Despite having a sophisticated health-care system and spending more on health care than do most countries in the world, by the early 2010s the Netherlands experienced some of the poorest perinatal-health outcomes in the European Union. Birth-related complications among women and infants were driven primarily by economic and social inequality. For example, women living in the country’s low-income neighborhoods were up to four times more likely to die during childbirth than the Dutch average. In partnership with university researchers, the municipalities of Rotterdam, Groningen, and Tilburg began tackling the problem. After discovering that the growing disparities in perinatal health outcomes were driven in large part by social and economic challenges rather than by purely medical factors, the cities set out to build integrated, multisectoral teams­—local coalitions—that brought together service providers working in both the health-care and social domains. To tailor care to an individual patient’s own circumstances, the coalitions transcended the traditional boundaries that separated physicians, midwives, municipal officials, social workers, and other service providers. They worked to integrate their records and come to agreement on ways to monitor progress, and they designed referral systems and procedural road maps to deal with specific and individual client problems. In 2018, the national Ministry of Health, Welfare and Sport expanded the use of such local coalitions to reduce early-childhood health disparities in municipalities throughout the country. By early 2022, 275 of the Netherlands’ 345 municipalities were participating in the program, dubbed Solid Start, and the new national government pledged to expand the program to every municipality in the country.

Leon Schreiber drafted this case study based on interviews conducted between September 2021 and April 2022. Case published May 2022. This case study was supported by Bernard van Leer Foundation as part of a policy learning initiative. Please note that the Solid Start program described in the case is not an instance of the foundation’s Urban95 strategy, which features in several other ISS case studies that are part of the learning project.

Narrowing the gap between rich and poor was a top priority for Teresa Surita, five-time mayor of Boa Vista, Brazil. Surita had long viewed early childhood development services as crucial for improving life chances and attaining that goal, and she had partnered with several programs to expand parent coaching and other opportunities. As her fifth term began in 2017, she turned to a program called Urban95, which called for making a top priority the needs of young children and their families in all of the city’s planning and programs. Building on work the city had already done, Surita and her department heads undertook projects that included adapting a neighborhood to the needs of young children and their caregivers and building a cutting-edge data dashboard and alert system designed to ensure citizens would get help when they needed it. The city sought to keep those efforts on track while also extending assistance to families among the refugees fleeing deprivation and violence in neighboring Venezuela. As the term of the initial phase drew to a close in September 2019, municipal officials began to take stock of progress and results. Despite some philosophical disagreements and some uncertainties about the future of vital federal funding, the city was on track to achieve its project goals. 

Bill Steiden drafted this case study based on interviews conducted in Boa Vista and Sao Paulo, Brazil, in July and August 2019. Case published October 2019. The Bernard van Leer Foundation supported this case study to foster early-stage policy learning.

In its 2006 national vision to end poverty, Ethiopia set its sights on becoming a middle-income country by 2025. It was a hugely ambitious goal for a country that, at the time, was one of the poorest in the world. To support development objectives put on hold during a decade of political turbulence, including a costly border war with Eritrea that drained public coffers, the Ethiopian government sought to expand its resources by significantly boosting tax revenues. The new plan called for a sharp increase in the ratio of tax revenue to the size of the economy—and within four years. The government merged its separate customs and domestic tax offices into a single entity and restructured the new agency’s operations along functional lines, increased salaries, adopted stringent anticorruption rules, implemented a modern information technology system, and launched public awareness campaigns. It was important that the new revenue authority worked to improve its coordination with the tax offices of subnational governments, which operated with substantial independence under the country’s federal system. Although unproven charges of corruption against the Ethiopian Revenues and Customs Authority’s long-serving director general in 2013 stalled progress, a new round of IT and legal reforms in 2016 helped increase tax collection significantly: to US$7.8 billion in 2017 from US$1.3 billion in 2006 (measured in constant 2010 US dollars). Nonetheless, revenue gains continued to lag behind economic growth. In 2018, under a new prime minister, the government began to take further steps to strengthen tax collection.

Leon Schreiber drafted this case study based on interviews conducted in Addis Ababa, Ethiopia, in October 2018. Case published December 2018.

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In 2009, South Africa's health-funding system teetered on the verge of collapse. Despite the adoption of a transparent and credible budget framework in 1994, large parts of the public health system suffered from chronic overspending and poor financial control. As wage hikes and supply costs ate into the health budget and as government revenues plummeted in the wake of the 2008 global financial crisis, the national health department had to find ways to preserve priorities, linking them more effectively to the budget. The department won agreement on a list of non-negotiable expenditure items to protect in provincial budgets, used earmarked conditional grants to channel funds to key programs, cut medicine costs by improving central procurement, rolled out a new information technology system, and improved its monitoring of provincial finances. Although the country's nine provincial health departments had important roles to play, most of them struggled. However, the Western Cape was able to set a model by controlling personnel costs, improving monitoring, and creating incentives for health facilities to collect fees. Nationally, total per-capita government revenues dropped by 5% in the immediate aftermath of the financial crisis and grew only slowly thereafter, but the health sector's strategy helped ensure progress on its key priorities even as resources fluctuated.

Leon Schreiber drafted this case study based on interviews conducted in Pretoria and Cape Town, South Africa, in August 2018. Case published October 2018.

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Rwanda’s public health system was among the many casualties of the country’s 1994 genocide. In the aftermath of the violence, health workers were in short supply, maternal and child mortality rates spiked, and infectious diseases such as HIV/AIDs and tuberculosis often went untreated. By 2011, Rwanda had made enormous progress in remedying the situation, but much more remained to be done. From 2011 to 2016, officials in the finance ministry and health ministry worked together to develop five-year plans for public health, translate their new priorities into annual budgets, and monitor spending so as to ensure progress toward national goals. They revised the budget calendar to improve the planning process, helped local authorities build medium-term public-health strategies, and refined the tools used for tracking spending in the health sector. They met or surpassed more than half of the top targets they set for 2015, cementing the gains Rwanda had made since 1994.

Simon Engler drafted this case study with the assistance of Louise Umutoni Bower, based on interviews conducted in Kigali, Rwanda in March, April and August 2018. Case published September 2018.

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As Vietnam gradually became a middle-income country during the early 2000s, its tax agency struggled to keep up. In the decade and a half following the Communist Party–led government’s 1986 decision to establish a market-based economy, local entrepreneurs launched businesses, foreign investors poured into the country, and the average annual rate of economic growth soared to 7.5%. But during the same period, tax revenues declined as the General Department of Taxation (GDT), which previously collected almost all of the country’s taxes from a small group of state-owned enterprises, strove to keep pace with the economic dynamism. In 2004, the department established an internal reform team and adopted a strategy to make sure those who could pay covered their fair share of the cost of government services. The GDT worked with the finance ministry’s tax policy department and the parliament to implement a raft of legal changes. The department then reorganized each of its 758 tax offices along functional lines, rolled out a new IT system, improved staff training, and created a unit to bolster taxpayer compliance. It later adopted a personal income tax and tried—sometimes unsuccessfully—to close exemptions created earlier to attract foreign investors. Although its collection levels began to plateau after 2010, in the decade or so from 2004 to 2015 the GDT increased the number of registered taxpayers in the country to 15 million from 2 million and tripled the amount of taxes it collected annually, maintaining one of the highest tax-to-GDP ratios in East Asia.

Leon Schreiber drafted this case study on the basis of interviews conducted in Hanoi, Vietnam in May 2018. Case published in August 2018. 

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After the 1994 genocide that claimed hundreds of thousands of lives, Rwanda’s tax collection collapsed to $132 million in 1996 from $225 million in 1990. Aside from its desperate need for money to pay for reconstruction, the new unity government, led by Paul Kagame’s Rwandan Patriotic Front, was also determined to break its dependence on foreign donors by becoming entirely self-funding. To do that, Kagame’s government had to convince a traumatized and distrustful public to pay its fair share of taxes. In 1998, the government replaced the existing tax and customs departments with the Rwanda Revenue Authority (RRA), a semiautonomous tax agency. The RRA overhauled tax collection procedures, increased staff capacity, improved information management, and launched a massive and sustained public education campaign in an effort to build a new social contract. As a result, in 2017 Rwanda collected in three weeks the same amount of tax it had collected annually a dozen years earlier. From 1998 to 2017, Rwanda’s tax-to-GDP ratio improved from 10.8% to 16.7%, and total tax revenues collected grew more than 10-fold to $1.3 billion. Moreover, from 2007 to 2017 alone, the number of registered taxpayers grew 13-fold—from 26,526 to 355,128—though Rwanda was one of the world’s poorest countries and most of its labor force of 6.3 million still had incomes below the threshold that made them tax eligible. By 2017, the government financed 62% of its annual budget from domestic tax revenues, up from just 39% in 2000. The country was on its way to ending donor dependence.

Leon Schreiber drafted this case study based on interviews conducted in Kigali, Rwanda in March 2018. Case published May 2018.

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In June 2012, Rwanda’s national land registry completed a nearly four-year project that mapped every one of the country’s 10.4 million parcels and prepared title documents for 8 million landholders. It was an unprecedented accomplishment in a country in which lack of land titling had weighed on the economy and led to escalating conflict over access to land. The mapping program promised to reduce tensions by establishing an orderly system for registering and transferring landownership. However, the system could work only if Rwandans registered every transaction, and in 2012, a survey found that only about one of every eight landowners had even bothered to pick up their official titles. The registry urgently had to both make it easier to register transactions and build public awareness about the importance of keeping the land database up-to-date. A registry team launched a nationwide campaign to raise awareness about the importance of titling and of reporting all land transactions. Managers simplified procedures and registration forms. And to provide greater access in rural areas, where titling was nearly unknown, the registry decentralized services and introduced a new software platform to speed transactions. By mid 2017, more than 7 million people had collected their titles, and registrations of sales, purchases, and other kinds of transfers had begun to improve. Still, the number of transactions reported in 2016 fell short of the registry’s target, indicating that further work lay ahead.

Leon Schreiber drafted this case study based on interviews conducted in Kigali, Musanze, and Huye, Rwanda, in June and July 2017. Fortunee Bayisenge, Lecturer and Dean of the Faculty of Development Studies at the Protestant Institute of Arts and Social Sciences, collaborated on the research. The British Academy-Department for International Development AntiCorruption Evidence (ACE) Program funded the development of this case study. Case published September 2017.

In 2014, Ghana began to implement its National Anti-Corruption Action Plan, adopted a decade after the West African country signed the United Nations Convention against Corruption.  With over 120 goals, the plan’s strategy was wide-ranging and ambitious. The goals included strengthening the public service code of conduct, improving the asset declaration system, and expanding freedom of information, as well as adopting many new laws. About 15 other countries around the globe had announced similar aims, though few included as many goals in their plans or required as many statutory changes. Ghana’s Commission on Human Rights and Administrative Justice, which was responsible for translating the strategy into practical accomplishments, faced stiff challenges, including limited coordination capacity, electoral disruption, reluctant legislators, and a few scandals that drew the government’s credibility into doubt. By the early months of 2017, the commission was still struggling to implement important parts of the strategy, but there were a few signs of progress: more public agencies were beginning to report regularly on the actions they had taken to meet their goals, a memorandum of understanding to improve coordination among parts of the anticorruption system was in place, and the Electoral Commission had stepped in to require asset declaration by candidates—even while bigger changes remained mired in the legislature. Ghana’s experience illuminated the challenge of introducing broad anticorruption policies in the face of embedded opposition and the ways that dedicated citizens and officials could take smaller but still significant steps to improve governance.

Tristan Dreisbach drafted this case study based on interviews conducted with the assistance of Gordon LaForge in Accra, Ghana, during September 2016, February 2017, and August 2017. The British Academy-Department for International Development Anti-Corruption Evidence (ACE) Progamme funded the development of this case study. Case published September 2017.

In the early 2000s, Tanzania struggled to protect the land rights of the 75% of its citizens who lived in rural areas. Rapid population growth and rising investment in commercial agriculture had increased land scarcity and created the potential for violent conflict in parts of the country. In accordance with the provisions of a new law, the national lands ministry launched a pilot project in 2004 to title 158 villages and more than 1,000 individual parcels. Building on lessons from the project, the government passed a new land-use planning act, created a new implementation program, and drew up a strategic plan to title rural land throughout the country. Starting in 2008, the lands ministry worked with community leaders to grant villages and their residents title documents that protected them from land grabbing. Villages also decided how they would use communal land and how they would set up committees to resolve boundary disputes. Officials constructed registry buildings in villages and districts to house title documents before surveying individual land parcels and handing over titles to village residents. By 2017, more than 11,000 of Tanzania’s approximately 12,500 villages had mapped their outer limits, and about 13% of villages had also adopted land-use plans. Of the approximately 6 million households located within rural villages, about 400,000 also had obtained individual title documents.

Leon Schreiber drafted this case study based on interviews conducted in Dar es Salaam and Arusha, Tanzania, in April 2017. The British Academy-Department for International Development Anti-Corruption Evidence (ACE) Program funded the development of this case study. Case published June 2017.

A 2017 workshop, Driving Change, Securing Tenure, profiled recent initiatives to strengthen tenure security and reform land registration systems in seven countries: South Africa, Canada, Jamaica, Kyrgyzstan, Mozambique, Australia and Tanzania.

Watch the video of Seraphia Robert Mgembe - Program Coordinator, MKURABITA