world development report 2004

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world development report 2004
Making Services Work for Poor People
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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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A framework of relationships of accountability
Poor people
Providers
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A framework of relationships of accountability
Policymakers
Poor people
Providers
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A framework of relationships of accountability
Policymakers
Providers
Poor people
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Short and long routes of accountability
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Decentralizing

• Make services closer to clients ?
• Make government closer to citizens ?
• Or Make government closer to services ?

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Decentralization
National policymakers
Local policymakers
Poor people
Providers
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Decentralization and the service delivery
framework
Center
Devolution
Sub-national government
Politicians
Policymaker
Politicians
Policymaker
Voice
Delegation
Compact
Deconcentration
Citizens/clients
Providers
Poor
Non Poor
Organizations
Frontline
Clients power
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Not One Size Fits All
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What is to be done?

• 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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So what about health services

• Multiple outputs, different nature of services
• -Population Oriented services
• -Family Oriented services
• -Individual Oriented services

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Homogenous needs and easy to monitor by
policymaker/ government ?
YES
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Population Oriented Outreach

• Providers
• Integrated in clinical services (clinics, GP)
• Integrated in schools, workplace
• Outreach health post
• Mobile Activities
• Home visits, door to door activities

Lower Asymmetry of information Less Transaction
intensive Low discretion standards Public good
nature or network externality
Lever Collective action Government Primarily
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Population Oriented Services

• Needs for services are homogeneous in the
  population. Periodic Outreach by skilled health
  staff to poor populations has been shown to work
  campaigns, mobile/itinerant clinics, home
  visits, site inspections.
• Decentralization can pose problems as economies
  of scale can be important for those services
  because of network externalities (eg needs for a
  logistic chain for immunization or itinerant
  services) or public good nature of services (eg
  control of vectors, air/ water quality)

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Population Oriented Services
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Heterogeneous needs and easy to monitor by users
?
YES
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Family Oriented Support to self care
Providers Retail Community based organizations/
associations Cooperatives Social marketing,
media, Womens groups, associations etc
Low asymmetry of information Transaction light
High discretion in taste/ values
Lever Imitate the market Direct control of
users
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Family Oriented Services

• Needs are heteregeneous differences in culture
  and values. Asymmetry of information is low no
  need for skilled health staff. Use of market/
  community/civil society channels has been shown
  to work for poor people.
• Decentralization likely to benefit those services
  when addressing the geographical heterogeneity of
  health needs and risk factors linked to cultural
  behaviors.

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Family Oriented Services
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Heterogeneous needs and difficult to monitor by
both users and government ?
YES
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Providers Hospitals Clinics Individual
practitioners (licensed or not)
Individual Oriented Clinical Care
High asymmetry of information Transaction
intensive High discretion
Levers Direct control of users Self
Regulation Sophisticated purchasing capacity
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Individual Oriented Services

• Needs are heteregeneous (biological as well as
  lifestyle differences) and difficult to predict.
  Financing through insurance thus possible. High
  discretionclients are sole observers of the
  transaction. High asymmetry of information
  contracting requires a sophisticated purchasing
  function and/or intrinsically motivated skilled
  health providers. Need of a combination of
  monitoring mechanisms client control,
  government regulation and professional self
  regulation.
• Decentralization may help address some
  geographical heterogeneity but risk of reducing
  crossubsidies/size of risk pool and difficulties
  in developing the local technical capacity for
  strategic purchasing of services.

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Individual Oriented Services
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world development report 2004
Making Services Work for Poor People