Learning Curves

OED
February2007

ADBsPolicyfortheHealth Sector

TheAsiaandPacificregionishometo690millionpeoplelivingonincomesoflessthan$1 perday.Theyaccountformorethantwothirdsoftheworldspoor.Mostliveinareaswhere healthservicesareinadequateornonexistent.Povertyleadstopoornutritionandinadequate accesstohealthcare,whichcausehealthtodeteriorate.Inturn,poorhealthpreventsthepoor frombeingproductivemembersofsociety.Thisisaviciouscycleofimpoverishment.Health isalsoakeyinputtoeconomicdevelopment:goodhealthenhancestheproductivityofthe workforceandincreasestheattractivenessoftheeconomytodomesticandforeigninvestors. TheMillenniumDevelopmentGoalsemphasizethemanydimensionsofpovertyand explicitlyrecognizethathealthinterventionscanreducepoverty. ADBsPolicyfortheHealthSector,approvedin1999,aimstoprovidedirectiontoADBs operations,informdevelopingmembercountriesaboutADBspriorities,andassistthemto identifyprioritiesandstrategiesforachievingthem.
Background ThefirstloanoftheAsianDevelopmentBank(ADB) inthehealthsectorwasapprovedin1978.Overthe period19782004,ADBlent$2.45billiontosupport66 healthprojects,includingtwoprivatesectorprojects. Thisrepresents2.7%ofcumulativeADBlending.Over thesameperiod,144technicalassistanceprojects, includingsomefundedbytheJapanFundforPoverty Reduction,wereapprovedfor$71.9million. Additionally,34regionaltechnicalassistanceprojects, includingfourfundedbytheJapanFundforPoverty Reduction,werefinancedatatotalcostof$34.8million. Despiteprogress,muchneedstobeaccomplishedin thehealthsector.Thepoor,women,andindigenous peoplesaredisproportionatelypreytoillhealth. Almosthalfofthefinancialcrisesfacedbythepoor comefrommeetingmedicalexpenses.Infantmortality rates,especiallyinSouthAsia,arehigherthaninany otherregionintheworld,exceptSubSaharanAfrica. AsiaandthePacificishometothreequartersofthe malnourishedchildrenoftheworld.Thepoorest incomequintilesuffersinfantmortalityratesthatare almostthreetimeshigherthanthewealthiestquintile, andthepoorsuffergravereconomicconsequencesfrom
Operations Evaluation Department Asian Development Bank

beingsick.Womenalsofaceaburdenofdiseaseas witnessedbyhighmaternalmortalityratiosthathave changedlittleinthelast25years.Inmostcountries, indigenouspeoplessufferaninfantmortalityratethat isabouttwicethatofthegeneralpopulation.Despite progressinmakingmoderncontraceptionavailable, therearestillcountriesandregionswherefertility constrainseconomicandsocialdevelopment.Smoking, HIV/AIDS,anduseofillegaldrugsareincreasingtoo. ThepolicyintendedtomakeADBseffortstomeet suchchallengesmoreeffectiveandefficient.Underthe policy,ADBsactivitiesareguidedbyfivestrategic considerations:(i)improvethehealthofvulnerable groups;(ii)focusonachievingtangibleresults;(iii) supporttestingofinnovationsanddeploymentofnew technologies;(iv)encouragegovernmentstotakean appropriateandactivistrole;and(v)increasethe efficiencyofhealthsectorinvestments.Thepolicydoes notcovernutritionindetail. In2004,inthefifthyearofimplementation,the RegionalandSustainableDevelopmentDepartment requestedtheOperationsEvaluationDepartmentto conductanindependentevaluationofthepolicy.The SpecialEvaluationStudyonADBPolicyforthe

6 ADB Avenue, Mandaluyong City, 1550 Metro Manila, Philippines Tel +63 2 632 4444; Fax +63 2 636 2444; evaluation@adb.org; www.adb.org/evaluation/

HealthSectorreviewed209ADBdocumentsonhealth andnonhealthloan,grant,andtechnicalassistance projects;informationonhealthfromtheprepolicyand postpolicyperiods;andcountrystrategiesand programs.1ItselectedBangladesh,PeoplesRepublicof China,Indonesia,Mongolia,PapuaNewGuinea, Philippines,andVietNamforindepthreview.The OperationsEvaluationDepartmenthadearlier conductedaSpecialEvaluationStudyonSelected ADBInterventionsonNutritionandFood Fortification.2 SummaryofFindings Thestudyassessedthefirststrategicconsideration asrelevant,thesecondashighlyrelevant,thethirdas relevant,thefourthasrelevant,andthefifthashighly relevant. ADBhasgenerallyadheredtoandimplementedthe policysstrategicthrustsandincorporatedpriorities intopostpolicyhealthrelatedoperations,asshownin assessmentsofhealth,nutrition,andpopulation operationsthatcomparedthoseapproved5years beforethepolicywasadoptedandwiththoseapproved 5yearsafter.Ingeneral,increasesweredemonstrated underallfivestrategicthrusts.Forthisreason,ADBs adherencetoandimplementationofthepolicywere consideredsatisfactory. Thepolicyhadapositiveimpactinchangingthe wayADBoperatesinthehealthsector.Positivetrends wererevealedby:(i)thelargeincreaseinthenumberof loansusingspecifichealthoutcomeindicators;(ii)the inclusionofcostbenefitand/oreconomicsustainability analysisinallloansapprovedsince2001;(iii)the inclusionofeconomicrateofreturncalculationsinmost oftheseprojects;and(iv)theattentiontosupporting governancethroughhealthsectorreformsand institutionalcapacitybuilding. Thepolicydidnotleadtoanincreaseinlendingto thehealthsector.Manyclientsdonotborrowordinary capitalresourcesfromADBforhealthanddonotsee thatADBhasacompetitiveadvantagethere.Thishas implicationsforADBpolicies,strategies,andproducts thatcannotbeaddressedinasinglesectorpolicystudy. Recommendations ThestudysupportedADBsplantoupdatethe policyandrecommendedthatitbetransformedintoan integratedstrategyforhealth,nutrition,andpopulation by2006.

Coverhealth,nutrition,andpopulationandother relatedsocialsectors; Identifyinnovativeloanandgrantproductsthatwill facilitategreaterADBinvolvementinhealth, nutrition,andpopulation; Covergovernanceandcorruptioninthecontextof ADBsoverallinitiativeoffightingcorruptionin eachdevelopingmembercountry; AllowADBtofinancehealthinfrastructureand equipment,particularlyinadecentralizedsystem wherethesearelacking; Placemoreemphasisondevelopingpartnerships withotherdonors,theprivatesector,andcivil society;and Analyzethestaffingimplicationsassociatedwith differentoptionsconsideredsothattheBoardof DirectorsandADBManagementunderstandthe tradeoffsbetweenstrategicoptionsandresource considerations. Feedback ADBManagementsResponserecognizedthatthe studylaidanexcellentfoundationforremoving constraintsfacedinthehealthsectorand mainstreaminghealthinterventionsinADB. Managementexpressedthehopethatapaperon EnhancingAsianDevelopmentBankSupportto MiddleIncomeCountriesandOrdinaryCapital ResourcesBorrowersmightsuggestwaysforADBto meetthefinancingdemandfromthesocialsectorsof thesecountries.ADBsInnovationandEfficiency Initiativewouldalsopilotfinancinginstrumentsand modalitiestofacilitategreaterADBinvolvement.The ChairsSummaryoftheDevelopmentEffectiveness CommitteeDiscussionscommendedthehighquality ofthestudyandacknowledgedManagements supportiveresponse
ADB.2005.SpecialEvaluationStudyonADBPolicyforthe HealthSector.Manila.Available: http://www.adb.org/Documents/Reports/Evaluation/sst reg200504.pdf 2 ADB.2004.SpecialEvaluationStudyonSelectedADB InterventionsonNutritionandFoodFortification.Manila. Available: http://www.adb.org/Documents/Reports/Evaluation/sst reg200419/sesfoodnutrition.pdf
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Learning Curves available @ www.adb.org/evaluation/

Team Leader: Kus Hardjanti; Tel +63 2 632 6715; khardjanti@adb.org