Opinion: Revitalize World Bank health spending with 3 pragmatic changes

As long-standing supporters of the World Bank, we have worked alongside the institution’s staff and projects for over three decades. Unfortunately, multilateral development banks, including the World Bank, are increasingly seen as “stuck in place”: Not doing enough to support low- and middle-income countries and in particular impoverished communities to meet the collective challenges of our times, including health and pandemic preparedness and response. Sadly, we often hear that the bank is viewed by many as the place where good ideas go to die. Whether or not this view is fair, the perception is a reality the bank’s new president, Ajay Banga, must confront. Much recent discussion has been on the role of climate funding in the bank’s portfolio but, vital as this issue is, there are more basic issues, whatever the bank funds. Although the bank has proposed reforms, these are unlikely to address the most important issues. Based on our long-standing support for and close partnership with the bank, we believe the following three fundamental changes are needed to strengthen its health programming and make it work for countries in greatest need: reshape what it funds, rework how it funds, and focus its role. 1. Reshape what the World Bank funds in its health projects The bank should fund not only investment costs, e.g., buildings, but also operating costs, e.g., salaries, maintenance, and supplies. In particular, projects must have sufficient staff to work within government programs. How many health care facilities and shiny laboratories are constructed or renovated without technical personnel being given a chance to upgrade their skills, receive fair compensation, and be integrated into adequately staffed and supplied teams? Health care infrastructure without well-trained staff and capacity leads to empty buildings and underutilization of the investments made to improve people’s lives. A more effective use of World Bank resources would be to always include time-slice funding of staff, medications, reagents, and maintenance costs. This means funding essential staff working in health, whether public health or primary care, with 90% to 100% of salaries initially paid by development loans or grants and then decreasing, depending on a country’s economic level, to 0% over five to 10 years as governments fund these essential staff. This will also require mechanisms that enable government bureaucracies to efficiently hire, promote, and terminate staff. This is a major challenge for virtually every government in the world. It is also a problem that, when addressed, will have major benefits for the provision of public services and the ability to meet the World Bank's mission of ending poverty. Bank support can enable countries to build local skills and capacities and the human infrastructure needed for sustained health protection and progress. Less hardware, more human power. Less stuff, more staff. Analogously, the bank can strategically expand its projects that result in change and restructuring of the political economy of health and health systems. These can be policies on tobacco taxation and funding of anti-tobacco activities or healthy nutrition policies, including those that reduce sodium consumption and other policy changes that maximize health. 2. Rework how the World Bank funds health projects The bank must overhaul its operating procedures. These procedures are complex, rigid, and slow. Even after funding is approved it can take months or years before funds flow to designated health projects. Intricate disbursement and procurement processes involving multiple layers of documentation, approval, and compliance checks create challenges in accessing funds. Cumbersome administrative and reporting requirements result in countries’ scarce human and administrative resources being devoted to learning the arcana of World Bank procedures rather than improving program implementation. High transaction costs imposed on countries often lead to underspending and missed opportunities to protect and improve health. Although safeguards and oversight are needed, streamlining these procedures and increasing mutual accountability in ways that deliver results and strengthen systems would reduce friction and increase efficacy. For example, there’s no valid reason why all World Bank projects should not be able, if they choose to and without further approval steps at the bank, to procure medications and equipment through Global Fund or UNICEF mechanisms. Funding through government-approved transparent fiscal intermediaries is one way to increase speed, effectiveness, and transparency. Rapid action is essential in the early phase of outbreak response, during which countries’ need for small amounts of funding to cover expenses such as fuel and communication services cannot be readily met by well-resourced standing programs. Our experience from working with more than a dozen countries developing and implementing World Bank projects is that its procedures greatly constrain countries’ ability to use bank resources in a timely and effective way. 3. Focus the World Bank’s role The bank needs to sharpen its focus on serving the current needs of lower-income countries. It’s shocking — though not the result of World Bank loans — that billions of people live in nations that spend more on debt interest than on education and health. In that context, it’s understandable that country enthusiasm for even low-interest loans has waned. In response, the bank’s upcoming replenishment round should increase the proportion of concessional and grant loans available, enabling the institution to ramp up grant provision while using its leverage to advance debt relief, thus freeing national resources. The bank has made recent attempts to act as a technical adviser. These have failed; commercial consultancies simply outcompete. Calls for the bank to play a role in reducing debt have been made for at least a quarter of a century; now it’s time to act. By having a clear focus on a grants-and-debt-relief model, the bank can clarify its role as a financial institution supporting countries and delivering sustainable impact. For the World Bank to make progress, it needs to make these three changes — efficiently funding what’s needed in ways that support countries’ financial progress and independence. In so doing, the bank can live up to — and succeed — in its mission of poverty reduction and shared prosperity. However, it will require a more practical approach that better adapts to and addresses the needs on the ground and creates a sustainable future for its investments. Simple, clear, and direct actions can make a world of difference. It’s time the World Bank embodied that approach to improving health.