Change from the Bottom Up: Examining the Potential for Citizen-led Action to Improve Health Outcomes

December 9, 2016
T4D community activists in Uganda
Community activists in Tanzania develop health action plans.

A subsistence farmer in Indonesia. A disabled US veteran. An orphaned child living in a Mumbai slum. A woman giving birth in a remote part of Malawi. Each may rely on government services or outside aid agencies to provide basic services like health care or education. But too often these services are inadequate and unresponsive to their needs. Among the many reasons are corruption, inefficiency, and simple lack of dedication and effort — the kinds of problems that too often prove difficult for governments and donors to solve.

How can governments, nongovernmental organizations (NGOs), and civil society organizations (CSOs) faced with these sorts of problems do a better job of being responsive and accountable to the poor? One answer may lie in empowering everyday citizens to advocate for their basic rights, and push for public services to be more responsive and accountable to their needs.

In recent decades, transparency and accountability (T/A) techniques have emerged to address these challenges and alleviate the difficulties they pose to the capabilities, health, and wellbeing of individuals across the globe. Used by NGOs, CSOs, and other players in the development field, T/A techniques begin with data collection and dissemination. Organizations aggregate information on government spending, service provision (or lack thereof), and other relevant metrics like health outcomes and education levels. This information is presented to citizens and government officials in the form of social audits, public expenditure tracking surveys, citizen report cards, absenteeism studies, and community scorecards. The simple idea at their core is that making these data open and available empowers citizens and civil society, helping them diagnose problems and motivating them to push for solutions that improve service delivery in their communities.

Although T/A interventions have come to be widely used within the development sector, there is mixed evidence of their effectiveness, and little to shed light on why they work and in what contexts. In an effort to address this research gap, in 2013, the William and Flora Hewlett Foundation, the Bill & Melinda Gates Foundation, and the Department for International Development in the United Kingdom released a request for proposals — brokered by the Transparency and Accountability Initiative, a donor collaborative — to study the impact of transparency and accountability initiatives on health and other social sector challenges.

Transparency for Development

Archon Fung, Academic Dean of Harvard Kennedy School (HKS); Stephen Kosack, HKS Senior Research Fellow and a professor of public policy at the University of Washington; and Dan Levy, HKS Senior Lecturer in Public Policy; along with Courtney Tolmie and Jean Arkedis from the nonprofit Results for Development Institute (R4D), successfully applied to the foundations’ request and designed an intervention and mixed methods evaluation to explore the conditions by which accountability efforts can improve governance and health-care service delivery. 

The project, Transparency for Development (T4D), is the largest and most rigorous research study ever conducted on T/A interventions. Running from 2013–2018, it currently spans 400 communities in both Indonesia and Tanzania, and is expanding to three additional countries in early 2017. The implementation of the intervention was designed in partnership with two CSOs, the Clinton Health Access Initiative (CHAI) in Tanzania and PATTIRO in Indonesia, in order to leverage their local knowledge and expertise in the areas of health and community engagement.

After carefully assessing a host of public health challenges and service gaps in these countries, the T4D team chose to focus on improving maternal and neonatal health, which aligns with the United Nations Sustainable Development Goals and is an area where health indicators have remained relatively low in many countries. Even more important, maternal and newborn health care is a public service that citizens typically care a great deal about and may be highly motivated to help improve. “Birth is one of the most important moments in life,” reflected Kosack. “When the health-care system fails a mother or child, citizens experience it in very acute ways. It’s they or their sister or wife or baby who is suffering. And when newborn health outcomes are poor, that has long-term implications for the health and wellbeing of the whole community.”

The project employs a mixed methods approach utilizing randomized controlled trials (RCTs) and rigorous qualitative field research to determine whether the intervention was successful, as well as why, and whether success differed in different contexts. In addition to community surveys as part of the RCT, the team is using focus groups, surveys and interviews with participants, and detailed observation of project meetings. Ethnographers also lived in a small subset of communities over the course of the program, to gain a deeper understanding of the village context and of the ways participants experienced the intervention. “This project is designed to shed light on the creative ways in which transparency can empower local communities to improve health information to improve public health outcomes,” said Fung, the project’s principal investigator. “We hope that our approach will create greater insight into the impact of transparency policies and the mechanisms that produce that impact.”

The Intervention in Action

The T4D project, like most RCTs, begins and ends with data collection. Prior to the start of the intervention, the T4D team captured survey data on local health clinics, service utilization by mothers and babies, and community empowerment across treatment villages — those that participated in the intervention — and control villages — those that did not. 

In parallel, CHAI and PATTIRO collected similar data from each intervention village. A survey of mothers who had recently given birth determined their knowledge and usage of maternal and neonatal healthcare services. Health clinic data provided insights into the services offered to mothers and babies in each village, including the availability of pharmaceutical drugs, the presence or absence of key medical staff, cleanliness, and privacy.

After collecting data on each village, community engagement workers for CHAI and PATTIRO, known as facilitators, held a series of meetings to guide the intervention:

  • The facilitators first introduced themselves to village elders and local leaders and provided an overview of T4D’s overall structure and goals.
  • Following this introduction, the facilitators organized two daylong meetings with a small group of community activists selected based on a number of criteria, such as personal interest in maternal and neonatal health, leadership potential, and desire to work on behalf of the community. During the first meeting, the facilitators shared the results of the health clinic and service utilization survey, and informed the community of how they fared compared to country targets. For many citizens, it was a unique opportunity to learn of best practices regarding maternal and neonatal health and discuss both their own experiences and ideas for improving health in their community.
  • During the subsequent meeting, the group identified the top barriers to maternal and newborn health-care provision, which included problems like lack of transportation to attend check-ups, absenteeism on the part of the midwife, the clinic’s disregard for cultural norms, and costs associated with receiving services. The facilitators presented a series of “social action stories,” which demonstrated how other communities had organized to develop concrete steps to confront barriers to care. The group then brainstormed ways to improve service provision and increase utilization for mothers and babies, and created action plans to address the specific barriers in their community.
  • The facilitators returned 30, 60, and 90 days later to meet with the community activists and gauge their progress.

Each action is led by the community members themselves with limited guidance from the facilitators and without monetary support. Though end-line data will not be available until 2018, the project has already shown many promising instances of community members organizing and advocating for improved health-care services.

In many villages, community activists began by implementing education campaigns: going door-to-door and handing out information on what constitutes a good maternal and newborn health-care package, or emphasizing the importance of giving birth in a facility with a trained midwife or medical professional. Many communities established transportation funds for pregnant women to use for check-ups and delivery. Others installed suggestion boxes in their local health-care facility, and some are in the early stages of building new clinics. Absenteeism on the part of the village midwife was a common barrier in many villages, and community activists have come up with a variety of ways to address this issue. 

“Every village has unique health-care challenges,” says Courtney Tolmie, Senior Program Director at R4D and an HKS Research Fellow. “What underlies this intervention is the idea that citizens themselves are in the best position to know, understand, and address the problems impacting their community — far more so than an outsider would be.”

Change from the Bottom Up

Although many T/A interventions work at the level of local government officials, this project is unique in its reliance on everyday citizens to propel change in their communities. “The problems that contribute to poor maternal and neonatal health outcomes often manifest at the hyper-local level,” says Tolmie. “For T4D, we really wanted to put the power in the hands of the community members who suffer the most from poor service delivery.” Furthermore, the intervention itself was designed jointly through collaboration between the university-based researchers and NGOs in Indonesia and Tanzania.

It is the T4D team’s hope that the grassroots nature of the intervention continues to benefit the villages beyond the point of end-line data collection and the issue of maternal and newborn health. “What we are trying to do is empower citizens and build a sustainable, long-term solution that will encourage these communities to organize and advocate for themselves,” said Kosack.

Designed to advance the theory and practice of transparency and accountability interventions, T4D has the potential to shed light on the connections between transparency, participation, and government accountability; the pathways between them that lead to improved government services; and the differences in place that impact those pathways. “For the CSOs and NGOs engaged in T/A techniques, this project will provide nuance and detail into how and under what conditions they are effective,” says Jessica Creighton, Assistant Director of the T4D project. “In regions of the world where resources are scarce, it’s critical to find the most effective and sustainable means of making peoples’ lives better.”