At the annual meeting of the World Health Organization (WHO) in Geneva, which closed on 27 May, the World Bank president, Jim Kim, made an impassioned speech, in which he signalled fundamental changes in the World Bank’s approach to health policy and lending, significant for WHO as well as his own institution.
Jim Kim, an anthropologist and a doctor by training, has a distinguished career in global health. He was co-founder of an innovative NGO (Partners in Health) in 1987 and an influential academic at Harvard University until 2003 when he was appointed to WHO to be responsible for the 3 by 5 programme (to get 3 million people on HIV treatment by 2005).
When he became World Bank president last year there were high hopes that he would reinvigorate a global health movement suffering from something of a hangover. After more than a decade with health in a leading position on the global development agenda, and a rapid expansion of funding for health, the financial crisis and shifting global concerns had dented the confidence of the global health community. In the debate about the future development agenda after the current Millennium Development Goals (MDGs) expire in 2015, health professionals are having difficulty getting their case heard against rival claims, in particular from the advocates of sustainable development. This is in sharp contrast to the prominence of health in the MDGs.
Since joining the Bank, Kim has said little about health, and it was feared by some that the Bank’s powerful economistic culture would neutralise his demonstrated lifelong commitment to improving health. This fear now appears to be unfounded – it underestimates both Kim’s strategic skills and the time needed for any new incumbent to reshuffle top management in his own image. He recently appointed Tim Evans, a former colleague at Harvard and WHO, as his director of health, nutrition and population. He still needs to find a like-minded vice–president for human development ready to pursue his agenda.
Relations between the World Bank and WHO have always been fraught with tension. WHO is overwhelmingly dominated by public health professionals. According to WHO’s annual human resources report, they account for nearly 50% of the staff but just 0.1% of WHO’s staff are economists. By contrast, the World Bank is famously dominated by economists, although it also has numerous specialists in all areas relevant to development including health. Its annual lending of $20 billion is ten times WHO’s budget.
Periodically, WHO and the Bank have tussled over who sets the agenda for global health. WHO declared a policy of ‘health for all’ at a conference at Alma-Ata in 1978. At the same time the World Bank was developing its antithetical policies of structural adjustment which restricted social sector spending and promoted user fees in health and education. The Bank’s influential World Development Report (WDR) in 1993 set out a comprehensive agenda for health development, based on evaluating the cost-effectiveness of interventions in relation to health outcomes. When Gro Harlem Brundtland led WHO in 1998-2003 she sought to resolve this tension by importing people and ideas from the Bank, providing a unified agenda very much modelled on the ideas in the 1993 WDR – but the resulting culture clash had not entirely happy results.
Under the leadership of current Director-General Margaret Chan, WHO, supported by other advocates such as the Rockefeller Foundation, has promoted the concept of universal health coverage (UHC), meaning providing access to affordable quality healthcare for all – a distant cousin of 'health for all'. It published an influential World Health Report on the subject in 2010. In December 2012 more than 90 countries, including the USA, endorsed a UN resolution on the subject.
Given the history, including the Bank’s ambivalence about 'health for all', one question was what would be the reaction of the World Bank to the UHC initiative? Jim Kim’s speech at this year’s World Health Assembly may have settled the issue.
First, he endorsed wholeheartedly the spirit of the Alma-Ata declaration – a highly symbolic act in the context of the WHO-Bank relationship. Second, he committed the Bank to pursuing UHC. He praised Thailand’s adoption of UHC policies, noting that they had been introduced in spite of fiscal concerns raised by the Bank. Third, he unequivocally condemned user fee policies as 'unjust and unnecessary'. These are all powerful messages – directed at his own staff as much as at WHO. He concluded with a plea to reduce the fragmentation of global health funders which was ‘literally killing people’.
So Jim Kim has finally revealed his hand on the Bank’s future approach to health. But the details of practical implementation are yet to be seen, and changing long-entrenched mindsets and direction in a supertanker like the Bank is a massive challenge.
But if Kim is successful in directing the Bank’s impressive lending and analytical capacity towards helping countries to implement UHC, it raises questions about WHO’s role. WHO, with its 0.1% economists, is very thinly resourced (in both human and financial terms) to offer sustained advice to countries on implementing UHC in competition with the Bank. How could it compete? And would it really matter if it couldn’t? It might do if Kim’s vision is subverted by the vested interests in the World Bank.