HNP Sector Strategy: Summary

Development Challenges and Policy Directions

As described in Chapter I, this century has witnessed greater gains in health, nutrition, and population outcomes than at any other time in history.

These gains are partly the result of improvements in income and education, with accompanying improvements in nutrition, access to contraceptives, hygiene, housing, water supplies, and sanitation. They are also the result of new knowledge about the causes, prevention, and treatment of disease, and the introduction of policies that make interventions more accessible.

Despite past achievements, however, 2 million childhood deaths occur annually due to vaccine-preventable diseases; 200 million children under the age of five still suffer from malnutrition; 120 million couples still lack options in family planning; 7.5 million children die every year during the perinatal period; and 30 percent of the world is still without access to safe water and sanitation systems. In addition, disease patterns observed during the past century are rapidly changing.

As shown by broad international experience, the underlying threats to good health, nutrition, and population outcomes are well known, and affordable solutions are frequently available. But, because of weak government implementation capacity and market imperfections in the private sector, potentially effective policies and programs often fail.

Reform strategies to address these problems often require a redefinition of the role of the state, with greater government involvement in providing public health activities with large externalities, securing access to essential health services for the poor, providing information, supporting research and development (R&D) and medical education, regulating the sector, and securing adequate financing. They also require enhanced partnerships with non-governmental providers.

The Bank's Growing Engagement in the HNP Sector

Chapter II explains why investing in people is at the center of the Bank's development strategy, reflecting the fact that no country can secure sustainable economic growth or poverty reduction without healthy, well-nourished, and well-educated people. Since none of the international organizations can address today's complex health, nutrition, and population challenges alone, the Bank works closely with many other organizations. The Bank's comparative advantage is its global experience and ability to combine country-specific research and analysis with the mobilization of significant financial resources across many sectors.

Bank involvement in the HNP sector, which started in the early 1970s, initially helped countries strengthen and expand the infrastructure and supplies for basic programs. Although modest success was achieved through this approach, it became apparent that institutional and systemic changes were often needed for a sustained impact on outcomes for the poor, improved performance of health systems, and sustainable financing. The Country Assistance Strategy (CAS) is a key instrument for mobilizing the multi-sectoral involvement that is often needed to address systemic problems.

Since its first HNP loan in 1970, the Bank's activities in this sector have grown rapidly to the point where it is now the single largest external source of HNP financing in low- and middle-income countries. Today, there are 154 active and 94 completed Bank HNP projects, for a total cumulative value of US$13.5 billion in 1996 prices. This paper elaborates on the lessons learned from this experience and raises concerns about the recent decrease in analytical and policy work, a weakening in the presentation of HNP issues in the CAS, and the number of projects at risk.

The Bank's Strategy in the HNP Sector

Chapter III describes the Bank's enhanced commitment to the HNP sector during the period leading into the 21st century. The Bank's objectives in the HNP sector are to assist client countries to:

• improve the health, nutrition, and population outcomes of the poor, and to protect the population from the impoverishing effects of illness, malnutrition, and high fertility
• enhance the performance of health care systems by promoting equitable access to preventive and curative health, nutrition, and population services that are affordable, effective, well managed, of good quality, and responsive to clients
• secure sustainable health care financing by mobilizing adequate levels of resources, establishing broad-based risk pooling mechanisms, and maintaining effective control over public and private expenditure.

The Bank's strategic direction in the HNP sector will continue to evolve in a dynamic way based on international best practice. The complexities of the HNP sector and changing approaches to health, nutrition, and population problems generally do not lend themselves to rigid policy prescriptions. Instead, policy advice and financial support will continue to be guided by country-specific approaches. This will be achieved through action in the following four areas:

Sharpening Strategic Directions. Governments will be encouraged to address each of the three HNP priorities outlined above, through decentralization, greater partnerships with non-governmental providers, and a more direct public involvement in securing sustainable financing. Governments will also be encouraged to address often neglected areas that have an impact on health, nutrition, and population outcomes such as rural and urban development, other broad-based popula-tion and social policies, education, control of tobacco and alcohol abuse, food and agricultural policies, environment, water supply, sanitation, and transportation.

The Bank's Country Assistance Strategy papers will be used as key instruments for delivering this message during high-level country dialogue. Greater efforts will be made to ensure that adequate budgets and staff time are allocated to the preparation of these important documents. Efforts will also be made to underpin lending with better research and analysis by reversing recent cutbacks in country-specific sector studies and linking the Bank's research agenda more closely to the HNP priorities. Staff will be encouraged to increase selectivity based on consistency with the HNP policy objectives, potential development impact, and political commitment by clients to significant reform.

Achieving Greater Impact. The quality of client services and client responsiveness will be enhanced by strengthening the HNP knowledge base; applying lessons learned more systematically; enhancing the quality of project preparation and the piloting of new approaches; improving supervision of existing projects; using a broader range of instruments; streamlining business processes and procurement procedures; and conducting client satisfaction surveys. Finally, a renewed effort will be made to strengthen monitoring and evaluation by developing better indicators and by integrating monitoring and evaluation into project designs.

Empowering Bank HNP Staff. Resolving three staffing issues will be a key priority for the new HNP Sector Board. Are there enough staff? Are their skills adequate to the tasks they must perform? Are they deployed effectively between headquarters and resident missions? This paper suggests how the Bank will be enhancing its capacity in these areas. An effort will be made to link training to the three strategic directions, include both Bank staff and clients in training events, increase participation by resident mission staff, and extend the target audience to sectors outside the HNP sector.

Building Partnerships. The Bank will continue to build relations with partners based on its comparative advantage and clear agreement on mutual roles, as it is now doing with WHO and UNAIDS. It will build on the past success in river blindness control and support other international health, nutrition, and population initiatives. Likely candidates include collaboration with African governments in a major effort to control the malaria epidemic, work with WHO and others to combat the pandemic of tuberculosis and to promote integrated management of childhood illness, and work with many partners to launch the Global Forum on Health Research. Through such actions, the Bank expects to enhance its contribution to the global effort to improve human development during the first decade of the 21st century.