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Background Health tourism or treatment tourism is one of threatening fields that causes (added s) increase in prevalence of job stress and illnesses among hospital staff of providing health tourism services (HSPHT). The aim of this study is to determine the prevalence of job stress and illnesses among hospitals staff of providing health tourism services in touristic cities as Tehran and Shiraz in Iran. Methods This cross-sectional, descriptive-analytical study was carried out among the staff of 10 hospitals providing health tourism services in cities of Tehran and Shiraz, Iran, in 2019. In these hospitals, 1250 staff were chosen by cluster sampling method from each job task as doctor, nurse, office worker, and paramedical and cleaner worker. Also, 1100 staff working in other general hospitals (non-HSPHTS) were selected as the control sample. Then, the demographic information and prevalence of job stress were gathered by Osipow job stress questionnaire and the illnesses were accumulated by self-reporting questionnaire. Finally, data were analyzed in SPSS 20 software. Chi-square and Pearson’s parametric tests were used in the study. Results Prevalence of illnesses among HSPHTS was more than that in general hospitals (Pvalue Pvalue Conclusion Results of the study showed that the prevalence of job stress (%33.76) and illnesses (%43.66) among the HSPHTS was respectively 2 and 2.6 times more than that among the staff of general hospitals. Thus, it is necessary to observe sanitary actions and considerations more seriously in these hospitals.

This paper explores the relationship among religion, spirits and healing in the Tehuledere community in the northeastern part of Ethiopia and focuses on how this knowledge can inform primary healthcare reform. The study employed qualitative ethnographic methods. Participatory observation, over a total of 5 months during the span of 1 year, was supplemented by focus group discussions (96 participants in 10 groups) and in-depth interviews (n = 20) conducted with key informants. Data were analyzed thematically using narrative strategies. The present study revealed that members of the study community perceive health, illness and healing as being given by God. Many of the Tehuledere people attribute illness to the wrath of supernatural forces. Healing is thought to be mitigated by divine assistance obtained through supplication and rituals and through the healing interventions of nature spirit actors. We found that the health, illnesses and healing were inextricably linked to religious and spiritual beliefs. Our findings suggest that religious and spiritual elements should be considered when drafting and implementing primary healthcare strategies for the study communities and similar environments and populations around the globe.

Microbial contamination of fresh produce (fresh fruits and vegetables) poses serious public health concerns worldwide. This study was conducted as a comprehensive analysis of biological hazards in the global fresh produce chain. Data about produce-related outbreaks and illness were collected from the annual reports and databases of foodborne outbreak surveillance systems in different regions and countries from 2010 to 2015. The global patterns of and regional differences in documented outbreaks and cases were analyzed, and produce commodities and pathogens of greatest concern were identified. Data on sporadic illnesses were also collected through a comprehensive literature review of case-control studies. We found 988 produce-related outbreaks (with known agents) and 45,723 cases in all regions and countries. The numbers of produce-related outbreaks per million person-years were approximately 0.76, 0.26, 0.25, 0.13, 0.12, and 0.05 in New Zealand, Australia, the United States, the European Union, Canada, and Japan, respectively. The top three food categories and pathogens contributing to produce-related outbreaks were vegetables and nonfruits (i.e., food other than fruits; 27.0%), unspecified vegetables (12.2%), and vegetable row crops (11.7%) and norovirus (42.4%), Salmonella enterica (19.9%), and Staphylococcus aureus (7.9%), respectively. Produce consumption was identified as a protective factor, a risk factor, and either a protective or risk factor for sporadic illnesses in 11, 5, and 5 studies, respectively, among 21 case-control studies. Risks associated with produce consumption in the United States and the European Union have been linked to various factors such as irrigation water, cross-contamination, storage time and temperature abuse, infected food handlers, and unprocessed contaminated ingredients. The results of the current study indicate the complexity of produce products consumed across the globe and the difficulty in tracing illnesses back to specific food ingredients.

The Ebola pandemic has been one of the most virulent pandemics in modern times. By the end of 2015, the epidemic had cost the lives of more than 11,300 people in Guinea, Liberia, and Sierra Leone, including more than 500 frontline health care workers. After good growth performance between 2011 and 2013, Guinea’s economy has suffered a number of setbacks, including the Ebola crisis and a sharp drop in new investment in the mining sector. As part of the international effort to understand and manage the Ebola crisis and to obtain microeconomic data, the World Bank partnered with Guinea’s National Institute of Statistics (INS) to conduct a mobile phone survey to measure the socioeconomic impact of Ebola on households, following in the footsteps of similar mobile surveys conducted in Liberia and Sierra Leone in 2015. The study finds that the pandemic had ripple effects on the economic fabric and that the economic effects of Ebola have outlasted the epidemiological ones. In addition to the great loss of life, the epidemic has caused great damage to the countries’ economies. As part of the international response, the World Bank Group has significantly financed the Ebola-affected countries. Guinea was significantly affected by the Ebola pandemic, jeopardizing some of the gains in macroeconomic stability and poverty reduction during the last few years. The survey was conducted in all provinces of Guinea, with 60 percent of the respondents residing in the areas strongly affected by Ebola. Using newly collected data through a mobile phone survey, this study analyzes the socioeconomic impact of Ebola on households in Guinea. The survey shows that all parts of Guinea were economically affected by Ebola, with greater impacts in the southeast and the areas around Conakry. It is interesting to note that a quarter of respondents in the severely affected areas reported experiencing proven cases of Ebola in their neighborhood or village. In relation to agriculture, it is found that Ebola did not negatively affect agricultural production and food price. Another surprising finding is that despite Ebola and risk of contamination, households that needed treatment for malaria and diarrhea still visited a health facility, whereas a significant proportion of households reduced their attendance of health facilities. Income loss for rural households was much more related to difficulties in selling their production, than to lower agricultural production or lower food prices. However, Ebola has had a larger effect on urban employment, as illustrated by the increase in the urban unemployment rate. On the other hand, due to Ebola, children dropped out of school, and households adopted coping strategies by reducing their food consumption and selling key assets.

This paper examines the effect of air pollution on labor supply in Lima, Peru. It focuses on fine particulate matter (PM2.5), an important pollutant for health according to the medical literature, and shows that moderate levels of pollution reduce hours worked for working adults. The research design takes advantage of rich household panel data in labor outcomes to address omitted variables and allows investigation of whether the response to air pollution is non-linear. The analysis finds that the effect of moderate pollution levels on hours worked is concentrated among households with susceptible dependents, that is small children and elderly adults, while the highest concentrations affect all households. This suggests that caregiving is likely a mechanism linking air pollution to labor supply at moderate levels. Further evidence of this mechanism is provided using DHS data on children morbidity for the same time period. Finally, no evidence is found of intra-household attenuation behavior. For instance, there is no re-allocation of labor across household members, and earnings decrease with air pollution.

Did unemployment in the Great Recession hurt people's health? The broad answer is no: job losses have statistically insignificant impacts on mortality. The exogenous sources of job losses in a U.S. county is the tradable job losses driven by external demand collapses during the Great Recession. The insignificant relationship holds for males and females, for all age groups, and for almost all categories of mortality. Three important exceptions are Alzheimer's, poisoning, and homicide.

Improved outcomes for women and children - more education, lower fertility rates, higher nutritional status, and lower incidence of illness, among other outcomes - have broad individual, family, and societal benefits. For nearly 15 years, the targets of the millennium development goals (MDGs) have been a bellwether for progress, particularly for maternal and child health (MCH) - a two-thirds reduction in under-five mortality in MDG 4 and a three-quarters reduction in the maternal mortality ratio in MDG 5. This systematic review by the Independent Evaluation Group (IEG) is a learning exercise that looks beyond World Bank experience. It is intended to be used a reference for practitioners in the Bank and elsewhere with an interest in interventions that have demonstrated attributable improvements in skilled birth attendance and reductions in maternal and child mortality. This review also identifies important gaps in the impact evaluation evidence for interventions that may be effective in reducing maternal and child mortality but whose impacts have not yet been tested using robust impact evaluation methods. The systematic review provides findings on what is known about the effects of interventions on skilled birth attendance, maternal mortality, neonatal mortality, infant mortality, and under-five mortality, as well as the effect of skilled birth attendance on these and other intermediate MCH outcomes. Finally, the review highlights the main gaps in the body of impact evaluation knowledge for maternal and child mortality.

Worldwide, deaths from cancer exceed those caused by human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), tuberculosis, and malaria combined. Seventy percent of deaths due to cancer occur in low-and middle-income countries, which are often poorly prepared to deal with the growing burden of chronic disease. Over a period of 18 months, the cancer care and control South-South knowledge exchange brought together a group of stakeholders from five countries in Africa - Botswana, Kenya, Rwanda, Uganda, and Zambia to share experiences, lessons, and good practices through a set of video conferences and a site visit to Zambia. All five countries have demonstrated commitment, initiated various cancer control and cancer screening programs, and expressed interest in sharing their experiences. The knowledge exchange on cancer care and control aimed to raise awareness, increase knowledge of effective strategies, and strengthen regional collaboration in cancer control planning and expanding equitable access to cancer treatment. This paper presents highlights of the country experiences shared, common challenges discussed, and innovative solutions explored during the knowledge exchange. Topics addressed include population-based surveillance and data collection to better document the burden of cancer; strategies for designing and implementing successful national cancer care and control programs; innovative approaches for strengthening cancer prevention efforts such as human papilloma virus (HPV) vaccination programs; task sharing and other strategies to build capacity and increase access to services; analytical tools for understanding the costs of programs; financing models, including public private partnerships, to increase cancer prevention and care; policy reforms needed to improve access to palliative care; and opportunities for regional collaboration.

This paper introduces a simple framework for understanding the dimensions and determinants of health worker performance based on the idea that there can be three different gaps affecting performance: a knowledge gap, the knowledge-capacity gap and the capacity-performance gap. The paper argues that performance is determined by a combination of competence, capacity and effort, and that any of these elements may lead to poor performance, and applies this framework to the measurement of health worker performance in Tanzania. Whilst discussing and highlighting key findings related to the assessment of health worker performance in Tanzania, the overarching objective of the paper is to offer a systematic way to analyze health worker performance through primary data collection and analysis to benefit researchers and countries beyond Tanzania.

El Salvador’s development over the past decade has been dichotomous. On the one hand, economic growth has remained persistently low, employment and labor force participation have barely increased, and progress on poverty reduction has slowed. On the other hand, inequality has fallen, and shared prosperity improved together with advances in many social indicators, such as pre-primary enrollment rates, access to prenatal care, immunizations, and water and sanitation. The increase in the use of social spending, which now accounts for 12.4 percent of GDP, together with an improvement in the quality of social spending, explain at least part of this dichotomy of redistributive and social gains despite low growth, a tight fiscal situation and generally low government revenues and spending. Looking forward, the key challenges El Salvador faces are related to continuing improving the quality and efficiency in the social sectors, while maintaining the overall level of social spending within an increasingly constrained fiscal environment, where fiscal constraints, low revenues, and the need to cut the deficit by 3 percent of GDP are significant elements, as well. Priority will have to be given to reallocations and improvements within the spending envelope for the social sectors to maximize impact. This document analyzes social spending for El Salvador for the education, health and social protection and labor sectors in depth and explores a series of policy options for El Salvador to reallocate social spending for more effective impacts, to enhance and reform social policies and social service delivery, and to improve the management of public spending and budget execution in the social sectors.

This paper highlights challenges that the government of Papua New Guinea faces in delivering equitable health care. It analyses findings from the 2010 household survey, including sickness reporting, health service utilization and out of pocket expenditure, concluding that the poorest quintile is most vulnerable to illness, yet has the lowest utilization rates of healthcare facilities. The lack of healthcare workers and the distance to facilities are among the most dominant reasons cited for not utilizing healthcare facilities in the poorest quintile while out-of-pocket payments have minimal catastrophic impact, yet have still been found to be a barrier to utilization. The paper also sets out policy implications of these findings, including the need for the government to focus on, and prioritize, strengthening the health services delivery to achieve universal health coverage.

This paper presents direct evidence on the quality of health care in low-income settings using a unique and original set of audit studies, where standardized patients were presented to a nearly representative sample of rural public and private primary care providers in the Indian state of Madhya Pradesh. Three main findings are reported. First, private providers are mostly unqualified, but they spent more time with patients and completed more items on a checklist of essential history and examination items than public providers, while being no different in their diagnostic and treatment accuracy. Second, the private practices of qualified public sector doctors were identified and the same doctors exerted higher effort and were more likely to provide correct treatment in their private practices. Third, there is a strong positive correlation between provider effort and prices charged in the private sector, whereas there is no correlation between effort and wages in the public sector. The results suggest that market-based accountability in the unregulated private sector may be providing better incentives for provider effort than administrative accountability in the public sector in this setting. While the overall quality of care is low both sectors, the differences in provider effort may partly explain the dominant market share of fee-charging private providers even in the presence of a system of free public healthcare.

The Service Delivery Indicators (SDIs) provides a set of key indicators serving as a benchmark for service delivery performance in the health and education sectors in Sub-Saharan Africa. The overarching objective of the SDIs is to ascertain the quality of service delivery in primary education and basic health services. This would in turn enable governments and service providers alike to identify gaps and bottlenecks, as well as track progress over time, and across countries. The SDI survey interviewed 403 heath providers across Tanzania between May 2014 and July 2014. This technical report presents the findings from the implementation of the SDI in the health sector in Tanzania in 2014. Survey implementation activities took place following extensive consultations with the government and key stakeholders on survey design, sampling, and adaptation of survey instruments. A major challenge for Tanzania’s health sector is the shortage of skilled human resources for health (HRH). This survey found that provider knowledge and abilities were not adequate to deliver quality services. Caseload per provider and absenteeism are relatively low, so the issue is not over burdened providers. There seems to be ample room for a significant increase in the caseload of Tanzanian providers, i.e. the level of productivity in health service delivery, without jeopardizing quality. In addition to increasing the volume of skilled HRH to address the shortage of providers, improvements in management, supervision and training is important to improving service delivery. Health for all in Tanzania will mean the simultaneous availability of widely accessible inputs and skilled providers.

This paper lays out a roadmap to achieve social justice in healthcare by prioritizing areas related to service delivery, financial protection, and quality of care. The aim is to assist the Government of Egypt (GoE) in realizing the principle of social justice in the provision of healthcare. In doing so, the roadmap aims to prioritize key areas of focus for Egypt, including describing which existing programs to continue supporting and which new programs to consider for development, all under an integrated and interdependent structure. It is a focused assessment of how the overarching aim of social justice can be achieved in the healthcare sector through an emphasis on improving services for the most disadvantaged groups. This roadmap suggests recommendations that will result in incremental improvements in Egypt’s healthcare system in the short to medium term with a focus on disadvantaged groups. Achievement of these results should situate Egypt on the path to achieving social justice in healthcare in the long term.

This study was jointly undertaken by the Climate Change and Health Promotion Unit of the Ministry of Health and Family Welfare, the International Centre for Diarrheal Disease Research, Bangladesh, and the World Bank. This study had two broad objectives: (1) to assess national vulnerability and impact on major diseases of increased climate variability and extreme events in Bangladesh; and (2) to assess existing institutional and implementation capacity, financial resources at the local level, and existing public programs targeted at climate-sensitive diseases.

Investments in education, health and social protection are the key to improving the state of human development in any society. In recent years, Nepal too has invested heavily in these sectors, particularly in education and health. This note provides an overview of the progress and current state of access and equity in these three sectors. It also presents evidence on some aspects of quality in the education and social protection sectors. While the country has made substantial improvements in different indicators of access at the aggregate level, disaggregated data show that disparities in access continue to exist across demographic and geographical dimensions. There is some evidence of improvement in the quality of educational inputs over the years, but the quality of outcomes remains poor.

This report presents an analysis of the early childhood development (ECD) programs and policies that affect young children in the Gambia and recommendations to move forward. This report is part of a series of reports prepared by the World Bank using the systems approach for better education results (SABER) - ECD framework and includes analysis of early learning, health, nutrition, and social and child protection policies, and interventions in the Gambia, along with regional and international comparisons.

The study covered a wide range of topics, making data collection especially challenging. Key informants were sometimes new to their posts and were unable to provide details on specific programs, policies, or coverage rates. Few countries in Latin America and the Caribbean mainstream into their crisis and emergency plans protection of the nutritional status of mothers and children in the first 1,000 days of life. All countries should reinforce the promotion and protection of breastfeeding in emergencies, notably by providing an enabling space for mothers to safely breastfeed their children and by managing the provision of artificial milk formula. It is concerning that during emergencies most countries provide powdered artificial formula instead of ready-to-use artificial milk formula to infants that cannot breastfeed, greatly increasing the risks of illnesses and malnutrition as a result of inappropriate dilution and unsafe water. All countries need to reinforce their monitoring and evaluation systems, including surveillance of food and nutrition insecurity. While most countries have some form of monitoring system, few of those systems are computerized, which impairs timely and informed decision making. Systematic evaluations of emergency and crisis response are seldom performed. A number of countries would benefit from updating their nutrition policy and protocols based on the latest available evidence. Of particular importance are updates to the prevention and treatment of micronutrient deficiencies with micronutrient powders; treatment of acute malnutrition, notably with the use of ready-to-use supplements; and efficient treatment of diarrhea through the use of oral rehydration solution and zinc. Most countries will benefit from adapting the food and water rations given in emergencies to the specific nutritional needs of pregnant and lactating women and children

There are three main messages running throughout this report. First, Non Communicable Diseases (NCDs) can impose large health, financial and economic costs on countries. This is particularly important in the Pacific where Government already finances, and provides, the bulk of health services. Second, risk factors in the Pacific are feeding a pipeline of potentially expensive to treat NCDs, including diabetes and heart disease, but governments are already fiscally constrained in how much more they can provide to the health system. Third, from public health and public finance perspective, many of the NCDs are avoidable, or their health and financial costs can at least be postponed, through good primary and secondary prevention. This will require a more coherent approach to health system financing, and health system operations more generally.

Southeast Sulawesi is one of Indonesia's developing provinces and over the past five years has achieved one of the country's highest growth rates. In 2010, Southeast Sulawesi's economy grew at 8.2percent the third fastest in Indonesia. The poverty rate has declined significantly in the past 10 years and the unemployment rate is one the lowest in Indonesia. Per capita expenditure in Southeast Sulawesi has increased nine-fold compared to pre decentralization rates Southeast Sulawesi's consolidated per capita expenditure now falls in the top 10 in Indonesia. However, Southeast Sulawesi is still facing a range of challenges. The Human Development Index (HDI) has continued to lag at 25th in Indonesia over the past five years. Although regional Gross Domestic Product (GDP) has grown rapidly, in real per capita terms it is still far below the national provincial average. Southeast Sulawesi' poverty rate also remains above the national average. It will be important for the high and growing rate of per capita expenditure to be matched with improvements in public financial management capacity within the local government. In the context of overcoming these challenges and capitalizing on expanding opportunities, the local governments in Southeast Sulawesi and in particular the provincial government need to work harder to make the most of its budgetary resources. The development agenda and programs must be sharpened and budget allocations must be optimized to achieve development targets, especially in the strategic sectors of education, health, infrastructure and agriculture. This report contains findings and recommendations intended to support sub national governments in Southeast Sulawesi province to enhance their public financial management performance; improve the quality of evidence based planning and budgeting; and accelerate the achievement of existing development targets.

The purpose of this report is to examine and propose options for policy design and implementation, based on a situational analysis for six Eastern Caribbean countries and a review of the lessons of other nations in prevention and control. A committed partner of the Organization of Eastern Caribbean States (OECS) countries, the World Bank is responding to their needs to address the increasing Non-Communicable Diseases (NCDs) burden by providing this report. This report analyzes the situation, reviews lessons learnt in other countries in the prevention and control of major NCDs, and proposes policy options to address the challenges. Specifically, this report aims to provide policy makers with an overview of the NCDs and key risk factors in the region and make inter-country comparisons; assess the economic impact of key NCDs and risk factors where data are available; outline policy options and cost effective interventions for controlling major NCDs that are common to the OECS countries; and provide input for developing a regional health strategy. In the belief that powerful information can drive strategic action, the report aims to: raise awareness of the reality and consequences of failure to take strong action; and identify priority actions that are realistic and tangible for policy makers in developing strategies and allocating resources.

China's 12th five-year plan (2011-2015) aims to promote inclusive, equitable growth and development by placing an increased emphasis on human development. Good health is an important component of human development, not only because it makes people's lives better, but also because having a healthy and long life enhances their ability to learn, acquire skills, and contributes to society. Indeed, good health is a fundamental right of every human being. Good health among a population can also enhance economic performance by improving labor productivity and reducing economic losses that arise from illnesses. The findings and recommendations can inform and promote a broad dialogue toward the development of a multisectoral response to effectively address the growing burden of Non Communicable Diseases (NCDs), including a better alignment of the health system with the population's health needs. The report also advocates implementing 'health in all' policies and actions for a multisectoral response to NCDs in China to help achieve the ultimate goal of 'harmonious' development and growth.

This paper is one component of a global study on the Economics of Adaptation to Climate Change (EACC) in developing countries; the focus in this paper is human health. The main human health impacts of climate change are increased incidence of vector-borne disease (malaria), water-borne disease (diarrhea), cardio respiratory diseases, heat- and cold-related deaths, injuries and deaths from extreme weather events (flooding), and a greater prevalence of malnutrition. Adaptation measures comprise all actions taken to reduce, prevent, or treat these additional cases of disease or death, including actions outside the health sector such as disaster reduction programs, food and water security measures, and the provision of infrastructure services. For tractability and to reduce duplication with other components of the EACC study, the scope of this paper is limited to conventional public health adaptation activities, with a focus on malaria and diarrhea. This study also incorporates updates and revisions to the unit cost of prevention and treatment for malaria and diarrhea and updates to the exposure-response functions used to compute the relative risk for malaria.

As gains in basic health care increase life expectancy, more people live past the age of 65, a time when the risk of dementia and other degenerative diseases is higher and people are more likely to require long-term care (LTC) services. Whether at home or in an institution, such care is an important way to protect the lives and dignity of a country's elderly citizens. Unfortunately, the cost of LTC, especially in institutions, can be catastrophic for families. Without public social protection systems many people cannot afford the care they need or the high cost of care sends them and their families into poverty. Thus, LTC is not only a health issue, but also a fiscal issue and as the European population ages, it is crucial for states to develop comprehensive LTC systems that address this interrelated issue. The next section explores the demographic background of the Bulgarian population, which is one of the fastest aging in Europe. This is followed by s short-description of the macro-economic and fiscal framework in post-crisis Bulgaria. Next, an overview of LTC service provisions is given, followed by a section on financing of LTC services. The last section concludes by introducing some guiding principles for future policy reforms.

This study outlines the initial challenge presented by the HIV/AIDS epidemic, describes Djibouti's response, reviews the results achieved and the enabling factors in curbing the spread of the epidemic, and identifies remaining challenges. Between 2002 and 2008, HIV prevalence among young pregnant women aged 15-24 was reduced from 2.7 percent to 1.9 percent and among sentinel surveillance groups from 2.5 percent to 1.9 percent. HIV prevalence among tuberculosis patients was reduced from an estimated 22 percent to 12 percent. Condom use during last intercourse outside marriage increased from 27 percent to 55 percent and reached 95 percent among sex workers. Among the general population, awareness of HIV/AIDS increased to 95 percent and knowledge about transmission and prevention rose to 50 percent. Political commitment, engagement of community and religious leaders, rigorous communication, social marketing and the provision of an integrated package of medical and social services, and donor harmonization were among the key factors that contributed to the achievement of these results. Despite these impressive results in a relatively short period, Djibouti still has to address several challenges and consolidate program gains, but most importantly, funds are being mobilized from government resources to sustain the national AIDS control program.

This paper summarizes the key findings of an 'After Action Review' (AAR) that reflects a decade of experience in designing and implementing ten HIV/AIDS projects in the Caribbean, financed by the World Bank. The objective is to identify what worked (and what didn't) in the project approach, design and implementation, distilling useful lessons for other projects in small states.

Backed by sound economic policies and until the global crisis, a buoyant global economy, many developing countries made significant movement toward achieving the 2015millennium Development Goals (MDGs), particularly those for poverty reduction, gender parity in education, and reliable access to safe water. But even before the global economic crisis, progress in achieving some MDGs, especially those on child and maternal mortality, primary school completion, hunger, and sanitation, was lagging. The global food, fuel and economic crises have set back progress to the MDGs. An estimated 64 million more people are living on less than $1.25/day than there would have been without the crisis. The challenges ahead are achieving the MDGs requires a vibrant global economy, powered by strong, sustainable, multi-polar growth, underpinned by sound policies and reform at the country level; improving access for the poor to health, education, affordable food, trade, finance, and basic infrastructure is key to accelerating progress to the MDGs; developing countries need to continue to strengthen resilience to global volatility in order to protect gains and sustain progress toward the MDGs; the international community must renew its commitment to reach the 'bottom billion', particularly those in fragile and conflict-affected countries; and global support for a comprehensive development agenda including through the G20 process is critical. In the wake of recent global crises, and with the 2015 deadline approaching, business as usual is not enough to meet the MDGs.

The FOAM (Focus on Opportunity, Ability, and Motivation) is a framework designed to help in the development, monitoring, and evaluation of handwashing behavior change programs. FOAM was developed for use in resource-poor settings, but it can also be adapted for other socioeconomic environments. This working paper is intended for use by program managers implementing handwashing behavior change initiatives, as well as multilateral and bilateral agencies, academic institutions, and government and nongovernmental organizations (NGOs) working in water and sanitation.

Globally, an estimated 24 percent of the disease burden (healthy life years lost) and an estimated 23 percent of all deaths (premature mortality) are attributable to environmental risks (World Health Organization, or WHO 2006). The burden of disease is unequally shared, with the children and the poor being particularly affected. Among children between the ages 0 and 14, the proportion of deaths attributable to environmental risks, such as poor water and sanitation, indoor air pollution and vector-borne diseases, is estimated to be as high as 36 percent (WHO 2006). Several key messages have emerged from the process of putting together this study: (i) environmental health risks impose a significant burden on Nicaraguas economy, amounting to 2.6 billion Nicaraguan Cordoba (NIO) or 2.4 percent of the countrys Gross Domestic Product (GDP), and result in premature deaths and infections, especially in children under five; (ii) cost-effective interventions to address these environmental health risks exist and should be prioritized in Nicaragua; (iii) country-specific health and environmental data are somewhat limited, especially in the case of air quality, and data collection and monitoring need to be further strengthened; and (iv) the capacity of Ministry of Environment and Natural Resources (MARENA) and Ministry of Health (MINSA) staff to conduct environmental health costing analysis needs to be strengthened through proper training.

Although Sub-Saharan Africa has some of the worst nutrition indicators in the world, nutrition remains a low priority on the policy agendas of many African governments. This despite the fact that proven interventions are known and available and that investment in them is considered a cost-effective strategy for poverty reduction. This case study is one in a series seeking to understand (1) what keeps African governments from committing fully to reducing malnutrition, and (2) what is required for full commitment. It documents how the Ghanaian government has addressed the issue of malnutrition since Independence, examines what political and institutional factors have prevented full commitment, and identifies what conditions have moved the nutrition agenda forward at different points in time. The primary objective of this study as well as the series as a whole is to help African governments, development partners, and nutrition and health practitioners identify, understand and address the political and institutional obstacles preventing sustainable progress in nutrition.

Communicable diseases are a major burden of disease among the poor, and communicable disease control is central to achieving the Millennium Development Goals (MDG) adopted at the Millennium Summit in 2000. Over the years communicable disease control has featured prominently in several strategic Bank documents. In the 1997 Health, Nutrition, and Population (HNP) Sector Strategy communicable disease control was one of the essential HNP priorities. The 2007 HNP sector strategy made extensive reference to the need for synergy between communicable disease control (especially disease-specific projects) and health system strengthening. Communicable diseases also feature as one of four priority areas in the global public good strategic theme in the Bank's six strategic themes identified in 2007. This paper is organized into five chapters. The following chapter describes the sample of projects covered in this review and the methodology. The results of the review of approved and closed projects follow in the third and forth chapters, respectively, and the last chapter summarizes the conclusions.

Usage of health facilities in Ethiopia is among the lowest in the world; raising usage rates is probably critical for improving health outcomes. The government has diagnosed the principal problem as the lack of primary health facilities and is devoting a large share of the health budget to building more facilities. But household data suggest that usage of health facilities is sensitive not just to the distance to the nearest facility but also to the quality of health care provided. If the quality of weak facilities were raised to that currently provided by the majority of facilities in Ethiopia, usage would rise significantly. National data suggest that given the current density and quality of service provision, additional expenditure on improving the quality of service delivery will be more cost-effective than increasing the density of service provision. The budget allocation rule presented in the article can help local policymakers make decisions about how to allocate funds between improving the quality of care and decreasing the distance to the nearest health care facility.

This article presents an approach to public policy in health that comes directly from the literature on public economics. It identifies two characteristic market failures in health. The first is the existence of large externalities in the control of many infectious diseases that are mostly addressed by standard public health interventions. The second is the widespread breakdown of insurance markets that leave people exposed to catastrophic financial losses. Other essential considerations in setting priorities in health are the degree to which policies address poverty and inequality and the practicality of implementing policies given limited administrative capacities. Priorities based on these criteria tend to differ substantially from those commonly prescribed by the international community.