PHA-Exchange> PHM Letter to WB vicepresidents

[Claudio]

Peoples Health Movement

Global Secretariat: Cairo, Egypt

 





The People's Health Movement has strong reservations about the World Bank Health, Nutrition and Population division's draft 10 year strategy, and in particular the aim to expand the influence of the Bank on health systems policy and development. We welcome the fact that other civil society organisations have expressed similar reservations. 

 

Although the draft strategy claims to have benefited from "extensive" consultation with civil society, this has not been our experience. 

 

The role of the Bank in the health sector

 

The World Bank is an important source of finance for health sector development and health programme implementation in low and middle-income countries (LMICs). It also has a significant influence on macro-economic and fiscal policies. Any health sector strategy of the Bank should therefore rightfully incorporate the explicit aim of strengthening health care systems and enabling LMICs to increase health care expenditure to adequate levels. 

 

We also agree with the Bank that the proliferation of global health financing mechanisms and initiatives obstructs the development of coherent, long-term and sustainable health systems development agendas. Donors, global public-private initiatives such as GAVI and the Global Fund, UN agencies, and the International Financial Institutions (particularly the Bank, the IMF and the General Agreement on Trade and Services) are fragmenting health care systems and pulling Ministries of Health in different directions. 

 

We therefore welcome the Bank's recognition of the problems caused by uncoordinated, multiple and over-verticalised health programmes. But, together with other actors, the Bank must take further action to improve coordination amongst donors, rationalise the global health architecture and strengthen the capacity of LMIC Ministries of Health to provide effective and accountable stewardship at the country level. 

 

The Bank also correctly emphasises the importance of multi-sectorality. Improving household food security and access to water, sanitation and education, as well as developing tele-communications and road infrastructrure will have profound positive health impacts in LMICs. Here, the Bank has an important role, although the lack of progress (in some cases, deterioration) in reducing malnutrition, poverty and illiteracy suggests the need it to redouble its efforts in these sectors.

 

Health systems policies

 

Although, the Bank has an important role to play in improving health and strengthening health systems, as noted above, it does not follow that it should provide a lead role in advising and influencing LMICs on health systems policy. 

 

The historical legacy of damage done by structural adjustment programmes and poorly conceived health sector reform packages challenges the Bank's claims of expertise and comparative advantage when it comes to "the design of health care financing systems", "demand-side interventions", "health purchasing arrangements", the establishment of private insurance markets and developing "the right financing incentives for research and development or for efficient allocation of human resources".

 

The Bank's track record in these areas has been characterised by an adherence to a school of thinking that has undermined Ministries of Health and public health principles; worsened health care inequities; magnified the inefficiencies and market-failures associated with commercialised health care; encouraged the fragmentation of health care provision; and at best, tolerated the widespread existence of regressive and poverty-creating user fees. 

 

Although the neoliberal rhetoric of the Bank has softened, the draft health strategy betrays a continued and inappropriate ideological bias towards the market. The document reveals:

·         support for the continued existence of competitive, private insurance markets in MICs;

·         the encouragement of so-called "production-based provider financing" in which health care providers are financed through expressed demand (as opposed to appropriately defined 'needs');

·         a continued appetite for quasi-market purchaser-provider splits and the exposure of public providers to market competition; 

·         an explicit statement that it will use the International Finance Corporation and the Private Sector Development Unit to encourage further the privatisation of health systems; and

·         an over-emphasis on the significance and effectiveness of community-based insurance schemes in LICs.

 

Many of these policies lack any evidence that they are capable of achieving the multiple objectives of efficiency, effectiveness, equity and public satisfaction. 

 

Omissions and gaps

 

The Bank's policy orientation is also revealed by the omissions and gaps in its draft health strategy. 

 

There is no mention, let alone any strategic direction, on how trends towards widening disparities in health care consumption and expenditure in LMICs will be reversed.

 

The 'globalisation of health care' which incorporates the massive movement of scarce and skilled human resources from poor to rich countries as well as the internal migration of skilled health workers from the public / non-profit sector into commercial enterprises (including a growing number of facilities catering for 'medical tourists' from developed countries) is not mentioned.

 

While constant reference is made to the expanded and positive potential of the private sector, little attention is paid to the need to strengthen public sector management and service provision capacity. Any emphasis on the public sector is limited to promoting the Bank's apparent expertise in combating corruption. Revealingly, there is no mention of the corrupt and unethical effects of commercializing health care systems. There is also little distinction made between the for-profit and non-profit private sector thereby glossing over fundamental differences between the NGO, faith-based and commercial sectors. 

 

The underlying obsession with financial incentives reflected in the draft strategy is corroborated by an inadequate mention of non-financial incentives, trust and public accountability mechanisms to improve health systems performance.

 

There is also an absence of any plans or strategies to establish the basic human infrastructure of health systems consisting of nurses, technicians, doctors and other allied health workers, nor how different health financing arrangements will ensure the appropriate remuneration, number, mix and distribution of skilled personnel.

 

While the strategy states that sufficient and sustainable funding must be raised equitably and predictably "in a way that minimizes economic distortions (and) contributes to sound fiscal management", there is no mention of the controversial IMF policies that effectively cap public expenditure in ways that prevent governments from paying their health workers an adequate living wage. 

 

While recognizing the fundamental impoverishment of both communities and health systems in LICs, nothing is said about the need to allow LICs a realistic chance of achieving economic growth or to establish new sources of global financing (e.g. through a currency transaction tax or by expanding the remit of airline taxes). Instead the focus continues to be limited to leveraging private household finance. 

 

Finally, despite the World Health Organisation being the UN specialised agency for health with a wealth of relevant experience and institutional memory, no mention is made of WHO's comparative advantage in providing leadership in the area of health systems strengthening and programme implementation. 

 

Conclusion

 

There are good reasons to oppose any positioning by the World Bank to be the lead global agency responsible for guiding health systems policy. 

 

If the World Bank wants to influence health systems policy, it must signal an explicit retreat from the many failed and harmful policies of the past three decades. It needs to recognise the limitations and perverse outcomes of markets, competition and financial incentives (particularly in environments where regulatory capacity is weak), and it needs to recognise the fundamental importance of public service provision. The latter does not mean advocating for the establishment of rigid, monolithic and bureaucratic public sector systems. There are ways to ensure efficiency, effectiveness, accountability and responsiveness within health care systems that are universal and public in nature (including public-public partnerships between government and non-profit private actors).

 

We therefore call on the Bank to re-write its health strategy to better reflect a commitment to:

·         Rebuild the capacity of Ministries of Health and ensure that salary pay scales disparities between the public and private sectors are monitored and minimised; 

·         Reign in and reverse the commercialisation of health care, whether practised by public or private health care providers;

·         Shape the private sector to serve the public interest; 

·         Incrementally work towards health care financing systems that are pooled at the country or provincial / state level and which allow for optimal risk-sharing and cross-subsidisation;

·         Establish mechanisms to direct health care inputs and ensure patterns of health care expenditure that are equitable and in line with need; and

·         Empower communities and strengthen public accountability systems at all levels of the health care system. 

 

 

We look forward to being able to engage with you further on these important issues and thank you for your time in reading this letter.

 

Dr. David McCoy, B.Med, M.Phil, DrPH, MFPH (UK)

On behalf of the Peoples Health Movement Global Secretariat

 
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