Participants in a march demanding health-care funding to fight maternal mortality, Kampala, Uganda, May 22, 2012
Victory! .. isn’t it? On February 27, the World Bank announced it was “indefinitely” delaying a scheduled $90 million loan to Uganda to improve health care, in response to the passing of the comprehensively repressive “Anti-Homosexuality Bill.” “We have postponed the project for further review to ensure that the development objectives would not be adversely affected by the enactment of this new law,” a Bank spokesman said.
In the circles where I move — international (that is, North-based) activists working on LGBT rights — rejoicing burgeoned: finally the big funders are getting serious about queer people’s oppression! Politicians joined in. Nancy Pelosi, ex-speaker of the US House, tweeted joyfully:
Jim Yong Kim, President Obama’s appointee to the lead the World Bank (an organization Washington still disproportionately funds and dominates) brought home the message with an op-ed the next day:
Institutionalized discrimination is bad for people and for societies. Widespread discrimination is also bad for economies … Legislation restricting sexual rights, for instance, can hurt a country’s competitiveness by discouraging multinational companies from investing or locating their activities in those nations.
Let’s pause to bask in the exhilarating effect of having a powerful institution intervene for LGBT people, with a leader in global development saying the “s” word — sex, as in “sexual rights.” Yes: it feels good.
Still, this is Africa. And this is the World Bank. For international activists to laud its actions so unreservedly involves a wretched show of amnesia.
We think that debt has to be seen from the standpoint of its origins. Debt’s origins come from colonialism’s origins. Those who lend us money are those who had colonized us before … Debt is a cleverly managed re-conquest of Africa, aiming at subjugating its growth and development through foreign rules. Thus, each one of us becomes the financial slave, which is to say a true slave.
Probably few of my international colleagues will recognize those words– another leftist rant, right? But many Africans know them. It’s Thomas Sankara, then president of Burkina Faso, speaking to the African Union in 1987. Sankara had rejected the mandates of the World Bank and the International Monetary Fund and launched on a development path that promoted economic equality, gender justice, education, and health care as basic rights. Three months after saying that, he was dead: murdered in a coup. France and other creditor nations tacitly endorsed his killing. He’s remembered and mourned across Africa today. His successor brought the country back under World Bank and IMF tutelage; as a result, as a South African analyst remarks, “Today Burkina Faso remains one of the least developed countries in the world.”
For twenty-five years, the World Bank has pushed essentially unvarying policies across the developing world: privatization, cutting the public sector, fostering an export-based economy (so that poor countries become suppliers of raw materials to the industrial North, and don’t grow their own industries and markets). It imposed these restrictions as conditions for loans; that debt, in addition to crippling Southern economies, then became a weapon to enforce more conditions. Poverty spread, not development. The Bank has been friendlier to civil society than its IMF sibling; but their ideologies and impacts have been the same. Praising a World Bank intervention for LGBT rights in Africa while forgetting this history is like praising Putin’s tender concern for Crimean Russians, while forgetting the Ukrainians next door.
You can use the power of international lenders for certain instrumental ends. That doesn’t mean you have to love them. We shouldn’t just hail what they do, we should scrutinize it. And please. You cannot condemn (as indeed you should) the neocolonialism of foreign evangelists exporting homophobia to Africa, and ignore the neocolonialism of foreign financial institutions that enforce neoliberal economics on an abject continent. Why is it wrong to import one devastating ideology, and OK to import another? Sorry. You need to be consistent.
So in the spirit of scrutiny, some questions arise about what the World Bank did.
First of all: why postpone this loan? Mainly, the $90 million was earmarked to combat maternal mortality: aimed at “maternal health, newborn care and family … through improving human resources for health, physical health infrastructure, and management, leadership and accountability for health service delivery.” It entailed funding to expand and train medical staff, to “professionalize and strengthen” management, for obstetric equipment and medicines including contraceptives, and for renovating hospitals. These goals are unlikely to be “adversely affected” by the Anti-Homosexuality Bill. The real reason for the selection is that this loan was up for board approval on February 28. The Bank seized on the first loan that came along to postpone. It was a matter of convenience, not strategic targeting.
Second point: Maternal mortality is serious in Uganda — and a political issue.
The country’s rate of maternal mortality is extremely high. In the Millenium Development Goals — endorsed by nations at a UN summit back in 2000 — countries committed to reduce the level of maternal mortality by 75% by 2015. For Uganda, this would mean cutting a rate that hovered appallingly around 600 per 100,000 live births in the 1990s, to 150. A 2013 report found the rate had fallen to 310 per 100,000 live births — around a 3.2% reduction every year, the UN said, but still well above the goal. Fewer than half of mothers had adequate antenatal care, and only a third had sufficient postnatal care. Less than 60% had a skilled attendant at delivery. Despite the government’s loud promise of a National Minimum Health Care Package (UNMHCP) for all Ugandans, health services still fail to reach many poor and rural women.
By some estimates, between 6,500 and 13,500 women and girls in Uganda die each year due to “pregnancy-related complications.” That means at least sixteen women die every day.
In 2011, a coalition of NGOs petitioned Uganda’s courts to intervene. They argued
that by not providing essential health services and commodities for pregnant women and their new-borns, Government was violating fundamental human rights guaranteed in the Constitution, including the right to health, the right to life, and the rights of women.
The case has stayed stalled in the legal system. At a September 2013 hearing, the government simply failed to show up, forcing an indefinite postponement. In May 2012, an emotional procession of women and health-care providers marched through Kampala’s streets to support the lawsuit. They got an apology from the judiciary for delays — too few judges, too little time — but the delays continued. They also met with Finance Ministry officials to demand increases in the health sector budget; those didn’t happen. Leonard Okello of the International HIV/AIDS Alliance Uganda told the press, “Dying mothers are not a priority in Uganda.”
Marchers in Kampala, May 22, 2012
Corruption and cronyism are undoubtedly at issue (top government officials waste a small fortune traveling for health care abroad), but the basic question is budgeting. Museveni has successfully battled back the political pressure to reorder his priorities. In 2001, African Union countries signed the Abuja Declaration, committing them to raise health spending to at least 15% of budget. (The development field seems particularly prone to these lofty professions of faith, which multiply like theological credos in the early Church.) Despite all its challenges, including one of the world’s best-known AIDS crises, Uganda has rarely made it much more than halfway to this target. The figures for recent years show a large decrease in the health sector’s budget share — from just over 10% in 2010 to under 8%:
Who gets the money instead?
Interesting question. Here are the allocations by sector from Uganda’s budgets for the last two fiscal years.
(Note the percentage figures on the right, and ignore the numbers in shillings, which are made irrelevant by inflation.) Health’s share goes down again, to less than half the Abuja Declaration goal. Other losers are education, agriculture, water and the environment. Huge shares of the budget are taken up by “Energy and Mineral Development” and “Works and Transport.” These partly reflect the growing exploitation of Uganda’s oil reserves. They also reflect the priorities neoliberal lenders like the World Bank have always urged on developing countries: go produce raw materials for export to the industrialized North! and go build the infrastructure to get them there! One commentator says the country is “focusing on physical capital at the expense of human capital.” That’s an understatement.
But the other big factor is the security sector.
Security doesn’t look so massive: only 8.2% of the latest budget. That’s only the tip of the AK-47, though. Many defense expenditures remain hidden. Uganda’s Independent newspaper noted that the “the budget for Defence in the BFP [Budget Framework Paper] has always been smaller” than the reality:
[I]n real terms that figure excludes monies accrued to Defence from external sources. The figure also does not include classified expenditure that is usually Defence’s biggest component. Because of national security, the army does not reveal certain expenditures.
The 2013/14 budget featured “about ten new taxes… introduced partly to finance the Ministry of Defence.” These included a value-added tax (VAT) on water and on wheat and flour, regressive imposts designed to squeeze money from the poor. Security is Museveni’s “topmost priority,” the Independent says, and it’s the great enemy of health. In 2012, rebel parliamentarians proposed cutting the military’s largesse by 15 billion shillings (about US$6 million) and boosting health spending by 39 billion (US$15.5 million). Museveni quashed the move in fury. He snarled that he “couldn’t sacrifice the defense budget for anything.”
The President prizes his troops: “a large military war-chest increases Museveni’s regional and international leverage, and helps cow opposition to him at home.” But the US loves the Ugandan military as well. America wants to see plenty of money spent on it.
David Hogg, Commander of US Army Africa, inspects Ugandan troops in April 2011. Photo: U.S. Army. .
I wrote two years ago about the US’s aims for strategic hegemony in Africa, driven by the promise of buried resources and the threat of China. Uganda, as ally and partner, is key to this design. Obama actually sent US troops to Uganda in 2011, to join its army in chasing the warlord Joseph Kony, loathed by well-meaning white people everywhere. This was a small reward for Museveni’s larger services in bringing a desolate stability to Somalia. In 2012, the Pentagon “poured more than $82 million into counterterrorism assistance for six African countries, with more than half of that going to Uganda.” Money and equipment keep flowing to Museveni’s forces. Obama showers Uganda with “lethal military assistance,” writes the pundit Andrew Mwenda, because “America’s geostrategic interests in our region, and Museveni’s pivotal role in them, demand that the American president pampers his Ugandan counterpart.”
And here is where we can start to understand some ambiguities in the World Bank’s actions.
The $90 million loan for “Uganda Health Systems Strengthening” that the Bank was on the verge of giving drew on two earlier Bank analyses of Uganda’s health crises. There’s a 2009 paper, Uganda: A Public Expenditure Review 2008, With a Focus on Affordability of Pay Reform and Health Sector. A longer 2010 working paper, Fiscal Space for Health in Uganda, elaborated on this. (Peter Okwero, task team leader for the loan, helped compose both.) They’re fascinating documents that reveal much about Uganda and much more about the Bank. It’s an honest institution in many ways, frank with figures and often good at diagnosing what’s wrong. But its prescriptions seem to come from a different place from its diagnoses — one permeated with politics and ideology. Its medicines rarely match the disease.
The findings are unsurprising. Aside from considerable waste (caused by theft of drugs but also poor procurement and storage practices) the main problems in health care stem from lack of funds. Capital spending in hospitals has shrunk; many hospitals are old and decaying. Medical costs are rising: “Growing resistance to the existing treatment for malaria (and more recently for TB), is forcing Uganda to adopt more expensive treatments.” Meanwhile, “Uganda faces a serious shortage of health personnel in the workforce,” with only 8 doctors per 100,000 population. Staff are underpaid (even drug stealing, a major component of waste, is surely related to salaries, though the reports don’t draw the connection). And many sick people need resources just to use the system:
65 percent of women reported lack of money to pay for treatment as a constraint to seeking treatment. Other problems included travel distance (55 percent), the necessity of taking public transportation (49 percent), concern over unavailability of medications (46 percent) …
“Preliminary health sector modeling work carried out under this study suggests that Uganda clearly needs to increase public health spending for non-salary cost at clinics and hospitals.”
Student nurses in the caesarean section ward of Rukungiri
hospital, 2007: © Patricia Hopkins, ABC news (Australia)
Except the conclusion is, weirdly, Uganda can’t. Here’s where the medicine stops fitting the diagnosis. “[Only] limited opportunities for additional public funding seem to exist,” the 2009 report says. The reports adduce this from looking at the national budget, and finding there’s just no flexibility there.
Can Uganda increase the share of its Government budget devoted to health? Reprioritizing health spending at the expense of other sectors seems unlikely. It is not clear which other sector budgets can feasibly be cut in order to increase allocations to health. Government policy has emphasized fiscal consolidation, whilst agriculture, energy, roads and USE [universal secondary education] are each identified as priorities in the coming years. … The best option for generating more health outputs in Uganda would seem to be through improved efficiency of Government spending rather than increasing Government spending. [Emphasis added]
So much for those lawsuits based on human rights! Instead … blah, blah. “Uganda’s health policymakers must identify a combination of efficiency savings and re-prioritization to sustain progress towards health targets … Efficiency gains will be needed and can be found … The most pressing priority is to utilize the existing funding for health more efficiently.” (Italics added.) The reports show that Uganda needs increased health spending. But they end with “Recommendations to reduce the growing pressure to increase health spending.” They remind you mothers are dying, and then offer Museveni advice: how to tell those irritating women who march about dying mothers to get lost.
And it’s very interesting what budget sectors the World Bank looked at. They examine “agriculture, energy, roads” and education and find there’s nothing there to give to health care (even though Uganda’s most recent budgets managed to cut the first and last items). What the Bank doesn’t mention — not once — are defense and security, the military and police. Shifting money out of those sectors isn’t even under consideration. For the Bank, Museveni’s guns are sacrosanct. It’s the butter that needs trimming.
It’s tempting to say the Bank is showing a delicate sensitivity to Museveni’s feelings here. Why antagonize the old dictator by menacing his pet Praetorians? But the World Bank has never hesitated to tell governments to cut their favorite projects. Instead, we need to recall the Bank’s political situation. The US is its largest shareholder; the American President appoints its head; the Yankee-led Bank put the Washington in the Washington Consensus, balancing off the European-dominated IMF. The Bank’s approach to Ugandan budgeting reflects the US’s priorities. The US gives its share of support to health care in Uganda, through PEPFAR and other programs; but its main interest is Museveni’s military, and it has no desire to see money for soldiers shifted to obstetricians. The Bank, likewise, is not going to threaten the defense sector. If that’s the choice — and they don’t even dare to suggest it — health care has to fend for itself.
The Washington Consensus: Street art from Argentina
The $90 million loan was meant as a way out of this dilemma, giving the Ugandan health system a bit more breathing room. It’s interesting, then, how the Bank moved so quickly to suspend it. According to BuzzFeed, the Democratic leader of the House herself called the Bank:
“Yesterday, Leader Pelosi [a curiously North Korean locution] spoke with President Kim to express the concerns of Members of Congress about the legislation enacted in Uganda,” Pelosi’s spokesman, Drew Hammill, told BuzzFeed in an email. “While we appreciate the difficult decisions President Kim has to make and their impact on the lives of many in the developing world, many Members believe that such a blatant act of discrimination should not go unnoticed.”
How odd that Pelosi phoned the Bank about its aid package before dialing her own government’s agencies. Yet it makes a certain sense; for Obama was under pressure to do something about Uganda, and some were pointing to that sacred military aid as a tempting target. Just one day earlier, Stars and Stripes — the US Army’s own newspaper – suggested as much.
[D]owngrading cooperation with Uganda’s military would be a way to send a signal to the leadership in the country, said J. Peter Pham, director of the Atlantic Council’s Africa Center. …
“Military assistance is the one area where the U.S. has options,” Pham said. “[T]he Ugandan People’s Defence Force remains one of the few bastions of professionalism in the country, and its leadership is about the only check on Museveni and his ambitions to impose his son as a successor; hence, a shot across the UPDF’s bow might get some attention from those best positioned to get the president’s attention.”
The paper quickly backtracked: “Some experts, however, say that military ties are unlikely to be cut. Given the role the Ugandan military plays in promoting regional stability, dramatic cuts in aid should be avoided.” Lovely stability! You can see how the World Bank’s loan postponement was a happy distraction. It ended any pressure on the US government to trim its military commitments to Kampala. Uganda was already suffering, and Obama no longer needed to pile on. Pelosi’s call served its purpose.
This is stability: Ugandan soldier in Mogadishu, 2007
The gesture is more a symbolic than a real one. The World Bank is unlikely actually to cut the loan, with four years of planning behind it. Sheila Gashishiri, the Bank’s spokesperson in Kampala, told the AP on February 28 that “the project run by Uganda’s Health Ministry will continue despite the postponement.” That probably means the funds will come through after a suitable interval.
In fact, Museveni’s regime will benefit. The whole brouhaha gives him wonderful room for rhetorical posturing. “The West can keep their ‘aid’ to Uganda over homos,” the ruling party’s press man Ofwono Opondo said, adding both that “Africa must stand up to Western domination” and that “Western ‘aid’ to Africa is lucrative and profitable trade they cannot cut off completely.” The politicos can have their cake of indignation — and ultimately eat their cake of $90 million credits too. Their rage, their language, pits LGBT people against pregnant women — a terrible side-effect of the Bank’s action. Surely that can only help brutal violence against the former spread.
Moreover, even a brief interruption in the health care loan gives Museveni ammunition. He can stand up to NGOs, Parliament, and even the courts if they demand more funding for the health sector to fight maternal mortality. “What money? The World Bank money? Where is it? There is no cash.” Those marching women can just go away. His security budget is even safer now from niggling jealousies.
And yet all this aid-cutting and health-care gutting is, we’re told, a blow for equality, against discrimination. We talk so much about “equality,” in the Western LGBT movement! The word is our fetish; we raise up those rosy equal signs as if they were the Black Madonna of Częstochowa. But maybe we need to think more deeply about equality’s meaning.
Here is the logo for the State Department’s Global Equality Fund, which supports LGBT organizing around the world.
You have to love that rainbow circle: it’s seductive as the One Ring. So, too, is the call for dialogue. But what if that sphere dialogued with this one – a chart of global inequality, prepared by no less impeccable a capitalist center than a famous Swiss bank:
It’s a bit more … detailed. As are these circles:
You’ll notice that Africa, with one-sixth of the world’s population, has one percent of its wealth. Uganda is a tiny, tiny sliver within that. I want the rainbow ring, but there’s something missing. How do these visions of equality connect?
The US-based Human Rights Campaign, which gave those iconic equality symbols to the world, also weighed in on the World Bank’s statement, inveighing at recalcitrant countries that
you will pay a high price for discriminatory practices. Whether viewed through a moral or economic lense [sic], discrimination does not pay. … HRC applauds Secretary Kerry and World Bank President Kim for taking a stand on LGBT equality. But the work is far from done.
HRC’s international work, of course, is mainly supported by the profits of vulture funds, exploiters who traffic in Third World debt and immiseration. Equality can mean so many things.
So who won, and who lost? The World Bank won. They’ve sent the US a message that they are pliable to its political requirements. They’ve sent Uganda a message that there will be Consequences, but the Consequences won’t affect the programs Museveni most loves — the ones with guns. Then, messages mailed, the World Bank can finally produce the loan, which will take it off the hook (except to collect the interest). Uganda’s government is also a winner. They get to stand up theatrically to the blackmail of perversion; in the end, they probably get the cash. They also get an excellent argument against shifting money from the security establishment, or ending the deaths of pregnant women.
To these you can add the US government, which can rest confident that its military aid to Museveni has again evaded question. And you can add Western gay movements — especially those in the United States, allied not-quite-knowingly but easily with the administration’s interests. They’ve flexed their macho muscles and proven that they have some power, power to make the poor pay for what other people have done. I mean, it’s true that LGBT communities in Uganda are still laboring under oppression, and we haven’t done so much about that; but at least we get to oppress someone too. Isn’t that a consolation?
The losers are all in Uganda. They’re folks whose voices, though sometimes ventriloquized, are too faint or peripheral to be heard: mothers, children, LGBT people. Here’s to the victors! Great job.