If only you knew the power of nagging

Give quiche a chance

I’m naturally a bit skeptical of ground-level interventions that don’t involve cash, needles or textbooks. Anything that involves dubiously-titled training or “empowerment”¬† sets off my very cynical alarm bells. However, I’m beginning to be persuaded by the evidence that targeted information campaigns work.

First there was Pedro Vicente and Paul Collier’s study on a randomised anti-violence campaign staged prior to the 2007 Nigerian elections, showing significant reductions in the treated districts. Then there was the Heckle and Chide’s study of minibuses in Kenya: a random treatment group were given posters advising passengers to speak up if the minibus drivers drove dangerously (which is pretty much what minibus drivers are born to do). The treatment group saw sizable declines in insurance claims, including those for injury and death.

Now there is a soon-to-be-published paper by Martina Björkman and Jakob Svensson, offering a unique randomised intervention:

  1. Assess local health providers and inform the communities on their relative performance using ‘report cards’,
  2. Encourage these communities to form groups to monitor local health performance.
  3. Sit back and see what happens.

A year after the intervention, a repeat study revealed that the treated communities had: harder working health providers, higher rates of immunization and significantly reduced rates of child mortality and underweight children, all with the same levels of funding.

The best part of the study was the lack of investigation into what the communities were doing to make changes – (there is some rough evidence that the communities were more active in electing and dissolving the local provider management committees). My guess is that a fair amount of nagging was involved.

I’ve come to believe that a crucial part of development is strengthening the accountability link between citizens and their government (not to be confused with enforcing accountability externally), especially when the citizens face a trade-off for enforcement (in this situation, that trade-off is time spent hassling health workers).

A few questions remain:¬† is it persistent (or would health workers become more resistant to this informal accountability over time?) Is this scalable? Which part of the intervention was key: the information transfer allowing for yardstick comparisons between district, or the “empowerment” workshops? My hunch is the former.

(Bonus points to those that got the Red Dwarf reference).