 (full P2P replication and interface only), the local NGO also organized meetings between health facility staff and representatives of the local community to discuss how to proceed in light of the action plans developed by each party.

As in P2P, the main intervention was supplemented in each (non-control) treatment arm with half-day follow-up meetings every six months for community members and health workers to enable participants to track the implementation of the action plan, determine new areas of concern, and come up with a new set of recommendations for improvement of local health services.

Midline data (using the same instruments employed at baseline, with some additional questions to better ascertain the quality of treatment take-up and to help understand the mechanisms at work in generating treatment effects) are collected 12 months after the baseline data. Endline data is then collected again at 24 months. Since P2P reported treatment effects at 12 months, the main replication of P2P involves a comparison of baseline and midline data. A comparison of baseline and endline data provides an opportunity for assessing the longer-term effects of the intervention(s).

For further details, please see the PAP.

2014-09-15

2017-12-31

Since the objective of the study is to (1) replicate the original Power to the People study by Björkman and Svensson (2009) and (2) to disentangle the mechanisms through which their bundled intervention had such a large treatment effect, the main outcome measures we will collect come directly from the original Power to the People study. We also introduce a set of improved dependent variables. See PAP for details.

Process outcomes:
-Number of facilities with suggestion boxes, numbered waiting lists, posted free ser-vices, and posters describing patient rights and responsibilities
-Performance of health center staff more often discussed in village meetings
-Household awareness of roles and responsibilities of health unit management commit-tee

Treatment practices and management outcomes:
-Any equipment used during examination, waiting time (total time spent at facility per visit), absence rate (% of staff absent), condition of clinic (clean floor, clean walls, no smell of urine etc.), % of HH have received info on importance of visiting facility rather than self-medicating, % of HH that have received info on importance of family planning, share of months in which stock cards indicated no availability of drugs (e.g., five key tracer drugs; HCT kits, ARVs, if applicable)
-Vaccination rates of children under 5 for polio, DPT, BCG, and measles; provision of vitamin A supplements
-Number of patients receiving different services (deliveries, outpatient, etc.), based on institutional records & household data

Health outcomes:
-Births, pregnancies and death of children under 5
-Weight of all infants (under 18 months) and children (18 to 36 months) in sampled the household.

We employ a factorial design to replicate the Power to the People study and also break its complex treatment into two of its principal components: 1) the provision of information about health delivery quality to citizens and clinic staff and the mobilization of these actors in light of this information and 2) the holding of interface meetings between community members and clinic staff in which the action plans they each develop can be discussed and coordinated. 379 health facilities (and associated catchment areas) are randomized to receive each part of the treatment (or, in some cases, both together, as in P2P).

Health centers are randomly assigned to one of four conditions:
1) Full ACT Health program implemented by GOAL Uganda, replicating the Power to the People intervention
2) Provision of citizen report cards on health center performance but without the interface meeting between community members and healthcare workers
3) Interface meetings between the community members and healthcare workers but without the provision of citizen report cards and separate meetings of healthcare workers and citizens
4) Status quo

See the PAP for further details.

The randomization of health centers (and their respective catchment areas) to one of the four treatment groups was conducted using STATA.

The unit of randomization is the health center and respective catchment area.

Yes

379 health center catchment areas

15,360 households

Approximately 94 health center catchment areas in each of the three treatment groups and the control. See PAP for further details.

Pre-analysis Plan