GENDER ACCOUNTABILITY
SERVICES FAIL POOR WOMEN
Annette Evertzen GADE
July 2006
CONTENTS TABLE
I. Gender accountability. Services fail poor women; an overview
INTRODUCTION 2
1. MAKING SERVICES WORK FOR POOR PEOPLE 3
2. Services fail poor women 7
3. SOCIAL INCLUSION AND EMPOWERMENT 10
4. GENDER SPECIFIC PLANNING AND BUDGETING 17
5. THE INFLUENCE OF CIVIL SOCIETY 25
6. The role of donors 30
GUIDELINES FOR GENDER ACCOUNTABILITY 34
Annex 1: Policy Framework and Action Points WITH RESPECT TO EDUCATION 36
ANNEX 2: Checklist for women’s health and equity 38
References 40
II. A BIBLIOGRAPHY
INTRODUCTION
This publication deals with gender accountability, especially with regard to service delivery. It presents an overview of literature, interlarded with cases and practical examples, and is meant to inspire donors, especially members of Dutch embassies, in their work towards gender equality and women’s empowerment.
The focus of donors has shifted from the micro to the macro level, demanding new strategies with regard to gender mainstreaming. In these strategies an important role is reserved for accountability issues. Partner countries and donors can hold each other accountable in a mutual accountability process, as is embodied in the Paris Declaration, during a conference of donors and partner countries in 2005. In this declaration partner countries commit to reinforce participatory approaches, involving both parliamentarians and a broad range of development partners in national development strategies and budgets. Clients of aid, either foreign aid or internal service delivery, are not longer seen as passive clients, but as active agents, having rights on these modalities. Clients can hold service deliverers accountable.
The first chapter of this publication describes how services fail poor people, and deals with an accountability model that is developed by the World Bank: the accountability triangle. The following two chapters are dedicated to gendered public services by the inclusion of poor women and men, and to the empowerment of poor women; initiatives of the women themselves to hold persons from the powerful part of the triangle accountable. The next two chapters are dealing with the influence of the civil society and with the role of donors. The last chapter contains guidelines about gender accountability for donors.
1. MAKING SERVICES WORK FOR POOR PEOPLE
This publication focuses on gender accountability with respect to public services, mainly health and education. In this chapter is described how services fail poor people. An accountability triangle, a model developed by the World Bank, is introduced. After the summary of this model some limitations of this model, especially with respect to gender issues, are given.
Services fail poor people
The World Development Report from 2004, called Making services work for poor people, states that too often, services fail poor people — in access, in quantity, and in quality.
The report describes how services are failing poor people in four ways:
First, while governments devote about a third of their budgets to health and education, they spend very little of it on poor people — that is, on the services poor people need to improve their health and education. Public spending on health and education is typically enjoyed by the nonpoor.
Second, even when public spending can be reallocated toward poor people — say, by shifting to primary schools and clinics — the money does not always reach the frontline service provider.
Third, even if this share is increased, teachers must be present and effective at their jobs, just as doctors and nurses must provide the care that patients need. But they are often mired in a system where the incentives for effective service delivery are weak, wages may not be paid, corruption is rife, and political patronage is a way of life. Highly trained doctors seldom wish to serve in remote rural areas.
The fourth way services fail poor people is the lack of demand. Poor people often don’t send their children to school or take them to a clinic. Weak demand can also be due to cultural factors, notably gender differences. Some parents refuse to send their daughters to school. Husbands have been known to prevent their wives from going to clinics — even for deliveries. And the social distance between poor people and service providers is often a deterrent.
From their sides, poor clients encounter different problems in their access to public services.
The affordability of services
The availability of services varies dramatically across countries, but often poor people need to travel much longer distances than richer people in the same country to reach health and education services. Even when the services are free, many poor rural families cannot afford the time it takes to travel the distance to the nearest primary school or to the nearest medical facility.
Another problem is the limited opening hours in public facilities or the absence of teachers in schools or health providers. These opening hours (only in the morning in farm communities, for example) are often not adapted to the possibilities of poor people. Poor people spend a greater part of their money on services, and poor people often need to pay more for the same goods (water, for example). Another problem encountered is corruption in various forms. Teachers might solicit bribes to admit students or give better grades, or they might teach poorly to increase the demand for private tuition after hours. “Free” public services are often very expensive.
The poor also lack insurance for expensive services, and therefore resort to informal moneylenders who charge very high interest rates.
The quality of services.
In low- and middle-income countries alike, if services are available at all they are often of low quality, especially in remote or poor areas. The more skilled the workers, the less likely they are to accept a job as a teacher or a health worker in a remote area. For example, health workers with low skills give the wrong medical advice or procedure, or schools use ineffective teaching methods. The quality of services also depends from the right materials — books in schools, drugs in clinics.
The provider’s behaviour
Services also fail in the interaction between provider and client. The provider’s behaviour is not always respectful, especially women and ethnic minorities are too often discriminated in their interaction with providers of services. The “social distance” between providers and their clients can be large.
Discrimination and social distance are barriers to services even when the services are free.
A triangle of accountability
The World Development Report means by accountability a relationship among actors that has five features: delegation, finance, performance, information about performance, and enforceability
In buying a sandwich you ask for it (delegation) and pay for it (finance). The sandwich is made for you (performance). You eat the sandwich (which generates relevant information about its quality). And you then choose to buy or not buy a sandwich another day (enforceability), affecting the profits of the seller.
In a city the citizens choose an executive to manage the tasks of the municipality (delegation), including tax and budget decisions (finance). The executive acts, often in ways that involve the executive in relationships of accountability with others (performance). Voters then assess the executive’s performance based on their experience and information. And they act to control the executive — either politically or legally (enforceability).
Weaknesses in any aspect of accountability can cause failure. One cannot strengthen enforceability — holding providers responsible for outputs and outcomes — in isolation. If providers do not receive clear delegation, precisely specifying the desired objectives, increasing enforceability is unfair and ineffective. If providers are not given adequate resources, holding them accountable for poor outcomes is again unfair and ineffective.
The Report distinguishes a triangle of accountability relationships, with the following roles:
• Citizens/clients: patients, students, parents, voters.
• Politicians/policymakers: prime ministers, presidents, parliamentarians, mayors, ministers of finance, health, education.
• Providers: organizational providers like health departments, education departments, water and sanitation departments, and frontline professionals like doctors, nurses, teachers, engineers.
Source: World Development Report 2004.
In the ideal situation these actors are linked in relationships of power and accountability. Citizens exercise voice over politicians. Policymakers have compacts with organizational providers. Organizations manage frontline providers. And clients exercise client power through interactions with frontline providers. In low-income countries a fifth role, played by external finance agencies, affects each of these relationships.
The Report states that to make services work for the poor, accountability has to be strengthened in three key relationships in the service delivery chain: between policymakers and poor people, between policymakers and providers, and between providers and their clients.
§ Of politicians to citizens: voice and politics.
For poor people the only routine interaction with the state may be at the delivery point of services.
Public services often become the currency of political patronage and clientelism. Politicians give “phantom” jobs to teachers and doctors, or they build free public schools and clinics in areas where their supporters live.
The Report uses the term voice to express the complex relationships of accountability between citizens and politicians. The voice relationship includes formal political mechanisms (political parties and elections) and informal ones (advocacy groups and public information campaigns).
The citizen policymaker link is working either when citizens can hold policymakers accountable for public services that benefit the poor or when the policymaker cares about the health and education of poor people. These politics are “pro-poor.”
When elections are not enough to make services work for poor people, political pressure builds for new approaches that enable citizens to hold politicians and policymakers more directly accountable for services. The rapid growth of citizen initiatives has been described as a new accountability agenda.
Enthusiasm for direct citizen involvement comes from mounting frustration with the dominant mode of a national civil service delivering services that meet some technically predetermined “needs” of the population. Two separate trends are discernible in citizen voice initiatives: activities based on consultation, dialogue, and information sharing, and activities more direct and controversial, related to monitoring, compliance, and auditing.
One of the most powerful means of increasing the voice of poor citizens in policymaking is better information. Citizens need information about how actions of the state have promoted their well-being. But information is not enough. Accountability must have the quality of answerability (the right to receive relevant information and explanation for actions), and enforceability (the right to impose sanctions if the information or rationale is deemed inappropriate). Voice only is not sufficient for accountability; it may lead to answerability but it does not necessarily lead to enforceability. Citizens need some mechanism for enforceability, to make sure politicians and policymakers are rewarded for good actions and penalized for bad ones.
Voice is only one part of accountability. The impact on services depends also on the compact relationship between policymakers and providers. Even strong voice may fail to make basic services work for poor people because the compact is weak.
§ Of the organizational provider to the state: compacts.
The relationships between policymakers and service providers can be thought of as compacts: a broad agreement about a long-term relationship, whereby the provider agrees to deliver a service, in return for being rewarded or penalized depending on performance. Enforceability comes into play when the compact also specifies the rewards (and possibly the penalties) that depend on the service provider’s actions and outputs. The compact may be an explicit contract with a private or non-profit organization, or it could be implicit, as in the employment agreements of civil servants.
Since the contract cannot be fully specified, policymakers look to other means of eliciting pro-poor services from providers. One way is to choose appropriate providers who have an intrinsic motivation to serve the poor. Another way is to increase incentives to serve the poor or work in underserved areas. A third way is to solicit bids or services and use the competition in the bidding process to monitor and discipline providers
Generating and disseminating information are powerful ways of improving service delivery. Good information on the actions of providers and the outcomes of those actions must get to the policymaker. And remuneration must be tied as closely to these outcomes as possible. Separating the policymaker from the provider organization also helps to increase the accountability of providers.
§ Of the provider to the citizen-client: client power.
Because the policymaker cannot specify all actions of providers in the compact, or they just don’t care about the outcomes, citizens must reveal to providers their demand for services and monitor the providers’ provision of services. In systems that lack accountability relationships, public service jobs (teachers, policemen) are given as political favours. Services are allocated in ways that reward (or punish) communities for their political support. This system of clientelism creates a relationship not of accountability but of political obligation.
When services are failing the poor, clients can play two roles in strengthening service delivery.
First, for many services, clients can help tailor the service to their needs. Second, clients can be effective monitors of providers, since they are at the point of service delivery. Clients are usually in a better position to see what is going on than most supervisors in government hierarchies. Improvements in basic education have often depended on participation by parents. Although parents cannot monitor all aspects of education, they can monitor attendance by teachers and even illiterate parents can tell if their children are learning to read and write.
Public policy can help poor people acquire better services by expanding the choice of providers. Female patients who feel more comfortable with female doctors can go to one. The competition created by client choice also disciplines providers. When there is no choice of providers, increasing poor people’s participation in service provision can achieve similar results. Governments can expand consumer power by giving them the ability to monitor and discipline the provider and establishing procedures to make sure complaints are acted on.
Improving services means making the interests of poor people matter more to providers. The services have to be tailored to their needs and clients have to participate actively. Empowerment, increasing consumer power through participation, is a key concept.