Transcript Making Services Work for Poor People

world development report 2004
Making Services Work
for Poor People
Messages
• Services are failing poor people.
• But they can work. How?
• By empowering poor people to
– Monitor and discipline service providers
– Raise their voice in policymaking
• By strengthening incentives for service
providers to serve the poor
Outcomes are worse for poor people
Deaths per 1000 births
Source: Analysis of Demographic and Health Survey data
Growth is not enough
East Asia
Percent living on
Primary completion
$1/day
rate (percent)
Target 2015 growth Target 2015 growth
alone
alone
14
4
100
100
Under-5 mortality rate
Target 2015 growth
alone
19
26
Europe and
Central Asia
Latin America
1
1
100
100
15
26
8
8
100
95
17
30
Middle East and
North Africa
1
1
100
96
25
41
South Asia
22
15
100
99
43
69
Africa
24
35
100
56
59
151
Sources: World Bank 2003a, Devarajan 2002. Notes: Average annual growth rates of GDP per capita assumed are: EAP 5.4; ECA 3.6; LAC 1.8;
MENA 1.4; SA 3.8; AFR 1.2. Elasticity assumed between growth and poverty is –1.5; primary completion is 0.62; under-5 mortality is –0.48.
Making Services Work for Poor People
But increasing public spending is also not enough
* Percent deviation from rate predicted by GDP per capita
Source: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002
Vastly different changes in spending can
be associated with similar changes in
outcomes.
Sources: Spending data for 1990s from World Development Indicators database. Child mortality data from Unicef 2002. Other data from
World Bank staff
How are services failing poor people?
• Public spending usually benefits the
rich, not the poor
Expenditure incidence
Health
Source: Filmer 2003b
Education
How are services failing poor people?
• Public spending benefits the rich more
than the poor
• Money/goods/people are not at the
frontline of service provision
– Public expenditure tracking results on
what reaches or is at the facility level
Nonwage funds not reaching schools:
Evidence from PETS (%)
Country
Ghana 2000
Madagascar 2002
Peru 2001 (utilities)
Tanzania 1998
Uganda 1995
Zambia 2001 (discretion/rule)
Source: Ye and Canagarajah (2002) for Ghana;
Francken (2003) for Madagascar; Instituto Apoyo and
World Bank (2002) for Peru; Price Waterhouse
Coopers (1998) for Tanzania; Reinikka and Svensson
2002 for Uganda; Das et al. (2002) for Zambia.
Mean
49
55
30
57
78
76/10
Access to primary school and health
clinics in rural areas
Distance to nearest
primary school (km)
Chad 1998
Nigeria 1999
CAR 1994-95
Haiti 1994-95
India 1998-99
Bolivia 1993-94
Morocco 1992
Distance to nearest medical
facility (km)
GNI per
capita
Poorest
fifth
Richest
fifth
Ratio
Poorest
fifth
Richest
fifth
Ratio
250
9.9
1.3
7.6
22.9
4.8
4.8
266
819
336
462
1004
1388
1.8
6.7
2.2
0.5
1.2
3.7
0.3
0.8
0.3
0.2
0.0
0.3
5.5
8.9
6.4
2.3
13.1
11.6
14.7
8.0
2.5
11.8
13.5
1.6
7.7
1.1
0.7
2.0
4.7
7.1
1.9
7.2
3.6
6.0
2.9
Source: Analysis of Demographic and Health Survey data.
Note: GNI per capita is in 2001 US$. Medical facility encompasses health centers, dispensaries, hospitals, and pharmacies.
How are services failing poor people?
• Public spending benefits the rich more
than the poor
• Money/goods fail to reach frontline
service providers
• Service quality is low for poor people
Percent of staff absent in primary schools
and health facilities
50
40
30
20
10
0
Bangladesh
Ecuador
India
Indonesia
Primary schools
Papua New
Guinea
Peru
Primary health facilities
Zambia
Uganda
But services can work
• Motivating health workers reduced infant mortality in
Ceará, Brazil
• Contracted services in Johannesburg, South Africa
improved transport and water delivery
• Cash transfers to families in Mexico increased enrollment,
lowered illness
• Citizen report cards improved services in Bangalore, India
• Publicizing what schools were supposed to get resulted in
more money reaching primary schools in Uganda
• Delegating project choice and management to villagers
improved infrastructure in Indonesia
A framework of
relationships of accountability
Poor people
Providers
Short and long routes of
accountability
The relationship of accountability
has five features
A framework of
relationships of accountability
Policymakers
Poor people
Providers
Client-provider
Strengthen accountability by:
• Choice
• Participation: clients as monitors
Making Services Work for Poor People
FSSAP Bangladesh
• Criteria:
– Attendance in school
– Passing grade
– Unmarried
• Girls to receive scholarship deposited to
account set up in her name
• School to receive support based on # of
girls
Client-provider:
EDUCO Program in El Salvador
• Parents’ associations (ACEs)
– Hire and fire teachers
– Visit schools on regular basis
– Contract with Ministry of Education to
deliver primary education
EDUCO promoted
parental involvement…
Source: Adapted from Jimenez and Sawada 1999
…which boosts
student performance
The Bamako Initiative
•Community managed services
•Partnership between state and community
organizations
•Financial contributions from users locally retained,
owned and managed
•Government contract and subsidy
Making Services Work for Poor People
Client-Provider:
Bamako Initiative
Evolution of antenatal care
coverage Mali 1987-2000
Evolution of national
immunization coverage
Making Services Work for Poor People
Client-Provider:
Bamako Initiative
Under five mortality decrease
….among the poor in Mali
No blanket
policy on
user fees
A framework of
relationships of accountability
Policymakers
Poor people
Providers
Citizen-policymaker
• Political economy of public services
Why
don’t
services
work for
poor
people?
Ah, there he is again! How time flies! It’s time for the
general election already!
By R. K. Laxman
PRONASOL expenditures according to
party in municipal government
Source: Estevez, Magaloni and Diaz-Cayeros 2002
Citizen-policymaker
•
•
•
•
Political economy of public services
Formal channels
Importance of non-formal channels
Role of information
– Citizen report card (initiatives in Vietnam,
Indonesia, Philippines)
– Publicizing textbook distribution in
Philippines—and engaging communities as
monitors
Schools in Uganda received more of
what they were due
Source: Reinikka and Svensson (2001), Reinikka and Svensson (2003a)
A framework of
relationships of accountability
Policymakers
Poor people
Providers
Policymaker-provider
• “Hard to monitor” versus “Easy to
monitor”
• Information for monitoring
Policymaker-provider:
Contracting NGOs in Cambodia
• Contracting out (CO): NGO can hire and fire,
transfer staff, set wages, procure drugs, etc.
• Contracting in (CI): NGO manages district,
cannot hire and fire (but can transfer staff),
$0.25 per capita budget supplement
• Control/Comparison (CC): Services run by
government
12 districts randomly assigned to CC, CI or CO
Utilization of facilities by poor People
sick in last month
Source: Bhushan, Keller and Schwartz 2002
Making Services Work for Poor People
Ceara : increased effectiveness of
government services
Source: www.developmentgoals.org
A framework of
relationships of accountability
Policymakers
Poor people
Providers
What not to do
• Leave it to the private sector
• Simply increase public spending
• Apply technocratic solutions
What
not to
do…
technocratic
solutions…
Of course we have progressed a great deal, first they were
coming by bullock-cart, then by jeep and now this!
What is to be done?
• Expand information
– Generation and dissemination
– Impact evaluation
• Tailor service delivery arrangements to
service characteristics and country
circumstances
Eight sizes fit all?
Eight sizes fit all?
Eight sizes fit all?
Eight sizes fit all?
Eight sizes fit all?
Eight sizes fit all?
What are we up against when attempting
to improve aid efficiency?
WDR messages to donors
• Harmonize policies and procedures
around recipient’s systems
• Where possible, integrate aid in
recipient’s budget
• Finance impact evaluation of service
delivery innovations
– $300 million a year in Bank projects
allocated for evaluation
world development report 2004
Making Services Work for Poor People
http://econ.worldbank.org/wdr/wdr2004
Strengths of Clients and
Policymakers as monitors
Individual Oriented
clinical care
Providers:
Hospitals
Clinics
High asymmetry of information
Transaction intensive
High discretion
Individual practitioners
(licensed or not…)
Bottlenecks:
Skilled human resources
Physical access
Levers:
Quality
Direct control of users
Cost
Self Regulation
Sophisticated purchasing capacity
Providers
Population Oriented
•Integrated in clinical
Outreach
services (clinics, GP)
•Integrated in schools,
workplace
•Outreach health post
•Mobile Activities
Lower Asymmetry of information
Less Transaction intensive
Low discretion: standards
Public good nature or network externality
Levers:
Collective action: Government
Primarily
•Home visits, door to door
activities
Bottlenecks:
Low demand
Low continuity
Opportunity Cost
Providers
Retail
Family Oriented
Support to self care Community based
organizations/
associations
Low asymmetry of information
Transaction light
High discretion in taste/ values
Levers:
Imitate the market
Direct control of users
Cooperatives
Social marketing, media,
Women’s groups,
associations etc
Bottlenecks:
Knowledge
Availability
and cost of commodities
A framework of
relationships of accountability
Policymakers
Poor people
Providers
Decentralization
National policymakers
Local policymakers
Poor people
Providers