Improving Health Service Delivery Through Community Monitoring and Non-Financial Awards

Context of the Evaluation:

Sierra Leone’s health indicators are among the lowest in the world, and the country’s health system is plagued by such chronic worker absenteeism, resulting in part from a lack of accountability between service providers and patients, and the weak incentives healthworkers face. Alongside a national decentralization program introduced in 2004, the Government of Sierra Leone launched an ambitious policy in 2010 to institute free healthcare for pregnant women, new mothers and children under-five. The policy abolished user fees, while at the same time raising workers’ salaries. However, these reforms occurred without introducing institutional features to improve oversight of health workers or changing underlying incentive systems, leaving the health sector at risk of further weakening in response to rising demand for free health services.

This project evaluates two social accountability interventions aimed at improving health service delivery via community monitoring and the introduction of an incentive scheme to reward worker performance on the basis of non-financial awards. The 254 clinics taking part in the study have been assigned to participate in either intervention or act as a comparison, with one third of clinics allocated to each group.

The community monitoring intervention introduces health scorecards that provide information regarding the state of health care in each community, and facilitates interface meetings between community members and health facility staff. During these meetings, information about the state of healthcare is disseminated via a community scorecard and mutual commitments are made to improve services through a joint action plan addressing areas such as staff absenteeism, maternal mortality and vaccination rates. This framework aims to ensure participatory decision-making and hold both healthcare workers and the community mutually accountable, fostering increased access to and utilization of maternal and child health services. Researchers evaluate whether service quality and quantity improve due to the lower costs of collective action introduced through these meetings and the social accountability contract.  

The second intervention, non-financial incentives,facilitates a yardstick competition among groups of maternal and child health clinics, and rewards workers at the most improved facilities. The relative rankings of clinics on key measures of such as worker absenteeism, staff attitude and charging of illegal fees will be advertised publicly, and staff at winning clinics will receive letters of commendation from high-ranking politicians, and an award at a public ceremony.

The project is being conducted in partnership with the Government of Sierra Leone and the interventions have been designed with a self-sustainable model for scale-up through the Ministry of Health and Sanitation in mind. Researchers will assess the cost-effectiveness of each intervention, as well as their cost-effectiveness relative to one another, and findings will directly inform the government’s decision to scale up these interventions in future years.

Results forthcoming