Transparency for Development: Do Transparency and Accountability Interventions Improve Health Outcomes?

The Challenge

Recent decades have seen vast expansions of public health services across much of the developing world. But the quality of these services is often lacking, limiting their ultimate impact on the world’s poor. Transparency and accountability (T/A) techniques—such as social audits, public expenditure tracking surveys, citizen report cards, absenteeism studies, and community scorecards—are increasingly seen as one potential solution to some of these problems in that they allow communities to identify breakdowns and hold responsible agents or decision makers to account. Yet the evidence about the effectiveness of these interventions is frustratingly mixed. Further, evidence on successful interventions provides few insights into why these interventions worked, what aspects of the context played a role, and whether they truly empowered poor communities or were largely irrelevant to the deeper problems of power inequity, institutional failure, or social conflict that often foster slow and uneven development.

The Opportunity

A major opportunity exists to develop a more nuanced and action-oriented understanding of whether and in what context T/A interventions work – and to provide evidence that can be useful both to academics and to those working on the ground to improve health, accountability, and citizen participation. Specifically, such evidence could be used to:

  • Provide CSOs and practitioners with actionable information about intervention design features that are more and less effective in different contexts;
  • Reveal information for donors about T/A interventions that have a high potential for impact on health and other development outcomes;
  • Provide evidence for health sector experts and policymakers regarding whether T/A practices can impact health outcomes and how to undertake T/A work to strengthen health service delivery; and
  • Highlight research lessons to motivate the research questions and agenda of the next generation of academics and others undertaking research in the areas of transparency, accountability, and community participation.

Our Work

The Transparency for Development (T4D) project (2013-2019) was designed to investigate the questions of whether well-designed T/A interventions improve health outcomes and under what conditions and to generate actionable evidence for practitioners, researchers, and other stakeholders working to improve health, accountability, and citizen participation.

R4D — in partnership with the Harvard Kennedy School and local partners in five countries (Ghana, Indonesia, Malawi, Sierra Leone and Tanzania_ — designed, piloted, and rigorously evaluated a series of T/A interventions across several countries and contexts carefully selected to allow maximum potential for producing generalizable results about whether, where, and why T/A interventions improve development outcomes.

Our Results

The results from the Transparency for Development project reveal the complex and challenging nature of designing transparency and accountability for better health while still highlighting important potential pathways for better outcomes:

  • We found that the simple community scorecard implemented in two countries (Indonesia and Tanzania) did not lead to statistically significant improvements in the maternal and newborn health outcomes, including a majority of intermediate outcomes related to service quality and utilization.
  • However, many communities that participated in the program designed and completed diverse and relevant actions to seek improvements in healthcare, suggesting that these actions were not enough to translate to health improvements.
  • The program also led to improvements in the self-efficacy of many participants, especially in Indonesia.
  • Finally, an adapted community scorecard that included the engagement of subnational government champions showered positive evidence of achieving concrete health changes in two of three countries in which it was piloted (Ghana and Sierra Leone).

Each of these results is explored in more detail in T4D publications under Papers and Publications below.

The project is generously funded jointly by the William and Flora Hewlett Foundation, the U.K. Department for International Development, and the Bill and Melinda Gates Foundation and is brokered under the Transparency and Accountability Initiative.

Papers and Publications

Transparency for Development – Results and Implications 
Jessica Creighton, Jean Arkedis, Archon Fung, Stephen Kosack, Dan Levy & Courtney Tolmie; January 2021

Insights from Transparency and Accountability Action Plans in Indonesia and Tanzania
Jessica Creighton, Jean Arkedis, Archon Fung, Stephen Kosack, Dan Levy & Courtney Tolmie; January 2020

Can Transparency and Accountability Programs Improve Health?
Faculty Research Working Paper Series, Arkedis, J. Creighton, J. Dixit, A. Fung, A. Kosack, S. Levy, D. Tolmie, C. 

Encouraging Participation
Working Paper, Kosack, S. Bridgman, G. Creighton, J. Tolmie, C. Fung, A., December 2019

Transparency for Development: Pre-Analysis Plan
Bombyk, M. Creighton, J. Dixit, A. Levy, D. & Roots, L. April 2018

Citizen Voices, Community Solutions: Designing Better Transparency and Accountability Approaches to Improve Health
Working Paper, Transparency for Development Project Team, 2017

Phase 2 Evaluation Design
Working Paper, Transparency for Development Project Team, 2017

Transparency for Development Intervention Design
Working Paper, Transparency for Development Project Team, 2016

Baseline Report
Transparency for Development Project Team, September 2016

Evaluation Design Report
Working Paper, Transparency for Development Project Team, 2015

Does Transparency Improve Governance?
Annual Review of Political Science, Vol. 17, pp. 65-87, Kosack and Fung, 2014

Transparency for Development: Intervention Design and Evaluation Approach
Working Paper, Kosack and Fung, 2013


Ghana, Indonesia, Malawi, Sierra Leone, Tanzania


William & Flora Hewlett Foundation, Bill & Melinda Gates Foundation, U.K. Department for International Development (DFID)


Harvard Kennedy School, University of Washington, PATTIRO (Indonesia), CHAI (Tanzania), JPAL Southeast Asia, WASH-Net (Sierra Leone), Center for Democratic Development (Ghana), Malawi Economic Justice Network, Economic Development Initiatives, Ideas in Action (Tanzania), SurveyMETER (Indonesia), Innovations in Poverty Action (Sierra Leone and Tanzania)



Global & Regional Initiatives

R4D is a globally recognized leader for designing initiatives that connect implementers, experts and funders across countries to build knowledge and get that knowledge into practice.