By Ciro Avitabile
DOCTORA

There is no way around it, when people aren’t well incentivized to do their jobs (with monetary or non-monetary incentives) the quality of the work decreases. This happens to be the case in many developing countries with teachers and doctors. The lack of appropriate incentives translates into higher absenteeism and less dedication to their jobs. Economists have long tried to understand how to improve the quality of services in contexts where professionals receive low salaries and the quality of the institutional supervision is poor.

Both academics and policy makers have advocated the idea that local communities can contribute to improving the quality of social services by monitoring the actions of education and health professionals through organized groups of parents and patients by constantly supervising and giving feedback to the professionals. As a result, many projects that are designed to induce local communities to speak-up have recently been implemented. Does this type of community monitoring work? Let’s look at the evidence.

Most places where community monitoring programs have failed are characterized either by large socio-economic disparities or deep ethnic fractionalization. Socio-economic and ethnic elites tend to render the action of community groups ineffective. But this is not the case in Nicaragua, a country with a strong tradition of community participation.

The IDB is now working on an evaluation to better understand the outcomes of a project on Early Childhood Development carried out by the Government of Nicaragua. The program’s objective is to provide all children aged between 0 and 6 and their families with a home stimulation visit to improve the measures of cognitive and non-cognitive development. The evaluation was designed not only to help us understand whether the home visits are an effective tool for the Nicaraguan children but also to answer the question of whether community supervision can increase the effectiveness of the home visits.

As part of the impact evaluation, 200 communities will be randomly selected into groups. Three of these groups will receive the home visits and one will only do it at a later stage so it serves as a control group. Among the communities receiving the home visits, three strategies for monitoring home visitors’ work will be tested: (a) no monitoring, (b) families’ feedback through bimonthly meetings and a permanent suggestions box, and (c) random checks carried out by an external party.

The visits will be conducted by professionals from three ministries (Health, Education and Family) on a voluntary basis outside their normal work hours. Parents, home visitors and community organizations will come together to discuss the positive and negative aspects of the visits and will lay out an action plan. The content of these meetings will be monitored and the topics will be based on suggestions from parents.

Even though many community monitoring programs have failed, we have reasons to believe that Nicaragua might be a place where organized local groups can actually help improve the effectiveness of childhood programs. Since home visitors provide the service on a voluntary basis, they cannot be fired if their performance is ranked poorly. Nor can they be paid more if they rank well. Nevertheless, the wish to be acknowledged as a good educator in her/his own community might be a sufficiently motivating incentive to encourage the volunteers to do a good job and follow the program’s guidelines.

The study will reveal whether community feedback in Nicaragua can improve the quality of services delivered by the practitioners. Early childhood programs need to be scaled up, but the cost is high for low-income countries and the answer about how to make them more cost- effective might be right before our eyes.

Ciro Avitabile is a consultant in the Social Protection and Health Division at the IDB in Washington, DC. Ciro’s interests include the design of impact evaluations and analysis of the socio-economic determinants of health decisions.

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