The World Bank announced last week the first major restructuring of its health development programs in over a decade. From 1997 to 2006, the Bank assisted through its Health, Nutrition and Population Strategy (HNP) over 100 countries through 500 projects as well as disbursing $12 billion and lending of $15 billion. The Bank also provided substantial policy and technical advice, as well.

But in its own self-critique, the Bank admitted that the monitoring and evaluation of HNP results on the ground was weak, with impact data being “scarcely available.” In addition, the Bank’s active financial commitments for HNP decreased by 30 percent from FY01 to FY06. And to make things even worse, the HNP lending portfolio had the “lowest performance among all sectors in the Bank since 2001.”

With the continuing worldwide threats to health still formidable — SARS, HIV, drug-resistant TB, avian flu etc — the Bank over the last year has been formulating a new strategy that places emphasis in several key areas:

• Bank Results Framework — The framework is intended as guidance on outcomes and outputs expected (such as the United Nations Millennium Development Goals) for country-specific HNP activities and for Bank operations and programs.
• Strengthening of Health Systems — Well organized and sustainable health systems are necessary to achieve results. The support for financing mechanisms, regulatory frameworks , governance, insurance, information, trained personnel, basic infrastructure etc. needs to be there to save and improve people’s lives.
• Changing the Bank’s Role — Since the amount of money the Bank distributes through HNP is too small to drive relationships with client countries, the focus will be on “the quality of the policy and technical dialog and the strategic focus of Bank lending that will define the true magnitude of the Bank contribution to country efforts in HNP in the next decade.” This approach will exploit the Bank’s special strengths in service to HNP.
• Building Global Partnerships — In the last several years a number of new players in health such as the Bill and Malinda Gates Foundation have emerged. The Bank will seek a collaborative division of labor with these newer global entities so as to more effectively deploy resources.

The globalization of health care as seen in this announcement, along with that of the World Health Organization’s program to reduce medical errors (see my earlier post), is in full swing. I suspect that it will be more and more difficult over time to have discussions on U.S. health policies and programs without getting caught up in the affairs of other nations. Almost every significant domestic health care issue has contributions to its cause, or its solution, lying beyond our borders. How long it takes for us to integrate that understanding into our thinking remains to be seen.