Ugandaâs laws, policies and health sector strategies codify openings for citizen participation in planning and monitoringgovernment services, yet these spaces are often inaccessible in practice. In response to this, a consortiumof civil society organizations led by GOAL designed and implemented the Accountability Can Transform Health(ACT Health) program in Uganda from 2012 to 2018. This paper draws on program monitoring data, empirical evidence,and supplementary interviews to analyze how and the extent to which the ACT Health multi-level, peoplecenteredadvocacy campaigns strengthened accountability for health from the bottom up.The ACT Health program reviewed in this paper had two distinct phases. Phase 1, from 2014 to 2016, included aseries of CSO-facilitated dialogues between community members and health workers in 282 government healthfacilities. These yielded action plans, which were then reviewed in follow-up meetings every six months. Phase 1was designed to be evaluated through randomized control trial (RCT) research, which tested the impact of citizenreport cards (information) and community-level dialogues on a series of 12 outcome indexes. Given the complexityof health system governance in Uganda, the ACT Health strategy anticipated that issues identified at thecommunity-level would require coordinated citizen action to address bottlenecks above and beyond frontlinehealth centers. After the RCT ended, Phase 2 of the program added a new approach: accompanying networks ofvolunteer grassroots community advocates from 98 health center catchments in 18 districts to organize, design,and deliver multi-level advocacy campaigns. In Phase 2, from 2016 to 2018, 396 community advocates identifiedadvocacy priorities, then planned and delivered advocacy campaigns to a wide range of government officials upto the national level. In 14 districts, communities built advocacy campaigns around the complex issue of healthworker absenteeism.The RCT intervention tested in ACT Health Phase 1 was based on the influential âPower to the Peopleâ researchpublished in 2009, which reported that improved information through citizen report cards and facilitated dialoguesbetween community members and health workers dramatically improved health outcomes (Björkmanand Svensson 2009). While the âPower to the Peopleâ study remains influential in the transparency, participationand accountability field, researchers tested the intervention in 25 health facilities, resulting in a statistically underpoweredRCT.Ten years later, the ACT Health RCT re-tested the intervention in 282 health facilities, increasing thestatistical power of the analysis. The ACT Health RCT findings published in 2019 detected modest improvementsin âtreatment qualityâ and âpatient satisfactionâ, but found no evidence of improved health outcomes reportedin the original âPower to the Peopleâ research a decade earlier (Raffler, Posner, and Parkerson 2019). The presentpaper reviews the ACT Health RCT findings, unpacking how key outcome measures such as âcommunity monitoringâwere operationalized and exploring the limits of the relatively âlight touchâ approach tested.Support to collective, multi-level advocacy campaigns in Phase 2 of the ACT Health program was part of the strategyfrom the beginningâit was neither tied to nor contingent upon the RCT findings from the Phase 1 intervention.Starting in 2016, community advocates (selected by other community members) collected data throughdirect monitoring of health facilities, analyzed that data, developed petitions, recruited allies, mobilized resources,organized collective actions, and directly engaged government officials from the village to the national level. CSOstaff helped community advocates conduct their own political economy analysis, tapping into advocatesâ knowledgeof authorities and government systems. Independent monitoring of government services in Phase 2 was nota one-off exercise. Community advocates in 18 districts engaged in on-going monitoring to assess the effects oftheir advocacy campaigns. In almost half of the 98 health facility catchments, advocates leveraged their knowledgeand skills to launch special advocacy campaigns to tackle additional challenges they had independently identified.
