The World Bank

Friend or foe to the poor?

Education and debate p 865

Why should British and other western doctors be interested in the World Bank? This week's BMJ includes the first of Kamran Abbasi's articles on the World Bank (p 865),1 yet with health system reforms, performance reviews, racism in health, plummeting morale, and continued underfunding, haven't we got enough to occupy us? Yes, but what of the plight of the 1.3 billion people living in absolute poverty on less than $1 a day? Their health is as abysmal as their wealth, and until their poverty is relieved their health will not improve. The World Bank's mission statement is “to reduce poverty, and improve living standards by promoting sustainable growth and investment in people.”2 For health workers concerned with the pathology and relief of poverty, knowledge about the bank is as important as anatomy is to surgeons.

Like the Christian churches in the nineteenth century, the bank has enormous influence in former colonies. It helps set, fund, and implement the policies which drive the economies of many nations and billions of people. As well as formulating economic policy and carrying out development projects, the bank has also become the key player in international health. Since 1990 the bank's health, nutrition, and population division has lent $9bn to the health sector and usurped the World Health Organisation's leadership role in developing global health policy.

Given its central role, how is the bank performing? Have the economic policies initiated by the bank improved the health of the poor? What has been the impact of its health policy recommendations? Have projects funded by the bank succeeded in their aims?

Controversy reigns and evidence is mixed in all three areas. In the wake of the 1980s debt crisis, the bank and the International Monetary Fund initiated harsh economic reforms (known as structural adjustment programmes), which included currency devaluation, public expenditure cuts, and a move toward privatisation. The expected economic regeneration often failed to materialise and the reforms provoked a storm of criticism because of their negative social impact. Structural adjustment programmes continue to this day and remain controversial: Latin America and sub-Saharan Africa, epicentres of the debt crisis and beneficiaries of bank and fund programmes for the past 20 years, still faced persisting or rising levels of poverty as they moved into the mid-1990s.3

The bank has advocated the use of safety nets to protect the poor during periods of economic crisis and reform as well as the protection of government expenditure on health and education. However, a fundamental need remains for decision makers to assess the likely health and poverty impact of the economic reforms themselves and to adjust their policies accordingly before they are implemented.

For the past decade the bank has also promoted the introduction of market oriented healthcare reforms, including cost sharing mechanisms such as user charges. The latter inevitably compromise the poor's access to health services.4 These changes were intended to solve the crisis in healthcare financing, yet in many of the poorest countries more is spent on debt repayments than on health. While the bank has pushed for debt reduction, the amounts earmarked for cancellation under the “highly indebted poor countries” initiative designed by the bank and the International Monetary Fund are miserly. Much deeper debt relief, along the lines proposed by the Jubilee 2000 coalition, may release new resources which could help rejuvenate cash strapped health sectors.

As Abbasi shows in his article,1 the bank's individual projects are also under the microscope. An internal review revealed that only 17% of completed bank projects in the health, nutrition, and population division sector contributed substantially to the development of local institutions, and only 44% were likely to be sustainable.5 Since becoming president in 1995, James Wolfensohn has emphasised the need for better “partnerships” between the bank and its borrowers. However, to build effective partnerships health partners need to make policy and hold budgets together. Change can be achieved here by renewed commitment to listening to and working with local partners, but the objective is compromised by unresolved structural issues. Since the rich nations wield the financial and political power within the bank, their objectives, not those of the poor, dominate the bank's decision making. The possibility of effective partnership is thus undermined by the structure of the institution itself.

More recently, Mr Wolfensohn has proposed a new framework for development which gives equal status to social and environmental as well as economic considerations. To be useful, this framework should be explicit about the extent of the impact of economic change on health and should lead the bank to put health concerns right at the heart of economic policymaking.6 Is such a shift in perspective possible for the bank? Health professionals in those countries which control the bank have a public health duty to help it do so, by making representations to the bank and by putting pressure upon their governments.