Making the link: from managing finances to providing services

At a World Bank governance conference last week, I was surprised to find that there is relatively little knowledge on how public financial management affects service delivery. Advice and assistance to public financial management is largely considered one of the Bank’s successes in recent years. Unlike, programmes supporting large scale public sector reform, which have generally not had impressive results, assistance for improving financial management has been fairly effective. Yet, how such improvements in financing affect the quality of the services they fund is not really understood.

In recent weeks, I’ve been looking at the challenges of reforming healthcare, and in this the system for financing healthcare is very important. Donor sponsored systems for payment by results are particularly popular and have been shown to really raise the quality and accessibility of healthcare by using financial incentives. However, I would argue that this does not provide a long-term solution. For example, using financial rewards to encourage healthcare staff to turn up to work or change the way they treat patients is not sustainable if it relies on donors always providing the money. Rather, I think that understanding what else motivates and constrains the way health workers behave is more important for really improving healthcare services.

I believe we need to look beyond money to the many other pressures which health workers are likely to face. For example, having attentive supervision from senior staff members may give a sense that their work is important and so be a motivating factor. Or, unhelpfully, demand from patients for antibiotics and more technical treatment may push health workers to prescribe unnecessary medication. Recognising the non-financial pressures which shape behaviour is crucial for understanding how and why healthcare workers do their job but I’m not sure that social and cultural incentives receive the attention they deserve. Analysis of incentive structures seems to focus more on financial or political gains without enough consideration of factors outside the regular political science field.

Having spent some weeks reviewing how donors try to support public sector reform and service improvement, I am convinced that we do not think broadly enough about how a public service functions. Drawing on knowledge and theory from other fields, such as organisational management, psychology, and anthropology could be really useful for better understanding how service provision could be improved. I think that it’s time we looked beyond the international development literature and integrated more learning from other disciplines. Combining expertise on many subjects should, I believe, help us to join up the dots from budgets and finance to behavioural norms, and so support better functioning public services overall.