Page 1 Report No. 39863 Project Name Senegal-HIV/AIDS Prevention and Control Project Region Africa Sector HA - HIV/AIDS Project ID P074059 Borrower(s) Government of Senegal Implementing Agency Multi-Sector Government Agencies Ministry of Health and Prevention Address: Building Administratif, Dakar, Senegal Contact Person: Dr Omar K.Faye, Director of Health Tel: (221) 644 34 85 Fax: (221) 869 42 49 Programme National de Lutte contre le SIDA (PNLS) Contact Person: Dr Ibrahima Ndoye Tel: (221) 869 09 09 Fax: (221) 820 34 79 Email: indoye@cnls-senegal.org Environment Category B Date PID Prepared November 22, 2001 Date PID Revised May 10, 2007 Appraisal Date November 19, 2001 Board Date January 17, 2002 1. Country and Sector Background Senegal continues to shoulder a heavy burden of preventable and largely treatable disease. Senegal has increased health investment from US$8 per capita in 1996 to US$15 in 2007. It has also implemented a clear policy shift toward the prevention of disease Page 2 2 through the decentralization of health services and through the involvement of beneficiaries and NGOs, particularly in the management and implementation of programs. However, these efforts risk being undermined by Senegal's rapid population growth and still high but stable HIV prevalence rates among specific high risk groups (20% of CSW and 21% of Men having Sex with other Men are HIV positive). Furthermore, the extent of behavior change is still limited compared to the high level of awareness and requires a significant effort for the promotion of safer sexual behavior and to increase the median age at first sexual contact. The population is expected to attain 16 million in 2020, almost doubling from 2000 (9.4 million), pushing the urban population to about 9 million. This will exert unrelenting pressure on social services, and in the event of weakening economic conditions, poses a major threat of increased prevalence of communicable diseases, notably HIV/AIDS. Senegal has a reasonable chance of significantly containing HIV/AIDS during the next years. Factors which have helped Senegal's success in maintaining one of the lowest prevalence in the region and which favor further reduction of new infections are: strong commitment at the highest level of government and civil society; an early and unanimous decision (1986) to confront STD and contain HIV infections; consistent and sustained strategic direction and management of the program; a high level of sensitization to the issues on the part of civil society, the private sector and government, leading to strategic alliances between Muslims and Catholics, the NGOs and key groups such PLWHA, women, youth and high risk groups; strong capacity for policy formulation and strategic planning; a good network of primary, secondary and tertiary health care facilities; tested delivery systems and increasingly robust mechanisms for M&E and grassroots participation; the development of best practices with the assistance of major international research institutions, now disseminated widely in the Region. The 2002-2006 and 2007-2010 National Strategic Plans Against HIV/AIDS in Senegal ( Programme Multisectoriel de Lutte Contre le SIDA - PMLS ) were developed and adopted through a multisectoral consultative process in 2001 and is considered by Government as an integral part of the broader framework for poverty alleviation. It builds on the earlier National Strategic Plans, and constitutes a synthesis of sector strategic plans that were elaborated through a series of consultations within each sector and at the regional level. These multi-sector regional plans involve the government ministries, private sector and civil society and stress the need for partnership among all the actors on the ground to ensure a coordinated, localized response to reducing the spread of HIV infections and the socio-economic impact of AIDS. The Government of Senegal has thus requested access to IDA resources within the framework of the second phase of Multi-Country HIV/AIDS Program (MAP2) for the Africa Region was presented to the Board of Directors on January 17, 2002 . Senegal is eligible for MAP funding and has satisfied the four MAP eligibility criteria as follows: a) Senegal already has a coherent national strategy and has developed a comprehensive medium- term multi-sector plan in a participatory approach with all concerned stakeholders; b) it has created a national HIV/AIDS council chaired by the Prime Minister with broad representation from all sectors and civil society including people living with HIV/AIDS, to coordinate the implementation of the national plan; c) the Government has agreed to use exceptional implementation arrangements by channeling funds directly to both public and private sector implementing agencies, civil society organizations, associations of PLWHA, and to communities; and, d) Government has agreed to outsource important Page 3 3 implementation aspects such as behavior surveys, operation research, financial management and program management monitoring and evaluation. 2. Objectives The overall development objective of the Project is to contribute to the Borrower’s efforts in controlling the HIV/AIDS epidemic by: (i) expanding HIV/AIDS prevention interventions among vulnerable groups including, youth and women, and high risk groups (commercial sex workers, tuberculosis patients, truck drivers); (ii) expanding access to treatment, care and support for people living with HIV/AIDS in Senegal; and (iii) supporting civil society and community initiatives for HIV/AIDS prevention and care. These initiatives are put forward by beneficiary groups selected on the basis of the technical quality and likely impact of their proposals. The project will support the implementation of Senegal's strategic plans against HIV/AIDS for the period 2002-2006 and 2007-2010 ( Plan Multisectoriel de Lutte Contre le SIDA-PMLS ). The 2002-2006 plan's specific goals aimed to maintain the prevalence level of HIV below 3% in the country by 2006; mitigate the health and socio-economic impact of HIV/AIDS at individual, household and community levels; and create an enabling environment for a broader and stronger public/private partnership to implement the plan. The 2007-2010 plan focuses more on vulnerable and high risk groups who will be targeted by behavior change communication campaign aimed at increasing the utilization of voluntary counseling and testing, prevention of mother to child transmission, as well as psychosocial and medical care services. 3. Rationale for Bank's Involvement The project allows IDA to provide continued support to a successful program and promotes Senegal as a flagship of performance to date and herald for future directions in sub-Saharan Africa (with MAP II). However, this requires that it build on its successes and ensure program sustainability and effectiveness. Senegal so far has done a lot with limited resources involving high transaction costs. The project under MAP II significantly reduced the costs of coordinating HIV/AIDS financing by applying the UNAIDS “Three Ones Principles” – one strategic plan, one coordinating mechanism and one monitoring/evaluation system. IDA support is also important as Senegal needs a substantial injection of finance to entrench and widen the program, particularly to fill existing gaps and finance future directions to strengthen weak elements of its program, such as: limited multi-sectoral approach to date under-resourced decentralized/community approach to care and prevention weak capacity of both the public sector and the civil society need to scale up a number of successful pilot activities Taking ART beyond pilot (including testing hypothesis that ART reduces overall treatment costs) Financing research in needed areas Fighting ongoing stigma issues (homosexuality, workplace treatment of PLWHA)The Bank support complements other development partners, including pharmaceutical companies in a joint effort in support of the national program of containment and eventual marginalization of the malady. It brings to the table substantial financing required to intensify HIV prevention, scale up the treatment of AIDS and OIs as well mitigate the socio-economic impact of the disease. Page 4 4 Since the Bank has good working knowledge of the other sectors, it can assist in making the technical ministries' programs more effective. Finally, by promoting emphasis on monitoring and evaluation as well as research and dissemination, it assists Senegal in maintaining its all important "success story" - a powerful force for emulation by other countries in the sub-region struggling with significantly higher levels of prevalence. 4. Description The project supports implementation of Senegal's HIV/AIDS strategic plans by a wide variety of public sector agencies, private and non-governmental organizations, and by community-based organizations. It is planned to cover a five-year period extending from 2002 to 2006 to coincide with the strategic plan's duration and is be complementary to other donors activities. However, the NAC obtained a 30 million grant from The Global Fund against HIV/AIDS, Malaria and TB, which resulted in slower disbursement than planned and a two-year extension will be needed to disburse remaining funds on successful and promising strategies. The project aims at building additional planning, implementation, monitoring and evaluation capacity of public and private entities and expanding existing prevention, treatment and mitigation programs. It is implemented in close coordination with other bilateral and multilateral organizations and complements their contributions toward implementation of the strategic plan. The project is implemented through four major components as follows: A. Strengthening the capacity of implementing agencies and coordination structures (US$ 2.0 million) This component is designed to reinforce the resource management, implementation and monitoring and evaluation capacity of government agencies, civil society and the private sector, and to strengthen the capacity of local organizations and rural communities in the design and implementation of demand-driven HIV/AIDS activities. The national HIV/AIDS Council, its Secretariat and its decentralized structures at the regional and district levels are regularly provided with technical, financial and material support to coordinate, monitor and evaluate implementation of the national strategic plan. More specifically, capacity- building support consists of two sub-components: Sub-component one covers the provision of technical support services and training to HIV/AIDS units of line ministries, NGO and CBO personnel, with an emphasis on project design, participatory planning, and monitoring of community-based activities, It also trains laboratory technicians, medical and paramedical staff and social workers to strengthen VCT, the prevention of mother to child transmission, the prevention and treatment of opportunistic infection and tuberculosis and the provision of ART; and Sub-component two consists of the provision of technical support services, equipment and materials to implement a comprehensive Monitoring &Evaluation plan. The National Executive Secretariat (NES) coordinates and ensures implementation of the following M&E components, outsourcing them to government and private agencies: (i) surveillance; (ii) epidemiological research; (iii) financial monitoring; and (iv) project monitoring. Surveillance comprises biological and behavioral surveillance. Biological surveillance is conducted among 6,600 antenatal women in 11 sites (Dakar, Kaolack, Saint-Louis, Ziguinchor, Thies, Mbour, Fatick, Louga, Diourbel, Kolda and Tambacounda), 300 STI patients in Dakar, 2,400 TB patients in 8 regions, 2,400 hospital patients in 8 regions and 2,500 sex workers in 7 regions. Behavioral surveillance is conducted among 3,200 sex workers in 10 regions, 10,000 in- Page 5 5 school youth in 10 regions, 500 apprentices in 10 regions, 1,000 soldiers/policemen in 10 regions, 1,000 customs/border guards in 6 regions, 1,000 seasonal workers in 3 regions, 1,000 mobile workers in 5 sites, 1,000 fishermen in Dakar and 1,000 port workers in Dakar. Combined biological and behavioral surveillance is conducted in pilot studies of mobile populations. Epidemiological research conducts etiology and sensitivity studies, track STI/HIV trends and evaluate HIV prevention and care interventions among priority groups. Financial and project monitoring focuses on NES's contracting and coordinating capacity and the relevance, quantity, quality and economy of public sector and civil society services. Operations research examines what is working and disseminate important lessons. NES coordinates the above M&E components as follows. Biological and behavioural surveillance is coordinated by NES, assisted by the Epidemiology Group, the Bacterial-Virological Laboratory and research institutions. Epidemiological research is also coordinated by NES, assisted by the Epidemiology Group, the Bacterial- Virological Laboratory and research institutions. Financial and project monitoring is combined and delegated to one agency, for economy and effective financial-project cross-verification. Structured reporting and assessment forms and procedures are utilized to ensure sound project monitoring. Financial and project monitoring generates verified primary data to inform internal and external supervision. The World Bank Washington supports operations research, to ensure maximum project cross-learning and dissemination. On financial and program management monitoring, Senegal has agreed to outsource the projects financial management to a single agency which is also responsible for financial and program management monitoring and evaluation. Terms of reference were prepared and agreed upon during project preparation and a firm was appointed before credit effectiveness. B. Support to civil society and community-based initiatives in the area of prevention, care and mitigation (Total Grant US$12.5 million). Using a grant mechanism, this component is designed to intensify prevention, care and social support to meet the information needs of specific target groups and PLWHA and their families. It ensures the continuity and expansion of successful HIV/AIDS mitigation activities adapted to local conditions and managed by grassroot organizations and communities. The component also promotes and encourages the HIV/AIDS initiatives of private sector enterprises aimed at developing and implementing prevention, care and support strategies designed for their employees and their families. This is done in close coordination and complementarily with the recently launched ILO financed project of the Ministry of Labor. Funds are channeled directly through grants to associations, religious organizations and communities, private enterprises, NGOs and community-based organizations to cover a wide range of activities including: (i) prevention and sensitization activities targeted to communities as well as specific groups at high risk and aimed at building awareness, reducing the stigma associated with HIV/AIDS and the adoption of safer sex behavior; (ii) provision of home and community-based care for AIDS patients; and (iii) social support to PLWHA, orphaned children and households affected by HIV/AIDS through income generation activities and support to local caregivers. The Government and grants recipients' responsibilities are be embodied in a contractual agreement signed before works start. Eligibility criteria, norms and standards for implementation of sub-projects under this grant mechanism are described in a specific module of the project operation manual. With regard to activities aimed at helping orphaned children, the project finances investments to improve their nutrition, their Page 6 6 access to education and health care, as well as their integration into host families and communities. Sub-projects proposed by NGOs and CBOs and financed under the IDA Credit complements and reinforces ongoing or new initiatives such as the Hope For African Children Initiative launched by Care, Plan International, Save the Children, The Society for Women Against AIDS in Africa (SOWA) and the World Conference on Religion and Peace. The Initiative has received a US$ 10 million grant from the Bill and Melinda Gates Foundation and has been endorsed by UNICEF, the World Bank and USAID.C. Support to Governmental Agencies Multi-Sector program (US$ 12.5 million). The purpose of this component is to support a major expansion of HIV/AIDS activities implemented by government entities. Several ministries are in the process of developing detailed work plans and budget and are eligible for support under the project as of project year one. These are the MOHP, the Ministry of Youth, The Ministry of Interior, the Ministry of Education, and the Ministry of Technical and Vocational Training, Literacy and National languages. Additional ministries would also have access to IDA funds once they develop their own plan. Activities under this component cover the full spectrum of prevention, treatment, care and support and include: (i) the design, implementation and evaluation of information, education and communication (IEC) programs aimed at specific audiences and high risk groups of the population such as adolescents (both genders) in and out of school, women, youth, and men in uniform; (ii) the promotion and distribution of condoms; (iii) the promotion of and access to voluntary HIV counseling and testing (VCT) and (iv) ART, PMCT and the prevention and treatment of STIs, other opportunistic infections and tuberculosis. The IEC program which will be supported under this component aims at maintaining people's awareness of HIV/AIDS risks and protection measures. It promotes behavior change for safe sex practices and risk reduction and advocacy among public and private leaders on human rights protection, abolition of discriminatory practices and learning to live with PLWHA. Use of the mass media would be an important channel of communication. The component supports the use of social marketing for condom promotion and distribution. Peer groups, vending machines and other social marketing strategies are also used to make condoms accessible to all segments of the adolescent and adult population. Each ministry can choose its strategy to make condoms available and accessible to its staff and clients, and visible access to condoms in public places is encouraged. Implementation of MOHP HIV/AIDS clinical programs would also be supported under this component. This includes: i) the prevention of HIV/AIDS mother to child transmission. The project supports the decentralization of MOHP pilot PMCT program to at least one clinical site in each of the ten regions of the country during the period 2002-2006. The objective is to achieve a 80% level of awareness of mother to child transmission among women 15 to 49 and to reduce the transmission rate from 30% to 15%-. 90% of children born to HIV infected mothers would be provided the care and treatment at the end of the project. Specific activities consist of: a) the progressive creation, training and equipping of multidisciplinary teams in each of the ten regions of the country under the supervision of a national team composed of leading gynecologists, pediatricians, biologists and social assistants; b) implementation of a program of pre-test and post-test counseling and the voluntary testing of a target total of 58,000 pregnant women in pre-natal consultations during the period 2002-2006; c) expanding access to short regimen treatment using Zidovudine or Nevirapine drugs; d) expanding access to antiretrovial treatment therapy in accordance Page 7 7 with national standards; e) the development and implementation of specific psycho-social support and IEC activities targeted to HIV infected pregnant women covering topics such as nutrition, breast feeding practices and the use of milk substitute; and f) the establishment of a supervision and monitoring system to ensure effective control and quality of implementation of PMCT protocols and guidelines and efficient follow-up and monitoring of patients. ii) the diagnosis, treatment and care of HIV/AIDS patients. This was be based on the expansion of ISAARV (Senegal Initiative for the Introduction of Antiretroviral Therapy) . Launched in 2000 and limited to the city of Dakar during its pilot phase, ISAARV was progressively decentralized all the 11 regions of the country. Currently 53 treatment sites covering 5500 patients in Decmeber 2006.. To achieve this objective, the project strengthened voluntary counseling and confidential testing and laboratory capacity to help scale up the diagnosis, treatment and care for HIV/AIDS patients. This is part of the MOH's objective to reduce HIV transmission, reduce worker disability and improve the quality of life for HIV/AIDS patients. The component also supports activities aimed at improving the diagnostic and treatment of sexually transmitted diseases, opportunistic infections, and tuberculosis. It contributes as needed, to strengthening drug management, patient management (eligibility, clinical and biological follow-up) and psycho-social and economic support to PLWHA. Bio-medical equipment is purchased to monitor the immunology and virology parameters of HIV infection and financing is made available to cover the costs of minor renovations in selected laboratory facilities, the procurement of reagents and drugs for the treatment of STIs, Opportunistic Infections, TB and other HIV related illnesses. The Government of Senegal continues its ARV drugs procurement plan under arrangement with five international pharmaceutical companies (Merck, Pfizer, Bristol-Meyers, Boehringer/Ingelheim and Roche) as part of the "Access Initiative" of these companies in Africa; but also partners with other initiatives aiming at decreasing prices of ARVs, such as the Clinton Foundation. Funds under the IDA Credit would also be made available as might be needed, to supplement Government financing of ARV drug procurement. D. Support to project management and administration (US$ 3.0 million). This component provides support to facilitate the programming, coordination, and monitoring of project operations, including support to National Aids Council (NAC) and National Executive Secretariat (NES) to ensure complementarity and efficient coordination of activities by all concerned parties and to consolidate activity plans, budgets and progress reports. The component supports the deployment of skilled and experienced manpower to staff essential coordinating structures and funds services of a financial management agent, technical and financial audits, logistic support to facilitate project supervision and reporting, and the organization of CMLS/NES regular meetings and annual project reviews. A. Strengthening capacity of implementing agencies and coordinating structures B. Support to civil society and community-based organizations' Initiatives C. Support to Govt. Agencies Multi-Sector Programs and Line ministries D. Project Management and Administration 5. Financing Page 8 8 Total ( US$m) BORROWER 13.5 IDA 30 EC: EUROPEAN COMMISSION 2.8 CANADA, GOV. OF 1.5 FRANCE, GOV. OF 1 GERMANY, GOV. OF 1.5 UN UNAIDS 0.5 UN FUND FOR POPULATION ACTIVITIES 0.8 WORLD HEALTH ORGANIZATION 0.4 THE GLOBAL FUND AGAINST HIV/AIDS, MALARIA AND TUBERCULOSIS: 30 Total Project Cost 82 6. Implementation Institutional arrangements. (i) Project coordination. Overall coordinating responsibility for the PMLS is undertaken by the National HIV/AIDS Council (CMLS). The CMLS members include representatives from all government ministries, the private sector, an observer designated by the group of international donors and representatives of the civil society including youth, women, religious groups, PLWHA, NGOs, regional and local communities as well as recognized experts in HIV/AIDS that the CMLS may deem necessary to call upon for advice (nonvoting). The Prime Minister assumes the chairman ship of the CMLS and chair its meetings. The Minister of health assumes its vice- chairmanship. The number of CMLS members is limited to a maximum of 30 persons. It should l meet once every six months or, exceptionally, at the request of its chairperson and/or one third of its members. The CMLS is responsible for:(i) advocacy, strategic direction and policy coordination to ensure conformity with the PMLS;(ii) mobilization of financial, human and physical resources necessary to carry out the PMLS;(iii) oversight of the plans for implementation of the PMLS throughout the country;(iv) ensuring the legal and ethical aspects of the fight against HIV/AIDS.The CMLS executes its mandate through a National Executive Secretariat (NES) that has responsibility for overall coordination of the PMLS. The NES is largely representative of all parties to the national strategy including the focal persons in each of the key ministries, representatives of civil society, the private sector, local communities and vulnerable groups. It meets at least every three months. The NES has a permanent core of executive staff including an Executive Secretary, an Administrative and Financial Officer, and two Program Coordinators. The NES executive secretary is the project director and reports to the Minister of Health, as vice-chairperson of CLMS. The NES is responsible for:(i) Recording decisions taken during meetings of the CMLS and ensuring their execution;(ii) Overseeing the contracts and conventions signed between the financial management agency and the implementing agencies, and ensuring their overall execution and quality assurance;(iii) Representing the CMLS in meetings with various levels of government and other partners; (iv) Ensuring the provision of technical assistance and quality assurance to partners involved in the national responses;(v) Ensuring monitoring and evaluation of sector and local plans; (vi) Presenting the annual financial statements and program reports to the CMLS; (vii) Organizing occasional meetings between all the Page 9 9 partners in the program;(viii) Coordination with the Financial Management Agency (FMA);(ix) Ensuring overall monitoring, evaluation and coordination of the program. The NES coordinates with other IDA funded projects and with HIV/AIDS related projects financed by other bilateral and multilateral agencies. The NES meets regularly with UNAIDS thematic Group and participates in meetings of HIV/AIDS Donors led by UNDP. Some of the functions of NES are carried out at a decentralized level by existing regional and departmental HIV/AIDS committees that provide general policy and technical guidance to partners operating at regional, departmental and community levels. These Committees are composed of representatives of government agencies, municipal and communal councils, civil society, the private sector and presided over by a coordinator chosen by the members of the Committees. The Regional and Departmental Committees: (i) provide technical assistance to implementing agencies; (ii) coordinate meetings to synthesize reports on activities in the region; (iii) provide support as needed to the FMA; and (iv) ensure the monitoring and evaluation of the response to HIV/AIDS at a decentralized level. The Regional and Departmental Committees are physically hosted by other organizations in the regions and the NES is responsible for coordinating their activities. (ii) Project Implementation. The project finances a series of HIV/AIDS action plans presented by line ministries, as well as projects proposed by a large number of civil society organizations, including NGOs, women's groups, Associations, unions, private enterprises and community-based organizations (CBOs). Line Ministries received approximately 40% of project funds. The breakdown between sectors was determined during appraisal and the largest allocation was made to the Ministry of Health, because of its important role in the prevention and treatment of HIV/AIDS. These funds are complemented by contributions from line ministries' budgets, including provision for a Focal Point or HIV/AIDS unit that is responsible for policy coordination, monitoring and reporting on the sector ’s response to HIV/AIDS. Line ministries implement their respective plans through their existing central, regional and departmental units. They provide administrative and technical support to their implementation units, including relevant guidelines, training and monitoring and evaluation. They also ensure that appropriate financial, human and physical resources are channeled to regional and departmental governments to enable a decentralized response to HIV/AIDS. A formal contract including a work program and budget with agreed input and output indicators guide the relationship between line ministries, the NES and the FMA. The NES be responsible for providing technical assistance and quality control to line ministries. Civil Society receive approximately 40 % of project funds through sub-projects proposed and implemented by a variety of organizations. Communities and CBOs organize themselves and present their project proposals to the respective regional or departmental committee and be responsible for executing their projects. Communities and CBOs may decide to enter into contract with a non governmental organization to assist them in the preparation and implementation of projects. The cost of such assistance does not exceed 20% of the total project cost. Communities contribute in kind to sub-project financing for a minimum amount of 5% of total project costs. Other civil society organizations (including NGO, religious organizations, associations, unions, and private enterprises) may present sub- project proposals of a national, regional or departmental scope to be directly financed by the project. Eighty percent of total sub-project costs must be directed to activities targeted to beneficiaries. Some private sector organizations may also be contracted to implement Page 10 10 specific project activities in the areas of research and evaluation or in any other topic as deemed necessary. The criteria for eligibility as well as funds allocated to each organization are determined according to a set of criteria established for different categories of applicants. A roster of over 200 civil society organizations working in HIV/AIDS has been established and reflects different categories of NGOs and CBOs, classified according to their experience, geographic coverage, target beneficiaries and ability to carry out HIV/AIDS projects. The roster is updated to include private sector organizations and other associations and was reviewed during appraisal. The project is implemented in an incremental manner starting with those line ministries, NGOs and CBOs which already have HIV/AIDS work plans and projects. Coverage has been extended to other sectors and organizations of the civil society as their implementation capacity is strengthened and their work plan and projects prepared. Line ministries and their regional and district structures prepare annually, a work plan and budget for each fiscal year. Planned activities for the first year of project implementation was reviewed at appraisal. The project provides for a mechanism to establish capacity-building partnerships between NGOs at different levels, whereby less experienced, smaller NGOs work with larger, more experienced NGOs in order to gain technical and project management skills as they implement projects under the guidance of the larger NGO. National NGOs are required to work in partnership with local NGOs as a criterion for eligibility, and are afforded resources to provide such technical assistance. Other eligibility criteria for any applicant organization include coherence with the strategic directions of the PMLS, experience with HIV/AIDs and Community Development, Management Capacity and Community Participation. A project operation manual which describes in detail the project's institutional and implementation arrangements, and administrative procedures was prepared and reviewed at appraisal and midterm review. The manual sets out the functional relationships between the different organs in the institutional framework, the criteria and guidelines for allocation of funds including under the grant mechanism, as well as accounting norms and reporting requirements for all responsible and implementing agencies. External technical and financial audits of the project are carried out regularly by the government in order to ensure financial and technical compliance and quality control. Financing for the project is mobilized through public sector budget contributions (investment and recurrent expenditure), current resources committed by bilateral agencies and multilateral organizations and international NGOs, and private sector donations. IDA resources through the MAPII Project serve to complete the HIV/AIDS program financing plan. In order to ensure a multisectoral and local response in the fight against HIV/AIDS, IDA resources are allocated approximately in the following manner: 40% of the Project's resources are directed towards the public sector and 40% to the civil society and the private sector. 65% of the funds are channeled to community level, 15% to the regional level and 20% to the national level.15% of the total credit goes towards project management, including the fee of the financial management agency, independent financial and technical auditors, operating costs of the National Secretariat and administrative support to the Regional and Departmental Committees. (iii) Project monitoring, supervision and evaluation. It is proposed that surveillance and epidemiological research should be managed by the HIV/AIDS unit of the MPOH, assisted by the Epidemiology Group, the Bacterial-Virological Laboratory, and research institutions. Financial and program management monitoring are combined Page 11 11 and delegated to one agency, for effective financial program cross-verification. Structured reporting and assessment forms and procedures are developed to ensure sound program monitoring. Financial and program monitoring generate verified primary data to inform internal and external supervision. Line ministries and other implementing agencies supervise their own activities at all levels within their respective sector mandates. They provide the NES and FMA information on a number of agreed upon variables on a quarterly basis. Regional and departmental HIV/AIDS committees representing each sector and incorporating community based and civil society organizations supervise project activities at departmental and community levels. Analyses are conducted by the FMA to assess the performance of community based organizations and other civil society entities as needed. The executive secretariat core team also supervises overall project implementation and assesses effectiveness and efficiency of implementation at central, regional and departmental levels, working in close collaboration with the FMA under its defined terms of reference for program management monitoring. The NES core team consolidates progress reports, organizes regular meetings of NES members to discuss progress of each type of implementing agency. It organizes the annual project reviews, the mid-term review and the project completion review to assess the performance of the project, its components and its contribution to the national strategic goal of reducing the spread and impact of HIV/AIDS. The project's annual stakeholders meetings form the basis for the next year annual work program and budget. The draft project operational manual and Annex 4 to the PAD provides a detailed description of the project monitoring, institutional and implementation arrangements and was reviewed during appraisal and at midterm review. (iv) Procurement procedures. Line ministries procure works, goods and services in relation to the respective activities in accordance with the Bank's “Guidelines: Procurement under IBRD Loans and IDA Grants” dated May 2004; in particular sections related to Community Participation in Procurement. Consulting services by firms, organizations or individuals financed by IDA are contracted in accordance with the Bank's “Guidelines: Selection and Employment of Consultants by World Bank’s Recipients” dated May 2004. The Government contract with the “ Pharmacie Nationale d'Approvisionnement (PNA )» a public autonomous drug procurement agency to carry out the procurement of large items and packages such as diagnostic kits and reagents and pharmaceutical products and drugs for the diagnosis and clinical management of HIV/AIDS, sexually transmitted infections and other opportunistic infections including Tuberculosis. Other United Nations Organizations' procurement agents may be contracted for the procurement of specific items such as condoms. Communities use the Bank's Simplified Procurement and Disbursement procedures for Community based Investments to procure goods and services needed to implement their respective HIV/AIDS initiatives. Since each sub-project costs would be modest, local shopping be a standard procurement method. To facilitate speedy import of items valued at less than US$100,000 equivalent, required urgently for diagnosis and treatment and institutional strengthening, contracts may be made based on international shopping and national shopping procedures, respectively or through procurement from the United Nations. The project procurement and disbursement arrangements were reviewed with the Borrower and finalized during appraisal and detailed in the Project Implementation Manual and in annex 6 of this report. (v) Financial management and disbursement. Financial Page 12 12 management of the project and the monitoring and evaluation of program management is contracted to a private sector financial management agent selected on a competitive basis. This is in line with MAP best practice to ensure the most rapid, flexible and efficient mobilization of resources to the beneficiaries of the project. As part of its contract with the Government, the FMA is required to develop a fully integrated financial and accounting system using appropriate software as well as a detailed manual of financial procedures and chart of accounts including the format, content and periodicity of the various financial statements to be produced. The FMA has also been required to set an appropriate financial and accounting system at regional and departmental levels. Transfer of funds to line ministries, NGOS, CBOs and private sector organizations and mechanisms for tranche releases and the scaling up of successful projects is made by the FMA in accordance with eligibility standards and implementation procedures as described in the project operation manual and guidelines. For each category of applicants, there are clear eligibility criteria, thresholds as well as requirements for contributions, depending on size, experience and sector. Applications are made directly to the FMA and disbursements processed, with no ex ante veto by other bodies (the NES is automatically be copied with each application). For all applicants, no more than 20% of any funding can be used for overheads. The terms of reference of the FMA were reviewed and agreed to by IDA at pre-appraisal and a firm was appointed before credit effectiveness. The objective is to put in place sound financial management and output monitoring systems and to introduce the World Bank Financial Management Initiative to administer the credit. However, in its initial phase, the project is operating under traditional disbursement procedures until its financial management is deemed satisfactory by IDA to fulfill the requirements of PMR-based disbursement. Government opened a special account at a commercial bank and all disbursements are fully documented at the time of submission of withdrawal applications, except for expenditures made against Statement of Expenditures (SOE). A plan of action is established at appraisal in order to make the project ready for PMR-based disbursement within 18 months of Credit Effectiveness. 7. Sustainability The project is built upon the established partnership between Government and the civil society, their past and current collaboration in various social sector projects and their strong ownership of the national multi-sector plan against HIV/AIDS. The project expands and intensifies existing programs by mainstreaming prevention care and support activities of several line ministries and the civil society and by tapping and reinforcing community resources and community organizations' potential for mobilization. The government policy of decentralization and the project's emphasis on capacity building at all levels of project implementation would also enhance sustainability. 8. Lessons learned from past operations in the country/sector The National Forum on HIV/AIDS held in December 2000 and joint reviews organized in 2005 clearly identified the successes and failures of the national program in place since 1986, drawing lessons for project design. Findings from the evaluation of MAP I as well as from other countries' experiences were also incorporated into project design. Lessons Page 13 13 include: (i) Political leadership and commitment is key to success : political "champions" are key to mobilizing national and donor resources for the fight against the HIV/AIDS epidemic. The Government of Senegal has been a model of early, high level leadership given its firm commitment to the fight against HIV/AIDS. The Government recognizes the social as well as the economic imperatives to keep a very low HIV/AIDS prevalence and therefore is committed to supporting a sustained program and is now establishing a multisectoral national commission (CMLS) chaired by the Prime Minister; (ii) Need for a multi-sectoral approach and community participation : experience in many countries demonstrates the fact that the health sector alone is not capable of winning the war against AIDS on a sustained basis. There is need for a multi-sectoral approach involving key ministries in government at all levels, the private sector and the non- government/community sector. For the Senegal MAP, a multisectoral team - including civil society representatives - was involved in project design from the beginning. At the same time, the role of the Ministry of Health is recognized as pivotal, particularly with respect to treatment of STIs, OIs, provision of ART, MTCT treatment, VCT, blood transfusion services, procurement, epidemiological surveillance and general health-related technical training and oversight; (iii ) Contracting out of financial management and procurement improves implementation and can make “the money work” : lessons from MAPs to date indicate the importance of contracting out financial management in order to maximize effective and rapid access to funds by the various stakeholders, particularly to those that are community-based. Eligibility criteria must also be made clear and transparent to all potential implementing agencies. In particular, high priority must be put on financing "software" rather than "hardware" - funding people directly involved in HIV/AIDS activities rather than equipment and civil works. In the Senegal project, all financial management is contracted out to a private sector financial management agency (FMA) and no major civil work program is envisioned. The FMA is responsible for disbursements to all applicants from the civil society and the private sector as well as government ministries to implement their sector plans. The Government has also agreed that M&E of program management be contracted to the same agency or to other research organizations as may be deemed; (iv) Need to put in place financing and capacity building mechanisms for civil society : In order to ensure a widespread, sustained and cost-effective response to the disease, it is imperative that the community take primary responsibility for prevention and care of orphans and PLWHA. A lot has been learned with regard to the mobilizing and financing of community based initiatives over the last few decades. Senegal already has a highly active civil society with over 200 NGOs involved in HIV/AIDS and 300 women's groups. In the Senegal MAP, at least 50% of project funds are directed to civil society; (v) Need for strengthening capacity of implementing agencies : based on past experience, greater priority needs to be given to enhancing the capacity of institutions in program management, procurement, financial management, monitoring and evaluation. In Senegal, Project Component 1 provides significant capacity building for implementing agencies, the NES and regional and community equivalents. At the technical level, training of health personnel in both the technical and psycho-social dimensions of HIV/AIDS forms a key subcomponent of the project; (vi) Importance of monitoring and evaluation : monitoring and evaluation of project activities is important for assessing progress and the impact of interventions as well as identifying corrective measures in the course of implementation. The HIV/AIDS Page 14 14 surveillance systems need to be strengthened for effective monitoring and evaluation of the trends of the HIV/AIDS epidemic so as to identify areas that need to be tackled for the greatest impact. Senegal has a developed M&E surveillance system that has provided critical data for identifying high risk groups and tracking PLWHA. The MOHP is reinforcing its second generation surveillance system by expanding it to all regions during the Project. In addition to the program monitoring role of the multisectoral NES and regional and local equivalents, there has been an independent performance review and audit of the NES and financial management agency. The civil society is involved in M&E through its roles in the CMLS, NES and regional/community equivalents, but it lso participates in the annual supervision missions; (vii) Importance of clarifying roles : It has been very important to delineate the roles of different agencies. Experience from other countries has demonstrated that the central organs can be easily rendered ineffective and overly bureaucratic if their roles are not clearly defined, including their functions in relation to other key players. In Senegal, clear terms of reference for the CMLS, the NES and the regional and community equivalents are fully developed and regularly reviewed in the Project Implementation Plan (PIP); (viii) Addressing vulnerability factors and targeting high risk groups are key to future success : The HIV/AIDS epidemic is driven by underlying vulnerability factors among populations and high risk groups. The combination of poverty, illiteracy and gender disparities exacerbate exposure to the virus. For this reason, the project targets these groups with differential information geared to behavior change and also pilots some income-generating activities. It also supports efforts to reduce stigmatization of PLWHA and homosexuality, in order to bring these in line with Senegal's progressive approach to CSW. This project specifically focuses on vulnerable groups, including youth (in and out of school), women, workers, CSW, armed forces, PLWHA, prisoners and others; (ix) Good donor coordination is necessary : this can significantly reduce the government's transaction costs for management of externally funded programs. Common arrangements for program reviews, monitoring and evaluation, planning of financial and technical assistance, support missions, funding of programs or program components are all areas pursued in close cooperation with UNAIDS and other cooperating partners. The UNAIDS (WHO) representative has been part of the project design team and the project benefits from the strong donor coordination and complementarity that exists already in Senegal. Other donors , such as The Global Fund choose to utilize the same FMA as IDA, as a vehicle for channeling their funds to Senegal's National Program. 9. Program of Targeted Intervention (PTI) Y 10. Environment Aspects (including any public consultation) Issues The project is not expected to generate major adverse environmental issues. However, there are risks attached to the handling and disposal of HIV/AIDS infected materials. These risks potentially affect: personnel in hospitals, health centers and municipalities who handle waste, families whose income is derived from the triage of waste and also the general public to the extent that waste is not disposed of on site or safely contained in protected areas. A medical waste management plan was be prepared by the Government nd is being implemented. Institutional arrangements and the cost of Page 15 15 its execution are made clear in the PAD as well as the DCA. The plan includes the proper disposal of hazardous bio-medical waste, a bio-safety training program for the staff of all hospital, health center and community-based programs, including traditional midwives and practitioners, who may be involved in testing and treatment. The training program will include specific instruction on the triage, transport and disposal of waste. In addition the project implementation manual includes guidelines to ensure that environmental considerations are taken into account in the selection and design of project activities. With the assistance of the Africa Safeguard Policy Enhancement Team (ASPEN), TORs have been prepared for such a plan which was reviewed by the Bank prior to credit effectiveness. The task team organized a presentation on medical waste management attended by members of the Senegalese project preparation team and a follow-up workshops are regularly organized in coordination with the MOH HIV/AIDS Division. Safeguard advice is regularly provided by a member of the ASPEN team. 11. Contact Point: Task Team Leader Aissatou DIACK The World Bank 3, Place de l’Indépendance Immeuble SDIH, 5 étage BP 3296, Dakar, Sénégal Telephone: 221 849-50-00 Fax: 221 849-50-27 12. For information on other project related documents contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http:// www.worldbank.org/infoshop Note: This is information on an evolving project. Certain components may be updated throughout the life of the final project. This revised PID was processed by the InfoShop during the week ending May 18, 2007