Document of The World Bank FOR OFFICIAL USE ONLY Report No: 59664-NE PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 12.8 MILLION (US$ 20.0 MILLION EQUIVALENT) TO THE REPUBLIC OF NIGER FOR A SECOND HIV/AIDS SUPPORT PROJECT March 31, 2011 This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s Policy on Access to Information. i CURRENCY EQUIVALENTS (Exchange Rate Effective March 4, 2011) Currency Unit = CFAF US$1 = CFAF 469.2 SDR 1 = US$1.58 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AIDS /SIDA Acquired Immune Deficiency Syndrome / Syndrome d’Immunodeficience Acquis ARV Antiretrovirals BCC Behavior change communication CAS Country Assistance Strategy CCT Conditional cash transfer CFAF Communauté Financière Africaine Franc CISLS Coordination Intersectorielle de lutte contre le SIDA (The National Intersectoral AIDS Agency) CFP Call for proposals CNLS Comité de Lutte contre le SIDA (National AIDS Commission) CRLS Comité(s) Régional(s) de Lutte contre le SIDA (Regional AIDS Commission(s)) CSO Civil society organization DHS/EDS Demographic and Health Surveys/Enquêtes Démographiques et de la Santé FAO Food and Agricultural Organization GDP Gross domestic product GFATM Global Fund to fight AIDS, Tuberculosis, and Malaria GP General population HIV/VIH Human Immunodeficiency Virus/ Virus d’Immunodéficience Humain IDA International Development Association IEC Information, education, communication IPPF International Planned Parenthood Federation ISHSSP Institutional Strengthening and Health Sector Support Project MAP Multi-country AIDS Program for Africa M&E Monitoring and evaluation MOH Ministry of Health NGO Non-governmental organization ORAF Operational risk assessment framework PAD Project Appraisal Document PBC Performance-based contracting PDO Project Development Objective ii PLWHA Person(s) living with HIV/AIDS PMTCT Prevention of Mother-to-Child Transmission PNLS Programme National de Lutte contre le SIDA (National AIDS Program) RBF Results-based financing RH Reproductive health STI/IST Sexually transmitted infection/ Infection sexuellement transmise SW Sex worker TB Tuberculosis TTL Task team leader ULSS Unité de Lutte Sectorielle Santé / Health Sector Coordination Unit UNAIDS United Nations Joint Program on HIV/AIDS UNFPA United Nations Population Fund UNDP United Nations Development Program UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund VCT Voluntary counseling and testing WFP World Food Program WHO World Health Organization Regional Vice President: Obiageli Katryn Ezekwesili Country Director: Kathryn Hollifield (Acting) Sector Director: Ritva S. Reinikka Sector Manager: Eva Jarawan Task Team Leader: Djibrilla Karamoko iii   NIGER Second HIV/AIDS Support Project TABLE OF CONTENTS Data Sheet   I.  Strategic Context ..................................................................................................................... 1  A.  Country Context ............................................................................................................... 1  B.  Sectoral and Institutional Context .................................................................................... 5  C.  Higher Level Objectives to which the Project Contributes .............................................. 5  II.  Project Development Objectives............................................................................................. 5  A.  PDO .................................................................................................................................. 5  1.  Project Beneficiaries ..................................................................................................... 6  2.  PDO Level Results Indicators ...................................................................................... 6  III.  Project Description.................................................................................................................. 6  A.  Project components....................................................................................................... 6  B.  Project Financing .......................................................................................................... 8  1.  Lending Instrument....................................................................................................... 8  2.  Table on Project Cost and Financing Plan.................................................................... 8  C.  Lessons Learned and Reflected in the Project Design ................................................. 8  IV.  Implementation .................................................................................................................. 10  A.  Institutional and Implementation Arrangements ........................................................ 10  B.  Results Monitoring and Evaluation ............................................................................ 11  C.  Sustainability .............................................................................................................. 11  V.  Key Risks and Mitigation Measures ..................................................................................... 11  VI.  Appraisal Summary ........................................................................................................... 12  A.  Economic Analysis ..................................................................................................... 12  B.  Technical .................................................................................................................... 13  C.  Financial Management ............................................................................................... 14  D.  Procurement ................................................................................................................ 14  E.  Social (including safeguards) ..................................................................................... 15  F.  Environment (including safeguards) .......................................................................... 16  Annex 1: Results Framework and Monitoring.............................................................................. 17  iv Annex 2: Detailed Project Description ........................................................................................ 23  Annex 3: Implementation Arrangements ..................................................................................... 29  Annex 4 Operational Risk Assessment Framework (ORAF) ....................................................... 42  Annex 5: Implementation Support Plan ........................................................................................ 44  Annex 6: Team Composition ........................................................................................................ 46  Annex 7: Results Based Financing (RBF) ................................................................................... 47  Map No. IBRD 33457 v PAD DATA SHEET Niger Second HIV/AIDS Support Project PROJECT APPRAISAL DOCUMENT Africa Regional Office AFTHE Date: March 31, 2011 Sectors: Health (50%), Other social services (50%) Country Director: Kathryn Hollifield Themes: Fighting communicable diseases (P), Civic (Acting) engagement, participation and community driven Sector Director: Ritva S. Reinikka development (S), Health system performance (S), Sector Manager: Eva Jarawan Population and reproductive health (S), Vulnerability Team Leader: Djibrilla Karamoko assessment and monitoring (S) Project ID: P116167 Lending Instrument: Specific Environmental Assessment screening category: B Investment Loan Partial Assessment Project Financing Data: Proposed terms: [ ] Loan [ X ] Credit [ ] Grant [ ] Guarantee [ ] Other: Source Total Amount (US$M) Total Project Cost: 20.0 Cofinancing: - Borrower: Total Bank Financing: 20.0 IDA 20.0 New Borrower: Republic of Niger, Ministry of Economy and Finance BP 389 Niamey - NIGER Tel: 227 20 72 23 74 Fax: 227 20 73 59 34 Responsible Agencies : 1. Ministry of Health Unité Sectorielle de lutte contre le SIDA BP 623 Niamey NIGER Contact Person: Dr Fatimata Djermakoye Telephone No.: +227 20 72 69 10 Email: ulssmspniger@googlemail.com vi 2. Coordination Intersectorielle de Lutte contre les IST/VIH/SIDA Présidence de la République - BP 1077 Niamey NIGER Contact Person: Dr. Mahamadou Issaka Kamaye Telephone No.: +227 20 73 54 60 Fax No.: +227 20 73 27 65 Email: cislsniger@intnet.ne Estimated Disbursements (Bank FY/US$ m) FY 2012 2013 2014 2015 2016 Annual 2.0 3.5 4.5 5.5 4.5 Cumulative 2.0 5.5 10.0 15.5 20.0 Project Implementation Period: 5 years Expected effectiveness date: September 30, 2011 Expected closing date: June 30, 2016 Does the project depart from the CAS in content or other ○ Yes � No significant respects? Does the project require any exceptions from Bank policies? ○ Yes � No Have these been approved/endorsed (as appropriate) by Bank ○ Yes ○ No management? Is approval for any policy exception sought from the Board? ○ Yes � No Does the project meet the Regional criteria for readiness for � Yes ○ No implementation? Project Development Objective (PDO): The development objective of the proposed project is to increase the access to HIV/AIDS/STI related services by high-risk groups in Niger. Project description 1. Strengthening health service delivery for HIV/AIDS/STI (US$10.0 million) 2. Prevention of HIV/AIDS/STI among high-risk groups (US$7.0 million) 3. Management, monitoring and evaluation (US$3.0 million) Safeguard policies triggered? Environmental Assessment (OP/BP 4.01) � Yes ○ No Natural Habitats (OP/BP 4.04) ○ Yes � No Forests (OP/BP 4.36) ○ Yes � No Pest Management (OP 4.09) ○ Yes � No Physical Cultural Resources (OP/BP 4.11) ○ Yes � No Indigenous Peoples (OP/BP 4.10) ○ Yes � No Involuntary Resettlement (OP/BP 4.12) ○ Yes � No Safety of Dams (OP/BP 4.37) ○ Yes � No Projects on International Waters (OP/BP 7.50) ○ Yes � No Projects in Disputed Areas (OP/BP 7.60) ○ Yes � No vii Conditions and Legal Covenants Credit Description Date due Agreement Section 4.01 (a) The Recipient has updated: (i) the Project Effectiveness of the FA Implementation Manual (including with the introduction of guidelines and procedures which may be applicable, as the case me be, for the contracting of NGOs to carry out Prevention Activities under Part 2 of the Project, and their payment on the basis of agreed unit costs of their inputs), (ii) the Manual of Administrative, Financing and Accounting Procedures, and (iii) its financial management software in CISLS, all in a manner satisfactory to the Association. Section 4.01 (b) The Government has established the project’s Steering Effectiveness of the FA Committee in a manner acceptable to the Association. Schedule 2, No later than three (3) months after the Effective Date, Effectiveness + 3 Section 4. (e) of the Recipient shall recruit an additional accountant for months the FA ULSS, selected on the basis of terms of reference, qualifications and experience satisfactory to the Association and in accordance with the provisions of Section III of Schedule 2 to this Agreement. Schedule 2, (i) The Output-based Financing Procedures Manual Disbursement Section has been adopted in form and substance acceptable to condition IV.B.1(b)(i) and IDA, and the Output-based Grant has been provided in (ii) of the FA accordance with agreed-upon procedures and terms and conditions, set forth in the Output-based Grant Agreement and the Output-based Financing Procedures Manual; and (ii) The Independent Evaluator has been recruited, and the proposed payment has been verified for accuracy and eligibility, and deemed consistent with the performance targets and other provisions of the Output- based Grant Agreement and the Output-based Financing Procedures Manual. Schedule 2, As part of the project annual reviews, IDA and the Annual Section II.A.2 Government will review the amounts to be committed by of the FA the Government for ARV treatment for the following year. Schedule 2, Recruitment of independent auditor Effectiveness + 6 Section II.B.4 of months the FA viii   I. Strategic Context A. Country Context 1. Niger is a large, poor, landlocked country in sub-Saharan Africa endowed with substantial natural resources. The gross national income per capita was estimated at US$368 in 2010. In 2010, real Gross Domestic Product (GDP) growth reached 7.5 percent. On the outskirts of the Sahara desert, Niger faces recurrent droughts, and only about 12 percent of all its land is arable; rainfall in these areas averages less than 350 mm per year. In 2010, UNDP’s Human Development Report ranked Niger 167th out of 169 countries1. Poverty is more acute though not limited to rural zones, with 63.9 percent of the rural population being poor and 30.3 percent extremely poor. However, the country is endowed with important mineral resources such as uranium, gold, and oil. Niger is the fifth largest producer of uranium in the world and is expected to triple its production by 2018. 2. Niger’s political situation has been relatively stable since 2000. However, in early 2009, political tensions escalated when the President expressed his intentions to remain in power beyond his second term. He dissolved the Parliament in May 2009, held a referendum in August to adopt a new Constitution and held parliamentary elections in October 20, 2009. The political situation was complicated when a military coup d’état took place on February 18, 2010. The military junta announced a one-year transition period before the reinstatement of democratically governing institutions in early 2011. The first round of presidential elections took place in January 2011, with the second round held on March 12, 2011. A new President has been elected and will assume his position on April 6, 2011. 3. Niger faces challenges to meet the health needs of its young and growing population. Niger has one of the world’s highest population growth rates (3.7 percent per year). The population was estimated at 15.2 million in 20102. On average, women give birth to seven children over the course of their reproductive lifetime. Niger’s population is concentrated in the southern region of the country, as the northern two-thirds of the country is desert land. Over the last quarter century, desertification has pushed more Nigeriens to seek economic opportunities in urban zones. The population is very young; half of Nigeriens are under the age of fifteen, and two-thirds are under 25 years old. While the gross primary school enrolment rate has increased significantly from about 29 percent in the early 1990s to 68 percent in 2009, over 70 percent of adult Nigeriens are illiterate. The health sector struggles to meet the needs of the population, with a majority of households citing lack of financial means (65%), transport difficulties (51%) and distance (51%) as significant constraints to their ability to access care. Another challenge that the country faces is responding to people and communities affected by HIV/AIDS. Selected demographic and health indicators are presented in Table 1. 1 UNDP 2010. Human Development Index Value. 2 Niger, National Institute of Statistics, Population projection 2010. 1 Table 1: Selected demographic and health and indicators Population (projection for 2010) 15.2 million Population growth rate 3.7% Contraceptive prevalence rate, modern* 16% Total fertility rate 7.1 HIV prevalence (adult population 15-49) 0.8% Estimated number of people living with HIV** 61,000 Literacy rate 28.7% Percentage of population living on less than $2/day 46.7% Percentage of households having difficulty in accessing health services (financial, geographical and/or logistical barriers)*** 78% Government expenditure on health per capita (Intl $, US)**** $12 Number of physicians per 100,000 people **** 2 Sources: World Bank MDG Database - Most recent MDG indicators: 2005 to 2008. *MOH, CPR National Survey in 2009. ** UNAIDS, 2010. *** DHS 2006. **** WHO, 2008. 4. In Niger, HIV/AIDS is concentrated in high-risk groups, notably sex workers, their clients and partners. Although the overall HIV prevalence is still low and relatively stable (about 0.8 percent among adults), the rates are worrisome among high-risk transmitters. One in four Nigerien sex workers and one in five persons with tuberculosis is HIV-positive (CISLS 2008). In order to most effectively and efficiently break the chain of transmission and prevent new infections, interventions should focus on sex workers and their clients. A socio-geographic mapping of hotspots3 for HIV transmission has been undertaken by the University of Quebec during project preparation. Zones where new HIV infections have been observed are in Niamey and the urban areas of the regions of Diffa, Tahoua, and Agadez (where a large uranium mine and military base are located). Towns in the Maradi and Zinder regions that share a border with Nigeria (where HIV prevalence is 3.1%) also present high HIV prevalence among sex workers. In Maradi, about three in five (60.6%) sex workers are HIV-infected. Niamey, Zinder, Maradi, and Tahoua include 84% of sex workers in Niger. Figure 1 shows the regional distribution of HIV prevalence by subpopulation. Other sub-populations with a documented HIV prevalence above the general population are divorced women (6.4%), widowed women (3.9%), military (3.8%), prisoners (2.8%), pregnant women (2.02%), truck drivers (1.83%), non-military security forces (1.56%), teachers (1.4%) and migrants (1.03%)4. Investing on effective HIV programs focused on the contexts of risks in the geographical priority regions, where the majority of new infections are generated, will prevent further spread of the HIV epidemic. 5. An expansion of the epidemic would present serious challenges to Niger’s economic development. Recurrent droughts have resulted in famines and placed poorer households at great vulnerability. For lack of other means, single mothers, divorcees and widows may be forced into transactional sex in order to feed themselves and their families. The AIDS epidemic is increasing the mortality of adults, with potentially severe consequences for surviving family members. UNAIDS estimated that 25,000 Nigerien children were orphaned by AIDS in 2008. Building on 3 Geographical areas known to have higher HIV prevalence than other areas. 4 CISLS, Enquête de seconde Génération, October 2008. Data on HIV prevalence of divorced and widowed women from the Enquête démographique et de santé (DHS-III), 2006. 2 evidence for effective programs on HIV prevention in concentrated epidemic, Niger has the opportunity to focus on risks contexts and prevent the majority of new HIV infections, mitigate the epidemic impact, and control the economic and social costs of further epidemic escalation. Figure 1: Distribution of HIV prevalence by region in Niger in the general population5, pregnant women and sex workers6, and adult (15-49 years) HIV prevalence in bordering countries7 Libya: no data Algeria: 0.1% Mali: 1.5% AGADEZ GP : 1.6 % PW: 1.7% SW: 24.5% GP: 0.4 % NIAMEY PW: 1.3% NIGER GP: 1.4 % SW: 16.7% DIFFA PW: 1.5% GP: 1.7 % SW: 35.6% TAHOUA PW: 2.2% GP: 1.0% SW: no data ZINDER PW: 2.7% TILLABERI GP: 0.5 % Chad: SW: 43.5% PW: 1.2% MARADI SW: 41.7% 3.5% DOSSO Burkina GP: 0.5 % GP: 0.3 % PW: 1.7% PW: 1.1% Faso: 1.6% SW: 19.8% Nigeria: 3.1% Benin: SW: 60.6% 1.2% GP = general population PW = pregnant women SW = sex workers 6. Niger’s traditions, low education, high fertility, and young population make it important to contain the HIV/AIDS epidemic and control STIs. Cultural norms pushing for large families and limited demand for family planning, sexual and reproductive health services make it challenging to reach the population of reproductive age. Niger’s high illiteracy rates and high levels of poverty may inhibit individuals from obtaining reliable information about HIV and AIDS, thus reducing their opportunity for prevention and care. The 2006 DHS showed that only 16% of males and 13% of females aged 15-24 years could correctly identify modes for HIV transmission and reject misconceptions about it. The low socioeconomic status of women may further prevent them from seeking health care. If a pregnant mother is the first in her family to be tested for HIV in the context of PMTCT and antenatal care, she may be stigmatized by her husband and family, increasing her vulnerability. These challenges will be further compounded 5 DHS-III, 2006. 6 Sentinel surveillance, 2009. 7 UNAIDS/WHO, 2010. Global Epidemic Report. 3 as Niger’s adolescents approach reproductive age. The median age at first intercourse is 12 years for females and 15 years for males. 7. Extensive internal and external migration patterns – of truckers, merchants, security forces, miners and other men – and the context of society’s overall poverty are risk factors for HIV. As desertification and fewer agricultural opportunities lead more Nigeriens to migrate to urban zones and surrounding countries, hotspots may intensify in cities and along main roads as higher risk behaviors for HIV transmission increase. The high-risk behavior of an increasing number of mobile female merchants is also a concern of the Nigerien AIDS authorities. Migration, particularly seasonal migration, also makes it more difficult for Nigeriens to regularly access health care and follow up. Niger’s plans to expand mining industries in the northern region of Agadez will bring many more young miners to hotspots where HIV-infected sex workers gather. 8. In addition, people living with tuberculosis have been identified as a group with high HIV prevalence in Niger. Over 21% of them have tested positive for HIV. The HIV-TB co-epidemic presents an additional challenge to Niger and other African countries. Since those diagnosed with TB have already been in contact with the health system, the integration of HIV-testing at TB treatment sites would be an effective and targeted approach. 9. The ability of the country’s health system to address HIV prevention, treatment and care has increased, but much improvement is still needed. As is the case in a number of West African countries, Niger’s health system continues to face limitations in human resources, both at the service delivery and management levels, inadequate laboratory equipment, and supply chain weaknesses that result in drug stock-outs and emergency purchases. There is a large geographical disparity, with more services being available in urban areas compared to rural ones. There are substantial gaps in treatment. UNAIDS estimated that 61,000 Nigeriens were HIV positive in 2010, of whom an estimated 16,000 needed ARV treatment. About 40 percent of eligible pregnant mothers still do not receive treatment for PMTCT, although this method normally has a success rate of more than 95 percent. Health care workers have been known to inappropriately divulge a person’s HIV status to others, putting the individual at risk of rejection by their families and communities due to stigma. HIV/AIDS patients may also receive compromised care due to insufficient safety measures for health care workers. 10. The previous Bank-financed Multi-Sector HIV/AIDS Support Project, implemented from 2003 to 2009, helped strengthen the Government’s efforts in fighting HIV/AIDS. The project helped establish the Comité National de Lutte contre le SIDA (CNLS), an institution that has become key in coordinating Niger’s efforts to control the epidemic. The project also helped strengthen the capacity of the Ministry of Health (MOH) in prevention and treatment, and that of other ministries in protecting their staff and clients. Civil society organizations (CSO), which played a large role in providing prevention services, also saw their capacity increase. The project resulted in significant achievements. By 2008, condom use by sex workers had reached 87 percent. Knowledge of HIV transmission also improved, with 39 percent of young women and 51 percent of young men correctly identifying preventive measures. The percentage of HIV- positive women receiving ARV treatment reached 61 percent in 2006. The total number of patients being treated has increased to about 7,500 in 2010. 4 B. Sectoral and Institutional Context 11. Rationale for Bank involvement. Bank assistance to governments in improving health outcomes is central to its mandate of poverty reduction: better health contributes to higher productivity and incomes, while poor health both results from and exacerbates poverty. In the case of Niger, it makes sense for the Bank to support the Government’s continuing efforts to prevent and contain HIV/AIDS, especially since the epidemic has not yet spread widely. It is also effective to intervene earlier in the epidemic to prevent the spread of HIV/AIDS. In addition, it could raise the demand for relatively expensive medical care and fuel a resurgence of tuberculosis, its most common opportunistic infection. AIDS deaths would not only rob the workforce of some of its most skilled members, but leave families without breadwinners and children without parents. Overall, HIV has a negative impact on economic growth. 12. The Bank’s role is to help the Government strengthen a coordinated approach to the health sector, which ultimately contributes to the sustainability of its interventions. Most of Niger’s development partners provide only technical assistance to the Government’s response to HIV/AIDS (see Table 2 on page 31), with the exception of the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). The GFATM8 finances a variety of HIV/AIDS prevention and treatment activities, but the amount is insufficient and limited to only certain HIV-related expenditure categories. Therefore, the Bank’s involvement is critical. C. Higher Level Objectives to which the Project Contributes 13. Aligned with Niger’s National Strategic Framework 2008-2012, the proposed project supports Pillar 2 of Niger’s Country Assistance Strategy (CAS) of May 2, 2008, which aims at strengthening human capital through equal access to social services. It is also aligned with one of the key objectives of the Poverty Reduction Strategy Paper (PRSP): to provide equitable access to quality social services. It is also in line with the Africa Strategy and the Africa Region HIV/AIDS Agenda for Action. It will help Niger to attain Millennium Development Goal (MDG) 6 – halting and reversing the spread of HIV/AIDS by 2015. Finally, this operation would complement the Bank’s current intervention in the health sector: the Institutional Strengthening and Health Sector Support Project (P083350), scheduled to close on June 30, 2011, and the Multi-Sector Demographic Project (P096198), effective through March 2013. II. Project Development Objectives A. PDO 14. The development objective of the proposed project is to increase access to HIV/AIDS- and STI-related services by high-risk groups in Niger. 15. The specific objectives of the Project are to support the National Strategic Framework in: (i) expanding the provision of prevention services; (ii) increasing the utilization of HIV/AIDS/STI services; (iii) improving the Monitoring and Evaluation (M&E) by establishing one overall national M&E system including a biological and behavioural surveillance system. 8 GFATM – Round 7 has committed to Niger: $4.1 million in 2010, $8.1 million in 2011, and $9.2 million in 2012. 5 1. Project Beneficiaries 16. Direct beneficiaries of the project are people living with HIV/AIDS (PLWHA), and high- risk groups in Niger: sex workers, their clients, and TB patients who will have improved access to HIV/AIDS/STI-related services. The estimated 25,000 AIDS orphans and vulnerable children would also benefit through social protection activities. Indirect beneficiaries of the project include health care seekers as the Ministry of Health will strengthen its capacity for service delivery and health systems strengthening. The national AIDS coordination entity, the Coordination Intersectorielle de lutte contre le SIDA (CISLS), will benefit from increased capacity for program coordination, monitoring and evaluation, and program implementation. 17. To ensure that activities to increase supply and demand are appropriately targeted to these beneficiaries, the Task team has worked with the University of Quebec to undertake a social mapping exercise for groups at high risk of HIV/AIDS throughout Niger. In early March 2011, preliminary results were reviewed with the Government and other stakeholders in Niger and targets for specific geographical regions were discussed. Additional information about the social mapping exercise is provided in Annex 2. 2. PDO Level Results Indicators Pregnant women living with HIV who received antiretroviral to reduce the PO Indicator 1 risk of MTCT (number) [Core IDA Indicator] Adults and children with HIV receiving antiretroviral combination therapy PO Indicator 2 (number) [Core IDA Indicator] Percent of sex workers using a condom in their most recent sexual PO Indicator 3 encounter. [UNGASS Indicator] 18. The comprehensive results framework and monitoring plan are presented in Annex 1. III. Project Description A. Project components 19. The project will help the Republic of Niger implement its National Strategic Plan for HIV/AIDS/STI. It will have three components: (i) Strengthening of health services delivery for HIV/AIDS/STI; (ii) Prevention of HIV/AIDS/STI for high-risk groups; and (iii) Management, monitoring and evaluation. 20. Component 1: Strengthening health services delivery for HIV/AIDS/STI (US$ 10.0 million). This component will consist of two subcomponents: (1.1) Improving the quality and availability of health service delivery; and (1.2) Piloting the output-based financing of HIV/AIDS services. 6 22. Subcomponent 1.1: Improving the quality and availability of health service delivery, by: (a) Improving the quality of services provided by HIV/AIDS/STI testing, care and treatment centers in Niger, through the provision of tests, drugs and equipments, and the training of medical staff in said centers; (b) Improving the management of the supply chain to support HIV/AIDS treatment, through: (i) the carrying out of an assessment of the MOH’s strengths and weaknesses for the management of the HIV/AIDS treatment supply chain; and (ii) the provision of equipments (including information technology equipment and software) and training to address weaknesses identified by said assessment; (c) Improving biosafety in HIV/AIDS/STI testing, care and treatment through the provision of training and equipments for the implementation of the Waste Management Plan; (d) Strengthening the prevention of mother-to-child transmission, through the provision of contraceptive, tests, drugs and equipment to health centers involved in providing reproductive health services, and the training of their medical staff; (e) Strengthening HIV/TB service integration, through the provision of tests, equipment and training to increase the percentage of TB patients tested for HIV, and the percentage of HIV- positive people screened for TB; and (f) Developing a second-generation surveillance of AIDS cases, new HIV infections, behaviors and characteristics of people at high risk. 23. The above subcomponent will finance goods, consultants, and training. 24. Subcomponent 1.2: Piloting the output-based financing of HIV/AIDS services : (a) Carrying out a feasibility study of the output-based financing of HIV/AIDS services, and based on the outcome of a feasibility study, developing tools, resources and capacity for the output-based financing of HIV/AIDS services, including: (i) the preparation of the Output-based Financing Procedures Manual; (ii) the selection and recruitment of the Independent Evaluator; and (iii) the provision of training to the staff involved in the provision of HIV/AIDS services. (b) As shown in other countries, RBF increases the motivation and accountability of service providers to achieve results. RBF bonuses will be paid which will provide cash at facility level to cover the local costs of delivering the services. The results achieved against defined targets will be regularly assessed by a third party to avoid the “numbers game� in which health workers may report higher services than actually provided. Social accountability will also be strengthened through enhanced participation of communities in planning and implementation of community- based activities, using tools such as community score cards and disclosure of information on the use of RBF incentives in health facilities. 25. The above subcomponent will finance goods, consultants, and operating costs. 7 26. Component 2: Prevention of HIV/AIDS/STI for high-risk groups (US$7.0 million). This component will consist of carrying out prevention activities for (i) the prevention of HIV/AIDS/STI targeting sex workers and/or their clients; and (ii) the provision of support to AIDS orphans (including children of sex workers). 27. Component 3: Management, monitoring and evaluation (US$3.0 million). This component will strengthen CISLS’ capacities in management and coordination of activities in the fight against HIV/AIDS/STI subsector through the provision of administrative, management and fiduciary support, capacity building at the central, regional and local levels, technical support to enhance the design of policies and strategies and implement monitoring and evaluation. 28. This component will finance goods, consultants, training, and operating costs. B. Project Financing 1. Lending Instrument 29. The project will be financed through a Specific Investment Loan (SIL) of US$20.0 million equivalent over a five-year period. 30. The project will finance equipment and consultant services as well as management and training programs which are required for institutional strengthening and capacity building. The proposed IDA financing would fill part of the funding gap9, and may likely attract additional funding from other development partners, and technical support from UN agencies. 2. Table on Project Costs and Financing Plan Project cost IDA Percent of Project Components (US$ million) Financing Financing 1. Strengthening health service delivery for HIV/AIDS/STI 10.0 10.0 50 2. HIV/AIDS/STI prevention for high-risk groups 7.0 7.0 35 3. Management and M&E 3.0 3.0 15 Total Baseline Costs $20.0 $20.0 100% C. Lessons Learned and Reflected in the Project Design 31. The Bank’s support to a follow-on operation builds on the lessons of the first project and would help the Government sharpen its prevention strategy. During the preparation of this second operation, the Bank has been assisting the Government to better align its response strategy with the modes of transmission of the epidemic, to target high-risk groups, and to use preventive interventions known to be successful. 9 The Global Fund Program of US$22 million is committed only until 2012, and to date there are no indications of a follow-up program. A large proportion of the Global Fund program covers treatment, and relatively less for prevention, leaving substantial funding gaps in that area. 8 32. The Bank’s Independent Evaluation Group (IEG) conducted a comprehensive assessment of the Bank’s assistance for HIV/AIDS control.10 IEG reviewed the objectives of the Africa Multi-Country AIDS Program (MAP), the validity of the assumptions underlying the rationale, and assessed the program’s design and risks. The experience of the previous Bank-financed Niger Multi-Sector HIV/AIDS Support Project, implemented from 2003 to 2009, is directly in line with IEG’s conclusions to reduce the breadth of multisectoral engagement and focus on key populations, both of which better align with epidemiological trends and HIV transmission modes. 33. As a first-generation MAP, the institutional arrangements for the first project were not ideal. They depended exclusively on a newly-created institution: the CISLS that was going to manage the country’s whole HIV/AIDS program. It took time for the CISLS to acquire capacity and experience. Secondly, the engagement of a large number of sectors in implementation, many of them with no apparent comparative advantage in addressing AIDS, increased the complexity and created coordination problems. Strong emphasis on the need to work in multiple sectors resulted in a certain disengagement of the Ministry of Health, which is in fact the lead technical agency for the long-run fight against AIDS. The project engaged with as many as 24 line ministries without much prioritization. This lack of focus was also translated in the way the project dealt with NGOs and CSOs. As a result of the demand-driven approach, there was limited guidance on priorities in terms of activities, geographical areas, or groups at high risk of transmitting the epidemic. Smaller-scale projects were favored, resulting in a huge number of proposals and high transaction costs. There was no clear distinction between the actors enlisted for purposes of political mobilization and those with the grassroots expertise, and thus comparative advantage to implement activities with a direct impact on the drivers of the epidemic. Also, the project’s M&E had a number of weaknesses, notably limited data on behavior change by specific groups, except for sex workers and youth. There was a wealth of data on volume and dollar value of subprojects approved as well as on basic output indicators, but a paucity of information for assessing project outcomes and impact. 34. This proposed project takes into account these lessons and will aim to help the Government of Niger to be more strategic and selective, prioritize, and use the existing capacity for implementing programs that will have the greatest impact on the HIV epidemic. Based on epidemic analysis, the project will be implemented through a phased approach, focusing initially on the four regions: Niamey, Zinder, Tahoua, and Maradi. The MOH has a significantly larger responsibility than in the first-generation HIV/AIDS projects. The activities of the MOH are also pre-defined in specific areas. The prevention activities to be implemented by NGO/CSOs are pre-defined through a package of intervention and standard operating procedures, evidence- based and focusing on the prevention of transmission in risk context generating the majority of new infections. The project will engage NGOs and CSOs with performance-based contracts, a huge improvement on first-generation MAPs. The activities with line ministries that have high- risk groups have been streamlined to be included in NGO/CSO-implemented prevention activities on the ground. Finally, the CISLS will be less involved in day-to-day implementation, and much more in overall coordination, monitoring, and evaluation. The design of M&E is 10 IEG: Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance - An OED Evaluation of the World Bank’s Assistance for HIV/AIDS Control (2005). 9 improved and evidence-based, with a strong focus on measuring behavior change among the high-risk groups known to be the main drivers of the epidemic. IV. Implementation A. Institutional and Implementation Arrangements 35. The project will be implemented by two main agencies, the MOH and the CISLS (and by NGOs to be subcontracted). The CISLS is staffed by a multidisciplinary team including: a coordinator; an administrative and financial management specialist; experts in the monitoring of health sector and CSOs; a communication specialist; a public relations specialist; and a specialist in monitoring and evaluation. Most of these staff participated in the implementation of the previous project. The procurement function is staffed by a Procurement Specialist who has been recruited by the CISLS as part of the Global Fund financing. They have the skills and experience for project implementation, including planning, procurement and financial management, supervision, and M&E. Supervision responsibilities will be decentralized to the regional level, including NGO and CSO contract management. This decentralization will be linked to the amount of the contract and the scale of the work which needs to be implemented on the ground. 36. The Ministry of Health is technically strong in HIV/AIDS prevention and treatment with qualified personnel, equipment and facilities to provide their services, although more progress is needed to improve coverage in rural areas. Under Niger’s ongoing Institutional Strengthening and Health Sector Support Project (ISHSSP) (P083350), the ministry has acquired substantial experience in project management. It has established a pool of fiduciary specialists, including qualified procurement and financial management specialists, and an adviser to the Secretary General, all of whom have demonstrated project implementation experience. As needed, they may also be supported by the Directorate of Infrastructure and Equipment for the preparation of procurement documents and the evaluation of bids and proposals. 37. Supported by the ongoing GFATM project, CISLS and its regional offices have strengthened capacity through the recruitment of the additional staff (Accountants, Procurement Specialists, and Technical Assistants). To further strengthen management capacity of the CISLS and the MOH, the project will provide staff training in procurement, financial management, environment, and supervision during the first year of the project. The organization of the project implementation is presented below. RESPONSIBLE COMPONENT IMPLEMENTERS HOW? FOR WHO? (Coordination) Targeting Commercial sex 1. Strengthening health Annual Work workers, pregnant women, services delivery for Ministry of Health Ministry of Health plan for service PLWHA, TB patients, and HIV/AIDS/STI delivery people asking for VCT services. 2. Prevention of CISLS and CRLS Calls for Identified high-risk groups HIV/AIDS/STI (CISLS Regional proposals for NGOs and CSOs (Commercial Sex workers among high-risk Coordination performance- and Orphans) groups Units) based contracts 3. Management, CISLS and CRLS Annual Work Oversight and M&E to Monitoring and CISLS CNLS plan other project components Evaluation 10 38. More detailed descriptions of the coordination and implementing arrangements can be found in Annex 3. B. Results Monitoring and Evaluation 39. A comprehensive description of the project’s results framework for monitoring and evaluation is described in Annex 1. C. Sustainability 40. Politically, the project is expected to be sustainable because its point of departure is the leadership and commitment shown by Government, and the current strong ownership of the Ministry of Health, the Ministry of Finance and the key sectoral ministries which developed and executed their own sectoral HIV/AIDS Action Plans in the past years. The Government’s commitment is also shown by the introduction of a line item in the budget for prevention, care and treatment of PLWHA. 41. To tackle the issue of organizational and technical capacity, the project will help strengthen the capacity of the CISLS to oversee the national program, to extend and to consolidate the Government ownership in the implementation of the annual work plan by the sectoral ministries. 42. In order to build and maintain the supply chain management of drugs, the Government will undertake a reform of the national drugs purchasing agency. The reform will be supported by partners involved in the health sector, including the Bank. The technical capacity of staff will be strengthened at the central and regional level in order to avoid drug stockouts. A stockout indicator will be monitored by the project and linked to the results-based financing mechanism. 43. Given the importance for Niger to ensure the sustainability of treatment, the Bank has initiated discussions on this issue with the Government, which has resulted in the adoption of a specific line for treatment financing in the national budget. As part of the project annual reviews, IDA and the Government will review the amounts to be committed by the Government for ARV treatment for the following year. 44. The project mechanisms, designed on the basis of the established successful in-country experience with subcontracting through calls for proposals and direct financing of the annual work plan in order to empower the sectors, are expected to bring early successes in the scaling up and replication of existing HIV/AIDS preventive activities and care services for PLWHAs. This should help generate sustained support, and stimulate further replication. V. Key Risks and Mitigation Measures 45. The key risks of the proposed project are related to implementation and coordination capacity, specifically: (i) concern regarding the Ministry of Health’s role and capacity in assuring national coverage and quality of key HIV/AIDS/STI prevention, treatment and care services; (ii) the inadequate capacity at different levels of country systems; (iii) the limited ability of NGOs and CSOs to support and empower high-risk groups; (iv) low capacity of the CISLS and its 11 partners in their role of organizing and consolidating the national response, monitoring and analyzing data to guide the national response under the National HIV/AIDS Strategy framework; (v) the sustainability of the treatment program if the country is not committed to allocate funds through the health budget for ARVs; and (vi) fiduciary risks related to procurement and financial management. Technical assistance and capacity building will take place at the central and regional levels. A complete discussion of risks and mitigation measures is provided in Annex 4, the Operational Risk Assessment Framework (ORAF). VI. Appraisal Summary A. Economic Analysis 46. An uncontrolled HIV/AIDS epidemic would have devastating effects on Niger’s economic growth. Many studies have estimated that HIV/AIDS reduces the economic growth of African countries with high HIV prevalence by 1 percent annually, with some studies estimating up to 2 percent annually. HIV/AIDS undermines human capital development by affecting adults -- teachers, doctors, civil servants, businessmen and women, police, and military -- in their most productive years. Agriculture can also be severely affected. The FAO estimates that some Southern African countries may lose more than 20 percent of their agricultural labor force by 2020. At the household level, the epidemic creates havoc. If the main wage earner dies, poverty and lack of resources may force the survivors to exchange sex for goods, services and cash in order to survive. 47. HIV/AIDS also has second-order macroeconomic effects. These occur as: (i) increased cost of treatment diverts funds from other productivity enhancing expenditure such as education or infrastructure; (ii) firms’ cost of training workers increases; (iii) reduced profits leave less for new investment; and (iv) soil fertility declines as there is less labor available for tasks like weeding, mulching, pruning, and the clearing of land. 48. Among of the most tragic outcomes of the HIV/AIDS epidemic is the generation of thousands of dependent AIDS orphans. The orphaning of children is a lagged effect of the epidemic. Even when Niger will have succeeded in reducing HIV incidence, the number of orphans will continue to increase. Unless safety nets are put in place, orphans will have a limited opportunity to develop their human capital, as on illness or death of a parent, children’s time is allocated away from schooling towards care giving, house chores and work to supplement the family income. Increasing the survival of HIV-infected parents through treatment would help reduce the number of orphans. 49. Finally, and difficult to estimate is the extent to which the epidemic destroys the social fabric of communities. As the dependency ratio increases, households may be headed by children or the elderly with practically no source of income, which further places young girls at risk of exposure to transactional sex. 50. The economic benefits of the proposed project are multifold. First, since this project aims to increase utilization of HIV-related services, including testing, treatment, RH and TB services, and care for HIV-affected families, the majority of Nigeriens will benefit directly and/or indirectly. By increasing the number of persons tested for HIV and providing them with the 12 means to prevent HIV, the number of new infections will be reduced. By ensuring the increased utilization of HIV services, specifically ARV treatment, the viral loads of AIDS patients will be reduced, further reducing HIV transmission rates. In addition, PLWHA will be able to lead longer and more productive lives, supporting their families and communities by benefitting from better management of opportunistic infections, STIs, TB, and improved access to good nutrition. Further, orphans, widows, and other HIV-affected groups will have improved economic prospects with increased access to education, social benefits and other mitigation efforts. Finally, an emphasis on targeted prevention among key groups is more cost-efficient than waiting to intervene after HIV infection has reached the general population. A widespread HIV/AIDS epidemic, such as in a number of Southern African countries, can have devastating effects on economic growth. Various studies estimate that HIV/AIDS may reduce economic growth by 1 percent and some by as much as 2 percent per year. B. Technical 51. The technical design of the proposed project is based on lessons learned from Niger’s and sub-Saharan Africa’s experience with HIV/AIDS projects, as well as international best practices. 52. First, it was necessary to better understand the nature of the HIV epidemic in Niger by identifying the modes of transmission, the high-risk groups and determinants for high-risk behaviors. In addition, the areas for improvement from the first Niger HIV/AIDS project were examined, including low VCT rates, low demand for and access to services and the complexity of a fully multisectoral arrangement. For this reason, the institutional arrangements have been modified, using civil society capacity to drive demand for VCT. 53. The project will contribute to implement the 2008-2012 National Strategic Framework, and the forthcoming framework for 2013-2018. To achieve these specific goals, the project will use two types of approaches so as to use the funds to target high-risk groups: (i) a call for proposals for prevention, care, and support activities from NGOs and CSOs, and the private sector; and (ii) results-based financing for care, treatment and logistics management for public services. 54. Call for Proposals: The project will build on the success of the previous one, by launching a call for proposals in some specific areas to hire better-performing local NGO and CSOs and reputable international NGOs to implement prevention and care activities. It will be a competitive recruitment at market rates to implement specific activities aimed at specific results such as strengthening service delivery, expanding coverage, and improving quality and equity. The package of services and intervention design will be in line with quality criteria, including standard operating procedures per each intervention to ensure quality in implementation. 55. Results-Based Financing: RBF has been used in the health sector as an output-based approach to improve health service delivery. Health services are often of low quality, with issues like drugs being unavailable and the lack of motivation of personnel. In most cases, the inefficient allocation of resources rather than their lack is the reason why poor people have a low access to quality health care. RBF is a powerful way of improving resource allocation in a health care system. It gives service providers the freedom to take decentralized decisions on how to 13 provide services. It also provides an incentive to use resources in an efficient way, as it shifts performance risks to service providers, for example, by reimbursing them for interventions performed or by making a proportion of their earnings contingent on meeting predetermined targets. C. Financial Management 56. A financial management assessment of the CISLS and MOH was carried out. Inherent and control risks were identified and related mitigation measures were developed and agreed upon with the CISLS and the MOH. Overall, the residual financial management risk of the project is assessed as Medium-Likelihood. CISLS, the project coordination unit under the President’s office, will be the implementing entity for Components 2 and 3 while the MOH will implement Component 1. Both CISLS and MOH have experience in managing Bank-funded projects. The current staffing arrangements in both agencies are adequate to ensure sufficient segregation of duties. All operational procedures will be documented in the administrative, financial and accounting manual. The proposed financial management arrangements for this project are adequate to meet the Bank’s minimum fiduciary requirements as per OP 10.02; there are no overdue audit reports and interim financial reports from these entities. Additional FM mitigation measures related to the results-based financing under sub-component 1.2 will be proposed upon the completion of the feasibility studies aiming at defining the implementation arrangements for the results-based financing. These measures include having in place: an output-based grant agreement, an independent verifier, third party monitoring, technical audits, publication of RBF credit and payments made, and mechanisms for checking fraudulent actions. Annex 3 provides additional information on financial management. D. Procurement 57. Procurement would be carried out in accordance with the World Bank’s "Guidelines: Procurement under IBRD Loans and IDA Credits", dated May 2004, revised through May 2010, and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers", dated May 2004, revised through May 2010. “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants", dated October 15, 2006, and revised in January 2011 shall apply to the project. 58. Procurement activities will be carried out by (i) the Ministry of Health for component 1; and by (ii) the National HIV/AIDS Coordination Unit (CISLS) for components 2 and 3. 59. An assessment of the capacity of the Implementing Agencies to implement procurement actions for the project was carried out during the project preparation and confirmed during appraisal. The assessment reviewed the organizational structure for implementing the project and the interaction between CISLS and the Ministry of Health, and the project’s staff responsible for procurement within the Ministry and the Procurement Division in the Ministry’s Central unit for administration and finance. 60. The CISLS is staffed by a multidisciplinary team including a coordinator, an administrative and financial management specialist and experts in monitoring of health sector 14 and non-health sector, communication specialist, public relations specialist and specialist in monitoring. Most of these staff have participated in the implementation of the previous project, and therefore possess the required experience to handle the preparation of various procurement documents (i.e. TORs, technical specifications, request for proposals, evaluation reports). The procurement function is staffed by a Procurement Specialist who has been recruited by the CISLS as part of the Global Fund financing. 61. The Ministry of Health has established a pool of experts including fiduciary, in the context of the multi-donors health project. The fiduciary arrangement includes a procurement specialist recruited through the Bank-financed Institutional Strengthening and Health Support project (P083350), an adviser to the General Secretary and a Head of Procurement Division, whom all have demonstrated experience in procurement procedures, including World Bank procedures. Regarding procurement document preparation and the evaluation of bids and proposals, the involvement of the Directorate of Infrastructure and Equipment could be a great asset to the process. 62. Risk mitigation measures have been discussed and agreed with the agencies, and the residual risk is assessed as moderate. A draft procurement plan for the project has been prepared and found acceptable. It was finalized and agreed upon at negotiations. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. A summary of the procurement capacity assessment and project procurement arrangements are provided in Annex 3. More details are available in the project files. E. Social (including safeguards) 63. Neither in formal law, nor in practice, do women have equal rights with men in Niger, and in cultural practice, especially in the countryside, women often have no public voice in social or sexual matters. The virus is transmitted predominantly through heterosexual contact, and while women, children, and commercial sex workers are the key groups with increasing rates of infection, or at very high risk, men play a predominant role in the continued transmission of HIV. The virus is also spread through mother-to-child transmission, for which the socially disempowered status of women is a powerful underlying factor. 64. PLWHA were consulted during the preparation of the project, and helped improve its design by identifying appropriate actions. PLWHA are now well represented in Niger at the central and local levels. The project will provide support to PLWHA through associations and within communities. Increased coverage and improved quality of care services for PLWHA, and consequently improved quality of life for them, will be an important social development outcome. 65. Important short and medium-term social benefits of the project will be: (i) the strengthening/establishment of social support systems, such as counseling services and support groups for PLWHAs, orphans and vulnerable youth with the objective of reducing the economic and social burden on patients and families; (ii) increased access to testing and treatment for pregnant women; and (iii) increased access to blood bank services and management of STIs. 15 Project actions will have social benefits for individuals and families, while helping to slow the transmission of HIV/AIDS at the population level. 66. Important longer-term social benefits of the project will be: (i) reduced social stigma attached to HIV/AIDS, which over time, will increase the possibility for the earlier detection of the disease; and (ii) changes in social and sexual attitudes and behavior will contribute to reducing the overall rate of transmission. 67. No social safeguards policies will be triggered by project. F. Environment (including safeguards) 68. The increasing utilization of HIV-related services, notably VCT and ARV treatment, will result in additional medical waste, which will need to be safely disposed of at health centers and laboratories. A Waste Management Plan was prepared for the Multi-Sector STI/HIV/AIDS Support project (P071612). It was updated in December 2004 and more recently in 2010 as part of the ISHSSP (P083350) implementation. The latest version includes the progress made so far in the implementation and the experiences gained in the management of infected materials. The Waste Management Plan was disseminated during appraisal (March 2011). 69. The Ministry of Health designed and built incinerators in various health facilities, and purchased appropriately more complex imported models complying with international norms which have been allocated to centralized health facilities (hospitals). The key health personnel have been trained, and the project will continue the systematic training and the capacity building of health personnel responsible for managing incinerators and the infected materials. 70. The Project will be aligned with the Niger ISHSSP (P083350) in its efforts to develop and ensure that annual work plans comply with environmental waste management standards, and adhere to the priorities identified in the Waste Management Plan. The Project will finance selected investments in waste management, such as protective clothing for health care workers, equipment for presorting, collecting, storing and transporting medical waste, and burial pits. 16 Annex 1: Results Framework and Monitoring Niger Second HIV/AIDS Support Project Project Development Objective (PDO): To increase access to HIV/AIDS /STI-related services among high-risk groups in Niger Cumulative Target Values** Responsibility Core PDO Level Results Unit of Data Source/ Description (indicator definition Baseline Frequency for Data Indicators Measure 2012 2013 2014 2015 2016 Methodology etc.) Collection Number of pregnant women receiving POI# 1. Pregnant women antiretroviral prophylaxis per WHO living with HIV who Service recommendations. To be collected Number 1,603 from ULSS, public and private health received antiretroviral to 2,000 2,200 2,300 2,500 2,800 Annual Delivery CISLS (2009) facility reports to CISLS. The reduce the risk of MTCT Report project’s component 1 will contribute [Core IDA Indicator] to the MOH’s ongoing efforts to scale- up PMTCT. Number of adults (over 15 years of POI# 2. Adults and age) and children (under 15 years) that children with HIV Service are taking antiretrovirals as per WHO Number 7,445 CISLS / MOH recommendations. To be collected receiving antiretroviral 7,800 8,000 8,500 9,000 9,300 Annual Delivery (2010) and ULSS from ULSS, public and private health therapy [Core IDA Report facility reports to CISLS. This is an Indicator] indicator that IDA will contribute to, i.e. partial attribution. Respondents are answering the following question: “did you use a condom with your most recent client?� Numerator: Number of respondents who reported that a condom was used with their last client Denominator: Number of respondents who reported having commercial sex POI# 3. Sex workers in the last 12 months Second To be disaggregated by sex and age using a condom at their Percentage 84.66 Every 2 84.66 - 90 - 90 Generation CISLS (<25; 25+) most recent sexual (2008) years This number is already relatively high Survey encounter [UNGASS] currently. The goal (in setting targets) would be to maintain, if not increase the percentage. 17 Intermediate Result (Component One): Strengthening health service delivery for HIV/AIDS and STI Cumulative Target Values** Responsibility Core Intermediate Results Unit of Data Source/ Description (indicator Baseline Frequency for Data Indicators Measure Methodology definition etc.) 2012 2013 2014 2015 2016 Collection Subcomponent 1.1 Improving the quality and availability of service delivery Number (cumulative) of (public and private) health personnel trained in 1. HIV-related 500 1,000 1,500 2,000 2,500 the quality provision of HIV care prevention and treatment services as per the HIV/AIDS Strategic IOI# 1. Health personnel 2. Supply chain Framework. management 500 1,000 1,500 2,000 2,500 Disaggregated by training: receiving training [Core Number Annual Report ULSS/MOH - the quality provision of HIV IDA Indicator] prevention and treatment services; - supply chain management ; - biosafety. 3. Biosafety 500 1,000 1,500 2,000 2,500 Individuals may be trained in more than one area and thus counted more than once. List of key ARV products for IOI #2. ARV treatment monitoring defined by ULSS/MOH centers with ARV according to national standards. The 5 (out of 12) products stocked out in at Number 3 1 0 0 0 Annual Report ULSS/MOH goal (in setting targets) would be to (2009) maintain the number while any time during the past 12 months. improving the efficacy of stock management. IOI#3. Health facilities Number of (public and private) health facilities where voluntary offering high quality HIV 270 Number 280 300 400 500 546 Annual Report ULSS/MOH counseling and testing for HIV can counseling and testing and (2010) be accessed according to referral services WHO/national standards. Number of (public and private) IOI# 4. ART treatment health facilities that offer services 12 that can be accessed according to sites offering high quality Number 12 13 15 17 17 Annual Report ULSS/MOH (2009) WHO/national standards. The goal services (in setting targets) would be to maintain the number. Number of (public and private) Pilot design health facilities where all PMTCT report and services (ANC with HIV testing; IOI#5. Health facilities 245 Number 250 300 350 450 493 Annual RBF MOH/CISLS ARV prophylaxis, skilled attended offering PMTCT services (2010) delivery, and monitoring of child) implementatio n manual can be accessed regularly and according to national standards. IOI#6: Sex workers Referral card This will not be a cumulative, but screened for sexually Number 0 1,000 2,000 3,000 3,500 4,000 Annual from ULSS / MOH rather annual, as regular access to transmitted diseases NGOs/CSOs to health services is the desired 18 (annual) health facilities outcome. Numerator: Number of sex workers presenting a referral card to health facility to access STI screening in a given year Denominator: Number of sex workers receiving SRH referral cards during that year. Numerator: Number of TB patients who have also been tested for HIV IOI #7: TB patients test Percentage 0% 10% 20% 40% 60% 80% Annual Report MOH Denominator: Total number of TB for HIV patients counted by the health system Sub-component 1.2: Piloting of output-based financing for HIV/AIDS services After the pilot, the Government IOI #8: RBF pilot design Memorandum will share a memorandum to all validated by Government Yes/No No No No Yes - - Annual MOH signed by the stakeholders in order to confirm of Niger/MOH/CISLS MOH the results of the RBF pilot. Contracts Contracts signed with health IOI #9: RBF contracts Yes/No No No Yes Yes - - Annual signed and MOH centers identified to participate signed with health centers notarized in the RBF pilot MOH / MOF / IOI #10: Pilot health Records/ PADS Number of health districts whose districts with RBF results Number 0 0 10 20 - - Annual reports of Annual internal RBF results have been fully verified fully verified by verification audit (by MOH independent third party inspectorate) Intermediate Result (Component Two): Prevention of HIV/AIDS and STI for high-risk groups Cumulative Target Values** Responsibility Core Intermediate Results Unit of Data Source/ Description (indicator Baseline Frequency for Data Indicators Measure Methodology definition etc.) 2012 2013 2014 2015 2016 Collection Number of peer educators trained who provide effective, evidence- based HIV prevention education to high-risk groups, including PLWHA (education including VCT, PMTCT, IOI #11: PLWHA, sex TB testing, condom use, STI workers and their NGO/CSO prevention, reducing partners, being NGO/CSO and clients trained as peer Number 0 0 1,000 2,000 2,000 2,000 Annual activity faithful, and other prevention CISLS methods). Training should include educators for HIV reports prevention basic skills in communications. As reported to the CISLS from the contracted CSOs/NGOs and validated by independent 3rd party. Trainers to be disaggregated by risk group, age, gender and region. 19 Number of peer educators actively conducting targeted educational IOI# 12. Peer educators NGO/CSO and sessions among high-risk groups. To providing peer NGO/CSO CISLS with be disaggregated by risk group, age, Number education for HIV 0 0 1,000 2,000 2,000 2,000 Annual activity independent 3rd gender and region. A peer educator prevention to high-risk reports party would be considered active in a groups verification given year if s/he conducts at least one peer education session per quarter. The number of people identified as IOI #13. People in high risk (PLWHA, TB patients, sex worker, trucker, miner, military, high-risk groups and Number 0 0 10,000 20,000 25,000 30,000 Annual Report CISLS MSM) receiving new knowledge by PLWHA receiving peer peer educator. To be disaggregated education by risk group, age, gender, and region. Numerator: Number people in high- risk groups who can identify three prevention methods (using condoms, IOI# 14. People in limiting partners, abstinence, not high-risk groups Second sharing needles or razors) and reject correctly identifying Generation misconceptions (healthy physical Percentage Sex workers Every 2 ways to prevent HIV 30 - 50 - 70 Survey / CISLS appearance does not mean a person 10% years is sero-negative, AIDS cannot be and correctly reject Sociographic misconceptions mapping transmitted by mosquitoes, [UNGASS] witchcraft, or sharing a meal) Denominator: people identified as high-risk (sex workers and clients) from the socio-geographic mapping Numerator: Number of OVC registered and who received care, Association psychosocial support, educational IOI #15. OVC registers and NGO/CSO and support through NGOs/CSO in last receiving care and Percentage 0% 0% 20% 40% 60% 80% Annual NGO/CSO CISLS 12 months. Support Denominator: Total number of OVC reports registered by NGOs/CSOs. IOI#16. Direct project beneficiaries (number) Project Number 0 13,000 21,000 33,000 39,000 45,000 of which female Annual monitoring CISLS (Percentage) (n/a) (60%) (60%) (60%) (65%) (65%) (percentage) [Core IDA reports Indicator] **Target values should be entered for the years data will be available, not necessarily annually. 20 1. The Results Framework for this project is strongly informed by the advances in M&E thinking in the Bank,11 and in particular by the criticisms of M&E in HNP.12 The Results Framework focuses on accountability for results — i.e., moves beyond the usual tracking of inputs and outputs, and places a strong emphasis on intermediate outcomes. In addition to the accountability function of evaluation, this Results Framework also emphasizes the learning function of evaluation. To the extent possible, the proposed results framework uses existing indicators and data to measure the progress of both the project and its contribution to the overall national program, not only for efficiency, but also to build on and strengthen existing data collection mechanisms. 2. Disaggregation of indicators. The focus of this project is on improving access for sub- populations within Niger that have been identified as high risk. During project implementation, a socio-geographic mapping exercise took place to identify these sub-populations (geographically, demographically) so that they could be appropriately targeted through project activities. Results will be measured based on the effectiveness of their reach. The gender of project beneficiaries will be tracked for IDA Core Indicators, and additional indicators will be disaggregated by risk group, age, gender and region as specified in the table above. Attaining this level of information about these subpopulations is means to further reinforce the capacity of national stakeholders in the AIDS response. 3. The quality of data planning during the project preparation is a key determinant of successful M&E implementation. The CISLS has an M&E directorate with key skilled staff deployed in the region and at the national level. Technical specialists will work with the stakeholders – MOH, CISLS and its regional coordination units - to ensure the implementation of a data collection, reporting, and supervision. They will also work with the National Institute of statistics, universities, national research institutions and private consulting agencies to systematically structure a sustainable system of surveillance of the HIV/AIDS epidemic in Niger. It is also recognized that it will be necessary for the CISLS, in collaboration with the MOH, to sustain stakeholders' ownership and involvement by ensuring regular dissemination of findings and the progress made with the implementation of the project. 4. With the recognition that women, including sex workers, face many barriers to sexual behavior change, including negotiating condom use by partners, there may be limitations to the data collected for POI #3. It is recognized that there may be a response bias to self-reported survey questions due to the weight of cultural or gender norms and respondents’ comfort in reporting self behavior. HIV prevention interventions that help women develop risk reduction skills and redefine social and peer group norms to reinforce risk reduction carry considerable promise and may be concurrently promoted during project implementation. 5. An external evaluation institution will be hired as third party, in order to independently assess implementation performance for Components 1 and 2. This third party will help the 11 QAG, 2009a,b; IEG, 2009a. 12 In support of the 2009 IEG HNP Evaluation, a background paper on M and E quality in HNP investment operations raised concerns about: (i) the poor quality of results frameworks, (ii) the absence of baseline data; (iii) poor or failure to collect baseline data or within first year of the project approval; (iii) unrealistic indicator targets; and (iv) poor data quality. 21 Government to evaluate progress made and to determine the required funds needed to continue achieving results. 6. Partners have made efforts to harmonize indicators and agreement on a single M&E framework was reached in June 2008. This framework is now implemented by the CISLS and will be revised in 2011. The system will be strengthened in order to help the CISLS to provide timely and accurate data on HIV/AIDS for decision making. The M&E activities will be carried out by the CISLS and the MOH, but it will also be contracted out to external agencies/consulting groups to ensure an independent analysis that tracks project performance against targets in compliance with the established protocols. In order to proceed with the RBF, an external or consultant – firm will be hired in order to assess the performance of the project implementation. 7. It is also anticipated that project finances may support capacity building in some of the national institutions carrying out data collection and synthesis, such as the National Health Information System, the National Statistics Institute. The institutional capacity for epidemiological surveillance will also be strengthened early on during implementation by providing targeted technical assistance. 8. The project monitoring system will include:  Identification and consolidation of M&E indicators;  Training and capacity building initiatives at the national, regional and local level;  Standardized methods and tools to facilitate consistent collection, consolidation and sharing of information;  A computerized information system at the national and regional levels to integrate data collected from the various actors : NGOs, MOH, multilateral partners;  An independent review led by an external technical consultants;  Annual program evaluations and strategic planning exercises for each component. 9. During the first year of the project, the main objectives will be to strengthen the management information system, including installing the tools for collection and analysis of information, and to start the building capacities for all staff involved in the M&E system. 22 Annex 2: Detailed Project Description Niger Second HIV/AIDS Support Project 1. The development objective of the proposed project is to increase the access to HIV/AIDS and STI related services by high-risk groups in Niger. 2. Based on the lessons learned from the Bank’s first HIV operation in Niger (P071612) and the country’s demonstrated performance when resources were channeled to key interventions, this proposed project will be built around three specific measures: (i) transferring greater responsibility for service delivery to the health sector, with a designate account established in the MOH and its qualified health staff managing and procuring the sector’s needs; (ii) focusing prevention activities on high-risk groups by launching a call for proposals (CFP) for NGO/CSOs at the regional level; and (iii) using results-based financing (RBF) mechanisms in order to improve the equity, quality, accountability and cost-effectiveness of HIV/AIDS and STI-related service delivery. 3. HIV/AIDS/STI-related services may be defined as prevention, treatment, care and support to those infected by and/or affected by HIV/AIDS/STIs. They include, but are not limited to: - Prevention: information, education and communication (IEC) activities such as peer education; condom demonstrations, access and distribution; voluntary counseling and testing; antenatal care and PMTCT (VCT for pregnant women at ANC, skilled assisted delivery, ARV therapy at partum and post partum,); TB screening, screening and treatment of STIs; and family planning consultations. - Treatment: Antiretroviral drug therapy; viral load, blood and CD4 laboratory testing; treatment of opportunistic infections, including TB. - Care and Support: Community outreach; accompagnateurs; educational support to orphans; income generation activities for HIV-affected families; psychosocial support; inheritance planning; nutritional support; follow-up with PLWHA. 4. The Second HIV/AIDS Support project will have three components: (i) strengthening health services delivery for HIV/AIDS/STI; (ii) prevention of HIV/AIDS/STI among high-risk groups; and (iii) management, monitoring and evaluation. 5. Component 1: Strengthening health services delivery for HIV/AIDS/STI (US$ 10.0 million). This component will consist of two subcomponents: (1.1) Improving the quality and availability of health service delivery; and (1.2) Piloting of output-based financing of HIV/AIDS services. 6. Subcomponent 1.1: Improving the quality and availability of health service delivery, by: (a) Improving the quality of services provided by HIV/AIDS/STI testing, care and treatment centers in the Recipient’s territory, through the provision of tests, drugs and equipments, and the training of medical staff in said centers; 23 (b) Improving the management of the supply chain to support HIV/AIDS treatment, through: (i) the carrying out of an assessment of the MOH’s strengths and weaknesses for the management of the HIV/AIDS treatment supply chain; and (ii) the provision of equipments (including information technology equipment and software) and training to address weaknesses identified by said assessment; (c) Improving biosafety in HIV/AIDS/STI testing, care and treatment through the provision of training and equipments for the implementation of the Waste Management Plan; (d) Strengthening the prevention of mother-to-child transmission, through the provision of contraceptive, tests, drugs and equipment to health centers involved in providing reproductive health services, and the training of their medical staff; (e) Strengthening HIV/TB service integration, through the provision of tests, equipment and training to increase the percentage of TB patients tested for HIV, and the percentage of HIV- positive people screened for TB; and (f) Developing a second-generation surveillance of AIDS cases, new HIV infections, behaviors and characteristics of people at high risks, through: (i) the carrying out of an assessment of the strengths and weaknesses of the current surveillance system (including a proposal of the development of a second-generation surveillance system); (ii) the identification of health centers for the collection of data; and (iii) the development of tools, provision of equipment (including information technology equipment and software, laboratory equipment) and training of staff in data collection and analysis. 7. The above subcomponent will finance goods, consultants, and training. 8. Sub-component 1.2: Piloting of Output-Based Financing for HIV/AIDS services. The sub- component will conduct, through selected health facilities, a pilot RBF program during the first two years of the project implementation. Based on the results of the pilot, the program could be expanded to all health facilities providing HIV/AIDS services. Through this mechanism, funds will be transferred to health facilities using the mechanism with aims to strengthen health services, improve quality, and motivate staff. 9. The component would cover the following activities: 10. Improving quality of services for HIV/AIDS/STI testing, care and treatment centers in the country. Niger has expanded its voluntary counseling and testing (VCT) by expanding the number of services (12 – outside of the public health centers) and established AIDS treatment centers (13) within the 8 regions. The Government strategy is increasing the ARV treatment centers and the use of testing services by encouraging the population to be tested and referred to the treatment centers. This will lead to an increase in demand for test kits and medications such as ARV. Focus will be placed ensuring that STIs and health clinics collaborate with the HIV prevention programs to ensure regular services to the risk groups. The project would fill the funding gap for rapid tests in the MOH program, and train health workers in counseling and treatment. The project will help strengthen the management and supervision of the HIV/AIDS 24 program by the MOH. It will finance training, operating costs, goods, and studies (such as an impact evaluation of the project). 11. Improvement in supply chain management. In order to support an HIV/AIDS treatment program, dozens of medical commodities are required. The success of the program depends upon the ability to consistently supply the commodities to health facilities. The project will support: (i) consulting services to assess the strengths and weaknesses of the current system; (ii) technical assistance to strengthen the MOH capacity of forecasting drug needs, procurement, warehousing, inventory management, and quality assurance; and (iii) computer equipment, software, and strengthening of the capacity for staff handling the commodities. Substantial drugs and commodity inputs will be provided through Global Fund support. As a result, commodity financing is limited in the project. 12. Improvement in biosafety. Health workers are at higher risk of acquiring HIV because of their occupational exposure to blood or other potentially infectious materials. The majority of these cases are the result of needle stick accidents or exposures through a wound. The MOH will implement programs to raise awareness and train health workers about how to reduce their exposure risk. The project would allow the Government to finance equipment, materials, and training to improve biosafety. The project will support: (i) staff training on the dangers of exposure to blood and infected material; and (ii) the protection of personnel and the general population with the implementation of the Waste Management Plan. The Waste Management Plan was disseminated during appraisal (March 2011). 13. Strengthening the prevention of mother-to-child transmission (PMTCT) program. The strengthening of the PMTCT, including reproductive health, will be carried out through improving the quality and expanding coverage to include the integration of management of STIs, HIV and reproductive health (RH) services. The AIDS epidemic is integrally linked to sexual and reproductive health; the majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding. Linking HIV and AIDS interventions with reproductive health services strengthens both through synergies in staffing, supplies, equipment and facilities. The project will ensure that the provision of antenatal care (ANC) and integration of reproductive health services in PMTCT to include: (i) family planning; (ii) voluntary counseling and testing for HIV/STI within family planning services and couple counseling; (iii) the promotion of facility-based deliveries; (iv) obstetric and gynecological services for HIV- positive women; and (v) the promotion of exclusive breastfeeding. Activities will include assisting the Government to adequately equip health centers, purchase contraceptives and drugs, and provide training for health workers. 14. Strengthening HIV/TB service integration. TB/HIV collaboration is important because TB is a major cause of morbidity and mortality for people living with HIV, and it is worthwhile to create synergy between TB and HIV/AIDS control programs. This requires joint planning, testing, training of health personnel, and the provision of comprehensive TB and HIV prevention, care and support services, and monitoring and evaluation. The MOH work program supported through the RBF would be expected to achieve the following results: (i) increased percentage of TB patients tested for HIV; (ii) increased percentage of HIV-positive people screened for TB. 25 15. Development of second-generation surveillance. Second-generation surveillance consists of a nationwide system that combines information on AIDS cases, new HIV infections, and behaviors and characteristics of people at high risk. This would allow the Government to track the epidemic and direct HIV prevention funding to where it is needed the most. Surveillance of high-risk behaviors, would allow detecting changes which may foster a rapid spread of infection. The project would finance: (i) an assessment of the strengths and weaknesses of the current surveillance system, and a proposal to develop a second-generation surveillance system; (ii) computer equipment and software in order to complete the effort made by other donors for the health information system; (iii) laboratory equipment; and (iv) training of staff in surveillance and use of data for decision-making. 16. The above subcomponent will finance goods, consultants, and operating costs. 17. Component 2: Prevention of HIV/AIDS/STI for high-risk groups(US$7.0 million). This component will consist of carrying out: (i) the prevention of HIV/AIDS/STI targeting sex workers and/or their clients; and (ii) the provision of support to AIDS orphans (including children of sex workers). 18. Prevention activities for sex workers. Because of their high HIV infection rates and large numbers of sexual partners, sex workers are high transmitters of HIV and other sexually- transmitted infections. With HIV prevalence 45 times higher that in the general population and the presence of sex work setting and high-level interactions, sex workers are at the center for an effective response. Progress has been made in this area under the first project, but further efforts are required. The proposals expected from NGO/CSOs would be expected to achieve the following results: (i) behavior change in HIV/AIDS prevention by SWs through peer led outreach education; (ii) increased use of condoms and other methods; and (iii) increased demand for sexual and reproductive health services, including prevention of mother-to-child transmission (PMTCT) and STI control and treatment. 19. Prevention activities for clients of sex workers. Many clients of sex workers have sexual relationships with multiple partners and are highly mobile, creating an environment conducive to the transmission of HIV/AIDS across the country. The proposals prepared by NGO/CSOs would be expected to achieve: (i) increased knowledge of clients about HIV/AIDS prevention; (ii) increased use of condoms; and (iii) increased uptake of early treatment for STIs and HIV/AIDS. 20. Support to AIDS orphans and HIV-affected children, including children of sex workers. The AIDS epidemic is increasing the mortality of adults, with potentially severe consequences for surviving family members. The children hit hardest by the death of a parent or other adults are those in the poorest households, and those with uneducated parents. Children who are orphaned by AIDS are often the first to be denied education when their extended families cannot afford it. Often emotionally vulnerable and financially desperate, orphaned children are more likely to be sexually abused and forced into abusive situations, such as prostitution, as a means of survival. They are at far greater risk than their peers of becoming infected with HIV. Activities for this project would be for NGOs/CSOs to identify these vulnerable families and integrate them into the Niger Safety Net project (P123399). The safety net project is targeting its efforts in five regions of Niger (Dosso, Maradi, Tahoua, Tillabéri, and Zinder). 26 21. Component 3: Management, monitoring and evaluation (US$3.0 million). This component will strengthen CISLS’ capacities in management and coordination of activities in the fight against HIV/AIDS/STI subsector through the provision of administrative, management and fiduciary support, capacity building at the central, regional and local levels, technical support to enhance the design of policies and strategies and implement monitoring and evaluation. 22. This component will finance goods, consultants, training, and operating costs. 23. The component will include the following: (i) Planning and coordination of activities; (ii) enhancing fiduciary and administrative capacity; and (iv) implementation support for monitoring and evaluation. 24. The component will support the CISLS to strengthen its capacity to lead the country response in the campaign against the HIV/AIDS epidemic. The component will help to strengthen the capacity of CISLS to coordinate the National HIV/AIDS Program in its role focused on: (i) overall planning, budgeting and coordination of the National AIDS Program: (ii) catalyzing greater involvement by society in the HIV/AIDS response: (iii) building a strong coalition across civil society and donors for prevention, care and treatment; (iv) monitoring program execution; (v) strengthening the governance of the National program; and (v) evaluating preventive approaches and disseminating best practices. 25. The project will finance: (i) administrative and management costs, including the recruitment of key fiduciary staff; (ii) capacity building in CISLS and decentralized units (regional and local committees); (iii) technical support to enhance the design of policies and strategies including the analysis of ART financing options which will be conducted in the project first year; and (iv) implementation of the M&E system throughout the country including a biological-behavioural surveillance system and an impact evaluation. 26. Planning and coordination of activities. The project will support the planning of the National HIV/AIDS program by providing technical assistance and enhanced capacity in the annual planning process, including the design of policies and strategies. The national strategic framework for 2008-2012 and its multisectoral plan will be updated. Each year, an operational annual work plan will be drawn from the five year plan with its expected results. The work plan will be submitted to the technical and financial partners for funding. The coordination of the multisectoral approach will be developed with all structures of the central and regional level. The coordination will be handled through joint meetings every six months, and especially each year by the National Aids Coordination lead by the President of the Republic. A coalition with the private sector, civil society organizations and the technical and financial partners will be established in the first year of the project implementation. 27. Enhancing fiduciary and administrative capacity (Financial Management and Procurement). The project will contribute to the administrative and technical management of the program by building capacity for procurement and the financial management. As learned from the previous project, two designate accounts will be opened for health activities and those implemented by the national coordination unit (CISLS). The fiduciary capacity will be assessed 27 and the guidelines will be detailed in the Financial Manual and the project implementation manual. Figure 2: Relationship of Project Components to PDO Increased demand High-Risk Groups* MOH Facilities Component 2: Prevention of - Prevention activities for - Improved supply chain IMPROVED UTILIZATION HIV/AIDS/ sex workers and their management, drug STI among clients (Peer education) provision Component 1: high-risk - PMTCT and VCT - Scaling up of testing and Strengthening groups through - Support for AIDS treatment health service NGO/CSO orphans - RH and TB integration delivery for ($7.0m) - 2nd generation surveillance HIV/AIDS/STI - Improved biosafety by the MOH - Capacity building ($10.0m) Increased Improved prevention quality behaviors and social and protection access to services Increased supply Component 3: Management, M&E by the CISLS ($3.0m) 28 Annex 3: Implementation Arrangements Niger Second HIV/AIDS Support Project 1. Project institutional and implementation arrangements A. Project administration mechanisms 1. Project management and monitoring and evaluation: CISLS will be responsible for the management as well as the monitoring and evaluation of the proposed project. CISLS will (i) coordinate the project activities including those implemented by the MOH; (ii) carry out financial management for project activities under the three components; (iii) prepare consolidated annual work plans and budgets for submission to the Steering Committee and the Association; and (iv) ensure M&E and reporting. 2. The Ministry of Health (MOH). The health sector coordination unit (unité de lutte sectorielle santé - ULSS) of the MOH will directly implement Component 1 and will be fully responsible for managing its funds. It will prepare regular annual work plans. The annual work plan will be reviewed by the Steering Committee and the CNLS. It will have its own designated account to which it will receive (i) funds for the eligible expenditures during the first two years, and (ii) transfers of funds after the sector performance assessment is carried out by a third party within the RBF framework, which will be the financing mechanism in the health sector after the mid-term. 3. The Ministry of Health will conduct a pilot phase of the RBF in limited selected health facilities, during the first two years of the project. This will lead to the preparation of the manual and required guidelines for a successful RBF mechanism implementation which will be annexed to the PIM. 4. The Inter-Sectoral Program Coordination Unit (La Coordination Intersectorielle de la Lutte contre les IST/VIH/SIDA) (CISLS) will implement component 2 and 3, serving as secretariat to the CNLS, and the MOH will hold regular meetings with the World Bank, the Global Fund, and UNAIDS. The first two are the main financiers in the HIV/AIDS sector, and UNAIDS which plays an active role with the Bank in policy dialogue and has actively participated in the project preparation. Located in the office of the President, the CISLS is responsible for the coordination of the strategic planning and implementation of the national STI/HIV/AIDS program. Its key functions and staffing cover: overall program coordination, administration and finance, communications and public relations, technical support and liaison with public sector agencies of execution, liaising and conducting outreach with civil society, and monitoring and evaluation. 5. The CISLS is responsible for both the management of the IDA project and Global Fund grants, which enhances harmonization of investments and facilitates the process of planning for sustainability. Implementation of project activities will be carried out by a variety of actors at different levels, including regional directorates, civil society organizations, and the private 29 sector. It will also use a Steering Committee for the technical monitoring of the National program implementation. As described in the Strategic Framework, the main tasks of the Steering Committee will be to (i) discuss and review the strategies implementation, and (ii) to monitor and assess the implementation and results of the National program. The composition and the working modalities of the committee have been developed in the Strategic framework. The CISLS will have the leadership in order to coordinate, monitor and evaluate the project and the program implementation. It will conduct sectoral analyses, including the impact evaluation of the national AIDS program. The Administration and Finance section of the CISLS will be responsible for project financial management of Components 2 and 3. 6. The Regional HIV/AIDS Coordination Unit (La Coordination Régionale de Lutte contre le SIDA) (CRLS): Under the project’s second component, Niger’s CISLS will work with the regional units to implement component 2. The eight CISLS regional HIV/AIDS coordination units (CRLS) will oversee prevention activities for the high-risk groups located in each region, will be carried out directly by contracted NGOs and CSOs. A Technical Assistant will be hired and posted in each CRLS unit in order to reinforce their capacity for contracting and managing these community-based subprojects. The cycle of calls for proposals, submission, review, approval, financing and evaluation will be described in detail in the Operations Manual. 7. The National AIDS Commission (Le Conseil National de Lutte contre les IST/VIH/SIDA) (CNLS), is chaired by the President of the Republic of Niger and will approve policy and strategic orientations and work plans of line ministries. The CNLS will mobilize and coordinate technical and financial assistance of all partners and evaluates program performance and impact. 8. Coordination with ongoing IDA operations. Several investment projects are being implemented in the country with funding from IDA, including in the health, education, rural development, water, urban, and transportation sectors. A coordination system will be established to share and complement the project’s efforts, in line with their capacities and geographical coverage. The NAC and the CISLS’ Steering Committee will be the framework for this coordination. The details of the coordination will be described in the Operations Manual of the project. 9. Partnership arrangements. There has been close collaboration during project preparation between GFATM and the Bank and other agencies involved in HIV/AIDS in order to ensure optimal complementarities and efficiency of project management and implementation. Among the donor community in Niger, the main players in the HIV/AIDS sector are GFATM, UNAIDS, UNICEF, UNFPA, WHO, UNDP and WFP. They provide financial and technical support in the sector. The UNAIDS Country Coordinator has helped foster the policy dialogue and has actively participated in the project preparation. Coordination between donors, stakeholders, and the Government will be further enhanced through the National program implementation, which has support from all donors. The CISLS, who manages the program, will ensure better coordination so that the contributions of each donor and agency may be more clearly attributable to the other institutions. The indicative support of the donors is as follows : 30 Table 2: Indicative partnership commitments to HIV/AIDS in Niger (US$) Partners 2010 2011 2012 ADB (Regional Project) 483,970 417,710 417,710 UNICEF 524,234 483,723 483,723 WHO 46,050 57,563 57,563 UNAIDS 227,518 378,189 378,189 UNDP 359,136 359,136 359,136 UNFPA 1,199,138 690,756 690,756 WFP 544,144 403,324 403,324 Global Fund R7 NGR- 4,144,118 8,156,124 9,253,969 708-G08-H Total $7,528,308 $10,946,525 $12,044,370 10. Implementation Responsibilities of the three components are as follows: 11. Component 1 - Strengthening health service delivery for HIV/AIDS/STI, including Subcomponent 1.1: Improving the quality and availability of health service delivery, will be implemented by the Health Sector Coordinating Unit (Unité de Lutte Sectorielle Santé - ULSS) of the MOH. This Coordinating Unit consists of health sector specialists, a financial management specialist, and a procurement specialist. The same unit has been implementing in the on-going Bank-financed Institutional Strengthening & Health Sector Project and has sufficient capacity to implement component 1 of the present project. Its annual work plans will be approved by the Steering Committee. 12. As for Subcomponent 1.2: Piloting of output-based financing for HIV/AIDS services, the Government will prepare an Operational Manual for Piloting RBF for HIV/AIDS Services in the health sector including (i) guidelines and procedures; (ii) monitoring and evaluation arrangements, and disbursement methodology, having regard to agreed performance targets and third party verification arrangements; and (iii) model forms of output-based financing agreements. This will be a condition of disbursement for subcomponent 1.2. The Manual will be completed according to the timetable in Annex 8. 13. Component 2 – Prevention of HIV/AIDS/STI among high-risk groups - will be implemented by the eight Regional Coordinating Units of the CISLS, as mentioned, through a system of calls for proposals by which the submitting organizations will be invited to present proposals to achieve specific results, mostly focused on the prevention of transmission of HIV/AIDS by high-risk groups. Based on the high-risk groups identified, the AIDS Regional Coordination Unit, with the support of the technical directions of key line ministries, will prepare the terms of reference (TOR) and launch the calls for proposals. NGO/CSOs will submit their proposals to the AIDS Regional Coordination Unit. The review of proposals will be undertaken by the AIDS Regional Coordination Unit shortly after the call for proposals submission deadline. 14. The cycle of calls for proposals, submission, review, approval, evaluation and payments will be described in detail in the Operations Manual. 31 15. Component 3 - Management, monitoring and evaluation – will be implemented by CISLS. Its key functions and staffing cover overall program coordination, administration and finance, communications and public relations, technical support and liaison with public sector agencies of execution, liaising and conducting outreach with civil society, and monitoring and evaluation. In practice, this will be carried out by a Steering Committee. The CISLS is also responsible for the management of the Global Fund financing, thus ensuring coordinated planning and avoidance of overlap. B. Financial Management 16. Project administration mechanisms. Overseen by office of the President of Niger, La Coordination Intersectorielle de la Lutte Contre les IST/VIS/SIDA (CISLS) will be the Project Coordination Unit (PCU) and will be responsible for the management and coordination of the proposed project. The CISLS will (i) coordinate implementation of project activities for components 2 and 3 through its regional offices, in addition to the overall coordination of the proposed project; (ii) carry out the financial management of the proposed project which includes the preparation of consolidated interim financial reports, consolidated annual financial reports as well external auditing of these financial statements; (iii) prepare annual budgets and work plans; and (iv) ensure M&E and reporting. The Ministry of Health (MOH) through ULSS will implement component 1 of the proposed project activity. 17. Both the CISLS and the MOH have experience in implementing Bank funded projects and are familiar with required Bank procedures. The current staff in both entities has experience in managing Bank-funded projects. Financial Management constraints to be addressed include: (i) Outdated administrative, financial and accounting procedures manual and the project implementation manual at CISLS (to be updated by project effectiveness to include the new activities and processes in the proposed project); (ii) both entities (CISLS and MOH) will need to implement all the external auditors recommendations in order to improve their respective overall internal control systems (to be included in the updated manual of procedures); and (iii) recruitment of external auditor to carry out the audit the project no later than six months after effectiveness. 18. Financial Management. Overall, the residual financial management risk of the project is assessed as Medium-Likelihood. The CISLS, the project coordination unit under the President’s office will be the implementing entity for component 2 and 3 while the MOH will implement component 1 under the proposed project. Both CISLS and MOH have experience in managing Bank-funded projects. The current staffing arrangements in both agencies are adequate to ensure sufficient segregation of duties. All operational procedures will be documented in the administrative, financial and accounting manual. 19. Therefore, it will be pertinent for the MOH management to implement the recommendations of external auditor (audit report 2009) to improve the system on internal control over advances and the budgetary control process to ensure that only those activities budgeted for are financed using project funds. In July 2010, the MOH hired an internal controller and regional accountants who will work on the financial management functions in the different areas where project activities are implemented. Further, to improve the system of 32 internal control: (i) the MOH will establish deadlines for justification of advances and accounting for related expenses for regional activities. This process will be ensured by the internal controller; (ii) the regional accountants will send financial reports to the central office in Niamey and, when required, accounting documentation for their respective regional expenses on a regular basis; (iii) the internal controller will ensure that procedures in the administrative, financial and accounting manual are adhered to, in order to facilitate the production of reliable financial statements. 20. Budgeting. The budget process will be clearly stipulated in the administrative, financial and accounting manuals. Annual budgets and work plans will be coordinated and prepared by the CISLS. They will be approved by the Steering Committee at the beginning of the year and any changes in the budget and work plans will also be approved by the Committee. In addition, the Steering Committee will: (i) discuss and review implementation strategies; and (ii) monitor and assess the implementation and results of the National Program. Under both CISLS and MOH, sub-accounts will be opened in commercial banks for regional office coordination units. 21. During the first two years, the project will disburse against the eligible expenditures. The fund would finance categories of expenditures, including goods, services, drugs, operating costs, training and consultants, as long as these conform with the approved annual work plan, budget, and procurement plan. In the meantime, the RBF mechanism will be designed and the pilot phase will cover a 2-year period in limited health facilities, after which a decision will be taken whether to expand to all health facilities offering HIV/AIDS services. 22. Results-based Financing (RBF). This is under subcomponent 1.2 implemented by the MOH through output-based grant agreements. The RBF system will be designed and piloted in a limited number of selected health facilities. Following the two-year pilot study evaluation, RBF mechanisms suitable to Niger may be scaled up throughout the country. Funds will be transferred from the Designated Account to the sub-accounts in the regional coordination units. Payment to health facilities based on the results under RBF will be made from the regional offices. As is the case currently, regional offices will account for funds advanced to them on a regular basis as spelt out in the procedures manuals and send financial reports to the national office. Appropriate mitigation measures (e.g. having an independent verifier, third party monitoring, technical audit, publication of RBF credit and payments made, and mechanisms of checking fraudulent activities) will be provided upon completion of the feasibility studies aiming at defining the implementation arrangements for the RBF. These mitigation measures will be included in the project implementation manual. 23. Under Component 2, the payments will be made based on the achievement of performance indicators agreed upon with nongovernmental organizations (NGOs) and civil society organizations (CSOs) to be recruited on a competitive basis. Payments will be made at the regional coordination units. CISLS will open designated sub-accounts for this project at the regional offices from which payment for regional activities will be made. The accounting for expenses at the regional level will be made on a regular basis as stipulated in the procedures manual. 33 24. Contracts will be drawn for NGOs and CSOs recruited to carry out activities in the various regions. The contracts will outline the eligible expenses to be paid by the project as well as the results expected (disbursement-linked indicators) through terms of reference agreed upon. Subsequent disbursements to contracted NGOs and CSOs will be made following the achievement of indicators listed in the terms of reference. 25. Accounting. Project accounting, policies and procedures are in line with OHADA (Organisation pour l’Harmonisation en Afrique du Droit des Affaires) accounting standards and documented in the procedures manuals which will be updated by effectiveness. The current accounting software in both CISLS and MOH are multi project and multi site and will be used to prepare interim financial statements as well as annual financial statements for the proposed project. 26. Internal controls. The current staffing arrangements in the financial management units in both CISLS and MOH are sufficient to ensure adequate internal controls are in place for the preparation, approval and recording of transactions as well as segregation of duties. The financial management procedures will be outlined in the administrative, financial and accounting manual to be updated. 27. Financial reporting. The CISLS will prepare quarterly consolidated Interim Financial Reports during the project implementation. CISLS has regional offices who prepare monthly financial reports using the current accounting software. The reports are sent to the central office by email at timelines set out in the procedures manual. The disbursement methods will be replenishments and reimbursements based on consolidated quarterly IFRs submitted by CISLS for all activities in the three components of the project. Consolidated Interim Financial Reports will be furnished to the Bank not later than 45 days after the end of the quarter. Consolidated annual financial statements will be prepared by the CISLS and will be subject to annual external audits. 28. External audit. The annual financial statements of the Project as well as the system of internal controls will be subject to an annual audit by a reputable, competent and independent auditing firm, based on the terms of reference satisfactory to the Bank. The auditor will provide an opinion on the consolidated financial statements of the project prepared by CISLS (including the financial statements of MOH) as per auditing standards acceptable to the Bank. The audit report will be submitted to the Bank not later than six months after the end of each financial year. The external auditor will also prepare a management letter following the review of the internal control systems at CISLS and at ULSS (MOH). The terms of reference of the external auditors will be developed emphasizing the reliance on International Standards on Auditing (ISA) and particularly ISA 240 and ISA 250 on fraud and corruption. They will be amended upon implementation of the results-based financing activities. To this end, they will include verification of credit allocation/credit spent, validation of unit costs and related changes, and verification of correct payment to the actual beneficiaries. In line with the new access to information policy, the project will comply with the Bank disclosure policy of audit reports (e.g. make publicly available, promptly after receipt of all final financial audit reports, including qualified audit reports) and place the information provided on its official website within one month of the acceptance of the final report by the team. 34 29. Supervision: In addition to the regular internal and external audits, the Bank task team will conduct regular supervision missions on an annual basis in the first year of implementation. The intensity of the supervision could be reassessed depending on the implementation progress. During these supervision missions, Bank financial management staff will evaluate the FM arrangements to ensure that they remain adequate for the implementation of the Bank-funded project. 30. Action Plan: The agreed upon action plan to strengthen the FM is summarized below: Action Date Due by Responsible Updating the accounting, financial 1 By effectiveness CISLS and administrative procedures manual Upgrading of accounting software and 2 By effectiveness CISLS computer hardware Recruitment of an additional Within 3 months of 3 ULSS (MOH) accountant at the Central office project effectiveness 31. Disbursements. Both CISLS and MOH will each open a Designated Account with a commercial bank in Niger that is acceptable to the Bank. All the documentation supporting expenses must be easily accessible and kept at an appropriate place for control and audit purposes. The Designated Accounts will be managed according to the disbursement procedures described in the Disbursement Letter. 32. Method of Disbursement. Disbursement from Bank will follow the transaction-based method which includes the submission of Statement of Expenses (SOEs), Direct Payments and Reimbursement. The initial deposits into the Designated Accounts will be based on four month forecasts prepared by CISLS for both CISLS and MOH submitted together with Withdrawal Applications. 33. Designated Accounts. Upon Project effectiveness and request from the project, the Bank will deposit funds into each of the Designated Accounts. The Designated Accounts will be used for payments of amounts up to twenty percent of the authorized allocation. Replenishment applications will be made against withdrawal applications supported by appropriate documents. 34. All documentation for all transactions shall be retained by the CISLS and MOH and shall be made available for audit and to the Bank and its representatives, if requested. Detailed disbursement procedures will also be stipulated in the updated administrative, financial and accounting manuals. Upon completion of the feasibility studies on the RBF, an adequate reporting system will be developed to trigger disbursement against agreed indicators and included in the procedures manual. 35 Figure 3: Disbursements Chart IDA CREDIT 1 Financial Report DESIGNATED DESIGNATED ACCOUNT – A (MOH) ACCOUNT – B (CISLS) Component 1 Component 2 Component 3 35. Fraud & Corruption: the reliance on existing implementing entities with adequate track record in implementing Bank financed projects and the recruitment of independent external audit with terms of reference drawn with an emphasize on auditing standards related to fraud and corruption, are concrete mitigation measures aimed at addressing the risk of fraud and corruption. Upon definition of the RBF implementing arrangements, additional mitigation measures will be proposed to deter and prevent fraud and corruption. Such measures will include transparency by means of publication on a quarterly basis in health centres of the RBF credit management, recruitment of independent verifiers, third party monitoring, and a mechanism of handling fraudulent cases (e.g. 1st fraud 25% of deduction of the credit, 2nd fraud 50% of deduction of the credit, 3rd fraud exclusion from RBF arrangements). 36. The categories of disbursement would be as follows. Table 3 : Allocation of Financing by Disbursement Category Category IDA (US$) IDA (SDR) Goods, consulting services, non-consulting services, 4,500,000 2,900,000 training, and audits for Part 1 Goods, consulting services, non-consulting services, 8,000,000 5,100,000 training, and audits for Part 2 Operational costs for Part 1 1,500,000 950,000 Operational costs for Part 2 1,000,000 650,000 PPF 500,000 340,000 Non-allocated 4,500,000 2,860,000 Total financing 20,000,000 12,800,000 C. Procurement 37. Procurement for the proposed project will be carried out in accordance with the World Bank’s "Guidelines: Procurement under IBRD Loans and IDA Credits" dated May 2004, revised October 2006 and May 2010; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated May 2004, revised October 2006 and May 2010; and the provisions stipulated in the Financing and Project agreements. 36 38. About twenty percent (20%) of the amount of the Project will be disbursed under Results Based Financing (RBF) arrangements with public structures and will not follow Procurement and Selection of Consultant Guidelines. Specific arrangements detailed in the implementation manual and acceptable to the Bank will apply. 39. All procuring entities, as well as bidders, suppliers, and contractors shall observe the highest standard of ethics during the procurement and execution of contracts financed under the project in accordance with paragraph 1.15 and 1.16 of the Procurement Guidelines and paragraphs 1.25 and 1.26 of the Consultants Guidelines. "Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants", dated October 15, 2006, and revised in January 2011, shall also apply to the project. 40. Procurement responsibilities and accountability. Procurement activities will be carried out by: (i) The National HIV/AIDS Coordination Unit (CISLS) for component 2 and 3; and (ii) the Ministry of Health for component 1. The specific tasks of each executing agency in terms of procurement include: (i) Managing the overall planning of activities, and implementation of procurement processes and monitoring activities/component for which the entity is directly responsible on a day-to-day basis, in line with the PIM and the Bank Guidelines; (ii) Preparing draft bidding documents, draft requests for proposals (RFP), evaluation reports; (iii) Overall coordination and quality control/assurance of all draft procurement documents (bidding documents, RFP, evaluation reports, TORs, contracts, etc.); (iv) Preparation and updating of the procurement plan: and (v) Seeking and receiving approval from national entities and then from IDA on all procurement documents, as necessary. 41. The National HIV/AIDS Coordination Unit (CISLS) will consolidate all procurement information, the procurement reports and the preparation and updating of the procurement plan of the whole project. The Ministry of Health will copy the CISLS on all exchanges with IDA and national entities will send to CISL regularly the quarterly procurement report, and the draft and any update of procurement plan for consolidation. For facilitating the monitoring and procurement reporting, a CISLS representative will be member of procurement committee to be established by the Minister of Health for all procurement related to this component. 42. Packaging. The Recipient, before appraisal, developed a procurement plan for project implementation which provides the basis for the procurement methods and packaging. This plan was finalized and agreed upon during negotiations. Immediately upon approval of the Credit, and with the Recipient’s agreement, the plan will be published on the Bank’s public website and will be available at the CISLS and Ministry of Health. The packaging of contracts was designed to minimize the number of contracts and achieve efficient procurement. 37 43. Procurement Reviews. Prior-review and procurement method thresholds for the project are indicated in Table 4 below. Table 4: Procurement Thresholds Expenditure Threshold for Procurement Contracts Subject to Prior Review Category Method (US$) Method >=300,000 ICB All Goods and non- <300,000 NCB First two contracts and selected contracts in consulting the PP services <50,000 Shopping None Direct contracting All QCBS, QBS, FBS, Consulting >=200,000 All contracts of $200,000 and above and LCS services from the first two contracts/selected contracts firms and QCBS, CQS, LCS, identified in the PP under $200,000 <200,000 NGOs† FBS, QBS Single Source All Individual IC All contracts of $100,000 and above consultants† ICB – International Competitive Bidding QBS – Quality Based Selection method NCB – National Competitive Bidding QCBS – Quality and Cost-Based Selection method LCS – Least Cost Selection FBS – Fixed Budget Selection method CQS – Consultants’ Qualification Selection method IC – Individual Consultant Selection method †All Terms of Reference for consulting services are subject to prior technical review, regardless of the value of the contract. 44. All amendments of contracts of Goods and Services raising the initial contract value by more than 15 percent of the original amount or above the prior review thresholds will be subject to prior review by the Bank as specified mandatory in Paragraphs 2 and 3 of Annex 1 as appropriate of the Consultant Guidelines, and the Procurement Guidelines 45. Post Review. For each contract for goods, and consulting services not submitted to prior review, the procurement documents will be submitted to IDA post review in accordance with the provisions of Paragraph 4 of Annex 1 of the Bank’s procurement Guidelines. The post review will be based on a ratio of at least 1 to 5 contracts. 46. Short list comprising entirely of national consultants. A short list of consultants for services, estimated to cost less than US$200,000 equivalent per contract, may comprise entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. 47. Capacity Assessment and Remedial Actions. An assessment of the capacity of the Implementing Agencies to implement procurement actions for the project has been carried out on September 22nd, 2010 and March 2011. The assessment reviewed the organizational structure 38 for implementing the project and the interaction between CISLS and the Ministry of Health, and the project’s staff responsible for procurement within the Ministry and the Procurement Division in the Ministry’s Central unit for administration and finance. 48. The CISLS is staffed by a multidisciplinary team including a coordinator, an administrative and financial management specialist and experts in monitoring of health sector and non health sector, communication specialist, public relations specialist and specialist in monitoring. Most of this staff had participated in the implementation of the previous project. Therefore the staff has the required experience to handle the preparation of various procurement documents (TORs, technical specifications, request for proposals, evaluation report…). The procurement function is staffed by a Procurement Specialist who has been recruited by the CISLS as part of the Global Fund financing. 49. The Ministry of Health has established a pool of experts including fiduciary, in the context of the multi-donors health project. The fiduciary arrangement includes a qualified procurement specialist recruited through the current Bank-financed ISHSSP, an adviser to the SG and a Head of Procurement Division, which all have a proven experience in procurement procedures in general and the World Bank in particular. Regarding the preparation of procurement documents and evaluation of bids/proposals, the team of the Directorate of Infrastructure and equipment will provide support. 50. Adequate documentation and tools (manuals, tracking software and filing) are available, but may require upgrading or updating. 51. The key issues and risks concerning procurement for implementation of the project have been identified and include i) possible confusion between the national procurement rules and IDA procedures, and (ii) delays in the examination of procurement decisions and their approval by the proper authority An agreement has been reached on the following corrective measures: (i) Additional training in Bank procedures and procurement of staff involved is needed to consolidate skills at the beginning of the project. The PS should benefit of additional training in a specialized center as an opportunity for him to update his Knowledge on World Bank procurement procedures; (ii) Non-application of the notified list of clauses of the National Procurement Code which are not partially or entirely consistent with the World Bank’s procurement guidelines. This list will be provided to the project and discussed deeply during the workshop at the beginning of the project; (iii) The filing system in CISLS and Ministry of Health will be improved ; the hard copies of the previous project will be archived in secured locations to release spaces for the new project, and equipments will be procured to file all the documents in compliance with the manual recommended for World Bank financed projects; and (iv) The Project manuals (PIM and the Manual of Procedures) should be updated to reflect the description and institutional arrangements of the new project, take into account new Bank guidelines (including revised prior review thresholds) and updated national procurement 39 laws, and to clarify the role of each member involved in the procurement process and in the review and approval system 52. The measures to be taken to mitigate the procurement risk and prior review thresholds should be re-evaluated once a year with a view of adjusting them to reflect changes in the procurement risk that may have taken place in the meantime and to adapt them to specific situations. In case of failure to comply with the agreed mitigation measures or with Bank guidelines, a re-evaluation measure of both types of thresholds, ICB and prior review, may be required by IDA. 53. The overall project risk for procurement is Moderate. 54. Monitoring and Updating of Procurement Plan. The Procurement Plan will be updated by CISL in collaboration with the Ministry of Health annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. 55. Supervision. In addition to the prior reviews to be carried out from IDA offices, the capacity assessment recommended two field supervision missions and at least one post- procurement review per year. The Procurement Specialist in the Niamey Country Office will provide continuous support to implementing agencies. Independent procurement reviews will be carried if necessary. D. The Environmental and Social (including safeguards) 56. The project will contribute to the implementation of the Waste Management Plan which will be finalized and disclosed before the appraisal. The implementation will be made by the MOH through its technical hygiene direction. The activities developed will be monitored by the health coordination unit and also by the technical expert from the IDA team. All implementation support mission will have a social and environmental expert who will assess the progress made and will provide guidance and advise for the management of the waste produced by the health sector. E. Monitoring and Evaluation 57. Under the proposed implementation arrangements, each component will be managed by dedicated implementers: health, key line ministries, Regional coordination unit and CISLS. Each “component leader� will be responsible for Monitoring and Evaluation for his/her respective component (this will be specified in their Terms of Reference). The CISLS will ensure that each “component leader� fulfils his / her responsibilities and the final M&E report will be prepared by the CISLS M&E Direction and share with all stakeholders. 58. Monitoring and evaluation indicators will be closely reviewed by the CISLS, the National AIDS Council, the third party (external Consultant) and by the World Bank team in charge of the supervision of the project to ensure that the required results are achieved. If ever the planned results are not reached, the implementation support team will need to closely analyze the reasons and – based on the reasons – develop a strategy (possibly to review the approach to the component or sub-component if results are disappointing). 40 F. Role of Partners 59. In Niger, the technical and financial partners in the HIV/AIDS sector are GFATM, UNAIDS, UNICEF, UNFPA, WHO, UNDP and WFP. They provide financial and technical support in the implementation of the HIV/AIDS program, but the main partners are GFATM and WB. The UNAIDS Country Coordinator has helped foster the policy dialogue and has actively participated in the implementation of the national program. 60. The financing partnerships are structured around the priorities agreed in the National Strategic framework. They supported the prevention, care and the treatment activities under the health sector, the key line ministries and several NGOs. The other donors’ support may also make substantial (direct or indirect) contributions to promote care and prevention activities linked to the project nationwide advocacy and BCC campaigns. A coordination system will be established to share and complement the project’s efforts, in line with their capacities and geographical coverage. The CNLS and CISLS’ Steering Committee will be the framework for this coordination. The details of the coordination will be described in the Operations Manual of the project. Figure 4: Organizational Chart: CISLS and Related Agencies 41 Annex 4 Operational Risk Assessment Framework (ORAF) Negotiations and Board Package Version Project Development Objective(s) To increase access to HIV/AIDS/STI related services by high-risk groups in Niger PDO Level Results 1. Pregnant women living with HIV who received antiretroviral to reduce the risk of MTCT [Core IDA Indicator] Indicators: 2. Adults and children with HIV receiving antiretroviral therapy [Core IDA Indicator] 3. Sex workers using a condom at their most recent sexual encounter [UNGASS Indicator]    Risk Category Risk Rating Risk Description Proposed Mitigation Measures Project Stakeholder Risks Uncertainty and volatility of Niger’s largest other In the event that Global Fund commitments for ARV financier, Global Fund. treatment plateaus or declines, the Government has H committed to fund ARVs through its own budget, which will be monitored on an annual basis by IDA. Implementing Agency Risks Limited resources of implementing agencies could Project design, implementation and fiduciary M- prevent the timely conduct of activities and arrangements attempt to optimize implementing Likelihood disbursement of funds. The political situation may agencies’ strengths. Activities include capacity affect implementing agencies’ ability to conduct building and a pilot of the innovative RBF design. activities. Innovative project design could be a challenge to implement. Project Risks  Design Project’s effectiveness in responding to the HIV Strong evidence base and documented lessons learned epidemic in Niger may be limited due to the low used to structure project design in Niger’s social socioeconomic status of women despite their context. When appropriate, gender-sensitive and L important role in project activities. gender-transformative approaches will be taken to ensure women’s participation. Key project indicators will be disaggregated by sex.  Social and Environmental Improper disposal of hazardous biomedical Implementing agencies have familiarity with Bank L materials could put medical personnel or environmental safeguards procedures, and additional communities at greater risk of exposure to HIV. trainings will be conducted prior to disbursement of 42 funds for medical materials. This is included in project design with adequate funding.  Program and Donor Duplication of efforts between this project and The same TTL will oversee this project and the health other health sector project would reduce efficiency. sector project. Regular communication between L Differences in targeted beneficiaries between this common stakeholders of both projects, in addition to project and social protection project could diminish UN system actors, will improve synergy. effectiveness.  Delivery Quality Inability to measure performance timely and Close monitoring and treating the size of incentives accurately to allow for timely payments of RBF during implementation as needed. Building capacity incentives. of Government agencies to help them become effective purchaser of services A thorough analysis of financial management and procurement capacities will be conducted during appraisal. If needed, additional support (TA) will be provided through the project. M– Impact Health workers might neglect non-RBF, non HIV- Primary health care indicators must be included in the priorities. RBF scorecard. Inappropriate size of the RBF incentive which Conducting an RBF feasibility study using (i) focus might either (i) destroy the intrinsic motivation of group discussions and (ii) RBF pilots to determine the service providers (if too large) or (ii) fail to motivate right kind and size of incentive (iii) piloting and them to achieve results (if too small). evaluating the approach before considering scale-up. Overall Risk Rating at Overall Risk Rating Comments Preparation During Implementation Given the issue of sustainability of ARV financing beyond the project life, the Government has Moderate Moderate recently agreed to include a budget line to that effect. A legal covenant will be included to address this issue. 43 Annex 5: Implementation Support Plan Niger Second HIV/AIDS Support Project Strategy and approach for Implementation Support 1. The strategy for Implementation Support has been developed based on the nature of the project and its risk profile. It will aim at making implementation support to the client more flexible and efficient, and will focus on implementation of the risk mitigation measures defined in the ORAF. Technical inputs. The technical team will provide regular inputs to the CISLS and the ULSS on technical issues. In particular, it will review Work program, Terms of Reference and draft reports prepared by the Government. The team will closely follow new development in the area of HIV prevention (microbicides, Pre-exposure prophylaxis, etc.) care and support including proven interventions in the project as soon as they emerge.  Procurement and financial management inputs. A close supervision on procurement and financial management will be deployed. Procurement supervision will include prior reviews of procurement activities as well as post reviews. In addition, procurement progress against the detailed procurement plan will be closely monitored. On Financial Management, the project will be supervised regularly on a risk-based approach. The project will implement the Result based financing (RBF) on a pilot basis in order to strengthen the prevention and treatment services in the country, after which it will be decided whether to expand to all health facilities providing HIV/AIDS services. So as to avoid any financial management issue, technical support missions will be held by the IDA team locally. The supervision will also focus on the status of financial management system to verify whether the system continues to operate well and provide support where needed. It will comprise inter alia, the review of audit reports and IFRs, advice to task team on all FM issues, review of annual audited financial statements and management letters.  Environmental and Social Safeguards inputs. The Bank team will supervise the implementation of the agreed actions plans in the Waste Management Plan and provide guidance to CISLS and the MOH to address any issues. Implementation Support Plan 2. Most of the Bank team members will be based in the Niger country office and other country offices in the region to ensure timely, efficient and effective implementation support to the client. Formal supervision and field visits will be carried out semi-annually. Detailed inputs from the Bank team and the UNAIDS country coordinator (who has been associated with the preparation of the project) are outlined below:  Technical inputs. The technical supervision of the project requires expertise in HIV/AIDS, project management, social development, and Results-based financing. Technical supervision missions will be undertaken on a semi-annual basis. The TTL will ensure that overall project implementation – both technically and operationally – is progressing satisfactorily. 44  Fiduciary requirements and inputs. The procurement specialist is based in the region, while the financial management specialist is based in Niger. Procurement and the financial management supervision will be carried out on a timely basis as required by the client.  Safeguards inputs. Inputs from an environment specialist (based in Cote d’Ivoire) and a social specialist (based in Togo) are required. On the social side, supervision will focus on ensuring the implementation of the Civil Society organization activities within the high-risk groups. Formal supervision mission on safeguards will take place on a semi-annual basis. 3. The main focus of implementation support is summarized below. Time Focus Resource Estimate TTL 3 SWs Procurement review and training Procurement specialist 4 SWs FM training and supervision FM specialist 2 SWs First 12 Use of Civil Society Organizations Social specialist 2 SWs months Environmental training and supervision Environmental specialist 2 SWs Technical specialists 7 SWs Technical supervision (on site and off site) TTL 2 SWs Team leadership TTL 3 SWs RBF Specialist TTL 3 SWs TTL 3 SWs Procurement review Procurement specialist 3 SWs FM supervision FM specialist 2 SWs 12-48 Use of Civil Society Organization Social specialist 2 SWs months Environmental supervision Environmental specialist 2 SWs Technical specialists 7 SWs Technical supervision (on site and off site) TTL 2 SWs Team leadership TTL 3 SWs Note: SW – Staff-Week 4. Staff skill mix required is summarized below: Number of Number Skills Needed Comments Staff Weeks of Trips Task Team Leader 8 SWs annually 2 Based in the country RBF specialist 3 SWs annually 2 Based in the region Public Health Specialist 4 SWs annually 2 Based in HQ Project Management Specialist 4 SWs annually 2 Consultant HIV/AIDS specialist 4 SWs annually 2 Based in the country and HQ M&E specialist 4 SWs annually 2 Consultant or Staff based out of the country Financial management specialist 2 SWs annually 2 Based in the region Procurement specialist 4 SWs annually 2 Based in the region Social specialist 2 SWs annually 2 Based in the region Environment specialist 2 SWs annually 2 Based in the region 5. Technical Partners. Name Institution/Country Role HIV/AIDS Specialist UNAIDS/Niger Technical Supervision M and E Specialist UNAIDS/Niger Day to day support 45 Annex 6: Team Composition Niger Second HIV/AIDS Support Project Name Title Unit World Bank Hélène Bertaud Legal Counsel LEGAF Jean Jacques de St. Antoine Lead Operations Officer / Cluster Leader AFTHE HNP Wolfgang M. T. Chadab Finance Officer CTRFC Aissatou Diack Senior Health Specialist AFTHE Sidy Diop Procurement Specialist AFTPC Rachel Hoy Junior Professional Associate AFTHE Daniele Jaekel Senior Operations Analyst AFTHE Djibrilla Karamoko Task Team Leader AFTHE Jody Kusek Adviser, HIV/AIDS M and E Specialist WBICR Karima L. Ladjo Program Assistant AFMNE John F. May Lead Population Specialist AFTHE Son Nam Nguyen Senior Health Specialist ECSH1 Ibrah Rahamane Sanoussi Procurement Specialist AFTPC Abdoul-Wahab Seyni Social Development Specialist AFTEN Nko Etesin Umoren Resource Management Analyst AFTFM Albertus Voetberg Lead Health Specialist, HIV/AIDS SASHN Specialist Beth Wanjeri Mwangi Financial Management Specialist AFTFM Noma Salifou Team Assistant AFMNE UNAIDS Felicite Nsabimana Country Coordinator UNAIDS Amadou Dambagi M and E specialist UNAIDS Government CISLS ULSS Ministry of Economy and Finance 46 Annex 7: Results Based Financing (RBF) Niger Second HIV/AIDS Support Project 1. The innovative intervention adopted under the project will aim to improve health service delivery by introducing a Results-Based Financing (RBF) approach. The expected results would be an increased use of services by the targeted population, notably high-risk groups. The impact will come from the: (i) improved availability of services; (ii) increased motivation of health workers; (iii) reduced financial barriers to vulnerable patients; (iv) improved quality of the services provided; (v) the use of the internal and the external controls of the results achieved by the health facilities; and (vi) increased demand for services from people living with AIDS and infected by STI. 2. The project will support the identified high-risk groups to provide them prevention, care and treatment services in the eight regions of the country. High-risk groups will receive full coverage of services benefitting from prevention, treatment, care and support in order to reduce their vulnerability and reduce further HIV transmission. 3. In the first two years, the project would support a feasibility study and pilot phase for RBF implementation through the provision of payments to eligible health centers that will carry out Voluntary Counseling and Testing (VCT), care and treatment for STI and HIV. The RBF will be implemented in selected health facilities (i.e. treatment centers and the VCT centers at the district and regional levels). The project’s pilot will inform the implementation process to scale up RBF throughout the health sector after the project midterm. The expansion of the RBF to the whole country and through all project activities will be decided after the project midterm review. 4. According to the tasks which need to be undertaken in order to start the pilot phase and the RBF implementation cycle, the proposed key dates and the activities are following: A. The RBF Implementation Cycle is as follows: PREPARATION OF THE WORK PLAN (INCLUDING THE  TARGETED INDICATORS) EVALUATION OF THE RESULTS BY THE  CONTRACT  (AGREEMENT SIGNED  PURCHASING AGENCY AND BY THE SECTOR  BETWEEN THE HEALTH FACILITIES AND THE  PEER REVIEWER (EVALUATION EVERY  PURCHASING AGENCY) QUARTER) IMPLEMENTATION OF THE WORK PLAN 47 B. Key steps for the RBF pilot implementation Activities Expected date Year 1 - Feasibility Study February 28, 2012 - Preparation of the Manual and Guidelines - Preparation of the costing table - Identification of the pilot zone - Training for key actors - Hiring of the Performance Purchase Agency (PPA) Year 2 - Pilot Phase of RBF for treatment, VCT and PMTCT January 30, 2013 Year 3 - Midterm Review : Decision for expansion April 30, 2013 5. The project will finance RBF payments and provide support for the design, implementation and supervision of the RBF pilot, through contracting of a third party namely a Performance purchase agency (PPA). This agency will contract with health facilities in the selected districts and regions based on payments for a defined set of services (see below). The amount of services provided and the quality of care would be evaluated by the PPA (in collaboration with external reviewers) every three months. Based on the final verified results, the health facilities would receive an agreed payment (linked to the results achieved). 6. The third party (PPA) will be responsible for undertaking an assessment of the capacity of health facilities, calculating the unit cost of the services, contracting with health centers, and verifying achievement of results. In each district, hospital and selected health facilities, technical assistants of the PPA will check the consistency between reported results and health facility records. In addition, NGO/CSOs will be contracted to undertake external verification through random household checks to confirm that beneficiaries actually received services. 7. In order to avoid a manipulation of the results data, the use of a third party and the field surveys conducted by NGOs to measure and verify the achievements, will limit the risk of misusing of the RBF approach. 8. The transfers under the RBF will reimburse health facilities for the provision of services including: health care, treatment, laboratory tests, and preventive services. The final list of items for measuring quality of care, treatment, VCT and prevention will be included in the RBF operational manual. For each of the RBF outputs, the operational manual will define the unit costs to be used for calculating RBF payments to facilities. A study on unit costs will be undertaken accordingly and these unit costs will be estimated more precisely before the start of the RBF process. They will also be reviewed and updated annually. Table 5: Example of RBF Services Type of services 1. Antenatal care visit (including testing for STI/HIV) 2. Antenatal care visit 3 3. Care for women under the MTCT 4. Care for Child under the MTCT 5. High risk group member tested for HIV 6. High risk group member tested for STI 7. High risk group member tested for Tuberculosis 8. Voluntary counseling and Testing for STI/HIV/AIDS (general population) 9. Treatment for people living with AIDS 10. Drugs and reagents management (no stock out) 11. Laboratory test for people under treatment 48 9. In order to ensure that facilities are focusing on the quality of the services they provide, the payments given to facilities will be adjusted according to a quality score during the quarter. The quality score will be given following an assessment carried out in health centers and hospitals, based on a broad variety of indicators such as the availability of staff and medicines, cleanliness, and the quality of recordkeeping. The payment to the health facility will be adjusted according to the given quality score. 10. Facilities will have considerable autonomy in spending RBF payments. The health facilities will have substantial autonomy over how to use the funds they receive, although the CISLS (in collaboration with the health sector coordination unit) and the PPA will set some general guidelines in the RBF manual. For example, the RBF payments cannot be used for construction and the percentage of its funds a health facility can spend on performance incentives to staff will be limited. However, the facilities can spend these funds on buying “small� equipment, medicines, maintaining the facility, and supporting outreach activities in order to boost the use of services by targeted groups. 11. An Implementation Manual will be prepared and adopted by the country. The CISLS and the MOH will develop an implementation manual for the RBF model with details including: (i) institutional arrangements; (ii) roles and responsibilities for the verification and control of results for payment and auditing purposes; (iii) indicators and targets to be met; (iv) penalties and sanctions for exaggeration or fraud in the amount billed; (v) management and data collection tools; (vi) rules for the use of funds; and (vii) reporting mechanisms. The manual will be a working document that will be regularly updated on the basis of agreements reached between the third party (Performance Purchase Agency) and the health facilities but subject to the non-objection of the Bank. The non-objection of the Bank to the manual is a disbursement condition for this activity. 49 50