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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Outcomes are worse for poor peopleDeaths per
1000 births
Source Analysis of Demographic and Health Survey
data
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Growth is not enough
Percent living on 1/day Percent living on 1/day Primary completion rate (percent) Primary completion rate (percent) Under-5 mortality rate Under-5 mortality rate
Target 2015 growth alone Target 2015 growth alone Target 2015 growth alone
East 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.
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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
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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
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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 Filmer 2003b
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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

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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.
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Access to primary school and health clinics in
rural areas
Distance to nearest primary school (km) Distance to nearest primary school (km) Distance to nearest primary school (km) Distance to nearest medical facility (km) Distance to nearest medical facility (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.
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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

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Percent of staff absent in primary schools and
health facilities
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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

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A framework of relationships of accountability
Poor people
Providers
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Short and long routes of accountability
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The relationship of accountabilityhas five
features
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A framework of relationships of accountability
Policymakers
Poor people
Providers
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Client-provider

• Strengthen accountability by
• Choice
• Participation clients as monitors

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FSSAP Bangladesh
Making Services Work for Poor People

• 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-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 boosts student performance
Source Adapted from Jimenez and Sawada 1999
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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

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Client-ProviderBamako Initiative
Making Services Work for Poor People
Evolution of antenatal care coverage Mali
1987-2000
Evolution of national immunization coverage
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Client-ProviderBamako Initiative
Making Services Work for Poor People
Under five mortality decrease
.among the poor in Mali
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No blanket policy on user fees
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A framework of relationships of accountability
Policymakers
Poor people
Providers
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Citizen-policymaker

• Political economy of public services

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Why dont services work for poor people?
Ah, there he is again! How time flies! Its
time for the general election already!
By R. K. Laxman
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PRONASOL expenditures according to party in
municipal government
Source Estevez, Magaloni and Diaz-Cayeros 2002
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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
  Philippinesand engaging communities as monitors

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Schools in Uganda received more of what they were
due
Source Reinikka and Svensson (2001), Reinikka
and Svensson (2003a)
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A framework of relationships of accountability
Policymakers
Providers
Poor people
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Policymaker-provider

• Hard to monitor versus Easy to monitor
• Information for monitoring

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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
Source Bhushan, Keller and Schwartz 2002
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Ceara increased effectiveness of government
services
Making Services Work for Poor People
Source www.developmentgoals.org
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A framework of relationships of accountability
Policymakers
Poor people
Providers
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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 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!
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What is to be done?

• Expand information
• Generation and dissemination
• Impact evaluation
• 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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What are we up against when attempting to improve
aid efficiency?
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WDR messages to donors

• Harmonize policies and procedures around
  recipients systems
• Where possible, integrate aid in recipients
  budget
• Finance impact evaluation of service delivery
  innovations
• 300 million a year in Bank projects allocated
  for evaluation

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world development report 2004
Making Services Work for Poor People
http//econ.worldbank.org/wdr/wdr2004
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Strengths of Clients and Policymakers as monitors
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Individual Oriented clinical care
Providers Hospitals Clinics Individual
practitioners (licensed or not)
High asymmetry of information Transaction
intensive High discretion
Bottlenecks Skilled human resources Physical
access Quality Cost
Levers Direct control of users Self
Regulation Sophisticated purchasing capacity
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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
Bottlenecks Low demand Low continuity Opportunit
y Cost
Levers Collective action Government Primarily
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Providers Retail Community based organizations/
associations Cooperatives Social marketing,
media, Womens groups, associations etc
Family Oriented Support to self care
Low asymmetry of information Transaction light
High discretion in taste/ values
Bottlenecks Knowledge Availability and cost of
commodities
Levers Imitate the market Direct control of
users
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A framework of relationships of accountability
Policymakers
Poor people
Providers
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Decentralization
National policymakers
Local policymakers
Poor people
Providers