Radical new approach to global health

Despite major advances in knowledge and unprecedented gains in global wealth, health inequities between the rich and poor are increasing, both within and among countries (1). Poverty, poor living and working conditions and the inability to influence these conditions are directly related to poor health. The 2008 report of the World Health Organization’s (WHO) Commission on Social Determinants of Health observes that ‘social injustice is killing people on a grand scale’ (2).

The WHO report is one of three recent publications that highlight the urgent need to improve universal access to health care by means of a new approach to health. This approach, which is gaining momentum among specialists worldwide, involves addressing health issues in a comprehensive way – with a focus on systems instead of sectors – and tackling head-on the socio-economic causes of poor health and health inequity.


Alamy / Iain Masterton

It is not the first time that such a proposal has been made. The Alma Ata Declaration of 1978, which established the ‘Global Strategy for Health for All (HFA) by the Year 2000’, emphasizing the need for a new international economic order as a prerequisite to reducing health inequity (3). This was not realized. Today’s call to revisit the essence of Alma Ata assumes special urgency as governments rethink the operations of the global economy in the wake of the 2008 financial crisis. Moreover, it comes at a time of profound changes in the global health policy landscape, as private funders take an increasingly influential role.

Based on the insights of the three recent publications – the Commission on Social Determinants of Health report, the World Health Report 2008 and Global Health Watch 2 – this special report analyzes the current situation and points to approaches to reduce health inequities, including what needs to be done, how, and by whom. It highlights the need, not only for a reorientation of global health policies and priorities, but also for fundamental changes to the global economy and genuine democratization of global governance.

By Françoise Barten, a senior scientist in international health at the Radboud University Medical Centre, UK, in the department of primary and community care; Ted Schrecker, a scientist and associate professor at the University of Ottawa’s Institute of Population Health and David Woodward, an independent consultant on development issues and previously the head of the New Global Economy programme at the new economics foundation in London.

Footnotes

(1) Marmont, M. (2007) Achieving health equity: from root causes to fair outcomes. The Lancet, Volume 370, Issue 9593.
United Nations Development Programme (2005). Human development report 2005- International cooperation at a crossroads: aid, trade and security in an unequal world. UNDP.

(2) Commission on Social Determinants of Health. (2008) Closing the Gap in a Generation: Health equity through action on the social determinants of health (final report). WHO. Retrieved via the WHO website.

(3) WHO. (1978) Declaration of Alma Ata: Report on the International Conference on Primary Health Care, Alma Ata, ISSR. WHO.

The global health policy landscape has changed considerably over the past decade. There is more money available to allocate to health initiatives than ever before, a large percentage of which has come from private funds and public private partnerships (PPPs). Some experts have welcomed these changes, while others have had considerable reservations. Despite positive developments, such as increased access to antiretroviral therapy for patients with HIV/AIDS, the health situation in poor countries and for the poor communities of rich countries remains abominable. It is often in the world’s poorest countries that the highest percentage of health costs is met with private, out-of-pocket spending. This creates poverty traps that can be impossible for people to escape.   Read more>>



Readers' Comments

The World Bank Unveiled: Inside the Revolutionary Struggle for Transparency
Dear Mr. Woodward:

Parkhurst Brothers Publishing and the University of Chicago Press hasrecently published The World Bank Unveiled: Inside the Revolutionary
Struggle for Transparency. I thought it might be of interest to you. Thebook documents my experiences inside the Bank seeking to reform the institution into one that is more open and accountable to its stakeholders. The book addresses several keys questions: What does
transparency mean?; How does the World Bank view initiatives to make it more transparent?; and, How does transparency impact the Bank’s work on poverty reduction?

In the years following the 9/11 tragedy and up to 2008, wealthy donor countries pledged to increase assistance to the developing world but these
promises were not been fulfilled. The World Bank, as the key international institution charged with reducing global poverty, has the lead role in advocating on behalf of the poor for greater resources. Yet it was an ineffective advocate during this period. There were three reasons behind the Bank’s failure of leadership: Rich countries were skeptical about the effectiveness of the Bank’s lending; borrowing countries chaffed at the conditions the institution imposed on its loans; and, civil society groups and private citizens didn’t trust an institution they view as having a culture of secrecy, an aversion to openness and a lack of accountability. The World Bank Unveiled is an in-depth analysis of why greater transparency within the institution is critical to the Bank’s ability to reduce poverty. The book examines the structural inefficiencies of the institution and its unique cultural
environment to reveal answers and suggest reforms that can improve the Bank’s ability to help the poor.

The UN estimates the repercussions of the global economic crisis may push more than 100 million people below the poverty line of living on $1.25 per
day. But the crisis has also put the World Bank back on to center stage. In April 2009, the G-20 pledge to fund it with billions of dollars to combat the effects of the financial downturn for developing countries. The question is whether the Bank will be any more effective in reducing poverty with these new financial resources than it was prior to the economic crisis? These issues are what The World Bank Unveiled addresses. The book examines the inner workings of the organization through one compelling case study. From its trenches, it explores how the institution thinks, operates and acts. Through a more robust understanding of what drives institutional practices, the book seeks to allow a new operational model to be brokered that fosters transparency and accountability and ultimately greater effectiveness.

I invite you to read more about the book at:

http://www.worldbankunveiled.com.

There you will also find commentary about the book, excerpts, questions and answers and other materials. In addition, please visit the World Bank
Unveiled blog at: http://theworldbankunveiled.wordpress.com/.

There you can share your thoughts, perspectives and experiences on the Bank and its transparency and accountability. I also invite you to read the comments below that key international development practitioners have already provided about the book. The book is available through Barnes and
Noble, Borders, Amazon and the World Bank’s InfoShop (20% off for Bank staff, www.worldbank.org/infoshop). I believe The World Bank Unveiled can have an important, lasting and positive impact on the Bank’s efforts to reduce global poverty. I hope you will agree.



1 - To many people engaged in the effort to mitigate the effects of
poverty around the globe, the World Bank is a black box. Its development
contributions and its great potential are hindered by processes and
systems that obscure rather than illuminate. David Shaman undertook yeoman
efforts to reform the institution, using modern communications technology
to achieve more transparency. Now in this superb book, Shaman reveals the
resistance he faced and offers important recommendations for reform. He
explores the crisis of identity that has plagued the Bank since its
creation: Is it a financial institution requiring appropriate
confidentiality and the discretion of a bank, or is it a development
agency whose mission requires openness, participation and widely-shared
results metrics? Shaman leans toward the latter. This view merits deeper
reflection and debate which this book should provoke."

J. Brian Atwood, Dean of the Hubert H. Humphrey Institute of Public
Affairs, University of Minnesota, and former Administrator of the U.S.
Agency for International Development
2 - “Impressive, as it is highly readable while thoroughly researched.
Compelling.”

Jo Ritzen, President, Maastricht University, former World Bank Vice
President, and author of A Chance for the World Bank

3 – “This is a knock-out of a book. It tells the inside story of how a
small group of “guerrilla” staff members, initially working on
environmental issues, wheeled and dealed to get the World Bank to accept
unedited presentations of its activities both to its own staff and to the
wider public. And of how some Bank managers out-machiavellied Machiavelli
in their efforts to wrestle control from them so that they could use the
technology (webcasting to stream video content over the Internet) to
present a more sanitized version of the Bank in line with corporate
objectives. I know of no other study which illuminates the
“street-level” politics of a multilateral organization so well, or
which shows culturally quite different notions of “transparency” and
“accountability” being used as weapons in bureaucratic struggles over
budgets and authority.”

Robert H. Wade, Professor of Political Economy and Development, London
School of Economics, noted expert on the World Bank and recipient of the
Leontief Prize in Economics 2008

4 - "A fascinating and frightening expose of the World Bank’s
operations. An insider’s intimate view of how an organization meant to
help the developing world actually hindered progress. A must read!"

Arun Gandhi, grandson of Mahatma Gandhi, and Founder/Director, Gandhi
Worldwide Education Institute, USA

5 – “In this book David Shaman takes us on a conducted tour of what
many regard as one of the world’s more extraordinary institutions, the
World Bank. This is in the context of his efforts to promote B-SPAN, an
internal World Bank service he launched to provide video coverage of
important events and analyses both to the Bank itself and to its external
stakeholders. He captures very well the mix in the Bank of everything from
enormous ability focused on advancing the cause of the poor to bureaucracy
devoted to empire-building and the denial of information, with no holds
barred in naming his adversaries and identifying their defects. Given this
mix, you can rely on finding something to love or hate in the Bank,
depending on one’s prejudices.”

John Williamson, Senior Fellow, The Peterson Institute for International
Economics, and author of phrase “Washington Consensus”


6 - “This is an inside story about the World Bank and the challenges it
is facing, from outside and within. It is a story about accountability. It
is a personal account of an expert, who has tried to bridge the gap
between a bureaucracy and the people that should be served. The story is
frightening and challenging at the same time. The world needs this Bank.
But Bank reform is due. I hope this book is widely read.”

Jan Pronk, Professor of Theory and Practice of International Development
at the Institute of Social Studies in The Hague, former Assistant
Secretary-General of the United Nations, former Deputy Secretary-General
of UNCTAD and former Dutch Minister for Development Cooperation

7 - “David Ian Shaman's "The World Bank Unveiled" is required
reading for anyone who believes public institutions should be transparent
and accountable. His hard-won insights provide valuable guidance for
concerned citizens and government watchdogs.”

Melanie Sloan, Executive Director, Citizens for Responsibility and Ethics
in Washington

8 - “David Shaman's The World Bank Unveiled offers an unparalleled
account of the inner workings of the Knowledge Bank experiment under James
Wolfensohn. As the leader of one of the innovative projects - B-SPAN -
that were part of attempts to transform the Bank into a more transparent
and humble partner for development, Shaman is able to provide a
fascinating case study of the way that this vision withered in the face of
the powerful existing culture of the Bank. Whilst there have been many
books this decade from ex-Bank staff questioning the Bank's role in
poverty reduction and development, Shaman's is by far the most significant
account of the Knowledge Bank experiment, its potential and its ultimate
demise.”

Simon McGrath, Professor of International Education and Development,
University of Nottingham and co-author of Knowledge for Development?
Comparing British, Japanese, Swedish and World Bank Aid
9 - "The World Bank is a big agency with an even bigger mission. How
does it manage constantly to reinvent itself from within? David Shaman
gives us an insider’s account of a crusade within the Bank by staff with
a shared passion for sounder environmental policies, and a belief in
transparency. He details with relish the battles, allies, and enemies
which shaped their successes and setbacks. Early on a senior colleague
tells him that in bringing about change “it is better to ask forgiveness
than permission”. The fact that this credo works for the reformers
highlights a strength in the less-than-totally-disciplined Bank - the
flipside of the disparaging observation once made that the World Bank is
a “travelling seminar”. Shaman’s tale reveals life within that
travelling seminar and the possibilities which emerge when an organization
is requestioned from within."

Ngaire Woods, Director of the Global Economic Governance Programme,
University of Oxford, and author of The Globalizers: the IMF, the World
Bank, and their Borrowers

10 - The World Bank Unveiled is a well written, lengthy tome that is part
history of the World Bank - especially focusing on the wheeling and
dealing behind B-Span, part personal memoire, part scathing critique, and
part policy prescription. These parts can be hard to balance. Yet while
Shaman is clearly a man on a mission to make the World Bank more
transparent and more accountable, the book offers numerous credible
insider details as it builds its case, and for the most part avoids being
overly self-congratulatory or ideological. From selecting its presidents
to self-evaluation of project effectiveness, the World Bank lacks
transparency. However deserved critiques of the World Bank may be, at
least some of these critiques spring from a deeper source over which the
World Bank has only partial responsibility. No one really knows how to
cause development. It is an art as much as a science, and either way, it
is a field marked by failure and inefficiency. That said, thos
e whose job it is to help the starving and the poor have a special
responsibility to go beyond the call of duty to be effective. Whatever
those in the World Bank and its stakeholders make of Shaman’s book, I
hope they confront it, and make themselves more effective as they
respond. My research suggests that organizations become more effective
as they increase their efforts and abilities to explain themselves. I
endorse Shaman’s call for more transparency at the World Bank.

Dan Lindley, Associate Professor, Department of Political Science,
University of Notre Dame, and author of Promoting Peace with Information:
Transparency as a Tool of Security Regimes



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