Elizabeth Lule Manager ACTafrica

1. What Role Should the World Bank Play in HIV/AIDS Campaign in Africa 2007-2011 Elizabeth Lule Manager ACTafrica Consultation with Key Stakeholders August 13, 2006 – Toronto, Canada

2. A global view of HIV infection 2

3. 50 40 30 20 10 0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 The Diverse Epidemics Manzini Kampala Dakar

4. Much Higher Global Funding for HIV/AIDS (US$ millions) Avg Price of ARVs $7,944-20,224/ Person per year G8 PEPFAR 3 by 5 World Bank MAP GFATM Avg Price of ARVs $50-200/Person per year * Projected funding Source: UNAIDS, 2004.

5. 14 000 12 000 Accelerating Access Initiative 10 000 8 000 Price US$ 6 000 Generic companies start production Further price reductions Further price reductions 4 000 Negotiations by Clinton Foundation 2 000 0 Jun 98 Jul 98 Aug 98 Sep 98 Jun 00 Oct 00 Nov 00 Dec 00 Jan 01 Feb 01 Mar 10 Apr 01 May 01 Jun 01 Jul 01 Aug 01 Mar 03 Sep 03 Oct 03 Much lower ARV prices and more emphasis on expanding access to treatment e.g. Uganda 1998−2003, first line ARV, US$/year Source: UNAIDS/WHO, 2004.

6. Resources Available Compared to Estimated Need $11.6 billion $14.9 billion $22.1 billion Source: The Henry J. Kaiser Family Foundation (www.kff.org) Original source UNAIDS

7. MAP Status Update • 29 countries + 4* sub-regional projects • $1.12 billion committed so far • $744 million disbursed • > 50,000 civil society subprojects funded • Laid the groundwork for other donors • 2nd phase MAPs prepared in 5 countries – 4 approved and 3 under preparation

8. World Bank Funds

9. Multi-Sectoral Use of Funds

10. Russian Federation Burkina Faso India Public 9% World Bank loan 27% All donors 14% World Bank credit 32% Public 36% Global Fund 2% Bilateral 35% Global Fund 9% Multilateral (excluding GF) 3% Public 86% Multilateral (excluding GF) 15% Bilateral 32% HIV and AIDS spending per capita US$ 1.87 US$ 0.59 US$ 0.28 Source: UNAIDS, based on National AIDS Spending Assessments. 10.11 Sources of HIV Spending in Three Countries

11. 1.0 0.9 0.8 0.7 0.65 HIV per capita spending (US$) 0.6 0.5 0.49 0.4 0.31 0.3 0.22 0.2 0.15 0.1 0.0 2001 2002 2003 2004 2005 Sources: Countries reporting on UNGASS on domestic public expenditure; UNAIDS estimates 11.3 Trends in HIV and AIDS per-capita expenditures in current US$, selected sub-Saharan countries

12. What has changed from 2000 to date? • Many more players since 2000 • Regional variations and diverse epidemics • More resources but unpredictable, conditional, ideological and funding gaps persist • Health systems, supply chains, and infrastructure are overwhelmed with program demands of multiple diseases • Human Resource crisis more critical • Use of Line 2 ARVs may increase and costs remain too high

13. What has changed (2) • New and emerging development agendas, budget support, HIPC and other instruments but HIV/AIDS not adequately integrated in development agendas • Other emerging priorities (Avian Flu) • Imbalance between treatment, care and support and prevention • Feminization of the epidemic • The “’Three Ones” and Universal Access • New World Bank Global Program of Action in 2005

14. 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 • Donor coordination and priorities

15. AIDS stakeholders and donors in one African country WHO INT NGO CIDA 3/5 UNAIDS GTZ RNE UNICEF Norad WB Sida USAID T-MAP MOF UNTG PMO US$ 50M CF DAC GFCCP PRSP PEPFAR US$ 60M HSSP GFATM MOEC MOH SWAP US$290 M CCM NCTP CTU CCAIDS US$200M NACP LOCALGVT CIVIL SOCIETY PRIVATE SECTOR

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

17. Strategic Challenges: Tensions and Trade Offs • Fiscal sustainability versus promise of universal access • Vertical programs versus horizontal spending • Grant funding versus credit funding • Health sector response versus multisectoral response • Project approach versus budget support • Integration of HIV, TB, SRH and other health issues • Accountability and effectiveness • Balancing investments between the public sector, private sector or community response

18. Objectives of the World Bank Africa HIV/AIDS Agenda for Action • Reaffirm the Bank’s commitment to long term vigorous support for HIV/AIDS control in Africa • Articulate the Bank‘s role and comparative advantage in a harmonized international program of support • Identify priority interventions for the next generation of activity based on evidence of success and lessons of experience • Identify the role of the Bank to fill financing gaps, in non-lending activities, TA and analytical work, capacity building and mainstreaming HIV/AIDS in other sectors

19. What role should the World Bank play in HIV/AIDS Campaign in Africa 2007-2011 • What is the comparative advantage of the Bank relative to other donors and development agencies? • How can the Bank better support client countries to integrate HIV/AIDS in broader development frameworks (PRSPs, MTEFs, sectoral annual budgets) and also sustain the local response? • What might be the realistic expectations for results 2007-2011 • How can the Bank support Middle Income Countries worst affected? • How do we improve the linkages between HIV/AIDS and health sector reform and health systems strengthening? • How should we improve mainstreaming in other sectors? • How can the Bank better support the Three Ones • How can the Bank improve coordination and collaboration with other partners (GFATM, PEPFAR, European donors, UN Agencies, & foundations)