Memorandum submitted by Save the Children
UK
THE WORLD
BANK AFRICA
ACTION PLAN:
A MISSED
OPPORTUNITY
"And because we owe it to all the people
who suffer needless pain and avoidable deaths, owe it to every
child denied the chance of school, owe it to every human being
who goes hungry every night, let us join together to affirm that
to finally and truly make poverty history, Britain will lead a
worldwide effort to ensure for the poorest countries universal
free public services: universal free schooling for all children
and free universal health care for all who need it".
Speech by Chancellor Gordon Brown MP at Labour
Party Conference 2005.
I. Time for Change
1. 2005 has seen increasing recognition
of the barrier which user fees present to enabling access by the
poor to health care and primary education. This has led to mounting
political consensus and pressure that fees for such services could
and should be abolished. The G8, [99]World
Health Assembly[100]
and the UN[101]
have all states their support for the elimination of fees. The
world then looked to the World Bank and IMF Annual meetings for
this commitment to be confirmed.
2. World Bank policies have the power to
play a critical signalling role to governments, opening up the
grounds for discussions on establishing the conditions in which
fees can be eliminated. The new World Bank Africa Action Plan
was approved at the Annual Meetings, but included no reference
to the importance of access to free healthcare and primary education
to get the Millennium Development Goals (MDGs) back on track.
Through this omission the World Bank, one of the original major
proponents of user fees, has failed to use the opportunity to
acknowledge the role which abolition must play in improving the
lives of millions of the poorest children in sub-Saharan Africa.
3. This failure comes at a crucial time,
as five years on from the initiation of the Millennium Development
Goals, progress towards achieving the goals is desperately off-track:
8,000 children under five continue to die every day in sub-Saharan
Africa from preventable causes; [102]whilst
40.3 million children are out of school in sub-Saharan Africa[103]
and the first MDG target on achieving gender parity in education,
will be missed this year. Save the Children UK's research[104]
has shown that fees for essential health services and primary
education are a key factor in preventing poor children using health
services or attending school. It has also demonstrated that removing
these fees would be a small but essential step towards achieving
the MDGs; a cost-effective step which would deliver tangible and
immediate results.
4. Using a simulation model, Save the Children
UK analysed how many child deaths might be prevented if user fees
were removed in 20 African countries. [105]It
was calculated that elimination of user fees for health could
have an immediate and substantial impact on child mortality, preventing
an estimated 233,000 deaths annually in children aged under five.
This amounts to 6.3% of deaths in children under five in these
20 countries. Most of these lives would be saved by increased
use of simple curative interventions, such as antimalarials and
antibiotics combating dysentery and pneumonia. The abolition of
fees in these countries would cost less than US$1 billion per
year and would, according to the World Health Organisation's criteria,
represent a "very cost-effective" intervention. A clear
example of this in practice is Uganda, where on abolition of fees,
out-patient utilisation increased by 77% with the poor benefiting
disproportionately.
5. Despite a longer history of support for
free primary education for all, fees remain widespread and are
a particular barrier for girls. Among the 20 countries in sub-Saharan
Africa with the highest proportions of girls out of school, at
least eight charge tuition fees for primary education. [106]In
many more countries, parents have to pay charges for textbooks,
uniforms and transport. Based on net enrolment increases achieved
in the Gambia, Lesotho, Tanzania and Uganda when fees were abolished,
Save the Children UK's research shows that if fees were abolished
in the 13 sub-Saharan African countries known to still charge
tuition fees, as many as 4.5 million more children would go to
school within three years. [107]
II. The World Bank: the need for change
6. Although the World Bank supports free
primary education, its only official policy statement on fees,
published in the World Development Report 2004, entitled
"No blanket policy on user fees", is ambiguous[108]
and acknowledges that in many of the poorest countries fees will
be a "necessary evil".
7. Save the Children UK's research into
the extent to which World Bank projects operate within user fee
systems, [109]demonstrates
the continued heavy reliance on fees as part of health financing,
and very little evidence that the World Bank is working to help
governments move away from fees to alternative types of financing.
In the countries in sub-Saharan Africa with World Bank health
programmes, 28 out of 32 charge fees for essential healthcare,
and in almost half of these countries user fees form an integral
part of World Bank project design. In fact in only two countries
do projects actively support free treatment, and these are both
HIV/AIDS-related projects.
8. For education, the research shows much
clearer support to governments to get rid of fees but still some
way to go before the entire education project portfolio is operationalising
support for primary education which is free of charge. In only
three countries (out of 21 countries with World Bank education
programmes) did school-related charges comprise a part of the
project design. However even with education, work to help reduce
the burden of charges for education on poor people is often not
given much priority, sometimes amounting to no more than providing
free textbooks.
III. Financing the abolition of fees
9. The World Bank not only needs to signal
its support for free services it also needs to help finance the
abolition of fees. Sufficient sustainable and predictable financing
is needed. Without a commitment of funds there remains a lack
of confidence from developing countries to cut fees, without having
the finances to sustain it. The replenishment of the International
Development Association (IDA) 14 (and the forthcoming commitments
from the G8) means that the World Bank could take steps towards
providing sustainable financing. Whilst Save the Children UK is
relieved that the Annual meetings did at least endorse the G8
debt deal, we hope that this deal can be implemented sooner than
the middle of next year, as currently planned, and that the deal
can be extended to other highly indebted countries very soon.
10. A further challenge to providing free
healthcare and education using increased aid is ensuring that
governments feel able to rely on the aid flows. Aid flows must
be committed for the long-term, planned over at least five years,
preferably longer. This means that governments can plan and implement
long-term health and education strategies and know that the resources
will arrive each year. Donors must also ensure that aid conditionalities
are fully owned by the recipient country and are reasonable. Additionally,
aid must be predictable within year; ie it must be delivered evenly
throughout the year. Currently donors are slow to release money
at the beginning of the year, delivering higher amounts as the
year-end approaches. This means that governments cannot meet fully
recurrent costs such as salaries every month. Currently, many
governments are nervous about increasing access to health and
education through an increased reliance on aid; they are concerned
that aid will run out after a couple of years or fluctuate and
that health and education systems will suffer as a consequence.
The World Bank must extend its Poverty Reduction Support Credit
planning period from three years and work to improve conditionalities,
which currently reduce disbursement rates since they can be overly
complex or insufficiently owned by the recipient country, through
a practical implementation of its conditionality good practices.
IV. Observations and recommended action by
the UK Government through their role within the World Bank
11. In the run up to the Annual Meetings,
Save the Children UK held a meetings with key World Bank personnel,
including the Vice President for Human Development, the Vice President
for Operations Policy and Country Services, the Director of the
Africa Human Development Unit and the Director for Health, Nutrition
and Population, in addition to European Executive Directors. Although
we are disappointed in the final outcomes of the Africa Action
Plan, we hope that the arguments presented to the World Bank will
lead to discussions and progress on the World Bank's position
on fees.
12. There is clearly much need for change
by the World Bank in both policy and practice, and this action
is needed now, if there is to be any hope of achieving the MDGs.
It is, therefore, vital for the UK Government to call for change
within the World Bank. The efforts of Tom Scholar's office to
table the issue of user fees, particularly for health, for debate
amongst World Bank Executive Directors are greatly appreciated.
This momentum needs to be built on quickly and the issue should
be discussed at forthcoming Board meetings with a view to moving
the World Bank to a clearer and stronger position by the time
of the Spring meetings 2006.
V. Recommendations for action by the UK Government
— Publish the UK Government's
position on user fees for health and a strategy for operationalising
it.
— Ensure that this issue is key priority
for the UK Government at the Third High Level Forum on the Health
MDGs (Paris, 14 and 15 November 2005).
— Include within the UK Government's
objectives for the World Bank/IMF Spring Meetings the achievement
of a real commitment to the abolition of fees.
— Take forward the issue of financing
at the highest level in order to resolve blockages to the widescale
abolition of fees and delivery of sufficient and predictable funding.
Measures must address:
— Eliminating all remaining conditions
within Development Programme Lending which support the implementation
of user fees for health and education.
— Committing new resources to Development
Programme Lending in sub-Saharan Africa to support the abolition
of fees ensuring that funding is long term (at least five years),
that disbursals are highly predictable within each year and over
several years, and that conditions are not overly complex and
are fully owned by the country through the implementation of the
World Bank's recently released Conditionality Good Practices.
— In new and existing health and education
investment World Bank staff should initiate discussions with governments
on alternatives to fees. Task Managers should ensure in any new
health-related projects that the project budget does not rely
on income from fees by providing matched funding through budget
support into the recurrent budget.
— Use the UK's Presidency of the
EU to build support on the issue and work towards reaching a European
wide position on fees.
Further related resources:
Time for change: Fees for health and education,
Save the Children UK briefing paper, 2005,
http://www.savethechildren.org.uk/scuk—cache/scuk/cache/cmsattach/3408—IFI%20Briefing.pdf
Killer Bills, Save the Children UK briefing
paper, 2005,
http://www.savethechildren.org.uk/scuk—cache/scuk/cache/cmsattach/2966—Killer%20Bills.pdf
An unnecessary User fees for healthcare in
low income countries, Save the Children UK, 2005,
http://www.savethechildren.org.uk/scuk—cache/scuk/cache/cmsattach/3027—An%20Unnecessary%20Evil.pdf
60 Million Girls, Save the Children UK,
2005,
http://www.savethechildren.org.uk/scuk—cache/scuk/cache/cmsattach/3288—girlsedsb.pdf
THE WORLD
BANK AFRICA
ACTION PLAN:
A NEW OPPORTUNITY
1. In contrast to the failure on health
and education outlined above the Africa Action Plan includes a
commitment to "reinvigorate [our] nutrition funding and to
expand IDA support to a minimum of eight African countries with
the worst nutritional indicators". Save the Children UK welcomes
this, believes investment in nutrition in these countries is urgently
needed, and will take an active interest in this new initiative.
2. In order to maximise impact of these
investments the UK should take a leadership role within the World
Bank to ensure that they deliver progress on the MDGs.
3. Research has shown that World Bank projects
in nutrition have had very limited impact on child nutrition in
several countries including Uganda and Bangladesh. Specifically,
research funded by DFID, has shown that a $60 million programme
in Bangladesh has had no population level impact on malnutrition
in children after more than five years of investment. Unfortunately
to date the results of this research have had little influence
on new programming and currently the World Bank and DFID are part
of a consortium of donors who will fund a scale-up of this programme
within the new Health, Nutrition and Population sector wide programme.
We do not believe that DFID is using its role on the consortium
to ensure that this new investment is designed taking into account
the lessons from the evaluation of earlier projects.
4. We therefore urge the UK Government to
use the experience gained by the World Bank, Save the Children
UK and DFID in Bangladesh to ensure that these new investments
in Africa, referred to in the Africa Action Plan do not repeat
mistakes made elsewhere and waste precious resources. This will
require the World Bank to reconsider its approach to tackling
malnutrition in the poorest countries and design its nutrition
investments to take into account recent programme evaluations.
Further related resources:
Operations Evaluation Department, 2005, Maintaining
Momentum to 2015? An Impact Evaluation of Interventions to Improve
Maternal and Child Health and Nutrition in Bangladesh. World Bank
http://www.worldbank.org/oed/ie/bangladesh—ie.html
World Bank, 2005, Project performance assessment
report Bangladesh Integrated nutrition project (credit 2735-bd),http://www-wds.worldbank.org/servlet/WDS—IBank—
Servlet?pcont=details&eid=000090341—20050707090711
Hossain, M, Duffield A and Taylor A, 2005, An
evaluation of the impact of a US$ 60 million nutrition programme
in Bangladesh. Health Policy and Planning 20 (1) 35-40.
October 2005
99 G8 Communique« (Africa Section), Gleneagles,
July 2005. Back
100
World Health Organisation, World Health Assembly Resolution 58.31,
2005, Agenda item 13.2, "Working towards universal coverage
of maternal newborn and child health interventions". Back
101
UN, draft Outcome Document of the High-level Plenary Meeting of
the General Assembly of September 2005. Back
102
G Jones et al and the Bellagio Child Survival Study Group,
"How many child deaths can we prevent this year?" The
Lancet, Vol 362, 5 July 2003. Back
103
UNESCO, Education for All The Quality Imperative: EFA Global
Monitoring report 2005, UNESCO 2004. Back
104
Save the Children UK briefing paper, Killer Bills, 2005;
Save the Children UK, 60 Million Girls, 2005. Back
105
C James et al, "Impact on child mortality of removing
user fees: simulation model" British Medical Journal, Vol
331, 1 October 2005. Back
106
Save the Children UK programmes, Kattan, RB and Burnett, N, 2004,
User fees in primary education, World Bank, Washington, UNESCO
Institute for Statistics. (Note, there are a number of countries
for which data was not available on the number of girls out of
school). Back
107
Estimate based on 15 percentage point increase in Net Enrolment
Rate across three years from removal of fees. This estimate is
drawn from similar increases already seen: Uganda 55-67%, Gambia
52-67%, Lesotho 61-86%, Tanzania 63-88%. Population figures from
UNESCO. Back
108
World Bank, World Development Report 2004: Making services
work for poor people, 2004. Back
109
Analysis of the World Bank project database of project appraisal
documents or project information documents of active projects
in sub-Saharan Africa with a focus on primary education, general
education or health were reviewed. Where there was more than one
relevant project sector support projects were prioritised. www.worldbank.org Back
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