The World Bank and IMF Respond to Gorik Ooms and Ted Schrecker -- By Jean-Louis Sarbib, Senior Vice President for the World Bank's Human Development Network and Peter S. Heller, Deputy Director, Fiscal Affairs Department, IMF

June 18, 2005

By Jean-Louis Sarbib, Senior Vice President for the World Bank's Human Development Network and Peter S. Heller, Deputy Director, Fiscal Affairs Department, International Monetary Fund
Published in The Lancet
June 18, 2005

It is disheartening to see your esteemed medical publication providing a forum for serious accusations about the IMF and World Bank ("Expenditure ceilings, multilateral financial institutions, and the health of poor populations", May 21). For all of the strong rhetoric of the article, one fact stands out: the authors fail to cite a single instance in which Bank or Fund policies actually restricted spending on HIV/AIDS.

Take the example they offer of Mozambique, where, according to the authors, officials allegedly were told in 2002 that their spending plans were "too ambitious." The numbers tell a very different story. From 2001 to 2004, Mozambique's economy grew about 9 percent a year, after taking into account inflation. Meanwhile, the government's spending on health programs and HIV/AIDS programs grew exactly in line with that level of growth. That adds up to a substantial real increase in spending on HIV/AIDS every year.

As with so many other accusations leveled by our critics, they do not stand up to the experience of front-line practitioners. A recent survey by the Washington, D.C.-based Center for Global Development—which drew 353 responses from professionals familiar with HIV/AIDS prevention, treatment, and care—showed the following concerns: "lack of political will" (29 percent); "poor national coordination" (28 percent); "shortcomings of the health care delivery system" (14 percent); "national absorptive capacity constraints" (8 percent); "policy confusion" (7 percent); "donor interference" (3 percent).; "Ministry of Finance unwillingness to permit additional spending" (3 percent); "Global Fund restrictions/requirements" (2 percent); "World Bank restrictions" (1 percent); "IMF caps" (1 percent); "other" (5%). (The survey results are available at These results underline, if need be, that fighting the AIDS pandemic is a complex and multi-faceted challenge, as your authors undoubtedly agree.

But that does not mean enough is being done, in Mozambique or many other developing countries. The authors correctly point to the international community's failure to provide the resources needed to combat HIV/AIDS (and, we would add, the other diseases afflicting the poorest countries). But blaming the IMF and the Bank for these failures removes the spotlight from the real issues that we need to address: getting the donors to live up to their commitments and helping recipient countries to use additional money in best way possible.

The Medium-Term Expenditure Frameworks (MTEFs) that the authors single out are not a reflection of some malign intent. They simply are tools to enable forward-looking policy planning. The MTEFs plainly state what money is available and what programs are possible within the context of that resource envelope. They do not in any way restrict the additional spending of new grant aid. Make more aid reliably available, and more long-term programs will be possible.

We have stated all of these points publicly many times. And we would have been pleased to show the authors how we are pressuring donors to increase aid and to make aid flows predictable, and how we are working with countries when more money is made available. (A good example is Malawi, where a major increase in grant aid to the health sector began last year.) We also could have described our extensive consultations with UNAIDS, the Global Fund and PEPFAR. Indeed, in the last year we have worked closely with Peter Piot of UNAIDS and his staff to ensure adequate coordination in our mutual efforts in the area of HIV/AIDS. And we would have highlighted the chronic problem that afflicts healthcare throughout Africa—the desperate need for large numbers of skilled doctors and nurses. This is a problem that cannot be solved overnight and that clearly requires vast and coordinated efforts from both countries and donors to which our institutions are deeply committed.

The Bank and the Fund have made an "unequivocal commitment" to support international efforts to solve the health crisis of the low-income countries. We are ready to work with all parties to achieve this goal. This will help us get there more effectively than polemics.

Jean-Louis Sarbib is Senior Vice President for the World Bank's Human Development Network and a former Vice President for the Bank's Africa region. Peter S. Heller is a Deputy Director in the IMF's Fiscal Affairs Department.


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