Tuesday, October 19, 2010

Investing in Healthcare


Access to healthcare is a basic human right. The World Bank is playing an important role in helping South Asian countries to provide this right to their citizens.

Developed countries of the world have in place a robust infrastructure and institutions that see to the provision of these rights, while developing countries struggle with funds and weak healthcare systems. When resources fail to meet demand, various world aid agencies help bridge the gap with financial and technical assistance. The World Bank has been a consistent supporter of South Asian governments in tackling serious health issues like HIV/AIDS and Polio mellitus.


Acquired Immune Deficiency Syndrome (AIDS) weakens the immune system and exposes the body to infections. Although AIDS was first recognized by the US Center for Disease Control (CDC) in 1981, in its third decade it still eludes a cure, there is no vaccine and preventive measures involving practices of safe sex and Syringe Exchange Programs (SEPs) have been advocated as the best approach. In 2007, roughly 33.2 million people lived with AIDS worldwide. An estimated 2.1 million people have also died of it.

Epidemiologists have conducted extensive studies to understand and identify high risk groups and formulate effective management strategies. However, South Asian countries present a unique challenge because of their population diversity which hampers effective management. The World Bank’s report, AIDS in SA: Understanding and responding shares the scope and dynamic of this infection in South Asia. It points out the most vulnerable groups as being Sex Workers (SWs), their clients, homosexual men (MSM), and Injecting Drug Users (IDUs). Once infected, these groups are more likely to transmit infection to large numbers of contacts.

These high-risk groups are present in significant numbers in some South Asian countries. In 2004, India harbored more than 60 percent of the HIV infections in Asia (UNAIDS). In 1998, Prime Minister Vajpayee declared HIV/AIDS as “India’s most important public health problem.” India has a legalized sex industry and at least 500,000 female sex workers (SWs). These SWs are receiving help and information regarding safe sex practices to control the pace and spread of infection. In countries where sex is not a legalized industry, most SWs operate from homes dissemination of information becomes a challenge. Sri Lanka, which has an estimated 30,000 female SWs, is also estimated to have 40,000 to 50,000 drug users. Pakistan has about 500,000 chronic heroin users (UNODC 2002). Figures from neighboring Afghanistan show that, of an estimated 920,000 illicit drug users, 120,000 are women and 60,000 are children (UNODC 2005).

The Detailed Implementation Review (DIR), a World Bank, document gives information on WB contribution in this regard: The World Bank had been a consistent supporter of initiatives in South Asia and has financed HIV/AIDS prevention and treatment programs extensively. In 1992, a World Bank (Bank) assessment revealed that India could “follow in the footsteps of some of the worst affected countries in Africa, resulting in the erosion of many of the past gains in human development.” WB sponsored the Indian government’s National AIDS Control Projects (NACPI, NACPII) and in 1998 the Bank was acknowledged to be its single largest donor. The positive results of the project have now been acknowledged widely.

The World Bank has also conducted studies to help governments understand the best approaches. For South Asia, the costs of treatment to the disease-afflicted populations and consequently, the economy of the country is a serious concern. Mariam Claeson, WB's HIV/AIDS Coordinator for South Asia explored the impact on economic growth in South Asia in the report,’ HIV and AIDS in South Asia’ as a regional development issues: “Although HIV prevalence in South Asia is comparatively low, the region faces a number of challenges including the risk of escalation of concentrated epidemics, the economic welfare costs, and the fiscal costs of scaling up treatment for AIDS. If HIV infections are distributed across the range of South Asian living standards, then only 30 percent of the cases would be above the more generous poverty line of US$2.15. And the poorest 10 percent of these would be pushed down into poverty by AIDS treatment expenditures.” Preventive strategies have thus been propagated as the best approach.


The Global Polio Eradication Initiative was launched in1988; polio was endemic in 125 countries around the world at the time, and 350,000 children a year became paralyzed because of it (WHO). Thanks to the successful global polio vaccine campaign over the past 20 years, it exists only in four countries including three Asian nations (India, Pakistan and Afghanistan) and one in Africa (Nigeria). These countries remain a cause of grave concern as travel to and from these countries challenges containment, and eradication continues to be an elusive goal despite an expenditure of more than $6billion so far.

For Pakistan and Afghanistan, war and instability seems to be a contributor in the spread of polio. In the latter half of 2008, large scale movement of populations from the Northern areas of Pakistan took place due to militant violence and resulting military action. The Internally Displaced Persons (IDPs) from war-affected areas took up residence in camps or with relatives in other parts of the country and the virus moved into areas previously considered free of it. The recent floods have again rendered almost 20 million homeless and forced them into camps. Although updated assessment of spread of disease among them is not currently avialable but it is predicted to be a helathcare nightmare unfolding slowly but surely. In Afghanistan, ongoing decades old war continues to hamper administration of OPVs to affected areas.

The Director of Polio Eradication Initiative at WHO, Dr. Bruce Aylward, in his report to the World Health Assembly said that 2008 was “a very difficult year for the eradication programme." in Nigeria because there was” "a simple failure to reach and vaccinate children,” According to the disease surveillance unit of the WHO, Nigeria accounts for 61 per cent of global polio cases and 95 per cent of cases in Africa. Although southern Nigeria has been polio-free for a couple of years, northern Nigeria, in 2003, stopped immunizing its children against polio when hard-line Nigerian clerics called for the boycott. The result was the spread of polio virus from Nigeria to 23 polio-free countries around the world, including nations as far away as Indonesia and Yemen, effecting nearly 1500 children. The reason for persistence of disease in the Pakistan and Afghanistan rests on similar misconceptions regarding the contamination of polio vaccine with infertility drugs and AIDS virus. This has resulted in stiff resistance against polio eradication campaigns and threats to government and aid officials, challenging containment efforts in these countries

The governments of Pakistan, Afghanistan and Nigeria are trying to reach people through media and religious leaders to remove misconceptions. The campaigns are not likely to meet with success despite support form World community unless religious and cultural concerns are addressed. The number of reported cases in 2009 clearly show more needs to be done – 57 in Pakistan, 22 in Afghanistan, 327 in India and 379 in Nigeria (Global Polio Eradication Initiative) The World Bank is part of the ‘Partnerships for Polio Eradication Project’, and its IDA is providing additional financing of $50million would finance the increased resources required for the procurement of Oral Polio Vaccine (OPV) in support of Nigerian government’s efforts. In Pakistan, the World Bank has supported all initiatives for Polio Eradication. The combined World Bank financing for Polio eradication in Pakistan during 2003-2007 amounts to US $110.78 million. The Bank also approved the credit of US$74.68 million to Pakistan for a Third Partnership for Polio Eradication Project.

While the work done in the health sector of the South Asian countries has been universally recognized and appreciated, some strong criticism has also been noted of the WB policies setting strict financial pre-requisites and asking countries to raise interest loans and reduce government spending in order to get bailout loans during periods of economic decline. Mark Levinson wrote in The Cracking Washington Consensus, how “International financial institutions, the World Bank and the International Monetary Fund (IMF), pressed developing countries to conform to the formula as a condition of their loans.” He also quoted a study from the Center for Economic Policy research which states that , “there is no region of the world that the Bank or Fund can point to as having succeeded through adopting the policies that they promote—or in many cases—impose on borrowing countries.”

There may be truth in that criticism, but it is also a fact that many critical healthcare initiatives in South Asian countries may not have come about without the active support and engagement of World Bank. For this reason, South Asia continues to partner closely with the World Bank to achieve its goals.

SouthAsia Magazine "A Healthy Future" October 2010

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