Albert Francis E. Domingo, MD

my flight of ideas

MSc Essays – World Bank Structural Adjustment Programs in the Philippines

Posted on | June 12, 2015 | No Comments

Critically assess the World Bank’s impact on public health with reference to structural adjustment. Discuss with reference to a specific country or region.

Albert Francis E. Domingo, MD[1]

[Also available as a PDF at this link.]

Introduction

On 14 October 2014, the Philippines’ Finance Secretary heralded news that the country has signed on to a new Third Development Policy Loan (DPL 3) worth $300 million with the World Bank. As reported in the mainstream news media, “[u]nder the loan, the Philippines will receive support in strengthening priority public investmentment implementation, reducing the cost of doing business for jobs creation and poverty reduction, developing the human capital of the poor, promoting fiscal transparency and good governance, as well as consolidating fiscal sustainability through revenue mobilization and risk management,” and the Department of Finance will promote “policy dialogue and monitoring and evaluation” with other government agencies, including the Department of Health (Rivera 2014). A few months later at a press conference in Japan, World Bank Group President Jim Yong Kim (2015) gave an optimistic overview of how the Bank can end extreme poverty by the year 2030, thereby boosting shared prosperity. In his speech, Kim made reference to an earlier pronouncement by his predecessor in 1973, Robert McNamara, who described a situation that the Bank wanted to avoid: “a condition of life so degraded by disease, illiteracy, malnutrition, and squalor as to deny its victims basic human necessities.”

In 1980, after McNamara eloquently sketched the above picture of “absolute poverty” and shifted the Bank’s focus from post-war reconstruction to poverty eradication (Konkel 2014), the Philippines, with then President Ferdinand Marcos in power, signed on to its first Structural Adjustment Loan (SAL) Agreement (Loan Number 1903; Anon 1980). There have been earlier efforts (as far back as 1949) at structural adjustment independent of the Bank’s influence. One closer action was by the International Monetary Fund (IMF) in 1976-1979 through its Extended Fund Facility (EFF) (Montes 1988). Often lumped together with other “neoliberal” policies, structural adjustment programs (SAP) by the Bank have been strongly criticised globally as having a negative impact on public health, through its three main policy interventions of (i) reduced government expenditure, (ii) liberalisation of markets, and (iii) exchange rate devaluation (Breman and Shelton 2007). Caution has often been aired however that a nuanced analysis of this claim has to be informed by a specific country context, including how macroeconomic policies translate to microeconomic decisions of the population being studied, and that as far as is practicable, an empirical and data-driven approach should be used (Herrin 1992).

This essay shall critically assess the World Bank’s impact on public health with reference to structural adjustment. It will do so with reference to the country experience of the Philippines. It shall begin by describing the original mandate of the Bank, and analysing how a financial institution for post-war reconstruction turned into an influential actor in global health. It will then examine the actual practices of the Bank in a specific period known for neoliberal policy influence and structural adjustment through conditionalities imposed as part of contractual loans, including how these have affected public health outcomes. At that point, the unique country context of the Philippines will be highlighted – particularly in light of political developments that may have provided justification for neoliberalism first as a tool to enrich a dictator and his cronies, and then as a means to undo the damage that was inflicted by a corrupted state. The essay will then discuss frameworks by which SAP impacts on public health may be evaluated, how difficult it is to do this, and how empirical data on the Philippines may be interpreted both positively and negatively. A brief update on the changing context both as regards the Bank’s practices and concerning the Philippines’ situation will then be provided. The essay will finally conclude with a summary of its key points, and some recommendations for further analysis. 

An International Mandate for Reconstruction and Development

Formally known as the International Bank for Reconstruction and Development (IBRD), the World Bank has in its Articles of Agreement (Anon 2012) five purposes, foremost of which is

“[t]o assist in the reconstruction and development of territories of members by facilitating the investment of capital for productive purposes, including the restoration of economies destroyed or disrupted by war, the reconversion of productive facilities to peacetime needs and the encouragement of the development of productive facilities and resources in less developed countries.”

Notwithstanding the four other purposes, an ordinary meaning interpretation of the above would seem to imply that well after members have recovered from the second world war, which occurred right before the Bank was established in 1944, then it would have accomplished its purpose and perhaps proceed with permanently suspending its operations and closing down, the procedures for which are also provided for in its Articles of Agreement (Art VI, Sec 5). An analysis of its institutional design however explains that, unlike other more recent global and inter-governmental initiatives that responded to specific crises, the Bank’s greater formality and legal structure makes it less disposable and thus enduring (Wouters and Odermatt 2014).

On the one hand, this staying power of the Bank may be attributed to its ability to continually redefine its purpose, through supposedly narrow restriction brought about by the “political activity prohibited” clause in its Articles of Agreement (Art IV, Sec 10). The Bank does this through an as-needed reinterpretation of what “economic considerations” mean. Thus, where the Bank used to always focus on discrete and often literally concrete projects towards the exclusion of a country’s political sphere, it now provides inputs to a country’s general policy environment under the justification that doing so addresses the economic considerations upon which the project must be completed (Bradlow and Grossman 1995). On the other hand, this flexibility as to its mandate has also been criticised as “mission creep”; furthermore, grouping this with the Bank staff’s loyalty to the institution alone (and not so much to its member states) and its access to large amounts of resources, there is the apprehension of it having a “Frankenstein problem” where the members may have lost control over time due to increasing autonomy (Wouters and Odermatt 2014).

It must be noted however that the Bank’s inclination towards development is not just an after-thought, but is integral to its very genesis. The 1944 Bretton Woods conference is often cited as the conceptual birth of the Bank (specifically the IBRD), but its design can be traced earlier to efforts to establish an Inter-American Bank pushed by Latin American countries and then rejected/accepted by the United States at varying instances and for different reasons. In describing this formation, Helleiner (2009) seems to have shown the precursor for a public (Keynesian) vs private (neoliberal) sector leadership debate even then, when internal US debates between private bondholders and the US Treasury as to the IBRD’s financing prevailed. Initially, there was an analogy that framed the Bank as an international equivalent of the domestic state’s role in equitably redistributing accumulated wealth. In any case, the Marshall Plan of 1947 meant that huge sums of money were made available for post-war reconstruction apart from the Bank’s own funds (Konkel 2014). Henceforth, “[r]elieved of the reconstruction burden, the bank’s directors turned their full attention to development” (Ruger 2005, p.62).

The Bank’s Macroeconomic Development Policies and their Effects on Public Health

The Bank’s current influence in global health stems from its activities and interests in Health, Nutrition, and Population (HNP), within its flexible mandate of development. In his treatise on the concept of poverty in the Bank’s history, Konkel (2014) outlined how the institution considered poverty and its social dimensions, health being one of them, and how “absolute poverty” was seen as an impediment to the successful repayment of loans taken out by its members. From the moment Bank President McNamara differentiated “relative poverty” from “absolute poverty”, poverty was reinterpreted within the “economic considerations” that would justify bank intervention.

To make itself more influential in domestic policy notwithstanding the small percentage of its loan amounts in the financing of development costs in developing countries, the Bank introduced conditionalities into its loan instruments, which had the force of contract law between itself and its client states. The “neoliberal” orientation of the Bank’s policy prescriptions was not part of its design or mandate; it came in the 1980s coincidental with the prominence of the Washington consensus. This took place internally via a personnel overhaul that included the appointment of Anne Krueger who had a strong neoliberal orientation (Konkel 2014).

The above being said, four elements should be distinguished at this point of the essay, namely that (1) outside of the original mandate of the Bank, (2) it imposed structural adjustment as a precaution to minimise the risk of non-repayment, (3) through the contractual/legal mechanism of loan conditionalities, and (4) incidentally with the ideological motivation of neoliberalism prevalent at the time. It is the confluence of these four elements that has been extensively assailed as harmful to public health, especially that of the poor; for convenience and the purposes of this essay, a structural adjustment program (SAP) by the Bank shall mean this confluence.

An SAP is said to affect public health because of its requirement for a government to reform its macroeconomic policies so that it will be able to repay loans that it will be provided by the Bank. Typically, this means the legislation of measures “to “adjust” the structures within which economic activity occurs, or social and economic policy is made, so that these structures are more likely to produce economic growth” (Bradlow and Grossman 1995, p.421). These adjustments are often classified under three general themes: (1) reduction in government expenditure (i.e., austerity measures), (2) liberalisation of markets, and (3) exchange rate devaluation (Breman and Shelton 2007). Gostin (2014) cites the influential nature of an SAP, because its acceptance and implementation by a debtor country signalled to other sources of foreign funding whether a government could be trusted to repay its loans, through responsible macroeconomics.

Scholars who have defended the rationale for SAPs often say that the short-term negative impacts of austerity measures and other related neoliberal adjustments will be outweighed over the medium- to long-term by gains in prosperity and development. While to some extent this “intertemporal trade-off” may be tolerated in specific sectors, the same cannot be said for public health, as for example in the case of children (Peabody 1996, p.827):

“Tomorrow’s generation are today’s children. If they bear the burden of reform or, more specifically, their health bears the burden, they are more likely to be poor and less likely to contribute in a future, successfully reformed economy. The short-term deterioration of children’s health, therefore, imposes long-term costs that cannot be recovered by future economic growth.”

Herrin (1992) cautions that any empirical impact evaluation of SAPs on public health will have to be well-informed as to the specific implementation nuances of policy adjustments, as well as the pertinent characteristics and behaviors of the supposedly affected population. He also raises the need for a research strategy that includes the assessment of a counterfactual, because SAP impact on the public health of a particular population has to be evaluated relative to another population group wherein an alternative set of policies were implemented. Thus the debate on whether or not SAPs are bad for public health continues up to the present. Breman and Shelton (2007, p.229) provide a dispassionate overview of recent trends in published literature:

“It is not possible to conclude that the empirical evidence shows purely negative or positive health outcomes resulting from structural adjustment. Furthermore, there is no evidence that more recent studies are more positive/negative than are previous ones. The outcomes seem to depend on the variables investigated, the country or region, and the method used.”

Even with the difficulty of obtaining empirical evidence on the impact of SAPs on public health, there still are critiques that build on this very difficulty of measurement. For instance, Babb (2005, p.204) reasons that the divergent social outcomes of SAP programs are due to Bank’s policy prescription for markets to be uniformly “transplanted to alien worlds, governed by different norms and rules, and lacking the supporting institutions that took decades or even centuries to develop organically in their original contexts”. Interestingly, she posits that in its approach to SAPs, the Bank may have been misguided because of a heavy reliance on economics as a “hard” discipline, to the exclusion of other “soft” disciplines such as sociology, history, and philosophy that could have better informed the content of what debtor countries were required to do.

Konkel (2014) describes how the Bank, even while outwardly monolithic in its pronouncements and policies during the period of SAP implementation, has had stirrings of dissent within its ranks. There were internal papers that called for social indicators of health and nutrition to be included with existing economic indicators in identifying the poor. There was cognitive dissonance because of the extensive use of monetary poverty lines, notwithstanding recognition for poverty’s multidimensional nature that includes health. These apprehensions finally surfaced in the Bank’s 1990 World Development Report (WDR), where investments in primary health and education were advocated as a means to enhance the poor’s productive capacity. This epiphany came at the same time with a belated public acknowledgment by the Bank that its SAPs did have harmful effects on the poor, as a response to widespread criticism that included UNICEF’s annual report entitled “Adjustment with a human face”.

A Dynamic Sociopolitical Role for SAPs in the Philippines

The Philippines’ transactions with the World Bank spans decades (as far back as 1949), similar to the experience of many other low- and middle-income countries (LMICs) that availed of foreign financing to stabilise their economies (Montes 1988; Orbeta 1996; Simbulan 2001). The country’s receptivity to the Bank’s influence may be traced to the former’s status as a colony of the United States. In fact, the “Philippine Commonwealth”, as it was then known, was one of the original members of the new IBRD, with a subscription of $15 million (Anon 2012). This amount made it the 19th out of 45 original member countries in terms of the ascending order of subscription.

When the Philippines entered into its first SAP, Ferdinand Marcos was its President. Marcos started out as a popular and democratically-elected leader in 1966, but in 1972 he declared martial law and started exercising authoritarian, strongman rule over the archipelago. He has been summarily accused of “bankrupting the economy, abusing human rights, turning the Parliament into a rubber stamp, prostituting the military, and undermining the judiciary” (Aquino 1986, p.156). In her paper published on the same year that the Marcos regime was peacefully ousted by “People Power”, Aquino (1986, p.158) recalled how Marcos and his cronies used the Philippine state machinery for personal profit and gain:

“Marcos and his technocrats blamed international economic changes for the country’s economic debacle, but the real reasons are government misspending and inefficiency, extravagance, corruption, ill-advised priorities and the creation of monopolies in major industries controlled by Marcos’s close associates. In a system that was popularized as “crony capitalism,” friends and relatives of the First Family enjoyed tremendous privileges, like huge government loans to run businesses that eventually failed and had to be rescued by the government.”

The situation turned the Philippine state away from the ideals of a “Weberian state”, which is one that recognises the positive contribution of market-oriented institutions so long as they are complemented by “bureaucratically structured public organizations… characterized by meritocratic recruitment and predictable, long-term career rewards…” (Evans and Rauch 1999, p.749). A Weberian state should have been the basis for the neoliberally-oriented Bank SAPs to work; it was not what the Philippines had when the SAPs were introduced to it. The Philippines under the Marcos regime had a state that continually intervened in the economy as a matter of policy (Landé and Hooley 1986).

Of great interest is how the Bank’s SAPs interacted with the Philippines from this era of its sociopolitical history and beyond. Initially, the Bank and its SAP was manipulated by Marcos and his cronies in order to extract resources from the international arena, funds that would be used to strengthen the corrupted state and finance its predation of the local economy, and no complete structural adjustment by the Bank’s influence took place; it was selective, by internal decision of the dictator: “[F]or a full decade Marcos adroitly managed to extract enormous sums from the IMF and World Bank, bilateral donors, and commercial banks,” but “the basic question that observers debate is whether Marcos ever genuinely adopted the reform agendas of the World Bank, the IMF, and his technocrats…” (Hutchcroft 1991, pp.428-430). Towards the successful People Power revolution of 1986, the situation reversed: from helping finance the Marcos regime, the neoliberal, anti-state intervention and pro-free market tenets of the Bank’s SAPs were used by the new and popular administration to undo the “patrimonial plunder” practices of monopolies, state control, and other abuses (Hutchcroft 1991; Landé and Hooley 1986; Montes 1988). Stated differently, Marcos provided an adverse and corrupt personification of Keynesian developmentalism that required state roles to develop, and in doing so, Filipinos may have openly accepted the new neoliberal Bank prescriptions as a way to break free from corrupt Marcosian state intrusion (Bello 2009).

SAP Impacts on Philippine Public Health

The above political situation and interactions between the Philippines and the Bank notwithstanding, we now turn to examine impacts on the country’s public health.

In his empirical analysis that was later on also seen by Orbeta (1996), Herrin (1992, p.7) observed that during the 1980s, even as Philippine government expenditures in general either increased or decreased,

“the expenditures for health and education tend to be more stable… they neither rise in proportion to the rise in total expenditures nor fall sharply with a drastic decline in total expenditures. So if there were adverse (favorable) effects on health and education during the period in question (a difficult statement to make with confidence, in view of limited data), it could not have been simply due to cuts (increases) in real government expenditures in the health and education sectors. The answer has to be found elsewhere: (1) in declines (increases) in private spending as a result of declining (increasing) growth of per capita incomes; and (2) in the manner in which public resources in health and education are being spent (i.e., either less efficiently or more efficiently).”

Herrin’s indication of the need to investigate other indirect pathways by which the SAPs could have affected public health outcomes has been echoed in the literature, as for example when macroeconomic policies on wage limits affect the salaries of health workers, and when currency devaluation increases the prices of imported medicines and medical equipment (Kentikelenis et al. 2015).

While it clearly falls under grey literature and is clear in admitting the difficulties of empirical measurement and establishment of causality, a report written by Simbulan (2001) is worth exploring to see examples of how Bank SAPs may have affected Philippine public health. To some extent, it provides an anthropological perspective similar to the broader and published work of Pfeiffer and Chapman (2010). Simbulan correctly observed that the government’s maintenance of general expenditures for the social sectors throughout the SAP period is in itself an austerity measure, because while health needs increased as part of population growth, public sector capacity to deliver health services stagnated. The Philippine government itself acknowledged this negative impact, when as part of its recent administrative order for universal health care, the Secretary of Health wrote (Anon 2010) that

“Public hospitals and health facilities have also suffered neglect due to the inadequacy of health budgets in terms of support for upgrading to expand capacity and improve quality of services… Data have also shown that the poorest of the population are the main users of government health facilities. This means that the deterioration and poor quality of many government health facilities is particularly disadvantageous to the poor who needs the services the most.”

Bank analysts also recognise, although in a conservative and subtle manner officially challenged by management, its shortcomings in the Philippines insofar as public health is concerned (Zanini 1998, p.4):

“Assistance has ranged from relevant and marginally satisfactory in some sectors (water and sanitation, and transport) to poorly relevant and/or unsatisfactory in others (health, education, agriculture, energy, decentralization)… Bank assistance did not focus, until recently, on access to educational services among the poor, and it has been limited in health and family planning.”

A Changing Context

With the moderated recognition of its shortcomings as far as SAPs are concerned, it seems that the Bank is now catching up and renewing its focus to be more sensitive not just to the “economic considerations” of its activities, but also to their social impacts including health. Ever optimistic about the Bank, Ruger (2014) cites exciting times ahead, with a global health expert now President. She also mentions that the newer approach of poverty reduction strategy papers (PRSPs) places the Bank in a position to “serve countries in achieving their own goals” (Ruger 2014, p.2). Wamala et al. (2007) are not quick to agree however, noting that even with the more consultative nature of PRSPs, they still are not that objective in recognising health as contributory to economic growth because of the lack of explicit linkages to health outcome targets in the monitoring and evaluation frameworks of PRSPs. They even ask: “Do PRSPs represent SAPs under another name?” (Wamala et al. 2007, p.246).

As far as the Philippines is concerned, an opportunity for policy coherence between macroeconomic and health reforms (Blouin 2007) has emerged recently. The Sin Tax Law of 2012 increased excise taxes on tobacco products and alcohol, which as a revenue measure means better macroeconomic performance, and as a health measure means a decrease in smoking prevalence alongside significantly large increases in government budgets for health (Sta. Ana and Cruz 2014).

Without passing judgment on whether this is consistent with earlier SAPs, what is clear is that the country may now be in a better position to negotiate the terms and conditions of any lending instruments it wishes to sign, if at all. This brings to mind possibilities for new engagement models between the Bank and the Philippines. For example, the Bank can be a coach for health systems strengthening, given its technical and even political familiarity with the country (de Beyer et al. 2000; Levine and Buse 2006).

Conclusion and Recommendations

In this essay, we have critically assessed the World Bank’s impact on public health with reference to structural adjustment and in the country context of the Philippines. First, we returned to the Bank’s Articles of Agreement and then drew upon prevailing literature to show how the Bank’s original mandate for post-war reconstruction shifted to a very flexible interpretation of development that now includes global health. Second, we examined the actual practices of the Bank during the period of SAPs – clearly distinguishing between and among the Bank’s mandate, structural adjustment as a fiscal policy, the contractual/binding nature of loan conditionalities, the neoliberal development ideology, and the confluence of all of these as would affect public health. Third, we explored the unique context of the Philippines, where a dictator in power used a predatory and corrupt state to engage the Bank in a complex game to maximise personal gain, thus also laying the sociological context for neoliberal interventions to take hold and undo his machinations. Fourth, we discussed how public health in the Philippines fared while the political and economic upheavals during the SAP period took place: what empirically appeared as no change in government expenditure on health in one perspective also meant in another perspective that the health system was not being expanded as it should be. Finally, we point to a possibly new direction for the Bank to engage a country with relatively better macroeconomic performance, giving it a stronger position to negotiate unlike the circumstances prevailing when SAPs were first introduced.

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[1] The author submitted this essay to The University of Edinburgh for assessment in the course “Global Politics of Public Health”. He was a student in the MSc Health Systems and Public Policy programme of the university in the 2014/15 academic year. The views expressed herein are the author’s own, and do not necessarily represent those of the university or its faculty.

Suggested citation: Domingo, A.F.E. (n.d.) Critically assess the World Bank’s impact on public health with reference to structural adjustment. Discuss with reference to a specific country or region. [Unpublished].

 

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