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AAAH Conference Beijing, China October 2007. Samuel S. Lieberman. CHANGING WB PROFILE.

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Aaah conference beijing china october 2007

AAAH ConferenceBeijing, ChinaOctober 2007

Samuel S. Lieberman

Changing wb profile

  • The World Bank continues to support health development in more than 20 countries in the East Asia and Pacific region by providing grants and low-interest loans for development projects, as well as expert advice and consulting services. s3

  • WB is not the dominant source of health funding that it was through 1997 s4,5

Major health sector donors in eap
Major Health Sector Donors in EAP

Share of Commitments by Major Donors

(based on 2002-2005 annual average)

Note: GAVI data is from its own website and is the annual average for 2001-2005

Source: WB BW; OECD DAC CRS (Creditor Reporting System)

What happened to ibrd and ida
What Happened to IBRD and IDA?

Share of Commitments by Major Donors














Other bilateral

Note: Total may not add up to 100% due to rounding; GAVI data is from its own website and is the annual average for 2001-2005

Source: WB BW; OECD DAC CRS (Creditor Reporting System)

What happened to loans
What Happened to Loans?

What Happened to Loans?

Share of Commitments by Type and Donor

Grants & Grants-Like

(all donors)

Other bilateral






Note: Total may not add up to 100% due to rounding

Source: WB BW; OECD DAC CRS (Creditor Reporting System)

Inter related challenges
Inter-related Challenges

  • WB support for health in EAP continues through large scale funding and analytical/ policy development initiatives (AAA)-- 25 projects are ongoing, 9 are under preparation, and 40+ have been completed.

  • The aim of this work is to help countries to respond to the inter-related challenges of:

    Improving the health, nutrition and population outcomes of the poor, while protecting the near poor from health-based income shocks;

Improving system performance
Improving system performance

  • Establishing and securing sustainable health care financing at a time of increasing health financing needs due to rising incidence of “life-style” diseases, and strong “backlog effects” on service use by those newly insured.

  • Enhancing health care system performance in a region that had habitually, often successfully turned to government-run mechanisms to deliver public health services. However, the “platforms” adapted to deliver a subset of health services on a mass basis were inefficient and inequitable, or unworkable when linked to the larger health system..

Hwf as entry point
HWF as entry point

  • The World Bank’s revised Health Strategy points to the health workforce (HWF) as a crucial health system dimension. Accordingly, difficulties in deploying qualified professionals and other health workers to poor and remote areas, defective provider payment procedures, and so forth are seen as contributing to low quality care and inequality in access, and more broadly, as highlighting for policy makers possible entry points for addressing systems problem. *

Needed eclectic thinking piloting
Needed: Eclectic Thinking/ Piloting

  • Meanwhile, symptoms of system performance failure can vary and may be masked by changes due to rapid, unrehearsed decentralization, stronger market-pressures and widening income inequalities. WB thinking ties system faltering to an MOH unwillingness to switch from direct provision to the role of health regulator, health promoter, consumer educator and policymaker.

Planned aaa
Planned AAA

  • Clearly, more work is needed on system performance, determinants, and policy inferences. The WB is sponsoring in cooperation with the Dutch government

  • policy analysis of key HWF issues, public and private, in EAP countries, i.e., Cambodia, Indonesia, Timor Leste, Vietnam, and possibly Thailand, facing shortages of skilled health service providers. These will address the knowledge gap by country and look into provider payment issues, incentives, public/private partnerships and access to the poor. Political dimensions will be considered, work will be done collaboratively with local institutions and in a capacity building manner.

More aaa
More AAA

  • Other work is planned including: on Indonesia, analyses of “Dual Practice, the Private Sector and Access to Care,” and “The Distribution of the Health Workforce and Employment Duration” that will connect to earlier work.

Project support
Project Support

  • The HWF and Systems Performance agendas pertain as well to the 25 ongoing, 9 forthcoming investment portfolio. This is asignificant increase from where we were three years ago.

  • Do we have the right focus within health the best balance among instruments, sectors, countries, etc.?

Assessing the portfolio
Assessing the Portfolio

  • How to evaluate a diverse set of projects located in longstanding clients with established programs as well as more recent additions, with these initiatives undertaking a variety of activities in response to local needs?

  • Look at “best practice” workforce/labor market thinking?

Rely on wb internal review
Rely on WB Internal Review?

  • These procedures, e.g., consistency with sector/country analysis and strategy; lending lessons; economic, social, fiscal, and environmental, indigenous peoples assessments; quality at entry, outcome ratings, overall and by component; sustainability; and “Major Factors Affecting Implementation and Outcomes” are extensive and rigorous and link up with professional and technical literatures and cross-sector, cross-country, and cross-project experiences. But they are obviously unsuitable in other respects and are not readily available.

    Do any alternatives come to mind, e.g., AAAH-based?

    Or is it best to proceed on a country-wise/inter-country basis, and how?

Country wise assessment
Country-wise Assessment

  • Track HWF components across projects, over time

  • Compare new with new

  • Check for best practice

  • Follow innovations


  • The Government is unable to deploy and retain qualified staff in remote areas. To address this key HWF bottleneck, the Health Sector Support Project contracts NGOs to help to manage health services, provides performance based incentives to staff in health facilities and strengthens management and monitoring functions in 11 of 77 Operational Districts. Project-supported equity funds (HEFs) also pay official user fees in 29 Districts for the identified poor, with 60% of fee revenues available for staff incentives. HEF- supported health facilities receive management and quality improvement support. The project also applies the Merit Based Pay Initiative to policy makers, supports the Human Resource and Personnel Departments and regional training centers in the central MOH, and funds in-service (but no pre-service) training for midwives and other health personnel.


  • The PHPsI support pre-service training through fellowships in response to MOH policy that nurses and midwives should have at least D3 education, and the 3 projects support a wide range of in-service training for various health sector programs.

  • The 3 PHPs address improvement of HRH quality through strengthening the regulatory framework. Jogjakarta, a leader in this area has prepared standards of competence for various professions, and instruments for accreditation of primary health care facilities. It has also established a Quality Council, whose task is to conduct competence assessment in collaboration with the professional associations and provide recommendation for licensing of providers. .

  • HWS is also providing support in the following areas:

  • Development of the new competency based curriculum for medical education (done)

  • Development of competency based specialist education (ongoing)

  • Developing and piloting family physician program (ongoing through IMA)

  • HRH is one of the two main focuses of the AAA work on health sector reform in Indonesia.


  • HWF activities (52% of HSIP costs) aim to upgrade a poorly trained work force, and include in-service (i) competency-based initial and refresher sessions for Integrated Community Health Centre staff; (ii) training for village volunteers in the management of drug kits; and (iii) training in service delivery and outreach management at the health centre level and below. Pre-service training is assisted: (i) support to Family Medicine Internship Program - new type of providers for work at province and district level; (ii) 2-year master degree courses in Thailand for the faculty; (iii) improve infrastructure of the Faculty of Medical Sciences and teaching hospitals


  • The SEMP2 did not have interventions in HHR. The WHSMP2 is piloting two innovations in national HHR policies. The first innovation is a performance-based grants to Women's Health Teams if they get their patients intpo birth plans and to deliver in health facilities. The second is the bringing of private training providers in the training of government health workers. The NSSHRP is expected to help finance the implementation of the national health human resource master plan of the DOH. In both the WHSMP2 and the NSSHRP, we work with the DOH and the local government units


  • Thailand has implemented successful HWF policies that facilitated recruiting, deploying, and maintaining professional health staff in rural areas, including three year mandatory public service for new medical graduates; incentives that include hardship allowances, no-private practice allowances, over-time payments and non-official hours special service allowances; and, non-financial incentives such as higher career statis of rural doctors, preferential entry to residential programs, etc. The Human Resource Component will undertake an in-depth review of health workforce challenges in the past and at present in Thailand and an evaluation of strategies for workforce management in order to identify effective and ineffective practices. It will also support regional learning and dissemination activities on effective health sector human resource policies.

Timor leste
Timor Leste

  • Support to restore basic services and priority programs, and longer term rehabilitation and capacity building

    • Health Sector Rehabilitation and Development Project

    • Second Health Sector Rehabilitation and Development Project

  • Transition (Consolidation) Support Program

    • Multi-donor program of grant financed budget support

    • Supports policy measures in governance, employment creation and private sector development, and service delivery

  • Health Sector Review (HSR)—work in progress

    • Broad review of HNP status, policies and strategies, service delivery, and financing

    • Significant HR component


  • interventions have evolved as regards the scope and target of training investments and scale and focus of “parallel” measures. In two 1990s vintage “first generation ” projects (e.g., Population and Family Health Project, National Health Support Project) delivered short-term training on selected topics to lower level health staff in provinces in each region.

  • MRHSP, the first of several second generation projects, allows for tailoring interventions to local features, and includes degree-training, and a review of HWF gaps linked to an analysis of various “non-training” incentives and other measures.

  • The Northen Uplands Health Support Project (NUP) funds skills upgrading for available clinical staff in the region, as well as the development and piloting of incentive schemes to improve recruitment and retention of staff in the NU provinces, given that this is one of the main constraints to improve human resources for health capacity.