How should we measure quality of life in urban centres?

This blog, written by David Satterthwaite with the International Institute for Environment and Development (IIED), discusses what indicators are needed in order to assess the quality of life of the urban poor. The post is part of the Wikiprogress series on the quality of life.

Mexico City

 

Almost 1 billion people currently live in slums, and this number is expected to grow by nearly 500 million by 2020 - if we're to ensure that no one is left behind in the future development agenda, we need to determine whether progress is really reaching these marginalised groups. And for that, we need appropriate indicators and data.

 

 

Rather than reviewing the appropriateness of existing indicators on urban quality of life, this blog begins by considering what indicators are needed. This allows an assessment of existing or proposed indicators for their appropriateness and shows the huge inadequacies in the indicators currently used.

These indicators can be divided into those relating to living conditions (who 'lives in poverty'), access to public services and income and assets. They could include indicators relating to possibilities for citizen and community engagement – a voice for the urban poor, for example that includes whether they can get on the voter register or access public services and the possibilities of getting appropriate responses from government agencies.

Living conditions among urban populations

These should include sufficient indoor space per person, housing constructed with permanent building materials, and a secure site that does not pose any risk (so not on a site at high risk of flooding or under threat of eviction). They should also include safe and regular supplies of drinking water piped to the home, and a good-quality toilet in the home that all residents can use.

Data on each of these indicators should be available for each dwelling unit. The current indicators fail to show us which dwelling units have these conditions. Furthermore, the data is from national sample surveys, with the sample sizes too small to give a clear indication as to where living conditions are poor.

So for example, the Demographic and Health Surveys or Living Standards Measurement Studies may tell a government that X per cent of their urban population lack safe drinking water piped to their dwellings, but they fail to identify the deficient urban centres, let alone pinpoint where the individual dwellings are.

The data collected at the moment is also inadequate in itself. The definitions of what constitutes ‘improved’ water and sanitation are so broad that they include forms of provision that are grossly inadequate for most urban contexts. Even when there is data on water supply, it does not include details of the cost, quality or regularity of supply of that water.

Urban dwellers’ access to public services

Every urban household needs a solid-waste collection service, and a regular toilet-emptying service if not connected to sewers. Urban dwellers need access to good-quality healthcare and emergency services, schools (and day-care provision), public transport, and policing in their settlements to ensure the rule of law. They also need to be able to vote and hold local politicians to account.

At best, data for these indicators is only available from national sample surveys, so once again it’s of no use in identifying where needs are located. In fact there is no data at all for many of these. One surprising fact revealed in studies of informal settlements is that there are often private schools because the inhabitants cannot get their children into government schools without a legal address. Toilet and washing facilities are also often provided by private companies, and these services have to be paid for.

Income, assets and the poverty line

Indicators relating to whether individuals or households have sufficient income to meet their needs are particularly valuable in urban contexts because most aspects of good living conditions have to be paid for. But the monetary poverty line (the minimum income required to meet needs) must be set to reflect local costs.

The costs of food and non-food needs vary a lot within nations; usually they are highest in larger and more successful cities (especially rent for housing). They also rise where provision for water, sanitation, schools and healthcare is inadequate and people have to pay private enterprises for these services.

So poverty lines need to be adjusted to reflect differences in costs within nations – and we must avoid the application of the same monetary poverty line across a nation. The large variation in costs within nations is already recognised by the United Nations when setting the daily allowances for their own officials; yet this variation is not applied to poverty lines.

The worst offender is the US$1.25 a day poverty line: in many nations this figure bears no relation to the costs of needs (including adequate living conditions) and includes no adjustment for where such costs are particularly high.

The need for local data on urban poverty

Measuring urban quality of life has to be about better measurement in each locality, not more questions in national sample surveys. This needs to be linked to the institutions with responsibilities for addressing needs – mostly local governments and civil-society organisations.

It is also about better use of census data so local authorities can see where the deprivations are located. The collection of data should engage the urban poor themselves; this becomes easier and far more productive where there are representative organisations formed by those living in informal settlements or slums (now the case in over 30 nations).

Engaging with the women-led savings groups at the foundation of most of these federations will produce far more accurate data about living conditions, therefore about what is needed and what it costs. And there are some amazing examples of data on living conditions in informal settlements done by the inhabitants themselves.

Unfortunately, most of what is suggested above does not generally figure in discussions on measuring urban poverty. Debates over how to measure poverty in a post-2015 framework typically fail to acknowledge how the income required to avoid poverty varies within nations and how high that income requirement usually is for those living in informal settlements in cities; nor do they mention the need for official statistics to support local action and actors. If these key necessities were recognised, it really would promote a revolution in national statistical offices.

There is no discussion of the role of urban-poor groups themselves as data-gatherers and users, or as people with the right to question ‘expert’ judgements made about their needs. And there is no mention of the fact that the $1.25 a day poverty line is hugely inappropriate even for measuring ‘extreme’ poverty because of the size of the urban population with a higher income than this figure yet still living in extreme poverty.

 

 

- David Satterthwaite

This blog appeared first in early January as part of the ODI series on "Measuring progress in the quality of life of the urban poor: are indicators and data fit for purpose?".

See also 

Quality of life in Europe: Subjective well-being

Quality of Life in Urban Neighborhoods in Costa Rica

Quality of Life in Urban Neighborhoods in Metropolitan Lima, Peru

Online discussion "Calidad de Vida Urbana"

 

 

The Road to 2015 is Paved with Open Data

This blog, by David Hall-Matthews, managing director at Publish What You Fund is about the data revolution, specifically concerning aid transparency. This is the 17th post in ODI's blog series on ‘What kind of ‘data revolution’ do we need for post-2015?’ This post is also a part of the Wikiprogress series on Data and Statistics and Post-2015. 

Transparency is a key pillar of sustainable development: an essential piece of the puzzle to enable effectiveness, accountability and social change. And in recent years, information on aid spending has slowly become more available and open.
 

The basic principle that aid information should be publicly available is now accepted as an essential component of international development. Nowhere has that been seen more prominently than the discussions around the post-2015 Development Goals.

We have two years to create new goals. Too often, in development, looming deadlines induce resignation and recrimination – but there are still reasons to be optimistic for the future of aid transparency and open data within the post-2015 process.

Credit is due to the High Level Panel for their boldness and dynamism. Their call for a “data revolution” set the tone for debates on a range of issues, and quickly became one of the buzz phrases of 2013.

There is no question that the “data revolution” means open data. Making detailed information available to everyone, even on something as well-established as aid, would be genuinely radical.

But buzz phrases can mean different things to different people. Many commentators have focused on inequalities of access to information. While it is of course essential to highlight obstacles to data use by the poorest, it would be foolish to put the cart before the horse. Before anyone can use data, there must be data out there.

Others have pointed out that the data revolution can’t be imposed from above. I agree – but we shouldn’t let an insistence on bottom-up approaches let those at the top off the hook on their own transparency commitments. Changes at the top can make a difference.

Aid may not be the most important resource flow after 2015, but making it transparent can make a significant difference to the problematic top-down relationships between donor and recipient nations – and it can set an example for other flows, because aid transparency has had a head-start.

The International Aid Transparency Initiative (IATI) is the only existing international open data standard now in use. Knowing how difficult it is to make new agreements – let alone implement common standards – that’s a massive achievement. Any serious attempt to start a data revolution in 2015 would be crazy to overlook a system that works.

IATI works because:
It’s relatively easy to publish to it. Organisations only need to convert information they hold into a common format, then send links to an online registry.
It’s relatively easy to use the data. It’s raw, and will need to be interpreted to make sense to everyone (like all information), but it’s fully accessible and – critically – comparable.
It’s relatively easy to adopt the standard. Many non-traditional providers of development finance, including NGOs, climate finance providers, philanthropic foundations, development finance institutions and private companies have published to IATI.

IATI itself will be too limited to encompass all resource and information flows. But new standards – for example on domestic budget transparency, or extractive industry payments, could adopt the template – and common code – to make it as easy as possible for users to compare, contrast and collate.

There is increasingly more data out there – now we must make it a useful weapon in the fight to end poverty. We are working hard to ensure donors are becoming more open and now we are working hard to ensure information will be put to use.

We know that raw data may not be understood by the average person on the street, but don’t be fooled into thinking that only small packages of neatly visualised information can be understood. That’s an excuse used too easily by those seeking to control what data is released.

IATI was built specifically in response to partner country, civil society and government requests for more detailed, useful information on money coming into their countries. All donors should publish to IATI if they want to truly bolster the bottom-up approach to international development. It doesn’t make sense for donors to be suggesting new goals and ways to hold partner countries to account, without doing their own bit first.

The end of 2015 is not only the deadline to agree new Development Goals. It is also the date by when the Busan Partnership Agreement needs to be implemented.

Our Aid Transparency Index, the industry standard for assessing transparency among the world’s major donors, shows that most donors have quite a way to go to meeting their Busan commitments. The average score for all 67 organisations was disappointingly low, despite the many international commitments and speeches about openness.

For example, France is the third largest donor in the Democratic Republic of Congo (DRC), spending over USD 1 billion in 2011. But we could find no comprehensive listing of the country’s current aid activities for DRC – or for any other recipient country. Similarly, Japan is the second largest donor in DRC, spending over USD 1.2 billion in 2011. But their database does not include basic information on the projects it’s funding, such as start or end dates of projects or their current status.

In other words, over USD 2 billion in aid to DRC – an aid dependent and fragile state –remains unmonitored. And much of the information we could get was out of date, patchy and difficult to compare with that of other funders operating in DRC.

It’s not all bad though. A leading group of organisations is publishing large amounts of useful information on their current aid activities. And some donors have made real progress over the past year. So there is reason to hope for better aid transparency by 2015.

Open data and transparency are becoming fashionable watch words, but we’re checking if donors are really delivering, looking beyond high-level commitments and long-held reputations. Crucially, we are measuring donors’ progress on the road to 2015.

- David Hall-Matthews

This post first appeared January 16, 2014 on ODI's Post2015.org site.

Transparency and governance in the land sector: two sides of the same coin?

This blog, written by ODI's Anna Locke, discusses land governance and transparency definitions, initiatives and key lessons. The post is part of Wikiprogress' spotlight on governance. 

Land transparency has been on the public agenda again since the G8 summit in June this year. Two events in the same week in October showcased the issue: the Open Government Partnership annual summit in London (which publicised the recent Open Government Guide on Land), and the Global Soil Week conference in Berlin, which dedicated a session to partnerships for responsible land governance – an issue that is rarely discussed by soil scientists. 

A couple of things hit me from these recent discussions. First, the public discussion has broadened from land transparency to land governance. The G8 communique published in June does not refer to a land transparency initiative as such but talks about ‘global activities to improve land tenure governance’. 

Transparency served as an immediate umbrella to bring together different initiatives in a very short time in the run-up to the G8 summit 2013 but seems to have been a launch pad rather than the end point. Similarly, the Open Government Guide on Land focuses on land governance while acknowledging the need for transparency, participation and accountability at the heart of open government. 

I welcome this broader agenda as it provides more of a framework to see how transparency can effect meaningful change.

However, at the risk of being pedantic on this issue (I have form on this– see my blog on the World Bank conference) once again, I want to pin down the terms of the debate and look at the underlying assumptions. It is important to make sure that we are all talking about the same thing, particularly as we prepare for an ODI Roundtable on the whole issue of Land Transparency in December.

First, definitions

What is land governance? The Open Government Guide on Land defines it as a series of processes, including recognition, registration and enforcement of land tenure rights, land-use administration, management planning and taxation, information provision and dispute resolution.

It then identifies the elements that characterise good governance: governments should help to ensure that these processes are ‘clear, transparent and fair… [with] human rights of citizens protected’; that they include‘accountable decision-making about how best to use land… improving the openness’[of those processes, I assume]; and that they ensure ‘consultation with those potentially affected by changes… [which] can help communities and households protect their rights’. 

The Guide suggests the Land Governance Assessment Framework (LGAF) mechanism launched by the World Bank as the main reference point for a baseline evaluation of the state of land governance. The LGAF measures governance in five thematic areas: legal and institutional framework; land use planning, management and taxation; management of public land; public provision of land information; and dispute resolution and conflict management. In turn, the main reference point for the LGAF is the World Bank’s definition of governance as the ‘manner in which public officials and institutions acquire and exercise the authority to shape public policy and provide public goods and services’. 

I would be more specific on two things. Yes, the discussion of land governance highlights the issue of how institutions can carry out the work of land titling, registration and administration. But it also needs to look at how they take and implement decisions on land – who takes part in decisions on land allocation, use and management, and how different interests in competing social and economic functions of land are reconciled. That goes beyond consultation. Indeed, it goes to the heart of the political economy of decision-making and the power relations that are involved. This is recognised implicitly in the Open Government Guide in its recommendation for participatory land and resource use planning. 

And what is the role of the private sector in all of this? Does the shift (back?) from transparency to governance mean a refocusing on governments, instead of the broader private sector actors targeted under pre-G8 discussions? These have been targeted directly through efforts to increase contract disclosure and public provision of information on holdings.

Second, what is the relationship that is assumed between transparency and governance? 

The G-8 Communique talks about the Voluntary Guidelines on the Responsible Governance of Tenure as ‘providing global policy guidance for good land governance and transparency’. So are they of equal importance or does one feed into the other?

The Open Government Guide takes the transparency of processes as a central element that feeds into governance (openness and accountability are others). The LGAF recognises the role of transparency in promoting better governance in the land sector, particularly in land-use restrictions, valuations, expropriation, the transfer of public to private land and in levying fees for different services provided by governments. Its emphasis on the provision of information, particularly through registries and cadastres, is the starting point for transparency in any form. 

The work of ODI (ADP,PoGo) and others, such as Global Witness, on transparency reveals a growing recognition of the importance of transparency for good governance. But it also shows that transparency is not enough, on its own to achieve the standard of governance in the land sector that we are striving for. This was also acknowledged in the Berlin discussions in October.

So, what can we take away from this? I see three key lessons.

1. Yes, the shift to a broader perspective on land governance is useful. But we need to acknowledge areas of agreement and difference on what we mean by governance, particularly in the presence of conflicting interests in land processes, and recognise the role of the private sector. 
2. We need to be clear about the role of transparency in promoting good governance – transparency and governance are not two sides of the same coin although progress on one depends on progress in the other. 
3. And finally, let’s carry the debate on the pathways from transparency to accountability to meaningful change into the debate on governance. This means talking about the content, timing and transmission of information; mechanisms and timescales to ensure meaningful participation and consultation; and getting accurate indicators that measure impact, not just processes.

All of these will issues were discussed at the ODI Roundtable on Land Transparency at ODI on 10 December 2013.

- Anna Locke

*The blog first appeared on 20 November 2013 on the ODI blog site. 

This post features the author's personal view and does not represent the view of ODI.    

Measuring poverty below the averages

This is the fifth in a series of blogs from the ODI that debate how a post-2015 framework ought to measure poverty - find out more.

Among the achievements of the Millennium Development Goals (MDGs), the halving of extreme poverty has been celebrated as the great success. The target of reducing the number of people living on less than $1.25 a day is expected to be reached globally, if not surpassed, by 2015. We cannot take this figure at face value though: this progress has not been evenly distributed, and China’s success boosts the average of overall global poverty reduction. But these discrepancies aside, it is reasonably accepted that income poverty is declining, at least to some degree, in all major regions of the world.

At the national level - the standard focal point for most measures of poverty - the picture is slightly less clear, but overall we tend to see a positive trend. The classic conception of nationally distributed poverty is distorted however by the fact that it is no longer concentrated in low-income countries, the class of countries conventionally singled out for high rates of impoverishment. A number of high-poverty countries have graduated to middle-income status, which means it is less easy to capture poverty by measures of average income or consumption.

The changing dynamics of inequality, both across and within countries (see Milanovic, 2012 for an overview), further complicates our view of poverty. Aggregate measures of poverty such as average consumption rates and poverty head-count statistics, while instructive of absolute poverty levels, fail to capture uneven distributions of income or uneven progress on non-income dimensions of poverty.

The distortions caused by aggregate measures of poverty have led us back to the drawing-board, asking: what exactly do we want to measure with poverty statistics? But a more important question is: what will we use these poverty statistics for? If intended as a tool for national policy-makers to make informed decisions about strategies to reduce poverty within their societies, then it makes sense to look beyond national averages towards poverty rates among particular groups and at different income levels.

Narrowing the lens of poverty measurement to the sub-national-level is challenging, not least because the data is often lacking to do so, but if we wish to address the barriers facing the remaining 50 per cent of the world’s poor who have not yet been raised out of extreme poverty, then this is where the measurement of poverty can be most effective.

There are three useful ways to look below the averages, two of which are reasonably straightforward and can be achieved with the statistics already at hand, and one of which will require more effort to measure given its context-specificity. These measures are presented here as complements to, rather than replacements for, existing aggregate measures of absolute poverty, since both types of measures are instructive for the setting of national and international priorities.

1. The share of the poorest quintile in national consumption. This measure can be found in the MDG framework already, though it has not been used. An extension of this would be to look further below the poorest quintile, to consider the bottom 10 per cent and 5 per cent’s share of national consumption. These measures capture two important elements of poverty.

• They draw out the distributional aspects of income at a national level, thereby highlighting inequalities in income shares held by different segments of the population. We might consider this a measure of relative poverty. Poverty and inequality are not mutually exclusive, and the added appeal of this simple measure is that it can be used to examine both.

• They allow for a disaggregation of the population into income groups relevant for policy-makersin their design of strategies to address the structures that keep people impoverished.

In a recent blog focusing on the inequality dimensions of these poverty measures, we drew upon the case of Brazil to show how aggregation can distort our view of poverty and inequality trends. Poverty and inequality have both declined over the past 20 years by most accounts, but the income share held by the bottom decile in Brazil has increased only marginally and from a very low point.

This perspective draws our attention to situations of poverty that are likely to persist amidst wider gains in income growth. The case of Brazil points to the need for retaining absolute measures of poverty, as these are still useful in explaining the country’s laudable achievements in overall poverty reduction over the past 20 years, but also the need to include measures accounting for the distribution of progress alongside them.

Disaggregated income distributions in Brazil 1981-2009

(Lenhardt & Shepherd, 2013)

2.  A comparison of the outcomes of these disaggregated income groups on indicators of human development such as education, health, hunger and employment. We have shown that recent gains in education access, another highly celebrated outcome of the MDGs, have not been evenly distributed within countries when comparing across different income levels. This research showed that the poorest women were indeed reporting more years of education in the 2000s than in the 1990s, but their progress lagged behind gains made by the median income group. Progress was also slower in indicators of early marriage, women’s empowerment and child mortality.

Tracking gains across the multiple dimensions of poverty among different income groups will allow policy-makers to ensure that the policies and programmes they have introduced to tackle these issues are indeed reaching the people in greatest need of them.

3. The horizontal dimensions of inequality which result in higher rates of impoverishment among particular segments of society including ethnic minorities, spatially disadvantaged communities and disempowered women. Marginalised groups, as identified within country contexts, could be disaggregated from national poverty statistics and their group averages on income and human-development outcomes compared to the national average or median for those indicators.

In combination with absolute measures, these three simple disaggregations would highlight those segments of a given society that are most disadvantaged and would allow policy-makers to track progress on poverty reduction among those more likely to face social, political and institutional barriers to broader poverty-reduction efforts.

Other contributions to our debate on measuing poverty come from Martin Ravallion on two goals for fighting poverty, Lant Pritchett on the case for a high global poverty line, Stephan Klasen's argument for internationally coordinated national poverty measurement and Sabina Alkire's proposal for a multidimensional poverty index post-2015.

Amanda Lendardt is Development Progress' new Research Officer. Her research focuseses include intersecting inequalities and discourses surrouding the inclusion of inequality on the post-2015 agenda.  Prior to joining ODI, she conducted research on smallholder farmer market access in Indonesia.

Governance: Our new theme of the month!

‘Governance is the manner in which power is exercised in the management of a country’s economic and social resources for development.’ The World Bank

So it’s a new month, and you all know what that means, a new Wikiprogress theme! Over the last period we have focused on Post 2015 and Health and during the next few weeks we will be looking at Governance in relation to progress and well-being. Responsive and answerable institutions are key in contributing to societal well-being. Countries with effective, accountable and transparent governing bodies prosper ‘in a range of dimensions of human development and social cohesion’ (How’s Life Report). This blog is a means of introducing our new theme and highlighting a number of key resources related to governance that we plan to reference in the coming weeks.

- OECD’s Better Life Index  - The OECD Better Life Initiative provides a comprehensive understanding of what drives the well-being of people and nations and identifies what needs to be done to achieve greater progress for all. The Index uses eleven dimensions, including Civic Engagement and Governance in an attempt to present accurate, comparable and comprehensive well-being indicators.

According to the report a cohesive society is one where a citizens have a high confidence in their governing institutions and public administration. It seems that more than ever, citizens are demanding greater transparency from their governments. In the United Kingdom for example, the ruling parties are under permanent scrutiny from the country’s media and focus organisations like Transparency International. The Index cites transparency in communication and open access to regulations as promoters of government accountability, resulting in high voter turn out, increased participation in the legislative process and compliance with rules.

- 4^TH OECD World Forum, New Delhi - At the Forum in November last year, the OECD ran a session on Building effective and responsive institutions with the likes of Sue Taylor, the Director of the Social and Progress Reporting of the Australian Bureau of Statistics and Arun Maira, a member of the Planning Commission in the Government of India speaking:

‘If you want to understand well-being ask the citizens. They understand.’ Arun Maira

The discussion identified some of the common characteristics of successful governing institutions including; effective regulatory frameworks, streamlined and efficient public services and tough anti corruption practices. It concluded by emphasizing the necessity of NGOs, civil servants and governments to work collaboratively in an effort to improve the well being of citizens.

- ODI – Politics and Governance – The Overseas Development Institute focuses much of its work on governance, providing resources on Democracies in Transition, Justice and Security Sector Reform, Politics and Service Delivery and Applied Political Economy. Since two-thirds of the world’s population now lives in a democracy of some sort, the ODI explores the socio-political and economic factors that shape transition processes in a bid to support hybrid democracies that are vulnerable to backsliding. The organization is currently focusing on elections, the interaction between different dimensions of governance transitions and political voice and accountability in a bid contribute to the post 2015 framework.  

Finally, make sure you check out the Wikiprogress page where all our articles related to the theme are kept. We look forward to bringing you governance related articles over the next month.

The Wikiprogress Team

What’s driving the quiet revolution in basic healthcare?

This article by Romina Rodriguez Pose, ODI, is part of the Wikiprogress #health series.

Rarely a day goes by when the news is not filled with both warnings about possible epidemics and more encouraging tales of medical breakthroughs. And yet, while these often extreme perspectives occupy the limelight, more nuanced and in-depth understandings of how and why things are working in certain countries and not in others remains relatively unheard.

Health is a key component of ODI’s Development Progress project, which for the past three years has been documenting national-level case studies (on what is working in development and why), enabling us to reflect on how far we have come in addressing basic health issues around the world and uncover hidden stories of progress.

The project’s first-round health case studies explored progress in Bangladesh, Eritrea and Rwanda and were carried out between 2009 and 2011. The second round, currently underway, has two focus areas: maternal health (with case studies in Nepal and Mozambique) and neglected tropical diseases (NTDs) (Sierra Leone and Cambodia).

Maternal health is intrinsically important because people’s prospects in life depend on it to a large extent. It is also a proxy for the capacity and strength of health systems and government’s ability to deliver core services. NTDs are of particular interest as they disproportionally affect the world’s poorest and are dependent on and can accelerate progress in a range of other development areas (poverty, nutrition, water and sanitation, women’s empowerment, education).

Although these countries represent very different local contexts, we can identify clear and consistent factors driving progress across them all:

• Strong leadership and sustained political commitment have been key to pushing through reforms and engaging populations in development processes. Progress is not possible without the prioritisation of health within governments’ agendas.

• Bottom-up approaches invoking social mobilisation and community participation were the cornerstone for progress in all three case studies in the first round, and preliminary findings from Nepal and Sierra Leone support this trend. Community participation and involvement in health service delivery have not only helped alleviate staff shortages, but also proved extremely effective in accessing hard-to-reach populations, bringing services closer to the community while at the same time allowing for behavioural change. They have also transformed community members from being passive recipients to being active participants in their own development and wellbeing. Among other things, the empowerment of women and their increased decision-making power in health matters has been key in both Bangladesh and Nepal.

• The role of donors has been instrumental, not only financially but also through the provision of evidence of successful schemes in similar countries. All the countries studied are heavily dependent on external funding, but all have mechanisms to ensure funding is aligned with national planning (e.g.implementation of health sector-wide approaches has helped governments shape health policy, strengthen delivery and make health financing more predictable and flexible). Balancing government ownership of a development agenda with outside help can be challenging but is essential to ensure commitment and sustainability. Ownership varies across the countries studied, with some governments acting more strongly than others in responding to priorities on the development agenda.

• Both demand- and supply-side interventions have been put in place and contribute towards progress in health in these countries. Community health insurance schemes (e.g. mutuelles de santé in Rwanda) and removal of users fees (e.g. free health care for pregnant and breastfeeding women and children under five in Sierra Leone) have boosted demand for health services by removing financial barriers for underserved populations. From a supply point of view, rewarding health service providers for their performance incentivises them and enhances their commitment to working to higher standards in the delivery of services, although strong controls and quality checks need to be in place.

Despite the high levels of progress these strategies have attained, challenges remain. For instance, the provision of health services has relied widely on community involvement and voluntarism. Despite volunteers being rewarded in terms of respect shown by members of their communities and by the few incentives in place (e.g. provision of mobile phones, T-shirts etc.), keeping them motivated is becoming increasingly challenging. In the same vein, progress has been possible as a result of the financial flows provided by donor countries, which puts sustainability in question, as aid budgets in the developed world are under threat. As such, there is still a need for countries to mobilise internal resources in order to reduce their dependence on aid.

The bigger picture, however, should put a spring in our step. We can state, without doubt, that progress in health care is happening and reaching the most underserved populations in the poorest countries in the world. The increasing body of evidence documenting how progress has been achieved in some settings provides a great opportunity for policymakers from countries facing similar challenges to get inspired by successful strategies and best practices that have worked elsewhere.