A report released today by the World Bank’s own Independent Evaluation Group faults the Bank for allowing AIDS to drive out many other programs to improve health. To make things worse, the Bank’s AIDS effort itself failed to accomplish much – only 29 percent of AIDS projects (and only 18 percent of AIDS projects in Africa) had a satisfactory outcome – while other efforts were much more effective (89 percent satisfactory project rate for other communicable diseases).
Despite the poor results on AIDS and better results on malaria and TB, AIDS accounted for 57 percent of Bank projects on communicable disease during 1997-2006 (the period covered by the evaluation), compared to 3 percent for malaria and 2 percent for TB.
The report notes the large share of health funding earmarked for AIDS tended to pull scarce resources in the local health system such as nurses and doctors away from other health problems. Within overall constrained donor budgets, AIDS financing tended to crowd out projects that support overall health system reform, despite the urgency of the latter issue to get any good results on any health outcome.
“A case in point is Malawi: because of constraints in the availability of Bank budget for supervision, IDA funds were available for the health {sector-wide reform} or … AIDS… but not for both. The Bank opted to drop support for the health {sector-wide reform} and continue support for HIV/AIDS.” (p. 40) The Bank did this even though a lot of other donor funding was already earmarked for AIDS.
Another victim of the AIDS emphasis was nutrition. The share of projects with nutrition objectives dropped by half; Bank support for nutrition reached only a quarter of countries with high stunting. This is particularly sad because many nutritional interventions are relatively cheap and easy to administer (for example, nutritional supplements, which had a big payoff in the PROGRESA program in Mexico).
The AIDS crowding out troubled the independent Advisory Panel that IEG asked to comment on the report. At a time when international AIDS funding was surging, the Panel said, “we were surprised that the Bank did not provide a countervailing trend…there was a fall in nearly half in the share of projects with objectives to reform the health system.” (p. xxvv)
Given what looks to be irrational behavior, my guess is that the Bank made these choices for purely political reasons. It is extremely sad that such politics caused the Bank to neglect many other treatable and preventable health tragedies, without any countervailing benefit even for AIDS victims given the poor performance of the Bank’s AIDS projects.
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I’m surprised to see this done by the bank (even if by an “independent” group within the bank). Though they’re not the first to say it, I’m still impressed that they’re early on the train critical of AIDS exceptionalism. Roger England has written about AIDS exceptionalism recently in the BMJ [ungated here], calling for an end to UNAIDS:
Some colleagues and I are writing up findings of public opinion surveys in sub-Saharan Africa, as well as data from a demographic and health survey in Malawi to show that folks who are facing the epidemic in their everyday lives prefer resources be allocated to other pressing issues.
How likely is it that those decisions were informed by the Bush Administration emphasis on AIDS? While it’s not as though the US “owns” the World Bank, it’s not exactly like it doesn’t either.
If that’s the case, then could politics fix the unintended problem it may have caused?
How much of the political reason by the World Bank to choose AIDS is because of grassroots advocacy on AIDS?
The problem is the WB is not listerning to the people and they do what is their agenda to be seen as caring for the poor. HIV.AIDS has been turned into platform for gaining money and votes for both rich and poor politicians. Until people’s voice are heard in planning for aid there will be no change.
This is not terribly unexpected. There are so many instances in public policy and in our spending priorities, that for whatever reason we have ultimately valued to life of a person with one particular disease more so than a person with another disease.
Breast cancer is one such issue that parallels HIV/AIDS versus TB/malaria. There are far more active and involved political and public faces pushing for breast cancer support than for lung cancer, yet more people die of lung cancer. This parallel isn’t necessarily an perfect one, but it does demonstrate that HIV/AIDS is not the only disease that has garnered more support for is cause than other disease that are afflicting more people. This is not necessarily a good or bad thing in my view, but it is the reality of our world
I am trying to look at this as a good thing. The WB is recognizing its own mistakes, and the worm is turning on our obsession with funding HIV programs at the expense of health systems.