Originally posted here (Google+).
I’m reading loads of stuff about community based monitoring of health services, like community scorecards of health worker performance (Bjorkman, M. and J. Svensson (2007). Power to the People: Evidence from a Randomized Field Experiment of a Community-Based Monitoring Project in Uganda, http://vle.worldbank.org/bnpp/en/publications/governance/power-people-evidence-randomized-field-experiment-community-based-monitoring) and community monitoring of diseases (Maes, E. and S. Zimicki (2000), http://www.aed.org/Publications/upload/GhanaCBSEvalrep_3-00.pdf). In both cases lay community members are trained to participate in the monitoring process. The first reference is an RCT which showed significant results in improving the quality of care.
It’s obvious that for an approach like this to work, whatever is being monitored needs to be objectively measurable. What I also assume, though, is that it is also important that whatever is being monitored needs to matter to the people doing the monitoring. In the first example, things like waiting times, availability of health care personnel – I’m pretty sure they matter. In the second example, the specific diseases being monitored were fairly common and “felt”, so I reckon they mattered too.On the other hand I’ve seen a few community monitoring projects where communities are encouraged to monitor things that they probably don’t really care about. Things like immunization rates or mosquito net usage rates (as opposed to the positive outcomes of these). And because they don’t care, they have to be given some other sort of externally provided incentive to do the monitoring like, for instance, a community party being thrown for them if they hit their targets. I understand the importance of incentives and of using them creatively but I reckon, as much as possible, it is probably preferable to try and find incentives within the positive impacts of what people are doing (i.e. my incentive is that I get better care) rather than relying too much on unrelated ones (i.e. I worked to improve health care so that I could get a free t-shirt). The other thing is, a lot of discussions of this problem focus on a particular issue: the notion that “national” or “donor” priorities are imposed on communities and that as a result communities are forced to monitor things that are not important to them. (See for instance O’Meara, W. P., B. Tsofa, et al. (2011). “Community and facility-level engagement in planning and budgeting for the government health sector–a district perspective from Kenya.”, http://www.hubmed.org/display.cgi?uids=20888061). This is a problem, but it’s also a reality that sometimes, a national point of view can reveal things that a community one cannot. Patterns of HIV infection, with its long latency period and its tendency to affect marginalised groups and behaviours, are more easily picked up in national surveys than in local conversations. It doesn’t make the problem any less real.