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World Development Report 2004: Making Services Work for Poor People suggests ways by which countries can speed up progress towards the Millennium Development Goals by assuring that public services benefit the poor
 The World Bank's latest report, World Development Report 2004: Making Services Work for Poor People, published in September 2004, says that too often key services fail the poor -- in access, quantity and quality. This imperils a set of eight development targets, known as the Millennium Development Goals (MDGs), to be achieved by 2015.
The report warns that improvements in human welfare would not occur unless poor people received wider access to affordable, better-quality services in health, education, water, sanitation and electricity. Without such improvements in services, freedom from ill health and illiteracy -- two of the most important ways poor people can escape poverty -- will remain elusive to many. WDR 2004 also suggests ways by which countries can speed up progress towards the MDGs -- agreed to by the international community -- by assuring that public services benefit the poor. The goals include halving the number of people living on less than $1 a day, achieving universal primary education, reducing the under-five mortality rate by two-thirds and reversing the spread of HIV/AIDS. This 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. “Mobilising 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.” The report also provides powerful examples of where services do work, showing how governments and citizens can do better. It says that there have been spectacular successes and miserable failures in efforts made by developing countries to make services work. It notes that the main difference between success and failure is the degree to which poor people themselves are involved in determining the quality and quantity of the services 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 -- recognising 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.” How services are failing poor people WDR 2004 contains personal accounts from poor people across the globe, describing the shoddy services they receive. In terms of access, poor people often have to travel longer than rich people to avail of basic services. According to WDR 2004, in India the distance to the nearest medical facility is, on average, 2.5 km for the poorest fifth of the population, while it is only 0.7 km for the richest quintile. Examples like these are supported by accounts from other countries as well. The average poor child in rural Mali has to walk eight kilometres to a primary school. In rural Chad, residents have to walk 23 km to get to a clinic. 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 of women who had given birth at rural health centres in the Mutasa district of Zimbabwe is that they were hit by staff during delivery. A billion people worldwide lack access to a proper water source; 2.5 billion lack access to improved sanitation. Even when poor people have access to services, the quality is distressingly low. The reasons for this are many -- widespread absenteeism among key staff at public facilities, like doctors and teachers, lack of toilet facilities in schools, dilapidated classrooms, inadequate teaching-learning materials, unavailability of drugs and basic medical equipment at public health centres. In random visits to 200 primary schools in India, investigators found no teaching activity at half the schools at the time of visit. Upto 45% of teachers in Ethiopia were absent at least one day a week before a visit -- 10% of them for three days or more. A survey of primary healthcare facilities in Bangladesh found the absenteeism rate among doctors to be as high as 74%. The poor often pay more than the rich for the same service. In Pune, one of the largest cities in the state of Maharashtra, low-income purchasers of water paid more than 30 times that paid by middle-class households with access to a metered water supply service. “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,” explains 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. “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.” The success stories However, WDR 2004 does give several examples of how public services can work for the poor. Indonesia used its oil windfall to build new schools and hire more teachers, doubling primary enrolment to 90% 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 programme in Mexico, that gives cash to poor households if they visit a clinic regularly and their children attend school, reduced illness among children by 20% and increased secondary enrolment by 5% for boys and 8% for girls. Three recommendations The report documents three ways in which services can be improved. Firstly, by increasing poor people's choice and participation in service delivery, so they can monitor and discipline providers. School voucher schemes -- such as a programme for poor families in Colombia, or a girls' scholarship programme in Bangladesh (that paid schools based on the number of girls they enrolled) -- increase clients' power over providers and substantially increase enrolment rates. Community-managed schools in El Salvador, where parents regularly visited schools, lowered teacher absenteeism and raised student test scores. Second, by raising poor citizens' voices through the ballot box and by 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 neighbouring districts, increased demand for better public services and forced politicians to act. Third, by rewarding the effective and penalising 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 faulty argument? Providing communities with healthcare, education and other services has been a contentious issue in many countries, with government services pitted against large-scale privatisation. The report says that while there are frequent problems with public services, it would be wrong to conclude that governments 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 improvements in child mortality and primary education without government involvement. Private-sector participation in health, education and infrastructure is not without its problems -- especially in reaching poor people. But the extreme position that the private sector should do everything is clearly not desirable either. 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 ask, why give more aid to those governments? The report contends that when policies and institutions are improving, aid should increase not decrease. 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. Conclusions The report concludes that there is no ‘silver bullet'. “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.” The type of service delivery mechanism needs to be tailored to the characteristics of the service and circumstances of the country. For instance, if the service is easy to monitor, such as immunisation, 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 better 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, rules-based programmes, such as Mexico's Progresa programme, are more likely to work for poor people. Replicating the good examples Innovating with service delivery arrangements will not be enough, according to the report. What is needed are ways to widen the reach of these innovations, or ‘scaling up', so the entire country can benefit. To achieve this, the report emphasises 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% of the money due to primary schools was actually reaching schools, galvanised the populace into action. The share now is 80% 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 programme being scaled up to cover 20% of the Mexican population. (InfoChange News & Features, October 2003)
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