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world development report 2004 Making Services Work for Poor
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 peopleDeaths per 1000 births
Source: Analysis of Demographic and Health Survey data
Growth is not enoughPercent living on
$1/dayPrimary completion
rate (percent) Under-5 mortality rateTarget 2015 growth
aloneTarget 2015 growth
aloneTarget 2015 growth
aloneEast Asia 14 4 100 100 19 26
Europe and Central Asia
1 1 100 100 15 26
Latin America 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.
But increasing public spending is also not enough
* Percent deviation from rate predicted by GDP per capitaSource: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002
Making Services Work for Poor People
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 Education
Source: Filmer 2003b
• 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
How are services failing poor people?
Nonwage funds not reaching schools: Evidence from PETS (%)
Country Mean Ghana 2000 49 Madagascar 2002 55 Peru 2001 (utilities) 30 Tanzania 1998 57 Uganda 1995 78 Zambia 2001 (discretion/rule) 76/10
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.
Access to primary school and health clinics in rural areas
Distance to nearest primary school (km)
Distance to nearest medical facility (km)
GNI per capita
Poorest fifth
Richest fifth
Ratio Poorest fifth
Richest fifth
Ratio
Chad 1998 250 9.9 1.3 7.6 22.9 4.8 4.8
Nigeria 1999 266 1.8 0.3 5.5 11.6 1.6 7.1
CAR 1994-95 819 6.7 0.8 8.9 14.7 7.7 1.9
Haiti 1994-95 336 2.2 0.3 6.4 8.0 1.1 7.2
India 1998-99 462 0.5 0.2 2.3 2.5 0.7 3.6
Bolivia 1993-94 1004 1.2 0.0 - 11.8 2.0 6.0
Morocco 1992 1388 3.7 0.3 13.1 13.5 4.7 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.
• Public spending benefits the rich more than the poor
• Money/goods fail to reach frontline service providers
• Service quality is low for poor people
How are services failing poor people?
Percent of staff absent in primary schools and health facilities
0
10
20
30
40
50
Bangladesh Ecuador India Indonesia Papua NewGuinea
Peru Zambia Uganda
Primary schools Primary health facilities
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 accountabilityhas five features
A framework of relationships of accountability
Poor people Providers
Policymakers
Client-provider
Strengthen accountability by:
• Choice
• Participation: clients as monitors
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
Making Services Work for Poor People
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
Under five mortality decrease
….among the poor in Mali
Client-Provider:Bamako Initiative
No blanket policy on user fees
Poor people
Policymakers
A framework of relationships of accountability
Providers
Citizen-policymaker
• Political economy of public services
Ah, there he is again! How time flies! It’s time for the general election already!
Why don’t services work for poor people?
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
Providers
Policymakers
Poor people
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
Ceara : increased effectiveness of government services
Making Services Work for Poor People
Source: www.developmentgoals.org
Poor people Providers
Policymakers
A framework of relationships of accountability
What not to do
• Leave it to the private sector
• Simply increase public spending
• Apply technocratic solutions
Of course we have progressed a great deal, first they were coming by bullock-cart, then by jeep and now this!
What not to do…
technocratic solutions…
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
Making Services Work for Poor People
http://econ.worldbank.org/wdr/wdr2004
world development report 2004
Strengths of Clients and Policymakers as monitors
Bottlenecks: Skilled human resources
Physical accessQuality
Cost
Individual Oriented clinical care
High asymmetry of informationTransaction intensive
High discretion
Levers:Direct control of users
Self RegulationSophisticated purchasing capacity
Providers:
Hospitals
Clinics
Individual practitioners (licensed or not…)
Bottlenecks: Low demand
Low continuityOpportunity Cost
Population Oriented Outreach
Lower Asymmetry of informationLess Transaction intensiveLow discretion: standards
Public good nature or network externality
Levers:Collective action: Government
Primarily
Providers
•Integrated in clinical services (clinics, GP)
•Integrated in schools, workplace
•Outreach health post
•Mobile Activities
•Home visits, door to door activities
Bottlenecks: KnowledgeAvailability
and cost of commodities
Family Oriented Support to self care
Low asymmetry of informationTransaction light
High discretion in taste/ values
Levers:Imitate the market
Direct control of users
Providers
Retail
Community based organizations/ associations
Cooperatives
Social marketing, media,
Women’s groups, associations etc
Poor people Providers
Policymakers
A framework of relationships of accountability
Poor people Providers
National policymakers
Decentralization
Local policymakers
