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Contents
Public successes 6
Governments that provide essential services for all
Public failures: 12
Fees a life or death issue
Missing professionals
Unaffordable and unavailable medicines
Public failures: 20
Unco-ordinated and fragmented services
Rich countries pushing the private sector
Conclusion 30
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Afsana was a pupil at the school where The Indian governments commitment to
she now teaches. In a big break from local education has improved a lot recently, she
convention, she left her village to study for a says. Teachers salaries and training are
teaching degree in a nearby city. The girls I better than they were, and more is being
teach tell me theyre motivated by me, she spent on books and teaching materials. As
says. They think if I can leave the village, a result, parents especially those with girls
study at university, and become are now more inclined to send their
a teacher, then they can too. children to school.
She grew up living with her parents, five Afsana loves working with children,
sisters, and four brothers. Her parents both especially interacting with them and helping
tailors played a big part in her becoming a them learn, but conditions here arent easy.
teacher. They managed somehow to find Afsana is one of two teachers at the school,
the money so I could finish high school, and and each of them has to teach around 175
help me study to become a teacher. children. As she says: The children have
different levels of learning, so how can the
Traditionally, educating girls has been quality be as good as it needs to be?
considered less important here than
educating boys. As Afsana explains, before Imagine what she could achieve if there
she got her degree, none of the local girls were more teachers and she could spend
used to leave the village and continue their a little more time with her students.
studies. Now, many do, and more and
more parents are starting to see the
value of education.
INDIA PROFILE
836 million people in India are poor and More than half of all Indian women are illiterate.
vulnerable. Compare this with Indias 33
billionaires; the largest number in Asia,
Maternal and infant mortality rates in the
countrys poorest states are worse than in
including Japan. sub-Saharan Africa.
Of all the countries in the world, India has the
largest number of people without access
to education.
Providing long-term,
predictable aid IS
Easily affordable.
To meet the MDGS on
health, education, and
water and sanitation
would require an extra
$47 billion a year.
Annual global military
spending is $1 trillion.
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Public successes
Sanitation coverage
The Index shows that some governments It shows that even the poorest countries
have performed unexpectedly well: in Sri can achieve huge amounts where there is
Lanka, even though more than 33 per cent the political will.
of its population lives below the poverty line:
- maternal mortality rates are among the Successful governments have achieved
lowest in the world results by:
- there is a 96 per cent chance a woman will - guaranteeing essential services
be attended by a qualified midwife available to all
- there is free medical treatment in public - expanding government provision
clinics, staffed by qualified nurses, within of services
walking distance - abolishing fees in health and education
- free primary schooling, and education for - subsidising water and sanitation services
girls is free up to university level. - expanding services into rural areas
- investing in teachers and health workers
- strengthening womens social status
and autonomy as users and providers
of services.
8
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Services routinely
fail women and
girls, yet investing
in their welfare is
the cornerstone
of development
increasing their
life chances and
those of their
children.
10
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Hes also something of a miracle worker. and theres a problem finding obstetrician
Despite having to deal with staff shortages, nurses to look after mothers and children.
insufficient funding, a lack of water, and a
sporadic electricity supply, since arriving at Working in secluded villages also brings
this rural hospital hes helped tackle some challenges. Many local people are
serious local health problems. Weve pastoralists who move regularly. To reach
eradicated meningitis and whooping cough, nomadic people you need to go to them, but
and you can count the number of measles we only have two cars and few trained staff.
cases on one hand. I know change is
possible thats what gives me hope. Emilien is understandably proud of what has
been achieved. Its a sensational feeling to
Emilien decided to be a doctor when he was change the health of a village. It motivates me
a child. He trained in the capital, Bamako, to work hard for the people, and inspires me
but unlike most of the doctors who qualified to keep going.
with him, decided to work in rural Mali.
Government support has increased recently.
Ansongo is the main hospital for the region, There is now no charge for Caesarian births,
and referrals come from 11 health centres. mosquito nets are freely available, anti-
Staffing levels, however, are nowhere malarial tablets will soon be free for under-
near adequate. fives, and the price of medicines is falling.
There are two doctors, including myself. But while Emilien still has to contend with
There are few nurses that are trained to the many obstacles, the progress he has made
level needed. There arent any doctors or seems incredible. I am very proud to be a
nurses with specialist skills like radiography, doctor and I love my job.
MALI PROFILE
Mali has the highest percentage of people living One-in-four children die before they reach their
below the poverty line of any country in the fifth birthday.
world. Ninety per cent of Malians survive on
less than two dollars a day.
Eight out of ten women cannot read.
Public failures:
Fees a life or death issue
In the health centre they get annoyed when Most poor people have to pay for
they treat you. If you dont have the money medicines. In some countries it can
they wont take you. Then what? Well, youll equate to 5080 per cent of peoples
just be left to die. available income.
Marta Maria Molina Aguilar, mother of a sick In one district of Nigeria, the number
child, Nicaragua of women dying in child-birth doubled
after fees were introduced for maternal
For the vast majority of poor people in health services.
developing countries public services are: In Georgia, the introduction of fees for
- unavailable health care saw hospital admission rates
- skewed towards the needs of the rich fall by 66 per cent.
- dauntingly expensive. Deprived of public water services, poor
consumers have to buy water from private
All of which drives up social inequality. traders, spending up to five times more
per litre than richer consumers who have
Despite obvious gains in countries that access to piped water.
have abolished fees in primary education,
children still have to pay to go to school in
89 out of 103 developing countries. This
forces many poor children to leave
education particularly girls.
13
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150 Cameroon
Uganda
140 Malawi
130
Gross Enrolment (%)
120
110
100
90
80
60
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Public failures:
Missing professionals
Missing teachers
180
160
140
120
100
80
60
40 UN recommended 40
20
0
South Africa
Bangladesh
Malawi
Eritrea
Benin
Mozambique
Burkina Faso
Lebanon
Ethiopia
Nepal
Niger
Republic of Congo
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
UN recommended 400
0
African Republic
Rwanda
Honduras
Gambia
Ethiopia
Chad
Mali
Uganda
Liberia
Eritrea
Bolivia
Paraguay
Central
(Source: Oxfam calculations, based on data from Joint Learning Initiative 2004)
Based on a minimum standard of 2.5 health More than 40 million people are living with
workers per 1,000 population: HIV and AIDS, and around 8,000 of them die
- at least 75 countries do not have enough every day as a result mostly in the worlds
trained health workers to meet their needs poorest countries.
- of these, 53 countries have fewer than half
of the trained health workers needed As much as we want to scale up, there are
- in ten countries, there are only enough no people. You cant translate money into
trained health workers to cover ten per action when there are no people.
cent of the population. Biswick Mwale, head of Malawis National
AIDS Commission
HIV and AIDS redoubles the challenge
Africa is likely to lose 20 per cent of its health
workers to the disease in the coming years.
Moreover, many health workers are risking
their lives because they have to work without
gloves.
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Public failures:
Unaffordable and unavailable medicines
Its a complicated job, but to put it simply, information and advice on their rights
she spends her time working to get health and on the benefits available to them. I tell
care for people who otherwise wouldnt be them about existing local and national health
able to afford it. Im driven by the desire to programmes. And I give out information, and
help and represent poor people, she says. advocate for change.
Its essential that the government expands
the range of medical services it provides, so Having spoken to people who are missing
everyone can access quality health care. out on basic health care, Nana is convinced
Healthy people make a healthy country. that the new system has to change. The
government needs to improve and modify
The Georgian government has recently state assistance to include families who do
begun to prioritise privatisation in the health not presently qualify for it but are genuinely
sector. Some estimates suggest that as in need.
many as 52 per cent of the population lives
in poverty, meaning that the new privatised The current situation shows some of the
system will leave many people unable to problems that can arise when free, good
afford medical care. quality health care is not available to
everyone. Nana shakes her head as she tells
As a health ombudswoman working for local stories of people missing out on state
organisation Step Forward, Nana monitors treatment because they were unable to pay,
peoples access to care in Batumi and the but she remains totally committed to her role.
surrounding villages. I help to protect, and I love my job and the work I do, she says.
advocate for, the rights of medical patients, Every day that I am in a position to help
she explains. I provide people with people in need is a happy day.
GEORGIA PROFILE
Georgia is a middle-income country but has 52 per cent of the population lives below the
seen a severe deterioration in public investment national poverty line.
in health and education since independence:
the government spends just one per cent of its
12.6 per cent of the population is unemployed
(World Bank) but some civil-society
gross domestic product (GDP) on health and organisations estimate that unemployment
2.9 per cent on education. This is far less rates have reached 35 per cent in towns and 60
compared with other countries in the region, per cent in rural areas.
which have had similar histories.
Public failures:
Unco-ordinated and fragmented services
When governments fail to provide services, Evidence shows that citizens initiatives
most poor people get no education, health work best when integrated into a publicly led
care, clean water, or sanitation. Those who system, with their contribution recognised
do either have to bankrupt themselves to and supported by government. For example,
pay for private services, or rely on in Kerala state in India, and in Malaysia and
civil-society providers such as mosques, Barbados, governments have helped to fund
churches, charities, and community groups. church schools, and have regularly
monitored them to maintain standards.
Informal provision of health care and
education through local organisations is
common in many countries. Although they
can pioneer innovative approaches to
service provision, and support citizens in
claiming their rights to health, education, and
water, their coverage is partial, services are
hard to scale up, and the quality can
vary greatly.
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Faced with failing government services, The Georgian government has recently
many turn to the private sector. begun to prioritise privatisation in the
But private providers: health sector. Some estimates suggest
- provide their services only to the lucky that as many as 35 per cent of the
few who can afford to pay population lives in poverty, meaning that
- are hard to regulate the new privatised system will leave many
- steal staff from the public sector people unable to afford medical care.
- can have a negative impact on the poorest Regulating private providers, especially
and most vulnerable communities. multinational companies, can be more
difficult for states than providing services
Water privatisation is the most notorious themselves. The global water market is
example, but under-regulated private-sector dominated by a few US, French, and UK
involvement in health care in developing companies, such as Bechtel, Suez, and
countries is also spreading rapidly. Biwater: the contracts they negotiate often
require guaranteed profit margins. If
When China phased out free public health, governments try to terminate these
household health costs rose forty-fold and contracts, they risk being sued, as in the
progress on tackling infant mortality cases of Tanzania and Bolivia.
slowed. Services are paid for through
health insurance, which covers only
one-in-five people in rural areas.
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Public failures:
Rich countries pushing the private sector
Rich-country governments and international At the same time, rich countries are
institutions such as the World Bank can have simultaneously urging poor countries to
a major influence on poor countries. meet the MDGs, while aggravating skills
Advice from outside experts, funded by aid, shortages by proactively recruiting
can help determine the reforms that a thousands of their key workers.
government adopts. - Of the 489 nursing students who
graduated from the Ghana Medical School
But instead of helping to build public between 1986 and 1995, 61 per cent have
services, rich-country governments and left Ghana, with more than half of them
agencies often push private-sector going to the UK and one-third to the USA.
alternatives to public-service failures:
- The World Bank and IMF still often use
their influence to insist that governments
introduce privatisation and increase
private service provision in return for aid
or debt cancellation.
- The WTO and bilateral/regional Free
Trade Agreements also threaten public
services by limiting how governments
regulate foreign service providers.
- The IMF sets arbitrary ceilings on
government spending, including on
teachers and health workers.
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Not only are rich countries often pushing the been left out of the deal altogether.
wrong solutions, they are also failing to Poor-country governments not only need
deliver on their aid commitments, and to more aid, they also need aid that is well
ensure that debt relief is given to all co-ordinated, predictable, and channelled
countries that need it. through national budgets to support public
systems. But what they typically get is
Despite rich countries promising in 2005 to short-term, unpredictable aid, disbursed
deliver US$50 billion per year by 2010, aid through a jumble of different projects that
levels fell in 2006. If current trends continue often directly compete with public services
Oxfam estimates that rich countries will miss for scarce resources and staff.
their target by a staggering $30 billion. At
$103 billion, aid represents just ten per cent Only eight cents in the aid dollar are
of global military spending and just 0.3 per channelled into government plans that
cent of rich countries income. This is less include the training and salaries of
than half of the 0.7 per cent target they teachers and health workers.
signed up to in 1970. As much as 70 per cent of aid for
education globally is spent on technical
In 2005, rich countries also agreed to provide assistance, much of it to highly paid
debt cancellation to some of the worlds most consultants from rich countries.
highly indebted poor countries. Twenty-four More than four-fifths of 35,000 aid
countries have benefited so far, but 17 are transactions that take place each year are
still waiting. An additional 19 poor countries worth less than $1 million, and require
that desperately need debt cancellation have 2,400 quarterly progress reports,
according to the UK Secretary of State for
Zambia reaping the benefits of International Development.
cancelled debts Aid is extremely unpredictable. In 2005,
Zambia introduced free health care for Zambia was promised US$930 million in
people living in rural areas for the first time aid, but at the end of the year, rich
in April 2006, scrapping fees which for years put countries only gave US$696 million
health care beyond the reach of millions living in nearly one-third less.
poverty. This dramatic move was the direct result In health, donor demands for numerous
of debt cancellation and aid increases agreed at different vertical (disease specific)
the G8 in July 2005. Zambia received $4 billion in initiatives waste officials time, duplicate
services, and distort health priorities.
debt relief releasing money that is now being
Angola and the Democratic Republic of
poured directly into health and education. Extra
Congo, for instance, have each been
spending on education will include funds to recruit
required to set up four separate HIV and
more than 4,500 teachers, and to construct and AIDS co-ordinating bodies.
rehabilitate schools in rural and urban areas.
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Poor-country governments must show - In 2005, the worlds biggest ever anti-
leadership in delivering essential services poverty coalition was formed, the Global
for all. They should spend more on these Call to Action against Poverty (GCAP).
vital services and spend it better. And to Last year, in the space of just one day, 24
make this happen, civil society must pile on million people in more than 80 countries
the pressure. stood up symbolically against poverty. Its
key demands include quality universal
Across the world, activists are doing this: public services for all.
getting debates on essential services into - In January 2007, civil-society coalitions
the newspapers and onto politicians lists launched the 9 is Mine campaign to
of priorities. pressure the Indian government to invest
- In Kenya, the national coalition of six per cent of GDP in education and three
education groups, Elimu Yetu (Our per cent in health. The campaign
Education) played a pivotal role in making mobilised hundreds of thousands of
free primary education a central election children from across 14 states of India to
issue, ensuring it was introduced in 2003; sign a petition. India spends less on social
the result was that 1.2 million children services than Uganda, a scandal in a
went to school for the first time. country that prides itself on strong
economic growth and that does not rely
heavily on external aid.
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Win the fight against corruption - The Civil Society for Poverty Reduction
(CSPR) in Zambia monitors the use of aid
Oxfams experience from working in more funds by the Zambian government.
than 100 countries does not support the - A national network of education
view that all aid is misused or wasted organisations in Malawi works closely
through corruption. with the Parliamentary finance committee
to monitor government budget
Many governments are working hard commitments to education over the last
to fight corruption and improve financial three years.
management, although there is a long way
to go in many instances. A recent survey by But the G8 and other rich countries must
the IMF of countries receiving debt relief also do more to tackle the supply side
found that spending on tackling poverty of corruption: the export credit agencies,
in those countries has increased by 33 per companies, and individuals from their own
cent since 2002, which is ultimately the countries, who either pay or tacitly tolerate
greatest test of whether money is reaching the paying of bribes.
the poorest.
Tackle the workforce crisis
Aid can also play a key role in fighting
corruption. It can: All successful countries have built an ethos
- pay to train lawyers of public service, in which public-sector
- support the free press workers are encouraged to take pride in their
- increase salaries of the police and other contribution to the nation. Society in turn is
public-sector workers. urged to grant them status and respect.
- Pay on its own does not always increase
In short, aid can help build the only long-term motivation, but it is the first priority where
answer to corruption: effective public earnings are currently too low.
services and strong democratic institutions, - Better pay needs to be matched with
supported by active and informed citizens better conditions. Housing is a major issue
who refuse to tolerate dishonest gain. for most teachers, especially women
teachers in rural areas.
Citizens of poor countries themselves can - Governments must work with trade unions
also play a key role in fighting corruption. to achieve improved pay and conditions,
Oxfam funds partners all over the world to combining them with codes of conduct to
fight corruption: ensure that workers do their jobs.
- The SEND foundation in Ghana runs
monitoring committees made up of Drastically scaling up the numbers of
citizens in poor northern districts. They teachers and health workers is a huge task
ensure that money from debt cancellation that requires strategic, co-ordinated planning
is spent effectively and is not lost
through corruption.
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Although there is still a long way to go, the Developing-country governments must:
situation in Malawi has slightly improved. abolish fees for basic education and
The Malawi government has been working health care, and subsidise water for
with the UK and other countries to poor people
co-ordinate the funding and different make services work for women and girls,
programmes that exist to improve Malawis and improve their social status
health service. The benefits are clear. In the train, recruit, and retain desperately
past year, the salaries of nurses and doctors needed health workers and teachers
have increased by 52 per cent. The set salaries of existing health workers and
government is also planning to double the teachers at dignified levels, in
number of nurse and midwife technicians. collaboration with their unions
build an ethos of public service, in which
Make services work for women both public and essential service workers
are encouraged to take pride in their
Investing in basic services that support and contribution.
empower women and girls means promoting
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Conclusion
Within a generation, for the first time We know how to achieve this political
in history: leadership, government action, and public
every child in the world could be in school services, supported by long-term flexible
every woman could give birth with the best aid from rich countries and debt cancellation.
possible chance that neither she nor her
baby would die We know that the market alone cannot do
everyone could drink water without risking this. Civil society can pick up some of the
their lives pieces, but governments must act. There
millions of new health workers and is no short cut, and no other way.
teachers could be saving lives and
shaping minds To achieve these goals, developing-country
everyone could have access to affordable, governments must fulfil their responsibilities,
quality medicine. their citizens must pressure them to do so,
and rich countries must support and not
undermine them. And rich countries must
deliver what they have promised.
For all
Building strong public services could transform the
lives of millions of people and, with political
leadership, it is well within the grasp of our generation.
This booklet has all you need to know about the role of
public services in developing countries, and their role
in making poverty history.
It has information on how governments, civil-society
organisations, private companies, international donors,
and the World Bank and International Monetary Fund,
must change the way they act to guarantee health and
education for all.
Oxfam International is a confederation of thirteen development agencies working together in more than
100 countries to find lasting solutions to poverty and suffering: Oxfam America, Oxfam-in-Belgium,
Oxfam Canada, Oxfam France - Agir Ici, Oxfam Australia, Oxfam GB,
Oxfam Hong Kong, Intermn Oxfam (Spain), Oxfam Ireland, Oxfam Novib (Netherlands),
Oxfam New Zealand, Oxfam Quebec, and Oxfam Germany.
The international NGO dedicated exclusively to the provision of safe domestic water,
sanitation and hygiene education to the worlds poorest people.
Charity registration number 288701