A team from the World Bank, DFID, UNAIDS and MAP International carried out an Interim Review of the first phase of the Multi-Country HIV/AIDS Program for Africa (the MAP Program) in January/February 2004. It visited projects in six countries: Benin, Burkina Faso, Ghana, Malawi, Mozambique and Sierra Leone.
The principal objective of the review was to assess (i) the continuing viability and appropriateness of the objectives, approach and design of the MAP program, (ii) progress in its implementation, and (iii) the effectiveness of the Bank, and to draw lessons of experience to help guide preparation of the future MAP program. Given the significant changes in the overall environment for HIV/AIDS prevention, care and treatment since 2000, the Review team focused particularly on recommendations for adaptation of the Program to enhance its effectiveness.
The principal conclusions of the review:
Objectives, Approach and Design
- The objectives, approach and design of the MAP Program have generally been appropriate
- The original objectives are in the process of being realized
- Experience with implementation of individual projects and sub-projects has been mixed and often disappointing
- However, most projects are new and need time to mature
- The context for dealing with the HIV/AIDS epidemic in Africa has changed significantly since the Program was launched in 2000
- Consequently, the future MAP program will need to become more strategic, collaborative and evidence-based.
The original objectives of the MAP Program were appropriate: raising awareness, commitment and resources for HIV/AIDS, supporting a multi-sectoral approach, stressing community mobilization and using alternative means to channel funds.
The approach has been very innovative for the Bank: flexible, open-ended, quick, client-driven, collaborative. In less than four years, just over $1 billion has been committed to 28 countries in sub-Saharan Africa. By almost any measure, in its concept and design, the MAP Program has been a major achievementвЂ”the largest single commitment to HIV/AIDS ever undertaken by the Bank.
There is positive experience in most projects. Disbursement levels overall are now comparable to health and social sector projects at the same stage of implementation. The community-based interventions appear to be the best performing component, suggesting the existence of some local capacity. At the same time, implementation of individual projects has been rather disappointing and in some cases inadequate. The team noted several common problems:
The Changing Context
- There is no fully operational national monitoring and evaluation system in place in any country and little incentive to establish one, with other donors insisting on separate mechanisms
- The governance aspect of the national response is troubling. National HIV/AIDS Councils (NACs) are not providing consistent leadership and oversight. NAC Secretariats have often become implementation agencies rather than coordinators and facilitators. There is no real accountability to the general public. Moreover, not all donors use a common structure. The
Global Fund, for example, currently has a separate country coordinating mechanism (CCM) to submit proposals for funding
- Procedures for approving community-based programs often involve a multi-tiered maze of approvals with opportunities for rent-seeking. Delays of six to nine months are not uncommon. Frustration levels among civil society partners in these circumstances is high
- The multi-sectoral approach is often pro forma, with almost identical action plans by ministries focused in the initial stages on workplace programs rather than beneficiaries, and
- The health response has generally been weak. Most Ministries of Health have been slow to respond to the epidemic and some have actually felt disempowered by the MAP approach.
There have been major changes in the overall environment for tackling the HIV/AIDS epidemic in Africa since the MAP program was initiated in 2000. Major new funding has been committed by the Global Fund, the US PEPFAR initiative, private foundations and others. There is an intense emphasis on treatment, with many questions about the pace of increased access tied to strengthening
health service delivery in both the public and private sectors. Information on the epidemiology of the disease and behaviors is growing but data on the coverage, reach and quality of HIV/AIDS services is still inadequate. Lessons of experience on effective interventions are emerging from the MAP Program and others. These developments have important implications for the future MAP
The Future Strategic Direction of the MAP
To help ensure a coordinated response to the epidemic, UNAIDS has formulated the principle of "The Three Ones": one national authority for HIV/AIDS, one strategic framework and one M&E system. A principal goal of the MAP Program is to help realize this vision and improve the national response, by working to strengthen governance, promote the new generation of strategic frameworks
and implement a common national monitoring and evaluation system usable by all partners.
Specifically, the MAP program should:
With a more effective, single system in place for coordinating the national response, future MAP projects can be more effective, tailored to the unique circumstances of individual countries. While retaining the flexibility and openness of the original projects, the next generation can be more focused on results and provide incentives for effective performance. They can also be designed more explicitly in conjunction with a broader health and social sector response contained in poverty
reduction strategies and programs. Specifically:
- Support the new strategic frameworks. Many countries are beginning to revise their national strategies. The Bank and its partners can help ensure the new generation of national strategic frameworks are evidence-based, action-oriented, prioritized, costed and useful as a management tool. They should be developed with the full participation of the civil society
and external partners committed to operating within the common framework
- Help improve governance and accountability. The MAP Program and its partners can also help strengthen the performance and accountability of a single national authority, by ensuring NAC Secretariats respect their role as facilitators, promoting transparency and accountability of the NAC and NAC Secretariat to the public, improving incentives for performance and integrating separate mechanisms for project development and implementation into one overarching organization
- Ensure development of a common M&E system. Fully operational national M&E systems to serve all partners should be in place by the end of the first MAP project and a condition for any future commitment by the Bank. Funds for M&E should have a separate, non-fungible budget.
To be able to play this broader strategic, collaborative and differentiated role, the Bank can improve its own effectiveness, strengthening internal technical capacity to support MAP Projects, particularly in the areas of M&E, communications and institutional design. Locating task team leaders (TTLs) in country offices demonstrably helps build the trust and effective partnerships that are essential to this highly collaborative approach to the epidemic.
- Incentives for performance. To encourage achievement of results, future projects should incorporate explicit incentives to encourage and reward good performance. In collaboration with other partners and using the unified M&E system, a performance-based approach linking disbursements to agreed goals and indicators should be considered
- Differentiated projects. New projects can be tailored to the unique epidemiological, economic, behavioral and social circumstances of individual countries. Where other donors are focused on their own explicit priorities (such as treatment), the Bank can use the flexibility of the MAP approach to serve as the "donor of last resort," filling funding gaps in the national response
- The health sector response. Future programs should take the overall needs of the health sector into account, with direct support to the Ministry of Health where appropriate and in collaboration with other interventions by the Bank and others within the framework of the poverty reduction and health sector strategies for the country.