Improving the delivery of public services is a pressing policy concern for governments in the developing world. Presently, little is known about the role non-financial incentives could play. This project, a partnership between the IGC, the Government of Sierra Leone (GoSL), and the World Bank, constitutes two interventions into health services in Sierra Leone. The first intervention tackles worker motivation by introducing yardstick competition among health clinics, and providing non-financial awards to facilities that show the largest improvement in performance. The second intervention strengthens bottom-up accountability by disseminating information on the state of health services to communities through a ‘scorecard’, and facilitating meetings between community members and health workers to help them develop joint action plans for improving the provision of health services. Scorecard-based community monitoring efforts have been used successfully in other contexts, including Uganda, but have never been tried in Sierra Leone, or attempted at scale in partnership with the national government.
These interventions will be introduced on the heels of an ambitious national effort to remove user fees for maternal and child health, and are viewed as vehicles for improving provider incentives to ensure that fees no longer continue to be levied in future years. The interventions will be implemented for a period of 12 to 18 months, and rigorously evaluated by researchers from the IGC, in close collaboration with the GoSL and the World Bank, to assess the impact of each intervention on the quantity of health services provided, the fees charged for services, and associated health outcomes. These interventions present a unique opportunity to learn how the provision of basic services can be improved.
Interventions will be evaluated using a randomized controlled trial (RCT), wherein approximately 150 chiefdoms and over 400 health facilities will be randomly allocated to ‘treatment’ and ‘control’ groups. Large-scale quantitative surveys of households and health facilities will measure services provided and utilized, both before and after the interventions have been piloted. Impact will be estimated by comparing the change in health outcomes across the treatment and control groups. Results from the RCT will inform the GoSL and other policymakers of the impact and cost-effectiveness of each intervention, and inform the prospects for national scaling-up.
The baseline data-gathering effort is to be conducted in partnership with the GoSL, which regularly conducts its own national surveys on service delivery. IGC researchers will assist the GoSL in conducting these national surveys and train survey enumerators in the use of CAPI technology. In addition, the data gathered will be used to monitor the immediate impact of an ongoing national policy effort to remove user fees for mothers and children. Data will also be integrated with other national data sources and will assist the government in monitoring and evaluation of the public health sector.