I M P ROV I N G E F F E C T I V E N E S S A N D OUT C O M E S F O R T H E P OO R I N H E A LT H , N UT R IT I O N , A N D P O P U L AT I O N
Despite this progress, nearly three-quarters of developing countries are either off track or seriously off track for achieving the MDG of reducing under-five mortality by two-thirds. Maternal mortality is declining by only about 1 percent annually, a fifth of the rate needed to achieve the goal of reducing it by threequarters by 2015 (World Bank 2008a). Further, average outcomes conceal important differences in progress across countries, within regions, and within countries. Under-five mortality rates in 30 countries have stagnated or increased since 1990;3 in some countries, high fertility rates have remained unchanged Despite improvement in or even increased slightly since the some key health outcomes 1990s (Wagstaff and Claeson 2004, p. since 1990, there are 36). Despite some progress in important differences Bangladesh and India, undernutrition across and within remains very high in South Asia, while countries. in 26 countries, primarily in Africa, malnutrition is increasing (Shekar, Heaver, and Lee 2006, p. 3). Maternal mortality remains extremely high in Africa, where the average woman faces a nearly 1 percent risk of dying from pregnancy and childbirth, and very high fertility repeatedly exposes women to these high risks.4 Communicable diseases account for about a third (36 percent) of the disease burden in developing countries (Jamison and others 2006b); within countries, the burden of morbidity and mortality is greatest among the poor (Gwatkin and Guillot 2000). In some countries, HNP outcomes have improved disproportionately among the poor, while in others they have improved primarily among the non-poor. The gaps between the poor and non-poor, even when closing, often remain substantial, in part reflecting lower access of the poor to public services (Gwatkin, Wagstaff, and Yazbeck 2005; Filmer 2003). The burden of disease is distributed differently within developing Regions, with communicable disease and maternal, perinatal, and nutritional The Bank committed conditions as a group predominating about $28.7 billion and in Africa, while in the remaining five IFC about $951 million developing Regions, the burden of to HNP from 1970 to non-communicable disease is equal or mid-2008. greater (figure 1.2). 4
Rationale for World Bank Group Investments in Health, Nutrition, and Population The mandate of the World Bank Group is to reduce poverty and promote economic growth. Poor health and malnutrition contribute to low productivity of the poor, so improving HNP outcomes is seen as a major way of reducing poverty. But poverty is also a prime cause of poor health, malnutrition, and high fertility. The poor have low access to preventive and curative care (both physically and financially) and are more likely to be malnourished, have unsafe water and sanitation, lack education, have large families and closely spaced births, and engage in activities that may put them at heightened health risk. Within the World Bank Group, the World Bank (International Bank for Reconstruction and Development [IBRD] and the International Development Association [IDA]) have committed about $28.7 billion to help governments improve HNP outcomes in 132 countries since 1970 (figure 1.3).5 In addition, IFC has invested $951 million in the private health and pharmaceutical sectors of developing countries.6 The World Bank supports government HNP policies and programs. The World Development Report 1993: Investing in Health (World Bank 1993c) highlighted the major rationales for a government role in the health sector; many of these also apply to nutrition and population: • To provide public goods and invest in HNP services with large positive externalities, which the private sector would have no incentive to provide in adequate quantity • To enhance equity by ensuring provision of cost-effective HNP services to the poor, who are otherwise unlikely to gain adequate access to essential clinical services or insurance7 • To address uncertainty and multiple market failures in health, including problems of adverse selection, moral hazard, and asymmetry in information between providers and patients.8 IFC supports investments and Advisory Services to the private sector in health and pharmaceuticals to build institutional and systemic capacity and