The first annual Health Forum?a two day discussion among all stakeholders?was held by the Health Ministry almost one month ago but little or no follow up action seems to have been taken on vital proposals such as a comprehensive Patients` Charter, a constitutional amendment declaring health as a fundamental right and the implementation of a National Medicinal Drug Policy which was approved by the Cabinet in October 2004.
The Health Forum was sponsored by the World Bank, which has formulated another health sector development plan for Sri Lanka. But the Health Minister, top officials and the government need to reflect deeply on a report published in last Friday`s Daily Mirror Health Action page giving the text of a letter sent by the People`s Health Movement to the World Bank. They also need to take note of two articles that appeared in Health Action on January 26 and February 2 outlining the negative impact on public health in developing countries since the World Bank took over leadership in health policy planning in the early eighties.
Critical analysis of data was presented to show how structural adjustment programmes and poverty reduction strategy papers, had reversed the gains in public health achieved by developing countries in the previous two decades. The World Bank Health, Nutrition and Population Division has prepared a draft 10 year strategy. Civil society has strong reservations about this strategy. This is contained in the letter addressed to the World Bank by the PHM. This letter reiterates the concerns expressed in the two earlier articles in Health Action and refers to the historical legacy of damage done by structural adjustment programmes and poorly conceived health sector reform packages. The PHM concludes by calling on the Bank to re-write its health strategy. The PHM has its roots deep in the grassroots people`s movements and owes its genesis to many health networks and activists who have been concerned by the growing inequities in health over the last 25 years.
The PHM has expressed strong reservations, in particular, about the aim to expand the influence of the Bank on health systems policy and development. Other civil society organisations have expressed similar reservations. Although the draft strategy claims to have benefited from `extensive` consultation with civil society, the PHM says this has not been its experience. The WB is an important source of finance for health sector development and health programme implementation in low and middle-income countries (LMICs). It also has a significant influence on macro-economic and fiscal policies. Any health sector strategy of the Bank should therefore incorporate the explicit aim of strengthening health care systems and enabling LMICs to increase health care expenditure to adequate levels. The PHM says if it agrees with the Bank that the proliferation of global health financing mechanisms and initiatives will obstruct the development of coherent, long-term and sustainable health systems and development agendas. Donors, global public-private initiatives such as GAVI and the Global Fund, UN agencies, and the International Financial Institutions (particularly the World Bank, the IMF and the General Agreement on Trade and Services) are fragmenting health care systems and pulling Ministries of Health in different directions. The PHM welcomes the Bank`s recognition of the problems caused by uncoordinated, multiple and over-verticalised health programmes. But, together with other actors, the Bank must take further action to improve coordination amongst donors, rationalise the global health architecture and strengthen the capacity of LMIC Ministries of Health to provide effective and accountable stewardship at the country level.
The PHM says that the lack of progress--in some cases, deterioration -in reducing malnutrition, poverty and illiteracy suggests the need for the Bank to redouble its efforts in these sectors.
Although, the World Bank has an important role to play in improving health and strengthening health systems, as noted above, it does not follow that it should take a leading role in advising and influencing LMICs on health systems policy.
The World Bank`s track record in these areas has been characterised by an adherence to a school of thinking that has undermined Ministries of Health and public health principles; worsened health care inequities; magnified the inefficiencies and market-failures associated with commercialised health care; encouraged the fragmentation of health care provision; and, at best, tolerated the widespread existence of regressive and poverty-creating user fees.