The World Bank today launched a new health, nutrition, and population, strategy that will help developing countries strengthen their health systems to improve the health and well-being of millions of the world’s poorest people, boost economic growth, reduce poverty caused by catastrophic illness, and provide the structural ‘glue’ that combines multiple health-related programs within client countries. Called Healthy Development: The World Bank’s Strategy for Health, Nutrition, and Population Results, the new plan updates the Bank’s contribution to improving health outcomes at the global, regional, and national levels, including the 2015 Millennium Development Goals, at a time when new multilateral organizations and foundations are increasing their prominence in health financing—such as the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria, and the Bill and Melinda Gates Foundation—and pandemics and regional epidemics have continued to emerge, while others have expanded—HIV/AIDS, malaria, drug resistant-TB, SARS, avian flu.
According to the Bank’s new strategy, there have also been significant increases in premature deaths related to chronic diseases—diabetes, pulmonary diseases, hypertension, cancer—linked to the tobacco-addiction and obesity pandemics. Malnutrition is problematic not only in poor countries (with both under-nutrition and obesity), but also in rich countries confronted with a rapidly growing prevalence of obesity. “Global health has changed so radically over the last decade that the Bank is redoubling its commitment to help developing countries and global partners achieve better health for people, and especially poor and vulnerable communities,” says Joy Phumaphi, the World Bank’s Vice President for Human Development, and a former WHO Assistant Director-General for Family and Community Health. “While there is more health financing available to countries than ever before, much of it is earmarked for fighting priority diseases such as HIV/AIDS, malaria, tuberculosis, and some vaccine-preventable diseases, and there’s less available for strengthening health systems at country level, for maternal and child health, for nutrition, and for family planning priorities.” The Bank consulted widely in preparing its new strategy with more than 400 local and global leaders from developing and middle-income countries, development donors, and civil society groups in nine partner countries, namely: Argentina, Algeria, Armenia, Tanzania, Mali, Djibouti, Mexico, India, and Indonesia. At the global level, it also conferred closely with the World Health Organization, the Global Fund, and other specialized health agencies with which it will coordinate and implement its new health systems approach.
Strengthening health systems
Phumaphi says ‘strengthening health systems’ may sound more abstract and less important than fighting specific diseases, but she argues that well-organized and sustainable health systems are necessary to achieve results. For example, protecting people from malaria deaths and illness calls for strong health systems as well as specific disease control measures, such as insecticide-treated bed-nets, indoors residual spraying, and the use of Artemisinin-combination (ACT) drugs. On the ground, in practical terms, it means putting together the right chain of events (financing, regulatory framework for private-public collaboration, governance, insurance, logistics, provider payment and incentive mechanisms, information, well-trained personnel, basic infrastructure, and supplies) to ensure that poor people get the good quality health services they need to save and improve their lives. Many existing aid programs for health assume a functioning health system exists with the capacity to deliver drugs to the people who need them. But, as the strategy says, that is often not the case. “Strengthening health systems is essential but it’s not a result in itself,” says Cristian Baeza, the World Bank’s acting Director of Health, Nutrition, and Population, and coordinator of the new strategy. “Success in systems-strengthening cannot be claimed until the right chain of events on the ground prevents avoidable deaths and extreme financial hardship due to illness; because, without results, health system strengthening has no meaning. However, without health system strengthening, there will be no results.
Baeza says working ‘cross-sectorally’ is imperative to saving lives and improving the quality of health of the world’s poor—having health ministries, their local departments, and their international aid donors work more closely together with other strategic government ministries to achieve better health results within countries. According to the Bank’s new strategy, “many advances in health status achieved during the 20th century were the result of close synergy among health and other key sectors in the economy such as water and sanitation, environment, transport, employment, education, agriculture, energy, infrastructure, and public administration. For example, investments in girls’ education improve household decisions on nutrition and demand for basic health care. At the same time, investing in basic nutrition during pregnancy and infancy has a substantial positive effect on early childhood development, which, in turn, significantly contributes to educational attainment, employability, and future income.”
Good health also spurs economic growth
In its new health plan, the Bank says that health is often thought to be an outcome of economic growth. Increasingly, however, it maintains, good health and sound health system policy have also been recognized as a major, inseparable contributor to economic growth. Advances in public health and medical technology, knowledge of nutrition, population policies, disease control, and the discovery of antibiotics and vaccines are widely viewed as catalysts to major strides in economic development, from the Industrial Revolution in 19th century–Britain to the economic miracles of Japan and East Asia in the 20th century. Sound health policy, one that sets the correct incentive framework for financing and delivering services, also has important implications for overall country fiscal policy and country competitiveness.
Sexual and reproductive health
The World Bank continues to play a central role in ensuring access to all reproductive services through policy advice and financial assistance. In its policy discussions with client countries, the Bank will continue to affirm: its long-standing and strong commitment to the Cairo Consensus, the landmark 1994 agreement on family planning and sexual and reproductive health; and to provide countries with whatever financial and technical help they request in this area. Consequently, in its new strategy, the Bank commits itself to work on population issues in countries with high unmet needs in sexual and reproductive health in the following areas: assessing multi-sectoral constraints to reducing fertility, determining impacts of population changes on health systems and other sectors, and assisting countries in strengthening population policies; providing financial support and policy advice for comprehensive sexual and reproductive health systems and care, including family planning, and maternal and newborn health; generating demand for reproductive health information and systems, including improving girls’ education and women's economic opportunities, and reducing gender disparities; raising the economic and poverty dimensions of high fertility in strategic documents that inform policy dialogue (such as, Country Assistance Strategies, Country Economic Memoranda, and, country-led Poverty Reduction Strategies (PRSPs). “Women endure a disproportionate burden of poor sexual and reproductive health,” says the Bank’s Joy Phumaphi, who also served as Health Minister in her home country of Botswana from 1999-2003. “Their full and equal participation in development depends directly on accessing essential sexual and reproductive health care. This strategy commits the Bank to help these women, along with the UN Population Fund, WHO, and the technical health agencies, to make voluntary and informed decisions about fertility.”
Results Framework
The new strategy calls for greater linkage of health financing with better results. The best way to do this, it says, is to connect development aid as directly as possible to achieving health, nutrition, and population outcomes in developing countries. For example, programs and projects could directly finance targets for vaccination, women receiving prenatal care, and babies born with high Apgar scores which record a baby’s summary of vital signs. For example, the Banks says that Argentina and Rwanda both emphasize reducing deaths of children under the age of five years in their development plans, but each country has to take a different path. To reduce infant and neonatal mortality, Argentina is concentrating on improving provider incentives to expand access and quality of health service delivery for the poor mothers and children, particularly for neonatal care. In contrast, reducing under-five mortality in Rwanda requires a much broader inter-sectoral approach, entailing, for example, expanding basic vaccine coverage, increasing access to basic perinatal health services, raising educational levels, expanding access to safe water and sanitation, improving access to key micronutrients, and increasing birth space (closely linked to women’s participation in the labor market).
World Bank contribution to health over previous decade
Since the Bank’s last health strategy was approved in 1997, the Bank lent US$15 billion and disbursed US$12 billion in HNP for more than 500 projects and programs in more than 100 client countries, making the Bank one of the world’s largest international financing organizations of health, nutrition, and population activities in the last decade.
