Basic services for the poorest

David Hulme

Director, CPRC and Professor, Institute for Development Policy and Management,

University of Manchester

OutlineThe poorest – who, where, and how many?

Why is service delivery for the poorest important?

What do we know about services for the poorest?

An example from Bangladesh – education and health

Why don’t the poorest get services?

What can be done to improve services for the poorest?

Who are the poorest?

The severely poor – those ‘far’ below a poverty line at a point in time:

Food poverty, absolute poverty, destitution, indigence$1/day poverty? 1.2b

The chronically poor – those below a poverty line for ‘a long time’: 280-400m +

Poor for all or much of their lives, Pass on poverty to subsequent generations, or Die a preventable, poverty-related death.

Locating the poorest 1 South Asia: highest number of both severely and chronically

poor people, followed by China Sub-Saharan Africa (esp. West/Central): highest prevalence

of both severe and chronic poverty Latin America/Caribbean: relatively high proportion of poor are

chronically poor

Central Asia and Russia: fastest growth rates of chronic poverty

Spatial poverty traps (rural-urban): Remote Weakly-integrated

Less-favoured Low potential(socially and politically) (agro-ecologically)

Severe and chronic poverty still disproportionately rural, but increasingly urban and peri-urban

Locating the poorest 2

Social characteristics of the poorest

Discrimination and deprivation: Marginalised ethnic, religious, caste groups, incl. indigenous, nomadic peoples; Migrant, stigmatised, bonded labourers; Refugees, IDPs; Disabled people; People with ill-health, esp. HIV/AIDS; To different extents, poor women and girls.

Household composition, life-cycle positionchildren; older people; widows;

households headed by older people, disabled people, children, and, in certain cases, women

Why is service delivery for the poorest important?

Effective services can interrupt the processes that maintain and deepen poverty.MDGs, and post-MDGs:

Some MDGs can never be achieved without reaching the poorest.Other MDGs will be achieved fully or in part by excluding the poorest. The poverty of those left behind post-2015 will likely be even more intractable.

Moral case: basic services = basic human rightsGrievance-based politics

By denying the poorest – those with least to lose – access to services, we risk undermining political and economic stability

What do we know about services for the poorest?

There is plentiful qualitative and anecdotal evidence that:

The poorest often cannot access services, whether provided by the public sector, private sector, NGO or community-based groupsIf/when they do, services are of low quality and access is restrictedBoth direct and indirect costs are disproportionately high

Quantitative evidence is more limited

An example from Bangladesh

Education

PrimaryJunior

SecondarySecondary

Higher Secondary

Lowest Quintile 53.4 12.7 3.9 2.2

Poor 59.6 19.0 9.7 3.5

Highest Quintile 77.8 51.5 45.8 22.0

NET ENROLMENT RATES BY REAL EXPENDITURE QUINTILES (2000)

Source: ADB/WB (2001) Bangladesh poverty assessment – benefit incidence analysis: education and health sectors

An example from Bangladesh DISTRIBUTION OF PUBLIC EDUCATION

EXPENDITURES BY QUINTILE LEVEL (2000)

Source: ADB/WB (2001)

Overall share 1 Lowest 2 3 4 5 Highest

Urban

Primary 13 25 24 22 19 10

Secondary 27 4 12 23 27 34

Tertiary 38 6 1 8 33 53

All 23 9 12 20 26 33

Rural

Primary 87 21 22 23 20 16

Secondary 73 7 12 16 25 39

Tertiary 62 8 5 14 27 47

All 77 13 15 18 24 30

Education

An example from Bangladesh

Health

UTILISATION OF GOVERNMENT-

PROVIDED CURATIVE HEALTH SERVICES

(% in 30 days preceding survey)

Source: HIES 2000 in ADB/WB (2001)

Urban Rural

1 Lowest 2.2 1.1

2 2.8 1.0

3 1.9 2.0

4 1.9 1.9

5 Highest 1.4 2.5

Urban Rural

Lowest Quintile

3.5 1.3

Poor 3.1 1.7

Highest Quintile

12.1 3.3

UTILISATION OF GOVERNMENT-

PROVIDED BABY DELIVERY SERVICES

(% ever-married women who used the service)

Regressive costs of health careRural Nepal: the lowest income quintile spent 10% of their income on health, compared with an average of 6% for the highest quintile (Acharaya et al 1993).

Vietnam: average household health expenditure is 7.1% of household income, ranging from 3.9% by ‘rich’ households to 19.4% for ‘poor’ households, and 19.3% for ‘very poor’ households (Ensor and San 1996).

A large city in northern Thailand: heath expenditure of the poorest income quintile was 21% of household income, while for the richest quintile it was 2% (Pannarunothai and Mills, 1997).

A tribal area of Madhya Pradesh, India: overall spending on health was 3.4%, ranging from about 2% of income for comparatively high income households, to 10% for households in the lowest income quartile (Mishra et al 1993).

Why don’t the poorest get services?

Vicious cycles – poorest because very poor services, poorest get very poor services

Institutional weaknesses

Social exclusion

Geography, environmental conditions

Violent conflict, weak and failed states

Lack of resources, and cost recovery

What can be done to improve services for the poorest?

Overarching Issues:

Create knowledge about pro-poorest service delivery

Detailed national and institutional analyses

Critical analysis of role of decentralisation and participation in creating pro-poorest services

Increase financing of basic services for the poor and poorest by rich countries

Foster pro-poorest socio-political change to achieve social inclusion

Specific lessons:

Much pro-poor policy will be good for the poorest

Packaging services for the poorest e.g. Progresa (Mexico)

Linking social protection and livelihood promotion

Geographical targeting

Support for particularly vulnerable groups/individuals

Effective user charge- exemption schemes for the poorest