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Clients and providers

4
The well-being of poor people is the point of Report and this chapter try to give the term
making services work. The value of public “empowerment” a precise and concrete
policy and expenditure is largely determined interpretation. Specifically, the chapter dis-
chapter by the value the poor attach to it. When cusses the potential for poor people to
publicly provided and funded housing is left influence services by:
vacant,174 when food supplies are not eaten,
when free but empty public health clinics
• Increasing their individual purchasing
power.
are bypassed in favor of expensive private
care,175 this money is wasted. • Increasing their collective power over
Improving services means making the providers by organizing in groups.
interests of poor people matter more to • Increasing their “capacity to aspire”177:
providers. Engaging poor clients in an allowing them to take advantage of the
active role—as purchasers, as monitors, and first two by increasing the information
as co-producers (the “short route”)—can needed to develop their personal sense of
improve performance tremendously. capability and entitlement.178
How can public policy help poor people
acquire better services through this route?
By expanding the influence of their own
When will strengthening
choices. By having the income of providers the client-producer link
depend more on the demands of poor matter most?
clients. By increasing the purchasing power In the framework of chapter 3, improving
of poor people. And by providing better client power—the short route of service deliv-
information and a more competitive envi- ery—can overcome various weaknesses of the
ronment to improve the functioning of ser- long route (figure 4.1), even when services
vices. Where such choice is not feasible, remain the responsibility of government. The
governments can expand consumer power clearest case is monitoring providers. Clients
by establishing procedures to make sure are usually in a better position to see what is
complaints are acted on. going on than most supervisors in govern-
Sad to say, governments and donors fre- ment hierarchies—who provide the compact
quently neglect the possible role of poor and management. When the policymaker-
clients in sustaining better services—or provider link is weak because of scarce or diffi-
treat that role merely as an instrument for cult-to-manage supervisory staff, clients may
achieving a technically determined out- be the only ones who regularly interact with
come. Neither governments nor donors are providers. As discussed several times in this
accustomed to asking the poor for advice. Report, improvements in basic education have
Recent initiatives have begun to redress this often depended on participation by parents.
through a variety of ways to increase partic- Although parents cannot monitor all aspects
ipation by communities and civil society. of education, they can monitor attendance by
But the potential for improvement has not teachers and even illiterate parents can tell if
yet been adequately tapped.176 their children are learning to read and write.
In short, the key is to enhance the power Citizens as clients can also make up for
of poor clients in service provision. This shortcomings in the voice or politics relation-
64
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Clients and providers 65

ship. If governments cannot or will not try to Figure 4.1 Client power in the service delivery framework
determine and act on the desires of the pub-
The state
lic, or if the desires of poor people are system-
atically ignored, there may be few options for
poor communities but to develop mecha- of accounta
ro u te bili
nisms for getting services some other way. ng ty
Lo
The greater the differences among
clients—their heterogeneity—the more that S h o rt r o u t e
direct client power is likely to have an advan- Citizens/clients Providers
tage relative to the “long route.” The greater Nonpoor Poor Frontline Organizations
Client power
the individual differences in preferences for
the type and quality of services provided, the
greater the importance of discretion on the Services
part of providers and the more difficult it is
to monitor the use of this discretion centrally. extend these services in the first place. There is
Sometimes preferences differ geographically, no reason to believe they are all self-corrective
so different levels of government may reflect through replicating aspects of the free market.
this variation. But for many services, the het- Similarly, some settlements constitute
erogeneity of preferences applies all the way communities with sufficiently congruent
down to the individual. Take courtesy and interests among members, egalitarian norms
comfort (caring) relative to technical skill to protect the poor, mutual trust, and the
(curing) in health delivery—or farmers with ability to mobilize information and to act
constraints on their time and other workers collectively—that is, they have social capi-
in the same community with different con- tal.179 But some clearly do not. How many vil-
straints. Certainly people differ in the lages and urban neighborhoods are there in
amounts of water and electricity they want, the developing world? Hundreds of thou-
given their other needs. Government struc- sands? Millions? And how many kinds of
tures may not be flexible enough to accom- social structures are represented? Ensuring
modate this variety. And where local prefer- that poor people have a say in this variety of
ences vary systematically between the poor circumstances demands that policies be
and others, honoring poor people’s prefer- examined and designed with a great deal of
ences over those of the better-off can be a local knowledge and an understanding of
challenge. local conflicts and inequalities. Pretending
For some collective action problems, gov- otherwise will almost certainly do real harm.
ernments may not be located at the correct And some services, particularly for health
level to solve them, no matter how willing and modern water and sanitation, need tech-
they are to pursue the interests of the poor. nical inputs to be successful. Patients—as
The boundaries of the political jurisdiction individuals or health boards—are good
may not correspond to the boundaries of the judges of courtesy and attendance. But they
problem. So schools are often the most are much less able to judge clinical quality or
appropriate unit for management and opera- the appropriate mix of curative and preven-
tion. Sanitation services need community tive services. And some health problems have
pressure to ensure that everyone uses fixed- effects that spill over community boundaries.
point defecation, but they are often organized Large pest-control initiatives and other forms
around communities that are larger or of infectious disease control may seem a low
smaller than villages, depending on the den- priority for any one group of citizens, yet will
sity of population. A more active role for be effective only when all participate. Ulti-
communities is needed in such cases. mately, some wide-scale government inter-
It is important to avoid romanticizing vention is necessary. Still, emphasizing the
either form of increasing client power—nei- power of clients is a welcome tonic for the
ther choice nor participation is sufficient for top-down, technocratic orientation that has
all services. Market failures and concerns for characterized much development thinking
equity lead societies to want to improve or until now.
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66 WORLD DEVELOPMENT REPORT 2004

Increasing client power • Make better choices about which ser-


through choice vices to demand.
The most direct way to get service providers The first two work through providers, the
to be accountable to the client is to make second two through clients.
whatever they get out of the transaction
depend on their meeting client needs and
desires. That is, money (usually) or other ben- Provider behavior
efits from providing the service should follow Discourtesy, social distance, abruptness of
the client—the enforceability of a relationship care, discrimination against women and eth-
of accountability, discussed in chapter 3. nic minorities, service characteristics mis-
In market transactions, this is done by a matched to individual tastes—all are associ-
buyer paying money to a seller. But that is ated with provider behavior. And all can
not the only way. Payments by government improve with the purchasing power of
to schools (and the pay of teachers) can clients. Indeed, that is why the private sector
depend on the number of students enrolled is often seen as preferable to a public sector
and continuing. The vast majority of pri- with staff paid by salaries (box 4.1). These
mary education in the Netherlands is paid differences are echoed in studies from coun-
for by government but delivered by private tries as diverse as Bangladesh, China, India,
schools compensated in this way. Capita- Lao PDR, Thailand, and Vietnam.
tion lists are the dominant method of pay For courtesy, caring, and convenience the
for general practice medical providers in private sector usually has a distinct advan-
several European systems, particularly the tage. Private practitioners usually provide
United Kingdom. Overall consumer satis- services more convenient to the client. Lim-
faction can be expressed through the possi- ited hours in public facilities (only in the
bility of changing general practitioners, morning in farm communities) is often the
determining their income. reason people go to a private practitioner.180
Vouchers issued to consumers are another What accounts for the difference? Not the
method of linking service provider compen- training but the motivation: “. . . the same
sation to consumer choices, even though the government doctor who was not easily or
consumer is not the original source of funds. conveniently accessible, whose medication
All health insurance with some choice of was not satisfactory and whose manner was
provider is a form of voucher—one condi- brusque and indifferent transformed into a
tional on being sick. And intrinsically moti- perfectly nice and capable doctor when he
vated providers, whose sense of self-worth was seeing a patient in his private practice.”181
depends on having a large demand for their Why? Because the doctor wants the client to
services, try for more patients under any pay- return. If the staff is paid through salaries,
ment system. The essence of each of these there is no strong incentive to be accommo-
methods is that client well-being translates dating. This is not lost on clients: “Anyhow,
directly into provider well-being—the incen- they will get their money, so they don’t pay
tives are aligned. much attention.”182 Discrimination, particu-
Many service problems can be improved larly against ethnic minorities and women,
by making sure that payment follows clients. and social distance are barriers to services
Most of the evidence for this comes from even when the services are free, barriers that
studies examining the effect of fees on the frequently yield to market forces.183 The arti-
behavior of private providers (who must, of ficial scarcity of free services—ensuring
course, operate this way) but it applies to all excess demand—induces rationing by some
such methods. Payment can have four kinds other means (social status, personal connec-
of beneficial effects: tions, ethnicity), and poor people rarely have
these other means. Groups coping with social
• Improve provider behavior. stigma—such as prostitutes, who need to be
• Increase supply and sustainability. part of the battle against HIV/AIDS—often
• Increase vigilance and a stake in receiv- prefer the confidentiality and more consider-
ing better service from each transaction. ate behavior in private clinics.
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Clients and providers 67

The scarcity of commodities due to low there remain problems, such as ensuring the
pricing may lead to other commonly quality of the newly established schools, but
reported problems—illicit sale of materials these are secondary to getting girls to school.
and the demand for under-the-counter pay- The revenues that providers raise from
ments. Indeed, “free” public services are often charges at the point of collection are often the
very expensive. Many countries have serious reason some services can continue at all.
diversions of pharmaceuticals from the pub- Much of the success of the Bamako Initiative
lic stock into private markets, where they in West Africa (see spotlight) stems from the
instantly become expensive. In general, ser- supply of pharmaceuticals made possible by
vices that most directly resemble market charging users for them. Bamako Initiative
goods have a greater problem of diversion villages usually have drugs, other villages usu-
and implicit privatization. ally don’t. Sustainability in piped water sys-
In Eastern Europe the health systems are tems is almost always equivalent to financial
often ranked among the most corrupt of
public services (box 4.2). Under-the-table
payments and pharmaceutical sales to open BOX 4.1 The private sector is preferred in Andhra
markets are the main elements in this assess- Pradesh, India
ment. If directives against such practices can-
not be enforced, countervailing pressure is A study of consumer and producer attitudes was conducted in six districts in the southern
needed (see box 3.6). Formalizing fees and Indian state of Andhra Pradesh.The study included 72 in-depth interviews and 24 focus
groups.
putting purchasing power in the hands of
poorer clients is one possible source of such Private Public
pressure.184 ATTITUDES OF DOCTORS
Exemptions from fees can have perverse
“They speak well, inquire about our health.” “Does not talk to me, does not bother (about
effects by reducing this purchasing power. In my feelings or the details of my problems).”
Benin a measure to raise female school “Ask about everything from A to Z.”
“Don’t tell us what the problem is, first check,
enrollment—waiving fees for girls—led “Look after everyone equally.”
give us medicines and ask us to go.”
teachers to favor the enrollment of boys and “They take money . . . so give powerful
“They are supposed to give us Rs. 1000 and 15
medicine . . . treat better.”
to raise informal fees for girls.185 Of course, kg of rice for family planning operations; they
give us Rs. 500 and 10 kg rice and make us run
the problem could have been solved by abol- around for the rest.”
ishing fees for everyone (if the teachers could “Anyhow they will get their money so they
continue to be paid) or by closer monitoring don’t pay much attention.”
and enforcement by education officials. But CONVENIENCE
in a system that has problems paying teachers
“Treat us quickly. . . .” “Do not attend to us immediately.”
and weak administrative capacity, bolstering
the ability of girls to pay with vouchers seems “We spend money but get cured faster.” “Have to stand in line for everything.”

more likely to succeed. “I know Mr. Reddy. He is a government doctor “Doctor is there from 9 a.m. to 4 p.m.—when
but I go to him in the evening.” we need to go to work.”
“Can delay payment by 5–10 days. He is OK “I have not been there, but seeing the
Increase and sustain supply with that, he stays in the village itself.” surroundings . . . I don’t feel like going.”
Greater purchasing power may simply COST
increase supply and overcome bottlenecks “Recent expenses came to Rs. 500 for 3 days . . . “While coming out, compounders ask us for
due to supply problems. In Bangladesh the had to shell out money immediately.” 10–20 Rs.”
Female Secondary School program awards “We have to be prepared to pay, you never “Anyhow, we have to buy medicines from
scholarships to girls if they attend school reg- know how much it is going to cost you.” outside.”
ularly and gives secondary schools a grant ADVANTAGES
based on the number of girls they enroll. Sec- “Even if I have to take a loan I will go to “Malaria treatment—they come, examine
ondary school enrollment in Bangladesh is private place, they treat well.” blood, give tablets.”
increasing, and faster for girls than for boys. It “For family planning operations.”
also led to the establishment, at private “Polio drops.”
expense, of new schools. Desires for single- “In case I do not get cured in private hospital,
sex schools and separate toilet facilities for but it is very rare.”
girls were mysteriously accommodated when Source: Probe Qualitative Research Team (2002).
girls’ attendance meant more money. True,
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68 WORLD DEVELOPMENT REPORT 2004

services.186 Farmers in southern India


BOX 4.2 Bribery in Eastern expect the same from irrigation services
Europe (box 4.3).

Surveys in nine transition countries of Eastern


and Central Europe* asked: “In your opinion, in Making better choices
what area is bribery most common, widespread?” For some services consumer discretion is
Health systems rank highest overall, but with
important for allocating resources efficiently.
answers ranging from 11 percent in Bulgaria to
48 percent in Slovakia. Since there has been an Households determine water and electricity
overall contraction in public services with that in use, scarce goods that have costs associated
economic activity, the most likely reason is that with them. And facing marginal costs is the
these marketable services are naturally easy to
charge for and difficult to maintain without infu-
only way to ensure efficient use. The alterna-
sions of funds from patients. tives: wasted water leading to shortages,
unreliable service with serious consequences
Other/ for the safety of the water supply, and peri-
I don’t know
17% Health odic cuts in electricity familiar to most peo-
27% ple in developing countries. Protecting the
Education poor in network services can be achieved
6% (assuming that meters work) with “lifeline”
subsidies, in which the first few essential
Customs units are free but full marginal costs are paid
11%
beyond this level.
In health care, as in water and electricity,
Legal system more is not always better. Restricting
Ministries/offices and police
16% 23% demand for curative services by pricing
frees up providers, particularly public
*Bulgaria, Croatia, Czech Republic, Hungary, Poland,
providers, to do preventive health, for
Romania, Slovakia, Slovenia, and Ukraine.The which there is little private demand.187 As
diagram summarizes results averaged over these
countries (weighted by population).
the director of a prominent nongovern-
Source: GfK Praha—Institute for Market Research mental organization providing health care
(2001).
to the very poorest in Bangladesh puts it:
“Of course you must charge at least a token
amount for services, otherwise you keep
seeing people with paper cuts and other
sustainability. There might be some subsidy
minor things.”188 Similarly, crowding at
element included in pricing, but systems to
outpatient clinics at public hospitals can be
get water to a private home depend on
curtailed by charging enough so that people
charges for that water.
use a cheaper level of service.
All these advantages can be obtained in
Increased client stake—and vigilance ways other than charging fees at the point of
The third argument for having money fol- service. As long as clients consider the
low clients: when people buy things they resources used as belonging to them, the dis-
make sure they get them, and they pay more cipline of market-like mechanisms can be
attention to the quality of what they get. enforced. The Singapore Medical Savings
Money is a profound source of power for Accounts do this by allowing people to apply
poor people. When Zambian truck drivers funds not used for primary medical care to
were expected to pay into a road fund, they other purposes, such as pensions.189 Coun-
took turns policing a bridge crossing to tries with scarce administrative personnel
make sure overloaded trucks did not pass. and supervisory capacity may certainly want
Their money would have to be used to fix to enlist clients as monitors, and market
the bridge. Women living in slum areas of mechanisms are one way of doing it.
Rio de Janeiro proudly display bills they For any of these mechanisms to work,
paid for water and sanitation—it proves however, there must be a real choice with
their inclusion in society and their right to real options. Otherwise, giving schools pay-
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ment. In some cases the market would be


BOX 4.3 Payment and expected to wither away as the state increases
accountability its capabilities. In the meantime, three cate-
gories of policies can make the most out of
A conversation with farmers in Haryana state in clients acting on their own behalf:
India, who had been to see what had happened
in reforming Andhra Pradesh (AP):
• Increasing the power of the poor over
Q: “What did you learn when you visited AP?” providers by providing them with
A: “That the farmers are much poorer than us, finance directly.
but that they pay four times as much for
water” • Increasing competition.
Q: “The farmers in AP cannot be happy about • Increasing information about services
that. . . .” and providers.
A: “They are happy, because now the irrigation
department is much more accountable to
them . . . they know where the money goes Increasing the purchasing power of the poor.
and they have a say in how it is spent. . . .” The big problem with services that can, in
Q: “So then, you much richer farmers would be principle, be provided in markets is that
willing to pay more?”
poor people don’t have enough money to
A: “Only if the irrigation department makes the
same changes, otherwise we will refuse to pay for them. For market mechanisms to
pay.” help the poor, their purchasing power must
Q: “Ah, but this is just because there is a particu- be increased. The voucher mechanisms dis-
lar Chief Minister who is pushing that now . . . cussed are a direct way of handling this for
once he goes it will all go back to the same
old way.”
specific services. But additional mileage can
A: “We also wondered about that, and so we
come from more flexible transfers that can
asked the farmers in AP about that.They told be used for purposes that the family chooses.
us that ‘no matter who is elected as CM, we Flexible transfers can help to overcome
will never allow the government to again the weakness of the citizen-policymaker link
give us free water.’”
by giving poor people more direct say in what
Source: World Bank staff. gets delivered than even the political process
would give them—the transfers become their
money. Substantial work in South Africa has
shown the beneficial effects of cash pension
ments on the basis of enrollments is not far payments on the health and well-being of all
from what happens now in centrally owned members of a family.190 For services with
and managed school systems, with all the large externalities, demand for the service
problems we are trying to fix. Conversely, may not be great enough, even when the ser-
market mechanisms with a natural monop- vice is free, so the Bolsa Escola program in
oly don’t improve matters either. There is Brazil paid families to send their children to
no denying that sparsely populated rural school, as did the secondary school program
areas—where many of the world’s poor for girls in Bangladesh, while the Education,
people live—are much more constrained by Health, and Nutrition Program (Progresa) in
competitive supply than urban areas. But Mexico paid families to use preventive health
even these markets may be “contestable” in care (see spotlight).
the sense that other providers would be able Cash payments have problems though.
to enter the market if the current provider First, giving unconstrained cash transfers to
abused monopoly power or if monopolies poor people is often not politically palatable.
were periodically granted on the basis of Second, cash payments always have to be
competitive bids. administratively targeted, which requires
determinations of eligibility. Everyone likes
Policies to improve choice money, so self-targeting of cash transfers is
Choice-based improvements alone cannot be not possible. If a government has a hard time
a solution to the problem of bad services for getting goods and services into the hands of
the poor, though some may remain as instru- the poor, it may well have an even harder time
ments in a longer-run strategy by govern- getting cash, or cash equivalents, to them.
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Increasing the scope of competition. tioning competitive markets is the consumer’s


Sometimes increasing competition merely awareness. The private sector is a mixed bag.
means allowing a private sector to emerge Private “medical” providers vary from quite
where laws previously restricted entry. Jor- good doctors (including senior specialists
dan, after years of prohibition, allowed pri- from government hospitals in their off-hours)
vate universities in 1990. Ten years later, to totally unqualified, untrained people, some
enrollments in these institutions accounted of whom are downright dangerous.191 Private
for one-third of all university students. or NGO schools may cater to specific skills not
Bangladesh has had a similar experience in provided in public schools (foreign language,
the past decade. This increase in competi- religious studies, arts and music) or they may
tion allows governments to increase enroll- just be profiteers. An essential part of improv-
ments without extremely regressive subsi- ing peoples’ choices is to provide information
dies to public universities. about these providers. Many times, people
Competition can also be encouraged by simply don’t know enough to choose better or
allowing subsidies to the poor to be worse services. And sometimes they identify
portable between public and private good medical care with powerful medi-
providers. Private providers may not exist cines—which is quite wrong and potentially
simply because the public sector is free. dangerous.
Governments can increase competition by Information can be advice to families on
changing the form of subsidy from zero how to choose schools or medical care-
price to competitive prices, with cash or givers192 or on how to take care of them-
voucher payments to compensate. Univer- selves. This might be supplemented with var-
sity education government loans, usable at ious certification programs, standard setting,
any eligible institution, can increase compe- and laboratory checks (say, for water purity).
tition, improve quality in public facilities, Scorecards of public services should also be
and reduce subsidies for all but students extended to private or NGO providers. On
from poor families. the other side of the market, government
In some cases competition is not possible, may want to directly improve the quality of
at least not without substantial regulation. private services. Training, “partnership”
Health insurance markets are notoriously arrangements, contracting, and other means
prone to failure, and competition within of engagement can all be tried. But attempts
them can lead to both inefficient and to increase information should be subject to
inequitable outcomes, since firms can com- rigorous evaluation (chapter 6).
pete by excluding the sick, not by being more
efficient. Network services are also hard to Increasing consumer power
run without a monopoly. But in each case through participation
these markets can be contestable, capturing The accountability of providers to clients can
much of the benefit of competition. also be achieved when people voice their con-
Some readers may think that the forego- cerns. In this case, enforceability is not
ing arguments are just an attempted justifica- through clients’ money but through their
tion for user fees. This is wrong, for all the direct interaction—encouragement and com-
reasons put forth here. So, to make things as plaints. The scope for poor people to voice
clear as possible, the pros and cons of user complaints individually is very small. In rich
fees in general are laid out in box 4.4. There countries individuals get help from systems of
are times when user fees are appropriate— tort law that can handle individual litigation
and some when they are not. Based on the and from government-sponsored offices of
primary goal of making services work for consumer protection or ombudsmen. But
poor people, this Report argues against any these are rare to nonexistent for the poor in
blanket policy on user fees that encompasses developing countries (they don’t always work
all services in all country circumstances. so well for the poor in rich countries either).
Some problems for which voice might be
Increasing information to improve choices by expected to work are intractable. One
consumers. One critical limit to well-func- example is corruption: the public might
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Clients and providers 71

resent under-the-table payments, but there bers than from individuals going it alone.
may be no incentive to complain if, say, a So client power expressed outside market
doctor is using public facilities and materi- transactions will almost always be expressed
als at the same time. Clients know that the through collective action.
service is still cheaper than if they had to go Strengthening participation along the
to the market, and so do not complain.193 client-provider link can fix problems in the
There is a deeper constraint: even when long route of government provision. So com-
there is an opportunity to redress com- munity groups that take on complaining,
plaints, monitoring and follow-through are monitoring, and other means of making sure
public goods—the benefits accrue to the things work properly would be expected at
entire group while the costs are borne by a some point to become institutionalized
few. This is true for communities as well as within government (most likely local govern-
individuals, but groups of people generally ment), or possibly to be supplanted by gov-
find it easier to elicit support from mem- ernment as it improves. After all, collective

BOX 4.4 No blanket policy on user fees


The wide range of services and country
circumstances discussed in this Report Is the service excludable? Do not charge for service (because you cannot). Pest control for
Possible to keep people who No public health, surface (non-toll) roads, many police services.
makes it impossible to claim that a par-
do not pay from benefiting?
ticular level of user fees or none at all is
appropriate in every case. User fees, as Yes
with other public policy decisions, must
balance protection of the poor, Transfer money to poor people and
Can poor people be Can poor people Yes
efficiency in allocation, and the ability charge user fees.
distinguished from non-poor? be given money?
to guarantee that services can be imple- Administratively and Yes
Cash transfers or
mented and sustained.The following politically? No Charge for service with exemptions
vouchers or food?
for poor people. Targeting can be
flowchart summarizes the arguments
administrative, geographical, or via
and references in the text and raises self-selection.
most of the issues necessary in deter- No
mining whether user fees of any sort
“Lifeline” price schedule. For water and electricity, charge full
are appropriate in a given case.Three Can charges vary with
Yes marginal costs of services for use above specified maximum.
points: amounts used?
Make first few visits for medical care per year free for everyone.
• First,“efficiency” is shorthand for No
standard principles of public
economics (see any textbook) that Charge for service. Empirically, this may apply to many services.
Is service disproportionately
often but not always require prices No Example: for higher education institute loan programs without
used by poor people?
subsidy.
that equal social marginal cost and
may include subsidies, taxes, or other
Yes Charges are a necessary evil. Requires honest appraisal of ability
interventions independent of their
to deliver services along “long route.” If teachers or medical
distributional effects. For example, providers cannot be supervised and medical stores not
infectious disease control measures Will service be adequately maintained by government, then clients, by default, must bring
delivered without user fees? No
will have a subsidy element because purchasing power to bear. Revolving drug funds through the
of their external effects regardless of Bamako Initiative, irrigation charges (see box 4.3), possibly many
their impact on poor people. others including primary education if government is not reliable.
Yes
• Second, it is assumed that all subsi- Charge fees at a level that balances distributional effects with
dies are paid for by taxes.The net
effect on poor people depends on Will service be overused efficiency. Water (taps left running), electricity (interrupted
without user fees? Is waste service from overuse). Also applies to curative care if staff time
their contribution to tax revenue Yes
likely to be large if prices are available for higher-priority public health activities is crowded out
(possibly substantial when taxes are too low? or to outpatient clinics at hospitals when less expensive to treat
based on agricultural exports) and on the same problems at lower-level facilities.
their share of the deadweight loss
that taxes impose on the economy. Do not charge for service. Best example: primary education.
• Third, even when prices are not No
Attendance is limited to one (school year) per child. Social value
charged at point of service, commu- is considered high. Poor people use this more than non-poor
nities may want to make (figure 2.5).
contributions to capital costs by, say,
helping to construct or maintain
schools.
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72 WORLD DEVELOPMENT REPORT 2004

action is expensive—people, especially poor thus be compromised by too aggressive a


people, have more pressing things to do with stance. This is true for other professionals as
their time. They will want to transfer this well. In Kerala, maintaining staff at a health
responsibility to permanent structures as fast center became difficult when local residents
as they can.194 made too many demands on providers’
But local inputs and knowledge from time.197
direct participation may be needed for some Beyond monitoring, communities can
time, possibly permanently, and govern- be the appropriate locus for more direct
ment can help make those inputs more inputs, in effect becoming co-producers of
effective. Education provides many of the services. Some services cannot be delivered
better illustrations. Parents are in the best by state agencies very well because the envi-
position to see what is happening in schools, ronment is too complex and variable—and
and schools are usually the unit in which the cost of interacting with very large num-
decisions are most effectively made. So giv- bers of poor people is too great.198 Sanita-
ing parents power to influence school poli- tion programs often benefit from local par-
cies often has beneficial results. In the exam- ticipation and inputs, since social relations
ple of El Salvador’s Community-Managed in communities are often the best guaran-
Schools Program (Educo—see spotlight), it tors of compliance with sanitation policies
was the right to hire and fire teachers and and compliance must be universal if the
the regularity of visits from the local educa- community is to reap the health benefits.
tion committee, staffed in part by parents, Local perspective and knowledge are criti-
that led to the increases in teacher and stu- cal in transmitting needed information. The
dent attendance and in test scores. acceptability of messages on health-related
Madhya Pradesh, India, has seen sub- habits, preventive health measures, hygiene,
stantial improvement in test scores, com- sexual conduct, and other sensitive issues is
pletion rates, and literacy.195 Community much greater when those messages are con-
involvement is strong in recruiting teachers, veyed through informal face-to-face contact
getting new schools built, and encouraging in discussions among small groups of indi-
neighbors to enroll their children. Parents viduals with similar backgrounds. For
have been helped by the ability to hire local, instance, organized discussions among infor-
less-than-fully-trained teachers at a fraction mal women’s groups can enhance the credi-
of standard pay scales for government bility and impact of behavior change efforts.
teachers—with better results. It is possible, but unlikely, that outsiders may
This last aspect of the program compli- learn enough of local mores to influence local
cates scaling up. The ability to avoid con- conversations on these subjects.199
frontation with public sector unions has
been a great advantage. Will teachers’ Tapping local social capital
unions allow such recruitment to become Many communities have evolved means of
standard?196 Do teachers hired at low wages solving longstanding problems requiring col-
expect to be converted into full public ser- lective action. When the benefits of coopera-
vants? For now, however, the involvement tion are great enough, there is a way to enforce
of communities in Madhya Pradesh, which rules, and where there are no private alterna-
is much greater than in other states, has tives, organizations often emerge on their
made a big difference in performance. own.200 Communities have solved irrigation,
Other policy initiatives that can also forestry management, nutrition, and other
make client voice more effective include problems. Recently, governments (sometimes
offering more convenient venues to air with help from donors) have started to learn
complaints. Several studies have shown that from this experience, and have funded pro-
the relationship between parents and teach- jects and programs that rely on, and require,
ers is important: it should be supportive, the formation of local user groups and com-
respectful, and cooperative, not punitive mittees to choose and implement develop-
and confrontational. The success of local ment projects. Rather than give transfers of
communities in improving education can income to individuals, which can be both
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Clients and providers 73

politically and administratively difficult, gov- of participation.204 More recent programs in


ernments have channeled money through Indonesia have benefited from this experi-
community groups. The various approaches ence and have been designed to elicit more
that have been tried address two possible widespread participation (see spotlight on
weaknesses in the “long route” of accountabil- the Kecamatan Development Program).
ity through governments: implementation, or A real risk comes from the speed with
the “compact” by single-purpose user groups, which groups are constituted and funds dis-
and “voice,” which allows communities to bursed. Elites can mobilize more quickly,
decide on projects to undertake. master the rules of submitting applications
A recent evaluation of six early social (if they can read and the majority of the
funds, most initiated in response to crises, community cannot), and present them-
found that the programs were progressive, selves to the community as an effective con-
though more between than within duit for receiving such funds. In one Sahe-
regions.201 Special-purpose user groups have lian country a large fraction of project
been more common. In water supply and funds was diverted for personal gain.205
sanitation particularly, there are numerous Much of the blame lies with the speed at
cases of better implementation through which donors want to disburse funds
such groups. In Côte d’Ivoire, when respon- (chapter 11) and with the limits this puts on
sibility for rural water supply shifted from incentives and abilities to monitor the
central government to user groups, break- behavior of leaders. Rushing to create social
downs and costs were reduced.202 Some capital where it does not exist can do more
local communities have used local contrac- harm than good. If there were ever a case
tors, improving accountability and increas- for patience, this is it. It is not merely the
ing efficiency through explicit contracts.203 creation of participatory formats but the
When governments, especially local govern- encouragement of the abilities of poor peo-
ments, are severely hampered in delivering ple themselves that will have longer-lasting
services, these methods have the potential to effects. The policies to look for, then, may
bring about marked improvements. be those of education, freedom of expres-
These programs are new—and changing sion, transparency, and time.
as lessons emerge. Because of their potential, The problem of capture is not limited to
rigorous evaluation is a high priority. Which groups created for investment purposes. It
aspects are replicable? How can pitfalls be also affects existing community groups and
avoided? Some of the emerging lessons stem local governments. Both elitism and, in
from the difference between groups that many cases, gender (men as opposed to
emerge spontaneously and those that are cre- women) can determine who dominates tra-
ated from above for the purpose of channel- ditional communities and local govern-
ing money. ments.206 It is not clear that elite capture is
always a problem. Wade (1988) proposes
Capture. Groups constituted as a part of pro- that mobilizing community action may
jects funded by outsiders may be particularly require the leadership of the more educated,
prone to capture by elites. Local groups that connected elite. The lessons, though, are to
evolve as a result of long-felt needs may or make sure that either the types of services
may not be representative of the poorest funded by such methods have substantial
people. But when those groups are used by public good characteristics (putting health
higher levels of government or by donors to and education in a sort of “gray” area) or
channel formerly unheard of sums of that the right to leadership is contestable.
money, even representative groups tend to
change. In Indonesia, when participation Developing government capacity. Some
was mandated by national government to go special-purpose user groups, better funded
through village councils, the increased par- than local governments, have drawn off
ticipation of some members of communi- more capable officials to administer their
ties was found to have a “crowding-out” funds (the same effect is seen at the national
effect on others, leading to a net reduction level in other donor initiatives—see chapter
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74 WORLD DEVELOPMENT REPORT 2004

11). One hypothesis is that this slows the delivered to all people is one of the many
development of local government capacity. open questions on the agenda.
But the opposite argument has also been
made—that such groups are a catalyst for Client power in eight sizes
developing local government capacity. In To sum up, increasing client power through
northeast Brazil, social investment funds improved choice or direct participation will
led villagers to organize and petition higher be important when people differ—are het-
levels of government to, for example, guar- erogeneous in their preferences—or when
antee a teacher to staff a school built by the either of the two legs of the long route to
community.207 accountability is problematic. In terms of
the decision tree (figure 4.2) that deter-
Sustainability. Participatory water pro- mines which of the eight types of solutions
jects, underway since the 1930s and 1940s, is appropriate, client power matters at all
have often improved water supply—at least three decision points.
for awhile. But at some point water pumps
and other pieces of expensive equipment Decision 1: Are politics pro-poor? Reliance
break down. Covering the capital cost on client power should vary with the capac-
(which is expensive) and obtaining the ity and orientation of government. Also
technical help (also expensive) have always with the question of which level of govern-
been the bottleneck for water projects in ment is problematic. When governments
poor areas. When a new infusion of capital (central, local, or both) are pro-poor, they
is necessary at short notice, the community may choose to enlist client groups as moni-
must look either to donors or to regular tors or solicit their opinions regularly in
sources of funds, such as taxes or other gen- sizes 3 and 4. Sizes 5 through 8, however,
eral revenue. Eight or nine years after the require ways to avoid the problems of gov-
original investment, are the donors still ernment. All four will involve getting infor-
around? Do they have the same priorities mation to clients on their entitlements to
they originally had? Can they respond and the performance of services.
quickly to small individual requests? Often When levels of government differ in
not. These demands will have to be met by their commitment to poor people, the role
local government,208 and projects have been and sponsorship of user groups differ as
evolving to work through them. well. If central government is a better cham-
Such projects may have been a great deal pion of poor people, they may fund com-
better than relying on inadequate govern- munities (if preferences vary between
ment structures. The argument for them is them) or cash transfers or vouchers (if pref-
strongest where the current government erences vary within them) in cases 7 and 8.
system, especially the local government, is If local government is better, they can pro-
weak, with few prospects for changing any vide or contract for these services. When no
time soon. level of government is pro-poor, then
This should, however, be a tactic that donors, if they are inclined to be involved at
supports a longer-term strategy of develop- all, might choose to fund community
ing governmental capacity—strategic incre- groups or organizations within civil society,
mentalism, discussed in chapter 3. Caution being careful not to undermine the devel-
is required when there appears to be a opment of government capacities.
tradeoff between improving services in the
short run and undermining delivery capac- Decision 2: Does heterogeneity matter?
ity in the longer run. And the political con- Sizes 3, 4, 7, and 8 directly involve clients.
sequences of participatory projects should When preferences differ by location then
be the subject of careful evaluations. All this decentralization to local government or to
complicates bringing these interventions to community groups (depending on the
scale. It may be possible to replicate com- capacity and pro-poor orientation of the
munity efforts in many places, but whether former) makes sense. If they differ by indi-
this is the best way to make sure services are vidual, then purchasing power and compe-
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Clients and providers 75

Figure 4.2 Eight sizes fit all

1 Central government financing with contracting. Direct client input not


Easy to
monitor essential—citizen input through political process.
Hard 2 Central government provision. Government may choose to enlist com-
Homogeneous to monitor
clients munities or users as monitors but is optional.

3 Deconcentrated central or local government provision with con-


tracting. If individual, rather than community, variation in preferences
Heterogeneous is important, transfers or vouchers targeted to poor can be used but
Easy to
clients are optional. If preferences vary by community, local government
monitor
can work and direct client input is not essential.
Pro-poor Hard 4 Local or deconcentrated central government provision. Government
politics to monitor may choose to enlist communities or service users as monitors. If
preferences vary by individual, vouchers or cash transfers targeted
to poor can be used.

5 Client power—experiment with contracts. If all levels of government


are problematic, community user groups are essential and can be a
source of contracts to private sector or NGOs. Funding may have to
come from donors. If only local is problematic, center can fund com-
Easy to munities or poor people directly with transfers. If only the center is
monitor the problem, local government might provide adequately without
direct client input.
Clientelist 6 Client power—experiment with providers. Similar to 5 but relation to
politics Hard provider cannot be with explicit contracts—more active monitoring
Homogeneous to monitor of provider by the community is needed. If one level of government is
clients pro-poor, it may enlist community input as in size 2. Evaluation and
publicity of efforts of one community help others. Transfers or
vouchers subject to strict rules possible even though service is
uniform.

7 Client power—experiment with community control. Similar to 5 but


requires more discretion, “choice” on part of communities (if funded
Heterogeneous by donors or central government in case only the local government is
clients the problem), by local government (if funded by donors and it is only
Easy to the central government that is the problem), or by individuals. The
monitor added discretion is needed due to heterogeneity of preferences.
Explicit contracts with providers are possible.
Hard
to monitor 8 Client power—imitate market. Similar to 7 but explicit contracts are
not feasible. Evaluation and publicity of efforts in one community help
others.

tition for individual business are preferable. work service users improve services either
Providing information to clients is critical by choice in purchasing or by active partic-
for translating their choices into better ser- ipation.
vices. It is only in size 1, where government is
perfectly capable of providing services
Decision 3: Is monitoring easy or hard? directly, that client participation is optional.
When monitoring is easier for clients than Possibly size 3 as well if government can
for governments (at any level) then client accommodate varying needs of clients. For
input may be required for sizes 2, 4, 6, and all other cases, the client needs to be placed
8. Parents of children, patients, and net- more firmly at the center of service delivery.
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spotlight on the Bamako Initiative

Putting communities in charge of health services in Benin, Guinea, and Mali


In some of the world’s poorest countries, putting communities in charge of health services, and allowing them to charge
fees and manage the proceeds, increased the accountability of local health staff and improved health services for the poor.

T he Bamako Initiative in Benin,


Guinea, and Mali reconciled tra-
ditional community solidarity
and provider payments with the objec-
tives of the modern state.209 How? By
than 10 percent of families used modern
curative services.
The approach focused on establishing
community-managed health centers serving
populations of 5,000 to 15,000 people. An
• Standardizing diagnosis and treatment
and establishing regular supervision.

Scaling up incrementally
strengthening the power of communities analysis of the main constraints in the three The Bamako approach was implemented
over service providers. Policymakers bal- countries led to emphasis on service delivery gradually, with the support of UNICEF,
anced this power with sustained central strategies focusing on the poor.211 Priorities WHO, and the World Bank, building on a
involvement in subsidizing and regulat- included:212 variety of pilot projects.213 Since the early
ing services—and in guiding community 1980s, it was progressively scaled up in the
management. • Implementing community-owned revolv- three countries—from 44 health facilities in
ing funds for drugs with local retention Benin to 400 in 2002, from 18 in Guinea to
The initiative improved the access, avail-
and management of all financial proceeds. 367, and from 1 in Mali to 559. This raised
ability, affordability, and use of health
services. Over the more than 10 years of • Revitalizing existing health centers, the population with access to services
implementation in these three countries, expanding the network, and providing within 5 kilometers to 86 percent in Benin,
community-owned services restored access monthly outreach services to villages 60 percent in Guinea, and 40 percent in
to primary and secondary health services within 15 kilometers of facilities. Mali, covering more than 20 million peo-
for more than 20 million people. They • Stepping up social mobilization and ple. Importantly, a legal framework was
raised and sustained immunization cover- community-based communication. developed to support the contractual rela-
age. They increased the use of services tionship with communities, the cost-shar-
among children and women in the poorest
• Pricing the most effective interventions
ing arrangements, the availability of essen-
below private sector prices, through sub-
fifth of the populace. And they led to a tial drugs, and community participation
sidies from the government and donors
sharper decline in mortality in rural areas policies. Community associations and
and through internal cross-subsidies
than in urban areas. management committees were registered as
within the system. Local criteria were
Despite the various targeting mecha- legal entities with ability to receive public
established for exemptions (table 1).
nisms, affordability remains a problem for funds.
many of the poorest families. But even with • Having communities participate in a
biannual analysis of progress and prob-
limited inclusion of the poorest people,
lems in coverage with health services— Better health outcomes
improvements were significant.210
and in the planning and budgeting of for poor people
services. Over the 12 or so years of implementation
Revitalizing health networks • Tracing and tracking defaulters—and in Benin and Guinea, and more than 7 years
In these three countries, serious disrup- using community representatives to in Mali, health outcomes and health service
tions to the situation of health services had increase demand. use improved significantly. Under-five mor-
occurred during the 1980s as a result of a
severe economic recession and financial
Table 1 Reaching out to benefit the poorest groups
indebtedness. The health budget in Benin
went from $3.31 per capita in 1983 to Disease Geographical Cross-subsidies Exempting the poor
targeting targeting
$2.69 in 1986. In Mali, rural infrastructure
was almost nonexistent, and in Guinea, Focus on the burden of Focus on rural areas. • Higher markup and • Exemptions left to the
health services had almost totally disap- diseases of the poor: Larger subsidies to co-payments on discretion of
malaria, diarrhea, poorer regions diseases with lower communities
peared—except in the capital city, respiratory infections, levels of priority • Exempted categories
Conakry—during the last years of the malnutrition, • High subsidies for include widows,
Sekou Toure regime. The vast majority of reproductive health child health services orphans
poor families in the three countries did • Free immunization
and oral rehydration
not have access to drugs and professional therapy as well as
health services. National immunization promotion activities
coverage was under 15 percent, and less
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Spotlight on the Bamako Initiative 77

Figure 1 Under-five mortality has been reduced in Mali, Benin, and Figure 2 Improvements in under-five mortality
Guinea, 1980–2002 among the poor in Mali
Deaths per thousand Deaths per thousand births
450 400
Mali poor 1987
400 350 1996
Mali average Guinea average
350 300 2000
Guinea poor
300 Benin poor 250
250 200
Benin average
200 150
150 100
100 50
1972 1976 1980 1984 1988 1992 1996 2000 0
Source: Krippenberg and others 2003. Calculated from Demographic and Health Survey
Poorest Second Middle Fourth Richest
data for Benin 1996 and 2001; Guinea 1992 and 1999; and Mali 1987, 1996, and 2001. fifth fifth
Source: Calculated from Demographic and Health Survey
data 1987 and 1996 (based on births in the last five years
before the survey).

tality declined significantly, even among the fied with the quality of care, although 48 Community financing—a seat
poorest. The poor-rich gap narrowed in the percent were not “fully” satisfied. Health at the table
three countries (figures 1 and 2). In Guinea, care users found the availability of drugs to The community financing of key opera-
the decline was steepest for the rural popu- be high (over 80 percent said drugs were tional costs bought communities a seat at
lation and poorer groups. available) and the overall quality of care to the table. Donors and governments had to
Immunization levels increased in all be good (91 percent). systematically negotiate new activities with
three countries.214 They are very high in Greater access reduced travel costs, and community organizations. Governments in
Benin, close to 80 percent—one of the the availability of drugs reduced the need to all three countries, with the support of
highest rates in Sub-Saharan Africa. Immu- visit distant sources of care. Prices have donors, continued to subsidize health cen-
nization rates are lower in Guinea and Mali, been kept below those of alternative ters, particularly to support revolving drug
largely because of problems of access (fig- sources. In Benin the median household funds in the poorest regions. In Benin and
ure 3). Coverage of other health interven- spending on curative care in a health center Mali today the public subsidy to health ser-
tions also increased. The use of health ser- was $2 in 1989, less than half that at private vices is about the same per capita for rich
vices by children under five in Benin providers ($5) or traditional healers ($7).217 and poor regions. In Guinea, however, pub-
increased from less than 0.1 visit per year to Poor people still saw price as a barrier.218 lic spending has benefited richer groups
more than 1.0. In Mali exclusive breastfeed- And a large proportion of the poor still do most. But all three countries face the chal-
ing and the use of professional services for not use key health services in all three coun- lenge of emphasizing household behavior
antenatal care,215 deliveries, and treatment tries. In Benin and Guinea the health system change and protecting the poorest and
of diarrhea and acute respiratory infections allowed for exemptions, and most health most vulnerable. Establishing mechanisms
increased for all groups, including the centers had revenue that they could have to subsidize and protect the poor remains a
poorest (figure 4).216 used to subsidize the poorest, but almost priority of the current reform process.
In an independent evaluation in 1996 in none did. Management committees typi-
Benin, 75 percent of informants were satis- cally valued investment over redistribution.

Figure 3 Evolution of national immunization Figure 4 Antenatal care by medically trained


coverage (DPT3), 1988–1999 persons in Mali by wealth group
Percent Percent
100 100
Benin

75 Guinea 80
1996
Mali 60 2000
50 1987
40
25
20
0
1988 1990 1992 1994 1996 1998 0
Poorest Second Middle Fourth Richest
Sources: World Health Organization, UNICEF, and
fifth fifth
Demographic and Health Survey data.
Source: Analysis of Demographic and Health Survey data.

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