World Bank
Since its founding in 1944, the World Bank’s development priorities and approach—along with its global role—have changed from rebuilding Europe to relieving poverty in the developing world. The Bank has been the largest financier of health, nutrition, and population (HNP) programs in developing countries. It has expanded operational research and analysis, including its Special Programme of Research, Development and Research Training in Human Reproduction, WHO/United Nations Development Program (UNDP)/UNICEF/World Bank Special Programme for Research and Training in Tropical Diseases, and the Micronutrient Initiative.
Despite these historical contributions to healthcare, the World Bank and its policies are among the most hotly debated and highly criticized in the global development community. With regard to health sector policies, key concerns have involved structural adjustment, the use of disability-adjusted life years (DALYs) to measure overall disease burden, and privatization.
In the 1980s and 1990s, the Bank pressured countries to adopt structural adjustment programs for their economies and to follow many prescriptions of the Washington Consensus by opening markets (trade liberalization), reducing government expenditures (in some cases for health), and privatizing state-owned enterprises. Critics argue that such programs reduce health care spending and have deleterious health effects. UNICEF estimated that adjustment policies may have been associated with 500,000 deaths of young children in a twelve-month period.
The Bank also was criticized for introducing DALYs to global health assessments. Critics argue that DALYs lack a sound theoretical framework and are inequitable because they value years saved for the able-bodied more than for the disabled, the middle-aged more than the young or old, and the currently ill more than those who will be ill tomorrow.
Critics also have been concerned about the World Bank’s support for privatization in general and privatizing the health sector specifically. Research has demonstrated that a strong government is necessary to address market failures in financing, consuming, and providing both personal and public health services. Insurance market failures, credit shortages, information asymmetries, and insufficiencies in particular can prevent people from realizing the economic benefits of risk pooling. The Bank now admits that open markets and economic management are insufficient. But in the health sector specifically, critics argue the Bank needs to be clearer about the trade-offs between public and private financing and delivery of health services.
Development assistance for health (DAH), of which the Bank has previously been the largest single multilateral contributor, also has problems. The system allows the donors’ particular interests to be prioritized over the common goal. Furthermore, the DAH system itself does not have a substantive underlying goal of global justice. The promotion of economic development or welfare, as traditionally defined, does not necessarily promote global justice.
Overall, Shared Health Governance (SHG) recommends that the Bank helps countries strengthen health systems through a political economy of health approach. It needs to focus on the areas of its unique strengths: (1) growing the economies and economic equity of the countries, (2) establishing good public and health governance, and (3) reforming health policies. For example, the bank should enhance its role in providing policy advice. Firstly, this requires developing countries to see the Bank as an effective health partner. It is essential that the Bank works towards the common goal of health for all, and makes its efforts clear to its partners.
In the policy advice, the Bank can improve governance throughout the public sector. To be apolitical and avoid hypocrisy, the Bank itself needs to democratize itself. The Bank’s governance structure needs to change, especially its unequal distribution of executive board votes, opaque decision-making processes, and lack of board accountability to elected officials and legislative bodies in the countries the Bank aims to serve.
The Bank also has a role to play in generating political will and advancing shared norms and values. Individuals, groups, and national leaders need to coalesce around health system reform, particularly universal health coverage, make it a priority, and work tirelessly to achieve it. Few reforms succeed absent this thrust for change. Generating political will is often a lengthy and laborious process, involving numerous political and institutional elements—political parties, personal politics, legislative policy-making strategies, re-election incentives, financial incentives, civil society and interest groups, and political leadership. The Bank is in a good position to involve and guide its partners through this process.
Advancing norms is an essential role of the Bank as well. The Bank had successes in advancing some norms, for example, in eliciting participation from Brazilian AIDS activists in developing its first AIDS prevention and control loan in 1994. Since health system reform and universal health coverage requires citizens’ willingness to pay higher taxes to fund others’ health care, this policy requires a commitment to equity, and the ability to look beyond one’s own personal situation to achieve collective benefits at the national level.
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THE WORLD BANK AND GLOBAL HEALTH: TIME FOR A RENEWED FOCUS ON HEALTH POLICY