OV ER VI EW HEALTHY DEVELOPMENT THE WORLD BANK STRATEGY FOR HEALTH, NUTRITION, & POPULATION RESULTS Washington, DC © 2008 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: feedback@worldbank.org All rights reserved 1 2 3 4 11 10 09 08 The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development/The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgement on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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ISBN-13: 978-0-8213-7193-0 e-ISBN-13: 978-0-8213-7194-7 DOI: 10.1596/978-0-8213-7193-0 Cover design: Naylor Design, Inc. Cover photo: C. Carnemark/World Bank. Library of Congress Cataloging-in-Publication Data Healthy development : the World Bank strategy for health, nutrition, and population results. p. ; cm. ISBN 978-0-8213-7193-0 (alk. paper) 1. Public health--Developing countries—Finance. 2. Public health—Developing countries—International cooperation. 3. Nutrition policy—Developing countries—Finance. 4. Population assistance—Developing countries—Finance. 5. World Bank. I. World Bank. [DNLM: 1. World Bank. 2. Developing Countries. 3. Public Health. 4. Financial Support. 5. Interna- tional Agencies. 6. Public Policy. WA 395 H4347 2007] RA410.55.D48H45 2007 362.109172'4—dc22 2007022159 Overview Why Is a New World Bank HNP Strategy Needed Now? The 20th century marked a period of unprecedented growth and achieve- ment in improving the health of people in many countries throughout the world. Over the past 30 years, significant achievements have occurred in global health, such as reducing infant mortality and malnutrition; the world has also witnessed dramatic advancements in health innovations and tech- nologies. Yet the gap between rich and poor countries in health and incomes remains as stark as ever. Preventable communicable diseases in developing countries kill almost 11 million children every year. Malaria, a preventable disease, claims the life of a child somewhere in the world every 30 seconds. More than 500,000 women die during pregnancy and childbirth every year. Tuberculosis is curable, and yet 1.7 million die from it annually. The HIV/AIDS epidemic is still uncon- trolled in most low-income countries, with about 39.5 million people living with HIV/AIDS globally, two-thirds of whom live in sub-Saharan Africa. The World Bank’s last health, nutrition, and population (HNP) strategy, released in 1997, predated the creation of the 2015 Millennium Development Goals (MDGs) and the emergence of new multilateral organizations and foun- dations that have greatly increased their prominence in health financing—such as the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria, and the Bill and Melinda Gates Foundation. In the meantime, pandemics and regional epidemics have continued to emerge, while others have expanded. This new HNP strategy updates the Bank’s contribution to improving health outcomes at the global, regional, and national levels. It will help devel- oping countries strengthen their health systems, improve the health and well- 1 2 Healthy Development being of millions of the world’s poorest people, boost economic growth, reduce poverty caused by catastrophic illness, and provide the structural “glue” that combines multiple health-related programs within partner countries. The World Bank’s Strategic Focus in HNP Today, a heightened sense of urgency around global health has compelled the international community to respond swiftly to health crises. Single- disease approaches and initiatives have proliferated to meet these health challenges. New multilateral, bilateral, and private initiatives have joined the ranks of long-established organizations to address the growing chal- lenges. Development assistance for health has more than doubled in the past five years, from US$6 billion in 2000 to almost US$14 billion in 2005 (Fig- ure 1). Despite this dramatic surge in global attention to health in recent years, the importance of well-organized and sustainable health systems in devel- oping countries has been overlooked. All too often, poor health goes hand- in-hand with poverty and blunted economic prospects, with clear evidence in developing countries that weak health systems are a significant roadblock to improving the health of citizens. Figure 1: Development Assistance for Health by Source, 2000 and 2005 16 14 12 private nonprofit other multilaterals US$ billion 10 World Bank 8 development banks 6 UN agencies 4 bilateral agencies 2 0 2000 2005 year Source: C. M. Michaud 2007. Note: “Other multilateral” includes the European Union, Global Alliance for Vaccines and Immunisation (GAVI), and Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). “World Bank” total includes only IDA lending. Overview 3 This neglect of systems, however, is changing. The international com- munity is now fully committed to stronger health systems that will sustain the achievements and ensure the survival of vertical disease programs; that will derive the maximum development potential from new, record sums of health assistance now available; and that will achieve the HNP-related MDGs. The World Bank, for its part, has a key role to play in helping its partner countries succeed in this key health mission. “Strengthening health systems” may sound abstract or less important than disease-specific initiatives, but efficient and sustainable health systems are essential for achieving results. On the ground, in practical terms, strengthen- ing health systems means putting together the right chain of events (financing, regulatory framework for public-private collaboration, governance, insurance, logistics, provider payment and incentive mechanisms, information, well- trained personnel, basic infrastructure, and supplies); this will ensure equitable access to effective HNP interventions and a continuum of care to save and improve people’s lives (see “Elizabeth’s story” in the appendix). Good Health Brings Growth In its new strategy, the Bank envisions that its support and advice will help countries achieve better health results in a way that also boosts their global competitiveness, and enhances good governance. Good health has proven to be not just an outcome of economic growth, but rather a major, inseparable contributor to growth. Advances in public health and medical technology; knowledge of nutri- tion, population policies, and disease control; and the discovery of antibi- otics and vaccines are widely viewed as catalysts to major strides in eco- nomic development, from the Industrial Revolution in 19th century Britain to the economic miracles of Japan and East Asia in the 20th century. Sound health policy, one that establishes the correct incentive framework for financing and delivering services, also has important implications for a country’s overall fiscal policy and its competitiveness. Bank Strengths The World Bank has long provided policy and technical advice to partner countries and global partners in their efforts to achieve HNP results. In imple- 4 Healthy Development menting its new HNP strategy, the Bank will continue to generate the best “cutting-edge” knowledge, policy, and technical advice in key areas such as: • health system strengthening • a multisectoral approach to country assistance • advice to governments on regulatory frameworks for public-private col- laboration in the health sector • large-scale or ”scaled-up” implementation of projects and programs • convening capacity and global nature. The World Bank Group also has significant potential to engage private health actors through both the International Bank for Reconstruction and Development and the International Finance Corporation. Some of these strengths are fully developed while others, such as policy and technical advice on regulating the private sector and improving public-private collab- oration for HNP results, need significant reinforcement if the Bank is to effectively support developing countries and other partners in the interna- tional community. In strengthening health systems, the Bank provides expertise in health financing, insurance, demand-side interventions, regulation, and fiduciary and financial management. The World Bank is actively collaborating with its global partners to devise a clear division of labor that would allow us all to coordinate ourselves better and build on the existing political will and coordination at the country level to help communities and their govern- ments achieve long-term, sustained good health. Defining and Achieving HNP Results Under its new HNP strategy, the World Bank will help developing low- and middle-income countries to improve people’s health and guard against the poverty that can result from sudden illness. Poor families often tap into sav- ings or sell what they own to cover the costs of medical care. As a result, all too often people end up falling below the poverty line. Improving the per- ilous health of millions of the world’s poorest people is rightly one of the essential priorities of the global development community in this new century. Overview 5 Specifically, the Bank will help countries to control priority diseases where they constitute a large part of the burden of disease. However, the Bank will increasingly endeavor to ensure that Bank operational and policy advice support for priority diseases will strengthen the ability of health sys- tems to solve systemic constraints that impair the effectiveness of countries, the Bank, and the international financing community in achieving HNP results. The World Bank also believes that its support and advice will help coun- tries achieve HNP results in a way that also contributes to their overall fis- cal sustainability, economic growth, global competitiveness, and good gov- ernance. This new strategy is embedded in the core mission of the Bank to reduce poverty worldwide. How Will the Bank Help Countries Achieve These Results? Five new strategic directions are specified to improve Bank capacity to assist partner countries in achieving HNP results in the coming decade: • Renew Bank focus on HNP results. • Increase the Bank’s contribution to partner-country efforts to strengthen health systems for HNP results. • Ensure synergy between health system strengthening and priority- disease interventions, particularly in low-income countries. • Strengthen Bank capacity to advise partner countries on a multisectoral approach to HNP results. • Increase selectivity, improve strategic engagement, and reach agreement with global partners on collaborative division of labor for the benefit of partner countries (Figure 2). Renew Bank focus on HNP results A cornerstone of the strategy’s focus on HNP results will be linking new financing more closely with verifiable results on the ground with “results- based financing.” Time and again, evidence shows that by tying funding to specific, measurable goals, governments and communities are motivated to achieve results, such as increasing antimalaria bed-net coverage of children 6 Healthy Development Figure 2: Health System Functions and Other Determinants of Good System Performance stewardshipd resource financinga generationf HNP public and health, nutrition, and patients and results private provisione population interventions population DEMANDc system governanceb Source: Based on the World Health Report 2000. a. Includes funding (public, out-of-pocket, and DAH), contributions, pooling, and payment mechanisms. b. Includes financial management, procurement, and “other” systems. c. Influenced by preferences, beliefs, and behaviors. d. Oversight. e. Service delivery. f. Includes human resources, pharmaceuticals, and medical equipment. at night in Rwanda or raising Apgar scores for newborns in Argentina, which also have the additional valuable effect of strengthening the underly- ing health systems (Figures 3 and 4). This innovative approach requires baseline, target, and intermediate progress data and allows for regular review of successes, shortfalls, and bot- tlenecks. These “real-time” reviews allow for continual adjustments to imple- mentation plans should the need arise. “Results-based financing” can also improve incentives and accountability in both the public and private sectors. Working shoulder-to-shoulder with global partners, the Bank will also help countries improve their national public health surveillance and performance monitoring systems and monitor a core set of indicators at the global level. Increase the Bank contribution to strengthen health systems for HNP results Achieving HNP results requires a well-organized and sustainable country Overview 7 Figure 3: Rwanda—Performance-based Financing and Use of Assisted Deliveries Over Time Performance-based contracts Control 30 25 20 % of births 15 10 5 0 Butare Cyangugu Gikongoro Kibungo 2001 2002 2004 Source: Sekabaraga, Rusa, and Soucat “What It Takes to Scale Up for Better Health: The Experience of Rwanda 2004–2007.” Back- ground paper to “Innovations in Service Delivery.” Figure 4: Argentina—Output-based Lending Trazadora Results (Apgar Score) in Three of the Nine Poorest Provinces 50 40 30 20 10 0 Catamarca Chaco Tucuman First target (May–Aug 05) First actual Second target (Sep–Dec 05) Second actual Third target (Jan–Apr 06) Source: Argentina Provincial MCH Project 2006. health system to ensure equitable access to effective HNP interventions and a continuum of care. Policy makers in low- and middle-income countries face difficult challenges as they attempt to make their health systems deliver sustainable health services while they also work to protect people from poverty due to illness. Bank financing and advice are crucial to identifying policy actions and investments that will help overcome roadblocks prevent- ing the development of better and stronger health systems. 8 Healthy Development With its long-established country relationships and its expertise in eco- nomic and human development, the World Bank is well-placed to help countries improve their “fiscal space” and thus raise long-term public finan- cial resources that are predictable, as well as fairly and efficiently allocated to minimize economic distortions. Fiscal space refers to the amount of room a government has in its national budget to finance a given activity without jeopardizing its financial stability. Helping countries improve their fiscal space has become increasingly vital as they struggle to absorb record-high amounts of health aid funds that are often ear-marked for specific projects, that are not well coordinated with other donors, or that arrive halfway through a national budget cycle (Figure 5). To realize its full potential in health systems, the Bank’s HNP sector will strengthen its capacity in health financing (including fiscal management, health insurance, and health service purchasing) and in system governance. It will seek more effective multisectoral collaboration with its sister networks such as the Poverty Reduction and Economic Management Network (PREM) and sectors such as Financial Services and Social Protection. Accord- ingly, the HNP sector will assemble a health system policy advice team, which will allow it to respond more rapidly to the need for health system strength- ening to obtain solid HNP results on the ground. Figure 5: Volatility in Aid for Health, Selected Countries, 1999–2003 50 45 external resources for health as % of total health expenditures 40 35 30 25 20 15 10 5 0 1999 2000 2001 2002 2003 year Laos Lesotho Niger Zambia Source: WHO. World Health Report 2006. Working Together for Health. Geneva: WHO. Overview 9 Ensure synergy between health system strengthening and priority-disease interventions, particularly in low-income countries While continuing to lend for priority-disease control programs in countries, the Bank will stay focused on solving systemic hurdles to improve HNP results, and on ensuring synergy in priority interventions to improve health outcomes and strengthen health systems. Zero-interest financing through the Bank’s concessional lending facility, the International Development Association (IDA), plays a crucial role in HNP-enhancing interventions to ensure synergy between priority-disease interventions and health system strengthening in low-income countries. Technical advice and analytic and advisory work can play a valuable role in strengthening health systems by removing bottlenecks that prevent increased financing from achieving its maximum impact. Strengthen Bank capacity to advise partner countries on a multisectoral approach to HNP results Working “multisectorally” is imperative to saving lives and improving the quality of the health of the world’s poor—having health ministries, their local departments, and their international aid donors work more closely together with other strategic government ministries to achieve better health results within countries. According to the Bank’s new strategy, many advances in health status achieved during the 20th century were the result of close synergy among health and other key sectors in the economy such as water and sanitation, environment, transport, employment, education, agriculture, energy, infra- structure, and public administration. For example, investments in girls’ edu- cation improve household decisions on nutrition and demand for basic health care. At the same time, investing in basic nutrition during pregnancy and infancy has a substantial positive effect on early childhood development, which, in turn, significantly contributes to educational attainment, employ- ability, and future income. Multisectorality is one of the most important pillars of the World Bank’s development work—but it is also one of the hardest tasks to achieve in client countries. This is partly due to the traditional organization of government ministries, as well as among donors and development agencies. The Bank will therefore strengthen its multisectoral work to help countries and inter- national partners achieve the best possible HNP results (Figure 6). 10 Healthy Development Figure 6: Multisectoral Determinants of Global Burden of Disease high blood pressure smoking high cholesterol childhood underweight unsafe sex low fruit and vegetable intake overweight and obesity physical inactivity alcohol use indoor smoke from solid fuels unsafe water, sanitation, and hygiene zinc deficiency urban air pollution vitamin A deficiency iron-deficiency anemia unsafe healthcare injections illicit drug use 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 attributable mortality in thousands (total 56,242) developing countries developed countries Source: Jamison et al. 2006. To identify multisectoral constraints to achieving HNP results, effective core diagnostic tests are needed. The Bank will develop, test, and imple- ment a core diagnostic tool for systematic assessment of these multisectoral constraints (the Multisectoral Constraints Assessment for Health Out- comes) at the country level to identify the priority HNP outcomes: output and performance improvements for the specific country; constraints to improving those outcomes and performance at the national and/or subna- tional levels, and the key feasible multisector interventions. The results of this process will feed into the Country Assistance Strategy. Identifying and coordinating HNP-related programs and projects multisectorally in a new Country Assistance Strategy would be a big step toward developing, testing, and implementing a core diagnostic tool for multisectoral determinants of HNP results. Increase selectivity, improve strategic engagement, and reach agreement with global partners on collaborative division of labor for the benefit of partner countries As one of the leading global development organizations, the Bank collabo- rates with many other bilateral and multilateral organizations and global Overview 11 HNP partnerships in pursuit of its mission to reduce poverty and improve the social and economic well-being of the world’s poor. Working collabora- tively with a clear division of labor among global development partners— for example, under the aegis of the H-8 and the International Health Partnership—is essential if we are to respond most effectively to the needs of low- and middle-income countries. With the implementation of its new Health, Nutrition, and Population strategy, the Bank will evaluate the quality of its engagement with partners to ensure the best possible cooperation throughout the development field. The Bank will also step up its commitment to strengthening health systems as a proven vehicle for achieving verifiable and lasting improvements in health. A Window of Opportunity The expanded commitment of the international health community has opened an unprecedented window of opportunity for the World Bank to further contribute to HNP results. With record sums of aid flowing to global health, the Bank has an obligation to help ensure that this aid achieves transformational change and leads to better health and higher earnings within countries and communities. The World Bank is well-positioned—with its strong country focus and presence, its capacity for strengthening health systems, and its multisectoral approach—to bolster partner countries’ efforts to strengthen their health systems. Global health has changed so radically over the past decade that all of us involved need to redouble our commitment to help developing coun- tries and their communities achieve better health, higher economic growth, and more promising development prospects. 12 Healthy Development Appendix Could Elizabeth Have Been Saved? Why Health Systems Matter Elizabeth was Mary’s seventh child. She died at the age of three due to com- plications of malaria on February 17, 2003, at a clinic in San Pedro, one of the poorest municipalities, in a hypothetical but all-too-representative country. Why did Elizabeth die? What does health system strengthening have to do with saving her life? Elizabeth’s death had everything to do with a broken health system in desperate need of repair. The Single Disease Why Elizabeth died perhaps seems obvious. She caught malaria, developed a cerebral form of the disease, and a common, treatable infection killed her. But why Elizabeth? Had her family not received free bed-nets to prevent the infection? Was she not diagnosed and treated in time? What happened? The Broken System Finding out why Elizabeth died took so much time that Dr. Joy Macumbo, the local public health authority, almost gave up trying. So many children die every day in her district, how could she spare time to investigate just one? Finding out anything was so hard. There were almost no records of Eliz- abeth’s last few hours in the hospital or of her previous health history in the clinic. Dr. Macumbo was puzzled. According to her district data, for three years, San Pedro, Elizabeth’s town, had been receiving free bed-nets and anti- malarial drugs from the Ministry of Health (MOH). However, the district hospital was still reporting many cases of complications from malaria from the San Pedro area. Dr. Macumbo went to San Pedro to investigate. Dr. Macumbo discovered that the health center where Elizabeth should have received the bed-nets (and been diagnosed and treated early on) had had no health worker for at least 18 months. Bed-nets and drugs arrived from the MOH program, but often nobody was there to distribute the nets, or nobody who was trained to provide early diagnosis and treat the children was there. Some community volunteers helped visiting health workers catch up with distribution and treatment, but there were no guarantees (or records) Overview 13 of whether drugs had been stored properly (so they stay active) or administered correctly to San Pedro’s children. In some cases there were no records of what happened to the free bed-nets. Elizabeth had either not received (or used) a bed-net, had not been diagnosed and treated in time, and/or had not received treatment at all. Why had the health center gone so long without trained workers? Dr. Macumbo asked San Pedro’s mayor—management of health centers had been decentralized from district to municipalities five years earlier. Any trained health workers San Pedro managed to hire did not stay long in the poor town. The mayor said the job had been advertised for months, but the few qualified applicants did not want it. Working conditions in San Pedro were much harder than in South Port, the district capital, but the pay was the same under civil service regulations. To make matters worse, health workers on the center’s payroll often showed up late—because, the mayor discovered, they were moonlighting during center working hours. Some small, private providers paid them case by case, a supplement to their monthly salary. The scant records from Elizabeth’s stay at the district hospital and inter- views with her mother Mary and hospital staff showed that Elizabeth, with very advanced malaria complications, had arrived at the hospital on a weekend, long after the onset of the symptoms. Why did she arrive so late? Elizabeth’s mother said she could not afford to take her children to the hos- pital on a weekday. Dr. Macumbo was surprised—public hospital services are free in San Pedro. However, Mary said she had to sell one of her two cows, spend all her savings, and borrow money to cover expenses related to Elizabeth’s sickness. A trip to the hospital takes a full day because doctors show up late, so Mary would lose a day of work. She had to pay for transporta- tion, under-the-table fees for treatment as well as for additional supplies (anti- malarial drugs are free but the supplies are not). Years ago when her first child died, Mary endured a similar financial catastrophe. The community mutual aid scheme she joined after the death of her second child had gone broke after only three years. Around the world every day, there are thousands of cases like Elizabeth’s. Strengthening health systems is vital to prevent other deaths like Eliza- beth’s. It is about ensuring that the international community’s commitment to supply a San Pedro with bed-nets and drugs will not be wasted by the wrong chain of events. Strengthening health systems is about setting up the right sequence of events so that others survive. 14 Healthy Development The Right Chain of Events The right sequence of events might have saved Elizabeth. Strengthening a health system means: • ensuring the right logistics so that bed-nets (and other drugs and supplies) will reach the poor families at risk and that antimalarial drugs will not lose potency through poor storage; • helping the government change salary incentives so that workers show up for work at health centers to diagnose and treat children, and, at a mar- ginal cost, do well-child consultations at the same time, educate parents, distribute micronutrient supplements to expectant mothers (to help pre- vent low birth weights and malnutrition, which compound the effects of malaria), and deliver other services; • enhancing public-private partnerships (e.g., with community and/or faith- based organizations) in the delivery of services to complement each other and reduce supply gaps; • setting the right payment mechanisms for providers and linking workers’ salaries to both attendance and performance and reducing incentives to spend health center and hospital time on income-generating activities outside their workplace; • instituting governance arrangements that empower patients and the commu- nity to address issues such as informal payments and provider responsiveness; • setting the right insurance and/or public financing mechanisms (including donor financing) so that the cost of illness will not prevent a mother from taking a sick child for treatment and will not make her and her family destitute, forcing them to sell the few assets they possess; • taking advantage of decentralized decision making and management while, simul- taneously, putting in place compensatory mechanisms for capacity and equity issues; • having many more doctors and dedicated health professionals like Dr. Macumbo, so that countries and districts can identify and follow systemic problems without needing external assistance; and • having information systems that address all the key diseases so that doctors and health personnel can treat patients instead of filling out multiple, duplicative reports for each disease to each donor and/or government agency. 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