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District-level Service Delivery in Rural Madagascar:Accountability in Health and Education
Derick W. Brinkerhoffwith
Sarah C. Keener
July 2003
RESEARCH TRIANGLE INSTITUTE
Report prepared for the World Bank under Contract No. 7124704
Preface
This study was conducted for PREM/SDV and the Madagascar Country Office. It was written by Derick W. Brinkerhoff (RTI International.) with Sarah C. Keener (World Bank, SDV). Wendy Walker provided background information and clarification on cultural dimensions. Henri Abel-Ratovo participated as a member of the in-country study team, assisting with interviews, translation, data collection, and discussion of preliminary findings. The team thanks the staff of the World Bank Country Office in Madagascar, particularly Jesko Hentschel and Frank-Borge Weitzke, for support during the mission, and expresses appreciation to all those interviewed both inside and outside of government for sharing their views and experience.
Table of Contents
1. Introduction..................................................................................................................................11.1 Background............................................................................................................................11.2 Policy Context.......................................................................................................................11.3 Study Rationale......................................................................................................................21.4 Study Methodology...............................................................................................................21.5 Analytical Framework: Accountability.................................................................................3
2. The Governance Context.............................................................................................................42.1 Democracy and Decentralization...........................................................................................52.2 The 2002 Political Divide......................................................................................................52.3 Deconcentration and Service Delivery..................................................................................5
3. Health...........................................................................................................................................63.1 Formal Health Structures and Functions...............................................................................63.2 Health Functions by Level.....................................................................................................73.3 Traditional Health Care.........................................................................................................93.4 Health Service Delivery in Ambatofinandrahana and Farafangana......................................9
3.4.1 Context – Ambatofinandrahana......................................................................................93.4.2 Context – Farafangana..................................................................................................103.4.3 Accountability: The District Perspective......................................................................12
4. Education..................................................................................................................................294.1 Formal Education Structures and Functions........................................................................304.2 Education Functions by Level.............................................................................................304.3 Education Service Delivery in Ambatofinandrahana and Farafangana...............................32
4.3.1 Context – Ambatofinandrahana and Farafangana........................................................324.3.2 Accountability: The District Perspective......................................................................33
5. Conclusions................................................................................................................................455.1 Features of the Case Study Districts....................................................................................455.2 Accountability Patterns........................................................................................................465.3 Discretionary Decision-making...........................................................................................475.4 Political and Governance Factors........................................................................................485.5 Incentives.............................................................................................................................495.6 Capacity...............................................................................................................................50
6. Recommendations......................................................................................................................50Bibliography..................................................................................................................................53Annexes.........................................................................................................................................55
1. Persons Contacted..................................................................................................................552. Operating Budget Execution Procedures...............................................................................61
1. Introduction
1.1 BackgroundThe government of Madagascar has made a strong public commitment to improved service delivery and to increased access to basic services by the poor. The eradication of poverty among the most vulnerable groups is a government priority, reflected in the Poverty Reduction Strategy Paper (PRSP) and the economic and social recovery program initiated following the resolution of the political crisis in August 2002. Critical to poverty-focused service delivery are administrative systems that can efficiently and effectively reach the poor. In the case of Madagascar, this means service provision that extends to rural areas of the country, beyond the urban poor in the capital and secondary cities.
However, previous studies have shown that the formal and informal incentives, and dysfunctional administrative processes of those institutions tasked with providing services, present bottlenecks to reaching the rural poor with key services.1 Resources such as those through the HIPC program have been made available in the recent past to help target resources to the poor; however, the question of the incentives and motivation of those institutions delivering these services remains at the heart of how effective such expenditures will be in alleviating poverty.
At present, public services remain heavily concentrated, with about 87% of expenditures executed at the central level, although the sectors of health and education are more deconcentrated than others. In health, 52% of recurrent expenditures are deconcentrated to the provincial and district level, and in education 62% of recurrent expenditures are assigned to these levels as well. Yet, despite deconcentration in these sectors, there is evidence of administrative inefficiencies and leakage of funds at the district and facility level, according to a World Bank-supported study being conducted by the National Institute of Statistics. These problems appear to be particularly strong in the most remote districts and communities of the country, thus further reinforcing geographical inequalities in the quality and access to basic services.
1.2 Policy ContextIn order to address some of these issues, the World Bank is supporting a comprehensive public expenditure review (PER), which could provide a useful analytical base for an eventual Poverty Reduction Strategy Credit. Both the health and education sectors are considering reforms to increase the equity of service provision. For education, the Government of Madagascar has adopted a policy of “Education for All,” which would involve extending primary education even to poorer rural households. In health, the government is also pursuing a policy of expanding service coverage. Following a period in which a cost recovery system for medicines and services
1 For example, the National Institute of Statistics analyzed expenditures in education and health and found differences between urban and rural facilities (INSTAT 2003). In education, it found that for fiscal year 2001 urban primary schools received three times as much expenditure on supplies as did rural schools, and that expenditures declined the further the primary school is from the district education office. In health for 2001, the study found that urban health posts received two times the expenditure on supplies and equipment as rural health posts, and similar to education, distance from the district health office had an impact on expenditure. Health posts located less than 10 kilometers away received two times the expenditure of the farther health posts.
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was suppressed (PFU), the Ministry of Health is considering how to re-introduce such a system while including mechanisms to protect the indigent. Both of these policies require assessment of the ability and/or interest of lower levels of government (i.e. the district level) to distribute or target resources to poor rural areas.
1.3 Study RationaleThis study will serve as an input into the Madagascar PER, and was designed to complement parallel studies on expenditure tracking in the health and education sectors, facility-level service delivery patterns, and community factors influencing service provision. The purpose of the study is to identify and analyze the dynamics of formal and informal administrative procedures, accountability mechanisms and institutional constraints in Madagascar’s deconcentrated health and education districts, and to examine the assumption that deconcentrated districts have decision-making discretion over the allocation of resources. The focus is on understanding the perspective, motivation, and incentives of district health and education authorities. More specifically, it seeks to address the following three types of questions relevant to the pro-poor policies being considered in these sectors:
1. What incentives or pressures favor or impede the provision of quality health and education services for the rural poor? For example, do the current incentives facilitate targeted provision? Are district authorities held accountable for providing quality services to the poor?
2. What policies or administrative changes could improve the equitable delivery of services in the health and education sectors?
3. If more financial resources were to be allocated to the district level of government, how would those institutions use these resources and who would they likely benefit? What criteria do these institutions currently use in allocating their discretionary budgets?
As part of understanding the sources of pressure on district authorities (question number one), the report also touches on whether communities are able to demand services and to demand that budgets be allocated for community priorities, on the extent to which they are likely to hold district authorities accountable, and on how they exercise accountability. Though these issues are referenced here, they will be covered in greater depth in the parallel community level study. 2
1.4 Study MethodologyThe study covers two rural districts, one on the highlands and the other on the coast, within the province of Fianarantsoa as targets for qualitative case studies. The selection of the province and the districts, Ambatofinandrahana, located on the highlands, and Farafangana, located on the coast, was made based on the following criteria: a) high levels of poverty relative to other provinces/districts based on the poverty map, b) regional and cultural diversity (highlands versus coastal communities), c) overlap with the local facilities study sites, and d) overlap with sites included in the expenditure tracking survey. In each of the two districts, at least two facilities per sector were selected for visits, one located near the district headquarters and the other in a more remote location; a total of four schools and five health posts were visited. 2 The Community Driven Development study being managed by Borge Weitze.
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In-country fieldwork took place during May 19-June 6, 2003, with a research team of one international consultant (institutional specialist), one Bank staff (social development specialist, SDV) and one Malagasy consultant (economist). In Farafangana, a local translator was also hired in an effort to adequately address differences in dialect and facilitate openness to the visiting researchers. Interviews were held in both Malagasy and French with those above and below the district authorities, including NGOs, church groups, elected officials, parents, FAFs, FRAMs, teachers, health center users, provincial and central authorities, in addition to substantial time spent with district authorities (see Annex 1 for a list of persons interviewed). The methodology involved probing key informants on similar issues, and triangulating this information.
1.5 Analytical Framework: AccountabilityThe study adopts a framework that considers accountability (see Table 1) as a key contributor to effective service delivery (see Brinkerhoff 2003). Accountability involves the obligation to provide information about use of resources, performance, and/or results. It also involves enforcement, or sanctions (both positive and negative) applied to responsible actors. Three categories of accountability can be identified: financial (the most commonly understood notion of accountability), performance, and political/democratic accountability.
Accountability generally focuses on three purposes: (i) to reduce abuse, (ii) to assure compliance with procedures and standards, and (iii) to improve performance/learning.
Table 1. Accountability Categories, Activities, and Purposes
Category Activities Purposes
Financial Tracking and reporting on allocation, disbursement, and utilization of financial resources
Cost accounting/budgeting for: personnel, operations, equipment/supplies
Purpose is to comply with prescribed procedural standards; cost control; resource efficiency measures; elimination of waste, fraud, and corruption.
Performance Demonstrating and reporting on activities, achievements, results, and outcomes.
Assessing quality of service provision.
Monitoring service provider behavior.
To assure that that service delivery adheres to the legal, regulatory, and policy framework; that services are delivered according to quality norms, standards and values.
To improve performance by comparing with best practices and evaluating against them .
Political/democratic Assuring service delivery equity/fairness.
Disseminating information and notifying citizens of rights and responsibilities (transparency).
To ensure that taxpayer funds are used legally and that they are used to address the distribution of services in a manner consistent with stated policies.
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Category Activities Purposes
Responding to citizens’ needs and demands, either directly or through elected representatives.
Building citizen and service user trust.
Mediating/resolving disputes.
To allow citizens to monitor the performance of elected officials.
(i) Reducing abuse: Reducing abuse is an objective in its own right as well as a pillar supporting the other two purposes; it focuses on containment of fraud, misuse, and corruption. Reducing abuse targets active efforts to engage in corrupt practices, but may not reach management/operational systems weaknesses that contribute to service delivery inefficiency and ineffectiveness.
(ii) Assuring compliance with procedures and standards: Accountability that targets compliance with procedures and standards involves regulation, oversight, monitoring and reporting requirements. Enforcement is carried out through the country’s legal framework and judicial system, administrative rules and operating procedures, professional norms and ethics, licensing and accreditation, and sociocultural values.
(iii) Improving performance/learning: Accountability intended to improve performance and promote learning connects decision-makers with those affected by their decisions. It often includes the following elements: clarifying chains of accountability to determine more precisely who is responsible for what, shortening the chains to make feedback on performance more direct and more timely, and/or creating competition among service providers to increase incentives for responsive performance.3
2. The Governance ContextMadagascar’s governance system has long been highly centralized, and the country’s progress toward decentralization is both recent, dating from 1992, and somewhat faltering, due to recent political turmoil. Throughout this island nation’s history the state has been the major source of political and economic power—society was organized vertically to serve the interests of a small elite at the top. Centralization started first under the Merina kingdom, was strengthened under French colonial rule, carried over into the post-colonial First Republic, and later following the coup of 1972, into a series of military and socialist regimes culminating in the Marxist Second Republic of Didier Ratsiraka in 1975.4 Under the Second Republic, with nationalization of most enterprises and the centralization of planning and economic management, public decision-making was concentrated in the hands of a small coterie of government officials. Policy implementation was carried out by heavily bureaucratized state management structures with elaborate procedures and regulations. Political and economic power remained within a closed
3 The 2004 World Development Report on services for the poor stresses these elements as ways to improve service delivery performance.4 Under Merina and French rule, central control was most often achieved by assigning individuals in the name of the state to remote areas, although coverage was not uniform throughout the country. This practice resulted in administrative structures that were imposed from the outside, and as a consequence had little understanding of local realities, preferences, or needs.
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circle of interlocking elites, a pattern that continues to the present day; repeated in several interviews for this study were references to the small number of families (30 –50) who control much of the government and business life in Madagascar.
2.1 Democracy and DecentralizationIn 1992 the economic failure of the socialist model led to popular dissatisfaction and unrest, culminating in a referendum on a new constitution that created a parliamentary regime, the stepping down from power of Ratsiraka, and the start of the Third Republic. In 1993 Albert Zafy was elected president. The transition to democracy saw the first steps toward decentralization, with commune-level elections held in 1995. Since then state-local government relationships have been in flux, subject to sometimes abrupt shifts and a lack of consensus on the appropriate degree and nature of delegation of powers from central to lower levels. Zafy’s inability to manage a coalition government and deliver results led to impeachment proceedings in the National Assembly and a political comeback for Ratsiraka, who was elected president in 1996. Among his key supporters were proponents of provincial autonomy, and he instigated a constitutional reform in 1998 that created six autonomous provinces with elected governors, who took office in 2001. One element of this reform was the transfer of service delivery functions to the provinces, with health and education to be the first services decentralized.
2.2 The 2002 Political DivideThe 2002 presidential election pitted Ratsiraka against the former mayor of Antananarivo, Marc Ravalomanana. Both candidates claimed victory, leading to a political and economic crisis with two competing governments.5 The provincial governors sided with Ratsiraka, and declared secession from the state. They and other AREMA supporters (Ratsiraka’s political party) mobilized a blockade of the capital, the stronghold of support for Ravalomanana. After several months of civil strife and economic disruption the standoff ended with victory for Ravalomanana and the departure of Ratsiraka into exile in France. The new government replaced the provincial governors with presidentially appointed representatives, but has yet to undertake the constitutional and legal changes to formalize this move. The status of political decentralization is uncertain; local communes remain the basic local unit of elected government, but until their relationship with the provinces is resolved, the extent to which they will receive additional financial and operational autonomy is unclear.6
2.3 Deconcentration and Service DeliveryIn terms of service delivery, the 1992 constitution laid the groundwork for moving toward decentralization and local management of services. Beginning in the mid-1990s, sectoral ministries took steps to shift some decision-making away from the center to lower levels, although most decisions and expenditure still take place centrally. Because lower level structures have little discretion in decision-making, it is more accurate to speak of deconcentration rather than decentralization. Deconcentration transfers responsibility for selected functions from central agencies in the capital to field offices of those agencies at lower levels.
5 The political crisis had serious impacts on the economy and on availability and use of basic services. See the analysis, for example, in Cornell University (2002), which shows impacts on incomes, health status, school attendance, and infant mortality. 6 For more detail on the role and operational procedures of communes in the context of decentralization, see World Bank (2003). For a general overview of governance and decentralization, see Gellar et al. (2001), and UNDP (2000).
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Central direction of those field offices takes place through control of the budget (see Annex 2), and through central ministry planning and oversight procedures.
Parallel to deconcentrated service delivery, local governments receive resource transfers from the center, earmarked for: a) basic investments, maintenance expenses, and procurement for public primary schools and health centers; b) the salary of the department head for the office of civil affairs and administrative services (l’Etat Civil); and c) the commune’s operating budget. Since 1997, Madagascar’s 1392 communes have received four central transfers. The amounts for health and education are based on a per commune resident formula (320 FMG/person for education, 400 FMG/person for health); the commune operating budget is also tied to population. Communes receive 30 million FMG per commune up to 7000 inhabitants; then over that number urban communes receive an additional 7000 FMG/person, and rural communes receive an additional 5000 FMG/person.7 Regarding the operating budget, the mayor prepares an annual plan for how he will spend the funds, which he submits to the Sous-Préfet for legal oversight (contrôle de légalité).
3. Health The following section provides an overview of the formal institutional structure in the health sector, and is followed by an analysis of formal accountability mechanisms, a description of how these mechanisms unfold in practice, an assessment of the types of pressures and constraints on district staff in terms of how this affects their ability to deliver services to the poor, and finally, provides an assessment of some of the factors that influence how district health staff allocate resources within their district.
3.1 Formal Health Structures and FunctionsAs noted, health, along with education, has a greater degree of deconcentrated recurrent budget expenditures than other sectors with 46% of recurrent spending at the center, 40% at the province and region, and 14% at the district.8 The majority of recurrent expenditure at the central and provincial levels gets absorbed by payments for salaries. In the study districts, the annual operating budget for the SSD is 250-275 million FMG, not including medicines.
The administrative hierarchy of structures in health is portrayed in Table 2.
Table 2. Health Structures by Level
Level StructureCenter Ministry of Health (MINSAN)
Central Purchasing Agency for Pharmaceuticals and Supplies-- Centrale d'Achats de Médicaments Essentiels et de Matériel Médical de Madagascar (SALAMA)
Province (Faritany) Inter-regional Directorate of Health (DIRSAN)
7 According to an interview with a senior staff member of the decentralization ministry, these figures have recently been changed. As of July 2003, $US 1 = 5,870 FMG.8 Figures from World Bank (2003).
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Level StructureDistrict (Fivondronana) District Health Office (SSD)
District General Pharmacy (PhaGDis)
District Hospital Center (CHD)
Commune (Firaisana) Local Health Post-- Centre de Santé de Base (CSB)
Community Pharmacy (PhaGCom)
Village (Fokotany) Centre de Santé de Base (CSB1 & CSB2)9
3.2 Health Functions by LevelThe following table summarizes the functions of the structures of the public health system by levels. There are 111 districts in Madagascar. The district health office, the SSD, is headed by the Médecin-inspecteur, who is the person responsible for assuring service delivery to residents of the district through the CSBs (1&2) and the district hospital (CHD1). The Médecin-inspecteur is in charge of all of the SSD functions listed in Table 3, supported by an administrator (adjoint administratif et financier) and another doctor (adjoint technique).
Table 3. Health Functions by Level
Level Formal FunctionsMINSAN Develops national health policy and regulations.
Prepares the budget.
Manages personnel according to civil service regulations, including hiring, promotions, and firing.; assigns doctors to posts.
Undertakes collection, monitoring, reporting, and analysis of national health data and statistics.
Carries out technical and financial oversight of the administrative units, laboratories, and health facilities under its jurisdiction.
DIRSAN Provides technical and financial oversight of the districts in the province.
Does province-level health planning to implement national policy, including preparation of an annual plan for the province.
Implements civil service personnel policy, including some health staff assignment to posts within the province.
Serves as the collection and transmission point for provincial health data.
SSD Provides supervision and quality control and training for service delivery of the primary care health posts (CSB1, CSB2), and one category of local hospital (CHD1).
Allocates staff among posts within the district (except for doctors).
Prepares an annual district workplan.
9 CSB1s are headed by a nurse or an aide-sanitaire, and CSB2s by a doctor.
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Level Formal Functions Executes the non-salary portion of the recurrent expenditure budget, and distributes
supplies among the health posts.
Compiles and reports on health statistics for the district.
CSB (1 & 2) Provides basic health services, undertakes community outreach and vaccination campaigns.
Collects and reports on health statistics.
Manages drugs and equipment allocated to them by the SSD.
Prepares annual workplans (new function– not yet in place)
A parallel, deconcentrated hierarchy exists for pharmaceutical supplies. At the center is SALAMA, the central purchasing entity for pharmaceuticals and medical supplies, which is charged with assuring stocks for hospitals and district health facilities. Local pharmacies carry out stocking and distribution at the district (PhaGDis) and community levels (PhaGCom). The operations of the PhaGDis are handled by what are referred to as NGOs, but in reality these are contractors, who in some cases also hold other posts within the hospital or government; thus they are not truly independent agents. The PhaGDis is located in the SSD; PhaGComs are located in the CSBs. At the community level, the pharmacy is overseen by a management committee (the COGE, Comité de gestion de la pharmacie à gestion communautaire), made up of a president, a treasurer, a dispenser, and the head of the CSB. The mayor pays the salary of the dispenser and of a guard for the CSB, though in Farafangana in a majority of cases there have been delays and gaps in these salary payments. Since the suspension of the cost-recovery scheme, these management committees do not appear to be active (see below).
Prior to the tenure of Minister Henriette Rahantalalao, MINSAN experimented with several pilot cost recovery schemes in pilot facilities, based on West African models where the money could be used for a variety of purposes. During the period, 1998-mid 2002, the health ministry installed a cost-recovery scheme for some pharmaceuticals and medical procedures, known as the PFU (participation financière des usagers).10 PFU funds were collected at the CSBs, and each month the chef-CSB would deposit the funds received in a bank account at the district headquarters and deliver the receipts to the SSD for accounting purposes. Minister Rahantalalao enforced the 35% markup, which left little money available for other purposes than restocking. Recently, MINSAN decided that some of the mark-up funds should be set aside in a special fund for indigent care. The amount decided upon was four percent of CSB receipts, a relatively small sum to meet the needs of the poorest users.
The PFU policy was suspended in July 2002 in response to the political crisis, with a six-month phase-out period, later extended to 12 months. However, in many CSBs the PFU has recently been relaunched on a semi-formal basis, although national policy now is that all pharmaceuticals and services are free. This was true of the CSBs in the two districts studied. The government
10 SALAMA buys medicines and sells them with a 35% mark-up to cover transport costs; this is a national norm even though transport costs vary. The PhaGDis sells drugs to the CSBs with a 6% markup to cover the costs of distribution and management. At the commune level the PhaGCom in the CSB sells drugs at a 35% markup.
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plans to restart the PFU in the near future, and is considering a number of ways to protect the very poor.11
3.3 Traditional Health Care It is important to recognize that in addition to the formal health system, there exists a set of traditional health practices and beliefs. These influence health care-seeking behaviors, particularly among rural people. Traditional caregivers are often both more accessible and more affordable to the poor. As the following box illustrates, they are in many cases the first source of health care sought by rural residents.
Box 1. Madagascar’s Traditional Healers
The term, ombiasy, can be roughly translated as traditional healers in Madagacar. As in many societies around the world, their role is to help maintain the spiritual and physical health of members of the community. Traditional belief systems view the spiritual and the physical as intimately connected. Ombiasy assistance is sought, especially by rural villagers, in curing ailments primarily with local herbs and forest resources. In rural areas where health care services are scarce, ombiasy are the first to be consulted. Only if their services fail do villagers turn to seeking care from the state health services. One of the constraints that inhibits people from seeking care from public health facilities is the frequent need for some payment in cash at the time of consultation. Ombiasy often accept payments in-kind or are are willing to spread payments over time. This flexibility, as well as their role in linking the spiritual and physical worlds, are two reasons why their status is so significant and an important factor in understanding how health services are used and perceived in Madagascar.
3.4 Health Service Delivery in Ambatofinandrahana and Farafangana
3.4.1 Context – AmbatofinandrahanaThe SSD in Ambatofinandrahana oversees one hospital (CHD2), 23 CSB1s, and nine CSB2s. Of the nine CSB2s, two are without doctors. Two private CSBs also operate in the district. The district is divided into nine communes with a total population of 121,878.
The residents of Ambatofinandrahana are predominantly of the Betsileo ethnic group, prevalent in the Fianarantsoa highlands. After the Betsileo, the Merina are the next most prevalent in the district, followed by Bara and some Antaisaka.12 As in much of the highlands, and indeed throughout the country, the Merina tend to be the Malagasy professional elite. Given the relative ethnic homogeneity of the district, key informants did not mention ethnicity as a factor in the allocation of staff or provision of services, and did not reference a role for traditional leaders. Nonetheless, family affiliation still appears to be an important element in social networks and ties.
In the western portion of the district, banditry and cattle theft contribute to rural insecurity, which affect the willingness of staff to be posted to remote CSBs and tend to discourage the SSD
11 For detailed discussion of the PFU, see the World Bank study by de Caluwé and Waty (2003).12 See Kottak (1980) for an anthropological study of Betsileo culture.
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from conducting supervisory visits to these CSBs.13 Several areas of the district have been categorized as “code red” for insecurity in the past.
3.4.2 Context – Farafangana In coastal Farafangana, the district health authority supervises 33 public health facilities: one hospital (CHD2), six CSB1s, and 27 CSB2s. Of the 27 CSB2s, three are closed, and five are operating without doctors. In addition to the public facilities, the district has five private health centers.
The district is composed of 30 communes with a total of 270,150 inhabitants. There are eight major ethnic groups in the region, with social organization centered around clans each descended from a common ancestor or sub-clan. The men are in charge of each structure and most decision-making. In each village, each clan has a traditional leader, or mpanjaka, who still plays an important role in village life.14 Ethnic identity plays an important role in Madagascar, as Box 2 indicates.
Box 2. Ethnic Identity in Madagascar
Much has been written about the role of ethnicity in Madagascar. While 18 different ethnic groups are recognized officially, in reality many more sub-groupings and classifications of identity exist and are important in explaining social relations and access to resources and power. For example in many regions, perhaps especially in the highlands, the former slave classes (mainty and andevo) continue to live in situations of semi-serfdom and thus find themselves economically and socially marginalized and vulnerable relative to descendants of either nobles (andriana) or free-born persons (hova). Clan and generational affiliations can also be important factors of social status locally. Beyond ethnicity, such sub classifications of social status also need to be considered. These ethnic and social distinctions can pose barriers to socio-economic advancement. For example, civil servants from mainty and andevo backgrounds are on occasion passed up for promotion or not allowed to occupy top positions.
Farafangana suffers from ethnic tensions, with conflict between two groups in particular-- the Antaifasy and the Zafisoro-- dating back to the 1850s when there were struggles over prime rice cultivation areas, and more recently erupting into violent conflict in 1947, again in 1989. and 1991.15 During the national political crisis in 2002 many Merina health staff fled to the north, though tensions have since subsided. There reportedly remain some sensitivities to the Merina, as having been slaveholders in the past and having dominated administrative positions in the French colonial government and subsequent governments. However, this dynamic is less important than the conflicts among ethnic groups within the region, although many medical personnel are Merina. These social tensions affect health care in several ways, as Box 3 illustrates.
Box 3. Ethnic Dimensions of Health Care in Farafangana13 See Fafchamps and Moser (2000) on rural crime and isolation in Madagascar.14 Rakotoarisoa (1986: 102-103) notes that the selection of the mpanjaka varies among different ethnic groups. In some the mpanjaka is an inherited role within a royal lineage, passed from father to son. In others, the mpanjaka is elected. 15 From UNICEF/MEN (1995).
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Tensions between Zafisoro, Antaifasy and Chinese in some cases affect the provision of health care in the following ways, according to several key informants. If a Zafisoro has gone to a health post, Antaifasy will not go there and vice versa. Resentment among the local population against the Chinese, who control a large share of the commerce of export crops in the region, can also at times translate into a refusal to frequent the same health post that Chinese clients use, particularly for women giving birth. The manifestation of these tensions and resentments is often veiled, couched in terms of taboos (fady).16
Several key informants reported that one of the ways that the government has dealt with the tension between the Zafisoro and the Antaifasy is to ensure a balanced ethnicity among the two elected national representatives; thus if the deputy is Zafisoro the other deputy will tend to be Antaifasy.17 Thus, as elected representatives press for health infrastructure in their area, they tend to try to balance things so that if a post is built in a Zafisoro area, one must also be built in an Antaifasy area. Thus, there are some cases where two health posts are located 2,000 meters apart, but clients of one will generally not visit the other. One of the largest neutral tribes, the Antaisaka, also feel that because they are not in conflict, they receive less attention and fewer resources. However, upon closer examination, on a per capita basis, this did not appear to hold true although the two competing regions did have more health posts, as this table shows.
CSBs per Person by Dominant Ethnic Group
Dominant Ethnic
Group in CSB Area*
Population (in CSB area)
Number of CSBs
Persons per CSB
Antaisaka 11,318 2 5,659
Antaifasy 39,469 6 6,578
Zafisoro 75,560 8 9,445
*Other CSB areas did not have one of these dominant groups and has not been included in this analysis.
3.4.3 Accountability: The District PerspectiveAs would be expected, accountability in the SSD is oriented upward towards the Ministry of Health and the DIRESEB, rather than down towards the communities or clients. Decision-making at the district and facility levels is highly constrained by policies and instructions from higher administrative levels, the DIRSAN and MINSAN.
16 According to UNICEF/MEN (1995), the Chinese practice of eating dog meat is considered taboo and may contribute to some of the tension : “En conséquence, tout mariage contracté avec les chinois(es) réputés comme un animal sale et méprisable, dans la tradition locale. La plus abominable des injures serait de comparer une personne à un chien (biby ratsy). On risque la peine capitale si on enfreint cette coutume : « rejet du kibory ». De tel fady laisse donc apparaître la hiérarchisation que les Malagasy ont établi entre les différents éléments de son monde environnant.” 17 In fact, central government interventions to assuage these tensions goes back to the 1890s when the colonial administration imposed a series of measures to reconcile the two groups (Ibid.).
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Reporting RelationshipsEffective accountability includes the obligation to provide information. At present, this information flow is primarily upwards from the CSBs to the SSD to the DIRESEB and MINSAN, with directives flowing in the opposite direction. SSDs hold monthly meetings with heads of CSBs to review progress on the district annual plans; these are based on a standard monthly activity form submitted by the CSBs to the SSD. In turn SSDs provide monthly, quarterly, and annual reports to the DIRSAN and the MINSAN on the following:
Staffing levels and vacancies, Financial audit information and status of recurrent budget expenditure, PFU accounting records from the PhaGComs and the PhaGDis, Activities, accomplishments, and issues.
None of the forms have a space reserved for reporting on poverty-focused expenditures, activities related to the poor and indigent, or outcomes broken out by poverty categories of any sort. Poverty data are not available at the districts that would allow for such reporting even if forms requested it.
The SSDs’ periodic reporting is punctuated by ad hoc demands from the MINSAN for additional information—sometimes passed on through the province-level directorates, but sometimes directly from the center. SSD staff interviewed said that frequently they received requests for further information related to a specific situation, for example, on outbreaks of a particular disease, or for explanation of information provided in a previously submitted report. Donor projects are another source of accountability pressures. These pressures are mainly expressed through MINSAN channels, where central ministry staff responsible for donor projects ask SSDs for information in response to project reporting requirements. In some cases, for example many USAID projects, there are specific reporting requirements, usually fulfilled by technical assistance contractors, but their counterparts in the SSDs often contribute to supplying the information.
Financial AccountabilityKey informant interviews revealed an overwhelming preoccupation with financial reporting in the SSDs in both districts at the expense of performance accountability. Preparing paperwork for purchases, documenting expenditures, retrieving and delivering supplies and equipment purchased, conducting audits and inspections, maintaining records and inventories, and reporting on these consume significant amounts of time and energy of district office staff, mainly the administrative adjoints and the office directors. The SSD heads, when asked what percentage of their time they spent on bureaucratic paperwork, provided estimates ranging from around 25% to 66%.18 According to the CDE Office in Manakara, which serves Farafangana, the SSD staff make the three-hour trip to Manakara for procurement issues two to three times per month. CSB staff also reported spending significant time filling in forms to estimate the value of materials used, even when in small quantities (i.e. the percentage of a bottle of alcohol used in a given month). This preoccupation reflects the importance of effective financial accountability in a situation such as Madagascar’s, of scarce and precious resources, and of widely perceived
18 This was defined as paperwork related to both financial and personnel management.
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problems of leakage, abuse, and corruption.19 The previous health minister instituted a system of annual audits throughout the health system in an effort to address such problems.
Limited capacity and limited resources available to the various actors to carry out financial oversight constrains the effectiveness of the procedures that are nominally in place at all levels in Madagascar, as noted in a variety of studies.20 At the district level, for example, the head of the CDE Office somewhat ruefully noted that he and his small staff could not always do the level of crosschecking he felt was necessary to assure the correctness of all expenditures. In particular, he noted the difficulty of knowing the correct unit prices for spare parts for vehicles. In interviews with SSD staff, they indicated that lack of vehicles, and lack of road access, made it difficult to reach all the health facilities in their districts, which hampered their ability to verify financial reports sent by the CSBs.
Thus, in spite of the focus on financial accountability, certain areas of potential leakage remain. For example, delays in authorizing annual operating budget credits in past years have reportedly forced some district authorities (not SSDs specifically) to rely only on those suppliers who would provide goods on credit thus eliminating the competitiveness of bids and price quotes. In addition, budgets for line items such as vehicle maintenance and fuel were markedly different for an SSD versus a CISCO in the same district, which suggests the possibility of leakage to non-official uses.21 In addition, although procurement of things like office furniture and supplies include extensive steps and forms to ensure financial accountability, for those CSBs that are some distance from the district capital, the lack of transport means that it is difficult to check whether such supplies are actually in use in the proper places.
Further, other studies have documented the common practice of CSBs charging consumers higher than official prices for medicines or for services. As the current administrative system focuses on accounting for the resources given from the center, rather than from the communities, this practice is not recognized in any official way. One consequence is that local populations sometimes feel taken advantage of, and question whether they are getting real medicines or just packets of other substances. This contributes to undermining trust in service providers.
Performance Accountability
Formal PlanningPerforming according to acceptable targets requires a process of planning performance targets, in line with available human and financial resources. The formal operational framework for performance accountability for SSDs is the annual workplan (plan de travail annuel, or PTA).22
19 See for example the USAID study of corruption in Madagascar: Brinkerhoff and Fox (1999). 20 See the World Bank’s public expenditure tracking surveys that are investigating financial leakages. See also the discussion of national audit agencies in Brinkerhoff and Fox (1999).21 40 million FMG for vehicle maintenance for one car and four motorcycles for an SSD versus 8 million for the one car for CISCO. 22 Interviewees mentioned a recent shift in workplans toward a “business plan” model. The terminology stems from President Ravalomanana’s private sector background, and reflects the intent to plan sector programs from a more
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The PTA becomes the benchmark for reporting progress to ministerial authorities at the provincial and central levels. Monthly, quarterly and annual reports provide progress updates against the PTA. According to interviewees, the formats of the PTAs and reports vary slightly depending upon who the minister is and his/her preferences, but tend to contain the same kind of information. In Farafangana, for example, the 2003 SSD PTA includes five general objectives:
Promote maternal and child health Combat infectious diseases Combat non-infectious diseases Combat malnutrition Improve the district health system.
These general objectives are the same ones that the MINSAN lists as its national objectives.23
The PTA emphasizes inputs and activities, rather than results and outcomes. The plan does not have a specific focus on reaching the poor with services. The enumeration of funding sources indicates that almost all programmatic activities (as opposed to salaries and maintenance) are heavily donor-funded. Thus, the SSD’s objectives reflect: a) the stated objectives of the central ministry, and b) donor priorities of their vertical programs, such as maternal and child health, child nutrition, family planning, vaccinations, HIV/AIDS, and so on. As the following box indicates, the influence of donors can skew priorities.
Although Médecins-inspecteur have relevant knowledge related to facilities placement, the SSD tends not to be consulted by higher MINSAN authorities in planning or deciding upon investments in new CSBs. As the discussion below on political accountability indicates, these decisions are strongly influenced by political dynamics at both the national and commune levels.
Box 4. An NGO Perspective on Local Program Planning and Priorities
An NGO staff from a neighboring district reported:
Donors want to apply their own agenda for vaccinations or other vertical programs that do not always match local needs. For example, Bill Gates [the Gates Foundation] wanted to finance certain actions, or Smith Klein Beacham went to Donor A saying it had hepatitis vaccine to offer. But this is not a big problem here – our priorities are more diarrhea and malaria, which contribute to one of the highest infant mortality rates in the country. However, because it is a gift, and people do not have other sources of financing, people are now getting hepatitis vaccine. We ourselves get 50% of our financing from one donor, and therefore hesitate to put forth other priorities as we risk losing our funding. Donors themselves are under pressure to report back on certain agreed priorities.
SupervisionAt the district level, SSD staff seek to ensure adequate performance through two avenues other than written reports. These are:
strategic perspective. Nobody could produce an example of a “business plan,” but from the description it appears to include planning and analysis techniques drawn from private sector strategic management. 23 In the Farafangana SSD workplan the general objectives are subdivided into specific objectives and related activities, followed by a listing of the responsible entity by activity and a rough timeline.
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Field visits to facilities . A supervisory visit to a CSB can involve the following oversight functions: verification of accounting/financial records; verification of stocks of pharmaceuticals, equipment, supplies; assessment of the status of the CSB physical plant; and review of vaccination records, patient records and services provided. Which of these areas is emphasized during a particular field visit depends upon who from the SSD conducts it. If the Médecin-inspecteur does the visit, all aspects are covered.
Monthly meetings in the district capital . These sessions are held at the SSD and are attended by all heads of CSBs. They combine financial review, reporting on the PFU, programmatic and technical oversight, and staff training. The monthly activity forms that the CSBs submit to the SSD are discussed and questions raised and answered. The SSD staff use the results of these meetings to prepare the monthly synthesis reports that they send upward to the DIRSAN and the MINSAN.24
Human Resource ManagementA key tool in ensuring performance is the feedback and incentives provided to staff in their performance evaluation process. First and foremost, the fragmentation of responsibility for personnel management influences the SSD’s ability to address staff performance and hold them accountable. All personnel actions related to doctors are handled at the central level; this includes postings, promotions, and salary issues. To deal with any sort of performance issue concerning a doctor, the Médecin-inspecteur must ultimately refer the matter to a higher level. This orients most personnel issues upwards to the center, and limits the SSD’s ability to resolve problems. As an interviewee put it, “We send complaints to MINSAN all the time about unqualified personnel, but we don’t receive answers.” For nurses and other paramedical staff, the Médecin-inspecteur has more direct power to hold them accountable and sanction non-performance because of his/her status as a doctor vis à vis medical personnel in a more subordinate category. Interviewees mentioned that this means that when the Médecin-inspecteur conducts supervisory visits to CSB1s, which are not headed by a doctor, he or she is in a stronger position to exercise oversight than when visiting CSB2s, where the relationship with the head of the CSB2 is on a more equal professional footing. Overall, however, as this box illustrates, performance evaluation is poorly understood and little used.
Box 5. Defining Good Performance – CSB Staff Perspectives
When asked about the performance evaluation process, and the definition of good performance CSB staff had the following responses:
24 At the provincial level the DIRSAN holds monthly meetings of the heads of the SSDs in the province with basically the same agenda as the district-level sessions. Training is less a focus, though the province holds periodic workshops on technical topics for district staff.
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“I do not know if there is a performance evaluation, who does it, or what the criteria are. I know there is a file on me somewhere but I think it is secret and I think it must be someone in the Ministry who has it. I do not know who evaluates me.”
“I know one time we did a good job because the Médecin-inspecteur came here and all of our program signs (leprosy, family planning, etc.) were displayed and we had a neat fence around the health center. I think the doctor was given some sort of an informal bonus. We also have to have good relations with the mayor, who we have been told is our local supervisor.”
“Doing a good job means filling in all the forms by the end of the month and posting the amount generated from PFU (when this was functioning) on a big public table at the SSD each month. Those who had a blank were in trouble.”
A second human resources factor affecting performance accountability is the absence of sufficient staff. In both districts, SSD staff pointed out vacancies in CSBs and the difficulties of maintaining service delivery with insufficient staff to fill positions. This lack of staff shifts the concern of the Médecin-inspecteur and the community wanting an operational CSB away from whether staff are doing their jobs to simply getting someone in place; the concern with performance, not strong in the first place, is further diminished.
Role of CommunitiesThere seems to be almost no role for health service users in performance accountability. In terms of community involvement in the provision of health care, in all cases key informants referred to the role of the community in helping the CSB. Thus, the most commonly cited roles for communities were:
To provide community contributions in labor to the construction of CSBs;25
To provide financing through the mayor for CSB staff, housing, and equipment; To provide people to help with the vaccination campaigns.
Absent were any references among SSD, CSB or other key informants to communities as clients with views to be considered. To the extent that could be determined, SSD staff conducting field visits to CSBs do not, as a matter of course, contact service users in the community regarding their views on services provided.
Interviewees mentioned that in the past some donor projects had funded community health committees, which played a role in community outreach and in marketing of family planning. However, with the termination of those donor projects, and the suspension of the PFU (which may have indirectly benefited the committees as contraceptives were allowed to be resold with a small markup), none of the CSBs visited were able to cite such a group. In addition, interviews with other donors confirmed that these organizations had diminished or dissolved.
25 Contributions of labor have a long history in Madagascar and often resurface in local memory. Corvée labor was extensively used by the French, and subsequent administrations have often called on community contributions for activities such as reforestation.
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The SSD receives some complaints about absences and lack of staff from mayors and traditional community leaders. However, direct downward performance accountability to service users is nonexistent. Interestingly, the Médecin-inspecteur in Ambatofinandrahana mentioned having received a MINSAN letter in April of this year instructing CSBs to set up a complaints file (cahier de doléances), which indicates some central-level concern with at least recording information on health service users’ views. During the interview he raised the question, but who is going to fill it out? As numerous interviewees confirmed, the Malagasy culture of nonconfrontation, the respect for authority, particularly for medical personnel, not to mention fear of retribution (e.g., treatment denied) and low literacy rates, all make it unlikely that such a file would yield much useful feedback on performance (see Box 6).
Political Accountability
National LevelRecent governments have shown some responsiveness to citizens’ expressed desires for increased availability and quality of basic services.26 Under the Ratsiraka government, the MINSAN, led by the dynamic and autocratic minister, Henriette Rahantalalao, assigned 1000 new doctors to rural areas of the country in 1998, which led to a noticeable increase in the quality of services available in CSBs. Many of these doctors are still at their posts, though they are now tending to see patients on the side in private practice as well as at the public facility. The doctors were willing to go to the rural areas because at the time there were 3000 unemployed physicians in Madagascar. The Ravalomanana government’s health policy statements espouse an interest in service delivery and rural outreach. One concrete manifestation of this policy is the use of resources from the Fonds d’Intervention pour le Développement (FID), a World Bank-funded social fund managed out of the prime minister’s office, to construct health facilities.27
However, the FID program allocates resources for investments in new health posts based on political demand, rather than on technocratic criteria. Thus, the Médecin-inspecteur of one district reported that there was typically no consultation on FID projects prior to the selection of the locale for a health post with regard to whether it was justified with respect to the number of people in the area. This practice illustrates a classic tension between political and performance accountability. Favoring political criteria for investment dilutes the Ministry of Health’s accountability for the quality of service or overall performance on output indicators as some of these posts have no staff.
District LevelPolitical accountability at the district level involves relations with mayors and other local officials, and with district representatives in the National Assembly (deputés). The SSDs are perceived as representing the MINSAN locally so these political actors press the SSDs to assign staff to fill empty slots in CSBs and in some cases to establish new CSBs in communities without access to health services, even though assignment of doctors and facility placement are not decisions that can be taken by SSDs. Sometimes they come directly to the SSD to meet with
26 For more detail on health service utilization and demand, see Glick et al. (2000).27 The FID, which has been in operation approximately ten years, provides resources for the construction of rural infrastructure, with a 20% local matching contribution.
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the Médecin-inspecteur to express their views, but they also seek responsiveness from higher levels, going to the MINSAN in Antananarivo or the DIRSAN in the provincial capital. The tendency to bypass the SSD, particularly on staffing issues, reflects: a) these actors’ accurate perception of the district office’s lack of power and authority regarding personnel, and b) their efforts to seek to pressure the SSD by influencing higher-level actors in the health bureaucracy.
The nature of the interactions between local politicians and the SSDs are influenced by the personalities of the people involved. Some SSD staff rebuff what they perceive as political interference. For example, the Médecin-inspecteur in Farafangana indicated that if she perceives a local official trying to “play politics” with the SSD, she suggests that they speak to the Sous-préfet. Some politicians are not above retaliating against service delivery staff that they feel have challenged them, as Box 10 illustrates.
Linked to the availability of services in rural areas is the issue of CSB staff absenteeism, which was mentioned in numerous interviews. When CSB staff want to leave their posts, they must get a carnet de déplacement from the mayor authorizing the absence. If the staff member is visiting the SSD, the head of the administrative unit signs and dates the carnet for the return trip, and the staff member presents it to the mayor upon arrival. The extent to which this official system is followed in the districts visited could not be determined.
Mayors and CommunitiesAn important gap in political accountability exists between mayors and their communities. Mayors, as mentioned above in the governance section, receive central transfers earmarked for health. However, in the villages visited it appeared that one-half or less of those funds were allocated to health expenditure, primarily salaries for the guard and pharmacist. Of this half, only about a quarter (in Farafangana) was paid. Mayors do not appear to be accountable for the use of these funds for a variety of reasons:
They were elected in November 1999 under the previous government and feel little obligation to the current administration. This will presumably change with the upcoming elections.
The lack of a banking system at the local level makes financial control and accountability very difficult. Mayors go to larger towns to physically collect the earmarked funds credits and because there is no place in their offices to safely keep the money they take it home. It is nearly impossible to track uses of funds and avoid mixing various funds together. This problem is aggravated by an insufficiency of government receipt forms for communes, so mayors buy receipt books of various kinds.
An acceptance on the part of local communities that politicians will profit socially and economically from their elected positions, coupled with the hope that they will share some of the spoils or at least not bring grief to their constituents. This tolerance and lack of questioning mean that citizens would hesitate to call their mayors to account (see Box 6).
Box 6. Social Relations with Local Officials
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Unlike Western models of democracy, where citizens see their local elected representatives and public service providers as “servants of the community,” and where these officials seek out citizens’ views and respond to their demands, in Madagascar the citizen-government official relationship is commonly described by way of analogy to parental and familial roles. However, relations between citizens and officials have less to do with a culture of parental deference than with power. People understand that state agents have control over assets and services, and have the power to inflict real damage: to imprison, to call gendarmes, to impose fines, or to deny access to government resources. Another factor is that, particularly in rural areas where government services are not available, citizens’ expectations of government are low, and thus they have little inclination to express demands since in their view such demands are unlikely to generate a response.
While it is true that direct criticisms and confrontations are generally shunned in Malagasy culture, people still have many means for expressing displeasure, even towards those in positions of power. Rural and poor Malagasy make use of the “weapons of the weak:” gossip, sabotage, accusations of witchcraft, withdrawal, and avoidance. These measures may not be direct, but they can be effective. For example, in one area villagers were upset with the way in which a school feeding program was being managed. During the night, someone climbed through a window of the school and deposited human feces on one of the tables. This act brought the program to an immediate halt since the area was believed to have been polluted. The only way to cleanse the room was to make a ritual sacrifice of an ox. However, no one in the community would come forward with a donation of an animal and the program was stalled until an adequate solution could be found.
These patterns of social relations influence people’s interactions with health care providers. With limited medical personnel in most rural villages – where everyone knows each other – residents hesitate to express a critical view of services. They experience the added fear of displeasing the sole caregiver, which could result in: a) poor medical care, or b) prompting a transfer of the staff. Often, their incentive is to keep the scarce medical staff in the village, and therefore not to lodge a complaint of any type.
Accountability in Practice: Discretion and SanctionsAs the above discussion of deconcentrated health service delivery makes clear, the extent of formal discretionary decision-making at the district and facility level is generally quite limited, despite some latitude in dealing with local politicians. In other words, although the SSDs formally control the execution of much of the operational budget, most categories of expenditure are actually decided upon at the ministry level. Similarly, although the SSDs nominally manage staff, they cannot promote them, reassign them, or fire them. SSDs may want to initiate planning based on local problems, but must maneuver through the vertical programs supported by donors in order to access resources and please their superiors in the MINSAN with little reward for doing a good job on output measures. Regarding functions besides financing, discretion in the SSD and the CSB is constrained by a combination of MINSAN and donor policy and program priorities. Table 4 summarizes the picture of formal discretion for both the district office and the CSBs.
Table 4. Degree of Formal Decision-Making Discretion: SSD and CSB
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Functions Degree of Discretion
Role of SSD Role of CSB
Planning Policy formulation
Program/project design
SSD: Limited
CSB: Minimal to None
No role in policy, sets district priorities in line with MINSAN and donor sectoral policies, prepares annual district workplan.
No role in policy, new for 2003 is a facility-level annual workplan.
Finance Revenue collection
Budgeting, revenue allocation
Expenditure management and accounting
Financial audit
SSD and CSB: Minimal to None
Oversees PFU accounts, prepares annual operating budget, executes budget according to official procedures, reports on spending, audits CSBs
Collects PFU funds.
Human Resources Staffing (planning, hiring, firing,
evaluation)
Salaries and benefits
Training
SSD: Medium
CSB: Minimal to None
Submits staffing needs to DIRSAN and MINSAN. Assigns staff, other than doctors, to posts. Provides input to personnel files. Distributes salaries; no role in setting pay rates or benefits. Provides some training to CSB staff.
Submits staffing needs to SSD. Attends training sessions. Chef-CSB supervises other CSB staff.
Service Delivery Defining service packages
Targeting service delivery
Setting norms, standards, regulations
Monitoring and oversight of service providers
User participation
Contracting
SSD: Medium
CSB: Limited
Contributes to service package definition and targeting within MINSAN and donor guidelines, applies national norms and regulations, monitors and supervises CSBs in district.
Implements service packages according to district workplan, targets local populations, monitors community needs, undertakes some outreach, particularly vaccinations.
Operation and Maintenance Drugs and supplies (ordering,
payment, inventory)
Vehicles and equipment
Facilities and infrastructure
SSD: Medium to Limited
CSB: Medium to Limited
Primary responsibility for district operation and maintenance functions, funded through annual recurrent budget and drugs through PFU. Little discretion within public expenditure rules.
Primary responsibility for facility-level operation and maintenance functions. Oversees PhaGCom accounting and inventory, orders restocking as needed.
Information Management Health information systems
(HIS) design
Data collection, processing, and analysis
Dissemination of information to various stakeholders
SSD: Limited
CSB: Minimal to None
No role in HIS design, collects health data and sends to DIRSAN and MINSAN, appears to play little role in data processing or analysis. Does some dissemination as part of service delivery.
Collects health and epidemiological data for transmission to higher levels, no role in analysis, some dissemination through community outreach and interaction with local officials.
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Formal DiscretionThe areas where the SSD has some discretion include:
Providing limited reimbursement for travel or per diems for some CSB staff (though many reported using their own funds to travel),
Commenting on the monthly activity plans submitted by CSBs, Reassigning non-medical staff within the district, Controlling use of vehicles,28
Controlling the distribution of supplies and equipment among CSBs.
In terms of financial decision-making, SSDs and CSBs are largely constrained by the legal requirements for public expenditure and paperwork-intensive procedures, which allow SSD managers very little flexibility (see Annex 2). The MINSAN provides a relatively standard operating budget each year (increased by 10% per annum), and once the annual budget is set, SSDs have the authority to shift funds only among budget paragraphs within the same chapter. Thus, in the case of Farafangana’s operating budget (Table 5), about 27% of the SSD’s recurrent budget is allocated to areas where movements can be made among paragraphs, and which are allocated at least in part to CSBs (not fixed costs such as fuel for refrigerators which is pre-determined and applies to all CSBs with refrigerators). Thus, the financial resources available for some narrow level of SSD discretion are both: a) a minor percentage of the recurrent budget, and b) a small sum in the aggregate, representing only about 76 million FMG.29
Table 5. Farafangana SSD Operating Budget 2003, Chapters and Paragraphs*
Budget Classification
Line Item Title Amount % of Line Item Spent on SSD Office
IMMOBILISATIONS CORPORELLES
Chapitre ACHAT DE MATERIELS ET OUTILLAGES 54,813,000
Paragraphe Materiels techniques 30,813,00010%
Paragraphe Materiels et mobiliers de bureau 20,000,000
Paragraphe Materiels et mobiliers de logement 4,000,000100%
CHARGES DE PERSONNEL
Chapitre SALAIRES ET ACCESSOIRES 9,964,000 50%
Paragraphe Personnels non permanents 9,964,000
Chapitre CHARGES SOCIALES ET PATRONALES 1,488,000
Paragraphe Cotisations a la Cnaps 1,488,000
ACHATS DE BIENS
Chapitre ACHATS DE BIENS DE FONCTIONNEMENT 30,475,000
Paragraphe Fournitures et articles de bureau 15,475,000 80%
28 In some cases, donor procedures limit this discretion; for example, in coastal districts of Fianarantsoa USAID’s Linkages Project provided vehicles to some SSDs, with USAID-specific accountability and reporting for their use assigned to individuals other than the head of the SSD.29 It is interesting to note that in spite of the common complaint among SSD and CSB staff of the lack of transport to effectively carry out their jobs, none of the vehicles in the districts had been purchased with government funds. The combination of small amounts of funds available plus the lack of discretion over their use precludes SSDs from purchasing vehicles.
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Budget Classification
Line Item Title Amount % of Line Item Spent on SSD Office
Paragraphe Imprimes, cachets, documentations administratifs 3,000,000100%
Paragraphe Consomptibles informatiques 12,000,000100%
Chapitre ACHATS DE BIENS A USAGES SPECIFIQUES 1,830,000
Paragraphe Fournitures menageres 1,830,00050%
Chapitre CARBURANTS-LUBRIFIANTS-COMBUSTIBLES 34,000,000
Paragraphe Carburants et Lubrifiants 14,000,000100%
Paragraphe Autres Combustibles (Petrole)** 20,000,0000%
ACHATS DE SERVICES
Chapitre ENTRETIEN ET MAINTENANCE 100,275,000
Paragraphe Entretien des batiments 57,319,250100%
Paragraphe Entretien des vehicules 40,000,000100%
Paragraphe Maintenance du materiel informatique 2,955,750100%
Chapitre CHARGES DE TRANSPORTS 2,000,000
Paragraphe Frais de deplacements interieur 1,000,000100%
Paragraphe Transports administratifs 1,000,000100%
Chapitre INDEMNITES DE MISSION 20,330,000
Paragraphe Indemnites de mission interieur 20,330,00060%
CHARGES PERMANENTES
Chapitre EAU ET ELECTRICITE 12,000,000
Paragraphe Eau et electricite 12,000,000100%
Chapitre POSTES ET TELECOMMUNICATIONS 8,000,000
Paragraphe Frais postaux 1,250,000100%
Paragraphe Redevances telephoniques 6,750,000100%
TOTAL 275,175,00081%
*Shaded areas indicate where the SSD can move funds within the same budget chapter. Data are from the SSD’s annual operating budget, figures are amounts allocated to each chapter.
* *This line item is allocated to kerosene to power CSB refrigerators.
Financial discretion in the use of PFU funds has been limited. The former health minister, Henriette Rahantalalao, allowed the mark-up funds to be used solely for restocking of pharmaceuticals. Before the end of the PFU, the minister decreed on a one-time basis that 50% of the PFU funds in district accounts should be transferred to the MINSAN for central procurement of materials. The ministry purchased a) a second-hand cobalt radiotherapy machine that was three years old, and b) large amounts of equipment and supplies for CSBs, which have recently begun to arrive in-country, though none of these resources had reached the districts visited.
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Informal DiscretionHowever, even in administrative structures with low degrees of formal decision-making discretion and restrictive procedural requirements, people find ways of coping so as to expand the decision space available to them. Particularly in remote CSBs in the hinterlands of Ambatofinandrahana and Farafangana where, as interviewees noted, supervision is rare, CSB staff have informal understandings with their SSD about permissible activities and practices. The scarcity of resources relative to need tends to lead to informal choices in resource allocation, which have an effect on the equitable distribution of health services. SSDs in the two districts studied devoted between one half (Ambatofinandrahana) and one fifth (Farafangana) of their operational budgets (excluding the CHD) to equipment, supplies, furniture, fuel, transport costs and per diems for CSBs. The criteria for how to distribute these resources tended to be informal and varied. In making decisions about restocking supplies for CSBs, the SSD in Ambatofinandrahana uses need plus accessibility as criteria; so if the CSB is only accessible during the dry season, the SSD will manipulate the budget to allow the Chef-CSB to order more supplies than immediately necessary and stockpile the oversupply for the rainy season. In Farafangana, the Médecin-inspecteur noted that she purchases at least one mattress for every CSB per year, and that the priorities are set by type of materials (for example mattresses taking priority over office equipment).30
Table 6 provides some data on distance and accessibility factors in Farafangana. With regard to the allocation of a key resource – transport – there appears to be no correlation with distance, and this emerged as the legacy of donor-supported projects. Where a donor happened to intervene, health staff received a bicycle or a motorbike but this allocation was not based on a district-wide analysis of need.
Table 6. Distance and Accessibility Factors in the Farafangana SSD
Name of CSB
Travel Time
SSD to CSB
(hours)Months
Accessible
Transport Equipment Available
Dominant Ethnic Group
Months Salary Paid/Total Months for which data available
% of time commune
pays salary
(supposed to =100%)
Population pertaining
to CSBPharmacist Guardian
CSB2 Farafangana 12 Mixed N/A N/A N/ACSB2 Anosivelo 0.5 12 Antaifasy 2 of 15 2 of 15 13% 7168
CSB2 Anosy Tsararafa 0.75 12 Antaifasy 9 of 15 9 of 15 60% 16785
CSB1Mahabo Mananiv 1 12 Antaisaka 3 of 27 3 of 27 11% 6941
CSB2 Manambotra 1 12 Antaifasy 4 of 15 4 of 15 27% 3250
CSB2 Vohimasy 1 12 Mixed 7 of 15 7 of 15 47% 4640
CSB2 Ambohigogo 2 12 Motorcycle N/A 1 of 15 1 of 15 7% 9101
CSB2 Amporoforo 2 12 Zafisoro 9419
30 Another informal criterion for how the Médecin-inspecteur distributes resources, though not a major one, is whether the CSB has the physical room to accommodate equipment and furniture. In six CSBs in Farafangana, according to her, there is no room for materials or furniture so they do not receive these (Etsingilo, Ambalavato, Firifiry, Iabdrani/Namohora, Sarinosy, Vohilava).
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Name of CSB
Travel Time
SSD to CSB
(hours)Months
Accessible
Transport Equipment Available
Dominant Ethnic Group
Months Salary Paid/Total Months for which data available
% of time commune
pays salary
(supposed to =100%)
Population pertaining
to CSBPharmacist Guardian
CSB2 Ankarana 2 12 Motorcycle Mixed 5 of 15 5 of 15 33% 8176
CSB2 Efatsy 2 12 Mixed 7 of 27 7 of 27 26% 9382
CSB2 Vohilava 2 12 N/A 0 of 5 0 of 5 0% 6319
CSB2 Vohitromby 2 12 Antaifasy 4 of 15 4 of 15 27% 3032
2 hours or less
Average:
25%
Atisiranambe 3 10 Antaisaka 2 of 15 2 of 15 13% 4377
Iabohazo 3 10 Antaifasy 3 of 15 3 of 15 20% 4715
Ivandrika 3 10 Motorcycle Antaifasy 4 of 15 4 of 15 27% 4519
CSB2 Maheriraty 3 10 Mixed 0 of 18 0 of 18 0% 4916
CSB2Comm Rurale Fenoaviro 4 0 N/A
CSB1 Mahafasa 5 12 Zafisoro 3 of 20 3 of 20 15% 8557
CSB2 Mahavelo 5 12 Zafisoro 3 of 15 3 of 15 20% 8462
3 to 5 hours
Average:
16%
CSB2Ambohimandroso 6 10 Motorcycle Mixed 3 of 15 3 of 15 20% 10477
CSB1 Etrotroka 6 10 Mixed 0 of 15 0 of 15 0% 16135
CSB2 Ihorombe 7 10 Mixed Antaifasy 3 of 15 3 of 15 20% 6695
CSB1 Tangainony 7 12 Zafisoro 5 of 15 5 of 15 33% 11699
CSB2Comm Rurale Tovona 8 N/A
CSB2 Etsingilo 8 6 Bicycle N/A 4 of 15 4 of 15 27% 2378
CSB2 Evato 8 12 Zafisoro 3 of 15 3 of 15 20% 14149
6 to 8 hours
Average:
20%
CSB2 Ambalavato 9 6 Zafisoro 3 of 15 3 of 15 20% 3642
CSB2 Sarinosy 9 9 N/A 0 of 15 0 of 15 0% 4519
CSB2 Bevoay 10 9 Mixed 2 of 15 2 of 15 N/A 5761
CSB2 Firifiry 10 0 N/A 4 of 15 4 of 15 27% 2347
CSB2 Iaborano Nam 10 10 Bicycle N/A 3 of 15 3 of 15 20% 4337
CSB1 Vohilengo 10 9 Zafisoro 2 of 15 2 of 15 13% 10067
CSB2 Marovandrika 11 3 Zafisoro 3 of 15 3 of 15 20% 3511
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Name of CSB
Travel Time
SSD to CSB
(hours)Months
Accessible
Transport Equipment Available
Dominant Ethnic Group
Months Salary Paid/Total Months for which data available
% of time commune
pays salary
(supposed to =100%)
Population pertaining
to CSBPharmacist Guardian
CSB1 Ambalatany 15 9 Zafisoro 3 of 27 3 of 27 11% 14516
CSB2 Ambalatraka 18 N/A 0 of 15 0 of 15 0%
CSB2Comm Rurale Sagamadio 18 N/A N/A N/A N/A N/A N/A
9 hours or more
Average:
14%
Another example of informal discretion comes from Farafangana. At the time of the monthly meeting of the expanded district management team (EMAD élargie), which includes all the Chefs-CSB, there is an informal understanding that the Chefs-CSB will stay in town for several additional days following the meeting. The official reason is to take care of collecting supplies and handling other CSB business; however, unofficially this practice recognizes that some of the Chefs-CSB maintain a second home in town where their families live and their children go to school, and that they need to spend time there.
Another classic strategy for increasing decision-making discretion is to bend the formal rules or make changes and then see if there are any negative consequences. Here is a quote from an interview that illustrates this:
I don’t like filling out repetitious forms that aren’t useful. We get lots for requests from the MINSAN and from donors for this and that sort of information, and I make adjustments in what I provide depending upon what is happening in my district and the needs here. Maybe they don’t like it that I do that, but so far nobody has complained to me.
It is likely that there are other instances where district and facility staff have selectively complied with directives from the center, or even ignored them, and have not been subjected to sanctions. Several interviewees, in fact, mentioned that information sent upwards rarely receives a response. A review of monthly activity reports for the facilities visited showed that SSD supervisors seldom commented on substance, but where there were comments they tended to be corrections on math or inconsistencies in how the form was filled out.
SanctionsSanctions serve to reinforce accountability. In the SSDs visited, the strictest sanctions were imposed for the misuse of funds, as reflected in the close attention paid to following financial procedures. There appear to be few sanctions related to performance or service quality. Interviewees mentioned criticism for filling out forms incompletely or incorrectly, not for performance failures. The workplans, reporting, and health statistics forms reveal a nominal performance orientation, e.g., use of strategic objectives and Logical Frameworks, but no-one focused on health impacts or targets. According to MINSAN interviews, the current minister does not have a strong performance orientation. In contrast, the previous health minister did not
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hesitate to suspend, transfer or publicly scold staff who were not considered to have performed. In fact, one of the most potent sanctions mentioned by health sector staff used by the Ministry is transferring from one location to another as a remote rural posting without family members versus an urban location can make a significant impact on quality of life. However, the criteria for suspension or transfer could also relate to displeasing an elected official, regardless of the specifics of the case. These actions undercut to an important extent the message that performance counts. CSB staff are instructed not to question elected officials, despite the fact that mayors control commune budgets allocated for health. As noted above, mayors who do not spend the money on health are not called to account for this gap, though it causes difficulties for CSB staff.
Another factor that limits the effectiveness of accountability mechanisms at the district and local levels is the dense network of informal social relations among actors. Many of the SSDs are composed of a small group of professionals who often have close family ties or multiple affiliations, thus providing room for degrading the effectiveness of internal oversight and auditing mechanisms or for benefits such as less formal sharing of resources (see Box 7).
Box 7. Informal Networks in Small Towns
In Ambatofinandrahana the head of the district hospital (CHD2) is married to the chief doctor of the town’s CSB, and is a member of the Health Management Committee tasked with oversight of the CSBs. The chief doctor at the CSB also directs the reproductive health program at the SSD.
The head of the NGO contractor for the PhaGDis serving the district hospital is also the administrator for the hospital, and a Council member in local government.
In Farafangana, the wife of the SSD adjoint administratif does audits for the district, which involves her in verifying the activities of her husband’s division.
In terms of the kinds of checks and balances that support formal accountability, these informal interrelationships risk compromising the necessary separation, and open the door to collusion and mutual “back-scratching.” Besides the “small world” phenomenon of family links, professional married couples, and the friendships that emerge from living in close proximity to colleagues in rural districts, informal connections within the broader Madagascar community of health care professionals derive from shared professional and academic training and people keeping in touch with their classmates.
Pressures and Incentives As the above accountability discussion shows, in the hierarchical health system, the major pressures on SSD and CSB staff are bureaucratic ones from higher administrative levels. The upwardly focused orientation of accountability relationships creates pressures and incentives to pay the most attention to what those above want and require. These desires and requirements focus largely on conformity with bureaucratic procedures and following plans. District and facility staff receive no explicit directives related to targeting the poor. Staff are consumed with the demands of operating in remote areas with insufficient infrastructure and struggle to provide services within their districts.
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Pressures and Incentives at the CSBTo oversimplify slightly, incentives can be summarized as: Don’t make mistakes. Follow the rules. Don’t take initiative. Don’t ask too many questions of elected officials. Keep superiors happy. These incentives apply at all levels, but appear to be strongest at the lowest level in the system: the CSB. With one exception, the CSB staff interviewed revealed a preoccupying concern with fulfilling the administrative and reporting requirements they are subject to. Questions about technical and service delivery issues yielded minimal responses. Few CSBs talked about what the key health problems were in their specific locale, none could quote figures with ease on local disease prevalence, none volunteered discussion of community customs and their impact on health-related practices.31
In Farafangana, CSB staff cited negotiations with mayors and with communities as a problematic source of pressure. Sometimes mayors make promises to their communities regarding health services and expect that CSB staff will step in to keep them. In the case of one CSB that is located in a building owned by the commune, the mayor is pressing the CSB to move out of the building even though a permanent facility, planned under the FID, has yet to be constructed.
The lack of resources is a frequently mentioned source of pressure and a disincentive for CSB staff. Insufficient staff, limited operating budgets, lack of transport, scarce equipment, inadequate buildings and lack of clean water supply were repeatedly cited as constraints for CSB staff providing health services. For example, because of insufficient per diems and travel funds, CSB staff use their own funds to attend meetings and pick up supplies. In addition, in Ambatofinandrahana, where the PFU had not been relaunched, CSB staff also reported a significant problem with lack of medicines.
Regarding motivators and incentives for CSB staff, interviewees responded with a list of factors led by salaries and promotions, housing, and transport. Farther down the list were sufficient equipment to do their jobs and training opportunities. A few interviewees mentioned professional commitment and conscience.
Pressures and Incentives at the SSD As noted above, mayors occasionally pressure the SSD to allocate health staff to vacant positions or to establish new CSBs. With their role in monitoring CSB staff absences, and in paying the salaries of the community dispenser and of the CSB guard, mayors are important local stakeholders. Relations with mayors are not always smooth, however. Disputes arise regarding the uses of the central transfers to the communes earmarked for health. Some mayors can be influenced by the SSD regarding the expenditure of their health funds, but others not. As noted below, mayors’ failure to pay pharmacist’s salaries appeared to be widespread in Farafangana, opening the door to temptation to steal medicines from the pharmacy, or contributing to increased pharmacist absences.32 The level of education of mayors plays a role in how
31 It is likely that some of the lack of response on these topics was an artifact of the interview situation. For those at the bottom of the hierarchy, being asked questions by foreigners introduced as being from the World Bank probably engendered some fear and uncertainty.32 It is not uncommon for hospital and health post personnel to provide their services privately at night and on weekends. There is also a large cadre of informal pharmaceutical peddlers who sell drugs and medicinal plants in local marketplaces and regularly travel by foot to remote villages.
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effectively health staff can interact with them and how efficient they are in spending their funds. It is likely that the less educated mayors live in more remote communities.
At the SSD as at the CSB, staff gaps, paltry operating budgets, lack of vehicles, aged and broken vehicles, equipment and supply shortages, and crumbling buildings were mentioned as constraints. In this operating environment, donors and their projects constitute both a major source of program resources for service delivery and another cause of pressure on district staff. This dynamic results in the classic incentive pattern, noted above, of health staff responding to what donors want and provide, even when the donor desires and resources may not necessarily correspond to the highest priority needs (see Box 4).
Incentives for SSD staff are a similar list to that of the CSB. Staff want livable salaries and promotions, housing, school opportunities for their children, and for professional couples to be posted in the same place. The previous minister was notorious for ignoring the latter, and assigning husbands and wives to widely separated posts.
Pressures of Geography and Remoteness A major source of pressure comes from the geography and logistics of operating in rural areas with poor roads, difficult accessibility, and limited communications. Most CSBs lack access to telephone or radio, other than on an emergency basis via the gendarmerie in a limited number of villages.33 The physical obstacles to travel and communication are an additional disincentive to exercising technical and administrative supervision and enforcing accountability. Oversight by SSD staff varies greatly by remoteness and accessibility. Laudably, some staff are committed to conducting CSB visits despite these problems. The Médecin-inspecteur of Farafangana reported that she visits all the CSBs in her district, which involves extended trips where she travels in dugout canoes and on foot to the farthest CSBs (see Table 6 above).
In the health sector, the pressures of geographic distance affect the quality of services provided for three reasons:
It is difficult to entice doctors with families to locate to remote rural areas, particularly when housing that is to be provided by the commune has not yet been constructed and as medical staff currently receive no bonus payment for remote location, and often use their own resources for transport.
The more remote locations require greater travel time for the doctors to attend the monthly district meetings, thus causing greater official absences.
While lack of payment for commune supported medical staff appears to be a problem regardless of location (payment 25% of the time or less, see Table 6), the smaller staffs in remote areas mean that the post cannot see clients if the doctor is gone, or if the commune paid staff have not been paid and are absent.
4. EducationThis section provides an overview of the formal institutional structure in the education sector, and then analyzes formal accountability mechanisms, describes how these mechanisms unfold in
33 The gendarmerie in each district has a radio telephone, which in terms of access to SSD or CSB staff is mainly for emergency use only, though in Farafangana it seems to used on a more regular basis than in Ambatofinandrahana.
28
practice, and assesses the types of pressures and constraints on district staff in terms of how their ability to deliver services to the poor is affected. Finally, it provides an assessment of some of the factors that influence how district education staff allocate resources within their district.
Besides health, education is the other sector with the largest percentages of deconcentrated recurrent budget expenditure. Recent figures for education reveal that 31% of recurrent expenditure took place at the center, 56% at the province and region, and 13% at the district (World Bank 2003). The majority of recurrent education expenditure at the central and provincial levels is allocated to salaries. There are 13,000 public primary schools in Madagascar, and 3,000 private primary schools.34 The administrative hierarchy of structures in education is portrayed in Table 7.
Table 7. Education Structures by Level
Level Education StructureCenter Ministry of Secondary and Basic Education (MINESEB)
Province (Faritany) Interregional Directorate of Secondary and Basic Education (DIRESEB)
District (Fivondronana) District Education Office—Circonscription Scolaire (CISCO)
Commune (Firaisana) Zone administrative et pédagogique (ZAP)
Public primary school (EPP)
Lower secondary school-- Collège d’enseignement général (CEG)
Higher secondary school (Lycée)
Village (Fokotany) Public primary school (EPP)
Parents-school partnership association (FAF)
Association of parents of students (FRAM)
4.1 Formal Education Structures and Functions
4.2 Education Functions by LevelThe following table lists the functions of the public education bureaucracy by level.
Table 8. Education Functions by Level
Level FunctionMINESEB Sets national policy and does country-wide planning for the sector.
Prepares annual investment and operating budgets.
Allocates resources to the provinces and school districts.
Carries out financial and technical oversight, and quality control of public
34 This category includes schools run by religious organizations and other NGOs.
29
Level Functioneducation institutions, and monitors private institutions.
Manages personnel, including hiring, promotions, and firing.
Manages the insurance fund for school-related accidents (PASCOMA, Protection Accidents Scolaire de Madagascar).
Sets curriculum content and pedagogical standards.
Assures teacher training and skills upgrading.
Collects, analyzes, and reports on education data and statistics.
DIRESEB Conducts province-level planning, and preparation of the annual plan.
Tracks and reports on provincial education indicators.
Does financial and technical oversight of districts and their schools.
Allocates staff within the province.
Provides training and technical support for districts and schools.
Serves as intermediary for CISCO reporting to MINESEB.
CISCO Supervises pedagogical activities, administration, and expenditures of the primary and secondary schools in the district (EPPs, CEGs, and Lycées).
Maintains student records and manages the annual examination for promotions and award of diplomas.
Allocates civil service staff within the district.
Manages teachers hired on a contract basis by communes and FRAMs.
Prepares an annual district workplan.
Manages the non-salary portion of the recurrent expenditure budget.
Manages the collection and accounting procedures for school fees, PASCOMA premiums, and other Caisse Ecole activities.
Handles distribution of supplies and equipment to schools through FAFs.
Compiles and reports on educational statistics for the district. ZAP Serves as the administrative and technical interface for the CISCO with about 8-
12 schools (some ZAPs have a secretary).
Provides oversight and support to school directors.
Facilitates information transmission to and from schools.
Assures monitoring at the school level.
Assists with the distribution of school supplies and equipment.
Interacts with members of the FAF and FRAM.
EPP, CEG, Lycée Manages the instruction provided to students.
Supervises teachers, both regular civil service employees and contract teachers (enseignants suppléants).
Maintains school records.
Transmits educational statistics for their schools to the CISCO via the ZAP.
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Level Function Oversees and accounts for supplies and equipment provided by the CISCO.
Serves as a designated member of the FAF management committee.
Interacts with the FRAM and individual parents.
At the district level, the CISCO and the ZAP are the key structures. The CISCO consists of a Chef-CISCO, who has the responsibility for fulfilling the list of functions presented in Table 8. The CISCO office is divided into three divisions: programming (programmation), pedagogy (pédagogie), and administration and finance. The programming division handles data collection, transmission, and monitoring related to public and private schools, teachers and staff, geographic distribution of schools (carte scolaire), and a variety of educational indicators; the division also does forward planning for investment, and needs assessments for staff and equipment. The pedagogy division is responsible for maintaining student records, handling student transfers and any disciplinary matters, managing examinations and graduations, assuring conformity with curriculum and instructional guidelines and procedures, providing training and oversight to teachers in district schools, managing and distributing instructional materials and equipment, supporting sports activities, and maintaining a documentation center. The administration and finance division handles personnel management, contracts, financial payments and records, budget planning and execution, logistics and maintenance of the CISCO office, and financial oversight of FRAMs and FAFs. The ZAP, which in most cases, is a single individual, serves as the major liaison between schools and the CISCO, and is the information and oversight conduit. Box 8 details the ZAP’s supervisory responsibilities.
At the local level, there are two community organizations in the education sector. The FRAM is the association of parents of students. It is supported by voluntary contributions from its members; in communities whose schools do not have enough teachers, FRAMs have hired teachers on a contract basis, paying them with a combination of money, bags of rice, and donated agricultural labor and land. FRAM members also provide in-kind support to school operations and rehabilitation, volunteering to carry materials and supplies from CISCO drop-off points to remote schools where vehicles cannot reach, and contributing labor to school projects as needed. FRAM leaders are elected by the community.
The FAF, a government-community partnership organization for school development (know by its Malagasy acronym), was created by MINESEB decree in September, 2002, largely in response to the need for a formal organization to receive HIPC funds.35 Its partnership structure combines civil servants (school directors) with elected community members to manage resources devoted to support educational establishments through a Caisse Ecole, whose transactions are publicly posted to assure transparency. The World Bank’s education sector project (CRESED II) is supporting the establishment of Caisses Ecole and FAFs. As part of the government’s effort to deal with the effects of the political and economic crisis provoked by the dispute over the results of the 2002 election, and to demonstrate responsiveness to citizens’ demands for basic services, the CRESED II funds, combined with HIPC funds, have been used to pay for school fees (reimbursing parents in cases where they already paid the fees), insurance premiums, facility 35 Its predecessor, the FRAM or parents’ association, does not have a formal legal status and thus cannot receive funds.
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rehabilitation and construction,36 cafeteria expenses, and the purchase of materials and supplies. The FAF management teams have handled informing community members about the designated uses of the Caisse Ecole funds, reimbursements, purchasing materials, contracting of services for rehabilitation, accounting for monies spent, and monitoring progress. They have also managed some CRESED funds, for example, for the purchase of high nutrition biscuits for the students. FAF leadership is drawn from the same pool of community leaders as the FRAM management committee, and in some cases includes the same individuals, though it tended to be much more dominated by men in the case study areas compared to the FRAM.
4.3 Education Service Delivery in Ambatofinandrahana and Farafangana
4.3.1 Context – Ambatofinandrahana and FarafanganaIn Farafangana there are 626 teachers, of which 27% are financed by FRAM, serving 34,487 students. In Ambatofinandrahana, 391 teachers, of which 21% are FRAM supported, serve 27,291 students. In Ambatofinandrahana not all schools are operational. The majority of teachers are civil servants, paid by MINESEB, but in both districts there are contract teachers paid through a variety of contractual arrangements with funding coming from a mix of sources: CISCO operating budgets, FRAMs, and communes.
4.3.2 Accountability: The District PerspectiveIn the education sector the accountability structures parallel those in health. Accountability in the CISCO focuses upwards, with district and school decision-making circumscribed by the DIRESEB and MINESEB, and by the procedures for public expenditure (see Annex 2).
Reporting RelationshipsIn education as in health, there is an upward reporting chain from school directors, to chefs-ZAPs, to the CISCO, to the DIRESEB, and to the MINESEB. Information flows upwards to the MINESEB and donors through monthly, quarterly, and annual activity reports; quarterly reports on staffing levels; status reports on recurrent budget expenditure; and accounting records, starting with the Caisses Ecole in individual schools. CISCO staff indicated that they are subject to central ministry demands for additional information on an ad hoc basis from time to time. Similar to the health sector, district education sector staff, as would be expected in small town and rural settings, have numerous informal connections with each other beyond the contacts occasioned by their formal roles.
Financial Accountability CISCO budgets consist primarily of non-salary recurrent expenditures. Financial reporting and accountability consume large amounts of staff time of the CISCOs in the two districts. For example, according to the CDE, the Adjoint Administratif travels to Manakar twice a month, though the CISCO reports that this can be three to four times a month, to handle paperwork for procurement for EPPs. The challenge is exacerbated by the requirements of different procedures for each budget source. As a result in Farafangana the Chef-CISCO is frequently on the road.
36 Since 2002, CRESED has ceased financing school construction. This responsibility is now part of the FID and is managed out of the Prime Minister’s Office.
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The top-down pressures on the CISCOs for proper accounting reach to the schools as well, and to community-based entities with responsibility for financial resources such as the FAF. The FAF structure was created precisely to establish a viable mechanism to manage money. FAFs manage considerable funds. For example, in Ambatofinandrahana in 2002/2003 CRESED II transferred 262,270,000 FMG to FAFs and HIPC transferred 223,849,000 FMG. Each school maintains a book of accounts and a personnel register. Usually the CRESED and HIPC funds are distributed at the commune level by the CISCO in the presence of the FAF and the school director. Within the FAFs, the school director jointly manages FAF accounts with the community’s elected FAF management team. The procedures put in place for the FAF call for at least one general assembly meeting each year, with others as needed.
At the community level the top-down pressures are met by bottom-up ones; FAF interviewees mentioned that community members are very interested in how funds are used and how “the books” are kept. Caisse Ecole budgets for the schools the team visited are publicly available, revealing an encouraging degree of transparency. Initially, community members wanted the funds for themselves, but once they understood the legal limitations of the Caisses Ecole they accepted the specified uses. Audits represent a key tool in enforcing financial accountability. In principle, ZAPs audit the Caisses Ecole, but (by self-admission) may not necessarily have the skills to do this effectively. However, the community awareness of what expenditures were allocated for their school and the visibility of what is purchased increases the effectiveness of financial oversight. For example, the CISCO in Ambatofinandrahana recounted a case where the FAF requested an investigation when a school director failed to follow procedures for the Caisse Ecole and bought supplies without consulting FAF or FRAM members and overbilled for the purchases. The CISCO audit verified the FAF’s accusations and the director was forced to make restitution.
CISCO staff indicated that lack of vehicles, and in some cases lack of road access, made it difficult to reach all the schools in their districts, which hampered their ability to conduct financial monitoring and supervision. This gap highlights the role of community oversight, such as the FAF example mentioned above, in helping district offices fulfill this accountability function. Unlike health, in the education sector, the ZAPs help to alleviate some of the CISCOs’ constraints in reaching local schools.
Performance Accountability
Formal PlanningAs part of its poverty reduction strategy, the government has made a commitment to increasing school enrollment, improving retention, reducing dropouts, and increasing graduation rates. These national level education objectives become the achievement targets for the districts. CISCOs employ a system of annual workplans plus monthly, quarterly and annual reports against those workplans. In education as well as health, the “business plan” methodology is being put in place. The MINESEB staff interviewed characterized these workplans as performance contracts with target indicators for school enrollment rates, repeat rates, etc. set with CISCO heads for their districts. MINESEB is also preparing job descriptions for the chef-CISCOs, who to date have had no performance criteria. These workplans and contracts result in
33
a much stronger focus on performance and outcomes in the CISCOs than in the health sector’s SSDs. For example, in Farafangana, the Chef-CISCO’s office had a large blackboard on which were recorded basic education statistics and indicators for the district. Staff mentioned that DIRESEB and MINESEB officials tracked the indicators and asked for explanations when there were changes, particularly negative ones, such as increased dropout or repeater rates.
As in health, the CISCO is not involved in investment planning of schools, which has become a demand-driven function of the FID rather than a technocratic planning function. These decisions are largely political.
SupervisionCISCOs have monthly meetings at the DIRESEB, and sometimes people from the central ministry attend. These face-to-face sessions complement the paper reports that CISCOs send to the DIRESEB and the MINESEB. In the words of one CISCO staff member, the DIRESEB acts like a policeman at the meetings: “attention à ceci, à cela.” These meetings combine personnel issues, administrative review, progress updates on indicators, and technical discussions. In cases where major problems emerge, according to MINESEB staff, the DIRESEB expects the MINESEB to intervene when CISCOs do not perform.
CISCOs concede that “the farther away the school is from the district headquarters, the looser the management.” Nevertheless, CISCOs do conduct some limited direct performance monitoring and supervision. In Ambatofinandrahana, the CISCO is able to conduct observation visits to only 30 of the 135 public primary schools (see discussion below of remoteness and accessibility). In that district, the primary school director in Soavina indicated that the last visit from a CISCO staff member was in 2001 when the head of the programming unit visited. On the relatively rare occasions when field visits take place, the CISCO reports that teachers generally welcome the technical support and advice provided during visits from the adjoint pédagogique. However, although CISCO staff may not visit schools very often, the major source of supervision at the school level is the ZAP. School directors generally noted that they saw their ZAP supervisors quite often. Box 8 details the ZAP’s oversight activities.
Box 8. The Chef-ZAP and Supervisory Activities
The main direct contact with schools for performance oversight is the Chef-ZAP. This intermediate entity between schools and the CISCO increases the amount of oversight and technical support that schools receive. For example the Mahavelo primary school in Farafangana reported that the Chef-ZAP visits the school once a week; topics of discussion cover a range of issues from the cleanliness of school grounds and the latrine, pedagogical subjects, and meetings with parents to encourage them to send their children to school. The Chef-ZAP holds quarterly meetings with the school directors under his jurisdiction to review indicators, pass on directives from the CISCO, and discuss problems. The Chef-ZAP sends monthly reports to the CISCO, and CISCOs hold monthly meetings attended by the ZAPs that report to them. The information collected through the ZAPs forms the basis for the CISCOs’ upward performance accountability to the DIRESEB and MINESEB, and for the exercise of CISCO oversight of what goes on in district schools. School directors hold monthly meetings with their teachers, and the reports of these meetings feed into what the ZAPs pass upwards to the CISCOs.
34
Performance accountability in education also involves the FAF, with the FAF both subject to accountability from the CISCO and ZAP, and as a participant in exercising accountability regarding schools. Regarding this former role, for example, in Ambatofinandrahana, some FAFs were summoned to “petit tribunals” at the CISCO because FAF leaders were dominating the process of deciding upon Caisse Ecole priorities and expenditures. CISCOs send their financial staff or the ZAP to periodically monitor the FAFs. Concerning the latter role, the Chef-ZAP on occasion talks to members of the FAF to gather opinions on teacher performance, largely limited to absenteeism.
Human Resource ManagementCISCO staff and teachers who are regular civil servants are subject to the same human resource management procedures as health sector public employees. The centrally controlled hiring, transfer, and reward practices limit the ability of district and school authorities to deal with performance issues. Between the CISCO and the school, the presence of the ZAP provides some degree of staff oversight and support, as Box 8 illustrates. The CISCO’s use of enrollment, dropout, graduation, and repeater rates as indicators forms the basis of performance accountability for individual school directors.
An important human resource issue is the widespread use of contract teachers. Their use reflects the problems of insufficient teachers to fill vacancies in rural schools. Contract teachers and their negotiations with the FRAMs and/or mayors paying them (or not paying them) constituted a significant management task for CISCOs and ZAPs. Interviewees reported spending time advising FRAMs, and discussing the needs of the contract teachers with them and their school directors. Whether contract teachers will continue to perform for low salaries and in-kind contributions will depend to some extent on whether the government will convert them to civil servant status.
Role of CommunitiesIn terms of downward performance accountability to service users, there appears to be very little, similar to health services. In principle, the CISCO, through the ZAP, controls and monitors schools, and reports findings and problems upward to the DIRESEB, thereby reinforcing the pattern of a closed circle of accountability internal to the educational bureaucracy. FAFs and FRAMs, as noted, have some role as both partners and clients, but the procedures of the education bureaucracy do not include formal or regular consultations regarding their views and levels of satisfaction with instructional activities or outcomes.
Through the Caisses Ecole, FAFs have involved parents in financial accountability for spending and distribution of equipment and spending on building improvements, but this kind of accountability is different from actions related to educational results. Community members’ ability to exercise performance accountability is limited by their lack of technical knowledge to appropriately evaluate teaching methods and outcomes. As an illustration of the gap in understanding, in one school the community challenged the FAF’s decision to spend Caisse Ecole funds on buying chalk rather than more furniture; in the eyes of the community chalk was not a desirable purchase because it didn’t last. Beyond the ability to assess accurately what schools need and what teachers should be doing, some parents do not accord school attendance for their children a high priority. School directors and teachers indicated that especially the
35
poorer parents depend heavily upon their children’s labor for their livelihoods, so that schooling is often in competition with economic need.37 To the extent that community members pay attention to what goes on in schools, FRAM and FAF members are much more likely to concentrate on how funds are spent and on the condition of the school buildings than on matters of student performance.
However, a number of interviewees pointed to differences between the health and education sectors in service users’ willingness to exercise voice with regard to service providers. As a CISCO staff member expressed it, “parents feel free to criticize teachers, not like in health. We accept this and try to make adjustments.” This greater sense of freedom to speak out may be due in part, to the fact that teachers live in the community and have daily interaction with both children and parents. In many cases, they are given a role, not just as a teacher, but as one of the influential elders and are drawn immediately into the local social world. The need to rely on others for help with agricultural labor and basic staples like rice also puts them into more of a reciprocal relationship with the community than their salaried health counterparts.
Political Accountability
National LevelIn the wake of the recent crisis the government is interested in providing demonstrable benefits not simply to urban elites, but to the rural majority as well. The donor-provided resources available to focus on poverty reduction offer an incentive for the government to make good on its espoused commitment to expanding availability and increasing the quality of education, particularly primary school education. People perceive access to education as an important public good, and one that has economic implications through improved job and earning prospects.38 The popular expectations in response to the announced “Education pour tous” policy have established a basis for political accountability, and the government has moved forward concretely in several ways. The government earmarked 25% of the HIPC debt relief savings to education, and has used HIPC funds in combination with CRESED resources to fund the Caisses Ecole, which have resulted in a significant allocation of resources to education and especially in rural areas of the country. The president’s radio announcements about the creation of the FAF, the establishment of the Caisses Ecole, and the payment of school fees can be seen as demonstrations of responsiveness to citizens.
District LevelDespite the respect for hierarchical authority, rural leaders show some isolated willingness to express demands. On occasion, FRAMs and FAFs have sent letters to the DIRESEB to request support or to make complaints. According to DIRESEB, often these complaints are based on misinformation or different opinions of how education services should be managed and delivered. For example, priorities may differ between the school directors and the president of the FAF; the school director may want notebooks, while the FAF places a higher priority on renovating the school building. As noted above, FAF-school conflicts occur in both districts.
37 See Glick et al. (2000) for more discussion of factors influencing demand for education.38 For a cultural history of education reforms in Madagascar and their links in explaining some of the difficulties in providing effective educational opportunities across the country today, see Sharp (2002).
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This usually occurs when the school director takes decisions about FAF funds without consulting FAF members. In such cases, the ZAP or the CISCO have intervened.
One of the key difficulties facing the CISCO in terms of political accountability involves the scarcity of resources relative to need and demand. While government education policy is publicly stressing “education pour tous,” CISCOs face the difficult task of allocating scarce materials and support that could never meet all the needs of every school. In Farafangana the Chef-CISCO makes these allocations according to a weighted formula based on the number of students served. In the case of indivisible goods he relies on the Chef-ZAP reports to make the allocation. At the moment in Farafangana, where cyclones regularly destroy infrastructure, there are 30 schools in need of rehabilitation, and the CISCO’s budget can cover only five of them. In the previous year, the CISCO gave sacks of cement and roofing to the FRAMs, and they organized to do repairs under the supervision of the Chef-ZAP. In an effort to respond to community requests for teachers, CISCOs sometimes simply move teachers from one school to another. Since overall there are not enough teachers, doing so deprives one school of a teacher in favor of another.
Commune LevelParents are generally supportive of education, recognizing the long-term value of schooling for their children. In many rural areas, people view literacy as an essential tool for communication with authorities and for protecting themselves from being taken advantage of. One of the reasons that people fear administrative interactions is that, for example, they are asked to sign or put their thumbprint to the tax receipt for their cattle, but they cannot read what they are signing. Investment in children’s education is one of the ways parents feel that they can gain control over these interactions.
Teachers interviewed reported that in the past parents’ attendance at FRAM meetings has been strong. However, the opportunity costs of children’s foregone labor, particularly for the very poor, can undercut this support and lead parents to focus on immediate income needs.39 For example, when FAF funds were announced on the radio in Ambatofinandrahana approximately 90% of the parents attended the meeting to set up the FAF. Their initial expectation, however, was that they would be given some of the funds directly, whether or not they had paid school fees. Once the accepted uses of the funds were explained, they nonetheless remained interested in how FAF funds would be used.
Mayors are also interested stakeholders, and in Farafangana, some mayors are former schoolteachers and thus have some degree of competence regarding education. Parents, FAF members, and mayors all at times present their concerns to the CISCO or the Chef-ZAP. Among the most frequent concerns are the assignment of teachers to understaffed schools, the rehabilitation or construction of school buildings, and conflicts over the contracts for locally paid teachers. In several communities, the government’s payment for enseignants suppléants covered only three months of the school year and FRAMs and communes did not necessarily continue
39 Glick et al. (2000: 18) note that, “In rural areas of Madagascar some 40 percent of boys and 30 percent of girls age 7-14 participate in income-generating work, primarily in agriculture. For girls of this age, household work is also significant.”
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payment once those funds ceased. This situation has drawn the CISCO into mediating disputes, as noted above.
Accountability in Practice: Discretion and SanctionsGiven that CISCOs, ZAPs, and public schools are part of the deconcentrated state education bureaucracy, the degree of formal decision space and discretion is highly circumscribed. The ability of these district and local structures to allocate and spend resources is hemmed in by the legal requirements regulating public expenditure.
Formal DiscretionLike the SSDs in health, CISCOs must follow specified spending procedures, cannot spend more than 50% of their annual operating budget credit in the first half of the fiscal year, and can only make minor adjustments to their operating budget line items (at the paragraph level). Within their annually budgeted line items, CISCOs have some discretion, for example, in choosing where to conduct selected site visits, and in deciding on the use of training funds. Their leeway with regard to education policy (e.g., curriculum content, graduation requirements, etc.) is close to nonexistent, as is discretion on personnel policy. The major exception to the latter is the ability to assign civil service teachers to schools (though sometimes these decisions are made at higher levels) and to hire contract teachers. ZAPs, as a direct extension of the CISCO, have no formal discretion beyond that available to the CISCO. Table 9 summarizes the formal discretion for the CISCO and EPP.
Table 9. Degree of Formal Decision-Making Discretion: CISCO and EPP
Functions Degree of Discretion
Role of CISCO Role of EPP
Planning Policy formulation
Program/project design
CISCO: Limited
EPP: None
No role in national policy, sets educational targets in cooperation with DIRESEB and donor sectoral programs, prepares annual district workplan.
No role in national policy.
Finance Revenue collection
Budgeting, resource allocation
Expenditure management and accounting
Financial audit
CISCO: Minimal to None
EPP: Minimal
Oversees FAF Caisse Ecole accounts through ZAPs, prepares annual district operating budget, executes budget according to official procedures, reports on spending, audits EPPs and FAFs.
Collects school and PASCOMA fees. Serves as secretary of FAF management team, reports on uses of funds.
Human Resources Staffing (planning, hiring, firing,
evaluation)
Salaries and benefits
Training
CISCO: Medium
EPP: Minimal to None
Submits staffing needs to DIRESEB and MINESEB. Assigns teachers to posts. Provides input to personnel files. Distributes salaries; no role in setting pay rates or benefits. Hires/fires “hors solde” teachers. Provides
Submits staffing needs to CISCO through ZAP. Attends training sessions. School director supervises teaching staff.
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Functions Degree of Discretion
Role of CISCO Role of EPP
some training to EPP and ZAP staff.
Service Delivery Defining service packages
Targeting service delivery
Setting norms, standards, regulations
Monitoring and oversight of service providers
User participation
Contracting
CISCO: Medium
EPP: Limited
Applies national education policy norms and regulations, targets service delivery through staff and resource allocation, monitors and supervises schools in district through ZAP. Meets with FAF and FRAM. Mediates disputes regarding contract teachers hired by communes and FRAM.
Implements MINESEB educational curriculum within national norms and regulations, manages civil service and contract teachers, oversees pedagogical process, responds to community needs, interacts with FAF and FRAM.
Operation and Maintenance Education and school supplies
(ordering, payment, inventory)
Vehicles and equipment
Facilities and infrastructure
CISCO: Medium to Limited
EPP: Limited
Primary responsibility for district operation and maintenance functions, funded through annual recurrent budget. Little discretion within public expenditure rules. Decides which schools receive rehabilitation and construction funds.
Responsible for school operation and maintenance functions. Oversees purchases of goods and services from Caisse Ecole in cooperation with FAF. Communicates needs to CISCO through ZAP.
Information Management Education information systems
(EIS) design
Data collection, processing, and analysis
Dissemination of information to various stakeholders
CISCO: Limited
EPP: Minimal to None
No role in EIS design, collects and reports on educational statistics to DIRESEB and MINESEB, plays some role in data analysis in monthly discussions at DIRESEB. Disseminates information as required.
Maintains student files, collects educational statistics for transmission to higher levels, no role in analysis. Disseminates some information to the community and local officials.
Informal DiscretionLocal schools have some liberty to adjust vacation times to fit the agricultural calendar and work needs of parents. For example, at the Tsararano primary school in Farafangana, the school director and the teachers noticed that enrollment had dropped from 228 students at the start of the school year to 150 because parents pulled their children out to work in the fields. They negotiated with the parents to guarantee that their children would be allowed to stay in school the following year, and formalized the agreement in a traditional form of contract, with penalties if the parents fail to respect the agreement (payment of cattle).
Local schools also have some discretion in deciding how to handle combining classes in situations where there are insufficient teachers and/or not enough classrooms. These arrangements need to be approved by the CISCO. Decisions about contract teachers also involve informal discretion; there do not appear to be centrally determined policies on the use of enseignants suppléants. This is an area where community demand, need, logistical, and distance factors come into play, as the next section discusses.
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Impact of Discretion on Resource AllocationBecause there are not specific guidelines indicating how operating resources are to be allocated, these decisions fall in a gray area between formal and informal discretion. As in health, poverty is not a specific criterion for resource allocation. In the absence of poverty maps and community income data, CISCOs do not have the information base to use poverty as a decision criterion for resource allocation. District staff face a struggle to place teachers in all their schools and keep them operational; to the extent that they consider poverty as a dimension of decision-making, it is expressed in terms of schools that are remote and difficult to reach. Thus distance becomes a key factor, with an implicit recognition among district staff that equity and distance are related. Several other studies have referred to the impact of distance on equity, and this was also found to be the case here. Anecdotal observations highlighted the increase in poverty levels the farther one went from accessible roads from the district capital. In one case in Farafangana the barrier is not only physical but also cultural (see Box 9).
Box 9. Barriers to the Equitable Distribution of Educational Resources
To reach the town of Mahavelo requires traversing both physical and cultural barriers. The road demands use of a four wheel drive vehicle and then one must cross a river on a hand-operated ferry barge consisting of three boats tied together with wooden planks on top. The route passes through an area dominated by the Zafisoro ethnic group, which has a history of conflict with the group resident in Mahavelo the Antaifasy (see Box 3). The conflict, or the fear of such conflict, may have discouraged CISCO staff from venturing to these areas, and may have limited the ability of the village residents to go to Farafangana, the district capital. The primary school in Mahavelo, as school staff and FRAM members pointed out, is in a state of severe disrepair.
CISCO staff noted that they were unable to visit large numbers of schools, though the system of supervision by ZAPs appears to function relatively well. Further, some noted that accessibility did factor into whether they would distribute goods and services. For example, for highly remote areas, villagers must walk to the nearest accessible point by road, and literally carry the classroom furniture and equipment back to their village. This anecdotal information is further reinforced from an analysis of existing data from schools in Farfangana. The results are presented in Tables 10 and 11, which illustrate the following points:
The farther from the district capital, the fewer teachers in each school and the greater the reliance on unpaid or poorly paid community (FRAM) supported teachers (only 18% in schools 20km or less from the district capital, but jumping to 41% plus once outside of 20 km). Closer to the capital, it appears that the communities can employ more FRAM teachers (though a smaller percentage of the total) than in the very remote (60km +) areas. The poverty of these very remote communities means fewer resources to pay teachers.
Accordingly, the number of pupils per teacher tends to increase with distance from the district capital, with an average of 83 students per teacher in schools over 60 km from the district capital, compared to 56 for those within 20 km of the district capital.
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The number of sections each teacher has to teach increases with distance and the physical assets (number of classrooms) declines as well.
Even the distance between the effective supervisory level (the ZAP) and the school increases with distance from the district capital: up to an average of 9 kilometers distance between the ZAP supervisors and the schools in schools over 60 km from the district capital (see Table 11). This supervision is done almost entirely on foot, given the lack of bicycles or other modes of transport (and lack of roads).
As a result, it is likely that the quality of education declines with distance from the district capital, and the ability of the schools to provide for the larger proportion of poorer students also declines.
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Table 10. Distribution of Educational Resources by Distance from District Capital: FarafanganaDistance
from District Capital
Number Students Number Sections
Number Teachers
Section / Teacher
% Teachers FRAM
financed
Students/ Teachers
Number Classrooms
Teacher Deficit
Total Girls % Girls Total Women FRAM 0-20 km Sum 8248 4084 211 169 111 30 1.25 136 Average 201 100 49% 5.1 4 4 1 18% 56 3.3 NA20 - 40 km Sum 8146 4240 258 170 70 77 1.52 145 6Average 120 62 52% 3.8 3 2 1 45% 51 2.1 40 - 60 km Sum 10062 4976 277 177 81 73 1.56 161 14Average 131 65 49% 3.6 2 2 1 41% 65 2.1 1.460 - 80 km Sum 8055 3919 220 110 42 52 2.00 109 24Average 122 59 50% 3.3 1.7 1.2 1.1 47% 83 1.7 2.2
Table 11. Average Distances and Travel Times CISCO-ZAP-School: Farafangana*Distance from District Capital
Distance ZAP - Ecole
Distance Cisco - ZAP
Distance Cisco - ZAP
Access by Car (Cisco - ZAP)
Access by Car (Cisco - ZAP)
Access by Foot (Cisco - ZAP)
Access by Foot (Cisco - ZAP)
Average Distance Cisco + ZAP +
School
Average Travel Time Cisco + ZAP + School
Kms Kms Hours Kms Hours Kms Hours Kms Hours0-20 km Average 3.2 13.0 1.5 9.5 0.53 5.6 1.6 13.7 2.1320 - 40 kmAverage 5.7 31.0 5.4 15.5 1.0 15.5 4.4 33.3 5.440 - 60 kmAverage 6.0 51.8 6.4 34.6 1.5 24.8 7.1 52.0 8.660 - 80 kmAverage 8.9 65.7 8.8 40.0 1.5 25.7 7.3 68.7 8.8
* Note: These represent average times thus individual times may vary.
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SanctionsSanctions to enforce rules and accountability focus most strongly on financial accountability, governed by the laws and regulations on public expenditure, accounting, and the required audit trail. Following procedures is key, and incorrect paperwork garners criticism. CISCOs call individual school directors to explain changes in educational indicators at the school level, and in turn the DIRESEB summons CISCOS to account for the aggregate of those educational indicators at the district level. However, there appear to be few sanctions related to negative performance on those indicators.
Pressures and IncentivesAs the discussion of the deconcentrated hierarchy in the education system demonstrates, the major pressures on CISCO and EPP staff derive from higher administrative levels. The upward focus of accountability relationships creates incentives to pay the most attention to the desires and requirements of administrative superiors. Pressures at the Individual School Level As with civil servants in other sectors, incentives for school directors and teachers are to avoid mistakes, follow proper procedures, and respond to requests and orders from the ZAP and the CISCO. At the primary school level, the enseignants suppléants, who are not civil servants, face stronger performance incentives than teachers who are regular public employees.
Regarding motivators, interviewees responded with a list of factors led by salaries, housing, and transport. For the civil servants, promotions were also mentioned, with expressed frustration over delays in advancement despite having passed sufficient time in grade. For the contract teachers, the difficulties of surviving on minimal pay were mentioned repeatedly. A major motivator for these contract teachers is to be converted to civil servant status; interviewees recounted that this is the main reason they are willing to accept the lower pay and difficult living conditions they face.
Other motivators noted, though less salient, were suitable physical facilities, sufficient equipment and educational supplies, and training opportunities. Some interviewees mentioned professional commitment to education and teaching. In February 2003, the MINESEB took steps to increase financial motivation for classroom teachers through two decrees: the first raised teachers’ salaries with a special supplement, the second established a bonus payment for teachers working in remote areas according to a three-zone classification system.40
Pressures at the CISCO and ZAPAt the district level, CISCO staff face similar pressures to respond to the demands of the DIRESEB and MINESEB, and to follow proper procedures. Questions about incentives elicited the familiar list of salaries, promotions, housing, availability of vehicles, sufficiency of supplies, and so on. CISCOs are also subject to some political pressures. Mayors and deputés have been known to pressure the CISCO to get rid of teachers who did not support them in elections or to hire political friends. One Chef-ZAP reported that he was pressured by the mayor when he was conducting a Caisse Ecole audit not to dig too deeply. As in the health sector, politicians sometimes go to the provincial or central level to lodge complaints about what happens in district
40 Zone I: 30,000FMG/month; Zone II: 65,000FMG/month; and Zone III: 100,000FMG/month.
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schools, and to seek to exert pressure from above. In some cases, as Box 10 illustrates, CISCO staff are occasionally at risk of political interference.
Box 10. Political Retaliation against a Chef-CISCO
A story about the fate of a Chef-CISCO in Manakara is a cautionary tale regarding the power of politicians and is well-known to CISCO staff in other districts. The district purchased building rehabilitation materials and did not have sufficient storage space to house it, so a local politician offered to store them. When the CISCO was ready to transport the materials to the schools targeted for rehabilitation the Chef went to the politician to make arrangements, only to be told the materials had already been used in construction of property belonging to the politician. The head of the CISCO indicated to the politician that this action was illegal and that he would have to report it to the authorities, which he did. The politician was outraged and exerted sufficient pressure that the Chef-CISCO was censured and removed from his post.
Community IncentivesIn the education sector, the role of FAFs and FRAMs is an important one in terms of exerting pressure on the educational bureaucracy to respond to local needs and desires. A finding regarding incentives for the community to continue its active role in education is a negative side-effect of the government’s policy of paying school fees. The team’s interviews revealed that due to the public resources available to FAFs, FRAMs are at some risk of weakening. Parents are less willing than before to make out-of-pocket contributions, and some FRAMs were said to be “asleep,” and relatively inactive compared to FAFs. This was noted in both districts visited. The salience of this diminished energy of the FRAMs is illustrated by their previous contributions to local schools. In Ambatofinandrahana one FRAM had previously raised 9500 FMGs per student and bought 40 bench tables for the school. Now, however, the FRAM is struggling to survive because parents no longer want to contribute resources, expecting and assuming that the state will step in with further funding.
Besides weakening FRAMs, the creation of FAFs has also changed the composition of who participates. Interviewees mentioned that in FRAMs women have had a relatively active role, but that FAFs have been dominated by men.
Pressures of Geography and RemotenessThe education sector faces the same pressures as health service providers of the logistics of operating and overseeing schools in remote rural areas where the roads are poor, accessibility is difficult, and communications are sporadic. As noted previously, CISCO staff admitted differences in oversight and supervision between more and less accessible schools. The existence of the ZAP, intermediate between schools and the CISCO helps to some extent to deal with remoteness by increasing supervisory contact in less accessible schools. However, interviews with Chef-ZAPs revealed that they, like the staff in the CISCO, felt these constraints keenly. The above discussion of discretion in resource allocation shows how these pressures can influence decision-making.
Some other geography and remoteness factors and their influences include:
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Mayors may not be as concerned with their more remote constituencies; thus they may be less inclined to spend their commune funds earmarked for education, and there may be more room for the misallocation of funds. Teacher housing often must be provided from the mayor’s budget or the community’s own resources, so more remote and poorer communities are at a disadvantage.
It is hard to find incentives for civil service teachers to go to remote areas, though the recent MINESEB decree specifying salary supplements for teachers in more remote zones is a step in the direction of stronger incentives. The fact that limits this to already strained resources in areas where the likelihood of misallocation is greatest.
It is harder for residents of remote areas to come to the CISCO to complain, if they were likely to do so in the first place.
5. Conclusions
5.1 Features of the Case Study Districts
More remote facilities receive less supervision and oversight, receive fewer resources, and rely more heavily on community participation (e.g., community members carry equipment and supplies to their villages when vehicles cannot reach them). As the data reveal, remoteness is not simply a matter of distance, but of accessibility and required travel time; thus facilities located only 40-50 kms from the district capital reflect this pattern. It also appears that when a supervisory visit requires an overnight stay, such trips are much less likely to be undertaken.
More remote facilities are more likely to be understaffed and to have a higher percentage of staff who are either voluntary or paid by the community. Districts are short of staff in both health and education. In Ambotafinandrahana, rural insecurity (cattle theft) contributes to the difficulty in staffing remote facilities.
Facility staff spend relatively large amounts of time away from their posts every month to attend meetings, collect their paychecks, pickup supplies, and so on. The availability of per diems for these trips is a contributing factor in prolonging them. This time away contributes to inefficiency of service delivery particularly in situations of understaffed facilities, where absences mean that no services are available. For more remote facilities, travel times are greater, so absences are longer.
In Farafangana, ethnic tensions have had an impact on the distribution of health and education services in the district. SSD and CISCO staff reported pressure to take into account ethnic balance in the district related to assigning/rotating staff and investment in new facilities. The perception is that facilities have been concentrated in regions where two ethnic groups (the Zafsoro and the Antaifasy) live in order to limit conflict, leaving the southern part of the district where a third, neutral group is located, underserved. The reality in health is that on a per capita basis CSBs are relatively evenly distributed among the three groups.
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While the cultural dynamics in Farafangana are distinct from those in Ambatofinandrahana and have influenced resource allocation to some extent, the administrative dynamics and accountability patterns in both districts are very similar. Thus the impact of standardized hierarchical relationships, uniform reporting procedures, and identical bureaucratic accountability demands is much greater than any regional differences between the two districts studied in terms of incentives, pressures, and health and education staff behaviors.
5.2 Accountability Patterns
As we expected to find, district and facility education and health staff face strong pressures for upward accountability internal to the health and education bureaucracies. The health and education systems have been deconcentrated, rather than decentralized (which includes higher degrees of local decision-making); thus although spending of recurrent budgets takes place at the district level, the accountability for the uses of those funds is to the province and the center, not to the communities receiving health and education services. This relatively closed circle of accountability orients health care providers and educators to their superiors within their respective ministries, with very limited openness to the views of service users.
The major emphasis is on financial accountability, driven by the impact of the public
budgeting system, and the concern of all stakeholders on allocation and uses of financial resources. As is the case in countries that base their public procurement and accounting systems on the French model, Madagascar has an elaborate and cumbersome set of administrative procedures for committing and spending budgeted funds, with many required steps and forms to be filled out and reviewed. In the health sector the user fee-based pharmaceutical system (PFU) in effect from 1998-2002, through which CSBs collected and accounted for funds from patients purchasing drugs has been an important element of financial accountability. Although the PFU was officially suspended as national policy, in the Farafangana the PFU has been relaunched on a semi-formal basis, with CSBs providing the SSD with monthly figures on purchases.
The use of performance output indicators as accountability tools is weak and haphazard. Education is stronger on this than health. For example in the CISCO in Farafangana, a set of education indicators are posted on the blackboard in the chef’s office (dropout and repetition rates, examination success rates, etc).41 Education staff have some incentives to pay attention to these; if these rates move in a negative direction, the Chef-CISCO is called to give account and explanation by the DIRESEB. In the health sector, no-one interviewed mentioned using performance indicators except those related to donor programs, for example, vaccination campaigns. There was no mention of anything related to quality of care.
There is no independent monitoring in either health or education service provision. Interviewees reported some cases of mayors complaining about CSB or EPP staff to SSDs and CISCOs. Sometimes they went over the heads of the districts and complained to the central ministries or to deputies in the national assembly, but these incidents were on a case-
41 The MINESEB has been providing training in planning for CISCOs; to date 100 CISCOs have participated in training workshops on planning techniques.
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by-case basis, not representative of a systematic monitoring effort by commune administrators. There were no signs of community monitoring outside of the FAFs, which although they contain community members in their management, are not independent entities. At the facility level of the health and education systems little room exists for feedback from the community or the mayors. This relates to capacity factors (see below).
The government’s civil service personnel management system offers little support to effective accountability. It is oriented toward salaries, promotion, seniority, and perks. The focus is a standard time-in-grade one, rather than on performance. Rewards are for filling out forms correctly, following procedures, avoiding criticism, and not making mistakes. In health, the legacy of the climate of fear created by the former minister remains strong, and staff try not to be noticed.
Existing pressures to increase accountability are: a) largely supply-driven, often linked to particular individuals (e.g., former health minister Henriette Rahantalalao, Lucie Ramanandraibe, Chef, Service de Santé de Base, or Georges Rakotoson, DIRESEB Director in Fiananarantsoa); b) irregular, being pushed by these individuals’ personal agendas and idiosyncratic commitment rather than resulting from a consistent and systemic effort to address accountability; and c) episodic, given that personal commitments to particular issues wax and wane over time. Thus while accountability pressures from ministry leaderships may peak at a specific moment, over time they fade and administrative routines continue as before.
Demand-driven accountability through local elected officials is limited by the nature of relations between those officials and the rural electorate. Rural voters hesitate to question those they vote for. Mayors and deputés switch parties depending upon the personalities involved and do not tend to have platforms and issues that serve as the basis for voter decisions, nor do they think of their role as serving to make good on a specific set of policy promises. Campaign slogans are broad and empty of policy content.42 Party representatives often visit villages to pass out gifts of money and goods (e.g., T-shirts, footballs) to influence voters.
5.3 Discretionary Decision-making
The degree of discretion SSDs and CISCOs have in making decisions is relatively limited. Although spending of their recurrent budgets has been assigned to the district level, the line items in the budgets are centrally determined in a relatively mechanical fashion (e.g., last year’s numbers plus 10%), and leave room for only minor adjustments by the districts. Because recurrent budgets are decided upon centrally, there can be a disconnect between funding levels and need; in principal district budgets are put together based on district-provided information, but this information is not always respected when budget decisions are made. The administrative burden of managing these deconcentrated funds is significant, involving travel (especially significant for Farafangana where the office of the CDE is in Manakara), and large amounts of time from the Chef-CISCO and the Médecin-inspecteur.
42 For example President Zafy’s slogan was, “For Development, Peace, and Security” (Marcus 2001: 228).
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Hiring, promoting, and firing of staff are handled centrally. SSDs and CISCOs can request staff from the center, but do not make the decisions on who is assigned to their district, who is promoted, or who is sanctioned. In Ambatofinandrahana, the chef CISCO said the minister makes the personnel decisions. The chefs CSB we interviewed, for example in Mahavelo, had no idea who made the decisions regarding whether they would receive a promotion, and they were ignorant of what was in their personnel files, saying those dossiers (Bulletin Individuel de Note, BIN) were treated as confidential (see Box 5).
While the naming of staff to districts is centrally determined, the assignment of staff to facilities within the district is to some extent at the discretion of SSDs ( with the important exception of doctors) and CISCOs. However in Ambatofinandrahana and Farafangana a more pressing concern is obtaining sufficient staff to fill existing slots. There were several examples of local staffing placement decisions being made in the capital; in some cases staff were not sent to the posts that the district felt had the strongest need.
5.4 Political and Governance Factors
Political accountability: the current government recognizes the political need to reach beyond its urban constituency to the rural areas, and is responsive to the need for demonstrable change in service delivery at the local level.43 In education, the Caisse Ecole has made a difference in getting resources out to schools, paying school fees has demonstrated government commitment. In health, increased spending (including earmarking of commune-level transfers to mayors), assignment of more doctors to CSBs, suppression of the PFU and the policy of free medicines have demonstrably improved the functioning of the health system.44
The president’s support for communes gives importance to mayors. The SSDs and CISCOs tell their facility personnel that they need to respond to mayors’ concerns and priorities. Chefs-CSBs and school directors hesitate to challenge mayors’ use of central transfers for health and education, even though legally those funds are for their sectors. Mayors face little challenge from their constituents regarding their decisions on the use of these funds. This situation means that in both health and education, service providers do not have available to them the full complement of resources nominally allocated to the sector.
In a political and governance setting where corruption is endemic, transparency is weak, and civil society advocacy groups remain nonexistent or nascent, the establishment of effective accountability mechanisms is a long-term process that will be unlikely to yield immediate results. Shifting the basis of the relationship between public officials and citizens so that citizens both know and understand their rights and the obligations of public-sector actors, and
43 This recognition is a legacy of the recent crisis. Ravalomanana’s core support is first and foremost from Antananarivo, and secondarily from the secondary cities of the highlands. To reunite the country, address the sociopolitical rift of the recent past, and remain in power, his government is keenly aware that services and benefits must be spread throughout the country, and particularly to poor and remote areas.44 For details, see the analysis in INSTAT (2001), which notes that although health spending increased, the PFU led to less utilization of health services by the poorest members of the population.
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will take action to press for accountability will require pilot programs at the village level and technical assistance.
5.5 Incentives
Health and education staff face weak incentives for innovation, discretionary decision-making, and paying attention to outcomes. Recognition is largely negative, that is, staff are noticed only if something appears not to be correct or if there is a problem/complaint. Thus staff tend to adopt a reactive orientation to requests/orders from above, and seek to keep their heads down.
At the district level, targeting services on the poor is not an explicit management criterion for either SSDs or CISCOs. Reporting forms do not have categories that allow for tracking of activities or results broken out by poverty levels, and pressures from above, to the extent that they go beyond conformity with administrative requirements, focus on service provision to all communities and inhabitants in the district, not on poorer residents. Poverty and income data are not readily available to district staff. Thus there are no direct incentives to use poverty levels for decision-making within districts. To the extent that district health and education staff made implicit reference to poverty it was in terms of remoteness and difficulty of access to facilities and services.
In education, there is a recent establishment of salary supplements for staff posted to remote facilities, according to a three-zone system with increasing amounts the more remote the zone. This represents a concrete incentive for service providers. At present health does not have a similar system, but it appears that one will be established through the CRESAN project.
Establishment of the FAF has provided an incentive for increased engagement of local community leaders in education sector resource management, but has negatively impacted the viability of the (potentially) more independent FRAMs. Leadership in FAFs, and to a somewhat lesser extent in FRAMs, appears to be largely male-dominated, reflecting the cultural hierarchy of Malagasy society. In the FAF in Ambatofinandrahana, the FAF management included one woman. In addition, the government payment of school fees has greatly reduced parents’ incentives to contribute resources (cash and in-kind).
In Madagascar, as in many countries heavily dependent upon external assistance, donor resources are important sources of incentives. In the study districts, for instance, all vehicles in both health and education appear to have been provided through donor projects. The MINSAN and MINESEB both receive large amounts of donor funds, e.g., CRESAN and CRESEB, and these projects shape incentives at all levels of the health and education systems. For example, interviews with CSB staff revealed incentives for vaccination campaigns, a classic case of the well-recognized impact of vertical programs.
5.6 Capacity
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The capacity for demand-driven accountability is very weak. Factors involved include: 1) insufficiency of health and education staff means that people are unlikely to press for removal or transfer if they cannot get a replacement; this is more pronounced the further the facility is from the district office; 2) high levels of poverty mean that parents pull their children out of school for work; 3) local people lack the capacity to assess educational outcomes and tend to focus only on physical facility so have little basis to make judgments, a similar problem exists for health outcomes; 4) the non-confrontational behavior characteristics of Malagasy culture, coupled with low expectations for service quality and availability, mean that people are unlikely to make demands on service providers.
There is weak capacity and motivation in CISCOs and SSDs to exercise supervision; this is clearly related to remoteness and accessibility of facilities. Other factors involved include: lack of vehicles or motorcycles, travel time to reach CSBs and schools plus inaccessibility in rainy season, anecdotal evidence that district staff are not terribly interested in doing field visits. As civil servants, district staff have few incentives to walk miles to remote facilities beyond their individual professional commitment to undertake field visits. Particularly for doctors, who tend to see themselves as high-status individuals who have the right to travel by car or motorcycle, walking to distant CSBs has little appeal. However, there is better supervision in education because of ZAPs, who tend to be physically closer to schools than CISCO staff (see Box 8).
6. Recommendations
Target resource transfers using remoteness and distance criteria rather than poverty. Efforts to transfer resources targeted on the poorest of the poor in settings where all are poor are likely to be ineffective and inefficient from a cost-benefit perspective. As noted, SSDs and CISCOs do not currently have incentives to use poverty levels as a decision-making criterion, and data to do so are not readily available. Local leaders are likely to dominate resource allocation and the very poor have limited capacity or inclination to challenge their authority. If more financial resources were allocated to the district level, there could be a formula based on distance and travel time that allocated more to more remote CSBs and EPPs. There could also be personnel allocation policies that favor assigning available staff to more remote facilities. Such a change, coupled with the government’s salary supplement incentive payments for teachers, and the planned similar system for health workers, could result in more service availability in remote areas, and hence more services available to the poor.
Increase supervision and oversight visits to remote facilities. Most health facilities, both relatively near to and far from the district office, receive insufficient oversight and supervision. Supervision and oversight afford opportunities for quality control, and for personnel in isolated facilities, visits send a psychological message that management is interested in what they are doing. The once-per-year target does not provide much opportunity for district staff to gain a hands-on perspective regarding facility performance and issues, and some of the more remote facilities are rarely if ever visited. Resources could be targeted on:
o Purchase of vehicles and motorcycles,
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o More funds for fuel and maintenance, per diems, and/or o Supplements for carrying out more visits.
Improve staff living conditions in remote facilities. A key source of dissatisfaction among staff and of conflict between staff and mayors is the inadequacy of housing and water supply in remote villages (beyond 40-50 kms from district capital). The central transfers to local government cannot be relied upon to fund this basic infrastructure, in some cases because the funds are insufficient in others because mayors choose to spend on other priorities. Communities themselves become the providers of last resort, a difficult burden particularly for the farthest away localities. Injecting funds targeted specifically for housing could provide an incentive for staff to remain at remote rural posts, and could reduce conflicts with local government officials.
Modify accountability criteria to include positive recognition of, and positive sanctions for,
performance. This study noted that existing accountability is heavily focused on following procedures and pays attention largely to failings, not successes. Introducing criteria that apportion credit, not just blame, and that identify positive outcomes of staff actions could pass the message that performance is both expected and valued. This recognition could be accompanied by some sort of reward or prize.
In the transport sector, invest in rural roads. Investment in roads and road maintenance in remote areas would have a number of positive externalities for health and education. Supervision would be increased by making remote facilities easier to reach. Delivery of needed supplies and equipment would be more frequent and regular. Facility-level staff would spend less time on the road traveling to district meetings. Wear and tear on vehicles would be reduced, cutting operating costs.
Pilot test service satisfaction surveys. To focus more attention on service users and on quality of services, the cycle of accountability upward and internal to the health and education bureaucracies needs to be expanded to include downward accountability to those who use the services. The Bank has a growing base of experience with service satisfaction surveys that could be tapped for rural Madagascar. The results of these surveys could be publicized in the media and could be the topic of discussion sessions at the district and commune levels. The number of NGOs at the local level appears small, but there are some capable groups that could be tapped to conduct the surveys, with some technical assistance. Building NGO capacity will take time, so starting with organizations with existing outreach networks and programs, such as Inter Aide in Manakara, or PISAF/Action Agro-Allemande in Farafangana, would help to achieve some early successes.
Modify reporting forms in the health sector to include feedback from service users in the community. Another service user accountability-enhancing measure could be pursued by changing the information requirements of the paper reporting system at the facility level. As recognized by SSD authorities, the complaints register proposed by the MINSAN is unlikely to be used. It could be more effective to have CSB staff made responsible for collecting some feedback from their clients and recording that information on their regular reporting forms. Effectiveness will depend upon a number of supporting conditions, and such a seemingly
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simple change will not yield immediate results. Clearly, higher levels of the health bureaucracy will need to indicate that such feedback is important and required. It may be that the collection of the feedback should be carried out through an intermediary (revived village health committees, for example), even if the reporting is done by the Chef-CSB, to deal with the reticence of service users to comment on medical staff behavior and actions. It could be that this recommendation should be undertaken following experience with the pilot service satisfaction surveys, to incorporate lessons on what kinds of questions could be usefully asked, what sorts of indicators are most appropriate, how feedback could be communicated, etc.
Increase transparency and information dissemination. Despite the encouraging signs of information availability relating to the Caisses Ecole and FAFs, there needs to be a larger and more broadly distributed flow of information about: what resources are allocated to health and education from all sources (including funds managed by the mayor), what purposes the funds are used for, who is responsible, and what results have been achieved. This kind of transparency will be particularly important for the restart of the PFU. Information on what constitutes quality service in health and education should also be disseminated to educate service users. Local-level resources could be used to:
o Support print materials and radio broadcastso Support citizen service quality/rights campaigno Support mayors’ education regarding social services and investments
Reinforce community organizations related to social services. FAFs, FRAMs, and village health committees are all local entities that help people to interact effectively with service providers for a variety of purposes: representing and expressing their views, making decisions jointly, and exercising accountability. Yet apart from the FAF, it appears that these local entities are weak and in some cases getting even weaker. An allocation of resources to support meetings and travel could support and resuscitate them. They could become the venue for the service quality/rights campaign mentioned in the previous recommendation, which would provide them with additional visibility and vitality, could help create a foundation for demand-making capacity, and could be used to proactively seek to increase the number of women involved in community activities. There is, of course, the usual time factor to be taken account of in thinking about expanding community participation; rural people are busy earning a living and sustaining themselves. Nonetheless, this study noted the interest of rural residents in increasing the availability and quality of health and education services.
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Annexes
1. Persons Contacted
Contacts Institutions
ANTANANARIVO
Mr. Julien Raharison, Statistician INSTAT Antananarivo
Mr. Gabhy Rajaonesy, Director, Promotion de la Coopération Décentralisée
Ministère Auprès de la Présidence Chargé de la Décentralisation, du Développement des Provinces Autonomes et des Communes
Dr. Jean-Pierre Manshande, Senior Health Specialist
Mr. Patrick Ramananatoanina, Education Specialist
World Bank, Madagascar Country Office
Mr. Frédéric Edigard, Director, Primary Education Component
Mrs. Antoinette Rasolofoniaiana, Director, Secondary Education Component
Projet CRESED II, Coordination Office
Mr. Louis Lai-Seng, Director General, Education Fondamentale et l’Enseignement Secondaire
Mr. Joel Ramanandraitsiory, Director, Administration and Financing (DAF)
Mrs. Tahinarinoro Razafindramary, Director General, Planning and Monitoring and Evaluation
MINESEB
Dr. Rigobert Rafiringason, Coordinator General, Projects
Dr. Ralijoana Osée, Adjoint technique, Direction des Services Medicaux et d’Appui aux Districts (DSMAD)
Dr. Lucie Ramanandraibe, Chef, Service de Santé de Base, DSMAD
MINSAN
Dr. Remi Rakotomalala, Monitoring and Evaluation Unit Head Projet CRESAN II, Coordination Office
Ms. Sandra Gagnaire, Chargé, Education and Health Sector European Union
Mr. Hirose, First Secretary Japanese Embassy
Ms. Catie Lott, Director, Office of Democracy and Economic Growth
USAID Madagascar
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Contacts Institutions
Mr. Brett Beach, Democracy and Governance Specialist
Ms. Wendy Benazerga, Deputy Director, Office of Health, Population and Nutrition
Mr. Celestin Rasolomaholy Rakotozanany, Secretary General Ministry of Interior and Administrative Reform
Mr. Zo Jarisetra Rambeloson, Coordinator for Monitoring and Evaluation, Linkages Project
Academy for Educational Development
Mrs. Noro Rakoto Joseph, Assistant Manager, Education de Base pour Tous Program
Dr. Norolala Rabarijaona, Assistant Manager, Health Program
UNICEF-Madagascar
Mr. Jean Désiré Ravoavison, Coordinateur de Projets Pedagogiques
Aide et Action
FIANARANTSOA
Mr. Niaina Randrianjanaka, Director INSTAT Fianarantsoa
Mr. Ratahinjanahary Edgard, Chef de Service, Administration and Finance
Dr. Ravelomanantsoa Henri, Chef de Service, Health Services
Provincial Health Direction (DPS)
Dr. Jacques Rakotonantoanina, Former Médecin-inspecteur, SSD Ambatofinandrahana
SSD Ihosy
Mr. Rakotoson Georges, Director DIRESEB
Mrs. Randrenalijaona Raharison Fanja, Provincial Technical Coordinator.
Projet d’Education de Base pour Tous les Enfants Malagasy, Programme Conjoint Madagascar–Nations Unies, Coordination and Implementation Unit
DISTRICT (FIVONDRONANA) AMBATOFINANDRAHANA
Dr. Randriatahina Raymond Naivo, Sous-Prefet Ministry of Interior and Administrative Reform, Sous-Prefecture Ambatofinandrahana
Mr. Rakoto Jean-Pierre, Vice-Mayor Mairie – Ambatofinandrahana
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Contacts Institutions
Mr. Rabearivelo, Président du Conseil Municipal (***)
Mr. Ratrimoson Norbert, Advisor
Dr. Ramasy Michel, Médecin-inspecteur
Dr. Razafimahatratra Armand Rodin, Adjoint Technique
Mrs. Ravoninahidraibe Viviane, Adjoint Administratif et Financier
SSD – Ambatofinandrahana
Dr. Daniel Andrianaivo, Médecin-chef CHD2 Ambatofinandrahana
Dr. Ravoniarisoa Alice, Chef de Poste CSB2 – Ambatofinandrahana
Mrs. Ranoronirina Pierrette, Employe de Service CSB2 – Soavina – Commune Rurale Soavina
Mr. Rabearivelo (***), Manager, PhaGDis NGO, Vatososa, Ambatofinandrahana
Mr. Rakoto Joseph Lamboarivel Nirina, Chef Cisco
Mr. Ramarokoto Pierre, Adjoint Programmation
Mr. Rafalimanana Jean Claude Eugenio, Adjoint Pedagogique
Mr. Fandrimahafaly, Adjoint Administratif et Financier
CISCO – Ambatofinandrahana
Mr. Rafaralahy, EPP Director and FAF Secretary
Mr. Rajosefasolo, FAF President
Mrs. Razafindravaoarivelo Lalao, Vice-President
Mr. Rabemananjara, Member
Mr. Rakotoarisoa Alfred, Commissaire aux Comptes
FAF, EPP Centre – Ambatofinandrahana
Mr. Ratsimbazafy Jean-Baptiste, President
Mr. Eugene Venance, Vice-President
Mr. Ralaimora Albert, Advisor
Mr. Rakotonirina, Advisor
FRAM, EPP Centre – Ambatofinandrahana
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Contacts Institutions
Mr. Ratsimbazafy Marcel, Commissaire aux Comptes
Mr. Rabenarivo Georges, Director
All Teachers
EPP Soanitsiriana – Commune Rurale Soavina
Sister Razafindratefy Lalao
Mr. Ranarivelo Desire Emmanuel, Enseignant
Eglise Sambalahy
Mrs. Rasoahasinina Dolly Myriame YWCA
MANAKARA
Mr. Jean Martin, Chef de Poste Controle des Dépenses Engagées (CDE) – Manakara
Mr. Raulin Pascal, Program Coordinator
Mrs. Soamaroroka Egyptienne, Health Coordinator
Bureau de Développement – Catholic Diocese (ECAR) – Manakara
Mr. Rasolonandrasana Hery, Responsible, Programme Education
Mr. Anicet Alexandre, Formateur Pedagogique
Mr. Patrick Mougenot, Program Manager
NGO, Inter Aide – Manakara
DISTRICT (FIVONDRONANA) FARAFANGANA
Dr. Zohra Bayant, Médecin-inspecteur
Dr. Andrianarison Dimby Mamisoa, Adjoint Technique
Mr. Ramanambohitra Celestin, Adjoint Administratif et Financier
Service de Santé de District (SSD) – Farafangana
Mrs. Rasoarivelo Vololona Odette, Chef de Poste, Sage-Femme CSB1 Vohilava – Commune Rurale Anosivelo
Mr. Jacques Arson, Chef de Poste CSB2 Mahavelo – Commune Rurale Mahavelo
Mr. Mananto Prosper, Paramedic CSB2 Vohimasy – Commune Rurale Vohimasy
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Contacts Institutions
Mr. Donazy, Chef CISCO
Mr. Tonet, Adjoint Administratif et Financier
Mr. Ravelomanantsoa Felix, Adjoint Programmation
CISCO – Farafangana
Mr. Emilson, Mpanjaka
Mr. Tsiahilika Justin, Mayor
Mr. Tata Auguste, Chef ZAP
Mrs. Raharinirina Emelie Valencia, Director
Mme Velomahita Blandine, Adjointe (Teacher)
Mrs. Kemba Beatrice – Adjointe (Teacher)
Mme Kemba Romaine, Adjointe (Contract Teacher)
Mr. Christophe Fidele, Adjoint (Contract Teacher)
Mr. Ralairivo, President FAF
Mr. Richard, Treasurer FAF
Mr. Sylvain, Secretary FAF
Mr. Andriamahatsiaro Florentin, Advisor FAF
Mr. Jean de Dieu, FRAM member (Fokonolona)
Mr. Saonina Emile, FRAM member (Fokonolona)
Mr. Tata Francois, FRAM member (Fokonolona)
Mr. Tsaravita, FRAM member (Fokonolona)
EPP Tsararano – Commune Rurale Vohimasy
Mr. Rahelison, Director
Mr. Randriamanavana, Contract Teacher
Mrs. Palestine Marguerite, Adjointe (Teacher)
Mr. Jean Narcisse Felix, Chef ZAP
EPP Mahavelo – Commune Rurale Mahavelo
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Contacts Institutions
Mr. Randrianasolo Ernest, Mayor
Mr. Manitra, FRAM member
Mr. Germain, FRAM member
Market Women Focus Group, Tsararafa NA
Dr. Joachim Andriamitantsoa, Chef Volet Nutrition et Hygiene
Mr. Ephraim Ravelomananjara, Chef Volet Socio-Organisation
Projet Intégré de Sécurité Alimentaire dans la Région de Farafangana (PISAF), Action Agro Allemande
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2. Operating Budget Execution ProceduresCISCOs and SSDs spend their annual operating budgets according to the standard budget execution procedures that involve numerous steps, control points, and in many cases, extensive travel to deposit forms with the offices of Contrôle de Dépenses Engagées (CDE). This annex describes the steps and provides copies of the forms that must be filed. At the beginning of the fiscal year (January 1), CISCOs and SSDs receive notification that they have been allocated a budget (un crédit) for the year. The budget specifies, by line item, what the funds may be spent on. Managers may move funds between line items only at the lowest levels of the budget (the paragraph and sub-paragraph). To spend funds the following steps are required.*
1. To start the process of obligating and liquidating operating budget funds, the manager fills out a Demande d’Engagement Financier and a Titre d’Engagement Financier (DEF-TEF). These are accompanied by a draft invoice for the goods (facture pro forma) or services (devis) that the manager wishes to procure.
2. The manager delivers these forms and accompanying paperwork to the local office of the CDE. The CDE undertakes the following:
a. The CDE reviews the DEF-TEF to determine if the request falls within the authorized budget line items and the amount of that line item.
b. He reviews the pro forma invoice to see if the prices appear reasonable. c. If the request is appropriate, if there are sufficient funds, and if the prices for what
is to be purchased are reasonable, then the CDE approves the transaction. d. He notifies the manager and returns one copy of the TEF. The law states that the
CDE must take action on a DEF-TEF within 48 hours, but most CDEs try to respond more quickly than this outside limit.
3. With the approved TEF, the funds are now committed, and the manager returns to the supplier, and submits the order for goods or services.
4. The supplier provides the goods or services, and submits a final invoice to the manager, which indicates that the manager received the goods/services.
5. In order to pay the supplier, the manager prepares a dossier with a cover sheet (bordereau des pièces), which lists all the contents of the dossier. This step is referred to as mandatement. The contents of the dossier de mandatement include: 1) the pro forma and the final invoices, 2) the TEF, 3) a form authorizing payment (mandat de paiement), and 4) either a bank transfer form (avis de credit) or a cash payment form (bon de caisse). This latter form is only valid for payments of less than 10 million FMG.
6. The manager submits one copy of the dossier to the sous-ordonnateur of the Ministry of Finance and Budget, and one copy to the provincial office of the national treasury (trésorerie provinciale).
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7. The sous-ordonnateur reviews the dossier to make sure that all the forms are included, correctly filled out, and that the expenditure will not exceed the authorized amount in the manager’s budget line item(s). If all is in order the expenditure is approved and the provincial treasury office is authorized to release the funds to the supplier.
8. The supplier, or his/her financial agent receives payment for the goods or services.
* Information compiled from INSTAT (2003) and interview with Jean Martin, Chef de poste, Bureau de Contrôle de Dépenses Engagées, Manakara.
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