Improving basic health service delivery in low-income countries: ‘voice’ to the poor

doi:10.1016/S0277-9536(01)00336-7

Social Science & Medicine

Volume 54, Issue 11, June 2002, Pages 1685-1690

https://doi.org/10.1016/S0277-9536(01)00336-7 Get rights and content

Abstract

Public social services, such as basic health care, represent the effective option for the poor, especially in the rural areas of low-income countries. The quality of such services are at present extremely deficient, largely due to resource constraints and lack of political will to make them function effectively. The state can no longer provide the comprehensive services it has in the past and which were highly successful in a number of ‘high-achieving’ developing countries. Yet, the state must turn priority attention to providing public services for the poor, in order to close the widening gap between rich and poor. It needs to do this in partnership with the population it aims to reach, through effective linkage with grass-roots organizations and with the support of non-governmental organizations. Giving ‘voice’ and participation to the population can not only increase the resource base for public services, but can also significantly improve the accountability of providers and lead to a cost-effective option for the poor.

Section snippets

‘Exit’ and ‘voice’ in the health sector

This paper argues that, at the present stage of development in Africa and South Asia, the accountability of the public system of providers can best be improved through the use of voice by the public. ‘Voice’ essentially means that beneficiaries have a say in how services are run. The context is the poor quality of state-provided health services in rural areas and the relative lack of easily accessible and comparable alternative sources, together with the complexity of using alternative sources

Characteristics of health policies in high-achieving states

Voice at the macro-level can be very important as well—as shown by the cases of high-achieving countries in terms of social development. Within the last 50 years, most developing countries have made health and educational advances that took nearly two centuries in the industrialized countries. However, 10 developing countries managed to exceed the scope and pace of social development of the majority of other developing countries. Those relevant to this paper are: Sri Lanka and Kerala State

The high-achiever model—still valid?

Are the essential characteristics of these health policies still valid in the countries of South Asia and sub-Saharan Africa where a health transition has not occurred and the disease pattern is still dominated by communicable and infectious disease? The answer is an unequivocal yes, but with a difference. The answer is yes because the state remains, even in these countries, the main provider of public health services, even though private expenditures on health are considerable. The difference

The household as investor in health

In looking specifically at health, an important additional reason for re-thinking the health approach for the majority of low-income developing countries is the recognition that the household is the most important producer of health. The household is not only the environment that influences most of the health, nutrition and education of children, but is also the principal financier of services. Half of all health expenditure in developing countries, or an estimated US$85 billion yearly, comes

GROs as health service partners

In seeing how the public can effectively exercise voice in the running of health services, it is important to review their own social structures, particularly GROs. GROs and NGOs are increasingly seen as channels for promoting economic and social development, also contributing to the democratization of the economy and society (Uphoff, 1993). Here it is important to distinguish between NGOs (interested parties coming together to help others) and GROs (interested parties coming together for

Conclusions

There are a number of conclusions to make, recognizing in particular that GROs are not as yet significant actors in the development of sustainable basic services. High-achievers have emerged where the State has been a provider of universally available and affordable system of health services, financed out of government revenues, functional at the lowest level, made effective by allocating resources at the lower end of the health system pyramid. The same model is still applicable, but with some

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