40928 HEALTHY DEVELOPMENT THE WORLD BANK STRATEGY FOR HEALTH, NUTRITION, & POPULATION RESULTS HEALTHY DEVELOPMENT THE WORLD BANK STRATEGY FOR HEALTH, NUTRITION, & POPULATION RESULTS HEALTHY DEVELOPMENT THE WORLD BANK STRATEGY FOR HEALTH, NUTRITION, & POPULATION RESULTS Washington, DC © 2007 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: feedback@worldbank.org All rights reserved 1 2 3 4 10 09 08 07 The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development/The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2422; e-mail: pubrights@worldbank.org. ISBN-13: 978-0-8213-7193-0 e-ISBN-13: 978-0-8213-7194-7 DOI: 10.1596/978-0-8213-7193-0 Cover design: Naylor Design, Inc. Cover photo: C. Carnemark/World Bank. Library of Congress Cataloging-in-Publication Data Healthy development : the World Bank strategy for health, nutrition, and population results. p. ; cm. ISBN 978-0-8213-7193-0 (alk. paper) 1. Public health--Developing countries--Finance. 2. Public health--Developing countries--International cooperation. 3. Nutrition policy--Developing countries--Finance. 4. Population assistance--Developing countries--Finance. 5. World Bank. I. World Bank. [DNLM: 1. World Bank. 2. Developing Countries. 3. Public Health. 4. Financial Support. 5. Interna- tional Agencies. 6. Public Policy. WA 395 H4347 2007] RA410.55.D48H45 2007 362.109172'4--dc22 2007022159 Contents Foreword xi Preface xiii Acknowledgments xv Abbreviations xvii Executive Summary 1 1 Introduction and Overview 11 The Importance of HNP in Socioeconomic Development 11 Significant HNP Gains but Large, Persisting Challenges 13 The Bank Role in HNP Improvements in the Past Decade 14 Opportunities and Challenges: The New International Environment and DAH 15 A Well-Organized and Sustainable Health System: Essential to Achieve HNP Results on the Ground 18 A Shift in the Driver of the Bank-Country Relationship toward High-Quality Policy Advice and Strategic Focus of Bank Lending on Structural HNP Issues 22 How to Best Serve Client Countries in This New Scenario? 22 Strategic Objectives: What HNP Results? 25 Strategic Directions: How to Support Country Efforts to Achieve Results? 26 Implementing the Bank HNP Strategy 29 A Window of Opportunity for Redoubled Support for Countries' HNP Results 30 2 Opportunities and Challenges in the New International Environment in Health 31 A New International Environment 31 The New Architecture for Development Assistance for Health 35 3 Bank Contribution and Challenges in Implementing the 1997 HNP Strategy 37 Bank Contribution to the New DAH Architecture 38 Taking Stock of the 1997 HNP Strategy 38 Lending Trends since 1997 39 Need to Rapidly Improve Quality Performance of HNP Portfolio 41 Need for Sharper Focus of Analytic and Advisory Activities 44 Imbalance in HNP Staff Trends 44 v vi Healthy Development 4 How Can the Bank Better Serve Client Countries in the New Environment? Bank Comparative Advantages for HNP Results 47 Bank Comparative Advantages 48 Knowledge and Policy Advice on Public Policy to Improve Public­Private Synergies for HNP Results 48 Providing Advice and Financing to Strengthen Health Systems for HNP Results. 49 Intersectoral Approach for Better HNP Results 53 5 New Bank Strategic Objectives: What HNP Results? 57 Strategic Objective 1: Improve the Level and Distribution of Key HNP Outcomes, Outputs, and System Performance at Country and Global Levels to Improve Living Conditions, Particularly for the Poor and the Vulnerable 58 Strategic Objective 2: Prevent Poverty Due to Illness (by Improving Financial Protection) 59 Strategic Objective 3: Improve Financial Sustainability in the HNP Sector and Its Contribution to Sound Macroeconomic and Fiscal Policy and Country Competitiveness 64 Strategic Objective 4: Improve Governance, Accountability, and Transparency in the Health Sector 66 6 New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? 69 Strategic Direction 1: Renew Bank Focus on HNP Results 69 Strategic Direction 2: Increase the Bank Contribution to Client­Country Efforts to Strengthen Health Systems for HNP Results 75 Strategic Direction 3: Ensure Synergy between Health System Strengthening and Priority­Disease Interventions, Particularly in LICs 77 Strategic Direction 4: Strengthen Bank Capacity to Advise Client Countries on an Intersectoral Approach to HNP Results 78 Strategic Direction 5: Increase Selectivity, Improve Strategic Engagement, and Reach Agreement with Global Partners on Collaborative Division of Labor for the Benefit of Client Countries 79 7 Implications for Priority Health, Nutrition, and Population Programs and Interventions 83 A Strong Commitment to Population, Sexual and Reproductive Health, and Maternal and Child Policy 83 Opportunities for Sustaining, and Challenges to Improving, HNP Contributions to Combating HIV/AIDS 90 Repositioning Nutrition to a Central Place in Development 93 8 Implementing New Bank HNP Strategic Directions 99 Action Plan for Implementing Strategic Directions 100 HNP Hub Mission and Organizational Changes 104 Rebalancing Staff Skill-Mix 107 Preliminary Estimates of Strategy Implementation Costs 107 Contents vii Annexes A HNP Hub Action Plan and Regional Action Plans 109 HNP Hub Action Plan 109 Regional Action Plans 110 Africa Region 110 East Asia and Pacific Region 115 Eastern Europe and Central Asia Region 119 Latin America and the Caribbean Region 123 Middle East and North Africa Region 127 South Asia Region 131 B Acknowledgments 135 C The New Global Health Architecture 145 Emergence of a New Global Health Architecture: Trends Since the Mid-1990s 145 Taking Stock of HNP Financing in the World 146 Challenges in the New Global Health Architecture 150 From Consensus on the Problems to Coordinated Action at Country Level 154 D The World Bank HNP Results Framework 156 E Multisectoral Constraints Assessment for Health Outcomes 169 Rationale I (for Countries and Country Directors) 169 Rationale II (for the HNP Family) 169 Objectives of the Multisectoral Constraints Assessment 170 F What Is a Health System? 173 A Complex System in Constant Flux 173 Health System Functions 174 "Systems" Thinking 177 G World Bank Partners in Health, Nutrition, and Population 179 Global Health Partnerships and Initiatives 179 Process/Programs without Financial Participation 180 Global Institutional Partners 180 Bilaterals/Partners 181 Foundations 181 H HNP Contributions to Combating HIV/AIDS: Background Paper to the World Bank HNP Strategy 183 The Relationship between Health System Strengthening and Priority­Disease Approaches 184 Overcoming Health Systems Constraints 185 Vision for HNP Contributions to Combating AIDS 190 The Bank's Contribution to HIV/AIDS through Health Systems 191 Notes 195 viii Healthy Development Bibliography 201 Index 211 Boxes ES.1 Healthy Development--The World Bank Strategy for Health, Nutrition, & Population Results 7 ES.2 Key Next Steps for Implementation 10 1.1 Could Elizabeth Have Been Saved? Why Health Systems Matter 19 5.1 What Are Governance and Corruption in the Health Sector? 68 6.1 Promising New Mechanism Linked to Results: Loan Buy-Downs for Polio Eradication Results in Pakistan 72 6.2 Argentina Plan Nacer--Health System Strengthening Built into Results-Based Lending for MCH 74 7.1 The World Bank Commitment to Reproductive Rights and Reproductive Health 85 A.1 HNP and the MIC Agenda 122 Figures 1.1 Development Assistance for Health by Source, 2000 and 2005 16 1.2 Total Global and World Bank Commitments for HIV/AIDS, 2000, 2002, and 2004 23 2.1 Treatment of Diarrhea 34 2.2 Who Uses Public or Private Health Facilities for Acute Respiratory Infections? 34 3.1 All HNP Total Commitments, Disbursements, and New Lending, FY1997­FY2006 40 3.2 Trends in IDA/IBRD Total New Lending for HNP, All Sector Boards Managed, FY1997­FY2006 41 3.3 Project Outcomes, by Sector Board, FY2001­FY2006 42 3.4 Trends in Portfolio Riskiness, HNP Sector Board versus Bank Overall, FY1997­FY2006 43 3.5 Trends in HNP Mapped Staff, FY1997­FY2006 44 3.6 Health Staff Composition, by Specialty, FY1997 45 3.7 Health Staff Composition, by Specialty, FY2006 45 3.8 New HNP Hires, Average Age 46 3.9 Staff Trends for HNP Hub, by Category, FY1999­FY2006 46 4.1 Health System Functions and Other Determinants of Good System Performance 50 4.2 Multisectoral Determinants of Global Burden of Disease 54 5.1 Trends in Infant Mortality, by World Bank Region, 1980, 1990, 2004 59 5.2 Most Frequent Shocks Causing Household Financial Stress, Peru 60 5.3 People Fall into Poverty due to Health Expenses 61 5.4 External Expenditures on Health, Selected Countries, 1999­2003 65 5.5 External Expenditures on Health, Selected Countries, 1999­2003 66 5.6 Creating Accountability in Health 67 7.1 Fertility Trends, by Geographic Region, 1950­2005 86 7.2 Fertility Trends, Selected High-Fertility Countries, 1950­2005 88 7.3 Population Activities Expenditures as Share of Total Population Assistance, 1995­2004 89 A.1 Results Framework: An Innovations Agenda 133 Contents ix C.1 Development Assistance for Health, by Source, 2000­2005 147 C.2 Net ODA as a Percent of GNI in DAC Donor Countries, 1990­2005, and Projected, 2006­2010 148 C.3 Volatility in Aid for Health, Selected Countries, 1999­2003 152 Tables 4.1 IBRD Net Staff By Sector Mapping, June 30, 2006 55 5.1 Time Series Trends in Health Expenditures, Low-Income Countries, FY1999­FY2003 61 5.2 Time Series Trends in External Expenditures for Health as Percent of Total Health Expenditures, FY1997­FY2003 62 5.3 Time Series Trends in External Expenditures for Health as Percent of Fiscal Health Expenditures, FY1997­FY2003 62 7.1 Some Characteristics of Countries According to Fertility Levels 87 7.2 Nutrition Provision Rated a Top Investment by Copenhagen Consensus 94 7.3 Progress toward Nonincome Poverty Target 95 8.1 Five-Year Action Plan--Renewing Focus on Results 101 8.2 Five-Year Action Plan--Strengthening Health Systems and Ensuring Synergy between Health System Strengthening and Priority­Disease Interventions 102 8.3 Five-Year Action Plan--Strengthening Bank Intersectoral Advisory Capacity 104 8.4 Five-Year Action Plan--Increasing Selectivity, Strategic Engagement, and Collaborative Division of Labor 105 A.1 Health Indicators in the Africa Region 111 A.2 Health Indicators in East Asia and Pacific Region 116 A.3 Health Indicators in the Eastern Europe and Central Asia Region 119 A.4 Health Indicators in the Latin America and the Caribbean Region 123 A.5 Health Indicators in the Middle East and North Africa Region 128 A.6 Health Indicators in the South Asia Region 131 C.1 Composition of Health Expenditures in World Bank Regions and Income Categories, 2004 148 H.1 Incentives Environment and Constraints for Health Systems in Low- and Middle-Income Countries 186 H.2 Levers of Influence for the World Bank in HIV/AIDS and Health Systems at Country Level 193 Foreword Reducing poverty and improving the quality of people's human and economic welfare constitute vital steps for developing countries as they strive to achieve sustainable economic growth and create lasting national development. With ill health both a major contributor to, and a result of poverty, the state of peo- ple's health is therefore highly relevant to governments and communities as they work to improve the education and skills of their citizens, raise national incomes, and chart more promising directions for their countries. The challenges to achieving better health and human capital, however, are profound. One noteworthy analysis of 30 countries shows that poor people living on less than $1 a day use health care services at a consistently lower rate than richer groups. Low-income countries also have difficulty ensuring physical access to clinical services for large numbers of their people. Almost 11 million children die every year, mainly from preventable causes such as diarrhea and malaria. More than 500,000 women die during preg- nancy and childbirth every year. In 2006, almost 3 million people died from HIV/AIDS. About 380,000 of these deaths occurred among children younger than 15 years of age. Tuberculosis is curable, yet 1.7 million people die from it every year. Malaria kills a child every 30 seconds somewhere in the world, infects millions of people with its debilitating illness, and under- mines national economies as adults become too sick to work and lose income. Studies have found that almost one-third of all households in a given group of low-income countries have had to sell assets or borrow to pay for medical expenses to treat a sick family member over the course of the previ- ous year. Other reports have found that a country's economic growth rate is significantly influenced by the health of its general population. It is little wonder, therefore, that illness is often a cause of poverty as well as a catalyst for sudden impoverishment, as families tap into savings or sell what they own to cover the costs of medical care. As a result, all too often people end up falling below the poverty line. Improving the perilous health of millions of the world's poorest people is rightly one of the essential priorities of the global development community in this new century. In another worrying trend, poor countries are catching up with their wealthier counterparts in the North in the growing numbers of prema- ture deaths caused by chronic diseases--cancer, diabetes, hypertension, xi xii Healthy Development pulmonary diseases--linked to tobacco-addiction and obesity pandemics. Malnutrition is problematic, not only in poor countries (with both under- nutrition and obesity), but also in rich countries that are confronted with a rapidly growing prevalence of obesity. Furthermore, strong commitment is required to address the lack of progress in improving sexual and reproductive health, which is not only a key development priority, but is also central to successfully achieving the 2015 Millennium Development Goals for maternal and child mortality, as well as to addressing HIV/AIDS. Given its mission to reduce poverty and inequity in low- and middle- income countries worldwide, the World Bank has updated its health, nutri- tion, and population (HNP) strategy to help developing countries strengthen their health systems to improve the health and well-being of mil- lions of the world's poorest people, boost economic growth, reduce poverty caused by catastrophic illness, and provide the structural "glue" that com- bines multiple health-related programs within partner countries. On the ground, it means putting together the right chain of events to ensure that poor people get sustained access to the good quality health serv- ices needed to save and improve their lives. In its new HNP Strategy, the Bank envisions that its support and advice will help countries achieve better health results in a way that also boosts their economic growth, global competitiveness, and good governance. Good health has proven to be not just an outcome of economic growth. At the same time, good health and sound health system policy have also been recognized as major, inseparable contributors to economic growth. The international community's expanded commitment to better health has opened an unprecedented window of opportunity for the Bank to further contribute to HNP results both at the country and global levels. Consultations in partner countries and with many global and country lead- ers in health, executive directors of the World Bank, and Bank management and staff have confirmed their expectations that we rise to the new challenges--and expeditiously. This Strategy presents the Bank's global short- and medium-term response to meet these new challenges. Joy Phumaphi Vice President for Human Development The World Bank Group Washington, DC Preface This new Health, Nutrition, and Population (HNP) Strategy was prepared in two phases. The first phase of preparation was completed at a briefing to the Committee on Development Effectiveness (CODE) in June 2006, as presented in the Background Note on the New HNP Strategy, dated May 30, 2006. That briefing culminated in a process of extensive consultations with global partners, Bank staff, and management and confirmed the pro- posed Strategic Directions. The second phase finalized necessary technical work to address the main comments from the CODE discussion and com- ments received from global partners before the CODE briefing and began consultations with client countries from all Bank Regions. More than 9 client countries in the field, 65 global partners--including civil society organizations, bilateral and multilateral organizations--and 160 Bank man- agers and staff from HNP and other sectors were consulted.1 The new Strategy benefits from the comments and suggestions given to the team during these enriching consultations. The Strategy is intended to inform the decisions of client­country policy makers, Bank country teams and Bank management, and global partners on country- and Region-specific strate- gies and action plans for achieving HNP results on the ground. This final strategy also benefits from comments and suggestions made during the CODE discussion held on March 14, 2007. This Strategy does not attempt to make in-depth, specific technical rec- ommendations on the diverse and complex range of issues involved in HNP policy today. In-depth technical recommendations must be country-context specific. Therefore, this Strategy does not, for example, list specific health system reforms to improve performance in specific country contexts, nor does it recommend the best approach to support much-needed improve- ments in HNP in post-conflict and fragile states or propose international arrangements necessary for sustainable donor HNP financing in low- income countries. Instead, this Strategy outlines a new strategic vision for the World Bank in improving its own capacity to respond to these urgent questions globally and with a country focus, ensuring that this capacity will be mainstreamed in Bank lending and nonlending country support and sup- port to global partners in areas of Bank comparative advantages. xiii xiv Healthy Development Although this HNP Strategy does not include country-specific technical recommendations, its preparation has been informed by abundant in-depth policy work, conducted by the Bank, setting forth analyses on health financ- ing,2 on nutrition policy,3 a Bank Global Program Action Plan for HIV/AIDS4 (World Bank 2006h), and a renewed commitment to sexual and reproductive health (World Bank 2006j).5 It provides the vision of the Bank on the need to strengthen health systems and refers to key challenges for the HNP sector in contributing to combating the HIV/AIDS pandemic, in repositioning nutrition on the development agenda, and in renewing its commitment to population policy in line with, inter alia, the Programme of Action of the International Conference on Population and Development (UNFPA 2004). Readers are referred to this specific technical work for fur- ther in-depth technical analysis. Through the implementation of this new HNP Strategy, the Bank plans to strengthen further its analytical and oper- ational work in these important areas. The new Strategy identifies a plan of action and internal functional adjustments for its implementation to bring about essential improvements in Bank work on HNP. It identifies necessary changes that would allow bet- ter support for government leadership and programs as well as global part- ners' efforts to achieve results. Country-driven and country-owned pro- grams are key to good HNP results on the ground. Acknowledgments This World Bank Health, Nutrition, and Population (HNP) Strategy was prepared by a team led by Cristian C. Baeza (Lead Health Policy Spe- cialist, LCSHH /Acting Director, HDNHE) and composed of Nicole Klingen (Senior Health Specialist, HDNHE), Enis Baris (Senior Public Health Specialist, ECSHD), Abdo S. Yazbeck (Lead Economist, Health, WBIHD), David Peters (Senior Public Health Specialist, HDNHE), Eduard Bos (Lead Population Specialist, HDNHE), Sadia Chowdhury (Senior Health Specialist (HDNHE), Pablo Gottret (Lead Economist, HDNHE), Phillip Jeremy Hay (Communications Adviser, HDNOP), Eni Bakallbashi (Junior Professional Associate, HDNHE), Lisa Fleisher (Junior Professional Associate, HDNHE), Jessica St. John (Junior Professional Asso- ciate, HDNHE), Elisabeth Sandor (Health Specialist, HDNHE), Andrian- ina Rafamatanantsoa (Program Assistant, HDNHE), and Victoriano Arias (Program Assistant, HDNHE). Special gratitude is due to the government officials of client coun- tries, global partners, and Bank management and staff who generously provided the team with valuable recommendations and guidance on how the Bank can better support client country efforts to improve the lives of those who are most vulnerable. A comprehensive list of acknowledg- ments is presented in annex B. Overall guidance to the team was provided by Jacques Baudouy (for- mer Director, HDNHE), Nick Krafft (Director Network Operations, HDNVP), Joy Phumaphi (Vice President, Head of Network, HDNVP), Jean-Louis Sarbib (former Senior Vice President, HDNVP), James Adams (Vice President & Head of Network, OPCVP and Regional Vice President, EAPVP), Danny Leipziger (Vice President & Head of Network, PRMVP), Xavier Coll (Vice President, HRSVP), Shanta Devarajan (Chief Economist, SARVP), Steen Jorgensen (Sector Director, ESDVP), Jamal Saghir (Direc- tor, EWDDR), James Warren Evans (Sector Director, ENV), Evangeline Javier (Sector Director, LCSHD), Julian Schweitzer (Sector Director, SASHD), Michal Rutkowski (Sector Director, MNSHD), Guy Ellena (Director, IFC), Debrework Zewdie (Director, HDNGA), Kei Kawabata (Sector Manager, HDNHE), Akiko Maeda (Sector Manager, MNSHD), Anabela Abreu (Sector Manager, SASHD), Armin Fidler (Sector Manager, xv xvi Healthy Development ECSHD), Eva Jarawan (Sector Manager, AFTH2), Fadia Saadah (Sector Manager, EASHD), Keith Hansen (Sector Manager, LCSHH), Ok Pan- nenborg (Senior Adviser, AFTHD), Bruno Andre Laporte (Manager, WBIHD), Elizabeth King (Research Manager, DECRG), and Susan Blak- ley (Senior Human Resources Officer, HRSNW). We also acknowledge the assistance of the Office of the Publisher--Paola Scalabrin, Dina Towbin, and Stuart Tucker--in preparing the manuscript for publication. Abbreviations AAA Analytic and advisory activities AAP Africa Action Plan ACT Artemisinin-based combination therapy ADB Asian Development Bank AFD French Agency for Development AfDB African Development Bank AFR Africa Region, World Bank AHI Avian and human influenza AMC Advance Market Commitment APL Adaptable Program Loan/Credit ARPP Annual Review of Portfolio Performance, World Bank ART Antiretroviral therapy ARV Antiretroviral drug AusAID Australian Agency for International Development BAPPENAS National Development Planning Agency, Republic of Indonesia CAS Country Assistance Strategy CCT Conditional cash transfer CDC Centers for Disease Control and Prevention, United States CDP Comprehensive Development Partnership CEM Country Economic Memorandum CMU Country Management Unit, World Bank CODE Committee on Development Effectiveness, World Bank CPIA Country Performance Institutional Assessment DAH Development assistance for health DANIDA Danish International Development Agency DEC Development Economics, World Bank DFID Department for International Development, United Kingdom DGF Development Grant Facility, World Bank DP Development Partner DPL Development Policy Lending EAP East Asia and Pacific Region, World Bank ECA Europe and Central Asia Region, World Bank ESW Economic sector work, World Bank EU European Union FAO Food and Agriculture Organization GAIN Global Alliance for Improved Nutrition GAVI Global Alliance for Vaccines and Immunisation xvii xviii Healthy Development GDP Gross domestic product GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GMR Global Monitoring Report GNI Gross national income GTZ German Agency for Technical Cooperation HA-LIC High-aid low-income countries, for which DAH is a large proportion of government or total expenditures in health HD Human Development Network, World Bank HNP Health, nutrition, and population HNPFAM Health, Nutrition, and Population Network of the World Bank HPAI Highly pathogenic avian influenza HR Human resources HSPT Health System Policy Team, World Bank IADB Inter-American Development Bank IBRD International Bank for Reconstruction and Development, World Bank Group ICPD International Conference on Population and Development ICR Implementation Completion Report, World Bank IDA International Development Association, World Bank Group IEG Independent Evaluation Group, World Bank Group IFC International Finance Corporation, World Bank Group IFFIm International Finance Facility for Immunisation IFPMA International Federation of Pharmaceutical Manufacturers and Associations IFPRI International Food Policy Research Institute ILO International Labour Organisation ISR Implementation Status Report, World Bank LA-LIC Low-aid low-income countries, for which DAH is a small proportion of government or total expenditures in health LCR Latin America and the Caribbean Region, World Bank LIC Low-income country M&E Monitoring and evaluation MCA Multisectoral Constraints Assessment for Health Outcomes MDG Millennium Development Goal MENA Middle East and North Africa, World Bank MIC Middle-income country MMB Marginal budgeting for bottlenecks MMR Maternal mortality rate MOF Ministry of Finance MOH Ministry of Health MTEF Medium-term expenditure framework NCD Noncommunicable disease Abbreviations xix NGO Nongovernmental organization NHA National health accounts Norad Norwegian Agency for Development Cooperation ODA Official development assistance OECD Organisation for Economic Co-operation and Development OECF Japanese Overseas Economic Cooperation Fund OOP Out-of-pocket spending OPCS Operations, Policy, and Country Services, World Bank PDO Project development objective PEPFAR United States President's Emergency Plan for AIDS Relief PER Public expenditure review PREM Poverty Reduction and Economic Management Network, World Bank PRH Population and reproductive health PRSC Poverty Reduction Strategy Credit PRSP Poverty Reduction Strategy Paper PSD Private Sector Development, World Bank QAG Quality Assurance Group, World Bank R&D Research and development RTA Reimbursable technical assistance SAL Sector Adjustment Loan/Credit SAR South Asia Region, World Bank SARS Severe Acute Respiratory Syndrome SIDA Swedish International Development Cooperation Agency SMU Sector Management Unit, World Bank SSA Sub-Saharan Africa SWAp Sectorwide approach TA Technical assistance TB Tuberculosis TF Trust fund TFR Total fertility rate TGHE Total government health expenditure U-5 Children under five years of age UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USAID United States Agency for International Development WBI World Bank Institute WDR World Development Report WFP World Food Program, United Nations WHO World Health Organization Executive Summary E Healthy Development: The World Bank Strategy for Health, Nutrition, & Popu- lation Results updates the 1997 World Bank Health, Nutrition, and Popula- tion (HNP) Strategy in light of the momentous changes of the past decade in the international architecture of development assistance for health (DAH)6 and of persisting and new HNP challenges worldwide. Ten years ago, the Bank was the main financier of HNP. Today, in addition to the Bank, new multilateral organizations, initiatives, and foundations have assumed a prominent role in financing HNP, among them the Global Fund,7 the Global Alliance for Vaccines and Immunisation (GAVI), the Global Alliance for Improved Nutrition (GAIN), and the Bill and Melinda Gates Foundation. Bilateral aid has also increased substantially. Much of this new funding is earmarked for combating priority diseases such as HIV/AIDS, malaria, tuberculosis, and some vaccine-preventable diseases; less for health system strengthening at country level, for maternal and child health, for nutrition, and for population priorities. The ultimate objective of World Bank work in HNP, reinforced by this new Strategy, is to improve the health conditions of the people in client countries, particularly the poor and the vulnerable, in the context of its overall strategy for poverty alleviation. To achieve this objective, this new Strategy states the vision and the action plan necessary to strengthen Bank capacity to better serve client countries by excelling in areas of Bank com- parative advantages and by improving its collaboration with global partners. The increased awareness and expanded international financing for HNP constitute a great opportunity for the Bank to help client countries and global partners improve HNP results on the ground, particularly for the poor and the vulnerable. However, the new environment also poses significant 1 2 Healthy Development challenges for the Bank, requiring important changes in the way the Bank operates in HNP to be able to rise to these challenges. This 2007 HNP Strat- egy outlines the Bank vision for improving its own capacity to respond glob- ally and with a country focus to the urgent issues posed by these challenges. Throughout this Strategy, the case is made for sharpening Bank focus on results on the ground; for concentrating Bank contributions on its compar- ative advantages, particularly in health system strengthening, health financ- ing, and economics; for supporting government leadership and interna- tional community programs to achieve these results; and for exercising selectivity in engagement with global partners. This focus is not intended to constrain what the Bank does--country circumstances must drive Bank pro- grams. However, a selective and disciplined framework is advocated, partic- ularly for policy advice and knowledge generation, to ensure that the Bank is appropriately staffed and ready to support country efforts and requests for assistance in a core set of key areas where the Bank can play a major role. This framework is also essential for the Bank to collaborate with global partner efforts to ensure aid effectiveness. Background Health, nutrition, and population policies play a pivotal role in economic and human development and in poverty alleviation. For a century and a half, HNP improvements, achieved through the contributions of multiple sec- tors of the economy, have contributed to economic growth everywhere. At the same time, improved economic growth has enabled improvements in health outcomes, creating a virtuous cycle--good health boosts economic growth, and economic growth enables further gains in health.8 The dra- matic increases in development assistance for health and shifts in the major players involved in the global health architecture show the widespread recognition of the tight link between investments in health and economic development. A multisectoral approach is essential for achieving HNP results. Many advances in health status achieved during the 20th century were the result of close synergy among HNP and multiple sectors of the economy such as water and sanitation, environment, transport, employment, education, agri- culture, energy, infrastructure, and public administration. For example, investments in girls' education improve household decisions on nutrition Executive Summary 3 and demand for basic health care. At the same time, investing in basic nutri- tion during pregnancy and infancy has a substantial positive effect on early childhood development, which, in turn, significantly contributes to educa- tional attainment, employability, and future income (Bloom, Canning, and Jamison 2004; Jamison 2006; World Bank 2003b, 2004, and 2006j). The Bank Contribution to HNP in the Last Decade: The 1997 HNP Strategy The Bank has contributed substantially to HNP in client countries in the last decade. Since the 1997 HNP Strategy, the Bank has decisively commit- ted to focusing its work on health gains for the poor. The Bank has also played a crucial role in advocacy, awareness, and development of new inter- national initiatives and organizations such as the Global Fund and GAVI. As one of the world's largest single international financing organization of HNP activities in the last decade, the Bank has been a significant source of funding and has made substantial contributions in policy advice for pri- ority­disease and HNP interventions. The Bank assisted more than 100 countries with more than 500 projects and programs, with cumulative dis- bursements of US$12 billion and cumulative new lending of US$15 billion from 1997 through 2006.9 Through more than 250 Analytical Sector Work reports and advisories, the Bank also provided substantial policy and tech- nical advice. Despite the many excellent projects and programs in various Regions, the implementation impact of the 1997 Strategy on HNP results on the ground cannot be systematically evaluated. Focus on monitoring and eval- uation (M&E) was weak during the last decade, and impact data are scarcely available. During the last decade, the Bank has also faced significant challenges. Its total active portfolio (active commitments) in HNP decreased10 by 30 percent from FY01 to FY06, and the implementation quality of the HNP lending portfolio had the lowest performance among all sectors in the Bank since 2001. Although the HNP sector operations are inherently complex and high risk as compared with many other sectors, much improvement is needed in the quality at entry and strategic focus of oper- ations to improve HNP portfolio performance. In addition, the focus of Analytical and Advisory Activities (AAA) has been insufficient, with less 4 Healthy Development than 35 percent of all AAA during the decade focused on areas of Bank comparative advantages.11 New and Persisting HNP Challenges in the New International Environment The last three decades have brought important achievements in HNP in the developing world, but formidable challenges persist. Actual and potential pandemics and regional epidemics have continued to emerge, and some have expanded (e.g., HIV/AIDS, malaria, drug- and multidrug-resistant TB, SARS, avian flu). A significant increase has occurred in premature deaths related to chronic diseases (diabetes, pulmonary diseases, hyper- tension, cancer) linked to the tobacco-addiction and obesity pandemics. The world population more than doubled in the second half of the 20th century, mostly from population growth in developing countries. High population growth poses significant challenges to country efforts to alle- viate poverty and to facilitate access to basic services. Malnutrition is problematic not only in poor countries (with both undernutrition and obesity), but also in rich countries confronted with a rapidly growing prevalence of obesity. The new opportunities brought about by the changes in DAH also pres- ent three special challenges: the need to focus beyond increasing available financing for HNP, ensuring that additional funds produce tangible results on the ground to improve the living conditions of the people, especially the poor and the vulnerable; the need to align and harmonize global partners' activities with country needs to prevent duplication, economic distortions-- and excessive administrative costs--ensuring country-owned and country- led DAH; and the need to ensure synergy between enhanced priority­dis- ease financing and strengthening of health systems, essential for achieving results and improving DAH effectiveness on the ground. Results on the Ground In this Strategy, HNP results encompass not only HNP outcome indicators, such as the United Nations Millennium Development Goals (MDGs), stunt- ing, or fertility rates but also health system performance, as reflected, for Executive Summary 5 example, in financial protection12 and utilization of essential health services by the poor. Other results targeted are: empowerment of the poor (as out- lined in World Development Report--2004 [World Bank 2003]), good sector governance, sector financial sustainability and its contribution to sound fis- cal policy and country competitiveness; key outputs such as the proportion of children immunized, proportion of children born under safe delivery con- ditions, and other outputs closely linked to achieving the HNP-related MDGs; and availability of essential drugs and personnel in rural clinics. All these results are examples of Bank HNP objectives in client­country work. For these results to be achieved, a multisectoral approach is essential. Annex D presents the World Bank Results Framework for HNP, which summarizes the main outcomes and outputs for the Bank in HNP. The Framework is intended as the guidance for country teams for developing country-specific and detailed results frameworks for Bank operations and programs. Strengthening Health Systems "Strengthening health systems" may sound abstract and less important than specific-disease control technology or increased international financ- ing to many people concerned about achieving HNP results. But, well- organized and sustainable health systems are necessary to achieve results. On the ground, in practical terms, it means putting together the right chain of events (financing, regulatory framework for private-public col- laboration, governance, insurance, logistics, provider payment and incen- tive mechanisms, information, well-trained personnel, basic infrastruc- ture, and supplies) to ensure equitable access to effective HNP interventions and a continuum of care to save and improve people's lives (see box 1.1 in "Introduction and Overview"). Strengthening health sys- tems is not a result in itself. Success cannot be claimed until the right chain of events on the ground prevents avoidable deaths and extreme financial hardship due to illness because, without results, health system strengthening has no meaning. However, without health system strength- ening, there will be no results. Achieving HNP results requires a well-organized and sustainable coun- try health system, capable of responding to the HNP needs of the commu- nity. Strengthening health systems to achieve HNP results requires a mul- tisectoral effort at the country level. There is consensus that a major, urgent 6 Healthy Development effort must be made to strengthen health systems if financial commitments enabled by the new DAH architecture are to succeed in improving the health conditions of the poor and achieve the HNP-related MDGs. The international community agrees on this principle after much debate in the early 2000s, centered on the false dichotomy between focus on priority dis- eases and focus on system strengthening. To make sure people's health and daily lives are really being improved with the money invested, actual results on the ground have to be evaluated. Measuring results requires systems for close and effective monitoring and evaluation, which are effectively linked to policy design and management. New Opportunities, Challenges, and the Bank Role in the New DAH Scenario The new aid architecture, persisting HNP challenges, and the urgency for strengthening health systems to achieve results represent major challenges, particularly to low-income countries and fragile states. The quality of Bank policy and technical advice will be critical for client­country response to these challenges. While still strategically very important, Bank financing, at roughly US$1.5 billion a year, is relatively small, compared with the overall large and increasing funding for the control of specific diseases. Financing no longer drives relationships with client countries. For example, as meas- ured by new annual financial commitments for HIV/AIDS, for malaria, and for tuberculosis, Bank financing in FY2005 represented about 5 percent,13 3 percent,14 and 7 percent,15 respectively, of total annual international com- mitments for each of these diseases.16 In this scenario, it is the quality of the policy and technical dialog and the strategic focus of Bank lending that will define the true magnitude of the Bank contribution to country efforts in HNP in the next decade. It is important to highlight that, although the share of Bank financing in total DAH has decreased, Bank lending, particularly through the Interna- tional Development Association (IDA), is strategically crucial to ensure much- needed health system strengthening (for which dedicated international financing is scarce), and it is essential to set the enabling environment for effective disease-spe- cific financing to achieve results. This was stated again and again by client countries during preparation of this new Strategy. This new Strategy for HNP Results asserts the global vision of the Bank Executive Summary 7 role in the new global architecture in HNP (box ES.1). It also attempts to give Bank regional and country teams guidance for addressing these ques- tions with a sharp focus on HNP results, working closely with global part- ners. For that purpose, it defines the strategic and operational changes nec- essary to assist these teams more effectively and suggests opportunities for collaborative division of labor among global partners. Box ES.1: Healthy Development--The World Bank Strategy for Health, Nutrition, & Population Results Strategic Vision With the implementation of this new HNP Strategy, the Bank aims to bolster client­country efforts to improve health conditions for the poor and the vulnerable and to prevent them from becoming impoverished or made destitute as a result of illness. The Bank envisions that its support and advice will help client countries achieve these HNP results in a way that also contributes to their overall fiscal sustainability, economic growth, global competitiveness, and good governance. This new Strategy is embedded in the core mission of the Bank to alleviate poverty worldwide. To achieve these objectives, countries need to articulate a response from multiple sectors that influence HNP results. The Bank, with its 19 sectors working globally in 139 countries, is uniquely positioned to support client­country efforts. Strategic Objectives: What HNP Results? · Improve the level and distribution of key HNP outcomes (e.g., MDGs), outputs, and system performance at country and global levels in order to improve living conditions, particularly for the poor and the vulnerable. · Prevent poverty due to illness (by improving financial protection). · Improve financial sustainability in the HNP sector and its contribution to sound macroeco- nomic and fiscal policy and to country competitiveness. · Improve governance, accountability, and transparency in the health sector. Strategic Directions: How should the Bank support country efforts to achieve results? · Renew Bank focus on HNP results. · Increase the Bank contribution to client­country efforts to strengthen and realize well- organized and sustainable health systems for HNP results. · Ensure synergy between health system strengthening and priority­disease interventions, particularly in LICs. · Strengthen Bank capacity to advise client countries on an intersectoral approach to HNP results. · Increase selectivity, improve strategic engagement, and reach agreement with global part- ners on collaborative division of labor for the benefit of client countries. 8 Healthy Development Long-Term Country-Driven and Country-Led Support Country-driven and country-owned programs are the key to good HNP results on the ground. A strong country presence, country focus, and coun- try-driven support are at the core of the Bank business model and are some of the most important comparative advantages of the Bank. Country teams working with Country Management Units (CMUs) embody the Bank country focus and its intersectoral approach to development. Strengthening and empowering CMUs to better serve client countries in collaboration with global partners working at the country level is therefore essential to ensure country-driven implementation of the HNP Strategy and, ulti- mately, sound HNP results. Results on the ground, especially outcome improvements, rarely occur in the lifetime of a single project nor are they achieved by any single sector. It is long-term Bank policy advice, technical assistance, and its strategically focused lending program as a whole that can influence client­country HNP policy actions, inputs, and structural changes in the health system and influ- ence HNP-relevant policies from other sectors. Therefore, proposed objec- tives and directions in this new HNP Strategy are geared to support the central role of CMUs in leading the Bank country support and in further improving the effectiveness of the Bank country focus in HNP. Upon country demand, the Bank will continue to lend in all areas deemed necessary to improve health status and financial protection for peo- ple, especially the poor and the vulnerable. This includes support for con- trolling priority diseases in countries where they constitute a large part of the burden of disease. However, the Bank will increasingly endeavor to ensure that Bank operational and policy advice support for priority diseases will strengthen the health system to solve systemic constraints that impair the effectiveness of country, Bank, and international community financing in achieving HNP results. Bank Comparative Advantages The Bank has special strengths (comparative advantages) for providing policy and technical advice to client countries and global partners in their efforts to achieve HNP results. The Bank will focus and enhance its capacity to generate knowledge and provide policy and technical advice in these areas. They include: its health system strengthening capacity; its intersectoral Executive Summary 9 approach to country assistance; its advice to governments on regulatory framework for private-public collaboration in the health sector; its capacity for large-scale implementation of projects and programs; its convening capacity and global nature; and its pervasive country focus and presence. Some of these strengths are fully developed in the Bank. Others, such as policy and technical advice on regulating the private sector and improving public-private collaboration for HNP results, health system strengthening capacity, and intersectoral work for HNP results, need significant strength- ening if the Bank is to scale up its efforts in this area and realize its full potential for supporting client countries and the international community effectively. Analytical capacity in economics and evaluation is also a Bank compara- tive advantage. The Bank will substantially increase both its analytical work on health systems and its monitoring and evaluation capacity to ensure that the renewed commitment to HNP is actually rendering results on the ground. It is also essential that this increased capacity and commitment to M&E be effectively linked to and inform policy design and policy manage- ment in the health sector. The Bank has comparative advantages for health system strengthening mainly in the areas of health financing, insurance, demand-side interven- tions, regulation, and systemic arrangements for fiduciary and financial management. The Bank will actively seek collaborative division of labor with global partners, based on respective comparative advantages. For example, leading agencies such as WHO, UNICEF, and UNFPA have clear comparative advantages in areas such as the technical aspects of disease con- trol (e.g., determine what is the best drug to treat malaria or how to over- come micronutrient deficiencies), human resource training in health, and internal organization of service providers (e.g., how to run medical services in clinics or hospitals). The Challenge of Implementation The resource requirements for implementing the HNP strategy will be a function of the pace of implementation of the Strategy (pace of change), the demand from countries, and the availability of resources in an environment of zero growth in the overall Bank budget. It is expected that the cost of implementing the new HNP strategy will involve a modest increase in the base budget for the Human Development (HD) Network over the FY2007 10 Healthy Development base budget, after taking into account one-off transitional adjustments. An extraordinary allocation to the HD Network above the regular base budget will be utilized to finance these transition expenses, as justified. A Window of Opportunity for Scaling Up Support to Country HNP Results The expanded commitment of the international community in health has opened an unprecedented window of opportunity for the Bank to further con- tribute to HNP results at country level and globally. Consultations in client countries and with many global and country leaders in health, including lead- ers of donor agencies, foundations, Ministries of Health and Finance of client countries, leaders of civil society organizations, Executive Directors of the World Bank, and management and staff from HNP and other sectors in the Bank have confirmed their expectations that the Bank needs to rise to the new challenges--and expeditiously. This Strategy presents the global short- and medium-term response of the World Bank to meet the new challenges. Box ES.2: Key Next Steps for Implementation The following are the key initial steps at country level to implement the Strategic Directions and Objectives defined in the Strategy. This box outlines key country-level actions to be taken in the next 18 to 24 months. · Launch health system strengthening assessment. Estimate the investment and policy reform gaps. · Assess fiscal space. Estimate the space for closing the financing gap at country level. · Rapidly mainstream system strengthening into priority­disease operations. · Multisectoral assessment of constraints to achieving HNP results (e.g. MDGs). · Offer policy advice on health system integration. Address the challenge of country systems fragmentation and, in close collaboration with IFC, improve policy environment for public- private collaboration. · Scale up output- and/or performance-based financing. · Strengthen client­country capacity in monitoring and evaluation (country-based) to meas- ure results. · Enter into specific agreements with the WHO and the Global Fund on collaborative division of labor at country level (next 12 months). · Implement the harmonization and alignment agenda at the country level. · Improve the quality of the Bank HNP portfolio. CHAPTER 1 Introduction and Overview Health, nutrition, and population (HNP) policies play a fundamental role in economic and human development and poverty alleviation. For more than a century and a half, health, nutrition, and population contributions to the improved health status of individuals and populations have also contributed to economic growth. In turn, improved economic growth has led to better health outcomes, creating a virtuous cycle: good health boosts economic growth, and economic growth enables further gains in health. Healthy Development: The World Bank Strategy for Health, Nutrition, & Population Results for the next decade updates the 1997 World Bank Health, Nutrition, and Population Strategy to enhance Bank capacity so that it con- tinues to contribute to this virtuous circle in light of the momentous changes of the past decade in the architecture of development assistance for health (DAH) and of persisting HNP challenges worldwide. This 2007 HNP Strategy outlines the Bank vision for improving its own capacity to respond globally and with a country focus to the urgent issues posed by these changes and challenges. It seeks to ensure that this capacity will be mainstreamed in Bank lending and nonlending country support and support to global partners in areas of Bank comparative advantages. The Importance of HNP in Socioeconomic Development Health is often thought to be an outcome of economic growth. Increasingly, however, good health and sound health system policy have also been recog- nized as a major, inseparable contributor to economic growth.17 Advances in public health and medical technology, knowledge of nutrition, population 11 12 Healthy Development policies, disease control, and the discovery of antibiotics and vaccines are widely viewed as catalysts to major strides in economic development, from the Industrial Revolution in 19th-century Britain to the economic miracles of Japan and East Asia in the 20th century. Sound health policy, one that sets the correct incentive framework for financing and delivering services, also has important implications for overall country fiscal policy and competi- tiveness (Schieber, Fleisher, and Gottret 2006). Many advances in health status during the 20th century are the result of close synergy among multiple sectors of the economy. For example, invest- ing in basic nutrition during pregnancy and infancy has a substantial posi- tive effect on early childhood development, which, in turn, significantly contributes to educational attainment (Bloom, Canning, Jamison 2004; Jamison 2006). The complex HNP-development dynamic operates in both directions. Higher incomes allow capacity expansion, which, in turn, may inspire investment in better access to safe water, sanitation, cleaner indoor envi- ronments, education, housing, diet, and health care. It also changes house- hold decisions on fertility, usually increasing birth space--all greatly improving health outcomes. This virtuous circle means that, particularly in low-income countries (LICs), ensuring economic growth is also crucial to achieve HNP results. How equitable improvements in health outcomes will be in a growing economy will depend on an effective pro-poor public pol- icy in the health and other sectors (World Bank 2003b, 2004). Longer-lasting achievements in HNP can improve the investment cli- mate and attract foreign direct investment, once labor forces no longer bear a heavy disease burden. Foreign companies are often deterred from invest- ing in countries with high burden of disease because of concerns about their own workers' health, the possibility of high turnover and absenteeism, and the potential loss of workers with "institutional knowledge" of the firm (Haacker 2004). In addition to the effect of returns from improving health to improve learning, countries in demographic transition witness a "baby boom" cohort that participates in the education, labor market, and pension systems. Because cohorts before and after the baby boomers are generally much smaller during the transition, the labor force is large relative to overall pop- ulation size. This means less dependency and greater potential for economic growth, which enables governments to raise investments in health and edu- cation and also to increase their economic investments (Jamison 2006; World Bank 2006j). Introduction and Overview 13 Significant HNP Gains but Large, Persisting Challenges The last three decades have brought impressive achievements in HNP: steep reductions in infant mortality and malnutrition in almost every coun- try, unprecedented innovation in health technology and discoveries in med- icine, and a steady decline in mortality. An aware international community has become a vocal and active financier of progress in HNP, dedicating mas- sive financial resources to bring it about. However, almost 11 million children die every year, mainly from pre- ventable causes such as diarrhea and malaria.18 Malaria kills a child some- where in the world every 30 seconds.19 More than 500,000 women die dur- ing pregnancy and childbirth every year.20 In 2006, almost 3 million people died from HIV/AIDS.21 About 380,000 of these deaths occurred among children younger than 15.22 Tuberculosis is curable, and yet 1.7 million peo- ple die from it every year.23 Infant and maternal mortality have marginally improved, if not wors- ened, in many African countries. Millions more face premature death due to both undernutrition and chronic diseases related to the obesity pandemic. The HIV/AIDS and malaria epidemics are still uncontrolled in most LICs. Illness throws millions into poverty and destitution every year (Baeza and Packard 2006). Well-organized and sustainable health systems and sound health financing policies (national and international) have proven essential to meet these challenges and achieve HNP results on the ground. Both are also vital for sound fiscal policy and country competitiveness, crucial to eradicating poverty in a global economy. By 2015, noncommunicable diseases (NCDs) will be the leading cause of death in low-income countries (Lopez, Mathers, Ezzati et al. 2006). Many of these deaths will occur prematurely, at an early middle age of adulthood. NCDs impose a significant economic burden, not just on patients, but also on their households, communities, employers, health care systems, and govern- ment budgets. An increasing burden of NCDs in developing countries will put an enormous strain on their weak health systems. Sound health policies are essential, for example, to protect households from the impoverishing effects of catastrophic costs associated with NCD-related medical care. Furthermore, health system strengthening is vital to address the growing burden of NCDs because their management and prevention requires long-term, sustained inter- action with multiple levels of the health system (World Bank 2007). Effective interventions and increased financing exist for many of the health problems afflicting the world's poor and vulnerable (Wagstaff and 14 Healthy Development Claeson 2004). However, in countries with weak health systems, reaching the people needing these interventions through health service delivery mecha- nisms and improved basic nutrition is challenging. Strengthening health sys- tems--so that these services can be delivered effectively, sustainably, and when needed--is critical to ensure that investments in health continue to foster economic growth to overcome poverty in generations to come. The Bank Role in HNP Improvements in the Past Decade As one of the pillars for eradicating poverty, the World Bank has supported countries' efforts to improve health, nutrition, and population policies and results for more than three decades. However, much has changed since the last Bank HNP Strategy was approved by the Board in 1997--and for the better. In the international community, awareness of the pivotal role of HNP policy in poverty eradication, and in economic development itself, has heightened. The central importance of HNP policy to development is reflected, for example, in the emphasis given to HNP in the United Nations Millennium Development Goals (MDGs). Three of the eight MDGs target HNP outcomes, and HNP policy greatly influences results for other MDGs such as poverty, environment, education, and partnerships. The Bank has substantially contributed to this increased awareness of the international community. Since the 1997 HNP Strategy, it has decisively committed to focusing its work on winning health gains for the poor. The Bank has also played a crucial role in advocacy, awareness, development of new initiatives, and financing of priority diseases and HNP interventions. From 1997 through 2006, the Bank lent US$15 billion and disbursed US$12 billion in HNP for more than 500 projects and programs in more than 100 client countries, making the Bank one of the world's largest inter- national financing organizations of HNP activities in the last decade. In this new Strategy for the coming decade, the Bank envisions that it will bolster client­country efforts to improve health conditions for the poor and to prevent households from becoming impoverished or made destitute as a result of illness. The Bank envisions that its support and advice will help client countries achieve HNP results in a way that also furthers good governance and their overall fiscal sustainability, economic growth, and global competi- tiveness. To achieve these four objectives, client countries need to articulate responses from multiple sectors that influence HNP results. The Bank, with Introduction and Overview 15 its 19 sectors working globally in 13924 countries, is uniquely positioned to support client­country efforts. This Strategy provides guidance to country teams on steps forward to ensure effective intersectoral work for HNP results. Opportunities and Challenges: The New International Environment and DAH The heightened awareness of HNP globally has dramatically changed the international architecture for development assistance in health.25 In addition to the Bank, new multilateral organizations, initiatives, and foundations have assumed a prominent role in financing HNP, among them are the Global Fund, GAVI, GAIN, and the Bill and Melinda Gates Foundation. Innovative financing mechanisms such as UNITAID,26 IFFIm,27 and Advance Market Commitments (AMCs) have also been developed to help to improve the pre- dictability of donor funds. Much of this new funding is earmarked for com- bating priority diseases such as HIV/AIDS, malaria, tuberculosis, and some vaccine-preventable diseases; less for health system strengthening. Bilateral aid, such as the United States President's Emergency Plan for AIDS Relief (PEPFAR), has also increased substantially. Thus, financial commitments from all sources have doubled in five years, from US$6 billion in 2000 to almost US$14 billion in 2005 (Michaud 2007) (figure 1.1). Annex C presents an overview of trends in DAH in the last decade. The new opportunities created by the changes in DAH also present three special challenges to: ensure tangible results on the ground for the money invested; align and harmonize global partners' activities with country needs to prevent duplication, economic distortions--and excessive administrative costs--ensuring country-owned and country-led DAH; and ensure synergy between enhanced priority­disease financing and interventions to strengthen health systems. Ensuring Tangible HNP Results HNP results in this Strategy encompass not only HNP outcome indicators such as MDGs, stunting, or fertility rates, but also prevention of poverty due to illness (financial protection) and health system performance indicators such as equity in utilization of health services and in health insurance28 cov- erage. Other results included are: empowerment of the poor, good sector 16 Healthy Development Figure 1.1: Development Assistance for Health by Source, 2000 and 2005 16 14 12 private nonprofit other multilaterals 10 World Bank billion 8 development banks US$ 6 UN agencies 4 bilateral agencies 2 0 2000 2005 year Source: C. M. Michaud 2007. Note: "Other multilateral" includes the European Union, Global Alliance for Vaccines and Immunisation (GAVI), and Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). "World Bank" total includes only IDA lending. governance, sector financial sustainability and its contribution to sound fis- cal policy and country competitiveness; key outputs such as the proportion of children immunized, proportion of children born under safe delivery conditions, and other outputs closely linked to achieving the HNP-related MDGs; and availability of essential drugs and personnel in rural clinics. All these results are examples of Bank HNP objectives in client­country work. They are determined not only by the inputs of the HNP sector but also by the effects of many other sectors and their interactions. To make sure people's health and daily lives are actually being improved with the money invested, results on the ground have to be closely moni- tored and evaluated. However, both client countries and the international community have lacked effective M&E systems for gauging the impact of increased financing on people, particularly the poor in low-income coun- tries. This lack deprives development policy makers of basic knowledge about what works and what does not, essential knowledge for effective use of resources now and for any future scaling up. The Bank has not escaped this knowledge-gap dilemma. Although there are good examples of individual projects, programs, and policy advice to client countries, and research, the impact of its 1997 HNP Strategy is hard to meas- ure. The impact on the ground of the 1997 HNP Strategy has not been sys- Introduction and Overview 17 tematically monitored or assessed, nor are there sufficient monitoring data to do it today. Assessment difficulties have been problematic not only for the Bank but also for most of the international community. In the past two years, the Bank has multiplied its HNP evaluation efforts, but the benefits of this effort will be useful only for assessing the impact of the new Strategy. A thor- ough assessment is not available at this time. However, the Independent Eval- uation Group will conduct in 2008 an evaluation of the Bank's client­country assistance in HNP since 1997. This evaluation will inform the implementa- tion of this new Strategy and adjustments will be made as appropriate. The Bank also faces important challenges in the implementation of its current lending and nonlending portfolio. The active HNP portfolio (active commitments) has declined since 2001 and the quality performance of the portfolio has been the lowest among all Bank sectors. In addition, AAA is not focused enough on Bank comparative advantages. The Bank, as a public international organization, is accountable for its expected contributions to country HNP results, especially for results of concessional lending under the International Development Association (IDA). The focus on increasing the link of Bank financing to results as well as on effective measurement and impact assessment is therefore essential. Harmonization and Alignment The multiplicity of actors offering generous financing has put an additional management and administrative burden on recipient countries. Essential to overcoming this burden are the use of effective country fiduciary systems (alignment)--financial management, procurement, logistics (which the Bank can help strengthen)--and the implementation of the Paris Declaration (OECD/DAC 2005) on harmonization of procedures, policy advice, strate- gies, and program implementation at country level among Bank and other global partners. The Bank is committed to contributing to alignment and harmonization efforts in the HNP sector at country level and will selectively strengthen its engagement with global partners. Synergy between Single-Disease Priority Programs and Health System Strengthening in LICs For most of the last decade, the changes in DAH have gone hand-in-hand with a focus on single-priority­disease programs (e.g., HIV/AIDS, malaria) 18 Healthy Development or single interventions (e.g., vaccines), often in the form of vertical pro- grams.29 However, the new focus of DAH on priority diseases has encoun- tered tight bottlenecks in LIC health systems at country and subnational levels. There is now consensus that, for the renewed commitments of client countries and the international community to realize their full potential, synergy must be ensured between efforts to strengthen the health system and a focus on priority­disease results in LICs. Focus on key priority dis- eases is essential in LICs, given the importance of a few priority diseases in the overall disease burden (e.g., HIV/AIDS, malaria, tuberculosis, vaccine- preventable diseases, micronutrient deficiencies, and perinatal diseases), their limited financial and fiscal space, and health system constraints. For this focus to be successful, a well-functioning health system is fundamental. In principle, there is no contradiction between a focus on a single priority disease and a system strengthening approach. When well implemented, they are complementary and synergistic, and the only practical way of addressing the multiple causes of morbidity and mortality that might at first appear to be caused only by a single disease. Increased awareness and financing offer client countries and the international community excellent opportunities to improve overall health system performance at marginal cost while concentrating the new resources on controlling priority diseases. Expanded financing has allowed considerable scaling up of HIV/AIDS treatment and is facilitating the scale up of malaria and tuberculosis treatments. If well-directed, scaling up holds great potential for improving access to priority services for the poor well beyond these three diseases in LICs. Countries and the international community have yet to take full advantage of this potential. Ensuring synergy between priority diseases and system strengthening will require a significant effort and discipline from client countries and all development partners, including the World Bank. This will be particularly challenging in Africa, the focus of most priority­dis- ease programs, global initiatives, and funds. The role of IDA financing in health system strengthening, with its capacity to flexibly address system con- straints, will be crucial to ensure this synergy and integration. A Well-Organized and Sustainable Health System: Essential to Achieve HNP Results on the Ground "Strengthening health systems" may sound abstract and less important than specific-disease control technology or increased international financing to Introduction and Overview 19 many people concerned about achieving HNP results, but it is not. On the ground, in practical terms, it means putting together the right chain of events (financing, governance, insurance, logistics, provider payment and incentive mechanisms, information, well-trained personnel, basic infrastructure, and supplies) to ensure equitable access to effective HNP interventions and a continuum of care to save children like Elizabeth (box 1.1). Success in strengthening health systems cannot be claimed until the right chain of events on the ground prevents avoidable deaths and impoverishment due to illness. Without results, health system strengthening has no meaning; yet, there will be no results without health system strengthening. Box 1.1: Could Elizabeth Have Been Saved? Why Health Systems Matter Elizabeth was Mary's seventh child. She died at the age of three due to complications of malaria on February 17, 2003, at a clinic in San Pedro (a pseudonym), one of the poorest municipalities, in an all-too representative country. Why did Elizabeth die? What does health system strengthening have to do with saving her life? Elizabeth's death had everything to do with a broken health system in desperate need of repair. The Single Disease Why Elizabeth died perhaps seems obvious. She caught malaria, developed a cerebral form of the disease, and a common, treatable infection killed her. But why Elizabeth? Had her family not received free bednets to prevent the infection? Was she not diagnosed and treated in time? What happened? The Broken System Finding out why Elizabeth died took so much time that Dr. Joy Macumbo, the local public health authority, almost gave up trying. So many children die every day in her district, how could she spare time to investigate just one? Finding out anything was so hard. There were almost no records of Elizabeth's last few hours in the hospital or of her previous health histo- ry in the clinic. Dr. Macumbo was puzzled. According to her district data, for three years San Pedro, Elizabeth's town, had been receiving free bednets and antimalarial drugs from the Ministry of Health (MOH). However, the district hospital was still reporting many cases of complications from malaria from the San Pedro area. Dr. Macumbo went to San Pedro to investigate. Dr. Macumbo discovered that the health center where Elizabeth should have received the bednets and been diagnosed and treated early on, had had no health worker for at least 18 months. Bednets and drugs arrived from the MOH program, but often there was nobody to distribute the nets, or nobody trained to early-diagnose and treat the children. Some community volunteers helped visiting health workers catch up with distribution and treat- (continues on the following page) 20 Healthy Development Box 1.1: (continued) ment, but there were no guarantees (or records) of whether drugs had been stored properly (so they stay active) or administered correctly to San Pedro's children. In some cases there were no records of what happened to the free bednets. Elizabeth had either not received (or used) a bednet, had not been diagnosed and treated in time, and/or had not received treat- ment at all. Why had the health center gone so long without trained workers? Dr. Macumbo asked San Pedro's mayor--management of health centers had been decentralized from district to munic- ipalities five years earlier. Any trained health workers San Pedro managed to hire did not stay long in the poor town. The mayor said the job had been advertised for months, but the few qualified applicants did not want it. Working conditions in San Pedro were much harder than in South Port, the district capital, but the pay was the same under civil service regulations. To make matters worse, health workers on the center's payroll often showed up late-- because, the mayor discovered, they were moonlighting during center working hours. Some small, private providers paid them case by case, a supplement to their monthly salary. The scant records from Elizabeth's stay at the district hospital and interviews with her mother, Mary, and hospital staff showed that Elizabeth, with very advanced malaria complica- tions, had arrived at the hospital on a weekend, long after the onset of the symptoms. Why did she arrive so late? Elizabeth's mother said she could not afford to take her children to the hospital on a week- day. Dr. Macumbo was surprised--public hospital services are free in San Pedro. However, Mary said she had to sell one of her two cows, spend all her savings, and borrow money to cover expenses related to Elizabeth's sickness. A trip to the hospital takes a full day because doctors show up late, so Mary would lose a day of work. She had to pay for transportation, under-the-table fees for treatment, as well as additional supplies (antimalarial drugs are free but the supplies are not). Years ago when her first child died, Mary endured a similar financial catastrophe. The community mutual aid scheme she joined after the death of her second child had gone broke after only three years. Around the world every day, there are thousands of cases like Elizabeth's. Strengthening health systems is vital to prevent other deaths like Elizabeth's. It is about ensuring that the international community's commitment to supply an area like San Pedro with bednets and drugs will not be wasted by the wrong chain of events. Strengthening health systems is about setting up the right sequence of events so that others survive. The Right Chain of Events The right sequence of events might have saved Elizabeth. Strengthening a health system means: · Ensuring the right logistics so that bednets (and other drugs and supplies) will reach poor families at risk and that antimalarial drugs will not lose potency through poor storage. · Helping the government change salary incentives so that workers show up for work at health centers to diagnose and treat children, and, at a marginal cost, do well-child consul- tations at the same time, educate parents, and distribute micronutrient supplements to Introduction and Overview 21 Box 1.1: (continued) expectant mothers (to help prevent low birth weights and malnutrition, which compound the effects of malaria), and deliver other services. · Enhancing public-private partnerships (e.g., with community and/or faith-based organiza- tions) in the delivery of services to complement each other and reduce supply gaps. · Setting the right payment mechanisms for providers and linking workers' salaries to both attendance and performance and reducing incentives to spend health center and hospital time on income-generating activities outside their workplace. · Instituting governance arrangements that empower patients and the community to address issues such as informal payments and provider responsiveness. · Setting the right insurance and/or public financing mechanisms (including donor financing) so that the cost of illness will not prevent a mother from taking a sick child for treatment and will not throw her and her family into destitution, forced to sell the few assets they possess. · Taking advantage of decentralized decision making and management while, simultaneously, putting in place compensatory mechanisms for capacity and equity issues. · Having many more doctors and dedicated health professionals like Dr. Macumbo, so that countries and districts can identify and follow systemic problems without needing external assistance. · Having information systems that address all the key diseases so that doctors and health personnel can treat patients instead of filling out multiple, duplicative reports for each dis- ease to each donor and/or government agency. Achieving HNP results requires a well-organized and sustainable coun- try health system. A major, urgent effort must be made to strengthen health systems, if financial commitments enabled by the new DAH archi- tecture are to succeed in improving health conditions of the poor and achieve the HNP-related MDGs in middle- and low-income countries. Improving HNP sector governance is also essential. On this, the interna- tional community agrees after much debate in the early 2000s, centered on the false dichotomy between priority­disease and system strengthen- ing focus. Policy makers in LICs and MICs face difficult challenges to make their health systems work and to protect people from poverty caused or deepened by illness. Middle-income client­country demand for policy and technical advice also makes it clear that health system strengthening is essential to ensure and sustain more comprehensive approaches to HNP results. 22 Healthy Development A Shift in the Driver of the Bank-Country Relationship toward High- Quality Policy Advice and Strategic Focus of Bank Lending on Structural HNP Issues The new DAH architecture, the persisting challenges, and the increasing importance of health systems in addressing them create a scenario in which Bank financing, though still very important, is increasingly small compared with the growing volume of disease-specific financing and no longer is the sole driver of relationships with client countries. In this scenario, it is the quality of policy and technical dialog and the strategic focus of Bank lend- ing (particularly IDA lending) that will define the true magnitude of the Bank contribution to country efforts in HNP. Strategic focus of Bank advice and lending is essential. Bank financing is strategically crucial to ensure much-needed health system strengthening (for which financing is scarce in the new DAH architecture) and to set the enabling environment for increased disease-specific financing to be effec- tive. This was stated again and again by client countries during preparation of this new Strategy. For example, Bank financing, as measured by new annual financial commitments for HIV/AIDS (figure 1.2), for malaria, and for tuberculosis represented in FY2005, respectively, about 5 percent,30 3 percent,31 and 7 percent32 of total annual international commitments.33 That the role of Bank financing is increasingly small, compared to overall international financing for health, is true mainly for middle-income and low-income countries for which DAH is a minor proportion of government or total health expenditures (low-assistance LICs, LA-LICs). Bank financ- ing is still an important source of financing for LICs that count on DAH to cover a large part of government expenditures on health (high-assistance LICs, HA-LICs). How to Best Serve Client Countries in This New Scenario? Within this new development assistance scenario, how can the Bank best serve client countries in their efforts to achieve their priority HNP results? How can the Bank contribute to the effectiveness on the ground of global partners' increased financial commitments? What is the role of Bank financ- ing in the context of globally expanded financing for HNP? This new Strat- egy for HNP Results states the vision of the Bank role in the new global Introduction and Overview 23 Figure 1.2: Total Global and World Bank Commitments for HIV/AIDS, 2000, 2002, and 2004 4,000 3,500 total global 3,000 commitments for 2,500 HIV/AIDS million 2,000 Bank commitments US$ 1,500 for HIV/AIDS 1,000 500 0 2000 2002 2004 year Source: J. A. Izazola-Licea 2006. Note: World Bank commitments reflect projects identified as having HIV/AIDS as a theme. World Bank commitments for HIV/AIDS in 2002 were approximately US$9 million. architecture in HNP. It also attempts to give Bank regional and country teams guidance for addressing these questions with a sharp focus on coun- try-led and country-owned Bank assistance for HNP results, working closely with global partners. Results on the ground, especially outcome improvements for the poor and the vulnerable, rarely occur in the lifetime of a single project, nor are they achieved by focusing on any single sector. It is long-term Bank policy advice, technical assistance, and its lending program as a whole that can influence client­country policy actions, inputs, and structural changes in the health system; HNP policy; and relevant policies from other sectors (e.g., environment, water, transport, social protection, education, agriculture). Therefore, the effectiveness of the Bank country focus in HNP is deter- mined by the quality of policy advice and the strategic focus of Bank lend- ing, as developed in the overall Country Assistance Strategy (CAS), to iden- tify long-term constraints to improving outcomes and country system performance and to define a set of multiple-sector lending and nonlending interventions to support countries' efforts. Under "New Bank Strategic Directions," a strategy is outlined for ensuring that this assessment becomes standard practice in the preparation of the CAS. The Bank has special strengths (comparative advantages) for providing policy and technical advice to client countries in their efforts to achieve 24 Healthy Development HNP results. The Bank will focus and enhance its capacity to generate knowledge and provide policy and technical advice in these areas. Bank Comparative Advantages in Helping Client Countries Achieve HNP Results The Bank has significant comparative advantages to help client countries improve HNP results in this new environment. These advantages include: the Bank health system strengthening capacity, including its potential capacity to disseminate country experience with alternative innovations and reforms; its multisectoral approach to country assistance, which allows it to engage at national and subnational levels with all government agencies (but particularly Ministries of Finance); its capacity for large-scale implementa- tion of projects and programs (including its financial management and pro- curement systems for extensive operations); its multiple financing instru- ments and products; its global nature, allowing facilitation of interregional sharing of experience; its core economic and fiscal analysis capacity across all sectors; and its pervasive country focus and presence. The World Bank Group also has significant potential comparative advantages in engaging private health actors through both the Bank (International Bank for Recon- struction and Development, IBRD) and the International Finance Corpo- ration (IFC). Some of these strengths are fully developed at the Bank; some, such as policy and technical advice on regulating private sector and improv- ing public-private collaboration for HNP results, health system strengthen- ing capacity, and intersectoral work for HNP results, need significant rein- forcement if the Bank is to give effective support to client countries and the rest of the international community. Country-Led Lending in HNP Country focus also means that the Bank will continue to lend, upon country demand, in all areas deemed necessary to improve health status and financial protection for people, especially the poor, in client countries. This includes support for controlling priority diseases because they constitute a large pro- portion of the burden of disease. However, the Bank will increasingly endeavor to ensure that its priority­disease support will strengthen health systems to solve systemic constraints that impair the effectiveness of country, Bank, and international community financing in achieving HNP results. Introduction and Overview 25 Strategic Objectives: What HNP Results? The ultimate objective of the World Bank work in HNP and of this new Strategy is to improve the health conditions of the people in client countries, particularly the poor and the vulnera- ble, in the context of the Bank's overall strategy for poverty alleviation. To achieve this objec- tive, this new Strategy states the vision and actions necessary to strengthen the Bank's capac- ity to better serve client countries by excelling in areas of Bank comparative advantages and by improving its collaboration with global partners. To contribute to improving the lives and health conditions of the poor and the vulnerable, the Bank will focus on client­country efforts to achieve results in four areas or Bank Strategic Objectives for HNP: STRATEGIC OBJECTIVE 1. Improve the level and distribution of key HNP outcomes, outputs, and system performance at country and global levels in order to improve living conditions, particularly for the poor and the vulnerable. STRATEGIC OBJECTIVE 2. Prevent poverty due to illness (by improving financial protection). STRATEGIC OBJECTIVE 3. Improve financial sustainability in the HNP sector and its contribution to sound macroeconomic and fiscal policy and to country competitiveness. STRATEGIC OBJECTIVE 4. Improve governance, accountability, and trans- parency in the health sector. These policy objectives represent continuity as well as change as com- pared with the 1997 HNP Strategy. Improving health outcomes of the poor and the vulnerable, protecting households from the impoverishing effects of illness, and achieving sustainable financing are still central HNP policy objectives. There are, however, three important changes in the new Strat- egy. First, improving governance and accountability is included as a new policy objective. Second, although focus on strengthening health systems is essential, this strengthening is seen as a crucial means of helping countries achieve HNP results rather than as a policy objective in itself. Third, HNP policy (e.g., regarding financing of health insurance or large scale up for HIV/AIDS) has heavy implications for country fiscal policy and competi- 26 Healthy Development tiveness. Therefore, linking HNP sectoral policy to these country objectives is essential. As presented in World Development Report--2004 (World Bank 2003b), good governance and accountability mechanisms are key determinants of health system performance. Although demand for advice shows that most countries value results in all four areas, their relative importance varies in different Bank Regions and in LICs and MICs. In LICs, improving outcomes, particularly for the MDGs, may have greater relative importance. In MICs, the priority is increasingly on financial protection and contributions to sound fiscal policy and country competitiveness, although improving health status remains important, par- ticularly to reduce inequities in access to services and financial protection and to address the increasing burden of premature death due to noncom- municable diseases. Governance and transparency are proving critical in all country settings. Although IDA and IBRD country priorities in health system strengthen- ing present significant similarities (e.g., the challenge of universal health insurance coverage, fiscal sustainability, public-private interface), the spe- cific options for addressing these priorities differ significantly between the two groups of countries. The Bank needs to be able to respond to both and ensure that it generates and disseminates lessons learned and experience among both groups of countries. Improving Bank capacity for health system strengthening will include both IDA and IBRD priorities. Strategic Directions: How to Support Country Efforts to Achieve Results? Five new Strategic Directions are specified to improve Bank capacity to assist client countries in achieving the HNP Strategic Objectives in the coming decade: STRATEGIC DIRECTION 1. Renew Bank focus on HNP results. STRATEGIC DIRECTION 2. Increase the Bank's contribution to client­ country efforts to strengthen and realize well-organized and sustainable health systems for HNP results. STRATEGIC DIRECTION 3. Ensure synergy between health system strengthening and priority­disease interventions, particularly in LICs. Introduction and Overview 27 STRATEGIC DIRECTION 4. Strengthen Bank capacity to advise client countries on an intersectoral approach to HNP results. STRATEGIC DIRECTION 5. Increase selectivity, improve strategic engage- ment, and reach agreement with global partners on collaborative division of labor for the benefit of client countries. STRATEGIC DIRECTION 1: Renew Bank Focus on HNP Results Focus on HNP outcomes, outputs, and system performance is the key Strategic Direction of the Bank in HNP, to which the rest of the Strategic Directions contribute. The cornerstone of this effort will be the Bank tight- ening the link between HNP-related lending and nonlending to secure demonstrable HNP results on the ground. Steps in that direction will include: increasing the proportion of output-based HNP lending and implementing up-front investment in monitoring and evaluation for all Bank HNP-related lending; improve quality at entry of new lending port- folio and adjust existing portfolio as needed to improve operations linkage to HNP results; help launch a major effort, in coordination with global partners and global initiatives, to help client countries improve their national public health surveillance and performance-monitoring systems and monitor a core set of indicators at global level; partner with client coun- tries to experiment and learn from innovation provided by country-led reforms and programs supported by the Bank; and set a common global HNP Results Framework for the Bank to guide regional HNP strategies, regional HNP business plans, and overall Bank/global partner monitoring and evaluation activities on HNP results. STRATEGIC DIRECTION 2: Increase Bank Contribution to Client­ Country Efforts to Strengthen and Realize Well-Organized and Sustainable Health Systems for HNP Results Achieving HNP results requires a well-organized and sustainable country health system to ensure equitable access to effective HNP interventions and a continuum of care. Policy makers in LICs and MICs face difficult challenges to make their health systems work in delivering sustainable health services and protecting people from poverty due to illness. The Bank has important com- parative advantages for helping client countries strengthen their health sys- 28 Healthy Development tems, but not for all aspects of it. Collaborative division of labor with global partners is needed to respond to the wide range of demand from client coun- tries (Shakow 2006). The Bank will step up its engagement in health system strengthening, with an unswerving commitment to making it an instrument for achieving concrete results on the ground, appropriate to the specific needs of both MICs and LICs. (For analysis of health system characteristics and challenges, see "New Bank Strategic Directions" and annex F). STRATEGIC DIRECTION 3: Ensure Synergy between Health System Strengthening and Priority­Disease Interventions, Particularly in LICs The Bank will make every effort to increase synergy between priority­dis- ease funding and health system strengthening in Bank operations in LICs, and, upon request, will advise client countries on how to achieve this syn- ergy with country and DAH financing. Synergy in this context means addressing priority disease­specific needs simultaneously with the key sys- tem constraints to getting the needed results for the priority disease(s) in question, while avoiding or limiting negative spillovers and maximizing pos- itive spillovers. Bank financing through the International Development Association plays a crucial role in HNP-enhancing interventions to ensure synergy between focus on priority diseases and health system strengthening in LICs. It also helps forestall allocative inefficiency and other distortions that can result from the allocation of large amounts of financing to a few diseases (and neg- lect of others). STRATEGIC DIRECTION 4: Strengthen Bank Capacity to Advise Client Countries on an Intersectoral Approach to HNP Results The HNP sector alone (at country level or internationally) cannot achieve the MDGs (and other priority outcomes) or improve health system per- formance. These HNP results are seldom determined by any single sector. Intersectorality is one of the most important comparative advantages of the Bank. It is also one of the most difficult to realize fully due to traditional compartmentalization of sectors in client countries as well as to contradic- tory incentives within the Bank. The Bank will therefore strengthen its intersectoral work to help client countries and the international communi- Introduction and Overview 29 ties achieve the best possible HNP results (see "New Bank Strategic Direc- tions" and annex E). STRATEGIC DIRECTION 5: Increase Selectivity, Improve Strategic Engagement, and Reach Agreement with Global Partners on Collaborative Division of Labor for the Benefit of Client Countries As one of the leading global multilateral organizations in development, the Bank collaborates with many other bilateral and multilateral organizations and global HNP partnerships. Engaging and collaborating with global part- ners contributes both to Bank capacity to serve client countries and to global partners' own capacity. The volume of the HNP partnership portfo- lio has increased dramatically over the past five years, mirroring the changes in the global health architecture. As a result, Bank engagement with global partners is fragmented and requires sharper strategic direction. With the implementation of the new Strategy, the Bank will assess its engagement with its partners to ensure effective and sustainable partnerships. For exam- ple, the Bank will seek a better balance in its partnerships and its regional work on LIC and MIC priorities, particularly on health systems and will substantially increase its strategic engagement with WHO, the Global Fund, and GAVI in LICs. In addition to collaborative division of labor in health system strength- ening, the Bank will: promote country-level collaboration for alignment and harmonization; direct Bank contributions to promoting global public goods and preventing and mitigating global public "bads" in areas of Bank com- parative advantages; and increasingly transition Bank advocacy engagement with partners toward health system strengthening with sharp focus on HNP results and toward synergy between priority­disease financing and system strengthening approaches. In management of trust funds (TFs) and the Development Grant Facility (DGF), the Bank will increasingly concentrate on trust funds and grants that are directly related to the implementation of its HNP Strategic Directions at country level. Implementing the Bank HNP Strategy To make full use of its comparative advantages in the new environment in the interests of its client countries, the HNP sector in the Bank needs to 30 Healthy Development make functional and organizational changes and rebalance the skill-mix of its staff and management. Sharpening the regional and Hub HNP units' focus on results, health system strengthening, and intersectoral work will be costly in the short term. Adjustments in skill-mix take time and effort (staff and management training; shifting recruitment toward senior health spe- cialists in systems, economics, and intersectorality skills development of core diagnostic tools). It will also require functional changes in the mission of the HNP Hub so that it becomes more oriented to support Region and country team work. Concomitantly, it will also require revitalization of the role and work of the HNP Sector Board. A summary Action Plan for implementing key features, leading to the new Strategic Directions and results, is part of this Strategy. It includes: pro- posals and targets to improve quality at entry of the HNP portfolio; actions to restructure current at-risk portfolio; a design, pilot, and implementation plan for a new tool, the Multisectoral Constraints Assessment for Health Outcomes (MCA); proposals for improving statistical capacity and moni- toring core indicators at country and global levels; a results framework to guide regional development of country strategies, and proposals for training and retooling HNP staff and management. It also includes key organiza- tional changes, particularly for the HNP Network (HNPFAM) and the HNP Hub. Finally annex A presents summaries of regional and HNP Hub Action Plans for Strategy implementation. A Window of Opportunity for Redoubled Support for Countries' HNP Results The expanded commitment of the international community in health has created an unprecedented window of opportunity for the Bank to further contribute to HNP results globally. Consultations with many global and country leaders in health, including leaders of donor agencies, foundations, Ministries of Health and Finance of client countries, Executive Directors of the World Bank, and management and staff from HNP and other sectors in the Bank have confirmed their expectations of the need for the Bank to rise to these new challenges--and expeditiously. This Strategy offers guidance for the Bank's short- and medium-term response to meet the new challenges. CHAPTER 2 Opportunities and Challenges in the New International Environment in Health A New International Environment Among the many new developments since the 1997 Bank HNP Strategy, particularly important are the: increased prominence of HNP in interna- tional development policy; radical changes in the international architecture of development assistance for health and proliferation in the number and influence of global organizations and partnerships; insufficient attention to ensuring results on the ground and installing the monitoring and evaluation systems essential to gauge them; recent revaluation by the international community of the importance of well-organized and sustainable health sys- tems for achieving HNP results; significant increases in efforts to introduce structural changes in the health system, particularly in MICs; proliferation and expansion of single-disease approaches, including vertical program implementation; increasing awareness, without sufficient public policy action, regarding the substantial role of private financing and private sector delivery of health services in client countries; impressive technological development in pharmaceuticals, especially vaccines and antiretroviral drugs (ARVs); and persisting challenges in public health, population, and nutrition. · Global attention to health policy and its challenges has burgeoned worldwide in the last 10 years. Global commitment to the MDGs is one prominent example. · With the increase in global attention to health policy, a radical change in the architecture of DAH has occurred. The number and influence of new mul- tilateral, bilateral, and private initiatives has exploded in the last decade. 31 32 Healthy Development The relative importance of Bank financing (in terms of volume) in HNP has decreased since 1997. In 1997, the Bank was the predominant HNP financ- ing organizations. Today it is one of a group of large financiers. In the next five years, annual DAH commitments increased from about US$6 billion in 2000 to almost US$14 billion in 2005 (figure 1.1). However, despite such large increases in DAH, the total is still far from the estimated amount needed to achieve the MDGs (Wagstaff and Claeson 2004). · Despite the increase in global attention to health, too little attention has been paid to ensuring results on the ground and establishing the monitoring and evaluation systems so essential for such a focus. Despite advances in data col- lection, the HNP sector (globally and within the Bank) is not much bet- ter-off today than it was 10 years ago in its capacity to generate basic, reli- able, timely information on outcomes, outputs, and inputs, particularly in LICs. This lack is a major obstacle not only for results monitoring but also for countries' own policy formulation and for strengthening causal pathways among inputs, outputs, outcomes, and policy actions. · At the same time, client countries have been ahead of the international com- munity in pursuing system strengthening. Efforts to introduce structural changes in health systems have significantly increased, mainly in MICs but also in LICs. Concomitantly, demand has swelled for sophisticated policy and technical advice on health financing, health insurance, and other health system functions. Client countries want to find out how to do it rather than what to do. · In the early 2000s, single priority­disease approaches also coexisted with a significant underestimation of the importance of well-organized and sustain- able health systems for achieving HNP results, but the international community has come to realize its full importance. This realization has brought a sense of urgency about ensuring smoothly functioning health systems, now seen as a prerequisite for obtaining solid HNP results on the ground. · Single-disease approaches have proliferated and expanded during the last decade, hand in hand with single priority­disease approaches and often with a vertical disease-control approach. This trend has created chal- lenges of its own, particularly in low-income countries, and especially in Africa. Multiple donors with different strategic and operational approaches are often an extra burden on policy makers in recipient coun- tries who have to allocate great effort to respond to uncoordinated donor Opportunities and Challenges in the New International Environment in Health 33 work. In many cases, concern is growing about the equity, effectiveness, and efficiency consequences of vertical implementation of single prior- ity­disease programs nationally. · Despite increasing awareness of the large role of private financing and delivery of health services, public policy action has been insufficient in most client coun- tries. Private providers deliver most ambulatory health services in most LICs, and even the poorest people often seek private care (figures 2.1 and 2.2). Nevertheless, public policy is still not attuned to ensuring public- private complementarity and synergies and effective resource use in the health sector. · Technological development in pharmaceuticals has been impressive, especially in vaccines and antiretroviral drugs. This development has reduced costs and improved the effectiveness of a number of priority­disease treatments (e.g., for HIV/AIDS, malaria). It has also introduced new vaccines (e.g., rotavirus and pneumococcal) with potential for cutting mortality in chil- dren under five years of age (U-5) in LICs. This good news for the inter- national community brings with it two important challenges. The first is to develop financing mechanisms (such as the Advance Market Commit- ment mechanism34) to encourage research and development (R&D) and manufacturing for LICs of much-needed technologies for which country fiscal constraints preclude demand. The second is whether and how to mainstream the new vaccines as well as how to sustain them financially in client countries. Finally, the last three decades have brought impressive achievements in HNP, but formidable challenges persist: · Actual and potential pandemics and regional epidemics have continuously emerged, and some have expanded during the last decade (e.g., HIV/AIDS, malaria, drug-resistant TB, SARS, avian flu). There has also been a sig- nificant increase in premature deaths related to traffic accidents and chronic dis- eases (diabetes, pulmonary diseases, hypertension, and cancer) caused by the tobacco addiction and the obesity pandemics. The international community has managed such threats in the past, for example, in eradicating small- pox and making deep inroads into the eradication of polio. Significant advances have been made on understanding the determinants of tobacco addiction and obesity. However, HIV/AIDS, malaria, TB, obesity, and new pandemics will continue to challenge client countries in the future. 34 Healthy Development Figure 2.1: Treatment of Diarrhea 60 50 patients seen in private 40 facility 30 percent patients seen in public 20 facility 10 0 India Bangladesh Cambodia Uganda 1999 2000 2000 2001 Source: HNP Strategy Facilitation Team 2006. Adapted from World Bank Institute data (A. Yazbeck and Hayashi). Note: Percentage of patients from the poorest quintile seen in public or private facilities. Figure 2.2: Who Uses Public or Private Health Facilities for Acute Respiratory Infections? Dominican Republic 100 86.4 80 66.9 77.9 62.1 64.2 60 percent 40 37.9 35.8 33.1 22.1 20 13.6 0 poorest 20% second middle fourth richest 20% public facility private facility Source: HNP Strategy Facilitation Team 2006. Adapted from World Bank Institute data (A. Yazbeck and Hayashi). Note: Breakdown by quintile. Opportunities and Challenges in the New International Environment in Health 35 Client­country public health surveillance systems must be ready to detect and respond quickly to outbreaks of infectious diseases and pro- mote behavioral changes for obesity and effective policies to reduce tobacco consumption (e.g., tax increases for cigarettes). · The world population more than doubled in the second half of the 20th cen- tury. Ninety-five percent of all population growth occurred in develop- ing countries. Since the middle of the last century, fertility and mortality trends almost everywhere have gradually converged toward low fertility and lengthened life expectancy. The exception is the Sub-Saharan Africa Region (east, west, and middle subregions) and many countries in the Middle East and North Africa, where total fertility rates (TFRs) are very high. The persistence of population growth in the absence of economic growth pose significant challenges to developing countries capacity to ensure access to basic services. · Malnutrition, now problematic in both poor and rich countries, affects the poor- est people most. Underweight and micronutrient-deficient children and overweight adults live in the same households in both developing and developed countries. Malnutrition, and its negative compounding effect on disease susceptibility, slows economic growth and perpetuates poverty through direct losses in productivity from poor physical status, as well as indirect losses from poor cognitive function and deficits in schooling and direct losses owing to increased health care costs. The New Architecture for Development Assistance for Health Over the last 10 years, there have been profound changes in the organizations that play key roles in global health, as large private foundations (e.g., the Bill and Melinda Gates Foundation) and large global funds35 have entered the scene with substantial amounts of grant money. Other disease-specific initia- tives36 were also founded and have brought new financial resources for spe- cific diseases. Annex C presents an in-depth overview of the new DAH. Successful advocacy for HNP and increase in DAH is good news. The new global architechture is here to stay, and most likely expand, and has cre- ated many opportunities for improving health conditions of the poor in low-income countries. However, it has also created major new challenges for recipient countries. Multiple donors, each with its own strategic and 36 Healthy Development fiduciary approach, have put a weighty managerial and administrative bur- den on recipient countries. The implementation of the Paris Declaration (OECD/DAC 2005), which is designed to harmonize all donor approaches including the Bank's, is essential to improve effectiveness at the country level. Determining how, in the new international environment, to make the most of the opportunities opened by increased awareness and financial com- mitment and minimizing distortions from DAH are essential for Bank effec- tiveness in HNP in the next decade. CHAPTER 3 Bank Contribution and Challenges in Implementing the 1997 HNP Strategy The Bank has substantially contributed to HNP in client countries in the last decade. Since the 1997 HNP Strategy, it has decisively committed to focus- ing its work on winning health gains for the poor. The Bank has also played a crucial role in advocacy, awareness, and development of new international initiatives. It has contributed substantial financing and policy advice for pri- ority diseases and HNP interventions, with more than 500 projects and pro- grams in more than 100 countries. With total cumulative lending of US$15 billion and about US$12 billion in cumulative disbursements, the Bank has been one of the world's largest international financiers of HNP activities in the last decade. The Bank has also provided substantial policy and technical advice through more than 250 analytical and advisory activities (AAA). However, the Bank faces important challenges. Despite the good number of excellent projects and programs to its credit in different Regions, the implementation impact of the 1997 Strategy on HNP results on the ground cannot be systematically evaluated, because focus on monitoring and evalu- ation during the last decade was weak, and impact data are not available. Additionally, the Bank has faced an increased reduction in volume and dete- rioration in the quality of implementation of its current lending and non- lending portfolio since 2002. The active portfolio has declined about 30 percent since 2001, and the quality of the HNP portfolio has been the low- est performing, below all Bank sectors average for project outcomes. In addition, the focus of AAA on health systems has also been insufficient, less than 35 percent of all AAAs. Although HNP sector operations are inher- ently complex and high risk as compared with many other sectors, much improvement is needed in the quality at entry and strategic focus of opera- tions to improve HNP portfolio performance. 37 38 Healthy Development Bank Contribution to the New DAH Architecture The Bank has played a significant role in shaping the new DAH architec- ture. Since 1997, it has participated in the creation and is on the Board of the main global partnerships, including: UNAIDS, Roll Back Malaria, Stop TB, GAVI, Global Fund to Fight AIDS, Tuberculosis and Malaria, Health Metrics Network, the Reproductive Health Supplies Coalition, UNITAID, and others listed in annex G. In addition to its contribution to these major global initiatives, the Bank has scaled up its engagement with many global partners and partnerships in HNP, mostly through the HNP Hub. Engagement with global partners is part of the Bank mission to better serve client countries by enhancing global public goods and preventing global public "bads." The HNP Hub works in specific areas with more than 55 organizations or initiatives at the global level, including other multilaterals, bilaterals, private foundations, and global partnerships. This extensive engagement also poses internal chal- lenges for the Bank. Taking Stock of the 1997 HNP Strategy Since issuing the 1997 HNP Strategy, the Bank has played a major role in HNP globally and has contributed to client­country efforts to improve health conditions of the poor. It has done so mainly through lending and nonlending country support and through contributions to most major global health initiatives. However, taking stock of the ultimate impact of the 1997 HNP Strategy is difficult for two main reasons. First, country-level outcomes and performance results are difficult to attribute directly to Bank financing, which is often relatively small. Second, monitoring and evalua- tion tools for most HNP-related lending and nonlending support are lack- ing. The Bank has played a central role in advocacy, awareness, and financ- ing of priority diseases and interventions in HNP in the last decade. Although there are multiple examples of excellent projects, programs, pol- icy advice to client countries, and research, the impact of the 1997 HNP Strategy has not been systematically assessed, nor do the available monitor- ing data allow it. The difficulties in obtaining monitoring and evaluation data for HNP projects are not new. In 1999, an evaluation of the effectiveness of HNP Bank Contribution and Challenges in Implementing the 1997 HNP Strategy 39 projects raised concerns about Bank M&E (World Bank 1999). Addition- ally, the review of all Implementation Completion Reports (ICRs) of HNP projects that closed in FY2004­FY2005 revealed that only 25 percent of all HNP sector­managed projects had a satisfactorily rated M&E (World Bank 2006e). According to the same review, less than half the projects included any outcome-output indicator in the results frameworks, and less than half of those that did measure these indicators did so at least twice. Another review of 118 ICRs in FY2003­FY2005 found that only a few Bank-assisted projects evaluated changes in health services (42 percent), health financing (17 percent), or health status (33 percent). The review also showed that any changes measured were always positive (Subramanian, Peters, and Willis 2006). Lending Trends since 1997 The Bank is still one of the world's largest single financiers of HNP activi- ties, as measured by cumulative commitments and cumulative disburse- ments. Total Bank active portfolio (projects and programs) amounted to about US$7.0 billion in FY2006, reflecting a steady decrease from US$9.5 billion in FY2001. Average annual disbursements hovered around US$1.1 billion in FY1997­FY2006 (figure 3.1). These numbers include all active lending for health, nutrition, and population (HNP sector and other sec- tors) by both IDA and IBRD. The Bank has contributed substantially to financing client­country HNP efforts during the implementation of the 1997 HNP Strategy through both lending and projects. World Bank cumulative HNP disbursements for FY1997 through FY2006 stand at about US$12 billion. Since FY1997, more than 500 projects with a health component have been approved. Bank lending through IBRD, however, has contracted since FY2001. While annual new IBRD lending grew from less than US$0.5 billion in FY2000 to more than US$1.0 billion in FY2004, in the last two years it dropped to around US$0.4 billion in FY2006 (figure 3.2)--in stark contrast to IBRD lending in other sectors. More important, annual commitments have followed the same trend since FY2001. Bank lending through IDA grew from US$0.5 billion in FY2000 to US$0.8 billion in FY2006, in line with international commitments for HNP results in LICs. However, debt relief will shrink the IDA lending envelope for a number of IDA countries 40 Healthy Development Figure 3.1: All HNP Total Commitments, Disbursements, and New Lending, FY1997­FY2006 12,000 10,000 8,000 million 6,000 US$ 4,000 2,000 0 2006 FY1997 FY1998 FY1999 FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 October annual disbursements total commitments new approvals Source: Business Warehouse October 2006. Note: Includes HNP Sector Board- and other Sector Board-managed lending (allocations to health, noncompulsory health finance, compulsory health finance). For new lending, FY07 figures are projections--as of October 2006--adjusted with the 0.7 coefficient of realism (ratio of approved new lending over target new lending at the beginning of a fiscal year as deduced by data manipulations from the past years in HNP). because each dollar of debt relief granted those countries will cut lending proportionately. A continuation of the cumulative IBRD reduction will have important implications for the Bank business model. No systematic analysis is available on the determinants of the reduction in IBRD lending, but anecdotal evi- dence suggests that many MICs are changing their engagement. Instead of just borrowing, they are seeking high-level Bank policy advice and knowl- edge or making such advice a condition for borrowing. This trend may reflect either better access to favorable borrowing condi- tions elsewhere or MIC capacity to finance interventions with their own resources. Although this is good news, it also means that the portfolio trends confirm clients' changed expectations of the role of the Bank, as stated in most country consultations. Thus, the quality of Bank policy and technical advice increasingly drives relationships with client countries. Bank Contribution and Challenges in Implementing the 1997 HNP Strategy 41 Figure 3.2: Trends in IDA/IBRD Total New Lending for HNP, All Sector Boards Managed, FY1997­FY2006 3,000 IDA, other Sector 2,500 Boards 2,000 IDA, HNP Sector Board million 1,500 IBRD, other Sector US$ Boards 1,000 IBRD, HNP Sector Board 500 0 a FY1997 FY1998 FY1999 FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 Source: Business Warehouse, HNP Quality Team, October 2006. Note: Represents new health lending commitment trends, in US$ million, broken down into International Development Agency and International Bank for Reconstruction and Development lending amounts. a. FY2007 figures are projections adjusted with the 0.7 coefficient of realism (ratio of approved new lending over target new lend- ing at the beginning of a fiscal year as deduced by data manipulations from the past years in HNP). Need to Rapidly Improve Quality Performance of HNP Portfolio The overall strategic direction and quality-control mechanism of the HNP portfolio needs reassessment. The performance of the Bank HNP sector portfolio needs major improvement. Portfolio quality, represented by proj- ect outcomes as measured by the Bank ("satisfactory" or "unsatisfactory"), has shown the lowest performance among all Bank sectors in the last five years. From FY1997 through October 2006, 423 projects including HNP objectives / activities closed.37 Of those, 202 were HNP Sector Board­man- aged projects; 221 were other sector­managed. Of all FY2001­FY2006 closed projects managed by the HNP sector, 66 percent were rated "satis- factory" or better in ICRs (World Bank 2006c), making HNP the worst- performing portfolio among all 19 sectors for the last five years in a row (figure 3.3). This trend seems to be continuing. According to preliminary Quality Assurance Group (QAG) findings (World Bank forthcoming a), only 66 per- cent of the assessed HNP-managed projects were rated "moderately satis- factory" or better, compared with 90 percent of Bank-wide projects. Key 42 Healthy Development Figure 3.3: Project Outcomes, by Sector Board, FY2001­FY2006 100 89 83 81 80 79 80 77 76 75 75 75 73 66 60 points % 40 20 0 TR ED RDV SP FSP EMT EP WS UD PS ENV HNP (n=140) (n=157) (n=241) (n=100) (n=74) (n=106) (n=84) (n=74) (n=88) (n=127) (n=91) (n=131) Source: Based on IEG evaluations from Business Warehouse. Note: Definition of acronyms by order of magnitude: Transport, Education, Rural Development, Social Protection, Financial Sector, Energy and Mining, Economic Policy, Water and Sanitation, Urban Development, Public Sector, Environment, and Health, Nutrition, and Population. determinants of poor portfolio performance in HNP are: quality and readi- ness of the results framework at entry; adequacy and speed of follow-up actions for nonperforming projects; and attention by management. On the other hand, HNP Sector Board­managed projects seem to perform better in areas of training, capacity building, and effective use of Bank resources. Projects at risk have increased steadily in the last four years (figure 3.4), with a recent improvement at end-October 2006. In May 2006, 34 percent of the projects and 35 percent of all commitments were at risk in the HNP sector. Despite the improvements noted in October 2006, both the per- centage of projects and commitments at risk (20 percent and 23 percent, respectively) remain well above the Bank-wide averages of 14 percent and 12 percent, respectively. In October 2006, 18 percent of all Bank projects that displayed unsatis- factory implementation progress or were at risk of not achieving their out- comes belonged to the HNP sector. In addition, 60 percent of these proj- ects had important M&E deficiencies, which will make the measurement of results and project impact difficult. The realism index38 is 80 percent; the proactivity index39 is low at 60 per- cent. Low proactivity needs urgent attention, because it signals that not enough is being done to put nonperforming projects back on track. Bank Contribution and Challenges in Implementing the 1997 HNP Strategy 43 Figure 3.4: Trends in Portfolio Riskiness, HNP Sector Board versus Bank Overall, FY1997­FY2006 40 35 30 risk at HNP Sector 25 Board 20 Bank projects overall of 15 10 percent 5 0 2006 2006 FY1997 FY1998 FY1999 FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 May October year Source: Business Warehouse October 2006. Note: FY1997­FY2006 data are estimates of each fiscal year; end-October 2006. Within the HNP portfolio, the HIV/AIDS portfolio faces significant challenges. Major steps have been taken to improve HIV/AIDS portfolio performance. As a result, the risk rate has decreased to 18 percent. Actions taken to improve the performance include changes in implementation arrangements to improve performance, establishment of a core quality team for HIV/AIDS projects in Africa, and project support to improve monitor- ing and evaluation arrangements. Improvement in multisectoral work for HNP results, improved coordination of health system strengthening work within the Bank, and further inclusion of health system strengthening in future operations, including HIV/AIDS, will help improve the HIV/AIDS portfolio performance. Overall, the HNP sector needs to strengthen its quality control capacity (at entry and during implementation). To do so, the right balance will have to be achieved between the Regions' responsibility for portfolio manage- ment and quality control and the responsibility of the HNP Hub and Sec- tor Board for monitoring and assisting Regions in fulfilling their quality control task. The forthcoming evaluation of the HNP portfolio by the Independent Evaluation Group (IEG) will also contribute substantially to informing the process of strengthening portfolio quality.40 44 Healthy Development Need for Sharper Focus of Analytic and Advisory Activities The Bank has invested significantly in analytic and advisory activities since FY2002. For FY2002­FY2007,41 380 economic sector work (ESW) and technical assistance (TA) activities were planned, and 297 have been deliv- ered. Of those 380 ESWs, 274 are ESW products and 106 are TA products addressing health, nutrition, and/or population policy and technical issues. From FY2002 to FY2005, HNP analytic and advisory activities increased substantially (from 46 to 82 activities), but decreased again, starting in FY2006, to 57 activities. This result is surprising, because AAA services were expected to increase as IBRD lending declined. The current AAA portfolio shows no particular focus; it includes many aspects of health systems and HNP, but less than 35 percent of the portfo- lio is concentrated on Bank comparative advantages. Imbalance in HNP Staff Trends Since 1997, the number of HNP sector staff has decreased by 15 percent, from 243 to 206 (figure 3.5). This decrease has occurred despite increasing lending and nonlending output and a massive increase in Bank engagement in global partnerships. The proportion of technical specialist staff has risen from 46 percent to 49 percent from 1997 to 2006 (mainly health specialists). Figure 3.5: Trends in HNP Mapped Staff, FY1997­FY2006 300 267 243 246 253 250 206 200 190 192 176 181 189 150 HNP mapped number staff 100 50 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 year Source: Human Resources October 2006. Bank Contribution and Challenges in Implementing the 1997 HNP Strategy 45 Figure 3.6: Health Staff Composition, by Specialty, FY1997 6% 25% operations 22% technical aspects of health Young Professionals economics 1% managerial/directors 46% Source: Human Resources October 2006. The proportion of staff with economics skills has decreased from 22 percent in 1997 to 17 percent in 2006 (figures 3.6 and 3.7).42 The average age of staff at recruitment has fallen from 48.6 in FY2000 to 39.9 in FY2006 (figure 3.8). The HNP Hub has undergone a substantial change in staffing since FY2000. Regular or open-ended staff members have decreased in number by 40 percent and have been replaced by Junior Professional Associates (JPAs), Extended Term Consultants (ETCs), and seconded staff, financed mostly by donor Trust Funds in areas of specific donor interest (figure 3.9). Figure 3.7: Health Staff Composition, by Specialty, FY2006 9% 23% operations 17% technical aspects of health Young Professionals 2% economics 49% managerial/directors Source: Human Resources October 2006. 46 Healthy Development Figure 3.8: New HNP Hires, Average Age 60 48.6 50 45.6 46.4 44.7 46.8 43.2 39.2 39.9 40 38.2 36.1 years in 30 age 20 10 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 year Source: Human Resources October 2006. Note: Represents average age at hire of staff mapped to HNP. Figure 3.9: Staff Trends for HNP Hub, by Category, FY1999­FY2006 30 25 GF+ staff 20 ETCs,coterms, JPAs number 15 10 5 0 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 year Source: HNP Strategy Facilitation Team, based on data from Human Resources, October 2006. Note: "ETCs": Extended Term Consultants; "Coterms": Coterminous staff with open-ended or term appointments that are entirely funded from sources other than the Bank Group's administrative budget; "JPAs": Junior Professional Associates; "GF+ staff" rep- resents staff with at least one master degree and 5 years or more of experience. CHAPTER 4 How Can the Bank Better Serve Client Countries in the New Environment? Bank Comparative Advantages for HNP Results The new DAH architecture, persisting global challenges, and trends in Bank portfolio performance consolidate a scenario in which Bank financing, though still important, is increasingly small, as compared with overall inter- national financing for health, and no longer drives relationships with client countries. Pressures on policy makers for sound allocation of these expanded resources have intensified. In this new scenario, the quality of pol- icy dialog and technical advice defines the magnitude of the Bank contribu- tion to country HNP efforts, not only for middle-income countries, but also for low-aid, low-income countries.43 Although this is also true for high-aid, low-income countries,44 Bank financing is still an important source of rev- enue for them. In what HNP policy and technical advice areas can the Bank contribute most in this new scenario? What is the role of Bank HNP- related financing? According to feedback from client countries and global partners, Bank comparative advantages lie in addressing "structural and health system constraints" (particularly health financing, regulation, insur- ance, and demand-side interventions) to improve outcomes and inputs, "linkages" of the health sector with macroeconomic, fiscal policy, and labor markets, and "public sector reform, governance, and fiduciary effective- ness." The Bank is also seen to be in a unique position for identifying and helping address multiple sectoral constraints to ensure effectiveness on the ground of the additional international funds. Feedback also indicates that the Bank has much less (or no) comparative advantages on technical issues of disease control or micro issues of provider organization such as develop- 47 48 Healthy Development ment of training curricula for health personnel, development of new drug technology, or advice on technology and clinical approaches to single-dis- ease treatment, except in contributing to country and global partners' efforts to create the appropriate incentive environment for providers. Bank Comparative Advantages Bank comparative advantages in the new scenario include: its health system strengthening and intersectoral approach to country assistance, which allows it to engage in day-to-day dialog at national and subnational levels with all gov- ernment agencies, but particularly with Ministries of Finance on fiscal and macroeconomic policy; its capacity for large-scale implementation of projects and programs (with its financial management and procurement systems); its multiple financing instruments and products; its global nature, which facilitates interregional sharing of experience; its core economic and fiscal analysis capac- ity across all sectors; and its substantial country focus and presence. The World Bank Group also has significant potential comparative advantages in engaging private health actors through both the Bank (IBRD) and IFC. Because of its strengths in multisectoral and macro approaches to HNP policy, the Bank is also uniquely positioned to help client countries integrate in their national strategic view the full array of national and international initiatives for improv- ing HNP results on the ground. Bank experience with Poverty Reduction Strategy Papers (PRSPs) is a good example of this integration role. Bank comparative advantages are distinctive assets for achieving HNP results, but the Bank is not tapping its full potential in some key areas: pub- lic policy toward private-public synergies in achieving HNP results at coun- try level, intersectoral approaches to HNP results, and health system strengthening to improve HNP results, particularly for the poor and the vulnerable. In this section, the importance of making full use of these strengths is analyzed. The Bank approach to realizing its full potential in these areas is discussed under "New Bank Strategic Directions." Knowledge and Policy Advice on Public Policy to Improve Public­Private Synergies for HNP Results Private service delivery and private funding via household out-of-pocket How Can the Bank Better Serve Client Countries in the New Environment? 49 spending dominate health systems in LICs and in many MICs. Indeed, pri- vate ambulatory basic health service provision dominates health systems in LICs (figures 2.1 and 2.2), particularly in Asia. Thus, improving HNP results requires the Bank to provide sound policy advice to client countries on how to ensure effective regulation to enhance equity and efficiency as well as synergy and collaboration between the private and public sectors to improve access to services for the poor. Bank advisory capacity on health system strengthening needs to be able to provide sound, feasible, and sustainable advice on when and how to invest in in-house public service delivery infrastructure or contract out with the private sector (for-profit and not-for-profit) in LICs and MICs. The Bank Group has a potential comparative advantage for contributing to client­country development of sound public policy toward the private sector, but the current tendency of the Bank HNP sector to focus on the public sector and of IFC to focus on business development for the private sector has created a vacuum in the Bank Group in terms of supporting client­country development of public policy toward the private health sec- tor. The HNP sector, in collaboration with Private Sector Development (PSD) and IFC, will fill this vacuum in the implementation of the new HNP Strategy. The collaboration will strengthen HNP policy analysis and advi- sory capacity as well as its engagement with key private actors and policy makers in the areas of public-private collaboration for HNP results. This enhanced capacity aims at generating policy knowledge and lessons learned to advise client countries on options. Ultimately, decisions on specific options are for client countries to make. Providing Advice and Financing to Strengthen Health Systems for HNP Results People's understanding of what constitutes a "health system" varies widely, but most specialists agree that it encompasses all country activities, organi- zations, governance arrangements, and resources (public and private) dedi- cated primarily to improving, maintaining, or restoring the health of indi- viduals and populations and preventing households from falling into poverty (or becoming further impoverished) as a result of illness (WHO 2000; Kutzin 2000, Baeza and Packard 2006). Annex F presents a basic dis- cussion of what a country health system is and why its smooth functioning 50 Healthy Development is essential to ensure equitable access to effective HNP interventions and a continuum of care to save and improve people's lives--to ensure results.45 Thus, health systems are not monolithic entities. Interaction among their multiple components results (or not) in sustainable and equitable delivery of public health and medical services to the population. Figure 4.1 depicts the key functions of a well-organized and sustainable health system. These key functions are: health services delivery, resource (input) generation (e.g., human resource training and generation of technological knowledge for disease control, pharmaceuticals, and medical equipment), and system over- sight (stewardship). Country and sector governance are also key determi- nants of system performance. Governments and partners look to the Bank for systemic policy advice on such questions as how to ensure sustainable financing and fiscal space for pri- ority health interventions; how to pay health service providers and set up the right incentives to maximize results on the ground and ensure a presence in Figure 4.1: Health System Functions and Other Determinants of Good System Performance stewardshipd resource financinga generationf HNP public and health, nutrition, and patients and results private provisione population interventions population DEMANDc system governanceb Source: Based on the World Health Report, 2000. a. Includes funding (public, out-of-pocket, and DAH), contributions, pooling, and payment mechanisms. b. Includes financial management, procurement, and "other" systems. c. Influenced by preferences, beliefs, and behaviors. d. Oversight. e. Service delivery. f. Includes human resources, pharmaceuticals, and medical equipment. How Can the Bank Better Serve Client Countries in the New Environment? 51 isolated geographical areas; how to strengthen the sector's fiduciary and financial management systems; how to set the right incentives for multiple branches of government to ensure an intersectoral approach to improving HNP outcomes, outputs, and system performance; how to design and imple- ment health insurance; how to create the appropriate regulatory environ- ment for effective and efficient private-public collaboration and develop- ment; how to link increased resources to results without jeopardizing medium-term flexibility in governments' management of funds, both essen- tial for allocative efficiency in public policy; and how to reach the right bal- ance between expanding "own" public health service infrastructure and con- tracting out with private providers for the needed expansion of health service supply. Both MICs and LICs consider these policy issues critical. The Bank has a considerable potential comparative advantage in health system development and strengthening, but not in every aspect. Many Bank strengths in health systems stem from its multisectoral nature, its core man- date on sustainable financing, and its fiscal, general economic, and insurance analytical capacity, on regulation, and on demand-side interventions. They also come from its years of experience advising governments and financing broad health sector reforms and infrastructure projects all over the world. Finally, they come from its experienced and motivated staff working in the Regions and the Hubs (Bank technical central units). Consultations with client countries confirm this view of Bank comparative advantages. However, a large part of health system advice has to do with the micro issues of health service delivery and provider organization, for which the Bank has little comparative advantage. Such issues include the organization of internal hospital or clinic incentives to raise worker productivity and responsiveness; the specifics of medical education appropriate to each coun- try; the development of core public health functions (such as epidemiologi- cal surveillance); and the development of specific-disease control knowledge (e.g., which vaccines or drugs to use against diseases in LICs and MICs). Resolution of these important micro issues, particularly internal organi- zation of providers, though essential for achieving HNP results, lags far behind developments in health financing policy. The international commu- nity needs to intensify its efforts to make progress in this aspect of health systems where the Bank has little comparative advantage. The Bank looks forward to a collaborative division of labor with global partners along each organization's comparative advantages, particularly with the World Health Organization (WHO) and the United Nations Children's 52 Healthy Development Fund (UNICEF) on leadership, disease control knowledge, and technology, epidemiological surveillance, and program and provider organization; with the United Nations Population Fund (UNFPA) on population, and with the Food and Agriculture Organization (FAO) and the World Food Program (WFP) on nutrition. The Bank also looks forward to close collaboration in the implementation of country-led system strengthening efforts and knowl- edge generation with global financing partners including bilateral agencies, regional banks, Global Fund, GAVI, GAIN, the Bill and Melinda Gates Foundation, and others. The following are some of the main health system functions, system activities, and other determinants of system performance. They are listed in descending order of strength of Bank comparative advantage: · Health financing. Funding policy (level, source, fiscal space); risk-pooling organization (health insurance); insurance regulation; health service pur- chasing and provider payment mechanisms; design of financing incentive framework for efficient allocation of R&D and human resources. · Fiduciary, logistical, and financial management arrangements of the system. · System governance. Accountability arrangements for providers, insurers, and government in health care investments; regulatory framework for private- public collaboration in the health sector; decisions on delegation of deci- sion rights and market exposure for public providers; fiduciary arrange- ments for fiscal resource management in the public and private sectors; linkage of specific HNP sector reforms to cross-sectoral public sector reforms (e.g., civil service reforms to attract practitioners into rural areas). · Positively influencing household demand for effective HNP interventions. Demand-side interventions (such as conditional cash transfers, girls' edu- cation, community-driven development, and voice and choice reforms in health service delivery). · Stewardship (sector oversight). Overall sector leadership; sectoral strategic planning; provider regulation; inputs and health service quality control; epidemiological surveillance; identification of health priorities for setting mandatory basic benefits packages. · Organization and management of providers. How to run a clinic, hospital, or provider network; organizing village volunteers; organizing NGO or private for-profit health service delivery. How Can the Bank Better Serve Client Countries in the New Environment? 53 · Technical aspects of disease control. · Human resource training and creation of medical technologies and advances. Human resources; R&D and manufacturing of drugs and supplies (beyond contributing to global financing and incentives for development and production of orphan drugs); R&D and generation of medical tech- nology. · Clinical and field research on disease-control intervention effectiveness and clin- ical protocols. Defining effective production functions; testing them in the field. Drawing on its main comparative advantages in health systems, the Bank will increasingly focus its knowledge creation on health system strengthen- ing mainly in the first five areas, above, and will actively seek advice from, and collaborative division of labor with, global partners in the other areas, particularly WHO, to include their knowledge in Bank priority­disease lending and to coordinate with WHO leadership in global epidemiological surveillance and country preparedness. Intersectoral Approach for Better HNP Results Good HNP outcomes and system performance are determined by multiple sectors of the economy. They are strongly influenced by income, education, access to clean water and sanitation, access to clean indoor environments, expedited transportation to facilities and providers, good country gover- nance, and sound macroeconomic policy. Together with basic public health interventions those factors are most likely to play a larger role than health service delivery in low-income/high-mortality country settings (figure 4.2). Therefore, improving HNP outcomes means ensuring an effective inter- sectoral response to HNP performance and outcomes, both within the Bank and within client countries. Intersectorality is potentially one of the Bank's most important strengths for contributing to HNP results at country level, both in other sectoral poli- cies that influence HNP results (e.g., environmental policy effect on indoor pollution, water and sanitation) and in its role in health system strengthen- ing.46 Intersectorality is also the most difficult objective to realize fully, due to both Bank and client­country constraints. Strengthening health systems 54 Healthy Development Figure 4.2: Multisectoral Determinants of Global Burden of Disease high blood pressure smoking high cholesterol childhood underweight unsafe sex low fruit and vegetable intake overweight and obesity physical inactivity alcohol use indoor smoke from solid fuels unsafe water, sanitation, and hygiene zinc deficiency urban air pollution vitamin A deficiency iron-deficiency anemia unsafe healthcare injections illicit drug use 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 attributable mortality in thousands (total 56,242) developing countries developed countries Source: Jamison et al. 2006. for HNP results, the key contribution of the Bank in the next decade, is a multisectoral endeavor. For example, improving the incentive framework for workers will require a combination of public sector reforms, health financing mechanisms, creation of fiscal space, improved fiduciary systems, and improved sectoral and country governance. For technical, governance, and economic expertise in these areas, the Bank counts on a large group of experienced professional staff (table 4.1). How Can the Bank Better Serve Client Countries in the New Environment? 55 Table 4.1: IBRD Net Staff By Sector Mapping, June 30, 2006 SECTOR MAPPING NET STAFF Environment 255 Rural Development 309 Social Development 165 Financial Sector 147 Education 181 Health, Nutrition, and Population 206 Social Protection 138 Energy and Mining 133 Infrastructure 94 Transport 130 Urban Development 112 Water Supply and Sanitation 124 Financial Management 143 Operation Services 113 Poverty Reduction 171 Economic Policy 349 Poverty 76 Public Sector 101 Public Sector Development 144 Source: Human Resources October 2006. Note: These data include professional staff grade GF and above. Data do not include support staff (Administrative and Client Ser- vices [ACS], Information Solutions Network [ISN], Resource Management [RM]). CHAPTER 5 New Bank Strategic Objectives: What HNP Results? To achieve the Bank vision for its HNP role over the next 10 years in the new external environment, making the most of its comparative advantages, the Bank has revised its global HNP policy objectives. The Bank will focus on contributing to client­country efforts to achieve results in four areas, the Strategic Objectives: · Improve the level and distribution of key HNP outcomes, outputs, and system performance, at country and global levels to improve living con- ditions, particularly for the poor and the vulnerable. · Prevent poverty due to illness (by improving financial protection). · Improve financial sustainability in the HNP sector and its contribution to sound macroeconomic and fiscal policy and to country competitiveness. · Improve governance, accountability, and transparency in the health sector. The revised Bank HNP policy objectives are both a continuation of and a departure from the 1997 HNP Strategy objectives (World Bank 1997). Three of the four Strategic Directions of the 1997 Strategy are still valid: to improve HNP outcomes for the poor; to protect households from the impoverishing effects of illness; and to work with countries to ensure sus- tainable financing. As a result of lessons learned in the last 10 years, how- ever, the new policy objectives differ in two respects. First, they include improving sector governance as a key strategic objective. Second, they do not include health system strengthening as an objective, but rather as a means for Bank country assistance to achieve all of them. Strengthening health systems is a tool for achieving the HNP strategic pol- icy objectives. The 1997 Strategy reflected knowledge of the HNP sector that 57 58 Healthy Development was current at that time. Since then, the Bank and the international commu- nity have learned that strengthening health systems is meaningless without demonstrable improvements in outcome results, outputs, and system per- formance.47 The Bank will ramp up its engagement in health system strength- ening, but with an unswerving commitment to results on the ground. Strategic Objective 1: Improve the Level and Distribution of Key HNP Outcomes, Outputs, and System Performance at Country and Global Levels to Improve Living Conditions, Particularly for the Poor and the Vulnerable Despite important gains in reducing avoidable mortality and the prevalence and incidence of disease in the last 10 years, the world still faces enormous challenges. Achieving the MDGs by 2015 is at risk due to a combination of insufficient financing and inefficient health systems. Health indicators are worsening in fragile states. The poor--households and countries--suffer most from avoidable mortality, morbidity, and malnutrition. Sub-Saharan Africa is the epicenter of challenges ahead, falling well short of achieving most of the MDGs. In MICs, the challenge is low efficiency, poor perform- ance, and financial difficulties. Health, nutrition, and population improvements in all Regions were a striking achievement for human welfare in the 20th century (figure 5.1), but as discussed above, formidable challenges still persist. Evidence-based, cost-effective interventions could drastically improve health outcomes. For example, controlling tobacco use (e.g., through taxa- tion) has proven effective in most client countries and is the single most important intervention for reducing premature mortality due to noncom- municable diseases (UN Millennium Development Project 2005). It is also one of the few interventions that directly increase fiscal revenue in the short term. Similarly, at a cost of only US$0.02 per dose, administering a vitamin "A" supplement every day to poor children would substantially reduce U-5 mortality in low-income/high-mortality countries. The Bank is committed to supporting efforts to reduce avoidable mor- tality and morbidity and improve the distribution of good health within individual countries and internationally. It will do so along the lines of its comparative advantages and Strategic Directions. The international com- munity knows the most cost-effective interventions for saving millions of New Bank Strategic Objectives: What HNP Results? 59 Figure 5.1: Trends in Infant Mortality, by World Bank Region, 1980, 1990, 2004 140 East Asia and Pacific 120 Eastern births) Europe and 100 Central Asia 1,000 Latin America and the (per 80 Caribbean rate 60 Middle East and North Africa 40 South Asia mortality 20 Africa infant 0 1980 1990 2004 year Source: World Bank 2001b, 2005h. lives, for example, access to safe water and sanitation. But everyone is still struggling to find the best ways of reaching the poor with these proven interventions in low-income countries, especially in Sub-Saharan Africa. A well-functioning health system is essential if these interventions are to reach the poor. Success will owe much to increased financial commitments by the international community, but money alone cannot guarantee a well-func- tioning health system. Bank experience in this realm, one of its comparative advantages, can contribute to solving this problem. Specific areas for reduction of mortality and morbidity are summarized in the Bank HNP Results Framework (annex D). The Framework serves as guidance for the Regions and country teams setting priority targets in the context of results-based CASs, when appropriate, and for all HNP pro- grams and projects in their respective countries. The Bank is committed to supporting client countries' efforts to achieve the MDGs. Strategic Objective 2: Prevent Poverty Due to Illness (by Improving Financial Protection) Health shocks--illness, accidents, even normal life-cycle events such as pregnancy and old age--can throw a household into poverty or become an obstacle to overcoming it. Illness is a determinant of poverty due to both 60 Healthy Development excess health expenditures and loss of income resulting from nonparticipa- tion in the labor market (or reduced productivity). Protection against the impoverishing effects of health shocks is an important challenge in both LICs and MICs. Figure 5.2 presents findings in Peru, where households report health shocks as a main cause of economic distress, second only to unemployment of the breadwinner. Figure 5.3, recent findings in four Latin American countries (Argentina, Chile, Ecuador, and Honduras) (Baeza and Packard 2006), shows that health shocks plunge between 1 percent and 10 percent of the population into poverty every year. Similar findings have been reported for China, Vietnam, and Thailand (Eggleston et al. 2006). Household out-of-pocket private funding dominates health financing in LICs and in many MICs. Indeed, except in a few client countries, out-of- pocket expenditures account for most health expenditures in LICs, even in countries receiving large amounts of DAH (tables 5.1, 5.2, and 5.3). Thus, improving financial protection requires the Bank to provide sound policy advice to client countries not only about the best use of DAH but also about how to pool household out-of-pocket expenditures for the nonpoor so that household demand and insurers (public and/or private) offer better pooling Figure 5.2: Most Frequent Shocks Causing Household Financial Stress, Peru 45 42.6 40 shocks 35 30 reported 25 total of 20 18.6 16.9 15 12.3 10 percentage 6.1 5 1.2 1.2 1 0 recession, policy/ natural other disability death sickness other usually political disaster disaster of family of family costly sudden job loss change and crime member member to treat increase in household costs Source: Baeza and Packard 2006. Note: Responses to survey question, "In the past three years, has your household experienced an event that has caused a signifi- cant loss of income?" New Bank Strategic Objectives: What HNP Results? 61 Figure 5.3: People Fall into Poverty due to Health Expenses 12 10 8 6 4 2 0 Argentina Chile Ecuador Honduras percent of total nonpoor population that falls below the poverty line and/or indigence line due to out-of-pocket health expenditures Source: Baeza and Packard 2006. Note: Percentage of nonpoor population forced into poverty or indigence by out-of-pocket health expenses. of financial risk. In the same context, user fees have a role to play as copay- ment when there is evidence of excess demand. Protecting the poor from further impoverishment from out-of-pocket financing will require increased fiscal capacity, fiscal space, and, in LICs, financial support from the international community. Upon client­country demand, the Bank stands ready to support countries that want to remove user fees from public facilities if: the lost revenue from user fees can be replaced with resources that reach the facilities in a timely Table 5.1: Time Series Trends in Health Expenditures, Low-Income Countries, FY1999­FY2003 FY1999­FY2003 FY1999­FY2003 FISCAL PRIVATE EXTERNAL OUT-OF-POCKET ALL LICS EXPENDITURE EXPENDITURE EXPENDITURE EXPENDITURE 1999 44.35 55.65 17.66 48.95 2000 45.07 54.93 19.70 47.77 2001 45.36 54.64 18.31 47.49 2002 46.37 53.63 16.48 46.84 2003 46.05 53.95 17.53 47.07 Sources: WHO 2006b; World Bank 2005h. Note: Total health expenditure is the sum of fiscal and private health expenditures. External resources for health are allocated to both public and private sources, but the proportion allocated to each is unknown. Out-of-pocket expenditures are one type of pri- vate expenditure, but in many low-income countries out-of-pocket spending accounts for most of private spending. 62 Healthy Development Table 5.2: Time Series Trends in External Expenditures for Health as Percent of Total Health Expenditures, FY1997­FY2003 EXTERNALa 1997 1998 1999 2000 2001 2002 2003 Income Low-income countries 6.4 7.6 7.0 8.1 7.1 7.9 7.1 Lower-middle income countries 0.8 1.2 1.4 1.2 0.8 0.7 0.6 Upper-middle income countries 0.4 0.6 0.7 0.5 0.5 0.4 0.3 High-income countries 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Regions East Asia and Pacific 1.2 1.7 1.8 1.6 1.1 0.7 0.9 Eastern Europe and Central Asia 0.8 1.0 1.5 1.6 1.4 1.6 1.3 Latin America and the Caribbean 1.5 1.6 1.7 1.6 1.5 1.4 1.1 Middle East and North Africa 1.2 1.2 1.1 1.2 1.2 1.1 1.1 South Asia 3.3 3.9 2.5 3.2 2.3 2.5 2.9 Sub-Saharan Africa 12.6 16.0 16.3 18.3 17.1 17.8 14.8 Sources: WHO 2006b; World Bank 2005h. Note: The data in this table are population-weighted. a. External resources for health are funds or services in kind that are provided by entities not part of the country in question. The resources may come from international organizations, other countries through bilateral arrangements, or foreign nongovernmental organizations. These resources are part of total health expenditures and are spent on both public and privately provided services. Table 5.3: Time Series Trends in External Expenditures for Health as Percent of Fiscal Health Expenditures, FY1997­FY2003 EXTERNALa 1997 1998 1999 2000 2001 2002 2003 Income Low-income countries 20.4 24.8 22.2 25.6 20.8 21.6 20.2 Lower-middle income countries 2.3 3.7 3.9 3.6 2.1 1.8 1.5 Upper-middle income countries 0.7 1.3 1.4 1.1 1.0 0.9 0.6 High-income countries 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Regions East Asia and Pacific 4.2 5.8 6.0 5.5 3.2 1.9 2.7 Eastern Europe and Central Asia 1.3 2.4 3.2 3.7 3.7 3.8 3.7 Latin America and the Caribbean 3.1 3.5 3.9 3.7 3.4 3.1 2.5 Middle East and North Africa 3.3 3.5 3.1 3.2 3.1 3.0 2.8 South Asia 15.9 13.7 9.6 13.6 8.7 10.1 10.5 Sub-Saharan Africa 27.9 48.5 45.8 49.9 44.3 44.8 37.9 Sources: WHO 2006b; World Bank 2005h. Note: The data in this table are population-weighted. a. External resources for health are funds or in-kind services that are provided by entities not part of the country in question. The resources may come from international organizations, other countries through bilateral arrangements, or foreign nongovernmental organizations. These resources are part of total health expenditures and are spent on both public and privately provided services. New Bank Strategic Objectives: What HNP Results? 63 and fiscally sustainable manner over the long-term; effective public financial management systems ensure that such financial transfer replacements will effectively reach the health facilities that need them the most and in the context of the appropriate incentive framework for the provision of services to the poor; and resource replacements will be used to pay for the delivery of effective quality services for the poor, provided at the health facilities. A well-organized and sustainable health system is essential to achieve financial protection by preventing the impoverishing effects of health shocks (e.g., through health insurance) and mitigating their effects. An effi- cient public financing and pro-poor subsidy policy in the health sector, access to effective financial risk-pooling mechanisms (e.g., health insur- ance), and household access to borrowing through better financial market environments are among the interventions that can help improve financial protection. Client countries face options in organizing risk pooling, includ- ing general tax-based systems, social insurance systems (financed out of pay- roll-tax contributions), and/or private health insurance arrangements, including not-for-profit community health insurance. Fragmentation48 of health systems hampers systemic capacity to provide effective access to services and financial protection (WHO 2000; Gottret and Schieber 2006; Baeza and Packard 2006). Unfortunately, health system frag- mentation is extensive in most client countries. The Bank will strengthen its capacity to support country efforts to improve health systems integration and reduce fragmentation. Countries have options to improve integration, includ- ing setting a common regulatory framework for public-private collaboration; giving incentives for aggregating existing pools to efficient pool sizes and improve the interactions among them; transitioning toward single risk pools (or very few of them), and/or transitioning to universal, general tax­financed risk-pooling arrangements. The Bank will provide technical and policy advice for countries to identify options; support fiscal, technical, and financial feasi- bility assessments; and advise on pros and cons of these different options for the specific country context and preferences. Ultimately, the choice of a path to transition toward health system integration is the country's decision. Widespread (and growing) labor informality (and its substantial overlap with poverty) as well as rural population dispersal (overlapping with both informality and poverty) pose a significant challenge to improving risk pool- ing. Extending risk pooling to the informal and the rural population will be a key priority of both the research agenda and the operational strategic focus of HNP in health systems in the implementation of this Strategy. 64 Healthy Development So far, judging by the evidence, there is no "silver-bullet" for organizing risk pooling, reducing excess out-of-pocket expenditures on health care, and extending risk pooling to the informal and rural poor. Therefore, the Bank is committed to advising client countries to increase risk pooling, but it does not promote any one-size-fits-all blueprint for organizing risk pooling across countries. Decisions on risk-pooling arrangements are country spe- cific, often based on historical events and cultural preferences. However, risk-pooling decisions need to be guided by solid evidence, which is unfor- tunately lacking so far, particularly for LICs. The Bank has a significant opportunity to learn from close monitoring and evaluation of Bank-sup- ported initiatives and programs. It also needs to assist countries in monitor- ing results of their initiatives to verify whether chosen arrangements actu- ally improve financial protection for everyone, but particularly for the poor and near-poor. The Bank will expand its knowledge creation and policy advice on improving financial protection. It will do so intersectorally, addressing the growing challenge of extending health insurance to the informal sector. The Results Framework presented in annex D summarizes the main out- comes on financial protection. Measuring, monitoring, and evaluating financial protection outcomes is a relatively recent field. A major challenge for Bank HNP work in this field is to facilitate collaboration for research with partners and experts in this field to develop, test, and scale up moni- toring of financial protection indicators. Developing such indicators and facilitating consensus on them among the international community will be a major early activity of Strategy implementation in this field. Strategic Objective 3: Improve Financial Sustainability in the HNP Sector and Its Contribution to Sound Macroeconomic and Fiscal Policy and Country Competitiveness For governments to ensure their people's access to essential services and financial protection, countries need to raise stable, sufficient, long-term public and private financial resources, predictably, equitably, efficiently, and in a way that minimizes economic distortions. Health sector financing pol- icy should also contribute to sound fiscal management, create necessary fis- cal space, and foster productivity, employment, and growth. On the spend- ing side, individuals need access to affordable basic services and financial New Bank Strategic Objectives: What HNP Results? 65 protection; spending should maximize health outcomes and ensure equi- table access and technically efficient production; cross-sectoral linkages should be explicitly addressed through planning and budget processes; and spending should be cushioned as much as possible against economic shocks in ways consistent with sound economic management. Financial sustainability has different implications for LICs and MICs. For LICs, it means: developing sound policy to leverage private household financing to expand participation in risk pooling (public and/or private);49 solving the DAH volatility problem, a major challenge in LICs (figures 5.4 and 5.5); and ensuring sufficient economic growth to sustain and increase pro-poor fiscal policy. MICs face two main challenges: fiscal sustainability linked to systemic efficiency and potential challenges from past decisions linking social health insurance financing to labor status. The insurance-labor link can distort labor markets and labor costs through the use of payroll taxes as the main revenue-raising mechanism for social health insurance. The World Bank is in a unique position to promote these objectives through its macroeconomic management, cross-sectoral purviews, and roles as a development institution, financial institution, and multisectoral knowl- edge-dissemination agency. The Bank's underlying charter as a develop- ment agency and bank uniquely qualify it to advise client countries on this complex menu of sectoral, fiscal space, macroeconomic policy, growth, and sustainable financing issues. Figure 5.4: External Expenditures on Health, Selected Countries, 1999­2003 40 35 30 expenditures 25 Mauritania health 20 Tanzania Mali total 15 of 10 percent 5 0 1999 2000 2001 2002 2003 year Source: WHO 2006b. 66 Healthy Development Figure 5.5: External Expenditures on Health, Selected Countries, 1999­2003 60 50 40 expenditures Benin Burundi health 30 Guinea Liberia total of 20 10 percent 0 1999 2000 2001 2002 2003 year Source: WHO 2006b. The Bank (HNP in working with PREM, Development Economics [DEC], and others) in collaboration with the IMF and other global partners will seek to develop, test, and support country monitoring of indicators for health sector/program fiscal sustainability, fiscal space, effects of health financing on labor markets, and other sustainability and potentially health sector­related country competitiveness determinants. Strategic Objective 4: Improve Governance, Accountability, and Transparency in the Health Sector Evidence shows that development assistance works--but mostly in coun- tries with good governance and little corruption. Kaufman and Kraay (2003) define good governance as "the traditions and institutions by which authority in a country is exercised." For the health sector, this definition means the set of relationships that hold health service providers, insurers, and govern- ments accountable to their clients and citizens for HNP results--health outcomes, income protection, and social inclusion (World Bank 2003b, fig- ure 5.6). Bardham (1997) defines corruption as the "use of public office for private gains." Poor governance in health care delivery does not necessarily mean cor- ruption (box 5.1). "Poor governance" can describe anything from haphaz- New Bank Strategic Objectives: What HNP Results? 67 Figure 5.6: Creating Accountability in Health government legislative politicians policy maker contracts- framework purchasing citizen's monitoring selection of providers participatory compact budgeting monitoring voice coalitions self-regulation client's power citizens/clients providers nonpoor poor frontline organization money power comanagement monitoring litigation Source: Adapted from World Bank 2003b. ard management to outright dishonesty. These indicators, to cite just a few, encompass: mismanagement; staff absenteeism and low productivity; leak- age of funds, drugs, and supplies; lax procurement and oversight practices; informal payments from patients; mistreatment of the poor by service providers; and patently corrupt practices ranging from petty theft to kick- backs to selling public office. Some of these events result from failure of clients' power--patients too poor or socially deprived to claim their entitle- ment to services from providers, frontline professionals, and staff. Voice fail- ures also occur, when the state simply does not care about providing serv- ices--or provides the bare minimum. There are also compact failures, in which the state fails to set incentives for public and private providers, to delineate their responsibilities, or to enforce accountability. An increasing concern in partner countries is the high transaction and administration costs of DAH governance on the ground in a very fragmented environment. Good governance and accountability, the enforcers of honesty, are key determinants of health system performance. Building accountability for health is not easy, due to the great asymmetry of information between users and providers and the difficulty of attributing most final outcomes to a par- ticular service provider. It is hard, for example, for patients to know whether the medical treatment they received was effective and appropriate for their 68 Healthy Development Box 5.1: What Are Governance and Corruption in the Health Sector? Health care provision depends on efficiency and honesty in combining financial resources, human resources, and supplies and on delivery of services, in a timely fashion, distributed equitably and spatially throughout a country. This requires a "system" that mobilizes and dis- tributes resources, processes and acts upon information, and motivates appropriate behavior by individual providers, health care workers, and administrators. Good governance is a critical factor in making such a system work. Governance and accountability can be improved through actions including: · Management and performance. Incentives for sound behavior by health professionals, including performance-based pay; drug distribution to ensure that demand and supply align; databases for tracking staff, supplies, and drugs; and local oversight of medical staff. · Anticorruption measures. National anticorruption initiatives; clear rules for and audits by enforcement agencies; community oversight; and drug procurement reform. · Affordability improvements. Charging formal fees with exemptions; reorganizing staffing and performance with reward systems; and seeking alternative financing options. · Accountability tightening. Embedding accountability at every level of the system, com- bined with clear and transparent expectations; contracting out services and overseeing performance; calibrating performance through consumer satisfaction surveys and citizen report cards. Accountability is the single most important element to ensure good governance--account- ability to ministries, local governments, managers, and citizens. It leads to better performance on other measures but is a difficult goal to meet in any setting. Increasing choice and alterna- tives for publicly subsidized health services increases empowerment of the poor vis-à-vis health service providers. Source: Lewis 2006. condition. To monitor health care outcomes, OECD countries have devel- oped a rich combination of direct control over users, governmental regula- tory instruments, and professional self-regulation. Yet, most LICs and many MICs are still developing their own instruments and institutional arrange- ments. Self-regulation is particularly underdeveloped in MICs and LICs, and many bureaucratic failures are still insufficiently addressed. The Bank will work intersectorally to strengthen governance and accountability rela- tionships within countries, support accountability-fostering instruments and institutions, and promote strong fiduciary systems. CHAPTER 6 New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? The new Strategic Directions will guide Bank efforts to help client coun- tries achieve the strategic HNP results over the next 10 years. To implement these new directions, this Strategy presents an Action Plan (last section) outlining key organizational changes and incentives, new analytical tools, and a rebalancing of the skill-mix of Bank management and staff. The new Strategic Directions for Bank HNP results are: · Renew Bank focus on HNP results. · Increase the Bank contribution to client­country efforts to strengthen health systems for HNP results. · Ensure synergy between health system strengthening and priority- disease interventions, particularly in LICs. · Strengthen Bank capacity to advise client countries on an intersectoral approach to HNP results. · Increase selectivity, improve strategic engagement, and reach agreement with global partners on collaborative division of labor for the benefit of client countries. Strategic Direction 1: Renew Bank Focus on HNP Results Renewing Bank focus on HNP results is the primary Strategic Direction for the Bank. All the others are based on it. As the cornerstone, the Bank will tighten the direct link between HNP-related lending and nonlending sup- 69 70 Healthy Development port and outcomes, outputs, and system performance. The Bank is amass- ing promising experience with output-based investment lending for HNP. A results focus poses some short-term challenges for the Bank, despite internal consensus on the need and willingness to move toward accounta- bility for outcomes. First, monitoring and evaluation systems have to be improved. Until recently, neither the Bank nor many client countries or global partners have systematically measured outcomes with sufficient pre- cision, frequency, and disaggregation to be useful for M&E. Second, achiev- ing results (final and intermediary outcomes) on the ground depends on many actors (different levels of government, service providers, citizens, donors) and on a variety of exogenous factors. Assessing the contributions of each actor and attributing results to their individual actions is often elu- sive, if not impossible. Furthermore, the Bank can affect outcomes only indirectly--using its lending and nonlending services to influence domestic actors, particularly governments. The Bank will substantially increase both its analytical work on health systems and its monitoring and evaluation capacity to ensure that the renewed commitment to HNP is actually rendering results on the ground. It is essential that this increased capacity and commitment to M&E also be effectively linked to and inform policy design and policy management in the health sector. Support the Shift toward Linking Finance to HNP Results The Bank will: partner with client countries to identify opportunities to experiment and learn from innovation in results-based lending; support the launch, in coordination with existing global initiatives, of a major effort to help client countries improve their national public health surveillance and performance-monitoring systems; set a common global HNP Results Framework for the Bank (annex D) to guide regional HNP strategies, regional HNP implementation plans, and overall Bank monitoring and evaluation of HNP results; and commit to monitoring a core group of indi- cators presented in the framework. Link Lending to HNP Results Financing inputs does not guarantee improvements in HNP conditions for the poor. Achieving the MDGs in lower-income countries requires sustain- New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? 71 ing and further scaling up of DAH. To achieve both--bringing lending close to results and scaling up in LICs--the Bank needs to increase output- based or performance-based investment lending and development-policy lending for policy action, mixed according to country needs and context. Some movement in this direction is occurring in HNP and vaccine "buy- downs" (box 6.1) and in direct payment of outcomes and outputs in mater- nal and child health, but it is not enough. Linking financing to results car- ries some risks, due mostly to bias in surveillance and monitoring reporting, introduced by perverse incentives, as well as risks due to systemic and gov- ernance fragility in many client countries. This is one reason the Bank teams up with client countries and global partners--to experiment and learn from innovation in results-based lending. Launch a Major Effort to Improve National Public Health Surveillance and Health System Performance Monitoring The Bank will work in close collaboration with global partners to persuade client countries, and support their efforts and those of global partners, to launch a build-up of public health surveillance and health system perform- ance-monitoring systems at country level. Launching this build-up will be one of the contributions of the Bank to HNP results in the first three years of the new HNP Strategy. A focus on results is not possible without reliable data. This contribution will be the foundation for a renewed culture, centered on the impact of HNP results within the Bank and in Bank relations with client countries. Close coordination with other institutions such as the Health Met- rics Network and other global initiatives will be important. Set a Common Global HNP Results Framework The Results Framework (annex D) will guide the Bank in developing regional HNP strategies and strengthening surveillance and monitoring. The Framework covers health MDGs, other priority HNP outcomes, financial protection indicators, governance, and financial sustainability indi- cators. It is intended to guide Bank development of HNP knowledge cre- ation and management, to direct the surveillance and monitoring initiative, and to provide general guidance to the Regions for the preparation (or update) of their own HNP strategies and implementation plans. Develop- ing some of the proposed outputs and outcomes will require an important 72 Healthy Development Box 6.1: Promising New Mechanism Linked to Results: Loan Buy-Downs for Polio Eradication Results in Pakistan The Concept Results-based investment credits and loans are linked to the achievement of specified out- puts, particularly where significant externalities or public good characteristics result in under- investment. As an incentive, grant money from foundations and bilaterals "buy down" the loan or credit if the agreed results are achieved. There are three parts to buy-downs: setting an appropriate target goal, tying performance (targets) to the financial buy-down, and monitor- ing actions and evaluating outputs. The Pilot The buy-down mechanism was piloted in several polio eradication projects in Pakistan and Nigeria approved by the Board between 2003 and 2005. Polio eradication was selected for the pilot because of its obvious global public good characteristics. Financial support was provided by the Bill and Melinda Gates Foundation, United Nations Foundation, Rotary International, and U.S. Centers for Disease Control and Prevention (CDC). The Bank is now moving forward with a modest expansion of the pilot to meet a broader range of client needs and to capitalize on country and donor interest. How does it work? The government and the Bank identify the outputs and targets that would trigger the buy- down of the IDA credit into a grant. In the polio eradication projects, the targets are timely receipt of polio vaccine and polio coverage. A financial incentive to achieve the targets is provided in tandem with the IDA credit. Donor funds are set aside to pay the credit fees and buy down the credit to a grant if the tar- gets are reached. The first project is coming to a close, and an independent performance audit will occur in early FY2007 to verify results. If the project's intended benefits do not material- ize, the funding remains an IDA credit, and no donor funds are awarded. The Future The initial pilot for polio projects was expanded by management to cover up to six health proj- ects, and IBRD buy-downs are being explored. For buy-downs, projects must meet the follow- ing eligibility criteria: · Significant cross-border externalities. The primary selection criterion is that eligible proj- ects or project components must have significant positive cross-border externalities linked to the achievement of the MDGs. · Measurable outcomes. Projects or components must have measurable and feasible out- comes that can be achieved through policy actions by the government so that the trigger- point for buying down the credit will be transparent and objective. Countries must also have adequate monitoring systems to measure these outcomes. · Standard Bank appraisal requirements. Projects must meet appraisal requirements and standards applied to all projects. In particular, investment in a project using a credit buy- down must be supported by a strong political commitment by the government and be used for activities that are cost-effective, fiscally sound, and equity enhancing. New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? 73 effort early in the Strategy implementation (e.g. financial protection, fiscal sustainability, and governance). The Bank portfolio is already focused largely on most of the proposed out- comes and outputs but has given insufficient attention to monitoring program performance and evaluating the implications of Bank and client­country trends for results. Most LICs and MICs are committed to health MDG outcomes, and the IDA-14 replenishment confirmed Bank and donor commitment to the MDGs and other priority HNP outcomes. The same is reflected in most regional and Hub Vice-Presidential Unit Strategic Performance Contracts. Most Bank operations already focus on health-related MDGs, improving sexual and reproductive health and child nutrition, as seen in the review of 116 Implementation Completion Reports for IDA and IBRD projects closed in FY2001­FY2005 and the review of current active portfolio project devel- opment objectives (PDOs) (Subramanian, Peters, and Willis 2006). These reviews reflect the emergence of common outcome and system performance objectives in client countries across all Bank Regions. The performance objectives include addressing and reducing the noncommunicable disease epidemic, improving financial protection, improving governance and reduc- ing corruption, and improving health sector financial sustainability in gen- eral and donor assistance and fiscal sustainability in particular. HNP out- comes included in the Results Framework potentially account for 60 percent of the total avoidable burden of disease in LICs and MICs combined. The global HNP Results Framework is presented to guide the Regions in elaborating their regional strategies and identifying constraints to improving in-country performance. Its country-driven application and adaptation must be ensured, and the framework should not be understood as a prescriptive, limiting instrument. The key to making a country-led approach and the Results Framework compatible is the systematic intersec- toral identification of constraints to improving HNP outcomes at country level and the subsequent design and implementation of effective sectoral interventions to overcome these constraints--tailored to individual country contexts. For example, the CAS and HNP portfolios of both Argentina and Rwanda emphasize reducing U-5 mortality, but each country has to take a different path. To reduce infant and neonatal mortality, Argentina is con- centrating on improving provider incentives to expand access and quality of health service delivery for poor mothers and children (box 6.2), particularly for neonatal care. In contrast, reducing U-5 mortality in Rwanda requires a much broader intersectoral approach, entailing, for example, expanding 74 Healthy Development basic vaccine coverage, increasing access to basic perinatal health services, raising educational levels, expanding access to safe water and sanitation, improving access to key micronutrients, and increasing birth space (closely linked to women's participation in the labor market). Box 6.2: Argentina Plan Nacer--Health System Strengthening Built into Results-Based Lending for MCH Plan Nacer is a two-phase Adaptable Program Loan of about US$440 million that supports the implementation of Argentina's public national maternal and child health program. The program ensures synergies between priority diseases and health system strengthening. It does so by directly (out of loan proceeds) paying for results (outputs and outcomes) for maternal and child health of the poorest population. Structural changes and health system strengthening inter- ventions are deeply embedded in program implementation design. The program is intended to: · Increase access to basic health services for uninsured mothers and children (up to six years old), contributing to decrease infant and maternal mortality. · Strengthen the health system and introduce structural changes in the incentive framework for the national-provincial and provincial-provider relationships, linking project financing with results (mainly output--health services delivered to target population--but also intermediary outcomes). Most (85 percent) of program proceeds finance a conditional matching grant from the fed- eral government to provinces to pay half the average per capita cost of providing a package of basic health services to uninsured mothers and children. The package covers 70 services addressing the main causes of child and maternal mortality. This capitation grant is the equiv- alent of financing a health insurance premium for the uninsured. Disbursements are made in two installments, if target results are met. By November 2006, more than half the originally targeted population had been enrolled (more than a half million mothers and children); and more than 2 million consultations and 20,000 deliveries had been financed by the program. Infant mortality in the target provinces has dropped. In addition to increasing access to services, the program has had significant health system strengthening effects. To be able to achieve the targets and ensure appropriate use of funds, provinces have introduced output-based payment for providers, contracting (public and/or pri- vate sector) mechanisms, health service purchaser agencies, independent concurrent auditors, incentives to high-performing personnel, significant upgrades in monitoring and information systems, and demand-boosting actions such as linking Plan Nacer with conditional cash trans- fer programs already existing in the country. The first two years of program implementation have been so successful that it is being expanded from the original nine provinces to the entire country, with a total beneficiary popu- lation of more than 2.2 million uninsured mothers and children. Source: World Bank 2006k. New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? 75 Strategic Direction 2: Increase the Bank Contribution to Client­Country Efforts to Strengthen Health Systems for HNP Results Despite the Bank's potential comparative advantages, its health system capacity has not escaped the consequences of global trends in vertical and single-disease approaches. Though still strong, current capacity in health systems is scat- tered throughout the Bank. To realize its full potential and to respond to growing demand from the international community, the Bank needs to raise its health system strengthening contributions to client­country efforts for HNP results in areas in which the Bank has comparative advantages. Client countries have been ahead of the international community debate on health systems. In the last decade, many health system reforms have begun throughout the world. In these reforms, governments attempt to address such basic health system questions as: how to ensure equitable access to effective, quality health services that respond to the needs of the commu- nity? what is the right balance between investments in the HNP sector and other sectors to achieve both HNP results and much-needed economic growth? what specific policies/actions are required to ensure synergy between priority­disease and system strengthening approaches? what type of provider governance, contracting, financial management, procurement, and provider-payment mechanisms are necessary to ensure efficient and equi- table results? how should government engage and regulate a predominantly private delivery sector in LICs to improve equity, ensure consumer protec- tion, and improve public-private collaboration to achieve HNP results? how can government ensure sustainable financing and improve fiscal space for priority diseases? what are the public and private sector roles in the quest to expand health insurance coverage and supply of priority health services? how can policy makers extend health insurance (public and/or private) to the large informal and self-employed sectors? and how can they leverage, for that pur- pose, most client­country high, private household (out-of-pocket) expendi- tures among the nonpoor? These are some of the key health system chal- lenges common to most Bank client countries. Middle-income countries face additional challenges derived mostly from past decisions on health system financing and organization (Baeza and Packard 2006). Among these new challenges are to: address gathering con- cerns about the effects of payroll-tax financing of social health insurance on labor markets; regulate competing private health insurance; and navigate the 76 Healthy Development transition in the public sector from historical input financing to production- based (output-based) provider financing ("money follows the patient"). A central objective of the implementation of this new HNP Strategy is to improve Bank capacity to help client countries find the most appropriate answer to these questions for their country context to get concrete HNP results on the ground. Strengthening health systems by setting the right incentives for efficiency will substantially contribute to broadening access to services. However, improving efficiency will be insufficient in LICs; strengthening systemic delivery capacity will also entail expanding the supply of cost-effective health services, fiscal space, and international financing, commitment permitting. Expanding health service supply capacity is particularly challenging in rural areas where high degrees of informality and poverty, usually compounded by geographical isolation, determine low levels of demand, making public invest- ments costly and lacking incentives for private provision of services. The Bank remains committed to supporting country efforts to strengthen health system infrastructure (e.g., clinics, hospitals, and medical equipment purchases). The Bank has comparative advantages in large infrastructure investments. However, client countries and country teams need to decide, case by case, Bank investments in health service delivery infrastructure in the context of allocative efficiency of country resources, in-depth analysis of all alternatives to increase service supply, and in line with the implementation of an adequate incentive framework for any new infrastructure so that HNP results on the ground are actually delivered. Investments in the absence of adequate incentive frameworks too often result in empty buildings. The Bank stands ready to support client­country efforts to expand health services to the poor. To do so, an in-depth assessment of health systems pol- icy and investment gaps is needed, to identify needs and options and set up the appropriate strategy to extend supply capacity. No country strategy to improve access to health services to its people, particularly to the poor, is complete without considering all potential alternatives to expand supply, including decisions assessing the appropriateness of investments on public sector capacity and/or expansion through publicly financed private sector provision of health service to the poor and/or private provision of privately financed services. IFC and the Bank will further enhance their collaboration to help client countries identify best options, and, upon country request, provide financial support to implement them. New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? 77 To realize its full potential in health systems, the HNP sector will reartic- ulate its health system capacity, now scattered throughout the Bank. It will strengthen its capacity in health financing (including fiscal management, health insurance, and health service purchasing)--and in system gover- nance. It will seek more effective intersectoral collaboration with PREM (on fiscal space and management and on public sector governance) and with Financial Services and Social Protection (on health insurance). To this effect, the HNP sector will assemble a health system policy advice team, which will allow it to respond rapidly to the need for health system strengthening to obtain solid HNP results on the ground. Details on team mission, work scope, and organization are provided under the HNP Hub Action Plan (annex A). Strategic Direction 3: Ensure Synergy between Health System Strengthening and Priority­Disease Interventions, Particularly in LICs Upon country demand, the Bank will continue lending for priority diseases and programs. But when doing so, it must stay sharply focused on solving systemic constraints to improving HNP results on the ground and on ensuring synergy in priority­disease treatment and system strengthening. Preliminary lessons from Argentina's maternal and child health program (box 6.2) suggest that this synergy can be better achieved by: packaging the main priority diseases in one program/project; and embedding in the proj- ect/program implementation design actions for health system strengthen- ing (e.g., provider payment per child vaccinated or malaria patient treated). Doing so will most likely require the implementation of multiple system strengthening activities. Bank financing through IDA plays a crucial role in HNP-enhancing interventions to ensure priority­disease and system strengthening synergy in LICs. It also helps forestall allocative inefficiency and other distortions that can result from the allocation of large amounts of financing to a few dis- eases (and neglect others) and to system strengthening in LICs. Technical advice and AAA can play a crucial role in strengthening health systems to remove country-identified bottlenecks that prevent increased financing from achieving its maximum impact. 78 Healthy Development Strategic Direction 4: Strengthen Bank Capacity to Advise Client Countries on an Intersectoral Approach to HNP Results It is universally acknowledged that reducing mortality, morbidity, fertility, and malnutrition requires intersectoral inputs and actions. However, little in-country systematic analysis has been done to document the bottlenecks in different critical sectors, set out a framework for prioritizing actions, or assess institutional constraints. Nor has this research been done within Bank lending operations. Preliminary evidence (World Bank 2006b) suggests that intersectoral approaches can greatly enhance results on the ground. Effective core diagnostic tools are needed to identify intersectoral con- straints to achieving HNP results. The Bank will develop, test, and imple- ment a core diagnostic tool for systematic assessment of these multisectoral constraints at country level. The results of this process will feed into CAS preparation. The main purpose of the process will be to identify the prior- ity HNP outcome(s), output, and performance improvements for the spe- cific country, the binding constraints to improving that outcome and per- formance at national and/or subnational levels, and the key feasible multiple-sector interventions (technical, investment, policy actions) critical to overcoming these constraints. This "Multisectoral Constraints Assess- ment (MCA) for Health Outcomes" will be referred to as "MCA" in the remainder of this Strategy. Annex E outlines the rationale and objectives of MCA, which will be developed and pilot tested in four client countries by FY2009. Country teams have no such process or tool today. Significant inputs for developing this core diagnostic tool will come from the method- ological discussions in the PRSP Sourcebook (World Bank 2002a) on identi- fication of constraints to improving specific outcomes, the experience of the Africa Region with the Marginal Budgeting for Bottlenecks tool,50 the expe- rience of the multisectoral economic sector work (ESW) for Orissa state in India,51 and the experience of the Recurso Peru ESW in LCR.52 Intersectoral identification of constraints should not be confused with a call for multisectoral investment projects across the board. One does not automatically lead to the other. In improving intersectoral work, the Bank needs to take into account the complexity that client countries face in improving their own intersectoral approach to HNP results. Given the much greater complexity and the often-difficult political economy of reform at country level, increasing intersectoral work will focus first on ensuring intersectoral identification of different sectors' lending and nonlending New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? 79 activities required to improve HNP outcomes and system performance at country level. Identifying those activities to inform CAS preparation would be an important contribution to a results-based CAS and to policy dialog with client countries when defining the strategic directions of the CAS. It will be up to the country team, based on context and needs, to decide whether to go for multisectoral projects/programs or for multiple parallel but coordinated sectoral projects or programs. In fact, considering the dif- ficulties client countries have implementing multisectoral projects, the effectiveness of such projects should not be taken for granted and should be pursued only when the approach promises good HNP results at the coun- try level. Identifying and coordinating HNP-related programs and projects intersectorally in a new CAS would be a big step toward the multisectoral determinants of HNP results. Strategic Direction 5: Increase Selectivity, Improve Strategic Engagement, and Reach Agreement with Global Partners on Collaborative Division of Labor for the Benefit of Client Countries As one of the leading multilateral organizations in development, the Bank collaborates with many bilateral and multilateral organizations and global HNP partnerships. This collaboration can facilitate harmonization of development partner efforts and can reduce transaction costs for client countries in their pursuit of improving HNP results. The volume of the HNP partnership portfolio has increased dramatically over the past five years, mirroring the changes in the global health architecture. As a result Bank engagement with global partners is fragmented and needs sharper strategic direction. With the implementation of the new Strategy, the Bank will assess its engagement with its partners to ensure effective and sustain- able partnerships. For example, the Bank will seek a better balance in its partnerships and its regional work on LIC and MIC priorities, particularly on health systems, and will substantially increase its strategic engagement with WHO, Global Fund, and GAVI, particularly in LICs. Engaging with global partners and partnerships has two main objectives for Bank work in HNP: to complement Bank work in areas in which it has no comparative advantages or to complement other partners needing Bank expertise, all in direct benefit of client countries on the ground; and to con- tribute to international community support of global public goods and pre- 80 Healthy Development vention of global public "bads." Good examples of this type of collaboration are Bank involvement in donor harmonization, efforts to address the avian flu livestock crisis and scale up preparedness in the case of a human health pandemic, and the design and launching of global financing instruments such as the Advance Market Commitment. For areas in which the Bank has comparative advantages (e.g., health sys- tem finance, intersectorality, governance, demand-side interventions), the Bank will: collaborate with partners that share all or part of these compara- tive advantages (e.g., IMF, regional banks, International Labour Organisa- tion Actuarial and Financial Services) to further develop and disseminate knowledge; and collaborate with other financing partners and technical agencies (annex G) to share Bank expertise and to coordinate further devel- opment of knowledge in areas in which Bank expertise might be needed. A good example of global partnership collaboration in knowledge creation is the analytical work contributed by the Bank to the OECD High-Level Forum (World Bank 2006a). For areas of expertise and knowledge in which the Bank has no compar- ative advantages, the Bank will seek out effective collaboration mechanisms and pursue collaborative division of labor at the country level and with other development organizations in their respective areas of comparative advan- tage as discussed, for example, in disease-control knowledge as well as micro-organizational aspects of provision and the need for collaborative division of labor with the WHO. This will ensure mainstreaming of part- ners' knowledge in Bank operations. Different areas of expertise offer opportunities for division of labor and collaboration among global partners. However, because the failure of any of the nine key functions may compromise overall health system performance, partners need to closely monitor collaboration at the country level. Many successful global advocacy organizations and partnerships have emerged in the last decade. Partnerships have potential for strengthening Bank effectiveness, but they can also "pull" the Bank policy function in directions that are not in line with its policy objectives, Strategic Directions, or comparative advantages. Engaging partners that best complement its own comparative advantages poses a great challenge to the Bank. Having contributed to the emergence, consolidation, and success of many of these advocacy organizations and partnerships, but confronted with the need for greater selectivity, the Bank will increasingly concentrate advocacy in HNP on sound intersectoral and health system strengthening policies. New Bank Strategic Directions: How Should the Bank Support Client­Country Efforts? 81 The Bank is increasingly involved in managing a multiplicity of Trust Funds (provided by bilateral agencies or private foundations). Many of them provide substantial support for Bank country-level operations. However, the Bank is managing more and more such funds with narrow objectives that may or may not fit into its overall comparative advantages, strategic policy objectives, and country work. Managing these funds has an opportu- nity cost for operational and policy focus. Some of these funds have the potential to de facto steer the operational and policy priority focus of the Bank, particularly the HNP Hub. The Bank will review current and future management of Trust Funds and be selective in managing only those directly linked to its strategic objectives and comparative advantages to sup- port country-level work. CHAPTER 7 Implications for Priority Health, Nutrition, and Population Programs and Interventions The new environment, Strategic Objectives, and Strategic Directions dis- cussed here apply to all HNP program areas for which the Bank provides technical and financial support, including nutrition, population, and HIV/AIDS. Some of the core policy implications of this Strategy in nutri- tion, population, and on HNP's contribution to combating HIV/AIDS are examined in this section. Upon country demand, the Bank will continue to support through lend- ing and policy advice, all health, nutrition, and population activities neces- sary to improve HNP outcomes, especially for the poor and the vulnerable. The Bank will increasingly ensure that Bank operational support and policy advice for priority areas in health will strengthen country health systems. Strengthening health systems will lead to removing systemic constraints and thus improve the effectiveness of country, Bank, and international commu- nity financing to achieve HNP results. Through policy analysis and policy dialog, the Bank can also assist countries in realizing levels of investment in HNP sector and rational allocations within the sector consistent with accel- erated progress toward MDGs 1, 4, 5, and 6, and with other international commitments to achieving better health outcomes and greater health equity. A Strong Commitment to Population, Sexual and Reproductive Health, and Maternal and Child Policy The term "population" covers a variety of topics. Within the HNP sector two broad areas are most commonly referred to as population: 83 84 Healthy Development · Reproductive, maternal, and sexual health issues, and the health services that are concerned with addressing them. · Levels and trends in births, deaths, and migration that determine popu- lation growth and age structure, and frequently have an impact on eco- nomic growth, poverty, labor markets, and other sectors. The Bank commitment to population issues is embedded in the Pro- gramme of Action of the International Conference on Population and Development (UNFPA 2004) and identifies a number of entry points for the Bank to engage in population issues from within and outside the health sector. The Bank endorsed the Cairo Consensus in 1994 and continues to do so (box 7.1). The ICPD called for achieving broader development goals through empowering women and meeting their needs for education and health, especially safe motherhood and sexual and reproductive health. It recom- mends that health systems provide a package of services, including family planning, prevention of unwanted pregnancy, and prevention of unsafe abortion and dealing with its health impact, safe pregnancy and delivery, postnatal care, as well as the prevention and treatment of reproductive-tract infections and sexually transmitted diseases, including HIV/AIDS. Background and Context to Today's Population Issues In the second half of the 20th century, the world population more than dou- bled, reaching 6.4 billion by mid-2004. According to current projections, 95 percent of all population growth will occur in developing countries (United Nations 2003). Since the middle of the last century, fertility and mortality trends almost everywhere have gradually started to converge toward low fertility and lengthened life expectancy. The exception is the Sub-Saharan Africa Region, where total fertility rates are still high: nearly 6 children per woman, compared with an average TFR of 2.6 in other low- and middle- income Regions (figure 7.1). About 200 million women who either want to space or limit their childbearing lack access to effective contraceptives. Intermediate fertility countries in South Asia and elsewhere, some with total fertility rates of 3 or 4, also continue to face challenges as they proceed through the demographic transition. Africa will be the fastest growing Region, but most of the people born into the world between 2005 and 2050 will be Asians, due to the huge pop- Implications for Priority Health, Nutrition, and Population Programs and Interventions 85 Box 7.1: The World Bank Commitment to Reproductive Rights and Reproductive Health The ICPD Programme of Action includes the following: · Improving knowledge and information on reproductive health services. · Providing access to quality services particularly for the poor and vulnerable groups (i.e., migrants, adolescents, etc.). · Including youth in sexual and reproductive health programs, outreach, and services (includ- ing provision of birth spacing methods). · Preventing sexually transmitted diseases, including HIV. · Promoting gender equality with particular attention to preventing violence against women. · Ensuring that decisions concerning reproductive health be free of discrimination, coercion, and violence. The ICPD Programme of Action states: "Reproductive health is a state of complete physi- cal, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes." (ICPD, Section 7.2) "Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases." (ICPD, Section 7.2) "While the International Conference on Population and Development does not create any new international human rights, it affirms the application of universally recognized human rights standards to all aspects of population programs. It also represents the last opportunity in the twentieth century for the international community to collectively address the critical challenges and interrelationships between population and development. The Programme of Action will require the establishment of common ground, with full respect for the various reli- gious and ethical values and cultural backgrounds. The impact of this Conference will be measured by the strength of the specific commitments made here and the consequent actions to fulfill them, as part of a new global partnership among all the world's countries and peo- ples, based on a sense of shared but differentiated responsibility for each other and for our planetary home." (ICPD, Section 1.15) Source: UNFPA 2004. 86 Healthy Development Figure 7.1: Fertility Trends, by Geographic Region, 1950­2005 7.5 5.5 rate fertility 3.5 total 1.5 1950­55 1955­60 1960­65 1965­70 1970­75 1975­80 1980­85 1985­90 1990­95 2000­05 1995­2000 year High-income Latin America and eastern Africa western Africa the Caribbean East Asia and Pacific South Asia middle Africa Europe and Central Middle East and southern Africa Asia North Africa Source: UNFPA 2006. ulation size of Asia (60 percent of the world's population in 2005) and the associated population momentum. Concurrently, most countries in Europe and Central Asia are expected to grow little, and a decline in population is projected in a few. Population aging is also a concern in many countries. Countries can be grouped into three categories with broadly similar pop- ulation issues (table 7.1): countries with high fertility rates (TFR over 5.0), often showing little change in fertility over time; countries with intermedi- ate fertility rates (TFR ranging from 2.5 to 5.0); and countries with fertility rates near replacement level and below. Individual country-level analyses of population trends will be required to identify specific constraints and reme- dies for policy formulation. Countries in various stages of fertility transi- tions face diverse challenges in the areas of sexual and reproductive health. Many aspects of effective reproductive and sexual health service delivery depend on overall health system strengthening, including planning, human resources, financing, regulation, information systems, management, and Implications for Priority Health, Nutrition, and Population Programs and Interventions 87 Table 7.1: Some Characteristics of Countries According to Fertility Levels TOTAL FERTILITY RATE GREATER BETWEEN LESS THAN 5 5 AND 2.5 THAN 2.5 INDICATOR [RANGE] [RANGE] [RANGE] Gross national income (GNI per capita, US$) 344 1,110 10,502 [90­950] [250­17,360] [540­56,380] Life expectancy at birth (years) 46 63 74 [38­61] [36­79] [61­82] Under-5 mortality rate per 1,000 175 75 25 [59­283] [6­156] [3­106] Primary completion rate, total 52 93 98 (% of relevant age group) [25­89] [29­107] [75­114] Population age over 65 years (% total) 3 4 11 [2­3] [2­10] [1­20] Sources: UN 2005; World Bank 2005h. commodity procurement and logistics. There is now a robust body of evi- dence and experience to guide the design, delivery, and assessment of sexual and reproductive health programs. However, the determinants and conse- quences of demographic change need urgent study, specifically on policies and interventions affecting fertility, family planning, population aging, and utilization of other sexual and reproductive health care. Trends resulting from demographic processes--large birth cohorts in high-fertility coun- tries, changes in the age structure resulting in large youth populations and rapidly growing elderly cohorts--all have profound implications for HNP, education, labor markets, pensions, poverty reduction, and environment. Countries with High Unmet Needs in Sexual and Reproductive Health as a Priority Despite the dramatic decline in global fertility rates, 35 countries, mostly in Sub-Saharan Africa, and a few countries in other Regions (Timor Leste, Afghanistan, West Bank-Gaza, and Yemen) still have fertility rates above 5 (United Nations 2003). Fertility rates in a number of these countries have not declined for several decades (figure 7.2), demonstrating their high unmet needs in sexual and reproductive health and maternal mortality reduction. The rationale for Bank focus on these countries, along the lines of Bank comparative advantages, is clear from an economic growth/poverty reduc- 88 Healthy Development Figure 7.2: Fertility Trends, Selected High-Fertility Countries, 1950­2005 9.0 8.5 8.0 rate 7.5 fertility 7.0 total 6.5 6.0 5.5 5.0 1950­55 1955­60 1960­65 1965­70 1970­75 1975­80 1980­85 1985­90 1990­95 2000­05 1995­2000 year Chad Mali Niger Burkina Faso Guinea-Bissau Somalia Angola Uganda Yemen Liberia Afghanistan Equatorial Guinea Source: UNFPA 2006. tion perspective as well as from equity considerations. The consensus today is that rapid population growth constrains countries at low levels of socioe- conomic development (Kelley 1988; Birdsall, Kelley, and Sinding 2001). It raises demand for public services and financial resources in countries that cannot create the fiscal space to provide either. Women endure a dispro- portionate burden of poor sexual and reproductive health. Their full and equal participation in development is therefore contingent on accessing essential sexual and reproductive health care, including the ability to make voluntary and informed decisions about fertility. Notwithstanding, global attention to population issues has been declin- ing (PATH/UNFPA 2006). The earlier success in reducing global fertility rates, the rise of competing priorities, the unintended loss of focus on fam- ily planning services within the broader ICPD agenda, and the changing Implications for Priority Health, Nutrition, and Population Programs and Interventions 89 environment have all contributed to persistently high fertility rates in some countries and declining funding for family planning (figure 7.3). Reposi- tioning family planning within the ICPD agenda and, in collaboration with development partners, strengthening its visibility, are important. Harmo- nization and aid alignment at the country level is necessary to make sure that sexual and reproductive health services are funded adequately in national budgets. A comprehensive operational and systems strengthening response is required from the Bank and its partners. Future Directions for the Bank The Bank commitment to population issues is embedded in the ICPD Pro- gramme of Action (ICPD 1994).53 The Bank recognizes that UNFPA and WHO are the main agencies working on the technical aspects of reproduc- tive health issues. The Bank will work on population issues on the basis of its comparative advantages. Upon country demand, the Bank will focus its contributions in countries with high unmet needs in sexual and reproduc- tive health in the following areas: Figure 7.3: Population Activities Expenditures as Share of Total Population Assistance, 1995­2004 70 60 50 40 percent 30 20 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 year family reproductive HIV/AIDS basic planning health research Source: UNFPA 2006. 90 Healthy Development · Assessing multisectoral constraints to reducing fertility, determining impacts of population changes on health systems and other sectors, and assisting countries in strengthening population policies. · Providing financial support and policy advice for comprehensive sexual and reproductive health services, including family planning, and mater- nal and newborn health. · Generating demand for reproductive health information and services, including improving girls' education and women's economic opportuni- ties, and reducing gender disparities. · Raising the economic and poverty dimensions of high fertility in strate- gic documents that inform policy dialog (such as CASs, CEMs, and country-led PRSPs). Opportunities for Sustaining, and Challenges to Improving, HNP Contributions to Combating HIV/AIDS The Bank Reaffirms Its Commitment to Assist Client Countries and the International Community in Combating the HIV/AIDS Pandemic This effort is a worldwide health priority, as articulated in 2005 through its Global HIV/AIDS Program of Action (GHAPA) for supporting the global, regional, and national AIDS response (World Bank 2006g). The pandemic jeopardizes economic development in many countries, particularly in Africa. Here, too, recent financial and political commitments for combating HIV/AIDS present new opportunities, but also new challenges. Much of the new funding is dedicated to expanding access to antiretroviral therapy (ART). By end-2005, the number of people on ART in low- and middle-income coun- tries amounted to 1.3 million, only an estimated 20 percent of the number needing treatment (UNAIDS 2006). Annex H summarizes the Bank vision on the HNP sector contribution to combating the HIV/AIDS pandemic. Scaling Up and Sustaining Prevention and Treatment Sustainable scaling up of HIV/AIDS prevention and treatment depends on health systems that can: overcome increasingly worrisome health financing Implications for Priority Health, Nutrition, and Population Programs and Interventions 91 constraints and set the right provider incentive framework for results; and solve supply bottlenecks through efficiency improvements and supply expansion, particularly in LICs. It also depends on the ability of the inter- national community to fulfill its promises. The Bank remains committed to financing HIV/AIDS interventions, upon country demand and in concert with integrated health system strengthening projects, programs, and ana- lytic and advisory services. Health Financing Constraints Some characteristics of development assistance for health that are relevant to HIV/AIDS cause increasing concern: the volatility and predominance of short-term commitments by the international community; increasing fund- ing distortions; allocative inefficiencies; and the need to find effective ways of creating fiscal space for HNP in general and HIV/AIDS in particular. · Volatility and predominance of short-term commitments. The amount of DAH funds countries receive varies greatly from year to year. This makes long-term planning difficult for Ministries of Health and Finance. · Funding distortions. Fragmentation of donor assistance to health distorts funding, making it difficult for governments to finance systemic require- ments for staff, supervision, training, management and maintenance, and expansion of access to ART. · Allocative inefficiencies. With the large influx of funding for HIV/AIDS, the question arises of whether the money is being used to its maximum net benefit. Funding for prevention has not been similarly expanded. ART appears to help prevent, as well as treat, HIV infection; but preventive interventions could do more to limit new HIV infections and are more cost-effective (Hogan et al. 2005; Salomon et al. 2005; Bertozzi et al 2006). Might some funds be better and more equitably spent on prevention? · Need to find effective ways to create fiscal space. Large increases in public spending on HIV/AIDS or health initiatives that create future spending commitments must be considered in the context of governments' ability to provide resources from current and future revenues. This is a serious constraint in low-income countries. The problem is compounded if large expenditures are financed by borrowing, which requires additional rev- enue to service the debt and could impair overall economic growth. 92 Healthy Development Improve Efficiency and, When Necessary, Expand Supply Capacity The Bank will contribute to: · Efficiency improvements. More funding is not enough; additional funding must be linked to improving health system efficiency, as discussed throughout this Strategy. · Supply capacity. The Bank remains committed to supporting country efforts to strengthen health system supply through infrastructure invest- ments (e.g., clinics, hospitals, and medical equipment purchases), when necessary. Bank Contributions to HIV/AIDS Financing The Bank will contribute to financing HIV/AIDS programs and health sys- tems in a several ways: · Supporting increased, long-term, predictable funding. Upon country demand, the Bank is committed to leveraging global partner funding and/or pro- viding increased and predictable long-term financing for the health sec- tor and HIV/AIDS. · Creating fiscal space and reducing distortions. The Bank will work intersec- torally with client countries, the IMF, and global partners to help coun- tries develop ways of enhancing capacity to absorb and reduce the adverse effects of fiscal shocks and create fiscal space for necessary HNP interventions, including HIV/AIDS prevention and treatment. · Enhancing accountability. The Bank will promote budgetary and financial reporting processes that accommodate and respond to the views of criti- cal stakeholders within the country. The Bank will support client­coun- try efforts to sustain specific efforts to protect the interests of poor, vul- nerable, and marginalized groups, including people living with HIV/AIDS, in order to increase accountability and enhance people's voices. · New types of financing. The Bank will provide financial, technical, and convening capacity to countries requesting help with development of health financing systems that promote accountability, efficiency, and financial protection. This work forms the framework for financing Implications for Priority Health, Nutrition, and Population Programs and Interventions 93 HIV/AIDS prevention, care, and treatment at country level. Upon coun- try request, the Bank will also test new country-led and country-owned approaches to its own financing of HNP and HIV/AIDS. Strengthening health systems is critical for scaling up and improving the effectiveness of HNP interventions, including HIV/AIDS treatment and prevention. As discussed throughout this Strategy, the Bank is committed to sharpening its focus and improving its capacity to support client countries in strengthening health systems, along the lines of Bank comparative advan- tages. It will seek to improve system capacity to deliver services for the entire range of disease interventions prioritized by client countries. HIV/AIDS, malaria, tuberculosis, maternal and child health, reproductive and sexual health, and micronutrient interventions are prominent in the agendas of most client countries, particularly LICs. Repositioning Nutrition to a Central Place in Development54 Malnutrition, and its negative compounding effect in disease susceptibility, slows economic growth and perpetuates poverty via three routes: direct losses in productivity from poor physical status, indirect losses from poor cognitive function and deficits in schooling, and losses owing to increased health care costs. Malnutrition's economic costs are substantial: individual productivity losses estimated at more than 10 percent of lifetime earnings and gross domestic product forgone as high as 2 to 3 percent. Improving nutrition is therefore at least as much an economic issue as one of welfare, social protection, and human rights. Investing in nutrition in early childhood lays the foundation for lifelong health and development. A well-nourished child, for example, is less likely to suffer from disease and more likely to achieve better educational attain- ment and labor productivity as an adult. Moreover, improving children's health has longer-lasting gains that may be discerned in the next generation of healthier and more productive people. Reducing undernutrition and micronutrient malnutrition also multiplies the effectiveness of health prevention and curative interventions and directly reduces poverty, broadly defined to include human development and human capital formation. Undernutrition is closely connected to income poverty. Malnutrition is often two, three, or more times more prevalent 94 Healthy Development among the poorest income groups than among the highest. This means that improving nutrition is a pro-poor strategy: it disproportionately increases the income-earning potential of the poor. The returns on investing in nutrition are high. The Copenhagen Con- sensus ranked returns on nutrition interventions among the highest of 17 potential development investments (table 7.2). Improving nutrition is essen- tial to reduce extreme poverty. The first MDG, for eradicating extreme poverty and hunger, recognizes this requirement. The key indicator for measuring progress on the nonincome poverty goal is the prevalence of underweight U-5 children. Yet most assessments of progress toward the MDGs have dwelled mainly on the income poverty tar- get and have found most countries on track. However, of 143 countries, only 34 (24 percent) are on track to achieve the nonincome target (nutrition MDG) (table 7.3). No country in South Asia, where undernutrition is high- est, will achieve the MDG--although Bangladesh will come close, and Asia as a whole will achieve it. More alarmingly, nutritional status is deteriorat- ing in 26 countries, many of them in Africa where the nexus between HIV and undernutrition is strong and mutually reinforcing. And in 57 countries, no data are available to evaluate progress. A renewed focus on the nonin- come poverty target, including nutrition, is central to any poverty reduction efforts. Table 7.2: Nutrition Provision Rated a Top Investment by Copenhagen Consensus RATING CHALLENGE OPPORTUNITY Very good 1. Diseases Controlling HIV/AIDS 2. Malnutrition and hunger Providing Micronutrients 3. Subsidies and trade Liberalizing trade 4. Diseases Controlling malaria Good 5. Malnutrition and hunger Developing new agricultural technologies 6. Sanitation and water Developing small-scale water technologies 7. Sanitation and water Implementing community-managed systems 8. Sanitation and water Conducting research in water and agriculture 9. Government Lowering costs of new business Fair 10. Migration Lowering barriers to migration 11. Malnutrition and hunger Improving infant and child malnutrition 12. Diseases Scaling up basic health services 13. Malnutrition and hunger Reducing the prevalence of low birth weight Poor 14­17. Climate/migration Various Source: Bhagwati, Fogel et al. 2004. Implications for Priority Health, Nutrition, and Population Programs and Interventions 95 Table 7.3: Progress toward Nonincome Poverty Target ON TRACK (24%) DETERIORATING STATUS (18%) AFR (7) ECA (6) MENA (5) AFR (13) ECA (4) Angola Armenia Algeria Niger Albania Benin Croatia Egypt, Arab. Burkina Faso Azerbaijan Botswana Kazakhstan Rep. of Cameroon Russian Federation Chad Kyrgyz Rep. Iran Comoros Serbia and Montenegro Gambia, The Romania Jordan Ethiopia Mauritania Turkey Tunisia Guinea LCR (3) Zimbabwe Lesotho Argentina Mali Costa Rica EAP (5) LCR (10) SAR (0) Senegal* Panama China Bolivia Sudan Indonesia Chile Tanzania MENA (2) Malaysia Colombia Togo Iraq Thailand Dominican Republic Zambia Yemen, Republic of Vietnam Guyana Haiti EAP (2) SAR (2) Jamaica Mongolia Maldives Mexico Myanmar Nepal Peru Venezuela, R. B. de SOME IMPROVEMENT, BUT NOT ON TRACK (18%) NO TREND DATA AVAILABLE (40%) AFR (14) EAP (3) MENA (1) AFR (14 ) ECA (17) LCR (12) CAR Cambodia Morocco Burundi Belarus Belize Congo, Dem. Rep. of Lao, PDR Cape Verde Bosnia and Herz. Brazil Côte d'Ivoire Philippines SAR (4) Congo, Rep. of Bulgaria Dominica Eritrea Bangladesh* Eq. Guinea Czech Republic Ecuador Gabon India Guinea Estonia Grenada Ghana Pakistan Guinea-Bissau Georgia Paraguay Kenya Sri Lanka Liberia Hungary St. Kitts and Nevis Madagascar ECA (0) Mauritius Latvia St. Lucia Malawi Namibia Lithuania St. Vincent Mozambique LCR (4) São Tomé and Principe Macedonia Suriname Nigeria El Salvador Seychelles Moldova Trinidad and Tobago Rwanda Guatemala Somalia Poland Uruguay Sierra Leone Honduras South Africa Slovak Republic Uganda Nicaragua Swaziland Tajikistan Turkmenistan EAP (11) Ukraine MENA (2) Fiji Uzbekistan Djibouti Kiribati Lebanon Marshall Is. Micronesia SAR (2) Palau Afghanistan Papua N. G. Bhutan Samoa Solomon Is. Timor-Leste Tonga Vanuatu Sources: Author's calculations based on data in World Bank 2006l; WHO Global Database on Child Growth and Malnutrition. Note: All calculations are based on 1990-2002 trend data from WHO Global Database on Child Growth and Malnutrition (as of April 2005). Countries indicated by an asterisk subsequently released preliminary Demographic and Health Survey (DHS) data that suggest improvement and therefore may be reclassified when their data are officially released. 96 Healthy Development The Alarming Shape and Scale of Malnutrition Malnutrition is now problematic in both poor and rich countries, but it affects the poorest people most. In developed countries, obesity is growing fast, especially among poorer people. An epidemic of diet-related NCDs such as diabetes and heart disease is raising health care costs and reducing productivity. In developing countries, obesity is also fast emerging as a problem, on top of widespread undernutrition and micronutrient deficien- cies. Underweight children and overweight adults often live in the same households in both developing and developed countries. Malnutrition also occurs in many nonpoor families. People do not always know what foods are best for them or their children, and the untrained eye does not usually notice abnormally slow growth or associate it with micronutrient deficiencies. Education can play a major role in correcting malnutrition stemming from ignorance. Effective interventions exist, so what is missing? Nutrition investments have been low priority for both governments and development partners for three reasons. First, there is little demand for nutrition services from com- munities because malnutrition is often invisible; families and communities are unaware that even moderate and mild malnutrition contributes substan- tially to death, disease, and low educational attainment; most malnourished families are poor and hence have little voice. Second, governments still do not recognize how high malnutrition's economic costs are; that malnutrition holds back progress toward all the MDGs, not just the nutrition MDG; and that plenty of experience has been acquired with implementing cost-effec- tive, affordable nutrition programs on a large scale. Third, there are multi- ple organizational stakeholders in nutrition. Because most country financ- ing is allocated by sectors or ministries, malnutrition can fall between the cracks in both national programs and global assistance. The Bank Contribution to Reposition Nutrition in Development Bank increased knowledge and policy development work on nutrition is summarized in Repositioning Nutrition as Central to Development (World Bank 2006l). In the area of nutrition, the Bank will further contribute by: expand- ing its capacity to generate country-specific policy knowledge and advice to identify the magnitude of malnutrition as an outcome and as a constraint to other outcomes; improving its capacity to identify structural issues (e.g., Implications for Priority Health, Nutrition, and Population Programs and Interventions 97 failures in agricultural, taxation, rural development, water supply and sani- tation, social protection, education, community-driven development, and other policies and devising multisectoral policies to help countries beset by malnutrition address it; upon country demand, supporting integration of appropriately designed and balanced nutrition policies and interventions in CASs and in client country­led PRSPs; improving Bank monitoring and evaluation capacity of nutrition-enhancing interventions to ensure evi- dence-based learning and policy adjustments; and including nutrition as one of the multisectoral parameters in the MCA tool. Beyond structural and sys- temic issues, the Bank will seek advice from specialized global partners for Bank in-country operations on the technical aspects of appropriate nutrition interventions. CHAPTER 8 Implementing New Bank HNP Strategic Directions To make full use of its comparative advantages in the new environment in the service of client countries, the Bank HNP sector needs to make functional and organizational changes and rebalance the skill-mix composition of its staff and management. Strengthening Bank capacity (regional and Hub) to sharpen focus on HNP results, health system strengthening, health economics, and intersec- toral work is costly in the short term. The requisite skill-mix adjustment will take time and effort (through staff and management training, reorientation of recruitment toward expertise in health financing/systems/economics/intersec- torality skills, development of core diagnostic tools). The adjustment will also require functional changes in the mission of the HNP Hub toward one more oriented to support Region and country team needs. Concomitantly, it will require revitalizing the role and work of the HNP Sector Board. This section includes a summary Action Plan to implement key features of the HNP Strategy that lead to the new Strategic Directions and results. It includes: proposals and targets to improve quality at entry of the HNP portfolio; actions to restructure the current at-risk portfolio; a design, pilot, and implementation plan for MCA; proposals for improving statistical capacity and monitoring of core indicators at client­country and global lev- els; a Results Framework to guide regional development of country strate- gies; and proposals for training and retooling HNP staff and management. It also includes key organizational changes, particularly for the HNP Net- work (HNPFAM) and the HNP Hub. Annex D presents the Bank HNP Results Framework, which summarizes the main outcomes and outputs for the Bank in HNP. The framework is intended as guidance for country teams for developing country-specific and detailed results frameworks for Bank operations and programs. The Results 99 100 Healthy Development Framework links the main outcomes and outputs for the Bank with the Action Plan for Strategy implementation. The Action Plan also includes transition proposals to implement a rapid Bank response in the areas of health system strengthening. Constraints on budgets and on the availability of health system experts would preclude short-term strengthening of every Region's capacity for health system advice. Thus, the Action Plan proposes creating and locating a health system policy team in the HNP Hub to support the HNP Sector Board (to take advantage of initial economies of scale) to: support Regions in their health system capacity strengthening process; provide support to Regions in their policy advice to client countries through their lending and AAA work during this transitional period (initially with IDA country focus); and advise the Bank and international community on next steps for developing and implement- ing the health system strengthening agenda. It also will include a moderate increase in senior health system experts at regional level. The Hub health systems team is envisioned as being fully functional 12 to 18 months after approval of the new Strategy, contingent on availability of transition funding. Action Plan for Implementing Strategic Directions Sharpening the focus on results will require intensifying both client­country efforts to identify, monitor, and evaluate government programs and Bank capac- ity to evaluate Bank-supported programs using country systems. It will also require innovation in linking lending to results to such output. Finally, it will require a significant effort to restructure nonperforming projects in the HNP portfolio to improve Bank-assessed results of closing projects. Table 8.1 sum- marizes actions to be taken by the HNP sector to sharpen its focus on results. Strengthening the Bank health system capacity and synergy among sys- tems and priority diseases will require hiring of additional health system staff for the Regions and the creation of a health systems policy team to take advantage of economies of scale and facilitate regional cross-fertilization. This team will give country teams immediate health system analytical and operations advice support in identifying actual constraints and provide rec- ommendations on Bank, donor, and government funding needed to achieve HNP results and to help Regions refine and develop their own health system capacity in the medium term. Table 8.2 summarizes actions to be taken by the HNP sector to improve Bank capacity on health system strengthening. Implementing New Bank HNP Strategic Directions 101 Table 8.1: Five-Year Action Plan--Renewing Focus on Results WHAT? BASELINE HOW MUCH AND BY WHEN? BY WHOM? 1. Build statistical capacity for client Less than 10% At least 40% of new CASs targeting Regional HNP Sector Manager countries on priority HNP outcome of CASs HNP results to be discussed with and HNP country team and Country indicators (disaggregated by gender targeting the Board in 2009 and thereafter Directors with technical support and age) directly through Bank opera- HNP results will identify capacity and systems from HNP Hub and Development tions and/or supporting global part- building activities (Bank and/or Economics (DEC), as needed ner's country support (e.g., MDGs). This coordinated with global partners) includes the development of country- for, monitoring, and evaluating HNP based frameworks for the collection results in government programs. of essential household HNP and multisectoral indicators. 2. Pilot and evaluate impact of 4 active projects By FY2010, at least 14 active Regional HNP Sector Manager and output-based and performance- in FY2006 projects with most loan proceeds HNP Sector Board with technical based financing for HNP-related allocated on output-based financing. support from HNP Hub, as needed projects/programs. Impact evaluation plans in place for 60% of these projects or more upon approval. 3. Develop Bank Global Results Presented with Strategy for global monitoring HNP Hub with support of HNP Sector Monitoring Framework for key this new HNP arrangement designed (in Board, DEC, and others outcomes, outputs, and system Strategy collaboration with global performance indicators to be moni- partners) by end-FY2008. tored by the Bank globally. This will Implementation launched by include indicators on gender end-FY2009. disparities in health. 4. Introduce results frameworks for all Less than 25% At least 70% of new projects/ Regional HNP Sector Manager and projects targeting HNP outcomes, of active proj- programs approved by the Board country team, with technical support outputs, and system performance, ects with satis- in FY2008 and thereafter. from HNP Hub including baseline data and output factory results targets. frameworks as of FY2006 5. Periodic data collection and updates Less than 15% At least 65% (annually) of all Regional HNP Sector Manager and (as appropriate to specific indicators) of active proj- projects/programs approved by country team, with technical support for at least 70% of the indicators ects as of Board in FY2008 and thereafter. from HNP Hub included in project results framework FY2006 and updated periodically in Implementation Status Reports (ISRs). 6. Develop indicators (including Does not exist Develop indicators by Identification of indicator needed: gender-based indicators) for priority end-FY2008. HNP country team and Regional HNP HNP outcomes for which no agreed Sector Manager indicators exist (e.g., financial pro- Development: HNP Hub in tection, governance in the health collaboration with PREM, DEC, and sector, and financial and fiscal country teams sustainability). (Continues on the following page) 102 Healthy Development Table 8.1: Five-Year Action Plan--Renewing Focus on Results (continued) WHAT? BASELINE HOW MUCH AND BY WHEN? BY WHOM? 7. Improve results in existing portfolio. Annual average 75% for FY2009 and thereafter (each Regional HNP Sector Manager with Review and restructure existing HNP of 66% of proj- Region and total HNP portfolio). support from HNP Sector Board HNP portfolio (project design and/or ects closing Hub, IEG, DEC and Operations, Policy, project development objective, PDO) with satisfac- and Country Services (OPCS) to achieve satisfactory PDO or higher tory PDO or outcome at project closing. higher result (FY2005 and FY2006) 8. Concurrent monitoring of overall Does not exist Develop by end-FY2008; Develop: HNP Hub in collaboration active Bank portfolio performance implement by end-FY2009. with results team in OPCS/DEC and and PDO indicators on HNP results. with Information Solutions Group Develop and implement central Implement: HNP Sector Board database with HNP project results Manage: HNP Hub and HNP Sector based on ISR and project results Board framework data online for monitor- ing portfolio results and quality. Table 8.2: Five-Year Action Plan--Strengthening Health Systems and Ensuring Synergy between Health System Strengthening and Priority­Disease Interventions WHAT? BASELINE HOW MUCH AND BY WHEN? BY WHOM? 9. Increase support to Bank country teams Less than 25% Develop operations toolkit for rapid Identify countries: Regional HNP to identify health system constraints identify health assessment of health system Sector Managers with support from (including gender-specific constraints) system constraints for better outcomes HNP Hub. to achieving HNP results and main- constraints. (completed by end- FY2008). Provide support to country teams: stream system strengthening actions to Less than 45% Complete identification of 7 Health System Policy Team (HSPT). overcome constraints in all new HNP include health countries by December 2007. Support client countries in designing operations (or other sectoral or global system Launch on-demand support in four system strengthening interventions: partner operations), including priority- strengthening countries by June 2008. Country teams with on-demand disease interventions. in areas of Put on-demand support in place to support from HSPT. Bank compar- Bank country teams in 7 countries Support country teams in assessing ative advan- by June 2009. health system constraints: HNP Hub. tages. At least 60% of projects approved in FY2009 and thereafter will include assessment of health system con- straints to reaching HNP results. At least 70% of those identifying constraints will include appropriate policy actions/investments to overcome them. (Continues on the following page) Implementing New Bank HNP Strategic Directions 103 Table 8.2: Five-Year Action Plan--Strengthening Health Systems and Ensuring Synergy between Health System Strengthening and Priority­Disease Interventions (continued) WHAT? BASELINE HOW MUCH AND BY WHEN? BY WHOM? 10. Assemble Health Systems Policy Team Does not exist Write TORs and launch recruitment HNP Hub in coordination with HD (HSPT) and hire additional health system process by December 2007. Council and HNP Sector Board. Team staff for the Regions. (Contingent to Complete recruitment by June 2008. would be located in restructured Budget Availability). Put team in place and working by HNP Hub. December 2008. Regional staff in regions. 11.Put in place arrangements for collabor- Does not exist Dialog in place for global Global arrangements: HNP Network ative division of labor on health systems arrangements by December 2007. Director with support from HD Vice with global partners at global and Launch collaborative division of labor President, HD Council, HNP Sector country levels. arrangements for at least 10 coun- Board, and HSPT. tries where projects/programs Country-level arrangements: Country include interventions requiring exper- teams with support of Regional Sec- tise other than Bank comparative tor Manager and HSPT. advantages (by December 2008). 12. Focus knowledge creation and policy Less than 35% By end-FY2008, 50% and by Regional HNP Sector Manager with advice (AAA) on Bank comparative so focused end -FY2009 70% of new HNP sector support from HSPT. advantage. AAA will be focused on areas of Increase proportion of country- and Bank comparative advantage in regional-level AAA, appropriate to specific areas appropriate for LICs' requirements of LICs and MICs, focused and/or MICs' requirements, on Bank comparative advantages. e.g., health system financing, demand-side determinants of results, intersectoral contribution to HNP results, private-public collaboration. 13. Develop and implement a training and Does not exist In place by end-FY2008; 30% of HNP HNP Sector Board with support from accreditation program for Bank staff on staff accredited by end-FY2009; HNP Hub, WBI, and DEC. technical and operational aspects of 60% of HNP staff accredited by health system strengthening. end-FY2010. Intersectoral work for HNP results will be strengthened in two phases. First, the Bank will develop necessary tools to identify intersectoral con- straints to achieving HNP results. The tools will be used to identify poten- tial operations (whose primary objective is achieving HNP results), or iden- tify potential actions/components (in operations whose primary objective is not HNP results) and to suggest the AAA work required to overcome the constraints. For that, the Bank will develop the Multisectoral Constraints Assessment tool. Second, the Bank, upon country demand, will further experiment with multisectoral operations when the country context lends itself to it. Table 8.3 summarizes actions to be taken by the HNP sector to improve intersectoral work for HNP results. 104 Healthy Development Table 8.3: Five-Year Action Plan--Strengthening Bank Intersectoral Advisory Capacity WHAT? BASELINE HOW MUCH AND BY WHEN? BY WHOM? 14. Develop, pilot test, and implement Does not exist First tool will be developed by Development: Intersectoral thematic Multisectoral Constraints Assessment end-FY2008 and pilot tested in group (all sectors concerned through (MCA) tool and process. Pilot test in a 2 MICs and 2 LICs by end-FY2009. respective Hub Sector Managers, led number of LICs and MICs. by HNP Hub Sector Manager). Ad hoc technical team to design instrument. Selection of country pilots: Virtual intersectoral thematic group and Country Directors. Implementation of pilots: Ad hoc TTL from country team and Regional Sec- tor Manager, under oversight of intersectoral thematic group. 15. Identify lending and AAA in CAS. Does not exist MCA will be used to identify 40% Regional HNP and other Sector Man- MCA-identified HNP-related Bank of projects/programs with HNP agers involved with support from projects/programs/components results included in at least 50% of HNP Hub and intersectoral thematic in CAS. new CASs discussed with Board by group. FY2010 and thereafter. 16. Develop, implement, and manage an Does not exist Functioning by December 2007. The thematic group would be com- intersectoral coordination thematic posed of interested sectors through group for HNP results. their respective sector Hub Managers. Development: HNP and other sector Hub Managers. Management: HNP Hub Director. To increase selectivity and achieve complementarity with global partners, the HNP sector will seek agreements with them on collaborative division of labor. The Bank will concentrate its knowledge creation and policy advice activities on its areas of comparative advantage. It will seek its partners' advice on areas in which it has limited or no comparative advantage. Table 8.4 summarizes specific actions to be taken by the HNP sector to improve selectivity and collaborative division of labor with global partners. HNP Hub Mission and Organizational Changes The HNP hub will facilitate HNP network implementation of the new Strategy. In order to adequately play its role, the Hub will adjust its organi- zational structure and functioning in four work teams as follows: Implementing New Bank HNP Strategic Directions 105 Table 8.4: Five-Year Action Plan--Increasing Selectivity, Strategic Engagement, and Collaborative Division of Labor WHAT? BASELINE HOW MUCH AND BY WHEN? BY WHOM? 17. Increase use of harmonization and By FY2011, at least 81% of projects Country teams with support of alignment principles for Bank projects approved by Board will be based on Regional Sector Manager, Regional in at country level. country fiduciary systems or will Fiduciary Teams, and on-demand have common fiduciary support from HSPT. arrangements/rules for all participating donors. 18. Develop overall HNP fiscal space Does not exist Develop and pilot fiscal space HNP Hub in collaboration with DEC assessment in priority countries assessment methodology (completed and PREM and with regional HD by end of FY2008). Departments. Full fiscal space assessment in 7 Country teams with support from priority countries in coordination HNP Hub. with Global Partners. 19. Review and reorient Bank grants (DGF) Currently less By end-FY2008, 5%, by end-FY2009 HNP Sector Board with support of in HNP toward areas of Bank compara- than 1% of DGF 30%, and by end- FY2010 50% of HNP Hub. tive advantages. grant financing DGF grant financing will be allocated is allocated to in partnerships related to Bank partners work- comparative advantages. ing on issues related to Bank comparative advantages. 20. Realign secondments and Trust Fund Currently 60% By end-FY2009, 80% of secondments management in HNP sector with Bank of secondments to Bank and 80% of total Trust Fund comparative advantages. in HNP sector financing managed by HNP sector are in areas in will be in areas of Bank comparative which Bank has advantages. little compara- tive advantage. Performance Monitoring and Action Team This team will be responsible for the maintenance of a data base of HNP indi- cators; the maintenance of a data base of health financing indicators; contribu- tions to institutional reports (Global Monitoring Report [GMR], Country Performance and Institutional Assessment [CPIA], World Development Report [WDR], etc.); portfolio monitoring and quality enhancement; moni- toring and evaluation capacity building (staff and clients); and regular updating of progress on the HNP Results Framework, including support to country teams on results framework development. 106 Healthy Development Global Health Coordination and Partnerships Team The following functions will be covered: coordinate work with global partnerships and initiatives; facilitate selective fund raising and TF man- agement for the HNP network; DGF management support; selective joint ventures around themes of convergence (comparative advantages); and harmonization and alignment. Health Systems Policy Team The preparation of the Strategy has identified a gap in high-level health sys- tem policy skills to guide the implementation of the Bank agenda and an unmet demand from the Regions to receive timely support in their country dialog. It has also identified the need for practical and concrete advice to country teams and partners on how to overcome health system constraints to DAH effectiveness for results. This will become even more pressing with the new policy drivers of the HNP strategy. The team will: provide country teams with overall policy, technical, and operational advice on health sys- tems; manage knowledge creation on health systems, develop and manage technical assistance for the Multisector Constraints Assessment tool; respond to country team demands on ensuring synergy between priority­disease and system strengthening approaches; and advise global partners on the health system aspects for which the Bank has comparative advantages. About 50 percent of their time will be allocated to country-team support and field work. The team will focus closely on the following themes identified as priori- ties by client countries and global partners: health financing and economics, including health insurance; linkage to macroeconomic and fiscal policy; health service purchasing; health system governance; and facilitating syn- ergy between priority­disease and system strengthening in Bank operations. Technical Aspects of Public Health, Nutrition, and Population The team will support the Regions on technical aspects of core public health functions, disease control, nutrition, and population, supporting with existing in-house expertise but, more important, helping country teams establish the necessary working collaboration arrangements at coun- try level with technical agencies such as the WHO, UNICEF, UNFPA, and others. Implementing New Bank HNP Strategic Directions 107 Rebalancing Staff Skill-Mix The staff is the single most important asset of the Bank and its most impor- tant comparative advantage. Bank personnel working on HNP results rep- resent a wealth of multisectoral experience and knowledge from almost every country. Managing and strengthening this asset is crucial for good Bank performance on HNP results. The skill-mix of the HNP sector staff has undergone important changes. Focusing on Bank comparative advantages will require rebalancing the skill- mix of staff and management in two directions through new hiring and retooling/training of staff and management: increasing the proportion of economics and health systems skills and, more important, increasing the proportion of staff with recognized seniority in hands-on health system experience and sufficient breadth of knowledge to encourage and lead inter- sectoral work for HNP results (the horizontal part of the HR "T" skills) in high-level policy dialog with government counterparts. The HNP Sector Board and HD Council will ensure that future recruitment seeks out those skills for both staff and management appointments, to reach a balance between health specialist and economics/senior systems specialist. Preliminary Estimates of Strategy Implementation Costs The Board and management are currently discussing the budget allocations for FY2008 and beyond as part of the four-point engagement on the budget previously agreed. In this context, management and staff are undertaking a more detailed task-based budgeting exercise as part of the normal budget cycle. The resource requirements for implementing the HNP strategy will be a function of the pace of implementation of the Strategy (pace of change), the demand from countries, and the availability of resources in an environment of zero growth in the overall Bank budget. It is expected that the cost of implementing the new HNP Strategy will involve a modest increase in the base budget for the HD network over the FY2007 base budget, after taking into account one-off transitional adjustments. An extraordinary allocation to the HD network above the regular base budget will be utilized to finance these transition expenses, as justified. ANNEX A HNP Hub Action Plan and Regional Action Plans HNP Hub Action Plan The Health, Nutrition, and Population (HNP) Hub will facilitate HNP Network implementation of the new Strategy. In order to adequately play its role, the Hub will adjust its organizational structure and functioning in four work teams as follows: Performance Monitoring and Action Team This team will be responsible for the maintenance of a database of HNP indicators, the maintenance of a database of health financing indicators, contributions to institutional reports (e.g., GMR, CPIA, WDR); portfolio monitoring and quality enhancement, monitoring and evaluation (M&E) capacity building (staff and clients); and the regular updating of progress on the HNP Results Framework, including support to country teams on results framework development. Global Health Coordination and Partnerships Team The following functions will be covered: coordinate work with global partnerships and initiatives; facilitate selective fund raising and Trust Fund (TF) management for the HNP Network, Development Grant Facility (DGF) management support; selective joint ventures around themes of convergence (comparative advantages), and harmonization and alignment. 109 110 Healthy Development Health Systems Policy Team The preparation of the strategy has identified a gap in high-level health sys- tem policy skills to guide the implementation of the Bank agenda and an unmet demand from the Regions to receive timely support in their country dialog. It has also identified the need for practical and concrete advice to country teams and partners on how to overcome health system constraints to development assistance for health (DAH) effectiveness for results. This will become even more pressing with the new policy drivers of the HNP Strategy. The team will: provide country teams with overall policy, techni- cal, and operational advice on health systems; manage knowledge creation on health systems, develop and manage technical assistance for the Multi- sectoral Constraints Assessment (MCA) tool, and respond to country-team demands on ensuring synergy between priority disease and system strength- ening; advise global partners on the health system aspects for which the Bank has comparative advantages. About 50 percent of the team's time will be allocated to country-team support and field work. The team will focus closely on the following themes identified as priori- ties by client countries and global partners: health financing and economics, including health insurance; linkage to macroeconomic and fiscal policy; health service purchasing; health system governance; and synergy facilita- tion between priority disease and system strengthening in Bank operations. Technical Aspects of Public Health, Nutrition, and Population The team will support the Regions on technical aspects of disease control, nutrition, and population, drawing on in-house expertise but, more impor- tant, helping country teams establish the necessary working collaboration arrangements at country level with technical agencies such as the WHO, UNICEF, UNFPA, and others. Regional Action Plans Africa Region Health outcomes in the Africa Region are not progressing fast enough to achieve economic growth and reduce poverty (table A.1), and the Region is unlikely to meet the health Millennium Development Goals (MDGs). Annex A. HNP Hub Action Plan and Regional Action Plans 111 Laboring under geographical, environmental, cultural, and political chal- lenges, the HIV/AIDS crisis puts a heavier burden on Africa than on any other part of the world. What should be the Africa Region's response to the situation? Table A.1: Health Indicators in the Africa Region MATERNAL PREVALENCE MORTALITY RATE OF CHILD HIV (MMR) MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-06 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2005 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) Low income Benin 510 4.9 10.2 150 850 30 1.8 Burkina Faso 400 6.1 26.8 191 1000 38 2.0 Burundi 100 6.7 28.5 190 1000 45 3.3 Central African Republic 350 4.1 47.7 193 1100 24 10.7 Chad 400 4.2 7.0 208 1100 37 3.5 Comoros 640 2.8 18.3 71 480 25 0.1 Congo, Dem. Rep. of 120 4.0 19.1 205 990 31 3.2 Côte d'Ivoire 840 3.8 5.0 195 690 17 7.1 Eritrea 220 4.5 59.6 78 630 40 2.4 Ethiopia 160 5.3 35.2 127 850 38 1.4 Gambia, The 290 6.8 23.0 137 540 17 2.4 Ghana 450 6.7 29.9 112 540 22 2.3 Guinea 370 5.3 9.5 160 740 33 1.5 Guinea-Bissau 180 4.8 31.6 200 1100 25 3.8 Kenya 530 4.1 18.3 120 1000 20 6.1 Liberia 130 5.6 37.8 235 760 27 n.a. Madagascar 290 3.0 45.5 119 550 42 0.5 Malawi 160 12.9 59.4 125 1800 22 14.1 Mali 380 6.6 13.8 218 1200 33 1.7 Mauritania 560 2.9 20.2 125 1000 32 0.7 Mozambique 310 4.0 55.9 145 1000 24 16.1 Niger 240 4.2 21.3 256 1600 40 1.1 Nigeria 560 4.6 5.6 194 800 29 3.7 Rwanda 230 7.5 37.1 203 1400 23 3.0 São Tomé and Principe 390 11.5 53.3 118 n.a. 13 n.a. Senegal 710 5.9 12.8 119 690 23 0.9 Sierra Leone 220 3.3 35.4 282 2000 27 1.6 Somalia n.a. n.a. n.a. 225 1,100 33 0.9 Sudan 640 4.1 5.1 90 590 41 1.6 (Continues on the following page) 112 Healthy Development Table A.1: Health Indicators in the Africa Region (continued) MATERNAL PREVALENCE MORTALITY RATE OF CHILD HIV (MMR) MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-06 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2005 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) Tanzania 340 4.0 27.1 122 1,500 22 6.5 Togo 350 5.5 8.9 139 570 n.a. 3.2 Uganda 280 7.6 25.2 136 880 23 6.4 Zambia 490 6.3 36.3 182 750 23 17.0 Zimbabwe 340 7.5 13.1 132 1,100 n.a. 20.1 Middle income Angola 1,350 1.9 9.1 260 1,700 31 3.7 Botswana 5,180 6.4 2.5 120 100 13 24.1 Cameroon 1,010 5.2 5.3 149 730 18 5.4 Cape Verde 1,870 5.2 20.7 35 150 n.a. n.a. Congo, Rep. of 950 2.5 3.6 108 510 n.a. 5.3 Equatorial Guinea n.a. 1.6 3.8 205 880 19 3.2 Gabon 5,010 4.5 1.3 91 420 12 7.9 Lesotho 960 6.5 8.7 132 550 18 23.2 Mauritius 5,260 4.3 1.4 15 24 n.a. 0.6 Mayotte n.a. n.a. n.a. n.a. n.a. n.a. n.a. Namibia 2,990 6.8 16.9 62 300 24 19.6 Seychelles 8,290 6.1 2.4 13 n.a. n.a. n.a. South Africa 4,960 8.6 0.5 68 230 n.a. 18.8 Swaziland 2,280 6.3 9.5 160 370 10 33.4 Source: World Bank 2006o. Strategic Directions: How Should the Bank Support Country Efforts? Opportunities exist for the Africa Region to help clients improve HNP out- comes through a specific focus on fiscal and economic policy. RENEW BANK FOCUS ON HNP RESULTS. The Africa Region staff work closely with central ministries on designing Poverty Reduction Strategy Papers (PRSPs), and assist with public sector reform initiatives. Achieving more efficient and equitable spending and allocation of resources will entail evidence-based plan- ning to target resources where they will do the most to improve outcomes and reduce disparities between regions and groups. Because absent or weak accountability mechanisms undermine HNP strategies, the Bank, tapping its expertise in public sector governance, will assist country efforts to strengthen national and subnational accountability mechanisms. Annex A. HNP Hub Action Plan and Regional Action Plans 113 STRENGTHEN HEALTH SYSTEMS FOR HNP RESULTS. The World Bank will emphasize health systems as a key vehicle for improving HNP outcomes and protecting people from the impoverishing impact of illness. The Africa Region will draw on the Bank's global knowledge base and experience to help strengthen systems and institutional capacity, focusing on: health workforce limitations; access to, and management of, pharmaceuticals; institutional frameworks, including planning and budgeting capacity for pro-poor service delivery; and expanding household demand for services. MULTISECTORAL ACTION TO IMPROVE HNP OUTCOMES. Because many determinants of health lie outside the health sector, the World Bank has a unique opportunity to foster multisectoral action in the Africa Region. From the Bank's decision to emphasize multisectoral action for HIV/AIDS, lessons applicable to other diseases have begun to emerge. Areas where collaboration will increase synergy include: education, agriculture and food security, water and sanitation, road safety, energy, telecommunications, and environmental actions. SUSTAINABLE FINANCING OF HNP INTERVENTIONS. Total health expendi- tures in Sub-Saharan Africa (SSA) average 6 percent of gross domestic prod- uct (GDP) and US$13 per capita per year, compared with 5.6 percent and US$71 per capita per year in other developing countries. The poorest 18 African countries spend much less, an average of only US$2.10 per capita in 2000. Debt relief and DAH have helped lighten the health care load, and governments are trying out a variety of strategies to manage health financ- ing. Classical health insurance is not an option in most SSA countries because formal employment is low and perceptions and practice of corrup- tion fragment the solidarity and confidence on which insurance must be founded. However, a number of countries have started to experiment with community financing such as health funds, mutual health organizations, rural health insurance, revolving drug funds, and prepayment initiatives. Payment remains a major obstacle to use of health services among Africa's poor, and user payments still account for up to half of health expen- ditures in some SSA countries. In 2000, private expenditure represented between US$0.50 and US$21 per capita per year in the 38 poorest African countries. This is an issue that the Africa Region is following. The Africa Region can help countries address efficiency and equity issues by finding the right mix of public expenditures and international financing over the medium term. The marginal budgeting for bottlenecks (MBB) 114 Healthy Development instrument has been introduced in at least 10 countries. Work is also being done on contracting for services, including capitation-based payments. Deriving and disseminating lessons on public and private expenditures for health will be a priority for the Africa Region. Implications for Operations in the Africa Region In line with the Africa Action Plan of April 2005, the Africa Region HNP operations aim to achieve sustainable improvements on MDG-related indi- cators with high-impact interventions: · Helping countries build outcome-oriented and evidence-based national strategies, plans, and budgets, building on global knowledge and experience. · Strengthening the capacity of client countries' health systems to imple- ment these strategies. · Integrating the scaling up of support to malaria control and HIV/AIDS and interventions to combat malnutrition and child and maternal mor- tality. · Helping clients mobilize domestic resources and international financing. · Monitoring and evaluating (M&E) the impact of country strategies on health outcomes and helping countries develop their own M&E systems. In line with the Paris Declaration on Harmonization and Aid Effective- ness, the Africa Region will support country-level negotiations to reach agreement between the government and development partners on improv- ing aid alignment and effectiveness. The Region will continue to promote sectorwide approaches to help ensure that strengthened public and private health care systems are mutually reinforced by disease-specific programs. To that effect, project implementa- tion units should be avoided and common implementation procedures should be an objective. Africa Region staff must ensure that clients receive the best possible technical support and refer them to other partners, as necessary. HNP activities will be financed through both investment projects and Development Policy Lending (DPL). The Africa Region's approach to the transfer of resources is shifting from free-standing projects toward program- matic lending. Adaptable Program Loans/Credits (APLs) would support long-term commitment to sector programs. Poverty Reduction Support Annex A. HNP Hub Action Plan and Regional Action Plans 115 Credits (PRSCs) or Sector Adjustment Loans/Credits would be preferred if the government has the proper systems and procedures in place. In some set- tings such as post-conflict African countries, strengthening the Bank's pres- ence in the sector through more targeted subsectoral operations may be required before engaging the country in discussions of a sectorwide approach. East Asia and Pacific Region As one of the most diverse regions in the world, the East Asia and Pacific (EAP) Region encompasses some of the world's least-developed countries (e.g., Cambodia, Timor Leste) and some of the most rapidly emerging economies (e.g., China, Vietnam). Countries in the Region also differ along other dimensions--size, epidemiological profile (table A.2), vulnerability to natural disasters, and political stability. Yet some regional trends and pat- terns are discernable. Overall, the Region has seen rapid growth, both a cause and a consequence of increasing migration and urbanization, but inequalities have also widened--across individuals, urban and rural areas, and regions within countries. All these changes create both opportunities and challenges in the HNP sector. Most countries in the Region face a double burden of disease, with non- communicable diseases becoming increasingly important, while infectious diseases persist and new and reemerging diseases strain scarce health resources further. Moreover, the nutrition and population agendas remain important in many countries. At system level, decentralization, rising inequalities, expanding needs and expectations, and a large private sector role in both financing and service delivery have brought health system issues to the fore. While the need for health system reform is increasingly recog- nized, the consequences of pandemics have also become apparent following the SARS epidemic, AHI outbreaks, and the ever-present threat of HIV/AIDS. As a result, public health surveillance and outbreak control have gained importance in many countries in the EAP Region. Strategic Directions: How Should the Bank Support Country Efforts? OVERVIEW. The HNP Strategy in the World Bank's EAP Region calls for a focus on improved health outcomes for the poor, enhancing the perform- ance of health care systems, and securing sustainable health care financing. 116 Healthy Development Table A.2: Health Indicators in East Asia and Pacific Region PREVALENCE MMR OF CHILD HIV MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-05 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2004 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) Low income Cambodia 350 6.7 28.5 87 450 36 1.6 Korea, Democratic People's Republic of n.a. 5.6 0.0 55 67 24 n.a. Lao PDR 390 3.9 10.2 79 650 40 0.1 Mongolia 600 6.0 4.6 49 110 13 0.1 Myanmar n.a. 2.2 13.1 105 360 32 1.3 Papua New Guinea 560 3.6 26.5 74 300 n.a. 1.8 Vietnam 540 5.5 2.0 19 130 28 0.5 Middle income China 1,500 4.7 0.1 27 56 8 0.1 Indonesia 1,140 2.8 1.3 36 230 28 0.1 Malaysia 4,520 3.8 0.1 12 41 11 0.5 Philippines 1,170 3.4 3.6 33 200 28 0.1 Thailand 2,490 3.5 0.3 21 44 n.a. 1.4 Source: World Bank 2006o. Within that framework, each country team has developed a strategy for HNP that is consistent with the Country Assistant Strategy (CAS) and which responds to both demands from client countries and Bank capacity. The country-specific strategy also takes into account the role and activities of other development partners. In a region as diverse as EAP and with a strong MIC presence, a strong country focus is essential and will be maintained as the Bank moves forward, emphasizing HNP outcomes and results. · In middle-income countries, the focus is on using various tools for innovation, learning, and addressing reform issues. Lending is expected to continue, but it will be centered on health system strengthening and supported by a strong program of analytic work. Analytic work and lending on disease- specific issues will continue where there is demand and a strategic role for the World Bank. · In low-income countries, external financing from the World Bank and other development partners will play an important role relative to domestic resources. Annex A. HNP Hub Action Plan and Regional Action Plans 117 Donor coordination is critical. As in middle-income countries, support of health system strengthening through both analytic work and lending will be important, but improved donor coordination and multisectoral work to address broader determinants of health outcomes are also critical ele- ments of success. Where governance and fiduciary systems permit, devel- opment policy lending will gain importance, but investment lending is likely to remain a relevant instrument. RENEW BANK FOCUS ON HNP RESULTS. Focus on HNP outcomes and results is an integral part of both the ongoing portfolio and pipeline activi- ties. This includes: · Outcome-based country strategies. As in other Regions, country strategies provide the basis for the HNP work program. Drawing on the regional strategy and the global HNP Strategy, country teams in the EAP Region prepare country strategy notes for the HNP sector. These strategy notes seek to identify key constraints to improving HNP outcomes, as well as strategic areas for Bank support to address these constraints, serve as the basis for dialog with government and key partners at the country level. · Strong results framework in programs and AAA work. Some of the success stories include the Timor health program (Bustreo et al. 2005), the HIV/AIDS prevention project in Vietnam that supported the develop- ment of a monitoring and evaluation framework, the National Sector Support for Health Reform Project in the Philippines that has piloted performance-based contracts between central and local government, and the Health Eight Project in China that has demonstrated results that have helped influence policy of rural health delivery programs in China. · Impact evaluation of selected programs. The Region has invested, and will continue to invest, in selected impact evaluation efforts. These are inte- gral to the overall knowledge generation and sharing efforts of the Bank to help inform broader policy dialog and program design. STRENGTHEN HEALTH SYSTEMS FOR HNP RESULTS. Many countries in the Region are exploring ways to make health financing more equitable, increase access to health care, improve the performance of both public and private health care providers, strengthen pharmaceutical systems, and address imbalances in the health workforce. Reforms in these areas are par- ticularly challenging as they are often being implemented in contexts where 118 Healthy Development governance arrangements, intergovernmental fiscal relations, and social security systems are changing at the same time. Given these challenges, client demand for support on health system strengthening, and on related governance and public sector management issues, has seen significant growth. Ongoing and planned activities include both lending and analytic work, often with strong complementarities. ENSURE SYNERGY BETWEEN HEALTH SYSTEM STRENGTHENING AND PRIORITY­ DISEASE INTERVENTIONS. The limited number of disease-specific programs in the Region reflect client demand and regional issues. Nevertheless, emphasis should be put on systemic issues and linkages to broader health sector reform. MULTISECTORAL ACTION TO IMPROVE HNP OUTCOMES. Cross-sectoral collaboration is an essential element of outcome-based strategies. These collaborations can take several forms: policy alignments with other sectors, joint sectoral programs to achieve desired impacts on health outcomes, and working with other sectors to achieve desired HNP outcomes. However, it is important to identify which cross-sectoral tasks are likely to produce the desired impacts on HNP outcomes. STRATEGIC PARTNERSHIPS. Strategic partnerships are fundamental to the EAP Strategy and are important for both analytic work and lending opera- tions. The key for such partnerships is how they work at the country level and leverage the overall agenda. Several business models developed through the various partnerships provide the flexibility needed to respond to client and donor needs. DIVERSE PRODUCT LINES. The EAP Region has been expanding its product line to respond to various demands and improve results. The Comprehen- sive Development Partnership model in Thailand (an excellent approach to work in partnership with MIC clients), the DFID-Bank partnership in China, the different partnership models and stand-alone trust-funded oper- ations, and the various lending instruments used for cross-sectoral work all reflect the wide range of AAA, lending, and partnership products being used. Impact evaluation is also seen as another stand-alone product line. Making sure that the different products come together at the country level is now critical to achieve the desired HNP outcomes and results. Annex A. HNP Hub Action Plan and Regional Action Plans 119 Eastern Europe and Central Asia Region In the ECA Region, the new World Bank HNP Strategy will have to reflect real and growing differences (table A.3) between countries and subregions. Implementation approaches will have to be custom-made to fit specific coun- try and/or subregional situations. A large part of ECA HNP staff is based in the field, which increases the ability to be responsive to counterpart needs. Table A.3: Health Indicators in the Eastern Europe and Central Asia Region PREVALENCE MMR OF CHILD HIV MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-05 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2005 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) Low income Kyrgyz Republic 440 5.6 15.1 67 110 7 0.1 Tajikistan 330 4.4 9.1 71 100 n.a. 0.1 Uzbekistan 510 5.1 3.9 68 24 8 0.2 Middle income Albania 2,580 6.7 2.4 18 55 14 n.a. Armenia 1,470 5.4 7.2 29 55 3 0.1 Azerbaijan 1,240 3.6 1.6 89 94 7 0.1 Belarus 2,760 6.2 n.a. 12 35 n.a. 0.3 Bosnia and Herzegovina 2,440 8.3 1.3 15 31 4 0.1 Bulgaria 3,450 8.0 1.0 15 32 n.a. 0.1 Croatia 8,060 7.7 0.4 7 8 n.a. 0.1 Czech Republic 10,710 7.3 0.0 4 9 n.a. 0.1 Estonia 9,100 5.3 0.5 7 63 n.a. 1.3 Georgia 1,350 5.3 9.8 45 32 n.a. 0.2 Hungary 10,030 7.9 0.4 8 16 n.a. 0.1 Kazakhstan 2,930 3.8 0.9 73 210 n.a. 0.1 Latvia 6,760 7.1 0.3 11 42 n.a. 0.8 Lithuania 7,050 6.5 3.1 9 13 n.a. 0.2 Macedonia, FYR 2,830 8.0 1.4 17 23 n.a. 0.1 Moldova 880 7.4 4.8 16 36 4 1.1 Poland 7,110 6.2 0.1 7 13 n.a. 0.1 Romania 3,830 5.1 25.0 19 49 3 0.1 Russian Federation 4,460 6.0 0.1 18 67 6 1.1 Serbia and Montenegro 3,280 10.1 0.5 15 11 2 0.2 Slovak Republic 7,950 7.2 0.0 8 3 n.a. 0.1 Turkey 4,710 7.7 0.0 29 70 4 n.a. Turkmenistan n.a. 4.8 0.4 104 31 12 0.1 Ukraine 1,520 6.5 0.7 17 35 1 1.4 Source: World Bank 2006o. 120 Healthy Development Strategic Directions: How Should the Bank Support Country Efforts? RENEW BANK FOCUS ON HNP RESULTS. The evolving issues across the ECA Region, together with the priorities reflected in the new HNP Strategy, have resulted in a focused and quantifiable set of results-based indicators: · HIV/TB rates in line with MDG targets. · Nutritional MDG targets achieved in Central Asia and Caucasus. · Premature death and disability from noncommunicable diseases reduced by 20 percent. · Increased sector transparency and improved governance, as measured by reduction in informal payments and transparent drug procurement. · Inequalities in access to necessary services reduced by 25 percent--par- ticular focus on minorities. · Health care infrastructure at sustainable levels, providing continuum of services at high-quality health and cost-effectiveness. · Increase patient satisfaction with service quality by 25 percent. · ECA countries to introduce risk-pooling arrangements, guaranteeing minimum protection and risk mitigation for poor. · ECA countries to develop plans for demographic transition, including long-term care financing and service provision. · Improved understanding, among decision makers, of public health and cross-sectoral dimension of health determinants (e.g., transport, water, infrastructure, education). STRENGTHEN HEALTH SYSTEMS FOR HNP RESULTS. Improved results must also be achieved on health system issues such as transparency, governance, informal payments, access to health services, and measurement of results. The largely unfinished agenda of ensuring appropriate health infrastruc- ture, including necessary intersectoral linkages to other types of social serv- ices, will also need priority attention. This will become increasingly impor- tant as more and more of the Soviet-era infrastructure wears out. ECA HNP sees an increasing emphasis from counterparts on health financing and fiscal sustainability (e.g., provider payments, benefits pack- ages, informal payments), as well as capacity building, including policy Annex A. HNP Hub Action Plan and Regional Action Plans 121 development, human resources management, health services planning (including with respect to rationalization of health facilities and services), health care management, quality improvement, national health accounts, and improved monitoring and evaluation systems. This reflects an ongoing shift from "rowing" to "steering" in the counterpart Ministries of Health, and the concomitant need for adaptation by other parts of the health sys- tem. Other evolving issues center on medical education and regulatory/gov- ernance functions (training/retraining, continuous medical education, licensing, and accreditation). MULTISECTORAL ACTION TO IMPROVE HNP OUTCOMES. The upgrading of public health/surveillance capability is an important issue in many countries, underscored by recent developments regarding avian flu. In light of the changing demographics and rapid aging in many ECA countries, appropriate provision and financing of long-term care is another emerging issue with signif- icant multisectoral implications, especially as related to the social protection system. Many countries are interested in private health insurance as a way of relieving pressure on government programs, but good examples are scarce. Similarly, a number of countries have expressed interest in health savings accounts and have asked for World Bank assistance in exploring this issue. The unfinished health infrastructure agenda will require increased interac- tion with the energy and infrastructure sectors, to ensure that proposed approaches are the most cost-effective available. Gains from energy effi- ciency investments alone could yield significant payoffs in terms of freeing up resources for direct service delivery. STRATEGIC PARTNERSHIPS. Key technical partners in ECA include the WHO- EURO, CDC, the European Center for Disease Prevention and Control, OECD, and the IMF. Strategic partners would include the European Com- mission, the European Investment Bank, and IFC (potentially in the area of public-private partnerships). A critical partnership is the ongoing collabora- tion with the European Observatory on Health Systems and Policies, which is supported by the World Bank (through the Development Grant Facility). Implications for Operations in the ECA Region Overall, it is expected that there will be less emphasis on direct financing of health infrastructure and equipment, and an increased need for developing capac- 122 Healthy Development ity for health technology assessment and attention on developing facility rationali- zation strategies, a large, unfinished agenda in most ECA countries. Ensuring high-quality portfolio performance is important as an accountabil- ity indicator, but also as evidence of the Bank's comparative advantage. There will also be a growing need to continue exploring a widened range of instruments for supporting client countries, including reimbursable TA, jointly funded programs, and subnational lending (in some countries). Both budget and staffing issues are interlinked constraints to achieving these results. In the face of declining Bank budgets (resulting from reduced lending activity), maintaining policy dialog with countries across the Region becomes increasingly difficult (box A.1). Perhaps even more important, continuity and relationship management issues must be addressed if the Bank is going to be suc- cessful. The skill set needed will include direct hands-on experience in health system reform and management, health financing, and other key areas, as well as the ability to identify needs, coherently engage in discussions with counter- parts, and quickly arrange for these needs to be addressed in a substantive way. This will be a critical element for maximizing both the Bank's ongoing engage- ment as well as new business opportunities: improving the capacity of staff to choose the right approach to meeting counterpart needs in terms of lending instruments, nonlending support, technical assistance, and policy dialog. Box A.1: HNP and the MIC Agenda The Bank, in its relations with middle-income client countries, will seek to: · Become reestablished as the partner of choice in development knowledge and finance, for its reservoir of global expertise, range of products and services, attractive financial terms, and ability to catalyze support from other partners. · Maintain and, where possible, increase the quality of lending and other services to meet increased demand. · Strengthen the ability of its staff to respond to the specific needs of the diverse group of MIC countries. These principles encourage MICs to continue or resume borrowing, by removing impedi- ments and providing other "value-added" benefits, such as policy advice and technical assis- tance. But what about countries that either no longer need or want to borrow? The lack of sustained engagement, in the absence of lending, weakens business development efforts and client relations generally, thus reducing further the prospects for new lending business. This is perhaps a more critical issue in HNP, where in-depth knowledge of the sector takes time and ongoing involvement. Source: World Bank 2006p. Annex A. HNP Hub Action Plan and Regional Action Plans 123 Latin America and the Caribbean Region Following a wave of health sector reforms, countries in the Latin America and the Caribbean Region (LCR) have made great strides in the way they finance, regulate, and deliver health care. Overall, impressive gains have been made in health outcomes and services in the past 15 years, but generaliza- tions are difficult in so widely diverse an area. Some groups have benefited far more than others from these advances, and results have been insufficient in some key areas such as malnutrition and maternal mortality (table A.4). Table A.4: Health Indicators in the Latin America and the Caribbean Region PREVALENCE MMR OF CHILD HIV MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-06 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2005 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) Low income Haiti 450 7.6 14.2 120 680 17 3.8 Middle income Argentina 4,470 9.6 0.2 18 82 4 0.6 Barbados .. 7.1 2.0 12 95 n.a. 1.5 Belize 3,500 5.1 5.3 17 140 n.a. 2.5 Bolivia 1,010 6.8 9.1 65 420 8 0.1 Brazil 3,460 8.8 0.0 33 260 n.a. 0.5 Chile 5,870 6.1 0.1 10 31 1 0.3 Colombia 2,290 7.8 0.1 21 130 7 0.6 Costa Rica 4,590 6.6 0.8 12 43 n.a. 0.3 Dominica 3,,790 5.9 3.0 15 n.a. n.a. .. Dominican Republic 2,370 6.0 1.5 31 150 5 1.1 Ecuador 2,630 5.5 0.8 25 130 12 0.3 El Salvador 2,450 7.9 1.2 27 150 10 0.9 Grenada 3,920 6.9 1.5 21 n.a. n.a. .. Guatemala 2,400 5.7 2.3 43 240 23 0.9 Guyana 1,010 5.3 8.2 63 170 14 2.4 Honduras 1,190 7.2 8.7 40 110 17 1.5 Jamaica 3,400 5.2 1.4 20 87 4 1.5 Mexico 7,310 6.5 0.3 27 83 n.a. 0.3 Nicaragua 910 8.2 11.3 37 230 10 0.2 Panama 4,630 7.7 0.2 24 160 n.a. 0.9 Paraguay 1,280 7.7 1.9 23 170 5 0.4 Peru 2,610 4.1 1.3 27 410 7 0.6 (Continues on the following page.) 124 Healthy Development Table A.4: Health Indicators in the Latin America and the Caribbean Region (continued) PREVALENCE MMR OF CHILD HIV MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-06 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2005 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) St. Kitts and Nevis 8,210 5.2 1.8 20 n.a. n.a. n.a. St. Lucia 4,800 5.0 0.7 14 n.a. n.a. n.a. St. Vincent and the Grenadines 3,590 6.1 0.1 20 n.a. n.a. n.a. Suriname 2,540 7.8 9.7 39 110 13 1.9 Trinidad and Tobago 10,440 3.5 0.2 19 160 6 2.6 Uruguay 4,360 8.2 0.3 15 27 n.a. 0.5 Venezuela, R. B. de 4,810 4.7 0.0 21 96 4 0.7 Source: World Bank 2006o. Note: n.a. = not available. Strategic Objectives: What HNP Results? Given the heterogeneity of the Region, the scope of Bank activities is nec- essarily broad. Consistent with its new HNP Strategy and in line with its comparative advantages, the Bank will continue to help countries pursue four broad Strategic Objectives: improve focus on the poor to reduce inequity; strengthen government attention to public goods; improve health financing for greater equity, efficiency, and sustainability; and improve health system stewardship and governance. Strategic Directions: How Should the Bank Support Country Efforts? RENEW BANK FOCUS ON HNP RESULTS. LCR has used the Bank's compar- ative advantage to help countries improve results in health and nutrition, with an emphasis on reducing inequalities by targeting the poor and most- vulnerable population groups. The Bank supported Argentina in developing and implementing a new maternal and child health insurance program (Plan Nacer), targeting poor and indigenous women and children living in urban and rural parts of the nine poorest provinces. Twenty months after the project went into effect, half of the eligible population (400,000 beneficiaries) was enrolled in the program. Ten months after the federal government negotiated targets with provincial health authorities, an average of 7 out of 10 indicators had been Annex A. HNP Hub Action Plan and Regional Action Plans 125 achieved or surpassed. Similar results-based models are being employed in Ecuador, Nicaragua, and Paraguay in Bank-supported projects. STRENGTHEN HEALTH SYSTEMS FOR HNP RESULTS. In high-middle-income and several low-middle-income LCR countries where most of the popula- tion has access to basic health care services, governments are expanding social protection in health. Other low-middle-income countries where the provision of basic services is still an important challenge are focusing on strengthening health systems to expand the supply of these services. The Bank has supported countries' efforts to strengthen health systems by developing new organizational and institutional arrangements to extend social protection in health, with a focus on basic health care services for poor mothers and children. In Bolivia, the Bank for the first time condi- tioned disbursements on the achievements of outputs and intermediate indi- cators to provide health insurance to poor mothers and children. Other sim- ilar efforts include the Argentina Maternal and Child Health Insurance, the Health Sector Reform in Bahia, Brazil, the PROCEDES Project in Mexico, and Maternal and Child Basic Health Insurance in Paraguay. The regional study Beyond Survival: Protecting Households from Health Shocks in Latin America (2006) has launched a regional dialog on this urgent topic. In Brazil, health sector projects such as Family Health Extension and the Second Disease Surveillance and Control Projects introduced performance- based financing in the federal Health Ministry (MOH). Based on a pooled- financing SWAp, these projects mingle loan financing with MOH grants to states and municipalities. Participating subnational entities sign contracts that specify activities and corresponding performance indicators. Achieve- ment of performance benchmarks determines future levels of financing. In Nicaragua, the Bank has worked with other development partners (UNFPA, IADB, and the governments of Austria, Holland, Finland, and Sweden) in supporting the government's national strategy and action plan to strengthen the health system to improve access to basic health care serv- ices. In Peru, the first Health Reform APL supported development of insur- ance for nearly three million mothers and children. In both countries, good results have been confirmed in coverage and equity. During Argentina's socioeconomic and political crisis that reached its peak in 2002, the Bank helped the government maintain the health system's capacity to deliver basic health services and goods to the poor and the unin- sured. The Health Emergency Project was part of a multisectoral strategy 126 Healthy Development and supported the government's effort to transform this major challenge into an opportunity to strengthen the health system. ENSURE SYNERGY BETWEEN HEALTH SYSTEM AND PRIORITY­DISEASE INTER- VENTIONS. The Bank works closely with governments in IDA-eligible or IBRD/IDA-mixed countries to balance single-disease and targeted pro- grams with health system strengthening. In Honduras and Nicaragua, for example programs that prioritize mother and child health interventions are fully integrated within the national strategies and action plans to improve national health care systems. In 10 Caribbean countries and Central America, the Bank is supporting HIV/AIDS programs that foster complementarities between health care systems and other important actors. MULTISECTORAL ACTION TO IMPROVE HNP OUTCOMES. The HNP team in LCR works actively with other sectors and departments on a broad range of analytical and operational work initiatives. Recent examples include a mul- tisectoral analysis combining HNP, the chief economist of the Bank, Social Protection, PREM, and the government of Mexico, reviewing options for improving social protection in Mexico. The last Institutional and Gover- nance Review of Bolivia, led by PREM with the active involvement of HNP, analyzed policy options for an inclusive decentralization process. In the Dominican Republic HNP and PREM coordinated action on public sector reform to improve human resource policy effectiveness and national health procurement accountability. A new basic services and employment project is being prepared in Brazil, where HNP worked with teams from the Water Supply and Sanitation and the Sustainable Development Sectors to design a project to improve quality of life and reduce poverty. Malnutrition is a serious intersectoral problem that hinders economic growth and improvement of population well-being in several LCR coun- tries. The design and implementation of conditional cash transfer (CCT) projects offered HNP an opportunity to work with Social Protection, Edu- cation, and PREM to improve health and nutritional outcomes among poor mothers and children in El Salvador and Ecuador. Nutrition work is also underway in Guatemala and Peru. STRATEGIC PARTNERSHIPS. The LCR Region will continue to engage in strate- gic partnerships such as the multiorganizational review of HIV/AIDS projects in the Caribbean in 2006, conducted in collaboration with the Global Fund, Annex A. HNP Hub Action Plan and Regional Action Plans 127 UNAIDS, DFID, and Pan American Health Organization (PAHO)/WHO. In coordination with UNFPA, the Bank Maternal and Child Health Care Project in Argentina supported the launch of a new reproductive health program and procurement of inputs, giving poor women, for the first time, access to preven- tive and family planning services. Implications for Operations in the LCR Region The chief constraint on LCR health work is the declining budget, which is beginning to erode the Region's capacity. The diminishing personnel budget has already imposed a small contraction on the Region, which, even by Bank standards, already carries a very heavy workload. This constrains analytic work and may become a growing business impediment in a Region where the clients are technically sophisticated and expect state-of-the-art advice from the Bank. Middle East and North Africa Region The Middle East and North Africa (MENA) Region has made significant improvements in the health status of its people (table A.5). However, high rates of infant and maternal mortality, malnutrition, and micronutrient defi- ciencies persist in the low-income countries and among certain population groups in middle-income countries. With growing prosperity, the preva- lence of lifestyle-related noncommunicable diseases is rising. Strategic Objectives: What HNP Results? The MENA HNP Strategic Objectives reflect the varying needs of four cat- egories of countries at different stages of economic development: · Yemen and Djibouti, the two IDA countries in the Region, face the greatest challenges and are at risk of not meeting the HNP-related MDGs. In Dji- bouti, the HIV/AIDS epidemic is taxing the country's economic resources. · Middle-income countries (Algeria, Egypt, Iran, Jordan, Lebanon, Libya, Morocco, Syria, and Tunisia) are generally on track for achieving the health MDGs but rural/urban disparities in health outcomes and gaps in health coverage persist. 128 Healthy Development Table A.5: Health Indicators in the Middle East and North Africa Region PREVALENCE MMR OF CHILD HIV MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-05 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2004 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) Low income Yemen 570 5.0 15.0 102 570 46 n.a. Djibouti 960 6.3 34.0 133 730 27 3.1 Middle income Algeria 2,270 3.6 0.0 39 140 10 0.1 Egypt, Arab Rep. of 1,250 5.9 n.a. 33 84 9 0.1 Iran, Islamic Rep. of 2,330 6.6 0.2 36 76 n.a. 0.2 Iraq n.a. 5.3 2.5 125 250 16 n.a. Jordan 2,260 9.8 7.1 26 41 4 n.a. Lebanon 6,040 11.6 1.7 30 150 4 0.1 Morocco 1,570 5.1 0.9 40 227 10 0.1 Syria 1,270 4.7 0.2 15 160 7 n.a. Tunisia 2,650 n.a. n.a. 24 120 4 0.1 West Bank and Gaza n.a. n.a. n.a. 23 100 5 n.a. Gulf Cooperation Council Bahrain 14,370 4.0 0.0 11 28 n.a. n.a. Kuwait 24,040 2.8 0.0 11 5 n.a. n.a. Oman 9,070 3.0 0.0 12 87 n.a. n.a. Qatar n.a. 2.4 0.0 21 23 n.a. n.a. Saudi Arabia 10,170 3.3 n.a. 26 23 n.a. n.a. United Arab Emirates 23,770 2.9 0.0 9 54 n.a. n.a. Source: World Bank 2006o. · Members of the Gulf Cooperation Council (GCC), assisted by high oil rev- enues, have achieved universal access to health services and good health outcomes, but still have room for efficiency and quality improvements. · Conflict-affected countries are suffering significant reversals in health status and deterioration of their health systems (West Bank and Gaza, Iraq, and Lebanon). Strategic Objectives: What HNP Results? The HNP business strategy for the MENA Region will need to find an appropri- ate balance in responding to growing demand for knowledge products and to emer- Annex A. HNP Hub Action Plan and Regional Action Plans 129 gency and reconstruction operations. Due to the availability of alternative financing, the Bank is not seen as a primary source. The HNP team will cap- italize on the Bank's extensive international knowledge base and analytical capac- ity in health systems. Strategic Directions: How Should the Bank Support Country Efforts? RENEWING THE FOCUS ON HNP RESULTS. A regional HNP Strategy Report (ESW) is proposed for FY2008 to develop a conceptual framework for defining the HNP Results Framework for the MENA Region. In paral- lel, the HNP team will review the portfolio to identify potential synergies and gaps in AAA and lending and to ensure timely application of the frame- work in upstream work on Country Assistance Strategy. A major investment will be needed to develop effective monitoring and evaluation tools for measuring HNP Results. STRENGTHENING HEALTH SYSTEMS FOR HNP RESULTS. Across the MENA Region, demand is growing for health system modernization. The challenge is to define the areas in which the Bank has a comparative advantage. The following priority areas are identified: health finance reforms to improve financial protection and access to health care; improving the performance of health service delivery systems; and enhancing the governance and steward- ship role of the state in the health sector. Many governments in the MENA Region are seeking alternatives to their centralized government-managed health system, toward a more plu- ralistic system that includes active private sector participation. Demand is growing in the Region for technical advice on design and implementation of effective governance and regulatory functions, particularly accountability, where the Bank has a comparative advantage. MULTISECTORAL ACTION TO IMPROVE HNP OUTCOMES. Within the MNSHD department, the introduction of an HD coordinator function has contributed to a more integrated approach to Human Development (Educa- tion, Social Protection [SP], and HNP) at country level. Under this frame- work, HNP and SP teams collaborate closely in the areas of social security admin- istration and health insurance. MENA Region programs on youth and early childhood development include a significant health component and offer a basis for strengthening collaboration between the HNP and Education teams. 130 Healthy Development Other opportunities for collaboration are being explored in the Water and Sanitation and the Urban and Transport Sectors. With the PREM group, the MENA HNP team will be collaborating on two priority regional themes: gender, and governance and anticorruption. Finally, the MENA HNP team has been seeking active partnership with IFC and the Private Sector Unit in MENA to promote private-public partnership in health. STRATEGIC PARTNERSHIPS. As part of the MENA Regional Strategy, the HNP team will expand its collaboration with key regional partners and con- tinue to work with bilateral, multilateral, and private donors in partnership with the IBRD and IDA countries receiving funding from these sources. To enhance the ability of policy makers and health care managers to evaluate the impact of HNP policies and programs, the Bank is collaborating with international organizations, nongovernmental organizations, and academic insti- tutions to establish a Middle East and North Africa Health Policy Forum, mod- eled on the European Observatory on Health Systems and Policies. ADDRESSING THE NEEDS OF FRAGILE STATES AND CONFLICT-AFFECTED COUNTRIES. An increasing share of Bank resources and HNP staff time is being directed toward mobilizing and coordinating contributions from the donor community during reconstruction in Iraq, Lebanon, and West Bank and Gaza. In this, MENA HNP team will work closely with the new Frag- ile States Unit (FSU) and Conflict Prevention and Reconstruction Unit (CPRU). The Bank could play an important role in bridging the gap between short-term humanitarian operations and longer-term development activities and in ensuring adequate attention to investments in human capi- tal in recovering countries. REIMBURSABLE TECHNICAL ASSISTANCE. Reimbursable programs in the MENA Region increased from US$6 million in FY2004 to US$10 million in FY2006, some 12 percent of the MENA FY2006 budget. Most of the growth occurred under reimbursable technical assistance (RTA), now com- prising about US$7 million. RTA will continue to be a growing and impor- tant component of the MENA regional program, provided that the Bank can translate its international experience and knowledge into practical, country-tailored implementation actions. This will require access to a net- work of international expertise and continuous upgrading of knowledge about new developments in health system reform. Annex A. HNP Hub Action Plan and Regional Action Plans 131 South Asia Region The South Asia Region (SAR) encompasses only eight countries (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), but it is home to a quarter of the world's population. The countries vary widely in size, wealth, and health problems (table A.6), and dependence on international assistance. For all these reasons, the SAR HNP needs a dif- ferentiated strategic focus: · India, Pakistan, Bangladesh: MDGs; focus on disadvantaged; new approaches to noncommunicable diseases (NCDs); financial risk protection. · Afghanistan, Nepal: (the poorest countries) focus almost entirely on achieving MDGs. · Sri Lanka, Maldives, Bhutan: more focus on NCDs; financial protection; macro-financing for the HNP sector. Strategic Objectives: What HNP Results? The Strategy focuses on two outcomes: improved health status particularly for the poor and reducing health-related impoverishment through Table A.6: Health Indicators in the South Asia Region PREVALENCE MMR OF CHILD HIV MODELED MALNUTRITION PREVALENCE, HEALTH EXTERNAL U-5 MORTALITY, ESTIMATES, 2000-06 2005 (% GNI PER EXPENDITURE, ASSISTANCE, 2005 (PER 2000 (PER (% OF OF TOTAL INCOME GROUP/ CAPITA, 2004 2004 1,000 LIVE 100,000 LIVE UNDERWEIGHT POPULATION, COUNTRY 2005 (US$) (% OF GDP) (% OF TOTAL) BIRTHS) BIRTHS) U-5 CHILDREN) AGES 15­49) Low income Afghanistan n.a. 4.4 6.1 257 n.a. 39 0.1 Bangladesh 470 3.1 15.1 73 380 48 0.1 Bhutan 870 4.6 14.5 75 420 n.a. 0.1 India 720 5.0 0.5 74 540 n.a. 0.9 Nepal 270 5.6 17.6 74 740 45 0.5 Pakistan 690 2.2 2.5 99 500 38 0.1 Middle income Maldives 2,390 7.7 1.6 42 110 30 n.a. Sri Lanka 1,160 4.3 1.2 14 92 29 0.1 Source: World Bank 2006o. 132 Healthy Development improved financial risk protection. Implementation of the new Strategy would lead to an HNP portfolio "make over" by 2011, resulting in more outcome-focused operations, inventive approaches aimed at strengthening health systems, probably fewer but larger operations that use innovative lending instruments, and a substantial Bank role in encouraging, analyzing, and evaluating novel approaches. The portfolio will have more sectorwide programming and will help strengthen the monitoring and evaluation sys- tems in client countries to bolster the results culture. Strategic Directions: How Should the Bank Support Country Efforts? RENEWING THE FOCUS ON HNP RESULTS. The SAR HNP business plan is based on a results framework that links outcomes with specific strategies (figure A.1). At the regional level, the strategic priorities guide analysis of how to focus the instruments available to the Bank to get results and what resources and actions need to be developed in the Region. These approaches/strategies have been formulated to address the follow- ing priority areas: · Political economy: To increase attention and commitment to HNP out- comes; · Financing for adequate resources: Many SAR countries are very low investors in public health; essential inputs are lacking; · Public health functions: Government has a critical stewardship role to play in the sector in terms of regulation, setting and enforcing standards, surveillance and information. Government also has an important role to address market failures and create demand for the right services; · System innovations: Service delivery suffers widely from poor access, quality, and efficiency; · Improved accountability and governance capacities: Accountability is a key tool for improving service performance and improved governance is essential for implementation of any plan; · Measurement: Measuring results is a necessary element to create a process of continual, evidence-based improvement. Recent operations of the SAR HNP unit already include several of the features mentioned, such as sectorwide approaches, strengthening of public Annex A. HNP Hub Action Plan and Regional Action Plans 133 Figure A.1: Results Framework: An Innovations Agenda Examples of Intermediate Approaches system innovations outcomes Goal · Engage in new ways · Public­private · Improving · Health status gains, in the political partnership ­ access; especially for the economy and ­ quality; and poor, disadvantaged, strengthen client · Multisectoral ­ efficiency in and vulnerable, with relations approaches services delivery focus on: for priority health ­ MDGs · Provide finance for · More effective outcomes ­ NCDs improved outcomes health communications · Enhance demand · Financial protection · Devise system · Pay for for priority from impoverishing innovations performance services effects of health shocks · Improve · Reforms in human · Enhance health- accountability and resources producing governance behaviors capacities · More effective public sector · Broaden access to · Increase focus on, management effective financial and improve protection measurement of, · New technologies mechanisms results · Decentralization · Increase focus on public health functions · Demand-side financing · Financial protection mechanisms health functions, health insurance, etc. The unit's portfolio will gradually better reflect these reforms over the coming years. STRENGTHEN HEALTH SYSTEMS FOR HNP RESULTS. The Strategy recog- nizes several causes for the poor performance of health systems in the Region. These include (in no specific order): insufficient drive for improv- ing health outcomes from government and civil society leaders; over- centralized systems in which not enough resources reach the periphery; public sector service delivery that suffers from a poor incentive structure, weak management, rigid organization, and lack of accountability, and has few reasons for improving human resources that suffer from inadequate supply, overconcentration in urban areas, weak management, and limited incentives; insufficient engagement with the nongovernmental sector, 134 Healthy Development which already provides most curative services, even for the poor; high out- of-pocket costs for all, especially the poor, even in the public sector, and lack of organized financial risk protection; few effective efforts to improve health-promoting behaviors; and little effective targeting to reduce health status disparities by income, gender, or geographical location. INTERSECTORAL APPROACH TO HNP OUTCOMES. A team led by an HNP lead specialist and comprised of a mix of Country Directors, Sector Direc- tors, Sector Managers, and sector specialists will explore opportunities for operations focused on the specific role of various sectors working together to achieve HNP-related MDGs. Implications for Bank Operations in the SAR Region The South Asia Region Human Development Department (SASHD) HNP business plan creates space for innovation wherever possible, using all the instruments at its disposal. New staff skills and financial resources will be needed to support this innovations agenda, both from traditional trust fund sources as well as from new global and regional development partners, such as private foundations. The continuation of a dedicated M&E team (with a specific budget) will assist in improving M&E designs and staff knowledge. LENDING. Where possible, the lending program will move toward more pro- grammatic financing, sectorwide support, or multisectoral lending in close cooperation with other development partners. The programmatic lending could take the format of development policy lending or be more broadly defined as output-based lending. In general, lending will shift away from traditional items of buildings and equipment and toward areas such as health financing linked to results/performance, financial protection, public health functions of government, and cross-cutting systems issues such as human resources. Priority would be given to MDG-related interventions. AAA. The analytical and advisory work of SASHD HNP will focus on strengthening the analytical basis for innovative approaches to service deliv- ery and on disseminating evidence and analysis to decision makers through partnerships with WBI, other development partners, in-country institu- tions, and civil society organizations. Health financing will remain central, and increased attention will be given to governance and accountability. ANNEX B Acknowledgments This Bank HNP Strategy was prepared by a team led by Cristian C. Baeza (Lead Health Policy Specialist, LCSHH /Acting Director, HDNHE) and composed of Nicole Klingen (Senior Health Specialist, HDNHE), Enis Baris (Senior Public Health Specialist, ECSHD), Abdo S. Yazbeck (Lead Economist, Health, WBIHD), David Peters (Senior Public Health Special- ist, HDNHE), Eduard Bos (Lead Population Specialist, HDNHE), Sadia Chowdhury (Senior Health Specialist (HDNHE), Pablo Gottret (Lead Economist, HDNHE), Phillip Jeremy Hay (Communications Adviser, HDNOP), Meera Shekar (Senior Nutrition Specialist, HDNHE), Kathleen Lynch (Consultant), Eni Bakallbashi (Junior Professional Associate, HDNHE), Lisa Fleisher (Junior Professional Associate, HDNHE), Jessica St. John (Junior Professional Associate, HDNHE), Elisabeth Sandor (Health Specialist, HDNHE), Andrianina Rafamatanantsoa (Program Assistant, HDNHE), and Victoriano Arias (Program Assistant, HDNHE), with contributions from Rama Lakshminarayanan (Coordinator, HDNHE), Ariel Fiszbein (Adviser, DECVP), Maureen Lewis (Acting Chief Econo- mist, HDNVP), Susan Stout (Manager, OPCRX), Paul Gertler (former Chief Economist, HDNVP), John Newman (Country Manager, LCCPE), Jed Friedman (Economist, DECRG), Alison Buttenheim (Consultant, DECRG), Kulsum Ahmed (Lead Environmental Specialist, ENV), Mukesh Chawla (Lead Economist, AFTH2), Alexander S. Preker (Lead Economist, Health, AFTH2), Kees Kostermans (Lead Public Health Specialist, SASHD), Samuel Lieberman (Lead Economist, EASHD), Agnes Soucat (Lead Economist, AFTHD), Jean-Jacques de St. Antoine (Lead Operations Officer, AFTH1), Dominic Haazen (Senior Health Specialist, ECSHD), Amie Batson (Senior Health Specialist, HDNHE), Meera Shekar (Senior 135 136 Healthy Development Nutrition Specialist, HDNHE), Peter Kolsky (Senior Water and Sanitation Specialist, EWDWS), Michele Gragnolati (Senior Economist, ECSHD), April L. Harding (Senior Economist, Health, LCSHD), Olusoji Adeyi (Coordinator, HDNHE), Anne M. Pierre-Louis (Lead Health Specialist, AFTHD), George Schieber (Consultant, HDNHE), Katherine Tulenko (Public Health Specialist, EWDWP), Nicole Rosenvaigue (Senior Execu- tive Assistant, HDNHE), Pedro Arizti (Ecomonist, OPCRX), Maria Euge- nia Bonilla-Chacin (Economist, AFTH3), Feng Zhao (Health Specialist, AFTH1), John May (Senior Population Specialist, AFTH2), Jody Zall Kusek (Lead Monitoring and Evaluation Specialist, HDNGA), Peter Berman (Lead Economist, SASHD), Jan Bultman (Lead Health Specialist, ECSHD), Gerard La Forgia (Lead Health Specialist, LCSHH), Claudia Rokx (Lead Health Specialist, EASHD), Loraine Hawkins (Country Sector Coordinator, EASHD), Muhammad Pate (Senior Public Health Specialist, EASHD), Marcello Bortman (Senior Public Health Specialist, LCSHH), Aissatou Diack (Senior Public Health Specialist, AFTH2), Joana Godinho (Senior Health Specialist, LCSHH), Toomas Palu (Senior Health Special- ist, EASHD), Sameh El-Saharty (Senior Health Specialist, MNSHD), Patricio Marquez (Lead Health Specialist, ECSHD), Eric de Roodenbeke (Senior Health Specialist, AFTH2), Emmanuel Malangalila (Senior Health Specialist, AFTH1), Peyvand Khaleghian (Senior Health Specialist, ECSHD), Paolo Belli (Senior Economist, Health, SASHD), John C. Lan- genbrunner (Senior Economist, Health, MNSHD), Shiyan Chao (Senior Economist, Health, ECSHD), Pia Rockhold (Senior Operations Officer, HDNSP), Menno Mulder-Sibanda (Senior Nutrition Specialist, AFTH2), David Evans (Health Specialist, EASHD), Christoph Kurowski (Health Policy Specialist, LCSHD), Firas Raad (Health Specialist, MNSHD), Mag- nus Lindelow (Economist, EASHD), Monique Mrazek (Economist, Health, LCSHH), Pia Schneider (Economist, Health, ECSHD), Gilles Dussault (former Senior Health Specialist), Roland Peters (Director, OPCS), Markus Kostner (Country Program Coordinator, MNCA4), Susan Hume (Country Program Coordinator, EACPQ), Preeti Ahuja (Country Program Coordinator, EAC1Q), Lilia Burunciuc (Country Program Coor- dinator, AFCZA), Myla Williams (Country Program Coordinator, ECCUS), Jill Armstrong (Country Program Coordinator, AFCET), Robert Floyd (Country Program Coordinator, SACPA), Tom Buckley (Adviser, TUDUR), Patrick Leahy (Manager, CHEPG), Robert Taylor (Principal Annex B. Acknowledgments 137 Financial Analyst, CASDR), Rita Klees (Senior Environment Specialist, ENV), Gail Richardson (Senior Operations Officer, OPCRX), Katrina Sharkey (Senior Operations Officer, AFC07), Maryse Gautier (Senior Urban Management Specialist, LCSFU), Meera Chatterjee (Senior Social Development Specialist, SASES), Sudip Mozumder (Senior Communica- tions Officer, SAREX), Ruma Tavorath (Environment Specialist, SASES), Mohini Malhotra (Regional Coordinator, WBIND), Alexandra Humme (Partnership Specialist, WBIND), Barbry Keller (Operations Officer, AFCGH), Rachid Benmessaoud (Operations Adviser, SACIN), John Underwood (Consultant, OPCCS), Mario Gobbo (Principal Investment Officer, CGMGT, former Bank staff), Sanjeev Krishnan (Investment Ana- lyst, CGMGT, former Bank staff), Emi Suzuki (Research Analyst, HDNHE), Rifat Hasan (Junior Professional Associate, HDNHE), Alexan- der Shakow (Consultant), and Yunwei Gai (Consultant). Overall guidance to the team was provided by Jacques Baudouy (former Director, HDNHE), Nick Krafft (Director Network Operations, HDNVP), Joy Phumaphi (Vice President & Head of Network, HDNVP), Jean-Louis Sarbib (former Senior Vice President & Head of Network, HDNVP), James Adams (Vice President & Head of Network, OPCVP and Vice President & Head of Network, EAPVP), Danny Leipziger (Vice President & Head of Network, PRMVP), Xavier Coll (Vice President, HRSVP), Shanta Devarajan (Chief Economist, SARVP), Steen Jorgensen (Sector Director, ESDVP), Jamal Saghir (Director, EWDDR), James War- ren Evans (Sector Director, ENV), Yaw Ansu (Sector Director, AFTHD), Tamar Atinc (Sector Director, ECSHD), Evangeline Javier (Sector Direc- tor, LCSHD), Emmanuel Jimenez (Sector Director, EASHD), Michal Rutkowski (Sector Director, MNSHD), Julian Schweitzer (Sector Direc- tor, SASHD), Guy Ellena (Director, IFC), Debrework Zewdie (Director, HDNGA), Kei Kawabata (Sector Manager, HDNHE), Akiko Maeda (Sec- tor Manager, MNSHD), Anabela Abreu (Sector Manager, SASHD), Armin Fidler (Sector Manager, ECSHD), Eva Jarawan (Sector Manager, AFTH2), Fadia Saadah (Sector Manager, EASHD), Keith Hansen (Sector Manager, LCSHH), Ok Pannenborg (Senior Adviser, AFTHD), Bruno Andre Laporte (Manager, WBIHD), Elizabeth King (Research Manager, DECRG), and Susan Blakley (Senior Human Resources Officer, HRSNW). 138 Healthy Development Special gratitude is due to: Government officials of client countries who generously provided us with valuable recommendations and guidance on how the Bank can better sup- port their efforts to improve the lives of those who are most vulnerable, including: Ginez Gonzales (Minister of Health, Argentina), Norair Davidyan (Minister of Health, Armenia), Angel Cordoba (Minister of Health, Mexico), Julio Frenk (former Minister of Health, Mexico), Haik Darbinyan (Ministry of Health, Armenia), Levon Yolyan (Ministry of Health, Armenia), Ara Ter-Grigoryan (Ministry of Health, Armenia), Vahan Poghosyan (Ministry of Health, Armenia), Gohar Kyalyan (Ministry of Health, Armenia), Michael Narimanyan (Ministry of Health, Armenia), Samvel Kovhannisyan (Ministry of Health, Armenia), Suren Krmoyan (Ministry of Health Armenia), Derenik Dumanyan (Ministry of Health, Armenia), Sergey Khachatryan (Ministry of Health, Armenia), Eduardo Gonzales-Pier (Ministry of Health, Mexico), Mauricio Bailon (Ministry of Health, Mexico), Jaime Sepulveda (Ministry of Health, Mexico), Jorge Roel (Office of the Chief of Cabinet, Argentina), Gerardo Serrano (Office of the Chief of Cabinet, Argentina), Carmen Odasso (Office of the Chief of Cab- inet, Argentina), Walter Valle (Ministry of Health, Argentina), Leonardo Di Pietro (Ministry of Health, Argentina), Oscar Filomena (Ministry of Health, Argentina), Deepa Jain Singh (Ministry of Women and Child Development, India), N. K. Sethi (Planning Commission, India), Shri Prashant (Ministry of Finance, India), Bouaré Mountaga (Ministry of Health, Mali), Amadou Sanguisso (Ministry of Health, Mali), Souleymane Traoré (Ministry of Health, Mali), Touré Cheikna (Mutualité Malienne), Traoré Mamadou Namory (Ministry of Health, Mali), Thiécoura Sidibé (Ministry of Health, Mali), Mahamadou Choulibaly (Ministry of Health, Mali), Ousmane Sylla (Ministry of Health, Mali), Sidi Yeya Cissé (Ministry of Health, Mali), Coulibaly Youma Sall (Ministry of Health, Mali), Cissé Djita Dem (National Council of Pharmacists, Mali), Dicko Aboubacar (SNV, Mali), Saleh Banoita Tourab (Ministry of Health, Djibouti), Simon Mibrathu (Ministry of Finance, Djibouti), Omar Ali Ismail (Executive Sec- retariat HIV/AIDS, Djibouti), Fatouma Kamil (Ministry of Health, Dji- bouti), Mouna Osman (Ministry of Health, Djibouti), Safia Elmi (Ministry of Health, Djibouti), Mohamed Ali (Ministry of Health, Djibouti), Samatee Said Hadji (Ministry of Health, Djibouti), Barihuta Tharcisse (Ministry of Health, Djibouti), Abouleh Abdillahi (Ministry of Health, Djibouti), M. Mahyab (Ministry of Health, Djibouti), Ali Hugo (Ministry of Health, Annex B. Acknowledgments 139 Djibouti), Farhan Said Bourkad (Ministry of Health, Djibouti), Bahya Mohamed (Ministry of Health, Djibouti), Mohamed Aden (Ministry of Health, Djibouti), Nasser Mohmad (Ministry of Health, Djibouti), Bourhan Ahmed Duni (Ministry of Health, Djibouti), Abdiuaoui Youssouf (Ministry of Health, Djibouti), M. Watta (Ministry of Health, Djibouti), Hassan Kamil (Ministry of Health, Djibouti), Simon Mibrathu (Ministry of Health, Djibouti), Mugisha Kamugisha (Ministry of Finance, Tanzania), Gilbert Mliga (Ministry of Health, Tanzania), Regina Kikuli (Ministry of Health, Tanzania), Faustin Njau (Ministry of Health, Tanzania), Gabriel Upunda (Ministry of Health, Tanzania), Herman Lupogo (Tanzania AIDS Commis- sion), Christopher Sechambe (Tanzania AIDS Commission), Beng'i Issa (Tanzania AIDS Commission), Donald Mmbando (Tanzania AIDS Com- mission), Willing Sangu (Tanzania AIDS Commission), Ayoub Kibao (Tan- zania AIDS Commission), Dr. Bushiri (Tanzania AIDS Commission), Hashim Kalinga (Tanzania AIDS Commission), B. Muhunzi (Tanzania AIDS Commission), Emmanuel Humba (National Health Insurance Fund, Tanzania), Abdelhak Bedjaoui (Ministry of Finance, Algeria), Mohamed Messouci (Ministry of Finance, Algeria), Hedia Amrane (Ministry of Finance Algeria), Ali Chaouche (Ministry of Health, Algeria), Leila Ben- bernou (Ministry of Health, Algeria), Cherifa Zerrouki (Ministry of Health, Algeria), Nacera Madji (Ministry of Health, Algeria), Leila Hadj Messaoud (Ministry of Health, Algeria), Benamar Rahal (Ministry of Health, Algeria), Benamar Regal (Ministry of Health, Algeria), Nassima Keddad (Ministry of Health, Algeria), Mosleh Bourkiche (Ministry of Health, Algeria), Ahmed Tani Abi Ayad (Ministry of Health, Algeria), Djamal Fourar (Ministry of Health, Algeria), Amar Ouali (Ministry of Health, Algeria), Faouzi Amokrane (Ministry of Health, Algeria), Zakia Fodil Cherif (Ministry of Health, Algeria), Houria Khelifi (Ministry of Health, Algeria), Djamila Nadir (Ministry of Health, Algeria), Djaouad Braham Bourkaib (Ministry of Labor, Algeria), Farida Belkhiri (Ministry of Labor, Algeria), Mr. Halfaoui (Ministry of Labor, Algeria), Mr. Muharso (Board of Health Development and Human Resources Empowerment, Indonesia), Dwi Atmawati (Board of Health Development and Human Resources Empowerment, Indonesia), Dewi Nuraini (Board of Health Development and Human Resources Empowerment, Indonesia), Rachmi Untoro (Ministry of Health, Indone- sia), Rini Yudi Pratiwi (Ministry of Health, Indonesia), Dr. Erna Mulati (Ministry of Health, Indonesia), Kirana Pritasari (Ministry of Health, Indonesia), Eka Susi Ratnawati (Ministry of Health, Indonesia), Setiawan 140 Healthy Development Soeparan (Ministry of Health, Indonesia), Ida Bagus Permana (Ministry of Health, Indonesia), Anhari Achadi (Ministry of Health, Indonesia), Dedi M. Masykur Riyadi (BAPPENAS), Mr. Hadiat (BAPPENAS), Mr. Haryo (BAPPENAS), Mr. Haryoko (PHP, Indonesia), Antarini Antojo (PHP, Indonesia), Sudianto Kamso (University of Indonesia), Sri Moertiningsih Adioetomo (University of Indonesia), Laksono Trisnantoro (University of Gajah Mada, Indonesia), Rossi Sanusi (University of Gajah Mada, Indone- sia), Istiti Kandarina (University of Gajah Mada, Indonesia), Regina Satyawiraharja (Atma Jaya University, Indonesia), Usep Solehudin (Yayasan Pelita Ilmu ­ Youth Clinic), Kartono Mohammad (Koalisi untuk Indonesia Sehat), and Mr. Soekirman (Koalisi Fortifikasi, Indonesia). The following global partners for their generous advice and contributions: Anders Nordstrom (WHO), Anarfi Asamoa-Baah (WHO), Andrew Cassels (WHO), Denise Coitinho (WHO), Timothy Evans (WHO), David Evans (WHO), Salim Habayeb (WHO), Liz Mason (WHO), Eva Wallstam (WHO), Marie Paule Kieny (WHO), Monir Islam (WHO), Paul van Look (WHO), Dan Makuto (WHO), Steffen Groth (WHO), Jihane Tawilah (WHO), Edward Maganu (WHO), Noureddine Dekkar (WHO), Joe Kutzin (WHO), Gerard Schmets (WHO), Ignace Ronse (WHO), Xavier Leus (WHO), Sara Bennet (WHO), Max Mapunda (WHO), Mark Wheeler (WHO), Gerard Schmets (WHO), Menno van Hilton (WHO), Jacoba Sikkens (WHO), Nick Drager (WHO), Nicole Valentine (WHO), Christopher Powell (WHO), David John Wood (WHO), Brenda Killen (WHO), Richard Feachem (Global Fund to Fight AIDS, Tuberculosis and Malaria), Neil Squires (EU), Juan Garay (EU), Christopher Knauth (EU), Elisabeth Pape (EU), Frederika Meijer (EU), Paula Quigley (EU), Philip Constable (EU), Pascale Sztajnbok (EU), Walter Seidel (Europe Aid), Christian Collard (Europe Aid), Christian Flamant (AFD), Alain Humen (AFD), Finn Schleimann (DANIDA), Hans Martin Boehmer (DFID), Andrew Rogers (DFID), Louisiana Lush (DFID), Nick Banatvala (DFID), Michael Borowitz (DFID), Jane Pepperall (DFID), Julia Watson (DFID), Billy Stewart (DFID), Carole Presern (Foreign and Commonwealth Office, UK), Gauden Villas (Embassy of Spain, London), Meinholf Kuper (GTZ), Andre Cezar Medici (IADB), Annette Gabriel (KfW Development Bank), Helga Fogstad (Norad), Bjarne Garden (Norad), David Weakliam (Devel- opent Cooperation, Ireland), Rob de Vos (Development Cooperation, Netherlands), Reina Buijs (Ministry of Foreign Affairs, Netherlands), Mar- Annex B. Acknowledgments 141 ijke Wijnroks (Ministry of Foreign Affairs, Netherlands), Anno Galema (Ministry of Foreign Affairs, Netherlands), Jacqueline Mahon (Swiss Devel- opment Cooperation), Bo Stenson (SIDA), Catherine Michaud (Harvard School of Public Health), David Dunlop (AusAID), Jim Tulloch (AusAID), Michelle Vizzard (AusAID), Frederic Goyet (Ministry of Foreign Affairs, France), Jette Lund (Royal Danish Embassy, Washington, DC), Rik Peep- erkorn (Netherlands Embassy in Dar Es Salaam), Jean-Pierre Notermann (Embassy of Belgium, Mali), Karima Saleh (ADB), Jacques Jeugmans (ADB), Patience Kuruneri (AfDB), Peter Heller (IMF), Dan Kress (Bill and Melinda Gates Foundation), Armand Pereira (ILO), Michael Sichon (ILO), Assane Diop (ILO), Emmanuel Reynaud (ILO), Philippe Marcadent (ILO), Rédha Ameur (ILO), Julian Lob-Levyt (GAVI), Andrew Jones (GAVI), Akaki Zoidze (Georgia), Malegarpuru W. Makgoba (Zambia), Char Meng Chuor (Cambodia), Richard Greene (USAID), Al Bartlett (USAID), Karen Cavanaugh (USAID), Bob Emrey (USAID), Tim Meinke (USAID), Hope Sukin (USAID), Charles Llewellyn (USAID), Thomas Hall (USAID), Robert Clay (USAID), Lisa Nichols (USAID), Gregory Adam (USAID), Sergio René Salgado (UN Presidential Malaria Initiative), Pascal Villeneuve (UNICEF), Felicity Tchibindat (UNICEF), George Gonzales (UNICEF), Marie-Claire Mutanda (UNICEF), Rudolf Knippenberg (UNICEF), Peter Salama (UNICEF), Amel Allahoum (UNICEF), David Hipgrave (UNICEF), François Farah (UNFPA), Laura Laski (UNFPA), Dorothy Temu (UNFPA), Venkatesh Srinivasan (UNFPA), Kamel Sait (UNFPA), Zahidul Huque (UNFPA), Desmond Johns (UNAIDS), Pradeep Kakkattil (UNAIDS), Denis Broun (UNAIDS), Soumaya Benzitouni (UNAIDS), Joseph Annan (UNDP), Koita Nouhoum (CARE), Damayanti Soekarjo (CARE), Adjie Fachrurrazi (CARE), Glenn Gibney (PCI), Mr. Tolley (PCI), Lina Mahy (Hellen Keller International), David de Ferranti (Brook- ings Institution), Amanda Glassman (UN Foundation), Nils Daulaire (Global Health Council), Ruth Levine (Center for Global Development), Todd Benson (IFPRI), Eric Chevallier (Medecins du Monde), Elena McE- wan (Catholic Relief Services), Carl Stecker (Catholic Relief Services), Vineeta Gupta (Stop HIV/AIDS in India Initiative), Suma Pathy (Stop HIV/AIDS in India Initiative), Ray Martin (Christian Connections for International Health), Cynthia Tuttle (Bread for the World Institute), Anna Taylor (Save the Children UK), Winifride Mwebesa (Save the Children USA), Harvey Bale (IFPMA), Patricia Scheid (Aga Khan Foundation USA), Tom Merrick (Hewlett Foundation), Atika El Mamri (Federation of the 142 Healthy Development Handicapped, Algeria), Salima Tadjine (Algerian Society of Research and Psychology), Mimi Rabehi (Association of People Affected by Cancer `El- fedjr,' Algeria), Adel Zeddam (Algerian AIDS Association), Othmane Bourouba (Algerian AIDS Association), Mouloud Hamdis (Algerian Associ- ation for Renal Failure), Indrani Gupta (Institute of Economic Growth, India), Alok Mukhopadhyay (Voluntary Health Association of India), Dileep Mavlankar (Indian Institute of Management), Ritu Priya (Jawaharlal Nahru University, India), Atanu Sarkar (Energy and Research Institute, India), Ramnik Ahuja (Cofederation of Indian Industry), Dr. Hariharan (Indian Medical Association), Narottam Puri (MAX Health Care Institute, India), and Laveesh Bhandari (Indicus Analyticus). The following Bank management and staff for their advice and recommendations: Vinod Thomas (Director General IEGDG), Geoffrey Lamb (former Vice President, CFPVP), Guillermo Perry (Chief Economist, LCRCE), Mustafa Nabli (Chief Economist, MNSED), John Page (Chief Economist, AFRCE), Robert Holzmann (Director, HDNSP), Hassan Tuluy (Director, MNACS), Ulrich Zachau (Director, LCRVP), John Roome (Operations Director, SARVP), Hartwig Schafer (Operations Director, AFRVP), Orsalia Kalat- zopoulos (Country Director, ECCU4), Pedro Alba (Country Director, AFC09), Theodore Ahlers (Country Director, MNC01), Judy O'Connor (Country Director, AFC04), James Bond (Country Director, AFC15), Isabel Guerrero (Country Director, LCC1C), Emmanuel Mbi (Country Director, MNC03), Annette Dixon (Acting Country Director, ECAVP), Donna Dowsett-Coirola (Country Director, ECCU3), Axel van Trotsen- burg (Country Director, LCC7C), Alastair McKechnie (Country Director SAC01), Charles Griffin (former Sector Director, ECSHD), Marilou Uy (Sector Director, FPDVP), Mayra Buvinic (Sector Director, PRMGE), Luca Barbone (Sector Director, PRMPR), Rodney Lester (Senior Adviser, FPDSN), Roberto Zagha (Senior Economic Adviser, PRMVP), Egbe Osifo-Dawodu (Sector Manager, WBIST), Dzingai Mutumbuka (Sector Manager, AFTH1), Laura Frigenti (Sector Manager, AFTH3), Jamil Salmi (Sector Manager, HDNED), Randi Ryterman (Sector Manager, PRMPS), Laura Tlaiye (Sector Manager, ENV), Elisabeth Lule (Manager, ACTafrica), Alain Barbu (Manager, IEGSG), Hans-Martin Boehmer (Man- ager, SFRSI), Alassane Diawara (Country Manager, AFMML), Roger Robinson (Country Manager, ECCAR), Gaiv Tata (Country Program Coordinator, MNCA3), Alexandre Abrantes (Country Program Coordina- Annex B. Acknowledgments 143 tor, LCC5A), Tawhid Nawaz (Operations Adviser, HDNOP), Adam Wagstaff (Lead Economist, DECRG), Martha Ainsworth (Lead Economist, IEG), Jeffrey Hammer (Lead Economist, SASES), Michael Mills (Lead Economist, AFTH1), Benjamin Loevinsohn (Lead Public Health Special- ist, SASHD), Tonia Marek (Lead Public Health Specialist, AFTH2), Julie McLaughlin (Lead Health Specialist, AFTH1), Suneeta Singh (Senior Pub- lic Health Specialist, SASHD), Chris Walker (Lead Health Specialist, AFTH1), Susanna Hayrapetyan (Senior Health Specialist, ECSHD), Mary Eming Young (Lead Specialist, HDNCY), Janet Nassim (former Senior Operations Officer, HDNHE), Nawal Merabet (Public Information Asso- ciate, MNAEX), Mikko Kalervo Paunio (Senior Environmental Specialist, ENV), Manorama Gotur (Senior Corporate Strategy Officer, SFRSI), Denise Vaillancourt (Senior Evaluations Officer, IEG), Sophia Drewnowski (Senior Partnership Specialist, GPP), Katja Janovsky (Consultant), David- son Gwatkin (Consultant, HDNHE), and Judith Heuman (Consultant, HDNOP). ANNEX C The New Global Health Architecture Emergence of a New Global Health Architecture: Trends Since the Mid-1990s Global health is on the international policy agenda as never before. Over the last 10 years, humanitarian concerns about the health of the world's poor, the spread of pandemics such as HIV/AIDS and fears about outbreaks of SARS and avian influenza, and the recognition that health is a key deter- minant of economic growth, labor force productivity, and poverty reduction have made health a central pillar of most development policies. At the same time, health is increasingly viewed as a human right, the fulfillment of which places obligations on both developed and developing countries. During the 1990s, the global community discussed ways of renewing emphasis and strengthening action to reduce poverty and improve the health of the world's poor. The culmination of these discussions--the Mil- lennium Declaration and the Millennium Development Goals (MDGs)-- reflects the prominence of health in the global policy arena: three of the eight MDGs relate directly to health; the poverty reduction MDG is affected when citizens are pushed into poverty by catastrophic health care costs or lost earnings resulting from ill health; and several of the other goals (e.g., education, sanitation) interact directly with health outcomes. In par- ticular, HIV/AIDS emerged as a challenge to be addressed multisectorally as the international community became increasingly concerned about it as a development issue. With these challenges, came a growing sense that the traditional system of bilateral agencies and international organizations acting as the primary development partners was inadequately prepared to assist the poor coun- 145 146 Healthy Development tries of the world scale up to achieve the MDGs. In the past decade, there have been profound changes in the organizations that play key roles in global health. Private foundations, such as the Bill and Melinda Gates Foundation, and large global funds, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and the Global Alliance for Vaccines and Immunisation (GAVI), have entered the scene with large amounts of grant money. Other disease-specific initiatives such as the Joint United Nations Programme on HIV/AIDS (1996), Roll Back Malaria (1998), and the Stop TB Partnership (1999) were also established and have brought new financial resources for specific diseases. Never before has so much attention--or money--been devoted to improving the health of the world's poor. However, unless deficiencies in the global aid architecture are corrected and major reforms occur at the country level, the international community and countries themselves face a good chance of squandering this opportunity. Taking Stock of HNP Financing in the World The Donor Level As a direct and positive consequence of health becoming a high-profile issue in the global arena and attracting new partners, development assis- tance for health (DAH) has increased from US$2.5 billion in 1990 (0.016 percent of gross national income, [GNI]) to almost US$14 billion in 2005 (0.041 percent of GNI) (figure C.1). As a proportion of official develop- ment assistance (ODA), DAH has increased from 4.6 percent in 1990 to close to 13 percent in 2005. Much of this assistance is targeted to specific diseases or interventions, which raises issues of funding imbalances and prioritization. As a result, direct disease funding now accounts for an increasing proportion of donor aid. The latest Global Monitoring Report shows that, while the share of health aid devoted to HIV/AIDS more than doubled between 2000 and 2004--reflecting the global response to an important need--the share devoted to primary care dropped by almost half.55 Most of the significant increases in development assistance for health come from bilateral donors, new global partnerships, and foundations, while contributions from the multilateral development banks and special- ized UN agencies have been relatively flat. Indeed, financing from bilateral Annex C. The New Global Health Architecture 147 Figure C.1: Development Assistance for Health, by Source, 2000­2005 (US$ billion) 14 private nonprofit other multilaterals 12 World Bank 10 development banks UN agencies 8 bilateral agencies billions US$ 6 4 2 0 2000 2005 year Source: Michaud 2007. Notes: The category "other multilateral" includes the European Union, the Global Alliance for Vaccines and Immunisation (GAVI), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The World Bank total includes only IDA lending. donors accounted for more than 50 percent of DAH in 2005, and financing from new partners such as the Gates Foundation, GFATM, and GAVI accounted for almost 13 percent (Michaud 2007). Although health-specific aid has increased, a significant gap persists between current aid volumes and estimated needs to reach the MDGs, for example. As shown in figure C.2, after a decade of decline in the 1990s in both real terms and as a share of GNI, ODA has indeed increased to some 0.33 percent of GNI in 2005. However, this level falls well short of the promised Monterrey targets of 0.7 percent of GNI and of the Millennium Project projections of 0.54 percent needed to achieve the MDGs (UN 2003, 2005). Other estimates of additional external assistance to help developing countries reach the MDGs range from US$25 billion to US$70 billion (Wagstaff and Claeson 2004). These shortfalls, when coupled with the low and inefficient spending at country level (discussed below), have serious implications for chances of achieving results. The Country Level Partially as a result of this increase in DAH, overall health spending in devel- oping countries has also been increasing. Between 1990 and 2003, total health 148 Healthy Development Figure C.2: Net ODA as a Percent of GNI in DAC Donor Countries, 1990­2005, and Projected, 2006­2010 0.40 0.35 0.30 total ODA projected 2006­10 0.25 total ODA total ODA 0.20 projected percent 0.15 SSA ODA allocated to Sub-Saharan SSA 0.10 Africa projected 2005­10 projected 0.05 0.00 1990 1995 2000 2005 2010 Source: Schieber, Fleisher, and Gottret 2006. spending56 in developing countries increased by more than 100 percent: from US$170 billion in 1990 to US$410 billion in 2003, or from 4.1 percent to 5.7 percent of developing-country GDP. However, despite these increases, domestic spending on health remains low and inefficient (table C.1). Table C.1: Composition of Health Expenditures in World Bank Regions and Income Categories, 2004 PER CAPITA PER CAPITA TOTAL HEALTH HEALTH HEALTH REGIONS AND PER CAPITA EXPENDITURES EXPENDITURES EXPENDITURES INCOME LEVELS GDP ($US) ($US) ($US PPP) (% GDP) East Asia and Pacific 1,457 64 239 4.4 Eastern Europe and Central Asia 3,801 249 552 6.6 Latin America and the Caribbean 3,777 271 608 7.3 Middle East and North Africa 1,833 103 270 5.6 South Asia 611 27 131 4.6 Sub-Saharan Africa 732 45 119 6.3 Low-income countries 533 24 105 4.7 Lower middle-income countries 1,681 91 298 5.4 Upper middle-income countries 5,193 339 689 6.7 High-income countries 33,929 3,812 3,606 11.2 Sources: World Development Indicators; IMF Government Finance Statistics. Note: Per capita indicators weighted by population. a. Revenue data reflect averages between 2000 and 2004. b. Out-of-pocket health spending in Sub-Saharan Africa excludes South Africa, which, if included, changes the estimate to 26 percent of total health spending. Annex C. The New Global Health Architecture 149 · Low-income countries spend less than 5 percent of their GDP on health, whereas middle- and high-income countries spend more than 6 percent and 11 percent, respectively. In exchange rate­based U.S. dollars, per capita total health spending was US$24 in low-income countries and almost US$4,000 in high-income countries, more than a hundredfold difference. Even after adjusting for differences in costs of living, the dif- ferentials are still on the order of 30 times (Gottret and Schieber 2006; WHO 2006b). · Some 70 percent of total health spending is out of pocket in low-income settings, declining to 15 percent in high-income settings. In Africa, out-of- pocket spending accounts for almost 50 percent of total health spending on average and in 31 African countries, accounts for 30 percent or more of total health spending (WHO 2006b). For the poor, out-of-pocket spend- ing is the most regressive source of health sector financing and also denies all individuals the benefits of risk pooling and financial protection. In addition, some regions' reliance on external assistance to finance health and other sectors has serious implications for sustainability and coun- tries' abilities to plan for the long term. For example, external assistance plays a more significant role in health sector financing in Africa than in any PUBLIC OUT-OF-POCKET EXTERNAL TOTAL TAX (% TOTAL (% TOTAL (% TOTAL REVENUE REVENUE HEALTH HEALTH HEALTH TO GDP TO GDP EXPENDITURES) EXPENDITURES) EXPENDITURES) RATIOa RATIOa 39.8 51.0 0.5 19.1 15.1 67.6 26.5 1.1 28.6 16.7 51.0 36.3 0.7 23.0 15.9 48.8 46.3 1.1 27.3 17.0 18.8 76.1 1.6 15.0 9.8 42.1 46.3b 6.8 22.9 18.2 23.9 70.0 5.5 17.4 12.8 47.3 42.9 0.7 24.2 16.9 57.6 30.3 0.7 28.5 17.6 60.3 14.9 0.0 35.2 20.4 150 Healthy Development other region, accounting for some 15 percent of all health spending on aver- age, while in other regions, it accounts for less than 3 percent. Further, of the 23 countries globally in which external assistance accounts for more than 20 percent of all health spending, 15 (65 percent) of them are in Africa (WHO 2006b). Moreover, in Africa, external assistance accounts for 55 per- cent of all external flows, while in the five other developing regions, worker remittances and foreign direct investment account for the bulk of external flows with external assistance accounting for only 9 percent (Gottret and Schieber 2006; WHO 2006b). Low and inefficient expenditure patterns in low-income countries (LICs) are matched by their domestic resource mobilization capacity. Most LICs face enormous constraints in raising additional domestic resources: on aver- age, LICs mobilize only 17 percent of their GDP from domestic resources (Gupta et al. 2004). Even if these countries could improve their capacity to raise resources domestically to finance health in an effort to scale up to reach the MDGs, massive increases in external assistance would be needed. Donors would still need to finance most of the gap. Challenges in the New Global Health Architecture The impact of increased resources on health has been mixed, especially con- sidering the persistence of stark imbalances between rich and poor countries in terms of disease burden, the huge unmet health needs in most develop- ing countries, and their lack of domestic resources to cope with these needs: · Ninety percent of the global disease burden is in developing countries that account for only 12 percent of global health spending. · High-income countries spent more than 100 times per capita on health than low-income countries. · Developing countries will need between US$25 billion and US$70 bil- lion in additional aid per year to remove the financing constraint to scal- ing up to meet the MDGs. · Further, most countries in Africa are off-track on all of the MDG health goals. More broadly, in all Bank Regions but the Middle East and North Africa (MENA) and South Asia (SAR), most countries are off-track with respect to the child mortality goal. Annex C. The New Global Health Architecture 151 It is in this context that questions have arisen about the effectiveness of health spending and, concomitantly, the integrity of the global aid architec- ture in health. Effectiveness of Aid for Health There are at least four important manifestations of ineffective health aid at the country level: · Aid is often not aligned with government priorities, and holistic health systems approaches are insufficiently funded. As discussed above, health aid is often earmarked for specific purposes. Only about 20 percent of all health aid goes to support the government's overall program (i.e., is given as gen- eral budget or sector support), while an estimated 50 percent of health aid is off budget (Foster 2005a). As a result, many countries report diffi- culties in attracting sustained, flexible funding that can be used to support the health system: staff, infrastructure, training, management, and so on. · Aid can be unpredictable, short-term, and volatile. In addition to being heav- ily earmarked, health aid can be very short-term and volatile (figure C.3). When the amount of aid a country receives is likely to change at short notice, it is impossible for Ministries of Health and Finance to make long- term plans--such as employing more doctors or nurses, widening access to HIV/AIDS treatment, or scaling up health service provision--without incurring major risks of sustainability of financing for these services. A related issue, which also creates difficulties for ministries of finance and planning, is that aid can be unpredictable (disbursements do not match commitments, even where the reasons are not related to performance). · Aid may be poorly harmonized, increasing transaction costs for government. The high number of donors present in health, the large number of sepa- rate health programs, and large volume of resources may carry unpre- dictable risks and transaction costs unless they are well coordinated-- both with each other and with government. A related issue is that the presence of multiple health partners may inadvertently undermine the government's broader efforts in the health sector. This is likely to affect the government's ability to deliver programs in other areas. · Integrity of the global health architecture. In addition to problems with the effectiveness of aid flowing into the health sector, some of the challenges 152 Healthy Development Figure C.3: Volatility in Aid for Health, Selected Countries, 1999­2003 50 45 as 40 Laos health 35 Lesotho health for 30 Niger total 25 Zambia of 20 resources expenditures 15 percent 10 5 external 0 1999 2000 2001 2002 2003 year Source: World Health Organization 2006b. of the new global health architecture stem from a lack of global gover- nance and overlapping mandates of different aid agencies. Problems at the country level and the inherent complexities of the health sector also contribute to the quandaries concerning the effectiveness of external assistance for health. Leadership at the Global Level There are more major global stakeholders in health than in any other sec- tor and literally hundreds of different flows of public and private funds to specific countries. Issues include: · Various international organizations and stakeholders have overlapping and unclear mandates--no single organization coordinates global health policy, financing, implementation processes, or knowledge dissemination at country or regional levels. · Global Health Partnerships (GHPs) were initially promoted as tools to better focus health aid in areas of perceived neglect and to simplify the aid architecture in health, and, as a consequence, make health aid more effec- tive. However, many observers believe--and a range of studies suggest57--that this objective has not been achieved. It is recognized that GHPs have mobilized important new resources for major health threats and brought much needed political and technical focus to priority dis- Annex C. The New Global Health Architecture 153 eases or interventions. However, there is concern that the rapid creation of new institutions in health is difficult for countries to manage and fur- ther complicates donor harmonization efforts at the global level. Finally, as in other sectors, donor governments find it politically advan- tageous to raise aid "vertically" to show their populations that their tax monies are being spent on "good causes." In particular, GHPs may inten- sify the "vertical" nature of health financing by focusing large amounts of new funding for specific, relatively narrow programs and interventions, cre- ating separate financing and delivery silos, and leaving recipients little flex- ibility to reallocate funds according to their priorities or to fund health sys- tem costs, such as salaries. While this is an issue in all sectors, the consequences are particularly acute in health, because there is a need for flexible resources that can be used to support recurrent costs, other sectors that have a direct impact on health, and health systems. Health Is a Complex Sector Complexities in the aid architecture for health mirror the complexities of the sector itself. Creating and sustaining population health, providing finan- cial protection from the consequences of ill-health, and managing, financ- ing, and governing the health system are all difficult and costly. · Numerous nonhealth-related factors affect health outcomes, necessitat- ing complex cross-sectoral approaches. · Health outcomes are reversible, if access to services is interrupted (unlike gains in education, for example). · Individual behavior plays a critical role in health outcomes and is very difficult to influence or change. · Measuring health outcomes--other than sentinel events such as births or death--and attributing causality to specific factors is inherently complex. · The costly financial protection element of health financing is largely unique to the health sector (except for a few standard social protection pro- grams such as pensions, unemployment insurance, and social assistance). · The bulk of the funding needed is for long-term recurrent costs rather than the traditional donor-financed short-term investment costs, raising 154 Healthy Development issues of sustainability and the need for countries to create adequate fis- cal space in their budgets. · The health sector is critical in terms of both its share of the public budget and as a major source of public employment. · Well over a hundred major organizations are involved in the health sec- tor, globally and nationally, far more than in any other sector. · The private sector plays a substantial, often predominant, role in both the financing and delivery of health care services and is often absent from the policy debate. · Market failures in insurance markets and in the health sector more gen- erally require complex regulatory frameworks and limit governments' abilities to simply rely on market mechanisms. From Consensus on the Problems to Coordinated Action at Country Level A consensus on the challenges has emerged, and new steps have been taken to improve the effectiveness of aid for health and streamline the new global health architecture through donor harmonization and alignment with coun- try systems. The Paris Declaration is a key reference point for improve- ments in health aid: as the framework for aid effectiveness in general, it also frames efforts to improve aid for health. UNAIDS, together with the Global Fund, bilateral donors, and other international institutions, has committed itself to harmonization and align- ment in HIV/AIDS through the concept of the Three Ones. These are: one agreed HIV/AIDS action framework for coordinating the work of all part- ners; one national HIV/AIDS coordinating authority with a broad-based multisectoral mandate; and one agreed country-level system for monitoring and evaluation. Subsequent to the agreement of the Three Ones, the Global Task Team on Improving AIDS Coordination among Multilateral Institutions and International Donors (GTT) was established. In June 2005 it presented a plan to further coordinate the HIV/AIDS response, making specific recom- mendations to partner governments, the United Nations system, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (though not to bilat- eral donors). In particular, the GTT recommended the development of a Annex C. The New Global Health Architecture 155 scorecard-style accountability tool to examine the performance of national partners in creating a strong HIV/AIDS response and international partners in providing support according to the GTT recommendations. The score- card is being piloted by UNAIDS in a number of countries. Stakeholders in the health sector have responded to aid shortfalls, aid effectiveness problems, and failures in the supply of global public goods for health through the development of innovative financing methods. These are: the International Finance Facility for Immunisation (IFFim), Advance Market Commitments (AMC), and UNITAID58 (previously called the International Drug Purchase Facility). The innovative finance agenda is seen as an important component of a more robust and performance-driven approach to development assistance. This is particularly true, given the unintended impact that unpredictable aid has had on markets, most notably for pharmaceuticals and vaccines needed by the poorest countries. The High Level Forum (HLF) was a series of three high-level meetings in 2004 and 2005 among key donors and some 20 countries that looked at many of the aid-effectiveness issues raised above. It also strengthened coop- eration among WHO, World Bank, IMF, bilateral donors, global health partnerships, and other UN agencies and has helped create a consensus for action around the scaling up of the agenda in health. As donors make good on their promises to scale up development assis- tance between now and 2015, many will wish to invest in health. Creating effective aid architecture in health--which delivers results--helps make the case that "aid works" and should leverage further resources for the sector and perhaps overall, while a dysfunctional health architecture does the opposite. One key challenge is to demonstrate the link between the aid effectiveness agenda and better health outcomes. The Paris Declaration emphasizes progress toward harmonization and alignment and has an in- depth monitoring and accountability process related to this objective. It does not, however, hold donors and countries accountable for development results in health or other areas. Taking forward the harmonization and alignment agenda in health is about managing complexity--recognizing that diversity can help bring results and that the health sector benefits from a range of partners with different ways of doing business. As part of the post-HLF agenda, there will be efforts at the country level to develop instruments for mutual accountabil- ity between donors and countries. These efforts will be initiated by the health community but will look beyond the sector and aim to ensure align- ment of health strategies and goals and other development objectives. ANNEX D The World Bank HNP Results Framework WHAT RESULTS ON THE GROUND ARE IMPORTANT? COUNTRY OUTCOMES HOW DO WE MEASURE HOW DO THESE RESULTS? WE MEASURE MULTISECTORAL INTERMEDIATE STRATEGIC THESE RESULTS? CONTRIBUTIONS INDICATORS POLICY FINAL FINAL TO INTERMEDIATE (REPORTING ACCOUNTABILITY OBJECTIVE OUTCOMES INDICATORS OUTCOMES/OUTPUTS OF SECTORS) (1) Improve the I. Childhood mortality U-5 mortality rate Water & Sanitation, Energy, HNP reporting accountability: level and distribu- reduced (by income quin- Environment, Agriculture, (1) Immunization coverage (DPT3, tion of key HNP tile) (MDG 4, Target 5 Education, Gender, HNP: measles, Hib, hepatitis B) outcomes, outputs, and MDG 7, Target 10) and system per- Reduced neonatal, infant (2) % pregnant women who have formance at coun- and under-five mortality and received a tetanus vaccine try and global morbidity by increasing levels in order to effective coverage with (3) % children with diarrhea that improve living con- high impact interventions received ORT ditions, particularly for the poor and (4) % of children with ARI taken to vulnerable health provider Water and Sanitation reporting accountability: (5) % population with access to improved water supply services Energy reporting accountability: (6) % of households with electricity (7) Energy from combustible renew- ables and waste (% of total energy) 156 Annex D. The World Bank HNP Results Framework 157 HOW DOES THE BANK HOW DO WE KNOW IF IMPLEMENTATION IS ON TRACK? CONTRIBUTE TO THESE RESULTS? PROCESS INDICATORS BANK BANK STRATEGY COUNTRY PROCESS INDICATOR BASELINE A. Renewing Focus on Results Number of active borrowers (1) At least 40% of new CASs tar- (1) Less than 10% of CASs tar- (alternatively, percent of coun- geting HNP results to be discussed geting HNP results. (1) Build statistical capacity for client tries by Region) who are able with the Board in FY2009 and countries on priority HNP outcome to measure causes of under- thereafter will identify capacity and indicators (disaggregated by gender five mortality at disaggregated systems building activities (Bank and age) directly through Bank opera- levels. Currently, fewer than a and/or coordinated with global tions and/or supporting global part- third of all low- and middle partners) for monitoring and evalu- ner's country support (e.g., MDGs). income countries have vital ating HNP results in government This includes the development of registration systems that are programs. country-based frameworks for the col- complete enough to monitor lection of essential household HNP trends in the U-5 mortality (2) By FY2010, at least 14 active (2) 4 active projects in FY2006. and multisectoral indicators. MDG. Bank will seek to projects with most loan proceeds increase this to the number of allocated on output-based (2) Pilot and evaluate impact of countries with sound systems. financing. output-based and performance-based Impact evaluation plans in place for financing for HNP-related projects/ National HNP outcome strate- 60% of these projects or more upon programs. gies and PRSPs with increased approval. use of multisectoral approach (3) Introduce results frameworks for to achieve results in HNP (3) At least 70% of new projects/ (3) Less than 25% of active all projects targeting HNP outcomes, outcomes. programs approved by the Board in projects as of FY2006 with sat- output, and system performance, FY2008 and thereafter. isfactory results framework. including baseline data and output targets. 158 Healthy Development WHAT RESULTS ON THE GROUND ARE IMPORTANT? COUNTRY OUTCOMES HOW DO WE MEASURE HOW DO THESE RESULTS? WE MEASURE MULTISECTORAL INTERMEDIATE STRATEGIC THESE RESULTS? CONTRIBUTIONS INDICATORS POLICY FINAL FINAL TO INTERMEDIATE (REPORTING ACCOUNTABILITY OBJECTIVE OUTCOMES INDICATORS OUTCOMES/OUTPUTS OF SECTORS) II. Childhood malnutrition Percentage of chil- HNP, Water and Sanitation, HNP reporting accountability: improved (MDG 1, Target dren under the age Agriculture, Environment, (8) % infants under 6 months who are 2) of five who are Energy, Education: exclusively breastfed underweight, stunted Reduced child underweight (9) % of children who receive breast- and stunting by increased feeding plus adequate complementary coverage with effective food (6­9 months) interventions Water and Sanitation reporting accountability: See (5) above Energy reporting accountability: See (6) and (7) above HNP, Education, Private HNP reporting accountability: Sector: (10) % children (6­59) months receiv- ing at least one dose of Vitamin A Reduced under-five supplementation micronutrient deficit (11) % households using iodized salt III. Avoidable mortality Adult mortality HNP, Education: HNP reporting accountability: and morbidity from rate (15­ 60) (12) % newborns with low birth chronic diseases and Reduced prevalence of low weight injuries reduced birth weight HNP, Education: HNP reporting accountability: (13) Smoking prevalence among Reduced exposure to risk teenagers and adults factors of NCDs and injuries (14) % of adult population with BMI above 25 Annex D. The World Bank HNP Results Framework 159 HOW DOES THE BANK HOW DO WE KNOW IF IMPLEMENTATION IS ON TRACK? CONTRIBUTE TO THESE RESULTS? PROCESS INDICATORS BANK BANK STRATEGY COUNTRY PROCESS INDICATOR BASELINE (4) Periodic data collection and Ministries of Finance allocate (4) At least 65% (annually) of all (4) Less than 15% of active updates (as appropriate to specific resources to and within the projects/programs approved by projects as of FY2006. indicators) for at least 70% of the sector on the basis of some Board in FY2008 and thereafter. indicators included in project results measures of performance. framework and updated periodically in Implementation Status Reports (ISRs). Countries have "policy analyt- (5) Develop indicators (including ic capacities" within MOH or (5) Develop indicators by end- (5) Does not exist. gender-based indicators) for priority mechanisms for contracting FY2008. HNP outcomes for which no agreed out policy analyses, perform- indicators exist (e.g., financial protec- ance review functions. tion, governance in the health sector, and financial and fiscal sustainability). (6) Improve results in existing portfo- (6) 75% for FY2009 and thereafter (6) Annual average of 66% of lio. Review and restructure existing (each Region and total HNP portfo- projects closing with satisfac- HNP portfolio (project design and/or lio). tory PDO or higher (FY2005 project development objective, PDO) and FY2006). to achieve satisfactory PDO or higher outcome at project closing. (7) Concurrent monitoring of overall (7) Develop by end-FY2008; imple- (7) Does not exist. active Bank portfolio performance ment by end-FY2009. and PDO indicators on HNP results. Develop and implement central data- base with HNP project results based on ISR and project results framework data online for monitoring portfolio results and quality. 160 Healthy Development WHAT RESULTS ON THE GROUND ARE IMPORTANT? COUNTRY OUTCOMES HOW DO WE MEASURE HOW DO THESE RESULTS? WE MEASURE MULTISECTORAL INTERMEDIATE STRATEGIC THESE RESULTS? CONTRIBUTIONS INDICATORS POLICY FINAL FINAL TO INTERMEDIATE (REPORTING ACCOUNTABILITY OBJECTIVE OUTCOMES INDICATORS OUTCOMES/OUTPUTS OF SECTORS) Infrastructure: Infrastructure reporting accountability: (15) % of road network with safety Reduced mortality/morbidity rating of 3 to 4 "stars" (on scale of 4) due to road traffic crashes IV. Improved maternal, Maternal mortality HNP, Education, HNP reporting accountability: reproductive, and sexual ratio Infrastructure: (16) % women with deliveries attend- health (MDG 5, Target 6) ed by skilled health personnel Total fertility rate Improved coverage with effective maternal and peri- (17) % women with at least one ante- Adolescent fertility natal interventions natal care visit during pregnancy rate Infrastructure reporting accountability: Increased birth (18) % of rural population with access spacing to an all-season road HNP, Gender, Education: HNP reporting accountability: (19) Contraceptive prevalence rate Improve family planning among women of reproductive age and sexual health (20) Unmet need for contraception (21) Prevalence rate of STIs among adults and young people (15­24 years) HNP: HNP reporting accountability: (22) HPV immunization coverage Reduced incidence of cervi- cal cancer Annex D. The World Bank HNP Results Framework 161 HOW DOES THE BANK HOW DO WE KNOW IF IMPLEMENTATION IS ON TRACK? CONTRIBUTE TO THESE RESULTS? PROCESS INDICATORS BANK BANK STRATEGY COUNTRY PROCESS INDICATOR BASELINE B. Strengthening Health (8) Develop operations toolkit for (8) Less than 25% identify Systems and Ensuring Synergy rapid assessment of health system health system constraints. between Health System Strength- constraints for better outcomes ening and Priority­Disease (completed by end-FY2008) Less than 45% include health Interventions system strengthening in areas Complete identification of 7 coun- of Bank comparative (8) Increase support to Bank country tries by December 2007. advantages. teams to identify health system con- straints (including gender-specific Launch on-demand support in 4 constraints) to achieving HNP results countries by June 2008. and mainstream system-strengthening actions to overcome constraints in all Put on-demand support in place to new HNP operations (or other sectoral Bank country teams in 7 countries or global partner operations), includ- by June 2009. ing priority­disease interventions. At least 60% of projects approved in FY2009 and thereafter will include assessment of health sys- tems constrains to reaching HNP results. At least 70% of those identifying constraints will include appropriate policy actions/investments to over- come them. 162 Healthy Development WHAT RESULTS ON THE GROUND ARE IMPORTANT? COUNTRY OUTCOMES HOW DO WE MEASURE HOW DO THESE RESULTS? WE MEASURE MULTISECTORAL INTERMEDIATE STRATEGIC THESE RESULTS? CONTRIBUTIONS INDICATORS POLICY FINAL FINAL TO INTERMEDIATE (REPORTING ACCOUNTABILITY OBJECTIVE OUTCOMES INDICATORS OUTCOMES/OUTPUTS OF SECTORS) V. Reduced morbidity and Adult HIV preva- Education, Infrastructure, HNP/GHAP reporting accountability: mortality from HIV/AIDS, lence among all HNP, Gender: (23) % young women and men aged TB, malaria, and other antenatal women 15-24 reporting the use of a condom priority pandemics (MDG and among Increased HIV/AIDS preven- the last time they had sex 6, Target 7 and 8) women 15­24 tion and case fatality reduction Water and Sanitation reporting Reduce AIDS mor- accountability: tality: % of people HNP: See (5) above living with AIDS who survive at Increased HIV/AIDS ARV Energy reporting accountability: least 12 months treatment See (6) and (7), above after a complete ART course HNP reporting accountability: (24) % men and women with advanced HIV receiving antiretroviral therapy (ART) HNP, Agriculture: HNP reporting accountability: (25) % children who slept under an Increased malaria preven- insecticide treated bednet (in malari- tion and treatment ous areas) (26) % of children with fever in malar- ious areas who receive antimalarial treatment (27) % of pregnant women in malari- ous areas who receive treatment or preventive treatment for malaria Annex D. The World Bank HNP Results Framework 163 HOW DOES THE BANK HOW DO WE KNOW IF IMPLEMENTATION IS ON TRACK? CONTRIBUTE TO THESE RESULTS? PROCESS INDICATORS BANK BANK STRATEGY COUNTRY PROCESS INDICATOR BASELINE (9) Put in place arrangements for col- (9) Dialog in place for global (9) Does not exist. laborative division of labor on health arrangements by December 2007. systems with global partners at global and country levels. Launch collaborative division of labor arrangements for at least 7 countries where projects/programs include interventions requiring expertise other than Bank compara- tive advantages (by December 2008). (10) Focus knowledge creation and (10) By end-FY2008, 50% and by (10) Less than 35% so focused. policy advice (AAA) on Bank compar- end-FY2009 70% of new HNP sec- ative advantage. Increase proportion tor AAA will be focused on areas of of country- and regional-level AAA, Bank comparative advantage in appropriate to requirements of LICs specific areas appropriate for LICs' and MICs, focused on Bank compara- and/or MICs' requirements (e.g., tive advantages. Health system financing, demand- side determinants of results, inter- sectoral contribution to HNP results, private-public collabora- tion). 164 Healthy Development WHAT RESULTS ON THE GROUND ARE IMPORTANT? COUNTRY OUTCOMES HOW DO WE MEASURE HOW DO THESE RESULTS? WE MEASURE MULTISECTORAL INTERMEDIATE STRATEGIC THESE RESULTS? CONTRIBUTIONS INDICATORS POLICY FINAL FINAL TO INTERMEDIATE (REPORTING ACCOUNTABILITY OBJECTIVE OUTCOMES INDICATORS OUTCOMES/OUTPUTS OF SECTORS) Reduced TB HNP: HNP reporting accountability: mortality Increased TB detection and (28) % TB cases detected and cured treatment under DOTS (29) Number of health Increased country Increased proportion of facilities/providers who routinely readiness to low-income countries with report ILI to national authorities detect outbreaks a functioning sentinel and prevent/con- surveillance scheme for (30) % increase in the number of ILI tain address rapid influenza-like illness reported annually (% to be defined for onset of pandemic each country). (e.g., avian Increased proportion of influenza) countries with an integrat- (31) Number of specimens from sen- ed avian influenza pandem- tinel surveillance sites examined and ic contingency plan. subtyped annually. (32) Evidence of secured source of funding for outbreak investigation as per the prerequisites of the integrated AI pandemic contingency plan (33) Evidence of simulation exercises being conducted in an integrated fashion together with veterinary authorities (2) Prevent poverty VI. Improve Financial Pro- % population HNP, PREM: HNP reporting accountability: due to illness (by tection (Reduce the falling below the (34) % out-of-pocket expenditures in improving financial impoverishing effects of poverty line due to Reduction of out-of-pocket health (for a basic package of servic- protection) illness for the poor or illness expenditures in health for es) as a proportion of total household near poor) "insurable events" income Annex D. The World Bank HNP Results Framework 165 HOW DOES THE BANK HOW DO WE KNOW IF IMPLEMENTATION IS ON TRACK? CONTRIBUTE TO THESE RESULTS? PROCESS INDICATORS BANK BANK STRATEGY COUNTRY PROCESS INDICATOR BASELINE C. Strengthening Bank Intersec- toral Advisory Capacity (11) Develop, pilot test, and imple- (11) First tool developed by end- (11) Does not exist. ment Multisectoral Constraint FY2008 and pilot tested in 2 MICs Assessment (MCA) tool and process. and 2 LICs by end-FY2009. Pilot test in a number of LICs and MICs. (12) Identify lending and AAA in CAS. (12) MCA will be used to identify (12) Does not exist. MCA-identified HNP-related Bank 40% of projects/programs with projects/programs/components in HNP results included in at least CAS. 50% of new CASs discussed with the Board by FY2010 and thereafter. D. Increase selectivity, improve strategic engagement, and reach agreement with global partners on collaborative division of labor for the benefit of client countries (13) Increase use of harmonization (13) By FY2011, at least 81% of and alignment principles for Bank projects approved by Board will be projects in IDA at country level. based on country fiduciary systems or will have common fiduciary arrangement/rules for all participat- ing donors. (14) Develop overall HNP fiscal space (14) Develop and pilot fiscal space (14) Does not exist. assessment in priority countries. assessment methodology (complet- ed by end of FY2008) Full fiscal space assessment in 7 priority countries in coordination with global partners. 166 Healthy Development WHAT RESULTS ON THE GROUND ARE IMPORTANT? COUNTRY OUTCOMES HOW DO WE MEASURE HOW DO THESE RESULTS? WE MEASURE MULTISECTORAL INTERMEDIATE STRATEGIC THESE RESULTS? CONTRIBUTIONS INDICATORS POLICY FINAL FINAL TO INTERMEDIATE (REPORTING ACCOUNTABILITY OBJECTIVE OUTCOMES INDICATORS OUTCOMES/OUTPUTS OF SECTORS) HNP, PREM: HNP reporting accountability: Increase in risk-pooling (35) % of lowest quintiles households schemes (contributory or participating in risk-pooling schemes noncontributory) (contributory or noncontributory) HNP, PREM: HNP reporting accountability: Reduction in income loss (36) % of households receiving due to illness income substitution of ill breadwinner (37) % of workers receiving treatment for common productivity reducing ill- ness (e.g., Intestinal worms, iron deficit anemia) (3) Improve finan- VII. Improve Funding Sus- To be developed To be developed To be developed cial sustainability tainability in the Public in the HNP sector Sector from Both Domes- and its contribution tic and External Sources to sound macroeco- nomic and fiscal policy and to coun- try competitiveness (4) Improve gover- VIII. Improved Gover- Improved CPIA Decreased proportion of To be developed nance, accounta- nance and Transparency indicator 9a rating household total health bility, and trans- and Reduced Corruption expenditures paid on parency in the in the Health Sector Reduced health "under the table" payments health sector (MDG 8, Target 12) workers absenteeism Decreased percentage of Reduced "under the off-the-international- table" payments market-price paid for medical supplies Reduced excess payment for med- ical supplies Note: This global HNP Results Framework is presented as guidance for the Regions, yet essential to ensure its country-driven application and adaptation. The Frame- work is intended to serve as guidance and support for Regions to elaborate their own HNP strategy and for country teams to help them identify constraints to improv- ing outcomes and performance at country level. The Framework should not be understood as a prescriptive, limiting instrument. The periodicity of the collection of data will vary. Not all indicators are measured annually. Countries conduct Health and Demographic Surveys 3 to 5 years apart. Annex D. The World Bank HNP Results Framework 167 HOW DOES THE BANK HOW DO WE KNOW IF IMPLEMENTATION IS ON TRACK? CONTRIBUTE TO THESE RESULTS? PROCESS INDICATORS BANK BANK STRATEGY COUNTRY PROCESS INDICATOR BASELINE (15) Review and reorient Bank grants (15) By end-FY2008 5%, by end of (15) Currently less than 1% of (Development Grant Facility, DGF) in FY2009 30% and by the end of DGF grant financing is allocat- HNP toward areas of Bank compara- FY2010 50% of Bank DGF grants ed to partners working on tive advantages. will be allocated in partnerships issues related to Bank compar- related to Bank comparative ative advantages. advantages. (16) Realign secondments and Trust (16) By end-FY2009, 80% of second- (16) Now 60% of secondments Fund management in HNP sector with ments to Bank and 80% of total in HNP sector are in areas in Bank comparative advantages. Trust Fund financing managed by which Bank has little compara- HNP sector will be in areas of Bank tive advantage. comparative advantages. ANNEX E Multisectoral Constraints Assessment for Health Outcomes Rationale I (for Countries and Country Directors) The attention to outcomes brought about by the Millennium Development Goals (MDGs) exposed a critical gap in client­country and World Bank programs for Health, Nutrition, and Population (HNP). While it is univer- sally acknowledged that reducing mortality, morbidity, fertility, and malnu- trition requires multisectoral inputs and actions, little analysis has been done at the country level to systematically document the bottlenecks in dif- ferent critical sectors, set out a framework for prioritizing actions, or assess institutional constraints. The proposed new economic sector work (ESW) instrument is designed to address this gap in the arsenal of client countries and development agencies. The proposed ESW will: systematically assess multisectoral constraints to achieving HNP results; provide a framework for prioritization of actions; and assess institutional factors and structures for facilitating coordinated actions by the prioritized sectors. For the World Bank country program, this new ESW product line will guide CAS devel- opment for multisectoral approaches to addressing the MDGs and other health outcomes, especially for the poor. Rationale II (for the HNP Family) Successful knowledge institutions (e.g., consulting firms or development institutions) put a premium on quality of knowledge, standardization of core competencies, and relevance to the clients. Within the World Bank, these success factors can be seen in the way groups like PREM and Social Pro- 169 170 Healthy Development tection select specific ESW lines that are high in quality, focus on the com- parative advantages of the World Bank, and target not only line ministries, but primarily the Ministry of Finance (MOF). For HNP to achieve similar success, the current practice of an ad hoc and unstructured ESW program has to give way to much more selectivity, based on comparative advantage and serving the need of MOFs and Bank Country Directors in addition to Ministries of Health (MOHs). The new World Bank HNP Strategy has identified two clear lines of ESW business that fit the above success criteria. One line of ESW should focus on the crucial link between the MOH and the MOF by building simple instruments that address contingent liabilities for a country's budget created by the health sector, issues around fiscal space, and issues around the allocative efficiency and the welfare impact of the health sector. The second line of ESW, addressed in this note, relates to systematic assessments of multisectoral constraints to achieving health out- comes as well as institutional frameworks to ensure coordination of inputs by different line ministries. The ultimate objective of this latter line of ESW is to provide a technical and institutional prioritization framework for Finance and Planning Ministries (and input for Bank CASs) and to help ele- vate MOHs from service delivery structures to a higher role of stewardship. Objectives of the Multisectoral Constraints Assessment Given the complex multisectoral determinants of HNP outcomes, it is crit- ical that decisions about investments in the different sectors be guided by evidence on distribution of these outcomes, assessment of the binding con- straints in relevant sectors, a prioritization framework, and an assessment of institutional factors that can help or hinder multisectoral coordination and sectoral implementation. A fully fledged application of this new ESW instrument has the following objectives (rapid MCAs take on a subset of the objectives): · Identifying outcome targets by reviewing and stratifying health, nutrition, and fertility outcomes at the national and subnational levels. Outcomes include mortality (infant, child, maternal, and adult), morbidity by cause of illness/injury, nutritional status, and fertility rates. Depending on the size and organization of the country assessed and the availability of data, the outcomes will be stratified by geographic groupings and socioeco- Annex E. Multisectoral Constraints Assessment for Health Outcomes 171 nomic status, including poverty levels, wealth groups, education, gender, and different sources of country-specific vulnerability factors (minorities, tribes, social castes, and so on). · Investigate sector-specific constraints by documenting the presence or absence of critical inputs for achieving the targeted HNP outcomes. Inputs include, for example, immunization rates, access to and use of attended deliveries, use of iodized salts, knowledge of and use of modern contraceptives, source of indoor cooking and heating, access to clean water, success of vector control measures, and availability of roads for emergency transport of pregnant women. The selection of constraints to be investigated is a function of the HNP outcome in question. · Guide decision making by using outcome and constraint assessments to develop a country-specific prioritization framework that outlines short-, medium-, and long-term policy actions by different sectors; develops alternative cotargeting maps and mechanisms that combine poverty and health outcome data; identifies institutional and operational constraints, as well as possible solutions for coordinated action; and lays out a menu of potential policy instruments. A number of these objectives can be addressed with existing ESWs in some countries, especially if large ESWs were undertaken, but the approach tends to be ad hoc in nature and focus almost entirely on one sector (e.g., HNP or Environment). Moreover, rarely are all the relevant sectors addressed at the same time to allow for prioritization and synergy. Even more challenging is to find institutional assessments or options that look at practical ways of ensuring coordination in the production and targeting of multisectoral inputs. What MCAs can do for health outcomes in any coun- try is to assess systematically technical and institutional constraints in order to create a prioritization framework for client countries and support World Bank country teams in addressing outcomes in the CAS process. ANNEX F What Is a Health System? A "system" can be understood as an arrangement of parts and their inter- connections that come together for a purpose (von Bertalanffy 1968).59 What sets apart a health system is that its purpose is concerned with peo- ple's health. A health system has many parts. In addition to patients, fami- lies, and communities, Ministries of Health, health providers, health serv- ices organizations, pharmaceutical companies, health financing bodies, and other organizations play important roles. The interconnections of the health system can be viewed as the functions and roles played by these parts. These functions include oversight (e.g., policy making, regulation), health service provision (e.g., clinical services, health promotion), financing, and managing resources (e.g., pharmaceuticals, medical equipment, informa- tion). Describing the parts, interconnections, and purpose, Roemer (1991) defined a health system as "the combination of resources, organization, financing and management that culminate in the delivery of health services to the population." The World Health Organization (2000) redefined the main purpose in its definition of a health system as "all activities whose pri- mary purpose is to promote, restore, and maintain health." In recent years, the definition of "purpose" has been further extended to include the pre- vention of household poverty due to illness. A Complex System in Constant Flux Many factors outside the health system influence people's health, such as poverty, education, infrastructure, and the broader social and political envi- ronment. Because they are open to influence from outside, health systems 173 174 Healthy Development are known as open systems. A health system's various parts operate at many levels. Smaller systems may be self-contained and have limited scale and scope, such as those involved in running a clinic or a managing a health information system. Larger systems might involve the coming together of various smaller systems (e.g., clinics, hospitals, health promotion programs) to provide coherence at community or national level. Given the purpose, scale, and scope of a country's health system, it is not effectively controlled centrally, and changes in a system are not predictable in great detail (even if some parts of the system appear to behave predictably). This is partly because people and organizations innovate, learn, and adapt to change and partly because reorganization occurs continually in health systems in both formal and informal ways. These features have led systems thinkers to describe health systems as complex adaptive systems (Plsek et al. 2001). Understanding health systems as complex adaptive systems has important implications for approaches to influencing health systems to produce better health outcomes, or to do so in a more efficient or equitable manner. Building on the definition of a health system, this annex describes the important functions of the main parts of the health system, highlighting some of the key issues for low- and middle-income countries. Interpreting the parts and functions of a health system can be done independently, but greater power comes in bringing the parts together to improve people's health and illness-related poverty. They are briefly examined in this annex. The annex concludes with further discussion of how to understand health systems as complex adaptive systems and the practical implications. Health System Functions Health service provision, health service inputs, stewardship, and health financing are the four main health system functions. Households' demand behavior as well as overall health sector governance largely determine how these functions perform. Stewardship (overall system oversight) sets the context and policy frame- work for the overall health system. This function is usually (but not always) a governmental responsibility. What are the health priorities to which pub- lic resources should be targeted? What is the institutional framework in which the system and its many actors should function? Which activities should be coordinated with other systems outside the realm of health care, Annex F. What Is a Health System? 175 and how (e.g., highway safety, food quality control)? What are the trends in health priorities and resource generation and their implications for the next 10, 20, or 30 years? What information is needed and by whom to ensure effective decision making on health matters, including prevention and mit- igation of epidemics? These questions are the core of the stewardship func- tion. An additional central function of stewardship is to generate appropri- ate data for policy making. These range from public health surveillance data to health system performance and provide the basis for assessing health sta- tus, regulating the sector, and tracking health system performance, effec- tiveness, and impact. Stewardship remains a fragile function in many Bank client countries. Public and private health service provision is the most visible product of the health care system. The best systems also promote health and try to head off illness through education and preventive measures such as well-child con- sultations. All these roles and activities mean that the system has to perform a wide range of activities. "Delivering health services is thus an essential part of what the system does--but it is not what the system is" (WHO 2000). Health service inputs (managing resources) is the assembling of essential resources for delivering health services, but these inputs are usually pro- duced at the borders of the health system. These inputs include human resources (produced mostly by the education system with some input from the health system), medications, and medical equipment. Producing these resources often takes a long time (e.g., a trained medical doctor, a new vac- cine or drug). This function is generally outside the immediate control of health system policy makers who, nevertheless, have to respond to short- term population needs with whatever resources are available. An example of this problem is the current crisis of medical education in Sub-Saharan Africa. Health system financing includes collecting revenues, pooling financial risk, and allocating revenue (strategic purchasing of services). We briefly examine them in this annex. Revenue collection entails collection of money to pay for health care serv- ices. Revenue collection mechanisms are general taxation, development assistance for health (DAH, donor financing), mandatory payroll contribu- tions, mandatory or voluntary risk-rated contributions (premiums), direct household out-of-pocket expenditures, and other forms of personal savings. Traditionally, each method of revenue collection is associated with a specific way of organizing and pooling funds and buying services. For example, pub- 176 Healthy Development lic health systems are typically financed through general taxation, and social security organizations are usually financed through mandatory contribu- tions from workers and employers (payroll contributions). In most countries, health financing is a mix of general taxation, manda- tory social insurance contributions, and household out-of-pocket expendi- tures (OOP). The relative importance of each source of financing varies greatly across countries. While OECD countries rely heavily on public financing (either fiscal or mandatory payroll tax), the importance of OOP is larger in middle-income countries (MICs), and it is the largest in low- income countries (LICs), where it often reaches 70 or 80 percent of total health expenditures. DAH is an important source of health financing in a number of LICs, mainly in Africa. However, DAH on average contributes only about 7 percent of all health expenditures in LICs, ranging from 3 per- cent in a few LICs to more than 40 percent in a few others. Risk pooling refers to the collection and management of financial resources in a way that spreads financial risks from an individual to all pool members (WHO 2000). Financial risk pooling is the core function of health insurance mechanisms. Participation in effective risk pooling is essential to ensure financial protection. It is also essential to avoid payment at the moment of utilizing the services, which can deter people, especially the poor, from seeking health care when sick or injured. Each society chooses a different way of pooling its people's financial risk to finance its health care system. Most high-income countries follow one of two main models: the Bismarck model (Bismarck's Law on Health Insurance of 1883) or the Bev- eridge model (from the report on Social Insurance and Allied Services of 1942--the Beveridge Report). In most developing countries, multiple and fragmented forms of risk-pooling arrangements coexist. Population partic- ipation in risk pooling is lowest in LICs and among the poor. It is also low in MICs among the informal and self-employed population. Improving financial protection in Bank client countries requires a substantial effort to increase participation in risk pooling. Fragmentation is the most distinctive characteristic of LIC and MIC health systems. Within each system, different types of risk-pooling arrange- ments coexist, creating a complex set of incentives for households trying to cover their health care costs. These incentives not only shape how house- holds decide to face potential financial losses from health shocks, but also influence life-style and economic decisions such as whether to work in the formal or informal sectors of the economy. Reducing health system frag- Annex F. What Is a Health System? 177 mentation is essential to improve performance and systemic capacity to serve and protect the poor. Strategic purchasing. Strategic purchasing is the way most risk-pooling organizations (purchasers) use collected and pooled financial resources to finance or buy health care services for their members. In the practical, day- to-day interaction between purchasers and providers, the purchaser, within a regulatory framework, plays a key role in defining a substantial part of the external incentives for providers to develop appropriate provider-user inter- action and health service delivery models. "Systems" Thinking When trying to intervene in any system, it is important to be able to distin- guish whether its nature is primarily mechanical or adaptive. In mechanical systems, what results will occur in response to a given stimulus can be pre- dicted, usually in great detail and under different circumstances. A mechan- ical system may be complex, like an automobile, but it does not show emer- gent behavior. Adaptive systems, on the other hand, have the freedom to respond to different stimuli in different and unpredictable ways and are interconnected with the actions of other parts of a system. Many human sys- tems, including health systems, are adaptive. Health outcomes are not merely a product of a set of physical inputs, human resources, organiza- tional structure, and managerial processes. They are complex adaptive sys- tems that have the following key characteristics (Plsek et al. 2001): · Adaptable elements. They can learn and change themselves. In mechanical systems, change is imposed, whereas under adaptive systems, changes can happen from within. · Context. Systems exist within systems, and this context matters, because one part of a system affects another. In health systems, chang- ing the financing system may change availability and performance of health workforce, the use of other inputs, and the relationship with patients. In adaptive systems, optimizing one part of the system may lead to poor overall system performance. In a hospital, for example, reducing the length of stay of patients in one ward may lead to queu- ing and readmission in other parts of the hospital, compromising over- all quality or cost. 178 Healthy Development · Inherent order. Systems can be orderly even if there is no central control, often because they self-organize. Health systems are self-organizing; dif- ferent types of provider organizations, associations, and behaviors emerge continually, either formally or informally. · Not predictable in detail. Changes are not linear or easily predictable. For example, a large health program may have little impact, but a rumor may spark a strike or a riot at a clinic. Forecasting and modeling in health sys- tems can be done to predict effects on health and poverty, but they are not predictable in detail because the elements and relationships are changeable and nonlinear, often in creative ways. The only way to know what complex adaptive systems will do is to observe them. What are the practical implications of viewing health systems as complex adaptive rather than mechanical systems? In the first place, giving up a mechanical approach means spending less time on blueprints and detailed plans. It also means that it is less important to search for the "correct" health financing or organizational approach for a given country or a given context. It does mean the following: · Understand the context, look for connections between the parts (e.g., between programs, between demand and supply, across sectors), antici- pating downstream consequences and identifying upstream points of leverage. · Focus on simple rules to produce complex outcomes. Balance three types of rules that: set direction (e.g., leadership and vision); set prohibitions (e.g., regulations and boundary setting); and provide permission (e.g., setting incentives or providing resources). · Understand how organizational structure influences behavior. How min- istries are organized, and how development assistance is provided matter a great deal. Health workers hired and trained under a centrally managed disease program will work differently from those accountable for all out- patient conditions and hired by a local health service organization. · Use data to guide decisions. Constantly looking at how health systems perform is the best way to see how it is actually behaving and whether a project or new intervention is making a difference. ANNEX G World Bank Partners in Health, Nutrition, and Population Global Health Partnerships and Initiatives African Program for Onchocerciasis Control (APOC) European Observatory for Health Systems and Policies Global Alliance for Improved Nutrition (GAIN) Global Alliance for Vaccines and Immunisation (GAVI) Global Forum for Health Research (GFHR) Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) International AIDS Vaccine Initiative (IAVI) International Lung Health Program ­ International Union Against Tuber- culosis and Lung Disease (IUATLD) International Partnership for Microbicides Joint United Nations Programme on HIV/AIDS (UNAIDS) Mainstreaming Nutrition in Maternal Child Health Program Medicines for Malaria Ventures (MMV) Population and Reproductive Health Capacity Building Program Roll Back Malaria (RBM) Stop Tuberculosis Partnership (Stop TB) United Nations Standing Committee on Nutrition West Africa Multidisease Surveillance Control WHO Special Programme for Research and Training in Tropical Diseases (TDR) WHO Special Programme of Research, Development and Research Train- ing in Human Reproduction (HRP) 179 180 Healthy Development Process/Programs without Financial Participation Child Health and Nutrition Research Initiative (CHNRI) Disease Priorities and Control Program (DCP2) Donors' Group on Adolescent Sexual and Reproductive Health and Rights Global Alliance to Eliminate Lymphatic Filariasis Global Alliance for Improved Nutrition (GAIN) Health Metrics Network (HMN) International Finance Facility for Immunisation (IFFIm) Interagency Working Group on Youth Micronutrient Initiative Nutrition and Gender The Partnership for Maternal, Newborn, and Child Health Reproductive Health/HIV Interagency Working Group Reproduction Health Supplies Coalition (RHSC) Road Traffic Injuries Research Network UNITAID Global Institutional Partners African Union (AU) Asian Development Bank (ADB) European Union (EU) Food and Agricultural Organization of the United Nations (FAO) Inter-American Development Bank (IADB) International Labour Organisation (ILO) Organisation for Economic Co-operation and Development (OECD) United Nations Children's Fund (UNICEF) United Nations Development Programme (UNDP) United Nations Population Fund (UNFPA) World Health Organization (WHO) World Organisation for Animal Health (OIE) Annex G. World Bank Partners in Health, Nutrition, and Population 181 Bilaterals/Partners Canadian International Development Agency (CIDA) Danida Dutch International Cooperation French Development Organization German Agency for Technical Cooperation (GTZ) Italian Development Organization Japan International Cooperation Agency (JICA) Norwegian Agency for Development Cooperation (Norad) Swedish International Development Cooperation Agency (SIDA) Swiss Agency for Development and Cooperation United Kingdom Department for International Development (DFID) United States Agency for International Development (USAID) United States Centers for Disease Control and Prevention (CDC) Foundations Aga Khan Foundation Bill and Melinda Gates Foundation Ellison Institute Ford Foundation Hewlett-Packard Foundation Rockefeller Foundation Soros Foundation United Nations Foundation Wellcome Trust ANNEX H HNP Contributions to Combating HIV/AIDS: Background Paper to the World Bank HNP Strategy HIV/AIDS is a health priority for low- and middle-income countries (LMICs). HIV/AIDS is the fourth leading cause of death and disability in LMICs (Mathers, Lopez, and Murray 2006), and in many countries, partic- ularly in Africa, the epidemic poses a major threat to their economic devel- opment. Although the global HIV incidence appears to have peaked, the number of new infections and deaths continues to rise (UNAIDS 2006). Recent financial and political commitments for combating HIV/AIDS have created new opportunities, but also new challenges. Much of the new fund- ing is focused on increasing access to antiretroviral therapy (ART). In the last two years, the number of people on ART in low- and middle-income countries has more than tripled to 1.3 million by the end of 2005. Yet this represents only 20 percent of those estimated to need treatment (UNAIDS 2006). Scaling up HIV prevention and treatment in a sustainable way will depend on health systems that can deliver care, fiscal space, and the ability of the international community to provide the financing. A comprehensive response to HIV requires action across many sectors. The health sector, however, has a unique and central contribution to make, especially in scaling up clinical aspects of prevention and treatment (e.g., voluntary counseling and testing, behavioral counseling for people with HIV, prevention of mother-to-child transmission (PMTCT), treatment of sexually transmitted infections, treatment for co-infections with tuberculo- sis and opportunistic infections, and ART), as well as for other public health functions such as disease surveillance and monitoring. 183 184 Healthy Development In 2005, the World Bank articulated its Global HIV/AIDS Program of Action (GHAPA) for supporting the global, regional, and national AIDS response. The Africa Region of the World Bank is developing an "HIV/AIDS Agenda for Action in Sub-Saharan Africa" to further articulate the Bank's role on HIV/AIDS in the Region most affected by HIV. The HNP Strategy is intended to complement these responses. This annex to the HNP Strategy: · Identifies the main constraints of health systems in contributing to the fight against HIV/AIDS and ways of overcoming these constraints. · Reviews the special challenges of financial sustainability in HIV/AIDS and health programs and identifies ways of overcoming these constraints. · Outlines the key contributions that HNP sector can make to combating HIV/AIDS. The Relationship between Health System Strengthening and Priority­Disease Approaches The decades-old tension between health system strengthening approaches and priority­disease approaches has changed to a growing consensus that both types of approaches depend on the other to achieve their common goals (Peters et al. 2006; High-Level Forum 2005; Mills 2005; Stillman and Bennett 2005). It is also recognized that the old labeling of "vertical" versus "horizontal" schemes is not an accurate portrayal of either HIV/AIDS or health system strategies. Although many HIV/AIDS pro- grams have created separate organizational units, with separate personnel, management, and accountability systems, the World Bank and other agen- cies have worked with countries to encourage programs to be broadly based and operate across sectors and civil society. By the same token, not all health system strengthening approaches are integrated "horizontally." Projects that focus on essential drug management or strengthening health information systems may be more "vertical" than HIV/AIDS programs when they use separate and hierarchical management and accountability structures, even if they function across diseases. In any case, important con- cerns remain about which approaches work best and how to find synergies between disease-specific and systems approaches. Annex H. HNP Contributions to Combating HIV/AIDS 185 Some have argued that priority programs such as for HIV or disease eradication should be able to strengthen health systems generally (Buve, Kalibala, and McIntyre 2003; Melgaard et al. 1999). Yet beyond the strength of expert opinion, there has been little evidence that these spillover effects actually occur (Peters et al. 2006). Some studies note that, although large disease control programs can be effective in addressing the specific prob- lems they target, they can also harm the general health systems when they create duplicative and uncoordinated management entities, financing struc- tures and reporting systems, or replace local priorities with those of donors, or distort salary and incentive structures and distract from other activities (High-Level Forum 2005; McKinsey&Company 2005; Stillman and Ben- nett 2005). In reviewing studies that examine approaches to strengthening specific programs and studies that attempt to strengthen a range of health services, Øvretveit and colleagues (2006) find little scientifically robust evi- dence for or against the view that disease-specific programs deflect overall health services from local needs. Nonetheless, they note that some strate- gies to deliver certain services, such as special payments to provide immu- nizations, can reduce the motivation to provide other services. They con- clude that disease- or service-specific strategies on their own are unlikely to bring about the changes needed in health systems to achieve the Millen- nium Development Goals (MDGs). Overcoming Health Systems Constraints A number of recent studies have identified common types of constraints in health systems in low- and middle-income countries that affect both disease- specific and health systems (Hanson et al. 2003; Oliveira-Cruz, Hanson, and Mills 2003; Travis et al. 2004). These constraints can be examined by how they relate to the incentives environment for the health sector (table H.1). There is little strong evidence to indicate which constraints are most impor- tant, or what strategies are most effective in overcoming these constraints. The reason is that the studies that comprise the evidence basis for the reviews are mostly of limited scientific value, due to flaws in study design. The studies often do not define the particular strategies under investigation or cannot attribute change to the strategies pursued (Øvretveit, Siadat, and Peters 2006; Peters et al. 2006).60 186 Healthy Development Table H.1: Incentives Environment and Constraints for Health Systems in Low- and Middle-Income Countries LEVEL OF INCENTIVES EXAMPLES OF CONSTRAINTS Individuals and Lack of demand; limited access to information; lack of financial resources; exclusionary communities social norms; fractured or weak community institutions; low community participation; limited influence over providers, health bureaucrats, and political leadership; physical barriers to care Health service Limited staff; inadequate provider skills, poor training and technical guidance; weak moti- providers vation; weak supervision and management systems; poor compensation and rewards systems; poor physical work environment (e.g., inadequate drugs, equipment, and buildings) Health sector Weak sector leadership and vision; inappropriate sector planning and regulatory systems; weak accountability mechanisms; purchasing and provider payment systems unrelated to performance; poor collaboration with nongovernmental organizations and private sector stakeholders; reliance on donors and donor priorities Macro environment Insecure or unstable social and political conditions; macroeconomic instability; poor gov- ernance and corruption; trade and migration pressures; weak sectors critical to health (education, communications, agriculture, labor); weak systems for reconciling cross- sectoral development priorities; inefficient, unresponsive, and rigid government bureau- cracies; confused or insufficiently supported decentralization strategies; poor physical environment (poor roads and communications infrastructure) The HIV epidemic itself places additional pressures on weak health sys- tems by increasing demand for health care and reducing the supply of health workers. It also reduces the supply of a given quality of health services at a given price, while increasing health expenditures (Over 2004).61 This is likely to translate into higher national health care expenditure in absolute terms and as a proportion of national income. This leads to reduced non- HIV patients' access to other health services, unless additional expenditures are made to finance those services. Health Financing Constraints The contrast between the enormous unmet health needs of poor countries and the resources they have to pay for them is well recognized. In a recent synthesis of health financing in low- and middle-income countries, Gottret and Schieber (2006) find that developing countries account for more than 90 percent of the global disease burden, but only 12 percent of global health spending. Between US$25 billion and US$70 billion in additional aid per Annex H. HNP Contributions to Combating HIV/AIDS 187 year has been projected as needed to achieve the MDGs. The Bank is con- cerned about a number of characteristics of development assistance for health (DAH), as described by Gottret and Schieber (2006), that are partic- ularly relevant to HIV/AIDS: · Volatile and short-term aid. The amount of DAH funds countries receive varies greatly from year to year, though the reasons may differ.62 Although funding for HIV/AIDS has increased rapidly, due largely to funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), more than 70 percent of these funds are concentrated in about 25 countries, whereas donors have health programs in about 140 countries.63 Volatile and short-term DAH makes it difficult for ministries of health and finance to make necessary long-term plans such as employ- ing more doctors or nurses, raising wages, or expanding access to ART. · Funding distortions. Fragmentation of donor assistance to health has cre- ated distortions in funding, making it difficult for governments to finance their system requirements for staff, supervision, training, management, and maintenance. For example, a government of Rwanda report identi- fied how donor funding has helped create a sixfold difference in per capita health spending between provinces (Republic of Rwanda Ministry of Finance and Economic Planning, Ministry of Health 2006). Physicians working for nongovernmental organizations (NGOs) providing HIV/AIDS services received six times the wages of MOH physicians, compromising human resources and service delivery in the public sector. The Ministry of Finance (MOF) argues that funding for HIV/AIDS is "disproportionate" when there is little funding for child health or other strategic objectives. The MOH says "single-issue funds and single-issue projects are being used to disburse funds through centralized allocation mechanisms that do not respond to the relative importance of needs as perceived by patients and health providers." Paradoxically, as donors move to provide more general budget support, spending on health and HIV/AIDS may decrease if governments choose different allocation pri- orities, particularly if they feel that donors will provide other support for health and HIV/AIDS. · Allocative inefficiencies. The large influx of funding for HIV/AIDS raises the question about whether the funds are used to provide maximum ben- 188 Healthy Development efit. The recent emphasis on expanding access to ART has not been met by a similar expansion of prevention efforts. Although ART appears to have a net beneficial effect on preventing HIV infection, and both can be relatively cost-effective, preventive interventions will have a bigger impact on reducing new HIV infections and are more cost-effective (Bertozzi et al. 2006; Hogan et al. 2005; Salomon et al. 2005). The prob- lem is particularly striking in PEPFAR, the largest funded program for HIV/AIDS, where prevention spending is falling and constrained by requirements for abstinence-until-marriage activities (Government Accountability Office 2006). If funding continues to increase for HIV/AIDS, and ART in particular, without concomitant increases in funding for other priorities, the question must also be asked if some funds would be better spent in other ways that can make a larger contribution to peoples' health or better address inequities. Alternative uses include programs targeted at the health of poor and vulnerable populations, other high-priority conditions that are relatively underfunded such as neonatal health, or desperately needed investments in human resources for health and other aspects of health systems. · Need to create fiscal space. Large increases in public spending on HIV/AIDS or health initiatives that create future spending commitments must be considered in the context of governments' ability to provide resources from current and future revenues and donors' willingness to provide long-term funding. The problem is compounded if large expen- ditures are financed by borrowing, which requires additional revenue to service the debt and has potential to impair overall economic growth. In the case of Rwanda, only 14 percent of the donor spending on health passes through the government. This makes it very difficult for govern- ment to diagnose fiscal problems or plan a response to manage large influxes or reductions in short-term aid (Republic of Rwanda Ministry of Finance and Economic Planning, Ministry of Health 2006). The Bank's Contributions in Financing for HIV/AIDS The Bank will specifically contribute to financing HIV/AIDS programs and health systems in several ways: · Providing increased, long-term, predictable funding. The World Bank is com- mitted to leveraging and providing increased and predictable long-term Annex H. HNP Contributions to Combating HIV/AIDS 189 financing for HIV/AIDS and the health sector. This includes a commit- ment to financing recurrent costs of HIV/AIDS and health programs in ways that help them increase their effectiveness and reduce wastage. When the World Bank funds ART programs, it will seek to do so in the context of long-term program funding, such as through Adaptable Pro- gram Loans or find new ways of funding cohorts of people on HIV treat- ment (e.g., 20-year horizon), rather than just through short-term projects. Shorter-term project support for HIV/AIDS and health initiatives should be selected and designed to meet shorter-term objectives, such as to test innovations, help create new institutions, support transitions in ongoing programs, or bridge especially unstable conditions. · Creating fiscal space and reducing distortions. The Bank will work with client countries, the IMF, and other donors to help them develop ways of enhancing country capacity to absorb fiscal shocks and reduce their adverse effects. This would involve working with Ministries of Finance, other sectoral ministries, and donors to ensure better complementarity of external financing flows and domestic resource mobilization. External flows should facilitate and help catalyze domestic financial resource mobilization rather than increase debt or aid dependency. The Bank will also ensure that financing and reporting procedures support local systems and are harmonized with those of other donors, as outlined in the Paris Declaration on Aid Effectiveness64 and the "Three Ones" for HIV/AIDS programs.65 · Enhancing accountability. The Bank will promote budgetary and financial reporting processes that accommodate and respond to the views of criti- cal stakeholders within the country. These processes will need to account for the interests of the poor, vulnerable, and marginalized groups, includ- ing people living with HIV/AIDS, in order to increase accountability and enhance people's voice. These processes offer important opportunities for debating and resolving concerns about allocative efficiency and equity, and for public disclosure of information and decisions over policy, financing, and program direction. · New types of financing. The Bank will provide financial, technical, and con- vening support to countries that request help with developing health financing systems that promote accountability, efficiency, and financial protection, and which form the framework for financing of HIV/AIDS 190 Healthy Development prevention, care, and treatment at the country level. The Bank will also test new approaches to its own financing of HNP and HIV/AIDS. Emphasis will be put on linking Bank financing to performance in purchasing HIV/AIDS and other health services, rather than rely on financing inputs. Such approaches accentuate the importance of using information and demonstrating results in HIV/AIDS and other health sector programs. More Funding Is Not Enough Although additional funds will be necessary for scaling up HIV/AIDS and other health services, additional funding can also play an important role in overcoming some health system constraints such as poor supply of drugs and equipment or weak demand for services (Hanson et al. 2003). However, there is an emerging view that funding alone is not sufficient to overcome constraints. Johnston and Stout (1999) argue that it is the continuous com- mitment to improvement, analysis of constraints, flexible implementation, and positive macroeconomic and governance environments that are most useful in strengthening health services. Lewis (2005) holds that the keys to effective absorption of funding for HIV/AIDS will require building up insti- tutions and human capacity in the health sector, as well as broader gover- nance capacity. Whitty and Doherty (2006) argue that the biggest barriers to fighting disease are not financing or political will, but the failure to match the recent investments in new drugs and tools with investments in training people and developing efficient systems to deliver them. This is exactly where the World Bank's HNP Strategy can assist countries to better tackle the HIV/AIDS and health problems they face. Vision for HNP Contributions to Combating AIDS In the "preferred future," countries' health sectors will make significant contributions to combating HIV/AIDS and improving their people's health, and the World Bank will help client countries: · Improve health status among vulnerable groups and the general popula- tion, including achieving the MDGs. Curbing the incidence of HIV infections across all key subgroups and the general population is a vital part of this. Annex H. HNP Contributions to Combating HIV/AIDS 191 · Fashion effective, equitable, accountable, affordable, and sustainable health systems that provide a full range of preventive, curative, and rehabilitative health services and make full use of public and non- governmental health actors and engage with and contribute to institu- tions outside the health sector. The Bank shares the collective goals of universal access to ART for people with HIV, universal childhood immunization, antenatal care and safe deliveries for all pregnant women, provision of directly observable treatment for all TB infected, and full access to other elements of locally defined "essential packages" of care. · Reduce the number of people plunged into poverty by health care costs. · Help individuals and households to make informed choices about healthy life styles and use of health services. The Bank's Contribution to HIV/AIDS through Health Systems The focus of health system strengthening for HIV/AIDS is to improve and expand HIV prevention, treatment, and care via the health systems that deliver these services. The HNP Strategy outlines how the Bank will focus on strengthening aspects of health systems related to its comparative advan- tages in financing, creating the right incentives environment, working across sectors, and demonstrating and using results in the context of coun- tries' human and economic development. In addition to addressing financing of HIV/AIDS and health (discussed above), the World Bank plans to strengthen health systems to contribute to HIV/AIDS by: · Integrating HIV/AIDS and health system programming to ensure that planning and financing of the health sector and HIV/AIDS programs support each other and do not create duplicative and competing struc- tures. The Burkina Faso Health Sector Support and Multisectoral AIDS Project is an example of the way health sector and HIV/AIDS allocation decisions can be made collectively: a common lending instrument is sup- porting two pooled funds (one for the health sector, one for multisectoral HIV/AIDS activities), which will facilitate alignment of financing, man- agement, and monitoring systems. 192 Healthy Development · Learning from the experiences of the AIDS Strategy and Action Plan (ASAP) service and the Global AIDS Monitoring and Evaluation Team (GAMET) program to provide task teams and country stakeholders with resources and tools to improve strategy development, engagement of civil society, and monitoring and evaluation. · Funding interventions that are important to the HIV epidemic or the health situation that might otherwise be neglected because they are polit- ically difficult for other agencies to finance (e.g., prevention and treat- ment programs for prisoners, harm-reduction programs for injection drug users). · Refraining from funding popular programs that other agencies can finance with grants (e.g., commodities for ART and prevention of mother-child transmission) or activities for which Bank support systems are inadequate (e.g., clinical trials). · Supporting systematic identification, monitoring, and evaluation of country-based Bank assistance to HIV/AIDS programs and the health sector to ensure that: ­ Country strategies, PRSPs, MTEFs, and sectorwide approaches ade- quately address HIV/AIDS and other priority health concerns, the inter- ests of the poor, and health system requirements for delivering services. These strategies will need to be appropriately budgeted and aligned with the country's macroeconomic framework and have sustainable financing that does not skew balanced development of the economy. They will also need a focused and balanced approach to demonstrating results. ­ The proposed financing and implementation arrangements for HIV/AIDS and the health sector are supportive of the "Three Ones" and the Paris Principles on Aid Effectiveness. ­ Support to specific-disease programs or institutions is contingent on identification of any potential harm to the health system (or other health programs and prior establishment of appropriate risk-mitiga- tion strategies. In day-to-day operations, the World Bank has numerous levers of influence to support HIV/AIDS and the health sector at country level. Table H.2 outlines these levers and summarizes how they can be translated into specific actions. Annex H. HNP Contributions to Combating HIV/AIDS 193 Table H.2: Levers of Influence for the World Bank in HIV/AIDS and Health Systems at Country Level LEVERS OF INFLUENCE Direct interventions Bank actions in HIV/AIDS and health systems Financing investments · Provide funding for agreed public sector programs that appropriately finance HIV/AIDS programs and health systems and operations in the context of PRSPs and MTEFs. · Direct health sector financing, for capital investment (buildings, equipment) and recurrent costs (staff, training, drugs, supplies, and activities) for HIV/AIDS programs, development of health systems, and delivery of services. Purchasing outputs/ · Link funding to provision of health or HIV/AIDS services, or locally relevant performance targets, affirming that outcomes results have been achieved as basis for disbursement. Expenditure control · When financing inputs, ensure that fund disbursements conform with procurement procedures acceptable to the Bank. · Assure probity of Bank funds through audits. INFLUENCING STRATEGIES Linking HIV/AIDS and · Facilitate communication between Ministries of Finance and sector ministries for development of national strate- health sector to public gies, planning, and evaluation to ensure that financing is sustainable and balanced across sectors and that the policy and financing health sector and HIV/AIDS programs have a relevant role. · Bring together health with other sectors and civil society organizations over broader government reforms (e.g., civil service reforms). Convening key actors · Bring together critical players within civil society and government within country for learning, consensus building, strategy development, and planning for HIV/AIDS programs and the health sector in the context of PRSPs and MTEFs. · Network with experts and colleagues across countries to ensure that the best possible technical advice is considered. · Facilitate learning by critical players within country through communications, training, sharing materials, and dis- semination of research and evaluation results. Designing HIV/AIDS · Use project preparation and supervision to ensure the best available technical assistance, software, training, and programs, health support systems in the design or redesign of programs and support systems. services, and their · Focus Bank technical resources to strengthen policy and strategy cycles, financing systems, monitoring and evalua- support systems tion systems, poverty concerns, and intersectoral linkages. Monitoring and · Ensure that appropriate plans for the monitoring and evaluation of health systems are developed, financed, and disclosing implemented and that the data are used for management and allocation decisions and for public disclosure and discourse. · Review performance of projects and HIV/AIDS and health sector programs for planning and disclosure purposes. Providing knowledge · Commission or conduct studies on relevant HIV/AIDS and health policy and operational issues, such as impact eval- and advice uations of major programs and innovations. · Pooling and synthesizing information and experience on health systems, health financing, and links to HIV/AIDS with a focus on translating knowledge into local policy and practice. Negotiating actions · Agree on actions for disbursement of Bank funds in the context of Poverty Reduction Strategy Credits that support for disbursements HIV/AIDS and health sector objectives. · Ensure that agreed actions are taken by the borrower when a basis for Bank financing. Notes 1. Interviews were conducted using a structured, open-ended interview technique, small group consultations, and consultations with partners at country and global lev- els. A questionnaire was sent to the Human Development (HD) Sector Management Units (SMUs) in all Regions, to the HNP Hub, the Global Program on HIV/AIDS, the World Bank Institute (WBI), and the International Finance Corporation (IFC) in March 2006. A consultation with the World Health Organization (WHO) was held in May 2006 in Geneva. Focus groups with randomly selected HNP staff (30 participants in all) as well as meetings with HNP teams at regional levels were organ- ized to discuss the same set of questions. Two preliminary consultations with global partners were held on May 18 and 23 and in October and November 2006. Between September and November 2006, the strategy facilitation team visited nine client countries (Algeria, Argentina, Armenia, Djibouti, India, Indonesia, Mali, Mexico, and Tanzania) to consult with government, civil society, academia, global partners in the field, and Bank country office staff. Additionally, the strategy facilitation team benefited from abundant information and analysis provided by Bank staff, other multilaterals, bilaterals, and foundations. The team held various discussion meetings with groups of civil society in Washington, D.C. 2. Preker and Langenbrunner 2005; Angel-Urdinola and Jain 2006; Baeza and Packard 2006; Cotlear 2006; Dussault, Fournier, and Letourmy 2006; Gottret and Schieber 2006; Marek, Eichler, and Schnabl 2006. 3. Allen and Gillespie 2001; Berhman and Rosenzweig 2001; Galasso and Yau 2006; Jamison et al. 2006; World Bank 2006l. 4. Bell, Bruhns, and Gersbach 2006; Duflo et al. 2006; Görgens et al. 2006; Görgens- Albino and Nzima 2006; Lutalo 2006; Malek 2006; Marquez 2006; Moses et al. 2006; Wilson and de Beyer 2006a, 2006b; Wilson and Claeson 2006. 5. Additional sources: Birdsall, Kelley and Sinding 2001; Wagstaff and Claeson 2004; Campbell-White, Merrick, and Yazbeck 2006; World Bank 2006j. 6. Development assistance for health (DAH) consists of all resources aimed at providing financial support to developing countries to improve the HNP conditions of their populations. DAH includes multilateral organizations such as the Bank, bilateral aid, and private philanthropic aid. Annex C presents an overview of actors and trends in DAH in the last decade. 7. Global Fund to Fight AIDS, Tuberculosis and Malaria. 8. Behrman and Rosenzweig 2001; Bell, Devarajan, and Gersbach 2004; Bloom, Can- ning, and Jamison 2004; Bloom, Canning, and Malaney 1999; Croppenstedt and Muller 2000; Fenwick and Figenschou 1972; Fogel 1994; Gallup and Sachs 2000; Glick and Sahn 1998; Jamison 2006; Shariff 2003; Smith 1999, 2005; Thirumurthy, 195 196 Healthy Development Zivin, and Goldstein 2005; Thomas 2001; Thomas et al. 2004; Thomas and Strauss 1997; Wolgemuth et al.1982. 9. As measured by cumulative disbursements for all HNP sectoral classifications man- aged by the HNP Sector Board and other sectors. 10. The active portfolio has decreased by 30 percent since FY2001, mostly due to declining IBRD lending. 11. Share of AAA focused on health systems performance. 12. Defined as preventing households from the impoverishing effects of illness and other health-related life cycle events. 13. World Bank 2006d; Lewis 2005. 14. World Bank 2006d; WHO 2005. 15. World Bank 2006d; WHO 2006a. 16. Commitments for each of the three diseases fluctuate considerably from year to year. FY2005 data, the only data available at this time, should not be used to draw general conclusions about Bank financing for these diseases. 17. Fenwick and Figenschou 1972; Wolgemuth et al. 1982; Fogel 1994; Thomas and Strauss 1997; Bloom, Canning, and Malaney 1999; Smith 1999; Croppenstedt and Muller 2000; Gallup and Sachs 2000; Behrman and Rosenzweig 2001; Thomas 2001; Shariff 2003; Bell, Devarajan, and Gersbach 2004; Bloom, Canning, and Jami- son 2004; Thomas et al. 2004; Smith 2005; Thirumurthy, Zivin, and Goldstein 2005; Jamison 2006. 18. UNICEF 2006a; Mathers, Lopez, and Murray 2006. 19. UNICEF 2006c. 20. UNICEF 2006b. 21. UNAIDS 2006. 22. Ibid. 23. WHO 2006a. 24. In terms of lending and/or policy advice. 25. Development assistance for health consists of all resources aimed at providing finan- cial support to developing countries to improve health conditions of their popula- tions. It includes multilateral organizations such as the World Health Organization, the World Bank, and UNICEF. It also includes bilateral aid and private philan- thropic aid. 26. UNITAID is an international facility for the purchase of drugs that fight HIV/AIDS, malaria and tuberculosis. It was founded in September 2006 on the ini- tiative of Brazil and France, and is to a great part financed by so-called innovative financing mechanisms, namely a solidarity levy on air line tickets. 27. International Finance Facility for Immunisation. 28. Throughout this Strategy, health insurance is used in its functional connotation (pool- ing of financial risk) and not as contributory insurance scheme à la Bismarck. Thus, Notes 197 the use of the term "insurance" means any effective risk-pooling arrangement, including those financed out of general taxation (pooling at societal level), contribu- tory payroll tax­financed social insurance, and private insurance (for-profit or not- for-profit). As discussed later, the Bank does not a priori promote, or discourage, governments and communities from choosing any of these arrangements. Specific preferences should be country-context specific. However, the Bank approaches pol- icy dialog with client countries with a focus on policy and technical advice that pro- vides options and supports their decision-making process for selecting and develop- ing the most promising arrangements to achieve and sustain the strategic policy objective of improving access to services, and financial protection, particularly for the poor and the vulnerable in the specific country context. 29. Verticalization is defined as replication of key health system functions and duplication of support systems, each handling the needs (in parallel) of exclusively single-disease programs such as HIV/AIDS. Verticalization creates distortions that can sap the effectiveness of resources and makes a country miss an opportunity for spillover of priority­disease financing into systemic reform positively affecting many other dis- eases at marginal additional cost. 30. World Bank 2006d; Lewis 2005. 31. World Bank 2006d; WHO 2005. 32. World Bank 2006d; WHO 2006a. 33. Commitments for each of the three diseases fluctuate considerably from year to year, and FY2005 data should not be used to draw general conclusions about Bank financ- ing for these diseases. 34. AMCs are intended to create a market-based mechanism to support research and production of vaccines for diseases that affect developing countries. Donors would guarantee a set envelope of funding at a given price for a new vaccine that meets specified requirements. 35. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the Global Alliance for Vaccines and Immunisation (GAVI). 36. For example, the Global Alliance for Improved Nutrition (GAIN), the Joint United Nations Programme on HIV/AIDS (1996), Roll Back Malaria (1998), and the Stop TB Initiative (1999). 37. Another 74 projects are expected to close by June 30, 2007 (38 HNP Sector Board managed and 36 other sector managed). 38. Realism is a measure of the extent to which task teams reflect potential implementa- tion problems in their project ratings. 39. Proactivity is a measure of steps taken to put unsatisfactory projects back on track. 40. The IEG review is expected during 2008. 41. This time frame is used because AAA coding is accurate for those years. Earlier data are not captured properly in the Bank's data warehouse. 42. Only staff at grade GF and above are included in the analysis. 198 Healthy Development 43. LICs for which official development assistance (ODA) and DAH represents a very small proportion of government/sector expenditures (e.g., India). 44. LICs for which official development assistance (ODA) and DAH represent a very large proportion of government and/or sector expenditures (e.g., Tanzania). 45. In-depth analysis of what a country health system is and how it works is outside the scope of this Strategy. Annex F refers readers to substantial analysis by the Bank and global partners. 46. Achieving results requires a combined effort from HNP, the Bank Poverty Reduc- tion and Economic Management Network (PREM), Social Protection, Financial Services, Private Sector Development, Information Technology, and so on. 47. System performance is defined as systemic efficiency in sustaining or improving cur- rent HNP outcome and output achievements. 48. Fragmentation is defined as multiple small (inefficient risk-pool size) insurance providers that seldom complement each other and often present significant barriers for the portability of benefits when individuals need or desire to change from one to another insurer. 49. Household private out-of-pocket health expenditures are by far the largest source of health financing for most LICs, even for those receiving large DAH. 50. Soucat el al. 2004. 51. World Bank forthcoming b. 52. Cotlear 2006. 53. Ibid. 54. This section summarizes findings and recommendations of Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action (World Bank 2006l). 55. Share of DAH devoted to primary care dropped from 28 percent in 1999 to 15 per- cent in 2004 (World Bank 2006f).. 56. Includes external and domestic spending. 57. Caines et al. 2004; Caines 2005; McKinsey&Company 2005. 58. See note 26. 59. Most of the discussion and information in this section draws (and quotes) extensively from findings and recommendations of: The World Health Report 2000, Health Sys- tems: Improving Performance, WHO 2000, Baeza and Packard 2006, and from con- tributions from the Health Services Team of the HNP Hub led by David Peters. 60. The common deficiencies in research design include: the strategies or intervention that are being pursued are not described in detail, so that it is hard to determine what the intervention actually consists of or whether it was implemented, and very differ- ent strategies are often given the same label; many strategies involve multiple com- ponents that are not specified or studied in a way that would indicate which compo- nent is essential, or where there are synergies between components; most studies do little to examine factors beyond the health system or the intervention itself that may Notes 199 influence the results being examined; there are limited attempts to design studies that can actually attribute results to the strategy, including use of time series, before- after data, or comparison groups and randomization. 61. The effects in a given country will depend on factors such as its HIV prevalence, demographic patterns, costs of ART, availability of health insurance, supply of health workers, their perceived and actual risks of HIV infection, and the costs of provid- ing services at the same level of quality (Over 2004). 62. These include the short-term commitments of donors--often no more than 12 months at a time--exchange rate fluctuations, and administrative delays by donor or recipient, and aid conditionalities. 63. GFATM grants typically have a two-year initial phase and a three-year second phase, with funding for the second phase conditional on acceptable progress in the initial phase, although grantees can apply for concurrent grants. PEPFAR was originally announced as a five-year program, with renewal under discussion. 64. 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World Health Report 2000. Health Systems: Improving Performance. Geneva: WHO. ------. 2002. The World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva: WHO. ------. 2003a. The World Health Report 2003. Shaping the Future. Geneva: WHO. ------. 2003b. Social Determinants of Health: The Solid Facts, 2nd ed, ed. R. Wilkinson, M. Marmot. Denmark: WHO. ------. 2005. World Malaria Report 2005. Geneva: World Health Organization; UNICEF. ------. 2006a. "WHO Tuberculosis Fact Sheet." http://www.who.int/media centre/factsheets/fs104/en/index.html. ------. 2006b. World Health Report 2006. Working Together for Health. Geneva: WHO. Yazbeck, A, and C. Hayashi. 2001. "How Well Are Bank-Supported Health, Nutrition, and Population Projects Designed to Benefit the Poor?" Seminar Report, World Bank, Washington, DC. Index Boxes, figures, and tables are indicated by b, South Asia Region, 134 f, and t, respectively. analytical capacity, 9 Angola, 88f, 112t AAAs. See Analytical and Advisory anticorruption, 68b Activities antiretroviral therapy (ART), 33, 90, 188 access to health services, 14, 59, 74b, 76 APL. See Adaptable Program Loan accountability, 17, 67, 67f, 68b, 166t Argentina, 60, 61f, 73, 123t, 124 for outcomes, 70 maternal and child health, 74b, 77, HIV/AIDS financing, 189 125, 127 Results Framework, 156t, 158t, 160t, Armenia, 119t 162t, 164t, 166t Asia, 94. See also South Asia Region Action Plan, 30, 69, 99­100, 101t­104t, avian flu, 33 104 Azerbaijan, 119t HNP Hub, 109 action plans, Regions, 110­134 baby boomers, 12 acute respiratory infections, 34f Bahrain, 128t Adaptable Program Loan (APL), 74b, Bangladesh, 34f, 131, 131t 114­115 Barbados, 123t adaptive systems, 174, 177­178 Belarus, 119t administrative burden, 17, 36 Belize, 123t Advance Market Commitments (AMCs), Benin, 66f, 111t 15, 80, 155, 197n Beveridge model, 176 advice, 26, 40, 47, 50, 51, 77 Bhutan, 131t HIV/AIDS, 193t Bill and Melinda Gates Foundation, 1, strengthening health systems, 49­53 15, 52, 72b, 146, 147 advocacy organizations, 80 Bismarck model, 176 Afghanistan, 88f, 131, 131t Bolivia, 123t, 125, 126 Africa Region, 94, 110­115, 111t­112t, Bosnia and Herzegovina, 119t 184 Botswana, 112t aging population, 121 bottlenecks, 114 aid, effectiveness of, 151­152, 152f, 155 Brazil, 123t, 125 aid, volatile and short-term, 187 budget allocations, 9­10, 107, 187­188 AIDS Strategy and Action Plan (ASAP), budget issues, 122 192 Bulgaria, 119t Albania, 119t Burkina Faso, 88f, 111t Algeria, 128t Burundi, 66f, 111t alignment, 17, 105t, 155 AMCs. See Advance Market Cairo Consensus, 84 Commitments Cambodia, 34f, 116t Analytical and Advisory Activities (AAAs), Cameroon, 112t 3­4, 17, 37, 77, 103, 103t, 163t capacity building, 49, 157t. See also World EAP Region, 117 Bank investment in, 44 Cape Verde, 112t 211 212 Healthy Development CAS. See Country Assistance Strategy country financing, 147­150 CCT. See conditional cash transfer country focus, 22­24, 53­54, 116 CDC. See United States Centers for Dis- country level approach, 5­6, 73 ease Control and Prevention Country Management Units (CMUs), 8 Central African Republic, 111t country outcomes, 156t­167t Chad, 88f, 111t Country Performance and Institutional challenges, 4, 6, 13­14, 33, 35, 75 Assessment (CPIA), 105 child development. See early childhood country strategies, outcome-based, 117 development country support, 7b, 8, 10, 30 Child Health Insurance, 125 country-led lending, 24 child mortality, 13, 33, 150, 156t country-specific prioritization framework, Africa Region, 111t 171 infant, 59f, 74b CPRU. See Conflict Prevention and under-5, 58, 73, 87t, 157t Reconstruction Unit World Bank Regions, 116t, 119t, Croatia, 119t 123t­124t, 128t, 131t Czech Republic, 119t Chile, 60, 61f, 123t China, 60, 116t, 117 data collection, 101t, 159t chronic diseases, 4, 13, 33 data, lack of, 16, 32 CMUs. See Country Management Units database for project results, 102t collaboration, 9, 29, 49, 53, 64, 104, 130, death, premature, 13 163t debt relief, 39­40 health systems, 51­52, 103t development, 11­12, 14, 31, 94t Strategic Direction, 79­81 nutrition impacts, 93­94, 96­97 Colombia, 123t development assistance for health (DAH), Committee on Development Effective- 1, 2, 6­7, 32, 110, 195n, 196n, 198n ness (CODE), xiii AIDS, 91, 187­188 Comoros, 111t architecture change, 31, 35­36, 38 Comprehensive Development Partner- by source, 16f, 147f ship, 118 LIC financing, 176 concessional lending, 17 new environment, 15­18, 22­24 conditional cash transfer (CCT), 126 worldwide, 146­147 Conflict Prevention and Reconstruction Development Grant Facility (DGF), 29, Unit (CPRU), 130 105t, 109, 121, 167t conflicted countries, 128, 130 Development Policy Lending (DPL), Congo, Democratic Republic of, 111t 114 Congo, Republic of, 112t diagnostic tool development, 78 constraints, 78, 169, 171, 186t. See also diarrhea, 34f Multisectoral Constraints Assess- disbursements, 39, 40f ment for Health Outcomes disease approaches, single and vertical, 75 overcoming, 185­190 disease burden, 54f, 115, 150, 186 Copenhagen Consensus, 94, 94t disease control, 53, 94t, 185 corruption, 66, 68b disease programs and health systems, Costa Rica, 123t 17­18, 77 costs of health care due to illness, 20b disease, barriers to fighting, 190 Côte d'Ivoire, 111t disease-specific financing, 15, 22, 146 Country Assistance Strategy (CAS), 23, disease-specific initiatives, 146. See also 78, 79, 104t, 169 priority­disease approaches Index 213 diseases, 4, 15, 18 fertility trends, 35, 86f, 88f Djibouti, 127, 128t financial protection, 15, 59­61, 63­64, Dominica, 123t 113, 164t, 176. See also health Dominican Republic, 34f, 123t, 126 insurance donor aid effectiveness, 151­152 Financial Services, 77 donor assistance fragmentation, 187 financing. See health financing donor assistance, AIDS, 91 fiscal management, 64­66 donor coordination, 117, 155 fiscal space, creation of, 91, 92, 105t, 188, donors and ODA, 148f 189 Food and Agriculture Organization early childhood development, 3, 12, (FAO), 52 93­94 foreign direct investment, 12 East Asia and Pacific (EAP) Region, foundations, 181 115­118, 116t, 148t Fragile States Unit (FSU), 130 economic growth, 2, 11­12 fragmentation of aid, 187 economic sector work (ESW), 44, fragmentation of health systems, 169­170 176­177, 198n Ecuador, 60, 61f, 123t, 126 funding, 1, 15, 60, 91, 187 education and fertility rate, 87t predictability, 188­189 Egypt, 128t private, 48­49 El Salvador, 123t, 126 volatility of aid, 151, 152f energy sector, 121 engagement, 79­81, 122b, 164t Gabon, 112t environment, international, 15­18, Gambia, The, 111t 31­33, 35 Georgia, 119t epidemics, 4, 33 Ghana, 111t Equatorial Guinea, 88f, 112t Global AIDS Monitoring and Evaluation Eritrea, 111t Team (GAMET), 192 Estonia, 119t Global Alliance for Improved Nutrition Ethiopia, 111t (GAIN), 1, 15, 52 Europe and Central Asia (ECA) Region, Global Alliance for Vaccines and Immu- 119­122, 119t, 148t nization (GAVI), 1, 3, 15, 29, 38, 52, European Observatory on Health Sys- 79, 146, 147 tems and Policies, 121 Global Fund to Fight AIDS, Tuberculo- Extended Term Consultants (ETCs), 45, sis, and Malaria (GFATM), 1, 3, 15, 46f 29, 38, 52, 79, 146, 147, 154, 187, external assistance, 119t, 123t­124t, 128t, 199n 149­150 LAC Region project review, 126­127 Africa Region, 111t global health architecture, 145­146, and health expenditures, 152f 150­154 EAP Region, 116t Global Health Coordination and Partner- South Asia Region, 131t ships Team, 106, 109 external resources, 61t, 62t Global Health Partnerships (GHPs), 152­153, 179 Family Health Extension, Brazil, 125 Global HIV/AIDS Program of Action family planning, 85, 89, 89f (GHAPA), 90, 184 fertility rates, 12, 84, 86, 87, 89, Global Monitoring Report (GMR), 105, 160t 146 214 Healthy Development global partners, 29, 152­153, 180 health indicators, 101t, 111t­112t, 119t, Global Task Team on Improving AIDS 120, 123t­124t, 128t, 131t, Coordination among Multilateral 156t­167t Institutions and International health insurance, 65, 113, 121, 125, 176, Donors (GTT), 154, 155 196n­197n. See also financial governance, 52, 66­67, 68b, 151­152, protection 166t Health Metrics Network, 38 grants, 167t health outcomes, 12, 15, 27, 42, 42f, 68, Grenada, 123t 153­154 gross national income (GNI), 111t, 116t, identifying targets, 170­171 119t, 123t­124t, 128t, 131t improving, 58­59 Guatemala, 123t health policy, global attention, 31 Guinea, 66f, 111t health provider management, 51, 52 Guinea-Bissau, 88f, 111t Health Reform APL, Peru, 125 Gulf Cooperation Council, 128, 128t health sector, 153­154, 183 Guyana, 123t Health Sector Reform, Brazil, 125 health service delivery, 51, 76 Haiti, 123t private, 33, 48­49, 175 harmonization, 17, 105t, 155 health service supply capacity expansion, HD. See Human Development 76 Network health shocks, 59­60 health architecture, 145­146, 150­154 health staff, attracting, 20b health coordination team, 106, 109 health staffing, 44­45, 44f, 45f, 46f Health Eight Project, China, 117 health surveillance, 35, 71 Health Emergency Project, Argentina, health system capacity, 100 125­126 health system performance, 15­16, 18, health expenditures, 61f, 61t, 147­148, 26, 58 149t, 150, 152f health systems, 19b­20b, 49­50, 68b, 75. by Region and income, 148t See also systems thinking external, 61t, 62t, 65f, 66f, 152f Africa Region, 114 single disease vs. general health, 187 and single-disease programs, 17­18 World Bank Regions, 111t, 113, 116t, constraints, 102t, 185­190 119t, 123t­124t, 128t, 131t fragmentation, 63, 176­177 health facilities, use of, 34f functions, 50f, 52­53, 174­177, 197n health financing, 1, 15, 22, 32, 33, HIV/AIDS, 90­91, 92, 193t 113­114, 120­121, 155 HNP results, 18­19, 21 and fiscal management, 64­65 MENA Region, 129 constraints, 186­188 parts, 173­174 country level, 147­150 performance monitoring, 71 developing, 92­93, 189­190 priority­disease interventions, 28, 126 donors, 146­147 stewardship, 174­175 health systems, 49­53, 52, 175­176 health systems policy team, 100, 103t, HIV/AIDS, 91­92, 188­190 106, 110 LAC Region, 125 health systems strengthening, 5­6, 9, 13, link to results, 70 17, 18­19, 19b­20b, 32, 93, out-of-pocket, 60 102t­103t trends, 39 1997 HNP Strategy, 57 vertical, 153 advice and financing, 49­53 Index 215 and priority disease approaches, total commitments, 40f 184­185 Health, Nutrition, and Population collaboration, 29 (HNP) Hub, 30, 38, 43, 45, 46f conducive environments, 190 Action Plan, 101t­104t, 109 country priorities, 26 mission, 99, 100 identifying constraints, 161t strategy implementation, 104­106 reproductive and sexual health, 86­87 Health, Nutrition, and Population Strategic Directions, 75­77 (HNP) Sector Board, 30, 41f, 43, to fight AIDS, 191­192 43f, 99, 100 World Bank Regions, 113, 117­118, Action Plan, 101t­104t 120­121, 125­126, 129, 133­134 Health, Nutrition, and Population World Bank support, 27­28, 49, 83 (HNP) Strategy, 2, 6­7, 11, 14­15, Health, Nutrition, and Population 76, xiii, xiv (HNP), 1, 3­5, 6­7, 13­15, 33, 35 EAP Region, 115­116 country focus, 23 ESW lines, 170 development impacts, 12, 31 HIV/AIDS, 191­192 financial sustainability, 64­66, 166t implementation, 9­10, 10b, 29­30, global architecture, 35 104­106, 107 health system capacity, 77 Health, Nutrition, and Population HIV/AIDS support, 90­93, 190­191 (HNP) Strategy--1997, 1, 3­4, 14, interventions, 52, 113­114, 193t 57 investment, 83 assessing, 38­39 lack of M&E, 38­39 measuring impact, 16­17 lending, 14, 27 Health, Nutrition, and Population Net- MIC agenda, 122b work (HNPFAM), 30, 109 outcomes determined by multiple sec- High-Level Forum (HLF), 155 tors, 53­54 HIV/AIDS, 13, 33, 43, 145, 190­191 population, 83­84 Africa Region, 111t portfolio, 37, 43f, 73, 100 DAH concerns, 187­188 improving quality of, 41­43, 102t, drug purchasing, 196n 159t EAP Region, 116t lending decrease, 196n ECA Region, 119t performance, 3, 17, 42 financing, 22, 92­93, 146, 189, 193t trends, 39, 43f Global Program of Action, 184 results, 4­5, 7b, 15­17 health care demand, 186 achieving, 24 LAC Region, 123t­124t, 126­127 Africa Region, 112 LMICs, 183 Bank focus on, 27, 69­72, 73­74 MENA Region, 128t country support, 10, 30 population expenditures, 89f ECA Region indicators, 120 prevention, 188 focus, 117, 124­125, 132­133 reduced mortality, 162t intersectoral approach, 28­29, 53­54, scorecard, 155 78­79 South Asia Region, 131t sustainable health systems, 18­19, 21 Three Ones, 154, 199n sector oversight, 52 treatment, scaling up, 90­91 staff changes, 99 World Bank financing, 188­90 staff skill mix, 107 World Bank influencing at country technical issues, 106, 110 level, 193t 216 Healthy Development World Bank support, 90­93, 191­192 Iran, 128t, 130 HIV/AIDS Agenda for Action in Sub- Iraq, 128t, 130 Saharan Africa, 184 Honduras, 60, 61f, 123t, 126 Jamaica, 123t Human Development (HD) Network, 9 Joint United Nations Programme on human resources, 53 HIV/AIDS (UNAIDS), 38, 127, Hungary, 119t 146, 154 Jordan, 128t IFFIm, 15, 155 Junior Professional Associates (JPAs), 45, Implementation Completion Reports 46f (ICRs), 39, 73 income levels by Region, 148t Kazakhstan, 119t Independent Evaluation Group (IEG), Kenya, 111t 17, 43 knowledge generation, 16, 80, 163t India, 34f, 78, 131, 131t Korea, Democratic Republic of, 116t indicators. See health indicators Kuwait, 128t Indonesia, 116t Kyrgyz Republic, 119t infant mortality. See child mortality infrastructure, 76, 121 Lao PDR, 116t inputs, 175 Laos, 152f International Bank for Reconstruction Latin America and Caribbean (LAC) and Development (IBRD), 24, 26, Region, 123­127, 124, 148t 55t, 73 Latvia, 119t lending trends, 39, 40, 41f, 44 leadership, 152­153 International Conference on Population Lebanon, 128t, 130 and Development (ICPD), Pro- lending, 24, 27, 40f, 134 gramme of Action, 84, 85b, 89, xiv linking to results, 70­71, 100 International Development Association trends, 39­40 (IDA), 6, 16fn, 17, 18, 73, 77 Lesotho, 112t, 152f country priorities, 26 Liberia, 66f, 88f, 111t lending trends, 39, 41f life expectancy, 87t priority­disease interventions, 28 Lithuania, 119t international environment, 31­33, 35 loan buy-downs, 72b International Finance Corporation (IFC), low- and middle-income countries 24, 49 (LMICs), 51, 79, 116t, 183 International Labour Organisation Actu- accountability, 68 arial and Financial Services, 80 health expenditures, 148t, 149 International Monetary Fund (IMF), 80 health indicators, 123t­124t, 128t, 131t intersectoral approach, 28­29, 53­54, 73, low-income countries (LICs), 12, 26­29, 78­79, 103 60, 65 Africa Region, 113 health indicators, 111t­112t, 119t South Asia Region, 134 inefficient expenditures, 150 intersectoral capacity, 164t intersectoral coordination thematic Macedonia, FYR, 119t group, 104t Macumbo, Joy, 19b­20b intervention deficiencies, 198n­199n Madagascar, 111t interventions, 52, 58, 77, 113­114, 193t malaria, 13, 19b­20b, 22, 33, 38 investment decisions, 12, 170 Malawi, 111t Index 217 Malaysia, 116t monitoring, country level, 66 Maldives, 131, 131t Monterrey targets, 147 Mali, 65f, 88f, 111t Morocco, 128t malnutrition, 4, 35, 96. See also mortality, 35, 58­59, 84, 158t, 162t undernutrition Mozambique, 111t children, 111t, 158t multisectoral approach, 2­3, 12 development impacts, 93­94, 94t Results Framework, 156t, 158t, 160t, World Bank Regions, 116t, 119t, 162t, 164t, 166t 123t­124t, 126, 128t, 131t World Bank Regions, 113, 118, 121, management in health care, 68b, 155 126, 129 marginal budgeting for bottlenecks Multisectoral Constraints Assessment (MBBs), 78, 114 (MCA) for Health Outcomes, 30, 78, maternal and child health, 71, 77, 126. 110, 164t, 170­171 See also reproductive health tool, 103, 104t Argentina, 74b, 124, 125, 127 Myanmar, 116t policy, 83­84, 85b, 86­90 Maternal Child Basic Health Insurance, Namibia, 112t Paraguay, 125 National Sector Support for Health maternal mortality, 13, 87, 111t Reform Project, Philippines, 117 Mauritania, 65f, 111t Nepal, 131, 131t Mauritius, 112t Nicaragua, 123t, 125, 126 Mayotte, 112t Niger, 88f, 111t, 152f MCA. See Multisectoral Constraints Nigeria, 72b, 111t Assessment for Health Outcomes noncommunicable diseases (NCDs), 13, mechanical systems, 177 58, 96 Mexico, 123t, 125, 126 nutrition, 3, 93­94, 94t, 96­97 micronutrient deficiencies, 96 Middle East and North Africa (MENA) obesity, 4, 13, 33, 96 Region, 127­130, 128t, 148t official development assistance (ODA), middle-income countries (MICs), 58, 60, 146­147, 148f 65, 122b, 127. See also low- and Oman, 128t middle-income countries open systems, 174 demand for advice, 26, 40 organizations, advocacy, 80 health indicators, 112t, 119t out-of-pocket expenditures, 60, 61t, 149, health systems, 27, 75­76 149t, 164t, 198n Millennium Development Goals outreach, 14, 59 (MDGs), 4­5, 14, 16, 73, 94, oversight of health systems, 174­175 145­146 achieving, 58 Pakistan, 72b, 131, 131t DAH, 147 Pan American Health Organization financing constraints, 150 (PAHO), 127 Millennium Project projections, 147 Panama, 123t MMR modeled estimates, 116t, 119t, pandemics, 4, 33 123t­124t, 128t, 131t Papua New Guinea, 116t Moldova, 119t Paraguay, 123t, 125 Mongolia, 116t Paris Declaration on Aid Effectiveness, monitoring and evaluation (M&E), 6, 9, 17, 36, 114, 154, 155, 189, 199n 16, 32, 38­39, 70 partners, 29, 38, 79­81, 104 218 Healthy Development bilateral, 181 project development objectives (PDOs), global, 152­153, 180 73 World Bank Regions, 118, 121, project outcomes, 42, 42f 126­127, 130 payment, 113 Qatar, 128t PEPFAR. See United States President's Quality Assurance Group (QAG), 41 Emergency Plan for AIDS Relief quality control capacity, 43 performance monitoring, 105, 109 performance objectives, 73 realism, 42, 197n Peru, 60f, 123t, 125 recruitment, 107 pharmaceutical developments, 33 Recurso Peru, 78 Philippines, the, 116t, 117 reimbursable technical assistance (RTA), Plan Nacer, 74b, 124 130 Poland, 119t reproductive health, 85b, 86­90, 89f, policy, 2, 11, 13, 25 160t. See also maternal and child analysis, 159t heath quality, 47 Reproductive Health Supplies Coalition, policy advice, 9, 50, 51 38 policy advice team, 77 results, 5, 8, 15­17, 23, 37 polio, 72b results focus, 2, 70, 100, 101t­102t pooling, 60­61. See also risk Results Framework, 5, 59, 64, 71, 73, 99, pooling 101t, 105 population, 12, 83­84, 85b EAP Region, 117 activity expenditures, 89f South Asia Region, 133f growth, 4, 35, 86, 88 text of, 156t­167t poverty, 14, 35, 61f, 93­94, 164t revenue by Region and income, 149t Poverty Reduction and Economic Man- revenue collection, 175 agement (PREM), 77, 126, 130, risk pooling, 63­64, 176, 177, 197n. See 169­170 also pooling Poverty Reduction Strategy Papers Roll Back Malaria, 38, 146 (PRSPs), 48, 112 Romania, 119t Poverty Reduction Support Credits Rotary International, 72b (PRSCs), 115 Russian Federation, 119t poverty targets, nonincome, 95t Rwanda, 73, 111t, 187, 188 priority­disease approaches, 24, 28, 126. See also disease-specific salary disincentives, 20b initiatives São Tomé and Principe, 111t and health system strengthening, 161t, SASHD. See South Asia Region Human 184­185 Development Department private foundations, 146 Saudi Arabia, 128t private funding, 48­49 Second Disease Surveillance and Control Private Sector Development (PSD), 49 Projects, Brazil, 125 proactivity, 42, 197n secondments, 105t, 167t PROCEDES Project, Mexico, 125 Sector Adjustment Loans/Credits, product lines, 118 115 program evaluation, 117 self-regulation, 68 programs, with no financial participation, Senegal, 111t 180 Serbia and Montenegro, 119t Index 219 severe acute respiratory syndrome Sub-Saharan Africa (SSA) Region, 58, 84, (SARS), 33 148t sexual health, 85, 86­90, 160t Sudan, 111t Seychelles, 112t Suriname, 123t shocks, 59­60, 60f Swaziland, 112t Sierra Leone, 111t Syria, 128t single-disease programs, 17­18 system performance, 198n Slovak Republic, 119t systems thinking, 177­178. See also health Social Insurance and Allied Services of systems 1942, 176 Social Protection, 77, 121, 125, Tajikistan, 119t 169­170 Tanzania, 65f, 112t socioeconomic development, 11­12 targets, identification of, 170­171 Somalia, 88f, 111t tax revenue by Region and income, 149t South Africa, 112t technical advice, 9, 47, 77 South Asia Region, 131­134, 133f, 148t. technical assistance (TA), 44, 130 See also Asia technological developments, 33 South Asia Region Human Development Thailand, 60, 116t, 118 Department (SASHD) business plan, Three Ones, 154, 189, 199n 134 tobacco, 33 Sri Lanka, 131, 131t Togo, 112t St. Kitts and Nevis, 123t total fertility rate (TFR), 35, 84, 86, 87t, St. Lucia, 123t 88 St. Vincent and the Grenadines, 123t training, 103t staff, attracting, 20b transparency, 166t staffing, 30, 107, 122 Trinidad and Tobago, 123t trends, 44­45, 44f, 45f Trust Funds (TFs), 29, 45, 80, 105t, 109, Stop TB, 38, 146 167t Strategic Directions, 7b, 69, 79­81, xiii tuberculosis (TB), 13, 22, 33, 38, 164t country support, 26­29, 75­77 Tunisia, 128t focusing on HNP results, 69­72, Turkey, 119t 73­74 Turkmenistan, 119t implementing, 10b, 100, 101t­104t, 104 Uganda, 34f, 88f, 112t intersectoral approach, 78­79 Ukraine, 119t Strategic Objectives, 7b, 25, 57, 58­59 UNAIDS. See Joint United Nations Pro- financial sustainability, 64­66 gramme on HIV/AIDS governance, accountability, and trans- under-5 mortality. See child mortality parency, 66­68 undernutrition, 13, 93­94 implementation, 10b UNITAID, 15, 38, 155, 196n MENA Region, 127­129 United Arab Emirates, 128t preventing poverty due to illness, United Nations Children's Fund 59­61, 63­64 (UNICEF), 52 Results Framework, 156t­167t United Nations Foundation, 72b South Asia Region, 131­132 United Nations Population Fund strategic purchasing, 177 (UNFPA), 52, 89, 127 Strategic Vision, 7b United States Centers for Disease Con- strategy deficiencies, 198n­199n trol and Prevention (CDC), 72b 220 Healthy Development United States President's Emergency LAC Region, 124­125 Plan for AIDS Relief (PEPFAR), 15, MENA Region, 129­130 187, 188, 199n South Asia Region, 132­133 Uruguay, 123t DAH, 6­7, 38 user fees, 61, 63 demand for advice, 40 Uzebekistan, 119t DGF, 167t HIV/AIDS support (See HIV/AIDS) vaccines, 33, 71, 72b HNP, 2, 14­15, xiv (See also Health, Venezuela, República Bolivariana de, 123t Nutrition, and Population) vertical financing, 153, 184, 197n intersectoral approaches, 28­29 Vietnam, 60, 116t nutrition role, 96­97 portfolio, 37, 43f, 73 West Bank and Gaza, 128t, 130 reproductive health, 85b, 89­90 women, 84, 88. See also maternal and Results Framework, 156t­167t child health; reproductive health; role in the new environment, 47­48 sexual health staff skill requirements, 30, 103t World Bank, 7b, 53, 83 World Bank Group (WBG), 48, 49 capacity building, 11, 24, 99, 164t, xiii World Development Report (WDR), 105 ECA Region, 121­122 World Food Program (WFP), 52 Strategic Directions, 26­29 World Health Organization (WHO), 29, collaboration and partners, 29, 164t 51, 53, 79, 127 comparative advantages, 8­9, 23­24, collaboration, 80 47­48, 103t health system definition, 173 country relationships, 22­24 population, 89 country support, 8, 10 Africa Region, 112­114 Yemen, 88f, 127, 128t East Asia and Pacific Region, 115­­117 Zambia, 112t, 152f ECA Region, 120 Zimbabwe, 112t Eco-Audit Environmental Benefits Statement The World Bank is committed to Saved: preserving endangered forests and natural resources. The Office of the Publisher has · 30 trees chosen to print Healthy Development: The · 1,396 lbs. of solid waste World Bank Strategy for Health, Nutrition, & · 10,868 gallons of water Population Results on recycled paper includ- · 2,618 lbs. of net ing 30% post-consumer recycled fiber in greenhouse gases accordance with the recommended · 21 million BTUs of total standards for paper usage set by the Green energy Press Initiative, a nonprofit program supporting publishers in using fiber that is not sourced from endangered forests. For more information, visit www.greenpressinitiative.org. H ealthy Development: The World Bank Strategy for Health, Nutrition, & Population Results updates the Bank's contribution to improving health outcomes, including the 2015 Millennium Development Goals, at a time when new and existing multilateral organizations, bilateral part- ners, and foundations are increasing their commitment to global health. After an extensive consultative process with governments and global partners, including civil society organizations and bilateral and multilateral organizations, the World Bank's new health, nutrition, and population strategy aims to help developing countries strengthen their health systems and improve the health and well-being of millions of the world's poorest people, boost economic growth, reduce poverty caused by catastrophic illness, and provide the structural "glue" that supports multiple health-related programs within countries. By renewing the Bank's focus on achieving results, this new strategy seeks to strengthen monitoring and evaluation systems in Bank programs and in partner countries and calls for a greater link between financing and achieving results on the ground. Achievements in health, nutrition, and population have important implications for overall country fiscal policy and country competitiveness and, ultimately, the Bank's mission to reduce poverty. This book will be a useful resource for policy makers and others working in these areas in the international arena. ISBN 978-0-8213-7193-0 SKU 17193