75650 The World Bank Health Nutrition and Population Public Health Policy Note Connecting Sectors and Systems for Health Results Anne Maryse Pierre-Louis, Sameh El-Saharty, Anderson Stanciole, Olga Jonas, F. Brian Pascual, Robert Oelrichs, Montserrat Meiro Lorenzo, Tonya Villafana, Fernando Lavadenz, Marcia Rock The World Bank Health Nutrition and Population Public Health Policy Note Connecting Sectors and Systems for Health Results Anne Maryse Pierre-Louis, Sameh El-Saharty, Anderson Stanciole, Olga Jonas, F. Brian Pascual, Robert Oelrichs, Montserrat Meiro Lorenzo, Tonya Villafana, Fernando Lavadenz, Marcia Rock December 2012 Table of Contents Preface...................................................................................................................................................v Executive Summary..............................................................................................................................vii Acknowledgements...............................................................................................................................xi Abbreviations and Acronyms..............................................................................................................xiii Introduction........................................................................................................................................ xv Chapter 1: Public Health: Core to Global Development and the World Bank’s Mission........................1 What is Public Health? Definition and Principles...................................................................................................1 Public Health – A Game Changer for Development, Equity and Poverty Eradication............................................2 The Role of Development Partners in the Global Public Health Arena..................................................................3 The World Bank’s Key Contributions to Public Health..........................................................................................5 Chapter 2: The Unfinished Revolution in Public Health: Progress to Date, Shifts in the Landscape, and Remaining Challenges..................................................................................7 Progress in Public Health over the Past Decade......................................................................................................7 A Shifting Landscape.............................................................................................................................................8 Key Challenges in Advancing Public Health.........................................................................................................12 Chapter 3: The World Bank Contribution to Public Health: Connecting Sectors and Systems for Health Results............................................................................................................15 The HNP Strategy...............................................................................................................................................15 The World Bank Footprint in Public Health – Making a Difference Through a More Strategic Approach...........16 Developing and Implementing a Robust Knowledge Agenda on Public Health within the Bank..........................22 Creating the Environment to Foster Action across Sectors within the Bank..........................................................22 Providing the Resource Base to Implement Actions..............................................................................................23 Bringing other Partners on Board.........................................................................................................................23 Chapter 4: Illustrative Examples of Ongoing World Bank Work in Public Health...............................25 Supporting Public Health Reform in Argentina...................................................................................................25 Providing Assistance to Countries on Tobacco Control........................................................................................26 Strengthening Risk-Based Governance at the Animal-Human-Ecosystem Interface..............................................27 Pharmaceutical Governance and Regulation: Building Public Health Capacity....................................................28 Promoting the Use of Economic Analysis to Support Public Health Operations..................................................29 Conclusion..........................................................................................................................................31 References............................................................................................................................................33 iv Connecting Sectors and Systems for Health Results Annex 1: What is Public Health?..........................................................................................................37 Concepts and Activities Embraced by the Field of Public Health.........................................................................37 Public Health Categories and Examples of Functions...........................................................................................37 Annex 2: Essential Public Health Functions Identified by PAHO/CDC/WHO...................................39 1. Health Situation Monitoring and Analysis.......................................................................................................39 2. Surveillance, Research and Control of Risks and Damages in Public Health.....................................................39 3. Health Promotion............................................................................................................................................40 4. Social Participation and Empowerment of Citizens in Health..........................................................................40 5. Development of Policy, Planning and Managerial Capacity to Support Efforts in Public Health and the Steering Role of the National Health Authority....................................................................................40 6. Public Health Regulation and Enforcement.....................................................................................................41 7. Evaluation and Promotion of Equitable Access to Necessary Health Services....................................................41 8. Human Resources Development and Training in Public Health.......................................................................41 9. Ensuring the Quality of Personal and Population-Based Health Services..........................................................41 10. Research, Development and Implementation of Innovative Public Health Solutions......................................42 11. Reducing the Impact of Emergencies and Disasters on Health.......................................................................42 Annex 3: Role of Development Partners in Global Health...................................................................43 Annex 4: The World Bank’s Contribution to Public Health.................................................................47 Lending...............................................................................................................................................................47 Analytic and Advisory Activities (AAA)................................................................................................................48 Knowledge Sharing and Dissemination................................................................................................................48 Current Engagement Across Sectors and Partnerships on Public Health...............................................................48 An Important Global Player on Key Public Health Actions..................................................................................49 Annex 5: Ten Notable Achievements in Public Health.........................................................................53 Annex 6: Illustrative Role of Different Sectors in Strengthening Public Health Programs and Outcomes..............................................................................................................................57 Annex 7: Multisectoral Impact on the Health Sector...........................................................................59 Annex 8: Illustrative Actions to Advance the World Bank’s Work in Public Health..............................61 Pillar I: Fostering Multisectoral Interventions to Maximize Returns on Investments in Health.............................61 Pillar II: Identifying Country-specific, Cost-effective Actions to Help Countries Face the Dual Challenge of Meeting MDGs and Addressing NCDs..................................................................................................62 Pillar III: Strengthening Governance and Leadership to Anticipate, Address and Manage Public Health Challenges............................................................................................................................62 Cross-cutting Theme: Economic Analysis to Underpin Decision-making.............................................................63 Preface S trengthening public health—that is, improving and heighten the risk of new ones. In this context, the health of whole populations through action health systems are likely to come under significantly across all relevant sectors—is at the heart of the greater pressure. World Bank’s mission. This Policy Note takes stock of the global progress in public health over the past The Note emphasizes that the Bank will need to root its decade; lays out the challenges that must be addressed future public health efforts in its areas of comparative for this progress to be sustained and accelerated; and advantage—including its capacity to analyze the eco- proposes an approach for the Bank to maximize its con- nomic and development impact of health investments, tribution to public health in the years ahead. and its extensive experience in working across sectors for health results. The Bank finances investments in all This Note comes at a critical juncture, given the impor- the sectors that impact health—including education, tant gains made in public health over the past decade. social protection, infrastructure, water and sanitation Key global indicators—including life expectancy at and transportation, to name a few—and is well placed birth, under-five mortality and maternal mortality—have to help mobilize such sectors through coordinated, shown steady improvement, while initiatives such as the population-based interventions to improve health and scale-up of polio vaccination and the distribution of bed accelerate development. Given its analytic capability, the nets to combat malaria have saved millions of lives. The Bank has a potentially critical role to play in focusing Bank is proud to have worked with countries and devel- finite budgets on the most cost-effective actions, partic- opment partners to contribute to these achievements. ularly in prevention and health promotion. Yet as we prepare to take our efforts to the next level, The dual challenge of meeting the health Millennium we must be cognizant of major changes and new chal- Development Goals (MDGs) and stemming the rise of lenges emerging in the public health landscape. For the NCDs has been described as a “tiger with two heads�. first time in human history, non-communicable diseases The public health arena in the years ahead will indeed (NCDs) have become the leading causes of death—but be a complex one. This Note sets out a clear vision for the battle against communicable diseases is by no means how the World Bank can navigate the challenges and won. At the same time, rapid urbanization, intensive ensure that its resources, along with the expertise of its livestock rearing, and the global movement of people staff, deliver the greatest possible contribution to public and goods hold the potential to spread existing diseases health in developing countries. Executive Summary T he world has seen significant advances in pub- Goals (MDGs). The preparation of the Policy Note is lic health over the past decade. Key global very timely. For one thing, major gaps remain in global indicators—including life expectancy at birth, public health, particularly in the health indicators of under-five mortality and maternal mortality—have the poorest populations and fragile states—underlining shown steady improvement, in good part thanks to the key role of public health in the Bank’s mission to public health interventions by countries and their devel- achieve a “World Free of Poverty�. Further, recent pan- opment partners. These include the unprecedented demic threats create a vivid reminder of the need to scale-up of vaccination against preventable diseases, strengthen prevention and preparedness efforts. access to safe drinking water, malaria prevention, HIV/ AIDS services, tuberculosis control, and tobacco control. At the same time, the global landscape is undergoing major shifts including globalization, rapid urbanization, The World Bank has played a major role in many of and climate change, all with profound implications for these efforts, working in strategic partnership with the public health agenda. Perhaps the most far-reaching countries and public and private agencies. The Bank’s shift is an epidemiological one, namely the rise of non- ramp-up of funding for public health—through proj- communicable diseases (NCDs) as the leading cause of ects driven by many different sectors—has formed death and disability in almost every region—even as part of the steady growth in Donor Assistance for many countries still face significant gaps in meeting the Health (DAH) over the past twenty years. Just as health-related MDGs and addressing major zoonotic importantly, the Bank has helped spark a growing diseases. Other developments provide important new realization that the health of a country’s people con- opportunities to advance public health, including a tributes significantly to its economic development. The revolution in technology; new evidence on the cost- Bank’s efforts have contributed to an increasing global effectiveness of prevention; and expanding DAH focus on population-based activities, spanning multi- contributions from Brazil, Russia, India, China, South ple sectors rather than healthcare alone, to improve Africa (BRICS) and other nations. health outcomes. And World Bank studies have shown how sound economic analysis can help focus limited In this complex and challenging context, this Policy resources on the most efficient health interventions, Note sets out a vision for the Bank’s approach to pub- particularly prevention. lic health over the next five years, formulated by the Bank’s Health, Nutrition and Population (HNP) family For the Bank’s work in public health, the question is on the basis of extensive consultations with regions and now: what next? sectors, analysis of the literature, and assessment of the Bank’s current footprint in public health. Although the Arriving at the answer is no simple matter, particularly Policy Note’s intended audience is primarily internal, it in the context of the current dialogue about global pri- will also inform collaboration with partners. This Policy orities beyond the 2015 Millennium Development Note is not a strategy or action plan, and therefore does viii Connecting Sectors and Systems for Health Results not include a detailed set of actions which those types NCDs—a veritable “tiger with two heads�. The third of documents would be expected to cover. However, it is to help build sufficient and sustainable government proposes ways to help move toward the vision. stewardship capacity for public health. In a nutshell, the vision is to connect sectors and sys- These pillars build on the main areas where the Bank tems for health results—a bold yet achievable outcome. can make a significant difference based on its areas The realization of this vision would see the Bank play- of comparative advantage, namely: the ability to fos- ing a core role in promoting sustainable goals on ter actions across sectors for health results; the ability healthy living—and helping ensure that high impacts to promote a systems-based approach to address major and high returns are delivered against these goals at public health threats; and the capacity to carry out eco- country level. While building on what has taken place nomic analyses to guide evidence-based policies and in public health in the Bank, this vision brings new influence high-level policy dialogue. dimensions for future directions. It would catalyze a shift in mindset within the Bank, placing the responsi- The figure shows how these pillars form the basis for an bility for health results not just in the HNP sector, but integrated approach by the Bank to strengthen public across multiple sectors, thus empowering other sectors health. The three pillars are detailed below. to pay greater attention to the health outcomes of their operations. This is a major departure from past experi- Pillar I: Fostering multisectoral interventions to ences in the Bank when involvement of other sectors in maximize returns on investments in health. In the health was mostly accidental as opposed to systematic. changing global context, sustaining ongoing gains Finally, the vision would strongly encourage the use of and making progress in public health will, in many economic evidence to inform policy decisions and prac- cases, require mobilizing across sectors, as a substan- tices, both within the Bank and at country level. tial part of the work and investment required will be from actors outside the health sector. Building on The vision is built on three strategic pillars, each one and strengthening its existing platform of intersec- imperative for advancing and sustaining public health. toral work, the Bank will involve non-health sectors The first is to galvanize actors outside the health sector in tackling the major socio-economic risk factors to to address the key determinants of health outcomes. address NCDs, communicable diseases and injuries. The second is to assist countries in facing the dual chal- In this context, developing a diagnostic tool to lever- lenge of meeting the MDGs and addressing the rise of age investments and policy action in non-health sectors depending on country context, will assist TTLs as well as policy makers to engage in a constructive dialogue Figure ES • World Bank Integrated and serve as a powerful catalyst for a shift in mindset Approach to Strengthen Public Health to improving health outcomes. This approach will be crucial, particularly in developing countries, to maxi- Country Context (Macro Environment) mize returns on investments in health and so prevent HEALTH GOALS premature, avoidable deaths and disability in people (Level/Spread) Health Status + Financial protection in their productive years, and promote healthy aging. + Satisfaction and Trust (Responsiveness) Pillar II: Identifying country-specific, cost-effective actions to help countries face the dual challenge of Multisectoral MDGs And Governance Interventions NCDs and meeting the MDGs and addressing NCDs. The Bank Stewardship will place particular emphasis on policy actions and interventions that can build synergies to advance both agendas simultaneously and increase the opportunity set Economic Evidence available to countries. At the same time, the Bank will initiate actions to assist countries in undertaking the Public Health health systems adaptations required to address the rise Executive Summary ix of NCDs, as this will also play an important role in the economic impact of NCDs; the economic returns of preventing premature death and disability. investments in prevention; and on the impoverishment impact of disease and injury. Pillar III: Strengthening countries’ governance and leadership to anticipate, address and manage public Finally, translating the vision and the three strategic health challenges. Particular emphasis will be placed on pillars into reality in the Bank’s operational work will enhancing countries’ capacity and stewardship role to require a strong institutional mandate. The full prom- perform essential public health functions at the national ise of multisectoral action in health is unlikely to be and regional levels, as well as on promoting interfaces met until the Bank takes a hard look at its organiza- across systems (human, animal and ecosystems), profes- tional structures and business procedures to break across sions and disciplines. silos and identify mechanisms to improve health out- comes. Working effectively across sectors will require an The Bank’s work under each of the pillars will be enabling environment which provides the right institu- supported by vigorous efforts to promote the use of tional incentives as well as adequate resources for staff economic evidence to inform the formulation of effec- across sectors to engage actively in this new way of tive public health policies. The Bank will take the lead doing business. in producing the necessary economic analysis, including   Acknowledgements             T he Public Health Cluster of the Human (Lead Operations Officer, AFTHE), Abdo Yazbeck Development Health, Nutrition and Population (Lead Economist, Health, AFTHE), Armin Fidler (Lead unit (HDNHE) acknowledges the regions and Adviser, Health Policy and Strategy, HDNHE), the the sectors of the World Bank and the many staff who members of the Public Health Community of Practice provided input to this Public Health Policy Note. Their Executive Committee, particularly Jacqueline Levine professional expertise, institutional knowledge and col- (Senior Water & Sanitation Specialist, TWIWP), François lective vision for public health provided the inspiration Le Gall, (Adviser, AES), Julie Babinard (Environmental for the document’s main messages and rich content. and Social Development Specialist, TWITR), Mikul The Policy Note was prepared by a team led by Anne Bhatia (Senior Energy Specialist, SEGEN), Sameer Maryse Pierre-Louis (Lead Health Specialist, HDNHE), Akbar (Senior Environmental Specialist, ENV), Patricio and composed of Sameh El-Saharty (Senior Health Policy Marquez (Lead Health Specialist, AFTHE), Leslie Elder Specialist, SASHN), Anderson Stanciole (Economist, (Senior Nutrition Specialist, HDNHE), Tamer Rabie HDNHE), Olga Jonas (Economic Adviser, HDNHE), (Senior Health Specialist, MNSHH), as well as John F. Brian Pascual (Operations Analyst, HDNHE), Robert Langenbrunner, (Lead Economist, HDNHE), Brian Oelrichs (Senior Health Specialist, HDNHE), Montserrat Bedard (Senior Livestock Specialist, ECSAR), Caroline Meiro Lorenzo (Senior Health Specialist, HDNHE), Plante (Livestock specialist, AES), Shiyong Wang (Senior Tonya Villafana (Senior Health Specialist, HDNHE), Health Specialist, EASHH), and Aparnaa Somanathan Fernando Lavadenz (Senior Health Specialist, LCSHH) (Senior Economist, EASHH). and Marcia Rock (Consultant, HDNHE).     Strong support and guidance were provided to the team The Team would like to extend its profound gratitude by Cristian Baeza, (Former HNP Director,) and Nicole to colleagues who have taken the time to review the Klingen (Acting HNP Director, HDNHE). Their input document several times during its production and pro- was sustained from the genesis through the development vided detailed comments, particularly Kees Kostermans and completion of the Policy Note. (Lead Public Health Specialist, SASHN), Son Nam   Nguyen (Senior Health Specialist, ECSH1), Irina Peer reviewers for the Policy Note included: Dominic Nikolic (Health Specialist, HDNHE). The team is also Haazen (Lead Health Policy Specialist, AFTHE), François grateful for the support received from Miyuki Parris Le Gall, (Adviser, AES), Claudia Rokx (Lead Health (Operations Analyst, HDNHE) and Victoriano Arias Specialist, ECSH1), Dr Isabella Danel (Associate Director (Program Assistant, HDNHE). for Program Development, Center for Global Health   CDC), Sir George Alleyne (Director Emeritus, PAHO), Overall guidance to the team and strategic input were Dr Keiji Fukuda (Assistant Director General, provided by Joana Godinho (Sector Manager, LCSHH), Health Security and Environment, WHO). The team Julie McLaughlin (Sector Manager, HNP, SASHN), Enis would like to express its appreciation for their comments Baris (Sector Manager, MNSHD), Jean J. de St. Antoine which have contributed to and enriched the document. Abbreviations and Acronyms AAAs Analytical and Advisory Activities EPHF Essential Public Health Function ACT Artimisinin Combination Therapies ESW Economic and Sector Work AES Agriculture and Environment Services EU European Union AFR Sub-Saharan Africa Region FAO Food and Agricultural Organization of the AHI Avian and Human Influenza United Nations AMFm Affordable Medicine Facility for malaria FCTC Framework Convention on Tobacco AMR Antimicrobial resistance Control AMRH East African Medicines Regulatory FESP First Education Sector Project Harmonization Project FMD Foot and mouth disease BBL Brown bag lunch FY Fiscal Year BMGF Bill and Melinda Gates Foundation GAVI Global Alliance for Vaccines and BOD Burden of Disease Immunization BRICS Brazil, Russia, India, China, South Africa GFATM Global Fund to Fight AIDS, Tuberculosis CAS Country Assistance Strategy and Malaria CDC U.S. Centers for Disease Control and GHG Green House Gas Prevention GHSi Global Health Strategies initiatives CD Communicable Disease GMAP Global Malaria Action Plan CHDI Community Health Data Initiative GMRH Global Medicines Regulatory COHRED Council on Health Research for Harmonization Development GPAI Global Program for Avian Influenza DAH Development Assistance for Health Control and Human Pandemic DALY Disability Adjusted Life Year Preparedness and Response DEC The research and data arm of the World GPARC Global Plan for Artimisinin Resistance Bank Containment DfID UK Department for International GPEI Global Polio Eradication Initiative Development GPIRM Global Plan for Insecticide Resistance DHS Demographic and Health Surveys Management DOTS Direct Observation Treatment GRSF Global Road Safety Facility DPL Development Policy Lending GIZ Deutsche Gesellschaft für Internationale EAC East African Community Zusammenarbeit (formerly GTZ) EACC Economics of Adaptation to Climate HDN Human Development Network of the Change World Bank EAP East Asia and Pacific Region HDNHE Human Development Health, Nutrition ECA Europe and Central Asia Region and Population – Health EP Emergency Program xiv Connecting Sectors and Systems for Health Results HDSS Health and Demographic Surveillance OIE World Organisation for Animal Health Systems P4R Program for Results HHS U.S. Department of Health and Human PAHO Pan American Health Organization Services (WHO Regional Office) HIC High Income Country PEI Polio Eradication Initiative HNP Health, Nutrition and Population PEPFAR President’s Emergency Plan for AIDS HSS Health Systems Strengthening Relief IANPHI International Association of National PH COP Public Health Community of Practice Public Health Institutes PH Public Health IAP Indoor Air Pollution PHC Primary Health Care IAVI International AIDS Vaccine Initiative PMI Presidents Malaria Initiative IBRD International Bank for Reconstruction and PPP Public Private Partnership Development PREM Poverty Reduction and Economic IDA International Development Association Management (Network) IHME Institute for Health Metrics and PVS Performance of Veterinary Services Evaluation PWID People Who Inject Drugs IHP+ International Health Partnership and RBF Results Based Financing Related Initiatives RBM Roll Back Malaria IHR International Health Regulations RHAP Reproductive Health Action Plan IMF International Monetary Fund SADC Southern African Development JICA Japanese International Cooperation Community Agency SAR South Asia Region LAC Latin America and the Caribbean SARS Severe Acute Respiratory Syndrome LIC Lower Income Country SDN Social Development Network LMICs Lower and Middle Income Countries SIL Specific Investment Loan MCA Multisectoral Contraints Assessment SUN Scaling-Up Nutrition MDG Millennium Development Goal TB Tuberculosis MDR TB Multi Drug Resistant Tuberculosis TTL Task Team Leader MIC Middle Income Country UN United Nations MNA Middle East and North Africa Region UNAIDS Joint UN Programme on HIV/AIDS MOH Ministry of Health UNFPA United Nations Population Fund MS Multisectoral UNIDO United Nations Industrial Development MSA Multisectoral Assessment Organization MSM Men Having Sex with Men USAID United States Agency for International NCD Non-Communicable Disease Development NEPAD The New Partnership for Africa’s USDHHS United States Department of Health and Development Human Services NGO Non-Government Organization WBG World Bank Group NHA National Health Accounts WBI World Bank Institute NPHI National Public Health Institute WDI World Development Indicators NTD Neglected Tropical Disease WHO World Health Organization ODA Official Development Assistance WSP Water and Sanitation Program OECD Organization for Economic Co-operation XDR TB Extensively Drug Resistant Tuberculosis and Development Introduction P ublic health has made great gains over the past will be from actors outside the health sector. It will also decade. Key global indicators—including life mean building solid capacity to help countries perform expectancy at birth, under-five mortality and their governance and stewardship role in public health. maternal mortality—have shown steady improvement in most countries. Initiatives such as the scale-up of polio Against this backdrop, the World Bank has a profound vaccination and the distribution of bed nets to com- opportunity to apply its public health capacity to con- bat malaria have had dramatic results, saving millions tribute to improved health results at the country and of lives. The substantial investments made by countries global level—not by diluting its efforts, but through and development partners in public health have cer- focusing its energies on a limited set of approaches tainly paid off, and there is every reason to continue and actions rooted in its areas of comparative advan- and step up these efforts. tage. The purpose of this Public Health Policy Note therefore is to set out a clear approach and roadmap Yet the public health landscape is undergoing major for the Bank’s work in public health over the next change, presenting both a new set of challenges and five years, building on existing work in this area. This fresh opportunities to improve health outcomes. For the approach will place primary emphasis on popula- first time in human history, non-communicable diseases tion-based actions and policies. It will also focus on (NCDs) are leading causes of death (WHO 2011a)— prevention as the most cost effective way for many but the battle against communicable diseases is by no countries to address the dual challenge of meeting the means won. Rapid urbanization, global movement of health Millennium Development Goals (MDGs) and people and goods, population encroachment in previ- the rise of NCDs. ously wild areas, and intensive livestock rearing have the potential for spreading existing diseases and heighten- The Policy Note has been prepared with the objective ing the risk of creating new ones, while putting greater of influencing World Bank operations staff whose work pressure on health systems. Recent and ongoing pan- relates to public health. It is intended to guide their demic threats are vivid reminders of the need to increase discussions in the Bank, within country teams and prevention and preparedness efforts, which will require with the Bank’s client countries—including how best active management of gaps among systems, institutions to mobilize key sectors to improve health outcomes. and professions. In this changing context, sustaining Although the Policy Note is primarily an internal doc- ongoing gains and making progress in public health ument, it is also intended to serve as a vehicle for will in many cases require mobilizing across sectors, as communicating the Bank’s vision to enhance its role in a substantial part of the work and investment required public health. Public Health: Core to Global Development and the 1 World Bank’s Mission T his Chapter defines and sets out the key princi- �� Multidisciplinary actions—beyond the health sec- ples of public health, and explains why public tor alone—are needed to address the risk factors and health is a “game changer,� fundamental for underlying determinants of health. development and core to delivering on the World Bank’s Mission. It then examines the roles of key play- Annex 1 defines public health in greater detail; Annex ers in public health, as well as the World Bank’s own 2 presents a set of essential public health core func- work to date in public health. tions identified by the PAHO, CDC and WHO, which serves to guide governments in playing their stewardship role in public health. What is Public Health? Definition and Principles Regardless of the particular country-level configuration of core functions, effective approaches to public health What is public health? A few overarching principles run are characterized by sound analysis and a demonstrable across the many definitions which exist (Acheson 1988; understanding of the various socioeconomic determi- World Bank 2002;): nants of health outcomes. These determinants might be proximal or distal, and include areas ranging from �� The focus is on the health of whole populations, water and sanitation, to food availability, quality, safety, with equity amongst different segments of society and prices, to household assets (see Figure 1). They as a basic tenet point to the need for a “whole of government� or �� Priority is given to prevention, particularly primary “health in all policies� approach to major public health prevention issues. Although discussions have taken place and are �� The state has primary responsibility for guiding still ongoing on this topic (Rio+20 Conference 2012; the development of policies and implementation of WHO 2012c), there has been insufficient emphasis actions aimed at protecting and promoting the pub- placed on addressing key determinants of health outside lic’s health as this stewardship function cannot be of the health sector, which leads to missed oppor- left to the market. tunities to improve health outcomes. Studies have, �� Society’s collective efforts to improve public health however, repeatedly shown the health benefits of pol- need to be organized around a set of actions that icies that are not directly related to the health sector are supported by science, and underpinned by the Baeza et al. 2011). There are mutually reinforcing links requisite skills and culture among improved health and economic development, 2 Connecting Sectors and Systems for Health Results Figure 1 • Determinants of Health Outcomes Health Outcomes Household and Communities Health System and Related Government Polices and Actions Sectors Health Service Overall Health Sector Household Provision Strategy, priority, Behaviors & Risk Availability, accessibility setting and resource Health Factors and quality of health allocation in public Outcomes Use of public and services; input markets sector, monitoring & Health & private health Household evaluation, advocacy, nutritional services, dietary Resources regulation, stewardship status, and sanitary Income, assets, mortality practices, lifestyle, land, education, Health Financing care and etc. Revenue collection, stimulation of pooling and children, etc. disbursement/ purchasing Other Government Policies Infrastructure, Supply in Related transport, energy, Sectors agriculture, water & Availability, sanitation, etc. Community Factors accessibility, prices & Environment, culture, quality of food, values, social capital, energy, roads, water ecology, geography, etc. sanitation, etc. Source: Claeson et al. 2001. labor productivity, and household resilience to shocks. In this context, public health is a “game changer� for As pointed out in a World Bank technical discussion unlocking equitable development, in several impor- document, “There is growing evidence on the health tant respects. For one thing, public health can guide impact of non-health sector investments in a number policies to anticipate and address the most press- of areas such as environmental pollution, transporta- ing population-wide health problems which affect the tion, and indoor air pollution. In some cases, such as poor most, and to allocate resources more efficiently in education, the impact is likely to be as great as or to achieve the greatest feasible reduction in the burden greater than for health-sector interventions.� (Baeza et of disease. In so doing, it can contribute significantly al. 2011). to economic growth and poverty reduction over the medium and long-term—making public health fun- damental to the World Bank’s mission to achieve a Public Health – A Game Changer “World Free of Poverty.� The measures promoted by for Development, Equity and such public health policies will typically emphasize pre- Poverty Eradication vention, to avoid unnecessary human, economic, and social costs. The health of the people of a country contributes to that country’s economic growth because disease acts as a tax For the poor, there can be a marked difference in socio- on labor and gives rise to health care costs. Since health- economic well-being between good and poor health. ier workers are more productive, missing fewer days from Poor populations often lack access to relevant infor- work, health is both an objective of development and a mation and preventive services that influence health factor of production. Furthermore, focusing on public status. This in turn leads to high incidence of condi- health provides more value for money: limited resources tions which could have been prevented, and treatments are spent on where they are most needed, and where which often impose unaffordable financial burdens on they have the greatest impact. poor households. Public Health: Core to Global Development and the World Bank’s Mission 3 Second, well-conceived public health measures can provide effective ways to control costs in the medium thwart epidemics promptly and effectively at their and long term. source, which is typically in livestock. Early detection and control of zoonotic diseases means acting before people become infected, contagion spreads, and costs to The Role of Development human health and to the economy rise rapidly. A severe Partners in the Global Public influenza pandemic (such as may originate in poultry or swine) with 70 million fatalities would have a global Health Arena economic cost of $3 trillion, or 4.8% of GDP (Burns Reflecting widespread recognition of the fundamental et al. 2008). Prompt control of infectious disease out- importance of health including public health, Donor breaks, requiring collaborative public health action across Assistance for Health (DAH) increased significantly countries, is a global public good which countries have between 1990 and 2010 (Murray et al. 2011). Other an interest in acquiring. Public health policies can curb key agencies such as the OIE, the reference organiza- these risks. Finally, increasing drug resistance, as is cur- tion for animal health and zoonoses, are also playing rently the case for tuberculosis; for malaria in Asia’s a critical role in public health globally. The number of Sub-Mekong region; and for antimicrobials and coun- health initiatives from public as well as private sources terfeit drugs point to the need for effective cross-border has also risen, with such initiatives often becoming action (WHO 2012a). more complex. Influenced by these developments, the roles of governments and traditional donors are adjust- Economic arguments for investing in public health ing. Additionally, many countries, most notably Brazil, include addressing market failures, increasing societal wel- Russia, India, China and South Africa (BRICS) have fare and boosting returns on investment in health and advanced onto the global development stage. These and other sectors. The existence of market failures does not other developments are changing the way that aid for automatically point to government provision or financ- health is being provided. ing. However, public health often requires government intervention, for example through regulation, taxation, subsidies and legislation. Global Initiatives and Developments in Foreign Assistance Some public health interventions deal with information asymmetries, for instance food labeling or information As shown in Figure 2, donor assistance more than dou- on health services quality. Others address externalities, bled between 2000 and 2011. However, progress toward such as vaccination and clean water legislation. Finally, the health MDGs remains insufficient to meet many some interventions have a public good nature such as targeted goals in the intended timeline, particularly clean air laws, as well as disease and risk factors sur- MDG4 (reduction in under-five mortality rate) and veillance. MDG5 (reduction in maternal mortality ratio). This was a leading impetus for the Paris Declaration which Public health improves social welfare. As stated above, led to coordinated efforts such as the International most public health interventions benefit the poor in Health Partnership and related initiatives (IHP+). greater measure because they address risk factors at pop- ulation level that affect the poor more than the rich, such as lack of healthy sanitation conditions, exposure to rodents, poultry and other livestock, or access to qual- Organizations, Agencies and Partnerships for ity health care. Health and Development From the public finance point of view, the increase in DAH has become increasingly broad and complex in chronic diseases that is taking place across the world is the last two decades (Ravishankar et al. 2009; IHME already straining government budgets. In this context, 2011). DAH increased from $5.82 billion in 1990 to public health interventions, which emphasize prevention, $27.73 billion in 2011. Assistance has been provided 4 Connecting Sectors and Systems for Health Results Figure 2 • Development Assistance for Health 27.73 28 NGOs Bilateral agencies: 26.66 Other foundations Other 25.69 26 BMGF Sweden 24.88 GFATM German 24 GAVI France European Commission Japan 22 WHO, UNICEF, UNFPA, UNAIDS, PAHO United Kingdom 21.20 World Bank – IBRD United States 20 World Bank – IDA Regional development banks 18.41 18 Billions of 2009 US dollars 16.86 16 15.00 14 13.23 12.32 12 10.86 10.82 9.87 10 8.63 8.94 8 7.82 8.06 8.15 6.76 6.29 6 5.82 5.67 4 2 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010* 2011* Year Source: IHME 2011. *Data are preliminary estimates based on information from above organizations, including budgets, appropriations, and correspondence. to respond to the HIV/AIDS epidemic, as well as other BRICS and Beyond diseases in particular to respond to those which afflict the world’s poor and vulnerable. The economies of BRICS have grown substantially (GHSi 2012). Each of these countries has provided Assistance through UN agencies and development banks foreign assistance for many decades and their contri- actually declined slightly between 2007 and 2011, but butions have increased between eight percent (South as support from special efforts became operative, such Africa) and 23 percent (China) each year from 2005 as from the President’s Emergency Plan for AIDS Relief to 2010. A significant portion of this assistance is for (PEPFAR), the U.S. President’s Malaria Initiative, the health, specifically through financing, capacity building, Global Fund to Fight AIDS, Tuberculosis and Malaria access to affordable medicines and development of new (GFATM), UNAIDS, and private philanthropic organi- tools and strategies. zations, funding levels rose significantly. Figure 2 shows the DAH to combat HIV/AIDS, malaria and other dis- In addition to the BRICS, several other countries are ease areas that afflict the world’s poorest populations. also active players in global health and development. While the increase in humanitarian assistance is indeed These include but are not limited to the Gulf States, good news, it brings increased attention to monitoring Turkey, Indonesia, Mexico and South Korea. Each of and effectiveness, and raises questions regarding sus- these nations has a substantial foreign assistance pro- tainability, funding gaps, population equity as well as gram and/or affordable health technologies for use in sub-additionality to national health budgets. Annex 3 resource-poor settings (GHSi 2012). It can be expected provides an illustrative overview of relevant donor orga- that the expanding contributions of the “BRICS and nizations, agencies and partnerships, listing the purpose beyond� will present a significant and beneficial shift in or mission statement of each. global development. Public Health: Core to Global Development and the World Bank’s Mission 5 The World Bank’s Key Since FY02, the Bank has approved $25.0 billion in health commitments for 785 country-specific projects Contributions to Public Health in 128 countries and 29 globally—or regionally-focused Health, including public health, represented 7 per- projects across sectors. Of this amount, $7.1 billion cent of the World Bank’s total lending portfolio during (28.5 percent) was committed for activities focused FY02–FY12 (Business Warehouse database, World on public health (Business Warehouse database, World Bank). Because of its wide-ranging areas in different Bank).1 The Bank has also played an active role in gen- sectors, the Bank is in a unique position to make a sub- erating and spreading knowledge on key public health stantial impact in public health—through knowledge, issues. In 1999, the World Bank published a land- convening and financial services at country, regional mark study that concluded that tobacco control brings and global levels, and in partnership between sectors unprecedented health benefits without cost to econo- and with other agencies. In the past decade alone, the mies (World Bank 1999). And by engaging in a range Bank’s IDA financing provided over 47 million people of strategic partnerships, the Bank has positioned itself with access to basic packages of health, nutrition and as a key global player in a number of areas. For exam- population services, as well as supporting countries in ple, since partnering with WHO, UNICEF and UNDP strengthening health delivery capacity, and improving in 1998 to launch the Roll Back Malaria Partnership, access to health services (World Bank 2011b). the World Bank has played a role in committing close Box 1. Illustrative Examples of the World Bank’s Role as an Important Global Player in Public Health As part of its involvement in the global arena on health, the World Bank has maximized the impact of its analytical and operational work. By en- gaging in a range of strategic partnerships, the Bank has positioned itself as a key global player in a number of areas. Illustrative examples include: • Nutrition. The Scaling Up Nutrition (SUN) Framework for Action, which outlines the principles for scaling up investments in nutrition, was launched at the World Bank in April 2010. Endorsed by more than 100 partner organizations, the SUN global movement has expanded rapidly, gaining momentum at global, regional and national levels. • Malaria control. The Bank is the third largest financier of malaria control efforts globally and is a founding member of the Roll Back Malaria Partnership (RBM), where its role includes assisting in donors’ harmonization efforts around national malaria control action plans. • HIV/AIDS. The Bank has been in the vanguard of the global response to the pandemic. The Bank serves as the current Global Coordinator for UNAIDS. In this role, the Bank is responsible for leading and coordinating the ten UNAIDS partners towards the goal of “Getting to Zero�, or no new infections, the centerpiece of UNAIDS’ strategic plan. • Tuberculosis. The Bank is a member of the STOP TB Board and plays an important role in shaping policies and actions globally to help achieve the objective “zero TB deaths� set forth by the partnership. • Food safety. Food safety is of critical importance to public health, agri-food trade and market access, rural livelihoods, and poverty alleviation. The Bank is playing a leading role in food safety capacity building through the new Global Food Safety Partnership being established and a new multi donor trust fund as part of a collaborative multi stakeholder engagement on food safety. • Avian and Human influenza. Since 2005, the World Bank has committed $1.3 billion for 72 operations in 60 countries to address AHI. • Pharmaceutical governance and regulation. In 2011, the World Bank established a Multi-Donor Trust Fund for the Global Medicines Regulatory Harmonization (GMRH) project with an initial contribution of $12.5 million from the Bill and Melinda Gates Foundation. The GMRH project falls under a larger umbrella program in HDNHE focusing on Pharmaceutical Governance and Regulation. • Road Safety. The Global Road Safety Facility was established by the World Bank to generate increased funding and technical assistance to tar- get and overcome country safety management capacity weaknesses, in accordance with agreed principles and good practices. The World Bank supported the launch of this initiative through funding from its Development Grant Facility, in partnership with its founding donors such as the FIA Foundation for the Automobile and Society, the Government of the Netherlands, the Swedish International Development Cooperation Agency (Sida), and the Australian Agency for International Development (AusAID), among others. 1 In this section the following themes are captured under public health: Nutrition and Food Security; HIV/AIDS; Malaria; TB; other communicable diseases; and injuries and non-communicable diseases. We recognize that there are other projects in the portfolio that address other public health aspects such as public health functions (e.g. surveillance). However, these are not included because a break- down of projects at that level is currently unavailable. 6 Connecting Sectors and Systems for Health Results to $1 billion since 2005, to greatly increase the reach of Despite its substantial involvement in public health to protective interventions against malaria, while strength- date, a more selective approach going forward will allow ening health systems. And in response to road deaths the Bank to capitalize on its comparative advantages in and injuries, of which 90 percent occur in developing addressing global public health challenges. It will also be countries, the World Bank established the Global Road important for the Bank’s future focus on public health Safety Facility aimed at scaling up global efforts to stop to be cognizant of several key shifts in the global land- road-related casualties that disproportionately harm the scape (discussed in the next Chapter) that have will poor. Annex 4 provides further detail on the Bank’s impact on its role. public health contribution to date. The Unfinished Revolution in Public Health: 2 Progress to Date, Shifts in the Landscape, and Remaining Challenges B efore considering the main areas in which the the scale up of polio vaccination, in part driven by Bank should focus its efforts in public health, the Global Polio Eradication Initiative (GPEI), was a it is worth reviewing the context in which these contributing factor that led to a sharp decline in polio- efforts will take place. This chapter therefore highlights related mortality and morbidity. Figure 3 shows both the main achievements in global public health over the the progress and remaining challenge of wiping out the past decade, assesses several key shifts underway in the vaccine-preventable disease. Also, the number of chil- global landscape, and identifies the major public health dren younger than five sleeping under nets treated with challenges that will need to be tackled in the years ahead. insecticides is credited with a significant reduction in under-five mortality (WHO 2011b). Other developments have been more incremental however, and attribution of Progress in Public Health over progress to these in isolation can be difficult. the Past Decade In an exercise published by the U.S. Centers for Disease As discussed above, there has been a concerted global Control and Prevention, (CDC 2010) a panel of experts effort over the past decade to strengthen public was asked to nominate the most notable achievements health—an effort in which the World Bank has played of global public health over the first decade of the mil- a significant part. A review of the main aspects of pub- lennium. While also revealing the gaps that remain, the lic health highlights major advances, yet also reveals ten items (considered in more detail in Annex 5) high- major remaining gaps, disproportionately affecting the light the progress that has been made: poorest communities and countries. 1. Global childhood mortality in children less than Key global health indicators—including life expectancy five years of age has dropped by 40 percent since at birth, under-five mortality and maternal mortality— 1990 from 87 deaths per 1,000 live births to 53 per have shown steady improvement over the last decade. 1,000 live births in 2010 (WDI dataBank, World While these gains are in part due to improvements in Bank), mostly thanks to simple public health inter- incomes and education, public health interventions have ventions and cost-effective therapies such as oral played a major role in many cases. For example, rehydration therapy. 8 Connecting Sectors and Systems for Health Results Figure 3 • Global Wild Poliovirus Cases 1985–2010 450,000 Launch of GPEI 400,000 2,500 350,000 2,000 300,000 1,500 250,000 1,000 500 200,000 0 150,000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 100,000 50,000 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: Global Polio Eradication Initiative. 2. Immunization currently averts an estimated two- 9. Each year, 1.3 million people are killed on the three million deaths every year in all age groups world’s roads—leading the United Nations to launch from diphtheria, tetanus, pertussis (whooping a “Decade of Action for Road Safety� in 2011. cough)and measles. The number of polio cases has 10. Public health authorities gained a better appreci- also been reduced. ation of risk communications and of the role of 3. Access to safe water and sanitation has virtually robust veterinary and public health systems as they eliminated water-borne diseases such as typhoid and responded to zoonotic outbreaks such as SARS and cholera in the developed world. influenza. 4. Global efforts have led to a 38 percent decline in global malaria deaths worldwide, with an estimated A Shifting Landscape 1.1 million children in Sub-Saharan Africa saved over the last decade. To sustain and extend public health advances, it will be 5. The expansion of the global epidemic of HIV/ necessary to be cognizant of a set of major global shifts AIDS has stabilized and the annual rate of new that are currently underway—economic, social, epidemio- infections is declining thanks to prevention and logical and environmental. Some of these changes present treatment measures. significant new threats to public health, while others pres- 6. The WHO’s directly observed short course (DOTS) ent opportunities to improve health outcomes at speed and strategy for tuberculosis (TB) control, launched in scale. This section provides an overview of seven key devel- 1995 and substantially scaled up in the following 15 opments in the global landscape: demographic changes and years, has resulted in substantial progress against the urbanization, globalization, the rise of NCDs, pandemic disease. About 46 million people were successfully threats, climate change, new information on preventive treated under the DOTS strategy in this period, and health interventions and changes in technology. nearly 7 million additional lives (as compared with non-DOTS treatment) were saved (WHO). 7. Neglected Tropical Diseases (NTD) affect more Demographic Changes and Urbanization than one billion of the world’s poorest people, yet 90 percent could be treated by administering medicine. Globally, populations are changing. Along with declining 8. Tobacco, the largest preventable cause of disease and levels of fertility, population aging worldwide has been death, leads to nearly six million deaths annually. well documented. The importance of population aging International efforts are focused on curbing its use. in low and middle-income countries (LMICs) should be The Unfinished Revolution in Public Health: Progress to Date, Shifts in the Landscape, and Remaining Challenges 9 recognized as in many developing countries, populations Figure 4 • Percent of Population in are growing old before they are growing prosperous, and Urban Areas (1990 and 2011) this is compounded by the challenges of healthy aging. (Cotlear 2011). The shifting demographic trends have 90 had a significant impact on the geographic concentration 80 70 of populations in every region. A substantial change in 60 the public health landscape has occurred with the migra- 50 40 tion to and natural growth of urban areas. For the first 30 time in history, more than half of the human popula- 20 10 tion lives in cities (Figure 4). The vast majority of them 0 are poor. In Africa and Asia, the urban population is World More dev. Less dev. Sub-Sah Africa Asia Europe Lat. Ame. and Carb. No. America expected to increase between 30–50% between 2000 and 2030 (UN 2011b). The challenge for the countries and the global development community is to understand 1990 2011 how to take advantage of city growth and to use urban dynamics to improve health and alleviate poverty. Source: UN 2011b. The implications of urbanization are both positive and 2025, it is estimated that seven million smoking-related negative, and profoundly affect health and welfare, food deaths will occur each year, 85 percent of which will be safety and availability, road safety and transportation, in LMICs. A majority of the 300 million cases of Type environment, energy, education, labor force, fertility rates 2 Diabetes are in middle-income and poor countries. and virtually every aspect of life. Urban living presents the set of risk factors which amplify the rate of growth of Alcohol is the fourth most important cause of disability NCDs, the highest cause of death in the 21st century (see worldwide (Lister 2000). below). Protecting the poor is of pre-eminent importance. The impact of globalization on health is a significantly It will be essential to work effectively across sectors to greater challenge for LMICs, as poverty remains a clear improve health outcomes in urban environments, and to predictor of health outcomes and status. Children under catalyze growth of cities that is healthier and more sound. five in Africa are seven times more likely to die than children in Western Europe, for example. As the effects Globalization of globalization intensify, more efforts toward invest- ments in stewardship, effective governance as well as fair Globalization involves political, technological and cul- and equitable economic policies, are required. tural aspects as well as economic ones. It is a recent phenomenon that is “intensifying human interaction by reducing the barriers of time, space and ideas� (Lister Epidemiological Shift: the Rise in Chronic 2000). This generates “widespread health impacts that Non-Communicable Diseases affect large-scale populations across boundaries of geog- raphy, time and cultures.� Examples of risks that have An historic epidemiological development has been the increasingly become international include infectious dis- emergence of NCDs as a larger portion of the burden eases (both animal and human), food price volatility of disease (BOD) than communicable diseases, leading and shortages, lapses in food safety, unhealthy lifestyle to earlier mortality in developing countries as compared and consumption trends, as well as long-term health to High Income Countries (HICs) (WHO, 2011a). threats posed by environmental damage. Increased numbers of people are at risk of succumb- ing to NCDs while at the same time there has been a A particular concern in LMICs is the heavy marketing decline in other causes of ill health and mortality. Only and easy availability of products such as tobacco, sug- in Africa is this trend not yet a reality (Figure 5), but ared drinks, processed food, alcohol and baby milk. By it is anticipated that it will be over the next 20 years. 10 Connecting Sectors and Systems for Health Results Figure 5 • NCDs will be the Largest NCDs strain economies, health systems, households and individuals, and exert a negative impact on labor pro- Share of Disease Burden and the Leading ductivity, medical treatment costs and personal savings. cause of Healthy years Lost across all Many households facing the burden of NCDs will find Country Income Groups by 2030 it increasingly difficult to meet their basic needs, and could be driven into poverty. Health systems in many Low-income Middle-income High-income Countries Countries Countries countries will need to undergo significant adaptation if Projected NCD-related DALY’s (millions) they are to address NCDs effectively. In addition to the +37% +11% increasing demand for healthcare services, NCDs will 394 358 398 288 +3% require health systems to improve across a number of 104 107 fronts, including service delivery, human capital, quality 2008 2030 2008 2030 2008 2030 control and licensing, organizational structure, infor- 100% Percentage Distribution of Projected DALY’s by Cause (%) mation management, infrastructure management, and 11% 15% 15% 14% 9% 9% health financing. Health coverage and benefits packages 37% 55% 65% 76% 86% 88% will need to adjust to the changing nature of demand, while the financing models will need to reflect the dif- 52% 30% 20% 10% 6% 4% ferent cost pattern of NCDs. Such reforms can be 2008 2030 2008 2030 2008 2030 undertaken in a less costly and more effective manner Communicable diseases, maternal, perinatal and nutritional conditions Noncommunicable diseases and conditions if strategic steps are taken in advance. Health systems Injuries adaptation stemming from the ongoing health/disease burden transition presents an important fiscal and strate- Source: Nikolic et al. (2011). gic challenge to the middle- and lower-income countries. The increase in chronic NCDs is now a major topic in As Bank studies indicate, the cost of treating NCDs global fora. In September 2011, the United Nations orga- will make it prohibitive for most countries to “treat nized a UN High Level Meeting on NCDs (UN 2011a). their way out� of the problem. Action must be taken More recently, in May 2012, the World Health Assembly on prevention, with collaboration required from many agreed to adopt a global target of reducing premature mor- sectors beyond health including education, urban plan- tality from NCDs by 25 percent by 2025, marking an ning, agriculture, Poverty Reduction and Economic historic first in recognition of this development (WHO Management (PREM), transport, and industry, which 2012c). At the Rio+20 UN Conference on Sustainable have an influence on the rate and severity of NCDs Development, a multi-organizational side event discussion (Nikolic et al. 2011). panel took place to address frameworks for NCD control and sustainable development (Rio+20 Conference 2012). Disability will also be an important part of the equation going forward. Christopher J.L. Murray, who headed There is growing global recognition of the challenge of the Global Burden of Disease Study (Murray, Lancet NCDs (particularly cardiovascular diseases, cancer, chronic 2012), summarized this well in a Washington Post arti- respiratory diseases and diabetes). For example, while cle on December 13, 2012 when he stated on the day mortality in childbirth per year (342,000 in 2008) has the results of the latest study were released that “we are been declining (Hogan 2010), annual deaths of women in transition to a world where disability is the dominant 15–59 attributable to breast and cervical cancer as well as concern as opposed to premature death. …The pace of diabetes (448,131 in 2008) are on the rise (WHO Global change is such that we are ill prepared to deal with what Health Observatory Data Repository 2011). The impact the burden of disease is in most places�(Brown 2012). of NCDs in China, for example, clearly illustrates that diseases such as diabetes, cardiovascular disease and lung cancer account for nearly 70 percent of the total disease Zoonotic Diseases and Pandemic Threats burden (World Bank 2011c). The first Global Ministerial Conference on Healthy Lifestyles and NCDs, which took Pandemics are a global catastrophic threat. Seventy-five place in Moscow (Frenk 2011) is yet further testimony to percent of infectious diseases now originate in animals, the enhanced attention to this growing threat. including influenza, TB, HIV/AIDS, SARS, plague, The Unfinished Revolution in Public Health: Progress to Date, Shifts in the Landscape, and Remaining Challenges 11 brucellosis, leptospirosis, and rabies. Zoonotic dis- New Evidence on the Cost-effectiveness of eases already exact a heavy toll: every year an estimated Prevention 2.4 billion people in developing countries are affected, and 2.2 million die (Grace 2012). Many of these cases Overall, prevention is cheaper than cure, and often dra- are undetected and misdiagnosed, as these diseases matically so. The substantial benefits of zoonotic disease disproportionately affect the poor. Risks in develop- prevention and control noted above yield a benefit:cost ing countries are increasing, due to growing densities ratio of 11:1. Reduction of the burden of brucellosis of livestock, incursions of humans and livestock into through vaccination and other disease control measures wildlife habitats and the impacts of urbanization and in livestock has also been shown as the more cost effec- globalization. Control of zoonotic diseases can be highly tive approach. Vaccination of dogs and control of strays cost-effective. The World Bank has estimated that sys- have also been shown to be less costly than allowing tem improvements in public health and animal health humans (especially children) to die. Other measures also to meet minimum WHO and OIE standards would have very small costs relative to the private and public cost $3.4 billion per year. Consider that six major zoo- health benefits of avoided illness and death, including notic outbreaks in 1997–2009 cost $80 billion, or $6.7 hand-washing, reduced alcohol consumption, reduced billion per year (World Bank 2012). Fortunately, none smoking, drinking, fewer sugar-laden drinks, and taking became a pandemic, but the damage they caused could exercise. For instance, the effectiveness of hand hygiene have been prevented if effective systems for early disease has been widely shown to reduce the spread of disease. control had been in place. A severe flu pandemic could There are now low-cost sanitation solutions, including cost $3 trillion, as mentioned above. With a 1 percent $10 aspirational and affordable toilets, that can dramat- probability of occurrence in any year, the expected bene- ically reduce the household members’ risks of disease fit from prevention is $30 billion per year. The expected and malnutrition (Smets 2012). In Peru, for example, value of the economic benefits from robust human and chronic malnutrition was reduced from 28.5 percent to veterinary public health systems is at least $36.7 billion 23.2 percent in just four years thanks to a program pro- annually. This is well above the investment and operat- moting toilets and sanitation for 500,000 beneficiaries ing costs of the systems, which were estimated at $3.4 (27 percent extremely poor) (Costain and Weitz 2012). billion per year at local, national and global levels, with Likewise, investments in key development infrastructure particular attention to the interface between animal and can yield major health and economic benefits. For exam- human health systems (World Bank 2012). ple, a recent cost-benefit analysis by WHO showed that achieving the global MDG target in water and sanitation would bring substantial economic gains to health and Vulnerability to Climate Change other benefits (consequences of reduction in diarrheal episodes). Each $1 invested would yield an economic Climate change is a serious threat to all countries, return of between $3 and $34 depending on the region. but developing countries are the most vulnerable. The health-related costs avoided would reach $7.3 billion The consequences threaten to reverse progress in pov- per year (WHO and UNICEF 2005). Such investments erty reduction and economic growth, posing risks to promote not only public health but also equity because food security, water supply, sound migration and dis- they reach those most often lacking access: the poor. ease control. Climate change has multiple impacts on human health. These include: increased incidence of vector- and waterborne diseases such as malaria, den- Revolutions in Technology gue and cholera; spread of zoonoses and other novel pathogens; increased mortality from heat-stress; and Revolutions in technology have changed the pursuit to increased harm and deaths caused by extreme weather improve health outcomes, in many ways. One of these events. Efforts to achieve the MDGs and to improve ways is the use of open data supported by innovations standards of living are being compromised. Indeed, in technology in the area of public health. An exam- according to a major World Bank study, it will cost ple is the Community Health Data Initiative (CHDI) developing countries an estimated $70–$100 billion at the U.S. Department of Health and Human Services per year through 2050 in adaptation to climate change (USDHHS n.d.). Open data is data that is freely avail- (World Bank n.d.). able for use without intellectual property restrictions, 12 Connecting Sectors and Systems for Health Results which can therefore be used to strengthen health sys- spread by consumption of contaminated water remain tems and improve outcomes. widespread. Diarrhea remains a leading cause of death in children under five years of age globally, surpassing The technology revolution is just as relevant in LMICs. HIV/AIDS, malaria and measles combined (Childinfo In Haiti, for example, cell phones were used for sur- 2012, UNICEF). Lack of clean drinking water drives veillance and to track populations during disasters such a host of other illnesses that include viral hepatitis, as the 2010 earthquake and the cholera epidemic that typhoid, cholera, and dysentery. An analysis of 172 followed (Bengston et al. 2011). In Zambia and other Demography and Health Survey data sets from 70 LICs, cell phones are being used to track stock-outs countries to estimate the effect of water and sanita- of essential medicines in government health facilities tion on child mortality and morbidity shows a robust (PlusNews 2009). And in Kenya (and elsewhere) text association between access to water and sanitation tech- messages are used to transmit routine health check-up nologies and both child morbidity and child mortality. information (PlusNews 2010). Sharing public health data The point estimates imply, depending on the technol- enables better and more effective utilization of existing ogy level and the sub-region chosen, that water and data that ultimately allows the use of a wider range of sanitation infrastructure lowers the odds of children to tools, perspectives and methodologies than are available suffering from diarrhea by 7–17 percent, and reduces in any one place, thereby adding value to science, while the mortality risk for children under the age of five promoting the use of sound evidence for policy making. by about 5–20 percent (Gunther and Gunther 2010). Distance learning, telemedicine, computer medicine, lab �� The massive declines in child mortality during the last networks also contribute to better surveillance, knowl- third of a century have been the result not only of edge sharing, health promotion, governance and can technological and economic change but also of social enhance other essential public health functions. change, of which the most important component for the survival of children through the first years of life has been parental education. There is evidence that Key Challenges in Advancing schooling brings about a new family system in which Public Health women and children are allocated higher priorities in terms of care and allocation of food (see box 2). Cutting across the challenges previously discussed are �� Limiting population exposure to vehicle and indus- three core imperatives that must be addressed in order to trial air pollution as part of an Environment sector sustain and advance public health over the decade ahead: project minimizes respiratory diseases, certain cancers �� Galvanizing actors outside the health sector to and loss of IQ in children (Lvovsky 2001). Likewise, address key determinants of health outcomes; multi-pronged interventions to reduce indoor air �� The dual challenge of dealing with rising NCDs and pollution, including provision of cleaner fuels and meeting the health MDGs targets; changes to living environments, can significantly reduce the associated negative health impacts while �� Building sufficient government capacity to address also generating economic and ecological benefits. current and emerging public health issues. �� Within the Road and Infrastructure sectors, specific activities can greatly reduce traffic injuries. The recent Galvanizing Actors Outside the Health Global Burden of Study (Murray, Lancet 2012) shows Sector to Address Determinants of Health that road traffic injuries accounted for 27% of total Outcomes. injuries in 2010. WHO reports that road crashes are the number one killer of young people age 15–29 The following examples illustrate yet more benefits of (WHO 2012b). A World Bank-supported study of galvanizing actors outside the animal and human health traffic accident costs in Thailand concluded that road sectors: accidents costs represented 2.8 percent of the country’s GDP in 2007, 60 percent more than what the gov- �� Despite the advances in Water, Sanitation and ernment allocated to health service delivery the year Hygiene discussed earlier in this chapter, diseases before (Thailand, Department of Highways. 2007). The Unfinished Revolution in Public Health: Progress to Date, Shifts in the Landscape, and Remaining Challenges 13 The Bank has conducted a detailed analysis of road Box 2. The Link between Education safety problems in Europe and Central Asia to help and Health galvanize multisectoral action (see box 3). �� One barrier to effective implementation of multi- In a data analysis from a World Fertility Survey in ten developing sectoral activities to improve health is the lack of countries, the analysis confirmed the major importance of parental ed- broadly accepted and rigorous analytic tools to quan- ucation, the impact of which is probably greater than both income tify the impact of the relevant key determinants of factors and access to health facilities combined. Rural/urban differ- entials are of small importance once parental education has been health. Such analysis is necessary for the prioritiza- controlled. The findings of the Nigerian study are modified in that pa- tion of action in non-health sectors at country level. ternal education is also shown to be important, though not as important as maternal education, and the step from primary to secondary school- ing is more important than that from illiteracy to primary schooling. Annex 6 sets out the illustrative role of different sectors in strengthening public health programs and outcomes. The massive declines in child mortality during the last third of the century have been the result not only of technological and econom- ic change but also of social change, of which the most important component for the survival of children through the first years of life The Dual Challenge of Addressing NCDs has been parental education. and Meeting the MDGs It is suggested that schooling introduces parents to a global culture. Age and sex differentiations in power, decision-making and benefits The dramatic rise in NCDs in developing countries within the larger family are reduced when schooling brings about a new family system in which women and children are allocated high- poses additional threats to achieving the MDGs, and er priorities in terms of care and allocation of food and in which population aging will contribute to the increase in non- parents can make decisions about health and child care without ref- communicable diseases. Countries face, in effect, a dual erence to their elders. challenge that has been aptly named “a tiger with two Research also shows that children who complete basic education heads� by some policy makers. For LICs with budget eventually become parents who are more capable of providing qual- ity care for their own children and who make better use of health constraints, focusing resources towards managing NCDs and other social services available to them. Evidence indicates that poses the real threat of diverting valuable resources away when girls with at least a basic education reach adulthood, they are from MGD goals, many of which have not been met. more likely than those without an education to manage the size of High treatment costs make it clear that countries will their families according to their capacities, and more likely to provide better care for their children and send them to school. not be able to “treat their way out� of NCDs. Thus, LICs and MICs must effectively maximize the impact Source : Caldwell and McDonald 1982; Veneman 2007. of their responses to both challenges. Box 3. Confronting Death on Wheels: Making Roads Safe in Europe and Central Asia The World Bank has released “Confronting Death on Wheels: Making Roads Safe in Europe and Central Asia�, which reviews the size, character- istics, and causes of the road safety problem in ECA countries. Together with seven other development banks, in November 2009 the World Bank issued a joint statement ahead of the Global Ministerial Conference on Road Safety that outlines a broad package of measures that each institu- tion would implement to reduce an alarming rise in the number of road injuries, fatalities, and disabilities in low- and middle-income countries. Unsafe road traffic conditions in the countries of Europe and Central Asia have tremendous adverse implications for their economic and social well- being. The treatment of road safety victims is imposing an increasingly insupportable burden on these countries’ health and social services. Road traffic injuries are a major cause of death and disability, affecting young and working-age groups of society in particular. A combination of weak capacity to manage road safety, deteriorated roads, unsafe vehicles, poor driver behavior, and patchy enforcement of road safety laws, alongside the exponential growth in the number of vehicles, are the key factors that are contributing to the rapid pace by which road traffic injuries and fatalities are multiplying. An effective strategy to improve the safety of a country’s roads requires a systematic, multisectoral ap- proach with a politically strong and technically competent lead agency to coordinate the involvement of the many government departments that have responsibilities towards road safety. Source : World Bank 2009a 14 Connecting Sectors and Systems for Health Results Figure 6 • NCDs Have Significant Impact on Economies, Health Systems, and Households Key drivers Economies Health systems Households and individuals • Reduced labor supply • Increased consumption of NCD-related • Reduced well-being • Reduced labor outputs healthcare • Increased disabilities (e.g., cost of absenteeism) • High medical treatment costs • Premature deaths • Additional costs to employers (per episode and over time) • Household income decrease, loss, or (e.g., productivity, insurance) • Demand for more effective treatments impoverishment • Lower returns on human capital (e.g., cost of technology and • High health expenditures, including investments innovation) catastrophic spending • Lower tax revenues • Health system adaptation • Savings and assets loss • Increased public health and social (e.g., organization, service delivery, • Reduced opportunities welfare expenditures financing) and adaptation costs Example impact areas Country productivity and Fiscal Health Poverty, inequity, competitiveness pressures outcomes and opportunity loss Source: Nikolic et al. 2011. In many developing countries, the discussion about con- effectively performing essential public health functions trolling the rise of NCDs and meeting the health MDG (Annex 2). For instance, many countries are having dif- targets is one and the same. For example, the increase ficulties complying with the requirements for the 2005 in risk behaviors such as smoking and alcohol abuse in International Health Regulation (IHR) framework that turn increase the likelihood of developing active TB and assumes that countries will build their national public reduce the effectiveness of treatment. This double bur- health surveillance and response capacities as part of a den of disease particularly threatens Sub-Saharan Africa functional health system. Several countries fall short of and South Asia, where communicable diseases includ- this intent, with a large number of LMICs experiencing ing TB, respiratory infections, water- and vector-borne serious gaps that result from poor disease surveillance diseases and HIV/ AIDS are predicted to remain prom- capacity, an absence of inter-sector collaboration, lim- inent even as the rate of NCDs grows rapidly (Engelgau ited technical expertise and weak leadership (Katz et al et al. 2011). In many LICs and MICs, NCDs will also 2010; Katz and Fischer 2010). An evaluation tool to coexist with a backlog of developmental issues, such as assess gaps in public health similar to the well estab- maternal and child health issues and poor nutrition. lished OIE Performance of Veterinary Services Pathway Other health challenges, some of which are linked to tools is missing. NCDs (for example, fetal and early childhood malnutri- tion) are expected to remain or increase in seriousness. Addressing emerging threats such as drug and insec- ticide resistance in malaria and TB control provide further rationale for countries to build such capacities. Building Sufficient Government Capacity for To move forward, decision makers must understand Promoting and Evaluating Efficient Policies the significant returns from cost-effective investments on the Basis of Health Outcomes on health outcomes, including investments in non- health sectors. Institutional and structural barriers within the public health system hamper many developing countries from The World Bank Contribution to Public Health: 3 Connecting Sectors and Systems for Health Results G The HNP Strategy iven the context set out in the previous chap- ters, this chapter defines the main areas which the Bank will emphasize in framing its work The World Bank’s 2007 HNP Strategy provides the on public health over the coming years—with the over- context and background for the articulation of a path arching aim of contributing toward improvement of forward for the Bank’s work in public health (World health outcomes. These areas will leverage and com- Bank 2007). The strategy focuses on healthy devel- plement the work of partners. They will also guide the opment for health results, the promotion of fiscal public health knowledge agenda within the Bank. sustainability, economic growth, global competitiveness and good governance (see Figure 7). As discussed below, two main parameters are used to guide the choice of future priorities for the The main strategic directions to achieve these objectives Bank—namely, selectivity and comparative advan- include the strengthening of a country’s health systems, tage. This chapter also reflects on the role of Bank ensuring synergies between health systems and priority management in creating a supportive environment for disease interventions, strengthening advice to countries the Bank’s proposed focus areas and actions in public on intersectoral approach to HNP, and improving har- health, including making available sufficient resources. monization and strategic engagement with global partners. Annex 8 lists a set of illustrative concrete actions and The 2009 strategy implementation report emphasizes opportunities that will allow the Bank to have an progress made in some areas, but also underscores areas impact and make a difference in public health over the where significant work remains to be done, including next five years, within the areas of strategic focus iden- in strengthening multisectorality in HNP interventions tified in this chapter. (World Bank 2009b). The Health Sector has the respon- sibility to play the governance and stewardship role necessary in connecting sectors and systems to improve health outcomes. 16 Connecting Sectors and Systems for Health Results Figure 7 • World Bank HNP Strategy 2007 Healthy Development: The World Bank Strategy for HNP Results The strategy has four objectives that focus on improving results Objective 1: Objective 2: Objective 3: Objective 4: Improve the level and Prevent poverty due to Improve financial Improve governance, distribution of key HNP illness (improving financial sustainability in the HNP accountability, and outcomes, outputs, and protection) sector and its contribution transparency in the health system performance at to sound macroeconomic sector country and global levels and fiscal policy and country competitiveness Source: World Bank 2007. The World Bank Footprint high level policy dialogue at global and country level. This is a growth area which, to date, the Bank has in Public Health – Making a not yet sufficiently developed in public health. Difference Through a More Strategic Approach Over the next five years, the World Bank will enhance its footprint in public health by focusing on three stra- Given the changes in the global landscape and the tegic pillars building on its comparative advantages. challenges discussed previously, “business as usual� in This approach will promote public health policies and addressing public health issues is not an option, particu- interventions within each country that achieve tangible larly given the challenges of improving public health in results in health and development. The three pillars are: poor populations. Over the coming years, decisions on where the Bank will focus its investments and efforts in I. Fostering multisectoral interventions (as well as public health will need to take into account the Bank’s interactions among public and private sectors and comparative advantages vis-à-vis other partners and civil society) to maximize returns on investments stakeholders. These advantages include: in health. II. Identifying country-specific, cost-effective actions to �� Ability to foster action across sectors for health help countries face the dual challenge of meeting results. Connecting sectors around actions to pro- MDGs and addressing NCDs. duce significant health results will be an overarching III. Strengthening governance and leadership to antici- principle which will guide action within the Bank pate, address and manage public health challenges. on public health over the coming years. �� Ability to promote a systems-based approach Building on the Bank’s commitment to support the to address disease prevention and control. The LMICs in achieving the MDGs and its comparative Bank is well positioned to promote efficiency and advantages, the Bank will also focus on implementing effectiveness in addressing both communicable and a key strategic cross-cutting theme—namely, the use of non communicable diseases, by prioritizing actions economic evidence to inform the formulation of effective which promote the biggest “bang for the buck� public health policies—in support of the above three and ensuring that public health is also an effective strategic pillars. These 3 pillars are interrelated: a multi- part of health systems. HDNHE and Agriculture sectoral approach will be needed to address MDGs and Environment Services (AES) are already collaborat- NCDs and to perform Essential Public Health Functions ing to achieve this common objective. (EPHFs). Strengthening governance and leadership will �� Capacity to carry out economic analyses to guide be critical to support the first two pillars, while integrat- evidence-based policies and to inform and influence ing economic evidence into policy decisions. The World Bank Contribution to Public Health: Connecting Sectors and Systems for Health Results 17 Figure 8 • World Bank Integrated to work across sectors to improve health outcomes. Approach to Strengthen Public Health Upholding this principle will yield multiple benefits across sectors (see Box 4 below, which provides exam- Country Context (Macro Environment) ples in Energy, Transport and Environment). Very few HEALTH GOALS organizations combine a multisectoral mandate with the (Level/Spread) resources, analytical and operational capability to influ- Health Status + Financial protection + Satisfaction and Trust (Responsiveness) ence public sector policies. Multisectoral MDGs And Governance Interventions NCDs and Box 4. Examples of Other Sectors Stewardship Leading Collaboration to Improve Health Outcomes Economic Evidence There are numerous examples across the World Bank of non-health Public Health sector actors leading cross-sectoral collaboration to evaluate and im- prove health outcomes. These include: 1. Animal health as a determinant of health outcomes. The World Bank contributed to the global response to the avian in- fluenza threats through a $1.3 billion multisectoral program of Figure 8 represents an integrated approach to strength- 72 projects in 60 countries, combining actions to strengthen systems for animal health, human health, disaster risk manage- ening public health, bringing together the strategic ment, and communications (World Bank 2011a). More than two pillars as well as the cross-cutting theme. thirds of the projects were managed by the agriculture sector, while the overarching goal of the program was to safeguard hu- The opportunities and actions proposed under each of man health security. 2. Energy as a determinant of health outcomes. The ener- these pillars and themes are explored below, and sum- gy sector’s ESW aims to develop a framework to Define and marized in Annex 8. Measure Access to Energy (ongoing analytical work, M. Bhatia and team, SEGEN), designed to complement ongoing work by It should be emphasized that a prerequisite for the WHO, UNIDO, UNDP and others. The ESW seeks to determine how energy is linked to poverty reduction and development effective implementation of these strategic pillars will aspects including potentially improving health outcomes by im- be the robust assessment of the key health-related issues proving access to better cooking and heating options, and in each country, so as to assist in formulating effective strengthening health services by identifying sustainable energy options for health care centers. policies to address the main causes of the burden of dis- 3. Transport as a determinant of health outcomes. A World ease and identify opportunities for improvement. Risks Bank report led by the transport sector states that many women associated with pandemics, environmental hazards and spend excessive time to reach a health facility with the capacity other emerging threats are also important to inform and to treat obstetric or infant complications. It was estimated that approximately 75 percent of maternal deaths might be prevented determine the optimal health policies for each coun- through timely access to essential emergency childbirth-related try. Such assessments will need to recognize that low care (Babinard and Roberts 2006). Therefore, transport inter- and middle income countries have very diverse prior- ventions which are specifically designed to improve access to ity health issues. health services should be planned as part of long-term health/ and transport strategies. 4. The link between Environment and Public Health – The MENA region. The Bank recently published a report on the costs PILLAR I: FOSTERING MULTISECTORAL of environmental degradation in the MENA region. The economic costs of environmental degradation are linked to health impacts INTERVENTIONS primarily through lack of access to water and sanitation servic- es, and outdoor and indoor air pollution. The costs associated The Bank is involved in high level policy dialogue and with these three factors in 2008 ranged between 1.1 percent of operations across 19 sectors in all regions. With all sec- GDP in Tunisia, and 2.9 percent of GDP in Egypt—with negative impacts on public finances, household budgets, economic com- tors focusing on improving development outcomes for petition and generational equality. the world’s poor, the Bank has a comparative advantage 18 Connecting Sectors and Systems for Health Results Table 1. World Bank Projects, by Sector and Commitment Amount, FY1990–2011 Total World Bank Projects $113.9 billion Health projects $44.6 billion Managed by HNP Sector Board $28.3 billion Managed by non-HNP Sector Board (mainly through the Social Protection, Economic Policy, Transport, Education, $16.3 billion and Urban Sectors) Non-health Projects $69.3 billion Source: Health in all the right places, Merrick, Yazbeck et al, forthcoming 2013. Indeed, a recent review of World Bank projects over the analysis could also provide the opportunity for useful past 22 years revealed that some 1,000 Bank-financed case studies to inform the knowledge agenda within projects outside of the health sector included a health the Bank on multisectoral action, as well as action sector component. As many policies and interventions at the country level. Examples of such opportunities beyond the health sector also have health consequences, include the Healthy City Initiatives, using urban space it would be appropriate to devise mechanisms and instru- to foster a “whole of government� approach. The ments to assess how “healthy� or “health promoting� recent work Defining and Measuring Access to Energy Bank operations are to the population, and to provide is another such opportunity to analyze the linkages constructive and pragmatic solutions to strengthen their of the health sector with access to energy/energy health impact or mitigate their potential negative effects. applications in the field of health, assessing poten- tial health impacts of the household energy sector in Under this pillar, the Bank will build on its existing developing countries, and mapping energy barriers to platform of intersectoral work relevant to public health, the achievement of outcomes in the health sector.2 placing particular emphasis on the following actions: �� Reaching out to other sectors to tackle the major risk factors to address NCDs, communicable dis- �� Carrying out multisectoral constraints assessments eases, other health MDGs and injuries. In the (MCA) to health results in a country. Because many context of scarce resources, particularly but not only determinants of health are not in the health sector, in LICs, cost-effective interventions and policies are such assessments will assist in identifying the major mostly centered on promoting healthy behavior and multisectoral interventions to improve health out- prevention. This will necessitate strong involvement comes as well as the constraints on their effective from sectors beyond health; particularly those which implementation in a country. This action is intended can help curb the growing threat of zoonotic dis- to build the evidence for priority actions across sectors eases and NCDs (Figure 9). Because much of the and empower staff in making the case for investments rise in NCDs in developing countries is attributable in other sectors to improve health outcomes. The to shared and modifiable risk factors (tobacco, alco- 2007 HNP action plan states that a tool to carry out hol, diet/nutrition, exercise, indoor air pollution), these assessments (World Bank 2007) was expected prevention has the potential to yield meaningful to be available in 2008 and tested in pilot countries results. Indeed, existing evidence suggests that more in 2009—but this expectation has not yet been met. than half of the NCD burden could be prevented �� Exploiting windows of opportunity to promote through a few key health promotion and disease actions across sectors. A quick analysis of sector prevention interventions that address such risk fac- portfolios and pipelines could help identify projects tors, amenable to actions beyond the health sector and countries which could improve health through (Meiro-Lorenzo et al. 2011). Likewise, on communi- investments and policies in other sectors. Such cable diseases, addressing risks such as poor hygiene, 2 In Marikina, Philippines, the Bank provided a $1.3m to the city for the construction of bicycle lanes; Healthy cities Illawara, Australia brings healthy and safe living to deal with injury prevention among children). The World Bank Contribution to Public Health: Connecting Sectors and Systems for Health Results 19 Figure 9 • Risk Factors Addressed by Sectors Poor Diet & Physycal Unhealthy Injuries & Tobacco Nutrition inactivity Alcohol environment Pathogens violence Health ✓ ✓ ✓ ✓ ✓ Education ✓ ✓ ✓ ✓ ✓ ✓ Finance ✓ ✓ ✓ ✓ Urban Planning ✓ ✓ ✓ ✓ Agriculture ✓ ✓ ✓ Industry ✓ ✓ ✓ ✓ Transport ✓ ✓ ✓ Source: Meiro-Lorenzo et al. 2011. water and sanitation, and weak veterinary systems, (i) incremental actions that can be promoted to leverage will have significant health impacts—including pre- the MDGs service delivery platforms at the PHC level venting pandemics. Finally, on injuries, addressing and start making progress against NCDs, especially in the some risky behaviors could help curb the high toll context of LICs; and (ii) how actions aimed at address- of road traffic injuries. ing NCDs can be introduced at little marginal cost. So far, the global conversation has mostly framed the dis- Annex 6 illustrates the roles different sectors play in cussion on MDGs and NCDs around the significant strengthening public health programs and outcomes, tradeoffs between both agendas. Indeed, there is growing while Annex 7 provides a conceptual view of how these concern, both from policy makers and the donor com- multiple sectors impact on health. munity, that responding to NCDs in LICs and MICs may divert valuable resources which should instead be directed to making progress toward the health-related PILLAR II: SUPPORT COUNTRIES TO MDGs. With severe budget constraints, focusing resources ADDRESS THE DUAL CHALLENGE OF on one area is likely to result in displacement in others, MEETING THE HEALTH MDG TARGETS especially in LICs. Some common ground exists on policy AND ADDRESSING NCDS. actions and interventions which can advance both agendas simultaneously and increase the opportunity set available The Bank’s work in public health is underpinned by the to countries. However, most countries have yet to focus need to sustain our strong commitment to the MDG effectively on exploiting those synergies. agenda. Countries are at different stages in their quest to achieve the health MDGs by 2015. Many countries Under this pillar, the Bank will primarily assist LMICs are still lagging behind in expected gains on nutrition, in exploring the points of intersection where synergies maternal and child health and communicable diseases. in service delivery and disease dynamics can positively The Bank remains strongly committed to helping coun- affect both NCDs and MDGs as well as understanding tries improve their performance to achieve the MDG the financial implications of such choices. At present, targets as stated during the UN meeting in 2010. there is still little understanding of the synergies and Because of this commitment, the public health actions tradeoffs between NCDs and MDGs, and how such to address MDGs, discussed below, must be seen as a synergies translate into actionable knowledge that can reinforcement of what the Bank is already doing on be applied at country level to optimize the allocation of that front, not as a substitution. limited resources to improve health outcomes. The final objective of this pillar will be to generate critical knowl- This pillar is not about defining the best buys to curb edge to assist countries in making decisions on the hard the growing threat of NCDs. It will focus initially on choices of dealing simultaneously with the unfinished 20 Connecting Sectors and Systems for Health Results MDG agenda and the growing burden of NCDs, tak- �� It will help manage the gaps which currently exist ing into account each country’s specific epidemiological between systems, institutions and professions to profiles and available resources. promote an effective response to contagious dis- eases arising at the animal-human-ecosystems Although the primary emphasis will be on building interfaces. Managing such gaps is critical to effec- these synergies, this Note recognizes the need to sup- tively mitigate the increasing number of dangerous port countries—particularly MICs—in initiating system pathogens (Annex 2, particularly essential public adaptation in the face of the heavy NCD burden they health functions particularly 6, 8, 10,11). are already experiencing. �� It will highlight the importance of public health as an integral part of the agenda to strengthen health systems, particularly at the primary health care level, PILLAR III: STRENGTHENING GOVERNANCE to improve population health and achieve the health AND LEADERSHIP TO ANTICIPATE, system’s goals. Indeed, health systems cannot deliver ADDRESS AND MANAGE PUBLIC HEALTH effectively and efficiently on these goals without a ISSUES. strong focus on public health (Annex 2, particularly essential public health functions 3,4, 7, 8, 9). The Under this pillar, particular emphasis will be placed on main functions of health systems (governance stew- strengthening countries’ capacity and stewardship role ardship, financing, resource generation and service and capacity to perform EPHFs at the national and delivery) apply as well as to public health as a sub- regional levels and on connecting systems to improve system (Figure 10). The East Africa Public Health health outcomes. Currently, many countries are not well Laboratory project (US$63.6 million covering equipped to address the full range of diseases and pub- Burundi, Kenya, Rwanda, Tanzania and Uganda), lic health threats they face, as they typically use their limited resources to focus on a few high-profile dis- eases and public health threats at a time. Building such capacity to promote efficiency and evidence-based public Figure 10 • Public Health is an Integral health policies is an area which has been mostly been Part of the HS Framework neglected so far. Connecting systems and addressing Public Health is an integral part of the HS Framework system issues to allow countries to respond to cur- PARTICIPATION – SOLIDARITY – EQUITY rent and forthcoming health issues in a more efficient manner is another area deserving immediate attention. Strengthening public health systems and institutions is likely to provide more value for money, particularly in a context of limited resources by fostering a multidisci- plinary response on several fronts: Governance and leadership Human Information Resources Service delivery �� It will assist countries in the formulation and implementation of evidence-based public health People actions, to address communicable and non com- Medical municable diseases, injuries, chemical hazards, food Financing products safety, and so on, by reinforcing capacity for data collection, monitoring and analysis—all of which are important to inform sound policy decisions, particularly across sectors. (Annex 2, particularly • Policy/planning • Promotion • Regulation • Prevention essential public health functions 1, 3, 5, 6, 8, 10) • Intelligence • Protection �� It will position countries to play their “global role� • Intersectoral dialogue • Care • International cooperation • Rehabilitation by assisting them in addressing trans-border issues of • M&E • Support a public good nature (Annex 2, particularly essential public health functions 2, 10, 11). Source: WHO Regional Office for Europe, 2010 The World Bank Contribution to Public Health: Connecting Sectors and Systems for Health Results 21 is an example of addressing global public goods and strengthening of national public health institutes (NPHIs, strengthening health systems for results. see box 6). Investing in NPHIs is an option that some countries have started to consider to complement (not to The focus on systems does not exclude specific actions substitute for) the MOH’s role in performing essential in countries aimed at addressing specific health risks public health functions (Frieden and Koplan 2010). For that impose, or are expected to impose, a major health example, Mexico established a new public health agency, toll on their populations. In this regard, the Bank’s as the government recognized the need to “mobilize all HNP portfolio in Argentina is worth highlighting as instruments of public policy in the pursuit of health, not an example: it focuses on strengthening the country’s as a specialized sector but as a shared social objective� EPHF, while at the same time reducing the burden of (Frenk 2011). Experience has shown that achieving and NCDs and preventing influenza (see Box 5 below). sustaining positive impact in public health is best served by a national organization which can help ensure a strong Effective action on the several fronts mentioned above and coordinated focus on public health to assist the gov- will only be possible if health sectors within countries can ernment in its stewardship role. ensure the strong governance required (i.e providing strate- gic direction for policy formulation, implementation and monitoring, coordination of actions across sectors and stake- Public Health Strategic Cross-cutting Theme – holders and developing an accountability framework). The Generating Economic Evidence major shifts in the global landscape (discussed in Chapter 2) as well as the need for countries to comply with the In pursuing the strategic public health pillars presented IHR regulations framework, make it even more impera- above, there is a need to capitalize on the compara- tive for countries to pay urgent attention to mobilizing the tive advantage of the Bank in generating the economic resources they need to perform the EPHFs. Ministries of evidence to underpin the different actions and inter- health (MOH) will have to move beyond their traditional ventions. role to bring on board and coordinate the inputs of other sectors and stakeholders to improve health outcomes. Limited resources, particularly in LICs and MICs, will make it necessary for countries to inform their policy One critical investment countries can make to assist decisions and resource allocations through robust eco- MOHs in their new role is the development and nomic analyses of the strategic choices they face. Under Box 5. The World Bank’s Public Health Portfolio in Argentina 1. The Essential Public Health Functions Project (P090993) focuses on strengthening national and provincial health stewardship and capacity to carry out core essential Public Health programs and functions. Using RBF (results-based financing for Public Health), the focus is on com- municable diseases, including epidemiological surveillance and control of vector-borne diseases. The project will close on December 31, 2012. US$ 220 million. 2. The Essential Public Health Functions and Programs II Project (P110599) will contribute to reducing the burden of disease associated with non-communicable diseases (NCDs) by strengthening MSN’s stewardship role in this area and by increasing coverage and clinical gover- nance of priority Public Health programs focused on NCDs. Using RBF for health promotion and prevention in Public Health applied to NCD’s, and Health Insurance premiums (capitas) for a Catastrophic Health insurance to cover NCDs and disabilities, the project will close on June 30, 2016. US$485 million. 3. The Emergency Project for the Prevention and Management of Influenza Type Illness and Strengthening of Argentina’s Epidemiological System (P117377) supports strengthening the capacity of Argentina’s epidemiological surveillance system to prevent, monitor and evaluate in- fluenza activities. The project wilI close on March 31, 2013. US$160 million. EPFH were identified by the Governments of the LAC Region after a Regional consultation lead by PAHO/WHO and CDC in 2002–2003, and refer to core elements of public health policy which apply across all Programs of public health, independent of specific diseases or levels of interventions. Source: World Bank Projects and Operations Portal 2012. 22 Connecting Sectors and Systems for Health Results Box 6. Historical Context for NPHIs Many of today’s comprehensive NPHIs have their roots in prevention and control of infectious diseases. For example, Brazil’s Fiocruz started as the Federal Seropathy Institute, created in 1900 to produce serums and vaccines against the plague. Finland’s KTL was established as the Temporary Serum Laboratory in 1911 to respond to cholera and plague, improve diagnostics for organisms believed to cause typhus and “paratyphus,� en- hance serologic testing, and produce antisera against rabies and diphtheria. The U.S. Centers for Disease Control and Prevention was created from an organization called Malaria Control in War Areas (MCWA); in 1946, the MCWA became the Communicable Disease Center, in recognition of the expansion of MCWA’s work into other vector-borne and infectious diseases. These NPHIs subsequently grew through a variety of processes, including the addition of existing organizations from other parts of government, ex- tension of existing programs into new scientific and programmatic areas, and creation of new programs through legislative or administrative decisions. Source: IANPHI 2007. this pillar, the Bank will promote the use of economic 2. Organizing field-based training for Bank staff in evidence to inform the formulation of sound public countries with improved public health systems func- health policies—both within the Bank, and to inform tions (for example, Argentina and Brazil) to provide the Bank’s policy dialogue with countries. Partners Bank staff with first hand exposure to best practices and countries expect the Bank to take the lead in this on public health. arena, as has been expressed several times in interna- 3. Promoting south-south learning to disseminate best tional fora such as the recent UN High Level meeting practices and stimulate the establishment of public on NCDs in September 2011 (UN 2011a). Examples health networks across regions. A trust fund cur- of economic analysis include the economic impact rently exists in the Bank to support such an effort. of NCDs and obesity in MICs; economic returns of 4. Ensuring regular updates of the knowledge repos- investments in prevention; economic benefits of early itory on public health, and meeting on-demand and effective disease control and of disease eradication; knowledge requests from the regions (short notes; and assessment of the impoverishment impact of dis- fact sheets, policy briefs). ease and injury. 5. Developing tacit knowledge to allow staff to record and share their experiences and lessons learned in developing policy dialogue and implementing projects. Developing and Implementing a This knowledge agenda will build on the foundation Robust Knowledge Agenda on of existing World Bank knowledge on public health. It Public Health within the Bank will also help the Bank play its role as a major convener globally and regionally. The recent conference of SADC A robust knowledge agenda focusing on solutions and countries on economics of tobacco in Southern Africa, impact at country level will underpin the Bank’s work organized by the Bank and sponsored by Bloomberg on the strategic pillars and initiative described above. Philanthropic and the BMGF is an example of the con- This agenda will take stock of specific actions taken, vening role that the Bank plays. in each fiscal year, to foster exchanges across regions and sectors, to bring TTLs up to speed on the latest ground-breaking activities and research on public health. This knowledge agenda will also include (but is not lim- Creating the Environment to ited to) the following: Foster Action across Sectors within the Bank 1. Empowering the recently established Public Health Community of Practice to discuss and promote Working across sectors has been on the internal action across sectors and to share and disseminate agenda for some time but has yet to be institu- knowledge. tionalized. Multisectoral work is often not seen as a The World Bank Contribution to Public Health: Connecting Sectors and Systems for Health Results 23 responsibility, nor as a major governance issue that strategy will be developed to promote knowledge gen- governments need to tackle to deliver health outcomes eration and dissemination, and help the Bank play or address global public health threats. Multisectoral fully to its comparative advantages. Indeed, the ambi- actions are often affected by a fundamental coor- tious agenda described above, cannot be delivered in the dination problem: while the positive outcomes are absence of adequate resource mobilization. In this con- perceived to benefit one specific sector, the necessary text, the Bank could follow the model implemented for coordination and implementation activities depend other themes in HNP, which have historically attracted crucially on other sectors. To overcome this issue, large trust funds by developing effective resource mobi- better recognition of the contributions of other sec- lization strategies to augment priority knowledge tors to the achievement of health outcomes is needed, generation and dissemination, to help the Bank improve as well as putting in place appropriate incentives for public health in its client countries, in line with its Country Directors to effectively support coordination comparative advantages. and to foster engagement in multisectoral activi- ties. In order to move ahead, candid discussions are needed to identify and address constraints and cre- Bringing other Partners on Board ate incentives—for example, explicit recognition and reward on cross sector work during annual evalua- As the Bank examines its comparative advantages in tion of staff performance—that enable and encourage development assistance and health, it is relevant to con- the Bank’s team leaders to engage in cross-sectoral sider the shifts underway on the world stage and to collaboration. One option is to formally institute identify opportunities for tandem and harmonized devel- dual task management (by co-task team leaders). In opment to effectively improve the lives of the poor and addition, management oversight of a multisectoral vulnerable. Effective partnerships will be a key feature in portfolio should be explicitly assigned to one of the implementing the World Bank vision in public health Sector Boards, with specified roles for the other Sector over the next five years. For the Bank to be optimally Boards involved. Management endorsement and sup- effective, it needs to work with other agencies and orga- port from the highest levels will send a strong signal nizations which have complementary competencies and that this shift in mindset is explicitly recognized as a value-added roles. The Bank will also strengthen collab- new way of doing business. oration with regional banks and institutions, as well as exploring the possibility of partnering with the BRICS countries to leverage Bank resources at country level. Providing the Resource Base to The examples of China, India and Russia are a prec- Implement Actions edent. They contributed resources to the Avian and Human Influenza Facility; moreover, Russia co-financed Additional resources will be needed to support effective projects in Mozambique and Zambia on malaria control, coordination and action across sectors to support new with IDA. Such models could be replicated to advance activities. In this context, a strong resource mobilization public health at country, regional and global levels. Illustrative Examples of Ongoing World Bank Work 4 in Public Health C hapter 3 defined the main areas which the drugs for the most vulnerable and protect priority pub- World Bank will emphasize in framing its lic health measures, including immunizations, disease work on public health over the coming years. monitoring, and the prevention and control of TB, den- This chapter provides a picture of what this direction gue and other vector borne diseases. will look like in action, by examining a few high-impact examples of the Bank’s recent work in public health. Despite Argentina’s rapid recovery from the crisis, seri- These include: ous structural and systemic problems were revealed in the sector during those years, suggesting a need for �� Supporting public health reform in Argentina serious long-term reform of the country’s public health �� Providing assistance to countries on tobacco control program and an urgent need for an improved Ministry �� Strengthening risk-based governance to prevent stewardship capacity to lead and assure effective imple- zoonotic diseases mentation of programs, improve the epidemiological �� Building public health capacity for pharmaceutical surveillance structure and expand coverage of key pub- governance and regulation lic health programs such as vaccination, TB control, �� Promoting the use of economic analysis to support dengue control and others. With these improvements, public health operations the Ministry aimed to reduce important inter-provin- cial inequities, high levels of fragmentation, systemic inefficiency and a weak regulatory framework in public Supporting Public Health Reform health, which impeded timely response to the popula- in Argentina tion’s needs. The Government requested the support of the World Bank to help implement a Federal Health During the severe economic crisis that hit Argentina in Plan; this was created in agreement with the provinces, 2001–2002, the country requested the World Bank to involved a roadmap for public health reform and pri- restructure all existing Bank-financed projects in order oritized health promotion, prevention, surveillance and to create an Emergency Program (EP) to mitigate the control of communicable and NCDs. While communi- most deleterious impacts of the crisis on the poor and cable diseases were prioritized through 70 percent of the vulnerable population. Priority actions were identified as country’s initial financial efforts, NCDs were a priority being in health, education, nutrition, temporary work, in the second phase. income support and community activities. The objective of the EP in the health sector was to help the govern- Public health was reformed in Argentina. Health ment protect the most vulnerable population and to systems and specific public health programs were keep public health programs running, provide essential strengthened, focusing first on ten selected EPHF 26 Connecting Sectors and Systems for Health Results that were key for building systems and strengthen- Providing Assistance to Countries ing the stewardship role of ministries. The next step on Tobacco Control was to consider the appropriate financing of the public health package of programs and, later, the prevention Tobacco control is a well-proven strategy to reduce of NCDs. Such programs are characterized by a col- illness and mortality attributable to TB, cardio-vas- lective health interest and represent either public goods cular diseases and certain cancers, inter alia. Tobacco or goods with important health externalities such as causes an estimated seven to eight million deaths each the vaccination program. The programs included had year. It is estimated to be the number one risk fac- important synergies between them, and were chosen tor for premature death in absolute numbers, second based on evidence, with a view to an extensive long only to unsafe sex in terms of lost DALY.The WHO term investment and using a 10-year strategy to impact Framework Convention on Tobacco Control (FCTC) is Argentina’s burden of disease. The program used a the first legally binding United Nations treaty addressing results-based governance framework and impact evalu- a major public health issue. The Framework recognizes ation system. the devastating worldwide health, social, economic and environmental impacts of tobacco consumption and In 2006, with support from the Bank, Argentina ini- exposure to tobacco smoke and includes both demand tiated its first results-based public health project, using and supply measures to curb its use. a “hybrid� vertical and horizontal public health pro- gram, which was selective both in functions to be The Bank has been one of the lead organizations strengthened in the health system and in public health supporting Article 6 of the Convention, dealing programs to be implemented. The project used a per- with tobacco taxation. High taxes on tobacco prices formance-based governance and financing framework have proven to be the most cost-effective method to and an impact evaluation system for measuring proj- reduce total consumption and most importantly, to ect results. This reversed the tradition in the country stop young people from starting to smoke. HNP has where the nation could provide only inputs—like sup- strengthened its technical capacity to respond to coun- plies, medicines and vaccines—without signing specific try demand and has launched a Tobacco Control agreements for results. In 2010 and 2012, the Argentine Technical Assistance Program. Supported by Bloomberg Government and the Bank agreed to complete the Philanthropies and the US Center for Disease Control trilogy of public health projects financed in the coun- and Prevention (CDC), the Program collaborates try for a total amount of $925 million (see Box 5 in closely with WHO and other tobacco-control partners. Section 3.2.3 above). There are two overall goals: (a) to increase aware- ness among key World Bank staff about the impact of Argentina’s public health reform to date has yielded tobacco control on development; and (b) most impor- promising results on communicable as well as NCDs. tantly to support Task Teams and country counterparts The EPHF are an integral part of public health, and in the implementation of tobacco control measures. the overall program built systems and strengthened This will be achieved through a series of products the stewardship role of ministries in improving health aimed at three objectives: and quality of life. Such stewardship—including robust public health surveillance—forms the foundation of 1. Launching internal dialogue on tobacco control in a public health system by providing information on general, and specifically on tobacco taxes within the disease outbreaks and patterns. Policy-makers both at Bank. Ongoing work includes preparing country national and provincial levels, will use this information fact sheets on tobacco control for seven countries to make better decisions about the efficient and effective in the South Asia Region, as well as for Bosnia and allocation of limited resources. In addition, regulation, Herzegovina and Kyrgyzstan for PREM and HNP quality control and health insurance monitoring are key colleagues. functions that FESP I and FESP II supported in the 2. Providing technical assistance to Task Teams and country. In particular, food regulation was a key suc- country counterparts on tobacco taxes. As an exam- cess of the regulation function. ple, this includes support to PREM and HNP teams Illustrative Examples of Ongoing World Bank Work in Public Health 27 in the Philippines, carrying out analysis to back the at the animal-human-ecosystem interface. Infectious Government’s proposed law to increase tobacco and disease prevention, prompt detection, accurate diag- alcohol excise taxes. This work has incorporated nosis and rapid and effective control are needed, analysis of the tobacco market structure, the impact preferably before humans are infected. Countries may on farmers, health impact and costs, revenue gener- request Bank support to assess these core functions, ation, tax administration and prevention of illegal bridge divides among ministries and reduce capac- trade in tobacco. ity gaps. 3. Compiling, creating and disseminating new knowl- edge on tobacco tax issues that are under-researched. During the avian flu response in 2005–12, more than The Bank is working with the CDC, Johns Hopkins 120 countries worked across sectors (veterinary services, University and the WHO on assessing the impact public health disaster management, etc.). Capacities of increasing tobacco control on the consumer-price improved as medium-term needs in zoonotic disease index Work at the country level includes sup- control informed the design of many emergency pro- port to the HNP teams in Russia and the Central grams. Government staff were trained in disease-control Asian republics to mobilize resources and carry out competencies, equipment and supplies were purchased, a regional background analysis aimed at exploring disease reporting and diagnostic capacities were estab- options to strengthen tobacco control regionally, lished, simulation exercises enhanced preparedness, including through possible harmonization of tobacco compensation arrangements were made and communi- excise tax rates. cations strategies were put in place. This response also revealed substantial capacity gaps, especially in veteri- Future activities will extend these objectives. BBLs/sem- nary services. inars will focus on the relationship between tobacco and poverty, public spending, taxation and other Some countries are already addressing these gaps. The instruments. Country and regional research will be Bank has supported in-depth assessments of systems provided on the impact of tobacco and the potential in several ECA countries to implement One Health for tax increases and their impact on health, public approaches (covering veterinary and public health health spending, family spending, illegal trade and fis- systems), with considerable success in stimulating cal revenue. Key areas for knowledge creation include follow-on programs to strengthen core functions system- the impact of tobacco use on poverty and household atically. Economic analyses complemented this work and investments, the impact of tobacco taxes on health and improved communications. As more countries adopt a poverty, as well as placing an emphasis on data gener- One Health approach to strengthen their systems, global ation and analysis. performance in disease control and prevention will improve as well. Regional capacity-building programs and coordination can also be a powerful way to acceler- Strengthening Risk-Based ate progress and thus contribute to global improvements. Governance at the Animal- Human-Ecosystem Interface OIE’s Performance of Veterinary Services (PVS) tool is an assessment method already used in more than 100 Most client countries do not have the requisite sys- countries. Public health functions, including those for tems in place and are ill-equipped to prevent human international health regulations, are not yet as well-gov- infections and to mitigate the losses from exposure to erned. From FY12, the Bank, WHO, OIE and FAO diseases of animal origin. This is an example of poor are working on system assessment tools for human governance and poses insidious public health risks, health and environmental disease risks; these tools poverty impacts, economic costs and potentially cat- will dovetail with the PVS. Pilots in several countries astrophic consequences in the case of a pandemic. will test operationality, especially for formulating pri- Prioritizing core public health functions is required, oritized investment plans (PVS is already tested). The especially those that reduce infectious disease risks. The Bank’s methodology for cost-benefit analysis makes greatest risks that therefore warrant particular care arise explicit the toll of zoonotic diseases, so as to inform 28 Connecting Sectors and Systems for Health Results communications with the public and policy makers. regulatory functions. Public health will be improved Official ownership of the WHO and OIE tools will by reducing the time it takes to register essential med- provide credibility and comparability. Countries could icines and better ensuring good quality products reach undergo periodic reassessments and achievements could the marketplace. be used by the Bank as indicators for P4R operations. Working with partners, the Bank would provide tech- In the longer term, harmonization of other regulatory nical assistance to governments to prepare programs functions and the development of regional author- based on the assessment results and mobilize the req- ities (similar to the EU model) can take over more uisite financing. complex activities. The AMRH initiative is led by the World Bank in consultation with the New Partnership Attention to building systems for core functions and for Africa’s Development (NEPAD) and WHO. The policy dialogue, based on credible assessments, rigorous Bank takes the lead on fiduciary oversight and over- analysis and adequate financing, will ensure sustain- all project management. NEPAD ensures support for ability and reduce disease risks. Specific disease-control regional project development and continent-wide coor- initiatives (e.g., brucellosis, rabies, avian flu, antimi- dination and WHO provides expert technical assistance. crobial resistance (AMR) and foot and mouth disease Meanwhile, The Bank has launched a multiple stake- (FMD)) would be a natural part of system-strengthen- holder forum on regulatory issues globally; this includes ing country programs, with coverage based on country donor organizations, regulators, the generics and innova- priorities. These initiatives will not only yield concrete tor pharmaceutical industry and associations. results, but also demonstrate the performance of systems in disease control and prevention. The East African Medicines Regulatory Harmonization Project is an example of strengthening capacity on gov- ernance and stewardship. Launched in March 2012 it Pharmaceutical Governance and is the first project to be financed from the Trust Fund. Regulation: Building Public Health The National Medicines Regulatory Agencies, the Capacity EAC secretariat, WHO, NEPAD and other partners involved in project implementation have been working Strengthening governance, regulations and accountabil- to move the project forward. The EAC Project Steering ity in the pharmaceutical sector are important aspects of Committee will oversee project operational activities health systems that lead to more competitive markets, in the region. Project components include: regional economic growth, improved access to new medicines, coordination and capacity building and institutional better quality of pharmaceuticals in circulation and ulti- development and strengthening of National Medicines mately better health outcomes. Regulatory Authorities. The Multi-Donor Trust Fund for the Global Work in other regions will provide an analysis of regula- Medicines Regulatory Harmonization (GMRH) tory functions and a discussion of options to strengthen Project, established by the World Bank in 2011, falls their capacity in order to become more compatible with under the HDNHE program, which focuses on phar- each other and with the emerging global standard. The maceutical governance and regulation. The overall Bank has allocated $500 thousand to regions outside of project goal for GMRH is to promote the harmoni- Africa to conduct exploratory work on medicines regu- zation of medicine regulation as a means to increase lation issues of relevance. patient access to safe, effective and good-quality essen- tial medicines. The Africa arm of the project, the Full harmonization of regulatory functions all over African Medicines Regulatory Harmonization Project Africa is a far-off vision that may take a generation (AMRH) focuses on medicine registration and the and a significantly larger budget to accomplish. With development and implementation of technical docu- initial progress on the regional level over the next ments, systems and partnerships at a regional level to five years, however, there is likely to be support from increase the quality, transparency and predictability of other sources of funding. The hope is that AMRH can Illustrative Examples of Ongoing World Bank Work in Public Health 29 provide a model for similar initiatives and a conven- cost, economic analysis will focus on collecting the evi- ing platform for learning and trust building, even if it dence to guide policy making. is not directly involved as a funding source. At a meet- ing on global pharmaceutical policy challenges and The proposal is (i) to review the evidence from current opportunities hosted by the Bank in June 2012, the literature that identifies promising examples of syner- Bank was requested to use its convening power to fur- gies that can be harnessed and (ii) conduct country ther the global dialogue on regulatory harmonization case studies to estimate the expected costs and benefits issues, including the contributions of competent regu- of implementing such activities, examining the coun- latory authorities. try-level implications of promoting such interventions, including an estimate of the likely cost-effectiveness compared with existing delivery models. The case stud- Promoting the Use of Economic ies will be conducted in a limited number of countries Analysis to Support Public Health to examine how existing health service delivery plat- forms servicing mainly the MDGs can be leveraged Operations to further strengthen interventions to address NCDs, A strong emphasis on economic analysis is a key com- assessing potential linkages in terms of delivery models, parative advantage of the World Bank. Its expertise infrastructure, information systems, human resources enables it to advise policy makers on areas such as and the supply chain, etc. health economic analyses on prioritization and resource allocation, return-on-investment, the economic impact Further extensions of this work are being envisaged of disease and injury, benefit-incidence and fiscal and to strengthen the Bank’s presence in economic analy- financial sustainability. sis in public health and NCDs in particular and will focus on expanding the scope of the current study to In this context, an important activity is currently additional countries. This might include, for instance, being developed to foster synergies between NCDs and (i) refining and complementing the estimation of mar- the MDGs and craft responses to both agendas in a ginal costs, (ii) conducting extensive cost-effectiveness resource-constrained environment. As became clear dur- and resource allocation analyses to advise countries on ing the recent UN High Level Meeting on NCDs (UN how best to shape their national service delivery plat- 2011a), country policy makers are seeking advice on forms to improve efficiency and achieve superior health prioritizing policies that can help advance the response outcomes at low cost and (iii) assessing more explic- to both agendas. To identify areas of common ground itly how to deal with the trade-offs that inherently can where effective actions can be undertaken to reinforce be found in the allocation of scarce resources in the both agendas at zero or negligible marginal incremental health sector. Conclusion E fforts to advance public health in the 21st cen- Under the second pillar, assisting client countries in mak- tury will take place against the backdrop of ing cost effective decisions to address the dual challenge of major shifts in the global landscape. More than MDGs and NCDs, the work will initially focus on pro- ever, strong coordination among key stakeholders at the moting synergies that can address both MDGs and global and country levels will be imperative to avoid NCDs at the level of primary health care service delivery, duplication and provide countries with the tailored at little marginal cost. In the medium to longer term, support they need—both to keep ahead of their major further analytic work will be conducted on health ser- public health threats in a time of major global change, vice delivery system adaptation at all levels of health care. and to face the MDGs/NCDs “tiger with two heads.� Indeed, the health care model will need to evolve from As a key multilateral development institution, the World its current structure—organized around acute episodes Bank will advance its work in public health by focus- of illness—to one adapted to address NCDs through an ing primarily on three pillars of action that build on its integrated approach that ensures continuity of care. comparative advantages. The key actions under the third pillar, strengthening gov- Under the first pillar, fostering multisectoral interventions ernance and leadership to address public health challenges, to maximize results on investments in health, some of the include supporting client countries’ capacity to perform the key proposed actions include designing and testing an essential public health functions, supported in this effort Multisectoral Constraints Assessment (MCA) tool to by the establishment of NPHIs, or similar institutions improve health results, exploiting windows of opportunity adapted to local contexts. Further actions include assisting to promote actions across sectors, and assisting country task team leaders in integrating public health compo- clients in implementing actions aimed at mitigating the nents in future operations; and promoting interfaces across major NCDs risk factors. The MCA tool will provide a human, animal and ecosystems and different disciplines. methodology for leveraging investments in non-health sectors, assisting the public health community to engage The Bank’s work under each of the pillars will be sup- early in country assistance strategy (CAS) discussions with ported by a cross-cutting theme that calls for vigorous country directors and country teams. It will also guide efforts to generate the economic evidence to inform the dialogue with policymakers at country level on this the formulation of effective public health policies and important topic. The tool can thus be a powerful cata- programs. This will be coupled with knowledge man- lyst for a shift in mindset for improving health outcomes. agement activities to ensure this knowledge is translated Furthermore, many of the risk factors driving the growing and adapted to local contexts. epidemic of NCDs in developing countries can be mit- igated by actions by non-health sectors, such as tobacco Moving forward, the Bank will use its various lending taxation and reduction of salt and fat in foods. Such and analytical instruments to implement the set of actions work could also provide useful case studies to inform the identified above in order to: (i) support client countries knowledge agenda of the Bank on multisectoral actions. in making the greatest possible improvement and sound 32 Connecting Sectors and Systems for Health Results investments in public health; (ii) strengthen its role as a Translating this vision into reality as the Bank’s opera- key knowledge broker by generating, disseminating, and tional work will require a strong institutional mandate, translating knowledge in its areas of comparative advan- backed by equally strong leadership. The full promise tage; and (iii) contribute to shaping public health policies of multisectoral action in health is unlikely to be met in the international arena. In a nutshell, the strategic unless effective mechanisms to break silos are identified framework described in this document is aligned with and implemented. Indeed, working effectively across the vision of World Bank’s President Jim Y. Kim of turn- sectors will require an enabling environment, which ing the institution into the “Solutions Bank� by providing provides the right incentives and adequate resources for client countries with evidence-based policies and interven- staff across sectors to engage actively in this new way tions to improve health outcomes. of doing business. References Acheson, Sir Donald. 1988. Independent inquiry into Caldwell, J. and P. McDonald. 1982. “Influence of inequalities in health report. The Stationary Office, maternal education on infant and child mortal- London. ity: levels and causes.� Health Policy Educ 2 (3–4): Babinard J. and P. Roberts. 2006. “Maternal and Child 251–67. Mortality Development Goals: What Can the CDC (Centers for Disease Control and Prevention). Transport Sector Do?� Transport Paper 12, World 2010. “Ten Great Public Health Achievements Bank, Washington, DC – Worldwide, 2001–2010.� MMWR 60 (24): Baeza, C., S. Lim, R. Lakshminarayanan, E. Gakidou, 814–818. A. Fidler, and C. Murray. 2011. “Accountability Childinfo. 2012. http://www.childinfo.org/ for impact of Investments in Development Claeson, M., C.C. Griffin, T.A. Johnston, M. Assistance for Health: a health systems approach McLachlan, A.L. Soucat, A.Wagstaff, and A.S. to lives saved estimations.� Technical Discussion Yazbeck. 2001. “Poverty Reduction and the Health Document, World Bank, Washington. DC and Sector.� In Poverty Reduction Strategy Sourcebook, Institute for Health Metrics and Evaluation, ed. J. Klugman. Washington D.C.: World Bank. University of Washington, Seattle. Costain J. and A. Weitz. 2012. “Integrating Hygiene Bengston, L., L. Xin, A. Thorson, R. Garfield, and and Basic Sanitation into Conditional Cash J. von Schreeb. 2011. “Improved Response to Transfer Programs.� Presented at the World Disasters and Outbreaks by Tracking Population Water Week 2012, “Water and Food Security,� Movements with Mobile Phone Network Data: A Stockholm, August 26–31. Post-Earthquake Geospatial Study in Haiti.� PLoS Cotlear, D. 2011. Population Aging: is Latin America Med 8 (8): e1001083. Ready. Directions in Development Series. Brown, D. “New Burden of Disease study shows Washington, D.C.: World Bank. world’s people living longer but with more dis- Engelgau, M., S. El-Saharty, P. Kudesia, V. Rajan, S. ability.� Washington Post , December 13, 2012. Rosenhouse, and K. Okamoto. Capitalizing on the Accessed December 13, 2012. http://www. Demographic Transition: Tackling Noncommunicable washingtonpost.com/national/health-science/ Diseases in South Asia. Washington, D.C.: World burden-of-disease-study-shows-a-world-living-lon- Bank. ger-and-with-more-disability/2012/12/13/9d1e527 Frenk, J. 2011. “Strengthening Health Systems to 8-4320-11e2-8061-253bccfc7532_story.html. address NCDs.� Speech at First Plenary Session, Burns, A., D. van der Mensbrugghe, and H. Timmer. First Global Ministerial Conference on Healthy 2008. “Evaluating the Economic Consequences Lifestyles and Noncommunicable Disease Control, of Avian Influenza.� Development Economics Moscow, April 28–29. Department Paper, World Bank, Washington, DC. Frieden, T.R. and J.P. Koplan. 2010. “Stronger National Business Warehouse (database). World Bank, Public Health Institutes for Global Health.� Lancet Washington, D.C. 376 (9754): 1721–1722. 34 Connecting Sectors and Systems for Health Results GHSi (Global Health Strategies initiatives). 2012. Lvovsky, K. 2001. “Health and Environment.� Shifting Paradigm: How the BRICS are Reshaping Environment Strategy Papers No. 1, World Bank, Global Health and Development, by Brad Tytel, Washington, D.C. Katie Callahan, Chandni Saxena et al. Durban. Meiro-Lorenzo, M., T. Villafana, and M. Harrit. 2011. Global Polio Eradication Initiative (GPEI). http://www. “Effective Responses to Non-communicable polioeradication.org/ Diseases.� Health, Nutrition, and Population Grace, D. 2012. “Zoonoses: The Lethal Gifts of Discussion Paper, World Bank, Washington, DC. Livestock.� Presented at the International Livestock Merrick, T., A. Goldman, A. Yazbeck, and Research Institute (ILRI) Livestock Live Seminar, A.Couffinhal. Forthcoming. Health in all theRight Nairobi, October 31. Places: Supporting Health and the Health Gunther, I. and F. Gunther. 2010. “Water, Sanitation Murray, C.J.L., B. Anderson, R. Burstein, K. Leach- and Children’s Health: Evidence from 172 DHS Kemon, M. Schneider, A. Tardif, and R. Zhang. Surveys.� Policy Research Working Paper 5275, 2011. “Development Assistance for Health: World Bank, Washington, D.C. Trends and Prospects� Lancet 378: (9785) 8–10. Hogan, M.C., K.J. Foreman, M. Naghavi, S.Y. Ahn, Murray C.J.L., T. Vos, R. Lozano, M. Naghavi, A.D. M. Wang, S.M. Makela, A.D. Lopez, R. Lozano, Flaxman, C. Michaud et al. 2012. “Disability- and C.J.L. Murray. 2010. “Maternal mortality adjusted life years (DALYs) for 291 diseases and for 181 countries, 1980-2008: a systematic anal- injuries in 21 regions, 1990-2010: a systematic ysis of progress towards Millennium Development analysis for the Global Burden of Disease Study Goal 5.� Lancet 375: (9726) 1609–1623 2010.� Lancet 380: (9859) 2197–2223. IANPHI (International Association of National Public Nikolic I., A. Stanciole, and M. Zaydman. 2011. Health Institutes). 2007. “Framework for the “Chronic Emergency: Why NCDs Matter.� Creation and Development of National Public Health, Nutrition, and Population Discussion Health Institutes.� Technical and Policy Briefs Paper, World Bank, Washington, DC. Number 1, Atlanta. PlusNews. 2009. Africa: Text Messages Highlight Drug IHME (Institute for Health Metrics and Evaluation). Stock-outs. IRIN News, September 17. http:// 2011. Financing Global Health 2011: Continued www.plusnews.org/ Growth as MDG Deadline Approaches. IHME PlusNews. 2010. Global: Seven Strategies for Smarter Report, Seatlle. HIV Programmes. IRIN News, July 22. http:// Katz, R.L., J.A. Fernandez, and S.J.N. McNabb. www.irinnews.org/ 2010. “Disease Surveillance, Capacity Building Ravishankar, N., P. Gubbins, R.J. Cooley, K. Leach- and Implementation of the International Health Kemon, C.M. Michaud, D.T. Jamison, and Regulations (IHR[2005]).� BMC Public Health 10 C.J.L. Murray. 2009. “Financing of Global (Suppl 1):S1. Health: Tracking Development Assistance for Katz, R. and J. Fischer. 2010. “The Revised Health from 1990 to 2007.� Lancet 373 (9681): International Health Regulations: A Framework 2113–2124. for Global Pandemic Response.� Global Health Rio+20 Conference (United Nations Conference on Governance Vol. 3 No. 2, Stimson Center, Sustainable Development). 2012. Conference Washington, D.C. focus on “ Green Economy in the Context of Krug, E., ed. 1999. Injury: A Leading Cause of the Sustainable Development and Poverty Eradication, Global Burden of Disease. Geneva: World Health and the Institutional Framework for Sustainable Organization. Development,� Rio, June 20–22. Lister, G. 2000. “Global Health and Development: Smets S. 2012. “Promising Approaches and Tools for The Impact of Globalisation on the Health of Reaching the Poor. Presentation.� Presented at Poor People.� White Paper on Eliminating World the World Water Week 2012, “Water and Food Poverty: Making Globalisation Work for the Security,� Stockholm, August 26–31. Poor, Department for International Development, Thailand, Department of Highways. 2007. The Study of London. Traffic Accident Cost in Thailand, Bangkok. References 35 UN (United Nations). 2011a. High-level Meeting ———. 2011b. The World Bank Annual Report 2011: on Non-communicable Diseases. New York, The Year in Review. Washington, D.C.: World Bank. September 19–20. http://www.un.org/en/ga/pres- ——— . 2011c. Toward a Healthy and Harmonious ident/65/issues/ncdiseases.shtml Life in China: Stemming the Rising Tide of Non- ———. 2011b. World Urbanization Prospects: The 2011 Communicable Diseases, by East Asia and Pacific Revision, by the Department of Economic and Region. Human Development Unit Report, Social Affairs/Population Division. Report ST/ Washington, D.C. ESA/SER.A/322, New York. ———. 2011d. Towards One Health: Interim Lessons UNICEF (United Nations International Children’s from the Global Program on Avian and Human Emergency Fund). 2012. “Water, Sanitation and Pandemic Influenza , by Agriculture and Rural Hygiene.� Press Release, May 26 (Updated 2012) Development Department and the Human USDHHS (United States Department of Health and Development Network, Washington, D.C. Human Services). n.d. Community Health Data ———. 2012. People, Pathogens and Our Planet, Volume Initiative. Washington. http://www.hhs.gov/open/ 2: The Economics of One Health, by Agriculture plan/opengovernmentplan/initiatives/initiative.html and Rural Development Unit. Report No. 69145- Veneman, A.M. 2007. “Education is Key to Reducing GLB, Washington, D.C. Child Mortality: the Link between Maternal World Bank Global Road Safety Facility. http://web. Health and Education.� UN Chronical, Volume worldbank.org/WBSITE/EXTERNAL/TOPICS/ XLIV Number 4, WHO, Geneva. EXTTRANSPORT/EXTTOPGLOROASAF/0,,m WDI dataBank (World Development Indicators data- enuPK:2582226~pagePK:64168427~piPK:64168 base). World Bank, Washington, D.C. http://data. 435~theSitePK:2582213,00.html worldbank.org/ World Bank Projects and Operations Portal. 2012. World Bank. n.d. “Economics of Adaptation to Climate http://www.worldbank.org/projects Change,� World Bank, http://climatechange.world- WHO (World Health Organization). 2011a. Global bank.org/ Status Report on Noncommunicable Diseases 2010. ———. 1999. Curbing the Epidemic: Governments and WHO Report, Geneva. the Economics of Tobacco Control. Development in ——— . 2011b. World Malaria Report 2011. WHO Practice Series. Washington D.C.: World Bank. Report, Geneva. ——— . 2002 Public Health and World Bank ———. 2012a. “Antimicrobial Resistance.� Fact sheet Operations . Health, Nutrition, and Population No. 194, March. Series. Washington, D.C.: World Bank. ——— . 2012b. “Road traffic injuries.� Fact sheet ———. 2007. Healthy Development: The World Bank’s N°358, September. Strategy for Health, Nutrition, and Population. ——— . 2012c. “Second Report of Committee A Health, Nutrition, and Population Report, (draft).� Report prepared for the 65th World Washington, D.C. Health Assembly.Geneva, May 21–26. ———. 2009a. Confronting “Death on Wheels�. Making WHO Decade of Action for Road Safety 2011-2020: Roads Safe in Europe and Central Asia, by P. global launch. 2011. http://www.who.int/road- Marquez, G. Banjo, E. Chesheva, and S. Muzira. safety/publications/decade_launch/en/index.html World Bank Report, Washington, D.C. WHO Global Health Observatory Data Repository. ——— . 2009b. Implementation of the World Bank’s 2011. Cause-specific mortality, 2008: LMIC coun- Strategy for Health, Nutrition and Population tries by WHO region (datafile). WHO, Geneva Results: Achievements, Challenges, and the (updated May 2011). http://apps.who.int/gho/ Way Forward – Progress Report 2009. Health, data/?theme=main#. Nutrition, and Population Report, Washington, WHO and Carter Center. 2008. “Integrated Control D.C. of the Neglected Trocpical Diseases: a neglected ——— . 2011a. “Avian Flu Resurgence R aises opportunity ripe for action.� Presented at the Concern in A sia, Middle East.� News & Global Health and the United Nations Meeting, Broadcast, March 10. Atlanta, May 8–9. 36 Connecting Sectors and Systems for Health Results WHO and UNICEF (United Nations Childrens Fund). Yazbeck, A. 2012. “What can we learn from 22 years & 2005. Water for Life: Making it Happen, by the $16 billion of Lending for Health through Non- Joint Monitoring Programme for Water Supply Health Projects and Can we do better?� Presented and Sanitation. Geneva. at the HNP Learning Program, “Health Insurance and Financing Seminar Series,� Washington, D.C., September 26. Annex 1: What is Public Health? Concepts and Activities Embraced Public Health Categories and by the Field of Public Health Examples of Functions �� Emphasis on collective responsibility for health and 1. Policy development the prime role of the state in protecting and pro- moting the public’s health �� Public health regulation and enforcement �� Focus on whole populations �� Evaluation and promotion of equitable access to �� Emphasis on prevention, especially primary necessary health services prevention on population-wide basis �� Ensuring the quality of personal and population- �� In addition to prevention, control of disease based health services �� Addressing the risk factors as well as the underlying �� Health policy formulation and planning socioeconomic determinants of health and disease �� Financing and management of health services �� Multidisciplinary and intersectoral �� Pharmaceutical policy, regulation and enforcement �� Partnership with the populations served �� Collection and dissemination of evidence for public health policies, strategies and actions 2. Collecting and disseminating evidence for �� Policy development public health policies, strategies and actions �� Human resource development and capacity building for public health �� Health situation monitoring and analysis �� Research, development and implementation of While the responsibility for public health is normally innovative public health solutions governments, NGOs, the community and the private �� Provision of information to consumers, providers, sector can all play a role, especially where government policymakers and financiers has no or low capacity. �� Health information and management systems �� Research and evaluation Source: The American Public Health Association, cited in Public Health and World Bank Operations, World Bank, 2002. Adopted from Financing of Essential Public Health Functions in Mexico, 1997. 38 Connecting Sectors and Systems for Health Results 3. Prevention and control of disease and sanitation, vector control in infrastructure, man- agement of medical wastes, tobacco control including �� Surveillance and control of risks and damages in taxation and school health/education public health �� Management of communicable and non-communi- cable diseases 5. Human resource development and �� Health promotion capacity building for public health �� Behavior change interventions for disease preven- tion and control �� Development of policy, planning and managerial �� Social participation and empowerment of citizens capacity in health �� Human resources development and training in �� Reducing the impact of emergencies and disasters public health on health �� Community capacity building Source : World Bank. 2002 Public Health and World 4. Intersectoral action for better health Bank Operations . Health, Nutrition, and Population Series. Washington, D.C.: World Bank. �� Includes the impact on health from environmental protection, road safety, indoor air pollution, water Annex 2: Essential Public Health Functions Identified by PAHO/ CDC/WHO  ealth Situation Monitoring 1. H  urveillance, Research and 2. S and Analysis Control of Risks and Damages in Public Health Examples: Examples: �� Up-to-date evaluation of the country’s health situation and trends and their determinants, with �� The capacity to conduct research and surveillance on special emphasis on identifying inequities in risks, epidemic outbreaks and patterns of communicable threats and access to services. and non-communicable diseases, accidents and expo- �� Identification of the population’s health needs, sure to toxic substances or environmental agents including assessment of health risks and the demand harmful to health. for health services. �� A public health services infrastructure designed to �� Management of the vital statistics and the specific conduct population screenings, investigate cases and situation of groups of special interest or at greater perform epidemiological research in general. risk. �� Public health laboratories with the capacity to �� Generation of useful information to evaluate the conduct rapid screening and process a high volume performance of the health services. of tests needed to identify and control emerging �� Identification of extra-sectoral resources to support threats to health. health promotion and improvements in the quality �� The development of active programs for of life. epidemiological surveillance and control of infec- �� Development of technology, experience and tious diseases. methodologies for the management, interpretation �� The capacity to develop links with international and communication of information to those respon- networks that permit better management of relevant sible for public health (including actors from outside health problems. the sector, health care providers and citizens). �� Preparedness of the national health accounts (NHA) �� Creation and development of agencies to evaluate the to mount a rapid response to control health problems quality of the data collected and analyze it correctly. or specific risks. 40 Connecting Sectors and Systems for Health Results 3. Health Promotion �� Reporting and lobbying government authorities concerning health priorities, particularly those that Examples: depend on improvements in other aspects of the standard of living. �� Community health promotion activities and devel- opment of programs to reduce risks and threats to health with active citizen participation.  evelopment of Policy, 5. D �� Strengthening of the inter-sectoral approach to make Planning and Managerial promotion activities more effective, especially those Capacity to Support Efforts in designed for the formal education of young people Public Health and the Steering and children. �� Empowerment of citizens to change their own life- Role of the National Health styles and become actively involved in changing Authority community habits and demand that the responsible Examples: authorities improve environmental conditions to facilitate the development of a “culture of health�. �� The development of political decisions in public �� The implementation of activities aimed at making health through a participatory process at all levels citizens aware of their rights in health. that is consistent with the political and economic �� The active participation of health services personnel context in which the decisions develop. in the development of educational programs �� Strategic planning on a national scale and support in schools, churches, workplaces and any other for planning at the subnational levels. organizational setting where information on can be �� Definition and refinement of public health conveyed. objectives, which should be measurable, as part of the strategies for continuous quality improvement. �� Evaluation of the health care system to develop a  ocial Participation and 4. S national policy that protects health services delivery Empowerment of Citizens in with a public health approach. Health �� Development of codes, regulations and laws to guide public health practice. Examples: �� Definition of national public health objectives to support the steering role of the Ministry of Health �� Facilitation of participation by the organized com- or its equivalent, in terms of setting objectives and munity in programs for the prevention, diagnosis, priorities for the health system as a whole. treatment and rehabilitation of health. �� Management of public health in terms of the �� Strengthening of inter-sectoral partnerships with civil process of constructing, implementing and society that make it possible to utilize all the human evaluating organized initiatives to address public capital and material resources available to improve health problems. the health status of the population and promote �� Development of competencies in evidence- environments that foster healthy lives. based decision-making that incorporate resource �� Support through technology and experience for management, leadership capacity and effective developing networks and partnerships with organized communication. society for health promotion. �� Quality performance of the public health system �� Identification of community resources that collabo- resulting from successful management that can be rate in promotional activities and in improving the demonstrated to the providers and users of such quality of life, enhancing their power and capacity services. to influence the decisions that affect their health and their access to adequate public health services. Annex 2: Essential Public Health Functions Identified by PAHO/CDC/WHO 41 6. Public Health Regulation and �� Close collaboration with governmental and nongov- ernmental agencies to promote equitable access to the Enforcement necessary health services. Examples: �� Development and enforcement of sanitary codes  uman Resources Development 8. H and/or standards to control of health risks related and Training in Public Health to the quality of the environment; accreditation and quality control of medical services; certification of Examples: the quality of new drugs and biologicals (medicinal preparations made from living organisms and their �� The education, training and evaluation of the public products, including serums, vaccines, antigens, anti- health workforce to identify the need for public toxins, etc.) for medical use, equipment, or other health services and health care, efficiently address technologies; and any other activity that involves priority public health problems and adequately compliance with laws and regulations geared to pro- evaluate public health actions. tecting public health. �� The definition of licensure requirements for health �� The creation of new laws and regulations aimed at professionals in general and the adoption of pro- improving health and promoting healthy environ- grams for continuous quality improvement in the ments. public health services. �� Consumer protection as it relates to the health �� The formation of active partnerships with programs services. for professional development to ensure that all stu- �� Carrying out all these regulatory activities properly, dents have relevant public health experience and consistently, fully and in a timely manner. receive continuing education in management and leadership development in public health �� Capacity-building for interdisciplinary work in pub-  valuation and Promotion of 7. E lic health. Equitable Access to Necessary Health Services  nsuring the Quality of 9. E Examples: Personal and Population-Based Health Services �� The promotion of equitable access to health care. This includes the evaluation and promotion of Examples: effective access by all citizens to the health services they need. �� Promoting permanent systems for quality assurance �� The evaluation and promotion of access to the and the development of a system for monitoring the necessary health services through public and/or pri- results of evaluations made through those systems. vate providers, adopting a multisectoral approach �� Facilitating the development of the basic standards that makes it possible to work with other agencies required for a quality assurance system and super- and institutions to resolve inequities in the utiliza- vising the compliance of service providers with this tion of services. obligation. �� The execution of activities aimed at overcoming bar- �� A health technology assessment system that sup- riers in access to public health interventions. ports the decision-making process for the entire �� Facilitating the linkage of vulnerable groups to the health system. health services (without including the financing for �� Use of the scientific method to evaluate health inter- this care) and to health education, health promotion ventions of varying degrees of complexity. and disease prevention services. �� Use of this system to improve the quality of the direct delivery of health services. 42 Connecting Sectors and Systems for Health Results  esearch, Development and 10. R  educing the Impact of 11. R Implementation of Innovative Emergencies and Disasters on Public Health Solutions Health Examples: Examples: �� The continuum of innovation, which ranges from �� The planning and execution of public health the efforts of applied research to promote changes activities in prevention, mitigation, preparedness, in public health practice to formal scientific research. response and early rehabilitation. �� Development of the health authority’s own research �� A multiple focus that addresses the threats and etiol- capacity at its different levels. ogy of any and all possible emergencies or disasters �� Establishment of partnerships with research centers that can affect a country. and academic institutions to conduct timely studies �� Participation of the entire health system and the that support the decision-making of the NHA at broadest possible inter-sectoral cooperation to reduce all its levels and in as broad a sphere of action as the impact of emergencies and disasters on health. possible. Sources : Adapted from Pan American Health Organization (PAHO). May 2000. “National Level Instrument for Measuring Essential Public Health Functions�; Public Health in the Americas. Washington DC: PAHO/U.S. Centers for Disease Control and Prevention/Centro Latino Americano de Investigaciones en Sistemas de Salud. Annex 3: Role of Development Partners in Global Health (Non exhaustive list of UN agencies and specialized organizations working in health: their purpose or mission statement as they appear on their web page) UN Agencies and specialized agencies working in health (not an exhaustive list) Food and Agriculture Organization of FAO focus is on food production and agriculture, reflecting its specialization and responsibility the United Nations (FAO) within the United Nations family. Assisting in preventing disaster-related emergencies, provid- ing early warnings of food emergencies and helping in rehabilitation of food production systems are FAO’s predominant roles in humanitarian aid. The main forms of FAO’s intervention include needs assessments, provision of agricultural inputs and technical assistance for the planning and management of sustainable recovery and rehabilitation of rural production systems International Monetary Fund (IMF): The IMF works to foster global growth and economic stability. It provides policy advice and financ- ing to members in economic difficulties and also works with developing nations to help them achieve macroeconomic stability and reduce poverty. United Nations Development Pro- Since 1966, the UNDP has been partnering with people at all levels of society to help build nations gramme (UNDP): that can withstand crisis and drive and sustain the kind of growth that improves the quality of life for everyone. UNDP works in four main areas: poverty reduction and achieving the Millennium Development Goals (MDGs); democratic governance; crisis prevention and recovery; environment and sustainable development. UNICEF: UNICEF is mandated by the United Nations General Assembly to advocate for the protection of children’s rights, to help meet their basic needs and to expand their opportunities to reach their full potential. The World Bank Group: Our mission is to help developing countries and their people reach the goals [of the elimination of poverty and sustained development] by working with our partners to alleviate poverty. We address global challenges in ways that advance an inclusive and sustainable globalization—to overcome poverty, enhance growth with care for the environment, and create individual opportunity and hope. World Health Organization (WHO): Mission: The attainment by all peoples of the highest possible level of health. Health, as defined in the WHO Constitution, is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. World Organization for Animal Health The need to fight animal diseases at global level led to the creation of the Office International (OIE): des Epizooties through the international Agreement signed on January 25th 1924 (predates the United Nations); OIE is the intergovernmental organisation responsible for improving animal health worldwide working with six mission objective areas – 1) Transparency, 2) Scientific information, 3) International solidarity, 4) Sanitary safety, 5) Promotion of veterinary services, 6) Food safety and animal welfare. (continued on next page) 44 Connecting Sectors and Systems for Health Results (continued) Bilateral Agencies (examples, including selected centers and institutes) The Centers for Disease Control and Vision: “Health Protection…Health Equity� Mission: Collaborating to create the expertise, informa- Disease Prevention (CDC): tion, and tools that people and communities need to protect their health—through health promo- tion, prevention of disease, injury and disability and preparedness for new health threats. National Institutes of Health (NIH): NIH’s mission is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce the burdens of illness and disability. Department for International Develop- Among its key objectives, DFID set out to make global development a national priority and promote ment (DFID – Great Britain): it to audiences in the UK and overseas, while fostering a new “aid relationship� with governments of developing countries GIZ – Deutsche Gesellschaft für Inter- Mission: Further political, economic, ecological and social development worldwide, and so improve nationale Zusammenarbeit (formerly people’s living conditions. Provides services that support complex development and reform GTZ – Germany): processes Japanese International Cooperation “Inclusive development� represents an approach to development that encourages all people to Agency (JICA): recognize the development issues they themselves face, participate in addressing them and enjoy the fruits of such endeavors. Mission areas: 1) address global agenda, 2) reduce poverty through equitable growth, 3) improving governance and 4) achieving human security U.S. Agency for International Develop- Supports sustainable development: economic and social growth that does not exhaust local ment (USAID): resources; that does not damage the economic, cultural, or natural environment; that per- manently increases the cohesion and productive capacity of the society; and that builds local institutions that involve and empower the citizenry. Working in 1) Environment, 2) Population and health, 3) Democracy, 4) Broad-based economic growth and 5) Humanitarian assistance and sup- port for post-crisis transitions. Private foundations and their Mission Statements (examples) Bill and Melinda Gates Foundation Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works (BMGF): to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift themselves out of hunger and extreme poverty Rockefeller Foundation: To promote the well-being of people throughout the world. Two fundamental goals: 1) build resil- ience that enhances individual, community and institutional capacity to survive, adapt and grow in the face of acute crises and chronic stresses; and 2) promote growth with equity in which the poor and vulnerable have more access to opportunities that improve their lives Selected Partnerships and Initiatives and their mandates Global Alliance for Vaccines and Im- Mission: Saving children’s lives and protecting people’s health by increasing access to immuniza- munization (GAVI): tion in poor countries International AIDS Vaccine Initiative To ensure the development of safe, effective, accessible, preventive HIV vaccines for use through- (IAVI): out the world Global Fund on AIDS, Tuberculosis and The Global Fund is a unique, public-private partnership and international financing institution Malaria (GTATM): dedicated to attracting and disbursing additional resources to prevent and treat HIV and AIDS, TB and malaria. This partnership between governments, civil society, the private sector and affected communities represents an innovative approach to international health financing. The Global Fund’s model is based on the concepts of country ownership and performance-based funding, which means that people in countries implement their own programs based on their priorities and the Global Fund provides financing on the condition that verifiable results are achieved. International Health Partners Plus The International Health Partnership and related initiatives (IHP+) seeks to achieve better health (IHP+): results by mobilizing donor countries and other development partners around a single country-led national health strategy, guided by the principles of the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. Launched in September 2007, the IHP+ aims to better harmonize donor funding commitments, and improve the way international agencies, donors and developing countries work together to develop and implement national health plans. (continued on next page) Annex 3: Role of Development Partners in Global Health 45 (continued) Presidents Emergency Plan for AIDS PEPFAR is the U.S. Government initiative to help save the lives of those suffering from HIV/AIDS Relief (PEPFAR): around the world; it operates according to five goal areas: 1) Transition from an emergency re- sponse to promotion of sustainable country programs, 2) Strengthen partner government capacity to lead the response to this epidemic and other health demands, 3) Expand prevention, care, and treatment in both concentrated and generalized epidemics, 4) Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems, 5) Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes. Polio Eradication Initiative (PEI): The Global Polio Eradication Initiative is a public-private partnership led by national governments and spearheaded by the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF). Its goal is to eradicate polio worldwide. President’s Malaria Initiative (PMI): Launched in 2005, the President’s Malaria Initiative (PMI) is a five-year, $1.2 billion expansion of U.S. Government resources to reduce the intolerable burden of malaria and help relieve poverty on the African continent. The goal of PMI is to reduce malaria-related deaths by 50 percent in 19 countries in Africa and the Greater Mekong Subregion in Asia with a high burden of malaria by expanding coverage of four highly effective malaria prevention and treatment measures to the most vulnerable populations: pregnant women and children under five years of age. Roll Back Malaria (RBM): The RBM Partnership is the global framework to implement coordinated action against malaria. It mobilizes for action and resources and forges consensus among partners. The Partnership is comprised of more than 500 partners, including malaria endemic countries, their bilateral and multilateral development partners, the private sector, nongovernmental and community-based organizations, foundations, and research and academic institutions. Stop TB: A Partnership to lead the way to a world without tuberculosis, a disease that is curable but still kills three people every minute. Founded in 2001, the Partnership’s mission is to serve every person who is vulnerable to TB and ensure that high-quality treatment is available to all who need it. Nearly 1000 partners are a collective force that is transforming the fight against TB in more than 100 countries. The secretariat is hosted by WHO (Geneva) and seven working groups work to accelerate progress on access to TB diagnosis and treatment; research and development for new TB diagnostics, drugs and vaccines; and tackling drug resistant- and HIV-associated TB. UNAIDS UNAIDS, the Joint United Nations Programme on HIV/AIDS, is an innovative United Nations Joint United Nations Programme on HIV/ partnership that leads and inspires the world in achieving universal access to HIV prevention, AIDS treatment, care and support.� Annex 4: The World Bank’s Contribution to Public Health Lending Figure 11 • Share of HNP Commitments from HNP and Other Sectors’ Projects, Since FY02, the Bank has approved $25.0 billion in FY08 to FY12 health commitments for 785 country-specific projects in 128 countries and 29 globally- or regionally-focused 100% 90% projects across sectors. Of this amount, $7.1 billion 80% (28.5 percent) was committed for activities focused on 70% 60% public health.3 Within the Bank, health and non-health 50% 40% sectors have been actively engaged, with 40 percent (or 30% $5.5 billion) of the $13.8 billion total health commit- 20% 10% ments during the last five years being managed by other 0% FY08 FY09 FY10 FY11 FY12 sector boards, including the top five sectors by com- HNP Other Sectors mitment amount: Economic Policy, Social Protection, Social Development, Public Sector Governance, and Source: World Bank Business Warehouse, May 2, 2012. Financial and Private Sector Development. Figure 11 provides the share of other sectors’ work in health, and how it has fluctuated each year. It is important to note that, without the Bank’s commitments, a signifi- (77 percent), AFR (67 percent), and LCR (58 per- cant void would have been left. For example, the Bank’s cent), while public health makes up about 50 percent multisectoral commitment of $1.3 billion towards 72 or less in EAP, ECA, or MENA (Figure 13). As part of projects on Avian and Human Influenza (AHI) since its operational work on health, the Bank has supported 2005 constitutes a third of the global commitment over projects on malaria, HIV/AIDS, and tuberculosis. It this period (Figure 12). has also emphasized and promoted core public health functions and has augmented this with public health Among the 109 active health projects at the Bank, the gap analyses countries, policy development and country share of public health components is highest in SAR investments (Claeson 2004). 3 In this section the following themes are captured under public health: Nutrition and Food Security; HIV/AIDS; Malaria; TB; other communicable diseases; and injuries/non-communicable diseases. We recognize that there are other projects in the portfolio that address other public health aspects such as public health functions (e.g. surveillance). However, these are not included because a breakdown of projects at that level is currently unavailable. 48 Connecting Sectors and Systems for Health Results Figure 12 • Number of AHI Operations Figure 13 • Public Health in Active by Region since 2005 Health Sector Projects by Region Avian and Human Influenza Operations since 2005 Injuries/NCDs, Communicable Disease and Nutrition/Food Security $1.3 billion in World Bank commitments Component in HNP Projects/AAAs for 72 operations in 60 countries SAR 6 SAR 9 MNA 10 LCR 11 LCR 12 MNA Region 17 ECA 13 EAP ECA 14 7 AFR EAP 8 0% 10% 20% 30% 40% 50% 60% 70% 80% 12 Africa 13 Projects AAA 0 2 4 6 8 10 12 14 16 18 No. Countries No. Operations Source: Business Warehouse (database), World Bank. Data generated November 29, 2012. Source: World Bank 2011d. to enhance their knowledge. One of WBI’s key strate- Analytic and Advisory Activities gies entails the sharing of information and experiences (AAA) through short courses among development practitioners and policymakers, including South-to-South practitioner At the core of the Bank’s knowledge platform are the exchanges. The WBI continues to provide an e-course Analytical and Advisory Activities (AAAs), which comprise on Strengthening Essential Public Health Functions, the majority of the knowledge sharing service the Bank developed in 2002. provides to clients and partners. Overall, nearly 1,000 (or 10 percent) of the over 10,000 AAA products gener- ated across all sectors within the Bank between FY02 and Current Engagement Across FY12 addressed health. The steady rise in the proportion Sectors and Partnerships on of health-related AAAs within the last few years signifies Public Health the increasing demand and importance of this instrument in delivering evidence-based findings and key messages. As mentioned above, the last ten years have shown Of the 280 AAAs by health unit throughout the Bank that the Bank has the capacity to work successfully within the last five years, 26 percent focused on HIV/ across sectors. The Bank contributed to, and often led, AIDS, leading all other public health topics. intersectoral coordination at country and global levels. Examples of multisectoral collaboration include: Knowledge Sharing and �� Road Safety – HNP worked with the Transport and Dissemination Infrastructure sectors in launching the Bank’s first standalone safety project in Vietnam, as well as con- The Bank has played an active role in generating and tributing to the WHO Report on road safety. spreading knowledge on key public health issues. The �� Indoor Air Pollution – HNP worked with the health sector produced 189 Discussion Papers over the Environment and Energy sectors and supported past decade, aimed at stimulating debate and quickly operations research in the Africa, South Asia and sharing new knowledge with staff and Bank clients. East Asia Pacific regions that linked health to indoor air pollution as a contributor to respira- The World Bank Institute (WBI) provides an additional tory illnesses, cardiovascular diseases, and chronic and valuable avenue for staff and Bank clients globally heart diseases. Annex 4: The World Bank’s Contribution to Public Health 49 �� Water, Sanitation and Hygiene – HNP worked a range of strategic partnerships, the Bank has posi- with the Water, Rural and Infrastructure sectors to tioned itself as a global leader in a number of areas, launch the Public-Private Partnership on hand wash- including: ing, and conducted a review of the evidence on the effectiveness of water supply, sanitation and hygiene �� Nutrition. The Scaling Up Nutrition (SUN) interventions in improving health outcomes. Framework for Action which outlines the principles �� HIV/AIDS HNP is working with Transport, Urban for scaling up investments in nutrition was launched and Water, Energy, and other sectors. Two regional at the World Bank in April 2010. Endorsed by more projects: the Abidjan/Lagos HIV/AIDS Transport than 100 partner organizations, the SUN global Corridor Project and the Great Lakes Initiative on movement has expanded rapidly, gaining momen- HIV/AIDS Project, have developed program guides tum at global, regional and national levels. In less and materials including “The Road to Good Living,� than two years since the launch, 27 countries have a widely circulated brochure on HIV/AIDS and declared themselves to be “early riser� SUN coun- transportation planning. tries, committing to the implementation of national �� “One Health� – HNP contributed to the global plans to address under nutrition at scale (See Annex “One Health� strategy, which the World Bank, Box 2). WHO, OIE and FAO presented to ministers of �� Malaria control. The Bank is the third largest health and agriculture in 2008. This strategy empha- financier of malaria control efforts globally, after sizes prevention of pandemic diseases, nearly all of the Global Fund and the US President’s Malaria which are of animal origin, by controlling pathogens Initiative. Since 2005, the Bank has contributed at their source in livestock (see Annex Box 1). close to $1 billion of IDA and other resources (from donors such as Russia) to malaria control efforts in To further identify high impact intersectoral interven- Africa and India. The Bank is a founding member tions for the World Bank and its partners, HNP has of the Roll Back Malaria Partnership (RBM), where collaborated with other sectors as part of its At-A- its role includes assisting in donors’ harmonization Glance series fact-sheets on HNP-related issues. These efforts around national malaria control action plans are focused on key public interventions proven to be (see Annex Box 3). effective in improving health, or provide knowledge �� HIV/AIDS. The Bank serves as the current Global notes to disseminate new findings and lessons learned Coordinator for UNAIDS. In this role, the Bank from the regions, specific to the Bank’s role in health. is responsible for leading and coordinating the ten The Bank has also recently established the public health UNAIDS partners towards the goal of “Getting Community of Practice, a multisectoral forum aimed at to Zero�, or no new infections, the centerpiece of fostering synergies and actions across sectors. UNAIDS’ strategic plan. The Bank’s most valuable contribution is through its economic competence in Despite the positive examples above, the Bank has yet four service lines: namely, improving the efficiency, to fully explore its major advantage in intersectoral effectiveness, financing and sustainability of the coordination to promote a systematic shift in mindset global AIDS response. and so ensure that all sector policies are “healthy.� Most �� Tuberculosis. The Bank is a member of the STOP activities aimed at strengthening the Bank’s intersectoral TB Board and plays an important role in shaping advisory capacities, under the 2007 HNP strategy, have yet to be implemented. policies and actions globally to help achieve the objec- tive “zero TB deaths� set forth by the partnership. An Important Global Player on The Bank has also engaged in powerful public health partnerships at country level. An illustrative example is Key Public Health Actions the “One Health� approach for preparedness for and As part of its involvement in the global arena on response to emerging infectious diseases in China (see health, the World Bank has maximized the impact of Annex Box 1). its analytical and operational work. By engaging in 50 Connecting Sectors and Systems for Health Results Annex Box 1: One Health Approach for Preparedness for and Response to Emerging Infectious Diseases in China China has been a prominent hotspot for novel infectious diseases. The World Bank has been working with the Government on a series of projects since 2007 in order to assist the country in improving Highly Pathogenic Avian Influenza (HPAI) and other zoonoses prevention and control, and pre- paredness for and response to human influenza pandemic in China. So far, two phases have been completed and Phase III project will start in June 2012. The total investment from the Avian and Human Influenza Facility (a World Bank administered trust fund with contributions from the European Commission and 9 other donors) will amount to US$8.8 million. Some highlights of its three phases include: • Situation and risk assessment: a joint WB-WHO assessment on the national strategic framework for Avian and Human influenza preparedness and response was conducted in December 2005 and endorsed by the Government of China and other international organizations. • A systematic One Health approach: emphasis was put on the whole of society approach and multisectoral collaboration. In phase I, the participating sectors were only health and agriculture. In the second phase, the two sectors were joined by finance, food and water supply, elec- tricity, public security, transportation, and within the health sector—Centers for Disease Control and Prevention and health service providers. • A number of innovations have been implemented to facilitate implementation of the “One Health Approach�: • Government-led HPAI response and human influenza preparedness. A whole of society approach has been adopted by the project provinces and counties. Collaboration between health and veterinary sectors has evolved to multisectoral participation including public security, transportation, food and water supply, as well as local communities; • A number of tools have been developed: (a) influenza pandemic preparedness assessment; (b) incident response information system for evidence- based emergency management; (c) standard operating procedure for rapid response teams and supply of standardized rapid response kits; (d) risk communication tools, and modules on risk communication for government spokespersons; (e) business continuity plan for pandemic influenza and risk containment plan; (f) manual for drills and exercises; and • Joint activities such as joint training and drills that involve different sectors have been implemented. The results to date have been encouraging. By the end of Phase II, the projects have successfully contributed to the revised national avian influenza surveillance strategy, development of a free poultry compartmentalization. Collaboration and cooperation among different sectors has become a norm. A set of generic skills and competencies such as risk assessment, surveillance and field epidemiology, laboratory investigation, clinical management of severe respiratory conditions, emergency management, risk communication, and monitoring and evaluation have been built up at project provinc- es, and they have benefited the responses to cholera outbreak in Anhui and anthrax case in Liaoning provinces. In the third phase, China intends to improve collaboration on infectious diseases with neighboring countries such as Mongolia and a number of central Asia countries to further enrich the concept and practices for One Health approach. Source: World Bank, EASHH Annex 4: The World Bank’s Contribution to Public Health 51 Annex Box 2: Working across sectors to address malnutrition in South Asia: Regional Assistance Strategy for Nutrition (RAS) • The challenge of hunger and malnutrition in South Asia is multi-faceted, and requires a multi-pronged approach, including interventions for greater availability of safe and nutritious food through improved agriculture production; enhanced livelihoods for secure access; education; clean water and sanitation; women’s empowerment; social protection; and a focus on infant and child care. • Despite unprecedented economic growth during the last decade, South Asia still has one of the highest rates of undernutrition in the world. The prevalence of child stunting in the region is estimated to be 47% of under five children compared to Sub-Saharan Africa with a stunting prevalence of 39%.a • The economic and human development costs of this high burden of hunger and malnutrition in the region are too great to be ignored. Malnutrition slows economic growth and perpetuates poverty through: direct losses in productivity from poor physical status (GDP lost to malnutrition can be as high as 2–3%) and indirect losses from poor cognitive function and deficits in schoolingb (productivity losses to individuals have been esti- mated at more than 10% of lifetime earnings) • To address hunger and malnutrition in South Asia, the World Bank South Asia Regional Management Team adopted nutrition as a regional priority and formulated a Regional Assistance Strategy for Nutrition (RAS) 2010–2015. The objective of the RAS is to expand the scale, scope and impact of the region’s work program on nutrition, while building SAR Bank staff’s as well as the clients’ commitment to, and capac- ity for, a multi-sectoral response to the nutrition crisis in the region. • RAS is expected to meet its objective through achieving four key results: (1)improved awareness and commitment by Bank and clients to addressing maternal and child nutrition; (2) increased World Bank lending for operations aimed at improving maternal and child nutrition; (3) increased World Bank funding/management of analytical work to address knowledge gaps in maternal and child nutrition; and (4)successful implementation of a multi-sectoral convergence model project aimed at improving child nutrition indicators. • Under the RAS, the South Asia Food and Nutrition Security Initiative (SAFANSI) was established in 2010 as a multi-donor trust fund by a joint undertaking of the World Bank, AusAID, and DFID. SAFANSI was formed with the recognition that ending the South Asia Enigma­­ — how chronic malnutrition remains intractable despite high economic growth —will take wide-spread reform and innovation in policies and programs. SAFANSI has the objective of fostering the cross-cutting actions that will lead to measurable improvements in food and nutrition security. a Table 2: Nutrition, The State of the World’s Children 2012. b Repositioning Nutrition as Central to Development: A Strategy for Development, 2006, The World Bank, Washington DC. 52 Connecting Sectors and Systems for Health Results Annex Box 3: The World Bank Involvement in Malaria Control: Delivering Results The World Bank is the third largest financier of malaria control globally, after the Global Fund and the U.S. President’s Malaria Initiative. Overall, the World Bank has committed close to $1 billion to malaria control: • In Africa from 2005 to 2011, the Bank committed $772.8 million to the fight against malaria in 20 countries—more than a ten-fold increase since 2000–2005. This financing helped support, among other activities, 73.8 million insecticide-treated mosquito nets (ITN) and 25.3 million doses of effective malaria medication. • In India, the Bank has allocated close to $190 million to malaria control efforts as part of a broader vector control project, and has financed 6.1 million ITN, as well as a substantial amount of rapid diagnostic tests and effective drugs. The Bank uses a two-pronged approach to support malaria control efforts: first, by scaling up effective interventions and second, by strengthening aspects of systems, for example related to supply chain, human resources, and monitoring and evaluation. The Bank has successfully leveraged its IDA resources to bring non-traditional donors to the fight, including the Russian Federation, which has co-financed World Bank malaria control ac- tivities ($16 million) in Zambia and Mozambique. The Bank’s malaria strategy also extends to sectors other than health. For example, a $42 million malaria program covering the Senegal River Basin (including Senegal, Mali, Mauritania, and Guinea) was embedded in a larger Water Resource Development Project covering the same countries. Likewise, in D.R. Congo, the Bank financed $13 million for the purchase of mosquito nets as part of an Emergency Urban and Social Rehabilitation Project. Through a grant from the Exxon Mobil foundation, the Bank has worked with countries to strengthen monitoring and evaluation capacity and conduct surveys to monitor progress and identify bottlenecks. Additionally, the Bank has launched evaluation work on the impact on malaria in Kenya and Senegal (school-based programs); Nigeria (impact of community distributors’ and patent vendors’ training); and India (improving malaria control outcomes through evidence-based, program design). Results include: • Rwanda: Bank support has led to a 63 percent increase in the use of ITNs; a 62 percent decrease in malaria incidence; and a 30 percent de- crease in child mortality • Ethiopia: 90 percent of children under five slept under ITNs in 2010, compared to 5 percent in 2003 • Zambia: The annual number of malaria deaths in the country decreased by 50 percent in 2000–2008, during which period the population rose by 30 percent, thus amounting to a reduction in the death rate of over 60 percent. These outcomes contributed to the reductions in the mor- tality of under-fives (29 percent) and infants (26 percent) observed between 2002 and 2007. During the years 2006–2008 (when IDA was a major financier of the National Malaria Control Program), under-five malaria deaths decreased from 3,235 to 2,680 (17 percent), indicating sig- nificant progress toward achieving the health-related Millennium Development Goals • Sierra Leone: • ITN Ownership – Household ownership of at least one ITN increased from 33 percent in 2010 to 87 percent in June 2011 • ITN Use – 68 percent of all household members slept under an ITN the night preceding the survey Source: World Bank 2012 Annex 5: Ten Notable Achievements in Public Health I n an exercise published by the U.S. Centers for in cases. Polio eradication efforts have reduced the Disease Control and Prevention, (CDC2010) a number of endemic countries to Pakistan, Nigeria, panel of experts was asked to nominate the most Afghanistan and India. New vaccines for the agents notable achievements of global public health over the which cause pneumonia, diarrhea, meningitis and first decade of the millennium. The ten items highlight cervical cancer (amongst others) are increasingly these achievements but also reveal the considerable gaps available and financed. Despite this, significant gaps that remain: remain in coverage in many of the poorest coun- tries and WHO estimates that 1.5 million children 1. Reductions in child mortality. Global under-five die yearly from diseases preventable by vaccines. mortality has dropped by 40 percent since 1990 3. Access to safe water and sanitation. The availabil- from 87 deaths per 1,000 live births to 53 per ity of clean drinking water has virtually eliminated 1,000 live births in 2010 (World Development water-borne diseases such as typhoid and cholera Indicators, World dataBank, World Bank), mostly in the developed world. However, much remains thanks to simple public health interventions—micro- to be done in low and middle income countries nutrient supplementation, immunization, safe water, (LMIC)—diseases spread by inadequate water, san- sanitation and insecticide-treated bed nets—and to itation and hygiene remain the second leading highly cost-effective therapies such as oral rehydra- cause of infant mortality worldwide (CDC 2010). tion therapy. The increasing availability of antibiotics There are also huge disparities between urban and and antiretroviral therapy for AIDS has also made rural areas. Progress in sanitation has not matched an impact. Despite this, in 2010, 7.6 million chil- advances in access to safe water and the MDG tar- dren under the age of five died, predominantly from gets for sanitation will not be met. By the end of infectious diseases for which effective intervention is 2010, 2.5 billion people still did not have access available—especially diarrhea, pneumonia, malaria to safe sanitation among whom 1.1 defecate in the and HIV (often combined with under-nutrition). open (UNICEF 2012). In many countries in Sub- 2. Vaccination against preventable diseases. Saharan Africa and South Asia, sanitation coverage Immunization currently averts an estimated two- is less than 50 percent. three million deaths every year in all age groups 4. Malaria prevention and control. Global efforts from diphtheria, tetanus, pertussis (whoop- have led to a decline in malaria deaths of 38 per- ing cough) and measles (WHO immunization cent worldwide (WHO, 2011b). Sub-Saharan monitoring global health database). Since the Africa, which bears the heaviest cost of malaria implementation of the Global Polio Eradication deaths, deserves special emphasis with an estimated Initiative (GPEI) there has been a sharp decline 1.1 million children saved from malaria over the 54 Connecting Sectors and Systems for Health Results last decade. The Roll Back Malaria Partnership was 2002, and all of WHO’s six client countries are on launched in 1998 by WHO, UNICEF, UNDP and track to achieve the MDG target that TB incidence the World Bank to provide a coordinated global rates should fall by half by 2015. However, signif- response to the disease. Since that time the finan- icant challenges remain. In 2010, there were 1.45 cial resources available for malaria programs have million deaths from TB. HIV fuels TB and about increased from $100 million to $1.8 billion. These 13 percent of TB cases occur among people liv- investments have supported public health interven- ing with AIDS. Further, health system weaknesses tions and curative health services that have greatly such as inadequate health worker training, and poor increased the reach of protective interventions (par- quality drugs lead to a rise in cases of highly drug ticularly insecticidal treated bed nets). However, resistant TB. much work remains to scale up effective treatment 7. Control of Neglected Tropical Diseases. More and assist countries in moving toward elimination. than one billion of the world’s poorest 2.7 bil- At the same time, emerging drug and insecticide lion people (defined as those who live on less than resistance are a major concern. $2.00 a day), are affected by one or more neglected 5. Prevention and control of HIV/AIDS. After years tropical diseases (NTD) (WHO and Carter Center of unrelenting expansion, the global epidemic of 2008). These are communicable diseases named for HIV has stabilized and the annual rate of new the relative failure to provide proper care or atten- infections is declining (UNAIDS global report). tion to their victims, in spite of great impact on In 33 countries, HIV incidence fell more than 25 individual livelihoods and communities. Of all percent between 2001 and 2009. This has been at NTDs, 90 percent could be treated with medicines least partly due to significant international invest- that are administered once or twice annually. There ments in prevention and treatment, which by 2010 is insufficient effort to combat NTDs, they are had resulted in an unprecedented scale-up of HIV/ traditionally under-reported and existing research AIDS services. Driven in most countries by inter- methods make accurate data collection difficult. national assistance, more than 6.5 million people Improving the quality of the data and an overall were receiving antiretroviral therapy at the end commitment to combat these diseases more effec- of the decade, resulting in a decline in mortal- tively has been identified as an important priority. ity from AIDS. Highly effective interventions to WHO released a road map for combating NTDs prevent mother to child HIV transmission have in early 2012. almost eliminated vertical spread of the virus in 8. Tobacco control. Tobacco use represents the larg- most developed countries, with coverage increasing est preventable cause of disease and death in the dramatically in LMICs. Despite this success, global world, leading to nearly six million deaths annu- prevalence remains high—34 million people were ally, projected to rise to more than eight million living with AIDS at the end of 2010. At the end by 2030. Despite increasing international consen- of 2009, only 36 percent (about 5.2 million) of sus around the importance of tobacco control, those who need it were receiving antiretroviral ther- consumption of tobacco products is increasing glob- apy in LMICs. Also, insufficient attention is paid ally. Nearly 80 percent of the world’s one billion to prevention in high-risk groups. smokers live in low- and middle-income countries. 6. Tuberculosis control. The WHO’s directly observed In 1999, the World Bank published a landmark short course (DOTS) strategy for TB control was study, Curbing the Epidemic: Governments and the launched in 1995 and has resulted in substantial Economics of Tobacco Control . The analysis con- global progress against the disease. For example, in cluded that tobacco control brings unprecedented China between 1990 and 2010, prevalence rates health benefits without cost to economies. In force were halved, mortality rates fell by almost 80 per- since 2005, the WHO Framework Convention on cent and TB incidence rates (i.e. new cases) fell Tobacco Control is now ratified by 172 countries. by 3.4 percent per year (CDC 2010). The abso- 9. Road safety. Each year, 1.3 million people are killed lute number of TB cases has been falling globally on the world’s roads. The loss of disability adjusted since 2006, incidence rates have been falling since life years (DALYs) due to road injuries surpasses Annex 5: Ten Notable Achievements in Public Health 55 malaria as a global burden of disease. Road acci- epidemics and pandemics do not develop. The last dents disproportionately harm the poor and 90 decade has seen remarkable progress. A SARS pan- percent of casualties occur in developing countries. demic was thwarted, though at high economic cost. Consequent injury and death can plunge families A major international effort was mounted to con- into poverty and represent a substantial drain on trol the highly pathogenic H5N1 virus at its animal country resources (World Bank Global Road Safety source (through the culling of up to 1 billion poul- Facility). This large and increasing burden was rec- try) and to help developing countries prepare for ognized in 2011 by the United Nations, with the a pandemic. The Bank has contributed $1.3 bil- launch of a “Decade of Action for Road Safety� that lion to the $3.9 billion global program, leadership aims at stabilizing and then reducing global road on a rapid and flexible global funding strategy, and deaths by 2020 (WHO Decade of Action for Road coordination for and assistance to, integrated ani- Safety 2011–2020: global launch 2011). The Bank mal health-human health programs in 60 countries has established “The Global Road Safety Facility,� (World Bank 2011d). To date, no severe flu pan- housed within the Transport, Water, Information & demic has emerged and countries are better prepared Communication Technologies Department, work- now than 10 years ago. But there are significant ing to scale up efforts to stop the silent epidemic risks that these gains are not being sustained. OIE on roads, particularly in poor countries. has identified priority investments required to bring 10. Prevention of pandemics such as SARS and influ- animal disease prevention and control systems in enza. Human health and economies benefit when developing countries to minimum standards, empha- zoonotic disease outbreaks—from pathogens that sizing the importance of collaboration between often originate in livestock—are controlled so that animal and human health services. Annex 6: Illustrative Role of Different Sectors in Strengthening Public Health Programs and Results Sector/Ministry Public Health Actions Finance • Increasing taxes/prices for tobacco, alcohol and sugar • Removal of subsidy for products harmful to health, such as tobacco leaf and tobacco products Agriculture • Support and promotion of local varieties of fruits and vegetables for homestead gardens • Work with veterinary services to reduce risks of zoonotic diseases, jointly address disease outbreaks, and systematically share information • Promotion of high-yielding varieties of basic crops (e.g. rice and wheat) to meet demand • Maintaining adequate land and water bodies for agriculture and food systems, especially fisheries • Crop substitution to promote food diversity • Development of enriched foods • BCC activities by agricultural extension workers at the community level to build awareness on food diversifi- cation and food security Food Industry • Production and marketing of healthy food • Salt reduction in processed and semi-processed food; reduction of trans-fat in food • Food fortification—iodine to salt, vitamin A to edible oil, micronutrient to rice (extruded) and flour • Improve food storage capacity to facilitate broader distribution of agricultural products Infrastructure, • Planning for road, transport, and housing to reduce environmentally noxious emissions Transportation, • Improve road planning and maintenance to reduce traffic accidents and injuries Public Works • Expand a reliable road network to improve accessibility to health services • Improve transport, including cycling and walking opportunities, building safer and more livable communities, and accessible facilities for physical activities • Improve rural roads for improved maternal and child health care. • Enforcement of drunk-driving, seat belts and helmets laws Education • Physical activity program among schoolchildren • School food and nutrition programs • Production of an adequate number of health professionals with needed skills for NCD prevention and care • Provision and maintenance of sanitation and hand-washing with soap facilities in schools • Promotion of hand-washing, personal hygiene and other healthy habits for school children • Deworming program in schools (continued on next page) 58 Connecting Sectors and Systems for Health Results (continued) Sector/Ministry Public Health Actions Social protection • Explore CCTs to modify individual and family behavior • Expand/improve social safety net programs to improve access to food, especially during the lean seasons • Use fortified food and other safety net programs to effectively address micronutrient deficiency among the poorest population Justice • Development and enforcement of pro-health policies and regulations on drunk driving, home violence, and a smoke-free environment • Enforcement of anti-air pollution legislation • Enactment of laws and regulations to protect the rights of patients and increase voice and accountability Science and Technology • Strengthen scientific and industrial research to effectively monitor quality of fortified food available in the market • Invest in R&D for low cost health technology Environment • Enforce environment standards particularly for indoor and outdoor pollution • Real estate developers can be encouraged or mandated to include physical exercise facilities in their projects • Regulate indoor and outdoor air pollution Water and Sanitation • Improve water and sanitation networks to prevent diarrheal diseases • Fund demand creation programs for improved sanitation and facilitate development of private sector to provide affordable quality products and services Information, Media • Promotion of change in social norms and behaviors concerning smoking, being sedentary, and alcohol abuse and advocating healthy lifestyles • BCC and mass campaign awareness on a) early detection and long-term impacts of malnutrition, b) adequate food diversity and quantity for infants and young children, c) hand washing with soap and other healthy behaviors • Dissemination of key nutrition messages (e.g. breastfeeding, etc.) through mass media • Educate journalists on the national and provincial pandemic response plans and share with them the coun- try’s risk communications plan Ministry of Interior • Enforcing certification of vehicle safety and driver competency • Enforcing seat belts and helmets • Establishing a hotline for medical emergencies Telecommunication • Increase access to mobile technology to facilitate access to health information and increasing awareness • Facilitate the connection of health facilities to communication networks Private sectors • Occupational health and work safety • Workplace wellness programs • Promote and expand social corporate responsibility for health interventions • Expand public private partnerships in areas of technology innovations and service delivery • Encourage preparation of emergency response plans, including for pandemics. • Voluntary reduction of unhealthy food additives Annex 7: Multisectoral Impact on Health COUNTRY CONTEXT (MACRO ENVIRONMENT) SOCIAL FACTORS MULTI-SECTORAL IMPACT ON THE HEALTH SECTOR WATER SANITATION ENVIRONMENT THE HEALTH SECTOR OTHER SECTORS EDUCATION GOVERNANCE & STEWARDSHIP (Leadership, Regulation, Legislation, Planning, Systems Intelligence) HEALTH SECTOR ECONOMIC FACTORS GOALS POLITICAL FACTORS (Level/Spread) • Health Status and Health Security SOCIAL PROTECTION PUBLIC HEALTH MDGs & NCDs • Financial AGRICULTURE STRATEGIES & SYNERGIES Protection ACTIONS • Satisfaction (Evidence-based) and Trust POWER/ENERGY INFRASTRUCTURE TRANSPORT CULTURAL FACTORS Annex 8: Illustrative Actions to Advance the World Bank’s Work in Public Health Pillar I: Fostering Multisectoral 3. Based on the above, assist client countries in Interventions to Maximize Returns identifying windows of opportunity in sec- tors’ project pipeline portfolios to incorporate on Investments in Health health objectives and engagement of the coun- To advance multisectoral engagement, a specific set of try’s public health authorities in project design and actions will be implemented on parallel tracks: implementation. The HNP anchor will track these multisectoral experiences and make the information 1. Design and test the MCA tool in a group of coun- on approaches available to the public health com- tries in order to make it available to TTLs in their munity and others. dialogue both within the Bank and at country level 4. Assist client countries in implementing actions in FY14, and position action across sectors as a way aimed at mitigating the major NCDs risk fac- to strengthen country governance and stewardship tors: primary focus will be placed on working with functions. The MCA tool would provide a meth- PREM to introduce tobacco taxation in new DPLs odology for leveraging investments in non-health and engaging with the relevant sectors on address- sectors, assisting the public health community to ing salt, alcohol, and fats as major risks factors. In engage early in country assistance strategy (CAS) addition to DPLs, efforts will be placed on support- discussions with country directors and country ing World Bank task team leaders in their policy teams. It will also guide dialogue with policy makers dialogue at country level to implement the key at country level on this important topic. The tool pillars of the Framework Convention for Tobacco can thus be a powerful catalyst for a shift in mind- Control. There is already substantial demand for set for improving health outcomes. such work across regions, and the HDNHE Public 2. Assist sectors in the preparation of a conceptual Health Cluster will benefit from the support of two framework, emphasizing the actions which can have economists, seconded by CDC to the World Bank the highest impact in improving health outcomes. to carry it out. This would help the broader country team in mak- 5. Convene a high level event within the Bank to ing any necessary trade-offs by evaluating the relative feature good practices on multisectoral action for merits of different sector programs for the pursuit of health outcomes. health objectives. 62 Connecting Sectors and Systems for Health Results Pillar II: Identifying Country- Pillar III: Strengthening specific, Cost-effective Actions Governance and Leadership to to Help Countries Face the Dual Anticipate, Address and Manage Challenge of Meeting MDGs and Public Health Challenges Addressing NCDs In supporting government capacity to perform the In assisting countries in making cost effective decisions essential public health functions, and to connect sys- to address NCDs and the MDGs, priority actions by tems, priority actions by the Bank will include: the Bank will include: 1. Engaging in a dialogue with governments to 1. Carrying out a review of evidence and case stud- strengthen essential public health functions by ies (during FY13) in selected countries across regions establishing National Public Health Institutes which face the dual challenge of meeting MDGs cou- (NPHIs) or similar institutions. Implementing this pled with the growing burden of NCDs. The review activity will take into account the local context in of the evidence aims to identify a number of key pri- order to meet countries at their point of need. For ority interventions and policy approaches that can be example, in low income settings, particular empha- shown to promote positive synergies to address both sis could be placed on some critical core functions MDGs and NCDs simultaneously. The main idea is (surveillance and response, population health assess- to carry out an in depth review including published ment; health education and promotion, public literature, ongoing experiences on pilots at country health work force development) as an initial step, level and the Bank tacit knowledge to produce a range while the engagement in middle-income countries of interventions according to the relative degree of could focus relatively more on other areas, including synergy in addressing MDGs and NCDs. This will be strengthening the regulatory capacity and promoting complemented by country-level case studies that will equitable access to health services. Moving forward, assess the likely impacts at country level if such inter- stimulating the dialogue at country level on build- ventions were brought to scale, focusing on the impact ing public health capacity will be supported by the on health expenditures, prevention and health out- development of a strong collaboration with techni- comes for both NCDs and MDGs of expanding the cal agencies such as the CDC and WHO, to bring interventions identified by the review of the evidence. together their technical expertise and the Bank’s 2. Initiating in the medium term, analytic work on substantial investments in countries where it is health system adaptation in health care service developing a public health portfolio. This collabo- delivery in a selected group of countries to identify ration will focus on technical assistance, knowledge key priority interventions that will equip countries generation, high level dialogue at country level, and to better address the changing pattern of burden of convening global and regional activities on pub- disease. This will include assessing which types of lic health. low-cost adaptations in service delivery are needed 2. Assisting TTLs in integrating Public Health com- to make sure that the prevention and treatment are ponents in future operations by providing them effectively integrated into different levels of care, with the technical support and the tools they including primary health, secondary care and higher need in designing these components taking into complexity health care, as well as surveillance sys- account the local context. As new projects are being tems of laboratories and diagnostic services. designed, ensuring that they include a basic package 3. Prepare regional briefs on the changing health of public health activities as discussed above—under- landscape during FY13, to assist the regions in their pinning the core principles of public health—will discussions in country team meetings. be an important contribution to “demonstrate pub- 4. Preparing and disseminating best practices to lic health� at country level and induce the shift in influence the dialogue at country level. mindset necessary to achieve health outcomes. Annex 8: Illustrative Actions to Advance the World Bank’s Work in Public Health 63 3. Working with AES to develop an operational Cross-cutting Theme: framework for the implementation of One Health Economic Analysis to Underpin approaches. The main objective would be to review and analyze the concrete steps and resources neces- Decision-making sary to strengthen animal health and human health Specific actions in this regard will include the following: systems, and how these systems work together effec- tively and efficiently. In this context, the Bank will �� Identifying and conducting specific analyses to work jointly with WHO, OIE and FAO to develop assist regions and countries in gathering the eco- an operational framework—using the existing and nomic evidence they need to support their dialogue forthcoming tools—which could be used by task and mobilize adequate resources on specific public team leaders working on public health to properly health issues with World Bank country directors and address the interfaces between the functions per- ministries of finance. Although compelling evidence formed by animal and human health services, to on the economic impact of investing in public improve early detection and prompt control of dis- health is a vital piece of information to influence eases at the animal source. This framework will be decision makers, so far this is not widely available. implemented in a group of pilot countries and the Efforts will be devoted to support new analytical lessons learned would add significant value to future work to produce leading-edge analyses and data on relevant Bank operations. the economics of Public Health, including for exam- ple analyses on: return-on-investment, economic impact, benefit-incidence and fiscal and financial sustainability. To leverage ongoing initiatives, close collaboration with other institutions in this area. �� Further, the economics research and analytical efforts will be complemented by knowledge management activities to make sure that the new evidence gen- erated is easily available and understood by policy makers, including the use of innovative communica- tion strategies and compelling graphic visuals.