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Making Services Work for Poor People

Making Services Work for Poor People. World Development Report 2004 (Green Cover Draft) Shanta Devarajan. 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

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Making Services Work for Poor People

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  1. Making Services Work for Poor People World Development Report 2004 (Green Cover Draft) Shanta Devarajan

  2. 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

  3. Universal Primary Education Why focus on human development?MDGs—Global Aggregates Eradicate Poverty & Hunger

  4. Why focus human development?MDGs—Global Aggregates Promote Gender Equality Reduce Child Mortality Ratio of girls to boys in primary and secondary school (%)

  5. Poorest quintile Richest quintile Outcomes are worse for poor peopleCumulative deaths per 1000 births Source: Analysis of Demographic and Health Survey data

  6. Richest quintile Poorest quintile Outcomes are worse for poor peoplePercent aged 15 to 19 completing each grade or higher Source: Analysis of Demographic and Health Survey data

  7. Growth is not enough

  8. How are services failing poor people? • Public spending usually benefits the rich, not the poor

  9. Percent to richest quintile Percent to poorest quintile Expenditure incidence Health Education Source: Compiled from various sources

  10. Access to primary school and health clinics in rural areas

  11. Richest quintile Average Poorest quintile Use of an improved drinking water source Source: Analysis of Demographic and Health Survey data

  12. 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

  13. 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

  14. 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.

  15. 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

  16. A framework of relationships of accountability

  17. A framework of relationships of accountability

  18. A framework of relationships of accountability

  19. Mexico’s 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%

  20. Mexico : average per capita PRONASOL expenditure according to party in muncipal government 450 400 350 300 250 Real pesos of 1995 per capita 200 150 100 50 0 1989 1990 1991 1992 1993 1994 PRI : Institutional Revolutionary Party PAN : National Action Party PRD : Party of the Democratic Revolution Other

  21. A framework

  22. 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

  23. Utilization of Facilities by Poor People Sick in last month, %

  24. A framework

  25. 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

  26. Eight sizes fit all?

  27. Eight sizes fit all?

  28. Eight sizes fit all?

  29. Eight sizes fit all?

  30. Eight sizes fit all?

  31. Eight sizes fit all?

  32. What we can do to scale up • Tailor service delivery arrangements to service characteristics and country circumstances • Expand information

  33. What we can do to scale up • Donors • Harmonize • Integrate aid in recipient’s budget system • Finance impact evaluation of service delivery innovations ($300 million a year)

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