Can Citizen Pressure Improve Public Service Provision?

Encouraging citizens to apply pressure on underperforming service providers has emerged as a prominent response to the failure of states to provide needed services. We outline three theoretical mechanisms through which bottom-up citizen pressure campaigns may affect service provision and investigate them via a large-scale field experiment in the Ugandan health sector. While we find modest positive impacts on health provider behavior, we find no effects on citizen pressure, utilization rates, or bottom-line health outcomes. Our findings cast doubt on the power of outside actors to generate improvements in development outcomes by mobilizing bottom-up pressure—at least under conditions similar to those in our study setting. Our results also underscore the importance of baseline health conditions for the success of bottom-up, citizen-oriented pressure campaigns. Such conditions shape outcomes both across countries and within countries over time, with the latter finding holding important implications for countries undergoing rapid socioeconomic change.