CONCEPT NOTE

HIV/AIDSAgenda for Action in Sub-Saharan Africa

Why is there a need for an Agenda for Action for the Bank on HIV/AIDS in Africa? How would it complement the World Bank’s Global HIV/AIDS Program of Action, the new health sector strategy and the Africa Action Plan? What should be the Bank’s role over the next five years on HIV/AIDS in Africa?

I. Introduction and Objectives

1. In 1999, the World Bank adopted a strategy to help combat the growing HIV/AIDS epidemic in Africa, and in December 2000, the Board approved a Multi-Country AIDS Program (MAP), whose goal was to dramatically increase access to prevention, care and treatment for HIV/AIDS. The AIDS Campaign Team for Africa (ACTafrica) was established and a budget allocated for it for the first time.

2. At the time, the Bank recognized that mitigating the epidemic was a long-term challenge, and committed itself to a 12-15 year program of support, in three phases. Phase 1 (MAP 1 and MAP 2) involved an emergency response in almost every eligible Sub-Saharan country-- 29 countries and four regional programs--with IDA credits and grants totaling $1.2 billion. The guiding principle of the first phase was learning by doing. Phase 2 would involve applying lessons learned and mainstreaming of interventions that proved most effective and continued expansion of coverage. Phase 3 would begin as the number of new infections declined and would have a sharp focus on prevention.

3. The MAP financing has now been fully committed, and IDA grant funding dedicated for HIV/AIDS in Africa is no longer available. The Bank’s Africa Action Plan is almost silent on HIV/AIDS, and current Bank country strategies and lending programs show a marked reduction in direct support for HIV/AIDS. The focus has shifted, even while the disease remains a critical problem. This will mean continuing emphasis on the multisectoral approach which is critical to prevention as health systems are critical to treatment.

4. The 1999 HIV/AIDS Strategy needs to be updated and refocused as an Agenda for Action for 2007-2011. It will have five basic objectives:

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, and

Suggest specific criteria for lending where there are financing gaps, identifying non lending activities including technical assistance, analytical work, collaboration and other work to mainstream HIV/AIDS efforts into country programs in Africa, and

Mainstream AIDS in other sectors in the Sub-Saharan Africa Region..

5. The Agenda for Action (AFA) FY07-11 will reflect the significant changes since 1999 in the understanding of the epidemic, the response, the number of donors, the proliferation of donor- driven vertical programs for HIV/AIDS and other diseases, competing claims on scarce human resources at the national level and other factors. Using available evidence, it will make a case for the continued preeminence of HIV/AIDS as a development issue in most African countries and a principal obstacle to realizing the Millennium Development Goals (MDGs). It will suggest a framework for action for the Bank over the next five years that (i) builds on its comparative advantages, (ii) harmonizes efforts at the global and national levels, (iii) applies lessons from the current portfolio of projects, (iv) differentiates responses among countries and regions, and (v) ensures longer-term, sustainable funding for prevention, care, treatment and particular attention to vulnerable populations.

6. Specific questions to be addressed during the preparation of the Agenda for Action will include:

What has changed since the original HIV/AIDS Strategy to warrant a fresh approach? With the fourfold increase in grant funding for HIV/AIDS in Africa since 1999, is there still a need for financing from the Bank? If so, where? Given the tight IDA country resource envelopes and increasing debt relief, how will the Bank fulfill its long-term commitment to support HIV/AIDS? How is sustainability of funding to be assured? What are the expectations of countries and other donors? How has the epidemiology changed?

What have we learned from the experience of the MAP Program over the past five years that will help shape the agenda for action? What does implementation experience of the first generation of MAP projects suggest for the design of individual projects and the focus of Bank assistance over the next five years? What are the principal lessons from the MAP program’s unique, unconventional approach? Where are we beginning to see impact, particularly in prevention, treatment, care and support?

How would a new strategy complement and add value to the World Bank’s Global HIV/AIDS Action Program, the Africa Action Plan and

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the forthcoming Health Sector Strategy? How might the Africa HIV/AIDS Agenda for Action deepen and “operationalize” the key aspects of the Bank Global HIV/AIDS Program of Action which is focused on (i) strengthening national strategies, (ii) continued funding for national and regional programs, (iii) accelerating implementation, (iv) improving M&E, and (v) knowledge generation and sharing? How might it complement the likely priority of the forthcoming Health Sector strategy on health systems, and how will it be integrated with related initiatives on malaria, TB, nutrition and reproductive health?

What might be the Bank’s comparative advantages in HIV/AIDS support relative to other donors and development agencies? Given its commitment to the “Three Ones” and a harmonized and coordinated approach to HIV/AIDS, as well as specific responsibilities given by the Global Task Team and UNAIDS (with respect to strategic planning, governance and financial management), what might be the areas where the Bank is especially qualified to provide a leadership role? A supporting role? No role? What do countries in Africa perceive as the Bank’s comparative advantages? What do development partners see as the Bank’s value-added?

What might be realistic expectations for results over the next five years, and how will it be measured? What might be the appropriate level and type of action in country contexts and sub-regions that could lead to a reversal of the deteriorating trend in infant-mortality, maternal mortality and HIV/AIDS prevalence? What should the Bank’s HIV/AIDS goals be in Africa over the next five years? How will progress be measured? To what should the Bank hold itself accountable?

How might the way of doing business change to implement the strategy and enhance the effectiveness of the Bank’s work on HIV/AIDS in Africa? What does “mainstreaming” HIV/AIDS into country programs mean in practice? Why has support for HIV/AIDS projects and analytical work diminished and what changes might be needed in institutional commitment, incentives, staffing and resource allocation to ensure the Bank’s activities lead to measurable change? How can the specialized HIV/AIDS unit in the Region (ACTafrica) best continue to play an appropriate advocacy and technical support role?

What role should the Bank play in the middle income countries in Southern Africa? What non-lending services might the Bank provide? What special skills and instruments are available or can be developed for the IBRD countries?

II. The Audience

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7. The Agenda for Action will have three principal audiences—the Bank, client countries and other development partners.

8. The first audience is internal. It comprises the regional, country and sectoral management and staff whose decisions and activities impact, directly or indirectly, on what the Bank can accomplish with respect to HIV/AIDS. It will assist this audience in making strategic choices to address HIV/AIDS. It will also inform their efforts to mainstream HIV/AIDS in the poverty reduction agenda, to incorporate HIV/AIDS into country assistance strategies and to advise countries on the design, implementation, monitoring and evaluation of effective programs. It will also advise the Region on staffing and organizational requirements for the Agenda and on the needs of the Bank’s internal workplace HIV/AIDS program.

9. The second audience consists of country clients, notably Ministries of Finance, Development, Health, Education, Transport, Defense, Agriculture, Interior, Women and Children and others, research institutions, communities, non-governmental organizations and the private sector and civil society. It will reinforce the importance of the multi-sectoral approach to the disease.

10. The third audience will be other development partners, including the multi-lateral and bi-lateral aid agencies, UN agencies, foundations and private sector partners. The Agenda for Action will suggest the appropriate role for the Bank and the continuing need to harmonize and coordinate efforts and honor the commitment to the “Three Ones” in specific country circumstances.

III. Background and Justification

The Epidemic

10. HIV/AIDS continues to be a major development challenge in the region, particularly in Southern Africa, the epicenter of the epidemic. It reverses life expectancy gains, erodes productivity, decimates the workforce, consumes savings and dilutes poverty efforts. Africa has an estimated 26 million people living with HIV/AIDS, and more than 23 million have died as a result of infection. Africa accounts for more than

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60% of the global number of people living with HIV/AIDS.

11. Women represent the majority of those infected and young people are at high risk. More than 12 million children have been made orphans by the disease in Africa.

Table 1: Impact of the Epidemic Category (as of end-2005)

Persons (millions) % of global total

Africans living with HIV/AIDS 25.8 60%Africans newly infected in 2005 3.2 64%Africans who died of AIDS in 2005 2.4 77%Total Africans who have died of AIDS 23.8 81%African children orphaned by AIDS 12.3 92%

The epidemic diminishes economic growth by up to 1.5% per annum in the most affected countries. The impact on human capital is devastating. Life expectancy has fallen below 50 years in several countries.

A Global View of HIV Infection

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Chart 1: Life Expectancy in Selected Countries

The epidemic differs between countries and within countries. Some are experiencing stabilization and reductions of new infections and HIV/AIDS prevalence. The overall adult infection rate in Kenya, for example, has decreased from a peak of 10% in the late 1990s to 7% in 2003. Declines in prevalence are also reported in Uganda, Zimbabwe, and urban Rwanda, Malawi and Ethiopia. On the other hand, Mozambique is showing rising incidence and there is no material change in new incidence among the most seriously affected countries of Southern Africa (UNAIDS 2006 Report).

The Millennium Development Goals (MDGs)

12. Most MDGs will not be achieved without progress in addressing HIV/AIDS in Sub-Saharan Africa. Contrary to several of the poverty and education MDGs, progress on almost all the health-related MDGs is stagnant. Most of the MDGs will not be realized in Africa without progress in combating HIV/AIDS:

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Chart 2: AIDS and the MDGs

Mill. Development Goal Africa progress AIDS effectReduce poverty/hunger Stagnant at best Large

Universal 1ary education Lagging ModerateGender equality Lagging Large

Child & infant mortality Worsening LargeMaternal health Worsening Large

Combat AIDS & diseases Worsening LargeEnvironmental sustainability On track MinimalImprove global partnerships On track Favorable

Funding

13. In the past five years, the international community has increased HIV/AIDS funding and technical support significantly through global commitments such as the Global Fund to Fight AIDS, TB and Malaria (GFATM), The US-sponsored PEPFAR Program, 3X5 (WHO), Universal Access to Treatment (from the G-8 summit at Gleneagles) and private foundations such as the Gates Foundation and the Clinton Foundation. Global funding for HIV/AIDS has increased by about $1.7 billion per annum since 2001, to about $6.1 billion by 2004. At the same time, funding still covers only a fraction of the need for treatment and is insufficient with regard to flexibility to cover operating costs, human resources for health, prevention, mitigation at community levels and dealing with vulnerable groups, especially orphans.

The Impact

14. (a) Prevalence and Incidence. According to the 2006 UNAIDS Report, the overall global HIV incidence rate (the proportion of people who have become infected with HIV) is believed to have peaked in the late 1990s and to have stabilized subsequently, notwithstanding increasing incidence in several countries. Changes in incidence along with rising AIDS mortality have caused the global HIV prevalence (the proportion of people living with HIV) to level off. However, the numbers of people living with HIV have continued to rise, due to population growth and, more recently, the life-prolonging effects of antiretroviral therapy. In sub-Saharan Africa, data suggest that the HIV incidence rate has peaked in most countries. However, the epidemics are especially severe in southern Africa, where some of the epidemics are still expanding. South Africa, for example, an estimated 18.8% of adults were living with HIV in 2005, with no sign of decline in new incidence.

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15. (b) Treatment. The most significant impact from the fourfold increase in funding has been the rapid growth in access to treatment. The number of people on antiretroviral therapy (ART) has increased eightfold in Sub-Saharan Africa between 2003 and the end of 2005, to about 810,000. This is equivalent to about 17% of those needing treatment. The number of treatment sites has grown exponentially, for example from 3 to 110 in Zambia and 3 to 60 in Malawi over the past two years. Treatment regimens have averted an estimated 250,000 to 300,000 premature deaths in developing countries in 2005, although the number is modest compared to the potential Nevertheless, many countries continue to depend on external assistance without integrating HIV/AIDS into medium or long-term budgetary planning.

16. (c) Governance. Most African countries have a functioning HIV/AIDS governance structure and management system, national strategies and elements of a national monitoring and evaluation system. Political commitment has grown and the subject is no longer taboo. The private sector is becoming engaged. Business coalitions are supported in 25 Anglophone and Francophone countries.

17. (c) Challenges. While there is clear progress, the challenges are enormous. Despite a widespread understanding of what causes HIV infection and how it can be avoided, attitudes and behaviors have been slow to change. Women and young people remain particularly vulnerable. The response is still compromised by very weak health systems in many countries. There is a persistent shortage of health workers. National budgets for health and for HIV/AIDS are chronically under-funded. The growth of the number of individuals on treatment and the adoption of the policy of “universal access” to prevention and treatment will place an even greater burden on health finance. And the increase in the number of global “vertical programs” for health (more than 70 in which WHO is a member) places extraordinary burdens on national health capacity to manage. Balancing prevention and treatment efforts is also a challenge.

IV. The World Bank’s Role in HIV/AIDS in Africa

The Regional HIV/AIDS Strategy

18. In May 1999 The Bank approved a strategy to combat HIV/AIDS in Africa in partnership with African governments and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Entitled Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis,” the strategy stood on four pillars:

Advocacy, to position HIV/AIDS as a central development issue and to increase and sustain an intensified response;

Increased resources and technical support for countries and Bank country teams to mainstream HIV/AIDS activities in all sectors;

Prevention efforts targeted at both general and specific audiences, and activities to enhance treatment and care; and

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An expanded knowledge base, to help countries design and manage prevention, care and treatment programs based on epidemic trends, impact forecasts and identified best practices.

19. The explicit objective was to place HIV/AIDS at the center of the development agenda and mainstream all aspects of the Bank’s work in Africa and in all channels of dialogue. The goal was to help clients expand their national response and help build capacity among Bank staff in all sectors to factor HIV/AIDS into policies and projects. HIV/AIDS became a corporate priority. The strategy was also designed to encourage other donors to increase their funding and leverage their resources.

20. To stimulate and support implementation of the strategy, a multi-sectoral AIDS Campaign Team for Africa (ACTafrica) was established with a separate budget allocation under the office of the Regional Vice President for Africa. Its purpose was to serve as the focal point and clearinghouse on HIV/AIDS, and to:

Support Bank country teams to mobilize African leaders, society and the private sector to intensify action;

Retrofit projects with HIV/AIDS components where possible and assist in the development of dedicated AIDS projects;

Support country teams in addressing AIDS in country assistance strategies; Collect and disseminate information; and Strengthen the Bank’s partnership with UNAIDS as well as key agencies, NGOs

and interested bilateral agencies.

The Evolution of the Strategy

21. In 2000, the strategy was translated into the “Multi-Country HIV/AIDS Program for Africa,” known as the MAP Program. The Executive Directors approved in September 2000 an initial $500 million commitment under the concept of a “horizontal” Adaptable Program Loan (APL), where country-specific IDA credits would be developed and presented to support national programs. To qualify for a MAP project, countries had to meet simple eligibility criteria: (i) evidence of a national strategy, (ii) a high-level HIV/AIDS coordinating body, (iii) willingness to use accelerated implementation arrangements, and (iv) agreement to fund multiple entities such as NGOs and community-based organizations.

22. In early 2002, an additional commitment of $500 million was approved by the Board for MAP 2, and the IDA-13 replenishment provided dedicated grant funding for HIV/AIDS in Africa. IDA-14, while a larger envelope, does not include earmarked funding for HIV/AIDS, making it just another option for country decision makers. IDA 14 does, however, include an indicator on curbing the spread of the disease as one determinant of IDA funding.

23. After a slow start in most countries, the HIV/AIDS Program has taken off:

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Table 3: World Bank-funded HIV/AIDS Credits and Grants FY00-FY06

Country Projects 29 approved, 3 repeater projectsSub-Regional Projects 4 approved ($107 million)

Total Commitments (end May 2006) $1.2 billion

Total disbursements (end May 2006) $694 million2nd Generation HIV/AIDS Projects Ghana, Madagascar, Eritrea (approved)

Burkina Faso and Kenya (awaiting Board approvalBenin and Ethiopia (under preparation)

24. In mid-2005, with the rapid growth of partners involved in HIV/AIDS in Africa and elsewhere, an agreement was reached to rationalize the global aid architecture. A division of labor was agreed by UN agencies and donor agencies. The Bank was designated by UNAIDS as the lead for support to strategy development, annual, costed work plans, financial management, human resources, infrastructure development, impact evaluation and sector work. The three major HIV/AIDS funders—the Bank, GFATM and PEPFAR--moved closer to realization of the concept of the Three Ones—one national authority, one strategy and one M&E system for HIV/AIDS, and have created a joint implementation support and coordination mechanism (GIST).

25. In December 2005, the Bank released “The World Bank’s Global HIV/AIDS Program of Action.” It provides a global context for future HIV/AIDS programming at the regional and country level. It identifies five over-arching action areas:

Support to strengthening national HIV/AIDS strategies, to make them truly prioritized and strategic, integrated into development planning and linked to gender and equity issues;

Continued Bank funding of national programs as a sustainable and predictable long-term source of finance, including the strengthening of national health systems;

Accelerated implementation of current programs; Strengthened M&E systems and evidence-informed responses; and Improved knowledge generation and sharing.

26. The Bank is currently developing a new strategy for its involvement in the health sector. (The 1997 health strategy did not include HIV/AIDS). It is likely to stress the importance of strengthening national health systems, unbundling the different aspects of an effective health service and suggesting where the Bank may have a comparative advantage. The HIV/AIDS Agenda for Action will complement and reinforce the health strategy. Moreover, the Agenda will continue to stress the importance of the multi-sectoral response, particularly for prevention, and the need for sustainable funding of treatment, care and support. It will also stress the unique contributions of the Bank in the focus on civil society and communities, mainstreaming AIDS programs in key ministries like education and on the regional dimensions of the epidemic and the response.

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V. Lessons of Bank Experience

27. The Interim Review of the MAP Program in 2004 endorsed the basic approach of the program but recommended much more was needed to realize the objectives of the “Three Ones.” Specifically, it suggested enhanced Bank support for revised national HIV/AIDS strategies, improved governance, greater differentiation among countries, incentives for performance and greater attention to the overall health system. It suggested the next generation of HIV/AIDS projects ought to be more evidence-based, and a functioning M&E system should be a prerequisite for continued Bank support.

28. The Interim Review and other regional efforts to evaluate the MAP provided the foundation for other assessments. In 2005, the Independent Evaluation Group (ex-OED) assessed the effectiveness of the MAP program as part of its global review of the effectiveness of the Bank’s assistance to HIV/AIDS control. It commended the Program for generating broad political support and intensified action, including the widespread involvement of civil society organizations, At the same time, it faulted the quality of many national strategic plans and the lack of effective M&E systems, limiting the benefits of learning by doing. It suggested the next generation of MAP projects could mitigate risks more effectively by (i) a thorough assessment of the technical and economic assessment of national HIV/AIDS plans, (ii) an inventory of what other donors are doing, (iii) greater clarity on the roles of CSOs and (iv) more focused attention of the multi-sectoral approach on the critical sectors with the greatest potential impact on the epidemic.

29. The World Bank Global HIV/AIDS Program of Action indicated that the Bank has helped redefine AIDS as a development issue and has provided strong economic and policy analyses and financial support. The Bank through its advocacy work had helped put HIV/AIDS on the priority agenda of most African countries. It acknowledged at the same time that the Bank had not done nearly enough and the record was far from perfect. However, the Bank remains a principal source of long-term, multi-year, predictable finance and a favored partner by many countries in combating the epidemic.

VI. Key Issues

30. The Agenda for Action will suggest the appropriate role for the Bank on HIV/AIDS in the Africa Region for the next five years, based on the following diagnosis:

What has worked and why--an analysis of the impact of the global response over the past five years

The strategic challenges—the major challenges to scaling up and accelerating control of the epidemic

The operational implications—the comparative advantage of the Bank in dealing with these challenges and the implications for partnerships, instruments, governance and priorities

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The results—the potential impact of the Agenda for Action and the global response over the next five years on the epidemic and life expectancy in Africa, and

The processes needed to ensure the effective realization of the Agenda and its contribution to the Africa Action Plan, the Bank’s global strategies for health and HIV/AIDS, the regional strategy for health and the realization of the UN Technical Support Plan for HIV/AIDS.

31. In each of these areas, the Agenda will analyze the major issues and recommend a course of action for the Bank. The specific issues to be addressed include the following:

The Diagnosis: do we know what works and why?

32. Given the emergency nature of the response to the epidemic, the initial focus has been on learning while doing. Systems and capacity to generate evidence on successful interventions and to monitor results are often still not in place. Consequently, evidence is only now beginning to emerge systematically on what is working most effectively in prevention, mitigation and even in treatment. The analysis will seek to assess the impact of the response to date, not only on awareness, political commitment, de-stigmatization and management, but on changes that affect the disease directly—such as condom use, age of sexual debut, number of partners and other attitudes and behavior. It will provide evidence, where possible, of changes in prevalence and incidence. The Agenda will assess the effectiveness of the commitment to the “Three Ones,” and suggest how a single M&E system for HIV/AIDS might be harmonized with the national health metrics network. The emerging evidence on the epidemiology of the disease may also suggest different responses in different settings, and a “strategy of strategies” for the Agenda.

The Strategic Challenges: how are the tensions and the trade-offs to be managed?

33. The radical and rapid change in the global environment for support to HIV/AIDS offers significant promise and also significant challenges. There are a number of tensions that will need to be addressed in the Agenda:

Financing:

Fiscal sustainability and the promise of “access to all.” How to manage the promise of universal access to prevention, treatment and mitigation with the limited financial capacity of most governments and somewhat unpredictable global funding

Vertical program funding and horizontal program spending. How to reconcile the very effective fundraising mechanism of single-disease

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programs with the needs of a country for spending “horizontally” across a wide range of health problems and developing an effective health system, and

Grant funding and loan funding. For the World Bank, how to remain engaged and active on HIV/AIDS in countries where grant funding is available from other sources or which are ineligible for concessional IDA funding.

Service Delivery:

The health sector response and the multi-sector response. How to ensure continued focus on sectors critical to the response such as education, transport, defense and youth while recognizing that HIV/AIDS is becoming a chronic disease requiring an intensified health sector responsibility

HIV/AIDS and related health imperatives such as TB, nutrition and reproductive health. How to ensure a vertical program for a single disease recognizes and integrates with other health problems closely related to prevention, its impact and amelioration, and

Accountability and effectiveness. How to balance the reliance on myriad local communities and non-governmental organizations for service delivery with the need to ensure integrity and accountability in the use of funds

Partnerships

The project approach and the programmatic approach. How to translate the global commitment to “harmonization” on HIV/AIDS to a reality on the ground, and

The public sector response and the private sector response. How to engage and support the private sector more effectively—both the business sector and the medical profession—while continuing to manage the public health crisis and accelerate an effective public sector response.

The Operational Implications: what will these choices mean for the World Bank?

34. By addressing these issues in a collaborative manner with other development partners, countries and other stakeholders, the Agenda for Action will identify an appropriate role for the Bank on HIV/AIDS in Africa for the next five years. The principal questions to be addressed will include:

The articulation of a vision, priorities, indicators and expected outcomes of the Agenda as part of the global response over the next five years

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The implications for individual country assistance strategies and programs, and involvement in the development of CAS, PRSPs, MTEFs and other instruments for setting priorities and allocating resources

The generation and diffusion of knowledge about the disease and the effectiveness of the response as a “global public good”

The organizational, budget and human resource needs for continued support to HIV/AIDS, including in countries where lending may be limited or non-existent

The appropriate future for specialized advocacy and support units such as ACTafrica, and

The explicit relationship between the Agenda for Action on HIV/AIDS and other Bank strategies such as the Africa Action Plan, the Global Action Plan for HIV/AIDS, the HNP health strategy and the Africa health Strategy.

The results: what could the epidemic look like in five years if the HIV Agenda for Action and the global response succeeds?

35. The analysis will assess the impact of the most important interventions on new infections and prolongation of life for people living with HIV/AIDS, and indicate the potential consequences and outcomes in terms of life expectancy, HIV prevalence, HIV prevalence at the younger ages—a proxy for incidence—AIDS deaths averted and AIDS mortality. To the extent possible, the analysis will also assess the impact of these changes on the economy as a whole (both positive, such as the rebuilding of human capital and potentially negative, such as the increase in recurrent health expenditure).

Internal processes and procedures: how do you ensure the Bank implements the Agenda?

36. Strategies have a tendency to remain documents with lofty ambition and little practical impact on the business of the institution. The Agenda for Action will suggest ways to help ensure the recommendations and directions are translated into unit work programs and budgets and made part of the internal monitoring and rewards system, on the premise that what gets measured gets attention.

VII. Approach Methodology

37. The Agenda for Action will be developed using the following methodology:

(i) Analysis will be initiated on:

the epidemic : the current epidemiology by region; the impact : the macroeconomic, social and gender consequences

of HIV; the response : the growth of global and national funding by source

and use;

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the technological advances : the impact of new approaches to drug manufacturing, testing, treatment and service delivery;

the lessons : emerging lessons from Bank-funded and other projects

the challenges : the financial consequences of universal access; national health systems; governance and corruption; rationalizing global aid architecture; and

the consequences for the Bank: current CAS strategies/lending pipeline/AAA for HIV/AIDS; gaps; opportunities;

(ii) Consultations will be carried out with relevant stakeholders within the Bank and at the national and global level on the Bank’s comparative advantages and the demand for Bank services. This will include CSOs, youth groups, other donors and the privates sector, where possible;

(iii) Guidance of the effort will be provided by an external advisory group to provide direction and feedback on strategic options;

(iv) Further consultations on the draft Agenda for Action will be initiated to confirm and refine the principal recommendations.

Work Program

38. The basic analytical work will be carried out by a working group from ACTafrica, the Africa Region, GHAP, the HNP anchor and the IMF. The basic benchmarks:

Concept Paper Review late-July 2006Analyses commissioned late-July 2006Consultations with other donors mid-August 2006Analyses completed end-August 2006Consultations with youth groups mid-October 2006Advisory Group meeting late-September 2006Draft Agenda for Action circulated early November 2006RMT meeting early November 2006Final draft Report circulated mid-November 2006Agenda for Action published and launched December 1, 2006 Dissemination and communications effort December 2006-June 2007

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Output

39. The final output will be a Report of no more than 30 pages, outlining the rationale and elements of an Agenda for the Bank’s five year program for HIV/AIDS in Africa. The Agenda for Action paper will include recommendations for action by senior management, county directors, country economists, sector managers in health, education, transport and other sectors, Africa regional technical staff, PREM and HD managers and staff and others. It will indicate desired outcomes of the strategy, principal responsibilities and indicators of success.

VIII. Dissemination Strategy

40. An effective dissemination strategy is critical to the success of the Action Plan itself. The dissemination strategy will consist of (i) engaging key stakeholders in the development of the Agenda itself, (ii) involving stakeholders in underlying analytical and preparatory work, wherever feasible, (iii) testing the preliminary ideas and strategic options at a relatively early stage with a broad array of interested groups, (iv) preparing and implementing a specific plan of action to present the results of the work in different forums, media and languages, and (v) conducting an evaluation of the effectiveness of the dissemination strategy in real time. The Agenda for Action will be available in English, French and Portuguese.

IX. Implementing the Agenda for Action

41. The Agenda for Action will include a proposed program of activities to implement the plan. It will include recommendations for:

Retrofitting current HIV/AIDS projects as appropriate during mid-term reviews Design of new projects in accordance with priorities for the Bank and components

identified in the Agenda Indicative targets for lending, TA, and other operational work Benchmarks and indicators of progress in the HIV/AIDS response Future analytical work Mechanisms for more effective harmonization of effort at the national level HR needs within the Bank to ensure availability of the requisite skills.

Attachments

ReferencesProposed Table of ContentsProposed Team, Peer Reviewers and Advisory Group

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Annex 1

Agenda for Action on HIV/AIDS in Africa 2007-2011.

References

Bill and Melinda Gates Foundation. 2005. Global Health Partnerships: Assessing Country Consequences. McKinsey and Co. for the High Level Forum. Seattle, Washington.

Global Fund to Fight HIV/AIDS, TB and Malaria/ World Bank. 2005. Comparative Advantage Study. Geneva and Washington, DC.

Kaiser Family Foundation. 2005. Financing the Response to HIV/AIDS in Low and Middle Income Countries. Menlo Park, California.

UNAIDS. 2006. Report on the Global AIDS Epidemic: A UNAIDS 10th Anniversary Special Edition. Geneva.

United Nations General Assembly Special Session on HIV/AIDS (UNGASS). 2006. Political Declaration on HIV/AIDS. New York.

World Bank. 1999. Intensifying Action against HIV/AIDS in Africa: Responding to a Development Crisis. Washington, DC.

World Bank. 2000. Project Appraisal Document on Proposed Credits to Kenya and Ethiopia in Support of the $500 Million Multi-country HIV/AIDS Program for the Africa Region. Washington, DC.

World Bank. 2001. Project Appraisal Document on a Proposed Credit to Senegal in Support of the Second Phase of the $500 Million Multi-country HIV/AIDS Program (MAP2) for the Africa Region. Washington, DC.

World Bank. 2004. Interim Review of the Multi-country HIV/AIDS Program for Africa. Washington, DC.

World Bank. 2004. Rising to the Challenges: the Millennium Development Goals for Health. Washington, DC.

World Bank. 2005. MDG-Oriented Sector and Poverty Reduction Strategies: Lessons from Experience. HNP Discussion Paper. Washington, DC.

World Bank and others. 2005. HIV/AIDS in the Caribbean Region: A Multi-Organizational Review. Washington, DC.

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World Bank. 2005. The World Bank’s Global HIV/AIDS Program of Action. Washington, DC.

World Bank. 2005. Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance. Operations Evaluation Department. Washington, DC.

World Bank. 2005. Quality of Country Analytical and Advisory Activities. Quality Assurance Group. Washington, DC.

World Bank. 2005. Meeting the Challenge of Africa’s Development: A World Bank Group Action Plan. Washington, DC.

World Bank. 2005. Disease and Mortality in Sub-Saharan Africa. Washington, DC.

World Bank. 2006. World Bank Strategy for Health, Nutrition and Populations Results. Washington, DC.

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Annex 2

Agenda for Action on HIV/AIDS in Africa 2007-2011

Proposed Table of Contents

1. Introduction: The Rationale for Action

The HIV/AIDS epidemic in Africa and its consequences for developmentThe impact of HIV/AIDS on the health and poverty-related MDGsThe global response since 2000The current state of knowledge, capacity, technology, governance, impact

2. The Bank’s Experience

The 1999 HIV/AIDS strategy and the MAP ProgramDramatic changes in funding from $10 million annually in mid-90’s to $250-300 million beginning in 2001 to recent decline in new commitmentsEmerging lessons: the Interim Review (2004), the Global Program of Action, Current trends: the changing epidemiology; new forms of funding (PRSCs); end to dedicated IDA grant funding for HIV/AIDS, debt-relief and the competition for IDA

3. The Challenges

Prevention: changing attitudes and behaviors; stigma and discrimination; focus on the most vulnerableTreatment: the financial impact of “universal access,” Care and support: The fiscal and human burden of 12 million orphansHealth systems: Reliance on often-dysfunctional health systemsThe multi-sectoral approach: managing multiple agency responsibilitiesGlobal health partnerships: rationalizing the response at the national levelGovernance: dealing with corruption, promoting transparency and accountability

4. The Consequences for the Bank

Regaining the focus on HIV/AIDS in Africa as a development issue for the BankMaintaining engagement in an environment of reduced lending for HIV/AIDSIdentifying the Bank’s comparative advantages in a collaborative international responseIdentifying the critical interventions based on evidence of success

5. An Agenda for Action for FY07-11 on HIV/AIDS in Africa

Identifying a program of investment, technical assistance, analysis and collaboration based on country and regional variations

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Costing and sequencing interventions that will achieve resultsIdentifying the internal staffing, organizational and instrument needs

6. Next Steps

7. Summary of key Messages to Stakeholders

Senior ManagementCountry Directors, Country Economists, PREM staffHNP sector managers and staffOther sector managers and staffDevelopment PartnersCountries

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Annex 3

Agenda for Action for HIV/AIDS in Africa 2007-2011

Proposed Working Team, Peer Reviewers and Advisory Team

(Subject to their agreement and availability)

Core working team: Elizabeth Lule (Task Team Leader, AFTHV), Daniel Ritchie (consultant), Cassandra de Souza (AFTHV), Richard Seifman (AFTHV), Nadeem Mohammad (AFTHV), John Nyaga (AFTHV), Sangeeta Raja,(AFTHV,), Albertus Voetberg ( AFTHV), Frode Devanger (AFTHV), David Wilson (HDNGA), Mario Bravo (EXTCD), EJ Ashbourne (OPCRX), Elizabeth Mziray (HDNGA), Jorge Arbache (AFRCE), Robert Greener (UNAIDS), Adyline Waafas Ofosu-Amaah (PRMGE).

Peer reviewers: Christian Baeza (LCSHH), Hart Schafer (AFRVP), Geeta Gupta Rao (ICRW ); Prof. B. Osotimehin (Nigeria),

Advisory Group: Debrework Zewdie (HDNGA), Jonathan Brown (HDNGA), Robin Gorna (DFID), David Benedict (DFID), Sigrun Mogedal (Norway), Michele Sidibe (UNAIDS), Keith Hansen/Mary Mulusa (LCSHH), Fadia Saadah./Maryam Salim (EASHD) Peter Heller (IMF), Kristan Schoultz (UNDP Botswana), Jacques Baudouy (HDNHE), Markus Haacker (IMF), Mark Dybal (PEPFAR), Mariam Claeson (SASHD), Bachir Souhal (MNSRE), Shiyan Chao (ECSHD), Don Bundy (HDNED), Sanjivi Rajasingham (AFTTR), Hans Binswanger (AFTS1), Ruth Kagia (HDNED), Ok Pannenborg (AFTHD), Alhaj Sy (UNDP), Helen Evans (GFATM), Mark Stirling (UNAIDS), Meskerem Grunitzsky-Bekele (UNAIDS), Teguest Guerma (WHO), Dr. Rui Vaz (WHO), Steven Krause (UNFPA).

Co-sponsors. Gerard Byam (AFTQK), Yaw Ansu (AFTHD), Sudhir Shetty (AFTPM), Michel Wormser (AFTPI), John Mcintire (AFTSD).

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