Robert Zoellick's Health Challenge at the World Bank

Roger Bate | 05 Jun 2007
During his short tenure as World Bank President, Paul Wolfowitz initiated an anti-corruption drive and a full health review. The former was both attacked and undermined by his own staff and European nations, and Robert Zoellick, the former U.S. Trade Representative who will succeed Wolfowitz, must decide whether to persist with this anti-corruption agenda or work to appease the militant staff left in his predecessor's wake. He cannot do both.

On the surface, there is more hope with the health sector. The Bank has a new health strategy[1] for the first time in a decade. The original draft I reviewed a year ago was considerably better than the revised version released on May 1, 2007. This version is weaker on several fronts, thanks primarily to dissenting opinions from health activists who balked at the proposed healthcare privatization set out in the new policy. But the real risk is that even the proposals in this watered-down version will not be enacted.

While lending to poor countries may have been its most important function historically, the Bank's most valuable role today is providing advice to ministries of developing countries. Quite often these government bureaucracies are staffed with incompetent personnel, appointed more for who they know rather than for what they know. As a result, good and constructive advice on program design, financing, and infrastructure development is often scarce.

Development economists at the Bank's Health, Nutrition, and Population (HNP) department are well-equipped to provide this expertise, but in the past decade HNP has been overrun with medical specialists who opt to advise on specific health programs in which they have knowledge, such as those to combat tuberculosis, HIV, and malaria.

Specific disease programs are worth undertaking. As a board member of a malaria charity, I would be hypocritical to argue otherwise. But it is not the Bank's job to run them.

Previous Bank President Jim Wolfensohn started on HIV, and Paul Wolfowitz committed to combating malaria and TB. Wolfensohn massively increased staffing to reflect this commitment; Wolfowitz did to a lesser degree as well.  But the Bank does not have institutional skill in disease programs or a mandate to undertake them, whereas the World Health Organization (WHO) does. The Bank's work on disease led to numerous breaches of WHO guidelines and was of dubious benefit, as my co-authored Lancet article[2] on its role in malaria explained. In dispensing poor disease control advice, the Bank neglected its prime role of advising on financing health systems. Without stronger health systems, 'vertical' disease control programs have insufficient 'horizontal' infrastructure and are doomed to fail.

To this end, it is pleasing that the new health strategy document concentrates on systems development, with the economists regaining control of policy. This is vital, and not just for the Bank. HNP economists should now be able to reclaim health systems development and finance from the WHO; the Global Fund to Fight AIDS, TB, and Malaria; and from the United Nations Children's Fund (UNICEF), whose real task is disease control, but who have taken an interest in system development, too. Having economists designing disease programs is bad enough, but having doctors making funding decisions is even worse.

Turf wars always occur in international organizations, but they are particularly bad in health, where every organization wants to get involved in everything and few actually achieve much. WHO, UNICEF, and the Global Fund, which was designed to procure drugs for poor countries, have been getting into the health systems business over the past few years and, like the Bank, have let their mission creep beyond their competence.

To support the new strategy Mr. Zoellick will have to resist pressure from socialist-leaning board members who oppose many of its key features: expanding private sector provision to increase pressure on public providers; developing competitive private insurance markets in poor and, especially, mid-income countries; and encouraging output-based provider financing and production-based provider financing, by which healthcare providers are financed through expressed demand as distinct from assessed needs. Most of all, these members oppose the proposed expanded role of the International Financial Corporation arm of the Bank, which is explicitly responsible for providing private solutions.

Zoellick's best bet moving forward will be to simplify the Bank's involvement in global health policy. He should get internal approval from other agencies (especially WHO) to support publicly his move to cut his own disease control staff, while at the same time hiring new personnel who are trained in health financing and systems development. These actions will convey the message that he is a determined leader who is cognizant of the Bank's skill set. Furthermore, his actions will remind the world that the Bank still has a useful role to play, even as it reinvents itself from a conventional loan-granting Bank to a technical advisory body.

I expect that Zoellick will fail in this pursuit. The medically qualified staff at the Bank obviously don't want to be fired, and will rally ample support from specific disease lobbyists (HIV activists are particularly powerful and blinkered). The broader health community will oppose his move because it will be portrayed by influential filters in ministries of health and newspapers as a move towards the privatization of health (although this wouldn't be the goal of the cuts). But also, the health community has benefited financially (through Gates, Buffett, G8, UN etc.) from the status quo, where apparent effort is more important than results and it is difficult to pinpoint blame for the myriad failures to combat disease.

If the Bank actually did its job and left other groups to do their jobs, it would be easier to identify who is to blame when things go wrong. But the international health community likes the current obfuscation of responsibility and so I expect they will not support the Bank's move to streamline its responsibilities. Without that support, European board members will throw their weight around to block staffing changes. And with the Wolfowitz fiasco still fresh in the memory, Zoellick may shy from infighting. The result will be an ineffectual Bank health policy. 

I hope I'm wrong, because the new health policy strategy has many merits and it should be given every opportunity to succeed.