Child mortality rates in sub-Saharan Africa are among the highest in the world. A majority of these deaths are caused by preventable and/or treatable illnesses. While there are many possible explanations for the high child mortality rates in this region, recent research points to poor monitoring systems of health care providers and low accountability of these providers as a potential explanation for the poor health outcomes.

A 2009 study in The Quarterly Journal of Economics titled “Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda,” assesses whether the use of community-based health care monitoring in Uganda increases the level and quality of health care, thereby improving health outcomes.

Using a sample of 50 public primary-care facilities in rural areas, with 25 facilities each assigned to the treatment and control groups, the study’s authors — from Stockholm University and Bocconi University — sought to increase the participation of rural Ugandans in monitoring health care service providers. The effort involved having local non-governmental organizations facilitate “two rounds of community meetings … aimed at energizing the community and agreeing on actions to improve service provision.” Data was collected through surveys of health care workers and users before the intervention and one year later.

The study’s findings include:

• Qualitative and quantitative evidence suggests that the communities that received the intervention “become more involved in monitoring the provider.”
• This increased monitoring had several positive effects on the quality of care, including decreased absenteeism of health care workers in the treatment group, improvement of preventative care practices in the treatment group (including increased dissemination about the dangers of self-treatment and better information about family planning), and less drug leakage in the treatment group, as compared with the control group.
• The intervention had a positive effect on the quantity of care: “Utilization (for general outpatient services) is 20% higher in the treatment facilities” one year into the project.
• The intervention also had a positive effect on a number of health indicators, including a 33% reduction in child mortality and increased weight for infants in the treatment group compared to the control groups.

“Although the results in the paper suggest that community monitoring can play an important role in improving service delivery when traditional top-down supervision is ineffective, there are still a number of outstanding questions,” the authors conclude. These questions include whether or not community-based intervention has a positive long-term effect on quantity and quality of care as well as health outcomes. The authors also note that more research is needed to determine if a combination of top-down reform and community-based intervention would yield more promising results than the intervention in the study.