HEALTH SECTOR (2010-2011)

Revised Draft Final Report March 2011

PACIFIC RIM INNOVATION AND M ANAGEMENT EXPONENTS, INC., PHILIPPINES

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TABLE OF CONTENTS Page List of Tables .................................................................................................................................. ii List of Figures ................................................................................................................................. ii List of Abbreviations ...................................................................................................................... iii I. II. A. B. III. A. B. C. D. E. IV. The ADB Health Sector: In Transition .................................................................................. 1 Project Approvals .................................................................................................................. 1 Summary of 2006-2008 Approvals ....................................................................................... 2 Summary of 2009-2011 Project Approvals ........................................................................... 4 Internalizing the OPH ......................................................................................................... 6 Health outcomes through Infrastructure Operations ............................................................. 7 Health outcomes through Governance and Public Expenditure Management ...................... 8 Health outcomes through Regional Public Goods ................................................................ 8 Generating Knowledge and Advancing Policy Dialogue ....................................................... 9 Strengthening Partnerships ................................................................................................ 11 Conclusions and Recommendations.............................................................................. 12

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LIST OF TABLES Number 1 2 3 4 5 Title Health Sector-Driven Investments, 2006-2011 Subsector Focus of Stand Alone Health Sector Projects: 2006-2008 Subsector Focus and OPH Theme(s) of Stand Alone Health Sector Projects: 2009-2011 ADB Publications for Health by Region in 20102011 Health in the Pipeline Page 2 3 4 10 12

LIST OF FIGURES Number 1 Title Health Sector-Driven Investments, 2006-2011 Page 1

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LIST OF ABBREVIATIONS ADB ADF ADTA ASEAN BAN CDTA ECD ESCAP GMS-CDC II HATAP HIV/AIDS HSDP ICT INO JUNIMA KGZ LTSF II M&E MDG MNCH MOU NEP NICE OCR OPH PAK PAL PATA PHC PHI PNG PPTA PRC RDTA REG RETA SRI SWAp TA UNAIDS UNDP UNICEF VIE WHO Asian Development Bank Asian Development Fund Advisory Technical Assistance Association of Southeast Asia Nations Bangladesh Capacity Development Technical Assistance Early Childhood Development Economic and Social Commission for Asia and the Pacific Second GMS Communicable Disease Control Project HIV/AIDS and Human Trafficking Prevention human immunodeficiency viru/acquired immune deficiency syndrome Health Sector Development Program Information Communication and Technology Indonesia Joint United Nations Initiative on Mobility and HIV/AIDS in Southeast Asia Kyrgyz Republic Second Long Term Strategic Framework monitoring and evaluation Millennium Development Goals Maternal and Child Health Nutrition Memorandum of Understanding Nepal Nutrition Improvement through Community Ordinary Capital Resources Operational Plan for Improving Health Pakistan Palau Policy and Advisory Technical Assistance primary health care Philippines Papua New Guinea Project Preparatory Technical Assistance Peoples Republic of China Research and Development Technical Assistance regional Regional Technical Assistance Sri Lanka Sector Wide Approach Technical Assistance Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Children's Fund Vietnam World Health Organizatio

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RSC-C13093 (OHQ) HEALTH SECTOR REPORT (2010-2011)

DRAFT FINAL REPORT

March 2012

PACIFIC RIM INNOVATION AND M ANAGEMENT EXPONENTS, INC., PHILIPPINES

THE ADB HEALTH SECTOR

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THE ASIAN DEVELOPMENT BANK HEALTH SECTOR I. The ADB Health Sector: In Transition

1. With the enunciation of the Second Long Term Strategic Framework (LTSF II) and the ensuing Operational Plan for Improving Health (OPH) Access and Heath Outcomes under Strategy 2020 which was approved in late 2008, operationalizing health outcomes will be increasingly sought through ADBs work in: (1) infrastructure; (2) governance and public expenditure management; (3) regional public goods; (4) generating knowledge, analysis and initiating and facilitating policy dialogues; and (5) forging partnerships. Time, internal social marketing and knowledge sharing are needed in transitioning to these expectations. Guided by DMC demands and strategicity,1 investment in standalone health sector projects continues, although expectedly in substantively reduced levels for both grants and loans. The OPH explains it quite clearly that new standalone investment projects would be pursued only if certain important conditions were met: highly selective and in partnership with agencies with technical expertise; meeting special country circumstances such as no other donor is able to fill the financing gap, or involving strong public-private partnerships. A good number of projects approved in the last three years in the health sector, and those that are now in the stage of preparation, carry the OPH themes as well this justification for standalone investments. The OPH envisions a much expanded base of responsibility-taking for health in ADB operations. Hence, an equally if not more compelling measure should be on how the other sectors in ADB are including health in the design of their projects. This report will examine if these opportunities for generating health outcomes are actually being optimized, while at the same time taking a close look into the kind of activities that ADB investments are supporting in the health sector as a distinct area for ADB operations. II. Project Approvals

2. ADB investment in the health sector, over the last six years (2006-2011), has been characterized by increases and decreases (Figure 1), reflecting selectivity in responding to specific DMC circumstances vis--vis the Banks new strategic directions for engagement in the sector.

Source: List of Health and Social Protection Sector Projects, 2006-2011

Strategicity, to mean no other donors can fill the financing gap or ADB support will jumpstart or facilitate partnership with other development agencies.

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3. For the period of 2006 to 2011, ADB investment in the health sector was highest in 2010 ($215,600,000) before it fell sharply in 2011 ($25,700,000).2 These amounts do not include some investments in social protection, multi-sector and other sector projects listed under health and social protection. The six projects approved in 2011 also represent the lowest number of approvals over the last six years. (Table 1)
Table 1: Health Sector-driven Investments, 2006-2011 Year
2006 Value Grants Technical Assistance Loans 73,992,400 4,179,000 0 Total 78,171,400
# of Projs

Type

2007 Value 30,500,000 2,643,523 50,000,000

# of Projs

2008 Value 13,900,000 2,800,000 172,000,000

# of Projs

2009 Value 32,200,000 5,200,000 50,000,000

# of Projs

2010 Value 36,000,000 2,600,000 177,000,000

# of Projs

2011 Value 2,000,000 3,700,000 20,000,000

# of Projs

7 5 0

3 6 1

3 5 2

8 8 1

3 6 2

1 4 1 6

12 83,143,523

10 188,700,000

10 87,400,000

17 215,600,000

11 25,700,000

Note: Social Protection Projects that have no or insignificant health components or with health components lumped with other sectors were not included in the computation in this report.

A.

Summary of 2006-2008 Approvals

4. This report covers the period of 2010-2011, but also seeks to track trends or changes, if any, in the years after the approval of the OPH (2009-2011), thus making a comparison with the pre-OPH years (2006-2008) necessary. 5. Of the 32 health sector projects approved from 2006 to 2008, 13 were grants, 16 were TAs, and three loans. In terms of subsector, two projects dealt with early childhood development (ECD); 7 focused on nutrition; nine on specific health programs; 20 projects on health systems strengthening; and two that address health financing (Table 2). 6. Subsector or thematic focus3. Of the seven projects on nutrition, the only loan was for Indonesias Nutrition Improvement through Community Empowerment (NICE) Project, amounting to US$50M, which supports Target 2 of MDG 1: to halve the number of underweight children under five years of age by 2015. Aside from a US$0.5M allocation for the M&E of NICE, the rest of the projects were grants provided to Mongolia (2 grants amounting to US$11M) Viet Nam (2 grants amounting to US$2.9M) and Pakistan (1 grant amounting to US$1.9M). Two of these projects (in PAK and VIE) addressed food fortification, one on breastfeeding and complementary feeding (INO), one on fortification (VIE) , one on micronutrient supplementation and fortification (INO) and two on policies, guidelines and capacity development (MON). (Please also refer to Appendix A: 2006-2008 Project Approvals.) 7. For the nine projects oriented towards specific health programs (other than nutrition), approved in the 2006-2008 period, Viet Nam had the highest share, with a US$72M loan for strengthening health programs in the South Central Coast Region, a grant amounting US$20M for HIV Prevention Among the Youth, a US$1.9M grant for Community-Based Early Childhood Development, and a PPTA costing US$0.5M. Papua New Guinea came second, with a grant of US$15M for HIV Prevention and Control in Rural Development Enclaves, and an ADTA costing US$0.85M for the Assessment of the Rural Health Services System. The ADTA for Mongolia, amounting to US$1M, which was also focused on HIV/AIDS, sought the institutionalization of HIV/AIDS prevention in ADB infrastructure projects and the mining sector. The RETA on
2 3

These amounts include cooperation funds administered by ADB. Using the

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Prevention and Control of Avian Influenza in Asia and the Pacific, amounting to US$25M was also one of the biggest projects, falling both under the rubrics of health systems and health programs. 7. Water and Sanitation is part of the $72M loan to Viet Nam for its Health Care in the South Central Coast Region Project. 8. For the 20 projects directly seeking to improve health systems, the Punjab MDG Program Subproject 1, a US$100M loan for reducing infant and maternal mortality rate in Punjab, gave Pakistan the highest share of sector investments dealing with this subsector. Viet Nams US$72M loan mentioned earlier also sought to strengthen health systems, along with 2 grants amounting to $21M (also touching on health programs), and 3 PPTAs worth US$1.45 M. Mongolia got a US$14M for its Third Health Sector Development Project and another grant worth US$2M for assessment and capacity development for improving access to health services by marginalized groups in Ulanbataar. The ADTA on HIV prevention in the infrastructure and mining sectors, costing US$1M, may also be considered as having a strengthening value to the health system. 9. As to health finance, the grant for Mongolias Third Health Sector Development Project, tackled among others health sector finance and health insurance. Another project, an ADTA worth US$.04 M sought to develop a sustainable health financing scheme for Palau. ADTAs like this can contribute to policy dialogues and decision making for health financing especially given the challenges to availability and accessibility of health services in the Pacific. Table 2: Subsector Focus of Stand Alone Health Sector Projects: 2006-2008
Subsector Number of projects, type of financing, value DMCs (by order of total value of projs: highest to lowest) VIE, KGZ Key Activities Areas

Early Childhood Development (ECD)

2: 1 PPTA, 1 grant

Nutrition

7: 1 ADTA, 6 grants, 1 Loan

INO, MON, VIE, SRI, PAK

Health programs

9: 3 ADTAs, 2 PPTAs, 3 grants, 1 loan

VIE, Regl, PNG, MON, LAO, INO

Health systems

20: 6 PPTAs, 5 ADTAs, 7 grants, 2 loans

VIE, MON, PNG, LAO, BAN, INO, PRC

Mother and child health: health, nutrition, cognitive and psycho-social development; ECCD modelling with capacity building and policy development; advocacy and communications Food fortification (human resources devt, policies and regulations; private sector participation; micronutrient distribution; breastfeeding and complementary feeding (along with human resources development, policies and regulation). Water and Sanitation improvement and capacity development; Communicable diseases (early reporting and containment, inter-agency and regional cooperation); HIV/AIDS (private sector development, CSO participation, cross-border collaboration ); Womens and Childs health (immunization, health services management) Human resources development; Health services management; policies and regulations; Public-Private Partnerships; Primary Health Care; Urban Primary Health Care; Rural Primary Health Care Health sector finance (along with infrastructure and capacity development); Health insurance; Advocacy

Health Finance

2: 1 ADTA, 1 grant

MON, PAL

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Note: There are projects that have more than one subsector.

B.

Summary of 2009-2011 Project Approvals

10. Of the 34 health sector projects approved during this period, 12 were grants, 18 were TAs, and 4 loans. In terms of subsector, 4 deal primarily with nutrition, 7 are focused on health programs, and 23 support health systems improvement. Of those dealing with health systems, 3 touch on health finance.4 (Table 3) 11. In 2009, only one loan was approved the Credit for Better Health Project for the Philippines, amounting to US$50M.5 Of the 8 grants amounting to US$32,200,000, 71 percent went to Lao PDR (3 approvals), 16 percent went to Mongolia (2 approvals), and the rest for Indonesia, Nepal and the Philippines with one approval each. Of the 8 TAs amounting to US$5.2M, more than 40 percent of the total amount went to regional undertakings: 3 advisory TAs and 1 PPTA. The rest were for the Philippines (1, for public-private partnerships), Mongolia (a PPTA for health systems strengthening), Papua New Guinea (a PPTA for women and childs health), and Lao PDR (a CDTA for health systems strengthening). (Please also refer to Appendix B: 2009-2011 Project Approvals.) 12. Almost 85 percent of the value of the 2010 loan approvals went to Pakistans Punjab Millennium Development Goals Program for the attainment of MDGs 4&5 amounting to US$150 million, while the rest for the Second Greater Mekong Subregion Communicable Diseases Control Project costing US$27 million. Of the 3 grants amounting to US$36M in 2010, 39 percent went to Mongolia (one approval), 33 percent for Lao PDR (one approval), and 28 percent for Cambodia (one approval). Of the six TA projects approved in 2010, amounting to US$2.6M, more than 65 percent of the total amount were for projects of regional scope (both dealing with evidence building and advocacy), 26 percent went to Bangladesh (one PPTA on urban primary health care) and the rest to PNG (one PPTA) and PRC (one PATA). 13. For 2011, the single loan project approved was the Rural Primary Health Services Development Project in Papua New Guinea with an amount of US$20 million, which was accompanied by a grant approval (for the same project) amounting to US$40M. The other grant approval in 2011 was for Nepals Reducing Child Malnutrition through Social Protection amounting to US$2M. Technical assistance projects amounted to US$3.7M in 2011, consisting of four PPTAs for Mongolia, PRC, Viet Nam, and one regional. 14. During the 3-year period, there were two private sector-related projects approved: the Credit for Better Health Project (loan) and a PPTA dealing with old-age care systems in PRC. 15. Subsector focus. The 4 projects classified6 as belonging primarily to the nutrition subsector were grants approved in 2009 (3) and 2011 (1) with a total of US$7.8M. Of these, the highest share went to Nepal with US$3.8M (2 grants), followed by Indonesia and Mongolia with US$2M each (one grant each). Food fortification and child nutrition through social protection (to be realized through inter-sectoral and community partnerships) were among the themes of the 2 grants for Nepal. The grant for Mongolia supported micronutrient distribution and training of primary health care (PHC) workers, while the one for Indonesia sought food fortification amongst community millers. Mongolia and Indonesia were also recipients of nutrition sub-sector investments in the 2006-2008 periods. The dwindling number of nutrition projects is notable given the slow progress in achieving the nutrition related MDG in at least 13 countries in South Asia,
4

5 6

Another loan project approved in 2009 for Mongolia, the Social Sectors Support Program amounting to US$43.1M has health, nutrition and hospitalization assistance, among others, dovetailed to social welfare assistance. Since this project, classified as multisector, also encompass other sectors like education and urban development, it was not included as health sector spending in this report. See footnote 3 Classification was based on ADBs 2009 Project Classification System.

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Southeast Asia and West Asia. The same can be said for ECD for which there were no approved investments from 2009 to 2011. 16. There were 7 projects focused on specific health programs (e.g., HIV/AIDS, MCH) amounting to US$16.75. The biggest share went to Lao PDRs Health Sector Development Program (US$10M program grant) which supports enhanced access to maternal and child health and nutrition services (MNCH). Mongolia comes second, with a US$3M grant for Protecting the Health Status of the Poor During the Financial Crisis, followed by a regional cluster development technical assistance on Combatting Dengue in Asia (US$1M). The rest of the projects under this subsector were: 2 PPTAs for Viet Nam, Lao PDR, for capacity building for HIV/AIDS, 1 PPTA for PRC for old age caring, and 1 PPTA (supplementary) for Papua New Guinea on Strengthening Rural Primary Health Services Delivery System. 17. The 23 projects that address health systems improvements7 consist of a mix of loans (4), grants (7) and different types of TAs (12). The biggest loan approval was Pakistans Punjab MDG Program Subprogram 2 (US$150M) for the attainment of MDG Goals 4&5 through improvement of quality availability, management and poor-poor orientation of primary and secondary health services delivery. The other loans were for the Philippines Credit for Better Health (US$50M), Viet Nams Second GMS Communicable Disease Control Project (US$27M) and PNGs Rural Primary Health Services Development Project (US$20M) which has an accompanying grant from the Australian government worth US$40M. Credit for Better Health seeks to leverage private sector participation with improvement in resource allocation for priority public health programs in the Philippines. The Second GMS Communicable Disease Control Project (GMS CDC II) supports enhanced regional CDC systems through stronger surveillance, response and outbreak control and cross-border collaboration between Viet Nam, Lao PDR and Cambodia. Papua New Guineas Rural Primary Health Services Delivery Project will be implemented under a Sector Wide Approach (SWAp) arrangement and will strengthen rural health systems in selected areas by expanding coverage and improving the quality of health care in partnership with state providers and NGOs. As to grants, Lao PDRs Health Sector Development Project has a program grant component (US$10M) that supports the strengthening of health care delivery systems. This is ADBs first program support to Lao PDRs health sector and, in orchestration with at least 8 development partners, will help the MoH move towards a sector program approach. The grant to Cambodia (US$10M) is also part of the GMS CDC II. A US$14M ADF grant was also approved in 2010 for Mongolias Fourth Health Sector Development Project. The rest are for PPTAs (9), PATA (4), CDTA (1), RDTA (1). 18. There were no projects approved during the period classified primarily under health finance, though there is one loan project for the Philippines (Credit for Better Health) that directly impacts on health sector financing and has a rate enhancing value to the countrys health insurance program. The Punjab MDG project (US$150M) also has in its design the development of a sustainable and pro-poor health care financing. There are also two TAs that touch on health sector financing: a CDTA for Lao PDR in relation to its health sector program approach; and a PPTA for Viet Nam to design the Second Health Care in the Central Highlands. Table 3: Subsector Focus and OPH Theme(s) of Stand Alone Health Sector Projects: 2009-2011
Subsector Number of projects and type of financing DMCs (by order of total value of projs: highest to lowest) Examples of Key Activities Areas OPH Area/s Articulated in Project Design

Most of these projects are also anchored on specific health programs.

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Subsector

Number of projects and type of financing

Nutrition

4: all grants (plus a health program subsector project)

DMCs (by order of total value of projs: highest to lowest) NEP, MON, INO

Examples of Key Activities Areas

OPH Area/s Articulated in Project Design

Health Programs

Value: US$7.8M 7: 4 PPTAs, 1 CDTA, 2 grants

LAO, MON, Regl, PRC, BAN, PNG, VIE

Prevention and reduction of micronutrients deficiency through fortification via participation of millers; Improved nutrition through interagency and community partnerships; micronutrient distribution, BCC and training of PHC workers. Maternal and Child Health and Nutrition; Targeting poor households for medical subsidy; Dengue; Old-age care; HIV/AIDS

Governance(1) Knowledge, Analysis & Policy Dialogues (3) Partnerships (4)

Infrastructure (1) Regional Public Goods (1) Knowledge, Analysis & Policy Dialogues (3) Partnerships (2) Governance and PEM (7) Regional Public Goods (2)

US$16.750M

Health Systems

23: 8 PPTAs, 3 PATAs, 1 RDTA, 7 grants, 4 loans

PAK, PHI, PNG, VIE, MON, LAO, CAM, Regl, BAN

US$303,750

Health Finance

4: covered by projects in the health systems subsector

PHI, PAK, VIE, LAO, PRC

Improving primary and secondary health services; Improving public allocation towards health priorities through greater private sector participation; Primary Health Care and NGO participation; Human Resources Devt (inc surveillance and response); Health services mgt (incl hospitals); model health villages; Pharmaceutical regulation; evidence building Leveraging private sector participation; Health sector finance (through PEM); Health Insurance; pro-poor health care financing system

Knowledge, Analysis and Policy Dialogues (6) Partnerships (8)

Governance and PEM (4) Knowledge, Analysis and Policy Dialogues (1) Partnerships (1)

Legends: Support for health outcomes through: (A) ADBs work in infrastructure; (B) Governance and public expenditure management; (C) Regional Public Goods; (D) Knowledge, analysis and policy dialogues; (E) Partnerships

III.

Internalizing the OPH

19. This sections aims to track health and health related initiatives in the health sector as well as in other sectors of ADB in the light of the Operational Plan for Improving Health (OPH) Access and Heath Outcomes under Strategy 2020.

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A.

Health outcomes through Infrastructure Operations

20. A cursory review of the design of projects in core infrastructure sectors (Water and Municipal Infrastructure and Other Services, Energy, Transport and ICT) and those classified as multisector shows the expanse of responsibility taking for health in ADB. 21. In the Transport and ICT sector, 72 loans and grant approvals were reviewed. Of these 55 are on road transport (with 5 on urban transport), 10 on railways, 4 on water transport, 2 on air transport and 1 on ICT. Almost all road and railway transport projects identify road safety or railway safety as a consideration in the design and operations. Of these 72 projects, there are 20 which include soft inputs for road safety (e.g., training, awareness drive, education campaign) or railway safety (in the case of a rail transport project) in addition to the design or engineering interventions that address safety concerns. Eighteen (18) of these 20 projects have indicative budgets for these soft inputs. As to HIV/AIDS, 33 of the 72 project documents reviewed articulated the need for HIV/AIDS prevention interventions that go beyond the construction camps. Of these, 19 have resources allocated for preventive activities (in the RRP or in the Resettlement Plan) reaching construction workers and affected communities. 22. TA approvals in the sector, except those for project preparation, were also reviewed. A total of 62 approved projects were reviewed (40 CDTAs, 20 PATAs, one RDTA and one ADTA). Of these, six include road safety (four CDTAs, two PATA) and 11 propose HIV interventions (nine CDTAs, two PATAs). As to proposed scope of interventions, five includes HIV and trafficking awareness for communities, three limits HIV/AIDS awareness drive to the workplace, two simply flags HIV/AIDS as a safeguard issue that should be addressed, while one was conceived to develop the country framework for HIV/AIDS and Human Trafficking Prevention (HATAP). 23. In the Water and Municipal Infrastructure and Other Services sector, health is clearly a basic consideration particularly in water supply and sanitation projects. Of 44 project approvals reviewed for this sector from 2009 to 2011, 30 (68%) have specific impact or outcome indicators related to water and sanitation, such as reduction of waterborne or diarrheal diseases in their DMF (Appendix C). Of these 30 projects, 22 (20 loans, 2 grants) have specific output indicators that support the achievement of the impact or outcome indicators, in addition to simply providing safe water sources and sanitation facilities. Examples of these output indicators are increased proportion of school children who know proper hand washing, increased proportion of households practicing sanitary waste disposal, or increased proportion of residents with proper hygiene practices. 24. In projects classified as Multisector, the 22 approvals from 2009 to 2011 include those dealing with economic recovery support (4 in Central Asia), small cities and towns development (6, all in PRC), disaster relief, rehabilitation and recovery (7), infrastructure financing (4), and social sectors (combined) support (1). Of these 22 projects8, 3 (grants and 1 loan) have health related indicators that are to be achieved through water supply and sanitation projects. (Appendix D) 25. In the Energy sector, 14 (4 grants, 10 loans) of 60 projects, from 2009 to 2011, that were reviewed either anticipated or stated with certainty the need for HIV/AIDS awareness for construction project employees, while 9 projects (4 grants, 5 loans) expressed the need for HIV/AIDS awareness raising for both construction workers and affected local communities alike. 26. Non-Sovereign investment facilities approved in the last three years also included infrastructure projects in various sectors. For the energy sector, there were at least 24 non8

Including a project listed under Health and Social Protection but classified as Multisector.

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sovereign project approvals during the period. Of these, at least 16 (ranging from US$40M renewable energy projects to a US$350M hydro power projects) may be considered as entailing major infrastructure development and movement of workers in and out of the project sites. Of these, at least eight cited public health as a concern, and of these eight, only three articulated (in the RRP or the Resettlement Plan) monitoring responsibility to ensure that public health is not adversely affected. These projects consist of support for a power corporation in the Philippines, an infrastructure financing facility for Indonesia, and a hydro project in Lao PDR. For nonsovereign 26. Transport and ICT projects, only one of the six projects identified health as a concern. The rest are either silent on health or mention health but in a nebulous fashion. As to Water and Municipal Infrastructure and other Services projects, for which there were four approvals, health was mentioned only in the context of occupational safety and health. B. Health outcomes through Governance and Public Expenditure Management

27. Of the 38 Health Sector projects, approved from 2009 to 2011, ten supported improved governance and public expenditure management. (Please refer to Table 3). There is also one multi-sector loan (Economic Support Program for Tonga: US$10M) that has a direct impact on public expenditure management for health. 28. For Public Sector Management (PSM), 45 approved projects (35 loans and 10 grants) were reviewed. Twenty-four (24) of the 35 loan projects and 7 of 10 grant-funded projects were directly linked to health (i.e., tacitly addressed health concerns in the design) and 4 are just indirectly linked (3 loans and 1 grant). The rest have no distinctive linkage to health. A few examples of interventions in PSM loan and grant projects that directly link them to health outcomes are provision of block grant for health for selected communities (Solomon Islands), strengthening database that identifies the poor (Nepal), crisis recovery financing support which includes provision for health services (Tajikistan), capacity building and adoption of performance-based budgeting for health (Maldives), public expenditure support for social safety nets including health (Bangladesh), and better fiscal management to ensure adequate social safety nets including health (India, Pakistan). 29. Forty-five (45) PSM TAs were also reviewed. Of these, 16 are directly linked to health, and 8 are indirectly linked. Among the interventions that directly the projects to health are training of women's groups to lay claim on services (Nepal), support for conditional cash transfer (Philippines), development of a regulatory framework for decentralization (Cambodia), support for E-procurement in the health sector (Philippines), capacity building for public financing that targets improved financing for the health sector (Philippines, Indonesia and Tajikistan), and capacity strengthening for gender mainstreaming which targets improved health access of women (Regional). C. Health outcomes through Regional Public Goods

30. Regional public goods (RPGs) are exemplified by the following ADB initiatives: (i) Combatting Dengue in Asia; (ii) Greater Mekong Subregion Second Communicable Disease Control (GMS CDC II) Project; (iii) three TAs dealing with evidence-based advocacy and action at the regional and country levels; and (iv) facilitation of the renewal of a memorandum of understanding between countries in the Greater Mekong Subregion to work together for reducing HIV vulnerability among mobile and migrant populations. 31. The Combatting Dengue in Asia project is a regional technical assistance, approved in 2009, that identified and piloted strategies for vector source reduction and control in Cambodia, Lao PDR, and the Philippines and supported regional dialogues regarding dengue control. The GMS CDC II project, approved in 2010, builds on the gains of its precursor project. It provides a vehicle for pursuing sub-regional cooperation in surveillance, reporting and response, especially in
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the light of risks and vulnerabilities resulting from contiguous national boundaries and increasing population movement. 32. There were also three TAs approved in 2009 and 2010 that serve the ends of regional and country level advocacy and actions by generating evidences on industrial pollution, HIV/AIDS prevention, and health sector reforms. The TA on Improving the Health Status of Vulnerable Communities Threatened by Legacy or Artisanal Pollution, approved in 2009, focuses on the adverse health impacts of industrial pollution sites, in particular those in which the polluter responsible is either not available (legacy pollution) or too small (often of the artisanal variety) to be charged with the costs of clean-up. This requires increased awareness and political commitment to put pressure on the polluters to reduce pollution and clean up their operations. The outcome of this TA will be better information and awareness among policymakers, development partners, and the general public of (i) the scope of the problem in Asia and the Pacific (inventory) and preliminary cost estimates of cleaning up operations; and (ii) possible approaches to deal with the problem, including funding mechanisms (feasibility study for a health and pollution fund). 33. Another TA is a follow-thru towards the sustainability of an earlier TA on the Regional AIDS Data Hub whose development started in June 2006. Developed jointly by the ADB, the United Nations Children's Fund (UNICEF), and the Joint United Nations Programme on HIV/AIDS (UNAIDS), the data hub was officially launched on World AIDS Day, 1 December 2008. With the positive initial response, as reflected by the number of hits (56,000 hits as of July 2009) and informal discussions with national AIDS committees, the data hub has proven to be a useful resource for planners and decision-makers. However, new financing resources are needed to maintain the functioning of the data hub. The new TA will consolidate results and build on the successful experiences and institutional structures established during the first phase. 34. The TA on Asia-Pacific Health Observatory, approved in 2010, is a joint undertaking of ADB, the World Bank, and the World Health Organization. It seeks to foster effective health systems by collecting and disseminating health-related information and good practices that will help governments adopt new health policies and reforms based on evidence. This TA has two components: the provision of funding and technical support for the Observatory, and follow thru efforts on an ADB-WHO initiative to involve the private sector in a public-private partnership for regional health security. Initial knowledge products from this undertaking are expected by the end of 2013. 35. A more recent RPG is the Memorandum of Understanding (MOU) on Joint Action between Countries in the Greater Mekong Subregion to Reduce HIV Vulnerability Associated with Population Movement. This MOU, which was first signed by the six GMS countries in 2005 and expired in 2009, was renewed in December 2011 during the GMS Summit in Myanmar. The MOU provides GMS countries with the needed policy platform upon which to pursue subregional cooperation for HIV/AIDS prevention, treatment, care and support for mobile and migrant populations. A Joint Action Programme (JAP) which operationalizes the spirit of the MOU identified key activities for which leverage funding will be provided by ADB.9 ADB will partner with the Joint United Nations Initiative on Mobility and HIV/AIDS in Southeast Asia (JUNIMA) and the Association of Southeast Asia Nations (ASEAN) in facilitating the implementation of the JAP by the GMS countries. D. Generating Knowledge and Advancing Policy Dialogue

36. Standalone research as well as studies conducted as part of direct intervention programs deepen the stock of knowledge in ADB in relation to pursuing health outcomes through the themes elucidated in the OPH. In addition to the TAs mentioned earlier that are geared towards
9

Support for the Joint Action Program will be provided through RETA 6321: HIV/AIDS Cooperation Fund.

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generating knowledge and evidences for health action, the following knowledge products were also published and disseminated:

Table 4: ADB Publications for Health by Region in 20102011

Title Between-Country Disparities in MDGs: The Asia and Pacific Region ( with a special emphasis on health MDGs) Handle with Care: Impact Stories from Fragile Situations Approaches to Combat Hunger in Asia and the Pacific In Focus: Health Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia Implementation Strategy of Basic Health Care System Lessons from the Northern Economic Corridor: Mitigating Human Immunodeficiency Virus (HIV) and other Diseases For Life, With Love: Training Tool for Human Immunodeficiency Virus Prevention and Safe Migration in Road Construction Settings and Affected Communities Practice Guidelines for Harmonizing Human Immunodeficiency Virus Prevention Initiatives in the Infrastructure Sector: Greater Mekong Subregion Accounting for Health Impacts of Climate Change Observations and Suggestions on Population Aging and Long-Term Health Care in the Peoples Republic of China Improving Health and Education Service Delivery in India through PublicPrivate Partnerships Reducing Child Malnutrition through Social Protection in Nepal Sustainable Health Care Financing in the Republic of Palau Bangladesh: Second Urban Primary Health Care Project Food and Nutrition Security Status in India Opportunities for Investment Partnerships Geographic Focus Regional Regional Regional Regional Central and West Asia East Asia Southeast Asia-Greater Mekong Subregion Southeast Asia--Greater Mekong Subregion Southeast Asia--Greater Mekong Subregion Regional PRC India Nepal Palau Bangladesh India

37. Health was also featured in Development Asias November 2011 issue with the cover story titled, Who Will Pay for Asia's Double Burden? The issue examines the double burden of communicable diseases, which remain a threat particularly to the poor in the region, alongside that of non-communicable diseases which are also known as lifestyle diseases resulting from rapid urbanization and the shift to more affluent and sedentary lifestyle. It elaborates on innovative financing as a response to this double health financing burden. In addition, there were 34 ADB news releases related to health in 2010, and 8 in 2011. 38. Two video documentations were also produced, as follows: Roads, Connectivity and HIV/AIDS (audio-visual material) Short video clips highlighting the nexus between increased connectivity and the risk of transmitting communicable diseases, especially HIV/AIDS; features innovative HIV risk mitigation schemes being implemented by NGO partners in the Greater Mekong Subregion Balay Mangyan: Where tradition and science meet (audio-visual material) A video documentary on how an innovative birthing facility changes the lives of Mangyans, an indigenous group in Mindoro Province, Philippines

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39. In addition, 13 knowledge and experience sharing sessions on critical health issues, including those that touched on gender and equity, were conducted in 2010 and 2011. Among the topics discussed where whole-of-society approach to emerging health threats, nutritional status of children, maternal and child health, health and gender adaptation to climate change, addressing cultural barriers to health access, public-private partnership, HIV/AIDS, climate change and health of the urban poor. 40. In addition, infrastructure sectors in ADB have also included health in their major events, such as the ADB Conference to Address Asias Water Crisis and the ADB Transport Forum, both held in 2010. The water conference included sessions on water safety and meeting the MDG (Target 7C), while the Transport Forum featured two sessions: one on road safety and another on HIV risks and mitigation in major road corridor projects. E. Strengthening Partnerships

41. In addition to the health TAs mentioned earlier that are joint undertakings with UN agencies, there are other health projects approved in the last 3 years with co-funding or parallel funding from various development partners such as:
Development Partner Sweden Name of Project and Amount of Funding Regional TA on Managing Climate Impacts on Health in Water and Agriculture Sectors and Disaster Risk Reduction (US$140,000) Fresh infusion to the ADB Cooperation Fund for Fighting HIV/AIDS in Asia and the Pacific (US$5.1M) Cluster Development Technical Assistance for Bangladeshs Second Urban Primary Health Care (US$225,000) Mongolia: Fourth Health Sector Development Project ($450,000) Supplemental funds for the PPTA for PNG on Strengthening Rural Primary Health Services Delivery (US$90,000) Rural Primary Health Services Delivery Project for PNG, (US$40,000,000 grant) Year Approved 2009

United Kingdom

2010 2010

WHO New Zealand

2010 2010

Australia

2011

42. The challenge of fostering harmonization among donors and development partners remain, and ADB project specialists working in the health sector try to maximize the opportunities for this through stronger project coordinating mechanisms at the country level and more focused stakeholders meetings where experiences and good practices are shared for continuing quality improvement. In HIV/AIDS, an attempt to better harmonize donors and development partners is reflected in the publication of the Practice Guidelines for Harmonizing Human Immunodeficiency Virus Prevention Initiatives in the Infrastructure Sector in the Greater Mekong Subregion, with funding support from the HIV/AIDS Cooperation Fund. These guidelines were finalized after a series of consultations with various development partners in the region. 43. In terms of CSO participation, various projects focused on strengthening health systems, as well as those focused on priority diseases like HIV/AIDS, have in their design the engagement of local and international NGOs. A good example of this is the Rural Primary Health Services Delivery Project for PNG which harnesses the strength and goodwill of CSOs to reach underserved and un-served communities. The participation of NGOs and community-based organizations is also very much alive in nutrition projects especially in targeting children and mothers from poor households and in conducting information drive and advocacy. In HIV/AIDS projects, particularly under the umbrella TA for the Greater Mekong Subregion, the implementation arrangements are designed to enable the participation of both international and local NGOs in the provision of prevention, care, treatment and support services for most vulnerable populations,
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such as entertainment workers, young people, client of female entertainment workers, mobile and migrant populations. Private sector participation is also part of the design of nutrition projects, especially on food fortification, and in health projects that segment the market for private sector health care providers in order to prioritize limited public resources for the poor. IV. Conclusions and Recommendations

44. A review of current Country Partnership Strategy (CSP) documents and Country Operations Business Plans (COBP) tend to support the trend towards a much reduced investment in stand-alone health projects in the coming years, as indicated below:
Table 5 : Health in the Pipeline Group A Group B1 (ADF only) (ADF w/limited OCR) Number of countries Number of countries with updated planning document(s) With health sector project in the pipeline Health through investment in Water and Sanitation Health through investment in other themes 14 12 5 9 8 2 4 1 Grp B2 (OCR with limited ADF) 5 5 2 3 Group 3 (OCR only)

7 3 2 -

Source: Categories of countries based on the ADB Graduation Policy, 2003

45. The latest in the series of MDG reports (ESCAP, ADB, UNDP) state that while the AsiaPacific Region has made significant strides towards achieving the MDGs, it has been slow to prevent people from going hungry, stop children dying before their fifth birthday, and prevent mothers dying from causes related to childbirth. Clearly, ADB is in a crucial junction --transitioning to the new direction for achieving health outcomes and at the same time maintaining its pivotal role towards the achievement of the MDGs. 46. In this context, the following recommendations are given: Strengthening water and sanitation projects by strengthening health in project design. Whenever the opportunity exists, behaviour change indicators (e.g., proper hand washing, proper defecation) and gender indicators (e.g., X% of poor households headed by women benefiting from improved water supply; X% of women comprising the leadership in community water and sanitation structures) should be included in water and sanitation projects. There are already projects that include these in their design and their outcomes and impacts should be shared within ADB and the DMCs. A comparative evaluation of the health impacts of these projects with those that do not have behaviour change and gender indicators can be helpful in scaling up good practices. Risks mitigation and infrastructure. As ADB anticipates increasing involvement in HIV risk mitigation associated with major road and infrastructure development projects, it should have the facility for internally providing TA to project specialists in: (i) assessing HIV risks and current programming in the areas to be affected by the infrastructure project; (ii) designing the interventions guided by lessons from other projects; (iii) identifying the most appropriate consultants and implementation
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arrangement; and (iv) monitoring if the project is on track. The Sustainable Transport Initiative, as conceptualized, is a step towards this direction, and other sectors can draw lessons from its operationalization. Sharing experiences and good practices should continue especially in the light of changing risk dynamics and new or innovative ways of addressing these risks. ADB should also leverage its assistance in inducing greater private sector participation for HIV risk reduction. The infrastructure multi-tranche financing projects in South Asia and in Indonesia (multisector and non-sovereign investments) provide ADB the leverage to advocate for the inclusion of health safeguards (e.g., road safety, HIV risk mitigation for construction workers and communities in the project area) in major infrastructure projects. Through this multitranche financing facility, a more meticulous public-private sector program for HIV/AIDS prevention should be explored. Strengthening Governance and Public Finance Management for Health. (will be informed by the PSM tables) o The substantive number of Public Sector Management Projects with strong linkage to health is an encouraging sign as it replies to pressing DMC concerns for equity (i.e., pro-poor targeting), transparency (i.e., in procurement, in the exercise of regulatory powers), and responsive sector planning, programming, financing and budgeting. Other activities in this sector related to health (e.g., gender mainstreaming, encouraging communities to demand for quality health care, support for social safety nets like conditional cash transfers) are also maximizing the opportunities for improved local health governance, as well as grassroots and inter-agency partnerships. To heighten ADBs impact on health through this sector, projects related to improving public finance management (with its vital linkages to local procurement processes, health financing, pro-poor targeting) should be documented. Knowledge products like diagnostic tools and menus of interventions, if available, should be disseminated and jointly processed (with the Health CoP, among others) to foster ownership, thus making public finance management a major pillar for strengthening the health sector in DMCs. DMCs including local government stakeholders should also be given the opportunity to reflect and actively share the insights and hindsights regarding public finance measures that actually result to greater resource mobilization and utilization for health.

Strengthening health promotion in the design of approved and pipeline projects. Cognizant of the social determinants of health, like poverty, lack of education and gender roles, and the increasing burden from non-communicable diseases, strengthening health promotion should be an essential ingredient in health sector projects. The importance of health promotion cannot be emphasized enough, especially in a time of global economic slowdown when coverage for health insurance and other social safety nets also contract. Yet, more often than not, health promotion is overlooked or left to the pity of government health education structures that pay very little attention or have very limited resources for educating the public about healthy lifestyle (e.g., smoking cessation, healthy food, exercise). In relation to this, ADBs role as a facilitator of policy dialogues should be exercised in areas like taxation of tobacco and alcohol products, and proper food labelling.

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Greater attention to nutrition. As noted in this report, the number of nutrition projects supported by ADB has dwindled, despite the slow progress in achieving the nutrition related MDG in a number of countries in the region (ESCAP, ADB, UNDP: 2012). In line with the ramp-up towards achieving the MDGs, nutrition should clearly be one of the priorities in the health sector especially in countries that are off track or have shown slow progress in achieving the nutrition MDG. Given its large investments in water and sanitation, ADB is also in the best position to reckon with and promote the link between nutrition and water & environmental sanitation, considering how waterborne diseases and parasitic infections due to poor sanitation are also causing children to be underweight. ADB is also in a strong position to advocate for synergy between nutrition programs and agriculture sector projects aimed at food security especially for poor communities, particularly households with pregnant women and children under 5. Generating Knowledge. To further effect and maintain an expanded base of responsibility taking for health in ADB, the Health CoP should take the lead in generating knowledge about improving health outcomes through the 5 thematic areas of the OPH, with greater focus on the activities of the core infrastructure sectors (transport and ICT, energy, urban development) and those on public sector management. Disseminating this in a way that will be absorbed by target audiences is half the challenge. Due to heavy workloads, short but crisp audio-visual materials, like 5-minute video clips, would tend to be a more attractive medium, but complemented by published briefs or guides on the specifics of achieving results.

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