Health, Nutrition and Population (HNP) Discussion Papers
387 items available
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This series is produced by the Health, Nutrition, and Population (HNP) Family of the World\r +
Bank's Human Development Network (HDN). The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate.
Items in this collection
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Publication
The 2022 Update of the Health Equity and Financial Protection Indicators Database: An Overview
(Washington, DC: World Bank, 2022-12)This paper outlines changes that have been made for the third version of the World Bank’s Health Equity and Financial Protection Indicators (HEFPI) database launched in 2022. Across all indicators, subpopulation breakdowns by urban and rural place of residence and subnational region were added. On the financial protection side, the number of indicators further expanded to 31, reflecting a broadening of the definition of medical impoverishment from being limited to those pushed below the poverty line by medical spending to also include those already under the poverty line who incur any medical spending, that is, those ‘further impoverished’ by medical spending. The additional financial protection indicators also include indicators that show the intersection of catastrophic and impoverishing health spending, that is, identify the populations exposed to both types of financial hardship simultaneously. The health equity side of the database now includes 19,820 country-level data points from 1,318 surveys across 35 service coverage and 38 health outcome indicators. An upgraded data visualization portal was launched alongside the new dataset. -
Publication
Performance-based Financing in the Health Sector of the Democratic Republic of Congo: Impact Evaluation Report
(World Bank, Washington, DC, 2022-10)The Democratic Republic of Congo (DRC) is the largest country in sub-Saharan Africa, by area. The country has a long history of conflict, political upheaval, and instability and has a very high poverty rate despite its abundance of natural resources. Mortality and fertility rates in DRC are among the highest in the world. The Health System Strengthening for Better Maternal and Child Health Result Project (PDSS – Le Projet de Développement du Système de Santé) was launched in 2015 with the objective of improving utilization and quality of maternal and child health services in eleven provinces of out of the provinces in the Democratic Republic of Congo (DRC). The main component of the project is the implementation of a provider payment system reform through Performance-Based Financing (PBF), launched in the end of 2016. Contracted health facilities receive quarterly payments conditional on the volumes of targeted services provided and on quality of care. The objective of this impact evaluation is to assess whether the PBF approach impacts utilization and quality of primary health services, in comparison to equivalent amounts of unconditional financing. The rational for comparing outcomes produced by facilities implementing PBF to those produced by facilities who receive equivalent amounts of unconditional financing is to isolate the impact of the PBF incentive mechanisms from the direct impact of the additional resources received through the program. -
Publication
Private Sector Engagement in Public Health Systems
(World Bank, Washington, DC, 2022-09)The aim of the literature review was to provide evidence on private health sector engagement globally, with a specific focus on the South Caucasus. The analysis focused on private sector engagement through the lens of policy dialogue, information sharing, regulation, financing, and private sector provision, including performance and private sector engagement modalities. Results showed that the private sector in Armenia, Azerbaijan, and Georgia is heterogenous. Regulation aimed to increase health coverage with quality services and increase the institutional capacity of the Ministries of Health to collect and analyze data to know better how the private health sector operates and promote private-public partnership to respond to public health challenges. The creation of an autonomous health superintendence would help improve the performance of the private sector: overseeing and supervising the service delivery of private providers and ensuring a strong regulatory environment within countries with high levels of out-of-pocket payments. This entity should enforce transparent behaviors of doctor practices, licensing of physicians, and accreditation of private providers. In addition, the South Caucasus countries can adopt a mix of payment systems with private providers and establish arrangements that ensure a strong private-public partnership (PPP) in health through well-defined contracts. Health facilities with management autonomy should also ensure quality-based purchasing. PPPs would be an optimal way for the South Caucasus to engage with the private sector. Political will, legislative environments and regulatory frameworks, transparency, public sector capacity, complete and flexible contracts, and broad stakeholder engagement are essential conditions to expand PPPs. Learning from best practices globally and expanding research on how health systems create and regulate mixed public-private services are also essential to improve quality, equity, and efficiency of these systems, as countries work to achieve universal health coverage. -
Publication
COVID-19 Vaccine Acceptance Among Marginalized Populations in Kosovo: Insight from a Qualitative Study
(World Bank, Washington, DC, 2022-09-01)Kosovo has fully vaccinated 45.5 percent of the population, below what is needed to slow the spread of COVID-19. The Roma, Ashkali, and Egyptian communities, as marginalized ethnic groups, have been identified as high risk for acquiring COVID-19 and for lower acceptance of vaccines. Factors associated with vaccine acceptance are examined in this qualitative study among Roma, Ashkali, and Egyptian community members and representatives from civil society, community leaders, health care providers, and government working directly within these communities. Using a social-ecological model, intrapersonal, interpersonal, community, and structural factors influencing vaccine acceptance were identified. Intrapersonal-level factors centered on fear of side effects and doubt about vaccine safety and effectiveness, and lack of trust of health care providers; at the interpersonal level, male head of households decided for the entire family whether to receive the vaccine; in the social context at the community level, exposure to prolific misinformation on social media, television news, and paper pamphlets distributed in study communities created fear, doubt, and anxiety about vaccines, and stereotypes about the strong immune systems of ethnic minority groups reinforced beliefs about the communities low susceptibility to COVID-19; and structural-level barriers included the requirement for identification documents, and a buildup of doubt about motivations of the vaccinators created by massive vaccine-promotion efforts and police harassment in implementing curfew, and other protective measures targeting ethnic minority communities. Implications of these findings highlight a need for a segmented approach in designing subgroup-specific and multicomponent interventions to promote vaccine acceptance. Strategies include training local opinion leaders in door-to-door awareness raising, directly addressing misinformation, and distributing vouchers to be exchanged for incentives after vaccination; using social media where respected health care providers and community members post videos promoting vaccination; and removing or providing an alternative to identification requirements. -
Publication
Impact of Health Sector Support Project on Essential Nutrition Services: Evidence from Bangladesh
(World Bank, Washington, DC, 2022-09)Despite progress over the past two decades, poor nutrition remains a significant public health challenge in Bangladesh. Stunting among children under five years declined from 43 to 31 percent between 2007 and 2018, while 42 percent of women between 15 to 49 years are anemic. The Ministry of Health and Family Welfare is implementing the Health Sector Support Project (HSSP) with financing and technical assistance from the World Bank in the Sylhet and Chattogram divisions of the country. The project considers improving nutrition outcomes as a core priority. Leveraging administrative data from 13,855 community clinics (CCs) from 2018 to 2020 and a difference-in-difference approach, the analysis finds that HSSP led to improvements in the delivery of both maternal and child nutrition services. The proportion of eligible pregnant women who received requisite antenatal services (receipt of at least 30 iron and folic acid tablets, nutrition counseling, and weight measurement) increased by 2.7 percent over the duration. Similarly, the proportion of children between 0 and 23 months, who received age-appropriate nutrition counseling, increased by 8.9 percent over the same period. The paper identifies several factors that led to these improvements and notes the impediments. The HSSP renewed focus on the importance of delivering quality nutrition services, and the technical assistance provided through the HSSP has strengthened capacity, not only around the delivery of services but also in improving the data ecosystem and quality of project monitoring and results verification. There are, however, issues impeding service delivery of nutrition services. The community health care providers (CHCPs) are often faced with competing priorities, as nutrition is one of the many services they provide. Similarly, the CHCPs have been found to lack the required capacity and skills in delivering services and are also burdened with poor information technology (IT) equipment. -
Publication
Verification and Monitoring of Results and Strategic Purchasing
(Washington, DC: World Bank, 2022-08-31)The aim of the study was to highlight the different verification processes that four countries and one province take to monitor efficiency, quality, coverage, financial protection, and health outcomes in health systems. The literature review focused on the experiences of England and Sweden, illustrating a comprehensive verification process. Norway, the Canadian province of Ontario, and Turkey collected data on health care provider performance but did not publicly report it. Different instruments were used. Performance measures of patient-reported experiences, compliance with clinical guidelines, and waiting times have become common measurement-based indicators. To improve verification processes, it is necessary to maintain accountability between providers and governments to ensure that the overall objectives of health care are achieved. Monitoring effective service coverage includes measuring the population in need of the service using administrative records from service providers, determining the effectiveness of service coverage using selected indicators, and monitoring equity in access to quality health services using data disaggregated by inequality dimensions. Verification of results is essential within the context of institutional arrangements for the purchasing of health care services to providers. There is autonomy over several significant decision areas such as staffing (numbers and skill mix); financial management (ability to take loans); the scope of activities and capital investments; governance mechanisms that make providers accountable to purchasers; and conditions that balance the power between purchasers and providers. Within this context, monitoring and verification of results is critical to enhance the performance of service providers and ensure value for money within health expenditure. This would be strengthened by previously agreed standards between providers and the implementing agency. Setting strong monitoring and verification procedures has become a key factor in the success of Results-Based Financing programs in general, strengthening health information and governance structures are the most valuable ‘spillover effects’ of such programs. -
Publication
Water and Health: Impact of Climate Change in Bangladesh
(Washington, DC: World Bank, 2022-08-31)The government of Bangladesh’s (GoB) Delta Plan 2100 (BDP 2100) disaggregates Bangladesh’s 64 districts into six ecological zones based on hydrological characteristics and climate risks and deems 58 districts to be “extremely vulnerable” to the effects of climate change. The heterogeneity in the water crisis across the different hotspots presents unique health challenges. This paper summarizes the effects of altered quantity and quality of water on human health for each of the ecological zones and provides recommendations based on the findings. Climate change continues to deteriorate the quality and quantity of water in Bangladesh and is one of the leading causes of morbidity and death. The consequences are particularly pronounced for pregnant women and children. There are substantial regional variations in the effects on health, driven by the country’s topological attributes, such as groundwater depletion in the Barind and drought-prone areas and salinity in drinking water in the coastal regions. To address these challenges, it is imperative for agencies such as the Institute of Epidemiology, Disease Control and Research (IEDCR) and the Ministry of Health and Family Welfare (MoHFW) to build research capacity and upscale comprehensive disease surveillance systems to monitor trends in existing and emerging communicable and noncommunicable diseases, and to rigorously evaluate the efficacy of disease prevention and control programs. A set of zone-specific health policies and actions needs to be formulated under the aegis of the MoHFW in collaboration with relevant GoB stakeholders such as the Bangladesh Bureau of Statistics, academics, practitioners, and policy makers, underpinned by credible evidence. -
Publication
Improving Monitoring Data Systems to Count and Account for Stillbirths
(World Bank, Washington, DC, 2022-08)Each year, globally, nearly 2 million pregnancies result in stillbirths. Almost half (42 percent) of all stillbirths occur during labor. Yet, stillbirth rates are generally not considered when assessing the impact of poor quality antenatal and intrapartum care. One of the reasons is that the availability of stillbirth data is still very limited in low, and middle-income countries (LMICs), where 84 percent of stillbirths occur. Many national data systems in LMICs do not record stillbirths, or the stillbirth data are unusable due to nonstandard definitions, inaccurate classification, or underreporting. Not counting the millions of stillbirths annually in the Global Financing Facility (GFF)-supported countries is a missed opportunity for measuring impact and return on investments. If Every Newborn Action Plan (ENAP) stillbirth target of 12/1,000 births were reached across the 37 GFF-supported countries, over 500,000 stillbirths will be averted each year based on 2019 estimates. The GFF commissioned this report to improve the monitoring and reporting of stillbirths for the 37 GFF-supported countries and to inform other LMIC governments, including those supported by the World Bank and other development partners. The objectives of the report are to: (i) synthesize challenges and enablers that modify routine stillbirth reporting in LMICs; (ii) synthesize the current landscape of stillbirth reporting across the countries with which the GFF partners; and (iii) provide guidance to the GFF, the World Bank, and other development planners on improving reporting of stillbirths. -
Publication
Safe, Healthy, and Sustainable Diets: Role of Food Regulatory Bodies and Innovations from India
(World Bank, Washington, DC, 2022-06)The paper discusses in brief India’s food regulatory system in the context of modernized frameworks and examples of well-developed and mature regulatory systems from five selected developed countries (Australia, New Zealand, Canada, the United States, and the European Union). India’s food regulator, the Food Safety and Standards Authority of India (FSSAI), established in 2008, has developed a modernized regulatory system that aligns well with the most recent food safety regulatory systems model of the World Health Organization (WHO) (2018). As it continues to strengthen the regulatory system to enhance food safety, FSSAI is applying innovative approaches to address the country’s unique challenges of food safety, public health, and sustainable diets. The paper discusses two of FSSAI’s innovations: (i) approaches to enhance the safety of food businesses operating in India’s huge informal food sector; and (ii) proactive direct engagement with consumers at scale to promote safe, nutritious, healthy, and sustainable diets by influencing behavior change, thus contributing to improvements in public health, nutrition, and environmental sustainability. The paper also describes FSSAI’s regulatory leadership during the COVID-19 pandemic to promote food safety. The paper concludes that the approaches and innovations adopted by FSSAI appear promising and there are lessons that could be adopted and adapted by other low- and middle-income countries (LMICs). These approaches have not yet been evaluated but do merit a deeper study and discussion that may well lead to expanding the roles food regulatory bodies could play in promoting food safety, public health and nutrition, and sustainability. Whether food regulators are well-placed to take on wider roles may vary by country and the system of public administration, but it is not inappropriate per se for regulators to have that expanded role. -
Publication
Primary Health Care in the World Bank’s COVID-19 Multiphase Programmatic Approach Portfolio Response: The Extent to Which Pandemic Response Activities Were Planned at the Primary Health Care Level within the World Bank’s COVID-19 MPA Projects
(World Bank, Washington, DC, 2022-06)Soon after the World Health Organization (WHO) declared a pandemic, the World Bank made available rapid financing to strengthen countries' ability to respond to COVID-19 through a multiphase programmatic approach (MPA). The MPA's immediate objective is to prevent, detect, and respond to the COVID-19 pandemic. By July 2020, the World Bank’s board of directors had approved financing for 74 countries. This evaluation aims to determine the extent to which response activities were planned at the primary health care (PHC) level, and the extent to which PHC was leveraged within the first wave of MPA projects was determined by the number of PHC activities listed in the project components and indicators. Of 74 projects evaluated, 70 (94 percent) had at least one PHC-related activity listed in the components. Frequently planned activities at the PHC level primarily included surveillance, handwashing, and community engagement–related activities. MPA projects did not prioritize a commitment to maintaining essential service delivery at the PHC level. Several projects showed a greater commitment to integrating response activities at the PHC level, including Côte d’Ivoire, Egypt, Liberia, and Papua New Guinea, Senegal, the Republic of Congo. Notably, except for Egypt and Papua New Guinea, these projects were in countries that have been affected or threatened by the Ebola pandemic. These countries emphasized the integration of pandemic response activities at the community level. Overall, this evaluation highlights three takeaways: (1) the most common project activities related to PHC focused on surveillance, community engagement, and disease prevention; (2) among MPA projects, those in the sub-Saharan African region integrated more pandemic response activities at the PHC level than did other regions; and (3) maintaining essential primary health care services was not a priority among MPA projects in the initial phase of the response.