Dr. Jim Yong Kim
The World Bank
1818 H St. NW
Washington DC 20433
Dear Dr. Kim:
We write to follow up on our letters of April 1 and May 6, 2014, regarding concerns about discrimination in Uganda’s health sector and the World Bank’s delay of its US$90 million loan.
We, once again, welcome your commitment to ensure that there is no discrimination in World Bank financed projects in Uganda and public recognition that discrimination is not only wrong, but undermines economic growth.
Six months after your decision to delay the health sector loan, we remain concerned that there are still not sufficient safeguards in place to prevent discrimination in health service provision for lesbian, gay, bisexual, transgender, and intersex (LGBTI) patients, or for women, among other groups in Uganda. In this letter, we share recommendations for the World Bank’s next steps in Uganda and request a meeting with your office as you chart a strategic way forward to ensure that World Bank funding does not entrench discrimination via its loans and other financial instruments. On August 26 during a meeting with the Robert F. Kennedy Center for Justice and Human Rights and Sexual Minorities Uganda (SMUG), Uganda’s former minister of health and new prime minister, Dr. Ruhakana Rugunda, made comments that reinforce this concern: he agreed that there is discrimination in the health sector, and that the government is not equipped to monitor the health sector for discrimination or to respond to discrimination when it occurs.
The Anti-Homosexuality Act
As you know, on August 1 Uganda’s Constitutional Court ruled that the Anti-Homosexuality Act was void due to a lack of quorum in parliament during the vote. While we welcome this important ruling, it did not address the substantive rights at jeopardy in the law.
Moreover the Ugandan government has unambiguously indicated that it remains committed to the discriminatory approach and practices that were reflected in the law. For example, the attorney general immediately filed an appeal to the Supreme Court; and while President Museveni has asked for the appeal to be put on hold temporarily, it is only so a ruling party parliamentary committee can determine if and how the law should be returned to parliament anew. Also, since the ruling, several government officials, including President Museveni, have spoken out in favor of the criminalization of the “promotion of homosexuality” which jeopardizes public health work.
The situation in Uganda remains volatile, especially as campaigning for the 2016 elections gets underway. There is a very real possibility all or significant portions of the discriminatory Anti-Homosexuality Act could be passed in parliament again in the next 12 to 18 months. Effectively, the Ugandan government’s pursuit of discriminatory policies against LGBTI people, including in the healthcare sector, is unchanged by the Constitutional Court ruling.
In what appears to be an effort to encourage donors, including the World Bank, to maintain funding to Uganda’s healthcare sector despite the discriminatory environment, the Ministry of Health produced a ministerial directive this year establishing guidelines for health workers who treat LGBTI people. While a written commitment to non-discrimination in the healthcare sector should not be dismissed, this directive is very problematic. 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 directive creates a de-facto “separate but unequal” system for LGBTI people seeking healthcare. It also remains wholly unenforceable in law. It provides no substantive protection to LGBTI people, or to healthcare workers providing services to LGBTI people, nor does it require any substantive action by the government in terms of upholding non-discrimination in the health sector. It should not be seen as meaningful action on the part of the government to address the World Bank’s publicly stated concerns which led to the loan’s delay.
The HIV Prevention and Control Act
Just as worrying, on July 31, President Museveni signed into law the HIV Prevention and Control Act, which not only criminalizes transmission and attempted transmission of HIV but allows for mandatory testing of pregnant women, their partners, and victims of sexual violence; allows certain people including health workers to reveal the HIV status of their patients without their patients’ consent; and enables courts to order the release of individuals’ HIV status without their consent.
Women tested against their will, or whose HIV status may be revealed against their will, may be exposed to potential physical violence from partners who fear or blame them for infection. Not only are the law’s provisions contrary to well-established international best practices of confidentiality, consent and counseling – a bedrock in the fight against HIV – but the well-documented impact of such punitive measures is to drive people away from services and fuel fear and further discrimination.
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. Such action could significantly contribute to mitigating against existing discrimination experienced by LGBTI patients, women, and other marginalized and excluded populations who are at disproportionately high risk of negative health outcomes and poverty.
We recommend that the World Bank:
1. Publicly share the outcome of the World Bank’s independent assessment of the impact of Uganda’s Anti-Homosexuality Act on the proposed $90 million loan.
2. Only fund the health sector through the proposed $90 million loan if it includes
(a) Components funding:
- Routine pre-service and in-service training of the Ugandan health workforce in non-discrimination in service delivery, building on existing training efforts led by civil society;
- Robust monitoring, and supervision measures to enforce expectations regarding non-discrimination, beyond current supervisory structures. This would include, in addition to other mechanisms, independent third party monitoring to identify instances of discrimination;
- Activities to promote all patients’ rights to non-discrimination, confidentiality, privacy, and consent to or to refuse treatment, and to be informed about risk of medical procedures during health service delivery – for example through public messages, health promotion activities, signs in clinics and public places, and other strategic communications efforts (in English and local languages); and
- Measures to determine consumer satisfaction with health service quality.
(b) Loan covenants:
- Prohibiting all forms of discrimination, including on the grounds of gender, sexual orientation, and gender identity, and all other grounds articulated under international law;
- Requiring the government to respect patient confidentiality, privacy, and informed consent to all treatment, which requires being fully informed of the risks involved with medical procedures and medication;
- Requiring that there not be any interference with any civil society or other third party monitoring of health institutions;
3. Through the Global Partnership for Social Accountability and other World Bank civil society funding mechanisms, provide financial support for patient advocates and legal counsel for individuals who face discrimination, breach of confidentiality, or other abuses in health settings;
4. Review Uganda’s new HIV law, in close collaboration with Ugandan civil society and independent experts, and describe mitigating measures the World Bank will take to ensure Uganda’s health systems is strengthened and HIV objectives are achieved given the discriminatory environment, and publish both the review and mitigating measures;
5. Publicly and privately at all levels urge the government to repeal all discriminatory laws and end discriminatory practices, emphasizing the importance of non-discrimination for health and development and emphasize that the government’s lack of progress in this area will increasingly call into question aspects of the government’s relationship with the World Bank.
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. Countries seeking to benefit from World Bank funding should clearly understand that the delay of the loan was not a superficial decision, but rather a serious statement about the deleterious economic impact of discrimination and a precedent-setting decision to stand up for human rights. But that is not possible if the delay is concluded without any substantive progress by government regarding nondiscrimination in the health sector.
We would appreciate the opportunity to discuss the way forward in Uganda with you given the critical World Bank engagement there and the impact of the situation in Uganda on other countries who may benefit from World Bank financial instruments in the future.
Thank you for your consideration of these important issues. We look forward to meeting with you or your staff to take this conversation forward.
Aaron Dorfman, Vice President for National Programs, American Jewish World Service (AJWS)
Kevin Robert Frost, Chief Executive Officer, AmFAR
Chad Dobson, Executive Director, Bank Information Center (BIC)
Moses Mulumba, Executive Director, Center for Health, Human Rights and Development (CEHURD)
Jeff Ogwaro, Coordinator, Civil Society Coalition on Human Rights and Constitutional Law (CSCHRCL)
Mark Bromley, Council Chair, The Council for Global Equality
Asia Russell, Director of International Policy, Health GAP
David Stacy,Director for Government Affairs, Human Rights Campaign
Jessica Evans, Senior Advocate/Researcher for International Financial Institutions, Human Rights Watch
Brant Luswata, Resource Center Manager, Icebreakers Uganda
Wade McMullen, Staff Attorney,Robert F. Kennedy Center for Justice and Human Rights
Frank Mugisha, Executive Director, Sexual Minorities Uganda (SMUG)
Moses Kimbugwe, Programs Director, Spectrum Uganda
Najib Kabuye, Director, Uganda Harmonized Rights Alliance
Kikonyogo Kivumbi, Executive Director, Uganda Health and Science Press Association (UHSPA)
Beyonce Karungi, Director, TransEquality Uganda
World Bank Board of Executive Directors
Hon. Ruhakana Rugunda, Prime Minister, Uganda
Mr. Makhtar Diop, Vice President for Africa, World Bank
Mr. Tim Evans, Health Sector Director, World Bank
Mr. Olusoji O. Adeyi, Sector Manager, Health, Nutrition and Population, Africa, World Bank
Mr. Philippe Dongier, Country Director, Uganda, World Bank
Mr. Moustapha Ndaiye, Country Manager, Uganda, World Bank
Mr. Peter Okwero, Health Specialist, World Bank, Uganda
Mr. Mark Dybul, Executive Director, The Global Fund to Fight AIDS, Tuberculosis and Malaria
Dr. Deborah Birx, U.S. Global AIDS Coordinator