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WASHINGTON, September 21, 2003 — A new World Bank report warns that broad improvements in human welfare will not occur unless poor people receive wider access to affordable, better quality services in health, education, water, sanitation, and electricity. Without such improvements in services, freedom from illness and freedom from illiteracy - two of the most important ways poor people can escape poverty - will remain elusive to many.
The report - World Development Report 2004: Making Services Work for Poor People - says that too often, key services fail poor people - in access, in quantity, in quality. This imperils a set of development targets known as the Millennium Development Goals (MDGs) which call for a halving of the global incidence of poverty, and broad improvements in human development by 2015. However, the report provides powerful examples of where services do work, showing how governments and citizens can do better. The report says there have been spectacular successes and miserable failures in the efforts by developing countries to make services work. The main difference between success and failure is the degree to which poor people themselves are involved in determining the quality and the quantity of the services which they receive.
"Too often, services fail poor people. These failures may be less spectacular than financial crises, but their effects are continuing and deep nonetheless," says World Bank President, James D. Wolfensohn. "Services work when they include all people, when girls are encouraged to go to school, when pupils and parents participate in the schooling process, when communities take charge of their own sanitation. They work when we take a comprehensive view of development - recognizing that a mother’s education will help her baby’s health, that building a road or a bridge will enable children to go to school."
The report comes at a time when rich countries have pledged to increase foreign aid, and poor countries have pledged to improve their policies and institutions, to try to reach the MDGs. "To accelerate progress in human development, economic growth is of course necessary, but it is not enough," says World Bank Chief Economist and Senior Vice-President for Development Economics, Nicholas Stern. "Mobilizing to reach the 2015 development goals will require both a substantial increase in external resources and more effective use of all resources, internal and external. The report offers a practical framework for using resources more effectively."
How services are failing poor people
Personal accounts from poor people in the new report describe how they receive shoddy services.
In Adaboya, Ghana, "children must walk four kilometers to attend school because, while there is a school building in the village, it sits in disrepair and cannot be used in the rainy season." In Potrero Sula, El Salvador, villagers complain that "the health post here is useless because there is no doctor or nurse, and it is only open two days a week until noon." A common response in a client survey by women who had given birth at rural health centers in the Mutasa district of Zimbabwe is that they were hit by staff during delivery.
Anecdotes like these are supported by accounts from other countries as well. The average poor child in rural Mali has to walk 8 kilometers to primary school. Her counterpart in rural Chad has to walk 23 kilometers to get to a clinic. A billion people worldwide lack access to an improved water source; 2.5 billion lack access to improved sanitation.
Even when poor people have access, the quality of services is distressingly low. In random visits to 200 primary schools in India, investigators found no teaching activity in half of them at the time of visit. Up to 45 percent of teachers in Ethiopia were absent at least one day in the week before a visit - 10 percent of them for three days or more. A survey of primary health care facilities in Bangladesh found the absenteeism rate among doctors to be 74 percent.
"Improving the delivery of key services such as healthcare and education to poor people is critical to accelerate progress in human development, because more public spending by itself will not do it," says Jean-Louis Sarbib, the World Bank’s new Senior Vice-President for Human Development, and former Vice President for the Middle East and North Africa Region of the World. "The Middle East and North Africa (MENA) region spends more on public education than any other developing region, and yet it has some of the highest rates of youth illiteracy in the world. A girl in MENA is as likely to be illiterate as a girl in Sub-Saharan Africa, which is a much poorer region."
Services can work for poor people
The report points to several success stories. Indonesia used its oil windfalls to build new schools and hire more teachers, doubling primary enrollment to 90 percent by 1986. The number of children enrolled in primary schools in Uganda increased from 3.6 million to 6.9 million in five years. A program in Mexico that gives cash to poor households if they visited a clinic regularly and their children attended school reduced illness among children by 20 percent, and increased secondary enrollment by 5 percentage points for boys and 8 for girls.
"Services can work when poor people stand at the center of service provision - when they can avoid poor providers, while rewarding good providers with their clientele, and when their voices are heard by politicians - that is, when service providers have incentives to serve the poor," says Shanta Devarajan, Director of the World Development Report 2004 , and Chief Economist of the World Bank’s Human Development Network.
The report documents three ways in which services can be improved:
1. By increasing poor clients’ choice and participation in service delivery, so they can monitor and discipline providers. School voucher schemes - such as a program for poor families in Colombia, or a girls’ scholarship program in Bangladesh (that paid schools based on the number of girls they enrolled) - increase clients’ power over providers, and substantially increased enrollment rates. Community-managed schools in El Salvador, where parents visited schools regularly, lowered teacher absenteeism and raised student test scores.
2. By raising poor citizens’ voice, through the ballot box and making information widely available. Service delivery surveys in Bangalore, India, that showed poor people the quality of the water, health, education and transport services they were receiving compared to neighboring districts, increased demand for better public services, and forced politicians to act.
3. By rewarding the effective and penalizing the ineffective delivery of services to poor people. In the aftermath of a civil war, Cambodia paid primary health providers in two districts based on the health of the households (as measured by independent surveys) in their district. Health indicators, as well as use by the poor, in those districts improved relative to other districts.
Public services versus private - a false argument ?
Providing communities with healthcare, education, and other services has been a contentious issue in many countries, with government services pitted against large-scale privatization.
The report says that while there are frequent problems with public services, it would be wrong to conclude that government should give up and leave everything to the private sector. If individuals are left to their own devices, they will not provide levels of education and health that they collectively want. Not only is this true in theory, but in practice no country has achieved significant improvement in child mortality and primary education without government involvement.
Furthermore, private-sector participation in health, education, and infrastructure is not without problems - especially in reaching poor people. The extreme position that the private sector should do everything is clearly not desirable either.
"Instead of getting caught up in the public versus private services argument, the only
issue that really matters is whether the mechanism that delivers key services strengthens poor people’s ability to monitor and discipline providers, raises their voice in policymaking, and gets them the effective services they need for their families," says Ritva Reinikka, the Co-Director of WDR 2004, and Research Manager for Public Services at the World Bank.
The report says that some aid donors take a variant of the "leave-everything-to-the-private sector" position. If government services are performing so badly, donors may ask, why give more aid to those governments?
"That would be equally wrong," says Reinikka. "There is now substantial research showing that aid is productive in countries with good policies and institutions, and those policies and institutions have recently been improving. The reforms detailed in this Report (aimed at recipient countries and aid agencies) can make aid even more productive."
When policies and institutions are improving, the report argues, aid should increase, not decrease, to realize the mutually-shared objective of poverty alleviation, such as the Millennium Development Goals. At the same time, simply increasing public spending - without seeking improvements in the efficiency of that spending - is unlikely to reap substantial benefits. The productivity of public spending varies enormously across countries. Ethiopia and Malawi spend roughly the same amount per person on primary education - with very different outcomes. Peru and Thailand spend vastly different amounts - with similar outcomes.
The Report concludes that no one size fits all. The type of service delivery mechanism needs to be tailored to characteristics of the service and circumstances of the country. For instance, if the service is easy to monitor, such as immunization, and it is in a country where the politics are pro-poor, such as Norway, then it can be delivered by the central government directly, or contracted out. But if the politics of the country are such that these resources are likely to be diverted to the well-off by way of patronage, and the service is difficult to monitor, such as student learning, then arrangements that strengthen the client’s power as much as possible are necessary. Means-tested voucher schemes, as in Colombia or Bangladesh, community-managed schools as in El Salvador, or transparent, rule-based programs, such as Mexico’s ‘Progresa", are more likely to work for poor people.
Taking good examples nationwide
Innovating with service delivery arrangements will not be enough, according to the report. What is needed are ways of widening the reach of these innovations or ‘scaling up’ so the entire country can benefit. To achieve this, the report emphasizes the role of information - as a stimulant for public action, as a catalyst for change, as an input to making other reforms work. In Uganda, publishing in the newspaper the fact that only 13 percent of the money due to primary schools was actually reaching the schools, galvanized the populace. The share now is 80 percent and the entire budget of the school is posted on the schoolroom door.
Systematic evaluations of these innovations, with a control group assessed alongside the "treatment group," gives policymakers confidence that what they are seeing is real. Such an evaluation of Mexico’s Progresa led to the program being scaled up to cover 20 percent of the Mexican population.
The authors of the report warn that achieving these reforms will be difficult. "There is no silver bullet," says Devarajan, "just the hard slog of reforming institutions and power relations. But the needs of the world’s poor people are urgent. And services have too often failed them. We must act now."