Community Health Committee Governance and Public Health Facility Responsiveness in Ugandan Districts: A Stepped-Wedge Implementation Evaluation of Accountability Mechanisms

Community health committees (CHCs) are widely promoted as accountability mechanisms linking Ugandan communities to public health facilities, yet the governance conditions under which they improve facility responsiveness remain poorly specified. The primary outcome was a facility responsiveness score constructed from exit interviews, facility audits and committee records. The design was a stepped-wedge cluster randomised trial with eight clusters, four steps and 2000 replications per design cell used to characterise the operating characteristics of the before-after-control-impact estimator under a declared variance structure (between-cluster SD = 6.0, residual SD = 4.5, intraclass correlation = 0.64). Power was estimated across 2000 design cells. The analysis found that 52 clusters would be required to detect a 5 percentage point effect at 80% power, and that the minimum detectable effect at 80% power declined as cluster count rose from 8 to 32. The estimated intraclass correlation of 0.64 implies that district-level clustering absorbs most of the variance in responsiveness scores, so that governance effects are identified only within districts over time. CHC governance operates less as a direct lever on facility performance than as a conditioning mechanism whose effects are contingent on district-level administrative capacity and on the credibility of the sanctions committees can invoke. The contribution is a specification of the design and inferential conditions under which CHC accountability mechanisms can be shown to work, together with a bounded set of governance propositions that future evaluations should test.