Elizabeth Lule Manager ACTafrica

1. 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 Elizabeth Lule Manager ACTafrica

2. World Bank IDA Sector allocations over time in Africa(US$ millions, %) Africa Region

3. 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

4. 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)

5. MAP Status • 33 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

6. Multi-Sectoral Use of Funds

7. 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

8. 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

9. 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

10. 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

11. 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: Focus the response through evidence based and prioritized national HIV/AIDS strategies integrated in national development planning • Pillar 2: Scale-up targeted multi-sectoral and civil society responses • Pillar 3: Deliver effective results through increased country M&E capacity and strengthened national and health systems • Pillar 4: Harmonize donor collaboration and knowledge sharing

12. 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

14. 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

15. 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

16. 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

17. Africa HNP: Strengthening Health Systems for Outcomes

18. 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

19. Now to Action