Eric Deserranno, Andrea Guariso and Gianmarco Leon-Ciliotta

Ministry of Health and Sanitation, CHAF

Sierra Leone

About 9,000 households and 1,000 health workers located across 140 Primary Healthcare Units across two districts in Sierra Leone

Digital technologies have advanced more rapidly than any other innovation in history. The gains from technology are however very heterogeneous across sectors and firms. This proposal aims to study:

(i) the ways governments can leverage new e-monitoring technologies to improve the supply of public services, and

(ii) whether gains from these technologies depend on the “verticality” of the organization (the ratio of supervisors to workers).

Technology might substitute in-person supervision, but might also complement supervisors’ activities, by allowing them to reallocate time towards more complex and productive activities, e.g., customized training and advising. This may in turn affect the optimal verticality of the organization and public service delivery. In collaboration with the Ministry of Health of Sierra Leone, we plan to run an experiment across four districts of the country, cross-randomizing the introduction of a new e-monitoring app to be installed on the frontline health workers’ phones, with variation in the local share of supervisors to workers.

More specifically, we will focus on the Community Health Worker (CHW) Program, a nationwide government program that aims at enhancing primary healthcare delivery. The program operates through Peripheral Health Units (PHUs) that operate with a team of local CHWs. CHWs deliver basic healthcare services to their communities, offering health education, non-severe illness treatment, and facilitating referrals for further care. CHWs typically have no prior experience in the health sector and are trained and monitored by supervisors, who split their time between monitoring and training. Existing evidence from Sierra Leone suggests that supervisors often provide inadequate support to CHWs, limiting their effectiveness. A standard solution to monitoring problems has been to increase the number of supervisors, which, however, is expensive and thus comes at the cost of reducing the number of frontline workers.  Digital solutions can provide a cheaper alternative. In our study we will introduce a cost-free GPS-enabled app on supervisors' and CHWs' phones. The app allows CHWs to record visits and services and tracks the CHWs' focus on remote, impoverished areas. Supervisors receive daily reports on visits and distance covered. This approach aims to improve monitoring, detect shirking, promote targeting of underserved populations, and enhance the quantity and quality of service delivery. We expect the benefit of this technology to vary with the “verticality” of the organization (the existing ratio of supervisors to workers) and with the level of substitutability or complementarity between technology and supervisors.

In order to fully understand the effects of the technology, we will therefore examine both workers’ and supervisors’ behavior as well as the quantity and quality of public service delivery. While previous research focused on the performance of frontline workers, to the best of our knowledge no causal evidence exists regarding the influence of technology on supervisors and the interplay between digital technologies and organizational structure. The only existing evidence is theoretical or correlational and focuses on the private sector. We aim to fill these gaps by leveraging random rollout of e-monitoring technologies and by experimentally manipulating the share of supervisors to workers across PHUs.