91814 the world bank BOTSWANA & HIV/AIDS: Innovative Financing Underpins Ibrd Support to Botswana’s Fight Against Hiv/Aids IBRD Results Synopsis Botswana’s HIV/AIDS epidemic has affected nearly one quarter of the country’s population, and IBRD has formed a partnership with the government to boost prevention efforts across the country. The proj- ect is in its infancy but has already introduced a new financial instrument, supported by the European Commission, which promises flexible and cost-effective support for a range of prevention efforts under the project. Challenge (BNAPS) Project. This project became operational in July 2009 and is making gradual progress toward its objec- tive: to assist the government of Botswana in increasing Botswana is affected by the second most severe HIV/AIDS the coverage, efficiency, and sustainability of targeted and epidemic in the world, after Swaziland. The scale of the evidence-based HIV/AIDS efforts. It aims to strengthen human cost of the epidemic is immense. AIDS-attributed institutional management and coordination capacity, and mortality in Botswana increased from 4 percent to 27 per- finance strategic and innovative HIV/AIDS-related pre- cent of all reported deaths between 1992 and 2003 and the vention and mitigation activities. national prevalence rate among adults of 15–49 years is now estimated at 24 percent, and a total of 283,000 people, Key indicators used to monitor the project, with a special out of a population of more than 1.8 million, were living focus on the institutional capacity of the National AIDS with HIV.AIDS in Botswana in 2008. Key factors fueling Coordinating Agency (NACA) and on the performance of the HIV/AIDS epidemic include the incidence of multiple the civil society and private sector component, include the concurrent sexual partnerships, the incidence of unprotect- following: ed sex and inter-generational sexual relationships, higher vulnerability among women, persistent inequality and pov- ÔÔ Performance of NACA assessed by NACA’s beneficia- erty, and high levels of population mobility. The impact of ries and of the technical advisors within NACA twice this sweeping epidemic has already undermined the very during the project (year 2 and 4); significant socioeconomic development achievements real- ÔÔ Proportion of sexually active males and females who re- ized over the past three decades. port having had sex with more than one partner in the past 12 months by age group: (a) 15-to-19 years; (b) 20- Results to-24 years; and (c) 25-to-49 years; ÔÔ Proportion of youths aged 15-to-19 years and 20-to- 24 years who both correctly identify ways of preventing The IBRD is supporting Botswana’s efforts to contain and the sexual transmission of HIV and who reject major reserve the spread of the HIV/AIDS epidemic through misconceptions about HIV transmission; the Botswana National HIV/AIDS Prevention Support March 2010 2 HELPING BOTSWANA CONFRONT A CHALLENGING FUTURE ÔÔ Proportion of youth aged 15-to-19 years and 20-to-24 years reporting either (a) no sexual activity; or (b) con- Partners dom use during the last sexual encounter with a non- The European Commission (EC) has also agreed to support regular partner in the past 12 months; and the financing of this project by helping reduce the interest ÔÔ Proportion of people 15-to-19 years and 20-to-24 rate cost to Botswana of the BNAPS buy-down loan. The years who report a sexual partner with more than 10 EC has approved an additional a €14 million (US$20 mil- years age difference during the last 12 months. lion) in its next four year Economic Development Frame- work to support Botswana’s access to the IBRD loan. Critically, the EC has agreed to provide its funds directly to Approach Botswana’s Ministry of Finance and Development Planning once performance targets are achieved, ensuring swift and The BNAPS project has been designed to address the stra- direct support. tegic and implementation gaps identified in Botswana gov- ernment’s response to HIV/AIDS, including its focus on In recent years, Botswana’s HIV/AIDS program has been prevention as a national “survival strategy”. The BNAPS supported by a few international donors, including the project additionally has been developed to support and cat- Global Fund Against AIDS, Tuberculosis, and Malaria, the alyze the implementation of the new National Operational U.S., other selected bilateral agencies, the Bill & Melinda Plan for Scaling-Up HIV Prevention in Botswana. The Gates Foundation, and Merck, an international pharmaceu- plan focuses on prioritization of targeted activities to the tical company. However, even the combined levels of donor most-at-risk-populations with the greatest potential impact and government spending have not kept pace with the ris- for preventing new HIV infections. It also enables a corre- ing cost of the response to the epidemic. Botswana’s gov- sponding prioritization regarding national resource alloca- ernment requested the IBRD operation in anticipation that tion. Overall, the project’s focus is on prevention within the these additional financial and technical resources would broader context of the government’s national plan for com- play a strategically significant role in supporting a more ef- bating the epidemic. ficient and evidence-based response to the epidemic. This was particularly so given the Bank’s comparative advan- tage in the areas of strategic planning, knowledge-sharing, IBRD Contribution implementation support, and the leveraging of additional resources. IBRD is supporting Botswana’s fight against HIV/AIDS with a US$50 million loan facility, known as a “buy-down” Given the magnitude and long-term impact of the epidem- program. This particular IBRD loan financing mechanism ic, another focus of the proposed operation will be to en- was developed to increase the flexibility and cost efficiency able a transition from an “emergency” response to a broader, of funding for projects tackling these kind of cross-border more strategic, and more sustainable approach. Addition- challenges. To date, the buy-down mechanism has been ally, in partnership with the government, the World Bank piloted on an IBRD project to support tuberculosis con- will seek to establish regular, collaborative development trol in China. This instrument relies on donor resources to partner forums towards facilitating a more synchronized, lower the cost of an IBRD loan targeted at a priority health complementary, and effective response. program. The release of donor funds is dependent on proj- ect performance, as measured against jointly-agreed indica- tors and targets. Given that its upper middle-income status excludes Botswana from the World Bank’s interest-free or Next Steps low interest rate IDA resources, Botswana asked that the The BNAPS Project is in its first year of a 5-year implemen- BNAPS project be financed utilizing this new IBRD facil- tation period. The government, with support from IBRD ity. IBRD RESULTS 3 and other development partners, has mobilized different evidence-based policymaking in the health sector through a sectors (Including health, transport, and education), civil modest agenda of research and evaluation at the Ministry of society organizations, and communities to increase their Health. By relying on local groups and specialists in build- capacity to respond to the demands of the HIV/AIDS ing this critically-important technical and institutional ca- epidemic. Although the project is a modest contribution pacity, it is expected that the core elements of the BNAPS to the overall national response, it provides focused assis- effort will continue well after the five-year project lifespan. tance of institutional strengthening, especially in key areas such: as fiduciary management and results reporting among learn more civil society organizations; strategic planning and monitor- ing and evaluation; managing targeted technical activities NACA: in participating ministries and government agencies; and www.naca.gov.bw/