Download a PDF version of the AFM letter here
Mr. Paul Wolfowitz, President
The World Bank
1818 H Street, NW
Washington DC 20433 August 29, 2006
Dear Mr. Wolfowitz,
In recent months, the World Bank has been harshly criticised for administering a malaria program that has not lived up to its promises or potential. Several authors have challenged the Bank for failing to reduce malaria morbidity and mortality rates, despite spending well in excess of $100 million, and for reporting false or inaccurate data about asserted accomplishments in Brazil, India and other countries.
Earlier this year, Dr. Amir Attaran and the co-authors of a paper in The Lancet called on the Bank to get out of the malaria control business entirely. Other writers, like Fiona Kobusingye, coordinator of the Congress of Racial Equality-Uganda, have suggested that the Bank focus on building new hospitals and clinics, supplying them with electricity and clean water, and providing financial support to Global Fund malaria programs. They argue that this would do much more than current World Bank programs to save and improve lives in the countries your organization serves.
Africa Fighting Malaria believes the Bank should consider these criticisms carefully. However, we realise that Bank officers, directors and personnel have committed themselves to malaria control and see this as central to their development role. In view of the devastating effect that this disease has on families, communities, countries, economies and healthcare systems, it is hard to argue that this perception is not on the mark. Moreover, AFM does not want to see a reduction in the funds that the Bank has been making available for malaria control. The fundamental question is whether the Bank's programs will control malaria and help achieve its development goals.
With this in mind, Africa Fighting Malaria will be willing to support the World Bank's malaria control activities, provided the following conditions are met.
a) The Bank's interventions must be in line with World Health Organization recommendations.
In the past, the Bank has failed to follow WHO guidelines on treatment, and has encouraged countries to abandon their IRS programs. The WHO is again calling for IRS, and the U.S. Agency for International Development has made a firm commitment to support IRS and DDT. We hope that the World Bank will do likewise. As with the World Bank's Tuberculosis program, we feel that the Bank should first seek technical approval for its malaria projects before they are implemented. This technical supervision will help to ensure that the failures raised the Lancet paper do not occur again.
b) The Bank should use its comparative advantage - finance and systems - in ways that help reduce malaria.
The World Bank has excellent technical capacity to help poor countries get the logistics and financing of malaria control right. In many cases, it is the absence of adequate financing and logistics that is impeding malaria control; so these changes could have profoundly beneficial effects.
c) The Bank must actually provide the money it has promised - and do so in the form of grants, not loans.
Several years ago, the Bank changed its AIDS support from loans to grants, out of a recognition that countries impacted most seriously by this disease simply cannot afford to repay loans until they are on better financial footing (which should occur when they begin to control this disease and increase the number of able-bodied workers. Malaria would benefit from the same policies.
d) The Bank must ensure that it collaborates and cooperates with existing WHO, USAID, Global Fund, private sector and country programs - so that duplication and overlap are minimized.
Many different programs are already underway, and many of them are achieving notable success. The Bank should ensure that it compliments those programs, rather than duplicating them, wasting funds or supporting programs that might even impede or contradict other efforts.
e) The World Bank must be open and transparent.
It must explain and account for how it is using taxpayer money. It must also open an ongoing dialogue with malaria experts and eliminate the need to engage in contentious public debates that undermine confidence in programs, and waste precious time that should be spent implementing programs that reduce disease and save lives. (Malaria control must cease being a battle of wills or ideologies - and become a coordinated effort on every front.)
Malaria ought to be the easiest to control of the three major diseases confronting developing nations. HIV/AIDS and tuberculosis are far more complex in both their origins and solutions. Controlling this mosquito-born disease should be an easy win for countries - a good public health investment that will quickly reap major returns in health and economic gains, thereby making vast human and financial resources available for productive endeavors and a greater focus on other public health problems, like AIDS and TB.
The Bank could play a positive and constructive role in this coordinated effort - saving lives, building strong economies, and reducing the need for foreign aid and perpetual malaria control programs that never seem to achieve their goals.
We hope you and your colleagues will accept this challenge - and look forward to working with you in achieving the goal I know we all share: a world free from this killer disease and thus able to reach previously unattainable productivity and human betterment.
Director, Africa Fighting Malaria