World Bank Vice-President Joseph Wood on his role in South Asia

Health issues in South Asia pose enormous challenges. What are the World Bank's goals in this area into the next century?

In the next decade or so, the World Bank hopes to assist South Asian countries to accomplish a number of key objectives in the health field. First, we will assist them to continue improving maternal and child health. Second, we will work with these countries on reducing the most pernicious forms of communicable disease, including TB, malaria, AIDS, and leprosy. In all of these efforts, we will pay special attention to the poorest and most vulnerable segments of the population. We will encourage the public sector to focus on those investments that yield the highest social returns, and strive to strengthen the links between public services in health and the work of the private sector and of the voluntary community.

Let's look at Sri Lanka and Nepal, for example. In Sri Lanka's case, demographic and health indicators are excellent - at levels usually associated with much wealthier, developed countries: infant mortality is below 20 per 1,000 live births, maternal mortality at developed country levels, life expectancy at birth more than 72 years and fertility rates near replacement levels. These results can be attributed to good primary health care and hospital systems, near-universal literacy among both men and women, and a strong 'service ethic' that has sustained the public health services for many years. Nevertheless, despite excellent progress in control of communicable diseases in Sri Lanka, several public health issues remain: the resurgence of malaria in recent years; over a third of children under five years of age are malnourished; and an AIDS epidemic is possible. Additionally, the aging of the population is associated with major changes in the disease pattern of the population as non-communicable chronic and degenerative diseases of adults become dominant. Thus, Sri Lanka has a unique dual morbidity profile that includes both persistent developing country maternal and child health morbidity programmes and adult disease patterns that reflect the increasing importance of non-communicable adult diseases.

Nepal, however, is quite different. The country's population and health indicators are among the worst in South Asia. The Bank's 1991 Poverty and Incomes Study for Nepal suggested that, given the country's limited economic prospects and in the absence of an effective programme to slow down population growth, per capita annual income might stagnate around US$180, resulting in a further 15 million absolute poor over the next two decades. The country's 1993 per capita GNP of US$190 ranked 125th among 132 countries cited in the 1995 World Development Report. Nepal's infant mortality rate of nearly 100, child mortality rate of nearly 200, and maternal mortality rate of about 8 per 1,000 are among the highest in the world; and life expectancy of 54 years at birth is among the lowest. The Total Fertility Rate (TFR) is 5.3 and the Contraceptive Prevalence Rate (CPR) - heavily accounted for by permanent sterilisation, rather than temporary spacing methods - is only 20 per cent. Early marriage, followed by early and repeated childbirth, represents a major hazard for female reproductive health, safe motherhood and child health.

In the light of these challenges, what projects are in the pipeline in South Asia?

The current Population and Family Health Project (IDA Credit of US$26.7 million, effective since July 1994) supports strengthening of outreach health facilities, logistics, and service delivery. Sector work on prioritisation of health interventions and resources for Nepal is currently in progress. This may be followed by a second Population and Health Project for Nepal, as called for in the World Bank's Nepal Country Assistance Strategy.

In Sri Lanka, a Health and Family Planning project was completed in 1995. A follow-on Health Services project is expected to go to the World Bank's Board in September 1996. The Health Services project includes some support for strengthening reproductive health services.

In Pakistan, projects currently under implementation include Family Health projects covering the Northwest Frontier, Sindh, Punjab and Baluchistan, a Population Welfare Programme and Pakistan's Social Action Programme. Projects in the pipeline include a second project in support of the Social Action Programme (which covers health, education, rural water supply and population). The Health Sector Reform project is expected to address problems evident in all of the provinces, including the organisation and management of the provincial health departments, control of communicable diseases, links between the public and private sectors, and the financing of health care. These initiatives will be followed by projects in individual provinces that will continue the focus on local-level services.

Pakistan has a separate ministry for population, the Ministry of Population Welfare, which provides family planning services through a network of facilities and workers. In addition, family planning services are supposed to be available at all health facilities as well, and progress towards achieving this goal is being made with the support of the Population Welfare Programme Project. It is anticipated that a second Population Welfare Programme Project will be undertaken, especially at community level in training and logistics aspects.

In Bangladesh, the Bank has led a consortium of donors in the population and health sectors since 1974. While the first project was relatively small and focused primarily on family planning, subsequent projects expanded on the accomplishments and lessons learned and gradually developed into more comprehensive health and population programmes. The current and planned population and health projects are similar; the objectives of both are to reduce fertility; maternal and childhood morbidity and mortality; and poverty-related communicable diseases. A nutrition project is under way. It aims to reduce malnutrition in those areas most severely affected through an integrated community-based approach with substantial NGO involvement. A subsequent project to specifically target one or more communicable diseases is also anticipated.

Could you outline the main elements of the India project unveiled in March?

The India State Health Systems Development Project II is the largest-ever World Bank health sector credit and is an investment project with substantial policy content. The objective of the project is to assist the governments of Karnataka, Punjab, and West Bengal to:

(i) improve efficiency in the allocation and use of health resources through policy and institutional development; and

(ii) improve the performance of the health care system in these states through improvements in quality, effectiveness and coverage at the first referral level and selective coverage at the primary level to better serve the poor.

The main areas of the policy reform are: The project will finance:

How realistic are its aims?

The states have shown a strong commitment to the policy issues and have taken several up-front actions to demonstrate their eagerness to undertake these changes. On the implementation side, there is a strong focus on strengthening the management capacities of the implementing agencies, which should help to complete the project according to plan. The overall development of the health care system at state level will improve the health of the people, especially the poor, by reducing mortality, morbidity and disability. It is also setting an example for other states to follow.

Family planning is clearly a key issue. What projects are underway in this field?

The Bank is financing a large number of family planning projects in the region: six in India, plus others in Bangladesh, Pakistan, Nepal, and Sri Lanka; major new projects are also being developed for Bank support in India and Bangladesh. In India alone, IDA has provided over $600 million for ten projects since the 1970s.

What are the main obstacles to effective family planning campaigns in South Asia?

Despite adverse socioeconomic and cultural conditions, family planning programmes in South Asia are succeeding, and these efforts need to be broadened and expanded. Widespread poverty, lack of education, especially of women, and traditional family structures were among the main obstacles, and remain so, but far less than twenty years ago. The main current obstacles are lack of access to high quality services for many couples. Other obstacles include: lack of effective government commitment at different levels; lack of adequate understanding of the population-development-environment linkages on the part of significant partners of the civil society - from the national to the grass-roots level; lack of a broad-based reproductive and child health approach; and, most importantly, inadequate attention to and investment in female education.

Nevertheless, contraceptive use is much higher, and fertility substantially lower, in all the countries of the region, but especially in Sri Lanka, India and Bangladesh. More effective promotion of family planning, a wide choice of contraceptive methods, and a bigger role for the private sector each has substantial potential for overcoming the remaining obstacles.

In Sri Lanka, which has a contraceptive prevalence rate of over 60 per cent and has essentially achieved replacement fertility, however, there are no significant obstacles. Family planning programme priorities include a reduction in the proportion of women using traditional contraception rather than more reliable modern methods and expansion and improvement of reproductive health services.

What impact has the Cairo Conference had on World Bank/IDA policy in this area?

The Cairo Conference provided strong impetus for the broad reproductive and child health approach espoused by the Bank since the mid-1980s. And the recommendations emanating from Cairo facilitated the transition of family planning programmes from a largely top-down, demographically-driven approach, to a broader approach emphasising the quality of services and the needs of the individual client. An example of an important change since Cairo is India's decision to drop method-specific contraceptive targets from April 1996.

The Bank is pleased to be assisting the government of India in the transition to a reproductive and child health programme.

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©Kensington Publications 1996