The World Bank president Jim Yong Kim has publicly prioritised universal health coverage (UHC), and education (see Update 86) however critics worry about increasing support for private companies to deliver these services.
In a late May speech to the World Health Assembly, Kim positioned universal health coverage as a critical part of the Bank’s commitment to free the world from absolute poverty by 2030, with an aspiration to “close the gap in access to health services and public health protection for the poorest 40 per cent of the population in every country”. Although Kim’s commitment to healthcare is unsurprising given his background in the World Health Organization (WHO), his vision of the Bank’s involvement using “the science of delivery” (see Update 86) takes it into new territory.
In his speech Kim was candid about the global development community’s record on health: “The fragmentation of global health action has led to inefficiencies” … parallel delivery structures; multiplication of monitoring systems and reporting demands; ministry officials who spend a quarter of their time managing requests from a parade of well-meaning international partners”, which are “literally killing people”. Although Kim highlighted that “elimination or sharp reduction of point-of-service payments is a common feature of all systems that have successfully achieved universal health coverage” he stopped short of calling for free healthcare, acknowledging that “countries will take different paths towards UHC. There is no single formula.” Kim nonetheless promoted Rwanda’s achievements under “results-based financing”, which involves “an up-front agreement between funders and service-providers about the expected health results” and Mexico’s ‘Oportunidades’ cash transfer programme as success stories. Both models are heavily donor-driven.
Rick Rowden of Jawaharlal Nehru University, India noted in a June paper, the “newly emerging consensus” against privatisation and user fees amongst the international health community, and the Bank’s change of heart on private health financing “from critic to advocate to critic again”, reflected in Kim’s support for the Alma-Ata principles (which recognised healthcare as a human right). David McCoy of Queen Mary University London and the Peoples Health Movement detected ambiguity in Kim’s speech: “It’s important to differentiate ‘universal health coverage’, which Kim is promoting, from ‘universal health systems’. UHC can be constructed in a way that will continue the Bank’s historical alignment with privatisation and commercialisation. Kim’s emphasis on performance-based funding is … potentially a worrying signal that the Bank intends to adopt a narrow, donor-led approach which will hinder the development of national institutions and systems. It is too early to pass judgement on Kim either way. But we need to keep a close eye on the Bank.”
Kim’s proposal for the Bank to play a bigger role in the architecture remains controversial as this is traditionally the province of the WHO and the politics of the model he is endorsing is unclear. According to UK-based NGO, Health Poverty Action, major differences have emerged between the two institutions on UHC with the WHO clear that the model “does not mean minimal benefit packages but the World Bank has been pushing this model for more than 20 years”.
Open door for private health?
It is not clear how widely Kim’s principles are shared internally. World Bank staffer Adam Wagstaff was less coy in asserting that the future is private healthcare. In a May post on the Bank’s blog Wagstaff said that “resources are finite, and especially in poor countries the available resources won’t allow us to get to UHC anytime soon”. He endorsed alternative healthcare financing models, such as a “cost-effectiveness analysis ” – which assesses the cost of a medical interventions “benefits package” that would be financed publicly. “Patients needing an intervention [outside the package] will have to pay out of pocket, or else go without it.” This offers the “big attraction” that it “will produce the maximum possible aggregate health for the population.” Wagstaff also talked about a randomised “lottery” system which would give “everyone – rich and poor – the same probability of getting the care they need without suffering financial hardship as a result of receiving it”.
Sidua Hor of the universal access to healthcare campaign, a Ghanaian campaign driven by a network of local and international NGOs, said the Bank’s push for private sector healthcare is “worrying”: “in Ghana, private health providers do not have the best human resources; the public sector does. Private providers are concentrated in cities where they can make more profit at the expense of peoples health, not in the rural and hard to reach communities where primary health care facilities are lacking.”
In May the Bank’s executive board approved the International Finance Corporation’s (IFC, the Bank’s private sector arm) $100 million investment in Fortis Healthcare to expand its private health services in India. Fortis runs private healthcare facilities across Aisa including Singapore and Malaysia. Meanwhile in the Indian state of Jharkand, the IFC outlined its plans at end May for a half a million dollar public-private partnership to expand a private hospital in the state capital, Ranchi by end June 2014.