Overview of the World Bank’s Response to the HIV/AIDS Epidemic in Africa, with a Focus on the Multi-Country HIV/AIDS Program (MAP)

By Nandini Oomman[1]

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I. Introduction

The World Bank Multi-County AIDS Program in Africa (Africa MAP) is one of many World Bank programs for HIV/AIDS assistance and specifically aims to provide long-term support (10-15 years) to combat HIV/AIDS and mitigate its impact in African countries. Designed to be demand-driven, multi-sectoral and often community oriented, the Africa MAP is clearly different from traditional World Bank lending, although projects are intended to fit within the country's development strategy and the Bank's strategy for overall lending in that country.

Launched in 2000, the Africa MAP was the first major donor initiative focusing on HIV/AIDS in African countries. The World Bank program overall, including the significant contributions from the Africa MAP, has grown to be the largest funder for HIV/AIDS within the United Nations system. However, the World Bank's funding for HIV/AIDS is small in comparison to new and larger donor initiatives such as the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for AIDS, TB and Malaria (GFATM).

This paper provides a general introduction to the Bank's assistance for HIV/AIDS, with emphasis on the Multi-Country AIDS Program in Africa. Additional information about the Bank's overall assistance for HIV/AIDS may be found on the World Bank's website.

II. History and Framework

The history of World Bank programming in HIV/AIDS can be divided into two phases, the first characterized by small-scale projects, and the second by more substantive initiatives including the Africa MAP.

Phase I:
During the first phase, from 1986 to 1997, about $500 million was committed in loans and credits to 8 free-standing projects and 17 significant components to support national AIDS programs throughout the world.[2] In addition, the Bank collaborated closely with the WHO Global Program on AIDS (GPA) in project design and in launching analytic work on the cost-effectiveness of AIDS interventions. This period was marked by low demand among country governments for HIV/AIDS programs and a failure among World Bank management and stakeholders to make HIV/AIDS a priority of the institution.[3]

Phase II:
The second phase of the Bank's response, from 1998 to the present, is one of high-level institutional mobilization and advocacy in which the Bank takes an active role in raising awareness and demand for AIDS support among its staff and client countries. Since 1998, HIV/AIDS strategies or business plans have been completed in nearly all geographic areas of the Bank, and an additional $2 billion has been committed to support national HIV/AIDS programs in 55 countries, at all stages of the epidemic. This mobilization has helped raise awareness and commitment among recipient governments and increase international attention to the issue.

As a part of the Bank's overall approach, the Multi-Country AIDS Program in Africa was established in 2000 as a longer-term effort to mitigate the effects of the HIV/AIDS epidemic and eventually reduce the rate of incidence of the disease in Africa. While the Africa MAP is the largest and oldest of the regional initiatives, other such regional programs have been created in East Asia and Pacific, Europe and Central Asia, Latin America, Middle East and North Africa.

Framework for the Africa MAP
The design of the Africa MAP is meant "to intensify action against the epidemic in as many countries as possible," with two explicit objectives:

a) to scale up prevention, care, support, and treatment programs; and
b) to prepare countries to cope with the impact of those who develop AIDS over the next decade.[4]

The objective of the first phase of $500 million (MAP I), approved in September 2000, was to increase access to HIV/AIDS prevention, care, and treatment programs, with emphasis on vulnerable groups (such as youth, women of childbearing age, and other groups at high risk). MAP II, approved in February 2002, had, in addition, the objectives of: (i) pilot testing antiretroviral therapy (ART); and (ii) supporting cross-border initiatives.

In addition, the Africa MAP introduced a number of priorities, including: a strong emphasis on monitoring and evaluation (5-10% of funding should be spent in this area); a commitment to streamlining World Bank funding and implementation procedures to disburse funding more quickly; and implementing new procedures to increase the participation of civil society and community-based organizations.

III. Structure of World Bank and its HIV/AIDS Programs

The World Bank is a multi-lateral financial agency owned by member governments who exercise their direction through a Board of Governors, consisting of one governor for each of the 184 member countries. The governors meet once a year to review operations and basic policies and delegate most functions and the responsibility for the day-to-day management of the organization to 24 full-time Executive Directors, who are located at the Bank's Headquarters in Washington, DC. At the staff level, the Bank is managed by a President, two to four Managing Directors, and about a dozen Vice-Presidents (including six regional VPs) who oversee major operational units at the Bank's headquarters in Washington as well as over 100 country offices.

Headquarters: HIV/AIDS related activities at the World Bank's headquarters are coordinated by the Global HIV/AIDS Program and regional teams such as ACT Africa (AIDS Campaign Team for Africa) and SARAIDS (South Asia Regional AIDS team).

Global HIV/AIDS Program: Founded in 2002, the Global HIV/AIDS Program sits within the Human Development Network of the World Bank and is responsible for supporting the cross-sectoral nature of programming in this area. Although separate from the regional HIV/AIDS initiatives, the Global HIV/AIDS Program supports Work Bank-wide programs by facilitating shared lessons and improved implementation practices, including monitoring and evaluation. In addition, the Global HIV/AIDS Program supports the World Bank in its efforts to mainstream HIV/AIDS into all sectors such as education, transport, urban development and water supply and sanitation projects. Finally, the Global HIV/AIDS Program is tasked with ensuring that the World Bank coordinates and harmonizes work with other donors.[5]

Regional Operations: The regional operations units, located within the regional vice-presidencies, and corresponding country offices, manage the bulk of the World Bank's grants and lending, analysis and policy discussions in HIV/AIDS. While individual country teams led by Task Team Leaders (TTLs)[6] are responsible for specific country HIV/AIDS projects, regional teams such as the ActAfrica team are directly responsible for the overall coordination and implementation of regional programs such as the Africa MAP. Although ActAfrica works with the country-teams on specific country implementation and support for strategy development, it serves as the region's focal point and clearinghouse of HIV/AIDS information, including providing information to countries in the region. Further details about other regional strategies may be accessed from the Bank's website.[7]

Field: World Bank country-based staff, led by a Country Director, and in collaboration with host-country governments design and implement specific country projects. Although most HIV/AIDS-related activities within World Bank mission offices falls within the health portfolio, the expertise of other social and economic sectors may be included in order to facilitate a multi-sectoral response. World Bank country-based staff works closely with staff located in the headquarters in the design and implementation of all programs.

IV. The Africa MAP: Available Funding

Since 2000, the Multi-Country HIV/AIDS Program (MAP) for Africa has committed more than $1.2 billion to increase national HIV/AIDS efforts and to support sub-regional (multi-country) HIV/AIDS programs on the continent. The Executive Directors of the World Bank initially approved $500 million for the Africa MAP Program in September 2000 and an additional $500 million in February 2002. The World Bank is also supporting four sub-regional cross border projects including the Abidjan to Lagos transport corridor as well as a project in the Great Lakes region ($107 million).

Africa MAP programs typically last between four and five years, however the Bank's commitment to "long-term efforts" to address the pandemic means that most grants are likely to be renewed. The World Bank has recently approved the first "MAP Repeater" projects for Eritrea ($24 million on June 30, 2005) and Madagascar ($30 million on July 12, 2005) and is currently preparing to renew several other grants.

V. What the Africa MAP supports

The Africa MAP initiative is dedicated to financing the HIV/AIDS strategies of recipient countries. Although the World Bank headquarters does provide general guidance for different activities for concentrated and generalized epidemics, there is no attempt centrally to prioritize activities or objectives in implementation. Instead, program priorities are determined by the World Bank country project team in conjunction with the recipient-country governments and generally align with the country's existing strategic documents, including the National AIDS Strategy, the Poverty Reduction Strategy Paper and the World Bank Country Assistance Strategy. Generally, World Bank funding is disbursed to the National AIDS Councils, although it may then be obligated to ministries, civil society organizations, private sector entities, in line with the agreement.

Africa MAP funding is available to all African countries that are eligible for International Development Association (IDA) funding[8] and meet the following criteria:

• Show evidence of a strategic approach to HIV/AIDS, developed in a participatory manner, or a participatory strategic planning process underway, with a clear roadmap and timetable;
• Demonstrate the existence of a high-level HIV/AIDS coordinating body, with broad representation of key stakeholders from all sectors, including people living with HIV/AIDS;
• Exhibit Government commitment to quick implementation arrangements, including channeling grant funds directly to communities, civil society, and the private sector;
• Agreement by the government to use multiple implementation agencies, especially Non-Governmental Organizations (NGOs) and Community Based Organizations (CBOs) to meet HIV/AIDS program objectives.

Unlike other funding mechanisms, which tend to organize HIV/AIDS programs around types of activities or objectives, in most MAP projects components are organized around the funding of an implementing entity--the public sector and civil society, for example. Of the first 24 Africa MAP projects, only four have components that reflect organization around the type of activity or objective.

Two examples of MAP projects in Africa help to clarify how World Bank funding for HIV/AIDS is based on country priorities and tends to focus on supporting implementing entities rather than specific activities:

An IDA loan of 42 million was committed in 2002 for 5 years to support the Zambia National Response to HIV/AIDS Project (ZANARA). This MAP project aims to reduce the spread of HIV/AIDS, to mitigate the socio-economic impact of the disease, and to increase access to care and support for people infected or affected by the HIV/AIDS epidemic in Zambia. The project characterizes itself as a financing mechanism for high priority interventions for which significant funding gaps exist. Its funds are divided across four areas:

1) Community-Based Organizations (CBOs); for community-level responses
2) National AIDS Council and Secretariat;
3) Line ministries, to mainstream HIV/AIDS related activities into their work programs and the Health Ministry, for implementation activities; and
4) Program administration.

In Burundi, the MAP project adapts itself to support a multisectoral response with a special focus on orphans, reflecting Burundi's priority for orphans and vulnerable children. In 2002, an IDA loan of 36 million was approved for a period of 4.5 years for the Multi-sectoral Control and Orphans Project. This loan supports the national program as described in Burundi's Action Plan for the Struggle Against HIV/AIDS for the period 2002-2006. The funds mainly support activities involving line ministries, civil society, private enterprises, and labor unions, in addition to women and youth, and NGOs. The project's goals include:

1) strengthening the public sector response to the HIV/AIDS crisis, by supporting selected activities, particularly for implementing the national medical waste management plan, and for prevention, mitigation, and capacity building;
2) increasing civil society response by supporting capacity building for NGOs and CBOs and firms (the last including prevention strategies for employees and their families);
3) supporting the placement of orphans with their extended families or with unrelated families (Orphans receive scholarships for primary education and vocational training, while the economic and nutritional status of their foster families are strengthened through investments and income generating activities);
4) strengthening the capacity of public and private agencies involved in the design and implementation of the control program, by supporting coordination activities and by developing quality monitoring and evaluation standards and practices; and
5) increasing project coordination by supporting operational costs, technical assistance, and supplies and equipment as required.

Further details of each MAP project in Africa and what it supports may be accessed from the MAP webpage on the World Bank's website.[9]

VI. How the Africa MAP Provides Funding

The Africa MAP provides all funding directly to the National AIDS Councils, who are then responsible for disbursing the funds to Government Ministries, community organizations and/ or service providers according to an agreed-upon plan.

Source: World Bank HIV/AIDS Program: A Guidance Note on Disbursement Procedures[10]

The Africa MAP projects[11], like all other Bank projects, are initiated, negotiated, approved and funded in a series of steps as outlined below:

1) Project Initiation: Prior to any lending activity, the Bank helps governments take the lead in preparing and implementing development strategies. In low-income countries, the Bank uses the Poverty Reduction Strategy (PRS) approach. The government (in theory) determines its own priorities from this process and produces targets for reducing poverty over a three to five year period. The Bank and other aid agencies align their assistance efforts with the country's strategy. The Bank also creates a blueprint for its work with a country in the form of a Country Assistance Strategy (CAS) which, in the case of low income countries, is derived from the priorities contained in the country's PRS Paper;
2) Project Identification: Bank teams work with the government to identify projects which can be funded as part of the agreed development objectives in the CAS. If an HIV/AIDS project has been identified, the Bank team creates a Project Concept Note (PCN) which is a short internal document that outlines the basic elements of this project, its proposed objective, likely risks, alternative scenarios to conducting the project, and a likely timetable for the project approval process;
3) Project Preparation: This step is driven by the country that the Bank is working with and can take anything from a few months to three years, depending on the complexity of the project being proposed. The Bank plays a supporting role, offering analysis and advice where requested. During this period, the technical, institutional, economic, environmental and financial issues facing the project will be studied and addressed - including whether there are alternative methods for achieving the same objectives;
4) Project Appraisal: The Bank is responsible for this step; Bank staff review the work done during identification and preparation, often spending three to four weeks in the client country. The Project Appraisal Document or the PAD is prepared at this step; and,
5) The Negotiation and Approval Phase: After project appraisal, the Bank and the country negotiate to finalize the project. When both sides come to an agreement on the terms and conditions of the loan, the PAD or the Program Document (PGD), along with other documents are submitted to the Bank's Board of Executive Directors for approval. The appropriate documents are also submitted for final clearance to the borrowing government. Once both parties approve the project, the loan agreement is formally signed by their representatives and the loan or credit is declared effective, or ready for disbursement.

Detailed information about the full project cycle from initiation to funding and all the way to evaluation may be obtained from the World Bank's web page on Project Cycles.

VII. The Africa MAP: Results Measurement[12]

Since 1998, the World Bank has placed more emphasis on evaluating the results of its lending programs in terms of impact rather than by measuring input levels. Several tools are used to carry out evaluations that focus on the effectiveness of individual projects including Implementation Completion Reports and Project Performance Assessment reports. Wider reviews of the Bank's work in entire countries and economic or social sectors of operation are also conducted, and these include Country Assistance Evaluations, Sector and Thematic Reviews and Process Reviews. Under the Bank's Disclosure Policy (pdf), many of these reports and evaluations are available to the public. Additional information about these documents may be obtained from the World Bank's web page on Measuring Results.

More specifically for MAP projects, the monitoring and evaluation (M&E) plans for individual grants are described in the Project Appraisal Documents (PADs).[13] Many of the PADs include specific indicators for monitoring and evaluation of output, process and outcome indicators, although there does not appear to be consistency in this area across grants. Some PADs include reporting requirements for impact indicators, although many do not due to the short tenure of MAP project (often 4-5 years) and difficulty with attribution. No information is available about how the indicators are measured and what data are provided.

Slow progress in designing and implementing (M&E) systems was recognized in the first joint World Bank and UNAIDS progress review mission in June/July 2001, at which time it was recommended that M&E functions be outsourced and M&E plans be finalized during project preparation. To date, however, only one project (Malawi) has a separate monitoring and evaluation component. To help Task Team Leaders and country counterparts address this weakness, the World Bank has (a) developed an operational guide for program M&E and (b) created special M&E country assistance capacity in the form of the Global Monitoring and Evaluation Support Team (GAMET), based at the World Bank.

VIII. Analyses written about the Africa MAP

Because World Bank and Africa MAP programs are ongoing and fit within the larger scope of World Bank lending for development there have been few comprehensive analyses of the strengths and weaknesses of the programs and program approaches. The most recent evidence comes from the World Bank's Independent Evaluation Group (IEG) (previously called the Operations Evaluation Department (OED)) who recently conducted an evaluation of World Bank HIV/AIDS programs.

Internal Reviews/ Evaluations:

1. OED Evaluation: Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance, World Bank, 2005
2. OED Evaluation Background Paper: Review of National HIV/AIDS Strategies for Countries Participating in the World Bank's Africa Multi-Country AIDS Program (MAP), 2005 (pdf)
3. Multi-partner Evaluation: Interim Review of the MAP Program for Africa. World Bank, October 2004 (pdf)

External Evaluations/ Commentaries:

1. Global Fund-World Bank HIV/AIDS Programs: Comparative Advantage Study, Alexander Shakow, 2006 This independent review was jointly commissioned by the World Bank and the Global Fund, in response to the Global Task Team's recommendation to improve coordination among multilateral donors. The review highlights comparative advantages (pdf) of the Global Fund and of the World Bank.

IX. Useful links

• Global HIV/AIDS Program of Action
• World Bank Commitments and Disbursements
  An excel file, listing all active and recently approved HIV/AIDS projects with funding of at least US$1 million for HIV/AIDS. Includes date approved, type and amount of financing committed, and disbursements to date. Updated monthly.
• Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis (pdf)
  Regional Strategy for Africa, 1999.
• Multi-Country HIV/AIDS Program (MAP)
• About ACTAfrica

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[1] The author benefited from the contributions of Celina Schocken and Myra Sessions, both of the Center for Global Development
[2] Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance, An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control, The World Bank, 2005. Pg. 12
[3] The World Bank's Global HIV/AIDS Program of Action. The World Bank, 2005 Pg. 26
[4] Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance, An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control, The World Bank, 2005. Chapter 4, Pg. 43
[5] The World Bank Global Program Website (Accessed April 3, 2006)
[6] Each project is handled by a Task Team Leader who has overall responsibility for the project from inception to completion, including monitoring, procurement and consultant selection.
[7] Regional Program Website
[8] The International Development Association (IDA) is the part of the World Bank that provides subsidized loans and grants to the world's poorest countries.
[9] World Bank Projects and Programs Website
[10] World Bank Loan Department with the World Bank Global HIV/AIDS Program; World Bank HIV/AIDS Program: A Guidance Note on Disbursement Procedures; p. 7.
[11] "Project" is used in the context of a World Bank project for a loan or grant to a specific country, and not as a country level program or set of activities.
[12] Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance, An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control, The World Bank, 2005. Chapter 4
[13] See Projects and Programs website for a list of the Africa MAP Project Appraisal Documents (PAD) that serve as the plan for a specific World Bank Project