Memorandum submitted by the UK Consortium
on AIDS and International Development (Health Systems Group)
With increased amounts of DFID's funding being
channelled though the World Bank it is vitally important that
this assistance is in line with DFID's priorities and objectives.
In particular, DFID's support to the World Bank should allow for
greater scrutiny of the Bank's reassertion of its role in the
health sector. Assessing whether DFID's priorities in health can
be pursued effectively through World Bank funding is especially
timely as the UK rolls out the planning of the International Health
Partnership (IHP) concept, in which the Bank has been delegated
with a conceptual role and will be a lead technical partner in
implementation.
THE ROLE
OF THE
WORLD BANK
IN STRENGTHENING
THE HEALTH
SECTOR
1. The World Bank has a history of promoting
policies such as; structural adjustment, user fees, and a decreased
role of the state in service provision, none of which enabled
increased access to basic health for poor women, men and children.[157]
Health systems in developing countries have been severely under-funded
for decades and the need to strengthen and, in many cases, rebuild
them now is a direct result of structural adjustment programmes
which undermined the public sector in many countries.
2. The Bank has recently developed a new
ten year Health, Nutrition and Population (HNP) strategy in which
it has positioned itself as a lead organisation on health systems
strengthening (HSS) and health systems policy advice at a global
level. Additionally it has worked to limit other development partners'
role in HSS, explicitly the Global Fund to Fight AIDS, Tuberculosis
and Malaria, a health financing partner whose programmatic reach
in the three diseases and integrated health services would be
sustained, given an expanded role in financing HSS. The Bank cites
its expertise in health financing, incentives for workers, governance
of health systems, amongst other issues, as the basis for taking
greater leadership.[158]
3. While the Bank is a key source of finance
for the health sector and for health systems strengthening in
the developing world, the role that the Bank has envisaged it
will play vis-a"-vis HSS is of concern. The role the Bank
plays in imposition of limits on public-sector spending and the
ongoing encouragement of the use of fees for public services countermands
the UK's own policy. This has a deleterious effect on public health
systems and throws into question whether the Bank can effectively
lead in redeveloping health systems to expand access to the human
right to health.
4. The Bank's HNP strategy calls for an
increased role for the Private Sector Development and International
Financial Cooperation sections of the Bank, which focus on encouraging
private sector growth.[159]
This increased focus on the private sector's role in health service
delivery is problematic. There is serious evidence that private
providers are unable to deliver equitable access to health services;
Oxfam's research in South Asia has shown that Sri Lanka and Kerala
State in India were able to provide far greater universal protection
from health risks through publicly financed models of public provision,
where services are free at the point of use.[160]
5. DFID must ensure that the Bank is fully
accountable to them as a major donor to IDA and the lead stakeholder
in the IHP. There must be consistency between the health policies
of the Bank and DFID. For example, DFID should ensure that whenever
DFID funding is used by the Bank, that cost recovery through user
fees is not encouraged. Moreover, DFID should ask the Bank for
a clear position on how to compensate for elimination of user
fees. Any policies promoted by the Bank must ensure that they
do not push people further into poverty, and that they actively
work to prevent this.
6. The Bank has a comparative advantage
in advising governments and donors on health sector financing
arrangements. But they must ensure that national financing supports
a vision of a well planned, well managed and well staffed public
health system for all citizens, based on need rather than ability
to pay.[161]
7. Given adequate policy coherence, DFID
should ensure that IDA expenditure prioritises the health sector
and meets health goals including the health MDGs and the targets
for universal access to comprehensive HIV/AIDS services. IDA could
be mobilized to channel funds directly through sector wide approaches
(SWAps) and help DFID to double the percentage of ODA for health,
recommended to meet its fulfillment of objectives set by the Commission
on Macroeconomics and Health.
8. DFID should work with the Bank to ensure
that macroeconomic constraints limiting public spending and other
fiscal policy conditions set by the International Monetary Fund
are lifted without impeding countries access to ODA. These policies
set strict limits on public spending in order to keep inflation
low and meet deficit reduction targets. Whilst macroeconomic stability
is important and runaway inflation is damaging, it is impossible
for countries to vastly increase public spending on health unless
these restrictions are changed.
9. DFID must do more to monitor the Bank's
policies and the impact of these on health care provision in the
developing world, and expand opportunities for civil society engagement.
The UK should set an example of transparency in governance and
public private partnership's in the planning and development of
IHP implementation in the pilot countries.
October 2007
157 Stop AIDS Campaign, Policy Briefing: Strengthening
Health Systems to Achieve Universal Access to HIV & AIDS Services,
January 2007 Back
158
McCoy, D. The World Bank's new health strategy: reason for
alarm? Lancet 2007; 369 May 5,2007 Back
159
Ibid. Back
160
Oxfam, 2007. Wrong Diagnosis, Wrong Medicine: World Bank strategy
for health, nutrition and population results 2007 to 2017, Oxfam
Response Back
161
Correspondence from NGOs and distinguished health experts to
Paul Wolfowitz, January 9th, 2007. Back
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