Monday, April 21
Grant Miller: Managerial Incentives in Public Service Delivery
Romani, John H., and Barbara A. Anderson. 2002. "Development, Health and the Environment: Factors Influencing Infant and Child Survival in South Africa." PSC Research Report No. 02-525. August 2002.
A central objective of economic and social development programs is improving the health status of the population. Good health is viewed not only as important in its own right, but healthy populations are seen as having a greater potential for productive economic activity that contributes directly to poverty reduction. Since a common measure of the health status of a society is its infant mortality rate, infant and child survival takes on a special importance for families, communities and countries in the developing world.
When the new South African government came to power in 1994 it made improvement of maternal and child health a major priority. Analysis of data from the 1994 October Household Survey showed that for African children, access to clean water was the most important factor in survival. For Coloured children, almost all of whom had clean water, sanitation played a key role in survival.
Since improvements in infant and child health are related to the conditions of life, it is relevant to examine changes in the lives of South Africans. Between 1994 and 1999 some things improved for rural Africans, the most disadvantaged group. The percentage with electricity in their residences increased. The percentage of rural Africans with clean water increased from 51% to 61%. Although this increase is substantial, it falls short of the pace of change that many had expected. There was virtually no change in sanitation.
The nature of health care facilities is also relevant to infant and child health. Many new clinics have been constructed and facilities have been upgraded, but there are continuing deficiencies in the public clinics. While 80% of the South African population uses public clinics for their health care, the 20% of the South African population who use private health care obtain services on a par with the best available anywhere in the world.
Compounding the task of meeting this challenge is the HIV/AIDS epidemic and its impact on the allocation of resources among competing development initiatives. One issue is the proportion of the overall budget devoted to health programs. Increasing health expenditures could limit investments in other areas that affect infant and child survival. A second matter is the proportion of Department of Health resources allocated to HIV/AIDS. Malaria continues to be a problem, and there have been recent outbreaks of cholera. Over 1/3 of the nation's children are not fully immunized. Shifting resources from these areas could create greater future problems for the public's health.
It is, however, in the interests of those concerned about child and infant health to argue that everything in this area is directly related to the HIV/AIDS epidemic. This strategy places those involved in a favorable position in relation to external and internal donors with specialized interests in HIV/AIDS. It further strengthens the push to give priority in internal public budgeting to such programs because of their centrality in dealing with HIV/AIDS.
Somewhat overlooked are some other realities. The decision in 1994 to alter the structure and processes of governance as a first step in reform of South African society meant that the reordering of economic and social conditions would occur within a democratic framework. Decisions now require extensive negotiations with numerous stakeholders. This has led to an increased politicization of the decision-making processes as well as slower progress towards the goal of a more equitable society. While this is neither unexpected nor undesirable, the task of dealing with the fundamental issues of sustainable development has been made more complicated.
A growing impatience with what has been accomplished is one consequence of this earlier decision. This is not to suggest that what was done was inappropriate. Rather it is to note that choices lead to consequences that become part of the new context in which economic and social development will take place. The emerging concern with the lack of immediate improvement in economic and social conditions as reflected in the continued presence of high levels of income inequality along with increased pressures to meet special interests are central elements in this new context. Those responsible for governance must take care that resources are allocated in a manner that recognizes the inter-relatedness of the economic and social development processes. Only in this fashion can both the particular needs of child and infant health be met as well as those of the country as a whole.