Is Uganda ready for a World Bank health sector loan? Groups advise a close look

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In June, some four months after Ugandan President Yoweri Museveni signed his country’s Anti-Homosexuality Act into law, two months after a U.S.-funded Military HIV Research Program clinic serving gay men in Kampala was shut down by police action, and in the midst of international sanctions and condemnation of the country’s approach to health and human rights, the government issued a “Ministerial Directive on Access to Health Services without Discrimination.” Intended to “reassure all citizens, development partners, and other stakeholders,” it asserted the right of all Ugandans, “including homosexuals, to enjoy continued access to health services without discrimination.”

Among those the “directive” was intended to reassure was the World Bank, which had suspended a planned $90 million loan to Uganda’s health system, following the law’s passage.

In a letter to the World Bank Tuesday, representatives of 16 international and local health and human rights organizations in Uganda urge the World Bank to look closely at efforts to provide health services without discrimination, before reinstating the loan. While a court overturned the law on a technicality in August, the writers note, Museveni has continued to voice support of a law criminalizing “promotion of homosexuality,” the provision of the previous law that led police to shut down the clinic in Kampala. “Effectively,” the letter says “the Ugandan government’s pursuit of discriminatory policies against LGBTI people, including in the healthcare sector, is unchanged by the Constitutional Court ruling.” With an election looming, the law, or parts of it could be reinstated within the next year and a half, the letter notes.

The letter also points to a clue to the government’s philosophy on healthcare access in the Ministry of Health’s “directive,” noting “it describes the provision of health services to LGBTI people as an ‘ethical dilemma,’ for healthcare workers — rather than a professional obligation or equal access to health care as a fundamental human right.”

The letter also points to the President’s signature in August on the country’s new “HIV Prevention and Control Act,” which criminalized HIV transmission, mandated HIV testing of pregnant women and their partners as well as victims of sex crimes and people accused of sex crimes, while allowing health workers to breach confidentiality by disclosing patients’ HIV test results to others (although the Ministry of Health directive also assures the right of “all clients” to confidentiality).

At deadline for this blog, the World Bank did not provide information on when the $90 million loan suspended in February will be reconsidered, but when it is, the letter urges, “Given Uganda’s ongoing discriminatory environment in the allocation of health services, we believe it remains very important for the World Bank to ensure strong safeguards are in place before the delayed loan is released.” Among the recommendations in the letter are that the bank only approve the loan if the health system strengthening it is intended to fund includes training for health workers in providing nondiscriminatory services, monitoring of services, and protection of patients’ privacy and informed consent as well as access.

“We firmly believe that the World Bank’s decision regarding the $90 million loan will have a profound impact on the credibility of the World Bank in Uganda and beyond,” the letter says, concluding with an invitation to World Bank officials to meet to discuss the status of the loan, and of ways to achieve its ends. It is the third letter from the organizations on the loan and concerns about Uganda’s health service provision since April.

“What happened in February is remarkable,” Asia Russell of Health GAP, one of the signers of the letter, said today, noting that the decision to suspend the loan then, in light of the law, provided an opportunity to examine the impact of discrimination on health care and on the outcomes the loan was intended to improve. She recalled then-Uganda Minister of Health Dr. Ruhakana Rugunda’s claim following the enactment of the Anti-Homosexuality Law that the legislation would not effect health service provision. The subsequent police raid on the Kampala clinic, she said, “exploded that myth.” Later, Rugunda himself acknowledged discrimination in health service provision, she added.

The discrimination goes beyond that based on sexual discrimination, she said.

“There’s discrimination for people with HIV, for young people, for pregnant women,. That discrimination is contributing to Uganda’s profound lack of progress in health indicators.”

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