poor in charge of key services
By Nicholas Stern and Shantayanan Devarajan
Thanks mainly to rapid economic growth in China and India, the world
as a whole will halve by 2015 the proportion of people who were
living on less than $1 a day in 1990.
as this growth is, it is unlikely to achieve the rest of the international
development targets known as the Millennium Development Goals, which
include calls for every boy and every girl to complete primary school,
as well as to reduce by two-thirds the number of children who die
before their fifth birthday, both by 2015.
where growth has been minuscule, the success in reducing poverty
in all its painful forms, remains elusive. Accelerating progress
toward the health and education goals will require rapid economic
growth, a substantial increase in foreign aid, and more effective
use of all resources, internal and external. These are mutually
reinforcing. Success will depend on achieving all three at the same
More effective use of resources means improvements in the delivery
of key services that contribute to better health and education results
for people and services such as water, sanitation, energy, transport,
health care, and education.
Too often, these
services are failing poor people. Governments spend very little
of their budgets on the services that poor people need to improve
their health and education. In Guinea, 48 percent of public health
spending benefits the richest fifth of the population; only 8 percent
is enjoyed by the poorest fifth. Even when public spending can be
devoted to the poor, say, by shifting resources to primary schools
and clinics, the money does not always reach frontline service providers.
In the early
1990s in Uganda, only 13 percent of non-salary spending on primary
education actually reached the primary schools; the rest was diverted
or stolen. Even increasing the share of spending that reaches poor
schools as Uganda has done is not enough.
results to improve, teachers must show up at work and do their jobs
well, just as doctors and nurses must do for people's health to
improve. But these service providers are often trapped in a system
where incentives for doing their jobs well are weak, corruption
is rife, and political patronage is a way of life.
A survey of
primary health care clinics in Bangladesh found the absenteeism
rate for doctors to be 74 percent. Services are failing poor people
because poor people have had little say in how their key services
are provided. As patients in clinics, students in schools, travellers
on buses, consumers of water, poor people are clients.
They have a
relationship with the schoolteachers, doctors, bus drivers, and
water companies who are their frontline providers. Poor people have
a similar relationship when they buy something in the market. In
a competitive-market transaction, they get the service because they
pay the provider directly. If they are unhappy, they have power
over the provider, they can refuse to do business with him or her
such as health, education, water, electricity, and sanitation, however,
society has decided that these particular services will not be provided
through market transactions because they are a public responsibility,
for reasons of market failures, and the fact that many of these
services are rights to which people are entitled and should have
the ability to assert.
So these services
are provided through the so-called "long route" of accountability,
by citizens influencing policymakers and policymakers influencing
providers. When the relationships along this long route break down,
services fail (absentee teachers, leaking water pipes), and human
first of the two relationships along the long route, the link between
poor people and policymakers or politicians. Poor people are citizens.
In principle, they contribute to defining society's collective objectives.
this does not always work. Free public services and "no-show"
jobs are handed out as political patronage, with poor people rarely
the beneficiaries. However, when poor people are better informed
about the quality of services, they put pressure on politicians
when the newspapers reported that primary schools were receiving
only 13 percent of the budget that had been earmarked for them in
the capital, the public started demanding that the entire school
budget be posted on the local schoolroom door. The share of non-salary
budgets going to primary schools has since increased to 80 percent.
Even if poor
people can reach their policymakers, services will not automatically
improve unless policymakers ensure that service providers really
do deliver. In the aftermath of a civil war, Cambodia paid primary
health providers in two districts based on improvements in the health
of households (as measured by independent surveys) in their district.
Health results, including access to poor people, increased noticeably
in those districts compared to others.
may not always be able to monitor whether a service has been provided,
much less impose penalties for underperformance. A problem like
teacher and health worker absenteeism is often the result. Given
the weaknesses in the long route of accountability, service outcomes
can be improved by strengthening the short route, by increasing
the client's power over providers.
are valued and motivated, they perform better and human development
improves. El Salvador's Educo programme gives parents' associations
the right to hire and fire teachers, and requires them to visit
the schools monthly.
Participation by the clients reduced teacher and student absenteeism
and improved student performance.No single solution fits all services
in all countries.
But they all
have to do with putting poor people at the centre of service provision
by enabling them to monitor and encourage, and if necessary, discipline
providers, by raising their voice in policymaking and by giving
providers incentives to serve the poor.
Mexico in 2002, the global community made a commitment to the world's
poor people that it would make the best effort possible to help
them reduce poverty in all its injurious ways.
includes more flexible foreign aid from rich countries, and reforms
in developing countries to make these and other resources more effective.
Service reforms that put poor people at the centre will quicken
progress towards the Millennium Development Goals. The time to act
is Chief Economist of the World Bank; Shantayanan Devarajan is the
Director of the World Development Report 2004, and Chief Economist
Designate of the World Bank's Human Development Network.