World Bank Misses the Boat on Tuberculosis in Africa

What happens when you pour billions of dollars in funding into an idealistic-sounding (if dubiously implemented) program for 13 years, but fail to invest evaluating it?

Well, sooner or later, a group like ACTION (Advocacy to Control Tuberculosis Internationally) comes along and calls you out on it. That's exactly what's happening today, with the release of a new report examining how the World Bank and its partners have failed to improve health through their use of sector-wide approaches.

Also known as SWAps, the sector-wide approach sounds pretty terrific on paper. Every bullet point of the strategy is equipped to please: unlike narrowly targeted projects, SWAps aim to broadly support government and the creation of a holistic, cross-sector strategy, with an emphasis on partnerships and the goal of promoting dialogue and coordination. In fact, that's exactly why SWAps emerged in the 1990s — as a way to counter-balance critiques that conventional projects sidelined governments and went too far in imposing donor priorities.

Unfortunately when it comes to health, says ACTION, such a set of seemingly noble aims has gone badly wrong. Their findings suggest that SWAps are characterized by a "general lack of attention to results," and an incredibly poor ability to monitor or evaluate any of the health programs they support.

If you aren't already familiar with ACTION, they're the authors of what's now become an increasingly gloomy trilogy of reports documenting the world's failure on tuberculosis. In 2006, they published a report documenting how less than 1% of the World Bank's health lending in Africa supported efforts to fight TB (Enduring Neglect: The World Bank’s Inadequate Response to Africa’s TB Emergency). In 2008, they authored Living With HIV, Dying of TB, a report chronicling the failure of the World Bank's lead multi-country HIV/AIDS program in Africa to tackle tuberculosis, despite the fact that (as Andrew's previously written here) the two are often linked.

Like its predecessors, the findings of this study (Aid WIthout Impact, backed by the Bill & Melinda Gates Foundation) are similarly grim. Though the World Bank has previously funded tuberculosis-specific programs in countries like India and China, the agency has chosen to rely on the broad SWAps model for Africa — and that choice, the report (which covers 2001 to 2008) suggests, has been fatal. "It was difficult," ACTION notes, "to find evidence that SWAps were enabling improvements in health outcomes."

Their recommendation? Try focusing on "better health outcomes," rather than seeing SWAPs as "an end in themselves."

Most people ACTION interviewed said they liked the SWAps approach and thought it was important — but were hard-pressed to avoid admitting that so far, it hasn't exactly translated into improved results for the sick. And after over a decade of funding, as the report makes clear, goodwill unattached to real results are hardly enough. Especially in a time of donor pullback, the message is obvious: quit putting funds into programs that don't work.

Photo Credit: US Mission Geneva