Recently, I’ve been conducting a strictly non-scientific survey aimed at answering that question. My unannounced telephone call to five fairly senior friends at the World Bank generated a considerable amount of head scratching and thoughtful reflection, followed by eight different interpretations. Corridor surveys at ODI revealed surprisingly similar results. My sense is that most donor agencies, non-government organisations and think tanks have a sense that something important is afoot at the World Bank. They’re just not sure what it is.
My take is that Jim Kim is highlighting a critically important issue. His starting point, as Adam Wagstaff points out in a thoughtful blog piece, is that governments have invested heavily in identifying what to deliver while neglecting how to deliver. This is a governance issue that figures prominently in our work at ODI, where service delivery is emerging as a central theme.
The consequences of the delivery gap are painfully apparent across many countries. Primary school enrolment in India may have surged, but what does this mean if 40 of the children sitting in grade 5 classes in India can’t read a simple sentence, or add a two digit sum? In Nigeria, the government has expanded the reach of a public health system which is supposed to provide access to vital immunisation, antenatal and child-care services for free, but families in the lowest income group end up paying for, or going without, basic services.
Citizens and policy-makers alike are often left frustrated by such low returns to public investment. In his statements on the ‘science of delivery’ Jim Kim addresses that frustration. The most voluble bee in his bonnet is the lack of evidence to explain either why provision so often fails, or why a development programme succeeded brilliantly in one setting, while a similar strategy in a neighbouring country cost more and delivered less.
The ‘science of delivery’ aims at closing this evidence gap. Kim’s approach is heavily influenced by his own background as a health professional and as President of Dartmouth College (which runs a programme in health-care-delivery science). His narrative is heavily clinical. He advocates the use of ‘clinical trials’ to test innovations, build evidence and spread best practice.Development agencies, he suggests, need ‘an extensive library of standardized case notes and other mechanisms for communicating results’. And public policy-makers should take a leaf out of the private-sector best-practice book. How come, Kim asks, Unilver and Coca Cola can deliver products to African villages where governments can’t deliver school books or medicines? You get the drift…
None of this is particularly new. But Kim has turned the spotlight on a critical set of concerns. The High-Level Panel on the post-2015 development goals established by the UN Secretary-General recommended adopting the principle that there should be ‘no-one left behind’. That’s easy to sign up to. But delivering essential services to people who are being left behind – the rural poor, urban slum dwellers, ethnic minorities, girls and women – will take some radical changes.
One version of the ‘science of delivery’ approach that has gained some currency focuses on performance management. This approach is captured in Sir Michael Barber’s book Deliverology 101 (the Scientologist’s copyright may have restricted title options).
Drawing on his experience of designing policy reform in education for Punjab Province in Pakistan, Sir Michael emphasises the importance of clear and ambitious targets, regular stocktakes, and – critically – high-level political buy-in. The barrier to effective delivery, in this view, is ineffective administration and weak implementation, with policy design a residual factor.
There are several problems with the ‘deliverology’ approach. One of the most serious is a narrow technical bias that focuses on the rules and incentives governing service providers. These rules and incentives matter. But what about the development of institutions needed to recruit, train, deploy and support health workers and teachers who are equipped to deliver services?
Another concern is the curious absence of power and politics in the deliverology tool-kit – a point made by Shanta Devarajan. There are many reasons why poor and marginalised groups face restricted access to quality services. They often have a weak voice. Even when public service facilities are available, the absence of staff is an indicator of limited accountability towards users. And the political bargains struck between elites often have the effect of excluding the poor. In Pakistan, an elite bargain on taxation aimed at minimising liability and maximising opportunities for evasion has produced one of the world’s lowest revenue-to-GDP ratios. That bargain has starved education of financing and transferred costs onto poor households (forcing millions out of school).
State failure to deliver basic services has generated a lively debate over alternatives. The market for innovation and private-sector delivery is growing. Yet as Jean Dreze and Amartya Sen demonstrate in their superb book on India – if you care about governance, read it – failures of public provision for the poor generate second-best market-based alternatives, many of which reinforce inequality.
Research at ODI has focused on ‘the politics of delivery’. The aim is to identify practical solutions to delivery failures by focusing on the complex web of incentives, rules, and power relationships – ‘the missing middle’ – that link service users to service providers and different layers of government:
· In Malawi formal policy commitments to provide free essential medicines have failed to prevent ‘stockouts’ in health clinics. The proposed solutions, financed largely by aid donors, have tended to focus on improving highly centralised management systems. Insufficient attention was paid to monitoring and supervision along the supply chain, where ODI’s research found that medicine supply was significantly affected by the relationships between politicians, drug companies, service providers and service users at the local level.
· Both Uganda and Rwanda have adopted strong formal policies aimed at reducing maternal mortality, but results in Rwanda have been far more effective. Why the difference? Policy coherence has been a factor. But Rwanda has also introduced a far more stringent accountability framework. Public-sector health workers are forbidden from running private health-care facilities (weakening incentives for non-attendance and the diversion of medicines), and they are subject, along with local officials, to performance targets and strong public-accountability mechanisms. However, the major difference with Uganda is high-level political engagement and enforcement.
· In Nepal, the unequal allocation of health professionals across urban and rural areas was traced partly to a problematic human-resource-management system. Health workers face weak incentives to work in remote rural areas, while patronage networks linked to political clientelism and party affiliation determined access to preferred urban posts.
ODI research also draws attention to some difficult questions for aid agencies. In Sierra Leone, donor interventions helped to tackle absenteeism among health workers by establishing a payroll, putting in place a monitoring system that records daily attendance, and providing support for salaries. Attendance levels and utilisation rates improved because of a shift in incentives – health workers faced the prospect of a loss of salary. But what happens when the external scrutiny linked to salary support is phased out?
The ‘science of delivery’ is addressing the right question, though its proponents might consider according more weight to politics. Society is not a petri dish in which the results of microbiological interventions can be identified, isolated and transferred. Yes, we need to learn from best practice. But we also need to turn the spotlight on the political forces and power relationships that deliver poor-quality services and perpetuate high levels of inequality.
