# clinics.

We attribute the effects on Ebola reporting to improved perceptions in the quality of care and greater trust and confidence in the government health system. The medium-run effects on satisfaction and utilization are also present in the subset of clinics used in our Ebola analysis. Moreover, we find that individuals in both treatments express greater confidence in western medicine in our endline survey relative to traditional and spiritual healers, the principal alternatives to government clinics in rural Sierra Leone. We combine our measures of utilization, satisfaction with public health workers, and the relative efficacy of western medicine, into a perceived quality of care index. Instrumenting that index with our treatment, we find that a one standard deviation change in the perceived quality of care increases total reported cases by 0.43 per section-week.

We do not find support for two alternative explanations. First, the interventions do not appear to have increased actual Ebola transmission. We find that all types of cases, including patients with both confirmed and negative test results, increase in sections with treated clinics. As a consequence, the ratio of confirmed to total cases does not change with treatment. To rule out contagion within clinics, we investigate whether confirmed cases test positive due to exposure that may have occurred upon reporting (e.g., through contact in a waiting room). We can rule out such nosocomial transmission (i.e., exposure originating in a clinical setting) in 99 percent of cases, based on the timing symptom onset and reporting. Second, we also do not find that sections with treated clinics have more resources for top-down surveillance: sections with treated clinics do not host more facilities specializing in Ebola care, and there are no differences in laboratory testing or case workers. If anything, we find that a higher proportion of confirmed cases undergo contact tracing (i.e., the process of identifying recent contacts to flag at-risk individuals) in sections with control clinics.

Our results highlight two important points. First, accountability interventions can improve health systems and health outcomes by increasing the perceived quality of care, and by building trust and confidence in health providers. Second, perceived quality of care and confidence in the health system may become especially important during crises, when individuals face a choice about whether to cooperate with response efforts, such as heeding an evacuation order, honoring a quarantine, or voluntarily reporting for medical testing. Experts argue that low confidence in health systems undermines efforts to contain the current outbreak of the novel coronavirus (COVID-19), which has already infected over 95,000 individuals globally.<sup>5</sup> In addition, trust in government has been shown to be correlated with the decision to utilize care during the Ebola crises of Liberia (Blair et al. 2017; Morse et al. 2016; Tsai et al. 2019) and the DRC (Vinck et al. 2019) — claims which mirror recent evidence showing that fear and distrust deter patients from utilizing

> 5 Wen (2020) writes, “A robust response [to COVID-19] from medical and public health practitioners has already begun. But for any response to be effective, people need to heed government officials’ orders, and for that, they must have faith that their leaders know what they’re doing and have the citizens’ best interests at heart.” In China, fears of under-reporting have led officials to adopt intrusive monitoring strategies (Mozur 2020) and begin offering large cash payments to patients who report, with one city reportedly offering over 1,400 USD to a patient who later tests positive (Bostock 2020).

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