The World Bank Group’s support for health, nutrition, and population (HNP) has been sustained since 1997—totaling $17 billion in country-level support by the World Bank and $873 million in private health and pharmaceutical investments by the International Finance Corporation (IFC) through mid-2008. This report evaluates the efficacy of the Bank Group’s direct support for HNP to developing countries since 1997 and draws lessons to help improve the effectiveness of this support.
The evaluation reviewed findings and lessons for three prominent approaches to raising HNP outcomes over the past decade — communicable disease control, health reform, and sector wide approaches (SWAps). These approaches have been supported by the Bank as well as the international community and are not mutually exclusive.
Support for communicable disease control can improve the pro-poor focus of health systems, but excessive earmarking of foreign aid for communicable diseases can distort allocations and reduce capacity in the rest of the health system.
Health reforms promise to improve efficiency and governance, but they are politically contentious, often complex, and relatively risky.Â
SWAps have contributed to greater government leadership, capacity, coordination, and harmonization within the health sector, but not necessarily to improved efficiency or better health results.Â
The contribution of other sectors to HNP outcomes has been largely undocumented; the benefits of intersectoral coordination and multiÂsectoral approaches need to be balanced with their costs in terms of increased complexity.Â
The Bank Group now funds a smaller share of global support for health, nutrition, and population than it did a decade ago, but its support remains significant —$17 billion in country-level project financing, in addition to policy advice, analytic work, and engagement in global partnerships by the World Bank and $873 million in private health and pharmaceutical investments by IFC from 1997 to mid-2008. The Bank Group continues to play an important role and add value in HNP.
About two-thirds of the Bank’s HNP projects show satisfactory outcomes. Performance can be substantially improved by reducing project complexity, strengthening risk assessment and mitigation, conducting more up-front institutional analysis, and incorporating more evaluation to promote evidence-based decisions. The performance of IFC health investments, mainly hospitals, has improved markedly, but IFC has had limited success at diversifying its health portfolio.
The accountability of Bank Group investments for demonstrating results for the poor has been weak. The Bank’s investments often have a pro-poor focus, but their objectives need to address the poor explicitly and outcomes among the poor need to be monitored. Importantly, the Bank needs to increase support to reduce high fertility and malnutrition among the poor and ensure discussion of HNP in poverty assessments. IFC-financed hospitals mainly benefit the non-poor; IFC needs to support more activities that both make business sense and yield broader benefits for the poor.
The Bank Group has an important role in helping countries to improve the efficiency of health systems. The Bank needs to better define efficiency objectives, track efficiency outcomes, and support better information and vigorous evaluation of reforms. IFC needs to enhance support to public-private partnerships and improve collaboration and joint sector work with the Bank.
The potential for improving HNP outcomes through actions by non-health sectors is great, but incentives to deliver them are weak. Adding HNP objectives to Bank projects in other sectors, such as water supply and sanitation, raises the incentive to deliver health benefits. Strengthening the complementarity of investments in HNP and other sectors can also improve outcomes. In IFC, incentives, institutional mechanisms, and an integrated approach to health are needed to improve coordination across units.
For the Bank Group to achieve its objectives of improving health sector performance and HNP outcomes among the poor, it needs to act in five areas:
Intensify efforts to improve the performance of the World Bank portfolio.
Renew the commitment to delivering results for the poor, including greater attention to reducing high fertility and malnutrition.
Build its own capacity to help countries to make health systems more efficient.
Enhance the contribution of other sectors to HNP outcomes.
Boost evaluation to implement the results agenda and improve governance.
 
The evaluation reviewed findings and lessons for three prominent approaches to raising HNP outcomes over the past decade — communicable disease control, health reform, and sector wide approaches (SWAps). These approaches have been supported by the Bank as well as the international community and are not mutually exclusive.
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