Health or Wealth during a global pandemic?
An interpretivist analysis of the World Bank Group’s COVID-19 strategy on health.
Mia Jacobsen
International Relations Dept. of Global Political Studies Bachelor Programme – IR103L 15 credits thesis Thesis submitted: 17/05/2021 Supervisor: Scott McIver
Student name: Mia Jacobsen DoB: 14/05/1996
ABSTRACT
As health transcends all borders so does the power of dominant global actors on health issues. The COVID-19 strategy of the World Bank Group will in this thesis be analyzed to demonstrate the dependency relations constructed through the World Bank Group’s health approach and its relation to Nigeria in particular. By adopting the theoretical perspective of dependency theory by Andre Gunder Frank (1969) this thesis will account for an interpretivist analysis of both quantitative and qualitative data. In analyzing the World Bank Group’s projects, loans and conditions this thesis accounts for how the World Bank Group are de-prioritizing health and prioritizing private over public sectors in its approach. The analysis demonstrates how this is identified both in its overall strategy and in the case study of Nigeria. Through a Critical Discourse Analysis of the WBG’s main strategy approach and partnership framework with Nigeria it is presented how the neoliberal discourse on health and development in general contributes to dependency relations of its borrowing states. The power of the World Bank Group is identified in its ability to construct such relations through its approach practically and discursively.
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Table of content
1. Introduction 1 1.1 Aim and research question 1 1.2 Structure of thesis 2
2. Theoretical Framework 3 2.1 Dependency relations in development finance 4 2.2 The World Bank Group in development finance 6 2.3 The World Bank Group in development finance on health 7 2.4 The World Bank Group’s COVID-19 strategy 8 2.5 Summary 9
3. Methodological framework 10 3.1 Case selection 11 3.2 Quantitative data 12 3.3 Critical Discourse Analysis 13 3.4 Limitations and ethical considerations 14
4. Analysis 15 4.1 The World Bank Group’s COVID-19 strategy 16 - 4.1.1 The World Bank Group in context 16 - 4.1.2 The World Bank Group during COVID-19 17 - 4.1.3 The World Bank Group on health during COVID-19 19 - 4.1.4 Saving Lives? 21 - 4.1.4.A First dimension: Discourse as text 21 - 4.1.4.B Second dimension: Discourse as discursive practice 22 - 4.1.4.C Third dimension: Discourse as social practice 23 4.2 The World Bank Group’s COVID-19 strategy in Nigeria 24 - 4.2.1 Nigeria in context 25
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- 4.2.2 The World Bank Group’s strategy in Nigeria during COVID-19 26 - 4.2.3 Health or Wealth? 29 - 4.2.3.A First dimension: Discourse as text 29 - 4.2.3.B Second dimension: Discourse as discursive practice 30 - 4.2.3.C Third dimension: Discourse as social practice 31
5. Discussion of findings and conclusion 32
6. Bibliography 35
7. Appendix 42
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List of Abbreviations
ASA Advisory Services and Analytics CDA Critical Discourse Analysis CDD Community-Driven Development FCSs Fragile and conflict-affected states FTCF Fast-Track Covid-19 Facility IBRD International Bank for Reconstruction and Development IDA International Development Association IFC International Finance Corporation IMF International Monetary Fund IO International Organization LMIS Low-and Middle-Income countries MFD Maximizing Finance for Development MIGA Multilateral Investment Guarantee Agency NCDC Nigeria Centre for Disease Council NFMH Nigerian Federal Ministry of Health NGO Non-governmental Organization PSW Private Sector Window PPAs Performance and Policy Actions PPP Public-private partnerships SDG Sustainable Development Goals SFL Systematic Functional Linguistic SMEs Small and Medium Enterprises UHC Universal Health Coverage USD United States dollar WB World Bank WBG World Bank Group WHO World Health Organization Health
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1. Introduction
The SARS-CoV-2 pandemic has put immense pressure on health systems demonstrating and aggravating the global inequalities in the world (WHO, 2020). As a result most Low and Middle- income Countries (LMICs) have been left vulnerable and dependent on external help to deal with the reality that hits them. The key external financier in global health is the World Bank Group, which during the pandemic has increased its distribution to meet such needs. But with power comes great responsibility and the World Bank Group (WBG) is an international actor that since its origin has been critiqued of its development strategy. The severity of vulnerability followed by the COVID-19 pandemic puts the WBG in a dominant position, which must be investigated. In most recent discussions on the WBG’s role in development finance the focus has been on its turn towards increased involvement of private sectors and Blended Finance (BF). It is interesting to study how this turn works in a time of a public health crisis, and at a time where the stakeholders of the WBG have a strong call for recovery of its borrowing states through a boost in public health and government preparedness (WBG, 2020c). This thesis will build on existing research by adapting a critical interpretivist perspective to analyze the WBG’s approach on health during COVID-19 and the associated power relations. By engaging with health and the power relations associated, it furthermore builds on health research predominantly let by positivist accounts. In the field of International Relations (IR) there has been a strong call for the inclusion of health to analyze issues of power (Stoeva, 2016) and this call has only grown stronger since the eruption of the pandemic (Davies and Wenham, 2020). This study listens to this call by adapting an interpretive epistemology to critically analyze the WBG’s strategy on health during the pandemic. This research furthermore positions itself within the wider academic discipline on development and contributes to the contemporary literature on the WBG’s approach by analyzing new data on health and development finance of the WBG during the pandemic. This thesis works to fill such gaps by studying the WBG’s COVID-19 strategy and its partnership framework with Nigeria.
1.1 Aim and research question Following the introduction the aim of this research is to critically analyze the World Bank Group’s power over borrowing states in the context of health. The research question is as following: ‘How does the World Bank Group’s COVID-19 strategy on health contribute to the dependency relations of its borrowing states?’
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To answer this research question, this thesis will address these following sub-questions: 1) How does the World Bank Group’s COVID-19 strategy indicate that it is doubling down on neoliberalism? 2) How does the World Bank Group construct health and development through discourse? 3) How is power embedded in this discourse? The main research question and sub-questions will all be analyzed in relation to the World Bank Group’s overall approach and similarly in more detail its relation to Nigeria. In answering these research questions this thesis will be sympathetic to dependency relations by Andre Gunder Frank (1969), which allows for a line to be drawn between the financial strategy of the WBG and its contribution to dependency relations of states as Nigeria. The assumption of the WBG’s commitment to neoliberalism is based on previous research on the topic as laid out in the theoretical framework. The first sub-question will work to account for the commitment to neoliberalism that in the context of the theoretical framework shows contribution to dependency relations. This thesis adopts an interpretivist account to analyze the construct of health and development finance by analyzing the meaning of the World Bank Group’s official COVID-19 approach and its partnership framework document with Nigeria. The two latter sub-questions aim to account for an analysis of further contribution towards dependency relations through the power of discourse. The aim of the study is to provide a deeper understanding of how the approach is reproducing relations of power between the WBG and its borrowing states in the context of the COVID-19 pandemic.
1.2 Structure of thesis Firstly this thesis will account for how it positions itself within current and relevant literature. The theoretical framework will entail an assessment of the literature on the four themes; ‘Dependency relations in development finance’, ‘The World Bank Group in development finance’, ‘The World Bank Group in development finance on health’ and ‘The World Bank Group’s COVID-19 strategy’. The theoretical framework works to link dependency theory by Andre Gunder Frank (1969) with relevant contemporary literature that combined lays the foundation for the concepts and methods that are utilized in this thesis. The next chapter, being the methodological framework, encompasses the selection of the case study of Nigeria, the quantitative data which will be analyzed and furthermore the framework of the Critical Discourse Analysis (CDA) which will analyze both the WBG’s strategy and its partnership framework with Nigeria. In having accounted for the theoretical and methodological choices and limitations the analysis will be laid out. The analysis of this thesis is divided into two main parts: one of the WBG’s overall
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strategy and the second of the case study of Nigeria. The first part of the analysis accounts for a brief elaboration of the WBG’s history in relation to development finance on health, which lays the groundwork to the power relations already constructed. Hereafter the World Bank Group’s strategy in terms of projects during COVID-19 on a larger scale is analyzed followed by an analysis of its health approach in particular to portray its prioritization of private sectors and de-prioritization of health. The last part of the first section of the analysis accounts for a CDA of the World Bank Group’s COVID-19 strategy to highlight the embedded power relations and how its approach is legitimized. The second part of the analysis will begin with accounting for the context of Nigeria in relation to the WBG and COVID-19. It will subsequently analyze the WBG’s projects during COVID-19 in Nigeria in particular on health to portray the tenants of neoliberalism associated. The latter part of this section includes a CDA of the WBG’s partnership framework with Nigeria to demonstrate the contribution to a dependency relation of Nigeria. The thesis will lastly account for a discussion and conclusion tying the two parts of the analysis together to illustrate how the analysis answers the research question(s). Conclusively the thesis portrays how the WBG’s COVID-19 is doubling down on neoliberalism both in terms of analyzing its projects in this time period and by conducting a CDA of its official documents. Through this commitment both on development finance in general and health it is concluded that the WBG’s COVID-19 strategy on health contributes to dependency relations of the borrowing states.
2. Theoretical framework
The academic work on health in development finance has been addressed from a variety of fields as Public Health, Development Studies and minimally in International Relations. This literature review will identify how this paper engages with literature and fills a gap on health in the field of International Relations. The theoretical framework engages with four different themes; ‘dependency relations in development finance’, the World Bank Group in development finance’, ‘the World Bank Group in development finance on health’ and ‘the World Bank Group during COVID-19’. By engaging with these four themes, this theoretical framework identifies how this thesis conceptualizes the concepts related to answering the research question(s) and simultaneously identifies a gap within the literature, which this paper wishes to fill.
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2.1 Dependency relations in development finance Literature on development finance has been of interest in a range of academic disciplines as Development, Anthropology and International Relations. In orthodox International Relations the topic has been driven by the liberal and later neoliberal perspective accounting for the positive effects of further global interdependence leading to the trickle-down effect; that economic expansion leads to growth in all social layers conceptualized in modernization theory by Rostow (1990). This perspective has been highly critiqued by scholars as dependency theorists for its assumption of foreign investments and non-intervention by governments as ideal for long-term development (Prebisch, 1968; Frank, 1969). Development and dependency relations are contested concepts understood differently according to one’s theoretical standpoint. This thesis will be sympathetic to dependency theory in analyzing the dependency relations between the WBG and its borrowing states as stated in the research question. Dependency theory is a collection of theoretical positions encompassing both Marxist (Frank, 1969; Wallerstein, 2004) and non-Marxist accounts (Prebisch, 1968; Haq; 1976). One of the most influential dependency theorists is the neo-Marxian Andre Gunder Frank (1969) who accounts for the expansion of the capitalist system that according to his theory ‘development of underdevelopment’ has penetrated even the most isolated sectors in the underdeveloped world. Developed countries as argued by Frank were never ‘underdeveloped’ but merely ‘undeveloped’ because it was free from structural constraints and the theory holds that the relation between developed and less developed states has worked to impact the latter negatively (Frank, 1969:4). Capitalism is hereby by Frank seen as the motive force behind dependency relationships, which has let to underdevelopment (1969). This link between increased capitalism leading to further underdevelopment rather than development as understood by neoliberalism is adapted in this paper to enlighten the contribution of the World Bank Group. In having identified how development and dependency relations are operationalized and will be used in this research paper from the perspective of dependency theory by Frank (1969), another key concept to identify is power. Power as conceptualized in Frank’s theory is shared with theories of imperialism from Marxism including that economic and political power are centered in the developed states. In opposition to classical Marxism dependency theorists as Frank does not focus on the expansion of capitalism but rather the consequences of it – the consequences of power (Ferraro, 2008:61). The developed states, embodying this type of power, are by Frank called the metropolis and the less developed states. which are dominated by the metropolis, called satellites (Frank, 1969).
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There is a whole chain of constellations of metropolis and satellites from the periphery of villages in satellites to the center of powerful states as the US (ibid). This research paper does not have the scope to identify all of these relations in accordance to this topic. But it is still crucial to acknowledge that the relations between an international actor working in the interest of the metropolis states has a wide variety of links from the satellite on a local, regional and global level (Frank, 1969). Ahiakpor accounts for such a link in Ghana arguing that financial institutions of the metropolis contributes to dependency relations through technological and financial expertise in that they do not account for the dissimilarities within states (Ahiakpor, 1985:537). The underdeveloped states are therefore alienated in the production and a large share of value added in production is lost and development potential hampered (ibid:536). The work of Frank and dependency theorists in general has been critiqued mainly for overestimating the power of capitalism and how they do not enlighten the internal characteristics of states (Smith, 1979; Friedmann and Wayne, 1977). But what is essential to acknowledge, and what will be enlightened within this case study, is that the internal characteristics of states are built on historical structural relations, which must be accounted for. The continuant relevance of dependency theory is as argued by Tausch (2010) inherent with globalization’s deepening and widening scope of neoliberalism in sectors and actors as international organizations and institutions. Such studies are seen by Musthaq (2021) who builds on Samir Amin’s approach in studying financial arbitrage or Agbebi and Vitanen (2017) approaching the role of China in Africa studying trade relations. The unit of analysis is divergent because it is not the state that is central to dependency theorists as orthodox International Relations but rather the relations between societies, which form the international system (bid). One of the core propositions mutual to dependency theorists is to highlight how external influences have the power to impact national states (Ferroro, 2008: 59). This assumption builds into one of the key tenants of International Relations theory in looking at how states’ agency is impacted by the structure of the world system, and in this context the world capitalist system (Halperin and Heath, 2017:39). To account for the contribution to dependency relations in studying health issues it is essential to account for the external interference of the WBG on its borrowing states. This correlates with enlightening how such works to benefit the dominant states rather than the less developed through capitalism as understood in Frank’s (1969) theory. This theory is utilized within this paper in that Frank’s (1969) rigorous theory provides a framework that establishes a link between the capitalist system and the contribution to dependency relations. It furthermore lays a framework for enlightening
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the link of satellites and the metropolis, which will be accounted for within the scope of the research topic. Capitalism is by Frank seen as the motive force behind dependency relationships, which has let to underdevelopment (1969). Capitalism will similarly in this research paper be seen as constructed through neoliberalism, as seen in contemporary literature, to identify the motive within the WBG’s discourse and approach in relation to the topic. The following sections will identify how capitalism as neoliberalism will be identified, operationalized and studied in relation to the research question.
2.2 The World Bank Group in development finance Literature on the World Bank Group in development finance has been of interest since its construction after the Second World War. Large amount of research has analyzed the WBG’s development strategy by studying it through a constructivist account analyzing the norm diffusion of the WBG on states (Park, 2005) or on other actors on the development finance arena (Heldt and Schmidtke, 2019). Babb and Kentikelenis (2021) accounts for how the global diffusion of market-led policies impacts states through the ‘Washington Consensus’. Washington Consensus understood as the coordinated campaign, constructed by the Western States through the Bretton Woods Institutions of the World Bank Group together and the IMF (ibid). Some scholars argue for a post-Washington Consensus (Güven, 2018) which states that the World Bank Group have increased flexibility and demand less structural loan conditions. This highlights an ongoing debate on the contribution of the World Bank Group. The literature on the World Bank Group’s contribution to its states in general lack to engage with the historical and structural issues associated with norm diffusion. Some scholars engaging with such accounts of macro-structures are Musthaq (2020; 2021) and Gabor (2020). Musthaq’s (2021) critical perspective builds on Samir Amin’s dependency theory and account for dependency relations in the context of financialization including financial arbitrage. In another account more focused on the WBG Musthaq (2020) accounts for the concept of global shadow banking meaning that rather than facilitating finance towards development objectives, the approach of the WBG seeks to integrate emerging markets into a system that accumulates global investors. Gabor (2020) similarly in focusing on the WBG’s relationship to its investors argues how it utilizes de-risking measures to protect global investors at expense of its borrowing states. Gabor conceptualizes the World Bank’s contemporary approach in a ‘Wall Street Consensus’ by focusing on its ‘Maximizing Finance for Development’ (MFD) approach from 2017. Neoliberalism is by Gabor (2020) identified in de-risking through
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public-private partnerships (PPPs). Gabor and Musthaq (2020; 2021) accounts for macro-economic structural accounts of the World Bank Group’s approach. This thesis wishes to engage with a critical perspective on neoliberalism as a means of the WBG to construct market-driven and foreign investment prone development finance.
2.3 The World Bank Group in development finance on health The literature on the World Bank Group’s approach to health in development the main perspective has been from a positivist epistemology. In conventional constructivist accounts as Elkins and Simmons (2005) they perceive the interdependence between the WBG and the borrowing states neither through collaboration nor imposition. In engaging with a more critical perspective, as will this thesis, literature is mainly engaging with the contribution of the WBG as a part of economic globalization on health. Lee et al. (2002) study globalization’s effect on policy-making in the health sector by engaging with a rather broad operationalization of health policies: “goals and means, policy environments and instruments, processes and styles of decision-making, implementation and assessment. It deals with institutions, political power and influence, people and professionals, at different levels from local to global” (ibid:10). Lee et al. (2002) do not focus on the WBG in particular but this extensive operationalization of health policies addresses the many components associated with health policies, which will similarly be adopted in this study. The literature concerning the WBG’s involvement on health has from a theoretical perspective been studied among others by Sell and Williams (2020) to highlight the structural and institutional conditions that shape global health. Kentikelenis et al. (2020) argues that the WBG has adverse consequences on health in pursuing fiscal objectives and deprioritizing investment on public health systems. This thesis will engage and build on this narrative. Schrecker (2020) similarly understands neoliberalism as a constraint to improving health in developing states by analyzing the power of discourse and the ‘production of health’ as a condition that enables or disables healthy lives. Harman (2009) as well studies the WBG in a discursive analysis focusing on how the WBG distances itself from negative connotations of structural adjustment on health. Harman (2009) adopts a political- economy governance perspective to look at neglected diseases in how the World Bank Group constructs health: accountability and transparency work as discursive instruments of ‘good governance’ to maintain the powerful position of the Bank’s program for global health. This thesis will similarly analyze the WBG’s construction of health in a neoliberal manner as in line with
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contemporary literature. Moreover it will build on this research by identifying the de-prioritization of health in the WBG’s COVID-19 approach.
2.4 The World Bank Group’s COVID-19 strategy In having established the broader understanding of the WBG’s approach as neoliberalism and in relation to health, this last section will account for the literature on the WBG’s COVID-19 strategy in particular. In analyzing the WBG’s contribution during COVID-19 it is for obvious reasons a new and vibrant type of literature. It has for the most part, as will this paper, critiqued the WBG’s COVID- 19 approach. When surveying literature on the WBG’s role within the COVID-19 pandemic it is mainly building on the discussion prior to the pandemic concerning the WBG’s ‘Maximizing Finance for Development’ (MFD) strategy and how public money is leveraged for private finance (Dimakou et al., 2020a; Kentikelenis et al., 2020). Kentikelenis et al. (2020) study this critically by focusing on the fiscal objectives of the bank and its de-prioritization of public health as mentioned in the previous theme. Williams et al. (2021) contributes to this critical view on neoliberal tendencies exposed across the board in the global pandemic. Their perspective is to look at how the effects of neoliberal policies has provided weak health systems due to for example the mix of public-private models of health systems and how this pressure them during COVID-19. The study in general deals with neoliberal structures in the global economy rather than the WBG in particular. Williams (2020) in another study accounts for the path-dependency of multilateral actors in LMICs and how it has produced a failure in global private health. He accounts for this by looking at the responses of states and the approach of multilateral actors as the WBG. This thesis will similarly engage with such construction of dependency relations with a key focus on the WBG and a case study of Nigeria. Engel et al. (2020) conducts a small-N case study of the WBG’s approach in Indonesia and Sri Lanka. They demonstrate how the WBG’s debt constraints and policies are in line with its neoliberal approach of MFD. To account for this. they as most other scholars in analyzing the WBG’s approach (Williams, 2020; Dimakou, 2020b; Gabor, 2020); look at amount of money distributed through which affiliate of the WBG. They identify the affiliates as contributing to either private, public or Blended Finance (BF). The two affiliates identified as leveraging public finance are the International Bank for Reconstruction and Development (IBRD) and the International Development Association (IDA) that together make up the World Bank. The International Finance Corporation (IFC) and the Multilateral Investment Guarantee Agency (MIGA) are identified as leveraging private finance (World Bank
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Group, 2021d). A fifth type of loans identified is the Private Sector Window (PSW) in the literature as BF (Gabor, 2020; Engel et al. 2020). The PSW was established by the IFC and IDA in combination in 2017 lending money to the most fragile states through public-private partnerships (IDA, 2021). Beyond looking for the type of lending arm as an indication of public, private or BF the scholarship furthermore identifies which type of loans and conditions are associated with the WBG approaches. These indicators are in line with previous research on the World Bank Group (Bayliss and Van Wayenberge, 2018). What Engel et al. (2020) arguably fails to account for are the structural power relations related to the contribution of the WBG. Dimakou et al. (2020b) follows Engel et al.’s (2020) line of thinking on the World Bank’s approach by conceptualizing it as a public-private nexus. They do so in looking at the first four months of the WBG’s crisis response and argue that when prioritizing private over public interests in its approach it is a sign of the WBG’s neoliberal market-driven approach. Dimakou et al. (2020b) study the prioritization of private over public especially Blended Finance (BF). Of the literature on the WBG’s COVID-19 strategy Dimakou et al. (2020b) accounts for the most thorough discourse analysis by looking at both meetings and also the World Bank Group’s ‘Saving Lives, Scaling-up Impact and Getting Back on Track – World Bank Group COVID-19 Response Approach Paper’ (WBG, 2020d). This thesis wishes to build on Dimakou et al.’s (2020) discourse analysis by enlightening the critical power relations constructed through the discourse, which Dimakou et al. (2020b) does not account for. The thesis will furthermore engage with the contemporary literature by accounting for similar identifications of neoliberalism by looking at the WBG affiliates, its loans and conditions both in its overall strategy but also in more detail in the case study of Nigeria.
2.5 Summary This thesis works to fill a gap in International Relations by including health in the understanding of power relations between the World Bank Group and its borrowing states with the case study of Nigeria. The theoretical framework utilized within this thesis is sympathetic to Andre Gunder Frank’s theory of ‘development of underdevelopment’ (1969). The theory establishes the contribution of the WBG’s neoliberalism as leading to underdevelopment rather than development. This perspective works in line with relevant contemporary literature taking a critical stand towards the WBG’s COVID-19 strategy in its way of doubling down on neoliberalism. Neoliberalism is identified in this analysis as contemporary literature looking at the WBG’s loans, leverage of affiliates and conditions
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to prioritize private or BF (Engel et al., 2020; Dimakou, 2020; Williams, 2021). The thesis furthermore builds on the macro-structural research of Gabor (2020) and Musthaq (2020; 2021) by identifying the de-risking methods and importance of foreign investment in the COVID-19 strategy. In the focus on health this thesis will build on the discursive accounts of Harman (2009), Dimakou (2020) and Schrecker (2020) in identifying how the WBG constructs health and development. It will build on this research by accounting for a Critical Discourse Analysis enlightening how the legitimization of power further contributes to dependency relations. This research paper moreover builds on the critical perspectives of neoliberalism on health as seen in the literature by Kentikelenis et al. (2020), Sell and Williams (2020) and Lee et al (2020). It adopts the operationalization of public health as Lee et al. to account for wider contribution to dependency relations on health.
3. Methodological framework
In establishing the methodological framework it is suitable here to recall the research question of this paper: ‘How does the World Bank Group’s COVID-19 strategy on health contribute the dependency relations of its borrowing states?’ This research questions is as established in the theoretical framework build on the assumption that the WBG as an international actor can contribute to the dependency relations of states through its strategy. The assumption of deliberate contribution to dependency relations is built on the puzzle of the WBG prioritizing private finance despite an international call for public health during the COVID-19 pandemic (WBG, 2020c). This thesis analyzes the power relations associated with how the WBG as a group of dominant states contributes to the dependency relations of less powerful groups. To answer the research question this thesis adopts an interpretive explanatory question that is constructed to understand the world of meanings inhabited by an actor (Halperin and Heath, 2017:98). The premise of this research is therefore that meaning is interpretive and that the discursive and narrative strategy form an important part of the WBG’s way of contributing to the dependency relations of its borrowing states. The dominant epistemology in the study of health has been positivist, but in breaking with this and adapting an interpretivist epistemology we can then consider both new empirical and theoretical perspectives and engage with discourse as an explanatory variable (Lamont, 2015: 39). This study attempts to answer the research question(s) by analyzing quantitative data and conduct a qualitative analysis. The quantitative data will not play the main role in this research, but will rather
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work to back up the interpretive analysis by accounting for descriptive statistics as a tool for measuring and analyzing the projects of the WBG (Lamont, 2015: 130). The quantitative data allows the thesis to be more effective in demonstrating the correlations between the WBG projects and its deprioritizing of health and prioritizing private sectors. The qualitative analysis uncovers the causal relations and processes associated with this correlations and how it is legitimized (ibid: 136). By utilizing a mixed-method framework a deeper comprehension of the strategy can be accounted for. This chapter accounts for the case selection, quantitative data and qualitative data utilized together with their limitations.
3.1 Case selection The thesis will account for an overall account of the WBG’s relation to its borrowing states through analyzing its strategy and in particular Nigeria. The case study of Nigeria establishes a high internal validity compared to the contemporary literature on the topic. The time frame of the collection of primary data is from the first of February 2020 to the 15th of April 2021. This time frame is chosen because it is from when the WBG began to establish projects in relation to the COVID-19 pandemic (World Bank, 2020b). The case study of Nigeria is working as a good case study both in relation to importance and availability of data. The WBG see Nigeria as a key actor in Africa: “… as the largest economy in SSA, Nigeria can play a leading role in promoting economic integration on the continent.” (WBG, 2020b:117). The key role of Nigeria gives an indication that the approach to Nigeria in particular are of great importance to the WBG in reaching its twin goals of promoting prosperity and eradication of poverty (WBG, 2014). The case of Nigeria can therefore give us a good indication of the WBG’s approach in a borrowing state. Another key reason of choosing Nigeria is the fact that the Nigeria – World Bank Group partnership framework was published in November 2020 making it one of the few partnership frameworks published in the time of the pandemic. The WBG publishes partnership frameworks with its borrowing states every fourth year, and the one with Nigeria is the most encompassing published since the eruption of the COVID-19 pandemic. Nigeria is furthermore an English speaking country, which makes the gathering of inquiry on the state’s national websites and journals accessible for the researcher.
3.2 Quantitative data
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The method utilized in this thesis is built on the contemporary relevant literature which take as their starting point to look at WBG’s projects during the COVID-19 to be whether private, public or Blended Finance (BF) as mentioned in the theoretical framework. The quantitative data will work as an indicator of how the WBG is doubling down on neoliberalism addressing the first sub-question. It will furthermore build on the current published data to look at the aggregate of health in these projects. A statistical dataset is conducted to indicate the WBG’s prioritization on public health or lack thereof. The key WBG organizations that provide these loans are the IBRD and IDA (WBG, 2021d). The quantitative dataset accounts for the amount of USDs in the WBG’s project, which has gone directly to public health. The statistical dataset accounts for projects from February 1st 2020 to April 15th in countries in the six regions laid out in the appendix receiving support from the WBG during the COVID-19 pandemic as established by the World Bank (WB) (World Bank, 2020c) 1. These countries are important to the World Bank in working towards its twin goals of eradicating poverty and promotion of shared prosperity (World Bank, 2014). It is interesting to compare all states because they have different health systems capabilities and also different amounts of COVID-19 cases. The dataset tables listed in the appendix has been conducted by looking at all IBRD and IDA projects in the time period, which in total is 558 projects (World Bank, 2020c; 2021c). The projects are identified as either directed towards health or not. Projects towards public health are identified as what the IDA and IBRD value as directed towards ‘Health’, ‘Public Administration –Health’ and/ or ‘Health Facilities and Construction’ (ibid). On the appendix attached; the country, the project ID number and amount of USDs are accounted for. Crucial here to acknowledge is that in some projects a small percentage of the projects are grants and not loans, both are measured equally in the dataset. As seen in the appendix some projects are both on the tables of projects directed towards health and not towards health – this is because some of the IBRD and IDA projects are distributed to separate sectors. In these cases the percentage of health has been calculated and the percentage is accounted for in the tables. In the analysis the overall amount will be portrayed from the regions. This data gives an indication of the amount the WBG has spent towards public health during COVID-19 pandemic in comparison to other projects. The amount distributed towards Nigeria will furthermore be looked into in more detail in the second part of the analysis comparing IBRD and IDA projects distribution towards health and IFC projects distributed towards health. The inquiry on IFC projects is from the
1 The appendix is attached to be transparent and give an overview of the data utilized. The dataset is not laid out similarly by the WBG but rather found through each project.
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IFC disclosures (IFC, 2021). The limitations with the data will be accounted for in the final part of this chapter.
3.3 Critical Discourse Analysis The qualitative analysis will account for answering the two latter sub-questions in relation to answering the research question. The Critical Discourse Analysis (CDA) will account for an interpretivist account with discourse as the explanatory variable to capture the power relations and legitimization of power involved with the WBG’s contribution to dependency relations in its borrowing states. The CDA conducted is as conceptualized by Fairclough (1992; 2001), who accounts for one of the most systematic CDAs to account for how texts works within broader social processes (ibid). The critical part of this analysis works to enlighten the ties between language, power and ideology in relation to the research question (Fairclough, 2001:4). The method allows the analysis to move beyond statistical datasets to highlight social structures and power relationships associated with dependency relations. The CDA works to discover the power of the dominant states in the WBG over its borrowing states and identify how the dominant actor creates this hegemonic discourse (Halperin and Heath, 2017:333). Fairclough’s three-dimensional model will be utilized to identify such discourse of power in this analysis by demonstrating how the WBG controls discourses on health and development finance from the theoretical perspective of dependency theory. Fairclough’s model includes the first dimension: discourse as text, second dimension: discourse as discursive practice and third dimension: discourse as social practice. The key within Fairclough’s model is to enlighten how these correlate by demonstrating the relations between the micro-context of WBG in the COVID-19 on health and the macro-context of neoliberalism in development finance (Fairclough, 2001). Fairclough presents a number of tools to analyze the linguistics of a text. A condensed version with only some of these tools will be utilized due to the span of this study. The tools utilized in this study will be transitivity, nominalization and modality. Transitivity accounts for how processes are linked with subjects and objects. Nominalization, which also analyzes agency, is a linguistic feature whereby a noun is positioned as the actors of a process (Jørgensen and Philips, 2002:83). When analyzing modality the focus is on the degree of affinity to the speaker / writer’s statement, one type of modality is to present a knowledge-claim as the truth (ibid:84). To account for these tools in a textual analysis Halliday’s (Halliday and Matthiessen, 2014) Systematic Functional Linguistic (SFL) is utilized. Halliday’s complete set of tools can again not be
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accounted for, but what will be utilized is: syntax (the structure of clauses), wording (choice of word and meaning) plus the semantic features that link members of a lexical set together as synonyms and co-meronyms (words constructed as a part of the same whole) (ibid: 16; 61). In the second dimension of Fairclough’s three-dimensional model the interdiscursivity of the texts will be enlightened drawing back on previous literature on discourses of neo-liberalism and development, and its effect on health. Here the key is in legitimization and the construction of a truth is of investigation itself, as is the construction of health (Lamont, 2015:44). The last dimension will enlighten the discourse as a practice to discover the dominance of power of one group over another (Fairclough, 2001). It will enlighten how the discourse, through the theoretical perspective of dependency theory by Frank (1969), works to construct relations of power in relation to historical and structural accounts. In focusing on the social practice of ‘neoliberalism’ and how it constitutes social order it allows us to form a link between the action through text and the structure in society (Fairclough, 2001:2). The body of material analyzed is officially published documents by the World Bank Group. One is a strategic document and the other a partnership framework document. First document analyzed is ‘Saving Lives, Scaling-up Impact and Getting Back on Track – World Bank Group COVID-19 Response Approach Paper’ (From here on ‘COVID-19 Response Approach Paper’) (WBG, 2020d) published by the World Bank in June 2020. It is the most inclusive and thorough document published to this date to explain its strategy during COVID-19. The second document chosen is ‘Country Partnership Framework for the Federal Republic of Nigeria for the Period FY21-FY25’ (From here on: ‘Country Partnership Framework for Nigeria’) (WBG, 2020b) published by the WBG on November 16 2020. This document accounts for the most rigorous partnership framework the WBG has conceptualized in one document during the pandemic. Both texts are working within the same discourse but enlighten different aspects of the same reproduction of power relations.
3.4 Limitations and ethical considerations Starting with the ethical considerations it is firstly vital to acknowledge that I as a researcher had a pre-exciting understanding of the WBG, which can have affected the outlook I have taken within this paper. By choosing a theoretical standpoint in line with CDA it takes away some objectivity in the analysis (Halperin and Heath, 2017:339). The theoretical standpoint of dependency theory highlights the structural power relations and gives a critical perspective; it therefore does not give as much room for positive effects nor national positions of borrowing states. The most vital ethical consideration is
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that I personally have little understanding of the Nigerian culture and societal aspects. This paper mostly enlightens the structural affects on states, but it is in no means to try to take agency away from non-Western states. The methodological limitations have first of all been the lack of span of this thesis in that many more aspects and nations could give a greater argument to answer the research question in center. By choosing to do a mixed-method of both quantitative data and qualitative analysis it gives a greater picture, but it furthermore delimits the options to go deeper into each method chosen. Both methods also has different epistemological standing points, which can make the data work against each other rather than together (Lamont, 2016:136). But it furthermore works as a powerful method to gather both discursive and practical data in answering the research questions (ibid: 114). The greatest limitation in relation to the gathering of inquiry was the transparency on projects of the WBG. The quantitative data I have chosen to analyze is country-specific but it is crucial to acknowledge that the organizations of the WBG also lent money across regions and continents, which are not accounted for in this research on the case study of Nigeria. The reason for this is that the regional projects were not transparent about which amount went directly to each state and to which sector. This was particularly an issue with the lending arm International Financial Corporation (IFC).
4. Analysis
The following chapter includes an analysis divided into two main parts. The first part consists of an analysis of the World Bank Group’s overall COVID-19 approach accounting for the bank’s historical context, its COVID-19 strategy, its health strategy during COVID-19 and lastly a CDA of the ‘COVID-19 Response Approach Paper’. The second part of the analysis encompasses a brief locating Nigeria in the context, the WBG’s COVID-19 health strategy in Nigeria and lastly a CDA of the ‘Country Partnership Framework for Nigeria’. The analysis portrays how the WBG’s COVID-19 strategy on health contributes to dependency relations of its borrowing states with the case study of Nigeria.
4.1 The World Bank Group’s COVID-19 strategy
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In analyzing the World Bank Group’s COVID-19 strategy’s contribution to dependency relations it is essential to get a greater understanding of the structural relations which has been established between the WBG and the its borrowing states prior to the COVID-19 pandemic, the first section will therefore give a brief account of such. Subsequently by analyzing quantitative data an analysis of the WBG’s COVID-19 strategy globally will be accounted for to demonstrate its commitment to neoliberalism as presumed in the first sub-question. The thesis hereafter accounts for a CDA to address the discursive power relations and embedded neoliberalism in the WBG’s approach to account for the two latter sub-questions.
4.1.1 The World Bank Group in context The largest development bank in the world, the World Bank Group, is inarguably given a massive role on the global stage during the COVID-19 pandemic; being one of the key financiers to LMICs and the largest external financier on health (Kentikelenis et al., 2020:758). This position in global health governance has evolved since its establishment in the midst of the Second World War (McInnes and Lee, 2012). As a part of the Bretton Woods institutions with the International Monetary Fund (IMF) the WBG worked to restructure policies throughout the European continent later spreading to encompass most states in the world deviating slightly dependent on each WBG organization (WBG, 2021d). The internal construction of the WBG has the United States, the Bank’s largest shareholder, as clear authoritative state being the only state to have encompassed the presidential position (WBG, 2021c). The unequal relations of emerging states having less available options to borrow money has put states in a position of dependency that is further reproduced when lending more money - leading to further underdevelopment in accordance to dependency theory (ibid; Frank, 1969). The World Bank Group has had profound influence and structural demands on loans giving them great influence on borrowing states in social policies as health (Engel et al. 2020:4). The neoliberal policies were strongly motivated by the rationale that developing states were not able to provide health services adequate to meet the needs of their population (Ruger, 2005). The level and type of influence has changed throughout its origin with a strong momentum during the structural adjustment systems in the 80s and 90s in developing states - which is furthermore when the bank embarked on funding health projects (Harman, 2009; Engel et al.: 2020:9).
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On health the World Bank’s rationale at this time changed to perceiving ‘good health’ as equal to enhance economic growth, which from the neoliberal perspective creates growth not only in the given state, but also in the world (Gabor, 2020). It meant that health became a global concern where global factors came to impact the local encounter with health (Davies, 2010; McInnes and Lee, 2012). The overt structural constraints has since gotten a lot of criticism from the international society changing the approach of the WBG by abandoning ‘structural adjustment’ from its vocabulary in 2004 (Schrecker, 2020:33). But by removing a word in its documents it does not change the name of the game. The increase of actors in the global health governance playing field brought about a new non- disease specific approach for the WBG to stay essential including technical and policy support on health sector together with ‘fitting’ macro-economic regulations (Engel et al., 2020:9). This rationale will now be demonstrated within the approach and analyzed as to how it contributes to dependency relations.
4.1.2 The World Bank Group in COVID-19 In March 2020 when the COVID-19 pandemic increasingly began to spread from the Asian continent to other parts of the world, the WBG took a big part in the international response by approving a 14 billion USDs Fast-Track Covid-19 Facility (FTCF) (Dimakou et al., 2020b:5). Subsequently as the severity of the pandemic became apparent the bank in March 2020 committed to provide 160 billion USDs for the following 15 months and 330-350 billion USDs by June 2023 (World Bank, 2021a). As part of the initial approach the WBG additionally suspended debt services for the time meaning that throughout April to December 2020 6.8 of the 19.5 billion USDs committed by the World Bank was in the form of grants (WBG, 2021a; World Bank 2021a). The International Development Association (IDA) explains this approach with the goal of moving towards more sustainable and transparent financing. What should be noted in this context is if a country does not meet the performance and policy actions (PPAs) and live up to the conditions set by the WB as on financial transparency it will not be able to access 10 to 20 percent of its IDA country allocations (WBG, 2021a). This demonstrates the key role fiscal transparency plays in the WB, which as argued by Harman (2009:13) is a key aspect in legitimizing its market-oriented understanding of health welfare. The conditions set up by the WBG on grants and also loans highlights the structural power of the WBG in the decision-making on projects giving the borrowing states less agency. This correlates with the key argument in dependency theory stating that stronger dependence rather than independence only equals further underdevelopment (Frank, 1969).
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Of the first 14 billion USDs provided by the FTCF in March 8 billion USDs went through the private sector arm IFC and 6 billion USDs through the public sector arms IBRD and IDA who together make up the World Bank (WB). Even on the surface these sums give an indication of the WBG’s prioritization of private or public sectors. The liberal economic perspective on this is that the private allows it to increase the market efficiency, which leads to more production that will further lead to increased development (Rostow and Rostow, 1990). This indicates the economic and political power of the WBG as a collection of dominant states let by the United States in deciding what lending arm to provide money through. By engaging with the tenants of Neo-Marxism within dependency theory it furthermore becomes a clear case of capitalism, as the private sector, is the cornerstone of its strategy (Ferraro, 2008:61). The prioritization of private sectors furthermore became manifested in the WBG’s strategy ‘COVID-19 Response Approach Paper’ (WBG, 2020d) published in June 2020. As part of the strategy the WBG puts strong emphasis on how the poor’s needs are met through its prioritization of small and medium enterprises (SMEs) (ibid). When taking into consideration that there is a large portion of informal workers especially in low-income and fragile states the reach to the poorest through enterprises becomes perplex. In relation to the benefits of its approach Dimakou (2020b:9) argues that the clients who benefits from International Finance Corporation (IFC) investments are predominantly banks and if not privately owned or multinational or big companies. Some of these clients are companies in which the IFC holds equity positions hereby directly benefitting themselves rather than the poorest as claimed to be its main objective in its twin goals (WBG, 2014). From the outlook of dependency theory the ‘national’ economic interest can only be met when the needs of the poor in a society are fully addressed and met (Ferraro, 2008:62). Even if these are empirically difficult to fully address the WBG are clearly stating to do so without accounting for evidence of its approach working. The World Bank Group’s strategy in general indicates a prioritization of its private sector arm IFC over the public sector arms making up the World Bank. A last sector to account for is Blended Finance (BF), which became a focal point in the WBG’s agenda in 2017 ‘Maximizing Finance for Development’ (MFD) that has only been doubled down in the WBG’s COVID-19 strategy (WBG, 2021b). The condition of the BF approach is for the state to share the risks to guarantee payment flows, which makes it more expensive than a public loan (Gabor, 2020:3). This strategy of MFD is most obviously seen through the emphasis on public-private partnership (PPPs) within the World Bank strategy and the increase of the Private Sector Window (PSW) for most fragile states (World
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Bank, 2020a). A quarter of the IDA resources within the WBG Covid-19 strategy are distributed through the PSW that aims to promote private sector investment in the poorest and most fragile states (ibid). De-risking hereby works as a link between the most fragile states and the global investors to engage them in the neoliberal economy. What should be kept in mind here is that part of the allocation of money through the IDA, as a public lending arm, are hereby going towards global investment rather than public social policies as health. The subject of health in the WBG’s approach will be analyzed in following section.
4.1.3 The World Bank Group on health during COVID-19 The prioritization of the private sector finance and public-private partnerships rather than public in itself enlightens neglect on public policies during the COVID-19 pandemic. In focusing directly on the loans related to the health sector it is crucial to consider the pre-existing structural and historical conditions as stated in the first section of this chapter. The severity of COVID-19 as a health crisis has been seen in a multitude of ways and the responses from each country has been equally as divergent (Baum et al., 2021). But what brings all of these together is that it has put a magnifying glass on the pre-existing health service complications in the public health sector (WHO, 2020). The World Bank Group in pillar 15 of the ‘COVID-19 Response Approach Paper’ identifies weak and under-resourced health systems especially in FCSs without accounting for how this has come about historically (WBG, 2020d:7). This indicates the lack of consideration to historical context of its borrowing states dependent relations on health as Frank critiques as integral in the maintenance of power of metropolis (1969:4). The WBG has identified the public lending arms IDA and IBRD as key players in the crisis response on health providing loans to support the public health sectors. Out of its 558 either new or refinancing projects from 1st of February 2020 to April 15 2021, 124 are related to health (See Appendix Tables 1A-6B). Diagram 1 shows how many million dollars were distributed to the health sector or not within the six regions from all of the IDA of IBRD loans and grants (World Bank, 2021e). The COVID-19 pandemic has hit very differently but it is still apparent that across the board health has been given a quite small share compared to loans towards other sectors as financial recovery or education (ibid). As argued by Kentikelenis et al. (2020) the de-prioritization of public health has unfavorable consequences on the health sector and is an indication of a market-oriented approach of the WBG. Some of the countries as Brazil and Mexico receiving no loans towards the
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public health sector have on the other hand received a large amount of resources through IFC in private health on investments such as Brazil’s leader in manufacturing medicines Viveo (IFC, 2021; World Bank, 2021e).
IDA and IBRD Million dollars loans and grants from February 1st 2020 to March 31 2021 20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0 Africa East Asia and Pacific Europe and Central Asia Latin America and Caribbean South Asia Middle East and North Africa
Health Not Health DIAGRAM 1
With respect to the fact that all states vary in opinion on the appropriate role of the state in health systems, the prominence of selectivity and conditionality of the WBG strategy must be emphasized. The WBG stresses that due to the unprecedented situation selectivity and conditionality in projects are of even greater importance than else seen (WBG, 2020d: 33). Another aspect to consider is that, as mentioned with Brazil and Mexico, the WBG are establishing private health services as prominent part of national health systems during a public health crisis (WHO, 2020). The WBG strategy creates a stronger tie of interdependence on health by prioritizing private sectors through a neoliberal approach. By prioritizing the private sector, bank loans and investments, it takes away agency of the states to choose to utilize the borrowed money as they wish. The technocratic decision-making on the health of a population is a clear indication that the agency has moved from a national to a global level. In accordance with dependency theory by Frank (1969) this does not improve health policies of a population by making it further dependent on the market and the metropolis.
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The construction of private health markets through time with impact of the WBG has received massive critique as previously mentioned (Williams, 2020:182). It has left states with vulnerable private sectors and insufficient public sectors due to lack of resources (ibid). The historical context has set states in a dependent relation on health in which they must rely on the dominant states to finance health goods and services (ibid). This construction is further reproduced by a continuant reproduction of similar policies by the WBG as seen in its COVID-19 approach of de-prioritizing health and prioritizing neoliberal tenants of private finance, de-risking and Blended Finance. This demonstrates a further reproduction of capitalist neoliberalism with market-oriented ideas in focus rather than health. The WBG as a financial institution is setting up conditions to make states more dependent on the global economy on and through health. This construction will in the following section be enlightened through a discourse analysis of its approach.
4.1.4 Saving lives? The World bank Group in June 2020 published its ‘COVID-19 Crisis Response Paper Saving Lives, Scaling-up Impact and Getting Back on Track – World Bank Group COVID-19 Response Approach Paper’ (WBG, 2020d). It encompasses three stages; relief, restructuring and resilient, which in its own words helps to bring states out of the pandemic in the most sustainable matter. The Executive Directors are the authors of this approach and it encompasses all of the organizations within the WBG. The approach is directed not only at the borrowing countries, but also its share- and stakeholders. Health is as mentioned a big part of development discourse and both health and development are therefore crucial to analyze in the discourse. A CDA will here be accounted for on the Covid-19 Crisis Response paper following Fairclough’s three dimensions.
4.1.4.A First dimension: Discourse as text The institutional structure of the WBG is crucial to consider in that it does not only need to legitimize its approach towards the borrowing states but also its member states and other share- and stakeholders. One key semantic strategy to construct such legitimization is for the WBG to refer to themselves as ‘the best’. “The comparative advantage of the WBG comes from the powerful combination of country depth and global breadth, public and private sector instruments and relationships, multi-sector knowledge and practitioner expertise, and the ability to mobilize and leverage financing.”(WBG, 2020d: vii). This exact sentence word for word is written out three times,
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which puts stronger emphasis on it. Beyond legitimizing them as the ‘the best’, throughout the document the WBG mention the importance of the approach by describing it with adjectives as “unprecedented”, “vital” and “exceptional’. By restating these synonyms it works to construct the WBG as the best, as the modality of the truth. The WBG works to emphasize and legitimize its neoliberal approach by modality throughout the text. Fiscal transparency is an aspect as previously mentioned oriented towards interest of foreign investment. Transparency is in the document put together with words that are given the same level of importance such as fair “burden-sharing”, “governance” and “respect for rule of law”. These are in the same order mentioned as core principles throughout the document and work as co-meronyms of ‘right policies’. The co-meronyms are utilized as textual triggers for positive valuation. Not only is the WBG emphasizing the positive aspects of neoliberalism but strengthens this argument by portraying government intervention in general negatively: “Private demand will be depressed, and government interventions will lead to higher debt and stronger public involvement in the economy.” (WBG, 2020d: 28). This quote is written in relation to the negative impact of the pandemic in which both government interventions and public involvement are seen as negative impacts. The construction of the linguistics here is through nominalization (to put the nouns as the active). By having ‘private demand’ as active in the clause and with the word choice of depressed it connects it with the emotions emphasizing the negative valuation. “Stronger public involvement” is in the clause constructed as negative when associated with other negative things as “higher debt” and “depressed”. By putting these complex phenomena in a simple clause construction, the WBG does not need to explain it further and through modality it becomes the one truth.
4.1.4.B Second dimension: Discourse as discursive practice In the second dimension in directing attention to the production, distribution and consumption of the text it is noticeable that this text has a high level of interdiscursivity. On such discourse is the institutional discourse in that the WBG as an international actor represents a large amount of states and is working within the institutional constraints associated with such. This means that the language is formal to maintain authority and professionalism within the international society. It also means that the WBG is both working as an actor in itself but also as a spokesman for most of the Western world. And the discourse found therefore goes way beyond that of the WBG - it situates in the discourse on global financial development. Part of such is seen in its strong emphasis on private-public relations
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and foreign investment throughout the article, which by Gabor (2020) is an indication of prioritization of private international investment and the global economy. The discourse legitimizes the WBG’s international interference through positioning themselves as the best as shown in the first dimension. The strong emphasis on the WBG as saviors is highlighted throughout the article, emphasized in the title of its strategy ‘Saving Lives’. This emphasizes the strong ‘need’ that its borrowing states have for the WBG plus it furthermore indicates that the WBG can better work to establish health policies and ‘save’ the population than the state itself. This interdependent relation directly works in the discourse of neoliberalism in development because foreign intervention will work to progress and develop the undeveloped states. Another discourse function is the way the WBG legitimizes its strategy, is by describing its approach as crucial to meet the Sustainable Development Goals (SDGs). It hereby use the rationalization of a global approved approach and link it to the WBG’s approach - being the sole way to meeting these goals. It speaks into a new paradigm with sustainability and inclusiveness and eradication of poverty as key points. The WBG establish a construct of a future, an example here: “Thinking early about what the new transformed world will look like and what policies, reforms and investments will be needed is essential – starting at the relief stage.” (WBG, 2020c: 27). It hereby leaps into a change in discourse; a paradigm shift, which brings the SDG’s to legitimize its market- led approach. It furthermore shows its interest in impacting the national choices of states. While claiming to become more sustainable and inclusive the main financial tendencies are through private- public partnerships, prioritization of private sectors and foreign investment as all stated to be trades of neo-liberalism in the contemporary discourse on the WBG in development finance (Musthaq, 2020; Gabor, 2020; Dimakou, 2020b).
4.1.4.C. Third dimension: Discourse as social practice The context in the wider political economy is that this strategy is an example of the political economic discourse of neoliberalism as constructed by dominant states. The WBG’s clear way of dividing the development and reply process in steps is itself an example of the ‘one size fits all’ model that Rostow (1990) in modernization theory came forward with. It furthermore is constructed as an ahistorical text, which omits the international involvement in why many of these states are currently in poor financial situations and with poor health care systems. The lack of history is exactly what dependency theory wishes to enlighten to explain why they cannot go through the same historical progress to modernization as the developed states (Frank, 1969).
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The way in which the WBG legitimize its approach as the truth is how it reproduces further dependency relations. By constructing its discourse as the truth and neoliberalism as the sole ideology it enlightens how the dominant group has the structural power to define the ideas of less dominant groups. This governmentality is reproduced in its discourses on development and health. When it comes to health this is indicated in that it constructs its approach to ‘save lives’. It underpins the need for the metropolis to ‘save’ its satellites, which reproduces its relationships. The impact on health policies is negative in that the stronger interdependence, as argued by Frank (1969), does not lead the states to become more developed but rather leads to further underdevelopment.
4.2 The World Bank Group’s COVID-19 strategy in Nigeria
In having analyzed the WBG’s overall strategy as operationalized in its Covid-19 Crisis Response Paper it can be concluded that it is pushing forward a neoliberal ideology which creates a stronger dependency between the WBG and its borrowing states. This is identified both when assessing its projects on health and its discourse on development in general. This section of the analysis will build on these conclusions by identifying these tendencies in the context of Nigeria. Nigeria has a massive role in the economy of developing states, which can be identified in the WBG’s COVID-19 strategy; because Nigeria is the largest borrower of loans in Africa during the time period, with Africa as the largest borrowing continent (See Appendix tables 6A and 6B). The first part of this chapter will address some contextual points in relation to the WBG, Nigeria and health. Hereafter the contribution to dependency relations will be identified by looking at the WBG’s COVID-19 strategy on health in Nigeria. In the latter part of this chapter a CDA will be accounted for to address the discursive way in which dependency relations are constructed and the power relations associated with such discourse.
4.2.1 Nigeria in context The World Bank Group’s historical interference in its borrowing state’s health systems, as demonstrated in previous section, is crucial to consider in its relationship to Nigeria. The historical dependency relationship between the WBG and Nigeria demands a lot more focus than what can be
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given in this paper, but it is crucial to consider because the COVID-19 strategy and partnership are not constructed ahistorically but as a reproduction of its time and context. Nigeria has since its first loan from the World Bank Group in 1958 been dependent on the loans of the bank and has been influenced towards participation in the capitalist economy (Olinger, 1978:101). Nigeria has always had a strong role in the WBG’s approach due to its large size and economy and as the Bank puts it ‘potential’ to become the largest economy in Sub-Saharan Africa (WBG, 2020b). Loans from the beginning were highly focused and conditioned on projects as railways and electric power to establish a state infrastructure, which works better within the capitalist international economy (Olinger, 1978:102). Restructuring economic departments and institutions were the means to generate neoliberalism, also on the institution of health (ibid). Nigeria today has a weak health system dominantly private sector lead (Mackintosh et al. 2016). The health quality is so poor that the Nigerian President Muhammadu Buhari in April 2021 went to London for a medical check-up (Nsofor, 2021). This is striking when the Nigerian government currently spends less than 5% of its federal budget on health and that the government is proposing to cut this by 43% (Akinwotu, 2020; Carsten and Eboh, 2020). This proposal is given due to the economic crisis followed by COVID-19 due to especially the dwindling oil sales seen across the nation (Akinwotu, 2020). Concurrently Nigeria is emphasizing its road towards Universal Health Coverage (UHC) (NFMH, 2021). This could indicate a will but lack of resources towards reaching the finish line of achieving UHC. The weak health system can arguably be seen as a result of the WBG’s strong emphasis on privatization of health and austerity in generating neoliberalism (Williams, 2020). When the pandemic hit Nigeria the health facilities and equipment were highly inadequate to tackle the emergency (Amzat et al., 2020). Nigeria per 15th of April 2021 has had around 163.000 thousand cases of COVID-19, with cases increasing (NCDC, 2021). Many countries around the world have had a lot more cases and deaths per capita. But what is essential to voice is that it has put the Nigerian health sector under pressure (Ozili, 2020). As most states in the world the pandemic has portrayed the limitations of the public health sectors. In the next section the WBG’s response to such pressure in Nigeria is analyzed. 4.2.2 The World Bank Group’s strategy in Nigeria during COVID-19 First thing to consider in analyzing the WBG’s contribution to dependency relation in Nigeria in its COVID-19 strategy is its projects distributed to Nigeria. The Government of Nigeria requested a large support package to its public health efforts (WBG, 2020: 32). It should be noted that the WBG do
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support the public health sector through the public lending arms IDA and IBRD with a combined loan of 100 million USDs to the sectors ‘health’ or ‘public administration health’ (World Bank, 2021e). This highlights an alignment of the request and hereby agency of Nigeria with the loans. But when put in opposition to the other loans and grants distributed throughout the pandemic we get a greater picture of the overall response. IDA and IBRD in total lend and grant 3,5 billion USDs to Nigeria throughout the pandemic with loans also going to other sectors as strengthening the financial sector, education etc. This indicates a de-prioritization of health despite Nigeria’s strong call for Universal Health Coverage (UHC) and support to its public health system during the pandemic (NFMH, 2021). In recalling the strong emphasis the WBG has on selectivity it demonstrates the structural power of the WBG in its impact on which loans are distributed. When looking particularly at the projects towards health: beyond the 100 million USDs towards health from IDA and IBRD projects, further 26 million USDs are directed towards health from the WBG to Nigeria, but through the private lending arm IFC (IFC, 2021). This brings the total amount of USDs towards health in the pandemic from the WBG to Nigeria to 126 million USDs (ibid). The IFC lending arm in total distributes 206,5 million USDs directly to Nigeria (what should be kept in mind here is that a large portion of IFC projects are directed towards regions and are not accounted for in these numbers, as mentioned in the limitations of this study) (ibid). What is apparent is that in projects directly distributed to Nigeria the proportion towards health from the IFC is around 10 percentage points higher than through the public lending arms as visualized in diagram 2.
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Diagram 2 highlights both the de-prioritization of projects towards health in general but furthermore the higher proportion in percentage on health in the private lending arm IFC than the two public lending distributers making up the World Bank (IDA and IBRD) (See Appendix Tables 6A and 6B; IFC, 2021). As previously argued the de-prioritization of health and progression of private health within Nigeria indicates the neoliberal approach of the WBG that in line with the theory of Frank (1969) contributes to stronger dependency relations on health. The further integration in the international economy through privatization could leave Nigeria further behind in progressing towards its goal of UHC. The two other lending arms important to this study are MIGA and PSW. MIGA’s 25,6 million USDs issue guarantees are directed towards equity investments of FirstRand EMA Ltd of South Africa to reduce risk of assets across the African continent (MIGA, 2020). As argued in previous research (Gabor, 2020; Musthaq, 2020) the WBG are doubling down on privatization through de- risking as a way of positioning emerging markets to accommodate international investors. This is according to Gabor (2020) an integral part of the Wall-Street Consensus along with the PSW lending arm. The IDA PSW distributes 200 million USDs throughout the pandemic to Nigeria directly towards public-private partnerships (PPPs). Through Frank’s (1969) theory of dependency the PPP’s has a negative impact on states because it is a clear indication of the WBG’s prioritization of foreign investment rather than national preferences leading to further dependent relations. The de-risking measures furthermore ends up being more expensive for Nigeria than public loans, which only
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increases its debt rates and in the end gives them less money to spend on social policies as health (Gabor, 2020). Another aspect to consider when enlightening the contribution to dependency relations is the position of the advisory institution of the WBG. In recalling Lee and Fustukian’s (2002:10) definition of health policies: that it is highly related to the policy environment, instruments and the power and influence in health policies. Nigeria’s COVID-19 strategy on health has been highly constructed around the influence of partnerships (Dan-Nwafor et al., 2020). In the WBG’s Advisory Services and Analytics (ASA) IFC plays the single role in advising on health. It is apparent that the ASA is not let by WBG organizations particularly associated with health as ‘Health, Nutrition and Population’ but rather the private sector arm (World Bank, 2021b). The direct link on health between Nigeria as a satellite and the metropolis of the WBG are hereby the financial expertise reproducing neoliberal structures and unequal power relations. The governors of Nigeria play a central part of the approach to build a resilient approach (WBG, 2020b:21). Nigerian Governors are similarly showing strong support for the assistance of the WBG (Nigeria Governors’ Forum, 2021). Similarly the Nigeria’s Federal Ministry of Health (NFHM) states that it wishes to ensure private sector involvement and also strengthen public-private partnerships in the health space (NFMH, 2021). This could indicate an alignment of agency of Nigeria and the strategy of the WBG. What Frank (1969) allows us to understand is that the metropolis through layers of elites in underdeveloped states establishes strategies that are attractive to them but not necessarily to the population as a whole. In comparing the WBG’s emphasis on governors to its emphasis on Community Driven Development (CDD), the emphasis on CDD is minor (WBG, 2020b). This is furthermore working against the World Bank’s ‘Strategy for Fragility, Conflict, and Violence 2020- 2025’ approach that emphasizes CDD and local experiences in general (WBG, 2020a). This is highly relevant since Nigeria is identified as a fragile state by the WBG (ibid). The WBG’s COVID-19 strategy in Nigeria hereby enlightens a de-prioritization of CDD on health and development strategies in general. It furthermore indicates a prioritization of further blended finance and private-public partnerships, which contributes to Nigeria being further dependent on global investment. The next section will highlight how its approach is legitimized through discourse and the construction of health and development by the WBG.
4.2.3 Health or Wealth?
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The World Bank Group published its partnership framework with Nigeria in November 2020: ‘Country Partnership Framework for the Federal Republic of Nigeria for the Period FY21-FY25’ (WBG, 2020b). The partnership framework encompasses as the WBG strategy three stages for Nigeria to deal with COVID-19 at written moment and beyond. The key recipient is the state of Nigeria, but furthermore also share- and stakeholders which has interest in the state of Nigeria.
4.2.3.A First dimension: Discourse as text In the partnership framework Nigeria is constructed both as an agent, which the WBG supports, and simultaneously as an actor, which is responsible to its population. The relationship between the WBG and Nigeria is sometimes constructed explicitly through ‘us’ and ‘them’ but there is an implicit unequal relationship between those in need of support and those providing that support. “Nigeria’s development agenda and development financing needs are vast, creating considerable excess demand for our support” (WBG, 2020b:4). Looking at the transitivity of the clause (subject linked with process) Nigeria is the active in the sentence and ‘our support’ passive, which indicates that Nigeria actively, seeks the need of support. This quote shows the construction of the WBG as a savior to Nigeria, and the underlying understanding is hereby that Nigeria would not succeed / develop without the support of the WBG. This construction of the WBG as a ‘savior’ towards Nigeria is seen throughout the text by the utilization of words as “support” and “help” - instead of financial terms as ‘loans’. These words with a connotation of the WBG as a savior establish the WBG as a giver of ‘support’ and help’ rather than conditional loans. This furthermore works to legitimize the WBG’s approach by emphasizing its borrowing states’ needs of them. An example expressing the relationship the WBG construct with Nigeria as a responsible actor rather than the receiver of support: “COVID-19 crisis presents an opportunity for Nigeria to renew its social contract by strengthening government legitimacy and building trust among citizens.” (WBG, 2020b:20). The nominalization of this sentence emphasizes how the WBG tries to omit itself as an actor by instead of mentioning the ‘WBG wants Nigeria to renew its social contract…’ COVID-19 is the active in the clause and hereby the reason for such decision-making. This statement furthermore gives a clear indication of how the WBG intervenes on the fundamental stone of the autonomy of Nigeria namely its social contract of its citizens. This quote furthermore presents another key theme in the text namely the importance of time and how COVID-19 becomes constructed as a now or never situation. The crisis of COVID-19 is throughout the document constructed as an opportunity for Nigeria to “change”, “reform”, “realize potential” and “develop” as synonyms. This is put in strong
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opposition to the issues seen if Nigeria does not make such change - which will be a further financial crisis. This is a clear use of modality in that change is constructed as the only ‘truth’. Another use of modality is seen by the construction of the WBG’s economic policies as the only truth. This is apparent in all themes as on health, gender, fragility etc. One clear example, which highlights this, is: “Nigeria’s development agenda must be private-sector-led” (WBG, 2020b:1). The utilization of the word “must” clearly emphasizes the modality used in this quote. It furthermore indicates the relationship between private finance and development in that the WBG constructs the two as dependent in that development cannot happen without being private-sector-led. The transitivity demonstrated in this quote is that Nigeria is active and hereby constructed as the actor in charge - while the WBG again is omitted in that it does not state ‘the WBG believes Nigeria…’. Without mentioning it is an opinion but rather stating it as the truth it establishes a stronger emphasis on the clause through modality. Another example emphasizing this: “… public sector needs to shift from being a primary source of formal wage employment to an enabler of private sector investment and formal job creation” (WBG, 2020b:16). The word choice “needs” hereby portrays same construction of modality by having ‘the public sector’ now as active in the clause and the WBG as omitted from the sentence. This type of constructions is seen throughout the document. Another thing highlighted in this quote, is the modality of private finance through its construction of ‘job creation’. The WBG regularly mentions the creation of jobs as an important part of Nigeria’s strategy and is in every instance associated with private jobs. By creating this relationship throughout the text, it leads the reader to always associate the two as a given.
4.2.3.B Second dimension: Discourse as discursive practice The above mentioned examples through a SFL analysis portrays some of the tools the World Bank Group utilizes to legitimize its approach of neoliberalism in development. This section will portray the production of their discourse and its connection to health. Some arguments apparent in the discursive analysis of the Covid-19 Crisis Response Paper are equally as applicable to this text, some of which will be highlighted again but also new perspectives added which becomes more apparent within a more country-specific document. The interdiscursivity of the partnership framework is dominated by the neoliberal development discourse. In the development discourse what is essential to notice is that the WBG are utilizing development as the legitimization of its approach. This plays into Harman’s (2009) argument that the WBG construct development as ‘good governance’ to legitimize its market-driven strategy. The
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discourse and power of constructing what is the right governance plus right development gives a great deal of power to the WBG. What is being constructed as a ‘good health approach’ is as explained in the previous section constructed by the advisory team let by the private lending arm IFC. As with development in general, health works both as part of the development discourse and is in itself used to promote the neoliberal discourse. As Sell and Williams (2020) argue; capitalism impact health of states by delimiting alternatives. Within the WBG partnership framework it forms the discourse around health to be the solely way to construct health. Another key aspect in the discourse concerning health is that it is constructed in the sense of human capital “… displaced health services may have knock-on effects on long-term human capital development.” (WBG, 2020b:12). By constructing it as human capital it portrays health as an asset towards productivity of a nation rather than as an individual right. It hereby works within the discourse of neoliberalism, which prioritizes productivity and a market-driven approach of states. The neoliberal discourse is in general constructed as market-driven. There is a great emphasis on Blended Finance (BF) and prioritization of privatization in the text. The discourse on necessity of BF is backing up the Wall Street Consensus of Gabor who furthermore accounts for the prioritization of foreign investors rather than national concerns. The emphasis on macro-financial ties through investment is seen in this example: “Macro-financial stability, and the ability to access foreign exchange for profit repatriation, is essential to attract and retain private investment and FDI.” (WBG, 2020b:39). The importance of foreign investment and intervention is in this example constructed as essential for macro-financial stability. The goal of private investment is constructed throughout the article, as not only something to strive for, but as essential to the development of Nigeria.
4.2.3.C Third dimension: discourse as social practice As previously stated this text situates within a discourse of development finance on health as well as in the structure of global development finance. The World Bank Group is a key player in upholding the dominant discourse within both these discourses. The discourse on development finance on health cannot be taken as separately in that it is an integral part of the global development finance discourse as the macro context. The institutional discourse of the WBG is legitimizing itself as an institution, which not only can, but must, provide support for states to survive and develop. As a result it does not account for the validity of its expertise nor SDG’s as much as seen in the ‘Covid-19 Crisis Response Paper (WBG, 2020d). The relationship, constructed through time, with Nigeria and its dependence relation is
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arguably enough in itself to legitimize the WBG’s partnership framework with Nigeria -indicating that discourse functions as hegemonic (Fairclough, 1992). This relationship between Nigeria and the WBG clearly highlights the structural constraints on Nigeria as a satellite, as argued in dependency theory (Agbebi and Virtanen, 2017:434). It simultaneously enlightens the capitalist power of the WBG to impact Nigeria towards a more market-driven and neoliberal approach that reproduces the dependency relation. In line with the ‘development of underdevelopment theory’ by Frank (1969) this relationship has throughout history let to the underdevelopment of Nigeria, which is only further reproduced in the discourse of this text. The text is in itself produced as an ahistorical text that while accounting for Nigeria’s previous financial crisis does not account for any international interference’s role within it nor the colonial past of the state. The text is reproducing development as to be met through universal steps as constructed similar to the modernization theory by Rostow (1990). This type of development, with health as an integrated part, works in the neoliberal hegemonic development discourse that contributes to further dependency relations. A real prioritization of health, in accordance with dependency theory, which will benefit the population, within a global pandemic, is therefore missing.
5. Discussion of findings and conclusion
This study provides a structural account of the WBG’s COVID-19 strategy on health and how this contributes to the dependency relations of its borrowing states. It is mainly focused on the WBG’s approach and how it constructs it, legitimize it and reproduce power relations of dependency through it. To further develop this account one aspect to highlight is the agency of the borrowing states. The focus on structure can lead to an assumption that the borrowing states do not have agency in the loans and health policies. In research in general there is an important gap to consider in this perspective. Further research could contribute to this by analyzing the agency of Nigeria or other borrowing states in relations to the COVID-19 pandemic’s health strategies. This study has focused on the WBG but further research could adapt a similar methodological framework to enlighten the role of other actors in global health. The WBG is far from the only actor on the arena of global health governance, and it would be interesting to look at other actors as Non- governmental Organizations, the International Monetary Fund (IMF), the World Health Organization, the Asian Development Bank etc. By highlighting the difference in power between these actors it
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could provide a stronger account of the WBG’s contribution to dependency relations. This has not been within the scope of this thesis, but the thesis in itself work as a good base to develop into further research. In focusing on the research of this study it appropriately answers the research question through analyzing how the World Bank Group’s COVID-19 strategy on health contributes to the dependent relations of its borrowing states. It works within a debate in International Relations on development and by adopting an interpretivist account the research has expanded the scope of health in the academic field of International Relation to further understand the great importance of international actors in the field of health. The WBG during the first year of the COVID-19 works as a great case to demonstrate such power in that it, despite the international call for public health, has de-prioritized health and prioritized privatization of development finance. This has been identified when analyzing quantitative data of its type of loans, type of lending arm and conditions associated with its projects. In answering the first sub-question ‘How does the World Bank Group’s COVID-19 strategy indicate that it is doubling down on neoliberalism?’ the conclusion is that the WBG is indicating a commitment to neoliberalism by prioritizing the lending arm of International Finance Corporation and increased influence of the blended lending arm Private Sector Window. The doubling down on neoliberalism is furthermore seen in its de-prioritization of health sectors and the vitality of selectivity, conditionality and private advisory on particular in health. In the analysis of the WBG’s strategy and partnership framework the discourse of neoliberalism is identified both in relation to development in general and in relation to health. The two correlates since health is a large part of development and development finance. The WBG throughout its approach and construction of discourse demonstrates how its strategy will contribute to further dependency of its borrowing states. This relationship will in accordance to dependency theory only lead to further underdevelopment and will have a negative impact on the health policies of states. When addressing the two latter sub-questions of this thesis ‘How does the World Bank Group construct health and legitimize its strategy through discourse?’ and ‘How is power embedded in its discourse?’ it is apparent that the WBG constructs health and development in line with neoliberal values and that the structural power between the metropolis and satellites are enlightened through the three dimensions of a Critical Discourse Analysis as understood by Fairclough (1992; 2001). To get a deeper understanding of the legitimization and power structures is it is crucial to account for the historical and structural ties between the WBG and Nigeria. By including these power structures from the theoretical standpoint of Frank (1969) it becomes apparent how the WBG
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discursively reproduces the dominant discourse of neoliberalism in its relation to Nigeria. In comparison to its overall strategy, which is legitimized mainly through being ‘the best’ and following the SDG’s - the partnership framework is mainly legitimized by claiming the approach to lead towards ‘development’. When bearing in mind the historical relationship between the WBG and Nigeria this can be explained by how the WBG through history has been able to construct what is the right approach and what is the right type of development in Nigeria. The neoliberal approach towards development and health as human capitalism is hereby already accepted as the hegemonic discourse. The WBG’s strategy plays within this discourse to stronger reproduce this unequal power relation. The WBG’s COVID-19 strategy on health contributes to dependency relation of its borrowing states by doubling down on neoliberalism through its projects in practice and discourse.
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https://openknowledge.worldbank.org/bitstream/handle/10986/35098/Nigeria-Country-Partnership- Framework-for-the-Period-FY21-FY25.pdf?sequence=1&isAllowed=y WBG (2020c) COVID-19 Strategic Preparedness and Response Program and Proposed 25 Projects under Phase 1. (Washington D. C.: The World Bank Group) Online: http://documents1.worldbank.org/curated/en/993371585947965984/pdf/World-COVID-19- Strategic-Preparedness-and-Response-Project.pdf WBG (2020d) Saving Lives, Scaling-up Impact and Getting Back on Track – World Bank Group COVID-19 Response Approach Paper (Washington D.C.: World Bank Group). Online: http://documents1.worldbank.org/curated/en/136631594937150795/pdf/World-Bank-Group- COVID-19-Crisis-Response-Approach-Paper-Saving-Lives-Scaling-up-Impact-and-Getting-Back- on-Track.pdf WBG (2021a) ‘Debt Service Suspension and COVID-19’, World Bank Group. Online: https://www.worldbank.org/en/news/factsheet/2020/05/11/debt-relief-and-covid-19-coronavirus (Last accessed: 08/04-2021). WBG (2021b) ‘Maximizing Finance for Development (MFD)’, World Bank Group. Online: https://www.worldbank.org/en/about/partners/maximizing-finance-for-development (Last accessed: 23/04/2021). WBG (2021c) ’Member Countries’, World Bank Group. Online: https://www.worldbank.org/en/about/leadership/members#5 (Last accessed: 08/04-2021). WBG (2021d) ‘OUR ORGANIZATION’, World Bank Group. Online: https://www.worldbank.org/en/about/annual-report/our-organization (Last accessed 01/05/2021). World Bank, (2020a) ‘IDA and the Private Sector Join Forces to Fight the Pandemic in the Most Fragile Countries’, World Bank Group. Online: https://www.worldbank.org/en/news/feature/2020/11/13/ida-and-the-private-sector-join-forces-to- fight-the-pandemic-in-the-most-fragile-countries (Last accessed 04/05-2021). World Bank (2020c) ‘World Bank Group’s Operational Response to COVID-19 (coronavirus) – Projects List’, World Bank. Online: https://www.worldbank.org/en/about/what-we-do/brief/world-bank-group-operational-response- covid-19-coronavirus-projects-list (Last accessed 18/04/2021). World Bank (2021a) ‘A new policy to help the world’s poorest countries manage debt vulnerabilities’, World Bank. Online:
40 Student name: Mia Jacobsen DoB: 14/05/1996
https://blogs.worldbank.org/voices/new-policy-help-worlds-poorest-countries-manage-debt- vulnerabilities (Last accessed: 17/04/2021). World Bank (2021b) ‘Health’, World Bank Group. Online: https://www.worldbank.org/en/topic/health (Last accessed: 01/05/2021) World Bank (2021c) ‘Maps’ World Bank Group. Online: https://maps.worldbank.org/ (Last accessed: 12/05/2021). World Bank (2021d) ‘Nigeria SFTAS Additional Financing for Covid-19 Response PforR’ World Bank Group, Online: https://projects.worldbank.org/en/projects-operations/project-detail/P174042 (Last accessed: 24/04- 2021). World Bank (2021e) ‘What We Do – Projects’, World Bank. Online: https://projects.worldbank.org/en/projects-operations/projects-list?strdate=03-01- 2020&os=0&enddate=04-01-2021 (Last accessed 12/05/2021).
6. APPENDIX
41 Student name: Mia Jacobsen DoB: 14/05/1996
Data is taken from the IBRD and IDA project website (World Bank, 2021e).
The appendix includes 12 tables: Table 1A: Middle East and North Africa – Projects on Health Table 1B: Middle East and North Africa – Projects not on Health Table 2A: East Asia and Pacific on health Table 2B: East Asia and Pacific not on health Table 3A: Europe and Central Asia on health Table 3B: Europe and Central Asia not on health Table 4A: South Asia on health Table 4B: South Asia not on health Table 5A: Latin America and the Caribbean on health Table 5B: Latin America and the Caribbean not on health Table 6A: Africa on health Table 6B: Africa not on health
TABLE 1A: Middle East and North Africa - PROJECTS ON HEALTH COUNTRY PROJECT ID MILLION PERCENTEGE DOLLARS ON HEALTH Djibouti P173807 5 100% Djibouti P174675 0 100% Arab Republic of Egypt P173912 50 100% Arab Republic of Egypt P172426 400 100% Jordan P173972 20 100% Morocco P173944 35 100% Tunisia P173945 20 100% Tunisia P175785 100 100% West Bank and Gaza P173800 5 100% Yemen P173789 0 100% Yemen P173862 26,9 100%
TABLE 1B: Middle East and North Africa - PROJECTS NOT ON HEALTH COUNTRY PROJECT ID MILLION DOLLARS PERCENTAGE NOT ON HEALTH Djibouti P171409 10 100% Djibouti P173702 160 100% Djibouti P171777 15 100% Djibouti P174128 3,36 100%
42 Student name: Mia Jacobsen DoB: 14/05/1996
Djibouti P172979 30 100% Djibouti P174556 15 100% Arab Republic of Egypt P172548 200 100% Arab Republic of Egypt P168582 500 100% Arab Republic of Egypt P175137 440 100% Arab Republic of Egypt P172373 0,75 100% Iraq P171446 5 100% Iraq P170704 12,5 100% Jordan P171172 100 100% Jordan P173091 81,4 100% Jordan P174076 1,03 100% Jordan P171426 8,8 100% Jordan P173974 350 100% Jordan P170669 163,1 100% Lebanon P173367 246 100% Morocco P173048 150 100% Morocco P170419 250 100% Morocco P172809 400 100% Morocco P171587 500 100% Tunisia P173324 175 100% Tunisia P173568 50 100% Tunisia P174017 1 100% Tunisia P173652 318 100% West Bank and Gaza P174781 0 100% West Bank and Gaza P172578 10 100% West Bank and Gaza P172571 15 100% West Bank and Gaza P171819 30 100% West Bank and Gaza P171328 3,25 100% West Bank and Gaza P175414 10 100% West Bank and Gaza P174355 20 100% West Bank and Gaza P174078 40 100% West Bank and Gaza P170928 14 100% West Bank and Gaza P175417 0 100% Yemen P173582 203,9 100% Yemen P174170 25 100% Yemen P172662 23,56 100% Yemen P175036 100 100%
43 Student name: Mia Jacobsen DoB: 14/05/1996
TABLE 2A: East Asia and Pacific - PROJECTS ON HEALTH COUNTRY PROJECT ID MILLION PERCENTEGE ON DOLLARS HEALTH Cambodia P173815 20 100% Cambodia P173769 11,34 81 % of 14 2 Cambodia P169629 15 100% Cambodia P174605 0 100% Fiji P173903 6,4 100% Indonesia P173843 250 100% Kiribati P174219 2,5 100% Lao People's Democratic P173817 18 100% Republic Lao People's Democratic P166165 23 100% Republic Marshall Islands P173887 2,5 100% Mongolia P173799 26,9 100% Mongolia P175730 50,7 100% Mongolia P174571 0 100% Myanmar P173902 50 100% Myanmar P160208 100 100% Philippines P173877 100 100% Philippines P175953 500 100% Samoa P171764 4,5 14% of 25 Samoa P173920 2,9 100% Solomon Islands P173933 5 100% Vietnam P174389 6,23 100%
TABLE 2B: East Asia and Pacific - PROJECTS NOT ON HEALTH COUNTRY PROJECT ID MILLION PERCENTEGE NOT DOLLARS ON HEALTH Cambodia P172351 4,42 100% Cambodia P173527 1,72 100% Cambodia P172630 5,95 100% Cambodia P171063 2,7 100% Cambodia P169930 100 100% Cambodia P171331 93 100% Cambodia P173769 2,66 19% of 14 China P168025 100 100% China P162178 400 100%
81% of the full project amount 14 million dollars. The rest of the projects that are partially directed towards health, are written in the same way.
44 Student name: Mia Jacobsen DoB: 14/05/1996
China P169758 300 100% China P172325 200 100% China P166061 150 100% China P158079 200 100% China P173746 300 100% China P172224 6,28 100% Federated States of P170718 30,8 100% Micronesia Federated States of P174075 2,5 100% Micronesia Fiji P173558 145 100% Fiji P163484 12,5 100% Fiji P175206 50 100% Indonesia P170940 300 100% Indonesia P173249 500 100% Indonesia P166244 110 100% Indonesia P166672 13,5 100% Indonesia P172381 400 100% Indonesia P165742 14,32 100% Indonesia P162172 0,73 100% Indonesia P173429 3,42 100% Indonesia P163797 0,48 100% Indonesia P174025 300 100% Kiribati P165821 19,5 100% Kiribati P165838 30 100% Kiribati P169179 5 100% Kiribati P171380 2 100% Lao People's Democratic P167601 25 100% Republic Lao People's Democratic P169194 35 100% Republic Lao People's Democratic P174169 40 100% Republic Lao People's Democratic P170559 34 100% Republic Lao People's Democratic P170810 5 100% Republic Lao People's Democratic P173407 30 100% Republic Lao People's Democratic P171406 7,37 100% Republic Lao People's Democratic P165751 42 100% Republic Marshall Islands P171924 10 100% Marshall Islands P172014 15,37 100%
45 Student name: Mia Jacobsen DoB: 14/05/1996
Mongolia P170676 41 100% Mongolia P174116 20 100% Mongolia P173126 12 100% Myanmar P164448 200 100% Myanmar P162151 350 100% Myanmar P163389 100 100% Myanmar P174386 0 100% Philippines P174066 600 100% Philippines P171440 500 100% Philippines P170914 600 100% Philippines P174120 500 100% Philippines P163428 88,28 100% Philippines P161833 300 100% Philippines P173706 0,85 100% Philippines P174480 3 100% Philippines P172399 370 100% Samoa P171764 21,5 86% of 25 Solomon Islands P167465 15 100% Solomon Islands P170283 2,2 100% Tonga P174683 30 100% Tonga P171377 2 100% Tonga P174077 2,89 100% Tonga P171071 5,5 100% Tuvalu P174089 2,5 100% Tuvalu P171681 14 100% Vietnam P171006 84,4 100% Vietnam P171700 126,9 100% Vietnam P166656 294,87 100% Vietnam P162605 51,5 100% Vietnam P172974 1,5 100% Vietnam P171511 0,52 100%
TABLE 3A: Europe and Central Asia - PROJECTS ON HEALTH COUNTRY PROJECT ID MILLION PERCENTEGE ON DOLLARS HEALTH Croatia P173998 200 100% Georgia P173911 32 40% of 80 Kyrgyz Republic P173766 12,15 100% Turkey P173988 100 100% Ukriane P179749 135 100% Uzbekistan P173827 38 40% of 95 Uzbekistan P174956 0
46 Student name: Mia Jacobsen DoB: 14/05/1996
TABLE 3B: Europe and Central Asia - PROJECS NOT ON HEALTH COUNTRY PROJECT ID MILLION PERCENTEGE NOT ON DOLLARS HEALTH Croatia P167247 110,3 100% Croatia P173996 300 100% Georgia P169913 49,6 100% Georgia P173911 48 60% of 80 Georgia P169698 40 100% Georgia P173965 48,9 100% Georgia P171796 20,4 100% Georgia P169599 1,14 100% Georgia P169082 40,6 100% Kyrgyz Republic P171934 2,66 100% Kyrgyz Republic P172761 55 100% Kyrgyz Republic P174316 17 100% Kyrgyz Republic P174028 50 100% Kyrgyz Republic P163711 35 100% Kyrgyz Republic P167428 60 100% Kyrgyz Republic P170542 50 100% Kyrgyz Republic P174072 50 100% Turkey P174112 500 100% Turkey P173998 160 100% Turkey P171766 347,35 100% Turkey P171448 273,58 100% Turkey P170532 350 100% Turkey P169996 148,8 100% Turkey P171456 48,04 100% Turkey P174144 300 100% Turkey P171543 54,7 100% Turkey P169143 325 100% Ukraine P172597 350 100% Ukraine P172348 100 100% Ukriane P172392 0,45 100% Ukraine P170563 150 100% Ukraine P174436 300 100% Uzbekistan P171751 500 100% Uzbekistan P158372 500 100% Uzbekistan P162263 239 100% Uzbekistan P173827 57 60% of 95 Uzbekistan P170206 50 100%
47 Student name: Mia Jacobsen DoB: 14/05/1996
Uzbekistan P170598 5 100% Uzbekistan P173948 200 100%
TABLE 4A: South Asia - PROJECTS ON HEALTH COUNTRY PROJECT ID MILLION PERCENTAGE ON DOLLARS HEALTH Afghanistan P173775 100,4 100% Afghanistan P174234 8 8% of 100 Afghanistan P176012 60 100% Bangladesh P173757 100 100% Bangladesh P171648 150 100% Bangladesh P175837 500 100% Bhutan P173787 5 100% India P173836 1000 100% Maldives P173801 7,3 100% Nepal P173760 29 100% Nepal P175848 75 100% Pakistan P164785 50 25% of 200 Pakistan P166309 82 41% of 200 Pakistan P166308 25,2 70% of 36 Pakistan P173796 200 100% Pakistan P173087 48 19% of 200 Sri Lanka P173867 128,6 100%
TABLE 4B: South Asia - PROJECT NOT ON HEALTH COUNTRY PROJECT ID MILLION PERCENTAGE NOT ON DOLLARS HEALTH Afghanistan P174348 55 100% Afghanistan P174119 155 100% Afghanistan P172211 160 100% Afghanistan P173387 97,5 100% Afghanistan P174234 92 92% of 100 Afghanistan P171886 100 100% Afghanistan P169970 50 100% Afghanistan P173213 35 100% Afghanistan P173314 25 100% Bangladesh P168724 250 100% Bangladesh P169880 500 100% Bangladesh P174085 200 100% Bangladesh P161432 170 100%
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Bangladesh P171779 100 100% Bangladesh P168725 250 100% Bangladesh P170688 500 100% Bangladesh P169342 200 100% Bangladesh P161534 120 100% Bangladesh P161086 295 100% Bangladesh P174056 40 100% Bangladesh P168484 202 100% Bangladesh P174268 14,8 100% Bangladesh P171086 100 100% Bangladesh P173748 6,5 100% Bhutan P171780 40 100% Bhutan P173008 14,8 100% India P169111 381 100% India P174027 400 100% India P168097 120 100% India P174292 750 100% India P166020 105 100% India P163328 82 100% India P173704 500 100% India P166868 500 100% India P167350 500 100% India P170645 100 100% India P172213 68 100% India P170873 250 100% India P167804 180 100% India P173958 32 100% India P170811 105 100% India P168633 105 100% India P169497 30 100% India P175827 2 100% Maldives P174012 12,8 100% Maldives P163957 16,5 100% Maldives P172788 12,4 100% Maldives P172631 3,1 100% Maldives P175542 21,6 100% Nepal P170409 450 100% Nepal P173044 200 100% Nepal P166788 50 100% Nepal P170248 100 100% Nepal P170215 80 100% Nepal P163418 150 100% Nepal P170798 24 100%
49 Student name: Mia Jacobsen DoB: 14/05/1996
Nepal P174209 10,85 100% Nepal P165375 45 100% Pakistan P171850 500 100% Pakistan P163461 450 100% Pakistan P171417 304 100% Pakistan P170568 500 100% Pakistan P164785 150 75% of 200 Pakistan P166309 118 59 % of 200 Pakistan P166308 10,8 30% of 36 Pakistan P174314 200 100% Pakistan P159292 35 100% Pakistan P173399 200 100% Pakistan P165542 50 100% Pakistan P173021 100 100% Pakistan P174484 600 100% Pakistan P174223 0 100% Pakistan P173087 162 81% of 200 Pakistan P151075 0 100% Pakistan P167843 700 100% Pakistan P173062 12 100% Pakistan P171659 8 100% Sri Lanka P172342 69,33 100% Sri Lanka P166865 69,53 100% Sri Lanka P174291 88,97 100%
TABLE 5A: Latin America and the Caribbean - PROJECTS ON HEALTH COUNTRY PROJECT ID MILLION PERCENTAGE ON DOLLARS HEALTH Argentina P174913 300 100% Colombia P169866 150 100% Colombia P174118 175 25% of 700 Dominican Republic P174145 37 37% of 100 Ecuador P176326 150 100% Ecuador P173773 20 100% Grenada P174527 2,75 11% of 25 Guatemala P173854 20 100% Guyana P175268 7,5 100% Haiti P173811 20 100% Haiti P171474 8 8% of 20 Honduras P173861 20 100% Nicaragua P173823 20 100% Panama P173881 20 100%
50 Student name: Mia Jacobsen DoB: 14/05/1996
Saint Lucia P174228 5 100% Saint Lucia P174797 0,94 100% Uruguay P173876 20 100%
TABLE 5B: Latin America and the Caribbean - PROJECTS NOT ON HEALTH COUNTRY PROJECT ID MILLION PERCENTAGE NOT ON DOLLARS HEALTH Argentina P173767 400 100% Argentina P174946 80 100% Argentina P173081 250 100% Argentina P172689 300 100% Bolivia P173984 254,3 100% Bolivia P165861 70 100% Brazil P174197 1000 100% Brazil P169272 0,94 100% Brazil P170850 38 100% Brazil P173621 1,3 100% Brazil P169134 80 100% Brazil P172455 200 100% Brazil P172605 125 100% Brazil P169140 97 100% Brazil P170682 123,65 100% Colombia P172972 42,97 100% Colombia P170728 400 100% Colombia P174118 525 75 % of 700 Colombia P173424 500 100% Costa Rica P160368 60 100% Costa Rica P168475 75,1 100% Costa Rica P181912 300 100% Costa Rica P172352 156,64 100% Dominica P174247 3,6 100% Dominica P174242 12,8 100% Dominica P174927 25 100% Dominica P172242 13 100% Dominican Republic P161182 25 100% Dominican Republic P174145 67 67% of 100 Ecuador P174115 500 100% Ecuador P173283 500 100% Ecuador P172899 260 100% Grenada P172951 17 100% Grenada P174527 22,25 89% of 25
51 Student name: Mia Jacobsen DoB: 14/05/1996
Guatemala P173698 500 100% Guatemala P173480 150 100% Guyana P170471 13,5 100% Guyana P170025 26 100% Haiti P175176 7,75 100% Haiti P173281 33 100% Haiti P174736 4 100% Haiti P170907 84 100% Haiti P174111 75 100% Haiti P168951 56 100% Haiti P171976 60 100% Haiti P171474 12 12% of 20 Honduras P175977 150 100% Honduras P169901 70 100% Honduras P173125 45 100% Honduras P169161 30 100% Honduras P172567 119 100% Mexico P164389 120 100% Mexico P174150 750 100% Mexico P172647 225 100% Mexico P174000 750 100% Mexico P169959 110 100% Mexico P172863 1000 100% Nicaragua P174677 6,77 100% Nicaragua P164134 2,74 100% Nicaragua P175878 80 100% Panama P174107 300 100% Saint Lucia P170860 45 100% Saint Lucia P166039 0,17 100% Saint Lucia P174346 30 100% Saint Lucia P170445 20 100% Saint Vincent and the P169956 40 100% Grenadines Uruguay P172796 400 100%
TABLE 6A: Africa - PROJECTS ON HEALTH COUNTRY PROJECT ID MILLION PERCENTAGE ON DOLLARS HEALTH Angola P160948 110 100% Benin P175441 0,94 100%
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Benin P173839 10,4 100% Burkina Faso P174315 14 14% of 100 Burkina Faso P173858 21,15 100% Burkina Faso P168823 10 100% Burkina Faso P170934 13,3 9% of 148 Cabo Verde P173857 5 100% Cabo Verde P175807 5 100% Cabo Verde P174299 0,94 100% Cameroon P174108 29 100% Cameroon P164954 15,2 42 % of 36 Central African P173832 7,5 100% Republic Central African P173900 2,75 11% of 25 Republic Central African P168474 5 10% of 50 Republic Chad P173894 16,95 100% Comoros P174227 5 100% Comoros P166013 30 100% Democratic Republic P173825 47,2 100% of Congo Democratic Republic P173415 200 100% of Congo Republic of Congo P173851 11,31 100% Ethiopia P175853 207 100% Ethiopia P173750 82,6 100% Eswatini P173883 6 100% Eswatini P174447 5,2 13% of 40 Gambia P175740 0,94 100% Gambia P173798 10 100% Gambia P173287 35 100% Ghana P173788 35 100% Ghana P174839 130 100% Guinea P174032 10,9 100% Guinea P174063 10,4 13% of 80 West Africa P154807 110 100% Guinea P174032 7,37 67% of 10,9 Kenya P175188 50 100% Liberia P169641 54 100% Liberia P173812 7,5 100% Madagascar P172393 0 100% Madagascar P174288 5,25 7% of 75 Malawi P173806 7 100% Mali P173816 25,8 100%
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Mauritania P173837 5,2 100% Mozambique P174152 13 13% of 100 Nigeria P173980 100 100% Rwanda P175252 0,94 100% Rwanda P173855 14,25 100% Sao Tomé and Príncipe P173783 2,5 100% Sao Tomé and Príncipe P174880 0,94 100% Senegal P173838 20 100% Seychelles P174198 2,55 17% of 15
TABLE 6B: Africa - PROJECTS NOT ON HEALTH COUNTRY PROJECT ID MILLION PERCENTAGE NOT ON DOLLARS HEALTH Angola P166805 250 100% Angola P168336 700 100% Benin P168132 160 100% Benin P174186 6,85 100% Benin P174008 50 100% Benin P170425 60 100% Benin P172749 100 100% Burkina Faso P166596 2,75 100% Burkina Faso P170452 100 100% Burkina Faso P175382 350 100% Burkina Faso P170934 119,88 81% of 148 Burkina Faso P174315 86 86% of 100 Cabo Verde P171099 20 100% Cabo Verde P174898 10 100% Cabo Verde P171080 25 100% Carbo Verde P175946 10 100% Cameroon P170561 125 100% Cameroon P172885 45 100% Cameroon P166072 200 100% Cameroon P164954 20,88 58% of 36 Central African P168474 50 100% Reoublic Central African P173900 22,25 89% of 25 Republic Central African P168474 45 90% of 25 Republic Central African P174547 16 100% Republic Chad P171611 50 100%
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Chad P171646 4,45 100% Chad P174214 0 100% Chad P172255 75 100% Chad P174600 15 100% Comoros P162783 40 100% Comoros P174866 6 100% Comoros P174260 10 100% Democratic Republic P171821 445 100% of Congo Democratic Republic P171141 500 100% of Congo Democratic Republic P172341 800 100% of Congo Republic of Congo P171854 15 100% Republic of Congo P174178 50 100% Estwatini P168564 20 100% Eswatini P174447 34,8 87% of 40 Ethiopia P174206 14,85 100% Ethiopia P171742 500 100% Ethiopia P168074 80 100% Ethiopia P169943 122,5 100% Ethiopia P174874 100 100% Ethiopia P172479 512,5 100% Ethiopia P169080 250 100% Ethiopia P169079 500 100% Ethiopia P172462 12 100% Ethiopia P174385 178,24 100% Ethiopia P169943 400 100% Ethiopia P171409 10 100% Ethiopia P173702 160 100% Gambia P166695 35 100% Gambia P164545 30 100% Gambia P174035 0 100% Gambia P173161 43 100% Ghana P171620 125 100% Ghana P170910 115 100% Ghana P173282 40,3 100% Ghana P169357 37,48 100% Ghana P175588 100 100% Ghana P169742 250 100% Ghana P166996 200 100% Guinea P174063 66,4 83% of 80 Guinea P164184 100 100%
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Guinea P168777 70 100% Guinea-Bissau P174336 15 100% Kenya P167814 150 100% Kenya P172321 1000 100% Kenya P174059 0 100% Liberia P172654 4,5 100% Liberia P173145 8,8 100% Liberia P173261 9,3 100% Liberia P173416 59 100% Liberia P174417 10 100% Madagascar P175172 33 100% Madagascar P174886 150 100% Madagascar P167725 50 100% Madagascar P174669 1,76 100% Madagascar P172051 47,25 100% Madagascar P179350 20 100% Madagascar P175087 50 100% Madagascar P169413 140 100% Madagascar P171056 100 100% Madagascar P174288 69,75 93% of 75 Malawi P168577 86 100% Malawi P164961 100 100% Malawi P167860 157 100% Mali P164032 80 100% Mali P168812 60 100% Mauritania P163143 40 100% Mauritania P174155 70 100% Mozambique P174294 73,5 100% Mozambique P174783 26,2 100% Mozambique P172657 160 100% Mozambique P172777 23,12 100% Mozambique P167054 104 100% Mozambique P171449 100 100% Mozambique P174152 87 87% of 100 Mozambique P163989 117 100% Nigeria P174042 750 100% Nigeria P172891 500 100% Nigeria P173104 176 100% Nigeria P170664 500 100% Nigeria P164001 750 100% Nigeria P174114 750 100% Nigeria P169921 75 100% Rwanda P170376 8,07 100%
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Rwanda P174046 9,72 100% Rwanda P172153 4,6 100% Rwanda P173882 100 100% Rwanda P172862 2,73 100% Rwanda P172735 150 100% Rwanda P165017 150 100% Rwanda P172594 150 100% Rwanda P171554 150 100% Sao Tomé and Príncipe P174539 8 100% Sao Tomé and Príncipe P169196 12 100% Sao Tomé and Príncipe P168335 10 100% Sao Tomé and Príncipe P169222 15 100% Senegal P170954 50 100% Senegal P173918 100 100% Senegal P164967 150 100% Seychelles P168993 622 100% Sierra Leone P174958 6,85 100% Sierra Leone P170604 30 100% Sierra Leone P174813 5,3 100% Sierra Leone P171059 50 100% Sierra Leone P164212 40 100% Sierra Leone P167897 50 100% Sierra Leone P169498 100 100% Sierra Leone P171225 300 100%
57