The NGO HealthGap has worked for several years to increase access to AIDS
drugs and promote other approaches related to equity in international
health. This NGO signon letter (below) urges the World Bank to increase
their equity orientation, including the concern of gender equity, and
voices other concerns about the Bank's upcoming 10-year strategy document.

I propose that NIHAC sign on to the letter - please let me know your
opinion.

Mary Anne


Begin forwarded message:

> From: Asia Russell <asia@...>
> Date: December 22, 2006 2:10:36 PM PST
> To: HCW@...
> Subject: [HCW] Sign on request: Draft World Bank Health Strategy
> Reply-To: HCW Discussion List <HCW@...>
>
> Dear Colleagues,
>
> As you might know, the World Bank is in the process of writing a
> new 10 year strategy on health. It has some good parts (that it
> talks about strengthening health systems) but it is also bad in
> that it largely promotes a model of privatization, ignores the
> Bank's own record in weakening health systems, and ignores gender.
>
> However, there is still a chance to influence the strategy - it
> will go to a committee of Bank Executive Directors in late January,
> and to the full Board in February). A group of health and World
> Bank-watching NGOs in Washington has signed this letter (pasted
> below). We'd like as many other NGOs to sign too - the Bank
> (management, staff and Board) needs to get a strong signal that
> there is a wide constituency of concerned people on this issue.
>
> Here is a link to the draft strategy:
> http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/
> EXTHEALTHNUTRITIONANDPOPULATION/0,,contentMDK:21010634~menuPK:
> 282527~pagePK:210058~piPK:210062~theSitePK:282511,00.html
>
> Please feel free to contact me any questions, and send your
> endorsements to me at asia@.... The current deadline is
> January 3 2007 for accepting sign ons.
>
> Best
>
> Asia
>
> --
> Asia Russell
> Health GAP (Global Access Project)
> tel: +1 267 475 2645
> asia@...
> http://www.healthgap.org
>
> -----------
>
> OPEN NGO LETTER ON THE WORLD BANK'S DRAFT HEALTH STRATEGY
>
> The World Bank’s Health, Nutrition and Population division is
> preparing a new 10 year strategy, to be presented to CODE on
> January 24th, and the Board in February 2007. This strategy
> analyses the Bank’s comparative advantages and proposes the
> development of operational and technical areas of expertise to
> assist recipient countries in their efforts to strengthen health
> systems.
>
> We are encouraged by and support the Bank’s focus on health system
> strengthening and greater accountability of financing linked to
> clear outcomes. However, we write to you as a coalition of civil
> society organisations from developed and developing countries to
> express our concerns with some key aspects of the current draft and
> to request your support to ensure that changes are made.
>
> We believe that the current strategy would further exacerbate
> existing shortages of health workers; would further undermine
> public health systems particularly in low-income countries; and
> would entrench two-tiered systems where the poor will continue to
> be denied access. In particular, the strategy fails to address the
> impact of these approaches on women’s health and rights.
>
> Strong public delivery systems of basic services are essential to
> ensure equitable access based on need, rather than ability to pay.
> The Bank can usefully play a role in advising both governments and
> donors on financing arrangements, but must ensure that these
> arrangements support a vision of a well planned, well managed and
> well staffed public health system for all citizens, based on need
> rather than ability to pay.
>
> We believe changes to the analysis and recommendations are
> important because the strategy will guide Country Directors’ in
> their role of supporting governments planning and delivery of
> health services for the next decade. The strategy is also highly
> likely to influence the recipient country governments in their
> decisions on how to provide vital healthcare.
>
> We ask that the HNP Strategy be redrafted to:
>
> 1. Include a thorough gender and human resources analysis of
> public health systems strengthening, with the explicit aim of
> providing equitable access based on need rather than ability to pay.
>
> 2. Support countries to scale up and widen the scope of public
> health system delivery of basic services to ensure equity of
> service provision. The strategy should move away from its current
> focus on contracting out, which risks establishing two-tier systems.
>
> 3. Affirm the fundamental importance of government financing
> for basic services in low-income countries, where chronic poverty
> denies access to individuals when even small payments are required.
> The World Bank should assist countries to remove user fees for
> basic health services.
>
> 4. Affirm the duty of the Bank to assist recipient countries to
> overcome constraints such as fiscal and absorptive capacity
> constraints, rather than advocating health system reforms that
> maintain the existing constraints.
>
> We explain our concerns that have lead to these requests in the box
> below.
>
>
> The draft dated May 30th omits a number of essential elements, and
> makes a number of flawed assumptions. Based on these flawed
> assumptions, we believe that the strategy presents an incorrect
> diagnosis and therefore incorrect prescription for reform.
>
> 1. A lack of gender analysis. The strategy omits any gender
> analysis and as a result proposes reforms that may further
> impoverish and discriminate against women and girls, particularly
> in low-income countries. The strategy fails to acknowledge the
> reality of women’s lack of access to resources, information,
> services and power in the household and labour market. For example,
> women need female health workers to improve maternal and child
> health, but equally female health workers need particular education
> and incentive interventions to enable them to get training and
> qualification, and to live in rural areas where they are at
> increased risk.
>
> 2. A lack of impact analysis on human resources for health. The
> WHO calculates that there is a global shortage of 4.25 million
> health workers. The strategy fails to address the chronic shortage
> of health professionals in recipient countries. This is one of the
> most glaring omissions in a strategy document, which is supposed to
> respond to pressing health system needs.
>
> 3. Flawed analysis on financing. The Bank presents evidence
> that private, out-of-pocket payments account for the majority of
> health care expenditure in many low-income countries. It then
> equates these payments with ability and willingness to pay for
> services, despite presenting evidence in the same document that
> such payments are the second major factor in impoverishing million
> so people in low-income scenarios. The strategy therefore
> contradicts itself by establishing payment as a given while at the
> same time acknowledging the impoverishing effects of these payments.
>
> 4. Partial diagnosis on financing. Based on the previous flawed
> assumption, the Bank proposes systematising existing levels of
> payments into formal, insurance-based systems. In low-income
> countries where the majority of the population lives on less than
> $2 a day, there is no evidence that this approach helps to build
> equitable health systems. On the contrary, there is evidence that
> publicly-financed systems are better able to provide universal,
> equitable access to services in low-income situations. Country
> Directors must be supported to advise recipient governments on
> financing systems that involve national revenues such as tax, aid
> and natural resource receipts, together with larger budget
> allocations. The strategy should be redrafted to make it explicit
> that Bank assistance will not come with a condition of establishing
> insurance-type financing systems.
>
> 5. Flawed analysis of private-sector health care provision. The
> Bank makes the assumption that private health providers are more
> accountable, of higher quality and more efficient than public
> providers. This is an analysis based on ideology rather than
> evidence. Public sector workers are presented as corrupt, with no
> analysis of why corruption thus defined occurs among this group,
> and no comparative analysis of how and why massive corruption also
> occurs in private provider contracts. The strategy ignores the
> evidence of successful reforms to strengthen the training,
> recruitment and retention of more highly motivated and better-
> compensated public sector health care workers, and proposes only to
> bypass the public sector in favour of a falsely valorised private
> sector. In promoting private service provision, the strategy is
> practically promoting internal migration from the public to the
> private sector and therefore further fragmentation of public health
> systems.
>
> 6. Improper diagnosis of the proper public sector role. Based
> on the above flawed assumptions, the Bank proposes support to
> recipient countries to contract out the provision of health
> services, leaving governments to assume the role of stewards. In
> low-income countries with weak capacity to deliver, there is
> overwhelming evidence that the state currently has very little
> capacity to regulate and incentivise private health providers to
> provide equitable access to services for all. This diagnosis takes
> the current situation as a given for the future and does not look
> for ways to improve public system capacity. For example, it does
> not address the acute shortage of health workers overall, and does
> not address public sector capacity to coordinate, regulate, and
> harmonize sustainable and robust health care systems. Above all, it
> ignores evidence that universal service coverage in low-income
> countries has only been achieved with strong public delivery systems.
>
> 7. Limited ambition on World Bank results. The strategy aims
> only to advise low-income countries on reforms within their fiscal
> and absorptive capacity constraints. The Bank should aim to assist
> recipient countries to overcome those constraints, rather than
> taking them as ‘givens’. The WB should not push LICs to be
> “selective and realistic” about which HNP results they can achieve
> but should, on the contrary, help LICs to “deliver a comprehensive
> package of health services to the whole population”.
>
> 8. A lack of inclusion of social sectors in the multi-sectoral
> approach. We are encouraged by and support the Bank’s multi-
> sectoral approach, but urge explicit inclusion of other government
> sectors especially the Ministries of Health, Education, Water, and
> Transport. The strategy fails to acknowledge the importance of
> social sectors and instead focuses primarily on Finance Ministry
> advice.
>
> 9. A lack of recognition of the role of the International
> Monetary Fund (IMF) in policy setting. The strategy fails to
> acknowledge the impact of IMF policies on countries’ ability to
> adequately address their human resource crisis and provide
> universal access of quality health care for all.
>
> 10. Limited collaboration with the World Health Organization (WHO)
> as a critical partner on technical assistance. The strategy fails
> to describe how it intends to collaborate with WHO to take
> advantage of its wealth of technical expertise in all aspects of
> delivering health care in low income countries.
>
> We thank you for your attention to these concerns and look forward
> to our continuing dialogue around the development of a new World
> Bank HNP strategy.
>
> Sincerely
>
> Oxfam International
> Health GAP
> Global AIDS Alliance
> RESULTS, USA
> Bank Information Center