Transcript Making Services Work for the Poor People

Making Services Work for Poor People
world development report 2004
Making Services Work
for Poor People
Flagship Course on Governance & Anticorruption
Washington DC, December 2, 2003
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
Making Services Work for Poor People
Why focus on human development
outcomes?
Millennium Development Goals: global aggregates
Eradicate poverty and hunger
Source: www.developmentgoals.org
Universal primary education
Making Services Work for Poor People
Millennium Development Goals:
global aggregates
Promote gender equality
Source: www.developmentgoals.org
Reduce child mortality
Making Services Work for Poor People
Outcomes are worse for poor people
Infant and child deaths per 1000 live births
Source: Analysis of Demographic and Health Survey data
Making Services Work for Poor People
Outcomes are worse for poor people
Percent aged 15 to 19 completing each grade or higher
Source: Analysis of Demographic and Health Survey data
Making Services Work for Poor People
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
Increasing public spending is 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
Making Services Work for Poor People
Increasing public spending is not enough
* Percent deviation from rate predicted by GDP per capita
Source: Spending and GDP from World Development Indicators database. School completion from Bruns, Mingat and Rakatomalala 2003
Making Services Work for Poor People
Similar changes in public spending can be
associated with vastly different changes in
outcomes
Sources: Spending data from World Development Indicators database. School completion from Bruns, Mingat and Rakatomalala 2003
Making Services Work for Poor People
and 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
Making Services Work for Poor People
How are services failing poor people?
• Public spending usually benefits the
rich, not the poor
Making Services Work for Poor People
Expenditure incidence
Health
Source: Filmer 2003b
Education
Making Services Work for Poor People
How are services failing poor people?
• Public spending benefits the rich more
than the poor
• Money fails to reach frontline service
providers
– In Uganda, only 13 percent of non-wage
recurrent spending on primary education
reached primary schools
Making Services Work for Poor People
How are services failing poor people?
• Public spending benefits the rich more
than the poor
• Money fails to reach frontline service
providers
• Service quality is low for poor people
Making Services Work for Poor People
Examples of low service quality
• India: Absenteeism rates for teachers in
government primary schools: 50 percent
• Bangladesh: Absenteeism rates for doctors in
primary health care centers: 74 percent
• Zimbabwe: “nurses hit mothers during delivery”
• Guinea: 70 percent government drugs disappeared
• India: Delhi & Chennai get 4 to 6 hours of water
per day, Hyderabad gets 1.5 hours every other day
Making Services Work for Poor People
But services can work
• Infant mortality and malnutrition reduced in
Ceará, Brazil
• Citywide services in Johannesburg, South
Africa reformed
• Municipal services improved in Bangalore,
India
• Rural electricity cooperatives increased
access to power in Bangladesh
• More money reached primary schools in
Uganda
Making Services Work for Poor People
What contributes to an effective
classroom or health clinic?
• For a service transaction to be successful,
we need a frontline provider who:
– is capable
– has access to adequate resources & inputs
– is motivated to pursue goals that can be
monitored
Making Services Work for Poor People
So, spend more money to hire
and train more teachers?
• But governments spend a lot on teachers’ salaries
– 16 out of 18 sub-Saharan African countries spent more than the
recommended 66% of recurrent education spending on teacher
salaries, some more than 90%
• It’s obvious this crowds out other inputs, yet
governments keep spending on salary budgets
• So problem is not these proximate determinants,
but with institutional context that generates and
sustains these decisions
Making Services Work for Poor People
One way of looking at the
problem of a motivated provider
• Reducing teacher absenteeism from, say,
12% to 7% is a matter of money and
technical solutions such as training: it’s a
managerial problem
• Reducing absenteeism 70% to 7% is not a
matter of money and technical solutions, it’s
an institutional problem
Making Services Work for Poor People
What, then, is the right question
to ask?
• What institutional conditions support the
emergence of good frontline providers and
services that work for poor people?
• The answer: Services work for poor people
when they involve institutional relationships in
which key players in service delivery are
accountable to each other
Making Services Work for Poor People
Accountability seems key to
service delivery…
• If accountability is strong or can be strengthened,
services may be improved by spending more on:
–
–
–
–
building more schools and clinics
training more teachers and health workers
designing better curricula & drug procurement schemes
building bigger infrastructure networks …
• But if accountability remains weak, addressing the
proximate determinants of success will not work
Making Services Work for Poor People
A framework of
relationships of accountability
Poor people
Providers
Making Services Work for Poor People
A framework of
relationships of accountability
Policymakers
Poor people
Providers
Making Services Work for Poor People
The relationship of accountability
has five features
Making Services Work for Poor People
A framework of
relationships of accountability
Policymakers
Voice
Poor people
Providers
Making Services Work for Poor People
Mexico’s PRONASOL, 1989-94
• Large social assistance program
(1.2 percent of GDP)
• Water, sanitation, electricity and education
construction to poor communities
• Limited poverty impact
– Reduced poverty by 3 percent
– Even an untargeted, uniform per capita transfer
would have reduced poverty by 13 percent
Making Services Work for Poor People
PRONASOL expenditures according to
party in municipal government
Source: Estevez, Magaloni and Diaz-Cayeros 2002
Making Services Work for Poor People
A framework of
relationships of accountability
Policymakers
Compact
Poor people
Providers
Making Services Work for Poor People
Policymaker-provider:
Contracting NGOs in Cambodia
• Contracted out: NGO managed & could hire,
fire, & transfer staff, set wages, procure drugs
• Contracted in: NGO managed and could
transfer but not hire and fire staff
• Control group: Services run by government
12 districts randomly assigned to each category
Making Services Work for Poor People
Contracting for Outcomes:
health services in Cambodia
Use of facilities by poor people ill in previous month
Source: Bhushan, Keller and Schwartz 2002
Making Services Work for Poor People
A framework of
relationships of accountability
Policymakers
Poor people
Providers
Client power
Making Services Work for Poor People
Keeping girls in secondary
school in Bangladesh: choice
• Girls to receive scholarship deposited
to bank account set up in their name if
• Attend school regularly
• Maintain passing grade
• Stay unmarried
• Schools receive grants based on
number of girls enrolled
Making Services Work for Poor People
EDUCO program in El Salvador:
participation
• Parents’ associations contract with
Education Ministry to deliver primary
education
• Associations have authority to:
– visit schools on regular basis
– hire and fire teachers
Making Services Work for Poor People
EDUCO promoted
parental involvement…
Source: Adapted from Jimenez and Sawada 1999
…which boosts
student performance
Making Services Work for Poor People
Accountability and decentralized
service delivery
National policymakers
Local policymakers
Poor people
Providers
Making Services Work for Poor People
Degrees of decentralization
Making Services Work for Poor People
What not to do
• Leave it to the private sector
• Simply increase public spending
• Apply technocratic solutions
Making Services Work for Poor People
What is to be done?
• Expand information
• Tailor service delivery arrangements to
service characteristics and country
circumstances
Making Services Work for Poor People
Eight sizes fit all?
Making Services Work for Poor People
Eight sizes fit all?
Making Services Work for Poor People
Eight sizes fit all?
Making Services Work for Poor People
Eight sizes fit all?
Making Services Work for Poor People
Eight sizes fit all?
Making Services Work for Poor People
Eight sizes fit all?
Making Services Work for Poor People
Eight sizes fit all?
Making Services Work for Poor People
Politics matters for service
delivery
• Lack of information among voters about
politician performance
• Social, cultural, & ideological polarization
that leads to identity-based voting
• Lack of credibility of political promises
• Politics dominated by clientelism, political
patrons providing “private” goods to clients
Making Services Work for Poor People
Some puzzles on politics
• Why do politicians who depend on political
support of poor people not deliver basic services
to them?
• Why are voters not able to provide stronger
incentives for politicians & service providers to
deliver better service outcomes?
• What is the impact of political market failures on
basic service outcomes for poor people?
Making Services Work for Poor People
How donors provide aid
matters…
Making Services Work for Poor People
Donors and service delivery
Policymakers
Project
implementation
units
Global
funds
Poor people
Providers
Community driven
development
Making Services Work for Poor People
What donors can do to scale up
• Harmonize procedures
• Integrate aid in recipient’s budget system so
that accountability is not undercut
• Finance impact evaluations of service
innovations ($300 million/year -World Bank)
• Create conditions for knowledge-driven
development, particularly in clientelist
settings
Making Services Work for Poor People
Implications for World Bank
adjustment lending
• PRSCs in Benin, Ethiopia, Rwanda, Madagascar
focusing on service delivery
• India: Andhra Pradesh, Karnataka, Orissa: rising
social sector expenditures — but impact?
• PRSCs supporting service delivery experiments with
evaluation: Ethiopia, Nepal
• Readiness for reform – “8 sizes fit all”?
• Staffing implications: who leads PRSCs?
Making Services Work for Poor People
Implications for policy dialogue
• Service delivery as entry point in difficult
political settings
– Middle East and North Africa Governance
Report
• Symptoms v. causes of corruption
– Ghost doctors in Bangladesh
Making Services Work for Poor People
Latin America
• Use WDR framework to understand success
and failures
– Cochabamba v. Cartagena
• Mainstream impact evaluation
– Cross-fertilizing experiences of evaluation and
scaling up
– Evaluation now a major emphasis in country
strategies
Making Services Work for Poor People
Plans in South Asia
• Background: rapid growth in India & Pakistan but
poor service delivery – MDG implications
• Fixing service delivery institutions: learning from
success & failure
– Power sector tariffs
– Contracting out education in Madhya Pradesh
• Providing knowledge services in high-capacity
settings
• WDR director will be new Chief Economist for
the South Asia region
Making Services Work for Poor People
Services work for poor people
when accountability is strong
Policymakers
Poor people
Providers
http://econ.worldbank.org/wdr/wdr2004