Applying the leech: the World Bank and the possibility of health-promoting structural adjustment

The publication of the World Bank's 1993 World Development Report, Investing in Health, was a major intervention in global health. My commentary on this report is here. Earlier drafts of this commentary were presented, first to a workshop on the report held on Canberra, in August, 1993, co-sponsored by the Australian Development Assistance Bureau, the National Centre for Epidemiology and Population Health and the Public Health Association of Australia; second, at the September 1994 Annual Conference of the Public Health Association of Australia; and finally to the December 1994 meeting of the International People's Health Council. 

The World Bank's 1993 World Development Report, Investing in Health, is beautifully presented, well illustrated and highly readable, but yet it is dangerous. It is innovative methodologically and is peppered with studies undertaken by Bank staff or consultants working on the huge data bases held by the Bank. It reviews a number of the key issues in health and development and makes some sensible suggestions. And yet it is a dangerous document.
The report comprises:

  • an overview of the health status of different populations around the world;
  • an analysis of the conditions for better health, focussing on "the household"; and
  • policy recommendations, pitched at the country level, for achieving better health.

The report is a danger to the health of poor people in developing countries. The immediate danger is that it will mute criticism of structural adjustment programs (as presently imposed by the IMF) by creating the illusion that if such programs were complemented by the health policies recommended in this report they could actually enhance people's health ("health-promoting structural adjustment"). Perhaps more real is the danger that the report will sustain the perception that the only pathway to better health in developing countries is through economic growth and that this can only be achieved on the Bank's terms (''suffer now for better health later"). A longer term danger is that the report will shore up the illusion among people in the North that health advancement for poor people in the South is compatible with the way in which the global economy presently operates (the possibility of "healthier poverty").  

Read full commentary here.