The HIV epidemic: squeezing out the African voice

Dear Sir, Two sets of factors help explain why Africa’s HIV epidemic is not under control. First, ‘the unique characteristics of the virus, such as persistent infection, vertical transmission and a variability that allows it to escape immunity and antiretroviral drugs’ and ‘human characteristics, such as a strong procreative instinct, drug use and ostracism’ [1] is well described in the literature. Second, the response to the epidemic, which was neither timely nor robust, and was undercut by ‘denial, myths and complacency’, has received markedly less attention; what literature there is tends to focus on the failure of African governments to prioritize and take direct steps to tackle the crisis [1]. Several pieces of evidence suggest that the key to understanding the poor quality of the global response to Africa’s epidemic and indeed, why we have not been able to control the pandemic, was the systematic squeezing out of the African voice from global and local discourse by players for whom the crisis was not a top priority. This note presents evidence that Africa’s health agenda, rather than being set by Africans, was largely determined by the World Bank-led International Donor Community (IDC) the structure and processes which excluded African participation in decision- and policy-making. The IDC is made up of United Nation organizations, bilateral aid agencies from individual countries and International Financial Institutions (IFIs) such as the World Bank. Effectively disinterested in the African perspective, the Bank was often out of touch with events on the ground in this region and lacked the incentives to identify and meet local health needs. In the early 1990s, with the onset of soaring HIV rates, this disinterest shifted to an aggressive effort to deliberately and purposively sideline the HIV epidemic to protect its health sector reform agenda despite knowing the probable consequences. Although ultimate responsibility for responding to the epidemic rests with national governments in Sub-Saharan Africa (SSA), the reality is that they have had minimal say in determining their health agenda over the last 40 years. In monetary terms, the IDC typically contributes about 20% of public health expenditures, sometimes ranging up to 30–80% in the poorest countries [2]. As governments had no long-term development framework or even a medium-term instrument such as a Poverty Reduction Strategy, the IDC had significant influence over priority setting and the development agenda in the 1980s and 1990s. The consensus is that it had ‘a heavy influence over policy’ that went far beyond financial contributions [3]. The key player within the IDC in the 1990s was the World Bank, which together with the United States provided almost 50% of the development assistance to the health sector in low-income countries (see Table 1). In SSA, its influence arose from a number of factors; it was overall, Africa’s main development partner across all sectors, both in finance and policy, and the lead donor in the health sector. It frequently acted as the ‘umbrella-funder’– designing and implementing integrated health strategies to which other donors would contribute. A key source of influence was the Bank’s ability to attach conditions to each loan that needed to be met by borrowing governments for the release of funds [3]. A senior World Bank economist states that ‘policy-based lending is where the Bank really has power – I mean brute force. When countries really have their backs to the wall, they can be pushed into reforming things at a broad policy level that normally, in the context of policies, they can’t’ [5]. Another type of influence was the signalling function which arose from the Bank’s close working relationship with the International Monetary Fund (IMF). ‘The Fund sits on top of the donors’ pecking order. A country cannot borrow from the Bank if it does not have a Fund program and no Fund and Bank programme means no bilateral will lend’. This power of the ‘off-on switch’ meant that African governments had no choice but to cooperate with the IFIs [6]. Not surprisingly, therefore, the Bank was perceived by Africans as domineering and aggressive. A World Bank-sponsored study of 2600 opinion leaders from 48 countries that probed perceptions of the Bank’s role in a world of globalization found that the view ‘that the Bank forces its agenda on developing countries is consistent and overwhelming in all regions and virtually in all countries’. In SSA, more than 70% of those polled had this perception [10]. Furthermore, this study found the view that ‘Bank policies are influenced by the United States political and economic policies’– was held by more than 70% of those polled in Africa [7]. Indeed, the consensus amongst experts and members of the IDC itself is that the Bank suffers a large democracy deficit, inequitable distribution of voting power and exclusion of poor countries from fair representation on the Bank’s Board. The British House of Commons Committee for International Development issuing its recent (March 2008) report on World Bank reform found that the ‘Bank’s decision-making structure and internal governance are dominated by industrialized nations’ and that ‘poor counties have so little voting power and they are unable to exercise any influence over decisions affecting the lives of their citizen’ [8]. Lack of consultation, participation, accountability and transparency means ‘developing countries are systematically denied a voice in decisions that profoundly affect the lives of their citizens. Nowhere is the democratic deficit more keenly felt than in Africa’ [9]. Whilst the Bank claims on its website that it ‘is like a cooperative, where its 185 members are shareholders’, [10] in reality, the five richest countries – the USA, Japan, Britain, Germany and France – have almost 40% of the vote whilst Africa, with 44 members, has a total of 4% of the vote [11]. The United States alone has the capacity to unilaterally determine aspects of policy and no policy or initiative goes forward in the Bank without its approval. The simple mechanism of threatening to reduce or withhold funding, for instance, is an effective determinant of output [12]. The African caucus of Ministers of Finance has repeatedly sought a fairer division of power in the World Bank but without success, most recently during June 28–30, 2007 meetings at Maputo, Mozambique. The caucus drafted a memorandum to the World Bank stating that ‘the voice of African countries has been shrinking over the decades, mainly because of diminishing importance of the basic votes in voting power’ [13]. The World Bank website which provides a summary of the Maputo meetings makes no reference to demands from the African caucus [14]. Without a strong African voice to inform the agenda, decision-makers within the Bank were out of touch with reality on the ground in SSA and lacked the incentives to address common health needs and conditions. Consequently, the population accessed only a fraction of the resources required (about one-tenth) and significantly less than other developing regions. Specifically, whilst SSA bore 90% of the global burden of disease for malaria and 10 million Africans, mainly children, died from the disease in the 1990s, the IDC provided about US$ 80 million, about 8% of requirements of the estimated US$ 1 billion needed. The World Bank only made loans targeting malaria control to Asia not Africa [15]. Similarly, whilst tuberculosis (TB) killed about 6 million Africans in the 1990s, the World Bank provided no loans to tackle Africa’s TB and is widely criticized because it invests about US$ 3 million for TB in SSA ‘a mere US$ 0.83 per TB case in Africa compared with US$ 9.33 in TB funding outside Africa’ [16]. It was therefore no surprise that of the paltry US$ 552 it invested in HIV (1986–96), US$ 274 went to all of Africa whilst Brazil, a relatively rich country with a HIV prevalence rate of 1% received US$ 160 million. In contrast, Zambia and Lesotho, low-income countries with HIV prevalence rates of about 25% were largely overlooked until 2000. By the end of the 1990s, the Bank had three projects in SSA all of which were winding down and there was nothing new in the pipeline [3]. The Bank in the 1990s eschewed positive steps recommended by its own analysts that could have put it in closer touch with Africa’s reality. For example, as early as 1992, Bank researchers stressed the need for ‘user involvement’ in project design, operation and decision-making, based on their research identifying a strong correlation (confirmed by significance tests) between various indicators of ownership and the satisfactoriness of program outcomes: ownership was high in programs achieving good results and low in ineffective programs and was predictive of program success in 73% of all cases [11]. Yet the Bank’s Operations Evaluation Department (OED) which has to provide independent evaluation of Bank operations, reports in 1999 that only 4 of 224 projects documented the presence of beneficiary in decision-making in project design in the 1990s [17]. Similarly, Bank researchers and analysts repeatedly showed that it was important to undertake thorough economic and sector work (ESW) in each country in which it intended to invest so that it could tailor country-specific program responses. They found that projects with poor local analysis were at least seven times more likely to perform poorly than were projects with good analysis [17]. OED found that in the health sector generally and with respect to its HIV/AIDS investments specifically, it failed to undertake reasonable ex ante or ex post evaluation and it actually cuts its resources for ESW [17, 18]. Throughout the 1990s, the World Bank was fully invested in its main agenda, health sector reform, which according to its critics, it pursued with ‘wild-eye fervour’ [19]. During a period when it’s health, nutrition and population (HNP) lending portfolio grew 10-fold, it focused on a set of reforms that were intended to improve the way the health care was delivered and financed. These reforms did not take a need-based approach to health care provision but rather a neoliberal, market-based, individualistic approach fashioned after the United States model [6]. When the HIV/AIDS epidemic began to emerge both as a public health and development crisis in the late 1980s and early 1990s, the Bank’s immediate response was to take proactive steps to ensure that it did not displace its health sector reform agenda. Pursuit of this course was not because of lack of knowledge about AIDS. Its 1993 publications, Disease Control Priorities in Developing Countries [20] and Investing in Health [21] demonstrated that it had a good understanding of the nature and extent of the epidemic and its implications: its health specialists provided a comprehensive review of the HIV burden of disease, its epidemiology and actions needed to tackle high-risk populations. Review of key World Bank documents from the 1990s by the Bank’s Independent Evaluation Group (IEG, the successor to OED) reports that ‘there was concern that the urgent need to address the AIDS epidemic might somehow compete with this agenda given scarce capacity. The 1992 AIDS strategy for Africa cautioned that an expanded role for the Bank should not be allowed to overtake the critical agenda for strengthening health systems’ [22]. Is 1994 Better Health in Africa [23] demonstrated that it perceived AIDS as a major threat to Africa but cited this as another reason for urgent systemic reform. IEG reports that ‘AIDS is grossly neglected in the document…AIDS does not figure in the main conclusions and recommendations of the report and HIV is absent from the country-level health indicators in the annex’. Coming from the newly restructured HNP family, the HNP Sector Strategy [24] contained ‘no discussion of HIV/AIDS, the impact of the epidemic on health systems or on priorities anywhere in the main body of the report’ [22]. The World Bank succeeded in deprioritizing HIV/AIDS and keeping the focus on health sector reform. OED reports the remarkable finding that as HIV spread throughout the 1990s, increasingly ‘AIDS was even less strategically prominent in the Bank’s health sector strategy’ [22]. In these circumstances, average per capita spending on HIV/AIDS in Africa declined in the 1990s to about $3 per person by the end of the decade when World Bank spending on HIV was coming to a standstill and no new projects were being prepared. Thus, whilst AIDS deaths reached 15 million by 1999 in Africa, and people living with HIV, 20 million, it took the Bank’s management until 1997 to acknowledge the severity of the HIV crisis until 1997 and 2000 before it began a robust funding effort to tackle it. Had there been a strong African voice contributing to World Bank decisions, it is unlikely that deliberate sidelining of HIV by health sector reforms would have taken place. However, given Bank’s architecture and processes, an adequate response to the crisis was a nonstarter; unlike mediocre responses to Africa’s other health needs, it has been less easy for the IDC to duck its responsibility and place the blame on its so-called African partners. Nevertheless, the lack of an African voice distorts historical analyses of the crisis often reflecting a western perspective, emphasizing the lack of political will and African governments’ failure to act, whilst underplaying the IDC’s shortcomings. The notion itself that the epidemic is 25 years old rather than the more accurate 75 years old reflects this distortion. Most of the responsibility rests with the Bank’s Board and top management. OED reports that it ‘could find no evidence that other top management raised the issue with borrowers or pushed the issue to a higher level internally’. Where there was positive response by the bank at the country level, ‘the initiative for AIDS strategies and lending came primarily from individual health staff in the regional and technical operational groupings of the Bank, but not in any coherent way from the Bank’s HNP leadership or top-level management’ [22]. The current initiative by the British House of Commons Committee for International Development to reform the World Bank effectively reverses the notion that the reform was all but impossible because it was a zero sum game. Today, however, its donor members may find the demonstrable unfairness and ineffectiveness less tolerable. It is unlikely that the next president of the Bank will be chosen solely by the United States. Reformers will now need to revise its constitutional rules, their balancing of stakeholder rights, their decision-making rules and practices and their staffing and expertise. The course of the HIV epidemic means that the status quo is no longer acceptable. No conflict of interest was declared.

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