Barbara Stocking, the Chief Executive of Oxfam GB, sent me a letter about the Africa Development Indicators essay on “Quiet Corruption.”
In order that others may join the conversation, I include here her letter and my response.
Please, feel free to share your views in the comments section below.
The Oxfam letter seems to indicate that the efforts to hold governments and providers accountabble for results will hurt the efforts to raise more resources for health systems.
I do not think these are mutually exclusive. If the MOH and service providers are held accountable for results, Ministry of Finance and donors are more likely to invest in health. As far as I know, there is not any example in which genuine and effective efforts to fight corruption and improve accountability have resulted in less funding for the sector. Rather, it is the lack of such efforts that leads to less confidence by financiers and less investment.
Obviously, the health sector need certain inputs to produce results and the health financing level in many African countries is still inadequate. However, even in the currently constrained environment, there is still room to improve the performance of providers, especially public providers. This is evidenced by studies showing that in Uganda, mission hospitals produce much better results than public hospitals, although both are operating in the same difficult environment, and health professionals working in mission hospitals are paid less than those in public facilities.
Yes, African health systems need more investment. But at the same time, they ALSO need more accountability.
Barbara Stocking's criticism makes it appear as though failure to reach the MDGs is the fault of one party or another. The report is not attacking hardworking medical and health professionals, it is pointing out how programs can potentially be improved and made more accountable. Shouldn't the service delivery outcomes be more important than concerns over public image?
The report highlights the issue of quiet corruption so that it can be addressed. I am glad that the World Bank is taking a more results based approach to their development programs, and that it is acting in a transparent manner. Glossing over the such issues ultimately harms individuals that are supposed to be helped by these programs--those who are already the poorest and most marginalized portions of the population.
Having read through "African Development Indicators," I think it is quite successful at illustrating how insidious "quiet corruption" can be and how it deprives people of much-needed services in the health and education sectors in particular. Why should such a fact-based report be suppressed and/or not supported so that the root causes of "quiet corruption" can be addressed? I respectfully disagree with the thrust of Barbara Stocking's criticism of the report.
Good idea on posting Barbara's letter and your response, as this not only acknowledges Oxfam's position on this but welcomes a wider debate on the topic. My own view on this is that one of the characteristic of this type of global report is that it has many audiences and is thus interpreted differently by each.
In this light, I can understand why Oxfam would feel that we are 'blaming the victim' by criticizing absentee public servants who they feel are generally poorly paid, work under less than adequate working conditions, and have may not have strong career incentives. The interesting counterpoint to this argument is that Bank studies demonstrate, as the previous blogger mentioned, that similar service providers who work for private sector or civil society (e.g. faith-based) schools or health clinics, perform at a higher level than public workers.
I feel that the report is most useful to government audiences as it reflects the Bank's new emphasis on good governance, not only at the top schelons but a the base of government services. Many CSOs have felt that in the past, the Bank supported inefficient and unresponsive government programs, thus they should welcome the Bank's new emphasis on improving government services through initiatives such as this report, citizens score cards, participatory budgeting, and community expenditure oversight.
Global Civil Society Team
@Anon - here's a link to Oxfam GB's 74-page 2009 report and accounts.
Also a link to our Accountability Report
We absolutely agree that accountability is key, and Oxfam supports partners around the world to carry out vital budget tracking work which allows ordinary people to ensure that expenditures committed by developing country governments - such as funding for local schools - are actually delivered. Here's a link to a report on a local accountability in Malawi, a programme supported by Oxfam.
But we need to take a step back in this debate. The reason that health and education services are failing poor people is not a 'series of accountability failures in the service delivery chain', but because countries have been unable to deliver an adequate system - that is health and education that is free and universally accessible - in the first place. In other words, there needs to be something to be held account for before we reduce the focus to a simple one of accountability.
The key reason for this systemic failure is that financing is inadequate: the lack of consistent, predicable aid flows have had a critical impact on the state's ability to deliver basic services. This, of course, is the fault of donor countries (in fact, IDA flows are relatively predictable, as the Bank gives a fairly high proportion of its aid in the form of budget support, which allows the finance, health and education ministries to plan for recurrent expenditures such as teachers' or nurses' salaries - although I should add that FTI funds are slow to disburse, which is highly problematic).
But another reason for the failure is that donors including the World Bank are not promoting publicly financed- and delivered-health services, which the WHO, Oxfam, and countless others have clearly shown is the only model for health and education systems that will reach the poor at scale in a sustainable manner.
Key roles that the World Bank has to play in the above is one, supporting developing country governments to, over time, develop the infrastructure of a public health system and two, provide alternative financing to governments so that they can remove user fees which prevent the poor from accessing services.
Once you have the correct system in place that will provide health and education that is free at the point of delivery, of at least a basic quality, and that can be scaled up to provide a nationwide service, then you can focus on accountability that the system is delivering that which it should.
It’s important to underline that while not wanting to negate the issue of corruption in service provision, health systems are by their very nature complex and poor accountability and corruption can be a problem regardless of whether services are privately or publicly provided. The process of contracting providers has significant potential for corruption, both in the context of securing tenders and the provision of services themselves. Even if contracts are awarded fairly regulated private providers in the public interest is exceptionally difficult, even in developed nations. A report commissioned by the Government of India, for example, found that hospitals contracted and subsidized by the state to provide free treatment to poor patients was failing to do so.
Finally, of course, developing country governments must also increase the proportion of their national budgets that is spent on health and education.
Its not only Bank studies that are showing that teachers perform differently and are often more accoutable to parents in community based low cost private schools. These teachers are also often paid much less (sometimes less than half) than government teachers but are accountaible because their salary comes from the school fees paid by parents. When the method of paying for education is changed this can have a considerable impact on the motivation of teachers and how they perform. Oxfam's refusal to even engage in this debate is a real concern and their failure to acknowledge the importance of a thriving market in budget private schools serving low income communities suggests that an outdated ideology in favour of government provision of all public services is still driving their mission. When an institution is committed to such an ideology it is difficult to see how their mindset can be changed. Perhaps if Oxfam committed some of their resources to investigating the differences between public and private schools and how their funding impacts their performance then perhaps they can begin to play a more constructive role in this important debate.
Perhaps it is unfair to suggest that only Africans can arrest the widespread corruption in their countries but it would more and more to be the reality. Not long ago, Obama responded to critics of his approach to solving the Israel/Arab conflict by stating something that could be paraphrased as that the US cannot want it more than the Arab and Israelis themselves. Lately we keep hearing the issue of accountability and governance but unfortunately, it is all from the donor’s side. Until African presidents and leaders start to echo these same comments/remarks ---with corresponding accountability measures on the ground---, I do not foresee any changes in the near future. The donors probably mean well but unfortunately shy away from tackling the issue at the root cause. Being accountable to almost no-one and enjoying the benefits that come with it is too good for these leaders to want to pass up voluntarily. We need to understand this last statement profoundly before we can tackle the root causes of poor service delivery and under-development. Many of us in the developing business have fairly confortable jobs/salaries and, except for our conscience, are not directly affected by developing country poverty. This game of continually appeasing governments and staying politically correct only helps to prolong the agony of our real clients, the poor. Seems so unfair.