Editorial
A decisive moment for The World Bank
The next few months will be vital for The World Bank.
In June, David Malpass will step down as President,
following his damaging equivocations about whether
fossil fuels are driving climate change. Malpass’ tenure
has undermined the credibility of the Bank as a trusted
source of assistance and advice at an important time.
The World Bank was established after World War 2 with
the initial aim to help rebuild countries devasted by the
war. It has since focused on reducing poverty, with a wide
portfolio that covers all sectors of development, including
health. Today, most countries’ health financing comes
from domestic resources rather than external aid or loans,
but the development gains of the past are under threat.
The COVID-19 pandemic triggered the largest setback
in poverty since the Bank’s founding. 719 million people
were living in extreme poverty in 2020, 11% more than
in 2019. With growing economic uncertainty and the
accelerating impacts of climate change, the case for a
global development institution that advocates for poverty
reduction and works across all sectors to address the
Sustainable Development Goals has never been stronger.
The potential is huge. The World Bank is a financial
powerhouse—it is the largest funder of development
projects in low-income and middle-income countries
and the second-largest funder of global health. In 2022
alone, it invested $104·4 billion. Over the past decade,
the International Development Association, The World
Bank’s fund for the poorest countries, has financed
essential health interventions for 880 million people,
including immunisations for 360 million children. The
Bank is also a source of ideas, not just capital. It has been
key in championing concepts such as cost-effectiveness,
disability-adjusted life-years, and the first estimates of
burden of disease, which are widely used to track progress
in health.
However, a recent Oxfam report that investigated
71 health projects under The World Bank’s COVID-19
Strategic Preparedness and Response Program concluded
that the Bank had missed vital opportunities to ensure
health for all. It failed in several aspects of health
systems strengthening, which is critical for protecting
health gains and building resilient and equitable health
systems. 16 projects indicated the possibility of private
sector engagement in health service provision, but there
was a worrying lack of transparency, regulation, and
www.thelancet.com Vol 401 March 4, 2023
accountability measures, despite well-evidenced risks of
engaging for-profit private health actors that are likely to
Peter Probst / Alamy Stock Photo
prioritise their own economic interests. Findings such as
these raise questions as to how much better The World
Bank could do to ensure health for all.
A key issue the Bank must confront is debt. Many
loans from the Bank come with stringent conditions
and end up hobbling countries with debilitating
repayments and high interest. Increasing debt, coupled
with the soaring cost of living and accelerating climate
change, risks greater hardships, widening inequality,
political upheavals, and a slower response to the climate
emergency. Concrete proposals to work differently do
exist. Barbados’ Prime Minister, Mia Mottley, argued
in a speech at last year’s UN General Assembly that The
World Bank and the International Monetary Fund are in
desperate need of substantial reform so that they can
tackle these issues. In the Bridgetown Agenda, Mottley
put forward mechanisms—many used already during
COVID-19—to give countries access to cheap liquidity
through unconditional credit and suspension of interest
payments and debt servicing, as well as expanded
multilateral lending and new means to stimulate private
investment in the low-carbon transition.
The World Bank, like all organisations, is imperfect. But
it still has an important role as an activist institution to
defeat global poverty. What happens next will depend
greatly on the next president. The structure of the Bank’s
leadership is, in essence, neocolonial. Although there have
been some reforms, the USA, as the largest shareholder,
retains the greatest voting powers on the Executive
Board. All the previous permanent presidents have been
American. Surely this approach can no longer be right for
a global institution tasked with driving development in
many of the world’s poorest countries. US President Joe
Biden recently announced Ajay Banga as his nominee
to replace Malpass. Born in India but now an American
citizen, Banga has spent most of his professional career
in private sector financing. Will he have the qualities For the Oxfam report see
https://oxfamilibrary.
to drive a true equity, anti-poverty, and decolonising openrepository.com/bitstream/
agenda? The next president has an opportunity to restore handle/10546/621113/bp-
catastrophe-catalyst-world-
confidence in The World Bank at an important, indeed bank-covid-19-041220-en.pdf
possibly existential, moment in its history. It will require For more on the Bridgetown
agenda see https://www.
a leader with the intellectual background, experience, and foreign.gov.bb/the-2022-
reputation to seize the opportunity. n The Lancet barbados-agenda/
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