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OutreachD E V E L O P M E N T

W O R L D B A N K I N S T I T U T EPromoting knowledge and learning for a better world

CLIENT POWER

Making Services Work

FOR THE POOR

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www.worldbank.org/wbiwww.worldbank.org/devoutreachdevoutreach@worldbank.org

World Bank InstituteFrannie Léautier, Vice PresidentThe World Bank1818 H Street NWWashington, DC 20433, USA

Editorial BoardSWAMINATHAN S. AIYARECONOMIC TIMES OF INDIA, NEW DELHI, INDIA

MICHAEL COHENNEW SCHOOL UNIVERSITY, NEW YORK, USA

PAUL COLLIERTHE WORLD BANK, WASHINGTON, DC, USA

JOHN GAGESUN MICROSYSTEMS, PALO ALTO, CALIFORNIA, USA

JOSEPH K. INGRAMTHE WORLD BANK, GENEVA, SWITZERLAND

KWAME KARIKARISCHOOL OF JOURNALISM AND COMMUNICATIONS,THE UNIVERSITY OF GHANA, LEGON, GHANA

VIRA NANIVSKAINTERNATIONAL CENTER FOR POLICY STUDIES, KIEV, UKRAINE

PEPI PATRONCATHOLIC UNIVERSITY, LIMA, PERU

J. ROBERT S. PRICHARDTORSTAR, TORONTO, CANADA

RAFAEL RANGEL SOSTMANNMONTERREY TECH UNIVERSITY SYSTEM, MONTERREY, MEXICO

ADELE SIMMONSCHICAGO METROPOLIS, CHICAGO, IL, USA

VIVIENNE WEECENTRE FOR ENVIRONMENT, GENDER AND DEVELOPMENT, SINGAPORE

Development OUTREACH is published three times a year by the WorldBank Institute and reflects issues arising from the World Bank’s manylearning programs. Articles are solicited that offer a range ofviewpoints from a variety of authors worldwide and do not representofficial positions of the World Bank or the views of its management.

SUNETRA PURI MARY MCNEILEDITOR-IN-CHIEF EXECUTIVE EDITOR

ANNA LAWTONMANAGING EDITOR

MOIRA RATCHFORDPUBLICATION DESIGN

PHOTO CREDITS Cover: Moira Ratchford; Pages 4–5: Faucet: WorldBank/Eric Miller; School: World Bank/Curt Carnemark; Medicine:Richard B. Levine/Photographer Showcase; Telecom Worker: FredericJ. Brown AFP; Page 8: Reuters/Daniel Leclair; Page 11: AFP; Page 15: World Bank/Trevor Samson; Page 18: World Bank/EricMiller; Page 22: Reuters/Zohra Bensemra; Page 25: AFP/PrakashSingh; Page 27: World Bank/Ami Vitale; Page 30: Reuters/Ali Jarekji;Page 36: World Bank/Curt Carnemark.

ISSN 1020-797X © 2004 The World Bank Institute

This magazine is printed on recycled paper, with soy-based inks.

W O R L D B A N K I N S T I T U T EPromoting knowledge and learning for a better world

hen the World Bank published its WorldDevelopment Report on Poverty in 2000/2001,it refocused the development debate on theplight of the world’s poor. The report pre-

sented a policy framework for addressing global pover-ty by calling for action in three areas: opportunity,empowerment, and security, and demanded immedi-ate and concerted action to address poverty by bothdeveloped and developing countries.

The most recent World Development Report (2004),“Making Services Work for Poor People,” brings prac-ticality to the policy debate introduced four years ago.This recent work notes that the poor not only sufferfrom lack of income but from a failure in basic servicedelivery far greater than for those of the non-poor.Education, health, water, sanitation, and electricityservices simply do not work or are unavailable to theworld’s 2 billion poor people. If we cannot improve thedelivery of these basic services by 2015as called for inthe Millennium Development Goals (MDGs)—whathave our efforts at poverty alleviation amounted to?Have they really been effective?

What is needed, then, to improve these services? Asthe title of our issue points out, “client power” plays akey role in empowering people to demand, and partici-pate in, adequate service delivery. The WDR 2004 out-lines a triangle of accountability between the state, citi-zens/clients, and providers that must be strengthenedto improve services. But it also acknowledges that theweakest link in this triangle is the citizen/client. It bold-ly calls for “putting poor people at the center of serviceprovision: by enabling them to monitor and disciplineservice providers, by amplifying their voice in policy-making, and by strengthening the incentives forproviders to serve the poor.” This should come as nosurprise to those of us who believe improved efficiencycan result from strengthened accountability to the poor.

On a personal note, this is the last issue ofDevelopment OUTREACH for which I will be ExecutiveEditor. As Founding Editor, I will continue to con-tribute to issues of particular interest, especially thosefocused on social development and poverty reduction.I’d like to thank our readers for their support over thepast four years, and look forward to watching the mag-azine continue to improve and grow.

A B O U T T H I S I S S U E

W

Mary McNeilE X E C U T I V E E D I T O R

2 Development News

SPECIAL REPORTCLIENT POWER: MAKING SERVICES WORK FOR THE POOR

3 The Path to Education: A Multi-Dimensional ApproachMAMPHELA RAMPHELE

4 Making Services Work for Poor PeopleGuest EditorialRITVA REINIKKA

One must put poor people at the center of service provision by increasing client power.

8 Voice and Accountability in Service DeliveryANNE MARIE GOETZ AND ROB JENKINS

This article outlines trends in accountability relationships,while highlighting limitations of voice-based approaches.

11 Citizen Report Cards:An Accountability ToolSAMUEL PAUL

In Bangalore citizens assess the city’s public services throughCRC, and provide useful feedback on their quality, efficiency,and adequacy.

15 Applying the Service Delivery Triangle to Care and Treatment for HIV/AIDSSIGRUN MØGEDAL

The Service Delivery Triangle is a tool for exploring keyinteraction among state, providers, and citizens. It is applied here to the challenge of scaling up care and treatment of AIDS.

18 Pro-Poor Health Services: The CatholicHealth Network in UgandaDANIELE GIUSTI , PETER LOCHORO, JOHN ODAGA, AND EVERD MANIPLE

This article demonstrates how pro-poor ethos, supported bysoft regulations and technical assistance, can induce a processof change in a network of faith-based providers.

22 Scaling up Drinking Water ServicesJUNAID K. AHMAD, DAVID SAVAGE, AND VIVEK SRIVASTAVA

Three case studies in Australia, India, and South Africaprovide a common lesson: the success of water deliverydepends on whether service providers are accountable tocitizens.

26 Randomized Evaluations of Interventionsin Social Service DeliveryESTHER DUFLO, RACHEL GLENNERSTER, AND MICHAEL KREMER

This article focuses on randomized evaluation of educationalprograms, which offer both substantive and methodologicallessons.

30 Aid Agencies and Aid EffectivenessBERTIN MARTENS

The author aims to highlight some of the structural andorganizational problems that occur in the aid delivery processand affect aid effectiveness.

35 VOICES FROM THE FIELDA Call for More Community-Driven and Integrated ApproachesPATTI PETESCH

Examples of proposals on education worked out within communities in Colombia.

38 KNOWLEDGE RESOURCES

39 BOOKSHELF

40 CALENDAR OF EVENTS

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2 Development Outreach W O R L D B A N K I N S T I T U T E

Conclusions of the 2004 WorldEconomic Forum

At the closing session of the World Economic ForumAnnual Meeting, held in January in Davos, Switzerland, theco-chairs declared that corporate, government, and civilsociety leaders need to establish a more effective frame-work in order to interpret and manage the risks—and theperceptions of risk—as part of their partnership for pros-perity and security for the future. Over 2,100 participantsfrom 94 countries were asked to consider questions suchas: Should corporations focus more on the short term orthe long term? How do we develop more corporate respon-sibility at a time when businesses are becoming more glob-al? And most critically, how do we reconcile the varyingspeed of clocks between the public and the private sectors?It was suggested that the answer could only be found in asystemic approach based on partnership. For more information, visit: www.weforum.org

New LICUS Trust Fund

In January the World Bank created a $25 million Trust Fundto strengthen institutions, support early efforts at policyreform, and build capacity for social service delivery in theworld’s poorest countries. These countries, collectivelyknown as Low Income Countries Under Stress (LICUS), arecharacterized by very weak institutions and governance,and constitute the most difficult environments in which touse aid effectively. The Bank's LICUS initiative aims tosupport selective basic governance reforms and innovativemechanisms for social service delivery. The Trust Fund willtarget those LICUS countries that are not eligible to receiveInternational Development Association (IDA) funding dueto their arrears with the Bank. For more information, visit: www1.worldbank.org/operations/licus

EU ConferenceFocuses Attention on HIV-AIDS Threatin Eastern Europe, Asia

A two-day, 55-nation conferencetook place in Dublin in February,seeking closer cooperation in fight-ing HIV-AIDS in Europe and Central

Asia. While AIDS fatalities in Western Europe have fallensignificantly since the mid-1990s, thanks to antiretroviraldrugs that retard the progression of HIV infection intodeadly AIDS, the picture in Eastern Europe and CentralAsia makes for grim reading. A World Bank report pub-lished last fall said current efforts to "curb HIV-AIDS inthe region are too small to have an effect on the course ofthe epidemic." It called for spending on HIV-AIDS pre-vention and care, estimated in the region at $300 millionin 2001, to rise to $1.5 billion by 2007. For more information, visit: www.eu20004.ie

Sweden Integrated Development Policy

Sweden has become the first nation in the world to pass intolaw an integrated global development policy. The country’strade, defense, agriculture, environment, migration andother policies must now, by law, align to fight poverty andpromote sustainable development. The new policy takes asits starting point the Millennium Development Goals andthe Monterrey Consensus. It draws on eight fundamentalcomponents: democracy and good governance; respect forhuman rights; equality between men and women; environ-mental protection; economic growth; social development;conflict management; and global public goods such as financial stability, disease, and terrorism. With the newbill, Sweden is also committed to increasing its develop-ment assistance and encouraging the rest of the EU to do so.

Afghan Poppy Farmers Need ViableAlternative

The Food and Agriculture Organization (FAO) said thatAfghanistan's problematic and large-scale opium pro-duction could only be curtailed if poverty-stricken farm-ers have a reasonable alternative. FAO has requested$25.5 million to be disbursed over a five-year period to

agricultural development projectsgeared to offer farmers in fourprovinces an alternative to growingopium poppies. Production boomedto 3,600 metric tons last year, mak-ing Afghanistan the source of three-quarters of the world's opium.For more information, visit:www.fao.org/newsroom

D E V E L O P M E N T N E W S

News highlights on development issues from around the world

Send your views and commentson Development OUTREACH to:

devoutreach@worldbank.orgVisit us on the web at:

www.worldbank.org/devoutreach

BY MAMPHELA RAMPHELE

E D U C AT I O N AT T H E P R E S E N T T I M E sits squarely in thecenter of the development agenda. Education’s influence onpoverty reduction, inequality, and economic growth are nowwidely accepted in the development community. We knowthat greater education for girls has strong positive impactson the health of infants and children, on immunizationrates, family nutrition and the next generation’s schoolattainment. We understand that an educated and skilledworkforce is one of the pillars for a dynamic knowledge-based economy, and we see correlations between generallevels of educational attainment, gender parity in education,and democratic governance.

Truly sustainable development rests on a base of risingeducational attainment and high levels of human capital inall countries. With this notion comes an ineluctable chal-lenge—to make vastly improved education available to all theworld’s children. We are called on to show progress in theshort and medium term, to produce demonstrable resultsthat education for all is going from a rallying cry to a reality.

To achieve results we must keep two simple facts in mind.First, progress through education comes from improvingaccess and learning outcomes for all students at all levelsunder well-chosen curricula. It is not enough to increaseenrollment; it is not enough even to be successful at oneeducational level only. We must aim high, seeking broadgains in access and quality that rest on deepening andmaturing educational systems and structures.

Second, we must be brutally frank in assessing the effec-tiveness of our past interventions. This frank assessmentmust guide our actions. If it is lack of roads that is keepingchildren from attending school, we need to put the roads in.If it is lack of access to drinking water, pipes with cleanwater are needed. If it turns out to be lack of local educa-tional policy expertise and implementation experience,coupled with weak data, then we need to fix this situation.

We must have a comparable standard for adequacy of edu-cation quality, one that can be brought about only if stake-holders take a comprehensive and coordinated approach tothe current constraints. The first element of this coordinat-

ed approach is the recognition that ownership must reside asclose to the ultimate beneficiaries as possible. In the bestsettings, the balance of empowerment in education deci-sion-making should tend to favor those whose futures aremost immediately affected by the opportunity to acquire theskills and behaviors that quality schooling imparts. The sec-ond and third elements in this new approach fall more todonors and the external community. The shift toward deep-er ownership on the part of national and local stakeholdersmust be matched by a dedication among donors to harmo-nization and capacity building. That is, donors must lessenthe cost to recipients of doing business while at the sametime viewing every dollar, yen, or euro given in the name ofimproved education as an opportunity to build the localcapacity that will help move recipient countries fromdependency through ownership towards successful and sus-tainable development.

Essential to this approach are the aspects of develop-ment which bear on education, but which are not tradition-al “education concerns” within the discipline. I refer to,among others, the multi-dimensionality of developmentneeds and specifically the effects of areas such as infra-structure, public health and sanitation on education out-comes. In Morocco, for example, girls attendance at schoolmore than doubles with the existence of a paved road. InBangladesh, school attendance increases by 15 percent withaccess to piped water and lower water collection times.Likewise in health: on the positive side de-worming stu-dents led to a 15 percent increase in school attendance inKenya. Mothers who have completed primary education are50 percent more likely to immunize their children, and evi-dence is emerging that education can be an effective meansto lower HIV/AIDS infection rates. On the negative side,each year Zambia loses half as many teachers as it trains toHIV/AIDS, and overall about 20 percent of the EFA financ-ing gap (some $975 million) is attributable to costs associ-ated with the HIV/AIDS pandemic.

We see then, that part of the path to education for all iswith a coordinated approach to provision of infrastructureand health services. For donors and stakeholders alike, itmeans creating multi-sectoral teams of donors and partnerswho can appreciate the interrelationships and spillovers thatwork in one area of development brings to another. s

Mamphela Ramphele is Managing Director for Human Development,

The World Bank.

Excerpted from the 2003 Kneller Lecture Delivered at the Annual

Conference of the Comparative and International Education Society,

New Orleans, Louisiana, March 2003.

The Path to EducationA Multidimensional Approach

SPECIAL REPORT

SPECIAL REPORT

MAKING SERVICES WORK

BY RITVA REINIKKA

T O O O FT E N, S E RV I C E S FA I L P O O R P E O P L E —in access, inquantity, in quality. But the fact that there are strong exampleswhere services do work means governments, citizens, anddonors can do better. How? By putting poor people at the cen-ter of service provision: by increasing “client power” to enablethem to monitor and discipline service providers; by amplify-ing their voice in politics and policymaking; and by strength-ening the incentives for service providers to serve the poor.

Poverty has many dimensions. In addition to low income(living on less than US$1 a day), illiteracy, ill-health, genderinequality, and environmental degradation are all aspects ofbeing poor. This is reflected in the Millennium DevelopmentGoals, the international community’s unprecedented agree-ment on the goals for reducing poverty (Box 1). That five ofthese eight goals concern health and education signals howcentral human development is to human welfare.

To reach these goals, economic growth is essential. But itwill not be enough. The projected growth in per capita GDPwill by itself enable five of the world’s six developing regionsto reach the goal for reducing income poverty. But growth willenable only two of the regions to achieve the primary educa-tion goal and none of them to reach the child mortality goal. Ifthe economic growth projected for Africa doubles, the regionwill reach the income poverty goal—but still fall short of thehealth and education goals. More resources, domestic andforeign, have therefore been called for.

for poorpeople

WITH STARTING POINTS IN 1990, EACH GOAL IS TO BE REACHED BY 2015:

ERADICATE EXTREME POVERTY AND HUNGERHalve the proportion of people with lessthan one dollar a day.

Halve the proportion of people who suffer from hunger.

ACHIEVE UNIVERSAL PRIMARY EDUCATION Ensure that boys and girls alike completeprimary schooling.

PROMOTE GENDER EQUALITY AND EMPOWER WOMENEliminate gender disparity at all levels of education.

REDUCE CHILD MORTALITYReduce by two-thirds the under-five mortality rate.

IMPROVE MATERNAL HEALTHReduce by three-quarters the maternal mortality ratio.

COMBAT HIV/AIDS, MALARIA AND OTHER DISEASESReverse the spread of HIV/AIDS.

ENSURE ENVIRONMENTAL SUSTAINABILITYIntegrate sustainable development intocountry policies and reverse loss ofenvironmental resources.

Halve the proportion of people withoutaccess to potable water.

Significantly improve the lives of at least 100 million slum dwellers.

DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENTRaise official development assistance.

Expand market access.

THE EIGHT MILLENNIUMDEVELOPMENT GOALS

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Guest Editorial

But increased public spending does not necessarily meanmore services and better outcomes (Figures 2 and 3). Why?First, the non-poor typically enjoy a disproportionate share ofpublic spending. In Nepal 46 percent of education spendingaccrues to the richest fifth, only 11 percent to the poorest. InIndia the richest fifth receives three times the curative healthcare subsidy of the poorest fifth. Even though clean water iscritical to health outcomes, in Morocco only 11 percent of thepoorest fifth of the population has access to safe water, whileeverybody in the richest fifth does.

Second, even when public spending can be reallocatedtoward poor people—say, by shifting to primary schools andclinics—the money does not always reach the frontline serviceprovider. In the early 1990s in Uganda the share of nonsalaryspending on primary education that actually reached primaryschools was 13 percent. This was the average: poorer schoolsreceived even less than the average.

Third, even if this share is increased—as the Ugandanshave done—teachers must be present and effective at theirjobs, just as doctors and nurses must provide the care thatpatients need. But they are often mired in a system where theincentives for effective service delivery are weak, wages maynot be paid, corruption is rife, and political patronage is a wayof life. Highly trained doctors seldom wish to serve in remoterural areas. Since those who do serve there are rarely moni-tored, the penalties for not being at work are low. A survey ofprimary health care facilities in Bangladesh found the absen-tee rate among doctors to be 74 percent.

By no means do all frontline service providers behave thisway. Many, often the majority, are driven by an intrinsic moti-vation to serve. Be it through professional pride or a genuinecommitment to help poor people (or both), many teachersand health workers deliver timely, efficient, and courteousservices, often in difficult circumstances. The challenge is toreinforce this experience—to replicate the professional ethics,intrinsic motivation, and other incentives of these providersin the rest of the service work force.

The fourth way services fail poor people, is the lack ofdemand. Poor people often don’t send their chil-dren to school or take them to a clinic. In Bolivia60 percent of the children who died before agefive had not seen a formal provider during the ill-ness culminating in their death. Sometimes thereason is the poor quality of the service—missingmaterials, absent workers, abusive treatment. Atother times it is because they are poor.

Public services are provided, not through markettransactions or the “short route” of accountability,but through the government taking responsibility(Figure 1). That is, these services make use of the“long route” of accountability—by clients as citizenspaying taxes and influencing policymakers, andpolicymakers influencing providers and settingincentives for them. When the relationships alongthis long route break down, service delivery fails andhuman development outcomes are poor. When therelationships are strong, good outcomes result.

In this issue of Development Outreach we have collected arti-cles which reiterate the main findings of the WorldDevelopment Report 2004 in making services work for poor peo-ple. The articles focus on those services that have the mostdirect link with human development—education, health,water, and sanitation—and highlight key relationships ofaccountability between clients, policymakers, and providers.

An introductory note by Mamphela Ramphele stresses theimportance of the notion of multidimensionality whenexpanding education services and improving their quality.

In the first article of the Special Report, Anne-Marie Goetzand Rob Jenkins write about the politics of service delivery, witha strong focus on the accountability relationship between poli-cymakers and citizens and the effectiveness of citizen voices.

To make services work for the poor requires increasingtheir “client power” over providers to monitor and disciplinethem, mimicking the short route. Samuel Paul illustrates theuse of an innovative accountability tool—the citizen reportcard—in Bangalore, India, and its results over the past decade.

Sigrun Møgedal extends the World Development Report’sframework of accountability relationships to multisectoralHIV/AIDS services, highlighting the complexities involved inaddressing this enormous challenge facing the world.

Highlighting the relationship between policymakers andproviders, Daniele Giusti, Peter Lochoro, John Odaga, and EverdManiple discuss the role of not-for-profit providers in healthcare in Uganda and how they have been able to adapt to changingcircumstances. The article by Junaid Ahmad, David Savage andVivek Srivastava offers insights into scaling up drinking watersupply in Australia, India, and South Africa. One lesson is thatpolicy making, regulatory, and service provision functions needto be kept in separate organizations and processes.

Innovating with service delivery arrangements will not beenough. Societies should learn from their innovations by sys-tematically evaluating and disseminating information aboutwhat works and what doesn’t. Only then can the innovationsbe scaled up to improve the lives of poor people around theworld. In their article, Esther Duflo, Rachel Glennerster, and

6 Development Outreach W O R L D B A N K I N S T I T U T E

FIGURE 1—SHORT AND LONG ROUTES OF ACCOUNTABILITY

Source: WDR 2004

M A R C H 2 0 0 4 7

Michael Kremer show how we can learn from randomized tri-als about the most effective ways to increase school participa-tion and improve the quality of education. Creating a culturewhere rigorous randomized evaluations are promoted,encouraged, and financed, they argue, has the potential revo-lutionize social policy in the 21st century, just as randomized

trials revolutionized medicine in the last century.Foreign-aid donors should reinforce the relationships of

accountability, not undermine them. It involves changing theway much foreign aid is transferred. Harmonizing aid aroundthe recipient’s service delivery system would be one impor-tant way. Bertin Martens looks at incentives in donor coun-tries. He argues that aid effectiveness does not depend on therecipient’s performance alone, but has a lot to do with donoragencies and their institutional behavior.

Despite the urgent needs of the world’s poor people, andthe many ways services have failed them, quick results will behard to come by. Many of the changes involve fundamentalshifts in power—something that cannot happen overnight.Making services work for poor people requires patience. Butthat does not mean we should be complacent. Hubert Lyautey,the French Marshall, once asked his gardener how long a treewould take to reach maturity. When the gardener answeredthat it would take 100 years, Marshall Lyautey replied, “In thatcase, plant it this afternoon.” s

Ritva Reinikka is Research Manager, Development Research Group

(DECRG), The World Bank, Co-Director of the 2004 World

Development Report “Making Services Work for Poor People,” and

Development OUTREACH Guest Editor.

rreinikka@worldbank.org

FIGURE 2—CHANGES CAN DIFFER GREATLY IN PUBLIC SPENDINGON EDUCATION AND PRIMARY COMPLETION RATES

FIGURE 3—CHANGES IN PUBLIC SPENDING ON HEALTH ANDCHILD MORTALITY ARE ONLY WEAKLY RELATED

Public spending on education (1995 US$ per child) and primary completion

Source: WDR 2004

Per capita public spending (1995 US$) on health and child mortality

Source: WDR 2004

LENCAS CHILDREN WANT MORE ATTENTION TO HEALTH CARE ANDEDUCATION. NO MORE COMPROMISES.

M A R C H 2 0 0 4 9

BY ANNE MARIE GOETZ AND ROB JENKINS

A C C O U N T A B I L I T Y , B Y D E F I N I T I O N , implies voice—theaccountable agency is answering a question articulatedthrough a voice. Agencies must also face the other aspect ofaccountability, being vulnerable to sanction—another place atwhich a different type of voice is exercised.

The idea of a relationship between voice and accountabili-ty, however distant, is central to everyday understandings ofdemocratic systems. World Development Report 2004 mentions a“long route” to accountability: citizens provide mandates topolicy-makers to design services to respond to citizens’needs. If these needs are not met, this could result in electoralor other forms of political backlash, including demonstra-tions and legal proceedings.

A huge range of citizen-led efforts around the world hasbeen experimenting with various means of engaging directlywith accountability institutions that were once closed to non-state entities. Many civic groups are participating in new,hybrid forms of accountability, either in partnership withstate organizations or, more frequently, through protestaction, which increasingly takes the form of civil society-ini-tiated public hearings, people’s courts, and commissionedreports that mimic official state proceedings. Through theseand other means, ordinary people and their associations aregetting intimately involved, demanding the impartialenforcement of punishments for corruption, criminal negli-gence, and ineffective performance.

As with market-based reforms to public services, voice-based initiatives stress disintermediation–people are pursu-ing individual cases without the aid of auditors and inspec-tors-general. Those involved in pursuing what we have calleda “new accountability agenda” seem disproportionately to findthemselves working within shorter accountability time-hori-zons, the cycle from mandate to sanction radically com-pressed. This article outlines some of the salient features ofthese trends in accountability relationships while also high-lighting limitations of voice-based approaches.

Conceptual innovations and practicalexperiments

O R D I N A RY P E O P L E C O M P L A I N I N G about abuses of power, orparticipating in service delivery in order to better monitorproviders, are hardly new occurrences. Parent-teachers’ asso-

ciations around the world have long enabled clients of publicschooling to contribute to performance improvements. Whatis new is a considerable amount of conceptual innovation andpractical experiment in citizen-led accountability struggles.

Beginning with electoral institutions, there are numerousexamples of citizens engaging directly in the vertical accounta-bility relationship between voters and representatives.Improving electoral accountability was the objective of theElection Watch project in the north Indian state of Rajasthan,where during state elections in December 2003 a coalition ofcivic groups sought to improve public awareness of candidates’backgrounds. The Supreme Court had, earlier in 2003, ruledthat candidates could be required to disclose information abouttheir personal assets and histories. Volunteers crosscheckedinformation supplied by candidates about their assets, theiroutstanding debts, their criminal records, and their education-al attainments. This is similar to a project run by the PoderCuidano (PC), or Citizens’ Power, a civic organization seekingcleaner political competition in Argentina. The PC monitorscampaign finance norms, broadcasts information about theassets of politicians, and accumulates evidence that can be usedto expose political corruption. Both cases reveal ordinary peo-ple, almost by default, performing a function they might justlyhave expected the state’s electoral commission to discharge, tosay nothing of another great institution of intermediation, themedia. Both organizations represent the vertical (citizen-state)dimension of accountability intruding upon the horizontal (orstate-to-state) dimension of accountability–in the process,creating a set of locally adapted hybrid forms.

Public audit functions are notoriously closed to citizenengagement, but citizens have in some instances assumed theresponsibility of verifying whether local government spend-ing claims are accurate. The citizen-managed public audits oflocal government spending conducted by the Mazdoor KisanShakti Sangathan (Workers and Peasants Power Association)in Rajasthan have led to positive knock on effects: legislativechange obliging local government officials to supply, ondemand by any citizen, photocopies of all local public-spend-ing records, including supporting documentation. These offi-cial accounts are assessed by villagers who can verify whetheror not, for instance, minimum wages were paid on a road-building employment-generation scheme, or whether thestipulated quality of materials was used to construct a villageschool, or whether a community centre is being used for itsofficial purpose. Citizen engagement in public-expenditure

SPECIAL REPORT

Voice and Accountabilityin Service Delivery

10 Development Outreach W O R L D B A N K I N S T I T U T E

management is to be found in participatory municipal budg-eting in some cities in Brazil. This offers an opportunity forcitizens to express their needs and begin the accountability-seeking process ex ante–demanding explanations and justifi-cations from policy-makers regarding their plans and pro-posals, even before decisions are taken.

In countries like India and the USA, long-establisheddemocracies where rights are constitutionally guaranteed,citizens and their associations have used litigation as a way ofbringing themselves directly into judicial accountabilityprocesses. Using the tools available through litigation, indi-vidual citizens and activist groups become part of an officialfact-finding process. Discovery motions can lead to the avail-ability of government-held information that can incriminateofficials, who may never have expected such detailed scrutinyof their decisions. Courts in many countries are beingreformed to increase the direct participation of poor people.The most important innovation from this point of view hasbeen an expanded jurisdiction for Public Interest Litigation(PIL) in some countries, enabling people’s organizations toprosecute abuses of the rights of socially excluded groups andto hold power-holders more directly accountable to the poor.

Citizen-led initiatives

C I T I Z E N S ’ G R O U P S H AV E B E E N I N S T R U M E N TA L in creatingnew jurisdictions and institutions for accountability-seeking.This process is assisted by the growing legitimacy of a globalhuman rights regime. The non-governmental Coalition for anInternational Criminal Court (CICC) played an important rolein establishing the International Criminal Court (ICC). TheCICC mobilized global public opinion, influenced the diplo-matic procedure that led to the 1999-2000 Rome treaty, andcontributed important amendments to address rights abusesagainst vulnerable groups, particularly women. TheInternational Campaign to Ban Land Mines (ICBL), a diverseNGO coalition that was critical in creating the Ottawa Mine BanTreaty of December 1997, is another high-profile example.

This experimentation is altering popular understandings ofaccountability and how it should be achieved. It is expanding therange of accredited accountability-seekers. It is exposing dissat-isfaction with weak or consultative versions of accountability,those that de-emphasize the enforcement element of accounta-bility relationships. It is drawing attention to the need for de factoaccountability in the actions of non-state power-holders whosubstitute voluntary self-regulation for enforceable adherence tonorms of social justice. And it is promoting broad-based deliber-ation on changing standards of probity and justice in the actionsof power-holders. The results are new standards of what officialsought to be accountable for. Increasingly the standard is no longeradherence to procedure, but the achievement of outcomes,assessed in terms of their value for poor and vulnerable groups.

Pitfalls

T H E P R E O C C U PAT I O N W I T H “reinventing accountability”has come, in no small measure, from dissatisfaction with

state-led voice experiments, which often seem driven by pub-lic-relations concerns. At times they manage to inform offi-cials about public perceptions of government behavior. Butthey rarely include formal obligations on officials to supplyanswers, accounts, or other information–nor, for that matter,provisions for investigations to be automatically triggered byprima facie indications of corruption or poor performance. Inshort, voice is being over-sold, particularly as a means ofsecuring accountability to the poor. Formal institutions areprofoundly biased against socially excluded groups, denyingthem access and meaningful participation. This diminishesnot only their prospects for collective action, but even theirability to formulate common policy positions.

But expecting citizen-initiated voice initiatives to fill thegap left by distorted or underdeveloped expressions of voice issimilarly problematic. For a start, the suggestion that thoseworst afflicted by abuses of power ought to be directly involvedin checking those abuses is hugely unfair. Why should thosemost likely to suffer adverse consequences from a challenge toelite privilege be forced to lead the charge? It is, moreover,unrealistic to expect relentlessly valiant behavior of ordinarypeople, who often lack the voice resources of other socialgroups–elite connections, education, media savvy. In manycases, voice initiatives–for instance, certain democraticdecentralization programs and right to information laws–haveresulted neither from pressure by the poor, nor from purealtruism. Yet in the long run they can end up making publicinstitutions more accountable to the poor.

Citizen’s accountability initiatives, particularly those thatend up establishing scrutiny processes parallel to, rather thanin partnership with, official horizontal accountability institu-tions, have their own problems. The substitution of citizens’informal institutions for state accountability institutionsinevitably runs into problems of legitimate authority, controlson power, and at the same time, limited impact.

State-society accountability partnerships also must avoidpitfalls. These should be designed explicitly to increase thecapacity of public oversight institutions to answer to the poor.Such partnerships must provide rock-solid assurances to citi-zen participants with recognized roles in public oversightinstitutions, that they will possess certain rights–most notably,to access the same documentary information as their statecounterparts, to have procedural complaints independentlyassessed, to be able to cross-examine witnesses, and to issuedissenting reports to a higher body (such as the legislature).Voice without these basic tools of answerability and enforce-ability is a recipe for disenchantment and disengagement. s

Anne Marie Goetz, Institute of Development Studies,

University of Sussex.

Rob Jenkins, Birkbeck College, University of London

The ideas expressed in this article are drawn from Goetz and Jenkins,

Reinventing Accountability: Making Democracy Work for the Poor.

Palgrave Macmillan, forthcoming.

M A R C H 2 0 0 4 11

BY SAMUEL PAUL

U S E R F E E D B A C K is a cost-effec-tive way for a government to findout whether its services are reach-ing the people, especially the poor.Users of a public service can tell thegovernment a lot about the qualityand value of a service. Strangelyenough, this is not a method that isknown to or used by most develop-ing country governments. The con-tinuing neglect of the quality ofservices is in part a consequence ofthis gap. This is in sharp contrast tothe practice of seeking “customerfeedback" in the business world, orat least among those who produceand sell goods in the competitivemarket place. The “take it or leaveit” attitude one comes across—especially at the lower levels of thebureaucracy—is no doubt due to thefact that government is the solesupplier of most essential services.But the disinterest among the high-er levels of political and bureau-cratic leadership in seeking publicfeedback on the quality andresponsiveness of service providersreinforces this tendency.

What is CitizenReport Card?

W H E N A G O V E R N M E N T is indif-ferent, the initiative for changemust come from civil society.Citizens who elect and pay for gov-ernments cannot and should notremain quiet when essential serv-ices are in disarray and public

SPECIAL REPORT

Citizen Report CardsAn Accountability Tool

accountability is lacking. It was againstthis background that I, as a private citi-zen, launched a “citizen report card”(CRC) on public services in Bangalore,a large city in Southern India, in 1994.The CRC represents an assessment ofthe city’s public services from the per-spective of its citizens. The latter arethe users of these services and can pro-vide useful feedback on the quality,efficiency, and adequacy of the servicesand the problems they face in theirinteractions with service providers.When there are different serviceproviders, it is possible to comparetheir ratings across services. Theresultant pattern of ratings (based onuser satisfaction) is then converted intoa “report card” on the city’s services.

A citizen report card on public serv-

ices is not just one more opinion poll.Report cards reflect the actual experi-ence of people with a wide range of pub-lic services. The survey on which areport card is based covers only thosewho have had experiences in the use ofspecific services, and interactions withthe relevant public agencies. Users pos-sess fairly accurate information, forexample, on whether a public agencyactually solved their problems orwhether they had to pay bribes to offi-cials. Of course, errors of recall cannotbe ruled out. But the large numbers ofresponses that sample surveys generatelend credibility to the findings.

Stratified random sample surveysusing well-structured questionnaires arethe basis on which report cards are pre-pared. It is generally assumed that people

from similar backgrounds in terms ofeducation, culture, and so forth, are like-ly to use comparable standards in theirassessments. But these standards may behigher for higher income groups than forthe poor whose expectations about publicservices tend to be much lower. Dividinghouseholds into relatively homogenouscategories is one way to minimize thebiases that differing standards can cause.

The Bangaloreexperiment

THE PUBLIC AFFAIRS CENTRE (PAC) inBangalore has done pioneering work onCRCs over the past decade. The firstreport card on Bangalore’s public agen-cies in 1994 covered municipal services,water supply, electricity, telecom, and

12 Development Outreach W O R L D B A N K I N S T I T U T E

PROBLEM INCIDENCE ACROSS REPORT CARDS

BMP

BESC

OM

POLI

CE

BMTC

GOV.

HOS

PITA

LS RTO

BSNL BDA

BWSS

B

0

20

40

60

80

100

% in

cide

nce

1994 1999 2003

0

5

10

15

20

25

16165

2919

3120

39

8

27

7

2013

31

312 15

66

FIGURE 1—DECLINE IN PROBLEM INCIDENCE

1999 2003

BMP

BESC

OM BSN

GOV.

HOS

PITA

LS

POLI

CE BDA

BMTC RTO

BWSS

B

0

20

40

60

80

100

% s

atis

fied

41

5

47

6

42

4

67

9

3425

34

16

1

32

77

32

14

FIGURE 3—RISE IN SATISFACTION LEVELS

1999 20031994

2023

11

SPEED MONEY INCIDENCE ACROSS REPORT CARDS

BMP: The City Municipal Corporation

BESCOM: The Electricity Authority

BWSSB: The Water & Sanitation Board

BDA: Land Development Authority

BSNL: Telecom Department

BMTC: City Transport Company

POLICE: City Police

RTO: Motor Vehicle Office

73

94

73

92

7378

8596

n/a n/a

FIGURE 2—DECLINE IN CORRUPTION LEVELS(routine transactions)

Source: PAC, Bangalore, India

Source: PAC, Bangalore, India Source: PAC, Bangalore, India

OVERALL SATISFACTION ACROSS THREE REPORT CARDS

perc

enta

ge w

ho p

aid

LEGEND

M A R C H 2 0 0 4 13

transport. Since then, PAC has brought out report cards on sev-eral other cities, rural services and also on social services such ashealth care. But since it has tracked services for a longer periodin Bangalore, we shall refer to this experiment in detail below.

The findings of the first CRC on Bangalore were moststriking. Almost all the public service providers received lowratings from the people. Agencies were rated and compared interms of public satisfaction, corruption and responsiveness.The media publicity that the findings received, and the publicdiscussions that followed, brought the issue of public servicesout in the open. Civil society groups began to organize them-selves to voice their demands for better performance. Some ofthe public agencies responded to these demands and tooksteps to improve their services. The inter-agency compar-isons and the associated public glare seem to have contributedto this outcome. When the second report card on Bangalorecame out in 1999, these improvements were reflected in thesomewhat better ratings that the agencies received. Still sev-eral agencies remained indifferent and corruption levels con-tinued to be high.

The third CRC on Bangalore, in 2003, has shown a surprisingturnaround in the city’s services. It noted a remarkable rise inthe citizen ratings of almost all the agencies. Not only did publicsatisfaction improve across the board, but problem incidenceand corruption seem to have declined perceptibly in the routinetransactions between the public and the agencies (Figures 1, 2,3). It is clear that more decisive steps have been taken by theagencies to improve services between 1999 and 2003.

Lessons

W H AT A C C O U N T S F O R this distinct turnaround in Bangalore’spublic services? And what lessons can we learn from this exper-iment? Needless to say, without deliberate interventions by thegovernment and the service providers, no improvement wouldhave taken place in the services. But the key question is, whatmade them act? A whole complex of factors seem to have been atwork. The new Chief Minister who took over in 1999 was veryconcerned about the public dissatisfaction with the city’s serv-ices. He set in motion new mechanisms such as the “BangaloreAgenda Task Force,” a forum for public-private partnership thathelped energize the agencies and assist in the upgrading of theservices. The civil society groups and the media supported andmonitored these efforts. What is significant is that the initialtrigger for these actions came largely from the civil society ini-tiative, “citizen report cards.”

What are the pre-conditions for such civil society initiativesto work? It is obvious that these initiatives are more likely tosucceed in a democratic and open society. Without adequatespace for participation, CRCs are unlikely to make an impact. Atradition of activism within the civil society would also help.People should be willing to organize themselves to engage inadvocacy and seek reforms supported by credible information.Political and bureaucratic leaders must have the will andresources to respond to such information and the call forimproved governance by the people.

The credibility of those who craft CRCs is equally important.The initiators of the exercise should be seen as non-partisanand independent. They need to maintain high professionalstandards. The conduct of the survey and the interpretation ofthe findings should be done with utmost professional integri-ty. A report card does not end with the survey and its publica-tion. Much of the advocacy work that follows will draw uponthe report card findings. The CRC thus is a starting point, tobe followed by further action through organized advocacyefforts, including civic engagements and dialogues with therelevant public agencies.

Conclusion

W H E N A G O V E R N M E N T O N I T S O W N improves its servicesand accountability, initiatives such as CRCs may not be neces-sary. Even under these conditions, a report card can be aneffective means for civil society groups to monitor the per-formance of government and its service providers. Publicagencies can on their own initiate report cards on their per-formance as indeed some in Bangalore have done. But when agovernment is indifferent to these concerns, the report cardapproach can be an aid to civil society groups that wish to goadthe government to perform better. s

Samuel Paul is Chairperson, Public Affairs Center, Bangalore, India

The Handbook on PublicSector Performance Reviews

MAKING THE PUBLIC SECTOR RESPON-SIBLE, RESPONSIVE AND ACCOUNTABLE

Implementing citizen-centered governance

Measuring and evaluating government performance in the delivery of local public services

Governing for results and designing governmentsfor performance

Implementing decentralized public management

Understanding governance approaches to managing conflict

Rooting out corruption and malfeasance

Reforming bureaucracy

Ensuring accountability when there is no bottomline

Learning newer approaches to public sector evaluations

Tracking the success of health, education, and infrastructure investments

Learning about better practices in tax, expenditure, and transfer policies

And much more!

Volumes 1-3 available on the internet library at w w w.decentralization.org and on CD-ROM.Contact Theresa Thompson atTthompson@worldbank.org

Volumes 4-6 will be coming soon!

edited by Anwar Shah, World Bank

Including tools for:

DEFINITION DESCRIPTION AND EXAMPLES

Refers to the research, advocacy anddissemination of information onissues related to official budgets bycivil society and other actorsindependent of the government. The goals are to: n analyze the implications of

government budgets for differentstakeholder groups, particularlythe poor and underprivileged

n raise the overall level of budgetliteracy amongst the general public

n inform legislatures and policymakers themselves so that theycan engage in a more informedand efficient budget policy debate.

BUDGETARY PROCESS ANALYSIS: evaluating the knowledge of and generaltransparency surrounding the budgetary process (e.g. ADVA in Israel)GENERAL ECONOMIC ANALYSIS: Several groups look at whether themacroeconomic assumptions and forecasts made to guide medium termpolicies like the PRSP are realistic or not.BUDGET EXPENDITURE ANALYSIS: includes tracking public spending tocompare the "planned" budget to the actual budgetn Sector-Specific Analysis: examine the implications of the budget on

specific sector or area of public expenditure (health, education..)n Analysis of Effects on Different Population Groups: such as expenditure

oriented to the poor, the elderly or women(e.g. FUNDAR in Mexico).n Revenue Analysis: a) assessing the macroeconomic effects of tax increases

or cuts on the distributional effects of the tax system, b) connectingrevenue and expenditure analysis, and c) evaluating the tax collectioncapacity of the government.

n Evaluating Public Services or Programs: assessing the quality andeffectiveness of public services.

n Advancing Budget Literacy and Providing Budget Training: providingaccessible materials and training on budget-related issues.

BPET involves the use of civil society totrack how the public sector spends themoney that was allocated to it. This isusually done by ‘input-tracking’ ratherthan tracking of actual expenditures,since for most developing countrycontexts the most readily availabledata is on inventory records.

BPET allows a continuous public involvement in the exercise. It is the actualusers or beneficiaries of services (like parents of school-going children) thatcollect data on inputs and expenditures, rather than some technical agency,bureaucrat or external consultant. The results of the exercise are immediatelydisseminated to the public either via the media, or through publications inthe local language. This continuous transfer of information into the publicdomain either through an accompanying media campaign, public awarenessdrive, or via information dissemination and mobilization by CSOs is anintegral part of BPET, which differentiates it from the more orthodox methodslike public expenditure reviews (PERs).

The performance of the selectedpublic funded agencies or projects areassessed and monitored by thecommunity organizations/groups orNGOs using predetermined indicatorsand systems that they themselvesdecide upon. It also includescommunities or community groupstracking of progress of projects andsub-projects which they havedesigned and implemented usingtheir own funds or government funded(e.g. social investment funds).

n Community Score Cards. This is a community based qualitativemonitoring tool that draws on techniques or is sometimes called a hybridof social audit, community monitoring and citizen report cards. The processis also an instrument for empowerment and accountability as it includesan interface meeting between service providers and the community thatallows for immediate feedback.

n Citizen Report Cards. One of the more analytically robust and powerfulinstruments to monitor and evaluate public performance draws on aprivate sector practice of soliciting feedback from citizens and compiling‘report cards’. (e.g. Bangalore Report Cards and the Bank-funded FilipinoReport Card (2000))

n ‘Participatory’ or community based monitoring and evaluation. It is aprocess of monitoring and evaluating projects that have been designed bythe community or community groups themselves or by governmentagencies.

This involves direct citizen/CSOparticipation in formulating publicbudgets

n Participatory policy formulation has become an increasingly commontrend, particularly with the introduction of the PRSPs at the national leveland community driven development initiatives at the local level.

n Participatory budget formation, is less common and usually occurs at thelocal level (as in over 100 municipalities in Brazil or in Sirajganj district inBangladesh). But is also theoretically applicable at higher levels.Another approach to participatory budget formation is when civil societyactors prepare alternative budgets (such as South Africa’s Women’s Budgetor Canada’s Alternative Federal Budget) with a view to influencing budgetformulation by expressing citizen preferences.

OUTLINE OF SOCIAL ACCOUNTABILITY MECHANISMS

PARTICIPATORYBUDGETING

PARTICIPATORYPERFORMANCEMONITORING

PARTICIPATORYBUDGET ANDPUBLICEXPENDITURETRACKING

INDEPENDENTBUDGET ANALYSIS(IBA)

COMPONENTS OF SA MECHANISMS

WBI’s Community Empowerment and Social Inclusion Learning Program and the Bank’s Social Development Unit areundertaking a global stocktaking exercise in the area of social accountability. This table reflects topics to be covered by thestudy. For more information, see www.worldbank/wbi/communityempowerment

M A R C H 2 0 0 4 15

BY SIGRUN MØGEDAL

T H E S E RV I C E D E L I V E RY T R I A N G L E as presented in the 2004World Development Report (WDR) offers a tool for exploring keyinteractions in service delivery that can be usefully adapted tovarious contexts, services and service policies (Figure 1). Thisarticle is an attempt to apply the triangle concept to the chal-lenge of scaling up care and treatment for AIDS.

HIV/AIDS in a health system context

A I D S I S T O DAY A C H R O N I C D I S E A S E that can be treated, witha growing caseload that weighs heavy on weak health systems.Access to care and treatment is both a right for the individualand a public good, with widespread benefits for society. This isto a varying degree true also for other components of the

SPECIAL REPORT

Applying the ServiceDelivery Triangle

to Care and Treatment for HIV/AIDS

health care package. But health systems are often poorlyequipped to cope with these basic needs and rights, and facecompeting demands.

Much attention has in the past been given to reforminghealth system structures. In striving to reach the MillenniumDevelopment Goals (MDGs), there is now a growing concernabout performance and equity. This brings questions of accessand barriers to access to the forefront. Most of the access bar-riers are systemic in nature and therefore affecting all servic-es, including AIDS. Through its association with stigma, rejec-tion, and issues of power, poverty and gender discrimination,AIDS adds to systemic barriers and creates additional ones.

In spite of major efforts to simplify treatment routines,care and treatment for AIDS is more demanding than otherelements of the basic health care package. It is demanding interms of continuity in the health care chain from periphery toreferral, both because of its demand for diagnostics and clin-ical judgment and because of overall cost—although the drugcost has now been dramatically reduced.

The service delivery triangle iseasily adaptable to this context, butmay need to be interpreted through aspecial “AIDS lense” in order to offerclues on options and choices.

HIV/AIDS responseand stakeholders

T H E S E RV I C E D E L I V E RY T R I A N G L E

sets out key relationships ofaccountability between the client,the provider, and the policymaker.These stakeholder groups are basicto all service delivery and obviouslyalso to the AIDS response. But the way the stakeholders inter-act and the forces and drivers in each of the three corners ofthe triangle are not the same for all the elements of healthservices.

On the demand side, this is reflected in heterogeneity inthe client group. HIV/AIDS adds heterogeneity. Generally,one will expect to find important differences between demandfor curative and preventive services and between “high status”and ”low status” diseases. Demand will also reflect gender andage differences, social and economic groups, ethnicity, dis-tance from the provider and so forth. AIDS adds new dimen-sions of marginalization, aggravates the gaps between thenon-poor and the poor and creates new and competing inter-est groups and patterns of demand.

At the level of policymakers, the challenges of an emer-gency HIV/AIDS response in most heavily affected countrieshave led to the establishment of semi-independent, multi-stakeholder national authorities, linked up to the governmentstructures at the prime minister’s or presidential level. Theseauthorities serve as custodians of an exceptional nationalHIV/AIDS action framework, including policy co-ordination,umbrella functions for various partnerships mobilized forAIDS action, and for monitoring and evaluation. Bringing in a

national HIV/AIDS authority with exceptional policy and co-ordination responsibilities, in addition to the regular func-tions of the state, generates new challenges in terms ofaccountability (UNAIDS 2003).

For service providers, for the AIDS response it is critical tohave clear contracts with policymakers, as it brings added plu-rality in service provision. In many cases the financialresources for “outside-the-box” decision-making and provi-sion are far greater than what is available for a regular healthsector service package. There are new challenges in terms ofthe supply chain, both in quality and continuity. AIDS killshealth personnel and weakens the manpower base. At thesame time the multi-stakeholder response causes increasedcompetition for skilled manpower, moving health personnelfrom the public to the private, from the periphery to the cen-ter, and from low-capacity countries to countries with betterterms of employment. This situation is a major challenge topolicymakers and provider organizations and calls for codesof conduct to accompany market and purchase.

Client power and theAIDS response

C L I E N T P O W E R T H R O U G H PA R T I C -

I PAT I O N, watch, and purchase, is akey entry point for application of theservice delivery triangle offered bythe 2004 World Development Report todifferent types of services. The“eight sizes fits all” decision tree thatgoes with the triangle is central fordetermining which service deliveryarrangement would most improveprovision, along variables such as

centralized/decentralized decision-making and public-pri-vate provision (figure 2). When applying this decision tree toAIDS, each step needs a modifier reflecting whether the poli-cy environment is AIDS-sensitive or not.

With AIDS-sensitive government policies I mean policiesthat give visible political leadership to the HIV/AIDSresponse, fight stigma and discrimination, and are expressedin AIDS action frameworks and coordinating structures inclu-sive of non-governmental partners, particularly communitiesliving with the disease.

The first step of the WDR decision tree is to determinewhether government is pro-poor or clientelist. While in termsof the AIDS response this is a useful distinction, in the case ofpro-poor policies it makes a big difference whether thesepolicies are “AIDS-sensitive” or not.

The basic assumption must be that providers are able tocarry our the AIDS response as an integrated component, whichwould be exceptionally designed, visible, and have high priori-ty. This means that in countries with pro-poor policies that arenot AIDS-sensitive the health system cannot be the main serv-ice provider. In such cases central government contracting orcentral government provision without direct client input orclient monitoring will have to be ruled out. These options may

16 Development Outreach W O R L D B A N K I N S T I T U T E

FIGURE 1—ACCOUNTABILITY RELATIONSHIPS

Source: WDR 2004

not even be viable in a context of AIDS-sensitive policies,because of the need for broad involvement of multiple stake-holders to deliver and manage an effective AIDS response. Incountries with heavy AIDS load client groups become more het-erogeneous and thereby call for decentralized options. AIDSwill also tend to make services harder to monitor.

The mix of clientelist and AIDS-sensitive policies raiseschallenges, which do not fit easily into any of the boxes of thedecision tree. While seemingly a contradiction, it is importantto remember that government policies are often not coherentand may be contradicting—across sectors and levels as well aswithin them. Country-level analysis along the lines of povertyorientation and AIDS-sensitivity is therefore important.

It can be assumed that both poverty-orientation and AIDS-sensitivity are required in order to achieve the MillenniumDevelopment Goals (MDGs). MDG monitoring may thereforebe a useful tool to address issues of policy coherence.Strategies for basic health services as well as care and treatmentfor AIDS will need to be assessed as to whether they will useful-ly drive coherence, compatibility, efficiency, and sustainabilityin order to achieve the MDG. Clientelism, combined withAIDS-insensitive policies in countries heavily affected, poses aserious risk scenario for any public health effort.

Applying AIDS-sensitivity to the decision tree (Figure 2)

shows us that client participation and client power are criticalto make health services work, both for poor people and for aneffective AIDS response.

Demand and priority setting in thecontext of HIV/AIDS

T H E R E A R E M A J O R Q U E S T I O N S to address in the matchbetween supply and demand in the context of HIV/AIDS.Individual demand for treatment and care may overpowerpublic health imperatives, such as prevention. Stigma anddiscrimination require special measures to ensure that treat-ment is available for marginalized groups, even if notdemanded. In addition, the purchasing power, interest, andneeds of the individual have to be weighed against well estab-lished criteria for effective public health in order to serve pur-poses of common good.

There is a definite risk that separate provision of treatmentfor disease will risk reducing the demand for prevention andmay lead to reduced coverage of the basic health package. Andwhile accountability between the provider and the client may

M A R C H 2 0 0 4 17

S e r v i c e D e l i v e r y T r i a n g l e c o n t i n u e d o n p a g e

2 9

FIGURE 2—EIGHT SIZES FIT ALL

Source: WDR 2004

18 Development Outreach W O R L D B A N K I N S T I T U T E

BY DANIELE GIUSTI, PETER LOCHORO,JOHN ODAGA, AND EVERD MANIPLE

M O S T P R I VAT E N O T - F O R - P R O F I T ( P N F P ) health providersin Uganda are faith-based. They account for a sizeable pro-portion of the health services delivered in the country(Hutchinson 2001) and have as their prime concern the pro-vision of services to the poor. During the last century this sec-tor expanded substantially, especially in rural areas, providingservices at subsidized prices, thanks to the solidarity of sisterchurches and denominations. These providers are coordinat-

ed through umbrella organizations, such as the Catholic,Protestant, and Muslim Medical Bureaus and the UgandaCommunity Based Health Care Association.

During the era of socio-political upheaval and economicdecline in the 1970s and 1980s, the PNFP sector continued tooperate using several coping mechanisms aiming at cost con-tainment—such as underpayment of personnel, reliance onunqualified staff, increasing working hours, and disregard fordepreciation of capital assets and their maintenance—on theone hand, and at increasing reliance on support from externalcharities, on the other hand.

SPECIAL REPORT

Pro-Poor Health ServicesThe Catholic Health Network in Uganda

By mid-1990s both approaches showed their limitations.Attempts to restore physical and human capital occurred at thetime when new service standards were introduced and whenthe civil service reform was increasing public sector salaries,creating considerable pressure on the PNFP sector.Furthermore, the AIDS crisis became apparent, and inputsfrom private charities started decreasing. The only possibleoption was a heavier reliance on user fees. But this caused arapid decrease of utilization, accompanied by efficiency losses.

This article documents the experiences of the Catholichealth network in Uganda and its umbrella organization, theUganda Catholic Medical Bureau (UCMB) in making healthservices work for poor people. It demonstrates how the pro-poor ethos—derived from a longstanding tradition and the mis-sion of “healing by treating and preventing diseases, with apreferential option for the less privileged”—supported by “soft”regulation and technical assistance from the umbrella organi-zation can induce a process of change in a network of providers.

Preventing a crisis

BY M I D -1990s many providers in the PNFP health sector wereno longer able to cope with the increasing cost of service pro-duction. The UCMB estimated that, on average, the cost ofproducing one unit of output was increasing by 20 percent peryear. Given the importance of the PNFP sector, a major crisisin health care countrywide was to be expected. A particularconcern was that higher fees reduced access for the most vul-nerable groups: women, children, and the poor. A clear sign ofthe crisis was the decreasing volume of services delivered,expressed in standard units of output relative to outpatients(SUO op). Data prior to 1997/98 showed a steep decline of var-ious activity indicators; in several hospitals utilization was in afree fall. Also recognizing the signs of a crisis, the governmentagreed to support the PNFP sector by grants disbursed direct-ly to individual providers (hospitals and health centers). Sincethen, subsidies have increased from about 5 percent of theoperational cost of the sector to about 35 percent. Today thesector relies on user fees for about half of its operational costs.This intervention—a private-public partnership—was able toprevent a fatal crisis, reduce reliance on user fees, and, as aresult, increase utilization.

Developing monitoring tools

T H E U C M B WA S AWA R E of the need to monitor closely devel-opments in the delicate phase of transition. It was also awarethat it needed to account for the public subsidies. For thesereasons the Bureau undertook, since 1997/98, a systematicdata collection effort from the affiliated hospitals, coveringboth inputs and outputs. The analysis of these data has per-mitted the observation of trends in critical parameters (listedbelow). Since 2000/01 each hospital has received an annualfeedback report, containing information on its own perform-ance compared to other hospitals for each of the selected indi-cators. The aim of the feedback report is to help the hospital

management take a critical look at their performance andcompare it to that of the whole sub-sector, its peer group, andoutliers. In the absence of realistic “gold standards” of per-formance, this approach stimulates comparisons and triggersprocesses of steered change in an environment long dominat-ed by crisis management.

At the end of 2001/02, the following picture could bedetected from the performance indicators:n The volume of service outputs, measured by standard units of

output relative to outpatients (SUO op), was increasing steadi-ly, but so was the cost of the services produced. SUO op is acomposite activity index weighted by the cost of each activity.

n The productivity of staff (SUO op per staff), remained stable,and in some cases showed a decline.

n Fees (per SUO op), which had been decreasing for threeyears, had started increasing again.The interpretation that the UCMB gave to these observa-

tions was that the expansion of service volume had not beenaccompanied by the necessary efficiency gains, and thataccess by the poor was still a problem.

Accelerated reduction of user fees

A N E A R L I E R S T U DY commissioned by the UCMB had revealedthat a small group of hospitals in the network was operating athigher efficiency levels (Amone and others, 2000). A commonfactor for them was that they had introduced and maintainedlower and flat fees for selected target groups (children, moth-ers, and female patients). In 2000 a severely underutilizedhospital that had reached the verge of closure, was encour-aged—on the basis of the evidence gathered through the study—to flatten and lower fees for children and pregnant women. Theonly support the UCMB was able to provide was a moderatedegree of managerial assistance and the guarantee that finan-cial losses, if occurring, would have been met through externalaid. The experience of this hospital was a shocking revelation.In a few months patients started flocking back, without causingany financial shortfall (Santini, 2002).

Given this experience, the Bureau launched in 2002 a“strategy for accelerated reduction of user fees,” proposing it toall PNFP hospitals. In a nutshell, hospitals were asked to:n Pay a closer look at fees actually paid by patients, with a sys-

tematic approach (that is, a baseline survey and follow-up);n Reduce and/or flatten fees for children, mothers, and

women; andn Monitor utilization and provide this information to the

UCMB for aggregation across hospitals.

Results

I N L E S S T H A N O N E Y E A R from the consensus reached amongall affiliated health units in the Catholic health network, thefollowing results could be documented:n The annual increment of outputs has been the highest reg-

istered in the last 5 yearsn For the first time in 5 years unit cost has decreased (Figure 1)

M A R C H 2 0 0 4 19

20 Development Outreach W O R L D B A N K I N S T I T U T E

n Productivity of staff hasincreased in the last year(Figure 2)

n Fees per unit of output, whichhad started increasing again in2001/02, have decreased andare at the lowest value in 5 years( Figure 3).Results are all the more

remarkable if one considers that,contrary to the above pilot hospi-tal, the UCMB was not able to offerany guarantee that financialshortfall could be met by externalaid. Hospitals had to carry the riskthemselves and financial subsi-dies from government, which hadbeen growing rapidly in the previ-ous years, were leveling off.

These results point to the factthat intrinsic motivation, or the“ethos” of these hospitals, matters.A similar inference was made forthe PNFP lower level units by acomparative study of PNFP, privatefor-profit, and public health unitsin Uganda (Reinikka andSvensson, 2003). When an appealto this ethos is accompanied by arational argument, evidence, andsome know-how, major changesare possible. The results docu-mented thus far also provide someevidence that the hospitals havebecome more pro-poor. Althoughfee reductions were not targeted atthe poor, it is known that utiliza-tion by the poor is more elastic tofee adjustments (McPake, 1993).This implies that fee reductionsdisproportionately favor the poor.Since the largest majority ofCatholic health units operate inrural environments and a sizeablenumber of them in war-torn areas,it could easily be inferred that theirincreased utilization includedmore patients from poor socio-economic categories.

Improvinginformation

T O P R O V I D E f u r t h e r d o c u -m e n t a t i o n of the processesunder way, strengthen the rationalargument, and improve the know

FIGURE 1—MEDIAN VALUES OF COST PER 1 SUO op IN 27 UCMB HOSPITALS

FIGURE 2—MEDIAN VALUES PRODUCTIVITY OF PERSONNEL IN 27 UCMB HOSPITALS

FIGURE 3—MEDIAN VALUES OF FEES CHARGE PER 1 SUO op IN 27 UCMB HOSPITALS

Ugandan schilling

Ugandan schilling

M A R C H 2 0 0 4 21

how in view of limiting the degree of risk that hospitals have toaccept, the UCMB with the other denominations’ bureaus, wenta step further and carried out a study in a sample of affiliatedhospitals (Odaga and Maniple, 2003). Although the study didnot yield conclusive results, it provided additional insight in thedynamics at play and led to some interesting findings, summa-rized here, and communicated to all hospitals:n The majority of the hospitals have responded by reducing fees

and adopting a flat fee structure. Only 8 percent of hospitalshave not yet taken a decision to do so. Most hospitals have tar-geted services towards pregnant mothers and children.

n Fee reductions have generally resulted in increased utiliza-tion of all targeted services, and have especially favoredchildren.

n Responsiveness in maternal services was consistently low,implying presence of other important barriers.

n Flattening of the fee structure reinforced the effects of feereduction. However, the flat fee concept was not appreciat-ed the same way in all the hospitals.

n Response was stronger where the community could under-stand (and perhaps predict) the new fee structure. Althoughmost hospitals reported to have displayed their fees publiclyin their premises, this alone was not effective in informingthe community. Methods that reach out to the communitywere found to be more effective.

n Many hospitals still lack the technical competence to mon-itor the process of user fee reductions, even though most ofthem reported to have them in place.

Conclusion

M A K I N G H E A LT H S E RV I C E S W O R K for poor people is noteasy. The 2004 World Development Report provides an extensiveanalysis of the actors and factors at play. It has also suggestedthat with altruistically motivated providers the inherent pro-poor ethos can be banked upon if combined with regulationand support. This article has documented how this can indeedhappen. We would only like to add that managerial know-howis necessary to limit the risk that service providers take whenthey decide to be more pro-poor, in an environment wherepoverty is widespread and resources are extremely limited.Umbrella organizations can collect and make use of informa-tion to strengthen the pro-poor ethos and enhance self-regu-lation. They can also provide the much-needed additionalmanagerial capacity so often wanting at the implementationlevel in a resource constrained environment. s

Daniele Giusti, MD MPH, and Peter Lochoro, MBChB MSc HSM,

Uganda Catholic Medical Bureau (UCMB); Everd Maniple, MBChB

MPH and John Odaga, MBChB MPH, Uganda Martyrs’ University,

Department of Health Sciences.

dgiusti@ucmb.co.ug

ReferencesAmone, Joseph, Salome Asio, Adriano Cattaneo, Annette KakindaKweyatulira, Anna Macaluso, Gavino Maciocco, Maurice Mukokoma. 2000.“User fees in private not-for-profit hospitals in Uganda.” Health andDevelopment, Supplement to no. 2. CUAMM Organization, Padua, Italy.

Republic of Uganda. 2001. “Facility-based private not-for-profit healthproviders: A quantitative survey.” Kampala: Ministry of Health.

Hutchinson, Paul. 2001. "Combating illness," in Uganda's Recovery: TheRole of Farms, Firms, and Government, Ritva Reinikka and Paul Collier, eds.Regional and Sectoral Studies, Washington, D.C.: World Bank.

McPake, Barbara. 1993. “User charges for health services in developingcountries: A review of economic literature,” Social Science and Medicine,vol. 36, no.11.

Odaga, John and Everd Maniple. 2003. “Faithfulness to the mission: Effectof reducing user fees on access to PNFP health services.” Study Report,Uganda Martyrs’ University. October.

Reinikka, Ritva and Jakob Svensson. 2003. “Working for God?” Evaluatingservice delivery of religious not-for-profit health care providers in Uganda.”Policy Research Working Paper 3058, World Bank, Washington, D.C. May.

Santini, Stefano. 2002. “The Naggalama Initiative: How to revitalize a hospi-tal,” UCMB Bulletin, vol 4, no. 2, Kampala, Uganda.

M A R C H 2 0 0 4 23

SPECIAL REPORT

BY JUNAID K. AHMAD, DAVID SAVAGE, ANDVIVEK SRIVASTAVA

W O R L DW I D E T H E R E H AV E B E E N M A N Y S U C C E S S E S in thedelivery of drinking water services. The reform of PhnomPenh’s public utility in Cambodia and Cartaghena’s water pri-vatization in Colombia are outstanding examples. But, thereare also cases of dramatic failures—Cochabamba, Bolivia, orBangladesh’s arsenic crisis. These successes and failures offera host of lessons for reformers, but one stands out in particu-lar: the success of service delivery depends on whether insti-tutions of service provision are accountable to citizens. Thechallenge is thus “not to fix the pipes, but to fix the institu-tions that fix the pipes.”

Institutional changes, which ensure that service providersare accountable to all citizens, are a highly political endeavor.Undertaking such changes on a pilot basis is difficult enough;scaling it up across jurisdictions and sustaining it over time, is adaunting challenge. Yet, it is precisely the scaling up of institu-tional change that is needed to ensure that the goal of universalaccess to basic services can be realized. How can governmentsensure that all citizens have access—and quickly—to a basic levelof water and sanitation services, that these services are provid-ed on a sustainable basis, that service providers respond to avariety of consumer preferences across income levels, and canadapt endogenously to changing circumstances?

The historical experience of three countries—Australia,India, and South Africa—offer important insights into theprocess of institutional change in service delivery and thechallenges of scaling up of service provision. The country set-tings—demographics, political systems, geographical size,economics, and income levels—are different; but it is precise-ly this diversity that enables us to draw common lessons andprinciples from their experiences.

The case of Australia

R E S T R U C T U R I N G I N T H E A U S T R A L I A N WAT E R S E C T O R wasinitiated in the context of broader economy-wide reforms.Between 1960 and 1992, Australia slipped from being the

third richest nation in the world to the fifteenth. This declinedrove successive governments in the 1980s and 1990s to ini-tiate wide-ranging economic reforms, including reform ofpublic utilities in the infrastructure sector.

In this context, a compact was signed in the Council ofAustralian Governments between different tiers of govern-ment—the federal tier, the Commonwealth, and the states—tocreate an economically viable and ecologically sustainablewater industry. The states decided to restructure their publicagencies in the sector on the basis of agreed upon principles.These included introducing commercially viable and justifi-able water pricing; costing and transparency of (cross) subsi-dies; institutional reforms of public monopolies to achieveseparation of key institutional roles—policy, service deliveryand regulation; performance monitoring; intensive publicconsultations and education; and measures related naturalresource sustainability, including allocation and trading inwater entitlements.

In view of Australia’s federal structure, the actual reformpath—the implementation of the principles—was left to thediscretion of the states. Different states and territories areintroducing the reforms at different rates and in differentways. For examples, some states have viable state-wide utili-ties, others use local government utilities, some have statewide regulators other rely significantly on performance mon-itoring, and so on. These differences in implementationapproaches reflect the differences in the initial legislative,economic, and political conditions of the separate jurisdic-tions. But in all cases, the institutional choice adopted by thestates is defined by the agreed upon principles.

As an incentive, the Commonwealth makes fiscal paymentsto the states and territories for achieving the milestones ofreform. Although not large—less than one percent of the over-all budget of the Commonwealth and states—the fiscal trans-fers provide sufficient incentive at the margin for the states tostay committed to the reform program. The initial reformtimetable was optimistic and underestimated the complexityof the reform program requiring extensive research andanalysis for effective implementation, the need for extensiveconsultative and educative processes and the demand thatthese reforms placed on governments, institutions, and

Scaling Up DrinkingWater Services

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stakeholders. But, after more than a decade of sustained insti-tutional reform, Australia’s water sector has become animportant model for infrastructure reform.

The case of rural India

R U R A L I N D I A , W I T H 7 0 0 M I L L I O N P E O P L E , is currentlyundergoing a major reform in its drinking water and sanita-tion sector. A state subject under India’s Constitution, ruralwater services have traditionally been provided through statewater boards and departments. Water has been treated as asocial good by the state agencies, supplied without any usercharges or local stakeholder involvement in the deliveryprocess. Top down in their approach, the boards were profi-cient at delivering hardware, but less inclined to undertakethe operations and maintenance and manage service delivery.This was not surprising, as the boards were underwritten byCentral and State budgetary outlays regardless of perform-ance. The bias was for greater spending and often spendingcaptured by political interests.

Drawing on the lessons learned from smaller projects—oftenfinanced in partnership with donors—central government in1999 piloted the Sector Reform Program across all the statescovering 70 million people. In the SRP, communities weremobilized through user group committees to determine theirchoice of service standard and process for managing serviceprovision. Capital costs were shared between central govern-ment and communities, but communities were expected to payfully for operations and maintenance. Water was treated as aneconomic good—valued for its use—thus increasing accounta-bility to communities and enhancing their sense of ownership.

The SRP experience showed greater sustainability of servicesand more responsiveness to consumer preferences. But, scalingup of community delivery systems has proven to be a challenge—the problems of managing collective action, capacity constraints,and addressing the political context of existing state agencies areimportant policy issues that need to be addressed. Increasingly,local governments—panchayats—are being seen as the key link tomanaging a process of scaling up the SRP.

State governments are now being asked to develop a planfor shifting drinking water services in rural areas to a com-pletely demand-driven, participatory approach where com-munities and local governments are partners in the provisionof drinking water. In the process, states are being asked to re-define the role of the water agencies. The principles are fixed,but the state governments have the full flexibility to developtheir individual approaches to implementation. Onceendorsed by the political leadership of the states, the planswill form the basis of a Memorandum of Understandingbetween the state and central government, where the centerwill support the funding of the MoU against pre-agreed mile-stones of change proposed by the states. In addition, the cen-ter will provide funding for capacity support and clear moni-toring and evaluation of the process with the possibility ofbenchmarking performance of the states.

The transition from state agencies, to community systems,

and now to the proposed local government and communitymanagement of water and sanitation, reflects changes in thepolitics of India. While federal in structure—with a centralgovernment and several states—India adopted a centralizedeconomic and a political model after independence. Overtime, broader economic liberalization and strengthening ofthe federal system, including the introduction of local govern-ments into the Constitution about a decade ago have changedthe overall view of how services should be managed. Water andsanitation will not be an exception to these fundamentalchanges and success in scaling up service delivery will dependon the political, fiscal, and administrative relationshipbetween the different tiers of governments.

The case of South Africa

S O U T H A F R I C A’ S WAT E R S E RV I C E S S E C T O R has undergonefar-reaching transformation since the advent of democracy in1994. This transformation process has been underpinned by astrong commitment to eliminate the inequities of SouthAfrica’s apartheid past, but driven by a broader program todecentralize functions and finance to local government.

Although water services are defined as a local governmentfunction in the Constitution, the national government initiallytook the lead in expanding access to services. The CommunityWater Supply and Sanitation program was developed as anational investment program, implemented directly by theDepartment of Water Affairs and Forestry (DWAF) or throughnationally owned water boards or NGO’s. Initially, in the con-text of weak local government authorities, community man-agement structures were established—although considerableemphasis was placed on large regional scheme investments.

The restructuring of the local government system throughre-demarcation of municipal boundaries and a redefinition oflocal government functions created a structural conflictbetween community management structures and elected localgovernment authorities. This occurred at a time of growingconcern over the cost and sustainability of the national invest-ment program. A program of fiscal decentralization, whichinvolved the consolidation and decentralization of operatingand capital transfers to local government, sought to addressthese problems through placing accountability for investmentdecisions with the operating authority and ensuring greatercoordination between investment programs of all spheres ofgovernment.

Although DWAF has begun to transfer schemes it has builtand operated to local government, concerns about theircapacity to manage water distribution remain. Recognizingthe positive relationship between functional assignments andactual capacity DWAF has responded to the new environmentthrough re-positioning itself as a “developmental regulator”of water services, rather than an investment agent or serviceprovider. This focus on capacity building efforts at local gov-ernment level includes a policy framework that distinguishesbetween “authority” and “provider” functions and thus allowslocal authorities to engage other agencies, whether public orprivate sectors, to undertake actual provision of services

24 Development Outreach W O R L D B A N K I N S T I T U T E

M A R C H 2 0 0 4 25

under contract to the local authority. DWAF has also placedconsiderable emphasis on building local planning and infra-structure investment capacity and on developing effectivemonitoring and evaluation systems.

Some Lessons

A C C O U N TA B I L I T Y T O C L I E N T S is at the heart of successfulservice provision. How to expand this relationship of account-ability across the sector is central to the challenge of scaling updrinking water services. How can this be brought about?Australia, India and South Africa offer many lessons.

To begin with, scaling up of services is a political process.In Australia the broader forces of liberalization started it; inIndia it is the gradual opening up of the economy and thedemocratic forces of federalism; and in South Africa it was theend of apartheid and the emergence of a completely new dem-ocratic setting. These changes are complex and take time.None were big bang approaches to service reform and nonesaw the politics of reform in the water and sanitation sectorcome from within the sector.

Where the politics are not conducive to scaling up reforms,innovative pilots may have a demonstration role to play. But asthe case of SRP in India suggests, scaling up pilots is not sim-ply a replication of the pilots themselves. While pilots suggestimportant principles, the wider implementation of the prin-ciples may require a very different approach, as exemplifiedby the shift from SRP to a MoU between different tiers of gov-ernment—similar to Australia’s federal-state compact

In all countries, valuing water as an economic good andintroducing some level of user charges were essential to get-ting providers to become more accountable to consumers—rich and poor alike. This may well be a sine qua non of achiev-ing universal services. Once the value of water is reflected inthe transaction, allowing choices about standards and servicedelivery organization to be dictated by local preferences of

communities becomes essential. Separation of roles is also an essential element of the

reform process. Within the sector, the policy making, regula-tory, and service provision functions need to be kept in sepa-rate organizations and processes. Equally important, separat-ing the powers and roles of different tiers of government isessential to enable the center to play a role of providing incen-tives for change. But this requires that the fiscal rules of thegame between different tiers of government are clear andbinding. In Australia, and increasingly South Africa, this isthe case. In India, the reforms of rural drinking water maywell be delayed because the rules of India’s fiscal federalismare still in a state of flux. Importantly, the evolution of multi-tiered governments may well facilitate the separation of poli-cymaking from regulation and service provision, which isessential to the sector—the two processes are interlinked.

With the separation of roles emerges the potential forindependent benchmarking of providers and tiers of govern-ment responsible for service delivery. In effect, informationbecomes an important tool for catalyzing and sustainingreforms, and one, which is being widely used in Australia andincreasingly in the other countries.

Finally, reforms require mobilization of citizens andcapacity support to governments and communities to under-stand and undertake the changes. Central governments canplay a proactive role in designing such systems of capacitysupport. But the lesson is clear: such support is best deliveredin the context of on-going reforms. s

Junaid K. Ahmad is with the Water and Sanitation Program,

South Asia (WSP-SA).

David Savage formerly with National Treasury, South Africa,

now works in WSP-SA.

Vivek Srivastava is with the Africa Region, The World Bank.

wspsa@worldbank.org

26 Development Outreach W O R L D B A N K I N S T I T U T E

BY ESTHER DUFLO, RACHEL GLENNERSTER,AND MICHAEL KREMER

W H AT I S T H E M O S T E F F E C T I V E WAY to increase girls’ partic-ipation in school? How can we reduce the high absence ratesof teachers in many developing countries? We know surpris-ingly little about these questions, but finding answers is cru-cial to improving the quality of education in developing coun-tries and the effectiveness of aid. Every year, millions of dol-lars are spent on evaluating development programs but theseevaluations tend to focus on process: did the money go whereit was meant to? How many teachers attended training cours-es? How many textbooks were delivered to schools? Whiletracking performance at this level is important, we should alsobe evaluating programs at a more fundamental level to find outwhether, for example, training teachers or buying textbooksdoes more to raise test scores.

These fundamental questions, however, are hard toanswer. Imagine, for example, that a new headmaster arrivesat a school full of enthusiasm and new ideas. He wants to getthe parents involved and sets up a parent committee. Wordspreads that the new headmaster is good, and some childrentransfer into the school from other local schools. If an attemptwere made to evaluate the impact of the parents’ committee, itwould be extremely difficult to disentangle the effects of theparents’ committee, the impact of the headmaster’s enthusi-asm on the other teachers in school, and the influx of new stu-dents who might be more motivated than average.

The cleanest and clearest way to establish how a programwould work in an average school is to run a randomized trial.Choose 100 representative schools, initially establish a par-ents’ committee in half, phase in the program later in theother half, and in the meantime compare the outcomes in thetwo groups of schools. This approach, however, requires thatevaluation be built into the design of the original program andthat data be collected on all 100 schools, which can be expen-sive. However, this is what we do if we want to know whether adrug or vaccine is effective, and new research is showing thistechnique can teach us a lot about development.

Having strong evidence about what works is important for

many reasons. Non-governmental organizations (NGOs) andgovernments can use this evidence to focus their limitedbudgets on those programs that are most effective. With wide-spread cynicism about the effectiveness of aid, providing clearevidence on the impact of different programs can also helpgalvanize support for more development assistance.

Improving access to social services: theexample of school participation

T H E M I L L E N N I U M D E V E L O P M E N T G O A L S call for universalprimary school enrollment by 2015. However, until recentlythere were no good assessments of how best to achieveincreased participation in education or how much it would cost.

Recent research suggests that a simple means of increasingschool participation is by reducing the costs of schooling, oreven paying for attendance. The PROGRESA program inMexico provided cash grants to families if their childrenattended school regularly and received preventative healthcare like vaccinations. Schultz (forthcoming) takes advantageof the fact that the program was phased-in in different areasrandomly to assess its effectiveness. He finds an averageincrease in enrollment of 3.4 percent for all students in grades1 through 8, and 14.8 percent among girls who had completedgrade 6. In part because the randomized phase-in of the pro-gram made the benefits so clear, the Mexican governmentexpanded the program, and similar programs are now beingintroduced elsewhere in Latin America.

Randomized evaluations performed in the same settingprovide an opportunity to compare the cost effectiveness ofvarious interventions. A series of evaluations in Kenya is agood example which provides comparative costs of differentways to increase school attendance. The most cost-effectiveapproach was to implement a twice-yearly school-based masstreatment with an inexpensive deworming drug. As the chil-dren’s health improved, so did their attendance, and it costonly $3.50 per additional year of schooling induced (Migueland Kremer 2004). Providing school meals to pre-schoolerscost an average of $36 per additional year of schoolinginduced, and also improved test scores in schools where

SPECIAL REPORT

Randomized Evaluations of Interventions

in Social Service Delivery

M A R C H 2 0 0 4 27

teachers were well-trained prior to the program (Vermeersch2002). In contrast, even under optimistic assumptions, a pro-gram which provided free school uniforms (among otherinputs) cost $99 per additional year of schooling induced(Kremer and others 2003).

Overall, these results suggest that school participation isquite elastic to cost and that school health programs may beone of the most cost-effective ways of increasing school par-ticipation. Is access to health care similarly elastic to cost? Wewill only know for sure when we have conducted a randomizedevaluation of the policy.

Improving the quality of social services

W H I L E T H E S E R E S U LT S S H O W that improving access to socialservices is relatively easy, other evaluations have shown thatimproving the quality of education is more difficult. Non-

randomized evaluations suggest that providing additionalinputs (such as textbooks or flipcharts) to under-resourcedschools can improve learning and test scores (Glewwe andothers 2002; Glewwe and others, forthcoming). However,results from a randomized evaluation point to a subtler pic-ture: provision of textbooks increased test scores only amongstudents who had scored in the top 40 percent on pre-testsprior to the program, and did not affect scores for the bottom60 percent of students. Flipcharts had no impact on testscores. This result shows how misleading the results of non-randomized evaluations can be when, for example, inputs aremore available in richer schools (as was the case withflipcharts in this study).

It would be wrong to conclude from these studies that pro-viding inputs is necessarily ineffective. Banerjee and others(2002) conducted a randomized evaluation of a remedial edu-cation program run by an Indian NGO. The program hired

28 Development Outreach W O R L D B A N K I N S T I T U T E

young local women from the communities to provide remedialeducation to students who were identified as lagging behind intraditional classes, and was found to have substantial positiveimpacts on learning, particularly for the weakest students. Onaverage, student test scores increased by 0.39 standard devia-tions, and gains for the bottom third of students were 0.6 stan-dard deviations, a very large impact. The program was shown tobe at least 6 times more cost-effective than computer-assistedlearning implemented (and evaluated) in the same schools.

These studies show that intuition about what works and whatdoes not can be misleading. Substantial amount of money canbe saved by finding out which inputs work and which do not.

Improving governance

O N E O F T H E R E A S O N S W H Y P R O V I D I N G M O R E I N P U T S isnot always effective is that social service delivery in developingcountries is plagued by high absence rates and low effective-ness. If teachers don’t show up to school, the benefit of moretextbooks may be limited to the few who can read well at thestart. How to reform the governance of social services, however,is a complicated and hotly debated question. Several recentstudies involving randomized evaluations shed light on policiessuch as school reform, decentralization, and incentives.

A Colombian program provided vouchers for privateschools through a random lottery (due to budgetary con-straints), which thus allowed for credible estimates of programimpact (Angrist and others 2002). Lottery winners were 15-20percent more likely to attend private school, 10 percent morelikely to complete 8th grade, and scored the equivalent of a fullgrade level higher on standardized tests (note that the voucherswere renewable, conditional on satisfactory academic per-formance). The effects of the programwere larger for girls than for boys.Winners were substantially morelikely to graduate from high schooland scored higher on high schoolcompletion or college entranceexams. Overall, the benefits of thisprogram to participants clearlyexceeded the additional cost relativeto the alternative of providing placesin public schools.

In India, an important effort todecentralize social service deliverystarted in the mid-1990s. Local vil-lage councils, elected every five years,have the power to decide how to allo-cate expenditure on local publicgoods. The constitutional amend-ment that set up this program alsorequired that one-third of all posi-tions be reserved for women, and thata share equal to the representation ofdisadvantaged minorities (scheduledcastes and scheduled tribes) be

reserved for these minorities. To avoid any possible manipu-lation, the reserved positions were randomly allocated, allow-ing for a clear evaluation of the program. Chattopadhyay andDuflo (forthcoming) find that in villages reserved for women,the public goods chosen better reflect women’s needs, and invillages reserved for the scheduled castes, a larger fraction ofthe public goods is allocated in the scheduled caste hamlet.

Conclusion

T H E R E S U LT S D E S C R I B E D A B O V E offer both substantive andmethodological lessons. Inexpensive health programs, reduc-ing the cost of schooling to households, or providing mealscan substantially increase school participation. Given theexisting governance problems in many developing countries,simply providing more resources may have a limited impacton social service quality, unless the resources are carefullyallocated. Systemic reforms (such as school choice, or decen-tralization and involvement in decision making by disadvan-taged groups) have important impacts.

These results also show that randomized evaluations ofpolicy programs can be implemented successfully. They cantake place in the context of small NGO or pilot programs, lot-teries, or where a policy is phased-in over time. The resultscan be in sharp contrast to conventional wisdom and theresults of more traditional evaluations.

Finally, good evaluation promotes good policy. The positiveresults found through the rigorous evaluation of the PROGRE-SA program led to the implementation of similar programs inother Latin American countries. The NGOs that have partici-pated in the evaluations discussed in this article have used theresults to focus their resources where they are most effective.

Creating a culture in which rigor-ous randomized evaluations are pro-moted, encouraged, and financed hasthe potential to revolutionize socialpolicy during the 21st century, just asrandomized trials revolutionizedmedicine during the 20th.

Esther Duflo is Professor of Economics,

Department of Economics, MIT, and one

of the founders of the Poverty Action Lab

at MIT, eduflo@mit.edu.

Rachel Glennerster is Director of the

Poverty Action Lab at MIT,

rglenner@mit.edu.

Michael Kremer is the Gates Professor of

Developing Societies, Department of

Economics, Harvard University,

mkremer@fas.harvard.edu.

More detail on randomizedevaluations can be found at

www.povertyactionlab.com, thewebsite of the new center at the

Massachusetts Institute ofTechnology devoted to encouragingthe use of randomized evaluation asa way to improve the effectivenessof poverty programs in advanced

and developing countries.Randomized evaluations have been

applied in many areas besides socialservice delivery, such as savings and

credit, discrimination, andagricultural extension.

M A R C H 2 0 0 4 29

be strengthened by increasing the client’s purchasing power,this measure in itself may lead to a service that offers only thecomponents clients want to buy.

Private provision for one disease, such as AIDS, in a sys-tem with largely public provision for other diseases will alsorequire careful monitoring to avoid major inefficiencies andimbalances in investments (infrastructure and technology)and skilled personnel.

Conclusion

T H E S E RV I C E D E L I V E RY T R I A N G L E presented in the 2004WDR does not offer solutions to the many specific challengesof the AIDS response, but helps clarify them and link them tooptions for general service provision. The role of the policy-makers, politicians and the state in setting out an enablingpolicy framework is essential, also for the AIDS response. Theneed for corrective measures and watch through client andcommunity mechanisms that can guide choices on the basis ofquality and the common good is strengthened in the contextof AIDS. AIDS adds challenges to transparent priority settingand makes it harder for clients to hold providers’ and policy-makers accountable. But it also has the potential for directingpolicymakers’ and providers’ attention to the need forbecoming more responsive to demand and overcoming barri-ers to access. In this way the AIDS response offers opportuni-ties for new solutions and new alignment of interests to pro-mote better accountability and service delivery. s

Sigrun Møgedal is Senior Adviser, NORAD, and Senior Policy Adviser,

UNAIDS

sigrun.mogedal@eunet.no

References

UNAIDS 2003. Coordination of National Responses to HIV/AIDS. Guidingprinciples for national authorities and their partners.

ReferencesAngrist, Joshua, Eric Bettinger, Erik Bloom, Elizabeth King, and MichaelKremer. “Vouchers for Private Schooling in Colombia: Evidence from aRandomized Experiment.” American Economic Review, 92(5): 1535-1558,2002.

Banerjee, Abhijit and Michael Kremer; with Jean Lanjouw and Peter Lanjouw.“Teacher-Student Ratios and School Performance in Udaipur, India: AProspective Evaluation,” Mimeo, Harvard University, 2002.

Chattopadhyay, Raghabendra and Esther Duflo. “Women as Policy Makers:Evidence from an India-Wide Randomized Policy Experiment,” NBERWorking Paper #8615, 2001, forthcoming in Econometrica, 2004.

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c o n t i n u e d f r o m p a g e 1 7

Service Delivery Triangle

30 Development Outreach W O R L D B A N K I N S T I T U T E

BY BERTIN MARTENS

A I D E F F E C T I V E N E S S I S O FT E N L O O K E D AT

from the point of view of performance in therecipient country: are programme objectivesachieved in a sustainable manner, have poli-cy reforms been implemented, and do theyproduce results in terms of economic growthand poverty reduction? This view is biased inthe sense that it clears the aid suppliers of allresponsibility and puts the burden of effec-tiveness squarely on the recipient. It is alsosimplistic because it assumes that the soleobjective of all individuals and organizationsinvolved in the aid delivery process is therealisation of the program objectives. Whilesome of these may identify closely with thestated program objectives, others may pur-sue different objectives. Commercial suppli-ers and consultants pursue profit motives.Academic experts pursue their academicinterests. Political decision-makers aim forpolitical success, and civil servants seek toadvance their careers. This article presentsan approach to aid effectiveness that takesinto account an array of different motives. Itaims to highlight some of the structural andorganizational problems that occur in the aiddelivery process and affect aid effectiveness.

A broken feedback loop

W H E N A S U P E R M A R K E T A DV E R T I S E S “weaim to serve you,” the shopper knows that itreally aims to maximize profits and returnsfor its shareholders. But she also knows that,to achieve its aims, the supermarket willmake efforts to keep her satisfied and deliverthe products and services that she wants. Theshopper pays for these products, and thatgives her leverage over the supermarket. In

SPECIAL REPORT

Aid Agencies and Aid Effectiveness

M A R C H 2 0 0 4 31

the case of aid, the situation is different. The beneficiaries donot pay for the products and services they get. Donors in othercountries foot the bill and decide on the terms and conditionsunder which the aid is given. Decisions are taken in donors’political constituencies where beneficiaries of aid have no vot-ing rights. In other words, the feedback loop between benefici-aries and decision-makers is broken (Figure 1). Unlike super-market customers, beneficiaries of aid have little leverage overthe quality and quantity of aid delivered. Naturally, donor coun-try politicians and civil servants in donor agencies feel insulat-ed from the wishes of their “customers”. No wonder then thatrecipients do not always appreciate the products and servicesdonors deliver, or that recipients’ response is not what donorsexpect.

Many principals and agents

M O D E R N O R G A N I Z AT I O N T H E O RY can help us understandthe aid delivery process and aid effectiveness. It looks at large-scale organizations that are composed of individuals who arelinked through hierarchies and specialise in specific sets oftasks. Typically, a “principal” delegates tasks to an “agent.” Theagent carries out the task in return for a reward (a salary or theprospect of a promotion). Because of delegation of tasks and spe-cialization between individuals, no single individual has fullinformation on all tasks. Information is asymmetrically distrib-uted in organizations. This gives rise to two potential problems.First, the agent charged with a task may use his privileged infor-mation for his own benefit, and not necessarily to the full bene-fit of the principal. This is called moral hazard. Second, the prin-cipal may not receive all information that is relevant to his deci-sion to delegate a task. As a result, he may take a sub-optimaldecision. This is called adverse selection. Moral hazard andadverse selection are inherent in large-scale organizations.However, the magnitude of these potential problems can bereduced through good organizational design: providing agentswith incentives to reveal relevant information. Increasing thesize of the reward is usually not a solution. Increasing the visibil-ity of agents’ performance or putting them in competition witheach other may be more effective.

The aid delivery chain usually contains many pairs of prin-cipal-agent relationships. Donor-taxpayers delegate deci-sions to elected politicians. Politicians delegateimplementation to an (bilateral or multilateral)aid agency. Within an aid agency, several layersof hierarchy and delegation of tasks exist.Agencies often hire commercial suppliers, con-sultants, and experts to implement specifictasks. These contractors deliver their productsto recipient country organizations and agencies,also with their own internal chain of hierarchi-cal delegation of tasks. The ultimate beneficiar-ies often find themselves at the end of a longchain of intermediaries. Each of these interme-diaries may benefit from asymmetric informa-tion to advance his position. It is easier forprincipals to verify the quantity and quality of

tangible outputs delivered by their agents, such as roads built,than for less tangible outputs, such as institutional reforms.Also, it is generally easier to verify project inputs than outputsand impact. The longer is the aid delivery chain, and the lesstangible the outputs, the higher is the risk of diversion fromthe original aid objectives.

Why not shorten the aid delivery chain?

I F T H E L E N G T H O F T H E A I D D E L I V E RY C H A I N is part of theeffectiveness problem, why not shorten it? One extreme solu-tion would be to cut the entire chain and transfer aid directlyfrom donors to recipients. But this would run into transactioncost problems. Donors would have to spend considerableresources on identifying potential recipients, assessing theirneeds and delivering the funds. Aid agencies benefit fromeconomies of scale in information gathering about potentialrecipients and handling of transfers on behalf of donors—theyreduce transaction costs. However, if that would be the onlyrole of aid agencies, we could still do with a very short chain ofdelivery. The finance ministries of donor countries could sim-ply send a cheque with the agreed amount of aid to their coun-terparts in recipient countries. In reality, aid is not transferredas a “free” amount of money. It comes with an elaborate set ofconstraints attached to it. Donor agency and recipient organi-zation need to agree on programmes, including objectives,implementation arrangements, procurement procedures, andaccounting. Often, aid agencies even carry out the projectsthemselves. In short, what aid agencies do is to reduce thedegrees of freedom in the use of aid by the recipient.

Why would donors want to do that? If donors and recipi-ents fully shared the same objectives and preferences inspending aid, there would be no need to do so. Donors wouldconfidently hand over full and unconstrained ownership ofaid to the recipients and the latter would spend the funds inthe same way, as the donors would have done. The fact that aidis not transferred in this way indicates that donors and recip-ients have different preferences. Donors may seek commer-cial gains (tied aid) or have different views on policy reformsin the recipient country. Recipient organizations may havehidden political objectives, or face policy constraints. The roleof aid agencies as intermediaries is to negotiate a compromise

FIGURE 1—DONORS HAVE THEIR OWN AID DELIVERY TRIANGLE

Source: WDR 2004

32 Development Outreach W O R L D B A N K I N S T I T U T E

between donors and recipients regarding the constraints andconditions to be attached to the aid transfer. That explainswhy they “package” aid transfers in an elaborate set of proce-dures rather than simply carry out a financial transfer. It sus-tains domestic political support for aid in the donor country:donors-taxpayers feel that their preferences in the spendingof aid are taken into account. The need to package aid alsoimplies that full ownership by the recipient cannot beachieved. Aid remains a compromise.

The situation is somewhat different for multilateral aidagencies. Bilateral agencies usually spend taxpayers’ money,and are therefore subject to close supervision by taxpayers’political representatives. Domestic political concerns willinfluence decisions. To the extent that multilateral agenciesspend loans rather than tax revenue (grants), they can takesomewhat more distance from these concerns. To the extentthat beneficiary countries are effectively represented in theirdecision-making process, the broken feedback loop that is sotypical in bilateral aid may be somewhat restored.

It takes two to aid effectiveness

A L L T H E A B O V E H A S I M P L I C AT I O N S for the effectiveness ofaid. First, effectiveness is not only determined by the behav-iour of recipient countries and organizations. It depends on

the performance of intermediaries in the aid delivery processand the degree of asymmetry in information between theseintermediaries. Good organizational design can go a long waytowards avoiding these problems, by providing intermedi-aries with proper incentives to do what is expected of them.Second, there are inherent structural limits to effectiveness,if only because of the broken feedback loop and differences inpreferences between donors and recipients. Any aid packagenecessarily constitutes a compromise between these diverg-ing preferences. The ideal of a fully unconstrained aid trans-fer is generally out of reach. Third, it is difficult to define agood measure of aid effectiveness. If effectiveness is meas-ured solely in terms of recipient country objectives and pref-erences, and if aid agencies focus overwhelming on these,they will neglect donor preferences and thereby may reducedonor support for aid flows. If supermarkets would really “aimto serve you”, at the expense of their profit objective, theywould simply go bankrupt and disappear. s

Bertin Martens, Economist, European Commission.

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Ostrom E., et.al. Aid, Incentives and Sustainability: An Institutional Analysisof Development Cooperation, SIDA Studies in Evaluation 2002.

M A R C H 2 0 0 4 33

Abd al-Hameed, Muhammad.Children Worldwide Must Be Internet-Connected, Vol. 2, No. 2 (Spring 2000)

Adhar Utz, Anuja. Mapping Progresson the Road to the KnowledgeEconomy: Brazil, China, and India, Vol. 3, No. 3 (Fall 2001)

Agarwal, Anil. The Value of NaturalCapital, Vol. 3, No. 1 (Winter 2001)

Agénor, Pierre-Richard. Why CrisesAre Bad for the Poor, Vol. 4, No. 2(Spring 2002)

Ahmad, Nilufar. Opportunity forWomen in Energy Technology inBangladesh, Vol. 3, No. 2 (Spring 2001)

Aiyar, Swaminathan S. Labor,Governance and the Information Age,Vol. 2, No. 1 (Winter 2000)

Aiyar, Swaminathan S. UsingCommunity Empowerment to ReducePoverty, Vol. 2, No. 3 (Summer 2000)

Alonso, Rosa. The Revolt ofArgentina’s Middle Class, Vol. 4, No. 1(Winter 2002)

Annan, Kofi. Peace and Development—One Struggle, Two Fronts, Vol. 2,No. 1 (Winter 2000)

Aslund, Anders. Radical ReformersLead the Way, Vol. 2, No.1 (Winter2000)

Bandyopadhyay, Sudeshna. Growth:Quantity Versus Quality, Vol. 3, No. 1(Winter 2001)

Bebbington, Anthony. Development IsMore than Just Growth, Vol. 2, No. 3(Summer 2000)

Bellamy, Carol. We Must Invest inChildren, Vol.4, No.2 (Spring 2002)

Berry, Ron. E-Commerce EludesDeveloping Countries, Vol. 2, No. 2(Spring 2000)

Bidani, Benu, Homi Kharas, andTamar Manuelyan-Atinc. Coping withCrisis, Vol. 2, No. 3 (Summer 2000)

Birdsall, Nancy and Peter Hakim. TheCarrot Is Better than the Stick, Vol. 2,No. 2 (Spring 2000)

Birdsall, Nancy. Human Capital andthe Quality of Growth, Vol. 3, No. 1(Winter 2001)

Bloome, Anthony. Fighting theInsidious Killer: African TeenagersBattle HIV/AIDS through ICT, Vol.4,No.2 (Spring 2002)

Brown, Mark Malloch. The InformationRevolution and Development, Vol. 2,No. 2 (Spring 2000)

Calvo, Sara. Exchange Rates: TheTargeting Debate, Vol. 3, No. 1 (Winter2001)

Campbell, Tim E. Unknown Cities:Metropolis, Identity, and Governancein a Global World, Vol. 5, No. 3(November 2003)

Carothers, Thomas and MarinaOttaway. Defining Civil Society: TheElusive Term, Vol. 4, No. 1 (Winter2002)

Clark, John D. Global Is Good, GlobalIs Bad, Vol. 4, No. 1 (Winter 2002)

Clinton, Bill et al. The Global Divide inHealth, Education and Technology, Vol. 2, No. 2 (Spring 2000)

Dadush, Uri B. Toward a Pro-PoorTrade Agenda, Vol. 5, No. 2 (July 2003)

Dahlman, Carl J. Updating theEconomic Incentive and InstitutionalRegime for the Knowledge Economy,Vol. 3, No. 3 (Fall 2001)

de Wit, Joop. Dynamics ofParticipation in Bangalore’s Slums,Vol. 4, No. 1 (Winter 2002)

Dollar, David and Aart Kraay. Growth-Enhancing Policies Are Good for PoorPeople, Vol. 2, No. 3 (Summer 2000)

Dyson, Esther. On the Internet inRussia, Vol. 2, No. 2 (Spring 2000)

Edwards, Michael. More SocialCapital, Less Global Poverty?, Vol. 2,No. 3 (Summer 2000)

Ficinski Dunin, Lubomir.Decentralizing City Management: ASuccessful Experiment, Vol. 5, No. 3(November 2003)

Gage, John. From Digital Divide toDigital Opportunity: Business LeadersReport from Davos, Vol. 2, No. 2(Spring 2000)

Gama, Hobbs. Africa’s Brain DrainImpacts Health Sector, Vol. 4, No. 3(Fall 2002)

Gelb, Alan. Gender and Growth:Africa’s Missed Potential, Vol. 3, No. 2(Spring 2001)

Goetz, Anne-Marie and Rob Jenkins.Gender-Sensitive Local Auditing:Initiatives from India to buildaccountability to women, Vol. 3, No. 2(Spring 2001)

Gorostiaga, Xabier. The University IsResponsible for Development:Challenges and Solutions in LatinAmerica, Vol. 3, No. 3 (Fall 2001)

Harris, Bruce. Street Children: LatinAmerica’s Wasted Resource, Vol. 2, No. 3 (Summer 2000)

Haws, Chris. Battle for the Planet:Mission Impossible? Vol. 4, No. 3 (Fall 2002)

Heikkilä, Pauli. New InformationInfrastructure: A Knowledge Booster,Vol. 3, No. 3 (Fall 2001)

Herfkens, Eveline. Can We Do theRight Things? The Future of TechnicalAssistance and Capacity Building, Vol. 3, No. 3 (Fall 2001)

Heyzer, Noeleen. Violence againstWomen: With an End in Sight, Vol. 3,No. 2 (Spring 2001)

Hodges, Adrian. The Business ofYouth, Vol. 4, No. 2 (Spring 2002)

Hoekman, Bernard. More FavorableTreatment of Developing Countries:Toward a New Grand Bargain, Vol. 5,No. 2 (July 2003)

Homans, Hilary Yvonne. Tearing Downthe Wall, Vol. 4, No. 2 (Spring 2002)

Hsieh, Nien-Hê, William S. Laufer, andMark S. Schwartz. Business StudentsDebate Ethical Principles and SocialImpact, Vol. 4, No. 2 (Spring 2002)

Hübner, Danuta. Gender andTransition. The Cae of Eastern Europeand the Commonwealth ofIndependent States (CIS), Vol. 3, No. 2(Spring 2001)

Johnson, Ian. Johannesburg andBeyond: An Agenda for CollectiveAction, Vol. 4, No. 3 (Fall 2002)

Kenny, Charles and Anuja Adhar Utz.Korean Telecommunications Grow atRecord Speed: A Country Profile, Vol. 2, No. 2 (Spring 2000)

King, Elizabeth M. and Andrew D.Mason. Engendering developmentthrough gender Equality, Vol. 3, No. 2(Spring 2001)

Klein, Michael. Where Do We Standwith Private Infrastructure?, Vol. 5,No. 1 (March 2003)

Koro, Emmanuel. Africa LacksAdequate Expertise to Tackle Bio-technology, Vol. 3, No. 1 (Winter 2001)

Koro, Emmanuel. Armed ConflictsDestroy African Environment, Vol. 3,No. 3 (Fall 2001)

Koro, Emmanuel. LinkingConservation with Development:NEPAD Sets Goals at WSSD, Vol. 4, No. 3 (Fall 2002)

Koro, Emmanuel. Harare Loses Statusof Cleanest City in Africa, Vol. 5, No. 3(November 2003)

Léautier, Frannie. SustainableDevelopment: Lessons Learned andChallenges Ahead, Vol. 4, No. 3 (Fall2002)

Léautier, Frannie. Urban Air PollutionManagement, Vol. 5, No. 3 (November2003)

Leipziger, Danny. Achieving Socialand Political Consensus, Vol. 2, No. 1(Winter 2000)

Litan, Robert E. Accepting ForeignCapital: Lessons from Recent Crises,Vol. 3, No. 1 (Winter 2001)

Lubrano, Mike. Why CorporateGovernance?, Vol. 5, No. 1 (March 2003)

Lustig, Nora. Broadening the PovertyReduction Agenda, Vol. 2, No.3(Summer 2000)

MacDonnell, Roderick. Access toInformation: The Commercial Side,Vol. 5, No. 1 (March 2003)

Madani, Dorsati, Will Martin, and JohnPage. The Two Battles of Seattle, Vol. 2, No. 1 (Winter 2000)

Martin, Will. China and the WTO:Policy Reform and Poverty Reduction,Vol. 5, No. 2 (July 2003)

Mashelkar, Ragunat A. The IndianInnovation System, Vol. 3, No. 3 (Fall 2001)

Matovu, George W. M. Africa andDecentralization: Enter the Citizen,Vol. 4, No. 1 (Winter 2002)

Mbekeani, George W. M. GATSNegotiations Must Focus on ServicesLiberalization: The Case of SADC, Vol. 5, No. 2 (July 2003)

McNeil, Mary. Engaging the Poor, Vol.4, No. 1 (Winter 2002)

Meden, Natacha. From Resistance toNational Building: The Changing Roleof Civil Society in East Timor, Vol. 4,No. 1 (Winter 2002)

Mestrallet, Gérard. Bridging theWater Divide, Vol. 4, No. 3 (Fall 2002)

Michon, Louis. The Global Economy: AFlawed Ecosystem, Vol. 4, No. 3 (Fall 2002)

Molavi, Afshin. Supporting the PrivateSector, Vol. 3, No. 3 (Fall 2001)

Naidoo, Kumi. RethinkingGovernance: The Case of South Africa,Vol. 3, No. 1 (Winter 2001)

Nanivska, Vira. What’s Wrong withTechnical Assistance: The Case ofUkraine, Vol. 2, No. 1 (Winter 2000)

Index of Articles—Development OUTREACH 2000-2003

34 Development Outreach W O R L D B A N K I N S T I T U T E

Narayan, Deepa et al. Voices of thePoor, Vol. 2, No. 3 (Summer 2000)

Nassery, Homira, Jennifer Brinkerhoff,and Najma Siddiqi. Afghanistan andPakistan: At the Crossroads, Vol. 4,No. 1 (Winter 2002)

Nellis, John and Nancy Birdsall. TheDistributional Impact of Privatization,Vol. 5, No. 1 (March 2003)

Newfarmer, Richard. An InternationalInvestment Agreement: Promise andPotential Pitfall, Vol. 5, No. 2 (July2003)

Nogués, Julio J. AgriculturalProtectionism: Debt Problems and theDoha Round, Vol. 5, No. 2 (July 2003)

Ocampo, Luis Moreno. State Capture:Who Represents the Poor?, Vol. 3, No. 1 (Winter 2001)

O’Keefe, Joseph. The Private SectorDrives Economic Growth, Vol. 5, No. 1(March 2003)

Olorunyomi, Dapo. The AfricanCentury?, Vol. 2, No. 1 (Winter 2000)

Ouma Jura, Jairo. Africa’s BusinessGets Insurance Against PoliticalRisks, Vol. 3, No. 3 (Fall 2001)

Oyejide, T. Ademola. Trade Reform forEconomic Growth and PovertyReduction, Vol. 5, No. 2 (July 2003)

Papic, Zarko. Building Civil Society inFormer Yugoslavia, Vol. 4, No. 1(Winter 2002)

Penton, Ronald. Roaming the Streetsof Eastern Europe: The Children ofGloom, Vol. 2, No. 3 (Summer 2000)

Petkoski, Djordjija B. DevelopingYoung Voices, Vol. 4, No. 2 (Spring2002)

Quaynor, Nii. The Digital Divide inAfrica, Vol. 2, No. 2 (Spring 2000)

Ramphele, Mamphela. Keeping thepromise: A Better Future for OurChildren, Vol. 4, No. 2 (Spring 2002)

Rosen, Harold. Improved Access toFinance: A Key to SME Growth, Vol. 5,No. 1 (March 2003)

Sachs, Jeffrey D. The New UrbanPlanning, Vol. 5, No. 3 (November2003)

Santiago, Irene. Women and Power,Vol. 3, No. 2 (Spring 2001)

Saul, John Ralston. Globalization: TheChoices before Us, Vol. 2, No. 1(Winter 2000)

Savir, Uri. Glocalization: A NewBalance of Power, Vol. 5, No. 3(November 2003)

Serban, Daniel and Claudia Pamfil.Getting Involved in Romania, Vol. 4,No. 1 (Winter 2002)

Serra, Viktor. Learning from the Poor:Housing and Urban Land Markets,Vol. 5, No. 3 (November 2003)

Shalizi, Zmarak. Development at aCrossroads: Highlights from the WorldDevelopment Report 2003, Vol. 4, No. 3 (Fall 2002)

Siphana, Sok. Mainstreaming Tradefor Poverty Alleviation: A CambodianExperience, Vol. 5, No. 2 (July 2003)

Smilevski, Blasko. Shaping theFuture: Macedonia Children and YouthDevelopment Project, Vol. 4, No. 2(Spring 2002)

Sostmann, Rafael Rangel. MonterreyTech’s Virtual University, Vol. 2, No. 2(Spring 2000)

Soule, Jeffrey. Forward Thinking inNanjing: An Interview with JiangsuParty Secretary Li Yuanchao, Vol. 5,No. 3 (November 2003)

Stapenhurst, Rick. HelpingParliaments Help the Poor, Vol. 4, No. 2 (Spring 2002)

Stapenhurst, Rick. MediaIndependence: Is Self-Regulation anAnswer?, Vol. 5, No. 1 (March 2003)

Stern, Nicholas H. EngenderingDevelopment: A Comment, Vol. 3, No. 2 (Spring 2001)

Svensson, Bent and Sascha Djumena.A Public-Private Partnership toReduce Global Gas Flaring, Vol. 4, No. 3 (Fall 2002)

Terry, Donald F. A New Way to Learnand Build Networks, Vol. 5, No. 1(March 2003)

Thomas, Vinod et al. The Quality ofGrowth: Key to Less Poverty and BetterLives for All, Vol. 3, No. 1 (Winter 2001)

Tinker, Robert F. Technology andEducation: The Trojan Mouse, Vol. 2,No. 3 (Summer 2000)

Tooker, Gary. WirelessCommunication: Linking RemoteAreas, Vol. 2, No. 2 (Spring 2000)

Trifonova, Elika. Hi-tech Booms inRussia, Vol. 5, No. 1 (March 2003)

Twose, Nigel and Ziba Cranmer.Responsibility Breeds Success, Vol. 5,No. 1 (March 2003)

Van Trotsenburg, Axel. Is HIPC DebtRelief Working? Vol. 3, No. 2 (Spring 2001)

Vest, Charles. OpenCourseWare, Vol. 3, No. 3 (Fall 2001)

Watkins, Kevin. Farm Fallacies ThatHurt the Poor, Vol. 5, No. 2 (July 2003)

Wilson, John S. Trade Facilitation,WTO Rules, and Capacity Building:What’s at Stake?, Vol. 5, No. 2 (July 2003)

Woicke, Peter. The Private Sector andSustainability, Vol. 4, No. 3 (Fall 2002)

Wolfensohn, James D. Fight Terrorismand Poverty, Vol. 3, No. 3 (Fall 2001)

Wolfensohn, James D. Cities and Citizens, Vol. 5, No. 3 (November 2003)

Yusuf, James D. Urban DevelopmentNeeds Creativity: How CreativeIndustries Can Affect Urban Areas,Vol. 5, No. 3 (November 2003)

Zaltman, Ann and Gerald Zaltman.Remembering the Future, Vol. 4, No. 2(Spring 2002)

Zegeye, Abebe. The Identity of SouthAfrican Youth, Vol. 4, No. 2 (Spring 2002)

Zhang, Shengman. Human CapacityBuilding for the New Economy, Vol. 3,No. 3 (Fall 2001)

Zurayk, Rami and Mona Haidar. TheDryland Predicament: Natural Capital,Global Forces, Vol. 4, No. 3 (Fall 2002)

M A R C H 2 0 0 4 35

V O I C E S F R O M T H E F I E L D

BY PATTI PETESCH

I N T H E S U M M E R O F 2002 , a new Voices of the Poor studyengaged 942 poor women and men of Colombia in discus-sions about urgent problems facing their families andcommunities. Despite the wider political violence, a sig-nificant finding from this work is poor people’s very wide-spread view that more cohesive and stronger families andlocal organizations are the bedrock to greater peace anddevelopment where they live. Study participants alsoinsisted that much could be gained from tackling theirproblems with more comprehensive approaches.

“I believe that if we have a good community organiza-tion, things will improve and we will deal with issues andwe will all benefit, without excluding anyone,” said a manfrom a poor coastal fishing community.” He continued,“Here, we fish and we’re organized, [so] we can have coldstoring rooms, marketing channels, and transformationactivities, and [we can] begin saving and have a permanentincome to improve the condition of our families.”

A focus on local organizations and cross-cutting strate-gies were also central features of proposals to reduce vio-lence and prepare youth for a better future as well as toimprove economic opportunities.

Problems: Severe and interlockinghardships

I N B O T H U R B A N A N D R U R A L A R E A S , the men and womenwho participated in the study reportthat employment opportunities havedeteriorated markedly in recentyears, and they rely largely on inse-cure and very low paid informalwork. Lack of adequate work is themost pressing problem, they say,fueling fear and insecurity in homesand on the streets.

With informal work largelyreplacing formal employment, peo-

ple struggle to be creative and entrepreneurial, but say thereare few rewards. Workers in the urban barrios considerCol$10,000 a day (less than US$4) to be a good wage;Col$5,000 or less is not unusual. A woman from Medellíndescribes the scramble to patch together enough earnings:“People seek a means to earn any cent: selling tamales, bloodsausages, performing housekeeping jobs by the day, sellingnewspapers and handicrafts. I, for example, go out to thestreets on holidays trying to sell anything I can. But thingshave become much worse. It’s terrible when you work sohard and earn less than before…You feel despair, because nomatter how stupid you are, you can see that something ishappening and someone should be found guilty for it.”

Study participants view the political violence and asso-ciated drug and arms trade as fueling unemployment andinsecure jobs and commerce. The violence is said to triggerunreliable or missing government services; growing juve-nile delinquency, gang violence and neighborhood crime;vigilante justice; and a cascade of other harmful political,social, and economic effects.

With very high frequency, poor men and women sayyouths are the principal perpetrators and victims of therising violence. In all of the study communities, peoplestress that a large number of poor children and youths areworking instead of attending school, leading to very highrates of school drop out and erratic attendance amongthose who remain in school. Poor people and youths alsoshare concerns about children’s extreme vulnerability toviolence by family members or to being abandoned to be

“raised by the streets.” Schools are seen to be failing poor

children and youths. While education isdeeply valued as a way out of poverty,poor people indicate that availableschooling and training opportunitiesare not equipping students with theskills required by the labor market.Participants express dissatisfactionwith the quality of instruction; over-crowded classes, high costs associated

A Call for More Community-Driven and Integrated Approaches

“Voices from the Field” providesfirst-hand insight into issues of

current concern to thedevelopment community. To

participate, send your stories to:devoutreach@worldbank.org.

Make your voice heard.

36 Development Outreach W O R L D B A N K I N S T I T U T E

with keeping a child in school, restricted access to educationbeyond primary years, and selected problems of discrimina-tion and abuse in the classroom. These problems, combinedwith the difficult economy and lure of fast money to be madeon the streets, especially drive youths to drop out. But teenpregnancy as well as high costs and limited benefits of stayingin school also contribute.

The diverse and numerous challenges to educating chil-dren faced by communities engaged in this study are sum-marized in Figure 1, a diagram by a discussion group of menand women in Medellín on the causes and impacts of schooldrop out. Taken as a whole, the diagram illustrates that poorpeople do not see education merely through a sectoral lens.Rather, they view education as part of a wider set of prob-lems that, without systemic change, hampers their capacityto take control of their lives, to develop and prosper.

People in the study feel the state has abandoned them,leaving them defenseless against key threats to their wellbe-ing—especially the total lack of public safety and justice, butalso increasing hunger, poor work opportunities, and thedeep vulnerability of poor children and youths. In nine of theten communities studied, and particularly in the urban areas,people identify a chronic lack of social cohesion in the veryheart of their communities as undermining their ability toaddress urgent local needs. In all six urban neighborhoods,people report physical and verbal aggression among neigh-

bors, and against those who are communityauthorities, as a daily occurrence.

Proposals: Strengthencapacities and institutions

F O R T H I S S T U DY, poor people put forward252 proposals of varying length and detail toexpand work opportunities, reduce violence,and improve education in their communities.The action recommendations reflect poor peo-ple’s sense that these problems are tightly con-nected, and that progress will have to be madesimultaneously on all three fronts if any is to bemade at all. Households are seen to be the criti-cal arenas in which development problems beginand then spread, and responsive and effectivelocal institutions are terribly important if poorfamilies and communities are to become moreharmonious, secure and prosperous.

A discussion group of women and men in abarrio of Pasto, which lies in the south ofColombia and contains large displaced popula-tions, developed an initiative to address house-hold-level violence, as shown in Figure 2. Theirproposal centers on making psychological assis-tance available to family members. The measurewould, they believe, help people recover moralqualities that families used to possess before vio-

lence was pervasive. Even if offered, however, study partici-pants recognize that many obstacles will have to be overcomebefore people will be able to take advantage of the services.For example, there is shame in seeking such help, people lacktime, many feel indifferent in the face of so many problems,and there is little communication between parents and chil-dren.

In Cali, study participants propose the establishment ofan integrated program of family support services providedby a single local agency to address pressing problems relat-ing to service delivery, political interference in projects,insecurity, discord among leaders, discrimination, andlack of resources. In their view, a focus on providing theseservices to families would help to make community inter-ests and cohesion a priority, and push community leadersto work together and support decisions based on objectivecriteria, among other benefits.

Proposals on education span diverse approaches thatwould improve access to quality education, and especiallyits relevance to work and family life. Study participantsmake recommendations for an education that is compre-hensive, affordable, and practical—and that will keep chil-dren and youths from the streets. Cali youths developed ayouth training proposal to build skills in such areas as“electricity, refrigeration, and leather work,” as illustratedin Figure 2. According to these youths, and many others in

M A R C H 2 0 0 4 37

the study, work-related training might help to pry apart theinterlocking disadvantages of unemployment, communityviolence, and low education levels.

Proposals to improve work prospects also emphasize aneed to build “good organizations” that can help peoplefind or generate work or improve the work they have. In thesharecropping community of Girón, study participantspropose to create a farmer association to market their pro-duce independently of intermediaries. Participants inBarrancabermeja put forward recommendations to form acooperative to produce and market detergent and textileitems. In the Cauca community, participants plan to mar-ket organic coffee internationally. In Medellín, women

propose to create an association of single mothers fordomestic and cleaning work.

The overwhelming perception about the importance oflocal organization is a striking finding from a country tornapart by violence. “Individually we have achieved nothing… however, if we organize ourselves we can do it,” insists acommunity leader in rural Girón.

Aligning development efforts with such priorities willrequire important redirections of development policies andprograms to support more community-driven approachesand to meet the needs of poor families in comprehensiveways. Poor people worldwide repeatedly demonstrate thatthey are willing to invest their scarce time in guiding and

overseeing development processes if theyfeel these actions can bring about positivechange. The challenge then becomes oneof unleashing such energies systematical-ly. While people’s aspirations may bemost operative at the micro level, theynevertheless require enabling policyframeworks and institutional structuresat the macro level. It is precisely withinthese critical national policy arenas, how-ever, where poor people’s voices are theleast heard. This must change. s

Patti Petesch is a World Bank Consultant with

the Poverty Reduction Group. She is co-author

of the second volume of Voices of the Poor

and co-editor of the third volume.

This article was adapted from Arboleda, J.,

P. Petesch, and J. Blackburn, Voices of the

Poor in Colombia: Strengthening Livelihoods,

Families, and Communities, Washington, DC:

World Bank, 2004.

FIGURE 1. CAUSES AND EFFECTS OF DROPPING OUT OF SCHOOL, A DISCUSSIONGROUP OF MEN AND WOMEN IN MEDELLÍN

FIGURE 2. ASSESSING OBSTACLES AND OPPORTUNITIES: A YOUTH TRAINING PROPOSAL, DISCUSSION GROUP OF YOUTH IN CALI

SCHOOL DROP-OUT

EFFECTS

Migration

Violence

Illiteracy

Ignorance Rise inUnemployment Increase

in Vices

LittleDevelopmentof the Region

Loss ofOpportunities

CAUSES

Insecurity

Mistreatmentfrom TeachersFamily

Disintegration

DiscriminationLack of Motivation

Lack ofWork

Education LosesImportance

No physicalspace

Lack ofresources

Adults do not havetime to teach them

Youth do not getalong with adults

Irresponsibilityof ParentsEconomic

Problems

YoungMothers

Lack ofcommunication

between thedifferent leaders

Delay due to lack ofknowledge and

technology

Youth gain confidence

Delinquencydecreases

Agreed-uponcommitments made

public

Quality of lifeimproves

Violenceis reduced

Many peoplebenefit

Unemployment is reduced,

families benefitYOUTH VOCATIONAL

TRAINING PROGRAM—EXCHANGE OF KNOW-HOW

Refrigeration

Others

LeatherworkElectricity

38 Development Outreach W O R L D B A N K I N S T I T U T E

K N O W L E D G E R E S O U R C E S

PUBLIC SERVICES RESEARCHwebsite profiles research-in-progress and related outputs onpublic service delivery in theDevelopment Research Groupof The World Bank. This work isorganized around three sub-topics: a) education; b) health,nutrition, and population; and

c) impact evaluation, finance, and public policy. Eachsub-topic has a document library with links to the researchoutputs, survey questionnaire, and other resources. Visit: www.publicspending.org

WORLD DEVELOPMENT REPORT2004 can be accessed through thisweb site. The report providespowerful examples of whereservices can do work, showing howgovernments and citizens can dobetter. The main differencebetween success and failure is the

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CESI, the World Bank Institute'sCommunity Empowerment &Social Inclusion learningprogram, works to help createthe conditions that enable thepoor and the excluded to shapetheir own development. Theprogram looks at the issues ofempowerment and governance,thus making the crucial link to

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POVERTYNET site is maintainedby the Poverty Reduction Group,part of the Poverty Reduction andEconomic Management Networkat the World Bank. The siteshighlights several topics andprograms: Social Capital forDevelopment—norms andnetworks that enable collective

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GLOBAL DEVELOPMENTLEARNING NETWORK (GDLN) uses distance learningtechnologies and methods tofacilitate interactive, cost-effective learning andknowledge-sharing forsustainable development andpoverty reduction. GDLN

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M A R C H 2 0 0 4 39

HOW TO CHANGE THE WORLD:SOCIAL ENTREPRENEURS ANDTHE POWER OF NEW IDEAS, byDavid Bornstein. Oxford UniversityPress, 2004.This book tells the fascinatingstories of a number of socialentrepreneurs, creative individualswho question the status quo andexploit new opportunities to remake

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PATHOLOGIES OF POWER:HEALTH, HUMAN RIGHTS, ANDTHE NEW WAR ON THE POOR,by Paul Farmer. University ofCalifornia Press, 2003.Paul Farmer, a physician andanthropologist with twenty years ofexperience working in Haiti, Peru,and Russia, argues that promotingthe social and economic rights of

the world's poor is the most important human rightsstruggle of our times. The author exposes the relationshipsbetween political and economic injustice, on one hand, andthe suffering and illness of the powerless, on the other.Farmer's urgent plea to think about human rights in thecontext of global public health and to consider criticalissues of quality and access for the world's poor should be offundamental concern to everyone interested indevelopment.

THE MYSTERY OF CAPITAL: WHY CAPITALISM TRIUMPHS IN THE WEST AND FAILSEVERYWHERE ELSE, by Hernando de Soto. Basic Books,Reprint edition, 2003.The world-famous Peruvianeconomist Hernando de Soto findsthat economic success is notdetermined by cultural differencesbut depends on the legal structure

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LIFELONG LEARNING IN THEGLOBAL KNOWLEDGEECONOMY: CHALLENGES FORDEVELOPING COUNTRIES,World Bank, 2003.This new World Bank reportswarns that developing countrieswill have little success boostingeconomic growth and reducingpoverty unless they can close agrowing knowledge, or education,

divide between themselves and richer countries.Investing in quality lifelong learning, the reports says, canhelp to close this gap by promoting economic vitality,reducing poverty, and encouraging open and cohesivesocieties. In a global economy which becomes faster andmore powerful every year, lifelong learning allows peopleto prosper. This book is a roadmap for policymakers whowish to know more about the key issues and challenges ofeducation in a knowledge economy.

THE INSTITUTIONALECONOMICS OF FOREIGN AID, by Bertin Martens with UweMummert, Peter Murrell, and PaulSeabright. Cambridge UniversityPress, 2003.This book deals with effectivenessof foreign aid from a newperspective and analyzes howresults can be improved. It claimsthat the results of aid are not solely

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