Elizabeth LuleManager

ACTafrica

What Role Should the World Bank Play in HIV/AIDS

Campaign in Africa 2007-2011

Consultation with Key StakeholdersAugust 13, 2006 – Toronto, Canada

2

A global view of HIV infection

2

3

The Diverse Epidemics

Manzini

Kampala

Dakar0

10

20

30

40

50

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

4

Much Higher Global Funding for HIV/AIDS (US$ millions)

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005*

World Bank MAP

GFATM

3 by 5PEPFAR

G8

Avg Price of ARVs

$7,944-20,224/Person per year

Avg Price of ARVs

$50-200/Person per year

* Projected fundingSource: UNAIDS, 2004.

5

Much lower ARV prices and more emphasis on expanding access to treatment

e.g. Uganda 1998−2003, first line ARV, US$/year

2 000

4 000

6 000

8 000

10 000

12 000

14 000

0

Pri

ce U

S$

Jun00

Oct00

Feb01

Apr01

Dec00

Nov00

Jul01

Mar03

Sep98

Aug98

Jul98

Oct03

Jun98

Sep03

Jan01

May01

Aug01

Mar10

Jun01

Accelerating Access

Initiativ

e

Generic companies start p

roduction

Further p

rice re

ductions

Further p

rice re

ductions

Negotiatio

ns by Clinton

Foundation

Source: UNAIDS/WHO, 2004.

6

Resources Available Compared to Estimated Need

$8.3 $8.9 $10.0

$3.3$6.0

$12.1

2005 2006 2008

Resource Available Gap

$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 Update29 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

Project Thematic Areas Estimated Percentage Estimated millions US$

Prevention 35% 455.52

Care and Treatment 22% 283.88

Mitigation (OVC) 13% 165.05

Advocacy 14% 178.25

Monitoring and Evaluation

4% 52.81

Other 14% 184.85

Total 100% 1,320.36

9

Multi-Sectoral Use of FundsProject Components Estimated Percentage

of FinancingEstimated overall allocation

Civil society 38% 501.74

Ministry of Health 17% 224.46

Other Ministries 13% 171.65

Capacity Building 11% 145.24

Monitoring and Evaluation

4% 52.81

Program Coordination 10% 132.04

Other 7% 92.43

10

Sources of HIV Spending in Three Countries

US$ 1.87

HIV and AIDS spending per capita

US$ 0.59 US$ 0.28

World Bank loan 27%

All donors 14%

Public 86%

Public 9%

Global Fund9%

Bilateral 35%

World Bankcredit 32%

Multilateral(excluding GF) 15%

Bilateral32%

Public 36%

Global Fund 2%

Multilateral(excluding GF) 3%

India Russian Federation

Burkina Faso

10.11Source: UNAIDS, based on National AIDS Spending Assessments.

11

Trends in HIV and AIDS per-capita expenditures in current US$, selected sub-Saharan countries

0.22

0.65

0.31

0.15

0.49

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

2001 2002 2003 2004 2005

HIV per capita spending (US$)

Sources: Countries reporting on UNGASS on domestic public expenditure; UNAIDS estimates11.3

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

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

16

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

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

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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

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What role should the World Bank play in HIV/AIDS Campaign in Africa 2007-2011What 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 2007-2011How 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)