HNP and the Poor: Inputs into PRSPs and World Bank Operations. Session 1. Authors: Agnes L. B. Soucat Abdo S. Yazbeck

Transcription

1 HNP and the Poor: Inputs into PRSPs and World Bank Operations Session 1 Authors: Agnes L. B. Soucat Abdo S. Yazbeck

2 Session Objectives In addition to introducing the main framework, this session will answer the following questions: What is the basic relationship between poverty and HNP (health status being both a determinant and a dimension of poverty)? How can Bank staff use our tools (Lending, Sector Work, CASs, and dialogue) to improve the equity performance of our clients? What can Bank staff do the help improve the quality of PRSPs produced by our clients?

3 Session Outline The poor and HNP outcomes The vicious cycle bad health and poverty A way forward (Logical Framework with examples) Bank Performance and Instruments PRSPs/HIPC and the opportunity of debt relief Poverty Focus and Bank Portfolio Using the Banks Lending and Non-Lending Instruments

4 Half Full Infant Mortality Rate Bangladesh India Nepal Pakistan Sri Lanka

5 Half Empty Infant Mortality Rate Poorest 20% Richest 20% 20 0 Pakistan (1990/91) Bangladesh (1996/97) Nepal (1996) India (1992/93)

6 Benin (1996) Fully Immunized Attended Delivery Poorest 20% Richest 20%

7 Bolivia (1994) Fully Immunized Attended Delivery Poorest 20% Richest 20%

8 Central African Republic (1995) Fully Immunized Attended Delivery Poorest 20% Richest 20%

9 Nepal (1996) Poorest 20% Richest 20% 10 0 Fully Immunized 3 Attended Delivery

10 Session Outline The poor and HNP outcomes The vicious cycle ill health and poverty A way forward (Logical Framework with examples) Bank Performance and Instruments PRSPs/HIPC and the opportunity of debt relief Poverty Focus and Bank Portfolio Using the Banks Lending and Non-Lending Instruments

11 Facts!! Income poverty leads to ill health 70% of the variance in infant mortality can be attributed to across and within country differences in income Half of the burden of communicable diseases is concentrated in the poorest 20% Globally the poorest 20% experience three and a half the mortality and four times the number of DALYs loss of the richest 20%, an equivalent to excess mortality of nearly 10,000, 000 deaths per year Communicable diseases are responsible for 60% of both deaths and DALYs loss in the poorest groups Ill health contributes to poverty A recent study estimated that Africa s income growth per capita is being reduced by about 0.7 percent per year because of HIV/AIDS Recent studies attribute a 20% loss of GNP in Sub-Saharan Africa to malaria Studies in East Asia show that 50% of financial crises in poor families are triggered by catastrophic illnesses including TB HV and severe malaria

12 Income Poverty and Ill-Health Food Security Household caring practices Female illiteracy Access to water sanitation, low access to preventive and basic curative care etc Income Poverty Poverty Ill health, Malnutrition High Fertility Health care is a high proportion of health expenditures Catastrophic illnesses increase economic vulnerability Loss of wages, economic opportunities

13 Poverty Reduction Oriented Strategies for HNP Income poverty leads to ill-health Ill Health contributes to income poverty Reaching the poor with essential quality services Limiting the impoverishing effect of health expenditures Ill health is inherent to the overall poverty concept? Developing participation for more system responsiveness and accountability to the poor?

14 Session Outline The poor and HNP outcomes The vicious cycle ill health and poverty A way forward (Logical Framework with examples) Bank Performance and Instruments PRSPs/HIPC and the opportunity of debt relief Poverty Focus and Bank Portfolio Using the Banks Lending and Non-Lending Instruments

15 Pathways Framework Beyond Recognition Motivating principles for suggested framework: poverty is primarily a household and community characteristic with limited resources and capacity comes the need to identify priority actions that can produce changes in outcomes

16 Pathways Framework The Framework in Words Health Outcomes -- assessing health outcomes and setting targets Households/Communities their role in generating poor health outcomes Health System and Related Sectors -- assessing health sector performance to support households for better health outcomes: Government Policies and Actions -- improving outcomes through government actions

17 HNP outcomes Pathways to Improved HNP Outcomes Households/ Communities Household behaviors & risk factors Community factors HNP outcomes Household resources Health system & other sectors Health service supply Other parts of health system Supply in related sectors Government policies & actions Health reforms Actions in other sectors

18 Outcomes

19 HNP outcomes Poverty Related HNP Outcomes Households/ Communities Health system & other sectors Government policies & actions Health outcomes nutrition, fertility, mortality Income protection Poor s involvement, participation?

20 Pathways Framework (Outcomes) Mortality and Nutrition Status Under 5 mortality and nutrition status by income group Burkina Faso Infant Mortality Under 5 Mortality Chronic Malnutrition Malnutrition Very Poor Poor Average Average- Rich Rich "Socio-Economic Differences in Health, Nutrition, and Population in Burkina faso." February/March Davidson R. Gwatkin, Shea Rutstein, Kiersten Johnson, Rohini Pande, and Adam Wagstaff. HNP/Poverty Thematic Group, The World Bank.

21 Pathways Framework (Outcomes) Income Protection OOPS on health: Burkina Faso 1998 Burkina Urban Rural Rural North OOPS per capita in FCFA 4,900 9,490 3,000 1,300 OOPS per capita in US$ % of income spent on health 10% 14.1% 9% Source: BCS 1998

22 Pathways Framework (Outcomes) Participation of the Poor:Benin % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Accountability: participation level Poor friendly organization: financial access

23 Relating HNP to the overall PRSP framework Ill Health contributes to income poverty Limiting impoverishing effect of health expenditures PRSP Protecting income Income poverty leads to ill-health Reaching the poor with essential quality services Improving quality of life Ill health is inherent to the overall poverty concept Developing participation for more system responsiveness and accountability to the poor Promoting involvement of the poor

24 Pathways Framework (Outcomes) Example: Mauritania s PRSP Improve Outcomes Protect Income Increase Participation Reduce IMR and U5MR Reduce MMR Control communicable diseases improve nutrition Increase affordability and financial access Increase risk sharing Increase transfers Participatory co-financing and co-management Participatory monitoring and micro-planning Support to civil society

25 Pathways Framework (Outcomes) International Development Goals and objectives Reduction in Infant Mortality and Under 5 Mortality Reduction in Maternal Mortality Reduction of TB and HIV

26 Household and Community

27 HNP outcomes Pathways to Improved HNP Outcomes Households/ Communities Health system & other sectors Government policies & actions Household behaviors & risk factors HNP outcomes Household resources Community factors

28 Pathways Framework (Household) Role of household factors Guinea, household behaviors No education Primary Education Secondary Education Rural areas Urban areas Average duration of breastfeeding with water only (in months) Treatment of diarrhea by increased liquids whether at home or in health services % men having ever used a condom 6.4% 3.7% 0.6% 6.4% 3.8% 51.7% 61.4% 55.4% 51.4% 57.9% 17.4% 44.9% 64.5% 22.8% 56% DHS 1999

29 Pathways Framework (Household) Role of household factors Gender influence on use of health services, Bangladesh medical visit for ARI, male medical visit for ARI, female 0 Poorest 2nd 3d 4th richest DHS

30 Pathways Framework (Household and Community) International Development Goals? Exclusive and Prolonged Breastfeeding Use of iodized salt No smoking Hand washing Waste disposal Use of latrines Safe handling of water (e.g. use of tap) Safe sex Home treatment of fever and diarrhea Children s books in the household... (actually this latter isn t but wouldn t it be a nice one?)

31 Pathways Framework (Household and Community) Strategies Support to Household and Community care practices: Home care Care seeking and compliance Effective use of preventive technologies Support to Communication Strategies: Assessment of current practices Communication for behavior change Community driven communication Support to local resources mobilization Subsidies for basic services Drug revolving funds Community funds

32 Pathways Framework (Household and Community) Existing Initiatives Community Driven Development (WB) Community based health/nutrition Early childhood development Information, Education, Communication, Social marketing Primary Health Care, (comprehensive) Bamako Initiative, Village health workers, community based agents Health and Sustainable development, WB UNICEF WB-UNICEF UNICEF-WHO USAID-GTZ WHO WHO-UNICEF WHO WHO

33 Health System and Related Sectors

34 HNP outcomes HNP outcomes Pathways to Improved HNP Outcomes Households/ Communities Health system & other sectors Health service supply Other parts of health system Supply in related sectors Government policies & actions

35 Planning Health sector Finance AgricultureSocial Protection Infrastructure Water and Sanitation Education Sector Health Outcomes Litteracy etc.. Improve Quality of Life Revenue generation Safety nets Increase and Protect Income Participation Increase Involvement

36 Utilization of maternal and child health services Cameroon 1998 Source: DHS % Assisted Delivery ANC (1st visit) Immunization (DTP3) 20 0 Very poor Poor Middle Rich Very rich

37 Pathways Framework (Health System) International Development Goals? Immunization rates Antenatal care Attended deliveries STDs treated TB treated

38 Pathways Framework (Health System) Strategies Access to basic social services health education Supply of a minimum package of cost-effective services responding to the poor s needs Outreach and targeting towards vulnerable groups: children, women poor groups, remote population, minorities high risk groups (AIDS)

39 Pathways Framework (Health System) Existing Initiatives WHO: programmmatic PHC (selective: EPI, CCCD, STOP TB), District Approach, Bamako Initiative, UNICEF: GOBI FFF, Bamako Initiative USAID: family planning programs GTZ: district approach

40 Government Policies and Actions

41 HNP outcomes Government policies and Actions for Improved HNP Outcomes Households/ Communities Health system & other sectors Government policies & actions HNP outcomes Health reforms Actions in other sectors

42 Pathways Framework (Policies) Allocation of resources can be inequitable Niger 1997 public resource allocation between regions Public Spending on health per capita (recurrent, non salary costs) Agadez Diffa Dosso Maradi Tahoua Tillaberi Zinder Niamey

43 Pathways Framework (Policies) International Development Objectives WHO: recommendation on health spending versus public expenditures/gdp Increase funding for social sectors (debt relief) Tobacco taxation and bans

44 Pathways Framework (Policies) Strategies Financing generation: Sin Taxes (two shots in one), multiple sources and mechanisms for revenue generation Purchasing, resource allocation, transfers targeted to poor areas, poor groups Stewardship: regulation, monitoring and evaluation

45 Pathways Framework (Policies) Existing Initiatives WHO: Sector Wide Approaches/Health Sector Reform, specific rallies ( GAVI) EU: Sector Wide Approaches/Health Sector Reform UNAIDS: partnership for Africa

46 Session Outline The poor and HNP outcomes The vicious cycle bad health and poverty A way forward (Logical Framework with examples) Bank Performance and Instruments PRSPs/HIPC and the opportunity of debt relief Poverty Focus and Bank Portfolio Using the Banks Lending and Non-Lending Instruments

47 Debt Relief in a Nutshell US$ 30% 70% Decision Point Completion Point Export Sustainable level Current Debt

48 HIPC Debt Relief and Creation of Fiscal Space 30 Debt Service-to-Revenues (in percent) Before debt relief 5 Debt Service (US$ in billions) Before debt relief 4 20 Revenue Effect Revenue Effect Debt Service Effect 3 10 After HIPC relief 2 Debt Service Effect debt service before relief projected in Decision Point Documents debt service held constant in dollar terms debt service after HIPC assistance projected in Decision Point Documents After HIPC relief debt service before relief projected in Decision Point Documents average debt service paid, debt service after HIPC assistance projected in Decision Point Documents

49 What Does it Mean for the Social Sectors? Potentially more money A seat at the table where macroeconomic and budgetary discussions take place Chance to respond to sector development challenges

50 Allocation of resources freed from debt relief for the 22 countries: Education: 39% Health: 25% Rest on HIV/AIDS; rural development & water supply; governance & institution; road construction

51 Issues with Health Budgets Information, understanding of the mechanisms Quality of Dialogue finance-health Donor oriented dialogue, crowding-out of domestic resources by donor funding? Lack of Programs: SWAPs or unfunded activities

52 Relation between HIPC and PRSPs 8HIPC measures are short-term structural changes in context of broader reforms for poverty reduction 8 Preparation of I-PRSP as part of documentation required at D.P. 8I-PRSPs an interim measure 8One-year satisfactory implementation of PRSP a condition for reaching C.P.

53 Five countries have completed full PRSPs Uganda Mauritania Burkina Faso Tanzania

54 Session Outline The poor and HNP outcomes The vicious cycle bad health and poverty A way forward (Logical Framework with examples) Bank Performance and Instruments PRSPs/HIPC and the opportunity of debt relief Poverty Focus and Bank Portfolio Using the Banks Lending and Non-Lending Instruments

55 Bank Portfolio Review Methodology Desk review of all HNP PADs in FY99 and FY00 (41 PADs) Standardized review instrument Project Objectives Project Analysis Project Design Monitoring and Evaluation Analysis of quantitative results Ranking (simulating different weights) Panel review for award selection

56 Bank Portfolio Review The Good News Positive findings and trends Majority focus on HNP outcomes of the poor as a critical objective of the project including reforms Equity-related quantitative analysis were conducted for the preparation of a majority of the projects Equity-related qualitative analysis were conducted for the preparation of a majority of the projects 90 percent of projects had some form of targeting (geographic, level of care, disease)

57 Bank Portfolio Review and the not so Good News Weaknesses Disconnect between objectives and M&E systems Disconnect between equity-analysis and design Weak equity impact analysis and risk mitigation mechanisms for reforms Not much other than targeting

58 Session Outline The poor and HNP outcomes The vicious cycle bad health and poverty A way forward (Logical Framework with examples) Bank Performance and Instruments PRSPs/HIPC and the opportunity of debt relief Poverty Focus and Bank Portfolio Using the Banks Lending and Non-Lending Instruments

59 Bank Instruments Non-Lending Focusing sector work on equity and poverty Documenting inequalities in HNP outcomes and outputs (Session 2 will expand on this) Understanding household and community constraints, asking the WHY questions (Session 3) Understanding systematic system failures and resource allocation problems (Session 4) Sharing global experience (positive and negative) Building technical analytical capacity in client countries Think Intersectorally (easier in AAA than Lending)

60 Bank Instruments Non-Lending (Continued) Dialogue and Advocacy Supporting the PRSP process through targeted ESW and sharing best practice and knowledge Building coalitions for poverty and equity work from both internal groups (NGOs and civil society) and external groups (Bilateral and Multilateral Groups)

61 Bank Instruments Lending Traditional Investment Lending Base design elements on equity analysis Make listening to the poor a habit (a critical element and not a check box) Follow the money (Influence resource allocation mechanisms) Monitor equity indicators

62 Program Lending (PERCs, PRSCs): Rewards: Easier to protect sectoral spending May allow for real intersector work May improve donor coordination Risks: Bank Instruments Lending (Continued) Macroeconomist s Disease Ignores years of OED and Management lessons Untested