The old image of the World Bank as a financier of dams, roads and power plants with no interest in the social sectors and grass roots development is no longer accurate. Although this largest of development agencies - $20 billion a year in loans - is still controversial, especially for its advocacy of structural adjustment, it is trying to change its image and focus. The Bank now says that its top priority is poverty alleviation, and is seeking to form strategic alliances with churches, missions and other Non-Governmental Organizations (NGO) in an attempt to make a difference at the village level.

NEW FOCUS ON HEALTH

In the old days, the economics profession, which dominates Bank thinking, regarded expenditures on health and education as "non-productive." They were seen as social goods, not investments. By 1980, economists had discovered what other people knew all along, i.e., that the level of health and education of a country has an enormous influence on the bottom line. The Bank was converted, and lending for health, nutrition and population jumped from 1 percent of total lending in 1987 to 7 percent in 1991. By 1995, it tripled again, reaching a billion dollars in 1995, making the Bank the largest single source of external funding in health development.

External development assistance for the health sector is difficult to measure. It is estimated at between $3.3 and 4.8 billion in 1990, averaging roughly one dollar per capita in developing countries. Approximately $1 billion is channeled through NGOs including churches. Although these amounts may sound impressive, we must remember that this assistance represents only about 2% of total health expenditures in developing countries (20% in Sub-Saharan Africa). Most third world health care is paid for by their own governments, companies, and families themselves.

The World Bank is increasingly realizing that its primary contribution to health development is not its dollars, but the introduction of new health technologies, better management practices, and innovative health care financing mechanisms. The recent launching of an environmental health initiative demonstrates the growing recognition that hospitals, health centers and doctors may not be the only requirement for a healthy population, perhaps not even the main one. This growing realization of the limited impact of money alone to successful development is illustrated in the description of the Bank by its President, James Wolfensohn, as a "knowledge institution" as well as a financing institution.

Although the Bank can lend funds only to governments, a variety of mechanisms have been devised with the agreement of borrowing governments to channel resources to churches and other NGOs for project implementation at the grass roots level. About half of Bank-financed health loans include (mostly indigenous) NGO components. Bank experts who observe the frequent constraints and inefficiencies of government-delivered health care hope this proportion of assistance through NGOs will rise even further. Strengthening the capacity of NGOs to manage funds and to reach effectively the grass roots has become a major Bank objective.

WORLD BANK - CHURCH PARTNERSHIPS

Some national churches and mission organizations are content to pursue health programs with little interaction with their governments or international aid agencies. Others see the donor organizations as potential cash cows and scheme to get grants to expand their programs. Still uncommon, but increasingly possible, is a mature partnership where each participant benefits from the collaboration.

North American churches are growing in their sophistication about global development policy concerns. Church leaders are bolder in speaking to the secular powers. For example, Protestant church leaders have met twice with the head of the International Monetary Fund, the Bank's sister agency, to talk about the crushing debt burden on many poor countries.

The World Bank, threatened by cuts in U.S. contributions from a conservative Congress, is looking for alliances with churches in hopes that they will lobby for foreign aid. Mr. Wolfensohn has met with a group of Catholic bishops. He would welcome meeting Protestant church leaders, should they ask to see him.

Although donors have also found that NGO health projects sometimes end in fiascoes, on average they are more efficiently managed and reach people more effectively at lower cost than government-run health services. With growing pressure on the World Bank to show impact (shoveling money to countries is no longer enough), Bank project managers see churches with their grass roots connections as one avenue to get positive results.

With taxpayers and contributing governments demanding more accountability, the old arrogance of Bank officials is yielding to a willingness to listen. Church leaders should take advantage of this new opportunity and boldly seek a seat at the table when governments and donor agencies debate policies and budgets.

ISSUES IN INTERNATIONAL HEALTH ASSISTANCE

The growing openness of donor organizations to partner with churches and the other institutions of civil society, combined with the trend toward democratic government sweeping the world, provides unprecedented opportunity for churches to play key roles in addressing the major challenges in improving health and well-being. Churches should be in active dialogue with governments and donors on the following issues:

• redefining the roles of donors, national governments, the private for profit sector, and NGOs in providing health care services and developing successful modalities for collaboration among the respective partners;

• finding remedies to the collapse of government health systems in many countries; • changing the tendency to focus narrowly on the delivery of health care services, rather than addressing health and well-being in its broad context including environmental and even spiritual dimensions;

• finding workable solutions to dilemmas of separation of church and state when governments and donors finance health facilities and programs managed by churches;

• combating donor fatigue and the declining levels of foreign assistance as well as mobilizing national resources on the scale needed;

• advocating broad health policy reform to promote sustainable programs that are cost effective and have a real impact at the grass roots level at a time of difficult structural adjustment in macroeconomic policies;

• enhancing local ownership of donor-financed projects; and

• engaging beneficiaries in the selection of priorities and in project design and implementation.

CONCLUDING INVITATION

As a World Bank employee who is committed to greater partnership with churches and other NGOs, I would welcome feedback from readers about these issues. I would also encourage readers to find ways to interact with the World Bank. Examples could be a) Bank reports (for those with Internet access, check www.worldbank.org, b) information about Bank- financed projects and possible resources for NGOs, c) contacts with project officers responsible for the country or countries where you are involved, and d) ideas about avenues for advocacy to reach decision-makers.