IFI governance


Building back better health systems: lessons from the WBG’s Covid-19 response and recovery plans

6 October 2021 | Minutes

The WB financed developing countries’ response to the COVID-19 pandemic and is working to boost access to vaccines. In this context, recent WB publications highlight the centrality of public finance for healthcare systems. This panel aims to facilitate a dialogue on reimagining health care systems, central to a just and equitable recovery.

  • Moderator: Marco Angelo, Wemos, Global Health Advocate
  • Panelist 1: Rossella De Falco, Global Initiative for Economic, Social and Cultural Rights (GI-ESCR), Programme officer on the Right to Health
  • Panelist 2: Allana Kembabazi, Initiative for Economic and Social Rights (ISER), Programme Manager on the Right to Health
  • Panelist 3: Els Torreele, UCL Institute for Innovation & Public Purpose (IIPP), Policy Associate
  • Panelist 4: Christoph Kurowski, World Bank Group, Global Lead for Health Financing

Marco Angelo, introduction.

CSO & researchers gather together for lessons learnt after Covid-19 pandemic.

Christoph Kurowski

Presents report: “From double shock to double recovery”, looking at macrofiscal impact, health spending consequences and implications for double recovery from the Covid-19 pandemic.

Recovery based on three premises:

  • End pandemic
  • Prevent future health crisis
  • Regain losses from pandemic

From the latest findings in terms of macrofiscal features of recovery:

  • In 2021 we will be returning to grow by 2pt of GDP
  • And by 2023 we will be returning to pre-covid levels

However, there will be large disparities in the countries’ capacity to build out public investments: 126 GGE pc growth countries versus 52 non GGE pc growth countries. Shocks have hit 52 LICs extremely hard, meaning they would need to double their share of GDP going to health in some cases, which is unprecedented. In many of these countries, spending is ‘expected’ to fall.

Government health spending scenarios:

  • Business as usual: budget decisions do not change
  • Budget change and increase towards universal health coverage

LIC countries will be facing tough choices as the expected growth in governments health spending go well beyond what the government can pay.

In order to meet needs for a full recovery in health governments will need to increase health budgets:

  • By managing uncertainty: Provide sufficient contingencies/reserves and increase in-year budget flexibility.
  • By making fiscal adjustment work: through spending reviews, budgeting strategies (protect critical programs, move performance budgeting and adopt whole governments approach) and macrofiscal analyses (account for human capital in CGE and consider non-debt liabilities in balance sheet).

Rossella De Falco

Presents report on Italy’s experience and the limits of the privatisation of healthcare, “Lessons from Italy: The limits of privatisation in healthcare delivery”. Case study of Lombardi region, one of the wealthiest in Italy – and the epicentre of Italian Covid pandemic.

Main issues analysed in the report:

  • Where are these resources crucially important.
  • Should private sector be included in the recovery of the crisis?

The report focuses on Lombardy and compared to Veneto (two very similar regions in terms of income and services).

Lombardy region become the archetype of a disaster response.

Since 1992 the government promoted programs of private health sector providers.

Among failures on response to pandemic:

  • Lost of time, scarce testing and tracking patients at home. It had a hospital-centred response, in contradistinction to a community-centred response to the crisis.
  • Healthcare system was below average: prevalence of private health providers and less services (home care, prevention, practitioners)

Lombardy’s poor response to Covid-19 was the logical endpoint of a system that “transformed health into a commodity, ignoring prevention because it does not produce benefits.”

What lessons can be learnt?

  • Privatised and commercialized healthcare system are less effective in responding to crises such as pandemic.
  • States must ensure their healthcare system is built on strong, quality, coherently regulated non-commercial sector.
  • Commercialization of healthcare might constitute a violation of State’s human rights obligations enshrined in the Constitution and national las as well as in international human rights law.

Allana Kembabazi

Case of Uganda

Spending in public health system is very low. With Covid-19 it went even lower.

Two questions:

  • Where do we go from here?
  • What was happening? where was the WBG when they needed support?

Two lessons:

  • There was systematic marketisation of health (bouchers for services etc., leaving out the poor). Promotion of PPPs. Majority of providers of health services in Uganda are private.
  • There is a big difference between what is said in WBG reports and what is done. The policies that are done at country level are much different than the urgency intimated in the WBG’s research.

Private sector can complement the public sector but there have to be strong pillars and systems.

Grants given to Uganda are not consulted with people, CSOs, etc.

The debt is getting unsustainable.

The money is supposed to go to public health (test kids, rapid response settings), but this is not happening. There are reports inconsistencies: money given for specific actions that later did not take place

WBG needs to match its rhetoric to end poverty. Not about speech but real actions.

People need more info on where the money is going, conditions, etc. – more consultation is needed.

Els Torreele

GDP growth is treated as the ultimate measure of how well a country is performing. But this does not reflect how the population is doing, it’s just a small part (business, etc.). There is a real need to rethink the way we measure value in economic activities.

We need to think fresh and put aside all the traditional economic thinking (austerity for instance).

Health for all (in the broader sense) should go into every economic system, not as an aside effect but a real part of it.

We need to finance for health, across sectors. Need a cross-sectoral approach to finance for health (social services, labor, etc).

We need to acknowledge that health and finance for health is not an expenditure, it’s an investment.

There is abundant evidence that there’s a central role of public finance and public leadership towards ensuring health for all.

We think that the private sector needs to fill in the gap we do not have in the public sector. There’re more places we can expand for the public sector. If the private sector takes part it should be ensured this is used towards our public goods (development of vaccines, for instance)

We have failed to ensure the private sector will actually contribute to the public sector.

Questions & Answers:

Q(to Christoph): Budget impacts of neurological conditions from Covid

Cristoph Kurowski

Mental health is part of a broader agenda on non-covid related diseases.

Need to have a focus on mental health more broadly, as these are not prioritised. Primary health needs to be accounted for – platforms for service delivery. In the middle of replenishing IDA (shouldn’t be loan it should be grant – hoping for a big replenishment).

Q: As financing for health in many countries is going to reduced (based on Outlook from Christoph report). What WB is going to do differently based on scenarios and lessons from pandemic in terms of financing for governments? 

Cristoph Kurowski

Private health is not only personal care services. They are community-based health services.

Q: IMF continues to back role countries. What are the ways we can ensure there’s accountability on the money is given by IMF goes to what they’re actually financing?

Cristoph Kurowski

In the middle of replenishing IDA. We hope for big tourn out of Ida to be able to give larger financing to countries in need

Q: Are you worried about the WB financing for vaccines – may this be displacing other resources from IDA for public resources as these are ben directed to vaccines? What are the solutions to this? Oxfam has been calling for vaccine support to be grant-based and additional.

We found that most projects weren’t addressing out-of-pocket payments/costs in Covid-19 response. Please to see call this year that it should be free at the point of service.

Cristoph Kurowski

In first MPA, it was additional to IDA, 2nd one was not. We have additionality on the radar screen, and much will depend on the size of the IDA replenishment. If it comes at the cost of their IDA envelope, this will affect decisions. Out of pocket expenditures – this is a very sobering picture globally, in terms of what is happening. Need to see what people can get for the money they spend. Our position is that there should not be any barriers to access on the supply side.

Q: At what point does the bank put out a statement on this, as there is much money that this changing hands. There have been no vaccine purchases. Why is the Bank staying silent?

Cristoph Kurowski

There are many redress mechanisms to raise issues within the Bank; will convey what I am hearing to the country office.

Final remarks

Marco Angelo

Health is an investment as part of what we should do as part of a full recovery.

Els Torreele

We need to have a new economic thinking to see health as an investment

Capitalism – we have increased inequality and there are things we need to do to change

Private sector is not evil – but need to be careful with maximization of revenues. A financialised system is not able to respond to what society needs. We need to build public sector financial capacity. Covid has shown North-South relation is not working any more.

Allana Kembabazi

We need to continue to be the eyes but the WB needs to be serious.

There’s need for conversation, consultation, not redress mechanisms. WBG needs to invest in public health sector.