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Lancet. 1993 Aug 14; 342(8868):440-1.The policy recommendations in the 1993 world development report (WDR) call for more investment in public health and clinical care, reducing poverty, increasing education for girls, and private health care provision. The structural adjustment policies supported by the World Bank influence growth, poverty, and health expenditure. All but 2 of the 10 studies on the effect of such policies on poverty and health were produced by or for the Bank. One study concluded that poverty levels increased in both Latin America and Africa between 1985 and 1990 and remained static in south Asia. Another study endorsed the view that structural adjustment in Africa had failed to generate economic growth, and it had resulted in a significant decline in investment. After nearly $150 billion of adjustment lending by the World Bank and the International Monetary Fund, there is a need to look for alternative policies. WDR claims that public spending on health in countries implementing structural adjustment policies recovered faster in the last few years of the 1980s than in non-adjusting countries. Yet the adjusting countries' per capita expenditure declined by the same amount as that of the non-adjusting countries between 1980 and 1990. The report's estimate of $12 per person for the cost of public health and essential clinical services in low-income countries is far beyond the health budgets of many for minimum levels of coverage of health services. In sub-Saharan Africa, donors already finance an average of 20% of health expenditure. In many areas where user charges have been introduced, there have been sharp declines in essential services and primary education and some evidence for reversals in maternal and perinatal mortality rates. In Guinea and Benin, the success of cost-recovery schemes and the improved services were in part achieved by the subsidies by UNICEF. The report does not suggest a strong commitment to integrated health systems.