Dr. Kim and the World Bank’s Health Role

President Barack Obama’s surprise nomination of Jim Yong Kim to lead the World Bank has revived debate over the presidency remaining in U.S. hands. It has also spurred discussion over the attributes needed to run a global development institution.

The Bank has long been a major player in global health and development, dating to the 1968-1981 presidency of Robert McNamara. It has helped spur funding and analysis of public health and medical efforts in poor countries, though there was always debate within the Bank regarding whether investment in health ought to await economic development, or if it would hasten prosperity even without direct business investment.

An examination of the Bank’s historical role in advancing worldwide health care and Kim’s high-profile efforts to combat tuberculosis and HIV/AIDS offers a sense of the challenges that could await him.

Disease and Development

A turning point in the Bank’s perspective came with the release of its 1993 world development report, "Investing in Health," which argued that the global burden of disease represented a key obstacle to development. For the first time, the Bank drew on mathematical tools and data assumptions, concluding that the institution had long underestimated the scale of epidemics such as AIDS and drug-resistant tuberculosis, and failed to appreciate how significantly disease slowed individual and societal development, particularly in sub-Saharan Africa. The report called for significant changes in government and multilateral strategies, with greater emphasis on broad primary care programs rather than specialty care for members of nations’ elite classes.

In 2000, the Bank endorsed the Millennium Development Goals (MDGs), four of which represent direct health targets; since then, the Bank has invested $24 billion in programs aimed at those health MDGs. Over the last decade, the Bank’s role in health has been threefold. First, it held and managed funds intended for use by the Global Fund to Fight AIDS, Tuberculosis and Malaria; and other multilateral agencies. Second, it directly invested in those institutions and provided funding for a broad range of health initiatives and infrastructure.

And finally, the Bank has provided macroeconomic and financial analysis of health spending, drawing on its technical staff to produce critical assessments of programs and governments’ efforts, forecasting future investment needs, and searching for cost-effective methods for improving both access and quality of health delivery.

Today the World Bank is focused on systems of health care and delivery, directly investing in the infrastructure, skills training, and economic analysis to create and sustain horizontal programs. Simultaneously, the Bank is engaged in a classic vertical program, MAP--the Multi-Country HIV/AIDS Program for Africa, which was launched in 2000 and is due for completion in 2015 in thirty-five countries.

If Kim is elected by the Bank’s board later this month, he will be at the helm of what is already one of the world’s most influential global health players. And though Kim comes from that arm of the global health movement that strongly advocates increased donor spending as key to solving health crises, he will discover that sentiments inside the World Bank are moving in a different direction.

In McNamara’s day, poor countries were far poorer than they are today, and dependency on external aid ran high--70 percent of capital inflows to the entire developing world were in the form of foreign aid. That is no longer true. In 2011 only 13 percent of inflows to developing countries were foreign aid, while 77 percent represented trade.

With the exception of a shrinking number of extremely poor, resource-scarce nations, the developing world in 2012 is, well, developing, growing its GDP and increasing its relative contribution to global trade. Should he become president, Kim will find that few countries want the Bank to map out their health strategies for them, and the old top-down approach to development and global health that had Washington and Geneva deciding what course the poor world ought to follow is no longer palatable. Grand schemes from on high are out; investment in locally derived systems is in.

Battling TB and HIV/AIDS

Kim first rose to prominence with Partners in Health, which he founded in the late 1980s with Paul Farmer and a few other Harvard physicians. In the early years, Kim’s schemes were derived at Harvard and implemented in Haiti and Peru. Local health experts contributed to the planning and execution in those cases, but his short term leading HIV/AIDS programs at WHO reflected a classic top-down approach.

In the 1990s, Kim ran a Partners in Health program in Lima, Peru, where tuberculosis was rampant and drug-resistant forms of the microbe were common. The Peru TB project came on the heels of a multidrug-resistant TB outbreak in New York City, caused by a strain of the microbe that had originated in a prison in Tomsk, Russia. When a Russian strain slammed New York City, local health officials learned how difficult it was to both obtain adequate supplies of the ten key drugs used in combinations to treat the disease, and to get patients to take those drugs every single day for a minimum of six months.

Kim and his Peruvian colleagues drew from the treatment experiences in New York, Tanzania, and several other countries that had battled such mutant strains of TB, adopting the strategy previously dubbed Directly Observed Therapy (Short-course), or DOTS.

Kim’s chief innovation was in applying basic DOTS in an impoverished setting rife with mutant drug-resistant TB. He and Farmer developed what they dubbed DOTS+, which entailed giving a larger combination of antibiotics to poor patients and battling drug companies to knock medicine prices down to rock bottom. They released several documents in support of DOTS+, calling upon WHO to implement their scheme worldwide. The 2002 strategy was not initially well received by WHO, where Kim locked horns with pragmatists that felt the method was overly complex and costly to prove feasible in poor countries. Though WHO’s position on DOTS+ has changed, the strategy remains controversial because tuberculosis is evolving faster than health experts can manage to adapt treatments.

WHO estimates that in 2010, 8.8 million people had active tuberculosis, and rates of drug resistance are soaring so rapidly that over the next three years, at least two million will contract multidrug-resistant TB. Far from proving to be the end-stage TB strategy, Kim’s 2002 DOTS+ scheme seems to have spawned a virtual industry of constantly revising approaches to tuberculosis control and treatment.

Of course, Kim cannot be blamed for the failure of his DOTS+ strategy to stop TB; he also cannot be credited with finding the magic bullet (though some enthusiastic commentators have so-portrayed the situation).

WHO’s resistance to the DOTS+ idea cemented strong distrust of the agency in Kim’s mind. When fellow Korean Dr. Lee Jong-Wook was nominated to lead WHO in 2003, Kim enthusiastically joined forces with him. Lee put Kim in charge of the agency’s 3-by-5 Initiative, a plan to provide three million people with HIV/AIDS in low- and middle-income countries with antiretroviral treatment by the end of 2005.

Once again, Kim’s leadership had controversial outcomes. Guided by his past experience battling what he called "one of the most complicated bureaucracies in the world," Kim entered WHO’s Geneva headquarters with sharp elbows, shaking up staff. Moreover, the Initiative was launched without backing from major donors, and was in competition with President George W. Bush’s PEPFAR program. (In fairness, PEPFAR leaders at the time spoke of "parallel efforts.") Unable to gain significant funding or take leadership in policy directives, the 3-by-5 Initiative failed to meet its targets.

Stiff Competition to Lead Bank

Though Kim’s nomination has received rave reviews from a number of quarters, he faces unprecedented competition. One contender, Ngozi Okonjo-Iweala, is Nigeria’s minister of finance and former managing director of the World Bank. She has received strong endorsement from the Economist and appears to be highly popular among World Bank staff. She has served as both finance and foreign minister of Nigeria, authored two books, and managed the World Bank.

As if Okonjo-Iweala weren’t enough of a challenge, Brazil--one of the World Bank’s greatest success stories--nominated Jose Antonio Ocampo, former finance minister of Colombia. Ocampo has been an influential economics and development advisor across Latin America and the Caribbean. Within minutes of his formal nomination, the Financial Times published a blog post supporting Ocampo’s candidacy.

Because Ocampo’s work has focused on climate change and "green development," there are many inside the Bank working on those problems who fear his presidency could pose a problem.

Similarly, there is considerable nervousness inside the health programs of the Bank regarding Kim’s likely accession to the presidency. The worry is that Kim might put greater emphasis and funding into HIV in particular and other health programs, driving a jealous wedge between the global health sectors and development programs.

Like his nominated opponents, Kim has amassed impressive credentials. On April 11, Kim stressed his willingness to "challenge existing orthodoxies" and eschewed a "rigid, ideological approach" to development issues in his prepared statement to the World Bank’s board. Yet to date, Kim has favored a big donor approach to disbursing aid. The World Bank needs to be directed from its old G7-think to a post-G20 worldview that not only embraces the macroeconomic strengths and power of the major emerging powers--China, India, and Brazil--but also the relative prosperity and political influence of rapidly growing economies in sub-Saharan Africa, Southeast Asia, and the Pacific.

Whether it is Kim, Ocampo, or Okonjo-Iweala, the new president must steer every Bank program toward truly transformative investments, elevating the most impoverished states into sustained governance, finance, agricultural production, and health. If all goes well, the World Bank should be out of the development game altogether before mid-century.