Since the early 1980s, the HIV/AIDS epidemic has devastated the social, economic, and political landscape of sub-Saharan Africa, and has continued to impose a significant challenge against the region’s development. Indeed, the widespread proliferation of the disease has led to the immense regression of many sub-Saharan African countries. According to UNAIDS in 2013, there were an estimated 24.7 million people living with HIV in sub-Saharan Africa – nearly 71% of the global total, with 1.1 million people dying from AIDS-related illnesses.
In the fight against HIV/AIDs, organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the World Health Organisation (WHO) have often been regarded as the international forerunners in HIV/AIDS governance in sub-Saharan Africa. However, the role and impact of the World Bank on HIV/AIDS in the region has largely been ignored within public health and public policy literature. In fact, the World Bank have been pivotal to the proficiency of the sub-Saharan African response to HIV/AIDS at all levels of governance, playing a decisive role in both exacerbating, and reducing the effects of the disease throughout the region.
The role of the World Bank on HIV/AIDS governance originates from the organisation’s recovery programme for sub-Saharan African economies during the 1980s and 1990s, principally through Structural Adjustment Programmes (SAP). However, the World Bank’s market-oriented lending policy in sub-Saharan Africa was crucial in weakening the functionality of sub-Saharan African governments prior to the outbreak of the epidemic. The strict conditionalities that formed part of SAPs in order to encourage political and economic reform had extensive destabilising effects on sub-Saharan African societies, particularly on the delivery of basic services such healthcare, education and welfare. In implementing austerity measures under SAPs, social spending in sub-Saharan Africa per capita declined to 76 per cent of the level spent in 1981 by the 2000s, impoverishing several countries throughout the region, and was exceptionally damaging for the poorest individuals. This is despite the fact that there is little conclusive evidence that SAPs had a positive impact on economic growth in sub-Saharan Africa.
The depleted basic services helped to reduce the governmental response to HIV/AIDS, and shaped the conditions for the proliferation of the disease. Inflated food prices lessened employment and trade opportunities, particularly in rural areas – increasing the threat of the disease by encouraging rural migration to urban areas. Moreover, the introduction of user fees in health and educational services decreased the accessibility of treatment and HIV/AIDS awareness. In fact, basic services themselves – such as health centres, became sources of HIV infection. Cuts to civil services also restricted the capacity of several governments, deteriorating the administrative ability of sub-Saharan Africa countries in addressing the disease.
The World Bank’s response to HIV/AIDS in sub-Saharan African countries during the adjustment period was also limited. World Bank funding for HIV/AIDS projects began in 1986, however the organisation’s support remained limited over the next decade. Prior to 2000, the World Bank funded a number of generic projects with HIV/AIDS components throughout Africa, none of which exceeded US$10 million. Three projects in Zimbabwe, Uganda and Kenya did receive more substantial funding from the Bank in the early 1990s, however these projects focused more broadly on sexually transmitted infections (STIs). Although the World Bank’s relative inactivity during this period echoes the dormancy of other multilateral organisations, and the general misunderstanding and stigma surrounding HIV/AIDS at the time, as academic Chris Simms argued the World Bank’s significant influence and leadership in the region should have warranted a greater response against the disease. Undoubtedly, the World Bank’s inactivity and its agenda for reform through SAPs contributed to the catastrophic impact HIV/AIDs would have on sub-Saharan Africa. In fact, between the early 1980s and 2000s, people living with HIV infection in sub-Saharan Africa increased from less than one million to 22 million.
However, the growing severity of HIV/AIDS on sub-Saharan African development, and its threat to human and national security in the absence of an effective cure would eventually prompt the World Bank to take emergency action against the disease. Thus, in 2000 the Multi-Country HIV/AIDS Programme (MAP) was launched. Under the MAP, the World Bank would pledge over $1 billion into the fight against HIV/AIDS, drastically expanding the Bank’s financial commitments against the disease. The programme was designed to scale up state-led responses to the epidemic, underpinned by a multi-sectoral framework that encouraged the participation of the public and private sector, NGOs and community organisations in anti-HIV/AIDS projects in the region. The MAP elevated HIV/AIDS governance to the pinnacle of the organisation’s development agenda in sub-Saharan Africa.
The MAP and the extensive impact of the disease on development in the region provoked a shift in the way the World Bank financed governments in sub-Saharan Africa. In contrast to the stringent conditionalities under the SAPs, MAP funding was issued without a specific link to macroeconomic performance. This allowed countries to scale up their response to HIV/AIDS without the explicit strain of further economic liberalisation. However, although the MAP appeared to represent a ‘softer’ financial relationship between the World Bank and sub-Saharan Africa, the organisation’s wider policy of ‘good governance’ and its neoliberal dogma remained intact. MAP funding may have not imposed strict economic conditionalities on sub-Saharan Africa, but it still required states to meet specific eligibility criteria that encouraged the decentralisation of HIV/AIDS governance.
It is true that the MAP did facilitate a number of breakthroughs in the governance of HIV/AIDS in sub-Saharan Africa. The MAP increased the political commitment towards HIV/AIDS at the highest government level, particularly through the creation of national AIDS councils. The programme also succeeded in promoting a multi-sectoral, decentralised response to HIV/AIDS by allowing national, regional and local actors to play an active role against the disease. Furthermore, the MAP also helped to mobilise larger donor initiatives such as the GFATM and the President’s Emergency Plan For AIDS Relief (PEPFAR), strengthening the response to the disease. As of 2008, development partner funding had increased by 2,240% and 502,958 people infected or affected by the disease were receiving support.
However, the MAP should not be exempted from its flaws; the programme had a consistent issue relating to the non-accessibility of funding for projects, particularly damaging for the most vulnerable in the region. This was as a result of the MAPs inability to remove the weak institutional capacity within sub-Saharan African governments, harming service delivery and the coordination of donor efforts to public and private actors, and communities. The MAP also failed to support effective monitoring and evaluation systems, which affected the veracity of HIV/AIDS outcome indicators, though efforts were made to address this in phase 2 of the MAP in 2006. The clearest indication of the MAP’s shortcomings is that HIV prevalence and infection rates have remained relatively unchanged in sub-Saharan Africa. Thus, while the MAP revolutionised sub-Saharan African HIV/AIDS governance, and produced a number of positive outcomes, its overall success is questionable.
The World Bank’s restructuring of sub-Saharan African governance through the SAP significantly undermined the capacity of the region’s governments against HIV/AIDS, with the adjustment programmes enervating vital preventative functions against the disease, and as a result, propagating its escalation. However, by the new millennium the growing impact of HIV/AIDS on the development of sub-Saharan Africa would inspire the World Bank to redefine its approach to HIV/AIDS, and its governance reform measures in the region overall. This led to the formulation of the MAP, placing the fight against HIV/AIDS at the centre of the World Bank’s relationship with sub-Saharan Africa, and drastically increasing the organisation’s obligation towards reducing the effects of the epidemic. However, the MAP has failed to convincingly tackle HIV/AIDS, and has once again demonstrated the uneasiness in implementing the World Bank’s philosophy on governance in sub-Saharan Africa. As such, it remains unclear whether the World Bank can be considered as the perpetrators or defenders against HIV/AIDS in sub-Saharan Africa. However, could the World Bank – or indeed any other organisation have done more against the disease?