World Bank Response to Report by TB advocacy group ACTION

Washington DC, June 9, 2010—Tuberculosis (TB) and other communicable diseases are serious health and development challenges. The World Bank, its developing country clients, and their aid partners agree that TB must be better prevented and treated in Africa.

However, the Bank disagrees with the basic approach of “Aid without Impact”, a new report by Advocacy to Control TB Internationally (ACTION). This one-dimensional report sets out to critique sector-wide approaches (SWAps)^[1] in Africa and in particular their impact on TB. It does not consider the Bank’s work on health in Africa as a whole. Yet ACTION makes the broad claim that the Bank’s health programs fail to improve health outcomes. This claim is based on weak methodology and a linear look at a complex picture involving many actors and multiple health sector reforms being implemented in parallel.

The Bank is focused on achieving tangible results. The Bank is committed to carefully monitor results on the ground and is widely acknowledged as a leading institution in the area of monitoring and evaluation. For example, the Bank has carried out hundreds of randomized trials of development innovations and invests heavily in building national capacity to measure socioeconomic progress.

A number of different partners are involved in SWAps in Africa. Notably, the World Bank provides a relatively small share of the financing—usually less than 20 percent—with many other donors contributing. For example, in the large Tanzania SWAp, the government is by far the largest financier. Of the numerous donors’ contribution to this SWAp, the World Bank only accounts for about 15 percent^[2]. Partners currently contributing to the pooled funds include Canada, Denmark, Germany (GTZ and KfW), Ireland, Netherlands, Norway, Switzerland, UNFPA, UNICEF and the WB. Other major donors outside the pool include DfID, USAID and the Global Fund.

The majority of World Bank health operations in Africa do not involve SWAps. The Bank has 50 ongoing health operations in Africa, including projects covering health systems, communicable disease control, and nutrition. Of these, less than 10 percent support SWAps. It is therefore unclear why the report, which is largely about SWAps, headlines the World Bank. While the report surfaces a number of useful observations, many of which have already been expressed by the Bank’s Independent Evaluation Group^[3], it is incorrect in attributing most SWAp weaknesses to the Bank.

The Paris declaration principles behind SWAps (and other similar approaches) are fundamentally sound—country ownership, a single strategic framework including for monitoring and evaluation, coordination, and lower transaction costs for governments. In practice, more attention is required to results, and on this point the Bank is in agreement with the ACTION report.

That is why the World Bank has stepped up support for results-based approaches and is increasingly rolling out rigorous impact evaluations to understand what works and what does not. The Bank emphasizes Results-Based Financing (RBF)—a primary component in, for example, a recent health system performance project in Benin. The Bank is working with 24 governments in Africa on RBF, including 10 countries in which the Bank is currently providing financing. RBF efforts are much more common than SWAps in the Bank’s portfolio and many include indicators related to TB.

With regard to TB, the Bank is particularly concerned with the rise of multi-drug resistant strains which can spread easily within and across countries, and with the poor diagnostic capacity seen in vulnerable regions. A key project launched recently is the US$63.66 million East Africa Public Health Laboratory Networking Project across Kenya, Tanzania, Rwanda and Uganda—where TB-HIV co-infections are highly prevalent. This is an innovative, next-generation effort to speed up the accurate diagnosis and hence rapid treatment of key communicable diseases, including TB, among vulnerable populations living in cross-border areas. The project seeks to forestall potential epidemics that could occur with the thinning of economic borders in the region and greater labor mobility going forward. It serves not just TB patients, but all patients, and draws on expertise from other leading health agencies.

Finally, it is noteworthy that in 2007, after extensive consultations with WHO, the UN health agencies, country clients, and various foundations, the Bank was asked—based on its comparative advantage—to help countries strengthen their overall health systems to achieve better health for mothers, children, families, and communities. Fewer TB infections is one of these many health outcomes that is a high priority for the Bank and its clients. The Global Fund to Fight AIDS, TB, and Malaria; the WHO; the Stop TB partnership; and the TB Drugs Facility are at the forefront of this fight, while the Bank works with countries to build stronger underlying health systems that will help governments and disease-specific agencies to deliver more sustainable results over the long term.