GLOBAL HEALTH WATCH
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Goa still grappling with tuberculosis
World i uucfCUiOSiS isay Will OC COiiifiicuiOfatcd 'die WOi ld OVcf Oil
Wednesday. bin does Goa have any reason to par irseif on rhe back9
Are government officials reallv serious about alleviating the situation
io the SfaTe which has remained status quo tor the last decade or so?
Goa ranked iiunibei one m terms of health lias still nut implemented
rhe Directly observed treatment short course (DO is) chemotherapy
for treatment of tuberculosis as compared to 70 per cent of the country
nhe’-ldv covered >'ru'er »h»s iHOgiarnmy
Hie number of tuberculosis patients in lire Stale is ebiimaied to be around
16,000 to 20,000, ot which one iorth is infectious Ihis situation has
certainly not improved in the last decade, and in fact, the seriousness of
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Training oi doctors and staff for the implementation of the DOTS programme
started in the year 2002, informs a doctor of the Health Services. Ln tact,
assurances were given by a senior bureaucrat of the Directorate of Health
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programme has stiii not been implemented.
"We wanted to start the programme by March 24 (tomorrow), but it is not
possible. The work is still going on, such as renovation of laboratories.
GneijidtiOu of private pfavutiviiers also Has to oe uOiie", says Dr
AS
Palekar. Chief Medics i Officer. TB Control Programme
A senior V'ureaucrat of the DHS, who prefers to remain anonymous says,
"Goa is in ths final stags of preparing for the programme. Almost all the
li timing of medical office! is> done. Civil work is being undertaken.
Lhe programme may oe launched in the first week of May, after the
elections.
"It has been observed the world over that the National 'tuberculosis Control
Programme (NTCr) which is Mowed in Goa is not the best way io treat
Tuberculosis", says Dr L Da Costa, Associate Professor, TB and Chest
Disease Hospital "The hallmark of rhe new treatment (DOTS) is directly
observed ueatment which eliminates default'1 he adds.
Explaining the advantages of the DOTS programme. Dr Da Costa says
that it makes sure that there is no default on account of shortage of
medicine as a complete kit of medicines is given to the patient. In addition.
it chcckt; dciiuit 21 th? cii iicst 2nd f2.ciii13.tcs ccri” ditsvnosis of side
One 01 the main aspects of the Do i S programme is that it involves sputum
microscopy diagnosis, which detects ’positive' sputum, the more serious
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For the purpose or imp'emenring the programme; Goa has been divided
into three units: Paniim. Marjac and Pcnda. Each unit will have five sputum
microscopy centres where r'iaMposi> w>" be done Ewh centre will then
have a number of DOT S centres where treatment will be given. The entire
setup will ensure that the patient will get the tieatrnent at the closest piace
to him
HERALD 2-t : Gt Page 1
GOA CTVTC AND CONSEr.JER ACTION NETWORK
to promote civic anti consumer rights in Goa
5/6/04
(Z& n-t y\ '
falls vjini ba ro c :o naaltf
People1s Health Movement
Global Eauii? Gauge Alliance
Global Health Watch
Global civil society has not adequately participated in international health advocacy. Although highprofile success has been achieved with some campaigns, most notably around access to medicines
and breastfeeding and certain diseases, there has been a striking lack of involvement and pressure
from health campaigners on broader public health and health systems issues. In addition, disparities in
health between the rich and the poor have grown at alarming rates both within and between countries,
leaving society and the public health movement with a large humanitarian and moral challenge.
The increasingly global dimensions of poverty, disease and health policy require a much more vigorous
input from public health experts, civil society and non-government organisations. The People's Health
Movement, the Global Equity Gauge Alliance and Medact therefore propose to mobilise a fragmented
global health community through the publication of an annual Global Health Watch. This publication
will be used to shift the health policy agenda away from a technocratic approach to delivering health, to
one that recognises the important political, social and economic barriers which prevent the achievement
of better health.
We want the Watch to strengthen the calls for a broad approach to health amongst policy-makers,
health professionals, campaigners, researchers and others concerned with health and to act as a
reality-check on those formulating health policy by providing a forum which magnifies the voice of the
poor and vulnerable and those who work with them.
The Watch will consist of a compilation of chapters on various global health issues written by NGOs
and academics. Stories, experiences and analysis direct from poor communities will be threaded
through the chapters and enable those who are traditionally unheard to voice their concerns on global
health issues:
The Global Health Watch team is now looking both for authors to write chapters and for stories and
experiences from around the world. For more information on the areas we are covering, go the Medact
website www.medact.org
Medact
The Grayston Centre
28 Charles Square
London N1 6HT
United Kingdom
Tel: +44 20 7324 4733
Fax: +44 20 7324 4734
www.medact.org
October, 2003
SUMMARY OF CHAPTER HEADINGS
Preface
Introduction
SECTION A: INTRODUCTION TO GLOBAL HEALTH INEQUITIES
A1: Health in a Divided World (Socio-economic, health and health systems inequities)
SECTION B: THE POLITICAL ECONOMY OF HEALTH, DEVELOPMENT POLICY AND
HEALTH SYSTEMS
B1. The Politics and Economics of Poverty - A Global Public Health Priority
B2. Failing Prescriptions - Social Sector Policy and Ideology
B3. Health Policy: The Privatisation Agenda
B4. Where are our doctors? The Global Brain Drain of Health Personnel
B5. Big Pharma and the Future of Accessible Medicines
B6. Global Heath Leadership
SECTION C: BEYOND THE HEALTH SECTOR
C1. Agriculture and food security (long)
C2. Water (short/medium)
C3. Militarism and health (medium)
C4. Environment (medium)
C5. Gender and 'Women's Access to Health Care and Reproductive Rights (medium)
SECTION D: MONITORING AND ADVOCACY SECTION
This section will consist of a number of sub-sections each of which will highlight a few key institutional
case studies (we want a report that is monitoring the performance of key actors) and policy
recommendations related to the earlier chapters. The purpose of these sub-sections will be to affirm
the notion accountability to civil society, and at the same time inform the advocacy and lobbying
actions of a global progressive health movement committed to a just world and health for all. There
would be a number of sections, for example:
•
•
•
•
•
.
•
•
•
•
•
Trade and WTO
ODA
HIPC initiative
IMF
Global political and economic governance
WB Watch
WHO and other international health agencies
GATS and Health Watch
Global medicines watch
Global health research watch
Donor watch
Suggested individuals
or NGOs to co-author or
endorse chapter
Nelson Mandela /
Desmond Tutu / Graca
Machel
Preface
Introduction
Why have an alternative world health report. Why a focus on equity. Structure and purpose of report
GEGA/PHM/Medact
SECTION A: INTRODUCTION TO GLOBAL HEALTH INEQUITIES
A1: Health in a Divided World (Socio-economic, health and health systems inequities)
Introduce the socio-economic and political determinants of health and how socio-economic inequities affect health inequities
Overview of the distribution of wealth (poverty) / health (ill health and mortality) / health care resources. Provide historical overview
of socio-economic development and equity since WW2 and describe the current concentration of economic wealth amongst rich
nations and fewer and fewer TNCs, and the existing levels and distribution of poverty
WDM
Oxfam
SCF
GEGA/ Equitap
Describe trend of growing inequities within rich countries as well as within in poor countries.
Describe health inequities globally, inter-regional and in-country - emphasise HIV/AIDS, TB and malaria, but also of childhood
killers, trauma and violence related health.
There are many reasons for this picture, but this section of the report will highlight the political and economic causes at a global
level; with the understanding that poverty will not be addressed without inequities being reduced.
Describe the state of health care in relation to the state of health, and the way health systems can determine health inequities
Describe health care and health systems inequities globally, inter-regional and in-country - incorporate a case study on the collapse
of African health systems.
SECTION B: THE POLITICAL ECONOMY OF HEALTH, DEVELOPMENT POLICY AND HEA LTH SYSTEMS
B1. The Politics and Economics of Poverty - A Global Public Health Priority
Explain and summarise key global trends that are relevant to the current picture of growing inequities and the poverty traps that
many poor countries are in. Highlight:
> Unfairness and effect of the global trading system (including double standards re tariffs and subsidies)
•
•
•
Noreena Hurtz
George Monbiot
Naomi Klein
>
>
>
>
>
>
>
Effect of protectionism and subsidies amongst rich countries
Declining levels of ODA, inequitable distribution of aid amongst developing countries and poor quality ODA (tying of aid; donor
uncoordination; appropriateness of aid; linkage to privatisation policies)
Burden of debt and inadequacy of debt relief
Effect of global financial system on macro-economic stability and development in poor countries
Capture of the wealth of natural resources by small numbers of people
Policies which transfer assets from sovereign debtors to international creditors
Impact of Washington Consensus policies on development and equity.
•
•
Susan George + staff
and fellows of
Transnational
Institute
Martin Khor and
Chakravarthi
Raghavan (Third
World Network)
Describe the political processes that underpin the current global economic structure and system and highlight issues about global
economic and political governance. These issues include the accountability of global governance institutions to civil society and the
democratic deficit; lack of transparency and accountability; corporate control and influence; lack of power of developing countries in
the face of increasing economic and financial globalisation and concentration of political and economic power amongst rich nations
and corporate sector; the elevation of the rights of foreign creditors over those of citizens.
Relate these issues to (each as a sub-section):
•
International financial system;
•
Regulatory structures and systems for trade + WTO
•
Regulatory structures and systems of TNCs
.
IMF
•
UN
•
Intellectual property rights regime
Emphasise the link between all of this with health and that unless the underlying socio-economic determinants of poverty are
addressed and unless countries are adequately resourced to ensure effective health systems, we will not deal with the 30,000
preventable childhood deaths a day, the HIV and TB epidemics etc.
Conclude that there is a need for:
> Reform of global economic and political institutions
> Much greater transfers of resources and wealth from rich to poor.
> Bold and radical departure from business as usual.
> Global health institutions such as WHO and other health associations and organisations to elevate the political economy of
health as a public health priority.
B2. Failing Prescriptions - Social Sector Policy and Ideology
Describe the current (neo-liberal) economic theories and ideology that underpins the general social sector development discourse,
and the influence of WB, IMF and OECD. Describe the growing privatisation agenda and the policy convergence among WB, IMF
and bilaterals. Make link between the privatisation agenda in the social sector with the global political economy.
Explain the effects of such policies on poverty alleviation and inequity.
Citizens Network on
Essential Services (Nancy
Alexander and Tim
Kessler)
Contrast with examples of countries whose social policies have been pro-poor and where real advances have occurred.
Include sub-sections:
•
Critique of the current World Development Report
•
Critique of selected PRSPs
•
Extent of and the effects of the privatisation of basic services (water and electricity) on health, poverty and inequities
Patrick Bond (South
Africa)
WEED - German NGO
working on privatization of
water.
Bretton Woods Project
and BIC
Public Services
International Research
Unit (PSIRU)
B3. Health Policy: The Privatisation Agenda
Overview
Overview of development of international heath systems policy since the 1960s.
Describe the heterogeneity of health systems, but the growing worldwide trend of a shrinking public sector. Describe the demise of
the principles of the PHC Approach and how it is misunderstood and misapplied. Report on the growing emergence of selective
primary health care and the global verticalisation of health interventions in contrast to the development of coherent health policy and
health systems development.
Mike Rowson
Fran Baum
Ravi Narayan
David Sanders
David Woodward
Andrew Green / Charles
Collins
Privatisation
Abhay Shukla
Describe the trends on the privatisation of health care. Describe trends in public health budgets and health care expenditure',
declining public health budgets and rise in out-of-pocket expenditure. Describe the lack of regulation of the private medical care in
developing countries and the growth of the private medical insurance industry.
Describe the various forms of privatisation incl. cost recovery mechanisms, user fees and subcontracting of services to NGOs, and
critique the targeting of services approach (as opposed to strong universal care systems). Emphasise also how public sector budget
cuts lead to 'de fact' privatisation.
Describe the policies, ideologies, reforms and forces that are contributing to this and raise the issue of increased inequities,
inefficiencies, segmentation of health systems and weakening public health capacity. Make reference to WB and WHO positions in
this regard.
Review evidence about the performance of the private for-profit sector in terms of efficiency and effectiveness, as well as their
John Hilary/WDM
(Jessica Woodroffe and
Claire Joy) / Sarah Sexton
Maureen Mackintosh
impact on equity. In contrast, discuss the evidence that exists to suggest that universal public sector state services are inherently
inefficient and inequitable - will need to tackle some of the WB papers and views on this directly.
Build on case studies - for example, describe what is happening in a number of countries (for example, India, Mexico, South Africa,
Australia, Malaysia, USA and one East European country), and then propose an appropriate health sector reform package.
Describe Free Trade Agreements and GATS, and their impacts (or likely impacts) on increasing privatisation, increasing health
systems inequities and weakening government regulatory capacity.
The new Public Management
Another increasingly dominant policy / approach within development and social service delivery is the new public management - the
promotion of market-based, private solutions to public sector management. Describe extent to which this is being promoted and
critique its appropriateness for the delivery of social goods and services such as health care (develop a box summarising the
reasons why health and health care require the state and are failed by the market and market-based reforms of the public sector).
B4. Where are our doctors? The Global Brain Drain of Health Personnel
Equinet-HRH network
Indicators to monitor the equitable distribution and availability of health personnel
Describe the central importance of health personnel to functioning health systems, and the picture of global health personnel
inequities. Describe the aggressive recruitment of health personnel from the south. In short, the political economy of health
personnel availability and training.
Rockefeller - WHO team
members
Describe efforts underway to address this problem, including the Rockefeller 1 WHO initiative. Describe what WHO, ILO and other
UN agencies are doing. Describe some of the other stakeholder positions. Monitor development and implementation of policies to
mitigate the global brain drain
B5. Big Pharma and the Future of Accessible Medicines
Describe the multi-billion dollar pharmaceutical industry in relation to global health and world poverty
Report on progress with respect to:
•
TRIPs and the implementation of the Doha agreement
•
Accelerated access initiative
•
Regulation of the pharmaceutical industry
•
Progress towards EDP implementation
Describe the efforts of the pharmaceutical industry to remain non-transparent, to inflate their research and developments costs; as
well as to promote a deregulation of the market whilst strengthening their capacity to protect patents and to fix prices.
MSF, HAI and TAG
Describe progress re: development of pharmaceutical manufacturing capacity in developing countries
Set out an agenda of action for WHO, including distancing itself from the influence of the pharmaceutical industry and calling for a
international framework for the transparent regulation of the pharmaceutical industry as well as the development of generic
manufacturing capacity in developing countries.
B6. Global Heath Leadership
The whole concept of global health governance needs to be described and explained in relation to many of the earlier chapters. It
should point to a lack of global public health leadership in addressing the underlying determinants of poverty and disease;
inadequate mechanisms for civil society engagement and participation; dangers of GPPIs etc.
This chapter will include a critique of some of the key health sector specific multi-lateral agencies:
•
World Health Organisation
•
UNAIDS
•
UNICEF
It will look at overall performance; the extent to which a broad public agenda is acknowledged and supported; the extent to which
there has been adequate civil society engagement especially with developing country civil society; the extent to which they have
been compromised by corporate interests etc.
It should build on some concrete case studies including:
•
involvement and influence of pharmaceutical industry within WHO
•
breastfeeding, the state of play re: infant feeding code and the influence of baby food industry on health policy agencies
•
the tobacco control initiative + WHO's desire to stand up to the sugar and food industry .... positive examples of health
leadership
SECTION C: BEYOND THE HEALTH SECTOR
C1. Agriculture and food security (long)
•
•
•
•
•
Describe state of hunger and malnutrition, and growing inequities in food consumption
Increasing oligoopolisation of food industry
Critique of agri-business, GMOs and TRIPS-related developments
Comment n the weakening of public distribution systems for food security (e.g. various forms of rationing and food subsidies)
under neo-liberal regimes
Report on unfair agricultural subsidies and dumping
Tim Lang is Professor of
Food Policy at Thames
Valley University.
Alliance for People’s
Action in Nutrition
Vandana Shiva
Critique of UN / donor / FAO approach to household food security. Critique WHO's approach and performance related to food
security, agriculture, nutrition. Report on WHO's recent battles with the sugar and food industry. Make mention of the millennium
development project's background paper.
Propose alternative strategies
Emphasise the importance of this as a health issue. Determine some key recommendations that we can ask health associations
and health-related NGOs, as well as the global health institutions such as UNICEF and WHO to advocate for, and which GHEW can
monitor on an annual basis.
C2. Water (short/medium)
Explain importance of basic utility services (water, sanitation and electricity services) to health, emphasising again the importance of
addressing the broader determinants of health.
Describe the global situation in terms of coverage, access and utilisation (including inequities in consumption). Review, assess and
critique the current state of international treaties and conventions related to water and energy.
C3. Militarism and health (medium)
•
•
•
•
Report on trends related to military expenditure and its direct and indirect effects on development and health (describe
inequitable distribution of the consequences of war and conflict)
Report on trends related to the effect of war, violence and conflict on health
Describe on-going threats of nuclear weapons and its impact on health
Case studies (possibly from Bosnia, Sri Lanka, Afghanisatan, Iraq, Sierra Leone, Congo, Columbia and Palestine / Israel):
o What is happening from a health perspective
o What have been the post-war responses to reconstructing the health system
Brief summary of what is happening in the UN and the various other weapons control treaties and conventions. Construct this as a
report card of progress and failure - naming and shaming of perpetrators and problem countries.
Emphasise the importance of this as a health issue. Determine some key recommendations that we can ask health associations
and health-related NGOs, as well as the global health institutions such as UNICEF and WHO to advocate for, and which GHEW can
monitor on an annual basis.
Medact / IPPNW
Centre for Humanitarian
Dialogue (Human Security
and small arms project)
Saferworld - independent
foreign affairs think tank;
has two research
programmes: Arms and
Security, and Conflict
Prevention
Federation of American
Scientists - Arms Sales
Monitoring Project - works
for transparency,
accountability and deep
reductions in global
conventional weapons
production and trade.
Case studies:
The Regional Centre for
Strategic Studies in Sri
Lanka
Regional Human Security
Center in Jordan
Institute for security
Studies in South Africa
C4. Environment (medium)
Report on the continued and growing threats to health from environmental degradation and pollution:
•
global warming
•
ozone depletion
•
water pollution from pesticides, sewage etc.
•
deforestation
Make link between poverty, environmental degradation and health. Introduce concept of ecological debt.
Summary of what is happening in the UN and through the Commission for Sustainable Development. Describe the shortcomings of
the current system of global economic governance in protecting the environment as well as the weakness of the international
regulatory system to identify and punish environmental offenders. Construct a short report card of progress and failure related to the
various treaties and conventions - naming and shaming of perpetrators and problem countries.
Relate this back to the health community. What should they be doing? What should WHO be doing? For example, has it spoken out
against the failure of the Kyoto protocol from a public health perspective?
Bank Information Centre
(BIC) has been working
on the multilateral
development banks from
an environmental
perspective.
The Center for
International
Environmental Law NGO that provides
environmental legal
services, as well as policy
research, advocacy,
education and training.
Friends of the Earth
Greenpeace
C5. Gender and 'Women's Access to Health Care and Reproductive Rights (medium)
Highlight the specific needs and challenges to addressing women's health. Describe the progress that has been made since Cairo,
but highlight the fact that while the world is long on bold policy statements and declarations, it is short on changing the lives of
millions of women who suffer from discrimination and a lack of adequate health care. Provide what data there is to demonstrate the
health inequity between men and women.
Make the link between the collapse of health systems to women's health.
Make the link to broader social and cultural issues, and describe attempts to empower and liberate women through health care.
Critique the role and effectiveness of international and multi-lateral agencies to address this issue.
SECTION D: MONITORING AND ADVOCACY SECTION
Womens Global Network
for Reproductive Rights
This section will consist of a number of sub-sections each of which will highlight a few key institutional case studies (we want a
report that is monitoring the performance of key actors) and policy recommendations related to the earlier chapters. The purpose of
these sub-sections will be to affirm the notion accountability to civil society, and at the same time inform the advocacy and lobbying
actions of a global progressive health movement committed to a just world and health for all. There would be a number of sections,
for example:
Trade and WTO
•
In terms of trade, concrete issues to monitor might include the rich country tariffs and subsidies; and the removal of appropriate
protectionist barriers in poor countries. This might include a 'report card' of the fairness of the Cancun talks.
•
In terms of WTO, highlight the need for reform of purpose, governance and accountability.
ODA
•
Provide detail of good and bad performers.
•
Develop donor country case studies (possibly a mix of good performers and bad performers) - to look at quantity, quality,
conditionality and politicisation of aid
•
G8 report card
HIPC initiative
•
Describe the lack of progress related to debt cancellation as well as the inappropriate / unfair conditionalities.
IMF
Global political and economic governance
•
Regulation of global financial and capital markets
•
Recommend and monitor progress towards policy proposals such as Tobin tax
•
An effective global tax system
WHO and other international health agencies
Assess their positions and actions on the political and economic issues listed above (include absence of such issues in macroeconomic commission on health).
WB Watch
Develop a critique of the World Bank which can be used to make specific demands of the Bank and to monitor the Bank - this can
be tracked in subsequent GHEWs. Include issues related to governance, transparency and policy (possibly the other MDBs?)
WHO and other international health agencies
Assess their views, positions and actions on issues raised in C1 and C2. For example, WHO's position on privatisation within health
care systems + critique WHO's position and policies with regard to GATS and FTAs.
GATS and Health Watch
Development Initiatives they compile an annual
review of all ODA
•
Kees Biekehart. TNI
Fellow working on aid
impact
•
David Sogge. Works
on development aid
and aid policy in
Southern Africa.
•
North-South Institute independent institute
that conducts
research on Canada's
relations with
developing countries
and its foreign aid
programs.
Anne Pettifor - works on
debt relief and HIPC
Global medicines watch
Global health research watch
Progress on the widely publicised 10:90 mismatch between the allocation of research funds and the burden of disease.
Donor watch
Although the WB is probably the biggest influence on health systems policy / health sector reform, bilateral donors can be influential
at the country level. Therefore important for there to be a greater “donor assessment" within the health care sector to determine how
well aid is being used to support appropriate health systems development and equity. Also how are donor countries choosing
between different countries? How much aid is recycled back to home country consultants? To what extent are trade objectives and
religious agendas being promoted through donor programmes?
APPENDICES : VOICES FROM THE GROUND
End with something positive that talks about various alternatives (the PHM network can provide many examples) and which
illustrates the vision envisaged in the People's Health Charter.
Identify and promote good models and countries which have continued to strengthen universal health care systems.
PHM
Page 1 of2
Main Identity
S====X===S2========±X
From;
"Ruggiero, Mrs. Ana Lucia (WDC)" <ruglucia@PAHO.ORG>
To:
Sent:
Subject:
Tuesday, January 13. 2004 8:37 PM
[EQ] Towards a global health workforce strategy
<EQUIDAD@LISTSERV PAHO.ORG>
......Original Message----From: Mario R Dal Poz [mailto:dalpozm@WHO.DJT]
Towards a global health workforce strategy
A new book on human resources for health issues was launched in December:
Ferrinho, P .Lisbon University. Dal Poz M. World Health Organization & Rio de Janeiro University
(cds.)
Antwerpen: ITGPress, 2003: 488 pp. |ISBN 90-76070-26-11
A free downloadable full-text copy [PDF file] is available at:
http://www.itg.be/itg/GeneralSite/InfServices/Downloads/shsop21.pdf
"....The papers presented in the book cover the main dimensions of HRD in health: planning and
managing the workforce, education and training, incentives and working conditions, managing the
performance of personnel and policies needed to ensure that investments in human resources
produce the benefits to which the investing populations arc entitled.
Authors write from diverse professional, regional and cultural perspectives, and yet there is a high
degree of consistency in their diagnosis of problems and proposals lor strategies to address them.
They all agree on the multidimensionality of problems and on the need for solutions that take into
account all dimensions. They also agree that if problems tend to be similar- in nature, they take forms
that are lime and context-determined.
This set of papers raised questions and give insights into strategies that are relevant to developed and
1/14/04
Page 2 of 2
developing countries
Bank Institute)
*
*
*
" Orvill Adams (World Health Organization) and Gilles Dussault (World
1k
This message from the Pan American Health Organization. PAHOAVHO. is part of an effort to
disseminate
information Related to: Equity: Health inequality: Socioeconomic inequality in health:
Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity;
Ethics;
Information Technology - Virtual libraries; Research & Science issues. [DD/ IKivl Area]
"Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the
findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan
American
Health Organization PAHO/WHO or its country members".
PAHO/WHO Website: hup:/7www.paho.org/
EQUITY List - Archives - Join/rcmovc: http://listscrv.paho.org/Archivcs/cquidad.html
1/14/04
1.
WHAT ARE THE INEQUALITIES IN HEALTH IN YOUR COUNTRY
l.a) This question is rhetorical in the Indian context, where
gender, class, ethnic group, age, area of residence all have
bearing on factors such as availability of food grains,access to
safe drinking water ,sanitation,education,and health care servic
es.The infant mortality rate varies from 13 (Kerala) to 97
(Madhya Pradesh) (1996 figures), while in Madhya Pradesh itself
the rural areas have an IMR of 102 compared to an IMR of 61 in
the urban areas. Whereas the average no.of villages covered by a
PHC in Kerala is 1.44, the figure for Madhya Pradesh is
51.98(ref. Health Monitor 1997). The expenditure by the state on
health is also variable, e.g. with a percapita expenditure of Rs
14.49 in Bihar in 1980-82, to Rs.101.29 in Himachal Pradesh.
(Health Status of the Indian People
1 b) Many of the goals outlined in the Declaration of Alma Ata
have yet to be realized. Most critical to health is the absence
of implementation of the minimum wages act, which keeps a large
no. of unorganized labor (especially farm labor)in poverty. The
govt, is yet far from fulfilling its commitment to provide safe
drinking water to every village by 2000 A
1 c) The problems resulting from inadequate allocation of re
sources, administrative failure are exemplified by the perfor
mance of the National Tuberculosis Control Program, and the
National Malaria Control Program. Corruption in health regulatory
bodies like FDA, have led to deaths due to administration of
contaminated glycerol(Bombay), IV fluids (Delhi), and the recent
dropsy epidemics in North India. The influence of pharmaceutical
companies on the drafting of the National Drug Policy, has caused
great harm to the people's right to essential drugs at affordable
prices. Health resource allocation continues to suffer from an
urban and curative bias. The expansion of the private sector in
health care has been abetted by large scale exemptions on import
duties,and in some cases provision of land at ridiculous
prices(the Apollo Indraprastha hospital in Delhi, one of India's
most expensive, was provided land at the cost of Re 1/.by the
Delhi administration)
2.
HOW WOULD YOU MEASURE THESE INEQUALITIES
a) These inequalities manifest themselves in the form of differ
entials in morbidity and mortality,life expectancy,
malnutrition,percapita food grain consumption, the access to and
utilization of health services.
b) The Census data, the sample registration system and other
reports of the from the office of the Registrar General of India,
research studies conducted by health and social science profes
sionals, documents brought out by voluntary agencies & focus
groups, and the Central Bureau of Health Intelligence.
However there is a serious lacuna due to the absence of a sur
veillance mechanism for monitoring disease status , demography,
nutritional status at the district level. The community health
centers being established now were to have a post of community
health officer who is a public health specialist who would under
take surveillance at the local level, so that the center could
function as a epidemiologic surveillance station. However this
has not been implemented in most of the states. Also the private
sector which caters to the health of a large no.of people should
be involved in surveillance programs. An initiative of this kind
to document morbidity due to six communicable diseases, was
successfully attempted in North Arcot district by faculty of the
Christian Medical College, Vellore.
c) It is a widespread belief that data from the Government, lacks
accuracy and transparency. The data pertaining to immunization
and family welfare activities are often overestimates, while the
figures for morbidity/mortality due to communicable diseases are
often grossly underestimated.e.g vital statistics of India col
lected separately reported malaria deaths as 137,846 in 1985 and
75,285 in 1987 whereas the NMEP figures were 213 and 188 respec
tively .( Ref . Towards an appropriate malaria control strategy 1997.
VHAI-SOCHARA document.)
d) Yes, there is a need for primary collection of data, although
it is possible to analyze the existing data.
e)
Some of this data is readily available as reports, documents.
f) Verification is a difficult task unless a system for monitor
ing and surveillance involving both the government and private
sector run services is in place. Crude estimates of the problem
can sometimes be had from the estimates of drug consumption e.g.
of chloroquine for malaria, anti tubercular drugs for tuberculo
sis .
g) The need to protect sources may arise in case the data is
being provided by voluntary agencies and is at variance with the
official data.
h) The national level data may be monitored by an independent
body which actively networks with academics and public health
specialists, health professionals, voluntary agencies(e.g.the
voluntary health association of India and the community health
cell )
and focus groups (e.g. those active in the areas of
women's health, drug issues, worker's and consumer rights,
environmental groups), and associations of health
professionals.(e . g . the Indian Medical Association).
i) The benefits of knowing accurately the magnitude of health
problems, and of monitoring trends will far outweigh the modest
costs incurred.
3.
ADVOCACY
2
a) In public forums including citizen groups, panchayati raj
institutions, the the printed and the electronic media, in acade
mic forums, with the bureaucracy .judiciary and the legislatures.
b) The inequalities in health should form part of the agenda of
any voluntary agency active in health and allied areas, and
should be brought to the attention of the public using the media,
and available public forums including the panchayati raj institu
tions. The academia , the focus groups and the associations of
health professionals should use the leverage they possess to
highlight health issues. The judiciary which has become increas
ingly responsive to health issues can be approached to
provide/enforce
the legal provisions to address public health
problems. Finally voluntary agencies should create a climate
where issues of health and health care, and allocation of re
sources are seen as priority issues for the people, and taken up
by the legislative structures.
c) The answer to this question has been covered in response to
question 3(b).
d) These initiatives would be deemed successful if they result in
health issues being highlighted at a national and international
level, and create pressure for remedial actions to address ineq
uities in health. The gross neglect of public health by govern
ments, resulting in denial of safe drinking water, sanitation,
and a clean environment, and a public health care system which
does not deliver the goods, are concerns which this watch should
address.An increase in allocation to health by governments and
the utilization of these resources in a manner which meets peo
ple's basic health needs should be one of the goals. By monitor
ing the activities of international organizations, one should be
able to provide a counterpoint to inappropriate prescriptions
which less developed countries are being made to follow because
program funding is made conditional to their acceptance. A case
in point was the allocation of funds by the World Bank to the
Indian government for the Revised National Tuberculosis Program,
on the condition that Direct Observation of Therapy would be
universally followed in the program. The effects on the health
status of a people , of the rapid changeover to a market economy
under the regimen of globalisation, need to be urgently studied.
Apart from the above a health watch could provide reliable infor
mation about changing trends in the health status of people and
help focus attention on priority areas, feedback which could help
change policies as well as systems and early warning of public
health disasters.
e)
Yes.
4
PARTNERS
a) Voluntary organizations working at the grassroots level,
coordinating agencies (like the VHAI), research institutions
3
(ICMR, ICSSR, Malaria Research Center, National Tuberculosis
Institute , National Institute of Health and Family Welfare,
National AIDS Research Institute , National Institute of Occupa
tional Health, National Institute of Environmental Engineering,
etc), the various centers of development studies, organizations
like SOCHARA, and focus groups including advocacy groups.
b) The primary data collection would be done by the NGOs , re
search institutions as a part of their work, and by focus groups.
The watch would thus receive inputs from multidisciplinary sourc
es. The analysis and dissemination of this data would be done
both at the state level and at the national level by an independ
ent body.This data could also be provided to various focus
groups, advocacy groups, media, citizen groups, and the decision
makers in the bureaucracy and legislature,which they would then
respond to.
5.ORGANIZATION
a) How would a national watch be organized ?
This question is difficult to answer at this preliminary stage,
and much thought and discussion needs to follow. But a decentral
ized approach with strong involvement of grassroots level organi
zations and of persons with a strong pro-people commitment should
be central to the character of the watch.
4
GLOBAL HEALTH WATCH
1 What are the inequalities in Health ?
• Regional - access/spending - interior and isolated areas ,
north / south
• rural-urban
• economic status
• level of monetisation
• terrorism and insurgency affected states
• urban slums
• nomadic/immigrant labour
• inequal budgetary allocation against PHC
• historical processes through states go through
• information / awareness / education
• employment status
(ii)
• gender - esp as sex of doctor available is most often male
• caste
• life expectancy
• age - geriatrics / adolescent
• tribals-2
• religion
(b) Implementation of conventions / performance
government
• No - 4
• not fully -4 , due to subtle changes being made over time
• yes- 1
of
(c) Factors compounding inequalities.
• SAPs
• media explosion leading to changed values
• management structures not suiting Indian ethos
• corruption-3
• inadequate / untimely release of funds
• lack of infrastructure.
• drugs and pharmaceuticals
• lack of private sector effort / involvement
• complete dependence of government
• lack of seense of participation
• lopsided priorities
• poor information base
• illiteracy / unaware citizenery
• uncommitted proffessionals,
lack of monitoring
supervising
• external aid
• urban bias of NGOs
• insurgency / violence
• environmentally unfriendly development projects
• eco non-friendly tourism
• western based education / medical education.
2 How would you measure Health inequalities ?
(a) How to show they exist ?
• government data including - census /SRS / NFHS /
disaggregating for different
variables
• comparative perspectives
• qualitative and case studies , narratives
• per capita expenditure in various areas
• sale of drugs etc / utilisation of hospital services.
• NO NEED TO DEMONSTRATE.
• pattern of unfilled posts./ idle time in PHCs
/
- by
2
(b) Sources of data ?
• Govt, reports - SRS / census / NFHS / NSS / expert
comittee reports
• reports from other agencies - NGOs / NCAER
• cause of death survey
• HMIS
• media and media archives
• internet
• rural health bulletin
• full extent of inequalities can be appreciated only through
micro studies
(c) What about accuracy and transparency of government data
?
• every boday felt that it was inaccurate and not transparent
but is was the only regular
source of large scale
data.
• quality of data correlates with, the quality of health services
/ admin.
• SRS / NFHS - have been found reliable
(d) Is there a need for primary collection or would it be
possible to analyse existing data?
• Not required - 3
• yes - 6 small sample size and rigid supervision / would it be
possible?
(e) How is it possible to gain access to the data ?
• right of infornation law
• trust building
• partnership with the government.
3
• funding agencies making loan availability conditional to
provision of data
• govt data more easily available than NGO data
(f) How to verify if the data is reliable and accurate ?
• internal consistency checks
• following time trends
• cross - checking representative samples
• small sample surveys
• regular monitoring
• focussing on one or two important areas
(g) Is there a need to protect sources, and if so, how?
• most responses -no (as it would decrease the credibility of
data)
• two responses -yes; for fear of data being withheld in the
future
• classify data into common and classified
(h)
Who
would monitor the data and how?
• academics / researchers
• policy makers
• programme planners
• NGOs / activists
• government-NGO partnerships
• selected sensitive government officials
• parallel monitoring groups / special research teams
• individuals / groups outside the government
• press / media
•
(ii)how?
undertaking cross-check studies internal auditing
(j)What are the cost implications?
• large costs-2
4
• not much-3
• depends on design
3. ADVOCACY
(a) Where can issues of inequality in health be take up?
• public fora including caste parichayats etc.
• media
• govt -NGO interactions
• take matters to court
• academic -govt interactions
• focussed conferences
• raising matters in the legislature
How
(b)
can these issues be taken up?
• publications, lay and scientific
• public announcements / media releases
• NGO-community groups meetings
• general awareness/ sensitising campaigns like jan adalats /
jan jatthas
• making issues part of political agenda
• by framing issues in a non-threatening manner
• participate in policy making bodies , state and national
planning bodies
• school and college competitions
(c)
With
whom should they be taken up?
• as in 3(a)
• corporate sector
(d)
What
is the likely impact?
• keepinh govt MIS on its toes
5
• watchdog on any policy having health implications
• sensitising policy makers
• achievement of equity
• impact immeasurable before major commitments of
resources are made
• possible negative impacts like hostility or mistrust
• depends on the method of presentation to relevant authority
Is there is a need for alternate reporting systems?
(e)
• yes-5
• no-2
4. Partners.
(a) Which organisations or persons would be able to
participate in this kind?
• academic institutions like JNU / TISS
• NGOs - recognised / reliable/ reputed / grass roots /
research
• professionals outside government or political parties or
health industry
• Autonomous institutions financed by govt / industry
• training institutions - medical / social / nursing
• govt.
• IMA
• press
(b) What different roles could they play ?
• design and analysis of studies
• collection and provision of data
• think tank
• advocacy groups
• dissemination for wider debate
• watch dog for influences of other policies on health
• training government officials in data collection
• networking
6
5. Organisation
(a) How would a national watch be organised?
• Federal set up
central secretariat with state branches
including at levels SRS, govt and
NGOs
• network of elected / selected / involved
(b) What should be the structure ?
• international - national - Ngo/ civil society / individuals
• to be coordinated by an NGO person . Govt to participate as
equal.
• Like SRS data to be collected from NGOs and collated
upwards
• no need of new formal structure
(c) How should it relate to a global health watch ?
• global watch - global issues - global advocacy
• relationship with GHW to be part and parcel of NHW
• through multilateral bodies like WHO / UNDP
• using foriegn soil to make contentious observations,
especially against non-democratic
states
• if in India NICNET could link up with all available sources of
data it would be helpful as a web site for the national watch
(d) How should the capacity of national and local NGOs from
the South be strengthened ?
• capacity building for • research and ideas
• communication facilities
• data handling mechanisms
• reference libraries include web based information
• inculcating pro-advocacy role
• funding for training, interactions and for capacity building
• support of international agencies like WHO could enhance
their capability for advocacy
• management information systems
7
does not require any strengthening!
(e) How can a wide, sustainable and independent funding base
be maintained?
• independent fund-raising activity
• contributions rather than funding which always comes with
a tag
• tie-up with UN organisations for fixed percentage of funds
• multilateral/govt/local funding - govt, especially supporting
research
• userfees by data-users
• private funding
6.Do you have any suggestions for the national watch to
feedback on global issues?
• dialogue with international organsiations
• active media lobbying through personnel dedicated for the
same
7. Additional points
• emphasis on constructive criticism
• impartial conduct in analysing/reporting
• regular interaction with govt
H - S'?, >
O
WORLD
BANK
OPERATIONS
EVALUATION
DEPARTMENT
SPRING
1999
Global Health:
Meeting
the Challenge
Up HE WORLD BANK’S INVESTMENT IN THE HEALTH,
nutrition, and population (HNP) sector has evolved from
J_L relatively modest investments in population and family plan
ning in the 1970s, to direct lending for primary health care in the
1980s, to support for health system reform in the 1990s. The Bank is
now the major source of external finance for the sector in the devel
oping world, with average annual commitments of $1.3 billion. Its
advice and research influence HNP policies at many levels.
Assessing
Effectiveness
The Bank has made important contribu
tions to strengthening health, nutrition,
and population policies and services
worldwide with support for HNP activi
ties in some 92 countries. To assess the
effectiveness of this effort, the Operations
Evaluation Department (OED) recently
carried out the first comprehensive study
of Bank assistance to the HNP sector.
Because lending has expanded dra
matically during this period —three-quar
ters of the total has been lent since 1990 —
the HNP portfolio is young. By fiscal
1997, only a third of projects had been
completed and evaluated. As'a result, the
OED evaluation incorporated assessments
of both completed and ongoing projects.
This Precis summarizes the final synthesis
report of the OED evaluation, which
included a review of the evaluation litera
ture, a desk review of the HNP portfolio,
four country case studies (Brazil, India,
Mali, and Zimbabwe), and consultations
with Bank staff, borrowers, NGOs, and
donors.
The. overarching recommendation of
the study is that the Bank should seek to
do better—not more. The rapid growth of
the portfolio —and the complex challenges
posed by health system reform —requires
consolidation, with a focus on selectivity
and quality. OED specifically calls for
increased attention to institutional devel
opment in project design and supervision,
and substantial improvement in monitor
ing and evaluation.
■ OED also recommends strengthened
efforts in health promotion and inter
sectoral interventions; a renewed emphasis
on research; greater understanding of stake
holder interests; and the forging of strategic
alliances with development partners at the
local, regional, and global levels.
World Bank Operations Evaluation Department
Health and the Health System
Morbidity, mortality, nutritional status, and fertility are
determined by many factors in addition to health ser
vices. The most important are income, education, and
the quality of the environment—including access to safe
housing, clean water, and sanitation. Also important are
individual and community practices related to nutrition,
sanitation, reproduction, alcohol and tobacco use, and
other behaviors that affect health, behaviors that are
shaped by social and economic status and culture.
HNP interventions can reduce the burden of disease
through preventive services, by encouraging healthy be
havior, or by providing curative care. Increased under
standing of the causes of disease and improved interven
tions for both preventive and curative services—such as
antibiotics and vaccination —have improved HNP out
comes throughout the world. Prevention is often —al
though not always —more cost-effective than treatment,
but strong demand for curative services can lead to a
disproportionate emphasis on the medical care system,
both in public policy and in the health care market.
Project Performance
Of the 107 HNP projects completed between FY75 and
FY98, OED rated 64 percent satisfactory, compared with
79 percent for non-HNP projects. But efforts by the Bank
and sector staff to improve performance may be showing
results. Seventy-nine percent of projects completed in
FY97/98 satisfactorily achieved their development objec
tives, close to the Bank average. Although only half of all
completed HNP projects were rated as likely to be sustain
able, this figure rose to two-thirds in FY97/98.
Yet recent improvements should not be a cause for
complacency. A third of ongoing HNP projects are cur
rently rated “at risk” by the Bank’s portfolio monitoring
system. Moreover, high rates of completion of physical
objectives disguise difficulties the Bank has encountered
in achieving policy and institutional change in HNP.
OED rated institutional development as substantial in
only 22 percent of completed HNP projects, which in
creased to only 25 percent in FY97/98, well below the
Bank average of 38 percent for the same period (figure
1). Improving institutional development performance is
therefore a major priority for the Bank’s HNP sector.
Factors Influencing Performance
Based on a statistical analysis of completed HNP projects,
OED found borrower performance, to be the most impor
tant determinant of HNP project outcome. But borrower
performance is not entirely independent; it is influenced by
the Bank’s assessment and encouragement of project own
ership, the fit between the project design and borrower ca
pacity, and the effectiveness of supervision.
Figure 1: Outcome, Sustainability,
and Institutional Performance
------ Outcome (percent satisfactory)
---- — Sustainability (percent likely)
Institutional Development (percent substantial)
The country institutional context— including the pre
vailing levels of corruption—was the next most impor
tant factor. Although national institutions evolve slowly,
this suggests that the institutional context must be clearly
understood, and informed choices made of instruments
and objectives.
With regard to Bank performance, quality at
entry —particularly the quality of institutional analysis—
was found to be the most important element, followed by
the quality of supervision. OED found that quality
at entry has improved in recent years, but institutional
analysis remains a key HNP weakness. OED also tabu
lated the most commonly cited lessons from completed
projects. Among unsatisfactory projects, inadequate as
sessment of borrower capacity and commitment, inad
equate Bank supervision, little or no monitoring and
evaluation, and excessive complexity of project design
were at the top of the list.
Major Findings
World Bank support has helped to expand geographical
access to basic health services, sponsored valuable train
ing for service providers, and offered other important
inputs to basic health services. The Bank has also used
its lending and nonlending services to promote dialogue
and policy change on a variety of key issues, including
family planning, health financing, and nutrition strate
gies. Clients find the Bank’s broad strategic perspective
an asset, and the Bank has taken on a growing role in
donor coordination.
Despite an initial focus on government health ser
vices, the Bank has moved increasingly to deal with
issues of private and NGO service delivery, insurance,
and regulation. In recent years, the Bank has also placed
greater emphasis on client ownership and beneficiary
views in project design and supervision. With the current
Precis
Box 1: Successful Institutional
Development
OED RATED THIRTEEN PROJECTS COMPLETED
between FY91 and FY98 as having substantially
achieved their institutional objectives. These projects
shared several characteristics:
■ A consistent commitment to achievement of institu
tional objectives. Consensus was promoted among
stakeholders regarding priorities and approaches.
When necessary, strategies were developed to an
ticipate and soften resistance.
■ Project design based on solid analysis of the
underlying constraints to improved performance.
Sector work, evaluation of previous experience,
and dialogue with key stakeholders were combined
to reveal impediments. Designers developed realis
tic strategies to address these constraints, including
attention to the proper sequencing of interventions.
■ Flexible project implementation. Progress toward
institutional objectives was reviewed regularly,
with proactive attention to problems by Bank staff
and borrowers. About half the projects that sub
stantially achieved institutional goals were signifi
cantly modified during implementation.
■ A governance and macroeconomic context support
ive of institutional and organizational develop
ment. If this was not the case, the above factors
were particularly important.
generation of projects, the Bank and its partners are
attempting to address underlying constraints to sector
performance, while recognizing the difficulty of improv
ing health sector effectiveness and efficiency—even in
developed countries. The following broad concerns
emerge regarding the Bank’s performance to date.
Disappointing Institutional Impact
The Bank generally has been more successful in expand
ing health service delivery systems than in improving
service quality and efficiency, or promoting institutional
change. There are several dimensions to this problem.
First, in seeking to promote institutional change and
build borrower capacity, the Bank often does not
adequately analyze the constraints underlying current
performance. Although the quality of institutional analy
sis has improved in recent years, the Bank is often better
at specifying what practices need to change than how to
change them or tuhy change is difficult.
Second, weak analysis contributes to a lack of clar
ity in the articulation of institutional development objec
3
tives, including whether the instruments selected are the
best choices to bring about change. Bank projects have
traditionally addressed capacity constraints through the
provision of training and additional resources. The ab
sence, until recently, of appropriate indicators for insti
tutional goals has contributed to the tendency to assert
that “capacity was built” because training or technical
assistance was provided. The Bank is adopting increas
ingly sophisticated approaches to promoting sector re
form, but the institutional problems being addressed are
increasingly difficult. Yet experience shows that realis
tic objectives, together with increased attention to why’s
and how’s, increase the likelihood of achieving institu
tional objectives (see box 1).
Third, the Bank often does not adequately assess
borrower capacity to implement planned project activi
ties. For example, Bank project designs tend to be more
complex —with a greater number of components and
organizational units —in countries with weak institu
tional capacity and with slower rates of decline in infant
Figure 2: High Complexity in Difficult Settings
High
Institutional Quality
n = 75 countries
mortality (see figure 2). This partly stems from an
understandable desire to address many problems at
once. The challenge therefore is to get complexity
“right,” including proper assessments of existing imple
mentation capacity, greater effort to prioritize and
sequence interventions, and targeted provision of techni
cal assistance and training.
Weak Monitoring and Evaluation
During project implementation, the Bank typically
focuses on providing inputs rather than on clearly defin
ing and monitoring progress toward HNP development
objectives. Because of weak incentives and systems for
Precis
OED
PARTNERSHIPS
AND
KNOWLEDGE
GROUP
Editor-In-Chief: Elizabeth Campbell-Page
Series Editor: Caroline McEuen
Graphic Design: Kathy Strauss, Lunn Lestina
Box 2: Successful M&E:
Lessons from Couniry Experience
SUCCESSFUL APPROACHES TO ASSESSING THE
effectiveness of project interventions, strengthening
borrower health information and disease surveillance
systems, or monitoring progress toward sectorwide
objectives have been demonstrated by a number of
projects, including the following:
■ Brazil’s Amazon Basin Malaria Control project helped
to train malaria fieldworkers and strengthen disease
surveillance systems, which—together with a shift in
strategy from eradication to control, early treatment,
and case management—contributed to a decline in
malaria incidence and fatality rates.
■ Tamil Nadu’s Integrated Nutrition project in India
established a community-based system for regularly
monitoring the growth and weight of children found
to be malnourished. The project significantly reduced
severe malnutrition in the target group. The moni
toring system both contributed to and documented
the impact.
■ Mali’s Health and Rural Water Supply project (199198) eventually helped establish a nationwide health
information system, although data were not available
until the final years of the project. This illustrated the
importance of balancing long-term efforts to
strengthen borrower monitoring capacity’ with provi
sions for periodic external qualitative or quantitative
assessments, including rapid assessments.
■ In the current sectorwide health reform programs
in Bangladesh and Ghana, government and donors
(including the Bank) agreed—after lengthy negotia
tions—on a limited number of national indicators
that will serve as benchmarks for joint annual
reviews of sector performance. Remaining chal
lenges include better linkage of system performance
indicators to HNP outcomes, and ensuring that
national indicators create incentives for perfor
mance at lower levels of the system.
monitoring and evaluation (M&E) within both the Bank
and borrower governments—and inadequate attention to
building borrower M&E capacity—there is limited evi
dence regarding the impact of Bank investments on sys
tem performance or health outcomes for the poor. The
Bank therefore has not used its lending portfolio to sys
tematically collect evidence on what works, what does
not, and why.
Experience shows that effective M&E design
enhances the focus on results and increases the likelihood
Assistant: Juicy Qureishi-Huq
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The World Bank’s Experience with Post-Conflict Reconstruction
OED Mutilingual Series
Assessing Development Effectiveness: Evaluation in the World
Bank and the International Finance Corporation
Appreciation de I'efficacite du developpement:
L’evaluation a la Banque rnondiale et d la Societe financiere
internationale
Determiner la eficacia de las actiindades de desarrollo:
La evaluacid en el Banco Mundial y la Corporation Financiera
International
Cote d'Ivoire Revue de I'aide de la Banque rnondiale ait pays
Philippines: From Crisis to Opportunity
Filipinas: Crisis y oportunidades
Rebuilding the Mozambique Economy:
Assessment of a Development Partnership
Reconstruir a Economia de Mozambique
of achieving development impact. This would
include the selection of a limited number of appropriate
indicators and attention to responsibilities and capacity
for data collection and analysis. But methodological
challenges can make it difficult to conclusively link
project interventions with changes in HNP outcomes
or system performance. Yet while most HNP projects
identify key performance indicators, and design of
M&E has improved in recent years, the overwhelming
problem stated in project completion reports is that
the data required were not adequately collected or
analyzed.
A number of Bank HNP projects have included
components to strengthen health information systems,
but these have tended to focus excessively on hardware
and training, and not enough on increasing demand
for, and the use of, information in decisionmaking.
Strengthening borrower systems for the collection,
analysis, and use of health information in policymaking
is a long-term process. But progress can be achieved if
sufficient attention and resources are mobilized during
program design and implementation, including mea
sures to strengthen incentives for M&E (see box 2).
Weak Intersectoral Coordination
With some notable exceptions, the Bank has not placed
sufficient emphasis on addressing determinants of health
that lie outside the medical care system, including
behavior change and cross-sectoral interventions. The
incentives and mechanisms for intersectoral approaches
currently are weak, both within the Bank and in bor
rower governments, and intersectoral coordination can
be difficult, so priorities must be carefully chosen. The
Bank has a fundamental responsibility, however, to
more effectively link its macroeconomic dialogue
with sector dialogue, particularly on issues of health
financing, the health workforce, and civil service
reform.
Flexibility and Learning
Promoting health reform requires strategic and flexible
approaches to support the development of the intellec
tual consensus and the broad-based coalitions necessary
for change, but the Bank is still in the early stages of
adapting its instruments to emphasize learning and
knowledge transfer. System reform is difficult and
time-consuming, and stakeholders outside ministries of
health can determine whether reforms succeed or fail.
This highlights the importance of realism in project
objectives, strong country presence, stakeholder analy
sis, and a more strategic use of the Bank’s convening
role. While incremental approaches are arguably more
appropriate, the Bank may have been excessive in its
encouragement of dramatic, overly ambitious reforms.
6
Recommendations
The overarching recommendation of the review is that
the Bank should not seek to do more, but to do better. To
move in that direction, OED recommends the following
measures.
' Organizational Strategy
* Enhance quality assurance and results orientation.
To improve portfolio quality, the HNP Sector Board
and regional technical managers should continue cur
rent efforts to strengthen their role in monitoring port
folio quality, establishing mechanisms to provide
timely support to task teams in project design and
supervision. The HNP sector should develop stan
dards and good practice examples for M&E, and
increase staff training. But strengthening incentives
to achieve results and to use information, both within
the Bank and in client countries, is critical to enhanc
ing borrower M&E capacity'. Increased experimenta
tion with and learning from performance-based
budgeting mechanisms in Bank projects would be
an important step.
■ Intensify learning from lending and non-lending
services. In light of the institutional challenges facing
the health sector and weak institutional performance,
the Bank should seek to establish appropriate tools,
guidelines, and training programs for institutional
and stakeholder analysis. This should include
strengthening analytic work on major institutional
challenges and providing flexible support to task
teams facing difficult institutional problems.
■ Strengthen partnerships and increase strategic selec- ■
tivity. Achieving change in HNP requires effective
partnerships with local stakeholders, international
partners, and within the Bank. It also requires judi- '
cious use of limited resources. The Bank should select
a few strategic areas for enhanced intersectoral coor
dination, including macroeconomic dialogue and
health workforce issues. In client countries, the Bank
could encourage communication and collaboration
among government ministries, and between govern
ment and other partners. At the international level,
the Bank could strengthen its partnership with WHO
and other interested agencies to address such priori
ties as strengthening M&E and performance-based
health management systems in client countries.
World Bank Operations Evaluation Department
Policy and Practice
■ Increase emphasis on health promotion and behavior
■ change,- including attention to information, education,
and communication campaigns and the broader
policy and regulatory changes essential to success.
» Avoid overly complex project design by combining an
assessment of the capacity of implementing organiza
tions with a greatet,effort to prioritize and sequence
interventions.
■ Place a stronger emphasis on targeting the poor, measur
ing HNP outcomes, and assessing the poverty impact of
HNP policies and programs. More work is needed to
analyze factors that lead to ill health among the poor
and to select interventions that are likely to achieve the
maximum impact on their overall disease burden.
" Develop the intellectual consensus and broad-based
coalitions necessary for change. This requires an
understanding of the political context of reform, the
interests of the broad range of stakeholders, and facili
tating increased “voice” for the community in the
planning, implementation, and management of HNP
programs.
Management
Response
OED CONSULTED WITH THE HNP SECTOR
' Board throughout the study, including an intensive
review of the draft synthesis report and policy ledger.
Management has broadly endorsed the findings of the
review, and the HNP Board has prepared an action
plan to respond to the recommendations. The HNP
Board plans to phase implementation, however, in
light of the wide-ranging recommendations and con
straints on staff and resources.
■
The World Bank Executive Board’s Committee on
Development Effectiveness (CODE) endorsed the analy
sis and recommendations of the OED study, and wel
comed the collaboration between OED and the HNP
Board. The committee noted that some of the issues
highlighted are Bank-wide, and will require efforts
beyond the HNP sector. While recognizing the need for
a phased approach to the recommendations, it empha
sized that strengthening borrower capacity in monitor
ing and evaluation must be given sufficient priority if
results are to be achieved in the medium term.
►This Precis is based on Development Effectiveness in Health, Nutrition, and Population:
Lessons from World Bank Experience, by Timothy Johnston and Susan Stout, Report No.
19266, May 1999. The following case studies are also available: Brazil (18142), India
(19537), Mali (18112), and Zimbabwe (18141). Available to Bank Executive Directors and
staff from the Internal Documents Unit and from regional information service centers, and to
the public from the World Bank InfoShop.
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People’s Health Watch : Skeletal Framework
Overview
Given the profound on-going changes in global., national and local economies
and societies, the concept of a Global Health Watch and the subsequent
People’s Health Watch emerged from various forums as a means to
a) independently and credibly monitor health inequalities.
b) promote the concept of health as a fundamental human riglit.
c) promote a more equitable distribution of health rights.
d) confront/dialogue with and hold governments, Ngos, and policy makers
and health practitioners accountable.
e) explore credible ways of advocacy through adverse publicity, campaigns,
censure and sanctions (suggestion).
Working definition
Tool that enhances everything that Community Health Cell and its partners do
in terms of empowering people and communities to demand and access health
as a fundamental riglit and to participate in health action as a responsibility.
Password : Watch—Bark—Bite—Watch—etc.
Communication Model
The basic components of the model are
Inputs------ Fiitering/Processing------ Outputs----- Feedback Loop—Linkages
Conceptual Core
Andrew Haines and his colleagues first proposed the idea of a Global Health
Watch in 1993, as a means of monitoring the impacts of environmental change12.
The idea for a Global Health Watch (GHW) was taken by the Ngo Forum for
Health in May 1997 in Geneva after it came up again as an idea in a
consultation of WHO with Ngos from all over the world on evolving a Global
Health policy." The concept was further developed by a small group of resource
persons including RN of CHC and supplemented by an in house study of other
watches by a department of WHO. Tire group met at various policy meetings
to elaborate on the idea. Similarly, meetings were held m different regions.
CHC hosted an Indian meeting in Bangalore.
The GHW was meant as a tool to “monitor the progress of WHO and member
countries towards Health for All goals and ..other key health hazards and
1 The Lancet vo\ 342, Dec 11, 1993, p 1464.
2 Concept paper /initial stage of GHW.
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problems’”. The GHW is modelled after similar frameworks used in the
tracking of human rights (Human Rights Watch, environment and ecology
(World Watch Institute).
As formulated in the concept paper the GHW was seen as “a body which can
a) respond to globalization from a positive perspective.
b) work against the negative effects (of globalization) on global, national
and local health”.
The Watch process was deemed necessary because of the following reasons
(HTfV?)
w increasing disparities within/between countries in socio-economic
and health indicators
kt global environmental changes are adversely affecting health
“ globalisation of trade/aid policies have serious implications for the
health of poor and excluded groups
Hr the downsizing of public health systems/privatisation and user fees
with crisis implications for the vast majority in the South.
t— The series of UN summits/conventions promising "Health for All
Dy 25 t/t/lr
w The explosive growth of the global arms trade/intensifying
raciai/religious/ethnic pogroms/wars with ‘"devastating health
consequences „4 .
The Objects of the Watch process (What?) include
w Equity between/within countries and between/within social,
cultural and geographical divisions
National Health commitments to primary7 care/the adequacy of
health budgets/viable training/placement of health workers.
nr International health policies of agencies like the WHO, UNICEF,
World Bank, WTO and their impacts on poor communities.
nr Policies focussing on environmental pollution/alcohol &
tobacco/phannaceuticals/bio-technology/weapons industries.
The impacts of wars/disasters/ and the effect of responses such as
embargoes/sanclions/' relief activities ’.5
Contributors to the Watch process (Who?)
Ct- People and communities.
Ngos working with poor and excluded communities
3 Supporting WHO’s GH policy process.
’ Reflections on a Global Health Watch. RN
5 See footnote 4.
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r-' National, regional and international, ngos. networks/associations
providing data on regional diversities/disparities and intersectoral
issues.0
Focus of Monitoring and Reporting
GHW is meant to monitor and report
rr- Development/implementation of policies which promote/protect health
directly/in directly
r— Implementation of health related human rights
Performance of governments
Progress towards “Health for All”.
Key Focus of People’s Health Watch
Evolving from GHW, the idea of a People’s Health Watch (PHW) emerged out
of CHC's reflections on its involvement in the People’s Health Assembly,
process in India, leading up to the .Tana Swasthya Sabha in Kolkata and the
People's Health Assembly held in Dhaka, in December 2000. The strategic
core of the evolving PHW idea consists of the following:
A primary focus on People’s Action
Facilitating direct people/community generated inputs and
people’s/community access to information and data.
o- Emphasis on direct and meaningful people/community participation in
reporting/monitoring and holding accountable of local, regional, national and
international actors and institutions
ft- a process of “Walch-Bark-Bite” within the many layered institutional arena
of health.
r— It seeks to meaningfully empower people and communities to act as selfconscious and well-informed agents in the shaping and practice of health .
The PHW could ultimately evolve into an initiative that includes much of what
the GHW idea included. The impetus for the change of name was inspired by
PHW’s emphasis on one specific aspect that tended to get disregarded or
inadequately addressed in most initiatives, namely the focus on people’s action
at the community or other levels. This was somewhat true even in the PHA.
Even though an effort was made consciously to focus on people’s action the
tendency was to privilege networking between ngos/activist academics and
policy researchers.
6 See footnote 4.
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lustra mental Strn eta re
The PHW will operate as
a. web-based information sourcing, filtering/piocessing and broadcasting
system.
“ PHW will actively incorporate the most effective of the range of emerging
information and communication technologies. Examples: web-broadcasting,
communitv radio, net-conferencing, wireless technologies, mobile phone
based audio-visuals, community information/altemate technology-resource
centers, liquid crystal display bulletin boards.
Data‘ Collection
Key words:
w Authenticity/credibility
kt- Objectivity/Autonomy
r-~- Reliability/validity
w Sources
k- Agents/Tnclusiveness/(rrnps?/compounders)
kz Education/training for data collectors.
w Translation from/into local languages
Data Processing
Key words:
w Inputs/Processing/Oiitputs/Feedback loop
w Translate from vernacular.
“ Activc/Passivc rcccntion/broadcast
pz Decode/Translate/Demystify
w Direct Uploads/Automatic Alerts
Measure/Monitor/Question/Evaluate
nr Interprel/Verify
Audit/Account
Data Types
Key words:
w Drug Policy/Healtli Budgets/Health Policy
w PHCs/CHCs/Emergency Sendees
kz Communicable diseases
**- Non-communicable diseases
rz Patents/Licensing/Pharmaceutical companies
Drug testing and approval
7 Data here refers to any subject. material, information, etc. that is relevant to PHW.
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w Tnsur^ce/User fees/taxes
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