Service Delivery and Culture of Entitlement

The poor get poor service, not only because of bad provision and roll-out, but because the poor expect too little. 

A doctor friend of mine who moved from South Africa to UK recently remarked on the difference in patient behaviour between poor South Africans and the UK. In the UK, patients are more likely to question and challenge the doctors’ decisions. In South Africa, poor patients stoically accept doctors’ judgement. As a result, doctors in the UK are held more accountable by their patients. 

As another example, a South African friend failed to navigate the public health system when his wife got cancer. He was illiterate with no experience with hospitals. But more than that, he was intimidated. He was unwilling to push to receive the treatment he deserved. As a result, uptake is lower.

These examples show that improved quality and use of public service provisions is not only about management and access. It requires a better appreciation of the poor’s engagement with service providers. Accountability and uptake will be lower if clients expect too little. 

What explains this difference in behaviour? Maybe it is low expectations, learned from a history of bad service delivery. Maybe it is lack of confidence: asymmetric power relationships, which still remain after apartheid ended. Maybe the poor don’t believe they deserve good service. 

Annette Lareau (2011) argues that middle class parents cultivate in their children a sense of “entitlement”. They believe they deserve more and as a result get more. So, poor South Africans don’t have too much of a culture of entitlement, as many claim, they have too little. 

If a sense of entitlement is learned in the middle class household, then maybe public policy can do the same for the poor. Maybe it is possible to shift expectations through appropriate provision of information.  Ray (2003) argues that one poverty trap is a “failure of aspirations”. This could be applied to individual dreams (expectations of personal achievement), but also expectations of service delivery.