BY 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 disease. The developed world is challenged to make antiretroviral drugs available", declared Uganda's President Yoweri Museveni in the December 11 Kampala New Vision.
Yet, because of the harsh rules imposed by the International Monetary Fund (IMF), Uganda's ministry of finance has made it virtually impossible for the ministry of health to accept a grant from the fund established by the G8 countries to fight AIDS, tuberculosis and malaria. The grant could have helped to make antiretroviral drugs available for HIV/AIDS patients.
"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 (quoted in the British Lancet on December 7). In other words, the IMF has decreed that if Uganda gets the US$52 million it has asked for from the Global Fund, it must reduce its own contribution to the health budget by the same amount.
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 funds approved by the Global Fund — is clearly not acceptable.
This means that 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, the inaccessibility of antiretroviral therapy will continue. It makes you wonder who the real decision-makers are in Uganda: the president, the minister of finance or 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 were obliged to adopt — the IMF and World Bank economic and development doctrine, in the form of a Structural Adjustment Program (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 fixed 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 public health services).
'Temporary' problem
This would be just a temporary problem, the IMF and the World Bank assured the poor countries. Soon there will be economic growth, they promised. This 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 the rich countries to reduce their international aid to the poor countries. Not only did it justify giving less, but rich countries could claim they were doing poor countries a favour by doing so (and thus stimulating economic growth, it was argued). In the 1990s, international aid levels dropped dramatically.
Fifteen years later, the "temporary problem" has been solved for the less than 3% of Mozambicans who can afford private schools and private clinics. Another 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 centres at all.
The IMF and World Bank no longer promote SAPs; they have invented a new game and called it "poverty reduction". In theory, poor countries' Poverty Reduction Strategic Papers (PRSPs) are meant to be guarantees that the benefits of any debt cancellation will invested directly in poverty reduction. In reality, they just protect the core conditions 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, Nigeria, in April 2001, they promised to substantially increase their public health budgets. I wondered at the time if they had realised 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 United Nations Special Session on HIV/AIDS 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 World Health Organisation's Commission on Macroeconomics and Health, which was an implicit but clear condemnation of IMF and World Bank policies. The WHO argued 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 Mozambique's request for funds was not included, but was satisfied to see that similarly poor countries would receive substantial amounts that would result in their health budgets breaking through the ceilings foreseen in their respective PRSPs.
The World Bank Multi-sectoral AIDS Plan (MAP) team visited Mozambique for the third or the fourth time in October 2002, announcing that Mozambique's MAP would be funded with a grant, not a loan. The World Bank also announced MAPs for other countries that totalled $1 billion. If this $1 billion went to the countries that need it most, it would lift their budgets well over the PRSP ceilings. I concluded that, if the World Bank supports such a strategy, surely 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.
Real answer
We have the real answer now. No matter how much international donors and the Global Fund are willing to provide, Uganda cannot increase its health budget and therefore it will not provide antiretroviral therapy (unless 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 destabilise Uganda's economy; the way to increase expenditure on health is through sustained economic growth; and Uganda must reduce its dependence on donors.
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 Kampala? Does it really matter if the South African form of structural adjustment — GEAR — was voluntarily adopted by President Thabo Mbeki, strongly encouraged by the IMF and the World Bank, or imposed by them?
It doesn't make any difference to South Africans, many of whom died of cholera in 2000 because they suddenly had to pay for water and couldn't afford to. Poor South Africans don't get antiretroviral treatment when they need it because of the need for "financial discipline" in a vain pursuit of economic growth.
Does it really matter that the New Partnership for African Development — the neoliberal plan for the African continent championed by Mbeki, which hardly mentions AIDS at all, let alone AIDS treatment — is the fruit of an "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.
Africa requires a new development vision that understands that only a healthy and well-educated population can create real and sustainable economic growth. A vision that understands that access to treatment is a human right!
[From the Network on Equity in Health in Southern Africa. Visit <http://www.equinetafrica.org/>.]
From Green Left Weekly, February 5, 2003.
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