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This article originally appeared online in This is Africa, a publication of the Financial Times
10 October 2012
By Claire Lauterbach
Global reproductive health has improved significantly over the past 20 years. The HIV infection rate has slowed, the number of women dying in pregnancy and childbirth has dropped. This trend has spawned ambitious talk about getting to "zero" new HIV infections, discrimination and deaths. Donors boldly pledged $2.6 bn to reproductive health at last June's London Summit on Family Planning, adding to the billions of dollars of development aid so far from private foundations, international donors including multilateral development banks, and governments from South Africa to Nigeria.
Yet sub-Saharan Africa still has the World's highest percentages of HIV−positive people and maternal deaths. To tackle these problems, the World Bank and African Development Bank have spent almost two billion between them from 2006−2012. Despite imposing loan conditions over decades that eviscerated Africa's public healthcare sectors, they are still major funders of reproductive health and HIV/AIDS programs in the region.
The World Bank and AfDB declare that women's full involvement is necessary for good reproductive health. So why do they ignore key gender issues in their reproductive health and HIV/AIDS investments?
Gender Action explores this gap in a new report, 'Banking on Health.' Together with Cameroonian and Ugandan partners, Gender Action reviewed World Bank and AfDB reproductive health and HIV/AIDS investments for their sensitivity to gender. Their gender record needs improvement.
Many projects show surprisingly little attention to gender roles. Economic dependence on male providers leaves many African women unable to negotiate safe sex practices with their partners or choose if and when to bear children. Women's unpaid, time−consuming care work can make it difficult to travel long distances where and when clinics or services are available. Yet projects often show little to no indication that these concerns were taken into consideration.
The banks also promote user fees, which cover few project costs. Women are particularly affected as they often do not control household revenues. When a woman must choose between buying food and getting pre-natal care, as we saw in Uganda, something is wrong.
The Banks also hardly track how specific investments affect women. Project monitoring and evaluation frameworks frequently make no mention of women, nor do they sex−disaggregate key indicators like whether women are equally involved in project design or have equal access to project benefits, like HIV services or recently refurbished clinics.
Quality aid fully considers gender roles and inequalities in project design, implementation and monitoring. That means mandating clear sex−disaggregated indicators to measure whether Bank − funded projects are working for women. Quality aid actively engages women 'beneficiaries' before projects begin and at convenient times in places where their voices won't be drowned out by men's. It engages men in their own sexual health and encourages them to promote their partners'.
Quality aid at the institutional level should fund strengthening health systems through grants. The World Bank and AfDB mostly make debt − burdening loans whose payment squeezes funds for health services. A full 45 percent of the World Bank's reproductive health and 60 percent of its HIV/AIDS investments in sub−Saharan Africa from 2006−2012 were loans. At the AfDB this figure is 60 percent.
Quality aid does not create empty clinics or programs that are inadequately serviced by regularly − and sufficiently − paid, trained national staff. Quality aid promotes the sustainable elimination of all financial barriers to health care, especially unaffordable user fees for essential services.
Finally, quality aid is accountable aid − judging aid's impact is impossible without data on what or how we spend. Information on AfDB spending amounts on reproductive health was "simply not available" according to one official. This is surely not aid accountable either to 'beneficiaries' or taxpayers. Tax-payer-funded banks need to better track and publish their healthcare spending data.
While the momentum is still strong to make good on the London Summit on Family Planning pledges, multilateral development banks and other donors should recognize that good quality matters as much as high quantity reproductive and sexual health and HIV/AIDS spending.
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© 2012 Gender Action, All Rights Reserved
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