This article was written by Yusra Ribhi Shawar, an Assistant Scientist at the Johns Hopkins University Bloomberg School of Public Health with a courtesy appointment at the Paul H. Nitze School of Advanced International Studies, and Jennifer Prah Ruger, the Amartya Sen Professor of Health Equity, Economics, and Policy at the University of Pennsylvania.
Right-based health practice at the World Bank is complicated. On the one hand, the World Bank supports human rights through its efforts. This is reflected in its pledge to help countries achieve universal health coverage and in its “twin goals” of ending extreme poverty and promoting shared prosperity. These commitments implicitly contribute to the realization of social and economic rights. On the other hand, however, the World Bank rejects a formal legal obligation for mitigating human rights risks, it lacks any systematic examination of the potential social harm that it sponsors, and there is evidence that some of its projects have economically or physically displaced millions of people. The United Nations Special Rapporteur on extreme poverty and human rights has recently described the institution as a “human rights free zone.”
Given the institution’s central and growing role in health funding and policy, the extent to which the World Bank applies right-based approaches is relevant to those working in global health. The World Bank formally became involved in global health in 1979 – 35 years after its establishment in 1944 – and is now considered one of the leading global health institutions. It manages a Health, Nutrition, and Population portfolio of US $11.5 billon, plays a significant role in global health cooperation, and provides millions with essential health, nutrition, and population services.
We highlight five key challenges and five opportunities for advancing rights-based health approaches at the World Bank.
Five Challenges to Rights-Based Health Approaches at the World Bank
What explains the Bank’s caution with – and at times, outright rejection of – integrating rights-based approaches in its health work?
Unresolved Legal Constraints
A principal barrier to human rights integration lies in the institution’s founding documents: the Articles of Agreement. In order to protect state sovereignty, the founding member countries purposefully restricted the Bank’s mandate to economic activities and explicitly forbid it from intervening in a country’s political affairs or engaging in decision-making based on political considerations. By prohibiting engagement in political activity, the Articles of Agreement restrict the Bank’s involvement with human rights, which continue to be understood as “political considerations.”
Economists occupy most senior management positions at the Bank, and their way of thinking reigns, influencing how institutional goals are crafted and justifications are articulated within the institution. From this economist perspective, an explicit commitment to rights-based approaches (which requires projects to be participatory, transparent, etc.) is perceived to run counter to the Bank’s central economic goal of efficiency (swiftly designing and implementing projects with few obstructions and impediments).
Internal Knowledge Gap
The World Bank’s engagement with human rights is hindered by the lack of staff knowledge concerning the application of human rights. Bank teams are often not trained about how human rights can be applied in their work and are uncertain about how human rights can help provide concrete answers.
Some key countries oppose the Bank’s engagement with human rights, arguing that the rights-based approach interferes with state sovereignty. Other countries resist rights-based approaches because they already face challenges with gender equality or the existing, basic governance indicators required by the Bank. These countries are concerned that a rights-based approach at the World Bank would expose their human rights records and require them to undertake rigorous assessments as part of the loan process. In addition, some member countries believe that a formal Bank endorsement of human rights could result in demands for political democracy – a threat to non-democratic governments that could result in the destabilization of states lacking democratic institutions.
Competition with Emergent Lenders
New multilateral investment banks (e.g., the Asian Infrastructure Investment Bank and the New Development Bank) and emergent national development banks in countries such as Brazil, China, and India do not have the same social standards as the Bank. Because of this, there are fears that the Bank will increasingly be swayed from integrating human rights requirements in their lending in order to remain competitive with other banks and be perceived as the most efficient, with the fastest speed of fund disbursement and least project requirements offered to country borrowers.
Five Opportunities to Advance the Right to Health through the World Bank
Despite these challenges, are there reasons for optimism in integrating rights-based approaches in the Bank’s health work?
The Nordic Trust Fund
Established in 2009 with contributions from Denmark, Iceland, Norway, Finland, Sweden, and Germany, the Nordic Trust Fund is a US $34.8 million internal “knowledge and learning initiative” that clarifies for Bank staff how human rights relate to their work and goals. It essentially sidesteps the Bank’s lack of institutional policy on human rights by improving project-level rights protections, including on several health-focused projects.
Implementation of the New Environmental and Social Framework
Made official in August 2016, the Environmental and Social Framework (ESF) incorporates important reforms to the previous ad hoc and burdensome loan policies, including the addition of stakeholder engagement throughout the project lifecycle and a greater focus on strengthening borrower frameworks and capacity building. One of the ten Environmental and Social Standards (ESS 4: Community Health and Safety) explicitly addresses the “health, safety, and security risks and impacts on project-affected communities,” with special attention to vulnerable populations, and there may be opportunities for rights-based approaches to be applied in their implementation.
Organizations such as Human Rights Watch, the International Consortium of Investigative Journalists, the Bretton Woods Project, and the Bank Information Center serve an important human rights accountability function by monitoring and reporting on the negative impacts that some Bank projects have on the human rights of specific populations. By uncovering the adverse impacts of Bank projects, these NGOs improve existing accountability mechanisms and help create the evidence for considering an explicit institutional commitment to human rights.
Internal Human Rights Research
There is a growing body of research within the Bank that concerns human rights. This research builds on studies conducted by the Bank in the past, which have found large and statistically significant effects of civil liberties on the rates of return of investment project.
Appointed in 2012, World Bank President Jim Kim is unlike past World Bank presidents. Once a major critic of the Bank, he is a medical doctor, anthropologist, and co-founder of Partners in Health – a global health organization dedicated to improving the health of impoverished populations. His humanitarian experiences and perspectives – coupled with his reputation for expanding the institutional boundaries of the Bank’s mandate – make him a potential champion for catalyzing the institution’s application of right-based approaches in health.
Optimism for a Rights-Based Approach to Health at the World Bank?
There remain several deeply embedded institutional challenges to adopting rights-based approaches in the World Bank’s health work, but there are also emergent opportunities that may be instrumental to overcoming entrenched institutional challenges or, at the very least, facilitating a renewed conversation about the World Bank’s role in supporting human rights for global health.
Read more about the World Bank’s efforts to engage a rights-based approach to health in:
Human Rights in Global Health: Rights-Based Governance for a Globalizing World (2018) available from Oxford University Press or Amazon.com
Shawar YR, Ruger JP. (2018). The World Bank and the right to health: A study of the institution’s right- based discourse. Global Health Governance. 12(1), 87-107.