In recent years the World Bank has become “the world’s largest external funder of health.”1(p61) According to Ruger, this situation reflects the Bank’s increased sensitivity to poverty and its growing sophistication—beginning under the leadership of US Secretary of Defense turned World Bank President (1968–1981) Robert McNamara—about development theory and practice. Such an uncritical portrayal befits the World Bank’s own Web site (a major source for Ruger’s article), but Journal readers should expect more.
Missing from this officialist version are discussions of the Bank’s undemocratic governance and decisionmaking structures; the untoward human effects of longstanding World Bank pro-privatization policies and practices, most notably structural adjustment programs (which have denuded the social welfare infrastructure of developing countries in areas such as housing, education, health services, subsidies, and family transfers); and the impact on health of the Bank’s newfound focus on the health sector.
Ruger repeats the insider’s lament that lending policies were perennially subject to the exigencies of Wall Street bondholders, but she overlooks the far larger question of the nature and distribution of power at the World Bank. With votes directly related to shareholding size, World Bank decision-making is profoundly undemocratic, favoring elite interests within wealthy nations (the United States alone commands 16.4% of votes within the Bank). Any account of the Bank’s evolution ought to consider the impact of this governance structure on the roles and activities that the Bank adopts.
According to both internal and external observers, the neoliberal policies advocated by the Bank and its sister institutions beginning in the 1980s have provoked or worsened dire economic conditions—and the attendant health effects, such as increased rates of malaria, HIV/AIDS, and tuberculosis—in much of the developing world.2–5 This “role of the World Bank in global health” remains unaddressed by Ruger.
Indeed, the negative impact of structural adjustment programs on health conditions in developing countries helped spur the Bank’s focus on health in the late 1980s.6 With its double-entendre title, the Bank’s influential 1993 report Investing in Health hailed the importance of health to development while advocating the privatization of health services.7 But the Bank’s approach to health sector lending has exacerbated poor health outcomes by reducing access to health services for those unable to pay for care in newly privatized systems, which focus on cost recovery.8,9 Recent targeted programs aimed at the poorest ignore structural deficiencies in social services.
In sum, Ruger portrays the Bank’s increasing involvement in the health sector as un-problematic. Critics are dismissed as a handful of cranks rather than as serious academic and policy researchers.10–12 The author’s reliance on official Web sites and published histories rather than internal memos, archives, and interviews, to which a former speech-writer for the World Bank president might have sought access, is disappointing. In failing to convert the price tags of projects into inflation-adjusted dollars—a surprising oversight for a health economist—Ruger underestimates the impact of past World Bank activities.
Overall, this one-sided article fails to elucidate the powerful political and economic forces motivating World Bank policies and activities and does not provide the carefully researched historical analysis we have come to expect from “Public Health Then and Now” articles.