At the recent “New Directions in Governance” meeting it was suggested that future meetings should bring governance advisors together with sector-specific colleagues. The different language we use in our respective disciplines is a serious barrier to taking forward an agenda of real importance and hence this message seemed particularly pertinent. I came to the meeting with a number of thoughts on how public finance management (PFM) rules often hinder health system performance, some of which I outline below.
Over the past three decades a major focus in low- and middle-income countries has been to seek new revenue sources for health services to overcome strict controls over the use of budget funds which were seen as inefficient but difficult to address. Community-based health insurance schemes have been widely introduced, as were patient user charges and payroll tax-funded social health insurance schemes. These various developments reflected a belief that governments were unlikely to increase funding to health, or to introduce the flexibility in budget funds required to incentivize improvements in service delivery.
The outbreak of disease is often a latent but hard-hitting global concern, as currently exemplified by the flurry of anxiety swirling around Ebola. Many efforts have sprung up to fight spread of the disease, including the World Bank which has recently committed $400 million to said cause. While the growing human cost of the disease is distressing enough, if Ebola is not contained, the World Bank has estimated an additional economic cost of $32.6 billion to the West Africa region.
To find out, we recently spoke with Clark Freifeld, co-founder of HealthMap.org, a web-based tool that has been in the news for detecting Ebola 9 days before the World Health Organization officially announced it. Started in 2006 at Boston Children's Hospital, HealthMap uses public health, media, and open data sources to provide real-time information and alerts about disease outbreak based on a number of filters, including location.
In response to such situations, development specialists typically call for sector-wide reforms. And the design of such reforms draws on sector policy analysis and on the assessment of service delivery arrangements and capacity. Increasingly, since the 2004 World Development Report, sector reforms also seek to make teachers, health professionals and other service providers accountable to citizens and communities.
The idea that citizens can directly contribute to strengthening the governance and quality of service delivery has been gaining momentum. The recent globabl uprisings, from revolutions in Egypt and Tunisia to the Occupy Wall Street movements here in the US, have highlighted the important role that individuals play in demanding more accountable governments and policies.
Child malnutrition may not be apparent to parents, especially if other children in the village look the same. Similarly, it can be hard for parents to recognize when their children are doing poorly in school. And – sad, but true – badly trained health staff and teachers too often miss these things, as well. Fixing this disconnect in perceptions may be one way improve health and education outcomes.
I want to share something puzzling that has troubled me for some time: Why don’t development agencies use results-based financing more consistently as a way of supporting stronger governance in developing countries? Let me explain the source of this puzzle and give you my personal take on the issue.
I am writing from Seoul, where I participated in the Economic Development and Impact Evaluation conference organized by the Korea Development Institute. Korean officials at the conference had a consistent and forceful message: aid works.