Improve Public Services with the Support of the People

The improvement of education services and health in Africa is central to economic development of the continent. Since they are public goods, the state has been and will be absolutely central to these efforts. The development support by international donors has allowed the creation and expansion of schools and medical centers all over the African continent. However, advances have been mainly in terms of physical infrastructure. In other words: cement.

But the cement alone can really improve the indicators of education and health in Africa?

The answer is: probably not. School systems and providing functional and efficient health also require (i) well-prepared and motivated employees, and (ii) informed and cooperating populations. Both of these requirements have nothing to do with cement and is more related to something more “invisible”.

The preparation and remuneration of teachers, educational agents in general, doctors and nurses has already been an old challenge. Limitations of higher education in Africa are themselves a product of the disabled indicators of basic education and health of those countries. In short, we face a vicious cycle of poverty, which tends to remain.

We can only then try to improve the motivation and incentives of agents providers of education and health. And we can only try to increase the information and capabilities of users. This has been the focus of many recent initiatives to support the development, with strong support from the World Bank. In fact, it is possible to simultaneously improve the intrinsic motivation of teachers and nurses, and information levels of caregivers and patients. And both can have a considerable impact on the final product: the quantity and quality of service delivery in education and health.

The Community Based Development

Technically, these innovative initiatives fall into the idea of Community-driven Development. The essence of the concept is the placement of the community initiative and pressure for change from the bottom-up.

In practice, these initiatives often materialize through the Community Assessment Questionnaires (“Community Score-Cards”), the QAC. The process of QAC is typically initiated through a listening of the users about the quality of that service. This consultation usually takes the shape of a population survey. Then the results of the investigation are made public in community meetings. In each community the results of school or clinic in this community are explicitly compared with those of other communities. Action plans to address gaps in services are then outlined in these meetings in cooperation with the providers of services. These action plans are reviewed at subsequent meetings with high frequency (at least monthly).

The example of Uganda

Let’s see the results already obtained. In Uganda, the World Bank has supported these initiatives on medical posts. The procedure was as described above. A rigorous evaluation of the impact of QAC was also implemented. This review compared the communities where the QAC was conducted with control communities (much like the first but without QAC). This comparison was made only a year after the start of the QAC, i.e. one year after the submission of the questionnaire to the population, or in other words, with just a year of community meetings focused on improving the local surgery.

A year QAC these Ugandan communities decreased the mortality of newborns by 3 percentage points and the mortality of children under age 5 by 5 percentage points. It also increased the ratio of weight for age, a prime indicator of nutrition. In addition to these impressive facts about the health of the populations affected by the program, it was discovered that the QAC also increased the quantity and quality of health service provision, for example in the areas of immunization and family planning. Finally, satisfaction of service users was also improved.

Based on these results, we conclude that the pressure of population provided a strong incentive for improving the delivery of local health agents, and that the specialized information passed in community meetings strengthened health care populations. Without cement. And much cheaper than cement.

And Angola? Is this a good idea to implement in Angola? The cement is already advance. The training and deployment of teachers and nurses too. Maybe it’s time to ask for a direct support to the population: who may be more interested in education and health in the country?


Written by Pedro C. Vicente, Scientific Director of the Center NOVAFRICA and Associate Professor of Economics at the Nova School of Business and Economics