Document of The WorldBank FOROFFICIAL USEONLY ReportNo: 31853-ER PROJECT APPRAISAL DOCUMENT ONA PROPOSEDGRANT INTHEAMOUNT OF SDR 15.9MILLION (US$24.0 MILLIONEQUIVALENT) TO THE STATE OF ERITREA FORA HIVIAIDSISTI, TB, MALARIAAND REPRODUCTIVE HEALTHPROJECT(HAMSET 11) {May 31,2005) HumanDevelopment 1 Afr-icaRegion This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosedwithout World Bankauthorization. CURRENCY EQUIVALENTS (Exchange Rate Effective April 30, 2005) Currency Unit = EritreanNafka Nafka 15.0 = US$1 USs1.512 = SDR 1 FISCAL YEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS ANC Ante-natal Care ACT Artemisinine Combination Therapy BCC Behavior Change Communication BIDHO National Association of People LivingWith HIV/AIDS BOD BurdenofDisease CCM Country CoordinatingMechanism(for the Global Fund) CDC Communicable Diseases Coordinator CDD Community DrivenDevelopment CMHRP Community ManagedHAMSETResponseProgram CMT Community Management Team CPAR Country Procurement Assessment Review CPPR Country Portfolio Performance Review csw Commercial Sex Worker DHS Demographic and Health Survey DOTS Direct Observed Treatment Strategy EmOC Emergency Obstetric Care FBO Faith-Based Organization FGM Female GenitalMutilation FMR Financial MonitoringReport GDP Gross Domestic Product GFATM Global Fundfor HIV/AIDS,Tuberculosis and Malaria GoE Government of Eritrea HAART Highly Active Anti-retroviral Therapy HAMSET HIV/AIDS,Malaria, SexuallyTransmittedInfections andTuberculosis Project HAMSETI1 HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject HCWMP Health Care Waste Management Plan HMIS HealthManagement Information System HPU HealthPromotion Unit HRH HumanResources for Health ICR ImplementationCompletion Report IDA InternationalDevelopment Association IMR Infant Mortality Rate I S N InterimStrategy Note ITN Insecticide-Treated Nets JAPR Joint Annual Programme Review LLIN LongLastingInsecticide-Treated Nets LMIS Logistics Management Information System LQAS Lot Quality Assurance Survey FOROFFICIAL USEONLY LSS Life Saving skills MAP Multi-Country AIDS Program MDG MillenniumDevelopment Goals M&E Monitoringand Evaluation MHMIS Modular HealthManagement InformationSystem MMR MatemalMortality Ratio MOH Ministry o fHealth MTEF Medium-Term Expenditure Framework MTR Mid-Term Review NATCoD National HW/AIDS/STI and Tuberculosis Control Division NGO Non-Govemmental Organization NMCP National MalariaControl Program NNM NeonatalMortality NSF National Strategic Framework NSP ._ _ Naiior~alstrategic Plan NSC National Steering Committee N T C National Technical Committee NUEW National Union of EritreanWomen NUEYS National Union of EritreanYouth and Students 01 Opportunistic Infection OM Operations Manual PA ParticipatingAgency PDO Project Development Objective PHC Primary HealthCare PLWHA People Living with HN/AIDS PMTCT Prevention of Mother-to-Child Transmission (of HN) P M U Project Management Unit R&HRDD Researchand HumanResources Development Department RH Reproductive Health RRI Rapid Result Initiatives SRS Southern Red Sea SSA Sub-Saharan Afnca STI Sexually Transmitted Infection SWAP Sector-wide Approach TB Tuberculosis UNICEF UnitedNations Children's Fund UNAIDS UnitedNations Programme on HIV/AIDS USAID United States Agency for International Development VCT Voluntary Counseling and Testing VHC Village Health Committee WHO World Health Organization ZHMO Zoba HealthManagement Officer ZPMU Zobal Project MonitoringUnit zsc Zoba Steering Committee ZTC Zoba Technical Committee Vice President: Gobind T. Nankani Country Directorhfanager: Colin Bruce/ Florian Fichtl Sector Manager: Dzingai Mutumbuka Task Team Leaders: Christopher D.Walker, SonNamNguyen This document hasa restricteddistributionand may be usedby recipientsonly in the performanceof their official duties. I t s contents may not be otherwise disclosed without World Bank authorization. ERITREA HIV/AIDS/STI. TB. Malaria andReproductiveHealthProject(HAMSET 11) CONTENTS Page A. STRATEGIC CONTEXT AND RATIONALE ................................................................. 4 1. Country and sector issues.................................................................................................... 4 2. .Rationale for Bank involvement ......................................................................................... 7 3. Compliance with repeater requirements: ............................................................................ 8 4. Higher level objectives to which the project contributes.................................................... 8 B PROJECTDESCRIPTION . ................................................................................................. 9 1. Lending instrument............................................................................................................. 9 2. Project development objective andkey indicators.............................................................. 9 3. Project Descriptionby Components ................................................................................. 11 4. Project Description byDiseases: ...................................................................................... 14 5. Lessons learned andreflected inthe project design.......................................................... 17 6. Alternatives considered and reasons for rejection ............................................................ 19 C. IMPLEMENTATION ........................................................................................................ 19 1. Partnership arrangements (ifapplicable) .......................................................................... 19 2. Institutional andimplementation arrangements................................................................ 20 3. Monitoring and evaluation of outcomesh-esults................................................................ 23 4. Sustainability..................................................................................................................... * . . 25 5. Critical risks andpossible controversial aspects............................................................... 25 6. Grant conditions andcovenants ........................................................................................ 28 D. APPRAISAL SUMMARY ................................................................................................. 28 1. Economic and financial analyses ...................................................................................... 28 2. Technical........................................................................................................................... 29 3. Fiduciary ........................................................................................................................... 29 4. Social................................................................................................................................. 31 5. Environment ...................................................................................................................... 32 6. Safeguard policies............................................................................................................. 33 7. Policy Exceptions andReadiness...................................................................................... 33 Annex 1:Country andSector or ProgramBackground ......................................................... 34 Annex 2: Major RelatedProjectsFinancedby the Bankand/or other Agencies .................38 Annex 3: ResultsFrameworkandMonitoring ........................................................................ 40 Annex 4: DetailedProjectDescription ...................................................................................... 53 Annex 5: HIV/AIDS/STI ............................................................................................................ 60 Annex 6: Malaria........................................................................................................................ 66 Annex 7: Tuberculosis ................................................................................................................ 70 Annex 8: ReproductiveHealth .................................................................................................. 73 Annex 9: CommunityManagedHAMSETResponse ............................................................. 85 Annex 10: HumanResourcesfor Health ................................................................................. 93 Annex 11: AnnualProgramReviews ....................................................................................... 97 Annex 12: ProjectCosts ............................................................................................................. 98 Annex 13: ImplementationArrangements ............................................................................... 99 Annex 14: FinancialManagementandDisbursementArrangements ................................. 107 Annex 15: ProcurementArrangements .................................................................................. 113 Annex 16: EconomicandFinancialAnalysis ......................................................................... 120 Annex 17: SafeguardPolicyIssues .......................................................................................... 124 Annex 18: ProjectPreparationandSupervision ................................................................... 126 Annex 19: Documentsinthe ProjectFile ............................................................................... 129 Annex 20: Statementof LoansandCredits ............................................................................ 130 Annex 21: Country at aGlance ............................................................................................... 130 Annex 22: Map (No IBRD 33403) . ........................................................................................... 133 ERITREA ERITREA HIV/AIDS/STI,TB, MALARIAAND REPRODUCTIVE HEALTHPROJECT (HAMSET11) PROJECT APPRAISAL DOCUMENT AFRICA AFTH1 Date: May 31,2005 Team Leaders: Christopher D.Walker, Son NamNguyen Country Director: Colin Bruce Sectors: Health(70%); Other social services Sector ManagedDirector: DzingaiB. (15%); Sub-national government Mutumbuka administration (10%); Central government administration (5%) Themes: HIV/AJDS(P); Other communicable diseases (P); Population andreproductive health (P); Health system performance (S); Participation andcivic engagement(S) Project ID: PO94694 Environmental screening category: Partial Assessment LendingInstrument: Specific Investment Loan Safeguardscreening category: Limitedimpact [ ] Loan [ ] Credit [XI Grant [ ] Guarantee [ ] Other: For Loans/Credits/Others: Total Bank financing(US$ m.): 24.00 ProPosedterms: - 1 Financing Plan (US$ m) Source Local Foreign Total BORROWEWRECPIENT ~. 2.00 0.00 ..__ _.- 2 00- IDA GRANTFORPOST-CONFLICT 24.00 0.00 24.00 LOCAL COMMUNITIES 0.50 0.00 0.50 Total: 26.50 0.00 26.50 Borrower: State o fEritrea Responsible Agency: Ministry ofHealth P.O. Box 212 Asmara Eritrea Tel: 291-1-2029171291-1-120297 Fax: 291-1-122899 IFY Estimateddisbursements(Bank FY/US$ m) 2005 2006 2007 2008 2009 2010 0 0 0 Annual 0.00 3.4 6.5 5.9 5.5 2.7 0.00 0.00 0.00 Cumulative 0.00 3.4 9.9 15.8 21.3 24.0 0.00 0.00 0.00 Project description[one-sentence summary of each component] The project has four components: 1. Multi-Sectoral Response (US$ 3 million): This component supports key (non-health) line ministries and civil society organizations at bothnational andzoba level to scale up prevention (especially behavior change communication (BCC) and stigma reduction), care and support interventions for HIV/AIDS/STI, malaria, TB and RH(with emphasis on mobilizing communities to utilize health services). 2. Health Sector Response (US$ 14million): This has five sub-components: HIV/AIDS/STI (US$ 3 million), TB (US$ 2 million), malaria (USS2 million), RH(US$4 million) andHuman Resources for Health (US$3 million). Each o fthe first four sub-components will comprise three activity categories: (a) Improve the informationbase for decisionmaking; (b) Scale upprevention interventions; and (c) Scale up diagnostic, treatment, care and support services; IHumanresources for HAMSETdiseases(US$ 3 million): HAMSETI1will improvehuman resources for the fight against HAMSET diseases by supporting the development and 2 mplementation o f an overall HumanResourcesfor Health(HRH)policy and strategic plan. 1. Community ManagedHAMSET ResponseProgram (US$4 million): As acontinuation of 3AMSET's Community-Managed HAMSET ResponseProgram (CMHRP), this component iimsto scaleup andconsolidatecommunity-driven initiatives to address HAMSETdiseases ncludingreproductive health. $. Project Management and Coordination, Capacity Building, M&E, and Innovation andNew Iolicy Development (US$ 3 million): This has four sub-components. :a) Project managementandcoordination (US$ 1million); :b) Capacity building (US$ 0.5 million); :c) M&E (US$ 1million); and :d) InnovationandNew Policy Development (US$ 0.5 million). Which safeguardpolicies are triggered, if any? The safeguardpolicies for Environmental Assessment OP/BP/GP 4.01) andPest Management :OP 4.09) are triggered. Significant, non-standardconditions, if any, for Board presentation: Loadcredit effectiveness: Conditions of effectiveness are: (i) the Operations Manualhas been adopted; and (ii) the Project account hasbeen openedandthe initial deposit made. Covenantsapplicable to project implementation: Other major conditions are as follows: (i) the National Strategic Plan for RHis developed and adoptedby December 31,2005; (ii) the operational plan for M&E of HAMSETdiseases i s inplace by March31,2006 (iii) the project i s implementedinaccordancewith the O M and any substantialchange inthe O M would require prior IDA approval; (iv) the project activities are implemented inaccordancewith annualwork programs which are agreedwith IDA; (v) annualjoint-reviews are conductedfor eachHAMSETdisease andmajor project components; and (vi) amid-termreview is implementedno later thanJune 30,2008. 3 A. STRATEGICCONTEXT AND RATIONALE 1. Countryandsector issues The proposed project i s the follow-on to the IDA-financed Eritrea HIV/AIDS/STI, Malaria and Tuberculosis Control Project (HAMSET) (US$ 40 million IDA credit, expected closing date March31,2006). This section highlightsthe key country and sector issues since the start of HAMSET in 2001. Country issues: Eritrea remains one o f the poorest countries inthe world with an annual Gross National Income per capita of US$ 180 and 66 percent o f the population living in poverty. Economically, it has not fully recovered from the 1998-2000 border war with Ethiopia. The current "no war, no peace" situation created by the border demarcation impasse with Ethiopia as well as well as frequent droughts continue to restrict severely the country's economic development. Eritrea's level o fhumandevelopment remains low. In2003, itranked 156thamong 177countries inthe UNDP's HumanDevelopment Index. Sector issues: Despite the challenging macro-economic environment, Eritrea continues to make great efforts to improve the health status o f its citizens, especially inreducing child mortality, fightingmalaria andcombating HIV/AIDS. Its infant mortality rate (IMR) fell from 72 deaths per 1,000 live births in 1995 to 48 in 2002, while under-five mortality rate (U5M) fell from 136 to 93 over the same period. These are well below the Sub-Saharan Africa (SSA) average o f 101 for IMR and 171 for U5M. Immunization coverage is one o f the highest in SSA, with 76 percent o f children aged 12-23 months fully immunized in2003. This represents an 83 percent improvement over the 1995 level -- at a time when immunization rates have generally been decreasing across Africa. Malaria mortality and morbidity were reduced by more than 80% in the last four years, by far the best performance in SSA. Eritrea also has one o f the best insecticide-treated nets (ITN) coverage in SSA. HIV/AIDS prevalence remains relatively low at 2.4% o f pregnant women in 2003 (compared to 2.8% in 2000). Over the same period, the number o f reported sexually transmitted infections fell by a quarter. Inthe last four years, Eritrea has initiated an excellent peer-led Behavior Change Communication (BCC) program for HIV/AIDS as well as a successful condom promotion anddistribution initiative. Blood safety has greatly improved with 100% o f blood units now screened for HIV. Notwithstanding such successes, the control o f HIV/AIDS/STI, TB and malaria -- important causes o f the burden o f diseases (BOD)-- remains an unfinished agenda in Eritrea. Reproductive health, which has strong two-way links to HAMSET diseases, is a major health problem and has not been successfully addressed. Below is a summary o f 4 the key challenges Eritrea i s facing in HAMSET diseases'. Further details can be found inAnnexes 5,6,7 and8. HIV/AIDS/STI: Compared to other SSA countries, Eritrea's adult HIV prevalence remains relatively low at 2.4% in 20032. However, the infection rate is very high in certain areas and populations. Geographically, HIV prevalence is much higher in the Assab/Tio cluster inthe Southern RedSea zone (7.2%), EdagaHamus andAkria clusters o f the Maekel zone (4.5% and 4.1% respectively) and Massawa cluster of the Northern Red Sea zone (2.9%) than the national average. Socio-economically, certain groups exhibit very high infection rates: bar, hotel or tea shop workers3 (11.9%), housemaids or servants (9.5%), military or national service personnel (6.0%) and truck/bus drivers (4.0%). Demographically, unmarried urban women aged 15-24 are disproportionately affected (8%). These facts point to (i) the need to target vulnerable groups4 and (ii) the threat o f a more generalized epidemic in urban areas. In order to avoid a full-scale epidemic, the country needs to intensify its efforts to prevent infection in vulnerable groups and transmission between vulnerable groups and the general population. Voluntary Counseling and Testing (VCT) and Prevention o f Mother-to-Child Transmission (PMTCT) still require a major scale up, especially outside the capital area. Syndromic management o f STI needs much strengthening. Treatment, care and support for people living with HIV/AIDS (PLWHA) remains limited as it is estimated that only one infive PLWHA are receivingcare and support. Malaria: The epidemiology o f malaria in Eritrea i s very complex with different transmission patterns in different parts o f the country. The successful malaria control program has made Eritrea one o f a few countries likely to meet both the Abuja Targets and the Roll Back Malaria Goals. However, without continued vigorous control efforts, there is a significant risk o f malaria outbreaks, especially as Eritrea's neighboring countries are less successful in fighting malaria. In 2004, only 7.5% o f under-five children with fever presented to health facilities received appropriate treatment within 24 hours according to national guidelines. The majority o f fever cases are now treated at the community level by malaria health agents, but little i s known about the quality o f such treatment. Newer technologies and tools, such as long-lasting insecticide-treated bed nets (LLINs) and Artemisinin-based Combination Therapy (ACT) are under evaluation and will need to be deployed appropriately. Efforts must be redoubled to target the most vulnerable, particularly pregnant women, under-five children, non-immune populations andpeople living inhigh-transmission areas. Fromthis point onward, inthe context of HAMSET 11, the term "HAMSET diseases" denotes HIV/AIDS, STI, TB, malaria and reproductive health diseasesand conditions. Ministry ofHealth of Eritrea, 2004. HIV Prevention Impact inEritrea: Results from the 2003 Round o f HIV Sentinel Surveillance. Asmara, Eritrea. There are currently no statistics ofthe HIV/AIDSprevalence rate among commercial sex workers (CSW). I t is likely that some o f the hotelhadtea shops workers engage incommercial sex. InEritrea, vulnerable groups at ahigher riskofHIV/AIDS/STI infection include the followings: CSWand their clients; bar, hotel and tea shop workers; national service personnel, truck drivers and young unmarried urban women. The spouses of these groups are thus also vulnerable. 5 Tuberculosis: In 2004, MOH reported Direct Observed Treatment Strategy (DOTS) population coverage o f SO%, a case detectionrate o f 70% and a treatment success rate o f 82%. However, the TB recording and reporting system is not reliable and such statistics might not reflect the actual situation o f TB control in Eritrea. The low proportion of smear positive cases (19%) and high proportion o f smear negative pulmonary cases (43%) suggest problems with smear microscopy as well as over-reliance on radiology for TB diagnosis. The TB control program has been affected by inadequate capacity, weak supervision, and lack o f quality assurance as well as a limited information base for decision making. For these reasons, progress in TB control progress i s lagging behind that inmalaria andHIV/AIDS/STI. Reproductive Health: In2002, while 70% o f pregnant women had at least one ante-natal care (ANC) visit, only 28% were delivered by a skilled birth attendant. A very low 8% o f women in the reproductive age used modem contraceptive methods. The harmful practice o f female genital mutilation (FGM) remains widespread with 85% prevalence in 2002. Accessibility, availability and quality o f emergency obstetric care are limited. As a result, the matemal mortality ratio (MMR) remains very high at 998 per 100,000 live births, above the Sub-Saharan African (SSA) average. Disparity in reproductive health (RH) outcomes is large, with MMRinthe SouthernRed Sea (SRS) zoba 30 times higher thanthat inthe central zoba. Insummary, Eritrea's RHindicators are amongthe worst in SSA and RH is an important outlier among an otherwise encouraging set o f health indicators. Cross-cutting issues: The cross-cutting issues identified in the HAMSET Project Appraisal Document are still relevant to varying extents. A highly mobile and dispersed population i s a challenge for the provision o f services. The lack o f information for decision making has been addressed in malaria and, to some extent, in HIV/AIDS, but not inTB' and RH. Insufficient health financing remains a great challenge for the sector. Little information is available on the effectiveness and efficiency o f health expenditure. Coordination between the technical programs o f the MOH needs improvement, while collaboration across sectors has improved under HAMSET. Shortage o f qualified health staff, especially in remote areas, is still one o f the most critical challenges, although the Government has attempted to address this problem with (i) the establishment o f the Orotta Medical School and (ii) scaling up the training o f nurses, associate nurses, public health workers and laboratory technicians (the latter supported in part by the IDA- financed EritreaHealth and HAMSET projects). Recipient's policies and strategies: The Government o f Eritrea (GoE) has formulated a draft health sector policy, which emphasizes equitable provision ofbasic health service to its people. Priority is given to the control o f infectious diseases, especially HIV/AIDS/STI, TB and malaria, as well as the reduction o f matemal mortality. With regard to specific HAMSET disease control programs, the country has developed and i s implementing well-defined, comprehensive five-year strategic plans for HIV/AIDS/STI (2003-2007), TB (2004-2008) and malaria (the 2001-2005 plan was successfilly The on-going TB prevalence survey financed byHAMSET, once completed, will provide critical informationfor TB control. 6 executed, the 2006-2010 plan has been adopted). These strategic plans provide the framework for the HAMSET project's support. A draft National Sexual and ReproductiveHealthPolicy hasjust beenprepared. Recipient's commitment and actions: The Government is strongly committed to improving health in general and to the fight against HIV/AIDS/STI, TB and malaria in particular. This is a critical element behind Eritrea's achievements in child health, malaria and HIV/AIDS as discussed above as well as the successful implementation o f the on-going HAMSET project. HAMSET is the best performer in IDA's portfolio in Eritrea. It also compares favorably with other IDA-financed Multi-Country AIDS Program(MAP)projects inthe region. The Mid-Term Review o f the HAMSET project concluded that the Government has made impressive progress in the multi-sectoral control of HAMSET diseases (especially promoting healthy behavior though multi-level communication), strengthening HAMSET diagnostic, health care and counseling services, and community-based response. The strong leadership o f the MOH and good collaboration with line ministries and civil society are key to the good performance o f this project. 2. Rationale for Bank involvement The link betweenhealth andmacroeconomics is well established. For a low-income SSA country like Eritrea, the rationale to combat HIV/AIDS/STI, TB, malaria and RH, all o f which are MillenniumDevelopment Goals (MDGs), i s beyond dispute. Implementation o f the HAMSET project has been successful. With the prospect o f the HAMSET credit being fully utilized soon, it is important to maintain the momentum in addressing HAMSET diseases and to scale up success. As a very poor country facing economic difficulties, Eritrea i s unable to raise adequate domestic resources for this purpose. Although Eritrea was allocated modest amounts o f US$ 8.1 million for HIV/AIDS andUS$2.6 million for malaria by the Global Fund(GFATM) under the first phase, the country receives limited extemal financing for the health sector and thus IDA support is critical. IDA's contribution to health sector development inEritrea is significant andhas evolved over the years. Both the recently closed Health project and the nearly fully disbursed HAMSET project supported the implementation o f key priorities for the sector. Policy dialogue which started within the context o f these projects has continued. Another pivotal development was the preparation o f the Health Sector Note (Report No. 28267-ER72001) which formed the basis o f the Government's health sector policy preparation. Currently, IDA is the largest external financier for the health sector as well as for the control o f HIV/AIDS, TB and malaria. Except the GFATM, other donors typically provide supporting technical assistance. The updated Interim Strategy Note (ISN) for 2005-2007 states that IDA will continue to maintain its engagement with the Government in addressing humanitarian and social vulnerability. Investing in the follow-on o f the successful HAMSET project would be part o f the effort to improve the performance o f the IDA portfolio in Eritrea. Thus, the 7 proposed project is consistent with the ISN objectives. It i s also in line with the World Bank's overall goal for health, nutrition and population inthe Africa region, which aims to help client countries achieve sustainable improvements in their health outcomes, especially for the poor. The World Bank's comparative advantages in (i) macroeconomics and health, (ii) multi-sectoral actions for health and (iii) system health strengthening can support countries inmeeting this objective6. 3. Compliance with repeater requirements: Compliance with basic repeater requirements: The on-going HAMSET Project has been rated satisfactory for implementation progress and achievement o f development objectives in all Project Status Reports since effectiveness. The Mid-term Review confirmed that: (i) the project implementationis on track; (ii) development objectives the are likely to be met; and (iii) Development Objective ratingis satisfactory. Available the information shows that impact so far has been consistent with original Project Appraisal Document (PAD) expectations. There are no unresolved fiduciary issues, or any environmental, social and safeguard problems. As discussed above, external support for health and HAMSET diseases i s limited and without a repeater project, the country will not be able to maintain the momentum, scale up interventions or address RH. Compliance with MAP repeater requirements: The National Strategic Plan for HIV/AIDS/STI was developed in2003. It reflects Eritrea's HIV/AIDS priority areas and corresponding strategies to address them. Leadership and coordination is provided by the national high level HAMSET Steering Committee in which line ministries and civil society are represented. Community grant applications have been processed within a reasonable time. The country has initiated exceptional, innovative implementation measures such as the highly-successful RapidResult Initiatives. MOH and other technical units inthe line ministries have provide good technical support for subprojects andpublic sector activities. The only requirement which the country has not fully met i s the establishment o f an operational M&E system for HIV/AIDS. This is also a weakness for most MAP projects as identified by the Interim Review o f MAP. However, progress in M&Ehas beenmade recently, such as the finalization o f the National M&E Framework for HIV/AIDS/STI. An M&E system will be fully operational under HAMSET 11, (see SectionC). 4. Higher level objectives to which the project contributes Among the MDGs, Goal 4 (improving maternal health), Goal 5 (reducing child mortality) and Goal 7 (combating HIV/AIDS, malaria and other communicable diseases) are health- related. By addressing HAMSET diseases, the proposedproject would directly contribute to all o f these goals. The addition o f the reproductive health component provides the opportunity to address two additional MDGs; Goal 4 (promote gender equality and empowerment o f women) and Goal 6 (improve maternal health). Based on the current trends, Eritrea could, with continued investment and support from development partners, TheWorld Bank. Improving Health, Nutrition, and Population Outcomes in Sub-Saharan Africa: The Role of the World Bank. WashingtonDC, 2005. 8 be one o f a very few SSA countries to achieve many o f the health-related MDGs, especially those for child mortality, malaria and HIV/AIDS. Given the clear linkage between health, poverty and economic development, the project would ultimately contribute toward achieving Eritrea's poverty alleviation and economic growth objectives. B. PROJECTDESCRIPTION 1. Lendinginstrument This project is a Sector Investment Grant under IDA'SMAP for the Africa Region. It i s the follow-on to the Eritrea HIV/AIDS/STI, MalariaandTB Control Project (HAMSET). 2. Projectdevelopmentobjectiveandkey indicators The project's development objectives are to: (i) contain the spread o f HIV/AIDS/STI in vulnerable groups as well as the general population through a focused multi-sectoral approach, with renewed attention to the most vulnerable populations; (ii)expand the coverage o f Directly Observed Treatment (DOT), improve case detection and treatment outcomes for TB; (iii) reduce or at least maintain malaria mortality and morbidity at the current low levels; (iv) improve the coverage o f effective Reproductive Health (RH) interventions; and (v) strengthen the overall health system, including humanresources for health, to enable the country to better address HAMSET diseases. As HAMSET I1 supports the priorities and activities o f the National Strategic Plans (NSP) for HAMSET diseases, the project adopts selected indicators from the NSPs as its keyperfonnance indicators. Indicators End-of-projecttarget HIV/AIDS/STI - HIVprevalence among CSWs and I - Maintain HIVprevalence under 12% pregnant women aged 15-24 among CSWs and 3% among pregnant women aged 15-24 - Syphilis sero-prevalence amongpregnant - Reduce syphilis sero-prevalence among women pregnant women from 1.6% to under 1%% - Case detectionrate - Detect at least 70% o finfectious cases in the population - Percentage o fdetected TB casesunder - Treat at least 80% o fdetected TB cases Directly Observed Treatment (DOT) with Direct Observed Treatment - Cure rate - Cure at least 85% o fnew smear positive cases - Further reduce or at least maintainmalaria - Furtherreduce or at least maintain morbidityandmortality at the current low malaria morbidityandmortality at the 2004 levels levels 9 Remoductive Health - Percentage o fpregnantwomen receiving - Increaseby20% focused ante natal care - Percentage o fpregnantwomen who - Increase from 28% to 60% deliver with skilled birth attendance - Percentage facilities with emergency - All public hospitals andhealthcenters -obstetric deaths care offer EmOC Neonatal - ReduceNNMfrom 25 to 20 deaths per -1,000 100% o ffacility-based matemal births - Matemal mortality audit Audit deaths and 50% o f community-reported matemal deaths. - ContraceptivePrevalence Rate (modem - Increase from 4% to 10% methods) - Proportion o f facilities offering post- - All public hospitals andat least 50% o f abortion care health centers - Combat gender basedharmfultraditional - Reduce FGMprevalence among female Dractices infants by 10% Human Resourcefor Health - Training outputs bykey cadre categories - Train at least 200 nurse midwives, 200 Public Healthtechnicians and 200 laboratory technicians - Proportion o fMOHemployees working - Not more than35% inreferralhospitals andat the headquarters - Proportion o fhealthstations with at least - Increase from 28% to 50% one nurse - Proportion o f facilities (hospitals and - 100% o fhospitals and 50% o fhealth health centers) conducting staff appraisal centers on an annual basis. - Instructorto student ratio into 1:15 - Development andimplementationo fthe result-based annual work plan for Research -- Reduce from 1:25 to 1:15 Percentage o f actions inthe result-based andHumanResource Development annual work planfor HumanResource (R&HRD) Development (HRD) successfully implemented. Guidingprinciples for HAMSET11: Theproject aims to: Provide flexible funding to help the GoE fill the financing gap for HAMSET diseases; 10 Support the implementation o f the National Strategic Frameworks (NSF) for HAMSET diseases7, with a renewed focus on targeting the most vulnerable groups and socio-economic "hot spots". with effective interventions; Build upon the successes and lessons o f HAMSET, scale up what works, and address unfinished agendas in HAMSET diseases and the links between them (e.g. HIV/AIDS and TB, HTV/AIDS and RH, RH and malaria, malaria and HIVIAIDS); Promote a deeper community-managed response and a more focused multi- sectoral approach; Systematically institutionalize the result-based agenda, which was successfully introducedunder HAMSET with the Rapid-Result Initiatives (RRI); Givepriority to evidence-based, effective interventions while allowing innovative implementation approaches; Strike a balance between "software" and "hardware", supply and demand measures, prevention and treatment, and support investment at the lower levels where front line services are delivered; Broadenthe evidence base for HAMSET diseases; Promote the integration o f activities at all levels by supporting the "Three Ones" approach not only inHIV/AIDS but in all HAMSET diseases, especially through (i)the development of national and local comprehensive work plans encompassing all activities, not just those funded by HAMSET and (ii) conducting annual joint-reviews o f HAMSET diseases. This i s to avoid duplication of efforts, maximize efficiency and synergy, ensure complementarity andhelp lay the foundation for a future "Sector-Wide Approach" to health sector development; and Strengthen the collaboration between HAMSET I1and other concurrent human development (HD) and non-HD operations by IDA in the country (Integrated Early Childhood Development, Education, Power Distribution and Rural Electrification, etc.) The Mid-termReview o fthe HAMSET Project, conductedinNovember-December2004, providedmajor inputs for the preparationo fHAMSET 11. 3. Project Descriptionby Components The project's total cost is estimated at US$ 26.5 million. This would be financed by a US$ 24 million ant from IDA, US$ 2 million* from the GoE and US$ 0.5 million from the communities? The project has four components: Multi-Sectoral Response (US$ 3 million): This component supports key (non-health) line ministries, and civil society organizations" at both national and zoba level to scale Inthe case of RH, the draft nationalstrategic planhasnotyetbeenfinalized. HAMSETI1wouldhelp with the finalization of the plan. * This isa tentative number. Community contributions are often in-kind. 11 up prevention (especially behavior change communication (BCC) and stigma reduction), care and support interventions for HIV/AIDS/STI, malaria, TB and RH (with emphasis on mobilizing communities to utilize health services). The multi-sectoralresponse will be more focused than under HAMSET. With technical guidance from the MOH and the Project Management Unit (PMU), multi-sectoral partners will be facilitated inidentifying evidence-based interventionstargeting vulnerable groups. Work planswill be subject to a competitive appraisal process with a set o f clear eligibility criteria that reflect the project's priorities and take into account various factors such as implementers' comparative advantages, past performance as well as their compliance with M&E requirements. There will be no "hardware" activities (e.g. construction) under this component. Where multi-sectoral partners have zoba level presence, it is expected that the majority o f resources and implementationwill be carried out at the zoba level. For both national and zoba implementers, the project will support the development, implementation and monitoringhpervision o f their annual integrated HAMSET work plans. Their preliminary work plans are to be prepared by October o f each year and finalizedby the end o fFebruary o f the following year. Health Sector Response (US$ 14 million): This has five sub-components - HIV/AIDS/STI (US$ 3 million), TB (US$ 2 million), malaria (US$ 2 million), RH(US$ 4 million) and HumanResources for Health (US$ 3 million). Each o f the first four sub- components will comprise three activity categories: (a) Improve the information base for decision making: The project will support disease surveillance and reporting, surveys and operational research. Priority is given to (i) routine disease reporting over "drop-in" surveys; (ii) activities that build up in-country capacity and make use o f existing mechanisms (e.g. Integrated Disease Surveillance system o f the MOH)" and (iii)practical operational research. For each of the HAMSET diseases, one major undertaking for the health sector response is to coordinate a mapping exercise o f high risk groups and the current coverage o f interventions to identify vulnerable populations and strategic areas for targeted interventions. (b) Scale up prevention interventions: The project will support the MOH (in close collaborating with other sectors and the communities) to scale up the successful BCC program for HIV/AIDS under HAMSET and, wherever appropriate, expand it to cover allHAMSET diseases inone integratedmessage. The project will also support other effective non-BCC prevention interventions for HAMSETdiseases. Details are elaborated in the Annexes on the project description and for each disease. (c) Scale up diagnostic, treatment, care and support services: The project aims to help the MOH improve the availability, accessibility and utilization o f quality loCivil Society organizations refer to BIDHO (an organization o f People Living with AIDS andHIV or PLWHA), NationalUniono f EritreanWomen, National Union o f EritreanYouth, NationalConfederation o f Workers and the faith based organizations. ''New important mechanisms will also be introduced, e.g. maternal mortality audits. 12 services for the diagnosis, treatment, care and support services for,HAMSET diseases. Human resources for HAMSET diseases (US$ 3 million): HAMSET I1will improve human resources for the fight against HAMSET diseases by supporting the development and implementation o f an overall Human Resources for Health (HRH) policy and strategic plan. Not limited to pre-service training, this sub-component will address other systemic HRH issues such as HRH management, coordinated HRH planning across the sector, retention and deployment, the piloting o f incentive mechanisms for HAMSET service providers, etc. By doing so, the project will contribute to increasing the number o f appropriately trained, motivated and equitably distributed health care providers for Eritrea. Although in-service training for HAMSET diseases will be the responsibility o f each technical program inthe health sector response, the Research and Human Resource Development (R&HRD) Department will play an important role in coordinating different in-service training activities to promote maximumefficiency and integration. Community Managed HAMSET ResponseProgram (US$4million): As a continuation o f HAMSET's Community-Managed HAMSET Response Program (CMHRP), this component aims to scale up and consolidate community-driven initiatives to address HAMSET diseases including reproductive health. Learning from the HAMSET experience, CMHRP will (i) empower communities to take charge o f their health through the support o f small-scale, genuinely community-managed sub-projects; (ii)promote results-based approaches such as the use o f RRI in sub-project implementation; (iii) strengthen the links, coordination, and synergies between community subprojects and activities by other HAMSET implementers; and (iv) developing the capacity o f communities to prepare and implement subprojects. CMHRP has two sub-components. HAMSET Grants for Sub-projects (US$ 3.4 million): This subcomponent will finance community-managed initiatives that directly address HAMSET diseases. Priority will be given to low-cost, effective community interventions for HAMSET diseases, especially those targeting the most vulnerable groups. CMHRP will adopt a results-based framework that is aligned with the national objectives and priorities in HAMSET diseases. An "open menu" o f activities inconjunction with a negative list will be used to help communities choose effective interventions and, at the same time, allow innovations and flexibility. Community groups, with technical support from other HAMSET I1 participating partners operating at the local level, will identify, develop implement, and sustain community subprojects. Community Mobilization and Capacity Development (US$ 0.6 million): This subcomponent will support community-based activities to: (i) mobilize communities and help them identifyandprioritize their HAMSET problems; (ii) communitycapacity build to develop and implement subprojects through skills in participatory planning, sub- project management and implementation; (iii) the RRI approach in community apply subprojects; and (iv) monitor and evaluate sub-projects, including participatory assessments to obtain feedback from beneficiaries. Capacity building activities will be 13 strategically provided by the C M H W team in collaboration with other implementing partners. Project Management and Coordination, Capacity Building, M&E, and Innovation and New Policy Development (US$3 million): This has four sub-components. Project management and coordination (US$ 1 million): This will cover the operating costs o f the existing national and zoba Project Management Units (PMU) as well as the costs for coordination o f project activities at the central level. Capacity building (US$ 0.5 million): This aims to mobilize and build the capacity o f non-health cadres (e.g. in non-health sectors, local governments and civil society) in planning, management and implementation o f project activities. The project will promote knowledge sharing and the dissemination o f best practices among the implementers. M&E (US$ 1 million): While the Health Sector Response Component supports epidemiological and behavioral surveillance, disease reporting, etc. (the outcome and impact aspects o f the overall M&E framework), this sub-component focuses on cross-cutting, operational aspects o f M&E. These include the development and implementation o f a comprehensive M&E system and the use o f data to improve program management and decision making. Details are further discussed in section C3 andAnnex 3. Innovation and New Policy Development (US$ 0.5 million): This sub-component supports the development, piloting and evaluation o f innovative approaches in service delivery which can then be used for system-wide application; for example, incentive mechanisms for service providers and users, conditional cash transfers for maternal and child health, a community report card on HAMSET services, preparation work for a possible sector-wide approach (SWAP)program, etc. 4. Project Descriptionby Diseases: HAMSET I1components are mainly organizedby implementing agencies as described above. This sectionprovides a project description by diseases. HIV/AIDS/STI Prevention: The project supports key priorities in the NSP for HN/AIDS/STI, with a renewed focus on targeting vulnerable groups such as CSWs and their clients, truck drivers, badtea houseshotel workers, conscripts and populations living in urban "hot spots". The rationale is to constrain transmission among vulnerable groups and from vulnerable groups to the general population. For this purpose, the project will support (i) a socio-geographic mapping exercise o f vulnerable groups1*; (ii)scaling up BCC, l2 Some vulnerable groups inEritrea have already been identified epidemiologically by the 2001and 2003 prevalence surveys. Socio-geographic mapping is the next step to identifythe size o f such vulnerable groups, their distribution, social networks, etc. for targeted interventions. Inaddition, mapping will help 14 condom and STI referral programs for such populations; (iii) increase the coverage and quality o f VCT services, including the possible "routine VCT" approach for selected urban hot spots (especially Assab) in which people are offered VCT services (with an "opt out" option) every time they come into contact with the health system. At the same time, HAMSET I1will continue to support efforts to raise the levels o f knowledge, good behavior and practices related to HIV/AIDS and reduce stigma inthe general population (especially through an increase in the involvement o f PLWHA in HIV/AIDS education efforts). Treatment, care and support: HAMSET I1will focus on: strengthening syndromic management o f sexually transmitted infections (STI); financing support activities which are crucial for successful highly active anti- retroviral therapy (HAART) implementation - such as management o f opportunistic infections (01),multivitaminsupplements for PLWHA, training o f health professionals in HAART, improving the laboratory capacity for HAART, procurement o fHIV/AIDS commodities and supplies (as ARVs will be financed mainly by GFATM), and strengthening logistic management information system for ARVs andAIDS supplies; care and support for PLWHA by religious groups, communities and networks o f PLWHA - the latter through facilitating the formation and effective operation o f BIDHO (the NGO o f PLWHA inEritrea) at the zoba levels (and sub-zoba levels where the prevalence is high);and care and support for AIDS orphans. Expanding the information base for decision making: HAMSET I1 will support the monitoring o f the epidemic and its determinants in vulnerable groups and the general population. Malaria: HAMSET I1will continue to support Eritrea's highly successful multi-pronged strategy for malaria control. The project's approach is to help the National Malaria Control Program (NMCP) to at least maintain the current good coverage o f key interventions as well as address the areas that need further vigorous actions as identified by the evaluation o f the implementation o f the last National 5-year Strategic Plan. The latter include the need to (i) maintain and increase the coverage and use o f ITNs, (ii) improve the management o f fever at the community and health station levels, (ii) ensure the availability and accessibility o f antimalarials and complementary drugs, (iii) identify the most effective methods o f vector control and how they can be best targeted, (iv) introduce new effective malaria control commodities such as LLINs and ACT, and (v) identify and implement the most appropriate methods for reducing malaria morbidity and mortality inpregnant women. identify the extent of other vulnerable groups such as injection drugs users (IDU) and menwho have sex with men(MSM). 15 Tuberculosis: As progress inTB control under HAMSET was not on a par with malaria andHIV/AIDS, support for the TB programwillbe one o fthe key priorities o fHAMSET 11. To achieve the project development objective (PDO) o f improving DOTS coverage, TB detection and treatment outcomes, the project will especially support: (i) strengthening o f program management capacity at both national and zoba levels, (ii) improving TB management skills for health workers, (iii)fully operationalizing the quality assurance program for TB diagnostics set up under HAMSET to reduce the high percentage o f smear-negative TB cases, (iv) ascertaining and improving the quality o f TB recording and reporting, (v) strengthening supervision and (vi) enhancing community involvement in TB control (including an evaluation o f the Community DOTS (pilots under HAMSET for scaling up). Special attention will be paid to TB supervision from central to zoba levels and from zoba to sub-zoba levels. In addition, the zoba Communicable Disease Coordinator will conduct "quarterly TB monitoring Eieetings" which will bring sub-zoba TB staff together to review TB control activities (see Annex 7 for details). Reproductive Health: HAMSET I1will support the scaling up o f a set o f critical RH interventions which aim at reducingmaternal andneonatal mortality as well as improving adolescent reproductive health. These include: (i) improving the quality and coverage o f ANC; (ii) expanding access to skilled birth attendance and emergency obstetric care (EmOC); (iii) introducing maternal death audits; (iv) child spacing to improve maternal health and child survival; (v) increasing access to PMTCT; (vi) ensuringblood safety and availability for EmOC; (vii) increasing adolescents' access to appropriate, youth-friendly RH information and services; and (viii) reducing gender based harmful traditional practices such as FGM, early marriage and inappropriatefeeding practices. The key approaches are to: (i) integrate RHwith other HAMSET diseases; (ii) strengthen community level interventions to increase awareness o f RH risks and danger signs, promote good RHpractices as well as mobilize communities for care, support, referrals andmaternal audit; and(iii) inter-sectoral activities inRH. promote Details are elaborated in Annex 8. A draft National Sexual and Reproductive Health Policy has recently been drawn andwill be put inplace by December 2005. HAMSET I1 will support the keypriorities andactivities o fthe new policy and strategic guidelines. Links between HAMSET diseases: HAMSET I1will exploit opportunities to address the close links and complex interfaces betweenHAMSET diseases, such as: HIV/AIDS and TB: TB screening and prophylaxis for PLWHA, VCT referral for TB patients, treatment o fTB/HIV co-infection, RH and TB: effective treatment and follow up o f pregnant women with TB and their children; HIV/AIDS/STI and RH: VCT services as part o f ANC, PMTCT, integrated BCC for HIV/AIDS/STI andRH ; STIand HIV/AIDS: VCT referral andBCC intervention for STIpatients; and Malaria and RH: prevention andtreatment o fmalaria inpregnant women. 16 e Malaria and HIWAIDS: provisiono f ITNs to PLWHA. A flexible step-wise approach: The project will be implemented in steps. Each step equals one year, toward the end o f which there will be ajoint-review for each HAMSET disease which brings together all the key implementers and donors to review the overall program (not just activities funded by HAMSET 11). It will review the progress for the past year and the plans for the coming year (See Annex 11 for details o f annual joint- reviews) On the basis o f such reviews, and the lessons from the upcoming Implementation Completion Report (ICR) o f HAMSETI3 as well as other studies and surveys, the project content will be amended as necessary. This approach will also allow flexibility to address new HAMSET priorities which might surface during project implementation. Project activities and costing were calculated in detail only for the first year at appraisal, but with clear agreed milestones and indicative costs for each (sub) component for subsequent years. The proposedkey tasks o f each step include: 0 Year I:Start implementationo fHAMSET 11.Complete mapping exercises o f vulnerable groups. Finalize the National Sexual andReproductive HealthPolicy and start implementationo f selected activities. Put inplace annualjoint-reviews. 0 Year 2: Fullyoperationalize the nationalM&E frameworks for HAMSET diseases. Scale up successful interventions. Conduct 2nd Lot Quality Assurance Survey (LQAS). Conduct the mid-term review toward end o fYear 2. e Year 3: Maximize scaling up o f interventions withinthe project's capacity. 0 Year 4: Conduct 3rd LQASandother evaluation. Wrap up implementationand ICR. 5. Lessonslearned and reflected in the project design HAMSET as thefoundation of the new project: HAMSET i s a success and provides a solid foundation for HAMSET 11. Key findings o f the HAMSET Mid-Term Review (MTR) are incorporated inthe design o f HAMSET I1and successful interventions such as malaria control, RRI, and BCC under HAMSET will be the basis for scaling up. Project design will be further fine-tuned as new lessons from HAMSET emerge. Key cross-cutting lessons from the MTR o f the HAMSET project include: (i)a simple, functional M&E system which incorporates regular feedback is crucial for decision makingandprogrammanagement; (ii) communities can be mobilized for disease control efforts and behavior change, but they need to take charge and community initiatives need to be genuinely community driven; and (iii) all implementers (especially those at the local levels) needto give priority to the most effective interventions. The needfor a renewedfocus on targeted interventions for vulnerable groups and their linkages to the general population: Currently, HIV prevalence in Eritrea is highly concentrated among certain vulnerable groups such as CSWs, truck drivers, badtea houseskotel workers, conscripts and those living in urban hot spots. Evidence from HAMSET shows that targeting vulnerable groups in Eritrea is feasible. For this reason, l3The ICRfor HAMSET is expectedto be completedbyJune 2006. 17 one of the key features o f the design o f HAMSET I1is a renewed focus on interventions to, halt transmission o f HIV/AIDS among vulnerable populations and between such groups and the general population. Targeted interventions are also relevant for other HAMSET conditions such as malaria and RH, where mortality and morbidity differentials between different socio-economic and ruravurban groups are large and thus focusing on the most vulnerable groups is appropriate. Successfully reaching these populations i s thus strategically vital, and requires good mapping and actions from multiple sectors andactors as well as locally drivenprograms andresponses. Other disease-specijk lessons from HAMSET: These include: (i)strengthening management capacity and technical skills of TB staff; (ii) vigorous malaria control efforts needs to be continuedto avoid the re-emergence o f malaria outbreaks as well as to reduce further malaria mortality and morbidity; (iii) links between reproductive health and the other HAMSET diseases are two-way and the latter cannot be adequately addressed without improving RH services; and (iv) the commonality and synergy o f interventions for HAMSET diseases could be further exploited, especially inprimaryhealth care. Lessons from the Eritrea Health Project: The draft ICR for the recently closed IDA- supported Eritrea Health Projectt4 emphasizes the importance o f realistic and focused project development objectives which have clear links to project components and activities (a clear input-output-outcome production chain). It also points to the need for a balance between "hardware" and "software" activities. IDA support in malaria control andblood safety under the HealthProject was shown to bevery cost-effective. Lessonsfrom the Interim Review of MAP projects (October 2004). Strategic thinking is needed in terms o f how to invest in specific activities and interventions which have the greatest impact, based on analyses o f current epidemiological and behavioral data. An evidence-based approach that strikes the balance between broad-based general public intervention and the targeting o f vulnerable groups is called for. A performance-based disbursement system should be considered to encourage good perfonners. Civil society should be fully involved in the design o f materials and procedures for grant making, application and reporting. So far, no MAP has a fbnctional M&E system where data are systematically collected and utilized for sound and evidence-based decision-making purposes. Therefore, adequate resources should be set aside to develop operational M&E systems which can provide adequate biological, behavioral and routine program activity monitoring information. Inaddition, to enhance the quality of interventions, IDA should (i) better technical offer guidance to implementation agencies on good practices; (ii) assist with developing a standard set o f quality guidelines for sub-projects; and (iii) develop greater technical support capacity, especially for scaling up local responses, strategic planning, designing national M&EandimplementingARV procurement, supply anddelivery systems. l4EritreaHealthProject (IDA credit US$21.1 million, effective May 1998, closedDecember 2004) supported (i) expansion o f secondary care intwo o fthe six regions, (ii) strengthening ruralprimary health care nationally, (iii) development o f national bloodbank services, and (iv) capacity building. 18 6. Alternativesconsideredandreasonsfor rejection Same scope as HAMSET (namely, no inclusion of RH in the project): As discussed above, this was rejected due to (i) the urgent need to address the poor RH outcomes, which are an outlier in an otherwise promising set o f health indicators; and (ii)the existence o f clear two-way links between RH vs. malaria and HIV/AIDS, which cannot be adequately addressed ifRHservices are not improved concurrently. Programmatic approach: One alternative for the project design is to take a programmatic approach (e.g. a health sector development support program) inwhich IDA would finance all o f the health sector's priorities under the MOH's strategic plan, notjust HAMSET diseases. However, such a programmatic approach would require: (i)an advanced Health Sector Strategic Plan, (ii)a medium-term expenditure framework (MTEF) for health; and(iii) acceptable levels o f transparency and accountability inhealth planningand budgeting (e.g. public expenditure review for health). The current macro- economic environment is not conducive for such an approach. However, to the extent possible in the context o f a MAP project, efforts will be made inthe areas o f planning, financing and budgeting, implementation and M&E o f HAMSET I1 to prepare a foundation on which a future SWAPoperationcan be built. C. IMPLEMENTATION 1. Partnershiparrangements(if applicable) There are only a limited number o f development partners financing activities to address HAMSET diseases inEritrea15. These include international and bilateral agencies (most notably the Global Fund, UNAIDS, WHO, UNFPA, UNICEF, World Bank, USAID, and the Italian Cooperation) and one international NGO (Norwegian Church Aid). For HIV/AIDS, coordination between partners is through the Global Fund Country Coordinating Mechanism, the HAMSET Steering Committee and the UN Working Group on HIV/AIDS. For RH, there is a strong but informal coordinating committee that meets once a month and includes all donors, UN agencies, NGOs and the MOH. In addition, the HAMSET PMU i s also managing the Global Fund resources, so coordination i s also functioning at the project management level. Under HAMSET 11, IDA will continue to collaborate closely with the other development partners to assist the GoE in implementing the "Three Ones" principle, not just for HIV/AIDS but also for the other HAMSET diseases, especially in strategic planning and M&E. For each HAMSET disease, annual joint reviews and planning led by the Government will be the main coordination mechanism to foster collaboration among partners. l5Not only are there few development partners but their total contribution to health sector financing i s small. 19 Coordinationwith other IDA Projects There are a number o f IDA-financed projects which have links to HAMSET 11.First, the Integrated Early Childhood Development Project has clear links to both the reproductive health and malaria objectives o f HAMSET as well as the CDD implementation mechanisms. Second, the Power Distribution and Rural Electrification Project is linked with the Reproductive Health activities o f HAMSET I1 through the provision o f electricity supplies to obstetric care units in the areas it covers. Third, the Education Project has links to the BCC activities for HAMSET I1diseases implemented by the 4 Ministry o f Education. Finally, the Demobilization and Reintegration Project i s a valuable partner in reaching demobilized soldiers, who are a vulnerable group for HIV/AIDS/STI. Opportunities for coordination between HAMSET I1and the above IDA projects will be exploited throughjoint planning, implementation, supervision andM&E. 2. Institutionalandimplementationarrangements InHAMSET 11, the implementation arrangements will mirror those of HAMSET, with some minor strengthening. A detailed description o f the ImplementationArrangements is presented inAnnex 13. GeographicImplementation:The project will be implementednationally inall 6 zobas (districts). Socio-geographic mapping o f vulnerable groups ineach o f the zobas will help identifyhot spots and geographic areas o f priority. Special attention will be given to (i) Asmara, Assab, Massawa and other urban' areas for HIV/AIDS/STI; (ii)Gash-Barka, Debub, Northern Red Sea and Anseba for malaria; (iii) Northern and Southern Red Sea for tuberculosis; and (iv) rural areas, especially those of Northem and Southern Red Sea zobas, Gash-Baka and Anseba for reproductive health. Strategyand Oversight: TheNational HAMSET Steering Committee (NSC), chairedby the Minister o f Health, provides strategic direction and approves the annual work program and budget for the HAMSET implementing partners. As a high level political and strategic body, the NSC will be strengthened to hold implementers accountable for resu1tsl6. Implementation: The project will be implemented by the Ministry o f Health, selected non-health line ministries, national and local civil society organizations, and community groups. Eritrea has been very effective in decentralizing project implementation with Project Coordinating committees and Project Management Units at the central and regional levels. HAMSET I1will build upon the strong implementation arrangements established under HAMSET. l6 The Global FundCountry Coordinating Mechanism (CCM), chaired by the Minister o fNational Development serves a similar function for the GFATMwork program inEritrea andhas almost an identical composition (with the exclusion o f the Zonal Administrators andthe inclusion o fUNagencies). However, it was felt bystakeholders during the MTRthat the two committees were appropriate for specific tasks, and merging themwould not add value to either HAMSET or the GFATMwork program. 20 National-LevelCoordination& Implementation: National Technical Committee (NTC): This comprises the key implementing partners at the national level. Chaired by the Director General of Health Services o f the MOH, the N T C reviews workplans and activities o f implementing partners and addresses strategic implementation and coordination issues. The PMU serves as its secretariat. To improve the authority and functioning o f the NTC, under HAMSET 11: (i) the NTC will be reduced in size (to fewer than 10 members); (ii) the members will be of a Director General level (or equivalent); and (iii) a HAMSET Technical Working (comprising HAMSET focal persons for all implementing partners) will be established to support the NTC. Line Ministries Other than MOH and Civil Society Partners: As in HAMSET, the line ministries other than M O H and civil society partners will focus their activities on target groups within their constituencies (i.e. National Confederation o f Eritrean Workers may focus on mobile construction workers, Ministry of Labour and Human Welfare on orphans and commercial sex workers, etc) through BCC, IEC and other "software" interventions. While all of the multi-sectoral partners add value to the HAMSET I1 project, some ministries and partners such as the Ministry of Defense, Ministry o f Education, Ministry o f Labour and Human Welfare, and National Union of Eritrean Women have more strategic roles to play. Other implementingpartners include BIDHO, National Confederation o f Eritrean workers, National Union o f Eritrean Youth and Students, Ministry o f Local Government, Ministry o f Information, Cultural Affairs Bureau, Faith Based Organizations, Ministry o f Transport and Communications, and other partners that may become active during the project cycle. Ministiy of Health: Many o f the units of the Ministry o f Health will be active in HAMSET 11, and will be expected to: (i) implement health-sector HAMSET activities; (ii) outnationalmonitoringandevaluationforHAMSETdiseases;and(iii) carry provide technical guidance to non-health and community implementers. The Regulatory Department and the Research and Human Resources Development Department are new partners. Under HAMSET 11, particular attention will be paid to the management o f HAMSET programs at the zoba level and health sector's support to the CMHRP and community participation. Project Management Unit: PMU i s accountable to the Minister o f Health, and responsible for various aspects o f project management such as financial management, procurement and facilitation support to the implementing agencies. Under HAMSET 11, the project will recruit a Project Monitoring and Evaluation Specialist. The Community Managed HAMSET Response Program (CMHW) will also be managed from within the PMU. 21 Unitsof the MinistryofHealth ResponsibleArea National HIV/AIDS/STI andTuberculosis Control HIV/AIDS and TB Division(NATCoD) National Malaria Control Program Malaria Family andReproductive HealthUnit Reproductive Health Regulatory Department Monitoring andEvaluation Research & HumanResource Development Department HumanResources for Health HealthPromotion Unit (HPU) Behavior Change Communication (BCCI Zoba-LevelCoordinationandImplementation: This largely mirrors the institutional arrangements at the national level. Under HAMSET, a Zoba Steering Committee (ZSC) provides oversight and strategic direction and i s ledby the Zonal Administrators. The ZSC also approves zoba HAMSET budgets. So far, only 3 Zobas have established ZSCs. Under HAMSET 11,maintaining or establishing ZSC is at the discretion o f the Zonal Administrators. Where there is no Zoba Steering Committee, its fknctions will be delegated to the Zonal Administrator who i s encouraged to convene ad hoc committees to support hindher in this capacity. Membership o f such committees shall be left at the Zoba Administrator's discretion, and may include heads o f departments, baito members (locally elected representatives), and/or representatives o f civil society organizations. The Zonal Administrators will be encouraged inHAMSET I1to guide implementers indeveloping effective and integrated interventions anddemonstratingresults. Zoba Project Management Unit (ZPMU) reports to the Zonal Administration (Zoba Administrator's Office) and includes a Project Officer, CMHRP Facilitator and an accountant. Under HAMSET 11, the ZPMU will hire additional support staff (data clerk/ secretary) and take a stronger role in programmatic monitoring and evaluation, supervisiono f community interventions andcoordinating capacity buildingactivities. Zoba Technical Committee (ZTC) is chaired by the Zoba Medical Officer and provided with secretarial support by the Zoba PMU. It includes all multi-sectoral and MOH implementers. The ZTC will be strengthened as a technical and coordinating body to improve the quality and integration o f Zoba workplans which are responsive to local priorities (as identified through mapping and LQAS surveys). The ZTC will also be oriented innewprocedures for reviewing and approving community subprojects. Line Ministries Other than the MOH and Civil Society Partners: Multi-sectoral partners inHAMSET I1will work with the ZTC andwith their central ministry/office to develop strategic workplans. Where community capacity i s weak, it is expected that multi-sectoral partners will provide mobilization and facilitation support to communities. As the GoE 22 formalizes the decentralization process, local government authorities will play a role in community mobilization andproject coordination. Zoba Health Management Ofice (ZHMO): Under the leadership o f the Zoba Medical Officer, the units o f the ZHMO will be coordinated to (i)implement health sector HAMSET workplans that respond to the targeting priorities identified through mapping and LQAS and (ii) provide technical support to non-health implementers. The Health Promotion Officer, and the Peer Coordinators supported by HAMSET, have the additional functions o f (i)coordinating the Behavior Change Communication activities by establishing and facilitating Peer Groups and (ii)providing, in coordination with the ZPMU, support to the Community Managed Response Component. Additional staff will be recruitedto facilitate M&E at the zoba level. VillageHealth Committees: These operate at the kebabi(village) level and are flexible in structure and composition. Most include local leadershillage administrators, sector workers and representatives o f civil society organizations. Under HAMSET 11, the Village Health Committees will continue to play an important role in identifying and mobilizingcommunities to develop sub-projects (with CHMRP). Community Management Teams (CMT): This is an elected body to represent the community group that will benefit from a subproject grant. Onbehalf of the community, the CMT plans, prepares and implements subprojects. Under HAMSET 11, there will be an emphasis on (i) reaching vulnerable populations and (ii)scaling up BCC groups. These CMT will benefit from additional capacity buildingunder HAMSET 11. Coordination and Planning: HAMSET I1will emphasize (i) integrated planning at the national and regional level and (ii) improved communication (including supervision, reporting, and sharing experiences) between national, Zoba and sub-zoba level implementers. 3. Monitoring and evaluation of outcomes/results With the exception o f malaria, which has a functioning M&E system, progress on monitoring and evaluation was uneven under HAMSET. (Some o f these deficiencies are discussed in Annex 3). The HAMSET I1 project supports the development and implementation o f a functioning and sustainable national M&E system for HAMSET diseases in Eritrea. In that context, HAMSET I1M&E i s an integral part of such a national system which should allow assessment o f (i) progress o f project activities the (monitoring), and (ii) overall effect o f the project on the beneficiary population the (evaluation). The key approach of M&Eunder HAMSET I1is to buildupon, consolidate and improve various existing M&E initiatives for HAMSET diseases in Eritrea. Every implementer at national, zoba and sub-zoba levels has a role to play in M&E, including the use o f M&E data for decision making. The proposed Annual Joint-Review o f HAMSET diseases is a keypart o fthe effort to promote one national M&E system. 23 TheM&E System M&E under HAMSET I1will focus on: (i) strengthening and consolidating the existing M&E systems in the MOH (particularly the Health Management Information System (HMIS); and (ii)developing a component of the M&E system to capture project management data from implementing agencies outside the MOH (line ministries, partner agencies andcommunity subprojects). Strengthening and consolidating the existing M&E systems in the MOH: A Modular HealthManagement Information System (MHMIS) will be developedwith the support o f HAMSET I1as well as other development partners such as USAID, using the existing HMIS as the base. It will consolidate: 0 facility-based information on morbidity and mortality as well as in-patient and out-patient interventions relatedto HAMSET I1diseases (the existing HMIS). 0 logistic management information system (the existing LMIS), which will be improved to include information about key equipment, pharmaceutical usage and supplies. 0 outreach activities by the MOH, including healthpromotion activities. Manual reporting forms from sub-zobas will be entered into a modular computerized information system at the zoba level which then feeds into a central MHMIS. At the national level, the Regulatory Department will carry out rapid analysis and prepare bulletinsabout keyindicators to informdecisionmakingbyimplementers at all levels. Capturingproject management datafrom non-MOH implementing agencies: The second M&E component is a system developed to support the PMUto manage the project and gather information from other line ministries as well as CMHRP. Both o f these data streams will be entered into a computer database at the zoba level and forwarded to the national PMU. The Regulatory Department will also analyze these data and report on them inbulletins. Data from the M&E system will enable: (i) a bi-annual management review at each level; and(ii) annualjoint review at the national level. an Every two years, the Regulatory Department will take the lead in a decentralized population based survey (LQAS) conducted by small sub-zoba teams to track selected outcome indicators such as changes in behavior, knowledge and attitudes, utilization o f services, etc. Other special studies will include health facility assessments. It is a complex task to develop an M&E system for a multi-sectoral project addressing four health issues. For this reason, a two-component M&E system is proposed as described above. To ensure that both components are mutually complementary, the MOHRegulatory Department will coordinate all M&E activities, and collate information from the MHMIS and the PMU. It will also collate and use information from other existing data streams @e., disease surveillance, population-based surveys, health facility 24 assessments, and other special studies). See Annex 3 for additional details about the M&Esystem. Priority activities to be carried out inthe first year under HAMSET I1are: 0 Draft the national M&E conceptual framework to include HAMSET I1diseases 0 Carry out a baseline survey Develop an M&E operationalplan. 0 Develop an MHMIS inone pilot zoba and scale this up to the five remaining zobas 0 Develop a computerized PMUM&E system inone pilot zoba and scale this up to the five remaining zobas. 0 Conduct the first annualjoint-review. 4. Sustainability Institutional and capacity sustainability. The Government o f Eritrea, with the support o f development partners including IDA, has mobilized different sectors, mass organizations and communities to respond to HAMSET diseases in a multi-sectoral approach. It i s highly likely that after the project, the social capital as well as the sectoral and community capacity built with HAMSET 11contributions will continue. For the health sector, the project would increase the institutional capacity to develop policies and workplans, implement programs, as well as monitor and evaluate interventions. Technical sustainability: As discussed in the technical appraisal section, HAMSET I1 supports well-established, simple technical interventions and practices. Most o f them have already been applied inthe country. Therefore, technical sustainability is likely. Financial sustainability: Although HAMSET 11's approach i s to focus on "software" and minimize the additional recurrent costs, financial sustainability seems unlikely given the current macroeconomic difficulties and limited domestic resources for health in Eritrea. However, the control o f communicable diseases is public goods and can evidently contribute to economic growth andpoverty alleviation. Plus, investing inHIV/AIDS/STI, malaria, TB and reproductive health i s cost-effective and with a highreturn o f economic and social benefits (see Annex 16 for details). These justify the investment despite the unlikely financial sustainability. In addition, it is likely that Eritrea would be able to access more resources from a wider range o f development partners as macro-policies and fiscal transparency improve. Thus, the capacity o f HAMSET to demonstrate results will be crucial. Long-term financial sustainability ultimately rests with Eritrea's ability to raise and allocate domestic resources for health in general and HAMSET diseases in particular. 5. Critical risks andpossiblecontroversialaspects Intenszjkation of border tension: Currently, the border dispute between Eritrea and Ethiopia is still unresolved. The risk o f escalating border tension remains a threat. Project implementation could be adversely affected as seen in the recently closed Eritrea 25 Health Project. The Project's flexibility in design and implementation would allow the GoE to adapt program activities insuch a circumstance. Risk of complacency: So far, political commitment in the fight against HAMSET diseases has been exceptionally high in Eritrea. However, there i s a small risk o f complacency, especially in areas where there has been success (e.g. malaria). Mitigation measures include: (i) continued dialogue; (ii)strengthening the information base for HAMSET diseases; and (iii) communicationprograms. Human resources shortage: Currently, Eritrea i s facing a shortage in human resources for health, especially inthe higher cadres (doctors, registered nurses). Although it is not due to a massive "brain drain" as in some other Sub-Saharan African countries, this i s nevertheless a major challenge for the sector and has the potential o f constraining Component 2 (Health Sector Response), especially inhealth system-dependent activities such as TB control and Emergency Obstetric Care (EmOC). Mitigationmeasures include: (i)supporting the implementation o f the HRH sub-component; (ii) working beyond the public sector (e.g. tapping the capacity o f communities, civil society organizations); and (iii) procurementofconsultancieswhilebuildingin-countrycapacity. strategic Failure to embrace the most cost-eflective interventions: Due to inadequate information as well as misconceptions about priorities and effective interventions by local leaders, implementers (especially at the zoba and community levels) might fail to embrace the most cost-effective interventions. This risk, ,which is higher for the multi-sectoral approach to H N / A I D S control than for other HAMSET diseases, would be mitigated through: (i)technical support and clear guidelines for zoba HAMSET technical committees for the technical appraisal o f various implementers' proposals and work plans; (ii) development o f guidelines and menus o f eligible interventions as well as a results-based framework for community sub-projects; and (iii) sharing information on best practices and cost-effective interventions with local implementers. Implementation failure: The Eritrea 2004 Country Portfolio Performance Review (CPPR) found the performance o f the IDA portfolio in the country to be mixed, and the GoE is working hard to improve the situation. HAMSET is the best performer, mostly due to a highly effective MOH, high commitment o f central and local governments as well as other implementers. Nonetheless, there i s a risk o f implementation failure for the proposed project due to cross-cutting challenges and underlying macroeconomic constraints. The risk o f implementation failure is higher for new and challenging components such as HRH and RH. Mitigation measures include close supervision, proactive implementation support andcontinued policy dialogue. Limited M&E: Given the patchy progress in M&E under HAMSETI7, the risk o f inadequate M&E exists for parts o f HAMSET 11. This would be mitigated by (i) application o f the simple yet highly effective M&E tool such as the LQASmethodology; "M&Estatusvariesfordifferentdiseases -- Malaria: excellent;HIV/AIDS/STI: one common national M&E framework hasbeendeveloped butneeds to be strengthened inimplementation andprogrammatic monitoring; TB: system is inplace but there are some issues with the quality o f reporting. 26 (ii)ring-fencing the budgetfor M&E; (iii) the operationalplanfor M&Eof making HAMSETdiseases aproject condition; and(iv) recruitingM&Estaff. Risk RiskMitigationMeasure FromOutputsto Objective Risk o f intensificationo fborder S Flexibility inproject design and tension .mplementation. Risk o f complacency, especially M :i)Continued policy dialogue, (ii) inareaswhere there hasbeen Strengthening the information base for success (e.g. malaria) HAMSET diseases and (iii) Communication ?rograms. FromComDonentsto Outnuts Humanresources shortage S [i) Supporting the implementationo fthe withinthe healthsector, HRHsub-component; (ii) Working beyond especially inthe higher cadres the public sector and (iii) Strategic (doctors, registered nurses) procurement o f consultancies while building in-country capacity. Failure to embrace the most M (i) Strengthening the capacity o f zoba cost-effective interventions, due HAMSET technical committees for technical to inadequate information appraisal ofproposals andwork plans, (ii) and/or misconceptions about Development o f guidelines andmenus o f priorities and effective eligible interventions as well as a results- interventions by local leaders'*. based framework for community sub- projects, and (iii) information on Sharing best practices and cost-effective interventions with local imdementers. Implementation failure due to S Close supervision, proactive implementation national cross-cutting support and continued policy dialogue. challenges and underlying socio-economic constraints. LimitedMonitoringand (i) ApplyingLQAS methodology inM&E; Evaluation, as exhibited under (ii) theoperationalplanforM&Eof making HAMSET. HAMSET diseases a project condition, (ii) establishing a computerized M I S inthe PMU, (iii) recruiting M&E staff, (iv) ring- fencing the budget for M&E Overall Risk Rating Project risks will be mitigatedthrough a step-wise approach with close coordination between implementers anddevelopment partners. '*Thisriskishigher for the multi-sectoral approach to HIVIAIDS control than for other HAMSET diseases. 27 6. Grant conditions and covenants Conditions o f effectiveness are (i) the Operations Manualhas been adopted; and (ii) the Project account hasbeen opened andthe initial deposit made. Other major conditions are as follows: (i) the National Strategic Plan for RH is developed and adopted by December 31, 2005; (ii) the operational plan for M&E o f HAMSET diseases is inplace by March 31, 2006 (iii) the project is implemented in accordance with the OM and any substantial change inthe OMwould require prior IDA approval; (iv) the project activities are implemented in accordance with annual work programs which are agreedwith IDA; (v) annual joint-reviews are conducted for each HAMSET disease and major project components; and (vi) a mid-term review i s implemented no later thanJune 30,2008. D. APPRAISAL SUMMARY 1. Economic andfinancial analyses Detailed economic analysis on HIV/AIDS has been carried out by both the HAMSET project and the Multi-Country HIV/AIDS Program for the Africa Region (Report No. 20727 AFR, paragraphs 76-78) which demonstrates the impact o f the epidemic on economic development and poverty as well as the cost-benefit o f HIV/AIDS interventions. There is also a large androbust body o f knowledge regarding the impact o f other HAMSET diseases on African economies and the economic rationale for interventions (see Annex 16 for details). The project will minimize its fiscal impact by prioritizing "software" over "hardware". Civil works will be minimal and restricted to renovation o f existing RH facilities. The recurrent cost of future maintenance for "hardware" and additional equipment financed by the project will be negligible. Additional staffing and operational costs are modest. Counterpart fimd requirements are reasonable and only cover duties andtaxes incurredby the project andpart o f the operating costs mainly salaries. However, the fiscal impact of the project is likely to be significant. A total o f US$24 million is expected to be disbursed from IDA during the project cycle. The Government will needto invest aroundUS$0.5 millionper year as counterpart funding for the project, which is equivalent to 5% o fthe MOH's recurrent budget inFY04. The Government will assume the responsibility for the maintenance o f project investments after HAMSET I1 closes. 28 2. Technical The proposed project is built on the principles o f internationally-accepted best practices for HAMSET diseases, taking into account the country's specific socioeconomic circumstances and epidemiological situation. For HIV/AIDS, the approach is one o f addressing an epidemic which i s not as generalized as in other SSA countries, yet very highincertainpopulationsandhot spots. Insuch a circumstance, the HIV/AIDS program needs to focus intensively on the most vulnerable groups and their linkages to the general population. Socio-geographic mapping o f hot spots will facilitate targeted interventions. For malaria, the project supports the Government's strategy in malaria control with interventions endorsed by the World Health Organization(WHO) andRoll Back Malaria. The malaria program was already very successful in implementing its first five-year strategic plan which was supported by HAMSET. For TB, the project will help scale up the implementation of DOTS, the intemationally accepted strategy for TB control. For RH, HAMSET I1supports a set of evidenced-based interventions which aim at reducing maternal and neonatal mortality as well as reducing gender based harmful traditional practices. The project would finance the development and implementation o f standard clinical management protocols developed by the MOH which are in line with the recommendations o f WHO andUNAIDS. Such protocols will be used for VCT, PMTCT, prevention o f opportunistic infections, clinical management o f sexually transmitted diseases, malaria, tuberculosis, antenatal, perinatal andpostnatal care as well as EmOC. The role o f different sectors and the community in the control o f HAMSET diseases is well established. Therefore, one o f the mainstays o f HAMSET I1 i s to support a decentralized approach to the implementation o f an integrated package of HAMSET interventions in which different sectors, communities and households are mobilized and empowered. The project also places great emphasis on strengthening institutions, learning andinnovation, andmanagingfor results. 3. Fiduciary HAMSET I1Project will make use o f the existing HAMSET institutional arrangements for procurement and financial management as well as the same control environment. Financial management and procurement at national level and related coordination and planning will be the responsibility of the Project Management Unit (PMU) as under HAMSET. 29 Financial Management IDA has reviewed the financial management arrangements of the current HAMSET project on several occasions as part o f the implementation support for ongoing projects in Eritrea. The most recent review was carried out in December 2004. This followed a previous assessment in February 2004 to evaluate the financial management arrangements for conversion to report-based disbursement. The project was the only one inIDA'SEritreaportfolio that met the requirement, andnow benefits from the flexibility provided under the report-based disbursement mechanism. Annex 14provides a detailed review o fthe financial management arrangements for the project. Inconclusion, the financial management arrangements for the HAMSETprojectmeetthe minimum requirements to comply with the Bank's OPBP 10.02. The project is well managed in the area o f financial management, thanks to the tremendous effort o f the project management, as well as the accounting staff. This inturn has had positive results in record keeping including the enhancement of the project' computerized accounting systems. These arrangements will need to be applied to the proposed project through an action plan included inAnnex 14. Procurement Similarly, procurement under HAMSET I1will continue to be carried out by the Project Management Unit on behalf o f participating agencies (PAS). The rationale for this arrangement is that the PMUhas demonstrated competence under both the former Health project and HAMSET to effectively and efficiently carry out procurement on behalf o f the PAS. An assessment o f the capacity o f the Implementing Agency to implement procurement actions for the project was carried out. The assessment reviewed the national procurement environment, organizational structure for implementing the project and the interaction between the project's staff responsible for procurement and for administration and finance. The key issues and risks concerning procurement for implementation o f the project have been identified and corrective measures have been agreed and described in anAction Plan. A Country Procurement Assessment (CPAR) was completed in June 2002 and a report submitted to the Government. The report incorporated an action plan for implementing recommendations for reforming the procurement system in Eritrea. An IDF grant was approved in M a y 2003 to assist the Government in implementing these reforms. The expected outputs o f the IDF grant are procurement legislation; procurement regulations, standard bidding documents; and guidelines for establishing an institutional framework which is not adequate at the moment and needs improvement. One o f the main findings o f the CPAR is lack o f procurement capacity in Eritrea. The joint CPPR conducted in December o f 2004 also confirmed that the overall procurement capacity in Eritrea is still weak, especially at the Regional level, due to lack o f skilled procurement staff. However, HAMSET is being implemented by a PMU which was initially established to implement 30 the Health Project. The PMU has therefore acquired a lot o f experience. The Assessment reconfirmed that the PMU has adequate capacity to implement HAMSET I1 andproposed some actions to strengthen this capacity at national and project level. The actions proposed include: continuing implementation o f the CPAR recommendations; preparation o f a procurement manual and standard bidding documents; definition o f the roles and responsibilities o f staff involved in the procurement process; review o f remuneration for PMU staff; continuous training o f the procurement officer and improvement inthe record keeping system. The procurement o f goods and services would be carried out according to Bank procurement guidelines. Details are presented inAnnex 15, 4. Social HAMSET I1will continue to pay close attention to social issues with a renewed focus on (i) (withemphasis onFGMandthe vulnerabilities ofCSW); (ii) risks gender the associated with active and demobilized soldiers; and (iii) mobile populations (both seasonal and cultural). Gender: Misconceptions and cultural beliefs drive many gender-based harmful traditional practices such as FGM, early marriage and short child spacing. They also hinder the utilization o f health services, including antenatal care and skilled care at delivery. These can only be successfully addressed through culturally sensitive interventions. With regard to HIV, social, cultural, and economic factors generally put women, and young girls inparticular, at a serious disadvantage compared to their male partners when negotiating the use o f condoms. Inaddition, biological factors put women more at risk to HIVinfection than men. Women lack the relativeprotectionthat male circumcision may offer. Moreover, the diagnosis and management o f Sexually Transmitted Infections (STI) is much less sensitive, specific and effective for women as compared to men, increasingthe risk to infection with HIVthough sexual intercourse. Commercial Sex Work and TransactionalSex: Limitedaccess to economic opportunities drive women to adopt economic coping mechanisms that may include transactional or commercial sex. Stigma and the cultural aspects o f CSW may prevent some CSW from actively participating in HAMSET I1activities. Women engaging in transactional sex may not identify themselves as CSW and may not benefit from targeted interventions. Armed servicepersonnel: In Eritrea, many men are in the armed services. Being away from families can makes them more vulnerable to HIV/AIDS/STI. Mobile Communities: Mobile communities, whether tribal nomads, seasonal migrants, or mobile laborers, may be less able to participate in and benefit from project activities due to their mobility and the possibility o fbeing overlooked by authorities andimplementers. 31 Project responses to social issues: The project would address these issues through supporting the GoE to: (i) continue to learn more about behaviors and circumstances that make target populations vulnerable (i.e. women, CSW, mobile populations, demobilized soldiers etc.), refine BCC and interventions to be sensitive to cultural issues (e.g. FGM, early marriage and gender) and ensure that messages and interventions are cross-cutting; (ii)implement patient exit polls at facilities offering HAMSET services; (iii) up hot- set lines where people facing stigma and discrimination can voice their grievances and seek help; (iv) support implementing agencies that work with targeted groups (i.e. Ministry o f Defense, Ministryo f Labour and Human Welfare, National Union o f Eritrean Women, National Confederation o f Eritrean Workers); and (iv) make sure the procedures for mobilizing and appraising o f CMHRP subprojects will facilitate the targeting o f potentially marginalizedgroups. Together with other initiatives in the country, HAMSET I1will work with community- based organizations to provide support for activities that reduce the risk o f HIV infection among women, such as basic education on sexual and reproductive health, HIV, and STI; activities for youth designed to delay sexual debut; harmonizing the age o f consent, marriage, and maturity to 18 years; encouraging voluntary testing; and empowering women on matters pertaining to access to information, employment, and economic/social recognition. HAMSET I1 will support the development o f culturally, morally, and scientifically acceptable AIDS education programs for youth in and out o f school and advocate for the protection o f youth against behaviors that place them at increased risk o f HIV infection. Furthermore, HAMSET I1 will contribute to the analyses o f risks, vulnerability and impact o f HIV/AIDS to identify gender disparities that perpetuate the risks o f HIV infection and vulnerability to the negative socio-economic impact o f AIDS. It would promote the just and fair distribution o f resources, efforts and interventions to protect women, men, youths and children and ensure the socio-economic rights o f every individual. 5. Environment The proposed project has been classified as category ((BDfor environmental screening purposes given the risks associated with the handlingand disposal o f medical wastes. As a repeater project, HAMSET I1will make use o f the existing arrangements for safeguard issues which havebeen successfully implemented under HAMSET. A Health Care Waste Management Plan (HCWMP) and an Environmental Assessment (EA) for insecticides were developed by the GoE and approved by IDA under HAMSET. Both documents were disclosed inEritrea and at the Bank InfoShop before appraisal o f HAMSET II. MOH has complied with the recommendations made by the EA. The proposed project will finance insecticides for malaria control activities, although the overall use will be relatively small (e.g. for impregnation o fbednets) andonly safe compounds approved by the World Health OrganizationPesticide Evaluation Scheme (WHOPES) will be used. The HCWMP has been under implementation since October 2004. The Ministry o f Health has established a task force to ensure dissemination o f the HCWMP as well as 32 compliance by all health facilities in the country. Supervision o f the Health and HAMSET projects has confirmed that the two regional hospitals financed by IDAwere in compliance with HCWMP requirements. A successful Rapid-Result Initiative to improve safe injectionpractices and management of sharps and medical waste has been scaledup to referral hospitals infive out of six zobas. 6. Safeguard policies Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [XI [I NaturalHabitats (OP/BP 4.04) [I [XI PestManagement (OP 4.09) [XI [I Cultural Property (OPN 11.03, being revisedas OP 4.11) [I [XI Involuntary Resettlement (OP/BP 4.12) [I [XI Indigenous Peoples(OD 4.20, being revisedas OP 4.10) [I [XI Forests (OP/BP 4.36) [I [XI Safety o fDams (OP/BP 4.37) 11 [XI Projects inDisputedAreas (OP/BP/GP 7.60)* [I [XI Projects on International Waterways (OP/BP/GP 7.50) [I [XI 7. Policy Exceptions and Readiness The project does not require exceptions from Bankpolicies. The project meets the Regional criteria for readiness for implementation. 'Bysupportingtheproposedproject,theBankdoesnotintendtoprejudicethefinaldeterminationof theparties' claims on the disputedareas 33 Annex 1: CountryandSector or ProgramBackground ERITREA: HIV/AIDS/STI, TB, Malaria andReproductiveHealthProject (HAMSET11) BriefCountryProfile Eritrea is a mountainous country in the Horn o f Africa bordered by the Red Sea on the east, Djibouti to the south-east, Ethiopia to the south and Sudan to the west and north. The population is composed o f nine ethnic groups - the Afar, Bilen, Hedareb, Kunama, Nara, Rashahaida, Saho, Tigre, and Tigrinya. The administrative structure is composed o f 6 zobas (regions), 58 sub-zobas, 699 Administrative Areas, and 2,564 villages. With 80 percent o f its population living in the countryside, Eritrea is one o f the most m a l countries in the world which hinders general development and service delivery. Likewise, 80 percent o f the population is illiterate, posing health communication, management, andhealth regime compliance challenges. The thirty year war for independence from Ethiopia damaged the mainly agrarian economy, destroyed much o f the infrastructure and depleted human resources. After gaining independence from Ethiopia in 1991,Eritrea went through a periodo f rapid and stable economic growth from 1993 to 1997, with an annual GDP growth rate averaging 7.4 percent. When the border war with Ethiopia broke out in 1998, GDP growth declined to less than 1 percent in 1999. An estimated 75 percent decline in crop production combined with the destruction and loss o f physical capital caused a 9 percent decline in GDP in 2000. Currently, the "no war, no peace" situation as well as frequent droughts continue to restrict economic development. DemographicProfile The population o f Eritrea i s 4.4 million, with an annual growth rate o f 2.2%. The total fertility rate is 4.8 children per woman and crude death rate i s 13.3 per 1,000 population. Life expectancy, at 52.3 years for women and 49.9 for men, remains low although the country has not experienced the full impact o f the HIV scourge to the extent o f many SSA countries. Total life expectancy increased from 48.9 to 51.1 years between 1990 and 2003 andis projected to reach 58 years by2020. Morbidity and mortality vary widely by region within Eritrea, with rural areas and areas near the border with Ethiopia carrying a much higher burden o f disease. The majority o f morbidity and mortality o f adults i s due to infectious disease, especially malaria, TB, HIV/AIDS, and diarrheal diseases. Malaria, HIV/AIDS, and TB will be discussed in more detail intheir separate annexes. Great strides have beenmade inchild health: from 1995 to 2003 IMR dropped from 72 to 45 deaths per 1,000 live births and the Under 5 Mortality Rate (USMR) fell from 136 to 84. The immunization rate i s one o f the highest in the region with 75.9 percent of children 12 to 23 months old vaccinated, which represents an 83 percent increase over 1995 levels at a time when immunization rates have been decreasing across Africa. Such impressive progress puts Eritrea on a par or better than some middle-income African countries in terms o f child health. In fact, 34 Eritrea i s one o f the few low-income SSA countries likely to meet some o f the health MDGs. The main caused o f under-five deaths include diarrheal diseases, respiratory infections, malaria, and malnutrition. Especially, malnutrition, a major contributing factor to child morbidity and mortality, i s high. Around 40% o f under-five children are stunted (chronic malnutrition), 16% are wasted (acute malnutrition) and 40% underweight (both chronic and acute malnutrition). Provision of Health Services The Eritrean health system has made significant progress, especially considering the destruction in physical infrastructure and human resources caused by the long independence war. Immediately after independence, the GoE adopted a Primary Health Care Policywhich guides the development o f the sector. The health delivery system i s divided into three tiers: primary, secondary and tertiary care. The lowest-level service delivery unit i s the Health Station staffed by a nurse or associate nurse which usually has a catchment area o f 5km radius that includes several villages. Many communities have informal community health agents andtraditional birth attendants who are supervised by the Health Station but are accountable to and paid by the community rather than the Government. The Mini-Hospital (the lowest level facility that has an operating room) provides services at the sub-zoba level, the Zoba Hospitals at the zoba level, and the ReferraVSpecialty Hospitals at the national level. The MOH restructured itself in 2003 to align hnctions within the Ministry and improve the efficiency and effectiveness o f its units. The MOH is now composed o f three principal departments (Health Services, Regulatory Services, and Research and Human Resources) whose Directors General report directly to the Minister. There are several other smaller support units whose managers also report directly to the Minister. Management o f health services is slowly improving and Eritrea has taken advantage o f management and uality assurance programs supported by development partners, especially in IMCI", maternal health and HIV/AIDS. Although Eritrea has made great strides in expanding its primary health care system, the percentage o f the health budget that goes to support hospitals is still large. In acknowledgement o f this, the M O H is working to increase the efficiency o f the hospital system. Private Sector Eritrea has a nascent private sector consisting o f both NGOs and for-profit providers, including a new public-private hospital for fee-for-service patients. There are a small number o f NGOs, but they are mainly involved in working with the Government rather than the direct provisions o f services as seen inEast Africa. l969 percent o f all facilities have a provider trained inIMCI(USAID). 35 Human Resources for Health Eritrea, like most SSA countries, is experiencing a shortage o f health care workers. See Annex 10 for a detailed discussion inHuman Resources for Health. Water, Sanitation, and Hygiene Over 70% o f Eritreans do not have access to clean water and even less have access to proper sanitation. Efforts have been made to introduce safe water systems, but progress has been slow, especially due to the rural nature o f Eritrea. There is a highprevalence o f diarrheal andrespiratory diseases inEritrea, especially among children. Further reduction o f child mortality andmorbidity could be achieved through improvements inclean water, sanitation, and hygienepractices Health Financing Health financing in Eritrea is a major challenge for health sector development. Information on Government budget for health is limited and National Health Accounts have not been prepared for Eritrea. As a result, the complete picture regarding revenues, expenditures, andthe flows o f funds inthe health sector is not available. According to WHO estimates, Eritrea's total health spending was US$9 per capita or 4.3 percent o f GDP in 2000, o f which, public expenditure was US$ 6 per capita (or 66 percent o f total expenditure on health) and private US$3 (or 34% o f total health expenditure). Public expenditure on health is around 4 percent o f Government's budget, which i s one o f the lowest levels in SSA. The largest share o f the national health budget comes from extemal assistance, at US$3.6 per capita (equivalent to 61 percent o f public expenditures on health, or 40 percent o f total health spending). Private health spending (for private care or users' fees in the public sector) constitutes only 3 percent o f total health spending. Government's contribution was US$2.3 per capita (39 percent o f public expenditures on health, or 26 percent o f total health spending). Between 1995 and 2000, there was significant reduction inGovernment's spending on health (32 percent reduction innominal US dollar terms, 43 percent reduction inshare of GDP terms)20.Most ofthe Government's budget for health comes from taxes. However, tax-based revenue has been stagnant innominal terms and declined inreal terms. On the other hand, this also means the MOH is efficient and becoming more so. The main challenges facing health financing inEritrea are increasing recurrent costs due to large capital investments, limited ability to expand domestic financial resources for health due to the stagnant economy, lack o f sound financial data for policy making, and limitedcapacity inhealth financing. *'These numbers are out-of-date. However, newer estimates arenot available. 36 37 Annex 2: Major Related Projects Financedby the Bank and/or other Agencies ERITREA: HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject (HAMSET 11) Bank-Financed Project Title Amount Project Status Sector Report Rating HIV/AIDS/Health HAMSET US$40million S Basic health and IntegratedEarly Childhood US$45 million S primary education DevelopmentProject Health HealthProject US$24.6 million S (closed) Multilateral Project Title Implementers Amount Agencies EU Alleviating poverty ofpeople living US$79,792 and affected by HIV/AIDS in Asmara (2004-2006) GFATM HIV/AIDSandmalaria US$ 8.1 million UNFPA Strengtheningnational capacity to MOH US$2.6 million improve coverage, quality and access to integrated RHservices (2002-2006) UNFPA Supportingmaternal healthby MOH US$600,000 establishing an obstetric fistula center (2005-2006) UNAIDSthrough Preventionof HIV/AIDS among EDF(MOD), US$734,164 UNFPA, Gov't of Eritrean Youth, the EritreanDefense NUEYS Norway through Forces andthe National Service UNFPA and COTS (2003-2005). UNICEF WHO Health and Environment, Blood MOH, EDF US$217,273 safety and clinical technology, Accelerating Prevention, Care and Support o f HIV/AIDSinthe Eritrean Defense Force (EDF) (2004-2005) 38 Bilateral Project Title Implementer(s) Amount Agencies DANIDAthrough Community-based HIV/AIDSCare UNFPA, MOH, US$350,000 UNFPA and Support (2002-June 2005) NGOs, FBOs Govt. Japan Mobilizing Communities to Reduce UNFPA, MOH, US$959,3 18 through UNFPA ReproductiveHealthMorbidity & NUEW, Mortality (2004-April 2006) I NUEYS, FRHAE, HABEN Government o f PHARPEI1(Public Healthand WHO, MOH US$lO.1million Italy Rehabilitation Programfor Eritrea, Phase 2) (2000-2005) 0 Support to the National Malaria Control Program and to the NationalTB Control Program 0 HumanResourcesDevelopment Support to the functioning of healthunits 0 Epidemiologicalsurveillance system for communicable diseases Government of PHARPE I1Plus (Approved, WHO, MOH US$2.9 million Italy duration 24 months). Improving the quality of services of 7 regonal referralhospitals through: 0 Supply ofhospitalequipment 0 Training ofhealthpersonnel 0 Training of hospital managers Govt. Italy Strengthening Reproductive Health UNFPA, US$320,000 through UNFPA Service Delivery Capacity inthe FRHAE, NorthernRed Sea Zoba "Saving NUEW, Women's Lives'' (2002-2005) NUEYS Govt. Netherlands Save the Mother and Her Baby UNFPA, MOH US$385,600 through UNFPA (2005) Govt. Netherlands Protection of women and the youth UNFPA, MOH, US$149,000 through UNFPA against HIVIAIDS(2005) NUEW NCA Female GenitalMutilation& N C A Eritrea, US$44,775 Harmhl Traditional Practices MOH (2000-2004) USAID Health and HN/AIDS21-largely for URC, TASC2, technical assistance FHI,PSI, RTI 21Reduce maternal and chld mortality (US$2.8 million); Prevent the spread o f HIV/AIDS(US$2.3 million); and Improve reproductive health services (US$500,000). The US$5.6 million is for October 2004 -September2005. 39 Annex 3: ResultsFrameworkandMonitoring ERITREA: HIV/AIDS/STI,TB, MALARIAAND REPRODUCTIVEHEALTH PROJECT(HAMSET11) Background With the exception of malaria, which has a good M&E system, progress on monitoring andevaluationwas uneven under HAMSET. Below are some o fthe deficiencies: An M&E conceptual fiamework and an operational plan (with an agenda and budget for HAMSET diseases) have been drafted but not finalized. Reporting forms concerning in-patient, out-patient, outreach activities of health facilities were either overly complex or not clearly related to management decisionmaking-or they didnot exist. No computerized management information system (MIS) has existed for most HAMSET activities (ie., at health facilities, for behavior change and communication (BCC), in the community managed HAMSET response program (CMHRP), and from line ministries andpartner agencies) The PMU has not had any M&E capacity and has not been able to effectively report on HAMSET activities. No M&E unit has existed in either the PMU or MOH units until recently, when the Regulatory Department was given the responsibility o f coordinating M&E. There are insufficient information technology and M&E resources (technology and humanresources) for M&E at the national and zoba levels. Data collected by different disease control programs are sent vertically to their respective National Management Programs and would not be collated at the zoba level in a way that would help zoba decision makers, including the Zoba Technical Committee. TheHAMSET 11Monitoring and Evaluation System HAMSET I1will support an integrated M&E system for HAMSET diseases, and in a broader sense, for Eritrea's health system through the development o f two harmonized, closely-linked information systems: 0 a Modular HealthManagement Information System (MHMIS) for the MOH and 0 a M I S system for project management data from non-MOH implementing agencies. Each computerized information system will collate information in each zoba, and then feed the data into a central information system which aggregate information at the national level. Both output indicators and outcomeshesults (i.e., treatment outcomes, changes inbehavior, knowledge and attitudes, etc.) will be monitored. 40 Modular HMISfor MOH 0 This will be based on the existing HMIS which, maintained by the Zoba Medical Team, currently collects information on facility-based service utilization, morbidity and mortality as well as epidemiological surveillance information. The HMIS will be strengthened and expanded with additional modules to include outreach andhealthpromotion activities. It will thus cover: (i) information about morbidity and mortality related to HAMSET I1diseases, service utilization, as in-patient andout-patient interventions, (ii) logistic management information system (LMIS) with information about key equipment, pharmaceuticalusage and supplies, and (iii) outreach activities by the MOH, including healthpromotion activities. Information will be recorded manually in sub-zobas by the health facility staff or Health Promotion (BCC) team and forwarded monthly to the Zoba Medical Team. At the zoba office, these data will be entered ina computer database and sent monthlyto the National HMISinAsmara where the 6 zoba databaseswill be aggregated. The resultingNational database will be forwarded on a quarterly basis to the Regulatory Department (and related MOH departments) for rapid analysis and preparation o f a bulletin about key indicators. The Regulatory Department will disseminate these bulletins quarterly to the Minister o f Health, the HAMSET I1 Technical Committee, and relevant MOH departments. This modular-base platform will gradually add all HAMSET health programs, starting with HIV/AIDS and STI (2005), then TB Control and Reproductive Health (2006). At the end o f this process, and ifappropriate, the Malaria Control program will be included. Every two years, the Regulatory Department will facilitate a decentralized population based survey to gather outcome indicator data to will track changes in behavior, knowledge and attitudes inzobas. These data will be collected by small sub-zoba teams using precoded questionnaires and entered into a database at the zoba level that will follow the same reporting stream described above. Other special studies to be carried out are health facility and quality o f care assessments. MISfor Project Management Data The second system is a MIS developed to support the PMU to manage the project and gather information from other line ministries and civil society implementers as well as the Community Managed HAMSET Response Program (CMHRP). The PMU will hire an M&E coordinator in the central PMU and a data ClerWadministrative support in each of the 6 zoba PMU offices. Using a simple, precoded Activity Reporting form line that can be combined with the Financial Management reporting system, non-MOH implementers (Le. line ministries, civil society organizations, CMHRP) will report to the zoba PMU specific activities carried out, their location, the target population and its size. Data will be entered into zoba computer databases and forwarded on a monthly basis to the central PMUwhere zoba information will be consolidated. The PMUwill send these 41 I - 1 #K. hospitals I #p healtt.Certers BCC 1 ('hart 2 43 Challenges, Priorities and Innovations It is a complex task to develop an M&E system for a multi-sectoral project addressing four health issues. To ensure that both systems are mutually supportive, the MOH Regulatory Department will coordinate all M&E activities, and collate information from the HMIS and the PMU. It will also collate and use information from other existing systems (i.e., disease surveillance, population based surveys, health facility assessments, and other special studies). It will also synthesize information inbulletins for formal disseminationwithin the GOE andto the Bank. Decentralized monitoring using Lot Quality Assurance Sampling (LQAS) as introduced during HAMSET will be used by Zoba and sub-Zoba managers to assess the status o f key outcome indicators in their catchment areas. LQAS is a sampling method adapted from industrial quality control methods; its key feature is that local managers using a very small sample o f interviews canjudge whether a predetermine coverage target has been reached. It can also be aggregated to calculate coverage proportions at Zoba, regional andnational levels. The Rapid Results Initiative (RRI) as introduced in HAMSET will continue to be institutionalizedto aid the MOHinstrategic planning. The use o f handheld computers and/or PDAs for decentralized data collection can be explored and piloted. This technology can reduce the error indata input and increase the speed inwhich information can be used for decision making. Capacity and TechnicalAssistancefor M&E Current M&E capacity in Eritrea is limited. Substantial amounts o f capacity building will be needed to put such a system inplace. HAMSET 11's support will focus on: 0 Finalizing national M&E framework andoperationalplan 0 Standardizing reporting forms 0 Designing the M I S for the units andthe Regulatory Department 0 Healthfacility assessments 0 HIVdrugresistance 0 LQAS O R R I 44 A First YearAgendafor M&E Activity Date Comments Baseline Survey September -October Baseline survey will be linked with 2005 final evaluation o fHAMSET. A reproductive health module will be added to obtain baseline data. Finalize national M&E January 2006 This work will build on the M&E conceptual framework to framework which is expected to be include HAMSET I1diseases completed under HAMSET Modifyproject planbased on A detailedimplementationplancan baseline data results. be developed following the project Establishproject targets February -April 2006 modification Develop M&EOperational January - June 2006 This work will buildonthe M&E Planwith agenda andbudget operationalplanwhich is expected to be completed under HAMSET Reporting forms to be developed at this time Develop M I S system ineach January - August 2006 This activity will take place operational unit, inthe PMU, simultaneouslywith other activities anda computerizeddatabase since IT specialist will be dedicated inthe RegulatoryDepartment to it. HealthFacility Assessments July2006 Assessments will be carried out on a sample o fHealthFacilities in Zobas This work will be followed by diagnostic work depending on the nature o f the problems detected. Produce two information November 2006 products bythe end o f year 1: (i) HAMSETI1Activity Status Report (ii) BaselineSurvey Report Firstannualprogramreview December 2006 using M&E data Beginwork to use P D N December 2006 handheld computers for data collection during2007 45 / I I / I I T Results Framework with Illustrative Indicators HIV/AIDSand STI Overall Goal: Support tk National Strategic Planfor HIV/AII /STI and its core objectives PDO ProjectImpact Indicators Use of ProjectImpact Information Contain the spread o f HIV prevalence is keptbelod4 To evaluate project's overall impact HIV/AIDS/STI invulnerable (i) amongAKCattendeesaged 3% groups and inthe general 15-24 (ii)12% among CSW To monitor the trends o fthe epidemic population through a multi- invulnerable groups sectoral approach which scalesup Syphilis sero-prevalence rate prevention, diagnosis, care, among ANC attendees aged 15- Track progress against MDGs treatment and support services 24 i s reduced from 1.6% to under 1% To assess effectiveness o f interventions and strategically modify them as needed IntermediateOutcomes IntermediateOutcome Indicators Vulnerable groups andthe general Percentage o f vulnerable groups2s To determine the effectiveness o f population exhibit behaviors reporting condom use inlast sex BCC interventions targeting which reduce their risk to with non-regular partners vulnerable groups HIV/STI transmission To determine the utilization of Highrisk groups and the general Percentage o fpregnant women services population use HIV/AIDS/STI who had an HIV test services for prevention, treatment To manage programs and make and care. tactical and strategic changesbased on IntermediateOutputs ProjectOutput Variables Access to HIV/AIDS/STI services Kumbero f sites offering VCT or PMTCT services per 100,000 pop. preventionltreatmenticare services (urban vs rural) To determine the quality o f services for promoting preventative behavior To manage programs and make tactical and strategic changesbased on evidence 24Figures are indicative o ftargets based on the current data. 25CSWs, barlhotelitea shop workers, National Service personnel, truck drivers 49 TB Overall Goal: Suppc the National Strategic Planfor TB a I its core objectives PDO ProjectOutcomeIndicators Use of ProjectOutcome Information ExpandDOTS coverage, improve Detect at least 70% o f infectious To evaluate project's overall impact case detection and treatment cases inthe population outcomes for TB Cure at least 85% o f new smear To assess the effectiveness o f positive cases interventions and strategically IntermediateOutcomeIndicators DOTS coverage Percentageo f detected cases under Direct Observed Treatment communication andbehavior change interventions To determine the utilizationo f services To manage programs and strategic IntermediateOutput Indicators Percentage o f health facilities with To determine the availability and TB microscopy and adequate at least one healthprofessional quality o f TB services stocks o f TB drugs trained inTB case detection and treatment Percentage ofhealth facilities with To aid HAMSET manage programs TB microscopy and make strategic changes based Percentage o fhealth facilities on evidence reporting stock out o f TB drugs in the last 3 months Malaria Overall Goal: Support the National Strategic Plan for Malaria and its core objectives PDO ProjectImpact Indicators Use of ProjectImpact Information Further reduce or at least maintain Proportional malaria mortality To evaluate project's overall impact malaria mortality and morbidity at 2004 levels Proportional malaria morbidity I I I To assess effectiveness o f interventions and strategically treatment with fever receiving appropriate BCC interventions Reduce exposure to malaria To determine the utilizationand infection years andpregnant women sleeping quality o f malaria services underITNs inthe previous night To aid HAMSET manage programs and make strategic changes based on evidence 50 Intermediate Outputs IntermediateOutput Indicators Use of IntermediateOutput Monitoring m a i l a b i l i t y o f malaria services IPercentageo fhealth facilities with ITo determine the availability of 1 stock-ouiof first-line anti-malarial malaria services and commodities drugs inthe last 3-months Percentageo f households with at least one ITNretreated within the last six months ReproductiveHealth ProjectImpactIndicators Use of ProjectOutcome Information Improvematernal and newborn Maternal mortality ratio Evaluation o f overall project impact outcomes and discourage gender- based hannful traditional practices Neonatal mortality rate Monitor trends among different socioeconomic groups and Contraceptive prevalence rate geographical areas Reducethe prevalence o f Female identify the most cost-effective GenitalMutilation (FGM) among interventions and share experience young girls at the customary time o f with other programs circumcision by 10% Track progress against the MDGs Project andProgrammanagement Dumoses b L IntermediateOutcomes IntermediateOutcomeIndicators Use of IntermediateOutcome Monitoring Increased access by women to Percentageo f deliveries attended by To determine whether pregnant quality: focused antenatal care, a skilled birthattendant women have access to appropriate skilled attendance at delivery, obstetric care andneonatal services emergency obstetric care, post abortion care, family planning. To determine whether health practitioners effectively promote appropriate safe motherhood and child care practices To determine the quality o f services for promoting treatment seeking andpreventative behavior To aidHAMSETmanageprograms andmake strategic changes based on evidence 51 IntermediateOutputs IntermediateOutputIndicators Use of IntermediateOutput Monitoring Improvedmaternal andnewborn - Percentage o fhospitals, health To increase access ofpregnant outcomes centers (HC), health stations (HS) women to quality emergency with focused ANC obstetric services Increased access bynewborns to - Numbero fhospitals, HC, HS with appropriate care family planning services per 100,000 pop. (urban vs rural) - For every 500,000 people, 4 facilities that provide basic EmOC, andone that offers more comprehensive care. HumanResource for Health PDO ProjectOutput/Outcome Use of ProjectOutput/Outcome Indicators Information To increase the number of Train at least 200 nurse midwives, To guide staffing and training plans appropriately trained, motivated 200 public healthtechnicians and and equitably distributedhealth 200 laboratory technicians service providers for Eritrea Increase the percentage of health To ensure andmonitor equitable stations withat least one nurse from distribution o f staff 28% to 50% Percentage o f actions inthe result- To guide the formation and based annual work plan for implementation o f annual R&HRD R&HRD successfully implemented work plans 52 Annex 4: Detailed Project Description ERITREA: HIV/AIDS/STI, TB, Malaria and ReproductiveHealthProject (HAMSET 11) The project's total cost is US$ 26.5 million. It is financed by a US$ 24 million grant from IDA, US$ 2.0 million from the GoE and US$ 0.5 million from the communities. The project has four components: Multi-Sectoral Response (US$ 3 million): This component supports key line ministries other thanthe MOH, local governments andcivil society organizations at bothnationalandzoba levels to scale up prevention (especially BCC and stigma reduction), care and support interventions for HIV/AIDS/STI, malaria, TB and RH (with emphasis on mobilizing communities to use HAMSET services). With fewer resources available for this component under HAMSET 11, the project will emphasize (i)integrated planning, (ii)focused interventions, and (ii) results-based implementation and reporting. Behavior Change Communication will be a focus area for all multi-sectoral implementers. Integration: Under HAMSET, the multi-sectoral response activities were implemented in a rather fragmented manner. Under HAMSET 11, the planningprocess will be strengthened so that integrated work plans are developed with the technical support o f the PMU and MOH which (i) reflect the comparative advantage o f each sector/implementer, the HAMSET priorities o f the locality and the immediate needs o f the most high-risk, vulnerable groups within each implementer's constituency, (ii)cover more than one HAMSET diseases with combined interventions wherever possible (e.g. a BCC intervention including HIV/AIDS/STI, RH and malaria messages), and (iii) complement activities being funded by other projects and initiatives to address HAMSET diseases (e.g. the GFATM, the Integrated Early Childhood Development Project, the Education Project). The socio-geographic mapping exercises of high-risk groups as well as the LQAS will provide the basis for such work plans. Preliminary work plans are to be prepared by October o f each year and finalized by the end o f February o f the following year. IDA reviewed all work plans for the first year and will randomly prior review a sample o fplans inthe subsequentyears. Focus: The multi-sectoral response will be more focused thanunder HAMSET. Not all the work plans will be funded as priority will be given to the most crucial sectors and implementers, especially those who (i) have large number o f vulnerable groups in their constituency, and (ii) have demonstrated their ability to deliver under HAMSET. Proposed key multi-sectoral implementers include Ministries o f Education, Defense, Labour and HumanWelfare, National Union o f Eritrean Women, National Union o f Eritrean Youth and Students, BIDHO, and faith- based organizations; modest support may be provided to other supporting organizations. The list o f implementers to be funded by HAMSET I1will be revisited annually and their work plans subject to a competitive appraisal process with a set o f clear eligibility criteria which will be further elaborated inthe Operations Manual. Inprinciple, the annual work plansneedto: (i) be inline with the National Strategic Plans for HAMSET diseases; 53 (ii) utilizeevidence-based,effectiveinterventions; (iii) have specified objectives and target populations (especially high-riskgroups); and (iv) clearly define the expected results andhow to monitor them Other factors to be taken into account include each implementer's comparative advantages, past performance as well as its compliance with M&E requirements. Activities that do not meet the criteria will not be supported. There will be no "hardware" activities (e.g. construction) eligible for funding under this component. In keeping with the project's emphasis on decentralizing implementation, the multi-sectoral proposals at the national level should quantify the proportions of resources to be implementedby central vs. local implementers. Good practice suggests that national agencies should, inmost cases26retain no more than 30% o f resources which are to be used activities at the central level. The rest shouldbe for activities at the local level. Results: HAMSET I1will pay special attention to the results-based agenda in the multi-sectoral response. As discussed above, clearly defined outcomes and methods to monitor them will be part o f the eligibility criteria. The project will encourage the application o f the Rapid-Result Initiatives inthe annual work plans o f the implementers. Behavior Change Communication (BCC): BCC will be emphasized as a priority under the multi- sectoral response component with the technical support, guidance and supervision o f the MOH (especially the Health Promotion Unit). The multi-sectoral partners are well placed to support BCC activities and reach out to vulnerable groups within their constituencies. Similar to HAMSET, the project will have a multi-pronged approach inBCC: (9 Promote healthy behaviors through multi-level communication: The HAMSET Project already supported the development o f communication strategies for HAMSET diseases. Implementers will be encouraged to continue implementing such strategies under HAMSET 11. Peer-led BCC and IEC campaigns for general population and vulnerable groups should: (a) raise awareness about HAMSET diseases (andharmful practices such as FGM); (b) promote healthy behaviors; and (c) reduce stigma and discrimination. (ii) Promotehealthylifestylesthroughtheeducationsystem:HAMSETI1willcontinue to support the key priorities inthe school healthprogram o f the Ministry o f Education inthe FRESH Partnership (Focusing Resources on Effective School Health-WHO, UNESCO, UNICEF and IDA). HAMSET I1will finance activities to: (a) implement school health curricula developed under HAMSET; and (b) support peer-led health education (e.g. through student health clubs). School sanitation (e.g. construction o f latrines, environmental activities for schools) have already been financed by HAMSET and the Integrated Early Childhood Development Project. Therefore, HAMSET I1will only focus on the "software" aspect o f school health. (iii) Sensitize 1ocaVopinion leaders and decision makers: There i s a high level o f awareness and commitment to the fight against HAMSET diseases among local/ leaders and decision makers in Eritrea. However, they still need to be further 26Exceptions to this include multi-sectoral partners such as Ministryo fDefense, Information, and Cultural Affairs that do not have decentralized units. 54 sensitized, especially regarding (i)the need for targeting vulnerable groups; (ii) effective interventions for HAMSET diseases; and (iii) which require greater areas efforts such as TB, RH, FGM, etc. The project will finance sensitization workshops for local leaders and decision makers, and training o f journalists on the reporting o f HAMSET diseases inthe mass media. HAMSETclubs for out-of-school youth. (Target group: youth) BIDHO(PLWHA) IIEstablish BIDHO offices in all zobas, provide care and support to Workers Health Sector Response (US$ 14 million): This has five sub-components - HIVIAIDSISTI (US$3 million), TB (US$ 2 million), malaria (US$ 2 million), RH(US$ 4 million) andHuman Resources for Health (US$3 million). Each of the first four sub-components will comprise three activity categories: (a) Improve the information base for decision making: The project will support disease surveillance and reporting, surveys and operational research at the national, zoba and sub-zoba levels. Timely, comprehensive and crucial information on HAMSET diseases will be used for policy formulation, annual work program planning and for rapid response to outbreaks o f HAMSET diseases. Priority i s given to (i) disease reporting over "drop-in" surveys; (ii) routine activities that build in-country capacity and make use of existing mechanism such as the IntegratedDisease Surveillance system o f the MOH; and (iii) operational research with practical implications. Key areas for the project to support include: 55 HAMSET disease surveillance and reporting: The project will continue to support HAMSET disease surveillance initiated under HAMSET. For example, HAMSET I1 will continue to finance sentinel surveillance for malaria, second-generation surveillance for HIV/AIDS/STI, TB reporting and recording. For maternal health, HAMSET I1will support the introduction o f cause-of-death reporting and maternal audits to help monitor maternal mortality and it causes. This sub-component therefore will finance the required consultant services, workshops, training, test kits andreagents for biological surveys, other recurrent costs for surveys and surveillance. Epidemic forecasting and preparedness: HAMSET 11 will continue to support the implementation of the national strategy for epidemic forecasting which was initiated under HAMSET. Operational research: The project will continue to support operational research in program management, epidemiology, entomology, drugresistance, risk factors, community and individual knowledge, attitude, practices and behaviors in HAMSET diseases. Especially, for each o f the HAMSET diseases, one o f the major undertakings for the health sector response inthis category is to coordinate a socio-geographic mapping exercise o f high risk groups and the current coverage o f interventions among them to identify strategic populations and areas for targeted interventions. This mapping exercise will provide the basis for planning o f work plans by implementers andis expected to be completed within one year after the project's effectiveness. HAMSET I1will foster the systematic use o f information for policy formulation, planning and budgeting. This will be through the (i)dissemination o f information and findings to key implementers (especially those in the non-health sectors, zoba HAMSET coordinating committees as well as zoba implementers) through preparation and distribution o f reports; and (ii) ofsuchinformationintheeligibilitycriteriaforprojectfunding. use (b) Scale upprevention interventions: Inthe prevention o f HAMSET diseases, the health sector plays two roles -- as the implementer o f selected interventions and as the technical advisor to non-health implementers (e.g. non-health line-ministries, local governments and communities) in their prevention activities. In both cases, the project will support the MOH to coordinate and scale up the BCC program for HIV/AIDS under HAMSET and, wherever appropriate, expand it to cover all HAMSET diseases in one integrated message. The project will also support other effective non-BCC prevention interventions for HAMSET diseases (e.g. malaria vector control). Activities financed by this sub-component therefore include: 0 Supporting the HPUand the MOHtechnical programs to design and implement BCC and IEC activities; 0 Financing the salaries and operating costs o f BCC coordinators at the zoba level who will expand their current focus from HIV/AIDS to all HAMSET diseases; 0 Strengthening the capacity o f PHUand the MOHtechnical programs to provide technical advice, guidance and supervision o f activities conducted bynon-health implementers; 0 Supporting environmentally sound and effective techniques for malaria vector control (e.g. ITN, IRS,larviciding, environmental control measures); 56 e Supporting the MOHto conducting formative research on RHand, on that basis, develop a communication strategy for RH; and e Supporting MOH's condom distribution efforts in collaboration with the Eritrea Social Marketing Group. (c) Scale up diagnostic, treatment, care and support services: The project aims to help the MOH improve the availability, accessibility and utilization o f quality services for the diagnosis, treatment, care and support for HAMSET diseases. Specific activities to be supported by HAMSET I1 for the control o f each disease are described in each corresponding annex (see Annexes for HIV/AIDS/STI, malaria, TB and RH). Insummary, these include: e Directly Observed Therapy, Short Course for TB (DOTS); e Early detection and treatment o f malaria in the community and health facility, especially among under-five children andpregnant women; e Management o f severe and complicatedmalaria inreferral facilities; e VCT, PMTCT for HIV/AIDS; e Management o f 01inPLWHA; e Ensuringa safe blood supply; e Supporting ARV implementation (as ARVs will be funded mostly by the GFATM, HAMSET I1will only finance a part o f ARV procurement. Instead, the project will focus more on supporting services for ARV implementation); e Syndromic management o f STI, with laboratory confirmation when available; e Focusedantenatal care, newbom care andpost-abortion care; and e Skilled attendance at delivery, EmOC and child spacing. Scaling up such activities will be a prioritized for the lower levels (zoba and sub-zoba) and for vulnerable groups where applicable. For the above activities, HAMSET 11will finance relevant drugs, reagents and medical supplies, equipment, minor renovation o f RH facilities, recurrent costs (where applicable) such as salary, per diem and incentives for MOH staff, operating and maintenance costs for facilities and equipment, as well as transport costs. (d) Human resourcesfor HAMSET diseases (US'$3.0 M): HAMSET I1will help the country to improve its human resources in the fight against HAMSET diseases and RH by supporting the development and implementation o f an overall HRH policy and strategic plan. Namely, the project will support the MOH to: (i) consolidate existing HRHpolicies; (ii) a five-year develop National Strategic Plan for HRH; and (iii) formulate and implement annual HRHwork plan in a coordinated manner across the sector. With regard to training, the project will support pre- service and in-service training, with an emphasis on an integrated approach to training in HAMSET diseases. The shortage o f midwives and anesthetists i s particularly dire and will be given special attention in response to the urgent RH needs. In addition to training, this sub- component also aims to address other systemic HRH issues such as HRH management, retainment and deployment, as well as the piloting o f incentive mechanisms for HAMSET service providers, etc. Under this component, the project will finance required consultancies, 57 workshops, recurrent costs for pre-service and on-the-job training, as well as development and dissemination o f training materials. Community Managed HAMSET Response Program (US$ 4.0 million): Building on the lessons and experiences o f HAMSET I,this component would finance: (i) community-demand driven subprojects that are effective, results-based and for which communities have a comparative advantage; and (ii) capacity development interventions for subproject implementers at the local level. Under HAMSET 11, CMHRP would aim to more closely relate investments in subprojects with humanand social capital development. For HAMSET 11, a results-based framework closely aligned with national objectives and priorities for addressing HAMSET diseases would be adopted, and within this fiamework a pilot an open menu along with a negative list inorder to provide flexibility and allow innovations for communities to identify and select their subproject interventions, based on their comparative advantage. Community-based subprojects would be implemented applying CDD approaches in order to give greater control over decisions and resources to community groups and local level stakeholders, inpartnership with local administration. In the initial phase, three windows for providing grants for community subprojects would be piloted: Window "A" includes subprojects with a value <$300, to be appraised and approved at village level andwith support from Village HealthCommittees. Window "B" includes subprojects with values ranging from >$300 but <$3000, to be appraised and approved at zoba level. Window "C" includes subprojects with a value <$5000 and which are specifically targeted to vulnerable groups, to be appraised and approved at zoba level. Subprojects to be financed under this Window are expected to be initially co-managed by beneficiary communities and relevant partner agencies collaboratingunder the Multi-Sectoral Response Component (i.e. BIDHO, Faith Based Organizations (FBOs), NUEWS, etc.) untilthe capacity o f the former is developed. An enhanced resource allocation andtargeting framework for HAMSET I1is beingdeveloped to better target vulnerable groups. Resource allocation and targeting would be undertaken to in order to: (a) ensure that a concerted effort i s made to reach vulnerable groups who have not, so far, beenable to fully benefit from CMHRP; and (b) serve as a monitoring mechanisminorder to assess if regions and specific geographic areas are able to meet their targets and to offer assistance (capacity building) where they are laggingbehind. This component would also assist HAMSET I1 to intensify its efforts to enable genuine community-driven development by enhancing community members' and their associated organizations' skills in social promotion, community mobilization, participatory planning, and community identification, prioritization, andmanagement o f subprojects. It would pay particular attention to collaborative facilitation, participatory monitoring and evaluation exercises to be 58 carried out at the local level. The bulk o f capacity development interventions for CMHRP would be strategicallyprovided along the subproject cycle. (For more details, please see Annex 9). Project Management and Coordination, Capacity Building, M&E, and Innovation and New Policy Development (US$3 million): This has four sub-components. (a) Project management and coordination (US$ 1.0 M): This will cover the operating costs o f the national and zoba Project Management Units (PMU) as well as the costs for coordination o f project activities at the central level. (b) Capacity building (US$0.5M): This aims to mobilize andbuildthe capacity o f non-health cadres (e.g. in non-health sectors, communities, and local governments) in planning, management and implementation o f project activities. The project will promote knowledge sharing andthe disseminationo fbest practices among the implementers. (c) M&E (US$1.0 M): While the Health Sector Response Component supports epidemiological and behavioral surveillance, disease reporting, etc. (the outcome and impact aspects o f the overall M&E framework), this sub-component focuses on cross-cutting, operational aspects o f M&E. These include institutionalizing routine programmatic monitoring and scaling up the successful Rapid Result Initiative pilots (which, by their nature, is a decentralized participatory M&E approach). A dedicated budget will be available for this purpose. For example, implementers will be provided a top-up as a small percentage o f their approved financing for routine M&E. For those who implement their work programs using the RRIapproach, technical assistance will be provided under this sub-component. The project will finance required consultancies, training, workshops, development of management and information systems to facilitate the implementation o f the national M&E frameworks for HAMSET diseases (see Annex 3 on M&E). (d) Innovation and New Policy Development (US$ 0.5 M): This sub-component supports the development, piloting and evaluation o f innovative approaches in service delivery which can then be used for system-wide application; for example, incentive mechanisms for service providers and users, conditional cash transfers for maternal and child health, community report card of HAMSET services, preparationwork for SWAP,etc. 59 Annex 5: HIV/AIDS/STI ERITFWA: HIV/AIDS/STI,TB, MalariaandReproductiveHealthProject(HAMSET11) Epidemiology Eritrea has a relatively stable HIV/AIDS epidemic with the general adult prevalence rate at 2.4 percent in 2003 (compared to 2.8 percent in 2001) and the disease still mainly confined to high risk groups and certain urban "hot spots". The main mode o f transmission in Eritrea is heterosexual sex between casual partners and this has been the main focus of the Government's response. CountryResponse The MOHhas a 2003-2007 National Strategic Plan for HIV/AIDS implemented by the National HIV/AIDS/STI and TB Control Division (NATCoD). NATCoD has five units: Prevention and Counseling Unit, HIV/AIDS Care Unit, TB Control Unit, and an Epidemiology and Monitoring Unit. Thenationalstrategy hasninepriority areas: 1. Strengthening o fthe multi-sector response to HIV/AIDS; 2. Scaling-up activities to prevent the sexual transmissiono fHIV/AIDS; 3. Increasingthe availability and capacity o fhumanresources inthe health sector; 4. Promoting early diagnosis andtreatment o f sexually transmitted infections; 5. Promoting the early diagnosis o f HIV infection through increased access to voluntary counseling and testing and the prevention of mother to child transmission o f HIV for the general population, and especially for the military, youth, andwomen; 6. Ensuring blood safety and adherence to universal precautions inhealth care settings and intraditional medicalpractices; 7. Improving the availability and quality o f comprehensive health care for people living with HIV/AIDS; 8. Expandingthe availability and quality o f psychosocial and economic support for people livingwithHIV/AIDS; and 9. Strengthening research, surveillance, monitoring, and evaluation of the HIV/AIDS/STI epidemic; Progress includes an almost universal awareness (99 percent) o f HIV/AIDS and its major modes of transmission, a reduction inthe number o f casual partners among young adults, a 20 percent reduction in STI cases in health facilities between 2001 and 2003, the establishment o f VCT clinics ineach zoba, the screening o f all donated blood and the exclusive use o f volunteer blood donors. Inhealthcare settings, guidelines for universal precautions, Post Exposure Prophylaxis (PEP), and medical waste management have been developed. Due to experience from neighboring countries, the army was targeted early with a variety o f programs and HIV prevalence has remained low inthis group. 60 Support from Other Donors The GoE's response via NATCoD has received support from several donors, including IDA, the Global Fund, USAID, and UNAIDS. The Global Fund has committed over US$8 million for HIV interventions insupport o fthe EritreanHIVIAIDS strategy, o fwhich over US$3 millionhas been disbursed to date. In addition to this donor-sponsored national intervention, there are multiple smaller donor programs by UNDP, Catholic Relief Services, UNFPA, Norwegian Church Aid, and Lutheran World Federation. These programs are limited in scope and rarely have budgets more than US$200,000 per year. Monitoring and Evaluation and Research The "Eritrea Risk Groups and Behaviors Identification Survey" (HIV/AIDS-RGBIS), a survey of HIV/AIDS risk group andrisk behaviors was completed in2001. It is a nationally representative cross-sectional sample survey of 4,753 individuals aged 15-49. The study included the general population and four subgroups: the army, antenatal attendees, bartender^^^, and students. Knowledge o f HIV/AIDS was almost universal at 99% with no significant variation across subgroups or geography. Knowledge o f prevention measures was high, especially among younger age groups. Unfortunately, this didnot translate into highcondom use: only 18 percent of young respondents reported using a condom at first sexual intercourse and on average there were four years between first sex and first use o f a condom. The study revealed that the group most likely to be HIV positive is bartenders. This highrate needs to be further investigated to identify possible links (impaired decision making due to use of alcohol and drugs, association of bars with commercial sex trade, and bartenders 60 percent perception of `no risk' for STI, etc) and potential interventions. The age groups most at risk for infection were young adult women (ages 20-34 years) and adult men (ages 25-39 years). The study also revealed that awareness o f non-HTV STDs and their affect o f HIV transmissionwere low. Radio was identified as the most common source o f general knowledge and knowledge regarding HIV/AIDS while less then one fifth of responders identified a health worker as a source of information about HIV/AIDS. Considerable knowledge gaps were identified. For example, a greater percentage o f respondents identified blood transfusion as means of transmission (15%) than vertical transmissionhreastfeeding (14%). At 89 percent, Eritrea has one o fthe highest rates o fFemale Genital Cutting (FGC) inthe world. There is evidence to support that FGC leads to increased HIV infection both through the use of contaminated cutting instruments as well as through the increased likelihood o f tissue damage andbleeding duringintercourse. 27Pleasenote that since the Eritrean law against commercial sex work i s strictly enforced, commercial sex workers are often referredto as "bar and hotel workers". 61 Figu af 90 - ___.- ____.- ..-I- - 80 70 60 w 50 a t 40 30 20 10 0 HAMSETApproachto HIV/AIDS In order to facilitate implementation and supervision, the project components are organized according to the implementers o f the activities and HIV/AIDS is integrated into these activities along with TB, malaria, and reproductive health. In this section, the HIV/AIDS activities are separated to get a complete view o f the comprehensiveness o f the planned HIV/AIDS interventions. Prevention and Stigma Reduction: The GOE recognized early on that HIV/AJDS is a cross- sector issue and that all ministries and sectors must get involved in order for the epidemic to be reversed. Each ministry will provide services to both their intemal clients (employees and their families) and to their external clients (the people whom the ministry serves). The Ministry of Education is expected to play an important role due to the vulnerability o f school-aged children, particularly adolescent girls, to HIV/AIDS and the "captive audience" of students. BIDHO networks o f PLWHA will play an important role in creating a supportive environment for PLWHA. Activities will occur on a national, zoba, and community level with each level conducting the interventions most suited to its skills. National IEC will include celebrities and opinions leaders inpublic service announcements. This work will lead to awareness but probably not result in much actual behavioral change. The work on the community level will be peer to peer, last longer, andmove people firther along the stages o fbehavior change toward initiation o f the new protective behavior andthen to maintenance o f the behavior. The MOH has a separate component for its involvement inHIV/AIDS/STI. The activities will improve the diagnosis and treatment o f HIV/AIDS/STI (described below). There is also a separate cross-cutting component on improving Human Resources for Health for HAMSET diseases, including the development o f an HRHstrategy. YCT: Voluntary Counseling and Testing centers have been opened inevery zoba inEritrea. In HAMSET 11, VCT services will be expanded to make services more accessible to high risk groups. For example VCT services will be made available at truck stops. In selected urbanhot spots, adults will be offered VCT with an "opt-out" option whenever they come into contact with the health system. . Safe Blood: Great strides were made in the improvement o f blood safety during HAMSET. With the addition o f reproductive health and Emergency Obstetric Care (EmOC) into HAMSET 11, the demand for blood is expected to increase and the capacity to deliver safe bloodwill need to be scaled up to include every health facility that will be providing EmOC. Activities will include the training o f lab technicians, the purchase o f testing kits, and the expansion o f blood processing, refrigeration, and delivery systems. N o w that Eritrea has strengthened an unpaid blood donor policy, new methods o freachingout to potential blood donors will need to be found. One possibility includes integrating appeals for blood donation into antenatal care. Partners and relatives o f pregnant women receiving ANC can be educated on the role that donated bloods plays in saving women's lives. Other possibilities include integrating blood donation into the 63 community component, either by itself or in conjunction with community planning for emergency transport o fpregnant women with danger signs. PMTCT: Given fertility rates in Eritrea, there are over 150,000 pregnancies per year in the count$'. PMTCT in Eritrea will pose some challenges, given that most pregnancies occur in rural areas where less than 20 percent o f births occur in health facilities. In 2001 the Government started a pilot PMTCT project in three sites in Asmara where 70 percent o f all pregnant women receive antenatal care and 90 percent o f all antenatal attendees deliver in a health facility. Lessons learned from this pilot project will be usedto expand the program. Care for P L W A and Impact Mitigation: The GoE has devised protocols for treating opportunistic infections (OIs), but several barriers still need to be surmounted. Methods to diagnose most 01s are not available and only a handful o f staff have been trained in01diagnosis and management. Several o f the needed medications are not on the essential drug list and most PLWHA are not aware of their status or where to go for treatment. Psychosocial support networks are just being established in Asmara with no services available elsewhere. Impact mitigation will involve support in income generation. Home care will provide support and dignity to those dyingo f HIV/AIDS. Efforts by Faith Based Organizations and BIDHO will be supported inthis area. The Government plans to treat 2,000 o f the estimated 60,000 to 70,0000 PLWHA with ART. The standard regime consists o f Nevirapine, Lamivudine, Stavudine which i s provided through special clinics. Through the Global Fund, money is available to purchase more ARVs but there are not funds allocated for the clinical, diagnostic, logistic, and supportive services that are needed to ensure consistent, high-quality ART and to prevent development o f resistance. HAMSET I1will support an analysis o f the contents and costing o f an appropriate minimal package o f services that must all be available in order to start a person on ART. Given the limited funds available for HIV/AIDS, the GoE and IDA will decide what amount to allocate to ART versus other forms or prevention, care, and support. Orphans: The GoE has recognized that the AIDS epidemic has increased the number o f orphans and vulnerable children beyond the coping abilities o f families and communities. The IDA- funded IECD project which is expected to close this year has done very successful work in the field o f orphan care and as IECD prepares to shut down, HAMSET I1will continue and expand GoE's orphan support. These activities will be part o f the community response component o f HAMSET I1 and also part o f the multi-sectoral interventions by the Ministry o f Labor and Human Welfare. Possible activities include economic, nutritional, and psychosocial support, support to stay in school, vocational training, and income generating skills. See the annex on community responses for more information on community support o f orphans and vulnerable children. Monitoring and Evaluation: In keeping with WHO'S "Three Ones", Eritrea has a unified national M&E system "to assess the magnitude o f the problem, track trends over time, identify emerging priorities, assist in advocating for greater investment in HIV/AIDS, and inform 29Global Fundapplication 64 decisions on resource all~cation.~'This system and the use o f the data it generates will be strengthened via improvements intechnology, training, supervision, analysis, andplanning. Research: Clearly more data are needed on HIV/AIDS risk factors, especially when compared to the wealth o f information from surrounding countries. One possible option for HAMSET I1i s to support the HIV/AIDS module o f DHS+, especially regarding the role o f male and female circumcision in HIV infection. Mapping and service targeting o f highrisk groups also needs to be conducted, especially for the groups inEritrea about which the least i s known: men who have sex with men and injection drugusers. Challenges The main challenges to the control o f the HIV/AIDS epidemic will be increasing condom use, especially with casual partners; continued expansion o f VCT and support services; and avoiding the complacency that can accompany early success. Although progress has been made, none o f the interventions have been operationalized on a national level. Given the near universal awareness o f HIV/AIDS, the focus o f HAMSET I1will be on scaling up behavior change to reduce risk factors especially among high risk and vulnerable groups. The desired behavior change includes: increased age o f first sex, reduced number o f casual sex partners, and increased use o f condoms for casual sexual encounters. Emphasis will be placed on creating an enabling environment within communities andhighrisk subgroups to make it easier for people to choose and maintain protective behaviors. The demobilization o f soldiers from the higher prevalence border areas back to their communities and families may result in an increase inthe rural areas which have so far remained at a low prevalence. Community involvement will need to be expanded, including tapping into the resources o f village health committees. More research i s needed on the barriers to condom use andthe behaviors o f highrisk groups including bartenders, commercial sex workers, menwho have sex with men (MSM), and Injection DrugUsers (IDUS). See the Tuberculosis Annex for information o fTB & HIV/AIDSjoint activities 30"The state ofEritrea's framework for monitoringandevaluating its nationalHIV/AIDS/STIResponse," September, 2004. 65 Annex 6: Malaria EFUTREA: HIV/AIDS/STI,TB, MalariaandReproductiveHealthProject(HAMSET 11) EpidemiologyinEritrea The epidemiology o f malaria in Eritrea is among the most complex inthe world. Transmission intensity ranges from year-round transmission in parts o f Gash-Barka to highly seasonal transmission in much o f the rest o f the country, to complete absence o f transmission in the highlands around Asmara. Most transmission areas o f the country are epidemic prone. With the exception of parts o f Gash-Barka, malaria transmission occurs almost entirely following the rainy season. Peak transmission season for inland regions runs from August through November. For the RedSea coast, the transmission seasonis from December throughMarch. Plasmodium falciparum is the primary infecting species, accounting for 84% of documented malaria cases. The remaining 16% i s caused by P. viva. In recent years, P. falciparum has developed moderate levels o f resistance to chloroquine, the traditional first-line treatment for malaria. Resistance to other antimalarials is uncommon. Studies conducted inthe last few years have demonstrated that Anopheles arabiensis i s the predominant vector o f malaria in Eritrea. Other Anopheles species play an insignificant role in malaria transmission. The predominant breeding site for An. arabiensis is small water bodies that develop on the edges of river beds as the rivers dry up. Adult mosquitoes prefer to rest and feed indoors, but have also been found to rest, to a lesser extent, outside. Currentstatus of malariamorbidity andmortality About 27,000 cases o f malaria were diagnosed at health facilities in 2004, which represents an 86% reduction since 1999. Another 88,000 suspected cases were treated by community health agents (CHAs) in the same year, which is a reduction from 120,000 cases in 2000. Overall, morbidity has dropped well over 80% since 1999, exceeding the goal set by Roll Back Malaria. Where malaria accounted for 32% o f outpatient visits and 28% o f hospitalizations in 1999, these figures have now dropped to 4% and 13% respectively. Duringthe same period, total outpatient visits increased by 8%. Similar results have been seen for mortality. Deaths o f patients seen at health facilities dropped by 84%; this represents a 35% decrease inthe case-fatality rate. Mortality o f children less than five years droppedby 53% andinolder children and adults by 64%. Controlstrategies The National Malaria Control Program (NMCP) and Zoba malaria control officers o f Eritrea have used a combination o f proven, cost-effective strategies for malaria control and have modified those strategies based on the findings o f aggressive monitoring and evaluation activities. The strategy strikes a balance betweentreatment andprevention activities. 66 The key strategies employed bythe NMCP are: 1. Early diagnosis, prompt treatment, and appropriate management: Persons with suspected malaria undergo appropriate diagnostic procedures and receive rapid effective drug treatment and supportive care, as necessary. Diagnosis and treatment is provided both at the facility level and inthe community, through trained CHAs. Severe cases will receive appropriate referral. During HAMSET, access to definitive diagnosis at the health center and hospital level was greatly expanded. Currently all hospitals and more than 80% o f health centers have this service. In addition, when evidence of chloroquine resistance was identified, national drug policy was changed to adopt a combination o f chloroquine and Fansidar (sulfadoxine- pyrimethamine) as first line treatment. This new policy has been implemented throughout the country. Efforts were also made to reduce stock-outs of drugs at health facilities. A recent health facility survey demonstrated that 82% o f health facilities reported no stock outs o f essential antimalarials in the last three months. More than 6000 CHAs have been trained inthe management o fmalaria inthe last 5 years andprovided with stocks o f antimalarial drugs. 2. IntegratedVector Management: Eritrea has employed a range o f interventions to reduce human-mosquito contact. Eritrea has used indoor residual spraying (IRS) for many years, but has become much more selective in its use. It has utilized surveillance data to target spraying activities much more effectively. Although DDT and Malathion continue to be the main insecticides used for IRS, HAMSET financed the identification o f environmentally-friendly alternatives to these chemicals. Under HAMSET, use o f alternative methods was greatly expanded. Inparticular, insecticide-treated bednets (ITNs) were significantly scaled-up inhigh risk areas. Approximately, 865,000 ITNs were distributed during the last five years and annual re-treatment campaigns now cover more than 0.5 million of these nets. Presently, about half o f all households in malarious areas have at least two ITNs. In addition, with the support o f U SAID'S Environmental Health Project (EHP), community-based environmental management and larviciding has been greatly expanded. EHP has also assisted NMCP inestablishing sentinel sites for monitoring vector dynamics and conducted assessments o f the effectiveness o f various vector control strategies. 3. Epidemic forecasting, early warning, and response: This has become a particularly important component o f Eritrea's malaria control strategy. NMCP, with the support o f the Research Triangle Institute, has developed an epidemic preparedness plan and has begun to implement it. It i s also working with this institute to improve its ability to forecast and detect epidemics. NMCP has procured reserve stocks o f drugs, bednets, and insecticides to facilitate its response to epidemics. 4. Operational Research: The NMCP has put great emphasis on conducting operational research and using the results to modify policies and programs. Drug efficacy trials provided essential information that led to a new malaria treatment policy. Entomologic studies have helped to clarify the predominant malaria vectors in Eritrea and helped to stratify malaria risk areas down to sub-zoba level and below. Pilot studies have been carried out on the use o f rapid diagnostic tests and to assess alternatives to DDT. Research is now focusing on the relative effectiveness o f various integrated vector management strategies. 67 5. Healthpromotion, communityeducation and involvement: Campaigns have been carried out to promote the use o f ITNs andrapid, effective treatment. Many o f these activities havebeen focused around Africa Malaria Day and National Malaria Week. Promotions activities have not yet been integratedwith other health promotion activities carried out bythe MOH. 6. Program management, supervision, and monitoring and evaluation: NMCP has an extensive, stand-alone surveillance system for malaria. As the MOHrolls out integrated disease surveillance, the malaria surveillance system will be incorporated into this system without compromising the valuable informationprovidedto the NMCP andZoba malaria authorities. Five year plan, 2005-2009 Buildingon the success o f the last five years, the NMCP and its partners have developed a new 5-year strategic plan for malaria control, covering the period from 2005-2009. The primary goal o f this plan is: To reduce morbidity andmortality due to malaria to such low levels that malaria is no longer a major public healthconcern inEritrea by the end o fyear 2009. Specific objectives include: 0 Reduce confirmed malaria related mortality by 50% between 2004 andthe end o f 2009. 0 Reduce reported malaria morbidity 30% betweenthe 2004 level andthe end o f 2009. 0 Reduce severe case fatality by 60% from that o f 2004, by the end o f 2009. 0 Prevent the occurrence o f malaria epidemics until2009. The new strategy builds on the existing successfkl program and continues all o f the current programactivities, including: 1. Earlydiagnosis andprompt treatment- at health facility andcommunity levels; 2. Lntegrated vector management- using selective IRS, scaling up ITNuse, and appropriate environmental management; 3. Epidemic forecasting and response- refining and simplifying current forecasting models for use at sub-national levels, strengthening capacities for quick response; 4. Operational research- to refine and strengthen existing strategies and assess new tools and approaches; 5, Health promotion- scaling up activities that promote prevention and control, integrating with other MOHhealthpromotion activities; and 6. Program management/Monitoring and evaluation- ensuring strong infrastructure for program implementation at all levels, strengthening use o f surveillance data inprogram decision making. It also details challenges to be addressed to further refine the program activities. Some o f these are: 68 0 Integrating malaria control activities with those o f other HAMSET diseases, as well as child health andreproductive healthactivities, particularly healthpromotion and service delivery at peripheral levels, and disease surveillance; 0 Further clarifying the effectiveness o f various vector control measures, particularly the role o f IRS, which recent studies have shownto be o f questionable value inparts o f the country; 0 Identifying cost-effective and environmentally friendly alternatives to DDT; 0 Developing strategies for preventingmorbidity andmortality inpregnant women; 0 Transitioning drug policy to adopt artemisinin-based combination therapy, as recommended byWHO; 0 Further refining and simplifyingprotocols for identifying and managing epidemics; and 0 Replacing current ITNs that requireperiodic retreatment, with long-lasting insecticide-treated nets. 69 Annex 7: Tuberculosis ERITREA: HIV/AIDS/STI, TB, Malaria and Reproductive Health Project (HAMSET 11) Epidemiology There i s little information on the epidemiology o f TB inEritrea. It is estimated that the Annual Risk o f TB infection is around 2 percent. This translates into over 8,000 new TB cases per year inEritrea, ofwhom 4,000 are infectious, smear-positive cases. With a HIV/AIDSprevalence of 2.4%, it seems that Eritrea so far has managed to avoid the HIV/TB dual epidemic which is ravaging other SSA countries. However, a 2004 study ina referral hospital inAsmara showed a HIV/AIDS prevalence o f 22.6% among 200 TB patients. This indicates the threat o f a dual epidemic is very real. Information on the situation of Multi-Drugs Resistant (MDR) TB in Eritrea i s not available. To expand the information base for decision making, a TB prevalence survey using florescent microscopy (financed by HAMSET, with technical assistance from Koninklijke Nederlandse Chemische Vereniging or KNCV, a Dutch NGO) is underway in Eritrea. National Response to TB The WHO-recommended DOTS strategy was introduced in 1996 and has been expanded to all 6 zobas. According to the MOH, 37 o f the 54 Health Centers are implementing DOTS. A National Strategic Plan (NSP) for TB (2004-2009) has been formulated. According to the NSP, the objective i s to increase coverage to 100percent, keep detection rates stable, and increase cure rate from 82.3 percent to 85 percent by 2006. The variety o f drug combinations currently being used will be standardized and drugs will be provided in fixed dose combinations inblister pack form rather than as loose pills to facilitate patient compliance andmonitoring TB control is the responsibility o f the National HIV/AIDS/STI and TB Control Division (NATCoD). At the zoba level, the Communicable Disease Coordinator (CDC) i s in charge o f coordinating TB control activities. Case detection: In principle, NATCoD adopts the passive case finding approach by sputum smear examination o f people presenting to health facilities with complaints o f chronic cough. In 2003, 4,708 new cases were detected (out o f the 8,000 new cases which were expected to occur in the population). However, the low proportion of smear positive cases (19%) and high proportion o f smear negative pulmonary cases (65%) points to possible problems with the quality o f smear microscopy as well as over-reliance on radiology for TB diagnosis. Findings o f the TB prevalence survey will shed light on this area. Treatment outcomes: According to NATCoD statistics, treatment success rate (sum o f cure and treatment completion rates) has been improved from 73% to 82.3% over the last two years. However, Bank field supervisions reveal various discrepancies and mis-categorization o f treatment outcomes in the TB reporting system at local levels. Therefore, such statistics might 70 not be accurate. Drugs are purchased through the Global Drug Facility and stock outs are reportedto be rare. TB & HIKAIDS: This area remains largely unexplored. Currently TB patients are not consistently counseled on HIV risk or referred for testing. Since TB is the number one cause o f death amongst PLWHA, a great deal needs to be done to put PLWHA on TB prophylaxis or into treatment should they develop active TB. The National TB Strategy has the following goals for HIV and TB: (i) establish integrated care of HIVIAIDS and TB in all primary health facilities by 2006; (ii) decentralize and combine training and supervision with HIV programs at the zoba and sub-zoba level; and (iii) joint Information andEducation Communication on TB, DOTS, andHIV. Donor Support: Inaddition to IDA support under HAMSET, the TB programhas been receiving assistance from the Italian Government and WHO in terms o f TB commodities and technical assistance. The Government currently does not receive TB funding from the Global Fundbut i s applying for funds through the next round. Summary of the challenges in TB: 0 Progress on tuberculosis has laggedbehindthat for AIDS andmalaria. 0 Quality o f the TB recording and reporting system is dubious. Current statistics might not reflect the actual TB situation. 0 A system o fsupervisionis not inplace. 0 Case detection needs improving, especially through strengthening o f smear microscopy andquality assuranceo fTB diagnostics. 0 TB management skills o f healthcare workers needto be improved. Lower TB staff need more training and support supervision. 0 Programmatic management needs to be strengthened at bothnational and zoba levels. 0 Transport for health care workers at the sub-zoba levels to follow up on defaulter cases is lacking. Approach of HAMSETI1 Support the key activities o fthe National Strategic Framework. Special areas for focus include: Capacity building(technical andmanagement skills); Quality control for smear microscopy; TB recording andreporting system; Programmatic M&E, regular supervision, quarterly monitoring meetings at the zoba level; Multi-DrugsResistance Tuberculosis surveillance; Operational research; Community DOT as well as other innovative means to follow up on TB patients at the community level; and HIV/AIDS and TB interface. 71 ProposedmilestonesunderHAMSETI1 Year 1: Fully operationalize the quality control system for smear microscopy (especially cross- checking o f smear microscopy); Complete training in programmatic management for key TB staff at national and zoba levels; Start the upgradingo f TB management skills for healthworkers (at least in3 zobas where DOTS outcomes are the worst); Implement the M&E framework for TB:supervision, monthly zoba monitoring meetings; Together with IDRS, conduct an audit o fthe TB reporting andrecording system ; Evaluate community DOT pilot under HAMSET; and Conduct first annualjoint-review for TB (with annual report). Year 2: 0 Continue the upgrading o f DOTS skills for healthworkers (inthe remainingzobas); 0 Scale up community DOT under the community response program; 0 Start Multi-Drugs Resistant TB surveillance system; and 0 Conduct Mid-termjoint-review for NSP for TB (with mid-tennreport). Year 3: Complete the upgrading o f DOTS skills for healthworkers (inthe remainingzobas); 0 Produce report on MDRTB; and 0 Conduct third annualjoint review for TB (with annual report). Year 4: 0 Conduct the joint-review o f the five year National Strategic plan (with five-year report); 0 Prepareandadopt the next five-year NSP. 72 Annex 8: Reproductive Health ERITREA: HIV/AIDS/STI, TB, Malaria andReproductive HealthProject (HAMSET 11) Introduction The MOH has identified reduction o f matemal mortality as the utmost reproductive health priority in Eritrea. The commitment was underlined at the conference on the Road Map for Accelerating Matemal and Newbom Health held in Asmara in October, 2004. With over 200 participants from all over the country, the conference discussed policy and strategic directions for improving matemal and newbom health and outlined a `road map' for achieving the objectives. Safe motherhood together with other components o f RHhas been emphasized in the new RH policy. The MOH intends to address child spacing, harmful traditional practices and adolescent sexual and reproductive health because o f their impact on matemal and child outcomes and gender. OverallAim and Strategy The overall aim o f the RH component o f HAMSET I1is to improve matemal and neonatal outcomes in Eritrea. This will be achieved by expanding availability and access to maternity services, by increasing their utilization through improved quality o f care, and by addressing specific gender-based harmful traditional practices that are a barrier to service utilization and impinge on the health andrights o fwomen. Both demand and supply issues31will be addressed through the implementation o f proven effective interventions in Safe Motherhood and for elimination o f gender-based harmful traditional practices. Special emphasis will be given to interventions that overlap with those for other HAMSET diseases in order to maximize the synergy and buildingon the success o f HAMSET. Synergy between reproductive health and H A M S E T diseases and benefits Reproductive health has been recognized as a major public health problem in Eritrea for a long time, as confirmed in the National Primary Health Care Policy o f 1998. To address the challenges and accelerate the pursuit o f the MDGs, the MOH intends to strengthen the reproductive program by integrating key interventions into HAMSET 11. There is a strong rationale for the integration based on the outcome overlaps and synergies: e Matemal and child MDGs cannot be achieved without improving access to reproductive health through the primary health care system. Matemal mortality is very high in Eritrea. The death o f a mother significantly decreases the survival chances o f her children. Inadequate care during pregnancy and child birth is also directly related to highneonatalmortalitythat accounts for 50% o finfantdeaths inEritrea; e Increasing access to reproductive health i s essential to improving the nutritional status o f women and children while greater attention to nutritional needs o f children, especially girls, is fundamental to their healthanddevelopment; 31Among supply interventions, one ofthe priority areas is security o fRHcommodities. 73 Because o f Eritrea's youthful population, investments in adolescent health and development should address their vulnerability to poor reproductive health, including HIVIAIDS; Identicalmodes o f transmission: HIV infection is predominantly transmitted through sex or from mother to child duringpregnancy and childbirth; Common risk groups: The same women and adolescent girls who are the most vulnerable to HIV infection are also at highest risk group for unplanned pregnancy and maternal morbidity and mortality. Adolescent sexual and reproductive health programs and antenatal clinics offer an ideal opportunity for expanding HIVIAIDS interventions to the vulnerable. Shared approaches - Pregnant women and children under 5 are the highest risk group for severe attacks o f malaria. Reaching mothers with bed-nets and IPT through antenatal clinics i s a known effective intervention inmalaria control programs. Similarly, PMTCT clients are a ready entry point for ART programs. Integrating reproductive health and HAMSET should bringincreased benefit to all, more so for women, children U5 and adolescents living indeprived rural areas by: Enhancing focus and investment on interventions to promote maternal and child health andeffective utilization o fexistingresources; Reducing health risks andburden o f disease associated with pregnancy and child bearing for women; Improving child survival by expandingprogram coverage, intensity and effectiveness o f interventions; Reducing sexual and reproductive health risks for adolescents by encouraging behavior change with specific attention to HIVIAIDS and early pregnancies; Encouraging community participation and ownership o f HAMSET activities, and addressing healthrelatedharmfultraditional practices and gender concerns; and Enhancingmultisector interventions to address factors beyond the health sector. Status of Reproductive, Maternal and ChildHealth in Eritrea Demographic indicators: Eritrea has a young population that exhibits the broad based pyramid typical o f countries at the beginning o f the demographic transition. Although there i s no recent census data, the population is currently estimated to be 4.4 million. Total Fertility Rate (TFR) is estimated at 4.8 (EDHS, 2002) and is higher in rural (5.7) than in urban (3.5) areas. It is projectedthat the population will increase by 20% by 2010 and by 50%, to nearly 6.5 million by 2020. Population under 15 years was 43% in2002 and is expected to increase inabsolute terms from 1.9 to 2.3 million by 2020. This youthful population will continue to drive Eritrea's population growth over the next two decades, despite declining fertility trends (from 6.7 to 4.8 children per woman between 1990 and 2002). Dependencyratio inEritrea is highand continuing to rise. In2002, almost halfthe populationwas either below 15 years or above 65 years, givinga total dependency ratio o f almost 100%. Today, Eritrea's vulnerable population is estimated to be 2.2 million, increasing from 1.9 million in 2004. Over a million internally displaced persons returned to their homes but are unable to restore livelihoods due to prevailing economic hardships. 74 Matemal and child health indicators :Although there have been tremendous healthachievements inrecent years, M C His still indire straights inEritrea. The reasons are many, including lack of knowledge on risks and illnesses, poor access to RH/MCH services, poor nutrition, hannfil traditional practices, and low levels o f education and low socioeconomic status o f womerdgender inequalities. 0 Poor access and utilization of RH services: Access and utilization o f M C H services in Eritrea is less than optimal. This was confirmed by EDHS (2002) where 72% o f women reported at least one constraint to seeking care. Cost, distance and lack o f transport were by far the commonest reasons sighted. 0 Family planning. The family planning program has not done well in Eritrea. Family planning has previously been sensitive and it has been easier to discuss it in the context o f child spacing and benefits to both matemal and child health. Spacing o fbirths for two years or more confers significant benefit not only to the mother but also to child survival. The CPR stagnated at 8% between 1995 and 2002, making it one o f the lowest inthe region. The DHS, however, confirmed increasing knowledge and awareness o f modem methods and desire to space and limit family size. There was also greater acceptance of FP among urban women (17%) who were up to four times more likes to use a family planning method than rural women (4%). Contraceptive use is closely correlated with female education and access to services. 0 Maternal and newborn health. Matemal and perinatal ill-health, together with childhood conditions (diarrhea and ARI) constitutes 50% o f the burden o f disease inEritrea. Malaria i s a major public health problem that affects 75% o f the population, especially children U5 and pregnant women. It remains a major cause o f indirect matemal mortality. Safe motherhood: Although much improvement has beenrecorded over the last two decades, matemal mortality rate i s still high, estimated variously at 998/100,000 live births between 1984 and 1994 (with a lifetime risk o f 1:14 inDHS, 1995) and 752/100,000 live births (with a lifetime risk o f 1:28 according to a 2005 study by Ghebrehiwet 32. This study also reported significant regional variations: from 46/100,000 in Zoba Maakel to 1,261/100,000 in Zoba Southem Red Sea. Three of the six zones (Anseba, Gash Barka and Southern Red Sea had MMR above 1,000/100,000 live births. Forty eight percent (48%) of matemal deaths occurred during delivery and 36% after. Direct causes o f matemal mortality in Eritrea are similar to elsewhere inAfrica with unsafe abortion as the single biggest killer. Other causes include hemorrhage, sepsis, obstructed labor and eclampsia. 32Ghebrehiwet, M.2005, Thehigh maternal mortality in Eritrea: determining riskfactors and health care gaps. Dr.PHThesis.Johns HopkinsUniversity,Baltimore, USA. 75 d to hc :rbrxvc 80%. child health indicators are worse among the semi-nomadic group that form 30% of the Eritrean population. Here, family planning i s almost non existent and antenatal care and skilled attendance in labor rare. Anemia in pregnancy is prevalent and hemorrhage, obstructed labor andcomplications o fabortion account for most maternalmortality andmorbidity. Child health and nutrition. Although child health indicators in Eritrea are poor, the trends have been more encouraging thanfor maternal health. Infantmortality rate decreased from 81 to 48/1000 live birthsbetween 1990 and2002. Under5 mortality also followed a similar trend, decreasing from 140 to 93/1000 live birthsbetween 1992 and 2002, albeit with significant rural urban inequities. Diarrhea, acute respiratory infections (ARI)and malaria are the commonest causes of child mortality and morbidity. Recent reports (EDHS 2002) show that although Under 5 diarrhea and ARI are common, only 68% o f mothers with children with diarrhea used ORT and 44% of children with ARI received modern health care. Under-5 malnutrition i s high and has seen little improvement since 1995. Over 50% o f U 5 are stunted and another 13 underweight. The prevalence o f underweight is highest inthe 6-24 month age group, a reflection o fboth low birthweight and poor weaning practices. Childhood anemia is equally prevalent, seen in 50% o f U5 children. This is higher than the regional average o f 32% and indicates the need to improve supplemental feeding and awareness o fmothers. Mother's education i s a major factor inchild malnutrition inEritrea. The 2002 EDHS also reported a full immunization rate o f 76% at 12-23 months. This was a slight decrease on the 2000 EPI survey which showed 79.4%. Overall most immunizable diseases were on the decline inthe last decade, indicating the success o f EPI. Tetanus data have been erratic, probably due to the poor performance o f antenatal care and TT efforts. Harmful traditional practices, which are gender-based, continue to undermine the health of women and children in Eritrea, especially those linked to nutrition and sexuality. FGM is the best known example. Eritrea has had a strong anti FGMprogram that has resulted in a modest drop inprevalence from 95% to 89% between 1995 and 2002. The decline was most notable in younger women below 25 years, indicating a change inpractice inthe communities. Government's Policy The current draft National Sexual and Reproductive Health Service Policy and Guidelines i s comprehensive and has been endorsed by all stakeholders. It builds on the previous outline and has the following components: 0 Adolescent Sexual and Reproductive Health (ASRH) 0 Safe Motherhood 0 Abortion Care 0 Child Spacing 0 Prevention andmanagement o f STDs, including HIVIAIDS 77 e Preventionandmanagement o f infertility e Preventionandmanagement o f cancers o fthe reproductive system e Management o fMenopause, Andropause andSexual Dysfunction e Women's Health and development, including reduction o f Domestic Violence harmful traditional practices such as FGM InterpersonalCommunication and counseling Reproductive Health Component of H A M S E T I1 The package o fplannedinterventions includes: Focused antenatal care. Inthe last decade, experts realized that mere access to and utilization o f antenatal care was not an effective way o f predicting which women are likely to develop life threatening complications during pregnancy and childbirth. The risk screening approach often incorrectly picked women who did not develop complications while missing many who subsequently had complicated pregnancy. Inaddition, the risk screening created a false sense o f security for women categorised as low-risk andtheir health providers. Antenatal care can detect and treat chronic conditions such as anaemia, diabetes and hypertension through clinical examination and laboratory tests (Hb and urinalysis) and is still an essential and important link betweenthe woman and the health services. To make it more effective, experts now recommend a more focused approach to antenatal care consisting o f four visits and: e Counselling about danger signs o f pregnancy and delivery complications andwhere to go incaseofemergency; Supplyo firon, folate andvitamin A supplements; Advice onproper nutrition duringpregnancy and lactation; Treatment o f conditions that affect pregnancy such as malaria, TB, hookworm infections, STDs, including HIV/AIDS; Providing tetanus toxoid immunizationsto protect the newbom; Voluntary HIV counselling and testing; Information on breastfeeding and contraceptives; and Screening for domestic violence andproviding appropriate counselling andreferral, Prevention of mother to child transmission o f HIV (PMTCT) will be offered as part o f the matemity package, starting with VCT for HIV in selected antenatal clinics. Using standard WHO protocols already tested in existing pilot sites in Asmara, the project will support expansion o fPMTCT programs to at least four other major towns. Skilled care during;preqnancv and deliverv. This i s defined as the process by which care i s provided to a woman and her newbom duringpregnancy, childbirth and immediately afterwards by a skilled health provider properly supported with equipment, supplies, communication and transport. Less than half o f births in Eritrea are assisted by a skilled\attendant due to such constraints as, availability (serious shortage of skilled attendants); access (physical, cultural and financial obstacles) and; poor quality o f care (both clinical and interpersonal staff attitudes). Studies also show that distance i s a major factor in the utilization o f skilled attendants by communities. Only one third as many women utilize these services when the facility i s 120 78 minutes away compared to 30 minutes. The project will improve access to skilled care by accelerating the training o f additional midwives and in service training in Life Saving Skills (LSS) and newborn care for doctors, nurses and associate nurses. Supplies and equipment will also be addressed. Special focus will given to behaviour change and community mobilization and ensuring a continuum o f care with emphasis on lower health facilities where most deliveries take place and are the first line o f contact with patients. Policies, norms and guidelines will be reviewed to support this process. Emergency obstetric care (EmOC) refers to management and treatment o f obstetric complications. It does not typically include preventive care, monitoring o f labour or newborn care. EmOC i s divided into basic (undertaken at lower levels o f facilities) and comprehensive (undertaken in at secondary or tertiary levels, usually involving a physician who i s able to perform a caesarean section). Although an EmOC survey has not been done, indications are that the situation in Eritrea is dire. The project will therefore support an EmOC survey and will strengthen delivery o f emergency services at the various levels, including review o f policies and establishment o f clear norms and guidelines for delivery o f services. Renovations are envisaged to provide theatre facilities in sub-Zoba hospitals for which equipment and supplies will be provided. Since Eritrea has only six obstetricians, Medical officers and Clinical officers will be appropriately trained inCaesareansection and LSS. The number of Nurse-anaesthetists will also be increase. to cover for expansion o fEmOC. Postnatalcare is the service provided to women inthe first 42 days after delivery. Most maternal deaths occur during this period, especially the first 24 hours, from complications such as haemorrhage, sepsis and eclampsia. Post natal care aims at maintaining the physical and psychological well being o f the mother and her newborn but is rather underdeveloped inAfrica, Eritrea included, Most mothers are discharged within 24 hours o f delivery inEritrea, makingan even stronger case for an organized PNC. Post abortion care. Complications o f abortion are a major cause o f maternal mortality and morbidity inEritrea. It accounts for 40% o f maternal deaths at the national Referral hospital in Asmara, 40% o f outpatient and 50% o f gynaecological admissions. The MOH, with support from UNFPA andUSAID, is introducing post abortion care (PAC) which will be available inall hospitals and health centres, performed by both physicians and nurses. PAC will include all the four elements: emergency evacuation o f products o f conception by manual vacuum aspiration (MVA), post abortion counselling and family planning, linkage with RHservices for follow up, and community participation and involvement. The project will supplement the contribution o f UNFPA and USAID to ensure that targets for PAC training and purchase o f MVA equipment andsupplies are met. Emergency referral i s a critical part o f safe motherhood. The project will adopt the Four Delay Model (Delay inrecognizing danger signs; in seeking care; inreaching appropriate care; and in receiving care at health facilities) approach to address this issue. While ambulances and telecommunication will be needed, the lasting solution lies ineffective liaisonbetween the health sector and communities and improvement o f roads and other transportation systems. The project will enhance referral systems between communities and health care providers by encouraging communities to create emergency transportation plans and establish maternity waiting homes 79 where appropriate. Telecommunication will also be addressed within the network limitations in the country. Child spacing or family planningis defined as a way o f thinking and living, adopted voluntarily, upon the basis o f knowledge, attitudes and responsible decisions by individuals or couples, in order to promote health o f the family group and thus contribute to social development o f a country. It allows couples and individuals to prevent mistimed, unwanted or high risk pregnancies and is therefore one o f the key pillars o f Safe Motherhood. Family planninghas not taken o f f in Eritrea and the CPR is one o f the lowest in the region. The project intends to promote child spacing through community mobilization and improved access to quality services. Within this context the feasibility o f expanding the community based distribution (CBD) approach will be considered. Capacity building. Shortage o f skilled service providers i s the most critical constraint to delivery o f RH services in Eritrea. There are 212 doctors (including 6 gynaecologists and 6 paediatricians), 993 nurses and 1576 associate nurses working for the MOH. Only 11% o f the nurses are midwives. Human Resources for RH is therefore a major area o f concern and the project will address it by supporting both pre-service and in-service training, taking into account the contribution o f other development partners. Planned capacity building activities are - training includes, pre-service training for 200 new midwives, 20 anaesthetic nurses; and extensive in service training in LSS, focused ANC, PNC, Amok and PAC for various cadres o f staff (see Operational Manual for details). Pre-service training will be coordinated by the R&HRDwhile the RHUwillberesponsible for in-servicetraining. Inlinewiththe MOHpolicy, training ofsemi-skilled communityhealthworkers suchas TBAs will continue andtheir activities closely integratedwith localhealth facilities. TBA activities are also eligible for funding from the community component o f HAMSET. The specific role o f TBAs needs special attention. Given the shortage o f skilled providers/midwives and prevailing cultural practices, communities will continue to trust and use TBAs for the foreseeable future. Recognizing what research has shown regarding their effectiveness in reducing maternal mortality but bearing in mind the reality o f the situation in Eritrea, the project will support training o f a number o f TBAs to recognize obstetric emergencies and promote early referral. They will be integrated with the health system, including allowing them to accompany the womento the facilities hospital andparticipation inmaternalmortality audits All the training activities will be harmonized and integrated to minimize duration o f absence o f staff from their duty stations. Infrastructure. The project will not support major infrastructure development. It will however support selective minor renovations and construction deemed to be o f directly relevance and benefit to RH, especially inimproving qualityof care. This includes renovations for EmOC (e.g. improvement of theatre facilities or additional space); renovations for skilled attendance (e.g. extra space and privacy for delivery or management o f pre-eclampsideclampsia) and modest installation o f utilities such as water and electricity. Maternity waiting rooms are not included in this package andwill be considered under the community component. Needs assessment will be conducted to inform selection o f projects to be supported and priority will be given to rural 80 facilities in the most deprived areas and to the health centres being upgraded to Community Hospitals. It i s noted that most health facilities inEritrea are inreasonable state andother donors are supporting infrastructure improvement. Eauipment. drups and supplies: The project will procure specific equipment and supplies to facilitate delivery o f appropriate maternal and newborn care. Eritrea has recently received RH equipment from other donors and the project intends to fill the critical gaps, identified by the needs assessment process. Pharmaceuticals and other consumable supplies will also be covered by the project, including antibiotics, analgesics, intravenous fluids, anaesthetic drugs, oxytocics, Diazepam, Magnesium sulphate, Ferrous sulphate, Folic acid and Vitamin A. Contraceptive security i s another important consideration. UNFPA i s currently supplying all the contraceptives as well as MVA equipment for PAC. With increasing demands for FP, support at current levels may soon be insufficient. To cater for the uncertainty and avoid any shortages, the project will provide an allocation for both FP andPAC commodities. Such funds will be used to cover other pharmaceuticals and supplies ifnot needed for the intended purpose. Focused ANC requires improved laboratory services. Currently, syphilis screening, blood grouping andHb are not routinely done inANC. It is estimated that 4% o fEritreanpopulation i s Rhesus negative, indicating that considerable rhesus iso-immunisation may be takingplace but i s undetected. The project will therefore support improvement o f laboratory services as detailed in the work plan, to ensure that all Health centres and hospitals can do urinalysis (uristicks for protein), Blood group/Rh and haemoglobin. The Global Fundwill provide adequate test kits for syphilis. Behaviour change and community mobilization. There a range o fphysical, cultural and financial obstacles that prevents women and communities from using available maternity services. Women's low status, lack o f education and income, and limited rights and freedoms also affect their ability to seek and receive quality care. Bringing these barriers down requires a strategy that goes beyond information and awareness creation. The project proposes to apply Behaviour Change Communication, an informed approach for promoting and sustaining behaviour change in individuals and communities, implemented through the development and dissemination of specific health messages using a variety o f channels. This should make it possible to achieve strategic and measurable behaviour change because it will be based on in-depth qualitative understanding o f knowledge attitudes and values o f communities; it will identify current behaviour among women, community leaders and men and promote desired behaviour that is feasible; it will identify and address barriers and constraints to behaviour change; it will also identify external barriers such as perceived poor quality o f services and staff behaviour that discourage utilization o f maternity services by communities. The five core issues to be addressedby BCC are e Attitudes o fhealth providers e Birthspacing andfamily planning Safer sex (ABC), Safe motherhood (ANC, Skilled care and obstetric emergencies) and, 0 Harmfultraditional practices (FGM, early marriage, adolescent pregnancy, gender-based violence, feedingpractices andnutrition). 81 Multisector activities will be supported under a different component o f HAMSET. Itis clear that many factors influencing maternal and newborn outcomes lie outside the health sector. Harmful traditional practices and gender issues fall in this category. The key sectors for RH include: Education (Family Life Education programs); Labour (Culture and gender concerns); Local Government (Community mobilization and coordination); Information (information, education, communication, advocacy and community sensitization); Transport and Communication (Roads and emergency referrals) and Agriculture (Food security and nutrition). All these sectors have extensive outreach that will be mobilized to supplement RH activities by the health sector. The project will buildon the success o f HAMSET inthis endeavour, linking closely with HIV/AIDS andMalaria andharmonizingthe messages and activities. Role o f other donors. The role and extent o f other development partners to RH in Eritrea is summarized in Annex 2. The project design has taken these activities into account, to ensure complementarity and reduce overlaps and avoid duplication. Great care has been taken to harmonize and coordinate HAMSET I1supported activities with others and ensuring that the MOH and PMU are in the driving seat, playing the critical coordination role. This will be supported by the joint supportive participation o f the RHCoordinating Committee, consisting o f all donors working inRH, which meets once a month. Joint supervision o f activities will also be encouraged. Monitoring Progress. In line with the National Sexual and Reproductive Health Policy and Guidelines, the RH component o f HAMSET I1is planned and will be supervised, monitored and evaluated within the context o f the overall PrimaryHealth Care (PHC) program. This bottom-up approach will be augmented to satisfy project specific requirements and in conformity with the national integrated supervisory strategy. For this to be effective, the Reproductive Health unit will be strengthened with technical support from UNFPA andUSAID. This will be followed by enhancement o f supervisory and monitoring capacity at the Zoba and sub-Zoba levels. A comprehensive supervisory work plan will be developed by the RHU and the Zobas, in collaboration with other stakeholders and will be integrated with integratedwith other HAMSET components. HealthManagement Information System. The project will support review and standardization o f existing data collection tools and encourage analysis at the point o f collection to influence decisions and change o f practice. Special attention will be given to data collection at the community level, which is currently weak or non existent, as well as household and community- level factors that influence the utilization o f maternity services and attitudes to harmful traditional practices. BCC interventions will be monitored through qualitative approaches, using rapid household surveys or focused groups at the beginning and towards the end o f the project. This will focus on key behaviors o f interest and appropriate indicators to measure changes in knowledge attitude andbehaviors. Maternal Audits. Making information available to policymakers has been shown to generate commitment and positive reaction. While maternal mortality levels are difficult to measure, innovative efforts will be employed to assess the extent o f maternal and newborn morbidity and deaths. First, matemal mortality is to be declared as notifiable inEritrea. This will be followed 82 by establishment o f a maternal audit system to be phasedinnationwide. There will be two types o f audits: Clinical audits to be conducted on all maternal and neonatal deaths that occur within health facilities, and Community audits for deaths occurring in the villages. The clinical audits will bemandatory inall hospitals andwill critically analyze the quality o fmedical care provided and lessons learnt on prevention. Linking clinical and community audits will facilitate systematic exploration o f the `road to death 'that individual women take, including the accounts of families and health care providers. The project will support formation and operations o f maternal Audit teams at both national and Zoba levels, with strong participation o f health professionals, communities, local government and women's groups. Participation and leadership o f staff and students o f Orotta Medical School and Nurse training colleges in the audit process will be actively sought. Operations research. In addition to the above the project will support a selected number o f operations research activities. One o f them will be a Reproductive Age Mortality Study (RAMOS) to estimate the maternal mortality at the end o f the project. Maternal mortality data from the study conducted by Ghebrehiwet in2005 will be used as baseline. Tarnets and Indicators. Project performance will be monitored and assessed against specific milestones and targets. The project will be centrally coordinated by the PMU while service delivery on the other hand, will be monitored by technical departments in close collaboration with the PMU. It is importantto note that the project is also supporting the overall improvement of the National Health Information Management System that will improve data collection analysis and feedback at all levels. Every effort has been made to ensure that the targets are in line with the RH policy and strategic guidelines which are currently in draft form. The targets also take into account and the human resource situation, the resource envelope, role o f other partners and the duration o f the project. HAMSET is not the only donor supporting RH in Eritrea and the activities o f all the other components o f HAMSET contribute to the RH outcomes. These considerations also inform the choice o f indicators, ensuring that they are in line with the policy guidelines, are measurable and appropriate surrogates o fthe project. Inview ofthe above, the monitoringandevaluationframework doesnot intendto reinventthe wheel and has picked core indicators from the National guidelines and the relevant sections o f the MDGs. The selected indicators o f the RHcomponent are given inAnnex 3. Tracking progress toward the MDGs: Although assessing progress toward the MDGs can be complicated by uncertainties and differences on how indicators are designed and which measurement instruments are used, the project intends to track a few specific indicators for this purpose as summarizedbelow. 0 Goal 4: Promote gender equality and empowerment o fwomen. Target -Promote positive attitude andpractice by community leaders and heads of households to reduce gender-basedharmful traditionalpractices (FGM,early marriage and nutrition) 0 Goal 5: Reduce child mortality. Target -Improve neonatal care and outcomes. Goal 6: Improve maternal health. Target -Increaseproportion of births attended by skilledproviders; Increase number of facilities with EmOC; Decrease casefatality due to 83 direct obstetric causes; Improve maternal mortality reporting and monitoring; Reduce maternal mortality rate e Goal 7: Combat HIVIAIDS, malaria andTB. Target -Halt HIV/AIDSprevalence among pregnant women; IncreaseITIV use among women attending; Increase TB treatment completion rate amongpregnant women. In addition to the above, the following indicators will be monitored to confirm the pro-poor orientation o f the RHcomponent o fHAMSET 11: Improved stewardship role o f the MOH and successful implementation o fRHcomponent o f HAMSET I1(% disbursement o f budget allocation to districts and health centers; % facilities supervised regularly by Zoba HealthManagement Teams. Increased geographical and physical accessibility o f quality RH services (% facilities with EmOC; Unmet need for EmOC; % births with skilled attendance; % facilities with PAC; % facilities with FP). Improved human resource situation and availability of essential inputs (comprehensive HRM plan; annual training output for skilled staff in LSS and; number of graduating midwives and anesthetists; % facilities without stock outs o fRHmarker drugs). Increased utilization of services by the poor and stronger community satisfaction, ownership and participation in RH activities (% institutional births; number o f Village Health Committees (VHCs) established and functioning; changing attitudes and practices to 5 core RHissues). 84 Annex 9: CommunityManagedHAMSETResponse ERITREA: HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject(HAMSET 11) This component will finance small-scale community subprojects that directly respond to HAMSET diseases following a results-based framework and through the application o f community-driven development (CDD) approaches. The two-fold objective o f the Community- Managed HAMSET Response Program (CMHRP) are to: (i)finance subprojects that adopt effective interventions for HAMSET diseases, use results-based approaches (such as RRI) and that are especially suitable for direct management by beneficiary communities; and (ii) build human and social capital at community level to facilitate informed decision-making and collective action around common goals, with an emphasis on community participation, social inclusion, and mutual accountability. The CMHRP component builds on experience in HAMSET in channeling resources and in applying participatory andresults-based approaches to strengthen stakeholder involvement at the local level. Lessons from HAMSET and other World Bank financed community HIV/AIDS components illustrate that subprojects which communities themselves identify, select and manage are more likely to achieve results and promote ownership. Communities will take responsibility to ensure results and quality activities at the local level, using simple M&E indicators and methodologies. The importance o f monitoring and evaluation, particularly in a multi-sectoral operation such as HAMSET was emphasized in order to effectively monitor outcomes and impact o f development interventions, and where needed, strengthen and/or refine strategies and operational modalities based on timely feedback on lessons and experience gained on the ground. Lessons also reveal that subprojects which include activities that directly respond to HAMSET diseases, are results-oriented, and that promote positive behavior changes have higher value andhigher chances for sustainability. The use o f RRItools in particular has had a significant impact in empowering members o f the community to act and take charge in articulating and implementing their results-based goals to address HAMSET diseases. Short-term, results-based activities can strengthen the implementation and scaling up o f the local initiatives. With fewer resources available under HAMSET I1there is need to rationalize the use of resources. To this end Behavior Change Communication (BCC) programs that are evidence-based will be promoted rather than investments in physical infrastructure. Finally, more concerted efforts are needed to target strategically interventions to support vulnerable groups. These lessons are incorporated in the overall design o f HAMSET 11. For HAMSET 11, a results-based framework closely aligned with national objectives and priorities for addressing HAMSET diseases will be adopted. Within this framework, project inputs and activities will be implemented at the community level, applying CDD approaches in order to promote innovations and to give greater control over decisions and resources to community groups and local level stakeholders, in partnership with local administration. This component would also aim to more closely relate investments in subprojects with human and social capital development. Learning and participatory processes included in this component 85 aim to enhance and promote the sharing o f individuals' knowledge, skills, talents, attitudes and values at community level. Community subprojects will be planned and managed according to general principles governing development programs that support CDD, namely: Ensuring that subprojects respond to informed demand, are directly linked to HAMSET diseases and that communities, with facilitation by local partner institutions as necessary, have the capacity to manage and sustain them and that capacity building and development are invested in at all levels. All CMHRP grants are to be managed by locally elected Community Management Teams (CMT). Strengtheningparticipatoly mechanisms for greater community control and stakeholder involvement throughout all phases o f the subproject cycle, and devolving responsibilities to communities andlocal stakeholders as capacity is developed. Strategically integrating capacity building at the local level along with the subproject cycle. Working towards greater social and gender inclusion with explicit socially-inclusive and gender-sensitive approaches built into social mobilization modalities. Maintainingflexibility in design and implementation, especially with regards to M&E in order that direct feedback fkom the community can feed into further strengthening and/or refining project approaches. Developing transparent and equitable criteria for resource allocation andtargeting. Establishing a basis for ownership and mutual accountability at the local level, around which community initiatives can be sustained. Strengthening linkages, coordination, and synergies between activities by all implementing partners at community level and community subprojects. In order to achieve these objectives, the component will have two Sub-Components: Sub- Component I - HAMSET Grants for Subprojects (US$ 3.4 M) and Sub-component 2: Community Mobilization and Capacity Development (US$ 0.6M) A. Sub-component I:HAMSET Grants for Subprojects (US$3.4 million) This sub-component will support small-scale, effective, and demand-driven community subprojects that directly address HAMSET diseases and which are especially suitable for management by beneficiary communities. Particular emphasis will be given to support community subprojects targeted to vulnerable groups. This sub-component will support the strengthening o f community groups, .inassociation with partner institutions operating at the local level to identify, build consensus, plan, implement, monitor, and sustain community subprojects. 86 CMHRP will adopt a results-based framework, and within this framework pilot a fairly open menu along with a negative list in order to provide flexibility and allow innovations for communities to identify and select their subprojects, based on their comparative advantage. CMHRPResults-Based Framework (RBF). To assist communities CMHRP will operate with a results-based framework, which provides guidance on targets and results as formulated under national policies and strategies for HAMSET diseases. Key target results for each o f the HAMSET diseases are described in the CMHRP Operational Manual, not prescribing specific choices o f subprojects which can be considered for funding but providing flexibility and allowing innovations for communities, based on their comparative advantage, to identify, prioritize and select their results-based subproject to addressing HAMSET diseases. The implementation o f the open menu will be supported by "leaming by doing" and participatory approaches, with flexibility for CMHRP to adapt the rules according to experiences gained and difficulties identified duringimplementation. The implementation o f the open menu will be guided by the following principles, ensuring that subproject proposals: i. Genuinely reflect demand-driven community initiatives that communities identify, prioritize and select themselves and that they can implement and manage. In communities where capacity may be weak, the services o f relevant extemal support .. agents operating at the local level may be recruited to help facilitate implementation; 11. Using RRItools, focus on results as described in the Results-Based Framework and that planned activities are in areas where communities have a comparative advantage in ... implementing; 111. Are small-scale, effective, and can be managed by communities; iv. Wherever possible, include either (i) low cost and high impact community-based activities such as BCC interventions; or (ii) effective and sustainable service-oriented interventions that directly benefit vulnerable groups (i.e. support for orphans and home- based care for PLWHAs, etc.); V. Include, where appropriate, information describing community's plans for maintaining their subproject activities beyondthe subproject fundingperiod; and vi. Indicate whether proposed interventions are o f a short-term or long-term duration (i.e. whether proposed activities will require multiple grants as may be the case for support for orphans andhome-based care for PLWHAs. CMHRP will not finance the following negative items, namely: (i) civil works; (ii) new small civil works over and above $500; (iii) nutrition and food, except for specific target groups; (iv) income generating activities, except for specific target groups; (v) purchase o f vehicles; (vi) overhead costs over 10% o f total subproject costs; and (vii) drugs, medical fees (except for home-based care). Given the demand-driven nature o f subprojects to be financed under CMHRP, the types o f subprojects cannot be knowninadvance. Inthe initial phase, three windows for providing grants to community groups will be piloted. 87 Window "A": This includes subprojects with a value o f less than $300, to be appraised and approved at village level with support from Village Health Committees and village administration. Simplified procedures will be applied to encourage rapid implementation o f very small-scale activities, without imposing too many restrictions. The project will review the implementation o f activities under this window to ensure that there are no conflicts o f interest between implementing partners and approval mechanisms at the village level. Window "B": This includes subprojects with values ranging from $300-$3,000, to be appraised andapprovedat zoba level. Window "C". This includes subprojects specifically targetedto vulnerable groups, with a value o f less than $5000, and appraised and approved at zoba level. Recognizing the stigma and culturally-sensitive issues that make it difficult for some vulnerable groups to come forward with their proposals and to negotiate their viewpoints, target beneficiaries will probably require the services o f relevant external support agents to provide facilitative assistance inorder for them to access the stream o f benefits under CMHRP. It is envisaged that subprojects targeted to vulnerable groups will initially be co-managed by beneficiary communities and relevant partner agencies collaborating under the Multi-Sectoral Component (i.e. BIDHO, FBOs, NUEWs, etc.) untilthe capacityofthe former isdeveloped. Financing o f community subprojects, particularly those from vulnerable groups that are within the Result-Based Framework and comply with the guiding principles o f the open menubut may require additional resources to achieve optimal results, or continuous assistance for a longer period o f time @e. home-based care for PLHWAs, and support for orphans and vulnerable children (OVCs), will be considered on a case-by-case basis. Subproject proposals exceeding $5000 will require approval from central level. The implementation o f the results-based framework and the open menu will be closely monitored. Where necessary and in consultation with IDA, operational modalities and guidelines may be modified to better address the specific conditions o f Eritrea, increase responsiveness, maximize results o f CMHRP interventions and incorporate lessons and experiences during implementation and feedback from beneficiaries. Target BeneJiciaries. Overall, CMHRP's interventions are expected to benefit communities as a whole. Under HAMSET 11, however, greater emphasis will be given to support vulnerable groups. These include women, including pregnant women and mothers, commercial sex workers, HAMSET diseases affected or infected individuals and households, individuals living inurban "hot spots", youths and adolescents (in- and out of- school), truck drivers, conscripts, OVCs, PLWHAs, etc.). Relevant external support agents (civil society organizations, FBOs, BIDHO, NUEWS, etc.) and local government would also benefit through their facilitative collaborationwith beneficiary communities. Resource Allocation and Targeting Framework. The resource allocation and targeting framework under HAMSET I1is under development with particular focus on targeting the most vulnerable groups. 88 Resource allocation and targeting will be undertaken in order to: (a) ensure that a concerted effort is made to reachthose vulnerable groups who have not, so far, been able to fully benefit from CMHRP; and (b) serve as a monitoring mechanism inorder to assess ifregions and specific geographic areas are able to meet their targets and to offer assistance (capacity building) where they are lagging. Criteria for resource allocation will aim to provide that 50% of resources be allocatedbased on population, and the other 50% be allocated based on poverty and weightings o f epidemiological indicators inrelation to HAMSET diseases. Within each region's allocation, 25% o f funds will be earmarked to support specifically targeted interventions for the most vulnerable groups. Subproject level targeting. Besides resource allocation, HAMSET I1will use various ways to target vulnerable groups. Some o f these are integrated in the project cycle processes. Subproject-level targeting can take three forms: Self-targeting: Communities will identify their own projects with emphasis on small-scale, effective, and results-based interventions for which communities and sub-groups within a community have a comparative advantage inimplementing. Geographic targeting. Data on epidemiological indicators in relation to HAMSET diseases, zoba-level poverty profiles where available, health services data and information from LQAS and highrisk group mapping would collectively be usedto identify areas that are at ahigher risk. Community-based targeting: Extended participatory rural appraisals would be carried out to assist the process of ensuring that vulnerable groups benefit from HAMSET I1 resources. Through the Capacity Development subcomponent, social mobilization campaigns and awareness raising for local level stakeholders, including traditional institutions, community leaders, local administration, village health committees, CMTs, etc. would improve community- level targeting. These interventions would be reinforced through similar and complementary interventions implemented at a wider scale under the Multi-Sectoral Response Component. Appraisal and Approval. Subproject proposals under Window "A" will be appraised and approved with support from Village Health Committees and village administration. Subproject proposals under Windows "B" and "C" will be submitted by CMTs to Zoba PMUs for pre- screening (desk review), and appraised by Zoba HAMSET Technical Committees following eligibility criteria and guidelines described inthe CMHRP Operational Manual. The portfolio o f appraised subprojects under Windows "B" and "Cy' which are eligible for financing under the CMHRP will be forwarded to the Zoba Administrator's Office or through the Zoba Steering Committee where it exists for approval. The portfolio o f approved proposals in each zoba will be submitted to HAMSET I1PMU-CMHRP (central level) for consolidation in HAMSET 11's overall annual work program and budget. Subproject proposals that are within the RBF and comply with the guiding principles o f the open menubut exceed the threshold o f $5,000 would be reviewed and appraised on a case-by-case basis by the Zoba Technical Committees and approved by the National Technical Committee. Participatory Planning and Identification. Community-based participatory planning processes will be strengthened in order to reinforce the capacities o f communities to take the lead in 89 improving their health, requiring upgraded facilitation, capacity building and methodological innovations based upon participatory approaches, including use o f RRI tools piloted under HAMSET I.Community subprojects are to be identified, prioritized, selected, and prepared by beneficiary communities, led by Community Management Teams, facilitated by community facilitators, with technical back-stopping support o f a range o f external support agencies, including CMHRP, zoba-level technical staff, local administration and other intermediary groups, as appropriate. Subproiect Implementation. Community subproject launch workshops will be required, with the participation o f all relevant stakeholders (CMTs, Peer Groups, Zoba HAMSET PMUs, local administration, community facilitators, VHCs, and intermediaries and/or local partner institutions where appropriate). These workshops are intended to build ownership, enhance transparency o f the process and confirm amongst all stakeholders their roles, responsibilities and reciprocal commitments for project implementation. Supervision. Supervision will be an essential activity to ensure the quality and effectiveness o f subproject implementation andmanagement. The Zoba PMUwill have overall responsibility for supervision with support from CHMRP Facilitators and additional community support from BCC Peer Educators, members o fthe Village Health Committees, and local govemment staff. Monitoring, Evaluation and Learning. The project is a CDD endeavor based on simultaneous capacity building and direct investment efforts. As a CDD initiative, the project requires multiplelevels o f monitoring and evaluation procedures ensuring its contribution to community empowerment and capacity building to address HAMSET diseases in an integrated and sustainable manner. The enhanced subproject cycle will promote community participation and community ownership through the integration o f simple M&E mechanisms relevant for community decision-making and monitoring results. The M&E envisaged under the CMHRP Component is not only concerned with recording and reporting on project inputs and outputs, but is also intimately related to how different stakeholders, using participatory methods, can be facilitated in collecting and analyzing information for their own use and for holding others to account on their performance. The operational aspects o f CMHRP will continue to be monitored intemally and externally as part o f posteriori evaluations, audits, mid-term reviews, andparticipatory assessments. Completion. Formal handover to beneficiary community groups will be integrated in the subproject cycle to signal their responsibility for maintaining subproject activities. Sustainability. Participation o f community and local partner institutions (where appropriate), including local administration are important prerequisites for achieving sustainability goals. Participatory assessments, LQAS results, and other evaluation methodologies will be important tools to assess performance and outcomes. Post-evaluation. Post-evaluations will be carried out to assess whether communities are able to maintain their activities, where appropriate, beyond the subproject fundingperiod. 90 Procedures to be followed for targeting, social mobilization, facilitation, appraisal, approval, implementation andmonitoring o f subprojects are defined inthe Operational Manual. B. Sub-component 2: Community Mobilization and Capacity Development (US$ 0.6 million) This subcomponent will assist HAMSET I1to intensify its efforts to enable genuine community- driven development by enhancing community members' and their associated organizations' skills in social promotion, community mobilization, participatory planning, and community identification, prioritization, and management o f subprojects. It will pay particular attention to collaborative facilitation, participatory monitoring and evaluation exercises to be carried out at the local level. The bulk o f capacity development efforts under this subcomponent will be strategically provided along the subproject cycle. The focal areas o fcapacity development efforts are: a Social mobilization, focusing on community-level activities towards mobilization o f stakeholders at community level for effective and results-based interventions, inclusive and equitable community subprojects. a Delivery o f basic project management training to CMTs to develop their organizational, management, andbasic accounting skills. a Development o fparticipatory planningandappraisal techniques to enable communities to effectively identify and prioritize their HAMSET-related needs, and to develop appropriate, equitable and inclusive interventions which communities can manage and sustain. The RRI approach, including extended P U S , would be used to facilitate the participatorypreparation o fresults-based subproject proposals. a Development o f simple participatory monitoring and evaluation (PM&E) tools, suitable for community use, and relevant for decision-making and monitoring outcomes at community level. An illustrative list o f possible indicators which can be used to monitor CMHRP activities at community level has been developed and are described in the CMHRP Operational Manual. a Development and/or strengthening of technical handbooks to strengthen sub-project cycle management. a Training o f CMTs, CMHRP community facilitators and community coordinators, and local partner institutions in participatory planning and monitoring tools, subproject management and implementation, RRI tools, and on the use o f the CMHRP Operational Manual andvarious technical handbooks. a Carrying out participatory assessments to obtain direct feedback from beneficiary groups on the overall quality and effectiveness o f interventions provided under CMHRP. These assessments also serve as a monitoring tool to validate community satisfaction with services provided under CMHRP. a Documentation and dissemination o f information from beneficiary communities on the quality, overall satisfaction and impact o f their subprojects in addressing HAMSET disease, including lessons learned. 91 Capacity development activities will be delivered through a series o f workshops, training, learning-by-doing and complemented by the development o f community technical handbooks, and dissemination o f appropriate information which communities, for example, can use to strengthen the linkbetweentheir subprojects andrelated health services. This subcomponent will be managed by PMU-CMHRP, in collaboration with relevant technical staff at the zoba level. Where appropriate, CMHRP will draw on the expertise o f relevant participating agencies (i.e. MOH staff, local government, non-health line ministries , civil society organizations, NGOs, FBOs, etc) collaborating under the Multi-Sectoral Response Component to strengthen multi- sectoral linkages and to ensure complementary across capacity development activities financed under this subcomponent, and those implemented by other partner agencies. CMHRP may engage a limited number o f short-term technical assistance to provide support in specific areas where capacity may not be available. All short-term technical assistance recruited to support the activities o f CMHRP will be expected, as an explicit part o f their terms o f reference, to transfer "skills andknow-how" to core staff inCMHRP-PMU. An illustrative list o fpossible indicatorswhich canbe usedto evaluate CMHRP performance and achievements, discussed and reviewed during appraisal, i s provided below. Process indicators are described inthe CMHRP Operational Manual. 0 No. and type o f community subprojects that have achieved their target results, broken down bytype o f HAMSET disease, bytype o f results, by cost o f subprojects, by category o fbeneficiaries, by gender 0 No. and types o f completed subprojects targeted to vulnerable groups (i.e. CSW, OVCs, youths, women, etc.), broken down by type of subproject, by cost o f subproject, and by category o f highrisk group. 0 Balance o f composition in completed subprojects addressing prevention and care & support for HIV/AIDS affected andinfectedindividuals andhouseholds. 0 No. andtype o f subprojects that are continuing beyond subproject financing period. 0 Evidence o f increased capacity inbeneficiary communities 92 Annex 10: HumanResourcesfor Health ERITREA: HIV/AIDS/STI, TB, Malaria andReproductiveHealthProject(HAMSET 11) Staffingsituation Since independence in 1991, the Government has rapidly built up its workforce from a very low base. Current data i s mostly only available on employees o f the MOH. With nearly 6,000 staff, the Ministry o f Health is the largest employer of health workers. Other employers include the Ministry of Defense, faith-based organizations and a small number o f non-govemment organizations. The private-for-profit sector is relatively undeveloped. Table 1:Number o f staff employed bythe MOHin2004 Cadre Number Doctors* 196 Nurses 700 Nurse midwives 140 Asst. nurses 1,452 Lab technicians 187 Pharmacy technicians 89 X-ray technicians 48 Nurse anesthetist 42 Others 3.031 Total 5,885 Source: Figures derived from Human Resources Planning and Management Division (ZOOS). Annual report - for the year 2004 [Presentation]. * Ofthese 76 are expatriates The majority o f trained healthworkers are low skilled (two years or less training) andAssociate Nurses make up approximately 26% o f all trained staff. Doctor shortages are relieved by the use o f expatriates who make up approximately 32% o f all doctors employed by the MOH. For a country with a high maternal mortality rate, the 140 midwives (of which only 86 are located at zoba level) are clearly inadequate to meet the workload. Regarding doctor and nurse to population ratios, Eritrea ranks low in rest o f sub-Saharan Africa (SSA) (41Stout o f 48 for doctors and42ndout o f 47 for nurses andmidwives). The majority o f formal healthworkers (69%) are working at primary care facilities. Referral hospitals employ 26% o f staff, a 3% increase from 2003. Distribution of staff varies accordingto zobas (see Table 2). Table 2: MOH staff (professional and support) at zoba, referralhospital andheadquarter (2003) Mak Deb A n s GB N R S SRS R/hosp HQ Total Emdovee 813 905 515 709 625 336 1523 427 5853 %total 14% 15% 9% 12% 11% 6% 26% 7% 100% Source: Human Resources Planningand Management Division (ZOOS). Annual report for the year 2004. - 93 Little information i s available on staff performance, but the impression is one o f a motivated workforce, but there is currently less assurance o f the quality o f its performance. Inaddition, at the moment staff losses are relatively low, though it is uncertain how long this situation will continue. Professional staff are supported by an increasing number of non-formal andusually non-salaried health care providers. At least 900 trained TBAs assist with antenatal care and deliveries33. The malaria programme makes successful use o f over 2,000 Community Health Agents. The TB programme is beginning to train and use TB promoters to help with DOTS. Key challenges and current response The major areas that needto be addressedrelating to the planning, management and development o fhumanresources inthe health sector inEritrea are: 1. The number o fstaff available to provide healthservices, especially inthe higher cadre categories (doctors, nurse midwives, etc.) 2. The equitable distributiono f staff 3. The quality andperformance of staff 4. The capacity of the MOHandothers inthe sector to planfor, manage anddevelop appropriate staff to deliver the required health services. A major constraint to expandingthe size o fthe healthworkforce to meet current andfuture needs i s the training capacity. The Government i s addressing this challenge through various initiatives. It has recently established a medical school and currently has two batches of students enrolled. It is developing a college o f health sciences to upgrade skill levels o f health professionals. Training o f lower-level cadres is being decentralized to zoba level, thus increasing the catchment area for potential trainees. It has used bridging courses in the past to expand participation amongst groups that would not traditionally enter formal employment. Innovative forms o f training such as distance learning are being used and support from a number o f overseas institutions for curriculum development and the strengthening o f training. Individual programs have been providing much in-service training for specific skills, fundedby various programs including HAMSET. Therefore, training output has been increasing and will continue to increase. However this has been, to some extent, at the expense o f quality, as this expansion has been under resourced both interms ofteaching staffandfacilities andequipment. ~~ 33 Ministry ofHealth(2001). Eritrea HumanResource Plan2001(Draft) 94 MOHstrategy The MOH has started to develop Human Resources Strategic Plan. Work on this began with a four-day retreat in April 2005 which was facilitated by technical assistance from the World Bank. This work will continuewithwider stakeholders' involvement and the use ofstaffing data for analysis and future projections over the coming months. The process has general support across the sector andthe strategies so far developed are based on sound humanresource planning and management principles. Leadership for development and implementation of the plan is the responsibility o f the Research and Human Resource Development Department (R&HRDD) department on behalf o f the Ministry o f Health. A system to manage staff performance through individual annual appraisals has been developed and tested and is currently awaiting implementation. Donor support Health human resources is supported by a number o f development partners including USAID, WHO and the World Bank (through HAMSET and the Health Project) and others. Whilst there are examples o f good initiatives to tackle the human resources challenges, these could have more impact if they were better coordinated across the sector and more closely aligned to clear strategic directions. Approach of HAMSETI1 The human resource component o f HAMSET I1has been developed in tandem with the wider HumanResources Strategic Plan and the Year 1action planis derived directly from this process. Although the time frames differ by one year (the Human Resources Strategic Plan runs from 2006 to 2010), the overall objectives are virtually identical. The aim of the HAMSET I1 Human Resources Component i s "to increase the number of appropriately skilled, motivated and equitably distributed health service providers for Eritrea". This will be through the support for the development andimplementationo f the Strategic Planin HumanResource for Health. The key areas which HAMSET I1will focus include: a To develop a coordinated approach to human resources planning across the sector. This will include developing staffing targets based on an analysis o f existing staffing data and projections o f what i s feasible and desirable to support service needs. On this basis, the project will also support the finalization o f the Strategic Plan. T o increase numbers of staff in line with staffing targets developed. This will be done through expanding training output (increasing training places and numbers o f tutors). Efforts will be made to ensure training institutions are self-sufficient. A scheme to train and upgrade tutors will be developed and implemented. The project will support initiatives for (i)increasingnumber o f applicants for training courses and (ii) improving ways o f attracting and retaining staff, in particular in the less well staffed remote rural areas. 95 0 To increase performance of existing and new staff. This will be achieved through improving the quality of pre-service training (improving curricula, facilities and equipment); improving the quality and cost effectiveness o f in-service training (program- specific components will be developing their own in-service training programs, but the humanresources component will aim to help coordinate these inputs); andbyproviding managers with tools and expertise for improving staff performance. Training materials (text books, learning equipments) for the training institutions will be procured. 0 To increase the capacity within the sector to plan for and manage human resources. This will be through general management development at all levels which will include the management o f staff. It will also include strengthening the capacity o f the R&HRD department in particular through the provision o f technical assistance and training in humanresourceplanningandmanagement related skills. 96 Annex 11: AnnualProgramReviews ERITREA: HIV/AIDS/STI, TB, Malaria andReproductiveHealthProject(HAMSET 11) Rather than having each Partner have its own review processes and supervision missions, the objective i s to have Joint Annual Program Reviews (JAPR), for the four HAMSET conditions, led by the Ministry o f Health, supported by all interested partners, and carried out every year. The JAPR will include the involvement and contributions from other ministries, civil society- and faith-based organizations, communities andthe private sector. The JAPRbuilds on existing and evolving approaches in Eritrea: the malaria control program has experience with this modality and the HIV/AIDS program already has a detailed format for implementation support for the national strategic plan. The purposes o f the JAPR are: 0 First, to take stock o f the achievements of the Malaria, TB, HIV/AIDS and Reproductive Health programs during the previous year, as a necessary input for the preparation of the work plans, budgets and financing plan for the next year. Among the issues to be assessed i s the contribution to achievement o f the National Strategic Plan objectives, M & E indicators, results o f innovative projects and the Community Managed response, adequacy of institutional arrangements, evolving trends o f the epidemic inEritrea, best practices, innovations intreatment, lessons learned, etc. Second, to prepare the detailed workplans, budgets and procurement plan for the next fiscal year, based on achievements inthe preceding year. The JAPR i s a management instrument, designed for both the Government and the partners, to monitor progress in the implementation o f the programs and to verify that management and policy responsibilities are met. Each year, it will focus on any priority area that may be selected jointly bythe Government and the partners. The JAPR will be carried out under the authority o f the Minister of Health. The preparation process will start in October of each year and could include several steps: technical work, field visits andpolicy dialogue. The actual meetingwill be heldbefore midDecember o f each year. The format for the review will follow the national strategic plans for the different programs and their related M&E frameworks, including reporting on progress inaddressing issues identified in the previous year. The detailed annual workplans, budgets, expected results and/or targets will follow the same format. The issues identified in the Joint Annual Programme Review will form the agenda o f a policy dialogue to take place from January each year onwards between the Government, partners and other key stakeholders. Following the policy dialogue, the detailed workplans, budgets and procurementplan for the following year will be finalized. 97 Annex 12: ProjectCosts ERITREA: HIV/AIDS/STI,TB, MalariaandReproductiveHealthProject(HAMSET 11) Local Foreign Total ProjectCostBy Componentand/or Activity us us us $million $million $million 1.Multi-sectoralresponse 2.96 0.04 3.OO 2. Healthsector response 7.16 6.84 14.00 3. Community-managed HAMSETresponse 3.95 0.05 4.00 4. Project management andcoordination, capacity building, M&E, innovation andnew policy development 2.97 0.19 3.16 Total Baseline Cost 17.04 7.12 24.16 Physical Contingencies 0.86 0.07 0.93 Price Contingencies 1.26 0.15 1.41 TotalProjectCosts' 19.16 7.34 26.5 TotalFinancingRequired 19.16 7.34 26.5 98 Annex 13: ImplementationArrangements ERITREA: HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject(HAMSET 11) Summaryof lessonsininstitutionalandimplementationarrangementsfromHAMSET HAMSET I1 is built upon the existing implementation arrangements which have been functioning satisfactorily for the duration of HAMSET. Lessons learnt from HAMSET include the following: The multi-sectoral structure at the zoba level has been effective in galvanizing participation and commitment from various implementing agencies. However, implementers often lack the technical knowledge and information to adopt andimplement effective interventions. .. The Ministry o f Healthis facing humanresource constraints at all levels. Supervision o f community subprojects andnon-health sector interventions has beenweak. Information flows on project activities are not consistent across implementing agencies and across the HAMSETdiseases. Community subprojects have been, in some cases, initiated and implemented by line ministries (notably the Ministryo f Local Government) on behalf o f communities. Strategy and Oversight: Two high-level institutions have a strategic and oversight role inthe control o fHAMSET diseases inthe country. (i)TheNational HAMSET Steering Committee(NSC), chairedbythe Minister ofHealth, provides strategic direction and approves the annual work program and budget o f the HAMSET implementing partners. The Director General o f Health Services serves as secretary. Under HAMSET 11, the NSC membership will include the Ministers o f Health, National Development, Education, Defense, Labour andHumanWelfare as well as the six Zoba Administrators. As a high level political and strategic body, the NSC can and should hold implementers accountable for results. Under HAMSET I1the NSC will be strengthened in its oversight role, and in holding implementers accountable to workprograms that are integrated and targeted towards results. To this end, the type and quality o f reporting to the NSC will need to be revised and made more results-oriented. The NSC will meet at least twice a year and share the minutes o fkey issues discussed and agreed to all implementers and IDA. (ii) GlobalFundCountry CoordinatingMechanism(CCM), chairedbythe Minister of The National Development serves a similar function for the GFATMwork program inEritrea andhas almost an identical composition- with the exclusion o f the Zonal Administrators and the inclusiono fUNagencies34. 34 I t was felt by stakeholders during the MTRthat the two committees were appropriate for specific tasks, and merging themwould not add value to either HAMSET or the GFATMwork program. Given that the membership is fairly similar, coordination will likely be de facto. 99 Implementation: The project will be implemented b the Ministry o f Health, selected non- health line ministries, civil society organizations3< and community groups. A Project Management Unit will facilitate the implementation o f the project. As a small country, Eritrea has been very effective in decentralizing project implementation- with project Coordinating committees (Technical and Steering) and Project Management Units represented at the central and zoba levels. HAMSET I1 will build upon the strong implementation arrangements established under HAMSET. NationallevelCoordination& Implementation: Project Management Unit: At the national level, a PMU which is accountable to the Minister o f Health is responsible for various aspects o f project management such as financial management, procurement andmanagement support to the implementing agencies. The PMU, under HAMSET includes a Project Director, Program Coordinator, CHMRP Coordinator and a FinanciaVAdministrative Office with a senior Deputy Program Director, Procurement Officer, and an Accountant. Under HAMSET 11, the project will recruit a Project Monitoring and Evaluation Officer. The role o fthe PMUthus will be expanded to include project monitoring and evaluation- compiling and reporting on the activities (outputs) from all implementing agencies (particularly the multi-sectoral and community implementers). Reporting with simplified Activity and Financial Management Reporting Forms will be compiled by the PMU and submitted to the National Technical Committee. The PMU will also provide resources and technical assistance inthe use o f innovative implementation tools, such as RRI, by implementers at all levels. Under HAMSET 11, the Community Managed HAMSET Response Program (CMHRP) will also be managed from within the PMU. It is recognized that this is an unusual arrangement. To build capacity within the Ministryo f Health, the PMU team responsible for the Community Managed Response Program will establish close working relations with all o f the multi-sectoral implementers andunits within the Ministry o f Health (including the HealthPromotion Unit).The CMHRP unit will be managed by the PMUDirector and will be responsible for (i) ensuring that the CMHRP activities comply with the Operational Manual, (ii) providing technical guidance to support targeted and effective community interventions, (ii) collecting, compiling and sharing information -with all implementing partners- on community activities, and (iv) supporting zoba partners to identify and supervise community sub-projects. National Technical Committee (NTC): i s the technical body responsible for reviewing plans and activities of implementing partners and addressing strategic implementation and coordination issues. The Director General o f Health Services o f the MOHchairs the N T C andthe PMUserves as secretariat. Under HAMSET, the National Technical Committee (NTC) included key implementing partners at the national level, and occasional participation o f the 6 Zoba Medical Officers. In keeping with the need to target HAMSET interventions and streamline implementationprocedures, the N T C for HAMSET I1will be downsized to fewer members, and representatives to the NTC will be at least a Director General level. Under HAMSET 11,the NTC will meet more regularly (at least quarterly) and be strengthened to support integrated planning 35Civil Society organizations refer to BIDOH(an organization o f PLWHA), NationalUnion o f EritreanWomen, NationalUnion o f Eritrean Youth., NationalConfederation o f Workers and offices o f faith based organizations. 100 and supervision with a results focus- meaning that the activities within implementers' workplans should be targeted to achieve agreed upon HAMSET results (outcomes). To support the NTC inits mandate; a HAMSET Technical Working Group, comprising all o fthe HAMSET focal persons in each o f the implementing agencies, with occasional participation o f the Zoba Medical Offers, and will be expected to meet regularly (at least 6 times a year) to ensure the smooth planning, implementation and monitoring o f activities. The Technical Working Group i s expected to attend all N T C meetings, to support the members o f the NTC. Non-Health Line Ministries and Civil Society Partners: As in HAMSET, the non-health ministries and civil society partners will focus their activities on specific target groups (i.e. National Association o f Eritrean Workers will focus on workers, Ministryo f Labour and Human Welfare will focus on orphans and commercial sex workers, etc). In addition to implementing their workprograms, multi-sectoral partners at the zoba level will have a role to play in mobilizingand supporting CMHRP activities, as needed. While all o f the multi-sectoral partners addvalue to the HAMSET I1project, some ministries and partners such as the Ministryo f Defense, Ministry o f Education, Ministry o f Labour and Human Welfare, and National Union o f Eritrean Women have more strategic roles to play. Other implementing partners include BIDHO, National Confederation o f Eritrean workers, National Union o f Eritrean Youth and Students, Ministry o f Local Government 11, Ministry o f Information, Cultural Affairs Bureau, Faith Based Organizations, Ministry o f Transport and Communication, and other partners that may become active duringthe life o fthe project. Ministry of Health: Many o f the units o f the Ministryo f Health will be active inHAMSET 11, and will be expected to (i) implement health-sector HAMSET activities relating to HAMSET diseases, (ii) carry out national monitoring and evaluation (Regulatory Dept.), and (iii)provide technical guidance on non-health and community interventions,. Under HAMSET 11, attention will be paid to strengthening the management o f disease programs and supporting broader community participation. To improve program management, implementers within the Ministry of Health will be able to access capacity building support for results based management, and monitoring and evaluation (as supported under Component 4). Ministryof HealthUnit ResponsibleArea (NATCoD) National Malaria Control Program Malaria FamilyandReproductive Health ReproductiveHealth Regulatory Department Monitoring andEvaluation Research & HumanResource DevelopmentDepartment Training ofhealthstaff HealthPromotionUnit (HPU) Behavior ChangeCommunication (RCC) Zoba level Coordination and Implementation: HAMSET benefited from an extensive decentralized system o f implementation arrangements, with most national coordinating, technical andimplementing bodies beingrepresented at the Zoba level. 101 Under HAMSET, a Zoba Steering Committee (ZSC) provided oversight and strategic direction andwas ledby Zonal Administrators. The ZSC also approved zoba HAMSET budgets36.Under HAMSET, only 3 Zobas had established a ZSC. Under HAMSET 11, maintaining or establishing ZSC will be at the discretion o f the Zoba Administrators. If there is no ZSC, the hnctions o f such a committee will be delegated to the Zonal Administrator who i s also encouraged to convene ad hoc committees to support himher in this capacity. Membership o f such committees may include heads o f departments, baito members (locally elected representatives), and/or civil society organizations. The Zonal Administrators will be encouraged in HAMSET I1to guide implementers in developing effective and integrated interventions. Inaddition to reviewing and guiding integrated planning, the Zonal Administrator will also be encourage to hold Zoba level implementers accountable to demonstrate the results (outcomes) o f their activities and investments. Reporting on results and outcomes to the Zonal Administrator will be included as part o fthe annual project cycle. Zoba Technical Committee (ZTC) is chaired bythe Zoba Medical Officer andthe PMU serves as secretary. It includes all HAMSET I1multi-sectoral and MOH implementers. However the membership in the ZTC should be flexible and responsive to Zoba. In HAMSET, the Zoba Medical Officer was overly burdened providing technical support to the ZTC and so under HAMSET 11, the ZTC will be expanded to include more technical participation from the Zoba Health Management Office (e.g. CDC Coordinator, Primary Health Officer, andM&E Officer). The ZTC will be strengthened as the primary technical and coordinating body. They will be responsible for (i)developing and supporting implementation o f Zoba level integrated workplans- where all implementers plan their activities together to reach an agreed set o f outcomes (these should be responsive to local targeting priorities as identified through highrisk mapping and LQAS activities), (ii)reviewing, approving and supervising community subprojects, (iii) reporting on HAMSET I1 activities to the Zoba Administrator (through the PMU) as well as to their respective nationalbodies. Zoba Project Management Units (ZPMU) report to the Zonal Administration (Zoba Administrator's Office) and include a Project Officer (or Manager), CMHRP Facilitator and an accountant. UnderHAMSET 11, the ZPMU will include an additional support staff (data entry or secretary) and will be responsible for (i)supporting implementing agencies with project management (Le. procurement, reporting, etc.), (ii) coordinating capacity building activities for non-health implementers and Community Management Teams, (iii) coordinating programmatic supervision and monitoring o f all implementers (with emphasis on community response), (iv) carrying out Participatory M&E with Community Management Teams, and (iv) facilitating information flows betweenZobas, andthe National Technical Committee. Lessons from HAMSET suggest that the Zoba PMUCMHRP Facilitatorswere not being utilized most effectively and in HAMSET I1 they will be re-trained in supervision and monitoring (particularly inCDD approaches). 36The CMHRP budget is approved anddisbursed at the zoba level, whereas the Health, Multi-sectoral andPMU budgets are submittedto the National Technical Committee for final approval. 102 Non-Health Line Ministries and Civil Society Partners: Multi-sectoral partners in HAMSET I1 will work with the Zoba Technical Committee (for local strategic and technical guidance) and with their central ministry (for national priorities and sector specific guidance) to develop and implement HAMSET workplans. Where community capacity is weak, it i s expected that multi- sectoral partners will also provide facilitation support (in project preparation, etc.) to communities. The Zoba Administration, which is considered one o f the multi-sectoral partners, has a valuable role to play, with the Zoba PMU, in coordination between implementers and outreach to communities. Zoba Health Management Ofice: Inaddition to actively participating inthe ZTC, the units o f the Zoba Health Management office (under the leadership o f the Zoba Medical Director) will be coordinated to implement workplans that respond to local and national HAMSET priorities and complement the activities on non-health and community implementers. The Primary Health Care Officer and the to-be recruited M&E officers in each Zoba will be new players inHAMSET 11. Where appropriate, emphasis will be placed on community participation- particularly through sub-zoba health facilities. The Health Promotion Officer, through the BCC Peer Coordinators supported by HAMSET37,have the additional functions o f (i) coordinating the Behavior Change Communication activities by establishing and facilitating Peer Groups and (ii) providing, in coordinationwith the ZPMU, support to the Community ManagedResponse Component. Village Health Committees: operate at the village (kebabi) level and serve as interlocutors between the zoba level and the community. Village Health Committees are flexible in structure and usually comprise representative o f civil society organizations (Le. NUEW, NUEY, FBOs), and community-based health agents (i.e. malaria agents, TB promoters) and community members. Under HAMSET 11, the Village Health Committees will continue to play an important role inidentifying andmobilizing communities to develop sub-projects. Community Management Teams (CMT): comprise community members who plan, prepare and implement subprojects for CMHRP. Under HAMSET 11, there will an emphasis on (i) reaching vulnerable groups and (ii) scaling up and buildingupon the social capital o f BCC groups. These C M T will benefit from additional capacity buildingunder HAMSET11. Coordination between Implementing Agencies and Project Components: This is a priority area for HAMSET 11, particularly to improve M&E and integration o f interventions. The proposed improvements in Monitoring and Evaluation will require conducive implementation arrangements. Strengthening both vertical coordination (from national to zone) as well as the programmatic coordination (across components and Zobas) is important to minimize duplication and maximize learning. While the HAMSET coordinating bodies such as NSC and N T C are important, these should not replace the existing lines o f communication between levels- and all HAMSET activities should be reported on within the appropriate sectors, as well as through HAMSETmechanisms. Multi-Sectoval Response (Component 1): In HAMSET 11, the multi-sectoral response implementers will require technical support from the PMU and the MOH so that they can (i) 37As of 2005, there are 60 BCC Coordinatorsserving 15 Model Communities.Under HAMSET11,these willbe scaledup. 103 make strategic use o f their comparative advantage, and (ii) activities that will target high identify risk groups with appropriate activities. Where community capacity is weak, multi-sectoral implementers will also be partnersinmobilizing for CMHRP activities. Health Sector Response (Component 2): The Ministry o f Health will need to work closely with the PMU to integrate non-health and community interventions into the national HMIS system andto ensure that epidemiological information gathered is effectively channeled to allpartners to improve the quality o f targeting interventions. The M O H may wish to work with the PMU to implement a system where local HAMSET priorities (and project outcomes) are communicated as `Call for Proposals' that can help guide the activities o f multi-sectoral and community level implementers. In addition, the Health Promotion Unit will be tasked with supporting all implementers, particularly at the community level, in developing appropriate integrated BCC messages and interventions (that include Reproductive Health) and with monitoring the coverage o fpeer-led BCC inhighrisk groups. Community Response (Component 3): Given the emphasis in HAMSET I1 to focus on soft interventions, particularly the scaling up o f BCC interventions, the CMHRP Program will be closely linked with the Health Promotion Unit (inthe Ministry of Health) in terms of technical guidance and supervision. To reach out to communities, the CMHRP unit will also need to rely on the support on all Zoba level implementers (in the MOH, Ministry o f Local Government as well as the multi-sectoral implementers) to help communities in identifying their sub-projects andfacilitating their implementation(through technical support). Project Coordination, capacity building and M&E (Component 4): (M&E i s discussed separately in Annex 3). The Project Management Unit (at national and zoba level) will take primary responsibility for this project management component. Project supervision, particularly o f zoba level activities, was relatively weak in HAMSET. To improve this, under HAMSET 11, the PMU(with additional staff support described above) inclose coordinationwith implementers will support the (i) implementation o f a more systematic MIS to track project activities/ outputs and (ii) coordination o f more systematic supervision processes (utilizing integrated supervision modalities already underway within the Ministry o f Health). The PMU will also be responsible for making implementers aware o f available resources for (i) innovation and research (Le. high risk mapping exercise, Rapid Results Initiative) and (ii) related capacity building (i.e. project monitoring and evaluation, supervision skills, results oriented management, financial management etc.) with preference given to Zoba level implementers. Planning: Under HAMSET 11, there will be an emphasis on integrated planning by all implementers. For this to be effective, the project will emphasize the following: (i)All implementers are provided with information- well in advance o f the planning cycle- on the HAMSET priorities - and outcome targets (i.e. what are the expected outcomes after all o f the plans have been implemented) - both nationally and by Zoba. (ii) Zoba level planning Before commences, all Zoba level implementers are aware o f the priorities (and activities) o f their central counterparts. (Given the planning cycle, it is likely that this may consist o f a strategic document rather than a detailed workplan.) (iii) The Technical Committees (at both levels) will meet at least twice (ifnot more) during the planningprocess to ensure that proposed activities are well integrated, reflect the local priorities andtargets, andmeet the proposal criteria and (iv) The 104 integrated workplans will be presented to the Zonal Administrator along with the expected outcomes and the supervision and monitoring plan to measure progress. Plans should reflect activities of all decentralized implementers (at zoba, sub-zoba andkebabi levels as appropriate). 105 Figure1. HAMSET I1ImplementationArrangements NATIONAL LEVEL NATIONALSTEERING COMMITTEE Line Minis - Groups 106 Annex 14: FinancialManagementandDisbursementArrangements ERITREA: HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject(HAMSET 11) This Annex summarizes the financial management arrangements in place for the proposed Eritrea HIV/AIDS/STI, TB, Malaria and Reproductive Health (HAMSET 11) Project. The scope o f the work i s set out in the "Assessment of Financial Management Arrangements in World Bank-Financed Projects - Guidelines to Staf' issued by the Financial Management Sector Boardon October 15, 2003. Under the Bank's OPBP 10.02 with respect to projects financed by the Bank,the Recipient and the project implementing agencies are required to maintain financial management systems, including accounting, financial reporting, and auditing systems, adequate to ensure that they can provide the Bank with accurate and timely information regarding project resources and expenditures. The guidelines issued by the Bank's Operations Policy and Country Services regarding Financial Monitoring Reports (FMRs) require adequate financial management arrangements, including the ability to produce timely FMRs, to be in place by effectiveness. HAMSET I1 Project will use the existing HAMSET institutional framework as well as arrangements in place for procurement and financial management. The coordination, planning, financial management, and procurement at national level will be the responsibility o f the Project Management Unit (PMU) set up for the Health Sector Project, the IDA credit which closed on December 30, 2004. The PMU is now responsible for the implementation o f the current HAMSET Project. The two projects, Health and HAMSET, shared the same control environment inthe area o f financial management, beingmanaged by the same implementing unit and subject to the same control mechanisms; similar arrangements will be used for both the ongoing HAMSET as well as the proposedHAMSET I1project. A financial management review of the current HAMSET project was carried out in February 2004 as part o f the ongoing implementation support. Project management had indicated their desire for the HAMSET project to convert from the traditional transaction-based disbursement to the more streamlined report-based disbursement. The review therefore focused on making a determination as to whether the financial management arrangements in place met the Bank's criteria for report-based disbursement. To be eligible, the project needed to meet stringent conditions set by IDA, including an adequate financial management system capable o f producing FMRs. The project met the requirements, the only one to do so inthe Bank's Eritrea portfolio, andnow benefits from the flexibility provided under the report-based disbursement mechanism. A further financial management review was carried out in December 2004 to assess the appropriateness o f the arrangements in place for the implementation o f both the Health and HAMSET projects. The Health project's IDA credit was closing on December 31, 2004 and the work was part of the Implementation Completion Review; the HAMSET project was undergoing a mid-term review. The conclusion was that both projects were well managed in the area o f financial management, thanks to the tremendous effort o f the project management, as well as the accounting staff. This in tum has had positive results in record keeping including the enhancement o fthe projects' computerized accounting systems. 107 The conclusion is that the current financial management arrangements for the HAMSET project meet the minimum requirements to comply with the Bank's OPBP 10.02. These arrangements will need to be applied to the proposed project to achieve this, and an action planis included at the end o fthis annex. RiskAssessment The risk ratings below are showing low to medium, reflecting the sound financial management arrangements built up over the period o f implementing the Health and HAMSET projects. Capacity and experience at central level is already inplace to address identifiedweaknesses and provide the necessary expertise during project implementation. Mitigating factors to address identified risks are noted below. In addition, an action plan will be agreed with the project management to ensure that financial management arrangements are in place during the implementation o f the HAMSET I1Project. I Risk 1 RiskRating 1 RiskMitigation Measures 1 Inherent Risk Country-Specific High No EntitvSDecific Low Yes Project Specific Low Yes Control Risk Implementing Entity Low Yes FundsFlow Medium Yes Staffing Lowmedium Yes Accounting Policies and Low Yes Procedures I Internal Audit Medium Yes External Audit I Medium I Yes Reporting andMonitoring Low Yes Information Systems Medium Yes Country-Specific A Country FinancialAccountability Assessment (CFAA) has not yet beencarriedout. However, a number of other pieces o f diagnostic work have been carried out inrecent years and include a Country Economic Memorandum (CEM) and a Country Procurement Assessment Review (CPAR). Both o f these have dwelt on the limited capacity inthe country both in the public as well as private sector. This is especially the case in the area o f accounting and financial management where there is no established accountancy profession and only a limited number o f professionally qualified accountants. The unresolved conflict with Ethiopia has had a further negative impact on the economic environment as well as the implementation capacity. 108 E ntity-Specific The project will be implementednationally inall six zobas andthe implementationarrangements will mirror those o fthe current HAMSET project, which have functioned satisfactorily. Overall, a suitable environment exists for the proper operation o f the project: there i s support for a culture o f accountability in Government, and staff are dedicated, committed and have a clear sense o f responsibility. A PMU is in place for the sole purpose o f managing the implementation o f the project. This is staffed with a core team o f experienced professionals and is a sign o f commitment on the part o f the Government to, as far as possible, remove any impediments to the smooth implementation o f the project. The use o f a project-specific financial management and accounting system also addresses the weak financial management and accounting environment currently inthe public sector. Project Specific The project will be implemented by a number o f agencies o f varying degrees o f capability. The project also involves numerous small transactions. There i s therefore a need for effective coordination by the PMU o f these agencies, especially on the use and accounting for the use o f funds. A number o f lessons have been learnt from the implementation o f the HAMSET project which will be brought to bear on the new project. This includes improving the monitoring and evaluation function, o f which financial information will be a key input. The PMU will support additional supervision and guidance activities, at both central and zoba-level, including clear guidelines and definition o f roles o f the PMU, its staff and relationships to other agencies and units. Implementing Entity HAMSET I1 will be managed by the PMU established within the Ministry o f Health, and responsible for the implementation o f the current HAMSET project. The use o f an existing unit i s justified because staff i s already in place and has gained experience over the years in the implementation o f projects o f such nature, and also in the Bank's procurement, disbursement, accounting and auditing arrangements. The PMUis headed by a Project Director supported by a Finance and Administration Manager, Procurement Officer, and Accountant. In addition, the PMUis supported by a network o fzobaPMUsproviding management support at the local level. Funds Flow RegardingIDA andthe State o f Eritrea funding, the PMUwould maintainthree bank accounts at head office: a Special Account with the Bank o f Eritrea in United States Dollars to which the proceeds from the IDA grant would be deposited; an account in local currency with a commercial bank to which draw downs from the Special Account would be credited for project financing and administrative expenses; and an account inlocal currency with the Bank o f Eritrea to which counterpart funding by the Government would be deposited in respect o f any expenditures o fthe project that may be provided for inthe financing agreement. 109 Transfers o f funds to the zobas and sub-zobas, as well as for activities to be carried out at national level by implementing agenciedministries will be in the form o f advances based on approved work plans. Fundingwould only commence once a bank account solely for project use has been opened and successive advances would only be made after accounting for previous advances. Once the necessary documentation is reviewed and approved by the PMU, funds will be transferred to the zoba accounthmplementing agency's account. Details on surrender o f advances issued to the zobashmplementing agencies, and accountability o f the funds i s documented inthe Financial Procedures Manual. The current staff complement o f the Finance department o f the PMU comprise a Financial and Administration Manager; a Procurement Officer; and an Accountant. There is also an accountant forming part o f the zoba PMU. The levels and numbers o f staff would need to be determined taking into account the added responsibilities arising from the proposed project. Varying levels of training would be required in financial management and disbursement, information systems andcomputer applications; andprocedures relatingto utilization o f funds. Accounting Policies and Procedures The PMU has a written manual o f financial procedures that describes the accounting system, intemal control procedures, basis o f accounting, standards to be followed, and policies and procedures that guide activities o f the current HAMSET and ensure staff accountability. These policies andprocedures have been adequate and have satisfactorily served the implementationo f the current project; however, these will need to be updatedto reflect the specific requirements o f the proposed project. Internal Audit The PMU has an intemal audit unit. The extent to which this unit is being used beyond routine pre and post-auditing o fpayment vouchers will need to be determined. External Audit The Project would be a Government program and the Office o f the Auditor-General is mandated to audit all Government programs, irrespective o f the sources o f funding. In general, the Auditor-General has always sub-contracted this responsibility inrespect o f donor funded projects and the indications are that this would be the case for this project as well. In due course, therefore, the PMU in consultation with the Auditor-General and IDA would appoint independent auditors in compliance with the financial covenants that would be contained in the IDAgrant agreement. The audit work would be modeled on the new "Guidelines - Annual Financial Reporting And Auditing For World Bank-Financed Activities issued by the Bank on June 30, 2003. This will " take advantage o f the use o f a single audit opinion and other flexibility provided under the new guidelines. The following audit reports would be requiredto be submitted to the Bank: 110 Audit Report Due Date Project Financial Statements Six months after each fiscal year end Management Letter Six months after each fiscal year end Reporting and Monitoring The financial transactions relating to this operation would be recorded and monitored using a project-specific computerized financial management and accounting system. The Finance and Administration Manager would determine: the project's Chart o f Accounts as well as the format and content o f quarterly reports and annual financial statements; the selection and adoption o f accounting policies and accounting standards; and the need to include any supplementary notes to the project financial statements inorder to enhance the presentation o f a "true andfair view ". Subject to a decision being made, these reports would include financial statements (e.g. sources and application of funds; expenditure classifiedby project components, disbursement categories, expenditure types, and comparison with budgets). The reports would closely follow sample formats that are given in the World Bank's `%i`nancial Monitoring Reports for World Bank- Financed Projects: Guidelines for Borrowers ", copies o f which have already been made available to PMU management. Similar reports are already being prepared on regular basis for the current HAMSET project, bothfor monitoring as well as disbursement purposes. Information Systems The HAMSET project's financial management and accounting system i s sound and well maintained. The system is capable o f and does in fact produce FMRs regularly. The system is also capable o f producingannual financial statements fairly quickly after the end o f the year, and the project continues to be one o f the first on the Bank's Eritrea portfolio to submit audited financial statements to the Bank. The accounting system is computerized using FINPRO accounting software and was recently upgraded by the software vendor. However, the new version had not yet gone live at the time o f review in December 2004 and was being tested in parallel with the current (old) version. This meant that the enhanced features o f the new system were yet to be realized. There was need to fully test the new system to obtain optimal performance so that anyproblems were identified and rectified inreadiness for going live. Disbursement Arrangements The current HAMSET project meets the eligibility criteria for report-based disbursement method, which includes an adequate financial management system capable o f producing FMRs. Projects that meet these criteria still have a choice o f transaction-based disbursement, with the FMRs being used only for reporting purposes, or report-based disbursement. The PMU management already made a choice with regardto the disbursement method to be adopted under HAMSET 11. 111 Next Steps Detailed below are issues that will need to be addressed to cater for the proposed project. 0 Determine the levels and numbers o f accounting staff for the proposed project both at head office and zobas; 0 Establish a financial managementand accounting system, including a Chart o f Accounts, for the project. The PMU would set up and maintain a separate, project-specific accounting, budgetary and financial management system. This would take the form o f computerized accounting software usingthe existing accounting software; 0 Develop formats and contents o f the various periodic reports to be generated from the computerized financial management and accounting system. The financial reports should include quarterly management reports to monitor project performance; annual financial statements detailing sources and uses o f funds by expenditure, and comparison with budgets; 0 Update the Financial Procedures Manual documenting the operations o f the financial management system for the proposedproject inso far as these are not already reflectedin the existing manual; and 112 Annex 15: ProcurementArrangements ERITREA: HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject(HAMSET 11) General Procurement for the proposedproject would be carried out inaccordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated M a y 2004; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated M a y 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Grant, the different procurement methods or consultant selection methods, the need for pre- qualification, estimated costs, and time frame are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actualproject implementationneeds and improvements ininstitutional capacity. ProcurementofWorks Works procured under this project will consist o f minor renovations o f Health and Education facilities including: selected health centers, Assab M C H electrical works; Maekel School; Mendefera School; Ghindae School and the existing CNHT. All these renovations are expected to cost less than US$ 150,000 per contract and they will be procured through shopping where quotations will be sought from at least three reputable small contractors, or through community participation. Any works estimated to cost more than US$lOO,OOO will be procured through National Competitive Bidding. The procedures to be used for N C B and shopping, as well as community based procurement will be described in the Procurement Manual which will be prepared for use by beneficiaries and relevant stakeholders. A draft o f the manual has been submitted to the Bank and comments made. As far as Standard Bidding Documents are concerned, the current SBD for NCB will need to be revised to make it consistent with the new (May 2004) Guidelines. The revised SBD will be reviewed by the Bank. Inremote areas where private sector contractors are few or not available at all, direct contracting or force account may be used. Procurementof Goods Goods procured under this project would mainly include drugs; medical supplies and equipment; mosquito bed nets; computers; office equipment and supplies; books; and motor vehicles. The goods will be procured using procedures described in the HAMSET I1procurement manual. Since most o f the goods to be procured would be imported, the threshold for ICB has been set fairly low, at US$150,000. Procurement o f imports will be carried out at central level by the PMU. In the case o f medical supplies and equipment, procurement will be carried out in coordination with PHARMACOR. A I D S i H N related drugs and long lasting treated mosquito nets may be procured through International Limited Bidding (LIB) since only a limited number o f bidders can supply the WHO approved drugs and nets needed for the project Contracts estimated to cost less than US$150,000 may be procured usingNCB. Contracts estimated to cost US$75,000 and less may use the Shopping method or IAPSO. Other specialized UN agencies such as UNICEF may also be used for procurement o f medical supplies. Direct contracting may 113 be used when it can be justified that a competitive method would not yield better value for money. ConsultingServices andTraining Consulting services to be procured under this project would include various studies and training in the different components. Ingeneral, large consulting assignments will be managed by the PMU and awarded under "Quality and Cost based selection" (QCBS) procedures with the exception o f assignments o f a standard or routine nature such as audit assignments, design o f non-complex works, etc. where well established practices and standards exist. For these least cost selection (LCS) will be used. The bulk (in number) o f the consulting contracts will be relatively simple assignments below the threshold for prior review, carried out at regional level by different organizations under two o f the major components o f the project: the Community Managed HAMSET Response Program (CMHRP) and the Multi-sectoral response program. Consulting firms for services estimated to cost more than US$lOO,OOO would be selected through QCBS. Consulting firms for services estimated to cost less than US$lOO,OOO may be selected usingthe consultant's qualification method. Individual consultants will be selected on the basis o f their qualifications in accordance with the Procurement Manual. Single source selection may be used where it can be justified. Short lists o f consultants for services estimated to cost less than $100,000 equivalent per contract may be composed entirely o f national consultants in accordance with the provisions of paragraph 2.7 o f the Consultant Guidelines. Inthe event that there i s a need, for capacity reasons, UN agencies and NGOs could be selected to assist where they have advantage over commercial firms. Operating Costs: The operating costs for HAMSET I1 shall consist o f office supplies, operation and maintenance costs for vehicles and equipment, communication charges and utility expenses among others. These will be procured using the procedures described in the Procurement Manual. Others: The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for works and goods procured, are presented inthe Procurement Manual, currently under preparation. Assessment of the agency's capacityto implementprocurement Procurement under HAMSET I1will be carried out at three levels: centrally bythe national PMU in the Ministry of Health; regionally by the regional PMUs and at community level by the community management teams. An assessment o f the capacity o f the Implementing Agencies to implement procurement actions at national and regional levels has been carried out in April 2005. The assessment reviewed the national procurement environment, organizational structure for implementing the project and the interaction between the project's staff responsible for procurement and for administration and finance. The key issues and risks concerning procurement for implementation of the project have been identified and are discussed in the following paragraphs. The corrective measures, which have been agreed are described in the Action Plan. 114 Country Procurement Environment A CountryProcurement Assessment (CPAR) was completedinJune 2002 and areport submitted to the Government. The report incorporated an action plan for implementing recommendations for reforming the procurement system in Eritrea. An IDF grant was approved in May 2003 to assist the Government inimplementing these reforms. The expected outputs o f the IDF grant are procurement legislation; procurement regulations, standard bidding documents; and guidelines for establishing an institutional framework which is not adequate at the moment and needs improvement. One o f the main findings o f the CPAR i s lack o f procurement capacity inEritrea. A joint CPPR exercise conducted in December o f 2004 also confirmed that the overall procurement capacity in Eritrea is still weak, especially at the Regional level, due to lack o f skilled procurement staff. The CPPR identified four well performing IDA projects o f which HAMSET i s one. HAMSET i s being implemented by a PMUwhich was initially established to implement the HealthProject. The PMUhas therefore acquired a lot o f experience. Since the recommendations o f the CPAR are still being implemented, an appropriate legal and regulatory fi-amework, an acceptable procurement Regulations and Procedures and national standard bidding documents are under development. HAMSET uses the Bank's SBDs for I C B and a standard bidding document has been approved by the Bank for NCB. HAMSET I1will continue using the Bank's SBDs for ICB contracts but for NCB a new SBD will have to be prepared by the PMUand submitted to the Bank for review because the current SBD i s based on the old Guidelines while HAMSET I1will use the new (May 2004) Guidelines. The same is true for the Procurement Manual. Institutional arrangements at central level As mentioned above, HAMSET I1is a direct continuation o f two previous health sector projects inEritrea, the Health and HAMSET projects. The proposed HAMSET I1project will therefore be able to count on a well experienced PMU. The PMUconsists o f a coordinator and specialists for different sectors (procurement, engineering, financial management and M&E) working closely with a procurement agent, PHARMACOR which assures quality control on medical supplies and equipment. In the case o f civil works the PMU, through its engineering staff receives technical support fi-omthe Ministry o f Public Works. The PMUhas also close ties with other relevant Ministries such as the Ministry o f Local Government and its six Regional Administrations (which assist in the supervision at regional level) and Ministry o f Defense (Medical services). Staffing The PMU has a procurement office supervised by the Deputy Director in charge of procurement, finance and administration. The office has acquired experience and implemented HAMSET successfilly but still needs to be strengthened through continuous training in works, consultancy and medical supplies. Inorder to promote clarity inthe roles and responsibilities o f the staff who are involved inthe procurement process, terms o f reference have been included in the OperationalManual. 115 Institutional arrangements at regional level Part o f the procurement will be carried out at regional level by participating agencies (PA) based on a list of requirements and implementation schedule to be verified and agreed with the P M U before the start o f the activity. There are no procurement specialists at the regional level; procurement at this level, including Community sub-projects, would be based on simple procurement methods and procedures. Procurement at this level i s carried out by purchasers in Ministries after approval o f the evaluation report by the purchasing committee. These methods and procedures will be described in the Procurement Manual, which is part o f the Operational Manual, andwhich will be reviewed by the Bank. Record Keeping There is an existing filing system under HAMSET. The current system is generally good. A procurement filing review and training to improve the system was conducted by the Bank. Suggestions for improvement were agreed by the PMU. The overall project risk for procurement i s Medium. Action Plan to Mitigate the above Risks RiskFactor Action to mitigate risk Action by Deadline for Completing Action Legal and Continue implementationo f MoND According to the CPAR Regulatory CPAR Recommendations Framework under Drocess Inadequate National Prepare Procurement Manual PMU July 31,2005 Regulations and Procedures No revised SBDs Prepare SBD for N C B in P M U July 31,2005 compliance to the New Guidelines Include inthe OPM Define the roles o f all those PMU July31,2005 TORSo f staff involved inthe procurement involved in process Drocurement Strengthen TrainProcurement staff in PMU Within One Year of Procurement Selection o f Consultants and Effectiveness Capacity at PMU Procuremento f Works Inadequate Train procurement staff at PMU Continuous procurement regional level capacity at regional level RecordKeeping Introduce improvements in PMU Continuous the filing system as agreed 116 Prior Review ThresholdsandSupervisionPlan ExpenditureCategory ContractValue Procurement ContractsSubjectto Threshold Method Prior Review (US$ (US$) Million) 1. Civil Works >=2,000,000 ICB All <2,000,000 NCB >=500,000 <=100,000 Shopping Post Review CP All Direct Contracting All 2. Goods >=150 ICB All <150 NCB PostReview <75 Shopping Post Review CP All Direct Contracting All 3. Consultancy >=loo QCBS, QBS, FBS, All Services (firms) LCS 4 0 0 CQS Post Review All Single Source All 4. Consultancy >=50 ICs All Services (Individuals) <50 ICs Post Review ICB- Intemational Competitive Bidding NCB-NationalCompetitive Bidding CP -Community Participation QCBS - Quality and Cost BasedSelection QBS -Quality Based Selection FB-FixedBudget Selection LCS -Least Cost Selection CQS -Consultants Qualification Selection ICs -Individual Consultant Selection 117 Procurement Plan The Recipient, at appraisal, developed a procurement plan for project implementation which provides the basis for the procurement methods. This plan was agreed between the Recipient and the Project Team before negotiations and i s available at HAMSET's PMU offices inAsmara. It will also be available in the project's database and in the Bank's external website. The Procurement Plan will be updated inagreement with the Project Team annually or as required to reflect the actual project implementationneeds and improvements ininstitutional capacity. Frequency of Procurement Supervision Inadditionto the prior review supervision, the capacity assessment ofthe ImplementingAgency recommended supervision missions to visit the field to carry out post review o f procurement actions once every six months (which includes special procurement supervision for post reviewlaudit. Details of the ProcurementArrangements Involving International Competition 1. Goods, Works, andNonConsulting Services (a) List o f contract packages to be procured following ICB and direct contracting: IAPSO 3.1 ARV Drugs 182,500 LIB Prior 17101106 PMU 3.2 LongLastingBed 239.200 LIB Prior 21/09/05 PMU Nets 3.3 Drugs 655,488 I C B Prior 13/06/06 PMU 118 (b) Works estimated to cost above US$500,000 and Goodsgreater than US$150,000per contract and all direct contractingwill be subject to prior review bythe Bank. 2. ConsultingServices (a) List of consulting assignments with short-list ofintemational firms. N/A 119 Annex 16: Economic and FinancialAnalysis ERITREA: HIV/AIDS/STI, TB, Malaria andReproductiveHealth Project (HAMSET 11) This proposed project is a follow-on to the ongoing HAMSET project in Eritrea. Detailed economic and financial analysis has been conducted by the HAMSET project. The Multi- Country HIV/AIDS Program (MAP) for the Africa Region also carried out an integrated economic analysis on the MAP projects (Report No. 20727 AFR). This Annex provides (i) a brief summary o f the economic rationale for investing in the HAMSET diseases and reproductive health, based on previous analysis and evidence from literature; and (ii)financial a analysis on the fiscal impact o fthe project. Economic rationale The project will have positive effects on the country's economic growth,poverty alleviation and cost-effective use of resources. Economic growth: the adverse effect o f HAMSET diseases andreproductive healthproblems on economic growth i s well documented. It i s estimated that an HIV/AIDS epidemic can reduce GDPby up to 1.0 percent per year38;andmalaria by 1.3 percent per year3'. The potential cost of lost productivity due to TB i s of the order of 4 to 7 percent o f GDP globally4'. Sexual and reproductive health problems currently account for 18 percent o f the total global burden of diseases and 32 percent o f the burden among women o f reproductive age41, which has become a major barrier to economic development. After gaining independence from Ethiopia in 1993, Eritrea went through a period o f rapid and stable economic growth from 1993 to 1997, with an annual GDP growth rate averaging 7.4 percent. When the border war with Ethiopia broke out in 1998, GDP growth declined to less than 1 percent in 1999 (IMF, 2001). An estimated 75 percent decline in crop production combined with the destruction and loss o f physical capital caused a 9 percent decline inGDP in 2000. Currently, the economy is in a recovery mode and facing many challenges, including recurrent droughts. Tackling of the HAMSET diseases and reproductive health problems will improve the productivity o f the country's work force and give a boost to economic growth. Poverty alleviation: Eritrea remains one o f the poorest countries in the world with an annual Gross National Income per capita o f US$180 and 66 percent o f the population living inpoverty. L o w income has constrained households from investing in optimal amounts o f health care. Consequently, the poor, especially those living inrural areas, suffer the worst health problems. One o f the great challenges facing Eritrea's efforts to alleviate poverty i s a high Burden o f Disease (BOD) from communicable and preventable diseases. Around 71 percent o f the ~ 38World Bank, Project Appraisal Document in Support of the First Phase of the Multi-County HZV/AZDS Program from the Africa Region. Report No. 20727 AFR 39 Sachs, J., Malaney, P. 1998. The economic and social burden of malaria. Nature 415 (6872): 680-685. 40WHO TB control website: www.who.int/gtb. 41The Alan Guttmacher Institute, UNFPA,2003. Adding it up: the benefit of investing in sexual and reproductive health care. 120 country's BODis due to communicable diseases. Based on facility-based data, the top causes o f adult mortality were the consequences o f HN/AIDS, TB and Malaria. This has resulted in a tremendous loss o f productivity and opportunities, andhas created a vicious cycle o f poor health and poverty. Investing inthe HAMSET diseases and reproductive health can ease the adverse impact o f income inequalities. Malaria, TB and reproductive health problems are particularly associated with low income levels because the poor have limited access to health services, information andprotective measures. Although there i s no evidence to suggest that HIV/AIDS i s disproportionately affecting the poor, the poor are the least able to bear the significant costs o f treatment and the corresponding loss o f income resulting from sickness and death. By focusing on these diseases or problems particularly affecting the poor, this project expects to ease the burden o f diseases and to contribute to the country's poverty alleviation efforts. Cost-effective use of resources: Investing inHIVIAIDS, malaria, TB and reproductive health i s . proven to be cost-effective. The World Bank's 1993 World Development Report42presented an "essential health package" that would make the most efficient use o f scarce health resources. Prevention andtreatment o f HIV/AIDS/STI, malaria, andTB as well as maternal health care and family planning are key elements o fthe package due to their highcost-effectiveness. An overall economic assessment on HIV/AIDS carried out under the Multi-Country H N / A I D S Program (MAP) indicates significant net economic benefits o f investing in HIV/AIDS with an internal rate of return at around 30 percent'. The cost-effectiveness o f investing inmalaria control can be an impressive US$2,672 per life saved or US$69 per Disability-Adjusted Life Year (DALY)43. WHO estimates that every dollar invested in the TB DOTS program would lead to a US$55 return to the count$. A recent UNFPA report claims that investing insexual andreproductive health can result innot only the direct medical benefits but also tremendous economic and social benefits4. Based on the evidence above, the economic benefits o f the proposed project are manifold: (i) it would directly and indirectly help to improve Eritrea's macroeconomic situation and to boost economic growth; (ii) it would reduce the country's major burden o f disease; (iii) would it improve the country's human capital by reducing the risks imposed on the most productive segment o f the population; and (iv) it would likely generate a high rate o f return from the investment. Financial analysis The total cost o f the proposed project is US$ 26.5 million, including US$ 24 million grant from IDA (90%), US$ 2 million from the Government o f Eritrea (2%), and US$0.5 million from the community's contribution (2%). 42World Bank, 1993. World Development Report 1993: Investing in Health 43Akhavan, D.et al. 1999. Cost effectiveness o fmalaria control programinthe Amazon Basin o fBrazil. Social Science andMedicine 49 (1999): 1385-1399 121 Table 14.1: FinancingofHAMSET I1 Government Community IDA 24.0 90% Total (including 26.5 100% The distribution o f project resources reflects a strategy of prioritizing software over hardware. Civil works represent a very small fraction o f the total budget at 4 percent, covering only the renovation o f existing facilities. No new construction is planned. The largest budget goes to a software category-including training, workshops, studies, and consultant services-accounting for about 36 percent of the total project budget. Goods and equipment (including drugs, condoms, bednets etc.) are the second largest expenditure category, with a share of 29 percent o f the total project resources. Table 14.2: Overallallocationof expenditures 1.Civil work 4 2. Goods & equipment 29 3. Services, studies, training & workshops 36 4. Sub-grants 13 5. Operatingcost 10 6. Unallocated 8 Although this is a repeater project and implementation systems in the country are well established, the project plans to disburse only US$ 3.7 million (14 %) inthe first year (FY2006) to avoid a heavy fi-ont-load and to allow some time for the country to implement the new activities inHAMSET 11, such as reproductive health andhumanresources. Table 14.3: Estimateddisbursementplan(in US$ million) FY 2006 2007 2008 2009 2010 Annual 3.4 6.5 5.9 5.5 2.8 Cumulative 3.4 9.8 15.7 21.2 24.0 % of annual disbursement over the total budget 14% 27% 25% 23% 12% 122 The proposed project will minimize counterpart funding inorder to ease the fiscal burden on the country. The Government will only cover duties and taxes incurredby the project (about US$ 1 million) and part o f the operating costs, mainly salaries (about US$ 1million). The community contributions o f US$ 0.5 million (about 15 percent o f the community sub-grants) are mostly in the form o f in-kindmaterials and labor. The above financial arrangements were made inorder to accommodate and reflect the country's macroeconomic context, to ensure smooth implementation, and to sustain the impact o f the project activities inthe longer term. Eritrea is a country with a difficult macroeconomic situation andthe intensifying border situation with Ethiopia casts many uncertainties on the country's economic growth. The country's total debt reached 1.4 percent o f its total GDP in 200244. The difficult macroeconomic situation has restricted the country from spending sufficient resources on health. Based on an estimate by UNDP, public expenditure on health was only 3.7 percent of the total GDP in 200145. At this time, Eritrea has not yet established its National Health Accounts; no detailed data on health spending are available. WHO has estimated that Eritrea's total health spending was US$ 9 per capita in2000. Ofthis, public expenditure was estimated at US$6 per capita. The largest project disbursement i s expected in the second year o f the project at about US$ 7.2 million, which is equivalent to 27 percent of the annual public spending on health in Eritrea (if the WHO- estimated 2000 spending level persists). Therefore, the fiscal impact o f the proposed project is likelyto be significant. The recurrent cost required after the project support is estimated at about US$ 1.4 million, which includes maintenance, supervision, continuation of training activities, etc. Although this recurrent cost amount i s small in absolute terms, it is not trivial when compared with the total recurrent expenditure o f the MOH in 2004, which is only US$ 9 million. In principle, the Government is expected to assume the responsibility for sustaining the project activities. During negotiations, it was agreed that a plan to ensure sustainability after project implementation would be prepared. Despite the difficult situation facing the country, the health sector has shown good absorptive capacity and a good track record o f project implementation. The HAMSET project invested a total of US$ 50 million, twice the size o f the proposed HAMSET I1project. The HAMSET funds will be fully disbursed before its closing date o f March 2006; it has become a star performer among the Bank's projects inthe country and the MAP projects inthe Afiica region. Inaddition, the project team andGoEhave initiateddialogue with other donors andthe GFATM to harmonize support to project activities and coordinate efforts for sustainability. 44UNDP, HumanDevelopment Report, 2003. 45UNDP, HumanDevelopment Report, 2003. 123 Annex 17: Safeguard Policy Issues ERITREA: HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject (HAMSET11) The proposedproject has been classified as a category "B" for environmental screening purposes given the risks associated with the handling and disposal o f medical wastes. As a repeater project, HAMSET I1will make use o f the existing arrangements for addressing safeguard issues which have been successfully implementedunder HAMSET. A Health Care Waste Management Plan (HCWMP) and an Environmental Assessment (EA) for insecticides were developed and approved by IDA under HAMSET. Both documents were re-disclosed inEritrea and at the Bank InfoShop prior to Appraisal o f HAMSET 11. Environmental Assessment MOH has complied with the recommendations made by the EA. Under HAMSET, an EA was undertaken to review elements o f the National Malaria Control Program that might lead to negative environmental impact unless properly planned and managed, namely the use o f chemicals. A Pesticide Management Plan (PMP) was prepared following the EA conclusions and recommendations. It has been determined that the EA adequately discusses pesticide use andmanagement issues and mitigation measures. Inlieu o fpreparing a new vector control plan, the project re-disclosed the EA anduse provisions o fthe same instrument as guidance. The proposed project will finance insecticides for malaria control activities, although the overall use will be relatively small (e.g. for impregnation o f bed nets) and only safe compounds approved by the World Health Organization Pesticide Evaluation Scheme (WHOPES) will be used, namely temphos (a larvicide) andpyrethroid. DDT will not be procuredunder the project Health Care Waste Management Plan The HCWMP has been under implementation since October 2004. The Ministry o f Health has established a task force to ensure dissemination o f the HCWMP as well as compliance by all health facilities in the country with day-to-day implementation being the responsibility o f the Environmental HealthUnit inthe Ministry o f Health. Supervision o f HAMSET confirmed that the two regional hospitals financed by IDA were in compliance with HCWMP requirements A successful Rapid-Results Initiative to improve safe injection practices and management o f sharps and medical waste has been scaled up to referral hospitals infive out o f six zobas. The HCWMP provides recommendations for the improvement o f HCWMP within the healthcare facilities o f the country. It also contains a National H C W M plan to be implemented by MOH. The Action Plancontains the following actions according to objective: 124 GeneralFramework for Implementation ofthe National Action Plan: 0 Organization of a national workshop including national and local institutions, civil society representatives (NGOs and private manufacturers), and representatives of international agenciesworking inEritreato validate the nationalHCWMP and strategy. 0 Establishment o f an institutional framework to initiate the HCWMP, including the recruitment of a Project Coordinator and a National Steering Committee for HCWM to superviseandmonitor the overall implementation o f the HCWMP. DevelopmentofLegalandRegulatory Framework 0 Development o f clear national guidelines for HCWM 0 Establishment of a code ofhygiene for hospitals. 0 Legislation on hazardouswaste management. Standardization of HCWM Practices 0 Define requirements for disposal technologies, national catalog o f equipment for segregation, handling, packaging collecting and transporting HCWM, and technical specifications for installationhehabilitation o f centralized treatmentplants inAsmara. StrengtheningInstitutional Capacity of Stakeholders 0 Recruit additional staffat Environmental HealthUnito fMOH. 0 Set up a Group o fTrainers and elaborate a specific detailed training package. 0 Set up awareness campaign for medical andparamedical staff inhealth care facilities. 0 Review academic programs inCollege of Nursing and Health Technology, University o f Asmara, and Orotta Medical School. 0 Setup in-service training programmesfor medical, paramedical andtechnical staff. Development o f aHCWMMonitoringPlan 0 Completion o fHMIS. 0 Standardization o f annualreports. 0 Set up HCWMplans at health care facility level. 0 Completion o f annual Zoba andNationalAction Plans. 0 Establishment o f an operation andmaintenance strategy for each category o f HealthCare Facility. 125 Annex 18: Project Preparation and Supervision ERITREA: HIV/AIDS/STI, TB, Malaria and ReproductiveHealthProject (HAMSET 11) Planned Actual PCNreview 3/16/2005 311612005 InitialPID to PIC 3121/2005 InitialISDS to PIC 3/21/2005 3/22/2005 Appraisal 5/2/2005 5/2/2005 Negotiations 5/16/2005 5/16/2005 BoardRVP approval 613012005 Planned date o f effectiveness 10/3/2005 Planned date o fmid-termreview 613Of2008 Planned closing date 12/30/2009 Keyinstitutions responsiblefor preparationofthe project: MinistryofHealth Bankstaffandconsultantswho worked onthe project included: Name Title Unit SurendraK.Agarwal Operations Advisor AFTHD MarylouR. Bradley Sr. Operations Officer AFTH1 Marcel0 Castrillo M&EConsultant Frode Davanger Operations Officer AFTHV EfremFitwi Procurement Analyst AFTPC Lori A. Geurts Sr. Program Assistant AFTH1 SteveJ. Gaginis Sr. Finance Officer LOAG2 Rogati Anael Kayani LeadProcurement Specialist AFTPC BrightonMusungwa Sr. Financial Management Specialist AFTFM KhamaOderaRogo LeadHealthSpecialist AFTHD SonNam Nguyen Health Specialist AFTHl Nightingale Rukuba-Ngaiza Sr. Counsel LEGAF Nina Schuler Junior Professional Associate TUDUR Helen Giorghis Taddese Program Assistant AFTH1 Katherine Anne Tulenko Public Health Specialist EWDWP JosephJ. Valadez Sr. Monitoring & Evaluation Specialist HDNGA AlbertusVoetberg LeadHealthSpecialist AFTHV Christopher D.Walker LeadHealthSpecialist AFTHl FengZhao HealthSpecialist AFTH1 Bank hnds expendedto date onproject preparation: 1. Bankresources: US$209,462 2. Trust funds: 0 3. Total: US$209,462 126 IDA'SSupervision Plan The supervision and implementation support o f the proposedproject will be conducted from the World Bank Asmara office, the Nairobi office, and from Headquarters. As under HAMSET, it will include other development partners involved in the fight against HAMSET diseases in Eritrea. Partners will be invited to participate in the implementation support missions to ensure the complementarity o f interventions, foster strong partnerships, and facilitate cross-fertilization o f experiences. Other HD Bank staff visiting the region may also provide implementation support, inparticular staff working on other HD sector projects inEritrea (e.g., IntegratedEarly Child Development Project, and Education). The project will require intensive supervision given its fast-track preparation, innovative approach, its multi-sector and multi-agency nature, the wider span o f activities than a regular MAP,andto provide guidance onanyrevisionsto the institutional arrangements. Inparticular, M&E needs attention due to its mixed progress under HAMSET. Therefore, the finalization and implementation o f a national M&E framework and system will require substantial technical support, and will require significant implementation support from M&E technical experts. The project will continue addressing the HAMSET diseases, and will expand by allocating substantial resources to addressing reproductive health (RH). RH indicators in Eritrea are abysmal, while other health indicators are encouraging. Therefore, an RH specialist will provide extensive support inorder that this component receives the same level o f attention duringsupervision as the other HAMSET diseases. TB also needs close implementationsupport, as progress could have been better under HAMSET The community and public sector response will adopt a more targeted and focused approach, in order to provide much needed support to vulnerable populations. This new approach will also require assistance, making sure that access criteria are developed ina participatory andtransparent manner, and enabling the Government to allocate scarce resources where they will achieve the most impact. It is envisioned that two (2) implementation support missions will take place annually (typically inJanuary andJuly ) andthat the January visit willbe to undertake the annualjoint Government and development partners review. .Technical experts will on an ad hoc basis and depending on the need, visit Eritrea to provide technical support. Procedures for IDA supervision will follow the recommendations o f the CPPR. Multipleskills for supervision will be needed on a regular basis, while others will be requiredon an ad hoc basis. A core supervision team will comprise staff addressing the major interventions financed by the project. The core team will include the following: i)TTL; ii)malaria expert; iii) TB specialist; iv) RHexpert; v) HIV/AIDS specialist; vi) the community response specialist; vii) financial management specialist; viii) procurement specialist; ix) humanresources specialist; x) andM&E specialist. Non-core members, or technical experts that will be required on an ad hoc basis include: i)implementation specialist; ii)M&E (for specific aspects, such as MIS, LQAS, etc.); iii)BCC/communications; and iv) other related HD sector specialists. 127 Supervision Plan Total Estimated Staff Weeks per fiscal year: 57 Core Team 42 Task Team Leader (HQ) 8 Health SDecialists TB 4 Malaria 3 Reproductive Health 4 Monitoring& Evaluation 6 Multi-sector Response 3 Community Response (field) 4 FinancialManagement 2 Procurement (field) 2 HumanResources 3 Other Technical Experts 15 M&E MIS 3 @ R R R 3 LQAS 3 RH 4 Environment 2 Estimated annual supervision cost: US$ 150,000 128 Annex 19: Documentsinthe ProjectFile EFUTREA: HIV/AIDS/STI,TB, MalariaandReproductiveHealthProject(HAMSET11) Proceedingso f seventhNational Annual Assessment Malariaworkshop, March2004 M&Efi-ameworkfor HIV/AIDS/TB Mid-termReports from Zoba Maekel, Debub, Ansaba, N N S and S N S HAMSET CMHRP Operational manual National Strategic Plan on HIV/AIDS/STI (2003-2007) MalariaControl Strategic Plan (2005-2009) FiveYear Strategic Panon Tuberculosis (2004-2009) Draft National Strategic Planon Sexual andReproductive Health(2006-2010) DCA for HAMSET Eritrea UNDAF theme group onHIV/AIDS, 2005 Joint UNandPartners Implementation Support Plan (ISP) to the National Strategic Plan on HIV/AIDS/STI CMHRP Guidelinesfor Subproject Appraisal CMHRP Guidelinesto monitor subprojects andto train subproject managementteam CMHRP Guidelines for preparingsubproject proposals Africa Region Working Paper Series #79: Experience inScaling up Support to Local Response inMulti-CountryAIDS Programs(MAP) inAfrica, December2004 Procurement Plan, May 2005 129 Annex 20: Statementof LoansandCredits ERITREA: HIV/AIDS/STI,TB, Malaria andReproductiveHealthProject(HAMSET 11) Differencebetween expected andactual Original Amount inUS$ Millions disbursements Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm.Rev'd PO57929 2005 ER-PowerDistribution SIL (FY05) 0.00 29.00 0.00 0.00 0.00 48.71 -3.35 0.00 PO70272 2003 ER-EducationSector SIL (FY03) 0.00 45.00 0.00 0.00 0.00 38.56 -1.05 0.00 PO58724 2002 ER-CulturalAssets RehabLIL(FY02) 0.00 5.00 0.00 0.00 0.00 4.30 3.19 0.00 PO73604 2002 ER-EmergDemob& Reint ERL(FY02) 0.00 60.00 0.00 0.00 0.00 65.93 32.42 0.00 PO65713 2001 ER-AIDS, Mal, STD, TB Cntrl APL 0.00 40.00 0.00 0.00 0.00 12.01 1.39 0.00 (FYO1) PO68463 2001 IntegratedEarlyChildhoodSIL (FY05) 0.00 40.00 0.00 0.00 0.00 14.64 11.85 0.00 PO34154 1998 ER-Ports Rehab SIL (FY98) 0.00 30.30 0.00 0.00 0.00 12.95 11.63 10.14 Total: 0.00 249.30 0.00 0.00 0.00 197.10 56.08 10.14 ERITREA STATEMENT OF IFC's HeldandDisbursedPortfolio InMillions ofUSDollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. Totalportfolio: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ApprovalsPendingCommitment FY Approval Company Loan Equity Quasi Partic. Total pendingcommitment: 0.00 0.00 0.00 0.00 130 Annex 21: Country at a Glance ERITREA: HIV/AIDS/STI,TB, Malaria and Reproductive Health Project (HAMSET 11) I Sub- POVERTY and SOCIAL Saharan Low- Eritrea Africa income Developmentdiamond. 2003 4.4 703 2,310 GNI percapita (Atlas method, US$) Lifeexpectancy I90 490 450 GNI (Atlas method, US$ billionsJ 0.85 347 1,038 Average annual growth, 199743 T Populabon(%J 2.5 2 3 1 9 Laborforce (%J 2.7 2.4 2.3 GNI + Gross I I primary Most recent estimate (latest year available, 199743) per capita enrollment Poverty(% ofpopulationbelownationalpovertyline) Urban population(% oftotalpopulation) 20 36 30 Lifeexpectancyat birth(years) 51 46 58 Infant mortality(per 1,000livebirths) 59 103 82 Childmalnumtion(Om ofchildren under5J 40 44 Access to improvedwater source Access to an improvedwater source (% ofpopulation) 46 58 75 Illiteracy(% ofpopulationage 15+J 35 39 Gross pnmaryenrollment (% ofschool-agepopulationJ 61 87 92 - Eritrea Male 67 94 99 Low-incomegroup Female 54 80 85 KEY ECONOMIC RATIOS and LONG-TERMTRENDS I 1983 I993 2002 2003 Economlcratios' GDP (US$ billions) 0.47 0 63 0.69 Gross domesticinvestmenVGDP 17.0 266 224 Exportsof goodsand services/GDP 30 6 20 3 13.7 Trade Gross domesticsavingsIGDP -24.0 -33.0 -62.9 Gross nationalsavlngs/GDP 15.1 27.1 -42 Currentaccount balancdGDP -0.4 0.3 -12.9 InterestpaymentsiGDP 1.o 0 9 Domestic Investment Total debffGDP 83.9 90.9 savings Total debtservice/exports 3.3 10.1 Presentvalue of debffGDP 46.9 46.3 Presentvalue of debtlexports IO5 I 1426 Indebtedness 1983-93 199343 2002 2003 200347 I (average annualgrowth) GDP ..... 2.7 0.7 3 0 0.6 - Eritrea GDP per capita 0.0 -1.6 0.8 -0.7 Low-incomegroup Exportsof goods and services -40 -2.9 ~ -32.0 -2.3 STRUCTUREof the ECONOMY 1983 1993 Growthof Investmentand GDP (%) (% of GDP) I I Agriculture 22.4 12.9 13.9 40T Industry 15.7 25.0 24.7 2o Manufacturing 9.0 11.9 11.3 o Services ........ 61.9 62.1 61.4 .20 Private consumption 92.8 89.3 111.3 401 General governmentconsumption 31.2 43.7 51.7 Importsof goods and services ...... 71.5 80.0 99.1 -GDI -O-GDP 1983-93 1993-03 2o02 (average annualgrowth) [ Growthof exportsand Imports(Ye) 1 Agriculture ........ -2.0 -30.1 10.8 50 Industry 8.2 8.0 1.9 25 Manufacturing 6.6 10.0 5.5 Services 2.8 1.4 1.8 O - Privateconsumption -4.1 16.9 -5.1 General governmentconsumption 13.3 -8.9 23.5 -50 Gross domesticinvestment 4.3 -12.4 -26.7 Importsof goods and services ........ Exports ."Imports 2.7 -3.4 1.3 Note: 2003 data are preliminaryestimates. * The diamondsshowfour key indicatorsin the country(in bold)comparedwith its income-groupaverage. Ifdata are missing,the diamondwill be incomplete. 131 2002 8 9 8 2 T R A D E I 1883 21182 Expr, I 2062 UB 505 "378 G 384 2 R -7 31 %n E X T E R N A L D E B T atid .tB$3 20112 S2# 8 2% G $1 $4 u 1 12 20 0 65 52 0 1.32 Annex 22: M a p ERITREA: HIV/AIDS/STI,TB, Malaria andReproductive HealthProject (HAMSET 11) 133 MAP SECTION