Multi-Country HIV/AIDS Multi-Country HIV/AIDS Program for AfricaProgram for Africa

--Disseminating Good --Disseminating Good Practices--Practices--

Miriam SchneidmanWORLD BANK

MAP Consultation WorkshopADDIS ABABA, February 15, 2005

Overview of Presentation

• Background

• Rationale

• Vision & Design

• Key Challenges

BACKGROUND “Learn by doing”

approach requires good documentation & transfer of experiences and knowledge

Learning initiatives are often fragmented & it is not easy to learn from many good examples

Pressures on Bank & Clients to show results and demonstrate impact

Enormous opportunities to take advantage of initiatives underway (UNAIDS, WB)

RATIONALE• Documenting best practices

facilitates sharing of experiences, drawing lessons, & improving effectiveness of investments

• Empowering clients to create, share & apply knowledge enhances ownership

• Informing key stakeholders internally and externally about MAP-funded activities

through learning lealearninglearning from MAP investments

through research & evaluation

with partners across countries

through improved interventions

with our partners in country public, private & civil society

and learning from our successes &and & failures

Sharing Knowledge

Creating Knowledge

Applying Knowledge

VISION OF MAP LEARNINGVISION OF MAP LEARNING

MAP II Preparation in Madagascar

Bank Resear

ch

ACT Africa

World Bank MAP Network of World Bank MAP Network of Practitioners in ActionPractitioners in Action

UNICEF                                                                                     

                                 

Global AIDS Unit

DESIGNING CASE STUDIES Capturing “what

works” and why through case studies will inform investments & avoid reinventing the wheel

Collecting information systematically will facilitate task of producing comparable case studies

Using participatory approaches which involve stakeholders will be more empowering

Establishing mechanisms for analyzing results and modifying what is funded as a result is critical to the learning process

UNAIDSBest Practice Collection

Series of UNAIDS information materials that promote learning & sharing experiences among those engaged in expanded response

Provides voice to those combating epidemic

Provides information about what has worked for benefit of those facing similar challenges

Provides state of the art knowledge on prevention, care and impact alleviation

Stimulates new initiatives to scale up response to HIV/AIDS

Represents a UNAIDS interagency effort in partnership with other organizations & parties

UNAIDS Best Practice Case Study Criteria

EFFECTIVE: success of practice in producing desired outcome and its impact on HIV/AIDS

RELEVANT: intervention responds to a given setting and respects cultural & traditional norms

ETHICAL: intervention follows acceptable social & professional conduct

COST-EFFICIENT: relationship between costs & results

REPLICABLE: ability of program to be adapted to other settings

SUSTAINABLE: ability of program to continue after external support has ended

”Millions Saved” Selection Criteria

SCALE: National, regional or global

DURATION: At scale for at least five years

COST-EFFECTIVENESS:Used cost-effective intervention

IMPORTANCE: Addressed health condition of public health significance

IMPACT:Had a large positive impact on public health

”Millions Saved” Preventing AIDS in Thailand

Health Condition: At the end of the 1980s, HIV was a growing threat in Thailand, particularly among “sentinel” groups such as sex workers. Between 1989 and 1991, the proportion of brothel-based sex workers infected with HIV rose from 3.1 percent to 15 percent

Intervention or Program: In 1991, the National AIDS Committee led by Thailand’s prime minister implemented the “100 percent condom program,” in which all sex workers in brothels were required to use condoms with clients. Health officials provided boxes of condoms free of charge, and local police held meetings with brothel owners and sex works

”Millions Saved” Preventing AIDS in Thailand

Impact: Condom use in brothels nationwide increased

from 14 percent in early 1989 to more than 90 percent by June 1992

An estimated 200,000 new infections were averted between 1993 and 2000

The number of new STI cases fell from 200,000 in 1989 to 15,000 in 2001

The rate of new HIV infections fell fivefold between 1991 and 1993-95

Cost and Cost-Effectiveness: Total government expenditure on the national AIDS program has remained steady at approximately $375 million from 1998 to 2001. This investment represents 1.9 percent of the nation’s overall health budget

Benin MAP:--Using voodoo leaders to disseminate messages about

HIV/AIDS & stimulate the demand for VCT--

EFFECTIVE: increased demand for VCT and improved awareness of HIV/AIDS among voodoo leaders

RELEVANT: intervention creatively uses cultural & traditional norms to disseminate messages about HIV/AIDS

ETHICAL: intervention appears to follow acceptable social & professional conduct

--Mobilizing voodoo leaders--

COST-EFFICIENT: relationship between costs & results needs to be verified

REPLICABLE: general approach of coupling HIV/AIDS messages with provision of VCT being replicated to other settings

SUSTAINABLE: ability of program to continue after external support has ended is uncertain

Benin MAP:

EFFECTIVE: Expanding quality of life and longevity for

PLWHA with roughly 1000 patients under ART

Getting good treatment success with an adherence rate of 95%, which is line with international norms

Having a positive impact in terms of averted number of OVCs but ultimate impact on prevention and epidemic remain to be assessed

RELEVANT: majority of patients (70%) are female who are disproportionately affected by the epidemic; program targeted to remote areas, ensuring pro-poor focus

ETHICAL: patients selected by therapeutic committee; provision of ART is done in confidential manner, according to norms and protocols issued by TRAC and follows social & professional ethical practices

Rwanda MAP:-- Providing life saving ART to patients in underserved provinces at highly subsidized prices within the context of the national plan --

COST-EFFICIENT: collaboration with CF has generated important savings on drugs & diagnostics, allowing MAP to fund a higher number of patients than planned at appraisal

REPLICABLE: provincial model of ART care developed under the MAP is now being replicated and scaled up with other donor funds (PEPFAR, GFATM)

SUSTAINABLE: ability of program to continue after external support has ended is good in terms of ‘institutional sustainability’ but probably less so in terms of ‘financial sustainability’

Rwanda MAP:

EDOUARD’S EXPERIENCE WITH ART 

In 2002 Edouard, a 36-year old male, suffered from frequent episodes of opportunistic

infections. He was treated for meningitis, TB, pneumonia and skin infections. By 2004, when the IDA-funded ARV program started at Butare

Hospital, his weight plummeted to 35 kilos. The father of two was completely bedridden and needed to be looked after by his HIV+ wife.

Following the initiation of ARV treatment Edouard’s weight rose to 56 kilos and the CD4

count bounced up to about 650. Even though he experienced side effects initially after 3 months these were under control. Edouard was able to

take advantage of the government’s highly subsidized treatment for ARV drugs and exams

as he, like most other Rwandans participating in the program and earning $3 days per day,

receive free treatment.

He was able to return to the fields to cultivate food for his family. Edouard’s infected wife, who had recently given birth, was referred to the ARV program to determine whether she is yet eligible for treatment. In the words of one of the nurses working at the Butare Hospital,

the “availability of life saving ARV drugs is not only providing hope to people who are

desperately ill but is also leading to a greater acceptance of PLWHA, as there is a discernible reduction in stigma associated with expanded access to ARV therapy”. Decreased stigma is

reflected in reduced number of patients reporting complaints about abusive behavior of community members, a willingness to come out

and discuss their status, and an increased demand for HIV testing.

KEY CHALLENGES Making knowledge

management under MAP operations systematic, strategic & mainstreamed

Supporting an enabling environment for knowledge management requires: Capacities & Skills Incentives & Rewards Leaders Networks

Fostering creativity & accountability and ensuring reliability of information

Building strategic partnerships (Bank/UNAIDS & others) to exploit synergies between initiatives

Enhancing Client Capacity• Recruit & train personnel in

techniques of producing and disseminating best practice case studies

• Organize workshops in country to review & discuss results of case studies

• Support networks of practitioners within & across countries to capture, organize and disseminate knowledge

Africa’s tomorrow depends on Africa’s tomorrow depends on

what we, together, do about what we, together, do about

HIV/AIDS todayHIV/AIDS today