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Challenges and Regional Differences

Key challenges

Older woman scarfStrengthening Policies, Institutions, and Improving the Knowledge Base

Countries are facing a difficult challenge in striking the right balance between becoming sufficiently cost-effective and improving the equity and quality of services.   The Bank supports country efforts to achieve this balance through its lending and advisory services, and in-depth understanding and knowledge of the issues at hand. Examples of this assistance include strengthening governance, helping to root out corruption, developing systems and institutions that can fulfill the role of the state in more decentralized health systems, and building capacity.

Health Management, Medical and Nursing Education
The World Bank is helping institutions train skilled professionals to serve as policy advisors, managers, technical analysts and health sector leaders. The Bank assists countries to rationalize and improve the quality of their medical and nursing educational institutions.

Public Health Priorities
To be successful in achieving public health objectives, many of our clients have realized the need to improve the functions and approaches of public health institutions. The following groups of issues should be high on countries’ agenda for such improvements: 

  • Policy, including setting goals and standards, financing of key roles;
  • Science, and in particular promoting research and development;
  • Public health functions, including disease surveillance, data for decision-making, food safety;
  • Capacity building, such as establishing and/or financing institutions, training and deployment of skilled personnel; and
  • Social responsibilities, including addressing inequities in risks and outcomes, and protecting vulnerable populations.

Regional Differences

Addressing Diversity: Grouping the Countries in the Region

Since the early 1990s, the Region’s countries have embarked on systemic as well as economic reforms. While the nature and pace of reforms varied from country to country, several common themes have emerged:

  • New social insurance system;
  • Decentralization;
  • Selected privatization of delivery systems;
  • A new focus on primary and outpatient care;
  • Downsizing the hospital sector; and
  • New approaches to public health surveillance and infrastructure.

Over time, ECA countries have diverged both in terms of economic development and overall health sector status. Some countries have shown significant improvement in delivery systems and health outcomes, while others appear to be improving more slowly and even doing worse than before in some areas.

Based on the extent of their macroeconomic and sectoral reforms and review of their healthcare systems, ECA countries can be loosely classified into three clusters:

1) Low income countries: Several of ECA countries are also The International Development Association (IDA) countries in the World Bank’s classification, entitling them to additional support in the form of interest-free loans and grants for programs aimed at boosting equitable development, and helping pay for programs that build the policies, institutions, infrastructure and human capital required. Many of the Bank’s operations in these countries are on a relatively smaller scale, of limited geographic coverage and often in the form of pilot projects. Many of these countries are in the midst of restructuring the health sector and are currently facing challenges related to infrastructure and equipment availability for access to health care services, especially in hospitals.

2) Middle income countries: The Bank has been involved in many traditional projects in these countries. Some of these countries are now ready for operations involving a new level of sophistication in terms of approaches, whether it be in public health or new organizational models. Some of the "late reformers" in this category are now embarking on more fast-paced reforms with our assistance. Most of the countries have inherited cumbersome and inefficient health systems and infrastructures, and are in different stages of health system reforms, including financing, effectiveness, quality and efficiency improvements.

3) High middle-income, including EU accession countries. The Bank has an active history of engagement in these countries. With the increased level of development and self-sustainability in these countries, the scope of our activities is shifting from traditional lending operations to more complex arrangements (for example., sector-wide approaches), targeted activities (such as improving specific aspects of health care delivery to better match worldwide best practices), and advisory services.


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