The World Bank and HIV/AIDS Governance in Sub-Saharan Africa: Perpetrators or Defenders against the Epidemic?

Since the early 1980s, the HIV/AIDS epidemic has devastated the social, economic, and political landscape of sub-Saharan Africa, and has continued to impose a significant challenge against the region’s development. Indeed, the widespread proliferation of the disease has led to the immense regression of many sub-Saharan African countries. According to UNAIDS in 2013, there were an estimated 24.7 million people living with HIV in sub-Saharan Africa – nearly 71% of the global total, with 1.1 million people dying from AIDS-related illnesses.

In the fight against HIV/AIDs, organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the World Health Organisation (WHO) have often been regarded as the international forerunners in HIV/AIDS governance in sub-Saharan Africa. However,  the role and impact of the World Bank on HIV/AIDS in the region has largely been ignored within public health and public policy literature. In fact, the World Bank have been pivotal to the proficiency of the sub-Saharan African response to HIV/AIDS at all levels of governance, playing a decisive role in both exacerbating, and reducing the effects of the disease throughout the region.


The role of the World Bank on HIV/AIDS governance originates from the organisation’s recovery programme for sub-Saharan African economies during the 1980s and 1990s, principally through Structural Adjustment Programmes (SAP). However, the World Bank’s market-oriented lending policy in sub-Saharan Africa was crucial in weakening the functionality of sub-Saharan African governments prior to the outbreak of the epidemic. The strict conditionalities that formed part of SAPs in order to encourage political and economic reform had extensive destabilising effects on sub-Saharan African societies, particularly on the delivery of basic services such healthcare, education and welfare. In implementing austerity measures under SAPs, social spending in sub-Saharan Africa per capita declined to 76 per cent of the level spent in 1981 by the 2000s, impoverishing several countries throughout the region, and was exceptionally damaging for the poorest individuals. This is despite the fact that there is little conclusive evidence that SAPs had a positive impact on economic growth in sub-Saharan Africa.

The depleted basic services helped to reduce the governmental response to HIV/AIDS, and shaped the conditions for the proliferation of the disease. Inflated food prices lessened employment and trade opportunities, particularly in rural areas – increasing the threat of the disease by encouraging rural migration to urban areas. Moreover, the introduction of user fees in health and educational services decreased the accessibility of treatment and HIV/AIDS awareness. In fact, basic services themselves – such as health centres, became sources of HIV infection. Cuts to civil services also restricted the capacity of several governments, deteriorating the administrative ability of sub-Saharan Africa countries in addressing the disease.

The World Bank’s response to HIV/AIDS in sub-Saharan African countries during the adjustment period was also limited. World Bank funding for HIV/AIDS projects began in 1986, however the organisation’s support remained limited over the next decade. Prior to 2000, the World Bank funded a number of generic projects with HIV/AIDS components throughout Africa, none of which exceeded US$10 million. Three projects in Zimbabwe, Uganda and Kenya did receive more substantial funding from the Bank in the early 1990s, however these projects focused more broadly on sexually transmitted infections (STIs). Although the World Bank’s relative inactivity during this period echoes the dormancy of other multilateral organisations, and the general misunderstanding and stigma surrounding HIV/AIDS at the time, as academic Chris Simms argued the World Bank’s significant influence and leadership in the region should have warranted a greater response against the disease. Undoubtedly, the World Bank’s inactivity and its agenda for reform through SAPs contributed to the catastrophic impact HIV/AIDs would have on sub-Saharan Africa. In fact, between the early 1980s and 2000s, people living with HIV infection in sub-Saharan Africa increased from less than one million to 22 million.


However, the growing severity of HIV/AIDS on sub-Saharan African development, and its threat to human and national security in the absence of an effective cure would eventually prompt the World Bank to take emergency action against the disease. Thus, in 2000  the Multi-Country HIV/AIDS Programme (MAP) was launched. Under the MAP, the World Bank would pledge over $1 billion into the fight against HIV/AIDS, drastically expanding the Bank’s financial commitments against the disease. The programme was designed to scale up state-led responses to the epidemic, underpinned by a multi-sectoral framework that encouraged the participation of the public and private sector, NGOs and community organisations in anti-HIV/AIDS projects in the region. The MAP elevated HIV/AIDS governance to the pinnacle of the organisation’s development agenda in sub-Saharan Africa.

The MAP and the extensive impact of the disease on development in the region provoked a shift in the way the World Bank financed governments in sub-Saharan Africa. In contrast to the stringent conditionalities under the SAPs, MAP funding was issued without a specific link to macroeconomic performance. This allowed countries to scale up their response to HIV/AIDS without the explicit strain of further economic liberalisation. However, although the MAP appeared to represent a ‘softer’ financial relationship between the World Bank and sub-Saharan Africa, the organisation’s wider policy of ‘good governance’ and its neoliberal dogma remained intact. MAP funding may have not imposed strict economic conditionalities on sub-Saharan Africa, but it still required states to meet specific eligibility criteria that encouraged the decentralisation of HIV/AIDS governance.

It is true that the MAP did facilitate a number of breakthroughs in the governance of HIV/AIDS in sub-Saharan Africa. The MAP increased the political commitment towards HIV/AIDS at the highest government level, particularly through the creation of national AIDS councils. The programme also succeeded in promoting a multi-sectoral, decentralised response to HIV/AIDS by allowing national, regional and local actors to play an active role against the disease. Furthermore, the MAP also helped to mobilise larger donor initiatives such as the GFATM and the President’s Emergency Plan For AIDS Relief (PEPFAR), strengthening the response to the disease. As of 2008, development partner funding had increased by 2,240% and 502,958 people infected or affected by the disease were receiving support.

However, the MAP should not be exempted from its flaws; the programme had a consistent issue relating to the non-accessibility of funding for projects, particularly damaging for the most vulnerable in the region. This was as a result of the MAPs inability to remove the weak institutional capacity within sub-Saharan African governments, harming service delivery and the coordination of donor efforts to public and private actors, and communities. The MAP also failed to support effective monitoring and evaluation systems, which affected the veracity of HIV/AIDS outcome indicators, though efforts were made to address this in phase 2 of the MAP in 2006. The clearest indication of the MAP’s shortcomings is that HIV prevalence and infection rates have remained relatively unchanged in sub-Saharan Africa. Thus, while the MAP revolutionised sub-Saharan African HIV/AIDS governance, and produced a number of positive outcomes, its overall success is questionable.


The World Bank’s restructuring of sub-Saharan African governance through the SAP significantly undermined the capacity of the region’s governments against HIV/AIDS, with the adjustment programmes enervating vital preventative functions against the disease, and as a result, propagating its escalation. However, by the new millennium the growing impact of HIV/AIDS on the development of sub-Saharan Africa would inspire the World Bank to redefine its approach to HIV/AIDS, and its governance reform measures in the region overall. This led to the formulation of the MAP, placing the fight against HIV/AIDS at the centre of the World Bank’s relationship with sub-Saharan Africa, and drastically increasing the organisation’s obligation towards reducing the effects of the epidemic. However, the MAP has failed to convincingly tackle HIV/AIDS, and has once again demonstrated the uneasiness in implementing the World Bank’s philosophy on governance in sub-Saharan Africa. As such, it remains unclear whether the World Bank can be considered as the perpetrators or defenders against HIV/AIDS in sub-Saharan Africa. However, could the World Bank – or indeed any other organisation have done more against the disease?

Should the United Kingdom leave the European Union?: Challenging Eurosceptics on the British economy

On 23rd June 2016, the United Kingdom will vote to decide whether the country is to remain or leave the European Union. For the first time in a generation, the general public will have the opportunity to formally declare their position on the U.K.’s membership in the EU, a declaration that could potentially transform not only the country’s political, social and economic landscape, but the landscape of its European and international neighbours. In the lead up to the EU referendum, the main political parties have announced their allegiances to the opposing campaigns, which have either defended the U.K.’s commitment to the EU, or have argued for the country’s abandonment of the European politico-economic project. Within the Conservative Party, the EU referendum has reignited the historic divisions concerning the U.K.’s membership, creating a schism among the Tory leadership.

It is true that both the ‘In’ and ‘Out’ campaign groups have displayed instances of unsavoury scaremongering to encourage support for their respective causes. However, the fear-inciting tactics used in the defence of Brexit are in my view particularly concerning. Proponents of the Leave campaign, such as Nigel Farage, Michael Gove and Boris Johnson, have used the EU referendum to propagate misconceptions regarding the ailing state of the British economy, and promote an aura of hate towards immigrants across the country. The vile effect of the claims made by the ‘Out’ campaign have been exemplified by the brutal murder of Jo Cox MP by far-right activist Thomas Mair, who had previously links to neo-Nazi and pro-Aparthied organisations. But are ‘Brexiters’ correct in suggesting that the U.K. will be able to  improve the economy and control immigration if the country leaves the EU?

One of the central arguments advanced by the ‘Out’ campaign is that a Brexit would allow the U.K. to negotiate its own trade deals with other countries independent of existing EU trade agreements. There are currently no tariff barriers to trade for countries within the EU, creating a single market of goods and services (though non-tariff barriers such as product standards produce limitations on trade). However, EU member states (including the U.K.) are also subject to the trade agreements made with non-EU countries by the European Commission.

The EU trade agreements prevent the U.K. from negotiating separate trade deals with the rest of the world – which may appear suffocating given the rise in economic growth in the developing world, and the ever-increasing U.K. trade surplus with non-EU countries. In comparison, the U.K. has a trade deficit of £61 billion with the EU, with domestic consumer demand outweighing the value of our exports to the continent. In fact, U.K. exports have made a gradual shift from the EU to non-EU countries, with a decline in the EU share of total exports from 54.8 percent to 44.6 percent from 1999 to 2014. For Brexit campaigners, this illustrates the potential of the U.K.’s economic growth in the rest of the world, which could be maximised as a result of leaving the EU.

While it may be advantageous for the ‘Out’ campaign to postulate positive economic outcomes if the U.K. was to abandon the EU, we are simply unable to predict what kind of trading relationship the U.K. will be able to negotiate with the EU, or with the rest of the world. Eurosceptics have argued that the U.K. could negotiate a trade deal with the EU similar to that of Norway and Switzerland. Both countries are not members of the EU, but have access to the single market and can negotiate trade deals with non-EU countries independently. However, Norway and Switzerland are subject to EU rules and policies with limited or no influence, and make budget contributions to the union. Moreover, both countries must abide to the free movement of good, services and most importantly peoples.

On the other hand, Canada has also negotiated tariff free access to the EU, without making any budgetary contributions or the free movement of peoples. Though, the trade agreement took an incredible five years to complete, and is difficult to compare to a potential U.K. model as the EU’s share of Canada’s total exports was less than 10% – significantly less than the U.K’s. In the worst case scenario where the U.K. is unable to make any sort of trade agreement with the EU, the country would be subject to World Trade Organisation (WTO) rules. This would prevent access to the free trade agreements for goods or services with the EU, and the U.K. could face EU and non-EU external tariffs and no access to the single market. This uncertainty over what kind of trade deal can be arranged would heavily impact on the productivity of the U.K.’s economy in the interim, as the EU is the country’s main trading partner, evidently making Brexit a risky, uncalculated gamble.

Another important argument put forward by Eurosceptics regarding the economy is the view that the U.K. could save an estimated “£350 million a week” by leaving the EU – as quoted by Boris johnson in a recent television debate, as the country would no longer have to make a financial contribution to the union. It has been suggested that the £18 billion saved could instead be invested into public services, such as education or health care. However, as the Institute for Fiscal Studies noted, the figure of “£350 million a week” is absurd as it ignores the rebate the U.K. receives from the European Union. If the rebate is included the figure actually stands at £14.4 billion or 0.8% of GDP in 2014 (around £275 million a week).

The EU also spends £4.5 billion on the U.K. in areas such as agriculture and research, thus the U.K. only provides approximately £8 billion a year to the EU budget. Moreover, though the U.K. receive per-capita the lowest spend from the EU of any member state, EU spending is only 1 per cent of our GDP – lower than the EU average, and is a relatively small amount in comparison to the £169 billion spent on health and education alone by the government. It is also important to note that the membership fee also brings with it increased trade, investment and jobs, which the U.K. would lose if it is unable to negotiate a trade deal with the EU. In fact, many economists have revealed that lower economic growth as a result of leaving the EU will negate any savings made from EU contributions anyway.

Arguably the most distinguishable argument of the ‘Out’ campaign is the impact of EU immigration on the U.K. economy. UKIP leader Nigel Farage in particular has been defiant in his attempts to reduce immigration from the EU into the U.K., most demonstrable by the party’s  recent “breaking point” campaign poster. Nigel-Farage-UKIP-436573However there is no conclusive evidence to suggest that EU immigrants cause a strain on the British economy, with most studies suggesting that their impact is relatively small, costing or contributing less than 1% of  the U.K.’s GDP. Rather, a recent UCL report stated that since 2000, immigrants have made a more positive fiscal contribution than longer-established migrants – £5 billion from immigrants who entered the U.K. from countries that joined the EU in 2004. There is also evidence to suggest that EU immigrants pay more in tax than they gain in welfare or public services, and they have a higher net fiscal impact than non-EU migrants.

In any case, leaving the EU may not lead to a significant reduction in immigration. As alluded to above, the kind of trade deal the U.K. is able to negotiate with the EU after “Brexit” is pivotal to controlling immigration, as access to the EU single market is also likely to allow for the free movement of people. Therefore, it may require the U.K to leave the single market altogether in order to effectively control immigration, which could neverthless have a negative impact on the economy. In my view, the argument relating to the impact of immigrants is largely cultural; as Nigel Farage proclaimed “the country has become unrecognisable.” However, while the cultural impact of EU immigration is questionable, there is enough evidence to suggest that the economic value of EU immigration is likely to be beneficial to the U.K., counterpoising any superficial arguments that a Brexit will conclusively have a positive impact on the U.K. economy.

Finally, let us not forget the overwhelming consensus of economic institutions and researchers and businesses (according to the British Chambers of Commerce) that argue that the U.K. must remain in the EU in order to preserve economic stability and continued growth. There is one notable exception to this trend – the suitably named Economists for Brexit.  Supported by Patrick Minford and Roger Bootle, Economists for Brexit have predicted a net benefit to the U.K. economy. However, even the most comprehensive analysis on Brexit by independent think tank Open Europe has predicted that even if the U.K. is able to negotiate a trade deal GDP  could increase by 1.6% by 2030. However, if a trade deal is not negotiated GDP could be lower than 2.2% in the same period.

The argument against Eurosceptics is clear. I plead with the people of this great land, do not put our country at economic risk.