I vote for NIHAC signing on to the letter. Thanks Mary Anne for sharing this
message with us. And, happy holidays.

Amineh

On Sat, 23 Dec 2006, Mary Anne Mercer wrote:

>
> 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
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