236 Private Sector and Infrastructure March 2004 Findings reports on ongoing operational, economic, and sector work carried out by the World Bank and its member governments in the Africa Region. It is published periodically by the Knowledge and Learning Center on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. http://www.worldbank.org/afr/findings Taming HIV/AIDS on Africa's Roads 1. HIV/AIDS in Africa Social Impacts: breaking down of social cohesion, value systems, the The HIV/AIDS challenges faced by social fabric and traditional coping the African continent are relentless. mechanisms, changes in household · About 16,000 people in the world structure, increased dependency become infected with HIV each ratio and number of orphans. day. · Out of the 40 million HIV/AIDS 2. HIV/AIDS and the transport sufferers in the world, 70 percent sector live in Africa. · More than 20 million Africans Findings of international studies of have now died. the HIV/AIDS pandemic at work places suggest that, the transport · Orphans of HIV/AIDS in Africa are sector is a major vector for the dis- estimated to be more than 12 mil- ease. The reason is simple. People lion. working in the transport sector are · HIV/AIDS has become the lead- mobile, they spend weeks and ing cause of adult deaths in Africa. months away from their families The impacts are severe on the de- and their homes and many satisfy mographic, the economic and the their sexual needs "on the road." social spheres. Migration, short-term or long-term, increases opportunities for sexual Demographic impacts: Increased relationships with multiple partners, child and adult mortality, especially transforming transport routes to in the productive 20­40 year age critical links in the propagation of group, and reduced life expectancy. HIV/AIDS. International studies Findings Economic Impacts: Reduction of la- also suggest that long-haul truck bor force, erosion of productivity, in- drivers are the highest risk group creased sector costs induced by high in the road sector.1 Clearly, social labor turnover, increased recruit- capital is at risk. ment and training costs and per capita growth reduced. In Africa, studies assessing the 2.1 The Corridor Project were established by including in the relationship between transport and The objective of the project is to in- project's governing body the heads HIV/AIDS are still partial and em- crease access along the transport of the national HIV/AIDS programs bryonic. Yet, situational analyses corridor to HIV/AIDS prevention, and/or agencies (as well as repre- undertaken to date suggest that basic treatment, and support and sentation from national transport HIV/AIDS has become a major care services by underserved vulner- ministries). threat to the social capital of the able groups. The project includes five transport sector and to transport op- countries (Nigeria, Benin, Togo, 2.2. The Ethiopia Project (RSDP) erations, but few actions are taken Ghana, and Côte d'Ivoire) organized The objective of the RSDP is to ad- to address the insurgence of the pan- under one institutional framework. dress road sector constraints related demic. Nonetheless, investing ad- The total cost is US$17.9 million of to restricted road network coverage equately in combating HIV/AIDS in which US$ 16.6 million is to be cov- and low standards. With a road den- Africa is now a precondition for all ered by a proposed IDA grant, the sity at 30 km per 1000 sq. km (2002), other development investments to first of its kind. Ethiopia has one of the lowest den- succeed. The target groups are the migrant sity road networks in Africa. To ad- The transport sector faces four population along the corridor and in dress the situation, the Bank as- major challenges: communities at the borders, par- sisted the Government of Ethiopia · Reduction of social capital ticularly: transport sector workers, to formulate a ten­year road devel- · Poor safeguard policies addressing commercial sex workers, travelers, opment program, (1997­2007). The HIV/AIDS at work places civil servants at borders and the lo- program is divided into two phases. · Absence of standard HIV/AIDS cal populations at border towns. For In the first phase (1997­2002) the clauses in works contracts the transport sector, this amounts Bank financed the rehabilitation · Limited sector analytical work on to a significant effort to protect so- and upgrading of ten national trunk HIV/AIDS. cial capital in the sector. There are roads and provided support for three project components: (i) HIV/ strengthening the capacity of the These challenges can be ad- AIDS prevention; (ii) HIV/AIDS Ethiopian Roads Authority (ERA). In dressed. Committed leadership, con- treatment, care and support; (iii) the second phase (2003­2008), the tinuous dialogue with clients, and Project coordination, capacity build- Bank's multi-phase support will con- strategic partnerships could make ing, and policy development. tribute to rehabilitating and upgrad- a difference. The HIV/AIDS pan- Component ii. (HIV/AIDS treat- ing federal roads and regional rural demic is global, but there is a grow- ment), which is critical for the qual- roads.Alsounderthisphase,thepro- ing consensus that solutions should ity of life of sufferers, consists of: (a) gram aims at strengthening its pov- be thought out at the local level, strengthening, where possible, pub- erty alleviating operations and therefore, there is a role for both lo- lic and private health care facilities thereby contributes to the realiza- cal and national leaderships. along the corridor to provide services tion of the Millennium Development Against this background, the Af- in the areas of Voluntary Counsel- Goals. Over the two-phase program, rica Region Transport Group ing and Testing (VCT), treatment of about 50,000 people are expected to (AFTTR) acted to promote measures STIs, and treatment of HIV/AIDS op- be employed in the program, includ- against HIV/AIDS-- namely, it (a) portunistic infections; (b) providing ing many to be engaged by interna- prepared an HIV/AIDS framework grants to Civil Society Organizations tional contractors. for the sector: AIDS and Transport in (CSOs) including NGOs and the pri- Most of them will be short-term Africa: A Framework for Meeting the vate sector, to undertake commu- migrants, commuting from project Challenge; (b) drafted standard nity based initiatives in HIV/AIDS site to project site, and presumed to clauses for works contracts; (c) ret- care and support; and (c) supporting satisfy part of their sexual needs "on rofittedtransportprojects,e.g.,Ethio- the disposal of medical waste related the road." This would most likely ex- pia; and (d) supported preparation of to project activities. pose them and others to HIV/AIDS. the Corridor Project. Linkages with the Bank's Multi- Ethiopia has one of the highest num- Country HIV/AIDS Program (MAP) ber of people infected with HIV AIDS in Africa, about 10­11 percent of the credits, was applicable since the engineers, lawyers, financial ana- 66 million population. project was regional and it was a lysts, and other technicians. Confronted with this challenge, grant. Who would be the recipient of Response of the Corridor Project the Bank Project Team initiated, the funds? Who would pay back the team. To secure project preparation together with the Ethiopian Roads PPF should the project not be ap- funding, the team applied for the Authority (ERA) through its Environ- proved by the Bank's Board? Japanese PHRD fund to cover costs mental Monitoring Branch (EMB), At the client level, project coun- for the various studies to be con- an HIV/AIDS strategy for the roads tries were accustomed to dealing ducted. In addition, the project team sector (including retrofitting of on- with sector projects within their line also applied for resources from the going projects). The target groups ministries. Thus, an across border Norwegian trust fund to cover costs are ERA staff (about 16,000), project project involving a number of sec- such as hiring of vehicle, purchase related personnel including inter- tors presented a challenge to their of laptops, fuel, and secretarial ser- national contractors and consult- way of working, which was already vices. This was to enable prepara- ants, and local communities at new and not well entrenched in tion to start in parallel to the defini- project camp sites. their practices nor in their country tion and agreement of country roles. The strategy has three compo- experiences. At the client level, the Bank nents: (i) information, education, The Ethiopia Project. Bank policy helped to facilitate the creation of a communication (IEC); (ii) care and towards funding of HIV/AIDS in transitional working group repre- support; (iii) capacity building and transport operations is focused on senting the five countries to spear- policy development. The source of the mitigation of adverse social im- head preparation. A number of op- finance is the MAP. The estimated pacts. HIV/AIDS is an adverse so- tions for an organizational structure total cost of the sector program is cial impact. Yet, a transport HIV/ were reviewed before it was decided about US $ 1.3 million. Linkages AIDS sector strategy did not include to create a small dedicated organi- with the MAP are maintained specific provisions for addressing zation under a conference of minis- through advisory and financial sup- that policy and all project funds had ters. At the same conference, roles portfromthenationalHIV/AIDSpro- been committed. Funding was of the different countries were de- gram. therefore a question mark in the fined which resulted, inter alia, in process of establishing an elaborated the identification of a grant recipi- operational strategy including a ent--i.e., the financial partner for 3. Challenges and responses baseline study addressing risk be- the Bank, Benin. havior and policy, there was a need Response of the Ethiopia Project 3.1 Institutional challenges for extra budgetary resources. The team. First, the team advised the The Corridor Project. A key chal- establishment of the Ethiopia MAP ERA to include HIV/AIDS clauses lenge for the regional project was to was considered an important oppor- into the works contracts. Second, the create capacity where none previ- tunity for leveraging resources. team assisted the ERA to apply for ously had existed and address two At the client level, the issue was funds from the Ethiopian MAP. At key questions. To what extent could how to find staff within the ERA who the client level, the team advised national capacities be harnessed to could be assigned on a fulltime ba- and agreed with ERA to hire consult- this end? Or would a preferred op- sis to work on the HIV/AIDS strat- ants to prepare the strategy and an tion be through the involvement of egy. There was a Medical Branch NGO to implement the work under a regional economic organization within the organization, but this the supervision of the Environmen- and, if so, which one? branch was disconnected from any tal Monitoring Branch in collabora- Added to this was the challenge of health work related to project opera- tion with the Medical Branch. finding the right financial mecha- tions. Supervision of the implemen- nisms for the Bank to support the tation of health clauses in project 3.2 Policy challenges preparation of the project. It was not contracts was carried out by the En- The Corridor Project. None of the clear whether the Project Prepara- vironmental Monitoring Branch and project countries of the Corridor tion Facility (PPF) used in standard the Contract Division, composed of Project had a transport HIV/AIDS sector policy, let alone poli- Table 1: Studies Conducted the HIV/AIDS consultants cies for work places. Like- Project Studies recruited. wise, there were no regu- "Corridor Project" Baseline Survey and Beneficiary Assessment lations governing the Common Policy Framework 3.3 Operational challenges rights of HIV/AIDS-infected Analysis of Elements Impeding the Smooth Circulation of Traffic For both projects, a key op- persons in the sector. In Medical Waste Management Plan erational challenge was addition, although useful, Gender Study how best to address social analytical works conducted Project Implementation Manual capital deficiencies. Gen- by UNAIDS to provide a re- erally speaking, in the gional situational analysis Ethiopia RSDP Baseline Survey, Risk Behavior and Needs ministries of transport and were in need of updates. Assessment in road sector agencies, This did not provide a HIV/AIDS was considered strong basis for the development of Benin would receive the IDA grant a soft issue. Although some engi- common policies which was an es- assistance on behalf of the other neers and technical staff are con- sential objective of the project. countries and could request a PPF versant with the social issues, they Associated with the absence of in their name. At the same time, cannot be expected to execute so- policies was the initial weak and dif- constituency building workshops cial scientific tasks--e.g., conduct fuse ownership of the project. This were organized to strengthen project base line studies or prepare a con- is not uncommon, however, for re- ownership and the multi-sectoral cept paper on HIV/AIDS--because gional projects in Africa, unless the understanding of HIV/AIDS. they don't have the appropriate issues at stake are perceived as of The team helped to draft terms of training or experience. vital and immediate importance to reference for seven basic studies At the ministries of health, HIV/ the project countries. Paradoxically, conducted in the process of estab- AIDS was seen primarily a health perhaps this was not the case of lishing the project work program, issue, yet thousands of new infec- HIV/AIDS in West Africa in spite of funded through a Japanese PHRD tions arise daily and thousands of recent research carried out under Grant. At the client level, the project people are dying despite the health UNAIDS auspices countries contributed through the care provided. To convince transport The Ethiopia Project. As in the recruitment of regional and national sector stakeholders that HIV/AIDS Corridor Project, the client had no consultants to execute the studies is a multi-sectoral issue was, and sectorpolicyontransport­HIV/AIDS and provided a forum in November still is, a daily challenge--even and, consequently, no ownership. 2002 where the study conclusions where in most countries multi- Also, there was no previous analyti- could be reviewed and recommen- sectoral HIV/AIDS commissions are cal work addressing the sectoral re- dations adopted. either established or in the process lationship between transport and The Response of the Ethiopia of being established. HIV/AIDS. Project team. The team advised the Relevant personnel trained to ad- Response of the Corridor Project ERA to carry out a baseline study fo- dress the pandemic from a multi- team. The team worked closely with cusing on risk behavior and needs sectoral perspective are still limited. the transitional working group to assessment within the sector, In addition, the subject still makes initiate and support a Common Dec- helped the client draft the TORs, and people uncomfortable because HIV/ laration, signed by the presidents of continued the HIV/AIDS dialogue. AIDS is considered a private issue the project countries in April 2002, Also, the team assisted the ERA to or a stigma. Model interventions in endorsing the basic principles of the develop a road HIV/AIDS strategy the transport sector need to be de- project: transport­HIV/AIDS; re- framework. veloped, taking account of parallel gional, multi-sectoral under one in- At the client level, ERA manage- experiences in other sectors--first stitutional framework. This re- ment included HIV/AIDS as a per- to get people comfortable in discuss- sulted in the conversion of the group manent subject in its yearly meet- ing the subject, and then to work out into a governing body for the project, ings with staff. HIV/AIDS commit- programs to combat HIV and its which has now a strong political tees were created to guide the Envi- causal factors mandatetoact.Italsoconfirmedthat ronmental Monitoring Branch and At the level of the contracting in- ciologist and a nurse) to start IEC This raises a fundamental question dustry, the problem was similar, work within the ERA while other for all HIV/AIDS projects in the even with international contractors. consultants were executing the transport sector or otherwise: How The Bank's leverage in the struggle baseline study. do we address problems that are ex- against HIV/AIDS in transport periencedbutnotexpressedandprob- project operations is presumed to be 4. Lessons learned lems that are neither experienced nor strongest at design level--that is, to expressed? include HIV/AIDS clauses in bid 4.1 Study/analytical findings documents. However, the Ethiopian · Migration, short-term or long- 4.2 Operational findings experience has shown that, inter- term, increases opportunities for · The HIV/AIDS pandemic has glo- national road consultants and con- sexual relationships with multiple bal impacts, but experience sug- tractors do not necessarily have the partners; and while transport, and gests that solutions should be social capital to implement the especially roads, are an important thought out and applied at the local clauses or the know how to hire ap- vector for HIV/AIDS transmission, level. The guidance of both local and propriate subcontractors to conduct the sector may also be seen as an national leaderships to champion the work. asset in the dissemination of HIV/ interventions is vital for success. Response of the Corridor Project AIDS information. For the transport sector, this means team. The Corridor Project is not · The social capital of the transport that not only national ministries, but yet fully operational. However, to- sector is mobile. People spend weeks sector agencies, transport unions, gether with the project countries, and months away from their fami- and other groups have a role to play. UNAIDS and other donors, the team lies and homes, and tend to satisfy · Contractors and consultants are has helped establish an executive their sexual needs "on the road." not necessarily cognizant of the HIV/ secretariat supported by a Bank-fi- Through this, they become both vic- AIDS pandemic in the country of nanced consultant. The secretariat timsandpropagatorsofbothSTIsand their work. Experience from Ethio- is in the process of putting together HIV/AIDS. Transport sector workers pia shows that they may benefit from an initial operational plan to start are a key group to influence and in- technical assistance in order to de- in 2003. volve in controlling the pandemic. liver and consistently implement To strengthen social capital, re- · Analytical work linking transport HIV/AIDS programs. current training of project stake- and HIV/AIDS is still partial and · The Bank's leverage in the holders in issues related to trans- embryonic. Future projects would struggle against HIV/AIDS in trans- port and HIV/AIDS, is included as benefit from conducting more com- port project operations is presumed part of the project work program. For prehensive analyses, including to be largely at the design phase. But the transport sector this is likely to baseline and impact surveys. the inclusion of HIV/AIDS clauses have two principal elements: devel- · Policies and regulations governing in the bidding documents does not oping HIV/AIDS prevention strate- the HIV/AIDS pandemic in the ensure their implementation. The gies in the transport sector which transport sector are still sketchy. Bank's leverage would benefit from will be national but also coordinated The Bank could make a difference project designs that take into ac- across borders; and facilitating the in helping African ministries of count HIV/AIDS issues during both smooth flow of traffic in cross-bor- transport to develop harmonized the design and the implementation der areas to contribute to the reduc- policies, in the context of regional phases. tion of risk. collaborative programs like the Cor- Also, strengthening the social Response of the Ethiopian ridor Project. capital of the client to ensure ad- Project team. Theteamadvisedand · HIV/AIDS belong to the category equate monitoring/supervision of assisted the ERA in including HIV/ of problems that are experienced but HIV/AIDS clauses in contracts has AIDS reports into road project con- not expressed (because the disease emerged to be the key to successful sultants' monthly project progress embodies a high risk for social implementation. reports. Also at the client level, the stigma), or that are neither experi- · The lead role of the Bank teams in team assisted the ERA to recruit two enced nor expressed because symp- initiating transport­HIV/AIDS dia- national long-term consultants (a so- toms may take time to manifest. logues with the clients has made a This article was written by Antoine difference in raising awareness and 1 See Giraud, P. (1993), "The Impact of Lema, Stephen Brushett, Negede Lewi, John Riverson, Silue Siele, and was creating the possibilities for a AIDS at the Sectoral Level," in Blom, D.E. and Lyons J.V. (eds.), The Econom- originally published as "Africa Trans- higher priority to be given to HIV/ ics of the Implications of AIDS in Asia, port Technical Note No. 35, May 2003. AIDS and for establishing the basis UNDP, New Delhi, and Marcus T. For more information about the Sub- (1997), "Interpreting the Risk of AIDS: of an operational response. First, it A Case Study of Long Distance Truck Saharan Africa Transport Policy helped create a social space that en- Driver's," in Development Southern Af- Program in the Africa Region, contact rica, Vol. 14, No.3. See also the series ssatp@worldbank.org. courages the client to break the si- AIDS BRIEF for Sectoral Planners and lence and the associated stigma, Managers. and take ownership in addressing the issue. Second, clients' owner- ship of transport HIV/AIDS initia- tives encouraged other donors and stakeholders to commit their sup- port to the work.