Friday, October 18, 2013

Why bureaucracy matters

This is my latest intellectual trip, especially the topic of public service delivery. It combines a lot of things I’m interested in – institution building, rule of law, making government work. I also like it because it touches on the existential question of all policy: what does government do well and how can it do this better? Where should government be involved and where not, and how can it function well where it exists? In the same way that people are starting to realize that the first rule of development should be to do no harm, I like applying this idea to all policymaking.  My current fellowship/job gives me a terrific platform to view this within the context of a developing country government.

Happily, I'm not alone here.  Chris Blattman thinks "'bureaucracy' will be the most topical development topic in five years," so I might as well get an early start.

Here’s a good passage from one of the foundational articles in this topic:
It is now widely appreciated that government failure may be as important as market failure, and the mere existence of the latter does not necessarily justify government intervention.  To the extent government intervention is called for, this does not automatically mean direct involvement of the state in economic activity and could entail indirect involvement through partnership with the private sector, and the “third sector” consisting of voluntary and community organizations.
And another:
The traditional model of state provision assumes away incentive problems, assuming that the government can stipulate and enforce a level of provision. It implicitly assumes that individuals who work in the public sector need little direct motivation to pursue the social good. Rewards therefore depended little on performance. The implicit assumption was that teachers, health care professionals and bureaucrats are publicly spirited and that this was enough. 
The article has lots of other little tidbits worthy of further exploration.  For instance:
Persson and Tabellini argue that proportional representation and parliamentary systems provide better  incentives for provision of public goods. 
Such an argument may help to explain (among other reasons) why Americans seem to get so little bang for their taxpayer dollar compared to, say, Germany.

Monday, October 14, 2013

Improving human resources in the health sector

The focus of my work conference this past week was on "how to improve human resources in the health sector."

There are several problems with human resources in Cote d'Ivoire's health system, but the main one is that there simply aren't enough people.  Not enough doctors, nurses, midwives, or health officials.  A lot of people left during the crisis this past decade, and the existing schools and training institutions are poorly equipped to fill the gap.

The schools are already overburdened and there is concern that increasing the ratio of students to teachers would decrease quality to unacceptable levels.  The Ministry of Health would like to create more schools and hire more staff for existing schools, but there are a lot of competing demands for funding.  They will probably be able to open a couple of schools and hire some more teachers, but not enough to produce the number of health sector personnel that is needed.  So what to do?

One option that was discussed is accrediting private schools to train health workers.  But a number of people were skeptical that this could work in a country of Cote d'Ivoire's level of development.  They cited recent privatizations of health training in Senegal and Benin as examples of why accrediting private institutions would not work in Cote d'Ivoire.  I was curious about the factual basis for these concerns.  Does a country need to attain a certain level of economic development or administrative sophistication before such public-private partnerships can function effectively?  Information on this topic is not easy to unearth.  The Center for Global Development discusses in a recent report on Partnerships with the Private Sector in Health:
Policies, such as those related to contracting or accreditation, that engage and influence the private sector are complex and challenging They require specialized skills and new practices built on experiences in other countries and basic principles of economics, regulation, business, and other fields The technical assistance available to public officials in developing countries, however, typically offers little support and expertise on private-sector engagement. 
The language is quite general, but it suggests that accreditation can be challenging for less experienced administrative bodies.  The opposing (libertarian) argument would be that it's unclear why the government should be so much better at creating effective schools and training institutions for health workers.  I don't yet have enough experience in developing country economies to know how strong this argument is.  On the one hand, if a private institution is churning out poor quality workers, won't hospitals and clinics stop hiring such workers?  On the other hand, I imagine the picture is much more complex than that.  From what I've seen, the Ivorian bureaucracy has a complex relationship with diplomas, trainings and other qualifications that I don't yet understand at all.  

I will revisit this question in a couple of months.  It seems that there are two main questions to be answered: 1) Could private accreditation of health worker training improve the human resources situation in Cote d'Ivoire? 2) And if so, what is the best way to institute a private accreditation program for health workers in a developing country?  This ASCP article provides some useful background on the latter question.