IFI governance


Development effectiveness of HIV/AIDS uneven

21 November 2005

A recent report by the Bank’s Operations Evaluation Department (OED) analyses the Bank’s current and historical work on HIV/AIDS, assesses the development effectiveness of its country-level HIV/AIDS assistance against the counterfactual of no Bank assistance, and sets recommendations for the future. The study focuses on the evaluation of country-level assistance, given that the Bank has never adopted an institution-wide strategy for HIV/AIDS.

The report says the Bank’s record on HIV is uneven, due to a slow response in the first phase. The Bank acknowledges that from 1986-1997, its own economic policies, in particular health sector reform, suppressed demands from developing countries for the loans it was trying to make available for HIV/AIDS. Simon Wright, head of ActionAid UK’s HIV/AIDS unit, says that “During this period, there was little systematic leadership for HIV and underinvestment in work with ‘high-risk’ and politically-sensitive populations, as previously identified in reports such as Low Credit:a report on the World Bank’s response to HIV in developing countries by ActionAid in 2003″.

The OED praises the Bank’s more systematic approach since 1998. In particular the Africa MAP’s emphasis on grants rather than loans has been much more successful. For the future, it recognises the importance of capacity building through governments and the strengthening of health systems as vital to HIV/AIDS responses. The OED also finds that mechanisms have been created to finance an AIDS response from civil society in many countries where they did not previously exist.

The report gives the Bank an uneven record on HIV

Overall, the OED found that in addition to increasing the resources for AIDS in many countries, the Bank has induced several governments to act earlier and in a more effective way than would otherwise have been the case. The main contribution of the Bank’s country-level HIV/AIDS assistance relative to the counter-factual of no assistance has been to:

  • expand political commitment to controlling the epidemic;
  • enhance the efficiency of national AIDS programmes;
  • help create/strengthen national and sub-national AIDS institutions, usually linked to high-level units in the ministry of health; and
  • encourage governments to build the capacity of NGOs and involve them in the national response.

More negatively the report found that the capacity of civil society to design, implement and evaluate AIDS interventions was overestimated in many countries, as was political commitment; and many projects under-invested in prevention programmes for high-risk groups.

HIV/AIDS advocates point out that the report has glaringly failed to identify where continued WB and IMF loan conditions have severely suppressed health sector spending and limited the retention of qualified medical staff, as analysed in the 2005 report by ActionAid USA, Changing Course:alternative approaches to achieve the MDGs and fight HIV/AIDS. They also criticise the report for failing to compare the effectiveness of the Bank with the Global Fund for AIDS, Tuberculosis and Malaria, in light of the recognition of the latter’s faster disbursement and greater country ownership.

Management responds

Bank management credits the OED with “a very useful overview”, before proceeding to attack it. Asserting that the report “has failed to assess the major efforts management is making to address many of the concerns raised”, criticism focuses on the OED’s coverage of the MAP, which it says presents “an unduly static picture”. Management also claims that the report does not reflect the fact that the MAP programme has evolved considerably over the two years since the OED study began. It expresses disappointment that the report did not give more recognition to the Bank’s draft global HIV/AIDS programme of action, of which an advance copy of the final draft was released in August. The programme of action describes the steps the Bank will take over the next three years in response to HIV/AIDS and is now said to be implementing many of the OED’s recommendations. Lastly, management questions the report’s methodology and evidence base, saying that OED conducted only one MAP project case study, that of Ethiopia. The Bank responds to specific recommendations in its management action record.