Basic services for the poorest

1. Basic services for the poorest David Hulme Director, CPRC and Professor, Institute for Development Policy and Management, University of Manchester

2. Outline • The poorest – who, where, and how many? • Why is service delivery for the poorest important? • What do we know about services for the poorest? • An example from Bangladesh – education and health • Why don’t the poorest get services? • What can be done to improve services for the poorest?

3. Who are the poorest? • The severely poor – those ‘far’ below a poverty line at a point in time: • Food poverty, absolute poverty, destitution, indigence • $1/day poverty? 1.2b • The chronically poor – those below a poverty line for ‘a long time’: 280-400m + • Poor for all or much of their lives, • Pass on poverty to subsequent generations, or • Die a preventable, poverty-related death.

4. Locating the poorest 1 • South Asia:highest number of both severely and chronically poor people, followed by China • Sub-Saharan Africa (esp. West/Central): highest prevalence of both severe and chronic poverty • Latin America/Caribbean: relatively high proportion of poor are chronically poor • Central Asia and Russia:fastest growth rates of chronic poverty

5. Locating the poorest 2 • Spatial poverty traps (rural-urban): • Remote Weakly-integrated • Less-favoured Low potential (socially and politically) (agro-ecologically) • Severe and chronic poverty still disproportionately rural, but increasingly urban and peri-urban

6. Social characteristics of the poorest • Discrimination and deprivation: • Marginalised ethnic, religious, caste groups, incl. indigenous, nomadic peoples; • Migrant, stigmatised, bonded labourers; • Refugees, IDPs; • Disabled people; • People with ill-health, esp. HIV/AIDS; • To different extents, poor women and girls. • Household composition, life-cycle position • children; • older people; • widows; households headed by older people, disabled people, children, and, in certain cases, women

7. Why is service delivery for the poorest important? • Effective services can interrupt the processes that maintain and deepen poverty. • MDGs, and post-MDGs: • Some MDGs can never be achieved without reaching the poorest. • Other MDGs will be achieved fully or in part by excluding the poorest. The poverty of those left behind post-2015 will likely be even more intractable. • Moral case: basic services = basic human rights • Grievance-based politics • By denying the poorest – those with least to lose – access to services, we risk undermining political and economic stability

8. What do we know about services for the poorest? • There is plentiful qualitative and anecdotal evidence that: • The poorest often cannot access services, whether provided by the public sector, private sector, NGO or community-based groups • If/when they do, services are of low quality and access is restricted • Both direct and indirect costs are disproportionately high • Quantitative evidence is more limited

9. An example from Bangladesh NET ENROLMENT RATES BY REAL EXPENDITURE QUINTILES (2000) Source: ADB/WB (2001) Bangladesh poverty assessment – benefit incidence analysis: education and health sectors Education

10. An example from Bangladesh DISTRIBUTION OF PUBLIC EDUCATION EXPENDITURES BY QUINTILE LEVEL (2000) Education Source: ADB/WB (2001)

11. An example from Bangladesh UTILISATION OF GOVERNMENT- PROVIDED BABY DELIVERY SERVICES (% ever-married women who used the service) UTILISATION OF GOVERNMENT- PROVIDED CURATIVE HEALTH SERVICES (% in 30 days preceding survey) Health Source: HIES 2000 in ADB/WB (2001)

12. Regressive costs of health care • Rural Nepal: the lowest income quintile spent 10% of their income on health, compared with an average of 6% for the highest quintile (Acharaya et al 1993). • Vietnam: average household health expenditure is 7.1% of household income, ranging from 3.9% by ‘rich’ households to 19.4% for ‘poor’ households, and 19.3% for ‘very poor’ households (Ensor and San 1996). • A large city in northern Thailand: heath expenditure of the poorest income quintile was 21% of household income, while for the richest quintile it was 2% (Pannarunothai and Mills, 1997). • A tribal area of Madhya Pradesh, India: overall spending on health was 3.4%, ranging from about 2% of income for comparatively high income households, to 10% for households in the lowest income quartile (Mishra et al 1993).

13. Why don’t the poorest get services? • Vicious cycles – poorest because very poor services, poorest get very poor services • Institutional weaknesses • Social exclusion • Geography, environmental conditions • Violent conflict, weak and failed states • Lack of resources, and cost recovery

14. Overarching Issues: Create knowledge about pro-poorest service delivery Detailed national and institutional analyses Critical analysis of role of decentralisation and participation in creating pro-poorest services Increase financing of basic services for the poor and poorest by rich countries Foster pro-poorest socio-political change to achieve social inclusion What can be done to improve services for the poorest? • Specific lessons: • Much pro-poor policy will be good for the poorest • Packaging services for the poorest e.g. Progresa (Mexico) • Linkingsocial protection and livelihood promotion • Geographical targeting • Support for particularly vulnerable groups/individuals • Effective user charge- exemption schemes for the poorest