 Hi everyone and welcome to a new issue of the People's Health Dispatch. So as most will know or have heard from previous issues of the People's Health Dispatch, of course we know that the World Health Organization is the international agency that we all look at when we want to know about people's health, about health systems and about global health. But then again recently we have noticed an increase in the influence of the so-called international financial institutions. So the World Bank for example and the International Monetary Fund which are not agencies with a health mandate but they do tend to push out the WHO out of the picture. So and one of those institutions as I said is the World Bank. Today we're going to do an interview to learn more about how the World Bank influences health in the global south and also in other parts of the world. And we are joined by Natalie Rhodes who's a PhD researcher at Leeds University and Remko van der Pas who's a researcher at the Center for Planetary Health and they are both affiliated with PHM. So welcome Natalie and welcome Remko. Okay so let's maybe start with hearing your thoughts on the formal mandate of the World Bank you know when it comes to health. Does it have any formal mandate to influence health policies and does this differ from reality in any way? Let me just kick off. The World Bank does not have the mandate directly to work in health but its mandate is to finance development and to facilitate investment and international investments too that helps a stabilizing economic policy outcomes of countries contributing to economic growth and by that let's say the loans and the finance that they provide are indirectly shape let's say health projects across the world but it's technically they can governments have this have a space to reject that they don't have to do that it's not the formal mandate for international health is with the WHO so it's an indirect one I would say and then I if Natalie would like to add on that. Yeah I would agree and I'd also add how World Bank has changed since its inception and how it's got increasingly involved in health and literally more directly but I'd also add that now quite directly in terms of it's now one of the biggest actors particularly if you look at the global stage across global health it's one of the biggest funders of health programs around the world it also is hugely influential in shaping agendas not just through the actual money and the type of programs that they fund but you know if you go to kind of events you often see the World Bank this person speaking they're seen as quite prestigious and very influential in what they contribute and the influence that they have on agendas and then also one way they have influences perhaps this is a bit more indirect is like they create a lot of evidentiary knowledge as well both on like health outcomes and status of different health systems and also the type of evidence they create for what interventions might work so there's lots of different paths that shapes health yeah and so very very influential perhaps you know one of the most powerful actors in health now yes and then of course you know during the pandemic we also saw international financial institutions joining the health discussion in new ways and we saw reactions in therefore by countries by members to actually see and how the international financial institutions can be used and how they can actually support providing more ample health care and one of those initiatives was of course the trips waiver initiative at the World Trade Organization but if we look at the World Bank so the discussion there was somewhat different and I believe that recently there was a new pandemic preparedness and response fund which was launched by the World Bank so I was wondering Natalie if maybe you could tell us a bit more about this and why it's important why should be we be looking at this more closely yes so this fund was created in response it's basically this number was going around estimating that we need an extra 10.5 billion dollars per year to be spent on pandemic preparedness and response to more effectively strengthen global architecture to respond better to future pandemics and so the fund was kind of created out of this need and the aim was like catalyse this funding it's been a very quick process of when it was announced and now next month it's expected it's going to be opening its first proposals so it follows a model that's seen across World Bank they've got many different types of these funds and but if we look at this fund specifically some of the kind of key things that are coming out of it and perhaps concerns is one it's not being particularly successful at raising this 10.5 billion it's not they I think and we just have a maybe two or three billion raised from funders so how effective is it going to be in that area also in the scope if you look at the type of activities that I mentioned on its website that he wants to focus on it's much more on response rather than actual preparedness so it's not necessarily about strengthening health systems but it's better how can we better be able to report and surveillance of health outbreaks so that's a really important area that's been potentially going to be missed there and also a key thing to look at that is coming out as around a governance structure the fund so the design process there was some potentially superficial engagement with outside of funders about the design process and it's now if you compare it to other funds it's you could say it's more inclusive in the sense that on the decision-making body it's not just funders as there's been in other funds but you actually have so you've got nine funders on there with voting power nine kind of implementing countries or co-investors they're being called one philanthropy seat and two CSO seats but it's even with that in place if you look at other similar funds or kind of governance arrangements it's not particularly hopeful that programs that will get funded through this will actually match national or local priorities in terms of the actual gaps in health systems and that they'll actually match priorities set by governments and governance and funding mechanisms already in place so these funds can actually just create more administrative work and a greater burden on recipient countries and may not actually create sustainable changes and sort of think health systems where it's needed so that's kind of the big concern and it potentially just going to kind of be business as usual with funders you know kind of potentially having a lot of influence and calling shots about where their money wants to be spent based on their own national priorities and political political will let me so the question is what is what is new with this fund vis-a-vis other funds that they've been doing in the past well you see that this this financing facility mechanism is now rather established within the world by the World Bank so it's not only in health there was the of course there was the global financing facility for the for the modern child health programs that is known by in the health field but they do it also in relation to other domains especially related to environmental projects etc so they have so it's it's it's streamlined across different sectors and domains so they take a certain template and then impose it also for working in health and the idea because it's very focused on efficiency on result is very targeted on relative short-term outcomes but one could argue whether such a fund would actually what it does with with public capacity and at at the national level and I think that's that's a major concern that's not new for the for the World Bank so they always bring in consultancies private actors whether NGOs or others to to work with them to get their results done so there's a big question also about sustainability there of all those projects next to next to the whole the whole the whole financial question so who pays for it in the end this whether these are grants or loans how is how does this ties into that restructuring and in that regard it's it's old wine quite smartly packaged in in new bottles and what is more worrying as so for what reason with the new pandemic fund whose risk is being covered here I mean the global fund it's about hv8 you could argue it's really targeted for health health outcomes access to treatment in in lower middle income countries but this is about protection against for pandemic risk that might affect the global north so to say and that I find also more that's really different from the global funds before I would say this is where the whole one health logic also comes in but leave it with here and Natalie you were saying you know that it's only one of those things that the World Bank is trying to push at global level for when it comes to health and then if we look at some of the other things that it's advocating for some of the policies and some of the things that it's trying to you know support directly or indirectly we also find the concept of universal health coverage but also of public private partnerships the ppp's so could we maybe spend a couple of minutes talking about that you know how what is the world world banks influence on the implementation of these kind of programs and what does this actually lead when we talk about access to health and people's right to help so the the public private partnership model is actively and in a way actually mandated by World Bank in their funds and you see in the pandemic preparedness and response there's these kind of implementing entities which if states or organizations want to apply for funding they have to collaborate with one of these organizations so these a list has come out for this one I think last week and this includes different banks so for example Asian Development Bank also includes Gaby the Global Fund but it also does include the World Health Organization and CEPI but through doing this and through kind of actively encouraging requiring these involvement of private actors it's directly feeding and driving this perception that we need private market solutions and they are key in playing integral role in the provision of health and that states and public approaches can't work alone um which just ties in with the the whole neoliberal agenda how and how that's impacting our health systems and increasing privatization of health um and this is obviously directly in contest with the aim to provide health care particularly primary health care which is very important that's accessible at three a point of care for all when you've got private actors who obviously just have you know different priorities and different ways of working um and how in the long term what does this mean for health systems and particularly around state provision of health and how the work of World Bank is you know actively kind of accelerating this anything to add then Ko? Yeah you refer to universal health coverage and how the World Bank has tied into that universal health coverage is built on the western model of um social health insurance where there is um uh where it which is based more and more on public private uh collaborations where there is uh what what is its strategic um how they call it strategic contracting of uh of uh of providers where there are packages where it's often the negotiation with efficiency uh and um and and and ensuring that uh the certain packages provided but often then also um a kind of a cherry picking approach focused on on treatment rather than on on prevention and at that model um um so the WHO's report on the health financing for health systems comes from 2010 and since then you have seen that the World Bank uh and they do this they also have they have this joint monitoring report between between them that comes out every nine they're collaborating in the UHC 2030 partnership and they talk about so it's all about the argument that there should be more domestic investment in health services without acknowledging that the international financial system hollows out any potential for real domestic investment uh in in in stronger health systems so then uh international uh financial investment can come in in the form of private money that finances also health services and and uh uh hospitals etc and that are tied into the UHC concept and then it's up to the states to regulate it and to ensure that that uh that that fits within uh that public health needs and that packages are being are being covered there um but of course with many states having very limited possibility to actually regulate that and with very strong lobbies both domestically and internationally to focus on certain uh service provision then you see that uh that the the actual services get skewed into a certain into a certain uh direction which often focus more on the provision for services for the middle class and then basic services get get hollowed out and the way the way the World Bank has always played with it uh and and not only the World Bank but a lot of development organization and NGOs as well is this concept of performance-based financing as an incentive to improve health services pbf may work in a very restricted setting on certain conditions but there's a whole it's yeah it leads to uh it's it's a perverse incentive to do certain to certain things but especially the more complex things required to uh to comprehensively deal with problems so that this is more also the social interlinkages that then always it falls out so that's it's so that's how they have engaged in in universal health coverage it's now interesting to see what happens after the pandemic because a lot of countries they are quite on their on in relation to you at sea they they have stagnated their their coverage goals etc and so I find it's also interesting that that whole UHC focus from the World Bank has also left a little bit now it's it's away from from their whole engagement more into into a health security and pandemic preparedness okay and then you know this is what's happening on the global level and what you're seeing when you look at the policy level uh but if we look at how countries are actually experiencing and going through the the World Bank programs are there any particular examples that come to mind you know when we talk about countries whose health systems have been hollowed out because of World Bank policies does any place in particular come to mind and what happened there you know just as an illustration of what what the World Bank actually means for people in real life I'm just I I try to do this based on on on the samples of international work I've been engaged in over the over the years see this is quite it's quite difficult because they don't directly hollow out projects it's just that they don't do certain things that's the I'm so in in true work via the Institute of Tropical Medicine in collaboration with Guinean partners after Ebola we've been working on health system strengthening and health workforce development and then you see that the World Bank come in in with projects to uh where they finance maternal and child healthcare um and also support for a while the the provision of maternal health services paying midwives to uh uh to do their work and doing vaccination etc and surveillance especially post Ebola with with the reforms um and they get also funny at money I think via the global financing facility and before the the Muscoca fund on uh that was initiated by the French G8 initiative on uh on on on getting maternal and child health goals out but once again it's quite limited then to one this to one region in Guine with a certain number of healthcare services with a certain number of of service provision and even though they talk about a broader approach and tying it into national priorities you see at the end that it's quite limited to uh to this to these specific aims so at the end of the at the end of the project I mean it's not that those midwives then stay in in they they stay in job or it's not that that those goals can be sustained but they have reached their their goals and then when they leave often also because of the the service they contract in it's up to the government to take that over and that's not so expected that this is kind of a co-investor logic you also see in the in the in the new pandemic fund now and if that if that government does not have the the fiscal space or the finance to do that you see that it just crumbles afterwards so the World Bank would then release its its goals etc but if you look a little bit later on the whole sustainability is quite is quite limited so that's one example I had in I had in mind but thanks for sharing that yes it uh it really makes it concrete um Natalie do you want to add yeah more yeah I don't have any exact country examples to bring up but just kind of more of uh highlighting a certain dynamic that will kind of lead to these what Remco just described so for example if in a fund maybe not necessarily with a new fund but particularly of previous funds if you have a decision-making body is made entirely particularly of funders or even if not and you do have kind of implementing countries also with decision-making power if a decision is made that this is we're going to make fund a proposal that is for example addressing maternal health um or and you know and then you have a particular program and if then that's okay this is a program that's going to get delivered um kind of what position and kind of government or ministry of health or local like expert stakeholders have that decision's already been made so do they it's kind of a dilemma do they say no we we don't want a program like that in that area that's not what is necessary it's more pertinent to do XYZ based off like the strategy and needs that we've identified and if they say no then they don't get any funding from that particular fund so it's this dilemma of actually what do you do when that happens and it's kind of present as dilemma that states can face and then they okay say yes and then as romko described um it's often not particularly sustainable and can just create an extra burden for countries and for governments where most of their people working on it and most of their resources is actually spent on reporting um requirements which can be mandated by funders because they won't have oversight and accountability because they also might have domestic pressures on how they're spending like aid for example so um yeah so that wasn't a particular example but just trying to imagine what this decision-making process can actually the dilemmas it can throw up thanks thanks uh thanks both for uh for clarifying that and then finally um maybe we could we could just chat about you know uh if you see any um anyways that the World Bank would actually do a better job at strengthening health systems you know can it play this role or it has to be erased completely but this is this is a the question is what is to be expected from the World Bank uh on the on the long term I think we need to be very humble there uh also geopolitically what it uh if it's really can be transformative and do things that would promote equity and social justice etc uh it's been born out of the Bretton Woods Agreement and the institutions and the and the notion to further economic development and the whole growthism that it that it supports and and by by doing that it need to it need to disperse finance and it needs to mobilize also uh capital to through certain services whether it's public or private capital it's about expanding the cake and um the question is whether they are willing to do that on on on on on on on on social protection for incentives on on essential primary healthcare or that they just follow the incentives and that they facilitate that they create demands so to say me because that's that's the idea about economic development is that you create uh artificial demand that might not uh might not necessarily exist I think a little bit about I don't know um the whole notion about rota vaccination I find very interesting we're also the Gates Foundation etc comes in uh is rota vaccination important yes maybe but at the same time nutrition and essential uh uh what wash provisions etc if one would have that then you would need to have much less uh a request for rota vaccines etc and children would would be uh enabled would have the uh would be uh well nourished enough and with there with a relative strong immune system to go through a rota um virus infection for instance I it's not to say that a vaccine should not have a role there but then it's really up to the countries to decide whether a vaccination is part of their essential service provision and the World Bank could there then follow much more than national priorities and the national strategies that are being designed but that at the at the moment it's very difficult for countries to to to to claim their autonomy because of the depths and because of the international financial regime they're locked in into a certain certain straitjacket so to give it to get to provide flexibility and to respect autonomy something that they could do but giving how it historically has been built up I would think we should be very humble to expect that that actually happens probably the thing that I've been thinking about the most is as I've already spoken about quite a bit around the governance um and for me the question nothing that I've always been thinking about recently is if you look at you know the the stated go take at a face value what the World Bank is wanting to do in terms of reducing poverty improving health outcomes strengthening health systems um and you know it's not just in this call that we're talking about the need for more sustainable initiatives and more holistic health system strengthening so if that's the case then it's key that initiatives and programs that have been funded actually match up with what is actually needed and the priorities set by that country um and the question that I just keep on thinking about that I'd like like to pose rather than giving an answer I guess is then if we look at these governance structures why do we have equal waiting to donors as we do to kind of implementing or recipient countries and to a bit more grapple with this power asymmetry this relationship that exists between funders and recipients um is it actually helpful to have donors with so much power like why are they even there what are they adding and is this potentially undermining the actual success of these programs in interventions not that I think this will change but I feel like that's kind of the thing that I'm stuck at and I've not read or heard any real strong justification on why they need to be so heavily involved beyond giving them money no but this is that that's a very fundamental debate about so what what can we expect from official development assistance channeled through the World Bank but also more bilateral and other channels and whether it can be really transformative for for countries to to deal with with with both ecological and social crisis we're we're in maybe yes but then it should really be linked also to the the economic conditions and financial conditions that enables countries to develop their economies in a way that that fits their their needs this is the whole idea about a new international economic order that was already posed in the in the 70s and that really has to do with countries being flexible and choosing their their trade relations with other countries including protection of their own industries etc having the flexibility also in relation to creating debt or not and how to how to feel in fiscal space to raise taxes now if if countries would have that space then there might be actually space also for development finance to to support that but the the the history from the last 40 50 years tells us that that's very it's only very limited being being done so so the development finance will only work if we give attention to that to that economic order and I think that Ron might have explained that about that as well in the articles and in the introduction of this of this series and I always find in discussions with the World Bank and with when it's when it's focused on health systems this discussion is dealing it's taken out of the debate because it's too difficult and I guess this requires much more much more attention