Acknowledgements

This report was written by Swati Narayan.

Special thanks for invaluable comments and inputs to Jean Drze, Bethan Emmett, Ben Phillips, Kate Raworth,
Balasubramanyam Muralidharan, Sarah Ireland, Sunitha Rangaswami, Anne Lancelot, Christian Dennys, Rajiv
Dua, Cherian Mathews, Ronnate Asirwatham, Prasen Jit Khati, Farid Hassan Ahmed, Madhusree Banerjee, Leslie
Browne, K. M. Enamul Hoque, Shipra Saxena, Jo Walker, Gopa Kumar, Kiran Bhatty, Tom Noel and Indivar
Mukhopadhyay. Thanks also to Anil Prabhakar Tambay, Jo Zaremba, Kate Simpson, K.A. Jahan Rume, G
Shantakumari, Kavita Gandhi, Divya Mukund, Basira Mojaddidi, Medha Soni and Roshani Yogaraja for sourcing
photographs.

The report was copy edited by Jacqueline Smith and designed and printed by Mensa Computers Pvt.Ltd, New Delhi;
mensa@vsnl.com

Oxfam International 2006

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Front cover images:

Child using a water tap at standpoint built near
campsites built after the earthquake at Gahridupatta
Muzaffarabad
Oxfam GB/ Pakistan/2006

School students studying in the open air in Badakshan

province
Basira Mojaddidi/Oxfam GB/Afghanistan/2006

Health service provider administering an injection to a

child at a dispensary/sub center in Bharatpur district,
Rajasthan, India
Oxfam GB/India/2006

Back cover image:

Government dispensary/sub-centre in Bharatpur district,
Rajasthan where a delivery had taken place the previous
night
Oxfam GB/India/2006
 Serve the Essentials
What Governments and Donors Must Do to Improve
South Asias Essential Services

International
 Foreword

One of the central insights of development economics is the importance of human capabilities,
both as an end and as a means of development. At early stages of development, capabilities
related to nutrition, health and elementary education are of special importance. For instance,
literacy and education (especially female education) make wide-ranging contributions not only to
economic growth but also to demographic change, social equality, political democracy, and many
other aspects of development. Similarly, good health is a fundamental basis of the quality of life
as well as of social progress.

Further, both theory and evidence point to the importance of public services in these fields. Economic
theory draws attention to pervasive market failures in the private provision (especially unregulated
provision) of essential services such as health care and elementary education. Empirical evidence
suggests that rapid reductions in undernutrition, illiteracy, ill health and related deprivations are
typically based on extensive public action. This pattern can be seen in South Asia itself, whether we
look (say) at Sri Lankas lead vis--vis other South Asian countries, or at Keralas outstanding
achievements vis--vis other Indian states.

This report presents an insightful assessment of essential services in South Asia, with special
focus on health and education. In this as in many other fields of social enquiry, the comparative
perspective is of great value, and the report makes excellent use of this perspective by scrutinizing
regional contrasts in South Asia between as well as within countries. Somehow, this comparative
South Asian perspective has been overlooked in development studies. For instance, an Indian
economist or sociologist is much more likely to compare India with, say, China or the United
States than with Bangladesh or Sri Lanka. Yet there is a great deal to learn from looking around
us within South Asia. For instance, I am sure that many development experts in India would be
surprised and interested to learn that private schools have been banned in Sri Lanka since the
1960s, or that in Sri Lanka few people live more than 1.4 km away from the nearest health
centre.

On the prescriptive side, this report argues that the state has an inalienable responsibility to
provide universally accessible and robust public delivery systems for essential services. In this
respect it is a useful antidote to the current passion for targeting, user fees and other means of
rationalizing (read downsizing) public services in developing countries. One can argue about the
precise range of services that should be provided through free and universal public facilities.
But when it comes to basic entitlements such as primary education and health care, I believe that
this is indeed the best approach. And it is certainly important to reaffirm the notion that ensuring
universal access to essential services is a social responsibility. This is, indeed, the central principle
of the welfare state.
There is an important complementarity between this emphasis on free and universal public services
and the rights approach to social policy. In this approach, essential services such primary
education and health care are seen as fundamental rights of all citizens, rather than as a form of
state largesse. The rights approach can be of great value in shaping public perceptions of the
social responsibilities of the state. It also draws attention to the possibility of legislative action
to ensure that some essential services become enforceable legal entitlements.

Recent experience in India provides rich illustrations of the value of a rights approach to social
policy and essential services. Wider acknowledgement of elementary education as a fundamental
right of every child (recently expressed in the 86th constitutional amendment) has contributed to
the rapid expansion of school education in the nineties. The Right to Information Act 2005 has
lifted the veil of secrecy from government documents, a major step towards restoring accountability
in public life. Supreme Court orders on the right to food have forced the Central and State
Governments to take major initiatives in this field, such as the provision of cooked mid-day meals
in primary schools. Last but not least, the National Rural Employment Guarantee Act 2005 has
empowered rural labourers to demand work as a matter of right and reversed the long-standing
neglect of rural employment in public policy. In the light of these experiences, there is a strong
case for extending the rights approach to many other domains.

India often becomes the centre of attention in South Asia, and some readers may feel that this
Foreword also fell into that trap. Let me admit it I have never been to Bangladesh or Sri Lanka,
let alone Afghanistan. This report, however, has motivated me to take more interest in other
South Asian countries. Indeed, it shows that India has much to learn from its neighbours just
like every other country in the region.

Jean Drze
Delhi School of Economics

Jean Drze, eminent economist and social activist, is Honorary Professor at the Delhi
School of Economics and former member of the National Advisory Council of India. He has
co-authored a number of books with Amartya Sen, including of Hunger and Public Action
(1989) and India: Development and Participation (2002). He is also active in the Right to
Food Campaign, the National Campaign for the Peoples Right to Information and other
social movements in India.
 Table of Contents

Executive Summary i

1. Essentials of Essential Services in South Asia 1

A. Divergent Paths Since Freedom at Midnight 2
Increased Spatial Inequality 2
South Asia will Make or Break the MDGs 2

B. Education: Time to Go Back to the Basics 3

Higher Education at the Cost of Basic Education? 4
Gender Disparity 4

C. Health: Hastening the Revolution 4

Highest Vulnerability: Maternal and Child Deaths 5
Medical Revolution Easily Within Reach 5

D. Water: Safety and Sanitation 5

Water Water Everywhere 6
Paradoxes of H2O 6
Sanitation Woes 6

Reflection: Development Challenges for South Asia 6

2. What Works? The Case for Universal Public Provision 8

A. The State in Action 8
Commitment to Public Action 8
Political Will to Make a Difference 9
Policy Space for Public Action 10
Commitment Translates into M.O.N.E.Y 11

B. Equity and Efficiency 11

Prioritise Primary Services 11
Non-Salary Recurrent Expenditure 12
Investing in Quality Service Providers 12
Free Services for All 13
Pro-Poor Policies 14

C. Capture Natural Synergies 15

D. Women as Change Agents 15

Reflection: Formula for Success 17

3. Whats Holding Others Back? 18
A. Incapacity 18
Public Delivery Systems: Need to Make them Extra Large 18
The Missing Millions Many More Teachers and Nurses Wanted 20

B. Inefficiency: Need Quality Improvements 21

Teachers, Doctors and Nurses Absent: Schools and Hospitals Not Fit to Work in? 21
The Vicious Tentacles of Corruption 22
Vertical Programmes 23

C. Inequality 25
The Human Face: Poverty, Caste, Class, and Gender 26
Why Subsidise the Rich? 27
Killer Fees 28

Reflection: Need to Rebuild Public Delivery Systems 29

4. How to Make a Big Dent 30

A. Get the Politics Right 31
i. Abolish killer fees: eliminate both direct and indirect end-user costs 31
ii. Universal access rather than poor targeting 32
iii. Fight corruption 33
iv. Make services gender-sensitive 34

B. Build Capacity in Public Systems 34

i. Financial priorities 35
- More money! 35
- Prioritise non-recurrent salary spends and primary services 36
ii. Invest in public systems: There are no quick fixes or magic bullets! 37
- Horizontal and vertical programmes 37
- Regulate the non-government and private players 37
iii. Rebuild the Public Service Ethos 38
- Pay suitable salaries, fill vacancies, and improve working conditions 38
- Create rural bias and invest in nurses and midwives 39

C. Work with Others 39

Civil Society as Symbiotic Partners 40
Community Involvement and Ownership 41

Reflection: Recommendations to Policy Makers 42

Endnotes 45
List of Tables
1 A balance sheet for human development and access to essential services i
2 South Asia expected to miss many MDG goals 3
3 Ratification of human rights treaties by South Asian countries 7
4 Population without access to improved water and sanitation 19
5 Most corrupt countries 22
6 Out of pocket expenditure as user fees for health 28
7 Current shortage of public sector workers 39

List of Figures
1 A comparison of poverty across South Asias national boundaries 1
2 Global likelihood of achieving MDG 3: eliminating gender inequities in 4
primary and secondary enrolments
3 Male relatives wait anxiously outside one of the few health clinics in Badakshan 5
4 Proportion of population using improved sources of drinking water 6
5 Flood-affected population in Bihar during the floods in 2003 without
access to safe drinking 6
6 A squatter area next to a heavily polluted river, Kathmandu, Nepal 6
7 Income and social development indicators: Pakistan and Bangladesh 9
8 Total enrolments in primary and secondary education under successive 10
governments in Bangladesh, 1950-2000
9 Number of primary schools in Sindh province of Pakistan, 1980-2000 10
10 Health expenditure as a percentage of GDP 1978-1993 11
11 Indicative workforce distribution patterns in Sri Lankas health care 12
system based on representative samples
12 Distribution of health payments and subsidies by income decile, Sri Lanka, 1995/96 14
13 Sri Lanka infant mortality rate per 1,000 live births 19462000 15
14 Growth of secondary school enrolment in Bangladesh, 19702003 16
15 Raku Devi, Samda Devi, and Champa informally visit health centres to inspect 17
the delivery of essential services in rural Rajasthan
16 Where do the 100 million out-of-school children live? 18
17 A temporary shelter/tent used as a girls school in Afghanistans Badakshan Province 19
18 Dhaka residents queue to collect clean water from a private water tanker 19
19 A multi-grade classroom in Uttar Pradesh, India where the teacher is 20
attempting to teach students of different grades simultaneously on two
different sides of the blackboard
20 The equipment used in a community health centre in Bharatpur district in 21
India for a delivery conducted the previous night
21 Ill-maintained X-ray facilities in a district hospital in Nepal 23
22 A noticeboard outside a health centre in Wardak managed by the NGO Swedish 23
Committee for Afghanistan
23 Government sub-district health complex, Rowmary, Kurigram 24
24 Free primary school, Rowmary, Kurigram 24
25 Difference in the educational attainment on the basis of wealth and gender
in South Asian societies 26
26 Percentage of hospitalised Indians falling below the poverty line from medical costs, 1995-96 29
27 How long will South Asia take to achieve the Millennium Development Goals? 30
28 Prevalence of child malnutrition in South Asia 32
29 A sign displaying the seeds given to a village affected by Bangladesh floods to sow crops by 33
Oxfams partner SKS and technical assistance by Padakhep Manabik Unayan Kendra
30 Women queuing in the waiting room of a primary heath clinic in Wardak, Afghanistan 34
31 Overseas Development Assistance (ODA) received as a percentage of GDP 35
32 United States assistance to Afghanistan 35
33 Intrasectoral public expenditure on education across South Asia 36
34 Real value of salaries of teachers in Sri Lanka in relation to other government 38
employees (1978 = 100)
35 Oxfam laying pipes for water connections to hand over to the Batticloa Water Board 40
36 Community working together for installation of sanitary latrine RSDA, 41
Kurigram in Bangladesh

List of Boxes
1 African Wave of Scrapping User Fees 13
2 If not for this government school, I would have never gone to school 14
3 Pull Girls into Primary Schools by Providing Incentives in Secondary Education 16
4 Informal Community Inspectors Monitor their Rights to Essential Services 17
5 Hierarchies of Access: Contract Teachers in India 20
6 Corruption Highest in Schools: Rs 4137 crore ($ 920 million) Paid in Bribes 22
7 Securing Basic Services for Sand Bank Dwellers of Bangladesh 24
8 Community Contribution for Water Supply Affects Women 25
9 Poor People Reduce Their Visits to Government Health Clinics with User Fees 28
10 Right to Information 33
11 Innovative Tax on Every Bar of Soap and Haircut Feeds Children in Indian Schools 36
12 Upgrade and Support Rather than Replace Government Services 40
13 NGO Eyes Monitors Government Services 41
14 Citizen Action Builds Accountability 42
Acronyms and Abbreviations
ADB Asian Development Bank
ANMs Auxiliary Nurse-Midwives
APL Above Poverty Line
ARDWSP Accelerated Rural Drinking Water Supply Programme (India)
ASER Annual Status of Education Report (India)
ASHA Accredited Social Health Activist (India)
BHUs Basic Health-Care Units (Pakistan)
BPHS Basic Package of Health Services (Afghanistan)
BPL Below Poverty Line
CABE Central Advisory Board of Education (India)
CAGR Compounded Annual Growth Rate
CAMPE Campaign for Popular Education (Bangladesh)
CCT Conditional Cash Transfer
CEDAW The Convention on the Elimination of All Forms of Discrimination Against Women
CERD The International Convention on Elimination of all forms of Racial Discrimination
CHV Community Health Volunteer (India)
CLTS Community Led Total Sanitation (Bangladesh)
CMP Common Minimum Programme (India)
CRC Convention on the Rights of the Child
DOTS Directly Observed Treatment Short Course
DPHE Department of Public Health Engineering (Pakistan)
DWSSA Dhaka Water Supply and Sewerage Authority (Bangladesh)
EFA Education for All
EPI Expanded Programme on Immunisation
FFE Food for Education (Bangladesh)
FSSP Female Secondary Stipend Programme (Bangladesh)
GATS General Agreement on Trade in Services
MDG Millennium Development Goal
GCE Global Campaign for Education
GNI Gross National Income
ICCPR The International Covenant on Civil and Political Rights
ICDS Integrated Child Development Services (India)
ICESCR International Convention on Economic Social and Cultural Rights
IIT Indian Institute of Technology
LGRDD Local Government and Rural Development Department (Pakistan)
LHW Lady Health Worker (Pakistan)
LTTE Liberation Tigers of Tamil Ealam
MKSS Mazdoor Kisan Shakti Sangathan
MMR Maternal Mortality Ratio
MOPH Ministry of Public Health (Afghanistan)
NGO Non Governmental Organisation
NGOCCEFA Collective Consultation of NGOs on Education for All
NGRPS Non-Government Registered Primary Schools
NHRM National Rural Health Mission (India)
NRSP National Rural Support Programme (Pakistan)
NSS National Sample Survey (India)
NWPF North West Frontier Province (Pakistan)
NWSC Nepal Water Supply Cooperation
OBC Other Backward Caste (India)
ODA Overseas Development Assistance
PEPP Primary Education Planning Project (Sri Lanka)
PHC Primary Health Care Centre (India)
PHED Public Health Engineering Department (Pakistan)
PIO Public Information Officer
PMA Pakistan Medicial Association
PNA Pakistan Nursing Association
PTA Parent Teacher Association
RHC Rural Health Centre
RNGPS Registered Non-Government Primary Schools (Bangladesh)
SAARC South Asian Association for Regional Cooperation
SMCs School Management Committees
TB Tuberculosis
TBA Traditional Birth Assistant
TWAD Tamil Nadu Water Supply and Drainage Board (India)
UMBVS Urmul Marusthali Bunkar Vikas Samiti (UMBVS)
UPA United Progressive Alliance (India)
UPPSS Uttar Pradesh Primary School Teachers Association
VECs Village Education Committees
YSWO Young Sheedi Welfare Organisation (Pakistan)
WFP World Food Programme
WSSD World Summit on Social Development
 Executive Summary

The boatman stands to declare

That the ship is in the midst of a storm

Shah Hussain,
17th Century Punjabi Sufi Poet (Translation)

THE GOOD, THE BAD AND THE UGLY

South Asia is a melting pot of contrasts. Three hundred and forty children die every single day in
Bangladesh due to untreated diarrhoea, but an average person in Sri Lanka can expect to live for
74 years. Thirty million children across South Asia who stay at home, work on farms, or beg at traffic
lights are out of school, while thousands of government-subsidised highly educated doctors and engineers
work in foreign countries. Nepal, Pakistan, and Afghanistan have a horrific record of deaths of pregnant
women and infants, while Indias private hospitals are a favoured destination for medical tourism,
attracting 150,000 foreign patients every year. These tragic inequalities resonate across South Asia.

While South Asia is witnessing unprecedented prosperity and growth, basic human development for
the vast majority is not happening. The region is expected to miss many of the Millennium Development
Goal (MDG) targets, and governments need to uphold the basic rights to essential services. Well-
planned actions need to be implemented on a mammoth scale to improve the delivery of education,
health, water, and sanitation. There are some examples of good practice within the region itself that
provide hope and demonstrate beyond a doubt that a mixture of the right policies and sincere political
commitment can indeed change the daily tragedies of impoverished communities.
Table 1: A Balance Sheet for Human Development and Access to Essential Services

What Has Progressed What Remains Deprived

India In 2004, universal education cess (tax
on all taxes) started to fund education
initiatives, including cooked midday
meals in every government school
Increased successful treatment of
tuberculosis cases from 3 out of 10 cases
to 8 out of 10 between 1993 and 2001
Water coverage in rural habitations
increased from 56% to 95% between
1995 and 2004
In 2002, 14 million school-age children
were out of primary school and the drop
out rate in primary education was 38%
80% of total health financing is from out-
of-pocket expenses of end-users and the
poorest 20% have double the mortality
rate of the richest quintile
Even if the MDG targets are achieved in
2015, 500 million people will lack access
to sanitation and 334 million access to
safe water

Pakistan The literacy rate increased from 33% in
1990 to 46% in 1999
38% of children are malnourished, which
is marginally better than most of the
other countries under study from South
Asia, except Sri Lanka
In 2002, 90% of the population had
access to improved drinking water
More than one-third of children are out
of school
Half the population do not have access
to health care and there is only one
nurse for every eight doctors
46% are without access to adequate
sanitation

i
 What Has Progressed
Bangladesh Increased primary school enrolment from
73% to almost 100% from 1990 to 2004,
and achieved gender parity in primary and
secondary education by 2005
In Bangladesh, the infant mortality rate
dropped dramatically: from 145 to 46 per
1000 live births between 1970 and 2003
Population with sustainable access to
improved sanitation increased from 23%
to 48% between 1990 and 2002
Sri Lanka Tuition fees from kindergarten to
university were eliminated in 1945, free
textbooks have been available since 1980
and free school uniforms from 1993
90% of child deliveries take place in a
public health facility by a skilled birth
attendant, health services are free and
few people live more than 1.4 km from
their nearest health centre
High mortality rates in urban areas and
estate plantations were partially
addressed through concerted efforts to
build water and sanitation facilities
Afghanistan Since the fall of the Taliban in 2001,
there has been a 400% increase in
school enrolments (up to 2005)
Measles claimed an estimated 30,000
lives a year, but a campaign in 2002
vaccinated 11 million children, which has
stopped the epidemic transmission
Nepal In 2002, community management of
schools by parents and local citizens has
been restarted, including their right to fire
government teachers and to index teacher
salaries to school performance
Community consultation in the $500
million Melamchi project has reduced
average connection cost and introduced
low cost tariff for the first ten cubic metre
with incremental increases by volume
With the recent end of monarchy, the new
draft constitution intends to guarantee free
universal access up to secondary
education and primary health care
ii
What Remains Deprived
In 2001-2002, the drop-out rate from
primary education was 45%
There is a 40% vacancy rate in doctor
postings in poor areas, with a
concentration of health workers in urban
centres
Arsenic in shallow tube-wells found in 59
out of the 64 districts has exposed an
estimated 25 million people to toxins
The midday meal programme,
restarted in May 2006, is not
universally applicable, and it is
targeted only to grade one and two of
7,384 schools in the poorest districts
Recent escalation in conflict in August
2006 has resulted in schools across the
country being closed for two weeks
In Jaffna in the last two decades of
conflict, maternal mortality rates have
increased ten-fold and are 10 times
that in Colombo
In 2002, 22% of the population was
without access to improved drinking
water
More than half the schools are in need
of major repair while 2 million students
study in tents or in the open air
Afghanistan currently has just over 800
Basic Health Units (BHCs) in total, but
it is estimated to need almost 6000
87% of the population are without
access to safe drinking water and 92%
without access to adequate sanitation
More than one-third of children stay out
of school
Only 20% of rural medical posts are
filled as compared to 96% in urban
areas
73% of the population are without
access to adequate sanitation
THE WOWS! AND THE HOWS...
In a mere seven years (194653), life expectancy in Sri Lanka increased by an incredible 12 years. In a
matter of decades, the Indian state of Himachal Pradesh not only ensured that every child is enroled
in school but also that they remain in school, by reducing the drop-out rate to 1 per cent, as compared
with the national average of 35 per cent. Similarly concerted government action has ensured that in
Bangladesh in the last few decades the infant mortality rate has fallen by two-thirds.

What are some of the key lessons from these remarkable success stories of the delivery of essential
services in South Asia?

States with a strong focus on action and accountability are high-achievers. A comparison between
Bangladesh and Pakistan illustrates this fact. While both countries have similar incomes, in the last
three decades Bangladesh has managed to reduce its infant mortality rates by two-thirds, while Pakistan
continues to have rates 60 per cent higher than the average for low-income countries. Similarly a huge
contrast is evident in the quality of governance between the Indian states of Kerala and Bihar, with the
former doing much better than the latter in basic human development indicators. Political commitment
and policy space for public pressure are crucial. High-achieving regions also consistently devote
substantive financial outlays as a higher percentage of GDP to essential services in comparison with
the rest of South Asia.

Equitable and efficient resource use ensures that a strategic deployment of resources generates the
maximum yield on the investments in essential services. Sri Lanka serves as an excellent illustration of
the range of farsighted measures undertaken by the state for the equitable development of its population.
The country has consistently prioritised a primary level of services. In its social development expenditures
it also ensures that a substantial chunk of its recurrent expenditure gets allotted to non-salary items
and to building a critical pool of trained service providers. Schools and health clinics with free and
universal services have gone a long way to satisfy the human development needs of the population.

Synergising social sector development also proves to be a prudent investment strategy. As 30 50 per
cent of infant deaths in South Asia are due to water-borne diseases it makes little sense to look at
health care without ensuring that the population has access to adequate water and sanitation. Education
of mothers has also been found to play a very important role in reducing child mortality. Experience
from Sri Lanka, Kerala, and Himachal Pradesh shows that it is necessary to have multi-pronged measures
when delivering essential services.

Bringing women forward as change agents is a challenge that some states are addressing head-on in
South Asia. This is a high priority, given the ugly reality that infant mortality is 3050 per cent higher
for girls than boys in this region. It is in this context that Bangladesh achieved the remarkable feat of
increasing girls enrolment in primary education from 73 per cent to almost 100 per cent between 1990
and 2004. Empowered and educated women also provide substantial value to the critical human resources
of a country. Women from traditional conservative societies are training to be mechanics and masons,
voluntarily becoming community inspectors of essential services, and silently transforming their role
into that of change agents.

AND THE WHY NOTS?

What are the retarding factors in the provision of essential services in the rest of South Asia? Why is
privatisation mushrooming almost by default? What are the key loopholes to be plugged in the

iii
 public delivery system, in order to ensure that governments in South Asia fulfil the basic rights of their
peoples to essential services?

Sheer incapacity of infrastructure is a stark reality across South Asia. While one-fifth of children in India
remain out of school, in war-ravaged Afghanistan an estimated 2 million children study in inadequate
tents or open spaces. In India and Pakistan the existing health facilities barely meet the needs of half the
population. About 170 million people in India do not have access to safe drinking water. It is not just the
public infrastructure which is grossly overstretched. The picture is equally grim when it comes to human
resources. Bangladeshi classrooms are packed with as many as 75 students per teacher. The entire region
also suffers from a skewed distribution of health workers an excess of doctors in urban areas, a massive
shortage in rural areas, and an acute shortage of nurses across the board.

Inefficiencies in the public delivery systems are mutually destructive. Across South Asia teacher and
health-worker absenteeism is rampant. An important contributory factor is that the existing infrastructure
in health care and education is in a state of crumbling disrepair. Thirty-five per cent of classrooms in
India have no blackboard, 62 per cent in Pakistan have no electricity, 40 per cent in Bangladesh have
no functioning toilets and 52 per cent in Afghanistan are without drinking water. Primary health
centres paint a similar dismal picture. Most do not have essential medicines, running water, electricity,
sanitation facilities, or adequate staff. It is perhaps of no surprise that all of these countries are widely
noted to be among the most corrupt in the world. Vertical programmes promoted by donors are
another cause of inefficiencies as they create unsustainable parallel structures.

Inequalities of gender, caste, income, and class also inevitably worsen the situation. Gender discrimination
in the patriarchal societies of the region is shocking in India a girl is up to 50 per cent more likely to
die before her fifth birthday than her brother. In Nepal dalit children have a literacy rate of only 10 per
cent and only 42 per cent of them are immunised, as compared with a national immunisation average
of 60 per cent. There is also a pro-rich bias in the delivery of services, with most subsidies accruing to
the rich despite the probability of the poor falling sick being 2.3 times that of the rich. Existence of
end user costs both direct and indirect further marginalises the poor. Forced to approach private
health-care systems, increasing numbers of people are being pauperised due to both simple and
catastrophic ailments. Indisputably the steep user costs involved in accessing essential services is one of
the important reasons for the trend of increasing inequalities both within and between countries in
the region.

THE DOCTORS PRESCRIPTION

The people of South Asia are living in interesting times. While some countries are still struggling to
emerge from the ravages of ethnic bloodshed, others are coming to terms with the democratic model
of governance, while still others are learning to live with their newfound global superstardom of
political and economic power. Common to all these countries futures, however, is the reality of huge
populations deprived of the basic needs of existence. The state must ensure that it lives up to the
expectations of impoverished peoples and communities (homeless street children, destitute pregnant
women in the rural heartland, slum dwellers living in sub-human conditions all waiting in long
queues at water standpoints, health clinics, and schools) to fulfil the most essential of human needs.
The vocal and powerful sections of the population need to ensure that the state is remorselessly held
accountable for the performance of its inalienable responsibility to provide universally accessible and
robust public delivery systems for essential services. Only then will this mercurial subcontinent succeed
in making the present rival its glorious past, and claim its rightful place in the new global order.

iv
A way forward for governments and donors in South Asia lies in suitable implementation of the
following actions:

Create a robust political commitment to the delivery of essential services

Eliminate user fees in education and heath
Eliminate both direct and indirect costs for all end-users of health and education services
and cross-subsidise water for poor people
Support universal rather than targeted programmes for the delivery of essential service
Ensure legal safeguards for universal access by adopting universal legislati
Adopt a multi-pronged strategy to fight corruption
Implement society-wide right to information laws
Weed out corruption in essential services delivery
Ensure that essential services are truly sensitive to the needs of women
Increase womens role in community decision-making
Hire more female teachers and health workers
Rebuild capacities in public delivery systems
Make financial commitments and priorities
Governments need to allocate at least 20 per cent of their annual expenditure to basic
services, based on their commitment at the Copenhagen summit in 1995
Donors need to reverse the trend of declining overseas development assistance in South
Asia and likewise invest at least 20 per cent of their aid to support basic services. This aid
must be co-ordinated, predictable, long-term and comply with the Paris commitment in
2006 on aid effectiveness.
Prioritise primary levels of service
Need to ensure that at the very least 1520 per cent of total government annual recurrent
expenditure is devoted to non-salary quality-enhancing inputs
Governments should regulate private service providers to ensure quality standards and
affordability
Build the public sector work ethos
Ensure teacher salaries are at least 3.5 times the national per capita GDP
Hire 800,000 teachers and 1.9 million health workers in South Asia
Improve infrastructural conditions in schools and health clinics
Create rural bias in service delivery through service contracts
Employ and train more nurses rather than doctors
Work with other stakeholders
Promote partnerships with civil society especially as policy partners and advocates
Foster social consensus and community ownership to value essential services from a rights
perspective

v
 ESSENTIALS OF ESSENTIAL SERVICES IN SOUTH ASIA

1 Essentials of Essential Services in

South Asia
One ordinary morning, at the age of twenty-nine when Prince Siddhartha Gautama stepped out for the first
time from the walled enclosure of his opulent palace and walked aimlessly in the bylanes of his fathers
kingdom, the sight of a decrepit old man, another suffering from chronic ill health and a corpse troubled
him so deeply that he sought to renounce the world and seek enlightenment (moksha).
Chronicle of the life of Gautum Buddha, 6 century B.C

We too need to open our eyes to the stark inequities that exist in our world. To this day in South Asia,
islands of prosperity and islands of impoverishment continue to coexist. A girl child born to a poor
Indian family is thrice as likely to die before her fifth birthday than if her family was rich. She would have
been able to increase her chances of survival twofold if her mother had a secondary education rather than
being illiterate. These realities of poor access to essential services resonate across South Asia as 30 million
children never see the inside of a classroom,1 and every 30 minutes an Afghan woman and six Indian
women die in childbirth.2

These untimely deaths can easily be prevented, as has been demonstrated time and again in South Asia
itself. Sri Lanka, the Indian states of Kerala and Himachal Pradesh, and more recently Bangladesh,
have made impressive strides towards providing good quality essential services education, health,
water, and sanitation to their populations.

In the last decade, South Asia has emerged as the hub of economic3 and political4 activity. It is therefore
appalling that governments here have failed to uphold the basic rights to essential services of the
overwhelming numbers of their populations who lag behind in terms of basic human development.
To improve their position on the world stage, the governments of South Asia need to rapidly upgrade
the scale and quality of delivery of essential services in tandem with the booming economic growth. It
is simply unacceptable that nearly 340 children die every single day in Bangladesh due to simple
untreated ailments like diarrhoea.5

This report6 reviews the potential role of South Asian governments and bilateral and multi-lateral
donors in fulfilling the aspirations of the people of this vast subcontinent to quality human development.
While provision of employment, food security and childhood care are important determinants of
human development this report concentrates on evaluating the delivery of education, health, water
and sanitation as key components of essential services.

1
 SERVE THE ESSENTIALS

This section provides a birds-eye view of the inequities in South Asias human development. Section
2 probes the key lessons from successful regions which have accelerated human development processes.
Against this backdrop, section 3 analyses the root causes of inequality of social and human development
in the region. The final section brings together practical recommendations to governments and donors
to improve the delivery of essential services. The aim is not only to avert millions of avoidable deaths
due to disease, lack of hygiene, and ignorance, but also to unleash the potential for growth and equitable
development in South Asia.

A. DIVERGENT PATHS SINCE FREEDOM AT MIDNIGHT

The service of India means the service of the millions who suffer. It means the ending of poverty and
ignorance and disease and inequality of opportunity.
Jawaharlal Nehru
Constituent Assembly on 14 August 1947

On gaining independence,7 the new nation-states in South Asia were comparable in most population
human development indicators. But despite the commitments of their founding fathers, progress since
then has diverged widely.

Increased Spatial Inequality8

In the last few decades South Asia has witnessed a marked increase in inequality (Gini coefficients)
especially within urban areas. While hindering poverty alleviation,9 this has meant the remarkable
progress of some areas along with the visible stagnation of others.10

Figure 111 exposes the cross-boundary contiguous stretches

of deprivation and prosperity which exist both between Figure 1: Comparison of poverty across
South Asias national boundaries
and within all countries. In India the poverty in the
BIMARU states12 across the Gangetic plain contrasts with
the high-growth information-technology metropolises
in the south. Similarly, while Nepal has reduced child
mortality in some pockets, it continues to battle extreme
poverty aggravated by long years of civilian conflict.
Bangladesh is making historic strides in human
development nationally but in its Sylhet district 88 per
cent of children are stunted due to malnutrition.
Pakistans concerns are concentrated on the widespread
poverty of the north-western regions. Afghanistan after
23 years of conflict suffers from a damaged social
infrastructure13 especially in the rural areas. While Sri
Source: Dixit Kunda (2005) A future out of grasp,
Lanka is hailed for its long commitment to social weve seen poverty, and it is us, Analysis, Himal
Magazine, November
development, the estate plantations and conflict-affected
north continue to remain disadvantaged in access to education, health, water, and sanitation. The
challenge for South Asia lies in spreading its prosperity more uniformly across its geography.

South Asia Will Make or Break the MDGs

South Asia holds the swing vote whether the Millennium Development Goals can be reached by 2015
South Asia has 40 per cent of the problem,which it means it has 40 per cent of the solutionSo this
region is most going to drive whether we reach the targets or not.
Mark Malloch Brown
UNDP Administrator, 2003 14

2
 ESSENTIALS OF ESSENTIAL SERVICES IN SOUTH ASIA

There is little doubt that South Asias progress is crucial to the global fulfilment of the Millennium
Development Goals (MDG)15 by 2015, as the region currently stands at the halfway mark. But at South
Asias current pace, several goals are expected to be comprehensively missed. Goals 1, 4, and 5, related
to poverty and health (marked in red and pink in Table 2) are of particular concern.

The MDGs are within reach. In the last decade alone South Asia has also witnessed remarkable progress.
From 19902004, Bangladesh increased girls enrolment in primary education from 73 to almost
100 per cent while rural India has increased access to safe water from 41 to 95 per cent of the population.
These substantive achievements now need to be replicated more equitably across the region.

B. EDUCATION: TIME TO GO BACK TO THE BASICS

It is the duty of every civilized government to educate the masses, and if you have to face unpopularity,
if you have to face a certain amount of danger, face it boldly in the name of duty. You will have the
whole educated public with you in the struggle on the battlefield.
Mohammad Ali Jinnah, First President of Pakistan
Imperial Legislative Council in April 1912
in support of Gopal Krishna Gokhales Elementary Education Bill

Most countries in South Asia verbally expressed their commitment for basic education as one of the
founding principles of independence. The Universal Declaration of Human Rights, formulated in
1948, was an added inspiration. Article 26 of the charter unambiguously states that Everyone has the
right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary
education shall be compulsory. But more than half a century later, and despite repeated reiteration of
this commitment to basic education by South Asian countries (as signatories in the International
Convention on Economic Social and Cultural Rights [ICESCR], 1966 and Convention on the Rights of
the Child [CRC]), this dream remains unfulfilled.

3
 SERVE THE ESSENTIALS

Higher Education at the Cost of Basic Education?

There are more Indian doctors per capita in the US than in India.16 South Asia produces the worlds
largest number of skilled doctors17 and engineers18 but many of them migrate abroad.19 While advances
in tertiary education are commendable, every Monday morning, 30 million children of primary school
age and half of the secondary age children in South Asia do not go to school! With the exception of Sri
Lanka, most South Asian countries have prioritised tertiary20 education over the last five decades even
though for the cost of educating one university student, it would be possible to educate 39 pupils in
primary education.21 This skewed prioritisation needs to be reversed.

Gender Disparity

Acute gender disparities in education have

Figure 2: Global likelihood of achieving MDG 3-
plagued the patriarchal societies of South eliminating gender inequities in primary and
Asia. Three-fifths of the primary age children secondary enrolments
who do not go to school are girls. The 2005
MDG deadline which aimed at the very least
to achieve gender parity equal number of
girls and boys in every primary and
secondary classroom was predictably missed
in many countries of South Asia. The region
is unlikely to achieve this goal even in 2015
(Figure 2) despite substantive increases in
girls enrolments in the last five years in
Afghanistan, India, and Nepal. A lot more
needs to be done especially to increase girls
access to secondary education. Bangladesh Source: UNESCO (2004) EFA Global Monitoring Report 2005,
and Sri Lanka have achieved not only parity Education for All: The Quality Imperative, Paris: UNESCO
but also universal enrolment and such
concerted state action is an important source of inspiration.

C. HEALTH: HASTENING THE REVOLUTION

We recognise health as an inalienable human right that every individual can justly claim. So long as wide
health inequalities exist in our country and access to essential health care is not universally assured, we
would fall short in both economic planning and in our moral obligation to all citizens.

Dr. Manmohan Singh, Prime Minister of India,

September 2005

State commitment to health care has often been repeated. Article 12 of the International Convention
on Economic Social and Cultural Rights (1966) states that the state is obliged to attain the highest
attainable standard of health for its populations. States are required to adopt appropriate legislative,
administrative, budgetary, judicial, promotional, and other measures towards the full realisation of this
right.22 But inequality in health care is pervasive across South Asia. With the growing threat of HIV/
AIDS (India has the worlds largest number of people infected with the disease) access and availability
of health care provision has assumed even greater significance.

4
 ESSENTIALS OF ESSENTIAL SERVICES IN SOUTH ASIA

Highest Vulnerability: Maternal and Child Deaths

India has the largest privatised health system and is

Figure 3: Male relatives wait anxiously outside
attracting 150,000 patients from all over the world one of the few health clinics in Badakshan
to its state-of-the-art medical facilities 23 . But
ironically India accounts for 20 per cent of global
maternal and child deaths. In Nepal and Pakistan
the situation is equally grim24. In Afghanistan, on
average every single day as many as 600 infants and
50 mothers die25. Badakhshan province (Figure 3)
records the worst maternal death rate26.

Almost all these deaths could be avoided if mothers

had routine primary health care and access to
emergency obstetric care. In rural India only half
the community health centres have the required
Source: Nasrullah Ahmadzai/Oxfam GB/Afghanistan/2005
delivery room and only a quarter have hygienic
delivery kits27. The situation is similar in Pakistan28.
Worse still, gender discrimination is evident at its starkest as infant mortality rates in South Asia are 30
to 50 per cent higher for girls than for boys as parents are slower to seek medical care for girls when
they fall sick29.

Medical Revolution Easily Within Reach

The health challenges for South Asia are several. But the spectacular success of Sri Lanka, which has
some of the best health indicators in the world, instils hope that sound policies can herald a medical
revolution even in a low-income country. In just seven years (194653) Sri Lanka increased average life
expectancy by an incredible 12 years. Sustainable change can be achieved even in short time spans of
less than a generation.

D. WATER: SAFETY AND SANITATION

When the Government cannot provide arsenic-free drinking water for its countrymen, or support thousands
of hungry children, provide shelter and food for the disabled old people, would it not be a huge waste of
money to spend taka one thousand crore for holding such a conference by a poor country like us.

Begum Khaleda Zia, 2004

Prime Minister of Bangladesh in her address to the nation
on the issue of cancellation of the Non-Aligned Movement conference
in Dhaka while maintaining Bangladeshs commitment to the movement

In 2002, the United Nations Committee on Economic, Cultural and Social Rights issued a General
Comment declaring that The human right to water entitles everyone to sufficient, affordable, physically
accessible, safe and acceptable water for personal and domestic uses. It also indicated that governments
have a duty to respect, protect, and work to achieve this right progressively and that the right extends
to providing the underlying preconditions of health including access to safe and potable water and
hygienic sanitation. South Asian governments have a mixed record of progress on this count.

5
 SERVE THE ESSENTIALS

Water Water Everywhere

Figure 4: Percentage of population using
improved sources of drinking water,
South Asia has made great progress in increasing access 1990 and 2002
to safe water from 71 to 84 per cent between 1990
and 2002 (Figure 4) and is well on track to achieve
the MDG target of reducing by half the the
proportion of people without sustainable access to
safe drinking water by 2015. Water is by no means
Source: Secretary-general (2005). The Millennium
scarce in South Asia. In fact, during the monsoons Development Goals- meeting Human Needs, in Larger
Freedom: Towards Development, Security and Human Rights
South Asia is often predictably in the news because for All new York: United Nations General Assembly,March 21

of cloudbursts, cyclones, landslides, downpours, and

floods.
Figure 5: Flood-affected population in
Bihar during the floods in 2003 without
Paradoxes of H2O access to safe drinking Water

Two problems however persist. First, access to water

sources is affected by regional differences in supply,
wastage of resources, and caste discrimination.
Second, the supply of polluted water for
consumption,30 improper disposal of wastewater,
and poor water management create serious health
hazards. The indirect costs of poor water quality
are very high and in Bangladesh 65 per cent of the
disease burden is water- and sanitation-related31.
Poor water supply increases the risk of diseases like
Source: OXFAM GB/India
malaria, cholera, and typhoid and fosters ill heath
especially during humanitarian crises and natural
disasters (Figure 5). Figure 6: A squatter area next to a
heavily polluted river, Kathmandu, Nepal

Sanitation Woes

Unlike water supply, access to hygienic sanitation

continues to be a challenge. In South Asia only 37
per cent of the population has access to adequate
sanitation and 1.4 million people continue to either
defecate in open areas or use unsanitary bucket
latrines 32 . With the trend of increased urban
migration, the situation in the slums of Mumbai,
Colombo, Dhaka, Karachi, Kabul, and Khatmandu
(Figure 6) is particularly dismal. Source: Oxfam GB (2005) Suffering in Silence: Terror on
the Terraces in Nepal, Public Health Assessment, June.

REFLECTION: DEVELOPMENT CHALLENGES FOR SOUTH ASIA

The picture of South Asia is often painted in different hues. The fast pace of economic growth in the
nineties the expansion of service-sector professions like information technology, call centres, and
medical tourism often steal the limelight in international media. But equally glaring is the life on the
other side of the spectrum. The fact that more and more people are being left behind in a region
which is experiencing skewed economic growth needs to be highlighted in mainstream debates. The
increasing levels of inequality are clearly unhealthy and unsustainable.

6
 ESSENTIALS OF ESSENTIAL SERVICES IN SOUTH ASIA

While South Asian governments have made a number of international commitments (Table 3) to
uphold the basic rights of their citizens by guaranteeing access to essential services, ensuring availability
of these services is crucially important. Unless governments fulfil these responsibilities the daily tragedies
of millions of poor and marginalised children, women, and men will continue to unfold.

Table 3: Ratification of human rights treaties by South Asian countries

South International The International The The Convention The

Asian Convention on Covenant on International on the Convention
Countries Economic Social Civil and Political Convention on the Elimination of all on the
and Cultural Rights, Elimination of all Forms of Rights of
Rights, ICCPR Forms of Racial Discrimination the Child,
ICESCR Discrimination, against Women, CRC
CERD CEDAW

Afghanistan 1983 1983 1983 2003 1994

Bangladesh 1998 2000 1979 1984 1990

India 1979 1979 1968 1993 1992

Nepal 1991 1991 1971 1991 1990

Pakistan Nil Nil 1966 1966 1990

Sri Lanka 1980 1980 1982 1981 1991

Various Sources

Reversing the trend is clearly possible and within reach. The greatest inspiration closest to home is Sri
Lanka, which through sheer political will and sound developmental policies has made historic progress
in the provision of universal education, health care, water and sanitation comparable with high-income
countries. While Sri Lanka must strive to continue its good work, the rest of South Asia simply needs
to follow suit soon.

7
 SERVE THE ESSENTIALS

2 What Works?
The Case for Universal Public Provision

Some developing countries have made great strides forward in health, education, water, and sanitation
in only a matter of decades. This kind of development took nearly 200 years in the industrialised
world. Sri Lanka, a middle-income country, today has a life expectancy of 74 years, which is comparable
with the United States, Switzerland, and Malaysia. Bangladesh, which in the 1970s had an infant mortality
rate higher than Pakistan, had by 2003 reduced the infant mortality rate to half the rate in Pakistan.
Bangladesh also increased primary school enrolment from 79 per cent to almost 100 per cent between
1990 and 1998.

What brings about these sustainable achievements in such short timeframes? This section analyses the
experience of high achievers1 from South Asia itself which shows that the keys to success are: the role of
the state in essential social services; giving high priority to equitable and efficient resource use; exploiting
synergies in social sector investment; and gender-sensitive policies which enable women to function as
active agents of change.

A.THE STATE IN ACTION

Commitment to Public Action

Finance is merely a matter of the heart being in the right place.
Sidney Buchman, 190275 2

Government actions matter more than national income. Countries with low per capita income can
transform scarce resources into quality essential services. The comparison between Bangladesh and
Pakistan is illustrative (Figure 7). While their income per capita is similar, a Bangladeshi child is 30 per
cent more likely to survive to age five and almost twice as likely to go to school and use a clean latrine
more frequently.

High human development achievers either rely entirely on publicly-led systems, or inject substantial
public finances into essential service delivery in order to uphold the basic human rights of their citizens.
The common feature is financial commitment and investment of governments in essential services.

8
 WHAT WORKS? THE CASE FOR UNIVERSAL PUBLIC PROVISION

Figure 7: Income and social development indicators: Pakistan and Bangladesh

Source: UNDP (2005) Human Development Report 2005, International Cooperation at the Crossroads: Aid, Trade and
Security in an unequal world, New York: Oxford University Press

Sri Lanka, which has fundamentally relied on public systems of delivery, is one of the few countries in
the world which has banned private schools from grades 19 since the 1960s.3 Similarly, due to investment
in public health infrastructure, 90 per cent of child deliveries take place in a public health facility, 96
per cent by a skilled birth attendant. Services are provided free of charge and few people live more
than 1.4 km away from their nearest health centre,4 and maternal and child mortality have declined
dramatically.5In India, the state of Himachal Pradesh in the last few decades has consistently constructed
government schools, recruited permanent teachers, and increased the per-pupil expenditure which has
resulted in the reduction of the number of single-teacher schools from 28 per cent in 1986 to 2 per cent
in 1995, enabling the achievement of the dream of gender parity and universal enrolment.6

On the other hand, in Bangladesh while 97 per cent of all secondary schools are managed by non-
governmental organisations (NGOs) and local school management committees (SMCs), they receive
substantial subventions from the government. Non-government registered primary schools (NGRPS
approximately 15 per cent of all schools) also receive 90 per cent of the base salaries of teachers from
the government. Free textbooks are provided to all schools public, NGO, community, and madrasa.7
NGOs also receive government grants for repair of school buildings.8 Similarly in the Indian state of
Kerala with near universal enrolment, 60 per cent of primary and 53 per cent of secondary schools are
private aided (i.e. the state government aids these private schools by paying the full salaries of their
teachers; and regulates, inspects, and monitors them to ensure conformity to quality standards).9

Safe drinking water with multiple externalities for good health when served as a public good can
also provide substantive benefits. In the last decade there has been an impetus for publicprivate
partnerships in water provision in urban areas which has had mixed results. Some positive changes
include - a change management process in the Tamil Nadu Water Supply and Drainage Board
(TWAD), India which has created a water revolution by sensitising an erstwhile bureaucratic
government body to support and uphold decentralised community water management.10 In Dhaka
and Chittagong cities in Bangladesh also, the local municipal bodies have worked in direct partnership
with local NGOs to ensure the expansion of utility connections to the poorest slum areas in the
cities, at a cost affordable to these areas.11

Political Will to Make a Difference

History shows that political will is an indispensable lever for sustainable change. A classic illustration of
the huge difference that political will can make is a comparison of Bangladesh with Pakistan. The two

9
 SERVE THE ESSENTIALS

countries used to share similar human development Figure 8: Total enrolments in primary and
indicators when they were still one country. But in secondary education under successive
governments in Bangladesh, 1950-2000
the past three decades, Bangladesh has surged ahead
of Pakistan in several human development indicators. 20000

It has managed the arduous task of reducing fertility 18000

16000
rates by more than half and infant mortality rates by

Students (000s)
14000
two-thirds. Pakistan however continues to have an 12000
10000
infant mortality rate 60 per cent higher than the 8000
average for low-income countries. 6000
4000
2000
At the heart of this transformation in Bangladesh 0
has been a rapid increase in school enrolment (Figure

1955

1965

1975

1985

1995
1950

1960

1970

1980

1990

2000
8) especially for girls, through consistent political Primary Secondary
commitment across successive governments. The Note: Primary excludes unregistered non-formal non-
phase of the highest growth in enrolments was in government schools.
Source: N. Hossain and N. Kabeer (2004) Achieving Universal
the period 199197 when democratic political Primary Education and Eliminating Gender Disparity, Economic
and Political Weekly, Sept 4
competition may have created a source of pressure
on the government in power to prioritise Figure 9: Number of primary schools in Sindh
province of Pakistan, 1980-2000
education.12 In contrast, in the Sindh province of
Pakistan there was ironically a marked decline of 50,000 Return of democratic
politics 1998
net enrolments 13 after the return of democratic 40,000
governance in 1988, despite a significant increase in
30,000
the number of schools (Figure 9) and teachers. These
expansions were heavily influenced by political 20,000

patronage and did not improve the quality of 10,000

education.
0
1980-81

1990-91

2000-01
1982-83

1992-93
1984-85

1994-95
1988-89

1998-99
1986-87

1996-97
In India the contrast between Kerala and Bihar is
insightful. Kerala has almost 96 per cent literacy while
Bihar lags behind with less than 50 per cent. The
Source: Z. Hasnain (2005) The Politics of Service Delivery in
former has reduced poverty to less than 15 per cent Pakistan: Political Parties and the Incentives for Patronage
1988-1999, Washington DC: The World Bank, May
while the later struggles with more than 40 per cent.
The stark differences in the quality of governance in the two states provide some analytical answers.
Bihar has had elections for decades, but unlike Kerala, elected leaders have simply (due to lack of
accountability) diverted precious developmental expenditure.

Policy Space for Public Pressure

While civil society organisations (CSOs) perform a variety of roles from service delivery and innovation
to working as policy partners and advocates, in the face of the instable character of some states/
governments, their role in building political momentum and instilling a culture of accountability and
support for civil-society voices are crucial steps, in prioritising essential services and reducing the ability
of politicians to act on pressures for patronage. In India the social mobilisation in the nineties which
preceded the constitutional amendment to guarantee education as a fundamental right and the public
interest litigation which resulted in the Supreme Court order to implement universal midday meals,
have respectively ensured successful implementation of these programmes.

In contrast, health care as a fundamental right in India suffers from a relative neglect and abdication of
state responsibility in recent years due its lack of social recognition as a fundamental right. Similarly
while the Supreme Court has issued an order for the universalisaton of Integrated Child Development
10
 WHAT WORKS? THE CASE FOR UNIVERSAL PUBLIC PROVISION

Services (ICDS) through the provision of functional anganwadis (child care centres) in every habitation
it has suffered from slower implementation due to the diminished public pressure14.

Several NGOs and civil society groups including CAMPE in Bangladesh, Parivartan and Pratham in
India have popularized the use of citizen report cards, expenditure tracking surveys, corruption audits
etc to increase public awareness of government actions and ensure significant impact on increasing
public pressure for improving services. The roles of the state vested with primary responsibility and
civil society as a key player in holding governments accountable are complementary in ensuring delivery
of essential services.

Commitment Translates into M.O.N.E.Y

Public expenditure is the most crucial indicator for analysing government commitment. Kerala and Sri
Lanka as high achievers have consistently
devoted a higher percentage of GDP to health Figure 10: Health expenditure as a
percentage of GDP 1978-1993
in comparison with the rest of South Asia
(Figure 10). In Sri Lanka, while initial high
investments were required in building long- 2.0
term sustainable primary services, once critical
1.5
goals in education and health were met, the
focus shifted to secondary and tertiary services. 1.0

Sustaining essential services becomes cheaper 0.5

once the initial scale-up has been completed.
Even though Sri Lanka currently spends only 3
15
per cent of GDP on education, its legacy of
educational infrastructure built in the 1950s and
1960s with an average expenditure of 5 per cent
of GDP and 15 per cent of the government
0.0
South Asia Kerala Sri Lanka
Source: Mehrotra, Vandemoortele, and Delamonica, (2000)
Basic Services for All? UNICEF Innocenti Research Centre,
Florence, Italy; Mehrotra (2000) Integrating Economic and
Social Policy: Good Practices from High-Achieving Countries,
Working Paper No. 80, UNICEF Innocenti Research Centre,
Florence.

budget, explains its continued ability to provide

free education for all children up to university.16 Similarly in Kerala between 1956 and the early 1980s,
priority for health care distinctly translated into financial expenditure for expansion of the government
health services at an annual compound growth rate of 13.04 per cent, outstripping both total government
expenditure at 12.45 per cent and state domestic product at 9.81 per cent.17 In Himachal Pradesh the
commitment to education is reflected in the fact that per capita expenditure on education is double
the average for Indian states.18 In India an increase in water coverage in rural areas from 56 per cent in
1995 to 95 per cent in 2004 is largely attributable to a 900 per cent increase in funds for the Accelerated
Rural Drinking Water Supply Programme (ARDWSP).19

B.EQUITY AND EFFICIENCY

The emphasis of high achievers has not only been on raising new monies but also on increasing the
cost effectiveness, allocative efficiency, and equity of public resources. These can be attained through
a number of strategies, which need to be simultaneously implemented for maximum efficacy.

Prioritise Primary Services

Prevention is better and often cheaper than cure. Tertiary health care is curative while primary is
preventive. It may therefore be more cost effective to allocate sufficient resources to primary levels of
care in order to prevent potential cases reaching hospitals. Similarly, the social returns of primary

11
 SERVE THE ESSENTIALS

education are known to be high. Therefore prioritisation of resources for primary health care and
schools, especially in rural areas, should potentially improve allocative efficiency and equity of government
expenditure as a whole for the benefit of poor people.

In South Korea in the 1950s, 70 per cent of public education investment was in elementary education
and only after its universalisation was attention shifted to secondary education. To this day tertiary
education largely remains in private hands, based on the premise that its high private returns will
enable students to easily repay education loans through potential future earning. Wide availability of
primary schooling has ensured that South Koreas pattern of growth has been largely equitable and
most of the population can benefit from it.20 In Himachal Pradesh priority has been given to primary
schools and most incentive schemes - scholarships and free textbooks - are concentrated at the primary
level of education.21

In Sri Lanka policy makers have always prioritised primary health care but have allocated at least 5065
per cent of total government health expenditure to hospital services since the 1960s as they acknowledge
that often even tertiary hospitals predominantly provide primary care.22

Non-Salary Recurrent Expenditure

Apart from salary expenditure, high performing countries also invest recurrent spends on non-salary
components. Sri Lanka allocates at least 27 per cent of education expenditure annually to non-salary
recurrent items, which go a long way towards ensuring education quality. Textbooks and school uniforms
are provided free to all students especially at primary education level, and these items receive 3 per
cent and 2 per cent of total education expenditure respectively. The balance operation and maintenance
funds are mainly used for electricity, communications, water and so on23 to maintain high quality standards
in schools such as ensuring availability of drinking water, functional toilets, and teaching materials.24

Popular and successful policies, such as the norm-based unit cost resource allocation mechanism in Sri
Lanka to distribute public resources to schools, have also greatly enhanced the equity of resource
distribution among schools. In India public health facilities
Figure 11: Indicative workforce
in four southern states Andhra Pradesh, Kerala, Karnataka, distribution patterns in Sri Lankas
and Tamil Nadu function better because drugs distributed health care system based on
representative samples
through the primary health-care network give patients a
reason to visit the facilities.25

Investing in Quality Service Providers

Efficient spends require investment in critical human

resources. Many outreach and preventive care activities
require more para-medical staff and nurses rather than
physicians. In Sri Lanka, the bulk of maternal health care is
provided by a large cadre of well-trained and low-cost
professional female nurses and midwives, closely supervised
by a few auxiliary nurse-midwives (ANMs) and a small number
of medical doctors (Figure 11). This workforce deployment
pattern has enabled the large force of nurses and midwives
to bridge financial, geographic, and cultural barriers to
medical access through their wide availability in rural areas,
Source: Joint Monitoring Initiative (2005)
with a steady supply of appropriate medicines and linkages Chapter 2, Human Resources for Health:
Overcoming the Crisis, Harvard University
to back-up services.26

12
 WHAT WORKS? THE CASE FOR UNIVERSAL PUBLIC PROVISION

Similarly well-trained teachers have been the heart of the education system in Himachal Pradesh. The
average primary school has more than three teachers, with a pupil:teacher ratio of 27:1, and approximately
40 per cent of teachers are female. Their responsible work ethos and positive rapport with parents
and the community is clearly visible.27 Similarly in Bangladesh the motivation of teachers especially
those working in several NGO schools have contributed considerably to dramatic increase in educational
attainments indicating the centrality of quality teachers at the heart of the education system.

Free Services for All

Essential services need to be provided free of charge to ensure greatest equity and access for poor
communities. The experience of elimination of direct user fees is not new to South Asia. Sri Lanka
eliminated tuition fees from kindergarten to university in 1945. User fees in health were abolished in
1951. Bangladesh has introduced a law for free and compulsory primary education, and provides girls
with free education up to secondary school. India has even made a constitutional amendment to
guarantee free and compulsory education,
but in practice user fees are pervasive. 28 Box 1: African Wave of Scrapping User Fees
Political will is key to eliminating user fees. In 2003, when President Mawai Kibaki of Kenya scrapped
Abolishing user fees is important as once tuition fees for primary education in keeping with his
election promise, a million new students surged into
eliminated, people begin to expect public
classrooms, indicating the pent-up demand for education.
services to be provided free of charge, and Bold moves towards free primary education have been
subsequent governments will find it seen in varying degrees in Malawi (1994), Uganda (1997),
politically difficult to reintroduce end- Cameroon (1999), Tanzania (2001), and Zambia (2002).
user costs. Enrolments increased by 51 per cent in Malawi, 70 per
cent in Uganda, 49 per cent in Tanzania and in Kenya 1.2
million new children entered schools. Similarly in 1994,
To maximise benefits it is also important
with the introduction of the Free Care Policy by South
that capacities of services which have been Africas new government, there was a 2060 per cent
pronounced free are enhanced, in order to increase in the use of public health facilities. It is evident
maintain their quality standards and ensure that end-user costs are a major deterrent for parents to
that free service does not equal poor send their children to school or seek medical care.

service. Free universal services guaranteed
by right-based legislation are meaningless
without sufficient good quality
infrastructure to avail of the services. After
the introduction of the free health-care
policy, the workload of health workers in
South Africa increased without any
additional support to deliver suitable health
care. Increased financial investment in
infrastructure, staffing capacity, and
availability of medicines can maximise
benefits from the elimination of user fees.
Tanzanias broad-based co-ordination with
donors for closing the funding gap, and
South Africas increase in health budgets,
offer important lessons for ensuring the
success and long-term sustainability of the
initiative (Box 1)
Indirect end-user costs are an even greater
obstacle to access essential services than fees.
To increase potential benefits of user fee elimination, it
is also important to build the capacity of public services
to deliver and maintain quality. In Malawi, the education
infrastructure was temporarily overstretched when there
was a surge in demand pupils:permanent classroom
ratio was 119:1; pupils:textbook ratio was 24:1; and
pupils:teacher ratio was 62:1. In Uganda total net primary
enrolment increased from 53 per cent to reach 84 per
cent immediately after the user fee elimination, fell to
76 per cent by 2000 due to decline in quality standards,
and has again risen to 84 per cent with quality
improvements in 2002. Tanzanias elimination of user
fees resulted in a less severe decline in quality at the
onset due to a strong government commitment, assured
external funding to close the financing gap, and
development grants to fund quality inputs such as non-
salary recurrent costs and per-classroom capital
expenditures, including teacher houses, sanitation, and
the provision of clean water. Similarly in South Africa
the free heath-care policy was accompanied by an
increased health budget especially for primary care and
for child and maternal health.
Source: R.B. Kattan and N. Burnett, User Fees in Primary Education, Education
Sector, Human Development Network, The World Bank July 2004; Gilson et.al.
1999 and South Africa Health Review 2001.
13
 SERVE THE ESSENTIALS

Transport, curricula textbooks, school uniforms, ambulance services, costs of medicines, medical tests
and so on balloon the actual costs of access. In eight states of India together containing two-thirds of
its out-of-school children, uniforms are one of the largest out-of-pocket expenses.29 To reduce the
effect of indirect costs Sri Lanka began providing free school lunches in the 1950s,30 free textbooks in
1980, and free school uniforms in 1993. The Sri Lankan government policy in 1935 recognised that the
economic costs of illness include not only the cost of medical treatment, but also the care and feeding
of the patient, and the loss of income of household members.31 In the 1990s, Bangladesh introduced
free textbooks for all children in primary school as a key measure to improve the quality of education.

Pro-Poor Policies

Country-specific equity-enhancing
Figure 12: Distribution of health payments and
strategies education in childrens subsidies by income decile, Sri Lanka, 1995/96
mother tongue, more female teachers,
300
compulsory rural services for personnel
trained with public funds and so on 250

can also be useful. Sri Lanka does not 200

permit the registration of doctors with
the General Medical Council without 150

requiring them to work for the 100

government health service in rural
50
areas32.
0
1 2 3 4 5 6 7 8 9 10
In Sri Lanka, health-care subsidies
Per capita expenditure decile
funded through taxation are Tax payment Out-of-pocket spending Subsidy received
progressive and pro-poor the rich pay
for out-of-pocket health-care Source: Sri Lanka National Health Accounts database, Dorabawila et.al.,
(2001) quoted in R. Rannan-Eliya (2001) Strategies For Improving The
Health Of The Poor The Sri Lankan Experience, Health Policy Programme,
expenditure and general taxes far more Institute of Policy Studies of Sri Lanka
than the poor, while the health subsidy
they receive is less compared to the poor (Figure 12). Universally accessible free public health care is
rationed through differences in consumer aspects of quality (for example television sets in private-
sector hospital rooms encourage the rich with demanding tastes to voluntarily use private services)
and time costs (for example long queuing time in a public health centre convinced Mala to choose a
private clinic for the birth of her child (Box 2)) between public and private sectors34.

Box 2: If not for this government school, I would have never gone to school
Thirty-four years ago, in Hakmana village in Sri Lankas Matara district, Mala Ratnaweera was born in a
regional government hospital. Throughout her life she has been able to take advantage of Sri Lankas
publicly-provided essential services and she now works as a Programme Officer for Oxfam GB. Mala attended
the only government school for girls in the village and admits that if not for this government school, I would
have never gone to school. Later she gained admission and a full scholarship to the government-funded
Ruhunu University. Mala again relied on government services when her mother was diagnosed with throat
cancer, the service and care given was wonderful and we did not have to spend anything.

However once Malas income increased for the birth of her child, she did break the tradition and use a
private hospital. I had no time to go to the government clinic which has long queues as they see only a
limited number of patients for four hours a day.

For the schooling of her child, Mala wants to choose a government school, as she believes that they not only
provide a good quality of education but also respect her ideals of identity and religion. Mala however is
struggling to get her child admitted into a good government school in Colombo as the quality is variable33.
Source: Oxfam GB staff in Sri Lanka

14
 WHAT WORKS? THE CASE FOR UNIVERSAL PUBLIC PROVISION

C. CAPTURE NATURAL SYNERGIES

You cannot talk in isolation about healthcare. It is linked with roads, sanitation and drinking water.
Aswini Kumar Nanda,
Researcher, India 35

MDG targets like reducing infant and maternal

Figure 13: Sri Lanka infant mortality rate
mortality cannot be effectively tackled unless per 1,000 live births 19462000
root causes like chronic incidence of anaemia,
lack of emergency obstetrician care, access to 140 141

hygienic water and sanitation, mothers education

120
and so on are addressed. High educational levels
ensure strong demand for and utilisation of 100

health services while critical investments in 82

80
childrens health, nutrition, access to safe water
and sanitation help to lower the level of 60 58

absenteeism and improve educational 48

attainments. Synergies across social sector 40 34

investment are crucial both for cost effectiveness 19

20 13
and in order to ensure scale and efficiency.
0
In Sri Lanka, there has been a consistent annual
1946
1949
1952
1955
1958
1961
1964
1967
1970
1973
1976
1979
1982
1985
1988
1991
1994
1997
2000
reduction in the infant mortality rate by 4.2 per
Source: World Bank (2005) Attaining The Millennium
cent, maintained over more than 50 years (Figure Development Goals in Sri Lanka: How Likely and What Will It
Take To Reduce Poverty, Child Mortality and Malnutrition, and
13). This has been achieved through a multi- to Increase School Enrolment and Completion? Human
Development Unit, South Asia Region, The World Bank
pronged approach of investment in social
infrastructure. High mortality rates in urban areas and estate plantations were partially addressed by
municipal authorities through concerted efforts to build water and sanitation facilities.36 Not only did
universal education (especially of mothers) in both urban and rural areas result in decline in infant
mortality; it also expanded the long-term supply of potential nurses and other health-care personnel
with a secondary education at lower costs in the long run.37

Himachal Pradesh had a literacy rate of only 19 per cent in the 1960s. But in the last three decades it has
accelerated progress to reach near universal primary enrolment.38 This is a reflection of the state
governments commitment to prioritise multi-faceted social sector expenditure. Improvements in rural
infrastructure, roads, bridges and transport have increased the accessibility of schools in a difficult
terrain. High levels of parental education have helped not only to create a conducive learning environment
at home, but also to monitor the quality of schools, make public services a common concern and
demand better facilities from political leaders39. Despite the difficult mountainous terrain, 98 per cent
of villages have safe drinking water.40 A health centre is available to 84 per cent of the population
within a radius of 5 km, which is particularly beneficial to women who suffer from reduced mobility
and function as primary care givers. By addressing the multi-dimensionality of equity and social sector
investment, high achievers have made exponential gains in increasing human development.

D. WOMEN AS CHANGE AGENTS

Promoting womens education and health as a precursor to improving their participation in public life
is crucial. In Sri Lanka and Kerala, where rural women have been educated, it is easier to hire and train

15
 SERVE THE ESSENTIALS

them as nurses and mid-wives. Conversely in

Figure 14: Growth of secondary school
many parts of north India, Nepal, and Pakistan enrolment in Bangladesh, 19702003
the shortage of local recruits has meant the
perennial under-supply of female health Girls Boys

workers. Gender-sensitive strategies need to be 9

Girls enrolment over 50% from 2000
adopted across the delivery of essential services. 8
Introduction of stipend

Number enrolled (millions)

7 programme, 1994
Bangladesh has paved the way in South Asia to
attain gender parity in education through 6 Free tuition for girls
in classes 68, 1980
concerted political commitment in a short 5
Free, compulsory
timespan. The compulsory education and 4 primary education, 1990

curriculum reform in the 1990s laid the 3

Girls enrolment
about 18%
foundation for a massive expansion in education
2
enrolments particularly for girls (Figure 14).
Gender disparities have been virtually eliminated 1
41
at the primary and secondary levels. Incentives 0
introduced in the 1990s to expand access 70 975 980 985 990 995 00 001 002 003
19 1 1 1 1 1 20 2 2 2
especially for girls and poor children has ensured Source: J. Raynor (2005) Educating Girls in Bangladesh:
that gender issues are integrated in the heart of Watering a Neighbours Tree? in S. Aikman and E. Unterhalter
(eds.), Beyond Access: Transforming Policy and Practice for
policy making. Recognising social and cultural Gender Equality in Education, Oxford: Oxfam GB

barriers resulting in unequal educational

opportunities for boys and girls, the Female Secondary Stipend Programme (Box 3) in particular has
succeeded in tackling demand- and supply-side constraints. Increased recruitment of female teachers
through the 60 per cent of reservation in government primary schools has also gone a long way to
improving girls enrolment and retention.42 These interventions not only draw girls into education
but also prepare them as future change agents.

Education NGOs like CYSD in Orissa and Pratham across India are encouraging parents and community
members especially women to voluntarily assist in assessing schools. Health NGOs are encouraging

Box 3: Pull Girls into Primary Schools by Providing Incentives in Secondary Education
The Female Secondary Stipend Programme (FSSP) in Bangladesh, initiated in 1982, is a conditional cash
transfer scheme (CCT) for girls education, which aims to increase girls enrolment in secondary school as
an incentive to encourage their transition from and retention in primary education. To be eligible for an
FSSP stipend a girl must have 75 per cent attendance, achieve at least 45 per cent examination marks and
remain unmarried. FSSP stipends reinforce the strategic goals of increasing access and improving quality
of education by increasing pressure for good performance and delaying girls marriage, which often
serves as a barrier to secondary education. A unique feature of the FSSP is that it not only supports
demand-side incentives but also supply-side incentives. Schools, which educate girls, are provided with
subventions for teacher salaries in order to cater for the projected increase in enrolment, with an emphasis
on recruiting female teachers. In fact, it is reported that many madrassas opened their doors for girl
students as the FSSP teacher subventions provided a sizeable incentive.
Currently in Bangladesh not only is there free tuition for girls up to class 10 but this serves as an
additional incentive for 2 million girls to complete primary education. There is a significant difference in
overall drop-out rates between stipend awardee girls (1.3 per cent) and non-awardee girls (50.3 per
cent). Most importantly, as this is a universal programme with no selection of stipend awardees and the
money is directly transferred to the girls bank accounts, the intervention minimises leakages and has
few hidden management costs. The main weakness of the programme however is the exclusion of the
poorest girls, because the stipend is too low to cover all the user/parental costs of sending a girl to
school. Further, in the absence of improvements to the quality of schooling, the declining performance of
girl students in examinations also needs to be addressed.
Source: Mahmud 2003, UNESCO Global Monitoring Report, 2002, Chapter 4. Lessons from Good Practice, JBIC 2002, Bangladesh Education
Sector Overview, JBIC Sector Study, March 2002, Japan Bank for International Cooperation.

16
 WHAT WORKS? THE CASE FOR UNIVERSAL PUBLIC PROVISION
governments to alter the top-down approach to
health planning to engage villagers as active and
primary stakeholders in decision-making through
participatory methodologies. In India, projects led
by WaterAid and Gramonati Sansthan in villages
around Mahoba in Uttar Pradesh have trained
women as mechanics, not only to ensure quality
maintenance of the water resources of the villages
but also to crusade for allied health and sanitation
issues to ensure larger benefits for the communities
they serve. Similarly in Rajasthan women from
traditional communities are working as informal
inspectors of essential services (Box 4). The central
rationale for the inclusion of women is to transform
their low position and engage them in the process
of change not just as beneficiaries but as agents of
change. In the process they are also silently bringing
about definite changes in the gender equations in
their communities.
REFLECTION: FORMULA FOR SUCCESS
Change is within reach. The formulas and key
ingredients of success in providing universal good
quality education, health, water, and sanitation in
South Asia vary across countries and local contexts.
But the common thread among high achievers is
that governments systematically prioritise and
provide critical investments in order to create
sustainable long-term, cost-effective essential
service delivery mechanisms. Experience of high
achievers also indicates that the level of income of
a country is not a deterrent and in fact it is feasible
to embark on this journey of transforming the
human development status of populations. The
critical point is that well-planned investments need
to be made in essential services, which ensure their
allocative efficiency, utlisation of synergies across
social-sector investment, and the active participation
of women as change agents.
Figure 15: Raku Devi, Samda Devi, and
Champa informally visit health centres to
inspect the delivery of essential services
in rural Rajasthan
Source: Jo Zaremba/Oxfam GB/India/2006
Box 4: Informal Community Inspectors
Monitor Their Rights to Essential Services
Walking across the sands of Rajasthan an unlikely
group of inspectors is ensuring that government
services are delivered. Three women, Raku Devi,
Samda Devi, and Champa (Figure 10), from
Goyalon ki dhani, Chheela, and Shivsagar villages
respectively work as fellows for NGO Urmul
Marusthali Bunkar Vikas Samiti (UMBVS), an
Oxfam partner. They visit local schools to check
that the midday meals are being provided, and
local health centres to verify that pregnant
mothers are receiving adequate care. Just by
turning up and asking questions they have been
able to ensure that government officials fulfil their
responsibilities, and long overdue cases are
followed up. This process of social auditing has
challenged some in authority but the women are
committed to monitoring the well-being of their
community and upholding its basic rights to
essential services. It is difficult and unusual for
women from oppressed castes of rural Rajasthan
to take on leadership roles, but their impact has
helped them to win over skeptics from the local
community.
Source: Oxfam GB staff in India.
17
 SERVE THE ESSENTIALS

3 Whats Holding Others Back?

The root cause of South Asias weak aggregate record of human development is inequity. While significant
progress has been made on the delivery of education, health, water, and sanitation, large areas need
attention. Strapped for cash both domestic resources and foreign aid many governments are unable to
uphold the basic rights of their citizens to essential services. In the last few decades, privatisation is
occurring by default as governments fail either to fund or to reform essential public services. In analysing
the causes physical, human, financial and social of this deficiency, three overarching issues can be
detected: incapacity, inefficiency and underlying inequities in the provision of essential services

A. INCAPACITY
When the wells dry, we know the worth of water
Benjamin Franklin, 1746

Figure 16: Where do the 100 million

The basic feature of incapacity is that the supply of out-of School children live
services is unable to keep up with the burgeoning
demand. Not only are 30 million children out of Arab States
South
school (Figure 16), but 11.3 million are not immunised.1 Asia
East Asia

South Asia also contains 65 per cent of the worlds Latin

America
population without safe water and 80 per cent of those
without sanitation. Several states have proved to be
unable to fulfill the basic rights of their people to
essential services. Sub
Saharan Africa

Public Delivery Systems: Need to Source: UNESCO (2004), EFA Global Monitoring Report
Make Them Extra Large 2005, Education for All-The Quality Imperative,
Paris: UNESCO

India has one of the worlds largest public primary education system2 for 115 million students, but one-
fifth (equivalent to the population of Australia) of the school age population remains out of school. In
Pakistan and Nepal more than one-third of the children suffer the same fate. Millions of Afghan
children are effectively denied access to education due to the lack of schools or teachers3 to cater for

18
 WHATS HOLDING OTHERS BACK?

the huge influx of students in the post-conflict era4.

Figure 17: A temporary shelter/tent used as
More than half the schools are in need of major a girls school in Afghanistans Badakshan
repair while 2 million children study in tents Province
(Figure 17) or in the open air.5 Across these countries,
it is students in rural areas who suffer the most from
the lack of infrastructure, as most schools are
concentrated in urban centres.
Health infrastructure is also inadequate across South
Asia. Despite its massive size,6 the infrastructure
barely covers half of Indias population7 primary
health-care centres (PHCs) serve only 21 per cent of
villages and medicines are not available in 74 per
cent of villages 8. HIV/AIDS poses an additional
challenge to the health infrastructure and a recent
Source: Basira Mojaddidi/Oxfam GB/2006
UN report estimates that economic growth could
decline by 0.86 percentage points in India over the
Table 4: Population without access to
next 10-15 years unless measures are immediately improved water and sanitation
taken to address its mushrooming spread.9 More than Country Drinking Sanitation
half of all Pakistanis also do not have access to health Water (%) (%)
facilities.10 Since independence in India and Pakistan,
Bangladesh 25 52
due to the failure of the public health infrastructure
Pakistan 10 46
to keep pace with the exploding demand, the private
sector has flourished.11 After 23 years of conflict and Nepal 16 73

political instability, the Afghan health system too is India 14 70

unable to cater for a significant proportion of the Sri Lanka 22 9
population, mainly in rural areas.12 In Afghanistan lack Afghanistan 87 92
of security plays a role, as health personnel are in
Source: UNDP 2005, Human Development Report 2005,
constant fear for their lives. In Nepal, during periods International Cooperation at the Crossroads: Aid, trade and
security in an unequal world, New York: Oxford University
of conflict, essential medicines often cannot be Press

transported to remote rural areas.

Figure 18: Dhaka residents queue to collect
Eight hundred and eighty million people in South clean water from a private water tanker
Asia are deprived of proper sanitation facilities
(Table 4). In Bangladesh, diseases are common during
floods, due to contaminated drinking water sources
and low sanitation levels. On the other hand in
Pakistan due to persistent droughts, water scarcity
is a significant issue, especially in the rural areas of
the north. In a country as large as India, over 170
million people do not have access to safe water and
70 per cent of the population (11 times the population
of the UK) lack adequate sanitation. Women in
urban slums suffer the most due to lack of privacy,
harassment, and reproductive health ailments. The
unregulated spread of bore wells has in some areas Source: Shafiqul Alam/ Oxfam
depleted groundwater reserves built up over the last
300 years. Water shortages in many areas have resulted in the emergence of water lords and private
tanker supply (Figure 18). In India, as primary responsibility for collection of water for the household
rests with women, it is estimated that they have to devote as much as 150 million working days per year
for the chore equivalent to the loss of $200 million.13

19
 SERVE THE ESSENTIALS

The Missing Millions Many More Teachers and Nurses Wanted

The school should have six teachers, but there are only three regular teachers available now. I teach
five classes a day with an average of 276 students.
Md. Mizanur Rahman Moolah, 2006
Assistant Teacher, Primary School
Bhedorganj, Shariatpur, Bangladesh

In India, one-third of all primary schools have only a single teacher, who is forced to manage hundreds
of students in multi-grade classrooms, as enormous numbers of teacher posts routinely remain vacant
(Figure 19).14 In Bangladesh in public schools the
Figure 19: A multi-grade classroom in
teacher:pupil ratio can be as high as 1:76. While Uttar Pradesh, India where the teacher is
officially there is no shortage of qualified teachers attempting to teach students of different
grades simultaneously on two different
in Pakistan, the national teacher:student ratio has sides of the blackboard
increased from 1:37 to 1:44 between 1990 and 2001.15
Multi-grade classrooms and high teacher:student
ratios reflect the lack of school teachers. India has
resorted to the hiring of contract teachers (Box 5)
to overcome this deficiency.

South Asia has a curious mix of too many doctors in

urban areas, too few doctors in rural areas and an
across-the-board shortage of nurses.17 India has an
excess of urban physicians and an acute shortage of
nurses.18 Worse still, only 40 per cent of registered Source: OXFAM partner/ AAK/India/2005
nurses are active, due to low recruitment, migration
abroad, and job attrition. Similarly, Pakistan has only one nurse for every eight doctors.19 Bangladesh
has a 40 per cent vacancy rate of doctor postings in poor areas,20 with a concentration of health
workers in urban centres.21 In Nepal many of the health posts, sub-health posts and district hospitals
lack human resources. 22
Afghanistan struggles Box 5: Hierarchies of Access - Contract Teachers
with being able to in India
convince expatriate In the last two decades, India has been witnessing a new phenomenon
doctors to return, because of employment of contract teachers or para-teachers in large numbers.

of security problems and
low wages many of those
who do return prefer to
be employed as guards
and drivers.23
In particular there is an
important need to
employ women as
teachers, health workers
and water technicians.
Women are particularly
effective in encouraging
increase in enrolment in
school and use of health
This phenomenon is influenced by extreme budget shortages faced by
national and provincial governments. The contract teachers come under
the auspices of externally-assisted programmes. In theory para-teachers
are hired on short-term contracts as shiksha karmis (education workers),
shiksha mitrs (friends of education), lok shikshak (peoples teachers),
or guruji (leaders). But they are paid much lower wages than their
counterparts in mainstream government schools, and barely trained.
This experiment has institutionalised a cheaper, inferior, parallel schooling
system for the poorest children. In some states, the para-teachers have
only passed class VII examinations. They are expected to teach children
in classes I-V all subjects, with meagre instructional materials, typically
with all students huddled in a multi-grade classroom, for a wage less
than that of a clerk! This strategy of hiring low-qualified para-teachers
is particularly absurd given that the economy is reeling under the strain
of jobless growth and has a vast army of educated unemployed.16
Note: The term Hierarchies of Access was used in Ramchandran (2004), Gender and Social Equity in
Primary Education: Hierarchies of Access, New Delhi: Sage.
Source: S Wadhwa (2004) Pencil Erasure, Education, Outlook, 1 March and R Atma (2002) Teachers
by Contract, The Statesman, 6 June

20
 WHATS HOLDING OTHERS BACK?

services. This is because women working as teachers are often role models for young girls. Female
nurses make it easier for local women especially from traditional societies to have the confidence to
access health services.24.

B. INEFFICIENCY: NEED QUALITY IMPROVEMENTS

The cost of inefficiency in essential services delivery in several pockets of South Asia is very high. In
Nepal 24.7 per cent of students in primary education are repeating years, compared with a low of 0.8
per cent in Sri Lanka. But even in Sri Lanka only 37 per cent of students pass the higher secondary
education examinations. The drop-out rate in primary education in India, Bangladesh, and Pakistan is
a shocking 35 per cent, and the majority of those who drop out are girls. In India at any given time, 15
per cent of waterpoints are unusable or dysfunctional.

Teachers, Doctors, and Nurses Absent: Schools and Hospitals Not Fit
to Work in?

Absenteeism among teachers is widespread across South Asia. In India, according to surveys, one in four
teachers is absent and only 45 per cent actively engaged in teaching at the time of an unannounced
inspection.25 The rate of absence is estimated at 16 per cent in Bangladesh.26 In a sample of public and
private schools in the North West Frontier Province of Pakistan, the rate of teacher absence averaged 20
per cent while the official absence rate according to school records was only 5 per cent.27 Even Sri Lanka
has reported an increase in teacher absenteeism due to imposition of various official duties on teachers.

Teacher absenteeism may be linked to bad quality school infrastructure teachers are de-motivated
about working in under-equipped, under-funded, under-staffed, and overcrowded schools. In India, half
the schools have a leaking roof and no water supply, 35 per cent have no blackboard or furniture, and
close to 90 per cent have no functioning toilets. Some school buildings are misused as cattle sheds, police
camps, teacher residences, or for drying cow-dung cakes.28 Similarly in Pakistan, 49 per cent of schools
have no toilets, 39 per cent no drinking water, 17 per cent no shelter and 62 per cent no electricity.29
While in Bangladesh, 40 per cent of schools do not have adequate toilet and water facilities,30 in Afghanistan,
52 per cent have no safe drinking water and 75 per cent inadequate sanitation facilities.31

Among health workers the rate of absence is reported to be even higher than that of teachers. In India
and Bangladesh, absence rates are recorded at 40
Figure 20: The equipment used in a
and 35 per cent respectively.32 In the Indian states government dispensary in Bharatpur
of West Bengal and Jharkhand 33 not only is district in India for a delivery conducted
the previous night
absenteeism high, the frequency of health workers
recommending that patients see them in their
capacity as private practitioners is widespread.

Doctor absenteeism is reported to be closely related

to difficulty of access, lack of electricity, poor latrine
facilities, and lack of piped water at the health
centre.34 In India, most rural primary health-care
centres (PHCs) do not have essential drugs,35 running
water, electricity, or medicines for even the
common cold, let alone telephones or vehicles.
Many PHCs lack hygienic facilities for deliveries
(Figure 20). In Pakistan similarly the majority of Source: Oxfam GB/India/2006

basic health-care units (BHUs) are dysfunctional.36

21
 SERVE THE ESSENTIALS

In Afghanistan, most health clinics do not have electricity and clean water, and sanitation remains a
major concern.37 In Bangladesh, 63 per cent have inadequate facilities, 60 per cent inadequate personnel,
and 80 per cent face a shortage of vaccines and medicines.38 Doctors simply cannot cure patients
without adequate equipment and supplies.

The Vicious Tentacles of Corruption

Corruption is an important hidden cost of access to services.

Table 5: Most corrupt countries
Often those who are least able to afford bribes are the according to Transparency
worst victims. According to a survey by Transparency International
International, Bangladesh for the fifth year running has Country World Rank
topped the list of most corrupt countries (Table 5). The
cost of corruption goes beyond the billions of rupees, takas, Bangladesh 1

and afghani lost to bribery and extortion. It leads to Pakistan 5

prescription of life-threatening treatments, helps trigger
Nepal 9
drug-resistant strains of diseases, denies poor communities
access to schools, erodes the sanctity of examinations, and India 13
compromises the health and education of communities, Sri Lanka 16
especially women in urban slums, by denying them access
Source: Transparency International 2005
to water and sanitation. The effect of corruption doesnt
end with the act; its impact continues for generations.

Corruption permeates the delivery of essential services in South Asia, both in public and private
sectors. In India corruption in education is reported to be rampant (Box 6). In Bangladesh, it was
found that 40 per cent of students at the primary level had to pay admission fees (the service is
supposed to be free), 22 per cent engaged private tutors from the same school where they were
enroled, and 32 per cent of girls entitled to the government stipend had to pay to receive their
entitlement.39 Corruption in classroom construction provoked outrage in Pakistan after the 2005
earthquake, which resulted in an
unnaturally large collapse of school Box 6: Corruption Highest in Schools:
buildings and child deaths.40 Rs. 4,137 crore ($ 920 million) Paid in Bribes
Transparency Internationals report on corruption in India
In the case of health services, indicates that the amount of corruption in education
corruption is mostly related to non- (contributed to by 18 per cent of households) is equal to
availability of medicines, getting what the government is trying to raise through the 2 per
cent education cess tax! Every year, parents are asked for
admission into hospitals, consultation
money to pay for improving educational programmes,
with doctors and use of diagnostic
maintaining school buildings, and buying equipment and
services. In Bangladesh it is reported supplies. The study found that 33 per cent of bribes involved
that 26.4 per cent of out-patients and additional school fees, 28 per cent related to obtaining
20 per cent of in-patients had to pay certificates and 26 per cent was admission related. Those
bribes to doctors for receiving who dont have access to and cannot afford private education
are the ones who suffer the most as bribe-givers. But the
medical treatment at the public
bribe-takers are also poor; 70 per cent of those who asked
hospital. 41 Access to essential for bribes had an average monthly household income of less
medicines is the primary source of than Rs 10,000 ($ 223). Bribe giving is more widespread in
corruption in the countrys public rural areas and in states with low educational development.
health facilities, with the poor paying Source: The Indian Express, July 14, 2005 quoted in http://www.infochangeindia.org/
features287.jsp Rashme Sehgal, If the politicians are corrupt, so too will be the
the greatest price.42 Apart from that, people, InfoChange News & Features, July 2005 based on Transparency Internationals
2005, India Corruption Study to Improve Governance, June 30, 2005, Centre for
in India and Bangladesh the X-ray Media Studies.

22
 WHATS HOLDING OTHERS BACK?

machines and pathological tests (Figure 21) seem to elicit Figure 21: Ill-maintained x-ray facilities
the greatest incidence of corruption.43 in a district hospital in Nepal

Vertical Programmes

Since the 1960s, donors have traditionally preferred large-

scale interventions in health care, where the successes are
easily measurable and visible as with disease-specific
immunisation,44 for example. These programmes can be
successful in combating large-scale mortality. Some
examples include Bangladeshs Expanded Programme on
Immunisation,45 Indias Directly Observed Treatment
Short Course (DOTS) against tuberculosis (TB) 5 and
Afghanistans measles vaccination.46

Stand-alone programmes however are often not cost-

effective if delivered through vertical organisational
Source: Oxfam GB (2005) Suffering in Silence: Terror on
structures for example in India currently there are district the Terraces in Nepal, Public Health Assessment, June
TB officers, district leprosy officers, district polio officers,
and so on. The recent National Rural Health Mission
(NRHM) in India purportedly intends to support inter-sectoral convergence across diseases but health
analysts are sceptical of the approach47 as it does not dramatically improve the underlying primary
health infrastructure. Underlying root causes of ill health are therefore often neglected. The Pulse
Polio campaign aims to target lameness in children but the majority of cases are due to unknown
neurological causes or water-borne viruses other than the polio.48 Ad-hoc prescriptions are sometimes
fatal.49

While NGOs and even the private sector offer Figure 22: A noticeboard outside a health
centre in Wardak managed by the NGO
interventions that are timely, innovative, and Swedish Committee for Afghanistan
fill the gap left by insufficient state capacity,
there are dilemmas in non-governmental service
delivery. The main difference between state and
non-state provision is the model of
accountability, which is pertinent for the end-
user. In Bangladesh, management of NGRPS
is decentralised to the school level to such an
extent that the Ministry does not even keep
records of NGO education service providers,
and large NGOs have even begun to sub-
contract services to smaller NGOs. 50 In
Afghanistan, while in the face of government
incapacity most donors and NGOs are
performing an exemplary role in health-care
provision for the nationally co-ordinated Basic
Source: Swati Narayan/OXFAM/Afghanistan/2006
Package of Health Services programme (BPHS)
(Figure 22), some bilateral donors have by-
passed it, which undermines the functioning of the government.

23
 SERVE THE ESSENTIALS

The most important question is who is answerable to end-users for upholding their rights to essential
services? Donors, NGOs, the private sector, and civil society do not share a mandate for accountability
to citizens; democratic governments do. A planned strategy to upgrade government capacities and
services to provide essential services to ALL needs to be prioritized (Box 7). Pratham as an NGO in
India has been therefore been working dedicatedly for the last 10 years to upgrade teaching practices
within government classrooms and provide extra support to academically weak students. On the other
hand, it is also crucial to alter the dependency syndrome created by some non-governmental providers.
Very often, once a non-government provider leaves a country there is rapid decline in quality of high-
cost services due to lack of large budgets and local capacity for maintenance.51 The model set by BRAC
offers an important solution as it has progressed gradually over the years from an almost entirely donor
funded small-scale project towards a large-scale provider with alternative self-financing income streams;
e.g. handicrafts, banking, business ventures etc; to support sustainable essential service delivery without
burdening end-users with heavy costs.

Without ensuring self-sufficiency in the long-run, the danger is the prolonged entrenchment of a two-
tier service delivery system. Citizens in areas dependent on non-government service delivery (who are
themselves often dependent on the vagaries of donor funds) may have more unpredictable and limited

Box 7: Securing Basic Services for Sand Figure 23: Government sub-district health
Bank Dwellers of Bangladesh complex, Rowmary, Kurigram

Ten million of the poorest people in Bangladesh

live on sandbanks called Chars , which are
vulnerable to flooding and erosion. The
geographical terrain makes it difficult to provide
essential services. Decisions on location of
schools and health centres are often made with
reference to the density of population. Since each
Char settlement has less than a thousand people
they are often by-passed altogether.

Oxfam has been working with local partner

organisations to lobby government officials and
politicians to provide essential services for Char
settlements. It has also built a small number of Source: Oxfam/Bangladesh/2006
non-formal primary schools to demonstrate that
it is possible despite the difficult terrain.
Figure 24: Free primary school, Rowmary,
Programme Co-ordinator Farid Hasan Ahmed Kurigram
explains, Our role is not to replace the
government but to help make it effective and
accountable. Ultimately it is only through the
government that access to quality basic services
for all can be secured. It is the governments
responsibility to provide basic services and
ensure peoples rights. The money is there both
the Government of Bangladesh and international
donors have the funds to ensure that everyone
in Char areas can have access to health care and
send their children to school. All we are asking
for is fulfilment of the rights enshrined in the 1972
Constitution of Bangladesh.
Source: OXFAM GB Bangladesh
Source: Oxfam/Bangladesh/2006

24
 WHATS HOLDING OTHERS BACK?

access to essential services than those with direct government provision. Therefore to ensure parity in
NGO-run schools CAMPE successfully lobbied with the Bangladeshi Prime Minister in 2005 to extend
the free textbook policy to NGO-run non-formal classrooms to ensure the existence of universal syllabi
and free access to all.

There is also the danger of abdication of responsibility by the government in the face of excessive donor
involvement, which proves to be self-defeating. For example in Bangladesh a trend towards 100 per cent
funding of urban water projects by donors led to a lack of ownership by the government which in turn
led to delays in required staff allocations, ultimate withdrawal of most donors, and dramatic decline in
their funding. To combat this in the water sector in recent decades donors are increasingly funding
NGOs to increase the capacity of citizens to demand that their political representatives uphold their
rights to basic services.52
Box 8: Community Contribution for
Water Supply Affects Women
With increased emphasis on decentralisation, most
Zero Point settlement, a village of 350 Mohanas
projects, especially those implemented by external
(fisher folk) households situated in the coastal
donors, have created community associations such
belt of Badin District of Sindh Province, suffered
as pani panchayats (water users association), village from acute drinking water shortage due to lack
education committees (VECs), and parent teacher of infrastructure repairs. During the three
associations (PTAs) as an integral component of months of fish breeding in particular, the local
the project implementation.53 While emphasis on contractor refused to provide the village with
community participation is admirable, it is drinking water through tankers. Women with
imperative that these groups are not nurtured primary household responsibility for fetching
water had to walk on foot for nearly four or five
mechanically. One concern is that these consumer
hours and carry containers from water sources
groups or end-user groups as parallel entities by-
58 kms from the village.
pass existing legal institutions of decentralised
In 2004 the Pakistani government declared that
governance such as panchayats at the lowest tiers in
repairs would be initiated only if local
India.
communities contributed at least 25 per cent of
the total cost of the water supply scheme, but
Proliferation of single-issue committees in each
this was beyond the existing financial capacity
village also dilutes their efficacy. Dominance of of the Zero Point community. Oxfam, with the
upper caste 54 groups, poor record-keeping, help of its local partner Young Sheedi Welfare
insufficient training and so on also hamper their Organization (YSWO), not only supported the
effectiveness. Social mobilisation of water and creation of water tanks in Zero Point but also
sanitation end-users, in Pakistan, indicates that encouraged the local community to talk with and
programmes which enter the community through lobby local and provisional governments to
ensure that their voice is heard by policy
local notables yield lower participation of poor
55 makers. The community demands focused on
people in decision-making. Artificially created
social groups therefore may not necessarily represent
the interests of the community at large. Community ownership is often simply a euphemism to insist
on the levy of a user charge to be borne by the community see Zero Point water project in Pakistan
(Box 8). In India, the Swajadhara programme, which expects village panchayats to contribute to 1020
per cent of capital costs and the entire operations and maintenance costs at waterpoints, has not been
as successful in mobilising community resources as envisaged.56

C. INEQUALITY
Across South Asia prevalent social inequities of income, class, caste, and gender contribute to lack
of access to essential services for the socially marginalised. Women suffer the most from lack of
services. Conflict-affected areas are also vulnerable to dramatic increases in inequality. Jaffna had the

25
 SERVE THE ESSENTIALS

best infant mortality rate and child nutrition status in Sri Lanka but in the last two decades skeletal
remains of shelled hospitals reflect the continued deprivation of basic health care.57 In South Asia
caste, class, and poverty continue to remain the predominant factors in inequity.

The Human Face: Poverty,

Caste, Class, and Gender Figure 25: Difference in the educational
attainment on the basis of wealth and gender in
Poverty exacerbates educational South Asian societies
deprivation. Figure 25 portrays the
Bangladesh 1999 Nepal 2001
disparity in completion of education Attainment profile, ages 15-19 Attainment profile, ages 15-19
between the richest 20 per cent versus .1
.1
the poorest 40 per cent of students from
.8
grade 1 to grade 9 (X Axis) in four .8

countries. The red curve in each graph .6

Proportion
Proportion
.6
indicates the inequities faced by girls from
the poorest households in access to .4 .4

education. Social factors like harassment

.2 .2
in schools, preference for male child,
responsibility for sibling care especially 0 0

for eldest girls and child labour constrain 1 3 5

Grade
7 9 1 3 5
Grade
7 9

educational attainment of girls especially Rich 20% Male Rich 20% Female

from poor households. In India almost Poor 40% Male Poor 40% Female

40 per cent of children from poor India 1998-99 Pakistan 1990-91

Attainment profile, ages 15-19 Attainment profile, ages 15-19
agricultural households are out of .1
.1
school.58 Caste is another major reason
for discrimination. In the prosperous .8
.8
Indian state of Punjab, government
Proportion

Proportion
.6
.6
schools are often referred to as dalit 59
schools. In Nepal, dalit children have a .4 .4
literacy rate of only 10 per cent and adult
.2 .2
women only 3.2 per cent.60
0 0
Diseases of the poor are similarly 1 3 5 7 9 1 3 5 7 9
worsened through neglect.61 In India, the Grade Grade

poorest 20 per cent of people have more

Source: Filmer and Pritchett (1999) The Effect of Household Wealth
than double the mortality and on Educational Attainment: Evidence from 35 Countries, Population
and Development Review 25 (1)
62
malnutrition rates of the richest quintile.
Amongst poor people, scheduled castes
and scheduled tribes suffer the most. In Nepal, only 42 per cent of dalit children are immunised,
compared with the national average of 60 per cent.63 In Sri Lanka extreme inequities exist in health
provision in the low-income plantation sector.64 The reasons for this systematic disparity are inherent
deprivations in livelihoods, nutritional security, safe water, sanitation, and health services across different
strata of society and discrimination within households.

Access to drinking water across South Asia has a clear caste and class geography. The dalit basti in India
and Nepal is always at the outskirts of the village, where there is least access to water. One hundred and
eighteen million households in India do not have drinking water at home,65 and as across South Asia
the primary responsibility for water collection rests with women, they are unduly burdened.66

Women have shorter lives than men due to acute lack of access to essential services and widespread
gender discrimination across South Asia.67 A girl in India is also 1.5 times less likely to be hospitalised

26
 WHATS HOLDING OTHERS BACK?

than a boy and up to 0.5 times more likely to die between her first and fifth birthdays.68 With the clear
trend of feminisation of HIV/AIDS in the last decade, women also suffer from a greater increase in
rate of infection.69 Gender division of labour in a majority of the patriarchal households in South Asia
consigns women to be the primary users of essential services - to wait in long queues at health centres
with sick relatives as the primary care givers for the family, to walk long distance to fulfill the
responsibility to collect water for the household, to make children ready for school daily and make
additional use of health centres for their own reproductive needs.

Several strategies to target women specifically have not worked in isolation. In Pakistan, Lady Health
Workers (LHW), despite covering one-fifth of the population, are largely ineffective due to lack of
medicines and referral support.70 In India, the National Rural Health Mission (NRHM) proposes to
appoint 250,000 ASHAs (Accredited Social Health Activist), similar to the previous appointment of
women community health volunteers (CHVs), which ran into serious problems due to misuse of the
selection process for political patronage; caste, class, and gender prejudices; and limited training. The
concept of Traditional Birth Attendants (TBA) has also proved to be a practical failure.71

Why Subsidise the Rich?

In Nepal, the wealthiest 20 per cent of the population receive about 40 per cent of the total public

The role of the state is to provide basic education to all, not higher education to a privileged few

Mahbub Ul Haq, 1997

subsidy on education while the poorest quintile receives less than 12 per cent.72 In India, where 25
million children are out of school, higher education receives 20 per cent of the public expenditure on
education. At the tertiary education level the pattern of public education spending is invariably regressive,
with benefits accruing disproportionately to the higher economic class. The recent reservation policy
in India in higher education for Other Backward Castes (OBCs) intends to reverse this trend.

The probability of the poor falling sick is 2.3 times more than the rich. Nevertheless, in India while
five-star hospitals and medical tourism receive government incentives,73 Primary health care centres
(PHCs) suffer from lack of government patronage.74 The poorest 20 per cent of the population captured
only 10 per cent of the total net subsidy from publicly-provided clinical services while the richest
quintile received more than the three times that.75 Unlike Sri Lanka where the top quintile pays more
than 50 per cent, tax financing of health care is moderately regressive in Bangladesh with the top
quintile contributing to only 39 per cent of overall payments to the health care system.76

The social benefits of water supply and sanitation, in terms of fewer illnesses, far exceed its costs. But
the poor continue to suffer from unequal access. In India only 38 per cent of the population have
piped household water but they continue to pay below cost and receive the greatest subsidies. In Delhi
city, inequity in supply results in the cornering of most of the available water for the elite residential
areas.77 The poor households and slum dwellers however are forced to pay exorbitant prices to water
vendors. In Pakistan too, poor people have to pay private water vendors as much as 10 times the cost of
piped water supplies for water of dubious quality.78 Bottled water companies, which are very high-
growth profit79 enterprises, also receive subsidised water.80 The General Agreement on Trade in Services
(GATS) has so far only focused on privatising water supply and opening markets to foreign investors,
but in future, requests for sanitation and sewage services may be included when WTO negotiations are
resumed. But private service providers are not too keen to provide water and sanitation facilities in
rural areas because they are generally considered unprofitable.

27
 SERVE THE ESSENTIALS

Killer Fees

End-user costs such as school tuitions, doctor consultation fees,

Table 6: Out of pocket expenditure
cost of essential medicines and so on are common across the as user fees for health
provision of essential services in South Asia. Schools in Pakistan Out of Pocket
and Nepal charge tuition fees for primary education.81 While Country Spending/Total
Health
Bangladesh officially provides free education, household
Expenditure %
spending on education constitutes over 60 per cent of the per
student public expenditure in primary education.82 Official Afghanistan 47
policy on user fees for public health clinics varies across countries Bangladesh 52

in South Asia83 but the unofficial practice of user fees, indirect Nepal 58
costs, and expenditure for private care is sizeable. In Pakistan India 82
since the 1980s hospitals no longer provide medication, meals, Pakistan 77
clinical care, beds, or clothing for patients, which has adversely
Sri Lanka 50
affected poor people.84 Even in Sri Lanka there is an increasing
Source: P. Musgrove, R. Zeramdini, and
tendency to charge indirect user fees for blood tests and other G. Carrin (2002) Basic Patterns in National
medical tests. In India over 80 per cent of total health financing Health Expenditure, Bulletin of the World
Health Organization 80(2): 13442.
is from end-users in out-of-pocket payments (see Table 6).

User fees often result in reduced use of services (Box 9), especially by those with the greatest need
poor and vulnerable people. In India, the number of users who reported not being able to access
health care due to the financial constraints imposed by increased user fees has risen from 13 to 23
per cent from 1986 to 1996. For the poorest expenditure deciles, the rate of untreated ailments
increased by 40 per cent.85 It is estimated that almost 43 per cent of households affected by HIV
had either borrowed money (double that of non-HIV households) or liquidated assets for
consumption.86 Asian Development Bank (ADB) water and sanitation projects in India, Bangladesh,
and Nepal have resulted in poor people being excluded from benefits due to lack of affordability
of the connection charge (equal to as much as 10 months income of a poor household) and
increased tariffs.87

People are often forced to resort to dubious low-cost providers due to user fees. In Pakistan only 21 per
cent of poor households use government health care and 54 per cent go to private medical practitioners
including amateur private doctors and faith healers. It is estimated that there are 1.25 million quacks in
India,88 600,000 in Pakistan89 and 40,000 in Colombo alone.90 The risk of neo-natal mortality was found
to be six times higher when mothers consulted self-styled health workers with no recognised
qualifications.91

Box 9: Poor People Reduce Their Visits to Government Health Clinics when User Fees
are Charged
User fees were introduced in secondary hospitals in the Indian state of Maharastra as part of the
reform process supported by the World Bank. As user costs rose sharply in the period 19992001
there was a simultaneous fall in overall utilisation for outpatient visits and inpatient care especially
amongst the poor which may be attributed to the following reasons: First, revenues from user fees in
Maharastra have largely remained unutilised and, therefore, have not contributed to quality
improvements. Second, the exemption (targeting) scheme for the poor may not have worked as
envisaged. There is evidence from the comparable state of Punjab that the process for obtaining
exemption cards was time-consuming and bureaucratic, making it virtually impossible for a poor
person to obtain the benefits associated with such cards. Without quality improvements and without
exemptions, it follows that utilisation by the poor must have declined and they must have shifted
either to self-care, or worse still to lower quality providers.
Source: National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, 2005

28
 WHATS HOLDING OTHERS BACK?

End-user costs are also a frequent Figure 26: Percent of hospitalized Indians falling into
reason for people falling below poverty from medical costs, 1995-96
the poverty line due to
catastrophic medical expenses. 92
One-quarter of hospitalised
Indians fall below the poverty line
as a result of their hospital stay
(Figure 26). More than 40 per cent
of hospitalised people take loans
or sell assets to pay for their
treatment. 93 Across eight Indian
states the indirect cost of
education in the form of uniforms
is the primary reason for children
dropping out of school. 94 User fees
and lack of public health-care
infrastructure collectively are
pushing poor people into a vicious
cycle of poverty, illiteracy, and ill
Note: Northeast states consist of Assam, Arunachal Pradesh, Manipur,
health. Meghalaya, Mizoram, Nagaland and Tripura.
Source: National Sample Survey Organisation (1998)

REFLECTION: NEED TO REBUILD PUBLIC DELIVERY SYSTEMS

Over the last two decades, South Asian governments have systematically reneged on their social
contract to deliver public services, adopting overarching skewed governmental priorities resulting in
rapid privatisation of public utilities and erosion of the public service ethos. Privatisation of water
supply has not only largely failed to deliver, but international private investment in water services has
also declined after peaking in 199699 apparently because returns were too low. With pressure from
widespread public protest, private water projects in Colombo, Karachi, and New Delhi have been
put on hold and the future of the Melachmi95 project in Kathmandu valley remains uncertain.

The analysis is unequivocal. The public delivery of essential services is deficient across large pockets of
South Asia. However, this should not translate into an absolute loss of faith in the public delivery
system. Rather it presents a strong and compelling case for the rebuilding of public infrastructure and
the service delivery ethos. In fact the incapacity, inefficiency, and inequity of the delivery mechanism
are a direct product of its neglect, which has eroded its efficacy.

29
 SERVE THE ESSENTIALS

4 How to Make a Big Dent

There is a tide in the affairs of men

Which, taken at the flood, leads on to fortune;
Omitted, all voyage of their life
Is bound in shallows and in miseries
On such a full sea are we now afloat,
And we must take the current when it serves
Or lose our ventures
William Shakespeare (15641616) 1

Despite South Asias emergence as an Figure 27: How long will South Asia take to achieve
important global political and the Millennium Development Goals?
economic force, if the current state of
Primary Gender Child Access Access
slow progress of delivery of essential Poverty Hunger Education Equality Mortality to to
Water Sanitation
services is maintained (Figure 27), the
2000
region is unlikely to reach the MDG South
Asia
goal of reducing child mortality until
South
after 2020, and is not expected to reach Asia
2015
the goal of universal primary education
until 2040.
2020
South South
Business-as-usual is clearly not a viable Asia Asia
South
option. Three important Asia
South
commitments need to be Asia
demonstrated by the regions 2050

governments and donors: in-

stitutionalising political commitment;
building capacity in public systems; and 2100
South
working with all stakeholders for the Asia
delivery of essential services. This
concluding analysis, based on insights 2200

from previous sections, clearly sets out

Source: UNDP (2003), Human Development Report 2003, Millennium
the specific action points that will Development Goals: A compact among nations to end human poverty, New
York: Oxford University Press

30
 HOW TO MAKE A BIG DENT

enable the achievement of the dream of universal, good quality education, health, water and sanitation
for all the most basic of civilisational goals.

A. GET THE POLITICS RIGHT

No, no we are not satisfied, and we will not be satisfied until justice pours down like water, and
righteousness like a mighty stream.
Martin Luther King Jr., 19632

Political will is one of the most crucial ingredients needed to build a high level of human development.
Governments need to fulfil their responsibility to uphold the basic rights of their citizens for essential
services. For this commitment to be sustainable, it needs to be integrated in the political system as the
bulwark of legitimacy. The necessary political change goals are: elimination of user costs; fighting
entrenched corruption; and making services work for women.

i. Abolish killer fees: Eliminate both direct and indirect

end-user costs

All I can say is this, Find money! Find money!! Find money!!! I appeal to the president, not as president
but as the finance minister. I say, find money. If you say you have not got enough money, discover and
tap new sources...
Mohammad Ali Jinnah, 1912
at the Imperial Legislative Council in support of the Gokhales Elementary Education Bill 3

Free doctor consultation, no school fees, a bucket of clean water, free medicines, and a hygienic toilet can
potentially save millions of lives in South Asia. End-user costs to access essential services often exclude
poor people, who are forced to resort to unregulated private services. Worse still, end-user costs are a
frequent reason for children dropping out of school or people falling below the poverty line due to
catastrophic ailments. In addition, user fees raise little money and are most often insufficient to cover the
cost of service delivery. The case for abolishing user fees is strong (see Section 3C: Killer Fees).

Bangladesh and Sri Lanka already provide free education and health care apart from support to a host of
indirect end-user fees for textbooks and uniforms, for example. India needs to act soon. The 1992
constitutional amendment to guarantee education as a fundamental right can only take effect after the
government passes and fulfils the financial commitments of the Free and Compulsory Education Bill 2005,
including provision of free books and uniforms.4 In Nepal, fees for in-patient care, including maternity care,
need to be eliminated. User fees in Afghanistan, which are common for patients seeking treatment, also
need to be eliminated. In Pakistan there is a need for elimination of direct user fees across the board, as
even PHC schemes run by NGOs do charge and achieve significant levels of cost recovery.

In the case of water, a precious natural resource, while some form of cost recovery is desirable to avoid
excessive usage; a minimum ration of free water (for example in India the norm is approximately 40
litres per capita per day - lpcd in urban and 135 lpcd in rural areas) along with a slab-based water tariff
that cross-subsidises lower consumption levels is desirable. Construction, operation, and maintenance
charges should also not unduly burden the community and their contribution can be encouraged only
in terms of physical labour to build a sense of ownership for the public good.

The World Bank in recent years has after a rethink endorsed this call for the elimination of user fees,
at least in primary education.5 The time is now ripe for countries in South Asia to implement well-
planned and sustainable mechanisms for scrapping user fees for health and education and ensuring
affordability and cross-subsidisation of water and sanitation facilities in order to make significant
improvements in access to essential services.
31
 SERVE THE ESSENTIALS

ii. Universal access rather than poor targeting

Why should essential services, especially in health and education, be free for ALL? The reasons are
multi-faceted.

Identifying who is poor is often difficult. The accuracy of data is often questionable and the process of
identification breeds corruption. India has had a long history of gross deficiencies in poverty
identification.6 In Bangladesh, unlike the stipends offered for secondary education, the poverty-targeted
Female Primary Education Stipend Programme (PESP) has been unsuccessful with two-thirds of the
eligible girls from the poorest households not receiving their entitlement. In fact, 27 per cent of those
from affluent households usurped the benefit.7

Selection of beneficiaries is not cost-effective if poverty is

Figure 28: Prevalence of child
widespread. In South Asia child malnutrition is in the range malnutrition in South Asia
of 3055 per cent (Figure 28).8 Ironically it is not limited to
poor people in India a quarter of the children in the richest

Bangladesh

Sri Lanka
fifth of the population are also underweight and nearly two-

Pakistan
Nepal
India
thirds are anaemic.9 Universal nutrition programmes like the
midday school meals in India10 are expected to improve child 60
53
nutrition, health, and education as well as address the malaise 50
48 48

of high drop-out rates and repetition in schools.11 In the Indian 40 38

33
state of Rajasthan, for instance, girl enrolment in Class 1 jumped
30
by nearly 20 per cent in a single year after midday meals were
20
introduced.12 While targeted school meal programmes exist
in Bangladesh,13 Afghanistan,14 and Sri Lanka15 there is a real 10

advantage in converting them to universal programmes. Such 0

programmes could also go a long way towards addressing
chronic malnutrition, which afflicts millions of children in
Nepal and Pakistan.
Source: World Development Indicators, 2004
graphically depicted in Suresh Babu, 2006,
Food Security in South Asia, South Asian
Journal

Targeting also excludes elites from access to, and monitoring of, public goods. For example, a politician
who sends her son to a government school would take a greater interest in its quality of education.
With targeting there is also a danger that poor people will be further marginalised due to their
diminished political voice to demand their rights.16

The movements for Education for All (EFA)17 and Health for All18 have therefore emphasised universal
access at least to basic levels of services for entire populations. Targeting problems in healthcare for
example arise due to a lack of comprehensive approach to both preventive and curative aspects. The keys
to success in Sri Lanka have been strong political commitment to universalism, good infrastructural
coverage of health clinics and schools, no user charges, no explicit targeting of services, and reliance on
progressive taxes.19

Legal safeguards to universal free delivery of essential services are also extremely important. In India
the passage of the legislation guaranteeing the fundamental right to education has played an important
role in the recent expansion of schooling though the fundamental problems of financial commitments
remain. Similarly financial commitment and legal safeguards for universal education and healthcare
need to be robustly implemented across South Asia.

32
 HOW TO MAKE A BIG DENT

iii. Fight corruption

The most effectual method to keep men honest is to enable them to live so An augmentation of salary
sufficient to enable them to live honestly and competently would produce more good effect than all the
laws of the land can enforce.
Thomas Paine, 1772 20

Corruption can be combated at various levels. For each specific essential service a number of steps can be
taken, including increasing salaries and improving working conditions. Codes of conduct21 and accountability
mechanisms also need to be strengthened. At the two extremes, banning22 and legalising23 private tuition24
and medical practice after working hours can both be effective. Simple practices like displaying noticeboards
of free and official charges for essential services (like Oxfams best practice depicted in Figure 29), regulation
of quality standards and inspections need to be instituted together with political commitment, to weed
out entrenched corruption.

Public action in democracies is a sustainable Figure 29: A sign displaying the seeds given to a
measure to fight corruption. Indias Right village affected by Bangladesh floods to sow crops
by Oxfams partner SKS and technical assistance
to Information movement (Box 10) is a case by Padakhep Manabik Unayan Kendra
in point as the popular movement has not
only created substantive social momentum
to pass the Right to Information laws in
India but also enable citizens to use these
laws and foster a culture of public vigilance.
At a political level, the existence of multi-
party democracies, the emergence of civil
society, and a free press are key building
blocks in this fight against corruption.
Effective practical solutions include
simplification of rules and procedures,
empowering the public, increasing
transparency, and effective punishment.25

Uprooting corruption at political and

societal level is the most effective. In Source: Gail Williams/Oxfam/2005/0563 84
Pakistan while a dozen anti-corruption

Box 10: Right to Information

On 15 June 2005, the Government of India passed the historic Right to Information Act inspired by a
long-standing grassroots movement Mazdoor Kisan Shakti Sangathan (MKSS) in Rajasthan, which has
repeatedly exposed corruption in rural development schemes. The MKSS has also popularised an
empowering strategy of Jan Sunwai or public hearing. In these gatherings, official documents related to
school buildings, health centres, water standpoints, dams, bridges, and other local structures are read
out to local villagers. When the records were read out it was sometimes immediately obvious that they
contained false information construction of non-existent structures, remuneration for ghost teachers,
overbilling for transporting materials, or people listed on the muster rolls that were long dead.
These successful social audits at the village level brought to the fore the question of accountability at
the macro policy level and led to the conceptualisation of the Right to Information Act enforced in 2005.
Every government office in India must now have a public information officer (PIO) and any citizen can,
for a modest fee, demand information on any government responsibility and action the absence of
teachers in government schools, insufficient medicines in hospitals, decisions on water provision, and so
on. This movement provides a model for other countries in South Asia and beyond on society-wide
initiatives for tackling the malaise of corruption.
Various Sources

33
 SERVE THE ESSENTIALS

commissions already exist, donors are investing heavily in ensuring their effectiveness.26 On the other
hand, while Bangladesh set up an anti-corruption commission in 2004,27 it has yet to appoint an
Ombudsman28 after 25 years of enactment of the Act. Political commitment at the highest level is
essential for uprooting corruption.

iv. Make services gender-sensitive

Women and girls as primary users need to
Figure 30: Women queuing in the waiting room of
be placed at the centre of all decisions a primary heath clinic in Wardak, Afghanistan
from the design and planning to operations
and maintenance of essential services.
Changing laws29 to institutionalise the voice
of women is important. Indias 1992
constitutional amendment to reserve one-
third of panchayat seats for women has
proved to be effective. There has been a
clear increase in spending on public water
and latrines for low caste communities when
women are in a majority in panchayats.30
Employment of women as teachers, nurses,
and doctors (as in Sri Lanka) is advantageous
as they serve as role models and improve
the comfort levels of women and girls from
traditional societies like Afghanistan (Figure
Source: Swati Narayan/Oxfam/Afghanistan/2006
30) when they access essential services.

However, both these strategies need to be sensitive to the country context (for example in Pakistan there
is an acute need for nurses to be protected from sexual harassment).31 Lessons need to be drawn from the
failure of CHVs in India and LHWs in Pakistan (Section 3C: Inequality: The Human Face Poverty, Caste,
Class, Gender).

Changing prevalent beliefs is equally important. In rural Gujarat, Anandi, a grassroots NGO, has
encouraged women from traditional households who suffered excruciatingly from the lack of privacy
and had to wait till dark to defecate in the open, to be trained as masons and construct toilets as
symbols of their empowerment in the community.

In classrooms across South Asia increasing the number of functioning latrines for girl students is
also an important need with potential synergies across the essential services of education, health,
and sanitation. Innovative demand- and supply-side incentives such as Bangladeshs FSSP (Box 4),
can be implemented to empower women to increase their expressed demand for and access to
essential services.

B. BUILD CAPACITY IN PUBLIC SYSTEMS

Government exists to defend the weak and the poor and the injured party; the rich and the strong can
better take care of themselves
Ralph Waldo Emerson, 1844

Free education and health care is meaningless without adequate classrooms, teachers, nurses, and
medicines to support the surge in latent demand. Maintaining quality standards is important. Access to
poor quality services is often tantamount to no access at all.32 Once a pupil drops out of school or a

34
 HOW TO MAKE A BIG DENT

patient has a bad experience at a heath centre, convincing them to use the service again becomes even
more difficult. Due to sustained neglect, in most South Asian countries public service delivery infrastructure
remains in disrepair. While privatisation has spread, its quality and affordability need to be strictly regulated.
The governments of South Asia need to honour their social contract by upholding the basic rights to
essential services.

i. Financial priorities
Figure 31: Overseas Development Assistance
More money! (ODA) received as a percentage of GDP

With rapid growth in South Asia, it should be

14
easier for governments not only to allocate greater
12
monies in absolute terms for essential services but
also a greater proportion of Gross National 10

Percent of GDP
Income (GNI) from the enlarged pie. 33 South 8
Asian governments need to honour their 6
commitments made at the Copenhagen summit
4
in 1995 to spend at least 20 per cent of their
2
current expenditure on basic services.34
0
Donor countries also need to ensure that they 1980 1991 2003

provide at least 0.7 per cent of their GNI in Nepal Bangladesh India

foreign aid and allocate at least 20 per cent of this Pakistan Sri Lanka

to basic services to ensure predictable aid especially

Source: SAAPE (2003) Poverty in South Asia 2003, Civil
for budget support as committed in the Paris Society Perspectives, South Asia Alliance for Poverty
Eradication: Nepal
conference on aid effectiveness in 200535. South
Asia has been systematically receiving less aid
Figure 32: United States assistance to
(Figure 31) in the form of overseas development
Afghanistan
assistance. This trend needs to be reversed. Based
on a conservative estimate South Asia would need 6,000.00
an additional $495 million per year to make any
advance in universal primary education. 36 To
5,000.00
provide access to clean water for 200 million
people without safe drinking water and 800
4,000.00
million people without proper sanitation in South
US $ Millions

Asia by 2015 another $4 billion per annum (i.e. a

10-fold increase)37 is required. 3,000.00

In Afghanistan in particular, donor aid needs to

2,000.00
increase considerably in tandem with stated
pledges and commitments (Figure 32). Donors
1,000.00
need to invest in building the capacity of
government systems to absorb funds, rather than
by-passing them.38 0.00
2003/4 2005/6
2001/3 2004/5
Year
In addition, national governments need to U.S. Pledges U.S. Commitments U.S. Disbursement
function more effectively and take action. In India,
the United Progressive Alliance (UPA) in its Source: Afghan Ministry of Finance quoted in B. Rubin (2006)
Afghanistans Uncertain Transition from Turmoil to Normalcy,
National Common Minimum Programme (CMP) Center for Preventive Action, Council on Foreign Relations,
has promised to allocate 6 per cent of GDP to CSR No.12, March

35
 SERVE THE ESSENTIALS

primary education but its current allocation
continues to hover around 4 per cent. On the
other hand, while there seems to be an excess
of funds allocated to rural water supplies in
India, the Total Sanitation Campaign suffers
from neglect and unless it is dramatically scaled
up to cover 20 million people each year, the
MDG target is unlikely to be met.
As allocations of annual expenditure are subject
to the vagaries of political negotiation,
sustainable mechanisms like the innovative
education cess in India (Box 11) need to be
instituted.
Box 11: Innovative Tax on Every Bar of Soap
and Haircut Feeds Children in Indian Schools
In May 2004, the United Progressive Alliance (UPA)
government in India imposed a well-planned and
executed 2 per cent universal cess (tax on tax) on all
central taxes to help raise funds for primary education.
Most of the funds have been used to provide midday
meals for school students. Due to the burgeoning fiscal
deficit of the state governments to the tune of 5 per
cent of their net domestic product, the central
government has sought to generate additional monies.
This cess (which imposes a universal tax of 2 per cent
on every transaction in the economy i.e. from the
purchase of a bar of soap to a haircut) for education
is expected to accumulate $ 1.5 billion per year and

Prioritise non-recurrent salary spends assures the sustainability of the midday meal scheme
and its detachment from annual political budget-making
and primary services
imperatives.

Teachers without blackboards, chalk, and Various Sources

textbooks simply cannot teach. In South Asia, an extremely high proportion (over 95 per cent) of
recurrent education budgets is spent on salaries of teaching staff, with negligible proportions (i.e.
below 5 per cent) remaining for educational material and maintenance.39 Even African countries devote
at least 5-10 per cent of the education budget to non-salary recurrent expenditure.40 In South Asia,
donors have also traditionally been unwilling to finance recurrent costs and prefer infrastructure costs
(such as schools and hospitals). This needs to change.

Nurses and doctors are unable to do their jobs

Figure 33: Intrasectoral Public Expenditure on
without medicines and supplies. In India, 65 Education across South Asia
per cent of the population is without access to
essential medicines.41 Sri Lanka, on the other
hand, ensures that medicines and supplies
account for one-third of recurrent expenditure.
The Sri Lankan government also generates
savings by procuring generic drugs at low cost.42
South Asian Association for Regional
Cooperation (SAARC) countries similarly can
explore a system of pooled procurement of
generic medicines so that the public health
system can save almost 3040 per cent on
costs.43 The price of all medicines (not just
essential ones44) needs to be controlled.45

Primary spends need to be prioritised. By 1900

most of the developed countries had almost
achieved universal basic education with 90 per cent literacy rates, but they continued to allocate 90 per
cent of education spends to basic education.46 Especially given that a majority of the tertiary spends
accrue to the rich (Section 3C: Why Subsidise the Rich?) and that countries like India already produce
an excess of urban doctors, focus needs to shift to primary education to promote social equality.47
South Asia too needs to increase expenditure on basic education to 90 per cent (Figure 33) to ensure
equal opportunities for the population at large to partake in economic growth.

36
 HOW TO MAKE A BIG DENT

ii. Invest in public systems: There are no quick fixes or magic bullets!
Horizontal and vertical programmes
Donors have typically emphasised vertical, disease-specific programmes for developing countries with
limited income streams. But Sri Lanka has succeeded not only in building a comprehensive horizontal
primary health care system with linkages of vertical disease-specific inputs but also spending less than
50 per cent of the World Banks stipulated minimum cost-effective package and without resorting to
user fees, community financing or third-party insurance. Its key to success has been consistent efficiency
gains of 25 per cent per annum48 through investment in primary health facilities, which can be used as
an infrastructure base for delivery of immunisation and other preventive services.

In the rest of South Asia there is an important need to integrate vertical programmes with the existing
infrastructure of general health systems in order to derive the greatest cost efficiencies and sustainability.
It is also crucial that in the process of replication and scaling up quality of essential service delivery
should not deteriorate or be compromised. The spread of HIV/AIDS in particular increases the urgency
of the challenges of ensuring quality healthcare. The region has particularly high levels of communicable
diseases and greater susceptibility of pregnant women to infectious and parasitic diseases than is the
case globally, and therefore holistic primary health care would have greater impact on preventing
avoidable deaths than disease-specific interventions.49

The Bangladesh NGO BRACs50 shashta shabikas (village-level community workers for primary care)
provide a useful model. These people are trained to deliver primary care, vertical programmes, or a
combination of both.51 The DOTS programme against tuberculosis was implemented as a partially
integrated programme with dedicated laboratory services, linked to generalist shasta shabikas in villages.
Innovative incentives were also introduced. Patients are required to pay a fee up-front, part of which is
returned upon successful completion of treatment and part retained by the shasta shabikas as an incentive
for patient compliance. Similar models of comprehensive primary health care need to be restored in
policy debates and practice across South Asia.

Regulate the non-government and private players

While governments need to play a leading role in financing and co-ordinating universal access to
essential services, given the trend of privatisation in South Asia, it is necessary to devise effective
strategies for collaboration. The state and non-state actors should function as symbiotic partners.
Governments need to co-ordinate the integration and regulation of the mushrooming private sector at
the primary level of education and health care. This can be best achieved by guaranteeing a legal
framework for essential services from a rights perspective and by monitoring and evaluation through
active engagement with both private sector and civil society as non-state actors.

That apart, suitable supply-side incentives such as large subventions of teacher salary based on free
enrolment of students (as successfully experimented with in the FSSP in Bangladesh) may be used as a
guide to register, inspect, and monitor the quality of private schools. In health care given the large
number of quacks and unregulated drugs on the market, a regulatory system with rigid quality standards
is essential to ensure that qualified retailers sell quality medicines only to recognised practitioners and
genuine patients.

Cost effectiveness and appropriateness of technology used for delivery of essential services are equally
important. Three-quarters of the aid to the water sector has been devoted to large systems of piped
water and sewerage connections. Instead, low-cost technologies52 like standpipes, hand pumps, gravity-

37
 SERVE THE ESSENTIALS

fed systems, rainwater collection, and latrines need to be promoted as not only are they more sensitive
to local needs but also have proven to be greatly cost-effective in terms of each incident of diarrhoea
death averted.53

iii. Rebuild the public service ethos

Their (relatives of patients) anger is spilling over in assaults on doctors, unheard of till now in a country
where the medical profession is worshipped next to God
Dr Armida Fernandes, 2005
Former dean of a state government hospital in Mumbai city 9954

Teachers, nurses, and doctors hold the key to the solution, not the problem. Given the sustained
neglect of most South Asian public services, they are generally unwilling to attend schools and
health centres, which are largely under-equipped, under-funded, understaffed, and overcrowded.
Increasing their work ethic and efficiency is crucial to make any visible progress in the delivery of
essential services.

Pay suitable salaries, fill vacancies, and improve working conditions

In order to supplement my salary of Tk 7200 per month, I cultivate land on holidays and vacations to
enable my family to meet its needs due to the high price of essential goods. I am not involved in private
tutoring. On an average I take 5 classes a day and the average size of the class is around 80 students.
Swapan Mitra, 2006
Headmaster, Khalilnagar Government Primary School, Bangladesh 55

In none of the South Asia countries is

Figure 34: Real value of salaries of teachers in
the salary of teachers greater than the
Sri Lanka in relation to other government
World Bank norm of 3.5 times of per employees (1978 = 100)
capita GDP. 56 In Sri Lanka, teachers
earned only about 85 per cent of their
130
incomes in 1978 in real terms, resulting Government minor employees
in poor teacher motivation (Figure 34).57 120
Salaries eroded by inflation affect teacher
and health worker morale, forcing them 110 All central government officials

to take second jobs and indulge in

Percent

100
corruption.58
Government non-executive officers
90
Ensuring suitable salaries of education and
health workers could go a long way 80
Teachers salaries
towards rebuilding their morale and
efficiency. When the Dhaka Water 70
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Supply and Sewerage Authority (DWSSA)
employees trade union was given one Source: World Bank (2005) Treasures of Education System in Sri Lanka,
zone to self-manage, it improved water Executive Summary, Overview, Principle Findings and Options for the
Future, World Bank, Sri Lanka
supply, customer services, and revenue
collection simply by doubling employee salaries and utilising their experience through participative
decision-making.59

A large number of teacher and health worker posts which routinely remain vacant across South Asia
need to be filled. In India, one-third of all primary schools are single teacher units with multi-grade
classrooms.60 In Bangladesh there enough trained schoolteachers for only half of the 18 million primary

38
 HOW TO MAKE A BIG DENT

school age children, at the recommended Table 7: Current shortage of public sector
ratio of 1:40. Health workers too need to workers
Primary Teacher Health Worker
take on multiple responsibilities. In rural
Shortage Shortage
India about 49 per cent of doctor posts in India 276,441 1,346,861
primary health centres remain vacant. 61
Pakistan 234,940 285,986
Despite the vast pool of educated
Bangladesh 246,883 200,399
unemployed, 62 India, Pakistan and
Nepal 20,638 52,691
Bangladesh rank as the top three countries
Sri Lanka 0 23,802
worldwide in terms of the shortage of
Afghanistan 52,722 46,374
teachers and health workers (Table 7).
Total 831,624 1,956,113

Teachers and health workers are less likely Source: Calculations by Oxfam based on consultation with
UNESCO, WHO, and GCE
to be absent from those schools and clinics
which have been inspected recently, have better infrastructure, and are closer to a paved road. Improving
working and living conditions is crucially important to rebuild public sector ethos.

Create rural bias and invest in nurses and midwives

The skewed deployment structure of health and education workers needs to change.

Because of inefficient placing and monitoring systems, many of our poorer schools are understaffed.
Angela Wijesinghe, 2006
All Ceylon Teachers Union in Sri Lanka63

Rural areas across South Asia suffer from an acute shortage of education and health personnel. Doctors and
teachers do not normally want to stay there. In Nepal only 20 per cent of rural physician posts are filled,
compared with 96 per cent in urban areas.64 In India, Pakistan, Bangladesh, and Afghanistan 7080 per cent
of the population live in rural areas but 90 per cent of the doctors are located in urban areas. This situation
needs to be reversed. Service contracts such as those used in Malaysia, the Philippines, and Sri Lanka can be
implemented to ensure that medical personnel spend a few years in public service in rural areas.65 The
existing ineffective transfer system for teachers in Sri Lanka and India also needs to be reformed.66

Nurses and midwives are essential to ensure the fulfilment of the MDG heath goals in South Asia.
India would require an additional 325000 nurses by 2015, and for national needs alone an additional 225
nursing colleges need to be constructed. 67 International migration of nurses also needs to be
rationalised.68 In Bangladesh, the engineering staff for water and sanitation in the Department of
Public Health Engineering (DPHE) need training in socio-economic disciplines, including
communication and awareness-raising, critical to sanitation and hygiene.

C. WORK WITH OTHERS

Civil Society Actors as Symbiotic Partners

South Asia has one of the worlds most buoyant civil societies, including over 100,000 non-government
organisations.69 In the last few decades, civil society actors have played multi-faceted roles such as
alternative service providers, innovators, critical thinkers, advisers, watchdogs, advocates, and policy
partners.70 The fundamental responsibility for the planning, co-ordination, regulation and provision of
essential services lies with the state. Civil society has proven to be an able partner when there is limited
state capacity to build systems which can potentially be transferred to the government for long-term
sustainability. The roles of the state and civil society are largely complementary in this regard.

39
 SERVE THE ESSENTIALS

In Bangladesh, a large proportion of those enrolled

Figure 35: Oxfam laying pipes for
in Registered Non-Government Primary Schools water connections to hand over to the
(RNGPS) compared to government schools are from Batticloa Water Board
households below the national poverty line. 71 In
Afghanistan due to low state capacity the interim
government has contracted external agencies, primarily
NGOs, in the Basic Package of Health Services (BPHS)
to avoid duplication of a multitude of donors. Donors
are also crucial partners in supporting long-term
investment and in Sri Lanka foreign assistance for
education covered 25 per cent of capital expenditure
over the period 19941998. 72 NGOs/CSOs are
important allies in the delivery and monitoring of
essential services.

The role of civil society working with the private sector

has led to encouraging innovations. For example Oxfam
Novib, through a collaboration with a Dutch
multinational and its NGO partner Proshika in
Bangladesh, has devised an innovative solution to tackle
the problem of arsenic contamination on a large scale.73
This can potentially save between 35 and 60 million Source: Oxfam GB/Sri Lanka/2006
people at risk. The best practice emphasis needs to be
on upgrading and supporting government systems rather than replacing them (Box 12).

Since the start of the new millennium there has been a trend among NGOs to shift their focus from
delivering services to being policy partners and advocates.74 For starters, they are being consulted more
and more in the policy-making process.75 As advocates, NGOs worldwide are increasingly forming
coalitions from the macro to the micro level (for example the Global Call for Action Against Poverty
and Indias Wada Na Todo coalition [Dont Break your Promises]) in order to perform their role as

Box 12: Upgrade and Support Rather than Replace Government Services
Pratham, an NGO that began in Mumbais slums in 1994 with the aim of helping the government in its
quest to universalise primary education, has today spread to 13 Indian states. Pratham has employed a
variety of strategies to improve the formal school delivery system. The accelerated learning method
teaches an illiterate child reading and basic mathematics in a mere three weeks to prepare out-of-school
children to re-enter formal school. Pratham also provides balwadi (crche) programmes for pre-school
children and balsakhi (tuition support) programmes to support academically weak students. Pratham
receives assistance from Oxfam Novib as well as other donors. It is based on a unique triangular partnership:
government, the corporate sector, and citizens. The model is easy to replicate as no immovable assets
are acquired. The unique feature of Pratham is that it does not create any parallel structures. It utilises
government schools to conduct after-school classes, improves quality within formal classrooms, and
supports home-based pre-school centres.
In Sri Lanka, Oxfam has supported the National Water Supply and Drainage Board to renovate and
rehabilitate the water supply system of Batticoloa Municipal Council and Kathankudy urban area. This is
expected to benefit more than 10,000 people. The project mainly covers repairs, operations, and
maintenance of existing water supply infrastructure (Figure 35). Similar initiatives are planned in
Thiruperumthurai areas to improve the distribution system in the tsunami-affected areas. Oxfam intends
not only to upgrade the facilities but also to train the local municipal staff in maintenance of equipment
and then hand over the renovated systems to the municipality to ensure the sustainability of the project.
Source: Oxfam NOVIB, Pratham and Oxfam GB in Sri Lanka

40
 HOW TO MAKE A BIG DENT

watchdogs of governments and donors.
Similarly, the Peoples Health Movement
(PHM) with a strong presence in Bangladesh
as a global coalition of varied civil society
actors including peoples organizations, civil
society organizations, NGOs, social activists,
health professionals, academics and researchers
from 80 countries upholds the vision of a truly
comprehensive Health for All agenda. In South
Asia, the experience of Prathams ASER Report
and CAMPEs Education Watch (Box 13) also
indicates that civil society voices have begun
to function as credible policy advocates. This
trends needs to be bolstered with state
commitment for inclusive stakeholder
Box 13: NGO Eyes Monitors Government
Systems
Education Watch is an independent citizens report
currently in its eighth year of publication in Bangladesh.
As the name suggests it watches and monitors different
aspects of the education for all agenda. Under the
auspices of CAMPE a coalition of around 700 NGOs
Education Watch has emerged as a leading civil society
voice in advocating for educational improvements. These
insights of an independent eye are particularly important
as Bangladesh has achieved massive increases in
enrolments in primary education in less than a decade.
Education Watchs research methodology and inclusive
civil society participation, which has been acclaimed by
Columbia University assessments, holds a mirror to the
government to guide and steer it towards the dream of
quality Education for All.

participation. Prathams Annual Status of Education Report (ASER), on

Community Involvement and
Ownership
As primary stakeholders, community
members hold the key to the monitoring of
essential services. Nepal 76 has recently
embarked on an ambitious effort to devolve
public school management responsibilities
to parents and influential local citizens. It is
the only country where the community has
been granted the right to fire government
teachers who do not perform their duties and to index teacher salaries to school performance. The
verdict on the suitability of this devolution of power is yet to be given, but it offers an important
model of inclusive community participation.
the other hand, monitors only one aspect of education quality
do children learn in school? The first edition, based on an
exhaustive nationwide survey in 2006, depicted startling
results: 35 per cent of primary school children were unable
to read a simple paragraph and 41 per cent unable to
solve a two-digit subtraction or division problem. Pratham
aims to conduct ASER surveys annually until 2010 (the
governments deadline to achieve universal elementary
education) in order to keep the issue alive in the public
eye and help planners devise strategies for improvement
of education quality, especially in regions with the greatest
deficit.
Source: Oxfam NOVIB, CAMPE, Pratham

In contrast, the Total Sanitation Campaign in India Figure 36: Community working together
suffers from lack of community ownership especially for installation of sanitary latrine,
Kurigram, Bangladesh
when construction activities are contracted out by
the panchayats 77. Community-managed urban toilet
complexes can be more desirable than contractor-
managed toilets in urban slums. WaterAid has
demonstrated in more than 400 villages in
Bangladesh that open defecation can be completely
stopped through participatory public outreach
programmes like Community Led Total Sanitation
(CLTS), which increase community awareness of the
risks of open defecation.78 Similarly, communities
have been encouraged to join citizen action groups Source: River Basin Programme/Oxfam GB/ Bangladesh/
2005
to monitor water service delivery (Box 14).

41
 SERVE THE ESSENTIALS

Box 14: Citizen Action to Build Accountability

WaterAid has pioneered the concept of Citizen Action, which enables communities to engage with
service providers and governments in order to improve water and sanitation services. To bridge the
accountability gap, WaterAid facilitates citizens to collect information about services, entitlements,
and responsibilities. Local communities use a range of methods for collecting and analysing information
report cards, community scorecards, mapping access, and control of water and sanitation facilities.
This leads to a process of constructive dialogue with providers on entitlements and practical solutions.

In Nepal this process has resulted in the production of a report card on governance in Thimi Municipality
and the creation of water and sanitation user groups across rural areas. Community consultation in
the disputed ADB $ 500 million Melamchi project in Kathmandu Valley has resulted in several positive
steps including a reduction in average connection cost from $156 to $26 per household, installment-
based payment systems for the poor, and low-cost tariff for the first ten cubic metres with incremental
increases by volume. However, some concerns, especially those of poor households, remain unresolved.
Source: WaterAid, 2006, Bridging the Gap: Citizens Action for Accountability in Water and Sanitation, New Delhi

Pro-poor community participation however need not only be at the decentralised level, which may
suffer from undue biases of caste, class, gender, and other entrenched societal forms of discrimination.
In Sri Lanka basic decisions about the health system are not taken at the local level, but nationally,
where poor people have a more powerful voice in macro issues, which can be resolved through central
government action; for example the redistribution of resources from the wealthiest parts of the country
to the poorest.79

Public perceptions and social consensus are important in ensuring effective implementation of the
legislation to guarantee universal rights to essential services. In Himachal Pradesh a large measure of
the success of the education revolution can be attributed to the social effectiveness and policy space
provided to parents to demand fulfilment of the right to education. The active participation of Gram
Panchayats, Mahila Mandals (womens groups), Yuva Mandals (youth groups), Parent-Teacher Associations
(PTAs) and Village Education Committees (VECs) have played an important role in improving
educational provision80. Multi-stakeholder participation in essential service provision across South Asia
needs to be encouraged in letter and spirit.

Voices of local communities as primary stakeholders of essential services have also been effectively integrated
at varied levels from the global to the local. The Global Campaign for Education (GCE)81 co-ordinates
decentralised policy calls by national civil society coalitions within an umbrella of global advocacy on
education (for example campaign actions include send your politician to school, creation of local missing-
out-maps etc.). Trade unions of teachers and health workers can also play a crucial supportive role in
campaigning. In the Indian state of Uttar Pradesh, the Primary School Teachers Association (UPPSS)
with a membership of 300,000 teachers has been working closely with UNICEF for the last eight years
to improve girls education through a School Chalo Abhiyan (Go to School enrolment campaign).82
These powerful multi-stakeholder campaign initiatives can potentially transform the delivery of essential
services in South Asia.

REFLECTION: RECOMMENDATIONS TO POLICY MAKERS

This report analyses the state of essential services in South Asia and the impact on the basic human
development needs of its inhabitants. While much progress has been made since independence, there
is widespread inequity of access to and variable quality of essential services due to sustained deterioration
of the public delivery mechanism. However, pockets of success indicate that change is within reach
the most crucial ingredient is political commitment to uphold the rights of the population and deliver

42
 HOW TO MAKE A BIG DENT

what they need. This commitment needs to be translated into the following mutually reinforcing
policy actions by both donors and governments across South Asia:

Create a robust political commitment to the delivery of essential services

Eliminate user fees in education and heath
Eliminate both direct and indirect costs for all end-users of health and education services
and cross-subsidise water for poor people
Support universal rather than targeted programmes for the delivery of essential service
Ensure legal safeguards for universal access by adopting universal legislation
Adopt a multi-pronged strategy to fight corruption
Implement society-wide right to information laws
Weed out corruption in essential services delivery
Ensure that essential services are truly sensitive to the needs of women
Increase womens role in community decision-making
Hire more female teachers and health workers

Rebuild capacities in public delivery systems

Make financial commitments and priorities
Governments need to allocate at least 20 per cent of their annual expenditure to basic
services, based on their commitment at the Copenhagen summit in 1995
Donors need to reverse the trend of declining overseas development assistance in South
Asia and likewise invest at least 20 per cent of their aid to support basic services. This aid
must be co-ordinated, predictable, long-term and comply with the Paris commitment in
2006 on aid effectiveness.
Prioritise primary levels of service
Need to ensure that at the very least 1520 per cent of total government annual recurrent
expenditure is devoted to non-salary quality-enhancing inputs
Governments should regulate private service providers to ensure quality standards and
affordability
Build the public sector work ethos
Ensure teacher salaries are at least 3.5 times the national per capita GDP
Hire 800,000 teachers and 1.9 million health workers in South Asia
Improve infrastructural conditions in schools and health clinics
Create rural bias in service delivery through service contracts
Employ and train more nurses rather than doctors

Work with other stakeholders

Promote partnerships with civil society especially as policy partners and advocates
Foster social consensus and community ownership to value essential services from a rights
perspective

43
 SERVE THE ESSENTIALS

The lives of millions of poor people in South Asia crucially depend on these basic actions. South
Asia, with the largest concentration of poor people in the world, needs to make a huge step forward
in this battle against impoverishment. Concerted action to provide universal education, health care,
water supply, and sanitation of good quality have enabled dramatic strides in human development
within some pockets of South Asia. The time has now come for the entire region to emerge as an
influential global voice on the strength of its overall development both economic and human. The
annals of history eagerly await the erasure of poverty and inequality. The efficient delivery of free
and good quality essential services will be key.

44

Endnotes
1. Essentials of Essential Services in South Asia
1
UNESCO (2006) EFA Global Monitoring Report 2006, Education for All:
Literacy for Life, Paris: UNESCO.
2 Annual Global Development Conference of the Global Development
Associated Press (2006) Mortality Rates climb in Afghanistan, Health,
20 April 2006; R. Bakshi (2006) Maternal Mortality: A woman dies every
5 minutes in childbirth in India, Health, 2 March 2006, UNICEF.
3 Ibid. In recent decades, the sectoral and geographical pattern of
With the exception of East Asia, South Asia has recorded the highest
worldwide average real GDP growth rates for the 10-year period 1998
2007. For the period 20012005, South Asian countries under study
grew at exceptional average growth rates: India 6.7 per cent, Pakistan
4.9 per cent, Sri Lanka 3.9 per cent, Bangladesh 5.3 per cent. Nepal,
due to its brewing political turmoil, has been an exception with only 2.6
per cent. Even Afghanistans 12.5 per cent since 2003, after the fall of
the Taliban, is substantive despite the low base. The growth rates of CIS
and East Asia are projected to taper off, while during the ten year period
19982007 the advanced countries are projected to have grown only at
2.6 per cent and Africa at 4.3 per cent. The International Monetary Fund
(2006) World Economic Outlook 2006: Globalisation and Inflation, World
Economic and Financial Surveys, Washington: IMF.
4
South Asia has emerged as an important political voice in recent years.
India has recently increased the pressure for its claim for a seat in the
UN Security Council based on its newfound economic and nuclear
prowess. Pakistan and Afghanistan have emerged as important allies of
the United States in the war on terror. As Nepal grapples with the recent
transition to democracy and cessation of conflict, its success could
provide precedents for the rest of the world polity. Sri Lankas ability as a
middle income country to achieve high standards of human development
provides important lessons in development. Bangladesh is also rapidly
making inroads onto the world economic stage.
5
In Bangladesh the deaths of 125,000 small children every year due to
diarrhoea would be avoidable if half the countrys population had access
to clean drinking water and hygienic toilets. A. Lawson (2003) Dhaka
tackles diarrhoea deaths, BBC News, South Asia, 27 May, 2003. In
Nepal 50 per cent and in Pakistan 30 per cent of the deaths of
children under five years of age are due to diarrhoea. IRIN Asia (2004)
National campaign to treat acute diarrhoea launched, Pakistan: IRIN Asia.
6
Of the six countries in South Asia under study in this report India,
Pakistan, Nepal, Bangladesh, Sri Lanka and Afghanistan - due to general
paucity of research data from Afghanistan and Nepal this report has found
it difficult to source more accurate information from these areas
7
India, Pakistan (its eastern part would become Bangladesh in 1971), and Sri
Lanka all gained independence from the British Empire between 14 August
1947 and 4 February 1948. Nepal and Afghanistan had a slight head start in
their historical journey towards independence. Britain recognised the absolute
independence of Nepal in 1923 while Afghanistan gained full control of her
foreign affairs after the third AngloAfghan war in 1921.
8
This sub-section mainly draws from D. Kunda (2005) A Future out of
Grasp, weve seen Poverty, and It is Us, Analysis, Himal Magazine,
November 2005: Kathmandu.
9
Across South Asia, while there has been decline in levels of poverty,
inequality has increased at different spatial levels especially in urban
areas. In India the Gini coefficient has increased from 0.315 in 1994 to
0.378 in 1997. If this change in inequality had not occurred, the head count
rate of poverty in 19992000 is estimated to have been 1.2 per cent lower.
In Bangladesh similarly if inequality had not worsened from 0.259 to
0.306 between 1991 and 2000, poverty would have declined at twice
ENDNOTES
the rate it actually did. S. Jayasuriya (2002) Globalisation, Equity and
Poverty: The South Asian Experience, paper presented at the 4th
Network on Globalization and Equity held in Cairo, Egypt, January
1921.
10
growth seems to favour states with better initial conditions, while
those with low levels of initial human development have not been
well suited to reduce poverty in response to economic growth. Similarly
in Sri Lanka the estate plantations, which have poor human capital,
have experienced a widening of the Gini coefficient from 0.27 to
0.44 between 1980 and 1995, while the national average during this
period has remained constant.
11
Afghanistan as a South Asian country has not been depicted on this
map.
12
BIMARU (Hindi translation: sick) is an acronym to refer to the Indian
states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. In
terms of human development Orissa is also often grouped with these
states due to its chronic pervasive poverty and pathetic human
development indicators.
13
The statistics and data on Afghanistan presented in this report
therefore need to be viewed in the historical context and are not
strictly comparable with other South Asian countries analysed.
14
Inter Press Service News Agency (2003) Development: South Asia
Holds The Key To Millennium Goals, 8 July. London: IPS quoted in M.
Kulshreshta and A.K. Mittal (2005) Water and Sanitation in South Asia
in the context of the Millennium Development Goals, South Asia
Economic Journal 6:1.
15
In September 2000, 189 UN Member States adopted the Millennium
Development Goals (MDGs), setting clear, time-bound targets for halving
world poverty by 2015.
16
S. Mehrotra (2004) Reforming Public Spending on Education and
Mobilising Resources: Lessons from International Experience,
Economic and Political Weekly, 28 February.
17
Ibid. This phenomenon can be attributed to the emphasis on higher
education through government educational institutions and subsidies as
high as 70 times the per capita GDP to train each doctor.
18
Approximately 10 per cent of all start-ups in Silicon Valley between 1995
and 1998 were by Indians, most of whom had come from an Indian
Institute of Technology (IIT). IITs have, perhaps, produced more
millionaires per capita than any other undergraduate academic institution
in the world. M. Kanta (2003) The IIT Story: Issues and Concerns,
Frontline Essay, Volume 20, Issue 3, February 114.
19
The migration of health professionals from India, Sri Lanka, and Pakistan
began in the 1950s70s and later extended to Bangladesh and Nepal.
Nursing professionals moved mostly to the Middle East, but have recently
shifted attention (like the doctors) to the UK, US, and Australia. This
worldwide phenomenon has been described as a global conveyor belt
of health personnel moving from bottom to top. B. V. Adkoli (2006)
Migration of Health Workers: Perspectives from Bangladesh, India,
Nepal, Pakistan and Sri Lanka, Regional Health Forum 10(1). Similarly,
almost half the annual output of the seven IITs goes abroad every year.
The US alone has 25,000 IIT alumni. Kanta, op.cit.
45
 SERVE THE ESSENTIALS
20
While it is acknowledged that tertiary (especially vocational) education
can play an important role in technology transfer and rapid national
economic growth, as witnessed in East Asia, it must be noted that
even in South Korea tertiary education is completely privatised. As
the private-sector returns on tertiary education are high the individual
is expected to earn sufficiently after his or her higher education to
repay the cost of the education incurred through easily available
loans etc. S. Mehrotra (2005) Only Tiger Cubs become Tigers,
Columns, The Indian Express, November 10.
21
K. Watkins (2001) The Oxfam Education Report, Oxford: Oxfam.
22
ICESCR (2000) Twenty-second session, 25 April12 May 2000, New
York: United Nations.
23
R. Chinai and R. Goswami (2005) Are We Ready for Medical Tourism?,
The Hindu, 17 April. Over the next 10 years health care is expected to grow
to be US$1 to 2 billion, contributing 6.2 to 7.5 per cent of Indias GDP.
24
More than 500 women die during pregnancy for every 100,000 live births.
Z. Bhutta, S. Nundy, and K. Abbasi (2004) Replicating Kerala and Sri
Lanka, Elsewhere, Himal Magazine, May.
25
This is based on a UNICEF estimate quoted in Associated Press (2006)
op.cit. and P. Garwood (2006) Life Ending Before its Begun, e-Ariana,
The Star, South Africa, 27 April.
26
Badakhshan has a maternal mortality ratio (MMR) of 6,500 maternal deaths
for every 100,000 live births. More than 60 per cent of all childhood deaths
in Afghanistan are due to preventable respiratory infections, diarrhoea,
and measles.
27
GoI (2003) RCH Facility survey quoted in A. Das (2006) A New Plan
for Safe Motherhood, Maternal Mortality, 7 March, http://
www.indiatogether.com/2006/feb/hlt-deliver.htm.
2. What Works? The Case for Universal Public Provision
1
This section draws heavily on the analysis of Mehrotra, Vandemoortele
and Delamonica (2000) Basic Services for All? UNICEF Innocenti
Research Centre, Florence, Italy and Mehrotra (2000) Integrating
Economic and Social Policy: Good Practices from High-Achieving
Countries, Working Paper No. 80, UNICEF Innocenti Research Centre,
Florence, Italy. These sources include Sri Lanka, the Indian State of
Kerala, Malaysia, and the Republic of Korea as high achievers from Asia.
2
Sidney Buchman was an American writer and producer and President
of the Writers Guild of America.
3
World Bank (2005) Treasures of Education System in Sri Lanka,
Executive Summary, Overview, Principle Findings and Options for the
Future, World Bank, Sri Lanka. It is interesting to note that education
has been a burning emotive rallying point and one of several factors,
which led to the Sri Lankan civilian crisis. The standardisation policy in
higher education in the 1970s, which meant that Tamil students would
have to secure more marks than their Sinhalese counterparts for parity,
was heavily contested. To this day, the separatist group, the Liberation
Tigers of Tamil Eelam (LTTE) claims that there is a surplus of nearly
14,000 Sinhalese teachers and a deficit of around 10,000 Tamil teachers
and that the contentious standardisation system has even trickled down
to the primary level. Language of education has also been a serious
bone of contention and the LTTE has taken an initiative to translate
textbooks into Tamil, prepare notes for teachers, buy textbooks from
publishing houses and appoint teachers with salaries in the conflict-ridden
North-East. The Government of Sri Lanka however has accused the
LTTE of using schools as platforms for propaganda. V.S. Sambandan
(2003) On Tiger Turf, Cover Story, Frontline, 5 December.
4
The exception has been that in the early 1980s Sri Lanka did rely heavily
on UNICEF and other NGO- sponsored programmes to deliver primary
health care nutrition supplements, recruitment and training of primary
health-care workers and so on in the plantation areas.
46
28
In Pakistan, more than 80 per cent of women give birth with the help
of traditional birth attendants (TBAs) but pregnancy complications
are on the rise due to lack of health-care facilities. G. Waqar (2004)
PMA report roasts health policy, practice, Daily Times, January 20,
based on evidence from the Pakistan Medical Association Annual
Report 2003.
29
In India a girl is 1.5 times less likely to be hospitalised than a boy.
Zinc Study Group (2005) The effect of maternal education on gender
bias in care-seeking for common childhood illnesses, Social Science
and Medicine, 60:71524. In Pakistan, there exists the curious
phenomenon of sons having better access to health care but not
necessarily being better fed than daughters. G. Hazarika (2000)
Gender Differences in Childrens Nutrition and Access to Health
Care in Pakistan, The Journal of Development Studies, 37(1): 73
92. It is argued that intra-household gender discrimination has primary
origins in higher returns to parents from investment in sons. In
Bangladesh, utilisation of health-care services even at a free
treatment unit showed marked male preferences. L. Chen, E. Huq,
and S. DSouza (1981) Sex Bias in Family Allocation of Food and
Health Care in Rural Bangladesh, Population and Development
Review, 7(1): 5570.
30
In Bangladesh, arsenic in shallow tube wells found in 59 out of the 64
districts has exposed an estimated 25 million people to toxins. In
Nepal, arsenic has been identified in 31 per cent of all tube wells.
31
West Baseline Livelihoods Monitoring Project reported in K. Kar
(2003) Subsidy or self-respect? Participatory total community
sanitation in Bangladesh, IDS Working Paper 184, Institute of
Development Studies.
32
UNDP (2003) Human Development Report 2003, Millennium
Development Goals: A compact among nations to end human
poverty, New York: Oxford University Press.
5
World Bank (2003) Investing in Maternal Health: Learning from
Malaysia and Sri Lanka. Washington, DC; World Bank (2003) Human
Development Network, Health, Nutrition and Population Series,
Washington, DC; and Mehrotra (2000) op.cit.
6
Literacy levels witnessed a quantum increase from 32 per cent in 1971
to 77 per cent in 2001 with female literacy trebling from 20 per cent to
68 per cent in the same period. Almost every child in the 614 age
group, regardless of sex or caste, is now enrolled in school. D. Sanan
(2004) Delivering Basic Public Services in Himachal Pradesh: Is the
Success Sustainable? Economic and Political Weekly, February 28.
7
A. Mansoor and R. Chowdhury (2005) Beyond Access: Partnership for
Quality with Equity, Beyond Access, Regional Seminar, Dhaka, 31
January1 February 2005.
8
Centre for Policy Dialogue (2003) Policy Brief on Education, Dhaka:
National Policy Review Forum Task Force Report.
9
Mehrotra and Jolly (eds.) (1997) Development with a human face:
Experiences in social achievement and economic growth, Clarendon
Press: Oxford.
10
V. Suresh and Vibhu Nayar (2006) Democratisation of water
management: Establishing a paradigm shift in the water sector: The
Tamil Nadu experiment with governance reform, WaterAid and World
Development Movement.
11
B. Calaguas and V. Cann (2006) Reforming public utilities to meet the Water
and Sanitation MDGs, paper presented at a conference at the UK DFID, 4
July 2006, organised by the World Development Movement and WaterAid.
12
N. Hossain and N. Kabeer (2004) Achieving Universal Primary Education
and Eliminating Gender Disparity, Economic and Political Weekly,
September 4. They argue that political support for educational expansion

in Bangladesh in the post-democratic period appears to derive from inter-
party competition for ideological influence in the form of teachers (or
village-level bureaucrats) not only to ensure a political presence at the
heart of rural society but also to control the curricula as a medium of
national identity formation. The active role of the student movement in
political struggle for independence in the 1970s and the subsequent
surge in educational expansion during Ershads time (198291), as a
measure to garner popular support for a military dictatorship, have also
contributed to the importance of education.
13
Z. Hasnain (2005) The Politics of Service Delivery in Pakistan: Political
Parties and the Incentives for Patronage 19881999, Washington DC:
The World Bank. With the arrival of democracy in Pakistan 1985, there
was a surge in school construction and teacher recruitment. From 1985
to 19992000, the number of public primary schools increased nationally
by 70 per cent and the teachers almost doubled. In the Sindh province
primary schools increased by 180 per cent and teachers by 125 per
cent! But ironically this was marked by a decline in net enrolments. One
reason could be that teachers were recruited primarily on patronage
grounds, and schools were built of poor quality because of the
commissions given to the contractors. Since non-salary recurrent spends
for operations and maintenance were neglected, the quality of education
was adversely affected. A political economy explanation could be that to
get elected, politicians must credibly communicate to voters that they
are personally responsible for certain improvements which tend to favour
targeted benefits or patronage, rather than universal public goods. For
example even though patronage-based recruitment of teachers benefits
only the teachers selected, these clients will be well-informed about
who was responsible for hiring them. But if meritorious teachers are
routinely recruited then while education will clearly improve, it will be
difficult for voters to assign credit to a particular politician. This reiterates
the fact that often there is no systematic relationship between
development expenditures and human development outcomes.
14
J. Drze (2004), Democracy and the Right To Food, Economic and
Political Weekly, 24 April.
15
There are a range of factors which contribute to Sri Lankas low spending
on education as a percentage of GDP in recent years. Sri Lanka built up
its capital stock of schools during the 1950s1970s, so that there is
now no need for major investment in the construction of classrooms and
new school buildings. The education capital budget has therefore sharply
declined in recent years with a high proportion of investment expenditure
financed through donor-funded projects (approximately 68 per cent of
the capital budget) and comparatively low teacher salaries (Sri Lankan
teachers receiving salaries about half or less, as a proportion of national
income per capita, than teachers in countries such as India, Bangladesh,
Malaysia, Thailand, and South Korea).
16
While education up to university level is free and enrolments near universal,
Sri Lanka has not yet achieved universal secondary completion, with about
18 per cent of children failing to complete grade 9.
17
S. Mehrotra (2000) Integrating Economic and Social Policy: Good
Practices from High-Achieving Countries, Working Paper No. 80,
UNICEF Innocenti Research Centre, Florence.
18
R. Cassen, G. Kingdon, K. McNay and L. Visaria (2005) Education and
Literacy, Chapter 7, Twenty First Century India: Population, Economy,
Human Development, and the Environment, New Delhi: Oxford
University Press
19
WaterAid (2005) Drinking Water and Sanitation Status in India:
Coverage, Financing and Emerging Concerns, New Delhi: WaterAid.
20
S. Mehrotra (2005) Only tiger cubs become tigers, Columns, The Indian
Express, November 10.
21
K. Bhatty (2006), Social Equality and Development: Himachal Pradesh
and its Wider Significance, Doctoral Thesis (unpublished) submitted to
the University of London, London School of Economics
ENDNOTES
22
R. Rannan-Eliya (2001) Strategies For Improving The Health Of The
Poor: The Sri Lankan Experience, Health Policy Programme, Institute
of Policy Studies of Sri Lanka.
23
World Bank (2005) Treasures of Education System in Sri Lanka,
Executive Summary, Overview, Principle Findings and Options for the
Future, World Bank, Sri Lanka.
24
S. Mehrotra (1998) Education for All: Lessons from High-Achieving
Countries, International Review of Education 44 (5/6): 46184, quoted
in UNDP (2003) Human Development Report 2003, Millennium
Development Goals: A compact among nations to end human poverty,
New York: Oxford University Press.
25
National Commission on Macroeconomics and Health, Ministry of Health
and Family Welfare, Government of India, 2005.
26
Joint Learning Initiative (2004) Communities at the Frontlines, Chapter
2, Human Resources for Health: Overcoming the Crisis, Global Equity
Initiative, Harvard University.
27
PROBE (1999) Public Report on Basic Education in India, New Delhi:
Oxford University Press.
28
In 2002, India passed the 93rd Constitutional Amendment to make
primary education free and compulsory for all. Nevertheless only 14
States and Union Territories have laws which aim to achieve free and
compulsory primary education through local bodies.
29
Mehrotra and Delamonica (forthcoming), Public Spending for the Poor:
Basic Services to Enhance Capabilities and Promote Growth, Oxford:
Oxford University Press, quoted in UNDP (2003) op. cit.
30
In Sri Lanka, the midday meal scheme was withdrawn in the 1970s for a
short period but restarted in all schools in the 1990s both government
and private. It was very successful, with all schools reporting a much
higher attendance rate, but discontinued in 1992. It has now been
restarted in May 2006. It is only applicable to grade one and grade two
of the poorest 7384 schools in the poorest districts. Projects to Improve
Nutritional Status of Children, Sunday Observer, Daily News Online
Edition, 21 May 2006. The definitions of poorest however have not
been clearly defined.
31
R. Rannan-Eliya (2001) Strategies For Improving The Health Of The
Poor: The Sri Lankan Experience, Health Policy Programme, Institute
of Policy Studies of Sri Lanka.
32
In Sri Lanka doctors need to serve in rural areas for 56 years, but if
they are specialising in areas which rural hospitals do not have the
capacity for, then they can seek exceptions.
33
There has been sharp increase in demand for popular, prestigious urban
schools and decreasing demand for rural and less prestigious semi-
urban schools. This shift in demand has led to the existence of a large
number of very small schools. About 60 per cent of schools have less
than 300 students and 14 per cent schools have less than 50 students.
This network of small schools is expensive to maintain and operate.
Sixty per cent have student:teacher ratios of 15:1 or less. These small
schools typically have unit recurrent costs about 100 per cent greater
than large schools with student:teacher ratios of about 25:1. World Bank
(2005) Treasures of Education System in Sri Lanka, Executive
Summary, Overview, Principle Findings and Options for the Future, World
Bank, Sri Lanka. Therefore the government has shut down a number of
schools in an attempt to rationalise education expenditure. In tandem,
supportive measures have been initiated, such as providing subsidised
transport for school children in recognition of the fact that some need to
travel longer distances.
34
R. Rannan-Eliya (2001) op.cit.
35
Centre for Research in Rural and Industrial Development, Chandigarh
quoted in A. Zaidi (2006) Ailing System, Public Health, Frontline, 21 April.
36
R. Rannan-Eliya (2001) op.cit.
37
Ibid.
38
The drop-out rate in primary schools is less than 1 per cent, single
teacher schools 710 per cent, and gender parity 100 per cent. S.
47
 SERVE THE ESSENTIALS
Akshay (2003) Himachal Pradesh: Critical Issues in Primary Education,
Commentary, Economic and Political Weekly, June 21.
39
K. Bhatty (2006), op.cit.
40
P. Tripathi (2006) A role model for development, Interview with Virbhadra
Singh, Chief Minister, Himachal Pradesh, Focus: Himachal Pradesh,
Frontline 23(2), Jan. 28Feb. 10.
41
The achievement of gender parity is reflected not only in national
aggregates but has truly percolated across the social structure of
3. Whats Holding Others Back?
1
UNICEF (2005) Children unimmunized against measles in South Asia
in 2003, A Report Card On Immunization: Number 3, September.
2 thirds of all hospitals and nearly 40 per cent of the hospital beds. R.
The government is the largest provider of education in India with
only about 15 per cent of children enroled in private institutions.
UNESCO (2004) EFA Global Monitoring Report 2005, Education for
All: The Quality Imperative, Paris: UNESCO.
3
The security situation has worsened, with schools having emerged
as the latest soft targets of arsonists. Especially in the south,
schools have been burnt, teachers threatened and some even killed.
(D. Walsh, Fears of a lost generation of Afghan pupils as Taliban
targets schools, Special report Afghanistan, March 16, 2006.)
4
The rate of growth of the enrolments in Afghanistan presents an
unprecedented challenge. According to the Ministry of Education
(personal communication with Mr. Hameeda Karbolai, Head of Basic
Education Dept, 4th April 2006), enrolment in the formal primary
school system was approximately 55.5 million in 2006, an increase
of 50 per cent from 3.1 million students in 2003. This is in addition to
the 350 per cent increase in enrolments since the fall of the Taliban
in 2001.
5
These figures are for the year 2003. A. Strand and Olesen (Eds.)
(2005) Afghanistan: Findings on Education, Environment, Gender,
Health, Livelihood and Water and Sanitation From Multidonor Evaluation
of Emergency and Reconstruction Assistance from Denmark, Ireland,
the Netherlands, Sweden and the United Kingdom, CMI Report, Chr.
Michelsen Institute, R 2005: 15.
6
The Indian public health infrastructure consists of 17,000 public
hospitals, 23,000 PHCs, 1,37,000 sub-centres and 3,000 community
health centres, serving the semi-urban and rural areas. A.
Krishnakumar (2004) An Unhealthy Trend, Public Health, 21(24) The
Hindu, December.
7
K.R. Nayar (2004) Rural Health: Absence of Mission or Vision?,
Commentary, Economic and Political Weekly, November 6, and Banerji
Debabar (2005), Politics of Rural Health in India, EPW Perspectives,
Economic and Political Weekly, July 23.
8
Wada Na Todo (2005) Securing Rights: Citizens Report on MDGs,
People Speak The Truth about MDGs, Chap 5: Securing Rights:
Citizens Report on MDGs, p.26.
9
Ojha V and P Basanta (2006), The Macro-Economic and Sectoral
Impacts of HIV and AIDS in India: A CGE Study, United Nations
Development Programme
10
In Pakistan, there are only 455 rural health centres expected to
serve two-thirds of the population with a patient:hospital bed ratio of
only 1500:1. M. Shafqat (2003) Pakistans budget 2003-04: The
economics of hypocrisy, Report, Himal Magazine.
11
In India at the time it gained independence only 8 per cent of all
medical institutions were operated by private agencies, and 5 per
48
schooling in Bangladesh. A household survey in the catchment areas of
selected primary schools in 10 Upazilas shows broad-based gender
parity across the board among catchment areas, upazilas, school types,
and socio-economic groups. CAMPE, Education Watch 2003/4: Quality
with Equity: The Primary Education Agenda, Education Watch School
Catchment Area Household Survey, 2004.
42
A. Mansoor and R. Chowdhury (2005) Beyond Access: Partnership for
Quality with Equity Beyond Access Regional Seminar, Dhaka, 31
January1 February.
cent by the non-government sector which received government
grants, but by 1995 private hospitals represented more than two-
Baru (2003) Privatisation in Health Services: A South Asia
Perspective, EPW Commentary, Economic and Political Weekly,
October 18.
12
Afghanistan currently has just over 800 BHCs in total, but health
experts have estimated that it needs almost 6,000, given its
population size. A. Frumin, M. Courtney and R. Linder (2004) The
Road Ahead: Issues for Consideration at the Berlin Donor Conference
for Afghanistan, A CSIS Special report, Post-Conflict Reconstruction
Project, Center for Strategic and International Studies, Washington
DC, March 31April 1.
13
UNESCAP (2005) A future within reach: reshaping institutions in a
region of disparities to meet the Millennium Development Goals in
Asia and the Pacific, Programme Management Division, United
Nations Economic and Social Commission for Asia and Pacific.: A
Future Within Reach
14
In Orissa at one time there were as many as 14,000 vacant posts
in primary schools, while 89,864 additional posts were needed. A.
Ram (2002) Teachers by Contract: Quality Education Calls for
Dedicated and Competent Faculties, The Statesman, New Delhi,
Thursday 6 June.
15
P. Nilsson (2003) Education For All: Teacher Demand and Supply,
Education International Working Paper No.13, Brussels.
16
In India, in the post liberalisation period, unemployment on a Current
Daily Status basis rose from 6 per cent in 199394 to 7.3 per cent
in 19992000 resulting in an additional 27 million job seekers. Of
these, 74 per cent are in rural areas and 60 per cent of them are
educated. Planning Commission (2000), Special Group on Targeting
Ten Million Employment Opportunities per Year, New Delhi:
Government of India
17
The World Bank benchmark for low-income countries is
physicians:population ratio of 0.1:1000. S.Mehrotra (2004)
Reforming Public Spending on Education and Mobilising Resources:
Lessons from International Experience, Economic and Political
Weekly, 28 February. High-achieving countries those where life
expectancy is high and under-five mortality is low tend to have
more nurses per doctor. Mehrotra and Delamonica, forthcoming,
op.cit.
18
D.H. Peters, A. S. Yazbeck, R.R. Sharma, G.N.V. Ramana, L.H.
Pritchett, and A. Wagstaff (2002) Better Health Systems for Indias
Poor: Findings Analysis and Options, Human Development Network,
Health, Nutrition, and Population Series, Washington DC: World
Bank. India has only 0.79 nurses per 1000 people. The rule of
thumb is that there should be between 2 to 4 graduate nurses per
physician. India has a nurse:doctor ratio of only 1:1.

19
There are 0.5 doctors per 1000 people in Pakistan. M. Shafqat (2003)
op.cit. There are a mere 46,331 registered nurses for a population of
150 million people, stated the Pakistan Economic Survey, (2005)
quoted in A. Yusufzai (2005), Nurses Get Little Training or Respect,
Inter Press Service News Agency, 4 June.
20
N. Chaudhury, J. Hammer, M. Kremer, K. Mularidharan, and F. H.
Rogers (2004) Roll Call: Teacher Absence in Bangladesh, June, World
Bank.
21
In Bangladesh, metropolitan centres have only 15 per cent of the
countrys population, but have a concentration of 35 per cent of
doctors and 30 per cent of nurses in government positions. Unlike
India there are almost no doctors or nurses in the private sector in
rural areas. Joint Learning Initiative (2004) The Power of the Health
Worker, Chapter 1, Human Resources for Health: Overcoming the
Crisis, Global Equity Initiative, Harvard University. In Bangladesh
the doctor:nurse ratio is 3:1 when ideally it should be 1:3.
22
In Nepal, training of Auxiliary Nurse Midwives (ANMs) is also an acute
need as they are often missed out of in-service training. Oxfam GB
Nepal (2005) op.cit.
23
UNICEF is cooperating with UNHCR in order to identify professionals
among the returnees who fled the country during the conflict years
and are reluctant to leave jobs in other countries. According to Dr.
Nayeem Azim, chairman of Afghan Medical Association, There are
estimated to be about a thousand Afghan doctors and a few thousand
nurses in Pakistan alone and thousands more in Europe and North
America. The challenge lies in attracting them back to Afghanistan.
The British Medical Association has suggested that as an incentive
donor countries may be able to contribute by not withdrawing the
status of asylum in the host country for health professionals willing
to go back to Afghanistan. M. Taksdal (2005) op.cit.
24
WaterAid (2005) Bangladesh, Water Sector: National Water Sector
Assessment, New Delhi: WaterAid.
25
N. Chaudhury, J. Hammer, M. Kremer, K. Muralidharan, and H.
Rogers (2004a) Teacher Absence in India: A Snapshot, Journal of
the European Economic Association. 9 (2): 85-110
26
N. Chaudhury, J. Hammer, M. Kremer, K. Muralidharan, and H. Rogers
(2004b) Roll Call: Teacher Absence in Bangladesh. World Bank,
Washington, D.C.
27
E. M. King, P. F. Orazem, and E. M. Paterno (1999) Promotion with
and without Learning: Effects on Student Dropout, World Bank:
Washington, DC, quoted in Chaudhury et al. (2004a) op.cit.
28
The Sixth All-India Educational Survey, National Council of Education
Research and Training cited in PROBE Team (1999) op.cit. Primary
school teachers at Bihars government schools spend less than two
months a year in the classroom. The shortfall of 199,014 classrooms
indicates that the teacher:pupil ratio is 1:122. Teachers are routinely
employed for non-classroom duties and the state has failed to get the
second instalment of the central grant for education due to non-
utilisation of funds.
29
Pakistan Development Forum (2004) Challenge of Education and Economic
Growth, Government of Pakistan, Ministry of Education, March 1719.
30
Government of the Peoples Republic of Bangladesh (2003), Education
for All: National Plan of Action II 20032015, Fourth Draft, Ministry of
Primary and Mass Education, May.
31
Bruns, Minger, and Rakotomalala (2003) Achieving Universal Primary
Education by 2015: A Chance for Every Child, Washington DC: World
Bank.
32
N. Chaudhury, J. Hammer, M. Kremer, K. Muralidharan, and H.
Rogers (2005) Provider Absence in Schools and Health Clinics,
Journal of Economic Perspectives. 9 (2)
ENDNOTES
33
Pratichi (India) Trust (2005), Pratichi Health Report, TLM Books, New
Delhi
34
N. Chaudhury and J. Hammer (2003) Ghost doctors: absenteeism in
Bangladeshi health facilities, Washington, DC, The World Bank,
Policy Research Working Paper No. 3065.
35
Data on availability of essential drugs show that between 198283
the gap in availability was only 2.7 per cent but by 199192 it had
risen to 22.3 per cent when the drug price control went out of the
window. A. Phadke (1998) Drug Supply and Use: Towards a rational
policy in India, Sage, New Delhi cited in Wada Na Too (2005) op.cit.
36
State Bank of Pakistan (2004) The State of Pakistans Economy
First Quarter FY 2004, Special Section 1, Making Health Services
Work for the Poor in Pakistan: Rahim Yar Khan Primary Healthcare
Pilot Project.
37
A. Frumin, M. Courtney and R. Linder (2004) op.cit.
38
R. Baru (2003) op.cit.
39
Transparency International Bangladesh (2005) Corruption in
Bangladesh: A Household Survey.
40
D. Montero (2005) The Pakistan quake: Why 10,000 schools
collapsed, World: Asia: South & Central, Christian Science Monitor,
8 November.
41
Transparency International Bangladesh (2005) op.cit.
42
T. Begum et al.(1999) Unofficial Fees in Bangladesh: Price, Equity
and Institutional Issues, Health Policy and Planning 14(2): 15263.
All patients are supposed to be provided with required medicines for
free at public hospitals. But medicines constitute 85 per cent of
unofficial payments in the hospitals surveyed. Findings suggest
that middle-income and to some extent poor patients pay relatively
greater proportions of unofficial fees than the comparatively wealthy.
43
Transparency International Bangladesh (2005) op.cit.
44
Bangladeshs Expanded Programme on Immunisation (EPI) is often
cited as a success story not only of NGOGovernment collaboration
(B. Afrose (2001) Government: NGO Collaboration in Health and
Population Management in Bangladesh: Experiences from the Field,
IASSI Quarterly 20(1) JulySeptember) but also of combating mortality
it saves an estimated 4 million children each year. The EPI helped
increase coverage against six preventable childhood diseases
diphtheria, tetanus, tuberculosis, whooping cough, polio, and measles
by 70 per cent in three decades from 1973. The identity-blind approach
of EPI and the high visibility of vaccinations also helped the
programme receive substantial foreign aid. L. Russell (2006) A
Quick Jab: Bangladeshs renowned vaccination programme turns its
focus on measles, and provides an example for the rest of South
Asia, Report, Himal Southasian, MarchApril.
45
India, which initiated the DOTS programme to fight tuberculosis (TB),
has increased successful treatment of TB cases from three out of
ten cases in 1993 to eight out of ten in 2001. This is an important
achievement as India accounts for a quarter of the worlds TB cases
421,000 deaths per year.
46
In Afghanistan under the Taliban, measles claimed an estimated
30,000 lives a year. A campaign led by the Ministry of Health with
donor technical support and funding visited mosques in 2002 and
vaccinated 11 million children between the ages of 6 months and 12
years. Ninety-four per cent coverage was achieved nationally and
epidemic transmission has stopped. Afghanistans Health Challenge,
Editorial, The Lancet 362(9387), 2004.
47
The NRHM proposes to appoint 250,000 women for medical care
jobs, chosen by and accountable to the women in the community,
titled ASHA (Accredited Social Health Activist). However this
experiment has been tried in the past with the large-scale employment
of community health volunteers (CHVs) and serious problems arose
49
 SERVE THE ESSENTIALS
in the misuse of selection processes for political patronage. Caste
and class social prejudices restricted the utility of the CHVs and with
their extremely limited training most of them became quacks. K.R.
Nayar (2004) Rural Health: Absence of Mission or Vision?,
Commentary, Economic and Political Weekly, November 6.
48
The first initiatives of the NRHM apart from the Pulse Polio campaign
also include the Hepatitis-B vaccination drive which targets chronic
liver disease in adults. However, major causes of cirrhosis of the liver
are alcoholism and malnutrition. Vaccination drives tend to create
false promises, divert attention from basic underlying causes and
create demand for medical technology that may have only marginal
benefit. P. Ritu, A. Sagar, R. Dasgupta, and S. Acharya (2004) CMP
on Health: Making India World Class, Perspectives, Economic and
Political Weekly, 3 July.
49
The World Banks Booster Program to combat malaria, launched in
April 2005 in India, has come in for sharp criticism because the
publicised statistics of the decline in disease-incidence are inaccurate
and the Bank sanctioned purchases of $1.8 million, i.e. more than
100 million tablets of chloroquine even though this violates WHO
guidelines that chloroquine should explicitly not be used in conditions
such as those in India where highly resistant strains of the virus
exist. Attaran et.al. (2006) The World Bank: false financial and
statistical accounts and medical malpractice in malaria treatment,
Viewpoint, Published online April 25.
50
Chowdhury et. al. (2005) Bangladesh: Study of Non-State Providers
of Basic Services, Technical and Policy Research, DFID.
51
An international NGO in healthcare pulled out of Afghanistan in July
2004, following the murder of five of their staff in Badghis province.
At the time they provided assistance in 13 provinces with 80
international and 1,400 Afghan staff members. Clinics were rapidly
handed over to other NGOs and the Ministry of Public Health (MOPH),
but not with sufficient budgets, resulting in rapid decline of quality of
services. Ewen MacAskill (2004) Aid Agency Quits Afghanistan Over
Security Fears, Special Report, The Guardian, July 29
52
WaterAid (2005) Bangladesh: National Water Sector Assessment,
WaterAid Bangladesh.
53
J. Isham and S. Khknen (2002) The Institutional Determinants of
the Impact of Community-Based Water Services: Evidence from Sri
Lanka and India, Economic and Cultural Change, 50(3) April, University
of Chicago Press. This was based on a study of three community-
based rural water projects in Sri Lanka and the Indian states of
Karnataka and Maharashtra started in the early nineties. It suggests
that communities with a high level of social capital community
groups and associations are more likely to have better monitoring
mechanisms in place so greater investment needs to be made in
social mobilisation efforts (e.g. strengthening of local organisations)
and more direct supervision by project personnel working in these
communities.
54
In the Indian state of Andhra Pradesh, the biggest landlords and
contractors of the region headed the Water Users Association. P.
Sainath (2006) Thirst for Profit, Cover Story, Frontline, 21 April.
55
The study compared the progressive National Rural Support
Programme (NRSP) to those run by the Local Government and Rural
Development Department (LGRDD) and Public Health Engineering
Department (PHED). Atiq-ur-Rehman (2000) Book Review of Shahrukh
Rafi Khan, 1999, Government, Communities, and Non-Governmental
Organisations in Social Sector Delivery: Collective Action in Rural
Drinking Water Supply, The Pakistan Development Review, 39(2)
summer, Islamabad.
56
WaterAid (2005) op.cit.
57
In Sri Lanka, health-care facilities are minimal in the conflict-affected
north. In Colombo, in 2001, the maternal mortality ratio (MMR) was
50
just 0.2 per 10,000 live births, while rebel-held Kilinochchi registered
an MMR of 14.3, the highest for any district. Across all northern and
eastern districts, the MMR has deteriorated in comparison to pre-
conflict times. In Jaffna the MMR has increased from 0.3 in 1981 to
2.8, from 2.7 to 9.7 in Mannar, in Batticaloa from 1.0 to 5.1, in
Ampara from 0.6 to 9.7 and in Trincomalee from 0.4 to 4.1. The
availability of health personnel is the lowest in Kilinochchi at 0.036
per million persons in comparison to the national average of 0.45.
V.S. Sambandan (2003) A war-ravaged economy, Sri Lanka, Frontline,
August 15, 2003, p. 128-130. In 1993 in Jaffna 18.9 per cent of
children under 3 years were wasted (acutely malnourished), 31.4 per
cent were stunted (chronically malnourished) and 40 per cent were
below the expected weight for their age. Wickramage Kolitha, no date,
World Health Organization, Sri Lanka and University of NSW, School of
Public Health and Community Medicine, Sydney, Australia.
58
J. Praveen (2005) Withering Commitment and Weakening Progress:
State and Education in the Period of Neo Liberal Reforms, Economic
and Political Weekly, 13 August.
59
Dalit refers to lower castes in Hindu societies who were referred to
as untouchable.
60
Oxfam GB Nepal (2005) Suffering in Silence: Terror on the terraces in
Nepal, Public Health Assessment, MayJune.
61
Diseases of the poor refer to the repeated outbreak of communicable
diseases like malaria, gastroenteritis, kala azar, Japanese encephalitis
and so on, which show a distinct regional and social variation. In
India, these outbreaks have been largely confined to the poorer
states like Bihar, Madhya Pradesh, Orissa, Andhra Pradesh, and
Rajasthan and tribal and dalit populations disproportionately bear the
burden of mortality. R. Baru (2004) Abdicating Responsibility, Seminar.
Volume 537.
62
D.H. Peters et.al. (2002) op.cit.
63
Oxfam GB Nepal (2005) op.cit.
64
Until the early 1990s, each plantation had primary health-care officers
(Estate Medical Assistants - EMAs) who were paid for by the estate
funds. Estate health care was perceived as better than rural health
care. After the privatisation of estates however, the private
companies refused to fulfil health care responsibilities and the
government stepped in. EMAs were axed and doctors were appointed
to the estates but due to the difficult terrain and language issues
most doctors do not take up their posts. Workers find it difficult to
leave the estates to attend to their medical needs because of the
expense (due to long distances) and difficult terrain.
65
P. Sainath (2006) op.cit.
66
N. Ilahi and N. Grimard (2000) Pubic Infrastructure and Private
Costs: Water Supply and Time Allocation of Women in Rural Pakistan,
Economic Development and Cultural Change, 49(1) October, The
University of Chicago Press.
67
Despite the fact that women have a biological tendency to outlive
men (in all developed countries and most undeveloped ones, women
outlive men, sometimes by a margin of 10 years), in Pakistan and
Nepal women actually have shorter lives than men and in Afghanistan,
Bangladesh, and India their advantage is less than one year.
UNESCAP (2005) op.cit.
68
WHO (2005) Making Every Mother and Child Count, Switzerland:
World Health Organisation.
69
In broad terms, Asia-Pacific is where Africa was 12 or 13 years ago.
The physiological fact is that women are more than twice as vulnerable
to HIV/AIDS infection as men. The sociological fact is that in South
Asia womens subordinate status, in marriage and society at large,
makes them even more vulnerable. Bloom et.al. (2004) Asias
Economies and the Challenge of AIDS, Manila: Asian Development

Bank. In India more than 90 per cent of HIV-positive women are
married and monogamous (statement by Dr. Nafis Sadik, Special
Adviser to the United Nations Secretary-General and Special Envoy
for HIV/AIDS in Asia and the Pacific at the Asia-Pacific Women,
Girls and HIV/AIDS Best Practices Conference, Islamabad, Pakistan,
29 November 2004).
70
Pakistans National Programme for Family Planning and Primary
Health Care, created in 1994 to improve access to health care in
rural communities and urban slums, has relied heavily on the
performance of its 80,000 Lady Health Workers. Serious institutional
weaknesses - and governance deficiencies have adversely affected
the programme - shortage of equipment and staff in district health
offices, Basic Health Units (BHUs) and Rural Health Centres (RHCs),
especially of female doctors, nurses, lady health workers, laboratory
equipment, and drugs continue to pose serious constraints as the
referral services of the LHWs prove ineffective. Pakistan: evaluation
of the Prime Ministers programme for Family Planning and Primary
Health Care. Interim report. Oxford, Oxford Policy Management, 2000
quoted in WHO (2005) Making Every Mother and Child Count,
Switzerland: World Health Organisation. Government of Pakistan (2004)
Pakistan Millennium Development Goals Report 2004, United Nations
and Centre for Research on Poverty Reduction.
71
In the 1970s, training of traditional birth attendants (TBAs) in modern
methods of delivery became widespread in regions with a lack of
professional health personnel or infrastructure for maternity care.
While WHO encouraged this strategy until the mid-1980s, evidence
emerged that it had little impact on maternal mortality. While TBAs
were expected to persuade women with complications to go to
hospitals, they tended instead to delay or discourage women from
doing so as it affected their income. It will have taken more than 20
years to realise the failure of this strategy and there is a growing
realisation of the need to train professional midwives. World Health
Organisation (2005) op.cit.
72
World Bank (2001) Nepal: Priorities and Strategies for Education
Reform, Human Development Unit, South Asia Region.
73
Negative experience of incentives given to private hospitals, such as
excise duty exemptions, free land, etc. in lieu of treating 10 per cent
of inpatients and 40 per cent of outpatients free have been a dismal
failure. R. Baru, I. Qadeer and R. Priya (2000) Medical Industry:
Illusion of Quality at What Cost, EPW Commentary, Economic and
Political Weekly, July 15-21.
74
Observations of Jean Dreze, economist from Delhi School of
Economics; R. Chinai and R. Goswami (2005) Are we Ready for
Medical Tourism?, The Hindu, 17 April.
75
D. H. Peters et.al. (2002) op.cit.
76
Triequity (2001) Equity in Financing and Delivery of Health Services in
Bangladesh, Nepal and Sri Lanka: Results of the Tri-country Study,
Data International Limited, Nepal Health Economics Association,
Institute of Policy Studies.
77
WaterAid (2005) Profiling Informal City of Delhi: Policies, Norms,
Institutions and Scope of Intervention, New Delhi: WaterAid India.
78
H. Mumtazah (2003) Water for People, Water for Life, For the Right
Price, Pakistan Water Gateway, 28 February.
79
India is the tenth largest bottled water-consuming nation in the world
and is one of the fastest growing industrial sectors with a compounded
annual growth rate (CAGR) of 25 per cent and gross profit of 25 to 50
per cent. B. Chandra (2006) Bottled Loot: The structure and economics
of the Indian Bottled Water Industry, Cover Story, Frontline, 21 April.
80
In the Indian city of Jaipur, Coca-Cola which produces the bottled
water brand Kinley is reported to extract millions of litres of water
per day at the cost of 14 paise per 1000 litres (it takes 2-3 litres of
groundwater to make one litre of bottled water). B. Chandra (2006)
op.cit.
ENDNOTES
81
R. B. Kattan and N. Burnett (2004) User Fees in Primary Education,
Education Sector, Human Development Network, World Bank
Publications, Washington DC.
82
JBIC 2002, Bangladesh Education Sector Overview, JBIC Sector
Study, March 2002, Japan Bank for International Cooperation.
83
In Nepal while some services are free, all out-patient care requires a
nominal registration fee. In India while practices differ by state,
there are no formal fees for primary care. In Bangladesh there are no
official user fees at the primary health-care level.
84
Now, a patient entering any hospital in Pakistan, private or public,
has to provide their own medication, food and so on. User fees have
particularly increased after the passing of the Punjab Health Ordinance
in January 2002. Sind and Baluchistan governments have refused to
impose them. I. Humeira (2003) Health Care Privatization In Pakistan,
Corporate, Globalisation, Znet, February 7.
85
Cited in R. Priya, A. Sagar, R. Dasgupta and S. Acharya (2004) CMP
on Health: Making India World Class, Perspectives, Economic and
Political Weekly, 3 July. Also 33 per cent of the poorest income quintile
reported cost as the reason for not seeking care. Morbidity and
Treatment of Ailments: NSS Fifty-Second Round, July 1995-June 1996,
Calcutta.
86
R Pradhan, R Sundar and S Singh (2006) The Socio-Economic Impact
of HIV/AIDS in India, United Nations Development Programme
87
Connection charges range from between less than one to more than
ten months income for a poor family. Tariffs were found to be as
high as 6 per cent of a poor familys monthly income and set to
increase based on project conditions. No examples were found of
different tariffs for the poor. WaterAid (2006) Water for All? A study
on the effectiveness of Asian Development Bank funded water and
sanitation projects in ensuring sustainable services for the poor: A
synthesis report, WaterAid.
88
In India, quacks routinely administer intravenous fluids, antibiotics,
steroids, give dental treatment, treat infants, set fractures, and treat
arthritis, tuberculosis, and sexually transmitted diseases.
Pharmaceutical companies woo these practitioners with free product
samples since they are a large source of prescriptions, nursing
homes give them a fee to refer any complications to them. The fake
drug manufacturing industry accounts for a whopping 30 per cent of
total production.
89
W. Gillani (2004) PMA report roasts health policy, practice, Daily
Times, Tuesday, January 20.
90
R. Lakshmini (2006) More than 40,000 quack doctors practising in
Colombo, Daily News, Friday 12 May.
91
World Health Organisation (2006) Working Together for Better Health:
World Health Report 2006, World Health Organisation, Geneva.
92
R. Rannan-Eliya and A. Somanathan (2005) Access of the Very Poor
to Health Services in Asia: Evidence on the role of health systems
from Equitap, Meeting The Health-Related Needs Of The Very Poor
DFID Workshop, Workshop Paper 10, Sri Lanka 14th and 15th February.
93
Hospitalised Indians, on an average, spend 58 per cent of their total
annual income on medical expenses; over 40 per cent borrow heavily or
sell their assets to cover medical expenses and over 25 per cent fall
below the poverty line because of hospital expenses. P. Ritu et.al.
(2005) op.cit.
94
Mehrotra and Delamonica (forthcoming) op.cit.
95
The $500 million Melamchi project includes a proposal to build a 27km
tunnel to bring water to the water-scarce Kathmandu Valley. The initial
World Bank conditions attached to the construction loans included
that Nepal Water Supply Corporation (NWSC) be privatised. The
Bank pulled out of the project and was replaced by ADB, which
proposed private sector participation under the management contract.
However, due to political upheaval in Nepal the project is clouded in
uncertainty.
51
 SERVE THE ESSENTIALS
4. How to Make a Big Dent
1 14
From William Shakespeares play Julius Caesar, Act IV, Scene 3.
2
Excerpts from Martin Luther Kings I Have a Dream speech delivered
on the steps at the Lincoln Memorial in Washington D.C. on August 28,
1963.
3
A. Cowasjee (2003) Pakistan First, Opinion, Dawn, June 15.
4
Report of the CABE Committee (2005), Universaliation of Secondary
Education, Ministry of Human Resource Development, Department of
Secondary & Higher Education, Government of India.
5
Coalition for Health and Education Rights (2002) User Fees: The
right to education and health denied, A policy brief for the UN Special
session on children, CHER, New York, May.
6
In India, several cases have been reported of poor people being
excluded and rich people usurping the privileges of a Below Poverty
Line (BPL) card due to local class and caste politics. A. Sethi (2006)
Life Above Poverty Line, The States, Frontline, 23(2) Jan. 28Feb.
10. At the macro level the 55th National Sample Survey (NSS)
Consumer Expenditure poverty estimation methodology has been
disputed as it simultaneously uses a 7- and 30-day recall from the
same sample households.
7
The PESP relies on School Management Committees and head
teachers to identify pupils in grades 1-5 from the poorest households.
The student must attain 40 per cent marks in examinations and have
85 per cent attendance. However, two-thirds of the children from the
poorest category were not selected to receive the stipend while 27
per cent from affluent households received it. Forty-six per cent of
the stipend holders did not receive the full eligible amount, with girls
and students from the poorer families receiving less on average. R.
Choudhury and A. Mansoor (2005), Beyond Access: Partnership for
Quality with Equity, paper presented at the Beyond Access Regional
Seminar, Dhaka, 31 January 1 February.
8
Forty-eight per cent of children in Nepal, Afghanistan, Bangladesh,
and India are undernourished. In Sri Lanka while only 29 per cent are
malnourished in aggregate terms, the figure is as high as 46 per cent
among disadvantaged populations especially in the North-East, North,
Central, and Uva provinces.
9
World Bank (2006) Repositioning Nutrition as Central to Development:
A Strategy for Large Scale Action, Directions in Development,
Washington DC: The World Bank.
10
In response to public interest litigation by the Peoples Union for Civil
Liberties (Rajasthan) in April 2001, a Supreme Court order has directed
all state governments in India to provide cooked midday meals for
all children in government schools. The production of food has been
decentralised to NGOs, self-help groups, corporate houses, or
assistants within schools.
11
The midday meal is expected to reduce the drop-out rate by 5 per cent
per annum and result in retention of an additional 1.5 million children
every year. Planning Commission (2005) Mid-Term Appraisal of the
Tenth Five Year Plan (20022007), Government of India, Box 2.1.1
and Para 2.1.29.
12
Cited in J. Drze (2004), op.cit.
13
In Bangladesh the PESP has replaced the earlier Food for Education
(FFE) programme, which provided 2.2. million children from selected
poor families with 1520 kg of uncooked wheat per month for regular
school attendance. N. Hossain (2004) Access to Education for the
Poor and Girls: Educational Achievements in Bangladesh, paper
presented at a conference on Case Studies in Scaling Up Poverty
Reduction - What Works, What Doesnt, and Why, A Global
Exchange for Scaling Up Success, Scaling Up Poverty Reduction: A
Global Learning Process, Shanghai, May 2527.
52
In Afghanistan, the World Food Programme (WFP) provided take-
home food rations to 1.2 million students in support of the governments
Back to School campaign in 2002, to alleviate hunger and to encourage
enrolment, attendance, and school performance especially among
female students. They were supplied with 50 kg bags of wheat and 4
kg of cooking oil. But the sustainability of this programme remains in
question. E. Ebadi (2005) Sarghailan Girls Search High and Low for
Educated Husbands, In Depth, 5 May, Badakshan, Afghanistan, World
Food Programme.
15
In Sri Lanka, the midday meal scheme has been re-started in 2006
but it is confined to the poorest schools in the poorest districts. The
definition of poorest is ad hoc, with only a few schools receiving this
assistance.
16
In India, since the government classifies the population into Above
Poverty Line (APL) and Below Poverty Line (BPL) families based on
regular surveys and no one has a right to a BPL card and its benefits
of subsidised food rations, it weakens the ability of BPL households
to demand their rights, and destroys solidarity between the two
categories of households. J. Dr ze (2004) op.cit.
17
Education for All (EFA) refers to the international commitment first
made in Jomtien, Thailand during the 1990 World Conference on Education
for All. Having failed to meet the original 2000 target, this was reaffirmed
during the World Education Forum, 2628 April 2000, Dakar, Senegal.
The Dakar Framework for Action commits governments to achieving
quality basic education for all by 2015, with emphasis on girls and a
pledge from donor countries and institutions that no country seriously
committed to basic education will be thwarted in the achievement of this
goal by lack of resources.
18
In 1978, WHO member nations took a pledge at Alma-Ata to ensure
not only universal access to primary health care, but health for all
by the year 2000. The vision was to create universal, vertically
integrated, publicly provided health-care systems which could
potentially capture synergies by linking preventive activities with
ambulatory and in-patient clinical care; to improve quality and generate
cost savings from an integrated referral chain; and to provide universal
and equal coverage for all.
19
R. Rannan-Eliya and A. Somanathan (2005) Access of the Very
Poor to Health Services in Asia: Evidence on the role of health
systems from Equitap, Meeting The Health-Related Needs of The
Very Poor, DFID Workshop, Workshop Paper 10, Sri Lanka 1415
February.
20
Thomas Paine (the author of Common Sense, The Age of Reason,
and The Rights of Man) before his rise to fame and involvement in
the American War of Independence 1776, worked as a local collector
of excise (indirect) taxes in England in 1761-65. When he wrote in
support of a petition by tax collectors for a pay rise, he was sacked
from the government. D. Hall (2003) Public Services Work! Information,
insights and ideas for our future, Paris: Public Services International.
21
In Bangladesh and the Uttar Pradesh, teacher codes of conduct
have been in existence since the 1920s and 30s and were revised in
the 1970s. In Nepal, formal codes have been adopted since 1940.
However, there has been no systematic capacity building and most
stakeholders are not very familiar with the procedures for lodging
complaints against erring teachers. Khandewal and Biswal (no date),
Ethics and corruption in education, Section Two. Teacher codes of
practice in Bangladesh, India (Uttar Pradesh) and Nepal: a
comparative study, UNESCO, International Institute for Educational
Planning (IIEP).
22
The excessive incidence of private tuitions (A. Sen (2002), Introduction,
The Pratichi Education Report, Number 1, Pratichi (India) Trust) hides

the inefficiency of the school system and increases the inequity of
education outcomes across income groups. In India, the Free and
Compulsory Education Bill 2005 (draft 14.11.2005), which intends to
impose a blanket ban, states that, No teacher shall engage in any
teaching activity for economic gain, other than that assigned by his
employer or supervisor.
23
Some states in India have implemented pragmatic solutions such as
legalised private health practice by government doctors as long as
they pay 25 per cent of their private earnings for the maintenance and
upgrading of facilities in government hospitals. Verma Amita (2001)
UP to allow private practice by Doctors, The Asian Age, Mumbai, 6
March; Govt. Allows private practice by doctors: Kerala/ Code of
Conduct Announced, Thiruvananthapuram, The Hindu, 12 January.
Even in Sri Lanka, in 1977 public medical officers were permitted to
practise privately outside their working hours without compromising
on their public sector work ethos.
24
In Bangladesh 43 per cent of primary school students engage private
tutors, often the same teachers as they have in school (R. Choudhury
and A. Mansoor op.cit.), which constitutes 39 per cent of household
expenditure on education (Japan Bank of International Cooperation,
2002, Bangladesh: Education Sector Overview, JBIC Sector Study,
March). India, Pakistan, Sri Lanka, and Nepal also witness this conflict
of interest. Shunaid (2003), Tuitions and the Educational Racecourse,
Daily Times, May 9.
25
N. Vithal (2000) Combating Corruption, India 1999: A Symposium on
The Year That Was, Issue 485, Seminar, January.
26
To combat corruption in Pakistan, the ADB supports a $350 million
Access to Justice Program Loan, $150,000 Technical Assistance to
the National Accountability Bureau and $300 million Decentralization
Support Program. The UN, World Bank, and CIDA also support
programmes for public sector management, good governance and
transparency in tune with the 2002 cabinet approved National Anti-
Corruption Strategy.
27
S. Khan (2004) Bangladesh to Set up Anti-Corruption Commission, OneWorld
South Asia, 20 February; (2006) World Bank terms Anti-Corruption
Commission in Bangladesh a joke, Asian Tribune, Dhaka, 18 May.
28
The Ombudsman Act, 1980, and the Minister for Finance and Planning,
Mr. M. Saifur Rahman had declared that, the Office of the
Ombudsman will be operational soon (Speech on The State of the
Economy and the Economic Stabilisation Programme at Bangladesh
Development Forum Meeting held in Paris, 2002); this has not been
implemented even in 2006 (M. A. Halim (2006), Office of ombudsman:
Why the delay?, Law and Our Rights, The Daily Star, Issue No: 223
January 21). The word Ombudsman is Swedish in origin and literally
translated means grievance person. One of the principal functions
is to oversee the activity of executive and other state authorities by
considering citizens complaints against the actions of authorities or
their officials who violate citizens rights and freedoms.
29
The Convention on the Elimination of all forms of Discrimination
against Women (CEDAW), 1979, established the principle of non-
discrimination as a binding agreement and provided the basis for
equality between women and men by ensuring womens equal access
to and opportunities in, political and public life including the right to
vote as well as education, health, and employment.
30
Basu (2005), Women, Political Parties and Social Movements in
South Asia, United Nations Research Institute for Social
Development
31
The sexual abuse and general image of nurses as professionals has
deteriorated so gravely that enrolments at Peshawars biggest
undergraduate nursing school, Hayatabad, fell by 10 per cent this
year. A. Yusufzai (2006) Nurses Get Little Training or Respect, Inter
Press Service News Agency, 4 June.
ENDNOTES
32
UNICEF (2003) Accelerating Strategies for Girls Education, Education
Division, Programme Division, United Nations Childrens Fund, New
Delhi.
33
The combined expenditure of Indian states in the 1990s on medical,
health, sanitation, water supply and family welfare declined from 8.4
per cent of total expenditure to 7.2 per cent in 2001. Public investment
in public goods and primary and secondary services alone will require
2.2 per cent of GDP at current government prices. When added to
the current level of 0.9 per cent, the total public health spending (i.e.
expenditures incurred by the health departments at central and state
level) in proportion to GDP will be about 3 percent. Such spending will
bring down the household expenditures by over 50 per cent and entail
substantial health gains. This expenditure includes capital investment
required for building up the battered health infrastructure; subsidisation
of the Universal Health Insurance Scheme (UHIS) programme for
the entire country over the next 10-15 years; and recurring costs
towards, salaries, drugs, training, research and so on. GOI (2005)
Financing the Way Forward: Issues and challenges, Section IV,
National Commission on Macroeconomics and Health, Ministry of
Health and Family Welfare, Government of India.
34
An important commitment is the 20-20 initiative made at the World
Summit for Social Development (WSSD) in Copenhagen, 1995. The
commitment seeks to establish a mutual contract between donor and
recipient countries in which 20 per cent of the donor countrys
commitment to Official Development Assistance (ODA) and 20 per
cent of the recipient countrys public expenditure will be used on
basic social services such as primary health care with clean water
supply, sanitation, basic education and so on, as well as the
institutional capacity for delivering those services.
35
The Paris Declaration, endorsed on 2 March 2005, is an international
agreement to which over one hundred Ministers, Heads of Agencies
and other Senior Officials adhered and committed their countries and
organisations to continue to increase efforts in harmonisation, alignment
and managing aid for results with a set of monitorable actions and
indicators.
36
B. Bruns, A. Mingat, and R. Rakotomalala (2003) Achieving Universal
Primary Education by 2015: A Chance for Every Child, Washington
DC: World Bank, p. 101.
37
M. Kulshreshta and A.K. Mittal (2005) Water and Sanitation in South
Asia in the Context of the Millennium Development Goals, South
Asia Economic Journal, 6(1). These estimates assume that $75 per
capita would be required apart from existing current domestic
investments and that additional domestic investments will be made
in the same proportion as the present.
38
Currently three quarters of the funds channelled by international
donors to private projects by-pass the government. The World Bank
has declared that a basic package of health services contracted
outside the government system can be 50 times more expensive.
For example, the Louis Berger Group, which was contracted to
construct 23 schools, has an average cost-per-classroom of $22813,
double the government average. F. Nawa (2006) Afghanistan Inc: A
CorpWatch Investigative Report, April.
39
In India, non-salary expenditures increased only modestly from 1.2
per cent of total expenditures in education in 1992 to 4.7 per cent by
1998 and from 18.5 per cent of total expenditure in health in 1992 to
29.5 per cent by 199899. In Pakistan the greatest deficit of non-
salary expenditure is in Punjab and Sindh provinces, which allocated
only 4 per cent of total expenditure to education in 198999. In North
West Frontier Province and Baluchistan approximately 10 and 8 per
cent respectively are dedicated to education. The health care situation
is comparatively better across Pakistan, with Punjab and Sindh
allocating 40 per cent to non-recurring expenditure. Z. Hasnain
(2005) op.cit.
53
 SERVE THE ESSENTIALS
40
During 197597 developing regions exhibited different patterns of
public enrolments and recurrent spending on primary education. In
South Asia, West Asia, and sub-Saharan Africa the number of
students enroled almost doubled, while recurrent spending increased
modestly. But in East Asia and Latin America and the Caribbean
enrolments remained stable, while recurrent spending increased
rapidly. Thus some regions invested in quantity (enrolments) and
some in quality (higher spending per pupil). UNDP (2002) Human
Development Report 2002: Millennium Development Goals: A compact
among nations to end poverty, New York: Oxford University Press.
41
UNDP (2001) Human Development Report 2001: Making Technologies
Work for Human Development, New York: Oxford University Press.
42
Mehrotra, Vandemoortele, and Delamonica (2000) Basic Services
for All?, UNICEF Innocenti Research Centre, Florence, Italy;
Mehrotra (2000) Integrating Economic and Social Policy: Good
Practices from High-Achieving Countries, Working Paper No. 80,
UNICEF Innocenti Research Centre, Florence.
43
GOI (2005) op.cit.
44
Price control should not be limited to essential drugs as the industry
can then simply switch its production to the non-controlled categories,
depriving people of access to essential drugs. Price control in
Canada is justified on the basis of the drug prices outstripping
wholesale price index. It will also address 5090 per cent of the
national health needs and reduce household spending. Ibid.
45
Rao (2005) Role of private Healthcare provider, Rural India, One
India One People, August.
46
Mehrotra (2004) Reforming Public Spending on Education and
Mobilising Resources, Lessons from International Experience,
Economic and Political Weekly, February 28.
47
In India in the midst of the recent upheaval of the reservation of
seats in tertiary education for Other Backward Castes (OBC), the
Prime Minister has announced plans to create four more Indian
Institutes of Technology (IITs) and dramatically increase the number
of medical seats at the cost of 8,000 crores to the exchequer, even
though India produces an excess of doctors.
48
R. Rannan-Eliya (2001) Strategies for Improving the Health of the
Poor: Sri Lanka Case Study, Health Policy Programme, Institute of
Policy Studies of Sri Lanka.
49
T. Mathew (2003) Matters of Life and Death, Essay, Himal South
Asia, April.
50
BRAC is the largest NGO in the world employing 97,192 people,
with the objectives of poverty alleviation and supports livelihoods
of around 100 million people in Bangladesh. From the time of its
inception in 1972, BRAC recognised women as the primary
caregivers who would ensure the education of their children and the
subsequent inter-generational sustainability of their families and
households. Its comprehensive approach combines micro-finance
with health, education and other social development programmes,
linking all the programmes strategically to counter poverty.
51
Joint Learning Initiative (2004) op.cit.
52
OECD (2003) Improving Water Management: Recent OECD
Experience, Paris. Cited in UNDP (2003) Millennium Development
Goals: A Compact among Nations to End Poverty, New York: Oxford
University Press.
53
UN (2006) Water a Shared Responsibility, The United Nations World
Water Development Report 2, Executive Summary, New York:
United Nations, UN-WATER/WWAP/2006/3.
54
Quoted in R. Chinai and R. Goswami (2005) Are We Ready for
Medical Tourism? Magazine, The Hindu, April 17.
54
55
Interview by Oxfam partner Uttaran in Upazila Tala in Satkhira District
Bangladesh in January 2006.
56
In the early 1990s, primary teacher salaries were 2.7 in Bangladesh,
3.4 in India, 2 in Nepal, and 3.6 in Pakistan in terms of GDP per
capita. Bruns et.al. (2003) op.cit.
57
While low teacher salaries have enabled the Sri Lankan education
system to deliver basic education services at a fairly low cost to the
government budget, this has hurt teacher morale and performance.
World Bank (2005) Treasures of Education System in Sri Lanka,
Executive Summary, Overview, Principle Findings and Options for
the Future, World Bank, Sri Lanka.
58
The starting government monthly salary for a medical doctor is BTK
7,400 (US$113), while for a nurse or a medical technologist it is BTK
2,550 (US$39). As a result of low salaries, it is estimated that about
30 per cent of those who work in the government sector are also
engaged in the private sector after government hours. World Health
Organisation (2006) Heroes for Health in Bangladesh: World Health
Day 2006, Working Together for Health, 20 April.
59
Similarly when Henry Ford in 1914 doubled autoworkers wages from
$2.50 to $5 per day, staff turnover and absenteeism fell and there
was a 5 per cent increase in labour productivity. D. Hall (2003)
op.cit.
60
PROBE (1999) Public Report on Basic Education in India, New Delhi:
Oxford University Press.
61
GOI (2005) op.cit.
62
In 2003 there were more than 10,200 unemployed qualified MBBS
doctors in India. More than 5,000 doctors in the Punjab, 3,000 in Sindh,
1,200 in Balochistan, and 1,000 in the North West Frontier Province
were jobless and most of the health units in the country were without
doctors. This was because provincial governments had a policy to
recruit doctors on contract only if they pass the Public Service
Commission examination which in Punjab has not been held for the
last ten years! G. Waqar (2004) PMA Report Roasts Health Policy,
Practice, Daily Times, January 20. H. Iqtidar (2003) Health Care
Privatization In Pakistan, February 7, Corporate Globalisation, Znet.
63
Telephone interview conducted by Oxfam GB staff in Sri Lanka in
May 2006.
64
WHO (2000) World Health Report 2000: Health Systems Improving
Performance, Geneva.
65
Service contracts, which require medical personnel to spend a certain
number of years in public service, are common in Latin America and
have also been implemented in the Philippines and Tanzania. In the
1970s Malaysia, another high performer, required all holders of
medical degrees to work three years for the government health
service enabling the government to post doctors to rural areas they
had previously avoided. UNDP (2003) op.cit. In India given the high
level of subsidies ($ 2000 per medical graduate) provided to public
medical students and the fact that more than 50 per cent of these
graduates each year migrate abroad, it is suggested that permanent
licenses and right to pursue postgraduate degrees be made dependent
on fulfilment of compulsory public service for at least five years, of
which three years must be at PHCs and rural hospitals. R. Duggal
(2000) Where are We Today, Unhealthy Trends: A Symposium on the
State of our Public Health System, Issue 489, Seminar.
66
In Sri Lanka, each teacher is transferred out to serve a minimum of
5 years in difficult districts even if their place of birth is classified
as a difficult district. This has led to high teacher absenteeism. In
India, the proposed Free and Compulsory Education Bill 2005 intends
to do away with the transfer system entirely and assign each teacher
to an individual school.

67
The demand from the United States alone is estimated to be 100000
nurses over the next decade. GOI (2005) op.cit. According to
established staffing norms for existing sub-centres, primary health
centres, and community health centres, the shortfalls range from 17
per cent for auxiliary nurse midwives, to 28 per cent for doctors, to
47 per cent for male multipurpose workers and nurse midwives.
Mehrotra (2004) op.cit. In India, the newly created Public Health
Foundation is mobilising resources to establish five schools of public
health spread through a publicprivate partnership with the Ministry
of Health. While this initiative is commendable, it needs to be
replicated multifold to make a sizeable impact on the nursing shortage.
According to Pakistan Nursing Association (PNA) chief Nazir Abdur
Rehman, in Peshawar in the capital of the North West Frontier
Province (NWFP), more than 100 nursing schools are without syllabus
or proper teaching staff and the stipend offered is unattractive.
68
WHO (2005) Efforts under way to stem brain drain of doctors and
nurses, news, In Focus, News, Bulletin of the World Health
organisation, February, 83(2).
69
Of these, 25,000 are in India, 22,000 in Bangladesh, 10,000 in
Pakistan, and about 18,000 in Nepal. S. Shah (2002) Development
critique, From evil state to civil society, Essay, Himal Magazine,
November. Some 30,000 are in Sri Lanka and 500 in Afghanistan.
70
UNESCO (2001) Report on the Special Session on Civil Society
Involvement in EFA at the International Conference on Education,
UNESCO.
71
NGO provision caters for around 1.3 million children, comprising
around 7 per cent of total enrolment. Of these, 60 per cent are
enroled in the BRAC primary education programme.
72
M. Ranaweera (2000) Donors and Primary Education in A. Little
(ed.) Primary Education Reform in Sri Lanka, Primary Education
Planning Project (PEPP), Educational Publications Department,
Ministry of Education and Higher Education, Colombo.
73
Oxfam Novib (2005) Clean Water for Bangladesh: DSM Dream Team
makes the dream a reality, Oxfam International website.
74
S. Schnuttgen and M. Khan (2004) Civil society engagement in EFA
in the post-Dakar period: A self-reflective review, Working Document
ENDNOTES
for the Fifth EFA Working Group Meeting (20-21 July 2004), UNESCO
NGOCCEFA (Collective Consultation of NGOs on Education for All).
75
In Bangladesh the Health and Population Sector Programme (HPSP)
in 1998 showed initial success in achieving radical structural reforms
(integration of health and family planning cadres under a single
management) and funding and official recognition of community
consultations in the design phase. But as this process was
abandoned in the implementation phase the new government was
easily able to reverse the unification process despite donor protests
due to lack of supportive civil society constituents. WHO (2005)
Making Every Mother and Child Count: World Health Report 2005,
Geneva: World Health Organisation, Box 7.6 Civil Society
involvement requires support.
76
Nepal has had a history of community-managed schools prior to
nationalisation in 1972 when the government took over. N. Choudhury
and S. Devarajan (2006) Human Development and Service Delivery
in Asia, background paper for the conference on Asia 2015: Promoting
Growth, Ending Poverty, London, March 6-7.
77
Twenty-five to 30 per cent of assets are out of function at any given
time. WaterAid India Annual Report 2005-2006.
78
K. Kar (2003) Subsidy or self-respect? Participatory total community
sanitation in Bangladesh, IDS Working Paper 184, Institute of
Development Studies.
79
R. Rannan-Eliya (2001) Strategies For Improving The Health Of The
Poor: The Sri Lankan Experience, Health Policy Programme, Institute
of Policy Studies of Sri Lanka.
80
K. Bhatty (2006), op.cit.
81
The Global Campaign for Education was created in 1999 by four
international civil-society organisations: Oxfam International,
ActionAid, Education International, and the Global March Against
Child Labour. The breadth of the GCE and its breadth of membership
has given its messages a greater legitimacy than campaigns of
individual coalitions.
82
Information from UNICEF Programme officer in Lucknow.
55
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