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

Last registered on September 17, 2015

Pre-Trial

Trial Information

General Information

Title
Accountability Can Transform (ACT) Health: A Randomized Evaluation of a Community-Based Monitoring Program of Healthcare Providers in Uganda
RCT ID
AEARCTR-0000771
Initial registration date
September 17, 2015

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
September 17, 2015, 10:01 AM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

Region

Primary Investigator

Affiliation
UCLA

Other Primary Investigator(s)

PI Affiliation
IPA
PI Affiliation
Yale

Additional Trial Information

Status
On going
Start date
2014-08-18
End date
2017-12-31
Secondary IDs
Abstract
Health care delivery at the local level is weak in many developing countries. In many cases, citizens have little information on the quality of the health services that are actually being provided and almost no basis of comparing what they can observe with what they are supposed to be receiving. They also have little sense of what they might do with the information they may have to improve the quality of local health service delivery. Furthermore, frontline health providers themselves may have little sense of how their performance, and the health of the community they serve, compares to that of other health facilities and communities.

This project constitutes a scaled up replication of the “Power to the People” intervention (Björkman and Svensson, 2009; henceforth P2P). P2P collected information about health delivery in local health facilities, distributed this information to citizens and frontline providers in a report card, mobilized citizens and providers in light of this information, and organized meetings in which citizens and providers could jointly discuss how to improve health outcomes in the community. The study reported striking impacts on infant weights, under-5 mortality, community engagement, and other outcomes. Given these extremely large reported effects, there has been strong interest in testing whether the P2P findings replicate at a larger scale.

The present study employs a factorial design to replicate P2P 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. 377 health facilities (and associated catchment areas) are randomized to receive each part of the treatment (or, in some cases, both together, as in P2P).
External Link(s)

Registration Citation

Citation
, , Daniel Posner and Pia Raffler. 2015. "Accountability Can Transform (ACT) Health: A Randomized Evaluation of a Community-Based Monitoring Program of Healthcare Providers in Uganda." AEA RCT Registry. September 17. https://doi.org/10.1257/rct.771
Former Citation
, , Daniel Posner and Pia Raffler. 2015. "Accountability Can Transform (ACT) Health: A Randomized Evaluation of a Community-Based Monitoring Program of Healthcare Providers in Uganda." AEA RCT Registry. September 17. https://www.socialscienceregistry.org/trials/771/history/5305
Sponsors & Partners

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Experimental Details

Interventions

Intervention(s)
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 377 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).
Intervention Start Date
2014-09-15
Intervention End Date
2017-12-31

Primary Outcomes

Primary Outcomes (end points)
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.

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.
Primary Outcomes (explanation)

Secondary Outcomes

Secondary Outcomes (end points)
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
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. 377 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

Experimental Design Details
Randomization Method
The randomization of health centers (and their respective catchment areas) to one of the four treatment groups was conducted using STATA.
Randomization Unit
The unit of randomization is the health center and respective catchment area.
Was the treatment clustered?
Yes

Experiment Characteristics

Sample size: planned number of clusters
377 health center catchment areas
Sample size: planned number of observations
15,360 households
Sample size (or number of clusters) by treatment arms
94 health center catchment areas in each of the three treatment groups and the control.
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB

Institutional Review Boards (IRBs)

IRB Name
A. Uganda National Council for Science and Technology (NARC)
IRB Approval Date
2014-07-31
IRB Approval Number
ARC 157
IRB Name
B. Innovations for Poverty Action IRB - USA
IRB Approval Date
2014-10-10
IRB Approval Number
0497
Analysis Plan

Analysis Plan Documents

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
No
Data Collection Complete
Data Publication

Data Publication

Is public data available?
No

Program Files

Program Files
Reports, Papers & Other Materials

Relevant Paper(s)

Reports & Other Materials