later stage. At the same time, it is possible that the treatment communities’ability to coordinate citizen actions has also been applied to other areas of concern (education, local road construction, etc.), in which case the aggregate return is even larger than what the above results suggest. It is also possible that even better results can be achieved by combining bottom-up monitoring with a top-down approach (supervision and possibly sanctions/rewards from someone in the institutional hierarchy assigned to monitor and control the primary health care providers).

Before scaling up, it is also important to subject the project to a cost-bene...t analysis and relate the cost-bene...t outcomes to other possible interventions. This would require putting a value on the improvements we have documented. To provide a ‡avor of such a cost-bene...t analysis, consider the ...ndings on averting the death of a child under ...ve. The intervention resulted in 1.7 percentage points fewer child deaths in the treatment communities during the ...rst project year. To the extent that this number is representative of the total treatment population, this would imply that approximately 550 under-...ve deaths were averted as a result of the intervention. A back-of-the-envelope calculation then suggests that the intervention, only judged on the cost per death averted, must be considered to be fairly cost-e¤ective. The estimated cost of averting the death of a child under ...ve is around $300 in the Citizen report card project. This can be compared to the numbers reported by Filmer and Pritchett (1999). They contrast the cost of averting the death of a child derived from increasing public expenditures on health (regression estimates range from $47,112 to $100,927), to more conventional health interventions based on cost-e¤ectiveness estimates of the minimum required cost to avert a death (ranges from $1,000 to $10,000 for diarrheal diseases, from $379 to $1,610 for acute respiratory infection, $78 to $990 for malaria, and $836-$3,967 for complications of pregnancy).<sup>40</sup> The Citizen report card project was implemented in nine di¤erent districts of Uganda and reached approximately 55,000 households. Thus, in this dimension, the project has already shown that it can be brought to scale. Still, this project is a controlled experiment in some dimension. Speci...cally, data collection and data analyses were supervised by the evaluators. To the extent that these tasks were delegated to local actors in the various communities, they could have been subject to capture. This is an issue on which our ...ndings do not shed any light. What our ...ndings strongly suggest, though, is that experimentation and evaluation of new tools to enhance accountability should be an integral part of the research agenda on improving the outcomes of social services. This is an area where at present, research on what works and what does not is lagging behind policy.

> 40These numbers should be viewed with caution. Naturally, the 95 percent con...dence interval would also include a much smaller estimate of program impact than the 1.7 percentage points used here. Moreover, since the largest cost item was the collection of data and these data were partly used in the intervention and partly to evaluate impact, the cost is a rough estimate. Filmer and Pritchett’s (1999) estimates of the cost of averting a child death derived from increasing public expenditures on health are subject to a variety of estimation problems and the health interventions based cost-e¤ectiveness estimates of the minimum required cost to avert a death are, as noted by Filmer and Pritchett, at best suggestive.

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