A Matter of Trust: Governance and Service Delivery in the Time of Ebola


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WHO team are preparing to remove dead bodies of people who died from Ebola.
"WHO logistician Jose and team are preparing to remove dead bodies of people who died from Ebola." Source: WHO

Why do people  sick with the Ebola virus in West Africa avoid public hospitals?   Or, why do children not learn basic skills in schools despite significant public investment in education? 

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.

Rarely, however, do specialists trace service delivery problems in sectors to deeper governance issues, such as the way institutions affect performance and trust, and how these in turn influence citizen actions. Research and experience show that weak institutions usually have negative effect on service delivery performance, and that poor performance erodes trust, making it less likely that citizen would routinely demand accountability.  This in turn triggers a cycle of poor performance. 

With shocks, like the latest Ebola outbreak or a conflict, the cycle of poor performance accelerates.  Public distrust of state institutions and the health system makes those sick with Ebola disbelieve official information, and as a result further spread the disease.  The lack of trust thus in effect paralyzes service delivery, making it ineffective when it is most critically needed.  Similarly, a conflict, largely a result of weak institutions as the WDR 2011 World Development Report showed, tends to further marginalize state institutions, escalate mistrust, and have citizens rely on informal, social institutions filling the void with unpredictable consequences.

Such shocks expose the crucial role of governance and trust for shared prosperity in a very concrete and urgent way. Unfortunate as they are, incidents like the Ebola outbreak suggest that there are no shortcuts to service delivery.  To gain public trust, the development of state institutions and service delivery systems must involve communities and their informal and social institutions. Without dependable institutions and citizen trust, there is no effective citizen engagement and there is no reliable service delivery. 

Building trust: How the World Bank can help 

While strong functioning health systems and education systems are necessary for quality services to reach the poor, this is not enough.  They need to be rooted in strong institutions at the center, and they need to perform so as to inspire citizen trust and engagement.  The upcoming World Bank Group regional flagship study on governance and social service delivery is proposing a possible conceptual framework and analysis to facilitate the way forward, with evidence focusing on the Middle East and North Africa region.

In rethinking the way development assistance approaches social institutions and citizen trust, there is also the task of harmonizing institutional development assistance provided at the center of government and in sectors.  At the center, donors tend to focus on diverse areas such as legal and regulatory frameworks, public finance management (PFM), procurement, public employment, and justice. The associated realms of Ombudsman, fiscal transparency, or civil service reforms, however, are relevant also for performance of schools and hospitals.

The implementation of health sector reform in China, for instance, has hinged on making subnational government officials accountable for equitable resource allocation and service delivery results within their jurisdictions. This has required an adjustment in the country-wide decentralization framework. The upcoming Independent Evaluation Group report on health financing identifies a number of such examples, as well as cases where health sector reforms cannot be sustained without being anchored in state institutions through, for instance, public finance law or civil service regulations.

Identifying and addressing such connections brings challenges. One of the most surprising is the difficulty in communicating across disciplines. As an example, at a recent innovative public expenditure review in the Middle East and North Africa region, it took several rounds of discussion before the health financing experts figured out that their PFM colleagues meant hospitals when saying “budget sub-entity”. Then, it took even longer for the experts to agree on the implications of the proposed introduction of performance-based hospital payment mechanisms and the desired increase in hospital autonomy for the overall government budget classification and financial management system.

There are however clear benefits to overcoming these challenges. There was more to the discussion among health financing and PFM experts, as it also involved stakeholders across ministries, service providers, and communities. These stakeholders learned to understand each other along with the experts. Moreover, the joint engagement helped to expand the common ground for the needed institutional reforms.

In promoting knowledge sharing and engagement across disciplines and stakeholders, problem-driven approach can help. Instead of offering country clients ready-made tools, this approach encourages development practitioners to recognize problems from the perspective of citizens ( mistrust of public services), and deconstruct such problems so as to identify their institutional roots at the center as well as in sectors, on the informal as well as formal fronts.

Addressing the Ebola outbreak of course requires emergency response to help those infected and others at risk. Beyond emergency response, however, development practitioners need to address the underlying governance challenges more fully – encompassing informal as well as formal institutions at the center as well as in sectors and communities – to ensure reliable service delivery and inspire citizen trust and engagement in the future. In reaching out across boundaries, we will need to accept with humility and patience that we may not understand each other at first but that over time we will learn from each other and be able to integrate our individual expertise-driven perspectives into more coherent and durable solutions.

Fact Sheet: World Bank Group Emergency Financing for the Ebola Crisis


Hana Brixi

Practice Manager, Social Protection, Labor & Jobs Global Practice

Join the Conversation

Amelia Lanham
September 15, 2014

You ask: " Why do people  sick with the Ebola virus in West Africa avoid public hospitals? " Maybe it would help the World Bank to check the real situation.
There are so many sick people with Ebola that there are not enough beds for them . Doctors without Borders estimated that there is a demand for 1,200 beds for people sick with Ebola in the Liberian capital of Monrovia. There are now 240 beds available. This is less than 1,200.
People are being left to die at the gates of hospitals. They try to get into hospitals but there is no room. It does not matter in this situation if some people are maybe avoiding hospitals. The hospitals are full.

Engineer-saripalli suryanarayana
September 26, 2014

While we think of development,and aid for education and development,let us not today forget the finacial management capabulities,expected out of national governance of each country.This has no relevence to taxation,income tax laws,it is also not related to money laundering,or even policng,or changes needed in judicial systems.
This is in relation to insuring the finacial investments in banking and other areas.For the present it is a meagere amount we assure if a bank collapses,and the depositor has to almost forefit about 90% of his hard earned money.Thus soverign nations are avoiding their actions against such collapses.The marginal depositors shall get at least 50% of their deposits depending on their investments.We are now not in pre 1907 times.
So is the case with the securities scams world wide where the investors are losing because the values are hyped by 10 times for issues by public,and such are falling in a year below par rate.Insurence to get at least 25% subscribed rate has to be done by the company before collecting public money.

Michael Scott
September 09, 2014

Governance is important during crisis response. Here there are already reports of rampant theft of official Ebola aid supplies:
what is the World Bank doing to stop this? The suffering people are even lacking food in hospitals.

Ravi Kumar
September 12, 2014

Dear Michael, please take a look at how the World Bank Group is helping fight Ebola: http://www.worldbank.org/en/topic/health/brief/world-bank-group-ebola-fa...

Michael Scott
September 13, 2014

Ravi, thank you for the link to ebola website. The only idea how to fight against theft of aid supplies that I found there is that the World Bank is doing "contract tracing".
There is no explanation how this tracing is done and how it could reduce corruption in Ebola aid, however. This was my question. Corruption is now a growing worry because of more and more aid coming, but I do not understand why is "tracing" needed at all for World Bank contracts. Are some of these contracts lost or misplaced so they have to be traced?