摘要：The World Bank began operations on June 25, 1946. Although it was established to finance European reconstruction after World War II, the bank today is a considerable force in the health, nutrition, and population (HNP) sector in developing countries. Indeed, it has evolved from having virtually no presence in global health to being the world’s largest financial contributor to health-related projects, now committing more than $1 billion annually for new HNP projects. It is also one of the world’s largest supporters in the fight against HIV/AIDS, with commitments of more than $1.6 billion over the past several years. I have mapped this transformation in the World Bank’s role in global health, illustrating shifts in the bank’s mission and financial orientation, as well as the broader changes in development theory and practice. Through a deepened understanding of the complexities of development, the World Bank now regards investments in HNP programs as fundamental to its role in the global economy. JUNE 25, 2004, MARKED THE 58th anniversary of the World Bank, which opened its doors in Washington, DC, in 1946. The International Bank for Reconstruction and Development, as it was initially called, was created at the Bretton Woods Conference in July 1944, along with its sister institution, the International Monetary Fund. At the outset, the bank’s dual roles were reconstruction and development, as implied by its original name. Its primary function was to reconstruct Europe after World War II. However, unlike other specialized United Nations (UN) agencies the bank raised funds through private financial markets and received donations on a regular basis from the world’s wealthiest countries. 1 With these funds, it provided interest-bearing and interest-free loans, credits, grants, and technical assistance to war-damaged and economically developing countries that could not afford to borrow money in international markets. These activities are ongoing, making the bank the “world’s premier economic multilateral” 2 institution. Over the course of more than 50 years, the bank’s priorities and development philosophy—along with its role in the world—have changed from reconstructing Europe to alleviating poverty in developing countries. Perspectives on development also have changed dramatically during that time. New theories and evidence have deepened and transformed the international development debate and have influenced the bank’s development practices and policy decisions. In particular, the bank now has a more sophisticated view of well-being, living standards, and poverty. In addition, evidence on the primary means of poverty reduction and development has accumulated throughout the bank’s history, and the bank now has an improved, though still evolving, understanding of how to achieve development objectives. In the 1950s and 1960s, for example, when the prevailing wisdom was that economic growth was the key to development, the bank focused primarily on large investments in physical capital and infrastructure, because such investments were viewed as the most likely to increase national income. However, in the 1960s through 1980s development theory shifted to encompass more than economic growth; it aimed at meeting individuals’ “basic needs,” because the objective was to provide all human beings with the opportunity for a “full life.” This approach appealed to bank staff and especially to Robert McNamara, then president of the bank. Consequentially, the World Bank’s focus began to slowly shift to investments in family planning, nutrition, health, and education. In the 1990s, the “Washington Consensus,” which emphasized macroeconomic stability, privatization, trade liberalization, and public sector contraction, dominated development thinking, and the bank focused on open markets and economic management. However, lessons learned from this period of market-oriented reforms demonstrated that good governance, strong institutions, and human capital are critical for eradicating global poverty. Today, the bank views development as a holistic and multidimensional process that focuses on people in the societies in which it operates. This “comprehensive development framework” now gives health, nutrition, and population (HNP) programs a central place in the bank’s work and mission. The World Bank is now the world’s largest external funder of health, committing more than $1 billion annually in new lending to improve health, nutrition, and population in developing countries. The World Bank has gone from having virtually no presence in global health to being one of the leading global health institutions. Over time, its loans, credits, and grants to fund HNP programs have become substantial. The largest shift occurred over the past 20 years: World Bank support for social services such as health, nutrition, education, and social security grew from 5% of its portfolio in 1980 to 22% in 2003. 3 The World Bank is now the world’s largest external funder of health, 4 committing more than $1 billion annually in new lending to improve health, nutrition, and population in developing countries.Moreover, it is one of the worlds’ largest external funders of the fight against HIV/AIDS, with current commitments of more than $1.3 billion, 50% of that to sub-Saharan Africa. 5 Because it allows long repayment periods (up to 35–40 years and a 10-year grace period), it provides the time and resources to address special problems, such as widespread disease epidemics.
