Making Services Work for Poor People

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Making Services Work for Poor People

• World Development Report 2004
• (Green Cover Draft)
• Shanta Devarajan
• Steve Commins

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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

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Why focus on human development?MDGsGlobal
Aggregates
Eradicate Poverty Hunger
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Why focus on human development?MDGsGlobal
Aggregates
Promote Gender Equality
Reduce Child Mortality
Ratio of girls to boys in primary and secondary
school ()
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Outcomes are worse for poor peopleCumulative
deaths per 1000 births
Source Analysis of Demographic and Health Survey
data
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Outcomes are worse for poor peoplePercent aged
15 to 19 completing each grade or higher
Source Analysis of Demographic and Health Survey
data
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Growth is not enough
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How are services failing poor people?

• Public spending usually benefits the rich, not
  the poor

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Expenditure incidence
Health
Education
Source Compiled from various sources
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Access to primary school and health clinics in
rural areas
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Use of an improved drinking water source
Source Analysis of Demographic and Health Survey
data
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How are services failing poor people?

• Public spending usually benefits the rich, not
  the poor
• Money fails to reach frontline service providers
• In Uganda, only 13 of non-wage recurrent
  spending on primary education reached primary
  schools

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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

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Examples of low service quality

• Bangladesh Absenteeism rates for doctors in
  primary health care centers 74.
• Zimbabwe 13 of respondents gave as a reason for
  not delivering babies in public facilities that
  nurses hit mothers during delivery.
• Guinea 70 of government drugs disappeared.
• Costa Rica absenteeism rate is 30 in public
  health facilities.

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But services can work

• Infant mortality and malnutrition reduced in
  Ceará, Brazil
• Citywide services in Johannesburg, South Africa
  reformed
• Cash transfers to households in Mexico increased
  enrollment, lowered illness cases
• Citizen report cards in Bangalore, India
• More money reached primary schools in Uganda

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A framework of relationships of accountability
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A framework of relationships of accountability
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A framework of relationships of accountability
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Citizen-Policymaker

• Political economy of public services

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Mexicos PRONASOL, 1989-94

• Large social assistance program (1.2 of GDP)
• Water, sanitation, electricity and education
  construction to poor communities
• Limited poverty impact
• Reduced poverty by 3
• If better targeted, could have reduced it by 64

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Citizen-Policymaker

• Pro-rich v. Pro-poor politics
• Role of information

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A framework
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Policymaker-ProviderContracting 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

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Utilization of Facilities by Poor People Sick in
last month,
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Policymaker-provider

• Hard to monitor v. Easy to monitor
• Information for monitoring

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A framework
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Client-Provider

• Reveal demand and strengthen accountability by
• Choice

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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

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Client-Provider

• Strengthen accountability by
• Choice
• Participation clients as monitors

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Client-ProviderEDUCO 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

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EDUCO promoted parental involvement which
boosted student performance ( increase in
test scores per visit)
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EDUCO Effect School days missed due to teacher
absence
Avg of days missed 1.34
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What not to do

• Leave it to the private sector
• Simply increase public spending

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Increasing public spending is not enough
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Increasing public spending is not enough
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Similar changes in public spending can be
associated with vastly different changes in
outcomes
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and vastly different changes in spending can be
associated with similar changes in outcomes.
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What not to do

• Leave it to the private sector
• Simply increase public spending
• Apply technocratic solutions

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What is to be done?

• Expand information
• Tailor service delivery arrangements to service
  characteristics and country circumstances

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Eight sizes fit all?
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Eight sizes fit all?
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Eight sizes fit all?
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Eight sizes fit all?
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Eight sizes fit all?
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Eight sizes fit all?
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Donors

• Harmonize
• Integrate aid in recipients budget system
• Finance impact evaluation of service delivery
  innovations (300 million a year)