IDA Support: Helping Country Health Systems Deliver Results in a New Global Context 95877 October 6, 2010 Helping Country Health Systems Deliver Results in a New Global Context Overview In health, nutrition, and population (HNP), the World Bank focuses on strengthening country health systems to improve health results, particularly for the poorest and most vulnerable. In fiscal year (FY) 2010, the World Bank mobilized US$4.38 billion in HNP investments, a 50 percent increase over the previous year’s record commitments. Fiscal year 2001-10 International Development Association (IDA) commitments averaged US$825 million annually, giving more than 47 million people basic HNP services packages, providing 2.5 million women with antenatal care, and immunizing 310 million children. A growing portfolio of International Bank for Reconstruction and Development (IBRD) lending averages US$1 billion annually, addressing inequities in health care access, financial protection, quality of care, and aging populations’ health needs.. Challenge MULTIMEDIA Encouraging gains in halting and beginning to reverse the spread of major communicable diseases—such as HIV/AIDS and malaria—are promising, but there is still much work to be done to achieve the Millennium Development Goals (MDGs). Weak health systems are undermining the ability of countries to achieve and sustain health results, and the recent financial, food, and fuel crises—which have pushed 64 million more people into extreme poverty in 2010—have made attaining the MDGs all the more challenging. More than 80 percent   of IDA countries are not on track to achieving MORE the under-five mortality and maternal mortality MDG1: Eradicate Extreme Poverty & Hunger  MDGs; progress toward maternal and child MDG4: Reduce Child Mortality  health and nutrition outcomes is particularly slow because these “neglected” MDGs are dependent MDG5: Improve Maternal Health  on well-functioning health systems and their MDG6: Combat HIV/AIDS, Malaria & other ability to reach the poor. Expanding the diseases  implementation capacity of health sectors and MDG8: Develop a Global Partnership for improving the quality, efficiency, and reach of Development health services is critical for programs to achieve sustainable results on necessary scales. The main challenges facing middle-income countries are inequities in access to health services, poor quality of health More Results care, large out-of-pocket expenditures for health care, and the growing burden of non-communicable diseases.  $8.25m Approach The Bank focuses on strengthening country health systems to improve health results, which ultimately strengthens health IDA lending for HNP averaged systems; boosts the prevention and treatment of annually over the last decade. communicable and non-communicable diseases; improves child and maternal health, nutrition, hygiene, and sanitation; and protects the poor from the impoverishing effects of high MORE INFORMATION and unpredictable out-of-pocket spending. Equity and financial protection for the poor are at the core of the Bank’s World Bank Health, Nutrition, HNP strategy, and the Bank supports countries in these and Population areas through policy advice and operations. World Bank 2007 HNP Strategy   & 2009 Progress Report An important pillar of the HNP Strategy is increased use of World Bank Reproductive Action results-based financing, which uses financial incentives to Plan reward the delivery of one or more verified health outcomes. World Bank Nutrition Results-based financing holds considerable promise for World Bank Poverty & Health increasing health service utilization, improving service quality, increasing efficiency, and enhancing equity. It Results-Based Financing for focuses attention on health results rather than inputs, thereby Health more tightly linking budgets and financing to results. Given IHP+ the interdependence of health outcomes and other key sectors, mainstreaming multisectorality is another pillar of the HNP Strategy. Building on the Bank’s comparative advantage in development finance, the Bank has supported   several innovative financing mechanisms such as the IDA buy-downs (for polio), Advanced Market Commitments (to create market incentives for the rapid production, distribution, and introduction of priority vaccines at low prices), and the Affordable Medicines Facility for malaria (to accelerate the global introduction of artemisinins). Another key component of the HNP Strategy is improving monitoring and evaluation. The Bank is working with partners to develop better ways to monitor the health MDGs, and IDA is increasingly encouraging countries to carry out rigorous impact evaluations of health innovations and programs, in addition to building effective monitoring and evaluation systems.. Results IDA and IBRD operations are designed and implemented with a particular emphasis on reaching the health MDGs. IDA commitments during the last decade have provided more than 47 million people with basic packages of HNP services; delivered antiretroviral therapies to almost 2 million adults and children with HIV; provided 2.5 million pregnant women with antenatal care; immunized 310 million children; provided 98 million children with targeted interventions to improve nutrition such as Vitamin A doses and deworming; purchased and/or distributed 813 million condoms for the prevention of HIV, sexually transmitted diseases, and unwanted pregnancies; purchased and/or distributed almost 33 million mosquito nets to prevent malaria; constructed, renovated, and/or equipped 23,000 health facilities to improve access to health services, and trained 1.8 million health personnel to improve the quality of health services delivery.   In the China Tuberculosis (TB) Control project, the case detection rate for new smear-positive TB cases increased from 23.26 percent in 2002 to 77.33 percent in 2010 (target: 70 percent) and the cure rate for smear-positive TB cases increased from 80 percent in 2002 to 92.9 percent in 2010 (target: 85 percent). In Senegal, the Bank supports an innovative multisector health program that operates at the community level in collaboration with local governments, district health authorities, and civil society organizations. National malnutrition rates have dropped to 17 percent from 22 percent, bringing Senegal within reach of achieving the MDG to halve the rate of malnutrition. In Rwanda, the Bank has bolstered budgetary support to improve health service delivery and governance, resulting in an increase in health insurance enrollment from 7 percent to more than 70 percent of the population, a 50 percent increase in utilization of health services by poor children, a 63 percent increase in the use of insecticide-treated bednets, more than doubling the use of family planning services, a 62 percent decrease in malaria incidence, and a 30 percent decrease in child mortality. In addition, early evidence of results-based financing for health programs suggests great potential. In Afghanistan, the government reduced the deaths of infants and children under five by 22 percent and 26 percent, respectively, in just three years. In Argentina, nearly 1.5 million previously uninsured pregnant women and children now have basic health insurance and secure access to services, and infant mortality began to decline again and has fallen 20 percent since 2002 (to 13.3 per 1,000), with the fastest improvement occurring in the poorest provinces.   Bank Contribution During FY05-10, IDA investments in HNP were US$5.6 billion. Health systems strengthening accounted for more than 30 percent of IDA’s and 60 percent of IBRD’s contribution in health. Simultaneously, a significant proportion of IDA investments went to key MDG themes such as child health (18 percent), TB and malaria (12 percent), population and reproductive health (11 percent), HIV/AIDS (10 percent), and nutrition (5 percent). In IBRD, other significant themes include injuries and non-communicable diseases (12 percent), child health and water safety/hygiene (6 percent each). The Bank’s multi-sector approach to health outcomes has gained momentum, with about 30 percent of new lending (US$1.6 billion) for health coming from operations in social protection, poverty reduction, economic policy, and public sector governance.   Partners The Bank and the World Health Organization (WHO) are coordinating the International Health Partnership (IHP+) to deliver improved results in health by implementing the principles of aid effectiveness (Paris Declaration) for health. The IHP+ continues to gain momentum, with 24 countries among the partners.   In September 2008, the Bank co-chaired the High Level Taskforce on Innovative International Financing for Health Systems. The taskforce identified innovative financing mechanisms to bridge health system financing gaps and urged donors to put the funds to use more effectively. The taskforce recommended the development of the Health Systems Funding Platform, which, in line with the IHP+, is a way for development partners—including the GAVI Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the Bank, with facilitation by WHO— to improve how they work together in countries. The taskforce will enable countries to use new and existing funds more effectively for health systems development, and facilitate easier access of donor funds that are more aligned to their own national processes.   The Bank is a member of the informal partnership of the eight health-related agencies, which was formed in July 2007 and meets bi-annually to strengthen linkages and work jointly to address challenges in expanding health services, particularly in low-income countries. The Bank plays a role in several other health partnerships, including the GAVI Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Roll Back Malaria; and the Partnership for Maternal and Newborn Child Health.   The Bank’s efforts to support results-based financing have intensified through the multi-donor Health Results Innovation Trust Fund. Contributions to this trust fund from Norway and the United Kingdom total US$543 million for use through 2022. To continue improving monitoring and evaluation, lending is much more focused on creating incentives for key results—clear and measurable objectives for health service delivery and for important health outcomes. Moving Foward The Bank continues to focus on more output- and results-based health lending and is using the resources of the Health Results Innovation Trust Fund to leverage additional IDA and IBRD funds. The Bank will continue to invest in strengthening health systems as a means of meeting disease-specific targets and achieving the MDGs. Particularly in Africa, with two health systems strengthening “hubs,” the Bank is well-positioned to provide non-lending assistance to countries in results-based financing, pharmaceuticals, health care financing—including community insurance—and the development of IHP+ compacts.   The Bank’s 2010-2015 Reproductive Health Action Plan focuses on health systems strengthening for better reproductive health outcomes—especially for the poor and youth—in countries with a high burden of maternal deaths and high fertility. The Bank puts much effort into improving health system governance and is developing a toolkit to measure health system governance to monitor accountability, which is being piloted in five countries. The Bank is also working with partners to develop better ways to monitor the health MDGs, including the estimation of trends in child and maternal mortality. Regions are explicitly identifying opportunities to address HNP priorities across operations outside the sector and build linkages with non-state actors to position the Bank as a knowledge partner (e.g. South Asia). The Bank is also pursuing multi-year programmatic analytic and advisory activities (e.g. Latin America and the Caribbean), non-lending technical assistance, policy notes, policy dialogue, and country-to-country learning to maintain engagement with countries even in the absence of lending.