December 10, 2011

Robert Zoellick
World Bank President
1818 H Street, NW
Washington, DC 20433

CC: Board of Directors
Senior Director, Gender and Development

Re: World AIDS Day Appeal to Dramatically Increase and Improve World Bank Investments in HIV Treatment and Prevention

Dear Mr. Zoellick,

In commemoration of this year's World AIDS Day, we, the undersigned individuals and civil society organizations, seek your commitment and leadership to dramatically increase the World Bank's HIV investments, including grants to expand access to antiretroviral (ARV) treatment and strengthen health systems to enhance HIV service delivery. Overall HIV funding levels, including contributions from international donors, are still far below what is needed to help developing countries reach the Millennium Development Goals by 2015. Since the Global Fund recently cancelled its next round of funding, the World Bank can no longer claim that the non-traditional sources provide sufficient support to the global HIV response. As a leader in this response and a supporter of the Millennium Development Goals, the World Bank must also promote the elimination of health care user fees, which create a critical financial barrier to HIV care for the poorest and most vulnerable populations.

World Bank Funding for HIV Treatment and Prevention
Although great strides have recently been made to improve the cost and accessibility of ARV treatment, fewer than half of the 14.2 million patients who are currently eligible for ARV treatment in low and middle-income countries actually receive it. Most Central and Eastern African countries cannot provide universal ARV treatment to HIV-positive pregnant women to prevent HIV transmission to their newborn children. Globally, 40 percent of HIV-positive people are not even aware that they have the disease. Now that research has shown that HIV-positive individuals who receive immediate ARV treatment are 96 percent less likely to transmit the virus to their uninfected sexual partners compared to those whose treatment is delayed, investing in universal HIV testing and treatment as a form of HIV prevention is more important than ever.

Gender Action's research shows that while World Bank HIV investments have increased in the last five years, the share of the World Bank's budget devoted to HIV-related projects has remained stagnant at less than one half of one percent. The World Bank's own calculations show that it disbursed US$1.5 billion to fight HIV in the decade between 1997 and 2007, which represents just 0.006 percent of the World Bank's total commitments during this period.

While this funding pattern is consistent with the World Bank's agenda to "shift its emphasis from principal financier" of the global HIV response to "facilitator and knowledge contributor," overall HIV funding levels-including contributions from the Gates Foundation, USAID, PEPFAR and other international donors--are still far below what is needed to help developing countries reach the Millennium Development Goals by 2015 and provide universal access to HIV testing and treatment. Since the Global Fund recently cancelled its next round of funding, the World Bank can no longer claim that the Global Fund provides sufficient support to the global HIV response. The World Bank must fill this critical funding gap and take the lead in dramatically increasing grants to support HIV services, as well as long-term interventions to strengthen developing countries' health care work force, infrastructure and supply chains.

The World Bank's Promotion of Health Care User Fees within HIV Investments
The World Bank has not only failed to adequately invest in HIV prevention and treatment among the world's most vulnerable populations, but has also promoted health care user fees within its HIV investments, which reduce poor people's access to HIV services. For example:

  • Between 2005 and 2011, the World Bank loaned US$20 million to Ghana for its "Sub-Saharan Multi-Country AIDS Program." The project relies on universal "cost recovery programs already in place, including patient co-payments for [ARVs] and monitoring" to cover the cost of health services. The project also fails to allocate funding for the treatment of opportunistic infections, relying instead on treatment funded by Ghana's National Health Insurance Scheme. Although the 2005 project appraisal document claimed that this approach would "guarantee equal access and ensure that cost does not constitute a barrier" to care, such insurance schemes at the time were known to fall far short of universal coverage and have little to no impact on quality of care. By the time the project ended earlier this year, an assessment found that "despite attempts to portray the NHIS as pro-poor," Ghana "struggle[d] to enroll poor segments of the population, with the rich at least twice as likely to enroll compared to the poor."
  • Between 2004 and 2011, the World Bank invested US$102 million in a "Multi-Sectoral AIDS Project" in the Democratic Republic of Congo, which "encourage[d] the development of a cost recovery culture by providing targeted groups with productive activities, and asking modest contributions in time, labor, and materials." While the project appraisal document refers to this as a form of "community empowerment," it is in fact a way to force project beneficiaries to pay for materials despite their "extreme poverty" and spend uncompensated time on the project when they must also engage in vital, time-consuming activities including collecting water, growing food and providing care for young and elderly household members.
  • Between 2000 and 2009, the World Bank invested a total of US$187 million in Tanzania's "Health Sector Development Program." US$162 million of these funds were disbursed as a loan, which pressures the Tanzanian government to spend its limited resources on debt repayment instead of ARVs and other essential health services. Among its many goals, the project aimed to improve the quality of service delivery with an emphasis on HIV services. The project appraisal document promised to "strengthen proven health financing modalities (e.g., user fees, community health funds, drug revolving funds, and national health insurance) in order to generate more resources in the health sector and to improve efficiency." This commitment was reiterated in a 2003 project paper, which added that in order to ensure equity of access to health services, the project would "monitor impact of fees on the poor." However, the negative impacts of health care user fees in Sub-Saharan Africa were already well known. Sure enough, nine years later, the World Bank reported that its "efforts to make the sector more sustainable and improve quality through the use of cost sharing mechanisms, user fees, and risk pooling ha[d] not been accompanied by effective measures to provide any reasonable expectation that those who are not able to pay will be provided access to essential health services."

Having recognized that the HIV epidemic "perpetuates poverty and deepens inequality," the World Bank must uphold its mission to fight poverty and fulfill its ethical obligation to expand HIV services among the world's poorest men and women, boys and girls. We join the World Bank's other stakeholders, including country officials, who identify the World Bank as "uniquely qualified" to serve as a "source of long-term financial support" for the global fight against HIV. In honor of this year's World AIDS Day, we urge you to consider your role in regard to your ultimate stakeholders-the billions of poor men, women, boys and girls around the world who are infected and affected by HIV-and dramatically increase grants for HIV prevention and treatment and promote the elimination of all public health care user fees.

The epidemic has already claimed at least 30 million lives, and orphaned an estimated 12 million children worldwide. The 34 million men, women and children who currently live with HIV and the thousands who contract it every day cannot afford to wait any longer for your leadership and support.


Gender Action
34 Million Friends of UNFPA (US)
ACT UP Philadelphia (US)
Agnes Juruwa Hilary (South Sudan)
Alison Wilson, PAGAC
Alternative Chance/Chans Altenativ (US)
Ann Oestreich (US)
Asia-Japan Women's Resource Center (Japan)
Association for Women's Rights in Development/AWID (US)
Atlantic States Legal Foundation (US)
Betty Abah (Nigeria)
Canadian HIV/AIDS Legal Network (Canada)
Caroline Hoisington (Australia)
Center for Health and Gender Equity (US)
Center for Partnership Studies (US)
Christa Sprinkle, PAGAC
Christy Abraham - ActionAid International (South Africa)
Citizens for Global Solutions (US)
Clearinghouse on Women's Issues (US)
CNCD-11.11.11 (Belgium)
Delores M. Walters, Ph.D., R.N. (US)
Diakonia (Sweden)
Douglas L. Campbell, Portland Community College
Professor Electa Arenal (US)
Professor Elissa Braunstein (US)
Dr. Ellen Boneparth (US)
FHI 360 (US)
Dr. Francine Moccio (US)
Foreign Policy In Focus (US)
Friends of the Earth US (US)
Friends of the Earth Nigeria (Nigeria)
Gender and Economic Alternatives Trust (Zimbabwe)
Government Accountability Project (US)
Grassroots International (US)
Heather Nordlander, Portland Community College
Hisako Motoyama (Japan)
Imad Sabi (Netherlands)
Institute for Justice & Democracy in Haiti (US)
Jamaa Resource Initiatives (Kenya)
Jean-Karlos Carrion, Portland Community College
Jeanne Koopman, PhD, Boston University (US)
Jennifer Baldwin, Africa Bridge
Joanna Kerr CEO - ActionAid International (South Africa)
Joel Lawson (US)
Jubilee Oregon (US)
Jubilee USA (US)
Just Associates (JASS) (US)
Dr. Judith Porter (US)
Kalokola Semiti
Karen Buckley-Camp (US)
Karyn L. Pomerantz (US)
Katarina Lindahl (Sweden)
Dr. Kate Bedford, University of Kent (UK)
Katherine Dasper-Beet, Portland Community College
Kavita N. Ramdas (US)
Kit Johnston
K.U.L.U. - Women and Development (Denmark)
Dr. Lanyan Chen, Nipissing University (Canada)
Laurette Cucuzza, MPH (US)
Margaret Melgarejo, Jubilee Oregon
Marie Brill - ActionAid USA (US)
Maryknoll Office for Global Concerns (US)
Maasai Girls Education Fund (US)
Martin Luther King Jr. Memorial Foundation (Cameroon)
Medical Mission Sisters (India)
Nancy Yuill, Jubilee Oregon
National Association for Women's Action in Development (Uganda)
National Association of Nurse Practitioners in Women's Health (US)
National Council of Women's Organizations (US)
Nepal A. P. Gautam (Nepal)
Nikka J, Portland Community College (Staff)
Other Worlds (US)
Pangaea Global AIDS Foundation (US)
Partners In Health (US)
Dr. Patricia J. Rumer (US)
Philo Morris (India)
Queerocracy (US)
Rafael Aviles, Equal Exchange
Regina Dumba
Robin Porter (UK)
Sally Fisher (US)
Sam Tanyos (US)
Dr. Sam Noumoff, McGill University (Canada)
Sarah Mitts, AWAZ
Sisters of the Holy Cross - Congregation Justice Committee (US)
Solutions for Women's Development (Uganda)
Starr Sterrek, Portland Community College
Tafadzwa R Muropa (Uganda)
Tanyi Christian (Cameroon)
Tenella Robinson, First Unitarian United Church/PAGAC
The Development GAP (US)
The Leadership Council Sisters, Servants of the Immaculate Heart of Mary (US)
The Norwegian Coalition for Debt Cancellation (Norway)
The Social Justice Committee of Montreal (Canada)
Theresa Burks, Zimbabwe Artists Project
Uche Idoko (Nigeria)
Uganda Land Alliance (Uganda)
United Methodist Church, General Board of Church and Society (US)
Dr. Vanessa Gamble
Dr Wambui R. Wamuthenya (Belgium)
Washington Office of Public Policy, United Methodist Women (US)
Women for Change (Zambia)
Women Integrated Initiative for Development (Uganda)
Women's Intercultural Network (US)
Women's Research & Education Institute (US)
Yifat Susskind (US)
Zaamu Kaboneke, Solutions for Women's Development (Uganda)


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