Will Barack Obama Call the World Bank for Advice about Fixing the U.S. Health System?

Along with positive feedback on yesterday’s post about the Global Fund, GAVI and the World Bank (all from individuals who didn’t want to post a comment publicly), I got one question: “Why did you say ‘self-proclaimed comparative advantage in financing and systems issues’? The Bank obviously has the comparative advantage on those topics.”How obvious the Bank’s comparative advantage is depends on the answer to the question “compared to what”?Compared to the Global Fund to Fight AIDS, TB and Malaria and the GAVI Alliance, two organizations established to collect and distribute money for disease-specific programs in developing countries, it’s undoubtedly true that the Bank has a set of assets that make it better suited to engaging in broad discussions about the direction of health financing and organization. The Bank has staff with knowledge about trends in health insurance, for example, and relatively easy access to Ministries of Finance. The Bank’s health sector portfolio has for a long while included many projects designed to improve management information systems, logistics and supply chain functions, health worker training, policymaking at central and subnational levels, and other “systems” stuff. In contrast, the Global Fund and GAVI don’t focus on those areas, for the most part, and have limited policy-level contacts outside of the health sector. So, compared to those two other organizations, the Bank has both the comparative and the absolute advantage in the health systems domain. Compared to other organizations, I’m not so sure. The Bank probably doesn’t look all that great in a line-up with a wide range of other organizations that have specialized expertise in some of the problematic areas that bedevil the health sector – how to establish the right skill mix and set the scope of practice for health workers, how to create an environment of extrinsic and intrinsic incentives for health workers and patients that are aligned with better health, how to determine the “benefit package” for those who are covered by public finance, and on and on.For this in-depth technical support, the UK’s National Institute for Health and Clinical Excellence (cost-effectiveness and decision analysis for resource allocation), the U.S. Joint Commission (accreditation), Mexico’s National Institute of Public Health (measurement and evaluation), South Africa’s Human Services Research Council (delivery models and access for underserved populations), the Zaragoza Logistics Center (supply chain management) and Sri Lanka’s Institute for Health Policy (health systems research) are just a few of the outstanding organizations that have much to offer.This is not a condemnation of the Bank. Its role is in fact not to have deep expertise in the “how” of health systems. It’s like a mortgage banker, specialized in how to put together a financing package and negotiate a deal; it’s not an architect, builder, electrician or plumber.If valuable expertise – the “how” knowledge – resides in diverse, specialized institutions, let’s figure out ways to make that available to policymakers and technical staff who are struggling with major policy challenges. And, moving away from a purely technocratic approach, let’s think carefully about how to ensure the best way to bring technical knowledge to bear within the local political context. It’s that context which, after all, determines whether there is room for positive change in such a sensitive sector. To take two simple examples: If there is no political space to change the relationship between the government (as employer) and health workers, then no amount of knowledge about “contracting in” will add up to better performance. If the public policy choices in a particular country are not motivated by an interest in improving the life prospects of minority populations, then clever “reaching the poor” delivery innovations are likely to fall flat.The trick is to connect the real-world expertise that exists outside of the oligarchy of international organizations with those who can use it. Would it be possible to create a virtual network of global technical expertise on health systems, with a focus on including organizations that are “do-ers”? And can the power to select which type of expertise is needed be placed in the hands of those at the national level who are prepared to champion new ideas and approaches?As plans are laid for a financing platform for health system strengthening, the challenge is to offer – unbundled from the money – the most useful knowledge the world has to offer.