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Making Reform Work: Institutions, Dispositions and the Improving Health of Bangladesh

Author: Jean-Paul Faguet, Zulfiqar Ali
Date: 2009
Size: 10 pages (267 KB)

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Summary

What is the role of social attitudes in supporting institutional reform? This article from World Development explores the institutional and social underpinnings of service provision by comparing decentralised health provision in the Bangladesh upazilas (sub-districts) of Rajnagar and Saturia. Regional variation in health outcomes is explained by the presence or absence of a dense web of relationships that enmeshed reformers in local systems of authority and legitimacy. Policymakers must focus on tailoring service provision to the specific needs and characteristics of the population. This involves increasing local level participation, improving accountability mechanisms, and providing incentives for good performance.

It is a commonly held belief that decentralisation improves good governance and service provision. Current literature suggests that decentralisation results in better information dissemination, greater levels of accountability and more opportunities for public participation. These three results are thought to create better policy that addresses local needs and conditions. This is because more opportunities to participate in policy creation should result in better public ownership and sustainability.

The disparity in health care provision in Rajnagar and Saturia upazilas reveals that this is not always the case, however. While both upazilas have similar populations and receive uniform support for government health services, Saturia’s health indicators are significantly better. This suggests that while decentralisation ensured that both upazilas had similar health system structures and asset bases, these are not the only factors that influence service quality.

Healthcare in Saturia was significantly better because it better suited the needs and characteristics of the population. Differences between upazilas in attitudes towards healthcare, local institutional relationships, and in location also seemed influential. For example:

• There was a greater need for health services in Saturia owing to more modern attitudes towards healthcare and better education. Rajnagar had less demand, mainly due to more conservative and traditional religious practices that created cultural barriers for those in need of healthcare.
• The local level government was more involved in health services in Saturia. Better accountability mechanisms and accessibility of local government officials allowed for more citizen participation in health policy.
• Saturia’s close proximity to the capital was also important as it resulted in a greater and more continuous NGO presence.

Therefore, decentralisation alone does not always ensure better social development. Policymakers must take into account how social systems are maintained and used to meet the populations’ specific needs. This means that policymakers must focus on:

• Improving local institutional relationships. Strong relationships between the citizenry, local government, and healthcare providers create binding upwards and downwards accountability.
• Promoting greater interaction between local elected representatives and service providers. This should include participation in the creation of incentives for health staff.
• Strengthening the institutional basis of service provision. This means increasing and sustaining efforts towards changing harmful ‘cultural’ behaviours.

NB: Author Jean-Paul Faguet may be contacted via the London School of Economics, Houghton Street, London WC2A 2AE, UK.

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Source: Faguet J-P., Ali Z., 2009, 'Making Reform Work: Institutions, Dispositions and the Improving Health of Bangladesh', World Development, Volume 37, Issue 1, pp. 208-218