Français Improving HNP Outcomes in Sub-Saharan Africa  Author: Ok Pannenborg, Senior Advisor for Health, Nutrition and Population, Africa Region of The World Bank.
This Leadership Forum summarizes the core recommendations made in the recent World Bank Publication -- Improving Health, Nutrition and Population Outcomes in Sub-Saharan Africa: The Role of the World Bank. The Report sets a new strategic direction for the Bank’s work in health in Africa. It is now more than 10 years since we issued the “Better Health in Africa” report, and much has changed in Africa, and not always for the better. Some of that report’s findings and recommendations still hold, as do some from the World Development Report 1993: Investing in Health, but most have yielded to the new health realities of Africa, including the devastating AIDS epidemic. Many of our African client countries are searching for the right strategic answers to address their long-term health challenges and are requesting the Bank’s support in those efforts. While this report provides a comprehensive overview and analysis of the challenges, it sometimes raises more questions than it answers by presenting a range of strategic options that will need to be tailored to the circumstances of each country or region. 
The report is intended to assist in setting a strategic agenda for finding the right answers—through country-level analytical work and evaluation of global and regional experiences. It summarizes and consolidates a multiyear effort begun in 2002 by the Africa Region’s Health, Nutrition and Population Family1 to strengthen the knowledge base and consensus on critical challenges in health development in Africa and to focus lending and analytical work around critical strategic challenges where the Bank has a comparative advantage. It also seeks to encourage efforts to organize operations and staff to more efficiently and effectively support client countries and complement efforts by other organizations to improve health outcomes among the poor in Africa. With the Bank’s commitment to the Millennium Development Goals, the impact of our work is also measured in terms of life expectancy, child and maternal mortality, malnourished children, access to reproductive health care, and reduction in the spread of HIV. This has implications for Poverty Reduction Strategies and Country Assistance Strategies. Although there are notable successes in some areas and some countries, progress in health outcomes in Africa overall is not making the gains needed to achieve economic growth and reduce poverty. In absolute numbers, household poverty has almost doubled over the last 20 years, and illness, malnutrition, high fertility, and premature death have become increasingly important and central determinants of poverty. Infant mortality remains the highest in the world, under-five mortality has worsened in a quarter of African countries, nutritional status has not improved over the past two decades, and the majority of countries still have high fertility and population growth rates. An overarching challenge is AIDS, which affects Africa more than any other region and is demonstrating how disease can dramatically undermine macroeconomic outcomes in addition to having devastating human costs. At the same time, there is a divergence between the health, nutrition, andpopulation (HNP)2 strategic priorities of the least developed countries of the world (most of the countries in the Africa Region, plus some 20 outside Africa3) and the issues receiving attention from international development institutions. The systemic, financial and behavioral challenges to improving health care in Sub-Saharan Africa are not prominent on the agendas of academic and research institutions, and the bulk of the work on health systems over the past decade has focused on high- and middle-income countries. There has been a recent surge of international attention to communicable diseases, specifically AIDS, tuberculosis and malaria. Nutrition and population issues in Africa deserve similar attention, because poor nutritional status and high rates of fertility contribute to deaths from communicable disease, impede higher educational attainment, and reduce economic growth. The overall goal of the health group in the Bank’s Africa Region is to support client countries to achieve sustainable improvements in their health outcomes, particularly for the poor. This report, prepared by a large cross-section of the health staff of the World Bank’s Africa Region, recognizes that macroeconomic development and progress in health are linked and that having a sustainable impact on communicable disease, nutrition, and population objectives requires sound human and institutional capacity in Africa’s health sector. World Bank interventions should therefore aim to strengthen the economic, institutional, and human capacity of client countries to identify and prioritize their health concerns, design locally appropriate policies that build on global and regional knowledge and experience, mobilize domestic resources and international development assistance, implement effective economic and health reform strategies, and monitor and evaluate their impact on health outcomes among the poor. Three areas are identified as strategic priorities for Bank interventions: integration of macroeconomic policies and health policies, multisectoral policies and actions outside the health sector that have major health effects (female literacy, water, electricity), and health system strengthening, including equitable and sustainable health financing, health economics, and health insurance modalities. Three mechanisms for intervention are also highlighted: resource transfer, knowledge transfer and policy advice, and monitoring and evaluation. Resource transfer, primarily health investment operations, already receives the most attention. This report proposes ways to better position the health staff in Africa to support knowledge transfer through lending and non-lending tasks and by strengthening partnerships to ensure complementary activities. Poverty Reduction Strategies, the Highly Indebted Poor Countries (HIPC) Debt Initiative, the Comprehensive Development Framework, and a greater appreciation for regional approaches and regional collaboration are all changing the environment in which development interventions are occurring. This new environment provides unique opportunities to address long-standing constraints to health objectives, but it also challenges us to ensure that the health sector contributes to poverty reduction through these new approaches. The report is not intended to be the Health, Nutrition and Population Strategy for Africa. Health sector strategies need to focus on the country level. And while Bank-defined strategies may influence and guide staff, partners, and client countries, they do not directly translate into operations on the ground. Thus the report offers a range of strategic options for clients, improves the quality of knowledge and advice to clients, and strengthens the ability of staff to respond to the specific needs of each client country in the Africa Region. For several critical areas identified in the report, the Africa Region has initiated separate strategic options working groups. These include: • Health economics and financing. • The public-private mix and partnerships. • The health workforce crises. • Pharmaceutical challenges. • Malnutrition risks. • Population and reproductive health perspectives. Each group is headed by senior Africa Region HNP staff and address such issues as health insurance and community financing, contracting-out, decentralizing and privatizing through partnerships, the crisis in health personnel, high fertility and low contraceptive prevalence, the challenges of providing the right drugs at the right time and place, and how to reverse the trends of stunting. Working groups are also being established for: • Macroeconomics and health. • Multisectoral approaches. While these areas reflect the core of the strategic work program, they are flanked by two equally important undertakings that will help to illuminate the key health challenges in Africa. One is the comprehensive analysis of death and disease problems across Africa, under the Disease and Mortality in Sub-Saharan Africa (DMSSA) project. The last similar overview was performed almost 15 years ago. The DMSSA will be the first comprehensive treatise on death and disease in Africa since the onset of HIV/AIDS changed the continent’s epidemiology. The work is being carried out mostly by African scientists, and their results are expected to be published next year. This work should provide a solid basis in fact to guide the efforts of African countries, the Bank, and others. The second is the Region’s Country Status Reports (CSRs), which have been expanded to include health, nutrition, and population issues. Health CSRs, guided and informed by DMSSA evidence and the “strategic options” products of the working groups, are an essential tool for translating regional findings and options to the country level and subsequent lending operations. The report also identifies strategic areas in which we need to acquire new skills and expertise and considers how most effectively to employ new instruments and staff. As such, this work is intended to guide Bank sector managers and country directors in the deployment of HNP staff in Africa and to inform the relationship between the Bank-wide Human Development Network and the Africa Region. Much of the Africa HNP strategic options work program (2002-2007) is carried out thanks to the generous financial support of the Netherlands Government under the Bank-Netherlands Partnership Program (BNPP), complimented by Bank budgets for the Africa Region. While all tasks are managed by senior World Bank health staff, the Report highlights the importance of engaging both African national partners and international partners in this effort. The report is quite clear on the importance of limiting the Bank’s role to health sector reform areas in which the Bank has a comparative advantage. Where it does not, its international and national partners (particularly the World Health Organization; the United Nations Children’s Fund, the Global Fund to Fight AIDS, Tuberculosis and Malaria; African universities and health research institutes; the private sector) are critical to a comprehensive and consistent effort to assist African client countries in developing strategies to improve the health outcomes of the poor. Ok Pannenborg top Related Event: Launch of the report "Improving HNP Outcomes in Sub-Saharan Africa: The role of the World Bank," Livingstone, Zambia, January 24-27, 2005 Agenda (PDF 124 KB); and in Hammamet, Tunisia, May 24-27, 2005. Feature Reading: Improving Health, Nutrition and Population Outcomes in Sub-Saharan Africa: The Role of the World Bank, by The World Bank, 2004. |
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