The World Bank's new health sector strategy: building on key assets.

For the last decade, the World Bank has been trying to find its footing on shifting ground in global health. In the mid1990s, it saw the blush fade on many health financing and organizational reforms that it actively promoted in middleincome countries in Latin America and elsewhere. Despite the application of big money and lots of brainpower, few of the new incentive programs, insurance mechanisms and decentralization policies survived intact the rough and tumble of politics; and even those that did rarely could demonstrate convincingly that they translated greater efficiencies into better health. Then, as Jeff Sachs wrote the gospel on how health leads to wealth,1 the richest man in the world started devoting most of his fortune to better health for the poorest on the planet, 189 nations signed on to Millennium Development Goals that are replete with ambitious targets for health improvements, and advocates for AIDS, malaria, immunization and other health priorities mobilized billions of grant dollars for single-minded programs designed largely by management consultants, the Bank found itself losing its preeminent place as the source of money—and ideas about how to spend it—for health. The drift in the Bank’s health portfolio is seen partly in the numbers. Commitments to health sector operations have been steadily declining in each of the past six years, from about US$10 billion in fiscal year (FY) 2001 to under US$7 billion in FY2006. The share of active projects judged by staff to be ‘at risk’ of not meeting their objectives has been on the increase since FY2003, and now includes a full third of all projects. Staffing in the sector has declined by 19%, from 243 to 197 staff since 1997.2 The allocation for health in the Development Grant Facility, a consolidated pool of the Bank’s grant funds, has declined in the past year, albeit by a small amount, while other sectors have grown. During his first year as World Bank President, Paul Wolfowitz has often spoken about the priorities of fighting corruption and responding to infrastructure needs, but has rarely highlighted the Bank’s role in the health sector. So— at a time when better health is universally recognized as an essential part of the development challenge, and when the vast potential of new preventive and therapeutic measures, innovations in service delivery and expanding financing have yet to be realized—objective measures suggest that the Bank is shrinking from the task.