Effect of Social Accountability on Improving Service Delivery and Outcomes in the Public Sector: a Cluster-Randomized Control Trial in Uttar Pradesh, India

The World Bank-supported Uttar Pradesh Health System Strengthening Project (UPHSSP) includes a component that calls for the implementation of social accountability (SA) interventions in UP, which aim to stimulate community action to demand better services, enhance positive health behavior and promote social audits of service delivery and resource allocation. Two key channels through which SA interventions operate are through (a) information provision and (b) fostering community engagement that enables grievance redressal. Prior to the implementation of SA interventions at scale in UP, this study aims to conduct rigorous impact evaluation of key components of SA interventions in order to learn about potential impact in the UP context and to learn about critical implementation issues regarding optimal methods to deliver information in the state with available technology and social networks.

The evaluation's overarching research questions are whether SA interventions in UP improve (1) objective measures of health service quality in practice, (2) village-level satisfaction with health services, and (3) village-level health outcomes. Importantly, the evaluation will seek to identify whether the information provision that is a standard part of social accountability interventions has an independent effect on outcomes that is comparable to the effect of the combined information and community engagement components. The investigators also test the effectiveness of alternative models of delivering information in order to inform implementation of accountability interventions at large scale in public policy settings. Given that the community health workers targeted by the intervention focus on maternal and child health, our measures of health system performance along these three dimensions will also emphasize maternal and child health. Measures of health service quality include availability of services such as immunization and primary care services, distribution of food and nutritional supplementation as recommended in the national nutrition program, and provider absenteeism. Measures of satisfaction with local health services will include process measures including availability of service, waiting time for services and whether or not community members perceive that they are treated by providers with respect as well as general subjective assessments of satisfaction with services. Health outcome measures will include child anthropometrics (weight-for-age and weight-for-height), self-reported morbidity in the preceding two weeks (diarrhea, cough, fever, headache, days of usual activities lost due to illness), and neonatal (0-28 days), infant (under age one), and child (under age five) mortality as well as maternal health indicators such as percentage of facility deliveries among mothers who gave birth in the past year.

Within the 2 study districts (Sultanpur and Fatehpur), in 120 villages that were selected at random, the SA interventions aim to distinguish the effect of provision of information and facilitated engagement of community members, from that of the effect of information alone. The 120 villages are randomized to either a control arm, or one of two treatment arms described below.

TREATMENT ARM 1 - Information & Awareness:

Community members will receive information about their rights, roles and responsibilities of healthcare providers, and also about health-related activities and programs taking place in their village. Importantly, besides assessing the effect of providing information on health service delivery and various health outcomes, our evaluation will also determine how best to provide the information.