Focus on South AsiaII: India and Pakistan

doi:10.1136/bmj.318.7191.1132

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Kamran Abbasi, assistant editor. (kabbasi@bmj.com)

BMJ, London WC1H 9JR

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

For a better understanding of the effectiveness of the World Bank's policies and of how they are perceived I visited bank projects in Bangladesh (see last week's article1), India, and Pakistan.

Summary points

India is the World Bank's largest single borrower, with cumulative loans over $44bn

India's diversity, “enormous” burden of disease, and chronic underfunding of health care have hindered progress

Despite Pakistan's relatively high gross national product per capita, its health indicators compare poorly with those of its neighbours

Social action programmes, promoted by the bank, have been controversial

Although the bank has adopted differing approaches to the countries of South Asia, the substantial challenges posed by the region mean that progress will be slow

India: diversity and disease

India's vastness, diversity, and poverty are challenges that the World Bank has responded to with huge sums of money. With cumulative loans of more than $44bn, India is the bank's largest single borrower. Even in fiscal year 1998 (from June 1997 to June 1998), when an exchange of nuclear tests with neighbouring Pakistan resulted in the temporary freezing of bank loans to the region, lending reached a record $3bn. India is also the recipient of the largest sum of interest free credits from the International Development Association. By April 1998, India had received 167 loans and 223 development credits, with 84 ongoing projects amounting to $14.5bn. Power projects accounted for 24% of lending, and health, nutrition, and population programmes received 14%. 2 3

The states of India

“The nuclear sanctions won't have greatly affected India,” argues Dr Anthony Measham, the bank's chief health adviser in the country. “Sanctions don't affect ongoing projects. The only ones that are affected are the new projects, and we are continuing all …