The New World Bank Health Service Delivery Model

The 1993 World Bank Development Report features an analysis of the health sector (World Bank 1993). In some respects, the Bank has changed its policies since the publication of its 1987 agenda for health financing reform (World Bank 1987). That report recommended the privatization of all health services and the use of non-governmental organizations (NGOs) to deliver care1 . Taking account of criticisms about the inapplicability of a universal model, the Bank now distinguishes the needs of low income countries from those of middle income and formerly socialist economies. Stepping back from the blanket recommendation to privatize all health care, the Bank now advises governments to provide some health services for the poor. It suggests that governments unable to afford this expansion turn to foreign aid. The effects of this recommendation will probably be to increase the dependence of low income countries on donors and to give donors more control over the internal affairs of client states2.

For low income countries, the Bank recommends an essential clinical package, which consists of perinatal and delivery care, family planning services, management of the sick child, treatment of tuberculosis, and case management of sexually transmitted diseases. "Clinical" in this context means services provided by nurses and midwives, not physicians. The expected impact of these new policies can be shown with one illustration--how they will affect the health of women and children.

This clinical package reduces women's health care to services during childbirth, showing once again that women are valued only for their reproductive role. Governments will subsidize family planning services but, because little money is intended for physician services (or the training of nurses and midwives in these tasks), women will receive contraceptives without medical supervision. The lack of medical screening and follow-up is potentially dangerous because the programs rely heavily on long-lasting hormonal drugs such as norplant and depo-provera, which have serious secondary effects and are life-threatening to women with cardiovascular and other health conditions.

Sick children are the main beneficiaries of this clinical package, in keeping with the assumptions that families will limit the number of births only after child mortality falls, and that mothers are more likely to accept family planning from health services that care for their sick children.

The World Bank's package of essential clinical services includes the treatment of tuberculosis, a disease that requires curative services for the sick if vaccination of children is to be an effective prevention. Perhaps another reason for the inclusion of tb treatment is the Bank's belief that the recent rise in tb cases is related to the spread of AIDS (rather than to the spread of poverty or the breakdown of basic health services). AIDS also motivates the inclusion in the package of clinics for the treatment of sexually transmitted diseases that are thought to accelerate the spread of HIV. No treatment of persons with AIDS is included, although African women have been asking for help (Ankrah, 1991; Bassett and Mhloyi, 1991).

Although the differentiation of health reform packages according to GNP addresses the fallacy of universal prescriptions, other faulty aspects of the 1987 recommendations are not corrected. The Bank still does not examine the interface between the public health sector (meaning free care in government facilities) and the private health sector, or how the privatization of health service delivery impacts the quality of public health care and the geographical distribution of health services3. The Bank continues to talk as if expansion of the private health sector were compatible with its recommendations for public provision of essential clinical services for the poor, as if expansion of the private sector did not shrink the public health sector by draining limited personnel and other resources, as if we had not learned from a decade of primary health care experiments that reform of the tertiary system (referral and teaching hospitals) is critical for success in rural areas. The Bank's policy amounts to a two-tiered system: good clinical care and environmental services for the rich and second-rate care for the poor.

The Bank's recommendation that governments shift service delivery to NGOs has a different impact on women and men. This is because many relief agencies working in the health field view women in their domestic roles only, as dependents with children or as pregnant or lactating mothers, thereby reinforcing sex stereotypes. Some NGOs reinforce patriarchal norms because they wish to appear sensitive to local cultures or because their ability to work successfully at the community level depends on it. "They do not want to be accused of cultural imperialism by tampering with sex roles, roles that are enforced by family and community and thus are the most resistant to change" (Yudelman 1987:181).

The 1993 World Bank report does acknowledge, for the first time, violence against women as a health issue. Domestic violence, rape, sexual abuse, and female genital mutilation are problems implicated in maternal deaths, miscarriage, low birth weight, and sexually transmitted diseases (including AIDS), as well as in higher rates of mental illness, alcoholism, drug addiction, depression, and suicide. Stewart (1992) reports that domestic violence and rape are serious social problems in Zimbabwe. Armstrong (1987) studied the rape cases prosecuted in Swazi courts and concluded that the incidence of sexual assault is high, and that girls under 16 account for the majority of cases tried, but that conviction rates are very low. Rates of rape in South Africa appear to outstrip even those in the United States and have increased dramatically in recent years--the figures for 1988 are 34 rapes per 1,000 adult women in South Africa, 18 per 1,000 in the USA (Heise 1993:177).

But the Bank stops at domestic violence and does not consider the health consequences of political violence, which has had a tremendous impact on African women and children, who make up the bulk of civilians caught up in war, civil unrest, assassinations, and torture with their attendant deaths, disabilities, psychological stress, and the destruction of health services (Zwi and Ugalde 1989). Indirect effects of violence also take their toll in decreased food production and distribution, family destruction, and the displacement of people. Refugees, 75 percent of whom are women and girls, are especially vulnerable to violence, a major issue in sub-Saharan Africa where the number of refugees is high.

References

Ankrah, E. M. (1991) "AIDS and the Social Side of Health." Social Science & Medicine, 32(9):967-980.
Armstrong, A. (1987) "Women as victims: a Study of Rape in Swaziland," in A. Armstrong (ed.) Women and Law in Southern Africa, Harare: Zimbabwe Publishing House.
Bassett, M. T. and Mhloyi, M. (1991) "Women and AIDS in Zimbabwe: The Making of an Epidemic." International Journal of Health Services, 21(1):143-156.
Heise, L. (1993) "Violence against Women: the Missing Agenda," in M. Koblinsky, J. Timyan and J. Gay (eds.) The Health of Women: A Global Perspective, Boulder, CO: Westview Press.
Stewart, S. (1992) "Working the System: Sensitizing the Police to the Plight of Women in Zimbabwe," in M. Schuler (ed.) Freedom from Violence: Women's Stategies from around the World, New York: UNIFEM.
World Bank. (1987) Financing Health Services in Developing Countries: An Agenda for Reform. Washington, DC: The World Bank.
---. (1993) World Development Report 1993. Washington, DC: The World Bank.
Yudelman, S. (1987) Hopeful Openings: A Study of Five Women's Development Organizations in Latin America and the Caribbean. West Hartford, CT: Kumarian Press.
Zwi, A. and Ugalde, A. (1989) "Towards an Epidemiology of Political Violence in the Third World" Social Science & Medicine 28(7):633-42.