How can donor support for health,nutrition, and population be more effective and reach the poor?

How can donor support for health, nutrition and population be more nutrition, and population be more effective and reach the poor?

Findings from an Evaluation of World Bank Group Support Since 1997

Global development financing for health, nutrition, and population more than doubled since 2000and population more than doubled since 2000

16

18Private non-profits 16.7

12

14

llars

Other multilaterals

IDA

Development banks

8

10

ons

of U

S do

l

UN agencies

Bilateral agencies

6.4 6.8

8.1

4

6

Bill

io 6.4

0

2

1997-99 2000 2002 2006

Source: World Bank, Global Monitoring Report 2008, and Michaud (personal communication)

Health conditions continue to improve in all regions, but inequities across and within countries remainbut inequities across and within countries remain

102

112 111

105

120

102

89

3

79

89

80

100

rths

595955

494444

6773

60

80

er 1

,000

live

birt Sub-Saharan Africa

South Asia

Middle East and North Africa

Eastern Europe & Central Asia44

36

44 4237

32

29

22

43

3530

3439

4340

Dea

ths

pe Eastern Europe & Central Asia

East Asia and Pacific

Latin America and Caribbean

Source: UNICEF 2006, 2009

2226

0

20

1990 1995 2000 2004 2007 ,1990 1995 2000 2004 2007

Lending by the Bank’s HNP sector has been sustained, but an increasing share is by other sectorsbut an increasing share is by other sectors

2500

2000

lion) HNP sector Other sectors Trend, HNP and

other sectors

1500

nts

(US$

mil

500

1000

Com

mitm

e

0

19701972197419761978198019821984198619881990199219941996199820002002200420062008

Source: World Bank data

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2

Fiscal Year of Approval

IFC lending to the private sector for health is on the rise, but the sector is still smallthe rise, but the sector is still small

350 14

250

300

US$ m

illion

)

10

12

ber)

Net CommitmentsProjects

100

150

200

mm

itmen

ts (U

4

6

8

Proj

ects

(num

0

50

100

Net c

om

0

2

4 P

0

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Fiscal year

0

Source: IFC data

M j fi di Major findings on country support

►►Two-thirds of Bank HNP projects had satisfactory outcomes, often in difficult environmentsenvironments

Malaria incidence was reduced in Eritrea

140 45 ITNs + bednetsreimpregnated

100

120

ns 30

35

40

100

,000

) m

m)

reimpregnated(10,000)Breeding sitesfilled andtreated (1 000)

60

80

nter

vent

ion

15

20

25

e ra

te (p

erai

nfal

l (10

m treated (1,000)Number ofhouses sprayed(1,000)

20

40

In

5

10

15

Inci

denc R

a

Incidence rate

A l01998 1999 2000 2001 2002 2003 2004 2005 2006

0 Average annualrainfall

Source: IEG Project Performance Assessment Report, Eritrea Health and HAMSeT Projects

Excess inpatient bed capacity declined in Kyrgyz RepublicKyrgyz Republic

90

100

70

80

90

popu

latio

n

40

50

60

l bed

s pe

r 10,

000

20

30

40

Hos

pita

10

1996 1997 1998 1999 2000 2001 2002 2003 2004

K yrgyz  R epublic Batken J alal‐AbadIssyk‐Kul Naryn OshTalas C hui B ishkek

Source: IEG Project Performance Assessment,Kyrgyz Republic Health Reform I & II Projects

M j fi di Major findings on country support

►►Two-thirds of Bank HNP projects had satisfactory outcomes, often in difficult environmentsenvironments

►Analytic work supported better outcomes

M j fi di Major findings on country support

►►Two-thirds of Bank HNP projects had satisfactory outcomes, often in difficult environmentsenvironments

►Analytic work supported better outcomes

►I i h lth t i t►Increasing health components in some sectors

M j fi di Major findings on country support

►►Two-thirds of Bank HNP projects had satisfactory outcomes, often in difficult environmentsenvironments

►Analytic work supported better outcomes

►I i h lth t i th t►Increasing health components in other sectors

►Performance of IFC hospital investments improved lessons learnedimproved, lessons learned

Sh i ff iShortcomings on effectiveness

►One third of Bank HNP support has not►One third of Bank HNP support has not performed well, especially in Africa

Performance of HNP projects stagnated while in other sectors outcomes continued to improveother sectors outcomes continued to improve

100

63 6772

79

70

8090

oder

ately

er

6470 68

40

50

60

ojec

ts ra

ted m

oac

tory

or h

ighe

3620

3040

Perc

ent o

f pro

satis

fa

Other SectorsHNP Sector

(n=14)

0

10

1987-91 1992-96 1997-2001 2002-06Fiscal year project closed

Sh i ff iShortcomings on effectiveness

►One third of Bank HNP support has not►One third of Bank HNP support has not performed well, especially in Africa

► Weak incentives to deliver health results in► Weak incentives to deliver health results in other sectors (water supply, transport)

Incentives for health outcomes of water supply and sanitation are weak and have declinedand sanitation are weak and have declined

92

8590

100

FY97-01 (n=62)

FY02-06 (n=55)

5560

70

80

proj

ects

FY02-06 (n=55)

55

44

40

50

60

cent

of W

SS p

15

5510

20

30Perc

552

0Environmental

improvements withplausible health

b fit

Health benefitscited as rationale

Explicit healthobjective

Health objectivetargeted to the poor

benefits

Sh i ff iShortcomings on effectiveness

►One third of Bank HNP support not performing►One third of Bank HNP support not performing well, especially in Africa

► Weak incentives to deliver health results in► Weak incentives to deliver health results in other sectors (water supply, transport)

► Lack of monitoring and evaluationg

If the evaluation design was not spelled out at the start the evaluation was unlikely to occurthe start, the evaluation was unlikely to occur

Completed HNP projects with pilot and impact evaluations approved in FY97 06

32

30

35

evaluations, approved in FY97-06

20

25

proj

ects

710

15

Nmbe

r of

p

7

4

0

5

Projects with a pilot or impactevaluation

Had a detailed evaluation designin the PAD

Conducted the evaluation

Sh i ff iShortcomings on effectiveness

►One third of Bank HNP support not performing►One third of Bank HNP support not performing well, especially in Africa, no signs of improvement

► Weak incentives to deliver health results in► Weak incentives to deliver health results in other sectors (water supply, transport)

►Lack of monitoring and evaluationg

► Fragmented organization of IFC health activities

W k f h Weak focus on the poor

►► Only half of HNP support had pro-poor focus, very few could show that poor benefited more

In most regions, government health spending is not pro-poorspending is not pro poor

35di

ture

20

25

30

men

t exp

en

10

15

nt o

f gov

ernm

0

5

Latin South Asia East Asia Europe & Sub-

Perc

en

America &Caribbean

& Pacif icp

CentralAsia

SaharanAf rica

Poorest quintile Richest quintile

W k f h Weak focus on the poor

►► Only half of HNP support had pro-poor focus, very few could show that poor benefited more

► D i d li i dd i f il► Dramatic decline in support addressing family planning, high fertility, and malnutrition

W k f h Weak focus on the poor

►► Only half of HNP support had pro-poor focus, very few could show that poor benefited more

► D i d li i dd i f il► Dramatic decline in support addressing family planning, high fertility, and malnutrition

►D li i t t t f HNP i t►Decline in treatment of HNP in poverty assessments

The share of poverty assessments with a focus on HNP declinedon HNP declined

100

8080

FY00-03 (n=50)

58

40

60

Perc

ent

FY04-07 (n=72)

28

1220

40

712

7

0Health Nutrition PopulationHealth Nutrition Population

W k f h Weak focus on the poor

► O l h lf f HNP h d f► Only half of HNP support had pro-poor focus, very few could show that poor benefited more► Dramatic decline in support addressing family► Dramatic decline in support addressing family planning, high fertility, and malnutrition►Decline in treatment of HNP in poverty p yassessments►IFC hospital investments primarily benefit

iddl d imiddle- and upper-income groups

1. How can HNP support be more 1. How can HNP support be more effective?

T b ff iTo be more effective,

►►Manage complexity, improve quality• Match complexity to capacity – sequence, prioritize, and phase reformsand phase reforms

• Ex ante risk analysis, especially political risks

• Ex ante institutional assessments

• Better definition of objectives

• Analytic work in support of design

T b ff iTo be more effective,

►►Manage complexity, improve quality

►Increase the impact of other sectors on HNP outcomes

• Incentives for demonstrating health impacts

• Links between water supply & sanitation & HNP• Links between water supply & sanitation & HNP

• Evaluation and monitoring of retro-fitted activities

T b ff iTo be more effective,

►M l i i li►Manage complexity, improve quality►Increase the impact of other sectors on HNP outcomes►Improve the results focus and better governance through evaluation

• Incentives for monitoring and evaluation• Baseline data requirements• Evaluation design for all pilots• Periodic evaluation of components• IFC health sector evaluation framework

2. How can HNP support better ensure 2. How can HNP support better ensure that the poor benefit?

T h h b fiTo ensure that the poor benefit…

►►Target support to the poor and monitor outcomes

T h h b fiTo ensure that the poor benefit…

►►Target support to the poor and monitor outcomes

►I d hi h f ili d►Increase support to reduce high fertility; expand support to reduce malnutrition

T h h b fiTo ensure that the poor benefit…

►T h d►Target support to the poor and monitor outcomes

►Increase support to reduce high►Increase support to reduce high fertility; expand support to reduce malnutrition

►Expand IFC support for private investments with greater social benefits

• Low-cost generic drugsg g

• Technologies that address problems of the poor

• Health insurance trainingHealth insurance, training

►Manage complexity, improve quality

To be more effective…

►Increase the impact of other sectors on HNP outcomes

►Improve the results focus and better governance through

evaluation

To ensure that the poor benefit…

►Target support to the poor and monitor outcomes►Increase support to reduce high fertility; expand support to reduce malnutritionexpand support to reduce malnutrition►Expand IFC support for private investments with greater social benefits