Dr. Kim's Prescription for Global Health

May 24, 2013

Todd Summers, Senior Adviser
Global Health Policy Center, Center for Strategic and International Studies

Earlier in the week, World Bank President Jim Yong Kim delivered a rousing speech to the World Health Assembly, the annual week-long jamboree of global health leadership.  It comes at a critical moment.  Work is underway to draft a new set of fifteen-year millennium development goals that will guide work on health and development through 2030.  Funding has leveled off, following an unprecedented rise in foreign assistance committed to critical health challenges including infectious diseases and maternal and child health.  New technologies offer great promise to alter significantly the course of big killer diseases like AIDS, tuberculosis, and malaria but only if they’re able to reach the millions who still wait for help.

It’s also a critical moment for the World Bank and for Dr. Kim.  Largely through its International Development Association (IDA) program, which offers grants and low-interest loans to developing countries, the World Bank has played a critical role in financing an array of health investments that address immediate emergencies as well as systemic weaknesses in health systems.  Yet its track record has been mixed.  Evaluations of its work on malaria and HIV, for example, have not been as positive as some expected.  Promises to ramp up support for the long-term challenge of building robust health infrastructure have not been followed by serious investments.  There was even some doubt that Dr. Kim would focus on health, perhaps over-correcting for concerns raised during his nomination that he was “just a health guy” and wouldn’t respond to the broader needs of developing countries (though those who know Dr. Kim only laughed, as if he’d ever give up his keen interest in addressing health disparities).

With such great expectations of Dr. Kim from the health community, his comments this week help us see the path he’s choosing.  He has given previous indications of direction through other important speeches, including early in his tenure when he spoke at the International AIDS Conference in Washington, DC.  In his July 2012 comments, he connected the fight against AIDS with broader efforts to build health systems and alleviate poverty. Furthermore, he committed the World Bank to leverage its experience to help countries leverage AIDS investments for broader benefit (“Building systems is what the World Bank does best”).  Dr. Kim also referenced the Bank’s work on social protections, which for health means reducing the risk that health problems bind people to, or push them into, extreme poverty.

He’s also made a few steps on new Bank staff.  Dr. Tim Evans, a widely respected international health expert, was appointed as director of health, nutrition, and population at the Bank, replacing Cristian Baeza (who tried hard to get things moving but seemed to lack top-level backing).  Dr. Evans starts later in June.  A new vice president for human development who oversees this work has yet to be selected.   Dr. Kim has reportedly been talking to candidates and the rumor mill is grinding out names, but we don’t know who will fill this really important post (World Bank insiders have told me that having a committed and connected VP is essential).

This leads us to the World Health Assembly speech.  Dr. Kim repeated themes from his AIDS conference plenary: health is part of poverty alleviation, social protection schemes are key, health systems development is a core Bank skill.  What was perhaps new was his emphasis on accountability for results, and using data to drive investments.  While supporting the use of “universal health coverage” as a new overarching millennium development goal, he also made clear that specific targets were needed to track progress lest the goal become “a toothless slogan that doesn’t challenge us, force us to change, force us to get better every day.”

He’s also sharpened his message on what he’s now calling “global health delivery science” that uses data and rigorous evaluation to identify and share best practices not just for ex poste assessments but for giving real-time feedback on programs and strategies to front-line staff.  Speaking to the developing country health ministers in the audience, he described this field as meaning that “frontline workers – the doctors, nurses, the managers and technicians – will have better tools and faster access to knowledge to provide better care for people.”  This sounds like a welcome challenge to flip the data demand on its head, shifting from an emphasis on meeting donor requirements (that are often confusing and contradictory) to one on country and service provider requirements.

Also new to me was a strong reference to results-based financing for health, something the World Bank has been testing under its Health Results Innovation Trust Fund, financed with $550 million by the United Kingdom and Norway.  This uses incentive schemes and other approaches to shift the emphasis from inputs and activities to outcomes and impact.  It’s a big change from what others have done, including the Global Fund, which describes its funding as “performance based” but has in the past focused its assessments of performance more on inputs than outcomes.  The Center for Global Development has been leading a working group on performance based incentives for health that I’ve joined, and it’s very promising stuff (report due soon!).

All in all, it looks like Dr. Kim is concretizing his health agenda, and tying it closely to broader World Bank efforts on poverty alleviation and economic development.  Critical next steps include:

• Hire an outstanding vice president for human development to support Dr. Evans and others, and ensure that this person has the authority, skills, and accountability to drive the health agenda forward.

• Set metrics for the World Bank’s performance on health, taking some of his own medicine to ensure that the World Bank lives up to its promises, that it’s investments in health systems translate into improved health outcomes, and that it’s more focused work on infectious and non-communicable diseases complement and leverage investments by the others, especially the Global Fund and the US PEPFAR and PMI programs.

• Capitalize on its relationship with Minsters of Finance.  The World Bank can help itself and other donors extract real commitments for increasing domestic financing for health (the recent joint meeting of Ministers of Health and Finance is a great start).  Studies have shown that donor funds coming in can displace domestic spending, reducing sustainability and political ownership.  In helping develop medium term expenditure frameworks, informing IMF structural adjustments, and otherwise engaging with budget experts, the World Bank has unparalleled access to decision makers that can be more fully exploited.

• Develop and expand social insurance and protection schemes, which the World Bank knows well, especially by helping the few countries that have done it well share best practices with those that haven’t.  The World Bank could also engage manufacturers of various health products to offer concessionary or tiered pricing for products purchased through these insurance schemes, reducing the cost of serving the poorest -- concessions that are often lost when countries graduate out of low-income status.

• Finally, expand results-based financing schemes to focus donors and implementing countries on maximizing health outcomes.  Why not agree on an annual cost for every person treated for HIV, for example, and fund against that?  Independent validation of quality and utilization should satisfy donors, who now spend inordinate amounts of energy tracking the cost of every little aspect of delivering treatment (leaving little time to look at quality, service retention, or unmet needs.

There are many more ways that the World Bank can contribute of course.  The World Bank Institute can help countries and donors understand some of the big issues coming forward (the rise of non-communicable diseases, the increasing percentage of extremely poor people in middle-income countries, and the challenge of transitioning away from donor dependency to self-sufficiency are just a few).  Better indicators for health systems investments are needed, as they are for human rights and gender programming.  Monitoring and evaluation efforts, especially to determine programmatic impact, could really use some help.

Most importantly, we need the World Bank fully (re)engaged on health, and so it’s good to hear Dr. Kim making clear that this is his intention.  We’ll expect to see that vision put into action soon!

To learn more about the activities of the World Bank and Dr. Kim, please see this recent blog, “World Bank Will Step Up Analytic Work in Support of Universal Health Coverage,” by my CSIS colleague, Nellie Bristol.