Paul Wolfowitz is trying to improve the World Bank's performance as co-sponsor of the Roll Back Malaria campaign, a coalition of multilateral health and aid agencies, including WHO and UNICEF that aims to combat the malaria burden in Africa. Improving RBM has been a long time coming. And as a director of Africa Fighting Malaria, a health NGO, I add my hearty welcome to this news, especially since, as far as anyone can tell, worldwide malaria rates are rising. However, in delving into operations in this one program, the former Deputy Defense Secretary may discover a far larger problem -- the Bank simply does not have appropriate skills amongst its staff to undertake its core mission.
The Bank is supposed to be the premier global development agency, and a budget of nearly $20 billion should enable it to play a pivotal role in helping to maximize the resources of a country's people through education and training and to build the physical infrastructure necessary for development -- roads, schools, clinics, IT and communications, etc.
At the same time the World Health Organization's job is to reduce the crippling burden of disease which, if it doesn't take life completely, dramatically reduces a person's potential for development -- for himself, his family and his community. Indeed, for the first 30 years of its existence the World Health Organization concentrated on mass campaigns directed at the worst scourges. These "vertical" operations gathered experts in particular diseases to design programs and then to fly in to train and supervise local people to administer vaccines/sprays/drugs etc. Occasionally these experts would help set up clinics to sustain reductions they had achieved and to dispense general health care, but this was largely the job of the host government.
Some countries did better than others in setting up primary healthcare facilities or "horizontal" development. Some were slow to act but built sustainable systems as their economies developed. Nepal, for example took 14 years to start to support the vertical malaria control program with general health services. Others took funds to establish clinics and hospitals then failed to deliver long-term funding to maintain them. Eventually, the WHO lost interest in the vertical approach and programs fell into disrepair. The malaria program collapsed entirely. The problem of capacity building remains the key impediment to improving health in many poorer countries, particularly sub-Saharan Africa. The WHO staff began to suffer from low morale and the lowest wages in the UN sector as donors were reluctant to fund failure.
The Bank attempted to fill the void; but since disease control is not its mission it lacked expertise. Or so I thought until I asked for data on the professional staffing at the Bank in its Health, Nutrition and Population (HNP) division. Where I expected to find health systems specialists, mainly health economists, consistent with the mission of the Bank, it seems of the 216 professional staff only 12% have advanced degree economics training with another 25% health systems experts. The majority - about 60% - consists of medical doctors or epidemiologists. To be sure, many may have made up for lack of systems training with field experience of development work, but it is in their nature to run disease-based programs.
As one economist at the Bank put it to me, "we all know that projects are geared towards the expertise of those implementing the projects." It's not quite as simple as saying country X gets an epidemiologically-driven project since the main agent for the Bank is an epidemiologist; but more often than not the bias comes through.
It is therefore not surprising that disease projects have proliferated at the Bank; medical experts whose proper place is at the WHO or elsewhere have found purpose there. Also disease projects lend themselves more to useful metrics. Reducing a disease incidence by half is the kind of aim most major aid givers like to endorse (not that historically measurement has occurred, and where measured most targets have not been hit). As with most aid bureaucracy, promotion goes to those who process most loans, so the medics gain dominance, like cuckoos in the nest. Building hospitals or structuring sustainable funding systems for the health service doesn't have the same cachet with donors, but without material and institutional improvements in health systems many disease control programs will not be maintained. No matter, there has been a positive feedback from the aid community, and the national Government backers of the World Bank, for disease control.
HNP is the most important division for health projects (both lending and grants), and is a resource that many of the poorest countries rely on for advice. But, against the valiant attempts of some excellent health economists, mission creep subverted the Bank into another ineffectual health agency. While both WHO and the Bank did a poor job of their own missions and got side-tracked into the other's territory, neither was looking after the basics. Data collection is still minimal and unreliable, little monitoring or evaluation is undertaken and informed analysis appears to be extremely rare.
For example, the World Bank and its RBM partners made promises to halve malaria rates by 2010 in 1998. This sounded great to the donors who were fed up of non-performing loans in support of health systems, but were entirely meaningless as nobody had any baseline data.
Today, the non-performance of malaria loans and grants as well as health systems and the entire loan/aid practice at the Bank should be overhauled. Mr. Wolfowitz may be the man to do it; but his first approach for malaria control has been to establish a matrix of health indicators. This is a good instinct, but it's like that old joke about Napoleon. If you meet someone who claims to be Napoleon, you won't help him out of his delusion by discussing the relative merits of cavalry positions at the battle of Austerlitz. And it's the same with the matrix -- the Bank is starting from the wrong place, because while the indicators are well considered and comprehensive, nobody has the data to make the vast majority of them meaningful. But most of all, the Bank shouldn't be in the business of disease control at all.
One thing Wolfowitz should do is change Roll Back Malaria. As a founder of RBM -- which has been characterized by one medical journal as a "failing public health program" -- the Bank should work with WHO's new malaria head, the energetic Dr. Arata Kochi, to push changes in RBM. Perhaps then the Bank could work more on systems and get its partners, UNICEF and WHO to reform their woeful vertical program performance.
Roger Bate is a Resident Fellow of the American Enterprise Institute.