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Helping Country Health Systems Deliver Results in a New Global Context

April 9, 2013

The World Bank is one of the most significant supporters of health, nutrition and population (HNP) programs worldwide, giving more than 68 million people basic HNP services packages, providing 55 million women with antenatal care, immunizing 343 million children, and providing vitamin A to 124 million children from 2000 to 2011.


Encouraging gains in halting and beginning to reverse the spread of major communicable diseases—such as HIV/AIDS and malaria—are promising, but there is still much to be done to achieve the Millennium Development Goals (MDGs). Weak health systems are undermining the ability of countries to achieve and sustain health results, and the recent financial, food, and fuel crises have made attaining the MDGs all the more challenging. Less than a fifth of IDA countries are on track to achieving MDG4 (reducing child mortality) and MDG5 (improving maternal health); progress toward maternal and child health and nutrition outcomes is particularly slow because these “neglected” MDGs are dependent on well-functioning health systems and their abilities to reach the poor. Expanding the implementation capacity of health sectors and improving the quality, efficiency, and reach of health services is critical for programs to achieve sustainable results on necessary scales. The main challenges facing middle-income countries are inequities in access to health services, poor-quality health care, large out-of-pocket expenditures for health care, and the growing burden of non-communicable diseases.


The World Bank’s work in HNP focuses on strengthening country health systems to improve health results particularly for the poorest and most vulnerable. It also supports the prevention and treatment of communicable and non-communicable diseases, improves child and maternal health, nutrition, hygiene, and sanitation, and protects the poor from the impoverishing effects of high and unpredictable out-of-pocket spending. Equity and financial protection for the poor are at the core of the Bank’s HNP strategy, and the Bank supports countries in these areas through policy advice and operations. The Bank supports developing countries’ efforts to achieve universal health coverage (UHC) and provide quality, affordable health care to everyone—regardless of their ability to pay—reducing financial risks associated with ill health, and increasing equity. The Bank’s aim is to help countries build healthier, more equitable societies, as well as to improve their fiscal performance and country competitiveness—toward the goals of ending poverty and boosting shared prosperity.

An important pillar of the HNP strategy is increased use of results-based financing, which uses financial incentives to reward the delivery of one or more verified health outcomes. Results-based financing holds considerable promise for increasing health service utilization, improving service quality, increasing efficiency, and enhancing equity. It focuses attention on health results rather than inputs, thereby more tightly linking budgets and financing to results.

Given the interdependence of health outcomes and other key sectors, one of the most important aims of the HNP strategy is to foster approaches that encompass all relevant economic sectors. Building on the Bank’s comparative advantage in development finance, the Bank has supported several innovative financing mechanisms such as the IDA buy-downs (for polio), Advanced Market Commitments (to create market incentives for the rapid production, distribution, and introduction of priority vaccines at low prices), and the Affordable Medicines Facility for malaria (to accelerate the global introduction of artemisinins). Another key component of the HNP Strategy is improving monitoring and evaluation. The Bank is working with partners to develop better ways to monitor the health MDGs, and IDA is increasingly encouraging countries to carry out rigorous impact evaluations of health innovations and programs, in addition to building effective monitoring and evaluation systems.




IDA and IBRD operations are designed and implemented with a particular emphasis on reaching the health MDGs. IDA commitments during the last decade have:

  • Provided more than 65 million people with access to health services.
  • Provided 188 million women with prenatal care.
  • Immunized 496 million children.
  • Purchased and/or distributed about 33 million mosquito nets to prevent malaria; a study of bed net usage in Western Kenya reported a 25 percent reduction in death among children.
  • Purchased and/or distributed more than 35 million mosquito nets to prevent malaria;
  • Constructed, renovated, and/or equipped 23,000 health facilities to improve access to health services.
  • Trained 1.8 million health personnel to improve the quality of health services delivery.

Across individual countries, some specific results include:

  • In Brazil (2004-2009, IBRD), the Bank provided support to strengthen the health surveillance system and expanded access to, and improved the effectiveness of, health, water, and sanitation services for especially vulnerable groups, including indigenous peoples. As a result, 74 percent of the indigenous population was fully immunized by 2010 and malaria-related deaths declined by 60 percent from 2003-2007.
  • In Senegal (2002-ongoing, IDA), the Bank supports an innovative multi-sector health program at the community level in collaboration with local governments, district health authorities, and civil society organizations. This project has contributed a drop in the percent of children with stunted growth to 20 percent in 2011 from 26 percent in 2005.
  • In Nepal (2004-2010, IDA), the Bank supported the national health sector program in expanding access to, and increasing the use of, essential health service, especially to under-served populations.  As a result, contraceptive prevalence (all methods) increased from 35 percent in 2001 to 51.7 percent (40.6 percent for the lowest quintile) in 2010 with a concomitant decrease in total fertility rate from 4.1 to 2.9 births per woman, and skilled attendance at birth increased from 8 percent to 35 percent. Additionally, the percentage of children immunized against measles/DPT3 increased from 62 percent in 2001 to 83 percent at closing for the lowest quintile.
  • In Armenia (2004-2010, IDA), the Bank contributed to the implementation of the government's health reform program through the expansion of access to quality primary health care, which led to a tremendous increase (from 17 percent in 2004 to 85 percent in 2010) in the population served by qualified family medicine practices. Overall satisfaction with the quality of and access to primary healthcare services rose from 87.6 percent to 95 percent.



In FY12, the Bank mobilized more than US$2 billion in HNP investments. During FY06-12, IDA investments in HNP totaled US$7.2 billion. Health systems strengthening accounted for more than 30 percent of IDA’s and 65 percent of IBRD’s contributions in health. Simultaneously, a significant proportion of IDA investments went to key MDG themes such as child health (18 percent), tuberculosis and malaria (12 percent), population and reproductive health (11 percent), HIV/AIDS (10 percent), and nutrition (6 percent). Through IBRD loans, US$10 billion has been invested in health for the same period, and other significant themes include injuries and non-communicable diseases, child health, and safe drinking water/hygiene. The Bank’s multi-sector approach to health outcomes has gained momentum, with about a third of lending for health coming from operations in social protection, poverty reduction, economic policy, and public sector governance.


The Bank and World Health Organization (WHO) coordinate the International Health Partnership (IHP+), delivering improved results in health by implementing the principles of aid effectiveness (Paris Declaration) for health. IHP+ continues to gain momentum, with 31 partner countries.  A key aim of IHP+ is to enable harmonized and aligned support behind one national health strategy, through compacts, joint assessments, joint fiduciary arrangements, common monitoring platforms, mutual accountability mechanisms and the engagement of all stakeholders including civil society.

The Bank is a member of the informal partnership of the eight health-related agencies, which was formed in July 2007 and meets biannually to address challenges in expanding health services, particularly in low-income countries. The Bank plays a role in several other health partnerships, including the GAVI Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Roll Back Malaria; and the Partnership for Maternal and Newborn Child Health.

The World Bank has joined with more than 100 partner agencies and organizations to endorse Scaling Up Nutrition: A Framework for Action, which sets forth principles and priorities for action to address undernutrition and help countries reach the MDGs by 2015.

The Bank’s efforts to support results-based financing have intensified through the multi-donor Health Results Innovation Trust Fund. Contributions to this trust fund from Norway and the United Kingdom totaled US$550 million for use through 2022. To continue improving monitoring and evaluation, lending is much more focused on creating incentives for key results—clear and measurable objectives for health service delivery and for important health outcomes.


The Bank continues to focus on more results-based health lending and is using the resources of the Health Results Innovation Trust Fund to leverage additional IDA and IBRD funds. The Bank will continue to invest in strengthening health systems as a means of meeting disease-specific targets and achieving the MDGs. Particularly in Africa, with two health systems strengthening “hubs,” the Bank is well-positioned to provide technical assistance to countries in results-based financing, pharmaceuticals, health care financing—including community insurance—and the development of IHP+ compacts.

The Bank’s 2010-2015 Reproductive Health Action Plan focuses on health systems strengthening for better reproductive health outcomes—especially for the poor and youth—in countries with a high burden of maternal deaths and high fertility. The Bank is also working with partners to develop better ways to monitor the health MDGs, including the estimation of trends in child and maternal mortality. Regions are explicitly identifying opportunities to address HNP priorities across operations outside the sector and build linkages with non-state actors to position the Bank as a knowledge partner (e.g. South Asia). The Bank is also pursuing multi-year programmatic analytic and advisory activities (e.g. Latin America and the Caribbean), non-lending technical assistance, policy notes, policy dialogue, and country-to-country learning to maintain engagement with countries even in the absence of lending.


In Brazil, 74% of the indigenous population was fully immunized by 2010.