People's Democracy

        World Bank And The Health Sector

Amit Sen Gupta

THE World Bank has been, for some time, soliciting comments on its Country Action Strategy (CAS) for the World Bank Group in India, which is essentially a draft plan for intervention in India by the World Bank in different sectors from 2005 to 2008. A careful reading of this paper would be useful, as the Bank’s prescriptions continue to be lapped up with all seriousness by our bureaucrats and policy makers.

A FLAWED STRATEGY

A close look at the section on health in the CAS brings out the fundamental premises of the World Bank’s prescription in the Health Care sector. Talking of “Reducing the Health Risks of the Poor” the document says: “ There are a range of health sector Interventions and services that are critical ….. These include accessible and good quality facilities for safe delivery care for acute respiratory infections and diarrhea in young children and effective health and nutrition promotion. Improving health outcomes for the poor will require a concerted effort to improve both the overall health system of the states – the public and private sector combined ….”

The basic approach to health care and health delivery needs that the World Bank proposal needs to be carefully examined. The World Bank continues to emphasise on 1) Selected Interventions (viz. safe delivery, diarrhoeal disease control; 2) A role for the private sector. From a public health perspective, both these approaches are deeply flawed. 

A public health approach is premised on the provision of comprehensive health care services to all by the state. A comprehensive health care system includes all services at relevant levels of the system, with adequate provisions for human power, resources and technical know-how. The World Bank’s attempt to reduce this approach to a few “magic bullets” that target a few interventions, in fact, led to the dilution and subsequent abandonment of the “Primary Health Care” approach that was fore grounded in Alma Ata in 1978 – especially given the World Bank’s increasing global clout in formulation of health policies.

Again, the World Bank’s regular tomtomming of the role for the private sector defies all conventional logic. Developed countries (and developing countries with strong health systems like Cuba) have built their health infrastructure through a public funded system. Being a “public good” private sector participation in provisioning of health care is a contradiction in terms. In a country like India – possibly the MOST privatised system of health care with just 16 per cent public spending on health care – it is ridiculous to continue to harp on a “role” for the private sector. What we should be talking about is in fact a much reduced role for the private sector and much greater regulation of this sector – which in fact is the largest unregulated sector of the Indian economy. 

PROMOTING PRIVATISATION

 
The Paper goes on to talk of some of the World Bank’s priority areas for intervention, where it says: “… new projects in these states … would seek to break new ground in forging public-private partnerships (including through progressive separation of public health financing from provision), strengthening oversight of private providers, increasing public expenditure on health, reorienting health facilities to ensure service for the poor and reducing vulnerability through creation of health insurance schemes”. 

What is this “public - private” partnership that the Bank talks about? Is it the “progressive separation of public health financing from provision.” Or it refers to “Health Insurance Schemes”. These are all euphemisms for legitimisation of the abandonment of the role of health care provider that the state should play. The key here is really public health expenditure. At 0.9 per cent of the GDP India’s public Health expenditure is one of the lowest in the world. In the liberalisation years (since 1991) this has come down from 1.3 per cent (in itself a very low figure. This is what the World Bank and IMF led reform has meant for the Health Sector – a savage cut in public expenditure. Now this is sought to be legitimised through doublespeak by the World Bank – essentially saying that if the State cannot or will not pay let us explore ways in which the people can be made to pay for their health care.

The Paper goes on to speak of water supply and sanitation: “one-fifth of India’s national disease burden can be attributed to environmental causes – with the largest environmental risks to health coming from the lack of access to safe water and sanitation, and cooking with traditional biomass fuels resulting in high levels of indoor air pollution… a major Bank study to measure the health impact of improved rural water supply is underway and will be completed in FY06..”

These are mere platitudes about issues that are common knowledge. Do we really require the World Bank to tell us that safe water supply, sanitation, education, public transport and safe work environment have a major impact on health? Why the World Bank should spend money on inflated “dollar” salaries for self-styled experts to reinvent the wheel is beyond comprehension. The real issue that the Paper does not address even in passing is that in all the areas the policies of neo-liberalism that the World Bank champions, have led to a steady deterioration of public facilities. In the economic “reform” period, public expenditure in these areas has declined and privatisation has been actively promoted.

The real intent of the World Bank’s interest in this area becomes clear when we read further: “There have been some important lessons from the Bank engagement. Foremost among these is that sustainability is a major challenge – which is best addressed by involving communities in the design, construction and operation of schemes, including through their contribution to capital costs and their full financing of operational costs”.

A brilliant piece of reasoning indeed! After saying that safe water supply and sanitation is critical for health care, the Bank now prescribes privatisation of the same as the only solution.

The Paper expands further on the World Bank’s strategy: “During FY05-08 the Bank would be ready to support this objective by lending to states that decide to adopt a participatory approach to Rural Water Supply and Sanitation (RWSS) statewide”.

Note the use of the phrase “adopt a participatory approach to RWSS statewide”. If read along with the previous paragraph, it means that the Bank is willing to assist those states that are willing to privatise their water and sanitation systems. “Participatory” has become an euphemism for ways in which the poor can be forced to “participate” in paying for services that the State should provide free of cost.

INFECTIOUS DISEASE CONTROL

 
The Paper then turns to the issue of “Controlling Infectious Diseases”. It says: “Future (World) Bank support for disease control is also focused on integrating programmes at the state level, reorienting public sector interventions towards priority outcomes and expanding on opportunities for public -private partnerships. For example, since most tuberculosis cases are seen by private medical doctors or other private practitioners, there are important potential benefits to reorienting the state public health system to work more closely with the private sector”. 

The World Bank’s fetish for the private sector is truly amazing. If, today, most patients of T B are forced to go to the private sector the remedy should be a strengthening of the public sector. In a weird sleight of hand the Bank believes that this constitutes an argument for strengthening the private sector. Tuberculosis is universally acknowledged as a “disease of poverty”, a disease furthermore that accounts for more than half a million deaths every year. Further, the whole approach of targeting a few diseases through vertical top-down programmes (no matter how important these diseases are) is essentially flawed. The attempt should be a strengthening of the entire public health delivery system and a location of diseases surveillance, control and prevention measures within such a comprehensive system. The World Bank is loath to suggest that such measures are against the grain of its philosophy of a reduced role for the State and a greater emphasis on market mechanisms.

The Report turns to immunisation, stating: “In close cooperation with the World Health Organisation (WHO), the Bank supports GoI’s polio eradication campaign. … GoI and the Bank are exploring ways to revitalize routine immunisation programmes in some states where they have been stagnant or even declining”.

This is gross dishonesty, for what the World Bank does not say is in fact the most contentious issue in this area. There is concern today about declining achievements of routine immunisation programmes because the entire emphasis of the health system as regards immunisation, has been on the pulse polio campaign. This is a clear example of the problems of running vertical campaigns without strengthening basic health service delivery systems. 

Finally, how can a multilateral agency not talk of HIV-AIDS. The Paper devotes a large section to HIV-AIDS control. The Paper says: “While ensuring a continued focus on prevention, the Bank Group could also provide assistance to GoI in monitoring provision of anti-retroviral therapy (ART) and measuring its impact as the treatment programme is rolled out. Assistance to … a manageable programme could also be provided”.

The difference in the ways in which India and Brazil have approached the problem of HIV-AIDS is worth looking at in this context. Brazil chose to make the public health system responsive to the problem by providing treatment for HIV-AIDS. India chose to set up a white elephant called NACO that just does surveillance studies and pontificates on the problem of HIV-AIDS (India is still to offer treatment with antiretrovirals through the public health system). There is absolutely no alternative again to the location of the treatment, control, surveillance of HIV-AIDS in the overall public health system. The issue then is where do the funds come from? Repeatedly we come back to the necessity of greatly enhancing the public expenditure on health care. The World Bank funds are incidental (they still constitute a fraction of what the GoI spends on health care). In the whole section on Health the Paper talks of the need for greater public expenditure in just one place – in passing.

It is easy to dismiss such prescriptions, because on merit they deserve to be dismissed outright. Unfortunately, the World Bank’s platitudes are taken as the gospel truth by people who formulate policy today. The World Bank can always say that its CAS is just its own strategy paper, and the Indian government is free to formulate its own policy. Unfortunately this is only half the story. We have seen over the last decade and a half how, shamelessly, the priorities of our domestic policies seem to echo the thrust areas that the World Bank sets itself. This hegemonisation of the policy making space by the World Bank is what makes papers like this dangerous. Dangerous because they will be taken seriously by those who formulate our policies.