Washington DC to New Delhi: the World Bank's influence in maternal and child health over the last five decades
INTRODUCTION: The World Bank is one of the biggest external funders for maternal and child health in India and the world. Despite being a major actor in the global landscape for maternal and child health, there is no comprehensive analysis of the Bank’s historical involvement and influence in this area. This study thus documents the contributions and limitations of the Bank’s involvement in maternal and child health globally over the last five decades, and examines its influence nationally through the case study of a Bank-funded flagship project in India. METHODS: I used a mixed methods research design for this study, consulting primary and secondary sources of data. For analysing the Bank’s historical involvement in maternal and child health over the last five decades, I consulted and analysed documents, archival records, and financial datasets from the World Bank, as well as relevant published literature and grey reports. For the case study of the Bank’s influence in maternal and child health at the national-level in in India, I conducted 30 key informant interviews, and reviewed project documents, archival records, and published literature. I analysed the India case study using a conceptual framework of donor influence developed based on theoretical and empirical literature. RESULTS: Globally, the Bank contributed $24.6 billion for 484 maternal and child health projects in low-and-middle-income countries from 1970 to 2018, $1.4 billion in trust funds from 2005 to 2015, and $106 million in special health programmes from 1987 to 2014. The Bank solidified its role for maternal and child health through its cooperation with donors, UN agencies, and NGOs, to form partnerships and global health initiatives. The Bank’s conceptualisation of maternal and child health has evolved from being purely instrumental to now being considered for its intrinsic value albeit along with the economic case of improving productivity and economic growth by saving lives of women and children. Over the years, the Bank has moved from employing a selective programmatic approach towards a more comprehensive agenda as demonstrated by the increase in its lending for projects on health systems strengthening and multi-sectoral issues. This study also found a shift in the Bank’s focus on public sector provision of maternal and child health services from the 1970s until the mid-1980s, to its promotion of private sector involvement, and its current support of publicprivate partnerships. The limitations of the Bank’s involvement in this health area primarily revolved around its promotion of privatisation and the reduced role of the state in financing and service provision, which undermined the access, availability and quality of health services for women and children, especially from socio-economically vulnerable communities. In India, the Bank used a range of resources and mechanisms to exert its influence over the Ministry of Health and Family Welfare to achieve six policy outcomes for maternal and child health viz. target-free policy for family planning, priority for reproductive and maternal health, decentralised planning, financial monitoring system, strengthened procurement system, and increased domestic financing. Contextual issues including political, economic, social, and organisational factors shaped the India-Bank interactions and subsequently, the process of donor influence. Ultimately, despite the influence of the Bank, the sustainability of the policy outcomes lies within the remit of the domestic agency. CONCLUSION: In order to be more responsive in this area, leaders within the Bank will need to consider reforms: such as framing maternal and child as a basic human right with intrinsic value, aligning its financing with countries that have the highest burden of maternal and child mortality, supporting countries with sustainable strategies for domestic resource mobilisation, increasing its support for health systems strengthening, and most importantly, including local voices and perspectives to inform its programmes.