Monitoring Service Delivery in the Financial Crisis Markus Goldstein (Interpreted by Jishnu Das) The findings, interpretations and conclusions expressed in this presentation are entirely those of Markus Goldstein. They do not necessarily represent the views of Jishnu Das and/or his family.

Predictions Lots of predictions that financial crisis will hit HD outcomes This is almost certainly correct for health (Baird, Friedman and Schady, 2007)

Predictions And probably true for education in low-income countries Source: Ferriera and Schady (2008)

Sources of the hit: Households Lots of micro-evidence that shocks to households (especially when they are correlated) lead to declines

Sources of the hit: Public Spending Some evidence that public spending declines with macro-shocks (Peru) Source: Paxson and Schady (2005)

Sources of the hit: Public Spending But this can be compensated for by donor spending (Indonesia)

Two Unknown Unknowns Will drops in public spending affect outcomes? If so, how? Do we have monitoring tools to capture household responses with sufficient speed to engender policy responses?

Remainder of presentation How new M&E tools are changing the way we think of the relationship between public spending & outcomes How these can be used for policy responses to the crisis A Proposal for monitoring in the crisis

Spending ≠ outcomes: In X- sections

& time-series Source: WDR 2004

Why? Evidence from new studies

New Evidence: Results from PETS What you get is not what was sanctioned

Across Countries Percent of school grants that actually reach schools

Indonesia 2000: Sources of school funding by grant receipt and public/private status Primary schoolsJunior Secondary schools In public schools, local government spending adjusted in response to grant No adjustment in private schools Substitution between grants and local government funding

New Evidence from QSDS: Public expenditures crowd-out private expenditures

Zambia 2001: Effect of a 100 Kwacha increase in expected and unexpected school grants on household expenditures on education Household spending falls by about 45 for each additional 100 Kwacha spent on anticipated grants Substitution between grants and household spending Source: Jishnu Das, Stefan Dercon, James Habyarimana, Pramilla Krishnan (2004) Evidence experimentally replicated in India, with identical substitution coefficients

New Evidence: Absenteeism Surveys

Absence rates among teachers and health workers Note: Surveys were all fielded in 2002 or Sources: Chaudhury et al (2006) except for PNG, World Bank (2004) and Zambia, Das et al (2005).

PNG 2002: Depletion of the effective supply of teachers Source: PESD Results from QSDS: Effective supply of teachers

As a consequence: Evidence from Quality Studies

Spending ≠ outcomes In health unqualified private sector doctors in Delhi provide better care than qualified public sector doctors In education the cost per percentage correct in tests is 3 times higher in public compared to private schools in Pakistan

So… There is plenty of room for improvements BUT There are good reasons to believe that we don’t know enough –Can’t find any studies of the effects of spending cuts that are causal (usually strongly correlated with economy wide problems)

Proposal based on lessons learnt Sentinel Surveillance Sites for Service Delivery (S 4 D)

IDEA High Frequency Surveys in limited sites (villages/neighborhoods) Collect information using a variety of different tools Household Surveys Facility surveys (education health) Outcomes (for instance, learning)

Precursors ICRISAT More recently –Financial Diaries in Bangladesh, India and South Africa (Bi-weekly for one year) –Morbidity and Health Seeking behavior in Delhi, India (Weekly and Monthly for 2 years) –LEAPS in Pakistan (Annually for 4 years) All these surveys are yielding valuable (and new) information on household and provider behavior—particularly in relation to shocks

The S 4 D Outline Work with limited sampling sites in a number of countries at higher frequency than usual Collect periodic information from –Households (Main outcomes, labor, wages) –Facilities (Absenteeism, PETS, Quality) –Higher administrative units to track budgets (Funds availability and flows) Fixed Reporting Formats + Public Data

Summary Financial Crisis will potentially lead to worse HD outcomes But This is also an opportunity –To address inefficiencies in the delivery of services –To set up a M framework that can provide real-time information for real-time policy Deepen our understanding of HD processes

Additional slides for discussion

And the same for health…

… and vastly different changes in spending can be associated with similar changes in outcomes.

Figure 1: Official vs. Effective Expenditures by Regional Health Delegations CHAD: On average, RHDs received only 26,7% of their official non-wage budgetary expenditures from the MoH

Percent of time present, and percent of time teaching Beyond absenteeism: Effective supply of teaching Sources: Lane and Millot (2002); Abhadzi, Millot and Prouty (2006).

Private MBBSPublic MBBSPrivate, No MBBS Health: What they know, what they do 40% of essential questions asked Percentage of Essential Tasks Completed Source: Das and Hammer (2008)

Education: Its not the money Source: Pakistan, The LEAPS Report