Publications

	Table of Contents
p. 4 of 27 BACK | NEXT Executive summary Introduction Major themes Development of the policy paper Regional health context The Bank’s involvementin the health sector Issues and options The Bank’s health policy

Policy for the Health Sector : Introduction

---

Development of the policy paper

This paper builds on previous Bank papers in the health and population sector, particularly Health, Population and Development in Asia and the Pacific (1991) and the Population Policy (1994).² While health and population activities are intimately linked, population issues are not examined in detail in this paper as they are addressed in the Population Policy. Similarly, this paper will not explore nutrition interventions in detail, as these are being examined under regional technical assistance and will be addressed in a forthcoming policy paper on nutrition. In developing this paper, broad and frequent consultations took place with a wide variety of stakeholders. In workshops in Bangladesh, Philippines, and Viet Nam, representatives of governments, academe, nongovernment organizations (NGOs), community organizations, and the private sector discussed a draft of this paper with Bank staff. Comments and suggestions were also sought from other DMC governments, NGOs, academic institutions, multilateral organizations, and individual experts, and more than 70 written replies were obtained. (A summary of the written comments and of the discussions in the country workshops is available on request.) In addition, detailed discussions were held with staff of the World Bank and the World Health Organization (WHO). The perceptions of beneficiaries were assessed in two ways: selected NGOs working directly in communities were asked about their clientele’s felt needs and their perceptions about health and health services generally, and the medical anthropology and sociology literature was also searched to find studies regarding beneficiary perceptions.

The diversity of the Bank’s DMCs, particularly their different stages of economic development, makes it a challenge to define issues that apply equally to all of them. There are certain problems that are more important for some DMCs than others. For example, diabetes is a much more common problem in the Pacific DMCs than elsewhere in the region, while malaria is a more serious problem in Southeast Asia. (Detailed statistics on the health status of each DMC are available in the Bank’s 1999 publication Health Sector Reform in Asia and the Pacific, Options for Developing Countries.) However, in spite of the heterogeneity of the DMCs, it is possible to identify common strategic issues and policy responses. For example, in all the DMCs, regardless of their level of development, insufficient attention to PHC can have devastating consequences. The Central Asian republics, despite having highly trained health workers and a sophisticated health care delivery system, have just emerged from the worst diphtheria epidemic since World War II, even though the vaccine needed to prevent the disease costs only $0.25 per fully protected child.

Given the challenges the region faces in the health sector, there is a need to innovate and evaluate new methods to address major issues. Since innovation is critical to success, the Bank can play a leadership role by actively encouraging and financing innovative approaches. Part of the process of innovation will involve careful testing and evaluation of these approaches so that useful ones can be separated from those that are merely novel. Many of the important innovations will arise in the area of the relationship between the public and private sectors. While this is an exciting area, it is also an area where little is known for certain and there will likely be important differences between countries. In settings such as this, it is inappropriate to be prescriptive. Rather, a learning, evolutionary, and empirically based approach is called for.

An empirical approach to testing new ideas in management and financing exem-plifies the need to apply scientific rigor more generally to health sector activities. The application of scientific methods and approaches will be a critical means for achieving results. For example, rigorous monitoring and evaluation of the effectiveness of health care delivery will help ensure impact and emphasizes the need for appropriate management information systems. Support for certain types of health research will also reap great benefits and provide the interventions that will constitute the opportunities of the next ten years. Discovering new interventions will not be sufficient. A scientific approach will also emphasize the rapid deployment of cost-effective new technologies. Finally, scientific approaches are needed to critically appraise the evidence for the specific interventions that are prioritized and the broad organizational changes that are recommended. The Bank can play a catalytic role by helping in the accumulation and dissemination of such evidence.

The Bank has been involved in the health sector for 20 years and has made 35 loans aimed at improving health and population services (see Appendix 1). It has made a significant contribution to the region’s concerted effort to expand publicly provided health services. Starting in the 1960s, developing countries in the region recognized the need to invest in health services and established large public health care systems, including large hospitals. The public health systems, particularly the health centers and health posts at the periphery, brought modern health care to hundreds of millions of people, who previously had not had access to such services. The results are impressive. The under-five mortality rate in the region fell 60 percent over the last 35 years, by far the fastest decline in its history. However, the recurrent costs of running large public health care systems have outstripped the governments’ willingness to allocate budgetary resources to the sector. The resultant lack of funding and hollowing out of the public health systems has brought into sharp relief the issue of the state’s role in the health sector. There is a growing recognition that laissez-faire policies will not work and that governments need to be actively involved in the health sector but that they should do “more steering and less rowing.” Many of the most important activities in the sector deserve to be publicly financed; however, that does not mean that they need to be publicly provided. Delineating appropriate roles for the state and the private sector in regard to health care constitutes a key issue for the Bank’s DMCs.

Back Major themes	Next Regional health context