Africa continues to face many challenges in achieving its development goals, and it is unlikely that many of the countries in Sub-Saharan Africa will be able to meet the Millennium Development Goals (MDGs) by 2015 as expected. The failure to meet the MDGs is due in part to the limited amount of resources that are devoted to delivering social services such as education and health. Resources are necessary to build schools and health clinics, train and hire qualified service providers, and equip the schools and clinics with the essential learning materials for schools and drugs for health clinics. However, resources represent just one challenge that is not necessarily the most important. Recent evidence suggests that a crucial explanation for the poor human development outcomes is the poor governance in the delivery of social services.


A common response to accelerating the pace of human development has been to call for more resources. Donor countries especially have been called on to support poor countries in delivering social services more effectively and to more of their people. But while it is crucial for more developed partners to honor their commitments, it is not reasonable to expect them to donate significantly more resources over the next two years, given that many of their economies are still experiencing slow recovery after the global economic and financial crisis. But improvement on the MDGs is still possible, and it does not necessarily require more resources to make additional gains. In fact, evidence shows that there is only a weak connection between more resources and improved delivery of essential public services like healthcare and education. Thus, increasing resources without implementing reforms in the systems of service delivery may not boost the MDGs progress trajectory at all.

A large volume of empirical evidence suggests that the most important barrier to progress in the MDGs is weak accountability in service delivery. When providers and policymakers are not held accountable by the citizens, resources made available to deliver public services do not translate into desired outcomes. Instead, service providers engage in activities that better serve their own interests, often at the expense of the citizens. One of the most direct manifestations of this is the leakage of resources: a large fraction of resources meant to procure drugs and materials for clinics or books for schools are siphoned by bureaucrats for their own use. The outcome of such leakages is obvious—a lower quality and quantity of goods and services are made available to those who should be benefiting from them. Such behaviors have greatly undermined the achievement of the MDGs.


The other dimension of weak accountability is reflected by low provider effort. The manifestations of this aspect are shocking in many developing countries, particularly in Sub-Saharan Africa. Teachers and nurses do not show up for work, are not present in the appropriate areas when they are at work, or do not provide the services that they should be while they are there. Because they are not held accountable, they may even be abusive to the clients they are supposed to be helping. Thus, visiting service facilities can be an agonizing process for many people, and is characterized by poor service delivery, delays and long wait lines. Moreover, while the failure of accountability in service delivery is detrimental to most of society, it is especially detrimental to the poor, who are disproportionately dependent on government assistance, are the most likely victims, and are least able to rebound from its effects. The poor often have no alternatives if they are denied medical treatment or a quality education. In addition to the fact that the poor have limited exit options from the publicly provided services, they also have limited capacity to hold the providers accountable.

We report on some recent data on service delivery in the health and education sectors in two African countries, Tanzania and Senegal, and on education only in Kenya. The results are based on recent surveys coordinated by one of the authors of this essay under the auspices of the African Economic Research Consortium and the World Bank. The focus is on social service delivery and specifically the delivery of primary education and also basic health care, which are considered critical aspects to human development. The surveys focus on service delivery failures associated with absenteeism, low-provider effort and leakage of resources. These are aspects of service delivery for which the providers have a fair degree of discretion and are thus susceptible to abuse. When providers are absent from work or do not put in the effort required, clients do not access the quantity and quality of services they are expected to receive. Likewise, resource leakages imply that the resource meant to finance the services are used to benefit public officials instead of the clients. These measures are meant to be “report cards” on the delivery of services as experienced by the clients. Having such an assessment is a crucial first step in improving service delivery outcomes for millions of people in Africa and the developing world.



Service Delivery Indicators

One of the most glaring pieces of evidence of poor service delivery in Africa is the poor learning outcome in primary schools. The data of the primary school enrollment MDG shows that there has been remarkable progress in getting children to schools; in fact many countries are on track to achieving this goal. Unfortunately, however, while children are going to school, the quality of learning is extremely low and does not measure up to expectations. For example, survey data from 150 primary schools in




Senegal, 180 in Tanzania and 300 in Kenya revealed that performance of pupils was generally poor (although not uniformly so). For example, while 86 percent of Kenyan fourth graders could read a basic sentence, only 33 percent and 6 percent of Senegalese and Tanzanian children in the same grade were able to do the same. Also striking was the fact that 8 percent of Kenyan children, 14 percent of Senegalese children and 17 percent of Tanzanian children were unable to calculate the sum of two single-digit numbers.

These results do not represent isolated cases. Poor learning outcomes are evidenced in many other countries, as demonstrated by the Brookings Institution’s Africa Learning Barometer. This is an interactive tool that was created by the Center for Universal Education at Brookings and This is Africa, which is a part of the Financial Times. The Barometer displays visualizations on metrics such as school enrollment and graduation rates, and levels of educational quality. The question then is why the children enrolled in schools are not learning. The answer is provided in part by three problems, the most serious of which is teacher absenteeism. Absenteeism is defined as the share of teachers who should be in school on a particular day but do not show up. Data on provider absenteeism collected through unannounced school visits found high rates of absenteeism: 23 percent in Tanzania, 18 percent in Senegal and 15 percent in Kenya. Teacher absenteeism in African countries compare dismally with those of the United States, where teacher absenteeism is, on average, 5.3 percent. Furthermore, it is important to note that in the United States, teacher substitutes are engaged to cover for absent teachers.


The other factor that contributes to poor learning outcomes is the low-effort among teachers: The survey results revealed that, even when teachers showed up for work, they were not in the classroom 53 percent, 42 percent, and 29 percent of the time in Tanzania, Kenya, and Senegal, respectively. Thus, being present in school does not mean that teachers are actually teaching. The combined effect of teachers being absent from school and also in class translates to a very low number of hours during which pupils are being taught. Based on the survey results, on average children were being taught for three hours and 15 minutes in Senegal, two hours and 40 minutes in Kenya, and two hours and four minutes in Tanzania every school day. Making matters worse, many of the teachers were not adequately prepared to teach their material. 52 percent of the teachers in Senegal, 42 percent of the teachers in Tanzania, and 33 percent of the teachers in Kenya lacked the requisite knowledge and understanding of the subjects they taught.


The third problem impacting learning outcomes is that of resource leakage. Ordinarily, resources that are meant to go to schools pass through various administrative levels: from the central government ministry to the Provincial and District levels, and eventually to the provider facilities. In the process of this flow, resources are lost through bureaucratic manipulation and irregular expenditures. The implication of resource leakages is that although a country may record high levels of resources allocated to primary schools, only a fraction of the resources may actually reach the intended beneficiaries. The survey results revealed that in Tanzania, 37 percent of a capitation grant intended for the purchase of school supplies was leaked and thus on average schools received only 63 percent of the intended allocation. Previous studies found resource leakage rates in healthcare to be 38 percent in Kenya and 70 percent in Uganda. One consequence of this form of corruption is that the materials used for instruction are often lacking and the physical conditions of the classrooms are often not conducive to learning. A scant 16 percent and 3 percent of schools in Senegal and Tanzania had access to electricity, improved sanitation, and clean water. Only 73 percent of Kenyan schools have clean toilets. Textbooks are scarce: there are 2.5 textbooks per student in Senegal, roughly one textbook per student in Tanzania, and one textbook for every three students in Kenya. Although we cannot attribute the poor state of facilities entirely to the leakage of the resources, it is apparent that such leakage does indeed contribute to a poor learning environment.

The study in Tanzania and Senegal also included an examination of the health sector in those countries, surveying roughly 150 medical facilities in Senegal and 175 facilities in Tanzania. The findings from these surveys are consistent with the results on the delivery of education services discussed above and are equally discouraging. Staff absenteeism was rampant: approximately one-fifth of medical workers from the two countries were absent during an unannounced spot check. Observed levels of effort were low: most of a clinician’s days are not spent counseling patients. On average, a clinician counsels patients for only 39 minutes a day in Senegal and 29 minutes a day in Tanzania. In essence, provision of medical services is characterized by very low provider effort. Although the cited study does not have data on the leakage of resources in the provision of medical care, it does have figures on the expenditure on primary health care which do reach the level of the clinic (on a per capita basis.) In Tanzania this figure is roughly US$7—for Senegal, it is US$1.78.

Compounding the failures due to provider absenteeism and low effort, the surveys also revealed that medical staff is under-skilled. In a simulation in which they were asked to diagnose patients complaining of particular symptoms, a correct diagnoses was ascertained 57 percent of the time in Tanzania and only 34 percent of time in Senegal. Alarmingly, only about a third of the clinicians in both countries are able to diagnose the often fatal disease of diarrhea. Finally, the poor infrastructure acerbates service delivery failures. Only about 40 percent of the facilities in Senegal have electricity, as well as clean water and sanitation facilities; about half that number had these essential infrastructures in Tanzania. Only 78 percent of clinics in Tanzania and 53 percent of clinics in Senegal have basic medical equipment like a thermometer or a stethoscope.

The results from these studies are in line with those of previous studies that have investigated service delivery in Africa and other developing areas. For instance, a 2005 study found absentee rates of 27 percent in primary schools and 37 percent in primary health centers in Uganda. The same study also found that only about 45 percent of teachers in India were actually teaching even though they were not absent. This means that just because teachers report for work, it does not necessarily imply that they teach when they are expected to be in class. Many times they are in school but absent from class when they are supposed to be teaching.


Institutional Failures and Poor Service Delivery

The evidence discussed above suggests that there are serious problems with the institutions of service delivery in developing countries. The massive resource leakages, high levels of provider absenteeism, and low effort have detrimental effects on the quantity and quality of services that the client, especially the poor, receives. Specifically, there are widespread accountability failures across the service delivery chain. This can be shown by looking at a simple framework of service delivery where several agents interact: policymakers, providers, and the client/citizen.


Policymakers allocate the state’s resources for particular services and make these resources available to the providers. The expectation is then that the policymakers will follow up with the providers to make sure that they deliver the services to the poor—in other words, the providers should be accountable to the policymakers. Service providers include school administrators, teachers, doctors, nurses, etc. The providers are the ones that interact directly with the clients and are expected to be also accountable to the clients by providing services as expected. But the policymaker should also be accountable to the providers by honoring agreements between the two: pay salaries and do so in time, provide logistical support, training, etc. The final group of actors are the clients or citizens who are supposed to receive the services and include students, medical patients, and, in a broad sense, taxpayers. In this framework, the clients/citizens should also be able to hold the policymakers and providers accountable. We look at these accountability relationships in more detail below.

Clients and Policy Makers

Occasionally referred to as the ‘long route’ of accountability, clients should hold their elected officials responsible for service delivery—what is referred to as voice. In fact, the idea that a population rewards or punishes its officials through elections is the basis of democratic theory. However, there are preconditions that must be satisfied in order for the system to work well. For one, the power of the political incumbency cannot be too strong; at a minimum, free and fair elections must be held. Secondly, there must be credible opposition parties that offer a distinct alternative to the policies of the incumbency. And thirdly, voters must vote based on service delivery performance, as opposed to voting along ethnic lines or for other reasons. It is difficult for accountability to flourish when one or more of these conditions are not satisfied. The service delivery failures observed above suggest that the accountability relationship between the clients and policymakers are weak—clients are not able to effectively hold the policymakers accountable. Thus, even when the clients do not receive the services due to them, they are not able to compel the policymakers to reprimand the providers.


Service Providers and Policy Makers

Policymakers must be able to hold service providers responsible for their actions. When such accountability breaks down, teachers and medical workers, despite being absent, incompetent, and/or engaging in larcenous behav- iors, are not fired, or even, in many cases, reprimanded. One general reason for this lack of accountability has to do with political power. In many countries, teachers and their unions exert influence over and in some extreme cases, have “captured” so much institutional power that they can effectively block any reforms they disagree with. A case study from Uganda illustrates this problem: the Ministry of Education proposed a reform that would allow school principals to devise performance goals to be achieved within a two year time-frame. Head teachers would then sign a contract with the local government, which stated that not achieving these goals were grounds for demotion or transfer. Despite the fact that the principals were to establish these targets themselves, the proposal was blocked by the teachers’ union in the country, which argued that the penalties were too stringent. In essence, the countervailing power of providers appears to be one reason for the poor accountability in service delivery in Africa.


Service Providers and Clients

Finally, clients need to hold service providers responsible for their performance—which is sometimes referred to as the “short route” of accountability or simply, client power. In order to engage in this type of collective action, clients need information to be broadly disseminated. Parents need to know how often their child’s teacher is absent for instance, or how much the school district should be receiving in state-allocated funds. A study that evaluated a newspaper campaign in Uganda that made available information regarding a large education grant that was disbursed in a monthly transfer to various school districts revealed that when armed with such information, citizens were able to monitor local officials and pressure the educational system to improve. As a consequence, there was less leakage of funds, higher school enrollment rates, and better student outcomes.

The foregoing discussion demonstrates the importance of good governance in the delivery of public services. Failure of accountability implies that both policymakers and citizens do not effectively monitor and censure providers for poor performance. Likewise, the citizens are not able to punish the policymakers for service delivery failures. It is because of such weak accountability relationships that primarily explains the poor state of service delivery.


Conclusion

There is no doubt that accelerating the pace of human development in Africa would require additional commitment of resources to deliver education and health services. However, more resources do not necessarily imply that the quantity and quality of services will improve. Even with the resources currently available, social service delivery could be enhanced if there were improvements in accountability. We have demonstrated that poor service delivery is in part due to weak accountability along the service delivery chain—policy-makers, service providers, and clients do not hold each other sufficiently responsible for high absenteeism, low-effort, and leakage of resources. Additional resources are therefore unlikely to result in major changes in terms of quality and quantity of resources unless there are institutional reforms that strengthen the accountability relationships. If the African countries are to make major advances in meeting the MDGs, they must focus on improving accountability in social service delivery.