World Bank AIDS Drive crowds out other health programs – but fails to make progress on AIDS

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.