In the past two decades, development policy has aimed to involve communities in the development process by encouraging the active participation of communities in the design and implementation of projects or the allocation of local resources. The World Bank alone has provided more than $85 billion for participatory development since the early 2000s.
The prevailing view is that through community engagement, development projects will better reflect local preferences and communities can improve their capacity for monitoring and evaluating public service providers. However, it has been difficult to empirically measure the effectiveness of these initiatives, in part because participation is typically happening alongside many other interventions.
Our recent paper addresses the question of whether participation, by itself, is an effective development tool. We ask: does participation increase accountability? We find that community engagement leads to improved service delivery by community-based public health workers, and in turn, better health outcomes, among women and children in the community.
For this study, we exploit the timing of a social mobilization program in rural Pakistan. The randomized intervention mobilizes citizens into grassroots organizations that appoint representatives to a village-level institution with the authority to decide on village development priorities and, eventually, allocate resources toward these goals. The program encouraged high-levels of participation by the community (with at least 40% of households per village participating) and focused specifically on increasing participation by women. For the first three years of the intervention, only social mobilization activities occurred. Therefore, by assessing impacts at the three-year mark, we can isolate the impact of community social mobilization efforts from the injection of resources or other inputs.
We examine the program’s impact on the performance and accountability of local health care providers. Villages in this study are characterized by relatively high levels of maternal and child mortality and malnutrition, and women have identified access to primary care as a critical need for themselves and their children. There are two main types of public health care providers available. First, community-based Lady Health Workers (LHWs) provide basic maternal and child health services, including pre- and post-natal care, well-baby visits to check infant health and growth, child immunizations, family planning advice, and health education. LHWs serve as the first access point to public health care, and all villages are supposed to have a dedicated LHW. Villagers also have access to primary care facilities, called Basic Health Units (BHUs), though these facilities are more spread out—most individuals must travel outside their village to receive care at the closest BHU.
In mobilized villages, we find significant improvements in service delivery and health outcomes under the purview of the LHW. Not only are these villages more likely to have an assigned LHW, but in addition, new mothers are more likely to see a LHW, utilize post-natal care, and receive well-baby visits from the LHW. Young children in these villages are also more likely to have an immunization card.
We also examine effects of village mobilization at the BHU-level, but find few significant effects. Individuals from treated villages that visited the BHU experienced shorter wait times, and pregnant women were more likely to register their pregnancy at the BHU. However, this latter effect may be attributed to LHW performance since they refer pregnant women to the BHU for pre-natal care. That treatment effects are stronger for LHWs compared to BHUs suggests that women can more effectively monitor locally-based providers that are from the community and therefore more accessible.
It is important to note that the social mobilization intervention did not focus on health-related issues and that no information was provided to community members on the performance of local public health workers. It is therefore noteworthy that we find significant effects of community mobilization on public health service providers although that was not the focus of the intervention.
Our results suggest that while community collective action is not a panacea for improving all levels of public service delivery, it can be quite effective in improving aspects of service delivery where community members have enforcement and monitoring capacity. Furthermore, the active engagement of women can have important payoffs in improved service provision targeting the needs of women and young children.
The original article was published as part of the World Bank’s Policy Research Working Paper Series. You can find the full article here.
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