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What will the new World Bank head do for global health?
World Report
What will the new World Bank head do for global health? The appointment of Paul Wolfowitz to take over as World Bank chief prompted a barrage of criticism from activists concerned about his role in the Iraq war. But are these protests justified? Health economist and former World Bank speechwriter Jennifer Prah Ruger reviews the evidence.
Who is Paul Wolfowitz? Wolfowitz has been a key architect of US military operations in Iraq and Afghanistan—actions he justifies in the name of expanding democracy. Regarded as a neoconservative “hawk”, Wolfowitz has sparked broad criticism for his part in the plan to overthrow Saddam Hussein and establish an Iraqi democracy, a plan whose flaws have since become clear. Furthermore, the astronomical costs of the war and reconstruction have defied his prediction that the operations would be “self-financing”. Opponents argue that he is a unilateralist, pursuing American geopolictical interests without regard for human suffering or international conventions. Stiglitz voiced fears in an interview with UK Channel 4 News that the bank will “become an explicit instrument of US foreign policy”. If these concerns prove justified, the institution could face real turmoil. The World Bank is a uniquely multilateral institution, crewww.thelancet.com Vol 365 May 28, 2005
ated in an era of post-World War II cooperation with a core mission of reducing poverty worldwide. But there is another side to Wolfowitz. Earlier in his career, while working as US Under Secretary of Defense for Policy during the George H W Bush administration, he won praise for developing strategic plans and obtaining financial support for the first Gulf War. His work as US Assistant Secretary of State for East Asian and Pacific Affairs also earned admiration for strengthening US relations with China, Japan, and Korea, and furthering the transition to democracy in the Philippines and Korea. But this past experience, focused on Asia, the middle east, and on US geopolictical interests, raises questions too: bank staff and clients will vigorously oppose reorienting the bank towards US global security concerns as an overarching development agenda. The burden of proof will be on Wolfowitz to prove the contrary. Suspicion and concern currently run very deep. Wolfowitz is known for his scholarly views on national security strategy and foreign policy, and he has written widely on these issues advocating, unsurprisingly, American global leadership and interest. He has amassed considerable expertise in military strategy. But, although he is former dean and professor of international relations at Johns Hopkins School of Advanced International Studies, he lacks specific expertise in development theory, practice, and dialogue. Although these deficits will not necessarily undercut his effectiveness, Wolfowitz’s silence on his vision of development and foreign aid is a concern to many. Jeffrey Sachs, development economist and director of the Earth Institute
at Columbia University told BBC News that the World Bank needs “an individual with a demonstrated track record and relevant professional expertise”. But, he added, “Mr Wolfowitz does not fit those criteria at all. He is a man without international development experience, without professional qualifications.” Personal associates of Wolfowitz describe him as an open, well-liked, and intelligent man who is willing to listen. He has won respect as an excellent manager, so much so that during his tenure at the US Embassy in Jakarta the US Inspector General cited the embassy as one of the best-managed diplomatic missions worldwide. These qualities will serve him well in a
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
On June 1, 2005, Paul D Wolfowitz will take over from James D Wolfensohn as president of the World Bank. Wolfowitz, a former US Deputy Secretary of Defense, US Ambassador to Indonesia, and US Assistant Secretary of State, comes to the job under a cloud of controversy over his previous work and ideological convictions. Former World Bank Chief Economist Joseph Stiglitz predicted that the appointment could “bring street protests and violence across the developing world.” The BBC reported the British-based World Development Movement describing his nomination as “terrifying”. So can Wolfowitz lead the bank effectively? And what will his presidency mean for health and human development?
Paul Wolfowitz takes over the World Bank helm on June 1, 2005
1837
World Report
10 000-person organisation with a US$20 billion annual lending portfolio. These attributes are also believed to be key reasons why Bush selected Wolfowitz as Wolfensohn’s successor. During Wolfensohn’s tenure, the Bush administration was critical of his eclectic management style. Observers expect Wolfowitz, by contrast, to focus on setting up systems to monitor aid effectiveness on the ground and to streamline operations. Wolfowitz’s ties with the Bush administration may also be a financial boon to the World Bank: these links could enable him to secure increased US foreign aid and trade reform, goals Wolfensohn was unable to achieve through his strained relations with the White House.
Wolfowitz’s key themes Analysis of Wolfowitz’s writing, speeches, public statements, congressional testimony, and service on public commissions reveals a core set of principles that are likely to shape his vision of a 21st century World Bank (panel). Democracy and good governance Wolfowitz wants to spread democracy and its institutions worldwide. The bank, by contrast, has claimed an “apolitical” stance and has not publicly embraced democratic development as part of its core mission. In recent years, however—especially since its major restructuring in 1997—governance issues have become a major focus. Indeed, since 1997, an entire public governance sector has been established to promote “building efficient and accountable public sector institutions”. Given the synergies between good governance and democracy, Wolfowitz is likely to expand the public-sector portfolio; investments in building efficient and accountable democratic institutions are probable as well. The bank might, for example, establish performance standards for effective parliaments or legislatures, multiparty competition, representation, and voting systems. On another tack, Wolfowitz might push a democracy-oriented agenda by 1838
imposing strong political conditions on aid. These conditions could range from public-sector effectiveness to requirements for the establishment of democratic institutions (eg, voting, legislative bodies, multiparty elections, free press, and constitutionalism). Making aid conditional on democratic reforms could, however, be a double-edged sword. In addition to the coercive nature of such demands, they could also result in lower lending and inhibit overall development. To avoid the perception of hypocrisy, a democracy-driven agenda would necessarily entail a third component: initiatives to democratise the World Bank itself. Critics have long protested against the bank’s governance structure for its unequal distribution of executive board votes, opaque decision-making process, and lack of board accountability to elected officials and legislative bodies in the countries the bank aims to serve. Private-sector-led reform Wolfowitz embraces the principles of private-sector-led growth in all countries, although some have criticised his support for policies that include little or no government market regulation, support, or oversight either nationally or internationally. The bank’s work in private-sector development has grown recently, including a 2005 World Development Report devoted entirely to investment climates in developing countries. It has focused on improving countries’ business environments through foreign direct investment, corporate governance, business regulations, improving small and medium enterprises, and corporate social responsibility. One would expect Wolfowitz to continue to foster these initiatives, perhaps with a focus on small and medium enterprises, a key engine of economic growth. In trade, Wolfowitz recognises the need for reform. He is likely to continue scaling up the bank’s current work, collaborating with the World Trade Organization (WTO), other mul-
tilateral agencies, and governments to reform the world trading system, and supporting country-level efforts to develop national trade policy and institutions. Regional focus The middle east, especially Iraq and Afghanistan, is predicted to be the main region of interest for Wolfowitz, and he will probably concentrate on rebuilding basic infrastructure (food, water, electricity, sewerage, education, health, and security). Pakistan, a US ally, may also win his attention due to its importance in American geopolitical terms. Although his past experience is mostly from Asia, Wolfowitz’s recent rhetoric on focusing the bank’s work in the very poorest regions of the world suggests that he might steer the bank away from many Asian economies. China and India, for instance, have experienced impressive growth rates and have already voluntarily reduced their bank borrowing significantly. Wolfowitz has declared an interest in prioritising Africa and the poorest areas within Africa. This vision would be consistent with the broader development agenda. The Commission for Africa led by UK Prime Minister Tony Blair, for instance, calls on the G8 group of industrialised nations to significantly increase aid to Africa over the next several years. A focus on Africa and the middle east would also mesh neatly with the now-famous 2000 Meltzer Report on the World Bank’s future. It is possible that Wolfowitz will follow the report’s recommendations, which called for scaling down the bank and its work to focus solely on the very poorest regions, such as Africa, central Asia, and the middle east, to phase out entirely from middle-income countries in Asia and Latin America, and to shift from credits to grant aid. Such downsizing could reduce the bank’s portfolio by 50% or more, and could have the unintended consequence of less concessional lending for poorer countries. www.thelancet.com Vol 365 May 28, 2005
World Report
Debt relief and grants Wolfowitz has publicly endorsed debt relief for heavily indebted poor countries and advocates moving towards grant aid and investments, and away from credits, to help address HIV/AIDS and malaria, especially in Africa. However, it is unclear where the money will come from to cover the loss in revenue. The bank’s heavily-indebted poor country initiative (HIPC) has already provided some relief, but the G8 has been asked contribute up to 50% of the remaining required financing.
Health and development Debt relief and health Wolfowitz’s commitment to debt relief gives some hope for health and human development. Debt relief for poor countries is typically a win-win situation for the health sector, as the savings in debt service payments can go instead toward basic health care and social services. In many struggling countries, debt service payments exceed health-sector investments. Where debt has been written off—in Benin, Senegal, and Mozambique, for example—health spending has increased. If Wolfowitz can persuade the G8 to contribute their share to HIPC, the initiative could well benefit health and other social sectors in debtor countries. Infrastructure and health At the same time that HIPC and grant aid might promise increased healthsector investments, a general trend during the past year or so has shifted bank investments toward infrastructure, at the expense of human development. Wolfowitz is likely to maintain this trend, resulting in greater reductions in health and social sector spending in the overall portfolio. Health and other social services currently comprise 15%, while infrastructure comprises 40% or more. HIV/AIDS and malaria Wolfowitz has announced his intention to make HIV/AIDS a priority, especially in Africa, and he also plans to focus on www.thelancet.com Vol 365 May 28, 2005
malaria. He has not indicated whether prevention or basic care and treatment of HIV/AIDS will take precedence. The bank has significantly sharpened its HIV/AIDS focus over the past several years, resulting in its being one of the world’s largest supporters in the fight against HIV/AIDS. It has committed more than $1·6 billion during the past several years and has created a self-contained bank unit focused solely on this problem. Wolfowitz is likely to maintain or expand these interests. Nutrition and public health Despite the acknowledged importance of, and gains from, addressing malnutrition, under-nutrition, micronutrient deficiencies, wasting, and stunting, Wolfowitz has expressed no interest in nutritional concerns in the past or during his transition to bank president. It does not appear to be a subject to which he has given much thought, nor does it seem to be a priority. Similarly, he has expressed little interest in broader public-health measures to address critical issues such as onchoceriasis (river blindness, one of the bank’s
early and premier health programmes), maternal and child health, tuberculosis, tobacco, mental health, school health, or road safety—all programmes the bank has been involved in for some time. It remains to be seen, however, if Wolfowitz will take after his predecessor, Robert McNamara, who, upon arriving at the bank surprised observers with the depth of his passion for nutrition, public health, and population and reproductive health issues. Population and reproductive health Given the Bush administration’s stance on family planning and reproductive health issues, at best Wolfowitz is likely to leave this unfinished health agenda alone, and at worst attempt to reduce resources devoted to it. Population and reproductive health is one of the bank’s oldest health portfolios; it began work in this area some three decades ago, under McNamara. To date it has loaned over $3 billion to such projects. Unwanted fertility and high maternal mortality and morbidity persist, and the lack of sexual and reproductive health care accounts for around 20% of the
Panel: Further reading Dahl RA. Polyarchy: participation and opposition. New Haven: Yale University Press, 1971. Lenski G. Power and privilege: a theory of social stratification. New York: McGraw Hill, 1966. Lipset SM. Some social requisites of democracy: economic development and political legitimacy. Am Pol Sci Rev 1959; 53: 69–105. Muller E. Economic determinants of democracy. Am Sociology Rev 1995; 53: 50–68. Ruger JP. Changing role of the World Bank in global health. Am J Public Health 2005; 95: 60–70. Ruger JP. Democracy and health. Q J Med 2005; 98: 299–304. Ruger JP. Health and social justice. Lancet 2004; 364: 1075–80. Ruger JP, Yach D. Global functions at the World Health Organization. BMJ 2005; 330: 1099–100. Ruger JP, Jamison D, Bloom D. Health and the economy. In: Merson M, Black R, Mills A, eds. International public health: diseases, programs, systems, and policies. Gaithersburg: Aspen Publishers, 2001: 617–66. Sikorski R. Paul Wolfowitz. Prospect, Dec 2004. Wolfowitz P. Clinton’s first year. Foreign Affairs, 1994; 73: 28–43. Wolfowitz P. Bridging centuries: fin de siecle all over again. National Interest 1997; 47: 3–8. Wolfowitz P. American power—for what? Commentary 2000; 109: 46–47. Wolfowitz P. The first draft of freedom. New York Times, Sept 16, 2004.
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World Report
global burden of disease and death. Still, Wolfowitz is unlikely to address these issues, especially if evidencedbased family planning contradicts Bush administration policy. Health system development The bank has been working to develop health systems for some time now, focusing especially on issues such as health financing, insurance, services and delivery, human resources for health, pharmaceuticals, hospital and clinic management, and public–private health-sector reform. In the past 5 years or so, however, the bank has lost momentum on these fronts, most notably to WHO, whose Commission on Macroeconomics and Health took the lead in studying and recommending health system and reform measures to meet the UN’s Millennium Development Goals. The bank has also lost a great deal of legitimacy because of its strong and unpopular stance on health system privatisation. The bank’s work has failed to distinguish between the most equitable and efficient public and private functions in the health sector, leaving it vulnerable to criticism and attack. By contrast, the commission report and other studies recognised the important role of public-sector financing in partnership with private service delivery in meeting essential health needs in developing countries. Wolfowitz will be wise to study research and practice in this area, as it provides him a unique opportunity to reclaim the bank’s vital role in an increasingly important global health arena. Democracy, governance, and health Will a democracy and governance agenda improve health? Although studies on the relation between political institutions and health are limited, researchers believe democracy can have a positive impact on health. One theory relating democracy to health argues that democratic principles— such as regular elections, universal suffrage, representation, multiparty 1840
competition, and civil liberties—generally produce competition for popular support among elites who are vying to maintain or win elected office. Authoritarian regimes, by contrast, suppress political competition and tend to have an interest in preventing human development because improved health, education, and economic security mobilises citizens to demand greater participation and more resources. Competition for votes increases political participation and can lead to universal health insurance and access programmes such as the British National Health Service or the Canadian Health Insurance system. Thus, democracy itself could have a positive influence on health. Within the health sector, principles of good governance can also improve health. Anti-corruption measures, for example, can highlight health sector dysfunction. Financial accountability can reveal mismanagement in healthsector investments. Reforming the fiscal, political, and administrative framework for subnational governments can improve health-sector performance and civic engagement and effectiveness in these local units. Finally, reforming tax policy and administration are critical for an effective health sector. Tax policy and administration pay for and regulate health insurance and health services. Without them, the health sector is unsustainable. Global governance for health The bank must better define its role in health at both the global and country levels during the next 5 years. As a lender to national governments, the bank has a unique role in helping countries with practical health-sector development and disease-specific programmes. At the same time, however, the bank, as the largest financier of health, nutrition, and population in developing countries, must stay involved in the global health agenda, which plays out in an increasingly pluralistic environment with multiple players assuming various roles. Wolfowitz,
with the help of his close health advisors, will need to identify the path the bank must take in a changing global environment. A few other issues relevant to the bank’s work in the years ahead merit attention. First, will the bank shift away from loans and credits and towards grants in aid? If it does, the health sector will probably benefit—like debt relief, grants are good for the health sector, enabling direct investments in basic infrastructure, services, and treatment. Second, what balance will the bank strike between its roles as technical and policy advisor and as lender? Under Wolfowitz, the balance is likely to tip toward the former, with intense scrutiny of all potential loans. This kind of emphasis may also benefit the health sector, especially if the bank can find the optimum balance between public and private sector roles and investments.
Conclusion On June 1, 2005, a distinctly different leader will take over the World Bank from James Wolfensohn. Wolfowitz is likely to take the bank in a new direction, although, like Robert McNamara decades before, Wolfowitz could surprise the development community and bring health and human development to the fore. One thing is clear: if Wolfowitz is to succeed at the bank, he must be able to change his image and the perceptions in both developing and creditor country governments. He must erase fears that he plans to use the bank to implement US foreign policy goals. Outgoing President Jim Wolfensohn has warned against politicising the bank and its mission. The world will be watching Wolfowitz’s every move.
Jennifer Prah Ruger JPR worked previously at the World Bank as a health economist in the health, nutrition, and population sector and as speechwriter to outgoing bank president James D Wolfensohn. She has also served on the health and development satellite of former WHO Director-General Gro Harlem Brundtland’s transition team.
www.thelancet.com Vol 365 May 28, 2005
What will the new World Bank head do for global health? The appointment of Paul Wolfowitz to take over as World Bank chief prompted a barrage of criticism from activists concerned about his role in the Iraq war. But are these protests justified? Health economist and former World Bank speechwriter Jennifer Prah Ruger reviews the evidence.
Who is Paul Wolfowitz? Wolfowitz has been a key architect of US military operations in Iraq and Afghanistan—actions he justifies in the name of expanding democracy. Regarded as a neoconservative “hawk”, Wolfowitz has sparked broad criticism for his part in the plan to overthrow Saddam Hussein and establish an Iraqi democracy, a plan whose flaws have since become clear. Furthermore, the astronomical costs of the war and reconstruction have defied his prediction that the operations would be “self-financing”. Opponents argue that he is a unilateralist, pursuing American geopolictical interests without regard for human suffering or international conventions. Stiglitz voiced fears in an interview with UK Channel 4 News that the bank will “become an explicit instrument of US foreign policy”. If these concerns prove justified, the institution could face real turmoil. The World Bank is a uniquely multilateral institution, crewww.thelancet.com Vol 365 May 28, 2005
ated in an era of post-World War II cooperation with a core mission of reducing poverty worldwide. But there is another side to Wolfowitz. Earlier in his career, while working as US Under Secretary of Defense for Policy during the George H W Bush administration, he won praise for developing strategic plans and obtaining financial support for the first Gulf War. His work as US Assistant Secretary of State for East Asian and Pacific Affairs also earned admiration for strengthening US relations with China, Japan, and Korea, and furthering the transition to democracy in the Philippines and Korea. But this past experience, focused on Asia, the middle east, and on US geopolictical interests, raises questions too: bank staff and clients will vigorously oppose reorienting the bank towards US global security concerns as an overarching development agenda. The burden of proof will be on Wolfowitz to prove the contrary. Suspicion and concern currently run very deep. Wolfowitz is known for his scholarly views on national security strategy and foreign policy, and he has written widely on these issues advocating, unsurprisingly, American global leadership and interest. He has amassed considerable expertise in military strategy. But, although he is former dean and professor of international relations at Johns Hopkins School of Advanced International Studies, he lacks specific expertise in development theory, practice, and dialogue. Although these deficits will not necessarily undercut his effectiveness, Wolfowitz’s silence on his vision of development and foreign aid is a concern to many. Jeffrey Sachs, development economist and director of the Earth Institute
at Columbia University told BBC News that the World Bank needs “an individual with a demonstrated track record and relevant professional expertise”. But, he added, “Mr Wolfowitz does not fit those criteria at all. He is a man without international development experience, without professional qualifications.” Personal associates of Wolfowitz describe him as an open, well-liked, and intelligent man who is willing to listen. He has won respect as an excellent manager, so much so that during his tenure at the US Embassy in Jakarta the US Inspector General cited the embassy as one of the best-managed diplomatic missions worldwide. These qualities will serve him well in a
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
On June 1, 2005, Paul D Wolfowitz will take over from James D Wolfensohn as president of the World Bank. Wolfowitz, a former US Deputy Secretary of Defense, US Ambassador to Indonesia, and US Assistant Secretary of State, comes to the job under a cloud of controversy over his previous work and ideological convictions. Former World Bank Chief Economist Joseph Stiglitz predicted that the appointment could “bring street protests and violence across the developing world.” The BBC reported the British-based World Development Movement describing his nomination as “terrifying”. So can Wolfowitz lead the bank effectively? And what will his presidency mean for health and human development?
Paul Wolfowitz takes over the World Bank helm on June 1, 2005
1837
World Report
10 000-person organisation with a US$20 billion annual lending portfolio. These attributes are also believed to be key reasons why Bush selected Wolfowitz as Wolfensohn’s successor. During Wolfensohn’s tenure, the Bush administration was critical of his eclectic management style. Observers expect Wolfowitz, by contrast, to focus on setting up systems to monitor aid effectiveness on the ground and to streamline operations. Wolfowitz’s ties with the Bush administration may also be a financial boon to the World Bank: these links could enable him to secure increased US foreign aid and trade reform, goals Wolfensohn was unable to achieve through his strained relations with the White House.
Wolfowitz’s key themes Analysis of Wolfowitz’s writing, speeches, public statements, congressional testimony, and service on public commissions reveals a core set of principles that are likely to shape his vision of a 21st century World Bank (panel). Democracy and good governance Wolfowitz wants to spread democracy and its institutions worldwide. The bank, by contrast, has claimed an “apolitical” stance and has not publicly embraced democratic development as part of its core mission. In recent years, however—especially since its major restructuring in 1997—governance issues have become a major focus. Indeed, since 1997, an entire public governance sector has been established to promote “building efficient and accountable public sector institutions”. Given the synergies between good governance and democracy, Wolfowitz is likely to expand the public-sector portfolio; investments in building efficient and accountable democratic institutions are probable as well. The bank might, for example, establish performance standards for effective parliaments or legislatures, multiparty competition, representation, and voting systems. On another tack, Wolfowitz might push a democracy-oriented agenda by 1838
imposing strong political conditions on aid. These conditions could range from public-sector effectiveness to requirements for the establishment of democratic institutions (eg, voting, legislative bodies, multiparty elections, free press, and constitutionalism). Making aid conditional on democratic reforms could, however, be a double-edged sword. In addition to the coercive nature of such demands, they could also result in lower lending and inhibit overall development. To avoid the perception of hypocrisy, a democracy-driven agenda would necessarily entail a third component: initiatives to democratise the World Bank itself. Critics have long protested against the bank’s governance structure for its unequal distribution of executive board votes, opaque decision-making process, and lack of board accountability to elected officials and legislative bodies in the countries the bank aims to serve. Private-sector-led reform Wolfowitz embraces the principles of private-sector-led growth in all countries, although some have criticised his support for policies that include little or no government market regulation, support, or oversight either nationally or internationally. The bank’s work in private-sector development has grown recently, including a 2005 World Development Report devoted entirely to investment climates in developing countries. It has focused on improving countries’ business environments through foreign direct investment, corporate governance, business regulations, improving small and medium enterprises, and corporate social responsibility. One would expect Wolfowitz to continue to foster these initiatives, perhaps with a focus on small and medium enterprises, a key engine of economic growth. In trade, Wolfowitz recognises the need for reform. He is likely to continue scaling up the bank’s current work, collaborating with the World Trade Organization (WTO), other mul-
tilateral agencies, and governments to reform the world trading system, and supporting country-level efforts to develop national trade policy and institutions. Regional focus The middle east, especially Iraq and Afghanistan, is predicted to be the main region of interest for Wolfowitz, and he will probably concentrate on rebuilding basic infrastructure (food, water, electricity, sewerage, education, health, and security). Pakistan, a US ally, may also win his attention due to its importance in American geopolitical terms. Although his past experience is mostly from Asia, Wolfowitz’s recent rhetoric on focusing the bank’s work in the very poorest regions of the world suggests that he might steer the bank away from many Asian economies. China and India, for instance, have experienced impressive growth rates and have already voluntarily reduced their bank borrowing significantly. Wolfowitz has declared an interest in prioritising Africa and the poorest areas within Africa. This vision would be consistent with the broader development agenda. The Commission for Africa led by UK Prime Minister Tony Blair, for instance, calls on the G8 group of industrialised nations to significantly increase aid to Africa over the next several years. A focus on Africa and the middle east would also mesh neatly with the now-famous 2000 Meltzer Report on the World Bank’s future. It is possible that Wolfowitz will follow the report’s recommendations, which called for scaling down the bank and its work to focus solely on the very poorest regions, such as Africa, central Asia, and the middle east, to phase out entirely from middle-income countries in Asia and Latin America, and to shift from credits to grant aid. Such downsizing could reduce the bank’s portfolio by 50% or more, and could have the unintended consequence of less concessional lending for poorer countries. www.thelancet.com Vol 365 May 28, 2005
World Report
Debt relief and grants Wolfowitz has publicly endorsed debt relief for heavily indebted poor countries and advocates moving towards grant aid and investments, and away from credits, to help address HIV/AIDS and malaria, especially in Africa. However, it is unclear where the money will come from to cover the loss in revenue. The bank’s heavily-indebted poor country initiative (HIPC) has already provided some relief, but the G8 has been asked contribute up to 50% of the remaining required financing.
Health and development Debt relief and health Wolfowitz’s commitment to debt relief gives some hope for health and human development. Debt relief for poor countries is typically a win-win situation for the health sector, as the savings in debt service payments can go instead toward basic health care and social services. In many struggling countries, debt service payments exceed health-sector investments. Where debt has been written off—in Benin, Senegal, and Mozambique, for example—health spending has increased. If Wolfowitz can persuade the G8 to contribute their share to HIPC, the initiative could well benefit health and other social sectors in debtor countries. Infrastructure and health At the same time that HIPC and grant aid might promise increased healthsector investments, a general trend during the past year or so has shifted bank investments toward infrastructure, at the expense of human development. Wolfowitz is likely to maintain this trend, resulting in greater reductions in health and social sector spending in the overall portfolio. Health and other social services currently comprise 15%, while infrastructure comprises 40% or more. HIV/AIDS and malaria Wolfowitz has announced his intention to make HIV/AIDS a priority, especially in Africa, and he also plans to focus on www.thelancet.com Vol 365 May 28, 2005
malaria. He has not indicated whether prevention or basic care and treatment of HIV/AIDS will take precedence. The bank has significantly sharpened its HIV/AIDS focus over the past several years, resulting in its being one of the world’s largest supporters in the fight against HIV/AIDS. It has committed more than $1·6 billion during the past several years and has created a self-contained bank unit focused solely on this problem. Wolfowitz is likely to maintain or expand these interests. Nutrition and public health Despite the acknowledged importance of, and gains from, addressing malnutrition, under-nutrition, micronutrient deficiencies, wasting, and stunting, Wolfowitz has expressed no interest in nutritional concerns in the past or during his transition to bank president. It does not appear to be a subject to which he has given much thought, nor does it seem to be a priority. Similarly, he has expressed little interest in broader public-health measures to address critical issues such as onchoceriasis (river blindness, one of the bank’s
early and premier health programmes), maternal and child health, tuberculosis, tobacco, mental health, school health, or road safety—all programmes the bank has been involved in for some time. It remains to be seen, however, if Wolfowitz will take after his predecessor, Robert McNamara, who, upon arriving at the bank surprised observers with the depth of his passion for nutrition, public health, and population and reproductive health issues. Population and reproductive health Given the Bush administration’s stance on family planning and reproductive health issues, at best Wolfowitz is likely to leave this unfinished health agenda alone, and at worst attempt to reduce resources devoted to it. Population and reproductive health is one of the bank’s oldest health portfolios; it began work in this area some three decades ago, under McNamara. To date it has loaned over $3 billion to such projects. Unwanted fertility and high maternal mortality and morbidity persist, and the lack of sexual and reproductive health care accounts for around 20% of the
Panel: Further reading Dahl RA. Polyarchy: participation and opposition. New Haven: Yale University Press, 1971. Lenski G. Power and privilege: a theory of social stratification. New York: McGraw Hill, 1966. Lipset SM. Some social requisites of democracy: economic development and political legitimacy. Am Pol Sci Rev 1959; 53: 69–105. Muller E. Economic determinants of democracy. Am Sociology Rev 1995; 53: 50–68. Ruger JP. Changing role of the World Bank in global health. Am J Public Health 2005; 95: 60–70. Ruger JP. Democracy and health. Q J Med 2005; 98: 299–304. Ruger JP. Health and social justice. Lancet 2004; 364: 1075–80. Ruger JP, Yach D. Global functions at the World Health Organization. BMJ 2005; 330: 1099–100. Ruger JP, Jamison D, Bloom D. Health and the economy. In: Merson M, Black R, Mills A, eds. International public health: diseases, programs, systems, and policies. Gaithersburg: Aspen Publishers, 2001: 617–66. Sikorski R. Paul Wolfowitz. Prospect, Dec 2004. Wolfowitz P. Clinton’s first year. Foreign Affairs, 1994; 73: 28–43. Wolfowitz P. Bridging centuries: fin de siecle all over again. National Interest 1997; 47: 3–8. Wolfowitz P. American power—for what? Commentary 2000; 109: 46–47. Wolfowitz P. The first draft of freedom. New York Times, Sept 16, 2004.
1839
World Report
global burden of disease and death. Still, Wolfowitz is unlikely to address these issues, especially if evidencedbased family planning contradicts Bush administration policy. Health system development The bank has been working to develop health systems for some time now, focusing especially on issues such as health financing, insurance, services and delivery, human resources for health, pharmaceuticals, hospital and clinic management, and public–private health-sector reform. In the past 5 years or so, however, the bank has lost momentum on these fronts, most notably to WHO, whose Commission on Macroeconomics and Health took the lead in studying and recommending health system and reform measures to meet the UN’s Millennium Development Goals. The bank has also lost a great deal of legitimacy because of its strong and unpopular stance on health system privatisation. The bank’s work has failed to distinguish between the most equitable and efficient public and private functions in the health sector, leaving it vulnerable to criticism and attack. By contrast, the commission report and other studies recognised the important role of public-sector financing in partnership with private service delivery in meeting essential health needs in developing countries. Wolfowitz will be wise to study research and practice in this area, as it provides him a unique opportunity to reclaim the bank’s vital role in an increasingly important global health arena. Democracy, governance, and health Will a democracy and governance agenda improve health? Although studies on the relation between political institutions and health are limited, researchers believe democracy can have a positive impact on health. One theory relating democracy to health argues that democratic principles— such as regular elections, universal suffrage, representation, multiparty 1840
competition, and civil liberties—generally produce competition for popular support among elites who are vying to maintain or win elected office. Authoritarian regimes, by contrast, suppress political competition and tend to have an interest in preventing human development because improved health, education, and economic security mobilises citizens to demand greater participation and more resources. Competition for votes increases political participation and can lead to universal health insurance and access programmes such as the British National Health Service or the Canadian Health Insurance system. Thus, democracy itself could have a positive influence on health. Within the health sector, principles of good governance can also improve health. Anti-corruption measures, for example, can highlight health sector dysfunction. Financial accountability can reveal mismanagement in healthsector investments. Reforming the fiscal, political, and administrative framework for subnational governments can improve health-sector performance and civic engagement and effectiveness in these local units. Finally, reforming tax policy and administration are critical for an effective health sector. Tax policy and administration pay for and regulate health insurance and health services. Without them, the health sector is unsustainable. Global governance for health The bank must better define its role in health at both the global and country levels during the next 5 years. As a lender to national governments, the bank has a unique role in helping countries with practical health-sector development and disease-specific programmes. At the same time, however, the bank, as the largest financier of health, nutrition, and population in developing countries, must stay involved in the global health agenda, which plays out in an increasingly pluralistic environment with multiple players assuming various roles. Wolfowitz,
with the help of his close health advisors, will need to identify the path the bank must take in a changing global environment. A few other issues relevant to the bank’s work in the years ahead merit attention. First, will the bank shift away from loans and credits and towards grants in aid? If it does, the health sector will probably benefit—like debt relief, grants are good for the health sector, enabling direct investments in basic infrastructure, services, and treatment. Second, what balance will the bank strike between its roles as technical and policy advisor and as lender? Under Wolfowitz, the balance is likely to tip toward the former, with intense scrutiny of all potential loans. This kind of emphasis may also benefit the health sector, especially if the bank can find the optimum balance between public and private sector roles and investments.
Conclusion On June 1, 2005, a distinctly different leader will take over the World Bank from James Wolfensohn. Wolfowitz is likely to take the bank in a new direction, although, like Robert McNamara decades before, Wolfowitz could surprise the development community and bring health and human development to the fore. One thing is clear: if Wolfowitz is to succeed at the bank, he must be able to change his image and the perceptions in both developing and creditor country governments. He must erase fears that he plans to use the bank to implement US foreign policy goals. Outgoing President Jim Wolfensohn has warned against politicising the bank and its mission. The world will be watching Wolfowitz’s every move.
Jennifer Prah Ruger JPR worked previously at the World Bank as a health economist in the health, nutrition, and population sector and as speechwriter to outgoing bank president James D Wolfensohn. She has also served on the health and development satellite of former WHO Director-General Gro Harlem Brundtland’s transition team.
www.thelancet.com Vol 365 May 28, 2005