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Banking on Health: World Bank and African Development Bank Spending on Reproductive Health And

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Banking on Health: World Bank and African Development Bank Spending on Reproductive Health And Banking on Health: World Bank and African Development Bank Spending on Reproductive Health and HIV/AIDS in Sub-Saharan Africa i Publication prepared by: Claire Lauterbach, Programs Associate, Gender Action With contributions from: Elaine Zuckerman, President, Gender Action Elizabeth Arend, former Programs Coordinator, Gender Action Patience Nyangoma, Executive Director, NAWAD Christian Tanyi, Chief Executive Officer, LUKMEF With support from: The William and Flora Hewlett Foundation The Tides Foundation Copyright © Gender Action 2012 About Gender Action Gender Action was established in 2002. It is the only organization dedicated to promoting gender justice and women’s rights in all International Financial Institution (IFI) investments such as those of the World Bank. Gender Action’s goal is to ensure that women and men equally participate in and benefit from all IFI investments. Gender Action 1875 Connecticut Avenue NW Suite 500 Washington DC 20009, USA Tel: 202 939 5463 Email: [email protected] http://www.genderaction.org ii Table of Contents List of Abbreviations .................................................................................................................................... iv Executive Summary....................................................................................................................................... v Introduction ..................................................................................................................................................1 Population and reproductive health at the IFIs ........................................................................................1 Adapting to a world with AIDS..................................................................................................................2 Current WB and AfDB policies on reproductive health and HIV/AIDS .....................................................2 I Quantifying PRH and HIV Investments ......................................................................................................3 Methodology.............................................................................................................................................3 World Bank PRH investments ...................................................................................................................4 World Bank HIV investments ....................................................................................................................4 AfDB PRH and HIV investments ................................................................................................................5 II Assessing the Gender Sensitivity of WB and AfDB PRH and HIV Investments ..........................................5 Inconsistent attention to gender roles and inequalities...........................................................................6 Inconsistent use of sex-disaggregated data..............................................................................................9 Promotion of user fees for PRH and HIV services...................................................................................11 III Country Case Studies ..............................................................................................................................15 Healthcare in Uganda .............................................................................................................................15 World Bank and AfDB PRH and HIV investments in Uganda ..................................................................17 Healthcare in Cameroon.........................................................................................................................24 World Bank and AfDB PRH and HIV/AIDS investments in Cameroon.....................................................25 Evaluating the World Bank’s and AfDB’s health impacts in Cameroon and Uganda..............................33 IV Discussion ...............................................................................................................................................34 Increasing grant funding .........................................................................................................................34 Addressing gender inequalities in project design, implementation and monitoring.............................34 Confronting user fees..............................................................................................................................35 Recommendations......................................................................................................................................36 Annex 1: World Bank and AfDB PRH and HIV Spending .............................................................................36 References ..................................................................................................................................................47 iii List of Abbreviations AfDB African Development Bank AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care CFA Central African Francs (Cameroon) DHS Demographic and Health Survey (Uganda) FGM Female Genital Mutilation HEF Health Equity Funds HIV Human Immunodeficiency Virus IFI International Financial Institution IHC Integrated Health Center IM International Monetary Fund ISRR Implementation Status and Results Report (World Bank) IUD Intrauterine Device LUKMEF Martin Luther King Jr. Foundation (Cameroon) MDBs Multilateral Development Banks MDGs Millennium Development Goals NAWAD National Association for Women’s Action in Development (Uganda) NHIS National Health Insurance System (Ghana) PAD Project Appraisal Document PID Project Information Document (World Bank) PRH Population and Reproductive Health RHAP Reproductive Health Action Plan (World Bank) SAPs Structural Adjustment Policies SSA Sub-Saharan Africa STI Sexually Transmitted Infection UA/UAC Units of Account (AfDB bank units) UN United Nations UNAIDS Joint United Nations Program on HIV/AIDS UNFPA United Nations Population Fund US United States USD United States Dollar UGX Shillings (Uganda) VCT Voluntary Counseling and Testing (HIV/AIDS) WB World Bank WHO World Health Organization iv Executive Summary Global reproductive health has improved significantly over the past 20 years. The number of women dying from pregnancy-related complications and childbirth has dropped sharply and the rate of new HIV infections has slowed worldwide. However, sub-Saharan Africa (SSA) still shoulders the greatest percentage of maternal deaths – 56 percent of total maternal deaths worldwide, despite representing 15 percent of the world’s population (WHO 2012:1) – and the highest estimated number of persons living with HIV/AIDS – 68 percent of the global HIV burden (UNAIDS 2010c). For decades, African governments have received billions of dollars in development aid from donor countries, private foundations and multilateral development banks (MDBs) to combat these problems. The World Bank and African Development Bank (AfDB) are the two key MDBs financing African countries’ health sectors. This Gender Action report evaluates the quality and quantity of the multilateral World Bank and AfDB reproductive and HIV/AIDS investments in sub-Saharan Africa from 2006 to 2012. With our partners, the Martin Luther King Jr. Memorial Foundation of Cameroon (LUKMEF) and the National Association for Women’s Action in Development (NAWAD), Gender Action conducted qualitative assessments of these banks’ PRH and HIV investments in Cameroon and Uganda, respectively. The World Bank and AfDB spend infinitesimally small amounts on reproductive health and HIV/AIDS programs in sub-Saharan Africa compared to their annual budgets, despite the region’s almost unparalleled demand for improved health services. The banks’ health sector support is overwhelmingly in the form of loans that incur new debts, perversely squeezing funding for health services. A full 45 percent of the World Bank’s reproductive health and 60 percent of its HIV/AIDS investments in sub- Saharan Africa from 2006-2012 were loans. At the AfDB this figure is 60 percent. Despite reproductive health and HIV/AIDS policies that increasingly recognize women’s rights, the World Bank and AfDB risk undermining their own health-related goals by overlooking women’s rights and needs. For example, few projects measure whether women benefit to the same extent as men, and many impose fees on basic project-financed services like antenatal care visits. The case studies in Cameroon and Uganda demonstrated that there has been too little to show on the ground for the World Bank’s and AfDB’s investments in reproductive health and HIV/AIDS. The challenges to providing affordable, high-quality reproductive and HIV care in resource-poor countries are immense. The publicly-funded World Bank and AfDB, as key health sector supporters worldwide, have a duty to address the flaws in their projects that prevent low-income women in particular from benefitting from them. Gender Action recommends an approach that would prioritize grants over loans, abolish user fees in bank-supported projects; promote sustainable, gender-sensitive staffing of projects; and address gendered barriers to access and use throughout project cycles. Better World Bank and AfDB spending to improve health care systems as a whole, and reproductive health and HIV/AIDS services in particular, will go a long way in reducing poor patients’ burden of formal and ‘informal fees’ and ensure access to reproductive
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