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Service Delivery in Education and Health in Africa Bernard Gauthier HEC Montréal H2011 Contents 1. Introduction 2. Public Service Provision Framework 3. Origin and Motivations 4. Main Findings Leakage Absenteeism Ghost workers Delays User fees Equity 5. Illustration 1: Chad Health Sector 6. Illustration 2: South Africa ECD programs 2 1. Introduction Access to quality services - in particular in health, education, water and sanitation - has been recognized as fundamental for wellbeing and economic development. However, in many African countries, access to quality services - in particular in health, education, water and sanitation, is often poor or non existents Service quality is low, basic materials, equipment, and staff are often lacking; access is difficult, costs are prohibitive for the poor, absenteeism, corruption, etc. 3 1. Introduction Inadequate service delivery is reflected in the poor results in terms of health and education outcomes. Current trends will not allow most countries to meet MDG For instance, only 3 out of 46 countries in SSA is on track to meet target of reducing child mortality by 2/3 between 2000-2015 Also, about 35 million children in SSA are not enrolled in primary school in 2006 (1/3 of the primary school age population) (UNESCO, 2008) Among adults, close to 40% of the estimated 161 million people in SSA remains illiterate, of which 62% are women. About 44% of population does not have access to safe drinking water, About 37% have no access to sanitation facility. 4 5 Source: World Development Report 2004, p. 134 Source: World Health Report 2003, p.8 6 1. Introduction To accelerate progress, donors, developing country governments and NGOs have committed increasing resources to improve service delivery in social sectors Low-income countries saw funding from external sources rise on average from 16.5% of their total health expenditures in 2000 to 24.8% in 2007. Government commitments for health reported by bilateral donors jumped from about US$ 4 billion in 1995 to US$ 17 billion in 2007 and US$ 20 billion in 2008. (WHR 2011, p.31) 7 1. Introduction However, increase expenditure is not sufficient to ensure improvements in service delivery performance and in population outcomes. Public service provision could be affected by institutional inefficiencies such as leakage of public resources, corruption, weak institutional capacity and inadequate incentives Indeed, a growing body of research demonstrates a weak relationship between public expenditure and population outcomes (Filmer and Pritchett, 1999; World Bank, 2003) 8 1. Introduction 9 Source: World Bank (2003) World Development Report 2004, p. 11 1. Introduction Tel qu’observé par Filmer et Pritchett (1999), les résultats dans le domaine de la santé sont principalement fonction de 6 variables principales : Ils estiment une fonction de production de la santé pour 100 pays dans les années 1990 à l’aide de l’équation suivante : Où M est le résultat (mortalité infantile et juvénile), les variables exogènes sont le log du revenu par habitant, le log des dépenses de santé en proportion du PIB, H est le niveau d’éducation des femmes et X est un vecteurs d’autres variables socio-économiques (religion, groupes ethniques, localisation, etc.). ** Filmer, D. and L. Pritchett (1999) “The impact of Public Spending on Health: Does Money Matter?” Social Science and Medicine 10 1. Introduction Ils estiment par MCO et ensuite par moindres carrés en 2 étapes (2SLS) afin de tenir compte de l’endogénéité de certaines variables: : i.e. causalité qui va aussi dans l’autre sens): gouvernements des pays qui ont des niveaux de mortalité élevés peuvent dépenser plus en soins de santé afin de réduire ce problème Résultats indiquent que les dépenses officielles de santé n’ont pas d’effet significatifs sur la mortalité des enfants le revenu par habitant et l’éducation des mères réduit significativement la mortalité des enfants. Également, 1% de plus d’inégalité accroît la mortalité de 1%. La diversité ethnique accroît aussi la mortalité, de même que l’appartenance religieuse 11 12 Source: Filmer and Pritchett (1999) 1. Introduction Also in education, while showing the highest spending per student as a % of GDP per capita, Mali, Burkina Faso and Niger also present the lowest primary enrollment rate and the lowest completion rates. 13 1. Introduction 14 1. Introduction At least 3 factors could explain this weak relationship: 1. In several countries, social sectors expenditures are not mainly targeted toward the poor. • Benefits incidence studies indicate that benefits accrue in a large proportion to rich and middle class groups. Ex: In Guinea, 48% of spending benefits the richest quintile. 2. Even for public expenditures that target poor households, there could be significant differences between official spending in sector and actual spending at the provider level • Corruption, rent capture and leakage of funds by the various layers of the political and administrative apparatus. 3. Even if public resources reach frontline providers, the incentives for providers to produce quality services could be weak. • Service providers in the public sector may be poorly remunerated, rarely monitored and incentives provided by the central bureaucracy may be lacking. 2. Public Service Provision Framework The quality of government provided services is function of a complex network of principal-agent relations: Characterized by delegation of responsibilities among clients/citizens, government and service providers. Citizens finance and delegate to government responsibility to provide services. The role of intermediary agent played by the government in the principal-agent relationship creates a situation where it is difficult for the principal (citizens) to evaluate and control the actions of the decentralized agent (service provider). Information about providers’ activities flows through hierarchical administrative structures (see Figure 1). Public Service Provision Framework In an ideal world, with perfect information, citizens would be able to evaluate actions taken on their behalf by governments and service providers, and to exercise control over agents’ behavior. In practice, citizens have weak capacity to exercise control as: information is imperfect and asymmetric, agents’ objectives do not coincide with those of the principal (citizens), and enforcement is inadequate. The 2004 World Development Report has identified 2 mechanisms by which citizens could exercise control in this context: The “long route” of accountability and the “short route” of accountability (see previous figure). Public Service Provision Framework The “Long Route” of Accountability is the relationship between citizens and policymakers -- in which citizens have to hold politicians (policymakers) accountable for allocating resources for service delivery and for providing appropriate incentives for performance. However, it could be broken for several reasons. There could be non democratic electoral system, or important information asymmetries or social polarization, the outcome may still be biased against certain groups, especially the poor. Also, politicians in turn may not be able to hold the providers accountable for bad performance. Indeed, in many poor countries the institutions assigned to monitor providers are weak 19 and malfunctioning Public Service Provision Framework The “short route” of accountability between citizens and providers enables clients to monitor and directly discipline service providers. One way citizens can exert leverage directly on service providers are through various feedback mechanisms, which depend on systems assessing and reporting what clients think of service quality. For instance, public service’s users could be surveyed to gauge their satisfaction. They can also participate in providers’ management committees or oversight agencies or simply lobby, individually or through civil society organizations, for improved public services from various agencies. Public Service Provision Framework Solutions to improve performance have focused on reducing information asymmetry and strengthening the accountability relationships, which are at the root of institutional deficiencies within service delivery systems. In addition, there is growing evidence that citizen participation in service delivery and better information can help improve outcomes, especially using mechanisms that enable clients to monitor and directly discipline service providers (World Bank, 2003; Banerjee et al., 2006). 21 Public Service Provision Framework Indeed, new approaches and tools are being developed to improve health and education for the poor—which, in turn, would boost economic and social development 1. Self interest/diverging objectives Modify the incentives and interest of agent by moving them closer to those of the principal. Incentives/Contract: salary based on the performance of organization or department 2. Asymmetry of information Create mechanisms of supervision and control. Collect information, indicators. Public Service Provision Framework In the last decade, “new” survey tools have been developed to provide adequate information on decentralized levels and service providers, to evaluate the efficiency or equity of government expenditures. Public Expenditure Tracking Survey : seek to track flows of funds and materials from the central government to basic service providers, via regional and local governments, to identify evidence of waste, inefficiencies and corruption. Verify if effective budget allocation at facility level corresponds to intended/official goals • Quantitative Service Delivery Survey: analyze the performance of service provision at facility level (to measure inputs, outputs and, for example, to analyze incentives) 23 Public Service Provision Framework Observational Study: Measure the quality of services, proxied for by the level of effort exerted or health vignettes (case studies that assess adherence to clinical protocols and diagnostics) Citizen Report Cards : Instrument to promote citizen awareness and participation. Used to collect information from users about experiences of service quality, disseminated back to citizens/users so have reliable information about how their community experiences quality and efficacy of service delivery. These instruments have proven to be powerful tools for identifying bottlenecks, inefficiencies and waste 24 3. Origin and Motivations of the First PETS and QSDS The first PETS was implemented in Uganda in the education and health sectors in 1996. The country was facing stagnant and even declining education and health outcomes despite important increases in expenditures in these sectors in the past decade. In education, despite the tripling of public expenditures, official primary school enrolment figures were stagnant. The central government had very little information about resource use and reasons for poor outcomes but it was suspected that local governments might be diverting resources for other purposes. 25 3. Origin and Motivations of the First PETS and QSDS The objective of the survey was to track expenditure flows in the hierarchical structure to identify factors explaining these poor results, and to measure potential leakages in school and health facility funding. Hypothesis for poor results was that public resources did not reach schools and health facilities (Ablo and Reinikka, 1998). Survey instruments were developed to compare official budget allocations with actual spending at various tiers of government, including primary schools and dispensaries. The survey consisted of three instruments. Data were collected at the central level, the district level (local government), and the public primary school and public health care facility level. 26 3. Origin and Motivations of the First PETS and QSDS In the education sector, the tracking exercise focused especially on a specific fixed-rule program “capitation expenditures” to schools--which was officially based on enrolment figures at the school level. The tracking survey in education was able to identify various problems in the sector, in particular large-scale resources leakage. On average, only 13% of the annual capitation grant from the central government reached the schools in 1991–95. Most schools received no grants at all. 87% was captured by local officials for purposes unrelated to education, yet there was no evidence of increased spending in other sectors (Jeppson, 2001). 27 3. Tableau 3: Dissipation des ressources non salariales dans le secteur de l’éducation primaire en Ouganda, 1991-95 et 2001 (pourcentage) Moyenne Médiane 1991 97 100 1992 96 100 1993 85 100 1994 84 100 1995 78 100 2001 18 18 Source : Reinikka (2001) et Reinikka et Svensson (2004) 3. Origin and Motivations of the First PETS and QSDS Following the tracking survey findings, the government implemented policy reforms, including an information campaign. Published monthly intergovernmental transfers of capitation grants in the main newspapers and requiring primary schools to post information on inflows of funds. An evaluation of the information campaign—using impact evaluation PETS in 1999 and 2001—reveals great improvements. While schools on average are still not receiving the entire grant, capture has been reduced to 18% in 2001. This success drew considerable attention to the new survey tool (Reinikka and Svensson, QJE, 2004). 29 3. Origin and Motivations of the First PETS and QSDS First QSDS also implemented in Uganda in health sector (2000) Despite an increasing health budget, health services were perceived as not meeting the needs of the population as health indicators (in particular immunization rates) were declining Survey collected quantitative and expenditure data at facility level. Information was collected from the head nurse or head doctor on infrastructure, inputs, output, financing, staffing and incentives (e.g. remuneration, institutional support, supervision). Also collected information at the district health administration level on various elements e.g. inputs, staffing, drugs, vaccines supplies and supervision An exit poll of patients was also conducted to gather information on the demand side, 30 e.g. individuals’ characteristics, behavior and perceived quality of services. 3. Origin and Motivations of the First PETS and QSDS Since then, more than four dozen PETS and QSDS, (as well as combined PETS-QSDS), were launched in low income countries, the majority in Africa. Most of these surveys were conducted in the health and education sectors A few also comprised works in other sectors, such as water supply, agriculture, rural roads, ECD... 31 4. PETS/QSDS Main Findings Leakage Public resources leakage has been identified on a very large scale (Table 1). For instance: As mentioned, the initial Uganda PETS estimated that 87% of capitation (per-student) grants for did not reach its destination. Tanzania and Ghana: leakage on non-wage education expenditures was 41% and 50% respectively Zambia: Important differences in efficiency/leakage between discretionary (76%) and rule-based funding (10%) 32 Main Findings Table 1: Leakage levels (%) Country Education Health Chad, 2004 - 80 Ghana, 1998 49 80 Kenya, 2004 - 38 Tanzania, 1998 57 41 Uganda, 1991-95 87 - Zambia , 2001 10 (rule-based) - 76 (discretionary) -- Not available 33 Main Findings Definitions of leakage: The “strict” definition of leakage introduced by Ablo and Reinikka (1998) for rule-based expenditures (hard allocation rule) is the share not received with respect to the expected (fixed-rule) entitlement: For non-fixed (soft) allocation rule flows (discretionary): “broad” definition: share of resources sent at a certain level and not received at the other, in particular the facility level: 34 Main Findings Absenteeism PETS/QSDS have also allowed to measure provider absenteeism. Results show absenteeism rates of between 27 and 40 percent for health care providers and between 11 and 27 percent for teachers. Absenteeism rates were associated with poverty and community characteristics related to effectiveness in monitoring. Because of poor accountability relationships and weak incentives, service provider absenteeism is prevalent in developing countries, which translates into low quality of services. 35 Main Findings 36 Main Findings Ghost Workers In a few countries, tracking surveys allowed to measure “ghost workers” Proportion of teachers or health workers who continue to receive a salary but who no longer are in the government service, or who have been included in the payroll without ever being in the service In Papua New Guinea, a 2003 PETS for ex. showed that 15% of teachers on the payroll were ghosts. In Africa, the comparable figures are even higher: 20% in Uganda in 1993 37 Main Findings Table 2. Ghost workers on payroll (%) Country Ghosts workers Education Health Honduras, 2000 5 8.3 Papua New Guinea, 2002 15 _ Uganda, 1993 20 _ Source: World Bank (2001) for Honduras; World Bank (2004) for Papua New Guinea; and Reinikka (2001) for Uganda.-- Not available. 38 Main Findings Delays Delays and bottlenecks in the allocation of resources have also been measured Salaries, allowances, financing, material, equipment, drugs and vaccines These issues could have important effects on the quality of services, staff morale and the capacity of providers to deliver services. In some countries, such as Nigeria, in one state, 42% of the health staff respondents reported not receiving salaries for the 6 months or more. 39 Main Findings User fees Tracking surveys have produced findings on the importance and impact of user fees. In several countries (e.g. Chad, Mozambique), user fees are sometimes the only source of revenues for service providers. On the demand side, however, they often constitute a very important part of service costs for users and could have considerable negative effects on accessibility. For instance in Uganda, although the government was trying to re-establish free education, the survey found that private contributions represented more than 60% of education costs at the school level. In Chad, for the poorest quintile, the average out-of-pocket medical expenses accounted for 21% of their monthly incomes. 40 Main Findings Equity In several countries, large variability of health and school spending across regions and districts, as well as within districts, was observed For instance: Mozambique, nine-fold variation of per capita health spending at the district level Chad: non-wage per capita public health spending showed important variations across districts (in a 16 to 1 ratio) Zambia: the most funded school district received 8 times more average per-student public resources than the least funded district. 41 5. Illustration: Chad Health Sector A combined PETS-QSDS was organized in the Chadian health sector by the World Bank in 2004. See : Gauthier and Wane (2009) “Leakage of Health Resources in Chad”, Journal of African Economies In a context of increasing oil revenues and public expenditures in social programs, government of Chad and international donors wanted to ensure that funding contribute to poverty reduction objectives by reaching its destination and benefiting the population. Chad: pop 10.5 million, one of poorest countries US$450 per capita, ranks 170 out of 177 countries in Human Development Index (2008) Adult illiteracy rate is 74.5%. Only 34% of the population has access to improved water and 8% to sanitary facilities. Life expectancy at birth is 43.6 years and the child mortality rate (under 5 years) is 200 per 1,000 live births. Mother mortality is among the highest in Africa, close to 1100 for 100,000 live births. 42 Chad Health Sector The health system in Chad is composed of a mixture of public, private for-profit and non-profit service providers. The public health system is structured around four levels of responsibility (Figure 4). Public health care providers (except some hospitals) do not receive any financial resources from the public administrative system, only in-kind resources. User fees are the only source of financial resources at the local provider level. Public resources arriving at decentralized levels from the Ministry of Health (MOH) are the sum of four components, namely (1) centralized credits, (2) decentralized credits, (3) ad hoc requests, and (4) medication and vaccine delivery. 43 Chad Health Sector 44 Chad Health Sector Centralized credits are resources purchased by the MOH (essentially materials and medications), intended for regional and district administrations and health centers Delegated credits are budgetary resources given to regional or district administrations. Resources are also transferred through ad hoc requests These materials are directly requested from the MOH and collected by regional health delegates and district heads in the capital. There is a budget for medications and vaccines destined for health centers and hospitals administered by the Central Pharmaceutical Procurement Agency (CPPA), Has a monopoly over drugs and medical products sold to the 14 Prefectoral Purchasing Pharmacies (PPP), as well as to the public and non-profit health facilities. 45 Chad Health Sector The survey focused on the health system as a whole (primary, secondary and tertiary health care providers). The objective was to compare resource access and level of services in health centers of all the country’s regional delegations. Specifically, the objectives were to analyze the impact of and bottlenecks and constraints in resource allocation and their impact on efficiency and performance of health care facilities; In addition to facility level data, information was collected at all levels of the public administration (MOF, MOH, regional delegates, district head doctors and regional pharmacy managers). A staff questionnaire and a patient exit poll were also 46 administered. Chad Health Sector Tracking Strategy Survey focus on all recurrent expenditures and tracked all financial resources from MoH to Health centers + Traced 8 medical materials received by health centers Mattresses, beds, sheets, blankets, blouses for nurses and midwives, soap and detergent. The choice of materials was based on their frequency in shipments. The risk of choosing a rare but high-value material would have been not finding that material in the visited health centers simply because not all of them were able to receive it. 47 Chad Health Sector On the contrary, by choosing frequently-shipped materials of small value, it is likely that a maximum number of health centers will report receiving them. This gives us an upwardly biased percentage of health centers receiving materials from the authorities. Traced also 11 drugs and medical consumables received by HC Also based on frequency of shipping Total value of resources reaching the health centers is the sum of the financial resources, medical materials, drugs and salaries received by health centers from the health administration. 48 5.1 Data Questionnaires administered to regional delegates, district head doctors and health center heads in all the regions of the country, in half of the districts and about half of the health centers. 281 health centers and 35 hospitals surveyed 1/3 of capital’s health centers are private vs 1/4 in other urban areas and 6% in rural areas. 49 5.2 The Extent of Leakage in the Health sector Health budget in 2003 represented 8.4% of the total government budget (an increase of 24% over 2002) Support from foreign donors : 48% of health budget. The analysis focuses on MoH recurrent expenditures (which represented 48% of the total budget) because of the absence of information concerning investments. A. Public Resources Reaching the Regional Level About 60% of the MoH recurrent budget (2/3 of the MoH non-wage recurrent budget) is devoted to the14 regional health delegations (RHD) 50 - 86% of the regional budget is controlled by MoH through centralized credits. - Remaining 14% of the regional health budget is managed at the regional level through decentralized credits 51 Figure 1: Official vs. Effective Expenditures by Regional Health Delegations 1000 45 900 40 800 35 Millions of CFA Francs 700 Percentage Received 30 600 Initial Allocation 25 Resources Received 500 Percentage 20 400 Average 15 300 10 200 100 5 0 0 al i ï jilé l ra ha c ri e . em bi at rm ne nta da .T La in ha nt ué eb am at nd id .E ui ilt an r ie e C G B K B ua ag id B Ta al K O en o cc S O B ay oy ri- O M ha go M ne C Lo go Lo • On average, RHDs received only 26,7% of their official non-wage budgetary expenditures from the MoH 52 The Extent of Leakage in the Health sector B. Public Resources Reaching Health Centers Health center administrators report receiving about 50 million CFAF of medical materials accounting for 17.8% of materials received by all RHDs Only 4 centers (2%) report receiving financial resources from the health administration in 2003. Total value of medication received by HC is estimated at 3% of the MOH official medication budget. See Document: Medication leakage in Chad 53 •Leakage is also pronounced at the regional level, since the health centers ultimately receive about 1% of MoH non-wage expenditures. 54 •Given leakage, the main source of health center financing is user fees •Government transfers account for only 2% of health center revenues (excluding salaries) and for one-quarter of their revenues including salaries. 55 5.3 Empirical Analysis A. Impacts of Public Resources on Health Production Do public expenditures have an impact on output in the health sector, in terms of patients treated in health centers? Several studies have questioned this relationship (e.g.Filmer et al, 2000). We compare the effects of official health expenditures and effective health expenditures in regional delegations and the number of patients visiting local health centers per 1,000 inhabitants in a region (Figure 3). 56 57 Impacts of Public Resources on Health Production We examine the relationship between official vs effective resources and health services: Cl l 2 l l Where Cl is the number of patient consultations taking place annually in a region or a district l Yl is a vector of region or district characteristics, including: Official or effective health expenditures in the region or district, Number of health centers and districts, Population served, Total revenues of health centers Total salaries. 58 59 Impacts of Public Resources on Health Production Official health expenditures do not explain health output at the regional level (columns 1-3, table 9). Effective health expenditures are always positive and significant (columns 4-8) Real public expenditures have a positive impact on health output at the regional level. For a million CFAF (US$1720) of effective public expenditures received in a region, 693 more patients would receive medical consultations in primary health centers in the region (column 6). We can estimate that close to 3 million patients do not visit health centers because resources do not reach service providers. If all public resources had reached frontline providers, number of patients seeking primary health care would have doubled. 60 Empirical Analysis B. Leakage of Resources and Mark-up One possible mechanism by which actual receipt of public resources would allow better access to health services is through the reduction of user fees in particular medication prices. In Chad, medication costs account for 75% of total medical costs for patients (85% in rural areas). Most HC have a pharmacy that sells drugs to patients. Survey collected information on 11 of the main drugs allocated by the MoH to intermediate levels and HC, as well as information on medication purchase prices at regional pharmacies and sale prices to patients. Leakage of Resources and Mark-up Relationship between leakage of public expenditures and drug mark-ups using OLS with clusters by regions (Table 10, columns 1 to 4). Econometric issue: Level of competition among HC is unlikely to be exogenous Certain types of health centers are more likely to be located in certain areas. In particular, private health centers are more likely to be located in urban areas and confessional centers in rural areas. In order to obtain unbiased estimates, we have estimated simultaneous equations of the determinants of mark-up and competition, using 3SLS method (columns 5-6). Empirical Analysis Results Leakage has a negative and significant impact on the prices of medications sold by health centers. Health centers that do not receive public support tend to charge significantly higher mark-ups on medications Leakage of government resources thus appears to have a significant and negative effect on user fees and to constitute a barrier to health service access. Greater competition among HC tend to significantly reduce average mark-up on drugs and thus be favourable to users. 5.4 Conclusion Because of leakage, the official health budget bears no relation to the actual situation on the ground. Despite that 60% of MoH recurrent budget is officially allocated to regions, HC receive only about 1% of non-wage resources Although the government officially allocates 680 CFAF (US$1.17) in health expenditures for the average Chadian, that person actually receives less than 10 CFAF (US$0.02). Contrary to pessimistic views, health expenditures do in fact have a positive impact on health services. Expenditures reaching health centers have a positive and significant impact on number of patients treated. If all expenditures officially targeted to regions had actually reached HC, the number of patients treated would have doubled. Conclusion Leakage has a negative and significant impact on the prices of medications sold by health centers. Health centers that do not receive public support tend to charge significantly higher mark-ups on medications Since the beginning of the “New initiative in the context of petroleum production” in Chad, expenditures in health and other social sectors have increased but without noticeable impacts on social indicators. The low percentage of public resources actually received at the operational level could certainly explain a large part of this phenomenon. A major reform of the public management and public expenditure system is required in order for service facilities and the population in general to benefit from public resources Conclusion Because of leakage, the official health budget bears no relation to the actual situation on the ground. Despite that 60% of MoH recurrent budget is officially allocated to regions, HC receive only about 1% of non-wage resources Although the government officially allocates 680 CFAF (US$1.17) in health expenditures for the average Chadian, that person actually receives less than 10 CFAF (US$0.02). Contrary to pessimistic views, health expenditures do in fact have a positive impact on health services. Expenditures reaching health centers have a positive and significant impact on number of patients treated. If all expenditures officially targeted to regions had actually reached HC, the number of patients treated would have doubled. 68 6. Illustration: South Africa Early Childhood Development PETS/QSDS organized by UNICEF on ECD in SA: ongoing ECD presented as one of top 4 priorities of SA government Children covered in ECD programs are 0-4 years & 5-6 years (Grade R) Central government is responsible for setting policies, regulation and oversight, while 9 provincial governments are responsible for policy implementation. Two main departments involved in ECD services: Department of Social Development (DSD) and Education (DOE). DSD has main responsibilities with respect to service provision while DOE mainly responsible for training of personnel and service quality. 69 South Africa Early Childhood Development While the central government has invested important resources for ECD in the last few years, difficult to determine if translate into actual spending at the provincial or facility level given central government’s views and budgetary expenditures are only indicative. Provinces are responsible for establishing their own allocation rules and for ensuring efficiency of spending At the central level, the DSD budget transfers to provinces are done through the “Children” budget line part of an “equitable share” formula. The National treasury or central ministries have no power to earmark ECD resources at provincial level. 70 South Africa Early Childhood Development Once transfers are made to the provincial treasury, they are allocated to provincial departments. At the provincial level, the budget allocated to the DSD includes amount for the department own administrative use and another for transfers toward facilities for service delivery. Ultimately, subsidy per child at facility level varies between 4.5R and 11R Facilities receive the subsidies Parents have little information on subsidies (not made public) Provincial DSD have weak enforcement capacity. There is no roster of students who qualify for subsidies or verifications of these lists This means that possibility of leakage will occur 71 South Africa Early Childhood Development Ultimately, current coverage of ECD programs is low. Currently, only about 20% of children of 0-5 years attend ECD programs, mostly 4-5 year age group. Various factors could explain low attendance including high user fees discouraging usage, geographical access, Combined PETS/QSDS focuses on establishing baseline data on the efficiency and quality of ECD 3 provinces covered: Western Cape, North West and Limpopo Sample: About 600 facilities (200 by province) 72 South Africa Early Childhood Development PETS/QSDS of ECD: main topics Equity and efficiency challenges (across and within provinces/regions) Resource availability and use, unit costs, users’ fees, etc. Human resources at sites, characteristics, incentives, etc. Standard and norms in service provision Financial and administrative capacity of management committees/sites…etc. 73 South Africa Early Childhood Development Tracking expenditures through government system toward service delivery facilities and measuring the level of services. Baseline data collection includes information on: i) Process (i.e. inputs); ii) Intermediate outputs (e.g. enrolment levels, dropout rates) Some preliminary results: Huge differences of services access and quality across and within provinces (rural vs urban, poor vs rich communities) Within facilities: subsidized and non subsidized users pay same fees Poorest communities and households not subsidized : i.e. don’t meet minimum requirements (e.g. infrastructure) : middle-class receive transfers 74 Draft instruments and other material available South Africa Early Childhood Development 75 References Bandiera, O.,A. Prat and T. Valletti (2007) “Active and Passive Waste in Government Spending: Evidence from a Policy Experiment”, London School of Economics, April, mimeo Davoodi, H.R. and V. Tanzi (1997) “Corruption, Public Investment and Growth” IMF Working Paper 97/139, International Monetary Fund, Washington, DC. Del Monte A. and E. 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World Bank’s Survey Tools: Human Development and Public Services Research http://econ.worldbank.org/external/default/main?theSitePK=477916&contentMDK=20292627&menuPK=546432&pagePK=64168 182&piPK=64168060#PETS
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