|World Bank Group management welcomes IEG’s evaluation of World Bank Group work in the health, nutrition, and population sector after 10 years of implementation of the 1997 health, nutrition, and population (HNP) strategy.
As a global development institution dedicated to supporting country and global efforts to achieve the better health outcomes that are central to reducing poverty and to achieve the 2015 Millennium Development Goals (MDGs), management appreciates the findings of this evaluation and other internal and external efforts to improve the World Bank Group’s effectiveness in this key sector. (For the full-length Management Response and the detailed World Bank Management Action Plan, click here.)
This IEG report is consistent with the findings of the World Bank’s own self-assessment, which prompted the Bank to adopt a new HNP strategy in mid-2007—Healthy Development: The World Bank Strategy for Health, Nutrition, and Population Results. In fact, IEG staff shared the preliminary results of their work with the strategy team that designed the subsequent 2007 strategy.
The new Strategy sharpened the Bank’s focus on results on the ground; concentrated Bank contributions on health systems strengthening, health financing, and economics; supported government leadership and international community programs to achieve these results; and focused on enhanced engagement with global partners. Early implementation of the strategy has been promising. An example is the success of Rwanda’s resultsbased approach to improving service delivery, with malaria incidence declining by 62 percent and child mortality decreasing by 30 percent.
Main Findings and Recommendations
The IEG evaluation covers a decade of Bank support, starting in 1997. The specific performance to date of the Bank’s new strategy, adopted in mid- 2007, is discussed in a separate Strategy Progress Report (World Bank 2009). Bank management has taken many of the findings and recommendations into account in the Progress Report and the Management Action Plan. While not detracting from the importance of the evaluation and its usefulness for the Bank’s future work in health, nutrition, and population, management has observations on some of the findings.
Quality of the Bank HNP Portfolio—The principal finding of the IEG evaluation is that, while two-thirds of the Bank’s HNP projects in the period 1997–2007 achieved their development objectives, one third, mostly in African countries, did not, clearly warranting close scrutiny. Current data on risky projects and programs in the HNP portfolio show that problems continue to be most acute in HIV/AIDS projects and in programs in the Africa Region. The HNP sector’s performance in much of the rest of the world is now near the performance of other sectors, and the Africa Region has developed new strategic approaches to improving portfolio quality, including a focus on results and emphasis on health systems strengthening.
IEG notes the underperformance of HIV/AIDS projects during the height of the epidemic in southern Africa during the late 1990s, a period characterized by regional conflict and instability, and the internal displacement of millions of refugees across borders in the Great Lakes Region of the continent. Current projects, focusing on highrisk groups, also constitute a disproportionate number of projects at risk in the current portfolio. In order to redress this situation, a comprehensive approach has been adopted to improve the quality of the Bank’s HIV/AIDS operations, including an umbrella restructuring of the Multi- Country HIV/AIDS Programs (MAPs).
Investing in Health Systems—The 2007 strategy underscores the need to focus on health system strengthening to ensure better health outcomes, particularly for the poorest and the most vulnerable. Over the past two years, projects with a primary focus on health systems have increased twofold. In line with the strategy, 67 percent of Bank programs approved since fiscal year 2007 that focused on priority disease areas also include strong components on health system strengthening. An Africa-focused initiative started in 2008 will improve the Bank’s capacity to provide rapid advice and assistance on the ground, particularly in health finance, human resources, governance, supply chain management, and infrastructure planning.
Doing More in Population and Reproductive Health—Bank management agrees with IEG that it should do more in this key area. The Progress Report highlights plans for strengthening support for population and reproductive health, using a health systems approach that is critical to improving maternal and child survival rates.
Investing in Nutrition Support—We also agree with IEG’s findings that the Bank needs to focus more on nutrition. The need for action is even more important today in the context of the ongoing crises in fuel, food, and fertilizers, as well as the escalating effects of the financial crisis. We are therefore investing significant resources in the next few years to ramp up the Bank’s analytical and investment work and leverage resources from other donors. The agenda for scaling up nutrition is being catalyzed with additional budget and external resources, starting in 2009 and continuing for three years.
Improving Monitoring and Evaluation (M&E)—As noted in the Strategy Progress Report, this is an important part of strategy implementation, (including the work on retrofitting projects and improving the design of new projects). Routine health monitoring systems (including surveillance, facility reporting, vital registration, census data, resource tracking, and household surveys) may first need to be strengthened to provide the data and indicators that are needed. The Bank is working with partners, such as the World Health Organization, to develop better ways to monitor the health MDGs, including the estimation of trends in child and maternal mortality, for which updates have recently been issued.
The International Financial Corporation’s HNP Footprint. IFC has considerably increased its footprint in HNP over the past decade and is prepared to intensify collaboration within the World Bank Group. There is a growing acknowledgement of the role of the private sector in health care in developing countries. The period under review has seen a marked increase in IFC’s activity in health. During this time, many lessons have been learned, specialist knowledge has deepened, and performance has improved by any measure applied. As in other sectors, IFC continues to strive for greater development impact, and we therefore welcome all input that could help us to do better.
Management Action Record
1. Intensify efforts to improve the performance of the World Bank’s health, nutrition, and population support.
a) Match project design to country context and capacity and reduce the complexity of projects in low-capacity settings through greater selectivity, prioritization, and sequencing of activities, particularly in Sub-Saharan Africa.
Management agrees that complexity can be at least partially addressed by adopting IEG recommendations, such as thorough technical preparation, including solid analytical underpinning, political mapping, high quality at entry, including prioritizing interventions relative to the institutional context, and establishing a good results framework, followed by in-depth supervision and parallel policy dialogue with client and partners.
However, HNP operations are rarely institutionally or technically simple, since the desired outcome depends on a complex and interacting set of social, cultural, and institutional factors. This is recognized by donors and policy makers, whether in low-income, middle-income, or high-income countries. The inherent complexity of the sector may be attributable to the political economy in a multi-stakeholder environment, the need for extensive coordination and partnership with national and international agencies and civil society organizations, and the often difficult technical and social nature of the subject. The recent international recognition of the need to invest in (complex) health systems in order to ensure the success of vertical disease control programs in low-income countriess is testimony to the fact that there are few easy ways to avoid systemic complexity. Investing in simple programs would not necessarily provide for lasting impact.
(b) Thoroughly and carefully assess the risks of proposed HNP support and strategies to mitigate them, particularly the political risks and the interests of different stakeholders, and how they will be addressed.
|Management agrees in principle to carry out political mapping exercises prior to investments in the sector where appropriate. As there are currently mandatory risk assessment and mitigation steps built into the project cycle and approval process, we anticipate improved risk mitigation strategies in newer HNP operations. These enable staff to identify major political and technical risks and devise with the client suitable risk-mitigation strategies. However, it is also evident that despite good assessments and risk-mitigation strategies, neither technical nor political risks can be completely offset.|
(c) Phase reforms to maximize the probability of success.
Management agrees with this recommendation and would note that more projects are now taking this approach.
(d) Undertake thorough institutional analysis, including an assessment of alternatives, as an input into more realistic project design.
Management agrees with this recommendation.
(e) Support intensified supervision in the field by the Bank and the borrower to ensure that civil works, equipment, and other outputs have been delivered as specified, are functioning, and are being maintained.
Management agrees in principle with this recommendation. Supervision requirements, both in terms of staffing mix and budgeting, are being reassessed Bank-wide within the context of the ongoing review of investment lending. Given the inherent dispersed nature of many HNP investments, care must be taken during project design to ensure that the client assumes responsibility for ensuring that civil works, equipment, and other outputs have been delivered as specified, are functioning and being maintained, while the Bank audits/appraises/confirms that such monitoring is taking place so that detailed supervision of projects can be properly conducted within likely budget norms.
Management action: In response to the portfolio quality challenges, the HNP Sector Board has introduced a quarterly portfolio monitoring and benchmarking system, which is being used by the Sector Board and regional management to improve portfolio performance.
2. Renew the commitment to health, nutrition, and population outcomes among the poor.
(a) Boost population and family planning support in the formof analytic work, policy dialogue, and financing to highfertility countries and countries with pockets of high fertility.
Management agrees with this recommendation for high-fertility countries and regions—in particular as those areas have received less attention from other development partners as well over the past decade. Demand for stand-alone population (family planning) programs has declined over time. The Bank should increase support for reproductive health programs, which are usually better implemented when they are fully embedded into public health/clinical services. We would generally not support a return to stand-alone vertical family planning projects. Moreover, AIDS control projects (or components) and the work through UNAIDS have substantially contributed to reproductive health—and greatly expanded coverage of family planning for otherwise hard to-reach population groups. In countries that are significantly advanced through the demographic transition, clients increasingly request advice and financing on financial protection, labor markets, and long-term care needs to address the ongoing demographic and epidemiological shifts resulting in an aging society. Finally, Development Grant Facility–financed programs such as the Special Program of Research, Development and Research Training in Human Reproduction (HRP), into which the Bank has substantial technical, financial, and managerial input, are contributing to the global reproductive health agenda.
(b) Incorporate the poverty dimension into project objectives to increase accountability for health, nutrition, and population outcomes among the poor.
Management generally agrees with the need to ensure that project design responds to the priorities and needs of the poor, and to measure the full impact of improved health services for the poor. Management will therefore seek to ensure that adequate attention is given to poverty dimensions in project design and supervision. However, direct assessments, where feasible, may be technically complex and expensive. The Bank publication Attacking Inequality in the Health Sector—A Synthesis of Evidence and Tools (Yazbeck 2009) lays out a policy menu (pro-poor policy reforms along six dimensions) and a list of the analytical tools for understanding the constraints to pro-poor targeting of public health investments in poor countries.
As opposed to specific income groups, disease control programs must focus on the prevailing epidemiology (for example an AIDS program must focus on high-risk groups, irrespective of income). A malaria program focused solely on the poor would fail to eliminate malaria. Polio could only be eradicated from the Western Hemisphere by focusing on large, inclusive campaigns targeting all income groups. Such investments in public health and control of communicable diseases are global public goods, generating positive externalities for society, irrespective of income status.
Investments in health systems should result in increased access and better quality of services— also benefiting the poor. Investment in social security and social safety net systems prevents the middle class from falling into poverty in case of a catastrophic health event.
Management notes the substantive improvements over the past years in quantity and quality of HNP involvement in Poverty Reduction and Economic Management Network (PREM)–led analytical work, and agrees that HNP must be fully included in all Poverty Assessments and fully examined in the preparation of CASs.
(c) Increase support to reduce malnutrition among the poor, whether originating in the HNP sector or other sectors.
Management agrees with this recommendation. Particularly in the context of the global food crisis, the Bank needs to increase investments in nutrition, with a particular focus on maternal and infant nutrition. Management is therefore investing significant resources in the next few years to ramp up the Bank’s analytical and investment work and leverage resources from other donors. the agenda for scaling-up nutrition is being catalyzed with additional budget resources, starting in 2009 and continuing for three years. The increased allocations are being utilized principally in Africa and South Asia, two Regions where the malnutrition burden is highest. These funds will be complemented by additional trust fund resources from Japan, and possibly from other donors that are currently engaged in discussions on this issue.
(d) Monitor health, nutrition, and population outcomes among the poor, however defined.
Management agrees in principle with this recommendation, and will seek to ensure adequate provision for data collection, where technically feasible, during quality-at-entry and supervision reviews, in particular as far as poverty targeting is concerned. In order to accomplish this in a sustainable manner, management believes that the first priority in many poor countries is to establish routine health monitoring systems (surveillance, facility reporting, vital registration, census data, resource tracking, household surveys, and the like). These data systems need to be strengthened in parallel to investing in project-specific management information systems, in order to provide data and indicators that are needed for program targeting and monitoring for (but not limited to) the poor.
(e) Bring the health and nutrition of the poor and the links between high fertility, poor health, and poverty back into poverty assessments in countries where this has been neglected.
Management agrees. Substantial progress regarding this recommendation has been made in some regions over the past years, both in terms of the analytical underpinnings, the need for capacity building, and investment needs. Management will seek to improve cross-sectoral collaboration with the PREM Network at country level as a precondition to further improvements.
Management action: Recent major analytical work for staff and policy makers prepared by the Human Development Network to improve effectiveness in reaching the poor includes: Reaching the Poor with Health, Nutrition and Population Services—What Works, What Doesn’t and Why (Gwatkin, Wagstaff, and Yazbeck 2005) and Attacking Inequality in the Health Sector—A Synthesis of Evidence and Tools (Yazbeck 2009). It is expected that this work will help clients and staff achieve better results in reaching the poor with health services.
Concerning nutrition, in addition to disseminating the new Nutrition Strategy (Repositioning Nutrition as Central to Development—A Large Scale Action [World Bank 2006c]) the Regional Reprioritization Fund will allocate US$4 million over fiscal years 2009–11 to strengthen Bank capacity to scale up nutrition support and leverage resources from other donors.
(a) Expand support for innovative approaches and viable business models that demonstrate private sector solutions to improve the health of the poor, including expansion of investments in low-cost generic drugs and technologies that address health problems of the poor.
Management agrees with working on innovative approaches and helping private providers to move down-market to serve lower-income groups and markets. IFC has several initiatives already under way to build on its work to date. Some examples include:
Health in Africa initiative.
Working with clients to invest expertise and capital from high-income to low- and lower-middle income countries, e.g., Saudi-German Hospitals, based in Saudi Arabia, opened hospitals in Yemen, Egypt, and Ethiopia with IFC finance, creating a South-South investment.
Output-based aid projects in Yemen and Nigeria, in which poor people get subsidized care in IFC-financed private facilities that otherwise would not exist.
Creating finance facilities for health care small and medium-size enterprises in low-income countries by use of structured finance, combined with technical assistance, that IFC pioneered with banks in Africa and elsewhere to finance education facilities, and building on that knowledge to apply it in health.
Working with clients to move down-market within their country, e.g., working with Apollo Hospitals in India to create hospitals in secondary cities.
(b) Assess the external and internal constraints in achieving broad social impacts in the sector.
A number of continually changing factors are enabling greater activity in the sector. Among others, the private sector partners with whom IFC must work are continually evolving and developing more capacity and professionalism than was the case 10 years ago, due in part to IFC’s involvement with them. Nevertheless, there is a lot still to be done and IFC needs more and larger partners with whom to work and is developing long-term partners and new approaches with a view to greater scale and impact. IFC’s recent Health in Africa initiative also analyzed constraints and ways to address them across multiple countries in a particularly difficult region. This is indicative of the organization’s evolving approach as both its knowledge and resources for addressing this recently entered sector expand.
3. Strengthen the World Bank Group’s ability to help countries to improve the efficiency of their health systems.
(a) Better define the efficiency objectives of its support and how efficiency improvements will be improved and monitored.
Management generally agrees with this recommendation. The efficiency argument is a key rationale, in particular for working with health systems in middle-income countries. Since national health expenditures rise with national income, improving sector efficiency makes an important contribution to fiscal sustainability. However, in the health sector there are important efficiencyequity trade-offs. This points to the fact that efficiency gains should not be the sole objective of Bank-financed health programs.
(b) Carefully assess decisions to finance additional earmarked communicable disease activities in countries where other donors are contributing large amounts of earmarked disease funding and additional funds could result in distortion in allocations and inefficiencies in the rest of the health system.
Management agrees that it is necessary to carefully assess the need for additional finance where other donors are contributing substantial amounts. While fiscal space and potential budget substitution by ministries of finance should be closely monitored, the empirical evidence of distortionary effects of large vertical disease programs is scanty. Proposals for Bank support for new disease-specific programs are closely coordinated with other donors and often fund complementary financing and institutional needs, for which financing was unavailable from other donors.
(c) Support improved health information systems and more frequent and vigorous evaluation of specific reforms or program innovations to provide timely information for improving efficiency and efficacy.
Management agrees partially with this recommendation: Technical support and financing for management information systems as well as routine surveillance and vital statistics systems should be ramped up. However, the outcomes of management information system investments may be hard to evaluate fully within the timeframe of a project, and multiple determinants influence health outcomes. Management also notes that the Paris and Accra Declarations and the new OP 13.60 emphasize the use of pooled funding and country-level M&E systems instead of ring-fenced funding and stand-alone M&E systems. Hence, the standard should be that sufficient evidence on outputs, intermediate outcomes, and outcomes should be collected to establish a credible story line to assess the link between Bank-financed investments and overall sector progress, including efficiency and efficacy gains.
Management action: The Human Development Network and the Regions have carried out major analytical work that will help policy makers and Bank staff to better understand challenges and trade-offs in health financing, risk pooling and insurance, the issue of fiscal space and external assistance (Health Financing Revisited—A Practitioner’s Guide [Gottret and Schieber 2006]). Furthermore, the Bank is a lead sponsor of the International Health Partnership (IHP+). This is a country-led and country-driven partnership that calls for all signatories to accelerate action to scale up coverage and use of health services and deliver improved outcomes against the healthrelated MDGs, while honoring commitments to improve universal access to health.
(a) Support public-private partnerships through Advisory Services to government and industry and through its investments, and expand investments in health insurance.
IFC has supported pioneering health public-private partnerships (PPPs) in Romania and Lesotho and continues to work in this area. While health PPPs are a relatively recent development in emerging markets, there is increasing interest in health PPPs as a means to expand and improve services for the public. The work in Lesotho is at the leading edge for emerging-country health PPPs in several aspects. From the investment aspect, partners in health PPPs to date have often been construction companies rather than health providers and have not required capital from IFC. In some of the few cases where it is truly health services, rather than construction and facilities management, that have been provided by the private sector, IFC has financed providers of renal dialysis services and diagnostic services to public health systems.
Many of IFC’s clients who provide health services have prepayment schemes for health care in operation and this makes the most business sense. In some instances, by creating more low-cost local capacity, IFC health-provider clients have made it possible for health insurers to offer new products with lower premiums. Experience to date has shown that the business case for direct investment in stand-alone private health insurance does not exist to the extent envisaged when the 2002 IFC health strategy was devised. The few health insurance operations found to date that actually needed capital have needed only very small amounts, too small to be viable transactions. This segment of the sector is intended to be addressed by the health-sector financing facilities now being developed and in early implementation. For the balance, typically the health insurer is one arm of a larger insurer that is well capitalized from its other operations such as life insurance or is a subsidiary or joint venture of a well-capitalized foreign parent company.
(b) Improve collaboration and joint sector work with the World Bank, leveraging Bank sector dialogue on regulatory frameworks for health to engage new private actors with value added to the sector, and more systematically coordinate with the Bank’s policy interventions regarding private sector participation in health.
In some situations, such as the Health in Africa initiative and the Lesotho healthcare PPP, IFC and the World Bank are collaborating very closely. In practice, there are times when this is practical and possible and times when it is not. The imbalance in the size of human resources working on health in the two organizations, with the World Bank having many more people dedicated to health, requires IFC to be judicious in how it allocates its resources to work with the Bank.
4. Enhance the contribution of support from other sectors to health, nutrition, and population outcomes.
(a) When the benefits are potentially great in relation to the marginal costs, incorporate health objectives into nonhealth projects, for which they are accountable.
Management agrees in principle, but implementation can be challenging. For example, health is a secondary objective for many clients in water and sanitation operations and borrowers are reluctant to add potentially costly components. In addition, the current mandate, staffing, and budget of the water sector does not allow the sector to be “accountable for health benefits” as IEG suggests. Under IDA 15 guidelines, it is mandatory to track “safe and sustainable access to water and or sanitation services” as an outcome, with health benefits classified as impacts, rather than outcomes. Because it is difficult and expensive to track health impacts, the number of water projects with a health objective has declined, and this trend is likely to continue absent changes in policy and/or additional resources.
(b) Improve the complementarity of investment operations in health and other sectors to achieve health, nutrition, and population outcomes, particularly between health and water supply and sanitation.
Management generally agrees that we need to support client countries to seek improved complementarity of water and sanitation programs with health projects, in particular as clients are reluctant to burden all water and sanitation operations with potentially small (albeit cost effective) health impact objectives, and to demonstrate and document empirically such impact and outcomes in each case.
(c) Prioritize sectoral participation in multisectoral HNP projects according to the comparative advantages and institutional mandates, to reduce complexity.
Management agrees and notes that significant additional resources have been mobilized from fiscal year 2009 on to better respond to client and partner requests for embedding Bank support in multisector programs, or to provide just-in-time advice to countries and partners in development. Specifically, over US$3 million additional Bank budget will be allocated per year to ramp up Bank support for the 14 IHP+ countries, mostly in Africa, including the establishment and staffing of two regional technical support hubs in Africa. Additional resources are being provided by other donors.
(d) Identify new incentives for Bank staff to work crosssectorally for improving HNP outcomes.
Management agrees, but notes that this is a concern across the institution that needs institutional analysis and solutions, including revisiting the incentives needed for improved cross-sectoral and cross-departmental collaboration.
(e) Develop mechanisms to ensure that the implementation and results for small health components retrofitted into projects are properly documented and evaluated.
Management agrees, subject to the limitations mentioned previously related to M&E and attribution.
Management action: the HNP sector continues to expand and deepen cross-sector engagement. Recent products include work on Social Safety Nets, Ageing and Demographic Change, Early Childhood Development and Poverty, Environment and Health. Ongoing initiatives include work with Water and Sanitation, Transport, Poverty Reduction and Economic Management, Agriculture and Rural Development, and Operations Policy and Country Services on global challenges ranging from global infectious threats, climate change (part of the 2010 World Development Report), road safety, and an Advanced Market Commitment to develop a pneumococcal vaccine suitable for use in Africa.
(a) Improve incentives and institutional mechanisms for an integrated approach to health issues across units in IFC dealing with health, including the way IFC is organized.
IFC is currently going through a period of reorganization aimed at achieving a number of goals. As part of this, industry clusters have been created and Health and Education are in the same cluster with Global Manufacturing and Services, which contains IFC’s pharmaceutical activities. Communication and collaboration between teams working on health care and pharmaceuticals are frequent and ongoing. The market reality is that it is rare for one organization to invest in both health care provision and pharmaceutical manufacturing. The knowledge needed to work with these clients is also very different.
Information is also exchanged between the Infrastructure Advisory group, advising on health PPPs, and the Health and Education investment department. Care has to be exercised that such information is exchanged only at appropriate points in project life cycles to avoid conflicts of interest that could arise in being both advisor to a bidding process and financier of a winner of a bid. Integrating these two functions too closely would create a conflict for PPP work.
5. Implement the results agenda and improve governance by boosting investment in and incentives for evaluation.
(a) Create new incentives for monitoring and evaluation for both the Bank and the borrower linked to the project approval process and the midterm review. This would include requirements for baseline data, explicit evaluation designs for pilot activities in project appraisal documents, and periodic evaluation of main project activities as a management tool.
Management agrees. We face the challenge that countries may be unwilling to borrow for M&E, particularly for expensive impact evaluations. These large-scale evaluations may require external (grant) financing in most cases, which can be particularly difficult to obtain in a middle-income country context. A second challenge is to ensure that data are readily available for public use. Some countries are not ready to fully share data and may be reluctant to include data in public documents, such as PADs, and the like. This can delay the establishment of appropriate baseline data and results frameworks prior to project approval.
Management action: The HNP Sector Board and the Human Development Network have made important progress to address M&E in the HNP portfolio: A number of Regions have carried out a complete portfolio review, including the retrofitting of all operations to assure an up-to-date results framework. Moreover, over US$2.8 million of Spanish Trust Fund (SIEF) resources are currently under implementation, benefiting impact evaluations of 15 HNP projects in all Regions, focusing on Pay for Performance in Health (5 projects, US$1.2m), Malaria Control (5 projects, US$600,000), HIV/AIDS Prevention (3 projects, US$750,000), and Innovations and “quick wins” (2 projects, US$300,000).
(a) Enhance its results orientation by developing clearly specified baseline indicators and an evaluation framework that adequately measures IFC’s health sector objectives and results.
At the project level, IFC has implemented the Development Outcome Tracking System toward the end of the period under review. Over time, this is expected to improve such results orientation and specifying of baseline indicators.
IFC also agrees that where there is a sufficient critical mass of projects in the health sector in a specific country, it makes sense to try to asses IFC’s development impact in the sector beyond aggregating project-level results. While recognizing that attributing sector development to IFC’s intervention is an issue that needs to be carefully addressed, IFC is looking into ways of measuring results beyond the project level. Among others, the work IFC is undertaking with the IDAIFC Secretariat in reviewing the CAS results matrix could lead to the establishment of a country-level sector development results framework that could be used in countries where IFC has a critical mass of projects in health. IFC is also exploring setting development impact and reach targets for investment departments, including health and education.
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