This presentation highlights the findings and recommendations of IEG's evaluation of the World Bank Group’s support for health, nutrition and population.

1. How can donor support for health,
nutrition,
nutrition and population be more
effective and reach the poor?
Findings from an Evaluation of World
Bank Group Support Since 1997

2. Global development financing for health, nutrition,
and population more than doubled since 2000
18
Private non-profits 16.7
16
Other multilaterals
14 IDA
B illio n s o f U S d o lla rs
12 Development banks
l
UN agencies
10
Bilateral agencies
8.1
8
6.4 6.8
o
6
4
2
0
1997-99 2000 2002 2006
Source: World Bank, Global Monitoring Report 2008, and Michaud (personal communication)

3. Health conditions continue to improve in all regions,
but inequities across and within countries remain
120
112 111
105
102
100
89 89
rths
79
80
Deaths pe 1,000 live birt
73
3
Sub-Saharan Africa
67
South Asia
59 59
60 55 Middle East and North Africa
49
er
44 44 Eastern Europe & Central Asia
42
43 37 36 East Asia and Pacific
40 43 32
39
Latin America and Caribbean
35 34
29
30
26 22
20
0
Source: UNICEF
1990 1995 2000 2004 2007
2006, 2009
,

5. Lending by the Bank’s HNP sector has been sustained,
but an increasing share is by other sectors
2500
2000
C o m m itm e n ts (U S $ m illio n )
Trend, HNP and
HNP sector Other sectors other sectors
1500
1000
500
0
70
72
74
76
78
80
82
84
86
88
90
92
94
96
98
00
02
04
06
08
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20
Fiscal Year of Approval
Source: World Bank data

6. N e t c o m m it m e n t s ( U S $ m illio n )
0
50
100
150
200
250
300
350
1970
1971
1972
1973
1974
1975
1976
1977
Projects
1978
1979
1980
Net Commitments
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
Fiscal year
1991
1992
1993
1994
the rise, but the sector is still small
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
IFC lending to the private sector for health is on
Source: IFC data
2006
2007
2008
0
2
4
6
8
10
12
14
P ro je c t s ( n u m b e r)

7. Major fi di
M j findings on country support
►Two-thirds of Bank HNP projects had
satisfactory outcomes, often in difficult
environments

8. Malaria incidence was reduced in Eritrea
140 45 ITNs + bednets
reimpregnated
40 (10,000)
Incidenc e rate (per 100,000)
120
35 Breeding sites
100 filled and
R ainfall (10m m )
30
ns
ntervention
treated (1,000)
(1 000)
m
80 25 Number of
60 20 houses sprayed
(1,000)
In
15
a
40 Incidence rate
10
20 5
0 0 Average annual
A l
rainfall
1998 1999 2000 2001 2002 2003 2004 2005 2006
Source: IEG Project Performance Assessment Report, Eritrea Health and HAMSeT Projects

9. Excess inpatient bed capacity declined in
Kyrgyz Republic
100
90
80
Hospital beds per 10,000 population
70
60
50
40
30
20
10
1996 1997 1998 1999 2000 2001 2002 2003 2004
K yrgyz R epublic B atken J alal‐Abad
Is s yk‐K ul Naryn Osh
T alas C hui B is hkek
Source: IEG Project Performance Assessment,
Kyrgyz Republic Health Reform I & II Projects

10. Major fi di
M j findings on country support
►Two-thirds of Bank HNP projects had
satisfactory outcomes, often in difficult
environments
►Analytic work supported better outcomes

11. Major fi di
M j findings on country support
►Two-thirds of Bank HNP projects had
satisfactory outcomes, often in difficult
environments
►Analytic work supported better outcomes
►Increasing h lth components in some sectors
►I i health t i t

12. Major fi di
M j findings on country support
►Two-thirds of Bank HNP projects had
satisfactory outcomes, often in difficult
environments
►Analytic work supported better outcomes
►Increasing h lth components in other sectors
►I i health t i th t
►Performance of IFC hospital investments
improved,
improved lessons learned

13. Shortcomings on effectiveness
Sh i ff i
►One third of Bank HNP support has not
performed well, especially in Africa

14. Performance of HNP projects stagnated while in
other sectors outcomes continued to improve
100
90
79
oderately
80 72
67
70 63
er
ojects rated mo
actory or highe
60 70 68
64
50
40
Percent of pro
satisfa
30 36 (n=14) Other Sectors
20 HNP Sector
10
0
1987-91 1992-96 1997-2001 2002-06
Fiscal year project closed

15. Shortcomings on effectiveness
Sh i ff i
►One third of Bank HNP support has not
performed well, especially in Africa
► Weak incentives to deliver health results in
other sectors (water supply, transport)

16. Incentives for health outcomes of water supply
and sanitation are weak and have declined
100
92
FY97-01 (n=62)
90 85
FY02-06 (n=55)
80
cent of WSS projects
70
60 55
p
50
44
40
Perc
30
20 15
10 5 5
2
0
Environmental Health benefits Explicit health Health objective
improvements with cited as rationale objective targeted to the poor
plausible health
benefits
b fit

17. Shortcomings on effectiveness
Sh i ff i
►One third of Bank HNP support not performing
well, especially in Africa
► Weak incentives to deliver health results in
other sectors (water supply, transport)
► Lack of monitoring and evaluation
g

18. If the evaluation design was not spelled out at
the start, the evaluation was unlikely to occur
start
Completed HNP projects with pilot and impact
evaluations,
evaluations approved in FY97 06
FY97-06
35
32
30
25
Nmber of projects
20
p
15
10
7
5 4
0
Projects with a pilot or impact Had a detailed evaluation design Conducted the evaluation
evaluation in the PAD

19. Shortcomings on effectiveness
Sh i ff i
►One third of Bank HNP support not performing
well, especially in Africa, no signs of improvement
► Weak incentives to deliver health results in
other sectors (water supply, transport)
►Lack of monitoring and evaluation
g
► Fragmented organization of IFC health
activities

20. Weak focus on the poor
W kf h
► Only half of HNP support had pro-poor focus,
very few could show that poor benefited more

21. In most regions, government health
spending is not pro-poor
pro poor
ment expenditure 35
30
25
Percen of governm
20
15
10
nt
5
0
Latin South A sia East A sia Europe &
p Sub-
A merica & & Pacif ic Central Saharan
Caribbean A sia A f rica
Poorest quintile Richest quintile

22. Weak focus on the poor
W kf h
► Only half of HNP support had pro-poor focus,
very few could show that poor benefited more
►D Dramatic d li i support addressing f il
i decline in dd i family
planning, high fertility, and malnutrition

23. Weak focus on the poor
W kf h
► Only half of HNP support had pro-poor focus,
very few could show that poor benefited more
►D Dramatic d li i support addressing f il
i decline in dd i family
planning, high fertility, and malnutrition
►Decline in treatment of HNP in poverty
►D li i t t t f i t
assessments

24. The share of poverty assessments with a focus
on HNP declined
100
80
80
FY00-03 (n=50)
58 FY04-07 (n=72)
60
Percent
40
28
20
12
7 7
0
Health Nutrition Population

25. Weak focus on the poor
W kf h
► O l half of HNP support had pro-poor f
Only h lf f h d focus,
very few could show that poor benefited more
► Dramatic decline in support addressing family
planning, high fertility, and malnutrition
►Decline in treatment of HNP in poverty
p y
assessments
►IFC hospital investments primarily benefit
middle- and upper-income groups
iddl d i

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

27. To be
T b more effective,
ff i
►Manage complexity, improve quality
• Match complexity to capacity – sequence, prioritize,
and phase reforms
• Ex ante risk analysis, especially political risks
• Ex ante institutional assessments
• Better definition of objectives
• Analytic work in support of design

28. To be
T b more effective,
ff i
►Manage complexity, improve quality
►Increase the impact of other sectors on HNP
outcomes
• Incentives for demonstrating health impacts
• Links between water supply & sanitation & HNP
• Evaluation and monitoring of retro-fitted activities

29. To be
T b more effective,
ff i
►Manage complexity, i
►M l i improve quality
li
►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

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

31. To
T ensure that the poor b
h h benefit…
fi
►Target support to the poor and monitor
outcomes

32. To
T ensure that the poor b
h h benefit…
fi
►Target support to the poor and monitor
outcomes
►Increase support to reduce hi h f ili expand
►I d high fertility; d
support to reduce malnutrition

33. To
T ensure that the poor b
h h benefit…
fi
►Target support to the poor and
►T h d
monitor outcomes
►Increase support to reduce high
fertility; expand support to reduce
malnutrition
►Expand IFC support for private
investments with greater social benefits
• Low-cost generic drugs
g g
• Technologies that address problems of the
poor
• Health insurance, training
insurance

34. To be more effective…
►Manage complexity, improve quality
►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 malnutrition
►Expand IFC support for private investments
with greater social benefits