Health, Nutrition, and Population Sector Strategy Paper
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Health, Nutrition,
and Population Sector
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Health, Nutrition,
and Population Sector
Strategy Paper
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Contents
a
CHAPTER I
CHAPTER II
CHAPTER III
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ANNEXES
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Foreword
v
Acknowledgments
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Summary
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Acronyms and Initials
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Development Challenges and Policy Directions: A Changing World
Impressive Recent Gains in Outcomes
Development Challenges
Major Policy Directions
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The Bank’s Role: Growing Engagement and Learning
Rationale for Bank Involvement
The Bank’s Involvement in HNP
Learning from Experience
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Into the 21st Century: Renewed Commitment and Focus
Sharpening Strategic Directions
Achieving Greater Impact
Empowering Staff
Strengthening Partnerships
From Vision to Action
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A.
HNP Sector At A Glance: Global, Regional, and Country Profiles
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B.
Highlights from Major International Initiatives in HNP
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C.
Essential Health, Nutrition, and Population Services
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D.
World Bank Organizational Charts
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E.
HNP Sector Portfolio and Management Indicators
69
F.
HNP Sector Strategy Matrix (FY 1998-2000)
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Sector Strategy
G.
World Bank Maps
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Fertility Decline, 1980-1995
Progress in Achieving Child Survival Goals, 1990-1995
Child Malnutrition, 1985-1995
Malaria Distribution and Reported Drug Resistance
Health Expenditures as Percent of GDP
Active and Future World Bank/IDA Financed HNP Projects
Q
The World by Region
TABLES
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Global Ranking of At-Risk Countries by HNP Indicators,
Low- and Middle-Income Countries
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A.2
Regional Ranking of At-Risk Countries by HNP Indicators
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A.3
HNP At A Glance: World Averages
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A.4
HNP At A Glance: At-Risk Countries, by Region
East Asia and Pacific
Europe and Central Asia
Latin America and the Caribbean
Middle East and North Africa
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South Asia
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Sub-Saharan Africa
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HNP At A Glance: At-Risk Countries Among High-Income Countries
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A.6
HNP At A Glance: Indicators by Country
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IBRD/IDA Lending Program, FY 1994-2000
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E.2
Status of Bank Group Operations in HNP: IBRD Loans and IDA
Credits in the Operations Portfolio
75
E.3
IFC and MIGA HNP Program. FY 1994-1996
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E.4
Summary of Economic and Sector Work
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E.5
HNP Sector: Selected Indicators of Bank Portfolio Performance
and Management
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Foreword
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The World Bank’s mandate is to work with governments to
achieve sustainable progress in reducing poverty, promoting
growth, and improving the quality of people’s lives in devel
oping countries. Current strategies to assist the poor rest on
three mutually reinforcing pillars of development policy:
expansion of opportunities through broad-based sus
tainable economic growth, especially to raise produc
tivity and employment of the poor
access by the poor to services that improve education,
health, and nutrition outcomes, and that reduce
fertility
?? appropriate social safety net programs to protect espe
cially vulnerable groups.
Good health, nutrition, and reproductive policies, and ef
fective health services, are critical links in the chain of events
that allow countries to break out of the vicious circle of pov
erty, high fertility, poor health, and low economic growth,
replacing this with a virtuous circle of greater productivity,
low fertility, better health, and rising incomes.
This Sector Strategy paper presents the World Bank’s strat
egy in the health, nutrition, and population (HNP) area, The
objectives of this paper are to:
a* review major trends in the HNP sector, key develop
ment challenges, and the emerging consensus on re
form strategies
assess past and current Bank involvement in the I INP
sector in low- and middle-income countries
define a clear strategy to guide the Bank's future work
in the HNP sector.
Many aspects of development policy that are not directly
related to the health sector or to health services affect health,
nutrition, and population outcomes. For example, education,
water, sanitation, transport policy, and gun control affect
health; agricultural and food policies affect nutrition; and
multiple social and cultural dimensions affect population
growth. Bank strategies toward the intersectoral determinants
of health, nutrition, and population outcomes will be presented
in forthcoming strategy papers.
In developing the Bank’s strategy for the HNP sector, the
following principles have been influential:
a focus on the human dimension of development
responsiveness to clients, especially the poor
sound technical analysis and attention to outcomes
recognition of the political dimensions of reforms
respect for diversity in values and social choices
the need for local ownership and partnerships.
The HNP Sector Strategy paper is the first major product
of the HNP Family, which is part of the Bank’s new Human
Development Network, under the general guidance of the
HNP Sector Board (see Annex D, Figure D.2). Its recom
mendations are closely linked to other Bank activities that are
intended to improve operational effectiveness and contribute
to each of five areas of responsibility of the HNP Sector Board:
strategy, knowledge, staff development, quality assurance, and
external partnerships.
An extensive consultative process has taken place to pro
duce this document, involving interested staff in the Regions
and the HNP Family as well as external partners. The strategy
has been approved by senior management and endorsed by
the Board.
The HNP Sector Strategy paper is not a final statement of
the Bank’s work in the HNP sector. This strategy will con
tinue to evolve over time and will be revised.
David De Ferranti, HD Network Head & Director
Richard G.A. Feachem, HNP Director
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Acknowledgments
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This report was prepared by a team of technical special
ists from the Health, Nutrition, and Population (HNP)
Family of the Human Development (HD) Network of
the World Bank under the guidance of the HNP Sector
Board. The process involved staff and managers in other
fields and sectors of the World Bank Group. The work
was led by Alexander S. Preker, Principal Economist;
Richard G.A. Feachem, HNP Director; and David De
Ferranti, HD Network Head and Director. The document
was edited by Madelyn Ross and document processing
was done by Sancta E.M. Watley.
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Summary
This HNP Sector Strategy paper is presented in three main
sections, with supportive statistical annexes.
Development Challenges and Policy Directions
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As described in Chapter I, this centuiy has witnessed greater
gains in health, nutrition, and population outcomes than at
any other time in history.
These gains are partly the result of improvements in in
come and education, with accompanying improvements in
nutrition, access to contraceptives, hygiene, housing, water
supplies, and sanitation. They are also the result of new knowl
edge about the causes, prevention, and treatment of disease,
and the introduction of policies that make interventions more
accessible.
Despite past achievements, however, 2 million childhood
deaths occur annually due to vaccine-preventable diseases; 200
miUion children under the age of five still suffer from malnutri
tion; 120 million couples still lack options in family planning;
7.5 million children die every year during the perinatal period;
and 30 percent of the world is still without access to safe water
and sanitation systems. In addition, disease patterns observed
during the past century are rapidly changing.
As shown by broad international experience, the underly
ing threats to good health, nutrition, and population outcomes
are well known, and affordable solutions are frequently avail
able. But, because of weak government implementation ca
pacity and market imperfections in the private sector,
potentially effective policies and programs often fail.
Reform strategies to address these problems often require
a redefinition of the role of the state, with greater govern
ment involvement in providing public health activities with
large externalities, securing access to essential health ser
vices for the poor, providing information, supporting research
and development (R&D) and medical education, regulat
ing the sector, and securing adequate financing. They also
require enhanced partnerships with non-governmental
providers.
The Bank’s Growing Engagement in the HNP Sector
Chapter II explains why investing in people is at the center of
the Bank’s development strategy, reflecting the fact that no
country can secure sustainable economic growth or poverty
reduction without healthy, well-nourished, and well-educated
people. Since none of the international organizations can ad
dress today’s complex health, nutrition, and population chal
lenges alone, the Bank works closely with many other
organizations. The Bank’s comparative advantage is its global
experience and ability to combine country-specific research
and analysis with the mobilization of significant financial re
sources across many sectors.
Bank involvement in the HNP sector, which started in the
early 1970s, initially helped countries strengthen and expand
the infrastructure and supplies for basic programs. Although
modest success was achieved through this approach, it be
came apparent that institutional and systemic changes were
often needed for a sustained impact on outcomes for the poor,
improved performance of health systems, and sustainable fi
nancing. The Country Assistance Strategy (CAS) is a key in
strument for mobilizing the multi-sectoral involvement that
is often needed to address systemic problems.
Since its first HNP loan in 1970, the Bank’s activities in
this sector have grown rapidly to the point where it is now the
single largest external source of HNP financing in low- and
middle-income countries. Today, there are 154 active and 94
completed Bank HNP projects, for a total cumulative value
of US$13.5 billion in 1996 prices. This paper elaborates on
the lessons learned from this experience and raises concerns
about the recent decrease in analytical and policy work, a
weakening in the presentation of HNP issues in the CAS, and
the number of projects at risk.
The Bank '$ Strategy in the HNP Sector
Chapter III describes the Bank’s enhanced commitment to
the HNP sector during the period leading into the 21st cen-
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■Nutrition,:and Population Sector Strategy
tury. The Bank’s objectives in the HNP sector are to assist
client countries to:
improve the health, nutrition, and population out(»mes
of the poor, and to protect the population from the
impoverishing effects of illness, malnutrition, and high
fertility
enhance the performance of health care systems by
promoting equitable access to preventive and cura
tive health, nutrition, and population services that are
affordable, effective, well managed, of good quality,
and responsive to clients
secure sustainable health care financing by mobilizing
adequate levels of resources, establishing broad-based
risk pooling mechanisms, and maintaining effective
control over public and private expenditure.
The Bank’s strategic direction in the HNP sector will con
tinue to evolve in a dynamic way based on international best
practice. The complexities of the HNP sector and changing
approaches to health, nutrition, and population problems gen
erally do not lend themselves to rigid policy prescriptions. In
stead. policy advice and financial support will continue to be
guided by country-specific approaches. This will be achieved
through action in the following four areas:
Sharpening Strategic Directions. Governments will be encour
aged to address each of the three HNP priorities outlined
above, through decentralization, greater partnerships with
non-governmental providers, and a more direct public involve
ment in securing sustainable financing. Governments will also
be encouraged to address often neglected areas that have an
impact on health, nutrition, and population outcomes such
as rural and urban development, other broad-based popula
tion and social policies, education, control of tobacco and al
cohol abuse, food and agricultural policies, environment, water
supply, sanitation, and transportation.
The Bank’s Country Assistance Strategy papers will be used
as key instruments for delivering this message during highlevel country dialogue. Greater efforts will be made to ensure
that adequate budgets and staff time are allocated to the prepa
ration of these important documents. Efforts will also be made
to underpin lending with better research and analysis by re
versing recent cutbacks in country-specific sector studies and
linking the Bank's research agenda more closely to the HNP
priorities. Staff will be encouraged to increase selectivity based
on consistency with the HNP policy objectives, potential de
velopment impact, and political commitment by clients to sig
nificant reform.
Achieving Greater Impact. The quality of client services and
client responsiveness will be enhanced by strengthening the
HNP knowledge base; applying lessons learned more system
atically; enhancing the quality of project preparation and the
piloting of new approaches; improving supervision of existing
projects; using a broader range of instruments; streamlining
business processes and procurement procedures; and conduct
ing client satisfaction surveys. Finally, a renewed effort will be
made to strengthen monitoring and evaluation by developing
better indicators and by integrating monitoring and evalua
tion into project designs.
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Empowering Bank I INP Staff. Resolving three staffing issues
will be a key priority for the new HNP Sector Board. Are there
enough staff? Are their skills adequate to the tasks they must
perform? Are they deployed effectively between headquarters
and resident missions? This paper suggests how the Bank will
be enhancing its capacity in these areas. An effort will be made
to link training to the three strategic directions, include both
Bank staff and clients in training events, increase participa
tion by resident mission staff, and extend the target audience
to sectors outside the HNP sector.
Building Partnerships. The Bank will continue to build rela
tions with partners based on its comparative advantage and
clear agreement on mutual roles, as it is now doing with WI IO
and UNAIDS. It will build on the past success in riverblind
ness control and support other international health, nutri
tion, and population initiatives. Likely candidates include
collaboration with African governments in a major effort to
control the malaria epidemic, work with WHO and others to
combat the pandemic of tuberculosis and to promote inte
grated management of childhood illness, and work with many
partners to launch the Global Forum on Health Research.
Through such actions, the Bank expects to enhance its
contribution to rhe global effort to improve human develop
ment during the first decade of the 21st century.
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Acronyms and Initials
AfDB
African Development Bank
ELO
International Labour Organization
AIDS
Acquired Immune Deficiency Syndrome
IMF
International Monetary Fund
AsDB
Asian Development Bank
LAC
CAS
Country Assistance Strategy
CODE
Committee on Development Effectiveness
LLC
Lea.-ning and Leadership Center
DEC
Development Economics and Office of the
Chief Economist
MIGA
Multilateral Investment Guarantee Agency
MNA
Middle East and North Africa Region
of the World Bank
EAP
East Asia and Pacific Region of the World
Bank
NGO
Non-Governmental Organization
EBRD
European Bank for Reconstruction and
OECD
Organization for Economic Cooperation and
Development
EGA
Europe and Central Asia Region of the World
Bank
EDI
Economic Development Institute
ESW
Economic and Sector Work
EU
European Union
FAO
Food and Agriculture Organization
of the United Nations
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Latin America and the Caribbean Region
of the World Bank
Development
OED
Operations Evaluation Department
PAHO
Pan American Health Organization
PPP
Purchasing Power Parity
PSD
Private Sector Development Department
QAG
Quality Assurance Group
R&D
Research and Development
SAS
South Asia Region of the World Bank
SECAJLs
Sector Adjustment Loans
SGP
Special Grants Program
SSA
Sub-Saharan Africa Region of the World Bank
TA
Technical Assistance
GDP
Gross Domestic Product
GNP
Gross National Product
HD
Human Development
HIV
Human Immunodeficiency Virus
HNP
Health, Nutrition, and Population
IBRD
International Bank for Reconstruction and
Development
UNAIDS
Joint United Nations Programme on AIDS
UNDP
United Nations Development Programme
IDA
International Development Association
UNFPA
United Nations Population Fund
IDB
Inter-American Development Bank
UNICEF
United Nations Children’s Fund
IFC
International Finance Corporation
WHO
World 1 lealth Organization
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CHAPTER 1
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Development Challenges and Policy Directions:
A Changing World
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Impressive Recent Gains in Outcomes
Advances in HNP during the past few decades are im
pressive. The increase in life expectancy and the de
crease in fertility throughout the world have been greater
in the past 40 years than during the previous 4,000 years.
Furthermore, based on projections, the year 2000 will
mark the mid-point of a century of global transition from
high mortality and high fertility to low mortality and
low fertility (see Figure 1.1 below and maps on Fertility
Decline and Child Survival Goals in Annex G).
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Unparalleled Improvements
in Life Expectancy and Fertility Rates
Life Expectancy in Years
Fertility Rates
6.0
80
1997
75
5.5
70
5.0
65
4.5
60
55
4.0
50
3.5
45
3.0
40
2.5
35
30
2.0
1950 60 70 80 90 2000 1 0 20 30 40 2050
Years
FIGURE 11
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As described by the World Health Organization
(WHO) in its 1996 World Health Report, hundreds of
millions of people in low- and middle-income countries
are on the threshold of an era in which they will be safe
from some of the world's most threatening diseases.
According to the 1996 State of the World’s Children, by
the United Nations Children's Fund (UNICEF), the
proportion of children who now die before reaching age
five is less than half the level in 1960. Immunization
saves an estimated 3 million children annually. Better
control of diarrhea saves over 1 million a year.
Economic progress during the past century has con
tributed significantly to health advances. Nutrition has
improved not only from higher agricultural outputs per
person and a greater ability to deal with local famines,
but also from the introduction of a more varied diet.
Child malnutrition rates in low- and middle-income
countries arc now 20 percent lower than they were 30
years ago, while cert ain nutrient deficiency diseases have
almost disappeared in some countries.
Population growth rates are also slowing. The aver
age number of children born to women of childbearing
age (the total fertility rate) is now three, down from five
in 1960. Some low and middle-income countries have
already reached replacement levels of around two chil
dren per family. Improvements in access to family plan
ning, together with rising incomes and better education
of girls and women, have facilitat ed this trend. Contra
ceptive use in low and middle-income countries rose
from 10 percent of married couples in the mid-1960s to
55 percent in 1990.
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Origins of Good Health and Illness
Several factors influence the great variability in health,
nutrition, and fertility still observed across population
groups. These include:
income levels and poverty,
impressive Gains in Health
at Similar Income Levels
Life Expectancy in Years
80 i-------- -- --------------- -----------------
70 -
education, especially of girls and women,
. About 1930
adequate food, clean water, and sanitation,
60
culture and behavior; and
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health-related public policies and interventions.
Economic growth and reductions in poverty—with
their impact on basic needs such as nutrition, better
housing, and access to clean water and satisfactory sani
tation-remain among the most powerful determinants
of good health at low-income levels.
As shown in China, Costa Rica, and Sri Lanka, basic
education of girls and women is also good for health.
Educated individuals tend to adopt healthier lifestyles,
make more efficient use of scarce resources such as food
and health care, and avoid risks caused by the abuse of
tobacco, alcohol, and illicit drugs. In most societies,
norms regarding childbirth and child care, the status of
women, personal hygiene, and sexual behavior exert
powerful influences on health and are deeply rooted in
local culture.
Population-based preventive services such as immu
nization play an important role in reducing the risk of
illness, and curative services can greatly ameliorate the
consequences of diseases and injuries when they occur.
Other public policies can enhance health by promoting
healthy environments and lifestyles, and regulating
against dangerous or unhealthy activities by individuals
and organizations. Successful public policies have helped
reduce pollution in India, make road travel safer in
Mexico, tighten gun control in the United Kingdom,
improve water and sanitation systems in Turkey, and
limit tobacco, alcohol, and illicit drug use in Indonesia.
Stronger public policies are also still needed to elimi
nate female genital mutilation.
As a result of complex synergies among income lev
els, education, behavior, public policy, and health ser
vices, people all over the world live almost 25 years longer
today than they would have at similar income levels in
1900 (see Figure 1.2).
Impact on Quality of Life and Productivity
About 1900
40
30
1
0
5,000
2
10.000
15,000
20.000
25,000
Income per Capita (1991 Dollars)
FIGURE 1.2
well as to productivity. Many diseases are not fatal, but
disabling. Some 200 million people throughout the
world--90 percent in Sub-Saharan Africa—are infected
with the parasitic schistosome worm, and 1 billion
people suffer from anemia. The economic burdens of
such illnesses include low productivity due to chronic
fatigue and other symptoms, loss of income, out-ofpocket expenditure, and the cost of treatment.
Good health, by contributing to human capital, is
essential to economic growth. For example, a single treat
ment of children in the West Indies for whipworm in
fection dramatically improved school learning. Labor
productivity has increased with better iron and calorie
intake in Indonesia and Kenya. Similarly, there is some
evidence that reduced fertility rates and declining youth
dependency ratios can have a positive impact on eco
nomic growth, if associated with domestic savings and
investment in human capital.
Development Challenges
To preserve past gains and address future threats in an
effective way. policymakers in low- and middle-income
countries face difficult challenges caused by continued
poverty, malnutrition, high fertility, and pool health,
poor performance of many health systems; and inad
equate and/or unsustainable health care financing.
Poverty. Malnutrition. High Fertility,
and Poor Health
Good health contributes to the overall quality of life as
1990
About 1960
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According to World Bank estimates, nearly one-quar
ter of the world’s population-1.3 billion people-continue to live in absolute poverty, earning less than US$1
per day. The 1993 World Development Report: Investing
in Health estimated loss of healthy life from over 100 of
the most common diseases and injuries. Of the total
global disease burden, 93 percent is concentrated in lowand middle-income countries and nearly 60 percent is
in China, India, and Sub-Saharan Africa.
The world’s poorest populations live in the shadow
of a group of old enemies-malnutrition, childhood in
fections, poor maternal/perinatal health, and high fer
tility (see Annex G map on Child Malnutrition). A
total of 2 million deaths in children occur annually due
to vaccine-preventable diseases; 200 million children
under the age of five still suffer from malnutrition and
anemia; 7.5 million children die every year during the
perinatal period, primarily due to poor maternal health
care; and 30 percent of the world is still without safe
water and sanitation. Furthermore, because 120 million
couples still lack options in family planning and receive
poor maternal health services, one in every 48 women
dies from pregnancy-related causes in low- and middle
income countries (585,000 deaths per year), compared
with one in 4,000 in higher-income countries.
Intrauterine or early childhood exposure to under
nutrition, micronutrient malnutrition (iron, iodine), oi
infection (diarrhea, malaria), often results in long term
or irreversible retardation of physical and mental devel
opment. These conditions are particularly devastating
to the poor, whose children enter adulthood and the
workforce handicapped by early life experiences.
Rapid population growth is also a major development
challenge in many poor countries and places a heavy
burden on health care and social services. Even when
fertility approaches replacement levels (close to two
children per family), birth rates will continue to out
strip deaths for several decades because of the young
population age structure t hat has resulted from past high
fertility rates. The world’s population could increase
from 5.3 billion people in 1990 to over 10 billion in
2100. Most of this population growth will occur in poor
countries.
The disease patterns of the past century are chang
ing as population groups move from high mortality and
fertility to low mortality and fertility. As a result, the
share of global disease burden due to non-communi
cable diseases (mainly cardiovascular and neuro-psychiatric diseases, and cancers) is expected to increase from
36 percent in 1990 to 57 percent in 2020, while the
burden due to infectious diseases, pregnancy, and peri
natal causes is expected to drop from 49 to 22 percent.
The emergence of new epidemics and drug resistant
microbes and parasites will figure prominently among
the remaining infectious diseases (see Annex G map
on Malaria Distribution and Reported Drug Resistance).
Poor Performance of Many Health Systems
Much more research is needed to understand fully the
factors that influence the performance of health systems.
Partially as a result of differences in the effectiveness of
broad social policies and health care systems, countries
vary greatly in terms of the health, nutrition, and popu
lation outcomes they achieve at similar income levels
(see Figure 1.3). As populations age and non-commu
nicable diseases increase in low- and middle-income
countries, there are obvious consequences for labor pro
ductivity, economic gr owth, and the cost of health care
Outcomes at Similar Income Levels
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Under-5
Under-5
Malnutrition Mortality
Total
Fertility
Maternal
Mortality
Children per
Deaths per
100,000
Children
1,000
Fertile Woman
Live Births
Malnourished
Age < 5
Malawi
67
Percent
Ivory
887
Coast
Vietnam
3.1
30 *M !Sri Lanka
180
Deaths per
700I
35
Indonesia
Brazil
57
13 — Bolivia 25 ■■ Venezuela
800
2.800
Approximate Income Levels (US$/capita/year)
FIGURE 1.3
systems (hat must be adapted to new disease patterns
and modes of intervention.
Differences in housing, access to clean water and
satisfactory sanitation, education, income distribut ion,
and culture all contribute to this variability, especially
in low-income countries. But the use of knowledge about
the determinants of poor health (e.g. the links between
maternal nutrition and low birth weight, hygiene and
infections, and smoking and heart disease) and imple
mentation of effective preventive and curative health
care (e.g. vaccinations, oral rehydration therapy, obstet3
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rical care, and drug treatment of tuberculosis) are also
important in explaining these differences.
Variability in Available Financing
Global spending on health care was about US$2,330
billion in 1994 (9 percent of global GDP), making it
one of the largest sectors in the world economy. While
low- and middle-income countries account for only 18
percent of world income and 11 percent of global health
spending (US$250 billion or 4 percent of GDP of devel
oping countries), 84 percent of the world’s population
lives in these countries, and they shoulder 93 percent
of the world’s disease burden. The sheer size of the sec
tor and the fact that growth in health expenditure ex
ceeds income growth, make it critical to understand the
economic and health impact of health financing policies.
Health care behaves like a superior good in economic
terms—poor countries spend much less than rich coun
tries, both relative to GDP and on a per capita basis
(see Figure 1.4). In addition, a country’s public expen
diture on health care rises with income both in absolute
and relative terms. This is reflected in the large differ
ences in the proportion of national GDP spent on
health-from under 1 percent in some countries to 15
percent in the United States. Per capita health expen
ditures (public and private) vary almost 1,000-fold
among countries—from around US$3 to $5 per capita
per year in some low-income countries such as Mali to
$3,600 in the United States (the ratio would be 225
Income and Health Spending
13 r-
11 -
Total
Spending
as Share
of GDP
9 7 '
5
3
1
90
Public
Share of
Total
Spending
70
50
30
using PPP-adjusted dollars).
The Sub-Saharan Africa (SSA), South Asia (SAS),
and East Asia and Pacific (EAP) regions spend the least
on health care in absolute terms (see map on Health
Expenditures in Annex G), and some countries are
spending less over time. Low tax collection capacity and
low personal income contribute to these trends. Lack of
financing usually translates into low levels of capital
stock such as beds, and of human resources such as doc
tors and nurses. Even where capital stock is more ad
equate on a national basis, inequitable resource
distribution may result in poor access to services by the
poor, such as in the Middle East and North Africa
(MNA) region.
Recently a growing number of countries face a diiierent challenge-rapidly rising health expenditures in both
the public and private sector. Some countries have in
creased health spending from 3-5 percent of GDP to 810 percent of GDP in only a few years. Argentina now
spends a higher share of GDP on health than Canada,
which for years ranked second only to the United States.
Often public funding is forced above what is fiscally sus
tainable, and too often additional spending goes to inef
fective, inefficiently managed, and low quality care.
Increased spending on health care alone does not neces
sarily increase health, nutrition, and population outcomes.
Attention to population-based approaches and broad
public health approaches are often needed before out-
comes are influenced.
The reasons for these increases in health care ex
penditure include rapid escalation in the cost of new
medical technology, the epidemiological transition in
disease patterns (increase in chronic diseases and reemerging or new communicable diseases), rising popu
lar expectations, and the growth of fee-for-service
medicine and third party insurance.
At a global annual growth rate for GDP of 3.5 per
cent, health care expenditure will increase by about
US$82 billion a year worldwide, or US$9 billion a year
in low- and middle-income countries at current rates of
growth. In principle, this is enough money to pay for
essential population-based preventive and curative ser
vices for the 900 million of the world’s estimated 1.3
billion poor who still do not have adequate access to
these services. However, if current trends persist, many
of these resources will go to those who already have ac
cess and use services, rather than to the poor.
5,000 10,000 15,000 20.000
GDP per Capita (1990 International Dollars)
FIGURE 1.4
4
Major Policy Directions
e
c
3
The underlying threats to good health, nutrition, and
population outcomes are well known, and affordable
solutions are frequently available. But because of weak
government implementation capacity and market im
perfections in the private sector (especially with respect
to public goods and activities with large externalities),
recommended policies often fail to benefit the poor, fail
to improve the impact of health systems, and fail to se
cure sustainable financing for the sector. This section
provides a framework for understanding recent changes
in the role of the state, and reforms that many countries
are adopting in the HNP sector.
The Changing Roles of the State
and Private Sectors
Throughout most of histoiy, people used home remedies,
private doctors and other health care workers, and non
governmental hospitals when they were ill. Often only
the rich could afford such care and the range of effec
tive treatment was limited. Today, in low-income coun
tries—where public revenues are scarce (often less than
20 percent of GDP) and institutional capacity in the
public sector is weak—the financing and delivery of HNP
services is largely in the private sector. In many of these
countries, large segments of the poor still have no ac
cess to basic or effective care for a variety of reasons
discussed below.
In most developed countries—and many middle-in
come countries—governments have become central to
social policy and health care. This involvement by the
public sector is justified on both theoretical and practi
cal grounds to improve: (a) equity, by securing access
by the population to health, nutrition, and reproduc
tive services; and (b) efficiency, by correcting for mar
ket failures, especially when there are significant
externalities (public goods) or serious information asym
metries (health insurance).
One of the clearest cases for strong government in
tervention in the HNP sector can be made when there
are large externalities (the benefits to society are greater
than the sum of benefits to individuals) . This is true in
the case of clean water, sanitation services, vector con
trol, food safety measures, and a range of public health
interventions (e.g. immunization, family planning, ma
ternal and perinatal health care, control of infectious
diseases, and control of tobacco, alcohol, and illicit drug
abuse). Medical education and R&D are two other ar
eas for active government intervention.
Private voluntary health insurance is one area which
is particularly prone to a number of market imperfec
tions, many of which relate to information asymme
tries. While insurance may succeed in protecting some
people against selected risks, it usually fails to cover
everyone willing to subscribe to insurance plans and it
often excludes those who need health insurance the
most or who are at greatest risk of illness. This hap
pens because insurers have a strong incentive to en
roll only healthy or low-cost clients (risk selection or
cream-skimming). Private insurers also have incen
tives to exclude costly conditions or to minimize their
financial risk through the use of benefit caps and ex
clusions. This limits protection against most expen
sive and catastrophic illnesses.
Because of these factors, individuals who know they
are at risk of illness have a strong incentive to conceal
their underlying medical condition (adverse selection).
Individuals who are—or at least think they are-healthy
will often try to pay as low premiums as possible. This
prevents insurers from raising the funds needed to cover
the expenses incurred by sicker or riskier members.
Worse, the healthy may even deliberately under-insure
themselves, in the hope that free or highly subsidized
care will be available when they become ill (free-riding).
When third-party insurers pay, both patients and pro
viders have less incentive to be concerned about costs,
and some may even become careless about maintaining
good healt h. This leads not only to more care being used
(the reason for insurance), but also to less effective care,
or care that would not be needed if people maintained
good health (moral hazard).
In addition to insurance market failure, private con- •
sumers arc also at t he mercy of medical providers who
charge what i he market will bear. Without good regula
tions and quality control systems, patients can spend a
significant amount of their personal income on ineffec
tive care. The poor and less well educated are particu
larly vulnerable to unscrupulous profit seeking by private
providers, due to information asymmetries.
The main actions taken by governments to correct
for such market failures, from least to greatest interven
tion, include: providing information to encourage be
havior changes needed for long-term improvements in
health, nutrition, and population outcomes; enforcing
regulations and incentives to influence public and pri
vate sector activities; issuing mandates to indirectly fi
nance or provide services; financing or providing
subsidies to pay for services or influence prices; and di
rect public production of preventive and curative health
services.
Both economic principles and empirical evidence
suggest that a mixture of public and private involve5
I
ment leads to the best results in the HNP sector. Nei
ther sector is effective by itself-each needs the other.
Both too much and too little involvement by either sec
tor are often associated with problems.
Unfortunately, in low- and middle-income countries,
weak institutional capacity to deal effectively with regu
latory problems in the private sector often causes gov
ernments to become excessively involved in the direct
production of health services. Such over-involvement
in public production is typically associated with insuffi
cient government involvement in: providing informa
tion about personal hygiene, healthy life-styles, and
appropriate use of health care; regulating the private
sector; financing essential health services, especially
for the poor; and securing access to public goods with
large externalities for the whole population. The re
forms that are needed to strike an optimal balance at
various income levels differ in the case of delivery sys
tems and financing. This will be discussed in more de
tail below.
Recent Reform Strategies
Recent dissat isfaction with poor health, nutrition, and
population outcomes, the low quality of health care in
both public and private facilities, and the lack of sus
tainable financing and/or cost escalation have led to a
wave of health care reforms throughout the world. (See
the At A Glance tables in Annex A for clusters of coun
tries that perfonn poorly in each of these three priority
areas.)
Improving HNP Outcomes for the Poor
The majority of the world’s 1.3 billion people identified
by the Bank as living in absolute poverty, with incomes
of less than US$ 1 per day, live in countries where a siz
able proportion of the population still lacks adequate
access to safe drinking water and sanitation, adequate
nutrition, basic shelter, basic education, family planning,
and essential health services.
In poor countries, the design of policies and programs
to ensure access to essential HNP services-whether
implemented through public or private channels-is an
absolute priority (See Annex B for a discussion of the
UN Basic Social Services for All initiative and Annex C
for a more detailed description of selected essential HNP
interventions). Often non-targeted and targeted strat
egies must be undertaken in parallel.
Non-Targeted Approaches. The experience in developed
and middle-income countries is that universal access is
one of the most effective ways to provide health care for
the poor. But non-targeted approaches can also be waste
ful. Some low-income countries spend as much as 4 per
cent of GDP on publicly-funded food subsidies with
little impact on the nutrition of the poor. In low-in
come countries, non-targeted approaches often have to
be restricted to a very limited range of public health
and food fortification programs, and a few essential
health services, to be financially viable.
c
c
c
c
Q
Targeted Approaches. It is possible to ensure that essen
tial programs reach those who need them most through
use of careful targeting. The following four approaches
are particularly relevant to the HNP sector in low- and
middle-income countries:
w
Focus specifically on the poor individuals or house
holds most vulnerable to illness, malnutrition, and
high fertility, by applying a means test to identify
the neediest and providing free or subsidized ser
vices to only those qualifying for preferential ac
cess on this basis. In most low-income countries
this technique is not administratively feasible on
a large scale.
Focus on poor regions within a country or on popu
lation groups that arc particularly vulnerable to pov
erty (e.g., women, children, and ethnic
minorities). At the global level, most of the
world’s 1.3 billion poor live in South Asia, SubSaharan Africa, and a few countries in other re
gions (see Annex A for country groupings).
Within countries, the emphasis can be on the
states, rural areas, and urban areas where the poor
live, or on specific sub-groups within these areas-such as when nutrition programs are targeted
at mothers and young children in disadvantaged
areas.
Emphasize health, nutrition, and reproductive prob
lems of the poor. The old enemies of the poormalnutrition, communicable diseases, childhood
illnesses, high fertility, and maternal and perina
tal conditions—can be specifically targeted in this
way (see Figure 1.5). More than half of the dis
ease burden in Sub-Saharan Africa and South
Asia can be addressed effectively through local
adaptation of interventions such as immuniza
tion, food fortification, targeted nutrition pro
grams, integrated management of childhood
illness, family planning, maternal and perinatal
health, and school health (see Annex C). As
►
►
►
»»
4
6
«•
f
'■Wi ■
populations age, non-communicable conditions
and injuries increase rapidly. The poor and less
well educated are particularly vulnerable to the
adverse effects of mass marketing of tobacco, al
cohol products, and unhealthy foods.
Give greatest attention to the types of service pro
viders from whom the poor receive most of their care.
This often requires upgrading and extending the
Communicable Diseases:
A Major Killer Among the Poor
Percentage of Total Deaths Within Specified Income Groups
100
PooresT 20 percent
90
70 -
Richest 20 percent
so 40 D
30 20
10
0 *—
IO
Communicable
Diseases
Non-communicable
Diseases
Raising efficiency in the use of scarce resources
through improvements in policymaking, gover
nance, encouraging market incentives, manage
ment, decentralization, and accountability.
Improving the effectiveness of interventions through
improved clinical and management skills, design
of basic preventive and clinical packages, treat
ment protocols, technology review panels, lim
ited drug formularies, training, and research on
the efficacy and cost of different interventions.
Raising the quality of care through incentives, im. proved information, training, accreditation sys
tems (for HNP staff and establishments), peer
reviews, inspection systems, and routine surveil
lance.
80 _ |m World Average
go -
least for the poor); (iii) interventions that are
less frequent, more damaging to health, and cost
lier but still within a country’s means.
□
Injuries
FIGURE 1.5
health, nutrition, and reproductive services (pub
lic and private) in low density rural areas and
urban slums. This would include improving the
supply of consumables and drugs, the manage
ment of facilities, and the skills of staff.
Enhancing Performance of HNP Services
Designing effective policies and reforms to improve the
performance of both government-run and private health
systems has bedeviled both rich and poor countries over
the past decade.
Reforms in Public Delivery Systems. Much remains to be
learned about how to make publicly-owned health sys
tems more effective. The following public sector reforms
are often needed:
Improving equity in access to a range of preven
tive and clinical services through: (i) reduced
geographic, financial, cultural, and other barri
ers; (ii) interventions that address conditions
that are frequent and inexpensive to treat (at
Maximizing consumer satisfaction through in
creased choice and attention to client, surveys.
The Limits to Public Sector Reforms. Public sector reforms
of government-run health services are often not enough
to correct the deep-rooted problems that plague these
systems. Despite years of effort and investment, many
government-run systems continue to be underfinanced
and perform poorly. In many cases they do not provide
the desired access, effectiveness, efficiency, and qual
ity. Even in the poorest of countries, patients frequently
turn to private providers. Those who can afford to pay
the price can sometimes find the quality of care that
they seek. The poor often fall prey to cheap and ineffec
tive remedies provided by unscrupulous profit seekers
in an unregulat ed market place.
More Balanced Public/Private Mix. Although the optimal
balance between public and private involvement varies
considerably from one country to another, and is differ
ent in the case of financing from that in the case of
service delivery, many recent reforms focus on correct
ing inequities and inefficiencies that occur when the
balance between government and private sector roles
becomes excessively distorted in one direction or an
other (see Annex A for a ranking of low- and middle
income countries that are at either extreme of the
public/private mix and the left box in Figure 1.6 for
distorted government roles).
Governments in countries that have introduced suc
cessful reforms often increase their role in providing in-
7
I
Improving Health Care Financing
Government Roles in HNP Sector
Distorted Roles
1
Information
R
Regulation
M
Mandates
F
Financing
P
Provision
R
C
C
C
I
C
c
M
FIGURE 1.6
formation, regulations, mandates, and financing. While
fostering a more balanced participation by NGOs, local
communities, and the private sector in the service de
livery systems, governments in these countries have
shifted their attention and scarce resources to: securing
access by the whole population to services with large
externalities (preventive public health services); pro
viding basic health, nutrition, and population services
for the poor; and assuming sectoral oversight responsi
bility for financing, medical education, R&D, and qual
ity control (see right box in Figure 1.6 and discussion
on financing in the section below)
The initial wave in reforms of the state often includes
a divestiture of state assets, or privatization, which is
concentrated on commercial enterprises. Success in this
area leads to a second wave-the divestiture of public
infrastructure and utilities. Finally, as confidence is
gained in these two areas, divestiture of state assets con
tinues, with a focus on non-govemmental and private
management and investment in health, education, and
pensions systems--the third wave.
As seen in other sectors that have gone through this
process and the health sector in the OECD, greater non
governmental participation does not necessarily imply
the sale of public assets. Instead, it can involve initia
tives that allow greater private sector participation, such
as private co-financing, management contracts, out
sourcing, and trusts. Divestiture of social assets requires
an enhanced, rather than a diminished, regulatory role
by governments in quality assurance, securing fair competit ion, and preventing abuses.
8
In health care financing, blind faith in the market is no
more likely to resolve the complex problems that face
the health sector than a naive belief in government. The
approaches used to pool risks, secure sustainable financ
ing, contain costs, and balance the budget in the HNP
sector are different from approaches used to enhance
partnerships with non-governmental and private pro
viders of services (see Annex A for groupings of coun
tries that have problems securing adequate levels of
financing or containing costs).
c
Pooling of risks. Some people are much sicker than oth
ers. Sharing of risks across population groups is a funda
mental aspect of social protection in the HNP sector.
Furthermore, people use health care most during child
hood, the childbearing years, and old age—when they
are the least productive ecoi lomically. Income smooth
ing across the life-cycle can, therefore, also contribute
to social protection in the HNP sector.
Yet as in 19th century Europe, when health care was
still in a primitive stage of development, direct out-ofpocket health expenditure continues to be a distinctive
feature of many low- and middle-income countries.
Household payments can account for as much as 80 per
cent of total health expenditures because of: nontrivial
user fees charged in public facilities (official and unoffi
cial); high copayments required in health insurance
schemes; and use of private health services (hospitals,
clinics, diagnostics, medicines, and health care provid
ers) . This undermines the social protection that could be
provided by the HNP sector even in low-income settings.
Experience has shown that strong action is needed
by the public sector to take advantage of the substantial
resources that can be mobilized through private chan
nels, while at the same time ensuring social protection
for vulnerable groups. Because of cost and the pro
nounced market failure that occurs in private health
insurance, this is not a viable option for risk pooling at
the national level in low- and middle-income countries.
Securing Adequate Levels of Financing. Strong, direct gov
ernment intervention is needed in most countries to
finance public health activities and essential health,
nutrition, and reproductive services, as well as to pro
vide protection against the impoverishing effects of cata
strophic illness.
In low-income countries, total government revenues
may constitute 20 percent or less of GDP. A country
with a per capita income in the range of US$300 to
c
I
1
4
MS
4
Low-Income Countries Have
Weak Capacity to Raise Revenues
*
A
Total Government Revenues as Percent of GDP
■ Governments
in many coun
tries often raise
less than 20%
80
of GDP in
public reve
nues; and
gQ
-V
•J
0
A
2
¥
■ The tax struc
ture in many
tow-income
countries is
often regressive.
40
20
‘0 1—
100
1.000
10,000
100,000
Per Capita GDP (Log Scale)
FIGURE 1.7
s
>
US$800 would have to spend in the range of 1.5 to 3
percent of GDP (equivalent to 7.5 to 15 percent of gov
ernment revenues) to finance a minimum level of pre
ventive andessential clinical services. Many low-income
countries spend less than this. Governments in these
countries may need to mobilize additional financing from
community sources and international donors to pay for
public health interventions with large externalities and
essential programs for the poor (see Figure 1.7).
In middle-income countries, with per capita incomes
above US$800, even at low tax collection rates, gov
ernments may choose to spend as much as 3 to 5 per
cent of GDP on health care. This is usually more than
sufficient to pay for care that goes well beyond essential
preventive and clinical services for the poor.
In these countries, other considerations become im
portant, such as tailoring the mix of broad-based financ
ing instruments to each country’s individual
circumstances. Critical factors in this respect would in
clude equity and efficiency in collection mechanisms,
administrative simplicity, budget mechanisms, cost con
tainment, willingness to pay, affordability of the benefit
package, and stability in the underlying macro-eco
nomic environment. It also involves ensuring that a
large share of financing derives from a prepaid source
of revenues (risk pooling through general revenues, and/
or social or mandated health insurance that is commu
nity rated) to avoid the equity and efficiency problems
associated with extensive reliance on user charges.
Containing Costs and Fiscal Discipline. Even in low- and
middle-income countries, a significant share of national
product and public resources is spent on health care.
Although there are no fixed upper limits, fiscal concern
may be warranted if total health spending is greater than
6 to 7 percent of GDP or if it is rising rapidly, since
public funds are often involved. In too many countries,
high expenditure levels involve public money spent on
ineffective services that benefit only a few, while large
segments of the population still do not have adequate
access to essential care. In cases where expenditure con
trol becomes an issue, governments have recourse to
three broad types of policies:
Policies that contain costs in the public sector
through supply, demand, and price control strat
egies;
Policies that regulate the private sector, discour
age the use of indemnity insurance, and encour
age capitation payments rather than fee-forservice; and
Policies that strengthen monitoring and track
ing of health expenditure patterns (using health
accounts).
Improving Budget Practices and Resource Allocation. Un
fortunately, in a large number of low- and middle-in
come countries, one of the key issues relating to health
care financing is neither lack of adequate resources nor
run-away expenditures. Rather, problems in health care
financing often result from poor budget practices in the
sector, including a habit of deficit financing and a mis
allocation of scarce resources on ineffective care. Three
policies help countries balance their budget:
Ensuring that income from all sources exceeds
expected aggregate recurrent expenditure levels
by a margin (often 3 to 5 percent) that is sufficient
to cover depreciation, and major maintenance:
Enforcing clear sanctions against budget over
runs and the accumulation of irreducible debt;
and
*
II
Allocating a large part of the budget envelope
to effective interventions that improve out
comes.
CHAPTER
i !
I I
c
The Bank’s Role*.
Growing Engagement and Learning
Rationale For Bank Involvement
Investing in people is at the center of the World Bank s
development strategy as it moves into the 21st century,
reflecting the fact that no country can secure sustain
able economic growth or poverty reduction without a
healthy, well nourished, and educated population.
to realize, extending beyond the average government’s
term and commitment to reform.
Finally, when financial assistance to the HNP sector
is sought in the form of credits and loans, this strategy
must be carefully balanced with the medium-term re
turns to such investments and the opportunity cost of
not investing in other spheres of the economy that im
pact on health, nutrition, and population outcomes.
What Developing Countries Say They Need
Role of the International Community
To address the HNP poverty agenda, improve the per
formance of health services, and secure affordable and
sustainable financing for the sector, most countries say
they need assistance from the international community
in the form of both broad international experience, and
country-focused policy advice and financing.
Yet responding directly to client demand in the HNP
sector is not straightforward. First, it is necessary to
reconcile the divergent views of the various interest
groups—the Bank’s clients (typically the ministries of
health and finance), stakeholders (local communities,
health care providers, and insurance companies). ben
eficiaries (patients, the poor, women, children, and
other vulnerable groups), and other development
partners.
Second, many countries have healtht nutrition, and
population problems precisely because governments in
troduced the wrong policies in the past. Often they failed
to implement good policies and were unable to harness
non-governmental resources effectively. Even small
changes in outcome may take as long as 10 to 15 years
None of the international organizations can address
today’s complex health, nutrition, and reproductive
challenges alone. This is especially true since overseas
development assistance from the world’s richest coun
tries has now dropped to less than 0.3 percent of their
combined GDP—its lowest level in 20 years.
The Bank works with many other international or
ganizations (FAO, ILO, UNAIDS, UNDP, UNFPA,
UNICEF, WHO), regional banks (AsDB, AfrDB, EBRD,
and IDB), the EU, bilateral organizations and NGOs,
and the private sector. The Bank's collaboration and
partnership with many of these agencies has improved,
but there is still room for further strengthening.
The Bank’s strengths are its global expertise, its multi
sectoral macro-level country focus, and the ability to
mobilize large financial resources (either directly or
through partnerships) . For technical expertise in spe
cific areas of the HNP sector such as disease control,
the Bank seeks assistance from its UN sister agencies
and other international partners.
*
t
10
r
f
I s
ii''-..........
3
5
3
3
The Bank’s Involvement in HNP
3
The Bank’s role in the HNP sector during the past 25
years has been one of growing engagement and learning
in two key areas.
First, the Bank has contributed to the genera
tion and dissemination of global knowledge on
health, nutrition, and population issues through
regional and global studies, operational research
and analysis, and shared international experi
ences.
Second, underpinned by the knowledge base that
it has accumulated in this work, the Bank has
been instrumental in catalyzing development
change at the country level through its main non
lending activities (described below) and its fi
nancing instruments.
3
3
0
3
3
3
3
World Development Report: Investing in Health. This re
port has already had a substantial impact on national
and international debates on health policies in low- to
middle-income countries, and on priorities for the Bank’s
work. The 1992 report on Development and the Environ
ment, the 1996 report on From Plan to Market, and the
1997 report on The Role of the State also dealt with HNP
issues.
In addition to such major policy reports, the Bank
has also published many books, technical notes, and
working papers that deal with HNP issues--163 such
studies were published by the end of FY96. Efforts have
been made recently to experiment with shorter, more
focused, and less resource-intensive products as well as
out-sourcing some of the research (e.g., the IFC’s 1997
Private Hospital Investment Study).
Operational Research and Analysis
'W
Generation and Dissemination of Global
Knowledge
Cross-Cutting Policy Studies
Many of the Bank’s past policy studies in the HNP sec
tor have focused on the role of the state and non-governmental sectors in addressing the health, nutrition,
and population needs of the poor, performance of health
systems, and sustainable financing.
Noteworthy early Bank policy papers include: (a) the
1970 Sectoral Programs and Policies Paper, which included
recommendations on population policies; (b) the 1973
Sector Program Paper on Bank nutrition activities; and
(c) the 1975 Health Sector Policy Paper.
The 1980 Health Sector Policy Paper was the first at
tempt to set out a solid rationale for free-standing Bank
invest ments in the health sector, drawing links between
health sector activities, poverty alleviation, and family
planning. The influential 1980 World Development Re
port on Human Resources highlighted the importance of
(he health sector, along with education and social pro
tection. to poverty alleviation strategies.
The 1984 World Development Report: Population and
Development emphasized the role of governments in re
ducing mortality and fertility. The 1987 policy study.
Financing Health Services in Developing Countries: An
Agenda for Reform, tackled the policy themes of ineffi
cient and inequitable public spending on health care
and recurrent cost financing.
The t heme of the role of governments was repeated
in t he Bank's seminal piece on the HNP sector, the 1993
s?
About US$20 million out of the approximately US$80
million allocated to the Bank’s Special Grants Program
(SGP) in FY96 went to HNP sector activities. Recent
HNP-related programs supported by the SGP include
the Special Program of Research, Development, and
Training in Human Reproduction, the WHO/UNDP/
World Bank Tropical Diseases Research Program, the
Internalional Health Policy Program, the WHO Ad Hoc
Review on Health Research, and the Global Micronu
trient Initiative.
Country-specific research and analysis of HNP issues
supported through Bank Ioans and credits has recently
ranged between approximately US$50 and US$75 mil
lion per year. This is 5 to 6 percent of total lending and
by far the largest source of external research funding for
HNP in client countries.
The Bank’s Policy Research Department has several
staff working on HNP-related issues and has conducted
a number of HNP studies in recent years. Its HNP re
search expenditure is about US$1.1 million per year or
8 percent of that department’s total research budget of
US$14.5 million. A major recent project has been the
preparation of a policy research report on AIDS and
Development. The Research Advisory Department also
supports competitive research projects in HNP.
Shared International Experiences
The Bank’s Economic Development Institute (EDI)
provides training and seminars for senior policymakers
in client countries on HNP issues. The Learning and
Leadership Cent er (LLC) of the Bank focuses on trainii
c
ing for Bank staff. The HNP Family of the HD Net
work, established in 1996, is leading HNP knowledge
management work in the Bank. All three groups are
making increasing use of partnerships and electronic
technologies to maximize their impact.
The EDI-HD Network fiagship course on Health
Sector Reform and Sustainable Financing in the fall of
1997-which involves six regionally-based partner institutes-will focus on the economic, political economy,
and institutional issues central to HNP reforms. During
the past two yean>, the LLC-HD Network training week
has provided staff with intensive training focused on
topical issues ip the HNP sector.
International conferences and scientific meetings
organized by both the Bank and other organizations
also provide training opportunities for Bank staff and
client countries. The Bank was a participant in the
1990 UNICEF-led World Summit on Children in New
York, the 1991 International Meeting of Partners for
Safe Motherhood in Washington, DC, the 1994 Inter
national Conference on Population and Development
in Cairo, the 1995 World Conference on Women in
Beijing, and the 1996 International Conference on
Early Childhood Development in Atlanta. In addition,
the Bank organized and hosted the 1997 International
Conference on Innovations in Health Financing in
Washington, DC.
The Bank encourages its client countries to partici
pate in such international conferences and scientific
meetings in an effort to strengthen institutional capac
ity and to provide an opportunity for shared learning.
Areas for Improvement as a Global Knowledge Broker
Although many Bank policy studies have had an im
pact on development, concern has been expressed re
cently that some lack operational relevance, that most
take a long time to develop, and that they are resource
intensive both in terms of direct cost and the opportu
nity cost of staff drawn away from other work. Research
and training--undertaken directly by the Bank or sup
ported indirectly through loans and grants—must also
remain relevant to the emerging development priorities
in the HNP sector, and to the operational needs of staff
and client countries. The research undertaken through
lending is typically not designed or supervised by staff
with training or skills in research. And recent budget
stringency and operational pressures often make it diffi
cult for staff to take full advantage of the training op
portunities available at the Bank and elsewhere.
12
Catalyzing Change at the Country Level
It is at the country level that the Banks global experi
ence, multi-sectoral macro-level country focus, and fi
nancial resources are brought together in an effort to
catalyze development change in the HNP sector as in
other sectors. Both the Bank’s non-lending activities,
in the form of country-specific economic and sector work
(ESW), and its financing in the form of loans, credits,
and grants, are used to promote needed systemic re
forms and maximize the impact of policy advice.
Country-Specific Policy Advice and Client Dialogue
The Country Assistance Strategy (CAS) has become
the Bank’s central vehicle for development assistance
in low- and middle-income countries. It provides an
opportunity to highlight stubborn cross-sectoral issues,
and to establish critical links between the HNP sector
and a country’s poverty and fiscal agendas. Since the
CAS sets the agenda for the Bank’s future work (both
studies and lending) in the HNP sector, inputs based on
country-specific sectoral analysis and assessments of the
effectiveness of past lending operations are a critical part
of the CAS process.
The FY96 Malawi CAS provides a good example of
how key issues relating to poor health and the lack of a
healthy environment (lack of sanitation, potable water,
basic education, and adequate income) can be presented
in the CAS. Reproductive health and human resource
development were identified as priority areas for the
country’s future growth and development. Based on this
analysis, the CAS presented a strategy for reform in the
HNP sector, which was linked to the macro-framework
and shortcomings in the government’s current health,
nutrition, and population policies.
In the future, HNP staff will work more closely with
other staff from the HD Network and country teams to
ensure adequate links between the HNP sector and the
Bank s poverty alleviation and macro-economic strate
gies. Currently, the analytical framework used to un
derpin most CAS recommendations does not include
quantitative variables for human capital or labor pioductivity. both of which are influenced by HNP out
comes and educational attainment. Furthermore,
reluctance to address politically sensitive topics Ls often
a key reason for not addressing deep-rooted systemic
issues that impact on the HNP sector. These problems
undermine the Bank’s comparative advantage as a multi
sectoral agency and diminish the impact of its macro
level focus on the HNP sector.
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For example, many CASs do not address financial
sustainability and manpower issues in the HNP sector
as an integral part of public finance and civil service
reforms. Furthermore, the CAS could be more explicit
about discouraging client countries from subsidizing
unhealthy agricultural products and wasting public re
sources on untargeted food compensation programs
Finally, glven the emerging chronic disease epidemic
chent countries should be encouraged to use taxation
instruments to combat tobacco abuse.
Most of the Bank’s policy advice in the HNP sector
relies on shared international best practice and adapt
ing apphcable lessons to country-specific settings For
examp'e, the approach to population issues is largely
gu< ed by the recommendations of the 1994 Interna
tional Conference on Population and Development in
Cairo (see Annex B). A similar approach is used in ^e
disease control and nutrition areas. This is considered
thebest way to address the complex issues faced in the
HNP sector. In the case of tobacco, international best
pract.ee ls reflected in the 1992 Bank policy of not supP^'i’g W tobacco production, processing, or market(Ooera ’
m1Ve'y enCOUra8ing ^bacco control
(Operational Directive 4.76).
Issues relating to the political economy of reform
tehav.or changes, and social marketing require more
auent.on re the future. A prerequisite for improvement
n hrs area rs to make staff more sensitive to the practiconstraints faced by politicians and bureaucrats in
countries trying to implement HNP reforms.
Country-Specific Analytical Studies in HNP Sector
Country-specific analytical studies-also known as ecoof the'Bank56''0' 7°^
30 imf~ P-t
the Bank s non-lending work in HNP. These studies
aHow Bank staff to learn about the health, nutrition
and populauon issues and investment needs in individual’
CAs' C0.UnitneS' They
a criticaJ inPut for both the
CAS and client dialogue. Many client countries w th
only moderate financial needs seek to gain access to the
ties shows that most of the foreign aid to the HNP sectorsimplysubstitutesforgovernmentspending Thereal
source of aid effectiveness in HNP is. therefore the re
forms resulting from policy advice that accom
)end
mg. not the Ioans themselves. In light of this finding
past and future cuts in the budget and staff-time allo
cated to analytical work are a worrisome trend (see Fig-
Decrease in Bank Budget for HNP-Related
Economic and Sector Work
FY96 USS (millions)
4.5 r---------- -———___ ___
2.5
2.0
1.5
10
0.5
7■
0
FY91
FY92
FY93
FY94
FY95
FY96
FIGURE 2.1
he Bank s past analytical work in HNP did not pay
suffioem attention to the political economy of reform
and ns economic, regulatory, and institutional underp.nmngs. More work is also needed to translate interna lonai experience with reform into practical solutions
at the country and local level. In the past, even when
best, practice reformation was available in some of these
--wnhm the Banks vast knowfedge base, this infer
mauon was not. always readily accessible to Bank staff.
Financing (Loans, Credits, and Grants)
Bank financial support for the Human Development
ies anJS “
T COUn^P^c sector stud-
FY96
h a
P°rU
ComPleLed
by the end
of
^96. hundreds
of shorter
working
documents
and
™ry strategy pape. have been
A
■ P1CSD' UCh studies have recently been done on
IraZl1' C,lile' China, Jordan, Kyrgyz Repub
lie, India, Malawi, Mexico, and Tunisia
P
One assessment of the impact of the Banks activi-
sector )egan with education lending in the 1960s
SLTnd
198^
‘O the HNP SeC,°r in lhe
US and 1980s. and later broadened to include social
investment funds, employment funds, training programs
chife XerS.(PenSiOnS and Safety
-”y
childhood development.
J
By I he end of FY96, 24 percent of the annual US$21
fellron re new Bank loans was directed to the HNP edu
cation. and social protection sectors. In addition to these
13
direct human development activities, an additional 23
percent of total Bank lending is devoted to the agricul
ture, water supply and sanitation, environment, and
rural/urban development sectors, which also impact on
health, nutrition, and population outcomes.
Since the Bank’s first loan of US$2 million to family
planning activities in Jamaica in 1970, its activities in
the HNP sector have grown to the point where it is now
the largest single external financier in low- to middle
income countries, with a cumulative portfolio value of
over US$ 13.5 billion in 1996 prices (see Figure 2.2). In
1976 the first nutrition loan went to Brazil, and in 1981
Tunisia was the first country to borrow for a project to
expand basic health services.
Cumu!ati\/e Growth in HNP Lending
and Projects (1996 prices)
$ Billions
$ Billtons
2501------
erage loan size per HNP project and US$80 million
Bank average.
Based on the planned pipeline, there will be contin
ued growth in the HNP sector during FY98-FY00, with
an expected annual lending of over US$ 1.5 billion and
approximately 22 new projects per year, after discount
ing by 40 percent for the usual loan drop rate (see An
nex E). Disbursements have followed these trends,
growing five-fold from US$318 million in FY92 to
US$ 1.5 billion in FY97. The growing portfolio will yield
anticipated annual disbursements well above the US$ 1
billion mark during the next three years.
There are important regional differences in the HNP
portfolio (see Annex G for map of Bank regions). The
Latin American and Caribbean (LAC) and SAS regions
are the biggest users of HNP financing. India is by far
the Bank’s biggest HNP client. The entry of the ECA
region in the early 1990s led to a further rise in total
Bank commitments. New approaches are needed to pre
vent lending in some regions from falling, as countries
such as China become ineligible for IDA credits.
225..
200
Bank Performance in the HNP Sector
150
6
100
2 -
50 -
1970
0L1970
Prqjects
■^/89
Countries
1996
1996
FIGURE 2.2
Ai the end of FY96, there were 154 active HNP
projects in 82 countries with total commitments of
US$9.2 billion (1996 prices), and 94 completed projects
(see Annex G for map of Active and Future Bank/IDA
Financed HNP Projects). About 48 percent of Bank fi
nancing from FY94 to FY96 in HNP was IDA credits,
targeted to poor countries. Total overseas development
assistance to HNP for the period from 1985 through
1993 was about US$2 billion annually in 1996 prices
(excluding Bank loans).
Although the HNP portfolio value has expanded rap
idly during the past 10 years, there is considerable varia
tion from year to year. FY96 was a record high, with
US$2.4 billion in new commitments, compared with ap
proximately US$ 1.1 billion in FY95 and US$0.9 billion
in FY97. The marked increase in FY96 was caused by
the approval of five large loans, ranging from US$270
to US$350 million, compared the US$50-60 million av14
Early Bank policy advice, lending, and credits to the
HNP sector focused mainly on helping countries
strengthen their basic health, nutrition, and population
programs. The benefits of interventions in the HNP sec
tor often appear years after specific activities have oc
curred, and factors outside the sector influence
outcomes. It has therefore been difficult to attribute
improvements in health status, nutrition, and fertility
that have occurred during the past 20 years directly to
policy advice and investments made by the Bank.
Early Bank involvement in the HNP sector appears
to have been most successful in focusing on capital in
vestment needs, developing infrastructure, and provid
ing supply inputs. Modest success was also achieved in
geographic targeting and addressing cert ain diseases of
the poor, partly because policy advice and credits pro
vided under IDA were automatically directed towards
poorer countries. This approach was consistent with
national HNP policies and a broad international con
sensus that increasing access to basic services would
automatically help improve outcomes.
Unfortunately, capital investments and the supply
of inputs are only part of the story. Demand is also an
important factor, because goods must be consumed and
services used to be effective. People’s perceptions about
quality and effectiveness of care, the attitudes of health
care providers, and the availability of essential
*
■
$
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»
*
-
i
9
!
■
consumables such as drugs, have a dramatic impact on
utilization. And carelessness in program management
and execution, such as a momentary break in a vacci
nation cold-cha in or lack ofjudgment on when to refer
complicated obstetrical cases, can make entire programs
ineffective. These factors, which are highly influenced
by the availability of adequate recurrent financing, did
not receive sufficient attention during the Bank’s early
involvement in HNP.
Furthermore, reviews by the Operations Evaluation
Development (OED) of 120 ongoing projects between
FY70 and FY95, and other assessments, have indicated
that—although inputs are important to the function
ing of basic programs—an input-oriented approach does
not achieve the institutional, management, and sys
temic changes needed to sustain impact over the long
run.
First, only 17 percent of completed HNP projects were
classified as contributing substantially to institutional
development. Several factors seemed to be responsible
for this observation: poorly specified institutional de
velopment objectives; lack of country commitment; lack
of borrower ownership especially in rural areas; inad
equate planning and management capacity; inadequate
incentives, regulations, information, and communica
tion strategies: poor involvement of non-governmental
partners; and lack of attention to monitoring and evalu
ation. Unrealist ic project objectives, complex designs,
lack of continuity, and inadequate supervision were
other contributing factors.
Second, only 44 percent of completed HNP projects
are rated by OED as likely to be sustainable. Poor qual
ity of economic and institutional analysis during project
preparation contributed to this failure. This included:
inattention to country macro-economic factors; under
estimates of recurrent coses implications and insufficient
funding to operate constructed facilities; overly optimis
tic economic benefit assumptions; and poor treatment
of intersectoral issues such as civil service, labor mar
ket. food subsidy, and tobacco, alcohol, and food taxa
tion policies.
Third, there was often a lack of continuity between
the Bank’s sectoral policy recommendations and the
design of HNP projects. It is instructive to note that,
although an increasing number of ongoing projects
examine non-governmental roles, none of the 68 com
pleted HNP projects included financing for privatelyowned facilities or activities. Furthermore, health sys
tems performance issues were dealt with mainly through
public sector interventions, with little attention to the
substitution effect and crowding out of private provid
ers. Private sector regulatory and quality control issues
were rarely addressed, and few projects have focused
specifically on resource mobilization issues.
Finally, recent OED reviews of 68 Project Comple
tion Reports indicate that only 59 percent of these
projects had satisfactory ratings, compared with 81 per
cent in education and 58 percent Bank-wide. Few of
these projects provided objective documentation of the
impact of project investments on health, fertility, or
nutrition outcomes. Since attribution of impact to spe
cific project activities is difficult, input/process/output
variables were usually tracked rather than outcomes.
Recently, these observations led the Bank to focus
more on systemic reforms, both in the case of broad
health systems/financing reforms and in the case of more
targeted interventions. Since few of these recent projects
have been completed, it is too early to evaluate their
success. Based on the FY96 Annual Reviews of Portfo
lio Performance, the newer HNP projects have kept pace
with the 80 percent Bank-wide average in terms of suc
cess in development objectives and implementation
progress. Causes for concern include the number of
projects at risk, the tendency for ratings to deteriorate
as the portfolio matures, and the failure of the current
peer review system to prevent these problems. Further
more, there was a significant drop in the resources per
project allocated to supervision activities between FY94
and FY96. With the recent increase in attention to
quality enhancement and assurance, this trend has
reversed itself in FY97 (see Annex E for a more de
tailed analysis).
In addition to this assessment of the performance of
specific investment projects, it is useful to recall that by
the end of FY96, more than 100 of the Bank’s adjust
ment operations had some health, nutrition, and/or
population content. These have tried to address diffi
cult inter-sectoral and systemic issues such as targeting
of the poor, civil service reform, sustainable rural devel
opment. decentralization, food policies, protection of
social expenditure, cost containment, and tax policy. A
thorough assessment of the HNP impact of these projects
still needs to be undertaken.
Learning From Experience
Achieving better results requires that the lessons learned
through recent reviews of the portfolio by the Quality
Assurance Group, the OED, and others be used to im
prove both the existing portfolio and the quality of new
projects. In the past, the lessons learned were often not
15
I
3
I
<-d when restructuring old projects
.w operations. Staff ski Ils-mix and staff-
Recommendations for Getting Results in HNP
.uos also did not keep abreast of portfolio
-«i and changing priorities.
In the case of the existing portfolio, the Project at
Ensure quality during project preparation
■
Risk concept has been developed to provide insights
k
■
that are not apparent from an analysis of implementa
tion and development objective ratings alone. Some
44 percent of the HNP portfolio was rated “at risk" in
■
early 1997, compared with 30 percent in mid-1996,
I
■
indicating the importance of an ongoing analysis of this
type. Sector managers are now considering how to re
■
structure or cancel some of the projects plagued by.
problems of civil unrest or refugee dislocation; slow
■
and uneven implementation in federated states and
participatory approaches to encourage client,
beneficiary, and stakeholder ownership
sectoral analysis to secure solid knowledge about
the issues and options being addressed, linking these
to the macro- context of the country in question
economic analysis to inform choices among op
tions, taking into account their costs and impacts
institutional analysis to ensure a realistic assessment
of policymaking and implementation capacity
sustainability analysis to assess financial viability,
risks, and alternatives (including exit strategies)
monitoring and evaluation to keep projects on
track and to draw lessons from experience
e
c
c
c
other decentralized settings; institutional capacity
problems in the face of complex project design; and
Adapt lending policies and procedures to client needs
■
test out project ideas on a small scale (pilot op
erations), to learn and incorporate lessons of ex
perience
■
use a process rather than a blueprint approach
for health reform projects
use a wider range of instruments
accommodate the highly decentralized nature
of the social sectors
modify the financing of recurrent costs
extend innovations in procurement rules to so
cial sector operations and be more flexible in their
application.
problems relating to procurement, disbursement, and
local counterpart funds.
Many of the relevant lessons have been highlighted
in past analyses and a working paper on quality assur
ance (see Box for summary). Few of the recommenda
tions require changes in current policies or procedures,
but most require affirmative action.
The past decade may bo seen as one of rapid growth
■
■
■
■
and learning in HNP. In the 1980s, US$35 was lent
per dollar spent (Bank administrative budget plus con
sultant trust funds), compared with more than US$60
in FY96 and US$30 in Bank-wide averages. Trust
funds-especially Japanese Trust Funds--added over a
third to the administrative budget for HNP. This trend
Develop and support staff
■
■
is not sustainable. The time is now for action to con
solidate the portfolio, to build on previous experience,
to avoid past mistakes, and to renew commitment to
HNP. Chapter III presents strategies for achieving these
*
■
build staff capacity through expanded training,
improved incentives, and recruitment of the best
strengthen the professional network and knowl
edge-sharing system and reward excellence
familiarize others with HNP sector issues, espe
cially country managers and procurement ad
visors
c
<•
<?
goals.
16
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4
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*
*
T
A
5
CHAP T"I rE R
Into the 21st Century:
Renewed Commitment and Focus
v
¥
Sharpening Strategic Directions
The Bank’s strategic direction in the HNP sector will
continue to evolve in a dynamic way based on interna
tional best practice. The complexities of the HNP sec
tor and changing approaches to health, nutrition, and
population problems generally do not lend themselves
to policy prescriptions. Instead, the policy advice and
financial support provided by the Bank will continue to
be guided by country-specific approaches to the three
major HNP development priorities outlined in Chapter
I and described in more detail below.
HNP Priority One: To work with countries to
improve the health, nutrition, and population
outcomes of the world’s poor, and to protect
the population from the impoverishing effects
of illness, malnutrition, and high fertility.
This strategy requires greater emphasis on designing
and monitoring programs that improve outcomes for the
poor. A variety of approaches is needed to adapt this
strategy to specific country and local settings, especially
in low-income countries where most of the rural popu
lation is often living below the poverty line, and in
middle-income countries with significant pockets of re
sidual poverty. The Bank will encourage the selective
use of the targeting mechanisms described in Chapter I.
It will emphasize the needs of the most vulnerable, such
as women and children, and the areas where scarce pub-
lie resources will have the greatest impact, such as pre
ventive public health activities with large externalities.
The latter would include protecting the poor against
high risk behavior such as smoking and the consump
tion of alcohol and unhealthy foods.
High fertility remains a major health and social chal
lenge in low-income countries. The Bank will continue
to emphasize the need for effective population and nu
trition policies to improve family planning and other
reproductive health services that help to increase the
demand for smaller family size, and to reduce unwanted
fertility. Likewise, in low-income countries, making food
more affordable, increasing the efficiency of food mar
kets, and providing nutrition safety nets can have a sig
nificant impacton health that reaches beyond what can
be achieved through improvement in health services.
Addressing these problems often requires a broad
range of social policies that improve and expand the life
choices available to the poor, especially girls and women,
including greater gender equality in education and im
provements in the status of women. Where women leave
home to earn money in the daytime, good childcare can
be as critical to improving child health as health ser
vices, if associated with appropriate nutrition and pre
ventive programs (e.g. immunization and dental care).
Addressing such problems may also require paying more
attention to traditional values and attitudes, such as
female patients not wanting to be treated by male doc
tors or low-income rural populations not feeling com
fortable seeking care in alienating institutional settings.
17
^^Bhipbpulation Sector Strategy
Due to transportation costs and direct loss of income,
the poor often fail to seek care if they have to travel far
only to receive low quality services, even when such
care is highly subsidized. The Bank will emphasize the
need to stimulate appropriate demand in these settings,
including that of traditional family units.
In very low-income countries, the international do
nor community must also strive to replace piecemeal
assistance with more coordinated sector-wide ap
proaches. The central objectives will be to enhance tech
nical, managerial, and political capacity, reduce donor
dependence over time, and secure minimum levels of
essential health, nutrition, and family planning services,
even if these are at lower levels than is desirable and
feasible in higher income countries. In some countries,
such action is urgently needed to bridge the financing
gap while medium- to long-term economic growth ob
jectives are pursued.
The Bank can also make a significant contribution
to the health of the poor at the inter-country and re
gional level. The Onchocerciasis Control Program (river
blindness), the African Population Advisory Commit
tee, and the Better Health in Africa Expert Panel are
helping to adapt international initiatives to African re
alities and to empower African leaders to take charge of
HNP challenges. Whether in disease control (e.g. ma
laria), or reducing micro-nutrient deficiency (e.g. salt
iodization), inter-country action has significant poten
tial to help some of the world’s poorest countries.
Finally, the Bank will encourage governments to ad
dress often-neglected multi-sectoral issues such as food
and agricultural policies, environment, water supply,
sanitation, and transportation that often have an indi
rect impact on health. In particular, the Bank will en
courage governments to introduce aggressive policies
to counter the adverse health effects of mass market
ing and inappropriate use of tobacco products and
alcohol.
To implement this strategy, the Bank needs to work
more closely not only with ministries of health, but also
with other ministries and stakeholders that address pov
erty and population issues as well as basic infrastructure
and rural community issues. Within the Bank, closer
links will be established between the Human Develop
ment (HD) Network, the Poverty Reduction and Eco
nomic Management (PREM) Network, and the
Environment, and Socially Sustainable Development
(ESSD) Network to ensure that, health, nutrition, and
population programs designed to assist the poor are an
integral part of broader poverty alleviation and mral
development strategies.
HNP Priority Two: To work with countries to
enhance the performance of health care systems
by promoting equitable access and use of popu
lation-based preventive and curative HNP ser
vices that are affordable, effective, well managed,
of good quality, and responsive to client needs.
Sector-wide reforms are often needed in countries
with serious systemic HNP sector problems. Although
there will be some overlap, the approach emphasized in
low-income countries will often differ from that recom
mended in middle-income countries. In low-income
countries, where private sector activities often domi
nate (see Annex A for a listing of countries with more
than 70 percent of health care expenditure in the pri
vate sector), governments will be encouraged to focus
their attention on the provision of: services with large
externalities (preventive public health services); essen
tial clinical services for the poor; and more effective regu
lations for the private sector. They will also be
encouraged to strengthen their management capacity,
support R&D and medical education, and secure sus
tainable financing (see HNP priority three), quality as
surance, and client satisfication.
In some low-income countries and many middle-in
come countries, where public sector activities dominate
(see Annex A for a listing of countries with more than
70 percent of health care expenditure in the public sec
tor) , governments will be encouraged to promote greater
diversity in service delivery systems by providing fund
ing for civil society and non-governmental providers on
a competitive basis, instead of limiting public funds to
public facilities. In many of these instances, rebalancing
the public-private interface will be preferable to an out
right privatization of social assets. Quasi-market mecha
nisms, such as vouchers, competitive contracting-out,
and the increased use of client feedback, can both im
prove public sector performance and encourage quality
participation by the private sector.
Where institutional capacity for financing and regu
lation is weak, a gradual approach emphasizing decen
tralization and internal markets is better than actively
transferring ownership of public facilities, with all its
attendant employment and political consequences. In
stronger institutional settings-when there is an appro
priate and effective regulatory environment--a more
active participation by nongovernmental providers can
be encouraged.
Governments need to become more effective in
policymaking, sectoral management, outcome evalua
tion, and regulation. Government and non-governmen-
c
4
18
e
I
Into the 21st Century: Renewed Cotunjftgjgn
-<1
-4
■'4
'jSi
1
v
1
4
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I
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4
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tai actors (professional associations, consumer groups,
and academic institutions) will be encouraged to gen
erate knowledge about improving access, the effective
ness of specific interventions, and efficiency in
managing services, controlling quality, and respond
ing to client needs. Effective incentives and provider
payment mechanisms can make a significant contribu
tion to improving the performance of health systems.
To implement this strategy, the Bank needs to work
closely not only with ministries of health, but also with
ministries of finance, privatization, and planning. Within
the Bank, closer links will be established with the IFC
and the Finance, Private Sector, and Infrastructure
(FPSI) Network to build on lessons learned about di
vestiture of social assets and to facilitate the flow of fi
nance to non-governmental recipients.
HNP Priority Three: To work with countries in
securing sustainable health care financing by
mobilizing adequate levels of resources, estab
lishing broad-based risk pooling mechanisms,
and maintaining effective control over public
and private expenditure.
The experience of most low- and middle-income
countries, as well as all OECD countries, suggests that
governments must play a major role in health care fi
nancing through regulations, mandates, and direct sub
sidies. Although considerable private resources may be
available, these resources are often wasted on ineffec
tive care wit hout effective government policies.
Based on this experience, the Bank needs to become
more active in helping countries to secure sustainable
recurrent financing for health, nutrition, and popula
tion programs, rather than in providing resources just
for capital investments. The mix of taxation instruments
(social insurance and general revenues) and copayments
needs to be tailored to each country. In low-income
countries, significant efforts are needed to complement
public resources with non-governmental community
based financing and international assistance (see An
nex A for list of low-income countries that fail to
mobilize the minimal levels of financing needed to pay
for essential services for the poor). At middle- and
higher-income levels, taxation instruments become a
more efficient way to mobilize financial resources and
expand risk pooling. Special attention will be given to
the associated fiscal and labor market, implications (see
Annex A for list of high-spending countries where fis
cal implications may be a potential concern).
Governments will also be encouraged to maintain
effective expenditure control and to ensure that the
HNP budget envelope is used on effective and quality
care that benefits those who need it most.
Experience has shown that when middle-income
countries expand coverage and begin to use a fuller range
of financing instruments, strong government action is
needed to prevent an expenditure explosion in the
health sector such as occurred in Argentina, the Czech
Republic, Jordan, and South Africa. The Bank will take
active steps to learn more about how to assist these
countries.
To implement this strategy, the Bank needs to work
closely with ministries of finance and ministries of so
cial security as principal counterparts in addition to
ministries of health. Within the Bank, the HNP Family
will work closely with the Poverty Reduction and Eco
nomic Management (PREM) Network in this work.
Achieving Greater Impact
The major expansion of the Bank’s work in HNP is now
about a decade old. The rapid growth has led to uneven
quality, fragmental ion of emphasis, and substantial con
cerns about impact and effectiveness. To implement the
strategy set out in this document, maximize the impact
of investments, and ensure that clients receive the best
possible service, the Bank needs to follow four principles:
emphasize strategic policy direction; underpin lending
with analysis and research; increase selectivity; and im
prove client services. These are explained in more de
tail below.
Emphasizing Strategic Policy Directions
HNP strategies have a development timeframe of 10 to
15 years, which exceeds the life cycle of most projects
(five to eight years), individual staff assignments (three
to five years), and ministers’ terms in office (one to four
years). Given this constraint, it is critical that the coun
try-specific HNP strategies presented in each CAS—as
well as the Bank's policy advice, lending, and research
agenda—focus explicitly on both medium-term objec
tives and shorter-term activities consistent with the three
HNP priority areas described above.
The CAS will be used as a key instrument for deliv
ering the Banks message about HNP priorities during
high-level country dialogue. HNP staff will work more
closely with country teams on the CAS in those coun
tries that have been identified as having particularly
serious systemic problems in the HNP sector (see An19
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^^haPopulation Sector Strategy
nex A for country rankings under each of the three HNP
priority areas). HNP staff will also work more closely
with the education and social protection sectors to de
velop quantitative measures for human capital forma
tion and labor productivity, which could be included in
the analytical framework that is routinely used to un
derpin CAS recommendations. Management will selec
tively monitor progress made in improving outcomes,
health systems performance, and health financing indi
cators in countries that have been identified as being at
greatest risk.
Underpinning Lending with Analysis
and Research
As the Bank continues to shift from a focus on physical
inputs and outputs to a greater emphasis on outcome
and process, it needs to experiment and learn. This can
best be accomplished through rigorous design, supervi
sion, and evaluation of pilot projects, and by placing
greater emphasis on the design and supervision of the
research components of investment projects.
Areas for increased attention include: (a) under
standing more fully individual and household responses
to prices, quality, access, public health policies, specific
interventions, the public/private interface, and various
aspects of the health production function; (b) encour
aging individuals and households to take more respon
sibility for their own health and to participate in
decision making; (c) exploring the factors that influ
ence performance of health systems such as the politi
cal economy of reforms, governance, and institutional
dimensions; (d) learning more about how to secure sus
tainable health care financing and broad risk pooling,
and how to use the results from health expenditure re
views (public and private) to set sectoral priorities (re
source allocation decisionsand cost containment); and,
(e) drawing out the experience from health sector re
forms across countries to clarify (he relationships be
tween intersectoral policies, health system performance,
financing, and outcomes.
Fulfilling this agenda requires a reversal of recent
cutbacks in sectoral analysis, an increase in the budget
for HNP research in line with the HNP portfolio size,
and a greater allocation of resources to help design and
implement innovative projects. In the future, the HNP
Family of the HD Network will ensure that staff make
more effective use of lessons learned from past experi
ence (positive and negative).
20
Increasing Selectivit}'
The Bank cannot do everything well. Difficult choices
must be made about where to intervene and where to
support other organizations or the private sector. The
Bank will continue to work closely with its partner or
ganizations, such as WHO, in defining a clearer divi
sion of labor to promote greater complementarity and
to avoid wasteful duplication. Product selectivity can
be improved by screening prospective projects based on:
(a) country needs in the three HNP priority areas; (b)
an objective assessment of the potential benefits-emphasizing activities that are associated with large externalities-and associated political, institutional, and
economic risks; and (c) commitment to significant re
form.
Selectivity in terms of countries needs to be consid
ered carefully. One way for (he Bank to maximize its
impact on the poor is to concentrate effort and resources
on the cluster of countries in which most of the poor
live (see Annex A for low-income country groupings).
Selectivity based on the degree to which policy dia
logue and project activities influence the allocation of
existing recurrent expenditure is another way for the
Bank to leverage its financing. Annual IDA resources
play a significant role in total health sector financing in
smaller poor countries (16.4 percent in Sub-Saharan
Africa and 13.1 percent in South Asia, excluding In
dia) but not in larger ones (0.5 percent in China and
0.7 percent in India). Annual IBRD assistance to
middle-income countries is similarly insignificant (0.6
percent in Jordan, 0.4 percent in Poland, 0.3 percent in
Argentina, and 0.2 percent in Mexico).
Finally, the CASs could provide a powerful tool for
increasing selectivity by focusing on HNP issues
that require broad systemic and multi-sectoral interven
tions, where the Bank has the greatest comparative
advantage.
Improving Client Services
The quality of services offered by the Bank to clients in
the HNP sector can be improved in several ways. First,
the Bank will strengt hen its HNP knowledge base. This
will include establishing: (a) health, nutrition, and popu
lation help desks; (b) an on-line database of policy pa
pers, best practice papers, electronic forums,
terms-of-reference, profiles of stall and consultants, and
links to external resources; (c) a Bank database on health
expenditure trends and a clearinghouse function for
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other HNP data; and (d) a knowledge base on various
other aspects of HNP systems such as demand and uti
lization patterns, behavior of providers, and health care
markets. The Bank will also keep up with global best
practice and developments in the HNP sector.
Second, more time and effort will be spent learning
about portfolio performance and applying the lessons
learned more systematically, both during project design
and implementation. This requires learning more about
what constitutes good project design by applying the
available tools of sectoral, economic, institutional, and
risk analysis. More time is also needed to pilot new ap
proaches such as-broad sector reforms and public/private partnerships. Projects that clearly fail to meet their
development objectives will be restructured, or canceled
if they fail to improve after a reasonable time. Finally,
an effort will be made to learn more about how to influ
ence external factors, such as political commitment from
one administration to another, and how to deal with
the institutional resistance when stakeholder interests
are threatened by reform proposals.
Third, a more flexible and broad range of lending
instruments will be tested. This includes greater use of
sector-wide approaches and adjustment loans to sup
port systemic reforms, and the use of the new micro-,
mini- and adaptable investment loans once they become
available. The use of smaller and innovative free-stand
ing loans will avoid adding complex sub-components to
standard projects. A Bank study has already begun to
explore the use of simpler and more flexible procure
ment and processing procedures.
Given the importance of good assessments of client
needs and communication strategies to health, nutri
tion, and population outcomes, user satisfaction surveys
will be initiated and used to inform future project designs.
Monitoring Dovelopment Impact
The ultimate objective of work in the HNP sector is to
improve health, nutrition, and population outcomes,
health systems performance, and healt h care financing.
The Bank needs to take steps to improve its own and
borrower capacity to monitor and evaluate progress in
achieving these objectives.
The tables in Annex A summarize key healt h, nutri
tion, and population issues for the world, for low-,
middle- and high-income countries, and for the Bank s
regions. They also measure performance under the three
different HNP priority areas based on general economic
and other human development determinants, indica
tors of health, nutrition, and population status, health
systems and health financing indicators, and data point
ing to future challenges in the HNP sector.
The indicators for performance of health systems are
weak. The Bank will work with other international or
ganizations and client countries to develop more effec
tive indicators, introduce incentives to encourage their
use (recognition, rewards, and reviews), and include
monitoring and evaluation components as integral parts
of project designs. The future pipeline, and restructur
ing of the current portfolio, will be guided by the likely
impact on these indicators.
Empowering Staff
The underpinnings for improved staff development and
management have already been initiated by the recent
establishment of an HD Network and Council, the HNP
Family and Sector Board, ai id the Regional Sector Heads
(see Figure D.2 in Annex D). Key staffing issues relat
ing to the Bank’s capacity to meet its objectives in the
HNP sector include: skills mix, number of staff, and
deployment.
First, recruitment, staff training opportunities, and
HNP sector professional standards will be adjusted
to reflect the sharpened policy directions. Priority is
being placed on the broad skills needed to deal with
a wider range of products and to address more effec
tively the three HNP priority areas. Special emphasis
will be given to staff who have practical experience
in the HNP sector, are able to work with complex
policy issues, and understand the political economy
of reform processes.
Second, the Bank needs to assure staffing in the HNP
sector reflects the size and growth of the HNP port folio.
Lending to the HNP sector during the past decade has
grown more rapidly than staff. HNP staff numbers in
creased by 86 percent between FY86 and FY96, whereas
lending grew by 272 percent. More recently, the aver
age annual rate of growth of HNP sector staff of 6 per
cent has continued to lag behind the expected 13
percent annual increase in lending. The new Network
structure is expected to improve the efficiency of staff
in the sector. The issue of assuring adequate staffin in
the sector is a management priority.
Finally, the Bank needs to explore two approaches
to bringing staff closer to clients. One approach, inspired
by the experience of the India resident mission, is to
have a senior Bank special ist oversee the work of a group
21
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Population Sector Strategy
of locally-hired staff within a single country. Another
approach is to coordinate the staff in several resident
missions through a regional hub, such as the human
development team in the Budapest resident mission.
Improved communications links between headquarters
staff, field st^ff, and clients help to bridge the gap in
cases where direct contacts are not possible.
In the case of training activities, the HNP Family of
the HD Network will: link training to the three strate
gic directions in the HNP sector; include both Bank
staff and clients; increase opportunities for resident mis
sion staff; and extend the target audience to sectors
outside HNP. Improving management skills of HNP staff
will be given particularly high priority.
Strengthening Partnerships
To meet the development challenges of the 21st cen
tury, the Bank needs to strengthen its partnerships with
clients, civil society, stakeholders, and other agencies.
WHO and the Bank have made great progress over the
past two years in clarifying their comparative advantages
and optimizing their collaboration in the interests of cli
ent countries. Two key forms of collaboration have been
agreed upon: (a) country-level collaboration in which
WHO technical expertise is mobilized to improve the
design, supervision, and evaluation of Bank-supported
projects; and (b) global collaboration in which WHO
and the Bank join forces to advance international un
derstanding of health, nutrition, and population issues.
Similar efforts are being made wit h UNAIDS, UNFPA,
UNICEF, and other agencies.
The Bank’s collaboration with other agencies on in
ternational research and development (R&D) will be
strengthened. First, the Bank will continue to support
the newly-established Global Forum on Health Research
using funds from the Special Grants Program. The Fo
rum provides a mechanism for focusing R&D resources
more tightly on priority subjects, including health policy
research, low-cost management of non-communicable
diseases, and slowing the spread of drug-resistant mi
crobes. Second, the cont inuation of grant financing for
priority international initiatives that improve and share
knowledge in the fields of nutrition and reproductive
health will be encouraged. Third, in partnership with
the Forum, the Bank will collaborate with the pharma
ceutical, vaccine, and biotechnology industries to
strengthen the R&D pipeline for products needed by
poor people in low-income countries—such as new drugs
for drug resistant malaria, a better vaccine for tubercu
losis, and improved diagnostics for sexually transmitted
diseases. Finally the Bank will seek ways to extend its
support for the International AIDS Vaccine Initiative
(IAVI), UNAIDS, and the private sector in the newly
heightened search for an AIDS vaccine.
An effort will also be made to replicate in other areas
the Bank’s successful partnership with other organiza
tions in river blindness control and to support other in
ternational health, nutrition, and population initiatives
with potentially large externalities. Likely candidates
include collaboration with African governments and
others in a major effort to control the malaria epidemic
on that continent, and work with WHO and others to
combat the pandemic of tuberculosis and to promote
integrated management of childhood illness.
*
From Vision to Action
Implementation of the HNP strategy will be linked
closely with the Bank’s new Strategic Compact. In close
consultation with staff at the regional level, the HNP
Sector Board will translate the objectives and broad
action plan outlined in the Strategy Matrix in Annex F
into clear performance benchmarks against which the
Bank will be judged by the t ime of the next HNP Sector
Strategy Paper.
Through such action, the Bank expects to enhance
its role in the global effort to improve human develop
ment during the first decade of the 21st century. The
Bank will continue to inform and influence the terms of
the global health policy debate and to strengthen part
nerships with its clients and fellow agencies.
*
22
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ANN E X A
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HNP Sector At A Glance:
Global, Regional, and Country Profiles
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Background
HNP At a Glance: World
The indicators shown in the following tables include
general economic and other human development de
terminants, indicators of health, nutrition, and popula
tion status, health finance and health systems indicators,
and future challenges in the health sector. Tables in
clude: (a) regional ranking of high risk countries by HNP
indicators, (b) global ranking of countries by HNP indi
cators, and (c) HNP At a Glance tables for the world,
for high income countries, for six regions, and for indi
vidual countries.
Table A.3 shows the level of indicators by region for
each of the following broad categories:
Key Economic Indicators
Average Annual Growth
Human Development Determinants
Health Indicators
Nutrition Indicators
S’
Reproductive Health Indicators
■3?
Future Challenges
Health Services Indicators
Health Finance Indicators
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Regional and Global Ranking by HNP
Indicators
Table A. 1 and A.2 show countries with high health risks.
The first table shows the ranking of low- and middle
income countries on eight key HNP determinants and
outcomes. This table shows that some countries and
some regions rank consistently high in terms of poor
HNP outcorpes and risks.
The second table shows ten countries per region
that have poor outcomes on HNP indicators or deter
minants, as defined in the table. In some regions for
some of the indicators, there are fewer than ten coun
tries ‘at risk’; in other regions the number of countries
exceeds ten, but only ten are shown in the order of
highest risk or poorest outcomes first.
HNP At A Glance: High Income and Regions
Table A.4 covers a number of countries in each region
selected on the basis of: (a) largest population; (b) pov
erty-related HNP indicators; (c) selected indicators for
health systems performance; and (d) selected indica
tors for health expenditure. Table A.4 also shows aver
ages for low- and middle-income countries and for each
region as a whole. Table A.5 covers at-risk countries
among high-income countries.
Largest Population
The country with the largest population is also the coun
try with the largest HNP portfolio in all regions except
23
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l^Sfeo&ilation Sector Strategy
MNA. The HNP indicators of these countries have the
largest impact on the regional averages that are popula-
tion weighted.
Lowest measles immunization rate. High measles immu
nization rates have been achieved in many countnes m
the developing world, averaging about 76 percent in the
early 1990s. A low level of immunization is an indica
tion of a failing health delivery system.
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Indicators of Poverty and HNP Outcomes
Four poverty-related indicators are used as criteria to
select countries:
Lowest per capita income in the region. A strong associa
tion between income and health status is evident, with
the poorest country showing below-average perfor
mance on most HNP status indicators in all regions.
Highest under-5 mortality rate (or next highest if this uplicates the country with the lowest income). Undermortality captures the impact of poverty on health bet
ter than infant mortality or other mortality indicators.
It measures the combined effect of nutrition, access to
immunization and curative health services, and local
conditions. High under-5 mortality has a large impact
on overall life expectancy; no country with an under-5
mortality rate of over 50 has a life expectancy of 70 or
above.
Highest child malnutrition prevalence (or next highest, if
this duplicates the country with the lowest income).
High child malnutrition is associated with poor perfor
mance on several other health indicators, as well as with
other child development aspects. This indicator has a
strong regional association: it is high in most countries in
the South Asia and East Asia and Pacific regions.
Highest total fertility (or next highest, if this duplicates
the country with the lowest income). Countries with
high fertility usually have high population growth rates,
large proportions of young people, and often high ado
lescent fertility rates. Maternal mortality is also asso
ciated with high fertility, especially when considered
as the life-time risk of dying from pregnancy-related
causes. High fertility is frequently found in poor house
holds, and poverty and high fertility are mutually rein
forcing.
Lowest access to health services (or next lowest, if there is
a duplication in previous indicator). The percent of the
population within one hour’s walk or travel to health
service providers measures the availability of health ser
vices to the population.
Selected Indicators of Health Expenditure
The percent of GDP spent on health is of interest both
as a determinant of health outcomes and equity, and as
an indicator of efficiency and fiscal burdens. The fol
lowing indicators were selected to illustrate these issues.
Low public expendifure (as percent of GDP) on health
care Countries with very low public expenditures are
usually the poorest performers on a range of health sta
tus indicators. Concern is warranted if public expendi
ture is less than 2 percent of GDP or total expenditure
is less than 3 percent of GDP. Such countries are prob
ably not allocating a sufficient share of national resources
to providing poor populations and other vulnerable
groups with protection against illness.
High total expenditure (as percent of GDP) on health care.
There are no firm guidelines on what constitutes too
much expenditure on health care. However, in some
countries, the share of national product and public re
sources spent on health care arc greater than expendi
ture on education and other social programs that also
contribute significantly to poverty reduction, economic
growth and overall well-being. Fiscal concern is war
ranted in low- and middle-income countries if total
health spending is greater than 7 percent of GDP. In
some of these countries, the extensive use of general
revenues and payroll-based taxes in the formal employ
ment sector probably has some negative implications for
labor costs, commodity prices, international competitiveness, and overall tax compliance.
Selected Indicators of Health Care Coverage
The following two indicators address two aspects of
health systems. Access to health services shows the po
tential of health systems to improve health status. Im
munization rates show the realized performance of the
health system.
24
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HNP At a Glance: Countries
Table A.6 provides data for over 200 countries using
the same indicators as shown in the regional tables,
and A.5.
*
Annex A:
>
Access to health services. The percent of the population
covered for treatment of common diseases and injuries,
including availability of essential drugs,
h°urS
walk or travel. Source: World Bank, World Develop
ment Indicators. 1997, based on and supplemented with
External debt. This represents the discounted present
value of future debt service payments, including private,
public, and publicly guaranteed short-term and long
term debt The discount rate reflects market lending
rates for the currency in which the loan is denominated.
'
data collected by WHO and UNICEF.
'
Access to safe water. The share of the population with
?
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reasonable access to an adequate amount of safe water
(including treated surface water and untreated but urn
contaminated well and spring water). Source. Wort
Bank, World Development Indicators, 1997. based on
and supplemented with data collected by WHO and
Gini coefficient. This index measures the extent to which
the distribution of income among individuals or house
holds deviates from a perfectly equal distribution. A Gini
index of zero represents perfect equality while an index
of 100 percent implies perfect inequality. Source. Wor
Bank, World Development Indicators, 1997, based on
household surveys conducted during the period
.
’
UNICEF.
to 1995.
.
Adolescent fertility rate. This measures the fertility rate
for women under age 20, shown per 1000 women under
age 20 These are estimates and projections based on
Demographic and Health Surveys, national estimates,
and other
sources of
of age-specific
age-specific fertility
rates. For some
and
other sources
fertility rates.
countries that lack age-specific fertility schedules, t e
Gross domestic investment. This consists of outlays on ad
ditions to fixed assets of the economy, plus net changes
in the level of inventories. Data for developing coun
tries are collected from national statistical organizations
and central banks by World Bank staff. Data for indus
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Definitions
from UNICEF and the Administrative Coordination
Committee/Subcommittee on Nutrition.
trial countries are from OECD data files.
figures are based on models.
|
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Adult HIV/AIDS prevalence. This measures the percent! 15 who are HIV positive. Source:
age of those over age
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UNAIDS, based on blood screening of pregnant women,
blood donors, and the general population.
'
Adult mortality rate. The probability of dying between
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ages 15 and 60 based on prevailing mortality rates. These
are World Bank estimates based on model life tables se
lected on the basis of overall life expectancy and infant
and under-5 mortality. For countries with vital registra
tion-based life tables, a close fit between these model
based estimates and the life table values has been found.
However, such agreement cannot be assumed for all
countries, and the data presented here should be inter
preted as indicative of the level of adult mortality rather
than as precise estimates.
Anemia—iron deficiency. This is defined as hemoglobin lev
els less than 11 grams per deciliter among pregnant women.
Source: WHO data and Micronutrients Initiative.
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Child malnutrition rate. Prevalence of malnutrition is mea
sured as the percentage of children under age five whose
weight for age is less than minus two standard devia
tions from the median of the reference populat ion. The
data are mostly from WHO. supplemented with data
GDP (al purchasers’ prices). This is the sum of the gross
value added by all resident and nonresident producers
in the economy, plus any taxes and minus any subsidies
not included in the value of the products. It is calcu
lated without making deductions for depreciation of fab
ricated assets or for depletion and degradation of natural
resources. Data for developing countries are collected
from national statistical offices and central banks by
World Bank staff. Data for industrial countries come from
OECD data files.
GNP per capita, (US dollars). From World Development
Indicators, 1997. GNP per capita is derived from GNr
converted to US dollars (using the World Bank Atlas
method) divided by the midyear population.
Gross secondary enrollment ratio. 1 he ratio of total en
rollment., regardless of age, to the population of the age
group that officially corresponds to the total level ol
education. Source: World Bank. World Development
Indicators, 1997. based on the 1995 Statistical Yearbook
from the United Nations Educational, Scientific, and
Cultural Organization (UNESCO)
Health expenditure (private). This includes spending on
health from the following sources: direct household ex25
^iy^dpulation Sector Strategy
penditure (out-of-pocket), private insurance, charitable
donations, and direct service payments by private cor
porations. Data are from World Bank, PAHO, IMF, and
other studies.
Health expenditure (public). This consists of spending from
the following sources: government (local and central)
budgets, external borrowings and grants, and social (or
compulsory) health insurance funds. All external assis
tance, including donations from international NGOs,
is included under the public expenditure category. Public
health expenditure is rePected in US dollars, PPP ex-
change rate, and as a percent of GDP. Data are from
World Bank, PAHO, IMF, and other studies.
Health expenditure (total). This includes outlays for the
provision of health services (preventive and curative),
population activities, nutrition activities, and emergency
aid designated for health. It does not include water and
sanitation. Figures are for actual year from which most
recent data is available. Total health expenditure in
cludes both public and private health expendituresand
is reflected in US dollars, PPP exxchange rate, and as a
percent of GDP. Data are from World Bank, PAHO, IMF,
and other studies.
Immunization of children under 12 months for measles, DPT.
The percentage of children under 12 months immunized
against measles (one dose of vaccine) and DPT (diph
theria, pertussis, and tetanus; at least two of three doses
of vaccine). Source; World Bank. World Development
Indicators, 1997, based on and supplemented with data
collected by WHO and UNICEF
Infant mortality rate. The number of deaths of infants un
der age one per 1,000 births. These are based on country
statistical offices, censuses and surveys. World Bank sec
tor studies, and—especially for countries without reliable
data—the UN Population Division’s estimates. For many
developing countries without reliable vital registration,
indirect estimates from demographic surveys are used.
In-patient hospital beds. This measure includes beds avail
able in public and private, general, and specialized hos
pitals and rehabilitation centers. Hospitals are
establishments permanent ly staffed by at least one phy
sician. Data are from government statistical yearbooks,
World Bank, OEGD, and WHO.
Life expectancy al birth. The average number of years a
newborn will live based on prevailing mortality rates.
26
Note that by definition these are based on period life
tables, and may not apply to any cohort for which mor
tality conditions may be different in subsequent years.
The sources for the data include the UN Population
Division, national statistical offices, and World Bank
estimates and projections from surveys and censuses.
For most countries, 1995 life expectancy estimates are
projections based on the trend in the previous decade.
HIV/AIDS prevalence data are used to adjust the trend,
and account for the declining life expectancy in coun
tries where AIDS mortality is high.
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Low birth weight. Defined as children born weighing less
than 2,500 grams, with the measurement taken within
the first hours of life, before significant postnatal weight
loss has occurred. Source: World Bank, World Devel
opment Indicators, 1997.
Maternal mortality ratio. This measures the number of
deaths to women during pregnancy and childbirth per
100,000 live births in the same year. The est imates are
from the Demographic and Health Surveys, national
estimates, and, for countries without such data, from a
model developed by WHO and UNICEF that is based
on fertility and other variables related to maternal mor
tality. The measurement of maternal mortality is often
inaccurate due to underreporting in vital registration,
large standard errors in survey-based estimates, and the
use of indirect methods that produce estimates for past
years. All maternal mortality estimates, but especially
the model-based figures, should be seen as indicative.
Obesity prevalence. This measures the percentage of the
population with a body mass index of 30 or higher. Data
denoted ‘a’ are for adults, data denoted 'b' are for chil
dren. Sources for the data are the FAO and the Demo
graphic and Health Surveys.
Population. Midyear estimates and project ions of total
de-facto population. Refugees not permanently settled
in the country of asylum are excluded from the esti
mates. Sources of population estimates vary from coun
try to country, and are based on the most recent census,
official country estimates, UN Popular ion Division es
timates, or on data from other international agencies.
Projections are based on the cohort component meth
odology, in which a baseline age-sex stnicture is pro
jected with fertility, mortality, and migration schedules.
For a detailed description of the methodology and as
sumptions, see: World Bank. World Population Projec
tions, 1994—95.
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Population growth rates. These are average annual rates
expressed in percentages, calculated from midyear esti
mates and projections using an exponential rate of
change.
Purchasing Power Parity conversion factor. The number of
units of a country’s currency required to buy the same
amounts of goods and services in the domestic market
as a dollar would buy in the United States. Source: World
Bank staff estimates.
Physicians. Defined as graduates of any faculty or school
of medicine who are working in the country in any medi
cal field (practice, teaching, research). Data are from
government statistical yearbooks, World Bank, OECD
and WHO.
Smoking prevalence. Percent of males and females over
age 15 who smoke tobacco products. Sources are WHO
and country surveys for the most recent year.
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Total fertility rate. This measures the average number
of children born per women entering the childbearing
age, if subject to prevailing fert ility rates. The sources
are the Demographic and Health Surveys, World Fer
tility Surveys, Contraceptive Prevalence Surveys, other
demographic surveys, vital registration, World Bank
staff estimates, and the UN Population Division. As
with some of the mortality data, estimates of past fer
tility are frequently based on indirect estimates from
survey data.
1
1
Tuberculosis incidence. This shows the estimated num
ber of new sputum smear positive (SS+) cases per 100,00
I
population in Tables A.3 to A.5, and the estimated TB
incidence (all forms) in Table A.6. Source: WHO 1997
Global Tuberculosis Control Report.
Under-5 mortality rate. This measures the probability that
a newborn will survive to exactly age five, based on pre
vailing mortality rates, times 1,000. The estimates from
1960 to 1990 are based on a methodology developed by
Hill and Yazbeck (1994) using regression analysis.
Weighted least-square regression was used in their analy
sis, assigning weights to each country’s data on the ba
sis of the validity of the data. Figures for 1995 are World
Bank staff estimates based on published sources such as
UNICEF’s State of the World's Children 1997 and on
projections from the latest available survey, census, and
vital registration data.
Urban population. This measures the percentage of a
country’s total population residing in urban areas. Defini
tions of urban areas are country specific, and vary consid
erably among countries. Source: UN Population Division,
World Urbanization Prospects, the 1994 Revision.
Unwanted fertility. Unwanted births are defined as those
that exceed the number considered ideal by women of
reproductive age. This is used to calculate a “total
wanted fertility rate", in the same manner that the total
fertility rate is calculated. The difference between the
total fertility rate and the wanted fertility rate is the
unwanted fertility rate. Women who do not report a
numerical ideal family size are assumed to want all their
births. Source: Demographic and Health Surveys (con
ducted in the past seven years).
■
i
-:
i :
i•
*:
27
i
1
and Population Sector Strategy
Burden of Disease, Prevalence, and Risk Factors
Burden of disease may be understood as the gap between
the health status of a population and some reference of its
good health. Measuring the burden is helpful as one tool to
rationally prioritize among various health interventions, or
to provide a quantitative basis for planning health services.
In practice, the burden of disease may be measured by a
number of indicators of morbidity and modality. These in
clude the frequency with which a disease or disability oc
curs within a population, the death rate, or an index that
combines measures of morbidity and mortality, such as dis
ability-adjusted life years (DALYs).
Understanding the epidemiologic characteristics of a dis
ease is useful in understanding how health interventions may
work in a population. The burden of disease is a function of
a number of epidemiologic characteristics, including fre
quency, duration, and severity.
Risk factors are attributes or exposures that are associated
with the probability of a health outcome, such as the occur
rence of a disease, its duration, or severity. Some risk factors
are known to be causally related to certain health outcomes.
For example, contaminated water supplies increase the risk
of diarrhea, and smoking increases the incidence of can
cers, heart disease, and stroke. Some types of risk factors
broadly influence the incidence of disease, but are not im
mediate causes of illness. These type of determinants in
clude income, education, and social class. Poor population
groups generally have a much higher incidence of most dis
eases than do rich groups. The poor also tend to have higher
case fatality rates, one measure of the severity of disease.
The case fatality rate is the proportion of people with a spe
cific condition who die within a given time period. Other
measures of severity indicate the degree of disability among
those surviving with a disease.
Burden of Disease = f (frequency, duration, severity)
The incidence of disease may oe reduced by some types
of preventive health measures, such as immunizations. The
Prevalence may be thought of as the proportion of the popu
lation with a given disease at any given point in time.
duration of illness, the case fatality rate, and other indica
tors of severity may be affected by both preventive and cura
tive health services. For example, antibiotics prevent deaths
Prevalence = number with disease
from acute respiratory infection, and low-cost de-worming
total population size
agents reduce morbidity from intestinal worms. Other types
of risk factors also matter, and suggest other points of inter
vention. For example, malnutrition and vitamin A deficiency
The incidence rate of disease represents the number of
new cases of a condition in the population within a speci
fied time frame, such as one year As a measure of the fre
quency of a disease, incidence reflects the probability or
risk of a health event occurring. Prevalence rates are differ
ent from incidence rates because they measure the frequency
of both new and existing cases of a disease. While preva
lence is a measure of disease burden (e g the frequency of
diabetes in a population), it is not a measure of the risk of
getting a disease. The duration of the disease is what links
incidence to the prevalence of a disease, commonly ex
pressed as.
increase the case fatality rate of measles Income, educa
tion, and other broad determinants may affect case fatality
rates or disease duration, possibly through differences in
utilization of health services, healthy behaviors, or expo
sure to other risk factors. Fatality is, of course, inevitable for
all persons and for some diseases despite health services.
Health systems are concerned largely with the health of
populations, and aim to decrease incidence by reducing
known risk factors, and to increase survival or the quality of
life by providing health services or changing behaviors af
fecting health. Health systems can also affect the broad socio
economic determinants of good health and illness indirectly,
through the relationships between health, productivity, and
Prevalence - Incidence
28
Duration
ability to earn income.
1 |
Li
Table A.1 Global Ranking of At-Risk Countries by HNP Indicators, Low- and Middle-Income Countries
Poverty and HNP Ouicnme Indicators
GNP per capita
Ixtw >-> High
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Mozambique
Ethiopia
Tanzania
Zaire
Burundi
Malawi
Chad
Rwanda
Sierra Leone
Nepal
Niger
Burkina Faso
Madagascar
Bangladesh
Uganda
Guinea-Bissau
Haiti
Mali
Nigeria
Yemen, Rep.
Under 5 mortality rate
High Low
Under-5 malnutrition
High o Low
Liberia
Afghanistan
Sierra Leone
Guinea-Bissau
Malawi
Guinea
Somalia
Gambia, The
Angola
Rwanda
Chad
Eritrea
Mali
Mozambique
Ethiopia
Equatorial Guinea
Djibouti
Zambia
Nigeria
Bhutan
Bangladesh
India
Nepal
Ethiopia
Mauritania
Mozambique
Viet Nam
Niger
Eritrea
Afghanistan
Lao PDR
Pakistan
Indonesia
Somalia
Maldives
Bhutan
Cambodia
Sri Lanka
Burundi
Angola
J
Niger
Yemen, Rep.
Gaza Strip
Oman
Ethiopia
Somalia
Angola
Afghanistan
Mali
Burkina Faso
Uganda
Maldives
Malawi
Liberia
Lao PDR
Burundi
Sierra Leone
Guinea
Togo
Mozambique
Immtmiuuion coverage Access to health services
Low u> High
Low <-> High
Chad
Niger
Angola
Haiti
Zaire
Cote d'Ivoire
Central African Rep.
Sierra I^eone
Nigeria
Eritrea
Mali
Burkina Faso
Cameroon
Gabon
Congo
Mauritania
Papua New Guinea
Italy
Lao PDR
Yemen, Rep.
Central African Rep.
Cameroon
Angola
Ghana
Chad
Mozambique
Niger
Senegal
Benin
Indonesia
Guinea
Haiti
Ethiopia
Thailand
Zaire
Guatemala
Cote d'Ivoire
Morocco
Honduras
Madagascar
Health Expenditure Indicators
Public health expenditure.tf]DP
Low <-> High
2
3
4
J
Coverage Indicators
Fertility rate
High >-> lx>w
5
6
7
8
9
10
II
12
13
14
15
16
17
18
19
2(1
Zaire
Nigeria
Myanmar
Gabon
Cambodia
Indonesia
Georgia
Pakistan
Lao PDR
Burundi
Guinea
Comoros
Guatemala
Cameroon
Paraguay
Ethiopia
Guinea Bissau
Madagascar
Mauritania
Viet Nam
Total health expenditures/GDP
High •-> Low
Argentina
Croatia
Czech Republic
Costa Rica
Uruguay
Macedonia, FYR
Belize
Jordan
South Africa
Armenia
Nicaragua
Namibia
Azerbaijan
Panama
Colombia
Brazil
Hungary
( amhodia
Equatorial Guinea
Venezuela
Public expenditures > 70% of total
High >-> Lo\>h-
Hungary
Russian Federation
Mongolia
Cameroon
Macedonia, FYR
Croatia
Belarus
Poland
Equatorial Guinea
Czech Republic
Bulgaria
Comoros
Sri Lanka
Belize
Costa Rica
Panama
Algeria
Tonga
Private expenditui
ires > 70^ of total
High O Low
Cambodi a
Bermuda
Azerbaijan
India
Mauritania
Viet Nam
Pakistan
Paraguay
Uruguay
El Salvador
Nepal
Nigeria
Thailand
•1
4.
r
I
29
A
Table A.2 Regional Ranking of At-Risk Countries by HNP Indicators
J
(Maximum ten countries per region)
Ptrrtrty md HNP Outcome Indicators
Region
Low GNP per capita
High child mortality
High child malnutrition
High fertility
Cambodia
Mongolia
Lao PDR
Solomon Isl.
Kiribati
Indonesia
Philippines
W. Samoa
Papua New Guinea
Vanuatu
Cambodia
Lao PDR
Myanmar
Papua New Guinea
Indonesia
Kiribati
Mongolia
Philippines
Solomon Isl.
Vanuatu
Vietnam
Indonesia
Lao PDR
Cambodia
Myanmar
Papua New Guinea
Philippines
Malaysia
Solomon Isl.
Lao PDR
Solomon Isl.
Vanuatu
Papua New Guinea
Cambodia
Micronesia, FS
W. Samoa
Kiribati
Philippines
Myanmar
Europe and Central Asia
Tajikistan
Georgia
Azerbaijan
Albania
Kyrgyz Rep.
Armenia
Macedonia. FYR
Turkmenistan
Uzbekistan
Bulgaria
Turkmenistan
Turkey
Tajikistan
Uzbekistan
Kyrgyz Rep.
Albania
Kazakhstan
Macedonia. FYR
Azerbaijan
Romania
Turkey
Azerbaijan
Romania
Tajikistan
Turkmenistan
Uzbekistan
Kyrgyz Rep.
Turkey
Latin America & Caribbean
Haiti
Nicaragua
Guyana
Honduras
Bolivia
Suriname
Guatemala
Ecuador
Dominican Rep.
Jamaica
Haiti
Bolivia
Guyana
Peru
Nicaragua
Honduras
Guatemala
Brazil
Paraguay
Belize
Guatemala
Haiti
Guyana
Mexico
Honduras
Ecuador
Bolivia
Nicaragua
El Salvador
Peru
Guatemala
Honduras
Bolivia
Haiti
Nicaragua
Paraguay
Belize
El Salvador
Ecuador
Peru
Middle East & North Africa
Yemen
Egypt
Morocco
Syria
Jordan
Algeria
Tunisia
Lebanon
Oman
Iraq
Yemen
Egypt
Libya
Morocco
Iran
Tunisia
Algeria
Syria
Lebanon
Yemen
Iran
Oman
Iraq
Algeria
Jordan
Morocco
Egypt
Ixbanon
Tunisia
Yemen
Gaza
Oman
Saudi Arabia
Libya
Iraq
Syria
Jordan
Iran
Qatar
South Asia
Nepal
Bangladesh
India
Bhutan
Pakistan
Afghanistan
Bhutan
Nepal
Pakistan
Bangladesh
India
Maldives
Bangladesh
India
Nepal
Afghanistan
Pakistan
Maldives
Bhutan
Afghanistan
Maldives
Nepal
Pakistan
Bangladesh
India
Sri Lanka
Sri Lanka
Liberia
Sierra I>eone
Guinea-Bissau
Malawi
Guinea
Somalia
Gambia
Angola
Rwanda
Chad
Ethiopia
Mauritania
Mozambique
Niger
Eritrea
Somalia
Burundi
Angola
Nigeria
Sudan
East Asia
Sri Lanka
Maldives
Sub Saharan Africa
30
Mozambique
Ethiopia
Tanzania
Zaire
Burundi
Malawi
Chad
Rwanda
Sierra Ixonc
Niger
Niger
Ethiopia
Somalia
Angola
Mali
Burkina Faso
Uganda
Malawi
Liberia
Burundi
-
ReSi<‘,.
Hctdih Experuhtures Indicators
Coverage liulicaiors
East 4
Low immunization
Papua New Guinea
LaoPDR
Myanmar
Cambodia
Philippines
Mongolia
Low access to health services
♦
Georgia
Azerbaijan
Kazakhstan
Albania
Turkmenistan
Croatia
Czech Rep.
Macedonia, FYR
Armenia
Azerbaijan
Hungary
Bulgaria
Belarus
Poland
Guatemala
Paraguay
El Salvador
Haiti
Dominican Rep.
Ecuador
Uruguay
Venezuela
Chile
Peru
Argentina
Costa Rica
Uruguay
Belize
Nicaragua
Panama
Morocco
Iran
Oman
Yemen
Morocco
l>ebanon
Egypt
Oman
Turkey
Iran
Tunisia
Jordan
West Bank/Gaza
Pakistan
Nepal
Bangladesh
Pakistan
Pakistan
Bangladesh
Nepal
India
Sri lank a
Bhutan
Chad
Niger
Angola
Zaire
Central African J^ep.
Cote d’Ivoire
Sierra Leone
Nigeria
Eritrea
Mali
Central African Rep.
Cameroon
Angola
Ghana
Chad
Mozambique
Niger
Senegal
Benin
Guinea
Nigeria
Zaire
Gabon
Burundi
Comoros
Guinea
Cameroon
Eritrea
Ethiopia
Guinea-Bissau
"••tral Asia
Georgia
Latvia
Uzbekistan
Bosnia & Herzegovina
Russian Fed.
Yugoslavia, Fed. Rep.
Kazakhstan
Armenia
Kyrgyz Rep.
Armenia
1 4 Caribbean
Haiti
Venezuela
Argentina
Brazil
Paraguay
Guatemala
Ecuador
Trinidad & Tobago
Costa Rica
Nicaragua
Haiti
Guatemala
Honduras
Ecuador
Panama
Colombia
Yemen
Algeria
Egypt
Middle b.
' North Africa
South Asu
•uh-Saha.
' ’ ica
High total health expenditure/GDP
Myanmar
Cambodia
Indonesia
LaoPDR
Viet Nam
Philippines
Malaysia
Thailand
China
Korea, Rep.
Indonesia
Thailand
Malaysia
Europ.
Latin a
Low public expenditure/GDP
Brazil
Colombia
Venezuela
Chile
South Africa
Namibia
Equatorial Guinea
31
/VU7
/OO
library
0616£
S oj
s ^.\ DOCUMENTATION
J "J
Table A.4 HNP At A Glance: At-Risk Countries, by Region
EAST ASIA AND PACIFIC
I
'1
I
Indicators
Low- and
middle
income
average
Health Expenditures
Coverage
Poverty and HNP Outcomes
General Indicators
3
High
Low GNP High under- High child fertility rate
Largest
Regional
average population per capita 5 mortality malnutritio (Solomon
(China) (Cambodia) (Laos) n (Vietnam) Islands)
(EAP)
Low
immunization
(Papua
New
Guinea)
Low access Low public High total
to health expenditure expenditure
services % GDP % of GDP
(Indonesia) (Myanmar)
(')
Key economic indicators (1995)
GNP per capita (USS)
Gross domestic investments/GDP
I
Present value of debt/GDP
3
O
GDP
GNP per capita (1985-95)
270
15
69
350
2.1
0.3
10.3
8.9
12.9
11.4
6.4
6.5
3.2
8.3
980
35
51
9.3
6.0
7.6
6.0
32
39
56
55
23
31
67
1.6
33
1.2
28
52
16
30
46
38
1.1
26
2.8
44
25
40
22
41
30
3.0
45
35
45
21
38
36
2.0
37
21
17
12
30
16
31
3.0
43
2.3
39
43
40
34
63
32
1.6
33
65
13
60
88
214
68
6
40
53
179
69
4
35
43
164
53
35
109
158
334
53
16
92
147
410
67
8
41
49
171
63
57
12
65
95
355
64
18
52
75
235
59
13
84
119
280
19
11
6
52
4.3
18
17
52
23
13
1.6
14
64
16
58
44
5.7
-15
30
3.5
-26
930
57
2.7
-38
0.5
390
24
137
13
Child malnutrition
Access to safe water
1
Gini index
Population growth rate
J
2.2
5.7
Human development (mr 1985-95)
Secondary school enrollment
Urbanization
Population under 15, % of total
38
21
13
31
26
39
1.7
36
Health (1995)
Life expectancy at birth
J o
1
620
41
16
Average annual growth (1990-95)
'll
{
830
37
28
43
1,160
19
46
910
2,650
27
29
3
4 3
I 3
4
1
Percent change. 1980-95
Infant mortality rate
Under-five mortality rale
Adult mortality rate
Nutrition
Low birth weight (mr 1990-96)
Anemia (mr 1970-95)
Obesity (mr 1976-97)
0.7
Reproductive health (mr 1985-95)
Adolescent fertility rate
Total fertility rate
Percent change, 1980-95
4^
41
52
284
94
6.8
-23
64
3.1
-24
25
2.2
-29
17
1.9
-24
108
4.7
3
59
6.7
42
5.1
-39
350
190
1 15
900
660
105
66
0.6
29
56
0.1
33
38
0.0
34
106
1.9
105
0.0
28
75
0.1
39
54
124
0.2
37
99
0.1
29
85
1.5
2.4
1.4
80
76
2.2
1.2
2.4
1.6
2.1
0.1
2.5
0.2
2.8
0.2
89
75
65
4.0
0.1
96
35
0.7
0.2
43
89
0.6
0.1
88
3.8
0.4
97
93
5.6
2.8
62
151
3.5
1.5
21
111
3.8
1.8
19
98
7.2
0.7
18
2.6
0.8
10
5.2
1.1
5.6
Unwanted fertility rate
Maternal mortality ratio
I
.4
518
Future challenges (mr)
Smear+Tuberculosis incid. (per 100.000)
Adult HIV/AIDS prevalence (%)
Smoking prevalence (%)
Health services (mr 1990—95)
4
In patient beds per 1,000 pop.
Physicians per 1,000 pop.
Access to health services, %
Immunization coverage, measles,%
3
Health finance (mr 1990—95)
Total health expenditure/GDP
3
4
u
J
3
66
Public health expenditure/GDP
Total health expenditurc/cap (USS)
Total health cxpenditure/cap (PPP)
2.8
39
11 I
1.5
0.7
14
63
0.4
Note: * indicates no country within the Region fils the profile
33
i
:
i
EUROPE AND CENTRAL ASIA
■:
Low-and
middle\ income
average
Regional
average
(ECA)
serwpuouc
High under
High
Low
Low access expenditure High total
Largest Low GNP 5 mortality High child fertility rate amutpopulation per capita (Turtmen mainutritio (Uzbeknizatiai
(A^fbatj^ .^ofODP
(Russia)(Tajikistan) istan)
n (Turkey)
istan)
(Georgia)
(*)
/Z'mwtWmI
)I
(Cmatia)
Key economic indicators (1995)
GNP per capita <US$)
Gross domestic investments/GDP
Present value of debt/GDP
2,650
27
29
2,240
24
25
2,240
28
26
340
21
22
920
Average annual growth (1990-95)
GDP
GNP per capita
2.1
0.3
-6.5
-9.8
-10.2
-18.1
-20.3
-10.6
88
100
73
32
___ _
Human development (mr 1985-95)
Secondary school enrollment
Child malnutrition
Urbanization
Access to safe water
Gini index
Population growth rate
Population under 15, % of total
1.6
33
0.3
25
-0.1
21
1.6
43
Health (1995)
Life expectancy ^t birth
Percent change, 1980-95
Infant mortality rate
Under-five mortality rate
Adult mortality rate
65
13
60
88
214
68
1
26
35
203
65
-2
18
21
286
66
-3
42
61
199
30
50
Nutrition
Low birth weight (mr 1990-96)
Anemia (mr 1970-95)
Obesity (mr 1976-97)
32
39
56
86
3
65
8
45
85
2,780
24
40
970
31
6
440
3
37
480
16
4
32
1.5
-4.4
-6.4
-26.9
-25.1
-202
-21.0
61
10
69
94
4
41
1.6
33
46
65
186
68
11
49
63
135
56
64
82
2.1
41
-0.3
23
0.9
33
-0.0
19
30
48
155
73
4
18
21
133
70
3
25
31
161
74
5
16
18
127
8
7.8
Reproductive health (mr 1985—95)
Adolescent fertility rate
38
31
48
26
44
43
Total fertility rate
Percent change, 1980-95
Unwanted fertility rate
Maternal mortality ratio
64
3.1
-24
2.0
-20
1.4
-26
4.2
-26
3.8
-24
2.7
-37
3.7
-23
350
60
52
39
43
183
43
Future challenges (mr)
Smear+ Tuberculosis incid. (per 100,000)
Adult HIV/AIDS prevalence (%)
Smoking prevalence (%)
66
0.6
29
33
0.0
41
45
0.0
49
60
0.0
32
0.0
14
26
0.0
44
25
().()
Health services (mr 1990-95)
In-patient beds per 1,000 pop.
Physicians per 1,000 pop
Access to health services, %
Immunization cpverage, measles.%
2.4
1.4
80
76
9.2
3.1
11.7
3.8
8.8
2.1
10.5
3.2
80
91
90
90
2.5
1.1
100
75
Health finance (mr 1990-95)
Total health expenditure/GDP
Public health expenditure/GDP
Total health expenditure/cap (USS)
Total health expenditure/cap (PPP)
5.6
2.8
62
151
5.5
4.5
120
272
4.8
4.1
96
225
6.4
2.8
34
83
8
4.2
2.7
99
239
33
28
2.3
-28
1J
55
29
10
21
0.0
21
32
0.0
43
29
0.0
38
8.4
3.3
8.2
4.1
10.0
3.9
5.9
2.0
71
63
3.5
0.8
40
90
7.5
1.4
32
96
f
f
c
<
88
92
4.5
39
19
58
3250
14
17
e
10.1
85
302
t
>
ZE
3
LATIN AMERICA AND THE CARIBBEAN
______________________________________ ■
•
3
3
Health ExpeitdUures
Coverage
Poverty and HNP Outcomes
General Indicators
Low
immu
nization
(Haiti)
Indicators
Low- and
middle
income
awrage
High child
High
Low GNP High under- malnutritio fertility
Largest
Regional
rate
average papulation per capita 5 mortality nfGuatemal
(Honduras)
(Brazil)
(Haiti)
(Bolivia)
a)
(LAC)
Key economic indicators (1995)
GNP per capita (USS)
Gross domestic investments/GDP
Present value of debt/GDP
2.650
27
29
3,300
20
30
3.640
21
27
250
3
24
800
15
62
1,340
18
20
600
26
96
250
2.1
0.3
3.2
1.4
2.7
1.0
-6.5
-8.4
3.8
1.8
4.0
0.0
3.5
1.1
32
39
56
51
II
74
75
28
32
28
1.6
35
2.1
40
16
58
60
42
24
41
24
33
42
1.6
33
43
7
78
92
63
1.4
32
60
2.9
44
32
18
48
70
53
3.0
44
65
13
88
214
69
6
37
47
148
67
8
45
57
152
56
8
73
101
360
60
15
70
96
264
65
14
45
58
206
67
11
46
59
138
19
10
11
33
5.4
15
12
54
14
Low access Low public
to health expenditure High total
services % of GDP expenditure
(Guatemala (Guatemala % of GDP
)
)
(Argentina)
24
1,340
18
20
1.340
18
20
8.030
19
27
-6.5
4.0
4.0
5.7
-8.4
0.0
0.0
4.9
24
33
42
64
60
2.9
44
24
33
42
64
60
2.9
4-1
72
2
88
M
1.3
29
8
65
14
73
45
73
5
22
27
130
3
Average annual growth (1990-95)
3
3
3
O
GDP
GNP per capita
Human development (mr 1985-95)
Secondary school enrollment
Child malnutrition
Urbanization
Access to safe water
Giui index
Population growth rate
Population under 15, % of total
Health (1995)
Life expectancy at birth
Percent change. 1980-95
Infant mortality rate
Under-five mortality rate
Adult mortality rate
i
3
Nutrition
Ixiw birth weight (mr 1990-96)
Anemia (mr 1970-95)
Obesity (mr 1976-97)
60
Reproductive health (mr 1985-95)
Adolescent fertility rate
o
c
4
3
3
<
2.8
14
1.8
2.1
40
101
58
360
2(X>
65
14
45
58
206
15
14
14
2.8
2.8
6
26
7.0
56
57
37
70
82
106
112
70
106
1(K>
62
Total fertility rate
Percent change, 1980-95
Unwanted fertility rate
Maternal mortality ratio
64
3.1
-24
2.8
32
2.4
-38
4.7
-28
4.5
-24
4.8
-23
4.8
2.7
-17
170
200
4.6
-17
1.9
373
4.8
-23
350
4.5
-24
1.8
6(X)
464
220
6(X)
464
4<>4
1 (X)
Future challenges (mr)
Smear+Tuberculosis incid. (per 1(X),(XX))
Adult HIV/A1DS prevalence (%)
Smoking prevalence (%)
66
0.6
29
40
0.5
31
36
0.7
33
150
4.4
151
0.1
36
49
0.4
31
60
1.6
24
150
4.4
49
0.4
31
49
0.4
31
22
0.4
32
2.4
3.0
83
1.1
0.8
60
84
1.0
0.4
62
90
0.8
0.1
45
24
1.1
0.8
60
84
1.1
0.8
60
84
4.6
2.7
78
0.8
0.1
45
24
1.4
0.5
76
2.3
1.4
79
85
5.6
2.8
62
151
7.2
3.0
234
412
7.4
2.7
261
428
3.6
1.3
8
35
5.0
2.7
38
138
2.7
0.9
33
92
5.6
2.8
34
121
3.6
1.3
8
35
2.7
0.9
33
2.7
0.9
33
92
10.6
4.3
877
932
Health services (mr 1990-95)
In-patient beds per 1.000 pop.
Physicians per 1.000 pop.
Access to health services, %
Immunization coverage, measles.%
3
M
28
32
28
Health finance (mr 1990-95)
Total health expenditure/GDP
Public health expenditure/GDP
Total health expenditure/cap (USS)
Total health expenditure/cap (PPP)
1.4
80
1.8
76
5
35
<
4
t
e
4
e
Table A. 4 (continued^
MIDDLE EAST AND NORTH AFRIC A
~
Indicators
Low and
middle
income
average
Key economic indicators (1995)
GNP per capita (USS)
Gross domestic investments/GDP
Present value of debt/GDP
~~
Low GNP High
under High
child
---- o
~
.
Regional
■ -rate
average population per capita 5 mortality malnulnt to
(Iran)
(Yemen)
(Iraq)
n(O
man)
(MEM)
High
IjOW
fertility
inunu
nization
(Yemen)
(Gaza)
1.780
22
29
28
2.1
2.3
-0.2
4.2
1.2
32
39
56
59
16
57
79
66
17
59
89
44
30
34
52
61
12
75
45
14
13
56
95
1.6
33
2.5
41
2.7
44
3.2
48
2.1
44
5.5
AG
6.3
48
65
13
60
88
214
66
13
54
72
194
68
13
46
59
154
53
9
101
145
358
61
-1
111
145
162
70
20
18
22
167
31
51
125
19
II
12
19
15
18
10
54
68
80
141
61
123
5.5
-15
7.1
-29
310
24
Health Expenditures
Low access Low public High total
to health expenditure expenditure
services % of GDP % of GDP
(Morocco) (Yemen)
(Jordan)
1,510
31
103
260
14
108
1,110
15
65
260
14
108
4,820
260
14
108
2.650
27
29
Average annual growth (1990-95)
GDP
GNP per capita
Coverage
Poverty and HNP Outcomes
General Indicators
c
8.2
3.6
1.2
-0.8
6.0
-0.8
0.3
Human development (mr 1985-95)
Secondary school enrollment
Child malnutrition
Urbanization
Access to safe water
Gini index
Population growth rate
Population under 15, % of total
Health (1995)
Life expectancy at birth
Percent change, 1980-95
Infant mortality rate
Under-five mortality rate
Adult mortality rate
Nutrition
Low birth weight (mr 1990-96)
Anemia (mr 1970-95)
Obesity (mr 1976-97)
Reproductive health (mr 1985—95)
Adolescent fertility rate
Total fertility rate
Percent change. 1980-95
Unwanted fertility rate
Maternal mortality ratio
64
3.1
-24
4.2
-31
4.6
-26
350
280
120
7.4
-6
1.7
1470
Future challenges (mr)
Smear+ Tuberculosis incid. (per 100,000)
Adult HIV/AIDS prevalence (%)
Smoking prevalence (%)
66
0.6
29
30
0.0
26
23
0.0
43
0.0
67
0.0
Health services (mr 1990-95)
In -patient beds per 1,000 pop.
Physicians per 1.000 pop.
Access to health services, %
Immunization coverage, measles.%
2.4
1.4
80
76
1.7
1.0
87
86
1.4
0.8
0.1
1.7
0.2
98
95
5.6
2.8
62
151
4.4
2.7
176
199
4.8
2.8
467
239
Health finance (mr 1990-95)
Total health expenditure/GDP
Public health expenditure/GDP
Total health expenditure/cap (USS)
Total health expenditure/cap (PPP)
36
73
95
49
2.6
1.1
39
44
30
34
52
53
10
71
89
43
4.3
42
3.2
48
24
10
48
59
39
2.0
36
3.2
48
53
9
101
145
358
66
14
56
75
188
53
9
101
145
358
31
33
145
19
9
45
5
19
7
1 19
141
38
141
43
7.1
3
190
7.4
-6
1.7
1470
3.5
-36
1.4
372
7.4
-6
1.7
1470
4.8
-30
1.6
132
9
0.1
43
0.0
56
0.0
24
43
0.0
6
0.0
45
0.8
0.1
1.1
0.4
62
92
0.8
0.1
1.6
1.6
90
92
3.4
1.6
36
126
2.6
1.1
39
44
30
34
52
89
98
49
2.5
2.6
1.1
39
49
c
70
7.9
3.7
118
347
II
4
i
SOUTH ASIA
a
Indicators
!
Key economic indicators (1995)
GNP per capita (USS)
Gross domestic investments/GDP
Present value of debt/GDP
1
1
1
1
1
1
1
l
I
4
I
4
4
I
i
Low access
to health Low public High total
Low
High under High child
High
services expenditure expenditure
immu
Largest
Low
GNP
5
mortality
malnutritio
fertility
Largest
Regional
nization (Banglades % of GDP % GDP
n(Banglade
population
per
capita
(Afghan
nfBanglade
rale
average
h)
(Pakistan)
<*)
(fndta)
(Nepal)
istan)
sh)
(Maldives) (Pakistan)
(SAS)
27
340
23
25
200
23
28
240
15
33
2.1
0.3
4.6
2.6
4.6
2.8
5.1
2.6
4.1
2.6
21
49
14
48
30
2.5
42
2.650
27
29
350
23
Average annual growth (1990-95)
GDP
GNP per capita
1
8
Ljow- and
middle
income
average
1/
>
■r
Human development (mr 1985-95)
Secondary school enrollment
Child malnutrition
Urbanization
Access to sate water
Gini index
Population growth rate
Population under 15, % ot total
32
39
56
52
26
63
1.6
33
1.8
37
53
27
63
34
1.7
35
Health (1995)
Life expectancy at birth
Percent change, 1980-95
Infant mortality rale
Under-live mortality rate
Adult mortality rate
65
13
60
88
214
61
15
75
106
235
62
17
69
95
224
19
33
3.3
88
0.5
65
Nutrition
Low birth weight (mr 1990 96)
Anemia (mr 1970-95)
Obesity (mr 1976-97)
Reproductive health (mr 198S—95)
Adolescent fertility rate
Health Expeathiures
Coverage
Poverty and HNP Outcomes
General Indicators
990
3.9
460
20
40
240
15
33
460
20
40
4.6
1.0
4.1
2.6
4.6
1.0
19
68
18
83
28
1.6
43
40
35
60
31
2.9
43
2.8
44
19
68
18
83
28
1.6
43
3.2
45
40
35
60
31
2.9
43
56
19
92
131
340
45
11
159
237
420
58
22
80
115
303
63
15
53
70
235
63
15
91
127
218
58
22
80
115
303
63
15
91
127
218
26
20
34
53
0.3
20
25
37
34
53
0.3
25
37
40
20
39
33
93
81
82
153
116
76
107
116
107
Total fertility rate
Percent change. 1980-95
Unwanted fertility rate
Maternal mortality ratio
64
3.1
-24
3.5
-34
5.3
-17
6.9
480
515
1,700
3.5
-43
1.3
887
6.7
-4
5.3
-24
1.2
34Q
3.5
-43
1.3
887
5.3
-24
1.2
340
350
3.2
-35
0.8
437
Future challenges (mr)
Smear+Tuberculosis incid. (per 100.000)
Adult HIV/AIDS prevalence
Smoking prevalence
66
0.6
29
108
0.3
99
0.4
75
0.1
125
0.0
54
0.1
23
22
99
0.0
38
67
0.1
16
99
0.0
38
67
0.1
16
Health services (mr 1990-95)
In-patient beds per 1,000 pop.
Physicians per 1,000 pop.
Access to health services, %
Immunization coverage, measles.%
2.4
1.4
80
76
0.7
0.3
77
73
0.8
0.2
0.1
0.2
0.1
0.8
0.1
84
78
19
0.3
0.2
74
96
0.7
0.5
85
53
0.3
0.2
74
96
0.7
0.5
85
53
Health finance (mr 1990-95)
Total health expenditure/GDP
Public health expenditure/GDP
Total health expenditure/cap (USS)
Total health expenditure/cap (PPP)
5.6
2.8
62
151
4.1
0.8
16
72
5.6
1.2
1 I
44
5.0
1.2
10
60
2.4
1.2
6
35
4.9
3.5
0.8
13
70
2.4
1.2
6
35
3.5
0.8
1.3
70
86
37
5
i
Table A.4 (continued^
I
SUB-SAHARAN AFRICA
General Indicators
Indicators
Key economic indicators (1995)
GNP per capita (USS)
Gross domestic investments/GDP
Present value of debt/GDP
2,650
27
29
490
20
56
260
20
106
80
58
281
1(X)
16
60
Average annual growth (1990-95)
GDP
GNP per capita
2.1
0.3
1.4
-1.2
1.6
1.1
7.1
4.1
1.0
47
34
28
20
45
48
13
27
2.9
44
2.4
45
2.7
47
Human development (mr 1985-95)
Secondary school enrollment
Child malnutrition
Urbanization
Access to safe water
Gini index
Population growth rate
Population under 15, % of total
32
39
56
24
30
31
51
1.6
33
2.7
45
35
39
43
38
2.9
45
Health (1995)
Life expectancy at birth
Percent change, 1980-95
Infant mortality rate
Under-five mortality rate
Adult mortality rate
65
13
60
88
214
51
8
92
157
397
53
15
81
176
414
47
4
114
190
385
46
-12
177
239
225
49
16
113
188
397
19
16
16
55
20
58
78
Nutrition
Low birth weight (mr 1990 96)
Anemia (mr 1970-95)
Obesity (mr 1976-97)
l!
Low and
middle
income
average
Low GNP
Largest per capita High under High child
Regional
average population (Mozam 5 mortality malnutrilio
(Liberia) n(Ethiopia)
(Nigeria)
hique)
(SSA)
Reproductive health (mr 1985-95)
Adolescent fertility rate
Health Expenditures
Coverage
Poverty and HNP Outcomes
High
fertility
rate
(Niger)
Low
immu
nization
(Chad)
220
180
52
0.5
-2.6
43
23
57
36
3.3
48
Low access Low public High total
to health expenditure expenditure
services % of GDP % of GDP
(CAR)
(Nigeria) (S. Africa)
260
20
106
3.160
17
38
340
13
45
1.9
-0.1
1.0
-2.2
1.6
1.1
0.6
-1.1
23
39
35
39
43
38
2.9
9
51
21
29
59
2.2
37
2.5
43
2.2
43
456
49
14
118
197
428
49
6
98
160
456
53
15
81
176
414
16
42
15
41
37
15
67
4.8
16
55
37
47
14
120
64
12
51
67
150
120
122
211
164
222
183
145
120
68
Total fertility rate
Percent change, 1980 95
Unwanted fertility rate
Maternal mortality ratio
64
3.1
-24
5.7
-15
6.2
6.6
7.0
8
1.510
0.6
560
1.530
1.590
5.1
-12
0.4
650
5.5
-18
1.0
1.000
3.9
-20
870
7.4
0
0.3
593
5.9
0
350
5.5
-18
1.0
1.0(X)
404
Future challenges (mr)
Smear+Tuberculosis incid. (per 100.000)
Adult HIV/AIDS prevalence (%)
Smoking prevalence (%)
66
0.6
29
100
4.3
100
22
16
85
5.8
45
1.3
70
2.5
65
1.0
75
2.7
63
5.8
100
2.2
16
112
3.2
35
Health services (mr 1990-95)
In-patient beds per 1.000 pop.
Physicians per 1,000 pop.
Access to health services. %
Immunization coverage, measles.'Z'c
2.4
1.4
80
76
1.2
0.1
53
53
1.7
0.9
0.7
0.9
0.0
13
70
1.7
Health finance (mr 1990-95)
Total health expenditure/GDP
Public health expenditure/GDP
Total health expenditure/cap (USS)
Total health expenditure/cap (PPP)
5.6
2.8
62
151
5.6
2.5
42
94
1.4
0.3
5
18
Note: .. indicates data not available
38
67
50
0.2
30
71
55
54
0.0
30
38
4.6
1.1
1.6
26
24
2.5
9
29
1.9
67
50
76
1.4
0.3
5
18
7.9
3.6
233
396
lx!
S'
___________
■ .'64^
f A
3
Table A.5 HNP At A Glance: At-Risk Countries Amoung High-Income Countries
HIGH-INCOME COUNTRIES
3
•3
3
3
Indicators
Key economic indicators (1995)
GNP per capita (USS)
Gross domestic investments/GDP
Present value of debt/GDP
3
Average annual growth (1990-95)
3
GDP
GNP per capita
3
3
J
Low and
middle
income
average
Coverage
Poverty and HNP Outcomes
(ieneral indicators
Regional
Ixirgest Low GNP High under High child
average
population per capita 5 mortality malnutritio
(high
income)
(USA)
(Portugal) (Qatar)
n(^)
Health Expenditures
High
fertility
rate
(UAE)
Low
immu
nization
(Italy)
Low access Low public High total
to health expenditure expenditure
services % of GDP % of GDP
(*)
(Singapore) (USA)
2,650
27
29
24,370
21
26,980
9.740
11,600
17.400
25.3
19.020
17.4
26.730
34.9
26,980
2.1
0.3
2.0
1.2
2.6
1.5
0.8
0.7
-5.1
-4.8
1.0
0.7
8.7
6.4
2.6
1.5
97
97
81
89
7
84
95
81
78
97
6
91
67
100
100
75
Human development (1985-95)
Secondary school enrollment
Chik! malnutrition
Urbanization
Access to sale water
Gini index
Population growth rate
Population under 15. % of total
32
39
56
78
94
76
90
36
1.6
33
0.4
19
1.0
22
0.1
19
5.8
30
5.0
29
0.2
15
1.9
24
1.0
22
Health (1995)
Life expectancy al birth
Percent change. 1980-95
Infant mortality rate
Under-five mortality rate
Adult mortality rate
65
13
60
88
214
77
5
7
9
97
77
4
8
10
123
75
6
7
11
120
72
8
19
22
140
75
10
16
19
110
78
5
7
8
91
77
7
4
6
103
77
4
8
10
123
19
6
7
5
7
7
lX)
Nutrition
Low birth weight (mr 1990-96)
Anemia (mr 1970-95)
Obesity (mr 1976-97)
4<)
Reproductive health (mr 1985—95)
Adolescent fertility rate
Total fertility rate
Percent change, 1980-95
Unwanted fertility rale
Maternal mortality ratio
64
3.1
-24
26
1.7
-11
60
2.1
+ 17
23
1.4
-36
350
14
12
15
Future challenges (mr)
Smear+ Tuberculosis incid. (per 100.000)
Adult HIV/AIDS prevalence (%)
Smoking prevalence (%)
66
0.6
29
9
0.3
30
4
0.5
25
27
0.2
27
Health services (1990-95)
In-patient beds per 1.000 pop.
Physicians per 1,000 pop
Access to health services. %
Immunization coverage, measles.%
2.4
1.4
80
76
7.6
2.4
4.4
2.5
83
89
4.3
2.9
100
94
Health finance (mr 1990-95)
Total health expenditure/GDP
Public health expenditure/GDP
Total health expenditure/cap (USS)
Total health expenditure/cap (PPP)
5.6
2.8
62
151
9.9
6.1
2.329
2.243
14.5
7.0
3.828
3.828
8.1
4.5
287
1.058
40
3.9
-33
23
1.5
87
2.8
343
511
58
3.6
-33
14
1.2
-25
13
1.7
0
M)
2.1
+ 17
33
12
10
12
13
0.0
11
0.3
38
37
0.1
17
4
0.5
25
3.1
0.8
90
90
6.7
1.7
4.4
2.5
50
3.6
1.4
100
88
2.2
1.9
379
378
7.7
5.4
1.471
1.605
3.5
1.1
621
823
14.5
7.0
3.828
3,873
89
Note: .. indicates data not available.
* indicates no country within the Region fits the profile.
39
Table A.6 HNP At A Glance: Indicators by Country
Key Economic Indicators Average A nnual Growth
Country
Afghanistan
Albania
Algeria
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas. The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt. Arab Republic
El Salvador
Equatorial Guinea
GNP/cap.
1995
(USS)
670
1600
410
Central
gov. exp.
1994-95
(USS
millions)
752
8030
730
18720
26890
480
11940
7840
240
6560
2070
24710
96366
80198
3020
3640
25160
1330
230
160
270
650
19380
960
146
1417
537
340
180
4160
620
1910
470
680
2610
660
3250
3870
29890
2990
1460
1390
790
1610
380
-2.3
-6.6
5.7
-21.2
4.9
-20.7
3.5
1.9
-20.2
4.1
2.6
1.1
-21.0
-1.9
3.8
2.6
-1.0
-9.9
1.1
0.9
1.6
3.8
1.8
1.8
4.2
2.7
2.6
I0
-4.3
2.6
-2.3
6.4
-1.8
1.8
-2.4
-0.4
-4.9
4.1
114776
180
12954
51052
2626
GNP/cap.
1990-95
(percent)
1.4
0.1
-4.1
1580
370
420
800
GDP
1990-95
(percent)
-9.3
1.1
-4.6
0.5
3.9
1.0
1.9
-2.2
-0.1
7.3
12.8
4.6
6.3
11.4
3.2
-1.7
-0.6
5.1
0.7
3.0
-2.5
8403
2418
18801
74968
1786
2604
1180
-2.6
2.0
3.9
3.4
1.3
6.3
1.8
2.2
3.0
0.9
-0.1
4.6
4.1
Human Development
Gross sec.
school
Child
Population enrollment malnutrition Urbanizatio Access to
Population growth rate mr
1985-95 mr 1985-95
------------------n
safe water Gini index
1995
1995
1995
(% ofage (% ofunder mr 1985-95 mr 1985-95 mr 1985—95
(millions)
(millions) (percent)
group) 5 age group) (% ofpop.) (percent)
(percent)
(percent)
23.5
3.3
28.0
10.8
2.8
0.0
2.2
3.1
0.1
34.7
3.8
0.1
18.1
8.1
7.5
0.3
0.6
119.8
03
10.3
10.1
0.2
5.5
0.1
0.7
7.4
4.4
1.5
159.2
0.3
8.4
10.4
6.3
10.0
13.3
29.6
0.4
0.4
1.3
1.0
0.9
1.1
0.7
0.9
1.6
3.2
1.6
0.8
0.2
0.4
2.6
2.9
0.8
3.3
6.4
0.1
14.2
1203.3
36.8
0.5
2.6
3.4
14.0
4.8
11.0
0.7
10.3
5.2
0.6
0.1
7.8
11.5
57.8
5.6
0.4
2.4
0.0
2.4
1.4
1.9
-0.7
2.8
2.6
2.8
2.9
1.3
2.2
2.2
2.5
-0.1
1.5
1.1
1.8
2.9
2.9
2.4
3.0
0.0
0.6
1.4
0.1
0.3
4.9
0.3
1.9
2.2
1.9
2.3
2.8
15
40
61
14
10
35
20
37
56
32
35
88
69
2
85
84
107
88
91
99
19
10
7
68
6
92
38
6
24
38
16
19
43
71
72
8
7
29
88
8
27
7
33
38
38
15
19
23
9
70
52
62
19
1
16
8
24
2
24
47
25
83
77
95
86
114
12
23
37
55
76
29
10
17
9
11
8
1
38.7
32
85
56
56
87
90
18
48
71
97
47
42
58
49
31
78
59
71
27
8
21
45
77
54
39
21
29
86
30
73
28
59
50
44
64
76
54
65
85
83
65
58
45
45
42
C
M
28.3
21.6
*
70
60
42.0
70
92
63.4
30.8
58
13
41
100
A
29
*
96
46
96
60
1(X)
56.5
41.5
51.3
46.1
36.9
82
96
►
94
100
26.6
►
79
70
84
62
50.5
46.6
32.0
4
4
40
*
Human Development
CNP/aip1995
(US$)
Central
gov. exp.
1994-95
(USS
millions)
2860
100
2440
20580
24990
738
1402
570
42692
713215
GDP
1990-95
(percent)
GNP/cap.>.
1990-95
(percent)
Country
Eritrea
Estonia
Ethiopia
1
Fiji
Finland
France
French Guiana
French Polynesia
1
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Greece
Grenada
Guadeloupe
0
Guam
Guatemala
‘ '.i
J
Guinea
Guinea-Bissau
*
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea. Dem. RepKorea. RepKuwait
Kyrgyz Republic
I aW PDR
Latvia
Lebanon
Lesotho
Liberia
Libya
Lithuania
Luxembourg
Macao
Macedonia, FYR
Madagascar
Malawi
Malaysia
l:
3490
320
440
27510
390
8210
2980
1340
550
250
590
250
600
22990
4120
24950
340
980
-92
1.0
1.2
-0.5
t.O
03
-23
1.6
-7.9
-4.7
-26.9
-25.1
816395
4.3
1.1
1.4
0.8
78
1156
4.0
3.8
3.5
0.0
2.0
0.4
10.9
-84
Cross sec.
Child
school
malnutrition Urbamzatio Access to Gini index
safe
water mr 1985-95
Population enrollment ^1985
'95
^-95 m!
1985-95
1985-95
mr 1985-95
Population
of under- mr
(<*>ofage (%
T^group) (Kofpop) (percent)
(perCen,)
1995
group)
(millions) (percent)
VI
41
14
393
2.6
3.6
73
92
-1.3
27
13
13
48
11
2.7
56.4
41
8
64
1.1
100
0.8
63
119
0.5
100
5.1
73
106
0.4
58.1
0.2
Li
1.1
0.9
54
81.9
17.1
103
0.1
04
0.1
10.6
6.6
2.7
23
3.6
6.3
-0.3
0.6
2.7
0.5
77
19
101
1.5
2.3
2.9
2.7
2.1
1.1
1.0
0.8
2.1
7.2
-63
3.0
5.9
1.1
3.5
1.8
6.2
3.9
5.6
-0.3
10.2
-1.3
-1.0
1.0
0.3
-0.2
2044
1.7
929
4
2.8
4.6
53659
1.6
193.3
6.0
7.6
28647
2.7
64.1
1.1
4.2
18470
2.1
20.1
0.4
3.6
4.1
4.7
2.7
14710
5.5
3.2
6.4
41178
0.2
15920
57.2
0.7
1.0
507926
1.0
19020
2.5
3.4
2.9
0.3
1510
125.2
0.8
1.0
4.3
39640
4.2
3.6
8.2
1875
-0.4
1510
16.6
-11.8
-11.9
2.6
1330
26.7
-1.3
1.4
2034
1.9
280
0.1
-0.4
1.8
920
23.9
0.9
44.9
6.1
7.2
80801
5.0
9700
1.7
13.7
12.2
13704
0.3
17390
4.5
-15.1
-14.7
3.0
7CX)
4.9
3.2
6.5
-1.4
350
23
-133
-13.7
1433
1.9
2270
4.0
3202
2.1
2660
2.0
1.9
73
2.4
770
2.7
33
54
-0.2
3.7
-9.7
-9.7
1520
1.4
1900
04
-3.1
6217
3.4
44210
0.5
1.0
2.1
3.1
860
13.7
-2.8
0.1
549
2.7
230
9.8
-2.2
0.7
2.4
170
20.1
5.9
8.7
19605
3890
27
51
38
42
30
22
36
32
48
95
65
92
27
34
59
75
58
33
24
23
27
28
18
24
12
6
57
32
81
103
53
40
16
12
43
66
44
105
87
81
66
67
61
50
26
95
58
87
36
65
15
17
56
33.9
64
49
57
59.6
46.8
56.2
28
70
52.7
27.0
33.8
31.7
63
63
89
45
99
67
55
78
71
60
28
10
3
10
1
23
53
90
25
93
6
25
87
76
26
97
78
54
18
4
59
40
9
21
20
5
32
28
23
61
81
97
39
22
73
87
23
45
86
72
89
99
60
27
14
54
41.1
70
95
89
43.4
32.7
57.5
49
89
75
41
57
30.4
27.0
56.0
30
33.6
32
54
90
43.4
48.4
41
I
Table A.6 (continued)
Human Dtvekrpatenl
Key Economic Indicators Average Annual Growth
Country
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Fed. Sts.
Moldova
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Kitts and Nevis
St. Lucia
St. Vincent & the Grenadines
42
GNP/cap.
1995
(US$)
990
250
460
3380
3320
2010
310
Central
gov. exp.
1994-95
(USS
millions)
2.5
3.9
-0.7
39
31
1.0
0.4
23
1.1
LI
2.5
1.4
15
59
48
15
918
0.1
4.3
2.5
0.0
26.6
162
45.1
1.5
21.5
15.5
02
02
3.6
4.4
9.0
111.3
4.4
22
129.9
2.6
4.3
4.8
23.8
68.6
38.6
9.9
3.7
0.6
0.7
22.7
148.2
6.4
0.1
19.0
8.5
0.1
4.2
3.0
5.4
2.0
0.4
9.5
41.5
39.2
18.1
0.0
0.2
0.1
1.9
2.2
-0.1
2.1
0.4
20
2.9
1.7
2.7
2.5
0.6
1.1
1.9
1.4
58
19
69
82
12
3.2
1064
915
4.0
4.9
1.5
3.4
63405
1.1
-1.2
206
739
201161
366
20605
627
50726
5124
13684
1970
1612
10917
51134
36990
-3.3
-5.9
12
7.1
5.7
3.8
5.1
1.8
-0.8
4.1
3.6
1.1
0.5
1.6
3.5
6.0
4.6
6.3
9.3
3.1
5.3
2.3
2.4
0.8
3.0
2.3
-1.7
-2.6
1.1
32
-0.8
1.0
4.6
6.0
0.0
3.7
0.5
2.9
0.7
0.8
2.6
1.3
-5.1
11600
1480
2240
180
350
6810
600
6620
180
26730
8200
2950
910
9607
85762
3160
13580
700
5170
3370
2280
40554
-1.4
-9.8
-12.8
1.7
1.9
269
179
-4.2
8.7
-2.8
-1.2
-102
-10.3
-1.5
-2.4
-0.7
2.6
6.4
-3.2
2.2
3649
65
82
0.6
1.1
4.8
-1.1
0.7
3.7
3.1
3.1
33
27
89
49
9
88
0.3
9.8
0.4
8034
14340
380
220
260
31250
4820
460
2750
1160
1690
2310
1050
2790
9740
GNP/cap.
1990-95
(percent)
117
1110
80
2000
200
24000
GDP
1990-95
(percent)
Gross sec.
school
Child
enrollment
malnutrition Urbanizafio Access to
Population
mr
1985-95
mr
1985-95
n
safe water Gini index
Population growth rate
(% of age (% of under- mr 1985-95 mr 1985-95 mr-1985-95
7995
1995
(percent)
group) 5 age group) (%
(%of
ofpop.) (percent)
(percent)
(~
(percent)
(millions)
2.9
3.1
3.3
2.9
0.5
5.5
2.9
1.6
2.3
2.7
2.0
2.2
0.2
0.1
LI
5.8
1.7
-0.5
-0.1
-2.8
2.5
3.8
2.6
1.6
0.8
1.9
0.4
-0.1
3.0
4.1
2.2
0.2
1.2
-0.5
0.9
0.7
35
7
55
21
93
104
41
7
29
116
61
64
12
37
65
79
79
78
54
41
10
47
31
26
49
12
43
35
14
40
7
30
4
11
30
83
6
82
88
10
6
3
29
17
29
II
104
84
89
85
17
77
113
74
103
20
6
29
14
21
39
9
38
75
28
52
61
14
48
34
26
37
14
89
70
62
86
63
23
39
73
13
35
55
16
53
72
54
65
36
73
91
68
55
73
6
47
80
42
65
36
100
59
64
17
26
51
76
22
46
46
47
44
72
100
42.4
87
50.3
34.4
54
59
28
39
57
48
1(X)
39-2
57
57
43
100
56
60
82
31
50.3
36.1
37.5
60
84
44.9 ■
40.7
27.2
36.7
312
56.6
25.5
49.6
28.9
9
54.1
1CX)
19.5
28.2
58.4
99
57
30.1
*
4
Human Development
Key Economic Indicators Average Annual Growth
Country
*
Sudan
Suriname
Swaziland
Sweden
4,
1
•)
3
4
4
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Isl.
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (UK)
Virgin Islands (US)
West Bank
West Bank/Gaza Strip
Western Samoa
Yemen. Rep.
Yugoslavia. Fed. Republic
Zaire
Zambia
Zimbabwe
GNP/cap.
1995
(USS)
880
1170
23750
40630
1120
12790
340
120
2740
310
1630
3770
1820
2780
920
Central
gov. exp.
1994 95
(USS
millions)
102898
11759
26450
37518
240
1630
17400
18700
26980
5170
970
1200
3020
4277
462387
1590000
5576
10976
GDP
1990-95
(percent)
GNP/cap.
1990-95
(percent)
6.8
2.4
-0.1
0.1
7.4
0.3
-1.4
-0.9
-0.9
4.3
-18.1
3.2
8.4
-3.4
1.0
3.9
3.2
-10.6
-20.3
0.4
7.1
-5.0
-0.3
0.0
1.5
1.5
6.6
-14.3
1.5
3.4
1.4
2.6
4.0
-4.4
-14-.4
1.3
2.4
8.3
1.5
3.9
-6.4
0.2
0.2
1120
260
120
400
540
468
691
-0.2
1.0
-13.4
-2.0
Gross sec.
school
Child
Population enrollment malnutrition Urbanizalio Access to
n
mfr waJer Gini index
Population growth rate mr 1985-95 mr 1985—95
(%of age (%cf under mr 1985-95 mr 1985-95 mr 1985-95
1995
1995
(percent)
group) 5 age group) (% ofpop.) (percent)
(millions) (percent)
26.7
0.4
0.9
8.8
7.0
14.1
21.1
5.8
29.6
58.2
4.1
0.1
1.3
9.0
61.1
4.5
2.1
0.4
2.5
0.6
0.9
3.0
0.8
1.6
3.0
0.9
2.9
3.1
0.8
1.8
1.6
4.5
19.2
51.6
2.5
58.5
263.1
3.2
22.8
02
21.7
73.5
3.2
-0.2
5.0
0.3
1.0
0.6
2.1
2.7
2J
2.0
0.1
1.2
-0.5
4.9
0.2
15.3
10.5
43.8
9.0
11.0
0.6
3.2
0.1
3.2
2.9
2.4
20
35
51
99
91
47
34
10
KX)
37
27
29
13
25
76
52
61
9
10
13
80
89
92
97
81
94
20
35
35
7
25
50
31
83
61
52
32
24
20
31
41
67
57
69
45
77
100
87
49
81
67
82
86
92
85
38.1
46.2
40.2
35.8
42
97
98
100
90
34
40.8
25.7
4
4
13
70
84
89
76
90
41
5
45
93
21
88
38
53.8
35.7
26
7
49
30
65
24
45
34
29
16
21
34
57
29
43
32
52
25
47
74
46:2
56.8
0
0
4
43
Table A.6 (continued)
NuiriiioM IruUcaiors
HeaUh Lntfcalors
Country
Afghanistan
Albania
Algeria
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas. The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina J-’aso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt, Arab Republic
El Salvador
Equatorial Guinea
44
Life expectancy % change in
life expectancy
at birth
1980-95
J995
(percent)
(yean)
45
73
69
47
75
73
71
11
-5
18
13
5
-2
Infant
mortality rate
1995
(per 1,000
live births)
Under-5
mortality rale
1995
(per 1.000
live births)
Adult
mortality rate
Anemia
Low birth weight
1995
mr 1985-95
1985-95
(per 1,000
(% ofpregnant
mr 1985-95
adults,
women)
(percent)
age 15-40)
159
31
34
124
’ 237
37
42
209
420
94
155
450
20
7
9
19
42
29
19
22
16
23
27
24
104
130
158
6
26
8
7
31
18
23
115
12
20
10
4Z>
156
85
106
161
119
139
303
101
200
101
147
436
34
10
65
41
Obesity
mr 1985-95
(% ofchildren
or adults)
*
77
77
70
73
73
58
76
70
77
74
50
4
6
3
8
7
19
5
-1
5
7
6
6
25
15
19
80
13
13
8
37
96
60
16
70
175
96
264
12
81
54
52
67
75
71
46
46
53
57
78
66
-10
7
6
0
5
-2
36
14
5
9
56
45
9
15
100
99
109
57
6
47
74
57
11
19
164
162
158
86
8
68
183
152
113
159
383
442
334
377
95
220
8
11
33
5.4a
24
68
1.2a
49
48
78
75
69
70
56
51
77
54
74
76
78
73
75
50
73
70
70
65
69
49
6
14
98
118
7
12
35
26
89
90
13
86
16
9
8
8
6
109
17
38
37
57
37
112
160
197
9
15
43
31
143
144
16
138
18
10
11
10
7
181
21
44
45
76
42
185
456
428
89
119
143
166
320
359
92
363
127
1(X)
88
139
119
412
121
128
145
258
192
433
8
6
11
3
6
7
5
3
4
4
1
13
10
10
17
20
14
6
12
53
29
0.3a
5
6
6
21
13
»
p
44
6
15
67
37
4.8a
7
6
17
13
52
24
6.6a
4.3a
3.4b
16
28
14
8
7
6
5
47
23
40
28
14
12
8
17
24
9.5b
I
'i
4
a
'4
•4
Country
4
4
4
si
4
5
5
I
Nutrition IntEcators
Health Indicators
-4
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Greece
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran. Islamic Republic
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea. Dem. Rep.
Korea. Rep.
Kuwait
Kyrgyz Republic
I^io PDR
l^tvia
Lebanon
Lesotho
Liberia
Libya
Lithuania
ILuxembourg
Macao
Macedonia, FYR
Madagascar
Malawi
Life ejtpeclancy % change in
life expectancy
at birth
1980-95
1995
(percent)
(years)
50
70
49
72
76
78
13
2
19
6
5
5
70
54
46
13
15
73
76
59
78
3
5
12
5
75
73
65
45
43
64
56
67
79
70
79
62
64
68
61
76
77
78
74
80
70
69
59
58
70
72
76
68
52
69
69
58
45
65
69
76
77
73
58
44
6
13
12
13
5
8
11
6
0
3
15
17
14
5
6
5
5
5
3
7
5
8
8
3
17
-1
6
10
-11
13
-2
5
17
14
-1
Infant
mortality rate
1995
(per 1.000
live births)
Under 5
mortality rate
1995
(per LOGO
live births)
Adult
mortality rate
Anemia
Low birth weight
1995
mr1985-95
1985-95
(per 1.000
mr 1985-95 (% ofpregnant
adults,
women)
(percent)
age 15-60)
132
14
113
21
5
6
196
16
188
25
5
9
385
189
397
133
107
107
17
90
127
31
18
6
74
8
24
145
213
51
21
7
116
10
32
14
12
58
220
233
82
101
59
6
14
6
95
75
59
145
7
9
8
15
6
33
35
90
75
32
14
14
42
147
20
40
121
239
75
19
9
9
31
127
225
185
354
465
125
133
108
287
87
11
9
45
129
137
61
73
46
5
11
4
69
52
46
111
6
8
7
13
4
31
27
59
56
27
10
11
30
92
16
32
77
177
62
14
6
7
23
90
133
112
139
206
498
578
200
360
138
83
234
80
224
233
154
162
99
85
91
117
74
145
208
329
159
163
97
198
410
215
163
302
225
190
201
108
118
415
520
Obesity
mr 1985-95
(% of children
or adults)
42
16
5
10
10
80
17
9
3.2b
14
21
20
2.8a
74
71
2.3a
14
1.8a
33
14
12
15
4
88
64
0.5b
11
6
7
40
15
9
16
18
11
35
15.0a
2.4b
4
40
0.7b
18
11
7
78
5
10
20
55
!
45
1
—I-
I
e
I'
I
I
Malaysia
71
7
12
14
8
56
Table A.6 (continued)
Health huiiaiton
Country
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Fed.Sts.
Moldova
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Kitts and Nevis
Life expectancy
at birth
1995
(years)
% change in
life expectancy
1980-95
(percent)
Infant
mortality rate
1995
(per 1.000
live births)
Nutrition Indkaton
Under-5
mortality rate
1995
(per 1,000
live births)
Adult
mortality rate
Low birth weight
Anemia
1995
(per 1,000
1985-95
mr J985-95
adults,
mr 1985-95
(% ofpregnant
age 15-60)
(percent)
women)
63
49
77
14
18
5
53
124
9
70
192
11
235
369
95
77
53
71
5
13
8
8
97
16
12
158
20
100
432
169
71
7
33
33
5
13
22
56
41
40
26
74
31
75
190
119
78
131
8
14
19
9
61
125
265
202
201
122
18S
385
280
330
340
88
88
125
104
153
455
414
89
167
218
113
355
133
184
222
136
120
104
139
131
195
322
502
117
165
529
147
529
103
157
134
284
356
M
69
65
73
66
46
59
56
56
78
77
73
76
67
47
52
78
70
63
74
57
69
66
66
72
75
76
72
74
70
65
38
69
70
50
72
36
76
72
74
62
48
64
77
73
69
14
6
13
6
17
3
8
12
4
15
12
14
3
19
14
5
12
3
13
8
1
5
3
8
8
0
-3
-16
15
11
2
1
2
5
13
13
2
7
25
56
114
84
62
92
6
11
16
7
47
120
81
5
18
91
23
65
41
48
40
14
7
11
19
8
23
18
135
61
21
63
15
182
4
II
7
41
129
51
7
16
31
176
8
22
127
28
95
52
62
53
16
11
15
22
10
29
21
200
78
31
97
19
236
6
15
8
52
218
67
9
19
38
Obesity
mr 1985-95
(% of children
or adults)
17
20
58
0_5a
11
8
29
5.6b
12
14
10
50
45
9
20
16
12
26
45
58
58
16
65
*
6
15
15
16
5
10
25
23
5
11
8
5
5.2a
36
41
55
54
37
13
29
53
48
16
1.6a
9.0b
0.9*
31
30
17
11
26
3.7b
17
7
6
6
16
78
37
17
39
W
140
169
0.1a
i.
46
I
1
5
5
17
71
72
St. Lucia
St. Vincent & the Grenadines
19
21
22
163
140
Nutrition Indicalors
Health fruiicatorz
Country
5
0
J
a
Life expectancy % change in
life expectancy
at birth
1980-95
1995
(percent)
(years)
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Isl.
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (UK)
Virgin Islands (US)
West Bank
West Bank/Gaza Strip
Western Samoa
Yemen. Rep.
Yugoslavia, Fed. Republic
Zaire
for adult6, Data for children.
Zimbabwe
53
70
59
79
79
68
76
66
51
69
51
69
72
69
68
11
7
15
4
4
11
4
0
2
9
3
44
69
75
77
77
73
-9
-1
10
4
4
4
64
72
68
6
7
6
11
11
76
69
53
72
4()
58
9
II
3
-8
5
Adult
mortality rate
Anemia
Low birth weight
1995
mr 1985-95
1985-95
(per 1,000
(% ofpregnant
mr 1985-95
adults,
women)
(percent)
age 15-60)
Infant
mortality rate
1995
(per 1,000
live births)
Under5
mortality rate
1995
(per 1,000
live births)
78
34
70
4
6
33
6
42
83
35
89
19
14
40
49
46
109
41
96
5
7
40
7
61
133
42
128
23
18
50
63
65
411
155
220
81
87
186
121
199
451
159
344
193
150
160
135
186
98
15
16
6
8
18
30
42
23
41
160
21
19
7
10
21
48
51
25
49
590
203
107
95
123
129
155
247
133
171
19
27
23
45
98
126
23
101
18
27
145
22
144
180
83
1<X)
358
134
109
55
514
392
Obesity
mr 1985-95
(<k of children
or adults)
36
15
5
5
8
50
14
13
20
13
10
8
57
48
13a
2.5a
53
3.3a
3.8a
30
2.4a
5
46
7
20
7.8a
10
17
29
52.3
33a
19
15
13
14
76
34
5.7b
4.4a
Note: .. indicates data not available.
47
I
4
c
I
I
Table A.6 (continued)
Country
Afghanistan
Albania
Algeria
Angola
Anguilla
Antigua and "Barbuda
a
I
I
4
■
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas. The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic-
Chad
Channel Islands
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt. Arab RepublicEl Salvador
Equatorial Guinea
48
Maternal
mortality rate
1990-95
(per 100,000
live births)
Tuberculosis
incidence
1995
(per 100,000
population)
Adult
HIV/AIDS
prevalence
1994
(percent)
-2
-27
-47
1
1700
23
140
1500
0.0
0.0
1.7
2.7
1.8
-21
-17
-22
140
35
278
40
53
225
20
20
50
40
0.4
0.0
63
1.9
-2
-10
-29
-41
-39
-43
-12
-31
-3
9
10
29
KM)
60
887
43
25
10
6
20
47
30
25
220
20
50
16
40
135
20
90
335
80
400
80
70
40
289
367
235
194
8
100
20
139
167
0.1
0.2
0.0
3.9
0.2
0.0
2.8
0.0
0.2
2.0
1.2
50
69
Adolescent
fertility rate
1995
(per 1,000
women,
age 15—19)
Total fertility
rate
1995
(per woman,
age 15^19)
Totalfertility
change
1980-95
(percent}
153
26
17
218
6.9
2.6
3.6
6.9
57
62
50
31
23
33
56
XI
116
50
39
11
92
127
67
82
28
106
37
28
60
149
66
108
136
25
26
145
183
21
48
17
80
131
140
67
136
28
68
34
34
18
171
47
53
68
56
91
182
a
Future Challenges
Reproductive Health Indicators
1.5
2.3
2.0
3.2
3.5
1.8
1.4
1.6
3.9
6.1
Unwanted
fertility rate
1990-95
(per woman,
age 15-49)
1.3
990
4.6
-17
4.4
2.4
3.0
1.2
6.8
6.5
4.7
5:7
1.7
4.0
-34
-38
-28
-40
-10
-4
3
-12
5.1
5.9
1.7
2.4
1.9
2.8
6.0
6.1
2.9
5.4
1.5
1.7
2.2
1.3
1.8
5.8
2.4
2.9
3.3
3.5
3.7
5.9
-11
0
18
-18
-24
-27
1.9
373
0.9
220
200
60
20
939
1327
900
550
6
0.6
-38
-1
-22
-28
649
1594
0.8
1.0
-16
-11
-38
16
-12
-34
-35
-32
-31
3
1.0
58
63
0.1
1.0
0.0
0.1
0.0
18.0
0.7
02
0.0
6.7
2.7
1.9
3.0
0.2
23
30
75
50
71
65
66
60
5.8
2.7
12
9
67
85
67
150
250
15
196
65
20
15
25
12
0.1
0.0
0.2
0.1
7.2
0.5
6.8
0.0
0.0
0.3
0.0
0.2
570
600
3.0
110
150
170
300
820
20
110
166
78
110
150
1.0
0.3
0.0
0.6
1.1
65
115
107
950
822
55
887
10
36
5
Smoking
prevalence
mr 1985-95
(% of adults)
63
68
54
55
75
64
50
74
74
80
41
50
4
4
4
Fulurt Challenges
Reproductive Health Indicators
4
*
4
4
4
Country
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia. The
Gaza Strip
Georgia
Germany
Ghana
Greece
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran. Islamic Republic
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea. Dem. Rep.
Korea. Rep.
Kuwait
Kyrgyz Republic
luio PDR
Latvia
Lebanon
Lesotho
Liberia
Libya
Lithuania
Luxembourg
Macao
Macedonia. FYR
Madagascar
Malawi
Malavsia
Adolescent
fertility rate
1995
(per 1,000
women,
age 15-19)
Totalfertility
rate
1995
(per woman,
age 15-49)
Total fertility
change
1980-95
(percent)
125
36
164
43
20
17
5.8
13
7.0
2.8
1.8
1.7
-35
8
-22
11
-13
51
150
167
119
40
14
109
19
59
34
58
106
213
186
56
70
112
13
31
29
81
57
80
61
23
28
14
67
6
43
40
95
54
30
8
45
44
59
34
43
55
211
106
34
16
15
38
145
151
30
3.0
5.2
5.3
7.1
17
-18
3
1.2
5.2
1.4
-21
-20
-39
2.1
2.7
4.8
6.5
6.0
2.4
4.5
4.7
12
1.6
2.1
3.2
2.7
4.6
5.5
1.9
2.4
1.2
2.5
1.5
4.8
2.3
4.8
3.8
2.2
1.8
3.0
3.3
6.5
1.3
2.9
4.7
6.6
6.1
1.5
1.7
1.9
22
5.9
6.6
3.4
-25
-23
7
0
-32
-24
-28
-40
-18
-14
-35
-39
-26
-15
-42
-26
-29
-35
-14
-30
-22
-39
-17
-28
-33
-44
-20
-2
-38
-29
-17
Unwanted
fertility rate
1990-95
(per woman,
age 15-49)
Tuberculosis
incidence
1995
(per 100,000
population)
Adult
HIV/AIDS
prevalence
1994
(percent)
1400
41
1528
90
H
15
155
60
155
40
15
20
100
60
100
166
3.2
0.0
23
0.0
0.0
03
70
18
222
12
20
20
80
110
166
0.0
0.1
23
0.1
483
1050
55
22
742
10
1.
1.8
0.8
0.5
2.0
464
880
910
600
220
7
10
0
437
390
120
310
10
7
12
120
18
132
53
650
48
30
18
80
660
40
3(X)
598
560
220
16
0
16
-24
12
-14
-10
-13
-19
Maternal
mortality rate
1990-95
(per 100,000
live births)
0.9
1.0
12
660
620
34
220
50
333
133
140
50
10
220
220
50
150
18
12
25
10
42
14
77
140
400
162
162
40
68
235
70
35
250
100
12
82
10
100
60
310
173
67
Smoking
prevalence
mr 1985-95
(% ofadults)
76
90
46
67
2.3
2.1
0.4
0.6
3.1
1.3
4.4
1.6
0.1
0.1
0.1
0.4
0.0
0.0
0.0
0.1
0.1
0.3
0.9
0.0
0.0
0.0
8.3
0.0
0.0
0.1
0.0
0.0
0.0
0.1
3.1
1.3
0.1
0.0
0.1
0.0
0.1
13.6
0.3
58
74
63
42
47
67
59
43
57
45
57
75
64
56
74
49
59
75
79
39
62
58
57
45
1
i
i
49
Table A.6 (continued)
Reproductive Health Indicators
■
i
<
J
4
II
I
(
I
*
i
Country
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, FecLSts.
Moldova
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Kitts and Nevis
St Lucia
St. Vincent & the Grenadines
50
Adolescent
fertility rate
1995
(per 1,000
women,
age 15-19)
Totalfertility
rate
1995
(per woman,
age 15-49)
76
190
13
6.7
6.9
1.9
32
123
42
57
51
46
45
62
38
122
30
130
82
8
33
47
43
136
222
120
22
123
107
61
44
72
52
47
28
23
48
40
51
34
31
65
149
61
118
51
203
13
35
19
94
191
68
11
33
68
84
52
Future Challenges
Unwanted
fertility rate
1990-95
(per woman,
age 15-49)
Maternal
mortality rate
1990-95
(per 100,000
live births)
0.7
-8
1249
0
2.0
5.2
2.2
-15
-17
-20
800
112
3.0
4.6
2.0
3.4
2.3
3.5
63
3.5
5.0
5.3
1.6
2.1
2.5
2.1
4.2
7.4
5.6
1.9
7.1
5.3
2.7
4.8
4.1
3.2
3.8
1.6
1.4
2.1
3.9
2.2
1.4
1.4
6.3
4.8
6.3
5.8
2.5
6.5
1.7
1.5
1.3
5.2
7.0
3.9
1.2
2.3
2.4
3.0
2.3
-34
110
-18
-37
34
240
Totalfertility
change
1980-95
(percent)
-37
-3
-32
-15
-17
-1
-11
-34
-1
-32
0
-19
9
-29
-24
-29
-15
-16
-31
-23
-29
-34
-17
-32
-29
-42
-26
-24
2.0
48
52
1512
-14
-14
0.9
18
510
0
-2
-34
-38
-23
0
-21
-47
-34
-32
1.4
0.3
1.0
1.2
1.5
1.2
372
1512
518
370
515
12
25
160
593
1000
6
190
340
55
930
180
280
208
10
15
21
8(X)
10
8
5
16(X)
404
7
30
Tuberculosis
incidence
1995
(per 100,000
population)
Adult
HFV/AIDS
prevalence
1994
(percent)
Smoking
prevalence
mr1985-95
(% ofadults)
120
289
10
150
20
220
50
0.1
13
0.1
58
0.7
0.1
51
60
60
70
100
20
125
189
189
400
167
13
20
90
10
110
144
222
8
20
150
90
275
166
250
400
0.4
53
0.0
0.0
47
50
60
8
50
120
99
260
KM)
22
166
40
167
82
40
35
120
222
250
49
167
25
20
25
0.0
5.8
1.5
6.5
0.1
0.0
49
0.1
0.1
1.0
2.2
0.1
0.1
0.1
0.6
0.2
0.1
0.2
0.1
0.1
0.2
46
0.1
0.0
0.0
0.0
7.2
65
31
72
32
76
74
30
54
51
80
53
91
0.0
1.4
83
3.0
0.1
0.0
0.0
35
69
58
03
3.2
0.6
0.1
69
73
56
5
3
3
3
5
3
3
3
0
Future Challetign
Reproductive Health Indicators
Country
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Isl.
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (UK)
Virgin Islands (US)
West Bank
West Bank/Gaza Strip
Western Samoa
Yemen. Rep.
Yugoslavia, Fed. Republic
Zaire
Zambia
Zimbabwe
__
Total fertility
change
1980-95
(percent)
Unwanted
fertility rate
1990-95
(per woman,
age 15-49)
Maternal
mortality rate
1990-95
(per 100.000
live births)
Tuberculosis
incidence
1995
(per 100,000
population)
Adult
H1V/A1DS
prevalence
1994
(percent)
4.8
26
4.7
1.7
1.5
4.9
1.8
4.2
5.8
1.8
6.4
3.3
2.1
3.0
2.7
3.8
-27
1.5
660
211
100
200
7
18
58
1.0
1_2
3.8
0.1
0.3
0.0
0.0
6.4
2.1
8.5
193
48
58
30
60
47
43
55
(X)
42
6.8
1.5
3.6
1.7
2.1
2.2
3.7
5.0
3.1
3.1
-6
74
90
2.4
5.6
133
187
173
244
40
20
55
57
72
20
300
50
30
12
10
20
55
120
44
166
20
20
42
141
41
221
122
68
4.3
7.4
1.9
-6
-20
5.7
3.9
-19
-43
Adolescent
fert'dity rate
1995
(per 1,000
women,
age 15—19)
Totalfertility
rate
1995
(per woman,
age 15-49)
84
52
111
20
7
89
24
48
123
18
124
32
46
32
44
26
-39
-26
4
-34
-33
-26
-14
-49
-2
-32
-35
-43
-37
-24
560
7
6
179
39
748
200
626
0.7
90
139
183
43
0.9
506
33
33
20
12
85
43
280
200
105
1.3
-25
-33
-10
12
-18
-23
-26
-39
1.7
35
1471
0.8
870
230
570
0.9
0.0
0.0
0.0
Smoking
prevalence
mr 1985-95
(% of adults)
41
46 ■
62
53
79
50
64
87
27
10
14.5
0.0
0.2
0.1
0.5
0.3
0.0
54
50
68
41
0.3
0.1
77
30
96
50
333
345
207
0.0
0.1
3.7
17.1
17.4
83
■16
51
Note: .. indicates data not available.
51
<O(J
0616S
fir
(
LIBRARY
>
£1)1
AND
DOCUMENTATION
UN,T
)
I
2
I
Table A.6 (continued)
Country
1
5
I
Health Finance Indicators
Health Services Indicators
Afghanistan
Albania
Algeria
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt. Arab Republic
El Salvador
Equatorial Guinea
52
Immunization
In-patient Physicians Access to
coverage,
health
per
beds per
1.000 pop. 1,000 pop. services, % measles, %
I
— mr 1990-95 mr 1990-95
mr 1990-95 mr 7990-95
0.2
3.2
2.1
1.3
6.1
4.6
8.4
8.9
9.3
10.0
3.9
0.3
8.4
11.6
7.6
2.8
0.2
1.6
1.4
1.8
1.6
3.0
10.6
0.3
0.7
2.1
2.6
6.0
1.6
3.0
0.9
0.7
3.1
2.4
1.4
2.8
3.3
2.5
0.8
5.9
5.4
9.2
5.0
2.6
2.6
2.0
1.6
1.9
1.5
0.1
1.4
0.8
0.0
1.1
0.9
2.7
3.1
1.1
2.2
2.6
3.9
1.4
1.3
0.2
1.1
4.1
3.7
0.5
0.1
1.2
0.2
0.5
0.5
19
91
69
32
24
76
95
86
60
91
88
90
96
52
96
70
83
72
100
100
74
1(X)
100
42
86
1.4
0.7
3.5
100
58
83
57
68
78
92
93
55
44
75
31
98
95
0.1
0.1
0.1
2.2
0.2
1.7
0.0
80
13
26
70
24
1.1
1.6
1.1
0.1
0.3
1.3
0.1
2.0
3.6
1.8
3.0
2.9
0.2
0.5
1.1
1.5
1.8
0.8
0.3
95
93
89
77
60
39
94
57
90
100
83
96
88
68
99
100
100
82
94
70
15
99
87
97
60
100
100
80
99
Health
Health
f__ ? Total health Total health
Total health expenditures expenditures
(public)
expenditures expenditures
expenditures (public)
(
ppps
% erf
% erf GDP C
, GDP per cap. US$ per cap. USS
Year
1995
1993
1991
1994
1994
1994
1995
296
354
11
484
877
5.8
6.2
1.4
2.6
1079
1524
4
321
1.2
4.4
5.3
7.0
6.1
1.7
0.5
2.2
2.7
3
290
1517
1866
161
5
165
10
20
1575
2404
24
546
473
6
449
1829
2125
214
20
1064
1725
2147
96
708
280
35
790
280
1784
472
83
38
138
1.9
2.7
1.8
5.5
23
0.9
07
1.0
7.0
3.5
2.8
1.9
2.5
52
95
269
56
7
81
261
171
428
70
17
296
43
2
5
1304
32
1082
6
4
18
7
1814
33
2213
9
29
2.5
1.8
3.0
0.9
3.6
6.3
1.4
8.5
7.9
93
9
55
5
44
158
10
253
241
19
138
7
83
214
25
302
652
98
487
18
183
536
71
4.6
9.6
6.6
7.7
5.5
336
1537
414
417
2191
5.3
5.3
5.3
5.0
7.2
2.0
2.0
2.2
1.2
5.8
27
30
23
18
22
71
78
56
74
27
4.7
6.4
10.6
7.8
1994
1994
1995
1994
1991
1995
1994
1995
1995
1994
1994
1994
1995
1994
84
9.7
7.5
4.4
5.7
2.4
6.9
6.4
8.0
8.2
1992
1994
1991
1992
1992
1995
1994
1994
1994
1994
1994
1995
1995
3.1
7.4
1994
6.5
3.8
7.4
1.2
6.8
8.5
3.4
10.1
1993
1994
1993
1992
1994
1995
1994
1994
1993
1995
1994
1994
1994
1990
1994
1990
16
61
60
2.7
3.3
4.0
2.2
3.9
4.3
3.1
4.6
3.5
5.0
6.9
5.5
7.2
1.4
9.8
4.8
247
85
932
140
27
2
1856
970
1497
220
253
191
132
c
■MMMH
______
•3
•A
-n
Health Finance Iruiicaiors
Health Services Indicators
Country
Access to Immunization
In patient Physicians
health
coverage,
per
beds per
1,000pop. 1,000 pop. services, % measles, %
mr 1990^95 mr 1990-95 mr 1990-95 mr 1990-95
liritrea
0
0
a
r>
1
4
Hl
n
I
v»
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Greece
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Dem. Rep
Korea, Rep.
Kuwait
Kyrgyz Republic
Lao PDR
I^atvia
I-ebanon
Lesotho
Liberia
Libya
Lithuania
Luxembourg
Macao
Macedonia, FYR
Madagascar
Malawi
Malaysia
8.0
0.2
10.1
9.0
3.1
55
0.6
2.7
2.8
1.3
87
3.3
0.6
8.2
9.7
1.5
5.1
8.1
4.1
3.3
1.1
0.6
125
2.8
0.8
1.0
4.3
9.9
15.9
0.8
0.7
1.4
1.7
5.0
3.2
6.7
2.1
15.5
1.6
11.6
1.7
4.3
0.8
0.1
4.1
10.9
2.5
12.1
4.0
100
25
4.0
0.6
1.4
0.1
0.1
0.4
1.3
3.4
3.0
0.2
0.2
2.0
60
45
80
45
62
43
73
98
100
1.7
0.5
1.8
1.6
3.6
0.0
0.2
1.2
0.0
3.2
0.2
2.9
1.3
0.0
4.1
I 1.9
1 1.8
1.0
4.0
2.2
5.0
0.9
1.6
2.0
2.1
0.1
0.0
0.4
KM)
90
KM)
1(X)
100
80
I(X)
65
80
88
Year
91
1
42
1196
1755
0.6
1.9
19
6
0.8
7.0
1.3
4.3
3
1751
3
305
2.7
0.9
0.9
1.1
1994
1994
1994
1994
1995
1992
1994
1990
3.6
5.6
4.3
7.3
8.1
5.6
1.5
4.8
1994
1990
1995
1994
1994
1994
1994
1992
1990
7.9
4.2
7.7
5.4
7.0
7.9
1992
1994
1995
1995
1994
1992
1994
5.4
1994
1995
1994
1992
1994
50
88
1994
1994
63
75
68
70
1995
1995
1995
1993
84
69
68
90
24
90
42
KM)
98
84
89
95
95
78
94
50
82
68
92
72
73
89
98
92
93
89
65
85
88
82
1994
1994
1994
85
59
99
81
2.0
1.1
6.3
1.1
2.0
6.2
7.7
45
81
54
93
98
76
89
94
80
Health
Health
Total health expendituresexpenditures Total health Total health
expenditures
(public) (public) expenditures expenditures
PPP$
% of GDP % of GDP per cap. US$ per cap US$
1995
1995
1993
1994
1995
1995
1995
1994
3.4
8.3
9.8
9.6
5.7
2.5
2.6
5.3
6.2
8.3
70
1591
2599
176
1585
2139
2823
1976
474
759
12
5
3
33
92
1.3
2.8
1.9
6.8
6.9
1.2
0.7
2.8
3
17
411
275
1596
2
8
34
944
295
2144
35
121
1036
496
1767
68
63
239
6.0
2.1
5.4
3.0
5.5
3.7
2.2
1.6
8.9
875
249
1051
51
2066
55
15
5
158
1151
546
1471
91
2947
1.8
3.6
3.7
1.3
4.4
2.1
3.5
127
543
12
5
78
34
16
5.1
6.2
76
1985
7.3
1.1
2.3
1.4
130
3
3
49
7
271
8
14
467
118
1451
665
1605
212
1659
347
8
34
379
518
10
87
2003
1983
146
53
*
Table A.6 (continued)
Health Finance Indicators
Health Services Indicators
Country
I
I
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia. Fed. Sts.
Moldova
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak RepublicSloven ia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Kitts and Nevis
St. Lucia
St. Vincent & the Grenadines
54
In patient Physicians Access to Immunization
health
coverage,
beds per
per
1,000 pop. 1,000 pop. services, % measles, %
mr 1990^95 mr 1990-95 mr 1990-95 mr 1990-95
0.8
5.4
2.3
0.1
0.1
2.5
Year
Health
Health
Total health expenditures expenditures Total health Total health
expenditures (public)
(public)
expenditures expenditures
(public)
% of GDP %
% of
ofGDP
GDP per
percap.
cap. USS
USSper
percap.
cap. USS
USS PPP$
86
49
90
1990
1991
4.9
2.7
1.2
3
53
85
1991
1991
5.2
3.4
1.1
2.1
6
56
28
90
75
408
90
76
98
85
1994
5.3
2.8
116
223
365
4.9
4.4
3.1
1.6
4.6
0.4
3.9
1.2
6.8
25
16
24
154
17
5
7
68
2
1495
194
26
277
36
174
133
10
2258
364
303
60
1825
5.7
4.3
1.6
0.3
6.9
828
19
4
1
1963
142
3
146
36
17
56
10
110
463
1078
34
1335
5
2078
18
1900
13
201
70
485
72
106
17
134
827
161
199
60
283
1058
343
511
96
225
16
202
8
621
22
823
8
15
C
C
1.7
0.7
2.9
0.1
0.8
1.3
12.2
11.5
3.5
2.7
0.5
0.4
1.1
0.9
0.6
5.0
0.2
11.3
99
0.1
0.2
0.1
2.5
1.4
91
100
62
30
100
92
71
66
57
78
95
1994
1992
1994
1993
1991
1994
1993
1995
1995
1994
4.7
5.6
3.4
7.6
5.0
8.8
4.8
126
►
7.3
1.8
2.1
0.7
0.0
1.7
2.1
0.7
2.5
4.0
0.6
1.4
1.4
6.4
4.3
7.7
11.7
1.7
4.8
2.5
0.7
3.6
7.6
5.7
2.8
0.7
4.2
2.7
9.2
4.3
5.0
3.3
0.6
0.5
1.6
0.1
0.3
1.0
0.1
2.3
2.9
1.8
1.5
100
30
67
100
89
85
82
96
1(X>
1.8
3.8
0.5
1.4
0.1
1.4
98
40
1(X)
3.0
2.1
0.2
4.1
90
0.9
0.5
0.5
87
81
38
50
93
98
53
84
35
76
97
86
96
94
1994
1994
1995
1994
1994
1991
1991
1994
1994
1994
1994
1991
1992
1995
4.3
4.9
2.4
6.0
8.1
87
1993
2.8
93
91
1994
1994
1990
1995
1991
1990
1994
1991
1994
1995
1995
1991
69
94
80
92
44
88
99
91
76
30
76
90
88
1(X)
94
1(X)
7.5
7.8
1.4
7.3
2.5
3.5
7.5
0.8
5.4
2.8
1.0
2.6
1.3
5.0
4.5
3.6
4.1
1.9
6.2
44
83
7
5.6
1.0
4.0
1.5
1.1
6.0
7.4
3.3
8
272
3
270
196
555
23
1993
1995
1993
1994
7.9
7.6
1.9
5.9
3.6
6.0
1.4
3.4
1994
5.9
4.0
4.8
C
c
C
22
2.2
3.6
3.5
►
*
►
39
111
105
854
8
173
233
1091
11
298
396
1166
61
604
86
129
*
4
5
4
Health Services Indicators
3
o
J
•3
3
3
3
3
3
s
Heaith Finance Indicator?
In-patient
beds per
Country
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Isl.
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (UK)
Virgin Islands (US)
West Bank
West Bank/Gaza Strip
Western Samoa
Yemen, Rep.
Yugoslavia. Fed. Republic
Zaire
Zambia
Zimbabwe
Note:.. indicates data not available.
Physicians Access to Immunization
l*r
o_,
health _____
coverage.
J,000 pop.
1.000pop. services, % measles. %
mr 1990-95 mr 1990-95
mr
1990-95
. .— ,5 mr 1990-95
1.1
5.7
6.1
8.7
1.1
4.9
8.8
0.9
1.7
1.5
3.2
1.8
2.5
10.5
0.9
11.8
3.1
5.1
4.4
4.5
8.4
2.6
3.8
4.8
0.8
13.6
1.4
0.5
70
0.8
0.1
3.1
3.1
0.8
1.3
2.1
0.2
0.1
0.5
0.7
0.6
1.1
3.2
0.5
100
100
99
93
59
99
90
ICX)
71
4.4
0.8
1.5
2.5
3.2
3.3
0.1
1.6
0.4
1.7
1.7
0.1
4.3
0.1
0.1
0.1
74
61
85
96
83
98
100
90
97
59
75
90
75
87
65
87
87
89
75
90
79
96
90
92
89
80
71
94
95
81
49
75
41
78
78
Year
1991
1994
1995
1994
1994
1993
1994
1995
1992
1991
1992
1994
1993
1994
1994
1994
1995
1994
1994
1995
1994
1994
1993
1994
1993
1994
1995
1992
1994
1994
1990
1990
1991
Health
Health
Total health expenditures expenditures Total health Total health
expenditures (public)
(public)
_________ expenditures
expenditures
% of GDP ~% of
-----GDP per cap US$ per cap. USS1
PPP$
0.3
5.0
7.7
9.6
4.9
5.3
3.4
4.0
3.9
5.9
4.2
3.9
4
2056
259
1742
3533
1540
2395
280
93
4
522
686
27
103
15
58
151
99
99
336
40
239
10
61
379
1205
3828
439
378
1366
3873
642
202
602
2.6
3.0
6.4
6.9
1057
35
1452
2537
2.6
6.4
3.0
1.4
1.2
2.9
2.6
3.0
2.7
2.8
5
42
100
51
65
62
1.8
5.0
2.0
5.8
7.0
2.0
3.5
3.3
2.3
1.1
2.6
4
35
307
1014
1614
104
5
34
66
63
29
17
113
2.6
3.4
3.1
1.1
3.3
6.5
0.2
2.3
2.3
12
14
17
41
2.5
6.9
14.5
8.5
7.1
5.2
5.3
6.2
381
862
39
31
122
55
*
>3
ANNEX B
Highlights from Major International
Initiatives in HNP
«
-4
s 0
0
Task Force on Basic Social Services for All
0
In October 1995, the United Nations Administrative
Committee on Coordination (ACC) established the Task
Force on Basic Social Services for All to ttelp coordi
nate the response of the United Nations system to the
recommendations of the recent UN conferences and sum
mits. The unifying theme of the system-wide action plan,
on which the Task Force is based, is the provision of as
sistance to countries for a concerted attack on poverty.
The Task Force on Basic Social Services for All
(BSSA) is based upon recent United Nations’ global
conferences and summits, particularly the International
Conference on Population and Development (ICPD)
in Cairo, 1994; the World Summit for Social Develop
ment (WSSD) in Copenhagen, 1995; the Fourth World
Conference on Women (FWCW) in Beijing, 1995; and
the Second World Conference on Human Settlements
(Habitat II)4n Istanbul, 1996?
The Task Porce is a broad United Nations initiative
to galvanize priority goals and objectives emerging from
0
0
5
3
I 15
I
I 3
5 3
I
I
■
r?
*
the recent United Nations conferences, and to ratio
nalize and strengthen follow-up mechanisms for deliv
ery of coordinated assistance at the country and regional
levels.
The six key areas included for consideration by the
Task Force are:
population, with special emphasis on reproduc
tive health and family planning services;
primary health care;
nutrition;
basic education;
drinking water and sanitation; and
shelter
Goals and Selected BSSA Indicators
Percentage of Population with Access to Health Services
All countries should seek to make primary health care,
including reproductive health care, available universally
by the end of the current decade (ICPD).
1. The members of the Task Force are: the United Nations Population Fund (UNFPA). which serves as Chair; the United Nations Secre
tariat (Department for Economic and Social Information and Policy Analysis (DESIPA), Department for Policy Coordination and Sustainable
Development (DPCSD), and Department of Humanitarian Affairs (DHA); regional commissions (Economic Commission for Africa (EC A),
Economic Commission for Europe (ECE), Economic Commission for Latin America and the Caribbean (ECLAC), Economic and Social
Commission for Asia and the Pacific (ESCAP) and Economic and SociaT Commission for Western Asia (ESCWAT Food and Agriculture
Organization of the United Nations (FAO) ; International Labour Organization (ILO); International Monetary Fund (IMF) ; Office of the
United Nations HigftCommissioner for Refugees (UNHCR); United Nations Centre for Human Settlements (Habitat); United Nations
Children s Fund (UNICEF); United Nations Development Fund for Women (UNIFEM); United Nations Development Programme fUNDP);
United Nations Educational, Scientific, and Cultural Organization (UNESCO); United Nations Environment Programme (UNEP); United
Nations Industrial Development Organization (UNIDO); United Nations International Drug Control Programme (UNDCP); United Na
tions Relief and Works Agency for Palestine Refugees in the Near East (UNRWA); World Bank; World Food Programme (WFP), and World
Health Organization (WHO).
57
3 ,C)n ector rate9y
Governments should promote full access to-preventive and curative health care to improve the quality of
life, especially for vulnerable and disadvantaged groups,
in particular women and children (WSSD).
Governments should provide more accessible, avail
able, and affordable primary health-care services of high
quality, including sexual and reproductive health care
(FWCW).
School Enrollment Ratio
Family Planning
All countries should strive to ensure complete access to
primaiy school er an equivalent level of education for
both girls and boys as quickly as possible, and in any
case before 2015. Countries that have achieved the goal
of universal primaiy education are urged to extend edu
cation and training and facilitate access to andcompletion of education at secondary school and higher levels
(ICPD, WSSD, and FWCW).
All countries should seek to provide universal access to
a full range of safe and reliable family-planning methods
Adult Illiteracy Rate
Underweight Prevalence among Preschool Children
The adult illiteracy rate should be reduced to at least
half its-1990 level, with an emphasis on female literacy
(WSSD).
By the yegr 2000, achieve a reduction of severe and
moderate malnutrition among children under five years
of age to half of the 1990 level (WSSD and FWCW).
Percentage of Population with Access to Safe Water
and to Sanitation
Maternal Mortality Ratio
Access to safe drinking water in sufficient quantities and
proper sanitation for all should be provided (ICPD.
WSSD, and Habitat).
a
5
Countries should strive to effect significant reductions
in maternal mortality by 2015; a reduction in maternal
mortality by one-half of the 1990 levels by the year 2000
and a further one-half by 2015 (ICPD, WSSD and
FWCW).
Floor Area per Person
The availability of adequate shelter for all should be
improved (WSSD and Habitat).
Infant Mortality Rate
By the year 2000, reduce mortality rates of infants by
one-third of the 1990 level. By 2015, an infant mortal
ity rate below 35 per 1000 births should be achieved
(ICPD and WSSD).
Under-5 Mortality Rate
Countries should strive to reduce their under-5 mortal
ity rates by one-third or to 70 per 1,000 live births, which
ever is less, by the year 2000. By 2015, all countries
should aim to achieve an under-5 mortality rate below
45 per 1,000 (ICPD and WSSD).
Life Expectancy at Birth
By the year 2000, life expectancy of not less than 60
years should be achieved in every country (WSSD).
Countries should aim to achieve by 2005 a life ex
pectancy at birth greater than 70 years and by 2015 a
life expectancy at birth greater than 75 years (ICPD).
Major International Conferences
In addition to the Task Force on Basic Social Services
for All, four international conferences have had a ma
jor impacton setting the broad policy agenda for inter
national work in the HNP sector. These include:
WHO s initiative to achieve Health For All by the
Year 2000 Strategy, presented at the Thirtieth
World Health Assembly in 1977 (enshrined at
Alma Ata);
UNICEFs initiative to improve the State of lEc
World’s Children, presented at the World Sum
mit for Children in 1990;
UNFPAs initiative to improve reproductive health,
presented at the International Conference on
Population and Development in Cairo in 1994;
and
The World Food Summit in Rome in 1996 and
the International Conference on Nutrition in
Rome in 1992.
58
______ ___________________
l<
Annex B Highlights from Major Internationa!
5
New Direction in Health: Update of the
Health For All by the Year 2000 Initiative
Oh weVV D"LeCtions in Carin9 for the World's
ChHdren: The 1990 World Summit for Children
The 1990 World Summit for Children set goa\s forreduc
heeh idhS' malnUtrition’ disea^, and disability among
the children of the developing world
iective ha?
3
3
3"'' (HFA> 35 3 ^^amental ob
The’;end1lf^bt„bZ9,°a,S: a9reed.t0 b* alm°« all the
jective has committed governments to attain "as a mini-
world’s governments following the Summit
can be summanzed by ten priority pointsBI A one-third reduction in 1990 under-5 death rates
(or 70 per 1 000 live births, whichever is less).
B A halving of 1990 maternal mortality rates
B A halving Of 1990 rates of malnutrition among
the world s under-5s (to include the elimination
of micronutrient deficiencies, support for
breastfeeding by all maternity units, and a reduc
tion in the mcdence of low birth weight to less
than 10 percent).
■ The achievement of 90 percent immunization
in a//countries. ^/easrsuch a level
of health that they are capable of working productively
and of participating actively in the social life of the com
XX'" Wh‘Ch
IIVe" (77?e World Health Report
T996, Fighting Disease, Fostering Development)
The Health for All goals in countries include:
,
PerCent
1,16 9ross n8tional Product
spent on health; a ’reasonable’ percentage of the
national health expenditure devoted to local
^a^care (reasonab.e defined by count,;
■
■
£
among children under the age of one, the eradi
cation of polio, the elimination of neonatal tetanus a 90 percent reduction in measles cases, and
a 95 percent reduction in measles deaths (com-
equitable distribution of resources, and
lat'ion17 hea'th
aVailable t0 the whole popuB
pared to pre-immunization levels)
^halving of child deaths caused by diarrheal
Primary health care targets by year 2000 include:
4
■
■
access to safe water (85 percent)
adequate sanitary facilities in the home (75 per-
■
■
immunization (90 percent)'
local health care (first-level 'facilities) with at least
20 essential drugs (85 percent), and
a
A one-third reduction in child deaths from acute
B
respiratory infections.
Basic education for all children and completion
as XT
B
framed personnel for pregnancy, childbirth and
carmg for children up to at least one year of age
(iUO percent).
y
E
In addition to disease-specific mortality and
argets. specified goals for the year 2000 are: morbidity
B
4
Infant mortality rate less than 50 per 1.000 live
" l6aSt 80 “-^'s
Clean water and safe
sanitation for all communities.
CnmpR0^
C°Un'rieS °f the invention
on the R.ghts of the Child, including improved
P otection for children in especially difficult circumstances.
Universal access to high quality family planning
information and services in order to prevent preg
laTX3'ar610° ear,y' tO° Cl05e'y Spaced’ 'o°
’ate. or too numerous.
■
■
Probability of dying before fifth birthday less than
70 per 1000 live births; and
Maternal mortality (per 100.000 live births) to be
reduced to 50 percent of 1990 level.
at Ihee hS ‘rhe 9l°ba' Pr°9reSS in the ^loment of HFA
i
kh WHO
d6Cade'
t0 Se‘ 3
di^on in
health. WHO is currently evaluating the oriainal nlnhai
-gets (economic, demographic, social, nuthtonal
estyle, water supp|y an[) sanjtatjon h(jman and
al resources, drugs, maternal and child health familv
aXyf The6 expectancy’ morta'ity, morbidity, and dis
no ' V r
eVa,Uat,On WlH contribute to a revised HFA
policy for action beyond 2000.
UNICEF has one of the most detailed programs for
monitoring and tracking progress of any of the interna
bonal organizations. The latest annual report-t”e
illustrations^'
7S'S'S~pr0'/'des s°me striking
lustrations o, both successes and failures dur,ng this
decade m ach.eving these goals. A major achievement
Safe Water Access
Sub-Saharan Africa
North Africa and Middle East
Latin America
South East Asia
South Asia
1980
1990
22%
30%
42%
38%
51%
52%
53%
66%
41%
31%
59
I
J
^Nutnuon.andPopu^on
Sector Strategy
New Directions in Population and Reproductive
Health: The 1994 International Conference on
Population and Development in Cairo
The 1994 International Conference on Population and
Development (ICPD) in Cairo, has set the agenda for
addressing population issues as we enter the 21st cen
tury. Several key changes in population dynamics and in
the policy environment have led to an international con
sensus on the approach to population and reproductive
health.
Major development otjectives expressed at the Confer
ence are to:
■ flratyethe gender gap in education;
■ Promote equity for women;
■ Reduce maternal mortality and morbidity;
■ Increase child survival; and
■ Provide universal access to reproductive health
and family planning services.
The ICPD approach does not abandon population issues
but puts individual needs first by:
■ continuing to assist the world's poorest countries
as they complete the demographic transition
(slowing population growth) during the next few
years (high birth rates and very young popula
tions make it more difficult to reduce poverty and
pursue sustainable economic development);
■ integrating population policies more effectively
with core development agendas such as seeking
better infant and child health, educating girlsand
empowering women (understanding the social,
economic, and political dimensions of urbaniza
tion, international migration, and aging);
■ providing the poor with access to high quality
and user-oriented (culturally sensitive) services
that offer a range of choices in addressing popu
lation and reproductive health needs; and
■ redefining the role of the state in population poli
cies (selective investments in service delivery in
frastructure and institution building in very poor
countries), while limiting activities to providing
information and improving the functioning of the
private sector in more advanced middle-income
countries
-j
J
I
1
-
The Bank's role in the implementation of the recom
mendations from this conference is described in greater
details in the Bank publication Population and Develop
ment: Implications for the World Bank. 1994.
I
New Directions in Nutrition:
The 1996 World Food Summit
The 1996 World Food Summit in Rome—and its nutri
tional antecedents the World Summit for Children and
the 1992 International Conference on Nutrition in
Rome—came to a consensus on the causality of malnu
trition: food, disease, and behavior
The World Food Summit emphasized the intersectoral
nature of effective nutrition policies. Unlike other health
problems, including maternal and reproductive health,
problems in malnutrition are not well addressed through
health services alone. Instead major reforms to address
malnutrition need to focus on policies in five major
intersectoral areas:
■ Policy and institutional framework to support
agricultural and rural development;
■ New role of the state, with an emphasis away
from heavy public intervention in the rural
economy, towards providing the enabling, sound
macro-economic, fiscal, and sectoral policy en
vironments;
■ Private sector involvement to mobilize the
needed investment capital, production, and ser
vices;
Community and local government participation
in designing and implementing nutrition policies
rather than relying on the central government;
and
■ Partnerships at all levels of involvement, rang
ing from central governments to local govern
ments to community participation to the private
sector
The World Summit for Children set specific quantita
tive goals for the year 2000 for nutrition, which remain
in force today. The International Conference on Nutri
tion broadened the anti-hunger strategy to include food
production, poverty alleviation, and nutrition-friendly
trade policies, in addition to the targeted nutrition inter
ventions highlighted at the World Food Summit.
Countries implementing prioritized and budgeted nu
trition policies include China, Indonesia, Tanzania, and
Zimbabwe. Promising new policy formulation and imple
—
e
c
c
mentation is taking place in a broad range of countries
including Albania, Bolivia, Burkina Faso, Mexico, Peru,
South Africa, Sri Lanka, Zambia, and Bangladesh.
Much remains to be done. The next generation of nu
trition action plans will include comprehensive food
policy reforms, heavy investment in communications for
behavioral change in nutrition, greater involvement of
private food industry, and reduced reliance on untargeted,
stand-alone food distribution programs.
<
60
*>
►
<►
A
2
ANNE X C
3
■3
Essential Health, Nutrition •>
and Population Services
3
Essential HNP Services
Q
*
z4
4
A
;
'
The old enemies of the poor include malnutrition, high
fertility, communicable diseases, childhood illnesses, and
maternal and perinatal conditions. More than half of
the disease burden in Sub-Saharan Africa and South
Asia can be addressed effectively through local adapta
tion of interventions such as immunization, integrated
management of childhood illness, family planning, ma
ternal and perinatal health care, food fortification, tar
geted nutrition programs, and school health.
As populations age, the disease burden and cost of
treating non-communicable conditions and injuries be
comes increasingly important. Ensuring universal access
to a limited range of public and private services that
address these conditions, and that are affordable in lowincome countries, helps not only the poor but also helps
others avoid impoverishment due to illness (see Figure
C.l adapted from Bulletin of WHO 1995, 73:735-740).
Immunization Policies
Three of the world’s poorest countries—Bangladesh,
India, and Vfet Nam—have improved immunization
coverage by over 25 percent since 1988 through effec
tive vaccination programs. Preventing childhood dis
eases through such programs remains one of the best
investments.xhat countries can make to improve health
for the poor. The cost is generally just US$ 12-30 per
disability-adjusted life year (DALY).
Cost-Effective and Affordable
Public Health and Clinical Services
Indicative Cost
in USS
Integraied Management
c< Childhood Illness
Immunizaiion (EPI Plus)
Prenatal denary care
4%
Family planning
I
3%
AIDS prevent ion.program
40.00
1.60
14.50
0.50
40.00
3.80
25.00
0.90
4.00
1.70
2.00
0.20
Treatment o( STDs
§ 1%
Treatment of Tuberculosis
1%
4.00
0.60
School hearth program
] U 1X
22.50
0.30
J 0.1 %
42.50
0.30
Tobacco and alcohol program
0
2
4 6 8 10 12 14 16
Percentage of Total Global
Disease Burden Averted
Cost
Annual
per
cm? per
DALY
capita
\
FIGURE C.1
Although immunization saves about 9 million lives a
year worldwide, 2 million children stilldie from current
immunization-preventable diseases. Furthermore,
UNICEF estimates that a total of 16 million people of
all age groups could be saved, if currently available vac
cines were deployed effectively against all vaccine-pre
ventable infectious diseases. Most of the effective
vaccines currently in use have been available for the
past 15 years. Yet, due to poor policies and problems in
implementation, immunization coverage is leveling off
61
!
t
The 200th Anniversary of Vaccine Discovery
On the 200th anniversary of the discovery of vaccines
I
I
Z3
by the English physician Edward Jenner in 1796, 44 lowand middle-income countries had already reached the
year 2000 target of 90 percent coverage set by UNICEF.
The successful eradication of smallpox saves 5 million
lives annually. Other infectious illnesses such as measles
(which currently kills 1.1 million children a year) could
accessible to the poor. It helps doctors, nurses, and other
health care providers to make more accurate diagnoses
and to know when to refer difficult cases. And it em
phasizes the need for better communications skills when
dealing with sick children and their mothers. This ap
proach is now being successfully introduced in Bolivia,
Ethiopia, Indonesia, Nepal, Peru, Philippines, Tanzania,
Uganda, and Zambia. Many other countries have taken
the first steps towards adopting this approach.
also be eliminated or at least controlled at low levels
with proper policies.
The year 2000 has been set as the target date by WHO
and UNICEF for the eradication of polio. Polio no longer
occurs In the Americas, China, and many other coun
tries.
The policy challenge for low- and middle-income
countries is to institutionalize immunizations within each
Reproductive Health
Each year, more than 200 million women become preg
nant. Of these more than 50 million experience acute
pregnancy-related complications, 15 million develop
long-term disabilities, and 585,000 die (see Figure C.2,
adapted from UNICEF 1996).
country's health program and develop national self-suffi
ciency in running these programs as part of essential and
affordable health services.
Can low-income countries afford to pay for such vac
Deaths in Pregnancy and Childbirth
cination programs?
Daily Toll
The answer is yes!
Already, 20 low- and middle-income countries pay their
own vaccine bills. They include large and poor coun
tries such as China, Egypt, and Indonesia. A further 15
nations pay over half of their own vaccine costs.
Maternal
deaths
per year
65
\
98----Middle
East &
Noah
Africa
615^8
Sub Saharan
Africa
in many countries and falling in others, with the global
rates having peaked at less than 80 percent according
to UNICEF estimates.
I
Integrated Management of Childhood Illnesses
|
!
1■
r
i
-
When children get sick they often have more than one
illness. By using treatment protocols that integrate the
management of all the major causes of childhood illness
and death (diarrhea, pneumonia, malnutrition, measles,
and malaria). misdiagnosis and incorrect treatment are
reduced. Such protocols can be taught through a single
course that facilitates the development of an integrated
approach to child health rather than a diagnosis-spe
cific programmatic approach.
Integrated management of childhood illnesses com
bines prevention (feeding advice, immunization, and
vitamin A) with cure. It uses a short list of effective and
affordable essential drugs, making life-saving treatment
62
Europe
3,000
Central Asia
14,000
Americas
23,000
ArtK_lK .r»
/81fi
As<a
and
Pacific
M East & N Africa
35,000
Sub-Saharan Africa
219.000
Asia and Pacific
291,000
WORLD
585,000
FIGURE C.2
In addition, poor maternal health and nutritional sta
tus, and inappropriate management of labor and deliv
ery, are responsible for 75 percent of the 7.5 million
annual perinatal deaths. This continues to be one of
the most neglected health problems in the world for
which effective and affordable interventions have been
available for decades. What is lacking are appropriate
policies to help families know when to seek health care
and to ensure that they have access to quality obstetric
care when needed.
Additional policies on reproductive health have
evolved out of the recommendations of the 1994 Inter
national Conference on Population and Development
in Cairo. These include:
»
J*
*
linking reproductive health policies to girls’ edu
cation, the^tatus of women, and overall poverty
reduction (e.g. Pakistan and Sri Lanka);
preventing unwanted pregnancies through infor
mation and contraceptive choice, and by train
ing female workers at the community level in
providing family planning (e.g. Tunisia and
Bangladesh);
facilitating safe pregnancy, deliveries, and moth
erhood by preventing and managing pregnancy
complications and by eliminating unsafe abor
tions (e.g. Romania);
promoting positive health practices such as safe
sex, early treatment of sexually transmitted dis
eases, delayed marriages, birth spacing, and edu
cation (e.g. Senegal) ;
preventing harmful practices such as genital
mutilation, discrimination, and domestic violence
(e.g. Ghana).
<r
Nutrition
*
%
«
Three types of nutrition problems predominate in lowand middle-income countries:
Undemutriiion—Overall inadequacy of food intake to meet needs for growth, immune function,
cognitive development, and reproduction affects
30 percent of children and 25 percent of women,
while 56 percent of all under-5 deaths is indi
rectly associated with some form of malnutrition
Deaths in Children Under 5
in Low- and Middle-Income Countries
DiairheH
,
Actne
Respiratory X.
Infections .Z'
/
19%
Perinatal
!
t
k
Malnutrition
56%
32%
tlx 7% 7
Other^
''Msasles
Malaria
___
FIGURE C.3
*
L
(see Figure C.3, adapted from WHO Division for
Child Health Development);
Micronutrient Malnutrition—Insufficiency of es
sential vitamins (e.g. Vitamins A, D, and folic
acid) and minerals (e.g. iron and iodine) in the
diet affects 1 billion people worldwide;
Overnutrition—Excess intake of calories relative
to energy requirements and an imbalanced in
take of other nutrients (generally excess fat and
insufficient fiber) are still small but growing prob
lems, particu larly in middle-income countries and
poor urban areas.
Malnutrition is the result of an interaction between
food intake, disease risk factors, and behavior.
The quality and quantity of food is a function of
household purchasing power (including subsistence pro
duction), food prices, and food preferences and beliefs.
Disease is the product of both-exposure to disease, re
sistance, and treatment (including dietary management)
at home, and medical interventions. Frequent diseases
associated with anorexia, fever, and diarrhea have the
greatest effect on nutrition. Malnutrition, in tum, re
duces resistance to disease. Nutritional behaviors—in
cluding breastfeeding, active feeding of toddlers, energy
expenditure, avoidance of empty calories, and frequency
of meals for youngsters—determine how well an indi
vidual is nourished at any given income level and for
any given disease environment.
The policy and programmatic options for dealing with
malnutrition must address these constraints. Increasing
the family’s food purchasing power is critical where food
insecurity is a major determinant of malnutrition. This
can be done through increasing employment,
microcredit and microenterprise, improving the effi
ciency of food production and marketing, encouraging
food industry development, or through targeted interven
tions and social transfer programs. But increasing income
alone is not enough to improve nutrition within a gen
eration-nutrition education to change behavior is
needed to accelerate the impact of income on nutrition.
Reducing the effect of disease on nutrition involves
immunization, improved water supply and sanitation,
improved hygiene, and access to minimum nutrition
inputs in the context of health care (growth promotion,
nutritional care of the sick child, micronutrient supple
ments, breastfeeding promotion, diet ary advice, and care
of the acutely malnourished child). Addressing malnu
trition also requires changing behaviors of policymakers,
bureaucrats, service providers, community leaders, and
beneficiaries, through individual counseling, informa63
few
tion dissemination, social marketing, taxation/subsidies,
regulation, advertising, and public relations.
Interventions to deal with nutrition problems require
action at both the macroeconomic and community level,
involving many sectors beyond the purview of health or
agriculture. Some of the most successful interventions
include:
community-level programs with heavy emphasis
on behavioral change and linked to other sec
tors as needed (education, agriculture, health,
and childcare in Indonesia, Tamil Nadu, Tanza
nia, Thailand, and Zimbabwe);
targeted income transfer or food marketing pro
grams that enable the poor to obtain more food
(Brazil, Colombia, Honduras); and
micronutrient programs (salt iodization in Ecuador,
vitamin A supplementation in Indonesia, iron for
tification of flour in Venezuela).
from tuberculosis, malaria, and HIV/AIDS infections—
without respect for national borders (e.g. Sub-Saharan
Africa). Prevention and treatment policies must be
adapted to keep up with these trends.
In tuberculosis control, the Directly-Observed Treat
ment, Short-course (DOTS) strategy has been highly
effective in detecting and curing patients, and prevent
ing drug resistance (e.g., China, India, Peru, and Tanza
nia) . Malaria control now relies on a combination of
approaches, such as treatment combined with insecti
cide-treated mosquito nets, and Less on household spray
ing. Such bed-nets have been shown to reduce under-5
mortality by 20 percent in several Sub-Saharan African
countries (e.g. Gambia).
Finally, new approaches in the control and treatment
of sexually transmitted diseases have already contrib
uted to controlling the incidence of the HIV/AIDS pan
demic (e.g. Tanzania, Thailand, and Uganda).
School Health and Nutrition
Non-Communicable Diseases
There are more children at school today than ever be
fore in human history, due to the success of child sur
vival strategies and global efforts to achieve universal
basic education. The accessibility of this school-age
population contributes to the cost-effectiveness of some
school-based health, nutrition, and reproductive pro
grams. Simple preventive services (health education,
family planning, and micronutrient supplementation)
and curative services (deworming, first aid) can improve
health for an age class that is often underserved by the
health systems of the poor, and will allow children to take
fuller advantage of what is often their only opportunity
for formal education. Participatory health education for
schoolchildren (counseling on targeted tobacco use, vio
lence, and reproductive health) is one of the most timely
and effective ways of promoting healthier life styles, and
of averting the emerging pandemic of non-communicable
disease among the next generation of poor.
Successful school health programs (e.g. Dominican
Republic and Guinea) require intersectoral partnerships,
and depend on the existing educational infrastructure
for aspects of service delivery. The health sector remains
responsible for technical oversight, including program
design, training, monitoring at the community level, and
supporting referral systems.
In the near future, non-communicable diseases
(NCDs)—led mainly by cardiovascular diseases, can
cers, and mental illness—and injuries will add to the
list of common affl ict ions t hat burden the poor and that
escalate costs of heait h care systems.
Tobacco 4s the most prominent cause of NCDs, along
with alcohol abuse and intake of foods high in saturated
fat. In many middle-income countries, cardiovascular
diseases are already the leading cause of death, and in
low-income countries they are becoming increasingly
important. Tobacco is a particularly difficult develop
ment challenge because:
annual deaths from tobacco will increase signifi
cantly over the next three decades, exceeding
combined deaths from AIDS, tuberculosis, and
the complications of childbirth by 2025 (see Fig
ure C.4 adapted from Global Burden of Disease);
half of tobacco deaths will occur during people’s
productive lives (35-69), with an average loss of
20 to 25 years of life;
tobacco consumption is most common among the
poor, rising rapidly in low-income countries;
related diseases are expensive to treat and they
compete for funding with other priority areas; and
tobacco causes at least a US$200 billion net eco
nomic loss globally, or about 1 percent of world
GDP.
I\c emerging or New Communicable Diseases
Increasing human mobility and t he spread of ant imi
crobial resistance have contributed to increased threats
64
The prevalence of debilitating or fatal injuries—duo
to road accidents, gender-based violence, homicide, and
‘
-
■
•
_
•
...
'
•'
■
'
-
•
Rise in DALYs Lost Due to Tobacco:
Worldwide, 1990 to 2020
100
Diarrhea
80
Tobacco
60
HIV
40
- 3
20
0
1990
2000
2010
2020
Year
, )
Core Population-Based Preventive Services
FIGURE C.4
)
A
these populations. Mortality from coronaiy heart
disease fell by more than one-third among Polish
men and women from 1991 to 1993, largely be
cause of declines in intake of saturated fat. These
dietary changes occurred when the government
ended subsidies for meat and dairy products,
chiefly butter subsidies.
Inter-sectoral coordination, legislation, and mass
education for road safety.
Undertaking appropriate research and develop
ment for these NCDs and injuries, including im
proved epidemiological and economic studies,
and better low-cost treatment and management
algorithms.
suicide will continue to rise. Current experience shows
that alcohol 2nd other intoxicants are major contribut
ing factors. Road injuries could become the third big
gest cause of disability and death by the year 2020
(comprising 5 percent of the burden of disease). Often
it is the world s poor who are most adversely affected by
these conditions since they have less access to quality
curative health services.
The best responses to NCDs and injuries are largely
policy-based. These include:
Encouraging tobacco control with; (a) high
prices; (b) serious and prominent health warn
ings, as in Thailand; (c) complete bans on adver
tising and promotion of all tobacco-associated
products or trademarks, as done in Turkey and
Slovenia; (d) focused mass media education mes
sages; (e) increasing capacity to monitor tobacco
burdens and control responses and to lobby for
control; (f) restrictions on the ability of the to
bacco industry to target young smokers and the
poor.
Providing low-cost clinical treatments for those
with existing clinical conditions. For example,
aspirin, beta-blockers, and diuretics cost about
US$1 to US$5 per month, and reduce mortality
after a major cardiovascular event by about 25
percent.
Not subsidizing meat or saturated fat production
in countries with prevalent, heart disease, because
such subsidies may help the rich more than the
poor, and because of adverse health impacts in
Central to the management of all population health pri
orities is an-infrastructure that sustains specific techni
cal capability in health promotion and disease control.
Such an infrastructure includes primary and continu
ing professional education in population-based health
skills such as epidemiology, biostatistics, policy analysis
and development, media communications, health edu
cation, environmental and occupational health, and
cultural awareness (see Figure C.5 for the process of af
fecting communication change).
The Process of Behavior Change
Unaware
♦
Knowledge
& Awareness
♦
Motivated
to Change
... J
j • Raise ewarerwss
’ • Recommend solution
• Identify barriers & baneftts
•-, . ..
J • Provide togisticaf Inforrmtion
i _ . ’ « Provide HTformaticn
Tries New
Behavior
• Reduce bamer# & bukf dulls
... • Provide social support
__
Sustains New
Behavior
] • Provide rerrnnders of benefits
j • Enure sustxnability
FIGURE C.5
An educated health workforce can best apply the core
functions of population health delivery. These core func
tions include (a) assessment: the identification, quanti
fication, and description of population health problems;
65
<
I
3'
I
i
i
f 1
I
(b) policy development’, regulation, analysis, advocacy,
and political action; and (c) assurance: evaluation and
improvement of policies and interventions intended to
solve health problems. Thus, population approaches may
support direct individual service delivery to ensure that
all persons identified as at risk for a given health prob
lem have access to and utilize an intervention. More
importantly, the population health infrastructure is re
sponsible for leadership, policy development, and ana
lytic work necessary to solve problems that impact on
the larger public good.
Finally, it must be emphasized that the nature of the
population health approach is inherently political. For
example, the poor are adversely affected by market forces
that seek to sell harmful products, and thus, political
action is necessary to contain these forces, just as envi
ronmental action is necessary to contain vectors of com
municable diseases such as mosquitoes.
Communication and information dissemination mo
bilize public opinion to support not only changes in per
sonal health behavior but changes in population-based
health matters. Regulation, taxation, and targeted in
terventions often evolve from political action at the
community and national level. Thus, intersectoral col
laboration must include a political effort, driven ulti
mately by a trained population health infrastructure that
identifies population health problems.
Several of these population health problems are par
ticularly amenable to behavior change, policy, and other
I
66
Global Burden of Disease and Injury
Attributable to Selected Risk Factors
Risk Factor
% Of
% Of
Deaths total YLLs
(mil) deaths (mil)
total
YLLs
YLDs
(mil)
% of
% Of
total DALYs total
YLDs (mil) DALYs
200
4 2
219
15.9
93
6.8
49
3.5
2.1
36
2.6
28
6.0
48
3.5
3.3
38
2.7
1 4
Malnutrition
5
117
199
22.0
Poor water.
Sanitation
3
5.3
85
9.4
8
Unsafe sex
1
2 2
28
3.0
21
4 5
Tobacco
3
6.0
26
2.9
10
Alcohol
1
1.5
20
2.1
Occupation
1
2.2
22
2.5
15
Hypertension
3
5.8
18
1 9
1
0.3
20
Inactivity
2
39
11
1 3
2
05
14
1.0
Illicit drugs
0.2
3
0 3
6
1.2
8
0.6
Air pollution
11
6
06
2
03
7
0.5
YLD = Years of Life Disabled
YLL = Years of Life Lost
DAI Y = Disability-Adjusted life Year
FIGURE C.6
public health approaches. They have been identified as
preventable risk factors by Murray and Lopez in The
Global Burden of Disease, 1996 (see Figure C.6). These
risk factors accounted for almost 20 million prevent
able deaths and for almost 40 percent of DALYs in
1990. Many governments are trying to incorporate this
set of risk factors in their country-specific health pro
gram strategies.
III
6
I
2
4
4
H
4
4
4
4
JI
A FM N F X D
4
Ji
4
4
4
4
4
I
I
4
4
World Bank Organizational Charts
r
^^pulauonseaor Strategy
5
The World Bank Group
ICSID
IBRD
MIGA
IDA
IFC
International Bank for Reconstruction and Development (IBRD)
International Centre for Settlement of Investment D sputes (ICSID)
Multilateral Investment Guarantee Agency (MIGA)
International Finance Corporation (IFC)
International Development Association (IDA)
FIGURE D.1
Bank Senior Management and New Technical Networks
Board of Governors
Executive Directors
I
_
PRESIDENT
.... - ' .•:
Managing Directors
4 Networks
6 Regional Vice Presidencies
II _l__
s
H
Is
H-«
II
5°
J •“
<4="^I , * J(z ZTS L—J
c 3
S E
UJ <
if
«8
/
\Dewtopme*/
i
HNP
FIGURE D.2
68
Education
Social
Protection
■r.
_____
.A
I3
3
3
3
3
3
AN NEX E
3
HNP Sector Portfolio
and Management Indicators
3
3
3
3
3
L Introduction
This Annex presents a set of selected indicatore for Bank
( portfolio performance and management based on the
standard CAS presentation, adapted forthe purpose of
4
this cross-cutting Sector Strategy Paper.
disci:us. A brief
--------1 sion and statistical data are provided under each of the
following categories:
3
IBRD/IDA Lending to HNP and Other Sectors
Status of IBRD/IDA Operations in HNP
IFC and MIGA Operations in HNP
Country-Specific Analytical Work in HNP
Selected Portfolio Performance Indicators
IBRD/IDA Lending to HNP and Other Sectors
This section-compares HNP lending to overall Bank
ending. During the past ten years alone, annual lend
ing directed towards sectors that have a major impact
on health, nutrition, and reproductive outcomes (HNP,
education, social protection) increased from about USS 1
billion in 1986 to over US$5 billion in FY96, or from 8
to 24 percent of the US$21 billion in new loans (see
Figure E.I and Table E.I).
During the past ten years, cumulative HNP lending
has tripled compared with Bank lending to other sec
tors, increasing from less than 1 percent of total cumu
lative lending in FY86 to more than 3 percent in FY96
- FvIcFi8Ure E'2)' A"nUal le,lding to the HNP sector in
„ 1' Y96 reached a record high of 1 1 percent of Bank lend
HD Lending Reaches 24 Percent
of Total Bank Lending in FY96
Agriculture 14 1%
Power 13 1%
|BK Water Supply 2 9%
Te^ 0.2%
23%: ggL Urban Devei
4.1%
HeeS* Environment 1 8%
Mum Sector 7 1%
24% ;
Ou & Gas 0 3%
HNP 11%
finance 6 4% \/\/
/ Education 8.0%
Mining 3 2%
Social proteaion 4 ?%
Transponauon 13 0% ~ ~ “
Industry 1 1%
figure e.i
ing or US$2.4 billion in new commitments (see discussion below for more details).
In addition to activities that have a direct impact on
health, nutrition, and population outcomes, an addi
tional 23 percent of total Bank lending is devoted to
agriculture, water supply, environment, and rural/urban
development, all of which have an indirect impact on
HNP outcomes.
Status of IBRD/IDA Operations in HNP
This section provides information on the sectoral dis
tribution of the Bank's current lending and proposed
69
I
I
and Populate Sector Strategy
.1
Cumulative HNP Portfolio As Share
of Overall Bank Lending
FY86 to FY97: New Commitments
and Disbursements in HNP Sector
Percentage
I
US$ Millions
3.5 r------------
2,500 ---------
3.0 -
■
■
2.5
S
2.0 -
(
1
—— Disbursements
T
■fl
all
...Is■ I III ___
lilt
<
1.5
i New Commitments
2,000
SI
1,500
S
1,000 ■
1.0 -
500
0.5
11
I
J
Fl
otS
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
I ........... ...soil
£
s... .
.......
ISl
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Fiscal Year
Fiscal Year
FIGURE E.2
FIGURE E.3
ftJ-'
pipeline in the HNP sector (see Table E.2). The Bank’s
activities in the HNP sector have grown steadily during
r
the past decade to the point where it is now the single
largest external financier in low- to middle-income coun
tries, with 154 active projects in 82 countries and an
nomenon. Based on the planned pipeline, there will
be strong continued growth during FY98-FY00, with
an expected annual lending of about USS 1.5 billion
ing from FY94 to FY96 in HNP was in the form of IDA
and approximately 22 new projects per year. As of June
97, cumulative disbursements in the HNP sector
ued to rise, it varies considerably from year to year. FY96
was a record high, with US$2.4 billion in new commit
ments (see Figure E.3). The reason for the marked in
crease in FY96 was the approval of five unusually large
loans (ranging from US$270 to US$350 million and
J
dation that took place in FY97 is a temporary phe
active portfolio value of US$9.2 billion at the end of
FY96 (1996 prices). About 48 percent of Bank financ
credits, targeted to poor countries.
Althoughthe cumulative portfolio value has contin
i
There are good reasons io believe that past growth
in the HNP sector will continue and that the consoli
above) in Argentina, Brazil, India, Mexico, and Russia,
bringing the average loan size to US$102 million com
pared with the usual US$50 to US$60million range for
the sector.
FY97 approvals for HNP are expected to be around
US$0.9 billion. This decrease in new commitments com
pared with FY96 reflects several factors: (a) a ret urn to
16 new projects per year, similar to the FY94 levels (all
regions except SAS were affected, but the drop was most
pronounced in LAC and MNA); (b).intensified super
vision efforts during FY97 in response to recommenda
tions by the Quality Assurance Group that the Bank
carry out a portfolio cleanup during FY97; and (c) reallo
cation of staff resources to set up the new professional
networks.
70
amounted to US$5.4 billion and the total undisbursed
amount was US$6.2 billion. Disbursements in HNP
for FY97 are expected to reach US$1.5 billion. A ma
jor challenge for the HNP sector is to sustain the an
ticipated growth without compromising quality and
development impact.
The population size of member countries varies from
less than 1 million (e.g. Virgin Islands) to more than 1
billion (e.g. China). Both the Bank’s budget resources
and lending commitments per capita have in the past
favored smaller countries (see Figure E.4). Since over
90 percent of t he world s poor live in twelve of the Banks
largest client countries, this lending pattern must be
adjusted to target poverty groups more effectively in the
future.
There are also significant regional variations in past
total lending and the future pipeline. The South Asia
and LAC regions are major users of HNP lending, cur
rent and projected (see Figure E.5). South Asia has 13
completed projects, 23 that are active, and seven in the
pipeline for approval in FY98 through FY99. Many of
the countries in the ECA region only joined the Bank
J
Annex E HNP Sector Portfoho.^^^
*
million in FY96 (See Table E.3). However, it is antici
pated that IFC activity in the health sector will increase
in the near future. MIGA does not have an HNP
Bank Lending per Capita for HNP
Less in Large Countries
Program.
Lending in US$ per capita
ioo.oo-------------- - —
------------ -————•
Country-Specific Analytical Work in HNP
Argenuna
5
♦
This section provides information on country-specific
analytical work (see Table E.4). A total of US$3.9 mil
lion was spent on country-specific analytical studies or
economic and sector work (ESW) in FY96, about 5 per
cent of spending on ESW Bank-wide.
10.00 -
1.00 -
Morocco
|
Mextcn
4
BiaziI
Vietnam *
Senegal w
#
4 Russia
Yenicti
4
4
* • Indonesia « imjuj
Kenya
Pakistan
Pt »< lippines
• Bangladesh
Coie d'Ivoire
♦Egypt
J_____
10,000
,000
100
10
Population
A
FIGURE E.4
J
0
0
0
during the past five to ten years. This has led to a rapid
rise in commjtmentsin that region. Lending to East Asia
could fall during the next three years, as some countries
become ineligible for IDA credits and must consider
IBRD loan terms.
IFC and MIGA Operations in HNP
IFC approvals in the health sector declined from US$61
million in FY94 to US$30 million in FY95 and to US$1
I
I
I ’
10
I •
11
This section provides information on selected HNP
portfolio performance indicators (see Table E.5). As
described in Chapter II, the current HNP lending port
folio is keeping pace with Bank-wide averages in terms
of the number of projects rated successful in terms of
development objectives and implementation progress
(see Figure E.6).
HNP loans grew in size from an average of US$21
million per loan in FY81 to about US$102 million in
FY96, both amounts expressed in 1996 prices. The FY96
Bank average per project was US$83 million. FY96 was,
however, an unusual year in this respect. In FY97, the
average loan size in the HNP sector was about US$60
million. This is still up from the US$45 million loan av
erage in FY95. Resources allocated to the preparation
Stable Portfolio Performance
Variation in HNP Lending by Region
(Annual Average Value)
Successful Projects (%)
583
South Asia
I ?89
■KS 552
Latin America and Caribbean
~-~l 504
Africa
Europe and Central Asia
I
i: z
Selected Portfolio Performance Indicators
East Asia and Pacific
Middle East and North Africa
'• "I 201
■s,
100 |-----------
Development
so - rE
Objectives
60 -
E
40 ’
m
20 ’
■M
°
1993
1994
ES 1997-99
■■I 118
□ 1994-96
0
400
FT . .
100
200 300
1996
Successful Projects (%)
Implementation
100
Progress
80
■■■ 135
~1 233
1995
500
600
60
EH Bankw de
40
■ HNP
20
E3 Education
r® i
0
1993
1994
1995
1996
USS millions
FIGURE E.5
FIGURE E.6
71
X
I
I
Nutrition, and Population Sector Strategy
and supervision of HNP operations has grown, but less
rapidly than the average loan size (see Table E.5).
A further test of the performance of the portfolio is
the ability of the Bank to mobilize additional resources
for the HNP sector through domestic and other donor
resources. There are some notable success stories in this
respect. For example, the Bangladesh Fourth Popula
tion Project (FY92) includes IDA financing of US$180
million, complemented by US$165 million from the
government and US$256 million from a consortium of
11 donor organizations. Thus the project mobilizes 3.3
times as much resources as the IDA credit. Another
example is the Zimbabwe Second Family Health Project.
In this case, the IBRD financing of US$25 million was
matched by US$53 million from the government and
US$37 million from a consortia of five donors.
These efficiency measures are affected by the use of
consultant trust funds as a major source of support for
HNP project preparation. Trust funds allow managers
to free up Bank resources for sectoi work and project
supervision. Today, such trust funds add over a third to
the Bank’s own administrative budget in the HNP sec
tor (see Figure E.7).
The HNP sector has also been more successful than
the Bank on average in mobilizing external budgetary
72
Increased Reliance on Trust Funds
for Core Administrative Functions
In millions (1996 prices)
40 p
Trust Funds
35 30 25 20 15 -
10 AdrmnisD'ative Budget
5 -
■
I
I
I
I
'l986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
0 -
Fiscal Year
FIGURE E.7
resources, especially Japanese Trust Funds. In the Af
rica region, for example, trust funds that support HNP
work exceeded the available Bank administrative bud
get in FY97.
___ ________________________________________
Table E.1 IBRD/IDA Lending Program, FY 1994-2000
FY94
FY96
FY97
FY98
FY99
FYiyj
20,836.0
22,521.7
21,352.2
19,559.5
28,086.7
33,128.6
26.90.9
17.0
10.4
7.7
4.9
7.2
3.1
0.1
6.9
5.5
4.3
3.4
O.9
2.0
15.9
6.0
4.7
9.3
9.3
10.0
3.7
13.6
1.3
0.1
13.8
2.7
5.0
3.9
4.1
1.4
9.8
7.7
4.4
11.8
8.0
13.1
4.1
6.7
12
32
7.0
0.3
11.0
8.8
4.7
02
13.0
4.1
2.9
18.5
5.2
9.8
kl
6.2
1.0
1.6
11.0
0.7
-5.1
6.1
7.0
0.0
19.1
4.2
3.5
13.0
8.6
10.9
2.3
6.0
0.6
3.7
9.1
2.9
45
6.3
4.2
0.4
14.5
6.6
6.5
14.8
8.7
10.1
5.9
6.4
2.7
0.0
5.7
0.3
8:9
45
34
0.1
15.0
6.8
6.9
13.0
7:1
82
6.3
3.7
O.4
0.0
2.6
3.0
11.3
5.7
4.8
0.0
18.4
7.4
8.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
13.8
86.2
23.6
76.4
21.1
78.9
26.0
74.0
16.9
83.1
10.9
89.1
7.9
92.1
100.0
100.0
100.0
100.0
100.0
100.0
100.0
Disbursements (OSSm)
Adjustment loans0
Specific investment loans and others
4303.7
11687.4
4710.5
13665.8
4726.9
14043.8
4228.4
13446.5
800.4
16628.8
111.1
12600.8
12.0
8550.8
Repayments (L'S$m)
11610.4
12289.4
12720.9
11742.9
0.0
0.0
0.0
Interest (US$m)
8249.8
8612.6
8747.3
7305.0
0.0
0.0
0.0
Category
CommitmenLs fpSSm)
A
A
5
Sector (%)b
Agriculture
Education
Electric Power & Energy
Environment
Finance
Industry
Mining
Multisector
Oil & Gas
Population, Health, Nutrition
Public Sector Management
Social Sector
Telecommunications
Transportation
Urban Development
Waler Supply & Sanitation
tr
TOTAL
Lending instrument (%)
Adjustment loans0
Specific investment loans and others
TOTAL
6
Plametf
Current
Past
FY95
a. Ranges (hat
that reflect the base-case (i.e^ most likely) scenario. For IDA countries, planned commitments are not presented by FY but as a three year-total range; the figures are
shown in brackets. A footnote indicates if the pattern of IDA lending has unusual characteristics (e g., a high degree of frontloading, backloading, or lumpiness). For blend countries. •
planned IBRD and IDA commitments are presented for each year as a combined total
b. For future lending, rounded to nearest 0 or 5%. To convey the country strategy more clearly, staff may aggregate sectors.
c. Structural adjustment loans, sector adjustment loans, and debt service reduction loans.
Note: Disbursement data is updated at the end of the first week of the month.
I
1
a
73
in HNP: IBRD Loans and IDA Credits in the Operations Portfolio
Table E.2 Status of Bank Group Operations
---------- ------ --------------------—
Original Amount in US$
Project ID
Fiscal
Year
Country
Project Name
Total
Project
Cost
IBRD
Elapsed Elapsed
Time
Time
ebetween
between between
Expected
Approval Initial
Environ- Develop
and
EPS and
ment
ntent
Impleand
ment
Actual
Board
DisburseCategory
Objective
mentation
Effective
Undis
Approval
mend
b
Progress
ness
bursed
————Dtfjerenc
"
IDA
Cancel
lations
Number of closed projects: 94
Active Projects
AL-PE-825 3
AO-PE-48
AR-PE-43418
AR-PE-6059
AR-PE-45687
AR-PE-40909
AR-PE-6030
AR-PE-6025
BA-PE-44522
BA-PE-44424
BD-PE-9496
BD-PE-9529
BF-PE-308
BF-PE-287
BG-PE-8318
BI-PE-216
BJ-PE-118
BJ-PE-98
BO-PE-6166
BR-PE-6554
BR-PE-6546
BR-PE-6403
CI-PE-1214
CL-PE-6639
CL-PE-6672
CM-PE-411
CN-PE-3589
CN-PE-37156
CN-PE-3634
CN-PE-3502
CN-PE-3624
CN-PE-3483
CO-PE-6854
CR-PE-6954
EC-PE-7087
EE-PE-8402
EG-PE-5163
EG-PE-5152
Albania
1995
Angola
1993
Argentina
1997
Argentina
1997
Argentina
1996
Argentina
1996
Argentina
1996
Argentina
1994
Bosnia-Herzegovina
1997
Bosnia-Herzegovina
1996
Bangladesh
1995
Bangladesh
1991
Burkina Faso
1994
Burkina Faso
1994
Bulgaria
1996
Burundi
1995
Benin
1995
Benin
1989
Bolivia
1990
Brazil
1996
Brazil
1994
Brazil
1990
Cote d’Ivoire
1996
Chile
1993
Chile
1992
Cameroon
1995
China
1996
China
1995
China
1995
China
1994
China
1992
China
1989
Colombia
1993
Costa Rica
1994
Ecuador
1993
Estonia
1995
Egypt
1996
Egypt
1992
Health Service Rehabilitation
Health
AIDS Prevention & STD Control
Maternal Child Health II
Health Insurance Task
Health Insurance Reform
Health Sector Development
Maternal Child Health & Nutrition
Essential Hospital Service
War Victims
Nutrition
Population & Health
Population/AIDS Control
Health/Nulrition
Health Sector Restructure
Health/Population II
Population & Health
Health Services Development
Integrated Health Development
Health Sector Reform
AIDS Control
NE Basic Health Service II
Population. Health and Nutrition
Health Sector
Technical Assistant & Rehabilitation
Health/Fertilization/Nutrition
Disease Prevention
Iodine Deficiency Disorder
Maternal Child Health
Rural Health Manpower
Infectious Diseases
Health Services
Municipal; Health Service
Health Sector Reform
Social Development Il/Health & Nutrition
Health
Population
Schistosomiasis Control
12.40
14.50
10.90
22.20
15.00
30.00
100.00
171.00
25.00
29.80
350.00
1500.00
101.40
144.00
100.00
160.00
15.00
33.50
5.00
30.00
59.80
67.30
180.00
600.00
26.30
23.40
29.20
40.50
26.00
47.10
21.30
36.70
27.80
34.10
18.60
32.00
20.00
40.00
300.00
750.00
160.00
250.00
267.00
610.60
40.00
51.00
90.00
298.80
27.00
45.30
43.00
48.08
100.00
200.00
20.00
7.00
330.00
90.00
138.70
110.00
192.00
129.60
271.00
52.00
113.00
50.00
100.00
22.00
50.00
70.00
102.20
18.00
34.50
17.20
19.35
26.84
44.70
*
C
2.15
8.76
T
12.70
14.74
C
15.00
B
100.00
C
-0.33
16.97
C
13.62
200.00
B
17.63
96.43
C
22.78
48.22
C
2.76
14.47
c
3.07
4.87
c
4.96
54.21
c
37.74
47.63
T
3.92
21.60
C
3.09
22.44
C
6.03
25.96
C
4.35
18.95
C
7.95
24.12
C
3.27
4.76
C
2.94
5.23
B
16.09
272.75
C
0.27
38.92
T
77.95
27.95
50.00
C
I. 29
37.08
B
35.83
43.29
C
3.25
3.25
C
12.45
38.58
C
22.40
87.76
C
16.00
20.95
T
5.13
43.43
C
24.33
58.02
C
48.10
67.85
C
-3.53
0.17
c
23.02
42.87
c
II. 27
16.81
c
19.19
38.04
c
7.21
17.37
c
1.54
16.56
c
13.69
22.55
<
T
s
u
s
s
3
7
HS
HS
HS
S
S
S
S
S
S
S
S
S
S
S
s
s
s
s
s
s
s
s
s
s
s
s
s
u
s
s
3
s
s
s
s
u
s
s
s
s
s
6
7
13
HS
s
u
s
s
u
s
s
6
3
4
10
6
10
3
3
4
8
7
18
HS
HS
<
7
2
3
2
2
9
12
14
7
9
14
7
7
s
s
s
s
s
u
s
s
s
u
s
s
u
s
u
s
u
s
T
f
10
6
12
f
32
38
15
8
12
12
24
19
9
6
61
32
17
84
37
85
35
31
27
12
17
33
20
28
9
57
13
30
22
42
16
27
72
21
16
15
17
32
r
f)
All
4
<)
<>
1
<;
<
cn
ET-PE-71!
GE-PE-8414
GH-PE-897
GM-PE-822
GN-PE-1070
GQ-PE-649
GW-PE-1002
GZ-SF-35996
HN-PE-7392
HR-PE-39450
HT-PE-7311
HU-PE-8484
ID-PE-42540
ID-PE-41896
ID-PE-39643
1D-PE-3965
ID-PE-3914
IN-PE-44449
IN-PE-10531
IN-PE-10511
IN-PE-10473
IN-PE-35825
IN-PE-10489
IN-PE-10457
IN-PE-10455
IN-PE-10424
IN-PE^9977
IN-PE-10393
IN-PE-9963
IN-PE-10361
IN-PE-9940
IN-PE-9932
IR- PE-5222
JO-PE-5319
KE-PE-1333
KE-PE-1339
KE-PE1312
KG-PE-8523
KH-PE-4034
KM-PE-596
LA-PE4200
LB-PE-34004
LK-PE 10526
LS-PE-1395
MA-PE-42415
MA-PE-5440
MG-PE-1520
MK-PE-36089
MEPE1727
MR-PE-1855
1988
1996
1991
1990
1994
1992
1993
1995
1993
1995
1990
1993
1997
1996
1996
1995
1993
1997
1997
1997
1997
1996
1995
1994
1994
1993
1993
1992
1992
1991
1990
1990
1993
1993
1995
1992
1990
1996
1997
1994
1995
1995
1997
1990
1996
1990
1991
1996
1991
1992
Family Health
Ethiopia
Health
Georgia
Health & Population II
Ghana
Women in Development
Gambia. The
Heallh/Nutrition Sector
Guinea
Health Improvement Plan
Equatorial Guinea
Social
Guinea-Bissau
Occupied Territories Education & Health Rehabilitation
Nutrition/Health
Honduras
Health Project
Croatia
Health & Population
Haiti
Health Services
Hungary
Iodine Deficiency Control
Indonesia
Capacity Building
Indonesia
Sexually Transmitted Diseases/AIDS
Indonesia
Health IV: Improving Health
Indonesia
Health
Indonesia
Rural Women Development
India
Reproductive Health
India
Malaria Contro)
India
Tuberculosis Control
India
State Health System 11
India
Ffealth
India
Population IX
India
Blindness Control
India
National Leprosy Elimination
India
ICDS II
India
AIDS Prevention
India
Population VIII
India
ICDS I
India
Population Training
India
Nutrition
India
Iran, Islamic Rep. of Health & Family Planning
Health II
Jordan
Sexually Transmitted Diseases
Kenya
Health Rehabilitation
Kenya
Population IV
Kenya
Health
Kyrgyz Republic
Disease Control & Health
Cambodia
Population & Human Resources
Comoros
Lao Peoples Dem. Rep. Health System Reform
Health Project
Lebanon
Health Services Developtnertt
Sri Lanka
Health/Population II
Lesotho
Health
Nforocco
Health Sector Investment
Morocco
National Health Sector
Madagascar
Health Sector Transition
FYR Macedonia
Health/Population
Mali
Health/Population
Mauritania
49.60
19.70
34.40
15.10
27.30
6.00
13.00
20.00
54.20
40.00
33.70
132.60
45.30
25.00
35.20
276.00
164.10
53.50
309.00
170.00
142.40
425.00
158.90
130.00
137.80
135.50
248.80
99.60
88.00
315.00
313.40
13940
294.00
30.00
95.00
34.00
37.00
20.10
35.60
16.00
24.00
35.70
22.60
21.50
6865.00
171.30
42.50
19.40
61.40
24.40
33.00
14.00
27.00
7.00
24.60
5.50
8.80
10.83
12.73
2.66
1.13
18.27
1.9$
2.93
25.00
3.96
13.73
22.09
69.03
27.50
19.41
24.07
82.41
37.37
18.79
249.80
164.80
136.94
315.56
117.23
75.7?
101.17
59.20
171.67
32.07
71.38
40.00
28.20
91.00
28.50
20.00
24.80
88.00
93.50
10.00
10.00
19.50
248.30
164.80
142.40
35O.O0
133.00
88.60
117.80
85.00
194.Q0
84.00
79.00
96.Q0
86.70
95.80
141.40
20.00
40.00
31.00
35.00
18.50
30.40
13.00
19.20
35.70
18.80
12.10
68.00
104.00
31.Q0
16.90
26.60
15.70
31.65
32.74
29.81
22.4?
8.69
3.49
105.03
18.48
33.75
18.91
26.80
16.5?
28.67
4.4fc
J5.90
34.75
18.09
3.83
68.00
16.75
9.65
16.18
6.07
3.51
10.48
0.89
1.49
0.45
2.24
1.86
2.41
10.67
3.03
13.73
19.07
45.33
-0.50
1.26
7.02
-5.49
5.21
2.32
12.01
18.24
11.99
19.43
35.46
72.26
29.76
44.97
44.18
37.34
22.87
80.27
6.18
7.45
18.94
24.63
-0.11
2.80
0.97
2.43
13.34
1.25
2.81
1.50
16.75
7.69
5.06
3.89
1.45
S
S
S
S
C
C
c
c
c
c
c
c
c
c
c
c
c
c
c
c
T
B
T
C
T
T
C
C
C
C
C
T
C
C
T
C
C
c
c
c
T
B
C
T
C
T
C
C
C
C
B
C
s
s
s
s
s
s
s
S
U
U
U
S
U
S
HS
S
HS
u
u
s
s
s
s
s
u
s
u
s
s
s
9
4
6
7
9
6
5
3
8
6
5
6
2
4
3
3
7
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
u
s
u
u
s
s
23
4
10
HS
HS
6
s
u
s
s
s
s
s
s
s
s
5
10
3
4
7
7
11
s
s
s
s
s
s
s
s
HS
s
4
3
3
3
8
9
6
6
6
1
12
5
8
6
5
6
12
7
21
15
45
31
44
47
35
7
16
5
27
19
15
10
13
35
71
13
24
20
41
14
18
22
22
17
51
7
30
29
17
26
9
44
15
47
10
25
13
38
71
13
28
32
39
18
49
21
54
56
(Table Continues on the following page.)
CD
Table E.2 (continued)
Original Anujunt in USS
Fiscal
Year
Project ID
1991
1996
1994
MW-PE-1646
MX-PE-7689
MY-PE-4312
MZ-PE-1792
MZ-PE-1801
MZ-PE-1787
NE- PE-1999
NE-PE-1976
NG-PE-2106
NG-PE-2094
NG-PE-2125
NG-PE-2091
NI-PE-7778
NP-PE-10460
PA-PE-7846
PE-PE-8048
PG-PE-4399
PH-PE-4567
PH-PE-4568
PH-PE-4518
PK-PE-37827
PK-PE-10492
PK-PE-10414
PK-PE-10371
PL-PE-8587
PY-PE-7927
RO-PE-8759
RU-PE-8814
RU-PE-38571
RW-PE-2237
RY-PE-5910
RY-PE-5822
SL-PE-2422
SN-PE-41567
SN-PE-35615
ST-PE-2542
TD-PE-35601
TD-PE-509
TD-PE-520
TN-PE-5738
TN-PE-5717
• A
A
1996
1993
1989
1997
1992
1991
1991
1990
1989
1994
1994
1995
1994
1993
1995
1993
1989
1996
1995
1993
1991
1992
1997
1992
1997
1996
1991
1993
1990
1996
1997
1995
1992
1995
1994
1990
1991
1991
■
»
'A
Country
Total
Project
Cost
Project Name
Health, Nutrition & Population Sector Credit
Malawi
Basic Health II
Mexico
Health
Malaysia
Health Sector Recovery
Mozambique
Food Security
Mozambique
Health & Nutrition
Mozambique
Health II
Niger
Population
Niger
Health Fund
Nigeria
Population
Nigeria
National Drugs
Nigeria
Health & Population
Nigeria
Health Sector Project
Nicaragua
Population & Health
Nepal
Rural Health
Panama
Basic Health/Nutrition
Peru
Papua New Guinea
Population Project
Women's Health & Safe Motherhood
Philippines
Urban Health & Nutrition
Philippines
Health Development
Philippines
Northern Health
Pakistan
Population Welfare
Pakistan
Family Health II
Pakistan
Family Health
Pakistan
Health
Poland
Mental Health/Child Development
Paraguay
Health Service Rehabilitation
Romania
Health Reform Pilot
Russia
Medical Equipment
Russia
Health & Population
Rwanda
Family Health
Yemen. Republic of
Health Sector Development
Yemen. Republic of
Health Sector
Sierra Leone
Endemic Diseases
Senegal
Community Nutrition
Senegal
Sao Tome and Principe Health & Nutrition
Population & AIDS Control
Chad
Health & Safe Motherhood
Chad
Social Development Program
Chad
Hospital Management
Tunisia
Population & Family
Tunisia
♦»
n
73.60
443.40
101.30
355.70
8.10
42.50
50.00
24.10
94.50
93.50
85.10
36.80
20.00
39.00
50.00
42.00
32.70
136.40
82.20
108.40
57.70
65.10
114.00
62.90
205.00
62.40
210.40
98.40
305.00
26.00
30.20
19.10
20.00
19.00
18.20
12.00
26.10
IBRD
IDA
55.50
310.00
50.00
98.70
6.30
27.00
40.00
17.60
16.00
70.00
78.50
16.20
11.74
68.10
27.60
15.00
26.70
25.00
34.00
6.90
18.00
70.00
70.10
26.70
65.10
48.00
45.00
130.00
21.80
150.00
30.00
66.00
66.00
252.18
16.88
23.74
10.49
17.69
15.03
14.05
5.89
15.87
8.08
1.89
16.34
3.95
19.60
26.60
15.00
20.00
14.90
18.20
11.40
20.40
18.50
23.20
30.00
26.00
1.
■
34.42
15.65
10.28
17.94
2.96
-28.89
0.57
5.99
49.06
50.69
35.36
16.72
2.09
11.53
12.96
11.55
3.88
1.66
17.94
2.50
33.05
287.81
38.94
87.63
4.08
1.35
38.83
7.91
38.66
66.41
22.31
4.98
5.40
24.66
22.96
24.11
5.84
17.62
59.67
2.50
25.61
56.04
37.73
31.15
53.72
21.22
55.70
270.00
30.00
53.80
49.50
63.20
Cancel
lations
Elapsed Elapsed
Differenc
Time
Time
e between
between between
Expected
Approval Initial
and
Environ- Developand EPS and
Actual
ment
ment ImpleUndis- Disburse- Category' Objective mentation Effective- Board
bursed mentsa
b
s
Progress ness Approval
2.66
9.47
15.93
20.78
61.86
0.17
55.70
-9.48
15.76
14.69
9.08
0.73
6.45
4.94
-1.05
-2.45
-15.05
16.21
3.95
l
<>
C
C
c
c
T
C
C
C
C
C
c
c
B
C
c
c
0
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
s
u
s
s
s
s
s
u
u
u
s
s
s
s
u
s
s
s
s
s
s
u
s
s
u
8
10
9
11
9
3
3
8
4
8
4
10
7
s
s
s
s
u
s
s
u
s
u
7
12
15
14
HS
s
s
s
s
s
s
s
7
10
S
HS
B
T
s
s
s
s
s
c
HS
> *
37
18
44
74
18
14
29
3
6
2
5
10
7
4
5
10
8
5
3
6
6
8
10
10
7
60
40
49
33
28
20
59
25
24
19
36
36
30
20
23
26
51
20
23
10
51
18
53
12
8
31
16
14
21
13
33
23
9
14
f*
f
I
I
A
■
1
o
<
TR-PE-9076
TR-PE-9030
TZ-PE-2774
UG-PE-2971
UG-PE-2963
UY-PE-8161
VE-PE-8215
VE- PE- 8227
VE-PE-8204
VN-PE-4841
VN-PE-4838
ZM-PE-3239
ZW-PE-33 3 3
ZW-PE-3302
1995
1989
1990
1995
1994
1995
1995
1993
1991
1996
1996
1995
1993
1991
Turkey
Turkey
Tanzania
Uganda
Uganda
Uruguay
Venezuela
Venezuela
Venezuela
Viet Nam
Viet Nam
Zambia
Zimbabwe
Zimbabwe
u> o o o €>
Sj?
Health II
Health I
Health & Nutrition
District Health
Sexual Transmission Intervention
Health Sector Development
Health Service Reform
Endemic Disease Control
Social Development
Population & Family
National Health Support
Health Sector
Sexual Transmission Intervention
Family Health II
200.00
146.30
70.00
63.00
70.00
28.00
108.00
188.00
320.90
133.00
127.20
557.00
87.30
117.00
TOTAL
24.095.03
Active Projects Closed Projects
2,691.89
121.77
2,683.21
577.87
5,375.10
699.64
Total now held by IBRD and IDA
8,787.80
1,982.71
10.770.51
0.00
0.00
7.95
7.95
7.95
7.95
6,183.27
20.53
6,203.80
Total undisbursed
O Q
150.00
75.00
47.60
45.00
50.00
15.60
54.00
94.00
100.00
20.00
15.00
50.00
101.20
56.00
64.50
25.00
4.390.40 4,752.34
u>
C>
136.17
27.16
24.00
37.30
40.41
13.55
51.72
47.17
52.44
45.83
93.19
46.78
34.34
6.27
<4
49.82
26.01
20.47
1.70
9.76
4.97
15.89
51.84
67.44
3.13
3.03
10.53
9.40
6.27
(j a
C
C
C
C
C
C
B
B
C
c
c
c
T
C
s
s
HS
HS
s
u
u
u
s
s
s
s
s
s
s
s
u
u
u
u
s
s
u
u
s
s
s
s
4
17
1
5
3
4
14
15
10
4
4
3
3
8
c* u >
70
35
26
19
58
27
32
17
16
24
51
18
8
42
253.14 6,183.29 1,916.86
Total
Total disbursed (IBRD and IDA)
Of Which repaid
Amount sold
Of which repaid
1
a. Intended disbursements to date minus actual disbursements to date us projected at appraisal.
b. The environment assessement category list is as follows:
A: Full environmental assessment required
B: Partial environmental assessment required
C: None required
D: Free-standing environmental project
T: lb be decided
“ 1“CT-b“5ed ,ystem W“ in,rodu“d («S=hi»hly
Note: Disbursement data is updated at the end of the first week of the month.
.. indicates data not available.
HU-hlghly
factory); „ Proposed Improvements In Project «rd
<
LJU
_
_ 1 Mk
JBk
A A UlHMi MMB,
Status of Bank Group Operations in HNP, 1997: IBRD Loans and IDA Credits In the Operations Portfolio
co
Project ID
1999
4034
6059
7927
8814
9095
10473
10511
10526
10531
36956
41567
42540
43418
44449
44522
TOTAL
FY98 to FY2000 Pipeline
Estimated FY98 Pipeline
Estimated FY99 Pipeline
Estimated FYOO Pipeline
■
>
Fiscal Year
Country
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
Niger
Cambodia
Argentina
Paraguay
Russia
Turkey
India
India
Sri Lanka
India
Indonesia
Senegal
Indonesia
Argentina
India
Bosnia-Herzegovina
Project Name
Health 11
Disease Control & Health
Mental Child Health 2
Mental Health/Child Develoment
Health
Primary Health Care Services
Tuberculosis Control
Malaria Control
Health Services Development
Reproductive Health 1
Safe Motherhood
Endemic Diseases
Iodine Deficiency Control
AIDS Prevention & STD Control
Rural Women’s Development
Essential Hospital Services
1997
Number
of Projects
27
42
40
Amount
US$m
1.260.1
2.955.2
3.033.6
Project Cost US$m
Amount US$M
50.0
35.6
171.0
31.2
100.1
200.0
142.4
203.9
22.6
309.0
40.0
19.0
45.3
30.0
53.5
33.5
40.0
30.4
100.0
21.8
70.0
15.0
142.4
164.8
18.8
248.3
40.0
14.9
28.5
15.0
19.5
15.0
1487.1
984.4
Discounted by 35%
Amount US$m
819.1
1.920.9
1,971.8
*>
<»
•r
O
O
dt
Table E.3 tFC and MIGA HNP Program, FY1994-1996
Past
Category
- 5
-
5
3
3
3
FY94
ms
FY96
IFC approvals (USSm)
Sector (%)
Financial Services
61
30
1
100
100
100
TOTAL
100
100
100
0
0
100
67
Investment instrument (%)
Loans
Equity
Quasi-equity”
Other
TOTAL
0
33
0
100
0
0
0
0
100
100
100
3
MIGA guarantees (US$m)
3
2
0
MIGA commitments (US$m)
Includes quasi-equity types of both loan and equity instruments.
Note:.. indicates data not available.
0
0
!
79
e
Table E.4 Summary of Economic and Sector Work
(US$ thousands)
Category
Last Fiscal Year Annual
FY97
FY98
FY99
6,445
6,179
2,347
5,332
2,075
171
144
Agriculture
3,279
Education
957
1,139
935
420
4.060
4,143
L324
30
4419
3^33
2,359
-0
5
904
5
486
8
0
461
0
0
31
71
0
17,453
14,535
16,496
658
1.752
699
386
3,867
3,239
1,821
252
Public Sector Management
7,762
4.107
275
Social Sector
Teiecommunicatioiis
5,338
4^62
3,964
3,078
410
394
262
79-
19
Transportation
3,208
1,486
98
Unidentified
14.213
13,472
672
8223
L363
Urban Development
1,204
1,228
1,056
"79
Water Supply & Sanitation
1321
821
682
0
76,537
63,183
49,476
4,004
Electric Power &4Energy
Environment
Finance
Human Resources
Industry
Mining
Multisector
Oil&Gas
Population, Health, Nutrition
TOTAL
c
r
Ongoing and Planned HNPEconomic and Sector Work, FY 1997-1999
Country
Project Name
Final Cover
$ Amount
(thousands)
Project ID
Fiscal Year
12930
15026
15837
16219
19389
19390
36239
36484
36485
36610
37171
38950
42453
43186
44882
45042
49394
49444
49445
49446
49519
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
1997
Estimated Number of Reports:
1996
Estimated Number of Reports:
1997
21
3.239
Estimated Number of Reports:
1998
15
1,821
Estimated Number of Reports:
1999
23
252
80
Mauritius
Health Sector Review
Africa Region
Bangladesh
Gender Action Plan
Population & Health Sector Strategy.
India
State Tlealth Reform
Azerbaijan
Poverty Assessment
Azerbaijan
Azerbaijan Health Note
Djibouti
Poverty Assessment
Kazakstan
Tlealth Sector Note
Tajikistan
Health Sector Note
Costa Rica
Poverty Assessment
Asia Region
Health Reform in Asia
Argentina
Health Financing
Russia
Health Sector Note
Ghana
Gender Strategy
Pakistan
Health Strategy
Philippines
Environmental Health Assessment
Russia
Social Challenges
Indonesia
Pharmaceuticals
Indonesia
Health Patterns
Indonesia
Health Financing
El Salvador
Rural Health Care
White
Green
Gray
White
Green
White
White
Gray
Yellow
Gray
White
White
While
Green
3.867
Table £.5 HNP Sector: Selected Indicators of Bank Portfolio Performance and Management
Indicator
FY94
FT95
FY96
FY97
122
139
4
154
151
4
4
Portfolio Performance
Number of projects under implementation
Average implementation period (years)3
Percent of problem projects rated U or HUb (for past years, rated 3 or 4)
Development objectives0
Implementation progress (or overall status for past years)'1
Canceled during FY in US$mr
Disbursement ratio (%)e
Disbursement lag (%)f
Portfolio Management
Supervision resources (total USS thousands)
Average supervision (USS thousands/project)
Supervision resources by location (in %)
Percent headquarters
PercenfTestderrt mission
Supervision resources by raring category (USS thousands/project)
Projects rated HS or S
Projects rated U or HU
4
12
7
8
7
20
15
15
21
80
129
52
75-
13
41
16
37
16
14
34
33
7.377
6,617
7,467
11,100
60
48
48
74
0
0
0
0
56
44
49
^2
57
47
50
48
53
74
80
51
a. Average age of projects in the Bank’s country portfolio.
b. Rating, scale: “HS" denotes highly satisfactory, “S" denotes satisfactory, “U” denotes unsatisfactory, and “HU" denotes highly unsatisfactory.
c. Extent to which the project will meet its development objectives (see OD 13.05, Annex D2, Preparation of Implementation Summary [Form 590]).
d. Assessment qf overall performance of the project based on the ratings given to individual aspects of project implementation (e.g., management, availability of funds, compli«nce with legal covenants) and to development objectives (see OD 13.05, Annex D2. Preparation of Implementation Summary [Form 590]). The overall status is not given a better
r*ting than that given to project development objectives.
e. Ratio of disbursements during the year to the undisbursed balance of the Bank's portfolio at the beginning of the year investment projects only.
f. For all projects comprising the Bank’s country portfolio; the-percentage difference between actual cumulative disbursements and the cumulative disbursement estimates as
tven in the “Original SAR/PR Forecast" or, if the loan amounts have been modified, in the “Revised Forecast" The country portfolio disbursement lag is effecuvely the weighted
r-'erage of disbursement lags for projects comprising the Bank’s country portfolio, where the weights used are the respective project shares in the total cumulative disbursement esti•nates.
Note: Disbursement data is updated at the end of the first week of the month. Supervision resources include Salaries, Benefits, and TYavel for all sources of funds but excludes
'AO staff and PCR task costs.
81
FW*'11
MB,-
£
vi
CJ
ANNEX F
HNP Sector Strategy Matrix
(FY 1998-2000)
V
<*
K-
AIV1FW WW
<
CO
i: i:
<
C, (,
<:
G <7
G' C €' €' €■ €' C a G' G G G c e O O O (J
HNP Sector Strategy Matrix (FY 1998-2000)
Bank Instruments
Lending/
Credits
Bank's HNP Sector Strategy
Progress Indicators
(See Annexes B to E)
9(X) million of 1.3 billion poor with- Improve the health, nutrition and
population outcomes of the world's
out access to basic health care
poor, and protect other segments of
the population from the impoverish2 million deaths annually due to
ing effects of illness by:
vaccine-preventable diseases
targeting of low income groups,
geographic locations, and pov
2(X) million children under 5 who
erty-related diseases, and ser
suffer from malnutrition and anemia
vices used by the poor
120 million couples without family • expanding equitable access to
basic health sendees
planning and 8.1 million maternal
• maintaining policy oversight in
and perinatal deaths annually
intersectoral areas such as rural
and urban development, social
30 percent of world without access
policy, education, agriculture,
to safe water and sanitation systems
and environment
Work closely wiih governments to
encourage them to provide, or mandate, affordable & cost-effective
services for the poor:
• basic immunization
• management of sick child
• maternal & perinatal care
• family planning
• targeted nutrition
• school health
• communicable disease control
Work with other sectors to ensure
healthy intersectoral policies such
as tobacco & alcohol control and
taxation, appropriate food subsi
dies, road safety. & environmental
issues
Health Indicators
• life expectancy
• infant and under-5
mortality
• adult mortality
• tobacco attributable illness
Nutrition Indicators
• low birth weight
• child malnutrition
• anemia
• obesity
Maternal and Reproductive Health
• fertility
• maternal mortality
Health Services
• access to basic care
• immunization coverage
FY98-00
Enhance the performance of health
care systems by:
• improving public services
(ensuring equitable access to
preventive and curative health
services that are affordable,
cost-effective, efficient, of good
Poorly regulated private sector lead
quality, responsive to consumer
ing to excess profit taking, problems
with quality control, ineffective
choice);
care, low coverage, and inadequate • harnessing non-governmental
resources more effectively (regrisk pooling
ulations, increased quality mon
itoring, licensing)
Pervasive patient dissatisfaction
Work closely with governments.
NGOs, and civil society to:
• strengthen policy making, gov
ernance. accountability, man
agement, and monitoring and
evaluation
• provide incentives for public
and private sectors to improve
efficiency, effectiveness, and
quality through competition
• foster partnerships with non
governmental providers
conduct consumer surveys
New indicators are needed in the
following areas:
• policy making, governance, and
management capacity
• access to health care
• utilization and demand
• efficiency and effectiveness
• quality control
• public and private providers
• consumer satisfaction
• regulatory systems
FY98-00
Secure sustainable health care
financing by
• mobilizing adequate levels of
health financing through broad
based risk pooling
44 low-income countries do not
have adequate financial resources to • maintaining effective public and
private expenditure control
pay the needed USSI0-USS20 per
• developing improved budget
capita for essential sendees
allocation processes at the
national and local levels
Some middle-income countries
Work closely with governments to:
• strengthen their policymaking
role and direct involvement in
health care financing, espe
cially in countries where health
care expenditure is less than 3
% or greater than 7 % of GDP
• use national health accounts and
other relevant data in policymaking processes
Coverage Through Risk-Pooling
• percentage of total population
Source of Financing
• general revenues
• social & private insurance
• user charges
• foreign aid
Expenditure categories
• by expenditure and service
• by public and private provider
• by recurrent expenditure
Use of micro and
mini loans to pilot
new lending
FY98-00
CAS and partner
dialogue
Increase health
financing
projects
Annually
Underlying HNP Issues
Developmen 1 Obj ec lives
Non-Lending
Other Partners
FY98-00
CAS&
partner dialogue
WHO, UNICEF.
UNFPA. UNDP.
UNAIDS. FAO,
ILO,
regional banks,
bilaterals, NGOs, &
private sector
A. SHARPENING STRATEGIC POLICY DIRECTIONS
Inadequate action by governments
in providing public health services
(underfinanced, low quality, poorly
managed, badly staffed, ill equipped
government inn services).
Low- and middle-income countries
consume US$250 billion in health
care (4 % of their GDP)
have uncontrolled cost escalation
Increase IDA and
IBRD loans for tar
geted programs for
the poor
Increase use of fis
cal instruments
(tobacco, alcohol
tax, etc.)
Annual
status rep
FY98
Regional
strategies
FY99
Country strategies
Use of micro and
mini loans to pilot
new lending
Increase in
sector-wide projects
FY98-00
CAS and
partner dialogue
FY98-99
OED and other
studies
WHO,
national agencies,
academic institutes,
and
private sector
OED. DEC. IFC,
PSD, and others
Develop indicators
Use SECALs
Use SECALs
Country and global
exp.
reviews
WHO,
national agencies,
academic institutes,
country debts, IMF
»
B. ACHIEVING GREATER DEVELOPMENT IMPACT
Human development (HNP. educa
tion. and social protection strate
gies) often poorly reflected in
CASs. CEM. and other documents,
and discussed only at low levels
Maximize policy impact
Focus attention on HNP priority
areas in ESW. CAS. and lending
Incr. inclusion of HNP priorities in
CASs, ESW, and lending operations
Elevate discussion on key HNP
issues to macro-level
Incr. inclusion of HNP priorities in
high-level country discussions
Drop in admin, budget for ESW and Underpin lending with better analy- Reverse recent cutbacks for sectoral
analyses and link research agenda
unfocused research
sis and research
more closely with operational priority areas in HNP sector
Inadequate supervision of opera
tional research components of
-Improve
,
. ■ ■ , •in design andj
quality
projects
supervision of operational research
Incr. allocation of administrative
budget for ESW, research, and
learning about HNP priority areas
Apply selectivity according to:
• the degree of consistency with
HNP policy objectives and
potential development impact
• impact on HNP outcomes for
large populations of the poor
• commitment by clients to sig
nificant reform
Incr. ESW and lending focused on
HNP priorities
Develop and maintain user-friendly
knowledge base in priority areas
Availability of help desks, on-line
database of reference and statistical
material, and knowledge base of
various aspects oi HNP systems
Unfocused portfolio (questionable
development impact in some cases)
Increase selectivity
Disproportionate Bank resources
spent on non-poor populations
Lack of clear commitment to
reform by some clients
Rapidly expanding underlying
knowledge base, but which is often
paper-based, disorganized, and
inaccessible
Improve quality of client services
Use broader range of instruments
(see attachment on sector wide
approaches and new instruments)
Narrow range of instruments used
Rigid application of business pro
cesses
Insensitivity and unresponsiveness
to clienl needs often leads to lack of
client satisfaction
Strengthen monitoring and evaluation (M&E) of impact
Country units, IMF,
DEC
Annual
status
reports
FY98-00
Country units, DEC
Annual
status
reports
Incr. consultation with technically
competent staff during design and
supervision of operational research
FY98-00
Country units
Annual
status
reports
Incr. ESW and lending in countries
with large poor population groups
Deer, lending in countries with lack
of commitment to reform
FY98-00
QAG. OED, CODE,
EDI
Annual
status
reports
Improve performance by applying
lessons learned, strengthening qual
ity at entry, and improving supervi- Improvements in QAG, OED, and
other quality ratings
sion of existing projects
Findings by OED, QAG. and other
groups often not implemented
Frequent lack of evidence-based
monitoring and evaluation (M&E)
criteria
FY98-00
External audit
Objective assessment of wider
application of lending instruments
Streamline business processes and
procurement procedures to HNP
Objective assessment of increased
flexibility in business processes and
procurement practices
Conduct client satisfaction surveys
Results of clienl satisfaction survey
Develop better M&E indicators
Tracking of development indicators
FY98-OO
Strengthen borrower and Bank
capacity and commitment to moni
toring and evaluation
Objective assessment of closer links
between HNP priority areas, project
design, and M&E
Annual
status
reports
OED, CODE
(Matrix continues on the following page.)
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HNP Sector Strategy Matrix (continued)
Bank Instruments
Underlying HNP Issues
Development Objectives
Bank’s HNP Sector Strategy
Progress Indicators
(See Annexes B to E)
Focus skill-mix, staff policies, and
training on priority areas
Objective assessment of skills-mix
staff policies and training programs
Ensure that staffing ratios in the
HNP sector are consistent with
Bank-wide norms and that staffing
ratios within the HNP sector are
realigned according to staff involvement in addressing the three priority
areas and relative responsibility for
the lending portfolio.
Adjustment in HNP staff’ according
to Bank-wide norms and relative
share of lending portfolio.
Lending/
Credits
Non-Lending
Other Partners
C. EMPOWERING STAFF
Many staff whose skills do not
match the HNP sector priorities
Empower staff
Low staff-lending ratios in HNP
sector compared with Bank-wide
norms and skewed distribution
across the regions
HQ staff are often insensitive to cli
ent needs and satisfaction
FY98-00
LLC,
EDI
Annual
status
reports
Incr. in number of skilled local resident staff’ and surveys on client salisfaction
Be more responsive to client needs
by listening more and getting closer
to the client in the field
D. STRENGTHENING PARTNERSHIPS
Limited partnerships with other
agencies despite clear increase in
international leadership
Often clients are left out of the lim
ited collaborative efforts that do
exist
Limited participation in major inter
national collective initiatives that
have a potential dramatic impact on
global health
Enhance partnerships
Join forces with other agencies
through country-level collaboration
and in addressing major issues such
as vaccination, the H1V/AIDS cri
sis, emerging drug resistance, and
child mortality.
Objective assessment of increased
partnerships with clients, civil society, stakeholders, and ocher agencies
Objective assessment of client par
ticipation in HNP initiatives
Involve clients more substantially in
collaborative work
Participate in major collective initiatives proposed by the Global
Forum on Health Research
Participation in one or more major
international initiatives
FY98-00
FY98-00
Support through
project
components
Use ofSGP
Annual reports
WHO, UNICEF,
UNFPA, UNDP.
UNAIDS. FAO,
ILO,
regional banks,
bilaterals, NGOs, &
private sector
I
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I*
1 iSS
Application of Lending Instruments
to HNP Sector
In low-income countries that use IDA credits—when
the proposed health, nutrition, and population inter
ventions wouldcontribute significantly to achieving pov
erty alleviation objectives— the Bank will:1
increase the IDA financing, where necessary, in
an effort to ensure that the development objec
tive of the operation is not compromised by lack
of counterpart funding;
mainstream comprehensive financing (recurrent
and capital expenditures) for activities supported
by the project (i.e., targeted disease control, nu
trition, and population programs that specifically
benefit the poor);
avoid a substitution effect by ensuring that Bank
resources contribute to a net increase in the re
sources available to the HNP sector rather than
allowing governments to shift their own resources
to other areas.
In the case of both IDA credits and IBRD loans—
when the main objective of the proposed operation is to
improve the performance of health care delivery sys
tems rather than poverty relief—the Bank will:
use smaller TA loans or pilot project facilities (cur
rently being developed by the New Products
Committee) to deal specifically with issues relat ing to enhancing the institutional capacity of gov
ernments in meeting their policy making,
management, evaluation, regulatory, and financ
ing responsibilities in the HNP sector;
use a coordinated pipeline of specific investment
loans or time-slice sector investment loans to
implement programs that have a medium-term
time frame for achieving development objectives;
increase product selectivity through: (i) more em
phasis on a few critical activities in (he public
sector that will facilitate a re-balancing in the
role of the state and non-governmental activi
ties in service delivery systems; (ii) on-lending
arrangements (subsidiagy loan -agreements) and
a closer partnership with the private sector de
velopment -and infrastructure hranches of the
Bank. IFC, and MIG Ain facilitating the flow of
funds to non-governmental health care delivery
systems;2 and (iii) introduction of mechanisms
that will allow clients to apply for financial sup
port from the Bank for a select group of “certi
fied” programs that would be fully developed and
implemented by other agencies or the private
sector; and
make more effective use of new lending instru
ments and sector adjustment loans (SECALs) to
support broad sector- wide institutional reforms
that have significant transition costs (avoid load
ing traditional investment loans with complicated
conditionalities).3
When the main objective is to improve financial
sustainability of health systems or introduce tighter ex
penditure controls that have fiscal implications, a more
aggressive strategy will be pursued to:
conduct detailed analysis of the fiscal implica
tions, public/private affordability, institutional ca
pacity, political commitment, and sustainability
of various reform options before proceeding with
such operations;4 and
include health financing contents, whenever pos
sible, as an integral pan of new lending instru
ments and broader public finance SECALs rather
than attempt complicated health financing re
forms under investment loans.
Such adjustment operations need to be comple
mented by direct investment loans that address under
lying institut ional and management issues.
1. The same recommendations would apply in a modified manner to IBRD loans to middle-income countries where the primary objective is
poverty alleviation.
2. A careful financial viability and risk analysis should always be undertaken as part of the project justification for this type of operation.
3. Specific targeted interventions often have a greater impact when underpinned by a combination of broad macroeconomic adjustment
operations, public sector reform projects, or sector adjustment loans that address resilient underlying sectoral distortions.
4. This should include detailed economic modeling and projections of existing and alternative"policy options
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