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