World Bank fails to focus on results in health

18 June 2010

A report published in June by civil society network Advocacy to Control Tuberculosis Internationally (ACTION) critically assesses Bank-assisted sector wide approaches (SWAps) to healthcare in Africa. It finds that, “there is an unacceptable dearth of scientific assessment that demonstrates the impact of SWAps on health outcomes, despite the billions of dollars that have been invested in this approach since the mid-1990s.” It states that, “the World Bank and its development partners are not addressing tuberculosis (TB) adequately or appropriately through SWAps in sub-Saharan Africa.”

The report outlines that, though health practitioners in Bank projects believe SWAps are important, for effective implementation the Bank must focus on regular independent reviews of health programmes, subject these reviews to public oversight, increase transparency, and invest more resources in rigorous monitoring and evaluation of actual health outcomes, not just processes. These findings dovetail with recent reports by the Bank’s Independent Evaluation Group (IEG, see Update 66), and the World Health Organisation’s Commission on the Social Determinants of Health (see Update 62). Both of these reports also emphasise poor outcomes in meeting Bank project objectives, and a lack of effective transparency and evaluation measures.

In a response posted online, the Bank said that SWAps are a relatively small component of its activity in the health sector, and involve many other actors. It also argued that the Bank is focused on results and “widely acknowledged as a leading institution in the area of monitoring and evaluation.” It said that its work on TB includes the East Africa public health laboratory networking project, which aims to improve diagnosis and treatment of communicable diseases, as well as TB being a priority outcome for its health system strengthening work.

In reply, ACTION acknowledged that SWAps are a complex instrument but pointed to the IEG’s observation that the Bank has played a major role as “leader and catalyst in the development and implementation of SWAps.” ACTION also challenged the Bank’s claims to effectively track results, referring to a 2009 IEG working paper featuring case studies of six SWAps, the Bank’s “neglect of monitoring and evaluation capacity building and use relative to the strong emphasis on procurement, disbursement and financial management has resulted in an insufficient results focus in five of the six countries.” It further suggests that TB is “not being addressed through programme-based approaches, including SWAps, in a rigorous manner, consistent with its importance”, pointing to the IEG’s 2009 report, which concluded that “intended integration of TB control with other health sector activities has simply not occurred on the ground.”

Despite consistent criticism of the Bank’s approach to health, including its promotion of private sector involvement (see Update 62), Lars Thunell, chief executive of the International Finance Corporation (IFC), the Bank’s private lending arm, has encouraged increased private equity investment in health and education in developing countries. In May, Thunell said that the IFC was increasing its target for private equity fund investment (see Update 68, 66), observing that “we should remember that it is the early stages of the recovery that are the most promising times to invest for private equity.” However, critics have highlighted how IFC investment through financial intermediaries such as private equity funds is only weakly answerable to the Bank’s performance standards on accountability, monitoring and transparency (see Update 70), exactly the areas the reports on health investment have highlighted as being in desperate need of significant reform.