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Policy for the Health Sector : The Bank’s health policy
The Bank’s health sector strategy
The Bank’s overall approach to the health sector will be to assist its DMCs in ensuring
that their citizens have broad access to basic preventive, promotive, and curative
services that are cost-effective, efficacious, and affordable. Increased access to
these basic services will have a significant impact on morbidity and mortality in the
short to medium term and will provide the foundation for more comprehensive
health services in the long term.
The Bank’s lending to the health sector has represented a small proportion of
its total portfolio. As a result of the economic crisis and emerging threats such as
tuberculosis, HIV/AIDS, malaria, and smoking, the health needs of the poor in the
region are growing significantly. To keep pace with these substantially increasing
needs, the Bank will strive to increase its lending to the sector. The increase will be
accomplished in the context of country operational strategies and country assistance
plans based on dialogue with all DMC stakeholders. In view of the lack of
increase in the level of official development assistance for the health sector over
the last decade, it is important that the Bank further strengthen its collaboration with
partner institutions in the sector, including multilateral and bilateral institutions. The
Bank will also continue to collaborate closely, and take advantage of the technical
expertise of the United Nations agencies involved in health including UNFPA,
UNICEF, and WHO.
The Bank’s activities in the health sector will be guided by the following
strategic considerations: (i) there will be continued focus on improving the health
of the poor, women, children, and indigenous peoples; (ii) investments will focus
on achieving tangible and measurable results; (iii) the Bank will actively support
rigorous testing of innovative approaches to the management and financing of the
health sector, and assist with the timely deployment of effective new technologies;
(iv) the Bank will play a significant role in policy reform by encouraging DMC
governments to take an appropriate and activist role in the health sector that includes
increasing public investment in PHC, facilitating private sector involvement in health,
and increasing the focus on public goods; and (v) the Bank will increase the efficiency
of its investments in the sector by assisting DMC governments to strengthen their managerial
capacity, improve economic and sector work, and strengthen linkages with other sectors.
Improve the health of vulnerable groups
Maintain Emphasis on PHC.
The Bank will focus its lending on activities
that will disproportionately improve the health of the poor, women, children, and
indigenous peoples. Without committing itself to any specific target, the Bank will
increase its health sector lending with a continued emphasis on PHC, including
reproductive health and family planning. A consensus has emerged that increased
allocative efficiency of health sector investments can be achieved by focusing on a
package of basic services. These services (described in Appendix 3) are highly cost
effective, address problems that account for a significant proportion of the burden
of disease, are of proven benefit, and provide disproportionate benefit to the poor.
In its policy dialogue, the Bank will encourage DMC governments to expand PHC
budgets and discuss means to improve allocative efficiency. It will also advocate
for a shift away from activities that mainly benefit the wealthy and that have low
benefit-cost ratios, such as tertiary care facilities. Focus on Vulnerable Groups and Measure Benefits
To ensure that the poor, women, and other vulnerable groups are actually
receiving the benefits of improved access to basic health services, the Bank will
track the impact of its investments on these groups. Health sector projects and programs
will identify the means for evaluating the effectiveness of activities in reaching
the poor, women, children, and indigenous peoples. Disaggregating data by
income or other easily obtained measures of deprivation will help ensure that the
striking discrepancies between the poor and the better-off are recognized and alleviated.
Given the importance and significant benefits of improving women’s health,
the Bank will also help ensure that data are disaggregated by gender. The Bank will
pay particular attention to the special needs of women in the design and implementation
of projects. Where appropriate, loans specifically targeted at women’s health
(including reproductive health, and the prevention and treatment of violence against
women) will be developed.
Focus on achieving tangible results
-
Further Strengthen Monitoring and Evaluation
To ensure the developmental impact of its investments in health, the Bank
will pay increased attention to measuring results. Investments in the health sector
rarely yield financial returns although the economic and social returns may be substantial.
The success of loans need to be judged on the basis of increased delivery
of services, improved quality of care, health impact, efficiency, and cost effectiveness.
Unfortunately, without explicit efforts to measure these, it is not possible to
determine success. Thus, health sector projects and programs will have (i) a set of
clearly defined, objective indicators of success; (ii) a coherent plan that specifies
how baseline and follow-up data will be collected and a budget for data collection;
and (iii) a plan for building the capacity of DMC governments to conduct M&E and
analyze the results. The Bank’s new project performance management system will
be an important contribution to implementing these M&E activities. In addition to
project and program specific M&E, the Bank will provide DMCs assistance to improve
the gathering and analysis of general health sector data to assist with planning and
policy formulation.
Focus on Interventions with Strong Evidence
The health sector benefits from the existence of scientifically rigorous studies
demonstrating the effectiveness of an increasing number of activities, such as vaccination,
micronutrient supplementation, and case management of TB. The exist-ence
of such studies significantly increases the likelihood that investments will result
in a substantial improvement in the health of the populations served, and yields
large economic and social returns. Where good scientific data are not available for
an activity, the Bank will be reluctant to invest, except to facilitate the gathering of
rigorous empirical evidence on promising interventions. The Bank will support
efforts to provide policymakers with state-of-the-art information on health interventions
of particular importance to developing countries.
Improve the Quality of Health Sector Loans at Entry
The technical nature of health sector lending makes it critical that activities are
based on solid scientific evidence and that lessons from experience in the field are
incorporated into designs. To improve the quality of health sector loans, the Bank
will strengthen its technical peer review process. To ensure effectiveness and
responsiveness to the needs of the community, the design and implementation of future
health sector loans will pay greater attention to participatory approaches. Increasing
the effectiveness of loans will also require flexibility in project design to respond
to local circumstances, thus greater use of process approaches will be encouraged.
Given that most PHC expenditures are made in local currencies, the Bank will adopt a
realistic approach to local currency financing.
Improve Implementation of Health Sector Loans
Successful implementation of health sector loans requires careful supervision
due to the decentralized nature of health services and the importance of systems
(software) development. The Bank will strengthen the supervision provided
to health sector loans through more frequent and more detailed review missions.
Procurement and disbursement procedures will take into account the special
requirements of the health sector, such as the need to purchase services.
Support testing of innovations and deployment of new technologies
Support Rigorous Testing of Innovative Approaches
The Bank’s DMCs will face important challenges as they work to improve the
health of the poor, confront emerging threats to health, and increase efficiency. To
develop the innovative approaches that will help meet the challenges, the Bank
will finance pilot tests of innovations in health care financing, organization, management,
and policy development. Such pilot tests will be undertaken on a scale
that can provide definitive results (at least hundreds of thousands of beneficiaries),
utilize an investment per beneficiary that is cost effective and feasible on a country-wide
scale, and will employ rigorous evaluation methods, including the use of
comparison groups and collection of before and after data. Help Finance Deployment of Effective and Affordable New Technologies
The Bank will vigorously support the deployment of new cost-effective technologies.
Particular attention will be given to ensuring that existing vaccines are fully
integrated into existing national immunization programs and that newly
developed vaccines are made available
once their effectiveness has been demonstrated. The Bank will also support the
further development of the interventions in Appendix 3, with a particular emphasis
on activities related to decreasing smoking and controlling HIV/AIDS.
Encourage governments to take an appropriate and activist role
.
Encourage Governments to Increase Allocations to Health
The DMCs, on average, are underinvesting in the health sector and devote a
smaller proportion of their budgets to health than governments anywhere else in
the world. Within the context of the 20/20 commitments made at the 1995 World
Summit for Social Development in Copenhagen, the Bank will encourage DMC
governments to increase their allocations for basic social services, including primary
health care. With the economic troubles facing the region, DMC governments
may be tempted to decrease budgetary allocations for health as an austerity measure.
However, austerity is no substitute for adjustment. The economic crises can be seen
as an opportunity to decrease government involvement in activities that should not
be publicly financed and to reallocate resources to investments in human capital,
such as PHC. The DMCs spend excessively on loss-making state-owned enterprises
and utilities whose subsidies are captured disproportionately by high-income groups.
The Bank recognizes this issue. Its energy policy explicitly encourages the DMCs to
facilitate private sector investment in the energy sector and to use the public resources
that are thereby saved for investments in human development. Bank projects or
programs involving reform of government finances, state-owned enterprises, and
publicly owned or publicly subsidized utilities, will ensure that some of the public
resources saved by these reforms are used to promote basic human services such
as PHC. Assist Governments to Diversify Health Care Financing
The Bank will actively assist the DMCs to diversify their financing for the
health sector. While increasing budgetary allocations will be necessary, it will not
be sufficient to meet the health challenges that the DMCs face. Finding additional
ways of mobilizing resources to finance public health services will be a priority for
the DMCs and the Bank over the next 20 years. Social insurance schemes, if well
designed and carefully implemented, can provide additional funding while pooling
risks. The Bank will work with the DMCs to pilot test social insurance schemes
on a gradually increasing scale, with the long-term goal of achieving universal
coverage.
The Bank will address cost recovery on a project-by-project basis taking into
account concerns about both equity and efficiency. The Bank’s interest in improving
PHC services for the poor will be jeopardized if user charges discourage their use
of such services. Thus, while the Bank will consider user charges for PHC services,
it will not insist on them unless there is some compelling, situation-specific reason
for employing cost recovery. Nonetheless, the Bank will ensure that PHC services
are efficient and cost effective. Regarding cost recovery for hospital services, the
Bank will help the DMCs test various approaches to user charges and copayments
with the proviso that such cost recovery mechanisms (i) will not decrease use of
public hospitals by the poor; (ii) will increase the proportion of the public subsidy
that is captured by the poor; and (iii) will improve the quality of care in these
public hospitals. Facilitate Government Collaboration with the Private Sector, including NGOs
There are likely to be real efficiency gains if DMC governments work
collaboratively with the private sector, including NGOs. While public-private
cooperation has expanded in other sectors, only tentative efforts have so far been
made in the health sector. The Bank will continue to facilitate public-private partnerships
in health as a way of increasing efficiency and building up the experience
of DMC governments in working with the large and growing private sector. This
collaboration should not be seen as a means for governments to decrease their
investments or interest in the health sector. In designing projects, the Bank and the
DMCs will explore opportunities for involvement by NGOs, private practitioners,
pharmacies, private hospitals, and traditional healers. As governments get used to
actively collaborating with the private sector, levels of trust will increase and governments
will do less direct service provision. Increase Support for Public Goods
Much of the progress observed in health in the region over the last 35 years
has resulted from technological advances and the research that produced them. Yet
support for research on the diseases of the poor appears to be declining. In addition,
there are many aspects of health research that will not be financed by the private sector
because the results cannot be commercially exploited. Therefore, there is a strong
rationale for the Bank and DMC governments
to invest in health research, particularly applied studies that are of little
commercial interest but are important to the health of the poor and other vulnerable
groups. Another almost pure public good that requires public financing is health
education, which can have a significant impact on the health of communities.
Regulation of the large private sector in health, and other private activities
that impinge on health, is clearly a role for government. However, until now, few
resources have been devoted to this function of government. There are many areas,
such as iodination of salt, where regulation can provide an extremely effective
means for governments to improve the health of the population at low cost. While
the benefits of regulation may be large, it may also create red tape and foster
corruption. In this challenging area, the Bank will cautiously explore various
mechanisms of government regulation through its lending and TA activities. During
policy dialogue, the Bank will actively encourage DMC governments to implement
regulations aimed at controlling tobacco consumption. The Bank will also
encourage its DMCs to raise taxes on tobacco on a regular basis such that prices
increase faster than inflation and growth in GDP.
Increase the efficiency of health sector investments
Improve Managerial Capacity
Increasing the efficiency of health sector investments will require improved
management capacity within DMC ministries of health. Whether or not governments
themselves directly provide PHC services, there is a clear need for better
management practices, particularly at the periphery, where PHC services are rendered.
As part of project preparation, the Bank will carefully analyze institutional
capacities and incentive structures. In addition to training, capacity-building efforts
will explore innovative organizational approaches and apply effective management
interventions. The success of management strengthening activities will be assessed
in terms of increasing the coverage of cost-effective services, improving quality of
care, and increasing the satisfaction of the community. Assessing these indicators
will require strengthening of management information systems through the use of
household, health facility, and client satisfaction surveys, as well as disease surveillance.
Improving the steering functions of ministries of health, such as policy formulation
and cost analysis, will receive more attention from the Bank and will also
be based on careful institutional analyses. Strengthen Economic and Sector Work and Intersectoral Linkages
Economic and sector work. Increasing the efficiency of health sector
investments will also require more economic and sector analysis. To improve its
economic and sector work in the health sector, staff of the project and program
departments will work closely to ensure the critical linkages between the health
sector and the Bank’s medium-term strategic objectives, including economic growth,
poverty, and improving the status of women, are properly reflected in country
operational strategy studies. Health sector reviews will be undertaken more frequently
and greater attention will be given to economic analysis of health projects
based on ongoing initiatives, including the development of a handbook for the
economic analysis of health sector projects.23
Intersectoral linkages. A challenging area for the Bank will be strengthening
intersectoral linkages so that health issues can be addressed by other parts of
the Bank. There are a number of important interventions in the health sector where it
will be more appropriate for other divisions to play a leading role. The Bank will be
careful that construction sites associated with power or road sector projects do not
become a focus of HIV infection. In future, large construction contracts will contain
standard clauses (already incorporated in some ongoing contracts) ensuring the
availability in and around construction sites of information about safe sexual practices,
condoms, and treatment of STDs. Other health interventions where a lead
role should be played by other parts of the Bank will include the following:
The Environment Division, working with other divisions, will provide the
necessary direction and strategies in addressing environmental health issues.
For example, in the transport sector, vehicular air pollution control strategies
that will eventually eliminate lead in gasoline and reduce the levels of other
pollutants will be the subject of policy dialogue. Other occupational health
and safety issues, including the effects of projects on public health, will be
considered as part of environmental impact assessment, based on the Bank’s
Guidelines for the Health Impact Assessment of Development Projects (1992). The transport divisions will take the lead in decreasing deaths and injuries
from motor vehicle accidents. Including health education into primary and secondary school curriculums
will be the responsibility of the education divisions. The Social Development Division will assist in providing guidance and support
to DMCs in addressing the health needs of vulnerable groups.
____________________
- TA No. 5761-REG: Strengthening of Capacity in Economic Analysis of Health Sector Projects
in DMCs, for $350,000, approved on 16 December 1997.
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