World Bank's new health strategy focuses on strengthening health systems

They'd waited until the weekend, several days after Elizabeth began having symptoms, because her mother knew doctors showed up late at the hospital and she couldn't afford to lose a day of work.

As it was, she had to sell one of her two cows, spend all of her savings, and borrow to pay expenses and under-the-table fees related to Elizabeth's sickness.
It was all for naught.

On February 17, 2003, Elizabeth became one of 840,000 children under age five to die that year from malaria.

Could Elizabeth have been saved?

What would it have taken to save her? Elizabeth's story, in a “hypothetical but all too representative country,” is highlighted in the World Bank's new health strategy approved yesterday by the Bank's Board of Directors.

The story reveals why money for medicine and equipment alone, without the “right chain of events” to deliver them or provide access to them, isn't enough to save lives in developing countries.

The links in the chain must include having enough nurses, doctors and other health care workers in the right place at the right time. It includes making sure medicine is stored properly, so it stays potent and effective, and that treatment is administered so drug resistance doesn't develop. It includes health insurance (public or private) to soften the blow of health shocks that currently throw families into greater poverty.

In developing countries, putting all these things together at the same time is an enormous challenge, and that is what the Bank's new health strategy is trying to do, says Cristian Baeza, the Bank's lead health policy specialist and team leader for the health strategy.

In Elizabeth's case, free bed nets could have protected her and children like her from malaria-carrying mosquitoes but had not been widely distributed to local people.

The town health centre that could have diagnosed and treated Elizabeth early on hadn't had a health worker on staff for 18 months.

Several had been lured to cities where they could make the same salary under the civil service pay system and enjoy better working conditions. The ones who stayed moonlighted for extra money and were frequently absent or late to work.

“Elizabeth's death had everything to do with a broken health system in desperate need of repair,” says Healthy Development: The World Bank Strategy for Health, Nutrition, and Population Results.

In fact, the “right sequence of events” might have saved her, such as ensuring bed nets, drugs and supplies reached poor families, or changing salary incentives so workers showed up for work at health centres to diagnose and treat children.

Public-private partnerships could be built with community or non-governmental organizations to deliver services, empowering patients and communities to address problems in the system, or setting the right insurance and/or public financing mechanisms so the cost of illness will not prevent a mother from taking a sick child for treatment and will not throw her and her family into destitution.

Strengthening health systems

Baeza says the new strategy is about strengthening health systems in developing countries while complementing the efforts of other organizations contributing billions of dollars to combat diseases such as HIV/AIDS and malaria.

Ten years ago, the Bank was the main financier of health and nutrition programs in the developing world.

Today organizations such as the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Roll Back Malaria Partnership, and the US President's Emergency Plan for AIDS Relief (PEPFAR) play a major role.

International grants have grown tremendously—from US$6 billion a year in 2000 to US$11 billion by 2005 and an expected US$14 billion in 2006/2007.

“This is good news,” says Baeza, “The world has woken up and put health squarely at the centre of the agenda.”

However, he stressed that the multiplicity of Funds and programs, particularly with a single disease focus, runs the risk of insufficiently focusing on strengthening the health system across diseases, which he says is essential to achieve results with the increased international financing for health.

In response, the Bank is shifting its focus to not only funding vaccines and medicine but doing so in a way that ensures a health system is capable of delivering vaccines, medicine, and general health care to more people, he says.

“The strategy is going to reposition the Bank to better serve client countries in their struggle to improve the lives of the people and prevent poverty due to illness,” Baeza says.

Julian Schweitzer, Director of Human Development for the Bank's South Asia region, says the effort is likely to be “as much intellectual as financial.”

“It's really helping countries think through what are extremely difficult and complicated issues—financing, management, implementation—because health economics and the whole issue of health financing is very complicated and fraught with failure.”

In addition, many health outcomes have nothing to do with the health sector, he says.

“They're to do with poverty. They're to do with water. And they're to do with behaviour,” among other things.

“For the poor, the biggest shocks they can face are usually health shocks,” adds Schweitzer.

“The thing which tips a poor person from relative poverty to absolute poverty is usually an event like a mother needing a C-section, or the chronic illness of a child, or an accident.”

“Much more attention needs to be paid to an obvious point: that unhealthy people are probably not just unhappy, but very unproductive.”

Incentives and results

The strategy updates a decade-old plan that committed a total of US$15 billion to 400 programs and projects in more than 100 countries from 1997 to 2006.

The new strategy aims to correct a failure under the old—the fact many countries did not collect and keep health data and records, making results very difficult to measure.

“You need to link the financing to results,” explains Baeza.
He believes the best way to do that is to offer incentives to make collecting data a natural part of the process.

Programs and projects, for instance, would offer bonuses to local districts that could show they met targets for vaccination, women receiving prenatal care, and babies born with high Apgar scores, to name a few examples.

“A traditional project might say we're going to build 20 clinics and buy 20 million vaccines and we're going to buy anaesthetic machines.  Rather than doing that we would increasingly help the government to directly link the vaccinating of a million kids with the disbursements of Bank loans,” he says.

The approach, already tried in several pilot programs, should work in many countries, says Baeza.

Particular focus needs to be on “fragile states”—countries suffering extreme poverty and/or recovering from conflict—where the Bank will “need to support the build up of basic health infrastructure, and help ensure access to basic services.”

“The strategy is not a one plan fits all. It is a way to support country teams to ensure a country owned, country led, and country context appropriate strategy to improve the lives of the people.”

” If you believe in governance, that's where governance takes place – at the country level. It's the people who run their countries and decide their destinies.”

Article courtesy of World Bank