systems, to make them more resilient to crises? The Lancet Global Health Commission focuses attention on two groups: patients — who must be “accountability agents, able to hold health system actors to account” — and providers: “Demotivated providers cannot contribute to a high-quality health system...[Resilience] requires accountable leaders who respect and motivate their frontline staff” (Kruk et al. 2018, e1200).

These recommendations echo claims in personnel economics about how to motivate difficult-to-monitor frontline workers (Finan et al. 2017). While the principal-agent model makes clear how financial incentives can induce effort, performance pay may not always be feasible under resource constraints. Moreover, if frontline health workers perceive intrinsic benefits from their work, financial rewards may crowd out intrinsic motivation (Benabou and Tirole 2003; Besley and Ghatak 2005; Dixit et al. 2002). Fortunately, non-financial approaches to motivating workers also exist. Organizations can harness social incentives that arise from interactions between providers and clients, or among providers themselves (Besley and Ghatak 2005; Ashraf and Bandiera 2018). For example, competition can be engendered among health workers as an alternate route for improving effort. Empowering citizens with monitoring tools to hold providers accountable can serve as another lever (Mansuri and Rao 2003).

We evaluate these two ideas using a field experiment implemented just before the Ebola outbreak in Sierra Leone.<sup>2</sup> In partnership with the Government of Sierra Leone (GoSL) and 3 international NGOs, we randomly assigned two interventions (and control) to 254 government-run health clinics.<sup>3</sup> The timing of the experiment relative to the Ebola epidemic affords us a unique opportunity to measure the effects of these interventions under business-as-usual and crisis conditions. Unlike past studies, we can observe whether the interventions contribute to the health system’s resilience — a capacity to respond to crises and changing population needs that we observe only when a system faces an adverse shock.

The first intervention promotes social accountability, providing patients with the information and forum to confront frontline health providers. Modeled on a program evaluated by Björkman and Svensson (2009), the community monitoring (CM) intervention creates scorecards ranking local health services; convenes interface meetings with community members and clinic staff to discuss these ratings and to develop “joint action plans” to improve service delivery; and follows up with meetings to monitor progress after 1, 3, and 9 months. The second intervention motivates clinic staff through a competition that provides non-financial awards (NFA) to the best and most improved clinic in each district. The competition is advertised to clinic staff, who are also revisited three times during implementation to sustain interest. The winners receive a letter of commendation from a high-ranking politician and a plaque or wall clock for the clinic. The interventions do not provide physical inputs to clinics; rather, they attempt to empower patients to demand, and motivate nurses to supply, higher quality care despite resource constraints.

> 2 Endline surveying for our evaluation concluded in June 2013; the first Ebola case was reported in May 2014 (see Figure 2).

> 3 The interventions were funded by the World Bank and implemented by Concern Worldwide, the International Rescue Committee, and Plan International with support from GoSL’s Decentralization Secretariat and the Ministry of Health and Sanitation.

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