The World Health Organisation and The World Bank: A Shift in Leadership?

Introduction

The political and economic pressures on the leadership in global health have
undergone significant change over the last generation. National sovereignty over
local economic policy has been weakened by external pressures accompanying the
steady evolution from centrally planned national economies to internationally
influenced market economies. 1

An increasingly complex arrangement has developed between the significant players

in global health. Specialist United Nations (UN) agencies such as the World Health
Organisation (WHO), traditionally tasked with the job of global leadership in health
programming, have been challenged in their leadership throughout the last two
decades. This challenge has come primarily from the World Bank, and increasingly,
numerous civil society organisations (CSOs), and other international donors.

This discussion will briefly look at how the players in global health have changed
over the last twenty years and how their roles have changed within the evolving
global political and economic environment during that time.

Post World War II

Health and poverty immediately following World War II were considered, on the
whole, as relatively distinct global concerns. This view was reflected in the mandates
of the international agencies set up following World War II. The World Bank and
International Monetary Fund (IMF) ostensibly taking charge global economic
stability and the redevelopment of Europe, and the remaining specialist UN agencies
taking charge of political and health security.
The World Health Organisation

Following World War II, global health was primarily seen to be the responsibility of
the WHO and its fellow UN agencies, the United Nations Children's Fund (UNICEF),
the United Nations Population Fund (UNFPA) and the and Agriculture Organisation
(FAO).

The WHO, set up as a UN agency in 1948, often played the lead role in development
of health programming. Its constitutional aims were

"...the attainment by all peoples of the highest possible level of health. Health ...as a
state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity. '

Strengths of the WHO

Its strengths in the few decades following its inception were in areas such as
communicable disease control, leading to real and significant advances in life-
expectancy and child mortality in many areas of the world.

The global health gains made from interventions in communicable diseases were
limited however, and during the 70's and 80's emphasis was to be placed on the
reformation of health systems, embodied by the declaration of Alma Ata in 1978 and
the ideals of primary health care. 6

Challenges for the WHO

Significantly, some of the challenges to the "Health For All" Alma Ata declaration,
supported by the WHO, were largely lack of progress in a push towards a "new
international economic order" 7 , and an increasing gap between the rich and the poor 4.
Poverty reduction was one critical aspect of improving global health largely out the
WHO's sphere of control.
Resource constraints have also acted to place significant pressure on the World Health
Organisation in effectively discharge its mandates. The last decade has seen a twenty
percent reduction in the real purchasing power of the WHO's allocated budget, and
this reflects, to a degree, progressively diminishing support form The United States. 8

It has also been suggested that in the changing political and economic climate over the
last few decades of the 20th century, the WHO was slow to restructure and adapt its
role in global health. Some may say this was manifested in its sub-optimal response to
the global HIV/AIDS pandemic. 6

Whilst WHO increasingly lacks necessary funding, it remains an important and

legitimate contributor to international health programming.

"An agency like the World Health Organisation has a unique mix of technical
expertise, legitimacy in all corners of the world, and especially an
operational presence on the ground in dozens of the world's poorest and
neediest countries. "Sachs 8

WHO Public-Private Partnerships

In an attempt to expand its effectiveness, the WHO commenced a strategy of

engineering health programming partnerships with private companies in the early
1990's. These public-private partnerships were partly a consequence of the pressures
of resource constraints.

The WHO states that the aims of these cooperative endeavours are to 9

• encourage industry to abide by the health-for-all principles;

• facilitate universal access to essential drugs and health services;
• accelerate R&D in the fields of vaccines, diagnostics, and drugs for neglected
diseases;
• prevent premature mortality, morbidity, and disability by giving
specialattention to policies and behavioural change;
 • encourage industry to develop products in ways that are less harmful to
workers and the environment;
• acquire knowledge and expertise from the commercial sector;
• enhance WHO's image among typically hostile constituencies.

The benefits to the private sector on these arrangements are improved corporate image
and attraction of new investment and markets 9. Critics suggest, however, that an
environment lacking adequate regulation of these partnerships entails significant risks
to both the outcome of the programmes and the integrity of the WHO and UN.

"In relation to the UN, fears arise that inadequately monitored relations with the
commercial sector may subordinate the values and reorient the mission of its organs,
detract from their abilities to establish norms and standards free of commercial
considerations, weaken their capacity to promote and monitor international
regulations, displace organizational priorities, and induce self-censorship, among
other things."

If these partnerships are well managed, the UN has the potential to play a powerful
role in a global market oriented economy by contributing to the responsible regulation
of the private sector in these expanding markets .

Throughout the 80's and '90s, the World Bank, civil service organisations, and other
donor groups, took on more significant roles in the development of global health
policy.10,11

The World Bank

The World Bank was formed in conjunction with the International Monetary Fund at
the Bretton Woods Conference in 1945. The publicised role of the World Bank at the
time was to assist in the redevelopment of post World War II Europe. The
International Monetary Fund was tasked with the job of protecting the global
economy from economic instability and collapse and prevent a repetition of the great
depression.
World Bank and Health Programming

The World Bank moved into health policy during the mid 1980's 6. Funding for health
programming steadily increased and the World Banks influence and budget allocation
in global health overtook that of the WHO in the late 80's. The World Bank 1993
World Development Report outlined the World Bank's intention to increase its focus
on the health outcomes of economic development, and at the beginning of the 21 st
century, the health expenditure of the World Bank was three times that of the WHO. n

Some would suggest that the World Bank, with its history in development, has a
significant repository of knowledge on poverty and its effects on health, and with
such a significant health budget, is well placed to take some leadership in health
programming.

Others would criticise the history of the World Bank in light of its past health policies
including those of structural adjustment, cost-recovery health financing, and
privatisation of health care. Some, justly, claim that the World Bank and IMF's
policies are largely dictated by their influential donors, as opposed to the actual
development needs of the countries targeted by these policies.

Globalisation

With increasing free flow of capital and the increasing economic influence of
international bodies such as the World Bank/IMF and transnational corporations, there
have been a demonstrable erosion of the national sovereignty, and the ability of
nations to conduct independent national policy. 10 Theoretically, international
investment in developing markets may provide much needed capital for early
economic growth and hence, theoretically, poverty reduction and improvement in
health.

Misregulation of bilateral and multilateral aid and lending, however, led to a

significant debt crisis amongst the developing world throughout the 80's and 90's.
Economic and health policies aimed at reducing the effects of these crises were, in
practice, often detrimental to the health of the developing world.

Structural Adjustment and Health

The World Bank throughout the 70's and 80's pursued a policy of utilising financial
loans to developing countries to leverage national economic policy change. This was
known as structural adjustment. The desired effect of these policies was to
incorporate previously centrally planned national economies into the evolving global
market-oriented economy of the time. By opening up the markets in these developing
countries to international investors, these policy changes aimed, ostensibly, to
generate economic growth and facilitate repayment of existing foreign debt.

Under these structural adjustment policies, the net effect was the diversion of national
resources away from essential national sectors such as health, education and
protection of local agricultural economics to the repayment of debt. The results were
often drastic falls in literacy rates, falls in the health status of populations, and
reduced viability of national agricultural industries. 6

Health Financing

Ghana was one of many developing nations targeted by the World Bank and WHO in
attempts to set up sustainable health care systems utilising cost-recovery health
financing policy. Analysis of the outcomes of these policies, over time, showed
deleterious effects on service utilisation and health outcomes. l3,14

The World Bank as part of its overall economic and health policy promotes
privatisation of health care. The long held belief is that a competitive service delivery
environment increases the overall efficiency of the system. There are significant risks,
however, to both individuals able to access private health care, and those still serviced
by the public system.

Under regulated private health sectors have, in many countries including those in
Africa, Asia and Latin America, led to inappropriate and expensive treatment for
those within private health care. Importantly, service delivery to those outside of the
private system tends to suffer as a result of decreased public spending. 15

Poverty Reduction

Given the close link between poverty and ill-health, would it seem reasonable to have
the World Bank play a major role in intervening in health at the economic level? True
economic recovery would be welcome, but given the World Bank and IMF's history
on economic policy, can they be relied upon to act on behalf of those countries in
economic need, or will the influence of its influential donor countries continue to
hamper its ability to effect true change?

It has been suggested that nothing short of a large net transfer of wealth from rich
nations to poorer nations will improve global health, and that no amount of good
governance and economic reform within national and international institutions will
compensate for negative effects of the wealth differential between the rich and the
poor. In reality, this would likely require cancellation of debt, and ongoing transfers to
the developing world for decades to come. 16

Civil Society Organisations

Civil Society, as a term in development, encompasses Non-Governmental

Organisations (NGOs), political groups active in lobbying and advocacy, the private
sector, and global philanthropists. NGOs have successfully advocated and lobbied on
behalf of marginalised populations on a diverse range of issues including human
rights, child labor, free trade , corporate responsisbility, and environmental
protection.6

Increasingly, donor agencies such as US AID are cooperating with, and providing
funds to, countries via these organisations. 6 The internet and communication
revolution has acted to increase the efficiency of information sharing amongst these
groups, hence increasing the size of the collective knowledge base from which they
can draw.
The Private Sector

The private sector stands to gain significantly from its involvement in public health
projects, and if well regulated, the public, too, have much to gain from the
partnership.

The private sector may participate in public health directly or in partnership with
NGOs or UN agencies, to enhance its reputation in corporate responsibility, and often
importantly, to gain strategically in potentially new global markets. 6

"Increasingly, firms realize that they cannot keep their workers productive, nor build
markets, without a healthy population, particularly when the main killers such as
HIV/AIDS in southern Africa or traffic accidents in Vietnam, do not respect company
boundaries."

In 1987, Merck initiated the Mectizan Donation Program, donating, as required,

amounts of the drug Mectizan for the treatment of onchocerciasis. At that time,
onchocerciasis was a significant public health issue in Africa with over 17million
people affected. 6

Philanthropy has also increasingly become another significant source of funding for
health projects. Individual support for the work of NGOs and support from large
philanthropic bodies is increasing. Not insignificantly, philanthropic foundations such
as The Bill and Melinda Gates Foundation, which over the last 4 years has donated
approximately US$3.6 billion towards Global Health projects are increasingly setting
priorities in the fields they involve themselves in. 6, 17

Conclusion

Since the WHO's inception following world war II, it has built up a repository of
technical expertise and legitimacy in many parts of the world. It led global health
towards significant health gains in its first few decades of its activity, and contributed
towards the global recognition of the importance primary health care principles.

The WHO was challenged, however, in the last three decades by the overall trend
towards global market economies and, ultimately, the influence of international
economic institutions such as the World Bank and IMF. Globally, emphasis was
increasingly placed on economic and health care reform.

World Bank led economic reforms often resulted in reduced national expenditure on
health and education, as national priorities were shifted towards repayment of foreign
debt. Health care reforms such as cost-recovery led to reduced service utilisation
amongst the poor in developing countries. Health privatisation, a result of the global
trend towards a market oriented economy, if under regulated, is likely to lead to
significant health equity issues.

Comparatively less resourced, the WHO was seen to lose ground to the World Bank
during the 80's and 90's as the World Bank progressively incorporated more health
policy, and invested more in health programming. By the end of the 20 th century the
World Bank's budget for health expenditure was three times that of the WHO and
hence its influence globally was increasingly significant.

As the number of players in global health increase, and the arrangements between
them become increasingly complex, the relative influence of international agencies
such as the WHO is gradually diminishing.

Poverty reduction, a key strategy to improving health globally, will require a

considerable and sustained global effort over the next generation. Promisingly, CSOs
have grown significantly in their influence in global health, and are seen as one
potential mechanism for communities to participate in the push for equity in global
health.
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