World Report
World Bank health projects get mixed review
An independent evaluation of the World Bank Group’s support for health, nutrition, and
population has enhanced debate on approaches to improve global health. Kelly Morris reports.
www.thelancet.com Vol 373 May 23, 2009
capacity when spending for specific
diseases is earmarked. In this context,
“the World Bank is in a good position
to help countries weigh these options
and support broader sectoral actions
to improve health systems”, he says.
The Bank is not alone in facing these
controversies; tensions between programmes for health-system strengthening and specific diseases have been
“The World Bank focuses more
on processes than outcomes. It
needs to monitor actual
progress on the ground.”
running for some time. “The IEG
report is important in giving the global
health and donor communities an
opportunity to air some views and have
a debate that was heretofore behind
the scenes”, says Rachel Nugent, deputy
director for global health for the Center
for Global Development, Washington
DC, USA. “Now, the question is how
to change that performance?” First,
“the Bank should set transparent goals
for the HNP portfolio and engage
with stakeholders in discussion about
whether it is reaching those goals”, she
says. Bobby John, president of Global
Health Advocates, India, concurs: “The
World Bank focuses more on processes
than outcomes. It needs to monitor
actual progress on the ground.”
What is most difficult, says Julian
Schweitzer, director of the Bank’s HNP
department, is measuring outcomes
such as malaria or HIV/AIDS incidence,
which requires “a systems approach
including better surveillance”.
The IEG report was released with
a detailed management response,
building on a 2007 strategic re-think
of HNP projects. Thomas said that
the management’s proposed action
plan and strategy are well-designed
to address IEG’s main findings and
recommendations, and follow-up
monitoring and evaluation is planned.
Recently, “the World Bank has
demonstrated strong results in the first
20 months of its new health systemsstrengthening strategy”, Schweitzer
explains, and it now has 16 active
projects with results-based financing
and impact evaluation, for example,
at health-centre level in Rwanda,
where research shows that “an equal
amount of resources without the
incentives would not have achieved
the same gain in outcomes”. Systemwide approaches are important to
tackle failures throughout the global
health community to improve broader
outcomes, such as maternal mortality,
says Schweitzer.
HNP strategy is now focused on
synergy
between
health-system
strengthening and projects for specific
diseases. Nugent notes that much
material is already available on “what
works and what doesn’t” for global
health improvements. It is time, she
says, to follow basic principles on
“clarity, conduct, and coherence”.
Kelly Morris
World Bank /Issa Michuci
Since 1997, a third of the World Bank’s
health, nutrition, and population
(HNP) projects have not achieved
satisfactory outcomes, according to a
review by the Independent Evaluation
Group (IEG), published on April 30.
Health-system strengthening and
sector-wide approaches by the Bank
are not working to improve health,
while some of its more specific
programmes are, according to the
report.
The Bank’s sector-wide approaches
have
contributed to
“greater
government leadership, capacity,
coordination, and harmonisation”,
the IEG report notes, but two-thirds
have not met their health objectives.
Richard Skolnik, a former World Bank
regional health director for south Asia,
oversaw some projects included in
the review. He explains that “as the
report suggests, there is a substantial
risk that both system strengthening
and harmonised approaches among
development partners will be treated
as ends in themselves and will not lead
to better health for poor people”. He
commends the report for “focusing on
the need to ensure that health-system
strengthening is explicitly linked
with improvements in specific health
outcomes for the poor”.
The IEG report found that the
Bank’s communicable-disease projects have generally done better than
broader approaches. Vinod Thomas,
director-general of the IEG, notes
that “communicable diseases often
disproportionately affect the poor,
their control has benefits for the
whole population, the programmes
can be cost effective, and they may be
logistically less complex than broader
health initiatives”. At the same time,
Thomas remains concerned about
the potential for distortion of health
spending and reductions in health
A World Bank project in Tanzania provides vouchers to new mothers to buy bednets
1749