【英语生活】穷人选择私立医院和学校的道理

Imagine that your daily earnings were less than the price of this newspaper. Would you consider buying private education and private healthcare?

Before you make up your mind, here are a few considerations: government healthcare and primary education are free; the private-sector doctors are ignorant quacks and the teachers are poorly qualified; the private schools are cramped and often illegal. It doesn't sound like a tough decision. Yet millions of very poor people around the world are taking the private-sector option. And, when you look a little closer at the choice, it's not so hard to see why.

Take the doctors of Delhi, who were studied carefully by two World Bank researchers, Jishnu Das and Jeffrey Hammer. These doctors are busy people – the average household visits a doctor every two weeks, and the poor are particularly likely to visit. And, surprisingly, three-quarters of those visits are to private practitioners – despite the fact that public-sector doctors are better qualified. Why?

Das and Hammer tested the competence and the practices of a sample of doctors by sending observers to sit in their surgeries. They discovered that “under-qualified private-sector doctors, although they know less, provide better care on average than their better-qualified counterparts in the public sector”. This is not particularly mysterious, because private-sector doctors don't get paid unless they can convince their patients that they're doing a decent job. Public-sector doctors draw salaries and, if they are held accountable at all, it is through indirect channels.

There is a similar story to be told about education – and it is well told in a new book, The Beautiful Tree, by James Tooley. A professor of education at the University of Newcastle, Tooley first encountered private schooling for the poor while exploring the slums of Hyderabad, again in India. It took little more than Tooley's curiosity to unearth a network of 500 private schools, typically charging less than $3 a month, and providing an education of sorts to thousands of children from very poor families. Many of the poorest children were on scholarships, educated for free by school owners with an eye on their standing in the local community.

Tooley has since gone on to catalogue cheap private schools for the poor across the world, and has also tested their quality. His research team discovered more committed teachers, and better provision of facilities such as toilets, drinking water, desks, libraries and electric fans. Most importantly of all, the children were learning more.

It is hard to be sure quite how widespread these cheap private schools are, but Tooley and his colleagues have found them in west Africa, east Africa, China and India. In the areas Tooley has studied, private schools are educating at least as many children as government-run schools – and sometimes up to three times as many.

Again, the outperformance of the private schools – in spite of low budgets and teachers with sometimes doubtful qualifications – is not a surprise when one looks at the weaknesses of state-run schools in some developing countries. Tooley toured Lagos, in Nigeria, with a BBC film crew and found teachers sleeping in lessons in the public schools – even though the film crew had given notice of their visit.

The lesson here is that a little accountability goes a long way – and fee-paying customers are in an excellent position to hold schools and clinics to account. By all means let's work out how to make government facilities more accountable, in order to provide better education for the world's poor. But we should also investigate how low-cost private services could be nurtured.

想象一下，如果你每天的收入还不到这份报纸的售价(2英镑)，你会考虑选择私立教育和私立医疗吗？

在做决定之前，请考虑以下几点：公立医疗和初等教育是免费的；私营部门的医生是些无知的庸医，老师的素质也较差；私立学校空间局促，而且往往属于违法经营。听上去，要做决定并不困难。但全球有数百万赤贫人口选择了私营部门。如果你更近距离地审视他们的选择，则不难看出其中的缘由。

以德里的医生为例——世界银行(World Bank)的两名研究员伊松努•达斯(Jishnu Das)和杰弗里•哈默(Jeffrey Hammer)对他们做过仔细研究——这些医生是大忙人，因为普通家庭每两周就要看一次病，贫困家庭则看得更勤。而令人惊讶的是，私营部门医生的接诊次数占到总数的四分之三，尽管公共部门的医生素质更高。原因何在？

达斯与哈默抽样选取了一组医生，派遣观察人员进入他们的诊室，对其能力和医术进行考察。他们发现，“与素质更高的公共部门医生相比，私营部门的医生虽然水平不够、知道的也更少，但平均而言却能为患者提供更好的护理”。这一结果倒不是特别不可思议，因为只有让患者认为他们的工作令人满意，私营部门的医生才能拿到报酬。而公共部门的医生是领工资的，对他们的问责即便存在，也只能通过间接渠道进行。

类似的情况也出现在教育领域，詹姆斯•托雷(James Tooley)的新书《美丽的树》(The Beautiful Tree)对此进行了很好的阐述。托雷是英国纽卡斯尔大学(Newcastle University)的教育学教授，他在考察海得拉巴——又是在印度——的贫民窟时，第一次接触到面向穷人的私立学校。托雷仅凭好奇心就轻松发现，当地存在着一个由500所私立学校组成的网络。这些学校通常收取每月不到3美元的学费，为数以千计来自赤贫家庭的孩子提供某种意义上的教育。许多最贫穷的孩子靠奖学金上学——考虑到自己在当地社区中的地位，学校所有者会免费为这些孩子提供教育。

自那时起，托雷就开始收录全世界范围内的廉价私立学校，并对其质量进行考核。他的研究团队发现，这些学校的教师更为敬业，在设施——比如厕所、饮用水、课桌、图书馆和电扇——的配置方面也做得更好。最重要的是，孩子们学到了更多东西。

很难确定这些廉价私立学校究竟有多普遍，但托雷和他的同事们已经在西非、东非、中国和印度发现了它们。在托雷做过研究的地区，私立学校的学生数量至少与公立学校相当，有时竟多达后者的3倍。

同样，如果观察一下某些发展中国家公立学校的诸多弱点，你就不会对私立学校相对优异的表现感到意外，尽管后者的预算较低，教师的资质有时也值得怀疑。托雷与英国广播公司(BBC)的电影摄制组走访了尼日利亚的拉各斯。他们在那里的公立学校看到教师在课堂上睡觉，尽管摄制组事先告知了访问时间。

此中的教训是：问责制的作用非常之大，而付费客户有充分的理由要求学校和诊所对其负责。让我们尽一切可能想出让公立机构变得更负责任的办法，以使世界贫困人口得到更好的教育。但与此同时，我们也应该就如何扶持那些低成本的私立学校做些研究。

译者/章晴