RHP&EO is the electronic journal of the International Union for Health Promotion and Education

The Moral Basis For The World Bank's Investing In Health

Reidar K. Lie

The World Bank published its World Development Report, Investing in Health, in 1993. It points to a number inequities in today's health care systems. Public money is spent on interventions of low-cost effectiveness for wealthy people in urban areas, at the same time as cost-effective interventions are not available for the rural poor. The Report instead recommends that public money should be used to deliver a package of essential public health interventions and essential clinical services. Delivering this package should be a government responsibility, and the essential package of health services should be available to everyone, independent of one's ability to pay.

The essential package should include services such as chemotherapy for tuberculosis, prenatal and delivery care, school health education, tobacco and alcohol control, and prevention of AIDS. The remaining clinical services should be financed privately or by social insurance.

The recommendations are based on the following principles:

1. No public money should be used for services that are not available for the poor;

2. If one has limited resources, one should select health services so as to maximize health benefits using the resources available;

3. Efficiency and quality are best promoted in an environment of competition.

If followed, the recommendations would result in major restructuring of health care services in many developing countries. They are also relevant for health care in industrialized nations. The recommendations are, however, based on controversial moral principles that will be examined in this paper. Some of these are:

1. The only morally relevant principle of resource allocation is health maximization;

2. In the calculation of health benefits it is assumed that a) later years count less than earlier years b) Time around age 20 is more valuable than earlier and later ages c) one should use a cost-effectiveness rather than a cost-benefit approach

3. A two-tiered system is preferable to a one-tier system;

4. It is assumed that one should calculate what services could be provided within a given budget, rather than start with notions such as basic human needs or Amartya Sen's capabilities approach.

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Last modified: October 07, 2000

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