OCIAL DEVELOPMENT NOTES ENVIRONM ENTALLY AND SOCIALLY SUSTAINABLE DEVEI.OPMENT NETWORK Note No. 37 May 1998 Social Assessment Helps Sharpen Sector Reforms in Armenia Armenia's recent experience underscores the education, equivalent to just 4 to 5 percent of value of using social assessment (SA) in social GDP in 1997, are much lower than in Central sector reform projects. The Government of and Eastern Europe's middle-income Armenia and the World Bank carried out an transition economies. Costs have shifted to the SA to evaluate the social and institutional population in the form of informal payments, feasibility of the government's proposed sharply limiting the poor's access to services. education and health sector reforms. The The health care system has failed to improve social assessment helped to identify key the population's health status, and school stakeholders and their expectations and enrollments and attendance continue to attitudes toward health and education decline. reforms; test the compatibility of beneficiaries' stated needs and the proposed reforms; adjust B proposed project components to meet Box 1. The Armenian Government's beneficiary needs and reflect socioeconomic Proposed Reforms realities; and collect and organize baseline Education: The Armenian government's data for ongoing participatory monitoring. education reform strategy is designed to rationalize school facilities and teacher Health and Education in Context deployment, implement cost recovery measures (for textbooks, university fees, elective and Many of the newly independent states of the vocational courses), promote school-based former Soviet Union inherited inefficient and management, financial independence for schools, deteriorating health and education services. and improve monitoring of educational outputs. Throughout the region ministries face Health: Strategies to restructure and strengthen enormous leadership challenges in setting primary health care include providing essential social sector priorities and developing health services free of charge to the entire regulatory systems. Gross human resource population, subsidizing essential clinical services imbalances continue to exist and oversized for disadvantaged groups and cost sharing for facilities, too costly to operate and maintain, nondisadvantaged groups, transferring full costs farhes deteriorating. coll o prae n nata,to patients for nonessential services, and are deteriorating, establishing performance contracts with service The situation is no different in Armiienia providers as a basis for financing the health care where state resources for health and system. Gillian Perkins is task team leader of the Education Financing and Management Reform Project. Laura Rose and Toomas Palu are co-task team leaders of the Health Financing and Primary Health Care Development Project. Alexandre Marc is program team leader for Human Development in Armenia. For more information on the social assessment, contact Mary Beth Schmidt, The World Bank, 1818 H Street, NW, Washington, DC 20433, USA, Fax: 202- 522-3665, E-mail: mschmidt@worldbank.org. Thie views expressed in this note are those of thze auithor(s) and do tot necessarily reflect tihe official policies of tte World Bank. Armenia's government dev eloped strategies Social Assessment Objectives and for sector reform and askied the World Bank to Methods help them prepare two projects-the Health Financing and Primary Health Care The social assessment sought to: Development Project and tlhe Education . Identify stakeholders and develop ways to Financing and Management Reform Project. involve key stakeholders in defining, Early in preparation, the Bank and counter- implementing, and monitoring the progress parts realized that there was little government and impact of reforms, especially on the poor or public ownership for the reform strategies and vulnerable on -which the projects were to be built. Low pay, difficult working conditions, and lack of * Collect information on community continuity in leadership undermined involvement, school enrollments, formal and ministerial capacitv to slhkare strategies with or informal expenses, health status and service generate support fromcivilsociety.Theseutilization, access to health and education generate support from civil society. These services, atttudes of service providers and same factors also seriously threatened the government's ability to implement reforms. users, satisfaction with and expectations of service, and the coping mechanisms (for The Government/ Bank team recognized that example, selling assets, or borrowing) used to before they could ensure that reform strategies obtain services were appropriate, or that they could be articulated through sustainable projects, they Establish channels for sharing information needed to gather and share a great deal of among ministries, local governments, information. The task team used social professionals, donors, nongovernmental assessment methods to carry out social and organizations (NGOs), and the public about the assessent mthodsto cary ou socil andsubstance and process of social sector reforms institutional analysis, and to foster stakeholder participation and ownership in policy reforms * Establish mechanisms for resolving conflicts and project components. and building consensus about reforms. Box 2. Sample Social Assessment Findings About Health Issue Finding Access - Access to hospital and inpatient services is limited by high informal payments required by doctors prior to consultations, diagnostics, and treatment. Utilization a Patients go to hospitals for inpatient care (47 percent of visits), outpatient care from a specialist (39 percent), and consultations or diagnostic tests (14 percent). * Reasons for polyclinic visits include patient's initiative (52 percent), need for immunizations (27 percent), follow-up or other visits initiated by a physician (15 percent), and to obtain free drugs (4 percent). Quality * More than 75 percent of survey respondents were satisfied or highly satisfied with their practitioner's expertise, attitude toward patients, and duration of waiting time. * Patients were most dissatisfied with the availability of medicines and the physical condition of facilities. Focus groups said that health facilities rarely distribute free medicines, even with a prescription. The groups did not trust doctors because they felt doctors are motivated by profit. Cost and a The mean cost of a polyclinic visit is US$8; the mean cost of a hospital stay is US$70. There is little coping opportunity to negotiate prices. strategies a Informal payments are less common in polyclinics than in hospitals. Respondents do not know if fees are official and legal, which limits their ability to claim free care. * Medical costs are financed with current income, savings, and above all the sale of assets (44 percent). Some patients borrow money to cover immediate costs until assets can be sold. * People without assets are reluctant to borrow money and likely to avoid or discontinue treatment. * When care is too expensive or initial treatnent is unsuccessful, Armenians turn to folk healers and elders who are compensated based on the patient's willingness to pay. Problems and . People believe that prices will be more transparent and doctors will be more accountable for service quality recommen- if fee recommendations are formalized. Overall costs will increase, however, because informal fees will dations continue. 2 Box 3. Sample Social Assessment Findings About Education Issue Finding Utilization . Nearly 90 percent of respondents support kindergarten attendance yet only 39 percent of children 3 to 7 years old attend kindergarten. * Nearly 5 percent of school-age students, most of them outside the capital, do not attend school. . Enrollment is stable for grades 1 through 8; after grade 8 enrollment drops. * More than one-third of students attend school sporadically, and 90 percent of absences last from 10 to 30 days. Among students absent for more than 10 days, 67 percent cited health reasons and 17 percent cited the poor physical condition of schools as the main cause. Quality * Rural schools are perceived as being of lower quality than urban schools. . Parents perceive education as geared toward higher education and not toward developing mnarketable skills. Technical and vocational schools are not widely available. . The cost of textbooks dramatically exceeds most parents' willingness to pay. The average cost is 500-800 COosit anad drams; parents are willing to pay 360 drams.. strategies . The mean cost for one child in kindergarten is 554 drams a month. The mean rate respondents are willing to pay is 903 drams a month. . Parents contribute 100-200 drains a year toward school repairs and supplies, as well as labor and fuel in rural areas. Those unable to contribute are not penalized. * To meet education expenses, rural households barter or sell crops early at disadvantageous prices. * School/parent councils take action on issues such as textbook problems, physical condition of schools, and heating. * To attract male teachers skilled in subjects in high demand to remote, small schools, parents recommend Recommen- reinstating the law exempting them from military service. dations . Parents also recommend adjusting the public transport schedule to the school schedule to reduce tardiness among students traveling from nearby villages. The ministry working groups responsible for National Institute of Health observed patients planning and implementing reforms were at selected health facilities. Their observations, involved in the SA from the design stage. The along with existing studies and reports on SA team included local and international health and education, informed the survey experts who combined quantitative and quali- questionnaire. The questionnaire and tative methods over a three-month period. discussion guides were also revised based on Household survey. Local researchers and State discussions with an education consultant Department of Statistics staff, who were responsible for advising the government on proficient with Livings Standards Measurements financing and delivering textbooks. In Survey methods, surveyed a representative addition, the ministerial working group on sample of 1,000 households to explore utilization education met with parents and headmasters rates, access, expenditures, and attitudes. in Armenia's 12 administrative districts. These meetings proved to be an excellent way for Participatory rapid appraisal methods. Focus parents and headmasters to voice their groups, semistructured interviews, and concerns and influence the education reforms. participant observations were undertaken in a sample of villages and urban areas to explore Stake holder workshops. The household survey issues that could not be easily capturedl by the and participatory rapid appraisal work were household survey. This field work was followed by a national stakeholder workshop supervised by an international consult:ant and to discuss findings (see Boxes 2 and 3) and conducted by local teams that had been consider lessons from reforms in other conducted by localteamshathcountries. Separate days were devoted to. trained for Armenia's participatory poverty health and education. Nearly 75 represent- assessment. atives came from different regions, levels of To formulate focus group and interview government, service providers, donors, United discussion guides, researchers from Armenia's Nations agencies, and NGOs. Continuousfeedback. To continue the process of sharing information and gathering Box 4. Practice Pointers feedback, the two projects that grew from Local capacity is key. Armenia's SA team benefited from sector reform plans -the Health Financing and working with local people trained in sampling procedures Primary Health Care Development Project and and questionnaire development. When local capacity is Education Financing and Management Reform lacking, SA teams should budget additional resources, Project -will hold systematic, regularly time, and supervision to build this capacity. scheduled regional workshops. The main tool Costs versus coverage. This SA covered two different used at the workshops will be the strategic sectors at one time, in an effort to keep costs down. Household survey and rapid appraisal activities were logframe, an approach that assists carried out when schools were out of session, This enabled stakehoiders in assessing issues and the SA team to interact with full families, but made it developing clear priorities or action plans. difficult to gather first-hand information from teachers and school management, or to observe community involvement Funding for the social assessment came from in schools. Separating the education from the health social the Japanese and Dutch governments. The assessment would have given the SA team flexibility to household survey, participatory rural appraisal explore education issues on a more appropriate schedule, report writing and translation, and stakeholder but costs would have at least doubled. workshop cost about US$150,000. Value Added The SA highlighted weak communication ubetween health and education ministry Baseline data. As a result of the SA, a wealth professionals, and the general public. As a result, of data is now accessible on health and project budgets for information and consultation education in Armenia. These data form the activities were increased to improve baseline against which projects will monitor dissemination and generate discussion and changes in attitudes, access, utilization rates, feedback about proposed changes. and expenses, as well as reveal the impact of the projects. Funds were set aside in both In addition, both projects will establish funds projects to finance surveys and workshops for for pilot activities to test ways of divesting social continuous monitoring and learning. infrastructure to communities, protecting access by the poor, and developing incentives for Project component design. The SA found that only professionals to improve service delivery. 30 percent of children have access to all of their textbooks - much less than reformers had Policyformulation. Ministry officials continue to estimated. The SA also found that parents support cite findings from the social assessment to justify a revolving textbook fund, but they are reluctant sectoral reforms. Quantitative data underscored to change pedagogical methods and approaches the scale of problems in health and education, and do not want to assume greater responsibility while qualitative data explained the reasons for managing schools. Education components were behind the demand for some changes and designed based on such findings. resistance to others. Similarly, health sector findings provided a Participatory process. The assessment also rationale for reforms to support preventive helped the government meet the social health care through primary care, which is less development needs of Armenia's Structural expensive than hospital-based curative care. Adjustment Credit, which requires ministries Under the health project, the government will to identify the stakeholders in reforms and develop the training and retraining capacity of establish a process for consulting and primary health care providers, rehabilitate and exchanging information with them. equip primary care facilities, and develop primary care guidelines. Social Development Notes are published informally by the Social Development Family in the Environmentally and Socially Sustainable Development Network of the World Bank. For additional copies, contact Social Development Publications, The World Bank, 1818 H Street, NW, Washington, DC 20433, USA, Fax: 202-522-3247, E-mail: sdpublications@worldbank.org. ® Pr nted on Recycled Paper 4