# 7.2 Processes

The initial phase of the project, i.e., the three separate meetings, followed a pre-design structure. A parallel system (visit by a member of the survey team) also con...rmed that this initial phase of the intervention was properly implemented. After these initial meetings, it was up to the community to sustain and lead the process that the intervention intended to initiate. In this section, we present some evidence on this ...rst component in the accountability chain depicted in ...gure 2; namely if the treatment communities become more involved in monitoring the providers.

To avoid in‡uencing local initiatives, the parallel system was only in place during the ...rst round of meetings. Therefore, we are not able to document all actions taken by the communities in response to the intervention. Still, we have two sources of information on how processes in the community have changed. First, the CBOs submitted reports on what type of changes they observed. This evidence is complemented by facility and household survey data as well as data assembled through a local council survey.

According to the CBO reports, the community-based monitoring process that followed the ...rst set of meetings was a joint e¤ort mainly managed by the local councils, HUMC (Health Unit Management Committee) and community members. In the communities, the performance of the health facility was discussed during village meetings. The local council survey also con...rms this. A typical village in the treatment group had, on average, six local council meetings in 2005. In those meetings, 89 percent of the villages discussed issues concerning the project health facility. The main subject of discussion in the villages concerned the community contract or parts of it, such as behavior of the sta¤.

The CBOs report that concerns raised by the village members were carried forward by the local council to the health facility or the HUMC. However, although the HUMC is an entity that should play an important role in monitoring the provider, it was in many cases viewed as being ine¤ective. As a result, mismanaged HUMCs were dissolved and new members elected, while others felt the pressure from the community to act and follow up on the issues covered in the community contract. These claims are also con...rmed in the survey data: More than one third of the HUMCs in the treatment communities were dissolved and new elected or received new members following the intervention. In the control communities, we observe no dissolved HUMC. Further, the CBOs report that the community also monitored the health facility sta¤ during health visits to the clinic, when they rewarded and questioned issues in the community contract which had or had not been addressed, suggesting a more systematic use of non-pecuniary rewards. Tools such as suggestion boxes (where community members could anonymously leave suggestions for change or comment on the lack of change that was supposed to have taken place), numbered waiting cards (to ensure a ...rst-come...rst serve basis), and duty roasters, were also reported to be put in place in several treatment facilities.

In table 2, we formally look at the program impact on these processes. We use data collected through visual checks by enumerators during the post-intervention survey.

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