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Services can work

for poor people
but too often they fail

With seven other children to care for, Maria’s outcomes. They are often inaccessible or pro-
mother, Antonia Souza Lima, explained that she hibitively expensive. But even when accessi-
could not afford the time—an hour-and-a-half
ble, they are often dysfunctional, extremely
chapter walk—or the 40-cent bus fare to take her listless
low in technical quality, and unresponsive to
baby to the nearest medical post. Maria seemed
destined to become one of the 250,000 Brazilian the needs of a diverse clientele. In addition,
children who die every year before turning 5. But innovation and evaluation—to find ways to
in a new effort to cut the devastating infant mor- increase productivity—are rare.
tality rate here, a community health worker
Many services contribute to improving
recently started to walk weekly to the Lima house-
hold, bringing oral rehydration formula for Maria human welfare, but this Report focuses on
and hygiene advice for her mother, who has a tele- services that contribute directly to improving
vision set but no water filter. Once a month, the health and education outcomes—health ser-
7,240 workers in the Ceará health program enter vices, education services, and such infrastruc-
the homes of four million people, the poor major-
ture services as water, sanitation, and energy.
ity of a state where most people’s incomes are less
than $1 a day. Erismar Rodrigues de Lima, a “Services” include what goes on in schools,
neighbor of the Limas, listened intently to instruc- clinics, and hospitals and what teachers,
tions on filtering drinking water. “I am the first nurses, and doctors do. They also include
member of my family to ever receive prenatal how textbooks, drugs, safe water, and elec-
care,” said the 22-year-old woman, who is expect-
tricity reach poor people, and what informa-
ing a baby in June.
tion campaigns and cash transfers can do to
From the New York Times40
enable poor people to improve outcomes
I go to collect water four times a day, in a 20-litre directly. Much of all this is relevant for other
clay jar. It’s hard work! . . . I’ve never been to sectors, such as police services, so the Report
school as I have to help my mother with her wash-
features examples from those sectors as well.
ing work so we can earn enough money. I also
have to help with the cooking, go to the market to Just how bad can services be? Testimonies
buy food, and collect twigs and rubbish for the show that they can be very bad. In Adaboya,
cooking fire. Our house doesn’t have a bathroom. I Ghana, poor people say that their “children
wash myself in the kitchen once a week, on Sun- must walk four kilometers to attend school
day. At the same time I change my clothes and
because, while there is a school building in
wash the dirty ones. When I need the toilet I have
to go down to the river in the gully behind my the village, it sits in disrepair and cannot be
house. I usually go with my friends as we’re only used in the rainy season.”42 In Potrero Sula, El
supposed to go after dark when people can’t see us. Salvador, villagers complain that “the health
In the daytime I use a tin inside the house and post here is useless because there is no doctor
empty it out later. If I could alter my life, I would
or nurse, and it is only open two days a week
really like to go to school and have more clothes.
until noon.”43 A common response in a client
Elma Kassa, a 13-year-old girl
from Addis Ababa, Ethiopia41 survey by women who had given birth at
rural health centers in the Mutasa district of
Citizens and governments can make services Zimbabwe is that they were hit by staff dur-
that contribute to human development work ing delivery.44
better for poor people—and in many cases This chapter illustrates many types of
they have. But too often services fail poor failures—inaccessible or unaffordable ser-
people. Services are failing because they are vices, and various shortfalls in quality—using
falling short of their potential to improve testimonials from poor people, compilations
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of data from several countries, and in-depth school.46 These countries are not special
studies. The chapter also provides examples cases. Worldwide more than 100 million chil-
of services that are working for poor people. dren of primary school age are not in pri-
Learning from success and understanding the mary school.47 Almost 11 million children,
sources of failure require a framework for roughly the population of Greece or Mali, die
analysis. Chapters 3 to 6 of the Report present before their fifth birthday.48
and develop that framework; Chapters 7 to Most countries have rich-poor differen-
11 consider options and issues for reform. tials in education or health outcomes. This is
Figure 1.1 Child mortality is not necessarily evidence of services failing
substantially higher in poor
households Outcomes are substantially poor people—there are many determinants
Deaths per 1,000 live births worse for poor people of outcomes (see crate 1.1 at the end of this
Central African Republic 1994–95 Just how bad are outcomes? Rates of illness chapter).49 Comparing outcomes for richer
200 and death are high—and rates of school and poorer people within countries high-
enrollment, completion, and learning are lights two things. First, it shows the absolutely
150 low—especially for poor people (box 1.1). In bad outcomes among the poor—for exam-
Poorest fifth
Cambodia under-five mortality is 147 per ple, in Bolivia 143 children of every 1,000
1,000 births among the poorest fifth of the from the poorest quintile died before their
population; in Armenia it is 63 (figure 1.1).45 fifth birthday, and in Niger fewer than 10 per-
Richest fifth
Many children are unlikely to complete even cent of adolescents from the poorest quintile
primary schooling. Among adolescents 15 to completed grade 6. Second, within-country
0 comparisons give a sense of the possible—
19 years old in Egypt, only 60 percent in the
Bolivia 1997
poorest fifth have completed the five years of that is, specific goals already being reached
primary school (figure 1.2). In Peru only 67 within a country.
percent of youths in the poorest fifth have
150 143 finished the six-year primary cycle, even Affordable access to services is
though almost all started school. In both low—especially for poor people
countries nearly all adolescents in the richest In many of the poorest countries, access to
50 fifth of the population completed primary schools, health clinics, clean water, sanitation

Cambodia 2000
BOX 1.1 Who are “poor people”?
200 Defining who is “poor” is always a difficult proposi- latter method are typically referred to as “asset” or
tion because there are several concepts of poverty. “wealth” quintiles (since asset ownership and hous-
150 147 Perhaps most familiar is the one used to identify the ing characteristics are arguably reflections of a
poor in sample surveys in low-income countries: that household’s wealth).51
is based on a composite measure of total household But poverty based on consumption,“wealth,” or
consumption per member (with adjustments for an alternative derived from income, is not the only
household size and composition).50 “Poor people” social disadvantage that creates difficulties in the
50 are then defined as those living in households below demand for and provision of services. Gender can
a particular threshold of this measure of consump- exclude women from both household and public
0 tion, such as below $1 or $2 a day, or below a nation- demands for better services. In many countries eth-
ally defined level. nicity or other socially constructed categories of dis-
Armenia 2000 An alternative approach divides the population advantage are important barriers. People with physi-
200 into various groups, for example, quintiles, according cal and mental disabilities are often not
to a ranked ordering of the measure.The poorest accommodated by education and health services.
150 quintile or poorest fifth, for example, is the 20 per- Even broader concepts of poverty are relevant to
cent of people who live in households with the low- effective services.“Poor people” include people expe-
est values of the consumption measure. riencing any of the many dimensions of poverty—
100 Many surveys, including some used in this and those vulnerable or at risk of poverty—in low-
63 Report, do not include consumption data, which income and lower middle-income countries.52 So
50 are difficult to collect. One approach to assigning poor people can be seen as the “working class,” or
people to quintiles is to aggregate indicators of a “popular” in Spanish, or simply just “not rich.” Even in
0 household’s asset ownership and housing charac- middle-income countries the “poor” includes a large
Under age 1 Under age 5 teristics into an index, and then to rank households part of the population: much of the population can-
according to this index. To distinguish these not insulate itself from the consequences of failures
Note: Fifths based on asset index quintiles. approaches in this Report, quintiles based on the of public services.
Source: Analysis of Demographic and Health
Survey data.
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Services can work for poor people but too often they fail 21

facilities, rural transport, and other services is and hire more teachers. Primary enrollment Figure 1.2 The poor are less likely to
start school, more likely to drop out
limited. For children in Aberagerema village doubled between 1973 and 1986, reaching 90 Percent of 15- to 19-year-olds who
in Papua New Guinea, the nearest school is in percent—though the story on quality is less have completed each grade or higher
Teapopo village, an hour away by boat, two positive.58 Despite a limited budget El Sal- Niger 1998
hours by canoe.53 This is not unusual: the vador expanded access to schooling in poor 100
average travel time to the nearest school in rural communities after a civil war in the
that country is one hour.54 The availability of 1980s by using innovative institutional 80

services varies dramatically across countries. arrangements (see Educo spotlight). 60

Typically, however, poor people need to travel The exact relationship between use of ser- Richest fifth
substantial distances to reach health and edu- vices and prices or family income varies, but 40

cation services—and often much longer dis- for poor people, lower incomes and higher 20
tances than richer people in the same coun- prices are associated with less use.59 Poor peo- Poorest fifth
try. In rural Nigeria children from the poorest ple spend a lot of their money on services: 75 1 2 3 4 5 6 7 8 9
fifth of the population need to travel more percent of all health spending in low-income Grade
than five times farther than children in the countries is private, 50 percent in middle- India 1998–99
richest fifth to reach the nearest primary income countries.60 Based on government 100
school, and more than seven times farther to sources, these broad aggregates are probably 80
reach the nearest health facility (table 1.1). underestimates, hiding the heavier burden on
And traveling theses distances can be hard. In poor people. And poor people often need to 60

Lusikisiki village, South Africa, it may be nec- pay more for the same goods. For example, 40
essary to hire neighbors to carry a sick person poor people often pay higher prices to water 36%
uphill to even reach the nearest road, which sellers than the better-off pay to utilities
may be inaccessible during the rainy season.55 (chapter 9). In Ghana the approximate price 0
On top of this, staff are getting rarer in paid per liter for water purchased by the 1 2 3 4 5 6 7 8 9
some parts of the world. There is mounting bucket was between 5 and 16 times higher Egypt 2000
evidence that AIDS is reducing the pool of than the charge for public supply, even 100
people able to become teachers or health pro- though women and children often had to
fessionals (box 1.2), and international labor walk a long distance to purchase the water. In 80
markets are making it hard to keep qualified Pune, India, low-income purchasers of water 60
medical staff in poor countries (chapters 6 paid up to 30 times the sale price of the 60%

and 8). metered water that middle- and upper- 40

Coverage of other services is also far from income households used.61 20

universal. More than a billion people world- The poor also lack the collateral needed to
wide have no access to an improved water formally borrow to pay for expensive services
1 2 3 4 5 6 7 8 9
source, and 2.5 billion do not have access to for which they lack insurance, and therefore Grade
improved sanitation. In Africa only half the resort to informal moneylenders who charge Peru 2000
rural population has access to improved very high interest rates. If this financing 100
water or improved sanitation. In Asia only 30 channel is unavailable, they use more expen- 80
percent of the rural population has access to sive traditional or private providers who
improved sanitation.56 Again, there are large often provide more flexibility in the terms of 60
variations across and within countries. In payment.62 40
Cambodia 96 percent of the richest fifth of This need not be. In Egypt making health
the population has access to an improved insurance available to school children in the 20

drinking water source, but just 21 percent of early 1990s almost doubled the probability of a 0
the poorest fifth does (figure 1.3). In health facility visit among the poorest fifth of 1 2 3 4 5 6 7 8 9
Morocco in 1992, 97 percent of the richest the population, substantially reducing the Grade

fifth of the population had access to an rich-poor gap.63 In Mexico an innovative pro- Notes: The grade number boldfaced denotes the
end of the primary cycle. Fifths based on asset
improved water source, but just 11 percent of gram—Progresa—provided parents with cash index quintiles.
the poorest fifth did. In Peru the correspond- transfers if they attended health education lec- Source: Analysis of Demographic and Health
Survey data.
ing shares are 98 percent and 39 percent.57 tures (where they also received nutrition sup-
This need not be. Indonesia expanded plements), and family members got regular
access to primary education in the mid-1970s medical checkups. The impact of this combi-
by using its oil windfall to build new schools nation of higher income and facility visits was
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Table 1.1 The nearest school or health center can be quite far
Mean distance to nearest facility in rural areas among the poorest and richest wealth quintiles in 19 developing
GNI per Distance to the nearest Distance to the nearest
capita primary school (kilometers) medical facility (kilometers)
Poorest Richest Ratio Poorest Richest Ratio
fifth fifth fifth fifth

Bangladesh 1996–97 374 0.2 0.1 1.6 0.9 0.7 1.3

Benin 1996 395 1.5 0.0 — 7.5 2.8 2.7
Bolivia 1993–94 1004 1.2 0.0 — 11.8 2.0 6.0
Burkina Faso 1992–93 336 2.9 0.8 3.9 7.8 2.6 3.0
Central African Republic 1994–95 819 6.7 0.8 8.9 14.7 7.7 1.9
Cameroon 1991 611 2.6 0.7 3.8 7.0 5.4 1.3
Chad 1998 250 9.9 1.3 7.6 22.9 4.8 4.8
Côte d’Ivoire 1994 788 1.4 0.0 — 10.5 3.4 3.1
Dominican Rep. 1991 1261 0.6 0.4 1.3 6.3 1.3 5.0
Haiti 1994–95 336 2.2 0.3 6.4 8.0 1.1 7.2
India 1998–99 462 0.5 0.2 2.3 2.5 0.7 3.6
Madagascar 1992 303 0.6 0.3 1.8 15.5 4.7 3.3
Mali 1995–96 281 7.9 5.2 1.5 13.6 6.7 2.0
Morocco 1992 1388 3.7 0.3 13.1 13.5 4.7 2.9
Niger 1998 217 2.2 1.5 1.5 26.9 9.7 2.8
Nigeria 1999 266 1.8 0.3 5.5 11.6 1.6 7.1
Senegal 1992–93 933 3.8 2.3 1.7 12.8 10.0 1.3
Tanzania 1991–92 224 1.2 0.6 1.9 4.7 3.0 1.6
Uganda 1995 290 1.4 0.9 1.5 4.7 3.2 1.5
Zimbabwe 1994 753 3.0 3.5 0.8 8.6 6.3 1.4

Note: Gross national income (GNI) per capita is that at the time of the survey, expressed in 2001 dollars. Medical facility encompasses
health centers, dispensaries, hospitals, and pharmacies. Although some of these data are a bit dated, they are the latest that were collected
in a consistent manner across these countries. The situation in some countries may be different today.
Source: Analysis of Demographic and Health Survey data.

significant: illnesses among children under five Punjab, Pakistan, only about 5 percent of sick
fell by about 20 percent (see spotlight). children were taken for treatment to rural
primary health care facilities; half went to
Quality—a range of failures private dispensaries, and the others to private
Lack of access and unaffordability are just two doctors.66 When quality improves, the
ways services fail. In low- and middle-income demand for services increases—even among
countries alike, if services are available at all poor clients.67
they are often of low quality. So, many poor
people bypass the closest public facility to go Services are often dysfunctional
to more costly private facilities or choose bet- Ensuring that positions are filled, that staff
ter quality at more distant public facilities. An report for work, and that they are responsive
in-depth study of the Iringa district in Tanza- to all their clients is a major challenge. The
nia, a poor rural area, showed that patients more skilled the workers, the less likely they
bypassed low-quality facilities in favor of are to accept a job as a teacher or a health
those offering high-quality consultations and worker in a remote area. A recent study in
prescriptions, staffed by more knowledgeable Bangladesh found 40 percent vacancy rates
physicians, and better stocked with basic sup- for doctor postings in poor areas.68 In Papua
plies.64 A study in Sri Lanka found similar New Guinea, with a substantial percentage of
behavior, with patient demand for quality teaching positions unfilled, many schools
varying with the severity of the illness.65 closed because they could not get teachers.69
One result: underused publicly funded Incentive payments might encourage profes-
clinics. In the Sheikhupura district of rural sionals to work in remote areas, but they can
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Services can work for poor people but too often they fail 23

Figure 1.3 Water, water everywhere, nor any drop to drink

BOX 1.2 HIV/AIDS is killing Percent of households who use an improved water source, poorest and richest
teachers Poorest fifth Richest fifth
Ethiopia 2000
Many countries lack reliable data on AIDS-related
Madagascar 1997
deaths and HIV prevalence among teachers, but
Chad 1998
the available information suggests rising teacher
Cameroon 1998
mortality in the presence of HIV/AIDS.For example:
Morocco 1995
In the Central African Republic 85 percent of Guinea 1999
teachers who died between 1996 and Mozambique 1997
1998 were HIV-positive. On average they Rwanda 1992
died 10 years before they were due to Kenya 1998
retire. Zambia 1996–97
In Zambia 1,300 teachers died in the first 10 Cambodia 2000
months of 1998, compared with 680 Senegal 1997
teachers in 1996. Central African Rep. 1994–95
In Kenya teacher deaths rose from 450 in Haiti 1994–95
1995 to 1,500 in 1999 (reported by the Niger 1998
Teaching Service Commission), while in Togo 1998
one of Kenya’s eight provinces 20 to 30 Yemen 1991–92
teachers die each month from AIDS. Nigeria 1999
HIV-positive teachers are estimated at more Ghana 1998
than 30 percent in parts of Malawi and Peru 2000
Uganda, 20 percent in Zambia, and 12 Burkina Faso 1999
percent in South Africa. Benin 1996
Sources: Coombe (2000), Gachuhi (1999), Kelly Mali 1995–96
(1999), Kelly (2000), UNAIDS (2000), World Bank Uganda 2000
(2002h). Indonesia 1997
Nicaragua 1998
Côte d’Ivoire 1998–99
Turkey 1998
be expensive. A study in Indonesia estimated
Bolivia 1997
that doctors would need to be paid several Namibia 1992
times their current salaries to induce them to Tanzania 1999
go to the most remote areas.70 Colombia 2000
Even when positions are filled, staff Zimbabwe 1999
absence rates can be high. In random visits to Dominican Rep. 1996
Kazakhstan 1999
200 primary schools in India, investigators Malawi 2000
found no teaching activity in half of them at Philippines 1998
the time of visit.71 Recent random samples of Kyrgyz Rep. 1997
schools and health clinics in several develop- Nepal 2001
ing countries found absence rates over 40 per- Brazil 1996
Pakistan 1990–91
cent, with higher rates in remote areas and for
India 1998–99
some kinds of staff—although there is wide Armenia 2000
variation within countries (tables 1.2 and Comoros 1996
1.3). Earlier studies have found similar results. Egypt 2000
Up to 45 percent of teachers in Ethiopia were Uzbekistan 1996
Bangladesh 1996–97
absent at least one day in the week before a
Guatemala 1999
visit—10 percent of them for three days or
0 20 40 60 80 100
more.72 Health workers in rural health centers
Percent of households
in Honduras worked only 77 percent of the
Note: The poorest fifth in one country may correspond to the standard of living in the middle fifth in
possible days in the week before a visit.73 In another country. Within-country inequalities reflect inequality in access to water and in the wealth
index used to construct quintiles. An “improved” water source, as defined by UNICEF, provides ade-
rural Côte d’Ivoire only 75 percent of doctors quate quality and quantity of water (that is, a household connection or a protected well, not an unpro-
were in attendance on the day before a visit.74 tected well or bottled water).
Source: Analysis of Demographic and Health Survey data.
Staff alone cannot ensure high-quality
services. They also need the right materials—
books in schools, drugs in clinics. Studies in
Ghana and Nigeria in the early 1990s found
WDR revised page 24 8/20/03 3:31 PM Page 24


Table 1.2 Staff are often absent that about 30 percent of public clinics lacked and the Russian Federation—more than 90
Absence rates among teachers
and health care workers in public
drugs.75 A quarter of rural clinics in Côte percent in Armenia.82
facilities (percent) d’Ivoire had no antibiotics.76 By itself, the Corruption hurts patients elsewhere too.
Primary Primary availability of drugs in a health facility is an For example, studies based on data from the
schools health ambiguous measure of quality: stockouts mid-1990s found that informal payments
could be caused by high demand. But when substantially increased the price of health ser-
Bangladesh — 35 medicines are lacking in clinics and available vices in Guinea and Uganda.83 A recent
Ecuador 16 — on the black market, as is often the case, some- review of case studies in Latin America found
India* 25 43 thing is amiss. Educational materials are simi- widespread corruption in hospitals, ranging
Indonesia 18 42 larly lacking in schools. In Nepal a study found from theft and absenteeism to kickbacks for
Papua as many as six students sharing local-language procurement.84 Villagers in one North
New textbooks. In Madagascar textbooks had to be African country where people are covered by
Guinea 15 19
shared by three to five students, and only half “free medical care” reported in a discussion
Peru 13 26 the classrooms had a usable chalk board.77 group that “there isn’t a single tablet in the
Zambia 17 — When staff report to work—as many do clinic and the doctor has turned it into his
Uganda 26 35 conscientiously—and when complementary private clinic.”85
*Average for 14 states. inputs are available, service quality will suffer Again, this need not be. In Benin cost-
if facilities are inadequate or in disrepair. sharing in health clinics—in line with the
Conditions can be horrific. An account of a Bamako Initiative—and revolving drug-
school in north Bihar in India describes class- funds increased the availability of drugs in
rooms “. . . close to disintegration. Six chil- clinics that previously provided services free
dren were injured in three separate incidents but almost never had any drugs. Use
when parts of the building fell down, and increased in all the clinics that introduced
Table 1.3 Absence rates vary a lot—
even in the same country even now there is an acute danger of terminal these measures (see spotlight).86 Innovative
Absence rates among teachers and collapse. . . . The playground is full of muck arrangements can encourage teachers to
health care workers in public facilities and slime. The overflowing drains could eas- report for work. In Nicaragua between 1995
in different states of India (percent)
ily drown a small child. Mosquitoes are and 1997 teacher attendance increased by
Primary Primary
schools health swarming. There is no toilet. Neighbors com- twice as much in primary schools that were
facilities plain of children using any convenient place granted autonomy as in state schools man-
Andhra Pradesh 26 —
to relieve themselves, and teachers complain aged through the bureaucratic system.87 In
of neighbors using the playground as a toilet India a large-scale basic education program
Assam 34 58
in the morning.” 78 The same study in India in the 1990s doubled the toilets and drinking
Uttar Pradesh 26 42
found that half the schools visited had no water facilities in schools in districts where it
Bihar 39 58
drinking water available. In rural areas of was implemented. Stakeholders can mobilize
Uttar Anchal 33 45
Bangladesh and Nepal a study found an aver- to reduce corruption. Public sector unions
Rajasthan 24 39 age of one toilet for 90 students, half of them have organized an anticorruption network
Karnataka 20 43 not usable.79 In Pakistan there were no sepa- (UNICORN) that is supporting national ini-
West Bengal 23 43 rate toilet facilities for girls in 16 percent of tiatives to protect whistleblowers.
Gujarat 15 52 schools visited in one study.80
Haryana 24 35 Another problem is corruption in various The technical quality of services is
Kerala 23 — forms. Teachers and principals might solicit often very low
Punjab 37 — bribes to admit students or give better grades, Services also fail poor people when technical
Tamil Nadu 21 — or they might teach poorly to increase the quality is low—that is, when inputs are com-
Orissa 23 35 demand for private tuition after hours. Sur- bined in ways that produce outcomes in inef-
veys in 11 Eastern and Central European ficient, ineffective, or harmful ways. For
Notes for tables 1.2 and 1.3: The absence rate
is the percentage of staff who are supposed countries found that the health sector was example, health workers with low skills give
to be present but are not on the day of an
unannounced visit. It includes staff whose
considered one of the most corrupt.81 Offi- the wrong medical advice or procedure, or
absence is “excused” and “not excused” and cially only 24 percent of health spending in schools use ineffective teaching methods.
so includes, for example, staff in training, per-
forming nonteaching “government” duties, as Europe and Central Asia is estimated to be Gross inefficiency was identified as the reason
well as shirking. private, but this fails to include the informal for soaring expenditures in a hospital in the
— indicates data not available.
Sources for tables 1.2 and 1.3: Chaudhury and payments—gratuities and bribes—that many Dominican Republic.88 A multicountry study
others (2003), Habyarimana and others (2003), patients pay. More than 70 percent of patients of health facilities in the mid-1990s found
and NRI and World Bank (2003). Data should be
considered preliminary. make such payments in Azerbaijan, Poland, shockingly low cases of proper assessments of
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Services can work for poor people but too often they fail 25

diarrhea in children under five, and even often starts at 8 a.m. while girls are still fetch-
fewer cases correctly treated or advised. For ing water, and school holidays are at odds
example, in Zambia only 30 percent of cases with local market dates.
were correctly assessed, and only 19 percent The “social distance” between providers
correctly rehydrated.89 Another study in and their clients can be large. In Niger, a
Egypt found only 14 percent of acute cases of mainly rural country, a study found 43 per-
diarrhea were treated appropriately with oral cent of the parents of nurses and midwives
rehydration salts.90 A recent study in Benin were civil servants, and 70 percent of them
found that one in four sick children received had been raised in the city. All of them went to
unnecessary or dangerous drugs from health work by car—a rarity in that country.99 Sad
workers.91 In India the contamination of consequences of the social distance between
injection needles used by registered medical providers and clients are not hard to find. In
practitioners was alarmingly widespread.92 Egypt participants in a discussion group com-
Even though technical quality is more dif- plained about the attitude of staff at the local
ficult to identify in basic education, some rural hospital, with one respondent summing
indicators raise alarm. For example, spending up the experience: “They have their noses up
is ineffectively allocated, with substantially in the air and neglect us.”100 In South Africa a
more going to teacher salaries relative to other focus group member comments about a pri-
factors that would be more efficient.93 Or time mary health care provider: “Sometimes I feel
is misspent: in five Middle Eastern and North as if apartheid has never left this place. . . .
African countries primary school students They really have a way of making you feel like
spend only about 65 percent of the potential you are a piece of rubbish.”101
time actually on task.94 In Indonesia first and Services must be relevant—filling a per-
second grade students officially spend only ceived need—or there will be little demand
2.5 hours a day in school, and absences and for them (box 1.3). If primary schools teach
classroom time spent on administrative tasks skills relevant only for secondary school—and
reduced time spent learning even further.95 not for life outside of school—only children
from richer families who expect to continue
Services are not responsive to clients to the secondary level will deem it worthwhile
Services also fail in the interaction between to complete primary school. In Ghana one
provider and client. Clients are diverse: they respondent claimed: “School is useless: chil-
differ by economic status, religion, ethnicity, dren spend time in school and then they’re
gender, marital status, age, social status, caste. unemployed and haven’t learned to work on
They may also differ in the constraints on the land.”102 In India one component of an
their time, their access to information and integrated childhood development program
social networks, or their civic skills and ability failed when beneficiaries rejected the food
to act collectively. The inequalities between
these groups are mirrored in the relationship
between clients and providers.96 In India dis-
tricts with a higher proportion of lower castes BOX 1.3 School services for girls are not in high demand
and some religious groups have fewer doctors in Dhamar Province, Yemen
and nurses per capita, and health outreach
“At the back of the classroom of 40 boys sat ceptable for them either to learn alongside
workers are less likely to visit lower-caste and 2 girls. . . .What did the girls want to be when boys or to walk to class in the street.“
poor households.97 Clients report that they they grew up? ‘A teacher,’ one said. ’A doc-
In Yemen girls make up about one in
value health facilities that are open at conve- tor,’ said the other. But less than a quarter of
three students at the primary level, one in
the women in Yemen are literate, and they
nient times, with staff who treat them with four at the secondary level. More than 75
must follow the path of the traditional vil-
respect. In El Salvador infrequent and incon- lage women, who usually marry in their
percent of women over 15 are illiterate,
compared with 35 percent of men. Girls’
venient operating hours greatly reduced the teens and have an average of 10 children. In
education is not the only problem, however.
use of health posts. According to focus group the countryside of Dhamar Province, one of
The net enrollment rate for boys is only 75
the country’s poorest, there are few profes-
respondents: “Health posts operate only sional activities for anyone, much less for
percent at the primary level, 70 percent at
twice a week. Waiting time is three hours on the secondary level.
women. Besides, most parents won’t let their
average. Only those who arrive by 8 a.m. get a daughters go to school—deeming it unac- Sources: Mayer (1997), World Bank (2002g).
consultation.”98 In Sub-Saharan Africa school
03_WDR_Ch01.qxd 8/14/03 7:36 AM Page 26


grain supplied. Eventually the program mental design, it is possible to learn about
changed what it offered to match varying systems and to innovate. For example, the
preferences in different parts of the country. Probe study in India documented a variety of
And again, this need not be. In the Nioki shortcomings of the quality of primary
area of Zaire (now the Democratic Republic schools. The widely publicized results con-
of Congo), where the use of health services tributed to mobilizing support for reform.106
declined substantially between 1987 and
1991, it increased in clinics with nurses who
had good interpersonal skills.103 Among Making services work
indigenous peoples in Bolivia, Ecuador, to improve outcomes
Guatemala, Mexico, Paraguay, and Peru, pro- Many of the examples discussed so far
moting bilingual and intercultural education describe failures in the public sector’s provi-
contributed to improved schooling out- sion of services, but they are not the only
comes.104 An innovative public health cam- story. The 20th century has seen enormous
paign among sex workers in Sonagachi, improvements in living standards. Life
India, trained “peer educators” to pass infor- expectancy has improved dramatically in
mation to their co-workers. Disseminating nearly every country. The expansion of
information in this way resulted in more con- schooling has been similarly remarkable. In
dom use and substantially less HIV infection nearly every country illiteracy has been
than in other cities. The approach had knock- reduced dramatically, enrollment rates have
on effects as well: sex workers organized a gone up, and the average schooling of the
union and effectively lobbied for legalization, population has more than doubled. Civil ser-
reduction in police harassment, and other vice bureaucracies providing good services
rights.105 have been integral elements of those suc-
cesses. In many settings staff must overcome
Little evaluation, little innovation, major obstacles—including threats to their
stagnant productivity own safety—in order to teach children or
In most settings there are few evaluations of provide care to the sick.
new interventions, and so no effective inno- What do services that work look like? Safe
vation and improvement in the productivity and pleasant schools with children learning
of services. Evaluating innovative service to read and write. Primary clinics with health
arrangements—such as new forms of workers dispensing proper advice and medi-
accountability—is rarer still. If systems don’t cine. Water networks distributing safe and
build in ways of learning about how to do dependable water. Direct subsidies to poor
things better, it should be no surprise when children and their families encouraging
they stagnate. Relying on research from other demand. Services that are accessible, afford-
countries, while useful, is not enough. Find- able, and of good quality—helping to
ing out how a particular intervention works improve outcomes for poor people.
in each country setting is crucial, since his- Governments take on a responsibility to
tory, politics, and institutions determine what make services work in order to promote
works, what doesn’t, and why. health and education outcomes. Chapter 2
Once again, this need not be. Although addresses the reasons for this responsibility,
rarely carried out, some programs have tried dwelling on three seemingly straightforward
to incorporate evaluation components to ways to discharge it: relying solely on eco-
learn about the program. Mexico’s Progresa nomic growth, allocating public spending, or
explicitly included randomization and evalu- applying technical fixes. None of them is
ation in its design. The results of the evalua- enough by itself. Making services work
tion—well documented and disseminated in requires improving the institutional arrange-
the media—helped solidify support for the ments for producing them. Chapters 3 to 6 of
program. They showed what was most effec- this Report develop a framework for analyz-
tive, contributing to the program’s extension ing those arrangements. Chapters 7 to 11
to a large part of the country’s poor people apply the framework and draw lessons for
(see spotlight). But even without an experi- governments and donors.
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Services can work for poor people but too often they fail 27

C R AT E 1 . 1 Determinants of health and education outcomes—within, outside,

and across sectors
Health and education outcomes are returns. But the returns might vary for differ- income by working inside or outside the
determined by more than the availability and ent people, such as lower expected earnings home (looking after siblings, working on the
quality of health care and schooling. Better for women or for ethnic minorities. In these family farm).The value of this contribution is
nutrition helps children learn. Better refrigera- cases one would expect different levels of forgone if they spend substantial time in
tion and transport networks help keep medi- investment: different desired levels of school- school.
cines safe. Many factors determine outcomes ing, for instance. A crucial element of The total cost of illness includes days of
on both the demand and the supply sides, demand is the degree to which individuals work lost recovering, seeking care, or looking
linked at many levels.The demand for health rather than society reap the rewards. Goods after the ill. Richer families can cope better
and education is determined by individuals with large positive externalities—in the with these costs, which leads to a direct asso-
and households weighing the benefits and extreme, public goods—will be demanded at ciation between income and outcomes. In
costs of their choices and the constraints they less than the socially optimal level. addition, better health and education are
face.The supply of services that affect health What are the costs? There are direct often valued in themselves. As incomes
and education outcomes starts with global costs: user fees, transport costs, textbook increase families demand more of them,
technological knowledge and goes all the way fees, drug costs. Some of these can be borne which again results in an association
to whether teachers report for work and com- by families—though not all families. Coping between income and outcomes.
munities maintain water pumps. mechanisms for those that cannot are often The production of health and education
hard to use. For example, the lack of insur- depends on the knowledge and practices of
Demand: individuals and households ance markets can make it hard to absorb adults in households.This works through
Benefits and costs determine how much an the financial burden of sudden illness. Or both the demand for human capital and the
individual invests in education or health. the inability to borrow against future earn- generation of outcomes. A review of four
What are the benefits? Higher levels of edu- ings can make it hard to borrow for school- hygiene interventions that targeted hand
cation and health are associated with higher ing investments. washing in poor countries found 35 percent
productivity—and higher earnings. Investing Indirect costs can also be large. For exam- less diarrhea-related illness among children
in human capital is a way to get those ple, children often contribute to household who received the interventions. And factors

The determinants of supply and demand operate through many channels

Policies, capacity, Health, nutrition, Households and

technical know-how, education sectors individuals
politics Behaviors and actions
• Service price, accessibility, and quality
• Global knowledge • Financing arrangements • Health: preventive care,
care-seeking for illness,
• National macro-, feeding practices,
sector-, and micro-level sanitary practices, . . .
• Education: enrollment
• Technical capacity to and school participation,
implement policies Related sectors Outcomes
learning outside of
school, . . . • Child mortality
• Governance; politics • Availability, prices, and accessibility
and patronage; political of food, energy, roads . . . Constraints
capacity; and incentives • Other infrastructure • Child nutrition
to implement policies • Environment • Income
• School completion/
• Wealth learning, achievement

• Education and knowledge

Local context
• Local government and politics
• Community institutions
• Cultural norms (e.g., women’s status)
• Social capital

Supply Demand

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C R AT E 1 . 1 Determinants of health and education outcomes—within, outside,

and across sectors (continued)
in the home complement schooling: books but for a school snack program there was level impact everyone’s health. In Peru the
and reading at home contribute to literacy. sharing in poorer families. sanitation investments of a family’s neighbors
Investments in the human capital of chil- Parents’ education has intergenerational were associated with better nutritional status
dren are sensitive to the allocation of power effects on the health, nutritional status, and for that family’s children.
within households: families in which the bar- schooling of their children. Adult female edu- The use of safe energy sources affects
gaining power of women is stronger tend to cation is one of the most robust correlates of both health and education. Indoor air pollu-
invest more in health and education. A study child mortality in cross-national studies, even tion—from using dirty cooking and heating
in Brazil found that demand for calories and controlling for national income. Similarly, fuels—hurts child health. One review of
protein was up to 10 times more responsive mother’s education is a strong determinant studies found that the probability of respi-
to women’s than men’s income.This result, of lower mortality at the household level, ratory illness, or even death, was between
strongest in societies that proscribe women’s though the relationship weakens when other two and five times higher in houses where
roles, tends to affect girls more than boys. household and community socioeconomic exposure to indoor air pollution was high. A
More generally, the roles and responsibili- characteristics are controlled for. A large part study in Guatemala found birth weights 65
ties of different household members can of this effect might not be general education grams lower among newborns of women
affect how investments are made. A woman but specific health knowledge, perhaps who used wood as a domestic cooking fuel.
in Egypt says:“We face a calamity when my acquired using literacy and numeracy skills Coping with the cold, in cold climates,
husband falls ill. Our life comes to a halt until learned in school, as a study in Morocco affects health and imposes substantial
he recovers.” Her husband’s earnings are cru- found.The effects can also be interspatial: a direct and indirect costs on households.
cial for sustaining the family. Since productiv- study in Peru found that the education of a Education is affected as well: schools have
ity is related to illness, households respond. mother’s neighbors significantly increases to close when there is not enough heat, and
In Bangladesh a study found that household the nutritional status of her children. Parents’ it is hard to imagine that working on
members who engaged in more strenuous education is similarly associated with the schoolwork at home is an option when
activities received more nutritious food. schooling of their children, though the mag- indoor temperatures are below freezing.
Daughters’ education might be less valuable nitude of the effect—and the relative roles of
to parents if sons typically look after them in mother’s and father’s education—vary sub- Supply: global developments
their old age, so parents might be less willing stantially across countries. At any given income, health and education
to send girls to school. Access to—and use of—safe water, as outcomes have been improving. A continu-
well as adequate sanitation, have direct ing trend in improvements in health going
Demand: links between sectors at effects on health status. Hand washing is a back several decades is interpreted as
individual and household levels powerful health practice, but it requires suffi- advances in technologies and leaps in
Health and nutritional status directly affects cient quantities of water. An eight-country knowledge about health and hygiene. More
a child’s probability of school enrollment and study found that going from no improved recently, at a national income of $600 per
capacity to learn and succeed in school. Mal- water to “optimal” water was associated with capita, predicted child mortality fell from
nutrition among children was associated a 6-percentage-point reduction in the preva- 100 per 1,000 births to 80—a full 20
with significant delays in school enrollment lence of diarrhea in children under three percent reduction—between 1990 and
in Ghana. Improving child health and nutri- years of age (from a base of 25 percent) in 2000. If this association were sustained,
tion at the pre-primary level has long-term households without sanitation. Nutritional major headway would be made toward the
impacts on development. A study in the status was likewise associated with access to Millennium Development Goal through
Philippines found that a one-standard-devia- improved water. But not all studies find these changes alone. Major breakthroughs
tion increase in early-age child health strong associations between water source in immunizations for malaria—or HIV—
increased subsequent test scores by about a and better health. could have a huge impact on mortality at
third of a standard deviation. The water source is only part of the story: all income levels.
Improving the health and nutritional sta- in Bangladesh water accessed through tube- Recent years have seen major develop-
tus of students positively affects school wells—an “improved” source— is frequently ments in global funding for health and edu-
enrollment and attendance. A longitudinal contaminated with arsenic. One study found cation expenditures. Debt relief through the
study in Pakistan found that a one-third of a that arsenic levels higher than the World Heavily Indebted Poor Countries initiative is
standard deviation increase in child height Health Organization’s maximum acceptable tied to increases in expenditures on these
increased school enrollment by 19 percent- level are associated with twice the level of sectors. New assistance, delivered through
age points for girls and 4 percentage points diarrhea in children under age six. Extremely multisectoral products such as Poverty
for boys. An evaluation of school-based mass high levels of arsenic are associated with Reduction Support Credits, requires explicit
treatment for deworming in rural Kenya shorter stature among adolescents. strategies for human development
found that student absenteeism fell by a The same eight-country study mentioned investments. Global funds for health and the
quarter—but test scores did not appear to above found that going to “optimal” “Fast-Track Initiative” for education are inter-
be affected. Improving nutrition is not as sim- sanitation from none was associated with a national pledges to support initiatives in the
ple as supplementary feeding at school: 10-percentage-point drop in recent diarrhea sectors (chapter 11). Easing financial
households can reallocate resources with the in households with no improved water constraints goes hand in hand with using
effect of “sharing” that food. A study in the source. As in education, there are spillover resources effectively to support services that
Philippines found no such sharing in general, effects: sanitation practices at the community work for poor people.
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Services can work for poor people but too often they fail 29

C R AT E 1 . 1 Determinants of health and education outcomes—within, outside,

and across sectors (continued)
Supply: national resources thousands did not. Wars, including civil wars, Supply: services and their financing
National income is strongly associated with lead to “lost generations” of undernourished Services themselves are important. Inacces-
child mortality and primary school comple- and undereducated children.These deficien- sible or poor-quality services raise the
tion. Income and health and education out- cies are difficult—if not impossible—to make effective price of health care and schooling,
comes build on each other. More income up for. When children have been out of which results in higher mortality and lower
leads to better human development school for a long time, it is hard to return. educational achievement. Poor-quality
outcomes, and better health and education And bad health and poor nutrition at an early schools deter enrollment and reduce
can lead to increased productivity and better age affect children throughout their lives. attainment and achievement, especially
incomes. Studies that have tried to disentan- Periods of national economic and social among children of poor families. Health
gle these relationships typically find income crisis can result in bad health and education clinics where the technical skills of staff are
to be a robust and strong determinant of outcomes.This is clear in Russia’s recent his- so bad as to be dangerous will lead to
outcomes. tory: adult mortality has increased dramati- higher mortality. Lack of water will signifi-
National endowments are also a strong cally over the past 10 years. Sustained cantly hurt child health.
determinant. Geography and climate some- economic depression can severely compro- Financing arrangements matter. Absorb-
times make it tougher to overcome health mise children’s health and have cascading ing the burden of unpredictable large expen-
problems. For example, areas conducive to effects on subsequent development and ditures through health insurance can reduce
mosquito survival have great difficulty in com- learning.The evidence of shorter-term eco- impoverishment, which in turn will affect
bating malaria—and widely dispersed popu- nomic crises is more mixed. In middle- outcomes. Financing primary schooling
lations are difficult to serve through income environments school enrollments might seem relatively minor: direct costs are
traditional school systems. might increase as the opportunity cost of typically small. Even so, a lack of access to
The performance of public expenditure in time for young people falls. Even in Indone- credit has been found to be associated with
producing outcomes varies substantially across sia, a relatively poor country, the deep lower school enrollment. Borrowing to pay
countries.There are large differences in economic and social crisis of the late 1990s the direct costs of primary school is almost
achievements at similar levels of expenditure had smaller impacts on outcomes than ini- unheard of, but there could be second-round
and similar achievements with very large differ- tially feared.This was partly because broad effects if the lack of access to credit means
ences in expenditures—conditional on income. social safety nets were rapidly put in place. that families need children to engage in
Spending more through the public sector is not home production.
Supply: the local context of government
always associated with improved outcomes.
and communities Supply: services working together to
This is not to say that spending cannot be help-
Decentralization can be a powerful tool for produce outcomes
ful—but the way resources are used is crucial
moving decisionmaking closer to those Links among services are critical. Vaccines
to their effectiveness.
affected by it. Doing so can strengthen the can become less effective, ineffective, or
Supply: political, economic, links and accountability between policymak- even dangerous if they get too hot, freeze,
and policy context ers and citizens—local governments are or are exposed to light. The ability to trans-
Governance affects the efficiency of expendi- potentially more accountable to local port and store vaccines properly thus
tures: in corrupt settings money that is osten- demands. It can also strengthen them determines the success of immunization
sibly earmarked for improving human devel- between policymakers and providers—local campaigns. In cold climates schools and
opment outcomes is diverted. Staffs governments are potentially more able to health facilities often need to close because
ostensibly delivering services do not. But the monitor providers. But local governments of the lack of heating, and dependable
effects of poor governance can be deeper. should not be romanticized. Like national energy sources can directly affect health
Famines are caused as much by human fac- governments they are vulnerable to and education outcomes. The accessibility
tors as by nature. And the repercussions run capture—and this might be easier for local of services can be a deterrent to their use:
across national borders. For example, a elites on a local scale. roads and adequate transport contribute to
drought combined with misguided policies Community-level institutions, shaped by the total cost of using a service. Since the
and bad governance in Zimbabwe resulted cultural norms and practices, can facilitate expected return to education determines
in a regional food shortage. or hinder an environment for improving the benefits of schooling, labor markets
Managing public expenditures can be a outcomes. A review of safe-water projects in that are not fundamentally distorted (for
critical link in ensuring that allocated expen- Central Java, Indonesia, associates success example, through discriminatory practices
ditures get put to uses that improve with greater social capital. In Rajasthan, toward marginalized groups) can
outcomes.“Cash budgeting” in Zambia led to India, manifestations of “mutually beneficial contribute to higher education
unpredictable social service spending and collective action” were associated with achievement. Services therefore need to
deep cuts in spending on rural infrastructure. watershed conservation and development work together to promote improved
Conflict leaves long-lived scars on health activities more generally. A broader review outcomes.
and education. Children in war-torn countries of the literature suggests that participatory
are hard to find, hard to get into school, and approaches to implementing projects are
hard to keep in school. During Sierra Leone’s more successful in communities with less
recent civil war, tens of thousands of children economic inequality and less social and eth-
attended primary school but hundreds of nic heterogeneity. Source: Sources are detailed in Filmer (2003a).
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spotlight on Progresa

Conditional cash transfers to reduce poverty in Mexico

Progresa, the Education, Health, and Nutrition Program of Mexico, transferred money directly to families on the condi-
tion that family members went for health checkups, mothers went for hygiene and nutrition information sessions, and
children attended school. By documenting success through rigorous evaluation, the program has improved, scaled up,
and taught others.107

When President Vincente Fox was elect- Almost 60 percent of program transfers

W hen Ernesto Zedillo became

Mexico’s president in 1995, a
fifth of the population could
not afford the minimum daily nutritional
requirements, 10 million Mexicans lacked
ed, his government embraced the program,
built on it using the evaluation results,
expanded it to urban areas, and renamed it
Oportunidades. By the end of 2002 the pro-
went to households in the poorest 20 per-
cent of the national income distribution and
more than 80 percent to the poorest 40 per-
cent. This is impressive. The median target-
gram had about 21 million beneficiaries— ing effectiveness in 77 safety net programs
access to basic health services, more than
roughly a fifth of the Mexican population. from around the world was to have 65 per-
1.5 million children were out of school,
cent of benefits go to the poorest 40 percent
and student absenteeism and school deser-
Designing a comprehensive (according to one recent study).
tions were three times higher in poor and
program Even with careful targeting and moni-
remote areas than in the rest of the coun-
toring, the program’s administrative costs
try. The country had a history of unpro- Children over seven were eligible for educa-
were less than 9 percent of total costs—sub-
ductive poverty alleviation programs. tion transfers. Benefits increased by grade
stantially lower than earlier poverty allevia-
Worse, the 1994–95 economic crisis left the (since opportunity costs increase with age)
tion efforts in Mexico. Despite its initial
government with even fewer resources— and were higher for girls in middle school,
large scale, the program did not cover all
and greater demands, as more people were to encourage their enrollment. To retain the
the poor, particularly in urban areas.
falling into poverty. benefits, children needed to maintain an 85
The administration decided that a new percent attendance record and could not
approach to poverty alleviation was need-
Boosting enrollments
repeat a grade more than once.
ed. The Education, Health, and Nutrition Eligible families could also receive a Girls’ enrollment in middle school rose from
Program of Mexico, called Progresa, intro- monthly stipend if members got regular med- 67 percent to around 75 percent, and boys’
duced a set of conditional cash transfers to ical checkups and mothers attended monthly from 73 percent to 78 percent. Most of the
poor families—if their children were nutrition and hygiene information sessions. increase came from increases in the transi-
enrolled in school and if family members Households with children under three could tion from primary to middle school (figure
visited health clinics for checkups and also receive a micronutrient supplement. 1). The program worked primarily by keep-
nutrition and hygiene information. The transfers went to mothers, who ing children in school, not by encouraging
The program was intended to remedy were thought more responsible for caring those who had dropped out to return. It also
several shortcomings of earlier programs. for children. The program imposed a helped reduce the incidence of child labor.
First, it would counter the bias in poor fam- monthly ceiling of $75 per family. In 1999
ilies toward present consumption by bol- the average monthly transfer was around
stering investment in human capital. $24 per family, nearly 20 percent of mean Figure 1 Higher school retention, more
transitions from primary to middle school
Second, it would recognize the interdepen- household consumption before the pro- Expected grade completion before and after
dencies among education, health, and gram. Transfers were also inflation-indexed intervention, and with and without Progresa
nutrition. Third, to stretch limited every six months (today the maximum is
resources, it would link cash transfers to $95 and the average is $35). 100
household behavior, aiming at changing Highly centralized, the program has just Post-intervention:
attitudes. Fourth, to reduce political inter- one intermediary between program offi- 80
ference, the program’s goals, rules, require- cials and beneficiaries—a woman commu-
ments, and evaluation methods would be nity promoter chosen by a general assembly 60
widely publicized. of households in targeted communities. She
The program has been rigorously evalu- can also liaise between beneficiaries and 40
ated, and evaluators have exploited the ran- education and health providers. Post-intervention:
domized way the program was rolled out. By the end of 1999 the program covered
The results have been impressive. To some 2.6 million rural families—about 40
emphasize the apolitical nature of the pro- percent of rural families and a ninth of all
gram, the government suspended the families in Mexico. The program budget 1 2 3 4 5 6 7 8
growth of the program for six months prior was almost $780 million, or 0.2 percent of
to the election in 2000—to show that gross domestic product and 20 percent of Note: Among children who enroll.
Progresa was not a political tool. the federal poverty alleviation budget. Source: Schultz (2001).
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Spotlight on Progressa 31

Labor force participation decreased by about Figure 2 Improving child health The evaluation design captures the
20 percent for boys. Still, a substantial num- Percentage of children reported to have had an many determinants of outcomes. But it has
ber of children from poor families continue limitations. Policymakers would benefit
to combine work with school. from knowing how the program could be
The impacts on learning are less clear. Age 0–2: Non-Progresa manipulated to improve impacts. For
Teachers report improvements, attributing example, what is the impact of condition-
40 Age 0–2: Progresa
them to better attendance, student interest, ing the transfers rather than giving pure
and nutrition. But a study conducted one unconditioned transfers? In addition,
year after the program started found no dif- 30 households in the control group might have
ference in test scores. been affected by the intervention or by
20 knowing that they might receive it in the
Improving nutrition and health Age 3–5: Non-Progresa
future, an effect that would muddy the
The program helped reduce the incidence 10 comparisons.
of low height for age among children one to Evaluations can address these issues, but
three years old. (Before the program stunt- Age 3–5: Progresa the complexity (and expense) increases
ing was very high, at 44 percent.) Annual 0 5 10 15 20
substantially. Alternative approaches that
mean growth in height was 16 percent for rely on modeling—imposing additional
Time since intervention (months)
children covered by the program. On aver- assumptions on the analysis—might be
Note: Age at start of intervention.
age, height increased by 1–4 percent, and Source: Gertler (2000).
necessary. Such analyses are currently
weight by 3.5 percent. These gains were underway.
achieved despite evidence that some house-
holds did not regularly receive nutrition cation impacts would increase them by 8 Evidence makes the difference
supplements and that supplements were percent. A general equilibrium analysis of A conditional cash transfer program can be
often “shared” with older children. Part of Progresa found that the welfare impact was a powerful way of promoting education,
the effect can be attributed to spending 60 percent higher than that of the highly health, and nutritional outcomes on a
more on food and to consuming more distortionary food subsidies that Mexico massive scale. The success of the Progresa
nutritious food, as recommended by the used previously. program has led to similar programs,
nutrition information sessions. There were especially in other Latin American coun-
also positive spillover effects for nonbenefi- Evaluating impacts tries (Colombia, Honduras, Jamaica, and
ciaries in the same community. Progresa was unusual in integrating evalua- Nicaragua).
The program substantially increased tion from the beginning, enabling it to Evaluation was not an afterthought. It
preventive health care visits. Visits by preg- assess impacts fairly precisely. To ensure continually fed back into improving pro-
nant women in their first trimester rose 8 political credibility, the evaluation was con- gram operations. And its rigor increased
percent, keeping babies and mothers tracted out to a foreign-based research confidence in the validity of assessments of
healthier. Illnesses dropped 25 percent group, the International Food Policy the program’s effects.
among newborns and 20 percent among Research Institute. Evaluation was important for domestic
children under five (figure 2). The preva- Phasing in communities in a random and international political and economic
lence of anemia in children two to four fashion—required for budgetary purpos- support—and thus contributed to pro-
years old declined 19 percent. Adult health es—allowed the construction of 186 con- gram sustainability. Unlike previous pro-
improved too. trol and 320 treatment groups. Having the grams, this one was not abandoned after a
control groups enabled evaluators to “wash change in government. Clear and credible
Reducing poverty out” confounding factors, including time evidence of large benefits for the country’s
The program is not only raising incomes trends and shocks (economic and climatic). poor contributed to maintaining the
temporarily, it should help raise future pro- Eventually all control communities were integrity of the program’s design (albeit
ductivity and earnings of the children ben- incorporated in the program. Both quanti- with a name change). It also made it easier
efiting. Modeling exercises find that nutri- tative and qualitative evaluations were con- to get support from the Inter-American
tional supplements alone would boost life- ducted, the latter using semistructured Development Bank for a major expansion
time earnings by about 3 percent and edu- interviews, focus groups, and workshops. of the program.