The World Bank and Global Health

by

Reiko Kanazawa

• LAST MODIFIED: 17 April 2025
• DOI: 10.1093/obo/9780197768723-0007

Introduction

Established to promote peaceful economic cooperation at the July 1944 Bretton Woods conference, the World Bank has played an important role in international health through its core mandate to reduce poverty. As of late 2024, its health strategy is squarely focused on universal health coverage, climate change, nutrition, and pandemic preparedness. Although its involvement has evolved throughout the years, the World Bank’s fundamental nature as an economic institution allows it keen insight into the structure and financing of health systems. Lending for health emanates primarily from the International Development Association (IDA) (grants or no-interest loans for the poorest countries, created in 1960) and the International Bank for Reconstruction and Development (IBRD) (the original institution established in 1944 making low-interest loans for middle-income nations), the two halves that make up the World Bank. Its foray into health began in the late 1960s through projects in population control and nutrition, areas that related more directly to its overarching mandate for economic development. Health-focused lending officially began in 1979 with the creation of the Population, Health and Nutrition Department (PHN) and activities expanded to infectious disease control and health systems reform. During the global economic recession of the 1980s, the World Bank facilitated dialogue on the relationship between health and economics, as well as the precise role that governments should play in the health sector. By the 1990s, a decade marked by declining aid and heated debates over developing country debt, the World Bank controversially pushed the issue of financing, efficiency, and cost-effectiveness of health systems under its renewed 1997 Health, Nutrition and Population Sector Strategy. Two more organizations in the broader World Bank Group—the International Finance Corporation or IFC (established in 1956) and the Multilateral Investment Guarantee Agency or MIGA (established in 1988)—began lending to private actors, such as corporations, lenders, and investors. At the same time, health practitioners, civil society watchdogs, and social medicine advocates across the globe began highlighting the negative effects of World Bank projects on the health sectors of lower-income countries. By the 2000s, the World Bank had to reconfigure its place in a rapidly evolving landscape of global health governance. Although its presence in global health has noticeably declined after the turn of the century, according to an August 2022 press release, the World Bank has committed over $200 billion (“an unprecedented level of financial support”) for COVID-19 responses.

Overviews

In its first few decades, the World Bank focused on infrastructural projects in rebuilding and reconstructing former warring nations and most lending was for power, telecommunications, and transportation. It had little interest in financing what was called “social sector” projects such as sanitation, nutrition, and public health, seen as fundamental responsibilities of national governments assisted by the World Health Organization, the UN’s specialized agency for health. World Bank staff perceived “social” projects as inherently difficult to manage and deliver, with ambiguous and unquantifiable indicators of success. There was also relatively low client demand for social welfare projects. By the late 1960s, with the appointment of Robert McNamara as president in 1968, the World Bank’s institutional focus shifted to address basic human needs in very poor countries. This new approach centering on poverty reduction expanded action in the health sector, as Staples and Sayward 2006 and Fair 2008 show. Family planning and demographic transition, education and literacy, agriculture and nutrition, maternal mortality and infant survival became significant areas of interest during the 1970s, as Ruger 2005 documents. The World Bank’s first major effort in infectious disease control was the long-term Onchocerciasis Control Program in West Africa (emanating from the Africa regional unit), the success of which led to the establishment of the Population, Health, and Nutrition (PHN) Department in 1979. Directed first by Canadian physician John Evans, PHN launched the Bank’s “operational focus” on health. Beyond project financing, World Bank activities in health expanded to policy guidance, which consisted of collating project findings in policy papers, strategy documents, and development reports. Though initially supportive of WHO’s Declaration of Health for All through Primary Care in 1978, the World Bank by the late 1980s focused on selective interventions for high mortality health issues, in particular endemic disease, as detailed in Cueto 2004 and Brown, et al. 2005, both pieces authored by medical historians. World Bank staff contributed widely circulated and highly controversial concepts in health economics, such as burden of disease and the disability-adjusted year life (DALY), as shown in Abbasi 1999a and Beyer, et al. 2000. Several waves of internal reform shifted the way its health output was managed, personally recounted by former staff in Abbasi 1999b, including a 1987 restructuring, which essentially repositioned the World Bank as operational support, followed by another 1993 reform that reinstated PHN (for a full breakdown, see World Bank 2024). Detailed extensively in Fair 2008, the next major shift came in 1997 under the renewed Health, Nutrition, and Population (HNP) Sector Strategy, which notably increased the role of the International Finance Corporation or IFC, the World Bank arm that lends to private entities.

• Abbasi, Kamran. “The World Bank and World Health: Healthcare Strategy.” British Medical Journal 318.7188 (1999a): 933–936.

  DOI: 10.1136/bmj.318.7188.933

  Part of a series published in the British Medical Journal by assistant editor Kamran Abbasi on the World Bank’s post-1997 strategy for health, this paper reviews some of the more controversial health economics concepts offered by the Bank as well as its views on the “‘optimal balance’ between public and private sectors” in health (p. 933).

• Abbasi, Kamran. “Interview with Richard Feacham.” British Medical Journal 318.7192 (1999b): 1206–1208.

  DOI: 10.1136/bmj.318.7192.1206

  For a more personal account of the evolution in the World Bank’s health activities, Abbasi interviews Richard Feacham, then director of the Health, Nutrition and Population Department (HNP—the new name of the PHN Department after 1997). Available online by purchase or subscription.

• Brown, Theodore M., Marcos Cueto, and Elizabeth Fee. “The World Health Organization and the Transition from ‘International’ to ‘Global’ Public Health.” American Journal of Public Health 96.1 (2005): 62–72.

  DOI: 10.2105/AJPH.2004.050831

  Situates the World Bank’s increasing influence in the long view of international health cooperation but tells this story through WHO’s eyes, focusing particularly on its loan-based model and perspectives on health financing in the 1980s.

• Cueto, Marcos. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health 94.11 (2004): 1864–1874.

  DOI: 10.2105/ajph.94.11.1864

  Examines how the World Bank’s response to the World Health Organization’s Declaration of Health for All (Declaration of Alma-Ata) by the year 2000, through the counterproposal of Selective Primary Care declared at the Health and Population Development Conference, held in Bellagio, Italy, in 1979, sparked thinking on the precise role of government in health care in many lower- and middle-income countries.

• Fair, Mollie. “From Population Lending to HNP Results: The Evolution of the World Bank’s Strategies in Health, Nutrition and Population.” Independent Evaluation Group (IEG) Working Paper 2008.3. Washington, DC: World Bank, 2008.

  The Independent Evaluation Group (IEG) evaluates World Bank projects for accountability and publishes performance ratings. This 2008 background paper for an evaluation of the World Bank’s health, nutrition, and population activities reviews population lending in the 1970s, primary care in the early 1980s, health financing and reform in the mid-1980s to mid-1990s, health systems in the late 1990s to the mid-2000s, and global public private partnerships and health systems strengthening in the 2000s. Students might start with Annex B (p. 43).

• Ruger, Jennifer. “The Changing Role of the World Bank in Global Health.” American Journal of Public Health 95.1 (2005): 60–70.

  DOI: 10.2105/AJPH.2004.042002

  Former HNP economist reviews the major changes in the World Bank’s development thinking, noting how the Onchocerciasis Program reshaped the institution’s approach to the health sector.

• Staples, Amy, and Amy L. Sayward. The Birth of Development: How the World Bank, Food and Agriculture Organization, and World Health Organization Changed the World, 1945–65. Kent, OH: Kent State University Press, 2006.

  Historical monograph arguing that these three agencies, the World Bank in economics, the Food and Agriculture Organization in agriculture, and the World Health Organization in health, each used their specific multilateral “methods of public-private cooperation” (p. 6) to construct and prescribe a particular worldview of modernization and development upon the less developed world.

• World Bank. “Population, Health, and Nutrition Sector.” Archives Catalogue. Washington, DC: World Bank, 2024.

  This description of records in the archives catalogue contains a precise account of the changes in internal departmental organization and portfolio management of the World Bank’s population, health, and nutrition activities.