39778 Opportunities TO IMPROVE SOCIAL SERVICES Human Development in the Pacific Islands The World Bank Human Development Sector Unit East Asia and Pacific Region Opportunities TO IMPROVE SOCIAL SERVICES Human Development in the Pacific Islands The World Bank Human Development Sector Unit East Asia and Pacific Region Contents Executive Summary................................................................................................................................................. I Chapter 1: Human Development in the Pacific.................................................................................................1 Background.and.Motivation.......................................................................................................................................1 Challenges.to.Delivering.Social.Services.in.the.Pacific.............................................................................................2 Framework,.Methodology.and.Outline.of.the.Report..............................................................................................6 Chapter 2: Social Outcomes and Service Delivery - Where Does the Pacific Stand?.................................9 Progress.Toward.the.Millennium.Development.Goals.............................................................................................9 Education.................................................................................................................................................................. 11 Health....................................................................................................................................................................... 12 Inequities.by.Socioeconomic.Status........................................................................................................................ 14 Social.Protection...................................................................................................................................................... 16 Human.Development.Agenda.in.the.Pacific........................................................................................................... 18 Chapter 3: Resources for the Social Sectors and their Effectiveness........................................................ 19 Public.Spending.on.Social.Sector.Services.............................................................................................................. 19 Governments.and.Donors.are.Spending.with.Mixed.Results................................................................................ 22 Government.Effectiveness,.Resource.Effectiveness,.and.Social.Outcomes.......................................................... 25 Chapter 4: Improving Education Performance.............................................................................................. 27 Performance.Issues.in.Pacific.Education................................................................................................................ 28 Options.to.Improve.Education.Performance.......................................................................................................... 34 Improving.School.Completion.and.Learning.Outcomes........................................................................................ 34 Management.Options.to.Improve.Quality.of.Education.Services........................................................................ 35 Governance.Options.to.Improve.Education.Quality.............................................................................................. 40 Improving.Equity:.Alleviating.Constraints.on.Poor.and.Vulnerable.People's.Participation.in.Education.......... 43 Strategic.Options.for.Education.Sector.................................................................................................................. 46 Chapter 5: Improving Health Sector Performance....................................................................................... 49 Performance.Issues.in.Pacific.Health...................................................................................................................... 50 Capacity.Constraints.or.Management.Challenges?............................................................................................... 53 Expanding.Service.Capacities.in.Pacific.Health.Systems....................................................................................... 53 Health.Service.Management.in.the.Pacific............................................................................................................. 55 Governance.over.the.Health.System....................................................................................................................... 60 Health.Sector.Strategic.Choices.for.the.Pacific....................................................................................................... 68 Chapter 6: Managing Social Risk....................................................................................................................... 71 Social.Risks.in.the.Pacific......................................................................................................................................... 73 Government.Systems.for.Managing.Macroeconomic.Risks.................................................................................. 78 Government.Programs.to.Help.Manage.Household.Risks.................................................................................... 78 Social.Protection.Strategic.Choices.in.the.Pacific................................................................................................... 83 Chapter 7: Managing Donor Resources............................................................................................................ 89 Patterns.of.Assistance.............................................................................................................................................. 89 Strategic.and.Policy.Alignments.............................................................................................................................. 92 Opportunities.for.Better.Donor.Alignment........................................................................................................... 95 Chapter 8: Moving Forward - New Directions for Human Development................................................. 97 Setting.National.Priorities....................................................................................................................................... 98 Regional.Policy.Actions.......................................................................................................................................... 101 Notes....................................................................................................................................................................... 104 Background.Papers.Prepared.for.the.Study.......................................................................................................... 108 Tables TABLE.11:.. PACIFIC.COuNTRy.CHARACTERISTICS.............................................................................................................................. 3 TABLE.12:.. POPuLATION,.GDP,.AND.INEQuALITy............................................................................................................................... 4 TABLE.13:.. IMMIGRATION.ACCESS.TO.DONOR.COuNTRIES.............................................................................................................. 5 TABLE.21:.. KEy.EDuCATION.INDICATORS.AND.PROSPECTS.FOR.REACHING.THE.MILLENNIuM. . DEVELOPMENT.GOALS.By.2015,.RECENT.yEARS..........................................................................................................11 TABLE.22:.. KEy.HEALTH.INDICATORS,.RECENT.yEARS....................................................................................................................14 TABLE.31:.. PACIFIC.ISLAND.COuNTRIES.SPEND.A.SuBSTANTIAL.SHARE.OF.THEIR.PuBLIC.RESOuRCES.. . ON.HEALTH.AND.EDuCATION.SECTORS.(19972003)...................................................................................................20 TABLE.32:.. TOTAL.RESOuRCES.PER.CAPITA.FOR.EDuCATION.AND.HEALTH,.19972003...........................................................21 TABLE.33:.. EFFECTIVENESS.OF.INCREASE.IN.PuBLIC.EDuCATION.SPENDING............................................................................25 TABLE.41:.. SCHOOL.STRuCTuRE.AND.AGE.GROuP.By.COuNTRy..................................................................................................31 TABLE.42:.. GROSS.SECONDARy.ENROLLMENT.RATES.IN.THE.PACIFIC.COMPARED.wITH.OTHER.ISLAND.ECONOMIES...31 TABLE.43:.. INTERNATIONAL.COMPARISONS.OF.PuBLIC.ExPENDITuRE.PER.STuDENT.AS.A.. . PERCENTAGE.OF.PER.CAPITA.GDP....................................................................................................................................35 TABLE.44:.. DISTRIBuTION.OF.RECuRRENT.ExPENDITuRE.ON.PRIMARy.AND.SECONDARy.EDuCATION.. . BETwEEN.SALARIES.AND.OPERATING.ExPENDITuRE.................................................................................................36 TABLE.51:.. POPuLATION.GROwTH,.TOTAL.FERTILITy.RATE.AND.uRBAN.POPuLATION..........................................................50 TABLE.52:.. TB.AND.LEPROSy.PREVALENCE.IN.THE.PACIFIC............................................................................................................51 TABLE.53:.. PuBLIC.HEALTH.FACILITIES.By.TyPE...............................................................................................................................53 TABLE.54:.. TyPICAL.STRuCTuRE.OF.A.HEALTH.SERVICE.IN.THE.PACIFIC....................................................................................54 TABLE.55:.. DISTRIBuTION.OF.RECuRRENT.GOVERNMENT.HEALTH.ExPENDITuRES...............................................................56 TABLE.61:.. OPTIONS.FOR.IMPROVING.SOCIAL.PROTECTION.IN.THE.PACIFIC............................................................................85 TABLE.81: SECTORAL.MANAGEMENT:.CHOICES,.ISSuES,.AND.ACTIONS...................................................................................100 TABLE.82:.. GOVERNANCE:.POLICy.LEVERS,.PERFORMANCE.ISSuES.AND.POLICy.ACTIONS..................................................101 Figures FIGuRE.11:..yOuTH.(1524.yEARS).IN.THE.PACIFIC.............................................................................................................................. 4 FIGuRE.21:..PERCENT.DEVIATION.BETwEEN.PREDICTED.AND.ACTuAL.VALuES.FOR.SOCIAL.OuTCOME.INDICATORS.......10 FIGuRE.22:..CHILDREN.NEVER.ENROLLED.IN.SCHOOL.AND.SCHOOL.DROP.OuTS......................................................................12 FIGuRE.23:..uNDERFIVE.MORTALITy.RATES.AND.PROSPECTS.FOR.ACHIEVING.MDG.TARGET.IN.2015.(19902000)...........12 FIGuRE.24:..TOTAL.FERTILITy.RATES.ARE.DECLINING,.BuT.THE.DECLINE.IS.LOwER.AMONG.wOMEN.. . IN.THE.LOwEST.wEALTH.QuINTILES.(19852000).......................................................................................................13 FIGuRE.25:..INCIDENCE.OF.HIV/AIDS.IS.STILL.LOw,.BuT.RISING.(1997.AND.2005).....................................................................14 FIGuRE.26:..CHILDREN.FROM.wEALTHy.FAMILIES.ARE.MORE.LIKELy.TO.REACH.SECONDARy.SCHOOL...............................15 FIGuRE.27:..OuT.OF.SCHOOL.CHILDREN.COME.FROM.POOR.HOuSEHOLDS................................................................................16 FIGuRE.28:..yOuTH.uNEMPLOyMENT.RATES.ARE.HIGH.IN.SOME.COuNTRIES...........................................................................17 FIGuRE.29:..DISABILITy.IN.THE.PACIFIC...............................................................................................................................................18 FIGuRE.31:..THE.ASSOCIATION.BETwEEN.PuBLIC.SPENDING.ON.HEALTH.AND.EDuCATION.AND.. . OuTCOMES.IN.THESE.TwO.SECTORS..AFTER.CONTROLLING.FOR.NATIONAL.INCOME.­.IS.wEAK...................23 FIGuRE.41:..EDuCATIONAL.ATTAINMENT.OF.DISABLED.AND.NONDISABLED.PEOPLE.............................................................29 FIGuRE.42:..RETENTION.RATES.IN.MICRONESIA................................................................................................................................29 FIGuRE.43:..PRIMARy.SCHOOL.PuPIL.TEACHER.RATIOS.IN.THE.PACIFIC......................................................................................37 FIGuRE.51:..PREVALENCE.OF.DIABETES.MELLITuS,.POPuLATION.AGES.2079.(PERCENT)........................................................52 FIGuRE.52:..SMOKING.PREVALENCE......................................................................................................................................................52 FIGuRE.61:..RELATIVE.VuLNERABILITy.TO.NATuRAL.SHOCKS.AND.CLIMATIC.VOLATILITy.....................................................74 FIGuRE.62:..RATIO.OF.NDI.PER.CAPITA.TO.GDP.PER.CAPITA.IN.SELECTED.SMALL.COuNTRIES................................................75 FIGuRE.63:..MALE.JOBLESSNESS.IN.THE.PACIFIC.REGION................................................................................................................76 FIGuRE.64:..POVERTy.HEADCOuNT.RATIO.By.SOuRCES.OF.HOuSEHOLD.INCOME.(TONGA)...................................................80 FIGuRE.65:..COPRA.SuBSIDy.PROGRAM.AND.SELFTARGETING.IN.KIRIBATI.(1999)....................................................................82 FIGuRE.71:..POST.SECONDARy.ASSISTANCE.AS.A.PROPORTION.OF.TOTAL.EDuCATION.ASSISTANCE.....................................90 FIGuRE.72:..AVERAGE.PROJECT.SIzE,.NuMBER.OF.PROJECTS.By.SECTOR.AND.COuNTRy,.19972003....................................91 FIGuRE.73:..TOTAL.DONOR.PROJECTS.By.SECTOR,.19972003.........................................................................................................91 FIGuRE.74:..PROGRAMMATIC.SuPPORT:.BuILDING.BLOCKS.OF.A.COMMON.FINANCING.AND.POLICy.FRAMEwORK.........93 Boxes BOx.31:. KAuFMANN,.KRAAy.AND.zOIDOLOBATON.(KKz).AGGREGATE.GOVERNANCE.INDICATORS..............................24 BOx.41:. SOME.FINDINGS.FROM.THE.PILL.TEST...........................................................................................................................30 BOx.42:. COuNTRy.ExAMPLES.FOR.SCHOOL.ATTENDANCE.By.wEALTH.QuINTILE.AND.TyPE.OF.SCHOOL....................33 BOx.43:. SETTING.SCHOOL.STANDARDS.­.PACIFIC.ExAMPLES...................................................................................................38 BOx.44:. COMMuNITy.SECONDARy.SCHOOLS.IN.SOLOMON.ISLANDS....................................................................................39 BOx.45:. A.SCHOOL.GRANTS.PROGRAM.IN.TONGA......................................................................................................................41 BOx.46:. MANAGING.TEACHER.ATTENDANCE.IN.KOSRAE.STATE.(FSM)...................................................................................42 BOx.47:. EMPOwERMENT.OF.PEOPLE.wITH.DISABILITIES.IN.SAMOA.....................................................................................44 BOx.48:. CONDITIONAL.CASH.TRANSFERS....................................................................................................................................45 BOx.51:.. COuNTRIES.SPEND.LITTLE.ON.PREVENTION.AND.EARLy.TREATMENT.OF.DIABETES..........................................57 BOx.52:.. IMPROVING.DIABETES.CARE.IN.RuRAL.AND.REMOTE.AREAS....................................................................................58 BOx.53:.. POOLED.PHARMACEuTICAL.PROCuREMENT.IN.THE.EASTERN.CARIBBEAN..........................................................60 BOx.54:.. DELEGATION.OF.PuBLIC.SERVICES.TO.LOCAL.LEVELS:.THE.CASE.OF.FIJI...............................................................61 BOx.55:.. CONTRACTING.wITH.NGOS.IN.CAMBODIA....................................................................................................................62 BOx.56:.. NEw.zEALAND'S.MEDICAL.TREATMENT.SCHEME........................................................................................................65 BOx.57:.. INCENTIVES.FOR.HEALTHy.BEHAVIOR...........................................................................................................................67 BOx.58:.. HEALTH.EDuCATION.THROuGH.COMMuNITy.AND.PATIENT.PARTICIPATION.­.THE.ExAMPLE.OF.FSM..........68 BOx.61:.. THE.MATAI.SySTEM.IN.SAMOA.........................................................................................................................................73 BOx.62:.. THE.wAVE.SuRVEy.OF.DOMESTIC.VIOLENCE.IN.THE.REPuBLIC.OF.MARSHALL.ISLANDS...................................77 BOx.71:.. THE.TONGA.EDuCATION.SuPPORT.PROJECT................................................................................................................94 BOx.72:.. RESOuRCES.AND.COORDINATION.FOR.PRIMARy.EDuCATION.IN.VANuATu..........................................................96 BOx.81:.. LESSONS.AND.MECHANISMS.FOR.PACIFIC.REGIONALISM........................................................................................102 This.is.the.final.report.of.the.Pacific.Human.Development.Review.conducted.by.the.world. Bank.in.conjunction.with.the.governments.of.the.Pacific.member.countries..The.report.was. prepared.by.a.team.led.by.Rekha.Menon.and.comprised.of.Christopher.Chamberlin,.Ian. Collingwood,.Sue.Dawson,.Jean.Fares,.Rapti.Goonesekere.and.Naoko.Ohno..The.task.was. managed.by.Rekha.Menon.and.Ian.Collingwood.under.the.management.of.Christopher. J.. Thomas,. Sector. Manager,. Education,. East. Asia. and. Pacific,. Emmanuel. Jimenez. and. Tamar.Manuelyan.Atinc,.Sector.Director,.Human.Development.unit,.East.Asia.and.Pacific,. and.Country.Director.xian.zhu..Sectoral.oversight.was.provided.by.Fadia.Saadah,.Sector. Manager,.Health,.Nutrition.and.Population,.EASHD.and.Ana.Revenga,.Manager,.Social. Protection.Cluster,.EASHD..Peer.reviewers.for.the.study.were.Deon.Filmer,.Annexte.Dixon,. Laurie. Dunn,. Philip. O'Keefe. and. Elisabeth. Huybens.. Eldaw. Suliman. and. Eiji. Mangyo. provided.statistical.assistance..Naoko.Ohno.provided.research.support..Dorothy.N..Judkins. and.Jane.Millicent.Sprouster.provided.editorial.assistance..Editorial.advice.was.provided.by. Fiona.Mackintosh..The.team.would.like.to.thank.Christopher.Bleakley.and.Elisabeth.Jane. Mealey.for.their.comments.and.support..The.team.would.like.to.thank.the.governments. of.the.Pacific.for.their.support.and.collaboration.during.the.preparation.of.the.study..The. team.also.benefited.from.discussions.with.Maris.O'Rourke,.Laurie.Dunn.(AusAID),.Linda. Petersen.(uNDP),.Ron.Duncan.(uSP),.Dr.wame.Baravilala.(ex-Dean,.Fiji.School.of.Medicine). and.our.development.partners.uS.Government.DOI,.AusAID,.NzAID,.JICA,.ADB,.wHO,. uNDP.and.uNESCO.among.others. Acronyms and Abbreviations ADB. Asian.Development.Bank APQN. Asia-Pacific.Quality.Network AusAID. Australian.Agency.for.International.Development EC. European.Commission EMIS. Education.Management.Information.System ESIRP. Education.Sector.Investment.and.Reform.Program Eu. European.union FBPS. Fiji.Bulk.Purchasing.Scheme FEMA. Federal.Emergency.Management.Agency FSM. Federated.States.of.Micronesia GDP. Gross.Domestic.Product GNI. Gross.National.Income HIV/AIDS. Human.Immunodeficiency.Virus/Acquired.Immunodeficiency.Syndrome IDB. International.Data.Base.of.uS.Census.Bureau IMF. International.Monetary.Fund JEMFAC. Joint.Economic.Management.and.Financial.Accountability.Committee MDGs. Millennium.Development.Goals MMR. Maternal.Mortality.Ratio NCDs. Non-Communicable.Diseases NDI. Net.Disposable.Income NER. Net.Enrollment.Rate NGO. Non.Governmental.Organization NzAID. New.zealand's.International.Aid.and.Development.Agency OECD. Organization.for.Economic.Co-operation.and.Development PCR. Primary.Completion.Rate PICs. Pacific.Island.Countries.(world.Bank.member.countries) PILL. Pacific.Islands.Literacy.Levels PNG. Papua.New.Guinea PTA. Parent.Teacher.Association RMI. Republic.of.Marshall.Islands SPC. Secretariat.of.the.Pacific.Community SwAPs. Sector.wide.Approaches TESP. Tonga.Education.Sectoral.Plan. TFR. Total.Fertility.Rate u5MR. under-Five.Mortality.Rate uN. The.united.Nations uNAIDS. The.Joint.united.Nations.Programme.on.HIV/AIDS. uSP. university.of.South.Pacific wDI. world.Development.Indicators wHO. world.Health.Organization Executive Summary 1 This.is.a.regional.study.of.social.service.delivery.in.nine.Pacific.countries.1.Education. and.health.services.have.been.a.focal.point.for.government.effort.and.donor.support. for.many.years.in.the.Pacific,.and.there.have.been.many.impressive.results.achieved.since. the.1970s.and.1980s.in.health.status.indicators.and.educational.attainments..In.these. early.years.after.independence.governments.and.donors.concentrated.on.expanding.social. services.to.remote.island.and.under-served.populations..Social.indicators.rose.steadily,.as. mortality.rates.and.primary.and.secondary.enrollments.all.improved..Kiribati,.Solomon. Islands,.Vanuatu.and.Republic.of.Marshall.Islands.(RMI).had.under-five.mortality.rates. (u5MR). above. 50. per. 1,000. live. births. in. the. 1990s.. with. sustained. investments. in. immunization,.Vanuatu.and.RMI.have.shown.real.progress.by.lowering.their.u5MRs.by.60. percent.and.50.percent.respectively.in.the.past.decade..Modern.health.interventions.helped. control.some.diseases.of.childhood,.and.governments.worked.closely.with.non-government. providers.to.insure.that.nearly.all.children.attended.primary.school..As.a.result,.several. countries,.such.as.Fiji,.Samoa,.and.Tonga,.have.achieved.net.primary.enrollment.rates.of. above.90.percent.since.the.1990s..Governments,.in.general,.have.directed.less.attention.to. social.protection.(Fiji.and.Kiribati.are.the.exceptions),.because.families.and.communities,. in.accordance.with.traditional.practices,.were.expected.to.care.for.indigent.people,.disabled. people,.victims.of.natural.disasters,.orphans,.the.elderly,.and.those.unable.to.find.work.. 2 In. recent. times,. a. level. of. disquiet. has. emerged. in. regard. to. the. changing. social. profile.of.the.Pacific..Although.most.children.are.enrolled.in.primary.school,.there.are. concerns.about.those.still.left.behind.and.those.attending.low.quality.schools..Enrollments. at.secondary.levels.of.education.have.stagnated..Equity.issues.have.appeared,.particularly. in.secondary.education.(see.figure.below),.as.poorer.children.dropped.out.or.were.squeezed. out.of.the.education.system.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.I ExECuTIVE.SuMMARy DIFFERENCE IN NEt SECONDaRy SCHOOl ENROllMENt RatES bEtWEEN HOuSEHOlDS IN tHE HIgHESt aND lOWESt WEaltH quINtIlE Vanuatu 1999 Lowest Wealth Quintile Samoa 2001 Highest FSM 2000 Wealth Quintile RMI 1999 Kiribati 1995 Palau 2000 Fiji 1996 Tonga 1996 0 20 40 60 80 100 Net Secondary Enrollment Rate 3 Public.health.systems.continue.to.be.faced.with.the.prevalence.of.diseases.such.as. malaria,. leprosy,. and. tuberculosis. (TB),. compounded. with. intractable. problems. of. non-communicable.diseases.(NCDs).of.youth.and.adulthood,.and.emerging.communicable. diseases.such.as.HIV/AIDs..Diabetes.(see.figure.below),.liver.disease,.and.cardio.vascular. problems.have.multiplied,.at.huge.additional.cost.to.the.public.health.apparatus..And,.as. these.problems.have.emerged,.funding.from.donors.and.governments.continued.to.flow. into.the.social.sectors,.but.now.with.apparently.less.effect.on.outcomes.. PREvalENCE OF DIabEtES MEllItuS, POPulatION agES 20-79 (PERCENt) New Zealand Japan Australia Vanuatu Tonga Solomon Islands Samoa Palau FSM Marshall Islands Kiribati Fiji 0% 2% 4% 6% 8% 10% 12% 14% II.|.wORLD.BANK ExECuTIVE.SuMMARy 4 Social.issues.have.become.more.visible.or.have.deepened.in.recent.years..youth.in.the. Pacific.is.a.large,.growing,.and.vital.demographic.group..young.people.pass.through. life-defining. transitions,. from. primary. education. to. further. schooling,. from. school. to. the.workplace,.to.families.of.their.own,.to.adult.lifestyles.and.health.risks,.and.to.the. responsibilities.of.citizenship..In.the.Pacific.as.elsewhere,.successful.transitions.for.youth. can.add.to.economic.growth.and.reduce.poverty..Failed.transitions.can.lead.to.poor.health,. unemployment,.and.weak.educational.preparation..Helping.youth.realize.their.full.potential. is. a. major. issue. to. which. Pacific. governments. are. dedicating. increasing. resources. and. attention..Other.social.issues,.long.present.in.the.Pacific,.have.become.better.known.and. more.urgent..Disabled.people.in.the.Pacific.have.long.been.ignored.by.most.governments,. and.their.conditions.have.not.improved..Indeed,.they.tend.to.live.in.poor.households,.drop. out.of.school,.and.face.daunting.obstacles.to.successful.livelihoods..Domestic.violence,. alcohol.abuse,.and.teen.pregnancy.can.plunge.a.family.into.prolonged.and.deep.hardship,. sometimes.beyond.the.coping.capacities.of.traditional.family.and.community.based.social. assistance.. Natural. disasters. and. volatile. economies. continue. to. inflict. temporary. and. sometimes.severe.losses.on.households.unable.to.withstand.such.shocks.. 5 In.this.challenging.environment,.the.world.Bank.and.its.Pacific.partners.decided.that. a.fresh.examination.of.the.social.sectors.would.be.potentially.useful..At.the.heart.of. the.undertaking.was.the.core.question.on.resource.effectiveness:.how.well.resourced.are.the. social.sectors.in.the.Pacific.and.how.could.those.resources.be.better.managed.and.governed. to.deliver.higher.social.outcomes? Abundant Resources ­ How Effective are they in Improving Social Outcomes? 6 As. shown. below,. Pacific. countries. are. better. resourced. than. others--on. average,. governments. and. donors. spend. around. uS$318.80. per. capita. on. health. and. education,.which.is.nearly.double.that.spent.in.other.similar.small.states..This.study. asked. if. resources. for. human. development. are. correlated. with. higher. outcomes. in. education.and.health.in.the.nine.Pacific.countries..This.relationship.is.statistically.valid. only.where.governments.are.successful.in.setting.up.institutional.structures.for.social. service.delivery.that.function.effectively..This.raises.the.question.of.whether.the.Pacific's. problem.areas.are.linked.to.shortfalls.in.`accountability'.in.the.relationships.between. the.key.actors.in.delivering.social.services..Are.the.behaviors.of.policy.makers,.frontline. service.providers.and.the.clients.they.serve.more.critical.than.the.number.of.service. facilities,.staff.and.equipment.at.their.disposal? Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.III ExECuTIVE.SuMMARy tOtal RESOuRCES PER CaPIta FOR EDuCatION aND HEaltH, 1997-2003 Average Annual Government Average Annual Recurrent GDP per capita Aid per capita for Expenditures for Country (constant 2000 US$) Population (`000s) Education & Health Education & Health 2003 2003 (US$, 1997-2003) (US$, 1997-2003) Total Pacific.Islands: Fiji 2,184 835 18.6 166.0 184.6 Kiribati 530 96 40.5 157.4 197.8 RMI 1,802 59 70.1 461.7 531.8 FSM 1,846 125 18.2 293.9 312.1 Palau 6,331 20 41.6 1,006.8 1,048.4 Samoa 1,381 178 37.6 124.6 162.2 Solomon.Islands 617 457 16.7 96.6 113.3 Tonga 1,617 102 46.1 122.4 168.6 Vanuatu 1,103 210 45.8 104.4 150.1 Average 1,934.3 . 37.2 281.5 318.8 Low.income.countries.with.abundant.aid: Madagascar 233 16,894 4.2 12.2 16.4 uganda 277 25,280 6.8 11.3 18.1 zambia 354 10,403 13.1 21.1 34.2 Average 288.0 . 8.0 14.9 22.9 Other.small.island.countries: Belize 3,635 274 7.7 276.6 284.3 Comoros 363 600 13.8 30.0 43.8 Djibouti 848 705 36.5 60.2 96.7 Dominica 3,477 71 6.0 386.7 392.7 Dominican.Republic 2,436 8,739 9.9 85.6 95.4 Guyana 951 769 22.0 122.3 144.3 Haiti 463 8,440 8.0 10.4 18.4 Maldives 2,529 293 13.8 188.3 202.1 Sao.Tome.and.Principe 334 157 39.2 36.8 76.0 St..Vincent.and.Grenadines 3,226 109 28.8 471.7 500.4 Average 1,826.2 . 18.6 166.9 185.4 Better Social Outcomes Through Management and Governance 7 Government. and. donor. resources. for. education. and. health,. as. shown. above,. have. attained.high.levels.compared.to.other.countries,.but.their.effectiveness.in.delivering. strong.outcome.performance.has.lost.momentum.in.key.areas,.such.as.equity.of.service. provision.and.in.such.indicators.as.fertility.and.school.completion..Both.donors.and.the. governments.they.support.have.focused.on.this.central.issue.of.resource.effectiveness,.and. have.asked.how.governments,.as.coordinators.of.foreign.assistance.and.managers.of.their. own.sectoral.programs,.can.get.more.from.the.comparatively.abundant.resources.at.hand. 8 The.role.of.governance.in.the.Pacific,.and.in.particular.the.`effectiveness.of.government'. is.thus.likely.to.be.more.influential.on.social.sector.outcomes.than.the.availability.of. resources.alone..But.what.does.effective.government.mean.in.the.context.of.social.services?. Iv.|.wORLD.BANK ExECuTIVE.SuMMARy This.report.adopts.a.framework.that.places.government.effectiveness.in.three.different. policy.domains..Governments.can.manage.serviceexpansion with.new.resources;.they.can. better.manage.the sector to.ensure.that.existing.resources.(no.matter.what.the.source.or. who.delivers.the.services).effectively.achieve.higher.outcomes;.or.they.can.reach.outside.the. sectoral.ministries.to.engage.broad.governance.reforms,.involving.communities.and.other. stakeholders.that.will.enhance.the.operating.environment.for.social.services.and.thus.raise. their.potential.impact..This.report.concludes.that.most.performance.problems.in.the.social. sectors.will.be.more.effectively.addressed.within.the.policy.domains.of.improving.service. management.and.multi-stakeholder.governance..with.some.important.exceptions,.such. as.secondary.schooling,.the.agenda.for.service.expansion.has.shrunk.dramatically.in.the. Pacific,.and.further.investments.will.prove.less.effective.than.new.efforts.in.management. and.governance..In.this.framework,.the.role.of.donor.funding.and.policy.advice.is.highly. relevant.in.the.way.that.donors.work.together,.and.as.a.potential.catalyst.for.progress.in. management.and.governance.. 9 The. framework. thus. suggests. new. directions. for. development. in. the. Pacific. -. accountability.for.improved.outcomes.2.Pacific.government.and.civil.society.no.longer. assume.an.automatic.impact.from.resources.spent.on.social.services,.but.are.trying.to. introduce.new.institutional.arrangements.and.management.instruments.that.target.services. to.those.in.need,.that.direct.public.budget.resources.to.programs.that.have.high.returns,. and.assign.accountabilities.more.clearly.to.the.front.line.where.services.and.clients.meet.. They.are.also.realizing.that.greater.gains.in.performance.may.come.from.cooperation.with. partners.outside.their.delivery.apparatus,.such.as.ministries.of.finance,.local.government,. civil.service.commissions,.NGOs.and.community.organizations.. 1 0 In.this.framework,.a.range.of.accountability.oriented.interventions.tend.to.coalesce. in.each.of.the.policy.domains..Government.interventions.in.service expansion. refer.to.the.more.familiar.efforts.in.the.Pacific.to.recruit,.train.and.qualify.staff,.and.to.build,. expand,.equip.and.supply.facilities..This.is.the.policy.domain.of.input.management.and. logistics..Management.refers.to.the.techniques.that.sectoral.policy.makers.can.utilize.to. get.more.out.of.the.existing.resources.at.hand..Examples.are:.delegation.of.responsibilities. to. local. providers,. setting. standards,. targeting. services. to. those. in. need,. cash. and. in. kind. incentives. to. staff,. and. allocating. resources. to. priority. programs. and. functions.. governance.initiatives.deal.directly.with.broader.forces.and.actors.outside.ministries.that. can.have.such.large.affects.on.sectoral.performance.and.are.regulated.by.government.as.a. whole.in.the.interest.of.the.public.good..These.include.the.areas.of.information.gathering. and.use,.transparent.processes.and.information.sharing,.service.decentralization.to.local. governments,. building. partnerships. with. the. private. sector,. use. of. prices. and. costs. to. attract.more.clients,.manage.demand,.and.community.mobilization.and.participation.. 1 1 The.report.focuses.on.strategic.policy.choices.which.emerge.from.the.analysis,. from.which.countries.can.select.those.that.apply.most.directly.to.their.unique. circumstances..These.choices,.by.their.very.nature,.are.complex.and.lead.to.changes.in. relationships.between.the.various.actors.involved.in.service.delivery..Pacific.governments. have.had.considerable.experience.in.reforming.institutions.as.they.have.already.introduced. and/or.are.currently.implementing.public.expenditure.management.reforms..Each.country's. experience.in.managing.the.transitions.in.service.delivery.reforms,.and.engaging.its.citizens. and.providers.to.promote.change.will.be.unique..In.this.context,.good.monitoring.and. evaluation.of.the.reform.initiatives.combined.with.continuous.dissemination.to.all.major. stakeholders,.holds.the.most.promise..The.report.recognizes.that.some.of.these.policy. actions.have.already.been.successfully.implemented.in.the.region.or.in.other.small-island. states.and.such.examples.are.highlighted.below.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.v ExECuTIVE.SuMMARy 1 2 In education,.Pacific.Island.countries.continue.to.face.two.major.challenges.. The. primary. priority. is. how. to. ensure. that. every. child. completes. the. basic. education.cycle.of.adequate.quality..The.second.is.to.ensure.access.to.an.equitable.and. quality. secondary. education. for. a. rising. proportion. of. children.. what. are. the. main. strategic.choices.in.the.Pacific.that.would.help.governments.improve.learning.outcomes. and.improve.equity.in.access?. .An.important.first.step.would.be the development and refinement of the strategic policy and financing framework..This.is.already.well.underway.in.several.countries,. and.is.vital.to.understanding.how.best.to.match.available.resources.against.pressing. performance. problems. in. the. sector.. A. careful. review. of. public. expenditure. patterns,.both.government.and.donor.financed,.would.be.essential.in.most.Pacific. countries..Governments.and.donors.might.do.well.to.examine.the.balance.between. funds.spent.on.tertiary.education.and.those.spent.on.interventions.for.improving. education.quality,.equity.and.meeting.secondary.education.needs..Currently,.over. 90.percent.of.primary.recurrent.education.expenditures.goes.towards.teacher. salaries;.expenditures.on.quality.related.inputs.and.operating.costs.are.by.contrast. almost.non-existent..Increasing.pupil.teacher.ratios.through.`clustering'.of.infant. and.lower.grade.schools.with.senior.`mother'.schools.as.in.Papua New guinea (PNg) and.developing.multi-grade.teaching.can.reduce.teacher.salary.costs.. .A.second.strategic.choice.is.for.governments.to.strengthen and refine partnerships with private sector and community in.increasing.both.the.supply.and.quality.of. secondary.education..Such.partnerships.however,.need.to.be.developed.within a coherent policy and regulatory framework..Enlisting.community.help.in.constructing. new.community-based.junior.high.and.high schools,.as.was.done.in.Solomon Islands,.may.help.address.the.shortage.of.places.in.secondary.education.and. the.high.costs.associated.with.attendance.at.secondary.schools.some.distance. from.remote.areas..Setting.quality.assurance.mechanisms,.such.as.setting.school. standards,.and.monitoring.their.achievement,.can.improve.quality.of.all.education. services..In.RMI,.private.schools.have.long.enjoyed.a.formal.accreditation.system. through.the.united.States.of.America's.(uSA).western.Association.of.Schools.and. Colleges.(wASC).while.the.public.system.has.turned.recently.to.teacher.testing. and.publication.of.results.as.a.standard.setting.and.monitoring.mechanism..The. experience. has. stimulated. school. level. discussion. about. quality. schooling. and. about.problem.solving.among.teachers.and.parents. .A. third. choice. is. a focus on issues that would facilitate school to work transition. High.rates.of.academic.failure,.language.loss.and.also.the.burgeoning.problem. of."educated.unemployment".and.the.attendant.disaffection.of.youth.are.a.rising. concern.. Curriculum. relevance. needs. to. be. enhanced. to. include. local. cultural. context.and.aspirations..Curricula.reform.can.ensure.that.children.attain.basic. skills. in. language,. mathematics,. problem. solving. and. information. technology,. and.that.they.have.options.for.technical.and.vocational.subjects.that meet the needs of the economy..Development.of.a.curriculum.relevant.to.the.job.market,.or. that.builds.entrepreneurial.skills,.through.partnerships.with.the.private.sector,. as.well.as.training.through.work.attachments.and.apprenticeships.can.facilitate. school.to.work.transitions. .A.fourth.is.in.the.area.of.delivery.of.school.services,.moving to more delegation of accountability to those delivering services on the ground.through.initiatives.such.as. school.based.management..Delegating.to.principals.some.discretionary.control. over.budget.to.purchase.the.teaching.materials.can.help.create.a.greater.demand. from. principals. and. teachers. for. quality. materials. that. support. teaching. and. learning..Principals.could.also.be.required.to.manage.the.ongoing.assessment. and.monitoring.of.student.achievement,.and.to.share.this.data.with.the.Parent. vI.|.wORLD.BANK ExECuTIVE.SuMMARy Teacher.Association.(PTA).and.wider.school.community..In.RMI,.the.renowned. Likiep.primary.school.outperforms.public.and.private.competitors.through.its. innovative.approach.to.school.based.management,.community.involvement,.and. monitoring.and.evaluation..This.achievement.data.can.help.guide.instructional. practices.and.provide.information.to.parents.to.enable.them.to.better.support. their. children's. learning.. Principals. can. also. be. empowered. to. better. manage. teachers.and.their.performance..In.the.Kosrea state of the Federated States of Micronesia (FSM),. the. government. is. experimenting. with. innovative. approaches.to.managing.teacher.absenteeism.by.using.team.teaching.and.making. up.missed.school.days.by.extending.the.school.year. .A.fifth.is.in.the.area.of.information.collection,.management,.use.and.sharing.. More.focus,.especially.in.countries.at.risk.of.not.meeting.the.MDGs,.needs.be. brought.to.put in place surveillance systems that allow policy makers and education managers track progress.in.terms.of.enrollment,.achievement.and.specific.`at.risk'. groups..This.would.involve.strengthening.or.developing.Education.Management. Information.Systems.(EMIS).. .A. sixth. is. in. the. area. of. alleviating constraints on poor people's participation in education through innovative programs.such.as.conditional.cash.transfers,.inclusive. or.special.needs.education.(as.appropriate).for.children.with.disabilities,.revising. school.fee.structures,.and.using.appropriate.pro-poor.targeting.mechanisms.(such. as.using.household.characteristics.as.done.in.Fiji and Kiribati).in.the.allocation. of.secondary.scholarships..Training.of.all.teachers.in.special.needs.education.and. other.reforms.instituted.in.Samoa.has.gone.a.long.way.in.improving.access.to. education.for.children.with.disabilities..Per.capita.grants.related.to.the.needs. of.special.needs.students.could.be.made.available.to.local.schools.and.private. providers.or.targeted.directly.to.families.with.special.needs.so.that.they.then.can. purchase.educational.provision.at.their.local.school..Income-related.sliding.fee. scales,.scholarship.policies.that.specifically.target.the.poorer.sections.of.society,. quota. systems. that. ensure. schools. equitably. select. students. from. different. regions. or. different. ethnic. groups,. and. boarding. subsidies. and. travel. grants. would.greatly.improve.access.to.secondary.school.for.many.poor.children.from. outer.islands..Kiribati.has.demonstrated.a.way.to.better.balance.in.secondary. school.enrollments.through.travel.grants.and.enrollment.quotas.for.outer.island. students.. Demand-side. subsidies. such. as. targeted. conditional. cash. grants to. families.can.encourage.parents.to.keep.their.children.in.school.. 1 3 In health,.countries.continue.to.face.challenges.such.as.the.unfinished.agenda.in. achieving.the.MDGs,.high.fertility.rates,.continued.prevalence.of.communicable. diseases.and.emerging.threat.of.HIV/AIDs,.combined.with.a.rising,.and.in.many.cases.a.crisis. in.NCD.prevalence..Pacific.health.systems.need.to.be.reoriented.to.face.these.challenges.in. order.to.ensure.that.health.services.deliver.results..what.are.the.main.strategic.choices.in. the.Pacific.that.would.help.achieve.desired.health.outcomes?. .One. is. better alignment of resources, both government and donor funds, toward achieving desired health outcomes as prioritized in country sector strategies.. This. requires.careful.thinking.about.the.outcomes,.how.best.to.address.the.underlying. causes.and.the.links.with.health.policy.and.service.delivery.aspects..It.needs.to. go.beyond.looking.at.the.service.delivery.alone.to.achieve.the.desired.impact. in.terms.of.outcomes..A.priority.area.for.action.is.increased.resource.allocation. for. cost-effective. preventive. and. primary. care.. Early. intervention. and. clinical. management.of.non-communicable.diseases.at.the.primary.level.will.help.prevent. these.diseases.from.progressing.and.thus.requiring.high-cost.interventions.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.vII ExECuTIVE.SuMMARy .A.second.strategic.choice.is.on.financing of health care,.both.in.terms.of.diversifying sources of finance from public revenues to risk sharing mechanisms. and individual payments..Equity.concerns.are.of.paramount.importance,.that.is.choices.regarding. who.should.benefit.most.from.free.health.services..One.option.is.to.introduce.or. increase.user.fees.for.outpatient.services.provided.at.hospitals.(with.exemptions. for.local.populations.who.have.no.other.lower.level.facilities.within.access).while. making. the. same. services. free. at. the. primary-care. level.. Additional. resources. could. be. used. to. strengthen. health. services. in. rural. and. remote. areas. and. to. provide. travel. allowances. to. patients. for. referral. care.. Other. options. include. experimenting.with.social.health.insurance.or.insurance.for.overseas.care.while. using.income-related.sliding.scales.and.co-payments.to.protect.the.poor..tuvalu,. by.sending.its.patients.to.Suva.for.overseas.care,.spends.half.as.much.in.this. category.as.it.would.do.if.it.sent.these.patients.to.New.zealand.or.uSA. .A. third. is. in. the. area. of. delivery. structure,. from. centralized. models. to. more. delegation of accountability to those delivering services on the ground.as.well.as.efforts. to.include.all.parts.of.the.delivery.system.in.our.thinking.about.health.sectors. -. i.e.,. public,. private,. non-government. providers.. Delegating. management. and. financial.resources.to.local.health.providers.can.better.assign.accountability.and. foster.improved.performance..with.dispersed.population.groups.and.geographic. barriers,.this.is.perhaps.a.necessity;.the.key.here.is.to.ensure.that.there.are.clear. links.across.all.levels.of.the.system..By.allowing.divisional.directors.to.allocate. human.resources.and.budgets.to.meet.local.needs,.Fijihas.succeeded.in.improving. morale.among.health.personnel.in.the.public.sector..where.government.services. are.unable.to.make.any.headway.in.addressing.specific.health.problems,.particularly. in.remote.areas.or.in.instances.of.highly.resistant.patient.behaviors,.contracting. with.churches.or.non-government.organizations.(NGOs).to.provide.services.would. enable. governments. to. focus. on. output. and. outcome,. circumvent. its. capacity. constraints,.take.advantage.of.the.flexibility.and.autonomy.of.the.private.sector,. and.to.use.competition.to.increase.effectiveness.and.efficiency..Recognizing.the. role.of.traditional.healers.(who.are.often.the.first.point.of.contact).in.the.health. sector,.and.building.partnerships.with.NGOs.and.communities.is.important.in.the. area.of.reproductive.health,.health.education.and.promotion.and.particularly.in. services.targeted.to.adolescents..For.example,.community.health.councils.in.RMI,. village.health.workers.in.Solomon Islands,.and.women's.committees.(which.are. responsible.for.maintaining.rural.health.facilities).in.Samoa.have.helped.control. the.spread.of.communicable.diseases,.and.in.vanuatu and Samoa,.communities. still.help.to.build.and.maintain.their.own.aid.posts.and.health.centers. .A.fourth.is.in.the.area.of.incentives,forserviceproviderstoensurethatqualityservices are delivered and for service users to ensure that services are utilized appropriately.. Linking remuneration.with.performance,.as.long.as.it.is.done.in.conjunction.with. broader.civil.service.reforms,.can.help.motivate.service.providers..In.Fiji, Samoa, vanuatu,.and Solomon Islands,.senior.managers.in.the.public.health.system. (CEOs.and.directors).are.now.appointed.with.five-year.performance.contracts.thus. improving.accountability..Improved.working.conditions.and.higher.remuneration. can. attract. qualified. personnel. to. work. in. remote. areas.. Doctors. have. begun. returning.to.Solomon Islands.because.the.scheme.of.service.was.updated.and. public. salaries. and. benefits. adjusted. in. line. with. current. market. conditions.. Innovative. mechanisms. such. as. health. equity. funds. (held. and. disbursed. by. local.authorities.to.poor.households).and.vouchers.can.encourage.utilization.of. immunizations.and.other.preventive.health.services.. .A. fifth. is. in. supporting initiatives that encourage people to lead healthy lifestyles.. with.high.prevalence.of.non-communicable.diseases,.especially.in.Micronesia.and. vIII.|.wORLD.BANK ExECuTIVE.SuMMARy Polynesia,.and.emerging.diseases.such.as.HIV/AIDs,.the.need.for.emphasis.on. behavior.change.­.diet,.smoking,.sexual.behavior.­.and.need.for.using.preventive. services.is.important..In.FSM the.diabetes.control.program.has.been.effective,. using.diabetes.patients.in.health.education.programs.for.spreading.the.message. on.how.diabetes.has.adversely.affected.their.lifestyle.and.how.important.it.is. to.prevent.it..Cash.or.in-kind.incentives.(smoking.cessation.programs,.fitness. program).to.encourage.people.to.take.effective.preventive.health.measures.can. help.to.reduce.the.prevalence.of.non-communicable.diseases.. .A.sixth.is.to.ensurestronglinkswithdemandsespeciallyatthehouseholdandcommunity levels..Little.is.known.about.the.use.of.health.services.by.the.population.and.on. the.costs.incurred.by.households.in.accessing.health.care.(such.as.transportation. costs,. drug. costs,. and. fees).. Governments. need. to. invest. in. population-based. surveys. and. qualitative. assessments. on. health-seeking. behavior,. in. addition. to.collecting.health.statistics.from.internal.service.based.information.systems.. tonga and Samoa.have.collected.household-level.data.on.health.care.use.and. expenditures,.and.they.produce.National.Health.Accounts,.using.survey.results,. on.a.regular.basis.to.inform.policy.and.planning 1 4 In social protection,. several. social. problems. have. worsened. in. recent. years. and. more. entrenched. issues. have. come. to. the. surface. including:. the. negative. effects.on.many.families.of.macroeconomic.volatility.and.weather.shocks;.the.emergence. of.a.large.population.of.restless.unemployed.young.people;.serious.urban.social.problems;. and.the.deprivation.of.chronically.poor.sub-groups..Social.protection.in.the.Pacific.is.thus. a.relatively.new.field.of.government.activity,.and.existing.programs.are.scarce..For.some. problems,.governments.will.need.to.engage.more.directly.in.this.little.known.social.sector.. what.then.is.the.role.for.government.in.social.protection.in.the.Pacific?. .The.first.is.to.ensure mechanisms exist to prevent and reduce social risk instead of managing or coping with the impact of those risks after they have occurred. Because. social.protection.is.nascent.in.the.Pacific.region,.carrying.out.country-specific. assessments.and.strategic.development.plans.are.key.first.steps..This.would.be. a.multi-agency,.multi-partner.activity,.through.which.governments.should.aim. to. produce. a. strategy. document. that. would. outline. the. country's. risk. profile,. the. government's. strategic. objectives. in. the. sector,. the. opportunities. for. risk. prevention,.risk.reduction.and.risk.coping.interventions,.the.appropriate.role.of. government.vis-à-vis.families,.communities,.and.NGOs,.and.a.series.of.prioritized. and.phased.actions.. .The.second.is.in.coordinating existing initiatives within a common financing and policy framework..This.will yield.as.many.benefits.as.launching.new.programs,.given.the. large.number.of.separate.independent.initiatives.usually.being.undertaken.by. donors,.NGOs.and.community.institutions..In.vanuatu,.development.projects. generally.must.pass.through.a.rigorous.process.of.review.by.government,.and. development.project.resources.are.now.being.channeled.into.a.single.fund.account,. so.that.activity.of.donor.financed.projects.can.be.tracked..Establishing.(if.none. exists).a.focal.point.for.the.government's.social.protection.strategy,.coordination,. and.monitoring.and.evaluation.would.also.yield.benefits,.and.could.fit.within.an. existing.social.ministry.or.in.a.planning.organization.and.could.be.integrated.with. similar.functions.for.other.social.sectors..The.Fiji Department.of.Social.welfare. is.one.such.focal.point..Developing.an.explicit.policy.approach.to.targeting.social. assistance. could. lead. to. considerable. savings. within. existing. programs.. For. example,.copra.producer.subsidies,.if.set.at.high.levels.without.regard.to.targeting. criteria,.can.lead.to.a.fiscal.drain.and.benefits.flowing.to.non.poor.farmers. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.IX ExECuTIVE.SuMMARy .The.third.is.in.identifying areas that require new policies, more capacity to implement programs, and the public resources to finance them..Innovative.approaches.such.as. conditional.cash.transfers.could.help.reduce.school.drop.outs.especially.among.the. poor..Disabled.children.in.particular.will.need.special.support.to.the.family.or.to. the.school.as.an.incentive.for.their.enrollment.in.school..In.Samoa,.an.effort.to. empower.rural.people.with.disabilities.links.education.and.training.with.income. generation.in.collaboration.with.local.NGOs.and.the.community..Jobless.youth. could.benefit.from.temporary.public.employment.in.new.public.works.schemes.. New.and.existing.interventions.should.be.evaluated.on.whether.they.will.add.value,. or.merely.replace.family.and.community.based.practices..Fiji has.pioneered.social. assistance.in.the.Pacific,.and.has.learnt.valuable.lessons.(such.as.the.unreliability.of. self-reported.income.as.a.good.targeting.mechanism).on.how.to.structure.benefits,. target.needy.groups,.and.monitor.the.impact.of.its.programs.. .The.fourth.is.in.building partnerships with the private sector and NGOs for the delivery of some services..For.instance,.gender.based.violence.needs.new.effort.from.most. Pacific.governments,.and.shelters.and.counseling.services.would.be.a.good.start,. perhaps.managed.by.an.NGO..Mapusa-o-Aiga,.a.local.NGO.in.Samoa,.operating. since.1993,.provides.counseling,.referrals.to.police,.legal.aid.and.health.services.for. victims.of.domestic.violence..Employment.services.for.youth.and.others.seeking. jobs.in.the.formal.sector.or.overseas.are.not.available.in.most.of.the.Pacific,.and. as. strategies. for. regional. labor. mobility. gain. a. foothold,. and. as. governments. introduce.public.employment.schemes,.such.services.could.play.a.vital.role.in. linking.job.seekers.with.public.and.private.opportunities..Kiribati and tuvalu's Maritime.and.Fisheries.Training.Centers.have.long.produced.seafarers.who.gain. commercial.employment.after.leaving.the.centers. .The.fifth.is.in.regular monitoring and evaluation of social protection programs.so.that. their.effectiveness can be measured and demonstrated..In.many.cases.this.would. require. the. development of high-quality and up-to-date information on social risk through.high-quality.participatory.fieldwork.as.well.as.socio-economic.surveys.. For.strategy.and.policy.purposes,.regular.household.surveys.need.to.be.conducted. that.include.questions.relevant.to.risk.management,.for.example,.on.labor.market. issues,. transfers. and. remittances. that. underpin. the. family-based. safety. net,. family.participation.in.social.assistance.schemes,.and.the.prevalence.of.disability. and.chronic.poverty..Such.surveys,.if.nationally.representative,.will.yield.accurate. and.up-to-date.data.that.will.be.an.invaluable.input.into.the.design.of.a.targeting. strategy.and.will.make.it.possible.to.check.the.coverage.rates.that.are.self-reported. by.social.protection.providers.. 1 5 Some.of.the.strategic.actions.outlined.above.cut.across.the.three.social.sectors..The. first.is.better public expenditure management.to.ensure.that.resources.are.targeted. towards.priority.social.outcomes.and.needs.identified.in.country.strategies..This.may.require. institutional and management reforms such.as.improved.public.expenditure.management. systems,. improved. financial. and. procurement. systems. and. delegation. of. accountability. to.lower.levels.of.government.as.appropriate..The.second.is.better systems for information collection, analysis and use.for.effective.sectoral.management.and.to.track.progress.on.social. outcomes..The.third.is.closer.alignment of sectoral and national policy priorities.with the service delivery challenges.on.the.ground..For.example,.in.some.countries,.teen.pregnancies,.youth. unemployment. and. high. rates. of. population. growth. are. core. development. issues,. but. national.policies.have.not.set.the.stage.for.vigorous.family.planning.promotion..Another. is.the.link.between.school.drop.outs,.joblessness.and.social.issues.which.would.require:. a.more.integrated.policy.for.keeping.kids.in.school.for.the.complete.general.education;. the.development.of.a.secondary.education.curriculum.with.relevance.to.the.job.market. X.|.wORLD.BANK ExECuTIVE.SuMMARy through.consultations.with.the.business.sector;.and.providing.awareness.campaigns.and. social.education.programs.on.HIV/AIDs.and.other.social.issues. 1 6 where.issues.span.across.country.borders.and.there.are.significant.economies.of. scale.from.regional.collaboration.a regional approach.might.yield.high.benefits. and.even.improve.outcomes..The.study.identifies.four.policy.initiatives.that.have.regional. implications.and.are.worth.highlighting: .Pharmaceutical procurement:.the.key.is.to.develop.a.mechanism.that.is.more. efficient.than.the.current.national.practices,.and.thus.to.avoid.costly.warehousing. and.distribution.in.parallel.with.the.suppliers.themselves.. .Natural disaster fund or insurance: as.the.most.disaster.prone.region.in.the. world,.there.would.seem.to.be.opportunities.to.upgrade.the.regional.response. mechanisms.to.natural.disasters,.which.are.largely.in.the.foreign.assistance.mode,. and.to.introduce.a.fund.or.regional.insurance.scheme.. .Common financing and strategic frameworks to guide donor assistance: the.recent.steps.to.improve.coordination.and.full.harmonization.by.sector.are. encouraging.and.need.to.be.refined.and.expanded.to.other.countries.and.sectors. .liberalized labor market access: this.was.a.major.focus.of.the.Pacific.Plan. Forum.meeting.in.October.2005,.and.if.progress.is.achieved,.promises.to.have. a.salutary.impact.on.some.countries.which.have.no.labor.migration.outlets,. and. high. under-employment. and. unemployment. rates.. Remittances. from. migrants. in. some. cases. can. play. a. highly. effective. role. in. helping. families. manage.risk.and.adversity. Leveraging all Resources to Improve Social Outcomes 1 7 In. the. Pacific,. donors. are. a. major. contributor. to. the. social. sectors,. but. much. of.their.resources.have.been.provided.traditionally.in.the.form.of.fragmented. `projects'.many.of.which.are.provided.`off-budget'.and.compete.for.already.scarce.human. resources.within.small.public.service.bureaucracies.. 1 8 As.shown.above,.there.is.a.clear.need.for.governments.to.adjust.priorities. to.achieve.their.desired.social.outcomes..This.would.only.be.possible.if.all. resources,.government.and.donor,.are.linked.to.outcomes.and.incentives.are.aligned. to.achieve.these.outcomes..Strategies.for.the.human.development.sectors.need.to.be. strengthened.to.focus.on.outcomes.and.identify.key.priorities.that.could.be.supported. within.a.medium-term.fiscal.framework..Aligning.donor.support.to.such.a.strategy.can. help.greatly.improve.aid.effectiveness..The.study.notes,.that.in.recent.years,.donors. have.sought.to.introduce.more.policy.and.strategic.coherence.through.a.variety.of. mechanisms,.some.country.wide.and.others.more.sectoral.in.focus..For.instance,.in.the. education.sector.in.tonga and Solomon Islands,.donor.support.is.provided.within. the.framework.of.a.common.sector.strategy.and.plan,.and.a.unified.sector.financing. strategy..More.attention.can.be.given.to.explicit.outcome.targets,.reform.milestones,. and.sectoral.budget.performance.monitoring. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.XI ExECuTIVE.SuMMARy 1 9 . Key.principles.that.help.guide.any.programmatic.or.sectoral.support.are: ·. existence of a coherent strategy.for.the.human.development.sectors; ·. government ownership.and.accountability.of.the.strategy.being.supported;. . ·. a focus on outcomes and prioritization. of. expenditures. and. scarce. administrative.capacities.in.support.of.the.outcomes.to.be.achieved.rather.than. just.on.input.management,.i.e..all.inputs.should.be.judged.in.terms.of.their. contribution.to.improved.outcomes; . ·. programmatic, organizational and management reforms. to. enable. the. outcomes.to.be.improved;. . ·. increasing use of core government systems. (a. "whole. of. government". approach).to.manage.resources.and.the.supported.programs.(including.through. strategic.partnerships.with.the.private,.church.and.NGO.sectors); . ·. developmental.and.recurrent.support.of.programs to be supported within a medium-term fiscal or budget framework with a focus on sustainability; . ·. stakeholder inclusiveness in design and implementation of strategies;. and . ·. transparency and probity in all processes.including.through.sound.financial. and.procurement.management. XII.|.wORLD.BANK 1 Chapter title Human Development in the Pacific Background and Motivation 1 This.is.a.regional.study.of.social.service.delivery.in.nine.Pacific.countries.3.Education. and.health.services.have.been.a.focal.point.for.government.effort.and.donor.support. for.many.years.in.the.Pacific,.and.there.have.been.many.impressive.results.achieved.since. the.1970s.and.1980s.in.health.status.indicators.and.educational.attainments..Governments. have. directed. less. attention. to. social. protection,. because. families. and. communities,. in. accordance.with.traditional.practices,.were.expected.to.care.for.the.indigent,.the.victims. of.natural.disasters,.orphans,.the.elderly,.and.those.unable.to.find.work..Hardship.and. poverty.were.known.to.exist.in.the.Pacific,.but.few.accepted.the.idea.that.Pacific.societies. contained.sharp.social.cleavages.or.classes,.and.that.large.social.inequities.would.be.evident. in.social.indicators..The.main.challenges.facing.social.services.were.to.extend.coverage.and. access.to.more.remote.islands,.bring.up.attendance.and.utilization.of.facilities,.and.increase. enrollments.and.years.completed.of.education,.while.lowering.mortality.rates.for.children. and.mothers.due.to.easily.prevented.diseases.of.poverty.. 2 Those. mandates. and. the. efforts. devoted. to. them. have. occupied. health. specialists. and.educators.in.the.Pacific.for.many.years,.but.in.recent.times,.a.level.of.disquiet. has.emerged.in.regard.to.the.changing.social.profile.of.the.Pacific..Results.from.student. achievement.assessments.such.as.the.Pacific.Island.Literacy.Levels.(PILL).data.provide. reasons.for.concern.about.the.quality.of.education.being.provided;.and.enrollments,.even. at.the.primary.level.but.most.dramatically.at.secondary.levels.of.education.have.stagnated.. Public.health.systems,.which.had.done.so.much.to.control.the.diseases.of.poverty.and.lower. infant.mortality,.now.are.faced.with.intractable.problems.of.NCDs.of.youth.and.adulthood,. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.1 HuMAN.DEVELOPMENT.IN.THE.PACIFIC and.emerging.communicable.diseases.such.as.HIV/AIDs..Diabetes,.liver.disease,.and.cardio. vascular.problems.have.multiplied,.at.huge.additional.cost.to.the.public.health.apparatus.. And,.as.these.problems.have.emerged,.funding.from.donors.and.governments.has.continued. to.flow.into.the.social.sectors,.but.now.with.apparently.less.effect.on.outcomes.. 3 youth.in.the.Pacific.is.a.large.and.vital.demographic.group..young.people.pass.through. life-defining.transitions,.from.primary.education.to.further.schooling,.from.school. to. the. workplace,. to. families. of. their. own,. to. adult. lifestyles. and. health. risks,. and. to. the.responsibilities.of.citizenship..These.transitions.are.fraught.with.risk.and.potential. reward..In.the.Pacific.as.elsewhere,.successful.transitions.for.youth.can.add.to.economic. growth.and.reduce.poverty..Failed.transitions.can.lead.to.poor.health,.unemployment,.and. weak.educational.preparation..Helping.youth.realize.their.full.potential.is.a.major.issue. on.which.Pacific.governments.are.dedicating.increasing.resources.and.attention..Some.of. the.consequences.of.slow.progress.on.this.front.can.be.seen.in.such.social.problems.as. alcoholism,.crime,.risky.sexual.behaviors,.and.perhaps.most.fundamentally.in.very.high. rates.of.youth.unemployment.and.joblessness.in.several.Pacific.countries.. 4 In.this.challenging.environment,.the.world.Bank.and.its.Pacific.partners.decided.that. a.fresh.examination.of.the.social.sectors.would.be.potentially.useful..A.substantial. endowment.of.empirical.and.policy.analysis.already.was.in.hand,.bringing.to.light.many.of. the.performance.problems.and.suggesting.ways.forward.4.There.was.still.interest,.however,. in.exploring.new.ways.to.look.at.these.problems.and.to.develop.innovative.frameworks. to.contend.with.them..The.growing.literature.on.accountability.in.social.service.delivery. could.be.helpful;.similarly.the.recent.work.on.governance.and.its.effects.on.social.service. outcomes. might. be. useful.. Finally,. the. global. interest. in. achieving. social. outcomes. generated.further.impetus.for.a.new.approach,.as.the.Millennium.Development.Goals. (MDGs).and.other.initiatives.began.to.shift.social.sector.planning.from.the.expansion. of.inputs.to.the.attainment.of.outcomes,.and.from.supply-side.constraints.to.failures.in. demand-side.management.. Challenges to Delivering Social Services in the Pacific 5 Diverse country settings..The.diversity.of.country.circumstances.is.often.cited.as. an.obstacle.to.the.design.of.regional.strategies.and.common.technical.solutions.for. the.social.sectors..Sub-regional.groupings.are.sometimes.used.to.show.how.some.countries. are.similar.in.settings.and.potentially.to.similar.approaches.to.human.development..The. most.commonly.used.set.is.one.that.selects.the.countries.of.Micronesia,.Melanesia.and. 2.|.wORLD.BANK CHAPTER.1 Polynesia..This.has.proved.useful,.particularly.on.issues.relating.to.language,.geography. and.population.growth,.as.shown.in.Table.1-1.5.Fiji.is.a.cross.roads.country,.with.strong. Melanesian.and.Polynesian.cultural.roots,.but.is.listed.as.Melanesian.. tablE 1-1: PaCIFIC COuNtRy CHaRaCtERIStICS Topography and Local Language Population Growth Country Group Cultural Grouping Island Dispersion Resources Dispersion Rates Samoa,.Tonga Polynesian Low Flat.to.low.mountains,. Low.. Low.(1%) good.water,.good.soils Vanuatu,.Solomon.Is.,.Fiji Largely.Melanesian Medium Mountainous,.good. High Medium.to.High.. soils,.abundant.water,. (1.4.to.3.1%) forests,.minerals Kiribati,.RMI.,.FSM,.Palau Micronesian High Flat.atolls,.very.poor. Low Medium.(1.to.2.4%) soils,.no.minerals,.but. large.ocean.territory. and.fishing.zones 6 The.sub-regional.groups.shown.in.Table.1-1.thus.are.useful.to.establish.some.of.the. setting.for.social.service.delivery..Island.dispersion.in.Micronesia.imposes.high.costs. on.communication.and.particularly.logistics;.so.that.teachers.and.nurses.are.unreliably. paid,.supplies.of.teaching.materials.and.medicines.are.sent.at.high.cost,.and.in.some.cases,. unreliably..These.problems.are.also.present.in.Melanesia,.but.distances.are.less,.particularly. for. Fiji.. Topography. and. resources. have. pervasive. implications. for. social. services.. The. mountainous.terrain.of.Melanesia.hinders.access.for.inland.villagers.to.schools.and.clinics. compared.with.other.groups,.but.water.quality,.soil.fertility.and.natural.resources.generally. are.far.superior.to.the.sandy,.infertile.atolls.of.Micronesia..Health.risks.follow.in.some. ways,.such.as.the.higher.nutrition.risks.in.Micronesia,.but.not.others..Malaria.is.a.problem. only.in.Melanesia,.not.elsewhere.. 7 In.Micronesia,.villages.and.farmers.face.high.risks,.as.droughts.and.wave.action.can. have. calamitous. effects.. The. larger. and. higher. islands. of. Melanesia. and. Polynesia,. although.highly.prone.to.weather.disasters.such.as.tropical.cyclones,.are.naturally.more. resilient..Indigenous.language.dispersion.is.highly.influential.on.learning.in.the.Pacific.. Melanesia.has.many.local.languages,.but.has.used.pidgin.as.a.lingua.franca,.which.has.served. according.to.some.analysts,.as.a.helpful.entry.point.for.English.language.learning.in.school.. Micronesian.countries.have.one.indigenous.language,.or.in.the.case.of.FSM,.a.small.number. of.local.languages..These.are.universally.used,.and.inhibit.the.use.of.English.in.schools,.even. when.required..Polynesian.countries.also.have.single.languages,.but.both.Tonga.and.Samoa. are.closely.linked.to.New.zealand.and.Australia.by.emigration.and.education,.and.thus.are. more.likely.to.use.and.learn.English.in.the.home.and.at.school..Population.growth.is.low. in.Polynesian.but.is.higher.in.both.Micronesia.and.Melanesia..In.the.Pacific.population. growth.is.influenced.by.migration,.yet.another.element.in.the.diverse.Pacific.setting.. 8 Economicanddemographicprofile..Gross.Domestic.Product.(GDP).growth.rates.are. volatile.in.the.Pacific,.and.nearly.all.Pacific.economies.are.highly.vulnerable.to.global. demand.shocks.given.their.small.size.and.limited.economic.diversification..Severe.weather. contributes.to.macroeconomic.volatility.as.well..Economic.volatility.has.passed.through. to.households,.but.the.impacts.seem.to.have.been.cushioned.to.some.degree.by.the.high. flows.of.external.income.to.Pacific.Island.countries,.flows.from.sources.that.are.relatively. immune.to.global.trade.shocks,.such.as.fishing.license.and.over-flight.revenues,.foreign.aid,. and.trust.fund.revenue..Serious.civil.unrest.in.the.nine.Pacific.member.countries.of.the. world.Bank.has.been.confined.to.Fiji.and.Solomon.Islands.in.recent.years,.and.GDP.has. fallen.temporarily.in.both.cases,.but.then.recovered,.as.shown.below.in.Table.3..Poverty.in. the.Pacific.is.an.under.utilized.concept,.and.has.been.measured.carefully.in.relatively.few. countries..Table.1-2.summarizes.the.available.macroeconomic.data. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.3 HuMAN.DEVELOPMENT.IN.THE.PACIFIC tablE 1-2: POPulatION, gDP, aND INEqualIty Population GDP per capita GDP per capita Population below (constant 2000 growth (annual %) basic needs poverty US$) line Country/ Year 2003 2000-2004 2000-2004 Fiji 835,000 2,136 1.1 25.5 Kiribati 96,377 531 -0.3 50.0 RMI 57,000 1,839 -1.9 20.0 FSM 124,560 1,801 0.4 27.9 Palau 19,700 6,256 0.6 N/A Samoa 178,000 1,392 2.3 20.3 Solomon.Islands 456,645 638 -6.0 N/A Tonga 101,524 1,583 2.3 22.3 Vanuatu 210,164 1,148 -2.0 N/A Source: World Development Indicators, World Bank; ADB Poverty Report. 9 Although.population.size.varies.widely,.Pacific.countries.all.have.large.proportions.of. youth,.defined.as.those.aged.15.to.24.(Figure.1-1)..Compared.to.the.low.and.middle. income.countries.of.East.Asia.and.the.Pacific,.the.youth.group.in.the.nine.Pacific.Islands.is. a.higher.proportion.of.the.population,.19.7.percent.as.against.16.3.percent..For.a.selected. group.of.other.small.and.island.countries,.the.nine.Pacific.countries.are.very.close.to.the. mean.of.19.97.percent..On.a.global.scale.Pacific.Island.countries.thus.are.in.the.high.end. of.the.proportionate.size.of.the.youth.group..The.significance.of.this.statistic.is.to.be.found. in.the.rapid.growth.of.the.youth.sub-group,.and.the.capacity.of.small.island.economies.to. provide.youth.with.meaningful.opportunities..youth.in.the.Pacific.is.an.under.utilized.asset,. even.in.places.where.unemployment.is.low,.because.there.is.widespread.under-employment. of.youth..Helping.youth.realize.their.full.potential.is.a.major.issue.in.the.Pacific..Some.of. the.consequences.of.slow.progress.on.this.front.can.be.seen.in.such.social.problems.as. alcoholism,.crime,.risky.sexual.behaviors,.and.perhaps.most.fundamentally,.in.very.high. rates.of.youth.unemployment.and.joblessness..Pacific.governments.all.are.searching.for.new. ways.to.help.youth.do.more.for.their.families.and.for.society,.including.new.opportunities. to.go.overseas.for.work.and.learning.. FIguRE 1-1: yOutH (15-24 yEaRS) IN tHE PaCIFIC 25% 20% 15% population 10% total of % 5% 0% ualaP aomaS ijFi utaunaV itabiriK a ngoT nomoloS sdnalsI IMR MSF ltaoT aisA.E cfiicaP Source: Secretariat of the Pacific Community, Population and Demography Section, 2004 estimates 4.|.wORLD.BANK CHAPTER.1 1 0 Migration.to.neighboring.OECD.countries.is.accompanied.by.remittances,.and. of.course.with.the.historical.events.that.have.opened.up.neighboring.countries. to.the.entry.of.labor.from.Pacific.countries..Access.to.neighboring.labor.markets.is.an. important.asset.in.the.Pacific,.both.for.the.remittances.that.flow.back,.and.for.the.safety. valve.for.the.unemployed.(Table.1-3).6.Access.is.entirely.open.for.the.former.uS.territories.in. Micronesia.and.more.restrictive.in.Polynesia.and.Fiji,.but.is.essentially.closed.for.Melanesia. and.Kiribati..There.are.reports.that.out-migration.has.grown.rapidly.from.both.RMI.and. Fiji.since.the.1990s..Donor.assistance.in.some.cases.has.responded.to.immigration.policies,. supporting.more.heavily.those.states.that.have.enjoyed.freer.labor.market.access,.such.as.in. the.case.of.uS.assistance.to.its.former.territories.in.Micronesia..New.zealand.and.Australia. assist.Tonga.and.Samoa,.but.there.are.other.donors.active.in.these.two.countries..Solomon. Islands.is.a.clear.exception:.high.assistance.flows.from.Australia.in.response.to.civil.unrest. have.not.been.accompanied.by.liberalized.access.to.the.Australian.labor.market.. tablE 1-3: IMMIgRatION aCCESS tO DONOR COuNtRIES Countries Immigration Access Migrants as % of Country Remittance Flows Population 2001 RMI Open.to.uSA RMI.10% yes* FSM FSM.10% yes Palau Palau.30% yes Samoa Fluctuating.access.to.Nz.and. 72% yes Australia. Open.to.uSA Tonga Fluctuating.access.to.Nz.and. 76% yes Australia Fiji Restricted.to.all.destinations;. 10% yes less.restrictions.for.skilled.Indo- Fijians,.soldiers.serving.abroad. Vanuatu Restricted.to.all.destinations. <.1% Negligible Solomon.Islands Restricted.to.all.destinations <1% Negligible Kiribati Restricted.to.all.destinations <.1% From.seafarers.only * RMI shows more remittances flowing out than in, an unusual pattern in the Pacific. 1 1 The. implications. of. such. uneven. access. are. significant. for. unemployment,. dependency.ratios,.income.based.poverty.and.possibly.social.risk.management,. as.will.be.seen.in.Chapter.6..It.would.be.expected.that.among.those.Micronesian.countries. with.open.access,.a.large.segment.of.their.populations.would.have.moved.to.the.uSA,.but. emigration.from.RMI.to.the.uSA.has.been.less.important.than.for.Tonga.and.Samoa.which. both. have. large. proportionate. populations. abroad,. despite. currently. restrictive. policies. in.Australia.and.New.zealand..Such.links.with.relatives.overseas.can.also.translate.into. increased.educational.opportunities.abroad.for.family.still.at.home.and.frequent.contact.and. visits.with.overseas.relatives.who.expose.their.families.to.new.ideas.and.opportunities.. 1 2 Role of state and public sector governance. The.role.of.the.state.in.the.Pacific. Islands.is.also.highly.variable..As.will.be.seen.in.the.chapters.that.follow,.health. finance.and.expenditure.varies.from.almost.100.percent.public.provision.to.more.diversified. arrangements.with.the.private.and.NGO.sector..In.education,.the.state.shares.provisions. nearly.everywhere.with.churches,.but.the.arrangements.vary..In.social.protection,.some. states.such.as.Fiji.and.Kiribati.are.active.and.spend.a.significant.proportion.of.GDP.on.risk. management.programs..In.other.countries,.there.is.next.to.no.effort.by.the.state.and.near. total.reliance.on.family,.community.and.charitable.NGOs.to.provide.assistance.to.those. that.have.fallen.into.poverty.or.other.problems..Outside.the.social.sectors,.government. policies.vary.in.regard.to.economic.growth.strategies,.with.some.almost.entirely.dependent. on.state.enterprise,.while.others.are.more.liberalized.in.their.approach.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.5 HuMAN.DEVELOPMENT.IN.THE.PACIFIC Framework, Methodology and Outline of the Report 1 3 The.Pacific.Islands.Human.Development.Review.has.progressed.through.three. phases.of.work..First,.the.team.examined.the.evidence.on.social.outcomes.to. understand.with.more.precision.what.the.performance.problems.are.in.the.Pacific,.and. in.particular.the.distribution.of.outcomes.among.different.societal.groups,.such.as.rich. and.poor..Census.data.was.used,.so.that.results.could.be.compared.with.some.rigor.across. countries..Then.the.team.pursued.the.funding.question,.to.ascertain.how.much.Pacific. countries.spend.on.their.social.services,.and.how.abundant.are.donor.and.government. resources.flowing.into.education.and.health.in.comparative.terms..The.third.phase.entailed. country.specific.study.teams.working.in.four.countries.in.depth,.attempting.to.understand. better.the.causes.of.performance.problems.in.social.service.provision. 1 4 This.report.is.thus.a.synthesis.of.the.many.analytical.inputs.that.were.prepared. as.part.of.the.Pacific.Islands.Human.Development.Review..Given.the.dominant. position. of. government. in. education. and. health,. while. acknowledging. the. presence. of. private.for-profit.and.not-for-profit.providers,.the.emphasis.of.this.report.is.on.the.role. of.government.in.achieving.human.development.outcomes..Governments.discharge.their. responsibilities.for.human.development.outcomes.by.providing,.financing.and.regulating. social.services..In.areas.where.there.are.externalities.or.market.failures.predominate.(such.as. the.absence.of.a.health.insurance.market.requiring.public.provision.and.financing.of.hospital. services).there.is.clearly.a.role.for.direct.involvement.of.government.in.service.provision.. Another.area.is.in.ensuring.equitable.access.to.services.to.poor.and.vulnerable.groups.in.the. society..where.such.direct.involvement.is.not.essential,.collaboration.with.private.sector. and.other.partners.can.help.achieve.better.outcomes..Either.delivering.social.services.often. entail.a.complex.set.of.institutional.arrangements..The.report.uses.a.framework.of.analysis. designed.to.explore.how.the.different.actors.in.social.service.delivery.­.policy.makers,.front. line.service.providers,.and.their.family.based.clients.­.interacted.with.one.another.to.either. depress.or.stimulate.service.performance..It.looked.at.accountability.relationships.between. these.various.actors.and.the.institutional.changes.that.would.be.required.to.strengthen. these.relationships.to.achieve.desired.outcomes..This.involved.less.focus.on.supply-side. constraints.(which.nonetheless.figured.prominently).and.more.attention.to.demand-side. issues.at.both.the.individual.and.community.level,.to.governance.and.transparency.aspects,. and.financing.and.expenditure.management.. 1 5 The.framework.places.effectiveness.of.government.in.discharging.its.responsibilities. in.three.different.policy.domains:.service expansion, sectoral management,. and multi-stakeholder governance. Governments.can.manage.service expansion with. new.resources;.they.can.better.manage.the.sector.so.as.to.ensure.that.existing.resources. (no.matter.what.the.source.or.who.delivers.the.service).are.effective.in.achieving.higher. outcomes;.or.they.can.reach.outside.the.sectoral.ministries.to.engage.broad.governance. reforms.that.will.enhance.the.operating.environment.for.social.services.and.thus.raise.their. potential.impact..These.domains.reflect.the.role.of.government.as.a.provider,.financier,. manager.and.regulator.of.social.services.. 1 6 The.framework.thus.helps.refine.the.paradigm.for.development.in.the.Pacific.by. emphasizing.accountability.for.improved.outcomes.7.Pacific.governments.and.civil. society.no.longer.assume.an.automatic.impact.from.resources.spent.on.social.services,.but. are.trying.to.introduce.new.institutional.arrangements.and.management.instruments.that. target.services.to.those.in.need,.that.direct.public.budget.resources.to.programs.that.have. high.returns,.and.assign.accountabilities.more.clearly.to.the.front.line.where.services.and. 6.|.wORLD.BANK CHAPTER.1 clients.meet..They.are.also.realizing.that.the.larger.gains.in.performance.may.come.from. cooperation.with.partners.outside.their.delivery.apparatus,.such.as.ministries.of.finance,. local.government,.civil.service.commissions,.NGOs.and.community.organizations.. 1 7 In. this. framework,. a. range. of. accountability. oriented. interventions. tend. to. coalesce.in.each.of.the.policy.domains..Thus,.service expansion.refers.to.the. more.familiar.efforts.in.the.Pacific.to.recruit,.train.and.qualify.staff,.and.build,.expand.and. equip.facilities..This.is.the.policy.domain.of.input.planning.and.logistics..Management refers. to. the. techniques. that. sectoral. policy. makers. can. utilize. to. get. more. out. of. the. existing.resources.at.hand..Examples.are.delegation.of.responsibilities.to.local.providers,. setting.standards,.targeting.services.to.those.in.need,.cash.and.in.kind.incentives.to.staff. and.allocating.resources.to.priority.programs.and.functions..governance.initiatives.deal. directly.with.broader.forces.and.actors.outside.ministries.that.can.have.such.a.large.effect. on.sectoral.performance.and.are.regulated.by.government.as.a.whole.in.the.interest.of. the.public.good..These.include.the.areas.of.information.gathering.and.use,.transparent. processes.and.information.sharing,.service.decentralization.to.local.governments,.building. partnerships.with.private.providers,.use.of.prices.and.costs.to.attract.more.clients.and. manage.demand,.and.community.mobilization.and.participation.. 1 8 It. is. reasonable. to. expect. public. bureaucracies. to. exhaust. the. more. accessible. initiatives. in. capacity. building. before. taking. up. the. more. difficult. tasks. in. management,. and. certainly. before. the. multi-stakeholder. coordination. and. negotiation. involved. in. governance. initiatives.. In. some. cases,. capacity. expansion. and. sectoral. management.will.be.closely.linked,.as.management.reforms.are.introduced.so.that.new. facilities.and.staff.perform.at.a.higher.level..As.will.be.presented.in.the.chapters.to.follow,. most.Pacific.countries.have.built.substantial.service.capacities.in.education.and.health,.and. are.now.turning.to.issues.of.under.performance.from.the.existing.stock..Management,.and. in.some.cases.governance,.policies.will.more.likely.deliver.outcome.improvement.in.those. cases.where.the.performance.issues.are.dependant.on.improving.counterproductive.client. behavior..A.dramatic.example.in.health.is.the.weak.adherence.to.public.health.guidance. and.treatment.regimens.among.adults.suffering.from.NCDs,.such.as.diabetes..However,. in.social.protection.for.example,.government.capacities.are.rare.or.non.existent.in.most. countries.(Fiji.and.Kiribati.excepted),.and.in.order.to.make.headway.in.managing.social. risks,.governments.will.need.to.build.substantial.new.capacities.. 1 9 The.report.is.organized.as.follows..As.a.starting.point.for.analysis,.Chapter.2.seeks. insights.in.the.performance.of.broad.human.development.outcomes.in.the.Pacific. (at.the.level.of.the.MDGs),.and.then.in.Chapter.3,.examines.the.scale.of.public.resources. that.finance.social.services.country.by.country,.and.the.relationship.of.these.two.with.the. way.services.are.organized.and.governed..Sectoral.chapters.are.next,.dealing.with.education,. health,.and.social.protection.respectively..The.role.of.donors.in.financing.social.services.is. covered.in.Chapter.7..The.final.chapter.provides.a.summary.of.promising.policy.options. that.Pacific.Island.countries.could.consider.in.their.efforts.to.raise.outcome.performance.. . Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.7 8.|.wORLD.BANK 2 Social Outcomes and Service Delivery - Where Does the Pacific Stand? Progress Toward the Millennium Development Goals 1 Progress.in.improving.social.outcomes,.as.reflected.in.the.MDGs.and.their.associated. indicators.and.targets,.is.mixed.both.within.Pacific.Island.countries.and.across.the. region.(see.Figure.2-1)..Some.countries.have.made.great.strides.toward.MDG.targets,.while. others.will.require.substantial.efforts.(those.that.are.shown.as.off.track.for.a.given.indicator).. Moreover,.within.countries,.performance.varies.from.one.MDG.goal.to.another.. 2 It.is.clear,.however,.that.Pacific.countries.perform.well.overall.when.compared.to.other. countries.of.similar.per.capita.income..The.three.charts.in.Figure.2-1.show.the.expected. value.for.the.social.indicators.(net.primary.enrollment,.u5MR,.and.life.expectancy).based. on.developing.countries.globally,.and.the.actual.indicators.for.the.Pacific.countries.8 Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.9 SOCIAL.OuTCOMES.AND.SERVICE.DELIVERy.-.wHERE.DOES.THE.PACIFIC.STAND? FIguRE 2-1: PERCENt DEvIatION bEtWEEN PREDICtED aND aCtual valuES FOR SOCIal OutCOME INDICatORS % Difference from predicted net primary enrollment rate (R-square=0.23) 140% 120% 100% 80% 60% ga 40% ijFi Ton 20% itabiriK MSF nuatuaV lauaP 0% -20% ao 0 2000 IMR 4000 6000 8000 10000 -40% Sam -60% -80% -100% -120% -140% .sI.loS GDP per capita (PPP adjusted, 1990s average) NEt PRIMaRy ENROllMENt (147 COuNtRIES) % Differencefrom predictedunder 5mortality rate(R-square=0.33) 400% 300% 200% 100% IMR 0% 0 2000 4000 6000 8000 10000 -100% -200% itabiriK .sI.loS ijFi lauaP -300% nuatuaV aom ga Sa -400% MSF Ton GDP per capita (PPP adjusted, 1990s average) uNDER 5 MORtalIty RatE (168 COuNtRIES) % Differencefrom predictedlife expectancy (R-square=0.40) 20% ga 16% MSF nuatuaV Ton 12% ijFi 8% itabiriK lauaP 4% .sI.loS aom Sa 0% 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 -4% -8% -12% -16% GDP per capita (PPP adjusted, 1990s average) -20% lIFE EXPECtaNCy (172 COuNtRIES) 10.|.wORLD.BANK CHAPTER.2 Education 3 A.closer.look.at.education.indicators.show.that,.while.net.primary.enrollment.rates. have.been.high,.rates.of.primary.school.completion.and.of.transition.to.secondary. school.remain.a.concern..Also,.the.data.indicates.high.levels.of.school.drop.outs.in.some. countries.and.low.student.achievement.levels.. 4 Fiji,.Samoa,.and.Tonga.have.had.net.primary.enrollment.rates.of.above.90.percent. since.the.1990s..But.in.RMI.net.enrollment.rates.have.declined.in.the.past.decade,. while.in.Vanuatu.enrollment.rates.have.barely.managed.to.keep.up.with.population.growth.. Among.those.who.do.enroll,.retention.rates.(measured.by.survival.to.grade.5.figures).are. not.increasing.rapidly.enough.to.meet.the.2015.MDG.targets.in.seven.of.the.nine.countries. (Table.2-1)..These.low.retention.rates.mean.that.many.children.do.not.stay.in.school.long. enough.to.acquire.the.skills.to.become.productive.members.of.society.. tablE 2-1: KEy EDuCatION INDICatORS aND PROSPECtS FOR REaCHINg tHE MIllENNIuM DEvElOPMENt gOalS by 20159, RECENt yEaRS Goal 2 Goal 2 Goal 3 Target 3 Target 3 Target 4 Countries Net enrollment rate in Grade 5 survival rate Eliminate gender disparity primary grades in primary education Fiji 98 88.4 0.98 Kiribati 95 86.3 0.93 RMI 86 86.1 0.83 FSM 82 71.9 0.93 Palau 88 N/A N/A 0.97 Samoa 98 97.3 0.93 Solomon.Islands 56 85.0 0.86 Tonga 99 84.0 0.90 Vanuatu 74 91.2 0.91 Achieved unlikely Likely N/A:.Not.available Note: Whether countries are likely to achieve their MDGs, is determined by comparing the current value of the appropriate indicator to the value on the `ideal trend line.' The `ideal trend line' is plotted using a country's baseline value for the given indicator for 1990 (or nearest date according to available census or household data) and the target for 2015. This is compared to the `actual trend line,' which plots a country's progress on the given indicator from its 1990 baseline value to the most recent year for which census or household survey data is available. 5 The.mixed.performance.in.these.indicators.is.mirrored.in.high.drop.out.rates,.and. low.student.achievement.levels..Analysis.of.poverty.rates.in.the.Pacific.has.been. fairly.limited,10.but.the.effect.of.low.income.and.hardship.can.be.seen.in.such.indicators. as. the. percentage. of. primary. school. drop. outs. and. of. children. who. never. attended. school,.as.depicted.below.in.Figure.2-2..Enrollments.and.survival.to.grade.5.are.only. proxy.indicators.for.the.achievement.of.a.minimum.standard.of.primary.education;. they.do.not.measure.the.quality.of.learning..Testing.students.is.the.most.direct.way. to. reveal. whether. they. are. learning. or. not.. In. many. Pacific. Island. nations,. student. performance.on.national.examinations.or.PILL.tests11.indicate.a.low.level.of.learning. in.literacy.and.numeracy..For.example,.in.English.literacy.tests.during.the.mid.1990s,. over.40.percent.of.students.in.several.countries.were.found.to.be.`at.risk'.in.year.4,.and. by.year.6.the.situation.was.even.worse.12. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.11 SOCIAL.OuTCOMES.AND.SERVICE.DELIVERy.-.wHERE.DOES.THE.PACIFIC.STAND? FIguRE 2-2: CHIlDREN NEvER ENROllED IN SCHOOl aND SCHOOl DROP OutS 14 Dropped Out 12 Never Been to School 10 8 6 4 2 0 6991ijFi 1002aomaS 1996 2000 ngaoT batiiriK 0002ualaP 2000 1999 1999 MSF nuatuaV RMI Source: Census data. Health 6 In.health,.most.countries.in.the.Pacific.have.seen.significant.declines.in.u5MR.in.the. past.few.decades..Kiribati,.Solomon.Islands,.Vanuatu.and.RMI.had.u5MR.above.50. per.1,000.live.births.in.the.1990s..Vanuatu.and.RMI.have.shown.real.progress.by.lowering. their.u5MR.by.60.percent.and.50.percent.respectively.in.the.past.decade.(Figure.2-3)..For. Solomon.Islands.and.Kiribati,.efforts.need.to.be.focused.on.ensuring.that.the.MDG.goal. of.a.two.thirds.reduction.in.u5MR.is.achieved..Clearly,.for.most.of.the.other.countries.in. the.region,.with.u5MR.ranging.between.20.and.30.per.1,000.live.births;.achieving.further. declines.in.mortality.rate.will.be.a.substantial.challenge.. FIguRE 2-3: uNDER-FIvE MORtalIty RatES aND PROSPECtS FOR aCHIEvINg MDg taRgEt IN 2015 (1990-2000) 100 1990 2000 90 2015 target 80 70 60 50 40 30 20 10 0 Fiji Kiribati Marshall FSM Palau Samoa Solomon Tonga Vanuatu Islands Islands Source: SPC MDG Website, Country reports. 12.|.wORLD.BANK CHAPTER.2 7 Between.1985.and.2000,.the.total.fertility.rate.(TFR).decreased.in.all.nine.countries,. but.the.decline.was.gradual.(see.Figure.2-4)..while.fertility.rates.have.been.declining. in.the.Pacific,.women.in.the.lowest.wealth.quintile.saw.a.smaller.decrease.than.those.in. the.highest.wealth.quintile.in.the.five.countries.where.data.is.available.(Fiji,.FSM,.Tonga,. Kiribati.and.Palau). FIguRE 2-4: tOtal FERtIlIty RatES aRE DEClININg, but tHE DEClINE IS lOWER aMONg WOMEN IN tHE lOWESt WEaltH quINtIlES (1985-2000) Palau Lowest 20% 7 Kiribati Highest 20% Tonga ijiF 1982 FSM 6 Fiji 1996 1985 5 MSF 1999 4 agnoT 1982 3 1996 itabiirK 1985 2 1999 1 ualaP1985 2000 0 0 2 4 6 8 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Source: International Data Base of US Census Bureau. Contraceptive.prevalence.rates.are.reported.to.be.low,.averaging.around.25-35.percent.in. most.countries.(Table.2-2)..while.all.available.estimates.indicate.that.maternal.mortality. ratios.(MMR).are.relatively.high.in.some.countries.in.the.Pacific.(Solomon.Islands,.Fiji,.FSM,. Kiribati),.these.ratios.vary.widely.from.one.database.to.another..The.discordant.data.make. it.difficult.to.ascertain.whether.countries.are.on.track.for.reducing.their.MMR..In.addition,. in.the.smaller.Pacific.Islands.countries,.such.as.Palau,.low.number.of.annual.births.and.the. even.lower.incidence.of.maternal.deaths.imply.that.MMR.is.not.an.appropriate.indicator.. In.most.countries,.the.percent.of.attended.deliveries.are.high.(Table.2-2).--however.this. only.indicates.that.these.deliveries.took.place.in.health.facilities.and.not.necessarily.that. these.births.were.attended.by.personnel.trained.to.manage.a.normal.delivery.and.diagnose. or.refer.obstetrical.complications. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.13 SOCIAL.OuTCOMES.AND.SERVICE.DELIVERy.-.wHERE.DOES.THE.PACIFIC.STAND? tablE 2-2: KEy HEaltH INDICatORS, RECENt yEaRS IMR Total Fertility Contraceptive Attended Measles Rate Prevalence Rate Deliveries Immunization Rate Fiji 16 2.7 44 99 73.6 Kiribati 43 3.6 26 85 76 FSM 40 3.5 25-35% 88 84 RMI 29 5.7 34 85 80 Palau 17 2.6 17 100 99 Samoa 18 4.0 30 80 98 Solomon.Islands 66 5.3 10 36 77 Tonga 13 3.4 33 95 95.8 Vanuatu 27 4.3 28 88 94 Source: International DataBase , US Census Bureau, Census Data, SPC MDG Website. 8 Malaria.is.prevalent.in.Solomon.Islands.and.Vanuatu..In.the.1990s,.Solomon.Islands. brought.malaria.incidence.down.to.155.per.1,000.population.from.455.--a.considerable. achievement--. but. the. country. has. suffered. a. setback. in. this. respect. since. the. recent. economic.crisis.and.the.ethnic.tensions.13.In.Vanuatu,.the.incidence.of.malaria.in.2002.was. 69.per.1,000.population,.down.from.85.per.1,000.population.in.1992..The.reported.number. of.HIV/AIDs.cases.remains.low.in.the.Pacific,.but.it.is.rising..Lack.of.routine.monitoring.and. surveillance,.however,.masks.the.true.picture.of.the.extent.of.HIV.infections.(Figure.2-5).. FIguRE 2-5: INCIDENCE OF HIv/aIDS IS StIll lOW, but RISINg (1997 aND 2005) 160 Reported cases 1997 140 Reported cases 2005 120 Cases per 100,000 population 1997 Cases per 100,000 population 2005 100 80 60 40 20 0 Fiji Kiribati FSM RMI Palau Samoa Solomon Is. Tonga Vanuatu Source: MDGs Report, SPC Inequities by Socioeconomic Status 9 Broad. aggregate. indicators. used. to. measure. progress. toward. MDGs. need. to. be. supplemented.with.household.income.data.in.order.to.see.the.substantial.variations. in.human.development.outcomes.according.to.family.socio-economic.status..For.this.study,. a.household.wealth.index.methodology.has.been.applied.to.available.census.data.to.obtain. a.measure.of.long-term.household.income.14. 14.|.wORLD.BANK CHAPTER.2 1 0 In.the.Pacific.Islands,.differences.in.net.school.enrollment.rates.by.household. income.are.not.pronounced.at.the.primary.level,.but.are.so.at.the.secondary.level,. indicating.that.children.from.poorer.households.are.less.likely.to.make.it.to.secondary. school.(Figure.2-6)..In.some.countries,.these.differences.can.be.quite.pronounced,.as.in. Vanuatu.and.Samoa,.where.children.from.the.top.income.quintile.show.enrollment.rates. higher.by.20.percent.than.the.poorest.. FIguRE 2-6: CHIlDREN FROM WEaltHy FaMIlIES aRE MORE lIKEly tO REaCH SECONDaRy SCHOOl Vanuatu 1999 Vanuatu 1999 Lowest Wealth Quintile Samoa 2001 Samoa 2001 Highest FSM 2000 FSM 2000 Wealth Quintile RMI 1999 RMI 1999 Kiribati 1995 Kiribati 1995 Palau 2000 Palau 2000 Fiji 1996 Fiji 1996 Tonga 1996 Tonga 1996 0 20 40 60 80 100 0 20 40 60 80 100 Net Primary School Enrollment Rate Net Secondary School Enrollment Rate Source: Census data. 1 1 Another.issue.of.concern.is.that.children.who.have.dropped.out.of.primary.school. or.who.never.entered.tend.to.come.from.disadvantaged.families. As.shown.in. Figure.2-7.below,.the.poorest.families.outnumber.the.richest.in.school.drop.outs.in.all. Pacific.countries,.and.particularly.so.in.FSM,.Vanuatu,.RMI,.and.Samoa..This.relationship.is. an.indication.of.the.importance.of.targeting.social.assistance.to.poor.families.with.children. out.of.school.for.two.reasons:.the.first.being.that.they.are.poor.and.may.need.assistance.to. cover.cash.schooling.costs;.and.second,.scarce.government.resources.will.be.saved.if.poor. instead.of.the.better-off.families.receive.such.assistance.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.15 SOCIAL.OuTCOMES.AND.SERVICE.DELIVERy.-.wHERE.DOES.THE.PACIFIC.STAND? FIguRE 2-7: Out OF SCHOOl CHIlDREN COME FROM POOR HOuSEHOlDS Lowest 20% Fiji 1996 Highest 20% Tonga 1996 Kiribati 2000 Samoa 2001 Palau 2000 Vanuatu 1999 RMI 1999 FSM 2000 0 5 10 15 20 25 Percent of school-age children in wealth quintile Source: Census data Social Protection 1 2 Social.protection.refers.to.the.arrangements.that.households,.communities.and. governments. make. to. manage. the. risks. that. can. cause. immediate. and. severe. harm.to.individuals.and.their.families,.often.in.the.form.of.catastrophic.costs.or.substantial. unexpected.loss.of.income..Statistics.on.risk.in.the.Pacific.are.relatively.scarce,.but.in.two. cases,.unemployment.and.disability,.reliable.data.can.be.presented..There.are.many.other. categories.of.social.risk.for.which.reliable.data.is.lacking,.such.as.severe.or.chronic.poverty,. destitution.in.old.age,.orphaned.children,.victims.of.natural.disasters.or.civil.strife,.and. social.problems.such.as.alcohol.abuse,.suicides.and.crime.. 1 3 Figure.2-8.presents.unemployment.rates.according.to.the.most.recent.censuses. in.all.nine.Pacific.countries.15.The.results.show.clearly.several.important.patterns.. First,.there.is.wide.variation.in.unemployment.rates.among.Pacific.countries..Solomon. Islands.reports.much.higher.levels.of.unemployment.than.the.other.countries,.with.the. former. registering. over. 30. percent. unemployment.. In. Tonga,. FSM,. and. RMI,. rates. are. moderate.(in.Tonga.and.Fiji,.officials.report.an.increase.since.1996)..It.is.important.to. note.that.in.countries.where.the.measured.unemployment.rate.is.very.low.(e.g..Kiribati). employment.is.predominately.in.subsistence.work..A.second.important.pattern.is.the.high. level.of.youth.unemployment..while.expected.to.be.relatively.high.in.any.labor.market,. youth.unemployment.is.more.than.double.the.total.unemployment.rate.in.five.of.the.Pacific. countries.(Samoa,.Tonga,.Fiji,.RMI,.and.Palau)..More.recent.data,.if.available,.would.alter.the. picture,.but.anecdotal.information.from.recent.visits.indicates.the.continuing.importance. of.youth.unemployment.in.the.Pacific. 16.|.wORLD.BANK CHAPTER.2 FIguRE 2-8: yOutH uNEMPlOyMENt RatES aRE HIgH IN SOME COuNtRIES 50 Youth (15-24) 45 Female 40 Male 35 Total 30 25 20 15 10 5 0 Vanuatu FSM RMI Solomon Tonga Palau Samoa Fiji Kiribati 1999 2000 1999 Islands 1999 1996 2000 2001 1996 2000 Source: Census Data16 1 4 Disability.affects.a.small.proportion.of.Pacific.island.populations,.but.disabled. people.are.more.likely.to.be.poor.than.the.non-disabled. Analysis.of.disability.is. just.beginning.in.the.Pacific..using.census.data.and.wealth.index.values.for.each.household,. a. preliminary. picture. of. disability. can. be. presented. in. Figure. 2-9. below.. Caution. in. interpretation.is.important;.two.of.the.countries.only.recorded.disability.for.those.aged.15. and.above.(Tonga.and.Vanuatu),.and.only.Fiji.shows.data.on.the.type.of.disability.(hearing,. seeing,.speaking,.moving,.gripping,.mental.and.multiple)..what.can.be.drawn.from.this. data.set.is.essentially.three.tentative.conclusions: ·. Rates.of.disability.(without.any.controls.for.types.of.disability.or.definitions.used).are. between.1.and.3.percent; ·. The.disabled.are.more.likely.to.be.poor.than.the.non-disabled,.except.for.Samoa;.and, ·. Education,.like.income,.seems.to.be.inversely.correlated.with.disability. 1 5 These.results.follow.in.broad.terms.the.patterns.found.for.East.Asia,.both.for. correlations.with.socio-economic.indicators.and.for.the.prevalence.data.17.The. findings. for. the. Pacific,. however,. could. benefit. from. a. more. thorough. and. coordinated. approach.to.measuring.disability,.such.that.definitions.would.be.harmonized,.and.more. informative.survey.instruments.developed..The.census.based.analysis.may.under-count. disabled.people..The.main.policy.issue,.as.will.be.discussed.later.in.Chapter.6,.is.whether. governments.have.taken.a.sufficiently.engaged.stance.in.regard.to.disabled.people.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.17 SOCIAL.OuTCOMES.AND.SERVICE.DELIVERy.-.wHERE.DOES.THE.PACIFIC.STAND? FIguRE 2-9: DISabIlIty IN tHE PaCIFIC 4.5 % of Population 4.0 % in Lowest Income Quintile % in Highest Income Quintile 3.5 t 3.0 encrep 2.5 2.0 1.5 1.0 0.5 0.0 Solomon Is. Fiji Tonga Vanuatu RMI Samoa Kiribati Source: Census data. Human Development Agenda in the Pacific 1 6 As.shown.above,.coverage.of.key.services.­.education.and.health.-.has.increased. in. most. countries. in. the. region. leading. to. improvements. in. social. outcomes.. Progress,. however,. has. been. unequal. between. countries,. among. the. different. social. indicators,.and.between.income.groups..The.agenda.for.human.development.in.the.Pacific. has.two.dimensions:.closing.remaining.performance.gaps,.and.reducing.the.inequities.that. underlie.those.gaps.. 1 7 Outcomes.by.themselves.reflect.the.results.of.past.investments,.and.most.critically,. the.past.decisions.of.policy.makers,.social.service.providers,.and.the.people.who. use.the.services..In.the.next.chapter,.the.role.of.financial.resources.is.examined.for.Pacific. social.services..would.more.resources.close.gaps.and.reduce.inequities.in.social.indicators,. or.are.there.other.factors.at.play? 18.|.wORLD.BANK 3 Resources for the Social Sectors and their Effectiveness 1 How.well.funded.are.social.sector.services.in.the.Pacific?.Are.donor.and.government. resources.for.education.and.health.services.generous.and.abundant.compared.to.other. comparable. developing. countries?. And. how. effective. are. these. resources. in. delivering. improvements.in.health.and.education.outcomes?.Those.questions.animate.this.chapter.. Social.protection.is.largely.excluded.from.this.chapter.because.of.three.considerations:.first,. the.level.of.social.protection.spending.is.low.in.most.Pacific.Island.countries;.second,.the. responsible.agencies.and.ministries.that.do.spend.on.such.services.as.retirement.benefits,. social.welfare.transfers,.and.employment.programs.are.scattered.widely.in.government,. making.expenditure.calculations.more.complex.than.for.education.and.health.services;.and. third,.the.range.of.outcome.indicators.in.social.protection.is.wide,.making.the.expenditure. effectiveness.analysis.much.more.demanding.than.for.education.and.health.18 Public Spending on Social Sector Services 2 Virtually.all.social.spending.in.Pacific.Island.countries.is.financed.by.governments.with. substantial.donor.assistance..Household.spending.is.in.most.cases.modest.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.19 RESOuRCES.FOR.THE.SOCIAL.SECTORS.AND.THEIR.EFFECTIVENESS tablE 3-1: PaCIFIC ISlaND COuNtRIES SPEND a SubStaNtIal SHaRE OF tHEIR PublIC RESOuRCES ON HEaltH aND EDuCatION SECtORS (1997-2003) Average annual government expenditure (1997-2003) as % of GDP (constant 2000 USD) as % of total government expenditure . Education Health Total Education Health Total Fiji 5.2% 2.8% 8.0% 16.5% 8.8% 25.3% Kiribati 17.8% 12.5% 30.3% 21.1% 14.8% 35.9% RMI 13.1% 11.3% 24.5% 15.3% 12.8% 28.0% FSM 10.5% 5.8% 16.2% 16.0% 8.8% 24.8% Palau 7.7% 8.2% 15.9% 12.2% 13.1% 25.3% Samoa 5.3% 4.1% 9.4% 22.2% 17.5% 39.7% Solomon.Islands 7.3% 5.1% 12.4% 19.4% 13.0% 32.4% Tonga 4.9% 3.2% 8.2% 16.7% 11.1% 27.8% Vanuatu 5.7% 2.9% 8.6% 25.0% 12.6% 37.6% Low.and.middle.income 3.9% 2.8% 6.7% N/A N/A N/A East.Asia.and.Pacific 2.6% 1.8% 4.5% N/A N/A N/A Note: * `Compact' countries (RMI, FSM, Palau): government expenditure includes: (1) general fund, and (2) special fund (including Compact fund and the Federal grant). Compact capital fund is excluded. Expandable trust fund is included for RMI because of Health Care Fund. ** Kiribati, Solomon Islands and Vanuatu: government expenditure excludes government capital expenditure and any donor fund. *** Fiji, Samoa, and Tonga: government expenditure excludes any donor fund. Source: Budget books, World Development Indicators, PRISM 3 Between.1997.and.2003,.on.average,.government.spending.on.health.and.education. as.a.percentage.of.GDP.ranged.between.8.0.percent.to.30.3.percent.-.and.in.most.cases. was.at.par.or.above.spending.for.countries.at.similar.levels.of.income.(6.7.percent.is.the. average.for.low.and.middle.income.countries).and.certainly.above.the.East.Asia.and.Pacific. average.of.4.5.percent.(Table.3-1).19.Social.sector.spending.is.also.high.as.a.proportion. of.total.public.expenditure.in.the.Pacific.Island.countries..Most.countries.in.the.region. spend.over.a.quarter.of.their.total.public.expenditures.on.health.and.education,.and.some. such.as.Kiribati.and.Vanuatu.and.RMI.above.35.percent..On.a.per.capita.basis,.government. spending.on.health.and.education.combined.is.quite.variable,.from.uS$97.in.Solomon. Islands.to.nearly.uS$461.in.RMI.and.even.higher.in.Palau.(see.Table.3-2). 4 To. estimate. the. total. resources. flowing. to. the. social. sectors. in. the. Pacific,. donor. funding.must.be.considered..Funding.from.aid.agencies.constitutes.a.large.part.of.social. sector.spending.in.Pacific.Island.countries,.but.much.of.the.aid.is.off-budget,.and.is.thus. not.available.from.government.sources..The.flows.that.do.appear.on-budget.are.typically. recorded.as.capital.budget,.not.recurrent..A.more.comprehensive.source.for.aid.flows.is. donor-reported.assistance,.as.recorded.in.the.OECD.Development.Assistance.Committee. database. Between.1997.and.2003,.average.aid.commitments.per.capita.to.the.social.sectors. were.high.in.the.Pacific..As.shown.in.Table.3-2,.per.capita.aid.flows.in.the.Pacific.well.exceed. the.averages.of.aid.abundant.large.countries.and.the.group.of.small.countries.. 5 Table.3-2.includes.the.findings.on.government.spending.and.donor.aid.commitments. to.estimate.total.per.capita.resources.for.education.and.health.both.in.the.Pacific.and. in.the.comparison.groups..This.approach.thus.unifies.an.estimate.of.government.recurrent. expenditure.(almost.exclusively.funded.from.government.revenues).with.an.estimate.of. donor.financed.capital.projects.over.the.seven.year.time.period..There.are.inevitably.some. omissions.(the.main.omission.would.be.government.financed.capital.expenditure,.which. should.be.modest.everywhere,.given.country.reliance.on.donors.for.the.capital.budget,. except.perhaps.Fiji)..The.advantage.of.this.approach.is.that.it.is.able.to.use.similar.data. 20.|.wORLD.BANK CHAPTER.3 over.a.wide.array.of.countries,.which.can.thus.be.compared..It.certainly.is.not.an.exact. accounting.of.total.budget.commitments.or.expenditure,.but.the.estimates.in.Table.3-2. are.a.useful.estimate.of.total.resources,.that.combine.government.and.donor,.as.well.as. recurrent.and.capital,.to.arrive.at.a.proxy.for.total.official.resources.in.the.social.sectors.. 6 Not.surprisingly,.the.results.show.the.Pacific.once.again.in.front.of.the.comparison. groups.. Other. small. countries. are. also. generously. supported,. which. is. perhaps. a. consistent.feature.of.low.population.settings,.where.economies.of.scale.are.absent,.and.aid. and.government.overheads.consume.larger.proportions.of.assistance..However,.the.Pacific. ranks.the.highest.by.a.substantial.margin. tablE 3-2: tOtal RESOuRCES PER CaPIta FOR EDuCatION aND HEaltH, 1997-2003 Country GDP per capita Population Average Annual Average Annual Total (constant (`000s) Aid per capita Government Recurrent 2000 US$) for Education & Expenditures for Education Health & Health 2003 2003 (US$, 1997-2003) (US$, 1997-2003) Pacific.Islands: Fiji 2,184 835 18.6 166.0 184.6 Kiribati 530 96 40.5 157.4 197.8 RMI 1,802 59 70.1 461.7 531.8 FSM 1,846 125 18.2 293.9 312.1 Palau 6,331 20 41.6 1,006.8 1,048.4 Samoa 1,381 178 37.6 124.6 162.2 Solomon.Islands 617 457 16.7 96.6 113.3 Tonga 1,617 102 46.1 122.4 168.6 Vanuatu 1,103 210 45.8 104.4 150.1 Average 1,934.3 . 37.2 281.5 318.8 Low.income.countries.with.abundant.aid: Madagascar 233 16,894 4.2 12.2 16.4 uganda 277 25,280 6.8 11.3 18.1 zambia 354 10,403 13.1 21.1 34.2 Average 288.0 . 8.0 14.9 22.9 Other.small.island.countries: Belize 3,635 274 7.7 276.6 284.3 Comoros 363 600 13.8 30.0 43.8 Djibouti 848 705 36.5 60.2 96.7 Dominica 3,477 71 6.0 386.7 392.7 Dominican.Republic 2,436 8,739 9.9 85.6 95.4 Guyana 951 769 22.0 122.3 144.3 Haiti 463 8,440 8.0 10.4 18.4 Maldives 2,529 293 13.8 188.3 202.1 Sao.Tome.&.Principe 334 157 39.2 36.8 76.0 St..Vincent.&.Grenadines 3,226 109 28.8 471.7 500.4 Average 1,826.2 . 18.6 166.9 185.4 Note: * The figures of government expenditure for comparison countries are recurrent expenditures for the year 2003. ** Government expenditure on education for Sao Tome, Principe and Haiti is not available. *** Average government expenditure for the `Compact' countries (RMI, FSM, Palau) includes the Compact fund and Federal grants from the US. Source: OECD database, budget book, World Development Indicators Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.21 RESOuRCES.FOR.THE.SOCIAL.SECTORS.AND.THEIR.EFFECTIVENESS Governments and Donors are Spending with Mixed Results 7 Economic. growth. is. an. important. determinant. of. improved. human. development. outcomes,20.but.this.alone.may.not.be.enough.to.help.countries.achieve.their.MDGs.. It.has.been.estimated.that.average.GDP.per.capita.growth.would.need.to.be.6.7.percent.per. year.to.reduce.u5MRs.by.two.thirds.between.1990.and.2015.-.and.there.is.wide.variation. in.service.outcomes.achieved.for.any.GDP.growth.rate.21.In.the.Pacific.Islands,.GDP.growth. rates.have.fluctuated.widely.over.the.past.decade..It.is.thus.true.for.the.Pacific,.as.it.is. elsewhere,.that.governments.must.make.special.efforts.to.improve.social.outcomes,.but. judging.from.the.resources.flowing.into.education.and.health,.governments.have.made. special.efforts..Are.the.results.commensurate?. 8 In. the. Pacific. Island. countries,. just. as. in. the. developing. world. as. a. whole,22. the. association.between.public.spending.on.health.and.education.and.outcomes.in.these. two.sectors.(as.measured.by.u5MR.and.net.primary.school.enrollment.rates).is.weak.when. other.variables.such.as.income.are.held.constant.(Figure.3-1).. 9 Evidence.suggests.that.public.resources.are.most.effective.when.targeted.to.specific. populations.and.income.levels.-.e.g..reducing.child.mortality.among.families.in.the. lowest. wealth. quintile. (lowest. 20. percent).23. A. successful. example. of. targeting. is. the. malaria. control. program. of. Solomon. Islands,. which. between. 1992. and. 1999. reduced. malaria.prevalence.rates.three-fold.(from.455.to.155.per.1,000.population).24.In.almost.all. Pacific.Island.countries,.a.high.proportion.of.government.spending.is.devoted.to.curative. care.services.and.overseas.treatment.(around.70.percent.of.the.recurrent.health.budget). -.services.used.by.the.better.off,.leaving.little.available.for.cost-effective.preventive.primary. care. and. public. health. services. which. are. used. by. all.. This. implies. that. there. is. much. more.scope.for.redirecting.available.public.resources.to.services.(primary.and.preventive. care).that.could.improve.the.outcomes.of.those.worse.off..Similarly.in.education,.much. of.Vanuatu.and.Solomon.Islands'.resources.were.focused.on.secondary.education--with. detrimental.effects.on.the.primary.school.system--despite.common.knowledge.that.social. returns.to.education.are.greatest.at.the.primary.level..As.a.result.of.a.catastrophic.decline. in.operational.grants.to.primary.schools.in.Solomon.Islands.between.1993.and.1999,.year. 4.literacy.declined.by.15.percent,.and.numeracy.by.9.5.percent.25 1 0 Public.resources.also.should.be.directed.to.activities.for.which.there.is.little.private. sector.interest..If.families,.rich.and.poor,.are.purchasing.in.competitive.markets. the.resources.they.need,.or.are.helping.one.another.with.gifts.and.credit,.governments. may.consider.the.option.of.not.intervening..In.many.countries.worldwide,.for.example,. the.private.sector.is.highly.effective.in.making.pharmaceuticals.widely.available.and.at.low. cost..Governments.need.not.duplicate.this.system,.but.might.complement.it.with.support. for.drugs.that.are.under.utilized.or.poorly.complied.with,.such.as.malaria,.TB.and.leprosy. therapies..Control.of.communicable.diseases.involves.a.public.role,.because.markets.seldom. take.account.of.the.benefits.of.widespread.prevention,.or.of.full.course.treatments..Another. example.is.social.assistance.to.families.that.have.experienced.a.sudden.misfortune..In.the. Pacific.and.elsewhere,.families.and.communities.play.a.strong.traditional.role.in.helping. those. less. fortunate. and. in. difficulty.. Governments. should. engage. only. where. those. mechanisms.are.failing.or.are.clearly.inadequate.to.address.the.scale.and.depth.of.risk.to. family.welfare.. 22.|.wORLD.BANK CHAPTER.3 FIguRE 3-1: tHE aSSOCIatION bEtWEEN PublIC SPENDINg ON HEaltH aND EDuCatION aND OutCOMES IN tHESE tWO SECtORS - aFtER CONtROllINg FOR NatIONal INCOME ­ IS WEaK 150 150 etaR 100 t 100 50 50 alitytroM5rednU 0 llmenornEy 0 -50 -50 -100 PrimarteN-100 -150-150 -150 -100 -50 0 50 100 150 0 1 2 3 4 5 6 7 8 Per capita public spending on health Per capita expenditure on education y = -0.0886x + 16.809 y = 1.9818x + 9.9856 R2 = 0.0174 R2 = 0.024 Note: Public spending, under-five mortality and net primary enrollment are given as a percent deviation from rate predicted by GDP per capita. Source: World Development Indicators. 1 1 Targeting.public.services.to.the.poorest.is.an.important.but.not.sufficient.step.to. improve.outcomes;.in.addition,.services.must.function.effectively..In.other.words,. teachers.must.be.well.qualified.and.present.at.school;.and.health.personnel.must.know. how.best.to.provide.care.to.their.patients.and.be.available.at.health.centers..In.Solomon. Islands.and.Kiribati,.for.instance,.it.has.been.difficult.for.the.government.to.place.doctors. and.teachers.in.the.remote.provinces..A.1996-1997.study.reported.that.teachers.were.away. from.school.(in.addition.to.their.regular.leave.allowance).on.average.18.days.per.year.in. Marshall.Islands,.22.days.in.Chuuk.State.of.FSM,.and.11.days.in.Palau.26 1 2 Growing. evidence. shows. that. while. targeted. spending. could. improve. MDG. outcomes.in.poorly.governed.countries,.good policies and institutions are crucial to ensuring the productivity of public spending.27.The.report.Governance:. The World Bank's Experience. broadly. defines. good. governance. as. "epitomized. by. predictable,. open,. and. enlightened.policy.making;.a.bureaucracy.imbued.with.a.professional.ethos;.an.executive. arm.of.government.accountable.for.its.actions;.and.a.strong.civil.society.participating.in. public.affairs;.and.all.behaving.under.the.rule.of.law."28.A.wealth.of.international.evidence. suggests.that.good.policies.and.institutions.are.linked.to.economic.growth,.and.specifically. growth.in.per.capita.income.29.Moreover,.it.is.associated.with.greater.income.growth.for. the.poorest.quintiles.than.for.the.richest,.suggesting.that.appropriate.policies.and.well. managed.institutions.that.target.the.poorest.can.make.the.greatest.difference.among.those. who.need.help.the.most.30.It.is.also.linked.to.aid.spending.and.improvements.in.social.sector. outcomes..when.implemented.in.a.sound.policy.environment.and.by.effective.institutions,. foreign. aid. has. a. positive. relationship. with. growth. and. reduces. infant. mortality31. and. improves.educational.outcomes.32. 1 3 These.findings.are.also.borne.out.by.the.results.of.an.analysis.undertaken.for.this. report,.in.which.the.quality.of.policies.and.institutions.was.ranked.using.three. indicators.measuring.government.effectiveness,.rule.of.law,.and.regulatory.burden.from.the. Kaufmann,.Kraay.and.zoido-Lobaton.(KKz).database.on.aggregate.governance.indicators. (see.Box.3-1.on.how.the.indicators.have.been.constructed). Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.23 RESOuRCES.FOR.THE.SOCIAL.SECTORS.AND.THEIR.EFFECTIVENESS bOX 3-1: KauFMaNN, KRaay aND ZOIDO-lObatON (KKZ) aggREgatE gOvERNaNCE INDICatORS D.. Kaufmann,. A.. Kraay,. and. P.. zoido-Lobaton. constructed. the. KKz. database. from. a. variety.of.sources..The.31.different.indicators.of.governance.were.developed.in.1997. and.1998.by.compiling.responses.on.the.quality.of.governance.from.a.number.of.large. surveys.conducted.among.enterprises,.citizens.and.experts.in.industrial.and.developing. countries,. including. the. Pacific. Island. countries.. The. data. was. provided. by. survey. institutes,.think.tanks,.non-governmental,.and.international.organizations.and.includes. one.hundred.and.sixty.countries..Each.governance.indicator.in.the.database.measures. the.relative.position.of.countries,.i.e..the.mean.of.each.indicator.is.zero..The.indicators. are.grouped.into.six.clusters.corresponding.to.six.basic.aspects.of.governance:.voice.and. accountability,.political.instability.and.violence,.government.effectiveness,.regulatory. burden,.rule.of.law,.and.graft..The.three.measures.of.governance.included.in.the.analysis. conducted.under.the.study.are:. (1).Government. effectiveness:. This. measures. the. effectiveness. and. efficiency. of. government. in. providing. public. services,. the. quality. of. the. bureaucracy,. the. competence. of. civil. servants,. the. independence. of. the. civil. service. from. political. pressures,.and.the.credibility.of.the.government's.commitment.to.policies. (2).Rule.of.law:.This.measures.the.extent.to.which.agents.have.confidence.in.and.abide.by. the.rules.of.society,.effectiveness.of.the.predictability.of.the.judiciary.and.enforceability. of.contracts.. (3).Regulatory.burden:.This.measures.the.incidence.of.market-unfriendly.policies.such. as. price. controls. or. inadequate. bank. supervision,. as. well. as. perceptions. of. the. burdens.imposed.by.excessive.regulation.in.areas.such.as.foreign.trade.and.business. development.. Source: Daniel Kaufmann, Aart Kraay and Pablo Zoido-Lobaton (1999). "Aggregating Governance Indicators". World Bank Policy Research Department Working Paper No. 2195. Daniel Kaufmann, Aart Kraay and Massimo Mastruzzi (2003). "Governance Matters III: Governance Indicators for 1996-2002". World Bank Policy Research Department Working Paper. 1 4 Governance.improves.as.these.indices.increase.from.negative.2.5.to.positive.2.5,. and.the.indicators.measure.the.countries'.relative.positions.33.As.Table.3-3.shows,. in.the.absence.of.good.policies.and.institutions.and.controlling.for.income,.public.spending. on.education.in.the.Pacific.Islands.has.a.very.negligible,.and.sometimes.negative,.impact.on. education.outcomes.as.measured.by.net.primary.enrollment.rate.--a.10.percent.increase.in. spending.leads.to.0.6.percent.increase.in.net.enrollment.rate..In.countries.with.good.policies. and.institutions,.especially.those.with.very.effective.government.institutions.(government. effectiveness.index.of.2.5),.a.10.percent.increase.in.public.spending.leads.to.a.1.7.percent. increase. in. primary. net. enrollment. rates.. In. governments. with. ineffective. government. 24.|.wORLD.BANK CHAPTER.3 institutions,.the.same.increase.in.spending.would.lead.to.a.0.5.percent.reduction.in.net. primary. enrollment. rates.. Governments. therefore. need. to. focus. on. shaping. effective. policies.and.institutions.to.accelerate.progress.towards.attaining.better.social.outcomes. tablE 3-3: EFFECtIvENESS OF INCREaSE IN PublIC EDuCatION SPENDINg Goes up with Quality of Policies and Institutions*** Governance Score Effect on net primary school enrollment rates (%) Government.effectiveness.index 2.5 1.7** 0 0.6** -2.5: -0.5** Rule.of.law.index 2.5 0.9* 0 0.6* -2.5 0.3* Regulatory.quality.index 2.5 1.1* 0 0.6* -2.5 0.1* Note: Evaluated at - mean, upper value and lower value. *Significantly lower than 0 at 10% level, **Significantly lower than 0 at 5% level, *** After controlling for income Government Effectiveness, Resource Effectiveness, and Social Outcomes 1 5 Government.and.donor.resources.for.education.and.health,.as.this.chapter.sets. out,.have.attained.high.levels.compared.to.other.countries,.but.their.effectiveness. in. delivering. strong. outcome. performance. has. lost. momentum. in. key. areas,. such. as. equity.of.service.provision.and.in.such.indicators.as.fertility.and.school.completion..Both. donors.and.the.governments.they.support.have.focused.on.this.central.issue.of.resource. effectiveness,.and.have.asked.how.governments,.as.coordinators.of.foreign.assistance.and. managers.of.their.own.sectoral.programs,.can.get.more.from.the.comparatively.abundant. resources.at.hand.. 1 6 The.`effectiveness.of.government'.in.the.Pacific.is.thus.likely.to.be.more.influential. on.social.sector.outcomes.than.the.availability.of.resources.alone..But.what.does. effective.government.mean.in.the.context.of.social.services?.This.report.adopts.a.framework. that.places.government.effectiveness.in.three.different.policy.domains..Governments.can. manage.service.expansion.with.new.resources;.they.can.better.manage.their.existing.resources. to.achieve.higher.outcomes;.or.they.can.reach.outside.the.sectoral.ministries.to.engage.broad. governance.reforms.that.will.enhance.the.operating.environment.for.social.services.and.thus. raise.their.potential.impact..The.impacts.of.these.three.policy.domains.will.vary.depending.on. how.far.policy.has.advanced.and.what.remains.to.be.done.in.each.area..In.the.Pacific,.service. expansion.with.new.resources.has.dominated.policy.for.a.long.time,.and.impacts.would.be. expected.to.be.modest.from.further.expansion.(with.some.important.exceptions)..Sectoral. management.and.governance.reforms.would.seem.more.promising.at.this.stage.for.most. Pacific.countries..In.this.context,.the.significant.role.of.donor.funding.in.the.social.sectors.is. important..As.mentioned.above,.most.social.sector.aid.is.provided.off-budget..This.can.create. distortions.if.funds.are.not.aligned.with.government.priorities.and.sectoral.strategies.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.25 RESOuRCES.FOR.THE.SOCIAL.SECTORS.AND.THEIR.EFFECTIVENESS 1 7 what.are.these.reforms.and.how.could.they.improve.social.outcomes?.The.next. three.chapters.(Chapter.4.to.Chapter.6).examine.the.three.human.development. sectors.in.more.depth,.seeking.better.evidence.on.performance,.and.the.reasons.behind. some. lagging. indicators.. Each. set. out. some. options. for. moving. forward. in. sectoral. management. and. governance. reforms;. they. also. point. out. the. remaining. agenda. for. service. expansion,. notably. in. secondary. education. and. social. protection.. Options. for. aligning.donor.funding.to.assist.governments.in.achieving.their.desired.social.outcomes. is.then.discussed.in.Chapter.7. 26.|.wORLD.BANK 4 Improving Education Performance 1 Educational.performance.has.been.the.focus.of.sustained.attention.by.governments,. aid. agencies. and. researchers. for. many. years. in. the. Pacific.. Many. Pacific. countries. have. in. place. strategic. plans. for. education. with. reform. programs. actively. underway. in. others..These.initiatives.provide.a.rich.source.of.information.and.data.about.educational. performance,.options.for.improving.education.outcomes,.and.evidence.of.successful.local. initiatives.that.could.be.adapted.in.other.country.situations..Despite.the.evident.successes.in. education,.there.remain.a.troubling.set.of.outcome.lags.and.shortfalls..Chapter.2.identified. low.retention.rates,.low.quality.educational.outputs.and.low.student.achievement.levels. as.significant.performance.issues,.based.on.analysis.of.comparable.Census.data.sets..As. indicated.in.Chapter.3,.these.outcomes.prevail.despite.the.resources.for.education.being. relatively.abundant.in.the.Pacific. 2 This.chapter.strives.to.better.understand.the.country.outcomes/performance.in.the. context.of.education.financing,.capacity,.management,.and.governance/participation. issues..It.will.also.provide.a.menu.of.possible.approaches.to.improve.performance,.based. on.best.practice.in.the.Pacific.and.elsewhere..This.chapter.thus.has.three.sections:.the.first. extends.the.performance.analysis,.using.a.variety.of.data.sources;.the.second,.considers. the.need.for.options.(service.expansion.initiatives,.management.options.that.ministries. of.education.could.undertake.and.governance/participation.options,.or.those.initiatives. that. require. multi-stakeholder. collaboration. to. alter. the. incentive. setting. in. which. education.services.are.delivered).to.better.utilize.existing.resources.and.achieve.higher. learning.outcomes;.and.the.last.section.looks.at.options.to.improve.equity.in.access.to. education.at.all.levels. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.27 IMPROVING.EDuCATION.PERFORMANCE Performance Issues in Pacific Education 3 Primary education: low retention, high repetition and low achievement rates.. Net.primary.enrollment.rates.are.relatively.high.in.the.Pacific..Based.on.census.figures,. Fiji,.Kiribati,.Samoa,.and.Tonga.have.net.primary.enrollment.rates.above.90.percent..This. has.been.achieved.through.sustained.investments.in.improving.access..Moreover,.countries. like.Samoa.and.Tonga,.where.the.terrain.ensures.easy.geographic.access.to.schools.and. compulsory.primary.enrollment.is.enforced,.seem.to.be.well.on.their.way.to.achieving.the. MDG.education.targets.(see.Table.2-1.in.Chapter.2)..In.some.counties,.such.as.RMI.and. Solomon.Islands,.however,.enrollment.rates.have.declined.in.the.last.decade,.while.in.others,. such.as.Vanuatu,.they.have.barely.managed.to.keep.pace.with.rapid.population.growth,. leaving.net.enrollments.stagnant..In.dispersed.populations.in.Melanesia.and.Micronesia. many.children.have.never.been.to.school.as.they.live.in.remote.areas.with.either.no.schools. or.with.schools.staffed.with.untrained.teachers.. 4 The.gender.disparity.in.primary.enrollment,.however,.is.no.longer.the.leading.issue.it. once.was..Proactive.government.policies.emphasizing.girls'.education,.donor.advocacy,. and.Pacific.families.which.have.placed.a.high.value.on.their.daughters'.education.have.all. helped.make.this.important.change..while.the.focus.on.gender.disparity.has.traditionally. been.on.ensuring.equality.of.access.and.opportunity.for.girls,.the.disparity.that.is.emerging. in.several.Pacific.countries.(and.in.some.comparator.countries).is.in.favor.of.girls.and.the. lower.participation.and.achievement.of.boys..This.is.a.matter.of.concern.in.a.number.of. countries,.with.Tonga.being.a.specific.example.where.gender.disparities.in.primary.education. have.been.eliminated,.and.although.the.overall.GER.slightly.favors.boys.at.primary.level,. girls.tend.to.do.better.than.boys.in.primary.school,.and.outnumber.boys.in.more.prestigious. government.schools. 5 Inequities in access for persons with disabilities..Based.on.census.data,.Chapter. 2.notes.that.people.with.disabilities.are.more.likely.to.be.poor.and.receive.lower.levels. of.education.in.the.Pacific..Analysis.of.disability.is.just.beginning.in.the.Pacific,.but.data. from.the.1999.Solomon.Islands.Census.and.the.1996.Fiji.Census.afford.a.more.detailed. perspective.and.illustrate.some.of.the.gaps.facing.disabled.people..Figure.4-1.presents.the. educational.attainment.(some.or.full.attainment.for.each.category).for.both.disabled.and. non.disabled.populations,.with.those.facing.multiple.disabilities.shown.separately.in.the. case.of.Solomon.Islands.to.illustrate.that.disabled.people.are.not.a.homogeneous.group.. Solomon.Islands.has.low.enrollments.overall.compared.with.the.rest.of.the.Pacific,.and. thus.may.exaggerate.the.differences.between.disabled.people.and.non-disabled,.however,. the.problems.disabled.people.face.in.attending.school.in.the.Pacific.are.clear.in.this.analysis. of.the.entire.population..In.Fiji,.individuals.with.disabilities.are.just.as.likely.to.attend. school.as.those.without.disabilities,.but.many.discontinue.education.with.only.some.or.full. primary.education.. 28.|.wORLD.BANK CHAPTER.4 FIguRE 4-1: EDuCatIONal attaINMENt OF DISablED aND NON-DISablED PEOPlE Solomon Islands Fiji Non-Disabled Individuals No Primary 80 Disabled Individuals 60 Some or full Primary 70 Multiple Disabilities 50 Some or full Secondary 60 Some or full Tertiary 50 40 % 40 % 30 30 20 20 10 10 0 y 0 Non-Disabled Individuals Disabled Individuals None Primar Tertiary Pre-School Secondary Vocational Source: Census data 6 low retention and high repetition rates..Despite.successes.in.primary.enrollment. and.gender-equality,.many.students.in.Fiji,.Kiribati,.FSM,.Palau,.RMI,.Vanuatu.and. Solomon.Islands,.do.not.stay.in.school.long.enough.to.acquire.competence.in.literacy,.or. develop.other.useful.skills..Others.are.pushed.out.because.there.are.not.enough.places.for. % them.at.the.next.level.of.education..Contributors.to.school.drop.out.include.low.quality. of.schooling,.discouragement.over.performance,.and.the.costs.of.education.34.Along.with. low.completion.and.survival.rates.in.some.Pacific.Island.countries,.there.are.also.high.rates. of.repetition..In.some.cases,.this.is.the.result.of.a.deliberate.policy.of.retaining.students. (for.example.in.Tonga,.RMI.and.Vanuatu).while.in.others,.it.is.a.choice.by.students.and. families.to.have.students.repeat.a.year.of.schooling.in.order.to.gain.entry.to.higher.levels. of.schooling,.and.to.pass.national.examinations..Retention.is.thus.an.issue.in.the.Pacific,. particularly.in.Melanesia.and.Micronesia..There.is.considerable.variation.in.the.ability.of. the.Micronesian.school.systems.to.hold.their.students.at.school..Figure.4-2.presents.the. school.retention.rates.for.the.1988.cohort.of.students.in.the.Micronesian.states.of.RMI,. Palau,.and.the.four.States.of.FSM.35.Note.that.the.first.selective.examination.in.these.states. is.at.Grade/year.8. FIguRE 4-2: REtENtION RatES IN MICRONESIa 100 Grade 1 90 Grade 8 80 70 Grade 9 60 Grade 12 % 50 40 30 20 10 0 Marshall Is. Palau Chuuk Kosrae Pohnpei Yap Source: Hezel, F. (2002). Taking Responsibility for our Schools. Honolulu: Pacific Resources for Education and Learning, (Pacific Resources for Education and Learning). Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.29 IMPROVING.EDuCATION.PERFORMANCE 7 low education quality..Another.emerging.concern.is.the.overall.quality.of.education.. while. there. are. several. shortcomings. in. available. data. such. as. lack. of. up-to-date. assessment. data,36. inconsistencies. and. reliability. problems,. objective. measurement. of. learning.levels.are.available.from.the.PILL.data.37.The.country.level.data.is.held.confidentially. for.all.but.a.handful.of.Pacific.countries,.but.analysis.of.regional.data.show.that.PILL.test. results.indicate.a.low.level.of.learning.for.many.countries..One-third.of.the.students.were. `at.risk'.of.failure.in.reading.and.writing,.both.in.English.and.in.their.vernacular.language,. and.also.in.basic.numeracy..The.most.recent.PILL.data.available.shows.that.three.countries. consistently. achieve. more. highly. than. others,. and. that. large. numbers. of. children. are. struggling.to.come.to.grips.with.the.English.language..By.year.4,.several.countries.had. over.40.percent.of.students.`at.risk'.of.failure,.and.by.year.6,.the.figures.were.even.worse.. These.results.indicate.that.the.quality.of.education.is.a.concern,.especially.if.it.does.not. provide.the.basic.literacy.and.numeracy.skills.required.by.an.increasingly.globalized.market. economy..weaknesses.in.education.might.be.one.of.the.contributing.factors.to.the.difficult. employment.issues.in.Pacific. bOX 4-1: SOME FINDINgS FROM tHE PIll tESt while.little.overall.data.on.literacy.and.numeracy.achievement.can.be.provided,.the.PILL. Test.data.for.RMI.is.made.publicly.available.by.the.Government..PILL.Test.results.for.RMI. identify.a.profound.problem.of.poor.academic.performance.in.RMI's.primary.schools,. particularly.the.public.system..In.none.of.the.subjects.tested.did.the.proportion.at.`risk. fall'.below.65.percent..Data.showing.changes.over.time.in.the.percentage.of.students.``'. in.RMI.shows.that.in.Marshallese.and.numeracy,.there.has.been.a.notable.increase.in.the. percentage.of.students.`at.risk'.between.1994.and.1998..This.is.particularly.marked.for. numeracy..In.contrast,.there.has.been.a.reduction.from.approximately.74.percent.to.just. under.70.percent.of.students.`at.risk'.in.English.language..Substantial.educational.gains. appear.to.have.been.made.by.Fijian.students.between.1993.and.2003..The.Fijian.Ministry. of.Education.administered.the.PILL.Test.to.a.large.sample.of.students.from.Grade/year.5. in.1993,.and.ten.years.later.to.a.selected.sample.of.Grade/year.5.students.in.schools.that. had.performed.badly.on.the.National.Examination.(in.Grade/year.6)..Comparing.the. results.from.the.two.surveys.showed.slight.gains,.however,.as.the.second.survey.tested. only.the.lower.achieving.schools,.it.is.likely.that.substantial.gains.may.have.been.made. in.the.intervening.years..Another.interesting.finding.emerging.from.the.PILL.data.is.that. countries.using.English.as.a.medium.of.instruction.earlier,.generally.obtain.better.results. in.the.PILL.test.in.English.and.in.numeracy,.than.those.countries.that.follow.a.policy.of. starting.with.the.native.tongue.through.to.the.later.years.of.primary.school..In.relation. to.gender,.girls.outperform.boys.in.literacy.in.all.countries,.and.in.numeracy.in.six.out. of.nine.countries.. Source: Fiji and RMI education sector background studies. 8 Secondary education: supply constraints leading to inequitable access..while. universal.access.to.secondary.education.is.not.one.of.the.MDGs,.in.the.increasingly. globally-dependent.economies.of.the.Pacific,.secondary.education.is.becoming.recognized. as.a.pre-requisite.for.economic.participation..Secondary.school.structures.vary.by.country. (Table.4-1).. In.Fiji,.Kiribati,.Vanuatu.and.Solomon.Islands,.it.consists.of.two.tiers.-.lower.or.junior,. and.upper.or.senior,.whereas.in.RMI,.FSM,.Palau,.Tonga.and.Samoa.there.is.only.one. secondary.level. 30.|.wORLD.BANK CHAPTER.4 tablE 4-1: SCHOOl StRuCtuRE aND agE gROuP by COuNtRy Primary Secondary Junior Senior Years (age group) Years (age group) Years (age group) Fiji 8.(6-13) 2.(14-15) 2.(16-17) Kiribati 6.(6-11) 3.(12-14) 4.(15-19) RMI 8.(6-13) 4.(14-17) FSM 8.(6-13) 4.(14-17) Palau 8.(6-13) 4.(14-17) Samoa 8.(6-13) 5.(14-18) Solomon.Is. 6.(6-11) 3.(12-14) 3.(15-17) Tonga 6.(6-11) 7.(12-18) Vanuatu 6.(6-11) 4.(12-15) 4.(16-19) tablE 4-2: gROSS SECONDaRy ENROllMENt RatES IN tHE PaCIFIC COMPaRED WItH OtHER ISlaND ECONOMIES Country Secondary School Enrollment Fiji 83% Kiribati 65% Marshall.Is. 41% FSM 32% Palau 63% Samoa 64% Solomon.Is. 28% Tonga 99% Vanuatu 32% Barbados 69% Singapore 94% Maldives 69% Mauritius 64% Trinidad.&.Tobago 69% Source: Census data for Pacific Island countries, UNESCO database for others. 9 Table.4-2.presents.the.percentages.of.students.enrolled.at.the.secondary.level,.with. some.comparative.data.for.five.other.non-Pacific.small.island.states..Overall,.secondary. enrollment.ratios.are.a.cause.for.concern..Tonga.has.enrollment.ratio.over.90.percent,.but. the.enrollment.ratios.in.FSM,.Solomon.Islands.and.Vanuatu.are.only.around.30.percent. 1 0 low retention and high repetition rates..In.Solomon.Islands.and.Vanuatu,. lower.enrollment.ratios.at.the.secondary.level.result.due.to.selective.national. exams.at.year.6.that.force.at.least.half.of.their.cohort.out.of.school.because.there.is.no. place.for.them.in.year.7..In.other.countries,.drop.outs.increase.after.Grade/year.7.and.8. of.the.system..These.low.retention.rates.mean.that.many.children.do.not.stay.at.school. long.enough.to.acquire.useful.skills,.and.they.present.a.potential.social.problem.if.they.are. not.usefully.occupied..However,.more.young.people.with.secondary.qualifications.may.put. further.pressure.on.already.over.crowded.job.markets.in.the.formal.sector..Governments. in.the.Pacific.thus.face.the.twin.challenges.of.funding.an.expansion.of.secondary.places. and.stimulating.job.growth.for.graduates..Only.some.(Tonga,.Samoa.and.to.a.lesser.extent. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.31 IMPROVING.EDuCATION.PERFORMANCE Fiji).have.been.able.to.manage.secondary.expansion.to.high.levels,.assisted.by.labor.out- migration.to.Australia.and.New.zealand. 1 1 Internal.inefficiencies,.the.high.physical.and.transportation.costs.of.provision.in. remote.outer.islands,.and.the.inability.to.find.qualified.teachers.have.resulted. in. the. establishment. of. only. comparatively. few. high. quality. secondary. schools,. which. are.often.residential,.in.urban.centers.of.Kiribati,.Vanuatu.and.Solomon.Islands..Access. to.these.schools.is.further.restricted.by.the.highly.competitive.entrance.examinations.. Student.aspirations.to.acquire.secondary.education.are.nevertheless.high,.and.as.a.result. many.attempts.are.made.at.achieving.the.exam.standards.required.to.gain.entrance..This. has.resulted.in.high.rates.of.repetition.as.well.as.low.completion.rates.at.the.primary.level. as.mentioned.above. 1 2 Inequities in access..The.above.supply.constraints.have.inevitably.raised.equity. concerns. in. the. access. to. secondary. education.. As. Chapter. 2. reports,. while. differences.in.net.school.enrollment.rates.by.wealth.are.not.pronounced.at.the.primary. level,.they.are.more.pronounced.at.the.secondary.level.in.some.countries..This.indicates. that.children.from.poorer.households.are.less.likely.to.make.it.to.secondary.school..Thus,. although.children.from.all.wealth.quintiles.have.over.70.percent.enrollment.rates.at.primary. level,.at.secondary.level,.enrollment.rates.from.poorer.households.fall.to.below.40.percent. in.some.cases..Furthermore,.hardship.at.the.household.level.leads.to.children.dropping.out. of.school..Specific.country.examples.using.census.data.presented.below.in.Box.4-2 indicate. that.this.phenomenon.of.poorer.students.being.less.likely.to.attend.secondary.school,.and. when.they.do.so,.to.be.more.likely.to.attend.lower.performing.schools.is.a.pattern.that.is. repeated.in.most.Pacific.countries. 1 3 The.above.country.examples.(see.Box.4-2).point.to.two.important.dimensions. in.relation.to.equity.of.access.by.island.or.atoll..One.is.the.effect.of.remoteness. and.access.issues.on.smaller,.more.remote.atolls;.the.other.relates.to.the.lower.levels.of. income.on.outer.islands.that.affect.the.ability.of.families.to.meet.the.costs.of.education. at.primary.school,.and.to.attend.secondary.schools.in.urban.centers,.many.of.which. may.also.charge.high.fees.and.associated.boarding.costs..Two.factors.limit.the.chances. of. children. from. outer. and. rural. atolls:. (i). low. quality. of. schooling. in. remote. areas. reduces.the.chances.of.outer-island.and.rural.children.to.pass.gate.keeping.education. exams;.and.(ii).in.cases.where.they.do.succeed,.income.constraints.make.it.difficult.for. them.to.attend.secondary.school.. 32.|.wORLD.BANK CHAPTER.4 bOX 4-2: COuNtRy EXaMPlES FOR SCHOOl attENDaNCE by WEaltH quINtIlE aND tyPE OF SCHOOl In.Kiribati,.2000.census.data.shows.that.students.17-30.year.olds.from.the.top.quintile.are.heavily.represented.in. the.upper.secondary.and.tertiary.attainment.group.and.weakly.in.the.primary.only.attainment.group..The.reverse. is.true.for.the.poorest.20.percent..Further.evidence.is.provided.for.15-17.year.olds.currently.enrolled.in.school,.by. wealth.quintile..For.example,.only.half.of.the.students.aged.15-17.in.the.bottom.quintile.are.enrolled.at.school,.in. contrast.to.70.percent.of.the.top.quintile..There.are.several.reasons.for.lower.levels.secondary.enrollment.by.poorer. students..First,.wealthier.students.tend.to.perform.better.on.the.highly.competitive.entrance.examinations.(the. highest.achievers.tend.to.come.from.wealthier.families),.while.students.from.low.income.families.have.to.enter. fee-paying.private/religious.schools..Second,.the.differential.cost.of.secondary.education.is.an.additional.factor. in.creating.inequalities..Government.upper.secondary.schools.are.considered.`elite'.and.have.no.fees,.while.the. religious.day.and.boarding.schools.can.cost.anywhere.from.A$200.to.$1,000.per.year.. In.Vanuatu,.there.are.severe.inequities.in.access.by.region.and.income..while.there.is.only.a.modest.variation. between.wealth.quintiles.in.primary.enrollments,.by.contrast.an.analysis.of.secondary.net.enrollment.rates. reveals. marked. differences. by. wealth. quintile.. The. secondary. net. enrollment. rate. (NER). for. the. poorest. is. approximately.15.percent,.while.for.the.wealthiest.it.is.50.percent..The.limited.secondary.places.tend.to.be.filled. by.students.from.the.wealthiest.20.percent.of.Vanuatu.society..Three.key.reasons.account.for.this.discrepancy.. First,.secondary.capacity.is.limited.and.access.to.secondary.school.is.severely.restricted.by.the.Grade.6.exam.. Second,.the.wealthiest.families.are.overwhelmingly.located.in.urban.islands.where.they.have.access.to.the.best. primary.schools.and.the.most.extensive.supply.of.secondary.schools..Third,.secondary.school.is.expensive.and. families.are.expected.to.contribute.to.the.cost.of.schooling,.even.at.primary.school..The.net.result.is.that.children. from.poorer.families.are.more.likely.to.drop.out.of.primary.school. In.RMI,.the.key.issue.is.not.the.inequalities.in.enrollment.by.income.group,.but.the.differences.in.the.type.of. school.attended.in.relation.to.income..The.type.of.school.attended.can.have.a.significant.impact.on.the.quality.of. education.and.the.outcomes.achieved..In.RMI,.6-14.year.olds.and.15-17.year.olds.from.the.lower.wealth.quintiles. are.concentrated.(on.average).in.the.lower.performing.public.schools,.while.wealthier.students.are.more.likely.to. be.in.better.performing.private.schools..The.concentration.of.the.poorer.students.in.public.schools.has.dramatic. equity.implications.because.of.the.differential.performance.of.the.types.of.school..So,.not.only.are.15-17.year.old. students.from.the.lowest.income.quintile.less.likely.to.be.in.school,.but.those.who.are.more.likely.to.be.in.lower. performing.public.schools..The.evidence.for.6-14.year.olds.is.presented.below. SCHOOl attENDaNCE by WEaltH quINtIlE aND tyPE OF SCHOOl, RMI 80 41-6puorgegafotnecreP Public School 70 Private School l 60 schoo 50 40 30 attending20 10 0 Wealth quintile Lowest 20% 2nd 20% Middle 20% 4th 20% Highest 20% Source: 1999 HIES Tongahas.a.two-tired.system.at.the.secondary.level.providing.very.different.standards.of.education..At.the.primary. level,.the.majority.of.students.are.enrolled.at.government.schools..In.contrast,.the.seven.year.secondary.education. cycle.has.around.70.percent.of.its.students.studying.in.non-government.church.and.private.schools..There.is. very.restricted.access.to.government-run.secondary.schools..widespread.perception.is.that.quality.of.education. provided.in.non-government.secondary.schools.is.lower.than.that.provided.in.the.state.schools.despite.the.higher. fees.charged..As.a.result,.the.NER.for.children.in.the.top.quintile.is.over.80.percent,.compared.to.65.percent.for. children.from.the.lowest.income.quintile..Children.from.outer.islands.have.lower.pass.rates.to.secondary.school,. and.the.majority.of.outer.island.students.receive.no.education.beyond.that.level..while.the.average.drop.out.rate. at.secondary.school.in.Tonga.is.low.at.6.percent,.the.rate.is.twice.as.high.in.non-government.schools.compared.to. government.schools..Similarly,.transition.rates.are.lower.in.non-government.primary.schools.. Source: Background papers. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.33 IMPROVING.EDuCATION.PERFORMANCE 1 4 In.summary,.selectivity.in.secondary.education.seems.to.operate.at.a.number.of. levels.in.the.Pacific..First,.in.poor.countries.lower.income.students.are.less.likely. to.attend.primary.school..Second,.those.who.do.attend.are.more.likely.to.attend.lower. performing.schools..Third,.as.a.result.of.their.attendance.at.lower.performing.primary. schools,.lower.income.students.are.less.likely.to.reach.the.cut-off.in.national.exams.used.to. determine.access.to.secondary.education..Fourth,.where.secondary.places.in.free.government. schools.are.severely.limited,.those.poor.students.who.do.reach.the.examination.cut-off,. but.do.not.achieve.highly.enough.to.gain.a.place.in.a.government.school,.have.only.the. option.of.attending.fee.paying.private.schools..Poor.students.are.further.deterred.by.the. considerable.distance.from.their.outer.island.homes,.making.the.cost.of.secondary.school. prohibitive.since.it.would.involve.travel.and.residential.boarding.costs.. 1 5 Another. consequence. of. the. selective. secondary. education. system. mentioned. above.is.the.way.in.which.it.limits.access.to.tertiary.and.post.secondary.education. opportunities..For.instance,.tertiary.scholarships.are.of.considerable.value,.both.in.financial. terms,.and.also.in.terms.of.the.labor.market.opportunities.they.provide.to.their.recipients.. If. a. small. `elite'. of. relatively. wealthy. students. disproportionately. accesses. secondary. education,.not.only.does.this.distribute.considerable.financial.benefits.and.opportunities. to.the.already.advantaged,.but.it.serves.to.perpetuate.an.education.system.which.excludes. a.high.proportion.of.the.population.. Options to Improve Education Performance 1 6 Pacific.Islands.continue.to.face.two.major.challenges.in.education..The.primary. priority.is.how.to.ensure.that.every.child.completes.the.basic.education.cycle. of.adequate.quality..The.second.is.to.ensure.access.to.an.equitable.and.quality.secondary. education.for.a.rising.proportion.of.children..Meeting.those.core.challenges.will.involve:. (i).expansion.of.service.capacity.at.the.secondary.level;.and.(ii).improved.management. of. existing. education. services. and. new. governance. initiatives. that. will. improve. school. completion.and.equity.in.access,.and.retention,.at.all.levels.. Improving School Completion and Learning Outcomes 1 7 Increased.primary.completion.rates,.a.key.MDG.indicator,.and.improved.learning. outcomes. can. be. achieved. through. improved. sectoral. management. as. well. as. through.improved.accountability.and.governance.mechanisms.that.increase.effectiveness. and.quality.of.education.services. 34.|.wORLD.BANK CHAPTER.4 Management Options to Improve Quality of Education Services 1 8 Given.the.plentiful.resources.for.education.in.the.Pacific,.educators.can.look.for. ways.to.extract.higher.performance.outcomes.from.the.resources.and.institutional. capacities. that. are. already. in. place.. working. within. the. formal. education. institutions,. such.as.ministries.of.education,.there.are.opportunities.to.improve.performance.through. innovative.management.approaches..This.and.subsequent.sections.set.out.some.of.the. more.promising.management.options.to.address.education.quality.. 1 9 aligning government resources to priorities and outcomes. In.the.Pacific. Island.countries,.as.in.several.other.developing.countries,.the.problem.appears.to. be.less.one.of.inadequate.resources,.and.more.a.function.of.inefficient.resource.allocation.. For.instance,.Table.4-3 shows.the.expenditure.per.student.as.a.percentage.of.per.capita.GDP. for.four.Pacific.countries..As.it.indicates,.per.student.expenditure.on.tertiary.education. is. high.. Given. the. unmet. needs. in. basic. education,. to. promote. pro-poor. development,. ministries.of.education.should.consider.reallocation.of.funds.to.interventions.for.improving. education.quality,.equity.and.meeting.secondary.and.primary.education.needs.and.find. cost-effective.ways.of.providing.higher.education,.e.g..through.regional.collaborations.and. distance.education.opportunities. tablE 4-3: INtERNatIONal COMPaRISONS OF PublIC EXPENDItuRE PER StuDENt aS a PERCENtagE OF PER CaPIta gDP Primary % Secondary % Post secondary % Vanuatu 17 137 327 Samoa 12 9 236 Marshall.Islands 61 156 547 Developing.countries 14 21 n.a. OECD.countries 19 25 21 Source: WDI, Government reports. 2 0 Even. within. primary. recurrent. education. expenditures,. over. 92. percent. in. all. countries.except.Kiribati.and.Vanuatu,.go.towards.teacher.salaries;38.expenditures. on.quality.related.inputs.and.operating.costs.are.by.contrast.almost.non-existent.(See.Table. 4-4)..This.could.be.due.to.two.factors:.high.teacher.salaries.and.low.pupil-teacher.ratios,.or. as.is.most.likely.in.the.case.of.the.Pacific.a.combination.of.both..How.well.are.teachers.paid. in.the.Pacific?.Comparing.a.primary.teacher's.salary.to.average.per-capita.GDP.in.Vanuatu,. shows.that.a.non-qualified.part.time.teacher.earns.over.3.0.times.GDP.per.capita,.while. a.primary.school.teacher.earns.between.4.0.and.6.0.times.per-capita.GDP.39.Other.Pacific. countries.follow.the.same.trend;.in.RMI,.primary.school.teachers.earn.salaries.around.4.9. times.per-capita.GDP,.in.Pohnpei.state.of.FSM.around.4.7.times.per-capita.GDP,.while.in. Fiji,.it.is.4.2.times.per-capita.GDP..This.is.higher.than.is.seen.in.many.developing.countries. where.salaries.for.qualified.primary.teachers.are.around.2.0.times.per-capita.GDP. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.35 IMPROVING.EDuCATION.PERFORMANCE tablE 4-4: DIStRIbutION OF RECuRRENt EXPENDItuRE ON PRIMaRy aND SECONDaRy EDuCatION bEtWEEN SalaRIES aND OPERatINg EXPENDItuRE Primary Secondary Salaries Operating Salaries Operating Fiji 92.6 7.4 69.2 30.8 Kiribati 76.8 23.2 61.5 38.5 RMI 96.7 3.3 84.1 15.9 Samoa 92.9 7.1 80.5 19.5 Solomon.Islands. 92.3 7.7 67.2 32.8 Tonga 97.6 2.4 79.9 20.1 Vanuatu 88.8 11.2 88.1 11.9 Source: Forum Education Ministers Meeting (2002). 2 1 At.the.secondary.level,.the.proportion.spent.on.salaries.tends.to.be.lower,.due.to. high.cost.residential.facilities.and.travel.costs..Allocation.for.teaching.supplies.at. secondary.level.has.been.less.than.half.of.one.percent..Such.uneven.resource.allocations. strongly. influence. the. quality. of. education. provided. and. performance. outcomes. in. the. region..The.burden.for.provision.of.materials.and.basic.maintenance.has.fallen.on.households. and.community.groups.such.as.PTAs..Increasing.pupil.teacher.ratios.through.`clustering'40. of.infant.and.lower.grade.schools.with.senior.`mother'.schools.(as.has.been.done.in.PNG),. and.the.development.of.multi-grade.teaching.are.options.for.reducing.costs.of.salaries.. 2 2 aligning donor funds with government priorities..As.discussed.above,.donor. efforts.in.education.are.a.significant.component.of.funding.for.education..Highly. fragmented.in.many.small.projects,.overly.focused.on.tertiary.education,.and.insufficiently. coordinated.among.themselves.and.with.government.strategy.in.the.sector,.these.resources. have.not.had.the.expected.impact.on.educational.outcomes..Several.efforts.are.currently. underway.to.better.unify.donor.assistance.to.the.education.sector.behind.a.clear.sector. strategy.and.policy/financing.framework..These.efforts.will.strengthen.national.ownership. of. donor-funded. programs,. induce. greater. use. of. existing. government. systems. thus. reducing.transaction.costs.and.building.local.capacities..Some.efforts.are.already.underway.. The.Tonga.Education.Sector.Program.(see.Box.4-5).is.one.example..The.Education.Sector. Investment.and.Reform.Programme.(ESRIP).in.Solomon.Islands.is.another..Here,.part.of. the.donor.funds.flow.directly.through.government.financial.channels,.and.management.is. under.the.Permanent.Secretary.of.the.Ministry.of.Education..Similarly,.in.Fiji,.the.Ministry. of. Education. is. already,. through. the. Fiji. Education. Sector. program. (FESP),. receiving. support.from.AusAID.and.has.begun.to.move.towards.a.more.integrated.donor.coordination. mechanism,.wherein.all.donor.partners.will.plan.their.support.within.the.sector.policy. framework,.moving.towards.a.system.of.budget.support.and.using.the.Government's.own. accountability.mechanisms..The.European.union.(Eu).is.already.moving.in.this.direction,. with.the.imminent.FESP-Eu.program.. 2 3 Instituting and strengthening surveillance system to track progress..As. mentioned.previously,.a.key.factor.affecting.the.decisions.and.quality.of.policy. making.in.the.education.sector.in.Pacific.Islands,.is.the.paucity.of.reliable.data.to.analyze. the.strengths.and.weaknesses.in.the.system..In.the.instances.where.data.do.exist,.weak. analysis. and. underutilization. of. the. data. result. in. unrealized. potential. from. a. policy. making.perspective..It.would.hence.be.important.for.Pacific.governments.to.put.in.place. surveillance.systems,.such.as.Education.Management.Information.Systems.(EMIS),.and. learning.assessment.systems.that.would.allow.policymakers.and.managers.to.track.the. ongoing.progress.in.the.education.sector,.especially.in.the.areas.of.enrollments,.quality.of. education,.and.access.issues.for.specific.`at.risk'.groups..Building.a.solid.data.and.analytical. 36.|.wORLD.BANK CHAPTER.4 foundation.would.help.focus.much.needed.attention.on.efforts.to.achieve.MDGs.in.those. countries.at.risk.of.falling.behind. 2 4 Improving teaching quality..A.constraint,.which.still.continues.despite.having. received.considerable.attention.and.investment.in.the.Pacific.over.the.years,.is. the.supply.of.suitably.qualified,.trained.teachers..Teacher.competence.and.commitment.are. of.crucial.importance.in.improving.student.achievement.levels..In.addition,.their.salaries. consume.most.of.the.public.spending.on.education..As.seen.in.Figure.4-3.below,.the.supply. of.school.teachers.at.primary.and.secondary.level.appear.to.be.adequate.and.even.generous. by.international.averages.for.student.teacher.ratios.41.However,.some.countries.have.issues. with.distribution.of.teachers.and/or.a.high.proportion.of.primary.teachers.who.have.only. completed.a.high.school.diploma.and.no.professional.training..untrained.teachers.account. for.over.20.percent.of.all.primary.teachers.in.Kiribati.(21.percent),.RMI.(20.percent),.Samoa. (23.1.percent),.Solomon.Islands.(29.percent).and.Vanuatu.(53.5.percent).42. 2 5 Creating. an. adequate. supply. of. trained. teachers. by. expanding. training. opportunities.is.a.capacity.issue.that.clearly.needs.to.be.addressed..Past.efforts. in.improving.teacher.education.and.training.were.aimed.at.revising.the.curriculum.for. pre-service. education. programs,. upgrading. technical. capacities. of. teacher. education. and.education.institutions,.and.developing.in-service.training.and.professional.support. systems.on.teacher.mentoring..yet.more.needs.to.be.done.to.build.a.system.that.provides. for.continual.professional.development.for.teachers..A.new.view.on.teacher.training.in. the.Pacific,.taking.into.account.the.career.long.professional.development.of.teachers,.is. recommended..This.would.cover.pre-service.training,.induction.into.schools.and.classroom. teaching,. professional. registration,. and. continuing. professional. development.. Creating. professional.networks.and.fostering.cross.country/intra-regional.exchanges.are.also.other. important.avenues.for.improving.the.capacity.of.teaching.staff. FIguRE 4-3: PRIMaRy SCHOOl PuPIl tEaCHER RatIOS IN tHE PaCIFIC 30 Primary Secondary 25 oitaRrehcaeT-tnedutS 20 15 10 5 0 Fiji Kiribati RMI Palau Samoa Tonga Vanuatu Source: UNESCO database. 2 6 Setting school standards..In.most.countries.in.the.Pacific,.education.is.provided. through.partnership.among.a.wide.range.of.providers.-.government,.churches. and.other.religious.organizations.and.private.providers..In.fact,.in.response.to.demand.for. more.secondary.schooling,.a.fee-levying.private.sector.(including.church/religious.schools). has.emerged.as.an.alternative.source.of.provision.to.ease.this.bottleneck.at.the.secondary. level..However,.there.is.significant.variation.in.the.quality.of.education.provided.in.both. public.and.private.secondary.institutions..To.ensure.quality.education,.such.partnerships,. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.37 IMPROVING.EDuCATION.PERFORMANCE however,.need.to.be.developed.and.strengthened.within.a.coherent.policy.and.regulatory. framework.. Currently. the. quality. of. education. provided. through. the. private. sector. is. uneven,.and.several.equity.issues.arise.(as.previously.mentioned)..Setting.quality.assurance. mechanisms,.such.as.developing.appropriate.school.standards.(see Box.4-3 on.existing. Pacific.examples).can.improve.quality.of.all.education.services. bOX 4-3: SEttINg SCHOOl StaNDaRDS ­ PaCIFIC EXaMPlES Several.countries.are.experimenting.with.setting.school.standards.and.monitoring.their. achievement..In.FSM,.for.example.the.Education.Sector.Review.(2003).proposes.that. a.school.accreditation.system.be.introduced.that."specifies.the.benchmark.standards. required.for.any.school.to.attain.in.order.to.be.accredited.by.government.as.meeting. minimum.service.requirements"..In.RMI,.private.schools.have.long.enjoyed.a.formal. accreditation.system.through.the.uSA's.western.Association.of.Schools.and.Colleges. (wASC)..The.public.system.has.turned.recently.to.teacher.testing.and.publication.of. results.as.a.standard.setting.and.monitoring.mechanism..Many.schools.and.teachers. subject.to.wASC.reviews.welcome.the.scrutiny,.while.some.see.testing.as.an.ordeal,. imposed.from.the.outside..The.reason.for.this.difference.could.be.seen.as.one.of.choice. and.control..Principals,.teachers,.and.parents.who.understood.the.purpose.of.assessment. invited.wASC.review.and.evaluation..Many.schools.undergoing.wASC.review.reported. the. experience. stimulated. school. level. discussion. about. quality. schooling. and. about. problem. solving. among. teachers. and. parents.. In. Solomon. Islands,. the. Ministry. of. Education. is. developing. a. `community. standard,. which. will. be. a. formula. to. cost. out. recurrent.resources.are.needed.to.maintain.a.school's.performance.at.agreed.levels..In. Tonga,.`minimum.service.standards'.are.to.be.developed.by.the.Ministry.of.Education,. which.would.apply.universally.to.public.and.private.schools.as.agreed.levels.of.provision. and.performance.to.which.all.schools.would.aspire.. Sources: Gannicott, K., R. Krech, and B. Graham, 2004. Education Performance in the Republic of Marshall Islands; ADB, FSM Education Sector Review, 2002; Catherwood et al (2003), Tonga Education Education Sector Study, NZAID. 2 7 Curriculum relevance and reform..Donors.and.governments.have.supported. curriculum.reform.initiatives.which.have,.among.other.changes,.sought.change.in. the.language.of.instruction.and.pedagogical.techniques..yet,.there.is.a.growing.concern.over. the.relevance.and.effectiveness.of.schooling.in.many.Pacific.countries..High.rates.of.academic. failure,.language.loss,.and.also.the.burgeoning.problem.of.`educated.unemployment'.and. the. attendant. disaffection. of. youth. are. a. rising. concern.. In. this. context,. governments. need.to.focus.on.issues.that.would.facilitate.the.school.to.work.transition,.e.g..curriculum. reform.that.ensures.children.attain.basic.skills.in.language,.mathematics,.problem.solving,. information.technology,.and.that.they.have.options.for.technical.or.vocational.subjects. which.meet.the.needs.of.the.economy..Successful.reform.of.school.curricula.can.achieve. the. multiple. benefits. of;. improving. student. motivation. and. achievement,. stimulating. teacher.performance.and.morale,.and.engaging.parents.more.fully.in.the.local.educational. experience..The.private.sector.is.a.key.player.here.and.can.provide.advice.on:.development. of.curriculum.relevant.for.the.job.market,.and.developing.entrepreneurship;.mentoring. and. networking;. as. well. as. workplace. attachments. and. apprenticeships.43. Improved. performance.indicators.for.attendance.(teachers.and.students),.completion,.transition,.and. indeed.academic.achievement,.should.flow.from.more.relevant.curricula.in.primary.and. secondary.education.. 2 8 An. important. new. movement. of. Pacific. educators,. under. the. banner. of. "Re- thinking.Pacific.Education".is.debating.concerns.over.the.perceived.mismatch.of. Pacific.and.western.culture.in.all.aspects.of.school.education,.including.pedagogy,.content. and. materials,. language. of. instruction,. and. training. models.44. The. need. for. enhancing. curriculum.relevance.to.include.local.cultural.context.and.aspirations,.while.also.preparing. 38.|.wORLD.BANK CHAPTER.4 students.for.participation.in.a.global.economy,.is.already.being.reflected.in.Government. education.strategies..These.are.not.incompatible.goals,.as.noted.in.the.Pacific.Education. Ministers.Meeting.Report.on."entrepreneurship.education",45.as.traditional.Pacific.cultural. values.of.integrity,.leadership.and.discipline.are.seen.as.a.powerful.factor.in.promoting. entrepreneurial. development.. In. Samoa's. 1995-2005. education. strategy,. enhancing. curriculum.relevance.is.a.key.education.policy.goal..At.the.primary.level.for.example,.the. goal.was.the.development.of.curricula."which.are.closely.related.to.the.needs.and.problems. within.the.local.community".46.This.is.to.be.backed.up.by.the.provision.of."an.adequate. supply.of.graded.readers.and.basic.textbooks.in.Samoan.and.English.for.every.classroom;. and.provision.of.pedagogically.sound,.relevant,.and.physically.durable.curriculum.materials. in.all.subject.areas,.for.teachers.and.students.in.every.classroom"..In.Solomon.Islands,. the.curriculum.and.support.materials.were.developed.over.20.years.ago.."The.education. system.is.seen.by.many.as.being.unconnected.and.antagonistic.to.the.social.and.cultural. values.on.which.Solomon.Island.communities.and.society.are.based".47.The.proposed.way. forward.is.that.basic.education.be."re-anchored.in.the.community,.and.while.facilitating.the. development.of.the.knowledge.and.skills.needed.for.economic.well.being.and.advancement,. that.basic.education.promote.and.develop.the.positive.aspects.of.village.society". bOX 4-4: COMMuNIty SECONDaRy SCHOOlS IN SOlOMON ISlaNDS In.response.to.supply-side.constraints,.there.has.been.rapid.growth.of.Community.High. Schools.in.Solomon.Islands.since.the.early.1990s,.and.these.have."significantly.increased. access. to. junior. secondary. education". (Education. Strategic. Plan,. 2002-2004,. p.. 18).. Community.High.Schools.follow.the.National.Curriculum.and.are.funded.(inadequately). by.the.government.. However,.the.Solomon's.Strategic.Plan.(2002-2004).notes.that.the.growth.of.the.schools. has. not. been. matched. by. the. government's. capacity. to. provide. teachers,. equipment. or.resources.."Most.lack.the.facilities.needed.to.deliver.quality.education.in.all.junior. secondary. subjects,. are. poorly. maintained,. and. are. staffed. by. many. inadequately. or. untrained. teachers". (p.. 18).. The. proposed. solution. is. to. control. the. growth. of. new. schools,.while.also.taking.a.detailed.census.of.the.existing.schools.and.their.needs..This. information.will.be.used.to.seek.donor.assistance,.to.rationalize.existing.provision.where. appropriate.and.to.identify.where.new.community.schools.are.required..while.the.rapid. growth.of.these.schools.has.clearly.outstripped.the.government's.capacity.to.fund.and. support.them,.they.demonstrate.the.appetite.for.community.based.and.managed.schools,. and.the.considerable.capability.within.even.small.communities.to.establish.schools.and. mobilize.resources.at.the.local.level.. Source: Ministry of Education, Education Strategic Plan, 2002-2004 2 9 Expanding secondary schooling through public-private partnerships. Developing.a.close.partnership.with.the.private.sector.in.the.provision.and.financing. of.education,.especially.at.the.secondary.level,.may.help.ease.capacity.constraints..In.Fiji,. Vanuatu,.Samoa.and.Solomon.Islands,.where.governments.in.whole.or.partly.subsidize. teacher.salaries.and.other.operational.expenses.for.all.registered.schools..Here.management. and.the.raising.of.further.funds.are.partly.or.wholly.the.responsibility.of.communities.and. churches.. Enlisting. community. help. in. constructing. new. community-based. junior. high. and.high schools.may.help.address.the.shortage.of.places.in.secondary.education.and.the. high.costs.associated.with.attendance.at.secondary.schools.some.distance.from.remote. areas..Evidence.shows.that.in.some.places,.families.prefer.local.secondary.schools.as.they. are.reluctant.to.send.their.daughters.to.residential.boarding.secondary.schools..Solomon. Islands.presents.an.intriguing.example,.as.described.in Box.4-4.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.39 IMPROVING.EDuCATION.PERFORMANCE Governance Options to Improve Education Quality 3 0 Governance.involves. multiple. stakeholders. inside. and. beyond. ministries. of. education,.and.changing.the.governance.of.education.means.altering.in.some. way.the.society.wide.frameworks.within.which.the.education.system.performs..This. typically.involves.information.flows.and.transparency,.changing.local.and.central.roles. in. service. provision,. and. community. voice. and. participation.. Almost. by. definition,. governance. undertakings. involve. the. construction. of. broader. political. and. social. coalitions,.are.more.difficult.for.educators.alone.to.make.happen,.and.in.some.cases,. have. the. potential. to. make. much. more. impact. than. the. strictly. sectoral. efforts. in. management.and.service.expansion.. 3 1 Schoolbasedmanagement-delegation..The.international.school.effectiveness. research48. shows. that. school-based. management,. including. giving. principals. discretionary.control.over.a.budget.to.purchase.textbooks.and.materials.for.classroom.use,. is.a.feature.of.effective.schools..The.lack.of.adequate.and.appropriate.teaching.resources. impacts.significantly.on.the.quality.of.teaching.and.learning.in.the.Pacific..Delegating.to. principals.some.discretionary.control.over.budgets.to.purchase.teaching.materials.may. create.a.greater.demand.from.principals.and.teachers.for.quality.materials.that.support. teaching.and.learning..In.remote.islands.and.atolls,.principals.and.teachers.are.known.to. raise.funds.locally,.and.to.use.them.for.purchase.of.basic.materials..Such.arrangements. need.to.be.strengthened.and.regularized,.so.that.accountabilities.are.clear.between.the. central. procurement. and. distribution. system. and. the. schools. themselves.. The. School. Grants.Program.in.Tonga.(described.in.Box.4-5).aims.at.devolving.responsibility.of.school. management.to.the.local.and.school.level.by.putting.an.effective.grants.program.in.place.. 3 2 It.is.expected.that.principals'.salary.and.conditions.of.employment.would.continue. to.be.the.responsibility.of.central.government..A.caution.needs.to.be.exercised. here.to.avoid.basing.the.principal's.accountability.on.standards.of.provision.and.outcomes. over.which.he.or.she.has.little.control..If.teachers.are.not.properly.qualified,.and.classroom. resources.are.limited,.it.takes.an.unusually.charismatic.leader.to.make.a.difference..The. school.effectiveness.evidence48.shows.that.it.is.important.to.hold.principals.accountable. for.the.effective.management.of.teachers,.and.for.providing.teachers.with.the.necessary. resources.and.support.for.effective.teaching..Principals.could.also.be.required.to.manage. the.ongoing.assessment.and.monitoring.of.student.achievement,.and.to.share.this.data. with.the.PTA.and.wider.school.community..This.achievement.data.can.be.used.to.guide. instructional. practices. and. to. provide. information. to. parents. to. enable. them. to. better. support.their.children's.learning..Principals.should.also.be.empowered.to.better.manage. teachers.and.their.performance.. 40.|.wORLD.BANK CHAPTER.4 bOX 4-5: a SCHOOl gRaNtS PROgRaM IN tONga Despite.its.relatively.strong.human.development.indicators.and.commendable.strides.in. achieving.universal.primary.education,.the.Government.of.Tonga.(GoT).has.recognized. the.need.to.improve.the.quality.of.education.it.is.delivering.in.order.to.meet.the.challenges. of. a. globalized. market. economy. as. well. as. the. aspirations. of. its. large. proportion. of. unemployed.youth..Accordingly,.the.Government.has.recently.developed,.through.a.two. year.long.consultative.process,.an."Education.Policy.Framework.2004-2019".(EPF).to. provide.a.vision.and.strategy.for.undertaking.comprehensive.reform.and.improvement. of.its.education.system.over.the.medium.to.longer.term. with. world. Bank. and. NzAID. financial. and. technical. support,. the. GoT. will. soon. launch.the.Tonga.Education.Support.Project.(TESP)..The.five-year.TESP.represents.the. implementation.of.the.first.phase.of.the.EPF.and,.in.particular,.focuses.on.improving. the.quality.of.primary.and.secondary.education,.the.equitable.delivery.of.services.and. resources,. and. a. strengthening. of. management,. policy. making,. and. monitoring. and. evaluation.within.the.sector.. A.key.outcome.of.the.TESP.will.be.a.tested.mechanism.in.place.that.supports.the. equitable. provision. of. a. quality. basic. education.. As. mandated. under. the. universal. Basic.Education.reforms.in.the.EPF,.a.policy.supported,.grants-based.school.financing. system.will.be.established..This.will.lead.to.the.empowerment.of.schools.and.their. communities,.and.provide.the.necessary.conditions.and.incentives.for.improved.and. more. equitable. outcomes. for. primary. and. secondary. school. students.. As. it. moves. to. more. directly. finance. schools,. the. GoT. will. gradually. transfer. a. portion. of. the. responsibility.for.system.outcomes.to.that.level..By.institutionalizing.results-based. management.and.financing.to.schools.and.to.the.sector,.TESP.provides.the.impetus. for.sector.programs.to.reach.beyond.the.provision.of.services.to.the.establishment.of. quality.services.and.improved.outcomes.. Source: Human Development Unit, East Asia and Pacific, "Project Appraisal Document for a Tonga Education Support Project (TESP)", World Bank 2005 3 3 A.report.on.teacher.attendance.in.the.Pacific.made.a.number.of.recommendations. for.improving.teacher.attendance.(which.research.shows.is.strongly.correlated. with.student.achievement).that.are.consistent.with.site-based.hiring.and.monitoring.of. performance.by.principals.and.PTAs.49.These.include.making.good.attendance.a.requisite. for. job. tenure. and. continuation. of. employment.. Each. Pacific. Department. or. Ministry. of. Education. has. a. leave. policy,. so. the. problem. of. personnel. leave. policies. is. their. implementation,. rather. than. their. non-existence.. Box. 4-6. below. provides. a. successful. approach.to.teacher.attendance.issues.in.FSM. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.41 IMPROVING.EDuCATION.PERFORMANCE bOX 4-6: MaNagINg tEaCHER attENDaNCE IN KOSRaE StatE (FSM) The.findings.from.the.RAPSTA.study.indicated.that.the.Kosrae.State.teachers.had.the. lowest.average.number.of.days.away.from.work,.five.days,.during.the.1996-97.school. year..This.low.rate.of.absenteeism.could.be.the.result.of.the.practices.that.are.being. effectively.implemented.in.this.state..Several.schools.in.Kosrae.have.developed.a.novel. approach.to.dealing.with.absenteeism..One.example.illustrates.Kosrae.State's.strategy. for.decreasing.teacher.absenteeism.is.the.following: In.the.event.of.a.funeral,.close.community.and.families.ties.prompt.several.teachers.to.take. leave.from.school.in.order.to.attend.or.prepare.for.the.solemn.occasion..The.principals,. along.with.the.teachers,.close.school.for.the.day.(or.days),.and.they.agree.to.make.up. these.days.in.the.future..These.make-up.days.may.take.place.subsequent.Saturdays.or. may.extend.past.the.scheduled.school.year..In.the.case.where.only.a.few.teachers.request. leave,.classes.are.combined,.and.the.remaining.teachers.cover.the.classes..Most.Kosrae. schools.use.team.teaching,.which.makes.for.an.easy.adjustment.when.available.teachers. combine.classes.to.cover.the.students.of.a.teacher.on.leave. Source: Uehara, 1999, p. 9-10.49 3 4 transparent information for accountability. Most. Pacific. countries. have. strategic.plans.for.education.but.their.public.are.often.unaware.of.government. education.policies.and.information.on.student.achievements..Collecting.information.about. levels.of.enrollment.in.relation.to.key.variables,.such.as.level.of.income,.location,.gender.and. disability,.is.an.important.prerequisite.for.establishing.benchmarks,.setting.targets,.and. holding.government.agencies.accountable.for.quality.and.equity.of.educational.provision.. Test.results.for.advancement.to.secondary.level.are.highly.publicized.in.some.countries. (Kiribati.is.an.example).and.even.as.far.as.listing.successful.students..However,.much.more. could.be.done.to.publicize.standardized.achievement.test.results,.such.as.PILL..These.are. currently.confidential,.except.for.the.notable.case.of.RMI,.which.has.taken.major.steps.to. improve.transparency.of.performance.measures.in.education.and.other.sectors.. 3 5 Providing. mechanisms. that. enable. teachers. and. principals. to. hold. the. central. bureaucracies.accountable.would.represent.a.significant.shift.in.approach.in.most. Pacific.countries..One.example.is.making.resource.allocation.to.schools.transparent.and. equitable.such.as.the.use.of.clear.and.simple.formulas.for.capitation.grants.to.schools.. Resource.flows.need.to.be.publicized.and.managed.on.the.basis.of.performance.metrics.and. process.norms.and.standards.. 3 6 Information.transparency.at.the.local.level.is.crucial.for.school.based.management. and. more. far. reaching. decentralization. reforms.. Local. level. involvement. in. government. school. management. is. often. limited. to. fund-raising. and. in-kind. support,. often.in.the.form.of.labor..There.is.limited.information.available.to.school.communities,. and.school.communities.are.often.unaware.of.exactly.how.revenue.collected.by.schools. from. parents. is. spent. and. accounted. for.. Parents. are. sometimes. unclear. about. their. school's.admission.policy.and.whether.it.is.transparently.and.fairly.implemented..As.more. information.about.the.performance.of.the.education.system.at.the.systemic.and.local.level. is.made.publicly.available,.it.may.have.the.effect.of.increasing.community.confidence.and. involvement.in.the.education.system,.a.necessary.prerequisite.for.increasing.participation. and.achievement.in.education.. 3 7 Community partnership - increasing community voice through delegation and local governance. Mechanisms.designed.to.hold.providers.accountable.for. the.quality.of.educational.provision.and.outcomes.are.gaining.more.attention.in.the.Pacific,. but.efforts.at.delegation.and.decentralization.of.education.still.have.a.long.way.to.go..In. most.Pacific.countries,.the.monitoring.of.schools.is.carried.out.centrally,.with.little.or.no. 42.|.wORLD.BANK CHAPTER.4 involvement.by.schools.or.communities..Some.countries.have.a.national.inspectorate.system. that.is.tasked.with.monitoring.whether.the.curriculum.is.being.correctly.taught,.whether. teachers.are.in.attendance,.and.whether.teachers.receive.professional.development.support.. In.Solomon.Islands,.there.is.an.Inspectorate.which.has.been.understaffed.in.the.past,.but. should.be.undergoing.some.strengthening.under.the.sector.wide.donor.support.program..In. RMI.subject.specialists.or.mentors.are.supposed.to.visit.public.schools.quarterly.to.support. teachers,.to.evaluate.school.principals,.and.administer.the.Grade.8.exams.and.teacher.English. language.proficiency.tests..In.practice,.in.most.countries,.ministry.of.education.inspection. of.secondary.schools.seems.to.be.minimal.and.the.schools.essentially.operate.themselves.. 3 8 In.most.Pacific.countries,.PTAs.are.actively.involved.in.their.local.school,.and.have. an.important.role.to.play.in.making.up.for.significant.short.falls.in.funding.and. resources.provided.by.the.government..This.support.may.take.the.form.of.fundraising.to. purchase.basic.supplies.and.helping.with.school.maintenance..However,.while.the.local. community's.support.is.vital.in.ensuring.even.a.minimum.level.of.adequate.provision.in. many.local.schools,.the.level.of.decision-making.authority.and.influence.that.communities. have.on.their.schools.is.very.limited.and.may.serve.to.decrease.the.level.of.community. support.for.schools..PTAs.could.be.given.greater.responsibility.and.supporting.budgets. to.enable.them.to.make.decisions.that.impact.on.the.quality.of.education.at.their.school.. Recent.research.in.PNG.indicates.that.strengthened.parent.and.community.involvement. contributes.to.better.education.by.lowering.teacher.absenteeism.and.improving.student. attendance.50.For.example,.in.RMI,.the.more.effective.private.schools.have.strong.well. attended.PTAs.at.both.primary.and.secondary.level..The.PTAs.demand.an.account.of.how. financial.resources.are.spent,.discuss.challenges.in.education.delivery,.and.are.involved.in. teaching.processes.through.topical.committees.(for.example,.curriculum)..In.Tonga,.for. example,.a.new.initiative.has.been.planned.based.on.enhanced.community.involvement. through. school-based. management,. coupled. with. a. school. grants. program. to. finance. locally.controlled.school.improvement..The.focus.will.be.on.outcomes.and,.though.careful. monitoring,.rewards.for.improved.performance.(see.Box.4-5). Improving Equity: Alleviating Constraints on Poor and Vulnerable People's Participation in Education 3 9 As.shown.above,.in.poor.countries.lower.income.students.and.students.with.special. needs.are.less.likely.to.attend.primary.school..Those.who.do.attend.are.more.likely. to.attend.lower.performing.schools,.are.less.likely.to.complete.primary.schooling,.and.are. less.likely.to.reach.the.cut-off.in.national.exams.used.to.determine.access.to.secondary. education.. where. secondary. places. in. free. government. schools. are. limited,. those. poor. students.who.do.reach.the.examination.cut-off,.but.do.not.achieve.highly.enough.to.gain.a. place.in.a.government.school,.have.only.the.option.of.attending.fee.paying.private.schools.. Poor.students.are.further.deterred.by.the.considerable.distance.from.their.outer.island. homes,.making.the.cost.of.secondary.school.prohibitive.since.it.would.involve.travel.and. residential.boarding.costs.. 4 0 To.address.inequities.in.educational.access.and.opportunity.and.ensuring.that. cost.does.not.constitute.a.barrier.to.participation,.education.subsidies.need.to. be.targeted.to.the.neediest.households.and.individuals.(such.as.the.poorest,.those.with. disabled. household. members,. children. with. special. needs,. or. those. in. remote. areas).. Effective.use.of.targeting.can.also.reduce.selectivity.at.the.secondary.level..Management. options.to.improve.equity.include.the.promotion.of.inclusive.special.education,.training. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.43 IMPROVING.EDuCATION.PERFORMANCE teachers.in.special.needs.education,.and.the.use.of.per.capita.grants.for.special.education. services,. manipulating. fee. structures,. revising. scholarship. policies,. introducing. quota. systems,.and.using.demand-side.subsidies..These.are.discussed.in.detail.below..Governance. options.include.use.of.communities.to.monitor.student.attendance.as.well.as.publicizing. information.about.levels.of.enrollment.in.relation.to.key.variables.such.as.level.of.income,. location,. gender. and. disability. to. hold. government. agencies. accountable. for. equitable. educational.provision. 4 1 targeting students with special needs..The.education.of.children.and.youth. with.disabilities.is.still.a.challenge.facing.many.governments.in.the.Pacific..Barriers. to.inclusion.of.children.and.youth.with.special.needs.in.education.and.training.are;.lack.of. policy,.lack.of.teachers.trained.in.special.needs.education,.physical.constraints.of.buildings,. as.well.as.attitudes..Some.governments.and.communities.in.the.region.have.been.addressing. these.constraints.and.a.number.of.Pacific.models.are.now.in.use.and.can.be.replicated..The. case.of.Samoa.is.presented.in.Box.4-7...The.most.common.model.is.the.use.of.segregated. special.schools..Experience,.however,.demonstrates51.that.integrated.or.inclusive.education. provides.the.best.opportunities.for.the.majority.of.children.and.youth.with.disabilities.to. receive.an.education..These.can.be..promoted.through.financial.subsidies,.such.as per.capita. grants.related.to.the.needs.of.special.needs.students.in.school.catchment.areas.and.could. be.made.available.to.local.schools.and.private.providers.who.provide.special.needs.services. for.students.and.meet.agreed.standards..Secondly,.funding.could.be.targeted.directly.to. families.with.special.needs.so.that.they.then.can.purchase.educational.provision.at.their. local.school..Providing.the.funding.for.special.education.services.directly.to.the.providers. creates.an.incentive.for.schools.to.make.this.type.of.provision.available.and.families.(who. are.best.suited.to.know.the.needs.of.their.child).are.able.to.hold.schools.accountable.for.the. quality.of.provision..In.conjunction,.awareness.of.children's.rights.to.education.needs.to.be. raised.in.families.with.children.with.disabilities..Teacher.training.also.needs.to.ensure.that. all.teachers.develop.the.attitudes.and.skills.that.equip.them.to.teach.children.with.diverse. abilities.in.both.regular.community.schools.as.well.as.special.schools. bOX 4-7: EMPOWERMENt OF PEOPlE WItH DISabIlItIES IN SaMOa The.Department.of.Education.in.Samoa.conducted.a.national.survey.in.2001.(with.uNDP. support).to.identify.all.children.0-14.years.of.age.with.special.needs,.the.majority.of.whom. live.in.rural.areas..It.then.provided.in-service.training.on.special.needs.education.to.all. teachers,.established.special.needs.units.in.village.schools.and.a.special.needs.education. coordinator.in.the.curriculum.development.unit.of.the.Department.of.Education..In. addition,.two.NGOs.in.the.country.are.focusing.on.linking.education.and.training.for. people. with. disabilities. with. income. generation. opportunities.. The. Organic. Farming. Association,. helped. by. the. women. in. Business. Foundation. (wIBF),. is. concentrating. on.training.farmers,.disabled.persons.and.unemployed.youth.in.new.skills.for.organic. farming.and.the.production.of.niche.items.for.export. Source: Issues in education for children and youth with disabilities, Pacific Islands Forum Secretariat, 2002. 4 2 Revising school fees structures..One.promising.approach.to.secondary.school. access.is.the.revision.of.fee.structures.to.encourage.enrollment.of.students.from. low.socio-economic.backgrounds..Adjustment.and.oversight.of.fees.charged.by.private.and. public.schools.are.important.to.apportion.schooling.costs.on.the.basis.of.need..Fees.and. public.subsidies.(and.church-donated.subsidies).can.be.seen.as.part.of.a.pooled.revenue. flow. to. schools,. with. both. sources. of. funds. fungible. at. the. school. level.. For. example,. government.subsidies.that.are.currently.distributed.to.private.and.church.schools.could.be. adjusted.to.encourage.such.schools.to.introduce.sliding.fee.scales,.so.that.per.capita.school. subsidies.would.rise.with.the.number.of.poor.students.enrolled.and.entitled.to.lower.fees.. Subsidy.policies.could.also.strive.to.equalize.the.effective.(public.and.private).subsidy.rate. 44.|.wORLD.BANK CHAPTER.4 to.schools..Such.a.policy.would.require.transparent.information.on.private.contributions. to.church.schools,.as.well.as.transparent.fee-setting.practices.and.revenue.reporting..The. first.objective,.however,.would.be.to.equalize.opportunities.for.children,.particularly.at.the. secondary.level,.where.two.tiered.systems.of.education.now.prevail.in.much.of.the.Pacific. 4 3 Revising scholarship policies.. Another. option. is. to. revisit. scholarship. policies.with.a.view.to.considering.selection.criteria.that.specifically.target.the. poorer.sections.of.society..For.example,.expanding.means.tested.scholarships.programs,. such. as. the. Kiribati. program. for. secondary. school. age. children. of. poor. families,. could. be.undertaken.with.less.administrative.effort.than.the.complex.arrangements.necessary. for.sliding.school.fees.and.subsidies..A.challenge.is.how.to.reliably.identify.a.poor.family. entitled.to.a.scholarship..Fiji.and.Kiribati.use.household.characteristics.associated.with. hardship,.such.as.single.parent.families..Another.approach.is.to.exclude.any.family.with. members.employed.by.government,.usually.associated.with.higher.income.status.in.the. Pacific..Another.is.to.use.proxy.means.test.formulae,.which.require.a.house.visit.and/or. questionnaires. to. ascertain. the. household. assets. of. a. prospective. recipient. family. and. then.the.calculation.of.a.score..This.is.done.widely.in.Latin.America,.even.in.smaller.island. countries.such.as.the.Dominican.Republic.. 4 4 Introducing a quota system..while.places.at.secondary.level.remain.limited,.a. quota.system.may.be.necessary.to.ensure.that.schools.equitably.select.students. from.different.regions.or.different.ethnic.groups..The.quota.system.used.in.Kiribati.to. allocate.secondary.places.to.those.from.remote.atolls.may.provide.an.effective.means.of. maintaining.a.balanced.student.intake..Currently,.most.Pacific.countries.do.not.finance. the.additional.expenses.involved.in.attending.boarding.schools,.but.boarding.subsidies.and. travel.grants.would.greatly.improve.access.to.secondary.school.for.many.poor.children.from. outer.islands. bOX 4-8: CONDItIONal CaSH tRaNSFERS Conditional.cash.grants.are.funds.given.to.parents.(frequently.to.mothers.and.usually. targeted.to.the.poor).on.the.condition.that.their.children.attend.school.and/or.obtain. recommended.preventive.health.care..Conditional.cash.grants.have.been.effective.in.several. Latin.American.countries.and.are.increasingly.being.used.to.encourage.human.capital. investments.in.poor.children.(Rawlings.and.Rubio.2003,.Barrientos.and.DeJong.2004). The. best. known. conditional. cash. grants. program. is. Mexico's. PROGRESA. program,. which.was.initiated.in.1997.in.selected.rural.areas.but.has.subsequently.been.renamed. Oportunidades.and.expanded.to.cover.selected.urban.areas.as.well..The.program.provides. scholarships.and.cash.grants.to.poor.households.on.condition.that.school.age.children. enroll.in.and.attend.school.regularly,.that.pre-school.age.children.obtain.recommended. preventive. health. care. and. that. their. mothers. attend. regular. health. and. nutrition. lectures..In.selected.areas.pre-school.age.children.and.pregnant.or.lactating.women.also. receive.nutritional.supplements. PROGRESA/Oportunidades.was.introduced.initially.in.randomly.selected.communities.. Extensive.baseline.and.follow-up.surveys.(longitudinal).have.been.conducted.to.evaluate. the.program,.which.has.been.shown.to.have.a.positive.impact.on.the.educational.outcomes. of.school-age.children.(Schultz.2000;.Behrman,.Sengupta.and.Todd.2000,.2005)..The. program.has.also.been.shown.to.improve.both.health.and.nutrition.outcomes.(Gertler. and.Boyce.2001,.Behrman.and.Hoddinott.2004)..As.a.result.of.the.program's.carefully. documented. success,. similar. programs. have. been. established. in. Brazil,. Nicaragua,. Honduras,.Colombia,.Jamaica.and.Turkey..Evaluations.of.these.other.programs.have.also. found.generally.positive.impacts. Source: Rawlings and Rubio 2003. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.45 IMPROVING.EDuCATION.PERFORMANCE 4 5 using demand-side subsidies..Costs.of.schooling.are.a.relatively.high.share. of.a.poor.household's.income.in.some.Pacific.countries..Even.where.user.fees. in. primary. education. have. been. abolished. formally,. for. example. in. Fiji. and. Vanuatu,. obligatory.contributions.such.as.development.fees.and.other.costs.(for.school.uniform,.for. example).remain.high..An.approach.is.to.consider.the.use.of.demand-side.subsidies,.such. as.targeted.conditional.cash.grants.to.families,.as.a.policy.tool.to.encourage.parents.to.keep. their.children.in.school..Conditional.cash.transfers.are.currently.being.used.in.several.Latin. American.countries.(see.Box.4-8)..In.the.1970s.and.1980s.in.Fiji,.Save.the.Children.Fund. Fiji.(SCFF).ran.a.successful.Child.Sponsorship.Scheme.aimed.at.keeping.vulnerable.children. in.secondary.school..An.internal.review.in.1998.pointed.out.its.shortcomings.as.being.a. welfare.model,.providing.a.lifeline.and.addressing.symptoms.rather.than.root.causes.and. cures,.but.it.also.praised.the.scheme.for.what.it.was.-.a.practical.and.effective.route.to. education.for.thousands.of.disadvantaged.Fiji.children.. Strategic Options for Education Sector 4 6 Pacific.Island.countries.continue.to.face.two.major.challenges.in.education..The. primary.priority.is.how.to.ensure.that.every.child.completes.the.basic.education. cycle. of. adequate. quality.. The. second. is. to. ensure. access. to. an. equitable. and. quality. secondary.education.for.a.rising.proportion.of.children..The.performance.issues.identified. and.the.options.outlined.in.this.overview.are.limited.to.those.that.tend.to.appear.in.a. majority.of.Pacific.countries..For.any.one.country,.the.set.of.priority.performance.issues. and.will.be.distinctive..The.education.challenges.range.across.the.three.policy.domains. of.service.expansion,.management.and.governance..Setting.priorities.and.taking.up.the. more.urgent.issues.would.be.a.complex.exercise.in.any.country.setting..As.these.important. efforts.gain.momentum.strategic.choices.will.need.to.be.made.and.a.balance.struck.between. the.more.traditional.focus.on.service.capacity.expansion.and.the.more.demanding.issues.in. management.and.governance.. 4 7 what.are.the.main.strategic.choices.in.the.Pacific.that.would.help.governments. achieve.improved.learning.outcomes.and.improve.equity?. ·. An.important.first.step.would.be the development and refinement of the strategic policy and financing framework..This.is.already.well.underway.in.several.countries,. and.is.vital.to.understanding.how.best.to.match.available.resources.against.pressing. performance. problems. in. the. sector.. A. careful. review. of. public. expenditure. patterns,.both.government.and.donor.financed,.would.be.essential..Governments. and. donors. might. consider. reallocating. funds. from. tertiary. scholarships. or. education.to.interventions.for.improving.education.quality,.equity,.and.meeting. secondary. education. needs.. Currently,. over. 90. percent. of. primary. recurrent. education. expenditures. goes. toward. teacher. salaries;. expenditures. on. quality. related.inputs.and.operating.costs.are.by.contrast.almost.non-existent..Increasing. pupil.teacher.ratios.through.`clustering'.of.infant.and.lower.grade.schools.with. senior.`mother'.schools.as.in.PNG,.and.the.development.of.multi-grade.teaching. can.reduce.teacher.salary.costs.. ·. A.second.strategic.recommendation.is.for.governments.to.strengthen and refine partnerships with private sector and community in.increasing.both.the.supply.and. quality.of.secondary.education..Such.partnerships,.however,.need.to.be.developed. within a coherent policy and regulatory framework.. Enlisting. community. help. in. constructing.new.community-based.junior.high.and.highschools.may.help.address. the.shortage.of.places.in.secondary.education.and.the.high.costs.associated.with. attendance.at.secondary.schools.some.distance.from.remote.areas..Setting.quality. 46.|.wORLD.BANK CHAPTER.4 assurance.mechanisms,.such.as.setting.school.standards.and.monitoring.their. achievements,.can.improve.the.quality.of.all.education.services. ·. A. third. recommendation. is. to. increase. the focus on issues that would facilitate school to work transition. High.rates.of.academic.failure,.language.loss,.and.also.the. burgeoning.problem.of.`educated.unemployment'.and.the.attendant.disaffection. of.youth,.are.a.rising.concern..Development.of.a.curriculum.in.partnership.with. the.private.sector,.while.including.local.cultural.context.and.aspirations,.can.help. build.entrepreneurial.skills.that meet the needs of the economy..Such.a.curriculum. will.help.children.attain.basic.skills.in.language,.mathematics,.problem.solving. and. information. technology. and. ensure. options. for. technical. and. vocational. subjects.. Training. through. work. attachments. and. apprenticeships. can. further. help.this.transition.. ·. A.fourth.recommendation.is.in.the.area.of.delivery.of.school.services,.moving to more delegation of accountability to those delivering services on the ground.thorough. initiatives. such. as. school. based. management.. Delegating. to. principals. some. discretionary.control.over.budget.to.purchase.the.teaching.materials.can.help. create.a.greater.demand.from.principals.and.teachers.for.quality.materials.that. support.teaching.and.learning..Principals.could.also.be.required.to.manage.the. ongoing.assessment.and.monitoring.of.student.achievement,.and.to.share.this. data.with.the.PTA.and.wider.school.community..This.achievement.data.can.help. guide.instructional.practices.and.provide.information.to.parents.to.enable.them. to.better.support.their.children's.learning..Principals.should.also.be.empowered. to.better.manage.teachers.and.their.performance.. ·. A.fifth.recommendation.is.in.the.area.of.information.collection,.management,. use.and.sharing..More.focus,.especially.in.countries.at.risk.of.not.meeting.the. MDGs,.needs.to.be.brought.to.put in place surveillance systems that allow policy makers and education managers track progress.in.terms.of.enrollment,.achievement. and. specific. `at. risk'. groups.. This. would. involve. strengthening,. or. developing. Education.Management.Information.Systems.(EMIS).. ·. A.sixth.recommendation.is.in.the.area.of.alleviating constraints on poor people's participation in education through innovative programs. such. as. conditional. cash. transfers,. inclusive. or. special. needs. education. (as. appropriate). for. children. with.disabilities,.revising.school.fee.structures,.and.using.appropriate.pro-poor. targeting. mechanisms. in. the. allocation. of. secondary. scholarships.. Per. capita. grants.related.to.the.needs.of.special.needs.students.could.be.made.available.to. local.schools.and.private.providers.or.targeted.directly.to.families.with.special. needs.so.that.they.then.can.purchase.educational.provision.at.their.local.school.. Income.related.sliding.fee.scales,.scholarship.policies.that.specifically.target.the. poorer.sections.of.society,.quota.systems.that.ensure.that.schools.equitably.select. students.from.different.regions.or.different.ethnic.groups,.and.boarding.subsidies. and.travel.grants.would.greatly.improve.access.to.secondary.school.for.many.poor. children.from.outer.islands..Demand-side.subsidies,.such.as.targeted.conditional. cash.grants to.families,.can.encourage.parents.to.keep.their.children.in.school.. 4 8 while. the. policy. options. discussed. above. relate. to. reforms. with. a. country's. national.borders,.there.are.a.number.of.issues.that.span.across.country.borders. and.can.benefit.from.regional.collaborations..These.include:.(i).evaluation.of.approaches. to. introduction. of. decentralization. in. education. including. school-based. management. approaches. and. their. impact. on. education. outcomes;. (ii). development. of. common. assessment.tools.and.regular.monitoring.of.education.performance.through.strengthening. the.role.of.South.Pacific.Board.of.Education.(SPBEA);.and.(iii).reviewing.the.provision.of. tertiary.education.in.the.region.with.the.goal.of.`cost-effectively.promoting.education'. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.47 IMPROVING.EDuCATION.PERFORMANCE 4 9 Pacific.governments.and.ministries.of.education.are.increasingly.aware.that.the. serious.performance.issues.at.hand.obviously.require.more.than.simply.enhanced. capacities,.and.require.a.more.focused.effort.to.better.manage.and.govern.the.system.. Donors.too.are.realizing.that.they.must.assist.the.shift.to.this.more.complex.agenda.which. would.require,.in.the.first.instance,.more.donor.harmony.and.less.fragmentation..Funding. for.education.has.long.flowed.in.relative.abundance.to.the.Pacific:.Pacific.educators.now.are. taking.steps.to.improve.performance.to.match. 48.|.wORLD.BANK 5 Improving Health Sector Performance 1 Health.indicators.have.improved.in.the.Pacific.and.progress.toward.MDG.goals.is.in. some.cases.encouraging..These.gains,.however,.are.not.consistent.across.countries,. nor.within.countries.by.income.or.region,.and.when.other.more.specific.health.indicators. are. considered,. the. assessment. is. further. qualified.. In. addition,. public. health. systems. are.now.faced.with.intractable.problems.of.NCDs.of.youth.and.adulthood,.and.emerging. communicable. diseases. such. as. HIV/AIDs.. This. chapter. considers. the. more. detailed. evidence.on.system.performance.in.the.Pacific,.how.health.status.and.service.coverage.vary. between.and.within.countries,.and.explores.the.issues.that.may.underlie.some.of.the.more. important.lagging.indicators.in.the.region.. 2 The.chapter.then.turns.to.policy.initiatives.that.hold.promise.of.lifting.health.sector. performance.in.the.Pacific..These.initiatives.are.grouped.under.three.policy.domains:. service.expansion,.meaning.efforts.to.strengthen.the.human.and.physical.assets.of.the. system.with.new.resources;.sectoral.management,.which.refers.to.the.steps.that.health. providers.and.policy.makers.can.take.to.improve.service.effectiveness.within.the.limits.of. existing.resources;.and.multi-stakeholder.governance,.which.covers.regulatory.initiatives. that.enhance.the.operating.environment.for.the.sector.and.raise.its.productivity.through. partnerships.with.institutions.and.actors.outside.the.sector..Special.attention.is.given.to. the.two.latter.reform.domains,.sectoral.management.and.multi-stakeholder.governance,. given.the.large.efforts.to.date.that.have.expanded.health.system.capacities.and.coverage. Opportunities.TO.IMPROVE.SOCIAL.SERVICES|.49 IMPROVING.HEALTH.SECTOR.PERFORMANCE Performance Issues in Pacific Health 3 There.is.of.course.wide.variation.in.the.Pacific.in.terms.of.health.status.and.the.rate. of.improvement..Performance.thus.needs.to.be.measured.against.past.achievements. and.scope.for.further.improvements..This.section.presents.the.evidence.for.those.health. indicators.for.which.some.Pacific.countries.are.encountering.stalled.progress.or.increasing. problems..Thus,.for.each.of.the.indicators.described.below,.there.will.be.at.least.one.Pacific. country.that.is.performing.well.. 4 unfinished agenda in child and maternal health. Most.countries.in.the.Pacific. have.seen.significant.declines.in.u5MRs.in.the.past.few.decades..Kiribati,.Solomon. Islands,.Vanuatu.and.RMI.had.uMRs.above.50.per.1,000.live.births.in.the.1990s..Vanuatu. and.RMI.have.shown.real.progress.by.lowering.their.u5MR.by.60.percent.and.50.percent. respectively. in. the. past. decade.. For. Solomon. Islands. and. Kiribati,. efforts. need. to. be. focused.on.ensuring.that.the.MDG.goal.of.a.two.thirds.reduction.in.u5MR.is.achieved.. Clearly,.for.most.of.the.other.countries.in.the.region,.with.u5MR.ranging.between.20.and. 30.per.1,000.live.births,.achieving.further.declines.on.MDG.scales.will.be.a.substantial. challenge..Maternal.mortality,.with.its.measurement.challenges.in.small.settings,.is.at. low.levels.in.most.of.the.Pacific,.but.Solomon.Islands,.Kiribati,.and.FSM.are.likely.to.have. elevated.levels.and.need.to.continue.with.efforts.to.raise.birth.attendance.and.better. manage.high.risk.pregnancies. 5 High fertility rates and population growth..The.demographic.transition.from. having.high.fertility.and.child.mortality.rates.to.having.low-fertility.and.low.child. mortality.rates.has.only.just.begun.in.some.countries.in.the.region..In.Solomon.Islands,. RMI,.Kiribati,.and.Vanuatu,.growing.populations.have.required.an.expansion.of.services,. yet. at. the. same. time. governments. have. been. hard. pressed. to. improve. the. quality. of. services..One.study.had.identified.reducing.Kiribati's.rate.of.population.growth.as.the. "most.important.factor.under.domestic.control.that.will.influence.future.levels.of.income. and.welfare.per.head".52. 6 High.fertility.rates,.an.outcome.of.a.demand.for.large.family.size.in.many.Pacific.Island. countries,.have.contributed.to.rapid.urbanization.by.increasing.natural.population. growth.rates.in.urban.areas..In.rural.areas,.insufficient.land.and.limited.opportunities.for. growth.to.sustain.the.growing.populations.have.contributed.to.increased.urban.migration. (Table.5-1).. tablE 5-1: POPulatION gROWtH, tOtal FERtIlIty RatE aND uRbaN POPulatION Fiji Kiribati RMI FSM Palau Samoa Solomon Tonga Vanuatu Islands Population.Growth.Rate. 1.2 1.6 1.6 1.8 0.9 3.1 0.4 2.3 (Average.Annual.%) Total.Fertility.Rate.(Births. 2.7 3.6 5.7 3.5 2.6 4.0 5.3 3.4 4.3 per.woman) urban.Population.(%) 73 21 29 42 19 44 20 Contraceptive.Prevalence. 44 26 34 25-35 17 30 10 33 28 Rate.(%) Source: World Development Indicators, Regional MDG report. 7 Reproductive.health.and.family.planning.services.are.poorly.used.and.high.rates.of. teenage.pregnancy.persist..Teenage.pregnancies.account.for.10.percent.of.all.births. in.Samoa,.17-20.percent.of.all.births.in.RMI,.14.percent.of.all.births.in.yap.in.FSM,.and. 50.|.wORLD.BANK CHAPTER.5 18.percent.of.all.births.in.Pohnpei.in.FSM..Currently,.little.research.is.available.on.young. people.and.their.vulnerability.to.various.types.of.adolescent.reproductive.health.problems.. However,. one. recent. study. of. Kiribati. teenagers'. knowledge. about. reproductive. health. revealed.some.serious.gaps,.despite.the.fact.that.about.one.in.four.teenagers.had.apparently. received.some.sex.education.53. 8 young.people.between.the.ages.of.15.and.24.constitute.a.large.and.rapidly.growing. segment.of.Pacific.Island.populations..As.discussed.in.Chapter.2,.youth.unemployment. and.jobless.rates.are.high,.and.may.be.linked.to.a.cluster.of.social.issues.found.in.the.Pacific. and.elsewhere..Some.of.these.challenges.are.clearly.behavior.related.(for.example,.early. initiation.of.sexual.relations,.experimenting.with.alcohol.and.tobacco,.and.reckless.driving),. and.problems.in.one.area.tend.to.reinforce.those.in.other.areas.(for.example,.the.likelihood. of.engaging.in.risky.sexual.behavior.increases.when.alcohol.is.consumed). 9 Malnutrition..Less.well.understood,.it.appears,.is.the.threat.of.malnutrition..The. available. information. is. limited. but. suggests. that. nutritional. disorders,. including. low.birth.weight,.protein-energy.malnutrition.in.young.children,.and.vitamin.A.and.iron. deficiencies.among.young.children.and.their.mothers.are.all.fairly.common,.particularly. among.the.poor.and.outer-island.populations..For.example,.between.8.and.11.percent.of. babies.born.in.Solomon.Islands,.Fiji,.and.RMI.have.low.birth.weights,.while.the.figure.for. babies.born.to.teenage.mothers.in.RMI.is.as.high.as.30.percent..Low.birth.weight.babies. are.at.high.risk.of.infection.because.their.immune.systems.are.not.fully.developed..Poor. nutrition. in. early. childhood. not. only. increases. the. risk. of. peri-natal,. infant,. and. child. morbidity.and.mortality,.it.also.affects.children's.long-term.physical.growth.54 1 0 Double burden of non-communicable and communicable diseases. In.RMI,. Vanuatu,. FSM,. and. Kiribati,. communicable. diseases. such. as. tuberculosis. (TB). and.leprosy.are.still.prevalent,.and.are.among.the.major.causes.of.morbidity.and.mortality. (see.Table.5-2)..Malaria.is.prevalent.in.Solomon.Islands.and.Vanuatu,.and.is.the.leading. cause.of.outpatient.visits.in.Solomon.Islands,.and.probably.a.leading.cause.of.mortality.. Communicable.diseases.of.childhood.still.account.for.child.deaths,.despite.high.coverage. of.immunizations..HIV/AIDS,.as.shown.in.Chapter.2,.is.a.growing.threat.in.the.Pacific,.as. is.the.incidence.of.sexually.transmitted.infections.(STIs),.which.are.highly.correlated.with. risk.of.HIV.infection..The.real.incidence.of.STIs.is.probably.higher.than.the.reported.rate,.as. knowledge.of.STIs.other.than.HIV/AIDS.is.almost.non-existent.among.young.people.. tablE 5-2: tb aND lEPROSy PREvalENCE IN tHE PaCIFIC Fiji Kiribati RMI FSM Palau Samoa Solomon Tonga Vanuatu TB.prevalence.rate.per.100,000 38 60 60 62 76 44 60 44 71 Leprosy.cases 2 21 76 89 7 11 5 0 7 Source: WPRO/WHO 1 1 Among.NCDs,.of.particular.concern.are.cardiovascular.and.coronary.heart.diseases,. cancers.(especially.lung,.bowel,.oral,.stomach,.liver,.cervical,.and.breast.cancers). chronic.obstructive.pulmonary.disease,.accidents.and.injuries,.hypertension,.diabetes,.and. end-stage.renal.disease..In.many.Pacific.countries,.the.incidence.of.these.diseases.(despite. low. and. late. detection55). now. approaches. that. in. many. industrialized. countries. in. the. region.such.as.Japan,.Australia.or.the.uSA.(see.Figure.5-1)..There.is.also.evidence.of.rising. prevalence.of.type.II.diabetes.among.children.and.adolescents.in.the.region..In.Kiribati,. the.annual.number.of.diagnosed.new.cases.of.diabetes.increased.from.over.100.in.1992. to.about.1,100.in.2001,.while.the.annual.number.of.diagnosed.new.cases.of.hypertension. increased.from.about.250.in.1992.to.more.than.1,200.in.2001..Hepatitis.B.prevalence.is. high.in.FSM,.Palau,.and.Kiribati..Liver.disease.(including.cirrhosis.and.liver.cancer.as.the. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.51 IMPROVING.HEALTH.SECTOR.PERFORMANCE result.of.high.levels.of.hepatitis.B.prevalence.and.excessive.consumption.of.alcohol).is. among.the.leading.causes.of.death.in.Kiribati.and.FSM..Cervical.cancer.is.a.leading.cause.of. death.among.women,.and.the.rise.in.its.incidence.may.be.directly.due.to.the.high.incidence. of.the.Human.Papilloma.Virus.(HPV),.a.sexually.transmitted.infection.. FIguRE 5-1: PREvalENCE OF DIabEtES MEllItuS, POPulatION agES 20-79 (PERCENt) New Zealand Japan Australia Vanuatu Tonga Solomon Islands Samoa Palau FSM Marshall Islands Kiribati Fiji 0% 2% 4% 6% 8% 10% 12% 14% Source: Diabetes Atlas, International Diabetes Federation. FIguRE 5-2: SMOKINg PREvalENCE 70 Overall Female 60 Male 50 40 30 20 10 0 Fiji Kiribati FSM Palau Samoa Solomon Tonga Vanuatu Source: WHO database, Household Survey Tonga and STEPS (Fiji, Samoa). 1 2 Of.equal.concern.is.the.prevalence.of.risk.factors.for.health.problems.such.as. obesity,.unhealthy.diets,.tobacco.consumption,.and.declining.physical.activity.. The.effects.of.these.risk.factors.are.profound..Smoking,.for.example,.increases.the.risk.of. cardiovascular.disease,.several.cancers.(including.lung.and.cervical.cancers),.and.chronic. lung. disease,. while. obesity. and. poor. diets. are. risk. factors. for. cardiovascular. disease,. 52.|.wORLD.BANK CHAPTER.5 diabetes,.hypertension,.and.other.cancers..Smoking.prevalence.rates.of.around.40.percent. (Figure.5-2).have.been.recorded.in.many.Pacific.countries,.and.the.prevalence.of.obesity.-.a. combined.indicator.of.poor.diet.and.declining.physical.activity.-.is.more.than.10.percent.in. about.half.the.countries.in.the.region..Traditional.diets,.which.were.healthier,.have.been. increasingly.replaced.by.imported.high-fat,.low-nutrient.processed.foods.. 1 3 As. can. be. seen. with. continued. prevalence. of. communicable. diseases. such. as. TB,.leprosy,.malaria.and.rising.rates.of.HIV/AIDs.as.well.as.NCDs,.most.Pacific. countries.now.confront.a.`double.burden'.of.infectious.diseases.and.NCDs.. Capacity Constraints or Management Challenges? 1 4 The. challenges. faced. in. the. health. sector. in. most. Pacific. Island. countries. are. high. fertility. rates,. the. unfinished. agenda. of. reducing. maternal. and. in. some. countries.infant.deaths,.continued.prevalence.of.scourges,.such.as.malaria,.leprosy,.and. TB,.emerging.diseases.such.as.HIV/AIDs.and.rising.NCDs,.including.lifestyle.diseases..The. key.for.Pacific.governments.is.to.orient.health.systems.and.services.to.be.better.aligned. with.outcomes.that.their.countries.are.trying.to.achieve..This.entails.linking.resources.with. outcomes.and.building.in.incentives.for.both.providers.and.clients.throughout.the.system.. Service.capacities.remain.a.concern.in.some.areas,.especially.in.human.resources,.but.most. Pacific.countries.have.extended.system.coverage.successfully..Service.expansion.is.briefly. discussed.below,.after.which.this.chapter.focuses.on.issues.in.health.sector.management. and.governance.and.how.they.might.be.approached.. Expanding Service Capacities in Pacific Health Systems 1 5 access to health facilities. In. almost. all. nine. Pacific. Island. countries,. the. government. is. the. main. provider. and. financier. of. health. services.. with. the. exception.of.Fiji,.the.resources.allocated.to.the.health.sector.are.comparable.to.those.in. most.middle.income.countries,.which.is.a.clear.indication.of.the.government's.commitment. to.the.health.sector.in.these.countries.. tablE 5-3: PublIC HEaltH FaCIlItIES by tyPE Population Referral and Area Hospitals Health centers Dispensaries* Specialized Hospitals Fiji 835,000 6 19 74 117 Kiribati 96,000 1 24 66 RMI 59,000 2 60 FSM 125,000 4 112 Palau 20,000 1 4 6 Samoa 178,000 1 3 7 16 Solomon.Islands 457,000 1 9 140 173 Tonga 102,000 1 3 14 34 Vanuatu 210,000 5 24 247 * Includes MCH Centers, Dispensaries, Nursing Stations and Aid Posts Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.53 IMPROVING.HEALTH.SECTOR.PERFORMANCE 1 6 Health.care.facilities.are.accessible.in.most.countries,.with.hospitals.providing. most. of. the. care. on. the. heavily. populated. islands. and. primary. health. care. facilities. providing. services. in. outer. islands. and. rural. areas.. However. small. dispersed. population.groups.remain.a.challenge..Solomon.Islands,.Kiribati,.FSM,.RMI.and.Vanuatu. have.dispersed.populations.across.many.islands..Despite.these.challenges,.each.of.these. countries.has.created.an.outer-island.health.infrastructure.to.provide.primary.health.care. to.its.population.(Table.5-3).. 1 7 Medicalpersonnelandmigration.Over.15.percent.of.Pacific.Island.doctors.and. nurses.have.migrated.to.the.uSA,.New.zealand,.Australia,.the.united.Kingdom. (uK),.and.neighboring.island.countries.in.the.past.two.decades,.and.this.trend.is.expected.to. continue..Medical.personnel.migrate.in.response.to.external.and.internal.factors..Internal,. or. push. factors. include. low. remuneration,. poor. working. conditions. (such. as. inflexible. work.hours),.shortages.of.supplies.and.equipment,.poor.working.environments.in.rural. and.remote.areas,.and.a.lack.of.continuing.educational.opportunities.for.professional.and. career.development..External,.or.pull.factors.include.better.opportunities.to.educate.their. children.and.higher.salaries.. 1 8 Pacific.countries.have.largely.dealt.with.shortages.in.personnel,.especially.doctors,. by. recruiting. foreign. professionals. through. donor-supported. programs. and. retirees..Governments.could.also.experiment.with.incentives,.such.as.improved.working. conditions.and.higher.remuneration,.to.retain.staff.in.remote.areas..Other.options.include. providing.incentives.to.attract.migrants.back.home,.like.the.return.fund.and.the.family. incentive.scheme.in.Cook.Islands,.or.the.`homecoming.program'.for.nurses.in.the.Caribbean. Doctors.have.begun.returning.to.Solomon.Islands.because.the.scheme.of.service.has.been. updated.and.public.salaries.and.benefits.adjusted.in.line.with.current.market.conditions.. tablE 5-4: tyPICal StRuCtuRE OF a HEaltH SERvICE IN tHE PaCIFIC Facility Location Personnel Referral.and.Specialist.Hospitals. Capital.city Specialists,.GPs,.Doctors,.Nurses,. Nurse.Aides Area/Provincial.Hospitals Major.islands/urban.centers Doctors,.Nurses,.Nurse.Aides Health.Centers Few.in.urban.areas. Nurses.(some.Clinical.Nurses),. Mostly.rural.or.outer.islands Nurse.Aides Aid.Posts/Dispensaries Mostly.rural.or.outer.island Nurse.Aides 1 9 In.most.Pacific.countries.there.is.a.public.spending.bias.in.favor.of.tertiary.care,. and. this. reflects. in. part. a. bias. in. the. allocation. of. most. skilled. personnel. to. hospital-based.services.(Table.5-4)..It.is.also.common.for.qualified.doctors.to.be.appointed. to.administrative.positions,.for.which.they.are.not.properly.trained,.and.in.which.they.still. must.deploy.their.clinical.skills,.especially.in.more.remote.hospitals..Also,.there.are.very. few.incentives.for.qualified.health.personnel.to.agree.to.work.in.rural.or.remote.areas.where. they.can.expect.to.have.to.endure.poor.living.conditions,.limited.educational.opportunities. for.their.children,.and.the.irregular.payment.of.salaries.due.to.the.inadequacy.of.banking. systems.in.rural.areas.. 54.|.wORLD.BANK CHAPTER.5 Health Service Management in the Pacific 2 0 Throughout.the.Pacific,.the.challenges.of.sectoral.management.are.displacing.the. earlier.focus.on.service.expansion..A.poor.country.with.rapid.population.growth,. such.as.Solomon.Islands,.still.confronts.service.access.issues.in.some.islands,.but.in.most. of.the.Pacific,.attention.is.shifting.to.better.management.of.the.existing.and.abundant. resources.for.health..Sectoral.management.at.this.stage.of.Pacific.health.development.is. more.likely.to.obtain.improved.outcome.performance. 2 1 Facility utilization..In.all.countries.in.the.region,.hospital.care.(inpatient.and. outpatient).is.provided.either.free.or.for.a.nominal.fee,.and.revenue.collection. is.weak..In.countries.where.population.dispersion.is.low,.such.as.in.Tonga.and.Samoa,. patients.tend.to.seek.outpatient.care.at.hospitals.rather.than.at.lower.service.levels.even,. when.such.services.are.available.at.primary.health.care.centers.56.There.are.many.reasons. for.over.utilization.of.tertiary.facilities:. ·. access.to.doctors.as.providers.of.outpatient.care.in.hospitals.compared,.to.nurses. in.primary.care.facilities;. ·. easy.access.to.higher.level.facilities;. ·. lack.of.a.functioning.referral.system;.and. ·. absence.of.any.penalties.(for.example,.higher.user.fees).for.not.using.services.at. the.lowest.appropriate.level.. 2 2 In.highly.dispersed.populations,.such.as.Vanuatu.and.Kiribati,.the.challenges.are. different.. There. is. very. unequal. access. to. heavily. subsidized. hospital. services.. For.example,.in.Kiribati,.urban.residents.(of.South.Tarawa.and.Besio).increasingly.bypass. primary-level.facilities.and.use.outpatient.hospital.facilities.for.all.levels.of.care.because. hospitals.are.easily.accessible.to.them..On.the.other.hand,.residents.of.the.outer.islands.live. a.long.distance.from.hospitals.and.must.incur.high.transportation.costs.to.access.that.level. of.care..This.is.also.the.case.in.Vanuatu.where.98.percent.of.hospital.inpatients.come.from. the.predominantly.urban.islands.on.which.the.hospitals.are.located..This.unequal.access. implies.that.the.benefit.incidence.of.public.health.subsidies,.given.that.hospital.share.of. government.health.funding.is.disproportionately.high.(see.Table.5-5),.is.heavily.concentrated. on.predominantly.urban.(and.usually.relatively.wealthy).inner-island.populations.. 2 3 allocation of resources by level of care.. There. are. four. main. sources. of. health.financing.in.the.Pacific.-.governments,.external.donors,.NGOs,.and.users. (thorough.direct.out-of-pocket.spending.or.insurance.payment.shared.with.employers).. while.the.prominence.of.the.public.sector.in.service.delivery.is.high,.much.of.household. out-of-pocket.spending.in.health.goes.to.the.informal.sector,.or.traditional.healers.and.for. transportation.costs.57.Most.funding.for.the.formal.health.sector.is.from.public.resources.. Despite.the.rhetoric.in.favor.of.preventive.and.public.health.in.the.health.sector.strategies. of.most.governments.in.the.region,.the allocation of public health resources to preventive and primary care are low..Hospital.costs.tend.to.absorb.more.than.one-half.of.governments'. recurrent.health.budgets.(especially.if.we.include.the.cost.of.pharmaceuticals.and.medical. supplies.used.for.inpatient.care).(Table.5-5),.even.though.these.hospitals.provide.very.little. tertiary-level. care.. In. comparison,. primary. and. preventive. services. are. not. adequately. funded.to.provide.quality.services..In.addition.to.equity.concerns,.governments.need.to. take.a.closer.look.at.the.range.of.interventions.and.their.cost.effectiveness.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.55 IMPROVING.HEALTH.SECTOR.PERFORMANCE tablE 5-5: DIStRIbutION OF RECuRRENt gOvERNMENt HEaltH EXPENDItuRES Administration Primary care & public health Pharmaceutical . and policy Hospitals Primary health Other development services care Public health Fiji 7.2 50.2 24.7 3.2 11.4 3.3 Kiribati 14.7 52.3 16.3 16.7 0 RMI 19.0 44.0 9.0 16.0 12.0 0 Samoa 3.0 44.7 14.7 7.4 27.6 2.5 Solomon.Islands 15.2 28.3 37.2 12.2 0 Tonga 16.0 45.0 12.0 10 12.0 5 Vanuatu 17.5 46.0 15.0 9.0 12.6 0 Source: Country budget documents. 2 4 In.FSM,.despite.the.high.prevalence.of.NCDs,.little.funding.is.allocated.to.the. primary-level. prevention. of. these. diseases.. The. insufficient. resources. for. the. prevention. of. major. communicable. and. non-communicable. diseases. means. that. the. hospital.sector.has.to.treat.many.diseases.that.could.have.been.prevented.if.resources.had. been.allocated.more.cost-effectively.(see.Box.5-1).. 56.|.wORLD.BANK CHAPTER.5 bOX 5-1: COuNtRIES SPEND lIttlE ON PREvENtION aND EaRly tREatMENt OF DIabEtES In.2001,.a.review.was.conducted.of.diabetes-related.expenditures.in.RMI,.Fiji,.and. Cook.Islands..The.review.divided.up.these.expenditures.into.packages.of.services.called. Health.Care.Resource.Groups.(HRG).including.health.promotion.(HRG.1),.prevention. activities.(HRG.2),.investigation.and.treatment.of.early.stage.diabetes.(HRG.3),. treatment.of.diabetes.(HRG.4),.and.treatment.of.related.complications.(HRG.5).. RElatIvE SHaRE OF EXPENDItuRE attRIbutED tO DIabEtES aND RElatED COMPlICatIONS Fiji RMI 90 Cook Islands 80 erutidnepxEfoearhS 70 60 50 40 30 % 20 10 0 HRG1 HRG2 HRG3 HRG4 HRG5 Healthcare Resource Groups The.review.found.that.expenditure.on.diabetes.prevention.and.management.(including. related. complications). ranged. from. 6. percent. of. the. total. spending. on. diabetes. and. related.complications.by.the.Fiji.Ministry.of.Health.to.14.percent.by.the.RMI.Ministry. of.Health.and.the.Environment.and.by.the.Cook.Islands.Ministries.of.Health.&.Outer. Islands..Crucially,.the.review.also.found.that.all.three.countries.spent.comparatively.little. on.prevention.and.early.intervention. Source: Beaver, C (2003). 2 5 Patients. with. NCDs. need. constant. care. and. expensive. medicines.. In. RMI,. admissions.to.hospitals.for.diabetes.and.related.complications.constitute.more. than.70.percent.of.all.admissions.and.absorb.over.14.percent.of.the.total.health.budget.. Demand. for. costly. technologies. to. treat. NCDs. (such. as. renal. dialysis. units). is. putting. further.pressure.on.health.budgets..In.1999,.treatments.for.major.NCDs.(including.cancer,. cardiovascular.disease,.diabetes,.hypertension,.and.chronic.obstructive.pulmonary.disease). absorbed.between.11.and.27.percent.of.all.health.spending.in.Samoa,.Tonga,.and.Fiji. 2 6 Hospitalization. of. NCD. patients. accounted. for. 66. to. 82. percent. of. these. expenditures,. while,. in. Samoa. and. Tonga,. government-funded. medical. expatriations.of.a.very.few.patients.to.countries.with.tertiary-care.facilities.accounted.for. 15.to.17.percent.of.public.health.expenditure..Diseases.such.as.diabetes.and.hypertension. can.be.successfully.managed.in.primary.care.facilities.in.remote.and.rural.areas.(see Box. 5-2),.which.means.that.it.is.essential.for.these.countries.to.spend.more.resources.on.early. intervention.and.clinical.management.of.diabetes.to.prevent.the.disease.from.progressing,. thus.requiring.high-cost.interventions.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.57 IMPROVING.HEALTH.SECTOR.PERFORMANCE bOX 5-2: IMPROvINg DIabEtES CaRE IN RuRal aND REMOtE aREaS Torres.Strait.Islanders.have.the.highest.prevalence.of.diabetes.in.Australia,.with.about. 25.percent.of.adults.being.affected.and.with.very.high.rates.of.complications,.including. heart,.renal,.and.eye.diseases,.skin.infections,.and.amputations.of.lower.limbs..From. March.1999.to.February.2000,.a.one-year.study.aimed.to.evaluate.a.system.for.improving. evidence-based.local.management.of.Melanesian.adults.with.type.II.diabetes.in.remote. islands.in.the.Torres.Strait.of.Australia..A.randomized,.unblinded.cluster.trial.was.carried. out.involving.21.primary.care.centers.and.678.Torres.Strait.Islanders.with.diabetes.. The.intervention.was.a.simple.paper-based.register.and.recall.system.managed.by.local. health.workers.who.had.basic.training.in.diabetes.care.and.who.were.visited.twice.yearly. by.a.specialist.diabetes.outreach.team..The.main.outcome.measures.were.regular.checks. of.weight;.blood.pressure;.eye.and.foot.care;.serum.lipid.levels.and.glucose.monitoring. and.control;.urinary.albumin.to.creatinine.ratio.and.serum.creatinine;.the.administration. of.recommended.vaccines;.and.hospitalization.for.diabetes-related.complications.in.the. previous.12.months.. There.was.improvement.in.most.measures.at.most.sites,.except.in.the.blood.pressure. measures.and.the.vaccinations..Greater.improvements.were.evident.in.the.indicators.for. the.intervention.sites.in.most.cases.than.in.those.for.the.control.sites.(combined.relative. risk,.1.21;.95.percent.confidence.interval.1.03-1.43)..In.the.intervention.group,.there. was. a. 32. percent. reduction. in. hospital. admissions. for. diabetes-related. complications. during.the.study.period.(p=0.012)..At.follow-up,.patients.at.the.intervention.sites.were. 40.percent.less.likely.to.be.hospitalized.for.a.diabetes-related.complication.than.were. those.at.the.control.sites.(RR,.0.60;.CI:.0.41-0.86,.p=0.007).. The.study.suggests.that.a.simple.register.and.recall.system.managed.by.local.health.care. workers.and.supported.by.a.diabetes.outreach.team.can.achieve.significant.improvements. in.diabetes.care.and.reduce.hospitalizations.in.a.high-risk.population..This.is.a.highly. cost-effective.intervention,.with.estimated.savings.of.more.than.AuS$170,000.in.the. first.year.in.hospitalizations.and.patient.travel.. Source: Robyn McDermott, Barbara Schmidt, Ashim Sinha, Phillip Mills. Tropical Public Health Unit, Queensland Health, PO Box 1103, Cairns, 4870 Australia as reported in Beaver (2003). 2 7 Health provider motivation and performance.. The. poor. performance. of.providers.is.a.concern,.including.the.erratic.attendance.and.availability.of. doctors.and.nurses.and.the.unsatisfactory.performance.of.health.assistants..This.resulted. in.the.breakdown.of.primary.health.care.services.in.yap.and.Kosrae.in.FSM.58.In.RMI,. community.members.have.reported.that.health.assistants.are.frequently.absent.from. dispensaries.because.they.have.to.procure.drugs,.go.for.training,.or.take.personal.leave.. Health.personnel,.especially.those.in.outer.islands.and.rural.areas,.are.in.some.countries. lax.in.reporting.service.statistics.to.the.central.ministries..One.explanation.why.providers. do.not.do.what.is.expected.of.them.could.be.because.their.remuneration.is.not.effectively. linked.to.their.performance.. 2 8 International. experience. shows. that. how. providers. are. paid. can. affect. their. economic.and.technical.efficiency.and.the.quality.of.their.services..Clearly.any. reforms.in.this.area.need.to.be.taken.into.account.within.the.context.of.broader.civil.service. reforms..Almost.all.countries.in.the.region.are.undergoing.civil.service.reforms,.during. which.policymakers.are.establishing.performance.standards..In.Fiji,.Samoa,.Vanuatu,.and. Solomon.Islands,.senior.managers.in.the.public.health.system.(CEOs.and.directors).are. now.appointed.with.five-year.performance.contracts..These.reforms.need.to.be.extended. to.include.individual.health.care.providers.so.that.they.can.be.held.more.accountable.than. is.currently.the.case. 58.|.wORLD.BANK CHAPTER.5 2 9 Inefficienciesinpharmaceuticalmanagement.Even.though.large.proportions. of.government.health.budgets.are.spent.on.pharmaceuticals.and.medical.supplies,. countries. frequently. run. out. of. essential. drugs,. and. drug. use. is. still. not. appropriately. managed..Each.country.has.its.own.procurement.process,.but.many.of.them.are.not.cost- efficient..In.FSM,.each.state.is.responsible.for.purchasing.its.own.drugs,.and.they.often. purchase. brand-name. drugs. in. small. amounts. from. retail. drug. companies. instead. of. buying.generics.at.wholesale.prices..Poor.inventory.management.often.means.that.health. personnel do.not.place.orders.for.replacement.drugs.in.time.to.meet.demand,.which.leads. to.shortages.in.health.centers.and.dispensaries..Other.problems.include.drugs.being.off- loaded.at.the.wrong.ports.and.airports,.or.otherwise.lost.. 3 0 Pharmaceutical.procurement.and.management.is.an.area.where.governments.of. Pacific.Island.countries.could.benefit.from.regional.or.sub-regional.partnerships.. Countries.with.similar.disease.patterns.(for.example,.Tonga,.Samoa.and.Fiji,.or.FSM,.RMI,. and.Palau).could.share.a.national.formulary.and.even.consider.pooling.procurement.of. pharmaceuticals.and.medical.supplies.to.take.advantage.of.economies.of.scale..Fiji.has. started.a.Bulk.Purchasing.Scheme.(FBPS).for.pharmaceutical.and.medical.supplies:.where. Fiji.acts.as.a."supplier".to.countries.that.wish.to.purchase.from.them..The.FBPS.eventually. could. be. developed. into. a. mechanism. for. pooled. procurement,. but. this. will. require. a. concerted.process.of.institutional.reforms.and.regional.commitments. 3 1 So.far.the.main.constraint.to.effective.pooled.procurement.systems.is.the.lack.of. political.will.and.commitment.to.purchasing.commodities.through.the.pooled. system..Currently,.only.Tuvalu.and.Nauru.routinely.use.the.FBPS,.and.Samoa,.Tonga,. and.PNG.sporadically.use.the.system.to.meet.their.emergency.needs..In.order.to.make. the.FBPS.work.several.steps.need.to.be.in.place..First,.more.governments.would.need.to. commit.to.FBPS.for.their.pharmaceutical.needs..Second,.once.an.agreement.is.reached. among.all.regional.users,.the.FBPS.may.need.to.become.an.autonomous.institution.that. receives.support.from.affiliated.governments.and.donor.support.for.capital.and.initial. recurrent.costs..The.FBPS.is.currently.constituted.as.a.quasi-governmental.agency.of.the. Government.of.Fiji. 3 2 Third,.drug.procurement.and.logistics.need.to.be.adapted.to.the.Pacific.context,. both.in.terms.of.drug.types.and.logistics..The.types.of.drugs.that.consume.the. largest.portion.of.the.government.drug.budget.in.each.country.need.to.be.analyzed.and. reputable.suppliers.identified..Fourth,.as.more.countries.join.the.scheme,.this.operational. scheme.will.need.to.be.modified.to.attain.higher.administrative.and.logistical.efficiency..The. Pharmaceutical.Procurement.Service.set.up.by.the.Organization.of.East.Caribbean.States. (Box.5-3).does.not.buy,.warehouse,.or.distribute.drugs.in.bulk,.like.the.FBPS;.instead,.it. acts.as.an.exclusive,.single.buyer.for.the.participating.countries.and.invites.pharmaceutical. companies.to.submit.bids.for.regional.drug.contracts.and.to.supply.the.countries.directly.. This.achieves.price.efficiency.through.large-scale.purchases.and.avoids.the.logistical.costs. of.warehousing.and.shipping.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.59 IMPROVING.HEALTH.SECTOR.PERFORMANCE bOX 5-3: POOlED PHaRMaCEutICal PROCuREMENt IN tHE EaStERN CaRIbbEaN In.the.1980s,.the.countries.comprising.the.Organization.of.Eastern.Caribbean.States. (OECS).explored.the.possibility.of.combining.their.purchasing.power.to.negotiate.lower. prices.from.suppliers.of.medical.and.drug.supplies..As.a.result,.OECS.established.a.regional. pooled.procurement.body.called.the.Pharmaceutical.Procurement.Service.(OECS/PPS).in. 1986..The.PPS.is.still.active.and.is.known.for.reducing.the.prices.paid.by.its.member. countries.by.44.percent.over.the.prices.paid.by.individual.countries.in.2001/02..The. member.states.procure.about.85.percent.of.their.public.sector.pharmaceutical.needs. through.this.program. There. are. several. key. reasons. why. the. OECS/PPS. scheme. was. successful.. First,. the. political.will.to.achieve.the.goals.of.the.regional.drug.procurement.initiative.was.clearly. demonstrated.by.the.prime.ministers.of.all.of.the.member.countries..After.all.of.the. participating.countries.signed.the.agreement.to.establish.the.PPS,.each.country.deposited. one-third.of.its.annual.pharmaceutical.budget.into.the.special.reserve.drug.account.at. the.Eastern.Caribbean.Central.Bank.(ECCB)..This.commitment.meant.that.the.PPS.could. guarantee.prompt.payment.to.drug.suppliers.and.could.maintain.a.revolving.drug.fund.. Centralizing.the.procurement.process.was.also.crucial.to.its.success..The.PPS.does.not. warehouse.supplies.but.instructs.suppliers.to.ship.consignments.directly.to.participating. countries..Its.role.is.to.invite.suppliers.to.submit.tenders.to.negotiate.a.regional.price. contract.. Hence,. PPS. has. become. an. exclusive. buyer. representing. the. participating. countries.. The. suppliers. invited. to. participate. in. this. process. are. carefully. selected. through.international.competitive.bidding..The.procurement.list.is.based.on.the.Regional. Formulary.and.Therapeutic.Manual,.which.is.updated.biennially.by.the.Technical.Advisory. Committee. (TAC).. All. suppliers. are. paid. by. the. ECCB. from. the. purchasing. nation's. account..All.of.the.countries.in.the.region.use.the.Eastern.Caribbean.dollar,.which.reduces. transaction.costs.significantly,.as.there.is.no.need.for.any.currency.exchanges..Lastly,.the. PPS.also.provides.technical.assistance.and.training.in.quality.assurance.and.drug.supply. management.to.participating.countries.. Source: Huff-Rousselle, M and Burnet F. Cost Containment Through Pharmaceutical Procurement: A Caribbean Case Study. International Journal of Health Planning and Management, Vol. 11, 135-157 (1996). Center for Pharmaceutical Management, Management Sciences for Health. Regional Pooled Procurement of Drugs: Evaluation of Programs. December 2002. Governance over the Health System 3 3 Governance.and.management.are.closely.related,.but.distinct.in.two.important. ways..Management,.refers.to.the.decisions.of.health.service.officials.to.put.their. inputs.to.better.use,.such.as.through.retaining.doctors,.appointing.more.nurses.to.rural. posts,.and.procuring.pharmaceuticals.in.a.more.timely.and.low.cost.manner..Governance,. refers.to.the.broader.institutional.arrangements.which.link.public.health.services.to.people. and.institutions.outside.of.health.services,.that.are.outside.the.immediate.scope.of.health. service.managers,.and.can.be.vital.in.lifting.health.sector.performance. 3 4 Delegation and decentralization of public services. Delegating.management. and.financial.resources.to.local.health.providers.can.better.assign.accountability. and.foster.improved.performance..Decentralization.is.based.on.the.expectation.that.more. autonomous. local. providers. will. compete. for. clients,. and. adapt. to. local. health. needs,. demands. and. preferences. for. care.. with. dispersed. population. groups. and. geographic. barriers,.this.is.perhaps.a.necessity.­.the.key.here.is.to.ensure.that.there.are.clear.links. across.all.levels.of.the.system..These.are.some.of.the.core.principles.underlying.the.health. sector.reforms.in.Fiji,.Vanuatu.and.Samoa,.which.have.delegated.responsibility.for.the. 60.|.wORLD.BANK CHAPTER.5 delivery.of.services.from.central.to.local.health.departments.(see.Box.5-4)..Building.capacity. to.manage.health.services.at.the.local.level.is.crucial.for.improved.performance.especially. in.decentralized.settings..The.health.sectors.in.Samoa,.Solomon.Islands,.Tonga,.Fiji,.and. Vanuatu.have.all.benefited.from.extensive.donor.support.in.strengthening.management. capacity.and.performance.in.support.of.the.ongoing.institutional.reforms..Ministries.of. health.acting.alone.can.undertake.deconcentrating.staff.and.their.responsibilities.to.local. offices,.but.full.administrative.decentralization.and.any.formal.links.to.local.government. involve.government.wide.endorsement.and.support. bOX 5-4: DElEgatION OF PublIC SERvICES tO lOCal lEvElS: tHE CaSE OF FIjI Fiji,. in. particular,. has. had. considerable. success. in. its. decentralization. efforts.. Geographically,.Fiji's.health.care.system.is.divided.into.three.divisions.(western,.Central. Eastern.and.Northern),.each.of.which.has.one.divisional.hospital,.several.sub-divisional. hospitals,.and.various.health.centers.and.other.facilities..The.decentralization.of.the. health.system.in.Fiji.was.achieved.in.two.stages..In.the.first.stage,.the.responsibility.for. budgets.and.human.resources.was.devolved.from.the.Ministry.of.Finance.and.Planning. and.Public.Service.Commission,.respectively,.to.the.Chief.Executive.of.the.Ministry.of. Health..In.the.second.stage,.authority.was.delegated.from.the.Permanent.Secretary.to. the.three.divisional.directors..Morale.among.health.personnel.in.the.public.sector.has. improved,.and.divisional.directors.are.now.able.to.allocate.human.resources.and.budgets. according.to.local.needs..Another.important.feature.of.the.health.sector.reform.agenda. in.Fiji.is.local.ownership--.specific.assistance.under.the.AusAID.support.for.the.reform.is. decided.on.an.annual.basis.based.on.the.needs.identified.within.the.Ministry.of.Health's. annual.corporate.plan.. Source: Bank staff consultations. 3 5 Delegation and decentralization: increasing provider choice..while.modes. of.service.delivery.vary.by.country,.most.health.services.in.the.Pacific.region.are. delivered.by.the.public.sector..59.In.Kiribati,.Vanuatu,.and.RMI,.health.services.are.almost. exclusively.provided.by.central.government,.unlike.the.education.sector.in.which.services. are.provided.by.a.mix.of.government,.churches.and.private.providers,.but.financed.mainly. by.the.government..Government.services.are.in.some.cases.unable.to.make.any.headway.in. addressing.specific.health.problems..For.example,.immunization.rates.are.low.in.RMI.and. Vanuatu,.and.communicable.diseases.are.still.a.serious.problem.in.Kiribati,.Vanuatu,.and. Solomon.Islands..In.RMI,.the.public.health.system.has.not.been.able.to.control.TB.despite. generous.funding.levels..In.some.of.these.cases,.particularly.in.remote.areas,.or.in.instances. of.highly.resistant.patient.behaviors,.public.services.may.not.be.the.most.effective.service. delivery.option.. 3 6 In.such.cases,.governments.might.contract.with.churches.or.NGOs.to.provide. services. to. remote. areas. with. performance. measures. built. into. the. contracts (see.Box.5-5 on.the.experience.in.Cambodia)..Contracting.has.several.benefits,.it.enables. governments.to.focus.on.output.and.outcome,.circumvent.its.capacity.constraints,.take. advantage.of.the.flexibility.and.autonomy.of.the.private.sector,.and.to.use.competition.to. increase.effectiveness.and.efficiency..If.contracting.is.introduced,.however,.public.sector. managers.must.be.able.to.monitor.contracts,.and.the.contract.specifications.should.be. sufficiently.detailed.so.that.performance.can.be.measured. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.61 IMPROVING.HEALTH.SECTOR.PERFORMANCE bOX 5-5: CONtRaCtINg WItH NgOS IN CaMbODIa In. the. mid-1990s,. war. and. political. upheaval. had. left. Cambodia. with. little. health. care. infrastructure,. especially. in. rural. areas.. There. were. sufficient. paramedical. and. management.staff,.but.their.training.and.the.quality.of.care.that.they.provided.were. inconsistent.and.morale.was.low..The.primary.health.care.system.was.unable.to.deliver. services.of.adequate.quality..Basic.services.like.immunizations.were.not.being.provided,. and. the. child. mortality. rate. was. very. high.. To. address. these. issues,. the. Ministry. of. Health.(MOH).contracted.NGOs,.initially.on.a.pilot.basis,.to.manage.the.district.level. of. the. public. health. care. system. using. a. results-based. contract. to. monitor. progress.. The.contract.required.the.NGO.to.provide.management.and.technical.support.to.help. the.public.health.system.to.provide.primary.health.care.services.to.rural.populations. efficiently.and.equitably..Three.health.care.delivery.models.were.used:.(i).contract-out, in.which.the.contractors.had.complete.management.responsibility.for:.service.delivery,. including.hiring,.firing,.and.setting.wages;.procuring.and.distributing.essential.drugs. and.supplies;.and.organizing.and.staffing.public.health.facilities;.(ii).contract-in,.where. the. contractors. worked. within. the. MOH. system. to. strengthen. the. existing. district. administrative. structure. and. health. care. personnel. with. government-supplied. drugs. and.consumables.and.a.nominal.budget.supplement.for.staff.incentives.and.operating. expenses;.and.(iii).government,.in.which.the.management.of.services.remained.with. the.government's.District.Health.Management.Team.(DHMT),.the.government.supplied. drugs.and.consumables,.and.the.same.nominal.budget.supplement.for.staff.incentives. and.operating.expenses.was.provided.to.the.contract-in.districts..NGOs.were.selected. using.a.competitive.bidding.process,.and.health.care.service.indicators.and.goals.for. improving. service. coverage. and. coverage. of. the. poor. were. defined. and. specified.. All. districts.were.mandated.to.target.services.to.the.poorest.half.of.the.population. There.were.large.increases.in.the.coverage.rates.of.health.services.in.all.of.the.pilot. districts,. whether. contracted. or. government-managed,. but. the. contracted. districts. achieved.much.higher.coverage.rates..The.immunization.coverage.rate.in.the.contracted- out.districts.increased.from.25.3.percent.in.1997.to.82.percent.in.2003..Contractors.were. more.successful.at.improving.the.quality.of.services,.and.the.distribution.of.services.was. more.equitable.in.their.districts..Per.capita.annual.public.recurrent.expenditure.in.NGO- contracted.districts.was.considerably.higher.than.that.in.government.districts,.while. private.out-of-pocket.expenditures.in.the.contracted.districts.were.significantly.lower.. The.larger.substitution.of.public.for.private.expenditures.in.contracted.districts.than. in.government.districts.benefited.the.poor,.and.the.overall.efficiency.of.the.health.care. system.in.contracted.districts.was.greater.than.in.the.government.districts. Source: Bhushan, I., E. Bloom, B. Loevinsohn and J. B. Schwartz,k 2005. "Contracting Health Care Services for the Rural Poor: The Case of Cambodia." Development Outreach, May 2005, World Bank. 3 7 Traditional.healers60.are.an.integral.part.of.the.informal.health.sector.in.the.Pacific. but.are.not.formally.recognized.by.governments.as.providers.of.health.services.. There.are.as.many.as.925.healers.in.Samoa.and.500.in.Tonga.(an.average.of.3.per.village). and.account.for.many.of.the.outpatient.consultations..The.Tonga.traditional.healers.survey,. conducted.as.part.of.the.National.Health.Accounts.Assessment.by.the.Department.of.Health,. estimates.that.household.expenditure.on.traditional.healers.was.high,.at.around.uS$19.6. per.visit.or.uS$14.6.per.capita.61.In.Samoa,.households.spent.uS$5.05.per.visit.(or.uS$4.43. per.capita).on.traditional.healers..Some.of.the.greatest.potential.benefits.from.building. partnerships.with.traditional.healers.and.non-governmental.organizations.in.the.health. sector.are.to.be.realized.in.the.area.of.reproductive.health,.and.particularly.in.services.such. as.sex.education.and.suicide.prevention.targeted.to.adolescents..For.example,.traditional. healers.are.often.the.first.point.of.contact.for.diagnosing.and.treating.reproductive.health. problems.(including.HIV.and.other.STDs)..If.public.health.facilities.could.work.in.cooperation. with.traditional.healers.then.perhaps.it.might.be.easier.to.conduct.effective.surveillance. 62.|.wORLD.BANK CHAPTER.5 of.STIs..In.Kiribati,.Samoa,.and.Tonga,.the.International.Planned.Parenthood.Foundation. has.funded.Family.Health.Associations,.which.supplement.the.services.provided.through. the.public.health.system.by.providing.reproductive.health.services.in.the.capital.cities.of. Tarawa,.Apia,.and.Nuku'alofa.. 3 8 Information-sharing and monitoring: data for decision making..A.lack.of. critical.and.up-to-date.information.often.hinders.effective.policymaking,.planning,. monitoring.and.evaluation..Policymakers.in.the.Pacific.tend.to.utilize.health.statistics.from. internal.service.based.information.systems..These.systems.have.undergone.many.rounds. of.improvement.and.upgrades.from.both.government.and.donors,.but.in.several.Pacific. countries.are.still.in.need.of.improvement,.especially.in.regard.to.registry.of.births.and. deaths,.and.the.integration.of.hospital.data.with.the.primary.care.information.systems.62. These.efforts,.well.within.the.remit.of.sectoral.management.within.ministries.of.health,. need.to.continue,.but.the.governance.agenda.on.health.information.is.in.a.much.weaker. position..Only.some.countries.(Samoa,.Tonga.and.Fiji).have.launched.comprehensive.health. surveys.of.expenditure,.utilization,.and.outcomes..Even.fewer.are.linked.to.measures.of. household.income,.which.is.necessary.to.understand.the.distribution.of.health.services.to. different.income.groups..Solomon.Islands.recently.launched.such.a.full.health.survey,.the. first.in.its.history.. 3 9 why.is.population.based.health.data.so.important.to.health.systems.and.to. their.governance? ·. population.based.surveys.and.censuses.provide.a.reliable,.independent.check.on. the.accuracy.of.service.based.statistics,.especially.when.conducted.by.an.agency. outside.the.ministry.of.health..For.example,.in.FSM,.evidence.from.population- based.surveys.show.that.only.70.percent.of.births.and.46.percent.of.deaths.are. reported,.largely.due.to.inadequate.recording.at.the.dispensary.level; ·. population.based.data.can.be.used.to.analyze.the.distribution.of.health.services.to. poor.and.wealthy.subgroups,.a.key.input.to.equity.driven.policy.making;. ·. population. based. data. can. be. used. for. evaluation. of. different. public. health. strategies;.and. ·. population.based.data.can.illuminate.how.much.is.being.spent.by.families.on.both. private.and.public.services.(demand-side.data),.thus.inform.public.policy.on.how. to.regulate.fee.charging.practices.that.are.blocking.progress.on.health.outcomes.. 4 0 Population. and. household. level. information. on. health. care. utilization. and. expenditures.is.available.in.very.few.countries..Little.is.known.about.the.use.of. health.services.by.the.population.and.on.the.costs.incurred.by.households.in.accessing. health.care.(such.as.transportation.costs,.drug.costs,.and.fees)..Household.Income.and. Expenditure.surveys,.which.have.been.conducted.in.recent.years.in.Fiji,.Vanuatu,.Tonga,. Samoa.and.RMI,.collect.information.on.households'.direct.expenditures.on.health.care,. but.lack.information.on.utilization,.access,.type.and.level.of.provider..Tonga.and.Samoa. are. exceptions. in. that. they. have. collected. household-level. data. on. health. care. use. and. expenditures,.and.they.produce.National.Health.Accounts.on.a.regular.basis.to.inform. policy.and.planning.63.More.needs.to.be.done.in.order.to.understand.household.demand. for.health.services,.using.health.specific.surveys.. 4 1 Financing of health services ­ managing fees. This. means. use. of. fees,. subsidies,. insurance. and. other. mechanisms. to. encourage. better. use. of. health. services.and.better.household.management.of.family.health..Pacific.countries.are.entering. this. area. perhaps. too. slowly. as. there. are. many. potential. gains,. such. as. more. effective. targeting.of.the.poor,.limiting.overuse.of.expensive.services,.bringing.overseas.referral.costs. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.63 IMPROVING.HEALTH.SECTOR.PERFORMANCE under.control,.encouraging.better.self.care.and.prevention,.and.introducing.the.concept.of. cost.and.responsibility.in.the.use.of.health.services.. 4 2 Fees. for. inpatient. and. outpatient. consultations. are. far. below. costs. at. all. public.health.facilities..Such.a.fee.structure.can often.exacerbate.inequity.and. inefficiency.because.it.encourages.urban.populations.(most.of.whom.are.wealthier.than. rural. populations). to. bypass. primary. care. providers. and. seek. care. at. hospitals. where. services.are.more.expensive..In.addition,.low.co-payments.for.hospital.services.fail.to.check. the.consumption.of.highly.subsidized.hospital.treatments.by.the.non-poor..For.example,. in.Samoa,.fees.do.not.vary.by.health.level..Also,.in.rural.areas.women's.committees.charge. non-members.an.additional.fee.for.use.of.health.centers,.making.services.at.lower.levels.of. care.more.expensive.than.hospital.outpatient.services. 4 3 One.approach.to.uncoordinated.fees.would.be.to.introduce.or.increase.user.fees.for. outpatient.services.provided.at.hospitals.(with.exemptions.for.local.populations. who.have.no.other.lower.level.facilities.within.access),.while.making.the.same.services.free.at. the.primary-care.level..The.additional.resources.could.be.used.to.strengthen.health.services. in.rural.and.remote.areas.and.to.provide.travel.allowances.to.patients.for.referral.care..Of. course.this.would.have.to.include.mechanisms.for.exempting.poor.patients.from.having.to. pay.user.fees..The.poor.in.RMI,.Fiji,.and.Tonga.have.reported.that.transportation.costs.are.a. major.deterrent.to.using.health.services..Several.developing.countries.in.East.Asia,.such.as. Cambodia.and.Laos,.and.in.other.regions.are.experimenting.with.using.health.equity.funds,. which.seem.to.be.a.cost-effective.solution.to.this.problem..Funds.are.held.and.disbursed. by.local.authorities.to.poor.households.in.order.to.encourage.utilization.and.better.care.. Other.options.for.governments.to.consider.include.providing.demand-side.subsidies,.such. as.issuing.vouchers.to.qualifying.households.as.incentives.to.increase.immunizations.and. utilization.of.health.services..The.challenge.for.such.subsidies.is.that.targeting.them.to. the.poor.demands.sophisticated.measures.of.household.income.or.wealth,.with.high.initial. costs.for.small.countries,.as.in.the.Pacific. 4 4 Introducing risk sharing mechanisms.. Most. countries. in. the. region. have. also.begun.to.introduce.risk-sharing.mechanisms..In.Samoa,.discussions.were. underway. on. alternatives,. including. a. medical. savings. scheme. which. covers. workers. employed.in.the.formal.sector,.their.spouses.and.two.of.their.children..Fiji,.Vanuatu,.and. Tonga.are.all.considering.introducing.social.health.insurance.and/or.increasing.user.fees.to. meet.the.rising.costs.of.health.care..To.protect.the.poor,.governments.in.the.region.could. subsidize.insurance.for.the.poor.using.income-related.sliding.scales.(this.was.being.done.in. Palau.until.1998).and.co-payments..Governments.could.also.introduce.specific.schemes.for. the.poor.like.the.Health.Care.Fund.for.the.Poor.adopted.in.Vietnam,64.where.each.province. is.mandated.to.set.aside.up.to.VND50,000.per.year.per.beneficiary.to.either.purchase. insurance.to.cover.health.care.costs.of.the.poor.who.use.public.health.facilities,.or.to.pay. public.providers.directly.using.this.Fund..This.would.require.means.of.identifying.the.poor. (see.Chapter.7.for.discussion.on.appropriate.targeting.measures.for.the.Pacific).and.would. require.the.government.to.reimburse.providers.in.a.timely.manner. 4 5 Managing. overseas care. Given. the. limited. tertiary. treatment. capacities. in. most.Pacific.countries,.most.governments.subsidize.overseas.specialist.care.on. referral..This.absorbs.a.significant.share.of.public.health.system.resources.but.finances.only. a.few.patients. Samoa's.Overseas.Treatment.Scheme.(OVT).absorbs.about.14.percent.of.the. government's.health.budget,.to.treat.only.0.1.percent.of.the.country's.population..The.cost. to.the.Samoan.Government.has.increased.dramatically.from.about.ST0.3.million.in.1991-92. to.ST3.7.million.in.2000-01..Following.the.signing.of.the.first.Compact.of.Free.Association. with.the.uSA,.FSM.ran.up.extensive.debts.to.military.facilities.in.Guam.and.Hawaii,.which. expected.to.be.reimbursed.by.FSM's.government..In.Palau,.a.private.insurance.company. 64.|.wORLD.BANK CHAPTER.5 administers.the.overseas.referral.scheme,.while.in.FSM.and.RMI,.the.governments.have. their.own.insurance.schemes..Patients.in.FSM,.Palau,.and.RMI.are.referred.to.the.Philippines. and.Hawaii,.and.Tripler.Army.Hospital.(TAH).in.Hawaii.provides.services.free.of.charge.. The.TAH.also.makes.its.specialist.physicians.available.for.consultations.via.a.secure.website. at.no.charge..In.addition,.overseas.development.aid.from.New.zealand.covers.overseas. treatment.costs.for.patients.from.Pacific.countries.through.a.medical.treatment.scheme. (Box.5-6)..Private.insurers.also.fund.a.limited.amount.of.overseas.medical.treatment. 4 6 Although. there. is. little. information. available. on. the. characteristics. of. those. patients.who.have.benefited.from.publicly.subsidized.overseas.treatment,.it.is. reasonable.to.assume.that.they.are.mainly.relatively.wealthy.inner.island.residents.because. these.are.the.people.who.have.the.greatest.access.to.domestic.hospital.diagnostic.services.65. Since.the.demand.for.overseas.care.far.exceeds.the.available.funds,.all.Pacific.countries.have. to.ration.access.to.overseas.care.to.those.most.in.need,.allocate.even.greater.proportions. of.the.health.budget.for.this.purpose,.or.cross.subsidize.the.schemes.from.other.insurance. premiums,.as.was.the.case.in.RMI..There.are.formal.processes.and.criteria.in.place.(for. example,.the.patient's.age.and.disease).for.deciding.which.patients.are.eligible..For.example,. Tonga.and.Samoa.use.the.same.guidelines.as.the.New.zealand.Medical.treatment.scheme.. It.is.unclear,.however;.to.what.extent.these.criteria.are.strictly.enforced..For.example,.there. are.reports.of.political.interference.with.the.selection.process.in.Fiji,.FSM,.and.Kiribati. bOX 5-6: NEW ZEalaND'S MEDICal tREatMENt SCHEME The.New.zealand.Medical.Treatment.Scheme.covers.seven.countries.in.the.Pacific.­.Fiji,. Kiribati,.Samoa,.Solomon.Islands,.Tonga,.and.Tuvalu..Patients.eligible.for.consideration. under.this.scheme.have.conditions.that.are:.(i).life.threatening.or.seriously.debilitating;. (ii).have.a.good.prognosis.(an.expectation.of.five.years.of.healthy.life.after.treatment);. (iii).cannot.be.treated.in.country.of.origin;.and.(iv).can.be.treated.in.New.zealand.. Exclusions.are:.(i).chronic.cardiac.failure;.(ii).chronic.renal.failure;.(iii).chronic.neurological. conditions;.(iv).conditions.requiring.heart.or.bone.marrow.transplants;.(v).significant. co-morbidities;.(vi).conditions.requiring.on-going.costs.after.treatment;.and.(vii).those. that.can.be.treated.locally.or.through.visiting.technical.specialists..Patients.with.access. to.private.insurance.or.government.treatment.schemes.are.also.excluded..Patients.with. the.ability.to.pay.may.be.required.to.contribute.. Patients.covered.by.the.scheme.are.entitled.to.treatment.costs.and.living.expenses.for. themselves.and.a.companion..The.patient's.country.government.covers.his.or.her.travel. costs..The.number.of.patients.treated.and.the.average.cost.per.patient.treated.under.the. scheme.is.provided.above.. Source: Human Development Unit, East Asia and Pacific, "Project Appraisal Document for a Tonga Health Sector Support Project", World Bank 2003 4 7 To.contain.escalating.costs.on.the.supply.side,.there.are.several.approaches.being. used.in.the.Pacific..As.seen.in.Box.5-6,.Tuvalu,.by.sending.its.patients.to.Suva,. spends.half.as.much.in.this.category.as.it.would.do.if.it.sent.these.patients.to.New.zealand,. which.in.turn.costs.much.less.than.sending.patients.to.the.uSA.for.treatment.as.happens.in. RMI,.Palau,.and.FSM..Other.ways.of.providing.overseas.care.include.use.of.visiting.medical. specialists.(which.is.currently.being.funded.by.donor.agencies),.twinning.arrangements.with. facilities.in.Australia,.New.zealand.or.the.uSA,.and.remote.management.models.(including. use.of.telemedicine)..Another.option.might.be.to.develop.local.specialty.services,.possibly. by.subcontracting.the.provision.of.these.services.to.private.hospitals.like.the.Suva.Private. Hospital.or.Medcen.in.Samoa..Here,.the.volume.of.services.required.under.the.contract. would.need.to.be.large.enough.to.make.this.a.viable.option,.as.would.be.the.case.for.some. diabetes.treatments.even.in.small.countries.like.RMI..All.of.these.options.would.reduce.the. current.costs.of.providing.tertiary-level.treatment.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.65 IMPROVING.HEALTH.SECTOR.PERFORMANCE 4 8 Looking. to. demand-side. solutions,. governments. could. also. purchase. health. insurance.to.cover.the.cost.of.overseas.treatment.with.contributions.from.those.in. formal.employment,.while.subsidizing.those.who.cannot.afford.to.purchase.insurance..This. could.be.introduced.independently.or.in.the.context.of.an.overall.reform.of.the.financing. of.both.in-country.and.overseas.care..If.countries.in.the.region.were.to.purchase.insurance. jointly.through.a.private.agent,.this.would.increase.risk.pooling.and.thus.reduce.the.cost.of. premiums..RMI.introduced.health.insurance.for.overseas.care.but.only.on.a.voluntary.basis.. Consequently,.the.scheme.experienced.`adverse.selection.'66.The.social.security.system.had. to.subsidize.the.overseas.health.insurance.scheme..This.can.be.expected.to.happen.in.any. voluntary.scheme.until.enrollment.rates.reach.a.high.level..Governments.should.not.be. deterred.if.the.insurance.scheme.runs.up.an.initial.deficit,.as.governments.were.already. financing.the.full.costs.of.overseas.care.before.the.schemes.were.introduced..As.long.as. premiums.are.actuarially.sound.and.are.not.increased.in.an.effort.to.cover.these.initial. deficits,.enrollment.rates.should.increase.over.time.and.the.problem.of.adverse.selection. should.diminish. 4 9 Programs that help people lead healthy lifestyles. Obesity,. poor. diets,. and. physical. inactivity. are. serious. problems,. contributing. to. high. and. rapidly. increasing.rates.of.diabetes.and.circulatory.disease..Excessive.consumption.of.alcohol.is. also.a.growing.public.health.problem..Rates.of.tobacco.use.are.also.high,.while.risky.sexual. practices. are. also. a. growing. threat. to. health,. particularly. among. young. people.. Health. education.and.promotion.has.had.little.success.to.date.in.changing.people's.behavior..The. main.issue.here.is.to.get.individuals.and.families.more.engaged.in.their.health..Incentives. to.changing.behavior.can.also.involve.issues.like.increasing.taxes.on.unhealthy.processed. foods.as.well.as.on.alcoholic.beverages.and.tobacco.products..Such.taxes.already.exist.and. could.be.a.disincentive.to.consumption,.but.are.often.too.low.to.have.the.desired.effect.. 5 0 Incentives.and.behavior.change.also.involve.better.case.management..For.instance,. poor. management. of. diabetes. by. those. who. have. the. disease. is. increasing.67. Poorly.managed.diabetes.leads.to.high-cost.complications.including.cardiovascular.disease,. cerebrovascular.disease,.renal.disease.(leading.to.end-stage.renal.failure),.impotence.in. men,.eye.disease,.and.diabetes.sepsis.(which.is.the.major.cause.of.lower.limb.amputation). 5 1 There. are. several. options. that. could. be. considered. to. raise. responsibility. and. empowerment.of.individuals.for.their.own.health..Clearly,.increasing.the.scope.for. risk-sharing.through.insurance.is.one.such.option..In.addition.to.risk-sharing,.introducing. incentives.to.encourage.people.to.take.effective.preventive.health.measures.might.help.to. reduce. the. prevalence. of. NCDs.. Increasingly,. insurance. companies,. employers,. and. local. governments.in.developed.countries.are.working.with.the.population.to.provide.incentives. such.as.smoking.cessation.programs,.and.cash.and.in-kind.benefits.that.encourage.healthy. behavior,.for.example,.by.subsidizing.fitness.programs.(Box.5-7).. 66.|.wORLD.BANK CHAPTER.5 bOX 5-7: INCENtIvES FOR HEaltHy bEHavIOR Crushed. by. health. insurance. increases,. companies. in. the. uSA,. are. implementing. wellness.programs.to.help.employees.lose.weight,.quit.smoking.and.work-out..yearly.uS. health.insurance.costs.related.to.obesity.alone.account.for.$7.7.billion,.according.to.the. washington.Business.Group.on.Health. Cash.incentives.are.sometimes.used.to.lure.workers.out.of.their.cubicles..workplace. programs. ensure. higher. participation. rates. and. offer. opportunities. for. positive. reinforcement..In.2002,.an.analysis.of.22.studies.showed.that.the.return.on.investment,. in.the.form.of.reduced.health.care.costs,.was.a.staggering.300.percent..wellness.programs. also.reduce.absenteeism.and.`presenteeism'.(where.workers.show.up.but.are.too.sick.to. really.produce)..Blue.Cross.Blue.Shield.of.Oklahoma.built.a.financial.incentive.into.the. wellness.program.it.uses.for.its.1,300.employees,.which.offers.weight.watchers.at.work. meetings..Employees.write.checks.to.participate.in.the.16-week.program,.if.they.attend. at.least.14.weekly.sessions,.they.get.their.checks.back..Since.the.meetings.began.in.1999,. Blue.Cross.Blue.Shield.employees.have.collectively.lost.nearly.20,000.pounds..A.highly. popular.program.called.HealthbyChoice.is.a.unique.partnership.between.the.employer,. employee.and.Priority.Health..It.is.designed.to.engage.employees.to.become.smarter. health.care.consumers.and.to.make.better.lifestyle.choices..Employees.who.choose.to. participate,.and.who.meet.their.commitments,.earn.incentives.such.as.cash.rewards. or.premium.rebates..The.employer.receives.a.premium.discount.of.up.to.1.percent.for. implementing.the.program.and.abiding.by.certain.guidelines. Source: Psychology Today, Carlin Flora. "Cash incentives: rewards at the office can keep workers fit." Jan-Feb, 2004, Wendy J. Wigger, Director of Wellness, Priority Health 5 2 Community partnerships in health..Building.on.traditional.partnerships.with. communities.could.go.a.long.way.toward.improving.health.outcomes..The.role. played.by.communities.in.providing.health.services.is.not.new.in.Pacific.Island.countries.. For.example,.community.health.councils.in.RMI,.village.health.workers.in.Solomon.Islands,. and.women's.committees.(which.are.responsible.for.maintaining.rural.health.facilities).in. Samoa.have.helped.to.control.the.spread.of.communicable.diseases,.and.in.Vanuatu.and. Samoa,.communities.still.help.to.build.and.maintain.their.own.aid.posts.and.health.centers.. Involving.communities,.especially.patients,.in.health.education.programs.as.was.done.in. FSM's.diabetes.control.program,.as.detailed.in.Box.5-8,.can.also.help.increase.awareness.of. non-communicable.diseases..But.elsewhere.community.partnerships.have.withered.or.are. not.yet.in.place..In.RMI,.currently.only.50.percent.of.the.community.health.councils.still. exist,.and.these.function.only.intermittently..The.rest.of.the.councils.ceased.to.function. because.council.members.were.not.given.adequate.training.in.their.functions.and.roles,. and.due.to.a.lack.of.ongoing.support.and.encouragement.from.the.Ministry.of.Health..In. Kiribati,.the.population.is.not.directly.involved.in.the.management.of.public.health.facilities. ­.no.village.health.committees.exist.to.provide.feedback.to.the.staff.of.health.centers,.and. hospitals.do.not.have.boards.with.citizen.representation..Governments.in.the.region.should. consider.reviving.and.extending.the.role.played.by.community.organizations.in.the.health. sector,.particularly.in.managing.the.primary.and.secondary.prevention.of.NCDs. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.67 IMPROVING.HEALTH.SECTOR.PERFORMANCE bOX 5-8: HEaltH EDuCatION tHROugH COMMuNIty aND PatIENt PaRtICIPatION ­ tHE EXaMPlE OF FSM In.response.to.the.rising.prevalence.of.diabetes,.the.diabetes.control.program.in.FSM,.has. focused.on.community.education.and.early.identification.and.prevention..Two.education. videos.have.been.produced.and.aired.on.local.television.and.used.in.other.education. programs..what.is.interesting.about.these.videos.is.that.they.involve.community.members. who.talk.about.how.diabetes.has.adversely.affected.their.lifestyle.and.how.important.it. is.to.prevent.it..while.the.impact.of.these.programs.on.individual.behavior.is.difficult. to.ascertain.and.evaluate,.local.residents.are.now.increasingly.aware.of.the.problems.of. diabetes.in.their.communities.and.that.it.is.related.to.poor.diet.and.lack.of.exercise. Source: Beaver, C (2003). Health Sector Strategic Choices for the Pacific 5 3 Although. there. are. common. performance. issues. in. the. Pacific. and. striking. similarities. in. the. structure. of. delivery. systems. and. their. financing,. Pacific. health.systems.are.nonetheless.notable.for.their.variability.and.distinctiveness..A.single. strategy.will.not.match.the.region,.and.thus,.in.this.section,.the.discussion.is.on.strategic. choices..Pacific.Island.countries.continue.to.face.challenges.such.as.the.unfinished.agenda. in.achieving.the.MDGs,.high.fertility.rates,.continued.prevalence.of.communicable.diseases. and.the.emerging.threat.of.HIV/AIDs,.combined.with.a.rising,.and.in.many.cases.a.crisis,. in.NCD.prevalence..Pacific.health.systems.need.to.be.reoriented.to.face.these.challenges.in. order.to.ensure.that.health.services.deliver.results.. 5 4 what.are.the.main.strategic.choices.in.the.Pacific.that.would.help.achieve.desired. health.outcomes?. ·. One. is. better alignment of resources, both government and donor funds, toward achieving desired health outcomes as prioritized in country sector strategies.. This. requires.careful.thinking.about.the.outcomes,.how.best.to.address.the.underlying. causes,.and.the.links.with.health.policy.and.service.delivery.aspects..It.needs. to.go.beyond.looking.at.the.service.delivery.alone.to.achieve.the.desired.impact. in.terms.of.outcomes..A.priority.area.for.action.is.increased.resource.allocation. for. cost-effective. preventive. and. primary. care.. Early. intervention. and. clinical. management.of.non-communicable.diseases.at.the.primary.level.will.help.prevent. these.diseases.from.progressing,.thus.requiring.high-cost.interventions.. ·. A.second.strategic.choice.is.on.financing of health care,.both.in.terms.of.diversifying sources of finance from public revenues to risk sharing mechanisms. and individual payments..Equity.concerns.are.of.paramount.importance,.that.is.choices.regarding. who.should.benefit.most.from.free.health.services..One.option.is.to.introduce.or. increase.user.fees.for.outpatient.services.provided.at.hospitals.(with.exemptions. for.local.populations.who.have.no.other.lower.level.facilities.within.access),.while. making. the. same. services. free. at. the. primary-care. level.. Additional. resources. could. be. used. to. strengthen. health. services. in. rural. and. remote. areas. and. to. provide. travel. allowances. to. patients. for. referral. care.. Other. options. include. experimenting.with.social.health.insurance,.or.insurance.for.overseas.care,.while. using.income-related.sliding.scales.and.co-payments.to.protect.the.poor. ·. A.third.choice.is.in.the.area.of.delivery.structure,.from.centralized.models.to. more.delegation of accountability to those delivering services on the ground.as.well. 68.|.wORLD.BANK CHAPTER.5 as.efforts.to.include.all.parts.of.the.delivery.system.in.our.thinking.about.health. sectors.-.i.e..public,.private,.NGOs.church.services,.traditional.healers,.and.even. households.as.providers.of.health.services..Delegating.management.and.financial. resources. to. local. health. providers. can. better. assign. accountability. and. foster. improved.performance..with.dispersed.population.groups.and.geographic.barriers. this.is.perhaps.a.necessity,.the.key.here.is.to.ensure.that.there.are.clear.links. across.all.levels.of.the.system..where.government.services.are.unable.to.make. any.headway.in.addressing.specific.health.problems,.particularly.in.remote.areas. or.in.instances.of.highly.resistant.patient.behaviors,.contracting.with.churches. or. NGOs. to. provide. services. would. enable. governments. to. focus. on. output. and.outcome,.circumvent.their.own.capacity.constraints,.take.advantage.of.the. flexibility.and.autonomy.of.the.private.sector,.and.to.use.competition.to.increase. effectiveness. and. efficiency.. Formally. recognizing. traditional. healers. (who. are. often.the.first.point.of.contact).in.the.health.sector,.and.building.partnerships. with. non-governmental. organizations. and. communities. is. important. in. the. areas.of.reproductive.health,.health.education.and.promotion,.and.is.particularly. important.in.services.targeted.to.adolescents.. ·. A.fourth.is.in.the.area.of.incentives,forserviceproviderstoensurethatqualityservices are delivered and for service users to ensure that services are utilized appropriately.. Linking remuneration. with. performance,. as. long. as. it. is. done. in. conjunction. with.broader.civil.service.reforms,.can.help.motivate.service.providers..Improved. working. conditions. and. higher. remuneration. can. attract. qualified. personnel. to.work.in.remote.areas..Innovative.mechanisms,.such.as.health.equity.funds. (held.and.disbursed.by.local.authorities.to.poor.households).and.vouchers,.can. encourage.utilization.of.immunizations.and.other.preventive.health.services.. ·. A.fifth.is.in.helping people to lead healthy lifestyles..with.high.prevalence.of.NCDs,. especially.in.Micronesia.and.Polynesia,.and.emerging.diseases.such.as.HIV/AIDs,. the.need.for.emphasis.on.behavior.change.­.diet,.smoking,.sexual.behavior.­.and. need.for.using.preventive.services.is.important..Cash.or.in-kind.incentives.(like. smoking.cessation.programs.and.fitness.programs).to.encourage.people.to.take. effective.preventive.health.measures.can.help.to.reduce.the.prevalence.of.non- communicable.diseases.. ·. A.sixth.is.to.ensurestronglinkswithdemandsespeciallyatthehouseholdandcommunity levels..Little.is.known.about.the.use.of.health.services.by.the.population,.and.about. the.costs.incurred.by.households.in.accessing.health.care.(such.as.transportation. costs,. drug. costs,. and. fees).. Governments. need. to. invest. in. population-based. surveys.(as.has.been.done.in.Samoa.and.Tonga).and.qualitative.assessments.on. health-seeking.behavior,.in.addition.to.collecting.health.statistics.from.internal. service.based.information.systems. 5 5 Ministries.of.health.in.the.Pacific.are.assigned.responsibility.for.improving.health. indicators,. and. as. has. been. seen,. many. interventions. aimed. at. that. goal. are. not.implemented.by.health.delivery.systems,.but.are.undertaken.within.broad.alliances,. partnerships.and.social.mechanisms..Most.health.performance.issues.seem.to.be.rooted.in. individual.behavior,.of.both.clients.and.providers,.and.thus.health.gains.in.the.Pacific.seem. more.likely.to.be.won.in.the.more.difficult.end.of.the.spectrum,.in.service.management.and. in.particular,.governance.where.demand-side.issues.can.be.addressed.. 5 6 The. strategic. options. discussed. in. this. chapter. need. to. be. placed. in. country. contexts..Many.would.be.inapplicable.in.specific.settings..But.policy.makers.still. must.make.priorities.and.chose.the.most.appropriate.interventions..In.Micronesia.and. Polynesia,.for.example,.there.is.a.crisis.in.NCD.prevalence.and.in.associated.hospital.costs. and.overseas.referrals..This.is.well.recognized.and.being.acted.upon..Behavioral.issues.are. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.69 IMPROVING.HEALTH.SECTOR.PERFORMANCE behind.cost.escalation.and.poor.disease.management..In.order.to.deal.with.those.issues,. more.challenging.(not.necessarily.more.expensive).interventions.need.to.be.considered,. particularly.on.the.governance.side,.with.a.focus.on.prevention,.behavior.change,.early. detection.and.management,.and.is.an.area.where.complex.multi-.stakeholder.arrangements. hold.much.promise..In.making.choices.among.those.options,.Pacific.policy.makers.are.aware. of.their.own.capacity.constraints.in.small.country.settings,.but.increasingly.realize.they. must.stretch.them.to.launch.effective.policies.. 5 7 Regional approaches. In.this.context,.regional.collaboration.can.be.helpful.in.at. least.two.aspects:.(i).issues.that.span.across.country.borders;.and.(ii).interventions. where.there.are.significant.economies.of.scale.from.regional.collaborations. One.example. is. a. regional. procurement. facility. for. pharmaceuticals. that. could. both. lower. costs. and. increase.quality,.while.decreasing.the.administrative.burden.on.small.country.ministries.. Another.approach.is.collaboration.among.governments.on.their.overseas.referral.policies. and.practices,.and.associated.risk.sharing.options.such.as.a.regional.insurance.program. for.overseas.referrals..Even.if.provided.at.highly.subsidized.rates,.overseas.referrals.can. encourage.moral.hazard.among.clients,.and.thus.worsen.case.management.issues.in.the. sending.countries..More.attention.to.how.Pacific.health.systems.can.better.manage.costs. and.patient.expectations.would.be.a.critical.shift.. 5 8 How.aid.assistance.is.provided.also.needs.to.be.modified.to.better.fit.with.the. strategic.challenges.confronting.Pacific.health.policy.makers..One.way.forward. is.to.orient.regional.support.to.bring.scale.and.efficiency.to.government.reforms..Another. area.is.donor.allocation.of.resources.by.level.of.care,.to.ensure.that.health.priorities.as. identified.within.government.sectoral.strategies.are.supported..Fertility.and.population. are.less.well.supported,.and.need.urgent.attention.in.some.countries..A.third.area.of.donor. assistance.is.in.the.realm.of.donor.coordination.and.harmonization.in.order.to.lower.the. management.and.transaction.costs.to.Pacific.countries..This.will.be.taken.up.in.Chapter.8. 70.|.wORLD.BANK 6 Managing Social Risk 1 Social.protection.is.an.area.of.human.development.that.focuses.on.managing.the.risks. that.can.plunge.families.into.adversity.and.poverty.and.cause.them.to.lose.opportunities.. Successful. risk. management. benefits. the. overall. economy. and. improves. welfare. at. the. household.level..In.practice,.social.protection.includes.labor.market.interventions.(labor. market.regulations,.employment.services,.and.wage.setting.rules),.social.insurance.programs. (such. as. pensions,. unemployment. and. family. benefits,. and. sick. pay),. social. assistance. (transfers.in.cash.or.kind,.subsidies,.and.workfare),.and.programs.to.assist.particularly. vulnerable.groups.(such.as.disabled.people,.orphans,.or.vulnerable.children). 2 There.are.two.types.of.risks.that.households.confront..The.first.type.is.aggregate.risks. that.are.so.broad.in.their.impact.that.nearly.everyone.in.the.country.feels.them..These. include.macroeconomic.shocks.that.bring.household.incomes.down.through.declines.in. export.prices,.sudden.rises.in.the.cost.of.living,.and.other.economy-wide.events..Natural. disasters.and.civil.conflicts.are.two.other.types.of.aggregate.risks.that.can.strike.a.country. and.inflict.unexpected.hardship.on.the.economy.and.on.many.families..The.Pacific.region.is. regarded.as.highly.prone.to.macroeconomic.volatility.and.natural.disasters.. 3 The.second.type.of.risk,.which.is.idiosyncratic.in.nature.and.specific.to.an.individual. or.a.household,.can.negatively.affect.a.family's.welfare.even.under.buoyant.economy- wide.conditions..These.risks.are.linked.to.household.constraints.and.behavior..Destructive. social.problems.such.as.domestic.violence,.alcohol.abuse,.suicide,.and.criminal.activity.are. obvious.sources.of.household.risk,.as.each.can.reduce.household.earnings.suddenly.or.more. gradually..Other.examples.of.household.risks.include.school.drop.out,.the.unemployment. of.young.people.or.the.family's.main.breadwinner,.catastrophic.illness.and.its.costs,.and. more.long-lasting.problems.such.as.disability,.and.loss.of.income.due.to.old.age.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.71 MANAGING.SOCIAL.RISK 4 How.these.risks.can.best.be.managed.depends.on.the.nature.of.the.risk.(macro.versus. idiosyncratic).and.on.the.country-specific.context..while.it.is.generally.more.effective. to.use.preventive.interventions.(such.as.sound.macroeconomic.policies,.more.education. and. skills. training,. and. social. outreach. services),. the. onset. of. adverse. events. typically. requires.households.and.governments.to.adopt.coping.and.mitigating.mechanisms.so.that. households.can.either.insure.themselves.against.risks,.or.be.directly.assisted.via.government. safety.net.programs.or.assistance.from.friends.and.the.community.. 5 The.key.issues.in.social.protection.in.the.Pacific.region.are.different.to.those.in.education. and.health..As.will.be.seen,.most.Pacific.governments.have.been.reluctant.to.finance. or.provide.social.assistance.and.social.insurance-type.programs.and.have.held.the.view.that. families,.communities,.and.NGOs.should.provide.vital.safety.net.services..Family-based. systems.are.impressive.and.some.of.them,.such.as.the.Matai System.in.Samoa.(Box.6-1),.are. very.well.organized..However,.this.arms-length.policy.on.the.part.of.governments.is.under. stress.in.the.Pacific.region.. 6 Some.social.problems.have.worsened.in.recent.years.and.new.issues.have.come.to.the. surface..Most.troubling.is.the.growth.in.numbers.of.youth.(so.called.`youth.bulge').and. their.higher.levels.of.joblessness..Some.countries.have.experienced.rises.in.social.issues,. such.as.crime.and.alcohol.abuse,68.although.the.evidence.base.is.weak..Other.issues.have. become.apparent,.such.as.domestic.violence69.and.teen.pregnancy..The.negative.effects.on. many.families.of.macroeconomic.volatility.and.weather.shocks.have.also.been.recognized.as. significant.in.the.Pacific..Thus,.the.emergence.of.a.large.population.of.restless,.unemployed. young.people.in.some.countries,.serious.urban.social.problems,.and.the.deprivation.of. chronically.poor.sub-groups.all.point.to.the.need.for.governments.to.take.a.more.strategic. approach. and. to. consider. more. formal. engagement. than. in. the. past.. Social. protection. in.the.Pacific.is.thus.a.relatively.new.field.of.government.activity,.and.existing.programs. (with.some.notable.exceptions).are.scarce..This.chapter.is.therefore.concerned.with.service. expansion.issues.in.social.protection,.and.less.so.on.sectoral.management.and.governance. of.existing.programs..The.central.question.is.whether.governments.should.intervene,.and. if.so,.where,.when,.and.how?. 72.|.wORLD.BANK CHAPTER.6 bOX 6-1: tHE MataI SyStEM IN SaMOa A.Matai.is.a.chiefly.title,.which.is.owned.and.under.the.authority.of.a.defined.descent. group,. the. 'Aiga.. The. Matai system. controls. all. local. government. and. reaches. into. the.highest.levels.of.national.political.life..Over.80.percent.of.the.land.in.Samoa.is. under.Matia.control,.and.some.65.percent.of.the.population.derive.their.livelihoods. from.Matai.land..The.'Aiga.in.rural.Samoa.are.redistributive.social.and.political.units,. pooling.resources.of.both.cash.and.food.for.allocation.by.the.Matai.chiefs.according.to. individual.needs..These.needs.may.be.for.sustenance,.clothing,.school.fees.and.similar. expenses.of.individual.families,.or.resources.can.be.directed.to.village.enterprises,.the. church.and.the.many.ceremonial.activities.that.mark.village.life,.such.as.weddings,. title-bestowals,.and.funerals.. Samoa.has.experienced.high.rates.of.out.migration,.and.population.growth.has.been. slow.in.comparison.to.some.of.its.Pacific.neighbors..Remittances.play.a.very.large.role. in.family.welfare,.accounting.for.the.single.largest.source.of.family.cash.income.in. one.village.survey..under.these.conditions,.socio-economic.differentiation.in.Samoa. between.families.in.rural.villages.is.probably.still.less.evident.than.in.other.Pacific. settings..Distribution.of.cash.and.in.kind.resources.to.needy.villagers.under.the.Matai system.is.thus.widely.regarded.as.an.effective.system.of.social.protection,.at.least.in. the.rural.village.context.. However,.recent.work.on.social.hardship.in.Samoa.indicates.that.some.Samoan.families. are.enduring.difficult.livelihoods.as.well.as.limited.access.to.social.and.economic.services.. It.is.difficult.to.conclude.that.the.Matai.system.has.addressed.every.social.need,.however. it.has.been.effective.in.alleviating.deprivation.and.managing.social.risk.in.Samoa. Sources: Anthony Hooper, "Pacific Islands Stakeholder Participation in Development: Samoa", World Bank, 1998; Huffler, Elise, "Beyond Governance in Samoa: Understanding Samoan Political Thought", The Contemporary Pacific, Vol. 17(2), 2005; ADB, "Priorities of the People: Hardship in Samoa", Manila 2002 Social Risks in the Pacific 7 Macroeconomic volatility..One.common.characteristic.of.the.Pacific.Island.countries. is.their.exposure.to.volatile.aggregate.conditions..A.recent.assessment.undertaken70. for.this.report,.on.variation.in.the.magnitude.and.sources.of.economic.volatility,.revealed. that.the.Pacific.Island.countries.are.more.volatile.than.other.developing.countries.and.other. small.island.states.71.External.factors,.such.as.terms.of.trade.shocks,.play.a.key.role.in.the. Pacific.region..Pacific.countries.are.also.more.vulnerable.than.countries.in.other.areas.to. natural.shocks.and.climatic.volatility,.including.rainfall.volatility.which.is.twice.as.high.as. in.other.developing.countries.and.small.economies..As.shown.in.Figure.6-1,.between.1992. and.2002,.Vanuatu.and.Fiji.ranked.first.and.second.in.terms.of.their.vulnerability.to.natural. shocks.and.climatic.volatility.among.all.nine.Pacific.member.countries..The.vulnerability. indices.for.FSM.and.Tonga,.while.relatively.low.in.the.Pacific.region,.are.nevertheless.still. higher.than.the.average.for.developing.countries.and.small.islands.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.73 MANAGING.SOCIAL.RISK FIguRE 6-1: RElatIvE vulNERabIlIty tO NatuRal SHOCKS aND ClIMatIC vOlatIlIty FSM Disaster Index (0-50) Rainfall Volatility Tonga Index72 (0-50) Marshall Is. Kiribati Palau Solomon Is. Samoa Fiji Vanuatu 0 50 100 Source: Brown, R., D. Headey, and G. Leeves (2004). 8 This.high.volatility.in.GDP.and.vulnerability.to.natural.disasters.may.be.cushioned. by.the.relatively.high.level.of.`transfer.income'.received.by.Pacific.countries.73.In.all. nine.Pacific.countries.covered.in.this.report,.including.Fiji,.National.Disposable.Income. (NDI),.which.adds.net.factor.income.and.net.transfer.income.to.the.GDP.measure,.is.higher. than.GDP.(Figure.6-2)..These.external.income.flows.may.help.to.smooth.incomes.in.the. volatile.Pacific.region.through.such.informal.safety.net.mechanisms.as.high.levels.of.public. employment.and.salaries,.and.various.government-funded.transfer.mechanisms..However,. those.linkages.are.difficult.to.demonstrate.empirically..Civil.conflict.is.also.a.source.of.risk. in.the.Pacific.region..For.example,.Fiji's.ethnic.tension.has.twice.led.to.political.instability. and.economic.setbacks,.while.a.recent.conflict.in.Solomon.Islands.plunged.the.economy. into.recession.and.has.required.a.long-term.peacekeeping.intervention.by.the.country's. Pacific.partners.. 74.|.wORLD.BANK CHAPTER.6 FIguRE 6-2: RatIO OF NDI PER CaPIta tO gDP PER CaPIta IN SElECtED SMall COuNtRIES 2.0% 1.8% 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% ualaP itabiriK .Is aomaS a ngoT Marshall .sInomoloS soromoC MSF dnalizawS suitiruaM utaunaV ijFi t encniV.tS aicuL.tS NDI/GDP per capita Source: Brown, R., D. Headey, and G. Leeves (2004). 9 Household risks - school drop outs. Despite.the.fact.that.recent.fertility.declines. in. most. Pacific. Island. countries. have. significantly. reduced. the. rate. at. which. the. population.of.young.children.is.increasing,.the.share.of.children.and.youth.in.the.overall. Pacific.Islands.population.remains.high,.and.young.people.aged.15.to.24.continue.to.be. a.rapidly.growing.segment.of.the.population..Children.and.young.people.face.significant. risks,.the.most.common.in.the.Pacific.region.being.dropping.out.of.school,.being.jobless,. and.getting.involved.in.crime.and.substance.abuse..Teenage.pregnancy.is.also.a.problem. for.out.of.school.girls..Chapter.2.presents.the.varying.proportions.of.primary.level.out-of- school.children.in.the.countries.of.the.Pacific.region,.with.some.countries.still.experiencing. a.serious.enrollment.gap.at.the.primary.level.(RMI,.Vanuatu,.and.FSM.have.the.highest.out- of-school.rates)..This.has.many.long-term.implications.for.societies.because.non-completion. of.primary.school.is.universally.known.to.be.a.predictor.of.adult.poverty.. 1 0 jobless young people..A.second.group.of.high-risk.individuals.is.unemployed. youth.. youth. unemployment. everywhere. in. the. Pacific. region. is. higher. than. adult.unemployment,.as.shown.in.Chapter.3..Higher.levels.of.youth.unemployment.can.be. expected.in.almost.any.labor.market,.but.in.most.of.the.Pacific.countries.-.Samoa,.Tonga,. Solomon.Islands,.RMI,.Palau,.and.FSM.­.it.is.more.than.double.the.total.unemployment. rate..However,.the.formal.unemployment.rate.probably.does.not.fully.capture.the.extent. of. joblessness. and. idleness. among. young. people.. Figure. 6-3. adds. together. the. formal. unemployment.rate.for.young.men.(in.this.case).and.the.rate.of.those.who.are.inactive,.or. in.other.words,.who.are.not.in.school.nor.employed,.to.yield.a.more.useful.indication.of. labor.market.difficulties.for.youth..Female.youth.show.high.rates.of.joblessness.as.well,.but. less.so.than.young.men.. 1 1 Joblessness.thus.measures.the.proportion.of.young.people.who.are.unemployed,. helping. out. at. home,. or. simply. idle.. Even. in. Kiribati. where. there. is. a. strong. work. ethic,. joblessness. among. young. males. is. nearly. five. times. higher. than. the. total. unemployment.rate..The.only.country.in.which.most.joblessness.is.accounted.for.by.the. unemployed.is.Tonga..Joblessness.and.high.rates.of.inactivity.have.implications.that.extend. beyond.the.economy.and.the.labor.market..High.rates.of.joblessness.among.young.people. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.75 MANAGING.SOCIAL.RISK tend.to.be.related.to.increased.involvement.in.risky.and.socially.destructive.behavior..One. hypothesis.is.that,.in.any.country.where.youth.joblessness.is.prolonged,.there.may.be.a. higher.risk.of.such.behavior.occurring..The.importance.of.education.in.preparing.young. people.to.enter.the.job.market.and.to.take.advantage.of.external.opportunities,.through. migration.and.temporary.employment.oversees.(where.they.exist),.is.well.recognized.by. governments.in.the.Pacific.74 FIguRE 6-3: MalE jOblESSNESS IN tHE PaCIFIC REgION Male Unemployed 45 Male Inactive 40 35 30 sselboJ 25 % 20 15 10 5 0 Samoa Tonga Fiji Solomon Is. FSM Kiribati Palau RMI Source: Census data Note: Joblessness is defined as being inactive and unemployed. 1 2 Social Problems and People `at Risk'..The.Pacific.countries.have.experienced.a. range.of.social.problems.in.recent.years,.particularly.(but.not.exclusively).in.urban. areas.. These. problems. include. crime. (including. prostitution),. substance. abuse. (mainly. alcohol.and.kava),.domestic.violence.and.sexual.assault.(often.alcohol-related),.suicides,. and. health. risks. such. as. sexually. transmitted. diseases. and. HIV,. and. growing. numbers. of.accidents.(also.often.alcohol.related)..Interestingly,.catastrophic.health.care.costs.are. incurred.not.by.families.but.by.the.state.in.most.Pacific.countries,.due.to.generous.provision. for.overseas.care..Most.of.these.problems.are.concentrated.among.the.young,.particularly. unemployment.(see.above),.suicides,.early.pregnancy,.and.alcohol.abuse,.but.many.others,. such. as. domestic. violence,. crime. and. accidents,. can. be. found. throughout. the. general. population..These.social.problems.usually.involve.costs.and.losses.that.can.take.affected. families.into.temporary.hardship.and.poverty..However,.in.the.case.of.HIV.mortality.(just. beginning.in.the.Pacific,.but.pronounced.in.PNG),.suicides.and.alcoholism,.the.effects.on. family.welfare.can.be.severe.as.well.as.prolonged.. 1 3 Data.from.the.Fiji.police.show.that.cases.of.domestic.violence.increased.by.68. percent.between.1997.and.2001,75.but.this.indicator.is.highly.sensitive.to.the. willingness.of.women.to.report.the.abuse..In.RMI,.the.women.united.Together.Marshall. Islands.(wuTMI).recently.attempted.to.get.a.more.in-depth.picture.of.domestic.violence.. They.carried.out.a.survey.(Project.wAVE).during.2003.and.2004.that.revealed.that.there. were.many.more.cases.of.domestic.violence.than.those.reported.to.the.police..Among.the. 117.women.interviewed.who.had.experienced.abuse.in.the.home,.only.14.percent.had. contacted.the.police..See.Box.6-2.for.a.summary.of.the.wAVE.survey.results. 76.|.wORLD.BANK CHAPTER.6 bOX 6-2: tHE WavE SuRvEy OF DOMEStIC vIOlENCE IN tHE REPublIC OF MaRSHall ISlaNDS The.survey.(Project.wAVE).organized.by.wuTMI.was.undertaken.during.2003.and.2004. on.four.selected.islands,.Majuro,.Mili,.Ebon,.and.Ebeye..A.snowball.methodology.was. used.to.find.all.the.women.on.these.islands.that.had.experienced.domestic.violence.in. their.lives..Thus,.86.percent.of.the.total.number.of.130.women.included.in.the.survey. answered.that.they.had.experienced.abuse..Abuse.included.sexual.(66.percent),.physical. (87.percent),.emotional.(84.percent),.and.verbal.(74.percent)..The.following.list.provides. some.highlights.of.the.findings.of.the.Project.wAVE.survey.on.the.types.and.context.of. domestic.violence.experienced.by.women.in.the.region:. ·. 65.percent.had.experienced.abuse./.violence.more.than.10.times. ·. 82.percent.were.younger.than.20.years.old.when.they.experienced.abuse.. for.the.first.time. ·. 92.percent.of.abuse.incidents.happened.at.home.(domestic.violence). ·. In.92.percent.of.cases,.the.abuser.was.the.woman's.husband. ·. 36.percent.of.women.had.scars.or.permanent.injuries. ·. Only.6.percent.of.women.had.gone.to.a.hospital.when.injured;.but.46.percent.. had.not.sought.any.treatment.at.all. ·. 52.percent.of.total.cases.were.alcohol-related,.but.45.percent.were.not.alcohol-related.. In.Majuro,.however,.86.percent.were.alcohol-related,.while.the.numbers.were.smaller. in.Mili.(48.percent),.Ebeye.(41.percent),.and.Ebon.(35.percent). ·. 86.percent.of.women.did.not.contact.the.police. ·. 93.percent.of.women.did.not.contact.a.doctor. ·. Only.66.percent.of.women.informed.others.. ·. 41.percent.blame.themselves.for.what.happened. ·. 91.percent.are.interested.in.protecting.themselves.from.domestic.violence,.and.92. percent.are.interested.in.receiving.training.in.self-protection. Other.interesting.findings.also.emerged.from.the.wuTuMI.survey..Domestic.violence. is.not.limited.to.poor.households.but.affects.women.of.all.educational.and.economic. backgrounds..Alcohol.use.in.RMI,.another.serious.social.problem,.is.one.of.the.major. reasons.for.violent.outbreaks,.especially.in.urban.areas..This.suggests.that.men's.problems. as.well.as.women's.protection.will.need.to.be.taken.into.account.in.programs.that.aim. to.address.the.problem..And.as.in.other.small.Pacific.countries.(Kiribati.for.example),. the.establishment.of.a.shelter.will.increase.the.chance.of.women.victims.escaping.from. abusive.situations.and.relationships..The.legal.sanctionsagainst.abuse.and.the.availability. of.protection.are.of.course.paramount.in.determining.whether.women.report.abuse.to. the.police,.in.RMI.and.elsewhere.in.the.Pacific.. Source: WUTMI, 2004. "Domestic Violence in the Marshall Islands." Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.77 MANAGING.SOCIAL.RISK 1 4 Disability and pockets of severe poverty. Disability.is.poorly.understood.in. most.of.the.Pacific,.and.as.shown.in.Chapter.2,.the.census.based.data.on.prevalence. of.disability.may.understate.the.true.dimensions.of.this.important.social.risk.factor,.which. available.data.show.as.affecting.between.1.and.3.percent.of.the.population..Disabled.people. tend.to.be.poor,.and.this.is.likely.a.lifelong.correlation..Other.groups.that.endure.severe. and.prolonged.poverty.are.difficult.to.identify.in.the.Pacific..Some.islands.in.Vanuatu,.for. example,. show. sharply. lower. family. wealth. than. most,. and. similarly. Solomon. Islands,. with.low.per.capita.GDP,.may.contain.some.highly.disadvantaged.rural.groups..It.is.not.yet. possible.to.quantify.the.dimensions.of.these.`at.risk'.groups,.nor.the.causes.of.their.relative. deprivation..In.Kiribati,.highly.vulnerable.rural.islands.are.protected.from.severe.poverty. through.generous.copra.price.subsidies..In.Fiji,.a.recent.survey.of.income.and.expenditure. was.analyzed.by.the.government,.and.showed.28.percent.of.the.population.as.living.below. an.absolute.poverty.line,76.however,.the.analysis.shows.no.sharp.patterns.by.ethnicity.or. by.rural/urban.. Government Systems for Managing Macroeconomic Risks 1 5 Some.Pacific.countries.have.already.developed.systems.for.dealing.with.natural. disasters..For.example,.the.uS.financed.Federal.Emergency.Management.Agency. (FEMA). provides. disaster. relief. funds. and. services. to. the. former. uS. territories. -. RMI,. FSM,.and.Palau..Vanuatu.has.established.its.own.National.Disaster.Management.Office. and.Fiji.also.has.an.office..There.are.regional.coordination.offices.based.in.Fiji..Regional. arrangements,. such. as. FRANz,. are. mobilized. to. help. coordinate. assistance. and. assess. damage..77.However,.there.could.be.more.emphasis.on.financial.mechanisms.at.the.regional. level..Because.there.is.an.even.greater.opportunity.to.pool.risks.at.a.regional.level.than.at. a.country.level,.Pacific.Island.countries.could.investigate.the.feasibility.of.establishing.a. region-wide.insurance.or.disaster.fund.. 1 6 Despite. the. severe. impacts. on. poor. families. of. weather. shocks. and. economic. volatility.in.the.Pacific,.none.of.these.Pacific.Island.countries.has.developed.public. works.programs.to.help.families.cope.with.the.impacts.of.natural.disasters.and.economic. shocks..Such.programs,.which.have.been.successfully.implemented.in.other.regions.of.the. world,.provide.short-term.work.to.low-income.individuals.to.rebuild.social.and.economic. infrastructure,. and. thus. accomplish. two. objectives. simultaneously. -. infrastructure. rehabilitation.and.temporary.incomes.for.vulnerable.families.(the.temporary.employment. and.training.for.youth.can.be.another.benefit.of.such.programs)..Disaster.response.in.the. Pacific.could.build.some.long-term.capacity.to.use.public.works.employment.as.a.disaster. management.tool.. Government Programs to Help Manage Household Risks 1 7 School drop outs..Primary.school.non.attendance.is.variable.in.the.Pacific,.but. elevated.in.some.countries,.such.as.RMI.and.Solomon.Islands..In.the.more.affluent. countries,. supply-side. education. inputs. can. be. ineffective. in. reaching. those. families. at. risk.of.withdrawing.their.children.from.school.78.Another.approach.is.the.introduction.of. targeted.demand-side.interventions.such.as.conditional.cash.transfers,.which.would.give. these.families.an.incentive.to.re-enroll.their.children.in.school.and.to.keep.them.there.. 78.|.wORLD.BANK CHAPTER.6 Conditional.cash.transfers.are.funds.given.to.parents.(usually.targeted.to.the.poor.and. frequently.given.to.mothers).on.the.condition.that.their.children.attend.school.and/or. obtain.recommended.preventive.health.care..Conditional.cash.grants.have.been.effective.in. several.Latin.American.countries.(see.Box.4-8).and.are.increasingly.being.used.to.encourage. poor.families.to.invest.in.their.children's.human.capital.development.79. 1 8 youthunemployment..Post.primary.education.is.a.core.element.in.any.strategy.to. help.today's.youth.lead.happy.and.productive.lives..Two.recent.household.surveys. in.Tonga.and.Fiji.show.a.strong.relationship.between.educational.attainment.and.overseas. migrants.in.both.countries.which.enjoy.favorable.access.to.OECD.labor.markets.80.To.help. students.prepare.for.the.transition.from.school.to.work,.vocational.training.institutes.need. to.do.a.better.job.of.matching.the.skills.that.they.teach.to.local.market.needs..There.are. some.examples.in.the.Pacific.region.of.highly.relevant.and.successful.vocational.education. institutions..For.example,.the.Fiji.Institute.of.Technology.is.building.a.new.tourism.school,. which.will.teach.much.needed.skills.for.the.growing.tourism.industry..In.Kiribati.(and.also. Tuvalu),.the.Maritime.and.Fisheries.Training.Centers.have.long.produced.seafarers.who.gain. immediate.commercial.employment.after.leaving.the.centers..unfortunately,.the.annual. graduation.rate.from.the.centers.has.remained.at.the.same.level.for.many.years,.despite. the.fact.that.the.global.shipping.industry.is.growing..If.the.centers.could.be.expanded.and. placement.arrangements.managed.more.flexibly,.they.would.be.able.to.provide.training.for. even.more.young.men.and.women.. 1 9 If.education.plays.a.clear.role.in.helping.young.people.access.overseas.jobs,.it. is. less. consistent. in. its. role. in. reducing. unemployment.. Multivariate. analysis. of.survey.and.census.data.was.done.for.Kiribati,.Tonga,.Fiji,.and.RMI..In.Kiribati,.where. youth.unemployment.is.barely.2.percent.nationally,.educational.attainment.is.correlated. with.declining.youth.unemployment,.as.might.be.expected,.but.not.in.RMI,.where.the. only.significant.variable.was.household.remittances.as.a.percentage.of.income,.suggesting. that.unemployed.youth.in.RMI.might.be.reluctant.to.enter.the.labor.market.at.existing. wages.on.offer..In.Tonga.and.Fiji,.the.analysis.was.of.overall.unemployment,.and.in.both. countries. educational. level. is. modestly. correlated. with. declining. unemployment. levels,. in.Tonga.even.less.so..In.both.countries.overall.unemployment.is.linked.most.strongly.to. age,.given.relatively.high.youth.unemployment..These.results.show.that.while.education.is. an.asset.used.by.households.to.lift.themselves.out.of.poverty.and.can.help.reduce.youth. unemployment,.improving.education.opportunities.alone.will.not.help..Countries.will.need. to.focus.on.good.economic.policies.that.help.create.job.opportunities.or.reduce.barriers.to. employment.and.allow.people.to.use.their.assets.productively..Thus,.labor.market.demand. and,.in.particular,.demand.for.family.workers.in.the.rural.sector,.may.help.explain.lower. unemployment.in.countries.such.as.Vanuatu.and.Kiribati.. 2 0 Employment. services. for. young. people. and. adults. are. almost. non-existent. in. the. Pacific. region,. other. than. the. Kiribati. Marine. Training. and. Fisheries. Training.centers..In.the.absence.of.private.job.services,.Pacific.governments.should.find. systematic. ways. to. regulate. and. facilitate. recruitment,. and. to. disseminate. information. about.employment.opportunities.in.the.Pacific.region.and.overseas..Second-chance.schools. for.those.who.did.not.pass.into.secondary.school.might.be.a.way.to.attract.jobless.young. people. back. into. the. education. system. in. order. to. develop. skills. required. by. the. labor. market..They.could.perhaps.be.integrated.with.other.non-formal.education.schemes.and. with.employment.services..young.people.would.also.be.a.logical.target.group.for.workfare. schemes.of.the.type.described.above.. 2 1 youth. and. working. age. adults. in. the. Pacific. have. embraced. overseas. job. opportunities. when. they. have. been. available,. and. the. impacts. on. sending. countries.has.in.some.cases.been.dramatic.81.In.some.countries.(such.as.Tonga,.Samoa,.and. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.79 MANAGING.SOCIAL.RISK RMI),.migration.has.alleviated.some.of.the.pressure.on.the.local.labor.market..Remittances. as.a.share.of.GDP.in.Samoa.and.Tonga.have.been.as.high.as.24.and.48.percent.respectively.. In.principle,.the.high.rate.of.remittances.sent.to.families.in.Pacific.Island.counties.from. overseas.should.help.affected.communities.to.smooth.their.income.in.the.wake.of.natural. disasters.or.economic.shocks,.and.to.lift.indigent.families.out.of.poverty.82.In.Fiji.and. Tonga,.there.is.strong.evidence.of.the.benefits.of.remittances.(and.net.internal.transfers). to.reducing.poverty.(see.Figure.6-4).83.Figure.6-4.shows.that.poverty.rates.vary.according. to.the.source.of.household.income,.and.that.with.remittances.included.(the.red.columns),. poverty.rates.decline.substantially.. FIguRE 6-4: POvERty HEaDCOuNt RatIO by SOuRCES OF HOuSEHOlD INCOME (tONga) Cash Income Only Income + Remittances Income, Remittances + Transfers 60 57 58.53 57.53 50 40 41.71 38.66 33.49 32.32 33.69 33.64 30 20 10 0 Tonga Urban & Rural Main Island Outer Islands Source: Labor Mobility Workshop Powerpoint, November 2005, World Bank. 2 2 Other.Pacific.Islands.(such.as.Solomon.Islands.and.Vanuatu).have.very.low.levels. of.remittances.mainly.because.citizens.of.these.islands.have.almost.no.access.to. OECD.labor.markets.for.complex.historical.and.political.reasons,.and.therefore.few.people. migrate.overseas..In.other.countries,.such.as.RMI.and.parts.of.FSM,.remittances.flow.out. of.the.Pacific.to.overseas.migrants,.who.may.be.working.or.studying.abroad,.but.apparently. at.lower.incomes.than.their.relatives.back.home..For.Tonga.and.Fiji,.migration.does.tend.to. take.more.qualified.workers.(`brain.drain'),.but.the.benefits.for.home.country.families.are. so.substantial,.as.they.are.in.other.Kiribati.and.in.several.smaller.islands.in.the.Pacific,.that. the.interest.in.labor.force.mobility.is.likely.to.remain.quite.high.in.the.region,.especially. for.those.countries.with.weak.job.creation.prospects.and.high.population.growth.rates.. One.of.the.central.aspects.of.the.social.protection.sector.in.the.Pacific.region.is.that.other. countries'.immigration.and.labor.policies.have.more.influence.on.Pacific.labor.markets.than. any.steps.that.the.governments.of.the.Pacific.Island.countries.may.take.unilaterally.84. 2 3 Social problems and programs. Designing.effective.interventions.to.address urban.social.problems.can.pose.challenges..However,.in.some.cases,.the.issues.can. be.addressed.effectively..For.instance,.in.the.late.1990s,.the.authorities.in.RMI.were.faced. with.a.surge.in.illegal.adoptions.of.children.destined.for.the.uSA.and.took.decisive.legal. action,.passing.the.necessary.legislation.to.outlaw.such.activities.and.enforcing.the.laws. strictly..Those.steps.quickly.ended.the.practice..Such.exemplary.results.are.not.easily.obtained. when.dealing.with.complex.behavioral.issues,.but.the.example.of.RMI.shows.how.effective. 80.|.wORLD.BANK CHAPTER.6 decisive.public.leadership.can.be..Another.promising.option.for.dealing.with.complex.social. issues,.such.as.domestic.violence.and.alcohol.abuse,.is.for.governments.to.support.NGOs. that.have.some.prior.experience.in.these.issues..A.first.step.for.each.government.would. be.to.make.a.systematic.assessment.of.the.country's.social.problems.and.the.adequacy.of. current.public.and.private.efforts.to.deal.with.them.in.each.country.setting..The.results. obtained.from.this.study.strongly.suggest.that.the.governments.of.the.region.have.not. given.sufficient.attention,.or.funding,.to.the.region's.most.serious.social.problems..The. most.promising.options.for.initial.government.action.are.the.establishment.of.temporary. employment.programs.for.young.people.(and.to.introduce.them.to.the.labor.force).and.the. provision.of.safe.haven.and.legal.protection.for.victims.of.domestic.violence.. 2 4 Social assistance and targeting the poor..In.the.Pacific.region.as.elsewhere,. there.are.some.chronically.disadvantaged.people.who.require.continuing.support. and.protection.to.survive..These.people.include.many.disabled.people,.destitute.elderly,. families.of.incarcerated.people,.and.the.vulnerable.residents.of.outer.islands.dependent.on. copra.or.other.volatile.commodities..There.is.a.sprinkling.of.social.assistance.programs.in. the.Pacific.region.to.support.these.`at.risk'.groups,.with.Fiji.and.Kiribati.having.the.most. extensive.programs..However,.not.all.of.these.programs.are.targeted.and.thus.have.large. inclusion.errors..Other.Pacific.states.have.long.relied.on.traditional.support.mechanisms. from. families,. overseas. migrants,. community. institutions,. and. churches.. One. example. is. the. Matai system. in. Samoa. (see. Box. 6-1).. Vanuatu. is. an. example. where. family. and. community.arrangements.are.the.main.support.for.the.long-term.poor,.as.the.government. has.not.funded.direct.social.assistance..Eligibility.for.social.assistance.programs,.where. such. programs. exist. in. the. Pacific. region,. is. determined. through. a. variety. of. different. mechanisms,.including.characteristic.targeting,.means.tested.targeting,.or.self-targeting. 2 5 Protecting the elderly. Characteristic.targeting.is.used.for.all.people.aged.70. and.over.in.Kiribati,.who.are.entitled.to.receive.a.stipend.of.AuD$40.per.month. from.the.government..There.are.no.income.criteria..The.Kiribati.program.achieved.full. coverage.of.the.over.70.group.in.its.first.year.of.implementation..However,.not.all.of.the. elderly.were.poor.before.the.program.was.launched;.in.fact,.only.23.percent.of.those.over. 70.in.Kiribati.had.incomes.in.the.lowest.quintile..Thus,.this.universal.Old.Age.Allowance. program.has.large.errors.of.inclusion.of.the.non-poor..This.is.a.common.problem.with. characteristic.targeting.. 2 6 Characteristic. targeting. is. also. used. for. the. most. common. program. for. the. elderly,. the. savings-based. provident. fund. found. widely. in. the. Pacific,. except. in. the. `Compact'. countries. of. Micronesia.. The. provident. funds,. all. publicly. chartered,. are.mandatory.savings.schemes.for.employees.and.employers.in.the.formal.sector,.and. members.accumulate.savings.and.returns.in.individual.accounts..Several.of.the.provident. funds.have.been.overcome.by.governance.problems.affecting.the.management.of.member. savings,.such.as.in.Vanuatu,.and.thus.returns.to.members.have.been.undermined..The. Kiribati.provident.fund.is.a.notable.exception,.thanks.to.an.early.decision.to.invest.in. offshore.equities,.and.has.delivered.steady.market.returns.to.members.85.Only.the.social. security.programs.in.the.former.uS.territories.qualify.as.risk-sharing.mechanisms,.as.they. are.defined.benefit.schemes.financed.on.a.pay-go.basis.modeled.on.the.uS.Social.Security. System.. However,. even. though. the. programs. are. open. to. informal. sector. workers. and. the.self-employed.(provident.funds,.it.should.be.noted,.have.difficulty.enrolling.the.self- employed),.in.practice.any.outer.island.residents.who.might.want.to.take.advantage.of.the. programs.are.unable.to.access.banking.facilities..Thus,.as.currently.constituted,.the.formal. sector.retirement.schemes.in.the.Pacific.region,.both.social.security.and.provident.funds,.do. not.have.pro-poor.targeting.capacities.and.will.need.to.be.fundamentally.reformed.before. they.will.be.able.to.serve.the.low-income,.the.self-employed.and.farmers..This.might.entail. some.government.contributions..To.better.ensure.financial.performance,.Pacific.provident. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.81 MANAGING.SOCIAL.RISK funds. would. do. well. to. follow. the. Kiribati. example,. through. insulating. fund. resources. from.political.interference.and.delegating.investment.to.offshore.intermediaries.with.clear. performance.benchmarks.. 2 7 Reaching poor and indigent families. Mixed.targeting.arrangements.are.used. in.both.the.Kiribati.Social.Affairs.Department's.School.Fee.Scheme.and.the.Fiji. Department.of.Social.welfare's.Family.Assistance.Program.(FAP)..Both.of.these.programs. provide.cash.transfers.to.certain.categories.of.people,.such.as.the.incapacitated.parents.of. secondary.school.students,.the.elderly,.families.with.a.breadwinner.who.is.incarcerated,. and.families.with.chronically.ill.breadwinners..Although.an.income.means.test.is.applied. in.both.programs,.this.is.self-reported.by.the.applicants,.and.it.is.likely.that.the.non-poor. receive.some.assistance,.particularly.in.the.much.larger.FAP.that.expended.uS$12.million. in. 2004.. The. Department. has. audited. files. and. successfully. removed. fraudulent. cases,. demonstrating.that.there.were.some.errors.of.inclusion..Long.waiting.lists.in.Fiji.for.the. FAP.program.also.suggests.that.it.has.errors.of.exclusion.(in.other.words,.eligible.families. who.are.not.yet.benefiting.from.the.program),.not.to.mention.chronically.poor.families. who.do.not.conform.to.the.required.categories.. 2 8 Self-targeting.is.used.to.target.the.copra.price.subsidies.that.the.governments. of.RMI.and.Kiribati.pay.to.low-income.copra.farmers.living.in.the.outer.islands.. Vanuatu.was.also.subsidizing.producer.prices.until.the.agricultural.reforms.of.2002..The. copra.subsidy.policy.in.Kiribati.is.a.more.explicit.safety.net.program.than.RMI's.subsidy,.as. it.involves.a.highly.subsidized.price.above.global.market.levels,.and.cost.the.government. AuD$12.million.in.2004..In.the.past.when.prices.were.lower,.the.program.was.effective. in.targeting.poorer.farmers,.as.can.be.seen.below.in.Figure.6-5..It.also.did.a.good.job.of. targeting.outer.island.residents,.as.no.subsidies.were.paid.to.residents.of.the.capital.on. South.Tarawa..The.program.in.RMI.pays.limited.price.subsidies.by.linking.them.closely. to.global.price.levels.and.at.an.aggregate.budget.ceiling.of.roughly.uS$1.million.in.public. subsidy.annually..This.has.kept.copra.prices.low.in.RMI.in.recent.years,.thus.effectively. `selecting'.only.the.poorest.families.in.the.outer.islands.to.benefit.from.this.less.explicit. safety.net.program.. FIguRE 6-5: COPRa SubSIDy PROgRaM aND SElF-taRgEtINg IN KIRIbatI (1999) 70 sdlohesuoH 60 50 40 30 intileuQfo 20 % 10 0 First 20% Second 20% ird 20% Fourth 20% Top 20% Income Quintiles Source: Country report 82.|.wORLD.BANK CHAPTER.6 2 9 Although.targeting.has.been.efficient.in.the.past,.this.efficiency.has.been.eroding. in.Kiribati.in.the.face.of.recent.increases.in.the.subsidized.producer.price,.as. approved.by.the.national.parliament..The.price.increases.have.stimulated.sharp.increases. in. annual. production. as. well,. signaling. the. entry. of. new. producers. and. probably. an. erosion.of.targeting.efficiency..The.fiscal.burden.of.the.program.has.expanded.accordingly.. The.self-targeted.copra.price.subsidy.programs.can.be.effective.in.reaching.the.poor,.if. price.subsidies.are.managed.well,.and.in.slowing.rural-urban.migration,.both.important. objectives.in.Kiribati.and.RMI,.where.overcrowded.capital.cities.on.fragile.atolls.have. created. major. environmental. challenges.. However,. no. public. assets. are. created. by. producer.subsidies,.and.they.have.and.will.continue.to.give.an.incentive.for.farmers.not.to. diversify.and.adopt.more.sustainable.livelihood.opportunities..Other.countries.have.used. public.works.programs.that.temporarily.employ.the.rural.poor,.and.the.governments.of. both.countries.should.consider.this.and.other.options.in.reviewing.their.rural.safety.net. policies,.as.should.governments.of.any.other.countries.in.the.region.that.need.to.combat. chronic.rural.poverty,.such.as.Vanuatu.. 3 0 Disabled people.Disabled.people.are.another.`at.risk'.group.that.has.been.under- served.in.most.Pacific.countries..Outside.of.Fiji,.there.are.few.public.programs. to. assist. disabled. people,. and. typically,. NGOs. have. taken. responsibility. for. providing. education,.training,.counseling,.and.financial.support.to.disabled.people.and.their.families.. In. Vanuatu,. the. Ministry. of. Education. is. currently. assessing. the. number. of. students. with.special.needs.in.public.schools,.and.its.preliminary.findings.suggest.that.many.such. children.seem.to.drop.out.as.they.progress.through.primary.school,.which.is.evidence.that. the.schools.are.not.meeting.their.needs.in.various.ways..However,.there.are.no.funds.or. policies.within.the.Ministry.of.Education.to.act.on.these.findings.or.to.establish.any.specific. learning.programs.for.disabled.people,.nevertheless.the.Ministry.should.be.commended. for.taking.even.these.initial.steps..Very.few.education.ministries.in.the.Pacific.region.have. yet.attempted.to.address.special.educational.needs.in.their.countries.(see.Chapter.4)..The. rationale.for.reaching.out.to.disabled.people,.as.an.appropriate.group.to.whom.assistance. should.be.targeted,.is.their.evident.low-income.status.and.elevated.poverty.rate.as.seen.in. Figure.4-1.in.Chapter.4.. Social Protection Strategic Choices in the Pacific 3 1 Policy choices. The. main. policy. challenge. and. strategic. choice. in. the. social. assistance.area.is.whether.to.introduce.or.expand.programs.run.by.the.public.sector,. given.the.sector's.limited.involvement.in.social.protection.at.the.moment..A.secondary. challenge.flowing.from.the.first.is.how.to.target.public.resources.efficiency.and.equitably.in. any.new.social.protection.initiatives..Most.Pacific.governments.have.so.far.declined.to.take. on.substantial.social.assistance.responsibilities,.preferring.to.rely.on.private.mechanisms.. Current.programs.tend.to.be.small-scale.and.at.arms-length.from.the.government,.run.by. local.and.international.NGOs.and.funded.by.external.donors..Targeting.policies.in.existing. schemes,.as.discussed.in.the.previous.section,.are.weakly.developed.and.only.in.a.few.cases. aimed.at.lower.socio-economic.households.. 3 2 Some.social.problems,.despite.their.severity,.may.be.difficult.for.government- managed.programs.to.address.due.to.inaccessibility.of.the.target.group.(some. youth.groups),.fiscal.constraints.in.dealing.with.large.scale.issues.(rural.poor.for.example),. or.lack.of.expertise.to.deal.with.problems.(such.as.prevention.of.domestic.violence)..There. are,.however,.promising.opportunities.for.well.crafted.interventions.that.could.lower.social. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.83 MANAGING.SOCIAL.RISK risks.and.help.restore.productive.lives..Some.basic.principles.have.been.developed.globally. to.help.guide.policy.makers.facing.such.choices:. ·. Preventing.and.reducing.social.risk.is.preferable.to.managing.or.coping.with.the. impact.of.those.risks.after.they.have.occurred. ·. Governments.do.not.need.to.finance.and.provide.social.protection.services;.instead,. they.can.provide.the.financing.and.contract.out.the.actual.provision.of.services.to. the.private.sector.or.to.NGOs.with.specific.expertise.already.developed.. ·. Coordinating.existing.initiatives.within.a.common.financing.and.policy.framework. may.yield.as.many.benefits.as.launching.new.programs,.given.the.large.number.of. separate.independent.initiatives.usually.being.undertaken.by.donors,.NGOs.and. community.institutions.. ·. Any.potential.intervention.should.be.subjected.to.the.rigorous.test.of.whether.it. will.add.value.or.merely.replace.family.and.community-based.practices.. ·. It. is. essential. to. have. high-quality. and. up-to-date. information. on. social. risk. so.that.programs.can.be.accurately.targeted.to.those.in.need,.this.may.require. governments.to.finance.and.carry.out.high-quality.participatory.fieldwork.as.well. as.socio-economic.surveys. ·. Regular. monitoring. and. evaluation. of. social. protection. programs. should. be. built.into.the.design.at.the.outset.so.that.their.effectiveness.can.be.measured. and.demonstrated.. 3 3 Policy options. Options.for.action.range.from.service.expansion.(or.creation.in. the.case.of.social.protection),.to.management.reforms.for.existing.programs.to. improve.impact,.or.to.governance.reforms.that.will.improve.the.environment.for.effective. social.protection,.both.private.and.public..Table.6-1.sets.out.the.three.policy.domains,.the. social.risks.that.could.be.addressed,.and.some.examples.of.promising.interventions.. 84.|.wORLD.BANK CHAPTER.6 tablE 6-1: OPtIONS FOR IMPROvINg SOCIal PROtECtION IN tHE PaCIFIC Policy Domains Performance Issues Service Expansion Service Management Governance 1..School.Drop.Outs ·.Conditional.cash.transfers.to. poorest.families.who.are.more. likely.to.withdraw.kids.from. school 2..Disabled.youth ·.Inclusive.school.programs.(see. ·.Training.teachers.in.special.needs. ·.Improve.survey.information.on. Chapter.4) education disability ·.Per.capita.grants.to.schools. for.enrolling.disable.students,. vouchers.for.parents.with.disabled. children 2..unemployed.youth ·.youth.public.employment. . ·.Government.subsidies.for.private. schemes;. sector.apprenticeships ·.Target.and.expand.access.to. ·.Access.to.overseas.labor.markets employment.services.to.improve. job.information ·.Improved.labor.force.survey.data 3..youth.Social. ·.Taxes.on.imported.alcohol. Problems ·.Survey.social.problems.to. identify.priorities.and.target. groups 4..Adult.Social. ·.Shelters.for.victims.of.domestic. ·.Legal.protection.for.women Problems violence ·.National.survey.on.domestic. ·.Counseling.for.families.of.. violence victims. 5..Poverty.in.Old.Age ·.Extend.coverage.of.provident. ·.Introduce.income.criteria.to. ·.Delegate.fund.investments.to. funds.to.self.employed better.target.universal.pension. overseas.investment.services ·.Minimum.pension.for.the. allowance.(Kiribati) ·.Government.contribution.to. poorest.in.risk.pooling.schemes. cover.fund.benefits.for.poorest 6..Severe.Poverty.and. ·.Shift.from.crop.subsidies.to. ·.Reform.crop.subsidies.to.cap. ·.Regional.insurance.or.fund. Indigence,.Victims.of. public.employment.schemes fiscal.burden,.use.lower.prices.to. mechanism.to.provide.automatic. Natural.Disasters ·.Flexible.public.employment. better.target.poorest.farmers. support.to.countries.hit.by.natural. schemes.to.help.families.recover. ·.Shift.from.characteristic.to. disasters from.natural.disasters income.based.targeting.of.social. assistance,.develop.use.of.proxy. means.test 7..Adult.Disabled ·.Public.financial.support.to. ·.Partnerships.with.NGOs.and. essential.services.(training,. advocacy.groups.to.deliver. counseling,.financial.support) services,.reach.inaccessible.clients 3 4 Expanding services. There.are.several.areas.of.risk.that.may.be.appropriate.for. government.intervention.in.the.near.term..These.areas.require.new.policies.in. most.cases,.more.capacity.to.implement.programs,.and.adequate.public.resources.to.finance. them..Pacific.governments.might.well.consider.a.step.by.step.approach,.beginning.with. the.larger,.more.readily.identified.target.groups.with.high.poverty.rates,.such.as.disabled. people,.severely.poor.sub-groups,.jobless.youth,.and.families.with.drop.outs.from.primary. school..But.choices.will.vary.country.by.country.according.to.each.distinctive.profile.of. social.risk,.fiscal.space.for.new.programs,.and.the.adequacy.of.private.family.based.systems.. Various.areas.in.which.governments.might.consider.intervening.include:. ·. SchoolDropOuts..Conditional.cash.transfer.programs.have.been.highly.effective. around.the.world.in.reducing.school.drop.outs.and.increasing.enrollments..Such. programs.require.careful.targeting.to.avoid.incurring.the.heavy.costs.of.a.universal. family.transfer.program..Making.the.receipt.of.the.grant.conditional.on.specific. kinds.of.behavior.from.families,.such.as.up-to-date.enrollment.evidence,.achieves. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.85 MANAGING.SOCIAL.RISK two.goals.at.once:.raising.the.incomes.of.the.poor;.and.keeping.their.children.in. school..This.kind.of.incentive.program.could.be.highly.attractive.in.Vanuatu,.RMI,. and.other.Pacific.countries.with.large.numbers.of.out-of-school.children.. ·. jobless young People..The.most.promising.area.for.government.intervention. is. likely. to. be. in. providing. public. workfare. schemes. to. employ. jobless. young. people..Closely.linked.to.such.schemes.are.improved.employment.services,.where. youth. and. other. unemployed. people. can. access. available. information. on. job. opportunities.nationally,.and.in.some.cases.in.neighboring.OECD.countries.. ·. youth Social Problems.. NGO-run. services. aimed. at. preventing. risky. sexual. behavior,.substance.abuse,.and.criminal.activity.are.widespread.in.the.region,. but.their.effectiveness.is.unknown..However,.before.using.these.as.models.for. government-run.initiatives,.policymakers.should.undertake.a.rigorous.evaluation. of.all.possible.models.in.the.region..One.candidate.is.for.funding.such.an.evaluation,. and.with.the.added.benefit.of.acting.as.a.deterrent,.is.to.increase.import.taxes.on. alcohol.products.being.over.consumed.by.youth.. ·. Disability.. One. area. where. government. intervention. might. be. appropriate. would.be.to.quantify.the.number.of.disabled.students.in.schools,.and.to.design.a. phased.program.of.support.for.disabled.children.so.that.they.can.continue.in.the. education.system.despite.their.disabilities.(see.Chapter.4.for.specific.proposals).. Another.useful.move.would.be.to.support.disabled.adults.so.that.they.can.become. more.independent.and.self-supporting..NGOs.in.some.countries.provide.such. services. and. would. certainly. welcome. regular. support. from. governments. to. supplement.the.funds.provided.by.donors.and.private.charities.. ·. Protecting the Elderly Poor..Provident.funds.are.poorly.suited.to.reach.the. indigent.elderly,.but.generalized.grants.to.all.elderly,.such.as.in.Kiribati,.are.costly. and.wasteful..Targeted.minimum.pensions.may.be.practical.in.some.countries,. but.this.would.probably.involve.government.subsidy.to.the.fund.to.supplement. employee. and. employer. contributions. and. to. preserve. earnings. for. members.. Poverty. in. old. age. may. be. less. prevalent. in. the. Pacific. than. elsewhere,. and. conducting.country.based.analysis.will.be.an.essential.first.step. ·. Domestic violence..There.are.two.areas.of.capacity.building.where.government. intervention.would.be.useful..The.first.would.be.to.make.shelters.and.counseling. available.to.victims.of.domestic.violence..The.second.area.would.be.to.support. those.NGOs.that.are.already.active.in.this.field.to.help.them.to.expand.access. to.their.services.(including.legal.assistance,.counseling,.and.outreach.community. information.services).. ·. volatile Rural Incomes..workfare.schemes,.used.widely.around.the.world.to. smooth. volatile. rural. incomes. and. to. employ. jobless. young. people,. are. as. yet. unknown.in.the.Pacific.region,.but.they.would.be.appropriate.in.countries.where. natural.disasters.are.especially.frequent,.where.there.are.pockets.of.severe.rural. poverty,.and/or.where.there.are.large.concentrations.of.jobless.urban.youth..The. key.features.of.successful.workfare.schemes.are:.(i).that.they.build.or.rehabilitate. public.assets;.(ii).that.the.work.is.temporary;.(iii).that.the.wages.of.the.beneficiaries. are.set.low.enough.so.that.the.well.off.will.not.bother.to.apply;.and.(iv).that.the. programs.are.flexible.enough.to.expand.quickly.in.response.to.sudden.shocks.and. then.contract.when.good.times.return.. 3 5 Managing services - targeting..Better.use.of.targeting.mechanisms.will.go. a.long.way.in.the.Pacific.region.toward.controlling.costs,.and.benefiting.those. who.are.poor.and.in.need.of.assistance..This.applies.most.directly.to.social.assistance-type. interventions,.such.as.the.Family.Assistance.Program.(FAP).in.Fiji.and.other.government. 86.|.wORLD.BANK CHAPTER.6 transfer.programs.in.the.Pacific.region..Some.of.the.options.to.consider.for.improving. targeting.include: ·. For.larger.programs,.in.Fiji.for.example,.targeting.by.proxy.means.tests.should. be.explored,.as.it.might.be.cost-effective,.more.easily.checked,.and.not.as.easily. manipulated.by.beneficiaries.as.is.the.self-reported.income. ·. For.copra.subsidies,.a.potentially.efficient.self-targeting.mechanism.is.the.copra. price.paid.to.farmers.by.the.marketing.authority,.and.this.should.be.adjusted. to.target.the.poorest.farmers..At.the.same.time.the.overall.fiscal.commitment. should.be.capped. ·. For. the. universal. pension. allowance. in. Kiribati,. an. income. test. needs. to. be. introduced.to.contain.costs.and.leakages.to.the.non-poor. ·. Targeting. on. the. basis. of. information. provided. by. communities. or. NGOs. is. appropriate.for.very.small-scale.programs.because.it.makes.use.of.local.knowledge.. It.can.also.be.used.to.correct.any.mis-targeting.at.the.local.level.. 3 6 governance - aligning services, financing, and policies.. Because. social. protection. is. nascent. in. the. Pacific. region,. carrying. out. country-specific. assessments.and.strategic.development.plans.are.key.first.steps.to.aligning.policies.with. services. and. financing.. This. would. be. a. multi-agency,. multi-partner. activity,. through. which.governments.should.aim.to.produce.a.strategy.document.that.would.outline.the. country's.risk.profile,.the.government's.strategic.objectives.in.the.sector,.the.opportunities. for.risk.prevention,.risk.reduction,.and.risk.coping.interventions,.the.appropriate.role.of. government.vis-à-vis.families,.communities,.and.NGOs,.and.a.series.of.prioritized.and. phased.actions.86. 3 7 It. will. also. be. important. to. establish. (if. none. exists). a. focal. point. for. the. government's. social. protection. strategy,. coordination. and. monitoring. and. evaluation..This.could.fit.within.an.existing.social.ministry.or.within.a.planning.organization,. and.could.be.integrated.with.similar.functions.for.other.social.sectors.. 3 8 governance - public-privatepartnerships.Pacific.governments.are.fortunate. in.that.they.can.learn.from.the.efforts.of.a.vibrant.community.of.NGOs.and. churches,.many.of.which.are.engaged.in.social.protection..Making.the.current.division.of. responsibility.for.providing.social.protection.work.more.efficiently.could.yield.substantial. rewards. in. the. Pacific. region.. This. could. be. done. by. governments. contracting. out. the. provision.of.specific.services.to.non-government.entities,.with.the.government.holding. these.entities.accountable.for.an.agreed.set.of.outcome.targets..Another.important.element. would.be.for.the.government.to.act.as.the.central.focal.point.for.information.sharing.and. coordination.on.social.protection. 3 9 governance - data availability..There.are.two.areas.where.better.information. and.more.transparency.could.make.social.protection.programs.more.rigorous.and. effective..Both.are.needed.to.help.put.social.protection.(which.is.a.new.sector.in.most.of. the.Pacific.countries).on.a.firm.footing,.both.with.policymakers.and.with.the.beneficiaries.. ·. At.present,.it.is.hard.to.get.accurate.information.on.the.costs,.beneficiaries,.benefit. levels,.duration.of.benefits,.and.targeting.efficiency.of.existing.social.assistance. programs.. This. makes. efficient. management. and. monitoring. and. evaluation. difficult..One.of.the.first.management.reforms.that.governments.need.to.make. to.any.existing.social.assistance.program.should.be.to.improve.data.management. and.increase.its.accessibility. ·. For.strategy.and.policy.purposes,.there.is.no.substitute.for.regular.household. surveys. that. include. questions. relevant. to. risk. management,. for. example,. on. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.87 MANAGING.SOCIAL.RISK labor.market.issues,.transfers.and.remittances.that.underpin.the.family-based. safety.net,.family.participation.in.social.assistance.schemes,.and.the.prevalence. of.disability.and.chronic.poverty..Such.surveys,.if.nationally.representative,.will. yield.accurate.and.up-to-date.data.that.will.be.an.invaluable.input.into.the.design. of.a.targeting.strategy.and.will.make.it.possible.to.check.the.coverage.rates.that. are.self-reported.by.social.protection.providers..87 4 0 Priority Setting. Every.country.situation.in.the.Pacific.is.unique,.and.each.will. require.careful.planning.to.put.in.place.a.rational.program.of.social.protection..An. initiative.that.might.appear.straightforward.may,.on.further.analysis,.prove.unworkable.or. redundant..For.example,.the.problem.of.youth.unemployment.in.RMI.is.certainly.a.serious. issue,.and.it.seems.to.be.linked.to.grave.social.problems.for.young.men..would.a.workfare. scheme. be. appropriate?. Probably. not,. for. in. RMI,. unemployment. seems. to. be. related. to. household. transfers. and. a. high. reservation. wage.. workfare. would. need. to. pay. high. wages.to.extract.many.male.youth.from.unemployment,.and.might.thus.be.unaffordable.. Employment.services.to.place.youth.in.overseas.jobs.might.be.more.productive,.as.access.to. the.uS.labor.market.is.open.for.Marshall.Islanders.. 4 1 For.the.two.countries.with.active.social.assistance.programs.(Fiji.and.Kiribati),. the.service.expansion.agenda.(for.unemployed.youth.and.social.problems).might. be.best.undertaken.with.savings.from.programs.that.could.be.better.targeted.and.managed,. such.as.FAP,.the.copra.subsidy,.and.the.old.age.allowance..In.Vanuatu,.social.protection. provided.by.the.public.sector.is.very.modest;.care.will.need.to.be.taken.to.begin.cautiously. with.certain.target.groups,.where.there.are.private.sector.partners.and.a.clear.need.for. public.action,.such.as.disabled.people,.victims.of.domestic.violence,.or.victims.of.natural. disasters.. 88.|.wORLD.BANK 7 Managing Donor Resources 1 Pacific. Island. countries. do. well. in. the. global. competition. for. aid. resources.. The. `Compact'.countries.in.Micronesia,.for.example,.receive.in.per.capita.terms.more.aid. resources.for.education.and.health.than.anywhere.else.in.the.world..The.role.of.donors.in. the.Pacific,.however,.is.more.complex.than.the.single.dimension.of.aid.abundance..The. effectiveness.of.resource.use.has.been.a.central.theme.of.the.previous.chapters.of.this. report,.and.examples.abound.of.donor.and.government.resources.flowing.with.insufficient. regard.to.the.performance.of.the.recipient.entity,.whether.it.be.the.increasing.copra.price. subsidies.in.Kiribati,.or.the.heavy.expenditure.on.overseas.health.care.almost.everywhere. in.the.Pacific..This.report.has.so.far.placed.the.onus.of.reform.on.Pacific.countries,.but.what. can.be.said.about.the.role.of.donors.themselves?.Are.there.ways.in.which.they.could.more. effectively.deploy.their.resources.to.improve.outcome.performance?.This.chapter.explores. that.important.question. Patterns of Assistance 2 The.OECD.data.base.on.donor.assistance.to.the.developing.world.can.be.used.to.analyze. three. important. dimensions. of. donor. strategy. in. the. Pacific:. sub-sectoral. resource. allocation;.project.size;.and.country.presence..Sub-sectoral.allocation.will.show.how.donors. are.choosing.between.basic.social.services.and.the.more.sophisticated.services.delivered. mostly.to.urban.populations..Figure.7-1.below.shows.Pacific.countries.ranked.according.to. the.proportion.of.post.secondary.assistance.received.over.total.education.assistance,.using. average.levels.of.assistance.during.the.1997-2003.period.to.smooth.out.annual.fluctuations. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.89 MANAGING.DONOR.RESOuRCES and.to.gain.a.more.cumulative.picture.of.donor.allocative.choices..Total.assistance.includes. assistance.projects.identified.as.primary,.secondary,.post.secondary.and.general.education.. Most.of.the.post.secondary.assistance.is.in.the.form.of.tertiary.scholarships..On.average,. Pacific.countries.are.receiving.over.50.percent.of.their.education.assistance.in.the.tertiary. sector,. a. high. proportion. by. international. standards.88. while. recognizing. that. higher. education. is. difficult. to. organize. for. small. populations. and. is. expensive. to. provide,. an. analysis.of.alternatives.and.outcomes.against.goals,.such.as.meeting.the.MDGs.and.EFA. targets,.show.that.too.much.goes.to.higher.education..As.shown.in.Chapter.4,.there.are. continued.unmet.needs.at.the.basic.education.level,.and.if.promoting.pro-poor.development. is.the.goal,.governments.and.donors.would.be.well.advised.to.examine.the.balance.of.aid. provided. to. the. tertiary,. secondary. and. primary. cycles.. Finding. cost-effective. ways. of. providing.higher.education,.e.g..through.regional.collaborations.and.distance.education. opportunities,.need.to.be.encouraged. FIguRE 7-1: POSt SECONDaRy aSSIStaNCE aS a PROPORtION OF tOtal EDuCatION aSSIStaNCE 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% RMI Vanuatu Samoa Kiribati Fiji Tonga Solomon Palau FSM Islands Source: OECD Development Assistance Data Base, average levels for 1997-2003. Note: For 2004, RMI proportion would be around 24 percent. 3 In.health,.the.picture.is.quite.different,.with.only.an.average.of.11.percent.of.all.health. sector.aid.assistance.going.to.the.tertiary.sector..Much.of.donor.assistance.(around. 59.percent).is.concentrated.in.overall.sectoral.assistance.for.health.policy.development,. management.and.human.resource.capacity.building,.so.it.is.more.difficult.to.assign.project. costs.to.primary,.secondary.and.tertiary.activities..Primary.health.care.activities.receive. the.remainder. 4 Another.measure.of.donor.performance.is.the.degree.of.fragmentation.of.effort,.both. among.donors.at.the.sectoral.level.in.a.given.country.setting,.and.at.the.project.level,. also.by.sector.and.country..It.would.be.expected.that.the.average.project.size.in.the.Pacific. would. be. modest,. given. the. country. populations,. all. below. 1. million,. and. many. under. 100,000..The.OECD.data.supports.that.expectation..Figure.7-2.presents.the.average.project. size.for.education,.health.and.social.protection.in.each.of.the.nine.Pacific.Island.countries. over.the.1997-2003.period,.and.the.number.of.projects.that.generate.these.relatively.small. project. sizes.. Projects. in. most. countries. and. sectors. average. below. uS$1. million. each,. including. loan. financed. projects. from. the. international. finance. institutions.. This. could. imply.a.disproportionate.total.cost.to.administer.such.projects,.both.on.the.donor.side.and. the.recipient.country.side..As.shown.in.Figure.7-3.education.is.particularly.fragmented. among.individual.projects.for.most.of.the.five.major.bilateral.donors.. 90.|.wORLD.BANK CHAPTER.7 FIguRE 7-2: avERagE PROjECt SIZE, NuMbER OF PROjECtS by SECtOR aND COuNtRy, 1997-2003 US$ `000s 2500 Education 6 Health 7 2000 Social Protection 4 1500 37 7 28 1000 16 66 29 26 13 59 18 95 500 8 20 7 30 27 12 12 32 34 8 30 8 6 0 Fiji Kiribati RMI FSM Palau Samoa Solomon Is. Tonga Vanuatu Source: OECD DAC data base. FIguRE 7-3: tOtal DONOR PROjECtS by SECtOR, 1997-2003 160 Education 140 Health Social Protection 120 100 80 60 40 20 0 Australia Japan NZ France EC Source: OECD DAC data base. 5 Could.donors.in.the.Pacific.be.better.coordinated?.If.one.looks.at.the.total.number.of. donors.present.in.a.country.and.within.a.sector,.health,.for.example,.Fiji.has.had.nine. different.donors.in.health.over.that.period,.eight.were.active.in.Solomon.Islands.in.education,. and.seven.in.Vanuatu.education,.and.on.down.to.five.in.health.for.RMI..For.the.`Compact'. countries,.there.are.some.coding.issues,.in.that.substantial.uS.assistance.is.provided.in.the. form.of.budget.support.and.cannot.be.decomposed.into.each.social.sector,.so.it.is.listed. under.social.protection,.thus.under.reporting.the.uS.presence.in.education.and.possibly. health..Overall,.based.on.global.data.for.all.sectors,.the.number.of.donors.present.in.the. Pacific.social.sectors.is.probably.less.plentiful.than.in.other.regions,.but.given.the.small.size. of.the.countries,.the.administrative.burden.on.recipient.country.bureaucracies.is.probably. higher.and.puts.pressure.on.Pacific.governments.to.expand.public.sector.employment.89. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.91 MANAGING.DONOR.RESOuRCES Strategic and Policy Alignments 6 The.question.that.is.so.difficult.to.treat.systematically.is.the.consistency.of.donor. policy.guidance.with.country.strategy.and.vision.for.each.sector..As.is.so.often.the. case,.donors.do.not.agree.among.themselves.on.which.direction.the.sector.should.take. in.a.particular.country,.nor.are.they.always.aligned.with.the.aspirations.of.country.policy. makers,.who.have.unique.local.mandates.and.constituencies.to.deal.with..This.problem.of. country.misalignment.is.more.serious.than.the.mere.cacophony.of.donor.voices.seeking.to. influence.country.policy,.it.goes.to.the.heart.of.what.development.assistance.is.attempting. to.achieve.. 7 As.is.evident.from.the.discussion.in.the.sectoral.chapters,.there.is.a.clear.need.for. governments.to.adjust.priorities.to.achieve.their.desired.social.outcomes..This.would. only. be. possible. if. all. resources,. government. and. donor,. are. linked. to. outcomes. and. incentives.are.aligned.to.achieve.these.outcomes..The.development.of.a.coherent.strategy. for.the.sector.which.focuses.on.outcomes.and.identifies.key.priorities.within.a.medium- term. fiscal. framework. is. essential.. Aligning. donor. support. to. such. a. strategy. can. help. greatly.improve.aid.effectiveness. 8 Recent.global.initiatives,.such.as.the.MDGs,.have.attempted.to.shift.the.focus.of.both. donors.and.governments.to.the.improvement.of.social.outcomes,.as.the.first.priority,. with.inputs,.and.even.policies.seen.as.means.rather.than.ends..In.recent.years,.donors.have. sought.to.introduce.more.policy.and.strategic.coherence.through.a.variety.of.mechanisms,. some.country.wide.and.others.more.sectoral.in.focus,.through.such.instruments.as.the. IMF. Policy. Framework. Papers,. the. world. Bank's. Poverty. Reduction. Strategy. Papers,. the. Comprehensive. Development. Framework,. Country. Assistance. Strategies,. Regional. Assistance.Strategies,.and.Sector.wide.Approaches.(SwAPs)..All.of.these.initiatives.have. sought.country.ownership.and.leadership.of.the.process.and.their.commitment.to.the.agreed. outcome. targets,. some. with. more. success. than. others.. Country. commitment. is. widely. accepted.as.the.single.most.important.determinant.of.effective.development.assistance.. 9 The.central.themes.of.any.programmatic.support.to.a.sector.by.development.partners. typically.emphasize.the.need.for:. ·. government ownership.and.accountability.of.the.strategy.being.supported;. ·. a.focus on outcomes and prioritization.of.expenditures.and.scarce.administrative. capacities.in.support.of.the.outcomes.to.be.achieved.rather.than.just.on.input. management,.i.e..all.inputs.should.be.judged.in.terms.of.their.contribution.to. improved.outcomes; ·. programmatic, organizational and management reforms to.enable.the.outcomes.to. be.improved;. ·. increasing use of core government systems.(a.`whole.of.government'.approach).to. manage. resources. and. the. supported. programs. (including. through. strategic. partnerships.with.the.private,.church,.and.NGO.sectors); ·. developmental.and.recurrent.support.of.programs to be supported within a medium- term fiscal or budget framework with a focus on sustainability; ·. stakeholder inclusiveness in design and implementation of strategies; ·. transparency and probity in all processes. including. through. sound. financial. and. procurement.management. Figure.7-4.presents.the.essential.building.blocks.of.such.a.programmatic.approach.or.a. common.financing.and.policy.framework. 92.|.wORLD.BANK CHAPTER.7 FIguRE 7-4: PROgRaMMatIC SuPPORt: buIlDINg blOCKS OF a COMMON FINaNCINg aND POlICy FRaMEWORK Harmonized Implementation Mechanisms & Use of Local Procedures Co-ordination /Alignment of (All) Resources Common Program / Expenditure Framework Agreed Policy Framework/ Strategies based on Shared Vision & Priorities Partnerships with Development Agencies Local Ownership & Leadership 1 0 where.does.the.Pacific.stand.in.terms.of.this.global.trend.toward.improving.donor. alignment. behind. agreed. strategies. and. social. outcome. targets?. The. situation. varies. enormously. from. sector. to. sector,. even. within. a. single. country.. Some. examples. present.below.will.illustrate.this..Perhaps.the.most.ambitious.undertakings.are.the.two. operations.that.have.been.conducted.for.the.education.sector.in.Tonga.and.Solomon.Islands.. Both.involve.multi-donor.participation,.both.are.based.on.country.leadership.and.donor. support,.and.both.involve.a.rigorous.process.of.defining.and.agreeing.upon.an.overarching. government.strategy.and.sectoral.financing.plan.. 1 1 The.Tonga.Education.Support.Project.supported.by.NzAID.and.the.world.Bank. is. such. an. example. (see. Box. 7-1).. Financial. fungibility. means. that. on-budget. assistance.can.displace.government.resources.without.actually.raising.the.total.resources. to.the.sector..This.has.been.addressed.in.some.countries.by.setting.minimum.recurrent. budget.allocations.for.a.specific.sector,.thus.conditioning.assistance.to.the.government's. financial.performance.as.well..Such.is.the.case.for.the.Solomon.Islands.Education.Operation. supported.by.NzAID.and.the.Eu. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.93 MANAGING.DONOR.RESOuRCES bOX 7-1: tHE tONga EDuCatION SuPPORt PROjECt The. Tonga. Education. Support. Project is. based. on. the. Tongan. Government's. overall. Strategic.Development.Plan.which.singles.out.the.education.sector.as.a.major.contributor. to.the.Government's.economic.growth.strategy..An.Education.Policy.Framework.was. developed.by.the.Ministry.of.Education,.including.a.financial.analysis.of.its.funding. requirements.and.the.gaps.in.need.of.external.support..This.provided.NzAID.and.the. world.Bank.with.the.sectoral.priorities.and.the.necessary.scale.of.their.contribution.to. the.sector..Both.will.provide.ear-marked.budget.support.to.the.Ministry.of.Education,. flowing.through.a.unified.trust.fund.that.will.finance.a.set.of.activities.around.the.goal.of. universal.basic.education.through.Grade/year.8..The.central.plank.of.this.strategy.is.the. introduction.of.school.grants.and.delegation.to.the.schools.of.management.responsibility. for.the.funds.and.educational.outcomes..A.second.set.of.activities.in.curriculum.reform,. teacher.education.and.student.assessment.will.be.funded.separately.by.a.direct.NzAID. grant..The.total.package.is.uS$10.million.over.five.years.. At.the.core.of.the.TESP.is.its.results.orientation..School.grants.and.other.reforms.are. aimed.at.improving.the.standard.basic.education.indicators,.such.as.net.enrollment,. repetition,.drop.out,.and.transition.rates..These.and.capacity.building.indicators.will.be. monitored,.and.the.program.reviewed.annually.by.donor.partners..The.other.fundamental. feature.is.that.no.project.specific.units.have.been.created;.the.project.is.integrated.with. Ministry.of.Education.structures,.and.is.under.the.direct.management.of.the.Director.of. the.Ministry.of.Education. TESP.strives.toward.common.financing.and.policy.framework.ideals,.but.in.this.first. phase.does.not.attain.all.of.them..For.example,.some.important.donors.in.the.sector. are.not.participating.(AusAID.and.the.EC);.although.monitoring.will.play.an.important. role.and.animate.donor.reviews,.there.are.no.explicit.performance.incentives.built.into. TESP;.not.all.funds.flow.through.the.Trust.Fund,.as.the.NzAID.second.`cluster'.activities. are.financed.via.direct.budget.support.grant.to.the.Ministry.of.Education..TESP.has. nonetheless.launched.a.long.term.program.that.is.designed.to.bring.all.donors.within.an. integrated,.results.oriented.sectoral.program,.managed.and.led.by.the.Tongan.Ministry. of.Education..This.marks.a.major.advance.for.the.Tongan.Government.in.its.management. of.donor.resources.and.in.its.leadership.of.education.reform.. Source: Human Development Unit, East Asia and Pacific, "Project Appraisal Document for a Tonga Education Support Project (TESP)", World Bank 2005. 1 2 Another. example. of. a. promising. building. block. is. the. Vanuatu. Development. Account,.which.government.and.donors.use.for.housing.capital.resources.and. for.disbursements.to.on-budget.capital.projects..with.AusAID.technical.support,.Vanuatu. established. this. exceptional. mechanism. for. donor. coordination. and. tracking. of. capital. project. activity.. Each. year,. donors. send. to. the. Ministry. of. Finance. their. new. project. proposals,.which.then.undergo.a.thorough.review.by.sectoral.ministries,.the.MOF,.and. final.approval.by.a.Ministerial.Budget.Committee.before.inclusion.in.the.Annual.Budget. document.that.is.submitted.to.Parliament..All.larger.project.resources,.once.approved.by. Parliament,.are.then.required.to.be.deposited.in.the.Development.Account,.from.which.the. MOF.approves.disbursement.requests.from.project.management.entities..Not.all.donors. participate.in.this.mechanism,.but.the.system.has.been.disbursing.from.the.Development. Account.over.the.past.two.fiscal.years,.and.is.considered.an.agile.and.practical.instrument. by.the.donors.who.are.using.it. 1 3 The.former.uS.territories.in.Micronesia,.the.so.called.`Compact'.countries,.entered. into.a.revision.of.the.original.Compact.of.Free.Association.with.the.uSA.last.year.. This.new.set.of.agreements.takes.the.substantial.uS.assistance.in.RMI,.for.example,.toward. a.results.oriented,.indicator.based,.government.managed,.on-budget.financing.mechanism. that. governs. most. of. uS. assistance. to. the. education. and. health. sectors.. Monitoring. 94.|.wORLD.BANK CHAPTER.7 arrangements.and.review.procedures.are.especially.well.developed..The.Joint.Economic. Management.and.Financial.Accountability.Committee.(JEMFAC),.established.under.the. new.Compact.arrangements,.is.chaired.by.a.uS.official.from.the.Department.of.Interior,.and. its.decisions.on.budget.matters.must.be.unanimous.among.its.RMI.and.uS.members..The. first.JEMFAC.meeting.took.place.in.August.2004,.at.which.sector.grant.allocations.of.uS$35. million.for.the.uS.fiscal.year.2005.were.approved..JEMFAC's.responsibilities.represent.a. significant.step.forward.in.mutual.accountability.for.results.under.Compact.arrangements,. including.not.only.the.approval.of.annual.allocations.of.uS.budget.assistance,.but.also. evaluation.of.the.progress.toward.agreed.performance.objectives..The.JEMFAC.mechanism. thus. has. many. SwAP. type. features,. but. lacks. one. crucial. ingredient:. the. aspiration. to. include.all.donor.flows.with.the.two.social.sectors.under.an.agreed.multi-donor.financing. and.review.mechanism..Since,.at.this.stage,.the.only.donor.participating.is.the.uSA. 1 4 In.Solomon.Islands,.the.Education.Sector.Investment.and.Reform.Program.(ESIRP). supported.by.NzAID.and.the.EC,.displays.some.prominent.building.blocks,.such. as.the.agreement.to.a.common.sector.strategy.and.plan,.and.a.unified.sector.financing. strategy..Part.of.the.donor.funds.flow.directly.through.government.financial.channels,. and. management. is. under. the. Permanent. Secretary. of. the. Ministry. of. Education. and. Human.Resource.Development..ESIRP.is.evolving.toward.a.more.comprehensive.sectoral. instrument.. However,. one. donor. still. provides. funds. through. a. dedicated. project. unit,. and.other.donors.active.in.the.sector.are.not.participating..Like.Tonga,.however,.Solomon. Islands'.ESIRP.sets.a.high.standard.for.donor.unification.behind.a.common.strategy.and. toward.educational.outcome.performance.goals..In.the.health.sector,.donors.are.discussing. how.a.coordinated.approach.to.donor.financing.might.be.structured,.inspired.by.ESIRP,.and. based.on.the.building.blocks.already.in.place.in.the.Ministry.of.Health,.thanks.to.AusAID. sponsored.management.reforms.and.sectoral.financing.practices.since.2003.. 1 5 As. donors. and. Pacific. governments. gain. confidence. in. sectoral. modes. of. assistance,.opportunities.to.support.sectoral.management.and.broad.governance. reforms.will.become.more.accessible..This.linkage.for.future.donor.assistance.is.crucial.. The.preceding.chapters.have.identified.many.initiatives.in.more.demanding.domains.of. sectoral. management. and. multi-stakeholder. governance.. Sectoral. assistance. can. help. forge.a.consensus.on.priorities,.focus.financing.where.it.is.needed.to.implement.those. priorities,.and.reward.high.country.performance.in.the.achievement.of.outcomes..Explicit. agreements.on.outcome.performance.should.be.a.prominent.feature.of.the.next.round.of. sectoral.assistance.in.the.Pacific.. Opportunities for Better Donor Alignment 1 6 As.shown.above,.the.presence.of.coherent.strategy.for.the.entire.sector.which. focuses.on.outcomes.and.identifies.key.priorities.within.a.medium-term.fiscal. expenditure.framework.is.clearly.the.first.step..To.be.effective,.all.donor.support.would. need.to.be.aligned.within.such.country.sector.strategies..There.are.several.options.on.how. such.assistance.can.work..One.such.option.is.programmatic.support.to.a.sector.on.a.sector- wide.basis..Not.all.countries.in.the.Pacific.maybe.ready.to.take.the.rigors.of.such.multi- donor.sectoral.assistance.mechanisms..There.are.several.options.which.focus.on.one.or. more.of.the.core.principles.underlying.this.approach.and,.as.shown.above,.these.are.already. being.implemented.in.the.Pacific. 1 7 Another. obvious. opportunity. is. in. the. financial. frameworks. of. assistance.. As. shown.at.the.outset.of.this.chapter,.donor.flows.are.not.well.allocated.in.some. cases..Post.secondary.education.receives.far.too.high.a.proportion.of.assistance.in.many. Pacific.countries..understanding.better.how.public.funds.have.been.allocated.in.the.past,. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.95 MANAGING.DONOR.RESOuRCES and.where.they.might.obtain.better.outcome.results.in.the.future,.is.a.first.stepping.stone. that. Pacific. governments. might. find. useful.. A. public. expenditure. review,. a. rarely. used. analysis.in.the.Pacific,.could.serve.that.need.and.complement.the.development.strategy. exercises.that.are.carried.out.regularly.in.the.Pacific.for.the.social.sectors..Box.7-2.below.is. drawn.from.a.case.study.by.world.Bank.staff,.using.Vanuatu.Government.sources,.to.show. some.of.the.allocation.issues.in.the.education.sector. 1 8 The.opportunities.for.donor.harmonization.and.performance.oriented.assistance. remain.abundant.in.the.Pacific..Most.countries.and.sectors.still.conform.to.the. traditional.pattern.of.many.donors,.large.numbers.of.small.projects,.and.in.the.country. aggregates,.evidence.of.misalignment.with.country.strategic.priorities..There.are.examples. of.cutting-edge.reforms.in.aid.management.in.countries.as.diverse.as.Vanuatu,.Solomon. Islands,.and.Tonga..It.is.worthwhile.for.donors.to.urge.governments.and.their.ministries. to.undertake.more.reforms.and.raise.performance..However,.donors.too.must.have.their. own. accountability. agenda:. to. move. beyond. narrow. project. based. mechanisms. toward. harmonized.assistance.that.can.be.better.focused.on.outcomes.and.priorities.identified.in. government.strategies.and.address.priority.performance.issues.in.the.Pacific. bOX 7-2: RESOuRCES aND COORDINatION FOR PRIMaRy EDuCatION IN vaNuatu Over.the.last.six.years,.Vanuatu.has.received.a.total.of.uS$53.million.in.grant.aid.for.the. education.sector..This.amounts.to.a.generous.per.capita.allocation.of.around.uS$42.per. year.based.on.latest.population.data..Despite.this.large.inflow.of.resources,.it.is.unclear. what. the. direct. or. indirect. impact. on. educational. attainment. has. been.. The. Eu. and. Australia.are.the.predominant.donors.in.education.in.Vanuatu..However,.as.shown.in.the. Table.below,.bi-lateral.assistance.from.these.and.other.countries.has.been,.and.currently. is,.targeted.towards.the.post.primary.levels.of.education..while.the.reasons.for.high.donor. allocations.for.secondary.and.post.secondary.education.may.have.seemed.justifiable.on.a. case.by.case.basis,.this.skewed.external.financing.in aggregate.has.created.a.vacuum.at.the. primary.level,.where.only.Japan.and.New.zealand.are.active..Japan.focuses.mainly.on. infrastructure.improvement.projects..However,.many.issues.remain.in.regard.to.access.for. disadvantaged.groups.and.school.quality..The.Government.of.Vanuatu's.own.expenditure. allocation.for.education.quality.improvement.at.the.primary.level.is.small.(e.g.,.block. grants.to.provinces.under.the.recently.initiated.scheme.of.decentralized.financing),.and. inefficiencies.within.the.system.prevent.the.timely.disbursement.of.funds.to.the.school. level..In.this.context,.initial.indications.are.that.financing.for.Vanuatu's.education.sector. is.currently.unbalanced..An.education.public.expenditure.review.would.likely.provide.the. necessary.budgetary.and.analytical.information.to.substantiate.these.initial.findings. tablE: vaNuatu- EXtERNal FINaNCINg OF EDuCatION by Sub-SECtOR, 1998-04 Level of Schooling Project Budget US$ Percent of Total Pre-School 741,501 1% Primary 1,969,330 4% Secondary 29,568,399 36% Post.Secondary 19,129,250 56% Other 1,325,767 3% TOTAL 52,737,747 100% Source: Department of Foreign Affairs, Aid Management Division; Department of Economic and Sector Planning (DESP). 96.|.wORLD.BANK 8 Moving Forward - New Directions for Human Development 1 The. Pacific. Island. Countries. have. performed. well. on. broad. human. development. indicators.such.as.life.expectancy.at.birth,.infant.mortality.rate.(IMR),.and.primary. net.enrollment.rate,.especially.when.compared.to.other.low.and.middle.income.countries.. Nonetheless,.MDG.indicators.in.health.and.education.show.a.mixed.picture,.with.some. goals,.such.as.u5MR.and.MMR.reduction,.primary.school.completion,.and.prevention.of. communicable.diseases.such.as.TB.and.malaria,.unlikely.to.be.met.in.some.Pacific.countries,. while.goals.for.net.primary.enrollment.and.gender.equity.are.showing.good.progress..The. MDG.indicators.are.valuable,.but.not.comprehensive..Many.issues.are.omitted,.such.as. the.quality.of.education.and.the.learning.achievement.of.students,.or.the.spread.of.new. communicable.diseases.such.as.HIV/AIDS,.and.the.rise.of.the.NCDs.of.adulthood,.such.as. diabetes..In.addition.an.asset.of.highest.potential,.the.region's.youth,.is.entering.a.period.of. elevated.risk.from.inactivity.and.other.problems.90.Some.social.problems,.such.as.domestic. violence.and.alcohol.abuse,.have.proved.highly.resistant.to.improvement.in.the.Pacific.. Another.key.dimension.is.equity.of.service.access.and.outcomes,.which.this.report.has. analyzed.extensively,.and.which.show.sharp.differentials.in.some.social.outcomes.between. the.rich.and.the.poor.in.the.Pacific.. 2 The.mixed.picture.in.social.indicators.coexists.with.a.relative.abundance.of.resources,. both.domestic.and.foreign,.flowing.to.the.social.sectors..In.particular,.the.long.standing. interest.of.foreign.assistance.in.the.social.sectors.of.Pacific.countries.is.intact.and.compares. favorably.with.other.developing.countries,.including.other.island.and.small.states..The. access.indicators.also.confirm.resource.abundance.in.such.measures.as.pupil.teacher.ratios,. primary.health.facilities,.and.large.budgets.for.overseas.referrals.for.tertiary.health.care.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.97 MOVING.FORwARD.-.NEw.DIRECTIONS.FOR.HuMAN.DEVELOPMENT 3 Some.Pacific.countries.are.better.resourced.than.others,.and.so.this.study.has.asked.if. resources.for.human.development.are.correlated.with.higher.outcomes.in.education. and.health..This.relationship.is.statistically.valid.only.where.governments.are.successful.in. setting.up.effectively.functioning.institutional.structures.for.social.service.delivery..Could. the.Pacific's.problem.areas.be.linked.to.shortfalls.in.`accountability'.in.the.relationships. between.the.key.actors.in.delivering.social.services?.Are.the.behaviors.of.policy.makers,. frontline.service.providers.and.the.clients.they.serve.more.critical.than.the.number.of. service.facilities,.staff.and.equipment.at.their.disposal?.Are.donor.assistance.strategies.still. built.around.inputs.and.service.expansion,.when.the.Pacific.is.more.in.need.of.outcome. based.assistance.and.support.for.reforms?. 4 In. the. Pacific. where. scale. limits. the. range. of. initiatives,. and. capacities. to. manage. programs.and.projects.are.of.necessity.thinly.distributed.in.government,.donors.and. governments.have.agreed.to.house.certain.projects.in.a.regional.rather.than.a.country. setting..A.regional.approach.is.also.appropriate.for.issues.with.important.spillovers.effects,. as.in.the.health.sector,.or.with.significant.inter-country.dimensions,.as.in.labor.migration.. There.are.many.such.programs.for.human.development,.and.a.basic.strategic.consideration. is. whether. to. launch. new. initiatives. in. country,. or. to. do. so. at. the. regional. level.. This. concluding.chapter.begins.with.issues.of.country.based.policy.and.action,.after.which.the. issues.for.regional.application.are.discussed.. Setting National Priorities 5 The. agenda. for. human. development. in. the. Pacific. has. two. dimensions:. closing. remaining.performance.gaps,.and.reducing.the.inequities.that.underlie.those.gaps..A. paradigm.shift.is.needed.to.reorient.social.services.to.achieve.better.outcomes.and.this.has. already.begun..A.key.step.is.to.focus.on.interventions.that.would.best.deliver.the.desired. results,.leveraging.all.available.resources..This.would.require.considerable.government.and. stakeholder.engagement..In.particular,.the.political.implications.of.the.institutional.and. redistributive.reforms.suggested.in.this.study.should.not.be.ignored..These.reforms,.by. their.very.nature,.are.complex.and.lead.to.changes.in.relationships.between.the.various. actors.involved.in.service.delivery.and.must.be.managed.carefully..Pacific.governments. have.had.considerable.experience.in.this.as.they.have.already.instituted,.or.are.currently. implementing,. public. expenditure. management. reforms.. Each. country's. experience. in. managing.the.transitions.in.service.delivery.reforms,.and.engaging.its.citizens.and.providers. to.promote.change.will.be.unique..In.this.context,.good.monitoring.and.evaluation.of.the. reform.initiatives.combined.with.continuous.dissemination.to.all.major.stakeholders,.holds. the.most.promise. 6 A.wide.array.of.priority.intervention.or.policy.actions.that.could.help.governments. for. address. performance. issues. and. improve. social. outcomes. are. outlined. in. the. sectoral. chapters.. These. are. grouped. into. three. domains. of. action:. service. expansion,. sectoral.management.and.multi-stakeholder.governance..The.findings.of.the.study.suggest. that.in.most.instances,.lack.of.resources.(capacity).is.not.a.major.constraint.in.improving. performance.. Rather,. the. challenges. lie. in. the. governments'. ability. to. manage. given. resources.efficiently.(sectoral.management).in.the.context.of.an.effective.and.transparent. governance. framework. that. delivers. results. for. all.. In. cases. where. service. expansion. is. needed,.it.is.noted.that.much.of.this.could.be.achieved.through.improvements.in.sectoral. management.and.building.partnerships.with.all.providers..The.primary.focus.of.the.study. is.thus.on.improved.sectoral.management.and.governance,.i.e..achieving.the.most.from. available.resources.. 98.|.wORLD.BANK CHAPTER.8 7 Expanding service capacity to improve social outcomes..The.service.expansion. agenda. is. not. exhausted. for. Pacific. human. development.. Social. protection. issues,. such.as.youth.inactivity.and.domestic.violence,.have.not.yet.been.taken.up.by.most.Pacific. governments,.nor.has.the.secondary.enrollment.problem.been.addressed.yet.by.the.necessary. expansion.of.secondary.schools..Similarly,.the.excessive.cost.and.number.of.overseas.health. care.referrals.can.be.addressed.through.carefully.designed.capacity.expansion.in.country,.so. as.to.offer.some.of.the.more.frequently.delivered.(and.less.complicated).overseas.services. in.the.Pacific.country's.own.tertiary.hospital..In.circumstances.such.as.these,.where.there. is.no.effective.private.alternatives.to.public.engagement,.governments.in.the.Pacific.are. already.considering.ways.to.find.the.resources.for.secondary.school.expansion,.and.are. anxious.to.develop.proven.programs.that.will.defuse.youthful.inactivity,.for.which.this. study. recommends. temporary. employment. programs. that. are. used. widely. elsewhere.. Ministry.officials.must.of.course.manage.capacity.expansion.through.improving.efficiency. in.resource.allocation,.and.do.so.at.the.lowest.cost,.in.a.timely.manner,.and.in.coordination. with.other.required.inputs..Private.public.provision.issues.must.always.be.built.into.any. decision.to.expand.or.launch.a.new.program,.all.of.which.adds.up.to.no.small.undertaking.. what.distinguishes.service.expansion.is.the.availability.of.fresh.resources.and.the.expansion. of.coverage.which.must.be.well.managed.to.the.extent.feasible.through.partnerships.with. private.sector.and.communities.and.more.efficient.allocation.of.resources.. 8 Improving outcomes through better sectoral management. Sectoral. policy. needs.to.be.dedicated.to.obtaining.better.outcomes.with.existing.resources..Sectoral. management.may.engage.outside.agents.to.help.achieve.the.ministry's.objectives,.but.this.is. a.contractual.relationship.with.an.NGO.or.a.firm..This.is.narrower.than.the.broad.alliances,. partnerships.and.social.acceptance.that.define.multi-stakeholder.governance.initiatives.. Table. 8-1. outlines. strategic. choices. (better. targeting,. delegation. to. those. who. deliver. services,.aligning.policies.and.resources,.using.costs,.prices.and.demand-side.incentives),. the.performance.issues.they.address,.and.policy.action.and.interventions.that.can.help. deliver.results.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.99 MOVING.FORwARD.-.NEw.DIRECTIONS.FOR.HuMAN.DEVELOPMENT tablE 8-1: SECtORal MaNagEMENt: CHOICES, ISSuES, aND aCtIONS Strategic Choices Performance Issues Policy Actions 1. targeting Education ·. high.primary.drop.out.rate.among.poor. ·. conditional.cash.transfers,.community.and.teacher. ·. low.enrollments.and.attendance.among. monitoring.of.at-risk.students disabled.people. ·. supplemental.grants.to.schools.enrolling.disabled. ·. inequitable.secondary.enrollments students,.vouchers.to.families.with.disabled.children ·. inequitable.secondary.student.fees.and. ·. scholarships,.quotas.for.poor,.disabled.and.rural.students school.subsidies ·. sliding.scale.fees,.quotas,.review.public/private.subsidy. ·. inequitable.access.to.tertiary.educational. differentials institutions. ·. means.tests.for.scholarships,.quotas Social Protection ·. leakage.of.social.assistance.to.well.off. ·. appropriate.targeting.mechanisms,.proxy.means.tests,. lower.copra.subsidies 2. alignment of Policies and Interventions Education ·. low.public.sector.allocation.for.quality. ·. increase.pupil-teacher.ratios.through.school.clustering,. related.inputs.and.operational.costs.of. multi-grade.teaching schools ·. national.leaders.campaigns,.national.media.and. ·. low.literacy,.English.language institutions.promoting.literacy.and.English. Health ·. low.public.spending.on.public.health.and. ·. re-allocate.budgets.to.focus.on.prevention.and.primary. preventive.health.services. health.care. ·. high.fertility.and.low.contraceptive. ·. increase.awareness.on.the.costs.of.high.population.growth,. prevalence.rates integrated.national.policies.for.population.control ·. high.pharmaceutical.costs ·. regional.pooled.procurement,.sharing.national.formularies. Social Protection ·. high.vulnerability.to.natural.disasters ·. regional.financing.or.insurance.mechanism. ·. high.youth.unemployment ·. liberalized.access.to.neighboring.OECD.economies. Cross-cutting ·. inequitable.social.outcomes ·. public.expenditure.management.reforms.to.ensure. ·. low.alignment.of.policies.to.service. targeting.resources.to.achieve.social.outcomes,.oversight. delivery.challenges of.link.of.budget.allocations.with.country.and.sectoral. ·. fragmentation.of.donor.projects.and. strategies instruments ·. integrated.policies.for.issues.that.cut.across.sectors ·. lack.of.information.for.policy.makers ·. donor.harmonization.and.common.strategic.and.financing. frameworks ·. better.systems.for.information.collection,.analysis.and.use 3. Delegation/Decentralization Education ·. low.student.achievement.and.repetition. ·. school.based.management ·. low.quality.of.education.services ·. instituting.surveillance.systems.to.track.progress,.setting. ·. low.teacher.quality school.standards. ·. creating.professional.networks.for.teachers,.training. including.pre-service,.in-class.instruction.and.professional. registration.and.development Health ·. low.technical.quality.of.health.services ·. delegation.of.accountability.for.budget.and.human. ·. low.compliance.with.drug.therapy,.diet. resources.to.local.health.authorities,.set.standards management.for.non-communicable. ·. engage.specialized.NGOs.to.raise.awareness.and.manage. diseases compliance,.community.monitoring.of.patients.by.local. health.staff Social Protection ·. domestic.violence ·. engage.specialized.NGOs.to.reach.`at.risk'.women 4. Costs and Prices/ Incentives Education ·. low.primary.completion.and.achievement. ·. relevant.curriculum.and.materials.(to.attract.student. ·. high.school.drop.out.rates attendance.and.motivate.achievement) ·. conditional.cash.transfers. Health ·. poor.performance.and.low.motivation.of. ·. civil.service.reforms,.setting.performance.standards,. providers. providing.performance-based.contracts. ·. high.alcohol.abuse.and.smoking. ·. higher.import.duties.on.alcohol.and.cigarettes,.taxes.on. prevalence local.liquor. 100.|.wORLD.BANK CHAPTER.8 9 Improve outcomes through better governance. Governance.contains.some.highly. promising.interventions.within.three.different.strategic.choices:.increased.delegation;. decentralization,.provider.diversification.and.partnerships;.information.transparency;.and. increased.community.voice/participation.Table.8-2presents.these.choices,.the.performance. issues.or.outcomes.they.target.and.suggested.policy.action.or.interventions. tablE 8-2: gOvERNaNCE: POlICy lEvERS, PERFORMaNCE ISSuES aND POlICy aCtIONS Strategic Choices Performance Issues Policy Actions 1. Delegation/Decentralization/Diversification Education ·. low.student.achievement.and.repetition ·. school.based.management Health ·. continued.prevalence.of.communicable. ·. delegation.of.accountability.for.resource.use.to.local. diseases.and.rising.NCDs/HIV/AIDs health.providers;.engagement.with.traditional.healers. (compacts);.contracting.with.private.providers.and. NGOs 2. Costs and Prices Incentives Health ·. over.use.of.tertiary.hospital.outpatient. ·. introduce.fees.for.hospital.outpatient.care.with. facilities. exemptions.for.poor.and.catchment.population ·. high.cost.of.overseas.referrals. ·. risk-sharing.schemes,.low-cost.alternatives.such.as. ·. rising.prevalence.of.NCDs referral.to.regional.private.hospitals. ·. unhealthy.lifestyles ·. incentives.for.preventive.actions,.promotion.of.healthy. lifestyle 3. Information/ transparency Education ·. low.student.achievement. ·. publicize.exam.results. ·. low.allocation.of.resources.for.quality.inputs ·. capitation.grants.for.schools.based.on.transparent. formulas,.resources.flows.to.schools.publicized.and. managed.on.performance.metrics,.norms.and.standards Social Protection ·. youth.inactivity ·. more.surveys.and.focus.groups ·. domestic.violence ·. publish.numbers,.promote.non-violent.dispute. resolution.and.women's.groups Cross-cutting ·. leakage.in.social.assistance,.scholarships,. ·. release.population.based.data.on.service.access,. overseas.referrals. effectiveness.and.outcomes 4. Increased voice/ Community Partnerships Education ·. low.student.achievement.and.high.repetition ·. .PTA.role.strengthened,.community.monitoring.of.high- ·. low.secondary.enrollment risk.students. ·. .community.participation.in.secondary.school. expansion. Health ·. high.fertility.and.low.CPR,.high.incidence.of. ·. .use.of.community.health.committees.and.women's. NCDs. groups.in.health.promotion.and.health.monitoring Regional Policy Actions 1 0 This.study.has.focused.on.what.sovereign.governments.can.achieve.within.their. own.borders..However,.some.cases.have.emerged.wherein.a.regional.approach. might.yield.high.benefits,.or.even.improve.outcomes,.and.are.listed.in.Table.8-2.under.the. alignment.lever..This.has.been.the.focus.of.the.Pacific.Plan.exercise.under.the.Pacific.Forum. of.Leaders,.and.their.recent.meeting.in.PNG.91.The.Pacific.Plan.contains.several.initiatives.of. great.importance.to.the.performance.of.social.sectors,.such.as.the.introduction.of.regionally. pooled.procurement,.which.is.also.proposed.in.this.study..Four.policy.initiatives.discussed. in.this.study.have.regional.implications.and.are.worth.highlighting.here: ·. Pharmaceutical procurement:. the. key. is. to. develop. a. mechanism. that. is. more.efficient.than.the.current.practices,.and.thus.avoid.costly.warehousing.and. distribution.in.parallel.with.the.suppliers.themselves.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.101 MOVING.FORwARD.-.NEw.DIRECTIONS.FOR.HuMAN.DEVELOPMENT ·. Natural disaster fund or insurance: as.the.most.disaster.prone.region.in.the. world,.there.would.seem.to.be.opportunities.to.upgrade.the.regional.response. mechanisms.to.natural.disasters,.which.are.largely.in.the.foreign.assistance.mode,. and.to.introduce.a.fund.or.regional.insurance.scheme.. ·. Common financing and strategic frameworks to guide donor assistance:. there. is. ample. evidence. of. excessive. donor. fragmentation. in. the. number. of. projects.supported,.and.the.variety.of.implementation.models,.inside.and.outside. Pacific.government.processes..The.recent.steps.to.improve.coordination.and.full. harmonization.by.sector.are.encouraging.and.need.to.be.refined.and.expanded.to. other.countries.and.sectors. ·. liberalized labor market access:.most.of.the.nine.countries.studied.do.not.enjoy. temporary.or.permanent.arrangements.for.labor.movement.to.and.from.neighboring. OECD.labor.markets..This.was.a.major.focus.of.the.Pacific.Plan.Forum.meeting.in. October.2005,.and.if.progress.is.achieved,.promises.to.have.a.salutary.impact.on. some.countries.with.no.labor.migration.outlets.and.high.under-employment.and. unemployment.rates..Remittances.from.migrants,.in.some.cases,.can.play.a.highly. effective.role.in.helping.families.manage.risk.and.adversity.. 1 1 This. is. a. modest. list,. for. two. reasons.. First,. the. Human. Development. Review. did.not.assess.existing.regional.programs,.but.only.observed.potential.areas.for. regional.action..Thus,.there.are.no.proposals.to.reform.or.change.the.way.regional.programs. now.function..The.Pacific.Island.Forum.has.already.taken.up.this.issue.directly..The.second. reason.for.prudence.in.recommending.regional.approaches.is.the.rigorous.criteria.that. should.govern.regional,.in.lieu.of.national,.solutions..These.have.been.well.presented.by.a. recent.ADB.publication.and.are.summarized.in.Box.8-1: bOX 8-1: lESSONS aND MECHaNISMS FOR PaCIFIC REgIONalISM lessons for Pacific regionalism: ·. Intervene. regionally. only. where. there. are. significant. economies. of. scale.. Avoid. interventions.where.there.are.significant.costs.associated.with.isolation..Sub-regional. provision.may.prove.optimal.in.the.face.of.high.isolation.costs ·. Intervene.regionally.only.where.the.market.cannot.provide.the.good.or.service,.and. where.significant.net.benefits.over.and.above.national.provision.exists ·. Intervene.where.specific.initiatives.are.essential.to.assure.services.are.provided.to.the. smallest.and.poorest.states,.especially.in.the.case.of.interventions.that.will.subsidize. commercial.provision.of.services Mechanisms for Pacific regionalism: ·. Regional.Cooperation.­.meetings,.binding.cooperation,.coverage.of.administrative.and. set.up.costs ·. Regional.Provision.of.Services.­.merging.of.national.services.to.provide.services.at.a. higher.level.and.low.cost,.thus.with.positive.benefits ·. Regional. Market. Integration. ­. lowering. the. barriers. for. movement. of. goods,. services,.and.people.between.countries,.so.that.there.are.more.opportunities.for. firms.and.workers Source: ADB, "Toward a New Pacific Regionalism" p. xvi. 1 2 For.nearly.all.of.the.major.policy.actions.presented.here,.there.is.at.least.one. example,.in.one.of.the.nine.countries.covered.in.this.study,.of.highly.effective. reform..The.Pacific.need.not.look.too.far.a.field.for.inspiration..The.challenge.for.many. countries,.from.the.many.consultations.undertaken.for.this.study,.is.not.increasing.the. knowledge.of.policy.makers,.but.rather.the.more.daunting.prospect.of.undertaking.the. 102.|.wORLD.BANK CHAPTER.8 complex.governance.processes.necessary.to.address.more.intractable.performance.issues.. There.are.options.within.service.expansion,.and.more.so.in.sectoral.management,.but.the. greatest.impact.seems.most.likely.to.be.achievable.within.the.governance.policy.domain.. Perhaps.the.most.complex.example.of.governance.processes.can.be.found.in.the.regional. arena,.where.not.only.ministries,.but.many.different.governments,.must.find.common. ground.on.regional.policy.actions.of.great.mutual.benefit.. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.103 NOTES Notes Chapter 1 1. This.study.is.confined.to.the.nine.world.Bank.member.countries.in.the.Pacific:.Fiji,.Samoa,.Solomon.Islands,.Federated. States.of.Micronesia.(FSM),.Republic.of.Marshall.Islands.(RMI),.Vanuatu,.Tonga,.Kiribati.and.Palau. 2.. The.framework.for.this.report.owes.much.to.the.recent.world.Development.Report.2004,.Making.Services.work.for.Poor. People,.world.Bank.2004..The.accountability.framework.introduced.in.that.report.is.a.key.point.of.departure.for.this. study.of.human.development.in.the.Pacific.Islands.. 3.. This.study.is.confined.to.the.current.world.Bank.member.countries.in.the.Pacific,.as.show.in.Table.1..This.necessarily. omits.important.players.in.the.Pacific,.such.as.New.Caledonia.and.Tahiti.in.French.Polynesia,.Cook.Islands,.Tuvalu,. American.Samoa,.and.others. 4. These. include:. Human. Development. Reports. of. uNDP,. the. ADB. monograph. series. of. macro. country. studies,. ADB. hardship.studies,.ADB.poverty.analyses;.uNICEF.Situation.Analyses,.etc. 5.. The.Asian.Development.Bank.constructed.a.typology.based.on.resources.and.incomes:.low.income,.resource.rich.countries. (Solomon.Islands.and.Vanuatu.in.the.wB.member.countries),.higher.income.countries.(Fiji,.FSM,.Samoa.and.Tonga),.and. other.atoll.countries.(Kiribati,.RMI).. 6.. See.world.Bank,.Migration,.Remittances.and.Brain.Drain.2006.for.global.evidence.on.the.importance.of.remittances.for. social.protection.and.poverty.reduction. 7.. The.framework.for.this.report.owes.much.to.the.recent.world.Development.Report.2004,.Making.Services.work.for.Poor. People,.world.Bank.2004..The.accountability.framework.introduced.in.that.report.is.a.key.point.of.departure.for.this. study.of.human.development.in.the.Pacific.Islands. Chapter 2 8.. Some.caution.with.these.results.is.warranted..GDP.per.capita.in.the.Pacific.does.not.include.the.substantial.external. transfers.that.flow.into.these.economies.and.which.raise.Gross.National.Income.by.as.much.as.twice.the.level.of.GDP,.far. more.so.than.other.developing.economies..GNI.per.capita.would.reduce.the.favorable.picture.in.the.above.figures.. 9.. Since.the.MDG.website.(www.developmentgoals.org).has.very.little.data.on.Pacific.Islands,.the.indicators.were.calculated. using.census.data.over.periods.of.time.to.track.progress.. 10.. A.multi-donor.financed."Pacific.Poverty.Program".designed.to.coordinate.efforts.at.building.poverty.statistics.and.build. demand.for.statistics.has.recently.been.developed.and.is.based.at.SPC. 11. PILL.tests.are.used.widely.in.the.region.for.measuring.basic.literacy.and.numeracy.at.year.4.and.year.6.of.primary.school.. 12.. Elley,.w,."Trends.in.Pacific.Island.education.outcomes,".Background.paper,.Pacific.Human.Development.Review.(2004). 13.. Solomon.Islands.Human.Development.Report,.uNDP.(1999),.world.Bank.mission.reports. 14.. The.wealth.index.used.in.this.paper.is.developed.based.on.the.Filmer.and.Pritchett.(1994).approach.to.measuring. household.wealth.without.income.or.expenditure.data..This.index.is.a.robust.proxy.for.household.long-run.wealth.. The.index.is.derived.by.assigning.weights.to.household.assets.or.housing.conditions.reported.in.household.surveys.or. censuses..The.weights.are.extracted.using.principal.component.analysis..The.first.principal.component,.which.is.simply. the.linear.combination.of.the.household.assets.and.housing.conditions,.is.used.in.this.analysis. 15.. The.definitions.of.unemployment.within.the.census.data.bases.differ.in.some.respects.from.those.used.to.calculate. unemployment.from.labor.force.surveys.due.to.the.limitations.of.the.census.instrument..For.example,.it.is.not.possible. to.distinguish.active.from.inactive.unemployed.in.all.surveys..However,.the.analysis.permits.a.consistent.comparison. between.and.within.countries.of.the.order.of.magnitude.of.unemployment.. 16.. The.working.age.population.is.restricted.to.individuals.aged.15-64.years..Excluded.from.the.labor.force.are:.students,. housewives,.retirees,.disabled.people,.and.prisoners..The.passive.unemployed.(those.who.are.not.actively.looking. for.work).are.also.excluded.when.they.are.identified..The.employed.definition.covers.all.types.of.work.including. subsistence..The.unemployed.are.those.in.the.labor.force,.not.working.and.looking.for.work,.this.applies.to.FSM,. RMI,.Palau,.Samoa,.Fiji.and.Solomon.Islands..For.Tonga.and.Kiribati,.the.unemployed.also.include.those.who.are.not. actively.looking.for.a.job.. 17.. yutaka.Takamine,."Disability.in.East.Asia:.Review.and.ways.Forward",.world.Bank.East.Asia.Human.Development. Department,.May.2004..Takamine.reports.very.high.rates.of.disability.in.Australia.and.New.zealand,.perhaps.linked.to. more.through.surveys.and.also.to.the.benefits.available.to.disabled.workers. Chapter 3 18.. For.a.more.detailed.discussion.of.the.issues.in.this.chapter,.see.world.Bank,."Current.Trends,.Future.Opportunities.. Human.Development.Outcomes.in.the.Pacific.".working.Paper.Series.no..14,.November.2004. 19.. The.public.expenditure.data.for.the.compact.countries.of.Micronesia.may.include.some.donor.assistance.during.the. seven.year.period,.in.that.some.uSA.flows.have.been.fully.integrated.into.the.government's.revenue.stream,.and.are.not. identifiable.by.source.of.finance.. 20.. Barro.(1991),."Economic.Growth.in.a.Cross-Section.of.Countries.".Quarterly.Journal.of.Economics.106(2):407-443;. Pritchett.and.Summers.(1996),."wealthier.is.healthier",.Journal.of.Human.Resources,.31(4):841-868. 21.. world.Development.Report.2004. 104.|.wORLD.BANK NOTES 22.. See.Filmer.and.Pritchet.(1999),."The.impact.on.public.spending.on.health:.does.money.matter?",.Social.Science.and. Medicine.49(10):1309-1323. 23.. See.wagstaff.(2003),."Child.health.on.a.dollar.a.day:.some.tentative.cross-country.comparisons",.Social.Science.and. Medicine. 57(9):1529-1538;. Bidani. and. Ravallion. (1997),. "Decomposing. social. indicators. using. distributional. data",. Journal.of.Econometrics.77(1):125­40;.and.Gupta.et..al.(2003),."Public.spending.on.health.care.and.the.poor",.Health. Economics.12(8):.685-696. 24.. Solomon.Islands.Human.Development.Report,.uNDP.(1999). 25.. Elley.(2004).and.Solomon.Islands.Human.Development.Report,.uNDP.(1999). 26.. "Retention.and.attrition.of.Pacific.school.teachers.and.administrators.(RAPSTA).study",.PREL.(1999). 27.. Rajkumar,.A.and.V..Swaroop.(2004).."Public.spending.and.outcomes:.Does.governance.matter?",.Policy.Research.working. Paper.#2840,.world.Bank. 28.. The.world.Bank..(1994)..Governance:.The.world.Bank's.Experience..washington.D.C. 29.. PREM..(2000)..Reforming.Public.Institutions.and.Strengthening.Governance..A.world.Bank.Strategy..The.world.Bank:. washington,.DC..Annex.5.lists.50.empirical.studies.that.link.various.measures.of.governance.to.economic.growth..See. also.Keefer,.P..(2004).."A.Review.of.the.Political.Economy.of.Governance:.From.Property.Rights.to.Voice"..world.Bank. Policy.Research.working.Paper.#3315,.world.Bank;.and.also.Kaufmann,.D..and.A..Kraay..(2002).."Growth.without. Governance.".Policy.Research.working.Paper.#.2928,.world.Bank. 30.. Knack,.Stephen.and.Gary.Anderson..(1999).."Is.`Good.Governance'.Progressive?".unpublished.manuscript..Quoted.in. PREM..(2000)..Reforming.Public.Institutions.and.Strengthening.Governance..A.world.Bank.Strategy..The.world.Bank:. washington,.DC..p..183. 31.. Burnside,.Craig.and.David.Dollar..(1998).."Aid,.the.Incentive.Regime,.and.Poverty.Reduction..".Policy.Research.working. Paper.No..1937.world.Bank,.washington,.DC.;.and.Dollar,.David.and.Lant.Pritchett..(1998)..Assessing.Aid:.what.works,. what.Doesn't,.and.why..Oxford.university.Press.for.the.world.Bank,.washington,.DC. 32.. Rajkumar,.A.and.V..Swaroop.(2004).."Public.spending.and.outcomes:.Does.governance.matter?",.Policy.Research.working. Paper.#.2840,.world.Bank. 33.. Daniel.Kaufmann,.Aart.Kraay.and.Massimo.Mastruzzi.(2003).."Governance.Matters.III:.Governance.Indicators.for.1996- 2002"..world.Bank.Policy.Research.Department.working.Paper. Chapter 4 34.. Pacific.Islands.Regional.MDG.report,.Secretariat.of.the.Pacific.Community. 35.. This.data.is.drawn.from.Hezel,.F..(2002)..Taking.Responsibility.for.our.Schools..Honolulu:.Pacific.Resources.for.Education. and.Learning,.(PREL). 36.. Most.recent.data.that.could.be.compared.is.only.available.for.1998. 37.. The.PILL.tests.were.developed.in.1990s.a.way.of.assessing.students'.performance.levels.at.year.4.(PILL.1).and.year.6. (PILL.2)..Students.in.eleven.Pacific.Island.Countries.were.tested.in.1994.and.1998..PILL.tests.literacy.in.English.and.the. local.vernacular.language,.and.numeracy. 38.. In.comparison,.in.most.OECD.countries,.teachers'.salaries.represent.60.percent.of.primary.and.secondary.education. spending.. 39.. In.comparison,.experienced.primary.school.teachers.in.OECD.countries.earn.salaries.that.range.just.below.per-capita. GDP.to.around.a.high.of.2.0.times.per-capita.GDP. 40.. Here.children.in.lower.grades.go.to.a.small.feeder.schools.and.older.children.attend.a.central.school..This.ensures.that. small.children.would.not.have.to.travel.long.distances.to.attend.school. 41.. The.common.factor.for.low.PTRs.is.the.proliferation.of.very.small.schools.outside.urban.areas.especially.in.countries.with. dispersed.population.in.RMI.and.Palau.. 42.. Forum.Education.Ministers.Meeting,.Session.Five:.Basic.Education.Finance.in.PFICs..December.2002. 43.. Recognizing.this,.a.workshop.for.senior.curriculum.development.officials.in.the.region,.on."Entrepreneurial.Education",. was.held.in.Fiji.in.April.2005..This.was.preceded.by.consultations.with.the.private.sector.on.curriculum.development. 44.. See.for.example.Pene.F.,.et.al..(2002)..Tree.of.Opportunity:.Re-thinking.Pacific.Education,.uSP.Institute.of.Education,. and.Sanga,.K..et.al..(Eds.)..(2005)..Re-thinking.Aid.Relationships.in.Pacific.Education.. 45.. "Entrepreneurship.Education",.Education.Ministers.Meeting,.Session.Nine,.April,.Sama,.23-24.May.2005. 46.. Samoa.Ministry.of.Education,."Education.Policies,.1995-2005",.p..13 47.. Solomon.Islands.Ministry.of.Education,.".Education.Strategic.Plan,.2002-2004",.p..1 48.. Bert.Creemers.and.David.Reynolds..(1996).."Issues.and.Implications.of.International.Effectiveness.Research"..International. Journal.of.Educational.Research..25(3):.257-266..Ken.Gannicott.and.David.Throsby..(1998).."Educational.Quality.and. Effective.Schooling.".In.Education.for.the.Twenty-First.Century:.Issues.and.Prospects..Paris:.uNESCO.Publishing..pp.. 215-230..David.Reynolds.et.al..(2002).."Creating.world.Class.Schools:.what.Have.we.Learned?".in.world.Class.Schools:. International.Perspectives.on.School.Effectiveness..David.Reynolds,.Bert.Creemers,.Sam.Stringfield,.Charles.Teddlie,. and.Gene.Schaffer,.ed..London.and.New.york:.Routledge-Falmer..pp..276-293..Michael.Rutter.and.Barbara.Maughan.. (2002).."School.Effectiveness.Findings.1979-2002"..Journal.of.School.Psychology..40(6):.451-475..Charles.Teddlie.et. al..(2002).."Comparisons.Across.Country.Case.Studies".in.world.Class.Schools:.International.Perspectives.on.School. Effectiveness..David.Reynolds,.Bert.Creemers,.Sam.Stringfield,.Charles.Teddlie,.and.Gene.Schaffer,.ed..London.and.New. york:.Routledge-Falmer..pp..255-275..J..Douglas.willms.and.Marie-Andrée.Somers..(2001).."Family,.Classrooms,.and. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.105 NOTES School.Effects.on.Children's.Educational.Outcomes.in.Latin.America.".School.Effectiveness.and.School.Improvement.. 12(4):.409-446. 49.. uehara,.L..(1999)..where.Are.The.Teachers?.A.Policy.Report.on.Teacher.Attendance.in.the.Pacific.Region,.PREL,.p..8. 50.. world.Bank,.Making.Services.work.for.Poor.People,.2004. 51.. uNESCO.2001,."understanding.and.responding.to.children's.needs.in.inclusive.classrooms,".Paris. Chapter 5 52.. ADB,.2002. 53.. Seniloli,.2002a.cited.in.MHMS,.2004c.. 54.. Behrman,.Alderman.and.Hoddinott.(2004).provides.a.comprehensive.review.of.much.of.this.literature..Also.see.Strauss. and.Thomas.(1998). 55.. According.to.wHO.(2000),.50.percent.of.diabetes.have.not.been.diagnosed.in.all.countries.in.the.region. 56.. It.should.be.noted.that,.in.Tonga.and.Samoa,.the.lack.of.primary-level.facilities.in.Nuku'alofa.and.Apia,.respectively,. means.that.the.main.referral.hospital.is.the.only.access.point.for.primary.and.preventive.care.for.over.40.percent.of.the. country's.population.. 57.. Household.survey.data.reveals.that.household.out-of-pocket.spending.amounts.to.21.percent.and.23.percent.of.all. health.expenditures.in.Samoa.and.Tonga.respectively.. 58.. ADB,.2003:.FSM.Health.Sector.Review. 59.. So.far,.private.sector.involvement.has.been.limited.to.two.hospitals,.one.each.in.the.capital.cities.of.Samoa.and.Fiji,. and.to.pharmacies,.medical.clinics.and.dental.clinics.in.urban.areas..Most.NGOs.offer.clinics.and.counseling.services. focusing.on.issues.affecting.adolescent.health.such.as.teenage.pregnancy,.alcohol/substance.abuse,.suicide,.and.STDs/ HIV..The.practice.of.traditional.medicine.is.common,.and.patients.often.turn.to.traditional.healers.before.trying.modern. medicine..Churches,.which.have.traditionally.provided.health.services.in.many.developing.countries,.have.a.limited. role.in.service.provision.in.Pacific.Island.countries,.except.in.Solomon.Islands.where.the.Seventh.Day.Adventists.run.a. provincial.hospital.and.other.churches.support.some.primary.facilities.. 60.. Traditional.Healers.may.be.herbalists,.bonesetters,.masseurs,.midwives,.acupuncturists,.psychics,.or.magicians....(Samoa. National.Health.Accounts,.2000/2001,.Government.of.Samoa). 61.. 17.percent.of.traditional.healer's.earning.are.in.cash,.53.percent.as.food.and.30.percent.in-kind.­.clothes,.furniture.and. handicrafts..(Tonga.National.Health.Accounts,.2001/2002,.Government.of.Tonga). 62.. A.Pacific.Public.Health.Surveillance.Network.(PHSN).composed.of.22.ministries.and.departments.of.health.in.Pacific. Island. countries. has. been. in. operation. since. 1995. for. improving. surveillance. of,. and. responses. to. communicable. diseases,.especially.those.that.are.common.in.the.region..In.addition,.risk.factor.surveillance.for.NCDs.(STEPs).has. been.conducted.in.FSM,.RMI,.Samoa,.and.Fiji.and.is.planned.in.Tonga,.Kiribati,.and.Palau..The.member.ministries.are. currently.considering.whether.to.include.NCD.risk.factor.surveillance.in.the.PHSN. 63.. Solomon.Islands.is.planning.to.launch.an.integrated.Household.Income.and.Expenditure.Survey.with.a.complete.health. services.and.status.module,.under.the.auspices.of.the.National.Statistics.Office,.and.funded.by.AusAID.and.NzAID. 64.. "Health.Care.Financing.for.the.Poor.in.Vietnam.".working.Paper.Series.No..2004-8,.Human.Development.Sector.unit,. East.Asia.and.Pacific.Region,.world.Bank.. 65.. This.is.the.pattern.that.was.found.in.the.Samoa.Health.Survey.of.2000.(Government.of.Samoa.and.the.world.Bank,.2005). 66.. Adverse.selection.refers.to.the.tendency.of.those.with.poorer.health.status.to.enroll.in.voluntary.health.insurance. schemes..Over.time,.adverse.selection.drives.up.the.cost.of.providing.benefits.to.those.insured.in.voluntary.health. insurance.schemes,.often.forcing.such.schemes.to.raise.premiums,.which.of.course.further.limits.the.enrollment.of.those. with.poor.health.status. 67.. Clients.in.clinics.in.Fiji,.RMI.and.Tonga.claimed.that.time.(work.and.family.commitments).and.costs.of.travel.prevented. them.from.regularly.attending.clinics.for.monitoring.and.general.follow-up..Compliance.with.recommended.diet.and. exercise.regimes,.and.post.surgery.follow-ups.were.also.low.(Beaver,.C,.2003). Chapter 6 68.. In.2003,.21.percent.of.traffic.accidents.and.11.percent.of.non-hospitalized.causalities.in.Fiji.were.related.to.alcohol.use.. In.Tonga,.tobacco.and.alcohol.were.responsible.for.10.4.percent.of.the.NCD.hospital.admissions.and.19.6.percent.of.all. hospital.expenditure.in.2002..The.Secretariat.of.the.Pacific.Community.report.http://www.spc.int/AC/Tobacco/tobacco_ alcohol_country.also.indicates.increased.teenage.drinking. 69.. The.first.large-scale.study.conducted.on.violence.against.Pacific.Island.women,.which.was.carried.out.in.Samoa.in.2000. by.SPC.and.the.united.Nations.Population.Fund.(uNFPA),.reported.that.alcohol.was.the.second.most.frequent.cause.of. violence.towards.women 70.. Brown,.R.,.D..Headey,.and.G..Leeves,.2004. 71.. The.regression.analysis.includes.95.developing.countries.and.allows.for.an.analysis.of.the.effect.of.several.factors.on.real. GDP.growth.. 72.. yearly.rainfall.data.was.used.to.generate.rainfall.volatility.data,.but.also.to.generate.rain.shocks..Positive.(`floods').and. negative.(`droughts').rain.shocks.were.generated.by.regressing.the.yearly.rainfall.data.against.a.time.trend..(That.is,. we.assumed.climate.change.rather.than.constant.mean.temperatures..In.fact,.the.coefficient.on.time.was.significantly. different.from.zero.in.most.of.the.eight.regressions.).The.residuals.from.these.regressions.were.then.used.to.measure. 106.|.wORLD.BANK NOTES shock. years. which. were. arbitrarily. defined. as. years. in. which. rainfall. was. one. standard. deviation. above. the. trend. (predicted).value.(to.give.`floods').or.one.standard.deviation.below.(to.give.`droughts').. 73.. In.this.report,.transfer.income.refers.to.those.components.of.disposable.income.that.are.not.included.in.the.usual. measures.of.GDP..These.are:.net.factor.income.(NFI),.which.is.recorded.in.the.current.account.of.the.balance.of.payments. and.when.added.to.GDP.yields.the.gross.national.income.(GNI).measure;.and.net.(unrequited).current.transfers.(NCT),. which.include.aid.transfers.in.the.form.of.grants.(mainly.to.governments.from.donors.).and.private.remittance.transfers. (mainly.to.households.from.migrants.living.abroad). 74.. Pacific.leaders.meeting.in.Papua.New.Guinea.in.October.2005.presented.to.the.Forum.a.request.that.temporary.work. arrangements.be.considered.for.Pacific.Island.country.workers.in.Australia.and.New.zealand. 75.. Fiji.Police,."Crime.Statistics.Report,.2001",.Suva.2002,.p..41. 76.. Pacific.Islands.Report,."28.percent.of.Fijians.live.in.poverty",.November.27,.2005. 77.. The.main.instrument.for.mobilizing.disaster.relief.in.the.Pacific.is.FRANz,.which.coordinates.disaster.response.between. the. development,. disaster. response. and. foreign. affairs. entities. of. France,. Australia. and. New. zealand.. The. united. Nations.Disaster.Assessment.Team.(uNDAC).deploys.a.Pacific.team..Other.uN.agencies,.donors.and.NGOs.provide.relief. and.reconstruction.assistance..Regional.organizations.such.as.the.Pacific.Disaster.Center.at.the.East.west.Center.are. specialized.in.information,.research,.training,.and.warning.systems. 78.. After.school.programs.and.training.teachers.to.deal.proactively.with.children.`at.risk'.are.examples.of.targeted.supply- side.programs.that.can.be.effective..However,.if.families.are.motivated.primarily.by.economic.considerations,.such.as.the. cost.of.schooling.and.transport,.demand-side.interventions.may.hold.more.promise.of.success. 79.. Rawlings.and.Rubio,.2003.and.Barrientos.and.DeJong,.2004 80.. world.Bank,."Improving.Development.Outcomes.in.the.Pacific.from.Labor.Mobility",.workshop.in.Suva,.November.2005 81.. For.a.useful.review.of.the.Pacific.remittance.literature,.see.Connell,.John.and.Brown,.Richard,."Remittances.in.the.Pacific:. An.Overview",.Asian.Development.Bank,.March.2005. 82.. Recent.survey.results.show.that.all.migrants,.even.the.poor,.remit.and.that.even.households.with.no.migrants.receive. remittances. 83.. world.Bank,."Improving.Development.Outcomes"..The.data.is.from.a.recent.household.survey.conducted.in.Tonga.and. in.Fiji.with.support.from.AusAID.and.the.world.Bank..Other.results.show.broadly.positive.household.impacts.from. remittances.in.Fiji.and.Tonga,.including.on.education.levels.of.children,.on.managing.health.shocks,.and.on.investment. and.savings.of.the.household.. 84.. The.world.Bank.has.just.published.a.report.on.migration,.Migration,.Remittances.and.the.Brain.Drain.(washington,. 2005),.which.argues.that.smaller.and.poorer.economies.suffer.the.highest.proportion.of.educated.migrants..The.Pacific. may.not.conform.universally.to.this.finding. 85.. Provident.fund.analysis.for.the.Pacific.countries.is.scarce,.but.problems.with.governance.and.returns.are.widely.noted.for. provident.funds.in.the.published.sources..See.John.A..Turner,."Social.Security.Development.and.Reform.in.Asia.and.the. Pacific",.discussion.paper.PI-0203,.Pension.Institute,.university.of.London,.2002;.and.world.Bank,.Averting.the.Old.Age. Crisis,.New.york.1994,.Chapter.6,.for.reviews.of.Pacific,.Asian.and.Caribbean.provident.funds..Also,.Robert.Holzmann.et. al,."Pension.Systems.in.East.Asia.and.the.Pacific:.Challenges.and.Opportunities",.Social.Protection.Discussion.Paper.No.. 0014,.June.2000.. 86.. Sector.background.papers.written.for.Kiribati,.Vanuatu,.Fiji,.and.RMI.utilize.some.of.the.analytical.techniques.that.could. be.employed.in.strategic.exercises,.but.the.building.of.consensus.and.support.around.such.a.strategy.would.be.part.of.the. political.process.. 87.. wHO.recently.announced.results.of.a.10.country,.15.site.survey.of.domestic.violence,.based.on.highly.specific.questions,. and.with.one.Pacific.island.country.included,.Samoa..See."wHO.Multi.Country.Study.on.women's.Health.and.Domestic. Violence.Against.women",.November.2005.. Chapter 7 88.. Average.of.the.proportions.shown.in.Figure.1..If.absolute.values.are.used,.the.regional.proportion.drops.to.41.percent,. still.high.. 89.. The.average.number.of.donors.per.country.recipient,.globally,.was.fourteen.in.2000..See.world.Bank,.world.Development. Report.2004..Making.Services.work.for.the.Poor..washington.DC.2003,.p..207 Chapter 8 90.. youth.unemployment.rate.is.an.MDG.indicator.within.the.goal.of.increased.international.cooperation.. 91.. Pacific.Island.Forum.Secretariat,."A.Pacific.Plan.for.Strengthening.Regional.Cooperation.and.Integration",.September. 2005;.Asian.Development.Bank.and.Commonwealth.Secretariat,.Toward.a.New.Pacific.Regionalism,.2005. Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.107 BACKGROuND.PAPERS Background Papers Prepared for the Study General Brown,.R.,.D..Headey,.and.G..Leeves,.2004..Macroeconomic.Volatility.in.the.Pacific:.A.cross-country.comparison. of.magnitude,.sources.and.consequences. Elley,.w.,.2004..Trends.in.Pacific.Island.Education.Outcomes.. Fares,.J.,.2004..Migration.and.Human.Development.in.the.Pacific.Islands:.Issues.Note.. Menon,.R.,.C..Chamberlin,.E..Suliman,.R..Krech,.and.N..Ohno,.2004..Current.Trends,.Future.Opportunities:. Human.Development.Outcomes.in.the.Pacific.Islands.­.Findings.from.Census,.Survey.and.Budget.Analysis.. working.Paper.Series.No..2004-14,.world.Bank. Fiji Moock,.P.,.I..Collingwood,.and.E..Suliman,.2004..Education.Sector.Report:.Fiji. Fares,.J.,.and.K..Subbarao,.2004..Social.Protection.Sector.Report:.Fiji. Mangyo,.E.,.et.al.,.2005..Report.on.Gender.and.Disability.in.Fiji.. Kiribati Knowles,.J.,.and.E..Suliman,.2004..Health.Sector.Report:.Kiribati. Chamberlin,.C.,.M..Brovnik,.and.E..Suliman,.2004..Social.Protection.Sector.Report:.Kiribati. Harris,.B.,.2005..Report.from.Interview.with.Focus.Groups.at.Bonriki.Village,.South.Tarawa,.Kiribati.. Chamberlin.C.,.2004..Human.Development.Review.of.the.Pacific.Islands.Country.Case.Study:.Kiribati. Marshall Islands Gannicott,.K.,.R..Krech,.and.B..Graham,.2004..Education.Performance.in.the.Republic.of.Marshall.Islands. Beaver,.C.,.N..Ohno,.and.B..Graham,.2004..Health.Sector.Report:.Marshall.Islands.. Chamberlin,.C.,.M..Brovnik,.and.B..Graham,.2004..Social.Protection.and.Risk.Minimization.in.Republic.of.the. Marshall.Islands Chamberlin,.C.,.2005..Human.Development.Review.of.the.Pacific.Islands.Country.Case.Study:.Republic.of.the. Marshall.Islands.. Solomon Islands Mangyo,.E.,.et.al..2005..Report.on.Gender.and.Disability.in.Solomon.Islands.. Tonga Collingwood,.I.,.and.R..Goonesekere.2005..Education.Sector.Report:.Kingdom.of.Tonga.. Nandakumar,.A..K.and.R..Menon..2005..The.Health.System.in.Tonga:.An.Assessment Vanuatu Gannicott,.K.,.and.E..Suliman,.2004..Education.Sector.Report:.Vanuatu. Harvey,.R.,.and.E..Suliman,.2004..Health.Sector.Report:.Vanuatu.. Chamberlin,.C.,.and.E..Suliman,.2004..Social.Protection.Sector.Report:.Vanuatu.. Knowles,.J.,.2005..Human.Development.Review.of.the.Pacific.Islands.Country.Case.Study:.Vanuatu. Sum,.J.,.2005..Vanuatu.Qualitative.Country.Study. 108.|.wORLD.BANK Opportunities.TO.IMPROVE.SOCIAL.SERVICES.|.109 110.|.wORLD.BANK