The World Bank’s president, Jim Kim, has now made two major speeches outlining his vision for the institution – one at the Annual Meetings the other at Georgetown University on April 2 ahead of the upcoming Spring Meetings.
Several themes are emerging. Two are easy to grasp and likely to resonate strongly with Bank staff and stakeholders: “ending poverty” and “boosting shared prosperity”. For years the Bank has seen fighting poverty as its mission. It has made major contributions in the areas of measuring and monitoring poverty – Bank staff have authored many of the world’s most-cited publications with poverty in the title. The Bank’s work at the country level has always had a strong anti-poverty focus. “Ending” poverty – rather than merely “fighting” it – is a natural next step. The idea of “boosting shared prosperity” also resonates. While economic growth is still seen as the principal driver of poverty-reduction, the goal has always been pro-poor growth – a concept that links naturally to the idea of “shared prosperity”.
One recurrent theme in President Kim’s speeches that’s less easily grasped is “the science of delivery”. Surprisingly – after all, it’s catchy and sounds like it’s been around forever – the expression “science of delivery” is actually a relatively new one. Google Scholar throws up just four publications with “science of delivery” in the title, the most-cited of which has been cited just 29 times, the second most cited has been cited just once, and the other two have never been cited. (To put this in context the 1,000 most-cited publications with “poverty” in the title have been cited collectively over 300,000 times.) The general Google search engine throws up more, but the one that appears top is the publication that’s been cited 29 times. Interestingly, the next two items both point to a video of a lecture on the “science of delivery” by Bank staffer Ani Dasgupta.
The fact that the expression “science of delivery” is so new should come as a relief to those Bank staff who think it must be old but feel nervous admitting they don’t quite know what it means. But its newness also presents them with an opportunity – to help concretize a new expression.
Solace in Molière?
So what does the “science of delivery” mean? It’s apparently a concept that Jim Kim developed with reference to health care while he was President of Dartmouth College. Writing in 2010 for the American Council for Education, Kim wrote:
“We cannot address the ever-increasing, unsustainable costs of health care without getting to the foundation of how care is provided. Nor can we achieve the social and moral goals we share – care that is safe, appropriate, effective, and high quality for every patient, in every community – without rethinking and redesigning delivery. Real improvements require a multidisciplinary approach that will bring the best minds to focus on the problem. Experts in management, systems thinking and engineering, sociology, anthropology, economics, medicine, health policy, and other fields must join together to fix the delivery system.”
The Lancet’s July 2012 portrait of Kim quotes the Bank’s President as saying:
“The enormous investments that have been made in global health should have led to what we might have called a science of implementation and execution, but this has not happened. In the US and developed world health-care systems, we focus so much on discovery, on the basic science of disease, and the development of new treatments. We have just not focused on the enormous complexity of delivering health care in a way that keeps people healthy – that provides high quality health care at low cost.”
Kim’s message – generalized – is that the world has invested too much in what to deliver and too little in how to deliver it, with the result that “it” often fails to reach and benefit people.
That’s a great message. And it’s one that’s completely consistent with the Bank’s everyday work.
To take just one example, in 2004 Mariam Claeson and I wrote a report “The Millennium Development Goals for Health: Rising to the Challenges”. One of our chapters was titled “Effective Interventions Exist – They Need to Reach More People”. In it we argued:
“It is not a lack of interventions that is the main obstacle to faster progress toward the Millennium Development Goals – it is the low levels of use, especially among the poor, of existing effective interventions. Globally, the use of effective interventions for child health is typically below 50 percent, and in many poor countries the figure is much lower. Using all known interventions appropriately – achieving 99 percent coverage rates – could avert 63 percent of child deaths and 74 percent of maternal deaths.”
Much of the discussion in the global health community at the time assumed that bednets, vaccines and breastfeeding could all be dropped by helicopter like manna from heaven. But that wasn’t the way our colleagues in the Bank were thinking. With their help, ideas and experiences, Mariam and I were able to assemble a rich report documenting the constraints to faster progress on the health MDGs, and how to remove them. Extra government spending was needed, but it wasn’t sufficient. Households aren’t passive – they deliver many key interventions themselves, and they demand (or don’t demand) services from others. It can’t be taken for granted that (professional) service providers will be present when they’re needed, and will deliver the required service to the best of their abilities. And it can’t be taken for granted that governments have the policies and institutions in place to make sure the necessary changes happen.
I don’t think these messages were especially novel to Bank staff in the health sector. And you see the same broad messages in Bank reports in other sectors. It’s precisely these issues that Bank staff focus on in their reports and in their day-to-work with countries. Whether it’s nutrition, secondary education or rural roads, Bank staff mostly leave the “what to deliver” question to others (including the UN technical agencies) and focus instead on the “how to deliver it” question – albeit at the level of the sector rather than at the level of the individual clinic, school and road-construction team.
Just as Molière’s bourgeois gentilhomme spent his whole life speaking prose without knowing it, World Bank staff have in effect spent their careers being a “delivery scientist” without knowing it! I’m not suggesting Bank staff all add “delivery scientist” to their business cards. But I think it is important that the “science of delivery” not be seen as something different from what Bank staff are already doing in their everyday work.
The Kim gauntlet
That’s not to say the Bank couldn’t be doing the “science of delivery” better. The Lancet’s portrait of Kim quotes him as saying:
“The spread of innovation and going to scale are critical, and the great development organizations in the world have not been as effective as they could be in tackling this issue.”
I suspect all Bank staff and World Bank stakeholders would agree. The institution can doubtless do better at managing, synthesizing and disseminating global and local knowledge about how to deliver goods and services effectively. It can doubtless do better at generating and disseminating knowledge gleaned through its own operational work – not only about how to deliver goods and services, but how to deliver development assistance. It can doubtless also do better at ensuring that its operations are built around this knowledge, and are able to adapt as new knowledge emerges during implementation, building perhaps on the “Problem-Driven Iterative Adaptation” approach sketched out by Matt Andrews, Lant Pritchett, and Michael Woolcock.
So, yes, we can think of much of the everyday work of the World Bank as the “science of delivery”. But like all science, the “science of delivery” needs to keep moving forward. What Jim Kim is saying, I think, is that during his presidency he wants the World Bank to give it a sharp push forward.
Amen to that.