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Does grass-roots civic engagement improve the quality of public services in countries in which formal oversight institutions are weak? It is obvious that formal oversight institutions are weak in developing countries, which causes low-quality public services. This weakness is particularly critical in the health sector - a service domain of crucial relevance for development. This observation has led practitioners to believe that the direct engagement of the beneficiaries of public services is a means to compensate the weakness of oversight institutions and to improve the quality of these services. Given that beneficiaries have incentives to demand good quality services, it is indeed logical to assume that their participation in the monitoring of public services helps to improve the quality of these very services. This positive view of grass-roots civic engagement resonates with the idea that an active civil society helps a political system to build up and sustain a high institutional performance In the eyes of the donors of development aid, this idea nurtures the expectation that strengthening civic engagement contributes to increased aid effectiveness. Accordingly, donor countries have increased their efforts to strengthen beneficiary participation since the 1990s, which moved the concepts of voice and accountability center-stage in the international development discourse. However, whether citizens' capacity to exercise pressure on service providers and public officials really improves the effectiveness of development aid remains an unresolved question. Building upon recent experimental and comparative case study evidence, the thesis examines the role of citizens' engagement in the effectiveness of development interventions. The focus is on such interventions in the health sector because population health is particularly critical for prosperity and development, and ultimately for democratization. The key question addressed is if and under what conditions ordinary people's engagement in collective action and their inclination to raise their voice improves the effectiveness of development assistance for health (DAH). I analyze this question from an interactionist viewpoint, unraveling the complex interplay of civic engagement and health aid with three key institutional variables: (i) state capacity, (ii) liberal democracy and (iii) decentralized government. Drawing upon social capital theory, principal-agent theory, and selectorate theory, I provide compelling evidence that health aid effectiveness depends on (a) bottom-up processes of demand from service users as well as (b) formal processes of top-down monitoring and horizontal oversight arrangements. In other words, the very interaction of behavioral and institutional factors drives the accountability in public service provision and thus the effectiveness of development assistance for health in recipient countries.