Intended for healthcare professionals

Education And Debate The World Bank and world health

Under fire

BMJ 1999; 318 doi: (Published 10 April 1999) Cite this as: BMJ 1999;318:1003
  1. Kamran Abbasi, assistant editor. (
  1. BMJ, London WC1H 9JR

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

    The World Bank is accustomed to criticism, and since the second world war few organisations have generated as much outcry. Most analysts, however, accept that the bank has conducted a successful campaign to improve its image over the past decade. Indeed, I was surprised during my meetings with health workers outside the bank that it attracted far less criticism than I had expected. None the less, reservations remain about the bank's approach, and this article discusses some of the most controversial aspects of the bank's policies.

    Summary points

    • Despite its recent change in image, the World Bank still has staunch critics

    • Structural adjustment, user charges, and DALYs (disability adjusted life years) are unpopular strategies that have attracted criticism for many years

    • Introducing evidence into policy making and ensuring sustainability of projects are key issues for the future

    • These issues and the bank's underuse of health outcome measures are stumbling blocks to wider acceptance of its policies

    Structural adjustment

    Critics of the World Bank argue that structural adjustment loans are a mechanism of forcing free market economics on countries through coercion. Countries with a debt crisis, whatever their other characteristics, agree to the bank's package of legal and economic reforms, and the bank agrees to lend them money. Argentina, Ecuador, and India have all either weakened their labour legislation or amended their land laws to qualify for an adjustment loan. India is reported to have changed 20 pieces of major legislation.1

    Common criticisms of the World Bank

    • Creating a climate where high levels of lending are deemed to be good

    • Advocating disability adjusted life years as a health measure

    • Disregard for the environment and indigenous populations

    • Evaluating health projects by looking at economic outcome measures

    • Insufficient evaluation of projects

    • Lack of sustainability …

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