THE World Bank has been, for some time,soliciting comments on itsCountry Action Strategy (CAS) for the World BankGroup in India,which is essentially a draft plan for intervention in Indiaby the World Bank in different sectors from 2005 to 2008. A careful reading ofthis paper would be useful, as the Bank’s prescriptions continue to be lapped upwith all seriousness by our bureaucrats and policy makers.
A close look at the section on healthin the CAS brings out the fundamental premises of the World Bank’s prescriptionin the Health Care sector. Talking of “Reducing the Health Risks of the Poor”the document says: “There are a range of health sector Interventions andservices that are critical ….. These include accessible and good qualityfacilities for safe delivery care for acute respiratory infections and diarrheain young children and effective health and nutrition promotion. Improving healthoutcomes for the poor will require a concerted effort to improve both theoverall health system of the states – the public and private sector combined….”
The basic approach to health care and health delivery needs thatthe World Bank proposal needs to be carefully examined. The World Bank continuesto emphasise on 1) Selected Interventions (viz. safe delivery, diarrhoealdisease control; 2) A role for the private sector. From a public healthperspective, both these approaches are deeply flawed.
A public healthapproach is premised on the provision of comprehensive health care services toall by the state. A comprehensive health care system includes all services atrelevant levels of the system, with adequate provisions for human power,resources and technical know-how. The World Bank’s attempt to reduce thisapproach to a few “magic bullets” that target a few interventions, in fact, ledto the dilution and subsequent abandonment of the “Primary Health Care” approachthat was fore grounded in Alma Ata in 1978 – especially given the World Bank’sincreasing global clout in formulation of health policies.
Again, theWorld Bank’s regular tomtomming of the role for the private sector defies allconventional logic. Developed countries (and developing countries with stronghealth systems like Cuba) have built their health infrastructure through apublic funded system. Being a “public good” private sector participation inprovisioning 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 centpublic 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 amuch reducedrole for the private sector and much greater regulation ofthis sector – which in fact is thelargest unregulated sectorof theIndian economy.
The Paper goes on to talk of some ofthe World Bank’s priority areas for intervention, where it says:“… newprojects in these states … would seek to break new ground in forgingpublic-private partnerships (including through progressive separation of publichealth financing from provision), strengthening oversight of private providers,increasing public expenditure on health, reorienting health facilities to ensureservice for the poor and reducing vulnerability through creation of healthinsurance schemes”.
What is this “public – private” partnership thatthe Bank talks about? Is it the “progressive separation of public healthfinancing from provision.” Or it refers to “Health Insurance Schemes”. These areall euphemisms for legitimisation of the abandonment of the role of health careprovider that the state should play. The key here is really public healthexpenditure. At 0.9 per cent of the GDP India’s public Health expenditure is oneof the lowest in the world. In the liberalisation years (since 1991) this hascome down from 1.3 per cent (in itself a very low figure. This is what the WorldBank and IMF led reform has meant for the Health Sector –a savage cut inpublic expenditure. Now this is sought to be legitimised through doublespeakby the World Bank – essentially saying that if the State cannot or will not paylet us explore ways in which the people can be made to pay for their healthcare.
The Paper goes on to speak of water supply and sanitation:“one-fifth of India’s national disease burden can be attributed toenvironmental causes – with the largest environmental risks to health comingfrom the lack of access to safe water and sanitation, and cooking withtraditional biomass fuels resulting in high levels of indoor air pollution… amajor Bank study to measure the health impact of improved rural water supply isunderway and will be completed in FY06..”
These are mere platitudesabout issues that are common knowledge. Do we really require the World Bank totell us that safe water supply, sanitation, education, public transport and safework environment have a major impact on health? Why the World Bank should spendmoney on inflated “dollar” salaries for self-styled experts to reinvent thewheel is beyond comprehension. The real issue that the Paper does not addresseven in passing is that in all the areas the policies of neo-liberalism that theWorld Bank champions, have led to a steady deterioration of public facilities.In the economic “reform” period, public expenditure in these areas has declinedand privatisation has been actively promoted.
The real intent of theWorld Bank’s interest in this area becomes clear when we read further:“Therehave been some important lessons from the Bank engagement. Foremost among theseis that sustainability is a major challenge – which is best addressed byinvolving communities in the design, construction and operation of schemes,including through their contribution to capital costs and their full financingof operational costs”.
A brilliant piece of reasoning indeed! Aftersaying that safe water supply and sanitation is critical for health care, theBank now prescribes privatisation of the same as theonlysolution.
The Paper expands further on the World Bank’s strategy:“During FY05-08 the Bank would be ready to support this objective by lendingto states that decide to adopt a participatory approach to Rural Water Supplyand Sanitation (RWSS) statewide”.
Note the use of the phrase “adopt aparticipatory approach to RWSS statewide”. If read along with the previousparagraph, it means that the Bank is willing to assist those states that arewilling to privatise their water and sanitation systems. “Participatory” hasbecome an euphemism for ways in which the poor can be forced to “participate” inpaying for services that the State should provide free ofcost.
INFECTIOUS DISEASE CONTROL
The Paper then turns to the issue of“Controlling Infectious Diseases”. It says:“Future (World) Bank support fordisease control is also focused on integrating programmes at the state level,reorienting public sector interventions towards priority outcomes and expandingon opportunities for public -private partnerships. For example, since mosttuberculosis cases are seen by private medical doctors or other privatepractitioners, there are important potential benefits to reorienting the statepublic health system to work more closely with the privatesector”.
The World Bank’s fetish for the private sector is trulyamazing. If, today, most patients of T B are forced to go to the private sectorthe remedy should be a strengthening of the public sector. In a weird sleight ofhand the Bank believes that this constitutes an argument for strengthening theprivate sector. Tuberculosis is universally acknowledged as a “disease ofpoverty”, a disease furthermore that accounts for more than half a milliondeaths every year. Further, the whole approach of targeting a few diseasesthrough vertical top-down programmes (no matter how important these diseasesare) is essentially flawed. The attempt should be a strengthening of the entirepublic health delivery system and a location of diseases surveillance, controland prevention measures within such a comprehensive system. The World Bank isloath to suggest that such measures are against the grain of its philosophy of areduced role for the State and a greater emphasis on marketmechanisms.
The Report turns to immunisation, stating:“In closecooperation with the World Health Organisation (WHO), the Bank supports GoI’spolio eradication campaign. … GoI and the Bank are exploring ways to revitalizeroutine immunisation programmes in some states where they have been stagnant oreven declining”.
This is gross dishonesty, for what the World Bankdoes not say is in fact the most contentious issue in this area. There isconcern today about declining achievements of routine immunisation programmesbecause the entire emphasis of the health system as regards immunisation, hasbeen on the pulse polio campaign. This is a clear example of the problems ofrunning vertical campaigns without strengthening basic health service deliverysystems.
Finally, how can a multilateral agency not talk of HIV-AIDS.The Paper devotes a large section to HIV-AIDS control. The Paper says:“Whileensuring a continued focus on prevention, the Bank Group could also provideassistance to GoI in monitoring provision of anti-retroviral therapy (ART) andmeasuring its impact as the treatment programme is rolled out. Assistance to … amanageable programme could also be provided”.
The difference in theways in which India and Brazil have approached the problem of HIV-AIDS is worthlooking at in this context. Brazil chose to make the public health systemresponsive to the problem by providing treatment for HIV-AIDS. India chose toset up a white elephant called NACO that just does surveillance studies andpontificates on the problem of HIV-AIDS (India is still to offer treatment withantiretrovirals through the public health system). There is absolutely noalternative again to the location of the treatment, control, surveillance ofHIV-AIDS in the overall public health system. The issue then is where do thefunds come from? Repeatedly we come back to the necessity of greatly enhancingthe public expenditure on health care. The World Bank funds are incidental (theystill constitute a fraction of what the GoI spends on health care). In the wholesection on Health the Paper talks of the need for greater public expenditure injust one place – in passing.
It is easy to dismiss such prescriptions,because on merit they deserve to be dismissed outright. Unfortunately, the WorldBank’s platitudes are taken as the gospel truth by people who formulate policytoday. The World Bank can always say that its CAS is just its own strategypaper, 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 anda half how, shamelessly, the priorities of our domestic policies seem to echothe thrust areas that the World Bank sets itself. This hegemonisation of thepolicy making space by the World Bank is what makes papers like this dangerous.Dangerous because they will be taken seriously by those who formulate ourpolicies.