Daniel Ortega
Director de evaluación de impacto en CAF -banco de desarrollo de América Latina
After a grueling, sleepless night, Carlos asked one of his sons to take him to a hospital for testing. The awful feeling for the last 4 days could only be caused by “the virus,” he thought. He had decided to isolate himself since he felt the first symptom, and that reassured him a little, but still, that night he was terrified. I don’t know if he saw his life flash before his eyes, but he did leave instructions for his son, just in case. His nerves were somewhat calmed by his trust in Dr. Iturbe, who had told him that he would be cared for and receive decent treatment at the hospital.
A three-hour wait just outside the entrance of the area where they keep the patients in most critical condition, and a bit too many “I’ll be with you in a few minutes” were almost enough to make him swallow his pride and call his ex-wife’s brother-in-law and ask him to see him in a private clinic—his insurance no longer covered such luxuries. As if he needed one more lesson, right before he got up, the doors opened wide and a voice announced they were about transfer the remains of those who had lost the fight against the virus. Faceless nurses in inappropriate gear moved the body bags unfazed, as if the grieving relatives were not there. They bid a brief farewell, and cried tears of sorrow.
“Good thing Maria is in Canada,” Carlos thought at the end of the day, at home, isolated, after receiving his diagnosis and prescription. The stabbing pain of the human tragedy of an inoperative healthcare system distressed him even more than his shortness of breath. He never thought that reality was so precarious, and knowing that’s all the vast majority can afford would keep him up that night as well.
Faced with the challenges of everyday life in Latin America, we can’t help but think about what it would be like if public institutions were able to provide the services they are supposed to, appropriately, effectively and fairly. How can we change public service to make it work to meet people’s needs? What is the key to improving the functioning of the state? Where do we start in order to understand the things we need to change? Are there reasons deeper than just corruption or the capture of the political system?
We set out to do just this, and decided to ask public officials of the region, in all countries, at all levels of government and branches of the state, to give us their impression on how decisions are made in the public sector, and how science or scientific knowledge influences decision-making. What about politics or interests of certain groups? How about institutional inertia? Are there other important factors? We received answers from 2,160 people in 14 countries, which gave us a clear picture. The typical professional public official noted that almost 70% of decisions are made following political criteria, by institutional inertia or simply based on personal motivations of the incumbent authority. In less than 3 out of 10 times, scientific or technical reasoning prevails.
The numbers are consistent with the experience of public service for many Latin Americans, but according to the protagonists themselves, what prevents things from being done differently? What prevents that potential leader from changing bad practices? Why do professional officials find it difficult to mobilize change? Four out of ten times, the problem lies in the people: Working conditions in the public sector often make it difficult to recruit the right people for certain positions, and when they are recruited, they don’t stay there for very long, and so their expertise goes with them and the institution gets stuck in the learning curve. Public officials recognize that the main problem is to capture, retain and keep civil servants happy and creative. And it doesn’t take much digging to see the signs of frustration, anger and apathy on officials who cruelly exercise their small portion of authority over citizens.
Public institutions with officials who are satisfied with their remuneration scheme and professional career path, with training and in a culture of transparency and checks and balances, are institutions where technical or scientific reasoning ends up having a greater influence than politicians or inertia. This is the data speaking. We have experiences in the region where the management of public funds is controlled by people who are happy with what they do, who bring new ideas and share their knowledge inside and outside the institution. This is what we can aspire to for our police, our healthcare services, education, social assistance, taxes, etc. Often the question will be, where can we start when the institution is already performing poorly?
One fact that is easy to forget amid the frustration of our struggle with poor service and malfunction of many of our institutions is that the vast majority of officials joined the public service following a genuine desire to contribute to the common good, to devote their lives to serving others, by vocation, not by ambition. Reviving this illusion for public service is one of the great challenges of modern public management, to have happy workers who are recognized for their work, where they can put their best efforts in delivering what is expected of them, but also in stimulating the search for better processes, greater accountability to the public and ultimately also greater well-being for all, because, for the foreseeable future, the functioning of the state will remain either the heaviest burden or the greatest driver of development.
In the healthcare system that treated Carlos, let us imagine that a group of professionals decided to improve the information system on the medical supplies each hospital receives, making it public and visible to workers and communities; and that they encourage the creation of working groups to monitor the use of supplies and find ways to use resources more efficiently, generating healthy competition between healthcare centers to see which has the best efficiency indicators. This helps improve the allocation of funds for infrastructure maintenance, supplies and personnel, channeling transparently the use of private donations and publishing regularly quality indicators of the provision of services. There is evidence that in middle- and low-income countries, promoting mechanisms for participation, inclusion, transparency and accountability in front-line services (such as healthcare) improves access to and quality of services as well as certain health indicators in the communities served, especially when these initiatives are supported or conceived by service providers themselves.
The capture of the system would become very difficult thanks to the quest for excellence and checks and balances provided by the participation of many players in healthy competition. There is also evidence of this. This would attract more funds to compensate workers decently, and in 10 to 15 years the healthcare system could show performance indicators similar to the average for rich countries.
Institutions not always require great leadership to set them on the path of change; they can gradually change after some positive—even if small—incentive. This number-based conversation with hundreds of officials from across the region suggests that such changes are possible, and that they may be better welcome by public officials than expected, many of whom still treasure an essential quality of their work: to serve others.
