Achieving an understanding of the factors that contribute to human development—especially in
the areas of health, education, and social protection—and of how to improve services to support
human development is a key element of the World Bank’s strategy for fighting poverty and
promoting economic growth. The Bank has been a major contributor to the knowledge in these areas in developing countries, but much remains to be done.
Investment in Human Development
Improving Service Delivery
Political Economy and Institution
Investment in Human Development
Using microeconomic household surveys, Bank research analyzes the factors that increase people’s investment in human development in a wide range of developing countries. Studies have explored the association between income, gender, household composition, and other household characteristics, on the one hand, and the use of services, on the other.
In health, research has examined the complex processes whereby households decide on what (and how much) health care to obtain and how illness is affected by household characteristics. It has focused on factors that increase people’s demand for health care and access to medical
treatment, such as the macro and micro conditions in which people live, episodes of economic crisis and political conflict, and socioeconomic and cultural inequalities.
In education, research has explored the determinants not only of school choice and enrollment but also of student performance and learning outcomes, and examined how measures of school quality are associated with these outcomes.
Research also examines the impact of out-of-pocket expenditures on demand for services, the incidence of benefits from public spending on human development, and the safety nets that are available to households. One research project, for example, has assessed the effectiveness of the public safety net in Vietnam, identifying the main sources of household vulnerability and assessing what is known about coping strategies.
Bank research highlights the interaction between human development and poverty. For example, research has shown that low birth weight and poor nutrition early in life lead to poor cognitive development and that low levels of cognitive development in early childhood are important
predictors of wages, contributing to the intergenerational transmission of poverty. Research has also shown that more schooling allows people to better process information, such as about health hazards, and thus to change their behavior accordingly. More research is underway on these topics.
Improving Service Delivery
Broad improvements in human development and welfare will not occur unless poor people receive wider access to affordable and improved services in health, education, water, and sanitation. A better understanding of how the delivery of services in the education, health, and social protection areas contributes to improving human development outcomes, and of how to make these services work better for the poor, is critical. Building on research undertaken for the 2004 World Development Report, Making Services Work for Poor People, (http://econ.worldbank.org/wdr2004) the Bank has been deepening its analysis of service delivery to the poor. The research is built around the premise that improving service delivery requires strengthening the relationships of accountability among policymakers, service providers, and users. The research explores the role of incentives to service providers, the role of information and participation of service users, and political economy issues.
A survey instrument has been developed to assess health and education services in country-specific contexts and in a way that facilitates cross-country comparisons. These quantitative service delivery surveys can be used to investigate the incentives that providers face (including institutional, administrative, and other factors influencing overall performance). Some of the surveys focus on the relationship of accountability between policymakers and provider organizations, including frontline service providers, while others focus on “client power”. These surveys have been undertaken on health services in Chad, India, Madagascar, Mozambique, Nigeria, and Uganda, and on education services in Bangladesh, Ecuador, Ethiopia, India, Indonesia, Laos, Pakistan, Papua New Guinea, Peru, Uganda, and Zambia. As a complement to these frontline provider surveys, the internal incentives of large organizations, including donor agencies, are also being studied.
While studies using these data are still underway, important results have emerged from the completed studies. To list just a few:
Absenteeism of public servants, long discussed as a barrier to effective delivery of public services, is very high in some areas. In Bangladesh, where the absentee rate for physicians was found to be 40 percent at the larger clinics and 74 percent at the smaller sub-centers, the research has been influential in forcing government to take a fresh look at incentives for public servants, especially in rural areas.
Public health systems seek to prevent and control diseases and other threats to public health, including through interventions to assure food safety, immunization, and disease vector control. Yet, very little is known about how to design and manage such services. For example, India has invested heavily, and successfully, in increasing health care, but there are large differences in the quality of care received by the rich and the poor. In poorer neighborhoods, both private- and public-sector doctors are systematically less competent than doctors elsewhere. Studies underway in Cameroon, Chad, Ethiopia, India, Madagascar, and Nigeria seek explanations for variations in efficiency across health care facilities and will propose policy changes to improve the efficiency of the worst performing providers.
Research findings highlight how institutional settings and funding structures affect the effectiveness of service delivery. Studies were conducted in Ethiopia to analyze health worker motivation and behavior, in Nigeria to assess the efficiency of local governments within a decentralized system for delivering health services, and in Zambia to examine how the linkages among different players involved in delivering education respond to changes in their funding structure and institutional setting.
In addition to the analysis of this data, impact evaluations of programs are being conducted to learn more about how service delivery can be improved. In Uganda, for example, evaluations are assessing the effectiveness of accountability tools, including citizen report cards on experience with service agencies. Evaluations in Ecuador and the Philippines are judging how government programs designed to improve maternal and child health and parenting are affecting child cognitive and physiological development and, later, education outcomes. In Lesotho, evaluations are studying the impact on enrollments of a scholarship program for disadvantaged students (mainly orphans) in upper primary and lower secondary schools and a program that has gradually abolished user fees. An impact evaluation in Burkina Faso looks at how schooling is affected by conditional cash transfers to orphans and vulnerable children.
Political Economy and Institution
Understanding the conditions and institutions under which political constraints increase or decrease is vital to helping the poor obtain better performance from their governments. Large variations in governments’ records in delivering public services and reducing poverty often can be attributed to differences in the incentives for politicians to allocate public resources. Even in developing democracies, where politicians depend on poor people’s votes, public spending often fails to deliver basic services to the poor. Instead, political agents misallocate public resources to draw private rents, or to make inefficient transfers that benefit a few at the expense of the majority.
Such misallocations can be traced to constraints on the extent to which poor people can hold governments accountable, such as lack of information about service quality, lack of credibility of political promises, and polarization of voters on social and ideological grounds. Constitutional rules, electoral regimes, and party systems interact with these constraints to determine outcomes.
Greater political accountability improves public services and reduces corruption. Research has found, for example, that transparency about government transfers to local spending units reduces leakage of those funds by as much as 90 percent. Some of the ongoing studies in this area address the politics of public finance and the role of information and the press in improving public services. A cross-country study of clientelism and failures in public service delivery investigates the impact of electoral rules, other political institutions, and the nature and extent of mass political participation on the incidence of service delivery failures. Another project focuses on the role of political incentives in determining resource allocation to basic services, and actual outcomes in terms of quality and actual service provision; it is exploring institutional solutions to improve outcomes, including decentralization to local agencies and community-based organizations.