The World Bank Global HIV/AIDS Program of Action. Briefing Note/Summary

Transcription

1 The World Bank Global HIV/AIDS Program of Action Briefing Note/Summary December

2 This note introduces the World Bank s Global HIV/AIDS Program of Action, summarizes some of the thinking behind it, and highlights the main features. Why has the World Bank developed this Program of Action? And why now? The epidemic, our response to the epidemic, and the global environment in which we work, have entered a new phase. This made it an opportune time to take stock of where we are, and do some careful strategic thinking about where the Bank s work on AIDS needs to go. Two key things have not changed: new HIV infections continue to rise (Figure 1), while efforts to prevent new infections remain inadequate, and crucial. The Bank has a crucial role, together with other development partners, in responding to the complex and pressing issue of HIV/AIDS that threatens to undermine progress in development. Figure 1: Growth of the AIDS epidemic Millions People with HIV/AIDS, Cumulative Regional Totals Sub-Saharan Africa Asia Latin America Europe & N. America* Eastern Europe & Central Asia North Africa & Middle East Caribbean *Western and Central Europe & North America. Source: UNAIDS/WHO, Among the main recent changes are that there are now several big new players, much more political commitment, and greatly increased levels of funding. Global HIV/AIDS funding has grown from US$300 million in 1996, to an estimated US$ 8 billion in 2005 (Figure 2). 2

3 Figure 2: Global spending for HIV/AIDS (US$ millions) Avg Price of ARVs $7,944-20,224/ Person per year World Bank MAP 3 by 5 GFATM PEPFAR * G8 Avg Price of ARVs $50-200/Person per year * Projected funding Source: UNAIDS, More money, and the falling prices of ART drugs (Figure 3), have raised hopes and expectations among donors and among people living with HIV/AIDS. There is increasing emphasis being given to treatment, placing even more demands on weak and overwhelmed health sectors. Figure 3: First line ARV prices, US$/year e.g. Uganda Price US$ Accelerating Access Initiative Further price reductions Generic companies start production Further price reductions Negotiations by Clinton Foundation Jun Jul Aug Sep Jun Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Mar Sep Oct Source: UNAIDS/WHO,

4 The health sector is the front line in many aspects of the response to AIDS, but it is clear that a successful response needs many other actors and sectors as well. So many countries are now taking a much more multisectoral approach. In this new phase, we have much more information about the epidemic than ever before. It is evolving in a complex and highly varied way across regions, and within countries. The data in Figure 4 from three cities in sub-saharan Africa, shows, for example, how differently the epidemic has evolved in southern, western and eastern Africa. We need to understand local transmission patterns and sources of vulnerability, and respond to them appropriately. Figure 4: Prevalence trends differ widely Manzini Kampala Dakar All six of the regions in the Bank have strategies or action plans on HIV/AIDS 1 (Figure 5). The Global HIV/AIDS Program of Action endorses and builds on the regional plans and is meant to give the Bank s overall work on HIV/AIDS a global focus and a niche among the many players. Figure 5: Regional HIV/AIDS strategies and action plans AFR: Intensifying Action against HIV/AIDS in Africa: Responding to a Development Crisis, 1999 EAP: Responding to HIV/AIDS in the East Asia and Pacific Region, 2003 ECA: Averting AIDS Crises in Eastern Europe and Central Asia, 2003 LCR: HIV/AIDS in the Caribbean: Issues and Options, 20; HIV/AIDS in Latin America The Challenges Ahead, 2003 MNA: Preventing the Spread of HIV/AIDS in the Middle East and North Africa, 2005 SAR: South Asia HIV/AIDS Business Plan FY04-FY The World Bank Regions are: Sub-Saharan Africa (AFR), East Asia and the Pacific (EAP), Europe and Central Asia (ECA), Latin America and the Caribbean (LCR), Middle East and North Africa (MNA) and South Asia (SAR). 4

5 The Program of Action was developed through careful reflection and much consultation some of it very searching and challenging. The core drafting group included people from the Bank s HIV/AIDS Global Program unit, from elsewhere in the Bank, from key partner agencies and civil society. The document went through several drafts, as we digested suggestions, criticisms and endorsements from a large number of Bank staff and managers, and a wide range of partner representatives, including at a large consultative meeting held in the Bank in May (Figure 6). The Executive Directors of the World Bank strongly endorsed the Program of Action at a technical briefing on August 25 th, 2005, and asked for a detailed Implementation Plan (which will be discussed by the Board in January 2006). Figure 6: Process consultative and inclusive January 2005 First draft by Bank staff, partners, and civil society May 2005 Consultations with staff and external stakeholders June-July 2005 Revisions after staff, partner, donor, recipient government and civil society feedback Informed by 3 recent Bank reviews and OED review, GTT, Three Ones Parallel with the work to develop the Program of Action, the Bank signed on to the Three Ones principles one national HIV/AIDS authority, one national strategic plan to guide action, and one monitoring and evaluation system. And the Bank was a key member of the Global Task Team on Improving AIDS Coordination Among Multilateral Institutions and International Donors (GTT). The agreements reached by the GTT, including the division of labor, are fully reflected in the Program of Action. 6 What does the Program of Action commit the Bank to? (Figure 7) The heart of it is to prevent new infections and to provide care and treatment for those who are infected and affected by the epidemic. The scope and scale of Bank support should be great enough to have a real impact. We will work more closely with others, for a more effective, coordinated and harmonized response. And we must ground our programs more firmly in evidence. Figure 7: The Actions Enhance & intensify Bank support to client countries for effective prevention, treatment, care and support Contribute to and complement the work of our partners, consistent with GTT Scope is Bank-wide, country, regional and global, big enough scale for impact Activities must be firmly grounded in evidence. 7 5

6 In deciding on how to focus our efforts and resources in the coming years, we reflected on a number of factors, especially: where countries most need our support to strengthen their HIV/AIDS programs, the Bank s mandate and comparative advantages, our firm commitment to the vision of the Three Ones, and better harmonization of efforts among donors, the changed environment for HIV/AIDS support, the persistent challenges and newly emerging challenges, and what we have learned during our efforts over the past 18 years and from reviews of the Bank s HIV/AIDS work. In recent years, the Bank has dramatically scaled up its financial support to countries, helping jump-start expanded programs in many of the hardest-hit places (Figure 8). Cumulative lending for HIV since the first project in 1988 is now over US$2.5 billion, and commitments in sub-saharan Africa have grown from $10 million annually ten years ago to $ million in each of the last four years. We have learned and improved as we worked, and have benefited from the findings and recommendations of our own reviews and of OED s recent review of the Bank s HIV/AIDS work. 2 Figure 8: World Bank HIV/AIDS projects: the global picture since 1988 Haiti Dominican Republic St Kitts & Nevis St Vincent & the Grenadines Cape Trinidad&Tobago Ver Grenada Barbados Jamaica Rwanda Burundi Both Of all that we have learned during our efforts to address HIV/AIDS over the years, six lessons stand out, as perhaps most important in guiding this Program of Action. The Bank can make a difference both in what it does, and in what it fails to do. But country ownership, capacity and leadership are crucial to success, which is why we must respect 9 2 Three reviews of HIV/AIDS work have been undertaken or commissioned by the Bank s operational units, including the Interim Review of the Multi-Country HIV/AIDS Program for Africa, done in Jan/Feb 2004 by a team from UNAIDS, DFID, MAP International and the World Bank, that visited six MAP project countries. A summary of the findings was published in October The OED review is Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance - An OED Evaluation of the World Bank s Assistance for HIV/AIDS Control, Operations Evaluation Department, World Bank, Washington DC

7 and work to realize the Three Ones vision. Third, HIV/AIDS programs must be informed by evidence, and respond to specific transmission dynamics and circumstances. However, without good monitoring and evaluation, we will never have the evidence we need in which to ground effective programs. Fifth, since AIDS is a development issue with broad consequences for countries, it needs to be integrated into broad development planning processes. And sixth, many groups and stakeholders need to play their parts if we are to succeed against AIDS. This includes governments, the private sector, community and civil society organizations, people living with HIV/AIDS, NGOs and international organizations. In thinking about where to focus our efforts in the next few years, we had to face an uncomfortable question. With all the increased funding flowing from the Bank, from PEPFAR, DFID, the Global Fund, the Gates and Clinton Foundations, and others, why aren t we seeing better results? What is stopping the increase in funding from making a real impact on the epidemic? We thought about the barriers and challenges that undermine our efforts to confront the epidemic, blunting their impact. Some are long-standing challenges that we have grappled with for years, others are newly emerging, but loom large in this new phase of the epidemic. The key barriers and challenges are: Many national HIV/AIDS plans are not strategic, and are poorly prioritized; Prevention, care and treatment efforts are too small, and coverage is too low. Management and implementation constraints hamper action, Health systems are weak and overwhelmed, but the demands on them grow, not least with efforts to expand access to treatment. The effort to expand ARV treatment offers hope and the potential for years of healthy life to people with AIDS, but also raises difficult issues of equity, sustainability, and adherence. Prevention remains inadequate and absolutely vital everywhere, no matter what the stage of the epidemic. Stigma and discrimination, denial, and silence persist, to the point that some people would literally rather die than let others know they are HIV positive. And donors sometimes create additional headaches and problems for countries. Figure 9 shows the situation in Tanzania, where program managers spend more time meeting the needs of visiting donors than implementing the programs. 7

8 Figure 9: AIDS stakeholders and donors in one African country GTZ RNE Norad Sida USAID CF PEPFAR GFATM CCM CIDA US$ 50M US$290 M US$ 60M HSSP HSSP NCTP NCTP US$200M UNAIDS WB T-MAP DAC MOH GFCCP WHO UNICEF UNTG SWAP SWAP NACP 3/5 PRSP PRSP CCAIDS MOF MOEC INT NGO CTU PMO LOCALGVT CIVIL SOCIETY PRIVATE SECTOR 13 Five of these challenges seem to us to be especially pressing, and particularly need the Bank s resources and attention. So the Program of Action focuses especially on these five, inter-related areas. These are also the areas endorsed by the GTT s division of labor. The first action area is to support better national HIV/AIDS planning; The second action is sustaining funding for HIV/AIDS programs and for strengthening health systems; Number three is accelerating implementation of national plans and programs; Fourth is building country monitoring and evaluation systems and capacity to collect, analyze and use data And fifth is our knowledge agenda impact evaluations and analytic work to improve knowledge and to use the knowledge to improve programs and their impact. It is worth emphasizing that the Bank is one of many players, and that our individual and collective efforts need to be well coordinated and harmonized, so that resources are used well, and for better impact. The following paragraphs/figures outline some specific actions planned in each area. 1. Support better national HIV/AIDS planning, and better integration of HIV/AIDS in national development planning If national plans are not based on the best available local information, prioritized and focused well, with funds allocated to the places and people with the highest risk of new infections, there is little chance of having much impact. For example, Figure 10 shows the misdirection of program efforts in one country, where 75% of infections involve sex workers, but less than 1% of funding targets this group. So we are going to put much more effort into helping countries to develop well prioritized, costed national plans that respond to their local epidemiological and risk patterns. We will do this through training and hands-on support, new guidelines, good practice notes, and by facilitating sharing of local expertise across countries (Figure 11). 8

9 Figure 10: Mismatch between funding and infection patterns 100% 80% 60% 40% 20% 0% Sex workers General population HIV rate Share of infections involving Share of funding Figure 11: Help countries to strengthen strategic, prioritized national planning Training and hands-on technical support HIV/AIDS to be better integrated in national development planning processes (PRSP, CAS, MTEF) Programs and planning to be evidence-informed Guidelines, good practice notes Support a network of country practitioners to share expertise Synthesis papers on national HIV/AIDS epidemiology and optimal responses to match Sustained funding for HIV/AIDS programs and for strengthening health systems (Figure 12) The Bank must continue to provide long-term funding for national and regional HIV/AIDS programs, at levels commensurate with the needs. The funding will be increasingly flexible, going to countries and activities that other donors cannot, or will not fund. The Bank must continue to support a multi-sectoral response, channeling funds especially to sectors with important roles to play and to civil society organizations, and communities, who shoulder the main burdens of care for people infected and affected by HIV/AIDS. There is strong consensus on the urgent need to do much more to strengthen health systems that are already under-staffed, under-funded and strained to the limit. And they must cope with rapidly rising numbers of people with AIDS who need treatment. The Program of Action includes a commitment to do more to strengthen health systems, within our HIV/AIDS operations, and through the broader health sector work of the Bank. 9

10 Figure 12: 2. Sustained funding for effective HIV/AIDS programs & to strengthen health systems Bank will remain a major funder, flexibly funding countries and activities others cannot fund Long-term funding to strengthen health sectors crucial for HIV/AIDS response and other health goals Supports stronger efforts in other key sectors Strong commitment to harmonize efforts among donors for better impact Ensure funding for CSOs and communities We will work with key Bank units and the IMF to mainstream HIV/AIDS within the Bank, and with relevant external partners to get HIV/AIDS better integrated into national development planning. We will try to remedy the tendency to overlook HIV/AIDS in Poverty Reduction Strategies, Medium Term Expenditure Frameworks and CASs, especially in countries where the epidemic is nascent. We know only too well that AIDS is a broad development challenge, that it is undermining progress towards improving poverty and hunger, maternal and child health and survival, gender equality and education. It needs to be properly incorporated in national development planning Accelerate implementation, to increase the scope and quality of priority activities The third key area of focus is continuing and building on our efforts to accelerate implementation. Newly available funding has done much to narrow the funding gap, but has opened an implementation gap between the funding now available, and its use (Figure 13). Figure 13: Funding and implementation gaps HIV/AIDS: Annual Needs, Commitments and Disbursements (US$ Billion) World Bank MAP GFATM PEPFAR Com. Disb. Needs 18 10

11 Most countries work within hard implementation constraints: too few skilled personnel; unpredictable and/or conditional funding; burdensome disbursement and procurement processes; government reluctance to contract implementation out to civil society or the private sector; and multiple management and monitoring and evaluation systems to meet differing donor requirements. The Bank can provide much needed implementation support to countries to move resources (Figure 14). Figure 14: Support to accelerate implementation Financial and technical support Adequate funding for supervision Simplify processes, procedures as needed Implementation Advisory Service Joint Problem Solving and Implementation Support Team (GIST) Ensure CSOs, PLWHA, communities, private sector all play a role as needed Networks among countries to share solutions, experiences We plan to intensify our financial and technical support to help loosen at least some of these constraints, to empower countries to accelerate and expand their programs. This will be done through continued support to enhance national capacity and systems, seeking to ensure adequate funding for supervision (from the Bank s internal budget and from external funding sources); and further simplifying our processes and procedures as needed. 19 The Bank s Implementation Acceleration Team will be strengthened, drawing on expertise from across the Bank, to be an Implementation Advisory Service that can help teams as needed. The Bank will work with partners through the Global Joint Problem- Solving and Implementation Support Team (GIST) to coordinate U.N., Global Fund and World Bank action and provision of technical support for accelerating HIV/AIDS responses in countries. We will continue to encourage countries to enable civil society and community organizations, PLWHA, and the private sector to play appropriate roles in the national HIV/AIDS response. And we will foster networks of country practitioners that can share experiences and practical advice on how to solve common problems. 4. Build country monitoring and evaluation systems and capacity to collect, analyze and use data The fourth action area continues and extends the support that the Global AIDS Monitoring and Evaluation Support Team (GAMET) provides to build a well-functioning monitoring and evaluation system in each country, to provide accountability and information that is then used to enhance the impact of national programs (Figure 15). 11

12 Working with partner agencies, GAMET will continue to provide intensive, practical, field support to build country systems and capacity, as well as training, clear guidelines and good practice examples. Figure 15: 4. Build country monitoring and evaluation capacity and systems, so that evidence informs responses GAMET country support team continue to provide intensive practical field support Develop/strengthen national M & E frameworks Guidelines, for national M&E systems Good practice examples Global, regional, and national M&E training goal: strong national M&E expertise More impact evaluation Support better use of data to improve programs Impact evaluation and analysis to generate knowledge, share and use it to improve program impact The last few years of intensive action in the Bank have mainly focused on getting resources to countries. The Program of Action commits the Bank to ensuring that more impact evaluations are done of Bank-supported HIV/AIDS programs, including prospective evaluations that must be designed and begun ahead of project implementation. The regional and country strategies include plans for analytic work, which will be complemented by analysis of key cross-cutting and cross-country issues, and new publications, especially to highlight good practices. Our website and dissemination will be improved, so that new knowledge is shared better, and can be used to improve programs and impact. 5. Generate, share and use knowledge. Do more impact evaluation and analysis Do more impact evaluations of Bank support With others, carry out new analysis in key crosscutting cross-country areas (e.g. poverty, finance) and country-specific AAA New publication series (a) good practice notes, (b) HIV/AIDS analytic reports Distribute reports, guidelines etc widely, target potential users Improve WB AIDS website 21 12

13 Finally, this Program of Action reaffirms our commitment to work together with our partners and across the Bank group, so that our collective and harmonized efforts can do more to empower countries for a real impact in the fight against HIV/AIDS. We are painfully aware that there are no quick solutions, and that we need to sustain a strong, long-term commitment to HIV/AIDS prevention, care and treatment. And, we need to act faster and more effectively than ever before, to stop new infections and prevent deaths in Africa and in all regions of the world. This is the challenge that our Program of Action seeks to meet. A comment by Jim Wolfensohn, made on the day we held our big consultation meeting to solicit feedback on an earlier draft, sums up the motivation and vision underlying this Bank Program of Action. Responding to praise for the Bank s AIDS work, from Peter Piot, and from representatives of client countries and of people with HIV/AIDS, Jim said: We have made a good start, but we are only at the beginning of the efforts that we really need to make on AIDS. In his foreword to the Program of Action, Paul Wolfowitz, World Bank President, summarizes the challenge and the Bank s commitment well: There is an urgent need to do more and to do it better, so that the results of our efforts can be counted in millions of infections prevented, millions of people with HIV/AIDS living more productive, healthy lives, and millions of children, so heartlessly orphaned by the disease, being properly cared for. 13