This is the fourth in a series of six articles examining the World Bank's role in international health

The World Bank's policies may sound reassuring in Washington, but their true efficacy can be gauged only at country level. Each region (figure) offers differing challenges—from economic collapse in the Far East to economic infancy in central Asia; from perpetual poverty in Africa to the floundering aspirations of Latin America. Perhaps, of all regions, South Asia is the most enigmatic. Sri Lanka's healthcare system is relatively successful despite the ongoing civil war, whereas Nepal and Afghanistan lie at the other end of the spectrum. Somewhere in between—geographically, and in terms of health indicators—are Bangladesh, India, and Pakistan.

A sixth of the world's population is crammed into what was, until partition in 1947, a single nation. Bangladesh, India, and Pakistan may have common cultures, but in their short, independent lives they have acquired distinct personalities which require differing approaches from the bank (table). In Bangladesh, approximately 35% of health sector funding of the government is coordinated through a large consortium of donors and aid agencies, headed by the bank. In India, specific disease control, health, population and family planning, and nutrition programmes are being increasingly linked through state-wide health reform programmes. In Pakistan, by contrast, lending for health is dependent on the government introducing institutional reforms. The regions within each of these countries can present equally diverse challenges.

Richard Skolnik, the bank's sector leader for health, nutrition, and population in South Asia, believes that the region is unique: “This region is especially important given the very large numbers of very poor people. Our aim over the long term would be to assist our client countries in establishing coherent, effective, and sustainable approaches to health.” Such approaches seem far off in an area that is …