AAAH Conference

Beijing, ChinaOctober 2007

Samuel S. Lieberman

CHANGING WB PROFILE

• The World Bank continues to support health development in more than 20 countries in the East Asia and Pacific region by providing grants and low-interest loans for development projects, as well as expert advice and consulting services. s3

• WB is not the dominant source of health funding that it was through 1997 s4,5

Major Health Sector Donors in EAP

Other Bilateral, 19%

Japan, 16%

US, 11%

Aus/NZ, 8%

UK, 8%

IBRD, 7%

IDA, 5%

ADB, 4%

EC, 4%

UN, 4%

GFATM, 11%

GAVI, 3%

Share of Commitments by Major Donors(based on 2002-2005 annual average)

Note: GAVI data is from its own website and is the annual average for 2001-2005Source: WB BW; OECD DAC CRS (Creditor Reporting System)

What Happened to IBRD and IDA?

20%

11%

10%7%

14%

24%11%

5%

0%

20%

40%

60%

80%

100%

1990-1993 1994-1997 1998-2001 2002-2005

Bilaterals

Multilaterals

Share of Commitments by Major Donors

Note: Total may not add up to 100% due to rounding; GAVI data is from its own website and is the annual average for 2001-2005Source: WB BW; OECD DAC CRS (Creditor Reporting System)

Aus/NZ

ADBEC

GFATM

IDA

Japan

Other bilateral

UK

US

UN

IBRD

GAVI

20%11% 10% 7%

14%24%

3%

6% 6%

7%

3%7%

8%4%

9%6%

10%

5%

47% 46%

61%74%

11%

0%

20%

40%

60%

80%

100%

1990-1993 1994-1997 1998-2001 2002-2005

What Happened to Loans?

Japan

Other bilateral

ADB

IDA

Grants & Grants-Like(all donors)

Note: Total may not add up to 100% due to roundingSource: WB BW; OECD DAC CRS (Creditor Reporting System)

Share of Commitments by Type and Donor

Loans

IBRD

What Happened to Loans?

Inter-related Challenges

• WB support for health in EAP continues through large scale funding and analytical/ policy development initiatives (AAA)-- 25 projects are ongoing, 9 are under preparation, and 40+ have been completed.

• The aim of this work is to help countries to respond to the inter-related challenges of:

Improving the health, nutrition and population outcomes of the poor, while protecting the near poor from health-based income shocks;

Improving system performance

• Establishing and securing sustainable health care financing at a time of increasing health financing needs due to rising incidence of “life-style” diseases, and strong “backlog effects” on service use by those newly insured.

• Enhancing health care system performance in a region that had habitually, often successfully turned to government-run mechanisms to deliver public health services. However, the “platforms” adapted to deliver a subset of health services on a mass basis were inefficient and inequitable, or unworkable when linked to the larger health system..

HWF as entry point

• The World Bank’s revised Health Strategy points to the health workforce (HWF) as a crucial health system dimension. Accordingly, difficulties in deploying qualified professionals and other health workers to poor and remote areas, defective provider payment procedures, and so forth are seen as contributing to low quality care and inequality in access, and more broadly, as highlighting for policy makers possible entry points for addressing systems problem. *

Needed: Eclectic Thinking/ Piloting

• Meanwhile, symptoms of system performance failure can vary and may be masked by changes due to rapid, unrehearsed decentralization, stronger market-pressures and widening income inequalities. WB thinking ties system faltering to an MOH unwillingness to switch from direct provision to the role of health regulator, health promoter, consumer educator and policymaker.

Planned AAA

• Clearly, more work is needed on system performance, determinants, and policy inferences. The WB is sponsoring in cooperation with the Dutch government

• policy analysis of key HWF issues, public and private, in EAP countries, i.e., Cambodia, Indonesia, Timor Leste, Vietnam, and possibly Thailand, facing shortages of skilled health service providers. These will address the knowledge gap by country and look into provider payment issues, incentives, public/private partnerships and access to the poor. Political dimensions will be considered, work will be done collaboratively with local institutions and in a capacity building manner.

More AAA

• Other work is planned including: on Indonesia, analyses of “Dual Practice, the Private Sector and Access to Care,” and “The Distribution of the Health Workforce and Employment Duration” that will connect to earlier work.

Project Support

• The HWF and Systems Performance agendas pertain as well to the 25 ongoing, 9 forthcoming investment portfolio. This is a significant increase from where we were three years ago.

• Do we have the right focus within health the best balance among instruments, sectors, countries, etc.?

Assessing the Portfolio

• How to evaluate a diverse set of projects located in longstanding clients with established programs as well as more recent additions, with these initiatives undertaking a variety of activities in response to local needs?

• Look at “best practice” workforce/labor market thinking?

Rely on WB Internal Review?

• These procedures, e.g., consistency with sector/country analysis and strategy; lending lessons; economic, social, fiscal, and environmental, indigenous peoples assessments; quality at entry, outcome ratings, overall and by component; sustainability; and “Major Factors Affecting Implementation and Outcomes” are extensive and rigorous and link up with professional and technical literatures and cross-sector, cross-country, and cross-project experiences. But they are obviously unsuitable in other respects and are not readily available.

Do any alternatives come to mind, e.g., AAAH-based? Or is it best to proceed on a country-wise/inter-country

basis, and how?

Country-wise Assessment

• Track HWF components across projects, over time

• Compare new with new

• Check for best practice

• Follow innovations

Cambodia HNP projectsCambodia Closed

projects• Disease Control and health Development Project

• Social Fund Project

Active projects

• First Poverty reduction and Growth Operation

• Health Sector Support Project

Pipeline projects

• Cambodia Second Health Sector Support Program

• Avian and Human Influenza Control and Preparedness Emergency Project

Cambodia• The Government is unable to deploy and retain qualified staff in

remote areas. To address this key HWF bottleneck, the Health Sector Support Project contracts NGOs to help to manage health services, provides performance based incentives to staff in health facilities and strengthens management and monitoring functions in 11 of 77 Operational Districts. Project-supported equity funds (HEFs) also pay official user fees in 29 Districts for the identified poor, with 60% of fee revenues available for staff incentives. HEF- supported health facilities receive management and quality improvement support. The project also applies the Merit Based Pay Initiative to policy makers, supports the Human Resource and Personnel Departments and regional training centers in the central MOH, and funds in-service (but no pre-service) training for midwives and other health personnel.

IndonesiaIndonesia Closed

projects• Social Safety Net Adjustment Loan Project• Fourth Health Project: Improving Equity and Quality of Care• Population Project• Health Project (03)• ID - Iodine Def. Control• Third Community Health and Nutrition Project• Safe Motherhood Project: A Partnership and Family Approach Project• Child Development Project• Water Supply and Sanitation for Low Income Communities Project• HIV/AIDS and STD Prevention and Management Project• Provincial Health Project (02)• Health Project (05)

Active projects

• Second Water & Sanitation for Low Income Communities Project• Second Urban Poverty Project• Additional Financing for Second Urban Poverty Project (UPP2)• Indonesia - Avian & Human Influenza Control and Preparedness • Provincial Health I• Health Workforce & Services (PHP 3)• Third Water Supply and Sanitation for Low Income Communities Project

Pipeline projects

• National Agency for Drug and Food Control Project

Indonesia• The PHPsI support pre-service training through fellowships in response to

MOH policy that nurses and midwives should have at least D3 education, and the 3 projects support a wide range of in-service training for various health sector programs.

• The 3 PHPs address improvement of HRH quality through strengthening the regulatory framework. Jogjakarta, a leader in this area has prepared standards of competence for various professions, and instruments for accreditation of primary health care facilities. It has also established a Quality Council, whose task is to conduct competence assessment in collaboration with the professional associations and provide recommendation for licensing of providers. .

• HWS is also providing support in the following areas:• Development of the new competency based curriculum for medical

education (done)• Development of competency based specialist education (ongoing)• Developing and piloting family physician program (ongoing through IMA)• HRH is one of the two main focuses of the AAA work on health sector

reform in Indonesia.

Lao HNP Projects

Lao Closed projects

• Lao PDR First Poverty Reduction Support Credit

• Health System Reform and Malaria Control Project

• Lao PDR Second Poverty Reduction Support Operation (PRSO2)

Active projects

• Avian and Human Influenza control and Preparedness Project

• Health Services Improvement Project (HSIP)

Lao

• HWF activities (52% of HSIP costs) aim to upgrade a poorly trained work force, and include in-service (i) competency-based initial and refresher sessions for Integrated Community Health Centre staff; (ii) training for village volunteers in the management of drug kits; and (iii) training in service delivery and outreach management at the health centre level and below. Pre-service training is assisted: (i) support to Family Medicine Internship Program - new type of providers for work at province and district level; (ii) 2-year master degree courses in Thailand for the faculty; (iii) improve infrastructure of the Faculty of Medical Sciences and teaching hospitals

PNG projects

Papua New Guinea

Closed projects

• Population and Family Planning Project

Philippines HNP Projects

Philippines Closed projects

• Second Social Expenditure Management

• Urban Health and Nutrition Project

• Women's Health and Safe Motherhood Project

• Health Development Project

• Early Childhood Development Project

Active projects

• National Sector Support for Health Reform

• Second Women's Health & Safe Motherhood

Philippines

• The SEMP2 did not have interventions in HHR. The WHSMP2 is piloting two innovations in national HHR policies. The first innovation is a performance-based grants to Women's Health Teams if they get their patients intpo birth plans and to deliver in health facilities. The second is the bringing of private training providers in the training of government health workers. The NSSHRP is expected to help finance the implementation of the national health human resource master plan of the DOH. In both the WHSMP2 and the NSSHRP, we work with the DOH and the local government units

Solomon Islands

Solomon Islands

Closed projects

• Health Sector Development • Education and Training Project (03)

Pipeline projects

• SB Health Sector Development Project 2

Thailand

Thailand Country Development Partnership in Health

A. Improving the Effectiveness of Thailand's HIV/AIDS Response

B. Improving the Effectiveness of Public Expenditures in the Health Sector;

C. Improving Human Resources in Health

Thailand• Thailand has implemented successful HWF policies that facilitated

recruiting, deploying, and maintaining professional health staff in rural areas, including three year mandatory public service for new medical graduates; incentives that include hardship allowances, no-private practice allowances, over-time payments and non-official hours special service allowances; and, non-financial incentives such as higher career statis of rural doctors, preferential entry to residential programs, etc. The Human Resource Component will undertake an in-depth review of health workforce challenges in the past and at present in Thailand and an evaluation of strategies for workforce management in order to identify effective and ineffective practices. It will also support regional learning and dissemination activities on effective health sector human resource policies.

Timor Leste HNP Projects

Timor Leste

Closed projects

• Health Sector Rehabilitation and Development Project• Agricultural Rehabilitation Project• Third Transition Support Program• Second Agriculture Rehabilitation Project

Active projects

• Second Health Sector Rehabilitation and Development Project

Pipeline projects

• TP - Health Sector Project

Timor Leste

• Support to restore basic services and priority programs, and longer term rehabilitation and capacity building– Health Sector Rehabilitation and Development Project – Second Health Sector Rehabilitation and Development Project

• Transition (Consolidation) Support Program– Multi-donor program of grant financed budget support– Supports policy measures in governance, employment creation

and private sector development, and service delivery

• Health Sector Review (HSR)—work in progress– Broad review of HNP status, policies and strategies, service

delivery, and financing– Significant HR component

Vietnam HNP Projects

Vietnam Closed projects

• Population & Family Health Project

• National Health Support Project

Active projects

• Regional Blood Transfusion Centers Project

• Vietnam Avian & Human Influenza Control & Preparedness Project

• Mekong Regional Health Support Project

• HIV/AIDS Prevention Project

Pipeline projects

• Northern Uplands Health Support Project

• Central Region Health Support Project

Vietnam• interventions have evolved as regards the scope and target of

training investments and scale and focus of “parallel” measures. In two 1990s vintage “first generation ” projects (e.g., Population and Family Health Project, National Health Support Project) delivered short-term training on selected topics to lower level health staff in provinces in each region.

• MRHSP, the first of several second generation projects, allows for tailoring interventions to local features, and includes degree-training, and a review of HWF gaps linked to an analysis of various “non-training” incentives and other measures.

• The Northen Uplands Health Support Project (NUP) funds skills upgrading for available clinical staff in the region, as well as the development and piloting of incentive schemes to improve recruitment and retention of staff in the NU provinces, given that this is one of the main constraints to improve human resources for health capacity.

China

China Closed projects

• Comprehensive Maternal and Child Health Project• Health (02)• Rural Health Workers Development Project• Fourth Rural Water Supply Project• National Rural Water Supply Project• Infectious and Endemic Disease Control Project • Disease Prevention (Health 7)• CN - Basic Health (Health 8)• Yangtze Flood Emergency Rehabilitation project• Integrated Regional Health Development Project• Rural Water Supply and Sanitation Project

Active projects • Western Provinces Rural Water Supply, Sanitation and Hygiene Promotion Project• Tuberculosis Control• China Health Nine Project

Pipeline projects

• CN - Rural Health• Rural Migrant Skills Development and Employment Project