L E S S O N S F RO M T H R E E A P P ROAC H E S TO I M P ROV E OUT C O M E S
health SWAp or the AIDS SWAp, but not for both. The Bank opted to drop support for the health SWAp and continue support for HIV/AIDS, despite the large share of earmarked funds as a percentage of overall health expenditure (Elmendorf and Nankhuni forthcoming). Despite these risks, the Bank has continued to approve new HIV/AIDS projects in small countries that receive a lot of other earmarked foreign aid. In sum, the past decade has seen an enormous increase in the share and absolute amount of World Bank support for communicable disease control, most of which has been for HIV/AIDS. Communicable disease projects other than for AIDS are more likely to be in large countries, perform better than the rest of the HNP portfolio, and are generally somewhat less complex. The HIV/ AIDS projects are almost all multisectoral and involve multiple public sector entities and diverse segments of civil society, in addition to dealing with a highly stigmatized disease. Furthermore, most are in Sub-Saharan Africa, and many are in smaller countries with a large donor presence. The complexity of the support and low capacity have resulted in lower outcomes. M&E has been inadequate for most communicable disease support, there is little evidence that the poor have disproportionately benefitted, and the actual costeffectiveness of interventions as implemented has rarely been calculated. There are signs that the high level of earmarked disease funds may be creating distortions in the health systems of some small countries.
Reforming Health Systems There is no internationally accepted model of how a health system should function; the specific activities or policy content of health reform are context-specific. Generally, however, reform programs are about fundamental changes in structure, incentives, and allocation of resources. Improved efficiency of health care delivery, coupled with improvements in health status and reduction in inequities, is often at the core of health reform programs. Health reform is thus distinct from efforts to improve outcomes by increasing inputs—money, training, salaries, facilities, and materials—although increasing inputs can be, and has been, used to leverage and support reforms.
About a third of all World Bank HNP projects approved from fiscal 1997 to 2006 had an objective to reform or restructure the health system. These included objectives involving health finance, health insurance, decentralization, or regulation of or enhancing the role of the private sector in service delivery.19 Implicitly if not explicitly, most of these projects aimed to improve the efficiency of the health About a third of Bank system.20 The share of approved proj- HNP projects had health ects with health reform objectives has system reform or declined by nearly half over time— restructuring as an from 45 percent of approved projects objective. during fiscal 1997–2001 to only 26 percent in fiscal 2002–06 (figure 3.3).21 The share has declined in all Regions except South Asia, and in Latin America and the Caribbean and Africa the decline is statistically significant.22 Health reform projects are concentrated in middle-income countries. Three-quarters of all health reform projects were in middle-income countries and half of all HNP projects in middle-income countries over the decade had health reform objectives, compared with only 18 percent of all projects in low-income countries. Health reform is an objective in about half of the projects in lower-middle-income countries and in 6 3 percent of the projects in upper- Health reform projects are middle-income countries. About two- concentrated in middlethirds of the HNP portfolio in Europe income countries. and Central Asia and the Middle East and North Africa is comprised of health reform projects, as is 43 percent of projects in Latin America and the Caribbean. Health reform projects have somewhat lower outcomes than do projects without reform objectives in middle-income countries, although this difference is not statisThey have somewhat tically significant. Seventy-one percent lower outcomes than do of closed projects with health reform projects without reform objectives in middle-income countries objectives. had satisfactory outcomes, compared with 86 percent of HNP projects with other objectives (table 3.1). The borrower’s performance is also slightly lower for health reform projects.
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