The landmark in the World Bank sanitary turn was the publication of the 1993 World Development Report “Investing in health” (thereafter 1993 WDR), which made official and rationalized the Bank investments in health as decisive elements in its strategy to alleviate poverty. It thus departed from decades-long commitments to a vision of development centered on the building of infrastructures, on the rise of agriculture productivity and – when it came to deal with populations as such – on birth control (Devesh 1997; Ruger 2005; Staples 2006).
The change was not a sudden, crisis-like event, solely grounded in the new sanitary disorder of the time associated, for instance, with the dramatic impact of the AIDS epidemics. Rather, it had deep roots in 1980s internal debates on the meaning and targets of development, which remain to be properly mapped. For instance the Bank’s Population, Health and Nutrition division priorities were deeply impacted by the 1970s and 1980s contestation of population control programs in the global South and the acknowledgment that some demographic transition was happening worldwide without much correlation with these programs. One critical aspect of these debates was the mounting importance of “human capital” as category for analysis and action as reflected in a wave of reports issued in the 1980s and 1990s (for instance Becker 1995). Human capital theories thus backed a gradual displacement of issues toward health, education and women empowerment reflected in the growing number of projects the PHN division launched and their shifting focus away from nutrition and population control.
A second dimension in the Bank’s sanitary commitment was the complex relationship the shift maintains to structural adjustment policies. Investing in health did not officially contradict the latter’s conditions for granting loans to nation-states caught in the debt crisis, namely the urgency of budget balancing and privatization. True, the Washington consensus singled out health and education as priorities. However, in practice, public investments in the social sector were very often severely cut as an effect of structural adjustment policies. Moreover, all along the 1980s cost recovery in the health system was a persistent motto in World Bank’s reports and memos of understanding with countries (De Ferranti 1985). This provided the background for the famous 1987 Bamako declaration through which African countries expressed their willingness to engage in the generalization of patients’ fees for hospitals services and drugs with the background motive that these fees would ease the financial burden of health institutions, provide rolling funds to improve supply and make “pseudo-clients” more responsible and attentive to the quality of what was provided. This agenda deeply backlashed and critiques escalated beyond the usual circles including public health circles and international organizations like WHO and UNICEF.
In the early 1990s World Bank officials knew it even if they disagreed about the interpretation of such developments, i.e. whether they should be considered as intrinsic flaws of the policy or signs of a misguided implantation by governments marginally interested in human capital development. A World Bank paper issued in 1995 thus tried to put adjustment’s impacts on health into perspective, stating that countries that had undergone adjustment policies were allowed to spend more on health when adjustment ended and when their economy recovered, their spending on health growing faster than in countries that had not followed adjustment policies.Footnote 2 The 1993 WDR was a de facto response as it offered an alternative by strongly endorsing the idea that markets cannot by themselves provide for health care, which is in most instances a public good. Investing in health thus meant in the first place strengthening public, meaning nation-states based, health systems.
Strong elements of continuity with structural adjustments nonetheless prevailed. In the Bank’s eyes, public management of health was only thinkable if cost-effective, if performance was placed center-stage, if targets were carefully accounted and outcomes measured. The introduction of the Disability Adjusted Life Years (DALYs) was therefore not only a way to take into account health problems neglected using the usual mortality/morbidity statistics but also and more importantly the introduction of a measure, which could help balance problems and solutions, could for instance help decide whether, in a world of limited resources, tuberculosis chemotherapy was worth doing and putatively more effective than HIV prevention. Even if the DALYs were eventually criticized internally for their medical rather than economical nature – they could not help decide if states should invest in genetically improved crops or in health centers – the dream of a general equivalent, money-like, was not far away.
Calculating the DALYs implied aggregating mortality and morbidity data under the umbrella of lost years of life and therefore mobilized two different calculations. The first one amounted, for each disease category, to weighting the distribution of death numbers associated with age groups against the life expectancy specific to each country on the basis of coefficients factoring in the decreasing economic usefulness of people according to their age. The main novelty regarded the addition of a certain number of years of life lost due to “disability” based on a fractional equivalence between a year of normal life and a year of impaired life with the disease in question. The coefficients applied for each disease to compute the impact of disabilities, i.e. the number of years of life lost due to bad health were in fact defined by using an average of the answers of a small number of experts to adapted questions in surveys designed to reveal preferences: “You are a decision maker who has enough money to buy only one of two mutually exclusive health interventions. If you purchase intervention A, you will extend the life of 1000 healthy (non-disabled) individuals for exactly one year, at which point they will all die…. The alternative use of your scarce resources is intervention B, with which you can extend the life of n individuals with a particular disabling condition for one year. If you do not buy intervention B, they will all die today; if you do purchase intervention B, they will die at the end of exactly one year.” (Arnessen and Nord 1999, p. 1424). Experts had then to choose the value for n that would make them indifferent between the two programmes (Murray et al. 2002).
Following the publication of the 1993 report, the calculus of DALYs has been much discussed including the ways in which the GBD numbers incorporate a productivity-based understanding of the value of life or a quantified understanding of how valuable, how normal, is a year of life with tuberculosis, diabetes or cancer. Bringing the impact of disease down to a single indicator based on age, gender, the disability situation and the moment when the disease began was justified by the need to build a comparison tool allowing decision makers to choose their interventions by comparing the incomparable, by evaluating, for instance, the difference between the cost of one year of life for a child suffering of vitamin deficiency and cost of one year of survival for a 50-year-old with cancer. Put it differently, the DALYs were an attempt to seize all kinds of suffering in a commensurable way, in order to compare the effects of very different health interventions and choose the most efficient ones in budget constraints contexts, i.e. to try to optimise investments in health by choosing the interventions that would be the most effective in relieving the “burden” of suffering. In resonance with M. Morgan’s analyses in the present book, the invention of the GBD could be understood as accounting data, data linked to the government’s need to monitor the economy in a constraint budget, to arbitrate between different social investments (others than health, also education, see M. Morgan’s chapter) and to evaluate and optimize the returns.
From this point of view, the DALY works in a similar way to the QALY (Quality Adjusted Life Years) in health economics. In fact, the discussion of DALYs in the 1990s was similar to the numerous debates about QALYs, their advantages and limitations; for example, targeting the coefficients used to give the deaths of children or old persons less weight (Gavin 2002), or the arbitrary nature of the assessments regarding the value of one year of life with various disabilities or the value of impaired functioning due to a disease, as if human misery, “evaluations of severity and its cost [could] be validly standardized across different societies, social classes, age cohorts, genders, ethnicities and occupational groups” (A. and J. Kleinman 1996). More important for this paper is however the connection the 1993 report made between the DALYs and the measurement of cost-effectiveness. This was a central ingredient in the valorization of the GBD as basis for triage. This linkage has been overlooked since – for reasons discussed below – it disappeared from the exercise when the GBD machinery moved from the World Bank/Harvard/WHO complex to the Gates/IHME nexus.
The calculus of DALYs was actually combined with a general evaluation of performance in national health systems. For the poorest countries, the recommendation was to stop financing high-technology hospitals and expensive care infrastructure, only of benefit to the middle and upper classes, and to privilege interventions that would meet the needs of the most destitute, populations “at risk”, less because of their peculiar exposure to pathogens than because of their social and economic vulnerability. Hence, the World Bank experts recommended reorganizing protection by defining a publicly offered and freely accessible basic system of care (the only one for which direct, centralized and evaluable action was possible).
One should not be mistaken, the point was not to leave out private actors, on the contrary, but to make a critical distinction between basic and more individual needs, between countries rich enough to cover costs, whatever the mechanism (taxation, insurance or patients’ contribution) without drastic triage and low- and middle-income countries with very limited resources, where most households were not in a position to provide for their health needs, where triage was operating de facto, without much rationalization, favouring the urban middle class, and where the public provision of an “essential package” of interventions (through both public and private, first of all NGOs, services) was indispensable: “Perhaps the most fundamental problem facing governments is simply how to make choices about health care. Too often, government policy has concentrated on providing as much health care as possible to as many people as possible, with too little attention to other issues. If governments are to finance a package of public health measures and clinical services, there must be a way to choose which services belong in the package and which will be left out.” (World Bank 1993 p. 59).
This plea for targeted investments was delineated in a much more detailed and prescriptive way with the selection of 47 interventions for which the Bank panels of economists and health specialists computed costs and numbers of years of life saved in order to provide cost-effectiveness ratio. This complex operation actually started before the writing of the 1993 WDR, namely in 1988, with the establishment of a “Disease Control Priorities” (DCP) working group within the PHN division of the Bank whose initial aim was to develop new tools for measuring the effectiveness (rather than the monetary benefits) of health investments.Footnote 3
The DCP project relied on another kind of triage to define the rationale for government’s involvement in health, not only in prevention but also in curative services. Indeed, published as background material to the WDR report, the DCP working group final document relied on the attempts by panels gathering epidemiologists and economists working on one pathology, i.e. tuberculosis, or one medical issue, i.e. mental health, to assess legitimate interventions in their field, gather all available economic evidence on their costs and outcomes under optimal conditions and – when possible – provide numbers for the cost per DALY avoided. These numbers were then used to rank interventions according to their effectiveness. A major result was that – in contrast – to the classical divide health economists were making between prevention and treatment with the former considered as “public good” due to the importance of externalities and the impossibility to accrue individual benefits to a putative buyer, economic legitimacy crossed the line with highly cost-effective clinical intervention such as tuberculosis chemotherapy and poorly cost-effective preventive intervention such as water sanitation (Fig. 2).
The final outcome of this ranking effort was the proposition of an “essential package of health services” in developing countries. Beyond effectiveness expressed in terms of cost for one DALY avoided, overall spending was critical in the selection: World Bank experts estimated unrealistic to bet on a massive increase of public expenditures in low- and middle-income countries even if they spend much less than developed ones in proportion of their GNP. The essential package was thus limited to a doubling of what low-income countries were already spending to reach the level of $12 per person per year. The package prolonged and provided new legitimacy to existing priorities like immunization, STD treatment, prenatal care, family planning or Aids prevention. Decisive novelty resided in a few items in the category of non communicable diseases prevention and clinical treatment: tobacco control or the more important “limited care” cluster focusing on the treatment of skin allergies and injuries on the one hand, access to medications for pain relief, diabetes, hypertension, and tuberculosis on the other hand (Bobadilla et al. 1994).
Cost-effectiveness and performance – the values imbedded in the first GBD as well as the associated expectations for an economically rationalized triage to some extent confirm the neo-liberal scenario with one qualification, which is to recognize that privatisation of health services was only marginally the issue while triage was the fundamental one. As C. Murray, the man who had so strongly pushed for the creation of the GBD summarized: « Decision-makers who allocate resources to competing health programs must choose between the relative importance of different health outcomes such as mortality reduction or disability prevention. Because money is one-dimensional, the allocation of resources between programs defines a set of relative weights for different health outcomes. The only exception to this is in a completely free market for health care where such decisions between competing health programs are not made by a central authority but by individuals, one health problem at a time. » (Murray 1994).
The logic of economic triage and package design thus exemplify the accounting nature of the DALYs calculus. The comparison of interventions for their cost-effectiveness and their putative inclusion in a public package of services operated within the framework of an imaginary budget balancing exercise, namely a search for the “best” equilibrium between “inputs” (financial resources, most often combining state and donors) and “outputs” (the costs of selected interventions) that may include increasing inputs but most often meant adjusting outputs to preset levels of inputs (see below the example of Bangladesh). Thus, rather than privatizing, states were now mandated to focus on investment performance. They were invited to enter what may be described as an audit culture (Power 1997) based on the use of a whole new range of evaluation and ranking instruments (Gaudillière 2014, 2016).
It was therefore not mere rhetoric when the authors of the report made an unexpected link with the old WHO primary health care strategy, explaining in their overview of the report that: “Provision of cost-effective health services to the poor is an affective and socially acceptable approach to poverty reduction. Most countries view access to basic health care as a human right. This perspective is embodied in the goal “Health for all by the year 2000” of the conference held by the WHO and UNICEF at Alma-Ata in 1978, which launched today’s primary health care movement. Private markets will not give the poor adequate access to essential clinical services or the insurance often needed to access such services. Public finance of essential health services is thus justified to alleviate poverty. Such public funding can take several forms: subsidies to private providers and NGOs that serve the poor; vouchers that the poor can take to a provider of their choice; and free or below-cost delivery of public services to the poor.” (1993 WDR, p. 5).