The three points made in my previous post—that services particularly fail poor people, money is not the solution, and “the solution” is not the solution—can be explained by failures of accountability in the service delivery chain. This was the cornerstone of the 2004 World Development Report, Making Services Work for Poor People. In a private market—when I buy a sandwich, for example—there is a direct or “short route” of accountability between the client (me) and the sandwich provider. I pay him directly; I know whether I got a sandwich or not; and If I don’t like the sandwich, I can go elsewhere—and the provider knows that.
For services such as education, health, water and sanitation, societies have eschewed private markets, and decided that they should be financed and/or provided by the state. The accountability then becomes an indirect one, where citizens influence politicians for the services they want, and the politicians or policymakers in turn have to influence service providers (teachers and doctors, for example) to deliver the services. There are now at least two places where accountability can break down. First, poor people may not have sufficient “voice” to influence politicians, so the lion’s share of public health spending goes to urban hospitals which the non-poor demand. Secondly, policymakers may not be able to hold providers accountable; absentee teachers and doctors are the result. Frustrated by the failure of the “long route of accountability”, poor people often resort to the short route, by sending their kids to private schools or private doctors, by buying water from tankers, etc.
Although the accountability triangle has become a workhorse in the service delivery field, ten years on, I see three shortcomings to the framework.
1. The two links of the long route are not symmetric. Since there are two places that accountability can break down—“voice” and the compact between policymakers and providers—it is tempting to work on both. From cameras in the classroom to bonus pay for showing up, people have proposed numerous ways to make providers accountable to policymakers. But if the underlying politics is dysfunctional, fixing the compact won’t work. An experiment in Rajasthan that introduced time-stamp machines to reduce nurses’ absenteeism failed when, the day before the program was to start, the machines were vandalized. A randomized control trial in Kenya had two groups—the government and an NGO—implement a program of contract teachers. Student learning outcomes improved for the NGO-run program only. The authors attribute the difference to the fact that the government-run program was captured by powerful teachers unions who delayed its implementation. On reflection, this point is not surprising. Why would we think that a politician who is not interested in delivering services to poor people would allow programs that strengthen provider accountability? Jim Robinson describes such programs as “politician-proof public policy.”
The implication is that, before trying to fix the incentives for providers, we need to work on the incentives facing politicians.But how?There are no easy answers, but information campaigns and citizen engagement can play a role, as discussed in several sessions of the WDR2004 Tenth Anniversary conference.
2. The only short route is the market. The market is certainly an example of the short route, as mentioned above. But other instruments, such as vouchers or citizen report cards, have been referred to as cases of the short route, including in the 2004 WDR. But a voucher program still requires a politician to decide that students should receive vouchers (rather than teachers or schools receiving the money directly). Once the decision has been made, then vouchers in the hands of students or their parents act the way market instruments do. Citizen report cards, while they provide clients with information about the quality of providers, do not strengthen clients’ ability to hold providers accountable unless the clients have a choice among providers, and a provider’s remuneration depends on clients’ choosing him (as with vouchers).
By not coming clean and saying in the 2004 WDR that the only short route is the market, we may be overlooking a host of distortions associated with markets—asymmetric information, oligopolies, etc.These could make the short route less attractive.Inasmuch as poor people are resorting to the market for services that government is failing to deliver, we should understand how these markets work and, if necessary, explore ways of regulating them to improve services.The work on education markets in Punjab, Pakistan is a fruitful step in this direction.
3. Changing incentives v. changing norms. The WDR accountability framework suggests that teachers and doctors are absent because (i) they get paid whether or not they show up for work; (ii) they have lucrative opportunities outside; and (iii) they have political power to maintain the status quo. But teachers and doctors in Sweden and France face the same incentives—and show up for work every day. The reason could be that providers in these countries behave according to a set of professional norms. Absenteeism hurts your reputation among your peers; and politicians will be blamed if teachers and doctors provide poor services. Meanwhile, in South Asia and Africa, provider absenteeism is accepted among peers, and even among the public. The question is: how do societies move from one set of professional norms to another? I am looking forward to this year’s WDR, “Mind and Culture”, for some answers to this question.
In sum, the 2004 WDR’s main contribution was the accountability framework. But with each leg of the triangle, there are some shortcomings—which is a good reason to have had a conference.