Lectures

Defining Wellbeing: Tensions in the World Bank’s approach to Universal Health Coverage

Promotional materials from the global campaign to achieve Universal Health Coverage by the year 2030. Copyright UHC2030 – reproduced here under ‘fair use’ for academic purposes. 

“Health for All?” critically explores global moves towards Universal Health Coverage and its language of rights to health, equity, social justice and the public good. Highlighting emerging ethnographic and historical research by both young and established scholars, the series explores the translations and frictions surrounding aspirations for “health for all” as they move across the globe. The series is edited by Ruth Prince.


Introduction

As different countries and institutions have attempted to combat and contain the COVID-19 pandemic since its appearance in late December 2019, it has become clear that the disease will have an unfathomable and tragic impact on our populations, health systems, and economies – and that these impacts have been and will continue to be uneven in their distribution. In the wake of the 2013-2016 West African Ebola Epidemic, the World Bank set up the Pandemic Emergency Financing Facility (PEF), a catastrophe bond-based financing scheme that has been roundly critiqued as serving private sector interests over global health security (Brim and Wenham 2019) and as privileging insurance risk over “more concrete preventative measures” (Stein and Sridhar 2017:2). In the context of COVID-19, the PEF is “too late and too little, by design,” as the triggers necessary to open up the maximum $196 million funding for the 76 countries that borrow from the World Bank have been lacking (Westfall and Jonas 2020). This includes the fact that epidemiological data from countries that do not borrow from the World Bank – i.e. where the majority of deaths have occurred – do not count toward triggering the scheme. Although the PEF has failed, as of April 2nd the World Bank has promised up to $160 billion in emergency funding over the next 15 months through its traditional channels of support, citing particularly the economic effect that the pandemic will have in the global South (World Bank 2020).

The damage wrought by epidemics and pandemics on both health systems and economies in the past two decades makes it evident that universal health coverage is a crucial tool for preparing for and counterbalancing these catastrophic effects with health equity in mind. However, at the heart of the goal of universal health coverage (UHC) is a tension between its two core components: universal financial protection for those seeking health care services, and universal access to quality health care and health commodities. This tension is visible in the frictions between the World Bank Group’s mandate to promote economic wellbeing and the World Health Organization’s (WHO) mandate to promote bodily and population wellbeing – mandates that can at times align and at other times be in contradiction.[v] This tension is also visible in the Bank’s own heterogeneous approach to UHC.

In my research I have been interested in the considerable influence that the Bank – as an organization whose primary goal is to support a global free market – has on what defines success in UHC. In particular, have sought to understand the ways that the Bank has framed inequity, which it has placed at the center of UHC. To this end, I have analyzed policy documents produced by the Bank and health policy research supported by the Bank, interviewed current and former Bank employees, and examined extensive Bank archival materials. I have also studied how Senegal has shaped its own UHC policy, through policy and public debate analysis, interviews with key figures, and attending meetings of national and global level policy makers in and around Dakar. What has become clear is that this tension between economic and bodily or population wellbeing is at the heart of why anything seems to go, to quote Kutzin (2012), in building a national UHC policy.

As many have noted (Kutzin 2012; O’Connell, Rasanathan, and Chopra 2014), both the Bank and WHO have attempted to define universal health coverage in a way that makes its achievement possible in different contexts.[vi] The original call for UHC at the World Health Assembly in 2005 emphasized how to support member states’ development of robust health financing systems and “coverage” referred largely to the availability of financial protection (WHA 2005). Yet, both the Bank and WHO have directly tied the UHC movement to the 1978 Alma-Ata Declaration that established the Health for All movement, which prioritized primary health care (WHO 2010; Kim 2013). Different groups at the Bank have been engaged with the concepts at the heart of UHC since it was established as a global health agenda item in 2005, including the centrality of health systems strengthening to the Health, Nutrition and Population group’s 2007 strategy, Healthy Development, and research on more effective means of measuring financial protection within the health system at the Development Research Group (Wagstaff 2008).

After physician-anthropologist Jim Yong Kim became president of the organization in 2012, the Bank became an advocate for universal health coverage. In a 2013 speech to the World Health Assembly, Kim asserted that the Health for All movement failed because it did not “provide concrete plans or effective metrics for delivering on its admirable goals” (Kim 2013). Thus, the Bank became a key promoter of the inclusion of UHC in the Sustainable Development Goals and administrator of its progress (WHO and World Bank 2015). Although people working within the Bank share a similar discomfort with the UHC movement as they had for the Health for All movement,[i] the Bank is intimately engaged in determining the shape of UHC.

The Bank’s work in health development over many decades has helped to shift responsibility for citizen health from states to global institutions and private industry. However, the pluralistic, public-private approach of the Bank to UHC is often at odds with WHO’s approach, which advocates for a greater role of the state in producing robust national health systems. In the context of UHC, the Bank has used the rhetoric of the universal right to health to assert that promoting health is a key tool for achieving economic prosperity. As the Bank doles out its emergency funding to low- and middle-income countries to combat the COVID-19 pandemic, it is likely that the existing problems within the Bank’s approach to UHC will remain – that is: tensions between different definitions of wellbeing and the ways that UHC often becomes its lowest common denominator without careful attention to health outcomes – as we will see further below.

What is in a name?

There was nothing inevitable about the arrival of the Bank onto the global health scene. For the first thirty-five years of its existence, the Bank provided funding for health only peripherally – on reproductive health interventions and fighting Onchocerciasis (river blindness), for example – and defined health as an expenditure rather than an investment. When the Bank finally entered the scene in earnest in the 1980s – beginning its direct lending almost simultaneously with the freezing of WHO’s budget in 1982 (Brown, Cueto, and Fee 2006; Sridhar, Winters, and Strong 2017) – it put the problem of health inequity at the center of its work, promoting user charges and a pluralistic approach to health financing as a solution to that problem.[ii] However, it became clear that user charges were actually likely to exacerbate the problem of health inequity, and it looks likely that, in some contexts, different UHC policies promoted by the Bank might similarly be “wolves in sheep’s clothing” (Russell and Gilson 1997).

Part of the problem comes with the expansiveness and the connotations of the concept of universal health coverage. In an interview in July 2018 about the World Bank’s universal health coverage work, a former Health, Nutrition, and Population employee at the Bank expressed his discomfort with the concept at length:

I’ve been a critic of UHC. And the reason is that it’s a wonderful concept, but it’s an old concept. Because if you would have asked even within WHO confines [sometime before 1989] and you would have said, in terms of coverage…, which country has the best health coverage in the world? The answer was absolutely evident…. It would have been the Soviet Union. Because by definition, simply as part of the structure of government, everybody was covered.… But it was meaningless, because, just take mental health, the moment you were politically diverse, you would be covered but you would be in an institution! And therefore, the government would even say you were covered, because you are even in one of our institutions! In my view… the concept is wrong, because the term “coverage” has no meaning. You can have a health worker in a clinic and the mother can come and she treats you wrongly and then you die the next day – and you are covered! So, it’s not good. You can measure it, and your measurement can show that you’re fine, but please go back to the Soviet Union in 1974. Everything was covered, nobody was not covered. The word was meaningless.”

(Former HNP Employee, personal communication, 24 July 2018).

According to this former Bank employee, the underlying philosophy of the World Bank Group is and always has been to promote a global free market economy, and that with the fall of the Soviet Union, the Bank helped push this goal forward. The vestiges of the battle between two distinct philosophies of economic wellbeing are evident in his discomfort with the concept of universal coverage, in ways that make clear that the goal of a global free market still reigns supreme at the Bank. Yet, this discomfort with the concept of “coverage” also points to the ways that, as a global goal, UHC often ends up meaning its lowest common denominator – financial support and access to health care, with the question of effectiveness or quality most often left out. This has implications both for the Bank’s work and for the goal of UHC in general – coverage is “meaningless” in the sense that, as a concept, it can hold any meaning. In the context of the Bank, as we will see in the next section, this openness has the ability to evacuate from UHC interventions the very structuring problematic of addressing health inequity itself.

A heterogeneous institution and a heterogeneous approach to UHC

Figure 1: World Bank approaches to UHC

There is no unifying policy on universal health coverage at the Bank; rather, it is constituted by different research groups within or funded by the institution, by joint policy documents with WHO, and by different partnership platforms with other global health entities.[iii] UHC is implemented by these partnerships but also by in-country Bank officials who advocate for certain policies over others on a case-by-case basis in their consultations with country officials.[iv] In the process, what gets primary attention in the two-part goal of UHC – financial protection and/or coverage of health care – vacillates depending on different groups’ priorities. Ministries of health and of finance must balance these different philosophies of health financing and health systems to arrive at a UHC policy that works for their own health systems.

The tension between limiting or expanding UHC is one of many spaces of friction within the Bank’s work on UHC. There are researchers and officials, both associated with the Bank and not, who advocate for more comprehensive ways of measuring and promoting robust UHC policies. They focus on how these policies actually impact population and individual health, rather than other forms of input or short-term outcome measurements (see the Bank’s work on quality and primary health care in Figure 1). However, there are also research groups supported by the Bank to promote policy-making tools to help countries establish “essential packages of care” that define an “essential UHC,” following a similar path to the establishment of selective primary health care in the 1980s (Figure 1).

In Senegal, for example, UHC is currently measured by the proportion of the population covered by health insurance – whether through employment-based schemes, community-based health insurance schemes, or other recognized risk-pooling schemes. Focusing its attention on the expansion of health insurance schemes through its Agence de la Couverture Maladie Universelle, the Senegalese state has set to the side the question of whether this approach to UHC will actually ameliorate financial insecurity or improve access to quality health care for the general Senegalese population. This has also added a layer of complication to the already entangled management of the demand and supply of health care in Senegal, by making the community-based health insurance schemes a key part of the management of citizen health care without providing the needed resources for them to do so, exacerbating existing debt loads of hospitals and other health facilities created by subsidized health care schemes and other health policies (Mbaye and Gollock 2012; Wood 2020).

By promoting and measuring UHC in this way, the Senegalese state uses a proxy that captures just one part of the larger economic component for assessing universal health coverage as a whole. This flexibility of UHC policies’ design and implementation – as different institutions’ and countries’ ideological frameworks about who is responsible for citizens’ health and wellbeing come into play – is required for creating context-specific policies. At the same time, it creates situations where a partial economic assessment stands in for the larger goal of securing populations’ physical wellbeing.

As UHC policies continue to unfold, it is important to recognize how policies that claim to be working to improve health can exacerbate existing health inequities. As anthropologists, we have a unique toolset for mapping how the liberating rhetoric of universal health coverage translates into actionable policy and interventions that can do the very opposite of what they were designed to do. In the months to come, as we attempt to stem the tide of the COVID-19 pandemic and begin to recover, it will be more important than ever to make explicit the tensions between definitions of economic and bodily wellbeing at UHC’s heart and the conditions by which we assure that UHC’s benefits are felt by all.


Marlee Tichenor is a postdoctoral research fellow with the “International Organizations and the Rise of a Global Metrological Field” project in the Social Policy Department at the University of Edinburgh. She is a medical anthropologist interested in the politics of evidence and data in global health policy and intervention. As a part of the Global Health Governance Program, she conducted research on the World Bank’s role in the rise of global health metrics and universal health coverage. Her doctoral research at UC Berkeley and UC San Francisco was a multi-sited ethnographic study of pharmaceutical interventions, antimalarial resistance research, and community-based approaches to the fight against malaria in Senegal.


Funding source

This work was supported by Wellcome Trust [106635/Z/14/Z]

Notes

[i] “The UHC movement is probably one of the worst policy mistakes in the sector and detrimental to the poor in [lower income countries]. In practice UHC has completely displaced concern with public health in the Bank and support to capacities for core public health functions is nearly nil. The Bank has become a charity” (Former Bank Employee, personal communication, 14 August 2018). 

[ii] In a report published in 1986, the Population, Health, and Nutrition division of the World Bank introduced “an alternative approach to financing health care,” which emphasized the importance of reducing “government responsibility” for paying for health services that benefited only a few and “freeing government (or public) resources” for services that benefited more of a society (Akin, Birdsall, and De Ferranti 1986:1).

[iii]These include WHO; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; Gavi, the Vaccine Alliance; the Bill & Melinda Gates Foundation; United States Agency for International Development; the Japan International Cooperation Agency; among many others.

[iv] This work included the successful advocacy at the Inter-Agency and Expert Group on SDG Indicators (IAEG-SDGs) for replacing the originally chosen indicator for measuring financial protection – “the number of people covered by health insurance or a public health system per 1,000 population” – with an attempt to capture the real expenditure on health through “household health expenditure as a share of total household income (or total expenditure or consumption)” (Wagstaff and Kutzin 2016), which was ratified by the IAEG-SDGs in 2017.

[v] Arguing that most low- and middle-income countries cannot afford to provide a comprehensive universal health coverage package, Jamison and his colleagues (Jamison et al. 2018) have applied econometrics to determining which interventions have the greatest impact for their cost, establishing economic reasoning as paramount to prioritizing a “selective” UHC.

[vi] With WHO and the Organization for Economic Co-operation and Development (OECD), the World Bank published an influential report on the foundational importance of attending to and measuring the quality of health care in different contexts (WHO, World Bank, and OECD 2018).

References

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