The World Bank World Development Report 1993: investing in Health. Reveals the burden of common mental disorders, but ignores its implications.
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The World Bank, the most important so-called development assistance agency, annually dispenses billions of dollars to Third World governments, ostensibly to "develop" their economics through a variety of loan projects. But even a superficial analysis reveals that the Bank is the perfect mechanism to help (i.e., subsidize) the large transnational corporations from the industrial countries to expand their industrial, commercial, and financial activities in the Third World, at the expense of the latter and particularly at the expense of the rural and urban proletariat. This article discusses Cheryl Payer's recent book, The World Bank: A Critical Analysis, in which she analyzes the Bank's role in the Third World and sets forth the major reasons why poverty, hunger, and malnutrition, as well as unemployment, and all the adverse social phenomena associated with them, are on the increase.
The 1993 World Bank Development Report analyzes the world health situation from an economic perspective. In spite of the fact that many of the discussed topics are controversial, the report accomplishes an interesting review of different health and socioeconomic indicators. The experts of WHO and the World Bank elaborated a new measurement of the global burden of disease, the Disability-Adjusted Life Years (DALYs). It's an indicator that summarizes the health status of a population, combining mortality, morbidity and disability data. We think that the development of this new indicator is the most novel and positive aspect of the report. This indicator stimulates comparisons between countries and facilitates decision making processes in the health field. The present work summarizes and analyses the most interesting and controversial aspects of the World Bank Development Report.
Investing in Health is the World Bank's blueprint for a new health policy within the context of structural adjustment. While this document includes a broad range of arguments, its implicit premises are neoliberal as can be deduced from its "agenda for action." Health is defined as a private responsibility and health care as a private good. This leads to a health policy based on two complementary principles: the reduction of state intervention and public responsibility, and the promotion of diversity and competition (i.e., privatization). Thus, public institutions should provide only a limited number of public goods and narrowly defined, cost-efficient forms of relief for the poor. All other health-related activities are considered private duties, to be resolved by the market, NGOs, or families. The World Bank policy provides a pragmatic contribution to efforts to achieve fiscal balance. However, it also pushes to recommodify health care and to turn health into a terrain for capital accumulation through the selective privatization of health-related financial and "discretionary" services. The proposal implies large-scale experimentation and dismantling of public institutions which are the only alternative now accessible to the majority. It rejects health as a human need and a social right, and violates basic values by claiming that life and death decisions can be justly made by the market or through a cost-effectiveness formula.
Politicians, the mainstream media, and orthodox social science have all been telling us of a final victory of capitalism over socialism, suggesting that capitalism is the only viable option for solving the world's problems. Yet, the global capitalist system is itself entering the third decade of a profound structural crisis, the costs of which have been borne largely by the exploited and oppressed peoples of the underdeveloped periphery. While the World Bank's latest World Development Report recognizes the current poverty crisis in the third world, its "two-part strategy" for alleviating poverty is based on an inadequate analysis of how peripheral capitalist development marginalizes the basic needs of the third world poor. Hence, the World Bank's assertion that free-market policies are consistent with effective antipoverty programs does not confront the class structures and global capitalist interests bound up with the reproduction of mass poverty in the third world. The World Bank's subordination of the basic needs of the poor to free-market adjustments and reforms in fact suggests that the real purpose of its "two-part strategy" is to ensure continued extraction of surplus from third world countries by maintaining the basic structure of imperialist underdevelopment.
Neoliberalism does not consider education a strategic investment. World Bank discourse for Latin America lacks a medium- and long-term view and is based on a short-term cost-benefit analysis. The Bank's education policy is determined by "adjustment" of countries economies so that they can go on paying their external debts. The goal is to eliminate educational expenses for the states by keeping education for elites, breaking up and privatizing the large public education systems, and nullifying teachers' contracts. To justify its policy, the Bank argues that governments should stop financing secondary and higher education and instead focus on primary education, where investments would be more efficient. But at the same time, governments should shift the financing of primary education to the private sector. Teachers' unions are now at the forefront of opposition to the World Bank's education reforms.
A World Bank report on the health sector in India has set out to offer an alternative policy framework to cushion the impact of structural adjustment programs on health services. By choosing health financing as a tool for policy analysis, it has arrived at highly questionable conclusions.
The final quarter of the 20th century saw a profound change in international health cooperation. The World Bank emerged and consolidated its position as the leading external financier of health-sector activities in countries of low and middle income. As a result of its resources, philosophy, and legitimacy, the World Bank leveraged fundamental reform of the health-sector agenda as well as institutional relations at global and national levels. The scope of the Bank's involvement, and the nature of its policy thrusts and investment strategy in the sector, are outlined in this paper and illustrated with specific reference to Bangladesh. This backdrop serves to raise four issues and enables us to explore their relevance to global health cooperation in the first quarter of the 21st century.