world development report 2004 Making Services Work for Poor People

Messages Services are failing poor people. But they can work. How? By empowering poor people to –Monitor and discipline service providers –Raise their voice in policymaking By strengthening incentives for service providers to serve the poor

A framework of relationships of accountability Poor peopleProviders

Poor people Policymakers A framework of relationships of accountability Providers

A framework of relationships of accountability Providers Policymakers Poor people

Short and long routes of accountability

Decentralizing Make services closer to clients ? Make government closer to citizens ? Or Make government closer to services ?

Poor peopleProviders National policymakers Decentralization Local policymakers

Decentralization and the service delivery framework Citizens/clients Center Politicians Policymaker Sub-national government Politicians Policymaker Poor Non Poor Providers Organizations Frontline Deconcentration Delegation Devolution Voice Client’s power Compact

Not One Size Fits All

What is to be done? Tailor service delivery arrangements to service characteristics and country circumstances

Eight sizes fit all?

So what about health services Multiple outputs, different nature of services -Population Oriented services -Family Oriented services -Individual Oriented services

Homogenous needs and easy to monitor by policymaker/ government ? YES

Population Oriented Outreach Lower Asymmetry of information Less Transaction intensive Low discretion: standards Public good nature or network externality Lever: Collective action: Government Primarily Providers Integrated in clinical services (clinics, GP) Integrated in schools, workplace Outreach health post Mobile Activities Home visits, door to door activities

Population Oriented Services Needs for services are homogeneous in the population. Periodic Outreach by skilled health staff to poor populations has been shown to work : campaigns, mobile/itinerant clinics, home visits, site inspections. Decentralization can pose problems as economies of scale can be important for those services because of network externalities (eg: needs for a logistic chain for immunization or itinerant services) or public good nature of services (eg: control of vectors, air/ water quality)

Population Oriented Services

Heterogeneous needs and easy to monitor by users ? YES

Family Oriented Support to self care Low asymmetry of information Transaction light High discretion in taste/ values Lever: Imitate the market Direct control of users Providers Retail Community based organizations/ associations Cooperatives Social marketing, media, Women’s groups, associations etc

Family Oriented Services Needs are heteregeneous: differences in culture and values. Asymmetry of information is low : no need for skilled health staff. Use of market/ community/civil society channels has been shown to work for poor people. Decentralization likely to benefit those services when addressing the geographical heterogeneity of health needs and risk factors linked to cultural behaviors.

Family Oriented Services

Heterogeneous needs and difficult to monitor by both users and government ? YES

Individual Oriented Clinical Care High asymmetry of information Transaction intensive High discretion Levers: Direct control of users Self Regulation Sophisticated purchasing capacity Providers: Hospitals Clinics Individual practitioners (licensed or not…)

Individual Oriented Services Needs are heteregeneous (biological as well as lifestyle differences) and difficult to predict. Financing through insurance thus possible. High discretion:clients are sole observers of the transaction. High asymmetry of information: contracting requires a sophisticated purchasing function and/or intrinsically motivated skilled health providers. Need of a combination of monitoring mechanisms : client control, government regulation and professional self regulation. Decentralization may help address some geographical heterogeneity but risk of reducing crossubsidies/size of risk pool and difficulties in developing the local technical capacity for strategic purchasing of services.

Individual Oriented Services

world development report 2004 Making Services Work for Poor People