Elizabeth LuleManager

ACTafrica

The World Bank’s response to HIV/AIDS in Africa: MAP

High Level Dialogue on Maximizing Synergies between Health Systems and Global Health Initiatives. Venice, June 22-23

Africa Region

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1,119 , 16%

2,881 , 39% 1,654 , 23%

480 , 7%

1,041 , 15%Agriculture

Infrastructure (Energy Mining & Transportation and Water/sanit/f lood protection

Human Development (Education, Health &Social Svcs)

Finance, Industry and Trade

Other (Public admin, Law )

World Bank IDA Sector allocations over time in Africa

(US$ millions, %)

Fiscal year 2006

585 , 12%

1,489 , 32%

953 , 20%

491 , 10%

1,268 , 26%

Fiscal year 2008

368 , 6%

2,404 , 42%

841 , 15%

326 , 6%

1,749 , 31%

Fiscal year 2009 (planned)

1,119 , 16%

2,881 , 39% 1,654 , 23%

480 , 7%

1,041 , 15%

Agriculture

Infrastructure (Energy Mining& Transportation andWater/sanit/f lood protection

Human Development(Education, Health &SocialSvcs)

Finance, Industry and Trade

Other (Public admin, Law )

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MAP reflected a long-term World Bank’s commitment to HIV/AIDS

Phase 1: Emergency response, scale up existing interventions and build capacity

• Phase 2: Mainstream programs that have proved effective, gather evidence, apply lessons learned and strengthen systems

• Phase 3: Focus prevention efforts in areas where spread of the epidemic continues; scale up and sustain care, support, and treatment for people who have developed AIDS

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Africa Strategy 1999 and the WB 2005 Global Program of Action (GHAP)

1999 Africa Strategy

• Advocacy to intensify action

• Resource mobilization – internal and external

• Knowledge management

• Mainstreaming

• Capacity building

• Partnerships

2005 GHAP Program of Action• Assist countries to

– prioritize and cost national strategies and annual action plans

– integrate HIV/AIDS into the broader development framework (PRSP, MTEF)

– mainstream HIV/AIDS in other sectors

• Fund HIV/AIDS programs, groups, activities not funded by others and health systems

• Accelerate implementation• Results focused (M&E)• Analysis and knowledge sharing• Partnerships

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MAP Status33 countries + 5 sub-regional projects

$1.83 billion committed so far

$ 1.3 billion disbursed since 2001

> 50,000 civil society subprojects funded

Laid the groundwork for other donors

2nd phase MAPs prepared in 11 countries countries countries

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Multi-Sectoral Use of FundsProject Components Estimated Percentage of Financing

Civil society 38%

Ministry of Health 17%

Other Ministries 13%

Capacity Building 11%

Monitoring and Evaluation

4%

Program Coordination 10%

Other 7%

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Country Challenges – persistent and emerging• National HIV/AIDS planning not strategic or prioritized• Stigma & discrimination, denial, silence persist• Prevention, care & treatment efforts are too small, coverage is

too low, and resource allocation dilemmas persist• Absorptive capacity low because of management, HR, and

implementation constraints• Lack of transparency, accountability and corruption• Investment in health system infrastructure are inadequate• Scaling up access to treatment raises issues of: equity,

financial sustainability, fiscal space, adherence, human resource needs

• Weak M&E and limited impact evaluation• Weak donor coordination and priorities

MOH MOEC

MOFPMO

PRIVATE SECTORCIVIL SOCIETYLOCALGVT

NACP

CTUCCAIDS

INT NGO

PEPFAR

Norad

CIDA

RNE

GTZ

Sida WBUNICEF

UNAIDSWHO

CF

GFATM

USAID

NCTPNCTP

HSSP

HSSP

GFCCP

GFCCP

DAC

CCM

T-MAP

3/5

SWAPSWAP

UNTG

PRSP PRSP

US$200M

US$290 M

US$ 50M

US$ 60M

AIDS stakeholders and donors in one African country

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Lessons Learned Political and sectoral commitment is key

Donor collaboration and coordination, led and owned by national authorities is vital

Strengthening country capacity in governance and accountability, coordination and implementation required

Countries must know the drivers of their epidemic, address gender inequalities, and engage civil society

Need to show results/impact and build M&E capacity

Integration of HIV/AIDS in national planning is critical

Cross border approaches to address the “public good” nature of the epidemics are needed

Current Crisis Suggests Potential for Slowdown Progress Toward the MDGs

• Financial crisis is trapping up to 53 million more people into poverty (<$2 per day)

• This is on top of the 130-153 million already pushed into poverty as a result of the food and fuel price increases in 2008

• Additional 44 million malnourished individuals• Slower growth rates will slow progress in reducing IMR

– 200,000 to 400,000 additional children may die every year

– Up to 1.4 to 2.8 million more infant deaths by 2015 if crisis persists

• Progress on MDGs affected by:– Reduction in income and spending on food, health, human K

– Governments’ ability to finance and deliver social services affected

• Reliance on ODA; devaluation of currency; real expenditure declines

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Agenda for Action’s Strategic Pillars

The Agenda for Action reaffirms the Bank's commitment to devote resources and remain actively engaged in supporting countries to achieve MDG 6.

The Agenda for Action is structured around four Pillars:

Pillar 1:Pillar 1: Focus the response through evidence based and prioritized national HIV/AIDS strategies integrated in national development planning

Pillar 2:Pillar 2: Scale-up targeted multi-sectoral and civil society responses

Pillar 3Pillar 3: Deliver effective results through increased country M&E capacity and strengthened national and health systems

Pillar 4Pillar 4: Harmonize donor collaboration and knowledge sharing

What the World Bank is Doing • Ensure women, newborns, and children are given a high priority

• Focus on nutrition and MDG 1c

• Promoting and supporting effective pro-poor policies and programs including financial protection strategies

• Supporting and strengthening health systems in the poorest countries and sustaining support to communicable diseases

• Promoting efficiency gains and making overall efforts effective

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Bank’s Africa HIV/AIDS Agenda for Action: Linking Objectives to Results Strategic Objectives Anticipated Results

Strengthened long-term, sustainable national HIV/AIDS response

At least $250 million annually committed to HIV/AIDS including IDA, IBRD, PRSCs, ACGF, IDF and other Trust Funds.

Making other donors’ money work.

Accelerated Implementation of HIV/AIDS programs

HIV/AIDS integrated in Bank lending and non-lending activities in priority sectors depending upon country context, and with special attention to vulnerable groups and Southern Africa.

Strengthened national and health systems

Countries have functional, harmonized M&E systems, and strengthened human resources and fiduciary capacity, procurement and supply chain management.

Improved Donor Coordination

More efficient, effective and sustainable HIV/AIDS resource allocation

Countries lead joint annual national program reviews and planning with donors adhering to national processes.

Learning and Knowledge Sharing

Incentive Fund actively supports knowledge generation and sharing.

Countries and partners fully engaged in knowledge generation and sharing.

Bank Lending and Grants Focused on MDGs (4,5,6,1c):

• HNP Strategy emphasizes results, pro-poor focus, health systems strengthening and monitoring.

• Health Systems for the Health MDGs in Africa– Launched in 2008– Focus on 14 IHP+ countries– Increasing on-the-ground technical assistance and coordination

for HSS– Two regional hubs (Dakar and Nairobi) established– Recruitment of 10 high level HSS experts– Implemented in strong partnership with HHA, H8

Bank Lending and Sector Work• Results-based Financing (RBF for Health)

– 2008 - 2012

– Tied to IDA

– Pilot projects in 8 countries: Zambia, Rwanda, Eritrea, Afghanistan, DR Congo, Benin, Ghana, and Kyrgyz Republic

– Focus on performance-based incentives to health workers, district managers, and conditional cash payments to households

– Many pilots focusing on mechanisms to improve quality and increase utilization of institutional deliveries

– All pro-poor focused

– Large impact evaluation component and assessment of cost-effectciveness (learning and evidence building)

– MDTF: Support

Bank Lending and Sector Work

• Continued health system strengthening as the ground floor upon which all of the benefits of other investments can be made

– Ensure budget expenditures targeting the poor remain– Assure essential drugs and commodities– Support HR strategies to ensure adequate numbers and distribution of staff– Strengthen and support insurance and risk pooling mechanisms– Governance– HMIS

• Nutrition– Ambitious agenda of scaling up nutrition portfolio– Focus on Africa and SE Asia, some LAC– Additional staffing for regions

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Africa HNP: Strengthening Health Systems for Outcomes

Africa HNP strategy: Achieving the MDGs through Strengthening Health Systems ….

Upstream diagnostic

Financing Projects and Programs

MDGs

Country Status Report on Health, Poverty, Health systems and the MDGs

Focused funds:,Malaria Booster, HIV/AIDS, Tuberculosis etc.

Bank operations: problem specific and health systemfocused (eg: SWAPs)

Joint Bank-Partners Programs (eg: Results-basedfinancing)

Nutrition (MDG1)

Child health (MDG4)

Maternal Healthand mortality (MDG5)

Malaria,AIDS, TB, prevalence and mortality (MDG6)

Financial protection

Non Communicable Diseases

Human Resources For Health

Pharmaceuticals

Governance and Service Delivery

Public finance and health insurance

Infrastructure and ICT

Health systems

One country, costed plan for country supported by all partners (IHP+)

Policy dialogue

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Strategic Challenges: Tensions and Trade Offs• Fiscal sustainability versus promise of universal access• Short tem results versus long term results• Health sector response versus multisectoral response• Project approach versus budget/program support• Integration of HIV, TB, SRH, nutrition and other health

issues versus vertical units within MOH • Accountability and effectiveness versus attribution • Measuring Outputs/trends versus measuring outcomes

and impact• Balancing investments between the public sector, private

sector or community response• Supply versus demand

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Now to Action