Summary

Classrooms with teachers; clinics with nurses; running taps and working toilets: for millions of people across developing countries these things are a distant dream. And yet it is these vital public services – health, education, water and sanitation – that are the key to transforming the lives of people living in poverty.

Building strong public services for all is hardly a new idea: it is the foundation upon which today’s rich country societies are built. More recently, developing countries have followed suit, with impressive results. Sri Lanka, Malaysia, and Kerala state in India, for example, have within a generation made advances in health and education that took industrialised countries 200 years to achieve. Building strong public services is not a new idea, but it has been proven to work. It should be at the very heart of making poverty history.

In the twenty-first century it is a scandal that anyone lives without these most basic of human rights, yet millions of families still do. Today:

• 4,000 children will be killed by diarrhoea, a disease of dirty water
• 1,400 women will die needlessly in pregnancy or childbirth
• 100 million school-age children, most of them girls, will not go to school.

This report shows that developing countries will only achieve healthy and educated populations if their governments take responsibility for providing essential services. Civil society organisations and private companies can make important contributions, but they must be properly regulated and integrated into strong public systems, and not seen as substitutes for them. Only governments can reach the scale necessary to provide universal access to services that are free or heavily subsidised for poor people and geared to the needs of all citizens – including women and girls, minorities, and the very poorest. But while some governments have made great strides, too many lack the cash, the capacity, or the commitment to act.

Rich country governments and international agencies such as the World Bank should be crucial partners in supporting public systems, but too often they block progress by failing to deliver debt relief and predictable aid that supports public systems. They also hinder development by pushing private sector solutions that do not benefit poor people.

The world can certainly afford to act. World leaders have agreed an international set of targets known as the Millennium Development Goals. Oxfam calculates that meeting the MDG targets on health, education, and water and sanitation would require an extra $47 billion a year. Compare this with annual global military spending of $1 trillion, or the $40 billion that the world spends every year on pet food.

Public success: governments that ensure essential services for all

To assess the performance of developing country governments, Oxfam has devised an Essential Services Index. This ranks countries in four social areas — child survival rates, schooling, access to safe water, and access to sanitation — and compares their performance with per capita national income. The comparison shows that some governments have consistently punched above their weights. Even though more than one-third of Sri Lanka's population still live below the poverty line, its maternal mortality rates are among the lowest in the world. When a Sri Lankan woman gives birth, there is a 96 per cent chance that she will be attended by a qualified midwife. If she or her family need medical treatment, it is available free of charge from a public clinic within walking distance of her home, which is staffed by a qualified nurse. Her children can go to primary school free, and education for girls is free up to university level.

Compare that with Kazakhstan. Even though Sri Lanka has 60 per cent less income per capita, a child in Kazakhstan is nearly five times more likely to die in its first five years and is far less likely to go to school, drink clean water, or have the use of a latrine.

Sri Lanka is not unique. Most recently, Uganda and Brazil have doubled the number of children in school, halved AIDS deaths, and extended safe water and sanitation to millions of people. In the Malaysian state of Pulau Penang, the public water utility company supplies water to over 99 per cent of the population and sets a subsidised price for the first 20,000 litres of water used by a household each month.

Successful governments have achieved results by providing universally available essential services which work for women and girls; abolishing fees in health and education and subsidising water and sanitation services; building long-term public capacity to deliver services; expanding services into rural areas; investing in teachers and nurses; and strengthening women’s social status and autonomy as users and providers of services.

Public failure — when governments fail to act

For every Sri Lanka, there are other poor countries where millions of people cannot afford the fee to see a doctor, whose daughters have never been to school, and whose homes have neither taps nor toilets. In Yemen, a woman has only a one in three chance of being able to read and write. If she has a baby, she has only a one in five chance of being attended by a midwife. If she and her child survive childbirth, her child has a one in three chance of being malnourished and a one in nine chance of dying before their fifth birthday. If she lives in a rural area, her family is unlikely to be able to access medical care, clean water, or basic sanitation.

As well as devastating poverty, Yemen exemplifies the deep underlying inequality between the sexes: services routinely fail women and girls. Yet investing in women’s welfare is the cornerstone of development – increasing both their life chances and those of their children. Across the developing world, women are more likely than men to fall ill, but less likely to receive medical care. They are expected to care for sick family members, but are often the last in the family to be sent to school and the first to be taken out when money is short. And it is — almost always, everywhere — girls and women who lose much of their day to hauling buckets of water over long distances.

The reality for the vast majority of poor people in developing countries is that public services are unavailable, or are skewed towards the needs of the rich, or dauntingly expensive — and this drives up social inequality. Children still have to pay to go to school in 89 out of 103 developing countries, meaning that many poor children are forced to drop out of education. Most of them are girls. In one district of Nigeria, the numbers of women dying in childbirth doubled after fees were introduced for maternal health services. Deprived of public water services, poor consumers have to buy water from private traders, spending up to five times more per litre than richer consumers who have access to piped water. In many places, corruption is a major problem in both private and publicly provided services. Corruption and inefficiency mean patchy coverage, absentee staff, and charges for poor quality services.

The public services that do exist are kept afloat by a skeleton staff of poorly paid, overworked, and undervalued teachers and health workers. Teachers’ salaries in least developed countries have halved since 1970. And there are not nearly enough of these public sector heroes to go around. In order to provide basic health care and education for all, the world needs 4.25 million more health workers and 1.9 million more trained teachers.

Read the full report