Health Systems Strengthening: Whither the World Bank?

The High Level Taskforce on Innovative International Financing for Health Systems met week before last in London. To their great credit, they’ve posted draft reports from their two Working Groups so interested observers can see the where they’re going. Working Group 1 seeks to identify the health systems-related constraints to achieving global health goals, and presents estimates of costs of achieving priority goals (e.g. targeted reductions in maternal and child health). Working Group 2 (WG2) aims to identify new sources of funding and lay out the best options for channeling the funding to countries to improve health system performance. Further work and consultation is pending over the next three months, and then the Taskforce will provide their suggestions to the G8 for consideration at the July Summit in Italy.Much can change between the draft and the final versions, and the impact of the final recommendations is unknown. But the draft reports do send signals – at a minimum some positive signs that attention is shifting, at least at the margins, to the unloved step-child of health development assistance, health systems strengthening (HSS). They also send a message in their silence about the potential role for the World Bank and regional development banks.The WG2 report confirms a commitment to identifying stable and predictable funding mechanisms. Such sources are much needed to enhance the impact of many global health programs, which suffer from the volatility and unpredictability that is endemic to most forms of development assistance. GAVI and the International Finance Facility for Immunization underscore the benefits of such funding arrangements.The WG2 report also emphasizes a commitment to allocating more funding to health systems strengthening. An explicit rationale for this is to accelerate progress in maternal and child health, which requires attention to the daily grind of financing and delivering a broad range of preventive and curative services. There are no campaigns or ‘jabs” to keep women from dying from hemorrhage in labor. That happens only with having in place a solid and far-reaching network of reasonably well equipped and supplied facilities, combined with a functional referral network.This is all good.One issue that members of WG2 have not yet confronted, at least on paper, is how donors and technical agencies should go about the business of supporting system strengthening. There are two parts of the how issue: First are technical questions about which approaches work to address persistent problems like inequitable access to services, or broken supply chains? These questions have to be addressed in specific country contexts, although there is a modest agenda for brokering knowledge that may be transferrable from place to place.Second are institutional questions, particularly about how the global health community and “architecture” will adapt or be modified to pursue this desirable goal of HSS. How do we turn (hopefully new) funds into effective HSS at the country level? On this, there is a long distance to go before the final report is issued.The WG2 report states:“A proposal could be to consider the Global Fund and GAVI as a conduit for additional resources for health systems and achieving MDG 4, 5 and 6 while maintaining a focus on results”.This is an interesting concept but should not be adopted without considering the potential risks and alternatives. Substantial risks lie in the assumption that because these global funds have demonstrated some success in relatively narrow areas means that they are suited for a far different challenge. GAVI has been a pioneer in trying to “do” HSS within an intervention-oriented program, and while it deserves recognition for making the effort the difficulties have been manifold (well documented by Joe Naimoli); the jury is out about whether the money has generated results. On the part of the Global Fund, which reflexively reminds us all that it’s only a financing mechanism and has no aspirations toward offering technical expertise, the support of HSS has also faced significant obstacles with uncertain pay-off. And with both GAVI and Global Fund, is it not possible that venturing into the important but admittedly far ranging area of HSS would distract them from their central purpose? Have their boards really thought through how to mitigate the risks of “mission creep”?And what about alternatives? The glaringly obvious ones are the World Bank and the regional development banks, but there is nary a word about them in the draft report. Odd, given that the Bank (a) has contacts with finance and planning ministries; (b) has an explicit mandate to work on a sectoral level; (c) has technical staff with expertise in health system organization and financing; (d) cites health systems work as a comparative advantage in its health sector strategy; and (e) is the home base (shared with WHO) for the International Health Partnership+. The regional development banks also have important institutional capabilities in the health systems area, and have been innovators: The much-cited Cambodia contracting experience was pioneered with support from the Asian Development Bank; the InterAmerican Development Bank has been an important partner to many countries in the region (Colombia, Brazil, Mexico and others) in supporting their health reform agendas.It is paradoxical that GAVI and the Global Fund, institutions established to pinch hit for the banks’ in areas where there are particular public health imperatives and impatience with the established international bureaucracies, are now apparently seen as superior in the banks’ alleged “sweet spot.” A person doesn’t have to be an uncritical proponent of the international financial institutions (are there any?) to wonder what’s going on here.The bottom line is that it looks like the Task Force has some more homework to do, and must take some responsibility for the signals it’s sending. At a minimum, if the Task Force determines that GAVI and the Global Fund are the best channels for new resources for HSS, either separately or in some super-size combination, it would be incumbent upon those organizations to demonstrate that they are up to the task, technically, administratively and politically. And if the World Bank ends up not being invited to the dance, an explanation is due.