Effective Implementation for Achieving theMDGs

Overview

• Elements of RB/PSM Implementation• Country experiences• Horizontal cross-sectoral• Vertical cross-sectoral• Challenges to implementation

Principles for better implementation/service delivery

• Horizontal linkage: plan priorities, budget support, and monitoring and evaluation systems and processes are effectively linked between central and sector agencies at the Subnational or local government ; multi-sectoral coordination

• Institutional priorities are aligned to budget deliverables.• Policies, people, and processes are oriented to deliver intended results• Service delivery standards are established• Service delivery is aligned to budget with measurable performance

indicators to facilitate results monitoring• Vertical linkage: plan priorities, budget support, and monitoring and

evaluation processes are effectively linked from National to the Subnational or local government, with diverse options for local implementation

Horizontal Implementation• Sector Specific:

One entity (agency or ministry) makes all policy and funding decisions • Split responsibility:

A Ministry sets policy and sometimes provides core funding to local or regional government, with a separate entity for earmarked funding and partnerships for specific implementation

• Split objectives: Two ministries or agencies with mandates for different areas of action set policy and provide funding individually

• Multiple actors: Delivery through multiple branches of government, and often also through municipal structures

Extreme Poverty• Halve, between 1990 and 2015, the

proportion of people whose income is less than $1 a day.

• Halve, between 1990 and 2015, the proportion of people who suffer from hunger.

Safe Water & Sanitation• Halve by 2015 the proportion of people without

sustainable access to safe drinking water.

• By 2020, achieve significant improvement in the proportion of people with access to sanitation.

Child & Maternal Health• Reduce by two thirds, between 1990 and 2015,

the under-five mortality rate.

• Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio.

Primary & Girls' Education• By 2015, boys and girls everywhere

complete a full course of primary schooling.

• Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015.

Communicable Diseases By 2015, halt and begin to reverse the spread of:

• HIV/AIDS• Malaria & • Other major diseases.

Horizontal Linkages: Multi-sectoral Approaches to Investments in Health

Social Funds

• Necessarily cross-sectoral mechanisms• Require cooperation of several ministries at

the national level• Require coordination between ministries and

local governments for implementation

Social Funds

Kalahi: • National: National Steering Committee • ( DSWD, NAPC, DBM, DOF, NEDA, DILG and three rep. From NGOs, Chairperson-

League of Barangays ) National: Project Management Team • Regional : Regional Project Management Team • ( Replication of the national member agencies ) • Provincial : Provincial Inter-Agency Committee ( Replication )

KDP: • National Level ; Government ; Inter- Ministerial Coordination Team;

National KDP Secretariat ; consultant/ facilitators ; Management Consultants (NMC)

Behavior of Individuals/Households

IncomeEducation

WaterSanitationNutrition

Performance of Health System•Clinical Effectiveness•Accessibility and Equity•Quality and Consumer Satisfaction•Economic Efficiency

Health Status Outcomes•Fertility•Mortality•Morbidity•Nutritional Status

Macro-economic Environment Health Care System

Delivery Structure•Facilities (public & private)•Staff (public & private)•Information, Education, & communication

Institutional Capacity•Regulatory & Legal Framework•Expenditure & Finance•Planning & Budgeting Systems•Client & Service Information/Accountability•Incentives

Projects and Policy Advice

Governance

Multi-sectoral: Achieving Change in Health

People, Policies, processes: enabling breastfeeding in the workplace

• Enabling workplace conditions for breastfeeding are important for the health of mother and child.

• The Philippines example of multisectoral action:– Key stakeholders involved:

• Department of Labour and Employment and DoH• Trade Union Congress of the Philippines (TUCP) • Employers Confederation of the Philippines (ECOP) • NGOs• WHO support

– Benefits• health benefits for mother and child, lower cost of infant feeding, improved

bonding,• lower absenteeism and higher productivity, enhancement of employer–employee

relationship.

Service delivery standards

• Afghanistan BPHS: focuses on health interventions including child immunizations, nutrition care; TB and malaria control; prenatal, obstetrical, and postpartum care; disability; familyplanning, and other curative services.

• MoPH and its international partners to contractwith NGOs to deliver the BPHS in 31 of the 34 provinces

• Maintain service delivery standards in difficult environment

• Enabled the MoPH to develop key indicators of public health impact and building blocks for monitoring and evaluation of the BPHS including the household surveys, and health facility assessments such as the “Balance Scorecard.

Institutional priorities/delivering results

Tamil Nadu Health Systems project • The Project has utilized several innovative and effective

measures • 80 comprehensive emergency obstetrics and neonatal centers • health education, nutritional support, and HIV/AIDS testing

and counseling• 385 ambulances have been provided under the project,

managed under a public private partnership, increasing emergency transport services in rural areas.

• public private partnerships have also provided mobile out-reach health services as well as other services.

Vertical Linkages: Unbundling the sectors & functions

Sector Intra-Sector Infrastructure & Services

Delivery Functions

Water Point facilities (rural); networked facilities (urban)

Standards; Monitoring; Investment; rehabilitation; routine maintenance

Education Pre-school; primary; secondary; Curriculum & standards; teacher hiring, training & management; books; school investment & rehabilitation; inspection

Health Health posts; clinics; referral hospitals; vaccination campaigns; public health education

Policy & standards; personnel hiring, training & managementt; drugs; cold chains; investment & rehab of facilities; O&M; inspection

Vertical implementation

• Governments choose between different mechanisms for implementation

• There are trade offs that differ by sector and by context

• Decentralized Sectors• Local Government• Community Mechanisms

Comparing ApproachesDecentralized

SectoralLocal

GovernmentCommunity Mechanisms

LessonsHow to deliver infrastructure and services

How to allocate resources flexibly and formalize accountability

How to empower people and get resources to beneficiaries

Limitations

Ensuring allocational efficien-cy, coordination, and accountability.

Ensuring service delivery and empowerment

Ensuring coordination and sustainability

• The three approaches share good practices involving common principles • Lack of a clear common language and consistent methods often makes linkages and

collaboration among approaches difficult • Tensions among approaches reflect different entry points as well as coordination problems

among sectors/organizations promoting them

Integrating Approaches to Local Implementation

DecentralizedSectoral Approaches

Local Government Approaches

Community Support Approaches

Linked Approaches

Examples of Linked Approaches

Community – Sectoral Links

Sectoral – Local Gov’t Links

Community –Local Gov’t Links

CBOs that govern and oversee service delivery units (e.g. parent-teacher organizations, village health committees, user-directed water services)CBOs that own their own infrastructure (e.g. water user groups, farmer-managed irrigation/drainage systems and grain stores )

Budget reforms emphasizing multi-sector local planning (e.g. devolution of investment decisions for primary schools, clinics, water points, and latrines)Sector policies dele-gating service delivery to LGs (e.g. mandated & centrally financed social service delivery or social safety nets)

CBOs as service or infrastructure co-producers in municipal systems (e.g. user-run standpipes in piped water systems, community mgmt of LG regulated schools)LGs as intermediaries in social fund programs (e.g. municipally administered grants to CBOs)

A Framework for Local Implementation

Local Gover-nance

Local Public Service Provision

Local Non-State Provision

Improved human development outcomes

Enabling National Policy and Institutional Environment

Capacity Enhancement and Resource Transfers

A simple conceptual basis which allows integration of the strategic elements and methods developed by the three complementary approaches

RB-PSM

Challenges to Integrating Local Implementation

• Managing complex processes across institutional boundaries – at both local and national levels

• Realigning power relations – central-local, state-society, and donor-client

• Reconciling different interests & values

• Changing attitudes and practices– donor, national, local, community

Implementation challenges

• Cross-sectoral• Exclusion• MDGs not static• Regional disparities: horizontal• Urbanization: vertical

Regional disparities: Horizontal/multi-sectoral approaches

• Chittangong• Mindanao• West Papua• Balochistan• Southern Thailand• “Extremist Affected States”

Regional disparities

Best Seven (2008-09 estimates) Worst Seven (2008-09 estimates)State IMR ((per ‘000’ live

births)State IMR (per ‘000’live births)

Kerala11

Tripura56

Puducherry19

Uttarakhand56

Daman & Diu21

Assam61

Goa24

Rajasthan78

Manipur28

Orissa79

Nagaland31

Uttar Pradesh81

Himachal Pradesh31

Madhya Pradesh86

Addressing regional disparities

We have two worlds of education, two worlds of health, two worlds of transport and two worlds of housing, with a gaping divide in between… In general, the contradiction between the tribal community and the State itself has become sharper, translating itself into open conflict in many areas … people feel a deep sense of exclusion and alienation, which has been manifesting itself in different forms. The failure to provide infrastructure and services … is one of the many discriminatory manifestations of Governance here. (Government of India, 2008, Development in Extremist Affected Areas, Report of An Expert Group to Planning Commission).

Urbanization: Vertical Multi-sectoral implementation

• Why focus on urban poverty? • Because of population growth, migration and recent

increase in urban poverty rate, the number of poor people living in urban areas in the developing world is increasing compared to those in rural areas

• The poor in urban areas have different characteristics than the rural poor

• People in urban areas face specific covariate and individual risks

• There is a gap between the needs of poor people and programs in urban areas

Urban Programs

• Lack of sufficient poverty alleviation policies and programs that effectively reach the intended beneficiaries

• Most of the existing urban programs and policies focus mostly on the improvement of physical infrastructure and delivery of basic services in low income areas and urban slums

• CCT experiences• UNDP/Bangladesh studies

Concluding issues

• Changes/adaptation of policies and procedures to fit multi-sector tasks, programs, and financial instruments;

• Enhanced institutional framework to support multi-sector teams such as allocation of staff time and budgets, incentive systems, and accountability mechanisms.;

• Learning and teaming practices across departments• Reviewing lessons from experiences in RB-

Implementation