India: Impact of Social Accountability Interventions on Healthcare Delivery and Health Outcomes in Uttar Pradesh, India

Across the developing world, public health systems struggle to provide high-quality care to the populations they are tasked to serve. But compounding low budget constraints is a lack of accountability, as well as high rates of worker absenteeism. Policy makers and researchers are evaluating innovative ways to boost both the quality and quantity of health services. One possibility is giving health care consumers more information about the quality of care they’re receiving to improve transparency and increase demand for better services. Another possibility is giving patients a forum to channel complaints directly to providers to improve accountable. This evaluation will provide evidence about the effectiveness of such community-driven interventions.

Research area: Health

Country: India  

Evaluation Sample: 120 Gram Panchayats (rural local governments) in two districts in Uttar Pradesh

Timeline: 2014 – 2019

Intervention: accountability, increased civic engagement 

Researchers: Manoj Mohanan, Duke University; Harsha Thirumurthy, University of North Carolina, Chapel Hill

Context

Uttar Pradesh, India’s largest state, with a population of more than 200 million, has among the lowest per-capita incomes in the country. Infant and child mortality rates are especially high and some 380,000 children under the age of five die every year. The Government of Uttar Pradesh, which seeks to improve its health care system, will be piloting social accountability interventions and considering them for scale-up as part of a World Bank-supported project. Researchers are working with the government to evaluate the effectiveness of these campaigns, which will provide policy makers with guidance on how best to implement change in the state’s health system on a large scale. 

Intervention and evaluation

Intervention

The World Bank-supported Uttar Pradesh Health Systems Strengthening Project aims to introduce and strengthen social accountability interventions in order to stimulate community action to demand better services, enhance positive health behavior and promote social audits of service delivery and resource allocation. The interventions include two key components: the provision of information and the active engagement of community members. 

Evaluation

The Uttar Pradesh State Government has selected 12 districts (out of 75 districts in the state) in which the pilot social accountability interventions will be implemented. The project will focus on rural areas and the interventions will be implemented in 80 randomly selected Gram Panchayats (rural local governments). These interventions will focus on services delivered by village-level health workers, including those providing primary care and maternal and child health services. The households surveyed in the project include those with children under the age of five. The evaluation will measure the impact on health outcomes and health service delivery.

The evaluation will randomize 120 Gram Panchayats: 40 in the first treatment arm, 40 in the second treatment arm, and the remaining 40 in the control. In each Gram Panchayat, the evaluation will randomly select one village for the intervention. There will be a baseline survey of households in the 120 Gram Panchayats and a follow-up survey with the same households approximately 12 months after the baseline survey.

The first treatment arm is an information and awareness campaign, in which community members will receive information about their rights, the responsibilities of health care providers, and local health system performance. Community members will also be given score cards that detail available health services and their village’s specific health outcomes.  In addition, they will receive regular text messages about a specific health issue or health indicator.

The second treatment arm includes an engagement component, whereby community members monitor health systems, address concerns to village representatives, and participate in preparing a village score card that rates the quality of the health services they receive. Researchers will evaluate whether increased monitoring from community members and public reporting of their findings improves responsiveness of providers. Specifically, they will determine whether health providers become more accountable, and whether the program influences health care and residents’ health.

Policy impacts

The evidence will give the Uttar Pradesh government guidance on how to expand the program at scale to provide better health care across the state to the people who need it most. The evidence can be used to inform policy in other Indian states, as well as in other countries across the globe that struggle with accountability and seek innovative ways to boost the quality of the health care they provide.  The evidence will also contribute to the understanding of the feasibility and effectiveness of interventions that aim to mobilize communities to demand— and receive— better health services. In addition, it has the potential to shed light on whether simply providing information about service availability and health care performance can result in better health service delivery and ultimately, better health outcomes—or whether additional interventions that bring together citizens and providers are needed.