Pulic sector reform
The public sector - how can it deliver?
Equal access to health and other services require adequate funding of the state.
The sun has been up for a couple of hours already in Dar es Salaam. At one of the city’s health centres, eight nurses and clinicians have their morning staff meeting on a couple of benches in the shade. Two young women delivered during the night. They share updates on the status of the cholera patients. In the outpatient department, patients begin to arrive. There is many of them – but only one doctor. Over the next four hours more than ninety patients will visit the doctor’s office, each spending two minutes or less inside. This is Africa’s health worker crisis.
At another health facility – this one in central, rural Tanzania – the sun has not really become hot before the line of patients has come to an end. Eight patients today – a little more than usual. The doctor is no doctor, but a medical attendant with no medical training. This is another face of the crisis; health workers with little education and patients that do not show up.
The Global Health and Development programme focuses on health service delivery and health system research. A core area of research has been to identify policies that may improve the quality of the primary health services. Findings suggest that there is considerable scope for improving the productivity of the health workforce and the quality of the health services without large increases in the resource envelope. Many health workers provide lower quality services than expected given their knowledge and available equipments. Sometimes this is due to a high number of patients, but more often it is because of low motivation. In many rural areas the number of patients is surprisingly low. Increasing the number of health workers will probably not improve the services. A more promising strategy is to attract more qualified workers to rural areas. Promising further education opportunities seems to be an effective policy instrument to this end.
Equal access to health and other services require adequate funding of the state. Through its programme on Financing the State, CMI has deepened its understanding of the role of the tax system in the context of decentralisation reforms, its impact on small and medium sized enterprises, and its role in state-building. Promoted by the International Monetary Fund and transnational tax organisations, tax reform in the developing world has unfortunately been driven by economic and fiscal considerations only – and by the perceived problems and needs of the richer parts of the world. A reform agenda focused on issues of state building in the poorer countries would look substantially different. The programme recently made a significant contribution to the Norwegian Expert Commission of Inquiry into Capital Flight from Developing Countries.
Revenues from natural resources are another important source of income in many low income countries. Through the Angola programme, a large joint research programme with the Centro de Estudos e Investigação Científica (CEIC) at the Universidade Católica de Angola, a number of activities have been initiated to support policy research and build capacity that may improve the utilisation of the natural resource revenues in this extremely resource abundant country. In order to avoid the “resource curse”, focus has been applied to mechanisms like public finance management. Activities have also been implemented in the areas of peace and democratisation, pro-poor growth and private sector development.
The sad fact is that public services and support often do not reach the poorest. This vulnerable group has been the focus of several long term projects related to the implementation of Mozambique’s poverty reduction strategy. Research has shown that there is an increasing marginalisation of the very poorest and most destitute from institutions of the state. For the rural poor, there is a close association between the strength of their linkages to urban life and improvements in social and economic positions over time. There is an ongoing masculinisation of poverty in urban slums; unemployed males are losing foothold.
