Low Credit: A Report on the World Bank’s Response to HIV/AIDS in Developing Countries

Published by ActionAid, this paper looks at the response to the HIV/AIDS crisis by the World Bank as a key member of the international donor/lending community, a leader in the international health community, and as Africa's principal development partner.

From the Executive Summary

This paper looks at the response to the HIV/AIDS crisis by the World Bank as a key member of the international donor/lending community, a leader in the international health community, and as Africa's principal development partner. In its seminal document, "Intensifying Action Against HIV/AIDS", the World Bank acknowledges both its special leadership role in fighting HIV/AIDS and the need that it be held accountable for its stewardship. It states: "those who look back on this era will judge our institution in large measure by whether we recognised this wildfire that is raging across Africa for the development threat that it is, and did our utmost to put it out. They will be right to do so."

This paper assesses what the Bank did in response to the epidemic, whether it could have done things differently, and given this, what should happen now. The main findings are as follows.

The World Bank failed the poor. It failed to protect social spending during its structural adjustment operations in the 1980s and 1990s, and this led to the deterioration of basic services - including those needed for the prevention and control of HIV/AIDS. It failed to consider the impact of its policies on the poor, who are already vulnerable to HIV, have less access to safe-sex information, are less likely to use condoms and have fewer STI/HIV services. The Bank failed to consider the possibility that its policies would reduce the safety of health systems and become a source of HIV, especially at the periphery of health systems.

In the 1990s, the World Bank failed to adequately invest in the fight against HIV/AIDS and the few investments it did make were ill chosen. For example, World Bank lending for the period 1986-96 was a paltry US$552million, which was inequitably distributed across regions. Brazil, for instance, a middle-income country with a low prevalence rate (less than one per cent), received US$160 million compared with US$274 million for all of Africa, where some least developed countries, such as Zambia and Lesotho (with prevalence rates of 20 percent), were largely ignored until 2000. The Bank's own data show that from a public health perspective, lesst han 25 per cent of its projects met its own criteria for good investment in sexual health interventions. From a public economics perspective, the Bank failed its basic mandate - to provide protection for the poorestgroups in society from contracting HIV and its consequences, and to target those most likely to contract and transmit HIV.

Instead of focusing on HIV/AIDS, the World Bank sought improvements in the way goods and services were provided and financed through health sector reforms, such as user fees, privatisation, decentralisation and integration of services. These reforms frequently had the unintended effect of reducing access to effective health care, including services aimed at the prevention and control of HIV/AIDS.

At the heart of the Bank's overall failure to respond adequately to Africa's health challenges over the lasttwo decades is the critique that, rather than relying on public health principles, it operated mainly as a ‘bank', with its core business processes and incentives focused on lending money, rather than achieving health impact. It failed to place sufficient emphasis on addressing determinants of health that lie outside the medical care system. Consequently, it focused on HIV/AIDS as a narrow health sector problem, rather than a multisectoral problem. No mechanism existed for staff to discuss and review progress on the HIV/AIDS crisis, or recognise and reward progress on public health investments. Because the Bank typically focused on providing inputs, its monitoring and evaluation systems were too weak to assess performance and alter course. This is key to understanding why misconceived policies and strategies tended to go unchecked while the epidemic spread. This isolation from reality on the ground was exacerbated because the Bank tended not to consult or co-ordinate with other stakeholders. As an institution, it lacked the strategic and flexible approaches needed to support the development ofintellectual consensus and broad-based coalitions necessary to tackle HIV/AIDS.

Over the last three years, the Bank has dramatically improved its approach to the HIV/AIDS crisis: increasing resources available; putting emphases on a multisectoral approach; working extensively at the community level with local organisations; building up institutional capacity; and developing partnerships with government, community groups and financing partners. Nevertheless, preliminary evaluation of the Bank's US$500 million Multi-Country HIV/AIDS Programme (MAP) for Africa, annual review of its development effectiveness (2003) and comprehensive development framework, show that the institutional weaknesses described in this report persist, and may take years to correct.

This report recommends that the Bank carefully assessi ts stewardship over the last 15 years. Its acknowledged failure to protect public health spending and basic services, and take proactive steps to protect poor households during its structural operations, has huge implications on the spread of HIV. This is because vulnerable populations lost the access to the health care needed for the prevention and treatment of HIV/AIDS. Furthermore, the link between the decline inquality and safety of health care, and the spread of HIV through the medical system deserves attention.This report recommends that, as an institution taking leadership on HIV/AIDS, the Bank would benefit fromimproved levels of accountability and oversight. The establishment of an external supervisory board ofindependent HIV/AIDS and public health specialists to provide direction and guidance to the World Bank would be a positive step in the right direction. Further recommendations are that the Bank: develops and implements institutional and programmatic mechanisms to ensure that a non-formulaic and multi-sectoral view is taken in all Bank funded HIV/AIDS work, especially MAP; places emphasis on evaluating impact and outcomes of HIV/AIDS initiatives, rather than focusing on inputs; ensures that its HIV/AIDS policies and programming are rooted in a sound poverty reduction strategy, taking into account inequalities within countries and specifically targets poor and vulnerable groups through genuinely involving civil society in decision making processes; “mainstreams” HIV/AIDS into its policy processes anddevelopment initiatives; ensures that its HIV/AIDS interventions such as MAP and other poverty reduction initiatives are not undermined by previous (though still influential) and current wider Bank policies, and implements mechanisms to protect poor and vulnerable populations from user fees; promotes the integration of HIV/AIDS services into FP activities services, with the recognition for the additional need for separate HIV/AIDS services that can target at-risk groups not likely to use FP services, such as men, sex workers, and men who have sex with men.

The report recommends that DFID undertake a “benchmarking” review of Bank HIV/AIDS work (particularly through MAP), using a monitoring and evaluation framework similar to that which it has proposed for theGlobal Fund to Fight AIDS, TB and Malaria. It also recommends that NGOs monitor MAP funding flows to both civil society groups and government, and endeavour to provide feedback on project successes and failures; and that NGOs monitor and make known inconsistencies between overarching or wider Bank policies and MAP aims and objectives.