THE WORLD BANK AND THE RIGHT TO HEALTH
While the World Bank has integrated rights-based principles in the implementation of some health programs it finances, it continues to deny a formal legal obligation for human rights. This study is a two-level case study methodology of the World Bank and its Health, Nutrition and Population (HNP) Department. Unlike quantitative methodologies, the employment of thematic and discourse analyses is ideal for analyzing the ways in which rights-based approaches are incorporated into World Bank health development discourse, examining achievements, obstacles, and opportunities.
This study constructed a historical narrative of key events and conducted a discourse analysis of relevant Bank statements and formal strategies by analyzing the conscious and unconscious agendas and meanings of selected texts. Following this, we analyzed five institutional factors that have historically challenged a World Bank commitment to the issue. A principal barrier to human rights integration in the World Bank is the Articles of Agreement. The World Bank’s founding member countries purposefully restricted its mandate to economic activities as a means to protect country sovereignty. A second factor challenging human rights mainstreaming concerns the World Bank’s institutional culture, which is dominated and largely influenced by an economic perspective. A third factor challenging to the World Bank’s engagement with human rights is the lack of knowledge that staff have concerning human rights application. A fourth factor challenging the World Bank’s engagement with a rights-based approach is country resistance. The final challenge to adopting rights-based principles concerns the World Bank’s emergent rivalries from other development banks that are increasingly being supported by its traditional backers.
Despite these challenges, three factors are likely to support the World Bank’s future engagement in rights-based approaches in its health initiatives. The first is the work of the Nordic Trust Fund (NTF), which sidesteps the World Bank’s lack of institutional policy on human rights by improving project-level rights protection. A second factor is the continued NGO pressure on the World Bank to engage in human rights principles in its work. Finally, the growing body of research within the World Bank that concerns human rights represents a potential opportunity for greater World Bank engagement.
Given the World Bank’s historical legal resistance to a rights-based approach, we argue for an ethical demand for health equity, which may be effectuated by a policy framework rather than a legal “right to health” approach. A rights-based approach is often understood within a legal framework, with a delineation of responsibilities based on legal commitments and liability for satisfying the rights of individuals through judicial processes. In contrast, an ethical approach demarcates respective roles and responsibilities based on moral obligations and accountability for ensuring justice and equity for individuals and populations.
While the judicialization of the right to health has been promoted by some scholars as a means to secure better health outcomes for the most marginalized, we argue that it is an insufficient and ineffective means to promote health equity at the World Bank. For one, legal right to health approaches are critiqued for regularly not empowering individuals, as intended, and contributing to or reinforcing paternalistic practices. Second, and relatedly, legal right to health approaches often may unintentionally deepen existing inequalities for access to health care. Third, right to health approaches tend to be top-down and one-size-fits-all in nature. In practice, they often pay insufficient attention to circumstantial social, political, and historical
conditions and tend to generalize.
In line with its political economy lens, the World Bank is designed to implement structural interventions to advance ethical demands for health equity – interventions that change finances, incentives, and power systems often well beyond the health sector. Furthermore, the World Bank is in the best position to effectuate policy—rather than legal changes—given its significant engagement with and influence on policymakers in low-and-middle-income countries (LMICs), representing various ministries. Finally, application of an ethical approach to health equity is in accordance with current World Bank reforms and initiatives.