[stop-imf] How IMF Policies Block the Global Fund for AIDS, TB and Malaria

[Robert Weissman]

Valuable analysis from a Mozambique-based health activist:



  How IMF Policies Block the Global Fund
  Gorik Ooms, Mozambique
  *********************

  "It is very genocidal for one part of the world to have the cure for the
  AIDS disease while millions of people in another part are dying from the
  same. The developed world is challenged to make antiretroviral drugs
  available", declared Uganda's President Museveni (New Vision, 11 Dec 02).

  But only weeks before this declaration, Uganda's Ministry of Finance
made it
  virtually impossible for the Ministry of Health to accept a grant from the
  Global Fund to fight AIDS, TB and Malaria, a grant that could help to make
  antiretroviral drugs available. "Any new donor monies absorbed into a
  government sector must be accompanied by a similar reduction within the
  sector in order to keep the expenditure limit", said Francis Tumuheirwe,
  director of budget in Uganda's ministry of finance (The Lancet, 7 Dec 02).
  In other words, if Uganda gets the $ 52 million it asked from the Global
  Fund, it will simply reduce its own contribution to the health budget, which
  will remain the same, with or without Global Fund monies. Obviously, the
  Global Fund will never accept this, since it can only give money for
  additional activities, not to replace Uganda's contribution to a fixed
  health budget. The solution proposed by Uganda's Ministry of Finance - to
  cut into other parts of the health budget to "make way" for the
  interventions approved by the Global Fund - is clearly not acceptable.

  This means that President Museveni can call for as much international
  financial support for antiretroviral therapy as he wants: as long as
his own
  Ministry of Finance is firmly committed to a public health budget that
  doesn't exceed $ 9 per person per year, "no matter how much donors are
  willing to provide", the inaccessibility of antiretroviral therapy -
  described as a 'genocide' by the President himself - will continue. It makes
  you wonder who the real decision-maker in Uganda is; the President or the
  Minister of Finance? Or is it someone working for the IMF?

  Like Uganda, Mozambique has a public health budget of $ 9 per person per
  year. Like Uganda, Mozambique wants to provide antiretroviral therapy
to the
  people who need it. Like Uganda, Mozambique is counting very much on the
  Global Fund to keep its people alive.

  Mozambique and Uganda have poor public health budgets because they are poor
  countries. But also because they have accepted - or, at least in the
case of
  Mozambique, was obliged - to adopt the IMF and World Bank economic and
  development doctrine, in the form of a Structural Adjustment Program (or
  SAP.) This doctrine is quite simple: it is based on the assumption
that real
  development and economic growth can only occur when governments limit public
  spending to a percentage of their gross domestic product. In very poor
  countries, this has resulted in ridiculously low public health and education
  budgets (less than 50% of children of school age attend school in
  Mozambique, less than 50% of the population has access to poor public health
  services.)

  But this would be just a temporary problem, assured the IMF and the World
  Bank. Soon there will be economic growth, they promised, economic growth
  will increase state budgets for public social services, and many
people will
  become rich enough to buy private social services. Very conveniently, this
  doctrine provided an excellent excuse for reducing international aid.
It was
  not only permitted to give less, rich countries were actually doing poor
  countries a favour by giving less (and thus stimulating their economic
  growth.) In the '90s, international aid levels dropped dramatically.

  Fifteen years later, the 'temporary problem' has been solved for less than
  3% of Mozambicans. They can afford private schools and private
clinics. 47%
  have access to poor public services, badly equipped and run by underpaid
  civil servants. The other 50% don't send their children to school and don't
  go to health centers. IMF and World Bank no longer promote SAPs, they
  invented a new game and called it 'poverty reduction.' In theory, Poverty
  Reduction Strategic Papers (or PRSPs) are meant to ensure that the benefits
  of debt cancellation are invested directly in poverty reduction. In reality,
  they just protect the core of the old SAPs, ensuring that public spending
  remains capped. While HIV infects more and more Africans, the IMF and the
  World Bank ensure that African countries are not able to provide enough
  education to their children to protect them against HIV, let alone provide
  lifesaving treatment.

  When African leaders, gathered in Abuja in April 2001, promised to
  substantially increase their public health budgets, I wondered if they
  realized they were defying IMF and World Bank policies. I felt
relieved when
  I read the 'Declaration of Commitment on HIV/AIDS' that came out of the
  UNGASS meeting in June 2001. The international community was actually
  supporting increased public spending to fight AIDS and other infectious
  diseases! The fulfilment of this commitment would require improved health
  and education services! Then came the report of the WHO Commission on
  Macroeconomics and Health; an implicit but clear condemnation of IMF and
  World Bank policies, arguing that increased spending on health would not
  harm but rather stimulate economic growth. When the Global Fund announced
  its first approved proposals in April 2002, I was saddened that the
  Mozambican proposal was not included, but satisfied to see that similarly
  poor countries would receive substantial amounts, amounts that would
  obviously make their health budgets break through the ceilings
foreseen in
  their respective PRSPs.

  I should have been completely convinced when the World Bank Multi-sectoral
  AIDS Plan (MAP) team visited Mozambique for the third or the fourth
time in
  October 2002, announcing that the MAP would be funded with a grant,
not a
  loan, and that the World Bank had secured $ 1 billion for several MAPs.
  Surely, if this $ 1 billion went to the countries that need it most, it
  would lift their budgets well over the PRSP ceilings. Surely, if the World
  Bank supports such a strategy, the IMF would not challenge it. The
door was
  open for a rights-based approach to health care and education.
Suspicious as
  I am, I questioned the World Bank MAP team about this. Did their
  macroeconomists agree with this? Because if not, that $ 1 billion was
  useless, it would only replace national contributions or contributions from
  other donors, but not increase the budgets. The answers were vague and
  evasive. One said that PRSP budgets were targets, not ceilings. The other
  admitted that there might be a problem.

  I guess we have the real answer now. No matter how much donors are willing
  to provide, no matter how much the Global Fund is willing to provide, Uganda
  will not increase its health budget and therefore it will not provide
  antiretroviral therapy (unless President Museveni has the courage to
  intervene directly.) The arguments used by Uganda's Ministry of
Finance are
  pure IMF doctrine arguments: increasing the health budget with the Global
  Fund grant would destabilize Uganda's economy, the way to increase
  expenditure on health is through sustained economic growth, Uganda must
  reduce its dependence on donors. This is probably why the chairwoman
of the
  parliamentary committee on social services wondered whether the
ministry of
  finance or the IMF was the architect of the low ceiling.

  Does it really matter? Does it really matter if the decision to sacrifice
  thousands of people living with AIDS on the altar of a development doctrine
  that has proven to be ineffective came from an office in Washington or from
  an office in Kampala? Does it really matter if the South African form of
  structural adjustment - GEAR - was voluntarily adopted by President Mbeki,
  strongly encouraged by the IMF and the World Bank or even imposed by them?
  It doesn't make any difference to South Africans, many of whom died of
  cholera in October 2000 because they suddenly had to pay for water and
  couldn't; they don't get antiretroviral treatment when they need it because
  of 'financial discipline' in a vain pursuit of economic growth. Does it
  really matter if NEPAD - the New Partnership for African Development that
  hardly mentions AIDS at all, let alone AIDS treatment - is the fruit of
  African Renaissance or the result of 20 years of indoctrination by
  Washington-based macroeconomists? The result is the same: poor health care
  and poor education for poor people.

  I believe the Global Fund has met its worst enemy in Kampala. Raising the
  funds needed to fight AIDS, TB and Malaria remains important, but it
is not
  enough. It must also promote a rights-based approach to social
services, one
  that legitimises public budgets that are in accordance with real
needs, not
  limited to a percentage of gross domestic product. Otherwise the
Global Fund
  will end up channelling funds to relatively well-performing countries only,
  while refusing agreements with the countries that really need it, because
  their budgets are capped and Global Fund money would only replace national
  contributions or contributions from other donors and would not create
  additional services.

  Both objectives, to raise more money and to create a climate that allows
  spending it where it is needed most, go hand in hand. Both require a new
  development vision. Both require a genuine understanding that only a healthy
  and well-educated population can create real and sustainable economic
  growth. Both require a genuine understanding that access to treatment
is a
  human right!

  Gorik Ooms
  Mozambique
  Email: gorik@hotmail.com