Millions of people in low-income countries have been forced to go without healthcare or have had to pay for it during the coronavirus pandemic, despite billions of pounds in emergency World Bank funding, research has found. The World Bank’s $6bn (£4.45bn) emergency health fund to 71 countries in response to Covid-19 failed to strengthen health systems or remove financial barriers to using them, according to an Oxfam report published on Friday. Oxfam reviewed the World Bank’s project documents to assess its support for water, sanitation and hygiene services and public health promotion; action to remove financial barriers to healthcare; and work on increasing the supply of healthcare workers and the role of the private sector in the public health response. While funding was considered strong in some areas, particularly disease prevention, the World Bank “missed vital opportunities to strengthen public health systems so they can tackle Covid-19 and deliver health for all in the future”, the report found. “We are in the middle of a global health emergency. All countries are facing vastly increased demand for healthcare. There has never been a more crucial time for World Bank leadership and funding to make access to healthcare free, and support millions of new paid and protected doctors, nurses and other health workers. They need to urgently change course to achieve this,” said Oxfam’s health policy adviser Anna Marriott. The most significant failure was in reducing out-of-pocket expenditure, Oxfam found. Every year, user fees block 1 billion people from accessing healthcare, causing avoidable deaths and increased disease transmission. Despite clear World Health Organization guidance that countries remove all user fees for all healthcare, at least for the duration of the pandemic, 89% of the World Bank’s country projects did not commit to that. Of the eight that did, none explicitly stated that the waivers covered all health services and, in three of those eight, the measure only covered treatment relating to Covid-19. “Let’s make no mistake, user fees for health [services] kill and are pushing millions of people into poverty,” said Marriott. “In the face of this pandemic, the World Bank has an urgent moral responsibility to support the removal of these fees.” The projects also failed to increase health worker numbers, the report found. Two-thirds had no plans to hire more doctors or nurses and others only for temporary workers. In 49 countries (69% of the total), the ratio of nurses for every 10,000 people was below the WHO recommended minimum, with 34 countries not even halfway to meeting it. In Malawi, where there is just one doctor for every 50,000 people, Bridget Malewezi, a doctor in the capital Lilongwe, told the Guardian that the pandemic exposed the country’s vulnerabilities. “Even before Covid-19 hit, we had a vacancy rate of about 48%, which means that if we needed 10 people in our hospitals, the reality was that we only had five,” said Malewezi. “In March the government recruited an additional 2,000 workers, but it was a drop in the ocean compared to the need. In Malawi, we have no user fees, so healthcare is technically free, but because resources are restricted, you usually end up paying out of pocket for your healthcare anyway. “We have doctors and nurses who have been trained but are sitting at home because a lack of funding means they haven’t been absorbed into the system yet. As we see the second, and even third waves of Covid cross the globe and hit closer to home like in Kenya, we worry that if we do get a second wave we will not be ready.” In a statement, the World Bank said: “The World Bank Group is working to support the COVID-19 health response in over 110 developing countries — home to more than 70% of the world’s population. “Our response is focused on saving lives and protecting the poorest households, so that people can rebuild their lives and livelihoods. We are also working to help at least 100 countries get ready to deploy COVID-19 tests, treatments, and vaccines, to ensure that developing countries are not left behind during this unprecedented crisis.”