People can’t afford to pay for health care in a pandemic. Why isn’t the World Bank doing more to help?

Anna Marriott Health, Inequality

As the World Bank’s Annual Meetings kick-off virtually this week, the COVID-19 pandemic is still surging in many countries, killing people, destroying livelihoods and deepening inequalities.

The World Bank’s health response has been lightning-fast (by donor standards) and important, with $6 billion in initial funding to help countries coping with the health impacts of the outbreak through its COVID-19 Fast Track Facility (part of a broader $160 billion committed across sectors through June 2021). But new research by Oxfam reveals disappointing gaps and missed opportunities in this health programming to tackle barriers to accessing healthcare and build up public health systems that serve everyone.

Minimal World Bank effort to tackle fees for healthcare

Our team analysed the project documents for the full set of emergency health projects that are part of the Bank’s COVID-19 Strategic Preparedness and Response Program (SPRP) as of June 30th, covering 71 countries. The full findings will be published next month, identifying many important interventions supported by the World Bank. But we feel the urgency to highlight a critical gap that emerged.

We found that despite World Health Organization (WHO) guidance to countries to suspend user fees for all essential healthcare from all providers during the pandemic, only 8 out of 71 World Bank COVID-19 country health projects included any plans to address healthcare user fees. This is also despite 80% of the project countries having out-of-pocket spending on health above the WHO’s indicated ‘safe’ level. Perhaps even more surprising is that for 25 of the country health projects, the World Bank itself identifies high out-of-pocket spending on health as a major barrier, yet then appears to take no action to redress them.

Healthcare fees are killing people, increasing poverty and slowing the COVID response

A decade ago, the WHO identified that at least one billion people were prevented from accessing healthcare each year because they couldn’t afford to pay for it. Since then, all governments have committed to reducing out-of-pocket payments for health, with the adoption of a specific target as part of the Sustainable Development Goals.

For the first time, Oxfam’s newly released Commitment to Reducing Inequality Index 2020 also includes data on out-of-pocket health spending, in recognition of the gravity of this problem. However, improved monitoring has revealed that the number of people facing catastrophic healthcare costs is rising, not falling. This is especially the case in Africa, where two out of three countries still charge user fees at all levels of care.

As livelihoods and incomes are destroyed due to the pandemic, the right to access healthcare is denied to more people if fees are required. Faced with mouths to feed and falling incomes, women are being hit hard and will be even less able to pay for COVID-19 testing, treatment, and other needed healthcare. While simultaneously taking on even greater levels of unpaid care for sick family members who can’t access health services.   

Ebola already taught us all this, and how fees delay detection. During the Ebola outbreak in 2018, the DRC made healthcare free and utilization of care improved across the board (not just for Ebola). Visits for pneumonia and diarrhoea more than doubled and women giving birth at a clinic increased 20-50%. Such gains were immediately lost once healthcare fees were reintroduced. For COVID-19, the WHO has issued clear warnings that fees should not be charged, as they are not only a barrier to access but can cause avoidable deaths and increased transmission.

The World Bank can do much more to curb health user fees

The World Bank is certainly not blind to the problem. Globally it champions Universal Health Coverage and works hand in hand with the WHO to monitor country progress towards it. Its own former President Jim Kim called health care user fees “unjust and unnecessary.” And the framework document for its emergency Covid-19 health response does mention that its finance could support measures to remove financial barriers for health care, despite the limited follow-up.

However, impatience with the World Bank’s lack of action on user fees is justified, and not just concerning Covid-19. It has taken insufficient action to remedy a well-evidenced barrier to healthcare it had a hand in building, through previous policies that encouraged fees as a method of ‘cost recovery.’  Past evaluations have shown the Bank’s support to remove user fees has been limited.

The World Bank is supporting countries in many important ways in their Covid-19 response but the urgency of action to remove financial barriers to health care could not be clearer, and its limited action here is of deep concern. The World Bank is one of the few donors supporting countries to strengthen their health systems. It is therefore well placed to massively expand efforts to help countries abolish out-of-pocket fees that are hindering the COVID-19 response and denying more people their right to health. The World Bank should urgently correct course in its COVID-19 response and take decisive action to support countries in existing and new projects, to eliminate financial barriers to health care.


Anna Marriott


Catalina Ruiz