Commentary
The World Bank and global health: time for a renewed focus on health policy Jennifer Prah Ruger In July 2013, Timothy Evans became Director of Health, Nutrition and Population at the World Bank. Just last year, President Obama nominated Jim Yong Kim, a global health expert, as president of the World Bank. These choices both signify global health’s ascendance in development practice and put the spotlight on global health in American foreign policy and international relations. Good news for global health. In an increasingly pluralistic and confused global health landscape, however, the World Bank, under new leadership, must map out and stick to a clear plan for global health impact, one that builds on and leverages its unique role in health and development policy and seizes opportunities in globalisation for global health equity. Some might question the World Bank’s involvement in global health altogether and such critiques are worthy of investigation beyond the scope of this article. Suffice it to say, however, that what follows argues that the World Bank does have a role in global health, one that requires significant focus for pronounced impact. To achieve health sector-wide results on the ground, the World Bank should focus on health policy and health systems in developing countries and leave narrow technical control of specific diseases to other global health institutions. And sustainability is key—the World Bank should seek to eliminate countries’ need for its assistance altogether. All this is possible: just look at the health policy achievements of South Korea, Japan and Singapore, countries that have developed their health systems alongside their economies, and ‘graduated’ from development assistance. Each now offers universal health insurance coverage to its population, seeking health equity efficiently. Health equity is an important goal and worth further scrutiny that is beyond this article’s scope; it should be noted, however, that the perspective herein relies on a foundational approach to global health equity
Correspondence to Jennifer Prah Ruger; [email protected]
grounded in the respective roles and responsibilities of global and national actors, institutions and agents guided by principles of global health justice and governance.1 Despite the unprecedented number of global health initiatives, programmes, organisations and actors, the World Bank maintains a unique position, and now has a unique opportunity, in global health. Unlike most global health institutions— for example, The Global Fund to Fight AIDS, Tuberculosis and Malaria and the US President’s Emergency Plan for AIDS Relief—that focus on specific diseases or conditions, or the Tobacco Free Initiative that focuses on specific interventions or practices, the World Bank takes a holistic approach to health and development. This broader perspective, rooted in the social sciences, combined with its vast financial and human resources and analytical and advisory capacities, renders the World Bank a go-to global health institution for health policy and health systems in developing countries. A few key areas of concentration are noteworthy. First, the World Bank can assist countries in developing the evidence base and analytical capacity critical for health reform and health policy implementation. In health financing, for example, where pooling risk across populations through insurance and government regulation of insurance and reinsurance markets are necessary, World Bank financial and technical assistance can be a helpful addition to country-led efforts. Countries need to know what policies have succeeded and failed, and what best practices exist, in their own and other countries. The World Bank, endeavouring to serve as the ‘knowledge bank’, generates and disseminates this policy knowledge and works with countries to build their own capacity for policy synthesis, analysis and decision-making. In Morocco, for instance, World Bank staff worked with officials in the Ministry of Health to develop and implement health policy reforms designed to expand health insurance to formal sector employees and to poor Moroccans.2 Through a joint World Bank and Government of Morocco symposium on health sector financing,
Prah Ruger J. J Epidemiol Community Health January 2014 Vol 68 No 1
covered by the Moroccan press and media outlets, an open and transparent dialogue made the public more aware of, and potentially more likely to support, policy proposals designed to address key health policy issues. And in Rwanda, in addition to expansion of health insurance from 7% to 85% of the population between 2003 and 2008, World Bank financial and technical assistance helped support Rwandan social protection (including health) efforts that yielded changes such as a 60% increase in facility-based births between 2006 and 2009. Child mortality declined by about 30%.3 Second, the World Bank could be instrumental in bringing the global trends in financing for health and political will to the domestic level. The past decade has seen a doubling in global health financing and increased political will for improving health in global politics. Health topics have been on the agenda at the United Nations General Assembly and the annual G8 summit, among other important global venues. Yet, in many countries, domestic health financing and investment have not kept pace with global funding increase, and there is evidence that increased development assistance for health leads to a reduction in domestic health financing. One study found that every $1 in development assistance to government for health was associated with a decrease in domestic public spending on health by $0.43–$1.14.4 This is a disturbing trend. The World Bank, however, with its bird’s-eye view of nations and its mission of reducing poverty through inter-sectoral country assistance, can help countries improve their budgetary planning to prevent this funding displacement. Additionally, the World Bank has the financial and political authority to assist countries in agenda setting and generating political will for collective action on health. In Brazil, for instance, World Bank loans supported the National AIDS Program (especially its prevention components) and facilitated the active participation of civil society, a key element of Brazilian HIV/AIDS efforts.5 Third, the World Bank can aid in establishing good governance in the health sector. While policy and programme implementation is a national and subnational activity, the World Bank can play a supportive and facilitative role from policy planning to programme implementation. The World Bank has established governance indicators that include metrics of voice and accountability, respect for rule of law, government effectiveness and regulatory quality, corruption control, and 1
Commentary political instability and violence.6 The World Bank can assist with the evidence, financial and budgetary assessments required for a comprehensive national health planning process, but also with advising governments on accountability and transparency measures such as clear goals, timeframes, evaluations, indicators and benchmarks. And the process by which plans are developed, implemented, evaluated and revised should be fair, transparent, inclusive and participatory. The World Bank learnt from past mistakes that top-down donor-driven development was both unfair and ineffective. With its poverty reduction strategy papers (PRSPs) and country assessment strategies, which take a country’s ‘own vision for its development’ as the point of departure, the World Bank now seeks to serve countries in achieving their own goals. PRSPs aim to assist countries in meeting the millennium development goals. Accountability in results for health, elimination of
2
corruption and participation are central to good governance. These are exciting times for the World Bank in global health. With a global health expert at the helm and a renewed focus on health policy, the World Bank has a chance to make development assistance for health a thing of the past. To be sure, some World Bank policies, with their neoliberal orientation, have been controversial, but the World Bank’s ability to provide health policy and health system assistance is auspicious. By committing to help countries develop the capacity to solve health policy problems and sustain health systems on their own, the World Bank’s role in global health as we know it may never be the same.
To cite Prah Ruger J. J Epidemiol Community Health 2014;68:1–2. Published Online First 18 October 2013 J Epidemiol Community Health 2014;68:1–2. doi:10.1136/jech-2013-203266
REFERENCES 1
2 3
4
5
Funding The Whitney and Betty MacMillan Center for International and Area Studies at Yale. Competing interests None.
6
Provenance and peer review Commissioned; externally peer reviewed.
Ruger JP. Global health governance as shared health governance. J Epidemiol Community Health 2012;66:653–61. Ruger JP, Kress D. Health financing and insurance reform in Morocco. Health Aff 2007;26:1009–16. Sekabaraga C, Soucat A, Diop F, et al. Innovative financing for health in Rwanda: a report of successful reforms. Yes Africa can: success stories from a dynamic continent. Washington, DC: World Bank Publications, 2011:403–16. Lu C, Schneider MT, Gubbins P, et al. Public financing of health in developing countries: a cross-national systematic analysis. Lancet 2010;375:1375–87. Parker R. Building the foundations for the response to HIV/AIDS in Brazil: the development of HIV/AIDS policy, 1982–1996. Divulgacao em Saude Para Debate 2003;27:143–83. World Bank. Governance and Anti-Corruption. http:// www.worldbank.org/wbi/governance (accessed 25 Mar 2012).
Prah Ruger J. J Epidemiol Community Health January 2014 Vol 68 No 1
The World Bank and global health: time for a renewed focus on health policy Jennifer Prah Ruger In July 2013, Timothy Evans became Director of Health, Nutrition and Population at the World Bank. Just last year, President Obama nominated Jim Yong Kim, a global health expert, as president of the World Bank. These choices both signify global health’s ascendance in development practice and put the spotlight on global health in American foreign policy and international relations. Good news for global health. In an increasingly pluralistic and confused global health landscape, however, the World Bank, under new leadership, must map out and stick to a clear plan for global health impact, one that builds on and leverages its unique role in health and development policy and seizes opportunities in globalisation for global health equity. Some might question the World Bank’s involvement in global health altogether and such critiques are worthy of investigation beyond the scope of this article. Suffice it to say, however, that what follows argues that the World Bank does have a role in global health, one that requires significant focus for pronounced impact. To achieve health sector-wide results on the ground, the World Bank should focus on health policy and health systems in developing countries and leave narrow technical control of specific diseases to other global health institutions. And sustainability is key—the World Bank should seek to eliminate countries’ need for its assistance altogether. All this is possible: just look at the health policy achievements of South Korea, Japan and Singapore, countries that have developed their health systems alongside their economies, and ‘graduated’ from development assistance. Each now offers universal health insurance coverage to its population, seeking health equity efficiently. Health equity is an important goal and worth further scrutiny that is beyond this article’s scope; it should be noted, however, that the perspective herein relies on a foundational approach to global health equity
Correspondence to Jennifer Prah Ruger; [email protected]
grounded in the respective roles and responsibilities of global and national actors, institutions and agents guided by principles of global health justice and governance.1 Despite the unprecedented number of global health initiatives, programmes, organisations and actors, the World Bank maintains a unique position, and now has a unique opportunity, in global health. Unlike most global health institutions— for example, The Global Fund to Fight AIDS, Tuberculosis and Malaria and the US President’s Emergency Plan for AIDS Relief—that focus on specific diseases or conditions, or the Tobacco Free Initiative that focuses on specific interventions or practices, the World Bank takes a holistic approach to health and development. This broader perspective, rooted in the social sciences, combined with its vast financial and human resources and analytical and advisory capacities, renders the World Bank a go-to global health institution for health policy and health systems in developing countries. A few key areas of concentration are noteworthy. First, the World Bank can assist countries in developing the evidence base and analytical capacity critical for health reform and health policy implementation. In health financing, for example, where pooling risk across populations through insurance and government regulation of insurance and reinsurance markets are necessary, World Bank financial and technical assistance can be a helpful addition to country-led efforts. Countries need to know what policies have succeeded and failed, and what best practices exist, in their own and other countries. The World Bank, endeavouring to serve as the ‘knowledge bank’, generates and disseminates this policy knowledge and works with countries to build their own capacity for policy synthesis, analysis and decision-making. In Morocco, for instance, World Bank staff worked with officials in the Ministry of Health to develop and implement health policy reforms designed to expand health insurance to formal sector employees and to poor Moroccans.2 Through a joint World Bank and Government of Morocco symposium on health sector financing,
Prah Ruger J. J Epidemiol Community Health January 2014 Vol 68 No 1
covered by the Moroccan press and media outlets, an open and transparent dialogue made the public more aware of, and potentially more likely to support, policy proposals designed to address key health policy issues. And in Rwanda, in addition to expansion of health insurance from 7% to 85% of the population between 2003 and 2008, World Bank financial and technical assistance helped support Rwandan social protection (including health) efforts that yielded changes such as a 60% increase in facility-based births between 2006 and 2009. Child mortality declined by about 30%.3 Second, the World Bank could be instrumental in bringing the global trends in financing for health and political will to the domestic level. The past decade has seen a doubling in global health financing and increased political will for improving health in global politics. Health topics have been on the agenda at the United Nations General Assembly and the annual G8 summit, among other important global venues. Yet, in many countries, domestic health financing and investment have not kept pace with global funding increase, and there is evidence that increased development assistance for health leads to a reduction in domestic health financing. One study found that every $1 in development assistance to government for health was associated with a decrease in domestic public spending on health by $0.43–$1.14.4 This is a disturbing trend. The World Bank, however, with its bird’s-eye view of nations and its mission of reducing poverty through inter-sectoral country assistance, can help countries improve their budgetary planning to prevent this funding displacement. Additionally, the World Bank has the financial and political authority to assist countries in agenda setting and generating political will for collective action on health. In Brazil, for instance, World Bank loans supported the National AIDS Program (especially its prevention components) and facilitated the active participation of civil society, a key element of Brazilian HIV/AIDS efforts.5 Third, the World Bank can aid in establishing good governance in the health sector. While policy and programme implementation is a national and subnational activity, the World Bank can play a supportive and facilitative role from policy planning to programme implementation. The World Bank has established governance indicators that include metrics of voice and accountability, respect for rule of law, government effectiveness and regulatory quality, corruption control, and 1
Commentary political instability and violence.6 The World Bank can assist with the evidence, financial and budgetary assessments required for a comprehensive national health planning process, but also with advising governments on accountability and transparency measures such as clear goals, timeframes, evaluations, indicators and benchmarks. And the process by which plans are developed, implemented, evaluated and revised should be fair, transparent, inclusive and participatory. The World Bank learnt from past mistakes that top-down donor-driven development was both unfair and ineffective. With its poverty reduction strategy papers (PRSPs) and country assessment strategies, which take a country’s ‘own vision for its development’ as the point of departure, the World Bank now seeks to serve countries in achieving their own goals. PRSPs aim to assist countries in meeting the millennium development goals. Accountability in results for health, elimination of
2
corruption and participation are central to good governance. These are exciting times for the World Bank in global health. With a global health expert at the helm and a renewed focus on health policy, the World Bank has a chance to make development assistance for health a thing of the past. To be sure, some World Bank policies, with their neoliberal orientation, have been controversial, but the World Bank’s ability to provide health policy and health system assistance is auspicious. By committing to help countries develop the capacity to solve health policy problems and sustain health systems on their own, the World Bank’s role in global health as we know it may never be the same.
To cite Prah Ruger J. J Epidemiol Community Health 2014;68:1–2. Published Online First 18 October 2013 J Epidemiol Community Health 2014;68:1–2. doi:10.1136/jech-2013-203266
REFERENCES 1
2 3
4
5
Funding The Whitney and Betty MacMillan Center for International and Area Studies at Yale. Competing interests None.
6
Provenance and peer review Commissioned; externally peer reviewed.
Ruger JP. Global health governance as shared health governance. J Epidemiol Community Health 2012;66:653–61. Ruger JP, Kress D. Health financing and insurance reform in Morocco. Health Aff 2007;26:1009–16. Sekabaraga C, Soucat A, Diop F, et al. Innovative financing for health in Rwanda: a report of successful reforms. Yes Africa can: success stories from a dynamic continent. Washington, DC: World Bank Publications, 2011:403–16. Lu C, Schneider MT, Gubbins P, et al. Public financing of health in developing countries: a cross-national systematic analysis. Lancet 2010;375:1375–87. Parker R. Building the foundations for the response to HIV/AIDS in Brazil: the development of HIV/AIDS policy, 1982–1996. Divulgacao em Saude Para Debate 2003;27:143–83. World Bank. Governance and Anti-Corruption. http:// www.worldbank.org/wbi/governance (accessed 25 Mar 2012).
Prah Ruger J. J Epidemiol Community Health January 2014 Vol 68 No 1
