40513 Our Commitment: The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 November 2007 Document of the World Bank ACRONYMS AND ABREVIATIONS AAP Africa Action Plan ISR Implementation Status Report ACTafrica AIDS Campaign Team for Africa MAP Multi-Country HIV/AIDS AFA World Bank's Africa Region Program for Africa HIV/AIDS Agenda for Action M&E Monitoring and Evaluation AIDS Acquired Immuno-Deficiency MDG Millennium Development Goal Syndrome MIC Middle-income country ART Antiretroviral therapy MOH Ministry of Health ARV Antiretroviral drug MSM Men Having Sex with Men ASAP AIDS Strategy and Action Plan MTEF Medium-Term Expenditure CAS Country Assistance Strategy Framework CCM Country Co-ordination NAC National AIDS Mechanism Committee/Council CDMAP Africa Capacity Development NGO Non-Governmental Organization Management Action Plan OECD Organization for Economic DEC Development Economics Vice- Co-operation and Development Presidency, World Bank Group OED World Bank's Operations and DFID Department for International Evaluation Department Development, United Kingdom OVC Orphans and Vulnerable Children GFATM Global Fund to Fight AIDS, PEPFAR President's Emergency Plan for Tuberculosis and Malaria AIDS Relief GHAP Global HIV/AIDS Program of PER Public Expenditure Review Action PLWHA People Living with HIV/AIDS GIST Global Implementation and PREM Poverty Reduction and Economic Service Team Management Network HD Human Development PMTCT Prevention of Mother to Child HIV Human Immuno-Deficiency Virus Transmission. HNP Health, Nutrition, and Population PRSC Poverty Reduction Strategy Credit HR Human Resources PRSP Poverty Reduction Strategy Paper IBRD International Bank for SRH Sexual and Reproductive Health Reconstruction and Development, SWAp Sector-Wide Approach World Bank Group TA Technical Assistance ICR Implementation Completion TB Tuberculosis Report UNAIDS Joint United Nations Program on IDA International Development HIV/AIDS Association, World Bank Group UNDP United Nations Development IDF Institutional Development Plan Program IDP Internally Displaced Populations UNHCR United Nations High Commission IEC Information, Education, on Refugees Communication UNICEF United Nations Children's Fund IEG World Bank's Independent USAID United States Agency for Evaluation Group International Development IFC International Finance WBI World Bank Institute Corporation, World Bank Group WHO World Health Organization Vice-President of Africa Region: Obiageli Katryn Ezekwesili Manager: Elizabeth Lule Task Team: Daniel Ritchie, Richard Seifman, Nadeem Mohammad, John Nyaga, Frode Davanger, Sangeeta Raja, Cassandra De Souza, Antonio C. David, Albertus Voetberg and Carolyn Shelton The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 TABLE OF CONTENTS FOREWORD .......................................................................................................................................................... i ACKNOWLEDGEMENTS................................................................................................................................ ii EXECUTIVE SUMMARY .................................................................................................................................iv 1. INTRODUCTION ................................................................................................................................ 1 2. THE DIAGNOSIS................................................................................................................................. 3 3. THE BANK'S RESPONSE TO DATE ............................................................................................ 9 4. STRATEGIC CHALLENGES IN THE NEW ENVIRONMENT.......................................... 13 5. THE AGENDA FOR ACTION 2007-2011................................................................................... 20 6. OPERATIONAL IMPLICATIONS FOR THE BANK............................................................. 33 7. CONCLUSION .................................................................................................................................... 37 8. REFERENCES..................................................................................................................................... 38 9. ANNEXES ............................................................................................................................................ 40 ANNEX 1 ­ HIV Prevalence, Income, Access to Treatment and Quality of Health Services in sub-Saharan Africa in 2006...........................................41 ANNEX 2 ­ The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations.................................................................43 ANNEX 3 ­ MAP Achievements...............................................................................50 ANNEX 4 ­ Africa Response to HIV/AIDS: A Chronology of Events..........................52 ANNEX 5 ­ Agenda for Action Consultations ............................................................54 ANNEX 6 ­ Agenda for Action: Implementation Plan and Results Framework................................................................................58 ANNEX 7 ­ HIV/AIDS Portfolio for Africa (1989-2007) ............................................68 ANNEX 8 ­ The HIV/AIDS Results Scorecard ..........................................................73 ANNEX 9 ­ The Bank's Role in the UNAIDS Division of Labor..................................76 ANNEX 10 ­ MAP challenges and Improving Performance of the Multi-Country AIDS Program (MAP) for Africa......................................................................77 ANNEX 11 ­ HIV Prevalence and Global Financing.....................................................79 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 TABLES AND FIGURES Table 1: Ten Most Common Causes of Mortality and Morbidity in sub-Saharan Africa......................3 Figure 1: Increasing number of persons living with HIV, especially in sub-Saharan Africa ..................3 Figure 2: The Heterogeneity of HIV in Africa...............................................................................................5 Figure 3: Changes in life expectancy at birth in selected African countries with high and low HIV prevalence: 1965-2005 .......................................................................................................................6 Table 2: Funding Sources and Commitments to MAP Countries...........................................................13 Table 3: Resource Needs for Universal Access in Millions of US$ (2007-2011)..................................14 Figure 4: Active HIV/AIDS Commitments by Sector Board...................................................................18 Figure 5: Global Funding for HIV/AIDS in the Top 10 High Prevalence African Countries ...........20 Figure 6: World Bank HIV/AIDS Lending in Africa FY00-FY07 ..........................................................21 Figure 7: World Bank HIV/AIDS Agenda for Action in Africa Conceptual Framework...................23 Table 4: Country Types and HIV/AIDS Typology...................................................................................26 Table 5: Possible Differentiated Responses ................................................................................................27 Table 6: Foundation........................................................................................................................................30 Table 7: Pillar 1 - Focus the Response Through Evidence-Based and Prioritized HIV/AIDS Strategies............................................................................................................................................30 Table 8: Pillar 2 - Scale Up Targeted Multi-sectoral and Civil Society Responses................................31 Table 9: Pillar 3 - Deliver Effective Results Through Increased Country M&E Capacity..................31 Table 10: Pillar 4 - Harmonize Donor Collaboration..................................................................................31 Table 11: HIV Prevalence, Income, Access to Treatment and Quality of Health..................................41 Table 12: Life Expectancy at Birth for Selected sub-Saharan African Countries (1965-2005) .............42 Figure 8: Life Expectancy at Birth for Selected sub-Saharan African Countries (1965-2005) .............42 Figure 9: Universal Access to Treatment Number of Deaths Averted (2007-2030) .............................44 Figure 10: Universal Access to Treatment: Cumulative Number of Life Years Gained in sub-Saharan Africa 2007-2011 .......................................................................................................45 Figure 11: Infections Averted Due to Prevention Efforts in sub-Saharan Africa 2007-2011................46 Table 13 & 14: Cross-classification of Interventions by Cost-effectiveness and Impact..........................47 Table 15: Summary of Studies on Cost Effectiveness of HIV/AIDS Interventions in sub-Saharan Africa..................................................................................................................................................48 Figure 12: Number of OVC in sub-Saharan Africa.......................................................................................49 Table 16: Systems Strengthing.........................................................................................................................50 Table 17: Outcome Level Results to which MAP Has Contributed.........................................................51 Table 18: Africa Response to HIV/AIDS, A Chronology of Events......................................................52 Table 19: Agenda for Action Consultations..................................................................................................54 Table 20: The Foundation - Renew the Commitment ................................................................................58 Table 21: Pillar 1 -Strengthened Long-Term Sustainable National Response.........................................60 Table 22: Pillar II - Accelerated Implementation of HIV/AIDS Programs............................................62 Table 23: Pillar III - Strengthened National Systems...................................................................................65 Table 24: Pillar IV - Strengthened Donor Coordination.............................................................................67 Table 25: Closed MAP and Stand Alone Projects........................................................................................68 Table 26: Closed Projects with HIV/AIDS Components..........................................................................68 Table 27: Active MAP and Stand Alone HIV/AIDS Projects...................................................................70 Table 28: Active Projects with HIV/AIDS Components...........................................................................71 Table 29: The HIV/AIDS Results Scorecard ...............................................................................................74 Table 30: World Bank Role in UNAIDS' Technical Support Division of Labor...................................76 Table 31: Overview of the Key Recommendations.....................................................................................77 Table 32: HIV Prevalence and Financing by Country.................................................................................79 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 FOREWORD HIV/AIDS is an unprecedented development and human challenge, especially in Africa. In many countries, the pandemic has cut life expectancy and robbed society of millions in their prime working years. It has dimmed the hope of living full and productive lives for millions of infants and young adults. The World Bank, an institution dedicated to the reduction of poverty worldwide, was one of the first organizations to respond to the HIV/AIDS emergency. Since 2000, it has provided over $1.4 billion to more than 30 countries in sub-Saharan Africa to combat the epidemic. The World Bank has helped put in place the foundations of an effective response--a governance structure, strategic direction, a multi-sectoral approach, community engagement and programs for prevention, treatment and care. World Bank support has also helped mobilize significant new funding for HIV/AIDS and harmonize collaboration among donors. Today, we have a better understanding of the epidemic and its transmission than at any time in the past. We now know that it is not one but several different epidemics. We are more conscious that this horrific scourge has disproportionately hit women and young girls, who need the legal, social, and economic power to protect themselves, access treatment and care, reverse infection, and stem stigmatization. And we have seen funding for HIV/AIDS quadruple over the past four years. HIV/AIDS remains the leading cause of premature death and a major threat to development in Africa. The World Bank is working vigorously together with the peoples of Africa - the communities, their national leaders and external partners ­ to find solutions to this scourge which is an attack on our common humanity. For this reason, the Bank rededicates itself to a long-term engagement in fighting HIV/AIDS in Africa. The title of this report is appropriate: Our Commitment: The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011. This Agenda for Action reaffirms the Bank's determination to remain a full partner in the fight against HIV/AIDS through the provision of funding, analytical support, capacity development and knowledge sharing. The Bank will use its convening power and other technical resources to combat the pandemic, including in the countries of southern Africa - the epicenter of HIV/AIDS - that are not eligible for IDA. The Bank will also focus on the strategic response, monitoring and evaluation to enhance effectiveness, the multi- sectoral approach and harmonization with other development partners. Together - as governments, communities, individuals, the private sector, development partners and donors- we must halt and begin to reverse the spread of HIV/AIDS. Let me end by thanking the many colleagues and partners around the world who have contributed their ideas and suggestions in shaping the Agenda for Action. Let me also thank the staff of the Bank, The Global HIV/AIDS Program (World Bank), the Africa Region, and ACTafrica for their persistence and patience in articulating this Agenda. Along with the Africa Action Plan, the World Bank Global HIV/AIDS Program of Action, and the Bank's Strategy for Health, Nutrition and Population Results (Healthy Development), this Africa Region HIV/AIDS Agenda for Action will help focus our effort, reaffirm the Bank's determination and contribute to the dream of an Africa liberated from the devastation of AIDS. Obiageli Katryn Ezekwesili Vice President, Africa Region i The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ACKNOWLEDGEMENTS The HIV/AIDS Agenda for Action team was led by Elizabeth Lule, Manager of the AIDS Campaign Team for Africa (ACTafrica), and included Daniel Ritchie, Richard Seifman, Nadeem Mohammad, John Nyaga, Frode Davanger, Sangeeta Raja, Cassandra De Souza, Antonio C. David, Albertus Voetberg and Carolyn Shelton. Support was provided by Therese Cruz, Mohammad Javed Karimullah and Annette Minott. The Agenda for Action was prepared under the guidance of John Page, (Chief Economist, AFRCE), Gerard Byam (Director, AFTQK), Yaw Ansu (Sector Director, AFTHD), and Debrework Zewdie (Director, HDNGA). Several individuals contributed to the development of the Agenda for Action, and all are thanked generously for committing their time, efforts, ideas, and experience. Consultations were held with a broad constituency over several months, including governments and country counterparts, civil society and PLWHAs (Nairobi, May 2006); bilateral donors (London, October 2006); the international HIV/AIDS community (Toronto, August 2006); multilateral development partners (New York, September 2006;, Geneva, October 2006; Johannesburg, November 2006; Dakar, January 2007); World Bank managers and staff (Washington, DC, September-December 2006); GFATM managers and staff (Geneva, September 2006); and country counterparts and youth (Johannesburg, February 2007). Well over 1,000 people from over 35 countries and many institutions participated in the Agenda for Action deliberative process. The lion's share was provided by our client countries in sub-Saharan Africa. They were representatives --at all levels-- of their communities, religious groups, local NGOs, research institutes, universities, the private sector, labor federations, local and national governments, and people living with HIV and AIDS (PLWHA). The entire gamut of age, profession, and gender spoke knowledgeably, frankly and with passion to us about the role of the Bank and their battle to overcome HIV/AIDS. We are very grateful for the inputs received from our external partners and the valuable insights provided by representatives of UNAIDS and its co-sponsors, other international organizations, bilateral and multilateral donors, governments of recipient countries, faith-based and civil society organizations, PLWHA, youth, international and national NGOs, foundations, research institutions, and the private sector. The consultations encompassed participants from many partner institutions, including: Christopher Armstrong (CIDA, Canada), Chris Austin (DFID, UK), Andrew Ball (WHO), Mazewa Banda (WHO), Ellie Bard (DFID, UK), Christophe Benn (GFATM), Andrew Berg (IMF), Jochen Bohmer (Ministry of Economic Development, Germany), Reina Buijs (DSI, the Netherlands), Thea Christiansen (Ministry of Foreign Affairs, Denmark), Clement Chan-Kam (WHO), Veronique Collard (WHO), Akinyele Dairo (UNFPA), Benedict David (DFID, UK), Jean Christophe Deberre (Ministry of Foreign Affairs, France), Mario Dolpoz (WHO), Norbert Dreesch (WHO), Duncan Earle (GFATM), Emma Fraser (DFID, UK), Robin Gorna (DFID, UK), Frederik Goyet (Ministry of Foreign Affairs, France), Lennarth Hjelmaker (Ministry of Foreign Affairs, Sweden), Lisa Kaalund-Jorgensen (Ministry of Foreign Affairs, Denmark), Louisiana Lush (DFID, UK), Amal Medani (GFATM), Jane Miller (DFID, UK), Asha Mohamud (UNFPA), Nosa Orobaton (GFATM), Mary Otieno (UNFPA), Mark Pearson (HLSP, UK), Sue Perez (RESULTS, US), Tim Poletti (AusAID, Australia), Jo Ruwende (DFID, UK), Daisuke Sakai (Japanese Embassy, London), Anita Sandstrom (Swedish Embassy), Mark ii The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Schreiner (UNFPA), Bernard Schwartzlander (GFATM), Clare Shakya (DFID, UK), Anne Skjelmerud (NORAD, Norway), Paul Spiegel (UNHCR), Mats Svensson (SIDA, Sweden ), Lia von Wantoch (US Embassy, London), Bruce Waring (HLSP, UK), and Sibili Yelibi (UNFPA), and Paul Zeitz (Global AIDS Alliance, US). A concept note was developed and reviewed by a team of World Bank staff in July 2006. In addition, a preliminary draft was circulated and reviewed at a decision meeting in April 2007. We especially thank the participants at these meetings in Washington, D.C., who took time to provide numerous comments and inputs that helped shape the final draft of the document. The following internal and external peer reviewers deserve particular praise for their commitment, insightful suggestions and attention to detail when analyzing previous drafts of the Agenda for Action. From the World Bank Group staff, the reviewers included Cristian Baeza (HDNHE), Christopher Walker (AFTH1), Hartwig Schafer (AFRVP) and Irene Xenakis (AFRVP). External peer reviewers were Fama Ba (UNFPA), Geeta Rao Gupta (ICRW), Sigrun Mogedal (Ministry of Foreign Affairs, Norway), Babatunde Osotimehin (NACA, Nigeria), Kristan Schoultz (UNDP), and Michel Sidibe (UNAIDS). We also thank the following colleagues from within the Bank as well as other institutions for their contributions and valuable feedback at different stages in the elaboration of the document: Martha Ainsworth (IEG), Beldina Auma-Owuor (AFREX), Evelyn Awittor (AFTH2), Mark Blackden (AFTPM), Rene Bonnel (HDNGA), Eduard Bos (HDNHE), Mario Bravo (EXTCD), Jonathan Brown (HDNGA), Donald Bundy (HDNED), Joy de Beyer (HDNGA), Jean Delion (AFTS2), Shantayan Devarajan (SAR), Aissatou Diack (AFTH2), Sheila Dutta (AFTH1), John Elder (AFTH3), Helen Evans (GFATM), Laura Frigenti (AFTH3), Rui Gama Vaz (WHO), Teguest Guerma (WHO), Keith Hansen (LCHH), Astrid Helgeland-Lawson (OPCIL), Janet Leno (HDNGA), Montserrat Meiro-Lorenzo (AFTH3), John May (AFTH2), Michael Mills (AFTH1), Norbert Mugwagwa (AFTHD), Dzingai Mutumbuka (AFTH1), Elizabeth Mziray (HDNGA), Francois Nankobogo (AFTPS), Robert Oelrichs (HDNGA), Judy O'Connor (AFCE1), John Page (AFRCE), Ok Pannenborg (AFTHD), Ritva Reinkka (AFCS1), Khama Rogo (AFTH3), Onno Ruhl (AFTRL), Jocelyn do Sacramento (AFTTR), Miriam Schneidman (AFTH3), Sudhir Shetty (AFTPM), Siele Silue (AFTTR), Bina Valaydon (AFTHV), and Guiseppe Zampaglione (AFTH2). We are also grateful to those who conducted the analytical work that forms the foundation for the Agenda for Action. These thoughtful efforts were our guiding lights during the elaboration of this five year HIV/AIDS Agenda for Action for the Africa region. In addition to the members of the core team (acknowledged above), the following individuals deserve recognition: Katrine Anderson (PREMGE), Jorge Arbache (AFRCE), Victor Barnes (Corporate Council on Africa), Lori Bollinger (Futures Institute), Esther Dassanou (Corporate Council on Africa), Arunima Dhar (PREMGE), Clare Dickinson (DFID, UK), Ken Grant (DFID, UK), Markus Haacker (IMF), Caroline Hope (Corporate Council on Africa), Paul Jensen (RESULTS), Lucy Keough (HDNDE), Josette Malley (PREMGE), Lana Moriarty (PREMGE), Waafas Ofosu-Amaah (PRMGE), John Stover (Futures Institute), Marisa van Saanen (HDNDE), Katherine Tulenko (ETWWP), and David Wilson (HDNGA). We wish to specially acknowledge the generous support of the Government of Norway, through the Ministry of Foreign Affairs and the Norwegian Agency for Development Cooperation, for its significant contribution in financing the preparatory process of this Agenda for Action. iii The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 EXECUTIVE SUMMARY The World Bank is committed to support sub-Saharan Africa in responding to the HIV/AIDS epidemic. This Agenda for Action is a road map for Bank management and staff over the next five years to fulfill that commitment. It underscores the lessons learned and outlines a line of action. HIV/AIDS remains--and will remain for the foreseeable future--an enormous economic, social and human challenge to sub-Saharan Africa. This region is the global epicenter of the disease. More than 25 million Africans are HIV positive, and AIDS is the leading cause of premature death on that Continent. HIV/AIDS affects young people and women disproportionately. 60% of those who are HIV positive are women, and young women are three times as likely to be HIV positive as young men. Due to the pandemic, there are an estimated 12 million children under the age of 18 who have lost at least one parent. Its impact on households, human capital, the private sector and public sector undermines the alleviation of poverty, the Bank's overarching mandate. In sum, HIV/AIDS threatens the development goals in the Region unlike anywhere else in the world. The Background The World Bank launched the first major global response to the disease in sub-Saharan Africa in 1999. It helped put in place the foundations of the response: national strategies, a governance structure, and systems for monitoring and evaluation. It promoted a multi-sectoral response by focusing on HIV/AIDS as a development issue and by engaging both local communities and the private sector. By November 2007, the Bank had provided US$1.5 billion for HIV/AIDS programs in over 30 countries, including 29 Multi-country HIV/AIDS Program (MAP) for African countries and 5 regional projects to address cross-border issues. The MAP, approved in 2000, was envisaged as a 15-year commitment by the Bank to be implemented in three stages. The first stage would be an "emergency response," which entails putting in place essential structures, policies and capacity, working with communities in delivering services, better understanding implementation dynamics, and generally, learning by doing. Stage two would scale up and mainstream prevention, treatment and care, based on evidence of effective innovation. Stage three would focus on areas or groups where the spread of the disease continued. During the first phase, the MAP built political commitment and enabled countries to begin implementing decentralized multi-sectoral national programs while strengthening institutions and accountability. This had an immediate impact on program coverage and paved the way for rapid expansion as other funding became available in later years. The MAP contributed to health systems strengthening, started several cross-border projects to address most at-risk populations and helped increase access to treatment. Recognizing that HIV requires changes in norms, beliefs, perceptions, and social and individual behavior, the MAP mobilized communities to provide an enabling environment. Since the MAP was launched, and partly due to its implementation, there have been major developments in the global response to the pandemic. Global funding for HIV/AIDS has grown dramatically--from US$1.6 billion in 2001 to US$8.9 billion in 2006 globally--with the creation of the iv The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM), the US President's Emergency Plan for AIDS Relief (PEPFAR) initiative, and the involvement of other donors. In 2005 the Gleneagles Summit endorsed the concept of aiming as close as possible to universal access. Universal access to effective prevention services would reduce the number of new infections from 3.5 million per year to 1.25 million at a cost between US$2,000 to US$3,000 per infection averted. By continuing to expand access to treatment, almost 1 million deaths will be averted annually by 2011. Conversely, inaction will have devastating consequences: 10 million new deaths and 14 million newly infected persons by 2011, an increase of 50 percent from 2006. There are positive indications of future increases in donor commitments to work towards achieving the universal access goal. Nevertheless, an estimated US$18 billion is needed to combat the disease in 2007 alone, with much of that funding needed for sub-Saharan Africa. Moreover, the GFATM, PEPFAR, and other donor institutions, including the International Development Association (IDA), are dependent on replenishments, with no certainty about the levels of future funding. Furthermore, access to treatment has expanded, thanks in part to a reduction in the costs of ARVs. Today, slightly more than one-quarter of Africans in need of treatment are on ARVs. Efforts to harmonize the international response were intensified under the UNAIDS banner of the "Three Ones1." Finally, prevalence rates are declining in some countries and communities. Continuing Challenges At the same time, the HIV/AIDS epidemic faces major strategic challenges, including: · ensuring an appropriate balance between prevention, treatment and mitigation interventions, · addressing human resource shortages and long-term fiscal sustainability of HIV/AIDS programs, especially in light of the commitment to universal access to prevention and treatment, · tackling the continuing crisis with health systems and linkages with other diseases (such as TB and malaria) as well as reproductive health, essential for an effective HIV/AIDS response, · mitigating gender inequalities that increase the vulnerability and risk of women to HIV, and · managing the complexity of the global aid architecture for HIV/AIDS. The first stage envisaged under the MAP program has effectively ended. In developing the next phase of support, the Africa Region faces its own challenges in sustaining its engagement. Dedicated grant funding from IDA is no longer available, and the next generation of projects must compete with infrastructure, education and other national priorities for scarce IDA resources. Moreover, in southern Africa, the epicenter of the disease, most countries are not eligible for IDA funding and are reluctant to borrow on harder International Bank for Reconstruction and Development (IBRD) terms. While the relative funding role of the World Bank (currently about 7 percent of new funding for HIV/AIDS in Africa) diminishes, other donors, development partners, NGOs and beneficiaries have cited unique contributions by the Bank to the fight against the epidemic, contributions that they wish to see continued and enhanced. In consultations on the Agenda for Action, these groups underscored 1One national strategic plan, one coordinating body and one M&E national framework. v The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 the Bank's (i) macroeconomic focus, i.e., treating HIV/AIDS as a development issue, (ii) multi-sectoral engagement, (iii) capacity-building experience, (iv) convening power, and (v) ability to form partnerships with communities and the private sector. The Bank's challenge now is to shift its emphasis from principal financier to facilitator and knowledge contributor. One of the explicit future strategic roles of the Bank is in dealing with global public goods; the fight against communicable diseases is a crucial component of this role. In this context, lies another reason for continued World Bank engagement in HIV/AIDS. The Bank needs to expand its knowledge-base and continue the learning process in how to effectively address global epidemics. Future Actions for the Bank The HIV/AIDS Agenda for Action 2007-2011 represents the Africa Region's next stage in its engagement on HIV/AIDS in Africa. The foundation of the AFA is our renewed commitment to remain actively engaged in combating the disease. A principal goal of the AFA is to reaffirm the Bank's promise to devote its resources to help halt and begin to reverse the spread of HIV/AIDS, one of the Millennium Development Goals. This reaffirmation would be demonstrated by the endorsement of the AFA by the Bank senior management and Executive Directors. The Bank would commit itself to (i) provide at least US$250 million per year for support to HIV/AIDS initiatives, based on client demand; (ii) work to establish an HIV/AIDS grant Incentive Fund of $5 million annually to promote capacity building, analysis and HIV/AIDS project components in education, transport and other projects; and (iii) expand and find innovative ways to engage in middle income countries at the epicenter of the disease in southern Africa, as well as with fragile States and through regional initiatives. The Agenda rests on four pillars that reflect the critical challenges--as much human and institutional as financial--for the next generation of support: · Pillar 1: Focus the response, through evidence-based and prioritized HIV/AIDS strategies. Through its unique analytical and advisory role, the Bank will help embed HIV/AIDS as a development priority; undertake diagnostics of modes of transmission, effective interventions for prevention, and assistance to vulnerable groups; support differentiated responses; recognize the crucial linkages with the health system as well as TB, reproductive health, malaria and nutrition; and help integrate these considerations into the HIV/AIDS agenda. This emphasis on "learning and sharing" is reflected in each of this Agenda's Pillars. · Pillar 2: Scale up targeted multi-sectoral and civil society responses. The World Bank is uniquely placed to promote the multi-sectoral response and, working with communities, to address the HIV/AIDS challenge. The next generation of Bank support will emphasize efforts to strengthen health systems, education (especially for orphans and vulnerable children), school-based prevention programs, gender equality, and to foster private-public partnerships. · Pillar 3: Deliver more effective results through increased country M&E capacity. The World Bank will continue to help strengthen M&E frameworks in the effort to enhance the efficiency, effectiveness and transparency of the HIV/AIDS response. This effort will contribute to improving existing structures of governance, public sector management, vi The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 community-level transparency, and accountability. The Bank will work to assist local and central government structures in improving implementation performance. The results of the Bank's contribution to the HIV campaign also must be measured and reported. · Pillar 4: Harmonize donor collaboration. The Africa Region will work with its key partners to make harmonization and alignment of the global response more effective at the country level in Africa. The Region will carry out joint planning and analytical work and participate in annual joint meetings with UNAIDS and other partners. It will seek to ensure that all partners operate within the framework of the "Three Ones." Building on lessons learned, the Agenda for Action will use a more selective, strategic focus. The Agenda will center on strong partnerships with governments, communities, the private sector, donors and other development partners and apply the Bank's unique strengths--focus on development, multi- sectoral and civil society engagement, analytical capacity, flexibility, ability to fill gaps, and capacity to serve as a source of long-term, predictable finance. Implications for the Africa Region Work Program The actions described above will require a shift over time in the work program of the Region. There will be a need to continue to give greater attention to HIV/AIDS as a development and poverty issue in the Bank's national dialogue with countries and in the relevant instruments. Strengthening links with health sector systems, as well as specific diseases such as TB and malaria, will take on greater priority. Mainstreaming and retrofitting of HIV/AIDS in sectoral products will be of increasing importance, with analytical support provided by an HIV/AIDS team and resources from the Africa HIV/AIDS Incentive Fund. Capacity building of national HIV/AIDS authorities to improve fiduciary implementation, and monitoring and evaluation support will also require heightened attention. What will be required of staff and management is commitment to pursue this Agenda for Action. Human and financial resources will also be required to support the HIV/AIDS specialized dedicated team as well as contributions from country and sector units. While the HIV/AIDS team would continue to provide key specialized and quality assurance support, the team will also depend on sector specialists and researchers from different units of the Bank to strengthen key sectoral responses. There are those who say that HIV/AIDS is over-funded relative to other diseases and that the Bank should refocus on other priorities. Others say the Bank has reneged on its commitment to stay engaged until the disease is brought under control. The realities are that the Bank brings to the international response strengths that no other organization possesses, that HIV/AIDS receives less than half the funding needed to meet the commitment to universal access, and that HIV/AIDS threatens the well-being of the Continent like no other single challenge. For these reasons, the Agenda for Action focuses the Bank's engagement on its strategic strengths and helps ensure a harmonized and effective global response. The audience of the report is the World Bank's Board of Directors, senior management and staff of the Africa Region. vii The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 1. INTRODUCTION 1.1. This is not a conventional strategy document. We have deliberately titled it Our Commitment: World Bank Africa Region HIV/AIDS Agenda for Action 2007-2011 to underline the importance of actions the Bank needs to take to continue to play a significant role in combating the HIV/AIDS epidemic in Africa. 1.2. HIV/AIDS is not a conventional disease. It is the largest single cause of premature death in Africa. With an average incubation period of eight years, the dimensions and the future consequences of the disease are not well known. Slightly more than a quarter of the Africans requiring treatment are currently being treated, but the promise of "universal access" to treatment and prevention has major financial and health care implications. Stigma and discrimination remain major obstacles to an effective response. 1.3. Nor is Africa a conventional region. National health systems are overwhelmed by numerous health challenges, and the capacity to respond and manage the overall health burden is often extremely limited. Most governments lack the fiscal space to cope with the funding of HIV/AIDS programs in the absence of external finance, which tends to be volatile and unpredictable. 1.4. We recognize that strategies are only useful to the extent that they meet three criteria: (i) client demand, (ii) client capacity, and (iii) the ability of the Bank to meet technical and resource demands. From our extensive consultations, we believe there is considerable demand for the Bank's continued active engagement from member countries, other development partners and service providers, such as civil society organizations. At the same time, we believe the Bank needs to reorient and retool its own effort to ensure it provides effective, efficient and sustainable support to containing the epidemic in the next five years. The principal audience of this report is the World Bank's Board of Directors, senior management and staff. 1.5. The Agenda for Action (hereafter "the AFA") has four principal objectives: · Reaffirm the World Bank's commitment to long-term support for HIV/AIDS control in Africa · Articulate the comparative advantages of the Bank in a harmonized international program of support and, consequently, the potential role for the Bank · Identify priority interventions for the next generation of activity, whether funded by the Bank or others, based on evidence of success and lessons of experience · Specify actions the Bank will need to take to ensure it can respond to the demands of member countries and other partners for financial, technical, analytical and collaborative support 1 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 1.6 The AFA articulates a program of support which fits squarely within the Bank corporate strategic priorities, as articulated by World Bank President Zoellick, in October 2007. It honors, reinforces and translates into discrete actions the six corporate strategic directions of the Bank's Global HIV/AIDS Program of Action (GHAP), the Africa Action Plan (AAP), the Africa Capacity Development Management Action Plan (CDMAP), and Healthy Development: The World Bank's Strategy for Health, Nutrition and Population Results (HNP). It focuses on mainstreaming HIV/AIDS activities into broader national development agendas as a critical aspect of economic growth and human capacity development. In preparing the Agenda for Action, consultations have been carried out over several months with a broad constituency, including countries, donors, communities, civil society, non-governmental and non-profit organizations2. 2Countries, civil society and PLWHAs (Nairobi, May 2006), bilateral donors (London, October 2006), the international HIV/AIDS community (Toronto, August 2006), multilateral development partners (New York, September, 2006, Geneva, October 2006, Johannesburg, November 2006 and Dakar, January 2007), World Bank managers and staff (Washington, DC, September-December 2006), GTAFM managers and staff (Geneva, September 2006), and Countries and Youth (Johannesburg, February 2007). See Annex 5 for details. 2 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 2. THE DIAGNOSIS The Epidemiology of HIV/AIDS in sub-Saharan Africa 2.1. HIV/AIDS remains an enormous economic and human challenge in Africa. It is the single greatest cause of death in the Region, responsible for more than 20 percent of total deaths in 2000 (see Table 1 and World Bank, 2006a). 2.2. Nearly 25 million Africans are living with HIV/AIDS, the vast majority of them adults in the prime of their working and parenting lives (UNAIDS, 2006 and Figure 1). Despite a peaking of new infections and a decline in prevalence in some countries, more than two million people-- about 5,000 per day--died from the disease in 2005 (UNAIDS, ibid.). Table 1: Ten Most Common Causes of Mortality and Morbidity in sub-Saharan Africa The 10 Most Common % of Total % of Total Disability-Adjusted Causes of Death Deaths in 2000 Life Years for the Region in 2001 HIV/AIDS 20.4 17.8 Malaria 10.1 10.3 Lower respiratory infections 9.8 8.4 Diarrheal diseases 6.5 6.1 Perinatal conditions 5.1 6.3 Measles 4.1 4.6 Cerebrovascular disease 3.3 Not available Ischemic heart disease 3.1 Not available Tuberculosis 2.8 2.4 Road traffic accidents 1.8 1.8 Source: World Bank (2006a) and Mathers et al. (2006) Figure 1: Increasing number of persons living with HIV, especially in Sub Saharan Africa Source: UNAIDS (2006) 3 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 2.3. Since 1999, when the World Bank published its first call to action, more than 10.5 million people have died from AIDS, erasing many of the development gains of the past generation and now threatening the gains of the next. AIDS also threatens the realization of the Millennium Development Goals. During the past decade, the disease has evolved and is today better understood. We know that it affects women and young people disproportionately. We also know that it is not one but several epidemics. The means of transmission have been more clearly established and, consequently, the responses more differentiated. 2.4. The human tragedy behind the numbers is enormous. In 2005, an estimated 2 million children younger than 15 years of age were infected with HIV (UNAIDS, 2006) and about 12 million African children under the age of 18 were either single or double orphans due to parental deaths from AIDS. The disease has deprived countries of their scarcest human capital. Zambia, for example, loses half as many teachers annually as it trains (Grassley et al, 2003). Private firms in some countries, especially in Southern Africa, recruit two workers for every job in anticipation of the loss due to the disease. The impact of the epidemic is countrywide, affecting both rural and urban households (UNAIDS, 2006). The feminization of the epidemic 2.5. In Africa, HIV/AIDS is predominately a disease of women and young girls. 60% of those infected are women, and young women in the 15-25 year old age group are three times more likely to be infected than young men in the same age group (UNAIDS, 2006). Because of gender inequalities, women are often more vulnerable. They lack skills or power to negotiate safe sex, including condom use and have poor access to the means to prevent HIV and other sexually transmitted infections (STIs); they are often prone to other sexual and reproductive related health threats to themselves or their children. Women are more likely to face stigma and discrimination than men, including harassment, abuse, violence, and lack rights to productive assets and other property (ICRW, 2006). Hence, the issues of gender inequality and vulnerability create a major barrier to effective HIV/AIDS prevention and treatment programs. Improvements in women's legal rights, opportunities, access to productive assets, workload and individual prevention mechanisms such as vaccines or microbicides will need to be better understood, and more effectively addressed. The impact on children, the young and disabled persons 2.6. Children continue to be the victims of the disease both directly (infected) and indirectly (stigmatization or the loss of a parent). Over 9 percent of children under the age of 15 have lost at least one parent to AIDS. Orphans are less likely to attend school. In 34 countries in Africa one survey found orphans were 13 percent less likely to be in school than non-orphans, and primary school completion rates tend to be much lower when a child has lost a parent, especially the mother (Evans & Miguel, 2005). Young people in Africa are particularly at risk. Almost half of all new HIV infections occur among youth ages 15 to 24 globally and more so in Africa. Disabled persons are also at increasing risk and vulnerability due to their limited access to information and services. People living with HIV/AIDS (PLWHA) are also likely to become disabled. HIV and refugees, internally displaced people and returnees 2.7. At the end of 2005, there were 8.4 million refugees worldwide according to UNHCR (2007), of which 30 percent were in sub-Saharan Africa. Refugees, internally displaced people (IDPs) and 4 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 returnees are potential vectors of transmission of HIV, but equally are vulnerable to infection by communities through which they pass towards a safer haven. This increase in vulnerability occurs as income sources disappear, social networks are destroyed and access to health and education services is reduced. Furthermore, those groups frequently face stigma and are perceived to present higher HIV prevalence rates than host communities. Not one but several epidemics 2.8. The epidemiology of the epidemic is much better understood today than it was six years ago. HIV/AIDS in Africa is not one, but several different epidemics among countries and within countries. In Africa, the HIV epidemic is far more heterogeneous than previously recognized. It can be divided into four distinct clusters, as noted in Figure 2. The epicenter of the epidemic is southern Africa, where HIV prevalence ranges from 15 to 35 percent. The hyper-epidemic of the countries in this epicenter is a continental--and global--exception, unlikely to occur elsewhere. East Africa's epidemics, for many years grouped with southern Africa, are far lower, ranging from 2 to 7 percent. Prevalence in West Africa, Africa's most populous region, ranges from 1 to 5 percent. In North Africa, prevalence seldom exceeds 0.1 percent (Wilson, 2006). Figure 2: The Heterogeneity of HIV in Africa Source: Adapted from D.Wilson (2006). Transmission is better understood 2.9. The transmission of HIV is also better understood today than it was a few years ago. Modes of transmission vary significantly among epidemics. In West Africa, more than 75 percent of transmissions are attributable to sex work (Wilson, ibid.). In the mixed epidemics of East Africa, transmission comes from both HIV-vulnerable groups (sex workers, men who have sex with men and injecting drug users) and the general population, while in southern Africa most transmission is driven by sexual behavior in the general population3. The better understanding of the means of transmission is contributing to the improved response. In 2006, several countries reported reduced HIV prevalence. While not attributable to any single program, the principal elements in this reduction include a decrease in the number of partners among adults-- particularly highly sexually active men--followed by deferred sexual inception by young people and increased condom use (Wilson, 2006). 3Injecting drug use is a growing but still less significant factor. 5 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 2.10. The evolution in the understanding of the disease offers opportunities for more focused responses and more effective measures to control the spread of the disease, particularly in terms of attention to women, vulnerable groups and, as far as southern Africa is concerned, the general population. The Development Impact of HIV/AIDS 2.11. In addition to the continuing human suffering and loss, HIV/AIDS represents an enormous hurdle to the development process in the region. The Bank is dedicated to the reduction of poverty worldwide and HIV/AIDS impacts on national and regional success in achieving poverty reduction goals. The pandemic depletes savings, reduces labor supply, increases households' vulnerabilities to shocks, reduces productivity in the private and public sectors and negatively affects public finances. Perhaps most worrisome is the fact that it has significant negative economic impacts that will persist in the long run, as the epidemic leads to increases in the number of orphans and affects human capital accumulation. The Impact on households and welfare 2.12. The HIV/AIDS pandemic has an obvious negative impact on welfare due to the increases in mortality rates and reversed gains in life expectancy associated with the disease (see Figure 3 and Annex 1). Households are directly affected through lost income and decreased labor supply as the health of household members, particularly "breadwinners," deteriorates. Where women are the heads of household, often limited empowerment, restricted access to and control over resources, assets and opportunity, compound the impact on the household. In Western Kenya access to antiretroviral therapy (ART) led to a 35 percent increase in weekly hours worked, thus illustrating the magnitude of the disease's impact on productivity and the potential economic benefits of treatment provision (Thirumurthy et al., 2005). In addition, increased out-of-pocket expenditures on health care, funerals and related costs deplete household savings, decrease consumption and reduce investment opportunities, contributing to the persistence of poverty. Studies for South Africa reveal that HIV/AIDS-related expenditures can amount to up to 25 percent of the income of a household worker in urban households and up to 50 percent of the income of a household worker in rural areas (Salinas & Haacker, 2006). Figure 3: Changes in life expectancy at birth in selected African countries with high and low HIV prevalence: 1965-2005 70 65 60 55 High Botswana 50 South Africa Zimbabwe Low Prevalence: 45 Senegal Madagascar 40 Mali 35 30 1965 1970 1975 1980 1985 1990 1995 2000 2005 Source: World Development Indicators 2007 6 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 The impact on the private and public sectors 2.13. HIV/AIDS leads to decreases in productivity and to increased absenteeism and turn-over (with associated costs) of the work force (Haacker, 2004a). In particular, the disease generally affects workers in the most productive years of their lives. In addition, costs of medical and death-related benefits increase. Small and medium businesses as well as the informal sector are likely to suffer more, as they lack the resources necessary to mitigate those costs (Corporate Council on Africa, 2007). At the same time that the epidemic causes an increase in the demand for government services, it leads to reductions in public revenues as the tax base decreases and the negative effects of the epidemic on long-run output is felt (Haacker, 2004b). Furthermore, there are a number of indirect fiscal costs, as Haacker (2007) highlights, including orphan support, gender differentiated survivor needs, and pension scheme benefits related to the death of HIV positive civil servants or eligible individuals, as well as increases in the dependency ratio. Hence, HIV/AIDS puts enormous strains on public and private sector finances. The impact on human capital and economic growth 2.14. HIV/AIDS leads to a direct depletion of the stock of human capital, as skilled workers die prematurely. In addition, the disease contributes to the persistence of poverty as it affects the accumulation of human capital and has adverse effects on the nutritional status of children (especially when the mother has HIV/AIDS), and in particular, for orphans. In fact, when parents die, orphans are threatened by financial distress and lack of care, which leads to increases in the incidence of child labor and/or reductions in school enrollment/attendance. Zivin et al. (2006) consider that the morbidity associated with AIDS may lead to reallocations of time and resources within the household. The potential negative long-run impact of HIV/AIDS on economic development can be quite substantial. Bell et al. (2006) estimated that in Kenya by 2040, Gross Domestic Product (GDP) per adult will be 11 percent less than it would have been in the No-AIDS Scenario. 2.15. Theoretical studies surveyed in Haacker (2004a) typically predict 1 percent to 1.5 percent declines in GDP growth rates for the worst affected countries (prevalence rates >20 percent). Results on the empirical link between the epidemic and economic growth seem to be mixed (Bloom et al, 1997, Corrigan et al, 2005, among others). As the HIV/AIDS pandemic dramatically affects mortality rates, some authors posit that parents will choose to have more children as an "insurance policy" to guarantee a certain number of survivors. Analysis of evidence for 44 countries in Africa (Kalemli-Ozcan, 2006) concluded that HIV/AIDS affects fertility rates positively and school enrollment rates negatively, mitigating the negative effect of the epidemic on population growth and reducing the amount of human capital investment. At the aggregate level those mechanisms result in slower per capita economic growth. The Implications for Africa 2.16. The epidemiology of HIV in Africa and the effect of the pandemic on development prospects suggest several priorities for the future. 2.17. First, given the heterogeneity of the disease, national AIDS programs and strategies will need to focus on a rigorous understanding of HIV transmission dynamics in each context. This, in turn, 7 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 will require improved surveillance and epidemiological analysis at both the national and sub- regional levels. Programs will need to focus on major drivers of transmission. 2.18. Second, southern Africa will need to be a central focus for HIV/AIDS analysis and investments. 2.19. Third, programs will need to target the sub-groups heavily impacted by the epidemic: women and girls, children, youth and particularly vulnerable and often stigmatized groups such as sex workers, men having sex with men, prisoners and disabled persons. Interventions need to be informed by evidence and analysis and a better understanding of underlying root causes of gender inequality and stigmatization. 2.20. Finally, because HIV/AIDS threatens the achievement directly or indirectly of many Millennium Development Goals and perpetuates poverty and deepens inequality, the response to the pandemic needs to be an integral part of the dialogue on poverty reduction with African countries. 8 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 3. THE BANK'S RESPONSE TO DATE The Africa Region's Response to HIV/AIDS 3.1. As early as 1985 there was growing evidence that a serious HIV/AIDS epidemic of unknown magnitude was spreading across sub-Saharan Africa, but most governments and the international community were slow to respond. It was only in 1999 that the World Bank came to recognize the enormous development threat posed by the disease and prepared a regional HIV/AIDS strategy--Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis. 3.2. In 2000, the World Bank Executive Directors approved the Multi-Country HIV/AIDS Program (MAP) for Africa, with a commitment of US$500 million as an initial "emergency response." To implement the strategy and provide operational support, an AIDS Campaign Team for Africa (ACTafrica) was created in the office of the Regional Vice-President (see Annex 4 for a chronology of events). 3.3. The MAP Program was envisaged as a 15-year commitment by the Bank, divided into three stages. The first stage would lay the foundation for an accelerated response, which included involving civil society; putting in place essential structures, strategies and capacity; and gaining implementation experience. The main goals were to dramatically increase the response in Africa, move governments from denial to commitment and action, build capacity for a broad multi- sectoral response, and catalyze other resources. Stage two would mainstream innovations that have proved effective towards nationwide coverage, and stage three would permit a much sharper focus on areas or groups where spread of the disease continued. 3.4. It was clear from the outset that the Bank's standard products would not address the epidemic adequately. Therefore, the MAP Program adopted a "horizontal Adaptable Program Loan" (APL) approach, allowing a rapid response in many countries using a common framework and promoting a radically different response, including funding of civil society organizations, the private sector, ministries outside the Ministry of Health and trans-boundary populations such as refugees. 3.5. The MAP processes were also highly innovative, reflecting the exceptional nature of the HIV/AIDS epidemic. Project design, approval and implementation focused on speed, flexibility, partnership, "learning by doing," reworking projects as needed and relying on the multi-sectoral and multi-agency implementation mechanisms for the widest possible coverage. 3.6. The result was a resounding success in generating support for HIV/AIDS and the national response. In February 2002 the World Bank Board approved an additional US$500 million as grant funding from IDA-13, thereby enabling MAP projects in all 29 IDA-eligible countries in sub-Saharan Africa, commitments of US$1.5 billion, funding of several regional programs, and second-generation projects in a number of countries (see Annex 7). 3.7. The MAP Program addressed four pressing country needs: · strong political and government commitment to respond to HIV; 9 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 · a conducive institutional environment with adequate resources and capacity to enable successful HIV and AIDS interventions to be scaled up to a national level; · a local response that is increasing community participation in and ownership of HIV and AIDS interventions through providing financial resources and capacity building; and · a multi-sectoral approach in which all government sectors are appropriately involved, with improved coordination at the national level and decentralization to the sub-national government structures. 3.8. Many of the hardest hit countries in southern Africa were not eligible for IDA. To reach these IBRD countries (and IDA countries in arrears), the Bank provided technical support for analytical work and capacity building as well as a regional integration mechanism. HIV/AIDS was made one of the five core categories for support from the Institutional Development Fund (IDF). So far, five IDF grants have been approved for roughly US$2.5 million, bringing Bank HIV/AIDS support for the first time to Namibia and Swaziland, as well as fragile States such as Somalia and Sudan. The Results 3.9. The initial goals of the MAP program were to raise political awareness; promote a strategic response; strengthen systems and institutions to help manage that response; mobilize communities to promote activities for prevention, care, mitigation and treatment; decentralize the response; create mechanisms to monitor and evaluate the results; and stimulate global funding for HIV/AIDS in Africa. The intention was to help lay the foundation for the long-term containment and control of the epidemic. The MAP program has achieved many of these goals, including the following (see Annex 3 and Grgens-Albino et. al., 2007 for a detailed description of the outputs and results): · Political commitment to HIV/AIDS. A high-level AIDS authority exists in 29 countries, one-third chaired by the President or Prime Minister and all others by a Cabinet Minister. In nearly half of the countries all donor financing is coordinated by this high-level AIDS authority (NAC). · Active mobilization and engagement of Civil Society. In all MAP countries, at least 38 percent of financing is through the civil society organizations. Major scale up of activities in the areas of prevention, mitigation and care has engaged over 29,000 civil society organizations who are implementing about 60,000 community level subprojects. · Increased funding for HIV/AIDS. Additional evidence of political commitment is the increased funding for HIV/AIDS from domestic resources. National budget funding in 29 reporting countries has reached $757 million in 2006. In addition--with the creation of the Global Fund, the US PEPFAR program and significant other bi-lateral and foundation funding--global funding has grown by more than 2000 percent since 2001. · Intensified response on prevention. Bank funding has contributed to the reduction of the risk of mother-to-child transmission (1.5 million women), voluntary testing (7 million people), prevention information (173 million people, especially vulnerable populations) and condom distribution. 10 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 · Intensified treatment, care and impact mitigation. Initially, the Bank provided limited funding for ARV treatment, given its high cost and the intense focus of other agencies on treatment. However, working with the World Health Organization (WHO) and other partners, it has provided stopgap funding to prevent drug shortages, helped build supply chain systems, and cumulatively supported more than 27,000 persons in need of ARVs. It has also supported mitigation measures for more than 500,000 adults and 1.8 million children through education, home-based care and income-generating activities. · The multi-sectoral response. One of the MAP Program's most important achievements has been the promotion of the multi-sectoral response. Recognizing that HIV/AIDS is not only a health issue, the Bank has taken the lead in involving a broad array of stakeholders, from civil society and the private sector to multiple agencies of government--education, transport, defense, interior, agriculture, gender, social protection, youth and other ministries. · Improved HIV/AIDS systems. Bank funding has supported training of over a half million people in service delivery, improved laboratory infrastructure and other health system facilities, provided technical support to over 41,000 organizations, and reached 2.2 million people with workplace education programs. 3.10. The outputs from the MAP program have been impressive. Two independent evaluations have commended the overall effort, but suggested that the effectiveness, efficiency and impact of the Program on the disease itself have been difficult to measure. The interim review of the MAP program in 2004 endorsed the basic objectives, approach and design of the program (World Bank, 2004). Nevertheless, this review suggested the MAP program needed to become more strategic, collaborative and evidence-based. The review particularly noted the lack of functioning M&E systems; problems in governance, implementation, management and complex procedures; and the generally weak health sector response. 3.11. The Operations Evaluation Department (now Independent Evaluation Group - IEG) examined the World Bank's global assistance for HIV/AIDS in 2005 and reached many of the same conclusions about the work in Africa (World Bank, 2005). The speed with which MAP projects had been developed in response to the emergency did not permit a thorough assessment of the risks associated with a program for which there was little baseline information and pilot efforts on which to build. While the approach to the emergency nature of the epidemic was to learn by doing and to supervise intensively, the lack of functioning M&E systems limited knowledge sharing and adaptation. These reports helped focus attention in particular on the need for better M&E systems and evidence-based interventions in the future. Annex 10 presented actions that are being undertaken to address the recommendations. Lessons Learned 3.12. The key lessons going forward from the MAP experience include the following (see also World Bank, 2006b): · Recognize that HIV/AIDS is a more formidable challenge than had been realized. Unrelenting effort is needed to end the epidemic. Uganda, long a beacon of hope against HIV, now offers a warning against complacency. It was the first country in Africa to make significant gains against the epidemic, reducing prevalence among antenatal clients in Kampala 11 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 from 30 percent in 1992 to 7 percent by 2001. Now there are worrying signs of HIV prevalence rising again, as it is in Thailand and other "success story" countries. · Integrate HIV into the overall development agenda. HIV/AIDS is a major obstacle to development in many African countries and needs to be treated as a development priority. To address long-term financial sustainability, countries should link their HIV/AIDS strategies and plans to their overall development programs and financing plans as outlined in the Poverty Reduction Strategy Papers (PRSPs) and Medium-Term Expenditure Frameworks (MTEFs). · Know the epidemic/invest in results-based M&E. Successful national and local responses are grounded in understanding and careful analysis of the epidemic and of the behaviors and groups driving infections. This requires investments in surveillance, data collection and analysis. · Integrate HIV/AIDS services with reproductive and maternal health, nutrition, and other diseases such as malaria and tuberculosis. Treating HIV/AIDS as a single disease has been a significant deficiency of national HIV/AIDS programs. The feminization of the epidemic and its linkages to sexual and reproductive health, the often co-infection with TB (and the emerging Extensively Drug Resistant (XDR) TB), as well as other opportunistic diseases, require providers to offer integrated services. · Strengthen administrative and management capacity. A lack of capacity slows down the scaling up of effective responses and diminishes the national response. Strengthening financial and procurement systems, health human resources, health facilities, health information systems and supply chains is critical to achieving universal access and ensuring good governance, transparency and accountability. · Build Strong Partnerships. Donors tend to pull countries in too many different directions, with diverging policies, priorities and processes that burden countries and undermine program effectiveness. Many donors have agreed to harmonize their support with country strategies, programs, systems and needs, coordinate their support better, and support the principle of the "Three Ones." · Focus on engaging stakeholders and working with communities. Civil society and communities can help strengthen decentralized national responses, lay the foundation for behavior change, scale up mitigation efforts, and contribute to improving health systems at the local level. 12 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 4. STRATEGIC CHALLENGES IN THE NEW ENVIRONMENT 4.1. Since 1999, there have been major developments in the effort to combat HIV/AIDS in Africa, including the increased knowledge of the disease, lessons learned to improve prevention, treatment and care, and dramatic increases in funding. These developments, in turn, have highlighted significant emerging challenges to the effective control of the epidemic, especially (i) sustainability of funding, (ii) governance and accountability, (iii) the balance among treatment, prevention and mitigation, (iv) links to sexual reproductive health and other diseases and to national systems including health systems, and (v) the consequences of gender inequality. Such developments have also prompted the World Bank to reconsider its particular strengths in helping to deal with these challenges in the context of a much more crowded arena than in 2001. Finance, Sustainability and Accountability (i) Global funding 4.2. Context: The global response to the HIV/AIDS epidemic has been unparalleled. Between 2001 and 2006, worldwide funding has grown fourfold--from US$1.6 billion to S$8.9 billion (UNAIDS, 2006). Funding to MAP countries in Africa from the three main international sources amounted to US$5.9 billion in the period from 1997 to 2006 (Table 2). Table 2: Funding Sources and Commitments to MAP Countries Funding Sources Commitments to MAP Countries (in US$ billion) World Bank (1997-2006) 1.3 PEPFAR (2004-2006) 1.9 Global Fund (2003-2006) 2.6 Total 5.9 Source: World Bank (2006b), PEPFAR (http://www.pepfar.gov/press/c19558.htm.), GFATM (www.theglobalfund.org/en/funds_raised/commitments/) 4.3. Despite these increases in funding, significant financing gaps remain. Bollinger and Stover (2007) estimate that the resource requirements to achieve universal access to treatment, prevention and mitigation interventions in Africa alone, in line with international commitments, would amount to over US$41 billion in the period from 2007 to 2011 (see table below). This indicates that a significant scale-up in the availability of resources is required if the commitments made at the 2005 G-8 summit in Gleneagles and reiterated by the United Nations General Assembly in June 2006 are to be honored. 13 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 3: Resource Needs for Universal Access in Millions of US$ (2007-2011) 2007 2008 2009 2010 2011 Treatment 1,035 1,467 1,959 2,507 3,153 Prevention 2,768 3,330 3,923 4,544 4,683 Mitigation 1,694 2,056 2,417 2,779 3,141 Total 5,498 6,852 8,300 9,830 10,977 Source: Bollinger and Stover (2007) 4.4. Challenge: The increase in financial resources presents two major challenges: ensuring the rapid, efficient and effective use of the available funds and reducing the continued shortfall between the verbal commitment to universal access and the reality of financial flows. One major concern is the efficiency and effectiveness with which available resources have been used, due in part to shortcomings in national fiduciary and health delivery systems, insufficient planning, leakages and corruption. An apparent paradox is that despite the increased funding for HIV/AIDS, there is frequently a shortage of resources devoted to addressing important country needs in the fight against the epidemic, such as recurrent expenditures and institutional capacity building. (ii) Global HIV/AIDS architecture and national institutions 4.5. Context: At the global level, there have been several commitments to a more harmonized approach among development partners, embodied in the Monterey, Rome and Paris Declarations, the New Partnership for Africa's Development (NEPAD) and, for HIV/AIDS specifically, the "Three Ones." Groups have been established to translate the global commitment to concrete action on HIV/AIDS, including a multi-institutional Global Task Team (GTT) responsible for creating a regular coordination and problem-solving mechanism, the Global Implementation and Service Team (GIST), a UNAIDS-funded Global Monitoring and Evaluation Team (GAMET), a country strategy/action plan improvement group (ASAP), and a procurement process review group. At national levels, the institutional capacity of AIDS authorities is seen as a crucial linchpin in effective utilization of external and internal, existing and future resources. 4.6. Challenge: Realization of the "Three Ones"--the UNAIDS-inspired term for the policy of harmonized response among development partners for a single national strategy, a single governance structure and a single monitoring and evaluation (M&E) system--has proven difficult at the country and institutional level. Work pressures and internal incentives conspire to keep most managers and staff from focusing on the labor- and time-intensive effort needed to foster genuine collaboration, and information systems at the national level are not geared to adequately track partner efforts. However, basic instruments are in place that could facilitate greater collective effort, such as sector-wide approaches (SWAps), pooled funding and programmatic lending. (iii) Fiscal sustainability of HIV/AIDS programs 4.7. Context: The scale-up in efforts to combat the epidemic and the commitment of the major industrial countries to universal access to treatment are welcome. At the same time, these efforts carry implications for macroeconomic and fiscal management in aid-recipient countries and for the effectiveness of public policy initiatives in different sectors. In addition, as discussed in 14 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 previous sections, HIV/AIDS has significant consequences for the public and private sectors in the affected economies, which can reduce national governments' own abilities to effectively respond to the epidemic. 4.8. Most countries in the region are still heavily reliant on external assistance to finance their HIV/AIDS programs. Previous research has indicated that this source of funding tends to be volatile (Eifert & Gelb, 2005). The evolving nature of the epidemic and the availability of lower- cost treatments are converting HIV/AIDS from a death sentence to a chronic disease. Once treatment begins, it is a life-long commitment. Suspending or ending treatment for lack of funding would be both a moral and a health hazard. Furthermore, capital investments and recurrent expenditures such as wages and training for health workers result in long-term expenditure commitments for governments. 4.9. There is significant uncertainty regarding the future costs of treatment as the risks of drug resistance increase as treatment is scaled up. Accordingly, the size of the future fiscal burden on the public sector associated with increased access to treatment in the medium to long term is far from resolved. 4.10. Challenge: At the moment, there is a clear mismatch between the erratic character of aid flows and the long-term nature of expenditures on HIV/AIDS treatment and prevention. To effectively address this imbalance, countries need to combine foreign aid with domestic efforts to raise resources to mitigate volatility in financing. The analysis of fiscal space and sustainability issues is inherently country specific, given the role played by local institutions and characteristics in determining outcomes. Nonetheless, from a regional perspective, it seems that, in sub-Saharan Africa, the scope for increases in fiscal space through increased indebtedness and seignorage revenues is limited. Efforts to increase the efficiency of expenditures, expand the tax base and fight leakages linked to corruption and poor governance appear to be more promising avenues to increasing fiscal space (David, 2007). (iv) Governance and accountability 4.11. Context: There has been growing concern about transparency and integrity in the use of funds. Recent in-depth examinations by the World Bank's Department of Integrity of selected MAP projects in Africa and projects in Asia revealed significant fiduciary risks, resulting in the suspension of disbursements in a health sector project and delaying new commitments for both HIV/AIDS and health sector projects. Similarly, the GFATM has suspended operations in several countries. 4.12. Challenge: Working through thousands of communities with many different stakeholders and service providers has proven to be an effective approach to HIV prevention, care and treatment. At the same time, this decentralization of effort carries with it an enhanced risk of fund wastage and leakage. The challenge is to ensure the integrity of fund use while promoting the active engagement of many small organizations and the effective flow of funds to where the needs are the greatest. (v) Implementation Capacity 4.13. Context: With the significant infusion of resources, increased numbers of stakeholders and service providers over a relatively short time frame, and broad acceptance of the notion of 15 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 universal access, the capacity of institutions and entities to effectively perform the variety of new tasks represents a major bottleneck, in many instances. Demand for planning, programming and costing, provision of service delivery, supervision, monitoring and evaluation and reporting capacity--whether at community, provincial or national levels--have outstripped the capability of many of those responsible. The burdens on AIDS authorities to provide adequate support for the multifaceted activities provided by many partners is only likely to grow as programs extend into universal access. 4.14. Challenge: The nature of the HIV/AIDS response, which is principally implemented at the grassroots level as well as in health facilities, encompasses behavioral change as well as provision of medical supplies and treatment. Effective implementation requires systems and skills that are not typically in large supply in many country situations. Thus, HIV/AIDS implementation requires appropriate and constant training of those engaged at centralized and decentralized levels, as well as systems that provide key and timely information and communication to authorities who focus on results, transparency, and good governance. Special attention will be required from World Bank staff on the issue of how to effectively access the CDMAP for priority HIV/AIDS implementation capacity development. Operational Issues (i) The balance between prevention, treatment and care 4.15. Context: In the past four years, the principal focus of the HIV/AIDS response has been on treatment, due in part to the priority of the new funders. PEPFAR, for example, follows a policy of distributing 70 percent of funds for treatment and care, and 20 percent for HIV prevention (of which one-third must be spent on abstinence programs), according to UNAIDS (2006). By the end of 2005 the Global Fund had spent almost half its HIV/AIDS funds on treatment (47 percent on drugs and commodities, 20 percent on human resources and training, 20 percent on physical infrastructure and administration, and 6 percent on monitoring and evaluation). For various political, cultural, financial and technical reasons, perhaps related to the difficulties in rigorously evaluating the impact of prevention, many countries have left prevention interventions relatively underfinanced and under-attended. The need to renew the emphasis on prevention was articulated at the XVI AIDS Conference in Toronto in August 2006 in recognition that an "ounce of prevention is worth many pounds of treatment," particularly given the potential fiscal savings from treatment costs avoided when prevention interventions are effective. 4.16. Challenge: Prevention responses cannot be "one-off" actions nor will one solution work forever. Over the long term, prevention efforts must adapt as the epidemic changes, responding to different infection patterns and social conditions. Countries in the Region have typically implemented generalized prevention programs, which may not have high impact in low prevalence countries. The current transmission and infection dynamics of the epidemic require greater focus on prevention interventions targeting: · women (especially young women) to reduce their vulnerability, · behavioral change in the general population to reduce multiple concurrent partners in high prevalence countries, 16 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 · men to increase their adoption of prevention mechanisms, and · vulnerable populations like sex workers, men having sex with men, injecting drug users, which are principal means of transmission in many countries with concentrated epidemics. 4.17. In short, prevention efforts need to recognize and adapt to the changing infection patterns and focus more on behavior change rather than on raising awareness. (ii) Gender inequality 4.18. Context: Gender inequalities in status and rights, gender-based violence, labor opportunities, access to productive assets, and workloads are at the core of young girls and women's greater HIV vulnerability and risk. Scaling up existing tools and methods, as well as providing innovative and effective prevention tools for women is needed. Some technological improvements (such as "microbicides" which would give women more control over their lives) hold promise, as does the broader application of traditional methods, specifically male circumcision, to reduce the risk of HIV transmission from female to male. 4.19. Challenge: With the feminization of the HIV epidemic, integration of gender equality into development policy and programs at the country level becomes the highest priority, but the lack of political will, limited capacity, restricted funding and weak institutions make such integration a major challenge. More in-depth analytical work to shape decision making, provide the basis for training, and integrate gender aspects into operational research, pilot testing and service delivery would have significant benefits, but requires heightened and sustained focus to alter deeply embedded practices. (iii) Multi-sectoral Engagement 4.20. Context: HIV/AIDS touches on virtually all sectors, and warrants response in varying degrees from those in the public sector as well as the direct and indirect beneficiaries of efforts to fight the disease. Agriculture, Child Welfare, Commerce, Defense, Development, Education, Finance, Health, Interior Justice, Municipal Affairs, Social Services, Trade, Transportation, Youth to name but a few sectors, all justifiably have valid reasons to concern themselves with the national HIV response. In practice, while there is rhetorical recognition by civil servants of the relevance of HIV to the workplace and the need to include HIV in the policies they develop and the services they provide to their clients, in most instances the response has been inadequate. The reasons are many, including overburdened agendas, overburdened staff without new resources to take on additional tasks, reluctance to address socially sensitive issues, reluctance to build partnership with civil society organizations, lack of leadership, and lack of tools, training and absorptive capacity. 4.21. Challenge: Convincing public sector leadership, civil servants, and their intended beneficiaries that HIV is a development problem and not just a health problem--one in which they can affect national success--and a priority for their attention, engagement, and action, is a difficult task. Identifying the key sectors on a country-by-country basis, finding receptive individuals, and providing the technical and financial support as well as encouragement can be done but will require World Bank sectors to identify such opportunities and draw on regional human and financial resources, so that HIV/AIDS becomes an integral part of sectoral programs. 4.22. Figure 4 illustrates the distribution of active HIV/AIDS commitments across the World Bank's sectors. While more than half of the portfolio (77 percent) is managed by the Health, Nutrition 17 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 and Population (HNP) sector, continued efforts need to be made to mainstream combating HIV/AIDS into non-health sectors. Figure 4: Active HIV/AIDS Commitments by Sector Board Agriculture and Rural Development 10% Education 7% Transport 5% Urban Development 2% Health, Nutrition and Population Financial and Private 71% Sector Development 2% Social Protection 2% Social Development 1% Source: Business Warehouse, November 2007. Data includes full commitment amounts for MAP projects and coded amounts for projects with HIV/AIDS components. (iv) Sexual and reproductive health (SRH) 4.23. Context: Family planning, maternal and child health, reproductive health and HIV/STI programs are closely inter-related. They are complementary and synergistic; that is, each benefits from the effective performance of the other. Unfortunately, in most sub-Saharan African countries, they are not dealt with in a mutually reinforcing manner, if they are dealt with at all. 4.24. Challenge: Various studies are underway on how best to link sexual and reproductive health with HIV services (see Lule, 2004). Although such linkages will vary from context to context, it is also clear that providing family planning services as part of counseling and testing and PMTCT, expanding youth-friendly reproductive services, sharing facilities and human resources, reducing duplicative tasks, and strengthening community-based services are all promising courses of action. Having national leaders acknowledge SRH and HIV is a priority, but obtaining their commitment to a policy that necessitates resources will require a concerted effort by many stakeholders. (v) Links to other diseases, especially Tuberculosis 4.25. Context: Since 1990, the number of new TB cases has tripled in Africa and with the emergence of Multi-Drug Resistant Tuberculosis (MDR TB) and Extensively Drug Resistant Tuberculosis (XDR TB), the complexity of the interactions between TB and HIV have been magnified. Malaria remains a major problem in much of sub-Saharan Africa, and those who are HIV positive are at greater risk of dying when stricken by malaria and vice versa. Malnutrition is another of the 18 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 significant contributors to HIV/AIDS vulnerability, impairing immune systems and heightening mortality. 4.26. Challenge: Taking concerted action to deal with relevant research, policy, technological advancements and their application requires cooperation among donors and national authorities. These national authorities are often overwhelmed by multiple burdens that vastly outstrip resources. External donors need to take into account the larger vulnerability picture in providing financial and technical support. (vi) Health services delivery 4.27. Context: The health sector is the one sector that cannot fail if there is to be effective HIV/AIDS surveillance, prevention, treatment, and care. Many health systems in the Region lack adequate facilities and outreach capability and effective systems (such as supply chains and monitoring and evaluation). They face chronic shortages of health workers to respond to the HIV pandemic (see Tulenko, 2006). Indeed, HIV/AIDS represents a heightened burden for national health systems in retaining health workers, even those who are trained, unless they are provided with the means to protect and treat themselves. 4.28. Challenge: While the health system faces a plethora of weaknesses needing attention, from an HIV/AIDS perspective the crucial areas are human resources, laboratory and pharmaceutical capacity, and effective supportive systems such as supply chain management, fiduciary management, and monitoring and evaluation. National health systems and HIV/AIDS strategies and responses must be coordinated, complementary and supported by national authorities and external partners. 19 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 5. THE AGENDA FOR ACTION 2007-2011 The Rationale for an Agenda for Action 5.1. HIV/AIDS remains a fundamental development challenge in many African countries-- threatening growth, livelihoods and human capacity and representing a tragedy for millions of families. 5.2. Since the articulation of the first Bank strategy for HIV/AIDS in Africa in 1999, the environment for combating HIV/AIDS has changed dramatically, with new donors, increased funding, more affordable treatment, a better appreciation of the disease and its transmission, and new appreciation of gender inequality in the feminization of the disease in Africa. 5.3. Despite intensified national and global responses, much remains to be done in terms of strategy and the wherewithal to implement a cohesive strategy, sufficient funding, human and institutional capacity, and attention to prevention. The need for continued Bank involvement in Africa is set against this backdrop, drawing on lessons of experience gained over seven years of extensive HIV/AIDS investment, a capacity to adapt to a changing epidemiological environment, and an intention to stay the course with other partners in containing the spread of the virus. 5.4. Among the most serious gaps is the absence of sustained international support for HIV/AIDS in the most seriously affected countries, especially in southern Africa, as indicated in Figure 5 (see also Annex 11). Figure 5: Global Funding for HIV/AIDS in the Top 10 High Prevalence African Countries Global Funding for HIV/AIDS in the Top 10 High Prevalence African Countries 650 40 600 35 550 500 30 -49 450 15 es sn 400 25 ag illio 350 e,c m 20 en $ 300 SU alv 250 15 pre 200 VIH % 150 10 100 5 50 0 0 Sw aziland Botsw ana Lesotho Zimbabw e Namibia South Zambia Mozambique Malaw i Central Africa African Republic Global Fund PEPFAR World Bank HIV Prevalence, 2003-March 2007 2004-2006 2001 - April 2007 Ages 15-49 % Sources: UNAIDS, 2006; Haacker, 2007; www.theglobalfund.org; and www.pepfar.gov/pepfar/press/81902.htm. Global Fund Financing from 2003 - March 2007. www.theglobalfund.org (March 31, 2007) PEPFAR financing from 2004-2006: www.pepfar.gov/pepfar/press/81902.htm World Bank MAP projects approved from 2001 to June 2007. 20 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 5.5. The role of the World Bank has also changed in the past seven years, from that of the major funder of HIV/AIDS programs in Africa to that of development partner and complementary funder, which is, in many ways, a larger and more complex role. Its financial role has diminished in relative terms, in part because of the absence of IDA grant funds for HIV/AIDS since IDA- 13 and in part because of the large infusion of funds from the Global Fund, PEPFAR and others. The reduction in the Bank's new commitments from about US$250 million per year to about US$80 million is pronounced after FY04 (Figure 6). Figure 6: World Bank HIV/AIDS Lending* in Africa FY00-FY07** 450 400 350 Total HIV/AIDS 300 Commitments sn 250 illio MAP M Commitments SU$200 150 100 50 0 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 *Data includes total commitment amounts for MAP projects and the amount of the HIV/AIDS component for projects with HIV/AIDS components. ** Data as of July 2007 Source: World Bank Business Warehouse 5.6. In other respects, the demand for the Bank's engagement continues to be very strong. UNAIDS co-sponsors specified the World Bank as lead organization with respect to "support to strategic, prioritized and costed national plans; financial management; human resources; capacity and infrastructure development; impact alleviation and sectoral work" (see Annex 9). Other partners look to the Bank to assist in making their money work more effectively through systems strengthening and institution building. The Bank is also a main partner with UNDP in addressing the broader development, governance, mainstreaming, and gender agendas; with UNICEF in procurement and supply management; and with the UNAIDS Secretariat in monitoring and evaluation, strategic information, knowledge sharing and accountability. 5.7. Stakeholders consulted for this Agenda for Action--including country officials, development partners, donors and civil society organizations--articulated roles for the Bank for which it was uniquely qualified (some of which were described as "core competencies" in the previous section), including: 21 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 · macroeconomic and fiscal analysis · multi-sectoral engagement, working in education, transport, agriculture, and other sectors, as well as closely with health · institutional and human capacity-building for health systems, financial management and procurement · convening power and catalytic role for innovation, for example in post conflict countries and in sub-regional integration · partnership with communities and the private sector · source of long-term financial support Strategic Objectives 5.8. The fundamental purpose of the AFA is to support countries in sub-Saharan Africa to assist countries to reach the sixth Millennium Development Goal related to HIV/AIDS--halt and begin to reverse the spread of HIV/AIDS. 5.9. The underlying premise of the AFA is that the fundamental obstacles to halting and reversing the spread of the disease in Africa are primarily related to institutional and implementation capacity and human resources as well as financial resources. While there remain shortages of funding for universal access and for intensifying the overall response in certain countries, the critical strategic objectives in the next five years are to: · Strengthen the long-term prioritized sustainable response through incorporating HIV/AIDS more explicitly into the national development agenda, focusing the response, articulating realistic strategies built on solid evidence generated by good monitoring and evaluation (M&E), and integrating HIV/AIDS efforts with those of other diseases; · Intensify and accelerate a targeted multi-sectoral response by interventions in education, transport, agriculture and health, by working with the private sector, with civil society organizations and local governments; · Build stronger national systems to manage the response effectively and efficiently in health service delivery, financial management and procurement, supply chain management, human resources and social services; and · Strengthen donor coordination by maintaining the commitment to the "Three Ones" and working effectively to rationalize the global aid architecture for health. Pillars of Action 5.10. To realize these goals, the AFA rests on four strategic pillars: · Pillar 1: Focus the response through evidence-based and prioritized HIV/AIDS strategies, integrated into national development planning · Pillar 2: Scale up targeted multi-sectoral and civil society responses · Pillar 3: Deliver more effective results through increased country M&E capacity · Pillar 4: Improve donor harmonization and coordination 22 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 The Cornerstone of the AFA 5.11. The Bank's commitment to continuing its active engagement in combating HIV/AIDS in Africa will underlie the AFA effort. With constrained budgets for IDA, the growing demand for infrastructure and other investment, and the availability of grant resources in several countries from other donors, there is a perception among some development partners that the Bank is receding, if not withdrawing, from its support in the fight against HIV/AIDS. The goal of the AFA is to demonstrate the Bank's determination to continue to play an effective role in combating HIV/AIDS in Africa, through its own actions and through supporting national and regional action. Overall Conceptual Framework 5.12. The conceptual framework for the AFA can be visualized in Figure 7: Figure 7: World Bank HIV/AIDS Agenda for Action in Africa Conceptual Framework MDG 6 ­ Halt and begin to reverse the spread of HIV/AIDS Strategic Objectives PLWHAs, I. Strengthened long-term sustainable national response M,T II. Accelerated implementation of HIV/AIDS programs III. Strengthened donor coordination GFA, IV. Strengthened national systems (public sector management, CB human resources, supply chain, health and social systems) Os, sector disabled NGOs, UNAIDS private Strategic Pillars FBOs, donors, people the 1. Strengthen evidenced-based and prioritized national HIV/AIDS Civil and labor rse strategies integrated in national development planning and 2. Scale-up targeted multi-sectoral and civil society response unions, soci multilateral 3. Deliver effective results through increased country M&E marginalized Partn ety and capacity foundations 4. Improve harmonization and donor coordination you th, bilateral cies, groups women's agen Bank specific actions Country specific actions ments, UN gro · Renew the commitment · Improved governance ups, govern other · Sector analytical work and · Improved institutional knowledge sharing capacity and program families, · Strategic planning management National · Fiduciary management · Sharpened gender focus · Capacity and infrastructure · Integrated HIV/AIDS development services with sexual · Impact alleviation and reproductive health, mitigation tuberculosis, nutrition and malaria · Address vulnerable groups 23 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 5.13. The specific objectives, planned actions, indicators and targets, critical assumptions, timelines and accountabilities for the AFA are described in the Results Framework and Implementation Plan attached as Annex 6. The following section summarizes the principal elements of the Foundation for the AFA, namely renewing the commitment and the actions and expected results for each of the four pillars. The Foundation: Renew the Commitment 5.14. The first goal of the AFA is an explicit reaffirmation of the Bank's long-term commitment to help fight HIV/AIDS in Africa, first articulated in 1999. Moving forward with the AFA by the Bank's senior management and the Executive Directors would affirm that determination. 5.15. The tangible demonstration of the renewed commitment would include the following: · Commit to remain a source of predictable, flexible and long-term finance. The Bank will be prepared to provide at least US$250 million annually for HIV/AIDS investments over the next five years, based on the demand from member countries. This commitment is a form of safety net and insurance for borrowers facing issues of fiscal space and the potentially volatile flow of funds from external sources. The funds might support stand-alone HIV/AIDS projects, "hybrid" projects integrated into health sector operations, components of other sector projects, or policy-based loans focused on health expenditures. Financial and program gap studies and the development of five-year financing plans and financial sustainability studies that incorporate donor and domestic commitments and long term commitments for treatment would be supported. This would involve pursuing innovative financing routes to respond to HIV/AIDS in sub-Saharan Africa. · Demonstrate the Bank's renewed commitment to combating HIV/AIDS in Africa through participation in all channels of policy dialogue. Senior Management would engage high-level policy makers to advocate for a response to HIV/AIDS. Advocacy by Bank staff would strongly reassert this position. · Create an HIV/AIDS Incentives Fund to enhance the evidence base, promote the multi-sectoral response and provide technical support, analysis and policy advice to countries. An "Incentive Fund" with an annual budget of US$5 million for five years would promote the analysis of and mainstreaming of HIV/AIDS interventions. The Fund would (i) help fill major gaps in the understanding of HIV in specific localities and (ii) assist task teams to design HIV/AIDS interventions in sector investment projects for education, transport, rural development and other key sectors. It would fund critical analysis, policy guidance, capacity building and project/program preparation, in line with the goals of the AAP and the Capacity Development Management Action Plan (CDMAP). The Fund would be available to potential recipients both inside and outside the Bank. · Promote work on sub-regional public goods and cross-boundary issues such as refugees. Regional efforts are important to complement national HIV/AIDS programs, and an integral part of Bank corporate strategic priorities. They represent, however, instances in which countries are either reluctant or unable to borrow. Conflict or post-conflict situations are common in many sub-regions, thereby making conventional credit operations unfeasible. Grants to deal with refugees, internally displaced populations (IDPs), transport corridors and 24 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 the like are virtually the only option available to respond to such crucial situations. The Bank has larger and more varied experience with HIV/AIDS sub-regional approaches than others. · Increase Bank engagement in the epicenter of the epidemic--southern Africa. The Africa Region must find instruments to support HIV/AIDS programs in countries such as Botswana, Namibia, Swaziland and South Africa, which are ineligible for IDA funding, whether through IBRD "buy-down" collaboration, grant-funded technical assistance sub- regional programs, or other mechanisms. The Bank could provide technical support and innovative instruments to assist middle-income countries (MICs) in southern Africa through Institutional Development Plans (IDFs), financing, analytical work and policy dialogue4. Pillar 1: Focus the Response Through Evidence-Based and Prioritized HIV/AIDS Strategies 5.16. The Bank can make a unique contribution to the HIV/AIDS response by helping to incorporate the AIDS program into a country's national development plan, poverty-reduction strategy and medium-term expenditure framework. A prioritized, costed HIV/AIDS strategy backed by a realistic annual work plan is an essential instrument for an effective response. Pillar 1 would help ensure appropriate attention and direction for the national HIV/AIDS program. Its principal elements are as follows: · Embed HIV/AIDS into national development strategies, medium-term expenditure frameworks and poverty-reduction programs. With the renewed commitment from Bank and Regional management on HIV/AIDS, 6 PRSPs and 10 CASs and Interim Strategic Notes (ISNs) should be reviewed annually to ensure that HIV/AIDS is reflected appropriately in the business plans of the country and the Bank. In the past, tools to help design MTEFs and PRSPs with due consideration for HIV/AIDS have been developed on an ad hoc basis, but now they should be routinely applied. · Respond to the specific country epidemics. The Bank should be prepared to assist countries with financial, technical and analytical support, depending on their individual circumstances, to understand their specific epidemics and to establish surveillance systems. A possible typology of responses based on the differentiated epidemics is outlined in Tables 4 and 5 on the following pages: 4The Bank currently supports analytical and advisory services and provided IDF grants for capacity building in Swaziland and Namibia. 25 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 4: Country Types and HIV/AIDS Typology Low-level Epidemic Concentrated Epidemic Generalized Epidemic Country Types Under 1% prevalence in Between 1-5% prevalence Above 5% prevalence among young women among young women young women (15-24) (15-24). (15-24) Countries Prev. Countries Prev. Countries Prev. Madagascar 0.3% Cameroon 4.9% Lesotho 14.1% Mauritania 0.5% Tanzania 3.8% Zambia 12.7% Senegal 0.6% Congo, Rep 3.7% Mozambique 10.7% Niger 0.8% Angola 2.8% Malawi 9.6% Nigeria 2.7% CAR 7.3% Angola 2.5% Kenya 5.2% Guinea-B 2.5% Uganda 5.0% Burundi 2.3% DRC 2.2% Chad 2.2% IDA Rwanda 1.9% Gambia 1.7% Eritrea 1.6% Burkina Faso 1.4% Guinea 1.4% Ghana 1.3% Mali 1.2% Benin 1.1% Sierra Leone 1.1% Liberia n/a Ethiopia n/a Sudan n/a IDA Countries Prev. Countries Prev. Countries Prev. (conflict and Somalia 0.6% Togo 2.2% Zimbabwe 14.7% non-accrual) Cote d'Ivoire 5.1% Countries Prev. Swaziland 22.7% IBRD Botswana 15.3% S. Africa 14.8% Namibia 13.4% Gabon 5.4% Source: UNAIDS (2006). This table provides only a broad typology, based on national-level data. The variations in the epidemiology within countries in West Africa and parts of East Africa can be significant (e.g. Kenya, Uganda, Ghana) and should be taken into consideration when elaborating a locally appropriate response. 26 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 5: Possible Differentiated Responses Factor Concentrated Mixed Generalized Geographic areas Parts of West Africa West Africa and parts of East Africa Southern Africa Focused prevention Lending Instruments projects/other sector project Hybrid* HIV/health projects Programmatic loans (SWAps) components Behavior change Investment Focus M&E, stigma reduction, Focused interventions on vulnerable groups sources of transmission Initiatives/treatment HIV mapping, interactions Attitude and behavior patterns Analytical focus among high-risk groups and Transmission dynamics general population Human resources for health Surveillance Focus Sex workers and men Vulnerable having sex with men groups/interaction Population-based surveillance Source: Wilson (2006). *Hybrid projects would include projects such as the Burkina Faso (half AIDS, half health) and the Eritrea projects covering HIV/AIDS/STI, TB, malaria and reproductive health, which are being replicated in other countries. · Support and build capacity for the development of prioritized, costed national HIV/AIDS strategies. The work of the recently established AIDS Strategy and Action Plan (ASAP) will be directed at approximately 20 sub-Saharan African countries over the next three years. · Integrate HIV/AIDS more fully into programs for health system strengthening, reproductive health, malaria, TB and nutrition. Experience has shown that there are programs and diseases which need to be more closely addressed in the context of HIV/AIDS national responses. With its multi-sectoral capabilities, the Bank will more intensively consider how to do so, whether through HIV/AIDS or related investments. · Share best practices on what works and what fails in HIV/AIDS programs. Operations research will be conducted on successes and failures in HIV/AIDS programs to better identify and share best practices. Pillar 2: Scale Up Targeted Multi-sectoral and Civil Society Responses 5.17. The Agenda for Action will support a multi-sectoral response at the country level and mainstream HIV in the Bank's key operations. The support will focus on a prioritized multi-sectoral approach to respond to the complexity of HIV as a broad development challenge and focus on sectors that have the greatest potential impact (depending on country context) in partnership with the civil society organizations and private sector entities. To achieve this objective, the Agenda for Action will support mainstreaming HIV/AIDS in the overall development and poverty reduction agenda and identify entry points for each sector to mainstream HIV/AIDS. Specifically, the Bank will: · Encourage HIV/AIDS integration in key sectors. The Bank will continue and expand its analytical work and investment operations designed to integrate HIV/AIDS policy, programs and service delivery in priority sectors. This will entail strengthening sectoral institutional 27 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 capacity to scale up and supervise activities, as well as multi-sectoral prevention operations research, pilot testing of promising approaches and service delivery. This may involve integrating HIV in new products or retrofitting existing operations. · Support civil society organizations in providing prevention, care, and mitigation services. Experience gained with the MAP in developing CSO participation and ownership and as service providers for prevention, care, and mitigation shows that civil society is a crucial participant in HIV/AIDS responses. CSOs will continue to be a mainstay of future Africa Region Bank efforts, with new products providing support for, or recognizing the need to significantly engage CSOs as an integral part of, a national solution. Civil society organizations will also be participants in the M&E approach to provide both realism and accountability. · Address gender inequality issues. Direct and indirect assistance will be needed to address HIV-related gender concerns. Analytical work which leads to greater knowledge of the varied effect of HIV on women, resulting in specific actions to change inappropriate gender responses will be an important part of future efforts. Workshops to build on such findings and train decision makers will be supported. In addition, these results will be integrated in key sectors, and appropriate Bank products will be developed with country teams, task team leaders and national counterparts. · Intensify prevention and support programs for youth and orphans and other vulnerable children. Each new generation of young women and men must be made aware of, and confront the risks related to, HIV/AIDS. The rapidly growing numbers of orphans and vulnerable children affected or infected by the virus represent a significant social and financial burden to societies. The Bank will contribute to the national and external donor response in conjunction with other lead donor financiers and lead technical partners, including UNFPA, UNESCO, and UNICEF, in the context of the agreed division of labor among UNAIDS cosponsors. · Strengthen health systems. Taking into account the April 2007 "Healthy Development; The World Bank Strategy for Health, Nutrition and Population Results", the Africa Region HNP strategy, and the Africa Region health sector portfolio and pipeline, working with Bank health sector specialists, support will be provided to strengthen those elements of the health system that present specific challenges to HIV/AIDS programs, such as human resources, supply chain and monitoring and evaluation systems, and health facility infrastructure, especially laboratory and pharmaceutical services. Particular attention will be paid to ways to multiply results through linkages with tuberculosis, malaria, reproductive health and nutrition. Pillar 3: Deliver Effective Results Through Increased Country M&E Capacity 5.18. The World Bank support would meet rigorous standards of evidence-informed actions, integrity and transparency to enhance efficiency, effectiveness and sustainability. Specifically, the Bank will support countries to: · Continue to strengthen monitoring and evaluation frameworks at the country level and tailor the responses. Monitoring and technical support to the development and operationalization of M&E systems--including adopting a standard "HIV/AIDS Results 28 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Scorecard" (see Annex 8) in all projects and developing impact assessment and evaluations and implementation of an early warning system for project performance--will be increased. Effective M&E systems can identify epidemic profiles and changing patterns and contextual areas (including socio-economic determinants) and develop tailored responses. GAMET, the UNAIDS program housed in the Bank, is charged with helping improve the quality of national M&E systems. Analytical work is also urgently needed to identify specific prevention interventions that will address the feminization of the epidemic and allow women and young girls to better protect themselves. · Improve existing governance structures, public sector management and transparency mechanisms and generate demand at the community level for better accountability. One of the Bank's most significant advantages lies in helping build national capacity in supervision and fiduciary management--better procurement, financial reporting and monitoring. Whether associated with World Bank funding or not, the Bank has a role to play in helping ensure the integrity of national HIV/AIDS programs, assessing anticorruption practices at all levels, developing guidelines, and building capacity. · Support knowledge generation and sharing to improve prioritization, decision making, and program design. Often, the use of knowledge gained through analytical work is not translated into improved decision making and program design. The Bank will support impact evaluations and project assessments. The Africa Region will pay greater attention to this nexus of knowledge and action. · Generate and utilize good practices case studies to support cross country learning and knowledge sharing. With its extensive portfolio of varied projects and programs, the Bank is well positioned to identify good practices and share them throughout the Region. Pillar 4: Harmonize Donor Collaboration 5.19. Countries face considerable difficulties in significantly scaling up program implementation. They need technical support that reinforces national ownership, addresses immediate needs and strengthens capacity in a sustainable manner. Areas of strategic planning, integration and M&E are all vital for "making the money work," that is, improving the efficiency, effectiveness and sustainability of national AIDS responses. 5.20. The Bank will work with governments and other development partners to honor the concept of the "Three Ones" and the commitments of the Paris Declaration on aid effectiveness: · Work with key partners to harmonize and strengthen national M&E systems, human resource capacity, procurement and supply chains. The Bank will continue to house the multi-donor effort to help strengthen M&E systems with support from GAMET. It will work with the lead organizations, as outlined in the UN Technical Support Division of Labor matrix, to address the human resource capacity, procurement and supply chain management aspects of the HIV/AIDS challenge. Support will be provided to countries and Bank project teams to improve harmonized planning, program design, financial management, rapid and effective disbursement, procurement and expenditure tracking. · Conduct joint planning and analytical work with UNAIDS and other partners. Taking into account the mandate of AIDS Strategy and Action Plans (ASAP), the Bank will carry out 29 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 its lead organization responsibilities as specified in the UN Technical Support Division of Labor matrix regarding strategic planning, financial management, human resources, capacity and infrastructure development, impact evaluation and sector work. · Participate in joint annual partner meetings. The Bank will actively seek to harmonize and align its work with other partners for greater aid effectiveness. It will participate or organize collaborative partnership information sharing and action events. · Strengthen and harmonize national coordinating institutions. The Bank will conduct institutional assessments with a view to identifying key constraints and provide the tools and training to effectively deal with the multiple stakeholders engaged in the HIV response. Anticipated Results 5.21. The AFA will help produce a stronger policy, institutional and human capacity framework which, in turn, will strengthen the HIV/AIDS response. Over time, it will contribute to a reduction of new infections, reduced prevalence and improved life expectancy. Within ten years, it will have helped realize the Millennium Development Goals goal to halt and begin to reverse the spread of HIV/AIDS. 5.22. The principal outputs from the AFA over the next five years are expected to be the following: Table 6: Foundation Objective Anticipated Results By Whom By When Respond to country demand for predictable, Countries' access to predictable, flexible and AFRLT. FY08-FY11 flexible and sustainable IDA financing for sustainable financing for HIV/AIDS provided. HIV/AIDS. Support for sub-regional and cross-border Support continued to sub-regional operations AFRLT, FY08-FY11 initiatives provided. to address cross-border issues. AFTHV, At least 2 new sub-regional operations. AFTHD. Africa HIV Incentive Fund to provide support Incentive fund finances 5 technical support CDMAP, FY08-FY10 for project/program development, policy products per year. AFTHV. advice and capacity building created. Table 7: Pillar 1 - Focus the Response Through Evidence-Based and Prioritized HIV/AIDS Strategies Objective Anticipated Results By Whom By When Appropriate HIV/AIDS efforts integrated into · HIV/AIDS addressed appropriately AFTHV, AFRLT, FY08-FY11 countries' development agendas and Bank through countries' and Bank development PREM, WBI, instruments (policy procedures). agenda. HDNGA, UNDP, IMF. Bank support in capacity building to develop · Strengthened capacity to develop HDNGA, ASAP, FY08-FY11 prioritized, and costed national strategies and prioritized and costed national action UNAIDS, AFTHV. action plans provided. plans in 20 countries. Integration of TB, reproductive health, · World Bank projects addressing HDNGA, AFTHV, FY08-FY11 malaria and nutrition into World Bank HIV/AIDS integrate TB, reproductive AFTHD, WHO, HIV/AIDS products ensured. health, malaria and nutrition when UNFPA, UNICEF. appropriate to epidemiological context. 30 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 8: Pillar 2 - Scale Up Targeted Multi-sectoral and Civil Society Responses Objective Anticipated Results By Whom By When HIV/AIDS policy, programs and service · Improved country capacity in key sectors to HDN, AFTHD, FY08-FY11 delivery integrated in priority sectors implement multi-sectoral approaches. PREM, IFC, (dependent upon country context). · Increased commitment in key Bank sectors AFTHV, to include HIV/AIDS component or sub- AFTPS, components in lending and non-lending AFTEG, activities, including adequate resources. AFTTR, AFTU, AFTRL. Support to strengthen elements of the health· Improved synergy between HNP and HDNHE, FY08-FY11 system that challenge HIV/AIDS programs. HIV/AIDS operations. AFTHD, AFTHV, WHO, UNFPA, UNICEF. Table 9: Pillar 3 - Deliver Effective Results Through Increased Country M&E Capacity Objective Anticipated Results By Whom By When Harmonized M&E frameworks at the country · Bank to continue to play leading role HDNGA, FY08-FY11 level strengthened. (GAMET) in supporting countries. AFTHV, · All countries have a functional harmonized GAMET, M&E system reporting and using data. UNAIDS. Knowledge generation and sharing to · Design and impact of HIV/AIDS investments HDNGA, FY08-FY11 improve prioritization, decision-making based on knowledge sharing. AFTHV, and program design supported. · Countries and partners fully engaged in GAMET, knowledge generation and sharing. AFTQK, DEC Table 10: Pillar 4 - Harmonize Donor Collaboration Objective Anticipated Results By Whom By When Collaboration with key partners to harmonize· GAMET to continue to support countries to HDNGA, FY08-FY11 and strengthen national M&E systems, HR strengthen M&E in close collaboration with AFTHV, PREM, capacity, procurement and supply chains other partners. GAMET, strengthened. · Better implementation of the global division AFTQK, of labor. UNAIDS, GFATM, PEPFAR. Joint planning and analytical work with · More efficient, effective and sustainable HDNGA, WBI, FY08-FY11 UNAIDS and other partners increased. HIV/AIDS resource allocation. AFTQK, AFTHV, UNAIDS, GFATM, PEPFAR. 31 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 The Potential Impact and Consequences of Inaction 5.23. Should universal access to treatment and prevention become a reality by 2011 as envisaged by the G-8 industrial countries, the impact on Africa would be significant. According to the analysis discussed in detail in Annex 2, universal access to effective prevention services would reduce the number of new infections from 3.5 million per year to 1.25 million at a cost between US$2,000 to US$3,000 per infection averted. In addition, these prevention interventions would entail savings in terms of treatment cost avoided alone in the order of US$6,570 per HIV infection averted. With continued expanded access to treatment, almost 1,000,000 deaths will be averted annually by 2011. In contrast, the consequences of inaction are frightening: new infections would continue to increase, and deaths due to HIV/AIDS would grow from the 2005 level of 1.9 million. The cumulative affect of no scaled-up effort over the next five years would be close to 10 million deaths and 14 million newly infected persons (an increase of 50 percent from 2006). 32 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 6. OPERATIONAL IMPLICATIONS FOR THE BANK 6.1. The role for the Bank in the coming five years in supporting Africa's fight against the HIV/AIDS epidemic will be no less challenging than it has been in the past five years. With the absence of grant funding, the demand for IDA credits is likely to be reduced and hence the traditional mechanism of engagement--MAP investment projects--will be less readily available. The principal responsibility for integrating HIV/AIDS into the development agenda and managing the multi-sectoral response in education, transport and other sectors does not rest with ACTafrica or with the Health, Nutrition and Population (HNP) family, but with other units in the Bank. And the most critical role for the Bank might shift from financier to facilitator in some countries with other donor financing, with consequences for budgeting, work program agreements and internal incentives. 6.2. As indicated in Part 6, other stakeholders consulted for the AFA consider the "soft" role as no less critical than the financial role to an effective HIV/AIDS response. They cited attributes they felt were in some cases unique to the Bank: · A potentially stable and predictable source of long-term financial support. Relative to other international financial partners, the Bank's presence in Africa for over 50 years demonstrates that it has been a stable and predictable source of finance. In a sense, it is an "insurance policy" so that treatment, care, prevention and mitigation programs, once scaled up, will not fall victim to unpredictable and volatile external funding, especially with the moral and health consequences of a start-and-stop regime for treatment. · A catalytic role in core economic and fiscal policy, and treatment of HIV/AIDS as a development as well as health issue. The Bank is considered to be uniquely positioned to place the HIV/AIDS epidemic within a macro-economic framework and within PRSPs, MTEFs and other mechanisms of national economic and fiscal policy. · Experience in dealing with communities and with the private sector. Much of the work on prevention, treatment, care, and mitigation interventions can be more effectively managed by private employers and workers, and by community-level organizations. The Bank has unique experience in working with these groups. · The multi-sectoral role. The Bank is active in the sectors that have critical roles in managing the HIV/AIDS epidemic, including education, transport, rural development, defense and health, as well as the private sector. · Analytical expertise. The Bank has the analytical capacity, as one of its core competencies, to support research and analysis to better understand the epidemic and the most effective means to change attitudes and behaviors. · Experience in developing institutional capacity. Bank support of national and decentralized HIV/AIDS institutions has been and will continue to be important. The Bank's knowledge and reputation in fiduciary management strengthening is widely seen as critical to implementing multi-sectoral programs. 33 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 · The Bank as convener and catalyst In the complexity of the global aid architecture for HIV/AIDS, the Bank's traditional role in convening partners to address common issues at both the country and global level is particularly valued. 6.3. At the same time, the consultation process identified areas where development partners felt the Bank had been less effective. A number of stakeholders and partners perceive a decline in the Bank's corporate commitment to HIV/AIDS in sub-Saharan Africa. They also believe that the Bank's limited country presence weakens its capacity to help harmonize the HIV/AIDS and broader health response at the local level. Another shortfall relates to the Bank's limited ability to operate in the epicenter of the epidemic, that is, in the middle income countries of southern Africa. Finally, the Bank is perceived as having been slow to put into practice lessons learned from the MAP program, to measure the program's impact, and to apply these lessons to the next generation of efforts to fight the disease. Work Program Implications for the Africa Region 6.4. The four pillars of the AFA will require that the Africa Region and the ACTafrica team design and develop a program of work very different from the one which drove the first phase of the MAP program. There will need to be new skills, an intensified focus on building and maintaining relationships inside and outside the Bank, new incentives and rewards to recognize the value of partnerships, and a new commitment to working across institutional boundaries. In particular, the Bank will need to: · Focus national development strategies on the role of HIV/AIDS as a development and poverty issue. The Bank can play a major role in incorporating HIV/AIDS into PRSPs and PRSCs, and in helping to design prioritized and costed national HIV/AIDS strategies. · Ensure Bank country assistance strategies reflect the appropriate attention to HIV/AIDS. A recent review of 34 current CASs for IDA countries in Africa indicated only 24 percent made HIV/AIDS a strategic priority. Few CASs analyzed the nature of the epidemic or assessed government strategy. Almost none identified what other partners were doing and how the Bank initiatives fit into the international response. · Help to develop a new generation of HIV/AIDS strategies and action plans based on evidence and focused on critical, cost-effective interventions, and funding them where demand exists. New projects are being prepared or have been approved in 8 of the 14 countries where MAP projects have been completed. Under the AFA, the Bank will be prepared to fund projects in the Region at least US$250 million per year. · Support the inclusion and design of HIV/AIDS-related components in other sector projects, SWAps and policy lending. The next generation of HIV/AIDS-related projects is likely to be concentrated in sectors such as education, social protection, transport and capacity building for health and fiduciary systems. ACTafrica can provide expertise and operational support where requested for both new products and retrofitting existing ones. The proposed Incentive Fund will provide funding to develop HIV/AIDS components in sector projects and analytical support on the epidemic for SWAps and policy loans. · Intensify implementation support. Many of the current projects in the HIV/AIDS portfolio are being reviewed, and, where necessary, an intensive program of retro-fitting 34 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 outputs and enhanced supervision for enhanced results is being initiated, in collaboration with our partner countries. GIST will continue to promote problem-solving among development partners. · Continue to support capacity building for HIV/AIDS governance, especially at the local level, M&E and good governance. Specialized units such as GAMET for M&E and ASAP for strategic planning may be expanded with heightened attention to sub-Saharan Africa. · Promote harmonization among development partners. By virtue of the pledge to the UNAIDS "Three Ones" principles, HIV/AIDS represents a model of the harmonization effort commitment under the Paris Declaration. 6.5. These principal areas of work--analysis, strategic development, project design, component design, implementation support, capacity building and partnership management--are spelled out in the proposed Results Framework and Implementation Plan presented in Annex 6. An HIV/AIDS Support Program for FY07-11 6.6. While it is difficult to predict the sources of future demand, the relatively underserved countries of Central and West Africa (that have no or limited PEPFAR funding and relatively modest GFATM support) and the LICUS and post-conflict countries with large refugee populations may be the most likely claimants of Bank funding. Epicenter countries such as Botswana, Namibia, Swaziland and South Africa may also consider funding from the IBRD, while the Bank on its side will explore innovative instruments for this purpose. Implications for Staffing and Budgeting 6.7. Implementing the AFA will require both human and financial resources from the Africa Region to support the HIV/AIDS specialized dedicated team as well as contributions from country and sector units, and specialists to take on their share of the responsibilities to mainstream HIV/AIDS. 6.8. The functions of the current dedicated specialized multi-sectoral team (ACTafrica) would require its transition from essentially an emergency response team carrying out the full gamut of advocacy, national project design and implementation supervision to one with greater focus on strategic planning; financing and program gap analysis and long-term financial sustainability; macro-economic and social analysis; fiduciary system strengthening, results monitoring and evaluation; knowledge generation and knowledge sharing; operational and technical support facilitation to Bank teams, countries and partners; partnership coordination; and regional/cross- border efforts. In addition, we envisage an evolution of the skills requirements over time based on the functions above and emerging demands. 6.9. While the dedicated team would continue to provide key specialized and quality assurance support across the sectors, it will also depend on Bank staff in the Region, other external partners, and co-sponsored operations such as GAMET and ASAP to provide substantial time to strengthen key sectoral responses. The dedicated unit would draw on specialized expertise from 35 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 other Bank operations such as DEC, the World Bank Institute and the International Finance Corporation. Additional skills and support would be drawn from the Global AIDS Program of the World Bank. 6.10. The cost of the dedicated specialized unit will involve a modest increase in the current base budget for ACTafrica. Such a modest increase would allow the unit to reconfigure its staff over time, take the substantive lead where appropriate, and provide both direct and indirect technical, facilitation and supplemental support for others in the Region with HIV/AIDS tasks, as described in the Results Framework. While the team will serve as the Region's focal point and information clearing house on AIDS and continue to build internal capacity, most of its work will be demand driven and funded from country budgets as well. 36 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 7. CONCLUSION 7.1. We have sought to present a convincing case for the Bank's future continued engagement in Africa's struggle to overcome the HIV virus and the suffering of its people. We provided the best available information on the epidemiology, the impact, what the Bank has done to date, and its future role. 7.2. As development practitioners, we know that HIV/AIDS threatens the realization of the Millennium Development Goals and has long-term economic and human impacts on the Region. The changing environment for HIV/AIDS--including the better understanding of the diversity of the epidemic, the drivers of transmission and the relative cost-effectiveness of different interventions, as well as the growth of funding--has resulted in new challenges for African countries and for the World Bank. The Agenda for Action responds to these challenges and to the priorities of the World Bank in sub-Saharan Africa through the Africa Action Plan, the World Bank's Global HIV/AIDS Program of Action, CDMAP and the World Bank HNP strategy. 7.3. Using knowledge gained from experience, the Agenda for Action is to be demand-driven, evidence-based and results-oriented. It will build capacity for monitoring and evaluation and epidemiological surveillance, and will continue the process of learning by doing and knowledge creation and sharing. For the Bank's Africa Region, this Agenda for Action would reinvigorate its engagement in the fight against HIV/AIDS. 7.4. While its funding role is likely to be modest in relative terms, the Bank's investments would remain significant in terms of being the lender of last--and sometimes first--resort. Its involvement would be significant in analyzing, generating and disseminating evidence, continuing the learning-by-doing process, building capacity for HIV/AIDS, strengthening health and fiduciary systems, generating high-quality prioritized strategic programs and action plans at the national level, and harmonizing the international response. Above all, the World Bank would provide a critical safety net for a sustained program of prevention, treatment, care and mitigation and support across the Continent to cushion the possible impact of volatile international funding over time. 7.5. The Agenda for Action will be implemented through partnerships across Bank units and other sectors working closely with client countries. It will collaborate and complement the work of UNAIDS, its co-sponsors, GFATM and other development partners to scale up a multi-sectoral response, mainstream HIV/AIDS in development agendas, build capacity, and, with the IMF, address fiscal space and long-term sustainability issues. 7.6. In 2000, the World Bank made a commitment to remain actively involved in combating the HIV/AIDS pandemic in sub-Saharan Africa for a generation. The Agenda for Action provides a program of strategic direction and effort to honor that pledge. This commitment has been reiterated on many occasions by Bank leadership and staff in numerous for a. Standing by this commitment through the unanticipated trials and tribulations of its clients will reinforce Bank credibility as a reliable partner, but more importantly, it will further our goal of alleviating poverty. 37 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 8. REFERENCES Bell, C. et al. (2006) "Economic Growth, Education and AIDS in Kenya: A Long-Run Analysis" World Bank Policy Research Working Paper 4025, October, Washington: DC. Bollinger, L. & Stover, J. (2007) "The Potential Impact of HIV/AIDS Interventions on the Epidemic in Africa: Background Paper Prepared for HIV/AIDS Agenda for Action in sub-Saharan Africa" World Bank, Washington: DC. Bloom, D. et al. (1997) "Does the AIDS Epidemic Threaten Economic Growth?" Journal of Econometrics, 77. Corporate Council on Africa (2007) "The role of the World Bank in strengthening the private sector response to HIV/AIDS in Africa" Background Note Prepared for HIV/AIDS Agenda for Action in sub-Saharan Africa, World Bank, Washington: DC. Corrigan, P. et al. (2005) "AIDS Crisis and Growth" Journal of Development Economics, 77. David, A. C. (2007) "Fiscal Space and Fiscal Sustainability of HIV/AIDS Programs in sub-Saharan Africa" unpublished manuscript, ACTafrica, World Bank, Washington: DC. Eifert, B. & Gelb, A. (2005) "Improving the Dynamics of Aid: Toward more predictable Budget Support" World Bank Policy Research Working Paper No. 3723, Washington: DC. Evans D., Miguel A. (2005) "Orphans and schooling in Africa: a longitudinal analysis", Center for International and development Economics Research, University of California Berkeley. Available at hhp://repositories.cdlib.org/iber/cider/C05-143. Grgens-Albino et al. (2007) "The Africa Multi-Country AIDS Program 2000-2006: Results of the World Bank's response to a development crisis" World Bank, May, Washington: DC Grassly, N.C., K. Desai, E. Pegurri, A. Sikazwe, I. Malambo, C. Siamatowe, and D. Bundy (2003) "The Economic Impact of HIV/AIDS on the Education Sector in Zambia." AIDS 17 (7): 1039-1044. Haacker, M. (2004a) "HIV/AIDS: The impact on the Social Fabric and the Economy" in Haacker, M (ed.) "The Macroeconomics of HIV/AIDS" International Monetary Fund, Washington: DC. Haacker, M. (2004b) "The impact of HIV/AIDS on Government Finances and Public Services" in Haacker, M (ed.) "The Macroeconomics of HIV/AIDS" International Monetary Fund, Washington: DC. Haacker, M. (2007) "HIV/AIDS, Public Policy, and Development in the 'New Age' of Expanded Access to Treatment," unpublished manuscript International Monetary Fund Washington: DC. Heller, P. et al. (2006) "Making Fiscal Space Happen! Managing Fiscal Policy in a World of Scaled-up Aid", IMF Working Paper, 06/270, December, Washington, DC. 38 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ICRW (2006) "HIV/AIDS Stigma Finding Solutions to Strengthen HIV/AIDS Programs" International Center for Research on Women Washington: DC. Kalemli-Ozcan, S. (2006) "AIDS, Reversal of the Demographic Transition and Economic Development: Evidence for Africa" NBER Working Paper 12181 April, Cambridge: MA. Lule, E. L. (2004) "Strengthening the Linkages between Reproductive Health and HIV/AIDS Programs" Presentation to the UK all parliamentary group on Population, Development and Reproductive Health, London, April. Mathers et al. (2006) "The burden of disease and mortality by condition: data, methods and results for 2001." in: AD Lopez, CD Mathers, M Ezzati, DT Jamison and CJL Murray, Editors, Global burden of disease and risk factors, Oxford University Press, New York. Salinas, G. & Haacker, M. (2006) "HIV/AIDS: The Impact on Poverty and Inequality" IMF Working Paper 126, May, Washington: DC. Thirumurthy, et al. (2005) "The Economic Impact of AIDS Treatment: Labor Supply in Western Kenya." NBER Working Paper No. 11871, December, Cambridge: MA. Tulenko, K. (2006) "Africa Health Worker Crisis: Options for Removing Bottlenecks to HIV/AIDS Prevention, Diagnosis, Treatment and Care" Background Paper Prepared for HIV/AIDS Agenda for Action in sub-Saharan Africa, World Bank, Washington: DC. UNAIDS (2006) "Report on the Global AIDS Epidemic" United Nations, Geneva. UNHCR (2007) "HIV and Refugees" UNHCR Policy Brief, United Nations, Geneva. Wilson, D. (2006) "HIV Epidemiology: A review of recent trends and lesson". Background Note Prepared for HIV/AIDS Agenda for Action in sub-Saharan Africa, The World Bank, Washington: DC. World Bank (2004) "MAP Interim Review report", October, Washington: DC. World Bank (2005) "Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance ­ An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control" July, Washington: DC. World Bank (2006a) "Disease and Mortality in sub-Saharan Africa" World Bank, Washington: DC World Bank (2006b) "Issues Paper on Improving Performance of the Multi-Country AIDS Program (MAP) in Africa" November, Washington: DC. World Development Indicators (2007) World Bank, Washington: DC. Zivin et al. (2006) "AIDS treatment and intrahousehold resource allocation" NBER Working Paper 12689, November, Cambridge: MA 39 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 9. ANNEXES ANNEX 1 ­ HIV Prevalence, Income, Access to Treatment and Quality of Health Services in sub-Saharan Africa in 2006 41 ANNEX 2 ­ The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations 43 ANNEX 3 ­ MAP Achievements 50 ANNEX 4 ­ Africa Response to HIV/AIDS: A Chronology of Events 52 ANNEX 5 ­ Agenda for Action Consultations 54 ANNEX 6 ­ Agenda for Action: Implementation Plan and Results Framework 58 ANNEX 7 ­ HIV/AIDS Portfolio for Africa (1989-2007) 68 ANNEX 8 ­ The HIV/AIDS Results Scorecard 73 ANNEX 9 ­ The Bank's Role in the UNAIDS Division of Labor 76 ANNEX 10 ­ MAP challenges and Improving Performance of the Multi-Country AIDS Program (MAP) for Africa 77 ANNEX 11 ­ HIV Prevalence and Global Financing 79 40 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 1 ­ HIV Prevalence, Income, Access to Treatment and Quality of Health Services in sub-Saharan Africa in 2006 Table 11: HIV Prevalence, Income, Access to Treatment and Quality of Health HIV Prevalence, Income, Access to Treatment and Quality of Health Services in sub-Saharan Africa in 2006 Country GDP per HIV Prevalence, Access to Population Population PLWH per PLWH capita (U.S.$) Ages 15-49 treatment per per Nurse Physician per (Percent) (Percent) Physician (Units) (Units) Nurse (Units) (Units) Angola 1,873 3.7 6 12,993 871 363 24 Benin 595 1.8 33 22,244 1,195 280 15 Botswana 5,829 24.1 85 2,510 378 378 57 Burkina Faso 438 2 24 16,975 2,427 190 27 Burundi 107 3.3 14 35,340 5,243 750 111 Cameroon 952 5.4 22 5,216 626 163 20 Central African Republic 336 10.7 3 11,819 3,293 755 210 Chad 601 3.5 17 25,664 3,709 522 75 Congo 1,751 5.3 17 5,050 1,040 159 33 Côte d'Ivoire 850 7.1 17 8,120 1,660 360 74 Dem. Republic of Congo 119 3.2 4 9,339 1,890 172 35 Equatorial Guinea 5,934 3.2 0 3,314 2,224 58 39 Eritrea 206 2.4 5 19,986 1,715 274 24 Ethiopia 153 0.9 ­ 3.5 7 36,507 4,746 n.a. n.a. Gabon 6,538 7.9 23 3,420 194 152 9 Gambia 304 2.4 10 9,141 830 128 12 Ghana 512 2.3 7 6,598 1,085 99 16 Guinea 355 1.5 9 8,734 1,812 86 18 Guinea-Bissau 181 3.8 1 8,181 1,483 170 31 Kenya 574 6.1 24 7,195 874 289 35 Lesotho 537 23.2 14 20,247 1,605 3,034 240 Madagascar 263 0.5 0 3,442 3,162 9 9 Malawi 161 14.1 20 46,380 1,698 3,534 129 Mali 421 1.7 32 12,734 2,051 123 20 Mauritius 5,058 0.6 n.a. 946 271 3 1 Mozambique 346 16.1 9 37,319 4,851 3,502 455 Namibia 2,870 19.6 71 3,363 327 385 37 Niger 278 1.1 5 32,931 4,571 210 29 Nigeria 678 3.9 7 3,551 590 83 14 Rwanda 242 3.1 39 21,150 2,360 474 53 Senegal 715 0.9 47 17,406 3,145 103 19 Sierra Leone 219 1.6 2 30,762 2,807 286 26 South Africa 5,100 18.8 21 1,298 245 158 30 Sudan 783 1.6 1 n.a. n.a. n.a. n.a. Swaziland 2,323 33.4 31 6,333 159 1,287 32 Togo 378 3.2 27 12,086 1,646 50 7 Uganda 326 6.7 51 44,131 2,729 1,217 75 United Republic of Tanzania 324 6.5 7 22,298 2,343 6,222 654 Zambia 609 17 27 8,642 575 870 58 Zimbabwe 383 20.1 8 6,199 1,382 815 182 Source: Haacker (2007) 41 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 12: Life Expectancy at Birth for Selected sub-Saharan African Countries (1965-2005) Country 1965 1970 1975 1980 1985 1990 1995 2000 2005 SSA 43 45 47 48 49 49 48 46 46 Angola 36 37 39 40 40 40 40 40 41 Botswana 53 55 58 62 64 64 57 43 35 Ethiopia 39 40 41 42 44 45 44 42 42 Cote d'Ivoire 47 49 51 53 54 52 49 47 46 DRC 44 45 47 48 47 46 43 42 44 Cameroon 43 45 47 50 52 52 50 47 46 Senegal 38 39 42 47 50 53 54 55 56 Zambia 48 49 51 52 50 46 41 38 38 Uganda 48 50 51 50 49 46 43 45 49 Tanzania 47 49 51 54 55 53 50 47 46 Sudan 43 44 47 49 51 53 55 56 57 South Africa 52 53 55 57 59 62 58 48 45 Zimbabwe 54 55 57 59 61 59 49 40 37 Rwanda 44 44 45 45 44 31 32 41 44 Nigeria 41 42 44 45 46 46 45 44 44 Mozambique 38 40 42 43 43 43 44 43 42 Malawi 39 41 43 45 46 46 43 40 40 Kenya 51 52 55 58 59 58 53 48 48 Ghana 48 49 51 53 55 56 57 57 57 Source: World Bank's Development Data Platform (DPP) Database. Figure 8: Life Expectancy at Birth for Selected sub-Saharan African Countries (1965-2005) 65 60 SSA Angola Botswana 55 Ethiopia Cote d'Ivoire DRC Cameroon 50 Senegal Zambia Uganda 45 Tanzania Sudan South Africa Zimbabwe 40 Rwanda Nigeria Mozambique 35 Malawi Kenya Ghana 30 1965 1970 1975 1980 1985 1990 1995 2000 2005 Source: World Bank's DPP Database. 42 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 2 ­ The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations This annex discusses the simulations on the impact and costs of HIV/AIDS prevention, care and mitigation interventions in sub-Saharan Africa (Bollinger & Stover, 2007). The results presented were based on models used for simulations published in Science and by UNAIDS. Methodology and the Consequences of Inaction Bollinger and Stover (2007) examined the consequences of three different scenarios regarding HIV/AIDS policies in the region: (i) a baseline scenario where coverage rates for prevention, treatment and mitigation interventions remain at current levels, (ii) a universal access to treatment scenario, where treatment services are scaled up to reach at least 80 percent of those in need by 2010, but other interventions remain constant, and (iii) a universal access to treatment and prevention scenario, where prevention interventions are also scaled up. The results presented were divided into three different sub-regions: East Africa, Southern Africa and Central/West Africa, in order to reflect the different nature of the epidemic in those areas. In the Base Scenario, new infections would continue to increase and deaths due to HIV/AIDS would grow from the 2005 level of 1.9 million. The cumulative affect of no scaled-up effort over the next five years would be close to 10 million deaths and 14 million newly infected persons (an increase of 50 percent from 2006). The Treatment Scenario consists of increasing coverage from the current levels that are in the Base Scenario to reach universal access by 2010 (defined as covering 80 percent of adults and children in need of ART). Annual costs of care and treatment are based on data from Khayelitsha, South Africa, including data on costs of and progression to first-line and second-line therapies, incidence and treatment of opportunistic infections, and configuration of palliative care. Costs of ART are based on the assumption that, on average, each person receives 7.5 years of ART. The Prevention Scenario builds on the previous scenario and assumes that prevention interventions are scaled up in a linear fashion from the existing 2005 levels to coverage levels of 80 to 100 percent by 2010. The impact of this increase in coverage on HIV infections averted is then calculated by (1) predicting the change in behavior that is due to this increased coverage; (2) estimating the impact of this behavior change on HIV incidence; and (3) examining the consequences of the changes in incidence. Changes in behavior are predicted based on an impact matrix that estimates the effect of the various prevention interventions on specific behaviors. The values of the matrix are derived from a review of the literature on approximately 100 impact studies. These behavior changes are then fed through an HIV/STI transmission equation to calculate new HIV infections. This equation calculates the probability of infection as a function of HIV prevalence in the partner population, the transmissibility of HIV, the impact of a sexually transmitted infection on HIV transmissibility, the proportion of the population with sexually transmitted infections, condom use, numbers of partners per year and number of sexual contacts with each partner. Finally, the Spectrum model is used to relate the changes in HIV incidence to other variables of interest. 43 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Impact of Universal Access to Treatment If the universal access to treatment scenario occurs, by 2010 more than 5 million people would be on treatment. The impact of scaling up treatment is immediate and dramatic. In 2007 alone, approximately 400,000 deaths would be averted and by 2011, the number of deaths averted annually rises to almost 1,000,000. The overall cost per AIDS death averted varies between US$2,500 and US$3,500, depending on the sub-region. One should note that there are a number of positive and negative external effects to a scale-up of treatment, such as benefits from orphan-life-years averted, emergence of drug-resistant strains of the virus, reduction in HIV transmission associated with lower viral loads, or increases in transmission due to longer duration of infectivity (Revenga et al., 2006). Figure 9: Universal Access to Treatment Number of Deaths Averted (2007-2030) 3,000,000 2,500,000 2,000,000 Southern 1,500,000 Central/West East 1,000,000 500,000 0 200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030 Source: Bollinger and Stover (2007) Another way to look at the impact of the increase in access to treatment is to calculate the amount of life years gained relative to the no-scale-up scenario. In total, almost 14 million life years will be gained relative to the Base Scenario (see figure below) at a cost of approximately US$1,400 per life year in East Africa and approximately US$600 per life year in Southern Africa and Central/West Africa . 44 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Figure 10: Universal Access to Treatment: Cumulative Number of Life Years Gained in sub-Saharan Africa 2007-2011 East Central/West Southern Source: Bollinger and Stover (2007) Impact of Universal Access to Prevention The Prevention Scenario assumes scaling up of prevention efforts to reach target levels set by UNAIDS by 2010. The number of annual new infections would be reduced from over 3.5 million to approximately 1.25 million by 2011. The total numbers of HIV-positive people would decline from 28 million to 22 million. The cost per infection averted decreases significantly between 2007 and 2011. Overall, the average cost per HIV infection averted in sub-Saharan Africa drops from about US$3,000 in 2007 to about US$2,000 by 2011 (more on the cost effectiveness of different prevention interventions below). It is also crucial to note that prevention interventions entail large benefits in terms of treatment costs avoided. In fact, Bollinger and Stover (2007) estimate overall cost savings of US$6,570 per HIV infection averted in the Region. Some authors have discussed the possibility of increased risk behavior due to "complacency" effects associated with treatment availability (Revenga et al., 2006). 45 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Figure 11: Infections Averted Due to Prevention Efforts in sub-Saharan Africa 2007-2011 2500000 2000000 1500000 Southern Central/West East 1000000 500000 0 2007 2008 2009 2010 2011 Source: Bollinger and Stover (2007) Cost Effectiveness of Prevention Interventions Results from ten different country-specific applications of the Goals model were used to calculate (unweighted) average impacts for ten different interventions: community mobilization, mass media, voluntary counseling and testing (VCT), interventions for sex workers, interventions for men who have sex with men (MSM), in-school youth programs (Education), blood safety, condom distribution, STI treatment, workplace programs, and programs to prevent mother-to-child transmission (PMTCT). These interventions were selected because they have the most robust results when calculating their impact coefficients. For each country, the full program of prevention interventions was scaled up to reach universal access targets by 2010, with the resulting number of total HIV infections averted calculated. After this, the funding was taken away from each of the ten interventions listed one at a time (and subsequently replaced), so that the marginal impact of the intervention could be measured. The tables below classify interventions by their relative cost-effectiveness ratios, as well as by their relative impact in terms of percentage of total infections averted. There are three categories of cost per infection averted: Low (US$3,000) and three categories for impact: Low (0-10% of total infections averted), Medium (10-20% of total infections averted), and High (>20% of total infections averted). These cost-effectiveness estimates should also be analyzed in light of monetary benefits associated with averted treatment costs for extended periods of time. 46 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 13 & 14: Cross-classification of Interventions by Cost-effectiveness and Impact Cross-classification of Interventions by Cost- Cross-classification of Interventions by Cost- effectiveness and Impact For East/Southern Africa effectiveness and Impact For Central/West Africa Impact (% of infections averted) Impact (% of infections averted) Cost per Low Medium High Cost per Low Medium High infection (0-10%) (10-20%) (>20%) infection (0-10%) (10-20%) (>20%) averted averted Low CSW PMTCT Blood Low CSW PMTCT Blood (< $1,000) MSM (< $1,000) MSM Medium Comm. Condom Medium Comm. Condom ($1,000 - Mobilization Dbn ($1,000 - Mobilization Dbn $3,000) VCT $3,000) VCT Education Education High Mass Media High Mass Media (> $3,000) STI (> $3,000) STI Treatment Treatment Workplace Workplace Source: Bollinger & Stover (2007) Source: Bollinger & Stover (2007) Both tables indicate that interventions targeting sex workers across all of sub-Saharan Africa are very cost-effective, with costs per infection averted of less than US$1,000. Interventions for sex workers have a much smaller target population, yet because the HIV prevalence rate in that group is usually quite high, a large number of infections can be averted. PMTCT and blood safety programs are also very cost-effective in East/Southern Africa, where HIV prevalence rates are higher and have a substantial impact on the number of total infections averted. In Central/West Africa, these two interventions are classified in the medium cost per infection averted category, and PMTCT contributes a substantial proportion of all infections averted. Finally, those interventions with the highest cost per infection averted in East/Southern Africa are mass media, STI treatment5, and workplace programs, while the corresponding interventions in Central/West Africa are community mobilization, mass media, sexually transmitted infections treatment, and Education for youth. Hence, it seems that four interventions are particularly highly cost-effective for sub-Saharan Africa: PMTCT, blood safety programs, and outreach programs for sex workers and men who have sex with men (MSM). The table below presents a summary of other studies on the cost effectiveness of HIV prevention interventions in the region that broadly corroborates the results previously outlined. One should be careful when analyzing the results presented, as they do not imply that prevention interventions should be considered in an isolated way. It is more useful to think in terms of packages of interventions, in particular, interventions that are mutually supportive and present complementarities. 5Note that the cost of STI considered here does not reflect the cost of STI treatment per se, but rather the cost of outreach programs. 47 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 15: Summary of Studies on Cost Effectiveness of HIV/AIDS Interventions in sub-Saharan Africa Intervention Cost Effectiveness in 2001 US$ VCT (Kenya and Tanzania) 270 to 376/HIV Infection 14 to 19 per DALY* VCT (Chad) 891 to 5,213 / Infection 45 to 261 per DALY Peer-Based Programs (Cameroon) 67 to 137/HIV Infection 3 to 7 per DALY Condom Distribution and IEC (South Africa) 378 to 4,094/Infection 19 to 205 per DALY Condom Social Marketing (Chad) 77 per HIV Infection 4 per DALY STI Treatment (Kenya) 11 to 16 per HIV Infection 1 per DALY STI Treatment (Tanzania) 326 per HIV Infection 16 per DALY STI Treatment (South Africa) 2,093 per HIV Infection 105 per DALY STI Treatment (Chad) 1,675 per HIV Infection 84 per DALY ART for MTCT: Nevirapine (sub-Saharan Africa) 142 to 306/HIV Infection 6 to12 per DALY Blood Safety (Chad) 75 to 151/HIV Infection 4 to 8 per DALY Blood Safety (Zimbabwe) 166 to 1,010/ Infection 8 to 51 per DALY Blood Safety (Zambia) 215 to 262 /HIV Infection 11 to 13 per DALY Sterile Injection (Africa) 91 to 230 per DALY *DALY: Disability Adjusted Life Years. Source: Bertozzi, S. et al. (2006) Mitigation HIV/AIDS is responsible for a significant part of the increase in the number of orphans and vulnerable children (OVC) in sub-Saharan Africa. This poses strains on traditional coping mechanisms (such as the extended family) and highlights the need to provide additional support to those groups. Bollinger and Stover (2007) provide simulations of the impact of HIV/AIDS on the number of OVC from 2007 to 2011, as well as projections on the number of those in need of assistance6. According to the figure below, the number of OVC in need would increase from about 19 million in 2006 to over 21 million in 2011. It is important to note that there is a global consensus that all orphans and vulnerable children in need should be supported, not only those whose parents have died of AIDS, to mitigate any stigma that might develop otherwise. 6The population in need is defined as all double orphans and vulnerable children, along with half of single orphans, who live in households under the poverty line. 48 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Figure 12: Number of OVC in sub-Saharan Africa 50,000,000 45,000,000 40,000,000 35,000,000 30,000,000 25,000,000 Total In need 20,000,000 15,000,000 10,000,000 5,000,000 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: Bollinger and Stover (2007) References Bertozzi, S. et al. (2006) "HIV/AIDS Prevention and Treatment" in Jamison et al. (eds.) "Disease Control Priorities in Developing Countries" 2nd Edition World Bank and Oxford University Press, New York: NY. Bollinger, L. & Stover, J. (2007) "The Potential Impact of HIV/AIDS Interventions on the Epidemic in Africa: Background Paper Prepared for HIV/AIDS ­ Agenda for Action in sub-Saharan Africa" World Bank, Washington: DC. Revenga, A. et al. (2006) "The Economics of Effective AIDS Treatment: Evaluating Policy Options for Thailand" The World Bank Health, Nutrition and Population Series. 49 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 3 ­ MAP Achievements Table 16: Systems Strengthening SYSTEMS STRENGTHENING Percentage increase in development partner funding 2,240% MAP management integrated into NAC functions 59% Outputs to which MAP Contributed Number of persons trained with MAP funds 562,366 (23 countries) Number of decentralized government structures that have implemented HIV 10,938 (25 countries) work plans Employees reached with workplace HIV programs 2,258,844 (23 countries) Number of organizations provided with technical support 41,107 (25 countries) GFATM and MAP coordinated from one unit 38% of NACs HIV PREVENTION Number of women enrolled in PMTCT since start of MAP 1,546,388 (23 countries ) Number of VCT sites in all MAP countries 8,812 (23 countries) Number of new VCT sites that MAP helped to establish 1,512 (17 countries) Number of persons who have received HIV test results 6,999,528 (25 countries) Number of male condoms distributed 1,294,369,023 (25 countries) Number of female condoms distributed 4,041,973 (15 countries) Number of persons reached with IEC/BCC programs 173,333,043 (21 countries) Number of IEC/ BCC events 726,876 (20 countries) HIV CARE AND TREATMENT Number of sites providing ART 3,012 (26 countries) Total # of people on ART 554,648 in total (27 countries) (26,699 with MAP funding) Number of PLWH treated for opportunistic infections 287,805 (20 countries) IMPACT MITIGATION Number of infected/affected persons receiving support 502,958 (21 countries) Number of vulnerable children receiving support 1 779,872 (22 countries) Number of income-generating activities supported 32,854 (18 countries) MONITORING AND EVALUATION (M&E) Average number of surveys/surveillance per country before MAP 2 Current average number of surveys/surveillance 4 Source: Grgens-Albino et al. (2007) "The Africa Multi-Country AIDS Program 2000-2006: Results of the World Bank's response to a development crisis" World Bank, May Washington: DC 50 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Table 17: Outcome Level Results to which MAP Has Contributed SYSTEMS STRENGTHENING The MAP has contributed to increased political commitment at the highest government level. The MAP gave countries a head start in achieving the "Three Ones." The MAP contributed towards institution building and strengthening of the NACs. MAP funding helped mobilize additional government resources for HIV. The MAP was a catalyst for increased international funding. The MAP sparked a quantum increase in the scale of country action on HIV. The MAP has contributed towards improved legislation related to HIV and AIDS. The MAP has succeeded in promoting and facilitating a multi-sectoral response. MAP funding has supported the decentralization of the HIV response. The MAP supported improved coordination of the HIV response by NACs and at decentralized levels. The MAP has supported international partnerships on HIV at country level. The MAP built capacity to plan, coordinate, monitor, evaluate and implement HIV services. HIV PREVENTION The MAP has increased the number of women who have accessed PMTCT services. The MAP has supported HIV education in schools and HIV testing among education sector staff. The MAP has contributed to increased knowledge about how HIV can be transmitted. The MAP has contributed to reductions in higher-risk sex in some countries. There is some evidence of the MAP focusing on the most vulnerable and at-risk populations. The MAP has contributed to an increase in condom use. The MAP has ensured that more people know their HIV status. The MAP has helped prevent transmission of HIV in health care settings. HIV CARE AND TREATMENT MAP funding has set up facilities that provide ARV and expanded access to ARV treatment. The MAP has strengthened infrastructure for delivering health services. IMPACT MITIGATION The MAP supported and promoted school attendance for orphans and vulnerable children. The MAP increased access to good quality psychosocial care for affected households and children. The MAP contributed to sustainable community-level care. MONITORING AND EVALUATION (M&E) In most countries, there is an M&E unit with an approved budget as a result of the MAP. Most countries also have an M&E Task Team that meets at least quarterly. Most countries have developed M&E training materials. Most countries have an approved M&E framework or strategy, with indicators agreed on by all partners. Many countries have a detailed M&E work plan, although only some are costed. Most countries have begun to build an HIV/AIDS database, but MOH data collection is still weak. Strategic information is flowing better than before. There is some evidence of data use. Source: Grgens-Albino et al. (2007) "The Africa Multi-Country AIDS Program 2000-2006: Results of the World Bank's response to a development crisis" World Bank, May Washington: DC 51 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 4 ­ Africa Response to HIV/AIDS: A Chronology of Events Table 18: Africa Response to HIV/AIDS, A Chronology of Events Timeline Action Taken Pre-1997 Bank's response constrained internally and externally by low demand for Bank's assistance and Bank's internal focus on health sector reforms during this period. 1997 The HNP strategy contained no discussion of AIDS except in a remote annex in the context of emerging diseases. A Bank policy research report, Confronting AIDS: Public Priorities in a Global Epidemic, highlighted the economic impact of AIDS. 1998 Africa RVPs called for new strategy for region in light of emerging data on development impact of AIDS. July 1999 AIDS Campaign Team for Africa (ACTafrica) established to support and coordinate the Bank's multi- sectoral response. It was placed in the office of the RVP and staffed with seconded multi-sectoral staff. Weekly Regional Leadership Team meetings regularly discussed AIDS. Accountability mechanisms were established requiring Country Directors to report regularly on AIDS activities. AIDS incorporated in Bank's instruments and procedures such as safeguards. 1999 The Bank adopted Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis to address the growing HIV/AIDS epidemic in Africa. 1999 AIDS activities added to existing projects in country portfolios and sectors other than health, such as education, transport, rural development, social protection. Retrofitting had mixed results because amounts were often too small to impact the spreading epidemic. January 2000 World Bank President addressed the UN Security Council and called for a "War on AIDS." April 2000 ACTafrica published its cross country analysis of economic impact, which was picked up by "Economics Focus" in the Economist. AIDS was top agenda item for the Spring Meetings. September 2000 The Bank's Board approved a Multi-Country AIDS Program for Africa (MAP), a 10-15 year program to intensify multi-sector action against AIDS and build political commitment. MAP defined eligibility criteria to raise political commitment and mobilization at country level. February 2002 MAP 2 approved with $500 million funding to pilot test antiretroviral therapy and support cross-border initiatives. IDA 13 provided grants in support of HIV/AIDS. January 2003 Implementation Acceleration Team established to address slow implementation and low coverage and strengthen institutional capacity as well as facilitate learning by doing. Higher supervision budgets were provided to MAP projects. October 2004 ACTafrica commissioned an Interim Review of MAP which basically confirmed validity of the MAP approach, highlighted progress made and suitability of interventions, and identified ways for future improvement. July 2004 ACTafrica moved to AFTQK for mainstreaming with quality assurance of HIV operations and knowledge generation and sharing. 2005 OED evaluated the World Bank's global assistance for HIV/AIDS and issued its report. 2005 AFTQK established an escrow account to support problem projects and encouraged all HIV projects to utilize this fund to address challenges. April 2006 The Africa Region reviewed all active HIV projects in collaboration with HDNGA, AFTHD, LEGAF, and HDNGA to assess implementation risks and opportunities to incorporate recommendations from the MAP interim review and OED evaluation. May 2006 ACTafrica and HDNGA conducted MAP TTL training on monitoring and evaluation and appropriate indicators. August 2006 The Africa Region established a core team to review and lead the work on restructuring (retrofitting) projects for improved performance and incorporate recommendations from MAP interim review and OED evaluation. Led by ACTafrica and AFTHD, the core team includes LEGAF, LOA, HDNGA (GAMET) and AFTRL. October 2006 Africa Region and HDNGA (GAMET) finalized a Generic Results Framework (GRF) and Results Score Card for all HIV projects inclusive of IDA-14 and UNGASS indicators, Africa Action Plan indicators and indicators from national M&E plans. 52 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Timeline Action Taken 2006 - Ongoing ACTafrica intensified technical assistance to operations by supporting project supervision, portfolio monitoring, and ISR reviews and by extending both financial and technical support to problem projects. HDNGA/ACTafrica further intensified monitoring and evaluation assistance in support of donor harmonization and alignment and strengthening of national AIDS strategies and plans through ASAP. 2006 - Present Africa Region began updating its 1999 HIV/AIDS strategy and developing an Africa AIDS Agenda for Action for 2007-2011. Consultations are ongoing with civil society, donors, stakeholders and countries, trade unions, UN agencies, private sector, youth, women's groups, global health partners working on sexual and reproductive health and Tuberculosis and Malaria. February 2007 Umbrella restructuring proposal of MAP projects was presented to the Board. The proposed restructuring took into account the findings from the MAP interim review, OED/IEG evaluation of global HIV projects, latest scientific evidence on prevalence, changed global financial architecture as well as agreement on the "Three Ones" by the global development community and governments on HIV and AIDS. April 2007 Progress on Africa AIDS Agenda for Action 2007-2011 was presented as part of the Africa Action Plan update during Annual Spring meetings. 53 The ANNEX 5 ­ Agenda for Action Consultations World Table 19: Agenda for Action Consultations Bank' Event Overview Broad Priority Areas Bank Comparative Specific Themes For Bank Resources Bank Weaknesses sAfric Advantage Bank And Institutional Structure aRegion Toronto HIV/AIDS a development "Three Ones" support Multi-year, sustainable Local response and "Financial gap" Apparent insufficient Stakeholder issue and a priority Alignment and harmonization financing prevention experience provider, utilizing its commitment/priority by Bank HIV/AID Consultations MDG responsibilities with other partners Integrated health sector various financing to long-term HIV/AIDS effort with Panelists response instruments Multi-sectoral engagement engagement Inadequate coordination with S (August 13, 2006) National capacity HQ and field presence health and other sectors Agend strengthening to support national Neither mainstreaming nor HIV/AIDS deliberation Regional programs and budget support translating and response emergency responses into HIV/AIDS resources afor Analytical capacity Action 2007 ASAP Alignment and harmonization National capacity HQ and field presence Absence of engaged field 54 Consultations with other partners strengthening to support national presence, technical expertise -2011 with UNAIDS HIV/AIDS deliberation (August 17, 2006) and response TTL Consultations MDG responsibilities Alignment and harmonization Africa-wide MAP Local response and "Financial gap" Apparent insufficient (September 18, Multi-sectoral engagement with other partners experience prevention experience provider, utilizing its commitment/priority by Bank 2006) various financing to long-term HIV/AIDS effort Knowledge management Multi-sectoral approach Integrated health sector response instruments and analytical capacity National capacity engagement Absence of engaged field HQ and field presence presence, technical expertise Convening power strengthening experience Scaling up good practices to support national Insufficient Bank staff HIV/AIDS deliberation incentives to pursue and response HIV/AIDS track Neither mainstreaming nor budget support translating into HIV/AIDS resources Absence of "ring-fenced financing" and BB support results in reduction of Bank HIV/AIDS support Insufficient awareness of reputational risks and governance considerations The Event Overview Broad Priority Areas Bank Comparative Specific Themes For Bank Resources Bank Weaknesses World Advantage Bank And Institutional Structure Bank' UNAIDS/Eastern Macro-economic access "Three Ones" commitment Multi-year, sustainable Local response and Financial gap provider, Absence of engaged field and Southern and dialogue Alignment and harmonization financing prevention experience utilizing its various presence, technical expertise sAfric Africa Knowledge management with other partners National capacity Regional programs and financing response Rigidity of fiduciary rules (September 23, and analytical capacity instruments Fulfill donor of last resort as strengthening experience emergency responses Need for a significant aRegion 2006) Convening power to inadequately treated Analytical work presence in southern Africa and/or sensitive issues and marginalized groups HIV/AID UN Agencies with MDG responsibilities Fulfill donor of last resort as Africa-wide MAP Local response and Financial gap provider, Absence of engaged field S Agend NY HQ Macro-economic access to inadequately treated experience prevention experience utilizing its various presence, with technical (September 28, and dialogue and/or sensitive issues and National capacity Integrated health sector financing response expertise 2006) marginalized groups instruments Convening power strengthening experience engagement Rigidity of fiduciary rules afor Regional programs and Need for a significant Action emergency responses presence in Southern Africa 2007 MDG responsibilities Alignment and harmonization Fiduciary expertise Local response and Rigidity of fiduciary rules 55 GFATM/Geneva -2011 (October 2, 2006) Macro-economic access with other partners National capacity prevention experience and dialogue strengthening experience Integrated health sector Knowledge management Support to national AIDS engagement and analytical capacity institutions, especially in costing, fiduciary and M&E UNAIDS/ Macro-economic access Alignment and harmonization Fiduciary expertise Analytical work (including Apparent insufficient Geneva and dialogue with other partners Multi-year, sustainable analysis of the financial commitment/priority by Bank consequences of "universal to long-term HIV/AIDS effort (October 2, 2006) Multi-sectoral engagement (contribute to it becoming a financing access") Convening power reality via support for Absence of engaged field independent monitoring of Local response and presence, with technical organization behaviors) prevention experience, expertise, and continuity including the private sector Lack of vision in integrating National capacity HIV/AIDS and health strengthening and need to systems do more at sub-national M&E effort needs to be better levels coordinated (GAMET and UNAIDS) The Event Overview Broad Priority Areas Bank Comparative Specific Themes For Bank Resources Bank Weaknesses World Advantage Bank And Institutional Structure Bank' WHO/Geneva Macro-economic access Discard notion of dichotomy National capacity Integrated health sector Rigidity of fiduciary rules (October 3, 2006) and dialogue between vertical versus strengthening experience engagement Africa MAP was isolated from sAfric Multi-sectoral/dimension horizontal programs, and Multi-year, sustainable other partner efforts engagement invest in both in a mutually financing reinforcing manner aRegion MDG responsibilities Fiduciary expertise (coupled with concern for equity in access and HIV/AID treatment) S Agend UNHCR/Geneva Multi-sectoral engagement Alignment and harmonization Multi-year, sustainable Regional programs and Apparent insufficient (October 3, 2006) Convening Power, with other partners financing emergency responses commitment/priority by Bank especially in inherently Local response and to long-term HIV/AIDS effort afor risky countries and prevention experience, in in refugee environments Action environments particular in income generation activities 2007 56 Nairobi Regional Multi-sectoral/dimension Alignment and harmonization Multi-year, sustainable Scaling up good practices Financial gap provider, Apparent insufficient -2011 Consultations on engagement with other partners, financing Local response and utilizing its various commitment/priority by Bank Civil Society Macro-economic access especially in the health sector National capacity prevention experience financing response to long-term HIV/AIDS effort Response and dialogue "Three Ones" commitment strengthening experience, instruments, Regional programs and Rigidity of fiduciary rules (May 8-11,2006) particularly for civil Knowledge management (but adapt M&E to the reality including strategic plans emergency responses society Absence of engaged field and analytical capacity of each country) and action plans Integrated health sector presence, with technical HQ and field presence engagement expertise, and continuity to support national HIV/AIDS deliberation Need for a significant and response presence in Southern Africa. The Event Overview Broad Priority Areas Bank Comparative Specific Themes For Bank Resources Bank Weaknesses World Advantage Bank And Institutional Structure Bank' Donor Convening power Alignment and harmonization National capacity Analytical work (including As an important Apparent insufficient Consultations Macro-economic access with other partners, strengthening experience, analysis of the financial financer, utilize its commitment/priority by Bank sAfric (London, October and dialogue (PRSP, particularly with the GFATM, including technical consequences of "universal various financing to long-term HIV/AIDS effort, 23, 2006) MTEF) and especially in the health assistance and training, in access") response instruments, coupled with current absence sector various aspects, including of key management aRegion Knowledge management Scaling up good practices particularly for civil strategic plans and action leadership and analytical capacity society plans Local response (civil society, Absence of engaged field HIV/AID Capacity to consider the private sector, NGOs) IDA-15 represents an Support to national AIDS presence, with technical multi-sectoral dimensions/ opportunity to revisit institutions, and prevention experience expertise, and continuity to engagement the ways and means to S especially in costing, Regional programs and maintain Bank engage in country dialogue Agend fiduciary and M&E emergency responses involvement and Uncertain extent to which Multi-sectoral approach via Integrated health sector momentum in GTT recommendations have mainstreaming or engagement responding to been adopted/embedded in afor integrating HIV/AIDS into HIV/AIDS Bank approach Action sector policies and Need for a significant programs, and presence in Southern Africa 2007 development of sectoral or Neither mainstreaming nor 57 topic specific guidelines budget support translating -2011 into HIV/AIDS resources Absence of "ring-fenced financing" and BB support results in reduction of Bank HIV/AIDS support Countries and Accelerating attention to Effective approaches and Advocate for Enhance youth capacity on Lack of specific focus on Youth and implementation of partnerships for addressing mainstreaming of youth in development concepts, youth HIV interventions (Johannesburg, youth activities youth government budget lines agendas, and frameworks Lack of segmentation February 2007) Improved integration of Strengthen linkages between and national frameworks e.g., PRSPs, budgeting, catering to varying needs of adolescent HIV and sexual adolescent reproductive Be a knowledge bank monitoring and different youth groups ­ reproductive health health and HIV services accountability Convening authority for limited attention to rural youth services Strengthen M&E and the dialogue with development Advocate flexibility in and gender differentiation Multi-sectoral engagement evidence base for youth- partners and government registration and mechanisms Inadequate consideration of friendly services and for youths to access Work with regional the 10-14 age group interventions resources establishments Weak youth participation in Alignment and harmonization Take leadership to bring key policy and programming with other partners groups together and give a decisions voice to youth Intensify analytical work, document and disseminate best practices and lessons learned The ANNEX 6 ­ Agenda for Action: Implementation Plan and Results Framework World Table 20: The Foundation - Renew the Commitment Bank' The Foundation: Renew the Commitment sAfric Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability7 aRegion 0.1. Respond to 0.1.1 Sustained support for HIV/AIDS to fill financial gaps for · At least $250 million · Predictable, flexible · Availability of IDA AFRLT (Regional HIV/AID country demand for the next five years. committed annually for the and sustainable IDA financing Leadership Team), predictable, flexible 0.1.2 Provide safety net financing for countries in the context next 5 years, including IDA, financing for · Financing from other HDNGA, ACTafrica and sustainable IDA of creating fiscal space for HIV/AIDS. PRSCs, ACGF, and IDF HIV/AIDS provided development partners PREM, IMF S financing for Agend · Financing gap studies remains unpredictable HIV/AIDS. completed in at least 10 and volatile countries (IDA and non- · Low country demand for afor IDA) IDA financing due to Action competing priorities 2007 0.2. High-burdened 0.2.1 Provide innovative financing to IBRD countries e.g., · Number of countries where · Technical and · Lack of instruments to AFRLT, ACTafrica 58 middle-income buydowns. the Bank responds to financial assistance engage high-burdened -2011 countries' access to 0.2.2 IDF grant financing provided for capacity building. country demands and accessible to high- MICs technical and/or supports AIDS responses burdened middle- · Weak donor commitment financial assistance 0.2.3 Analytical work on macro impact and regional and cross- through grants, loans, income countries to support innovative increased. border issues. blended instruments and/or 0.2.4 Conduct strategic analysis to identify new lending · Effective policy financing in middle knowledge support, policy instruments that are attractive to IBRD countries and focused dialogue income countries dialogue and capacity on increasing lending for HIV/AIDS. building · Effective partnerships · Continued scarce financing from other · Number of analytical · Cross regional/ donors in MICs studies completed country learning 7World Bank Unit acronym definitions available on request. The The Foundation: Renew the Commitment World Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability7 Bank' 0.3. Support to sub- 0.3.1 Provide financing to countries, including post-conflict · At least 2 new sub-regional · Improved HIV/AIDS · Lack of grant financing AFRLT, ACTafrica, sAfric regional and cross- countries, for regional HIV/AIDS response. operations approved in the awareness and · Weak institutional AFTHD AFCRI border initiatives 0.3.2 Design regional cross-border projects that address next 5 years prevention efforts capacity at regional level provided. aRegion vulnerable populations, e.g., refugees and IDPs. through sub-regional and cross-border · Lack of commitment to initiatives sub-regional initiatives HIV/AID · Realization of externalities S · Positive spill over Agend effects for more effective customs procedures and afor clearances Action 0.4. Africa HIV 0.4.1 Obtain financing for Africa HIV/AIDS incentive fund for · Incentive fund finances 5 · Critical analysis and · Lack of grant funding ACTafrica, CDMAP 2007 Incentive Fund to analysis, policy advice and capacity building in technical support products policy guidance 59 · Weak Bank commitment provide support for project/program preparation. per year achieved -2011 project/program 0.4.2 Use the funds to conduct policy dialogue, analytical work · Lack of commitment to a · Mainstreaming guidelines · Scaled-up multi- development, policy and capacity building in line with the AAP and CDMAP. multi-sectoral response developed for different sectoral responses in advice and capacity sectors key sectors building created. Assist teams to design HIV/AIDS interventions in sectoral investments. · Number of sectoral projects with HIV/AIDS components 0.5. Bank's senior 0.5.1 Bank's senior management reiterates commitment · HIV/AIDS included in · Senior Management · Competing priorities AFRLT, EXT, WBI, management through speeches, memos and discussions with partners. senior management speeches related to · Senior management fails UNDP, UNAIDS commitment to 0.5.2 HIV/AIDS continues to be a flagship program in the speeches and discussions the Bank's to enforce commitment HIV/AIDS renewed Africa Action Plan. with partners commitment to through regular reporting through inclusion and combating HIV/AIDS from CMUs on how action in all channels 0.5.3 Engage high-level policy makers to advocate for reflected in national HIV/AIDS is being of policy dialogue. HIV/AIDS response. and/or international addressed and on media harmonizing HIV/AIDS efforts The Table 21: Pillar 1 -Strengthened Long-Term Sustainable National Response World Pillar I: Strengthened Long-Term Sustainable National Response Bank' Pillar I: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability sAfric Focus the Response, 1.1. Appropriate 1.1.1 Review at least 10 CASs and · HIV/AIDS included in · HIV/AIDS addressed · Lack of management AFRLT, ACTafrica, through Evidence- HIV/AIDS efforts ISNs and 6 PRSPs to ensure HIV/AIDS all PRSCs appropriately through leadership WBI, UNDP, HDNGA, aRegion Based and integrated into is appropriately addressed. PREM, IMF · HIV/AIDS integrated countries' and Bank · Declining political Prioritized HIV/AIDS countries' development 1.1.2 Assure appropriate priority to into at least 75% of development agenda commitment Strategies agendas and Bank HIV/AID HIV/AIDS in PRSPs. PRSPs, CASs and instruments (policy · Fiscal space issues and ISNs prepared each procedures). 1.1.3 Bank support to incorporate long-term financial HIV/AIDS into guidelines and year sustainability issues not S Agend processes for preparing Medium-Term · Develop relevant tools adequately addressed. Expenditure Frameworks and annual to design MTEF budgets. · Poor coordination between IDA and IMF afor Action 1.2. Bank support to 1.2.1 Assist countries to analyze · 5 countries where · Improved evidence- · Lack of country level and ACTafrica, AFTHD, developing prioritized epidemics and optimal responses. epidemiological based country Bank expertise in HDNGA 2007 responses to diverse studies have been responses to differing supporting analytical work, 60 epidemics provided. 1.2.2 Provide financial, technical and -2011 analytical support to countries to conducted and epidemics as well as an adequate understand country epidemics, potential responses budget including the drivers of the epidemic formulated and to establish surveillance systems. 1.2.3 Conduct sub-regional epidemiological studies. 1.3. Bank support in 1.3.1 Support and build capacity in 20 · 20 countries over the · Strengthened · Unpredictable donor HDNGA, ASAP, capacity building to countries to develop prioritized, costed next 5 years have the capacity to develop financing to support UNAIDS, ACTafrica develop prioritized, and national strategies and annual action capacity to develop prioritized and costed national programs costed national plans. prioritized and costed national action plans · Lack of expertise for strategies and action 1.3.2 Provide technical support to strategies in 20 countries strategic planning and plans provided. countries for developing national costing work strategic planning. · Weak capacity for 1.3.3 Provide technical, financial and planning and program analytical support for better country- design specific HIV/AIDS program planning. The Pillar I: Strengthened Long-Term Sustainable National Response World Pillar I: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability Bank' Focus the Response, 1.4. Integration of TB, 1.4.1 Conduct operational research on · At least 60% of new · World Bank projects · Lack of technical expertise HDNGA, ACTafrica, sAfric through Evidence- reproductive health, integrating services within HIV/AIDS operations addressing HIV/AIDS and/or incentives to AFTHD, WHO, Based and Prioritized malaria and nutrition epidemiological context. have an integrated integrate TB, integrate UNFPA, UNICEF HIV/AIDS Strategies into World Bank aRegion 1.4.2 Ensure that the WB HIV/AIDS approach to SRH, TB reproductive health, · Institutional structures with HIV/AIDS products products address integration of TB and malaria malaria and nutrition different vertical units in ensured. reproductive health, malaria and · 3 country assessments when appropriate to MOH HIV/AID nutrition. would be conducted epidemiological · Donor procedures that 1.4.3 Actively participate in inter-agency and action plans to context hinder integration working groups on integrating HIV and integrate TB, malaria S Agend RH, and HIV and TB. and HIV developed · Intensify efforts in 9 high-TB-burden afor countries as well as Action high-burden HIV/AIDS countries 2007 · Good practices on 61 integration will be -2011 documented and disseminated 1.5. Good practices in 1.5.1 Conduct operations research, · At least 5 operational · Operational research · Lack of financing to AFTHD, AFTQK, HIV/AIDS programs including cost-effectiveness studies, on studies over the next and documentation of conduct operations ACTafrica, HDNGA based on operational success and failures in HIV/AIDS five years good practices in research research shared. programs. HIV/AIDS programs widely shared with countries and development partners The Table 22: Pillar II - Accelerated Implementation of HIV/AIDS Programs World Pillar II: Accelerated Implementation of HIV/AIDS Programs Bank' Pillar II: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability sAfric Scale-up targeted 2.1 HIV/AIDS policy, 2.1.1 Strengthen sectoral · Number of countries · Improved country · Lack of country commitment HDN, AFTHD, PREM, multi-sectoral and programs and service institutional capacity to scale up where Bank supports capacity in key sectors to from key sectors, including IFC, ACTafrica, aRegion civil society delivery integrated in and supervise HIV/AIDS-related institutional capacity implement multi-sectoral inadequate resources AFTPS, AFTEG, response priority sectors activities. building activities in approaches · Lack of clarity and guidance AFTTR, AFTU, AFTRL (dependent upon country 2.1.2 Conduct operational priority sectors · Increased commitment in from Management as well as HIV/AID context). research on multi-sectoral · At least 2 operational key Bank sectors to adequate budget to prevention, including pilot research studies include HIV/AIDS integrate HIV into sectoral testing of promising S documenting promising component or sub- activities Agend approaches. approaches to on multi- components in lending · Limited funds to conduct 2.1.3 In collaboration with the sectoral prevention and non-lending adequate supervision of IFC, support capacity building activities, including HIV/AIDS components in afor in the private sector to scale up adequate resources other projects Action its response. 2007 2.2 Bank support to care 2.2.1 Support care and · Number of countries · Capacity of NGOs and · Lack of government interest ACTafrica, CMUs, 62 and mitigation services mitigation service providers where HIV/AIDS care CBOs strengthened to engage civil society AFTHD, Other donors -2011 through civil society through civil society and mitigation services· Civil society continues to organizations continued. organizations and build are supported by civil be an integral part of the capacity of NGOs. society national solution to address HIV/AIDS 2.3 Bank support to 2.3.1 Support analytical work to · 5 pieces of analytical · Increased awareness of · Lack of country commitment PREMGE, AFTPM, address HIV-related identify specific actions which work specific steps to to implementing specific ACTafrica, AFTQK, gender inequality issues. would contribute to changing HDNGA, AFTHD, WBI · At least two knowledge- designing and actions to address HIV- inappropriate gender responses IFC, AFTPS, AFTEG, sharing events implementing gender- related gender inequalities to the epidemic. AFTTR, AFTU, AFTRL conducted on the gender appropriate HIV · Lack of support from Bank 2.3.2 Conduct knowledge dimensions of HIV/AIDS interventions management to dedicate sharing workshops to build on · Analytical work in the time and resources to analytical work findings and to · Develop appropriate sectors address gender operational research or build capacity among decision M&E indicators inequalities implementation of gender- makers to address gender and specific responses legal dimensions of HIV/AIDS among law, justice, medical and health professionals. The Pillar II: Accelerated Implementation of HIV/AIDS Programs World Pillar II: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability Bank' Scale-up targeted 2.4. Bank support to 2.4.1 Strengthen programs to · Number of countries · All education and social· Lack of country leadership in HDNED, ACTafrica, multi-sectoral and prevention and programs increase access to school of where Bank supports protection sector the education sector AFTSP, HDNSP sAfric civil society for youth and OVCs HIV/AIDS orphans. Address youth and OVCs investments include Children and Youth · Stigma continues response intensified. stigma in school-based HIV/AIDS prevention, Group, aRegion programs and learning. mitigation, social UNFPA, UNESCO, Strengthen school health protection and support UNICE, UNAIDS programs; disseminate good activities HIV/AID practice examples in school- based prevention programs, continue to improve the role of S Agend teachers in addressing HIV/AIDS; coordinate with partners and local experts. afor 2.4.2 Collaborate with the Action Bank's Social Protection sector to scale up mitigation efforts and conduct analytical work on 2007 63 orphans and affected families. -2011 2.5 Support to strengthen 2.5.1 Through the · At least 50% of new · Improved synergy · Lack of collaboration HDNHE, AFTHD WHO elements of the health implementation of the 2007 HIV/AIDS operations between HNP and between MOH and National UNFPA, UNICEF, system that challenge HNP strategy to strengthen address and support HIV/AIDS operations AIDS Commissions on ACTafrica HIV/AIDS programs. health systems, support health system resource allocation for health provided to human resources, challenges vis-à-vis systems supply chain management, HIV/AIDS · Agreement on a clear M&E, and health infrastructure, · 60% of HNP operations division of labor within the especially laboratory and address health system Bank as well as with its pharmaceutical services. challenges partners. · Health systems do not adequately address all implementation constraints, e.g., fiduciary and supply chain management The Pillar II: Accelerated Implementation of HIV/AIDS Programs World Pillar II: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability Bank' Scale-up targeted 2.6 Bank support to 2.6.1 Support the inclusion of · Number of key sector · Prioritized support to key· Lack of adequate and ACTafrica, IFC, multi-sectoral and known multi-sectoral HIV/AIDS components in projects with AIDS public sector and non- technical resources to AFTPS, AFTEG, sAfric civil society prevention approaches Transport and Infrastructure components public sector entities prepare and supervise AIDS AFTTR, AFTU, response and tools increased. sectors, including the having maximum impact components AFTHD, AFTRL aRegion preparation of an HIV/AIDS on the ground · Sector Focal persons not transport corridor project in identified Southern Africa. Require HIV/AID construction contracts to include HIV/AIDS-prevention activities. S Agend 2.6.2 Urban: continue efforts to support local governments' response to HIV/AIDS, afor including developing and Action updating monitoring and training tools and incorporating HIV/AIDS components in urban 2007 64 operations. -2011 2.7 Strengthen community 2.7.1 Provide technical support · Number of countries with · Capacity strengthened in · Lack of absorptive capacity ACTafrica, HDNGA, response and evaluate its to HIV/AIDS projects to revised and simplified designing and at the community level DEC, AFTSD effectiveness. strengthen, simplify and focus community HIV/AIDS implementing · High fiscal costs and community level interventions. response guidelines and decentralized multi- sustainability concerns 2.7.2 Conduct social trained personnel sectoral responses assessments and impact · National governments · Number of · More effective evaluation studies on unwilling to directly fund social/behavioral community responses community-based HIV/AIDS communities. assessments and impact interventions, including evaluations regarding · Lack of capacity at national identification of good practices. the effectiveness of and regional levels to train community based and support communities HIV/AIDS interventions The Table 23: Pillar III - Strengthened National Systems World Pillar III: Strengthened National Systems (Financial Management, Human Resources, Procurement, Supply Chains, Health And Social Systems) Bank' Pillar III: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability sAfric Deliver Effective 3.1. Ongoing HIV/AIDS 3.1.1 Complete restructuring of · 13 ongoing projects · Improved HIV/AIDS · IEG and Africa region ACTafrica, AFTQK Results through projects retrofitted with MAP project development reviewed and adjusted portfolio methodology in assessing aRegion increased country realistic goals and objectives and performance to realistic objectives · MAP projects evaluated project successes M&E capacity indicators. indicators. Technical support and goals on realistic goals and · Weak country support to HIV/AID teams to support country project indicators restructure teams. 3.2. Harmonized M&E 3.2.1 Assist countries to establish · 8 additional countries · In the next 5 years, all · Availability of resources to HDNGA, ACTafrica, S Agend frameworks at the monitoring systems. supported over five countries have a support technical support GAMET, UNAIDS country level 3.2.2 Develop and implement years to establish a functional, harmonized · Willingness of countries and strengthened. project performance early warning harmonized HIV/AIDS M&E system reporting partners to reduce number of afor system. monitoring system and using data indicators and implement the Action 3.2.3 Institutionalize the use of · Bank to continue to play principle of the "Three Ones" HIV/AIDS Results Scorecard. a leading role (GAMET) 2007 3.2.4 Conduct regional and in supporting countries 65 national M&E training courses. -2011 3.2.5 Train M&E specialists, building national capacity, gradually reducing the need for external support. 3.3. Countries' 3.3.1 Conduct country · 5 country epidemiology · National systems · Country commitment and ACTafrica, HDNGA surveillance systems epidemiology studies. studies conducted over strengthened for demand for capacity building strengthened and five years improved understanding to strengthen surveillance epidemiologic studies of the drivers of the conducted. epidemic 3.4. Bank studies of 3.4.1 Conduct analytical work and · 3 analytical · Evidence-based · Weak country commitment ACTafrica, HDNGA vulnerable groups in operations research on vulnerable studies/operations responses developed to work with vulnerable countries conducted. population needs with the aim of research completed on · Best practices groups informing policy dialogue. best practices and cost- disseminated · Weak capacity 3.4.2 Sharpen the HIV/AIDS effective interventions support to ensure that vulnerable · Vulnerable group · Stigma of vulnerable groups · Support 3 regional groups are appropriately targeted networks strengthened continues meetings with groups and their networks strengthened. working with vulnerable groups · 3 operations research studies The Pillar III: Strengthened National Systems World (Financial Management, Human Resources, Procurement, Supply Chains, Health And Social Systems) Pillar III: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability Bank' Deliver Effective 3.5. Countries' existing 3.5.1 Improve existing governance · Assessment of select · Governance and · Inadequate financial and PREM, INT, AFTQK, sAfric Results through governance structures, structures, public sector MAP projects on accountability improved technical resources HDNGA, ACTafrica, increased country public sector management and transparency governance and · Demand for · Lack of country commitment WBI, OPCS aRegion M&E capacity management, and mechanisms and generate accountability completed accountability generated to address corruption transparency demand for better accountability at · Institutional at the grass roots mechanisms improved the community level. assessments conducted HIV/AID with demand for 3.5.2 Assist countries strengthen · Improved institutional in 3 counties accountability at the fiduciary capacity. capacity and governance community level · Training activities structures S generated. 3.5.3 Assist countries streamline conducted in Agend administrative structures. collaboration with WBI 3.5.4 Integrate governance, accountability and anticorruption afor (GAC) into all new HIV/AIDS Action operations in collaboration with WBI. 2007 66 3.6. Knowledge 3.6.1 Provide operational support · One regional · Design and impact of · Continued financing for HDNGA, GAMET, -2011 generation and sharing in design and impact of HIV/AIDS consultation per year to HIV/AIDS investments annual knowledge learning ACTafrica, AFTQK, to improve interventions in sector encourage cross-country based on knowledge events in the region DEC, WBI prioritization, decision- investments. learning sharing · Coordination with other making and program 3.6.2 Engage countries and · Macro- economic · Countries and partners development partners. design supported. partners in knowledge generation analytical work and fully engaged in and sharing. financial sustainability knowledge generation studies conducted and sharing 3.7. Good practice case 3.7.1 Prepare good practice notes · 5 good practices notes · Improved country and · Available resources to GAMET, ACTafrica, studies to support that highlight examples of on national responses cross-country learning identify good practices and AFTQK, AFTHD, cross country learning promising national responses to · 2 workshops to share disseminate them. TTLs, WBI and knowledge sharing HIV/AIDS. experiences generated. 3.7.2 Develop and promote good practice guidelines by using selected case studies that illustrate common implementation constraints. 3.7.3 Support networks of program practitioners to exchange experiences, knowledge and practical advice on general operational issues. The Table 24: Pillar IV - Strengthened Donor Coordination World Pillar IV: Strengthened Donor Coordination Bank' Strategic Pillar IV: Specific Objectives Specific Actions Indicators Anticipated Results Critical Risks Accountability sAfric 4.1.Collaboration with key 4.1.1 Support countries HDNGA, ACTafrica, Harmonize Donor · Comply with and report · Better implementation of · Partners' readiness to take partners to harmonize extensively in areas where WB GAMET, AFTQK, Collaboration on Paris Declaration the global division of actions to align and aRegion and strengthen national is designated lead technical indicators labor harmonize M&E processes PREM network, M&E systems, HR organization. · Number of PERs · GAMET to continue to UNAIDS, GFATM, capacity, procurement 4.1.2 Work with key partners to conducted which include support countries to PEPFAR HIV/AID and supply chains harmonize and strengthen an HIV/AIDS strengthen M&E in close strengthened. national M&E systems, component. collaboration with other S procurement and supply chains. · Public sector partners Agend 4.1.3 Work with countries and management conducted Bank project teams to improve planning, budgeting, program · Proportion of countries afor design, financial management, with performance-based Action disbursement, procurement and procedures expenditure tracking. 2007 67 4.2. Joint planning and 4.2.1 Conduct joint planning · All countries moved · More efficient, effective · Lack of country ownership in HDNGA, ACTafrica, -2011 analytical work with and analytical work with towards joint annual and sustainable enforcing partners to move WBI, AFTQK, UNAIDS and other UNAIDS and other partners. national program HIV/AIDS resource in this direction UNAIDS, GFATM, partners increased. 4.2.2 Conduct strategic reviews and planning allocation · Lack of donor commitment to PEPFAR planning training courses to harmonize train national counterparts, Bank staff, development partners and consultants in strategic planning. 4.2.3 Support country practitioners' networks to contribute to strategic planning. 4.3. Bank's participation 4.3.1 Advocate and assist · Number of joint missions · Harmonized planning · Willingness of Bank units to WBI, HDNGA, in joint annual planning practitioners' networks to · Number of countries with and implementation participate ACTafrica, GAMET, with partners increased. contribute to strategic planning. one coordinating body · Inability of donors to UNAIDS, GFATM, 4.3.2 Participate in joint annual schedule joint activities PEPFAR partner meetings. The ANNEX 7 ­ HIV/AIDS Portfolio for Africa (1989-2007) World Table 25: Closed MAP and Stand Alone Projects Bank' CLOSED MAP and STAND-ALONE PROJECTS sAfric Country Project ID Project Title FY Approved FY Closed Closing Date Committed* aRegion Congo, DR P003116 National AIDS Control Program 1989 1995 12/31/1994 8.1 Zimbabwe P003333 Sexually Transmitted Infections 1993 2001 12/31/2000 64.5 HIV/AID Uganda P002963 Sexually Transmitted Infections 1994 2003 12/31/2002 50.0 Kenya P001333 SEXUALLY TRANSMITTED Infections Project 1995 2001 6/30/2001 40.0 S Eritrea P065713 ER-AIDS, Mal, STD, TB Cntrl APL (FY01) 2001 2006 3/31/2006 40.0 Agend Ethiopia P069886 ET-MAP (FY01) 2001 2007 12/31/2006 59.7 Gambia, The P060329 GM-HIV/AIDS Rapid Response (FY01) 2001 2007 12/31/2006 15.0 afor Ghana P071617 GH-AIDS GARFUND Response Proj (FY01) 2001 2006 12/31/2005 25.0 Action Kenya P070920 KE-HIV/AIDS Disaster Resp (FY01) 2001 2006 12/31/2005 50.0 Uganda P072482 UG-HIV/AIDS Control SIL (FY01) 2001 2007 12/31/2006 47.5 2007 Benin P073118 BJ-HIV/AIDS Multi-Sec APL (FY02) 2002 2007 9/15/2006 23.0 68 -2011 SUBTOTAL 422.8 Table 26: Closed Projects with HIV/AIDS Components CLOSED PROJECTS WITH HIV/AIDS COMPONENTS** Country Project ID Project Title FY Approved FY Closed Closing Date Committed* Angola P000048 HEALTH 1993 2000 12/31/1999 6.8 Burkina Faso P000308 POPULATION/AIDS CONTROL 1994 2002 9/30/2001 8.2 Comoros P000596 POP & HUMAN RESOURCE 1994 2000 6/30/2000 2.2 Chad P035601 POPULATION & AIDS CONTROL 1995 2002 12/31/2001 6.9 Cote d'Ivoire P001214 CI-Integ Health Serv Deliv (FY96) 1996 2005 12/31/2004 6.2 Eritrea P043124 National Health Devl. 1998 2005 12/31/2004 4.6 Gambia, The P000825 GM-Participatory HNP SIL (FY98) 1998 2005 6/30/2005 3.1 Malawi P001670 MW-Secondary Education (Fy98) 1998 2006 12/31/2005 6.3 Guinea P041568 Pop. & Reprod. Health 1999 2004 12/31/2003 2.3 Lesotho P056416 2nd Education Sector Dev. Proj (Phase 1) 1999 2004 12/31/2003 2.7 Malawi P036038 Pop./Family Planning 1999 2004 12/31/2003 1.0 Burundi P064556 Emergency Economic Recovery Credit 2000 2003 10/30/2002 6.0 Lesotho P053200 Health Sector Reform 2000 2005 6/30/2005 2.1 The CLOSED PROJECTS WITH HIV/AIDS COMPONENTS** World Country Project ID Project Title FY Approved FY Closed Closing Date Committed* Bank' Nigeria P066571 2nd Primary Educ. 2000 2005 12/31/2004 9.4 Tanzania P058627 Health Sector Development Program 2000 2004 12/31/2003 6.4 sAfric Zambia P063584 ZM-ZAMSIF (FY00) 2000 2006 12/31/2005 12.9 Zambia P064064 ZM-Mine Township Srvc SIL (FY00) 2000 2006 12/31/2005 4.9 aRegion Mali P040650 Edu Sec Exp Prgm APL (FY01) - (PISE) 2001 2007 12/31/2006 6.3 Congo Republic P074006 CG-Emerg Infrast Rehab & Living Cond Imp 2002 2007 1/31/2007 5.2 HIV/AID Nigeria P071494 NG-Univ Basic Edu (FY03) 2003 2006 6/30/2006 10.0 Malawi P072395 MW-FIMAG SAL (FY04) 2004 2006 6/30/2006 7.0 S Cameroon P100965 CM-Debt Relief Grant DPL (FY06) 2006 2007 12/30/2006 4.4 Agend SUBTOTAL 124.8 TOTAL CLOSED PROJECTS 547.6 afor Action NOTES: *Commitment amounts are in the dollar value at the time of approval. **Commitment amounts for projects with HIV/AIDS components reflect the HIV/AIDS component amount, not the entire project amount. 2007 69 -2011 The Table 27: Active MAP and Stand Alone HIV/AIDS Projects World ACTIVE MAP and STAND-ALONE HIV/AIDS PROJECTS Bank' Country Project ID Project Title Approval FY Approval Date Closing Date Commitment* Cameroon P073065 CM-MultiSecal HIV/AIDS SIL (FY01) 2001 1/12/2001 6/30/2007 50.0 sAfric Kenya P066486 KE-Decentr Reprod Hlth & HIV/AIDS (FY01) 2001 12/12/2000 6/30/2007 50.0 Burkina Faso P071433 BF-HIV/AIDS Disaster Response APL (FY02) 2002 7/6/2001 6/30/2007 22.0 aRegion Burundi P071371 BI-MultiSec HIV/AIDS & Orph APL (FY02) 2002 6/27/2002 11/30/2008 36.0 Cape Verde P074249 CV-HIV/AIDS APL (FY02) 2002 3/28/2002 12/31/2008 9.0 HIV/AID Central African Republic P073525 CF-HIV/AIDS (FY02) 2002 12/14/2001 6/30/2007 17.0 Chad P072226 TD-Pop & AIDS 2 (FY02) 2002 7/12/2001 9/30/2007 24.6 S Madagascar P072987 MG-MultiSec STI/HIV/AIDS Prev APL (FY02) 2002 12/14/2001 12/31/2007 20.0 Agend Nigeria P070291 NG-HIV/AIDS Prog Dev (FY02) 2002 7/6/2001 6/30/2007 90.3 Senegal P074059 SN-HIV/AIDS Prevent & Control APL (FY02) 2002 2/7/2002 9/30/2007 30.0 afor Sierra Leone P073883 SL-HIV/AIDS Response (FY02) 2002 3/26/2002 12/31/2007 15.0 Action Guinea P073378 GN-Multi-Sectoral AIDS SIL (FY03) 2003 12/13/2002 7/31/2008 20.3 Mozambique P078053 MZ-HIV/AIDS Response SIL (FY03) 2003 3/28/2003 12/31/2008 55.0 2007 Niger P071612 NE-MultiSec STI/HIV/AIDS 2 (FY03) 2003 4/4/2003 6/30/2008 25.0 70 -2011 Rwanda P071374 RW-MultiSec HIV/AIDS (FY03) 2003 3/31/2003 10/30/2008 30.5 Zambia P003248 ZM-Zanara HIV/AIDS APL (FY03) 2003 12/30/2002 2/28/2008 42.0 Congo, DR P082516 ZR Multi-sectoral HIV/AIDS 2004 3/26/2004 1/31/2011 102.0 Congo Republic P077513 CG-HIV/AIDS & Health SIL (FY04) 2004 4/20/2004 6/30/2009 19.0 Guinea-Bissau P073442 GW-HIV/AIDS Global Mitigation Sup (FY04) 2004 6/2/2004 12/31/2007 7.0 Malawi P073821 MW-Multi-sectoral AIDS - MAP (FY04) 2004 8/25/2003 12/31/2008 35.0 Mali P082957 ML-HIV/AIDS MAP (FY04) 2004 6/17/2004 7/31/2009 25.5 Mauritania P078368 MR-HIV/AIDS MultiSec Cntrl (FY04)-(PMLS) 2004 7/7/2003 3/31/2009 21.0 Sub-Regional P074850 3A-HIV/AIDS Abidjan Lagos Trnspt (FY04) 2004 11/13/2003 7/1/2007 16.6 Sub-Regional P082613 3A-Regional HIVAIDS Treatment Prj (FY04) 2004 6/17/2004 9/30/2007 59.8 Tanzania P071014 TZ-HIV/AIDS APL (FY04) 2004 7/7/2003 9/30/2008 70.0 Angola P083180 AO-HAMSET SIL (FY05) 2005 12/21/2004 6/30/2010 21.0 Burkina Faso P088879 HIV/AIDS Disaster Response Supplement 2005 5/3/2005 5.0 Eritrea P094694 ER-HIV/AIDS/STI/TB/Malaria/RH SIL (FY05) 2005 6/30/2005 6/30/2010 24.0 Lesotho P087843 LS-HIV/AIDS Cap Bldg TAL (FY05) 2005 7/6/2004 12/31/2008 5.0 Sub-Regional P080406 3A-ARCAN SIL (FY05) 2005 9/22/2004 6/30/2009 10.0 Sub-Regional P080413 3A-HIV/AIDs Great Lakes Init APL (FY05) 2005 3/15/2005 3/31/2009 20.0 Burkina Faso P093987 BF Health Sector Sup. & AIDS Proj (FY06) 2006 4/27/2006 6/30/2010 47.7 Ghana P088797 GH-Multi-Sector HIV/AIDS - M-SHAP (FY06) 2006 11/15/2005 6/30/2011 20.0 Madagascar P090615 MG-MultiSec STI/HIV/AIDS 2 (FY06) 2006 7/12/2005 12/31/2009 30.0 The ACTIVE MAP and STAND-ALONE HIV/AIDS PROJECTS World Country Project ID Project Title Approval FY Approval Date Closing Date Commitment* Bank' Benin P096056 BJ-HIV/AIDS SIL 2 (FY07) 2007 4/5/2007 12/31/2011 35.0 Cape Verde P101950 CV-HIV/AIDS MAP - Additional Financing (FY07) 2007 12/19/2006 5.0 sAfric Ethiopia P098031 ET-2nd Multi-Sectoral HIV/AIDS (FY07) 2007 3/8/2007 3/8/2007 30.0 Kenya P081712 KE-Total War Against HIV/AIDS (TOWA) 2007 06/26/2007 12/31/2011 80.0 aRegion Nigeria P105097 NG-HIV/AIDS APL - Additional Financing (FY07) 2007 5/22/2007 50.0 Rwanda P104189 RW-MultiSec HIV/AIDS - Additional Financing (FY07) 2007 2/1/2007 10.0 HIV/AID SUB-TOTAL 1,205.3 S Table 28: Active Projects with HIV/AIDS Components Agend ACTIVE PROJECTS WITH HIV/AIDS COMPONENTS** afor Country Project ID Project Title Approval FY Approval Date Closing Date Commitment* Action Guinea-Bissau P035688 National Health Development Prog 1998 11/25/1997 12/31/2007 2.2 Cameroon P048204 CM-CAPECE Env Oil TA (FY00) 2000 6/6/2000 11/30/2007 0.8 2007 71 Rwanda P045091 RW-Human Res Dev (FY00) 2000 6/6/2000 6/30/2008 8.0 -2011 Burundi P064961 BI-Pub Works & Employ Creation (FY01) 2001 1/23/2001 12/31/2007 16.2 Chad P035672 TD-Natl Transp Prgm Supt SIL (FY01) 2001 10/26/2000 1/31/2008 13.4 Zambia P057167 ZM-TEVET SIM (FY01) 2001 6/14/2001 12/30/2008 3.5 Burkina Faso P000309 BF-Basic Edu Sec SIL (FY02) 2002 1/22/2002 6/30/2008 4.2 Congo Republic P073507 CG-Transp & Gov CB (FY02) 2002 2/7/2002 12/31/2007 1.0 Eritrea P073604 ER-Emerg Demob & Reint ERL (FY02) 2002 5/16/2002 12/31/2007 7.8 Guinea P050046 GN-Education for All APL (FY02) 2002 7/24/2001 12/31/2007 15.4 Mozambique P001785 MZ-Roads & Bridges MMP (FY02) 2002 7/19/2001 6/30/2007 22.7 Mozambique P069824 MZ Higher Education SIM (FY02) 2002 3/7/2002 12/31/2007 8.4 Nigeria P069901 NG-Com Based Urb Dev (FY02) 2002 6/6/2002 6/30/2009 14.3 Rwanda P075129 RW-Emerg Demobiliz & Reintegr (FY02) 2002 4/25/2002 12/31/2007 3.3 Tanzania P047762 TZ-Rural Water Sply (FY02) 2002 3/26/2002 12/31/2007 4.4 Angola P078288 AO-Emerg Demob & Reinteg ERL (FY03) 2003 3/27/2003 12/31/2008 4.6 Chad P000527 TD-Edu Sec Reform (FY03) 2003 3/18/2003 6/30/2007 5.9 Ethiopia P044613 ET-RSDP APL1 (FY03) 2003 6/17/2003 6/30/2009 17.8 Ghana P073649 GH-Health Sec Prgm Supt 2 (FY03) 2003 2/6/2003 6/30/2007 15.2 Burundi P064876 BI-Road Sec Dev SIM (FY04) 2004 3/18/2004 12/31/2009 7.2 Burundi P081964 BI-Demobilization & Reint Prj (FY04) 2004 3/18/2004 12/31/2008 4.6 The ACTIVE PROJECTS WITH HIV/AIDS COMPONENTS** World Country Project ID Project Title Approval FY Approval Date Closing Date Commitment* Bank' Congo, DR P078658 CD-Emerg Demob Reintegr ERL (FY04) 2004 5/25/2004 3/31/2008 14.0 Ghana P050620 GH-Edu Sec SIL (FY04) 2004 3/9/2004 10/31/2009 15.6 sAfric Lesotho P081269 LS-ESDP II APL - Phase 2 (FY04) 2004 7/17/2003 12/31/2007 4.2 Sao Tome and Principe P075979 ST Social Sector Support 2004 5/18/2004 6/30/2009 1.1 aRegion Zambia P071985 ZM-Road Rehab Maintenance Prj (FY04) 2004 3/9/2004 6/30/2008 6.5 Angola P083333 AO-Emerg MS Recovery ERL (FY05) 2005 2/17/2005 12/31/2007 8.6 HIV/AID Congo, DR P088751 CD-Health Sec Rehab Supt (FY06) 2006 9/1/2005 6/30/2010 19.5 Ethiopia P079275 ET- Cap. Building for Agric. Serv (FY06) 2006 6/22/2006 10/31/2011 7.6 S Lesotho P076658 LS-Health Sec Reform Phase 2 APL (FY06) 2006 10/13/2005 3/31/2009 1.0 Agend Mozambique P087347 MZ Tech & Voc Edu & Training (FY06) 2006 3/21/2006 10/31/2011 4.2 Mali P090075 ML-Transp Sec SIL 2 (FY07) 2007 5/24/2007 12/31/2011 12.6 afor SUB-TOTAL 275.9 Action TOTAL ACTIVE HIV/AIDS PROJECTS 1,481.1 2007 NOTES: 72 *Commitment amounts are in the dollar value at the time of approval. -2011 **Commitment amounts for projects with HIV/AIDS components reflect the HIV/AIDS component amount, not the entire project amount. The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 8 ­ The HIV/AIDS Results Scorecard The Africa Region has developed a toolkit to support the countries in preparing their project specific Results Framework. This toolkit, a Generic Results Framework (GRF), has been discussed and shared with the countries, other development partners, and project Task Teams. The GRF is based on: (i) the indicators selected from globally agreed HIV indicators on prevention, care, treatment and mitigation required by UNGASS, MDG, IDA; (ii) several countries have the capacity to report on the indicators; and (iii) the OECD's Paris Declaration on harmonization and minimizing data requirements. The GRF proposes indicators for both groups of countries where the epidemic has reached the general population and for the countries where it is still within the concentrated populations. All GRF indicators are not mandatory. The GRF is a tool for task teams to use as a basis when developing or updating project's specific results framework A small set of mandatory indicators have, however, been extracted from the GRF to measure the overall progress with the HIV response to which the World Bank contributed in the Africa region. The Scorecard will therefore be used to measure progress under the Africa Action Plan as well as on IDA financing. The Scorecard contains both indicators for measuring long term results at the regional level, and indicators for measuring results to which specific Bank-funded HIV assistance projects have contributed. Two types data sources will be used to determine the values of the two types of scorecard indicators on an annual basis: (i) regional level data will be extracted from international reports and verified data sources with the support of GAMET and UNAIDS; (ii) project level data will need to be reported by all HIV projects using the project ISRs; and by ACTafrica through its annual MAP questionnaire. Adopting the scorecard in all ongoing and future HIV operations will reduce the burden on the countries and the task teams in terms of reporting progress. It will also enable the region to report on the aggregate achievements under IDA financing. The indicators, when fully adopted in all ongoing and future HIV operations, would be a major step towards achieving harmonization and alignment on M&E at the country, regional and global levels. These indicators are selected from globally agreed UNGASS, MDG and IDA indicators and are based on reporting capacities of the countries, availability of baseline data and agreement of our key partners such as UNAIDS and within the OECD's Paris declaration on harmonization and minimizing data requirements. The indicators in the Scorecard have been harmonized, where possible, with the indicator sets of other major partners in HIV/AIDS (US government's PEPFAR indicators and the Global Fund's list of "Top Ten" indicators). Neither the GRF indicators nor the Scorecard indicators are based on attribution, but rather on contribution. The scorecard and GRF therefore does not suggest that a separate World Bank HIV M&E system is required for a project; on the contrary, it suggests that indicator data from the national HIV M&E framework be reported to the World Bank on a regular basis. Table 1 presents the HIV Scorecard for the Africa Region. Indicators 4 to 13 in the Scorecard is mandatory for all for all ongoing, pipeline and future HIV operations in the region to report on through the project Implementation Status and Results Reporting system (ISRs). Key benefits of the Scorecard include: (a) Compliance with the Paris Declaration (to reduce burden on the countries); (b) Harmonization with UNAIDS (UNGASS) indicators and other key financers (such as Global Fund and PEPFAR in reporting on HIV/AIDS; (c) Support for regional IDA 73 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 financing and the Africa Action Plan; and (d) Utilization of existing country capacities in data collection and reporting. The Scorecard data will be collected through the following arrangements (per Africa Action Plan's 6 standard reporting sections: How Data will be Collected? A ­ Demographics WDI B ­ Development challenge indicators UNAIDS and WHO global reports C ­ Intermediate results indicators UNAIDS and WHO global reports D ­ Output indicators Annual ACTafrica MAP questionnaire and ISRs E ­ Financing indicators Client Connection, donor websites and their focal points The responsibility to report on the Scorecard will be by: (a) All country project teams; (b) GAMET will provide technical assistance to the Project teams; (c) GAMET and ACTafrica will gather data from the sources identified above, as well as from UNAIDS and update the Africa Action Plan progress reporting system; (d) TTLs need to assure that the Scorecard is agreed upon with their counterpart, with support from ACTafrica and GAMET. GAMET will provide technical support to country project teams and to TTLs in getting agreement with counterparts, and ACTafrica will provide support in integrating the Scorecard into the Bank system. Table 29: The HIV/AIDS Results Scorecard Note: The Africa region HIV scorecard uses the new UNGASS wording in line with the new 2008 UNGASS guidelines (released April 2007). INDICATOR INDICATOR UNIT DATA SOURCE ORIGIN A. Demographics 1. Total population (million) World Bank Number WDI database B. Challenge - to understand the overall development challenge created by HIV in the region 2. Estimated number of adults and children living with HIV UNAIDS Number UNAIDS Global Report 3a. Men and women aged 15-24 who are living with HIV (may need to be UNGASS, Percentage UNAIDS Global estimated from antenatal data) IDA14, AAP Report / WHO est. 3b. Most-at-risk populations who are living with HIV UNGASS Percentage UNAIDS Global Report / WHO est. C. Intermediate Results - to measure results contributed by Bank-funded projects 4a. Condom use: Women and men aged 15-49 who have had more UNGASS, Percentage ISR (extracted from than one sexual partner in the past 12 months reporting the use of AAP country UNGASS report) a condom during their last sexual intercourse 4b. Condom use: Female and male sex workers who report using a UNGASS, Percentage ISR (extracted from condom with their most recent client (of those surveyed having sex AAP country UNGASS report) with any clients in the last 12 months) 5. Women and men aged 15-24 who have had sex with more than UNGASS, Percentage ISR (extracted from one partner in the last 12 months AAP country UNGASS report) 6. Adults and children with advanced HIV infection receiving UNGASS Number ISR (extracted from antiretroviral combination therapy country UNGASS report) Percentage ISR (extracted from country UNGASS report) 74 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 INDICATOR INDICATOR UNIT DATA SOURCE ORIGIN 7. Pregnant women living with HIV who received antiretrovirals to UNGASS, Number ISR (extracted from reduce the risk of MTCT AAP country UNGASS report) Percentage ISR (extracted from country UNGASS report) 8. Orphaned and vulnerable children aged 0-17 whose households UNGASS Number ISR (extracted from received free basic external support in caring for the child in the country UNGASS report) past 12 months Percentage ISR (extracted from country UNGASS report) D. Outputs - - to measure results contributed by Bank-funded projects 9. Persons aged 15 and older who received counseling and testing World Bank Number ISR (from country M&E for HIV and received their test results system) Percentage ISR (from country M&E system) 10. Male and female condoms distributed World Bank Number ISR (from country M&E system) 11. Civil Society Organizations supported for subprojects (includes World Bank Number ISR (from country M&E NGO, CBO, FBO) system) Amount ISR (from country M&E system) 12. Public sector organizations supported World Bank Number ISR (from country M&E system) Amount ISR (from country M&E system) 13. National AIDS Coordinating Authority that report annually on at World Bank Percentage ISR (from country M&E least 75% of the indicators in its national HIV M&E framework and system) that disseminates the report to national-level leaders in at least three public sector organizations, national civil society leaders and business leaders in the private sector. E. Financing ­ to quantify funding provided by the Bank, government and other partners to respond to the challenge and achieve the outputs and intermediary results 14. Estimated investment requirements for HIV/AIDS, USD million World Bank Amount UNAIDS global data 15. Total financial commitments for HIV/AIDS, USD million World Bank Amount Calculation (15a + 15b + 15c) 15a. Country commitments for HIV/AIDS, USD million World Bank Amount ISR (extracted from country UNGASS report) 15b. World Bank commitments for HIV/AIDS, USD million World Bank Amount World Bank Business Warehouse 15c. Other development partner commitments for HIV/AIDS, USD World Bank Amount Development million partner websites 16. Financing gap to reach HIV/AIDS targets, USD million World Bank Amount Calculation (14 - 15) 17. World Bank financial disbursements for HIV/AIDS, USD million World Bank Amount World Bank Client Connection Notes: A: All of the indicators in the scorecard are based on the latest international thinking in terms of indicator wording. As there are currently efforts underway to harmonize indicators, the indicators in the scorecard may be slightly revised in 2008, when the harmonization process will be complete. B: Detailed indicator definitions will be released once the global indicator registry has been developed C: Projects are only required to report on indicators 9 to 13. 75 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 9 ­ The Bank's Role in the UNAIDS Division of Labor Table 30: World Bank Role in UNAIDS' Technical Support Division of Labor Technical Support Areas Lead Organization Main Partners 1. Strategic Planning, Governance and Financial Management · Support to strategic, prioritized and costed World Bank ILO, UNAIDS, UNDP, UNESCO, national plans; financial management, human UNICEF, WHO resources; capacity and infrastructure development; impact alleviation and sectoral work. · HIV/AIDS, development, governance and UNDP ILO, UNAIDS, UNESCO, mainstreaming, including instruments such as UNICEF, WHO, World Bank, PRSPs and enabling legislation, human rights UNFPA, UNHCR and gender. · Procurement and supply management, including UNICEF UNDP, UNFPA, WHO, training. World Bank 2. Scaling Up Interventions · Overall policy, monitoring and coordination on UNAIDS All Cosponsors prevention. 3. M&E, Strategic Information, Knowledge Sharing and Accountability · Strategic information, knowledge sharing and UNAIDS World Bank, ILO, UNDP, accountability, coordination of national efforts, UNESCO, UNFPA, UNHCR, partnership building, advocacy and M&E. UNICEF, UNODC, WFP, WHO Source: Global Task Team Report on Improving AIDS Coordination among Multilateral Institutions and International Donors, June 2005. 76 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 10 ­ MAP challenges and Improving Performance of the Multi-Country AIDS Program (MAP) for Africa Challenges In 2004, ACTafrica initiated an Interim Review of MAP to review the validity of the MAP approach, highlight progress made, the suitability of interventions and to identify lessons learned. The review concluded that the MAP objectives were still appropriate, highlighted implementation challenges and recommended that the MAP needed to become more strategic, collaborative, and evidence-based. In 2005, OED (now named IEG) conducted a separate independent assessment of the Bank's global HIV assistance to examine the assumptions, design and implementation of 24 country level AIDS projects. The OED report recommended a focus on capacity building, developing strong national and sub-national institutions, investing strategically in public goods and activities likely to have the largest impact, creating incentives for monitoring and evaluation, and using local evidence to improve performance. From these assessments, the Committee on Development Effectiveness (CODE) has recognized the achievements made in HIV/AIDS (MAP) programs and approved key recommendations for further improvement in all future HIV operations. CODE reaffirmed the Bank's role, together with other development partners, in responding to the complex and pressing issue of HIV/AIDS, the need for bold, innovative, and flexible responses, and also reconfirmed the need for a multi-sectoral approach to this development challenge. Table 1 provides a brief overview of the key recommendations from the MAP Interim Review report (October 2004), OED/IEG Report8, and CODE9 response and actions taken by the Africa region. Table 31: Overview of the Key Recommendations Recommendations Measures undertaken by the Africa region (i) Integrate HIV/AIDS in development planning, poverty IBRD and WBI in collaboration with UNDP have held two reduction strategies, budget allocation strategies and regional workshops to build capacity of country officials to mainstream in the country assistance strategies integrate HIV/AIDS in PRSPs, MTEF. ACTafrica will also continue to ensure that HIV/AIDS is sufficiently incorporated in the CAS. (ii) Support the development of prioritized, nationally The Bank and other partners (UNAIDS and UNDP) have rolled owned strategies with a nuanced understanding of the out the AIDS Strategy and Action Planning (ASAP10) program country epidemic, identification of cultural and social to provide direct technical support to countries on a demand- factors contributing to the spread, and assist driven basis in reviewing and producing evidence-based, governments to be selective and prioritize activities prioritized, and costed strategies and annual programs. that achieve the greatest impact. (iii) Adopt targeted approach in all next generation projects Adopted as a criteria for all second generation projects. Bank in low prevalence countries. and UNAIDS collaborated on a regional conference on targeting vulnerable groups. ACTafrica is also assessing the effectiveness of good practices targeting vulnerable groups. 8"Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance ­ An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control," July 2005. 9Committee on Development Effectiveness (CODE), Chairman's Summary, Appendix M to OED/IEG Report 10UNAIDS has raised US$5 million to finance these activities, which include workshops and direct assistance from the Bank and UNDP. 77 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 Recommendations Measures undertaken by the Africa region (iv) Improve governance and accountability measures The region continues to build capacity on improved fiduciary within projects to mitigate misuse of project funds and management and has developed a Guidance Note on ensure that funds are utilized for the intended Disbursement in HIV/AIDS Projects to assist in determining the beneficiaries. appropriate fiduciary steps for various levels. ACTafrica is initiating a study on governance and anticorruption practices at the community level by engaging grassroots level women groups in several countries and will develop guidelines for civil society organizations and local government authorities in addressing governance and corruption. (v) Ensure the development of a common, functioning GAMET11 has significantly increased their efforts to help M&E system at country level working with other countries build both their clinical and non-clinical indicators and partners, develop clear criteria and outcome indicators data collection mechanisms, and all repeater MAPs include for improved data collection, and improve the more attention and financing for scaling up M&E activities in evidence-base for decision-makers through local partnership with UNAIDS and other donors. Ongoing MAP capacity building and rigorous analytic work. operations are also providing increased financing for M&E implementation. GAMET and ACTafrica developed a generic in October 2006. (vi) Improve donor coordination and harmonization efforts A Global Task Team (GTT) comprising key UN agencies and to avoid duplication of efforts with the multitude of development partners agreed on a division of labor for all actors. agencies that countries can use in identifying technical support needs. Several countries have adopted joint annual reviews to encourage more harmonization of activities. (vii) Encourage performance-based disbursements. On going discussions with TTLs on methods for integrating this into HIV projects without hindering access to services. (viii) Continue to fully support the community response, Civil Society organizations are more actively involved than which is an important stakeholder group, by engaging before in HIV activities. The Africa region plans to carry out a them in the design of interventions and improved situation analysis of CS engagement. ACTafrica hosted a procedures for financing but also evaluate the consultation with civil society representatives from all MAP effectiveness of the community response. countries to brainstorm the roles, responsibilities and partnerships of CSO in responding to HIV. These recommendations are being incorporated in the revision of the Bank strategy for HIV/AIDS in Africa (2007-2011). (ix) Prioritized multi-sectoral approach to respond to the MAPs continue to use the multi-sectoral approach and address complexity of HIV as a broad development challenge HIV/AIDS as a broad development issue. ACTafrica will and focus on sectors that have the greatest potential ensure that this continues to be reflected in the CASs. Second impact such as health, education, transport, military generation MAPs will focus on sectors with the greatest and others depending on the country context potential within each country setting. (x) Clarify the role of the Ministry of Health to ensure that MOH is engaged in all MAP projects as evident from the MOH they are a principal partner in the national response being the second largest beneficiary of MAP financing after the and build MOH capacity while continuing to work with civil society component. All next generation MAP projects will other sectors. clarify the role and responsibilities of MOH as well as address issues related to strengthening health systems that can be integrated into HIV projects. (xi) Ensure consistency with Bank commitments to other The Bank is fully engaged with the GTT and will continue its global initiatives and partners and improve donor close partnership with UNAIDS. The Bank has also taken the collaboration. lead in collaborating with the Global Fund, PEPFAR, and other development partners and held a meeting in January 2006 to improve coordination. 11Global AIDS Monitoring and Evaluation Team (GAMET), hosted by the Bank on behalf of the Bank and UNAIDS. 78 The World Bank's Africa Region HIV/AIDS Agenda for Action 2007-2011 ANNEX 11 ­ HIV Prevalence and Global Financing Table 32: HIV Prevalence and Financing by Country HIV Prevalence* and Financing** by Country Global Fund Country HIV Prevalence, PEPFAR World Bank TOTAL Funds Ages 15-49 % 2003-March 2007 2004-2006 2001 ­ May 2007 Available Comoros 0.1 0.7 0.0 0.0 0.7 Madagascar 0.5 21.0 0.0 50.0 71.0 Mauritania 0.5 6.6 0.0 21.0 27.6 Mauritius 0.6 0.0 0.0 0.0 14.0 Cape Verde 0.8 0.0 0.0 14.0 14.0 Ethiopia 0.9-3.5 181.2 254.8 89.7 527.7 Senegal 0.9 8.8 0.0 30.0 38.8 Niger 1.1 8.5 0.0 25.0 33.5 Guinea 1.5 9.7 0.0 20.3 30.0 Sierra Leone 1.6 8.6 0.0 15.0 23.6 Sudan 1.6 46.1 0.0 0.0 46.1 Mali 1.7 23.5 0.0 25.5 49.0 Benin 1.8 39.0 0.0 58.0 97.0 Burkina Faso 2.0 10.6 0.0 74.7 85.3 Libera 2.0-5.0 19.7 0.0 0.0 19.7 Ghana 2.3 45.8 0.0 45.0 90.8 Eritrea 2.4 30.4 0.0 64.0 94.4 Gambia 2.4 14.6 0.0 15.0 29.6 Rwanda 3.1 56,6 168.2 40.5 265.3 Dem. Rep. of Congo 3.2 34.8 0.0 102.0 136.8 Equatorial Guinea 3.2 4.4 0.0 0.0 4.4 Togo 3.2 25.7 0.0 0.0 25.7 Burundi 3.3 21.7 0.0 36.0 57.7 Chad 3.5 7.4 0.0 24.6 31.9 Angola 3.7 26.7 0.0 21.0 47.7 Guinea-Bissau 2.8 1.2 0.0 7.0 8.2 Nigeria 3.9 74.4 344.8 140.3 559.5 Congo Republic 5.3 12.0 0.0 19.0 31.0 Cameroon 5.4 75.9 0.0 50.0 125.9 Kenya 6.1 109.6 443.7 50.0 603.3 Tanzania 6.5 134.8 309.5 70 514.3 Uganda 6.7 106.6 409.1 47.5 563.2 Cote D'Ivoire 7.1 51.0 115.3 0.0 166.3 Gabon 7.9 5.2 0.0 0.0 5.2 Central Africa Republic 10.7 29.6 0.0 17.0 46.6 Malawi 14.1 186.3 0.0 35.0 221.3 Mozambique 16.1 29.7 192.1 55.0 276.8 Zambia 17.0 97.3 360.8 42.0 500.1 South Africa 18.8 121.9 459.0 0.0 580.9 Namibia 19.6 31.3 124.3 0.0 155.6 Zimbabwe 20.1 46.2 59.4 0.0 105.6 Lesotho 23.2 39.3 0.0 5.0 44.3 Botswana 24.1 18.6 131.1 0.0 149.7 Swaziland 33.4 68.9 0.0 0.0 68.9 TOTAL FINANCING BY DONOR 1891.4 3372.1 1309.1 6572.5 *UNAIDS, 2006. Haacker 2007 ** Global Fund Financing from 2003 - March 2007. www.theglobalfund.org (March 31, 2007) PEPFAR financing from 2004-2006: www.pepfar.gov/pepfar/press/81902.htm World Bank MAP projects approved from 2001 to June 2007. Does not include $106m for sub-regional MAP projects 79