OVERVIEW 95737 Trust, Voice, and Incentives Learning from Local Success Stories in Service Delivery in the Middle East and North Africa Hana Brixi, Ellen Lust, and Michael Woolcock IBRD 41533 | MARCH 2015 B l a c k Sea C as p ian Sea Mediterranean Sea ATLANTIC Me S Y R IAN TUNISIA MALTA dite OCEAN rranean Sea LEBANON A. R . IRAQ ISLAMIC REP. MO RO CCO WEST BANK AND GAZA OF IRAN JORDAN KUWAIT A L G E R I A L I B Y A AR AB R E P . BAHRAIN OF E G Y P T SAUDI QATAR UNITED ARABIA ARAB EMIRATES Human Development O MAN Re Index (HDI), 2013 d Se a More than 0.8 0.71 – 0.8 REP. OF YEMEN 0.51 – 0.7 en Arabian Ad MENA average 0.72 f of Sea Gul 0.5 and less Non-MENA/non-OECD average 0.64 DJIBOUTI No data available OECD average 0.87 Data source: Human Development Index, United Nations Development Programme (UNDP). Overview Trust, Voice, and Incentives Learning from Local Success Stories in Service Delivery in the Middle East and North Africa Hana Brixi, Ellen Lust, and Michael Woolcock This booklet contains the Overview as well as a list of contents from the forthcoming book, Trust, Voice, and Incentives: Learning from Local Success Stories in Service Delivery in the Middle East and North Africa (DOI: 10.1596/978-1-4648-0456-4). A PDF of the final, full-length book, once published, will be available at https://openknowledge.worldbank.org/handle/10986/21607 and print copies can be ordered at www.amazon.com. Please use the final version of the book for citation, repro- duction and adaptation purposes. © 2015 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 18 17 16 15 This work is a product of the staff of The World Bank with external contributions. 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All queries on rights and licenses should be addressed to the Publishing and Knowledge Division, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@ worldbank.org. Cover design: Critical Stages Contents of Trust, Voice, and Incentives Foreword Acknowledgments Abbreviations Overview Introduction PART I Expectations, Reality, and Inspiration in Education and Health Services Delivery 1. A Demand for Better Services but Not Formal Accountability 2. The State of Education and Health Services Delivery: The Quality Challenge amid Impressive Advances 3. Local Successes: Satisfaction, Accountability, and Quality at the Local Level PART II  The Historical and Institutional Drivers of Performance 4. Historical and Cultural Roots of Citizens’ Attitudes and State Performance 5. Institutions Influencing the Cycle of Performance PART III  Service Delivery Performance 6. Service Delivery: Gaps in Providers’ Efforts and Abilities and in Inputs 7. Subnational Variation in Service Delivery Performance iii i v    Contents of Trust, Voice, and Incentives PART IV  Citizens’ Trust and Engagement 8. Citizens’ Response to Poor Performance and Unresponsive Institutions? Lower Trust 9. Effects of Lower Citizen Trust on Citizen Engagement: Circumventing the State, Relying on Wasta, and Pursuing Conflict PART V  New Openings 10.  Transitions, Conflicts, and Refugees: Both an Opportunity for and a Strain on the Cycle of Performance 11. Donor Support 12. Incremental Changes in the Social Contract and Local Empowerment Foreword T he Middle East and North Africa unprecedented improvements in basic human (MENA) is in a state of volatile development outcomes, as well as food and change. This period of change is fuel subsidies and employment in the public imposing hardships on the people of the sector. It gave rise to a social contract bind- region, and the outbreaks of conflict and ing governments and citizens, establishing violence represent a clear danger not only political legitimacy and strong nationhood regionally, but globally as well. and instilling citizens’ support for govern- Under the circumstances, it is essential to ment, as well as the expectation that the state focus on the welfare of the region’s youth and would assume responsibility for economic its economic and institutional health in order and social welfare. to build the foundation for lasting stability The post-independence social contract and shared prosperity. Public institutions and became unsustainable because it hampered services are central to this effort. In particu- the creation of the inclusive institutions and lar, it is crucial to harness the ability of pub- accountability mechanisms at the political, lic institutions to align their incentives with administrative, and social levels that would the needs of the people; the ability of educa- motivate providers, public servants, and tion systems to help the region’s children and policy makers to deliver quality services to youth develop the competencies and skills the poor and other non-privileged popula- that will serve them well for their future lives tions. As a consequence, the majority of Arab and livelihoods; and the ability of health sys- children are not learning well enough while tems to address the rapidly growing burden at school, and many mothers with young of chronic diseases, as well as the remaining children find health clinics closed, doctors pockets of high maternal and child mortality absent, or essential medicines out of stock and malnutrition. when they need medical help. In the aftermath of independence, lead- This report focuses specifically on the pub- ers of MENA countries promised their citi- lic institutions underpinning service delivery. zens industrialization and better standards In the right institutional environment, the of living through state intervention. That interactions between these various stakehold- intervention included the expansion of edu- ers create a virtuous cycle of performance. In cation and health services, which generated such a cycle, citizens have the means to inform v v i   F o r e w o r d policies and comment on the quality of ser- become a shared responsibility, and the results vices, and both public servants and provid- are impressive. The students excel in national ers are attuned to those opinions by a system tests despite the poverty and instability that of incentives that reward their effectiveness surround them. There are equally power- in responding to them. As services improve, ful examples in schools and health clinics in citizens’ trust in government increases, which Jordan and Morocco of citizens finding better serves to consolidate social cohesion. ways to provide services to their communities. However, this report documents that in There is no blueprint for creating the right the Middle East and North Africa this vir- accountability mechanisms to monitor and tuous cycle has not been achieved. Many of motivate public servants and service provid- the public institutions that deliver basic social ers. Every environment has its own distinct services are not responsive to citizens’ needs. social and political characteristics, and solu- As a result, services have suffered, leaving tions have to be either drawn from or adapted citizens with little recourse but to abandon to them. In this respect, we hope that the the system and seek alternate means of meet- report will prove useful to policy makers, ser- ing their needs. This negative cycle will have vice providers, and citizens alike. While map- to be broken in order for investments in edu- ping out the key drivers of effective service cation and health to begin delivering mean- delivery, it aims to launch a regional discus- ingful outcomes for the Arab people. The sion on local strengths as the source of poten- evidence clearly indicates that the poor— tial solutions. lacking the needed personal connections, the The World Bank Group stands ready to means to pay informal fees, or the luxury of contribute and help the governments and opting out from the public service system— people of the region promote inclusive insti- are the ones suffering the most from ineffec- tutions and create efficient service delivery in tive service delivery. order to better respond to citizens’ needs and In its search for solutions, the Bank team boost shared prosperity. has identified local examples of effective ser- vice delivery and shared the lessons learned. For instance, at a girls’ school in rural West Bank, a school principal has managed to Hafez Ghanem build a culture of inclusion and commit- Vice President ment among community members, parents, Middle East and North Africa Region and teachers. The success of the school has The World Bank Acknowledgments T his report is the product of the col- Jordanian governorates of ‘Ajlun, ‘Amman, laborative effort by a core team led by Al Balqa’, and Jarash; and a number of health Hana Brixi and composed of Ellen Lust clinics in Morocco. and Michael Woolcock (principal authors), This report benefited greatly from the as well as Jumana Alaref, Samira Halabi, feedback received during extended consul- Luciana Hebert, Hannah Linnemann, and tations. In particular, we are grateful to the Manal Quota. Brixi and Edouard Al Dahdah representatives of governments, academia, co-led the initial study design and coordi- nongovernmental organizations, and civil nated the early data analysis feeding into the society organizations who shared valuable background papers for this report. Those comments on the framework and findings papers were written by Hebert, Rohini Pande, of this report at the World Development and Quota. Alaref, Linnemann, Quota, and Report 2004 10th anniversary conference Woolcock developed the case study on edu- on “Making Services Work for Poor People: cation in Jordan, and Alaref, Osama Mimi, The Science of Politics of Delivery,” held in and Woolcock developed the second educa- Washington, DC, on March 1, 2014, and at tion case study, which is set in the West Bank. the Arab Development Symposium held in Melani Cammett, Cari Clark, Linnemann, Kuwait on November 5, 2014. We would also Lust, and Tamer Rabie delivered the case like to acknowledge the excellent comments study on health services in Jordan, and and suggestions received from participants in Cammett and Nejoua Balkaab produced the the Euro-Mediterranean Cycle of Economic one on health services in Morocco. Perspectives discussion series facilitated by the We sincerely appreciate the immense Center for Mediterranean Integration (CMI) hospitality and candor of the government in a seminar held in Paris on September 19, officials, health professionals, educators, par- 2014. Moreover, this report gained insights ents, and many other wonderful individuals from comments received from citizens of in various functions and roles who shared the Middle East and North Africa (MENA) their time and insights for the case studies: region in response to blog posts, online con- Kufor Quod Girls’ Secondary School in Jenin sultations, and social media outreach. in the West Bank; Jordan’s Zeid Bin Haritha Colleagues across the World Bank Group Secondary School in Yarqa; six clinics in the and members of the international academic vii v i i i   Ac k n o w l e d g m e n t s and research community contributed valu- We thank our peer reviewers, including able insights in a series of workshops and Mustapha Kamel al-Sayyid, Nick Manning, brainstorming meetings held from October Hart Schafer, and Allen Schick at the con- 2013 to November 2014, including the cept note stage, and Melani Cammett, Sami May 9, 2014 workshop hosted by the Middle Hourani, Stuti Khemani, Allen Schick, and East Initiative at Harvard Kennedy School; Joel Turkewitz in the decision review, for and the November 19, 2014, seminar spon- excellent comments and suggestions, which sored by the Global Partnership for Social have made a difference. Accountability in collaboration with the Our special thanks go to Shanta Devarajan Governance Global Practice, Education for strategic guidance; to Enis Baris, Mourad Global Practice, and Health, Nutrition and Ezzine, Caroline Freund, Guenter Heidenhof, Population Global Practice of the World Bank Steen Jorgensen, Harry Patrinos, and Hisham Group. They included Lindsay Benstead, Waly for insightful discussions and feedback Franck Bousquet, Marylou Bradley, Angela along the way; and to Mario Marcel Cullell Demas, Deon Filmer, Helene Grandvoinnet, and Joel Hellman for advice and qual- April Harding, Elena Ianchovichina, ity assurance at the final review stage. The Emmanuel Jimenez, Steen Jorgensen, Stuti work was supported by the MENA Chief Khemani, Elisabeth King, Pierre Landry, Economist’s Office, as well as the Governance Keit h M c L e a n , B a l a k r i sh n a M e non Global Practice, Education Global Practice, Parameswaran, Juan Manuel Moreno, Amr and Health, Nutrition and Population Moubarak, Stephen Ndegwa, Aakanksha Global Practice of the World Bank Group. Pande, Tamer Rabie, Halsey Rogers, Pia It was complemented by active engagement Schneider, and Joel Turkewitz. governance and service delivery in Jordan in ­ The following also provided very use- (Multi-Donor Trust Fund) and Morocco ful inputs: Dina Abu Ghaida, Ali Ahmed (Institutional Development Fund) and in Al-Mudhawahi, Edouard Al Dahdah, Ghazia the Local Governance Performance Index Aslam, Robert Beschel, Jurgen Blum, Kamel (MENA Governance and Anti-Corruption Braham, Dorothee Chen, Ernesto Cuadra, Fund), which are building on and seeking to Heba Elgazzar, Lire Ersado, Amira Kazem, operationalize the approach developed in this Hans Lueders, Alex Mckenzie, Marcos report jointly with clients and partners. Mendiburu, Paul Prettitore, Namrata Moving forward, the Governance Global Saraogi, Roby Senderowitsch, Samira Practice, Education Global Practice, and Nikaein Towfighian, Maria Vagliasindi, Health, Nutrition and Population Global Jeffrey Waite, Lianqin Wang, Clara Welteke, Practice of the World Bank Group have agreed Jakob Wichmann, and Noah Yarrow. to use the framework and conclusions pre- Heba Shamseldin, together with Ghanimah sented in this report as a prism in their effort Al-Otaibi, Ashraf Al-Saeed, Naga El-Swais, to enhance education and health services in Lara Saade, and William Stebbins, assisted the MENA region (see Maximizing the World in the online consultations and outreach con- Bank’s Impact in the Middle East and North ducted for the report. Sabra Bissette Ledent Africa: Global Practices—Middle East and edited the report. Etsehiwot Albert and Emma North Africa Region Partnership Report, Etori provided administrative support. published by the World Bank in 2014). Overview of Trust, Voice, and Incentives T he Middle East and North Africa out to the community, inspiring citizens’ trust (MENA) is a rising middle-income and engagement through transparent and region, and its citizens rightly expect inclusive decision making and the delivery of quality public services. Yet too often they excellent services. experience disappointment: students attend- Learning from such local successes is vital ing local schools are insufficiently prepared because there are no blueprints for solving for the 21st century economy, and those service quality problems. Countries around needing health care too often find that public the world are striving to improve education clinics have no doctors or medicines. Few in and health care quality. But simply modern- positions of authority are held accountable izing school and hospital facilities and train- for such shortcomings. This situation both ing staff are no longer sufficient. Delivering undermines the potential for improvement quality services requires motivated staff. And and heightens people’s unhappiness with the staff motivation arises in turn from values delivery system. and accountability, which are grounded in Although dissatisfaction with educa- the wider political, administrative, and social tion and health services is widespread in the rules, practices, and relationships. Providing MENA region, local successes do exist and high-quality services is hard; the World Bank offer inspiration. At the Kufor Quod Girls’ itself has struggled to ensure that its projects Secondary School in the rural West Bank, enhance incentives in country systems to for example, Ms. Abla Habayeb, the school’s achieve better learning and health outcomes. principal, provides her teachers with daily Finding solutions is especially difficult in encouragement and support, and she involves the institutional and sociocultural contexts community members, parents, and teach- in the MENA region. Its citizens not only ers in decisions about improving the school. demand better services but also expect their Teachers, students, and the community then government to provide them, reflecting the reciprocate that commitment. Thus, amid the promises made by Arab leaders at the out- surrounding poverty and instability, Kufor set of independence five decades ago that Quod girls excel in national tests. Similarly, the state would provide better living condi- in some poor villages in Jordan and Morocco, tions. Since then, MENA citizens have gained the leaders of schools and clinics are reaching nearly universal access to education and 1 2   T r u s t , Voice, and Incentives health care, which is a commendable achieve- adequate human and material resources, ment. Now they expect these services to be of and its g­ overnments are perpetually engaged high quality and create greater opportunities in reform efforts aimed at better service for all. ­ provision. And yet dissatisfaction among the Although they have excelled at building public runs so deep that failure to receive schools, constructing hospitals, and train- adequate services underpinned the calls ing staff, the region’s societies have fallen for karama (dignity) that echoed through- short in fostering the accountability and val- out the Arab Uprisings in 2010–11. Today, ues needed to motivate public servants and as the region continues to reel from deep service providers to deliver quality services. ­ d issatisfaction—struggling with ongoing Whether and how teachers teach, doctors transitions, conflicts, and fragility—it is ever treat the sick, and bureaucrats react to citi- more critical to assess the status of service zens’ demands do not seem to matter in the delivery, recognize the underlying causes of selection of leaders (and their promotions and problems, and look for effective solutions. salary increases) or in the social acceptance The dissatisfaction with services is wide- of public servants. Rather than performance, spread. In the 2013 Gallup World Poll, what seems to matter most for political and on average about half of respondents in professional careers are personal relation- the MENA region, compared with about ships and social ties. This limits citizens’ 30 ­ percent in Asia and Latin America and trust in and formal engagement with public the Caribbean, expressed their dissatisfaction institutions. To fulfill their needs, citizens with education services and health care in rely on their own relationships or informal their country. The 2010–11 Arab Barometer fees. Thus a cycle of poor performance has found that about two-thirds of MENA emerged, perpetuating a culture of privilege respondents perceived the performance of and cronyism. their government in improving basic health Improving the quality of public services services as “bad” or “very bad.” More will require breaking this cycle of poor broadly, citizens of the MENA countries tell ­ p erformance: making politicians, public pollsters that their government should do ­ servants, and providers accountable to citizens better in ensuring service delivery and fight- and promoting citizens’ trust in and engage- ing corruption. And yet they also express ment with state institutions. At the local little trust in their government’s involvement level, leaders and communities can inspire the in the social sectors. Moreover, they are less needed changes by demonstrating possible likely than citizens of other regions to seek local solutions and identifying the remaining accountability and tell public officials what systemwide constraints. Communities, states, they think (figure O.1). and donors that succeed in improving service quality and accountability will go a long way toward earning and retaining citizens’ trust. Local successes: Autonomy, accountability, and participation The average levels of citizens’ dissatisfac- Citizens’ expectations tion, however, mask significant variation The quality of social services provided in within countries and possible excellence in the Arab world lags surprisingly behind some localities. As we document here, some its potential. Historically, its citizens have communities have managed, often despite cared deeply about education, health, and difficult circumstances, to attain extraordi- other services; indeed, universal access to nary outcomes using innovative local solu- education and health is a constitutional right tions to the prevailing problems. These local in most countries in the Middle East and successes can provide useful insights and North Africa. The region is predominantly inspiration for practitioners, policy makers, composed of middle-income countries, with and donors. Ov e r v i e w o f T r u s t , V o i c e , a n d I n c e n t i v e s    3 Figure O.1  Voiced opinion to public officials in the last month: mena and other regions, 2013 100 90 80 70 60 Percent 50 40 30 20 10 0 Al p. Jo p. Ku p. n, m a Ar co Ye eba n en n Un t Ba Rep isia iA a ain A ria d an lic ic s Ba ia Qa t Sa L r W Ara Tu q A P R CD R C Ira ab E Gaz ta i am te ud iby L a m no e EN Re Re wa EA AF Ira EC b SA LA ite nk ub t, oc rd ,R ge Isl ira hr ra es b n OE M ab yp Mor Ar d Eg n ria Sy No Yes Source: Gallup World Poll, 2013. Note: AFR = Africa; EAP = East Asia and Pacific; ECA = Europe and Central Asia; LAC = Latin America and the Caribbean; MENA = Middle East and North Africa; OECD = Organisation for Economic Co-operation and Development; SAR = South Asia. Examples of local successes in service supervisors for Kufor Quod’s t ­ eachers, and delivery highlight the importance of auton- some autonomy in implementing school omy, accountability relationships, and par- improvement plans. ticipation at the local level. Although central Similarly, deep in Jordan the Zeid Bin management systems (such as the School Haritha Secondary School in the village of and District Development Program and the Yarqa has been achieving excellent results Health Care Accreditation Council in Jordan amid poverty and low capacity. Jordan’s or the Concours Qualité in Morocco) create national School and District Development environments conducive to providing quality Program, launched in 2009, encourages services, the impacts of such systems are not schools and directorates to collaborate with uniform. Our case studies uncover key drivers parents and communities, and it provides of change at the local level. They highlight the small school grants allowing some auton- importance of accountability relationships— omy. Involving parents and citizens as part- and the role of local leadership in sparking ners, however, has not come naturally in and institutionalizing such relationships—to traditional communities such as in Yarqa, trust and effective citizen engagement. with its deeply embedded lines of author- As noted earlier, the Kufor Quod Girls’ ity. It meant changing the leadership style Secondary School in a small village near of the school principal and teachers, creat- the city of Jenin in the West Bank traces ing a sense of common purpose around the its ­s uccess to parental and community school in the community, and establishing engagement and the ability of the school’s ­ new relations through a parent-teacher asso- principal to build and maintain a motivating, ciation and Education Council and making encouraging work environment for t ­ eachers. these new structures effective. Significantly, The principal has partnered with the Jenin the Education Council in Yarqa has reached school district to secure ­ support, such as out to parents and the wider community the pedagogical support of the ­ d istrict and gained their trust for its transparency 4   T r u s t , Voice, and Incentives and inclusive decision making. Furthermore, quality and innovative performance improve- friendly competition and rivalry among local ments among health workers. These clinics schools and communities have helped to exhibited a sense of a shared mission and a improve student outcomes. Student perfor- collaborative ethic, supported by good record mance in national tests has become a source keeping, transparency, participatory training of community prestige and pride. Supporting workshops, and attention to interpersonal student learning—and addressing obstacles relations. The clinic staff regularly communi- such as the school’s supply of electricity and cates with the provincial and regional officials some students’ vision impairments—has of the Ministry of Health to ensure adequate become a shared responsibility. supplies of medications and to solve related In the health sector, top clinics across implementation problems. Moreover, clinic Jordan benefit from partnering with local health workers actively engage with nearby social institutions and health committees and social organizations and ­ individuals—such as from formalizing health management pro- youth groups, the ­murshidat (women serving cedures at the local level. These steps have as religious guides), and women working in been facilitated by Jordan’s accreditation the local hammams (public baths)—to build process, which supports improvements in awareness of health issues such as family facility administration by establishing clear planning, HIV/AIDS testing, breast ­ cancer, rules and regulations and supporting moni- and chronic diseases. toring and transparency. Local leadership and engagement enhance the impact of such administrative reforms. In the locations we The cycle of poor performance visited, health committees have reached out Notwithstanding such examples of local to both citizens and health workers in gather- successes, a majority of MENA citizens rou- ing and addressing community needs, some- tinely experience a cycle of poor performance times uncovering—and resolving—hidden in their daily lives: political, administrative, challenges such as previously undetected high and social institutions fail to instill adequate levels of diabetes and hypertension in the Zay accountability and motivation in policy mak- community. In some communities, social ties ers, public servants, and service providers to have facilitated the process of establishing meet citizens’ needs. As citizens experience priorities, extending public health outreach, poor service quality, they increasingly regard and mobilizing resources to support health the government as corrupt and ineffective. clinic activities and development. Thus their trust in public institutions suffers, Finally, the best-performing rural health leaving them with few options other than clinics in Morocco draw effectively on their turning to informal social networks and strong partnerships with local communi- paying informal fees to tackle their individ- ties, on positive competition devised by the ual needs. As illustrated by our case studies, Ministry of Health, as well as on support the cycle of performance (figure O.2) may be from the provincial and regional offices of virtuous at the local level—with local formal the Ministry of Health available to reform- and informal accountability relationships oriented local leaders. Launched in 2007, filling the institutional gaps, motivating bet- Morocco’s Concours Qualité program of ter performance, and inspiring citizens’ trust competition among health facilities, involv- and formal participation—but it appears to ing self-assessment and audit by peers, recog- be stuck in a low equilibrium at the national nizes good work and motivates improvement. level in most MENA countries. The MENA It has been especially effective in the pres- region’s historical development explains ence of dynamic and visionary leadership at the initial factors underlying this cycle. As the local, provincial, and regional levels. The noted, that development led citizens to place excellent clinics we visited have translated a high value on education, health, and other such effective leadership into a culture of services and created expectations—stronger Ov e r v i e w o f T r u s t , V o i c e , a n d I n c e n t i v e s    5 than in other regions—that the state would Figure O.2  The cycle of performance provide these services, but the region largely eschewed the establishment of institutions geared toward meeting these ­ expectations. Citizens’ engagement: formal and informal Without dependable institutions and citi- zens’ trust in public institutions, there is little formal citizen engagement, institu- tions remain stagnant, and service delivery is poor. A central concern is thus how can this cycle of poor performance be overcome? Institutions: Below, we examine how the prevailing cycle Cycle of political is structured and reinforced. performance at administrative, Citizens’ trust in the national and and social public institutions local levels Political, administrative, and social institutions: Lack of formal accountability Political institutions in most MENA coun- tries lack accountability mechanisms, with citizens unable to obtain adequate informa- Performance: e ort and ability tion, voice demands, or incentivize policy to meet citizens’ needs makers and public servants through formal channels. Authoritarian regimes—which have the least constrained executives, the weakest parliaments, and the lowest l ­evels Citizens have few opportunities to provide of judicial independence in the world— feedback on performance quality and to seek dominate the MENA region. The region accountability. Accountability institutions lags behind other regions in its transparency, such as justice sector services, independent objectivity, and professionalism in civil ser- audit agencies, and ombudsmen are under- vice appointments and management. Directly developed in the region, making it difficult elected local governments are found in only a for citizens to submit complaints, hold public small minority of countries in the region, and servants and service providers accountable, where they do exist, councils have limited and obtain their rights. Executive authori- budgets and responsibilities. With the excep- ties tend to exercise influence over the judicial tion of the Arab Republic of Egypt, Morocco, branch and over agencies designed to address and the West Bank and Gaza, local council corruption. Independent audit agencies, budgets are less than 5 percent of total public inspectors general, and ombudsmen tend expenditures, far behind the world average of to lack resources, authority, and autonomy. 38 percent for federal systems and 22 percent Political capture has promoted a system that for unitary ones. lacks the information needed to monitor and Opacity further undermines ­ accountability. evaluate performances. As a result, there are Freedom of information and public disclo- few consequences when violations occur and sure laws and practices that would allow very few performance-oriented incentives citizens and intermediaries to monitor govern- and norms for providers and administrators. ment activities are either lacking or are not Weak, politically captured regimes are ­ implemented. On the Global Integrity Index, coupled with—and compound—ineffective the region ranks the lowest on the public administrative systems and accountability access to information indicator, the legal right mechanisms. Administrative institutions to access information, and whether the right suffer from highly centralized and opaque of access to information is effective. bureaucracies and weak management 6   T r u s t , Voice, and Incentives systems, and service providers and public regularly produce or disclose criteria against servants are rarely held accountable. Local which their performance could be indepen- administrators and service providers have dently monitored. This is in part because little influence on policy formulation and of capacity weaknesses—that is, a lack of implementation, and they lack autonomy facility-level information and weak monitor- to manage human resources, make finan- ing and internal controls—and little enforce- cial decisions, enforce rules, or bring about ment and performance management. It also change on their own without the blessing reflects political capture at the national and of the central authority. At the same time, subnational levels that subverts incentives they face little oversight of and pressure on toward establishing accountability. their own performance. Information on Because state institutions lack both inter- the performance of frontline service pro- nal and external accountability, social norms viders, such as schools and health facilities and regulations within society and com- and their staffs, is generally not collected, munities can play a vital role in motivating evaluated, or followed up on. For example, policy makers, public servants, and service surveys in Egypt and Morocco suggest that providers. Social institutions emphasize obli- ­ teachers appear to be minimally assessed, gations to members of social networks over and school inspections generate little action. national welfare. The result is the widespread With some exceptions (such as the United practice of wasta (figure O.3), a form of Arab Emirates) government agencies do not ­ clientelism, as well as a willingness to treat Figure O.3  Importance of wasta in obtaining a government job, by municipality: Jordan, 2014 100 90 80 70 60 Percent 50 40 30 20 10 0 a ad ra rn n n A Bayba in l A an a gh ha ad o ra Al ah bia M Sh kh W ssa S za fa dis ra n M ab ib ss uda Al ssak Afrah W Ma hn h sh GAl A kun Ha aribKara na im Ka Ass a i A fra uq Al alith a Sh ia s Al asi ara ha l R a Ka ayt za Al Al nje s ha a a A ’O ib Ni ia 1 Haith 1 l M asi 1 a2 nn je 3 W di M sou 2 a A an ar Al am ba 2 a w Deir adis a 1 a K A As ia 2 ’A A am 1 ad A S a 1 Al Al ma 2 ik yb 1 al 3 Ka 1 A ou a 1 Kh Al l Ma sa 2 ou 5 M Al 2 W Kaf Al Jo 3 i u 4 B am 2 M Th 2 A a i Al Mousa 4 As Al Tqab ni l Al l B lad Al Syim b’i i M hn f ir ma f Ta ari ba fr i yn l B al hm e fra Ra fri da da a m Th ayd uk A wd ut iri A Al lat Ja Ka ashm ad k u Am am Su il Al Al Z Raj ow Qa na a ub a n a Sh nje Ta ra Th sa Al ia id l ak m a ad o e i M usa un h br as ’E Ra az a a h l s’a Anjunu a r s Q m B w W i M nj Umshm u ro y H n r Ar S l A M ka Al lJ sh As aA yb un Al Ta sh As Al Essential Very useful Moderate use Some use No use Source: Governance and Local Development survey, 2014. Note: The numbers next to some localities (municipalities) indicate that they are sublocalities or areas within them. The numbers were added for survey purposes; they are not official administrative boundaries. Ov e r v i e w o f T r u s t , V o i c e , a n d I n c e n t i v e s    7 informal payments as a necessary practice. the local level. Surveys suggest that provid- Wasta allows individuals to obtain public ers may not possess the qualifications and services, jobs, and other economic opportuni- professional autonomy, among other things, ­ ties, and preferential treatment when dealing needed to deliver quality services, par- with administrative procedures. In this way, ticularly in rural localities. They also often wasta can undermine fairness and equality of lack key resources such as teaching materi- opportunity as well as erode administrative als and medicines. Meanwhile, their efforts systems and overall state performance (as, for appear to be lagging: 30 percent of students example, when the recruitment and advance- in MENA countries attend schools in which ment of administrators and service providers principals reported that teacher absenteeism are based on wasta rather than merit). The is a serious problem (figure O.5). Similarly, strength of social institutions at the local health professionals exhibit high levels of level varies and is likely to explain some of dissatisfaction, and absenteeism surpasses the variation in performance, including edu- 30 percent in countries for which data cation and health services delivery, as well as exist: Egypt, Morocco, and the Republic of some of the elements of success in the local Yemen. Where observations exist, the adher- case studies described in this report. ence to curricula in schools and to clinical care ­protocols in health facilities appears low ­(figure O.6). Public sector teachers and Performance in education and health: health workers tend to offer some services The quality challenge and subnational as private efforts for a fee, which can create variation a conflict of interest. In Egypt, for example, Education and health outcomes have 89 percent of private physicians also work in improved in recent decades, but they have public facilities where they may be absent or not kept up with demands. In most MENA extend little effort during official hours while countries, outcomes such as school enroll- giving their best performance at their private ments or child mortality have converged practice. to their expected levels based on economic development. The quality of services has not, however, kept pace with the broader socio- Figure O.4  Percentage of respondents reporting payment of economic transitions. MENA students score informal fees, education and health care sectors: mena region low on international competency tests, and and globally, 2013 graduates struggle to find jobs while employ- ers report vacancies unfilled due to skill 60 gaps. Health inequities based on income, gender, degree of urbanization, and age per- 50 sist. The out-of-pocket health expenditure is 40 high by international standards, leading to Percent 30 impoverishment and to forgoing health care because of its cost. Citizens typically find 20 little information publicly available about the 10 performance of schools and health facilities or about fees at health facilities. The lack of 0 . . ria an co za a ep ep q A transparency can give rise to informal user al si Ira EN Ga oc ob rd ge bR ,R ni M Tu Jo or en Al Gl nd ra fees, which about one-third of citizens of M m t, A ka Ye an yp MENA countries have reportedly paid in the tB Eg es education sector and especially in the health W Education sector Health sector sector (figure O.4). Service delivery is characterized by the Source: Global Corruption Barometer, 2013. weak efforts and capacity of providers at Note: MENA = Middle East and North Africa. 8   T r u s t , Voice, and Incentives Figure O.5  Percentage of students whose principals report that teacher absenteeism is a serious problem in their school: mena region and globally, 2011 60 56 50 40 40 33 Percent 30 27 26 24 22 20 18 13 12 10 7 7 5 2 1 0 s ic r a ain on CD CD p. co sia an an za A ta te bi bl EN Re Ga oc rd Om an ni Qa ira OE OE hr ra pu M Tu Jo or ic iA b Ba d Em n- Re am Le M n ud No ka ab b Isl Sa ra an Ar n, nA tB Ira d ite ria es W Un Sy Source: TIMSS, 2011. Note: MENA = Middle East and North Africa; OECD = Organisation for Economic Co-operation and Development. Figure O.6  Adherence to care protocols for diabetes and coronary heart disease in health facilities: Arab Republic of Egypt, 2010 Take blood pressure in the arm Examine the chest Examine the abdomen while the patient is in supine position Weigh the patient Examine feet or any wound or pressure points Examine the back of the thorax with a stethoscope Examine the patient for sensations and reflexes Measure the blood sugar with stick Measure the circumference of the waist Conduct an eye exam using an ophthalmoscope Measure the circumference of the hips 0 20 40 60 80 100 120 % of chronic care observations CHD Diabetes Source: EHGS, 2010. Note: CHD = coronary heart disease. Ov e r v i e w o f T r u s t , V o i c e , a n d I n c e n t i v e s    9 The quality of service provision varies sig- citizens and demonstrated by the available nificantly within countries, in part because of evidence can be traced to the weaknesses in the weak national political and administra- the effort and capacity of providers. Such tive institutions and the resulting influence weaknesses in turn reflect the characteristics of social institutions and local governance of the prevailing political, administrative, practices. Indeed, the results in education and social institutions, especially the weak (such as student test scores) and the quality accountability mechanisms facing policy indicators in health (such as the adherence to makers, public servants, and service provid- care protocols) exhibit significant subnational ers. The lack of simple monitoring and inter- variation. nal controls undermines the distribution of Service delivery process indicators vary textbooks to schools and medicines to health as well within countries. Examples are staff facilities. The interplay of formal and infor- absenteeism and qualifications and the avail- mal pressures and norms at the national ability of instructional materials, essential and local levels influences the efforts of medicines, and other key inputs (figure O.7). providers. The patterns across service delivery indica- tors also vary, showing little correlation, for Citizens’ trust and engagement: example, between staff effort and the avail- Shaped by service delivery and state ability of key inputs. This may indicate that performance staff, materials, and other inputs in service delivery are managed in an insular manner, Citizens’ experiences when they visit a health along the vertical administrative lines in the facility or observe their child’s learning, generally heavily centralized service delivery when they seek a job or deal with admin- systems in the MENA countries. istrative procedures, affect not only their The poor quality of education and health view of performance but also their attitude care as perceived by the majority of MENA toward the state. The low satisfaction with Figure O.7  Availability of aspirin, by province: Morocco, 2011 25 120 100 20 80 15 Number Percent 60 10 40 5 20 0 0 ich fa M ch m a ho an To a nm a ua ar ne i b Set t Al elaa en r Ou Ag ra sa Be sick ra z he Ra s Iar te Na ia er tat Tiz i El nit El dor am s Ta da Ou i me t a a ir ra J sset c e em d l s Ta jad za l Kh ge ba ne Er ou oh Fé ar -te ad n rir Be eim ta ar lla an an us jd ad Ch a-an id if Kh ma za ke ao Al sult M Ifra ac i jad Be ou n ek ha te er ch n no k bl rk i ra c s er m Sid m a- hi ay fid Sk Ca -h Al aa eb ns Ai % Facilities stocked out Number of facilities Number of weeks stocked out (mean) Source: PETS (health), Morocco, 2011. 1 0   T r u s t , Voice, and Incentives public services, perceived corruption and and holding them accountable), and v ­ oting nepotism, and, indirectly, unresponsive insti- (choosing political leaders committed to tutions appears to erode citizens’ trust in ensuring b ­ etter services). In the face of weak public institutions in many MENA countries. institutions, poor performance, and low trust Across countries, findings from the Gallup in public institutions, citizens tend to disen- World Poll, Arab Barometer, and Worldwide gage. In much of the region, people believe Governance Indicators reveal a high cor- they have little chance of succeeding by sim- relation between citizens’ satisfaction with ply following the rules. In surveys in Algeria service provision and indicators based on and Morocco, for example, only a quarter underlying measures of state institutional of respondents considered it effective to seek quality and performance such as government services or file complaints directly through effectiveness, rule of law, and control of cor- the relevant government agency; higher num- ruption. Furthermore, the data suggest that bers of respondents believed it was more trust in national government is highly associ- effective to go through family, friends, and ated with citizens’ satisfaction with education other social ties. In the Republic of Yemen, and health services and with their percep- only 10 percent of citizens who believed they tions of the pervasiveness of corruption. For had a valid reason to make a complaint actu- those MENA countries for which data are ally did. Furthermore, civil society organiza- available, our analysis suggests that the tions are subjected to state intervention and probability of trusting the national govern- crackdowns in most MENA countries, which ment increases by 13 percentage points when limit their effectiveness and may explain why respondents are satisfied with education and citizens rarely join such organizations. by 11 percentage points when they are sat- When citizens need services from the state, isfied with health care. On the other hand, try to resolve complaints and grievances, or citizens’ trust in public institutions declines have to deal with administrative procedures, by 35 percentage points when respondents they often do so through informal channels, believe that corruption is widespread within resorting to survival mechanisms such as their governments. These results also hold wasta or informal payments or, more rarely, across MENA countries when measuring demonstrations or rebellions. Unfortunately, trust in the judiciary. With respect to nepo- in doing so they exacerbate the existing tism, respondents are 10 percentage points problems, eroding formal accountability and ­ likelier to trust their national government norms of public service, undermining pub- when they believe that qualifications are more lic welfare, and widening the inequality of important than connections. Interestingly, opportunities. In more extreme cases, such though, we found that the influence of tribal as the Houthis’ rebellion in the Republic of affinities has only a small impact on citizens’ Yemen, stemming in part from the Houthis’ trust in national government. unresolved grievances related to poor public Low trust in public institutions—and services, they may unravel postconflict insti- perceived powerlessness over the decision-­ tutions and trust building. There are, how- making processes—undermines citizen- ever, instances—as our examples of local driven, bottom-up approaches and social successes illustrate—in which citizens’ trust accountability tools (such as public hearings, and engagement can be inspired by local community scorecards, public opinion polls, leaders and can support improvements in and civil society oversight committees) that service quality. Finally, the rising popularity could be used to improve service delivery. of social media and their use by citizens to Institutions in most MENA countries offer share their experience and demands, partly their citizens few opportunities to encour- facilitated by successful e-governance initia- age better service delivery through choice tives in several MENA countries, are opening (selecting better providers), voice (giving potentially effective engagement avenues for feedback to providers and public servants the future. Ov e r v i e w o f T r u s t , V o i c e , a n d I n c e n t i v e s    11 Bases for improvement gain c­ itizens’ acquiescence to reform despite poor performance. Such opportunities may Because of the complex circumstances facing be short-lived, however, and the extent MENA countries, it is necessary to build on to which they can be exploited is likely to evidence of local successes and positive trends depend on a number of factors such as the that show where and how the cycle of gen- strength of state institutions, the degree of erally poor performance can be challenged. polarization within ­ s ociety, and ­levels of We seek to identify the bases for improve- regional or international i ­ntervention. But if ment and encouragement so that citizens, citizens see improvements, they may remain civil servants, policy makers, and donors engaged, thereby positively motivating ser- can act on them. Many policy makers across vice providers and public servants and sup- the MENA countries want to deliver visible porting statewide reforms and institution results and, in doing so, bolster their author- building. ity and public support. Conflicts, crises, and It is therefore critical to seize the oppor- political transitions in the region may give tunities offered in crises to buoy service pro- national and local leaders a unique opportu- vision, press for institutional reforms, and nity to reform institutions and accountability foster citizens’ trust and positive ­engagement. mechanisms and tackle service delivery chal- Even in the midst of enormous difficul- lenges, as well as boost citizens’ trust in pub- ties that citizens and states face, there is an lic institutions and constructive engagement. opportunity to escape the cycle of poor per- Donors, including the World Bank Group, as formance. Preparing to face these challenges well as governments and civil service organi- and seeking ways to open new opportuni- zations, need to learn from their own (often ties for breaking the cycle of poor perfor- failed) efforts to support quality in education mance require a clear understanding of how and health services. In moving forward, the the international community, local policy MENA countries can explore possible incre- makers, civil society, and citizens can work mental approaches to systemic reforms, the together to improve the quality of ­ public options for empowering communities and ­services provision. local leaders to find local solutions, and pos- sible quick wins. Donor intervention Regardless of such extraordinary shocks, Extraordinary shocks donors have been only partly effective in sup- The extraordinary shocks spreading from porting education and health care quality in North Africa to the Arabian Peninsula—as the MENA countries. Over the last 10 years, unsettling, costly, and risky as they are— the World Bank Group has been increasingly can open possibilities for reform. Conflicts, highlighting the role of incentives and citi- refugee crises, and regime changes can make zen engagement in achieving equitable and national and local leaders more likely to take high-quality services. In the MENA region, risks, disrupt existing institutional arrange- this emphasis has figured prominently in the ments, and alter elite coalitions. Costly Bank’s analytical and reimbursable advi- events today may prompt changes in insti- sory activities but has been less pronounced tutions, trust, and engagement that result operations. Only about 10 percent of the in ­ in better ­p erformance. For example, tran- Bank’s projects in the MENA countries sitions triggered by dramatic ruptures can (compared with about 30 percent on average potentially, at least in the short run, increase in other regions) have promoted autonomy trust, engagement, and the possibilities of and accountability in education (figure O.8) institutional reforms. Elites often experi- or transparency and accountability in health ence a brief honeymoon period with much services delivery. This low rate—along with of the population, during which they can a relatively modest success rate of Bank 1 2   T r u s t , Voice, and Incentives Figure O.8  SABER analysis of World Bank School Autonomy and Accountability Interventions, by region, FY03–13 80 70 60 % of all operations 50 40 30 20 10 0 AFR EAP ECA LAC MENA SAR Budget autonomy Autonomy in personnel management Role of school councils (participation) Assessment Accountability Source: World Bank forthcoming. Note: SABER = Systems Approach for Better Education Results; AFR = Africa; EAP = East Asia and Pacific; ECA = Europe and Central Asia; LAC = Latin America and the Caribbean; MENA = Middle East and North Africa; SAR = South Asia. operations supporting education and health of a problem and developing a hypothesis services delivery in MENA countries—partly while being agnostic about the solution; by reflects the difficulty in developing interven- using evidence to inform the implementa- tions to address the cycle of performance tion of solutions; by taking an adaptable, beyond capital investments and capacity creative, and context-driven approach; and building and to motivate better performance by being able to capture cumulative knowl- by policy makers, public servants, and service edge when finding and fitting local solutions. providers and inspire citizens’ trust and con- Furthermore, the World Bank’s initiative on structive engagement. social accountability in the MENA region If programs, systems, and civil service appears to be a promising approach, even organizations supported by donors are to if its implementation requires time, money, be trusted by citizens, donors may need to and expertise in order to appropriately reach out to citizens directly to build trust. engage with local contexts. Examples of Simple measures such as providing them positive deviance—such as the Secondary with detailed information on donor support, Education Development and Girls Access objectives, interventions, and cost, disag- Project (SEDGAP) in the Republic of Yemen, gregated to the village level, would be a step which is seeking to engage community lead- forward and a possible model for promoting ers, parents, girls, and female teachers— transparency domestically. offer valuable lessons on how donors can Experience suggests that the usual focus help. Investing in the high-quality collection on identifying policy reform needs must be of local data can pay handsome d ­ ividends matched by a corresponding focus on how in terms of enhancing the efficiency and any given policy will actually be imple- effectiveness of everyday decision making, mented, by whom, and why. One might hope providing an evidence base for promot- that the new “science of delivery” approach ing organizational learning, and helping to provides a space within which such issues identify where, when, and how such positive can be explored by looking at the nature ­deviance occurs. Ov e r v i e w o f T r u s t , V o i c e , a n d I n c e n t i v e s    13 An incremental approach to systemic approach to institutional and policy reforms changes, local initiatives, and can combine considerations about feasibil- quick wins ity and political support with considerations about possible solutions. Such an approach Improvements in education and health ser- also can result in design reforms that align vices will not come simply through policy more closely with the existing reform space reforms, through modernization of schools and thereby gradually expand the space for and health facilities, or through training reform. of educators and health professionals. Our Drawing on the available evidence, we set analysis indicates that, to foster better perfor- forth two broad sets of ­ recommendations. mance, policy reforms and investments need First, we argue for a stronger social ­contract the backing of institutions—especially incen- providers. among public servants, citizens, and ­ tives and norms embedded in both formal and To that end, we propose an approach of informal accountability relationships—and ­ s trategic incrementalism toward improv- citizens’ trust and engagement. Experience ing institutional quality and accountability suggests that performance improves when mechanisms and motivating public servants ­ political institutions are the primary driv- and providers to serve the poor and other ers of outcomes, or—as our case studies nonprivileged populations. In particular, we ­ illustrate—when skillful leaders use them to explore options to tap into and exploit social institutions for better outcomes. Decentralization, incorpo- •  Develop effective external accountability rated in a broad package of reforms aimed at institutions such as courts, independent putting more power into the hands of local auditors, and ombudsmen to monitor— officials, can help strengthen incentives for and subject to public scrutiny—the perfor- better performance if supported by adequate mance of service providers and public ser- accountability mechanisms and resources. ­ vants and provide tools for the resolution The evidence on citizen engagement shows of citizens’ complaints and grievances. that information is necessary but not suf- •  Strengthen monitoring, internal controls, ficient to motivate collective action, to make and performance management in the pub- local or central officials accountable, and to lic sector as well as within the education influence public sector performance. More and health systems, including mechanisms promising results emerge from multipronged to share and act on performance informa- strategies that encourage enabling environ- tion, exposing service providers and pub- ments for collective action and bolster a state’s lic servants to internal accountability for capacity to actually respond to the voices of performance. its citizens. An ability to respond to citizens’ •  Modify mechanisms for selecting, encourag- feedback on the quality of service delivery is ing, and rewarding leaders, public servants, crucial to sustaining trust and participation. and service providers so as to internalize Meanwhile, to have an impact, institu- norms of personal responsibility, profes- tional and policy reforms must emerge from sional accountability, and public service. problem-led learning processes, facilitate ­ •  Learn from intracountry variations to the “finding and fitting” of context-­ specific design solutions that fit local contexts, solutions, and seek the participation of evaluate and strengthen policy imple- broad groups to ensure that new institu- mentation, inform citizens, energize local tions are shared, legitimate, and contextually leaders, and scale up local successes. appropriate. Reforms also need to recognize ­ Second, we call for empowering com- the actual incentives that prevail for stake- munities and local leaders to find “best- holders associated with a specific problem fit” solutions in motivating educators and in a ­ specific setting. Within the existing health professionals and in harnessing social constraints, an incremental, problem-driven accountability to inspire trust and empower 1 4   T r u s t , Voice, and Incentives citizens to act. Possible options for govern- institutions, performance, and citizens’ trust ments include measures to and engagement. We hope that this report and its recommendations will help citizens, •  Build coalitions among champions of civil servants, policy makers, and donors reforms in government, civil society, and alike jointly identify and build on the ­present the private sector to improve service deliv- foundation to improve the delivery of social ery, giving local actors space to engage in services, shifting the cycle of performance into ­ piloting possible solutions. a virtuous gear. An improved cycle of per- •  Systematically collect feedback on public formance is what those living in the MENA services from users, benchmark service countries deserve and what would enable them delivery and local governance perfor- to fulfill their hopes and dreams for the future. mance, and disseminate information on performance to provide a rigorous basis for citizen action. Reference •  Close the feedback loop among citizens, World Bank. Forthcoming. World Bank Support service providers, civil society organi- for School Autonomy and Accountability zations, and the private sector in order FY03-13. Washington, DC: World Bank. to strengthen the coherence of policy development; provide a foundation for Data sources prioritizing problems and possible solu- Arab Barometer, http://www.arabbarometer.org​ tions (with an emphasis on the most dis- /­instruments-and-data-files. advantaged, poor, and vulnerable); more EHGS (Egypt Health and Governance Study), equitably allocate finite public resources World Bank, http://documents.worldbank​ across the local and national levels; and .org /curated /en /2010/06/16332545/egypt​ improve implementation effectiveness by - m a n a g e m e nt- s e r v i c e - qu a l it y- p r i m a r y​ enhancing mutual accountability and the -health-care-facilities-alexandria-menoufia​ dissemination of useful information on -governorates. performance standards. Gallup World Poll, http://www.gallup.com​ /­services/170945/world-poll.aspx. In addition, quick wins are needed—­ Global Corruption Barometer, Transparency especially in countries in transition or emerg- International, http://www.transparency.org​ ing from a conflict and fragility—to gain and /­research/gcb/overview. retain trust and make the cycle of performance Global Integrity Index (no longer published), virtuous. Quick wins could come in any form Global Integrity, https://www.globalintegrity​ .org/. of improvements observable by citizens. The Governance and Local Development survey, state, for example, could reach out to iden- Prog ra m on G over na nce a nd L o c a l tify and popularize local successes through Development, Yale University, http://gld​ the media; hold public awareness campaigns .commons.yale.edu/research/. on citizens’ rights, service delivery standards, PETS (Public Expenditure Tracking Survey), and anticorruption; conduct solution-focused Wo r l d B a n k , h t t p : / / w e b .w o r l d b a n k​ public meetings to address problems such as . o r g / W B S I T E / E X T E R N A L / T O P I C S​ absenteeism and material shortages in service /­EXTSOCIALDEVELOPMENT/EXTPCENG​ delivery; expand opportunities for citizens’ /0,,contentMDK:20507700~pagePK:148956​ engagement; and demand a response to citi- ~piPK:216618~theSitePK:410306,00.html. zens’ feedback. Citizens’ experience with the SABER (Systems Approach for Better Education Results), World Bank, http://saber.worldbank​ state and with service delivery can improve .org/index.cfm. more rapidly with the appropriate use of infor- TIMSS (Trends in International Mathematics mation communication technology. and Science Study), Boston College, http:// We argue that because of the complex timssandpirls.bc.edu/. circumstances found in MENA countries, Worldwide Governance Indicators, World Bank, it is necessary to build on evidence of local ht t p: //data.worldba n k.org /data- catalog​ successes and positive trends at the level of /worldwide-governance-indicators. Introduction to Trust, Voice, and Incentives T he Middle East and North Africa Development Report 2004 approach to (MENA) region is at a critical juncture, ”making services work” by exploring how with complicated transitions and tragic political, administrative, and social institu- conflicts on one side and a tremendous poten- tions affect provider responsiveness. It also tial based on rich human and natural resources explores how a state’s performance shapes on the other. The majority of the population in citizens’ trust and the nature of their engage- the region is lacking economic opportunities, ment at the national and local levels, which in facing inequalities, demanding social injustice, turn further influence institutional develop- and expressing frustration and mistrust. In ment and performance (World Bank 2004). parts of the region, children, women, and other Focusing on education and health, this vulnerable population groups are suffering report illustrates how the weak external and from extreme insecurity or even open conflict, internal accountability relationships prevalent struggling for survival and in need of essential in the MENA political and administrative services. Meanwhile, political uncertainties spheres undermine incentives toward policy and poor state performance are exacerbating implementation and performance, and how tensions in the society, deepening mistrust, such a cycle of poor performance can be coun- and discouraging citizens from engaging with teracted. According to the evidence, weak the state. With visionary leadership, the right accountability as well as low satisfaction with policies, and inclusive institutions, this vicious public services negatively affects citizens’ trust cycle can be broken and a renewed social con- in the state. Low trust in public institutions tract can be established allowing citizens to explains in part why citizens seldom engage receive better services. A renewed social con- with the state and service providers through tract and better service delivery would also formal channels, relying instead on wasta empower young women and men to realize (personal relationships), informal payments, their aspirations and potential and build a and other survival mechanisms. Case stud- brighter future for the next generation. ies of local successes reveal the importance This report examines the role of trust, of both formal and informal accountability incentives, and enagement as critical deter- relationships and the role of local leadership minants of service delivery performance in in inspiring and institutionalizing incentives the MENA countries. It expands the World toward better service delivery. 15 1 6   T r u s t , Voice, and Incentives Even more broadly, enhancing the services such services, but states fail to meet citizens’ received by MENA citizens requires forg- expectations and overcome the service qual- ing a stronger social contract among public ity challenge, particularly in the public sector. servants, citizens, and service providers, as That said, examples of local successes can well as empowering communities and local be found, demonstrating that better realities leaders to find “best-fit” solutions. Lessons are possible. Why is this? Why does service learned from the variations within countries, delivery fall short of potential in the MENA especially the outstanding local successes, region? can serve as a solid basis for new ideas and We argue that the answer to this question inspiration for improving service delivery. lies in the cycle of poor performance that has Such lessons may help the World Bank Group emerged in much of the region (figure I.1). and other donors, as well as national and Institutions are a useful starting point for local leaders and civil society, develop ways understanding this cycle. In the MENA to enhance the trust, voice, and incentives for region, state institutions lack both internal service delivery to meet citizens’ needs and and external accountability, in part because expectations. of the shortage of information on perfor- mance that is needed to guide centralized decisions and in part because of the lack of Organization of this report incentives toward establishing accountability This report explores the perceptions, reali- mechanisms for performance in public sector ties, governance determinants, and possible services delivery. When institutions are weak, solutions for education and health services service delivery policies are not successfully delivery in the MENA region.1 The report is implemented. As Acemoglu and Robinson divided into five parts. (2012, 78) argue, “The low education level In part I, we describe citizens’ perceptions of poor countries is caused by economic insti- and expectations as well as the realities and tutions that fail to create incentives for par- local successes in social services delivery in ents to educate their children and by political the MENA region. First, we summarize institutions that fail to induce the government insights from surveys about ­ c itizens’ atti- to build, finance, and support schools and the tudes toward education and health services, wishes of parents and children.” their expectations about the government’s Based on their experiences with poor-­ role in providing those services, and how quality service delivery, as outlined in citizens try to fulfill their needs. Second, chapters 1 and 2, citizens perceive govern- ­ drawing on the literature and databases, we ments as corrupt and ineffective. Not only briefly review the impressive achievements do public services seem captured by public of the MENA countries in expanding access servants and local elites with limited account- to basic education and health services and ability to citizens, but a large share of private improving core human development out- services also appear captured by the same comes over the last five decades. We then public servants as part of their employment in highlight the remaining challenge of poor both the public and private sectors. This prob- service quality and citizens’ dissatisfaction. lem is not evident in many of the Gulf states Finally, we examine cases of local success in because an abundance of resources allows which schools and health facilities are per- these states to provide high-quality services. forming far beyond expectations under very But even there, service provision falls short of difficult circumstances. the promise these resources should provide. Overall, we find that the MENA coun- Low trust in institutions undermines tries are not meeting their potential in pro- ­ bottom-up pressures for improving service viding citizens with education and health delivery. Citizens can provide incentives for ­ services. Citizens demand quality services and public service delivery through choice (using believe the state is responsible for delivering public services), voice (giving feedback to I n t r o d u c t i o n t o T r u s t , V o i c e , a n d I n c e n t i v e s    17 providers), and voting (choosing political Figure I.1  The cycle of performance leaders who support service delivery systems). However, in the face of weak institutions, poor performance, and low trust people Citizens’ engagement: formal and informal often disengage. They turn instead to local nonstate actors and institutions for services. When they do demand services from the state, citizens tend to do so through informal channels and seek piecemeal, selective solu- tions to their individual problems. Institutions: Circumventing the state perpetuates insti- Cycle of political tutional weakness. When citizens walk away performance at administrative, Citizens’ trust in the national and and social from public services or fail to give feedback, public institutions local levels state actors lack the information they need to improve institutions. When political competi- tion is weak, there is little pressure to develop better state solutions. Indeed, the importance of political engagement to developing insti- tutions was clear in postcommunist eastern Europe. There, formal administrative institu- Performance: effort and ability tions and rules were established and enforced to meet citizens’ needs in countries that had the vibrant political competition needed to pressure governments for reform (Grzymala-Busse 2010). Cycles vary, of course, driven by differ- and extent of subnational variation in service ences in the available resources, societal com- delivery performance (chapter 7). The sub- position, and the agency/leadership of key national variation analysis underscores the actors. And they are alterable. As shown in message of chapter 3 that local successes can chapter 3, a virtuous cycle can develop at the be found and that much about service deliv- local level (even in context of a poor perfor- ery challenges and possible solutions can be mance at the national level) when local stake- learned in local contexts. holders are driven by individual will or social Completing the cycle of performance, in obligations to take initiatives. part IV we discuss how institutions and per- In part II, chapter 4 explains how histori- formance affect citizens’ perceptions of the cal experience has led citizens to value health state and the nature of citizen action vis-à-vis and education, fostered their dependence on the state. In particular, we seek to reveal how the state, and has limited state responsive- performance influences citizens’ trust in the ness. Chapter 5 provides a detailed picture of state (chapter 8), and how this trust in turn the political, administrative, and social insti- shapes the nature of citizens’ engagement at tutions that affect service delivery. both the local and national levels (chapter 9). In part III, we turn our attention to per- Because of the complex circumstances formance at the point of service delivery: we facing MENA countries, it is necessary to explore the efforts and abilities of teachers build on evidence of local successes and on and health professionals and the availability positive trends that buck the cycle of gen- of key inputs such as instructional materials erally poor performance. In this respect, in schools and medicines in health facilities. in part V, chapters 10, 11, and 12 identify We also discuss how these efforts and avail- the bases for improvement and encourage- ability are affected by institutions. Drawing ment so that citizens, civil servants, policy on surveys, we focus first on the national makers, and donors can act on them. We level (chapter 6) and then explore the nature acknowledge that many policy makers across 1 8   T r u s t , Voice, and Incentives the MENA countries want to deliver vis- administrative, and social institutions that ible results and, in doing so, bolster their affect state performance. To devise effective authority and public support. As we discuss solutions, these efforts can build on the local in chapter 10, conflicts, crises, and political success stories found in MENA countries. transitions give rise to a new dynamic, which may present national and local leaders with Note a unique opportunity to reform institutions and accountability mechanisms and to tackle 1.  Because of differences in the transliteration of Arabic, place-names often differ slightly service delivery challenges as well as boost from one source to another. The versions citizens’ trust and constructive engagement. of place-names appearing in this report are The cycle of poor performance can also be largely those used in the various surveys cited altered by reforms in the absence of such or those used by the World Bank’s country major disruptions. That depends on appro- offices. priate learning by and incentives from inter- national donors (discussed in chapter 11), or incremental institutional reforms and local References reform coalitions in society and govern- Acemoglu, Daron, and James A. Robinson. 2012. ment (chapter 12), or a combination of these Why Nations Fail: The Origins of Power, factors. Thus by arguing that much of the Prosperity and Poverty. New York: Crown MENA region is stuck in a low-equilibrium Publishers. Grzymala-Busse, Anna. 2010. “The Best Laid cycle of performance, we are not suggesting Plans: The Impact of Informal Rules on Formal that citizens are doomed to weak institutions, Institutions in Transitional Regimes.” Studies poor service delivery, dissatisfaction, and sub- in Comparative International Development optimal engagement. Rather, we are suggest- 45 (3): 311–33. ing that efforts to reform service provision World Bank. 2004. World Development Report in the region should foster citizens’ trust and 2004: Making Services Work for Poor People. engagement as well as enhance the political, Washington, DC: World Bank. IBRD 41534 | MARCH 2015 Bla c k Se a Ca s pi an Sea Mediterranean Sea ATLANTIC Me SYRI AN TUNISIA MALTA dite OCEAN rranean Sea LEBANON A. R. WEST BANK AND GAZA IRAQ ISLAMIC REP. M OROC CO OF IRAN JORDAN KUWAIT A L G E R I A L I B Y A ARAB REP. BAHRAIN OF EGYPT SAUDI QATAR UNITED ARABIA ARAB Government EMIRATES OMAN Effectiveness Index, 2013 Re d Se More than 1.0 a 0.1 – 1.0 REP. OF -0.4 – 0 YEMEN en Arabian -1.0 – -0.5 Ad MENA average -0.36 f of Sea Gul Less than -1.0 DJIBOUTI Non-MENA/non-OECD average -0.25 No data available OECD average 1.31 Data source: Worldwide Governance Indicators, World Bank. T his book examines the role of incentives, trust, and engagement as critical determinants of service delivery performance in the Middle East and North Africa (MENA) Region. Focusing on education and health, the report illustrates how weak external and internal accountability undermines policy implementation, service delivery performance, and citizens’ trust and how such a cycle of poor performance can be counteracted. Case studies of local success reveal the importance of both formal and informal accountability relationships and the role of local leadership in inspiring and institutionalizing incentives toward better service delivery performance. Enhancing services for MENA citizens requires forging a stronger social contract among public servants, citizens, and service providers while empowering communities and local leaders to find “best fit” solutions. Lessons learned from the variations within countries, especially the outstanding local successes, can serve as a solid basis for new ideas and inspiration for improving service delivery. Such lessons may help the World Bank Group and other donors, as well as national and local leaders and civil society, to develop ways to enhance the trust, voice, and incentives for service delivery to meet citizens’ needs and expectations. “This magnificent work is a model of multidisciplinary research and judicious harvesting of multiple sources of relevant data to assess why many MENA countries lag on vital education and health outcomes. In opening our eyes to the causes of failure, the book breaks new ground in pointing to how improvements in public services can uplift citizens and bolster the prospect for democratic governance.” — Allen Schick, Distinguished University Professor, University of Maryland “This report highlights innovative social accountability as a crucial element in improving the quality, efficiency, and equity of educational and health provision services in the MENA Region. It looks at how innovative engagement of citizens as an entry point to monitor and evaluate education and health services can create pressure on leaders, government officials, and service providers to improve their performance.” — Sami Hourani, Director, Leaders of Tomorrow, and Founder/CEO, Forsa for Education “This book makes valuable contributions by highlighting the importance of ‘soft’ inputs, notably multiple dimensions of governance, in driving the improvement of service delivery and by emphasizing the importance of the quality and not just the supply of social services. At the same time, the report delves into some of the deeper underlying social and political issues that stymie efforts to improve the quality of services in the ‘cycle of performance.’ The report homes in on the roots of service delivery problems, such as provider absenteeism, poor quality of teaching or medical care, and shortages of medicines and textbooks. Together, the theoretical and empirical chapters show that these problems require more than technical or financial solutions. Rather, these kinds of issues can often be addressed by devoting attention to cross-cutting components of governance such as transparency, public sector management and institutions such as the civil service or courts, and social environments that promote citizen action. Attending to bottlenecks in governance processes is necessary to solve a variety of service delivery problems.” — Melani Cammett, Professor of Government, Department of Government, Harvard University SKU 32920