43690 THE WORLD BANK'S COMMITMENT TO HIV/AIDS IN AFRICA OUR AGENDA FOR ACTION, 2007­2011 THE WORLD BANK'S COMMITMENT TO HIV/AIDS IN AFRICA OUR AGENDA FOR ACTION, 2007­2011 THE WORLD BANK'S COMMITMENT TO HIV/AIDS IN AFRICA OUR AGENDA FOR ACTION, 2007­2011 Washington, DC © 2008 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: feedback@worldbank.org All rights reserved 1 2 3 4 11 10 09 08 This volume is a product of the staff of the International Bank for Reconstruction and Development/The World Bank. The findings, interpretations, and conclusions expressed in this volume do not necessarily reflect the views of the Execu- tive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202-522-2422; e-mail: pubrights@worldbank.org. English: French: Portuguese: ISBN: 978-0-8213-7448-1 ISBN: 978-0-8213-7464-1 ISBN: 978-0-8213-7466-5 eISBN: 978-0-8213-7449-8 eISBN: 978-0-8213-7465-8 eISBN: 978-0-8213-7467-2 DOI: 10.1596/978-0-8213-7448-1 DOI: 10.1596/978-0-8213-7464-1 DOI: 10.1596/978-0-8213-7466-5 Cover design: Naylor Design, Inc. Cover photos: Curt Carnemark/World Bank (left & right); Robert T. Schreiber (middle). Library of Congress Cataloging-in-Publication Data World Bank. The World Bank's commitment to HIV/AIDS in Africa : our agenda for action, 2007-2011. p. ; cm. March 2008. Includes bibliographical references and index. ISBN-13: 978-0-8213-7448-1 (alk. paper) ISBN-10: 0-8213-7448-6 (alk. paper) 1. World Bank. 2. AIDS (Disease)--Africa, Sub-Saharan--Prevention--Finance. 3. AIDS (Disease)--Africa, Sub- Saharan--International cooperation. 4. AIDS (Disease)--Economic aspects--Africa, Sub-Saharan. I. Title. [DNLM: 1. World Bank. 2. Acquired Immunodeficiency Syndrome--economics--Africa--Tables. 3. HIV Infec- tions--economics--Africa--Tables. 4. Acquired Immunodeficiency Syndrome--prevention & control-- Africa-- Tables. 5. HIV Infections--prevention & control--Africa--Tables. 6. International Agencies--Africa--Tables. 7. International Cooperation--Africa--Tables. 8. Regional Health Planning--Africa--Tables. WC 503 W9273w 2008] RA643.86.A357W67 2008 362.196'979200967--dc22 2007051390 Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 The Agenda for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Continuing Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Future Actions for the Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Implications for the Africa Region Work Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 2 The Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 The Epidemiology of HIV/AIDS in Sub-Saharan Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 The Development Impact of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 The Implications for Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 3 The Bank's Response to Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 The Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 4 Strategic Challenges in the New Environment . . . . . . . . . . . . . . . . .25 Finance, Sustainability, and Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Operational Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 5 The Agenda for Action 2007­2011 . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Strategic Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Overall Conceptual Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 The Foundation: Renew the Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Pillar 1: Focus the Response through Evidence-Based and Prioritized HIV/AIDS Strategies . . . .41 Pillar 2: Scale Up Targeted Multisectoral and Civil Society Responses . . . . . . . . . . . . . . . . . . . .42 Pillar 3: Deliver Effective Results through Increased Country M&E Capacity . . . . . . . . . . . . . . . .45 v vi The World Bank's Commitment to HIV/AIDS in Africa Pillar 4: Harmonize Donor Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Anticipated Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 The Potential Impact and Consequences of Inaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 6 Operational Implications for the Bank . . . . . . . . . . . . . . . . . . . . . . . .51 Work Program Implications for the Africa Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 An HIV/AIDS Support Program for FY2007­FY2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Implications for Staffing and Budgeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 Appendixes 1 Agenda for Action Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 2 HIV Indicators for Sub-Saharan Africa . . . . . . . . . . . . . . . . . . . . . . . .67 3 Bank Response to HIV/AIDS: A Chronology of Events . . . . . . . . . .71 4 The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 5 World Bank HIV/AIDS Portfolio for Africa, Fiscal Years 1989­2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 6 MAP Achievements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 7 MAP Challenges and Improving Performance of the MAP for Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 8 HIV Prevalence and Global Financing . . . . . . . . . . . . . . . . . . . . . . . .91 9 The Bank's Role in the UNAIDS Division of Labor . . . . . . . . . . . . .93 10 Agenda for Action: Implementation Plan and Results Framework . .94 11 The HIV/AIDS Results Scorecard . . . . . . . . . . . . . . . . . . . . . . . . . .109 References and Other Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119 Contents vii Figures 2.1 Estimated Number of People Living with HIV in Sub-Saharan Africa, 1990­2007 . . . .11 2.2 The Heterogeneity of HIV Prevalence in Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 2.3 Changes in Life Expectancy at Birth in Selected African Countries with High and Low HIV Prevalence, 1965­2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 4.1 Active HIV/AIDS Commitments by World Bank Sector . . . . . . . . . . . . . . . . . . . . . . . . .32 5.1 Global Funding for HIV/AIDS in the Top 10 High-Prevalence African Countries . . . . . .36 5.2 World Bank HIV/AIDS Lending in Africa FY00-FY07 . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 5.3 World Bank HIV/AIDS Agenda for Action in Africa Conceptual Framework . . . . . . . . .40 A2.1 Life Expectancy at Birth for Selected Sub-Saharan African Countries, 1965­2005 . . .70 A4.1 Universal Access to Treatment: Number of Deaths Averted, 2007­2030 . . . . . . . . . . .75 A4.2 Universal Access to Treatment: Cumulative Number of Life Years Gained in Sub-Saharan Africa, 2007-2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 A4.3 Infections Averted Due to Prevention Efforts in Sub-Saharan Africa, 2007-2011 . . . . .76 A4.4 Number of OVC in Sub-Saharan Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 Tables 2.1 Ten Most Common Causes of Mortality and Morbidity in Sub-Saharan Africa . . . . . .10 4.1 Funding Sources and Commitments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 4.2 Resource Needs for Universal Access, 2007­2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 5.1 Country Types and HIV/AIDS Typology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 5.2 Possible Differentiated Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 5.3 Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 5.4 Pillar 1: Focus the Response through Evidence-Based and Prioritized HIV/AIDS Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 5.5 Pillar 2: Scale Up Targeted Multisectoral and Civil Society Responses . . . . . . . . . . . .49 5.6 Pillar 3: Deliver Effective Results through Increased Country M&E Capacity . . . . . . . .50 5.7 Pillar 4: Harmonize Donor Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 A1.1 Agenda for Action Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 A2.1 HIV Prevalence, Income, Access to Treatment, and Quality of Health Services in Sub-Saharan Africa, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 A2.2 Life Expectancy at Birth for Selected Sub-Saharan African Countries, 1965­2005 . . .69 A3.1 Bank Response to HIV/AIDS: A Chronology of Events . . . . . . . . . . . . . . . . . . . . . . . . . .71 A4.1 Cross-Classification of Interventions by Cost Effectiveness and Impact . . . . . . . . . . . .78 A4.2 Studies of Cost Effectiveness of HIV/AIDS Interventions in Sub-Saharan Africa . . . . .79 A5.1 Closed MAP and Stand-Alone Projects, and Closed Projects with HIV/AIDS Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 A5.2 Active MAP and Stand-Alone HIV/AIDS Projects, and Active Projects with HIV/AIDS Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 A6.1 Results in Countries in Africa with MAPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 A6.2 Outcome-Level Results to Which MAP Has Contributed . . . . . . . . . . . . . . . . . . . . . . . .86 A7.1 Overview of the Key Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 A8.1 HIV Prevalence and Financing, by Country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 viii The World Bank's Commitment to HIV/AIDS in Africa A9.1 World Bank Role in UNAIDS' Technical Support Division of Labor . . . . . . . . . . . . . . . .93 A10.1 The Foundation: Renew the Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 A10.2 Pillar 1: Strengthened Long-Term Sustainable National Response . . . . . . . . . . . . . . . .98 A10.3 Pillar 2: Accelerated Implementation of HIV/AIDS Programs . . . . . . . . . . . . . . . . . . . .100 A10.4 Pillar 3: Strengthened National Systems for Financial Management, Human Resources, Procurement, Supply Chains, and Health and Social Systems . .104 A10.5 Pillar 4: Strengthened Donor Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 A11.1 The HIV/AIDS Results Scorecard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Foreword HIV/AIDS poses an unprecedented development and human challenge, especially in Africa. In many countries, the epidemic has cut life expectancy and robbed society of millions of people in their prime working years. It has dimmed the hope of living full and productive lives for unimaginable num- bers of infants, children, 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 more than $1.5 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; a strategic direction; a multisectoral approach; com- munity engagement; and programs for prevention, treatment, and care. World Bank support has also helped mobilize significant new funding for HIV/AIDS and engendered collaboration among donors. Today, we have a better understanding of the epidemic and its transmis- sion than at any time in the past. We now know that it is not one but sev- eral 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 dramatically increase. HIV/AIDS remains, however, the leading cause of premature death and is a major threat to development in Africa. The World Bank is vigorously working 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: The World Bank's Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007­2011. This Agenda for Action reaffirms the Bank's determination to remain a full partner in the fight against HIV/AIDS through the provision of fund- ing, analytical support, capacity development, and knowledge sharing. The Bank will use its convening power and other technical resources to combat ix x The World Bank's Commitment to HIV/AIDS in Africa the epidemic, including in the countries of southern Africa--the epicenter of HIV/AIDS--that are not eligible for IDA assistance. The Bank will also focus on the strategic response, monitoring and evaluation to enhance effec- tiveness, the multisectoral approach, and harmonization with other devel- opment 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 to shape the Agenda for Action. Let me also thank the staff of the Bank, ACTafrica, the Global HIV/AIDS Program (World Bank), and the Africa Region for their persist- ence 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 Develop- ment), this Africa Region HIV/AIDS Agenda for Action will help focus our efforts, 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 Acknowledgments The HIV/AIDS Agenda for Action (AFA) team was led by Elizabeth Lule, manager of the AIDS Campaign Team for Africa (ACTafrica), and included Daniel Ritchie, Richard Seifman, Antonio C. David, Albertus Voetberg, Sangeeta Raja, Cassandra De Souza, Carolyn Shelton, Nadeem Moham- mad, John Nyaga, and Frode Davanger. Support was provided by Annette Minott, Mohammad Javed Karimullah, and Therese Cruz. AFA was pre- pared under the guidance of John Page (chief economist, AFRCE), Gerard Byam (director, AFTQK), Yaw Ansu (sector director, AFTHD), and Debre- work Zewdie (director, HDNGA). The HIV/AIDS AFA could not have moved forward without the leader- ship of the regional vice president, Obiageli Katryn Ezekwesili. We would also like to thank former regional vice presidents, Callisto Madavo and Gobind Nankani, who enabled the Bank's continued commitment to place HIV/AIDS at the center of the strategic development agenda for Africa. Several individuals contributed to the development of AFA, and all are thanked generously for committing their time, effort, ideas, and experience. Consultations were held with a broad constituency over several months, including governments and country counterparts, civil society, and people living with HIV/AIDS (PLWHAs) (Nairobi, May 2006); bilateral donors (London, October 2006); the international HIV/AIDS community (Toronto, August 2006); multilateral development partners (New York, Sep- tember 2006; Geneva, October 2006; Johannesburg, November 2006; Dakar, January 2007); World Bank managers and staff (Washington, D.C., September­December 2006); GFATM managers and staff (Geneva, Sep- tember 2006); and country counterparts and youth (Johannesburg, Febru- ary 2007). Well over a thousand people from more than 35 countries and many institutions participated in the AFA deliberative process. The lion's share of participants was provided by our client countries in Sub-Saharan Africa. They were representatives, at all levels, of their communities, faith-based organizations, local nongovernmental organizations (NGOs), research institutes, universities, the private sector, labor federations, trade unions, local and national governments, and PLWHA. People representing the entire gamut of age, profession, and gender spoke to us knowledgeably, xi xii The World Bank's Commitment to HIV/AIDS in Africa frankly, and with passion about the role of the Bank and their battles 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 cosponsors, other international organizations, bilateral and multilateral donors, governments of recipient countries, faith-based and civil society organizations, PLWHA, youth, international and national NGOs, founda- tions, research institutions, and the private sector. The consultations encompassed participants from many partner institutions, including Christopher Armstrong (Canadian International Development Agency), 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), Clement Chan-Kam (WHO), Thea Chris- tiansen (Ministry of Foreign Affairs, Denmark), 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), Alan Leather (Global Unions AIDS Programme), 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 Schreiner (UNFPA), Bernard Schwartzlander (GFATM), Clare Shakya (DFID, UK), Anne Skjelmerud (NORAD, Norway), Paul Spiegel (UNHCR), Mats Svensson (Sida, Sweden), Lia von Wantoch (U.S. Embassy, London), Bruce Waring (HLSP, UK), 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 par- ticipants 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. Acknowledgments xiii The following internal and external peer reviewers deserve particular praise for their commitment, insightful suggestions, and attention to detail when analyzing previous drafts of AFA. From the World Bank Group staff, the reviewers included Cristian Baeza (HDNHE), Hartwig Schafer (AFRVP), Christopher Walker (AFTH1), 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), Beld- ina 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), Ais- satou 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), John May (AFTH2), Montserrat Meiro-Lorenzo (AFTH3), Michael Mills (AFTH1), Norbert Mugwagwa (AFTHD), Dzingai Mutumbuka (AFTH1), Elizabeth Mziray (HDNGA), Francois Nankobogo (AFTPS), Robert Oelrichs (HDNGA), Judy O'Con- nor (AFCE1), John Page (AFRCE), Ok Pannenborg (AFTHD), Ritva Reinikka (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 AFA. These thoughtful efforts were our guid- ing lights during the elaboration of this five-year HIV/AIDS AFA 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 xiv The World Bank's Commitment to HIV/AIDS in Africa (HDNDE), Josette Malley (PREMGE), Lana Moriarty (PREMGE), Waafas Ofosu-Amaah (PREMGE), John Stover (Futures Institute), Kather- ine Tulenko (ETWWP), Marisa van Saanen (HDNDE), and David Wilson (HDNGA). We wish to especially acknowledge the generous support of the govern- ment of Norway, through the Ministry of Foreign Affairs and the Norwe- gian Agency for Development Cooperation, for its significant contribution in financing the preparatory process of this AFA. Abbreviations AAP Africa Action Plan ACGF Africa Catalytic Growth Fund ACTafrica AIDS Campaign Team for Africa AFA Agenda for Action AFCRI Africa Regional Integration Department AFRRMT Africa Region Management Team AFTEG Africa Energy AFTHD Africa Region Human Development Department AFTHV ACTafrica AFTPS Africa Private Sector AFTQK Africa Region Operational Quality and Knowledge Services AFTTR Africa Region Transport Group AFTU Africa Urban and Water AIDS Acquired Immune Deficiency Syndrome APL Adaptable Program Loan ART Antiretroviral Therapy ASAP AIDS Strategy and Action Plan BCC Behavior Change Communication CBO Community-Based Organization CDMAP Capacity Development Management Action Plan CODE Committee on Development Effectiveness CSO Civil Society Organization DALY Disability-Adjusted Life Year DDP Development Data Platform DEC Development Economics Vice Presidency FBO Faith-Based Organization G-8 Group of Eight GAMET Global AIDS Monitoring and Evaluation Team GDP Gross Domestic Product GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GHAP Global HIV/AIDS Program of Action GRF Generic Results Framework GTT Global Task Team HDN Human Development Network HDNGA Global HIV/AIDS Program HDNHE Health, Nutrition, and Population Team HIV Human Immunodeficiency Virus HNP Health, Nutrition, and Population IBRD International Bank for Reconstruction and Development xv xvi The World Bank's Commitment to HIV/AIDS in Africa ICRW International Center for Research on Women IDA International Development Association IDF Institutional Development Fund IDP Internally Displaced Populations IEC Information, Education, Communication IEG Independent Evaluation Group IFC International Finance Corporation IMF International Monetary Fund ISNs Interim Strategy Notes ISR Implementation Status Report JFC Joint Facilitation Committee LEGAF Africa Legal Department LOA Loan Department MAP Multi-Country HIV/AIDS Program M&E Monitoring and Evaluation MDG Millennium Development Goal MIC Middle-Income Country MOH Ministry of Health MSM Men Who Have Sex with Men MTEF Medium-Term Expenditure Framework NAC National AIDS Committee/Council NGO Nongovernmental Organization OECD Organisation for Economic Co-operation and Development OVC Orphans and Vulnerable Children PEPFAR President's Emergency Plan for AIDS Relief PLWHA People Living with HIV/AIDS PREM Poverty Reduction and Economic Management Network PMTCT Prevention of Mother-to-Child Transmission PRSC Poverty Reduction Support Credit PRSP Poverty Reduction Strategy Paper RVP Regional Vice President SRH Sexual and Reproductive Health STI Sexually Transmitted Infection SW Sex Worker SWAp Sector-Wide Approach TB Tuberculosis Three Ones One national strategic plan, one coordinating body, and one national M&E framework UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific, and Cultural Organization UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNHCR United Nations High Commission for Refugees Abbreviations xvii UNICEF United Nations Children's Fund USAID United States Agency for International Development VCT Voluntary Counseling and Testing WBI World Bank Institute WHO World Health Organization All dollar amounts are U.S. dollars. CHAPTER 1 Introduction The World Bank is committed to support Sub-Saharan Africa in respond- ing to the HIV/AIDS epidemic. This Agenda for Action (AFA) is a road map for the next five years to guide Bank management and staff in fulfilling 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. About 22.5 million Africans are HIV positive, and AIDS is the leading cause of premature death on the continent. HIV/AIDS affects young people and women dispropor- tionately. Some 61 percent of those who are HIV positive are women, and young women are three times as likely to be HIV positive than are young men. As a result of the epidemic, an estimated 11.4 million children under age 18 have lost at least one parent. Its impact on households, human capi- tal, the private sector, and the 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 Agenda for Action This is not a conventional strategy document. It is deliberately titled The World Bank's Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007­2011 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 The World Bank's Commitment to HIV/AIDS in Africa 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 treat- ment 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. Africa is also a unique 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 HIV/AIDS program funding in the absence of external financing, which tends to be volatile and unpredictable. 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 consul- tations, 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 epi- demic in the next five years. The principal audience of this report is the World Bank's Board of Directors, senior management, and staff. The AFA has four principal objectives: · Reaffirm the World Bank's commitment to long-term support for curb- ing the spread of HIV/AIDS in Africa; · Articulate the comparative advantages of the Bank in a harmonized interna- tional 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; and · 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. The AFA articulates a program of support that fits squarely within the Bank corporate strategic priorities, as articulated by World Bank President Introduction 3 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 (HNP) Results. 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 AFA, consultations have been carried out over several months with a broad con- stituency, including countries, donors, communities, civil society, non- governmental, and nonprofit organizations.1 Background The World Bank launched the first major global response to HIV/AIDS in Sub-Saharan Africa in 1999. It helped put in place the foundations of the response: national strategies, a governance structure, and systems for mon- itoring and evaluation. It promoted a multisectoral 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 $1.5 bil- lion for HIV/AIDS programs in more than 30 countries, including 29 Multi-Country HIV/AIDS Program (MAP) projects 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; bet- ter 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 multisectoral national pro- grams while strengthening institutions and accountability. This had an immediate impact on program coverage and paved the way for rapid expan- sion as other funding became available in later years. The MAP contributed to health-systems strengthening, started several cross-border projects to 4 The World Bank's Commitment to HIV/AIDS in Africa address the most at-risk populations, and helped increase access to treat- ment. Recognizing that HIV requires changes in norms, beliefs, percep- tions, and social and individual behavior, the MAP mobilized communities to provide an enabling environment. Since the MAP was launched, and partly as a result of its implementa- tion, there have been major developments in the global response to the epi- demic. Global funding for HIV/AIDS has grown dramatically--from $1.6 billion in 2001 to $8.9 billion in 2006--with the creation of the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (GFATM), the Pres- ident'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 to treatment and prevention services. Univer- sal 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 $2,000 and $3,000 per infection averted. By continuing to expand access to treat- ment, 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 commit- ments to work toward achieving the universal access goal. Nevertheless, an estimated $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 Interna- tional Development Association (IDA), are dependent on replenishments, with no certainty about the levels of future funding. Access to treatment has expanded, thanks in part to a reduction in the costs of antiretroviral drugs. Today, slightly more than one-quarter of Africans in need of treatment are on antiretroviral drugs. Efforts to harmo- nize the international response were intensified under the UNAIDS banner of the "Three Ones."2 Finally, prevalence rates are declining in some coun- tries and communities. Continuing Challenges At the same time, the HIV/AIDS epidemic faces major strategic challenges: Introduction 5 · ensuring an appropriate balance among prevention, treatment, and miti- gation interventions; · addressing human resources shortages and long-term fiscal sustainability of HIV/AIDS programs, especially in light of the commitment to uni- versal access to prevention and treatment; · tackling the continuing crisis with health systems and linkages with other diseases (such as tuberculosis [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 has effectively ended. In devel- oping 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 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 AFA, these groups underscored the Bank's (i) macroeconomic focus, that is, treat- ing HIV/AIDS as a broad development issue; (ii) multisectoral engagement; (iii) capacity-building experience; (iv) convening power; (v) analysis and pol- icy dialogue; and (vi) ability to form partnerships with communities and the private sector. The Bank's challenge now is to shift its emphasis from prin- cipal 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 address global epidemics effectively. 6 The World Bank's Commitment to HIV/AIDS in Africa Future Actions for the Bank The HIV/AIDS Agenda for Action 2007­2011 represents the Africa Region's next stage in its engagement on HIV/AIDS in Africa. The foun- dation 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 (MDGs). This reaffirmation would be demonstrated by the endorsement of the AFA by Bank senior management and executive directors. The Bank would com- mit itself to (i) provide at least $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 key sectors such as health, education, transport, public sector management, and other proj- ects as appropriate; and (iii) expand current and find new, innovative ways to engage with middle-income countries (MICs) at the epicenter of the dis- ease in southern Africa, as well as with fragile states and through regional initiatives. The AFA's four strategic objectives are to assist countries to develop long-term, sustainable responses that are integrated into national development agendas; accelerate and improve implementation; strengthen national fiduciary, monitoring and evaluation (M&E), and health systems; and enhance donor coordination and shared learning. The AFA 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; recog- nize the crucial links with the health system as well as TB, malaria, repro- ductive health, 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 multisectoral and civil society responses. The World Bank is uniquely placed to promote the multisectoral response and, working with communities, to address the HIV/AIDS challenge. The Introduction 7 next generation of Bank support will emphasize efforts to strengthen national and health systems, education (especially for orphans and vul- nerable children), school-based prevention programs, gender equality, and to foster private-public partnerships. · Pillar 3: Deliver more effective results through increased country monitoring and evaluation capacity. The World Bank will continue to help strengthen M&E frameworks to enhance the efficiency, effectiveness, and trans- parency of the HIV/AIDS response. This effort will contribute to improving existing structures of governance, public sector management, community-level transparency, and accountability. The Bank will work to assist local and central government structures in improving implementa- tion 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 AFA 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--its 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 pro- gram of the Africa Region. HIV/AIDS will continue to need greater atten- tion as a development and poverty issue in the Bank's national dialogue with countries and its relevant instruments. Strengthening links with health sec- tor systems, as well as with specific diseases such as TB and malaria, will take on greater priority. Mainstreaming and retrofitting of HIV/AIDS into sec- 8 The World Bank's Commitment to HIV/AIDS in Africa toral products will be increasingly important, with analytical support pro- vided 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 M&E support, will also require heightened attention. What will be required of staff and management is commitment to pursue this AFA. Human and financial resources will also be required to support the HIV/AIDS dedicated team as will be contributions from country and sector units. While the HIV/AIDS team would continue to provide crucial 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 overfunded 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 inter- national response strengths that no other organization possesses, that HIV/AIDS receives less than half the funding needed to meet the commit- ment to universal access to prevention and treatment, and that HIV/AIDS threatens the well-being of the continent like no other single challenge. For these reasons, the AFA focuses the Bank's engagement on its strategic strengths and helps ensure a harmonized and effective global response. Notes 1. Countries, civil society, and PLWHAs (Nairobi, May 2006), bilateral donors (Lon- don, 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, D.C., September­December 2006), GTAFM managers and staff (Geneva, September 2006), and country counterparts and youth (Johannesburg, February 2007). See appendix 1 for details. 2. One national strategic plan, one coordinating body, and one national monitoring and evaluation framework. CHAPTER 2 The Diagnosis 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 devel- opment gains of the past generation and now threatening the gains of the next. AIDS also threatens realization of the Millennium Development Goals (MDGs). During the past decade, the disease has evolved, but today it is better understood. We know that it affects women and young people disproportionately in high-prevalence countries. We also know that it is not one but several epidemics. The modes of transmission have been more clearly established and, consequently, the responses more differentiated. The human tragedy behind the numbers is enormous. In 2006, an esti- mated 2.2 million children younger than 15 years old were living with HIV and about 11.4 million African children under age 18 were either single or double orphans as a result of parental deaths from AIDS (UNAIDS 2007a). The disease has deprived countries of their scarcest human capital. Zambia, for example, loses half as many teachers annually as it trains (Grassly et al. 2003). Private firms in some countries, especially in southern Africa, recruit two workers for every job in anticipation of loss from the disease. The impact of the epidemic also affects both rural and urban households (UNAIDS 2006). The 2007 UNAIDS figures show downward trends in HIV prevalence in a number of countries--reflecting improved methodology and data collection--but also progress, where prevention efforts aimed at reducing new HIV infections since 2000 and 2001 are showing results. In most of Sub-Saharan Africa, national HIV prevalence has either stabilized or is showing signs of decline, particularly in urban and rural Kenya; urban areas of Côte d' Ivoire, Malawi, and Zimbabwe; and in rural Botswana (UNAIDS 9 10 The World Bank's Commitment to HIV/AIDS in Africa 2007a). Modest prevalence declines among young pregnant women have occurred in urban and rural Burkina Faso, Namibia, and Swaziland, urban Burundi and Rwanda as well as rural areas in Tanzania (UNAIDS 2007a). The Epidemiology of HIV/AIDS in Sub-Saharan Africa 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 deaths in 2000 (see table 2.1 and World Bank [2006a]). While the 2007 UNAIDS data show that the AIDS epidemic seems to have reached its peak and death rates are falling, more than two-thirds of all people living with HIV reside in Sub-Saharan Africa, where more than three-quarters (76 percent) of all AIDS deaths in 2007 occurred. An esti- mated 22.5 million Africans are living with HIV/AIDS, the vast majority of them adults in the prime of their working and parenting lives (UNAIDS [2007] and figure 2.1). Despite a peak of new infections and a decline in prevalence in some countries, more than 1.6 million people--about 4,400 per day--died from the disease in 2006 (UNAIDS 2007a). Table 2.1: Ten Most Common Causes of Mortality and Morbidity in Sub-Saharan Africa PERCENTAGE OF TOTAL PERCENTAGE OF TOTAL DISABILITY-ADJUSTED CAUSES OF DEATH DEATHS, 2000 LIFE YEARS, 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 NA Ischemic heart disease 3.1 NA Tuberculosis 2.8 2.4 Road traffic accidents 1.8 1.8 Sources: World Bank 2006a; Mathers, Lopez, and Murray 2006. Note: NA = Not available. Disability-adjusted life years (DALYs) measures population health combined with years of life lost from premature death and years of life lived in less than full health. See Mathers, Lopez, and Murray (2006) for further discussion of DALYs. The Diagnosis 11 Figure 2.1: Estimated Number of People Living with HIV in Sub-Saharan Africa, 1990­2007 s)n 25 (millio 20 HIV with 15 gn livi 10 people ofr 5 mbe 0 nu 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 year indicates the range Source: UNAIDS 2007. The feminization of the epidemic In Africa, HIV/AIDS is predominately a disease of women and young girls. Some 61 percent of those living with HIV/AIDS are women (UNAIDS 2007a), and young women in the 15- to 25-year-old age group are three times more likely to be HIV positive than young men in the same age group (UNAIDS 2006). Because of gender inequalities, women are often more vul- nerable. 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 trans- mitted 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 of 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, economic opportunities, and access to productive assets and workloads will need to be better understood and more effectively addressed. Developing individual prevention mechanisms such as vaccines and microbicides will need to be better funded and scaled-up. 12 The World Bank's Commitment to HIV/AIDS in Africa The impact on children, the young, and disabled persons Children continue to be the victims of the disease, particularly in Sub- Saharan Africa, where nearly 90 percent of the world's HIV positive chil- dren live (UNAIDS 2007a) and are affected both directly (infected) and indirectly (stigmatization or the loss of a parent). More than 9 percent of children under age 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 and 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, with an even higher proportion in Africa. Disabled persons are also at increased risk and vulnerability because of 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 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, and returnees are potential transmit- ters of HIV transmission, but also are vulnerable to infection by communi- ties through which they pass toward a safer haven. This increase in vulner- ability 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 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 epi- demics 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 2.2. 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 The Diagnosis 13 Figure 2.2: The Heterogeneity of HIV Prevalence in Africa 0­0.1% 1­5% 3­7% 15­35% no data JANUAR IBRD This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on Y 2008 35874 this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. Source: Adapted from Wilson 2006. Note: Overlaps and gaps in HIV prevalence in the categories above are due to variations in HIV prevalence within countries, or within country clusters. many years grouped with southern Africa, are far lower, with prevalence ranging from 3 to 7 percent. Prevalence in West Africa, Africa's most pop- ulous region, ranges from 1 to 5 percent. In North Africa, prevalence sel- dom exceeds 0.1 percent (Wilson 2006). Transmission is better understood 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 2006). In the mixed epidemics of East Africa, transmission comes from both HIV-vulnerable groups (sex workers, men who have sex with men [MSM], and injecting drug users) and the general population, while in southern Africa most transmission is driven by sexual behavior in the general population.1 A better understanding of the modes of transmis- 14 The World Bank's Commitment to HIV/AIDS in Africa sion is contributing to an improved response. In 2006, several countries reported reduced HIV prevalence. While not attributable to any single pro- gram, 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). The evolution in the understanding of the disease offers opportunities for more focused responses and more effective measures to control its spread, particularly through attention to women, vulnerable and high-risk groups, and, for southern Africa, the general population. The Development Impact of HIV/AIDS In addition to continuing human suffering and loss, HIV/AIDS poses 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 epi- demic depletes savings, reduces labor supply, increases households' vulner- abilities to shocks, reduces productivity in the private and public sectors, and negatively affects public finances. Perhaps most worrisome are the sig- nificant 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 The HIV/AIDS epidemic has an obvious negative impact on welfare from increased mortality rates and reversed gains in life expectancy associated with the disease (see figure 2.3 and appendix 2). 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 and restricted access to and control over resources, assets, and opportunity com- pound the impact on the household. In Western Kenya, access to antiretro- viral therapy led to a 35 percent increase in weekly hours worked, illustrat- ing the magnitude of the disease's impact on productivity and the potential economic benefits of treatment provision (Thirumurthy, Graff Zivin, and The Diagnosis 15 Figure 2.3: Changes in Life Expectancy at Birth in Selected African Countries with High and Low HIV Prevalence, 1965­2005 70 65 s)r 60 (yea thr 55 bi at 50 cyn 45 expecta 40 life 35 30 1965 1970 1975 1980 1985 1990 1995 2000 2005 high HIV prevalence low HIV prevalence Botswana Madagascar South Africa Mali Zimbabwe Senegal Source: World Bank 2007b. Goldstein 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 per- sistence of poverty. Studies in 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 house- hold worker in rural areas (Salinas and Haacker 2006). The impact on the private and public sectors HIV/AIDS leads to decreases in productivity and to increased absenteeism and turnover (with associated costs) of the workforce (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 because 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 16 The World Bank's Commitment to HIV/AIDS in Africa to reductions in public revenues as the tax base decreases and the negative effects of the epidemic on long-run output are felt (Haacker 2004b). Fur- thermore, 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 ser- vants 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 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 because it affects the accumulation of human capital and has adverse effects on the nutritional status of children (especially when the mother is HIV positive), and in particular, of orphans. In fact, when par- ents die, orphans are threatened by financial distress and lack of care, which leads to increases in the incidence of child labor and reductions in school enrollment and attendance. Graff Zivin, Thirumurthy, and Goldstein (2006) conjecture that the morbidity associated with AIDS may lead to real- locations of time and resources within the household. The potential nega- tive long-run impact of HIV/AIDS on economic development can be quite substantial. Bell, Bruhns, and Gersbach (2006) estimated that in Kenya by 2040, GDP per adult will be 11 percent less than it would have been in the no-AIDS scenario. Theoretical studies surveyed in Haacker (2004a) typically predict 1.0 percent to 1.5 percent declines in GDP growth rates for the worst affected countries (prevalence rates above 20 percent). Results on the empirical link between the epidemic and economic growth seem to be mixed (Bloom and Mahal 1997; Corrigan Glomm, and Mendez 2005; among others). Because the HIV/AIDS epidemic dramatically affects mortality rates, some authors posit that parents will choose to have more children as an "insurance pol- icy" 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 mecha- nisms result in slower per capita economic growth. The Diagnosis 17 The Implications for Africa The epidemiology of HIV in Africa and the effect of the epidemic on devel- opment prospects suggest several priorities for the future. First, given the heterogeneity of the disease, national AIDS programs and strategies will need to focus on a rigorous understanding of HIV trans- mission dynamics in each context. This, in turn, will require improved sur- veillance and epidemiological analysis at both the national and subregional levels. Programs will need to focus on major drivers of transmission. Second, southern Africa will need to be a central focus for HIV/AIDS analysis and investments. Third, programs will need to target the subgroups heavily affected by the epidemic: women and girls, children, youth, and particularly vulnerable and often stigmatized groups such as sex workers, MSM, 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. Finally, because HIV/AIDS directly or indirectly threatens the achieve- ment of many MDGs and perpetuates poverty and deepens inequality, the response to the epidemic needs to be an integral part of the dialogue on poverty reduction with African countries. Note 1. Injecting drug use is a growing but still less significant factor. CHAPTER 3 The Bank's Response to Date As early as 1985 there was growing evidence that a serious HIV/AIDS epi- demic of unknown magnitude was spreading across Sub-Saharan Africa, but most governments and the international community were slow to respond. While the World Bank responded to HIV as early as 1986, not until 1999 did the World Bank come to recognize the enormous development threat posed by the disease and prepare a regional HIV/AIDS strategy-- Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis. In 2000, the World Bank executive directors approved the Multi- Country HIV/AIDS Program (MAP) for Africa, with a commitment of $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 appendix 3 for a chronology of events). The MAP 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 multisectoral response, and catalyze other resources. Stage two would mainstream innovations that proved effective toward nationwide coverage, and stage three would permit a much sharper focus on areas or groups where spread of the disease continued. It was clear from the outset that the Bank's standard products would not address the epidemic adequately. Therefore, the MAP adopted a "horizon- 19 20 The World Bank's Commitment to HIV/AIDS in Africa tal Adaptable Program Loan" (APL) approach, allowing rapid responses in many countries using a common framework and promoting a radically dif- ferent approach, including funding of civil society organizations (CSOs), the private sector, ministries outside the ministries of health, and trans- boundary populations such as refugees. The MAP processes were also highly innovative, reflecting the excep- tional 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 multisectoral and mul- tiagency implementation mechanisms for the widest possible coverage. 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 $500 million as grant funding from IDA-13, thereby enabling MAP projects in all 29 IDA-eligible countries in Sub- Saharan Africa, funding of several regional programs, and second- generation projects in a number of countries (see appendix 5). The MAP addressed four pressing country needs: · strong political and government commitment to respond to HIV; · a favorable institutional environment with adequate resources and capac- ity to enable successful HIV and AIDS interventions to be scaled up to a national level; · a local response that increases community participation in and ownership of HIV and AIDS interventions through providing financial resources and capacity building; and · a multisectoral approach in which all government sectors are appropri- ately involved, with improved coordination at the national level and decentralization to subnational government structures. 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). To date, five IDF grants have been approved for roughly $2.5 million, bringing Bank HIV/AIDS support for the first time to Namibia and Swaziland, as well as to fragile states such as Soma- lia and Sudan. The Bank's Response to Date 21 The Results The initial goals of the MAP 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 has achieved many of these goals, including the following (see appendix 6 and Görgens-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 national AIDS committee or council (NAC). · Active mobilization and engagement of civil society. In all MAP countries, at least 38 percent of financing is through CSOs. Major scale up of activi- ties in prevention, mitigation, and care has engaged more than 29,000 civil society organizations that are implementing about 60,000 community-level subprojects. · Increased funding for HIV/AIDS. Increased funding for HIV/AIDS from domestic resources provides additional evidence of political commit- ment. National budget funding in 29 reporting countries reached $757 million in 2006. In addition, with the creation of the GFATM, PEPFAR, and significant other bilateral and foundation funding, global funding has grown by more than 2,000 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, vulnerable populations in particular), and condom distribution. · Intensified treatment, care, and impact mitigation. Initially, the Bank pro- vided limited funding for antiretroviral therapy (ART), given its high cost and the intense focus of other agencies on treatment. However, working 22 The World Bank's Commitment to HIV/AIDS in Africa 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 antiretrovirals. It has also supported mitigation measures for more than a half million adults and 1.8 million children through educa- tion, home-based care, and income-generating activities. · The multisectoral response. One of the MAP's most important achievements has been the promotion of the multisectoral response. Recognizing that HIV/AIDS is not solely 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 more than a half million people in service delivery, improved laboratory infrastructure and other health system facilities, provided technical sup- port to more than 41,000 organizations, and reached 2.2 million people with workplace education programs. The outputs from the MAP have been impressive. Two independent evaluations have commended the overall effort, but suggested that the effec- tiveness, efficiency, and impact of the program on the disease itself have been difficult to measure. The interim review of the MAP in 2004 endorsed the basic objectives, approach, and design of the program (World Bank 2004). Nevertheless, this review suggested the MAP 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. The Operations Evaluation Department (now the Independent Evalua- tion Group, or 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 few 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 The Bank's Response to Date 23 knowledge sharing and adaptation. These reports helped focus attention in particular on the need for better M&E systems and evidence-based inter- ventions in the future. Appendix 7 presents actions that are being under- taken to address these recommendations. Lessons Learned The key lessons going forward from the MAP experience include the fol- lowing (see also World Bank [2006]): · Recognize that HIV/AIDS is a more formidable challenge than had been real- ized. Unrelenting effort is needed to end the epidemic. Uganda, long a beacon of hope against HIV, now offers a warning against complacency. Significant gains against the epidemic were made in Uganda--the first country in Africa to make progress against the disease--reducing preva- lence among antenatal clients in Kampala from 30 percent in 1992 to 7 percent by 2001. Now there are worrying signs of rising HIV prevalence, as 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 sus- tainability, countries should link their HIV/AIDS strategies and plans to their overall development programs and financing plans as outlined in their Poverty Reduction Strategy Papers (PRSPs) and Medium-Term Expenditure Frameworks (MTEFs). · Know the epidemic and 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, nutri- tion, and other diseases such as malaria and TB. Treating HIV/AIDS as a sin- gle disease has been a significant deficiency in national HIV/AIDS pro- grams. The feminization of the epidemic and its links to sexual and reproductive health, and the frequency of co-infection with TB (and the emerging Extensively Drug Resistant TB) and other opportunistic dis- eases, require providers to offer integrated services. 24 The World Bank's Commitment to HIV/AIDS in Africa · 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 care human resources, health facilities, health information systems, and health 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 dif- ferent 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, pro- grams, 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. CHAPTER 4 Strategic Challenges in the New Environment Since 1999, there have been major developments in the effort to combat HIV/AIDS in Africa, including 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; (v) weak national systems and in particular, health systems; and (vi) 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 an arena much more crowded than in 2001. Finance, Sustainability, and Accountability The sources of funds to fight HIV/AIDS, the harmonization of interna- tional and national efforts, and the sustainability of, governance of, and accountability for the use of funds all pose challenges to Bank endeavors. Global funding Context. The global response to the HIV/AIDS epidemic has been unparal- leled. Between 2001 and 2006, worldwide funding has grown from $1.6 bil- lion to $8.9 billion (UNAIDS 2006). Funding to Africa from the three main international sources amounted to $9.9 billion in the period 1997 to 2007 (table 4.1). 25 26 The World Bank's Commitment to HIV/AIDS in Africa Table 4.1: Funding Sources and Commitments FUNDING SOURCES COMMITMENTS ($ BILLION) World Bank (1997­2007) 1.5 PEPFAR (2004­2007) 5.8 GFATM (2003­2007) 2.8 Total 9.9 Sources: Global Fund financing from 2003 through November 2007: www.theglobalfund.org; PEPFAR financing from 2004 through 2007: http://www.pepfar.gov/press/c19558.htm; World Bank financing includes MAP projects approved from 2001 to November 2007 and commitments for subregional projects. 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 interven- tions in Africa alone, in line with international commitments, would amount to more than $41 billion in the period 2007 to 2011 (see table 4.2). This indi- cates that a significant scale up in the availability of resources is required if the commitments made at the 2005 G-8 summit in Gleneagles and reiterated by the United Nations General Assembly in June 2006 are to be honored. Challenge. The increase in financial resources presents two major chal- lenges: ensuring the rapid, efficient, and effective use of the available funds, and reducing the continued shortfall between the verbal commitment to universal access and the reality of financial flows. One major concern is the efficiency and effectiveness with which available resources have been used, due in part to deficiencies in national fiduciary and health delivery systems, insufficient planning, leakages, and corruption. An apparent paradox is that despite the increased funding for HIV/AIDS, insufficient resources are devoted to addressing important country needs in the fight against the epi- demic, such as recurrent expenditures and institutional capacity building. Table 4.2: Resource Needs for Universal Access, 2007­2011 ($ millions) 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. Strategic Challenges in the New Environment 27 Global HIV/AIDS architecture and national institutions Context. At the global level, several commitments have been made to a more harmonized approach among development partners, embodied in the Mon- terey, Rome, and Paris Declarations; the New Partnership for Africa's Devel- opment; and, for HIV/AIDS, specifically, the Three Ones. Groups have been established to translate these global commitments into concrete action on HIV/AIDS, including the UNAIDS-funded Global AIDS Monitoring and Evaluation Team (GAMET); a country strategy and action plan improvement group (AIDS Strategy and Action Plan, or ASAP); and a pro- curement process review group. At national levels, the institutional capacity of AIDS authorities is seen as the linchpin for effective utilization of external and internal, and existing and future, resources. 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 levels. Work pressures and internal incentives conspire to keep most managers and staff from focusing on the labor- and time-intensive effort needed to fos- ter 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. Fiscal sustainability of HIV/AIDS programs Context. The scale up of efforts to combat the epidemic and the commit- ment of the major industrial countries to universal access to treatment are welcome. At the same time, these efforts carry implications for macroeco- nomic and fiscal management in aid-recipient countries and for the effec- tiveness of public policy initiatives in different sectors. In addition, as dis- cussed in 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. Most countries in the region are still heavily reliant on external assistance to finance their HIV/AIDS programs. Previous research has indicated that external funding tends to be volatile (Eifert and Gelb 2005). The evolving nature of the epidemic and the availability of lower-cost treatments are con- 28 The World Bank's Commitment to HIV/AIDS in Africa verting HIV/AIDS from a death sentence to a chronic disease. Once treat- ment begins, it is a lifelong commitment to the patient. Suspending or end- ing treatment for lack of funding would be both a moral and a health haz- ard. Furthermore, capital investments and recurrent expenditures, such as wages and training for health workers, result in long-term expenditure com- mitments for governments. Significant uncertainty surrounds the future costs of treatment because 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. 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 address this imbalance effectively, 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 gov- ernance appear to be more promising avenues to increasing fiscal space (David 2007). Governance and accountability Context. Concern has been growing about transparency and integrity in the use of funds. Recent in-depth examinations by the World Bank's Depart- ment of Integrity of selected MAP projects in Africa and projects in Asia revealed significant fiduciary risks, resulting in the suspension of disburse- ments in a health sector project and delaying new commitments for both HIV/AIDS and health sector projects. Similarly, the GFATM has sus- pended operations in several countries. 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 decentraliza- Strategic Challenges in the New Environment 29 tion of effort carries with it an enhanced risk of fund wasting and leakage. The challenge is to ensure the integrity of financing utilization while pro- moting the active engagement of many small organizations and the effective flow of funds to areas where the needs are greatest. Implementation capacity Context. With the significant infusion of resources, the increased numbers of stakeholders and service providers over a relatively short time frame, and broad acceptance of the notion of universal access to prevention and treat- ment, the capacity of institutions and entities to effectively perform numer- ous new tasks represents a major bottleneck, in many instances. Demand for planning, programming, and costing; and provision of service delivery, supervision, M&E, and reporting capacity--whether at community, provin- cial, or national levels--have outstripped the capability of many of those responsible. The burden on AIDS authorities to provide adequate support for the multifaceted activities provided by many partners is likely to grow as programs extend into universal access. Challenge. The nature of the HIV/AIDS response, which is principally implemented at the grassroots level as well as in health facilities, encom- passes behavioral change as well as provision of medical supplies and treat- ment. Effective implementation requires systems and skills that are not typ- ically in large supply in many countries. 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, trans- parency, and good governance. Special attention will be required from World Bank staff on the issue of how to effectively conduct capacity devel- opment under the umbrella of the Capacity Development Management Action Plan (CDMAP) for priority HIV/AIDS implementation capacity development. Operational Issues Bank efforts must be undertaken with an awareness of the numerous inter- twined operational issues that HIV/AIDS highlights. 30 The World Bank's Commitment to HIV/AIDS in Africa The balance among prevention, treatment, and care Context. In the past four years, the principal focus of the HIV/AIDS response has been on treatment, partly in response 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 GFATM 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 infra- structure 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 International 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. Challenge. Prevention responses cannot be isolated actions nor will one solu- tion work forever. Over the long term, prevention efforts must adapt as the epidemic changes, and respond to different infection patterns and social conditions. Countries in the region have typically implemented generalized prevention programs, which may not have a 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 concur- rent partners in high-prevalence countries; · men to increase their adoption of prevention mechanisms; and · vulnerable populations like sex workers, MSM, and injecting drug users, which are the principal modes of transmission in many countries with concentrated epidemics. In short, prevention efforts need to recognize and adapt to changing infection patterns and focus more on behavior change rather than solely on raising awareness. Strategic Challenges in the New Environment 31 Gender inequality Context. Gender inequalities in status and rights, labor opportunities, access to productive assets, and workloads, as well as gender-based violence are at the core of young girls' and women's greater HIV vulnerability and risk. Scaling up existing tools and methods, in addition to providing innovative and effective prevention tools for women, is needed. Some technological improvements (such as microbicides, which would give women more con- trol over their lives) hold promise, as does the broader application of effec- tive methods, specifically male circumcision, to reduce the risk of HIV transmission from female to male. Challenge. With the feminization of the HIV epidemic, integration of gen- der 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, pro- vide the basis for training, and integrate gender aspects into operations research, pilot testing, and service delivery would have significant benefits, but requires heightened and sustained focus to alter deeply embedded practices. Multisectoral engagement 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 wel- fare, commerce, defense, development, education, finance, health, interior, justice, municipal affairs, social services, trade, transportation, and youth, to name but a few sectors, all justifiably have valid reasons to concern themselves with the national HIV response. In practice, despite rhetorical recognition by civil servants of the relevance of HIV in 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 inade- quate. The reasons are many, including overburdened agendas; overbur- dened staff without new resources to take on additional tasks; reluctance to address socially sensitive issues; reluctance to build partnerships with CSOs; lack of leadership; and lack of tools, training, and absorptive capacity. 32 The World Bank's Commitment to HIV/AIDS in Africa 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 effect national success--and a pri- ority for their attention, engagement, and action, is a difficult task. Identi- fying key sectors on a country-by-country basis, finding receptive individu- als, and providing technical and financial support as well as encouragement can be done but will require World Bank sectors to identify such opportu- nities and draw on regional human and financial resources so that HIV/AIDS becomes an integral part of sectoral programs. Figure 4.1 illustrates the distribution of active HIV/AIDS commitments across World Bank sectors. While more than half of the portfolio (71 per- cent) is with the Health, Nutrition, and Population (HNP) sector, contin- ued efforts need to be made to mainstream combating HIV/AIDS into non- health sectors. Sexual and reproductive health (SRH) Context. Family planning, maternal and child health, reproductive health, and HIV and sexually transmitted infection (STI) programs are closely Figure 4.1: Active HIV/AIDS Commitments by World Bank Sector Agriculture and Rural Development 10% Education 7% Transport 5% Urban Development Health, Nutrition, 2% and Population Financial and Private 71% Sector Development 2% Social Protection 2% Social Development 1% Source: World Bank Business Warehouse, November 2007. Note: Data include full commitment amounts for MAP projects and the amount of the HIV/AIDS component for projects with HIV/AIDS components. Strategic Challenges in the New Environment 33 interrelated. 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. Challenge. Various studies are under way on how best to link SRH with HIV services (Lule 2004). Although such linkages will vary by context, it is also clear that providing family planning services as part of counseling, testing, and prevention of mother-to-child transmission (PMTCT) programs; expanding youth-friendly reproductive health 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 as a priority, and obtaining their commitment to a policy that demands resources, will require a con- certed effort by multiple stakeholders. Links to other diseases, especially tuberculosis Context. Since 1990, the number of new TB cases has tripled in Africa, and with the emergence of multidrug-resistant TB and extensively drug- resistant TB, the complexity of the interactions between TB and HIV have 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 significant con- tributor to HIV/AIDS vulnerability, impairing immune systems and height- ening mortality. Challenge. Taking concerted action to deal with relevant research, policy, technological advancements, and their application requires cooperation between 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. Health services delivery Context. The health sector is the one sector that must not fail if there is to be effective HIV/AIDS surveillance, prevention, treatment, and care. Many 34 The World Bank's Commitment to HIV/AIDS in Africa health systems in the region lack adequate facilities, outreach capability, and effective systems (such as supply chains and M&E) and face chronic short- ages of health workers to respond to the HIV epidemic (Tulenko 2006 and see appendix 2). Indeed, HIV/AIDS imposes a heightened burden for national health systems for retaining health workers, even those who are trained, unless they are provided with the means to protect and treat themselves. 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 M&E. National health systems and HIV/AIDS strategies and responses must be coordinated, complementary, and supported by national authorities and external partners. CHAPTER 5 The Agenda for Action 2007­2011 HIV/AIDS remains a fundamental development challenge in many African countries--threatening growth, livelihoods, and human capacity, and inflicting tragedy on millions of families. Since the articulation of the first Bank strategy for HIV/AIDS in Africa in 1999, the environment for combating HIV/AIDS has changed dramati- cally, with new donors, increased funding, more affordable treatment, bet- ter understanding of the disease and its transmission, and a new apprecia- tion of gender inequality in the feminization of the disease in Africa. Despite intensified national and global responses, much remains to be done in strategy development and building the wherewithal to implement a cohesive strategy with sufficient funding, human and institutional capac- ity, and attention to prevention. The need for continued Bank involve- ment in Africa is set against this backdrop, drawing on lessons of experi- ence gained over seven years of extensive HIV/AIDS investment, the capacity to adapt to a changing epidemiological environment, and an intention to stay the course with other partners in containing the spread of the disease. Among the most serious gaps is the absence of sustained international support for HIV/AIDS in the most acutely affected countries, especially in southern Africa, as indicated in figure 5.1 (see also appendix 8). 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. The Bank's 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 35 36 The World Bank's Commitment to HIV/AIDS in Africa Figure 5.1: Global Funding for HIV/AIDS in the Top 10 High-Prevalence African Countries 650 40 600 35 550 500 30 sn 15­49 450 400 25 ages millio 350 $ 20 300 ce,n US 250 15 200 150 10 evalerp 100 5 HIV 50 % 0 0 Swaziland Botswana Lesotho Zim- Namibia South Zambia Mozam- Malawi Central babwe Africa bique African Republic GFATM PEPFAR World Bank HIV prevalence, 2003­March 2007 2004­2006 2001­April 2007 ages 15­49 (%) Sources: UNAIDS 2006; Haacker 2007; www.theglobalfund.org; http://www.pepfar.gov/press/c19558.htm and World Bank Busi- ness Warehouse. GFATM financing from 2003 through November 2007. PEPFAR financing from 2004 through 2007. World Bank MAP projects approved from 2001 to November 2007. from the GFATM, PEPFAR, and others. The reduction in the Bank's new commitments from about $250 million per year to about $80 million is pro- nounced after FY04 (figure 5.2). In other respects, the demand for the Bank's engagement continues to be very strong. UNAIDS cosponsors specified the World Bank as the lead organization with respect to support to strategic, prioritized, and costed national plans; financial management; human resources; capacity and infra- structure development; impact alleviation; and sectoral work (see appendix 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 the United Nations Development Programme (UNDP) in addressing the broader development, governance, mainstreaming, and gender agendas; with the United Nations Children's Fund (UNICEF) in procurement and supply management; and with the UNAIDS Secretariat in M&E, strategic information, knowledge sharing, and accountability. Stakeholders consulted for this Agenda for Action (AFA)--including country officials, development partners, donors, and CSOs--articulated roles for the Bank for which it is uniquely qualified, including: The Agenda for Action 2007­2011 37 Figure 5.2: World Bank HIV/AIDS Lendinga in Africa FY00­FY07b 450 400 350 sn 300 250 millio 200 $US 150 100 50 0 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 total HIV/AIDS commitments MAP commitments Source: World Bank Business Warehouse. a. Data includes total commitment amounts for MAP projects and the amount of the HIV/AIDS component for projects with HIV/AIDS components. b. Data as of July 2007. · macroeconomic and fiscal analysis; · multisectoral 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 subregional integration; · partnership building with communities and the private sector; and · as a source of long-term financial support. Strategic Objectives The fundamental purpose of the AFA is to support countries in Sub-Saharan Africa as they strive to reach the sixth Millennium Development Goal (MDG) related to HIV/AIDS--halt and begin to reverse the spread of HIV/AIDS. 38 The World Bank's Commitment to HIV/AIDS in Africa 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 to financial resources. While there remain shortages of funding for uni- versal access and for intensifying the overall response in certain countries, the critical strategic objectives in the next five years are the following: · Strengthen the long-term prioritized sustainable response through incorporat- ing HIV/AIDS more explicitly into national development agendas, focusing the response, articulating realistic strategies built on solid evi- dence generated by good M&E, and integrating HIV/AIDS efforts with those of other diseases. · Intensify and accelerate a targeted multisectoral response by interventions in education, transport, agriculture, and health; and by working with the private sector, CSOs, and local governments. · Build stronger national systems to manage the response effectively and efficiently in health service delivery, financial management and procurement, sup- ply chain management, human resources, and social services. · Strengthen donor coordination by maintaining the commitment to the Three Ones and working effectively to rationalize the global aid archi- tecture for health. Pillars of Action 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 multisectoral and civil society responses. · Pillar 3. Deliver more effective results through increased country M&E capacity. · Pillar 4. Improve donor harmonization and coordination. The cornerstone of the AFA The Bank's commitment to continuing its active engagement in combating HIV/AIDS in Africa will underlie the AFA effort. With constrained country The Agenda for Action 2007­2011 39 IDA envelopes, the growing demand for infrastructure and other invest- ment, and the availability of grant resources for HIV/AIDS in several coun- tries 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 The conceptual framework for the AFA can be visualized in figure 5.3. 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 in appendix 10. The next sec- tion summarizes the principal elements of the foundation for the AFA, namely, renewing the commitment, the actions, and the expected results for each of the four pillars. The Foundation: Renew the Commitment 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. The tangible demonstration of the renewed commitment would include the following actions: · Commit to remain a source of predictable, flexible, and long-term finance. The Bank will be prepared to provide at least $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 opera- tions, components of other sector projects, or policy-based loans focused on health expenditures. Financial and program gap studies and the development { 40 The World Bank's Commitment to HIV/AIDS in Africa Figure 5.3: World Bank HIV/AIDS Agenda for Action in Africa Conceptual Framework MDG 6: Halt and begin to reverse the spread of HIV/AIDS Stragetic objectives ,S 1. Strengthened long-term sustainable national responses { PL 2. Accelerated implementation of HIV/AIDS programs W HAs, sector 3. Strengthened donor coordination families, UNAID 4. Strengthened national systems (public sector management, CBOs, human resounrces, supply chain, health and social systems) private donors, disabled the NGOs, and Stragetic pillars people, labor Civil multilateral 1. Strengthen evidence-based and prioritized national HIV/AIDS srentr strategies integrated in national development planning unions, society and and foundations, 2. Scale-up targeted multisectoral and civil society response marginalized 3. Deliver effective results through increased country M&E Pa youth, bilateral capacity agencies, 4. Improve harmonization and donor coordination women' UN groups sgroups, governments, other Bank-specific actions Country-specific actions TM,A · Renew the commitment · Improve governance · Improve institutional National GF · Sector analytical work and knowledge sharing capacity and program · Strategic planning management · Fiduciary management · Sharpen gender focus · Capacity and infrastructure · Integrate HIV/AIDS development services with sexual · Impact alleviation and reproductive health, mitigation tuberculosis, malaria, and nutrition · Address vulnerable groups Source: Authors. Note: CBO = community-based organization; NGO = nongovernmental organization; PLWHA = people living with HIV/AIDS. of five-year financing plans and financial sustainability studies that incorpo- rate 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 manage- ment would engage high-level policy makers to advocate for a response to HIV/AIDS. Advocacy by Bank staff would strongly reassert this position. The Agenda for Action 2007­2011 41 · Create an HIV/AIDS incentive fund to enhance the evidence base, promote the multisectoral response, and provide technical support, analysis, and policy advice to countries. An "incentive fund" with an annual budget of $5 million for five years would promote the analysis and mainstreaming of HIV/AIDS inter- ventions. 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 and program guidance, capacity building, and project and program prepa- ration, in line with the goals of the AAP and the CDMAP. The fund would be available to potential recipients both inside and outside the Bank. · Promote work on subregional public goods and cross-boundary issues such as refugees. Regional efforts are an important complement to national HIV/AIDS programs, and an integral part of Bank corporate strategic pri- orities. They represent, however, instances in which countries are either reluctant or unable to borrow. Conflict or postconflict situations are com- mon in many subregions, thereby making conventional credit operations infeasible. Grants to deal with refugees, internally displaced populations, transport corridors, and the like are virtually the only option available for responding to such crucial situations. The Bank has greater and more var- ied experience with HIV/AIDS subregional approaches than other partners. · 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, either through IBRD "buy-down" collabo- ration, IBRD grant-funded technical assistance subregional programs, or other mechanisms. The Bank could provide technical support and innova- tive instruments to assist middle-income countries in southern Africa through IDF financing, analytical work, and policy dialogue.1 Pillar 1: Focus the Response through Evidence-Based and Prioritized HIV/AIDS Strategies The Bank can make a unique contribution to the HIV/AIDS response by help- ing to incorporate the AIDS program into a country's national development plan, poverty reduction strategy, and MTEF. A prioritized, costed HIV/AIDS 42 The World Bank's Commitment to HIV/AIDS in Africa 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 follow: · Embed HIV/AIDS into national development strategies, MTEFs, and poverty reduction programs. With renewed commitment from Bank and Region management on HIV/AIDS, 6 PRSPs and 10 Country Assistance Strate- gies (CASs) and Interim Strategic Notes 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 5.1 and 5.2. · Support and build capacity for the development of prioritized, costed, national HIV/AIDS strategies. The work of the ASAP group 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 that need to be more closely addressed in the context of HIV/AIDS national responses. With its multisectoral capabilities, the Bank will more intensively consider how to do so, whether through HIV/AIDS programs 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 Multisectoral and Civil Society Responses The AFA will support a multisectoral response at the country level and mainstream HIV into the Bank's key sectors. The support will focus on a prioritized multisectoral approach to respond to the complexity of HIV as The Agenda for Action 2007­2011 43 Table 5.1: Country Types and HIV/AIDS Typology COUNTRY TYPES LOW-LEVEL EPIDEMIC CONCENTRATED EPIDEMIC GENERALIZED EPIDEMIC UNDER 1% PREVALENCE 1­5% PREVALENCE ABOVE 5% PREVALENCE IN YOUNG WOMEN AMONG YOUNG WOMEN AMONG YOUNG WOMEN AGES 15­24 AGES 15­24 AGES 15­24 PREVALENCE PREVALENCE PREVALENCE COUNTRIES (%) COUNTRIES (%) COUNTRIES (%) IDA Madagascar 0.3 Cameroon 4.9 Lesotho 14.1 Mauritania 0.5 Tanzania 3.8 Zambia 12.7 Senegal 0.6 Congo, Rep. of 3.7 Mozambique 10.7 Niger 0.8 Angola 2.8 Malawi 9.6 Nigeria 2.7 Central African Rep. 7.3 Angola 2.5 Kenya 5.2 Guinea-Bissau 2.5 Uganda 5.0 Burundi 2.3 Congo, Dem. Rep. of2.2 Chad 2.2 Rwanda 1.9 The 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 NA Ethiopia 0.8 Sudan NA IDA (conflict and non-accrual) Somalia 0.6 Togo 2.2 Zimbabwe 14.7 Côte d'Ivoire 5.1 IBRD Swaziland 22.7 Botswana 15.3 S. Africa 14.8 Namibia 13.4 Gabon 5.4 Sources: UNAIDS 2006 and extrapolation from Central Statistical Agency [Ethiopia] and ORC Macro, Ethiopia Demographic and Health Survey, 2005. Note: NA = Not available. This table provides only a broad typology, based on national-level data. Variations in the epidemiology within countries in West Africa and parts of East Africa can be significant (for example, in Kenya, Uganda, and Ghana) and should be taken into consideration when elaborating a locally appropriate response. 44 The World Bank's Commitment to HIV/AIDS in Africa Table 5.2: Possible Differentiated Responses FACTOR CONCENTRATED EPIDEMIC MIXED EPIDEMIC GENERALIZED EPIDEMIC Geographic area Parts of West Africa West Africa and parts Southern Africa of East Africa Lending instruments Focused prevention Hybrid HIV­health Programmatic loans (SWAps) projects and other sector projectsa project components Investment focus M&E, stigma reduction, Focused interventions Behavior change vulnerable groups on sources of transmission Initiatives for treatment Analytical focus HIV mapping, interactions Transmission dynamics Attitude and behavior among high-risk groups patterns and general population Human resources for health Surveillance focus Sex workers Vulnerable groups and Population-based surveillance Men who have sex with men interaction Source: Wilson 2006. Note: SWAps = sector-wide approaches. a. Hybrid projects would include projects such as Burkina Faso (AIDS and health) and the Eritrea projects covering HIV/AIDS/STI, TB, malaria, and reproductive health, which are being replicated in other countries. a broad development challenge and will focus on sectors that have the great- est potential impact (depending on country context) in partnership with CSOs and private sector entities. To achieve this objective, the AFA will support mainstreaming HIV/AIDS into the overall development and poverty reduction agenda and identify entry points for each sector to incor- porate HIV/AIDS. Specifically, the Bank will · Encourage HIV/AIDS integration into key sectors. The Bank will continue and expand its analytical work and investment operations designed to integrate HIV/AIDS policy, programs, and service delivery into priority sectors. This will call for strengthening of sectoral institutional capacity to scale up and supervise activities, in addition to multisectoral preven- tion operations research, pilot testing of promising approaches, and serv- ice delivery. This may involve integrating HIV into new products or retrofitting existing operations. · Support CSOs in providing prevention, care, and mitigation services. Experi- ence gained with the MAP in developing CSO participation and owner- ship 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 signifi- cantly engage CSOs as an integral part of, a national solution. CSOs will The Agenda for Action 2007­2011 45 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 that leads to greater knowledge of the different effects 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 into key sectors, and appropriate Bank products will be devel- oped with country teams, task team leaders, and national counterparts. · Intensify prevention and support programs for youth and orphans and other vul- nerable 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 disease pose a significant social and financial burden to societies. The Bank will contribute to national and external donor responses in conjunc- tion with other lead donor financiers and lead technical partners, including the United Nations Population Fund (UNFPA), the United Nations Edu- cational, Scientific, and Cultural Organization (UNESCO), and UNICEF, in the context of the agreed division of labor among UNAIDS cosponsors. · Strengthen health systems. Taking into account the Bank's 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 sys- tem that present specific challenges to HIV/AIDS programs, improve service delivery, human resources, and financial sustainability. Particular attention will be paid to ways to multiply results through linkages with TB, malaria, reproductive health, and nutrition. Pillar 3: Deliver Effective Results through Increased Country M&E Capacity 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: 46 The World Bank's Commitment to HIV/AIDS in Africa · Continue to strengthen M&E frameworks at the country level and tailor the responses. Monitoring of and technical support to the development and operationalization of M&E systems will be increased, including adoption of a standard "HIV/AIDS Results Scorecard" (see appendix 11) in all projects, development of impact assessment and evaluations, and imple- mentation of an early warning system for project performance. Effective M&E systems can identify epidemic profiles, changing patterns, and con- textual areas (including socioeconomic determinants) and develop tai- lored responses. GAMET, the UNAIDS program housed at the Bank, is charged with helping improve the quality of national M&E systems. Ana- lytical work is also urgently needed to identify specific prevention inter- ventions 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 trans- parency 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. Regardless of whether associated with World Bank funding, the Bank has a role to play in helping ensure the integrity of national HIV/AIDS programs, assessing anticor- ruption 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 pro- gram 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 Countries face considerable difficulties in significantly scaling up program implementation. They need technical support that reinforces national own- The Agenda for Action 2007­2011 47 ership, addresses immediate needs, and strengthens capacity in a sustainable manner. Strategic planning, integration, and M&E are all vital for "making the money work," that is, improving the efficiency, effectiveness, and sus- tainability of national HIV/AIDS responses. 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 by: · Working with key partners to harmonize and strengthen national M&E sys- tems, human resources capacity, procurement, and supply chains. The Bank will continue to house the multidonor effort to help strengthen M&E systems with support from GAMET. The Bank will also work with lead organizations, as outlined in the UN Technical Support Division of Labor matrix, to address the human resources capacity, procurement, and supply chain management aspects of the HIV/AIDS challenge. Sup- port 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. · Conducting joint planning and analytical work with UNAIDS and other part- ners. Taking into account the mandate of ASAP, the Bank will carry out 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. · Participating in joint annual partner meetings. The Bank will actively seek to harmonize and align its work with other partners for greater aid effec- tiveness. It will participate or organize collaborative partnership information-sharing and action events. · Strengthening and harmonizing national coordinating institutions. The Bank will conduct institutional assessments with a view toward identi- fying key constraints and will provide the tools and training to effec- tively deal with the multiple stakeholders engaged in the HIV response. Anticipated Results The AFA will help produce a stronger policy, institutional, and human capacity framework, which, in turn, will strengthen the HIV/AIDS 48 The World Bank's Commitment to HIV/AIDS in Africa response. Over time, it will contribute to a reduction of new infections, reduced prevalence, and improved life expectancy. Within 10 years, it will have helped realize the MDG to halt and begin to reverse the spread of HIV/AIDS. The expected principal outputs from the AFA over the next five years are contained in tables 5.3 through 5.7. The Potential Impact and Consequences of Inaction If universal access to treatment and prevention becomes a reality by 2011 as envisaged by the G-8 countries, the impact on Africa will be significant. According to the analysis discussed in detail in appendix 4, 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 $2,000 to $3,000 per infection averted. In addition, these prevention interventions would result in savings for avoided treatment cost alone of about $6,570 per HIV infection averted. With continued expanded access to treatment, almost a million deaths will be averted annually by 2011. In contrast, the conse- quences of inaction are frightening: new infections would continue to increase, and deaths from HIV/AIDS would grow from the 2005 level of 1.9 Table 5.3: Foundation OBJECTIVE ANTICIPATED RESULTS BY WHOM BY WHEN Country demands for predictable, Countries' access to predictable, AFRRMT FY08­FY11 flexible, and sustainable IDA flexible, and sustainable financing financing for HIV/AIDS receive for HIV/AIDS provided responses Support for subregional and Support continued to subregional AFRRMT FY08­FY11 cross-border initiatives provided operations to address cross-border AFTHV issues AFTHD At least two new subregional operations Africa HIV incentive fund (to Incentive fund finances five CDMAP FY08­FY10 provide support for project and technical support products AFTHV program development, policy per year advice, and capacity building) created Source: Authors. Note: AFRRMT = Africa Region Management Team; AFTHD = Africa Region Human Development Department; AFTHV = ACTafrica. The Agenda for Action 2007­2011 49 Table 5.4: Pillar 1: Focus the Response through Evidence-Based and Prioritized HIV/AIDS Strategies OBJECTIVE ANTICIPATED RESULTS BY WHOM BY WHEN Appropriate HIV/AIDS efforts HIV/AIDS addressed appropriately AFTHV, FY08­FY11 integrated into countries' through countries' and Bank AFRRMT, development agendas and Bank development agenda PREM, WBI, instruments (policy procedures) HDNGA, UNDP, IMF. Bank support in capacity building Strengthened capacity to HDNGA, FY08­FY11 to develop prioritized, and costed, develop prioritized and costed ASAP, UNAIDS, national strategies and action national action plans in 20 AFTHV. plans provided countries Integration of TB, malaria, Bank projects addressing HDNGA, FY08­FY11 reproductive health, and nutrition HIV/AIDS integrate TB, AFTHV, AFTHD, into World Bank HIV/AIDS malaria, reproductive health, WHO, UNFPA, products ensured and nutrition when appropriate UNICEF. to epidemiological context Source: Authors. Note: HDNGA = Global HIV/AIDS Program; IMF = International Monetary Fund; PREM = Poverty Reduction and Economic Manage- ment network; WBI = World Bank Institute; WHO = World Health Organization. Table 5.5: Pillar 2: Scale Up Targeted Multisectoral and Civil Society Responses OBJECTIVE ANTICIPATED RESULTS BY WHOM BY WHEN HIV/AIDS policy, programs, Improved country capacity in HDN, AFTHD, PREM, FY08­FY11 and service delivery integrated key sectors to implement IFC, AFTHV, AFTPS, into priority sectors (dependent multisectoral approaches AFTEG, AFTTR, upon country context) Increased commitment in AFTU, AFTRL. key Bank sectors to include HIV/AIDS component or subcomponents in lending and nonlending activities, including adequate resources Support to strengthen elements Improved synergy between HDNHE, AFTHD, FY08­FY11 of the health system that HNP and HIV/AIDS operations AFTHV, WHO, challenge HIV/AIDS programs UNFPA, UNICEF. provided . Source: Authors. Note: AFTEG = Africa Energy; AFTPS = Africa Private Sector; AFTTR = Africa Region Transport Group; AFTU = Africa Urban and Water; HDN = Human Development Network; HDNHE = Health, Nutrition, and Population Team; IFC = International Finance Corpo- ration; JFC = Joint Facilitation Committee. 50 The World Bank's Commitment to HIV/AIDS in Africa Table 5.6: Pillar 3: Deliver Effective Results through Increased Country M&E Capacity OBJECTIVE ANTICIPATED RESULTS BY WHOM BY WHEN Harmonized M&E frameworks Bank to continue to play HDNGA, AFTHV, FY08­FY11 at the country level strengthened leading role (through GAMET) GAMET, UNAIDS. in supporting countries All countries have a functional, harmonized M&E system reporting and using data Knowledge generation and sharing Design and impact of HIV/AIDS HDNGA, AFTHV, FY08­FY11 to improve prioritization, decision investments based on GAMET, AFTQK, making, and program design knowledge sharing DEC. supported Countries and partners fully engaged in knowledge generation and sharing Source: Authors. Note: AFTQK = Africa Region Operational Quality and Knowledge Services; DEC = Development Economics Vice Presidency. Table 5.7: Pillar 4: Harmonize Donor Collaboration OBJECTIVE ANTICIPATED RESULTS BY WHOM BY WHEN Collaboration with key partners GAMET continues to support HDNGA, AFTHV, FY08­FY11 to harmonize and strengthen countries to strengthen M&E PREM, GAMET, national M&E systems, human in close collaboration with AFTQK, UNAIDS, resources capacity, procurement, other partners GFATM, PEPFAR. and supply chains strengthened Better implementation of the global division of labor Joint planning and analytical More efficient, effective, and HDNGA, WBI, FY08­FY11 work with UNAIDS and other sustainable HIV/AIDS resource AFTQK, AFTHV, partners increased allocation UNAIDS, GFATM, PEPFAR. Source: Authors. million. The cumulative effect 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). Note 1. The Bank currently supports analytical and advisory services and provides IDF grants for capacity building in Swaziland and Namibia. CHAPTER 6 Operational Implications for the Bank 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 was in the past five years. With the absence of IDA grant funding for HIV/AIDS, 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 multisectoral response in education, transport, and other sectors does not rest with ACTafrica or with the HNP team, but with other units in the Bank. And the most critical role for the Bank might shift from financier to facilitator in some countries that have financing from other donors, with consequences for budgeting, work pro- gram agreements, and internal incentives. As indicated in chapter 5, other stakeholders consulted for the AFA con- sider the "soft" role to be no less critical than the financial role to an effec- tive 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 more than 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 vic- tim 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 a health issue. The Bank is uniquely positioned 51 52 The World Bank's Commitment to HIV/AIDS in Africa to place the HIV/AIDS epidemic within a macroeconomic 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 multisectoral role. The Bank is active in the sectors that have critical roles in managing the HIV/AIDS epidemic, including education, trans- port, rural development, defense, and health, as well as in the private sector. · Analytical expertise. The Bank has the analytical capacity--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 manage- ment strengthening is widely seen as critical to implementing multisec- toral programs. · 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 levels is particularly valued. At the same time, the consultation process identified areas where devel- opment partners felt the Bank had been less effective. A number of stake- holders 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 lim- ited country presence weakens its capacity to help harmonize the HIV/AIDS response and broader health responses at the local level. Another shortcoming relates to the Bank's limited ability to operate in the epicenter of the epidemic, that is, in the middle-income countries of south- ern Africa. Finally, the Bank is perceived to have been slow to put into prac- tice lessons learned from the MAP, to measure the program's impact, and to apply these lessons to the next generation of efforts to fight the disease. Operational Implications for the Bank 53 Work Program Implications for the Africa Region The four pillars of the AFA will require that the Africa Region and ACTafrica design and develop a program of work very different from the one that drove the first phase of the MAP. 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 will be needed. 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 Poverty Reduction Support Credits (PRSCs), and in help- ing to design prioritized and costed national HIV/AIDS strategies. · Ensure Bank CASs reflect 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 fund them where demand exists. New projects have been approved in seven of the nine countries where MAP projects have been completed. Under the AFA, the Bank will be prepared to provide funding of at least $250 mil- lion per year for projects in the Region. · Support the inclusion and design of HIV/AIDS-related components in other sec- tor 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, infrastructure, agriculture, and capacity building for health and fiduciary systems. ACTafrica can provide expert- ise and operational support where requested for both new products and for retrofitting existing ones. The proposed incentive fund will provide funding to develop HIV/AIDS components in sector projects and ana- lytical 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 inten- 54 The World Bank's Commitment to HIV/AIDS in Africa sive program of retrofitting outputs and enhanced supervision for enhanced results is being initiated, in collaboration with our partner countries. The Global Implementation and Support Team will continue to promote problem solving among development partners. · Continue to support capacity building for HIV/AIDS governance, especially at the local level, for M&E, and for 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 Bank's pledge to the UNAIDS Three Ones principles, work on HIV/AIDS rep- resents a model of the harmonization effort commitment under the Paris Declaration. 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 Frame- work and Implementation Plan presented in appendix 10. An HIV/AIDS Support Program for FY2007­FY2011 Although 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 Low- Income Countries Under Stress and postconflict countries with large refugee populations, may be the most likely claimants of Bank funding. Epi- center countries such as Botswana, Namibia, South Africa, and Swaziland may also consider funding from the IBRD, while the Bank explores innova- tive instruments for this purpose. Implications for Staffing and Budgeting Implementing the AFA will require both human and financial resources from the Africa Region to support the HIV/AIDS specialized dedicated team, contributions from country and sector units, and specialists to take on their share of the responsibilities to mainstream HIV/AIDS. Operational Implications for the Bank 55 The functions of the current dedicated specialized multisectoral 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 strate- gic planning; financing and program gap analysis and long-term financial sustainability; macroeconomic 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 and cross-border efforts. In addition, we envisage an evolution of the skills requirements over time based on these functions and emerging demands. While the dedicated team would continue to provide key specialized and quality assurance support across sectors, it will also depend on other Bank staff in the Africa Region, external partners, and cosponsored operations such as GAMET and ASAP to provide substantial time to strengthen key sectoral responses. The dedicated unit would draw on specialized expertise from other Bank operations such as DEC, the WBI, and the IFC. Addi- tional skills and support would be drawn from the Global AIDS Program of the World Bank. The cost of the unit will involve a modest increase in the current base budget for ACTafrica. This modest increase would allow the unit to recon- figure 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. CHAPTER 7 Conclusion We have sought to present a convincing case for the Bank's continued engagement in Africa's struggle to overcome HIV and the suffering of its people. We have provided the best available information on the epidemiol- ogy, the impact, the Bank's efforts to date, and its future role. As development practitioners, we know that HIV/AIDS threatens the realization of the MDGs 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 trans- mission, and the relative cost effectiveness of different interventions, as well as the growth of funding--has resulted in new challenges for African coun- tries and for the World Bank. The AFA responds to these challenges and to the priorities of the World Bank in Sub-Saharan Africa through the AAP, the World Bank's Global HIV/AIDS Program of Action, CDMAP, and the World Bank HNP strategy. Using knowledge gained from experience, the AFA is to be demand driven, evidence based, and results oriented. It will build capacity for M&E and epidemiological surveillance, and will continue the process of learning by doing and knowledge creation and sharing. For the Bank's Africa Region, this AFA will reinvigorate its engagement in the fight against HIV/AIDS. While its funding role is likely to be modest in relative terms, the Bank's investments would remain significant in that it would be the lender of last-- and sometimes first--resort. Its involvement would be significant in analyz- ing, generating, and disseminating evidence; continuing the learning-by- doing process; building capacity for national, effective, sustainable HIV/AIDS responses; strengthening health and fiduciary systems; generat- ing high-quality, prioritized strategic programs and action plans at the 57 58 The World Bank's Commitment to HIV/AIDS in Africa 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, mitigation, and support across the continent to cushion the possible impact of volatile international funding over time. The AFA will be implemented through partnerships across Bank units and other sectors working closely with partner countries. It will collaborate with and complement the work of UNAIDS, its cosponsors, GFATM, and other development partners to scale up a multisectoral response, main- stream HIV/AIDS in development agendas, build capacity, and, with the IMF, address fiscal space and long-term sustainability issues. In 2000, the World Bank made a commitment to remain actively involved in combating the HIV/AIDS epidemic in Sub-Saharan Africa for a generation. The AFA 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 forums. Standing by this com- mitment through the unanticipated trials and tribulations of its partner countries will reinforce Bank credibility as a reliable partner, but more importantly, it will further our goal of alleviating poverty. Appendixes 59 APPENDIX 1 Agenda for Action Consultations Table A1.1: Agenda for Action Consultations BROAD BANK EVENT OVERVIEW PRIORITY AREAS COMPARATIVE ADVANTAGE Toronto stakeholder · HIV/AIDS a development issue · Three Ones support · Multiyear, sustainable consultations with and a priority · Alignment and harmonization with financing panelists · MDG responsibilities other partners (August 13, 2006) · Multisectoral engagement ASAP consultations · Alignment and harmonization with with UNAIDS other partners (August 17, 2006) Task Team Leader · MDG responsibilities · Alignment and harmonization with · Africa-wide MAP experience consultations · Multisectoral engagement other partners · Multisectoral approach (September 18, 2006) · Knowledge management and · National capacity-strengthening analytical capacity experience · Convening power UNAIDS/East and · Macroeconomic access and · Three Ones commitment · Multiyear, sustainable Southern Africa dialogue · Alignment and harmonization with financing (September 23, 2006) · Knowledge management and other partners · National capacity-strengthening analytical capacity · Fulfill donor of last resort to inadequately experience · Convening power treated and/or sensitive issues and marginalized groups 60 Appendix 1: Agenda for Action Consultations 61 SPECIFIC THEMES BANK RESOURCES AND FOR BANK INSTITUTIONAL STRUCTURE BANK WEAKNESSES · Local response and prevention · "Financial gap" provider, using · Apparent insufficient commitment and priority by experience its various financing response Bank to long-term HIV/AIDS effort · Integrated health sector engagement instruments · Inadequate coordination with health and other sectors · National capacity strengthening · Headquarters and field presence · Neither mainstreaming nor budget support translating · Regional programs and emergency to support national HIV/AIDS into HIV/AIDS resources responses deliberation and response · Analytical capacity · National capacity strengthening · Headquarters and field presence · Absence of engaged field presence, to support national HIV/AIDS technical expertise deliberation and response · Local response and prevention experience · "Financial gap" provider, using · Apparent insufficient commitment and priority by · Integrated health sector engagement its various financing response Bank to long-term HIV/AIDS effort · Scaling up good practices instruments · Absence of engaged field presence, technical expertise · Headquarters and field presence · Insufficient Bank staff incentives to pursue HIV/AIDS to support national HIV/AIDS track deliberation and response · Neither mainstreaming nor budget support translating into HIV/AIDS resources · Absence of "ring-fenced financing" and Bank Budget support results in reduction of Bank HIV/AIDS support · Insufficient awareness of reputational risks and governance considerations · Local response and prevention · "Financial gap" provider, using · Absence of engaged field presence, technical expertise experience its various financing response · Rigidity of fiduciary rules · Regional programs and emergency instruments · Need for a significant presence in southern Africa responses (continues on the following page) 62 The World Bank's Commitment to HIV/AIDS in Africa Table A1.1: Agenda for Action Consultations (continued) BROAD BANK EVENT OVERVIEW PRIORITY AREAS COMPARATIVE ADVANTAGE UN agencies with · MDG responsibilities · Fulfill donor of last resort to address · Africa-wide MAP experience New York headquarters · Macroeconomic access and inadequately treated and/or sensitive · National capacity-strengthening (September 28, 2006) dialogue issues and marginalized groups experience · Convening power GFATM · MDG responsibilities · Alignment and harmonization with · Fiduciary expertise (Geneva, · Macroeconomic access and other partners · National capacity-strengthening October 2, 2006) dialogue experience · Knowledge management and · Support to national AIDS analytical capacity institutions, especially in costing, fiduciary, and M&E UNAIDS · Macroeconomic access and · Alignment and harmonization with · Fiduciary expertise (Geneva, dialogue other partners (contribute to it · Multiyear, sustainable financing October 2, 2006) · Multisectoral engagement becoming a reality via support for · Convening power independent monitoring of organization behaviors) WHO · Macroeconomic access and · Discard notion of dichotomy between · National capacity-strengthening (Geneva, dialogue vertical versus horizontal programs, experience October 3, 2006) · Multisectoral dimension of and invest in both in a mutually · Multiyear, sustainable financing engagement reinforcing manner · Fiduciary expertise · MDG responsibilities (coupled with concern for equity in access and treatment) UNHCR · Multisectoral engagement · Alignment and harmonization with · Multiyear, sustainable financing (Geneva, · Convening power, especially other partners October 3, 2006) in inherently risky countries and environments Nairobi regional · Multisectoral dimension of · Alignment and harmonization with · Multiyear, sustainable financing consultations on civil engagement other partners, especially in the society response · Macroeconomic access and health sector · National capacity-strengthening (May 8­11, 2006) dialogue · Three Ones commitment (but adapt experience, including strategic · Knowledge management and M&E to the reality of each country) plans and action plans analytical capacity Appendix 1: Agenda for Action Consultations 63 SPECIFIC THEMES BANK RESOURCES AND FOR BANK INSTITUTIONAL STRUCTURE BANK WEAKNESSES · Local response and prevention · Financial gap provider, using its · Absence of engaged field presence, with technical experience various financing response expertise · Integrated health sector engagement instruments · Rigidity of fiduciary rules · Regional programs and emergency · Need for a significant presence in southern Africa responses · Local response and prevention · Rigidity of fiduciary rules experience · Integrated health sector engagement · Analytical work (including analysis · Apparent insufficient commitment and priority by of the financial consequences of Bank to long-term HIV/AIDS effort "universal access") · Absence of engaged field presence, with technical · Local response and prevention expertise, and continuity experience, including the · Lack of vision in integrating HIV/AIDS and health private sector systems · National capacity strengthening · M&E effort needs to be better coordinated (GAMET and need to do more at and UNAIDS) subnational levels · Integrated health sector engagement · Rigidity of fiduciary rules · Africa MAP was isolated from other partner efforts · Regional programs and emergency · Apparent insufficient commitment and priority responses by Bank to long-term HIV/AIDS effort in · Local response and prevention refugee environments experience, in particular in income-generation activities · Scaling up good practices · Financial gap provider, using its · Apparent insufficient commitment and priority · Local response and prevention various financing response by Bank to long-term HIV/AIDS effort experience instruments, particularly for · Rigidity of fiduciary rules · Regional programs and emergency civil society · Absence of engaged field presence, with technical responses · Headquarters and field presence expertise, and continuity · Integrated health sector engagement to support national HIV/AIDS · Need for a significant presence in southern Africa deliberation and response (continues on the following page) 64 The World Bank's Commitment to HIV/AIDS in Africa Table A1.1: Agenda for Action Consultations (continued) BROAD BANK EVENT OVERVIEW PRIORITY AREAS COMPARATIVE ADVANTAGE Donor consultations · Convening power · Alignment and harmonization with · National capacity-strengthening (London, · Macroeconomic access and other partners, particularly with the experience, including October 23, 2006) dialogue (PRSP, MTEF) the GFATM, and especially in the technical assistance and · Knowledge management and health sector training, in various aspects, analytical capacity including strategic plans and · Capacity to consider the multi- action plans sectoral dimensions of engagement · Support to national AIDS institutions, especially in costing, fiduciary, and M&E · Multisectoral approach via mainstreaming or integrating HIV/AIDS into sector policies and programs, and development of sectoral or topic-specific guidelines Countries and youth · Accelerating attention to and · Effective approaches and partnerships · Advocate for mainstreaming (Johannesburg, implementation of youth for addressing youth of youth in government budget February 2007) activities · Strengthen linkages between lines and national frameworks · Improved integration of adolescent reproductive health · Be a knowledge bank adolescent HIV and sexual and HIV services · Convening authority for reproductive health services · Strengthen M&E and the evidence dialogue with development · Multisectoral engagement base for youth-friendly services partners and government and interventions · Work with regional · Alignment and harmonization with establishments other partners Appendix 1: Agenda for Action Consultations 65 SPECIFIC THEMES BANK RESOURCES AND FOR BANK INSTITUTIONAL STRUCTURE BANK WEAKNESSES · Analytical work (including analysis of · As an important financer, use its · Apparent insufficient commitment and priority by the financial consequences of various financing response Bank to long-term HIV/AIDS effort, coupled with "universal access") instruments, particularly for current absence of key management leadership · Scaling up good practices civil society · Absence of engaged field presence, with technical · Local response (civil society, private · IDA-15 represents an opportunity expertise, and continuity to engage in country dialogue sector, NGOs) and prevention experience to revisit the ways and means · Uncertain extent to which GTT recommendations have · Regional programs and emergency to maintain Bank involvement been adopted and embedded in Bank approach responses and momentum in responding · Need for a significant presence in southern Africa · Integrated health sector engagement to HIV/AIDS · Neither mainstreaming nor budget support translating into HIV/AIDS resources · Absence of "ring-fenced financing" and Bank Budget support results in reduction of Bank HIV/AIDS support · Enhance youth capacity on development · Lack of specific focus on youth HIV interventions concepts, agendas, and frameworks, · Lack of segmentation catering to varying needs of for example, PRSPs, budgeting, different youth groups; limited attention to rural youth monitoring, and accountability and gender differentiation · Advocate flexibility in registration · Inadequate consideration of the 10­14 age group and mechanisms for youths to · Weak youth participation in policy and programming access resources decisions · Take leadership to bring key groups together and give a voice to youth · Intensify analytical work, document and disseminate best practices and lessons learned APPENDIX 2 HIV Indicators for Sub-Saharan Africa Table A2.1: HIV Prevalence, Income, Access to Treatment, and Quality of Health Services in Sub-Saharan Africa, 2006 HIV PREVALENCE, ACCESS TO POPULATION POPULATION PLWHA PER PLWHA PER GDP PER AGES 15­49 TREATMENT PER PHYSICIAN PER NURSE PHYSICIAN NURSE COUNTRY CAPITA ($) (PERCENT) (PERCENT) (UNITS) (UNITS) (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 2.0 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, Dem. Rep. of 119 3.2 4 9,339 1,890 172 35 Congo, Rep. of 1,751 5.3 17 5,050 1,040 159 33 Côte d'Ivoire 850 7.1 17 8,120 1,660 360 74 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 NA NA Gabon 6,538 7.9 23 3,420 194 152 9 Gambia, The 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 NA 946 271 3 1 (continues on the following page) 67 68 The World Bank's Commitment to HIV/AIDS in Africa Table A2.1: HIV Prevalence, Income, Access to Treatment, and Quality of Health Services in Sub-Saharan Africa, 2006 (continued) HIV PREVALENCE, ACCESS TO POPULATION POPULATION PLWHA PER PLWHA PER GDP PER AGES 15­49 TREATMENT PER PHYSICIAN PER NURSE PHYSICIAN NURSE COUNTRY CAPITA ($) (PERCENT) (PERCENT) (UNITS) (UNITS) (UNITS) (UNITS) 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 NA NA NA NA Swaziland 2,323 33.4 31 6,333 159 1,287 32 Tanzania, United Republic of 324 6.5 7 22,298 2,343 6,222 654 Togo 378 3.2 27 12,086 1,646 50 7 Uganda 326 6.7 51 44,131 2,729 1,217 75 Zambia 609 17.0 27 8,642 575 870 58 Zimbabwe 383 20.1 8 6,199 1,382 815 182 Source: Haacker 2007. Note: NA = not available. Country HIV prevalence data is the most recent at the time of this publication. The UNAIDS publication of 2007 country estimates are expected in July 2008. Appendix 2: HIV Indicators for Sub-Saharan Africa 69 Table A2.2: Life Expectancy at Birth for Selected Sub-Saharan African Countries, 1965­2005 (years) COUNTRY 1965 1970 1975 1980 1985 1990 1995 2000 2005 Sub-Saharan Africa region 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 Cameroon 43 45 47 50 52 52 50 47 46 Congo, Dem. Rep. of 44 45 47 48 47 46 43 42 44 Côte d'Ivoire 47 49 51 53 54 52 49 47 46 Ethiopia 39 40 41 42 44 45 44 42 42 Ghana 48 49 51 53 55 56 57 57 57 Kenya 51 52 55 58 59 58 53 48 48 Malawi 39 41 43 45 46 46 43 40 40 Mozambique 38 40 42 43 43 43 44 43 42 Nigeria 41 42 44 45 46 46 45 44 44 Rwanda 44 44 45 45 44 31 32 41 44 Senegal 38 39 42 47 50 53 54 55 56 South Africa 52 53 55 57 59 62 58 48 45 Sudan 43 44 47 49 51 53 55 56 57 Tanzania 47 49 51 54 55 53 50 47 46 Uganda 48 50 51 50 49 46 43 45 49 Zambia 48 49 51 52 50 46 41 38 38 Zimbabwe 54 55 57 59 61 59 49 40 37 Source: World Bank's Development Data Platform (DDP) database. 70 The World Bank's Commitment to HIV/AIDS in Africa Figure A2.1: Life Expectancy at Birth for Selected Sub-Saharan African Countries, 1965­2005 65 60 55 50 45 40 35 30 1965 1970 1975 1980 1985 1990 1995 2000 2005 years Angola Ethiopia Nigeria Sudan Botswana Ghana Rwanda Tanzania Cameroon Kenya Senegal Uganda Congo, Dem. Rep. of Malawi South Africa Zambia Côte d'Ivoire Mozambique SSA Zimbabwe Source: World Bank's Development Data Platform (DDP). APPENDIX 3 Bank Response to HIV/AIDS: A Chronology of Events Table A3.1: Bank Response to HIV/AIDS: A Chronology of Events TIMELINE ACTION TAKEN Pre-1997 The Bank's response was 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 The Africa Regional Vice President (RVP) called for a new Regional strategy in light of emerging data on the develop- ment impact of AIDS. July 1999 ACTafrica was established to support and coordinate the Bank's multisectoral response. The unit was placed in the office of the RVP and staffed with seconded multisectoral staff. Weekly Regional Leadership Team meetings regularly discussed AIDS. Accountability mechanisms were established requiring country directors to report regularly on AIDS activities. AIDS was incorporated in Bank 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 were added to existing projects in country portfolios and sectors other than health, such as education, transport, rural development, and social protection. Retrofitting had mixed results because the commitment amounts were often too small to affect the spreading epidemic. January 2000 The 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 the top agenda item for the Bank's Spring Meetings. September 2000 The Bank's Board approved a Multi-Country HIV/AIDS Program (MAP), a 10­15 year program to intensify multisector action against AIDS and build political commitment. The MAP defined eligibility criteria to raise political commitment and mobilization at the country level. February 2002 MAP 2 was approved with $500 million funding to pilot test ART and support cross-border initiatives. IDA-13 provided grants in support of HIV/AIDS. January 2003 An Implementation Acceleration Team was established to address slow implementation and low coverage and strength- en 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, highlight- ed progress made and suitability of interventions, and identified ways for future improvement. (continues on the following page) 71 72 The World Bank's Commitment to HIV/AIDS in Africa Table A3.1: Bank Response to HIV/AIDS: A Chronology of Events (continued) TIMELINE ACTION TAKEN 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 use this fund to address challenges. April 2006 The Africa Region reviewed all active HIV projects in collaboration with HDNGA, AFTHD, and LEGAF to assess imple- mentation risks and opportunities to incorporate recommendations from the MAP interim review and OED evaluation. May 2006 ACTafrica and HDNGA conducted MAP task team leader training on M&E 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 the MAP interim review and OED evaluation. Led by ACTafrica and AFTHD, the core team includes LEGAF, Loan Department (LOA), HDNGA (GAMET), and AFTRL. October 2006 The Africa Region and HDNGA (GAMET) finalized a Generic Results Framework (GRF) and Results Scorecard for all HIV projects inclusive of IDA-14 and UNGASS indicators, AAP indicators, and indicators from national M&E plans. 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 M&E assistance in support of donor harmonization and alignment and strengthening of national AIDS strategies and plans through ASAP. 2006 ­ Present The Africa Region began updating its 1999 HIV/AIDS strategy and developing an "Africa HIV/AIDS Agenda for Action, 2007­2011." Consultations were held with civil society, donors, stakeholders and countries, trade unions, UN agencies, private sector, youth, women's groups, and global health partners working on sexual and reproductive health, TB, and malaria. February 2007 An umbrella restructuring proposal of MAP projects was presented to the Bank's Executive Board. The proposed restruc- turing took into account the findings from the MAP interim review, OED/IEG evaluation of global HIV projects, latest sci- entific 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 HIV/AIDS Agenda for Action 2007­2011" was presented as part of the AAP update during Annual Spring Meetings. November 2007 "Africa HIV/AIDS Agenda for Action 2007­2011" was discussed and endorsed by the Board at an informal meeting. APPENDIX 4 The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations This appendix discusses the simulations of the impact and costs of HIV/AIDS prevention, care, and mitigation interventions in Sub-Saharan Africa (Bollinger and Stover 2007). The presented results 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 "Base Scenario" where coverage rates for prevention, treatment, and mitigation interven- tions remain at current levels; (ii) a universal access to treatment scenario ("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 ("Prevention Scenario"), where prevention interventions are also scaled up. The results are divided into three different subregions--East Africa, southern Africa, and Central/West Africa--to reflect the different natures of the epidemic in those areas. In the Base Scenario, new infections would continue to increase and deaths from HIV/AIDS would grow from the 2005 level of 1.9 million. The cumulative effect 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 second case--the Treatment Scenario--consists of increasing coverage from the current levels that are in the Base Scenario to reach universal access to treatment by 2010 (defined as covering 80 percent of adults and children in 73 74 The World Bank's Commitment to HIV/AIDS in Africa need of ART). Annual costs of care and treatment are based on data from Khayelitsha, South Africa, and include data on costs of and progression to first- line and second-line therapies, incidence and treatment of opportunistic infec- tions, 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 third case--the Prevention Scenario--builds on the Treatment Sce- nario and assumes that prevention interventions are scaled up in a linear fash- ion 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: (i) predicting the change in behavior that is due to this increased coverage; (ii) estimating the impact of this behavior change on HIV incidence; and (iii) examining the consequences of the changes in incidence. Changes in behavior are predicted based on an impact matrix that esti- mates the effect of the various prevention interventions on specific behav- iors. The values of the matrix were derived from a review of the literature on approximately 100 impact studies. These behavior changes were then fed through an HIV/STI transmission equation to calculate new HIV infec- tions. This equation calculates the probability of infection as a function of HIV prevalence in the partner population, the transmissibility of HIV, the impact of an STI on HIV transmissibility, the proportion of the population with STIs, condom use, number 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. Impact of Universal Access to Treatment If the 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 a million (figure A4.1). The overall cost per AIDS death averted varies between $2,500 and $3,500, depending on the subregion. There are a num- ber 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 resulting from longer duration of infectivity (Revenga et al. 2006). Appendix 4: The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations 75 Figure A4.1: Universal Access to Treatment: Number of Deaths Averted, 2007­2030 3,000,000 2,500,000 2,000,000 tedr ave 1,500,000 deaths 1,000,000 500,000 0 3 2 2007 2008 2009 2010 2011 2012 201 2014 2015 2016 2017 2018 2019 2020 2021 202 2023 2024 2025 2026 2027 2028 2029 2030 Southern Africa Central/West Africa East Africa 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 Base Scenario. In total, almost 14 million life years will be gained relative to the Base Sce- nario (see figure A4.2) at a cost of approximately $1,400 per life year in East Africa and approximately $600 per life year in southern Africa and Cen- tral/West Africa. 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 more than 3.5 million to approximately 1.25 million by 2011. The total number of HIV-positive people would decline from 28 million to 22 million (see figure A4.3). 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 $3,000 in 76 The World Bank's Commitment to HIV/AIDS in Africa Figure A4.2: Universal Access to Treatment: Cumulative Number of Life Years Gained in Sub-Saharan Africa, 2007­2011 14% East Africa Central/West Africa 56% Southern Africa 30% Source: Bollinger and Stover 2007. Figure A4.3: Infections Averted Due to Prevention Efforts in Sub-Saharan Africa, 2007­2011 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2007 2008 2009 2010 2011 Southern Africa Central/West Africa East Africa Source: Bollinger and Stover 2007. Appendix 4: The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations 77 2007 to about $2,000 by 2011. (See below for more on the cost effectiveness of different prevention interventions.) It is also crucial to note that preven- tion interventions result in large benefits in treatment costs avoided. In fact, Bollinger and Stover (2007) estimate overall cost savings of $6,570 per HIV infection averted in the region. Some authors have discussed the possibility of increased risky behavior due to "complacency" effects associated with treatment availability (Revenga et al. 2006). Cost Effectiveness of Prevention Interventions Results from 10 different country-specific applications of the Goals Model (Futures Group 2005) were used to calculate unweighted average impacts for 11 different interventions: community mobilization, mass media, volun- tary counseling and testing (VCT), interventions for sex workers (SWs), interventions for men who have sex with men (MSM), in-school youth pro- grams (Education), blood safety, condom distribution, STI treatment, workplace programs, and programs for prevention of 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 10 interventions one at a time (and subsequently replaced), so that the marginal impact of the intervention could be measured. Table A4.1 classifies interventions by their relative cost-effectiveness ratios, as well as by their relative impact measured by percentage of total infections averted. There are three categories of cost per infection averted: Low (< $1,000), Medium ($1,000 to $3,000), and High (> $3,000); and three categories for impact: Low (0­10 percent of total infections averted), Medium (10­20 percent of total infections averted), and High (> 20 percent 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. 78 The World Bank's Commitment to HIV/AIDS in Africa Table A4.1: Cross-Classification of Interventions by Cost Effectiveness and Impact A. EAST AND SOUTHERN AFRICA B. CENTRAL AND WEST AFRICA IMPACT (% OF INFECTIONS AVERTED) IMPACT (% OF INFECTIONS AVERTED) Cost per infection Low Medium High Cost per infection Low Medium High averted (0­10) (10­20) (> 20) averted (0­10) (10­20) (> 20) Low SW PMTCT Blood Low MSM SW (< $1,000) MSM safety (< $1,000) Medium Community Condom Medium Blood safety PMTCT ($1,000 ­ $3,000) mobilization distribution ($1,000 ­ $3,000) Condom Workplace VCT distribution programs Education High Mass media High Community (> $3,000) STI treatment (> $3,000) mobilization Workplace Mass media programs STI treatment Education Source: Bollinger and Stover 2007. Both tables indicate that interventions targeting SWs across all of Sub- Saharan Africa are very cost effective, with costs per infection averted of less than $1,000. Interventions for SWs 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 and southern Africa, where HIV prevalence rates are higher and have a sub- stantial impact on the number of total infections averted. In Central and West Africa, these two interventions are classified in the medium cost per infection averted category, and PMTCT contributes a substantial propor- tion of all infections averted. Finally, those interventions with the highest cost per infection averted in East and southern Africa are mass media, STI treatment,1 and workplace programs, while the corresponding interventions in Central and West Africa are community mobilization, mass media, STI treatment, and educa- tion for youth. Hence, it seems that four interventions are particularly highly cost effective for Sub-Saharan Africa: PMTCT, blood-safety pro- grams, and outreach programs for SWs and for MSM. Table A4.2 presents a summary of other studies on the cost effectiveness of HIV prevention interventions in the region that broadly corroborates the results outlined here. Caution should be exercised when analyzing the results, because pre- Appendix 4: The Potential Impact of HIV/AIDS Interventions: Methodology and Simulations 79 Table A4.2: Studies of Cost Effectiveness of HIV/AIDS Interventions in Sub-Saharan Africa COST EFFECTIVENESS IN 2001 DOLLARS INTERVENTION PER HIV INFECTION PER DALY VCT (Kenya and Tanzania) 270­376 14­19 VCT (Chad) 891­5,213 45­261 Peer-based programs (Cameroon) 67­137 3­7 Condom distribution and IEC (South Africa) 378­4,094 19­205 Condom social marketing (Chad) 77 4 STI treatment (Kenya) 11­16 1 STI treatment (Tanzania) 326 16 STI treatment (South Africa) 2,093 105 STI treatment (Chad) 1,675 84 ART for PMTCT: Nevirapine (Sub-Saharan Africa) 142­306 6­12 Blood safety (Chad) 75­151 4­8 Blood safety (Zimbabwe) 166­1,010 8­51 Blood safety (Zambia) 215­262 11­13 Sterile injection (Africa) -- 91­230 Source: Bertozzi et al. 2006. Note: -- = not available; DALYs = disability-adjusted life years; IEC = information, education, and communication. vention interventions should not be considered in isolation. It is more use- ful to think in terms of packages of interventions, particularly interventions that are mutually supportive and complementary. 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 puts 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 of the number of those in need of assistance.2 According to figure A4.4, the number of OVC in need would increase from about 19 million in 2006 to more than 21 mil- lion in 2011. It is important to note that there is a global consensus that all OVC in need should be supported, not only those whose parents have died of AIDS, to mitigate any stigma that might develop otherwise. 80 The World Bank's Commitment to HIV/AIDS in Africa Figure A4.4: Number of OVC in Sub-Saharan Africa 50 45 40 ner 35 30 child of sn 25 20 millio 15 10 5 0 2 7 1 1985198619871988198919901991199 1993199419951996199 199819992000200 2002200320042005200620072008200920102011 total in need Source: Bollinger and Stover 2007. Notes 1. Note that the cost of STI considered here does not reflect the cost of STI treatment per se, but rather the cost of outreach programs. 2. The population in need is defined as all double orphans and vulnerable children, along with half of single orphans, who live in households below the poverty line. APPENDIX 5 World Bank HIV/AIDS Portfolio for Africa, FY1989­FY2007 Table A5.1: Closed MAP and Standalone Projects, and Closed Projects with HIV/AIDS Components COUNTRY PROJECT ID PROJECT TITLE FY APPROVED FY CLOSED CLOSING DATE COMMITTEDa CLOSED MAP AND STANDALONE PROJECTS Congo, Dem. Rep. of P003116 National AIDS Control Program 1989 1995 12/31/1994 8.1 Zimbabwe P003333 Sexually Transmitted Infections 1993 2001 12/31/2000 64.5 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 Eritrea P065713 ER-AIDS, Mal, STD, TB Cntrl APL (FY01) 2001 2006 3/31/2006 40.0 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 Ghana P071617 GH-AIDS GARFUND Response Proj (FY01) 2001 2006 12/31/2005 25.0 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 Cameroon P073065 CM-MultiSecal HIV/AIDS SIL (FY01) 2001 2007 6/30/2007 50.0 Benin P073118 BJ-HIV/AIDS Multi-Sec APL (FY02) 2002 2007 9/15/2006 23.0 Burkina Faso P071433 BF-HIV/AIDS Disaster Response APL (FY02) 2002 2007 6/30/2007 27.0 Madagascar P072987 MG-MultiSec STI/HIV/AIDS Prev APL (FY02) 2002 2008 12/31/2007 20.0 Sierra Leone P073883 SL-HIV/AIDS Response (FY02) 2002 2008 12/31/2007 15.0 Subregional P074850 3A-HIV/AIDS Abidjan Lagos Trnspt (FY04) 2004 2008 12/31/2007 16.6 Subtotal 551.4 CLOSED PROJECTS WITH HIV/AIDS COMPONENTSb 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 Côte 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 (continues on the following page) 81 82 The World Bank's Commitment to HIV/AIDS in Africa Table A5.1: Closed MAP and Stand-Alone Projects, and Closed Projects with HIV/AIDS Components (continued) COUNTRY PROJECT ID PROJECT TITLE FY APPROVED FY CLOSED CLOSING DATE COMMITTEDa Gambia, The P000825 GM-Participatory HNP SIL (FY98) 1998 2005 6/30/2005 3.1 Guinea-Bissau P035688 National Health Development Prog 1998 2008 12/31/2007 2.2 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 Cameroon P048204 CM-CAPECE Env Oil TA (FY00) 2000 2008 11/30/2007 0.8 Lesotho P053200 Health Sector Reform 2000 2005 6/30/2005 2.1 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 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 Burundi P064961 BI-Pub Works & Employ Creation (FY01) 2001 2008 12/31/2007 16.2 Mali P040650 Edu Sec Exp Prgm APL (FY01) - (PISE) 2001 2007 12/31/2006 6.3 Kenya P066486 KE-Decentr Reprod Hlth & HIV/AIDS (FY01) 2001 2007 6/30/2007 37.1 Congo, Rep. of P074006 CG-Emerg Infrast Rehab & Living Cond Imp 2002 2007 1/31/2007 5.2 Mozambique P001785 MZ-Roads & Bridges MMP (FY02) 2002 2007 6/30/2007 22.7 Ghana P073649 GH-Health Sec Prgm Supt 2 (FY03) 2003 2007 6/30/2007 15.2 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 Cameroon P100965 CM-Debt Relief Grant DPL (FY06) 2006 2007 12/30/2006 4.4 Subtotal 219.1 Total closed projects 770.5 Source: World Bank Business Warehouse. a. Commitment amounts are in the dollar value at the time of approval. b. Commitment amounts for projects with HIV/AIDS components reflect the HIV/AIDS component amount, not the entire project amount. Table A5.2: Active MAP and Stand-Alone HIV/AIDS Projects, and Active Projects with HIV/AIDS Components APPROVAL COUNTRY PROJECT ID PROJECT TITLE FY APPROVED DATE CLOSING DATE COMMITTEDa ACTIVE MAP AND STANDALONE HIV/AIDS PROJECTS 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 Central African Republic P073525 CF-HIV/AIDS (FY02) 2002 12/14/2001 9/30/2010 17.0 Chad P072226 TD-Pop & AIDS 2 (FY02) 2002 7/12/2001 1/31/2008 24.6 Nigeria P070291 NG-HIV/AIDS Prog Dev (FY02) 2002 7/6/2001 6/30/2009 90.3 Senegal P074059 SN-HIV/AIDS Prevent & Control APL (FY02) 2002 2/7/2002 9/30/2008 30.0 Guinea P073378 GN-Multisectoral 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 Appendix 5: World Bank HIV/AIDS Portfolio for Africa, FY1989­FY2007 83 Table A5.2: Active MAP and Stand-Alone HIV/AIDS Projects, and Active Projects with HIV/AIDS Components (continued) APPROVAL COUNTRY PROJECT ID PROJECT TITLE FY APPROVED DATE CLOSING DATE COMMITTEDa Niger P071612 NE-MultiSec STI/HIV/AIDS 2 (FY03) 2003 4/4/2003 6/30/2009 25.0 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, Dem. Rep. of P082516 ZR Multisectoral HIV/AIDS 2004 3/26/2004 1/31/2011 102.0 Congo, Rep. of 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 12/31/2008 7.0 Malawi P073821 MW-Multisectoral 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 Subregional P082613 3A-Regional HIVAIDS Treatment Prj (FY04) 2004 6/17/2004 9/30/2008 59.8 Tanzania P071014 TZ-HIV/AIDS APL (FY04) 2004 7/7/2003 9/30/2009 70.0 Angola P083180 AO-HAMSET SIL (FY05) 2005 12/21/2004 6/30/2010 21.0 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 Subregional P080406 3A- African Regional Capacity Building Network for HIV/AIDS Prevention, Treatment, and Care (FY05) 2005 9/22/2004 6/30/2009 10.0 Subregional 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 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 12/31/2008 5.0 Ethiopia P098031 ET-2nd Multisectoral HIV/AIDS (FY07) 2007 3/8/2007 6/30/2010 30.0 Kenya P081712 KE-Total War Against HIV/AIDS (TOWA) 2007 06/26/2007 12/31/2011 80.0 Nigeria P105097 NG-HIV/AIDS APL - Additional Financing (FY07) 2007 5/22/2007 6/30/2009 50.0 Rwanda P104189 RW-MultiSec HIV/AIDS - Additional Financing (FY07) 2007 2/1/2007 10/30/2008 10.0 Subtotal 1,106.7 ACTIVE PROJECTS WITH HIV/AIDS COMPONENTSb Rwanda P045091 RW-Human Res Dev (FY00) 2000 6/6/2000 6/30/2008 8.0 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, Rep. of P073507 CG-Transp & Gov CB (FY02) 2002 2/7/2002 6/30/2010 1.0 Eritrea P073604 ER-Emerg Demob & Reint ERL (FY02) 2002 5/16/2002 12/31/2008 7.8 Guinea P050046 GN-Education for All APL (FY02) 2002 7/24/2001 12/31/2008 15.4 (continues on the following page) 84 The World Bank's Commitment to HIV/AIDS in Africa Table A5.2: Active MAP and Stand-Alone HIV/AIDS Projects, and Active Projects with HIV/AIDS Components (continued) APPROVAL COUNTRY PROJECT ID PROJECT TITLE FY APPROVED DATE CLOSING DATE COMMITTEDa Mozambique P069824 MZ Higher Education SIM (FY02) 2002 3/7/2002 6/30/2009 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 12/31/2008 3.3 Tanzania P047762 TZ-Rural Water Sply (FY02) 2002 3/26/2002 6/30/2008 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 6/30/2009 5.9 Ethiopia P044613 ET-Road Sector Development Phase 2 (FY03) 2003 6/17/2003 6/30/2009 17.8 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 Congo, Dem. Rep. of 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 Lesotho P081269 LS-Second Education Sector Development (Phase 2) 2004 7/17/2003 12/31/2008 4.2 São Tomé and Principe P075979 ST Social Sector Support 2004 5/18/2004 6/30/2009 1.1 Zambia P071985 ZM-Road Rehab Maintenance Prj (FY04) 2004 3/9/2004 6/30/2010 6.5 Angola P083333 AO-Emerg MS Recovery ERL (FY05) 2005 2/17/2005 12/31/2009 8.6 Congo, Dem. Rep. of 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 Lesotho P076658 LS-Health Sec Reform Phase 2 APL (FY06) 2006 10/13/2005 3/31/2009 1.0 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 Kenya P087479 KE-Edu Sec Sup Project (FY07) 2007 11/7/2006 12/31/2010 12.8 Namibia P086875 NA-Education & Training DPL (FY07) 2007 5/24/2007 12/31/2008 1.3 Tanzania P102262 TZ-Zanzibar Basic Educ. SIL (FY07) 2007 4/24/2007 7/31/2013 8.4 Subtotal 241.2 Total active HIV/AIDS projects 1,347.9 Source: World Bank Business Warehouse. a. Commitment amounts are in the dollar value at the time of approval. b. Commitment amounts for projects with HIV/AIDS components reflect the HIV/AIDS component amount, not the entire project amount. APPENDIX 6 MAP Achievements Table A6.1: Results in Countries in Africa with MAPs SYSTEMS STRENGTHENING Percentage increase in development partner funding 2,240% MAP management integrated into NAC functions 59% OUTPUTS TO WHICH THE MAP CONTRIBUTED Number of persons trained with MAP funds 562,366 (23 countries) Number of decentralized government structures that have implemented HIV work plans 10,938 (25 countries) 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 number of people on ART 554,648 in total (27 countries) (26,699 with MAP funding) Number of PLWHA treated for opportunistic infections 287,805 (20 countries) IMPACT MITIGATION Number of infected or 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: Görgens-Albino et al. 2007. Note: BCC = Behavior change communication. 85 86 The World Bank's Commitment to HIV/AIDS in Africa Table A6.2: 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 toward 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 toward improved legislation related to HIV and AIDS. The MAP has succeeded in promoting and facilitating a multisectoral 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 the 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 ART and expanded access to ART. 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 ministry of health data collection is still weak. Strategic information is flowing better than before. There is some evidence of data use. Source: Görgens-Albino et al. 2007. APPENDIX 7 MAP Challenges and Improving Performance of the MAP for Africa Challenges In 2004, ACTafrica initiated an interim review of the MAP to review the validity of the MAP approach, highlight progress made, review the suitabil- ity of interventions, and 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 (which became today's IEG) conducted a separate inde- pendent 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 subnational institutions, investing strategically in public goods and activities likely to have the largest impact, creating incentives for M&E, and using local evidence to improve performance. From these assess- ments, the Bank's Committee on Development Effectiveness (CODE) rec- ognized 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 develop- ment partners, in responding to the complex and pressing issues of HIV/AIDS; the need for bold, innovative, and flexible responses; and recon- firmed the need for a multisectoral approach to this development challenge. Table A7.1 provides an overview of the key recommendations from the MAP interim review report (World Bank 2004), the OED report (World Bank 2005) and CODE response (appendix M to World Bank 2005), and actions taken by the Africa Region. 87 88 The World Bank's Commitment to HIV/AIDS in Africa Table A7.1: Overview of the Key Recommendations RECOMMENDATIONS MEASURES UNDERTAKEN BY THE AFRICA REGION (i) Integrate HIV/AIDS into development planning, PRSs, IBRD and WBI in collaboration with UNDP have held two regional budget allocation strategies, and mainstream in workshops to build capacity of country officials to integrate CASs. HIV/AIDS into PRSPs and MTEF. ACTafrica will also continue to ensure that HIV/AIDS is sufficiently incorporated in the CAS. (ii) Support the development of prioritized, nationally owned The Bank and other partners (UNAIDS and UNDP) have rolled out strategies with a nuanced understanding of the country epidemic, the ASAPa program to provide direct technical support to countries identification of cultural and social factors contributing to the on a demand-driven basis in reviewing and producing evidence- spread, and assist governments to be selective and prioritize based, prioritized, and costed strategies and annual programs. activities that achieve the greatest impact. (iii) Adopt targeted approach in all next-generation projects in Adopted as a criteria for all second-generation projects. Bank and low-prevalence countries. UNAIDS collaborated on a regional conference on targeting vulnerable groups. ACTafrica is also assessing the effectiveness of good practices targeting vulnerable groups. (iv) Improve governance and accountability measures within The Region continues to build capacity on improved fiduciary projects to mitigate misuse of project funds and ensure that management and has developed a Guidance Note on Disbursement funds are utilized for the intended beneficiaries. in HIV/AIDS projects to assist in determining the 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's 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 M&E system GAMET has significantly increased its efforts to help countries build at country level working with other partners, develop clear criteria both their clinical and nonclinical indicators and data collection and outcome indicators for improved data collection, and improve mechanisms, and all repeater MAPs include more attention and the evidence base for decision makers through local capacity financing for scaling up M&E activities in partnership with UNAIDS building and rigorous analytic work. and other donors. Ongoing MAP operations are also providing increased financing for M&E implementation. GAMET and ACTafrica developed a generic HIV/AIDS Results Scorecard in October 2006. (vi) Improve donor coordination and harmonization efforts to avoid A Global Task Team (GTT) comprising key UN agencies and develop- duplication of efforts with the multitude of actors. ment partners agreed on a division of labor for all 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. Ongoing discussions with TTLs on methods for integrating this into HIV projects without hindering access to services. Appendix 7: MAP Challenges and Improving Performance of the MAP for Africa 89 Table A7.1: Overview of the Key Recommendations (continued) RECOMMENDATIONS MEASURES UNDERTAKEN BY THE AFRICA REGION (viii) Continue to fully support the community response, which is an Civil society organizations are more actively involved than before in important stakeholder group activity, by engaging them in the HIV activities. The Africa Region plans to carry out a situation design of interventions and improved procedures for financing analysis of civil society engagement. ACTafrica hosted a consulta- but also evaluate the effectiveness of the community response. tion with civil society representatives from all MAP countries to brainstorm the roles, responsibilities, and partnerships of civil soci- ety organizations in responding to HIV. These recommendations are being incorporated in the revision of the Bank strategy for HIV/AIDS in Africa (2007­2011). (ix) Prioritized multisectoral approach to respond to the complexity MAPs continue to use the multisectoral approach and address of HIV as a broad development challenge and focus on sectors HIV/AIDS as a broad development issue. ACTafrica will ensure that that have the greatest potential impact such as health, education, this continues to be reflected in the CASs. Second-generation transport, military, and others depending on the country context. MAPs will focus on sectors with the greatest potential within each country setting. (x) Clarify the role of the Ministry of Health (MoH) to ensure that MoH is engaged in all MAP projects as is evident from the MoH they are a principal partner in the national response and build being the second largest beneficiary of MAP financing after the MOH capacity while continuing to work with other sectors. civil society component. All next-generation MAP projects will clarify the roles 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 global The Bank is fully engaged with the GTT and will continue its close initiatives and partners and improve donor collaboration. partnership with UNAIDS. The Bank has also taken the lead in collaborating with the GFATM, PEPFAR, and other development partners and held a meeting in January 2006 to improve coordination. Source: Compiled by authors. a. UNAIDS has raised $5 million to finance these activities, which include workshops and direct assistance from the Bank and UNDP. APPENDIX 8 HIV Prevalence and Global Financing Table A8.1: HIV Prevalence and Financing, by Country HIV PREVALENCE, GFATM 2003­ PEPFAR WORLD BANK 2001­ TOTAL FUNDS AGES 15­49 NOVEMBER 2007 2004­2007 DECEMBER 2007 AVAILABLE COUNTRY (%) ($ MILLION) ($ MILLION) ($ MILLION) ($ MILLION) Comoros 0.1 1.1 0.0 0.0 1.1 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 0.0 Cape Verde 0.8 0.0 0.0 14.0 14.0 Ethiopia 0.9­3.5 541.3 496.6 89.7 1,127.6 Senegal 0.9 23.5 0.0 30.0 53.5 Niger 1.1 10.7 0.0 25.0 35.7 Guinea 1.5 14.2 0.0 20.3 34.5 Sierra Leone 1.6 18.2 0.0 15.0 33.2 Sudan 1.6 58.9 0.0 0.0 58.9 Mali 1.7 52.3 0.0 25.5 77.8 Benin 1.8 40.7 0.0 58.0 98.7 Burkina Faso 2.0 47.1 0.0 74.7 121.8 Liberia 2.0­5.0 19.7 0.0 0.0 19.7 Ghana 2.3 45.8 0.0 45.0 90.8 Eritrea 2.4 30.5 0.0 64.0 94.5 Gambia, The 2.4 14.6 0.0 15.0 29.6 Rwanda 3.1 117.2 271.2 40.5 428.9 Congo, Dem. Rep. of 3.2 48.7 0.0 102.0 150.7 Equatorial Guinea 3.2 4.4 0.0 0.0 4.4 Togo 3.2 44.7 0.0 0.0 44.7 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 27.7 0.0 21.0 48.7 Guinea-Bissau 2.8 3.4 0.0 7.0 10.4 Nigeria 3.9 74.4 649.7 140.3 864.4 (continues on the following page) 91 92 The World Bank's Commitment to HIV/AIDS in Africa Table A8.1: HIV Prevalence and Financing by Country (continued) HIV PREVALENCE, GFATM 2003­ PEPFAR WORLD BANK 2001­ TOTAL FUNDS AGES 15­49 NOVEMBER 2007 2004­2007 DECEMBER 2007 AVAILABLE COUNTRY (%) ($ MILLION) ($ MILLION) ($ MILLION) ($ MILLION) Congo, Rep. of 5.3 12.0 0.0 19.0 31.0 Cameroon 5.4 76.0 0.0 50.0 126.0 Kenya 6.1 109.7 811.8 130.0 1,051.5 Tanzania 6.5 192.1 515.0 70.0 777.1 Uganda 6.7 106.7 645.7 47.5 799.9 Côte D'Ivoire 7.1 51.1 199.7 0.0 250.8 Gabon 7.9 5.2 0.0 0.0 5.2 Central African Rep. 10.7 29.6 0.0 17.0 46.6 Malawi 14.1 209.0 0.0 35.0 244.0 Mozambique 16.1 121.1 354.1 55.0 530.2 Zambia 17.0 117.1 576.8 42.0 735.9 South Africa 18.8 177.0 856.8 0.0 1033.8 Namibia 19.6 104.0 215.5 0.0 319.5 Zimbabwe 20.1 50.0 0.0 0.0 50.0 Lesotho 23.2 39.3 0.0 5.0 44.3 Botswana 24.1 18.6 207.3 0.0 225.9 Swaziland 33.4 68.9 0.0 0.0 68.9 Total financing by donor 2,783.2 5,800.2 1,389.1 9,972.5 Sources: Prevalence: UNAIDS 2006; Haacker 2007. Financing: GFATM financing from 2003 through November 2007, www.theglobalfund.org; PEPFAR financing 2004­2007 http://www.pepfar.gov/press/c19558.htm. World Bank financing includes MAP projects approved from 2001 to December 2007 and does not include com- mitments for subregional projects. World Bank Business Warehouse. Note: Country HIV prevalence data is the most recent at the time of this publication. The UNAIDS publication of 2007 country estimates are expected in July 2008. APPENDIX 9 The Bank's Role in the UNAIDS Division of Labor Table A9.1: World Bank Role in UNAIDS' Technical Support Division of Labor TECHNICAL SUPPORT AREAS LEAD ORGANIZATION MAIN PARTNERS 1. Strategic planning, governance, and financial management World Bank ILO, UNAIDS, UNDP, UNESCO, · Support to strategic, prioritized, and costed national plans; financial UNICEF, WHO management, human resources; capacity and infrastructure development; impact alleviation and sectoral work · HIV/AIDS, development, governance, and mainstreaming, including UNDP ILO, UNAIDS, UNESCO, UNICEF, WHO, instruments such as PRSPs and enabling legislation, human rights, World Bank, UNFPA, UNHCR and gender · Procurement and supply management, including training UNICEF UNDP, UNFPA, WHO, World Bank 2. Scaling up interventions · Overall policy, monitoring, and coordination on prevention UNAIDS All cosponsors 3. M&E, strategic information, knowledge sharing, and accountability · Strategic information, knowledge sharing, accountability, coordination UNAIDS World Bank, ILO, UNDP, UNESCO, of national efforts, partnership building, advocacy, and M&E UNFPA, UNHCR, UNICEF, UNODC, WFP, WHO Source: Global Task Team 2005. 93 APPENDIX 10 Agenda for Action: Implementation Plan and Results Framework Table A10.1: The Foundation: Renew the Commitment SPECIFIC OBJECTIVES SPECIFIC ACTIONS 0.1. Respond to country demand 0.1.1 Sustained support for HIV/AIDS to fill financial gaps for the next five years for predictable, flexible, and 0.1.2 Provide safety net financing for countries in the context of creating fiscal space for HIV/AIDS sustainable IDA financing for HIV/AIDS 0.2. High-burdened, middle-income 0.2.1 Provide innovative financing, for example, buydowns to IBRD countries countries' access to technical or 0.2.2 IDF grant financing provided for capacity building financial assistance, or both, 0.2.3 Analytical work on macro impact and regional and cross-border issues increased 0.2.4 Conduct strategic analysis to identify new lending instruments that are attractive to IBRD countries and focused on increasing lending for HIV/AIDS 94 Appendix 10: Agenda for Action: Implementation Plan and Results Framework 95 INDICATORS ANTICIPATED RESULTS CRITICAL RISKS ACCOUNTABILITY · At least $250 million committed · Predictable, flexible, and · Availability of IDA financing AFRRMT, HDNGA, annually for the next five years, sustainable IDA financing · Financing from other ACTafrica PREM, IMF including IDA, PRSCs, ACGF, and IDF for HIV/AIDS provided development partners remains · Financing gap studies completed unpredictable and volatile in at least 10 countries (IDA and · Low country demand for IDA non-IDA) financing due to competing priorities · Number of countries where the Bank · Technical and financial assistance · Lack of instruments to engage AFRRMT, ACTafrica responds to country demands and accessible to high-burdened, high-burdened, middle-income supports AIDS responses through middle-income countries countries grants, loans, blended instruments, · Effective policy dialogue · Weak donor commitment to or knowledge support, policy · Effective partnerships support innovative financing dialogue, and capacity building · Cross-regional, cross-country in middle-income countries · Number of analytical studies learning · Continued scarce financing completed from other donors in middle-income countries (continues on the following page) 96 The World Bank's Commitment to HIV/AIDS in Africa Table A10.1: The Foundation: Renew the Commitment (continued) SPECIFIC OBJECTIVES SPECIFIC ACTIONS 0.3. Support to subregional and 0.3.1 Provide financing to countries, including postconflict countries, for regional HIV/AIDS response cross-border initiatives provided 0.3.2 Design regional cross-border projects that address vulnerable populations, for example, refugees and IDPs 0.4. Africa HIV incentive fund to 0.4.1 Obtain financing for Africa HIV/AIDS incentive fund for analysis, policy advice, and capacity provide support for project and building in project and program preparation program development, policy advice, 0.4.2 Use the funds to conduct policy dialogue, analytical work, and capacity building in line with and capacity building created the AAP and CDMAP 0.4.3 Assist teams to design HIV/AIDS interventions in sectoral investments 0.5. Bank's senior management 0.5.1 Bank's senior management reiterates commitment through speeches, memos, and discussions commitment to HIV/AIDS renewed with partners through inclusion and action in 0.5.2 HIV/AIDS continues to be a flagship program in the AAP all channels of policy dialogue 0.5.3 Engage high-level policy makers to advocate for HIV/AIDS response Appendix 10: Agenda for Action: Implementation Plan and Results Framework 97 INDICATORS ANTICIPATED RESULTS CRITICAL RISKS ACCOUNTABILITY · At least two new subregional · Improved HIV/AIDS awareness · Lack of grant financing AFRRMT, ACTafrica, operations approved in the next and prevention efforts through · Weak institutional capacity AFTHD, Africa Regional five years subregional and cross-border at regional level Integration (AFCRI) initiatives · Lack of commitment to · Realization of externalities subregional initiatives · Positive spillover effects for more effective customs procedures and clearances · Incentive fund finances five · Critical analysis and policy · Lack of grant funding ACTafrica, CDMAP technical support products per year guidance achieved · Weak Bank commitment · Mainstreaming guidelines · Scaled-up multisectoral · Lack of commitment to developed for different sectors responses in key sectors a multisectoral response · Number of sectoral projects with HIV/AIDS components · HIV/AIDS included in senior · Senior management speeches · Competing priorities AFRRMT, External Affairs, management speeches and related to the Bank's commitment · Senior management fails to WBI, UNDP, UNAIDS discussions with partners to combating HIV/AIDS reflected enforce commitment through in national and international regular reporting from CMUs media on how HIV/AIDS is being addressed and on harmonizing HIV/AIDS efforts 98 The World Bank's Commitment to HIV/AIDS in Africa Table A10.2: Pillar 1: Strengthened Long-Term Sustainable National Response PILLAR 1 SPECIFIC OBJECTIVES SPECIFIC ACTIONS Focus the response through 1.1. Appropriate HIV/AIDS efforts integrated 1.1.1 Review at least 10 CASs and ISNs and 6 PRSPs evidence-based and prioritized into countries' development agendas and to ensure HIV/AIDS is appropriately addressed HIV/AIDS strategies Bank instruments (policy procedures) 1.1.2 Ensure appropriate priority to HIV/AIDS in PRSPs 1.1.3 Bank support to incorporate HIV/AIDS into guidelines and processes for preparing MTEFs and annual budgets 1.2. Bank support to developing prioritized 1.2.1 Assist countries to analyze epidemics and optimal responses to diverse epidemics provided responses 1.2.2 Provide financial, technical, and analytical support to countries to understand country epidemics, including the drivers of the epidemic, and to establish surveillance systems 1.2.3 Conduct subregional epidemiological studies 1.3. Bank support in capacity building to 1.3.1 Support and build capacity in 20 countries to develop develop prioritized, and costed, national prioritized, costed national strategies and annual action plans strategies and action plans provided 1.3.2 Provide technical support to countries for developing national strategic planning 1.3.3 Provide technical, financial, and analytical support for better country-specific HIV/AIDS program planning Focus the response through 1.4. Integration of TB, malaria, reproductive 1.4.1 Conduct operations research on integrating services evidence-based and prioritized health, and nutrition into World Bank within epidemiological context HIV/AIDS strategies HIV/AIDS products ensured 1.4.2 Ensure that the Bank HIV/AIDS products address integration of TB, malaria, reproductive health, and nutrition 1.4.3 Actively participate in interagency working groups on integrating HIV and reproductive health, and HIV and TB 1.5. Good practices in HIV/AIDS programs 1.5.1 Conduct operations research, including based on operations research shared cost-effectiveness studies, on success and failures in HIV/AIDS programs Appendix 10: Agenda for Action: Implementation Plan and Results Framework 99 INDICATORS ANTICIPATED RESULTS CRITICAL RISKS Accountability · HIV/AIDS included in all PRSCs · HIV/AIDS addressed appropriately · Lack of management leadership AFRRMT, ACTafrica, WBI, · HIV/AIDS integrated into at least through countries' and Bank · Declining political commitment UNDP, HDNGA, PREM, 75 percent of PRSPs, CASs, and development agendas · Fiscal space issues and long- IMF ISNs prepared each year term financial sustainability · Develop relevant tools to design MTEF issues not adequately addressed · Poor coordination between IDA and IMF · Five countries where epidemiological · Improved evidence-based country · Lack of country-level and Bank ACTafrica, AFTHD, studies have been conducted and responses to differing epidemics expertise in supporting HDNGA potential responses formulated analytical work, as well as an adequate budget · 20 countries over the next five · Strengthened capacity to develop · Unpredictable donor financing HDNGA, ASAP, UNAIDS, years have the capacity to develop prioritized and costed national to support national programs ACTafrica prioritized and costed strategies action plans in 20 countries · Lack of expertise for strategic planning and costing work · Weak capacity for planning and program design · At least 60 percent of new HIV/AIDS · World Bank projects addressing · Lack of technical expertise HDNGA, ACTafrica, operations have an integrated HIV/AIDS integrate TB, malaria, and incentives to integrate AFTHD, WHO, UNFPA, approach to SRH, TB, and malaria reproductive health, and nutrition · Institutional structures with UNICEF · Three country assessments would be when appropriate to different vertical units in conducted and action plans to integrate epidemiological context ministries of health TB, malaria, and HIV developed · Donor procedures that hinder · Intensify efforts in nine high TB-burden integration countries as well as high-burden HIV/AIDS countries · Good practices on integration will be documented and disseminated · At least five operations studies over · Operations research and · Lack of financing to conduct AFTHD, AFTQK, ACTafrica, the next five years documentation of good practices operations research HDNGA in HIV/AIDS programs widely shared with countries and development partners 100 The World Bank's Commitment to HIV/AIDS in Africa Table A10.3: Pillar 2: Accelerated Implementation of HIV/AIDS Programs PILLAR 2 SPECIFIC OBJECTIVES SPECIFIC ACTIONS Scale up targeted multisectoral 2.1 HIV/AIDS policy, programs, and service 2.1.1 Strengthen sectoral institutional capacity to scale up and civil society response delivery integrated into priority sectors and supervise HIV/AIDS-related activities (dependent upon country context) 2.1.2 Conduct operations research on multisectoral prevention, including pilot testing of promising approaches 2.1.3 In collaboration with the IFC, support capacity building in the private sector to scale up its response 2.2 Bank support to care and mitigation 2.2.1 Support care and mitigation service providers through services through civil society organizations CSOs and build capacity of NGOs continued 2.3 Bank support to address HIV-related 2.3.1 Support analytical work to identify specific actions gender-inequality issues that would contribute to changing inappropriate gender responses to the epidemic 2.3.2 Conduct knowledge-sharing workshops to build on analytical work findings and to build capacity among decision makers to address gender and legal dimensions of HIV/AIDS among law, justice, medical, and health professionals Scale up targeted multisectoral 2.4. Bank support to prevention and programs 2.4.1 Strengthen programs to increase access to school and civil society response for youth and OVC intensified of HIV/AIDS orphans. Address stigma in school-based programs and learning. Strengthen school health programs; disseminate good practice examples in school-based prevention programs; continue to improve the role of teachers in addressing HIV/AIDS; coordinate with partners and local experts. 2.4.2 Collaborate with the Bank's social protection sector to scale up mitigation efforts and conduct analytical work on orphans and affected families Appendix 10: Agenda for Action: Implementation Plan and Results Framework 101 INDICATORS ANTICIPATED RESULTS CRITICAL RISKS ACCOUNTABILITY · Number of countries where Bank · Improved country capacity in key · Lack of country commitment HDN, AFTHD, PREM, IFC, supports institutional capacity- sectors to implement multisectoral from key sectors, including ACTafrica, AFTPS, AFTEG, building activities in priority sectors approaches inadequate resources AFTTR, AFTU, AFTRL · At least two operations research · Increased commitment in key Bank · Lack of clarity and guidance studies documenting promising sectors to include HIV/AIDS from management as well approaches to multisectoral component or subcomponents in as adequate budget to integrate prevention interventions lending and nonlending activities, HIV into sectoral activities including adequate resources · Limited funds to conduct adequate supervision of HIV/AIDS components in other projects · Number of countries where HIV/AIDS · Capacity of NGOs and CBOs · Lack of government interest to ACTafrica, CMUs, AFTHD, care and mitigation services are strengthened engage civil society other donors supported by civil society · Civil society continues to be an integral part of the national solution to address HIV/AIDS · Five pieces of analytical work · Increased awareness of · Lack of country commitment PREMGE, AFTPM, · At least two knowledge-sharing specific steps to designing and to implementing specific ACTafrica, AFTQK, events conducted on the gender implementing gender- actions to address HIV-related HDNGA, AFTHD, WBI IFC, dimensions of HIV/AIDS appropriate HIV interventions gender inequalities AFTPS, AFTEG, AFTTR, · Develop appropriate M&E · Analytical work in the sectors · Lack of support from Bank AFTU, AFTRL indicators address gender inequalities management to dedicate time and resources to operations research or implementation of gender-specific responses · Number of countries where Bank · All education and social · Lack of country leadership in HDNED, ACTafrica, AFTSP, supports youth and OVC protection sector investments the education sector HDNSP Children and include HIV/AIDS prevention, · Stigma continues Youth Group, UNFPA, mitigation, social protection, UNESCO, UNICEF, and support activities UNAIDS (continues on the following page) 102 The World Bank's Commitment to HIV/AIDS in Africa Table A10.3: Pillar 2: Accelerated Implementation of HIV/AIDS Programs (continued) PILLAR 2 SPECIFIC OBJECTIVES SPECIFIC ACTIONS 2.5 Support to strengthen elements of the 2.5.1 Through the implementation of the 2007 HNP strategy health system that challenge HIV/AIDS to strengthen health systems, support provided to improve programs service delivery, human resources, and financial sustainability. Scale up targeted multisectoral 2.6 Bank support to known multisectoral 2.6.1 Support the inclusion of HIV/AIDS components in and civil society response prevention approaches and tools increased Transport and Infrastructure sectors, including the preparation of an HIV/AIDS transport corridor project in southern Africa. Require construction contracts to include HIV/AIDS-prevention activities. 2.6.2 Urban: continue efforts to support local governments' responses to HIV/AIDS, including developing and updating monitoring and training tools and incorporating HIV/AIDS components in urban operations 2.7 Strengthen community response and 2.7.1 Provide technical support to HIV/AIDS projects to evaluate its effectiveness strengthen, simplify, and focus community-level interventions 2.7.2 Conduct social assessments and impact evaluation studies on community-based HIV/AIDS interventions, including identification of good practices Appendix 10: Agenda for Action: Implementation Plan and Results Framework 103 INDICATORS ANTICIPATED RESULTS CRITICAL RISKS ACCOUNTABILITY · At least 50 percent of new HIV/AIDS · Improved synergy between HNP · Lack of collaboration between HDNHE, AFTHD, WHO, operations address and support health and HIV/AIDS operations ministries of health and NACs UNFPA, UNICEF, ACTafrica system challenges vis-à-vis HIV/AIDS on resource allocation for · 60 percent of HNP operations address health systems health system challenges · Agreement on a clear division of labor within the Bank as well as with its partners · Health systems do not adequately address all implementation constraints, for example, fiduciary and supply chain management · Number of key sector projects with · Prioritized support to key · Lack of adequate technical ACTafrica, IFC, AFTPS, AIDS components public sector and nonpublic resources to prepare and AFTEG, AFTTR, AFTU, sector entities having maximum supervise AIDS components AFTHD, AFTRL impact on the ground · Sector focal persons not identified · Number of countries with revised · Capacity strengthened in · Lack of absorptive capacity ACTafrica, HDNGA, DEC, and simplified community HIV/AIDS designing and implementing at the community level Environment and Socially response guidelines and trained decentralized multisectoral · High fiscal costs and Sustainable Development personnel responses sustainability concerns in Africa (AFTSD) · Number of social/behavioral · More effective community · National governments assessments and impact evaluations responses unwilling to directly fund regarding the effectiveness of communities community-based HIV/AIDS · Lack of capacity at national interventions and regional levels to train and support communities 104 The World Bank's Commitment to HIV/AIDS in Africa Table A10.4: Pillar 3: Strengthened National Systems for Financial Management, Human Resources, Procurement, Supply Chains, and Health and Social Systems PILLAR 3 SPECIFIC OBJECTIVES SPECIFIC ACTIONS Deliver effective results through 3.1. Ongoing HIV/AIDS projects retrofitted 3.1.1 Complete restructuring of MAP project development increased country M&E capacity with realistic goals and indicators objectives and performance indicators. Technical support teams to support country project teams 3.2. Harmonized M&E frameworks at the 3.2.1 Assist countries to establish monitoring systems country level strengthened 3.2.2 Develop and implement project performance early warning system 3.2.3 Institutionalize the use of HIV/AIDS Results Scorecard 3.2.4 Conduct regional and national M&E training courses 3.2.5 Train M&E specialists, building national capacity, gradually reducing the need for external support 3.3. Countries' surveillance systems 3.3.1 Conduct country epidemiology studies strengthened and epidemiologic studies conducted 3.4. Bank studies of vulnerable groups in 3.4.1 Conduct analytical work and operations research on countries conducted vulnerable population needs with the aim of informing policy dialogue 3.4.2 Sharpen HIV/AIDS support to ensure that vulnerable groups are appropriately targeted and their networks strengthened Deliver effective results through 3.5. Countries' existing governance structures, 3.5.1 Improve existing governance structures, public sector increased country M&E capacity public sector management, and transparency management, and transparency mechanisms and generate mechanisms improved with demand for demand for better accountability at the community level accountability at the community level 3.5.2 Assist countries to strengthen fiduciary capacity generated 3.5.3 Assist countries to streamline administrative structures 3.5.4 Integrate governance, accountability, and anticorruption into all new HIV/AIDS operations in collaboration with WBI 3.6. Knowledge generation and sharing to 3.6.1 Provide operational support in design and impact of improve prioritization, decision making, and HIV/AIDS interventions in sector investments program design supported 3.6.2 Engage countries and partners in knowledge generation and sharing 3.7. Good practice case studies to support 3.7.1 Prepare good practice notes that highlight examples cross-country learning and knowledge of promising national responses to HIV/AIDS sharing 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 Appendix 10: Agenda for Action: Implementation Plan and Results Framework 105 INDICATORS ANTICIPATED RESULTS CRITICAL RISKS ACCOUNTABILITY · 13 ongoing projects reviewed and · Improved HIV/AIDS portfolio · IEG and Africa Region ACTafrica, AFTQK adjusted to realistic objectives and · MAP projects evaluated on methodology in assessing goals realistic goals and indicators project successes · Weak country support to restructure · Eight additional countries supported · In the next five years, all · Availability of resources to HDNGA, ACTafrica, over five years to establish a countries have a functional, provide technical support GAMET, UNAIDS harmonized HIV/AIDS monitoring harmonized M&E system · Willingness of countries system reporting and using data and partners to reduce · Bank to continue to play a number of indicators and leading role (GAMET) in implement the principle of supporting countries the Three Ones · Five country epidemiology studies · National systems strengthened · Country commitment and ACTafrica, HDNGA conducted over five years for improved understanding of demand for capacity building the drivers of the epidemic to strengthen surveillance · Three analytical studies or operations · Evidence-based responses · Weak country commitment to ACTafrica, HDNGA research completed on best practices developed work with vulnerable groups and cost-effective interventions · Best practices disseminated · Weak capacity · Support three regional meetings with · Vulnerable group networks · Stigma of vulnerable groups groups working with vulnerable groups strengthened continues · Three operations research studies · Assessment of selected MAP · Governance and accountability · Inadequate financial and PREM, AFTQK, HDNGA, projects on governance and improved technical resources ACTafrica, WBI, OPCS, accountability completed · Demand for accountability · Lack of country commitment Department of · Institutional assessments generated at the grassroots level to address corruption Institutional Integrity (INT) conducted in three counties · Improved institutional capacity · Training activities conducted in and governance structures collaboration with WBI · One regional consultation per year · Design and impact of HIV/AIDS · Continued financing for annual HDNGA, GAMET, to encourage cross-country learning investments based on knowledge knowledge learning events in ACTafrica, AFTQK, DEC, · Macroeconomic analytical work and sharing the region WBI financial sustainability studies · Countries and partners fully · Coordination with other conducted engaged in knowledge generation development partners and sharing · Five good practice notes on national · Improved country and · Available resources to identify GAMET, ACTafrica, responses cross-country learning good practices and AFTQK, AFTHD, TTLs, WBI · Two workshops to share experiences disseminate them 106 The World Bank's Commitment to HIV/AIDS in Africa Table A10.5: Pillar 4: Strengthened Donor Coordination PILLAR 4 SPECIFIC OBJECTIVES SPECIFIC ACTIONS Harmonize donor collaboration 4.1. Collaboration with key partners to 4.1.1 Support countries extensively in areas where Bank harmonize and strengthen national M&E is designated lead technical organization systems, human resources capacity, 4.1.2 Work with key partners to harmonize and strengthen procurement, and supply chains strengthened national M&E systems, procurement, and supply chains 4.1.3 Work with countries and Bank project teams to improve planning, budgeting, program design, financial management, disbursement, procurement, and expenditure tracking 4.2. Joint planning and analytical work 4.2.1 Conduct joint planning and analytical work with with UNAIDS and other partners increased UNAIDS and other partners 4.2.2 Conduct strategic planning training courses to 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 in joint annual 4.3.1 Advocate and assist practitioners' networks to planning with partners increased contribute to strategic planning 4.3.2 Participate in joint annual partner meetings Appendix 10: Agenda for Action: Implementation Plan and Results Framework 107 INDICATORS ANTICIPATED RESULTS CRITICAL RISKS ACCOUNTABILITY · Comply with and report on Paris · Better implementation of the · Partners' readiness to take HDNGA, ACTafrica, Declaration indicators global division of labor actions to align and harmonize GAMET, AFTQK, PREM · Number of Public Expenditure · GAMET to continue to support M&E processes network, UNAIDS, Reviews conducted that include countries to strengthen M&E in GFATM, PEPFAR an HIV/AIDS component close collaboration with other · Public sector management partners conducted · Proportion of countries with performance-based procedures · All countries moved toward joint · More efficient, effective, and · Lack of country ownership HDNGA, ACTafrica, WBI, annual national program reviews sustainable HIV/AIDS resource in enforcing partners to move AFTQK, UNAIDS, GFATM, and planning allocation in this direction PEPFAR · Lack of donor commitment to harmonize · At least 10 joint missions · Harmonized planning and · Willingness of Bank units to WBI, HDNGA, ACTafrica, · At least eight countries have a implementation participate GAMET, UNAIDS, GFATM, strengthened single coordinating · Inability of donors to schedule PEPFA body joint activities APPENDIX 11 The HIV/AIDS Results Scorecard The Africa Region, in collaboration with GAMET, has developed a toolkit to support the countries in preparing their project-specific results frame- works. This toolkit, the HIV/AIDS Results Scorecard, has been discussed and shared with countries, other development partners, and project task teams. The Scorecard is based on: (i) the indicators selected from globally agreed HIV indicators for prevention, care, treatment, and mitigation required by UNGASS, the MDGs, and IDA; (ii) the fact that several coun- tries have the capacity to report on the indicators; and (iii) the OECD's Paris Declaration on harmonization and minimizing data requirements. The Scorecard proposes indicators for groups of countries where the epidemic has reached the general population and for the countries where it is still within concentrated populations. All Scorecard indicators are not mandatory. The Scorecard is a tool for task teams to use as a baseline for developing or updating a project's specific results framework. A small set of mandatory indicators have, however, been extracted to measure the overall progress of the HIV response to which the World Bank contributed in the Africa Region. The Scorecard will therefore be used to measure progress under the AAP as well as on IDA financing. It contains indicators for measuring long-term results at the regional level, and indica- tors for measuring results to which specific Bank-funded HIV assistance projects have contributed. Two types of data sources will be used to deter- mine the values of the two types of Scorecard indicators on an annual basis: (i) regional level data will be extracted from international reports and veri- fied data sources with the support of GAMET and UNAIDS; and (ii) project-level data will be reported by all HIV projects using the project ISRs and by ACTafrica through its annual MAP questionnaire. 109 110 The World Bank's Commitment to HIV/AIDS in Africa Adopting the Scorecard in all ongoing and future HIV operations will reduce the burden on the countries and the task teams in reporting progress. It will also enable the Region to report on the aggregate achieve- ments under IDA financing. The indicators, when fully adopted in all ongo- ing and future HIV operations, would be a major step toward achieving har- monization and alignment on M&E at the country, regional, and global levels. The Scorecard indicators have been harmonized, where possible, with the indicator sets of other major partners in HIV/AIDS (PEPFAR indica- tors and the GFTAM's list of "Top Ten" indicators). The Scorecard indica- tors are not based on attribution, but rather on contribution. The Scorecard therefore does not suggest that a separate 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 Bank on a regular basis. Table A11.1 presents the HIV/AIDS Results Scorecard for the Africa Region. Indicators 4­13 in the Scorecard are mandatory for all ongoing, pipeline, and future HIV operations in the Region, for reporting through the project ISRs. Key benefits of the scorecard include: (i) compliance with the Paris Dec- laration (to reduce burden on the countries); (ii) harmonization with UNAIDS (UNGASS) indicators and those of other key financers (such as GFATM and PEPFAR) in reporting on HIV/AIDS; (iii) support for regional IDA financing and the AAP; and (iv) use of existing country capac- ity in data collection and reporting. Scorecard data will be collected through the following arrangements: DATA SOURCES 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 Web sites, and their focal points Scorecard responsibility will be shared as follows: · All country project teams. · GAMET will provide technical assistance to the project teams. Appendix 11: The HIV/AIDS Results Scorecard 111 · GAMET and ACTafrica will gather data from the sources identified above as well as from UNAIDS, and will update the AAP progress reporting system. · Task Team Leaders need to ensure that the scorecard is agreed upon with their counterparts, with support from ACTafrica and GAMET. GAMET will provide technical support to country project teams and to Task Team Leaders in getting agreement with counterparts, and ACTafrica will provide support in integrating the scorecard into the Bank system. The Africa Region HIV/AIDS Results Scorecard in table A11.1 uses the new UNGASS wording in line with the new 2008 UNGASS guidelines, released April 2007 (UNAIDS 2007b). Table A11.1: The HIV/AIDS Results Scorecard INDICATOR INDICATOR ORIGIN UNIT DATA SOURCE 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 ages 15­24 who are living with HIV (may need to be UNGASS, percentage UNAIDS Global estimated from antenatal data) IDA-14, AAP Report, WHO estimate 3b. Most-at-risk populations who are living with HIV UNGASS percentage UNAIDS Global Report, WHO estimate C. Intermediate results: To measure results contributed by Bank-funded projects 4a. Condom use. Women and men ages 15­49 who have had more than one UNGASS, percentage ISR (extracted from sexual partner in the past 12 months reporting the use of a condom during their AAP country UNGASS last sexual intercourse report) 4b. Condom use. Female and male SWs who report using a condom with UNGASS, percentage ISR (extracted from their most recent client (of those surveyed having sex with any clients in the last AAP country UNGASS 12 months) report) 5. Women and men ages 15­24 who have had sex with more than one partner in UNGASS, percentage ISR (extracted from the last 12 months AAP country UNGASS report) 6. Adults and children with advanced HIV infection receiving antiretroviral UNGASS number ISR (extracted from combination therapy country UNGASS report) percentage ISR (extracted from country UNGASS report) (continues on the following page) 112 The World Bank's Commitment to HIV/AIDS in Africa Table A11.1: The HIV/AIDS Results Scorecard (continued) INDICATOR INDICATOR ORIGIN UNIT DATA SOURCE 7. Pregnant women living with HIV who received antiretrovirals to reduce UNGASS, number ISR (extracted from the risk of mother to child transmission AAP country UNGASS report) percentage ISR (extracted from country UNGASS report) 8. Orphaned and vulnerable children ages 0­17 whose households received UNGASS number ISR (extracted from free basic external support in caring for the child in the past 12 months country UNGASS report) percentage ISR (extracted from country UNGASS report) D. Outputs: To measure results contributed by Bank-funded projects 9. Persons ages 15 and older who received counseling and testing for HIV and World Bank number ISR (from country M&E 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. CSOs supported for subprojects (includes NGO, CBO, FBO) World Bank number ISR (from country M&E 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 Authorities that report annually on at least World Bank percentage ISR (from country M&E 75 percent of the indicators in their national HIV M&E frameworks and that system) disseminate 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 intermediate results 14. Estimated investment requirements for HIV/AIDS ($ million) World Bank amount UNAIDS global data 15. Total financial commitments for HIV/AIDS ($ million) World Bank amount Calculation (15a + 15b + 15c) 15a. Country commitments for HIV/AIDS ($ million) World Bank amount ISR (extracted from country UNGASS report) Appendix 11: The HIV/AIDS Results Scorecard 113 INDICATOR INDICATOR ORIGIN UNIT DATA SOURCE 15b. World Bank commitments for HIV/AIDS ($ million) World Bank amount World Bank Business Warehouse 15c. Other development partner commitments for HIV/AIDS ($ million) World Bank amount Development partner Web sites 16. Financing gap to reach HIV/AIDS targets ($ million) World Bank amount Calculation (14 - 15) 17. World Bank financial disbursements for HIV/AIDS ($ million) World Bank amount World Bank Client Connection Note: All of the indicators in the Scorecard are based on the latest international thinking about indicator wording. Because efforts are under way to harmonize indi- cators, the indicators in the Scorecard may be slightly revised in 2008, when the harmonization process will be complete. Detailed indicator definitions will be released once the global indicator registry has been developed. Projects are only required to report on indicators 9­13. References and Other Resources Bell, C., R. Bruhns, and H. Gersbach. 2006. 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"Global Task Team on Improving AIDS Coordination Among Multilateral Institutions and International Donors: Final Report." GTT. Görgens-Albino, M., N. Mohammad, D. Blankhart, and O. Odutolo. 2007. The Africa Multi-Country AIDS Program 2000­2006: Results of the World Bank's Response to a Development Crisis. Washington, DC: World Bank. Graff Zivin, J., H. Thirumurthy, and M. Goldstein. 2006. "AIDS Treatment and Intra- household Resource Allocation." NBER Working Paper No. 12689, National Bureau for Economic Research, Cambridge, MA. 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): 1039­44. Haacker, M. 2004a. "HIV/AIDS: The Impact on the Social Fabric and the Economy." In The Macroeconomics of HIV/AIDS, ed. M. Haacker, 198­258. Washington, DC: International Monetary Fund. ------. 2004b. "The Impact of HIV/AIDS on Government Finance and Public Ser- vices." 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Presentation to the UK All Parliamentary Group on Popula- tion, Development and Reproductive Health, London, April 19­20. Maddux, Catherine. 2006. "Quarter Million South Africans Getting Free AIDS Drugs." Voice of America News, Nov. 13. Mathers, C., A. D. Lopez, and C. J. L. Murray. 2006. "The Burden of Disease and Mor- tality by Condition: Data, Methods, and Results for 2001." In Global Burden of Dis- References and Other Resources 117 ease and Risk Factors, ed. A. D. Lopez, C. D. Mathers, M. Ezzati, D. T. Jamison, and C. J. L. Murray, 45­240. Washington, DC: World Bank, and New York: Oxford Uni- versity Press. Revenga, A., M. Over, E. Masaki, W. Peerapatanapokin, J. Gold, V. Tangcharoensathien, and S. Thanprasertsuk. 2006. The Economics of Effective AIDS Treatment: Evaluating Policy Options for Thailand. Health, Nutrition, and Population Series. Washington, DC: World Bank. Salinas, G., and M. Haacker. 2006. "HIV/AIDS: The Impact on Poverty and Inequal- ity." Working Paper 126, IMF, Washington, DC. Stover, J., S. Bertozzi, J. P. Gutierrez, N. Walker, K. A. Stanecki, R. Greener, E. Gouws, C. Hankins, G. P. Garnett, J. A. Solomon, J. T. Boerma, P. De Lay, and P. D. Ghys. 2006. "The Global Impact of Scaling-Up HIV/AIDS Prevention Programs in Low- and Middle-Income Countries." Science 311 (5766): 1474­6. Stover, J., and M. Fahnestock. 2006. "Coverage of Selected Services for HIV/AIDS Pre- vention, Care and Treatment in Low- and Middle-Income Countries in 2005." Con- stella Futures, Washington, DC. Thirumurthy, H., J. Graff Zivin, and M. Goldstein. 2005. "The Economic Impact of AIDS Treatment: Labor Supply in Western Kenya." NBER Working Paper No. 11871, National Bureau of Economic Research, Cambridge, MA. Tulenko, K. 2006. "Africa Health Worker Crisis: Options for Removing Bottlenecks to HIV/AIDS Prevention, Diagnosis, Treatment, and Care." Background paper pre- pared for "The World Bank's Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007­2011." World Bank, Washington, DC. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2005. "Resource Needs for an Expanded Response to AIDS in Low- and Middle-Income Countries." Geneva. ------. 2006. Report on the Global AIDS Epidemic. Geneva: Joint United Nations Programme. ------. 2007a. AIDS Epidemic Update. Geneva: Joint United Nations Programme. http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf. ------. 2007b. Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators: 2008 Reporting. Geneva: Joint United Nations Programme. UNHCR (United Nations High Commission for Refugees). 2007. "HIV and Refugees." UNHCR Policy Brief, United Nations, Geneva. Wilson, D. 2006. "HIV Epidemiology: A Review of Recent Trends and Lessons." 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World Development Indicators. Washington, DC: World Bank. Index Note: Boxes, figures, and tables are indi- pillar 2: acceleration of multisectoral cated by b, f, and t, respectively. and civil society engagement, 42­45, 49t, 100­103t pillar 3: increasing country M&E AAP (Africa Action Plan), 3, 57, 109, 110 capacity, 45­46, 50t, 104­5t acceleration of multisectoral and civil pillar 4: harmonizing donor collabo- society engagement by AFA, 42­45, ration, 46­47, 50t, 106­7t 49t, 100­03t operational implications of, 51­55 access as renewal of World Bank's commit- to health services, 33­34, 45, 67­68t ment to fight HIV/AIDS in Africa, to universal treatment/prevention, 1, 39­41, 58, 94­97t 74­77, 75­76f results scorecard, 109­11, 111­13t accountability and governance issues, role of World Bank and, 35­37, 28­29 36­37f, 51­52 ACTafrica (AIDS Campaign Team for staffing and budgeting implications of, Africa) 54­55 in chronology of Bank response to stakeholder consultations, 51­52, AIDS crisis, 71­72t, 87 60­65t MAP, 19, 87 strategic objectives, 2, 37­38 operational implications of AFA, 51, AIDS Campaign Team for Africa. See 53, 55 ACTafrica results scorecard, 109, 111 AIDS Strategy and Action Plan (ASAP), AFA. See Agenda for Action 27, 55, 60t Africa Action Plan (AAP), 3, 57, 109, 110 antiretroviral therapy, 14, 21 Africa Region results scorecard developed by, 109 balancing treatment, prevention, and work program, effects of AFA on, 7­8, care, 30 53­54 "base scenario," potential impact of Agenda for Action (AFA; 2007­2011), HIV/AIDS interventions, 73 ix­x, 1­3, 35­50 Bell, C., 16 Africa Region work program, effects blood safety programs, 77­78 on, 7­8, 53­54 Bollinger, L., 26, 73­80 anticipated results Botswana, 9, 54 of implementation, 47­48, 48­50t Bruhns, R., 16 of inaction, 48­50 Burkina Faso, 10 conceptual framework, 39, 40 Burundi, 10 coordination with other World Bank programs, 3 Capacity Development Management countries most likely to take advantage Action Plan (CDMAP), 3, 29, 57 of, 54 capacity issues four pillars, 6­7, 38­39 AFA capacity-strengthening goals, pillar 1: evidence-based and priori- 45­46, 50t, 104­5t tized strategies, 41­42, 49t, 98­99t implementation capacity, 29 119 120 The World Bank's Commitment to HIV/AIDS in Africa institutional capacity, 52 integration of HIV/AIDS into overall MAP, need for capacity-strengthening agenda, 23 learned from, 24 national development strategies, care, prevention, and treatment, balanc- embedding HIV/AIDS programs ing, 30 into, 42, 53 CASs (Country Assistance Strategies), 42, disabled people, 12, 17 53 donor collaboration CDMAP (Africa Capacity Development AFA plan for, 46­47, 50t, 106­7t Management Action Plan), 3, 29, 57 Africa Region work program's role in, 54 children and young people/youth MAP, lessons learned from, 24 AFA plan, addressing specific problems need for, 27 of, 45 disproportionate effect of HIV/AIDS economic growth, effect of HIV/AIDS on, 9, 12 on, 16 number of OVC in Africa, 79, 80f economic issues. See financing/funding potential impact of prevention/treat- issues for HIV/AIDS programs in ment programs on, 70­80 Africa programs' need to target, 17 emigration patterns and HIV/AIDS SRH services, integration of transmission, 9, 41 HIV/AIDS treatment programs evidence-based strategies, AFA use of, with, 33 41­42, 49t, 98­99t civil society organizations (CSOs) Ezekwesili, Obiageli Katryn, x AFA's accelerated engagement of, 42­45, 49t, 100­103t financing/funding issues for HIV/AIDS consultation with, 60­65t programs in Africa, 25­29 MAP program and, 19, 20, 21, 22, 24 AFA staffing and budgeting, 54­55 multisectoral engagement, importance changing role of World Bank in, of, 31, 42­45 35­37, 36­37f, 51­52, 57­58 need to engage with, 6­7 cost-effectiveness of prevention inter- CODE (Committee on Development ventions, 77­79, 78­79t Effectiveness), 87 countries most likely to take advantage co-infection issues, 23, 33, 42 of AFA, 54 collaboration of donors. See donor global funding, 25­27, 26t, 91­92t collaboration incentive fund, 41 Committee on Development Effective- prevalence of disease and financing by ness (CODE), 87 country, 91­92t consultations with stakeholders, 51­52, renewed commitment of World Bank 60­65t as source of finance, 39­40 costs. See financing/funding issues for HIV/AIDS programs in Africa G8 Summit, Gleneagles (2005), 4, 26 Côte d' Ivoire, 9 GAMET (Global AIDS Monitoring and Country Assistance Strategies (CASs), 42, Evaluation Team), 27, 55, 109, 111 53 gender. See men who have sex with men; CSOs. See civil society organizations women and girls Gersbach, H., 16 development GFATM. See Global Fund to Fight impact of HIV/AIDS in Africa on, HIV/AIDS, Tuberculosis, and 14­16, 15f Malaria Index 121 GHAP (Global HIV/AIDS Program of historical background on programs Action), 3, 57 addressing, 3­4 Gleneagles G8 Summit (2005), 4, 26 indicators for, 67­68t Global AIDS Monitoring and Evaluation integration of treatment with other Team (GAMET), 27, 55, 109, 111 health programs, 23 Global Fund to Fight HIV/AIDS, Tuber- M&E. See monitoring and evaluation culosis, and Malaria (GFATM) MAP. See Multi-Country HIV/AIDS changing financial role of World Bank, Program 36 mortality rates, 10t creation of, 4 operational issues, 29­34, 32f MAP, 21 program implications of, 17 operational issues and implications, 30, results scorecard, 109­11, 111­13t 54 transmission routes, 12, 13­14 rewards scorecard, 110 World Bank and. See World Bank stakeholder consultations with, 58, HNP (Health, Nutrition, and Popula- 62t tion) strategy, 3, 32, 45, 51, 57 global funding, 25­27, 26t, 91­92t households, impact of HIV/AIDS on, Global HIV/AIDS Program of Action 14­15 (GHAP), 3, 57 Goldstein, M., 16 IBRD (International Bank for Reconstruc- governance and accountability issues, tion and Development), 5, 20, 54 28­29 IDA (International Development Associa- Graff Zivin, J., 16 tion), 4, 5, 20, 35, 51, 109 IDF (Institutional Development Fund), Haacker, M., 16 20 Health, Nutrition, and Population IEG or Independent Evaluation Group (HNP) strategy, 3, 32, 45, 51, 57 (formerly Operations Evaluation health services delivery, 33­34, 45, 67­68t Department or OED), 22, 87 health systems, 2, 3, 5, 6, 7, 24, 25, 34, immigration patterns and HIV/AIDS 37, 45, 89, 102, 103 transmission, 9, 41 heterogeneity of HIV/AIDS epidemics in implementation capacity, 29 Africa, 12­13, 13f, 42, 43­44t inaction, anticipated results of, 48­50, 73 HIV/AIDS in Africa, ix­x, 9­17 Independent Evaluation Group or IEG Agenda for Action (AFA) (formerly Operations Evaluation balancing treatment, prevention, and Department or OED), 22, 87 care, 30 individual countries, differentiated chronology of World Bank response to, response to, 42, 43­44t 71­72t injecting drug users, 13, 17n1, 30 continuing challenges of, 4­5, 23, 25 Institutional Development Fund (IDF), current prevalence of, 9­10, 11t, 20 67­68t, 91­92t integration of HIV/AIDS programs with development impact of, 14­16, 15f other development strategies, 42, 53 epidemiology, 10­14, 10t, 11f, 13f internally displaced people and funding issues. See financing/funding HIV/AIDS transmission, 9, 41 issues for HIV/AIDS programs in International AIDS Conference XVI Africa (Toronto, 2006), 3, 60t heterogeneity of, 12­13, 13f, 42, International Bank for Reconstruction 43­44t and Development (IBRD), 5, 20, 54 122 The World Bank's Commitment to HIV/AIDS in Africa International Development Association for selected Sub-Saharan African (IDA), 4, 5, 20, 35, 51, 109 countries (1965­2005), 69t, 70f interventions, potential impact of, 73­80, most common causes of death, 10t 75­76f, 78­79t, 80f universal access to treatment potential number of deaths averted Joint United Nations Programme on by, 74, 75f HIV/AIDS. See UNAIDS potential number of life years gained by, 75, 76f Kenya, 9, 14, 16 MSM (men who have sex with men), 13, 17, 30, 77­78 labor market, effect of HIV/AIDS on, MTEFs (Medium-Term Expenditure 15­16 Frameworks), 23, 42 life expectancy. See mortality rates in Multi-Country HIV/AIDS Program Africa (MAP), 3­5, 19­24 achievements of, 85­86t mainstreaming, 3, 7, 36, 41, 44, 61, 64, active and closed projects (1989­2007), 93, 97 81­84t malaria challenges faced by, 87 co-infection issues, 33, 42 fiduciary risks of, 28 GFATM. See Global Fund to Fight IDA credits and, 51 HIV/AIDS, Tuberculosis, and key recommendations for, 87, 88­89t Malaria lessons learned from, 23­24, 51 Malawi, 9 results of, 21­23 male circumcision, 31 multisectoral engagement M&E, See monitoring and evaluation AFA pillar 2 addressing, 42­45, 49t, MAP. See Multi-Country HIV/AIDS 100­03t Program contribution of World Bank to, 52 MDG (Millennium Development Goals), importance of, 31­32, 32f 6, 9, 17, 37, 57, 109 Medium-Term Expenditure Frameworks Namibia, 10, 20, 54 (MTEFs), 23, 42 national development strategies, embed- men who have sex with men (MSM), 13, ding HIV/AIDS programs into, 42, 17, 30, 77­78 53 migration patterns and HIV/AIDS trans- New Partnership for Africa's Develop- mission, 9, 41 ment (NEPAD), 27 microbicides, 11, 31, nutrition, 16, 42 Millennium Development Goals (MDG), 6, 9, 17, 37, 57, 109 OED or Operations Evaluation Depart- monitoring and evaluation (M&E) ment (now Independent Evaluation AFA plan to increase country capacity Group or IEG), 22, 87 for, 45­46, 50t, 104­5t operational issues GAMET, 27, 55 of AFA program for World Bank, 51­55 importance of strengthening, 22­23 for HIV/AIDS programs in Africa, results scorecard, 109­11, 111­13t 29­34, 32f Three Ones, 4, 24, 27 Operations Evaluation Department or Monterey Declaration on HIV/AIDS, 27 OED (now Independent Evaluation mortality rates in Africa Group or IEG), 22, 87 life expectancy at birth Organisation for Economic Co-operation effect of HIV/AIDS prevalence on, 15f and Development (OECD), 109 Index 123 orphans and vulnerable children (OVC). results scorecard, 109­11, 111­13t See children and young people returnees and HIV/AIDS transmission, 9, 41 Paris Declaration on HIV/AIDS, 27, 109, Rome Declaration on HIV/AIDS, 27 110 Rwanda, 10 partnerships between donors. See donor collaboration scorecard, 109­11, 111­13t PEPFAR. See President's Emergency Plan Sector-Wide Approaches (SWAps), 37, for AIDS Relief 53 personnel implications of AFA, 54­55 sex workers (SWs), 13, 17, 30, 77­78 PMTCT (prevention of mother-to-child sexual and reproductive health (SRH) transmission) programs, 33, 77­78 services, integration of HIV/AIDS policy dialogue, World Bank's commit- programs with, 23, 32­33 ment to, 40, 51­52 sexual behavior and AIDS transmission, potential impact of HIV/AIDS interven- 13­14 tions, 73­80, 75­76f, 78­79t, 80f sexually transmitted infections (STIs), 11, poverty, effect of HIV/AIDS on, 16 32, 74, 77­78 Poverty Reduction Strategy Papers XVI International AIDS Conference (PRSPs), 23, 42 (Toronto, 2006), 3, 60t President's Emergency Plan for AIDS Somalia, 20 Relief (PEPFAR) South Africa, 54 changing financial role of World Bank southern Africa as epicenter of and, 36 HIV/AIDS, x, 12, 13f creation of, 4 funding problems associated with, 5, MAP, 21 20 operational issues, 30, 54 importance of focusing on, 6, 17 results scorecard, 110 renewed commitment of World Bank prevention of mother-to-child transmis- to addressing, 41 sion (PMTCT) programs, 33, 77­78 sexual behavior driving, 13 prevention scenario, potential impact of SRH (sexual and reproductive health) HIV/AIDS interventions, 73­80, 76f services, integration of HIV/AIDS prevention, treatment, and care, balanc- programs with, 23, 32­33 ing, 30 staffing implications of AFA, 54­55 prioritized strategies, AFA use of, 41­42, stakeholder consultations, 51­52, 60­65t 49t, 98­99t STIs (sexually transmitted infections), 11, private sector, effect of HIV/AIDS on, 32, 74, 77­78 15­16 Stover, J., 26, 73­80 PRSPs (Poverty Reduction Strategy Sudan, 20 Papers), 23, 42 supply chains, 24, 34, 47 procurement, 24, 36, 38, 47 sustainability, fiscal, of HIV/AIDS pro- public sector, effect of HIV/AIDS on, grams, 27­28 15­16 SWAps (Sector-Wide Approaches), 37, 53 refugees and HIV/AIDS transmission, 9, Swaziland, 10, 20, 54 41 SWs (sex workers), 13, 17, 30, 77­78 regional programs to fight HIV/AIDS, 41 reproductive health services, integration Tanzania, 10 of HIV/AIDS programs with, 23, TB (tuberculosis) 32­33 co-infection issues, 23, 33, 42 124 The World Bank's Commitment to HIV/AIDS in Africa GFATM. See Global Fund to Fight United Nations Educational, Scientific, HIV/AIDS, Tuberculosis, and and Cultural Organization Malaria (UNESCO), 45 Thailand, 23 United Nations General Assembly Spe- Thirumurthy, H., 16 cial Session on HIV/AIDS Three Ones, 4, 24, 27 (UNGASS), 109­11 Toronto XVI International AIDS Confer- United Nations High Commission for ence (2006), 3, 60t Refugees (UNHCR), 12, 62t, 93t transmission of HIV/AIDS in Africa, 12, United Nations Population Fund 13­14 (UNFPA), 45 treatment, prevention, and care, balanc- ing, 30 vulnerable children. See children and treatment scenario, potential impact of young people HIV/AIDS interventions, 73­75, vulnerable groups, 6, 13 75­76f tuberculosis (TB) welfare, impact of HIV/AIDS on, 14­15 co-infection issues, 23, 33, 42 WHO (World Health Organization), 62t GFATM. See Global Fund to Fight women and girls HIV/AIDS, Tuberculosis, and AFA plan for addressing gender Malaria inequality, 45 disproportionate effect of HIV/AIDS Uganda, 23 on, ix, 9, 11 UNAIDS (Joint United Nations Pro- as heads of household, 14 gramme on HIV/AIDS) operational issues caused by gender division of labor in, 45, 93t inequality, 31 GAMET funded by, 27 prevention interventions for, 30 results scorecard, 109 programs' need to target, 17 stakeholder consultations and partner- SRH services, integration of ing with, 36, 45, 58, 60­63t, 93t HIV/AIDS treatment programs Three Ones, 4, 24, 27 with, 23, 32­33 UNDP (United Nations Development workforce, effect of HIV/AIDS on, 15­16 Programme), 36 World Bank. See also specific programs UNESCO (United Nations Educational, Africa Region Scientific, and Cultural Organiza- results scorecard developed by, 109 tion), 45 work program, effects of AFA on, UNFPA (United Nations Population 7­8, 53­54 Fund), 45 chronology of response to HIV/AIDS, UNGASS (United Nations General 71­72t Assembly Special Session on commitment to help Africa respond to HIV/AIDS), 109­11 HIV/AIDS epidemic, 1, 39­41, 58, UNHCR (United Nations High Com- 94­97t mission for Refugees), 12, 62t, 93t continuing challenges and future role UNICEF (United Nations Children's of, 5­7 Fund), 36, 45 coordination of AFA with other pro- United Nations Children's Fund grams, 3 (UNICEF), 36, 45 funding issues. See financing/funding United Nations Development Pro- issues for HIV/AIDS programs in gramme (UNDP), 36 Africa Index 125 historical background to HIV/AIDS World Health Organization (WHO), programs of, 3­4 62t multisectoral engagement, importance of, 31­32, 32f XVI International AIDS Conference operational implications of AFA for, (Toronto, 2006), 3, 60t 51­55 young people. See children and young portfolio for Africa (1989­2007), active people and closed projects, 81­84t role in HIV/AIDS struggle, 35­37, Zimbabwe, 9 36­37f, 51­52 Zoellick, Robert, 2­3 Eco-Audit Environmental Benefits Statement The World Bank is committed to Saved: preserving endangered forests and natural resources. The Office of the Publisher has · 20 trees chosen to print The World Bank's Commitment · 1,217 lbs. of solid waste to HIV/AIDS in Africa: Our Agenda for Action, · 7,356 gallons of water 2007­2011 on recycled paper including 30% · 2,244 lbs. of net post-consumer recycled fiber in accordance greenhouse gases with the recommended standards for paper · 14 million BTUs of total usage set by the Green Press Initiative, a energy nonprofit program supporting publishers in using fiber that is not sourced from endan- gered forests. For more information, visit www.greenpressinitiative.org. "AIDS is an unprecedented development challenge in Africa requiring a long-term sustained response. After 25 years it is time to apply the lessons of experience and scale up what is working. With this Agenda for Ac- tion, the World Bank reaffirms its long-term commitment to assist partner countries achieve their Universal Ac- cess targets to HIV prevention, treatment, care and support by integrating AIDS into their national development agendas, scaling up national multisectoral responses, and strengthening national systems." --Peter Piot, Executive Director of the Joint United Nations Programme on HIV/AIDS, Geneva The World Bank's Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007­2011 updates and re- focuses the Bank's response to assist countries to achieve the sixth Millennium Development Goal, to help halt and begin to reverse the spread of HIV/AIDS. This Agenda for Action is a road map for reaffirming the Bank's commitment to combating AIDS in Africa, moving from its initial emergency response to how it will contribute to a long-term, sustainable, multipartner response. The World Bank's Commitment to HIV/AIDS in Africa aims to assist countries to develop sustainable re- sponses that are well integrated into national development agendas; accelerate implementation and close the implementation gap between available funding and the capacity to use it effectively; strengthen na- tional and health systems, and improve donor coordination and learning. This Agenda for Action is the re- sult of an extensive analytical and consultative process that included over 30 African partner countries and a wide range of external partners from U.N. agencies, multilateral and bilateral donors, community, faith- based and civil society organizations, research institutes, universities, the private sector, labor unions and youth, local and national governments, and people living with HIV/AIDS. ISBN 978-0-8213-7448-1 SKU 17448